Dup-FAQ

Dupuytren's

 DUPUYTREN'S DISEASE: FREQUENTLY ASKED QUESTIONS
AND LINKS TO PUBLISHED STUDIES: FAQS & FACTS

This page includes answers to frequently asked questions regarding Dupuytren's disease. There is quite a bit known about Dupuytren's, but because we don't yet have all of the pieces of the puzzle, the bits that we do know don't all fit tidily together. There are also a fair number of undocumented urban legends. This page only includes information which has been investigated and published in recognized medical journals - the stuff that doctors read. For verification and more information, this page links to source material at the National Library of Medicine. Browse around! There's quite a bit here to consider.

How do you pronounce the name "Dupuytrens"? Dupuytren is a French surname, and the closest approximation for the American English pronunciation is doo-pa-trens, with the accent or emphasis on the first syllable "doo". Although some pronounce the name Dupuy as doo-poo-wee, this does not apply to the name Dupuytren.

What is Dupuytren's disease? Dupuytren's contracture is a benign condition which causes a tightening of the flesh beneath the skin of the palm and can result in permanently bent fingers. There is a sheet of tissue just under the skin of the palm which is stuck to the undersurface of the skin of the palm. This layer, called fascia, reinforces the skin of the palm. The fascia looks like cloth, and has fine threads which run lengthwise from the palm into the fingers. Dupuytren's disease makes these lengthwise threads shrink, and they can become too short to let the fingers straighten all the way. Trying to straighten the fingers pulls the threads taut, and they feel like a string under the skin, called a cord. The taut cord holds the fingers bent like the string on a bow. The cord may feel like a tendon, but it is actually between the tendon and the skin. There are more common reasons for people to develop bent fingers, including arthritis, trigger finger, or the after effects of injury or reflex sympathetic dystrophy - but these conditions are not Dupuytren's disease and are treated differently.

 

The medical definition of Dupuytren's is a specific condition characterized by proliferation of contractile, fibroblastic cells involving the palmar fascia of the hand. It is chronic and progressive 11252689 . Involved areas show microscopic inflammation 10463754, similar to that seen in wound healing 6740656 and some types of cancer 6491814, as though the body were healing a deep wound beneath the skin 10473143, 8056970.

Why is it called "Dupuytren's"? Guillaume Dupuytren (1777-1835) was Napoleon's surgeon, and in his time was the most famous surgeon in France. In 1831 at the Hotel-Dieu Hospital in Paris, he performed surgery and then lectured on a condition causing bent fingers, which since has borne his name 9457317. Dupuytren was not the first to describe the condition - it could just have well been called "Cooper's Contracture": Sir Astley Cooper published a description of the disease and its surgical treatment in England nearly 10 years before Dupuytren 12864830. Others preceded him in describing the condition, including anatomist Felix Plater 200 years earlier 9206674, 7498844, 6360477.

Dupuytren's in History: Dupuytren's disease has been referred to as a Viking or Celtic disease, but existed in Europe earlier than the Viking Age 8345270 and originated much earlier in prehistory 12015711 . James Barrie, author of "Peter Pan" had a right contracture thought to be Dupuytren's, which formed the source material for Captain Hook's hook. The Papal Benediction sign, with bent ring and small fingers, may have started with a pope with the condition 10050238.

How common is Dupuytren's contracture? It depends on the genetic makeup of the population. Dupuytren's is estimated to affect 3% of the US population 2190416.

What areas are most often affected?

  • Dupuytren's is a change in normal structures 6099177, transforming the superficial palmar fascia into cords, and joins fascia to the undersurface of the skin to form nodules 7071229. Although resembling a tumor in some ways 6197420, it is not. The longitudinal (lengthwise) fibers of the superficial palmar fascia are clinically affected 3068887, but transverse (sideways) fibers also show chromosomal evidence of involvement 3414684. Although only certain regions of the fascia appear affected, the biochemistry of the entire fascia is abnormal 6197420. The ring finger is most commonly affected, then the small finger, and then the thumb (28%) 12531665. Thumb involvement can take many forms 3958553, 7049485, and usually occurs when other fingers are affected 10050250. Rarely, the wrist may be involved 11901473, 9119844 , 8771479. "Knuckle pads" 3190317, 2943155 on the dorsal PIP joints are apparently the same process as nodules in the palm. Although neither produce contractures 6707508, knuckle pads are associated with more aggressive forms of the disease 1960491. Isolated cords in the fingers may develop between the proximal phalanx periosteum (bone lining at the base of the finger) and the flexor tendon sheath at the middle phalanx level 3968392. Abductor pollicis muscle and tendon involvement may affect small finger contractures 6512361.
  • Normally, the skin is anchored down to the underlying fascia by many tiny tissue strands running perpendicular down to the fascia. When the fascia shrinks, these threads pull the skin, and may result in nodules, dimples, or both contour changes:
     
  • Secondary changes may also occur. The position of the finger nerves may be shifted by the growth of a "spiral cord", especially when the PIP joints become contracted 7822934, 1769988. Extensor tendons on the back of the finger may be indirectly affected 4015238: the central slip tendon which straightens the PIP joint may become stretched out from the joint being bent for a long time 7806815, and the transverse retinacular ligaments on the sides of the joint may become fibrotic, resulting in a boutonniere deformity 3249131, 3190317.
    Rarely, the extensor tendons may be affected by PIP knuckle pads 6693470 or distal to the PIP joint 7119399. Other changes in the PIP joint may prevent full correction of contracture 4078465 using surgical techniques which work for non-Dupuytren's PIP contractures 1779164. Bone spurs may develop in the finger bones as a result of tension on the attachments to bones 11982519, 10433443. Rarely, the DIP joints are involved 1773223.
  • Outside the hand, the sole of the foot (Ledderhose's disease) and the penis (Peyronie's Disease) may be affected in a similar fashion. The combination of all three conditions - Dupuytren's diathesis, Ledderhose's contracture and Peyronie's disease - is referred to as Dupuytren's diathesis 8817754 and is associated with a particularly aggressive condition.

How is it staged or graded? There are a variety of classification systems 10050245 , 9665513, 7521655, 2071079, 3190318, 3963905. A characteristic set of microscopic changes occur 4007638.

The disease process includes two structures, the nodule and the cord, which are quite different microscopically and biochemically 3351230, 12849947, 12087679, 12087251, 11599921, 9665511, 7594997, 3138883, 6491814, and early ("proliferative") nodules are biologically different from mature ("involutional") nodules 3958550, 6150573. Dupuytren's nodules represent the early, active form of fibrosis, and are the hard lumps in the palm. Cords develop later; they feel like strings beneath the skin and are responsible for the tethering which results in contractures.

Contractures often span several adjacent joints. For affected joints, if bending one joint allows the adjacent joint to be fully straightened and vice versa, the contracture is referred to as a "composite contracture". If an affected joint can not be fully straightened in any hand position, the result is called a "fixed contracture"


 

Tubiana's classification is simple and helpful. It grades the contracture into one of four stages based on the combined angles of contracture of the MCP and PIP joints, and may be applied to both composite and fixed contractures: This angle is illustrated by the blue lines in this diagram:

What is the natural course of the disorder with no treatment? The disease often causes progressive contractures. Involved tissues become fibrous and rarely may develop cartilage or calcium deposits 3624996. The younger the person is when they first develop Dupuytren's, the more likely they will need surgery 11252689, and the younger the patient is when surgery is needed, the greater the chance for recurrence 10473157. Overall, finger contractures develop in about one in 20 people with Dupuytren's disease 10760640. If finger contractures develop, eventually, function is lost - but function and dexterity can be improved with correction of the contractures 12162983. Spontaneous regression is rare 1402277. Spontaneous regression of knuckle pads has been reported in children 2943155.

What is it due to? The exact process is still unknown, despite many bits of information. The body chemistry is abnormal in the entire region, even in areas not visibly changed by Dupuytren's 3373152, 6768572, 589933, 9369955, 8501391. Here are a few parts of the picture - see if you can figure out how all of this fits together...

  • The balance between certain enzymes (matrix metalloproteinases 14504511, 9768907, fibrinolysins 3958550, plasminogen activators 3693826) and their natural inhibitors is disturbed in patients with active Dupuytren's disease, and may be affected by tension on the affected tissues 9665512.
  •  The cells in the cords of Dupuytren's disease are unusually sensitive to the effects of "growth factors", normal body chemicals involved in wound healing. These include transforming growth factor beta 1 (TGF-beta(1) 12849947, 12729127 , 8618012, transforming growth factor beta 2 (TGF-beta(2) 12678125, 8683048, basic fibroblast growth factor (bFGF) 1325742, platelet derived growth factor (PDGF)   12087679, 7822340, 1564283 and others 9120728, 7722248, 8056971, 8320323. The process may be triggered by a combination of mechanical stress and either TGF-beta 10050239, or PDGF 8893764 .
  • Dupuytren's cords have unusually high levels of levels of the protein tyrosine phosphorylated beta-catenin 12802275 , and the cells have higher than normal levels of the substance alpha smooth muscle actin 11599921 and the enzyme lysyl oxydase 6130030.
  • Cell-matrix interaction abnormalities, stimulating contraction 9369955, 9065582, 8525780. A three dimensional mesh of actin microfilaments (the "fibronexus") links cells to each other and to the extracellular matrix 1867394, which, in Dupuytren's disease, contains unusually high levels of fibronectin 3519746, 6386626.
  • Abnormal androgen receptors have been implicated in the abnormal tissue 11853085 , 10194020, 1798252, although not by all investigators 3794501.
  • Low oxygen levels resulting in reactive forms of oxygen (superoxide free radicals, oxygen free radicals) due to poor circulation have been implicated 12087679, 10050241, 1769989, possibly due to activation of the enzyme xanthine oxidase 1695516, 2825907. The blood clotting system may be triggered by production of high level of plasminogen activator 6197420. Microvascular circulatory changes develop, with narrowing and blockage of capillaries 1960491, 2322211, 2722922, microscopic hemorrhage 6693745 and other changes in the blood vessel walls 4082789, 6150573. This might explain the relationship of smoking to Dupuytren's. Miroculatory changes may arise from abnormal regulatory nerves in the fascia itself 2472714. Nodules show near complete absence of blood vessels 6693745, and other studies show evidence of low oxygen levels in the diseased tissues 6877040.
  • T-cell and B-cell Immune mechanisms , 9888668, 8099992, autoantibodies to collagen 8181183, 3485693 or other immune mechanisms 2471021, 3138883, 6353806 may be involved.
  • Genetic variations have been demonstrated in nodules, in the form of recurrent clonal numerical abnormalities 9973941, 9352799, 3414684.
  • The contraction is due to a mechanism also seen in other contracting tissues such as healing wounds and some types of cancers 6491814. Dupuytren's fibroblasts 6507097 can acquire smooth muscle characteristics and are then able to contract 7642925. These modified fibroblasts are called myofibroblasts 1960491, and are found in nodules, but not cords 1769990, 6491814, 7071229. In diffuse disease, these changes can affect cells in the skin as well as the fascia 8294839. Myofibroblasts contract through an interaction of myofilaments and the enzyme ATPase within their cell bodies, and the extent of recurrence after surgery correlates with myofibroblast activity at the time of surgery 6683733, 2754197.
  • Certain nerve endings (Pacinian corpuscles) are enlarged and surrounded by fibrous tissue in affected areas 3358315, 2472714.
  • Overall collagen metabolism may be disturbed in patients with Dupuytren's 2883783. Type III collagen is increased in Dupuytren's cords 6386626, 6740656.
  • Mechanical tension forces or stretching the affected area may provoke contracture 14599823, 12866952, 12449347, 10050239, 9763277, 9665511, possibly by stimulating changes in the microcirculation 8917718. Dynamic physical forces may produce biochemical changes through changes in tissue electrical fields 1284015 . Paradoxically, continuous tension on the tissues causes a temporary reversal of the process, probably by stimulating enzymes involved in tissue remodelling 7964107. One hypothesis is that loss of normal gliding motion between layers of fascia results in abnormal tissue tension which provokes the contracture process 7152372.
     


MEDICAL / ENGLISH TRANSLATIONS relating to Dupuytren's Disease

  • Aponeurosis same as Fascia.
  • Aponeurectomy same as Fasciectomy.
  • Aponeurotomy same as Fasciotomy.
  • Aponevrosis same as Fascia (French spelling).
  • Aponevrotomy same as Fasciotomy (French spelling).
  • Closed two meanings: (see open)
    • A procedure performed without any cut in the skin, as in a joint manipulation.
    • At the end of surgery, a wound can be "closed" by sewing the skin edges together or covering the area with a skin graft or skin flap.
  • Dermofasciectomy removing fascia and the overlying affected skin. This requires closing the wound with a skin graft or flap.
  • DIP Distal Interphalangeal Joint. The end joint of a finger.
  • Dorsal Back side of the hand, opposite of the palmar side.
  • Extension two meanings:
    • Straightening a joint (opposite of flexion or bending).
    • After surgery, Dupuytren's showing up adjacent to the area previously treated, technically different than recurrence.
  • Fascia a normal reinforcing layer of tissue, found in many areas of the body. In discussions of Dupuytren's, the fascia refers to the superficial palmar fascia, which is a clothlike layer of tissue beneath the skin of the palm, attached to the undersurface of the skin above it and the bones and muscle coverings below it. The fascia normally functions in a very similar manner to what is referred to in the garment industry as "interfacing": a layer of stiff cloth inside clothing which maintains the clothing's shape (interfacing and fascia share the same Latin root). The superficial palmar fascia normally acts as a scaffolding which anchors palm skin to the bones in the hand so the skin doesn't slide around while when we grip, hold, and twist things in our hands - it maintains the shape of the skin. The fascia is a normally unnoticeable layer, not a moving part, and not the tendons which we use to move our fingers. In Dupuytren's disease, it is the fascia which shrinks and thickens, pulling on the skin, pulling and bending the fingers. In the US, insurance companies use the term fascia, not aponeurosis.
  • Fasciectomy surgery to remove the fascia. Don't you need the fascia? Well, yes, but after fasciectomy, the body replaces what has been removed with a layer of scar tissue, which usually works well.
  • Fasciotomy cutting but not removing the fascia. This refers to cutting across tight bands of fascia, letting the edges gape apart and heal back at or closer to their natural length to restore the area's original flexibility.
  • Hematoma blood clot. After surgery, if much blood collects beneath the skin or beneath a skin graft, it may result in necrosis, or a wound where there should be skin. This slows recovery but is not the same thing or danger as a blood clot in the legs (DVT) after surgery.
  • Longitudinal lengthwise, as for a line drawn along the length of a finger, base to tip.
  • Necrosis dead skin. If the circulation isn't good enough to an area of skin, after a week or so, that area of skin will turn black and hard and eventually either fall off or need to be trimmed off. This can happen after surgery, usually at the edges of a cut, where it is referred to as marginal necrosis.
  • Open two meanings (see closed)
    • Surgically, open means regular surgery, where the skin is "opened" with a cut, as in fasciectomy. A wound which can be stitched back together. Not percutaneous.
    • After surgery, when the wound is literally left open, not stitched back together. Sounds gruesome, but it really isn't. This is what is done with the "open palm" surgical technique for Dupuytren's
  • Palmar The palm side of the hand or fingers - not just "the palm". Opposite of the dorsal side.
  • Patient You.
  • Percutaneous A procedure performed through a small puncture wound, using a needle, narrow knife or scope, no stitches.
  • PIP Proximal Interphalangeal joint, the middle joint in a finger.
  • Recurrence After surgery, Dupuytren's showing up in the area previously treated, technically different than extension.
  • Suture stitches
  • Transverse side to side, usually refers to a sideways cut in the palm used for fasciectomy

What other conditions predispose to Dupuytren's?

RISK FACTOR

AVAILABLE DATA

Genes

Dupuytren's disease is most common in white males of Northern European descent 1810624, 10050242. It is uncommon in blacks 11770364, 9665514, 8074370, and in blacks is more often associated with a history of trauma 8891992. A US Veterans study gave this racial breakdown: the incidence of Dupuytren's in their study was Caucasian: 0.7%; Hispanic: 0.2%; Black: 0.1%; Native American: 0.1%; Asian: 0.07% 10883614. Dupuytren's is six times more common in men than women 10883614, 10473157. Women develop the disease on the average ten years later than men 11357696, 10473157. The disease appears to run in families, and often follows an autosomal dominant inheritance 10050243. Dupuytren's contracture has been reported in in 21% of women and 39% of men over the age of 60 in North-east Scotland. 8501390. Even with a genetic predisposition, presentation is variable, and identical twins with Dupuytrens do not necessarily have identical disease 8345271. There are genetic differences between patients with and without Dupuytren's 12794452, 12783014 , 11924651. Although a genetic pattern of HLA DR antigens has been reported in both Dupuytren's and scleroderma 6334711, a "Dupuytren's gene" has not been identified 11895345.

Age Increasing age increases the risk of developing Dupuytren's 3592873. Although reported in infants 11418917, 3924790 children 12703034 , 11912542 and teenagers 8676015 , this is rare. Other childhood conditions 11117052 may mimic Dupuytren's, such as the benign recurring digital fibroma of childhood or malignant epithelioid sarcoma 11912542, 10612139, 7719607. In Iceland, where it is common, Dupuytren's in men found in 7% in the age group 45-49 years, 40% in those 70-74 years old 10760640. In Norway, 30% of the population over 60 has Dupuytren's 10050243.
Diabetes
 There is a five 7713273 to ten 9382632 times increased risk for diabetics to develop Dupuytren's contracture 8697659, 7722249, 10883614, 2522373, 10760640, related to the duration 3590817, 6343018, presence of diabetic retinopathy 6343018, but not severity of the diabetes 6608923, 6343018, 9002027, 2725939. In diabetics, Dupuytren's is often a less aggressive form, but the radial hand is more often involved 6725338.
Diabetic Limited Joint Mobility Syndrome Patients with this are twice as likely to have Dupuytren's than with diabetes alone 2057690, 2522373, 6608923, 2968881, and relates to the duration of diabetes 4042798. The relationship may be explained by smoking, which predisposes to both conditions 2022177, 2522859
Smoking
 Smokers have increased risk 9119843, 10883614, 2022177, 2522859,  3592873, 10760640, 10760640. Twice the risk of nonsmokers 3225413
Alcoholism
 Increased 2871816, 10883614, although some surveys dispute this 8426337, 11697563 The association may instead be with smoking 9119843 or hyperlipidemia associated with alcoholism 1447259, or alcoholic liver disease 7224858, 190684. Alcoholic liver disease is a risk factor,  nonalcoholic liver disease is not 3592873, although this is also disputed 6672504.

Thyroid disorders

Increased incidence, more for hypothyroidism than hyperthyroidism 12864792

Stretching

Contrary to natural instinct, the act of stretching the skin of the palm appears to aggravate or provoke Dupuytren's contracture 6884845.

Frozen Shoulder
 50% chance of developing Dupuytren's 11307078, 10509873, even more common with diabetes 10509873
Peyronie's Disease
 15 - 25% incidence 7150935, 9636000, 8976282, 80% in familial forms of Peyronie's 6980996.
Lederhosen Disease
 28% chance of having Dupuytren's 10919621
Rheumatoid Arthritis
 Lower chance of developing Dupuytren's 10568426, 6747420, but when present, requires special surgical planning 3336640

Trauma

 Dupuytren's may develop after hand trauma 3592873, 3744141, 4031627, particularly after Colles' wrist fracture (distal radius fracture) 3998585, 9382639, 1588210. One study reported a 40% incidence of Dupuytrens 18 months after Colles' fracture 10372776. Duputren's developing after surgery has also been reported 8856538.
Hyperlipidemia
 Increased 1447259
Vibration exposure
 Increased with vibration exposure 8732927, Patients with vibration white finger syndrome two times as likely to have Dupuytren's  1345125
Epilepsy
 When present, Dupuytrens appears to have a more aggressive character 1588209, although conflicting reports exist  932769. Association may be due to  phenobarbitone  medication rather than epilepsy itself 932769, 10751924 , although this is debatable as well 1588209. There may be an association between Dupuytren's, RSD and antiepileptic drugs 8156963, 2691374.
Gout
 No effect 1588208.

Glucosamine / Chondroitin Sulfate

Glucosamine / Chondroitin sulfate preparations are available as nutritional suppliments with claims of improving joint function. Although no cause and effect relationship has been established, chondroitin sulfate 9517845, 2493650, 6489852 and glycosaminoglycan 6854215 levels are elevated in the tissues affected by Dupuytren's contracture.

Growth hormone therapy

Possibly 8101283

Arcus senilis
 Increased incidence, possibly due to mutual association with hyperlipidemia 1280972

Reflex Sympathetic Dystrophy

 RSD after wrist fracture triples the risk of developing Dupuytren's compared to no RSD 10372776. There may be an association between Dupuytren's, RSD and antiepileptic drugs 8156963 . More common postop in women 2229974 and possibly related to psychological factors 1692417. There may be an association between Dupuytren's, thoracic outlet fibrosis and reflex sympathetic dystrophy 2707653
Hemodialysis
 Increased, although many factors may be at play 3113084
Palmaris longus
 Increased risk if this tendon is present in the wrist 3794480. Excision of the palmaris longus tendon has been reported to reduce recurrence 3740784
Increased serum IgA
 Increased risk 6672504, 6353806
Vascular insufficiency
 Increased risk 8501389

Manual Labor

Increased risk 10760640, 9382639, although controversial 10050242, 8732927, 1834729. Vibration exposure is a risk factor 8732927, 8672800, 1345125

Carpal tunnel syndrome

Although postoperative flare has been reported as more common with simultaneous fasciectomy and carpal tunnel release 7430596, contrary reports exist 2061659.

Vinyl Chloride

 HLA DR antigens have been identified both in Dupuytren's patients and in patients with vinyl chloride exposure related scleroderma 6334711. An increased incidence of  Dupuytren's was reported at a polyvinyl chloride (PVC) manufacturing plant in workers who extensively handled the product 7066227.

HIV infection

Increased risk debated 10050242


Condition If Dupuytren's is present, the risk for this is...
Diabetes
 Increased  7012682, 605747, 6725338.
Hyperlipidemia
 Increased: present over half the time 1280972
Psychological problems
 No association 8583880
Malignancy
 Increased sarcoma 11895346 , cancer 11781116, possibly due to mutual association with smoking and alcohol abuse 10961556.
Mortality
 Increased, especially when presenting under 60 years old 10597922, 11781116
Ulnar neuropathy
 Increased 186961
Cold induced  vasospasm
 Increased 186961
Thin (low triceps skin fold thickness)
 More likely to be thin 8501389 ? associated with smoking
 Does Dupuytren's by itself affect the risk of having other conditions?

What medical treatments have been shown to help? 10050246

What are other treatment options? There is a general tendency for surgeons to recommend minimal surgery (e.g... fasciotomy) for early disease, fasciectomy for established disease and more aggressive surgery (e.g... dermofasciectomy) for advanced or recurrent disease 6529287. Final outcome after surgery is worse in patients who have an earlier age of onset, severe PIP joint involvement, and small finger involvement 1284016. Surgery is usually recommended when MCP contractures progress to 30 degrees, when PIP contractures develop 1769986, or the patient develops a positive "table top test" 7060997, as shown here. Needle aponeurotomy may be performed when the fingers can't be lifted from a tabletop; open surgery is reserved for contractures which prevent the palm from fully contacting a flat surface:

Table Top Tests:

Normal

For NA

For Surgery
  • Procedures:
  • Closure techniques
    • Open palm 10050248, 9746881, 8856539 , 7847092, 1937183, 10050248, or modified open palm 8567134, 1564282, 1769994. In this method, the fascia is divided or removed using transverse incisions, which are left open to heal by themselves. The wound may be surprisingly large, but on the average heals in 3 to 5 weeks. The technique minimizes the chances of infection, hematoma, or skin necrosis, and has been reported to have lower rates of complications and recurrence 6693744, although contradictory reports also exist 3944435. As with other techniques, results following open palm technique are best in the treatment of isolated MCP contractures 6480188.
  • Complementary Procedures
    • Preoperative Stretching programs are different than simply trying to stretch the fingers straight. In the short term, stretching may straighten the fingers, but the long run, stretching alone probably worsens the contracture 6884845. Stretching exercises other than these are not recommended.
    • PIP Joint release, sometimes needed because the joint can remain bent even after releasing or removing all of the abnormal Dupuytren's tissue. Improvement in the operating room is usually better than the final result 12601600, 12073190, 9303892.
        • Percutaneous 3794477
        • Open Not indicated routinely 10050249, may require extensive release 9336654. Therapy is usually indicated after surgery for PIP contracture 10050247. Small finger is most likely to require release, and results are not a favorable as ring finger releases 9303892. Loss of flexion is common after open release 9303892. Wound healing problems are also common 9303892, 8596787. The effectiveness of PIP joint capsule release is debatable 8596787. On the average, there is less than 50% improvement in the final range of motion following PIP contracture 1430959.
    • PIP Arthroplasty (joint replacement) an uncommonly used alternative to PIP fusion or amputation 3908601.
    • Tendon Lengthening In patients with severe contracture, shortened muscle/tendon structures may prevent correction. In some patients, the tightest tendons may be lengthened through a separate operation in the forearm, called an intramuscular tenotomy 12531666
    • Excision of the palmaris longus tendon has been reported to reduce recurrence 3740784.
    • Osteotomy or PIP fusion for recurrent severe PIP flexion contractures with palmar soft tissue fibrosis 1769996, 3559089, 4078465.
    • Amputation for recurrent severe contractures with hygiene or overall health problems 8308443, 3449003, 4078465.
  • Radiotherapy 11757183, 11233838, 11172962, 10803052, 10758324, 9082583, 8960518, 3975949, controversial: 8359061 , 2071079
How effective is surgery?
  • Metacarpophalangeal (MCP) joint contractures involving only one finger can almost always be corrected with surgery or needle aponeurotomy. However, when two or more adjacent MCP joints are contracted, the skin is usually contracted as well, and complete correction is less likely.
  • For the Proximal interphalangeal (PIP) joint contractures, the realistic expectation is improvement, not perfection. PIP contractures due to isolated cords in the fingers have been reported to improve an average of 50% after surgery 3968392. Straightening achieved in surgery is often patially lost during the healing phase (see recurrence). Use this calculator to estimate the final degree of proximal interphalangeal (PIP) joint bend after surgery. The math is based on the 1980 statistical analysis of Legge and McFarlane, based on the finger involved, the contractures of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of that finger, and the number of fingers involved. This is a statistical estimate, to give an idea of how tricky the problem is, not a guarantee of result, which may be better or worse than predicted. Similar outcomes can be expected for needle aponeurotomy (percutaneous fasciotomy) as for open surgery.

PIP Improvement Calculator
What finger? Index Middle Ring Small
What is the PIP contracture of that finger? degrees
What is the MCP contracture of that finger? degrees
How many digits (fingers and thumb) are involved on that hand?
After all the dust settles, the final PIP contracture estimate is degrees

Complications of treatment  Postoperative complications include excessive inflammation, hematoma, ischemic skin necrosis, infection, granuloma formation, transient paresthesia, scar contracture, persistent proximal interphalangeal (PIP) flexion contracture, distal interphalangeal (DIP) hyperextension deformity, joint stiffness, poor flexion and grip strength, pain, and reflex sympathetic dystrophy (RSD). Comparing surgical incisions, skin necrosis, hematoma and pain problems are more likely with zig-zag exposures, while delayed healing and nerve injuries were reported more often after transverse incisions 7152373. Flare reaction after surgery may be more common in women 1769992. Surgery may actually aggravate the process, and patients may be worse off after surgery than they were before 1769994 . Complication rates following surgery have been reported in the range of 17% to 41% 8994009, 9303892, 9214276, 10050251, 3944435. Complications are nearly twice as common following repeat surgery than for primary surgery 9214276.

  • Post Surgical
    • Early
      • Hematoma
      • Swelling 11291357
      • Infection
      • Flare - more common in women 3693825.
      • RSD 7% following open, 1564282, more likely in women 2229974 0% following needle aponeurotomy. Incidence may be less in severe contractures when surgery is performed in two stages 4007639.
      • Wound dehiscence
    • Later
      • Pseudoaneurysm
      • Inclusion cysts
      • Finger stiffness / loss of flexion is common 3944435, especially in women 3693825.