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Clinical case: Dupuytren's contracture: want to learn more about it?

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Clinical case: Dupuytren's contracture

In this article, we describe a case of a woman suffering from Dupuytren’s disease. We will follow her journey from admission and history all the way to prognosis and evolution. We will also look at the classical sign of this condition called Dupuytren's contracture, together with possible treatment options and relevant anatomical considerations.

Case key facts
Treatment options Percutaneous Needle Aponeurotomy, enzyme injections, surgical removal of the palmar fascia
Flexor digitorum superficialis

Origin: medial epicondyle of the humerus, radial tuberosity

Insertion: bases of middle phalanges of the four fingers

Innervation: median nerve

Action: flexion of the middle phalanges

Flexor digitorum profundus

Origin: anterior and medial surfaces of the ulna, interosseous membrane, deep fascia of the forearm

Insertion: bases of distal phalanges of the four fingers

Innervation: ulnar and median nerves

Action: flexion of the middle phalanges and wrist

Trigger finger A snap or audible pop caused by the movement of a nodule within a palmar digital sheath during finger flexion. The nodule appears due to irritation and inflammation of a flexor tendon.

After reviewing this case you should be able to describe the following:

  • The overall goal of treatments for Dupuytren’s disease. What is meant by Percutaneous Needle Aponeurotomy (PNA). Other treatments for the condition.
  • The anatomical/functional differences between the flexor digitorum superficialis and profundus.
  • The synovial and fibrous digital sheaths of the hand. What is meant by trigger finger.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden. 

It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Case description

History and clinical presentation

Figure 1. Photograph of dissection of cadaver forearm showing flexor digitorum profundus (FDP) deep to flexor digitorum superficialis (FDS; reflected).

The patient is a retired, right-handed, 73-year-old woman with a history of smoking. The patient had previously undergone bilateral aponeurotomy (surgical release) for digitopalmar Dupuytren's disease. At her two-year follow-up exam, her left hand showed excellent results, but her right hand showed a recurrence involving the fourth digit near the metacarophalangeal (MCP) joint. A Percutaneous Needle Aponeurotomy (PNA) was performed in the digital area.

Three weeks later, the patient showed a marked flexion deficiency in the distal interphalangeal (DIP) joint, which occurred without making an effort; the patient did not undergo rehabilitation or wear a splint.

Figure 2. Cadaveric image showing the flexor digitorum superficialis (FDS) and profundus (FDP) tendons in digital sheaths of the fingers. The FDS tendon is splitting and inserting on middle phalanx. The FDS and FDP tendons are entering the fibrous digital sheath.

Imaging

An MRI showed a rupture of the flexor digitorum profundus (FDP) tendon at the first phalanx of the fourth digit with retraction of the proximal stump into the palm (Figures 2&3). This required outpatient surgical intervention.

Figure 3. Axial T2 MRI of the right hand showing absence of the FDP tendon to the fourth digit (highlighted with green). FPL, flexor pollicis longus.

Management and evolution

Under loupe magnification, the proximal stump of the profundus tendon was located in the palm and resected. In a later surgery, tenodesis (suture of a tendon to bone) of the distal stump was performed at the entrance to the fibrous sheath and at the palmar plate of the distal interphalangeal joint (DIP) at 10° of flexion. A dorsal splint that provided support to the DIP was worn five weeks. Six months after this surgery, the patient was satisfied but had a fixed flexure of the proximal interphalangeal (PIP) joint of 20° of her fourth finger.

Anatomical and medical considerations

Palmar aponeurosis

The palmar aponeurosis (palmar fascia) is a thick layer of fascia that invests the muscles of the palm, and is divided into central, lateral, and medial portions (Figure 4).

The central portion occupies the middle of the palm, is triangular in shape, and is thick. The proximal apex of the palmar aponeurosis is continuous with the lower margin of the transverse carpal ligament (flexor retinaculum), and is the insertion of the expanded tendon of the palmaris longus. The distal base of the palmar aponeurosis divides into four slips, one for each finger. Each slip gives rise to superficial fibers to the skin and finger; the deeper part of each slip subdivides into two processes, which are attached to the fibrous digital sheaths of the flexor tendons. This arrangement results in channels anterior to the heads of the metacarpal bones for the flexor tendons. The spaces among the four slips allow for passage of the digital vessels and nerves, and the tendons of the lumbrical muscles (first lumbrical is labeled in Figure 4).

Figure 4. Cadaveric image of the hand showing the main component of the palmar aponeurosis.

Dupuytren's disease

Dupuytren’s disease is a fibrosing condition that causes slowly progressive thickening and shortening of the palmar fascia, resulting in debilitating digital contractures, especially of the MCP or PIP joints (Figure 5). The condition usually begins with small hard subcutaneous nodules (Figure 5C) just under the skin of the palm. Dupuytren’s disease progresses until the fingers cannot be extended (Figure 5). Whereas typically disease is not painful, some aching or itching may be present. The 4th digit is usually the first one affected followed by the 5th and 3rd digits. The contractures interfere with most manual activities.

Figure 5. Photographs of the hands of patients with Dupuytren’s disease (not from patient in this case). A. Patient with typical contracture of ring finger. B. Patient with contracture of ring and little fingers. C. Nodule (and associated pit) on hand of patient. D. Patient with visible fibrotic cord. All photographs courtesy of Dupuytren’s Contracture Institute.

Clinical case: Dupuytren's contracture: want to learn more about it?

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