Dupuytren's contracture
Pathophysiology
- Local microvessel ischaemia thought to result in increased activity of xanthine oxidase
- Results in superoxide free radical production
- Stimulates myofibroblast proliferation and type III collagen formation
- Specific PDGFs and FGFs play role in aetiology
- Process of chronic inflammation thought to be essential to subsequent fibrosis
Approach
- Expose to elbows
- Ask patient to place hands palm up on a pillow
- Look
- Tethering/ pitting of skin on palmar aspect of the hand - also note any visible cords
- Look for scars from previous surgery
- Describe any flexion deformities at the metacarpophalangeal and proximal interphalaneal joints of the involved fingers
- Look for involvement of the thumb and the 1st web space (sign of more aggressive disease)
- Turn hand over - look for Garrod's pads
- Feel
- Palpate swelling, note fixation to skin
- Does palm have similar thickening?
- Move
- Assess range of motion in involved fingers
- Note presence of fixed deformities by passively moving involved joints
Completion
- Enquire about associations
- Idiopathic
- Liver disease
- Diabetes
- Epilepsy
- Age
- Family history
- Smoking
- Manual labour
- Peyronie's disease
- AIDS
- Assess function - writing / dressing
- Look for other features of diffuse fibromatosis
- Ledderhose disease: fibrosis of plantar aponeurosis seen in 5% patients with Dupuytren's
Differential diagnosis
- Skin contracture - scar from previous wound
- Tendon contracture - moves with passive flexion
- Congenital contracture of little finger
- Ulnar nerve palsy (hand of benediction)
Treatment options in Dupuytren's
- Operative management considered when contracture exceeds 30'
- Options
- Fasciotomy - for prominent bands
- Partial fasciectomy with Z-plasty to lenghten wound in conjunction with post-operative physiotherapy
- Dermofasciectomy (with full thickness skin grafting) associated with the lowest risk of recurrence
- Arthrodesis / amputation
