Seroma formation following percutaneous needle aponeurotomy and corticosteroid injection for Dupuytren’s contracture: first case report in the literature

Introduction

Dupuytren’s contracture is a fibroproliferative disorder of the palmar fascia that leads to progressive flexion deformities of the fingers, predominantly affecting the metacarpophalangeal and proximal interphalangeal joints, often treated with needle fasciotomy with or without corticosteroid injection (CSI). This condition compromises hand function and quality of life, particularly in advanced stages when digit extension becomes severely restricted. Surgical techniques, including open or limited fasciectomy, remain the traditional approach for severe Dupuytren’s contracture (1). However, these procedures often involve prolonged recovery periods, a substantial risk of complications, and a significant chance of recurrence (2).

Percutaneous needle aponeurotomy (PNA), first popularised by French rheumatologists Lermusiaux and Debeyre in 1979 (3), has gained popularity as a minimally invasive alternative. This approach offers faster recovery and fewer postoperative complications compared to traditional surgery (4). PNA involves the use of a hypodermic needle to perforate and release contracted palmar fascia cords, resulting in immediate improvement in digit extension (2). It can be safely and conveniently performed in an outpatient clinic under local anaesthesia (5), making it especially suitable for elderly patients with comorbidities or those presenting with mild to moderate contractures where extensive surgery may not be indicated (2).

Injections of triamcinolone acetonide have demonstrated significant regression of Dupuytren’s nodules, with sixty to eighty percent improvement typically achieved after an average of 3.2 injections per nodule (6). This treatment can reduce the necessity for surgical intervention. Documented complications from CSIs are generally minor and temporary, including subcutaneous fat atrophy at the injection site, local tenderness, temporary depigmentation, and rare cases of flexor tendon rupture following multiple injections (6).

To date, there have been no reports in the literature of seroma formation in the hand following CSIs or PNA for Dupuytren’s contracture. Here, we present the first reported case of seroma formation 6 weeks following combined CSI and PNA. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-320/rc).

Case presentation

A 67-year-old right-handed female was referred to the Dupuytren’s clinic for management of contractures affecting the right second and fourth rays. The patient was an ex-smoker of Scottish and English descent with no significant medical history.

Clinical examination demonstrated a flexion contracture of 10 degrees at the metacarpophalangeal joint of the second digit. The fourth digit exhibited a 45-degree flexion contracture at the proximal interphalangeal joint and a 10-degree flexion contracture at the distal interphalangeal joint. The patient underwent PNA, performed in the outpatient setting under local anaesthesia without sedation, in combination with an intralesional injection of 1 mL of triamcinolone acetonide (Kenacort™ A40, 40 mg/mL).

At a routine review 6 weeks post-procedure, the patient presented with a non-tender, fluctuant lesion over the medial aspect of the right palm (Figure 1). She had not previously sought medical attention for the lesion as it was non-tender. She denied systemic symptoms such as fever, malaise, or rigours. Prior to this review, she had managed the lesion on her own with compression using a bandage, without effect. Upon examination, she was afebrile with stable vital signs. The lesion was cystic, without surrounding erythema or signs of cellulitis. Clinical assessment revealed complete resolution of the Dupuytren’s contractures, with full extension achieved in the affected joints. Percutaneous aspiration of the lesion was performed under aseptic conditions, yielding 10 mL of purulent fluid, which was sent for microbiological analysis (Figure 2). The area was dressed with povidone-iodine gauze and compressive bandaging, and the patient was commenced on oral cephalexin 500 mg four times daily for 5 days.

Figure 1 Infected seroma of the right palm 6 weeks after percutaneous needle aponeurotomy and corticosteroid injection with Kenacort^TM A40.

Figure 2 Purulent discharge from right palm infected seroma percutaneously drained.

At the 5-day follow-up, a persistent seroma was noted; however, the patient remained systemically well, and the lesion was non-tender. A further 5 mL of purulent fluid was aspirated and sent for repeat microbiology culture. Antibacterial dressing was reapplied using compressive gauze and a crepe bandage. Microbiological testing identified Staphylococcus aureus, sensitive to flucloxacillin, erythromycin, and clindamycin. Given this susceptibility profile, the patient was prescribed clindamycin 450 mg three times daily for a duration of 5 days.

Two days later, the lesion was reassessed and found to contain a residual 2 mL of purulent fluid. A third aspiration was performed, and the fluid was again cultured. Microbiological findings confirmed Staphylococcus aureus, with susceptibility to cephalexin, flucloxacillin, erythromycin, and clindamycin. The patient was commenced on a further 5-day course of oral cephalexin. At 14 days following initial presentation, complete resolution of the seroma was achieved with no evidence of recurrence (Figure 3). A final review at 6 weeks post-drainage confirmed no fluid retention and no residual contracture or functional impairment.

Figure 3 Complete resolution of right palm infected seroma 14 days after initial drainage.

This unique case highlights how a seroma without erythema or pain formed following PNA and CSI. Failing conservative management with compression, it unfortunately developed into an infected seroma which was treated with percutaneous aspiration and oral antibiotics. Infected seroma is an uncommon complication following PNA and CSI, underscoring the necessity for heightened clinical awareness, preventive strategies, and further investigation into potential contributing factors.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This case report describes a novel complication of infected seroma following PNA with CSI for Dupuytren’s contracture. To our knowledge, this is the first reported case of an infected seroma that failed conservative management as a complication of this combined treatment approach.

PNA is widely accepted as a safe, minimally invasive treatment for Dupuytren’s contracture, with rapid recovery and reduced complication rates compared to traditional surgery (2,4). The most commonly reported complications following PNA include skin tears, infections, nerve injuries, tendon lacerations and regional pain syndromes (7,8). Minor complications include lymphadenopathy, pruritus, post-operative oedema and skin tears (9). Complications are rare (10) and skin tears are among the most frequent minor complications and typically resolve with simple wound care. Nerve injuries, although less common, can occur due to inadvertent damage during the needle procedure and may result in transient paraesthesia or permanent deficits (4).

Infection rates following PNA without corticosteroid administration have been reported to range from 0.7% (8) to 2% (7). However, none of the reviewed literature explicitly reported seroma formation or infected seroma as a complication following PNA, particularly when combined with CSIs (11,12). This highlights the uniqueness of the current case, suggesting that seroma formation after the procedure may be an exceedingly rare event.

The introduction of CSIs alongside PNA has primarily aimed to reduce recurrence rates and promote regression of Dupuytren’s nodules. Triamcinolone acetonide, the corticosteroid utilised in this case, has been beneficial in achieving nodule regression and minimising surgical intervention requirements (6). Reported complications from CSIs typically include localised skin atrophy, transient tenderness, temporary depigmentation, and rarely, flexor tendon rupture after multiple injections (6). Despite this, corticosteroid use has not previously been associated with the formation of seromas or infected seromas in the existing literature (7,11,12).

In this case, the seroma was detected post-procedure and was initially managed conservatively by the patient. At 6 weeks, it worsened and was associated with infection by Staphylococcus aureus. This pathogen is commonly implicated in superficial skin infections and postoperative complications. Given the absence of systemic features, the seroma formation and subsequent infection were localised complications. Routine follow-up and prompt management, including repeated sterile drainage procedures and targeted antibiotic therapy, ultimately resulted in complete resolution within 14 days.

This case report has limitations. A single case, although unique, limits generalisability. Long-term outcomes, such as further complications, may not be fully encapsulated given the short follow-up period of 6 weeks post seroma drainage. The mechanism underlying seroma formation in this case remains speculative. Possible factors include the CSI itself, which may alter local tissue healing processes and fluid balance, or the inadvertent creation of dead space during the percutaneous procedure, which could predispose to fluid accumulation and subsequent infection. Although the CSI may theoretically suppress local immune responses, thereby increasing disease susceptibility, this mechanism remains hypothetical and warrants further investigation. In our case report, we used triamcinolone acetonide (Kenacort™), whereas some studies involving PNA have utilised methylprednisolone (Depo-Medrol™) (10). In the literature, these CSIs have not been reported to contribute to seroma formation or infection. Their efficacy has been compared in the treatment of osteoarthritis, but not in the management of PNA. Future studies could endeavour to directly compare the use of triamcinolone acetonide and methylprednisolone in PNA, with or without CSI, to better assess their complications, benefits, and limitations.

Conclusions

This case report highlights infected seroma formation as an infrequent and previously unreported complication following combined PNA and CSI for Dupuytren’s contracture. The rarity of this complication underscores the necessity for careful monitoring of patients undergoing this combined procedure. Clinicians should be vigilant for this potential complication, particularly in patients presenting with unusual, localised swelling or cystic lesions post-procedure. Early recognition and management, including sterile drainage and targeted antibiotic therapy, can lead to favourable outcomes. Further investigation is required to elucidate the mechanisms underlying seroma development in this context and to develop strategies to mitigate this risk.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-320/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-320/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-320/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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