Dupuytren’s Contracture

Authors:
Tejaswini Potlabathini,
Elaine Tran,
PA Student, University of Texas Medical Branch, Galveston, Tx.
Amin H. Karim MD FRCP FACC

Patient Overview

A 72-year-old female with a past medical history of hypertension, hyperlipidemia, hypothyroidism, and prediabetes presented to the cardiology clinic for a routine follow-up. On examination, she was found to have a firm, nodular thickening of tissue on one palm over the third metacarpal area, associated with nearby skin puckering, prompting a presumptive diagnosis of Dupuytren’s contracture.

Description

Dupuytren’s contracture is a progressive fibroproliferative disorder of the palmar fascia that leads to flexion contractures of the digits. It affects approximately 0.6% to 31.6% of the general population, with prevalence increasing with age. While its exact cause remains unclear, it is believed to have a multifactorial etiology involving both genetic and environmental factors. Genetically, it follows an autosomal dominant inheritance pattern more commonly in individuals of Northern European descent. The condition predominantly affects men but can also occur in women, often with a later onset and milder progression. Dupuytren’s contracture is associated with other fibrotic disorders, including plantar fibromatosis (Ledderhose disease) and dorsal hand nodules (Garrod pads). Several risk factors have been identified, including diabetes mellitus, smoking, and chronic alcohol consumption, all of which may contribute to microvascular ischemia and tissue damage. Additionally, the condition has been linked to seizure disorders and chronic liver disease, particularly in patients with cirrhosis. Occupational risk factors, such as repetitive manual labor and prolonged exposure to hand-transmitted vibration, may also accelerate disease progression.

Etiology

Fibroblasts, which are mesenchymal cells responsible for tissue maintenance, play a crucial role in the pathology of Dupuytren’s contracture. The disease progresses through three stages: proliferative, involutional, and residual. In the proliferative stage, fibroblasts are stimulated and differentiate into mature myofibroblasts under the influence of transforming growth factor-beta (TGF-β) and mechanical stress from associated risk factors. As the disease advances to the involutional stage, nodules begin to form, producing an extracellular matrix (ECM) rich in type III collagen. In the residual stage, fibrotic tissue stabilizes as the ratio of type I to type III collagen increases, leading to collagen cross-linking. This results in the formation of fibrous cords, which cause progressive digital flexion contractures. Additionally, the presence of CD3-positive lymphocytes and the expression of major histocompatibility complex (MHC) class II proteins suggest a possible role for a T-cell-mediated autoimmune response in the disorder. In summary, Dupuytren’s contracture arises from fibroblastic proliferation and disorganized collagen deposition, ultimately leading to palmar fascial thickening and contracture formation.

Image Source: https://www.sciencedirect.com/science/article/pii/S0363502323000709

Clinical Presentation

Patients with Dupuytren’s contracture may present with painful or painless lumps in the palm, along with restricted finger mobility and decreased grip strength. As the nodules thicken and fibrous cords form, patients may experience difficulty straightening or spreading their fingers due to flexion contractures. The fourth and fifth digits are most commonly affected, with contractures typically involving the metacarpophalangeal (MCP) joint first, followed by the proximal interphalangeal (PIP) joint, and less frequently, the distal interphalangeal (DIP) joint.

Physical Examination 

On physical examination, the Hueston Tabletop Test can be performed. Patients are asked to place their palm flat on a table, and failure to do so indicates a positive test. If contractures are present, the angles at the MCP and PIP joints should be measured to assess disease severity and progression. Grading of Dupuytren’s contracture is as follows: Grade 1 presents as a thickened nodule and band in the palmar aponeurosis, which may progress to skin tethering, puckering, or pitting. Grade 2 presents as a peritendinous band, leading to limited extension of the affected finger. Grade 3 presents as a significant flexion contracture.

Treatment

Although there is no definitive cure for Dupuytren’s contracture, symptoms can be managed through nonsurgical and surgical options. Nonsurgical options include corticosteroid injections, collagenase clostridium histolyticum injections, and needle aponeurotomy. Corticosteroids alleviates symptoms by reducing inflammation while targeted collagenase injections can target and enzymatically degrade the collagen. In needle aponeurotomy, a fine needle is used to precisely cut through the fibrous cord. While this minimally invasive procedure does not remove the cord, a break in the cord allows for improved finger motion. Although more invasive and extensive, a partial palmar fasciectomy removes the abnormal tissue fibrous tissue and cords. Postoperative care includes splinting, wound care, and physical therapy. Emerging therapies include use of anti-tumor necrosis factors such as adalimumab injections to slow disease progression by targeting inflammatory pathways.  

References: 

1. American Academy of Orthopaedic Surgeons. Dupuytren’s disease. OrthoInfo. Updated March 2023. Accessed January 25, 2025. https://orthoinfo.aaos.org/en/diseases–conditions/dupuytrens-disease/
2. Dupuytren’s contracture. UpToDate. Updated January 15, 2025. Accessed January 25, 2025. https://www.uptodate.com/contents/dupuytrens-contracture
3. Hindocha S, Stanley JK, Watson S, Bayat A. Revised Tubiana’s staging system for assessment of disease severity in Dupuytren’s disease—preliminary clinical findings. EBioMedicine. 2018;36:86-90. doi:10.1016/j.ebiom.2018.06.022.
4. National Library of Medicine. Dupuytren contracture. MedlinePlus Genetics. Updated June 17, 2023. Accessed January 25, 2025. https://medlineplus.gov/genetics/condition/dupuytren-contracture/
5. Zarb RM, Graf AR, Talhelm JE, et al. Dupuytren’s contracture recurrence and treatment following collagenase Clostridium histolyticum injection: a longitudinal assessment in a veteran population. Mil Med. 2023;188(9-10):e2975-e2981. doi:10.1093/milmed/usad075.