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Dupuytren's contracture

INTRODUCTION

Dupuytren's contracture is a relatively common disorder characterized by progressive fibrosis of the palmar fascia [1]. Initial tendon thickening is painless and often goes unnoticed and undiagnosed. Joint stiffness and a loss of full extension develop insidiously over decades. As the scarring process progresses, nodules form on the palmar fascia and the finger gradually loses its flexibility, with contractures that draw one or more fingers into flexion at the metacarpophalangeal (MP) joint (picture 1) [2].

ETIOLOGY

The cause of Dupuytren's contracture is unknown. The presence of CD3-positive lymphocytes and the expression of MHC class II proteins suggest the possibility of a T-cell mediated autoimmune disorder [3]. It occurs primarily in white males over the age of 50 and appears to have a pronounced genetic predisposition: 68 percent of male relatives of affected patients develop the disease at some time.

Pathologically, Dupuytren's contracture is characterized by fibroblastic proliferation and disorderly collagen deposition with fascial thickening. Nodules form due to contraction of fibroblasts in the superficial palmar fascia. 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 [4]. The flexor tendons are not intrinsically involved, but invasion of the dermis occurs and results in characteristic puckering and tethering of the skin.

Dupuytren's contracture has been observed in association with the following conditions and habits [5-12]:

  • A literature review found that the incidence of Dupuytren's contracture is two to five times higher among workers exposed to repetitive handling tasks or vibration as compared to those not exposed such trauma [5].
  • Dupuytren's contracture occurs with increased frequency (16 to 42 percent) in adults with diabetes mellitus). (See "Musculoskeletal complications in diabetes mellitus".)
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References Top
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  2. Anderson, BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd ed, WB Saunders Company, Philadelphia 1999.
  3. Baird, KS, Alwan, WH, Crossan, JF, Wojciak, B. T-cell-mediated response in Dupuytren's disease. Lancet 1993; 341:1622.
  4. Badalamente, MA, Hurst, LC, Sampson, SP. Prostaglandins influence myofibroblast contractility in Dupuytren's disease. J Hand Surg 1988; 13:867.
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  6. Matsen, FA, Kirby, RM. Office evaluation and management of shoulder pain. Orthop Clin North Am 1982; 13:453.
  7. Bridgman, JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis 1972; 31:69.
  8. Lynch, M, Jayson, MIV. Fasciitis and fibrosis. Clin Rheum Dis 1979; 5:833.
  9. Wooldridge, WE. Four related fibrosing diseases. When you find one, look for another. Postgrad Med 1988; 84:269.
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  12. Frey, M. Risks and prevention of Dupuytren's contracture (Commentary). Lancet 1997; 350:1568.
  13. Leslie, BM. Palmar fasciitis and polyarthritis associated with a malignant neoplasm: a paraneoplastic syndrome. Orthopedics 1992; 15:1436.
  14. Mikkelsen, OA, Hoyeraal, HM, Sandvik, L. Increased mortality in Dupuytren's disease. J Hand Surg [Br] 1999; 24:515.
  15. Gudmundsson, KG, Arngrimsson, R, Jonsson, T. Eighteen years follow-up study of the clinical manifestations and progression of Dupuytren's disease. Scand J Rheumatol 2001; 30:31.
  16. Townley, WA, Baker, R, Sheppard, N, Grobbelaar, AO. Dupuytren's contracture unfolded. BMJ 2006; 332:397.
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  19. Roush, TF, Stern, PJ. Results following surgery for recurrent Dupuytren's disease. J Hand Surg [Am] 2000; 25:291.
  20. van Rijssen, AL, Werker, PM. Percutaneous needle fasciotomy in dupuytren's disease. J Hand Surg [Br] 2006; 31:498.
  21. Symes, T, Stothard, J. Two significant complications following percutaneous needle fasciotomy in a patient on anticoagulants. J Hand Surg [Br] 2006; 31:606.
  22. 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.
  23. Badalamente, MA, Hurst, LC. Enzyme injection as nonsurgical treatment of Dupuytren's disease. J Hand Surg [Am] 2000; 25:629.
  24. 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.
  25. Hurst, LC, Badalamente, MA, Hentz, VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med 2009; 361:968.
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