Dupuytren's contracture M72.0

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 25.06.2023

Synonym(s)

Aponeurosis fibrosa palmaris; crispatura tendinuum; Dupuytren's disease; Dupuytren's finger contracture; palmar fasciitis; palmar fibromatosis

History
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Plater, 1614; Dupuytren, 1831

Definition
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Circumscribed connective tissue induration of the palmar aponeurosis with bending contracture of the fingers. Pendant on the sole of the foot plantar fibromatosis (Ledderhose syndrome), see also polyfibromatosis. The ulnar fingers are usually most severely affected. Combination with Induratio penis plastica (Peyronie's syndrome) is possible.

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Dermatology

Psoriasis vulgaris

Psoriasis vulgaris" usually refers to the plaque or nummular type of psoriasis.

Occurrence/Epidemiology
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Accumulation in the Nordic cultural area (Scandinavia, Northern Germany). The prevalence is 1-17% in western cultural countries: The highest prevalence is in Africa 17%. Asia 15%. Europe 10%, America 2%.

Etiopathogenesis
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Genetic factors cause 80% of the factors, partly autosomal-dominant inheritance, reduced penetrance and variable expressivity is assumed. Other causes include trauma, long-term work with vibrating equipment (> 15 years), liver disease, diabetes mellitus, smoking with concomitant alcohol consumption, epilepsy or dialysis. Pathogenetically, increased local production of interleukin-1, basic fibroblast growth factor, and "transforming growth factor beta" lead to local proliferation of fibroblasts and overproduction of collagen. The transformation of fibroblasts into contractile myofibroblasts and impaired apoptosis lead to contractures in the course of the disease.

Manifestation
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Mostly in men in middle to later age. Men are affected 5-10 times more often than women.

Localization
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Mainly palmar aponeurosis; initially 4th and 5th fingers.

Clinical features
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Depending on the characteristics, a distinction is made between 4 stages:

1st degree: circumscribed, palpable node formation
2nd degree: incipient contracture, minor obstruction of finger extension in the metacarpophalangeal joint
3rd degree: Stretch impediment in the middle or base joint
4th degree: Additional hyperextension in the final joint and finally bending contracture of the fingers >135º.

Mostly unilateral, rarely double-sided pressure or spontaneously painful nodular hardening of the palmar aponeurosis near the joint; bending contracture of the ulnar fingers. Depending on the examiner, combinations with the following fibromatoses occur in about 5%:

Induratio penis plastica (Peyronie's disease)
Fibrosis mammae virilis
Ledderhose disease (plantar fibromatosis)

In addition, the occurrence of keloids, cirrhosis of the liver, "knuckle pads" or periarthritis humeroscapularis was observed.

Therapy
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Treatment depending on the severity by experienced hand surgeons (see Table 1).

Progression/forecast
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Recurrence rate after limited fasciectomy: 12-73% after 5 years; percutaneous needle fasciotomy: 85% after 2.3 years.

As prophylaxis in case of high familial risk or postoperatively in case of high risk of recurrence radiotherapy is to be considered.

Tables
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Therapy of Dupuytren's contracture

	Clinic	Therapy
1st degree	Circumscribed, palpable nodal formations without contracture	Physiotherapy, night splint, if necessary intralesional glucocorticoids1
2nd degree	Incipient contracture, slight impairment of finger extension in the base joint	Operative: limited fasciectomy / percutaneous needle fasciotomy
3rd degree	Impairment of extension in the middle or base joint	like grade 2
4th degree	Additional hyperextension in the terminal joint and ultimately flexion contracture of the fingers	as grade 2, in case of affection of the flexor tendons: tendon lengthening, ultima ratio: dermofasciectomy with skin replacement

Note(s)
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In a larger study (308 Pat), good results were achieved with intralesional application of collagenase from Clostridium histolyticum.

Literature
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Baird KS, Crossan JF, Ralston SH (1993) Abnormal growth factor and cytokine expression in Dupuytren's contracture. J Clin Pathol 46: 425-428
Brenner P et al. (2001) Dupuytren contracture in North Germany. Epidemiological study of 500 cases. Trauma Surgeon 104: 303-311
Dupuytren G (1831) De la rétraction des doigts par suite d'une affection de l'aponévrose palmaire. Opération chirurgicale, qui convient dans le cas. J Univ hebd Méd Chir prat Paris 5: 352-365.
Lopatecki M (2003) Dupuytren's contracture: aftercare and long-term results. Orthopaedics 32: 394-396
Orlando JC, Smith JW, Goulian D (1974) Dupuytren's contracture: A review of 100 patients. Brit J Plast Surg 27: 211-217
Plater F (1614) Observationum in hominis affectibus. Liber I, L. König, Basel, p. 140
Vogl A et al (2005) Skin and alcohol. J Dtsch Dermatol Ges 3: 788-790
Ruettermann M et al (2021) Dupuytren's disease: etiology and treatment. Dtsch Arztebl Int: 118: 781-788