Updated: 2/13/2020

Dupuytren Contracture

Topic
Review Topic
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Snapshot
  • A 60-year-old man presents to his physician for palmar contractures. He reports that his hand appears "deformed" and denies any pain. His past medical history is significant for alcoholic cirrhosis. Physical exam reveals thickened skin on his palms, contractures of his fourth and fifth fingers bilaterally, and several non-tender palmar nodules. He is counseled on this condition and he opts to try injected collagenase.
Introduction
  • Clinical definition
    • a benign fibroproliferative disorder characterized by contracture of the palms and palmar nodules
  • Epidemiology
    • demographics
      • male > female
      • onset typically after 60 years of age
      • northern European descent
    • risk factors
      • increasing age
      • family history
      • diabetes
      • alcohol
      • smoking
  • Pathogenesis
    • the exact pathogenesis is unknown but it may involve oxidative stress, impaired wound healing, and an abnormal immune response, resulting in hyperplasia of the palmar fascia
  • Associated conditions
    • alcoholic cirrhosis
  • Prognosis
    • typically progressive in severity
    • 10% of cases will spontaneously resolve
    • recurrence after treatment is high
Presentation
  • Symptoms
    • painless nodules on palms
    • contractures may limit function
      • patients often have difficulty wearing gloves or doing household chores like washing dishes or cleaning
  • Physical exam
    • thickened palmar skin with pitting, dimpling, or scarring
    • palmar fascial nodules
    • palmar fascial cords with tight bands
    • contracture of the fourth and fifth fingers and inability to extend those fingers
    • commonly bilateral
    • tabletop test
      • positive if the patient is unable to lay their palm completely flat against the table
Studies
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Trigger finger
    • distinguishing factors
      • painful contracture of the affected digit
      • clicking or locking of the digit
Treatment
  • Management approach
    • first-line therapies include injected collagenase and/or steroids
      • the patient and physician decide together which first-line therapy is used
  • Medical
    • injected collagenase (enzymatic fasciotomy)
      • indication
        • a first-line agent to reduce the contracture and restore function in the hands
    • injected steroids
      • indication
        • a first-line agent to reduce the contracture and restore function in the hands
      • outcome
        • recurrence is high
  • Operative
    • fasciotomy or fasciectomy
      • indications
        • if patients are refractory to first-line therapies
        • if the contracture causes impaired function
Complications
  • Limited function of the affected hand(s)

References

 

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