Figure 1. Anterior view of the right hand.
Figure 2. Lateral view of the right hand.
A 75-year-old man presents with a flexed ring finger of the right hand that has been deformed for the past few years (Figures 1 and 2). The patient lives in an assisted living facility and his daughter requested an examination of the finger. The patient denies any functional limitations other than difficulty shaking hands or wearing gloves. The deformity has progressed slowly over the last few years.
Which of the following is the best next step in management?
Submit your diagnosis to see full explanation.
Dupuytren contracture is a disease of unknown etiology that causes the palmar fascia of the hand to develop nodules or cords, which progressively shorten and lead to contracture of the joints of the fingers and the inability to extend the affected digits. Cords can extend from the palmar fascia into the finger along the flexor tendon and can cause skin thickening in the palm below the involved digit. Progressive contractures can cause fixed flexion deformities of the metacarpophalangeal and proximal interphalangeal joints, with the ring finger being the most commonly affected followed by the small and middle fingers. In early stages, Dupuytren disease presents with an enlarging nodule in the palm of the hand and progresses distally as the finger gradually begins to flex. The condition may cause difficulties putting the hands in a pocket, wearing gloves, and shaking hands.
When the contracture is not painful and does not cause functional impairment, observation alone generally is recommended, as the recurrence rate for all forms of treatment is high. Splinting and physical therapy fail to reverse or improve contractures and should not be used. A corticosteroid injection is administered occasionally for short-term relief and can reduce the size of symptomatic nodules. Palmar fasciectomy was the traditional treatment approach before collagenase Clostridium histolyticum injections were approved by the US Food and Drug Administration in 2010. The enzymes contained in this preparation digest diseased cords until they can be broken apart manually 24 hours after injection. This is followed by a period of splinting and occupational therapy.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
1. Riester S. Van Wijnen A, Rizzo M, Kakar S. Pathogenesis and treatment of Dupuytren disease. JBJS Rev. 2014;2(4).
2. Ghazi R. Dupuytren disease: anatomy, pathology, presentation, and treatment. J Bone Joint Surg Am. 2007;89(1):189-198.