Dupuytren’s Contracture Disease – The Healing Space Clinic

Dupuytren's Contracture Disease

BASICS

DESCRIPTION

Contracture of the palmar fascia due to fibrous proliferation resulting in flexion deformities and loss of function. Similar change may rarely occur in plantar fascia. It usually appears simultaneously.

System(s) affected: Musculoskeletal
Genetics:
- Autosomal dominant with variable penetrance
- 10% of patients have a positive family history
Incidence/Prevalence in USA:
- Unknown
- Norway - 9% males and 3% females
Predominant age: 50 for males; 60 for females
Predominant sex: Male > Female (ranges from 2:1 to 10:1)

SIGNS AND SYMPTOMS

Typical
- Caucasian male 50-60
- Bilateral with one hand more involved
- Family history
- Unilateral or bilateral (50%)
- Right hand more frequent
- Ring finger more frequent
- Ulnar digits more affected than radial
- Mild pain early
- Later painless plaques or nodules in palmar fascia
- Extends into a cord-like band in the palmar fascia
- Skin adheres to fascia and becomes puckered
- Nodules can be palpated under the skin
- Digital fascia becomes involved as disease progresses
- Web space contractures
- Dupuytren's diathesis can involve plantar (Ledderhose's - 10%) and penile (Peyronie's - 2%) fascia
- Knuckle pads
Atypical
- No age, gender differences
- No family history
- May have systemic disease (see Risk Factors)
- May have a history of trauma
- More common unilateral
- No ectopic manifestations (Ledderhose's or Peyronie's)
- Nonprogressive

CAUSES

Unknown
Ischemia to the fascia with oxygen free radical formation
Possibly related to release of angiogenic basic fibroblast growth factor
Related to microhemorrhage and release of growth factors

RISK FACTORS

Smoking (mean 16 pack-years, odds ratio 2.8)
Alcohol intake
Increasing age
Male/Caucasian
Diabetes mellitus (one-third affected, increases with time, usually mild; middle and ring finger involved)
Epilepsy
Chronic illness (e.g., pulmonary tuberculosis, liver disease)
Hypercholesterolemia
Liver disease
HIV infection

DIAGNOSIS

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Myofibroblasts
First stage (proliferative) - increased myofibroblasts
Second stage (residual) - dense fibroblast network
Third stage (involutional) - myofibroblasts disappear

SPECIAL TESTS

N/A

IMAGING

MR can assess cellularity of lesions which correlate with higher recurrence after surgery

DIAGNOSTIC PROCEDURES

N/A

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient monitoring and physical therapy
Inpatient if surgery indicated

GENERAL MEASURES

Steroid injection for acute tender nodule
Physiotherapy is ineffective alone
Isolated involvement of palmar fascia can be followed
Metacarpophalangeal (MP) joint involvement can be followed if flexion contracture is < 30 degrees

SURGICAL MEASURES

Surgery - selective fascial ray release
- Indications: Any involvement of the proximal interphalangeal (PIP) joints. Hueston's table-top test, if positive, consider surgery (when the palm is placed on a flat surface, the digits can not be simultaneously placed fully on the same surface as the palm because of flexion contractures).
- May require skin grafts for wound closure with severe cutaneous shrinkage
- 80% have full range of movement if operated on early
- Continuous elongation technique is useful to prepare a severely contracted PIP joint for surgery. The digit can frequently be completely extended, however, will relapse if surgery not performed.
- Amputation of little finger, if severe and deforming

ACTIVITY

No restrictions
Physical therapy after surgery - started 3-5 days after surgery (passive and active exercises, posterior dynamic extension splints)

DIET

No special diet

PATIENT EDUCATION

Avoid risk factors especially with a strong family history
Regular follow-up by physician every 6 months-1 year

FOLLOW UP

PREVENTION/AVOIDANCE

None known. Avoid risk factors when possible.

POSSIBLE COMPLICATIONS

Postsurgery development of reflex sympathetic dystrophy
Postoperative recurrence or extension 46-80%
Postoperative hand edema and skin necrosis
Digital infarction

EXPECTED COURSE AND PROGNOSIS

Typical
- Unpredictable, but usually slowly progressive
- Patients likely to have aggressive disease (one or more) < 40 at onset, knuckle pads, positive family history, bilateral disease involving radial side of hand
- Reports of clinical regression with continuous passive skeletal traction in extension and under a skin graft
- Recurrence rate after surgery is 10-34%
- Prognosis better for MP joint vs PIP joint after surgery
Atypical
- Nonprogressive
- Surgery rarely needed
- Recurrence unlikely if surgery performed

MISCELLANEOUS

ASSOCIATED CONDITIONS

Alcoholism
Epilepsy
Diabetes mellitus
Chronic lung disease
Occupational hand trauma (vibration white finger)
Shoulder-hand syndrome
Status post myocardial infarction
Hypercholesterolemia

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: Primarily in this age group
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

MP = Metacarpophalangeal
PIP = proximal interphalangeal

Clinical Investigations

ROLE OF HOMOEOPATHY

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