- Rohit Aggarwal, MD, MSc
Rohit Aggarwal, MD, MSc
- Assistant Professor of Medicine, Division of Rheumatology and Clinical Immunology
- University of Pittsburgh
- Philip E Blazar, MD
Philip E Blazar, MD
- Assistant Professor of Orthopedic Surgery
- Harvard Medical School
Dupuytren’s contracture is a relatively common disorder characterized by progressive fibrosis of the palmar fascia . It is a benign, slowly progressive fibroproliferative disease of the palmar fascia. Initial fascial thickening is usually seen as a nodule in the palm, which can be painful or painless and often goes unnoticed and undiagnosed. Joint stiffness and a loss of full extension develop insidiously over decades.
As the process evolves, nodules progress to form longitudinal bands referred to as cords on the palmar fascia, and the finger gradually loses extension, with contractures that draw one or more fingers into flexion at the metacarpophalangeal (MCP) joint (picture 1), proximal interphalangeal (PIP) joint, or both . The term Dupuytren disease (DD) is also used for this disorder, as the fingers are not always held in a fixed flexion deformity.
The cause of Dupuytren’s contracture is unknown; important factors include genetics, ethnicity, sex, and age and may include certain environmental factors and other diseases . The disorder, which most affects those of northern European ancestry, appears to have a pronounced genetic predisposition; 68 percent of male relatives of affected patients develop the disease. In a study involving patients from the Netherlands, Germany, and the United Kingdom, six of nine genetic loci found associated with genetic susceptibility to Dupuytren’s disease contained genes encoding proteins in the Wnt-signaling pathway . Overstimulation of this pathway, which can regulate cellular proliferation, could potentially lead to fibroblast proliferation and nodule formation in this disorder through effects upon beta-catenin .
Pathologically, Dupuytren’s contracture is characterized by fibroblastic proliferation and disorderly collagen deposition with fascial thickening. Formation of a nodule or nodules occurs in the early proliferative stage of the disease and is the pathognomonic lesion of Dupuytren’s contracture. Nodules form due to proliferation of fibroblasts in the superficial palmar fascia and histologically are composed of fibroblasts and type III collagen. Smooth muscle fibroblasts and myofibroblasts are present in the nodules; increased concentrations of prostaglandins are also found within the nodules and may influence myofibroblast contractility . The flexor tendons are not intrinsically involved, but invasion of the dermis occurs and results in characteristic puckering and tethering of the skin.
The presence of CD3-positive lymphocytes and the expression of major histocompatibility complex (MHC) class II proteins also suggest a possible role for a T-cell mediated autoimmune response in this disorder .
- Gudmundsson KG, Jónsson T, Arngrímsson R. Guillaume Dupuytren and finger contractures. Lancet 2003; 362:165.
- Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd, WB Saunders, Philadelphia 1999.
- Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Nat Rev Rheumatol 2010; 6:715.
- Dolmans GH, Werker PM, Hennies HC, et al. Wnt signaling and Dupuytren's disease. N Engl J Med 2011; 365:307.
- Bowley E, O'Gorman DB, Gan BS. Beta-catenin signaling in fibroproliferative disease. J Surg Res 2007; 138:141.
- Badalamente MA, Hurst LC, Sampson SP. Prostaglandins influence myofibroblast contractility in Dupuytren's disease. J Hand Surg Am 1988; 13:867.
- Baird KS, Alwan WH, Crossan JF, Wojciak B. T-cell-mediated response in Dupuytren's disease. Lancet 1993; 341:1622.
- Liss GM, Stock SR. Can Dupuytren's contracture be work-related?: review of the evidence. Am J Ind Med 1996; 29:521.
- Matsen FA 3rd, Kirby RM. Office evaluation and management of shoulder pain. Orthop Clin North Am 1982; 13:453.
- Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis 1972; 31:69.
- Lynch M, Jayson MIV. Fasciitis and fibrosis. Clin Rheum Dis 1979; 5:833.
- Wooldridge WE. Four related fibrosing diseases. When you find one, look for another. Postgrad Med 1988; 84:269.
- Wheeler ES, Meals RA. Dupuytren's diathesis: a broad-spectrum disease. Plast Reconstr Surg 1981; 68:781.
- Burge P, Hoy G, Regan P, Milne R. Smoking, alcohol and the risk of Dupuytren's contracture. J Bone Joint Surg Br 1997; 79:206.
- Frey M. Risks and prevention of Dupuytren's contracture. Lancet 1997; 350:1568.
- Leslie BM. Palmar fasciitis and polyarthritis associated with a malignant neoplasm: a paraneoplastic syndrome. Orthopedics 1992; 15:1436.
- Critchley EM, Vakil SD, Hayward HW, Owen VM. Dupuytren's disease in epilepsy: result of prolonged administration of anticonvulsants. J Neurol Neurosurg Psychiatry 1976; 39:498.
- Arafa M, Noble J, Royle SG, et al. Dupuytren's and epilepsy revisited. J Hand Surg Br 1992; 17:221.
- Tripoli M, Cordova A, Moschella F. Dupuytren's contracture as result of prolonged administration of phenobarbital. Eur Rev Med Pharmacol Sci 2011; 15:299.
- Geoghegan JM, Forbes J, Clark DI, et al. Dupuytren's disease risk factors. J Hand Surg Br 2004; 29:423.
- Mikkelsen OA, Høyeraal HM, Sandvik L. Increased mortality in Dupuytren's disease. J Hand Surg Br 1999; 24:515.
- Ross DC. Epidemiology of Dupuytren's disease. Hand Clin 1999; 15:53.
- Anthony SG, Lozano-Calderon SA, Simmons BP, Jupiter JB. Gender ratio of Dupuytren's disease in the modern U.S. population. Hand (N Y) 2008; 3:87.
- Abe Y, Rokkaku T, Ofuchi S, et al. An objective method to evaluate the risk of recurrence and extension of Dupuytren's disease. J Hand Surg Br 2004; 29:427.
- Abe Y, Rokkaku T, Ofuchi S, et al. Dupuytren's disease on the radial aspect of the hand: report on 135 hands in Japanese patients. J Hand Surg Br 2004; 29:359.
- Larocerie-Salgado J, Davidson J. Nonoperative treatment of PIPJ flexion contractures associated with Dupuytren's disease. J Hand Surg Eur Vol 2012; 37:722.
- Ketchum LD, Donahue TK. The injection of nodules of Dupuytren's disease with triamcinolone acetonide. J Hand Surg Am 2000; 25:1157.
- Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytren's contracture unfolded. BMJ 2006; 332:397.
- Trojian TH, Chu SM. Dupuytren's disease: diagnosis and treatment. Am Fam Physician 2007; 76:86.
- Yacoe ME, Bergman AG, Ladd AL, Hellman BH. Dupuytren's contracture: MR imaging findings and correlation between MR signal intensity and cellularity of lesions. AJR Am J Roentgenol 1993; 160:813.
- Roush TF, Stern PJ. Results following surgery for recurrent Dupuytren's disease. J Hand Surg Am 2000; 25:291.
- 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 2009; 91:374.
- van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in dupuytren's disease. J Hand Surg Br 2006; 31:498.
- McMillan C, Binhammer P. Steroid injection and needle aponeurotomy for Dupuytren contracture: a randomized, controlled study. J Hand Surg Am 2012; 37:1307.
- Symes T, Stothard J. Two significant complications following percutaneous needle fasciotomy in a patient on anticoagulants. J Hand Surg Br 2006; 31:606.
- van Rijssen AL, Gerbrandy FS, Ter Linden H, et al. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren's disease: a 6-week follow-up study. J Hand Surg Am 2006; 31:717.
- Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for Dupuytren contracture in over 1,000 fingers. J Hand Surg Am 2012; 37:651.
- Badalamente MA, Hurst LC. Enzyme injection as nonsurgical treatment of Dupuytren's disease. J Hand Surg Am 2000; 25:629.
- Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren's contracture. J Hand Surg Am 2007; 32:767.
- Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med 2009; 361:968.
- Peimer CA, Blazar P, Coleman S, et al. Dupuytren contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS study): 3-year data. J Hand Surg Am 2013; 38:12.
- Verheyden JR. Early outcomes of a sequential series of 144 patients with Dupuytren's contracture treated by collagenase injection using an increased dose, multi-cord technique. J Hand Surg Eur Vol 2015; 40:133.
- Coleman S, Gilpin D, Kaplan FT, et al. Efficacy and safety of concurrent collagenase clostridium histolyticum injections for multiple Dupuytren contractures. J Hand Surg Am 2014; 39:57.
- Seegenschmiedt MH, Olschewski T, Guntrum F. Radiotherapy optimization in early-stage Dupuytren's contracture: first results of a randomized clinical study. Int J Radiat Oncol Biol Phys 2001; 49:785.
- Betz N, Ott OJ, Adamietz B, et al. Radiotherapy in early-stage Dupuytren's contracture. Long-term results after 13 years. Strahlenther Onkol 2010; 186:82.
- Hurst LC, Badalamente MA. Nonoperative treatment of Dupuytren's disease. Hand Clin 1999; 15:97.
- Gudmundsson KG, Arngrimsson R, Jónsson T. Eighteen years follow-up study of the clinical manifestations and progression of Dupuytren's disease. Scand J Rheumatol 2001; 30:31.