Describe Dupuytren’s Contracture in detail.

Definition

Dupuytren’s contracture is a progressive fibroproliferative disease of the palmar (and digital) fascia, in which the fascia thickens and contracts, pulling the fingers into fixed flexion. It is not a disease of the tendons themselves. It is commoner in men of northern-European descent and increases with age.

Associations & Clinical Features

Recognised associations include a family history (autosomal-dominant tendency), alcohol and liver disease, diabetes, epilepsy/anticonvulsants and smoking. It usually begins as a painless nodule in the palm, most often in line with the ring and little fingers, progressing to a cord that causes fixed flexion at the MCP and PIP joints. The Hueston ‘table-top’ test (inability to lay the hand flat) indicates significant contracture.

Management

Early, non-progressive disease is observed. Intervention is indicated for a functionally limiting contracture (e.g. A positive table-top test or a fixed PIP contracture): options include needle aponeurotomy, collagenase injection, and surgical fasciectomy (excision of the diseased fascia), followed by splinting and hand therapy. Recurrence is common, particularly in aggressive (‘diathesis’) disease.

Prognosis & Recurrence

Dupuytren’s disease is chronic and tends to progress slowly over years, and no treatment cures the underlying diathesis. Recurrence after any intervention is common, and is more likely in patients with an aggressive ‘Dupuytren’s diathesis’ — young onset, strong family history, bilateral disease and ectopic fibrosis (Ledderhose’s and Peyronie’s disease). Realistic counselling about progression and recurrence is therefore an important part of management, and surgery is timed to functional need rather than the mere presence of a cord.

Table-top test indicates when surgery should be considered.

• Fibroproliferative disease of palmar fascia (not tendons) → fixed finger flexion.
• Men, northern-European descent; assoc. Family history, alcohol/liver disease, diabetes, epilepsy.
• Nodule → cord; ring & little fingers; positive Hueston table-top test.
• Observe if mild; fasciectomy / needle aponeurotomy / collagenase for limiting contracture; recurs.