December 19, 2021
dupuytrens contracture cover

Review on Dupuytren’s Contracture

Introduction

A Dupuytren’s contracture was first discovered in the 1600s and bears the name of a French surgeon who reported on the contracture in the Lancet in 1834 (1). The mechanism behind the formation of a Dupuytren contracture involves the formation of a nodule within the palmar portion of the hand that leads to skin tightness (4). The tension provided by the nodule can form a cord within the palm that leads to contractures of the MCP and PIP joints (4). The cords found in the palm of the hand are compromised of Type III collagen which differs from the Type I collagen that makes up the normal palmar fascia (1). 

Case Vignette

A 55 year old male is complaining of thick band like lesions in the center of his palm of the right hand. He says that he is struggling to straighten out his fourth digit due to the tightness in the band. He has had no injury or trauma. Which of the following could be used to treat the band and contracture?

A) Collagenase injection
B) Cortisone injection over the A1 pulley
C) Finger splint
D) Physical therapy with focus on soft tissue

dupuytren band

Tubiana staging for Dupuytren contracture (1)

Diagnosis

Male patients in their 50s are the predominant demographic at risk for developing a Dupuytren contracture (1). Most of the time, patients will be pain free but some will complain of pain with gripping as the contracture progresses (6). Physical exam will aid in making the diagnosis of a Dupuytren contracture. A palpable band will be found within the palmar fascia.  A palpable band will not be palpated with a trigger finger, which is sometimes confused with a Dupuytren contracture. Once a Dupuytren contracture has been found, providers should look for other associated fibromatoses within the plantar fascia, penis, and dorsal hands (1). A Dupuytren contracture can be staged using the Tubiana staging criteria (7). 

Tubiana staging for Dupuytren contracture

Tubiana staging for Dupuytren contracture (7)

Treatment

There are three primary treatments of a Dupuytren contracture, which are needle aponeurotomy, collagenase injection, and fasciotomy (1). A needle aponeurotomy involves using a needle to cut the band by repetitively perforating the cord with a needle until it ruptures (2). The primary risks involved due to the repetitive needling is developing a skin tear, injury to the flexor tendon, and injury to the neurovascular structures (2). One of the other downfalls of a needle aponeurotomy is the high risk for recurrence following the procedure (7).

Injections of collagenase, which is derived from Clostridium histolyticum, can also be injected into the cord to help rupture the cord (1). Typically, injection into the length of the cord can be done in the office and then within 1-7 days, the patient comes back in for digit manipulation and passive extension to rupture the cord (1). Primary side effects from a collagenase injection include pain and edema (3). 

Fasciectomy can also be done to debride the contracture (1). The overall risk for damage to the tendon with this procedure is 0.2% (3). The success of the procedure usually sits around 75% (6). Patients who undergo surgical fasciectomy compared to collagenase fasciectomy are  found to have a lower risk for recurrence (4). 

Conclusion

A Dupuytren contracture is a band within the palm of the hand that can form contractures of the MCP and PIP joint. Multiple treatments exist, including needle aponeurotomy, collagenase injection, and fasciectomy. These patients are typically referred to hand surgery for follow up. 

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By Gregory Rubin, DO

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Case Conclusion

Answer: A. The patient in the vignette likely has a Dupuytren’s contracture. These are Type III collagen nodules that form thick band-like palmar contractures that lead to finger flexion. The treatment options for a Dupuytren’s contracture are needle aponeurotomy, collagenase injections, or fasciectomy. A collagenase injection is a derivative of Clostridium Histolyticum and can be injected into the band to help rupture the band.

Gruber, Jillian S., et al. “Limited Fasciectomy Versus Collagenase Clostridium Histolyticum for Dupuytren Contracture: A Propensity Score Matched Study of Single Digit Treatment With Minimum 5 Years of Telephone Follow-Up.” The Journal of Hand Surgery, vol. 46, no. 10, Oct. 2021, pp. 888–95. PubMed, https://doi.org/10.1016/j.jhsa.2021.05.022

References

1)   Boe, Chelsea, et al. “Dupuytren Contractures: An Update of Recent Literature.” The Journal of Hand Surgery, vol. 46, no. 10, Oct. 2021, pp. 896–906. PubMed, https://doi.org/10.1016/j.jhsa.2021.07.005.

2)   Pess, Gary M., et al. “Results of Needle Aponeurotomy for Dupuytren Contracture in over 1,000 Fingers.” The Journal of Hand Surgery, vol. 37, no. 4, Apr. 2012, pp. 651–56. PubMed, https://doi.org/10.1016/j.jhsa.2012.01.029.

3)   Coleman, Stephen, et al. “Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for Multiple Dupuytren Contractures.” The Journal of Hand Surgery, vol. 39, no. 1, Jan. 2014, pp. 57–64. PubMed, https://doi.org/10.1016/j.jhsa.2013.10.002

4)   Gruber, Jillian S., et al. “Limited Fasciectomy Versus Collagenase Clostridium Histolyticum for Dupuytren Contracture: A Propensity Score Matched Study of Single Digit Treatment With Minimum 5 Years of Telephone Follow-Up.” The Journal of Hand Surgery, vol. 46, no. 10, Oct. 2021, pp. 888–95. PubMed, https://doi.org/10.1016/j.jhsa.2021.05.022.

5)   Chambers, James, et al. “Office-Based Percutaneous Fasciotomy for Dupuytren Contracture.” The Orthopedic Clinics of North America, vol. 51, no. 3, July 2020, pp. 369–72. PubMed, https://doi.org/10.1016/j.ocl.2020.02.008.

6) Dias, Joseph J., and Sheweidin Aziz. “Fasciectomy for Dupuytren Contracture.” Hand Clinics, vol. 34, no. 3, Aug. 2018, pp. 351–66. PubMed, https://doi.org/10.1016/j.hcl.2018.04.002.

7) Elzinga, Kate E., and Michael J. Morhart. “Needle Aponeurotomy for Dupuytren Disease.” Hand Clinics, vol. 34, no. 3, Aug. 2018, pp. 331–44. PubMed, https://doi.org/10.1016/j.hcl.2018.03.003.