Can You Identify This Patient’s Bilateral Hand Deformities and Loss of Motion?

Authors:
Sonia A. Talwar, MD; Abhinav Talwar; and Ankoor Talwar

Citation:
Talwar SA, Talwar A, Talwar A. Can you identify this patient’s bilateral hand deformities and loss of motion? Consultant. 2018;58(1):27.

A 65-year-old man presented to his primary care physician with a chief concern of a progressive bilateral loss of finger motion. He was a retired military veteran with a history of coronary artery disease and hypertension. He had smoked for 20 years but had quit 10 years ago.

On physical examination, he was alert, awake, and oriented. His pulse, blood pressure, and respiratory rate were within normal limits. Findings of cardiovascular, pulmonary, and abdominal examinations were unremarkable. Examination of the extremities, however, showed painless, bilateral, symmetric deformities of the hands. The patient stated that this condition had been slowly worsening over the past 30 years.

Answer: Dupuytren contracture

The man received a clinical diagnosis of Dupuytren contracture (DC).

Discussion

DC affects the palmar fascia.¹ Although it is considered a benign condition, DC can be debilitating due to the decrease in hand mobility and grip strength that it causes.

The ring finger is most typically affected in DC, followed by the little finger and the middle finger.¹ The condition begins as a firm nodule in the palm that causes a puckering of the overlying skin. Eventually, this develops into an inextensible thickened band running up to the fingers, causing loss of extension of the metacarpophalangeal joint and contracture of the interphalangeal joints.

DC predominantly affects older men of Northern European descent. Some patients may have a family history of the condition. DC is considered primarily a genetic disorder, but recent evidence suggests that environmental and occupational factors can contribute to its occurrence. Moreover, an association between the disease and alcohol consumption has been recognized.² This relationship has been long-established, but the pathway by which alcoholism relates to DC is unknown. The condition also appears to be linked to diabetes mellitus and smoking.³ In fact, the occurrence rate of DC is reportedly 3 times higher in smokers. Both of these relationships may be due to the microvascular changes in the hand that develop as a result of diabetes or smoking.⁴

The diagnosis of DC can be made by way of clinical presentation and a visual inspection of the hand. The severity of DC is graded on a 3-point scale. Hard nodules (Garrod nodules) with aponeurosis are characteristic of grade 1 DC. In grade 2, a peritendinous band develops, causing mild finger contraction. Full flexion contracture is indicative of grade 3, which is a severe presentation of the condition.⁵

The management of DC is focused on contracture relief to regain finger motility and hand function. Surgical intervention is effective in breaking tissue and straightening the fingers. Over the past few years, however, a shift has occurred toward less-invasive procedures such as collagenase injections and needle aponeurotomy. Collagenase injection of the joints has been used as a minimally invasive enzymatic fasciotomy and has shown reliable outcomes with few morbidities and early recovery.⁶ In needle aponeurotomy, performed under local anesthesia, a small, hypodermic needle is used to sever the contracting bands in the palm and fingers to gradually straighten the digits. It is generally most effective for the treatment of palm deformities, but it can be used in cases of finger contractures.⁷

The differential diagnosis of DC includes gout, rheumatoid arthritis, osteoarthritis, and limited scleroderma.

Gout results from tissue deposition of monosodium urate crystals. It classically manifests as recurrent attacks of acute arthritis, characterized by often painful articular and periarticular inflammation. Acute gouty arthritis is typically monoarticular.

Rheumatoid arthritis is a chronic, systemic inflammatory disease that primarily targets synovial tissue. The hands are a major site of involvement, and the disease typically starts with swelling of the proximal interphalangeal joint and metacarpophalangeal joint. The distal interphalangeal joints are rarely involved. In advanced stages, classic ulnar deviations are commonly seen.

Osteoarthritis is characterized physically by pain and functional limitations and radiographically by osteophytes and joint space narrowing of the involved joints. In the hands, osteoarthritis results in progressive bony enlargement of the distal interphalangeal joints (Heberden nodes).

Scleroderma is a chronic systemic disorder that affects the skin, musculoskeletal system, heart, lungs, and gastrointestinal tract. In limited scleroderma, skin changes are restricted to the face, neck, and areas distal to the elbows or knees but sparing the trunk. Flexion contracture of the fingers, wrist, and elbow can appear secondary to dermal sclerosis. Ulceration of the skin is a late complication.

Our patient was referred for consultations about surgical correction and collagenase injection. He declined both options but was referred for physical therapy. 

Sonia A. Talwar, MD, is Chief of Endocrinology at Plainview Hospital in Plainview, New York.

Abhinav Talwar is a student in the Honors Program in Medical Education at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Ankoor Talwar is a student in the Leadership in Medicine Program at Union College/Albany Medical College in Albany, New York.

References:

1. Shaw RB Jr, Chong AKS, Zhang A, Hentz VR, Chang J. Dupuytren’s disease: history, diagnosis, and treatment. Plast Reconstr Surg. 2007;120(3):44e-54e.
2. Noble J, Arafa M, Royle SG, McGeorge G, Crank S. The association between alcohol, hepatic pathology and Dupuytren’s disease. J Hand Surg Br. 1992;17(1):71-74.
3. Attali P, Ink O, Pelletier G, et al. Dupuytren’s contracture, alcohol consumption, and chronic liver disease. Arch Intern Med. 1987;147(6):1065-1067.
4. Renard E, Jacques D, Chammas M, et al. Increased prevalence of soft tissue hand lesions in type 1 and type 2 diabetes mellitus: various entities and associated significance. Diabete Metab. 1994;20(6):513-521.
5. Su C-K, Patek AJ Jr. Dupuytren’s contracture: its association with alcoholism and cirrhosis. Arch Intern Med. 1970;126(2):278-281.
6. Degreef I. Collagenase treatment in Dupuytren contractures: a review of the current state versus future needs. Rheumatol Ther. 2016;3(1):43-51.
7. Henry M. Dupuytren’s disease: current state of the art. Hand (N Y). 2014;9(1):1-8.