Dupuytren's Disease

Patients present with palmar nodules, progressive cord formation, and difficulty extending the affected digit. Pain is usually mild and intermittent; functional impairment is the dominant concern. Catching of the hand on pockets, gloves, or when shaking hands often triggers referral. Diabetics may have radial-sided distribution (thumb and index), in contrast to the classical ring/little-finger pattern.

Examination:

• •Inspect for palmar nodules, longitudinal cords running into the digit, skin pitting and tethering over the cord
• •Palpate for fixed, non-tender, firm nodules and discrete cords; the nodules do NOT move with tendon excursion (distinguishing from a trigger nodule)
• •Range of motion: MCP and PIP joint extension deficit. Document active and passive extension for each joint
• •Examine the feet (Ledderhose), penis (Peyronie's), and knuckles (Garrod's pads) for ectopic disease

Hueston tabletop test: the patient places the affected hand flat on a table. Inability to flatten the palm and digits against the surface is positive and suggests a clinically significant contracture warranting referral.

Differentials include trigger finger (catching that moves with tendon excursion, no cord), camptodactyly (congenital PIP flexion, no cord), and locked finger from joint pathology.

Dupuytren's disease is a clinical diagnosis. No imaging is required for typical presentations.

Ultrasound or MRI may be useful in:

• •Atypical presentations (rapid onset, soft mass, pain)
• •Distinguishing from soft tissue tumour, granuloma, or epithelial inclusion cyst
• •Pre-operative planning in complex recurrent disease

Baseline assessment should include the contracture angle of each affected joint (passive extension deficit measured with a goniometer), the Hueston tabletop test, and documentation of skin pitting, nodule sites, and cord pattern. Photographs are useful for serial review. Routine bloods are not indicated, though screening for diabetes is reasonable in undiagnosed patients given the strong association.

No serum biomarker reliably predicts progression. Tubiana classification (I-IV based on total flexion contracture angle) is sometimes used to grade severity but is more commonly applied in research than UK clinical practice.

Management is based on functional impairment, not the presence of disease alone (NICE TA459).

Observation: nodules and cords without contracture or functional impairment can be observed. Reassure and review at intervals (6-12 months).

Referral to hand surgery is indicated for MCP contracture over 30 degrees, any PIP contracture, positive Hueston tabletop test, rapid progression, or functional impairment.

Intervention options:

• •Percutaneous needle aponeurotomy (PNF): outpatient procedure under local anaesthetic, using a needle to divide the cord at multiple points. Low complication rate, fast recovery, but higher recurrence (50-65% by 5 years). Good for elderly low-demand patients and frail individuals
• •Collagenase clostridium histolyticum injection (Xiapex): formerly the option for moderate MCP contracture. Manufacturer discontinued European distribution in 2020, so it is currently unavailable in the UK
• •Limited fasciectomy: open surgical excision of diseased fascia, the UK gold standard for established contracture. Day-case under regional anaesthetic. Lower recurrence (~20% at 5 years) but longer recovery and higher complication risk than PNF
• •Dermofasciectomy with full-thickness skin graft: reserved for recurrent disease, severe skin involvement, or aggressive diathesis; lowest recurrence rate of any intervention

NICE TA459 historically endorsed collagenase for MCP contractures; absence of UK supply makes PNF and limited fasciectomy the active options. PIP contractures are technically more challenging and have higher recurrence regardless of technique - earlier referral improves outcomes.

Complications of surgery: digital nerve injury (~3-5%), wound dehiscence, complex regional pain syndrome, flare reaction, and recurrence. Counsel patients about expected residual deficit, particularly with PIP contracture over 60 degrees.

Hand therapy is integral to any intervention, and a hand therapy referral should accompany surgical or PNF treatment.

Post-procedure pathway:

• •Day 0-3: bulky dressing, elevation, early oedema control. Active range-of-motion exercises encouraged from day 1 after PNF and day 2-3 after fasciectomy
• •Day 3-14: dressing change at clinic, scar management commences. Custom-fabricated night splint in extension supports gained range
• •Week 2-6: progressive active and passive extension exercises, scar massage, oedema control. Strengthening commences as wound healing allows
• •Week 6-12: full return to most activities, with continued night splinting for 3-6 months in patients with significant pre-operative contracture

Night extension splinting at the affected joint(s) for 3-6 months post-operatively is the standard UK practice to maintain corrected position, though the evidence base is modest.

Persistent stiffness, deteriorating range, or recurrence warrants early reassessment by the hand surgeon - early identification of recurrence allows additional intervention before fixed contracture develops. Functional outcome correlates strongly with pre-operative severity and adherence to splinting and exercises.

• •NICE TA459 (2017) - Endorsed collagenase clostridium histolyticum for moderate MCP contractures; manufacturer-led UK withdrawal in 2020 means active UK options are PNF and limited fasciectomy.
• •BSSH Dupuytren's Disease Guidance - UK hand-surgery framework: limited fasciectomy is the surgical standard; refer when MCP contracture exceeds 30 degrees, any PIP contracture is present, or tabletop test is positive.
• •van Rijssen et al. (2012, 2018) - RCT comparing PNF and limited fasciectomy: PNF offered faster recovery and equivalent short-term contracture correction but 50-65% recurrence at 5 years versus ~20% for limited fasciectomy.
• •Hueston tabletop test (1969) - Persistent clinical reference for surgical referral threshold; inability to flatten the palm against a table indicates clinically significant disease.
• •Tubiana classification (1986) - Four-tier total flexion-contracture grading occasionally used to stratify severity; more common in research than UK NHS pathways.

• •Refer thresholds: MCP contracture over 30 degrees, any PIP contracture, positive Hueston tabletop test. PIP contractures progress faster and respond worse - earlier referral matters.
• •Dupuytren's diathesis (early onset, bilateral, family history, ectopic disease - Ledderhose, Peyronie's, Garrod's pads) predicts aggressive recurrence. Counsel before any intervention.
• •The palmar nodule does NOT move with tendon excursion - this distinguishes it from a trigger finger nodule. Cords are longitudinal and skin-tethered with pitting.
• •Diabetics often have a radial-sided pattern (thumb and index) rather than the classical ring and little finger.
• •UK active options are percutaneous needle aponeurotomy (faster recovery, higher recurrence) and limited fasciectomy (longer recovery, lower recurrence). Collagenase has been unavailable in the UK since 2020 despite NICE TA459 endorsement.
• •Major surgical complications: digital nerve injury (~3-5%), wound dehiscence, CRPS, and recurrence. Night extension splinting for 3-6 months post-operatively is UK standard practice.