A 70-Year-Old Man with Hand Numbness and Pain

Differential Diagnosis

• Dupuytren’s contracture
• Rheumatoid arthritis
• Carpal tunnel syndrome
• Trigger finger

Diagnosis

This patient was diagnosed with Dupuytren’s contracture, a fibroproliferative condition involving the palmar aponeurosis. At present, the pathophysiology of the disorder is not entirely understood, although several factors are believed to contribute to fibroblastic proliferation and altered collagen profiles, including specific platelet-derived fibroblast growth and transforming growth factors. White men of northern or eastern European descent aged 60 years or older are most commonly affected.

Learnings/What to Look for

• Initial symptoms include thickened nodules or plaques (Grade 1), followed by fibrous band development (Grade 2)
• With progression and increased fibrosis, flexion contractures develop (Grade 3)
• Patients may also present with similar findings in the plantar fascia
• Presentation can be unilateral or bilateral, with one hand typically being more severe than the other.
• Risk factors include alcohol abuse, tobacco use, and certain family history; evidence supports an autosomal dominant pattern of inheritance
• Research has identified nine loci associated with genetic susceptibility to Dupuytren’s contracture; six of the loci contain genes that encode proteins in the Wnt-signaling pathway, and the authors postulate that aberrations in this signaling pathway are related to the process of fibromatosis in the disease

Pearls for Urgent Care Management and Considerations for Transfer

• Treatment of Dupuytren’s contracture varies according to severity
• Nonsurgical options that may be administered in the urgent care center, depending on the severity of the condition, the provider’s experience, and available resources include enzyme injections and steroid injections
• injections of either
• Low-energy radiation therapy may provide symptom relief and prevent worsening of the condition
• Open surgery or needle aponeurotomy may be necessary
  A small portion of patients with Dupuytren’s contracture also develop Peyronie’s disease

Acknowledgment: Image and case courtesy of VisualDx (www.VisualDx.com/JUCM).