Depuytren's contracture
Progression of the contracture in Depuytren's pathology

Definition

Depuytren’s contracture is a disorder, which results in a progressive contracture of the fingers. This condition usually affects the ring and small fingers.

Changes in the palmar fascia result in the Depuytren's contracture

Pathology

A Depuytren’s contracture is caused by a progressive thickening and shortening of the palmar fascia particularly of the metacarpo-phalangeal (MCP) joints and the proximal inter-phalangeal (PIP) joints leading to a debilitating impairment of the finger posture and movements. The disease arises from fibroblast cell growth or fibromatosis and increased collagen deposition resulting in the thickening and hardening of the palmar fascia.

A Depuytren’s contracture is caused by a progressive thickening and shortening of the palmar fascia particularly of the MCP joints and the proximal PIP joints leading to a debilitating impairment of the finger posture and movements. The disease arises from fibroblast cell growth or fibromatosis and increased collagen deposition resulting in the thickening and hardening of the palmar fascia.

Grade 1 Depuytren's contracture

Classification

The severity of the disease is divided into three grades: 

Grade 1: thickened nodules in the palmar aponeurosis, skin colour changes

 

Grade 2 Depuytren's contracture

Grade 2: formation of pretendinous and cords, limited finger extension

Grade 3 Depuytren's contracture

Grade 3: permanent contracture of the affected finger(s)

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

The disease is frequent in older European men

Causes

The causes leading to Depuytren’s Contracture are not known. The condition is more frequent in older men of the northern European countries and is thought to have a hereditary aetiology.

Diabetes is a risk factor for Depuytren's contracture

Risk factors

Although risk factors leading to Depuytren’s contracture remain obscure, it is thought that the following demographic and life style components may pose a risk:

Age between 40 and 60 years

Northern European ancestry

Medical conditions: diabetes, seizures

Alcohol abuse

Severe contracture of the hand in advanced Depuytren's contracture

Symptoms

The symptoms arising from Dupuytren's contracture arise gradually and include:

 Appearance of nodules at palmar side of the hand

Pain at the nodules

Formation of rigid bands under the skin

Presence of flexion contracture towards the palm

Impaired finger extension

Movement restriction (grasping)

Left: Tabletop test demonstrates the inability to flatten the palm of the hand onto the table. Right image of a normal hand

Diagnosis

The diagnosis of Depuytren’s contracture does not require special tests. Medical examination is based on observation of the hand anatomy and palpation. The doctor looks for:

Thickening of the fascia, presence of knots at the palmar site (initial stage), along the fingers (at later stage) and finger contracture

Measurements of finger flexion are taken at regular intervals to monitor the progression of the disorder

Tabletop test: failure to flatten the hand and fingers together with the characteristic findings of nodules on the palm of the hand is indicative for Depuytren’s contracture.

Treatment

Local steroid injection reduces inflammation and the excessive fibrosis of the palmar fascia

Nonoperative

Management of the Depuytren’s contracture depends on the severity of the disease. Conservative treatment does not provide much benefit compared to surgical intervention, which is more commonly adopted. Enzymatic fasciotomy is a new method and consists in the injection of an enzyme into the cords to disrupt the thick tissue to regain flexibility and mobility of the fingers. This procedure is only recommended in the initial stages of the disease with only one finger being involved (usually at the MCP joint). Splinting is to be avoided as it may exacerbate the contracture. Additional treatments include:

Administration of NSAIDs

Local steroid injection

Illustration of needle aponeurotomy or percutaneous fasciotomy

Surgical treatment

Surgery is required in case of a severe contracture of both fingers.

Fasciotomy or fasciectomy consists in the removal of the thick bands (fascia) to restore motility (not always completely) of the fingers. This includes a radical fasciectomy when the surgeon removes both the palmar and finger fascia in case of a severe contracture. Hand and finger movement will commence early after surgery to help reducing swelling and restore finger flexibility. Approximately 20% of patients will have a recurrent finger contracture.

Needle aponeurotomy (or percutaneous fasciotomy) is an additional new treatment performed under local anaesthesia without a skin incision. It is based on the placement of needles to separate the thickened tissue. It can be performed at any disease stage. Despite surgery, the disease may return and affect other fingers.

Complications

Complications following surgical fasciotomy for Depuyten’s contracture are:

Limited straightening of the fingers

Requirement of skin graft in extensive surgery

Nerve damage

Joint pain and stiffness

Haematoma

Infections

Poor wound healing

Exercise to strengthen the hand muscles and improve the flexibility of the palmar connective tissue

Rehabilitation

A physical or occupational therapist recommends exercises to restore flexibility and strength of the fingers affected by Depuyten’s contracture. Standard rehabilitative therapy also includes:

Massage

Stretches

Ball exercises

Stretching the hand and fascia may help preventing a severe contracture of the palm

Prevention

There are no specific preventive measures to Depuytren’s contracture. Even surgery may be followed by a recurrent or worsening of the condition. Exercises to improve the flexibility of the fingers may assist in maintaining an acceptable function.