Residency · Residency · Plastic Surgery

Dupuytren Disease and Hand Contractures

Overview

Dupuytren disease is a fibroproliferative disorder of the palmar and digital fascia that causes progressive flexion contracture of the fingers. It predominantly affects individuals of Northern European descent and has a strong genetic component. Treatment options range from minimally invasive percutaneous techniques to open fasciectomy, with recurrence being a common challenge. ---

Epidemiology and Etiology

Demographics

Prevalence: 3-6% in Western populations; up to 30% in Scandinavian countries. Male:female ratio: 7:1 (earlier onset and more severe in males). Average age of onset: 50-60 years. Bilateral involvement in 45-65% of cases.

Risk Factors

Northern European ancestry ("Viking disease"). Positive family history (autosomal dominant with variable penetrance). Diabetes mellitus (higher prevalence but milder disease). Smoking and alcohol use. Epilepsy (phenobarbital use). Manual labor (controversial -- may accelerate but does not cause). HIV infection.

Dupuytren Diathesis (Aggressive Disease Markers)

Early onset (<50 years). Bilateral disease. Positive family history. Ectopic disease: Garrod pads (knuckle pads), Ledderhose disease (plantar fibromatosis), Peyronie disease (penile fibromatosis). Higher recurrence rates after treatment. ---

Pathophysiology

Myofibroblast-Driven Fibrosis

Key cell: myofibroblast (contains alpha-smooth muscle actin). TGF-beta is the primary growth factor driving fibroblast proliferation and myofibroblast differentiation. Disease progression: proliferative phase (nodules) --> involutional phase (nodules to cords) --> residual phase (mature cords with contracture).

Molecular Pathways

WNT/beta-catenin signaling pathway implicated. Elevated levels of TGF-beta, PDGF, FGF in Dupuytren tissue. Free radical involvement (ischemia-reperfusion theory). ---

Anatomy of Dupuytren Disease

Normal Palmar Fascia Structures

Pretendinous bands (become pretendinous cords). Natatory ligaments (become natatory cords -- cause web space contracture). Spiral band (becomes spiral cord). Lateral digital sheet (becomes lateral cord).

Grayson ligament (may become part of the central cord). Cleland ligament (NOT involved in Dupuytren -- dorsal to the neurovascular bundle).

Pathologic Cords

Pretendinous cord: MCP joint contracture; neurovascular bundle is deep and protected. Central cord: MCP and PIP contracture; neurovascular bundle is deep. Spiral cord: most dangerous -- displaces the neurovascular bundle superficially and toward the midline. Components: pretendinous band, spiral band, lateral digital sheet, Grayson ligament.

The digital nerve becomes superficial, central, and at risk during surgery. Natatory cord: web space contracture. Lateral cord: PIP contracture; lies lateral to the neurovascular bundle. Retrovascular cord: passes dorsal to the neurovascular bundle; rare; causes DIP contracture. Abductor digiti minimi cord: ulnar border of the small finger.

Digits Most Commonly Affected

Ring finger (most common) > small finger > middle > index > thumb. MCP joint contracture is more common and more amenable to treatment than PIP contracture.

<image>Palmar anatomical illustration comparing normal palmar fascia on the left with Dupuytren disease on the right. The normal side shows the pretendinous band, spiral band, natatory ligament, lateral digital sheet, and the neurovascular bundle in its normal position. The disease side shows the spiral cord displacing the neurovascular bundle superficially and medially toward the midline, with the pretendinous cord causing MCP flexion contracture, and the relationship of each pathologic cord to the digital nerve clearly labeled with danger indicators.</image>

Clinical Evaluation

Staging -- Tubiana Classification

Total contracture = sum of MCP + PIP + DIP contracture.

Hueston Table Top Test

Patient attempts to place the hand flat on a table. Positive if the palm cannot be placed flat (typically >30 degrees contracture). Simple screening test; positive result is an indication to consider treatment.

Assessment

Document contracture at each joint (MCP, PIP, DIP) individually. Assess passive correctability of each joint. Fixed PIP contracture (non-correctible with MCP extended) indicates joint involvement beyond fascial disease. Evaluate skin quality, previous surgical scars, neurovascular status. ---

Treatment Options

Indications for Treatment

MCP contracture >30 degrees. Any PIP contracture (PIP contractures progress and respond less well to treatment). Positive table top test. Functional limitation reported by the patient.

Needle Aponeurotomy (Percutaneous Needle Fasciotomy)

Office-based procedure under local anesthesia. Hypodermic needle (18-25 gauge) used to perforate and weaken the cord percutaneously. Finger is extended to rupture the weakened cord. Advantages: minimally invasive, rapid recovery, repeatable.

Disadvantages: highest recurrence rate (50-65% at 3-5 years), risk of nerve/tendon injury (blind procedure), less effective for PIP contracture. Best for: elderly patients, MCP contracture, single cord.

Collagenase Injection (Xiaflex / Clostridium Histolyticum Collagenase)

Injectable enzyme that lyses collagen in the cord. Injection into the cord in clinic; patient returns 24-48 hours later for manipulation (extension) under local anesthesia. Advantages: minimally invasive, office-based, faster recovery than surgery. Disadvantages: recurrence rate 35-50% at 3-5 years, skin tearing (common), swelling/ecchymosis, tendon rupture risk (rare), allergic reaction. Note: availability varies (withdrawn from some markets due to commercial/regulatory reasons).

The following table compares treatment options and their recurrence rates:

Open Limited Fasciectomy (Gold Standard)

Excision of the pathologic fascial cord(s) through palmar and/or digital incisions. Most common surgical approach. Incision options: Brunner (zigzag), midlateral, longitudinal with Z-plasty closure. Meticulous identification and protection of the neurovascular bundles (especially with spiral cord).

Allows direct visualization and excision of all pathologic tissue. Recurrence rate: 20-40% at 5 years. Complications: digital nerve injury (3-5%), wound healing problems, hematoma, infection, stiffness, CRPS, flare reaction.

Dermofasciectomy

Excision of the cord AND overlying skin; defect covered with full-thickness skin graft. Indicated for: recurrent disease, aggressive diathesis, significant skin involvement. Lowest recurrence rate (~8-12% at 5 years) -- skin graft acts as a "firebreak". Higher wound complication rate.

Radical (Total) Fasciectomy

Excision of all palmar fascia (diseased and uninvolved). Rarely performed due to high complication rate without proven benefit over limited fasciectomy.

McCash Open Palm Technique

Transverse palmar wound left open to heal by secondary intention after fasciectomy. Reduces hematoma formation and flare reaction. Wound heals in 3-4 weeks with satisfactory results. Useful for severe palmar contractures. ---

PIP Joint Contracture Management

Challenge

PIP contracture has the worst outcomes of any aspect of Dupuytren disease. Contracture involves not just the fascia but also the volar plate, accessory collateral ligaments, and checkrein ligaments. Chronic contracture (>45 degrees for >1 year) often has fixed joint changes.

Surgical Adjuncts

Volar plate release (checkrein ligament release). Accessory collateral ligament release. Joint capsulotomy (when passive extension is not restored after fasciectomy). Penrose drain traction ("skeletal traction" overnight) postoperatively. External fixation (compass hinge) for severe fixed contractures.

Salvage Options

PIP arthrodesis: for painful, stiff, or recurrent PIP contracture (functional position: index 25, middle 30, ring 35, small 40 degrees). PIP arthroplasty: preserves motion but limited durability. Amputation: for severe, recurrent, non-functional fingers (especially small finger with >60 degrees fixed PIP contracture). ---

Postoperative Management

Hand Therapy

Extension splinting: continuous for 2 weeks, then nighttime for 3-6 months. Active and passive range of motion exercises beginning within days. Edema control, scar management.

Flare Reaction

Inflammatory response with diffuse swelling, pain, stiffness. Occurs in up to 10% of patients. More common in women and after aggressive surgery. Management: gentle therapy, avoid aggressive stretching, low-dose corticosteroids if severe.

<image>Operative photograph-style illustration showing open limited fasciectomy for Dupuytren disease through a Brunner zigzag incision on the ring finger. The pathologic spiral cord is shown being excised with the neurovascular bundle identified and retracted with a vessel loop, displaced superficially and centrally by the cord. The pretendinous cord at the palm is also visible. Key structures labeled include the digital nerve (displaced), digital artery, cord being excised, and intact flexor tendon sheath beneath.</image>

Clinical Pearls

The spiral cord is the most dangerous structure in Dupuytren disease -- it displaces the digital nerve superficially and centrally, placing it directly in the path of surgical dissection. Cleland ligaments are NOT involved in Dupuytren disease (dorsal to the neurovascular bundle) while Grayson ligaments (volar) may be involved. PIP contractures have the worst prognosis and highest recurrence -- intervene early before fixed joint changes develop. Needle aponeurotomy and collagenase injection have faster recovery but higher recurrence rates than open fasciectomy -- appropriate patient selection is key.

The Hueston table top test (inability to lay the hand flat) is a simple indicator that treatment should be considered. Dupuytren diathesis (early onset, bilateral, family history, ectopic disease) predicts aggressive disease and higher recurrence regardless of treatment modality. Dermofasciectomy with full-thickness skin graft has the lowest recurrence rate and should be considered for recurrent or aggressive disease. Always warn patients that Dupuytren disease is not curable -- all treatments have recurrence rates, and multiple procedures may be needed over a lifetime. ---.

References

• Luck JV. Dupuytren's contracture: a new concept of the pathogenesis correlated with surgical management. J Bone Joint Surg Am. 1959;41(4):635-664.
• Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. 2009;361(10):968-979.
• Hueston JT. Dupuytren's contracture and specific injury. Med J Aust. 1968;1(24):1084-1085.
• Tubiana R. Evaluation of deformities in Dupuytren's disease. Ann Chir Main. 1986;5(1):5-13.
• McFarlane RM. On the origin and spread of Dupuytren's disease. J Hand Surg Am. 2002;27(3):385-390.
• van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129(2):469-477.
• Denkler K. Surgical complications associated with fasciectomy for Dupuytren's disease. J Hand Surg Am. 2010;35(7):1220-1228.

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