Dupuytren Contracture and Knuckle Pads

Knuckle pads are a variable finding of many conditions

Knuckle pads or Garrod pads are commonly associated with Dupuytren contracture.  They are well-circumscribed, smooth, firm, and skin-colored slight elevations, papules, or nodules, approximately 0.5-3 cm in size.  They are most commonly found on the back side of the hand at the main knuckles joints (metacarpophalangeal or MCP) and the first joints after them (the proximal interphalangeal or PIP), with the PIP being the most common site.  They are not to be confused with a Dupuytren cord which is a structure associated with the lump on palm of the hand.

When associated with Dupuytren contracture, since they occur in 45-55% of cases, Garrod pads usually suggests a more aggressive representation of the disease (a Dupuytren diathesis).

When firm, the knuckle pads or nodules may be only tender to palpation, otherwise they do not cause pain or other symptoms.   These nodules are closely adherent to the skin in Dupuytren contracture while movement of the nodule during finger flexion/extension suggests an association with the tendon sheath.

A history of repetitive injury to this part of the hand from work or sports activity is often present, as well as occurring without any physical explanation.

Garrod first described knuckle pads in the medical literature in 1893, but knuckle pads have been observed since the Renaissance era; Michelangelo’s statue of David has knuckle pads (Florence, Italy) as well as his statue of Moses (Rome, Italy).

In the U.S and the rest of the world knuckle pads are thought to be a common occurrence.  The prevalence of knuckle pads is difficult to determine because this problem does not cause physical symptoms and so people do not often seek medical attention specifically for them. Knuckle pads can be present in any age group, with the most common in adults 40 years of age and older, especially males who engage in heavy manual labor.  The condition also is seen in young children who suck their fingers.

Some cases of knuckle pads are clearly familial, having no other possible causation.   Most often they are associated with other disease processes such as reported in Dupuytren disease, Peyronie disease, Ledderhose disease, pseudoxanthoma elasticum, esophageal cancer, hyperkeratosis, and oral leukoplakia.

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Dupuytren Contracture and the Proximal Interphalangeal (PIP) Joint

Dupuytren joint information is important

Potential treatment outcomes can be roughly anticipated based on Dupuytren joint involvement.  This is especially helpful when dealing with someone who has a Dupuytren diathesis and is attempting to avoid Dupuytren surgery.

There are three joints of any finger that can be affected in Dupuytren contracture, although it is the 4th (ring) and 5th (little) fingers by far that are most often involved.   When a joint is affected by Dupuytren contracture it will be kept into a gradually advancing flexed or bent posture, curled down toward the palm.  When the proximal interphalangeal joint is involved in Dupuytren’s contracture, any form of treatment is more prolonged and difficult, especially surgical treatment.

Dupuytren treatment outcome affected by joint involvement

To understand and anticipate the degree of possible difficulty while undergoing Dupuytren joint contracture treatment , it is helpful to consider which joint(s) of which finger(s) are involved. To begin, it is helpful to know that each finger has three joints or points of articulation (see diagrams, below):

Metacarpophalangeal (MCP) joint – this is the joint at the base of the finger where it joins with the palm; it is the large knuckle joint when a fist is made

Proximal interphalangeal (PIP) joint – this is the joint in the middle of finger, the one above the MCP

Distal interphalangeal (DIP) joint – this is the joint immediately below the finger nail near the end of the finger

It is important to note which joint is affected when Dupuytren contracture occurs because the prognosis and the degree of difficulty of treatment are suggested by which joint or joints are involved in the finger contracture process.

Dupuytren disease and the proximal interphalangeal (PIP) joint  

Dupuytren contracture involving only the PIP joint usually takes longer to treat successfully and sometimes requires extended treatment after initial straightening since recurrence might develop if treatment is stopped too soon.  This is especially true of the 5th or little finger.

Dupuytren contracture which affects only the MCP joint is usually the most responsive to conservative Alternative Medicine treatment methods.

When Dupuytren contracture extends to both MCP and PIP joints of the same finger it tends to statistically improve the therapeutic outlook when compared to those cases of an isolated PIP contracture.  Outcomes to aggressive Alternative Medicine treatment for Dupuytren contracture are very favorable, especially when combined with light stretching of the flexor muscles and fascia.

There is a variation of the combined contracture of the MCP and PIP joints, discussed above, that includes the DIP joint when it is bent upwards or in an extended direction.  Typically, in Dupuytren contracture the finger bending is in the direction of a downward or flexion deformity, curled toward the palm.  In this variation, called a “Boutonniere deformity,” while the usual two joints (MCP and PIP) are flexed downward, and the last joint (DIP) is extended upward.   We have observed, and confirm the finding of others who report, that the boutonniere deformity of Dupuytren’s contracture is more difficult and prolonged to treat and has a higher recurrence rate than the other finger flexion patterns.

If you wish to learn more about the non-drug and non-surgical treatment of Dupuytren contracture, especially the proximal interphalangeal or PIP joint, please click on the following links:

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