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'''Original Editor '''- [[User:Gwen Fritsche|Gwen Fritsche]] and [[User:Lauren Leimbach|Lauren Leimbach]] from [[Temple University Evidence-Based Practice Project|Temple University's Evidence Based Practice Project]]  
'''Original Editor ''' - [[User:Gwen Fritsche|Gwen Fritsche]] and [[User:Lauren Leimbach|Lauren Leimbach]] from [[Temple University Evidence-Based Practice Project|Temple University's Evidence Based Practice Project]]  


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== Clinically Relevant Anatomy<br> ==
== Introduction ==


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 fourth 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.<ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref><br>
Dupuytren contracture is a benign, progressive disease of the palmar fascia which results in shortening, thickening, and fibrosis of the fascia and aponeurosis of the palm driven by myofibroblastic proliferation.<ref>E Soreide, M H Murad, J M Denbeigh, E A Lewallen, A Dudakovic, L Nordsletten, A J van Wijnen, S Kakar.Treatment of Dupuytren's contracture: a systematic review.PubMed.gov.National Library of Medicine. National Centre for Biotechnology Information.2018 Sep;100-B(9):1138-1145.doi: 10.1302/0301-620X.100B9.BJJ-2017-1194.R2.</ref>


[[Image:Cord.jpg|center|400x400px|Image 1: Clinical presentation of Dupuytren contracture]]  
[[Image:Cord.jpg|400x400px|Image 1: Clinical presentation of Dupuytren contracture|right|frameless]]
* Dupuytren disease is predominantly a myofibroblastic disease that affects the hand/fingers and results in contracture deformities.
* Commonly affected digits are those farthest from the thumb i.e. the fourth (ring) and fifth (pinky) digits.
* The disease begins in the palm as painless nodules that form along longitudinal lines of tension.
* The nodules form cords that produce contracture deformities within fascial bands and tissues of the hand.
* Dupuytren contracture is usually seen in Caucasians and the disorder often presents bilaterally. When unilateral, the right side is more likely to be involved compared to the left.
* In many individuals, there is a family history with males being more susceptible to the condition than females.<ref name=":0" /><ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref><br>
Image 1: Clinical presentation of Dupuytren contracture<ref>Dupuytren’s Disease. American Society for Surgery of the Hand Web site. http://www.assh.org/Public/HandConditions/Pages/DupuytrensDisease.aspx. 2010. Accessed March 19, 2011.</ref>


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 1: Clinical presentation of Dupuytren contracture<ref>Dupuytren’s Disease. American Society for Surgery of the Hand Web site. http://www.assh.org/Public/HandConditions/Pages/DupuytrensDisease.aspx. 2010. Accessed March 19, 2011.</ref>  
=== Etiology ===
Dupuytren disease is a genetic disorder expressed in an autosomal dominant fashion, but most frequently seen with a multifactorial etiology. It is associated with diabetes, seizure disorders, smoking, alcoholism, HIV, and vascular disease<ref name=":1">Walthall J, Anand P, Rehman UH. [https://www.ncbi.nlm.nih.gov/books/NBK526074/ Dupuytren Contracture]. StatPearls [Internet]. 2020 Sep 14.</ref>.


== Mechanism of Injury/ Pathological Process  ==
Ectopic manifestations beyond the hand can be seen in [[Plantar Fibromatosis]] (plantar fascia), 10% to 30%; Peyronie disease (Dartos fascia of the penis), 2% to 8%; and Garrod disease (dorsal knuckle pads), 40% to 50%.<ref name=":1" />


The exact etiology of Dupuytren disease is unknown; however, researchers have identified a number of risk factors.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> 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.  
==== Epidemiology ====
This condition is common in populations of Northern European/Scandinavian descent.  It is relatively uncommon in Southern European and South American populations and is rare in Africans and Asians. The disease affects men more severely than women. Males are affected by a 2:1 ratio compared to women. Younger age of onset is also associated with increased severity of disease progression. In Asian populations, the palm is more likely to be involved than the digits and thus often goes unnoticed.<ref name=":1" />


Twin and familial studies suggest that Dupuytren disease has a strong genetic component.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> 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.  
=== Pathological Process  ===
The pathophysiology of Dupuytren disease involves abnormal myofibroblastic growth in the hand.
* Type III collagen predominates, which under a non-disease state would be Type I collagen.  
* Dupuytren contracture progresses through three phases: (1) proliferative, (2) involution, and (3) residual. The proliferative phase has a characteristically high concentration of immature myofibroblasts and fibroblasts arranged in a whorled pattern. In the involution phase, fibroblasts become aligned in the longitudinal axis of the hand following lines of tension. In the residual phase, relatively acellular collagen-rich chords remain causing contracture deformity.
* The disorder is not always progressive and in at least 50-70% of patients, it may stabilize or even regress.
Several cords can develop which can cause unique deformities of the hand.
* Pretendinous cords cause skin pitting and metacarpal phalangeal (MCP) joint contracture.
* Natatory cords are responsible for webspace contractures.
* Spiral cords are the most important in the disease process and can cause proximal interphalangeal (PIP) contracture.
Risk factors for increased severity and recurrence of disease after treatment include- male gender; onset before age 50; bilateral disease; sibling/parent involvement; the presence of Garrod pads, Ledderhose, or Peyronies diseases.<ref name=":0">Walthall J, Rehman UH. [https://www.ncbi.nlm.nih.gov/books/NBK526074/ Dupuytrens Contracture.] InStatPearls [Internet] 2019 Feb 19. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK526074/ (last accessed 4.4.2020)</ref>


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.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> 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. <br>
==== Clinical Presentation  ====


[[Image:Risk Factors Dupuytren.jpg|center|Image 2: Risk factors of Dupuytren disease]]
Dupuytren contracture occurs slowly and typically progresses over the course of several years, but can also develop more rapidly over weeks or months.<ref name="Mayo Clinic">Mayo Foundation for Education and Research. The Dupuytren's Contracture Page. http://www.mayoclinic.com/health/dupuytrens-contracture/DS00732. Updated May 15, 2010. Accessed March 14, 2011.</ref> 


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 2: Risk factors of Dupuytren disease<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref>
[[Image:Pit Nodule.jpg|400x400px|Image 3: Skin pitting and the presence of nodules in Dupuytren disease|right]]It typically affects older men of European descent. 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 distally toward the fingers. This tightening and shortening eventually lead to the affected fingers being pulled into flexion. Dupuytren contracture typically occurs bilaterally, with one hand being more severely affected than the other.  


== Clinical Presentation  ==
Physical findings:
* Blanching of the skin when the finger is extended
* Proximal to the nodules, the cords are painless
* Pits and grooves may be present
* The knuckle pads over the PIP joints may be tender
* If the plantar fascia is involved, this indicates a more severe disease ([[Plantar Fibromatosis]])
* The patient may not be able to place the palm flat on the table<ref name=":0" />


Dupuytren contracture occurs slowly and typically progresses over the course of several years, but can also develop more rapidly over weeks or months.<ref name="Mayo Clinic">Mayo Foundation for Education and Research. The Dupuytren's Contracture Page. http://www.mayoclinic.com/health/dupuytrens-contracture/DS00732. Updated May 15, 2010. Accessed March 14, 2011.</ref> 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  =====
* [[X-Rays|X-rays]] of the hand should be obtained to examine for other contributing, bony abnormalities that may contribute to the loss of range of motion.
* Laboratory workup to rule out diabetes is recommended.
* [[Ultrasound Scans|Ultrasound]] may demonstrate thickened palmar fascia and the nodules.<ref name=":0" />


== Diagnostic Procedures  ==
==== Differential Diagnosis ====
Dupuytren disease should be distinguished from other diseases of the hand including stenosing flexor tenosynovitis, [[Ganglion Cyst|ganglion cysts]], and soft tissue masses<ref name=":0" />.


Diagnosis of Dupuytren disease can be done by physical examination and measurement of the degree of flexion contracture by goniometry.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> 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.  
===== Outcome Measures  =====
[[File:Patient reported outcome measure.jpg|right|frameless|200x200px]]
* Range of motion measurements of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints should be recorded ( flexion and extension of these joints, with measurements of passive and active range of motion). Take as a baseline measure and then throughout the treatment process, can help stage the severity of the contractures.


[[Image:Pit Nodule.jpg|center|400x400px|Image 3: Skin pitting and the presence of nodules in Dupuytren disease]]  
* Measure hand function by tests and measures such as eg Disabilities of the Arm, Shoulder, and Hand Questionnaire ([[DASH Outcome Measure|The DASH]]), or its shorter version The Quick Dash. 


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 3: Skin pitting and the presence of nodules in Dupuytren disease<ref>Dupuytren’s Disease. American Society for Surgery of the Hand Web site. http://www.assh.org/Public/HandConditions/Pages/DupuytrensDisease.aspx. 2010. Accessed March 19, 2011.</ref>
=== Medical Management  ===


The degree of flexion contracture in the affected digit or digits can be measured with a goniometer.<ref name="Hindocha et al">Hindocha S, Stanley JK, Watson JS, Bayat A. Revised Tubiana’s staging system for assessment of disease severity in Dupuytren’s disease – preliminary clinical findings. Hand. 2008;3:80-86.</ref> 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.  
Indications for treatment are based on the effects of disease on the patient's quality of life. Many patients with a positive tabletop test, MCP contracture of 30 degrees, or PIP contracture of 15 to 20 degrees will elect to have treatment.  


[[Image:Tubiana's Staging.jpg|center|Image 4: Tubiana's Staging System of Dupuytren disease]]
Treatment options consist of observation, needle aponeurotomy, collagenase injection, and/or surgical resection and fasciectomy.


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 4: Tubiana's Staging System of Dupuytren disease<ref name="Hindocha et al">Hindocha S, Stanley JK, Watson JS, Bayat A. Revised Tubiana’s staging system for assessment of disease severity in Dupuytren’s disease – preliminary clinical findings. Hand. 2008;3:80-86.</ref>  
Observation is appropriate for individuals with painless stable disease and no impairment in function. Follow up every 6 months may be done to assess the progression of the disorder.
* Physical and occupational therapy including ultrasound waves and [[Thermotherapy|heat]] can help during the early stage of the disease. Some patients may also benefit from a brace/[[splint]] to stretch the digits. The range of motion of the fingers is necessary to prevent adhesions.
* Corticosteroid injections may be beneficial for some patients eg those with painful nodules. Steroid injections do not work in all patients and a 50% recurrence has been reported. Corticosteroid injections can lead to fat atrophy, pigmentation change and there is the potential to cause rupture of the tendons.
* Other treatments that have been tried include-tamoxifen; anti-tumor necrosis factor agents; 5 fluorouracil, imiquimod; botulinum toxin. No evidence exists to say any of these treatments are superior or work for everyone.
* Radiation therapy may be beneficial during the early phase of the disease but has associated complications. It aims to slow down or halt the abnormal cell growth, being particularly effective when finger bending is minimal. A review of several studies indicated varied responses; some patients saw no change or improvement, while others experienced disease progression​<ref>Kadhum M, Smock E, Khan A, Fleming A. Radiotherapy in Dupuytren’s disease: a systematic review of the evidence. Journal of Hand Surgery (European Volume). 2017 Sep;42(7):689-92.</ref>. A long-term study revealed many patients remained stable or even improved, with minor late side effects like skin atrophy and dry skin being observed in some patients, yet no increased cancer risk was noted​<ref>Betz N, Ott OJ, Adamietz B, Sauer R, Fietkau R, Keilholz L. Radiotherapy in early-stage Dupuytren's contracture. Strahlentherapie und Onkologie. 2010 Feb 1;186(2):82.</ref>​. However, more research is needed to fully grasp the treatment's benefits and risks<ref>Solie P, Stump B, Cashner C, Lenards N, Hunzeker A, Zeiler S. A case study of radiotherapy treatment for Dupuytren's contracture and Ledderhose disease. Medical Dosimetry. 2023 Apr 12.</ref>​.[[Image:Collagenase Treatment.jpg|Image 6: Before and after collagenase treatment|right|frameless]]
* Needle aponeurotomy is typically reserved for mild contractures. The procedure is minimally invasive and is often performed in an office setting.
* Collagenase injections provide a minimally invasive treatment derived from Clostridium histolyticum. Night extension splinting is maintained for 6 months. Collagenase injections result in a 75% contracture reduction with a 35% recurrence rate. Complications include edema, skin tearing, tendon rupture, [[Complex Regional Pain Syndrome (CRPS)|complex regional pain syndrome]], and pulley rupture. Before and after collagenase treatment image at R <ref name="Harvard University">Harvard University. Nonsurgical approach unlocks contracted fingers. Harvard Women’s Health Watch. 2009:6-7.</ref>
* Surgical fasciectomy can be either limited or radical. The recurrence rate at 1 to 2 years is 30%, 15% at 3 to 5 years, and less than 10% after ten years.
* Total palmar fasciectomy can also be performed but is infrequently used as it requires resection of all palmar and digital fascia, including nondiseased tissue.  
* Complications of fasciectomy include skin necrosis, hematoma (most common complication), flare reaction, neurovascular injury, digital ischemia, swelling, and infection.  
Irrespective of the treatment, recurrence is common with all of them, approaching 20-50% at 5 years.<ref name=":0" />  


Dupuytren disease severity can also be determined using the Hueston tabletop test.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> The Hueston tabletop test is performed to help determine if a contracture of the hand exists. The test is performed by having the patient lie their hand down on a table with the palmar surface down.<ref name="Mayo Clinic">Mayo Foundation for Education and Research. The Dupuytren's Contracture Page. http://www.mayoclinic.com/health/dupuytrens-contracture/DS00732. Updated May 15, 2010. Accessed March 14, 2011.</ref> If it is possible for the patient to lie their hand down flat, then a contracture does not exist. <br>
==== Physical Therapy Management ====


== Outcome Measures  ==
===== Conservative Approach =====
Physical therapy may include [[Therapeutic Ultrasound|ultrasound]] waves: heat (early stage of the disease); brace/splint to stretch the digits; a range of motion of the fingers to prevent adhesions.
[[File:Power web WB.jpg|right|frameless]]


Because flexion contractures of the fingers are one of the primary impairments of Dupuytren disease, range of motion measurements of the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints should be recorded. This can include flexion and extension of these joints, with measurements of passive and active range of motion. These measurements should be taken as a baseline measure and then throughout the treatment process, as they can also be used to help stage the severity of the contractures.  
=== Postoperative Care/Rehabilitation ===
Patients often enter hand therapy to :
* Maintain the range of motion of the hand and fingers is important (for many activities of daily living), see [[Hand Exercises|hand exercises]]
* Extension splints often are used in conjunction with other modalities.
* Odema and [[Friction Massage|scar interventions]].<ref name="Engstrand et al">Engstrand C, Boren L, Liedberg GM. Evaluation of activity limitation and digital extension in Dupuytren’s contracture three months after fasciectomy and hand therapy interventions. J Hand Ther. 2009;22:21-27.</ref>
* Should be undertaken for at least 3 months to prevent contractures.
* Maximal benefits of surgery are not immediate, only become obvious after 6-8 weeks.<ref name=":0" />


It is also necessary to measure hand function which can be achieved by tests and measures such as the Disabilities of the Arm, Shoulder, and Hand Questionnaire ([[DASH Outcome Measure|The DASH]]), or its shorter version The Quick Dash. The DASH is a 30-item, self-report questionnaire that measures physical function and symptoms in individuals with musculoskeletal disorders affecting the upper extremity. Another outcome measure that is used for the evaluation of wrist and hand function is the Short Form-36, a 36 question survey.<ref name="Changulani et al">Changulani M, Okonkwo U, Keswani T, Kalairajah Y. Outcome evaluation measures for wrist and hand: which one to choose? Int Orthop. 2008;32(1):1-6.</ref> While this is more of a generic measurement that can be used for various conditions, it is beneficial for identifying the overall health and well-being of a patient. <br>  
A standard protocol for postoperative management of Dupuytren disease is shown below  (Engstrand et al. in 2009).<ref name="Engstrand et al" />
* Within the initial 5 days postoperative, the primary interventions are to educate the patient on decreasing edema and the importance of performing a range of motion exercises on the uninvolved fingers.
* After 5-7 days postoperative, the primary interventions shift to a range of motion exercises and splinting.  
* The exercises are adapted to each subject’s individual goals and are based on their impairment, physical status, and competency.  
* The types of splints used included volar splints, dynamic extension splint, dynamic flexion splints, exercise splints, and wrist splints.&nbsp;
[[Image:Standard Protocol Dupuytren.jpg|center|Image 5: Standard protocol for patients with Dupuytren contracture]]The video below gives a good summary of the condition and physiotherapy treatment (less than 4 minutes)
{{#ev:youtube|https://www.youtube.com/watch?v=a8KMCAFx8xw|width}}<ref>Physio vibes DUPUYTREN'S CONTRACTURE & PHYSIOTHERAPY MANAGEMENT Available from: https://www.youtube.com/watch?v=a8KMCAFx8xw (last accessed 5.4.2020)</ref>  
====== Conclusion ======
The key fact to appreciate is that not all patients need treatment.
* There are many treatments available for Dupuytren contracture and none is ideal or works consistently.
* Only symptomatic patients should be offered treatment because all treatments have complications.
* The patient must be educated about the potential complications of treatments, which are worse than the disorder itself.
* Close communication between the team is essential in order to improve outcomes.
* Overall, only a few patients achieve a desirable result.  
* In many cases, prolonged physical therapy is required to restore functionality<ref name=":0" />


== Management / Interventions<br>  ==
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{{#ev:youtube|yjYRlo_Zupw|300}} <ref>uwhand. Dupuytren's Contracture Release. Available from: http://www.youtube.com/watch?v=yjYRlo_Zupw[last accessed 25/05/13]</ref>
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Surgical intervention is the current mainstay treatment for Dupuytren disease.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> Surgical procedures for the correct of flexion contractures in the digits due to Dupuytren disease can be divided into four main categories: simple fasciotomy, partial fasciectomy, total fasciectomy, and dermofasciectomy.<ref name="Becker et al">Becker GW, Davis TRC. The outcome of surgical treatments for primary Dupuytren’s disease – a systematic review. J Hand Surg Eur. 2010;35E(8):623-626.</ref> These operative procedures are listed in order from least invasive to most invasive.
A simple fasciotomy can be performed either percutaneously or through small incisions, and involves the surgeon dividing the contracted tissue cord to release the flexion contracture.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> During a simple fasciotomy, the contracted cord is simply cut, but is not surgically removed from the digit. A simple fasciotomy is considered suitable for early-stage Dupuytren disease involving passively correctable flexion contracture in the metacarpophalangeal joints alone.
A fasciectomy involves removal of the diseased palmar fascia, including the contracted tissue cord and nodule.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> A fasciectomy can either be partial or total depending on the severity of the disease. A partial fasciectomy involves removal of the diseased palmar fascia, whereas, a total fasciectomy is more invasive, involving the removal of the entire palmar fascia; both areas affected by disease and areas not affected by disease.<ref name="Becker et al">Becker GW, Davis TRC. The outcome of surgical treatments for primary Dupuytren’s disease – a systematic review. J Hand Surg Eur. 2010;35E(8):623-626.</ref>
Dermofasciectomy is the most invasive surgical procedure for Dupuytren disease. Dermofasciectomy involves removal of the diseased palmar fascia, the contracted tissue cord and nodule included, and all overlying affected skin and subcutaneous fat.<ref name="Shih et al">Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Rheumatology. 2010;6:715-726.</ref> After a dermofasciectomy procedure is performed, a full-thickness skin graft is required to cover the surgical site. In cases of chronic advanced proximal interphalangeal joint contracture, external fixators may be indicated in addition to the dermofasciectomy procedure to keep the contracture from recurring. For severe Dupuytren contractures that keep recurring despite several surgical attempts at correction, amputation of the affected digits may be considered as a last resort.
Since Dupuytren disease is a connective tissue disorder of the hand, contracture recurrence is common even after surgical intervention.<ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref> However, the rate of recurrence is reduced with greatest removal of the affected tissues. For example, the rate of recurrence of Dupuytren disease is considerably reduced following a dermofasciectomy, where the affected fascia, subcutaneous fat, and skin is removed, than with a fasciectomy alone; removing only the affected fascia.
Due to the high rate of recurrance of Dupuytren disease, it is important for the surgeon to consider the ‘Dupuytren’s diathesis’ before deciding which surgical procedure would be most effective for the patient.<ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref> The Dupuytren’s diathesis is a collection of features indicative of an unfavorable prognosis; highlighted by an aggressive disease course and increased risk of disease recurrence.
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{{#ev:youtube|b7niXa484KA|300}} <ref>URehab. Dupuytren's Contracture Treatment Program. Available from: http://www.youtube.com/watch?v=b7niXa484KA[last accessed 25/05/13]</ref>
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These features include:
*bilateral involvement
*ethnicity (particularly individuals of northern European descent)
*the presence of ectopic lesions (lesions occurring at sites other than the hands)
*a positive family history of Dupuytren disease (at least one sibling or parent with Dupuytren disease)
*male sex
*age of onset before 50 years of age
Individuals with a positive diathesis may choose to delay surgery for fear of their high risk of contracture recurrence.
Because the primary treatment for Dupuytren disease is surgery, the physical therapist’s main role in the intervention process is postoperatively. Physial therapy after surgery typically includes splinting, exercises, and edema and scar interventions.<ref name="Engstrand et al">Engstrand C, Boren L, Liedberg GM. Evaluation of activity limitation and digital extension in Dupuytren’s contracture three months after fasciectomy and hand therapy interventions. J Hand Ther. 2009;22:21-27.</ref> The primary treatment objective is to maintain the range of motion that was obtained through the surgical removal of the fibrotic tissue. Functional range of motion of the fingers is imperative to many activities of daily living, making its preservation key.
A standard protocol for postoperative management of Dupuytren disease, developed by Engstrand et al. in 2009, is shown in Figure (1).<ref name="Engstrand et al">Engstrand C, Boren L, Liedberg GM. Evaluation of activity limitation and digital extension in Dupuytren’s contracture three months after fasciectomy and hand therapy interventions. J Hand Ther. 2009;22:21-27.</ref> Within the initial 5 days postoperative, the primary interventions are to educate the patient on decreasing edema and the importance of performing range of motion exercises on the uninvolved fingers. After 5-7 days postoperative, the primary interventions shift to range of motion exercises and splinting. The exercises used in Engstrand’s protocol were adapted to each subject’s individual goals and were based on their impairment, physical status, and competency. The types of splints used included volar splints, dynamic extension splint, dynamic flexion splints, exercise splints, and wrist splints.&nbsp;
[[Image:Standard Protocol Dupuytren.jpg|center|Image 5: Standard protocol for patients with Dupuytren contracture]]
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 5: Standard protocol for patients with Dupuytren contracture<ref name="Engstrand et al">Engstrand C, Boren L, Liedberg GM. Evaluation of activity limitation and digital extension in Dupuytren’s contracture three months after fasciectomy and hand therapy interventions. J Hand Ther. 2009;22:21-27.</ref>
<br>
While splinting is a widely used intervention for postoperative treatment, Larson and Jarosh-Herold argue its clinical effectiveness, stating that it is only supported by clinical reasoning and anecdotal evidence.<ref name="Larson et al">Larson D, Jerosch-Herold C. Clinical effectiveness of post-operative splinting after surgical release of Dupuytren’s contracture: a systematic review. BMC Musculoskel Dis. 2008;9:104.</ref> According to a systematic review by these authors, the clinical effectiveness of long-term static night splinting on finger movement and hand function remains unproven. They recommend that more research is done using randomized control trials and focus on various types of splints.
Although surgery is considered the mainstay of treatment for Dupuytren disease, not all individuals are willing to undergo surgery.<ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref> On the other hand, some individuals who elect to have surgery may be deemed unsuitable surgical candidates due to the presence of pre-existing comorbidities, old age, frailty, or lack of social support and assistance needed following surgery. Consequently, numerous nonsurgical treatments have been investigated for Dupuytren disease including hyperbaric oxygen, radiation, ultrasound therapy, vitamin E, physical therapy, steriod injection, interferon, and splinting. However, none of these therapies alone have been proven to be as clinically effective in the management of Dupuytren disease as surgery.
Currently, numerous research studies are demonstrating the clinical safety and effectiveness of Clostridium histolyticum collagenase injection as the promising new nonsurgical treatment for Dupuytren disease.<ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref> Researchers believe that an abnormal increase in the synthesis and deposition of collagen contributes to the formation of fibrotic tissue and contractures in Dupuytren disease. The clostridial collagenase injection has been shown to be effective in targeting excessive collagen deposition and rupturing the fibrous tissue cords that cause metacarpophalangeal joint and proximal interphalangeal joint contractures in Dupuytren disease.&nbsp;
A large prospective, multicenter, phase III clinical trial published in The New England Journal of Medicine in September of 2009, confirmed the effectiveness of Clostridium histolyticum collagenase in decreasing flexion contractures in the digits.<ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref> In this study, 308 individuals with Dupuytren disease were randomly assigned in a 2:1 ratio to receive up to three injections, 30 days apart, of either 0.58 mg of Clostridium histolyticum collagenase or a placebo injection into the contracted collagen cord. Thirty days after the final injection, 64% of the individuals in the Clostridium histolyticum collagenase injection group displayed a reduction in joint contracture to within 0 to 5 degrees of full extension compared to only 6.8% of individuals in the placebo injection group. However, the percentage of subjects who experienced adverse events was higher in the collagenase injection group with 97% of individuals compared to only 21% of individuals experiencing adverse events in the placebo injection group.<ref name="Harvard University">Harvard University. Nonsurgical approach unlocks contracted fingers. Harvard Women’s Health Watch. 2009:6-7.</ref> Adverse events reported were mostly mild and they included lymph node enlargement and tenderness, bruising, and bleeding, itching, swelling, or pain at the injection site. Of major concern were three serious treatment-related adverse events: two tendon ruptures and one case of complex regional pain syndrome, a progressive disorder causing severe pain, swelling, and skin changes.<ref name="Harvard University">Harvard University. Nonsurgical approach unlocks contracted fingers. Harvard Women’s Health Watch. 2009:6-7.</ref><ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref> Further studies are needed to determine the long-term benefits and rates of contracture recurrence with the treatment approach of Clostridium histolyticum collagenase injections.<ref name="Bayat">Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.</ref> <br>
[[Image:Collagenase Treatment.jpg|center|Image 6: Before and after collagenase treatment]]
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Image 6: Before and after collagenase treatment<ref name="Harvard University">Harvard University. Nonsurgical approach unlocks contracted fingers. Harvard Women’s Health Watch. 2009:6-7.</ref>
== Differential Diagnosis<ref name="Lewis et al">Lewis FS, Conologue TD. Dermatologic manifestations of Dupuytren contracture: differential diagnoses and workup. EMedicine from WebMD Web site. http://emedicine.medscape.com/article/1060763-diagnosis. February 3, 2010. Accessed March 19, 2011.</ref><br>  ==
Before determining a diagnosis of Dupuytren disease, it is important to consider other diagnoses that may present with nodules in the hand or flexion contractures of the digits. Differential diagnoses for Dupuytren disease include:
*Callus
*Epitheloid sarcoma
*[http://www.physio-pedia.com/Ganglion_Cyst Ganglion cyst]
*Stenosing tenosynovitis
*Giant cell tumor of the tendon sheath
*Prolapsed flexor tendon
*Ulnar nerve palsy
*Camptodactyly
*Fibromas and fibromatoses
*Palmar tendinitis
== Key Evidence  ==
http://www.nature.com/nrrheum/journal/v6/n12/full/nrrheum.2010.180.html
The above link is to a comprehensive review article on Dupuytren disease by Barbara Shih and Ardeshir Bayat from the December 2010 volume of the Nature Reviews Rheumatology journal entitled “Scientific understanding and clinical management of Dupuytren disease.”
http://www.nejm.org/doi/full/10.1056/NEJMoa0810866
The above link is to The New England Journal of Medicine’s September 3, 2009 issues’ article on the effectiveness of injectable collagenase clostridium histolyticum for Dupuytren contracture.
== Resources <br>  ==
<br>http://www.assh.org/Public/HandConditions/Pages/DupuytrensDisease.aspx
http://www.mayoclinic.com/health/dupuytrens-contracture/DS00732
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002213/
== Case Studies  ==
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
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</div>
== References  ==
== References  ==
References will automatically be added here, see [[Adding References|adding references tutorial]].


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    [[Category:Hand]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Temple_Student_Project]]
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[[Category:Hand - Conditions]]
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Latest revision as of 17:55, 16 October 2023

Original Editor - Gwen Fritsche and Lauren Leimbach from Temple University's Evidence Based Practice Project

Top Contributors - Lauren Leimbach, Gwen Fritsche, Admin, Kim Jackson, Lucinda hampton, Rachael Lowe, Kirenga Bamurange Liliane, Chrysolite Jyothi Kommu, Laura Ritchie, Vidya Acharya, Cindy John-Chu, Scott A Burns, WikiSysop, Fasuba Ayobami, 127.0.0.1, Carina Therese Magtibay, Lennert De Henau, Evan Thomas and Khloud Shreif

Introduction[edit | edit source]

Dupuytren contracture is a benign, progressive disease of the palmar fascia which results in shortening, thickening, and fibrosis of the fascia and aponeurosis of the palm driven by myofibroblastic proliferation.[1]

Image 1: Clinical presentation of Dupuytren contracture
  • Dupuytren disease is predominantly a myofibroblastic disease that affects the hand/fingers and results in contracture deformities.
  • Commonly affected digits are those farthest from the thumb i.e. the fourth (ring) and fifth (pinky) digits.
  • The disease begins in the palm as painless nodules that form along longitudinal lines of tension.
  • The nodules form cords that produce contracture deformities within fascial bands and tissues of the hand.
  • Dupuytren contracture is usually seen in Caucasians and the disorder often presents bilaterally. When unilateral, the right side is more likely to be involved compared to the left.
  • In many individuals, there is a family history with males being more susceptible to the condition than females.[2][3]

Image 1: Clinical presentation of Dupuytren contracture[4]

Etiology[edit | edit source]

Dupuytren disease is a genetic disorder expressed in an autosomal dominant fashion, but most frequently seen with a multifactorial etiology. It is associated with diabetes, seizure disorders, smoking, alcoholism, HIV, and vascular disease[5].

Ectopic manifestations beyond the hand can be seen in Plantar Fibromatosis (plantar fascia), 10% to 30%; Peyronie disease (Dartos fascia of the penis), 2% to 8%; and Garrod disease (dorsal knuckle pads), 40% to 50%.[5]

Epidemiology[edit | edit source]

This condition is common in populations of Northern European/Scandinavian descent.  It is relatively uncommon in Southern European and South American populations and is rare in Africans and Asians. The disease affects men more severely than women. Males are affected by a 2:1 ratio compared to women. Younger age of onset is also associated with increased severity of disease progression. In Asian populations, the palm is more likely to be involved than the digits and thus often goes unnoticed.[5]

Pathological Process[edit | edit source]

The pathophysiology of Dupuytren disease involves abnormal myofibroblastic growth in the hand.

  • Type III collagen predominates, which under a non-disease state would be Type I collagen.
  • Dupuytren contracture progresses through three phases: (1) proliferative, (2) involution, and (3) residual. The proliferative phase has a characteristically high concentration of immature myofibroblasts and fibroblasts arranged in a whorled pattern. In the involution phase, fibroblasts become aligned in the longitudinal axis of the hand following lines of tension. In the residual phase, relatively acellular collagen-rich chords remain causing contracture deformity.
  • The disorder is not always progressive and in at least 50-70% of patients, it may stabilize or even regress.

Several cords can develop which can cause unique deformities of the hand.

  • Pretendinous cords cause skin pitting and metacarpal phalangeal (MCP) joint contracture.
  • Natatory cords are responsible for webspace contractures.
  • Spiral cords are the most important in the disease process and can cause proximal interphalangeal (PIP) contracture.

Risk factors for increased severity and recurrence of disease after treatment include- male gender; onset before age 50; bilateral disease; sibling/parent involvement; the presence of Garrod pads, Ledderhose, or Peyronies diseases.[2]

Clinical Presentation[edit | edit source]

Dupuytren contracture occurs slowly and typically progresses over the course of several years, but can also develop more rapidly over weeks or months.[6]

Image 3: Skin pitting and the presence of nodules in Dupuytren disease

It typically affects older men of European descent. 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 distally toward the fingers. This tightening and shortening eventually lead to the affected fingers being pulled into flexion. Dupuytren contracture typically occurs bilaterally, with one hand being more severely affected than the other.

Physical findings:

  • Blanching of the skin when the finger is extended
  • Proximal to the nodules, the cords are painless
  • Pits and grooves may be present
  • The knuckle pads over the PIP joints may be tender
  • If the plantar fascia is involved, this indicates a more severe disease (Plantar Fibromatosis)
  • The patient may not be able to place the palm flat on the table[2]
Diagnostic Procedures[edit | edit source]
  • X-rays of the hand should be obtained to examine for other contributing, bony abnormalities that may contribute to the loss of range of motion.
  • Laboratory workup to rule out diabetes is recommended.
  • Ultrasound may demonstrate thickened palmar fascia and the nodules.[2]

Differential Diagnosis[edit | edit source]

Dupuytren disease should be distinguished from other diseases of the hand including stenosing flexor tenosynovitis, ganglion cysts, and soft tissue masses[2].

Outcome Measures[edit | edit source]
Patient reported outcome measure.jpg
  • Range of motion measurements of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints should be recorded ( flexion and extension of these joints, with measurements of passive and active range of motion). Take as a baseline measure and then throughout the treatment process, can help stage the severity of the contractures.
  • Measure hand function by tests and measures such as eg Disabilities of the Arm, Shoulder, and Hand Questionnaire (The DASH), or its shorter version The Quick Dash.

Medical Management[edit | edit source]

Indications for treatment are based on the effects of disease on the patient's quality of life. Many patients with a positive tabletop test, MCP contracture of 30 degrees, or PIP contracture of 15 to 20 degrees will elect to have treatment.

Treatment options consist of observation, needle aponeurotomy, collagenase injection, and/or surgical resection and fasciectomy.

Observation is appropriate for individuals with painless stable disease and no impairment in function. Follow up every 6 months may be done to assess the progression of the disorder.

  • Physical and occupational therapy including ultrasound waves and heat can help during the early stage of the disease. Some patients may also benefit from a brace/splint to stretch the digits. The range of motion of the fingers is necessary to prevent adhesions.
  • Corticosteroid injections may be beneficial for some patients eg those with painful nodules. Steroid injections do not work in all patients and a 50% recurrence has been reported. Corticosteroid injections can lead to fat atrophy, pigmentation change and there is the potential to cause rupture of the tendons.
  • Other treatments that have been tried include-tamoxifen; anti-tumor necrosis factor agents; 5 fluorouracil, imiquimod; botulinum toxin. No evidence exists to say any of these treatments are superior or work for everyone.
  • Radiation therapy may be beneficial during the early phase of the disease but has associated complications. It aims to slow down or halt the abnormal cell growth, being particularly effective when finger bending is minimal. A review of several studies indicated varied responses; some patients saw no change or improvement, while others experienced disease progression​[7]. A long-term study revealed many patients remained stable or even improved, with minor late side effects like skin atrophy and dry skin being observed in some patients, yet no increased cancer risk was noted​[8]​. However, more research is needed to fully grasp the treatment's benefits and risks[9]​.
    Image 6: Before and after collagenase treatment
  • Needle aponeurotomy is typically reserved for mild contractures. The procedure is minimally invasive and is often performed in an office setting.
  • Collagenase injections provide a minimally invasive treatment derived from Clostridium histolyticum. Night extension splinting is maintained for 6 months. Collagenase injections result in a 75% contracture reduction with a 35% recurrence rate. Complications include edema, skin tearing, tendon rupture, complex regional pain syndrome, and pulley rupture. Before and after collagenase treatment image at R [10]
  • Surgical fasciectomy can be either limited or radical. The recurrence rate at 1 to 2 years is 30%, 15% at 3 to 5 years, and less than 10% after ten years.
  • Total palmar fasciectomy can also be performed but is infrequently used as it requires resection of all palmar and digital fascia, including nondiseased tissue.
  • Complications of fasciectomy include skin necrosis, hematoma (most common complication), flare reaction, neurovascular injury, digital ischemia, swelling, and infection.

Irrespective of the treatment, recurrence is common with all of them, approaching 20-50% at 5 years.[2]

Physical Therapy Management[edit | edit source]

Conservative Approach[edit | edit source]

Physical therapy may include ultrasound waves: heat (early stage of the disease); brace/splint to stretch the digits; a range of motion of the fingers to prevent adhesions.

Power web WB.jpg

Postoperative Care/Rehabilitation[edit | edit source]

Patients often enter hand therapy to :

  • Maintain the range of motion of the hand and fingers is important (for many activities of daily living), see hand exercises
  • Extension splints often are used in conjunction with other modalities.
  • Odema and scar interventions.[11]
  • Should be undertaken for at least 3 months to prevent contractures.
  • Maximal benefits of surgery are not immediate, only become obvious after 6-8 weeks.[2]

A standard protocol for postoperative management of Dupuytren disease is shown below (Engstrand et al. in 2009).[11]

  • Within the initial 5 days postoperative, the primary interventions are to educate the patient on decreasing edema and the importance of performing a range of motion exercises on the uninvolved fingers.
  • After 5-7 days postoperative, the primary interventions shift to a range of motion exercises and splinting.
  • The exercises are adapted to each subject’s individual goals and are based on their impairment, physical status, and competency.
  • The types of splints used included volar splints, dynamic extension splint, dynamic flexion splints, exercise splints, and wrist splints. 
Image 5: Standard protocol for patients with Dupuytren contracture

The video below gives a good summary of the condition and physiotherapy treatment (less than 4 minutes)

[12]

Conclusion[edit | edit source]

The key fact to appreciate is that not all patients need treatment.

  • There are many treatments available for Dupuytren contracture and none is ideal or works consistently.
  • Only symptomatic patients should be offered treatment because all treatments have complications.
  • The patient must be educated about the potential complications of treatments, which are worse than the disorder itself.
  • Close communication between the team is essential in order to improve outcomes.
  • Overall, only a few patients achieve a desirable result.
  • In many cases, prolonged physical therapy is required to restore functionality[2]

References[edit | edit source]

  1. ↑ E Soreide, M H Murad, J M Denbeigh, E A Lewallen, A Dudakovic, L Nordsletten, A J van Wijnen, S Kakar.Treatment of Dupuytren's contracture: a systematic review.PubMed.gov.National Library of Medicine. National Centre for Biotechnology Information.2018 Sep;100-B(9):1138-1145.doi: 10.1302/0301-620X.100B9.BJJ-2017-1194.R2.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Walthall J, Rehman UH. Dupuytrens Contracture. InStatPearls [Internet] 2019 Feb 19. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK526074/ (last accessed 4.4.2020)
  3. ↑ Bayat A. A nonsurgical therapy for Dupuytren disease. Rheumatology. 2010;6:7-8.
  4. ↑ Dupuytren’s Disease. American Society for Surgery of the Hand Web site. http://www.assh.org/Public/HandConditions/Pages/DupuytrensDisease.aspx. 2010. Accessed March 19, 2011.
  5. ↑ 5.0 5.1 5.2 Walthall J, Anand P, Rehman UH. Dupuytren Contracture. StatPearls [Internet]. 2020 Sep 14.
  6. ↑ Mayo Foundation for Education and Research. The Dupuytren's Contracture Page. http://www.mayoclinic.com/health/dupuytrens-contracture/DS00732. Updated May 15, 2010. Accessed March 14, 2011.
  7. ↑ Kadhum M, Smock E, Khan A, Fleming A. Radiotherapy in Dupuytren’s disease: a systematic review of the evidence. Journal of Hand Surgery (European Volume). 2017 Sep;42(7):689-92.
  8. ↑ Betz N, Ott OJ, Adamietz B, Sauer R, Fietkau R, Keilholz L. Radiotherapy in early-stage Dupuytren's contracture. Strahlentherapie und Onkologie. 2010 Feb 1;186(2):82.
  9. ↑ Solie P, Stump B, Cashner C, Lenards N, Hunzeker A, Zeiler S. A case study of radiotherapy treatment for Dupuytren's contracture and Ledderhose disease. Medical Dosimetry. 2023 Apr 12.
  10. ↑ Harvard University. Nonsurgical approach unlocks contracted fingers. Harvard Women’s Health Watch. 2009:6-7.
  11. ↑ 11.0 11.1 Engstrand C, Boren L, Liedberg GM. Evaluation of activity limitation and digital extension in Dupuytren’s contracture three months after fasciectomy and hand therapy interventions. J Hand Ther. 2009;22:21-27.
  12. ↑ Physio vibes DUPUYTREN'S CONTRACTURE & PHYSIOTHERAPY MANAGEMENT Available from: https://www.youtube.com/watch?v=a8KMCAFx8xw (last accessed 5.4.2020)
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