Dupuytren's Contracture (Dupuytren Disease)

Definition and Pathophysiology

Dupuytren's contracture is a benign fibroproliferative disorder of the palmar fascia (aponeurosis) causing progressive thickening, nodule formation, and eventually flexion contractures of the fingers. The key cellular player is the myofibroblast - the predominant cell type found histologically in contracted Dupuytren fascia. These cells drive:

An increase in the type III : type I collagen ratio
Contraction of palmar fascia cords pulling digits into flexion
Skin pitting from local fibroblastic invasion (though the process is non-malignant)
The tendons and joints themselves are not directly involved with Dupuytren tissue

Dupuytren disease - bilateral hand contractures showing marked finger flexion deformities

Clinical manifestation of Dupuytren disease: bilateral hand contractures. Note the amputated little finger on the left hand from advanced disease. (Rheumatology 2-Volume Set, 2022)

Dupuytren contracture - early skin pitting and cord of the ring finger

Pitting of the skin and a longitudinal cord causing MCP joint flexion in early-stage Dupuytren contracture. (Rheumatology 2-Volume Set, 2022)

Epidemiology and Risk Factors

Most common in White patients of Northern European descent
Men affected ~7x more often than women
Rarely seen before age 40
Autosomal dominant with variable penetrance (patients often identify an affected family member)
Associated with: tobacco use, epilepsy (and anti-epileptic drugs), chronic pulmonary disease, HIV, diabetes, alcohol use, liver disease
Trauma has not been proven as a causative factor
Occupation is NOT an established risk factor

Anatomy - Key Points

Structure	Involvement
Cleland (dorsal) ligaments	NOT involved
Grayson (volar) ligaments	Involved
Spiral cord	Causes PIP contracture; displaces neurovascular bundle centrally and superficially (at risk during surgery)
Palmar fascia	Primary site of disease

Clinical Features

Fingers affected (in order of frequency): ring finger > small finger > long finger (bilateral in many patients)
Progression: palmar nodules (early) → longitudinal cords → flexion contractures at MCP and PIP joints
Usually painless (except early nodule stage can be tender)
The "tabletop test" (Hueston test): inability to flatten the hand against a flat surface is a classic functional finding
Patients also struggle putting a hand into a pocket or glove

Dupuytren Diathesis

A more severe, aggressive form. Features:

Earlier onset (younger patients)
Bilateral disease
Ectopic fibrosis at other sites: plantar fascia (Ledderhose disease), penile fascia (Peyronie disease), knuckle pads (Garrod pads), popliteal fascia

Staging

Tubiana Classification (based on total flexion contracture of MCP + PIP + DIP):

Stage 0: No deformity
Stage N: Nodule only, no contracture
Stage I: 0-45° total contracture
Stage II: 45-90°
Stage III: 90-135°
Stage IV: >135°

Treatment

Conservative (mild disease)

Local heat application, stretching exercises, protective gloves
Splinting does not alter disease progression
Intralesional corticosteroid injections may relieve pain from tender nodules

Indications for Intervention

Intervention is indicated when:

MCP joint flexion contracture > 30 degrees
Any PIP joint flexion contracture
Functional impairment (inability to flatten hand - positive Hueston test)

Treatment Options

Method	Description	Outcomes	Notes
Limited fasciectomy (open)	Surgical excision of diseased fascia; preferred technique	Best long-term correction	Risk: digital nerve injury, wound breakdown, CRPS
Total palmar fasciectomy	Wider excision ± skin grafting	For severe disease	Higher morbidity
Needle aponeurotomy (NA) / Percutaneous needle fasciotomy	Percutaneous division of cords	Effective short-term; smaller incisions	High recurrence rate
Collagenase clostridium histolyticum (CCH) injection	Enzymatic digestion of cord followed by manipulation	Comparable to surgery for MCP correction; up to 85% MCP correction, ~60% PIP correction	Skin tears more common complication than tendon rupture; growing first-line adoption

Recurrence is the most common complication after fasciectomy (also the most common complication overall)
Other surgical complications: digital nerve injury, wound breakdown, complex regional pain syndrome (CRPS), hematoma

Important Notes on Collagenase

Adverse effects of CCH injection: pain, swelling, bruising (temporary)
Skin tears > flexor tendon rupture as complication
Risk of recurrence remains significant regardless of method, especially in: younger patients, bilateral disease, strong family history, fibrotic lesions elsewhere (Dupuytren diathesis)

When Full Extension May Not Be Achievable

In long-standing disease, MCP or PIP joint capsules become contracted independently of the Dupuytren tissue. In these cases, full digital extension requires extensive joint release, which carries additional neurovascular risk.

Recent Evidence (2023-2026)

Recent systematic reviews provide updated guidance:

A 2023 meta-analysis (Zhang et al., PMID 37725027) comparing collagenase vs. needle fasciotomy for single-digit contractures found similar efficacy for MCP correction but collagenase superior for PIP joints.
A 2024 network meta-analysis (Nann et al., PMID 37246411) of surgical approaches found no single technique definitively superior, highlighting shared decision-making.
A 2025 GRADE-based systematic review (Shaheen et al., PMID 39451139) assessed all treatments, noting limited high-quality evidence overall.
A 2026 review (Pistone et al., PMID 40811833) examined needle fasciotomy with and without corticosteroids, suggesting adjunctive steroids may reduce early recurrence.

Key Exam Points Summary

Fact	Answer
Predominant cell type	Myofibroblast
Collagen ratio change	Type III : I increased
Ligament involved	Grayson (volar) - NOT Cleland
Most common finger affected	Ring finger
Surgical indication (MCP)	>30° contracture
Any PIP contracture	Indication for surgery
Gold standard surgery	Open limited fasciectomy
Most common complication	Recurrence
Test for indication	Hueston (tabletop) test
Structure at risk in surgery	Neurovascular bundle (displaced by spiral cord)

Miller's Review of Orthopaedics, 9th Edition, p. block5
Rheumatology, 2-Volume Set (2022, Elsevier), p. 725

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