Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Dupuytren Contracture

Basics
Description
  • Dupuytren contracture is a proliferative disorder of subcutaneous palmar fibrous tissue (fascia) that occurs in the form of nodules and cords and results in contractures of the finger joints.
  • It occurs typically in men in the 5th to 7th decades.
  • Younger patients are more likely to have rapid progression of disease with poorer long-term results and frequent recurrences.
  • Aggressive, early onset is seen in a subgroup of patients with Dupuytren diathesis.
  • Synonym: Dupuytren disease
Epidemiology
Incidence
  • Greatest in Northern Europe and in immigrants of Celtic origin
  • Incidence in the United States is 2-3% that of the general population.
  • Hand dominance not a factor
  • More frequent and severe in patients with diabetes
  • Increased incidence in patients with epilepsy and chronic obstructive pulmonary disease
  • Possible link to alcoholism and tobacco is controversial
  • More common in males than in females
  • In females, usually later onset and less severe disease
Risk Factors
  • Caucasian
  • Northern European descent
  • Increased age
  • Family history
Genetics
  • The disorder is autosomal dominant with variable penetrance.
  • Only 10% of patients with Dupuytren contractures have a positive family history.
Etiology
  • Unknown
  • Strong evidence for hereditary factors, possibly through transmission of defective genes responsible for collagen formation
Associated Conditions
  • Alcoholism (controversial)
  • Epilepsy
  • Diabetes
  • Chronic obstructive pulmonary disease
Diagnosis
Signs and Symptoms
  • Usually begins with 1 or more nodules in the palmar fascia of the ring and little finger rays
  • Often associated with skin dimpling over or around the nodules
  • Often bilateral (45%)
  • Rarely symmetric
  • As the disease progresses, the digital fascia becomes involved, usually producing contractures, first of the MCP joints, and then of the PIP joints.
  • Web space contractures can occur.
  • Knuckle pads over the dorsum of the PIP joints are present in ~20% of patients.
    • These usually are unnoticeable, but if large and prominent, they may be painful when hit.
  • In the subgroup of patients with Dupuytren diathesis, the disease involves the hands, feet, and penis.
    • Often associated with knuckle pads, plantar fibromatosis (Ledderhose disease), and penile fibromatosis (Peyronie disease)
Physical Exam
  • The Hueston table-top test is positive when the palm is placed on a flat surface and the digits, because of joint contractures, cannot be simultaneously placed fully on the same surface.
  • A positive test often is an indication for the consideration of surgical management.
Tests
Pathological Findings
  • Histologically, the important cells are the myofibroblasts, which seem to undergo pathologic proliferation.
  • An increase in the ratio of type III to type I collagen is found in Dupuytren disease.
Differential Diagnosis
  • Arthritis
  • Joint capsule contractures
Treatment
General Measures
In the absence of contracture, or when a contracture is progressing slowly and is not disabling, the patient should be observed every 3-6 months.
 
Special Therapy
Physical Therapy
  • The goals are to maintain the extension gained by the surgical procedure and to restore preoperative flexion and function of the hand.
  • A comfortable, well-fitted splint is an important adjunct to therapy.
  • Physical therapists play a major role in recovery, and their programs should stress performance of independent exercises.
Medication (Drugs)
  • Nonoperative management:
    • Vitamin E and splinting have been ineffective.
    • Cortisone injection of nodules that have not yet formed cords has been shown to suppress their development.
    • Injection also may be helpful in treating knuckle pads.
Surgery
  • Not indicated for static, painless nodules and rarely for knuckle pads
  • Early surgical intervention is indicated for any degree of proximal IP joint involvement or in the presence of progression of contracture or loss of function.
  • 5 surgical procedures are used in treating Dupuytren contractures:
    • Subcutaneous fasciotomy
    • Partial (selective) fasciectomy
    • Complete fasciectomy
    • Fasciectomy with skin grafting
    • Amputation
  • To choose the best procedure for a given patient, the clinician must consider:
    • The degree of contracture
    • Patient’s age, occupation, and general health
    • Nutritional status of the palmar skin
    • Presence or absence of arthritis
  • The frequency and duration of splinting after surgery vary with the severity of the disease.
    • A minimum of 3 months usually is required; many patients are instructed to wear a splint at night for up to an additional 3 months.
    • Return to normal activity usually is anticipated within 2-3 months after surgical intervention.
Follow-up
Prognosis
  • The normal postoperative expectation is a full range of flexion and extension in 80% of patients seen primarily.
  • The disease is likely to progress more rapidly and to recur more frequently in young male patients with a strong family history.
  • Patients with epilepsy, diabetes, and alcoholism tend to develop more severe disease.
  • Although long-term recurrence rates vary from 26-80%, often only the young patient with a strong diathesis will need multiple repeat procedures.
Complications
  • Joint stiffness usually can be prevented with early physical therapy and patient education.
  • 1-3% risk of nerve injury during surgery
  • 50% risk of recurrence after 5-10 years
  • Unfortunately, long-term complications often depend on the diathesis of the patient.
Patient Monitoring
  • Patients must be followed closely (each week during the 1st postoperative month) to help assess wound healing and to prevent stiffness.
  • Once healed, follow-up may be on an as-needed basis.
Miscellaneous
Codes
ICD9-CM
728.6 Dupuytren contracture
 
Patient Teaching
  • Patients should be aware that although MCP deformities usually can be corrected surgically, PIP deformities often may not.
  • The patient also must realize that surgery cannot cure Dupuytren disease.
Prevention
No effective means of prevention is known.
 
FAQ
Q: When is surgery indicated for a Dupuytren contracture?
A: Surgery is not indicated unless the patient has a functional disability and progression of the contracture. Typically, surgery is not considered until a >30° contracture is present at the MCP joint and/or some contracture at the PIP joint.
 
Q: Why is recurrence frequent?
A: The goal of surgery is release of contracture. Dupuytren contracture is a genetic condition, and surgery does not alter the genes, so recurrence is to be expected.

Comments are closed.