Progressive fibroproliferative disease of the palmar fascia causing flexion contractures of the digits.
Also known as: Dupuytren disease, Dupuytren contracture, palmar fibromatosis, Viking disease
Overview
A benign fibroproliferative disorder of the palmar fascia characterized by myofibroblast proliferation and abnormal collagen deposition, producing palmar nodules, longitudinal cords, and progressive metacarpophalangeal and proximal interphalangeal joint flexion contractures.
Epidemiology
Most common in Northern European descent (the 'Viking disease'). Prevalence rises with age, peaking in the sixth to seventh decade. Male-to-female ratio 5-7:1, with women presenting later and with milder disease. The ring and small fingers are most commonly affected.
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Question 1MusculoskeletalMedium
A 62-year-old man of Northern European descent presents with a 2-year history of a firm, painless lump in his right palm that has slowly enlarged. He now has difficulty laying his hand flat on a table and putting his hand in his pocket. He has a history of type 2 diabetes and reports moderate daily alcohol intake. On examination there is a firm nodule and a longitudinal cord at the distal palmar crease in line with the ring finger, with puckering of the overlying skin and a 35-degree flexion contracture of the metacarpophalangeal joint. There is no catching with motion and no tenderness. Which of the following is the most likely diagnosis?
AStenosing tenosynovitis
BFlexor tendon adhesions
CDiabetic cheiroarthropathy
DDupuytren contracture
ECamptodactyly deformity
Reveal answer & full explanation
Correct answer: D — Dupuytren contracture
AStenosing tenosynovitis
BFlexor tendon adhesions
CDiabetic cheiroarthropathy
DDupuytren contracture✓
ECamptodactyly deformity
Why Dupuytren contracture is correct
A painless palmar nodule with a longitudinal cord in line with the ring or small finger, skin pitting/tethering, and a fixed metacarpophalangeal flexion contracture in an older man of Northern European descent is the classic presentation.
Inability to lay the hand flat is the positive Hueston tabletop test, a sign of contracture sufficient to consider intervention; treatment is typically offered at an MCP contracture of 30 degrees or more, and this patient is at 35 degrees.
Diabetes and alcohol use are recognized risk factors; the disorder reflects myofibroblast proliferation and abnormal type III collagen deposition in the palmar fascia.
Pain is characteristically absent — its presence should prompt an alternative diagnosis.
Why the others are wrong
Stenosing tenosynovitis — trigger finger causes catching/locking with motion and a tender nodule at the A1 pulley, not a longitudinal cord or a fixed contracture; this patient has no triggering.
Flexor tendon adhesions — occur after tendon injury or surgery and limit both active and passive range of motion without a palpable palmar cord; there is no such history here.
Camptodactyly deformity — a congenital proximal interphalangeal flexion deformity of the small finger present since childhood, not a new palmar nodule and cord in a 62-year-old.
Diabetic cheiroarthropathy — diabetes plus an inability to lay the hand flat makes limited joint mobility syndrome tempting, but it causes diffuse, usually bilateral finger stiffness with thick, waxy skin (the prayer sign), not a discrete palmar nodule and longitudinal cord in line with a single digit.
Question 2MusculoskeletalMedium
A 62-year-old man of Northern European descent presents with a firm, painless nodule in his right palm near the base of the ring finger that he noticed several months ago. He reports no trouble buttoning his shirt, gripping tools, or doing his job as a carpenter, and has type 2 diabetes. On examination there is a small palmar nodule with mild skin tethering but no longitudinal cord; he can fully extend all digits and lays his palm completely flat on the tabletop. Which of the following is the most appropriate initial management?
APercutaneous needle aponeurotomy
BOpen limited palmar fasciectomy
CIntralesional corticosteroid injection
DNighttime static extension splinting
EClinical observation and follow-up
Reveal answer & full explanation
Correct answer: E — Clinical observation and follow-up
APercutaneous needle aponeurotomy
BOpen limited palmar fasciectomy
CIntralesional corticosteroid injection
DNighttime static extension splinting
EClinical observation and follow-up✓
Why Clinical observation and follow-up is correct
This is early Dupuytren disease: a painless palmar nodule without a cord and without a functional flexion contracture (full extension, negative Hueston tabletop test).
First-line management for a nodule without functional contracture is observation, patient education about the progressive natural history, and avoidance of repetitive trauma; stretching and splinting have no proven benefit at this stage.
Procedural intervention is reserved for an MCP contracture of 30 degrees or more or any PIP contracture (a positive tabletop test), which this patient does not have.
Why the others are wrong
Intralesional corticosteroid injection — sometimes used for a painful or rapidly enlarging nodule, but this nodule is painless and non-limiting, and steroid injection does not alter the natural history of the disease.
Percutaneous needle aponeurotomy — office-based division of a cord to release a contracture; with no cord and no functional deficit, there is nothing to divide.
Open limited palmar fasciectomy — the lowest-recurrence surgical option, but reserved for established, functionally limiting contracture; operating on an isolated asymptomatic nodule risks digital nerve or artery injury and wound complications without benefit.
Nighttime static extension splinting — splinting seems a low-risk way to keep the finger straight, but it has no proven benefit in early nodular disease and does not prevent cord formation or contracture progression; with full extension and a negative tabletop test, there is nothing for a splint to correct.
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Family history (autosomal dominant with variable penetrance)
Diabetes mellitus
Alcohol use and chronic liver disease
Tobacco use
Anti-epileptic medications (historically associated with phenytoin and phenobarbital)
HIV infection
Pathophysiology
Myofibroblasts within the palmar aponeurosis proliferate and contract, depositing type III collagen and producing the characteristic nodules and cords. The disease progresses through three histologic stages: proliferative (myofibroblast-rich, hypercellular), involutional (aligned myofibroblasts producing contraction), and residual (acellular, collagen-rich cords). The pretendinous, spiral, lateral digital, and Grayson ligaments are the typical anatomic contributors to digital contracture.
Clinical presentation
Symptoms
Painless palmar nodule, typically in the line of the ring finger at the distal palmar crease
Progressive inability to fully extend the affected digit
Functional limitations: difficulty placing the hand flat, putting hand in pocket, washing the face, shaking hands
Discomfort is uncommon; pain should prompt consideration of alternative diagnoses
Signs / physical exam
Firm palmar nodule and longitudinal cord, often in line with the ring or small finger
Active and passive flexion contracture of MCP and/or PIP joints
Positive Hueston tabletop test — inability to flatten the hand on a tabletop
Skin pitting and tethering of overlying skin
Classic findings
Painless palmar nodule with cord extending into the ring or small finger producing an MCP flexion contracture in an older man of Northern European descent.
Differential diagnosis
Stenosing tenosynovitis (trigger finger) — Catching with motion, palpable nodule at A1 pulley, no longitudinal cord or fixed contracture without triggering
Flexor tendon adhesions — Following injury or surgery; both active and passive ROM limited
Camptodactyly — Congenital flexion deformity of the PIP joint of the small finger, present from childhood
Palmar fascia callus — Hyperkeratotic skin without subcutaneous nodule or cord
Diagnostic workup
Diagnostic criteria
Hueston tabletop test — the patient is asked to place the palm flat on a table. Inability to do so indicates contracture sufficient to consider intervention. Treatment is typically offered for MCP contracture of 30 degrees or more or for any PIP contracture.
Labs
None required; consider HbA1c if not previously screened
Imaging
Clinical diagnosis; imaging not routinely required
Diagnostic algorithm
Modality
Setting
Recurrence
Recovery
Needle aponeurotomy
Office
Higher (50-65% at 5 yr)
Days
Collagenase injection
Office, 2 visits
Intermediate (35-45% at 5 yr)
1-2 weeks
Limited fasciectomy
Operating room
Lower (~20% at 5 yr)
6-12 weeks
Dermofasciectomy
Operating room
Lowest
Months
Comparison of treatment modalities for Dupuytren contracture by setting, recurrence rate, and recovery.
Treatment
First-line
Observation for nodules without functional contracture
Avoidance of repetitive trauma; no proven benefit from stretching or splinting
Patient education about progressive natural history
Collagenase clostridium histolyticum (Xiaflex) injection into the cord followed by manipulation 24-72 hours later
Limited or extensive palmar fasciectomy — gold standard surgical option with lowest recurrence; longer recovery and higher complication rate
Dermofasciectomy with skin grafting for severe or recurrent disease
Hand therapy and night splinting after definitive treatment
Complications
Recurrent or progressive contracture (most common after needle aponeurotomy)
Digital nerve or artery injury during fasciectomy
Wound complications, hematoma, and skin necrosis
Complex regional pain syndrome
Tendon rupture (rare, reported with collagenase)
PANCE pearls
Dupuytren diathesis describes aggressive disease with early onset, bilateral involvement, ectopic disease (Garrod knuckle pads, Ledderhose plantar fibromatosis, Peyronie disease), and Northern European heritage — predicts higher recurrence.
Pain is not a feature of Dupuytren disease — consider alternative diagnoses if prominent.
MCP joint contractures correct more reliably than PIP contractures because the MCP capsule tolerates prolonged flexion better.
The CORD-I and CORD-II trials established collagenase injection as an effective non-surgical option.
Genetic predisposition (Northern European ancestry, family history) is the strongest risk factor; diabetes, alcohol, and smoking are weaker associations, and diabetic Dupuytren tends to be milder.
References
JAAOS 2021 — Gil JA, Akelman MR, Hresko AM, Akelman E. Current Concepts in the Management of Dupuytren Disease of the Hand. J Am Acad Orthop Surg. 2021;29(11):462-469.
CORD-I — Hurst LC et al., Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture (NEJM 2009)
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