A 54-year-old man presents for evaluation of a painful hand
of several weeks' duration. He has been employed as a painter
for years. The hand has never been injured, according to the
patient's account, and he states that he has no surgical history.
In addition to pain, he is having difficulty extending his
fourth and fifth fingers. He denies any paresthesias. Past
medical history is significant for hyperlipidemia, for which
he takes atorvastatin. He also reports a 29 pack-year history
of cigarette smoking and an occasional drink after work, but
denies any use of illicit drugs. On physical examination,
you note a nodular lesion on the volar surface of the hand
at the metacarpophalangeal joints of the fourth and fifth
fingers.
The patient has a Dupuytren's contracture, a disorder characterized
by the insidious development of a fibrosed nodule on the palmar
surface of the hand. With progressive scarring, contractures
of the fourth and fifth fingers give the dermal tissue a puckering
appearance arising from flexion of the metacarpophalangeal joint.
The association of this condition with CD3-positive lymphocytes
suggests a T-cell mediated autoimmune disorder, but its etiology
is not precisely known. When assessing a patient for a Dupuytren's
contracture, differential diagnosis should include Volkmann's
contractures, trauma, intrinsic joint disease, and diabetic
cheiroarthropathy. Dupuytren's contracture is more likely to
occur in men more than 50 years old, workers engaged in repetitive
tasks, and patients with chronic conditions such as diabetes
or reflex sympathetic dystrophy. Treatment varies with the severity
of the condition.
Dr. Glavas is medical director of the emergency
department fast track at St. Mary's Hospital in Livonia, Michigan,
and assistant clinical professor in the department of family
and community medicine at Michigan State University College
of Osteopathic Medicine in East Lansing, Michigan.
