Dupuytren’s Contracture

Dupuytren`s contracture is a progressive fibroproliferative condition of the palmar and digital fascia characterised by the formation of pathological nodules and cords that progressively draw the fingers into flexion at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. It is one of the most common conditions encountered in hand surgery, particularly in populations of northern European descent, and its management requires careful assessment of patient factors, disease extent, and the growing array of available interventions.

• Epidemiology: prevalence up to 30% in adults of northern European descent by the seventh decade; male:female ratio approximately 7–10:1 (more severe disease in males); bilateral in approximately 40–60%; the ring finger is most commonly involved, followed by the little finger, middle finger, thumb, and index finger
• Risk factors: age (strongest); male sex; northern European ancestry; positive family history (autosomal dominant with variable penetrance); smoking; diabetes (associated with diffuse, bilateral, less amenable to treatment — `diabetic cheiroarthropathy`); alcohol excess; manual labour (controversial); HIV; epilepsy and certain anticonvulsants (phenobarbitone, phenytoin); prior trauma (`post-traumatic Dupuytren`s`) — these associations suggest a common fibroproliferative pathway
• Pathophysiology: normal palmar fascia → nodule formation (proliferative phase — myofibroblasts, type III collagen); → cord formation (involutional phase — contracted collagen type III replaces type I); → residual phase (matured cord); the nodule is the cellular active phase; the cord is the contracted end-result; myofibroblasts are the primary cellular mediators — they generate the contractile force; the Wnt signalling pathway and TGF-β are key molecular mediators
• Diathesis (Dupuytren diathesis): a cluster of features predicting aggressive disease and high recurrence after treatment — bilateral disease; involvement of radial digits (index, middle); ectopic disease (Ledderhose disease — plantar fascia; Peyronie`s disease — penile fascia; knuckle pads — Garrod`s pads on the dorsal PIP joints); positive family history; early onset (<50 years); each feature scores 1 point; diathesis score ≥3 predicts high recurrence

• Cords and their anatomical origins — key for surgical planning: the pretendinous cord (most common — from the pretendinous band of the palmar aponeurosis; causes MCP joint flexion contracture); the spiral cord (most surgically important — arises from the pretendinous band, spiral band, lateral digital sheet, and Grayson`s ligament; it spiralises around the neurovascular bundle, displacing the digital nerve medially and superficially — creating risk of nerve injury during surgical dissection); the lateral cord (from the lateral digital sheet; causes PIP contracture); the central cord (continues from the pretendinous cord into the digit); the natatory cord (in the web space; causes abduction contracture)
• The spiral cord and neurovascular bundle displacement: the spiral cord wraps around the digital nerve and artery, pulling them medially and superficially; the nerve may lie just beneath the skin in a severely contracted finger with a spiral cord; this is the most significant anatomical hazard of Dupuytren surgery and must be anticipated in all cases with PIP contracture

• History: progressive inability to flatten the palm; difficulty with handshakes, gloves, entering pockets; functional impairment with activities requiring finger extension; assess hand dominance, occupation, sporting activities, diathesis features
• Hueston tabletop test: the patient places their hand flat on the table; inability to place the palm and fingers flat simultaneously = positive = indicates significant contracture; a simple and rapid screening test; a positive test is often used as a threshold for offering treatment intervention — any patient who cannot place their hand flat on a table has a functionally significant contracture
• Measure the deficit: measure the total passive extension deficit (TPED) = the sum of MCP and PIP fixed flexion contractures; the degree of PIP joint contracture is particularly important — PIP contracture responds less well to treatment and recurs more rapidly than MCP contracture
• Indications for treatment: MCP joint contracture ≥30°; any PIP joint contracture (even 10–15° warrants consideration — PIP contractures deteriorate faster and recover less completely); positive tabletop test; functional impairment; patient wish; note that not all contractures require immediate treatment — disease in the nodule phase without contracture requires observation only

• Brunner (zigzag) incisions: the standard incision for Dupuytren fasciectomy; the zigzag design allows the skin flaps to be raised, exposing the cord, and avoids a straight longitudinal scar (which would contract and worsen the deformity); at skin closure, Z-plasties or the McCash technique (open palm — leaving the wound partially open in the palm to avoid haematoma and allow drainage) may be used; the McCash open palm technique reduces haematoma formation and CRPS rates
• Tourniquet: performed under digital or wrist block with a tourniquet (upper arm or wrist level); magnification is recommended for digital fasciectomy; careful loupe magnification identifies the neurovascular bundles before dividing any cord
• PIP joint contracture management during fasciectomy: after cord release, residual PIP joint contracture may remain due to secondary joint contracture (volar plate and check-rein ligament shortening); accessory collateral ligament and volar plate release may be required if the joint does not correct after complete cord excision; severe longstanding PIP contracture (>60°, >2 years duration) has poor prognosis for correction regardless of technique

• Spiral cord and nerve displacement: the spiral cord is formed from the pretendinous band, the spiral band, the lateral digital sheet, and Grayson`s ligament; as the cord forms and contracts, it wraps around the neurovascular bundle, pulling the digital nerve from its normal lateral position to a central, superficial position just beneath the skin; in a severely contracted finger the nerve may lie within millimetres of the dermis; failure to identify this displacement before dividing the cord will result in nerve transection; the nerve must be identified proximally (in normal tissue) before dissecting distally around the cord
• CRPS after Dupuytren surgery: a recognised complication occurring in approximately 5–10% of cases; characterised by disproportionate pain, stiffness, swelling, and skin changes after surgery; risk factors — female sex, high diathesis score, extensive surgery, tourniquet time, anxious personality; the McCash open palm technique may reduce CRPS risk; early physiotherapy is critical; managed with pain management, physiotherapy, and sympathetic nerve blocks if severe
• Recurrence and extension: recurrence is true regrowth of disease at the same site; extension is new Dupuytren`s in adjacent previously uninvolved areas; both are common in high-diathesis patients; dermofasciectomy (skin graft) provides the lowest recurrence rate; repeat fasciectomy is technically more difficult and has higher complication risk; needle fasciotomy can be used for recurrence as a staged procedure before considering revision surgery

• Dupuytren`s: fibroproliferative palmar fascia condition; ring finger most common; males 7–10:1; northern European ancestry; autosomal dominant with variable penetrance
• Hueston tabletop test: unable to place palm flat = positive = functionally significant contracture = consider treatment
• Diathesis: bilateral + radial digits + ectopic (Ledderhose, Peyronie`s, knuckle pads) + family history + early onset = high recurrence risk; each feature = 1 point; ≥3 = high diathesis
• Spiral cord: most dangerous cord; displaces digital nerve medially and superficially; identify nerve PROXIMALLY before dissecting around cord; major risk of nerve injury
• Treatment indications: MCP ≥30°; any PIP contracture (10–15° warrants consideration); positive tabletop test; functional impairment
• Partial fasciectomy: standard surgical procedure; Brunner (zigzag) incisions; 20–40% recurrence at 5 years; best PIP correction; risk of nerve injury
• Dermofasciectomy: lowest recurrence (~10–15%); skin graft replaces excised skin; for high diathesis, recurrent disease, young patients
• Needle fasciotomy (NA): percutaneous cord division; quick recovery; suitable for pretendinous cord, elderly patients; 50–85% recurrence at 5 years; can be repeated
• Collagenase (Xiapex): clostridial collagenase injection + manipulation 24 hours later; withdrawn from UK (2020); used internationally; risk skin tears, tendon rupture; spiral cord injection risks nerve injury
• PIP contracture prognosis: worse than MCP; severe longstanding PIP (>60°, >2 years) has poor correction regardless of technique; may require volar plate / check-rein ligament release