Dupuytren contracture is progressive contracture of the palmar fascial bands, causing flexion deformities of the fingers. Treatment is with corticosteroid injection, surgery, or injections of clostridial collagenase.
(See also Overview and Evaluation of Hand Disorders.)
Dupuytren contracture is one of the more common hand deformities; the incidence is higher among men and increases after age 45. This autosomal dominant condition with variable penetrance may occur more commonly among patients with diabetes, alcoholism, or epilepsy. However, the specific factors that cause the palmar fascia to thicken and contract are unknown.
Symptoms and Signs of Dupuytren Contracture
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The earliest manifestation is usually a tender nodule in the palm, most often near the little or ring finger; it gradually becomes painless. Next, a superficial cord forms and contracts and ultimately flexes the metacarpophalangeal (MCP) joints and interphalangeal joints of the fingers. The hand eventually becomes arched. The disease is occasionally associated with fibrous thickening of the dorsum of the proximal interphalangeal (PIP) joints (Garrod pads), Peyronie disease (penile fibromatosis) in about 7 to 10% of patients, and rarely nodules on the plantar surface of the feet (plantar fibromatosis).
Other types of flexion deformities of the fingers can also occur in diabetes, locked trigger fingers, an ulnar claw hand, systemic sclerosis, and chronic reflex sympathetic dystrophy, which need to be differentiated.
Treatment of Dupuytren Contracture
Corticosteroid injection (before contractures develop)
Surgery for disabling contractures
Injection of clostridial collagenase for certain contractures
Injection of a corticosteroid suspension into the nodule may relieve local tenderness if begun before contractures develop. However, this tenderness is self-limiting and often resolves with no intervention.
If the hand cannot be placed flat on a table or, especially, when significant contracture develops at the proximal interphalangeal (PIP) joints, surgery is usually indicated. Surgical options include percutaneous needle fasciotomy, temporary application of a dynamic external fixator for PIP joint contractures, and open palmar/digital fasciectomy. For severe disease with multiple finger involvement, open surgery with excision of the diseased fascia is the best treatment; excision must be meticulous because the tissue surrounds neurovascular bundles and tendons. Incomplete excision or new disease results in recurrent contracture, especially in patients who are young at disease onset or who have a family history, Garrod pads, Peyronie disease, or plantar foot involvement.
Injectable collagenase may reverse some contractures (1, 2), particularly those at the MCP joint. Collagenase injections and surgical fasciectomy result in similar improvements at the MCP joint, but injections lead to more rapid recovery with fewer early complications (3). However, when comparing midterm results (2 to 5 years after treatment) of collagenase injection, percutaneous needle fasciotomy, and surgical fasciectomy, injections had the highest recurrence rate requiring reintervention, whereas surgery had the lowest rate of recurrent contractures.
Довідкові матеріали щодо лікування
1. Hurst LC, Badalamente MA, Hentz VR, et al: Injectable collagenaseClostridium histolyticum for Dupuytren's contracture. N Engl J Med 361(10):968–979, 2009. doi: 10.1056/NEJMoa0810866.
2. Witthaut J, Jones G, Skrepnik N, et al: Efficacy and safety of collagenaseClostridium histolyticum injection for Dupuytren contracture: Short-term results from 2 open-label studies. J Hand Surg Am 38(1):2–11, 2013. doi: 10.1016/j.jhsa.2012.10.008.
3. Zhou C, Hovius SE, Slijper HP, et al: CollagenaseClostridium histolyticum versus limited fasciectomy for Dupuytren's contracture: Outcomes from a multicenter propensity score matched study. Plast Reconstr Surg 136(1):87–97, 2015. doi: 10.1097/PRS.0000000000001320.