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173: DUPUYTREN CONTRACTURE

Eric Shamus, PhD, DPT, PT, CSCS; George Hanbury, PhD

CONDITION/DISORDER SYNONYMS

  • Morbus Dupuytren

  • Dupuytren disease

  • Palmar fasciitis

  • Palmar fibromatosis

ICD-9-CM CODE

  • 728.6 Contracture of palmar fascia

ICD-10-CM CODE

  • M72.0 Palmar fascial fibromatosis [Dupuytren]

PREFERRED PRACTICE PATTERN

  • 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction1

PATIENT PRESENTATION

A 53-year-old man presents with stiffness in his hands. He says his hand began to feel stiff several years ago, and now he finds that he cannot straighten many of his fingers. He delayed seeing a physician because he did not feel any pain in his hands. He recently began having difficulty holding his woodworking tools and wants to regain the function he has lost in his hands.2

KEY FEATURES

Description

  • Usually painless thickening of the fascia, contraction of palmar fascia (aponeurosis)

  • Nodules develop along longitudinal tension lines

  • Characterized by development of nodules in the palmar and digital fascia

  • Can be associated with other fascial contractures

    • Feet (Ledderhose disease), callus under foot with curling of toes

    • Penis (Peyronie disease), curvature

    • Garrod knuckles, pads on back of finger knuckles

  • Named after Baron Guillaume Dupuytren

  • Viking disease

Essentials of Diagnosis

  • Classified into three biologic stages:

    • First stage (proliferative stage): Intense proliferation of myofibroblasts (cells believed to generate the contractile forces responsible for tissue contraction) and formation of nodules

    • Second stage (involutional stage): Represented by alignment of the myofibroblasts along lines of tension

    • Third stage (residual stage): Tissue becomes mostly acellular and devoid of myofibroblasts, only thick bands of collagen remain

General Considerations

  • Not usually associated with trauma, but can develop

  • after surgery

  • Unknown etiology, possibly autoimmune

  • Usually bilateral with one side more severely affected

  • Early stages based on palpable nodule, characteristic skin changes, changes in fascia, progressive joint contracture

  • Skin changes caused by a retraction of skin, creating dimples or pits

Demographics

  • Caucasian with Scandinavian/Northern European decent

  • Usually associated with family history

  • Rare with children

  • Men 7 to 15 times more likely than women to require surgery

  • Females develop less severe cases

  • Incidence increases with age >40 years

  • Higher incidence among people with alcoholism, diabetes, epilepsy

CLINICAL FINDINGS

SIGNS AND SYMPTOMS

  • Thickening and shortening of fascia of the hand

  • Contractures form at metacarpophalangeal (MCP), proximal interphalangeal (PIP), and occasionally distal interphalangeal (DIP) joints

  • Fifth finger involved in 70% of cases

Functional Implications

  • Limitation in opening hand, extending fingers fully

  • Can limit ability to shake hands

Possible Contributing Causes

  • Smoking may decrease vascular changes in the hands

  • Alcoholism3

  • Epilepsy4

  • Pulmonary tuberculosis5

  • Diabetes

  • Liver disease or cirrhosis

    • Heredity: heterogeneous

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