Clinical Example: Knuckle Pads: Dorsal Dupuytren Nodules

Patients with Dupuytren's disease sometimes also have localized firm areas beneath the skin dorsal to the finger joints. These may or may not be fixed to the skin or to the underlying extensor mechanism. The overlying skin may be normal, wrinked or somewhat thin.
Such lumps are referred to as ""knuckle pads" or "dorsal Dupuytren nodules" to distinguish them from simple callus or skin thickening over the joints, which are called "dorsal cutaneous pads". Knuckle pads are associated with Dupuytren's and with treatment-resistant Dupuytren's; dorsal cutaneous pads are not. This has been described in more detail by Rayan.

Knuckle pads are variable. They:
  • often precede the appearance of palmar Dupuytren's disease.
  • may resolve spontaneously.
  • may recur after excision.
  • may also have callused skin from local irritation.
  • may be red, painful or tender.
  • may be located over the PIP head condylar prominences or centrally over the dorsum of the joint.
  • may be single or multiple on the same joint.
  • are most often found on the PIP joint, but may may involve the MCP, DIP or thumb IP joints.
  • occur on fingers unrelated to the location of palmar Dupuytren's disease.
The following are examples of different variations of knuckle pads. Click on the thumbnails for a better look.
Click on each image for a larger picture


Typical appearing knuckle pads on the middle and ring finger PIP joints of this 38 year old man. He has no evidence of Dupuytren's disease.
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These are fixed to the extensor mechanism and are more prominent in PIP flexion.
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12 years later, the patient has developed Ledderhose disease of one foot and is recovering from an episode of frozen shoulder. Both diagnoses are associated with Dupuytren's disease, but he still has no evidence of this.
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His initial knuckle pads have resolved, but he has a new knuckle pad on the dorsum of his index PIP joint.
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He may or may not ever develop palmar Dupuytren's disease.
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Woman with multiple central knuckle pads and Dupuytren's contracture.
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Another patient with condylar knuckle pads.
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This patient has knuckle pads of every PIP joint but no fixed contractures.
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This patient has knuckle pads with some dimpling and loss of extension creases on the small finger.
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Knuckle pad of the DIP joint.
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Tight skin associated with early aggressive Dupuytren's.
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Ectopic Dupuytren's is associated with aggressive, recurrent, treatment resistant Dupuytren's. Knuckle pads are one ectopic location. less common locations include the pisiform / distal FCU sheath, as shown here.
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Knuckle pads on the same patient, showing some dimpling and skin flaking.
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Another patient with pisiform area involvement, showing scuff marks from a recent fall.
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Same hand showing inflammatory appearance of knuckle pads with some loss of skin extensor creases.
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Black woman with a new index finger knuckle pad. She had a similar knuckle pad on the middle finger of the same hand which resolved without recurrence after an intralesional steroid injection five years earlier.
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DIP knuckle pad resembling a mucous cyst.
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Another patient showing crease deformation.
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Same patient, other hand.
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Atypical very localized knuckle pad with loss of extensor skin creases.
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Same patient, other hand.
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Another patient, similar pattern to above.
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Well circumscribed knuckle pads with peripheral skin puckering.
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Circumscribed knuckle pad with fine dermal creases.
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Unlike a dorsal cutaneous pad, the epidermis is not hyperkeratotic.
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A variation is deformation or puckering of the skin creases without a mass effect, as in this patient.
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Same patient, other hand.
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Another example of this type of skin puckering.
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Same patient other hand.
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Central and lateral knuckle pads, top and side views.
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Three views of a hand with both single and double knuckle pads and a knuckle pad of the thumb IP joint.
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Knuckle pads with loss of extensor skin creases.
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"Active" knuckle pads: pink and tender.
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Knuckle pad dimpling and prominence.
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Bilateral knuckle pads.
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"Active"knuckle pads, pink and tender, both hands
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A patient with multiple knuckle pads and diffuse palmar involvement but no contractures - yet. This is the stage at which a biologic, disease-modifying therapy would be appropriate, before disabling structural changes occur. Such a treatment does not exist - yet.
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