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Dupuytren Contracture

(Palmar Fibromatosis)

by David R. Steinberg, MD

Dupuytren contracture is progressive contracture of the palmar fascial bands, causing flexion deformities of the fingers.

Dupuytren contracture is one of the more common hand deformities; the incidence is higher among men and increases after age 45. This autosomal dominant condition with variable penetrance may occur more commonly among patients with diabetes, alcoholism, or epilepsy. However, the specific factors that cause the palmar fascia to thicken and contract are unknown.

Symptoms and Signs

The earliest manifestation is usually a tender nodule in the palm, most often near the middle or ring finger; it gradually becomes painless. Next, a superficial cord forms and contracts the metacarpophalangeal (MCP) joints and interphalangeal joints of the fingers. The hand eventually becomes arched. The disease is occasionally associated with fibrous thickening of the dorsum of the proximal interphalangeal (PIP) joints (Garrod pads), Peyronie disease (penile fibromatosis) in about 7 to 10% of patients, and rarely nodules on the plantar surface of the feet (plantar fibromatosis). Other types of flexion deformities of the fingers can also occur in diabetes, systemic sclerosis, and chronic reflex sympathetic dystrophy, which need to be differentiated.

Treatment

  • Corticosteroid injection (before contractures develop)

  • Surgery for disabling contractures

  • Injection of clostridial collagenase for certain contractures

Injection of a corticosteroid suspension into the nodule may relieve local tenderness if begun before contractures develop. However, this tenderness is self-limiting and often resolves with no intervention. If the hand cannot be placed flat on a table or, especially, when significant contracture develops at the PIP joints, surgery is usually indicated. Surgical options include percutaneous needle fasciotomy, temporary application of a dynamic external fixator for PIP joint contractures, and open palmar/digital fasciectomy. For severe disease with multiple finger involvement, open surgery with excision of the diseased fascia is the best treatment; excision must be meticulous because the tissue surrounds neurovascular bundles and tendons. Incomplete excision or new disease results in recurrent contracture, especially in patients who are young at disease onset or who have a family history, Garrod pads, Peyronie disease, or plantar foot involvement. Injectable collagenase may reverse some contractures, particularly those at the MCP joint.

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