Dupuytren Contracture Injection

Indications and Clinical Considerations

Dupuytren contracture is caused by a progressive fibrosis of the palmar fascia. Initially, the patient may notice fibrotic nodules that are tender to palpation along the course of the flexor tendons of the hand. These nodules arise from the palmar fascia and initially do not involve the flexor tendons. As the disease advances, these fibrous nodules coalesce and form fibrous bands that gradually thicken and contract around the flexor tendons; the result is that the affected fingers are drawn into flexion. Although all fingers can develop Dupuytren contracture, the ring and little fingers are most commonly affected ( Fig. 99.1 ). If untreated, the fingers will develop permanent flexion contractures ( Fig. 99.2 ). The pain of Dupuytren contracture seems to burn itself out as the disease progresses.

Dupuytren contracture is thought to have a genetic basis and occurs most frequently in males of northern Scandinavian descent. The disease also may be associated with trauma to the palm, diabetes, alcoholism, and chronic barbiturate use. The disease rarely occurs before the fourth decade. The plantar fascia also may be concurrently affected.

In the early stages of the disease, hard, fibrotic nodules may be palpated along the path of the flexor tendons ( Fig. 99.3 ). These nodules often are misdiagnosed as calluses or warts. At this early stage, pain is invariably present. As the disease progresses, the clinician notes taut, fibrous bands that may cross the metacarpophalangeal joint and ultimately the proximal interphalangeal joint. These bands are not painful to palpation, and, although they limit finger extension, finger flexion remains relatively normal. It is at this point that patients often seek medical advice because they begin having difficulty putting on gloves and reaching into their pockets to retrieve keys. Although the primary pathologic process associated with Dupuytren contracture involves the palmar surface of the hand, changes involving the dorsum of the hand are also common ( Fig. 99.4 ). In the final stages of the disease, the flexion contracture develops with its attendant negative impact on function. Arthritis, gout of the metacarpal and interphalangeal joints, and trigger finger may coexist with and exacerbate the pain and disability of Dupuytren contracture.

Plain radiographs are indicated in all patients with Dupuytren contracture to rule out underlying occult bony disease. Ultrasound imaging will also provide valuable information regarding the condition of the tendon. Although as the disease progresses the diagnosis of Dupuytren contracture is usually straightforward, the condition can mimic the other diseases listed in Box 99.1 .

On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, uric acid, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the hand is indicated if joint instability or tumor is suspected. Electromyography is indicated if coexistent ulnar or carpal tunnel syndrome is suspected. The injection technique described later provides transient improvement of the pain and disability of this disease and can be used for the administration of collagenase Clostridium histolyticum injection, which has been advocated in the nonsurgical treatment of Dupuytren contracture, but surgical treatment may ultimately be required to restore function.

Clinically Relevant Anatomy

Dupuytren contracture is the result of the thickening of the palmar fascia and its effect on the flexor tendons (see Fig. 99.3 ). The primary function of the palmar fascia is to provide firm support to the overlying skin to aid the hand in gripping and to protect the underlying tendons.