K.W. is an active 92-year-old, right-handed, Caucasian female with nodule and contracture formation of the right palmar fascia with extension to the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.
She states that this condition has been present for at least 15 years and has slowly progressed. The patient hit the dorsal aspect of her right hand on a wooden railing 17 years ago and began noticing increased flexion in the months following the injury, which she attributed to age and arthritis.
At present, the fourth and fifth digits of the right hand are in fixed flexion (Figure 1). The digits are unable to be actively or passively extended. Obvious cord formation is present in the palmar fascia extending to the fourth digit PIP. The deformity limits the patient’s dexterity and hand function, including turning doorknobs, opening jars or other containers with screw tops, and various activities of daily living.
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For patients with Dupuytren disease, your treatment recommendation is usually:
She has never sought medical attention for the disorder, and the progressive flexion has not been therapeutically addressed by K.W.’s primary care provider.
Old disorder, new treatment approach
Dupuytren disease is an old disorder with a new therapeutic focus. Although the clinical prevalence is about 1% in the United States, patient-reported symptoms exhibit a prevalence of roughly 7%.1 However, because of the genetic nature of the disease, prevalence may exceed 50% in some geographic locations of the country. This disorder is more common in those of European ancestry and in males, which contributes to prevalence variability in the U.S.2
With its subtle initial presentation, Dupuytren disease can be easily overlooked in the primary care setting. Recent studies suggest that this is an area in which patients’ medical needs are not being met. Specifically, there is a need for better recognition of symptoms by patients and practitioners, as well as better education for clinicians not specialized in hand disorders.1
Dupuytren disease typically manifests in the fourth to fifth decades of life, with a mean age of 50 years in the U.S.1 It is a progressive fibroproliferative disorder affecting the palmar fascia of the hand with potential to extend to the MCP and the PIP joints causing fascia shortening and thickening, eventually leading to flexion contractures.3 Initially, a painless nodule develops (grade 1) and slowly progresses to a palpable cord (grade 2) and contracture formation (grade 3).
Figure 1. Patient presentation with Dupuytren disease.
Family history, tobacco and alcohol use, and diabetes correlate with an increased incidence of Dupuytren disease.4 As the disease progresses, it can be quite disabling and significantly decrease a patient’s quality of life. Although there is no definitive cure, treatment methods can help reduce morbidity and preserve hand function.
Early recognition of this disorder in the primary care setting will benefit patients, as earlier therapeutic intervention may allow for better treatment success and an overall more favorable prognosis, according to Mark Fulcher, MD, a hand surgeon at Georgia Regents University. Referral to a hand specialist should be advised if a patient can no longer flatten the hand against a tabletop.
Referral is also warranted after contracture formation, especially at the PIP joints, because correction is much more difficult as contracture progresses. Early intervention may be an important step in the overall treatment of Dupuytren disease. Surgical intervention is recommended for contractures exceeding 30˚ of flexion at the PIP joint, 20˚ of flexion at the MCP joint, or for patients with diminished hand function that interferes with daily activities (Fulcher M., personal communication, Oct. 27, 2014).
Because of the invasive nature of surgical fasciectomy and the higher incidence of complications, hand specialists are now recommending less invasive techniques to reduce or eliminate contractures. At the forefront are two options: (1) needle aponeurotomy; and (2) collagenase Clostridium histolyticum (CCH).5, 6 However, there is no consensus among hand surgeons regarding which method is most effective with regard to clinical outcome and recurrence rate.7 This article examines these two techniques and compares recurrence and overall patient satisfaction (Table 1).
