Snapshot A 60-year-old man presents to his physician for palmar contractures. He reports that his hand appears "deformed" and denies any pain. His past medical history is significant for alcoholic cirrhosis. Physical exam reveals thickened skin on his palms, contractures of his fourth and fifth fingers bilaterally, and several non-tender palmar nodules. He is counseled on this condition and he opts to try injected collagenase. Introduction Clinical definition a benign fibroproliferative disorder characterized by contracture of the palms and palmar nodules Epidemiology demographics male > female onset typically after 60 years of age northern European descent risk factors increasing age family history diabetes alcohol smoking Pathogenesis the exact pathogenesis is unknown but it may involve oxidative stress, impaired wound healing, and an abnormal immune response, resulting in hyperplasia of the palmar fascia Associated conditions alcoholic cirrhosis Prognosis typically progressive in severity 10% of cases will spontaneously resolve recurrence after treatment is high Presentation Symptoms painless nodules on palms contractures may limit function patients often have difficulty wearing gloves or doing household chores like washing dishes or cleaning Physical exam thickened palmar skin with pitting, dimpling, or scarring palmar fascial nodules palmar fascial cords with tight bands contracture of the fourth and fifth fingers and inability to extend those fingers commonly bilateral tabletop test positive if the patient is unable to lay their palm completely flat against the table Studies Making the diagnosis most cases are clinically diagnosed Differential Trigger finger distinguishing factors painful contracture of the affected digit clicking or locking of the digit Treatment Management approach first-line therapies include injected collagenase and/or steroids the patient and physician decide together which first-line therapy is used Medical injected collagenase (enzymatic fasciotomy) indication a first-line agent to reduce the contracture and restore function in the hands injected steroids indication a first-line agent to reduce the contracture and restore function in the hands outcome recurrence is high Operative fasciotomy or fasciectomy indications if patients are refractory to first-line therapies if the contracture causes impaired function Complications Limited function of the affected hand(s) References