Causes of Finger Contracture

I. Fascia / Connective Tissue Causes

Dupuytren's Contracture

• Rosen's Emergency Medicine, p. 3414; Sabiston Textbook of Surgery

II. Ischemia / Compartment Syndrome

Volkmann's Ischemic Contracture

• Mild (localized): Partial profundus ischemia; 2-3 fingers involved with flexion contracture
• Moderate: Long finger flexors + FPL + wrist flexors; intrinsic minus deformity; median/ulnar sensory changes
• Severe: All forearm flexors and extensors involved; nerves strangulated in fibrotic muscle
• Campbell's Operative Orthopaedics 15th Ed 2026, p. 4326-4360

III. Causes by Tissue Layer

Limited FLEXION (extension contracture):

Limited EXTENSION (flexion contracture):

• Campbell's Operative Orthopaedics 15th Ed 2026, p. 7575-7592

IV. Neurological Causes

Spasticity (Upper Motor Neuron Syndrome)

• Stroke, traumatic brain injury, spinal cord injury, cerebral palsy
• Spastic finger flexors cause flexion contractures due to prolonged abnormal muscle tone
• Common target: wrist and finger flexors post-stroke

Peripheral Nerve Injury

• Ulnar nerve palsy - "Claw hand" (intrinsic minus deformity) - ring and little finger clawing from unopposed extrinsic flexors with loss of intrinsic muscles
• Median nerve palsy - "Ape hand" deformity with thenar wasting; less clawing because FDP to index/middle is also lost
• Combined median + ulnar injury - Severe claw deformity

V. Skin and Soft Tissue Causes

VI. Musculoskeletal / Inflammatory Causes

VII. Congenital Causes

VIII. Metabolic / Systemic Causes

Summary by Deformity Type

Dupuytren's Contracture

Epidemiology

• Most common in men aged 50-70 years of Northern European (particularly Scottish, Scandinavian) descent
• 4:1 male-to-female ratio (estrogen may be protective)
• About 4 out of 7 cases have a positive family history; many are sporadic
• Bailey and Love's Short Practice of Surgery 28th Ed, p. 3070

Etiology and Risk Factors

• Andrews' Diseases of the Skin, p. 491; Bailey and Love, p. 3070

Pathology and Pathophysiology

1. Normal bands - The palmar fascia consists of collagen bundles (longitudinally oriented) between the skin and underlying tendons/neurovascular structures
2. Nodule formation - Increased collagen deposition + myofibroblast proliferation creates palpable nodules in the palm (typically proximal to the 4th finger)
3. Cord formation - Collagen becomes linearly organized; myofibroblasts cause contraction, forming cords that are the hallmark of symptomatic disease
4. Joint contracture - Cords tighten the MCP and PIP joints into fixed flexion

• Schwartz's Principles of Surgery 11th Ed, p. 2946-2948

Clinical Features

Dupuytren's contracture - little finger MCP flexion with visible palmar cord (Bailey and Love)

Signs and Symptoms (in order of progression):

• Palmar nodules - firm, non-tender (or mildly tender initially), typically proximal to ring finger
• Skin puckering - dimpling/pitting of the palmar skin (due to skin-fascia attachments)
• Palpable cords - longitudinal fibrous bands in the palm extending into the digits
• Flexion deformity - MCP joint first, then PIP joint; ring > little > middle > index > thumb
• Bilateral in ~45% of cases

Associated Features:

• Garrod's knuckle pads - thickened skin over the dorsal PIP joints (more severe disease)

Garrod's knuckle pads - thickening over dorsal PIP joints (Bailey and Love)

• Peyronie's disease - fibrous cord in the penis causing curvature (penile Dupuytren's)
• Ledderhose disease - plantar fibromatosis (fibrous nodules on sole of foot)
• Involvement is commonest on the ulnar side of the hand

Indications for Treatment

• Patient places hand flat on a table - if they cannot, intervention is indicated
• Positive = significant contracture requiring treatment

• MCP contracture ≥ 30°
• PIP contracture ≥ 20°
• Any PIP joint contracture (as PIP corrections are less predictable and worsen with delay)

Treatment

Non-operative (mild/early disease)

Minimally Invasive

Recent evidence: A 2023 meta-analysis (PMID 37725027) comparing collagenase vs. needle fasciotomy for single-digit Dupuytren's contracture found similar early efficacy, but fasciectomy remains more durable long-term. A 2024 network meta-analysis (PMID 37246411) of surgical approaches supports limited fasciectomy as the standard.

Surgical

• Z-plasties to lengthen skin
• Full-thickness skin graft (from anteromedial forearm - hairless area)
• Occasionally, open wound healing (McCash technique - open palm technique)

• Digital nerve laceration (most feared)
• Digital artery injury
• Skin buttonholing / necrosis
• Hematoma
• CRPS (complex regional pain syndrome)
• Recurrence

Postoperative Care

• Hand therapy starts within 1 week of surgery (edema control, early mobilization)
• Extension splinting: 4-6 weeks continuous, then nighttime splinting for 6-8 more weeks
• Serial follow-up for recurrence

Prognosis and Recurrence

• Recurrence is the rule, not the exception - occurs in all forms of treatment
• Needle fasciotomy: highest recurrence (~50% at 5 years)
• Fasciectomy: more durable but recurs in ~20-30% at 5-10 years
• Dermatofasciectomy: lowest recurrence rate
• "Dupuytren's diathesis" (young age of onset, bilateral disease, knuckle pads, Peyronie's, family history) = higher recurrence risk

Summary Box (Bailey and Love)

• Autosomal dominant inheritance, many sporadic cases
• Fibroblastic hyperplasia → palmar nodules → cords → fixed flexion deformity
• Intervention indicated when hand cannot be placed flat on a table
• Severe fixed deformity at PIP joint may ultimately require amputation