eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
Dupuytren Contracture
Updated: May 27, 2008
Introduction
Background
Dupuytren contracture results from contracture of the palmar fascia within the hand, possibly resulting in a fixed flexion deformity of the metacarpophalangeal (MCP) joints and the proximal interphalangeal (PIP) joints. This condition usually affects the fourth and fifth digits (the ring and small fingers).
Related eMedicine topics:
Dupuytren Contracture [Dermatology]
Dupuytren Contracture [Orthopedic Surgery]
Dupuytren Contracture [Rheumatology]
Hand, Dupuytren Disease
Pathophysiology
The palmar fascia within the hand may develop nodular, hypertrophic degeneration of uncertain etiology. The dense nodular fascia may become adherent to the overlying skin as the hypertrophic degeneration progresses, sometimes extending distally into the involved digit. This anatomic change may result in contracture of the involved fascia, causing fixed flexion of the MCP joint and sometimes of the PIP joint as well. The most commonly affected area is the ulnar aspect of the hand (digits 4 and 5).
Myofibroblasts are the primary cell type in Dupuytren disease.1
Frequency
United States
This disorder is relatively common, particularly in older adults.
Some studies have suggested a higher prevalence of Dupuytren contracture among people with diabetes, or among individuals who smoke or abuse alcohol. However, a large retrospective study by Loos and colleagues on 2919 hands on which surgery had been performed revealed no statistically significant evidence that the occurrence of Dupuytren contracture could be correlated with the presence of diabetes, with alcoholism, or with smoking.2
Mortality/Morbidity
- No mortality is associated with this condition.
- As the contractures progress, the physical impairments may cause disability if the individual is unable to perform tasks requiring full use of all digits, particularly when the dominant hand is involved.
Race
Dupuytren contracture is seen more commonly in patients of northern European descent (hence the term Viking disease).
Sex
This condition affects men more often than women.
Age
This condition is most often seen in individuals older than 50 years.
Clinical
History
Taking a thorough history from the patient often helps to exclude many other diagnostic considerations.3
A patient typically presents with a history of progressive loss of range of motion (ROM) of the affected finger(s), although fibrous contractures may appear elsewhere in the body, such as in the plantar fascia, knuckle pads, and shaft of the penis.
The fourth digit most commonly is involved. The fifth, third, and second fingers are involved in decreasing order of frequency. Specifically, there is a decreased ability to fully extend the MCP joint(s); a decreased ability to fully extend the PIP joint(s) is sometimes noted.
The history may refer to an isolated nodule in this area, initially somewhat tender, which may have hardened and then disappeared. Asking about functional disabilities may elicit a history of certain tasks that the individual can no longer perform, such as grasping objects and typing.
No sensory deficits are reported unless there is a concomitant pathology. The condition is painless in its later stages.
Physical
A careful physical examination often confirms the diagnosis without the need for further tests.3
- Examination reveals a palmar skin nodule, generally within the distal aspect of the palm.
- The nodularity generally is not tender to palpation.
- Puckering of the skin above the nodularity may be noted. Overlying skin may be adherent to the fascia, and a fibrous cord can extend into the finger.
- Flexion of the digit is normal for passive and active ROM.
- Conversely, extension is limited at the MCP and sometimes the PIP joints of the affected digits. This limitation in finger extension occurs when testing passive and active ROM.
- The ring finger (digit 4) is the most commonly involved site, followed by the small finger (digit 5). Other digits may be involved, although less commonly.
- Loss of progressive flexion of the fingers in the resting position from the radial to ulnar side may be noted.
- Although the patient may, because of the contractures, have difficulty grasping objects, strength is normal within the available ROM.
- Sensation is typically normal.
Causes
- Etiology includes a dominant genetic inheritance pattern that often involves individuals of northern European descent.
- In some cases, trauma may accelerate or initiate the process.
- There is conflicting literature regarding whether Dupuytren contracture can be seen with increased frequency in patients with a variety of other conditions. One study indicates no significant increase in the occurrence of Dupuytren contracture in patients with diabetes or alcoholism or who engage in smoking.2 Another report, however, notes that Dupuytren contracture is associated with several conditions (eg, alcoholism, diabetes, epilepsy, pulmonary disease) and with smoking.4 Nonetheless, even if such associations exist, no clear causal relationship has been established in the literature.
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| Follow-up: Dupuytren Contracture |
| Multimedia: Dupuytren Contracture |
| References |
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References
Bansal V, Naidu SH. Dupuytren's disease. Curr Opin Orthop. 2005;16(4):236-9.
Loos B, Puschkin V, Horch RE. 50 years experience with Dupuytren's contracture in the Erlangen University Hospital--a retrospective analysis of 2919 operated hands from 1956 to 2006. BMC Musculoskelet Disord. 2007;8:60. [Medline]. [Full Text].
Bayat A, Cunliffe EJ, McGrouther DA. Assessment of clinical severity in Dupuytren's disease. Br J Hosp Med (Lond). Nov 2007;68(11):604-9. [Medline].
Hnanicek J, Cimburova M, Putova I, et al. Lack of association of iron metabolism and Dupuytren's disease. J Eur Acad Dermatol Venereol. Apr 2008;22(4):476-80. [Medline].
Anwar MU, Al Ghazal SK, Boome RS. Results of surgical treatment of Dupuytren's disease in women: a review of 109 consecutive patients. J Hand Surg [Am]. Nov 2007;32(9):1423-8. [Medline].
Ketchum LD, Donahue TK. The injection of nodules of Dupuytren's disease with triamcinolone acetonide. J Hand Surg [Am]. Nov 2000;25(6):1157-62. [Medline].
Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren's contracture. J Hand Surg [Am]. Jul-Aug 2007;32(6):767-74. [Medline].
Badalamente MA, Hurst LC, Hentz VR. Collagen as a clinical target: nonoperative treatment of Dupuytren''s disease. J Hand Surg [Am]. Sep 2002;27(5):788-98. [Medline].
Starkweather KD, Lattuga S, Hurst LC, et al. Collagenase in the treatment of Dupuytren''s disease: an in vitro study. J Hand Surg [Am]. May 1996;21(3):490-5. [Medline].
Trojian TH, Chu SM. Dupuytren's disease: diagnosis and treatment. Am Fam Physician. Jul 1 2007;76(1):86-9. [Medline].
Corrado A, Cantatore FP. [Dupuytren's disease. State of the art and therapeutic perspectives]. Reumatismo. Apr-Jun 2007;59(2):118-28. [Medline].
Breen TF. Wrist and hand. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:99-138.
Brinker MR, Miller MD. The adult hand. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:196-220.
Dupuytren's disease. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:198-9.
McGee DJ. Forearm, wrist and hand. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:168-215.
Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:756-82.
Further Reading
Keywords
Dupuytren contracture, Dupuytren's contracture, Dupuytren's disease, Dupuytren disease, palmar fasciitis, palmar fibromatosis, Viking disease, metacarpophalangeal joint deformity, MCP joints, proximal interphalangeal joint deformity, PIP joints
