Dupuytren's contracture

Question 1

Describe Dupuytren’s contracture.

Answer 1

A benign, progressive fibroproliferative disorder of the fascia of the hands and fingers that can lead to disabling contractures

Question 2

What is the pathophysiology of Dupuytren’s contracture.

Answer 2

Excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia. The resultant digital flexion contractures may severely limit function

Question 3

What is the genetic link to Dupuytren’s contracture?

Answer 3

Believed to show autosomal dominant inheritance - ?16q mapping

Question 4

How common is DC?

Answer 4

Common

The overall prevalence in the UK is about 4%, increasing to about 20% in those aged over 65 years.

M>F 6:1

Question 5

What are the risk factors for Dupuytren’s contracture?

Answer 5

• Age >40yrs
• Male sex
• FH
• DM

Other:

• Smoking
• Alcohol excess
• Occupational exposure to hand-transmitted vibration
• Raised lipids
• Anticonvulsant medication

Question 6

What are the clinical features of DC?

Answer 6

• Difficulties with manual activities e.g. face washing, combing, putting hands in gloves
• Nodules in distal palmar crease- over the metacarpal head at the level of the distal palmar crease, proximal to MCPJ
• Skin thickening
• Cords - longitudinal thickenings
• PIPJ contracture
• Positive Hueston table-top test
• Bilateral involvement common
• Peyronie’s disease and Ledderhose’s disease may co-exist
• Garrod’s nodes

Question 7

What is Ledderhose’s disease?

Answer 7

Thickening of the ligaments of the bottom of the foot

Question 8

What is Peyronie’s disease?

Answer 8

Fibrous scar tissue develops on the penis and causes curved, painful erections.

Question 9

What is shown?

Answer 9

Garrod’s nodes AKA knuckle pads - found in half of patients with Dupuytren’s contracture

Question 10

What is the Hueston table-top test?

Answer 10

Involves the patient attempting to lay the palm of the hand flat on a table surface.

The result is positive if the patient is unable to flatten the hand on the table.

Question 11

What is the management of Dupuytren’s contracture?

Answer 11

If contracture or loss of function:

• Refer to local hand surgery service (plastic surgery/orthopaedics) - surgery considered when MCPJ is bent 30-45° and cannot be straightened; or PIPJ is bent permanently by 10-20°
• Conservative:
  
  • • Medical:
  • Corticosteroid injections
  • Collagenase injections
• Surgical:
  
  • Closed fasciotomy/percut needle fasiotomy/ needle aponeurotomy
  • Fasciectomy
  • Rarely: finger amputation

If no contracture or no loss of function:

• Conservative:
  
  • Expectant management - reassure that pain from nodules should improve over time. No need to refer if no contracture. Regular followup every 6 months.
  • Radiotherapy - preventative
  • Not recommended: splinting or stretching and corticosteroids
• Medical:
  
  • Corticosteroid injections
    *

Question 12

What is shown?

Answer 12

Incision type commonly used for Dupuytren’s contracture surgery - a transverse incision overlying the distal palmar crease, and oblique Brunner incisions coursing from it proximally and distally

Question 13

What is the prognosis with Dupuytren’s contracture?

Answer 13

Progressive

Men progress faster than women - smoking and alcohol increases risk of this

Question 14

What is the difference between Dupuytren’s and trigger finger?

Answer 14

Unlike a finger which is bent due to trigger finger, a finger bent by Dupuytren’s contracture is unable to straighten, even with help from the other hand