Dupuytren’s contracture

• Morbus Dupuytren
• Dupuytren's disease
• Palmar fasciitis
• Palmar fibromatosis

• 728.6 Contracture of palmar fascia

• M72.0 Palmar fascial fibromatosis [Dupuytren]

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

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's disease), curvature
  • Garrod’s 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

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 grasping, opening hand, extending fingers fully
• Can limit ability to shake hands

Possible Contributing Causes

• Smoking may decrease vascular changes in the hands
• Alcoholism
• Epilepsy
• Pulmonary tuberculosis
• Diabetes
• Liver disease or cirrhosis
• Heredity

Differential Diagnosis

• Dupuytren's constricture; a fixed-flexioncontracture of the hand

Diagnostic Procedures

• Visual and palpation for thickened scar tissue (fibrosis)
• Tabletop test; negative if able to lay hand flat on a table, palm down

Medication

• Enzyme injection; collagenase clostridium
• Histolyticum to soften and break down taught bands

• To hospital for surgery to release fascia
• For acupuncture
• To physician for enzyme injection of the collagen-eroding enzyme collagenase
• To physician for radiotherapy, radiation therapy (low energy x-rays)
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