Dupuytren’s Contracture

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Clinically Relevant Anatomy

Dupuytren contracture is a progressive disease of the palmar fascia which results in shortening, thickening and fibrosis of the fascia and aponeurosis of the palm. The palmar fascia is continuous with the antebrachial fascia, the deep fascia of the forearm, and the layer of fascia that covers the dorsum of the hand. The palmar fascia is thicker in the center of the palm and fingers where it forms the palmar aponeurosis and digital sheaths, respectively. The palmar aponeurosis covers the soft tissues of the palm and long flexor tendons. As the longitudinal bands of the palmar aponeurosis undergo fibrosis, the metacarpophalangeal and proximal interphalangeal joints get pulled into flexion. The fouth metacarpal is most commonly affected, followed by the fifth, third, and second. Recently, Dupuytren disease has become a more widely adopted term than Dupuytren contracture to name this condition, as the fingers are not always held in a fixed flexion deformity.1

Mechanism of Injury/ Pathological Process

The exact etiology of Dupuytren disease is unknown; however, researchers have identified a number of risk factors.3 Dupuytren disease is found most commonly in Caucasians of Northern European descent. The average age of onset of disease is 60 years old, with the incidence increasing with increasing age. Dupuytren disease occurs more often in men than in women, however, the sex difference in prevalence diminishes with increasing age.
Twin and familial studies suggest that Dupuytren disease has a strong genetic component.2 Individuals with a strong family history of Dupuytren disease may develop a more severe form of the disease and experience onset of disease at a younger age. Research studies on the prevalence of Dupuytren disease and phenotype in different ethnic populations also suggest a geographic pattern that is consistent with genetic predisposition.
Numerous environmental factors have been proposed to contribute to the development of Dupuytren disease, however, evidence for the association between Dupuytren disease prevalence and some of the environmental factors is conflicting.2 The proposed environmental risk factors include alcohol intake, smoking, manual labor or exposure to vibrations, elevated blood glucose levels, low body weight, low body mass index, and the use of anticonvulsant drugs. Dupuytren disease has also been associated with several other diseases, including epilepsy, diabetes mellitus, HIV, frozen shoulder, and cancer.

Clinical Presentation

Dupuytren contracture occurs slowly and typically progresses over the course of several years, but can also develop more rapidly over weeks or months.3 It typically affects older men of European decent. This condition most commonly begins with thickening of the skin on the palm, resulting in a puckering or dimpled appearance. As the condition progresses, bands of fibrotic tissue form in the palmar area and may travel distal toward the fingers. This tightening and shortening eventually leads to the affected fingers being pulled into flexion. Dupuytren contracture typically occurs bilaterally, with one hand being more severely affected than the other.

Diagnostic Procedures

Diagnosis of Dupuytren disease can be done by physical examination and measurement of the degree of flexion contracture by goniometry.4 Several features of Dupuytren disease should be noted upon physical examination, including: sites of nodules and bands or contracted cords, skin pitting, degree of skin involvement, measurement of the angle between the metacarpophalangeal and proximal interphalangeal joints, presence of any surgical scarring, and sensation in the palm and digits.

The degree of flexion contracture in the affected digit or digits can be measured with a goniometer (Hindocha). Tubiana created a staging system which uses the measurement of flexion contracture of an affected digit to determine the severity of Dupuytren disease; stage 1 indicates the least severe flexion contracture deformity while stage 4 indicates the most severe flexion contracture deformity.

Dupuytren disease severity can also be determined using the Hueston tabletop test (Barbara Shih). The Hueston tabletop test is performed to help determine if a contracture of the hand exists (Mayo). The test is performed by having the patient lie their hand down on a table with the palmar surface down. If it is possible for the patient to lie their hand down flat, then a contracture does not exist.

Outcome Measures

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Management / Interventions

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Differential Diagnosis

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Key Evidence

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Resources

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Case Studies

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References

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