Pearls and pitfalls of collagenase injection treatment for Dupuytren contracture. Treatment indications include the presence of a palpable cord causing at least 20 degree contracture of an MCP or PIP joint and no allergy to Clostridium histolyticum collagenase. The site chosen for injection should be the mid-portion area where the contracting cord is massively separated from the underlying flexor tendon to avoid tendon injury. An antiseptic is applied at the site of the injection and the skin is allowed to dry. The needle is inserted perpendicular through the skin into the underlying cord. Passive manipulation of the DIP joint is performed and movement of the needle is checked to ensure that the needle has not been improperly positioned within the underlying flexor tendon. The needle is withdrawn slightly and repositioned 2-3 mm proximal to the initial injection. Passive manipulation of the DIP joint is again performed prior to injecting the remaining volume of the drug. Rare flexor tendon ruptures have been reported following collagenase injection at the PIP joint of the little finger. Care should be taken to inject as close to the palmar digital crease as possible. The green zone indicates a safe area to inject while the red zone shows a danger area near the digital PIP joint crease. The patient is usually brought back within 24 hours for gentle passive extension of the finger to initiate cord rupture. Up to 3 attempts may be performed to get the finger maximally extended. Skin tears are common following finger extension. Patients should be reassured that it will heal. Avoidance of wound desiccation is achieved by application of medicated ointments 2 times a day and wrapping the wound with an adhesive strip bandage until the skin edges are approximated by secondary healing. It is essential that they continue full active range of motion during the wound healing phase. The patient returns 1 week post procedure and is able to demonstrate full finger extension and flexion. The skin tear is healed. He is recommended to continue to wear his night time splint for up to 4 months to maintain finger extension and to do range of motion exercises during that time. We would like to thank Dr. Fiore for his generous contribution of the clinical case and video to this presentation.

Collagenase injection

Dupuytren contracture

MCP and PIP joints

finger extension

night splint