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Dupuytren’s Contracture
Dupuytren's Contracture MICHAEL L. MASON, M.D., F.A.C.S. *
I DO not propose at this time to discuss the whole general problem of Dupuytren's contracture. A recent monograph on the subject, by Skoog,12 has well summarized present thinking on this subject and contains an exhaustive bibliography up to the year 1948. A few of the articles that have appeared since that time are listed here to indicate that the topic is of considerable current interest and that the problem of technic of surgical treatment still presents some differences of opinion. The flurry produced by the proposal of the use of vitamin E in the treatment of Dupuytren's contracture has entirely subsided. It is generally agreed today that surgical removal of the fascia is the only rational therapy. TECHNICAL PROBLEMS
Several problems face the surgeon in dealing with the correction of Dupuytren's contracture. These are largely technical in nature and have to do with the operative technic and after-care. Thorough excision of the palmar aponeurosis is a time-consuming procedure which must be done with care to avoid damage to nerves and blood vessels and to conserve as much palmar skin as possible. The certainty of eventual skin involvement even in the mild case makes early operation advisable, advice which may be difficult for the surgeon to give and for the patient to accept when there is little or no disability. When the case is far advanced and there is extensive involvement of skin overlying the diseased fascia, the surgeon is hard put to it to decide as to the need for skin excision, realizing the great recoverability of almost hopeless-appearing skin, and knowing full well the poor bed into which necessary skin grafts must be placed. The large area of palm uncovered and the thin overlying skin flaps which must be sutured back over it make an ideal site for hematoma formation which may be difficult to control despite meticulous hemostasis at operation and a resilient pressure dressing afterwards. From the Department of Surgery, Northwestern University Medical School, and PassulJant Memorial Hospital, Chicago.
* Associate Professor of Surgery, Northwestern University Medical School,' Attending Surgeon, Passavant Memorial Hospital. 233
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Removal of Fascia
It is universally agreed that a thorough removal of the entire fascia is the procedure of choice even in the early case when only one pretendinous band shows thickening. However, it is probably not so well recognized that the palmar fascia is not just a triangular plate of tissue lining the palm, but has connections with the skin above it, with the deep fascia over the metacarpals beneath and with the digital fascia distally. The connections with the over~ying skin are especially dense in the region of the distal palmar crease where the skin seems to lie as a thin coating of epithelium over a dense scar. Here the dissection of skin from the upper surface of the fascia is difficult and occasionally impossible, but should be attempted conscientiously because much of it will survive and form satisfactory coverage. Fascial attachment to the skin obtains not only here, but proximally and distally as well. The pretendinous band which seems at first instance to be free will be found to be attached to the under surface of the skin for a varying distance proximai to the distal palmar crease, and unless the surgeon is careful he will find at the completion of the operation that he has left strips of palmar fascia attached to the under surface of the skin which may later cause contracture. At~achment of the fascia to the skin also obtains on the fingers, particularly over the proximal phalanges, where thick nodules develop with deep puckering at the proximal interphalangeal joint. This skin too may usually be dissected free from the underlying fascia and saved, and the great pains taken to do so are well worth while. The deep attachments of the fascia are important from two stand: points. They spring as sheets from the under surface of the palmar fascia at the borders of the pretendinous bands and pass deeply to either side of the underlying tendons, to attach to the transverse metacarpal fascia beneath, forming a series of short tunnels through which pass tendons and neurovascular bundles. Thin sheets of fascia associated with the denser sheets enclose the digital nerves and vessels. As the fingers are approached, these fascial sheets become continuous with the digital fascia. Not only is it necessary to remove these fascial sheets to prevent recurrence, but the greatest care must be taken in their removal lest the digital nerves and vessels be damaged. These latter structures must be carefully identified in the proximal part of the palm and kept in view throughout the whole of the dissection. If this is not done, there is great danger of injuring the nerves and vessels, which may be' caught up by the contracted fascia and drawn to the midline of the finger or beyond. This obtains especially at the base of the finger just distal to the metacarpophalangeal joint over the proximal half of the proximal phalanx. The need for wide removal of palmar fascia dictates complete exposure of the palm and, when necessary, of the volar surfaces of o.t;te or
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more fingers. Many incisions have been used for the exposure, from simple longitudinal incisions over the bands to complicated Z-shaped and S-shaped incisions and even immediate primary excision of all involved palmar skin and underlying fascia. The exposure of the palmar fascia which I most often use is made through two incisions (Fig. 104) which follow physiolo;?;ic lines. One incision is transverse at the distal border of the palm paralleling or
Fig. 104. Incisions utilized for exposure and removal of palmar fascia and its digital prolongations. The Z-plasty incision indicated on the middle finger is the one described by Skoog as recommended by McIndoe.
following the distal palmar crease, from the ulnar to the radial side. This incision passes directly across the thickest part of the involved pretendinous bands, which may be divided at once, if necessary, to permit contracted fingers to be extended and thus facilitate further dissection. Obviously this incision runs transversely to the digital neurovascular bundles, which must not be injured. All these structures can be kept under visual control when the surgeon works in a bloodless field Eecured by means of a blood pressure cuff. Through this transverse incision the surgeon may dissect both proximallyand distally. The initial dissection consists in carefully separating the skin from the underlying fascia. This is done as gently as possible
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to avoid damaging the skin either by buttonholing it, crushing it with forceps, or forceful retraction or shaving it too thin. The skin in the palm has remarkable recuperative powers and should be saved if at all possible, but must not be traumatized severely, since otherwise healing disturbances will occur. A fair number of small subcutaneous blood vessels will be found crossing the line of incision. These should first be caught in fine forceps, then divided and ligated with fine silk. Other vessels will be found running to the under surface of the skin from the interspaces below. These likewise should be clamped and divided and both ends tied. Even tiny vessels may bleed postoperatively and lead to hematoma formation. The second palmar incision (Fig. 104) is made after the skin has been dissected free as far as possible through the distal palmar incision. The second incision is made along the border of the thenar eminence, following the crease or paralleling it, and extends from the base of the thenar eminence distally for from 2 to 2! inches. A good bridge of palmar skin should be left between the distal end of this incision and the radial end of the transverse incision. The surgeon cuts down to the palmar fascia, which will be found to lie deeply where it springs from the .transverse carpal ligament and to come progressively closer to the skin as it proceeds distally. The apex of the fascia is uncovered at its origin from the transverse carpal ligament and is divided, and the fascia is then lifted up and separated deeply and at the sides. Distal to the superficial volar arch the deep sheets will be found coming from the under surface of the fascia to attach to either side of the metacarpal bones and transverse metacarpal ligaments. The apex of the fascia is then passed distally beneath the palmar flap to be brought out through the transverse mClSlOn.
Removal of the fascia from this point on is a slow and painstaking procedure, since the deep fascial layers have now to be divided at their attachment to the transverse metacarpal sheets, and it is just here that neurovascular bundle distortion occurs. We have found it helpful to remove the fascia from this point on in segments rather than to attempt to remove it all as one sheet. The preteI,ldinous bands are cut longitudinally, right down to the underlying tendons. As the lateral half of the band is pulled up, the deep fascial sheet is rendered taut, and beneath it one can see the nerves and vessels. With these under direct vision, and with an assistant using a narrow spatula as a retractor to keep nerve and vessels out of harm's way, the surgeon then divides the deep attachments of the fascia. As the fascia is followed toward the base of the finger, greater and greater care must be exercised in visualizing the nerves, since they are more and more subject to distortion. As a matter of fact this stage of the operation must be looked upon as a meticulous anatomic dissection of the digital nerves. If the fascial contracture does not involve the finger, the operation can end now and the wound may be closed. If, however, the fingers are
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involved, the surgeon must remove the contracted fascia from them. It is seldom necessary to go beyond the level of the proximal interphalangeal joint, so that it is rarely necessary to uncover more than the proximal phalanx. The greatest care must also be exercised in the digital dissection to avoid damage to nerves and vessels which may be drawn completely over to the opposite side of the finger. Since they have so far been followed distally from the palm, the surgeon has a point of departure in seeking them out in the finger. Just as in the palm, so in the finger various incisions have been used to uncover the fascia. Midlateral incisions, useful for almost all other procedures on the fingers, do not serve here quite so well, since the surgeon usually must uncover both sides of the finger to dissect the fascia free, and this is difficult through a lateral incision. I have on several occasions used the incision described by Skoog (Fig. 104), which he ascribes to McIndoe and is in reality a Z-plasty. This incision is useful where the skin is badly contracted and one wishes to take advantage of the lengthening possibilities of the Z-plasty. In most instances, however, I have found an oblique incision to be advantageous. This incision (Fig. 104) starts in the region of the proximal interphalangeal or just distal to it on one side and then proceeds upwards and obliquely toward the opposite side of the phalanx to end just distal to the web, which must not be divided. Through this incision it is possible to dissect out the nodule of fascia which is the usual involvement at this point. The skin here should likewise be handled most cac·efully. It can usually be saved, and even button holes may be sutured with good chance of healing nicely. Closure of Incisions
Closure of the incisions may often be accomplished by suture if it has not been necessary to excise skin. Ordinarily only skin sutures can be used, since there is little or no tissue into which subcutaneous sutures can be placed. Fine, smooth skin sutures swaged on needles are useful, and a plastic suture in 5-0 size is available. Mattress-type stitches are necessary to secure good eversion of skin edges, placed ! to I inch apart. Then simple through-and-through interrupted sutures or a continuous suture may be used to obtain accurate edge-to-edge apposition. Smooth faultless closure is important. One or two fine strips of rubber about lIS inch wide and I! inches long, cut from thin glove rubber, may be introduced into the incision to promote release of blood. Despite accurate hemostasi:s, slight oozing may occur, and these tiny drains have been helpful in such instances. Skin Grafts If it has been necessary to excise skin because of its hopeless involvement, grafts will be needed to fill in the defects. We may use either
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free full thickness grafts or thick split grafts. These grafts may often be removed from the same forearm if not too large. They are sutured accurately in place and are held in firm appositiOh to the bed by means of a stentlike mass of fluffed gauze held in place by silk overties)nsert.ed about the periphery.
Fig. 105. The palmar incisions are shown closed by fine plastic sutures. Several mattress sutures are first introduced -to secure eversion and accurate apposition is then obtained by a series of interrupted or part interrupted and part running sutures. After the incusions have been closed silk overtie sutures are placed in pairs on either side of the palm. These sutures are not tied down tightly so as to avoid constricting the skin. It is often advantageous to introduce two or three very find glove-rubber strip drains, 2 to 3 mm. wide, into the transverse incision.
Pressure Dressings
It is helpful to tie the initial pressure dressing over the operative field with silk overties. To accomplish this, long sutures of 4-0 silk are placed through the skin on either side of the palm about! inch apart (Fig. 105). They run transversely through the skin, grasping about 1 inch, are tied loosely and the ends left long. The sutures are then laid to either side of the operative field and the incisions are dressed. Gauze sponges are placed between the fingers to prevent maceration, and the various incisions are covered with several thicknesses of gauze wrung out in
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normal saline solution. Over this is placed a large amount of fluffed-up gauze, to make a dressing 3 or 4 inches thick. While this thick dressing is held in place by the assistant, the surgeon ties it down with the silk overties, taking opposite pairs across the dressings and tying' them (Fig. 106). This portion of the compression dressing remains securely in place and exerts a firm, resilient pressure over the entire operative field. A large, resilient pressure dressing and splint are then.applied to exert
.
Fig. 106. A few moist sponges are laid directly over the suture lines and a large ball of fluffed gauze is placed in the palm and the silk sutures are tied over it to maintain resilient pressure and discourage bleeding. Gauze placed between the fingers prevents maceration of opposed skin surfaces.
even compression over the entire lower forearm and hand, leaving only the tips of the fingers and the thumb exposed. The dressing is applied before the blood pressure cuff is released so that, when the reactive hyperemia occurs, the tissues are firmly supported. It cannot be too strongly emphasized that the compression of the dressing should be secured by the use of large amounts of gauze and abdominal pads which evenly distribute the pressure, and that the woven elastic bandage is not in itself to be depended upon for this. Too often the uninitiated will wrap the woven elastic bandage snugly, but with insufficient dressings beneath. This defeats the dressing entirely; it is too tight and painful
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and is constrictive rather than compressive and does not furnish the necessary resiliency. As a matter of fact, the compression dressing may be applied without the use of elastic bandages, although it is somewhat more difficult to secure a firm, even pressur_e with plain gauze bandage. Splinting
Splinting is an important feature of the operation. The hand is splinted with the wrist in slight extension, with the fingers slightly flexed, and usually with the thumb free. If there is forced extension of the fingers, there is almost certain to be too great tension on the palmar suture line with resultant disturbed healing. The splint should be well padded with abdominal pads and an extra thickness of" pad should be placed over the metacarpus ending just proximal to the heads of the metacarpals, to prevent these bony prominences from being subjected to pressure . After-care
•
The initial dressings are changed on the fifth to sixth postoperative day, at which time the silk overties are cut, and fluffed dressings released and the rubber strips removed. The suture lines are inspected to see if any suture is too tight, and if so, it is snipped. A compression dressing and the splint are reapplied. Sutures are removed on the ninth or tenth day, by which time the dressing may be made much less voluminous. Splinting is maintained until the surgeon feels sure that the healing is secure and is then discontinued. Moderately firm dressings, however, are maintained for about two and one-half to three weeks altogether. After the second week, if healing is satisfactory, the patient is encouraged to use his fingers within the restricted limits permitted by the dressings. When dressings are discontinued, usually about the end of the third week, the patient is started on "home physical therapy," which consists of daily washing for fifteen to twenty minutes in warm soapy water, gently massaging the hand while doing so. The patient is encouraged to use the hand, but not to punish it. Forceful physical therapy and strenuous use, vigorous stretching and massage in the early postoperative period I am sure are quite harmful, in that they stretch and tear and traumatize, and prolong rather than hasten recovery. CASE REPORTS
The following cases illustrate various problems encountered in the surgical care of Dupuytren's contracture. CASE I. R. H., a 51 year old mechanical engineer, admitted June 27, 1950 and discharged July 1, 1950, had noted over a number of years increasing inability to extend the left ring finger. By 1948 the proximal interphalangeal joint of the finger could not be extended beyond 90
Dupuytren's Contracture degrees. He was operated upon elsewhere through a midline incision with no change in the contracture. When seen, the condition of the left hand was as shown in Figure 1(}7, a, b. The left ring finger could be flexed into the palm, but extension was restricted by a dense fibrous band which could be seen and felt extending from the base of the palm distally to the proximal interphalangeal joint of the finger. This band prevented extension of the joint beyond 90 degrees. Over this band Was the scar of the previous operation. There was mild restriction of extension of the little finger, but no palpable thickening of the pretendinous band to this finger. The patient had an early involvement of the pretendinous bands of the right middle and ring fingers also. At operation two incisions were made in the palm, one transverse in the region of the distal palmar crease, and the other oblique skirting the thenar eminence. The palmar plate and thick pretendinous band were re-
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b
c
d
Fig. 107 (Case I). a, b, Before operation June 28, 1950. c, d, After operation August 8, 1950. moved throughout the palm. The digital nerve to the ulnar side of the ring finger was found to be distorted in its course, but was not injured. The continuation of the fascia in the ring finger was removed through a midlateral incision on the ulnar side, where its major portion lay. Closure of the operative incisions was accomplished by suture, and pressure dressings were applied. Healing occurred by primary intention, and the patient returned to work some six weeks after operation. He was last seen seven weeks postoperatively. Extension was complete, but there was not yet complete flexion of the distal interphalangeal joints of the middle, ring and little fingers (Fig. 107, c, d). CASE II. J. W. D., a 35 year old die setter, admitted September 2, 1948, and discharged September 5, 1948, was seen because of nodules in the right palm and mild contracture of the ring and little fingers. He was not sure just how long these nodules had been present. They had been noted eight to ten months previously when he struck has hand with a wrench. His paternal grandmother and an uncle on his father's side had
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had contracture of the ring and little fingers. Examination showed (Fig. 108, a) thickening of the pretendinous bands to the right middle ring and little fingers, with two heavy nodules in the distal palmar crease at the base of the ring finger. The left hand showed no evidence of disease. The entire palmar fascia was excised without sacrificing any skin, and primary healing was obtained. Five weeks later he had returned to work (Fig. 108, b, c). CASE III. J. L. W., a 57 year old traffic manager of a large transportation system, admitted May 25, 1947, and discharged May 29, 1947, came for relief of contracture of the ring and little fingers of the left hand of some ten years' duration. He first noted a small nodular mass in the palm, which slowly increased in size and was followed by the develop-
a
b
c
Fig. 108 (Case II). a, Before operation September 3, 1948. b, c, After operation October 9, 1948. ment of thickened bands in the palm which slowly pulled the little finger, and to a lesser extent the ring finger into flexion (Fig. 109, a, b). Ten years previously the right hand had shown the same condition and had been operated upon elsewhere. Examination revealed marked puckering of the palmar skin with deep grooves along the distal palmar crease. The pretendinous bands of the palmar fascia to the ring and little fingers were palpably thickened, and that to the little finger extended as a thick mass over the maximal phalanx to the proximal interphalangeal joint crease. There was limitation of extension of all the joints of the little finger and of the metacarpophalangeal joint of the ring finger. Flexion of the distal interphalangeal joints of all the fingers was 5 to 15 degrees less than normal. At operation the palmar portion of the fascia was removed through two incisions, one transversely across the palm at the level of the distal crease, the other skirting the thenar eminence. It was necessary to sacrifice an elliptical area of skin in the palm where deep, long-standing puckering had been present. Excision of the fascia from the volar surface
Dupuytren's Contracture of the distal phalanx of the little finger proved difficult, and a segment of skin was sacrificed here. These two areas were closed with free full thickness skin grafts. Healing was satisfactory. The result at the end of seven months is shown in Figure 109, c, d. CASE IV. H. A. S., a 47 year old sales manager, admitted February 6, 1951, and discharged February 18, 1951, presented himself for surgical correction of a flexion contracture of the right hand. Some four years previously he had noted dimpling develop in the palm of the right hand. associated with what he thought was thickening and hardness of the skin. As time went on, the dimpling and hardness progressed, and the ring finger was drawn downwards into the palm by a dense band of tissue over which the skin was drawn into thick folds. The little finger was likewise drawn toward the palm, but not to the same degree as the ring finger.
a
b
c
d
Fig. 109 (Case III). a, b, Before operation May 26, 1947. c, d, After operation January 1948. During~the past"'year-a similar process was noted in the left palm, but it had _not"'progressed to such~a degree as the right. An older brother had similar changes in his hands, as well as a like process on the sole of the left foot. Otherwise, so far as the patient knew, no other member. of his family was or had been affected. Examination of the right hand (Fig. 110, a, b) revealed a thick band of fascia lying beneath"the skin of the palm and extending from the base distally and in line with the fourth metacarpal to the proximal interphalangeal joint of the ring finger. There was another band palpable and visible running from the region of the distal interphalangeal crease to the radial side of the little finger, and a firm band could be felt along the ulnar side of the base of the middle finger. The distal palmar crease was deep and adherent to underlying fascia, and the skin over the proximal phalanx of the ring finger was thrown into a deep fold or roll. At operation the· palmar fascia was exposed through a transverse incision across the distal palmar crease and a curved incision along the border of the thenar eminence. The skin was carefully dissected free from
Michael L. Mason the surface of the underlying fascia, a procedure that was difficult along the distal palmar crease but easier as the base of the palm was approached. The apex of the fascia was then divided where it took origin from the transverse carpal ligament, drawn distally and brought out through the transverse incision. The deep connections of the fascia were then divided, keeping the digital nerves and vessels constantly in view. The palmar plate of the fascia was then removed, and the prolongation into the ring finger was exposed through an oblique incision on the finger. The overlying skin was carefully dissected free from the underlying fascia, and then the fascial band was removed, likewise with constant visualization of the digital nerves and vessels. No skin was sacrificed, although it was thin in spots. Closure was affected by suture except for a small lozenge-shaped area in the palm into which a free full thickness graft was placed. The pressure dressings were held in place with silk overties. Healing occurred per primum, and the patient was allowed re-
a
b
c
d
e
Fig. 110 (Case IV). a, b, Before operation February 7,1951. c, d, e, After operation April 1951. stricted use of the hand in two and one-half weeks. The condition of the hand two and one-half months after operation is shown in Figure 110, c, d, e. REFERENCES 1. Bode, E.: Ueber die Dupuytruische Kontraktur. Brun's Beitriige z. klin. Chir. 179: 53-64,1949.
2. Bolgert, M.: Maladie de Dupuytren. Coussinets des phalanges. Semaine d. hOp. Paris, 26: 3011-3017, 1950 .• 3. Bruner, J. M.: The Use of Dorsal Skin Flap for the Coverage of Palmar Defects after Aponeurectomy for Dupuytren's Contracture. J. Plastic & Reconstruct. Surg. 4: 559-565, 1949. 4. Buff, H. U.: Bemerkungen zur Therapie der Dupuytrenschen Kontraktur. Helvet. chir. acta 12: 277-280, 1950. 5. Butturini, U. Sulla terapia del morbo di Dupuytren con acetato di alfatocoferolo. Minerva med. 11: 1235-1237, 1950. 6. Chevalier, C. H.: Refiexions a propos de 42 operations pour maladie de Dupuytren. Mem. de l'Acad. de Chir. Paris 77: 248--251, 1951. 7. Fonteux M. and Ripstein, C. B.: Dupuytren's Contracture Associated with Coronary Artery Disease. Canad. M. A. J. 68: 502-504, 1948.
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8. Gordon, S.: Dupuytren's Contraction. Canad. M.A.J. 58: 543-547, 1948. 9. Iselin, M. and Dieckmann, G.: Notre experience du traitement de la maladie de Dupuytren. Mem. de l'Acad. de Chir. Paris 77: 251-255, 1951. 10. King, R. A.: Vitamin E Therapy in Dupuytren's Contracture. Examination of the Claim that Vitamin Therapy Is Successful. J. Bone & Joint Surg. S1B: 443, 1949. 11. Langston, R. G. and Badre, E. J.: Dupuytren's Contracture. Canad. M. A. J. 58: 57-61, 1948. 12. Skoog, T.: Dupuytren's Contraction. Acta chir. Scandinav. 96: Suppl. 139, 1948. 13. Thomsen, G.: Treatment of Dupuytren's Contracture with Vitamin E. Brit. M. J. 2: 1382-1383, 1948. 14. Thomsen, W.: Technisches zur Behandlung der Dupuytrenschen Fingerkontraktur. Der Chirurg. 21: 359-361, 1950.
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I DO not propose at this time to discuss the whole general problem of Dupuytren's contracture. A recent monograph on the subject, by Skoog,12 has well summarized present thinking on this subject and contains an exhaustive bibliography up to the year 1948. A few of the articles that have appeared since that time are listed here to indicate that the topic is of considerable current interest and that the problem of technic of surgical treatment still presents some differences of opinion. The flurry produced by the proposal of the use of vitamin E in the treatment of Dupuytren's contracture has entirely subsided. It is generally agreed today that surgical removal of the fascia is the only rational therapy. TECHNICAL PROBLEMS
Several problems face the surgeon in dealing with the correction of Dupuytren's contracture. These are largely technical in nature and have to do with the operative technic and after-care. Thorough excision of the palmar aponeurosis is a time-consuming procedure which must be done with care to avoid damage to nerves and blood vessels and to conserve as much palmar skin as possible. The certainty of eventual skin involvement even in the mild case makes early operation advisable, advice which may be difficult for the surgeon to give and for the patient to accept when there is little or no disability. When the case is far advanced and there is extensive involvement of skin overlying the diseased fascia, the surgeon is hard put to it to decide as to the need for skin excision, realizing the great recoverability of almost hopeless-appearing skin, and knowing full well the poor bed into which necessary skin grafts must be placed. The large area of palm uncovered and the thin overlying skin flaps which must be sutured back over it make an ideal site for hematoma formation which may be difficult to control despite meticulous hemostasis at operation and a resilient pressure dressing afterwards. From the Department of Surgery, Northwestern University Medical School, and PassulJant Memorial Hospital, Chicago.
* Associate Professor of Surgery, Northwestern University Medical School,' Attending Surgeon, Passavant Memorial Hospital. 233
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Michael L. Mason
Removal of Fascia
It is universally agreed that a thorough removal of the entire fascia is the procedure of choice even in the early case when only one pretendinous band shows thickening. However, it is probably not so well recognized that the palmar fascia is not just a triangular plate of tissue lining the palm, but has connections with the skin above it, with the deep fascia over the metacarpals beneath and with the digital fascia distally. The connections with the over~ying skin are especially dense in the region of the distal palmar crease where the skin seems to lie as a thin coating of epithelium over a dense scar. Here the dissection of skin from the upper surface of the fascia is difficult and occasionally impossible, but should be attempted conscientiously because much of it will survive and form satisfactory coverage. Fascial attachment to the skin obtains not only here, but proximally and distally as well. The pretendinous band which seems at first instance to be free will be found to be attached to the under surface of the skin for a varying distance proximai to the distal palmar crease, and unless the surgeon is careful he will find at the completion of the operation that he has left strips of palmar fascia attached to the under surface of the skin which may later cause contracture. At~achment of the fascia to the skin also obtains on the fingers, particularly over the proximal phalanges, where thick nodules develop with deep puckering at the proximal interphalangeal joint. This skin too may usually be dissected free from the underlying fascia and saved, and the great pains taken to do so are well worth while. The deep attachments of the fascia are important from two stand: points. They spring as sheets from the under surface of the palmar fascia at the borders of the pretendinous bands and pass deeply to either side of the underlying tendons, to attach to the transverse metacarpal fascia beneath, forming a series of short tunnels through which pass tendons and neurovascular bundles. Thin sheets of fascia associated with the denser sheets enclose the digital nerves and vessels. As the fingers are approached, these fascial sheets become continuous with the digital fascia. Not only is it necessary to remove these fascial sheets to prevent recurrence, but the greatest care must be taken in their removal lest the digital nerves and vessels be damaged. These latter structures must be carefully identified in the proximal part of the palm and kept in view throughout the whole of the dissection. If this is not done, there is great danger of injuring the nerves and vessels, which may be' caught up by the contracted fascia and drawn to the midline of the finger or beyond. This obtains especially at the base of the finger just distal to the metacarpophalangeal joint over the proximal half of the proximal phalanx. The need for wide removal of palmar fascia dictates complete exposure of the palm and, when necessary, of the volar surfaces of o.t;te or
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more fingers. Many incisions have been used for the exposure, from simple longitudinal incisions over the bands to complicated Z-shaped and S-shaped incisions and even immediate primary excision of all involved palmar skin and underlying fascia. The exposure of the palmar fascia which I most often use is made through two incisions (Fig. 104) which follow physiolo;?;ic lines. One incision is transverse at the distal border of the palm paralleling or
Fig. 104. Incisions utilized for exposure and removal of palmar fascia and its digital prolongations. The Z-plasty incision indicated on the middle finger is the one described by Skoog as recommended by McIndoe.
following the distal palmar crease, from the ulnar to the radial side. This incision passes directly across the thickest part of the involved pretendinous bands, which may be divided at once, if necessary, to permit contracted fingers to be extended and thus facilitate further dissection. Obviously this incision runs transversely to the digital neurovascular bundles, which must not be injured. All these structures can be kept under visual control when the surgeon works in a bloodless field Eecured by means of a blood pressure cuff. Through this transverse incision the surgeon may dissect both proximallyand distally. The initial dissection consists in carefully separating the skin from the underlying fascia. This is done as gently as possible
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to avoid damaging the skin either by buttonholing it, crushing it with forceps, or forceful retraction or shaving it too thin. The skin in the palm has remarkable recuperative powers and should be saved if at all possible, but must not be traumatized severely, since otherwise healing disturbances will occur. A fair number of small subcutaneous blood vessels will be found crossing the line of incision. These should first be caught in fine forceps, then divided and ligated with fine silk. Other vessels will be found running to the under surface of the skin from the interspaces below. These likewise should be clamped and divided and both ends tied. Even tiny vessels may bleed postoperatively and lead to hematoma formation. The second palmar incision (Fig. 104) is made after the skin has been dissected free as far as possible through the distal palmar incision. The second incision is made along the border of the thenar eminence, following the crease or paralleling it, and extends from the base of the thenar eminence distally for from 2 to 2! inches. A good bridge of palmar skin should be left between the distal end of this incision and the radial end of the transverse incision. The surgeon cuts down to the palmar fascia, which will be found to lie deeply where it springs from the .transverse carpal ligament and to come progressively closer to the skin as it proceeds distally. The apex of the fascia is uncovered at its origin from the transverse carpal ligament and is divided, and the fascia is then lifted up and separated deeply and at the sides. Distal to the superficial volar arch the deep sheets will be found coming from the under surface of the fascia to attach to either side of the metacarpal bones and transverse metacarpal ligaments. The apex of the fascia is then passed distally beneath the palmar flap to be brought out through the transverse mClSlOn.
Removal of the fascia from this point on is a slow and painstaking procedure, since the deep fascial layers have now to be divided at their attachment to the transverse metacarpal sheets, and it is just here that neurovascular bundle distortion occurs. We have found it helpful to remove the fascia from this point on in segments rather than to attempt to remove it all as one sheet. The preteI,ldinous bands are cut longitudinally, right down to the underlying tendons. As the lateral half of the band is pulled up, the deep fascial sheet is rendered taut, and beneath it one can see the nerves and vessels. With these under direct vision, and with an assistant using a narrow spatula as a retractor to keep nerve and vessels out of harm's way, the surgeon then divides the deep attachments of the fascia. As the fascia is followed toward the base of the finger, greater and greater care must be exercised in visualizing the nerves, since they are more and more subject to distortion. As a matter of fact this stage of the operation must be looked upon as a meticulous anatomic dissection of the digital nerves. If the fascial contracture does not involve the finger, the operation can end now and the wound may be closed. If, however, the fingers are
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involved, the surgeon must remove the contracted fascia from them. It is seldom necessary to go beyond the level of the proximal interphalangeal joint, so that it is rarely necessary to uncover more than the proximal phalanx. The greatest care must also be exercised in the digital dissection to avoid damage to nerves and vessels which may be drawn completely over to the opposite side of the finger. Since they have so far been followed distally from the palm, the surgeon has a point of departure in seeking them out in the finger. Just as in the palm, so in the finger various incisions have been used to uncover the fascia. Midlateral incisions, useful for almost all other procedures on the fingers, do not serve here quite so well, since the surgeon usually must uncover both sides of the finger to dissect the fascia free, and this is difficult through a lateral incision. I have on several occasions used the incision described by Skoog (Fig. 104), which he ascribes to McIndoe and is in reality a Z-plasty. This incision is useful where the skin is badly contracted and one wishes to take advantage of the lengthening possibilities of the Z-plasty. In most instances, however, I have found an oblique incision to be advantageous. This incision (Fig. 104) starts in the region of the proximal interphalangeal or just distal to it on one side and then proceeds upwards and obliquely toward the opposite side of the phalanx to end just distal to the web, which must not be divided. Through this incision it is possible to dissect out the nodule of fascia which is the usual involvement at this point. The skin here should likewise be handled most cac·efully. It can usually be saved, and even button holes may be sutured with good chance of healing nicely. Closure of Incisions
Closure of the incisions may often be accomplished by suture if it has not been necessary to excise skin. Ordinarily only skin sutures can be used, since there is little or no tissue into which subcutaneous sutures can be placed. Fine, smooth skin sutures swaged on needles are useful, and a plastic suture in 5-0 size is available. Mattress-type stitches are necessary to secure good eversion of skin edges, placed ! to I inch apart. Then simple through-and-through interrupted sutures or a continuous suture may be used to obtain accurate edge-to-edge apposition. Smooth faultless closure is important. One or two fine strips of rubber about lIS inch wide and I! inches long, cut from thin glove rubber, may be introduced into the incision to promote release of blood. Despite accurate hemostasi:s, slight oozing may occur, and these tiny drains have been helpful in such instances. Skin Grafts If it has been necessary to excise skin because of its hopeless involvement, grafts will be needed to fill in the defects. We may use either
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free full thickness grafts or thick split grafts. These grafts may often be removed from the same forearm if not too large. They are sutured accurately in place and are held in firm appositiOh to the bed by means of a stentlike mass of fluffed gauze held in place by silk overties)nsert.ed about the periphery.
Fig. 105. The palmar incisions are shown closed by fine plastic sutures. Several mattress sutures are first introduced -to secure eversion and accurate apposition is then obtained by a series of interrupted or part interrupted and part running sutures. After the incusions have been closed silk overtie sutures are placed in pairs on either side of the palm. These sutures are not tied down tightly so as to avoid constricting the skin. It is often advantageous to introduce two or three very find glove-rubber strip drains, 2 to 3 mm. wide, into the transverse incision.
Pressure Dressings
It is helpful to tie the initial pressure dressing over the operative field with silk overties. To accomplish this, long sutures of 4-0 silk are placed through the skin on either side of the palm about! inch apart (Fig. 105). They run transversely through the skin, grasping about 1 inch, are tied loosely and the ends left long. The sutures are then laid to either side of the operative field and the incisions are dressed. Gauze sponges are placed between the fingers to prevent maceration, and the various incisions are covered with several thicknesses of gauze wrung out in
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Dupuytren's Contracture
normal saline solution. Over this is placed a large amount of fluffed-up gauze, to make a dressing 3 or 4 inches thick. While this thick dressing is held in place by the assistant, the surgeon ties it down with the silk overties, taking opposite pairs across the dressings and tying' them (Fig. 106). This portion of the compression dressing remains securely in place and exerts a firm, resilient pressure over the entire operative field. A large, resilient pressure dressing and splint are then.applied to exert
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Fig. 106. A few moist sponges are laid directly over the suture lines and a large ball of fluffed gauze is placed in the palm and the silk sutures are tied over it to maintain resilient pressure and discourage bleeding. Gauze placed between the fingers prevents maceration of opposed skin surfaces.
even compression over the entire lower forearm and hand, leaving only the tips of the fingers and the thumb exposed. The dressing is applied before the blood pressure cuff is released so that, when the reactive hyperemia occurs, the tissues are firmly supported. It cannot be too strongly emphasized that the compression of the dressing should be secured by the use of large amounts of gauze and abdominal pads which evenly distribute the pressure, and that the woven elastic bandage is not in itself to be depended upon for this. Too often the uninitiated will wrap the woven elastic bandage snugly, but with insufficient dressings beneath. This defeats the dressing entirely; it is too tight and painful
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and is constrictive rather than compressive and does not furnish the necessary resiliency. As a matter of fact, the compression dressing may be applied without the use of elastic bandages, although it is somewhat more difficult to secure a firm, even pressur_e with plain gauze bandage. Splinting
Splinting is an important feature of the operation. The hand is splinted with the wrist in slight extension, with the fingers slightly flexed, and usually with the thumb free. If there is forced extension of the fingers, there is almost certain to be too great tension on the palmar suture line with resultant disturbed healing. The splint should be well padded with abdominal pads and an extra thickness of" pad should be placed over the metacarpus ending just proximal to the heads of the metacarpals, to prevent these bony prominences from being subjected to pressure . After-care
•
The initial dressings are changed on the fifth to sixth postoperative day, at which time the silk overties are cut, and fluffed dressings released and the rubber strips removed. The suture lines are inspected to see if any suture is too tight, and if so, it is snipped. A compression dressing and the splint are reapplied. Sutures are removed on the ninth or tenth day, by which time the dressing may be made much less voluminous. Splinting is maintained until the surgeon feels sure that the healing is secure and is then discontinued. Moderately firm dressings, however, are maintained for about two and one-half to three weeks altogether. After the second week, if healing is satisfactory, the patient is encouraged to use his fingers within the restricted limits permitted by the dressings. When dressings are discontinued, usually about the end of the third week, the patient is started on "home physical therapy," which consists of daily washing for fifteen to twenty minutes in warm soapy water, gently massaging the hand while doing so. The patient is encouraged to use the hand, but not to punish it. Forceful physical therapy and strenuous use, vigorous stretching and massage in the early postoperative period I am sure are quite harmful, in that they stretch and tear and traumatize, and prolong rather than hasten recovery. CASE REPORTS
The following cases illustrate various problems encountered in the surgical care of Dupuytren's contracture. CASE I. R. H., a 51 year old mechanical engineer, admitted June 27, 1950 and discharged July 1, 1950, had noted over a number of years increasing inability to extend the left ring finger. By 1948 the proximal interphalangeal joint of the finger could not be extended beyond 90
Dupuytren's Contracture degrees. He was operated upon elsewhere through a midline incision with no change in the contracture. When seen, the condition of the left hand was as shown in Figure 1(}7, a, b. The left ring finger could be flexed into the palm, but extension was restricted by a dense fibrous band which could be seen and felt extending from the base of the palm distally to the proximal interphalangeal joint of the finger. This band prevented extension of the joint beyond 90 degrees. Over this band Was the scar of the previous operation. There was mild restriction of extension of the little finger, but no palpable thickening of the pretendinous band to this finger. The patient had an early involvement of the pretendinous bands of the right middle and ring fingers also. At operation two incisions were made in the palm, one transverse in the region of the distal palmar crease, and the other oblique skirting the thenar eminence. The palmar plate and thick pretendinous band were re-
a
b
c
d
Fig. 107 (Case I). a, b, Before operation June 28, 1950. c, d, After operation August 8, 1950. moved throughout the palm. The digital nerve to the ulnar side of the ring finger was found to be distorted in its course, but was not injured. The continuation of the fascia in the ring finger was removed through a midlateral incision on the ulnar side, where its major portion lay. Closure of the operative incisions was accomplished by suture, and pressure dressings were applied. Healing occurred by primary intention, and the patient returned to work some six weeks after operation. He was last seen seven weeks postoperatively. Extension was complete, but there was not yet complete flexion of the distal interphalangeal joints of the middle, ring and little fingers (Fig. 107, c, d). CASE II. J. W. D., a 35 year old die setter, admitted September 2, 1948, and discharged September 5, 1948, was seen because of nodules in the right palm and mild contracture of the ring and little fingers. He was not sure just how long these nodules had been present. They had been noted eight to ten months previously when he struck has hand with a wrench. His paternal grandmother and an uncle on his father's side had
11{ichael
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had contracture of the ring and little fingers. Examination showed (Fig. 108, a) thickening of the pretendinous bands to the right middle ring and little fingers, with two heavy nodules in the distal palmar crease at the base of the ring finger. The left hand showed no evidence of disease. The entire palmar fascia was excised without sacrificing any skin, and primary healing was obtained. Five weeks later he had returned to work (Fig. 108, b, c). CASE III. J. L. W., a 57 year old traffic manager of a large transportation system, admitted May 25, 1947, and discharged May 29, 1947, came for relief of contracture of the ring and little fingers of the left hand of some ten years' duration. He first noted a small nodular mass in the palm, which slowly increased in size and was followed by the develop-
a
b
c
Fig. 108 (Case II). a, Before operation September 3, 1948. b, c, After operation October 9, 1948. ment of thickened bands in the palm which slowly pulled the little finger, and to a lesser extent the ring finger into flexion (Fig. 109, a, b). Ten years previously the right hand had shown the same condition and had been operated upon elsewhere. Examination revealed marked puckering of the palmar skin with deep grooves along the distal palmar crease. The pretendinous bands of the palmar fascia to the ring and little fingers were palpably thickened, and that to the little finger extended as a thick mass over the maximal phalanx to the proximal interphalangeal joint crease. There was limitation of extension of all the joints of the little finger and of the metacarpophalangeal joint of the ring finger. Flexion of the distal interphalangeal joints of all the fingers was 5 to 15 degrees less than normal. At operation the palmar portion of the fascia was removed through two incisions, one transversely across the palm at the level of the distal crease, the other skirting the thenar eminence. It was necessary to sacrifice an elliptical area of skin in the palm where deep, long-standing puckering had been present. Excision of the fascia from the volar surface
Dupuytren's Contracture of the distal phalanx of the little finger proved difficult, and a segment of skin was sacrificed here. These two areas were closed with free full thickness skin grafts. Healing was satisfactory. The result at the end of seven months is shown in Figure 109, c, d. CASE IV. H. A. S., a 47 year old sales manager, admitted February 6, 1951, and discharged February 18, 1951, presented himself for surgical correction of a flexion contracture of the right hand. Some four years previously he had noted dimpling develop in the palm of the right hand. associated with what he thought was thickening and hardness of the skin. As time went on, the dimpling and hardness progressed, and the ring finger was drawn downwards into the palm by a dense band of tissue over which the skin was drawn into thick folds. The little finger was likewise drawn toward the palm, but not to the same degree as the ring finger.
a
b
c
d
Fig. 109 (Case III). a, b, Before operation May 26, 1947. c, d, After operation January 1948. During~the past"'year-a similar process was noted in the left palm, but it had _not"'progressed to such~a degree as the right. An older brother had similar changes in his hands, as well as a like process on the sole of the left foot. Otherwise, so far as the patient knew, no other member. of his family was or had been affected. Examination of the right hand (Fig. 110, a, b) revealed a thick band of fascia lying beneath"the skin of the palm and extending from the base distally and in line with the fourth metacarpal to the proximal interphalangeal joint of the ring finger. There was another band palpable and visible running from the region of the distal interphalangeal crease to the radial side of the little finger, and a firm band could be felt along the ulnar side of the base of the middle finger. The distal palmar crease was deep and adherent to underlying fascia, and the skin over the proximal phalanx of the ring finger was thrown into a deep fold or roll. At operation the· palmar fascia was exposed through a transverse incision across the distal palmar crease and a curved incision along the border of the thenar eminence. The skin was carefully dissected free from
Michael L. Mason the surface of the underlying fascia, a procedure that was difficult along the distal palmar crease but easier as the base of the palm was approached. The apex of the fascia was then divided where it took origin from the transverse carpal ligament, drawn distally and brought out through the transverse incision. The deep connections of the fascia were then divided, keeping the digital nerves and vessels constantly in view. The palmar plate of the fascia was then removed, and the prolongation into the ring finger was exposed through an oblique incision on the finger. The overlying skin was carefully dissected free from the underlying fascia, and then the fascial band was removed, likewise with constant visualization of the digital nerves and vessels. No skin was sacrificed, although it was thin in spots. Closure was affected by suture except for a small lozenge-shaped area in the palm into which a free full thickness graft was placed. The pressure dressings were held in place with silk overties. Healing occurred per primum, and the patient was allowed re-
a
b
c
d
e
Fig. 110 (Case IV). a, b, Before operation February 7,1951. c, d, e, After operation April 1951. stricted use of the hand in two and one-half weeks. The condition of the hand two and one-half months after operation is shown in Figure 110, c, d, e. REFERENCES 1. Bode, E.: Ueber die Dupuytruische Kontraktur. Brun's Beitriige z. klin. Chir. 179: 53-64,1949.
2. Bolgert, M.: Maladie de Dupuytren. Coussinets des phalanges. Semaine d. hOp. Paris, 26: 3011-3017, 1950 .• 3. Bruner, J. M.: The Use of Dorsal Skin Flap for the Coverage of Palmar Defects after Aponeurectomy for Dupuytren's Contracture. J. Plastic & Reconstruct. Surg. 4: 559-565, 1949. 4. Buff, H. U.: Bemerkungen zur Therapie der Dupuytrenschen Kontraktur. Helvet. chir. acta 12: 277-280, 1950. 5. Butturini, U. Sulla terapia del morbo di Dupuytren con acetato di alfatocoferolo. Minerva med. 11: 1235-1237, 1950. 6. Chevalier, C. H.: Refiexions a propos de 42 operations pour maladie de Dupuytren. Mem. de l'Acad. de Chir. Paris 77: 248--251, 1951. 7. Fonteux M. and Ripstein, C. B.: Dupuytren's Contracture Associated with Coronary Artery Disease. Canad. M. A. J. 68: 502-504, 1948.
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8. Gordon, S.: Dupuytren's Contraction. Canad. M.A.J. 58: 543-547, 1948. 9. Iselin, M. and Dieckmann, G.: Notre experience du traitement de la maladie de Dupuytren. Mem. de l'Acad. de Chir. Paris 77: 251-255, 1951. 10. King, R. A.: Vitamin E Therapy in Dupuytren's Contracture. Examination of the Claim that Vitamin Therapy Is Successful. J. Bone & Joint Surg. S1B: 443, 1949. 11. Langston, R. G. and Badre, E. J.: Dupuytren's Contracture. Canad. M. A. J. 58: 57-61, 1948. 12. Skoog, T.: Dupuytren's Contraction. Acta chir. Scandinav. 96: Suppl. 139, 1948. 13. Thomsen, G.: Treatment of Dupuytren's Contracture with Vitamin E. Brit. M. J. 2: 1382-1383, 1948. 14. Thomsen, W.: Technisches zur Behandlung der Dupuytrenschen Fingerkontraktur. Der Chirurg. 21: 359-361, 1950.
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