Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Report
Case Series
Commentary
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Report
Case Series
Commentary
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Technical Note
Techniques in Neurosurgery
View/Download PDF

Translate this page into:

Case Report
11 (
3
); 481-483
doi:
10.1055/s-0040-1708459

Dupuytren’s Contracture with Secondary Ulnar Neuropathy

Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
Address for correspondence Chen Fei Ng, MD, MRCP, Neurology Unit Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur Malaysia n.chenfei@gmail.com
Licence
This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Disclaimer:
This article was originally published by Thieme Medical and Scientific Publishers Private Ltd. and was migrated to Scientific Scholar after the change of Publisher; therefore Scientific Scholar has no control over the quality or content of this article.

Abstract

Abstract

Dupuytren’s disease is a progressive fibrotic condition of the hand. The underlying pathomechanism is not fully known. Dupuytren’s contracture can be seen in patients with diabetes mellitus, chronic alcoholism, smoking, or hand trauma. It is uncommon to affect the neurovascular supply causing clinical symptoms. We describe a patient with idiopathic Dupuytren’s disease complicated with bilateral ulnar neuropathies and highlight the importance of such rare treatable complication.

Keywords

Dupuytren’s disease
Dupuytren’s contracture
ulnar neuropathy
neurophysiology

Introduction

Dupuytren’s disease is a common fibroproliferative condition affecting the palmar and digital fascia. The prevalence of Dupuytren’s disease is higher in chronic alcoholic drinker. However, there is no clear causal relationship and there are many other factors that may predispose to the condition. The focal pathological process in the hands may potentially cause structural compression, in severe cases, leading to symptomatic neuropathy if surrounding neurovascular bundle is compromised.

Case Description

A 63-year-old man presented to neurology clinic with bilateral hand numbness and weakness for 6 months. The symptoms were preceded by a 5-year history of slowly progressive contracture of his fingers bilaterally. He had long-standing type 2 diabetes mellitus and hypertension for more than 10 years. There was no significant family history of note and he did not smoke or drink alcohol. On examination, there were mild wasting of the hypothenar eminences and interossei guttering. In addition, there were striking flexion deformity and clawing involving his fingers on the right hand, less so on the left hand (Fig. 1). The muscle power of the abductor digiti minimi (ADM) was Medical Research Council grade 2/5 on the right and 3/5 on the left, and the first dorsal interosseous (FDIO) was grade 3/5 bilaterally. The muscle power of abductor pollicis brevis, flexor digitorum superficialis, and profundus were normal. The biceps, triceps, and supinator jerks were present bilaterally. On sensory examination, pinprick sensation was reduced on the palmar aspect of the fourth and fifth fingers but normal on the dorsal surface bilaterally. The median and radial dermatomal distributions were spared. He had otherwise no stigmata of chronic liver disease. Routine blood tests for complete blood count, liver function test, and erythrocyte sedimentation rate were normal. Nerve conduction study and needle electromyography revealed active and chronic neurogenic changes in the ulnar-innervated muscles distal to the wrist with demyelinating and axonal features, much worse on the right side (Tables 1 2). He was diagnosed with bilateral distal ulnar neuropathies secondary to Dupuytren’s contracture and surgical release was subsequently performed.

Fig. 1 There was flexion deformity of the middle, ring, and little fingers with prominent wasting of the abductor digiti minimi muscle on the right side. On the left hand, palmar thickening and fibrotic cord were seen over the fourth metacarpophalangeal joint.

Fig. 1 There was flexion deformity of the middle, ring, and little fingers with prominent wasting of the abductor digiti minimi muscle on the right side. On the left hand, palmar thickening and fibrotic cord were seen over the fourth metacarpophalangeal joint.

Table 1:
Nerve conduction study of the upper limbs

Sensory nerve study

Recording site

Latency, ms

Amplitude, µV

Velocity, m/s

Abbreviations: ADM, abductor digiti minimi; APB, abductor pollicis brevis; L, left; R, right.

L median

Digit II

3.20

28.7

49

R median

Digit II

2.94

25.2

53

L ulnar

Digit V

4.58

11.2

32

R ulnar

Digit V

4.38

6.2

29

L dorsal ulnar cutaneous

Dorsal hand

1.89

12.4

52

L dorsal ulnar cutaneous

Dorsal hand

2.01

14.3

48

Motor nerve study

Recording site

Latency, ms

Amplitude, mV

Velocity, m/s

R median—wrist

APB

3.8

11.4

R median—elbow

APB

8.2

10.4

52

L ulnar—wrist

ADM

3.44

11.3 (dispersed)

L ulnar—below elbow

ADM

9.01

9.5 (dispersed)

54

R ulnar—wrist

ADM

3.65

9.9 (dispersed)

R ulnar—below elbow

ADM

9.27

9.0 (dispersed)

53

F wave (min)

Latency, ms

L ulnar

34.74

R ulnar

36.51

Table 2:
Needle electromyography of the upper limbs

Muscle

Spontaneous activity

MUAP

Recruitment pattern

Abbreviations: L, left; MUAP, motor unit action potential; R, right.

L first dorsal interosseous

None

Mildly prolonged and polyphasic

Mildly reduced

L abductor digiti minimi

None

Mildly polyphasic

Mildly reduced

L abductor pollicis brevis

None

Normal

Normal

R first dorsal interosseous

Positive sharp waves

Prolonged and polyphasic

Reduced

R abductor digiti minimi

Positive sharp waves

Prolonged and polyphasic

Reduced

R abductor pollicis brevis

None

Normal

Normal

R flexor carpi ulnaris

None

Normal

Normal

R extensor indicis proprius

None

Normal

Normal

Discussion

The presenting complaints of sensory and motor symptoms with claw hands led to the diagnosis of bilateral ulnar neuropathies evident on neurophysiology. The bilateral ulnar sensory studies showed prolonged latency and conduction slowing, with dispersed compound muscle action potential response on ulnar motor studies. These findings were highly suggestive of focal demyelination in keeping with structural compression. In addition, needle electromyography revealed active denervation changes in the right ADM and FDIO and chronic reinnervation in the bilateral ADM and FDIO indicating axonal loss. The normal studies for dorsal ulnar cutaneous nerve and flexor carpi ulnaris further localized the lesions distal to the wrists.

The presence of fibrotic cords and contracture clinched to the underlying etiology of Dupuytren’s disease. Dupuytren’s disease is a fibroproliferative condition of the hands. Although the pathogenesis is not fully understood, it was suggested to be due to local hypoxia and chronic ischemia. Factors such as alcohol, smoking, diabetes mellitus, and certain anticonvulsants are commonly associated with Dupuytren’s disease.1 Interestingly, ulnar neuropathy is not a recognized association. In Dupuytren’s disease, the normal fascial bands in the hand become fibrotic cord which may involve palmar, palmodigital, or digital regions. Pathological examination showed that digital cord arising from the ADM muscle may lead to entrapment and displacement of the underlying neurovascular bundle.2 The local compression, in addition to the predisposition of underlying microvascular disease due to diabetes has most likely resulted in secondary ulnar neuropathy. This association is rarely seen but important to recognize as prompt surgical release may prevent severe neuropathy and functional loss.

Conflict of Interest

None declared.

Funding None.

References

  1. , , , , . Dupuytren’s contracture unfolded. BMJ. 2006;332:397-400. (7538)
    [Google Scholar]
  2. , . Dupuytren disease: anatomy, pathology, presentation, and treatment. J Bone Joint Surg Am. 2007;89(1):189-198.
    [Google Scholar]
Show Sections