A 60-year-old man with Dupuytren disease

A 60-year-old man presents to his family physician with a firm, painful nodule and pitting in his right palm (Figure 1A). He first noticed it a year ago, and it is now causing discomfort when he holds tools. He has no history of trauma, foreign body, infection, or limited range of motion.

Figure 1:

Examples of clinical presentation of Dupuytren disease. (A) Early palmar nodule (red arrow) and pitting (black circle) over the distal palmar crease between the fourth and fifth rays. (B) Established palmar cord (black arrow) in line with the fifth ray, causing flexion contracture of the fifth finger (different patient).

What is the diagnosis?

The diagnosis is Dupuytren disease, a fibroproliferative disorder of the palmar fascia. A study from the United Kingdom demonstrated an incidence of 0.303 to 0.587 per 1000 person-years.¹ Diagnosis is clinical and can be made when palmar pits, nodules, or cords are palpable on the volar surface of the hand (Figure 1). Early palmar nodules may be painful; such nodules usually progress to become cords that cause flexion contractures, which can limit hand function.² Such progression varies but typically starts in the palm, limiting motion at the metacarpophalangeal joint and progressing to involve the proximal interphalangeal joint. Nodules and cords affecting the proximal interphalangeal joint may also occur in isolation.³ Imaging is not routinely required. The Hueston tabletop test can be used to check for inability to place the palm flat and guide surgical decision-making.⁴

Dupuytren disease is primarily genetic, with additional risk factors including male sex, northern European descent, smoking, alcoholism, diabetes, hand-transmitted mechanical exposure, and epilepsy. Risk increases with age, particularly after the age of 50 years.⁵ Similar fibromatosis may occur in the plantar fascia (Ledderhose disease), the dorsum of the proximal interphalangeal joint (Garrod pads), or the penis (Peyronie disease).² Dupuytren diathesis — marked by onset before age 50 years, family history, bilateral involvement, associated fibromatoses, and rapid progression — indicates a high-risk profile for aggressive or recurrent disease, warranting close surveillance and early referral.²

Differential diagnoses include hand tumours, such as inclusion cysts, giant cell tumours of the tendon sheath, and retinacular cysts (flexor tendon sheath ganglions), but these lack the progressive cords and palmar banding of Dupuytren. Ultrasonography can differentiate these conditions but is not required if the diagnosis is clear.

What is the initial management?

Management is determined by the level of functional impairment. Early management includes education and observation. In many cases, progression is slow, and not all require intervention.⁶ A systematic review found inconclusive evidence for physiotherapy or splinting.⁶

Intralesional corticosteroid injections may reduce pain but do not eradicate the disease and can cause skin atrophy and depigmentation.⁶ Patients with early nodules may be referred for radiotherapy, but a systematic review noted limited high-quality data and uncertainty regarding long-term outcomes.⁷ In Canada, radiotherapy is available only at select centres and is not routinely offered; referral for radiation may be best considered after discussion with a hand surgeon or a radiation oncologist experienced in benign hand fibromatoses.

When should patients be referred to a hand or plastic surgeon?

Referral is indicated for patients with rapid progression (i.e., Dupuytren diathesis), functional limitations, or diagnostic uncertainty. A failed tabletop test or functional limitations commonly prompts surgical intervention, as may trigger finger, which can occur with early Dupuytren disease.

Surgical options depend on disease severity, skin involvement, and patient preference. Interventions include percutaneous needle aponeurotomy (i.e., cutting the cord with the bevel of a needle), fasciectomy (excision of the affected fascia), or dermatofasciectomy (excising the disease with the overlying skin, and replacing it with a skin graft). In simple cases, surgery may be performed under local anesthesia. Postoperative hand therapy is not always required.

Direct injections of collagenase lyses the diseased fascial cords, with indications and outcomes comparable to needle aponeurotomy, as reported by a meta-analysis,⁸ but this intervention is no longer available in Canada.

What are the expected outcomes?

Dupuytren disease is chronic and common. The disease usually progresses gradually to contracture, although it does worsen rapidly in a minority of patients.⁶ Early recognition and referral can maintain long-term hand function. Patients should be counselled that treatment carries a risk of recurrence, which varies by procedure type.

Case revisited

The patient was counselled on his early Dupuytren disease and returned 2 years later with a firm, painless cord at the previous nodule site, which caused him difficulty in straightening all his fingers, gripping large objects, putting gloves on in winter, and washing his face (Figure 1B). Examination revealed a 90° contracture with proximal interphalangeal joint flexion of the fifth finger and a positive tabletop test. The patient was referred to a plastic surgeon and, following further counselling, elected to proceed with surgery.