Raiyyan Tahsan

Raiyyan Tahsan
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TC(1016).(05).Orthopedics Case No 94:- Dupuytren Contracture

Dupuytren Contracture — Bangla Clinical Notes

Important: Dupuytren contracture-এর মূল চিকিৎসা সাধারণত procedure/surgery/hand therapy। ওষুধ দিয়ে বাঁকা আঙুল সোজা হয় না। ওষুধ ব্যবহৃত হয় pain, inflammation, injection adjunct, procedure anesthesia, gastric protection—এই উদ্দেশ্যে।

1. Definition — সংজ্ঞা

Dupuytren contracture হলো হাতের তালুর নিচের palmar fascia-এর একটি benign fibroproliferative disorder, যেখানে fascia ঘন/শক্ত হয়ে nodule ও cord তৈরি করে এবং ধীরে ধীরে আঙুল—বিশেষ করে ring finger ও little finger—তালুর দিকে বাঁকা হয়ে যায়। এটি tendon বা joint arthritis নয়; সমস্যা মূলত palmar fascia fibrosis। BSSH ও NHS decision aid অনুযায়ী শুরুতে palm-এ hard lump/nodule দেখা যায়, পরে cord তৈরি হয়ে finger extension কমে যায়।

2. Etiology / Causes — কারণসমূহ

মূল কারণ

  • Exact cause unknown — নির্দিষ্ট একক কারণ জানা যায়নি।
  • Genetic predisposition শক্তিশালী ভূমিকা রাখে; family history থাকলে ঝুঁকি বেশি।
  • Fibroblast → myofibroblast activation হয়ে collagen deposition বাড়ে; ফলে palmar fascia thick, shortened ও contracted হয়।
  • TGF-β signalling, myofibroblast proliferation, type I/III collagen accumulation—এগুলো pathophysiology-তে গুরুত্বপূর্ণ।

Risk factors / Associated factors

  • বয়স বেশি, সাধারণত middle age বা elderly
  • পুরুষদের মধ্যে বেশি
  • Family history
  • Diabetes mellitus
  • Smoking
  • Alcohol excess
  • Epilepsy/antiepileptic drug association—reported, কিন্তু causality সবসময় নিশ্চিত নয়
  • Repeated hand trauma বা previous hand surgery-এর পর কিছু ক্ষেত্রে দেখা যেতে পারে, তবে manual work সরাসরি প্রধান কারণ নয়। BSSH notes: diabetes, smoking, high alcohol intake-এর association আছে, কিন্তু অনেক রোগীর কোনো risk factor থাকে না।

3. Pathophysiology — কীভাবে রোগ তৈরি হয়

  1. Palmar fascia-তে fibroblast/myofibroblast activity বাড়ে।
  2. Excess collagen ও extracellular matrix জমে nodule তৈরি হয়।
  3. Nodule থেকে longitudinal cord তৈরি হয়।
  4. Cord ছোট ও শক্ত হয়ে MCP/PIP joint-কে flexion position-এ টেনে ধরে।
  5. দীর্ঘদিন থাকলে joint stiffness ও fixed deformity হতে পারে।

4. Symptoms — লক্ষণসমূহ

  • হাতের তালুতে ছোট শক্ত গুটি/nodule
    • সাধারণত ring finger-এর লাইনে শুরু হয়।
    • প্রথম দিকে চাপ দিলে tenderness থাকতে পারে।
  • Skin pitting / dimpling
    • তালুর চামড়ায় ছোট depression বা টান দেখা যায়।
  • Cord formation
    • তালু থেকে আঙুলের দিকে শক্ত দড়ির মতো band অনুভূত হয়।
  • Finger bending
    • আঙুল ধীরে ধীরে palm-এর দিকে বাঁকা হয়।
    • Ring ও little finger বেশি affected।
  • Tabletop test positive
    • রোগী হাত পুরো flat করে টেবিলে রাখতে পারে না।
  • Daily activity difficulty
    • হাত ধোয়া, pocket-এ হাত ঢোকানো, handshake, glove পরা, typing, object ধরতে সমস্যা।
  • Pain usually minimal
    • বেশিরভাগ ক্ষেত্রে severe pain থাকে না; early nodule tender হতে পারে।
  • Bilateral disease
    • দুই হাতেই হতে পারে।
  • Associated findings
    • Knuckle pads/Garrod pads
    • Plantar fibromatosis/Ledderhose disease
      BSSH অনুযায়ী nodules থেকে cord হয়ে finger straightening বাধাগ্রস্ত হয় এবং progression সাধারণত মাস-বর্ষ ধরে ধীরে হয়।

5. Clinical Diagnosis — কীভাবে clinically diagnosis করবেন

Dupuytren contracture সাধারণত clinical diagnosis। Routine lab test লাগে না।

History

  • কতদিন ধরে palm nodule আছে
  • আঙুল কতটা বাঁকা হচ্ছে, progression rate
  • Pain/tenderness আছে কি না
  • Functional limitation: table flat করতে পারে কি না, daily কাজের সমস্যা
  • Family history
  • Diabetes, smoking, alcohol intake
  • Epilepsy/antiepileptic use
  • Previous trauma/surgery

Examination

  • Palm inspection: nodule, cord, skin pitting, dimpling
  • Palpation: hard cord along palmar fascia
  • MCP ও PIP extension deficit angle measure করুন
  • Hueston tabletop test
    • Patient হাত টেবিলে flat করতে না পারলে test positive।
  • Neurovascular examination
    • Sensation, capillary refill
  • Bilateral hand examination
  • Feet ও knuckles দেখুন: Ledderhose disease/Garrod pads

Diagnostic clue

  • Nodule/cord palm-এর fascia-তে থাকে।
  • Tendon disease হলে movement-এর সাথে tendon-related catching/triggering থাকে, Dupuytren-এ cord fixed fascial band হিসেবে থাকে।

6. Investigations — নির্দিষ্টভাবে কী করবেন

Usually not needed

  • Routine X-ray, blood test, MRI—diagnosis করার জন্য দরকার হয় না।

Specific indications

  • X-ray hand
    • যদি joint arthritis, old fracture, bony deformity, trauma, fixed joint pathology suspect হয়।
  • Ultrasound
    • Nodule/cord extent, soft tissue mass exclude, tendon relation দেখতে selected case-এ helpful।
  • MRI
    • Rarely needed; atypical mass, tumour suspicion, recurrent/complex anatomy হলে।
  • Blood tests
    • Dupuytren diagnose করার জন্য নয়।
    • Risk factor assessment:
      • Fasting glucose / HbA1c — diabetes suspicion
      • LFT — alcohol/liver disease context
      • Renal function — NSAID দেওয়ার আগে elderly/CKD risk থাকলে

7. Differential Diagnosis — যেগুলো থেকে আলাদা করবেন

  • Trigger finger / stenosing flexor tenosynovitis
  • Flexor tendon contracture
  • Skin scar contracture after burn/trauma
  • Camptodactyly
  • Ulnar claw hand
  • Volkmann ischemic contracture
  • Rheumatoid hand deformity
  • Ganglion cyst
  • Soft tissue tumour
    StatPearls differential list-এ trigger finger, flexor tendonitis, ganglion cyst, ulnar neuropathy, soft tissue tumours উল্লেখ আছে।

8. Complications — রোগের জটিলতা

Disease complications

  • Permanent finger flexion deformity
    • আঙুল স্থায়ীভাবে বাঁকা হয়ে যেতে পারে।
  • Loss of hand function
    • grip, writing, typing, tool use, dressing, hygiene কঠিন হয়।
  • Joint stiffness
    • দীর্ঘদিন contracture থাকলে PIP joint stiff হয়ে যায়, পরে treatment করলেও পুরো সোজা নাও হতে পারে।
  • Skin hygiene problem
    • খুব severe flexion হলে palm skin moist/irritated হতে পারে।
  • Psychological/work impairment
    • manual work, social interaction, self-care-এ সমস্যা হয়।

Treatment-related complications

  • Needle fasciotomy: infection, nerve/vessel injury, pain, stiffness; recurrence বেশি হতে পারে।
  • Collagenase: swelling, skin tear, pain, rare tendon rupture। AAOS flexor tendon rupture ও allergic reaction rare complication হিসেবে উল্লেখ করেছে।
  • Surgery: hematoma, infection, numbness, stiffness, neurovascular injury, skin necrosis, scar, recurrence। StatPearls মতে recurrence সব modality-তেই common।

9. Management — Guideline-based Treatment

A. Observation / Watchful waiting

যদি:

  • শুধুমাত্র nodule আছে
  • contracture নেই
  • tabletop test negative
  • daily activity affected নয়

তাহলে observation যথেষ্ট। EBI/NICE-related pathway অনুযায়ী no contracture বা mild non-progressive contracture হলে treatment indicated নয়।

B. When to refer to hand surgeon

Refer করবেন যদি:

  • Tabletop test positive
  • MCP contracture ≥30°
  • PIP contracture ≥20°
  • Thumb web contracture function affect করে
  • Rapid progression
  • Painful nodule not responding
  • Patient daily activity করতে পারছে না
    EBI recommendation অনুযায়ী MCP 30° বা PIP 20° extension loss হলে intervention consider করা যায়।

C. Non-surgical / minimally invasive

  • Needle fasciotomy / needle aponeurotomy
    • Local anesthesia দিয়ে cord needle দিয়ে release করা হয়।
    • Quick recovery, কিন্তু recurrence বেশি হতে পারে। AAOS/StatPearls একই principle উল্লেখ করেছে।
  • Collagenase clostridium histolyticum injection
    • Palpable cord-এ enzyme injection দিয়ে collagen cord weaken করা হয়।
    • পরে finger manipulation করা হয়।
    • তবে NICE TA459 withdrawn কারণ Xiapex UK-তে আর available নয়; Bangladesh MedEx search-এ কোনো registered brand পাইনি।

D. Surgical

  • Fasciotomy
  • Limited/partial palmar fasciectomy
  • Dermofasciectomy with skin graft — recurrent/extensive disease বা younger patient-এ consider
    BSSH surgical options হিসেবে fasciotomy, segmental fasciectomy, regional fasciectomy, dermofasciectomy উল্লেখ করেছে।

E. Hand therapy

  • Post-procedure edema control
  • Range-of-motion exercise
  • Scar management
  • Night splint as advised
  • Grip/function retraining

10. Bangladesh Prescription Drug List — Practical

Key point

Dupuytren contracture cure করার oral medicine নেই। Bangladesh doctors সাধারণত নিচের drug groups ব্যবহার করেন:

  1. Pain control — Paracetamol
  2. Pain + inflammation — NSAID: Ibuprofen/Diclofenac
  3. NSAID gastric protection — PPI
  4. Early painful nodule — Triamcinolone injection by specialist
  5. Procedure anesthesia — Lidocaine injection
  6. Collagenase — international option, Bangladesh MedEx-এ verified brand পাইনি

10.1 Paracetamol

  1. Generic name: Paracetamol
  2. Therapeutic category: Non-opioid analgesic
  3. Pharmacological class: Para-aminophenol derivative; analgesic + antipyretic
  4. Bangladesh available brand name with strength:
    • Napa 500 mg tablet — Paracetamol
    • Ace 500 mg tablet — Paracetamol
    • Xcel 500 mg tablet — Paracetamol
    • Fast 500 mg tablet — Paracetamol
    • Reset 500 mg tablet — Paracetamol
    • Fast XR / Xcel ER 665 mg — Paracetamol extended release
      MedEx brand list confirms many 500 mg and 665 mg paracetamol brands, including Napa 500 mg, Fast 500 mg, Reset 500 mg and ER preparations.

Why used:

  • Painful nodule, mild hand pain, post-procedure pain
  • Fever থাকলে
  • Fibrosis/contracture cure করে না

Adult dose:

  • 500 mg orally every 6–8 hours PRN
  • Maximum usually 3–4 g/day; liver disease/alcohol use থাকলে lower max

Duration:

  • 3–5 days PRN; chronic daily use avoid

Side effects:

  • Nausea, rash rare
  • Overdose → severe hepatotoxicity

Interactions:

  • Alcohol → liver toxicity risk
  • Warfarin long-term high-dose use → INR increase হতে পারে
  • Enzyme inducers: phenytoin, carbamazepine, rifampicin → hepatotoxic metabolite risk

10.2 Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: NSAID; analgesic, anti-inflammatory, antipyretic
  3. Pharmacological class: Propionic acid derivative NSAID; COX inhibitor
  4. Bangladesh available brand name with strength:
    • Advel 400 mg tablet
    • Profen 400 mg tablet
    • Inflam 400 mg tablet
    • Flamex 400 mg tablet
    • Reumafen 400 mg tablet
    • Brofen 400 mg tablet
    • Intaflam 400 mg tablet
      MedEx confirms multiple ibuprofen 400 mg brands including Advel, Brofen, Flamex, Inflam, Intaflam, Profen, Reumafen.

Why used:

  • Painful nodule বা hand pain with inflammation
  • Post-procedure pain/swelling
  • Disease progression stop করে না

Adult dose:

  • 200–400 mg orally every 6–8 hours after food
  • Usual short-course max 1200 mg/day OTC; physician-supervised cases higher হতে পারে

Duration:

  • 3–5 days, shortest effective duration

Side effects:

  • Gastritis, dyspepsia
  • Peptic ulcer, GI bleeding
  • Renal impairment
  • BP increase, edema
  • Bronchospasm in NSAID-sensitive asthma

Interactions:

  • Warfarin/DOAC/aspirin/clopidogrel → bleeding risk
  • Steroid + NSAID → GI bleeding risk
  • ACEI/ARB + diuretic + NSAID → acute kidney injury risk
  • Lithium/methotrexate → toxicity risk
  • Other NSAID সাথে একসাথে avoid

10.3 Diclofenac Sodium / Potassium

  1. Generic name: Diclofenac sodium or diclofenac potassium
  2. Therapeutic category: NSAID
  3. Pharmacological class: Phenylacetic/acetic acid derivative NSAID; COX inhibitor
  4. Bangladesh available brand name with strength:
    • A-Fenac 50 mg tablet — Diclofenac sodium
    • Clofenac 50 mg tablet — Diclofenac sodium
    • Voltalin Forte 50 mg tablet — Diclofenac sodium
    • Diclorex 50 mg tablet — Diclofenac sodium
    • Intafenac 50 mg tablet — Diclofenac sodium
    • A-Fenac SR 100 mg / Voltalin SR 100 mg / Ultrafen SR 100 mg
    • Voltaren 75 mg/3 ml injection — hospital/procedure pain context
      MedEx lists many diclofenac sodium 50 mg, 75 mg/3 ml injection and 100 mg SR/TR brands.

Why used:

  • Stronger pain/inflammation control
  • Post-procedure or post-operative pain
  • Dupuytren fibrosis cure করে না

Adult dose:

  • Diclofenac 50 mg orally 2–3 times daily after food
  • SR 100 mg once daily
  • Max 150 mg/day
  • Injection 75 mg IM only physician/hospital setting

Duration:

  • 3–5 days usually; long-term avoid unless strong indication

Side effects:

  • Gastritis, ulcer, GI bleeding
  • Kidney injury
  • Liver enzyme elevation/hepatitis rare
  • BP increase, edema
  • Cardiovascular thrombotic risk, especially high dose/long duration

Interactions:

  • Warfarin/DOAC/antiplatelet → bleeding
  • Steroid/SSRI → GI bleeding risk
  • ACEI/ARB/diuretic → renal injury
  • Methotrexate/lithium → toxicity
  • Other NSAIDs avoid

10.4 Esomeprazole / PPI

  1. Generic name: Esomeprazole
  2. Therapeutic category: Proton pump inhibitor
  3. Pharmacological class: H⁺/K⁺-ATPase inhibitor
  4. Bangladesh available brand name with strength:
    • Maxpro 20 mg / 40 mg
    • Esoral 20 mg
    • Esotid 20 mg
    • Maxpro MUPS 20 mg
      MedEx describes esomeprazole as a PPI that suppresses gastric acid secretion via H⁺/K⁺-ATPase inhibition and lists Maxpro/Esoral/Esotid brands.

Why used:

  • NSAID-associated gastritis/ulcer risk কমাতে
  • Elderly, ulcer history, steroid/anticoagulant use, high-dose NSAID হলে useful
  • Dupuytren disease treat করে না

Adult dose:

  • Esomeprazole 20 mg once daily before breakfast
  • NSAID course চলাকালীন ব্যবহার; high-risk হলে clinician duration ঠিক করবেন

Duration:

  • 3–7 days with short NSAID course; ulcer/GERD থাকলে 2–8 weeks depending indication

Side effects:

  • Headache, nausea, abdominal pain
  • Diarrhea/constipation
  • Long-term: hypomagnesemia, B12 deficiency, fracture risk, C. difficile risk

Interactions:

  • Clopidogrel effect কমাতে পারে—especially omeprazole/esomeprazole
  • Warfarin/phenytoin/diazepam level affect হতে পারে
  • Ketoconazole/itraconazole absorption কমতে পারে
  • High-dose methotrexate toxicity risk

10.5 Triamcinolone Acetonide Injection

  1. Generic name: Triamcinolone acetonide injection
  2. Therapeutic category: Corticosteroid / glucocorticoid
  3. Pharmacological class: Synthetic glucocorticoid corticosteroid
  4. Bangladesh available brand name with strength:
    • Alfacort 40 mg/ml injection
    • Cenolon 40 mg/ml injection
    • Cynocort 40 mg/ml injection
    • Emicort 40 mg/ml injection
    • Intracort 40 mg/ml injection
    • Trecilon 40 mg/ml injection
    • Triacin 40 mg/ml injection
    • Trialon 40 mg/ml injection
    • Triamon 40 mg/ml injection
    • Trimcort 40 mg/ml injection
      MedEx lists these 40 mg/ml triamcinolone injection brands and classifies it under corticosteroid/glucocorticoids.

Why used:

  • Early painful Dupuytren nodule-এ tenderness ও nodule size কমাতে specialist intralesional injection দিতে পারেন।
  • Fixed contracture সোজা করে না।
  • Literature-এ intranodular triamcinolone use reported, কিন্তু standardized guideline dose নেই; older study-তে 60–120 mg/injection at 6-week intervals reported।

Specialist dose concept:

  • Hand surgeon/orthopedic specialist দ্বারা intralesional injection
  • Practical dose varies by nodule size; avoid self-use
  • Strict aseptic technique mandatory

Duration / frequency:

  • Single injection বা repeated injection only specialist decision
  • Reassess pain, nodule size, skin atrophy, glucose

Side effects:

  • Injection pain
  • Skin atrophy
  • Depigmentation
  • Tendon weakening/rupture rare
  • Infection
  • Hyperglycemia, especially diabetic patient
  • Systemic steroid effects if high/repeated dose

Interactions:

  • NSAID + steroid → GI bleeding risk
  • Antidiabetic drugs → glucose control worsen
  • Warfarin → INR fluctuation
  • Live vaccines avoid if systemic/high-dose steroid
  • Diuretics/amphotericin → hypokalemia risk
    MedEx also notes steroid interactions with NSAIDs, antidiabetics, anticoagulants, vaccines and enzyme inducers.

10.6 Lidocaine Injection

  1. Generic name: Lidocaine hydrochloride injection
  2. Therapeutic category: Local anesthetic
  3. Pharmacological class: Amide-type local anesthetic
  4. Bangladesh available brand name with strength:
    • Lidocaine 2% injection
    • Jasocaine 1%, 2%, 4% injection
    • G-Lidocaine 2% injection
    • Locaine 2% injection
    • Chemocain 2% injection
      MedEx lists these lidocaine injection brands and describes lidocaine as amide local anesthetic with fast onset.

Why used:

  • Needle fasciotomy, steroid injection, minor hand procedure-এর আগে local anesthesia
  • Disease treatment নয়; pain-free procedure করার জন্য

Dose:

  • Infiltration dose depends on site/procedure
  • General maximum: lidocaine without adrenaline about 4.5 mg/kg; with adrenaline about 7 mg/kg
  • Must be administered by trained clinician

Side effects:

  • Local numbness
  • Dizziness, metallic taste, tinnitus
  • Seizure in toxicity
  • Arrhythmia/cardiac depression in overdose
  • Allergy rare

Interactions:

  • Antiarrhythmics
  • Beta-blockers/cimetidine may increase lidocaine level
  • Other local anesthetics additive toxicity

10.7 Collagenase Clostridium Histolyticum

  1. Generic name: Collagenase clostridium histolyticum
  2. Therapeutic category: Enzyme injection for fibrotic cord
  3. Pharmacological class: Collagenase enzyme
  4. Bangladesh available brand name:
    • MedEx Bangladesh search-এ verified brand পাওয়া যায়নি
    • International brands: Xiaflex / Xiapex
    • NICE TA459 withdrawn because Xiapex is no longer available in the UK।

Why used internationally:

  • Palpable cord-এ collagen breakdown করে contracture improve করতে
  • Injection-এর 24–72 hours পরে manipulation করা হয়। AAOS collagenase treatment as two-step process describe করেছে।

Side effects:

  • Pain, swelling, bruising
  • Skin tear
  • Tendon rupture rare
  • Allergic reaction rare

11. Bangladesh doctors commonly prescribe — short practical list

Dupuytren contracture patient Bangladesh OPD/ortho-hand practice-এ সাধারণত এই ধরনের prescription দেখা যায়:

  • Paracetamol 500 mg
    • mild pain/tender nodule/post-procedure pain
  • Ibuprofen 400 mg
    • inflammatory pain/swelling; short course
  • Diclofenac 50 mg or SR 100 mg
    • stronger musculoskeletal/post-procedure pain
  • Esomeprazole 20 mg
    • NSAID gastric protection, especially elderly/ulcer risk
  • Triamcinolone acetonide 40 mg/ml injection
    • early painful nodule; specialist intralesional use only
  • Lidocaine 1–2% injection
    • local anesthesia before needle fasciotomy/injection/procedure

Antibiotics: Dupuytren itself infection নয়, তাই routine antibiotic লাগে না। Surgery/procedure-এর wound infection বা surgeon-specific prophylaxis ছাড়া antibiotic দেওয়া উচিত নয়।

12. Prevention — কীভাবে প্রতিরোধ/প্রগতি কমানো যায়

Primary prevention নিশ্চিতভাবে সম্ভব নয়, কারণ genetic predisposition থাকে। তবে progression ও disability কমাতে:

  • Smoking বন্ধ করুন।
  • Alcohol excess এড়িয়ে চলুন।
  • Diabetes থাকলে HbA1c control করুন।
  • Palm trauma/pressure কমান; heavy vibration tools ব্যবহার করলে gloves ও rest নিন।
  • Monthly tabletop test করুন।
  • আঙুল বাঁকা শুরু হলে early hand surgeon consult করুন।
  • Forceful stretching করবেন না—injury হতে পারে।
  • Surgery/procedure-এর পর hand therapy follow করুন।
  • Splint/ROM exercise surgeon/therapist নির্দেশ অনুযায়ী করুন।
  • Painful nodule হলে early review; fixed severe PIP contracture হওয়া পর্যন্ত অপেক্ষা করবেন না।

Overview / Summary

Dupuytren contracture হলো palmar fascia-এর benign fibrosis, যেখানে nodule ও cord তৈরি হয়ে finger flexion contracture হয়। Diagnosis প্রায় সবসময় clinical—palm nodule/cord, tabletop test, MCP/PIP angle measurement। ওষুধ দিয়ে disease cure হয় না; definitive functional treatment হলো observation, needle fasciotomy, collagenase where available, fasciectomy/dermofasciectomy, এবং hand therapy। Pain control-এর জন্য paracetamol/NSAID, NSAID protection-এর জন্য PPI, early painful nodule-এর জন্য specialist steroid injection ব্যবহার হতে পারে।

Actionable Plan / Steps

  1. Assess severity: tabletop test + MCP/PIP contracture angle measure করুন।
  2. No contracture/function problem নেই: observe + 6–12 monthly follow-up।
  3. MCP ≥30° বা PIP ≥20° / daily activity affected: hand surgeon referral।
  4. Painful early nodule: steroid injection option discuss করুন—specialist only।
  5. Pain medicine: paracetamol first; NSAID short course only if no ulcer/CKD/anticoagulant/high CV risk।
  6. NSAID দিলে: high-risk patient-এ esomeprazole/PPI consider।
  7. Post-procedure: hand therapy, edema control, ROM exercise, splint as advised।
  8. Risk control: diabetes, smoking, alcohol, palm trauma control।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Apley & Solomon’s System of Orthopaedics and Trauma, latest/11th ed., Hand disorders / Dupuytren disease section.
  2. Maheshwari & Mhaskar, Essential Orthopaedics, latest ed., Hand deformities / Dupuytren contracture section.
  3. Green’s Operative Hand Surgery, latest ed., Dupuytren disease chapter.
  4. Robbins & Cotran Pathologic Basis of Disease, latest ed., fibrosis/wound healing principles relevant to fibroproliferative disorders.

Guidelines / Clinical resources

  1. British Society for Surgery of the Hand — Dupuytren’s disease patient information.
  2. NHS England Decision Aid: Making a decision about Dupuytren’s contracture.
  3. EBI/NICE-related Dupuytren pathway: intervention criteria MCP ≥30° or PIP ≥20°.
  4. AAOS OrthoInfo — Dupuytren’s Disease.
  5. NICE TA459: Collagenase clostridium histolyticum guidance withdrawn because Xiapex no longer available in UK.

Peer-reviewed journals with DOI

  1. Karbowiak M, Holme T, Khan K, Mohan A. Dupuytren’s disease. BMJ. 2021;373:n1308. DOI: 10.1136/bmj.n1308.
  2. Hurst LC, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. New England Journal of Medicine. 2009;361:968–979. DOI: 10.1056/NEJMoa0810866.
  3. Rodrigues JN, et al. Surgery for Dupuytren’s contracture of the fingers. Cochrane Database of Systematic Reviews. 2015;CD010143. DOI: 10.1002/14651858.CD010143.pub2.
  4. Verjee LS, et al. Unraveling signaling pathways promoting fibrosis in Dupuytren’s disease. PNAS. 2013. DOI: 10.1073/pnas.1301100110.
  5. Yin CY, et al. Long-term follow-up after triamcinolone injection in Dupuytren disease. Journal of Hand Surgery European Volume. 2017;42:678–682. DOI: 10.1177/1753193417690961.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Monday,Time:-12-36-12 Pm

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