Education: Pictorial Case Study

Contributed by Dr Jean Watkins, a sessional GP in Hampshire.

The case
This elderly man had, for eight years, ignored the changes in the fourth and fifth fingers of his right hand. The problem had progressed slowly from a tender thickening in his palm, to the increasing flexion of the fingers in a fixed position. At this stage the problem was interfering with his ability to use his hand.

What is the diagnosis, management and differential diagnosis?

Tender thickening of the palm progressed to fixed, flexed fingers

The patient was referred to the hospital where it was recommended that, at this late stage, the only approach to deal with the problem of Dupuytren contracture would be to amputate the fingers.

Dupuytren contracture is an autosomal dominant fibroproliferative disease that may also require environmental factors, such as an injury to the hand, to develop. It occurs most frequently in Caucasian men, usually after the age of 50. Fibrosis of the palmar aponeurosis leads to flexion at the metacarpo-phalangeal and proximal interphalangeal joints.

Initially, a tender palmar nodule and cord that are adherent to the skin may be noted. This is followed by a gradually progressive flexion contracture of the finger or fingers. The ring finger is usually the first to be affected, followed by the fifth and third. Both hands are often affected.

In mild cases, no treatment may be recommended but, if necessary, fasciotomy or fasciectomy may be carried out under local anaesthesia.


  • Flexor tenosynovitis
  • Rheumatoid arthritis
  • Trigger finger

Trigger finger

  • Stenosing tenosynovitis affecting the flexor tendon of the thumb or one or more fingers.
  • Affects normal gliding of the tendon within its sheath. A nodule may develop on the tendon, usually over the metacarpo-phalangeal joint.
  • Affected digit becomes painful and difficult to straighten. Pain is felt in the distal palm and into the digit.
  • Improvement in over half the patients following corticosteroid injections of the sheath.


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