|3475 Torrance Blvd., Ste F
Torrance, CA 90503
Office hours: M-F, 9am
– 5 pm
Worker’s compensation, Medicare
and most insurance plans accepted.
In September 2008, we will be moving to a beautiful new 4,400 sq ft,
state of the art dedicated hand center located at 2808 Columbia Ave
in Torrance, CA., which will feature onsite nerve conduction studies,
occupational hand therapy and digital x-ray.
Dupuytren’s contracture is a condition where normal connective (i.e.
fascial) tissue in the palm becomes infiltrated with scar tissue in a
very characteristic manner, resulting in progressive finger flexion contractures.
The condition is named after Baron Guillaume Dupuytren who gave his famous
lecture describing a palmar fasciotomy for the treatment of a subcutaneous
contracture in 1831, even though the disorder was described by others
as early as 1777.
The palmar aponeurosis is a triangular facial layer in the palm which
is just underneath the skin and subcutaneous fat , and covers the nerves,
arteries and tendons. It splits into Y-shaped extensions pretendinous
bands, that travel from the transverse crease at the end of the palm (distal
palmar crease) to the base of the finger, and then splits into 3 layers
which merge with the fascial tissue of the fingers and the webspace.
The 2 cells responsible for Dupuytren's disease are the fibroblast which
is the normal cell which lays down collagen or scar tissue, and the myofibroblast
which appears identical to a fibroblast but has contractile properties.
McFarlane implicated the myofibroblast as the cell responsible for contracture
The diseased tissue of Dupuytren's presents as nodules and cords, each
of which has a distinctive appearance under the microscope and which attach
to the skin. Electron microscopic studies have shown that contracture
of the myofibroblasts in the nodules is responsible for the finger flexion
contracture. Nodules pull on cords that have extended past adjacent joints.
This contracture across joints produces the pathologic flexion contractures
of Dupuytren's disease. The cords may insert centrally along the midline
of the finger (central cord) or they may spiral around the side of the
finger, intertwining with and displacing the nerves and arteries (spiral
Many factors have been considered to predispose an individual to Dupuytren's
disease. Alcohol consumption, smoking, diabetes, epilepsy, genetics, and
manual labor all have been implicated as potential etiologic factors,
however, there is little conclusive evidence regarding these risk factors.
The exact role that alcoholism plays in the development of Dupuytren's
contracture is not clear. There are no studies that show the quantity
of alcohol that leads to Dupuytren's disease or what the cumulative affect
is of alcoholism on Dupuytren's. There has long been an association between
epilepsy and Dupuytren's disease which may be related to the antiepileptic
medication. There has been little conclusive evidence to support manual
labor as the cause for most cases of Dupuytren's disease. There is a higher
incidence of Dupuytren’s disease in people of Northern European
descent. It is significantly less common in Mediterranean populations
and in Asia. Inheritance appears to follow an autosomal-dominant model
with variable penetrance.
The earliest sign of Dupuytren's disease is a nodule or incomplete cord
that appears in the palm. After the nodule development other changes including
thickening and pitting of the skin and scarring of the subcutaneous fat.
The formation of cords occurs as the nodules regress, although they may
both be present simultaneously. The cords may remain in the palm or progress
into the fingers. The ring finger is the most commonly affected digit
followed in order of frequency by the small finger, thumb, middle finger,
and index finger. Pretendinous or central cords form in the palm and cause
flexion contractures of the metacarpophalangeal joints (the first joint
at the base of the finger), as they mature and contract. Cords extending
into the fingers cause proximal interphalangeal joint contractures (the
middle finger joint).
Dupuytren's disease may affect other tissues through out the body. The
knuckle overlying the proximal interphalangeal joint may show subcutaneous
fibrosis termed knuckle pads or Garrods nodes. Prominent subcutaneous
cords may develop on the the soles of the feet (Lederhose disease) or
cause a deviation and contracture of the subcutaneous fascia of the penis
The term Dupuytren's diathesis refers to a patient with a more rapid progression
of the disease, who usually present at a younger age and have involvement
of both hands as well as other sites of involvement.
A variety of nonsurgical treatments have been attempted including radiation
therapy, dimethyl sulfoxide, physical therapy, and steroid injections
but unfortunatley they have not been found to provide a long-term solution.
Recently, direct cord injection with a collagenase, which is an enzyme
that dissolves collagen, followed by manual rupture of the cord has been
studied by investigators in New York and Stanford with encouraging results.
This treatment is still awaiting FDA clearance in the US and may hold
some future promise in selected patients.
Paradoxically, surgical treatment may lead to a faster progression and
quick return of the disease hence as a general rule Dupuytren’s
is observed until there is a significant joint contracture. A surgical
release is considered when the patient is no longer able to get their
hand flat on a table. The typical indications include a metacarpophalangeal
joint contracture of greater than 30° and proximal interphalangeal
(PIP) joint contractures of any degree due to its resistance to full extension
after Dupuytren's excision. Most PIP contractures will improve by only
about 50% after surgery hence the more contracted the finger joints prior
to surgery, the more residual contracture can be expected.
There are a variety of surgical techniques available. The goal of surgery
is to remove the diseased fascia while protecting the nerves and arteries
(i.e. neurovascular bundles) that run along each side of the finger and
thumb. (link to Dupuytrens video) These structures are most at risk with
advanced contractures and may limit the amount of correction since they
are prone to stretch injuries with long standing finger contractures.
A partial fasciectomy in which the Dupuytrens tissue that has formed cords
or nodules is excised. Normal-appearing fascia is left behind. Recurrent
contractures may require skin grafting, since the skin is part of the
disease process. Dupuytrens rarely recurs under a skin graft, but the
disadvantages of skin grafting including hyperpigmentation and a loss
of sensation over the graft. Postoperative therapy is important to achieve
the maximum correction of the joint contracture but to regain finger flexion
as well. Static progressive splinting with the use of an external fixator
such as the Agee Digit widget over a period of 6-8 weeks can markedly
improve a resistant contracture.