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A 52-year-old woman presents to the office for evaluation of a firm, painless nodule and cords in the palm of her right hand. On physical examination, the 2 cords involve the third and fourth digits of her right hand. She is able to use the hand without limitation and can fully extend all fingers with no flexion contracture of the metacarpophalangeal (MCP) joints.
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Dupuytren disease, or Dupuytren contracture, is an abnormal proliferation of the palmar fascia of the hand that leads to thickening of the palmar fascia. As the cord or thickening progresses, a flexion deformity of the MCP joint may start to develop.1,2 The patient in this case presents early in the disease with a painless enlarging nodule and 2 cords in the palm of her right hand.
Dupuytren disease has a strong genetic component. Researchers have identified 9 genetic loci associated with the disease, which explain approximately 1% of the heritability of the disease. In a recent study, investigators identified an additional 14 new genetic loci containing genes associated with the Wnt-signaling pathway, suggesting that these loci may play a critical role in Dupuytren disease.3
As there is no known cure, Dupuytren disease is difficult to treat and the disease often progresses. Observation is the best treatment option for patients who present early in the disease without pain and functional limitations.
Physical therapy and bracing have not been shown to prevent or reverse Dupuytren contractures. Intralesional steroid injections may soften the nodule and potentially slow disease progression. Injection of collagenase Clostridium histolyticum into the disease nodule can help break up and rupture cords to release flexion contractures. Surgical resection of the cords is indicated when there is decreased hand function caused by flexion contractures at the MCP joint of more than 30 degrees and at the proximal interphalangeal joint of more than 15 degrees.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 Orthopaedics for Physician Assistants.
References
1. Rayan G. Dupuytren disease: anatomy, pathology, presentation, and treatment. Instr Course Lect. 2007;56:101-111.
2. Riester S, van Wijnen A, Rizzo M, Kakar S. Pathogenesis and treatment of Dupuytren disease. JBJS Rev. 2014;2(4):e2. doi:10.2106/JBJS.RVW.M.00072
3. Becker K, Siegert S, Toliat MR, et al. Meta-analysis of genome-wide association studies and network analysis-based integration with gene expression data identify new suggestive loci and unravel a Wnt-centric network associated with Dupuytren’s disease. PLoS One. 2016;11(7):e0158101. doi:10.1371/journal.pone.0158101
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