Musculoskeletal · Hand Disorders
The facts most likely to be tested
Dupuytren contracture is a fibroproliferative disorder characterized by the development of palmar fascial nodules and longitudinal cords that lead to progressive flexion contractures of the digits.
The fourth (ring) finger and fifth (little) finger are the most commonly affected digits in patients with this condition.
Risk factors include Northern European ancestry, male gender, advancing age, diabetes mellitus, alcohol use disorder, and smoking.
The tabletop test is a positive clinical finding when the patient is unable to place their palm flat against a tabletop due to the fixed flexion deformity.
Associated conditions include Ledderhose disease (plantar fibromatosis), Peyronie disease (penile fibromatosis), and Garrod pads (knuckle pads).
Initial management for patients with significant functional impairment includes collagenase clostridium histolyticum injections, needle aponeurotomy, or surgical fasciectomy.
The condition is caused by the myofibroblast-mediated deposition of collagen type III within the palmar fascia.
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A 62-year-old male presents to the clinic complaining of difficulty grasping objects with his right hand. He reports that over the past year, he has noticed a thickening in his palm that has progressed to a point where he can no longer fully straighten his ring finger. Physical examination reveals a palmar nodule and a thickened cord extending to the base of the fourth digit. The patient is unable to place his palm flat on the examination table, demonstrating a positive tabletop test. He has a history of type 2 diabetes and consumes two alcoholic beverages daily.
What is the most likely diagnosis?
Dupuytren contracture
The patient's presentation of a palmar nodule, thickened cord, and fixed flexion deformity of the ring finger, confirmed by a positive tabletop test, is classic for Dupuytren contracture.
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Etiology / Epidemiology
Common in Northern European males >50 years old with diabetes or alcohol use disorder.
Clinical Manifestations
Painless palmar nodules progressing to fixed flexion contractures of the 4th and 5th digits.
Diagnosis
Clinical diagnosis via Tabletop Test; inability to lay palm flat on a table.
Treatment
First-line is collagenase clostridium histolyticum injection or needle aponeurotomy.
Prognosis
High recurrence rate; surgical fasciectomy reserved for severe cases.
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Epidemiology & Etiology
Strong genetic predisposition often seen in Viking descent populations. Associated with diabetes mellitus, chronic liver disease, and smoking. Often presents as a painless thickening of the palmar fascia.
Pertinent Anatomy
Involves the palmar fascia, specifically the longitudinal bands. The 4th (ring) and 5th (little) fingers are most frequently affected due to anatomical tension lines.
Pathophysiology
Fibroproliferative disorder characterized by myofibroblast proliferation and excessive collagen deposition. Leads to the formation of cords that tether the skin and pull the MCP and PIP joints into flexion. This process is distinct from tendon pathology.
Clinical Manifestations
Patients present with painless nodules in the palm, followed by the development of cords. The hallmark is a fixed flexion contracture of the MCP and PIP joints. Red flags include rapid progression or associated Ledderhose disease (plantar fibromatosis).
Diagnosis
Diagnosis is primarily clinical. The Tabletop Test is the gold standard for assessing severity; a positive result is the inability to place the palm flat on a table due to contracture.
Treatment
Initial management includes collagenase clostridium histolyticum injections or needle aponeurotomy for mild-to-moderate cases. Contraindications for surgery include active infection or severe vascular compromise. Surgical fasciectomy is reserved for advanced, debilitating contractures.
Prognosis
High recurrence rate (up to 50%) is common regardless of intervention. Patients require long-term monitoring for joint stiffness and functional impairment.
Differential Diagnosis
Trigger finger: locking or snapping sensation with movement
Stenosing tenosynovitis: localized tenderness over the A1 pulley
Ganglion cyst: transilluminates on physical exam
Camptodactyly: congenital flexion deformity of the PIP joint
Scar tissue: history of trauma or surgery