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Dupuytren contracture

A disorder of the palmar fascia characterized by flexion deformity of the 4th & 5th digits. Etiology: - unknown - associated with - occupations involving repetitive motion or vibration - diabetes mellitus - complex regional pain syndrome - alcohol use disorder = cigarette smoking Epidemiology: 1) most common age 40-60 2) male:female ratio 10:1 3) Scandanavians & northern Europeans Pathology: 1) modular fibroblast proliferation 2) thickening & shortening of the fibrous bands on the palmar surface of the hands & fingers 3) progressive fibrosis of the palmar fascia [7] Clinical manifestations: 1) generally asymptomatic, develops over decades 2) flexion deformity & interference with use of hands 3) ring finger most commonly affected - most commonly involves the third, fourth, & fifth fingers [7] 4) isolated painless nodules harden & mature into a cord 5) generally begins distal to the palmar crease - earliest sign is puckering of the skin over the flexor tendon in the palm [7] 6) overlying skin becomes adherent to fascia 7) contraction of fibrous cord pulls finger into flexion 8) 5th finger generally 2nd finger involved 9) soft tissue pads in knuckles may occur Differential diagnosis: 1) soft tissue tumor 2) tendon cyst Complications: 1) 5% of patients develop similar condition elsewhere a) Peyronie's disease b) Ledderhose disease Management: 1) stretching exercises 2) local heat 3) surgery*: fasciectomy (contraction or pain) [5] - limited fasciectomy favored over collagenase injections [6] 4) collagenase injections: a) collagenase clostridium histolyticum b) 0.58 mg into the contracted collagen cord c) injections every 30-day intervals d) joint manipulation one day after injection 5) needle fasciotomy * surgery more successful than collagenase injections or needle fasciotomy (78% vs 65%) [4]

General

joint contracture

References

  1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999.
  2. Ferri's Clinical Advisor, Instant Diagnosis and Treatment, Ferri FF (ed), Mosby, Philadelphia, 2003
  3. Hurst LC et al, Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture N Engl J Med 2009, 361:968-979 PMID: 19726771 http://content.nejm.org/cgi/content/short/361/10/968
  4. Raisanen MP et al. Surgery, needle fasciotomy, or collagenase injection for Dupuytren contracture: A randomized controlled trial. Ann Intern Med 2024 Feb 13; [e-pub]. PMID: 38346307 https://www.acpjournals.org/doi/10.7326/M23-1485
  5. International Dupuytren Society Techniques of hand surgery http://www.dupuytren-online.info/dupuytren_surgery_techniques.html
  6. Dias J, Tharmanathan P, Arundel C et al. Collagenase injection versus limited fasciectomy for Dupuytren's contracture. N Engl J Med 2024 Oct 9:10.1056/NEJMoa2312631 PMID: 39383454 PMCID: PMC7616701 Free PMC article. https://www.nejm.org/doi/10.1056/NEJMoa2312631
  7. Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025