Professor

Senior Resident

Assistant Professor

Junior Resident

Dept. of Medicine, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra

Address for correspondence

Dr Meenakshi Patil

Flat No. 702, Awesome Heights Society, Off Military Road, Marol

Andheri (East), Mumbai - 400 072, Maharashtra

Abstract

Dupuytren’s contracture (DC) is painless flexion contracture of ulnar side of palm where fingers bend towards palm and cannot be straightened. It is a fibrosing disorder that results in slowly progressive thickening and shortening of the palmar fascia, leading to the debilitating digital contractures. The prevalence of DC is found to be higher in patients with cirrhotic or noncirrhotic alcoholic liver disease. We report the case of a 56-year-old male chronic alcoholic who presented with distention of abdomen, yellow discoloration of sclera since 1 month and altered sensorium since 1 day. He had bilateral contractures on ulnar side of hands, suggestive of DC.

Keywords: Dupuytren’s contracture, fibrosing disorder, alcoholic liver disease, cirrhosis

Case Report

A 56-year-old male chronic alcoholic presented with distention of abdomen, yellow discoloration of sclera since 1 month and altered sensorium since 1 day. On examination, he had icterus, pallor, fetor hepaticus, spider naevi, ascites and had bilateral contractures on ulnar side of hands, suggestive of Dupuytrenscontracture (DC) (Fig. 1). Ultrasonography of abdomen revealed cirrhosis of liver with ascites. Our patient had alcoholic liver cirrhosis with bilateral DC. We rarely get to see this classic sign of alcoholic liver cirrhosis.

Discussion

Dupuytren’s contracture is painless flexion contracture of ulnar side of palm where fingers bend towards palm and cannot be straightened. It is named after the surgeon who described release procedure for such contracture.1Ring and little fingers are commonly affected and incidence increases after the age of 40. There are various theories regarding the etiology of DC such as genetic, microinjury, immunological, toxic and ischemic. The condition is a fibrosing disorder that results in slowly progressive thickening and shortening of the palmar fascia, leading to the debilitating digital contractures. Clinically, it starts with a nodule on palmar aspect of hand, which progresses to form cords along tendons, and this thickening progresses up to fingers.

Figure 1. Bilateral contractures on ulnar side of hands.

There is local fascial fibroplasia and development of a nodule, in which myofibroblasts proliferate and later, leaving acellular tissue and thick bands of collagen. It belongs to group of plantar fibromatosis (Ledderhosedisease), penile fibromatosis (Peyronie disease) and fibromatosis of the dorsal proximal interphalangealjoints.² DC is known to recur even after correction.

Although, many cases appear to be idiopathic and without coexisting conditions, a variety of associated diseases have been reported. Family history, manual labor with vibration exposure, prior hand trauma, alcoholism, smoking, diabetes mellitus, hyperlipidemia, Peyronie disease and complex regional pain syndrome.²

The prevalence of DC is found to be higher in patients with cirrhotic or noncirrhotic alcoholic liver diseasethan it is in patients with nonalcoholic liver disease, but it was not significantly different in alcoholic patients with or without liver disease.³ No specific test is required for diagnosis and contracture can be made out by table top test where patient has to put his hand straight palm down on table top. This condition if mild and hand function not compromised treatment is not required. If severe can be treated by fasciotomy, aponeurotomy, collagenase injection and radiation.

REFERENCES

1. Van Rijssen AL, Werker PM. Percutaneous needlefasciotomy in Dupuytrens disease. Hand Surg Br 2006;31(5):498-501.
2. Hindocha S, McGrouther DA, Bayat A. Epidemiologicalevaluation of Dupuytrens disease incidence and prevalence rates in relation to etiology. Hand (NY).2009;4(3):256-69.
3. Attali P, Ink O, Pelletier G, Vernier C, Jean F, Moulton L,et al. Dupuytrens contracture, alcohol consumption and chronic liver disease. Arch Intern Med 1987;147(6):1065-7.