eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions

Dupuytren Contracture: Treatment & Medication

Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Coauthor(s): Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine
Contributor Information and Disclosures

Updated: Feb 4, 2010

Treatment

Rehabilitation Program

Physical Therapy

Stretching with the application of heat and ultrasonographic waves may be helpful in the early stages of Dupuytren contracture. The physical therapist also may recommend that the patient wear a custom splint or brace to stretch the fingers further. ROM exercises should be performed several times a day. If the patient undergoes surgical correction of the contracture, physical therapy often is involved following the procedure. The postsurgical program consists of wound care, massage, passive stretching, active ROM exercises, and splinting.

Occupational Therapy

Through a course of occupational therapy, the patient may learn adaptive techniques and begin to use assistive devices that enhance functional abilities. For example, adaptive equipment can help a patient to open jars, despite contractures.

Medical Issues/Complications

  • The main complication is progressive impairment and disability secondary to continuing contracture.

Surgical Intervention

  • A patient with mild disease can be tracked clinically for progression before considering surgical intervention.
  • Consider surgical intervention for a patient with the following features:
    • Significant functional disability secondary to this disease
    • Significant MCP contracture (>30 º)
    • Any contracture of the PIP joint
  • Surgical interventions consist mostly of fasciectomy.7 Complete extension of affected joints may be possible with earlier intervention.
  • Surgical fasciectomy is the accepted treatment for Dupuytren disease; nonsurgical treatment options are either in their infancy or show little clinical efficacy.8 However, because surgery does not cure the disease and recurrence rates range from 26-80%, nonsurgical treatment options continue to be explored.1,6,9

Consultations

  • Surgical intervention may be appropriate in more severe cases. Consider surgical consultation with one of the following specialists:
    • Plastic surgeon
    • Orthopedic hand surgeon

Other Treatment

  • Intralesional corticosteroid injection may be helpful in the early stages of the disease.
  • In a clinical trial in which nodules of Dupuytren disease were injected with triamcinolone acetonide, researchers concluded that this compound might modify the progression of the disease.10
  • Enzymatic fasciotomy using collagenase clostridium histolyticum injection has shown potentially encouraging results and was approved by the US Food and Drug Administration (FDA) in February 2010. A prospective, randomized, double-blind, placebo-controlled trial by Badalamente and Hurst showed collagenase injections to be safe and effective, with a low recurrence rate; the authors proposed this as a viable, nonsurgical treatment option for Dupuytren contracture.11 Clostridial collagenase is thought to lyse and rupture excessive collagen deposition, which decreases the tensile strength of Dupuytren cords.12,13
  • In a prospective, randomized, double-blind, placebo controlled, multicenter study, Hurst et al found that in patients with advanced Dupuytren disease, joints treated with collagenase clostridium histolyticum demonstrated significant improvements in ROM and significant reductions in contractures.14
  • Some researchers have started looking into nonsurgical treatment options for Dupuytren disease, investigating how reported cellular mediators affecting the disease's pathogenesis might be harnessed.1
    • Myofibroblasts are the primary cell type in Dupuytren disease; 5-fluorouracil (5-FU) inhibits proliferation and myofibroblast differentiation in Dupuytren cell culture. Thus, 5-FU has a potential use as an adjuvant to reduce the rate of recurrence and contracture.1
    • Hyperbaric oxygen is another theoretical therapeutic option. Fibroblast and myofibroblast production may cease if hypoxic conditions are reversed by high tissue oxygenation.1
  • An in-office percutaneous needle aponeurotomy can be considered as an alternative to surgery.15
  • A percutaneous needle fasciotomy has been developed by a team of French rheumatologists, with results comparable to traditional surgery.16
  • It is hoped that further research will elucidate or more firmly establish the role of nonsurgical interventions (eg, injections and other previously mentioned therapies) in the treatment of Dupuytren contracture.

Medication

Because this condition is generally painless, analgesic medications usually are not required. No medications are known to decrease the progression of the contractures. Collagenase clostridium histolyticum was approved by the FDA in February 2010.

Enzyme

Collagenase clostridium histolyticum (Xiaflex) percutaneous needle fasciotomy was approved by the FDA in February 2010.


Collagenase clostridium histolyticum (Xiaflex)

Proteinase that hydrolyzes collagen in its native triple-helical conformation, resulting in lysis of collagen deposits. Injection into a Dupuytren cord (composed mostly of collagen) may result in enzymatic disruption of the cord. Indicated for Dupuytren contracture with a palpable cord.

Adult

Inject 0.58 mg into palpable Dupuytren cord with a contracture of metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint
If contracture persists 24 h following injection, perform finger extension procedure
May repeat injection and finger extension procedures up to 3 times per cord at 4-wk intervals
Inject only 1 cord at a time; if other cords with contractures exist, inject each cord in sequential order
Reconstitute lyophilized powder with supplied diluent prior to use (diluent volume depends on whether injecting MP or PIP joint)
Should only be administered by healthcare providers experienced with injection procedures of the hand

Pediatric

Not indicated

Data limited; safety and efficacy when coadministered with anticoagulants (other than low-dose aspirin up to 150 mg/d) within 7 d of administration is unknown

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Tendon rupture or other serious injury to the injected extremity reported in clinical trials; pruritus experienced in 15% (increased incidence after more injections); administration in patients with abnormal coagulation may result in ecchymosis/contusion or an injection site hemorrhage; common adverse effects (>25%) include edema of injected hand, contusion, injection site reaction, injection site hemorrhage, and/or pain in the extremity

More on Dupuytren Contracture

Overview: Dupuytren Contracture
Differential Diagnoses & Workup: Dupuytren Contracture
Treatment & Medication: Dupuytren Contracture
Follow-up: Dupuytren Contracture
Multimedia: Dupuytren Contracture
References
Further Reading
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References

  1. Bansal V, Naidu SH. Dupuytren's disease. Curr Opin Orthop. 2005;16(4):236-9.

  2. Vi L, Feng L, Zhu RD, Wu Y, et al. Periostin differentially induces proliferation, contraction and apoptosis of primary Dupuytren's disease and adjacent palmar fascia cells. Exp Cell Res. Dec 10 2009;315(20):3574-86. [Medline].

  3. 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].

  4. 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].

  5. 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].

  6. Balaguer T, David S, Ihrai T, et al. Histological staging and Dupuytren's disease recurrence or extension after surgical treatment: a retrospective study of 124 patients. J Hand Surg Eur Vol. Aug 2009;34(4):493-6. [Medline].

  7. 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].

  8. Mavrogenis AF, Spyridonos SG, Ignatiadis IA, et al. Partial fasciectomy for Dupuytren's contractures. J Surg Orthop Adv. Summer 2009;18(2):106-10. [Medline].

  9. Ullah AS, Dias JJ, Bhowal B. Does a 'firebreak' full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture?: a prospective, randomised trial. J Bone Joint Surg Br. Mar 2009;91(3):374-8. [Medline].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. Sep 3 2009;361(10):968-79. [Medline].

  15. Trojian TH, Chu SM. Dupuytren's disease: diagnosis and treatment. Am Fam Physician. Jul 1 2007;76(1):86-9. [Medline].

  16. Corrado A, Cantatore FP. [Dupuytren's disease. State of the art and therapeutic perspectives]. Reumatismo. Apr-Jun 2007;59(2):118-28. [Medline].

  17. 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.

  18. Brinker MR, Miller MD. The adult hand. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:196-220.

  19. Dupuytren's disease. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:198-9.

  20. McGee DJ. Forearm, wrist and hand. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:168-215.

  21. Rayan GM. Dupuytren disease: Anatomy, pathology, presentation, and treatment. J Bone Joint Surg Am. Jan 2007;89(1):189-98. [Medline].

  22. 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.

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Keywords

Dupuytren contracture, Dupuytren's contracture, Dupuytren's disease, Dupuytren disease, PIP joint, MCP joint, palmar fasciitis, palmar fibromatosis, Viking disease, metacarpophalangeal joint deformity, MCP joints, fasciectomy, proximal interphalangeal joint deformity, PIP joints

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Contributor Information and Disclosures

Author

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

Coauthor(s)

Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine
Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Rajesh R Yadav, MD, Associate Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston
Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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