Pathophysiology of Dupuytren’s Disease: Why Does the Hand Contract?
Dupuytren's disease is a progressive condition that causes the thickening and shortening of the palmar fascia, primarily affecting the fourth (ring) and fifth (pinky) fingers. It begins with painless nodules in the palm, which develop into fibrous cords, leading to contracture deformities. The condition is more common in individuals of white ethnicity, often occurs in both hands, and, when unilateral, typically affects the right hand. It has a strong genetic component and is more prevalent in men. In its early stages, the disease presents as palmar nodules with little or no finger contracture, but it can progress to significant functional impairment.
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​Dupuytren's disease initially presents with pitting and thickening of the palmar skin. However, early diagnosis relies on identifying a firm, painless nodule that is attached to both the skin and deeper fascia. Typically, this nodule appears before the formation of a cord. Over time—ranging from months to several years—the cord progressively tightens, pulling the metacarpophalangeal and proximal interphalangeal joints into flexion, leading to increasing digital deformity. While contracture is a frequent reason for seeking medical attention, concerns about malignancy or discomfort in social situations, such as handshaking, may also prompt consultation. The condition most commonly affects the ring and little fingers but can involve any digit. The primary impact is reduced hand function, which can interfere with daily tasks at work (e.g., manual labor, wearing gloves) and home (e.g., washing, dressing), potentially compromising independence.
Factors associated with Dupuytren's disease:
· Smoking
· Alcohol
· Diabetes mellitus
· Anticonvulsants
· Epilepsy
· Hypercholesterolaemia
· Manual labour
· Hand trauma
Nonsurgical Treatment:
In Europe, the only approved nonsurgical treatment for Dupuytren’s contracture (DC) is the injection of collagenase clostridium histolyticum (CCH) into the pathological cord. CCH works by enzymatically breaking down collagen, allowing the contracted cord to be disrupted with gentle manipulation 1–2 days post-injection. Treatment is considered successful if the affected joint achieves an extension of 0–5° from full extension and shows at least a 50% reduction in contracture.
Hand therapy plays a crucial role in restoring function and preventing further disability. Key components include patient education, oedema management, wound and scar care, splinting, exercises, passive stretching, and a gradual return to daily activities. Splinting primarily aims to reduce recurrence risk and prevent flexion contracture caused by scarring. Targeted splinting for proximal interphalangeal joint (PIPJ) contracture has shown positive outcomes after four weeks. For optimal results, splints should be carefully molded, applying low, sustained force to induce tissue elongation without causing micro-tears.
Since the ligaments and surrounding tissues in DC remain shortened for extended periods, regaining range of motion (ROM) requires elongation through finger exercises, hand use, and splinting. Exercises that keep the metacarpophalangeal joint (MCPJ) in flexion while actively extending the PIPJ can enhance PIPJ extension. To lengthen the often-contracted oblique retinacular ligament, the PIPJ should be fully extended while the distal interphalangeal joint (DIPJ) undergoes active movement.
If hand function is reduced, general hand exercises and daily functional use are essential. Studies suggest that purposeful activities resembling everyday tasks promote better recovery than isolated exercises, as they naturally increase movement repetitions. Encouraging patients to use their affected hand in daily activities can enhance functional recovery and overall satisfaction with hand use.
Surgical Treatment:
Several surgical options exist, each with varying efficacy, recovery time, and recurrence rates:
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Limited Fasciectomy (LF): The most common surgical treatment, offering good functional outcomes. However, recovery can be slow due to prolonged wound healing and scar maturation. Recurrence rates range from 12% to 73%, and complications, such as stiffness (3.6%–39.1%) and nerve injury (15.7%), may occur.
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Segmental Fasciectomy (SF): A less invasive option that removes small sections of the pathological cord. It has a lower complication rate (0–5.6%) and allows quicker recovery with less pain. However, its long-term recurrence risk remains uncertain.
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Percutaneous Needle Fasciotomy (PNF): The least invasive technique, suitable for contractures up to 90°. It offers quick recovery with minimal complications (0%) but has a high recurrence rate (85% after 2.3 years). Despite this, PNF is repeatable with good results and lower costs than other surgical treatments. It is less effective for thickened cords.
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Collagenase Injection (CCH): Previously used but largely discontinued due to its high cost and recurrence rates similar to PNF. It was most suitable for recurrent cases with wide cords or neurovascular complications.
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Dermofasciectomy (DF): A radical option for severe or recurrent cases, involving removal of affected tissue along with the skin, followed by grafting. Healing is prolonged, and sensation is permanently lost in grafted areas. It is reserved for aggressive disease where other treatments have failed.
Minimally invasive techniques (PNF, CCH) allow faster recovery but have higher recurrence rates. LF remains the preferred standard, while DF is considered for extreme cases.
References
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Nayar, S.K., Pfisterer, D., & Ingari, J.V. (2019). Collagenase Clostridium Histolyticum Injection for Dupuytren Contracture: 2-Year Follow-up. Clin Orthop Surg, 11(3), 332–336. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9465774/.
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· Aglen, T., Matre, K.H., Lind, C., Selles, R.W., Aßmus, J., & Taule, T. (2019). Hand therapy or not following collagenase treatment for Dupuytren’s contracture? Protocol for a randomised controlled trial. BMC Musculoskelet Disord, 20, 387. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC6695332/.
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· Smeraglia, F., Del Buono, A., Maffulli, N., & Denaro, V. (2022). Current management of Dupuytren's disease: a review of the literature. J Biol Regul Homeost Agents, 36(2 Suppl. 1), 1–7. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC8864671/.
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· Mafi, R., Hindocha, S., & Khan, W.S. (2012). Recent surgical and medical advances in the treatment of Dupuytren's disease – a systematic review of the literature. Open Orthop J, 6, 77–82. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC1370973/.
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· Hindocha, S., Stanley, J.K., Watson, S.J., & Bayat, A. (2009). Dupuytren's diathesis revisited: evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg Am, 34(9), 1628–1634. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC6712875/.
