What's the Take Home?

A 71-Year-Old Man With Pain and Stiffness in the Hand

Volume 60 - Issue 4 - April 2020

AUTHORS:
Ronald N. Rubin, MD1,2—Series Editor

AFFILIATIONS:
1Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
2Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania

CITATION: Rubin RN. A 71-year-old man with pain and stiffness in the hand. Consultant. 2020;60(4):22-24. doi:10.25270/con.2020.04.00005

DISCLOSURES: The author reports no relevant financial relationships.

CORRESPONDENCE: Ronald N. Rubin, MD Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140 (blooddocrnr@yahoo.com)

 

A 71-year-old man presents with a subacute history of pain and stiffness in his dominant left hand. The symptoms had begun 6 months prior with significant pain in the middle of his palm and down through his middle finger, affecting his metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.

Although he cannot recall any specific significant injury or trauma to the area, he is quite active, golfing regularly and participating in a number of softball leagues amounting to more than 100 games a year. He assumes that some sort of minor injury or overuse has caused the pain and stiffness in his hand. However, a period of rest has not improved the symptoms, and continuing to golf and play softball has not significantly worsened them. With time, the pain has lessened, but stiffness in the middle finger has settled in such that he cannot close the fist of his left hand, and the left middle finger remains somewhat flexed and will not straighten.

The situation has resulted in loss of strength in the left hand (especially his grip strength) and diminished acuity of fine movements. His writing function remains intact. He notes a prominence of the middle tendon of the palm and nodularity between the palmar crease and MCP joint.

He is otherwise quite healthy, with a medical history positive only for mild hypertension (controlled with losartan, 10 mg/d) and mild hypercholesteremia (controlled with atorvastatin, 10 mg/d). He consumes one cocktail each evening, and he has no smoking history other than an occasional cigar on the golf course. He is a retired white-collar professional, and except for his ongoing athletic activities, he has had no occupational exposure to trauma to his hand.

A focused physical examination reveals limitation of flexion of the middle finger of the left hand with inability to tightly close his fist and to totally straighten or flatten the finger on a flat surface. The palmar fascia in the middle of his palm is prominent and nodular. The flexor digitorum profundus of his middle finger is easily palpable and thickened. There is no redness, inflammation or significant pain with examination of these areas.

Answer: C, initiate a program of collagenase injections and manipulation if flexion worsens to 30° or greater and/or symptoms become QoL issues.

The clinical entity involved here is Dupuytren disease, and the choices offered above are potential management options. Dupuytren contracture classically is a condition involving the hand—most commonly, the ring, fifth, and middle fingers, in that order of incidence—wherein a fibrous overgrowth occurs in the palmar fascia and tendons of the hand. The most commonly affected areas are the MCP joints followed by the PIP joints; when progressive, which is usually the case, the thickened tendons cause tightening and eventual contraction with curling and bending of the fingers involved, creating difficulty in straightening. The condition is quite common. It occurs in all racial and ethnic groups but is most common in the white population (prevalence, 3% to 6%) and most frequently occurs in those of Northern European ancestry, with familial clustering. Dupuytren contracture has increasing prevalence with age; initially it is more frequent in men, but the sex distribution becomes more equal with advancing age.1 Interestingly, there seems to be no casual relation with trauma or excessive occupational use of the hands.

Pathologically, tissues do not demonstrate acute or chronic inflammation. Rather, it is an idiopathic overgrowth of benign fibroblasts, and there is no malignant progression of the condition. In light of familial clustering, genomic studies of patients with Dupuytren contracture have demonstrated 9 loci in genetic susceptibility to the condition, 6 of which encode for proteins in the Wnt signaling pathway, which is the first firm casual association in the otherwise poorly understood pathogenesis of the condition.2

Management of Dupuytren disease has seen significant evolution in the last decade. Prior to then, traditional treatment had been open fasciotomy. This is a complex surgical procedure with a quite prolonged hand immobility and convalescence that is often measured in months. The usual criteria for proceeding to open fasciotomy include significant functional and QoL impairment associated with a MCP joint contraction of 30° or greater.1 Unfortunately, there is a significant recurrence rate, the true prevalence of which is difficult to determine due to the great variability in definitions, duration of follow-up, study designs, and patient populations reported in the surgical literature.3 The next therapy method developed was percutaneous needle fasciotomy, a less-invasive procedure wherein the palmar fascia and flexor tendons are carefully “shaved” using specialized needles to thin the collagen buildup away from the effected tendons.4 And finally, in the past decade, again using needles but this time injecting collagenase clostridium histolyticum into affected cords, followed by manipulation, has come into more and wider use.1,5

The latter therapeutic option has many very significant advantages. It is far less invasive; it is an office procedure; it requires far less recuperation time and less extensive postprocedural hand therapy; and it does not require general anesthesia.1,5 Experience has blossomed in recent years and has answered many questions about this treatment. This includes good data confirming an overall 0.1% incidence of the dreaded tendon rupture complication, essentially similar to the 0.2% rate associated with open surgery; a success rate (defined as at least 50% flexion decrease from baseline) of 90%, with actual residual flexion of less than 30° in those patients; and a recurrence rate of 6.7% ±1.7% at 12 months, which is comparable to most surgical study results.1,3 A recent literature review strongly suggests that collagenase manipulation is the initial therapy of choice, based on comparative results and the fact that surgery remains a viable option in cases of failure or recurrence after collagenase.5 Therefore, the best strategy is described by Answer C.

Answer D, even as a straight true/false statement, is not correct. There is no timeline that if violated renders surgery ineffective or contraindicated. Corticosteroids (Answer A), whether oral or locally injected, are ineffective, given that there seems to be no active inflammatory process in Dupuytren disease. There is no acute or chronic inflammatory pathology found in specimens, rather just bland, benign fibromatosis, so it is not surprising that corticosteroids are ineffective. Finally, Answer B is related to surgical procedures for carpal tunnel syndrome, which is not the diagnosis here.

PATIENT FOLLOW-UP

The patient considered the various management options and their potential risks, benefits, rates of recurrence, and recovery times. His decision was to defer any procedures for now. His symptoms have been stable for the past 3 months, and he will evaluate the extent of interference of hand function and lifestyle issues going forward. At this time, should therapy be required, he would opt for collagenase injections.

TAKE-HOME MESSAGE

Dupuytren disease is a benign fibromatosis of the hands and fingers, most commonly the ring finger. With time, fibrous formation of palmar nodules and cords result in flexion contracture and variable degrees of disability of the hand. Demographic risk factors include genetic susceptibility with clustering of cases in families, Northern European descent, advancing age, and male sex. Interestingly, repetitive trauma does not seem to be a risk factor. Therapies include the traditional surgical open fasciotomy, needle fasciotomy, and the newer injection of collagenase followed by manipulation. None of these is curative, and all have similar recurrence rates and flexor tendon injury rates.

REFERENCES:

  1. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361(10):968-979. doi:10.1056/NEJMoa0810866
  2. Dolmans GH, Werker PM, Hennies HC, et al; Dutch Dupuytren Study Group, German Dupuytren Study Group, LifeLines Cohort Study, BSSH–GODD Consortium. Wnt signaling and Dupuytren’s disease. N Engl J Med. 2011;365(4):307-317. doi:10.1056/NEJMoa1101029
  3. Zhang P, Qin L. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. Letter. N Engl J Med. 2009;361(26):2578-2580. doi:10.1056/NEJMc0909497
  4. Holzer LA, Holzer G. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. Letter. N Engl J Med. 2009;361(26):2579-2580.
  5. Degreef I. Collagenase treatment in Dupuytren contractures: a review of the current state versus future needs. Rheumatol Ther. 2016;3(1):43-51. doi:10.1007/s40744-016-0027-1