A 52-year-old man diagnosed with Dupuytren contracture notices increasing contracture to his right ring finger. This image shows a large pretendinous cord in the palm of his hand in line with his ring finger.
Table top test of the patient’s affected hand.
A 52-year-old right-hand-dominant man presents with increasing contracture to his right ring finger. He was diagnosed with Dupuytren contracture a year earlier and has been monitoring the condition closely. Both his father and brother have Dupuytren contracture, with deformities much worse than his. On examination, the patient has a large pretendinous cord in the palm of his hand in line with his ring finger (Figure 1). He has an estimated 30-degree flexion contracture with good flexion strength. Table top test is shown in Figure 2. He has full range of motion of adjacent fingers.
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Dupuytren contracture is an abnormal thickening of the fibrous tissue under the skin in the hand that causes flexion of the fingers. The idiopathic condition is more common in men and is strongly associated with a family history.
Dupuytren generally starts as a firm lump or pit in the palm, and patients complain of difficulty placing the hand flat on a surface. The lump then progresses, causing tissue under the skin to form bands and contract. The fingers then begin to bend (most commonly, the 4th and 5th digits) and can no longer be fully extended. This progressive finger flexion makes it difficult for patients to do certain things like wear gloves, put the hand in a pocket, and take care of personal hygiene.1,2
First-line treatment of Dupuytren is observation, as the contracture may not be progressive. Splinting and physical therapy are not effective for initial treatment, although therapy may be used after injections or surgical treatment. Collagenase clostridium is an injectable enzyme that causes the collagen to degrade within connective tissue and helps release the contracture.
Collagenase clostridium is injected into the contracture and the patient is instructed to return to the office in 24 to 72 hours to undergo passive extension manipulation of the involved fingers using local anesthesia. After the manipulation has been performed in the office, the patient is often sent to physical therapy to work on finger extension and to be fitted for an extension night splint. The extension splint is typically worn at night for 4 weeks. Collagenase clostridium injection may be repeated after 6 weeks should flexion contracture remain.
Surgical treatments such as resection or fasciectomy are generally used when nonoperative treatments fail or when the flexion contracture progresses.1
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).
- Black EM, Blazar PE. Dupuytren disease: an evolving understanding of an age-old disease. J Am Acad Orthop Surg. 2011;19:746-757.
- Weatherford B. Dupuytren’s Disease. http://www.orthobullets.com/hand/6058/dupuytrens-disease. 2017. Accessed March 14, 2017.