Dupuytren's Disease

Aka: Dupuytren's Disease, Dupuytren's Contracture

1. Definition
   1. Idiopathic contractures of the palmar fascia
2. Epidemiology
   1. Onset after age 40 years
   2. More common in men
   3. Highest Incidence regions
      1. Northern Scotland
      2. Iceland
      3. Norway
      4. Australia
3. Risk Factors
   1. Diabetes Mellitus (comorbid in 3-33% of diabetes)
      1. Mild cases with slow progression
   2. Increased weekly Alcohol intake
      1. Dupuytren's does not suggest Alcoholism
   3. Tobacco use
   4. Trauma (inconsistent association from studies)
   5. Anticonvulsants (inconsistent association from studies)
4. Pathophysiology
   1. Progressive contractures of the palmar fascia
      1. Proliferating vascular fibrous tissue
      2. Collagen formation
   2. Results in flexion deformity of distal palm and fingers
   3. Unknown underlying etiology
   4. Often bilateral
   5. Autosomal Dominant inheritance, incomplete penetrance
5. Associated Conditions: Other fibrous contractures
   1. Plantar Fibromatosis
   2. Peyronie's Disease
6. Signs
   1. Distribution
      1. Fourth finger (most commonly involved)
      2. Fifth finger
      3. Third finger
      4. Second finger (least commonly involved)
   2. Initial: Isolated Nodule at finger forms
      1. Nodule hardens under distal palm
      2. Nodule eventually resorbs
   3. Next: Overlying skin adheres to fascia
      1. Strong fibrous cord develops and extends into finger
      2. Cord contracts and pulls finger into flexion
   4. Last: Deformity contracture of fingers
      1. Interference with hand use by contracted fingers
   5. Hueston tabletop test
      1. Patient unable to lay palm flat on tabletop
7. Grading
   1. Grade 1: Thickened Nodule/band in palmar aponeurosis
   2. Grade 2: Peritendinous band; limited finger extension
   3. Grade 3: Flexion contracture of finger
8. Management: Conservative (Grade 1)
   1. StretchingExercises
   2. Dupuytren's Nodule Corticosteroid Injection
9. Management: Hand surgery
   1. Indications for hand surgery referral
      1. Impaired function
      2. Progressive contracture or disabling deformity
      3. MCP contracture >30 degrees of flexion
      4. PIP contracture of any degree
   2. Surgical correction is ultimately needed in most cases
      1. If corrected early, complete extension is expected
      2. Fasciotomy indications
         1. MCP contracture >40 degrees
         2. PIP contractures >20 degrees
   3. Surgical procedures
      1. Incisional Fasciotomy
      2. Percutaneous Needle Fasciotomy (common in Europe)
         1. In-Office procedure under Local Anesthesia
         2. Foucher (2003) J hand Surg 28:427-31 [PubMed]
10. Prognosis
    1. Typical course is gradual progressive worsening
    2. Regresses spontaneously in 10% of cases
    3. Worse prognosis factors (faster or severe progression)
       1. Age under 50 years
       2. Tobacco use
       3. Alcohol use
    4. Worse prognosis following surgery
       1. PIP joint contractures
       2. Prognosis worsens the longer a deformity is present
11. References
    1. Bayat (2006) Ann R Coll Surg Engl 88:3-8 [PubMed]
    2. Thurston (2003) J Bone Joint Surg Br 85:469-77 [PubMed]
    3. Trojian (2007) Am Fam Physician 76:86-90 [PubMed]