Dupuytren's contracture

Definition

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

Pathology

A Dupuytren'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 Dupuytren'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.

Classification

The severity of the disease is divided into three grades:

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

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

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

Causes

The causes leading to Dupuytren'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.

Risk factors

Although risk factors leading to Dupuytren'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

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)

Diagnosis

The diagnosis of Dupuytren’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 Dupuytren’s contracture.

Treatment

Nonoperative treatment

Management of the Dupuytren’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

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

Prevention

There are no specific preventive measures to Dupuytren'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.