Dupuytren’s Contracture

Ovid: 5-Minute Sports Medicine Consult, The

Dupuytren's Contracture
Thomas Trojian
  • Contracture of the palmar fascia owing to fibrous proliferation and resulting in flexion deformities and loss of function. Similar changes rarely may occur in plantar fascia. Dupuytren contracture (DC) usually appears simultaneously.
  • Genetics:
    • Autosomal dominant with variable penetrance
    • 10% of patients have a positive family history.
  • System(s) affected: Musculoskeletal
  • Abbreviations: MP = metacarpophalangeal; PIP = proximal interphalangeal
  • Predominant age: 50 yrs for males; 60 yrs for females
  • Predominant gender: Male = Female (ranges from 2:1 to 10:1)
  • Prevalence is about 306/100,000.
  • Disease prevalence varies from 2–42% depending on population and risk factors.
  • Overall prevalence is 8.8% in Northern European population.
  • African Americans are less likely to get the disease.
  • Japanese and Taiwanese have a prevalence equal to that in Northern Europe. These patients usually present with a less severe form of the disease.
Risk Factors
  • Smoking (mean 16 pack-years; odds ratio = 2.8)
  • Alcohol intake
  • Both alcohol and cigarette use has a higher risk than individual use.
  • Increasing age (>40 yrs of age)
  • Male (increase in androgen receptors in nodules)
  • Northern European, Japanese, Taiwanese
  • Diabetes mellitus (1/3 affected, increases with time, usually mild; middle and ring fingers involved)
  • Epilepsy (may be medication or disease)
  • HIV infection (may or may not be associated)
  • Vibration work exposure (Some studies show increased risk, and other studies show no risk.)
  • Rheumatoid arthritis (lower risk)
  • Autosomal dominant with variable penetrance; in one family, the gene has been mapped to chromosome 16q.
  • >30 unique genes were upregulated, and 6 unique genes were downregulated by 4-fold or greater.
  • Upregulated genes include ones that code for fibronectin, tenascin C, transforming growth factor β2 (TGF-β2), collagen III, collagen IV, and collagen VI.
  • All 3 forms of TGF-β are upregulated. TGF-β2 is upregulated 10–20 times. As in tendinopathy, it may be a TGF receptor lack of response, so TGF continues to be made.
  • Musculoaponeurotic fibrosarcoma oncogene homologue B, or MafB, in the family of oncogenes is found in the cord but not paracord fascia of normal control individuals.
General Prevention
None known; avoid risk factors when possible.
  • Unknown
  • Ischemia to the fascia with oxygen free-radical formation
  • Possibly related to release of angiogenic basic fibroblast growth factor
  • Related to microhemorrhage and release of growth factors
Commonly Associated Conditions
  • Alcoholism
  • Smoking
  • Epilepsy
  • Diabetes mellitus
  • Occupational hand trauma (vibration white finger)
Physical Exam
  • Signs and symptoms:
    • Typical:
      • Caucasian male aged 50–60 yrs
      • Bilateral with one hand more involved
      • Family history
      • Unilateral or bilateral (50%)
      • Right hand more frequent
      • Ring finger more frequent
      • Ulnar digits more affected than radial
      • Mild pain early
      • Later painless plaques or nodules in palmar fascia
      • Extends into a cordlike band in the palmar fascia
      • Skin adheres to fascia and becomes puckered.
      • Nodules can be palpated under the skin.
      • Digital fascia becomes involved as disease progresses.
      • Web space contractures
      • Dupuytren diathesis can involve plantar (Ledderhose 10%) and penile (Peyronie 2%) fascia.
      • Knuckle pads
    • Atypical:
      • No age, gender differences
      • No family history
      • May have systemic disease (see “Risk Factors”)
      • May have a history of trauma
      • More common unilateral
      • No ectopic manifestations (Ledderhose or Peyronie)
      • Nonprogressive
  • Physical examination:
    • A firm nodule in the palm of the hand proximal to the metacarpophalangeal (MCP) joint
    • Hueston tabletop test
    • Test is positive if patient is unable to flatten his or her hand on the table.
Diagnostic Tests & Interpretation
  • Drugs that may alter lab results: N/A
  • Disorders that may alter lab results: N/A
  • Not needed except in rare cases
  • US can be used in diagnosis.
  • MRI can assess cellularity of lesions, which correlate with higher recurrence after surgery.
Diagnostic Procedures/Surgery
Rarely is a biopsy needed to differentiate Dupuytren nodule from a soft tissue tumor.
Pathological Findings
  • Myofibroblasts
  • 1st stage (proliferative): Increased myofibroblasts
  • 2nd stage (residual): Dense fibroblast network
  • 3rd stage (involutional): Myofibroblasts disappear.
Differential Diagnosis
  • Callus formation
  • Nodule on flexor tendon
  • Camptodactyly—early teens tight facial bands ulnar side of small finger
  • Soft tissue tumor


Ongoing Care
Follow-Up Recommendations
  • No activity restrictions
  • Physical therapy after surgery: Started 3–5 days after surgery (passive and active exercises, posterior dynamic extension splints)
Patient Monitoring
Follow patient in early stages of disease.
No special diet
Patient Education
  • Avoid risk factors, especially with a strong family history.
  • Regular follow-up by physician every 6 mos to 1 yr
  • Typical:
    • Unpredictable but usually slowly progressive
    • Patients likely to have aggressive disease (one or more): age 40 at onset, knuckle pads, positive family history, bilateral disease involving radial side of hand
    • Reports of clinical regression with continuous passive skeletal traction in extension and under a skin graft
    • Recurrence rate after surgery is 10–34%.
    • Prognosis better for MCP joint vs PIP joint after surgery.
  • Atypical:
    • Nonprogressive
    • Surgery rarely needed
    • Recurrence unlikely if surgery performed
728.6 Contracture of palmar fascia

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