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Surgical Correction of Dupuytren’s Contracture
Surgical Correction of Dupuytren's Contracture HOWARD R. CRAWFORD
THE treatment of Dupuytren's contracture becomes surgical when the fingers are forcefully drawn into the palm in spite of conservative measures directed at stretching and maintaining finger extension. Surgical excision of palmar nodules or linear thickening of the palmar fascia is not indicated unless finger flexion is progressive. Multiple measures can be used to avert surgery. Active finger stretching and extension, massage of palmar and finger skin, and simple adhesive tongue-blade splints can be used to delay and even prevent finger contraction. The tongue-blade, long condemned as a routine finger splint, can be used to advantage as a dorsal finger splint either before or after surgical correction of contracted palmar fascia. A simple adhesive loop, sponge rubber pressure pad and gauze tie quickly make an effective splint for night use in either the conservative or postsurgical treatment of Dupuytren's contracture (Fig. 261). The palmar fascia is the expansion and insertion of the palmaris longus tendon. Its fibers not only are longitudinal but also many are transverse; the latter unite the divergent longitudinal rays into a subcutaneous fibrous web. On the palmar surface many fibers are present which anchor it to the skin. These fibers interlace about subcutaneous fatty tissue and are the means by which the palmar skin maintains its normal concavity. On the deep surface of the palmar fascia, eight vertical septa divide the palm into compartments or tunnels which contain the flexor tendons, lumbricalis muscles, and neurovascular bundles. As each fascial ray enters its respective finger, it spreads and inserts both subcutaneously as a linear midline band along the axis of the finger, and deeply to embrace the flexor tendon sheath and neurovascular bundles as far distally as the middle phalanx. It inserts on the lateral surfaces of the proximal and middle phalanges. In the early stages of the process, the spreading rays of the palmar fascia develop nodular thickening, the bands stand out and the overlying skin becomes adherent. The skin loses much of its normal elasticity, a 793
Howard R. Crawford
794
result of gradual loss of the subcutaneous fatty tissue. The same process occurs in the terminal portions of the fascial bands in the bases of the fingers. This fascial contracture and thickening is the cause of the flexion deformity in the proximal interphalangeal joint. As these deformities become fixed, capsular changes and subluxation of the proximal interphalangeal joints occur. If these changes are allowed to take place, surgical correction becomes more difficult, and at times the interphalangeal joints never regain complete function. If the proximal interphalan- . Fig. 261.
Fig. 262.
Fig. 263. Fig. 261. A simple tongue-blade splint can be used singly or in pairs to extend the ring and little fingers once wound healing is complete. Fig. 262. Midlateral finger incision and curved incisions paralleling distal palmar and thenar creases are sufficient for extensive palmar fascial excision. Fig. 263. A massive pressure type dressing is applied which extends well up the forearm and down and over the wrist and hand to immobilize the metatarsophalangeal and proximal interphalangeal joints.
geal contracture and luxation are severe, correction cannot be obtained and amputation oftentimes is indicated. The surgical procedure is carried out under controlled tourniquet hemostasis of the blood pressure or compressed gas type, never of the Esmarch type. Access to the palmar fascia is best made through multiple incisions. In the palm, an incision paralleling the thenar crease, and a second one paralleling the distal palmar crease usually give adequate exposure. The sharp angle of the L shaped palmar incision can be avoided in this manner. This sharp angle is objectionable many times because it delays healing of the skin. The finger portions can be adequately excised through lateral incisions. These should be placed well dorsally because
Surgical Correction of Dupuytren's Contracture
795
when ventral to the axis of the bone, postoperative contractures tend to develop in the scars. These, of course, will prevent the patient from regaining normal extension in the metatarsophalangeal and proximal interphalangeal joints. Both ulnar and radial incisions can be made on an individual finger in order to excise the fascia adequately. At times it is difficult to avoid "buttonholing" the skin because of the scarcity of subcutaneous tissue (Fig. 262). Once the palmar fascia and its finger prolongations are removed, the metatarsophalangeal and interphalangeal joint motions can be accurately determined. Usually the metatarsophalangeal motion is complete and the proximal interphalangeal motion limited in the last 20 to 30 degrees of extension. Capsulotomy of the proximal interphalangeal joint adds little increase in motion at the time and seems to decrease the motion postoperatively as healing proceeds. The gaping skin wounds in the palm and the stretched volar skin of the fingers are disregarded in assessing the probable outcome of the procedure. If the fingers can be extended to near normal at this stage, active motion to this degree can be regained by the patient postoperatively. For this reason, it is felt that skin grafts are not indicated because they add more scar tissue to the palm and postoperative function seems to return easily without them. The fingers are allowed to flex until the skin wounds can be closed easily. Unless the procedure is unduly long, the tourniquet is not released until the wounds are closed and a massive pressure dressing is applied over the palm and fingers (Fig. 263). This dressing extends well distally to incorporate the metatarsophalangeal and proximal interphalangeal joints and terminates in the area of the middle phalanges. Such a dressing allows active finger motion in the distal interphalangeal joint and to a lesser degree in the proximal interphalangeal joint. Objection can be raised to this type of procedure and dressing because it does invite some danger of excessive bleeding and hematoma, but these have not occurred frequently. There seems to be less danger in proceeding in this manner than in releasing the tourniquet and controlling bleeding before the dressing is applied. This procedure at times requires insertion of a drain and its removal in 24 hours. The dressing is left in place for ten days. During this time active finger motions are encouraged, elevation is carried out routinely and the patient is generally comfortable. If skin healing is adequate at the end of the ten day period, a smaller type of dressing is applied and warm hand soaks and more active finger flexion can even be started. No active stretching of the fingers is begun until the skin wounds are firm. The patient can then start actively to extend the affected finger to the limits of pain. As extension increases, the posterior tongue-blade splint or splints can be used at night to maintain the extension gained. Patients have found various means to aid in gaining extension. Those who work at desk positions can learn to slip the hand
796
Howard R. Crawford
Fig. 264. a, Preoperative photograph. A dense bandlike contracture mass of progressive nature spanning the palm and extending up into the proximal phalangeal level of the ring finger had resisted all efforts to correct it. b, Condition two and one-half years after operation, showing normal extension of the ring finger.
under their buttocks and actively stretch the fingers by varying the weight on the dorsum of the hand. It is well to remember that if the fingers extended to near normal at the completion of the fascial excision, after operation the skin will usually accommodate to this by gradual stretching once the wound edges are well healed. Through this period there is diffuse swelling of the hand and fingers, especially about the metatarsophalangeal and interphalangeal joints.
Fig. 265. a, Preoperative photograph. A dense band similar to that shown in Figure 264 stretches across the palm of the hand into the base and even to the middle phalangeal level of the ring finger. b, Two years after operation. Normal flexion and residual flexion deformity in the proximal interphalangeal joint of the ring finger are shown.
Fig. 266. Severe deformity in both ring and little fingers. Note hyperextension of proximal interphalangeal joint of ring finger. This was a recurrence following excision of the palmar fascia more than three years earlier. To date correction has remained complete following a second radical excision of palmar fascia.
797
798
Howard R. Crawford
Routine measures of elevation and massage will help, but the most effective measure is continued active and passive exercises carried out by the patient. These patients are not given routine physical therapy because in the majority of cases their postoperative care can and should be managed by the patients themselves.
Fig. 267. a, The deformity of the little finger is severe and was not corrected by mUltiple subcutaneous divisions of the fascial band. This finger will be amputated at the metacarpal level. b, The ring finger of the other hand has been adequately corrected and the correction maintained.
Figures 264 to 267 show typical examples of Dupuytren's contracture, both preoperatively and postoperatively. In summary, it is well to emphasize that the palmar fascia should be adequately dissected and this dissection, must extend through the palm into the fingers, removing as much as possible of this fibrous tissue. Skin grafts have not been used routinely to bridge gaping wound defects after contracture of the fingers has been corrected. In the majority of cases
Surgical Correction of Dupuytren's Contracture
799
these hands can be restored to usefulness. By means of simple measures carried out by the patient, not only will adequate motion be regained in the affected fingers but also motion gained by the surgical procedure will be maintained postoperatively. Simple night splints also aid in maintaining finger extension. It is well to remember that correction of a flexed finger by producing extension is of little value if the finger cannot be flexed again. REFERENCES 1. Bunnell, S.: Surgery of the Hand. Ed. 2. Philadelphia, J. B. Lippincott Co., 1948. 2. Mason, M. L.: Dupuytren's contracture. S. CLIN. NORTH AMERICA 32: 233-245 (Feb.) 1952. 3. Meyerding, H. W.: Dupuytren's contracture. Arch. Surg. 32: 320-333 (Feb.) 1936. 4. Meyerding, H. W.: The treatment of Dupuytren's contracture. Am. J. Surg. 4£): 94-103 (July) 1940.
THE treatment of Dupuytren's contracture becomes surgical when the fingers are forcefully drawn into the palm in spite of conservative measures directed at stretching and maintaining finger extension. Surgical excision of palmar nodules or linear thickening of the palmar fascia is not indicated unless finger flexion is progressive. Multiple measures can be used to avert surgery. Active finger stretching and extension, massage of palmar and finger skin, and simple adhesive tongue-blade splints can be used to delay and even prevent finger contraction. The tongue-blade, long condemned as a routine finger splint, can be used to advantage as a dorsal finger splint either before or after surgical correction of contracted palmar fascia. A simple adhesive loop, sponge rubber pressure pad and gauze tie quickly make an effective splint for night use in either the conservative or postsurgical treatment of Dupuytren's contracture (Fig. 261). The palmar fascia is the expansion and insertion of the palmaris longus tendon. Its fibers not only are longitudinal but also many are transverse; the latter unite the divergent longitudinal rays into a subcutaneous fibrous web. On the palmar surface many fibers are present which anchor it to the skin. These fibers interlace about subcutaneous fatty tissue and are the means by which the palmar skin maintains its normal concavity. On the deep surface of the palmar fascia, eight vertical septa divide the palm into compartments or tunnels which contain the flexor tendons, lumbricalis muscles, and neurovascular bundles. As each fascial ray enters its respective finger, it spreads and inserts both subcutaneously as a linear midline band along the axis of the finger, and deeply to embrace the flexor tendon sheath and neurovascular bundles as far distally as the middle phalanx. It inserts on the lateral surfaces of the proximal and middle phalanges. In the early stages of the process, the spreading rays of the palmar fascia develop nodular thickening, the bands stand out and the overlying skin becomes adherent. The skin loses much of its normal elasticity, a 793
Howard R. Crawford
794
result of gradual loss of the subcutaneous fatty tissue. The same process occurs in the terminal portions of the fascial bands in the bases of the fingers. This fascial contracture and thickening is the cause of the flexion deformity in the proximal interphalangeal joint. As these deformities become fixed, capsular changes and subluxation of the proximal interphalangeal joints occur. If these changes are allowed to take place, surgical correction becomes more difficult, and at times the interphalangeal joints never regain complete function. If the proximal interphalan- . Fig. 261.
Fig. 262.
Fig. 263. Fig. 261. A simple tongue-blade splint can be used singly or in pairs to extend the ring and little fingers once wound healing is complete. Fig. 262. Midlateral finger incision and curved incisions paralleling distal palmar and thenar creases are sufficient for extensive palmar fascial excision. Fig. 263. A massive pressure type dressing is applied which extends well up the forearm and down and over the wrist and hand to immobilize the metatarsophalangeal and proximal interphalangeal joints.
geal contracture and luxation are severe, correction cannot be obtained and amputation oftentimes is indicated. The surgical procedure is carried out under controlled tourniquet hemostasis of the blood pressure or compressed gas type, never of the Esmarch type. Access to the palmar fascia is best made through multiple incisions. In the palm, an incision paralleling the thenar crease, and a second one paralleling the distal palmar crease usually give adequate exposure. The sharp angle of the L shaped palmar incision can be avoided in this manner. This sharp angle is objectionable many times because it delays healing of the skin. The finger portions can be adequately excised through lateral incisions. These should be placed well dorsally because
Surgical Correction of Dupuytren's Contracture
795
when ventral to the axis of the bone, postoperative contractures tend to develop in the scars. These, of course, will prevent the patient from regaining normal extension in the metatarsophalangeal and proximal interphalangeal joints. Both ulnar and radial incisions can be made on an individual finger in order to excise the fascia adequately. At times it is difficult to avoid "buttonholing" the skin because of the scarcity of subcutaneous tissue (Fig. 262). Once the palmar fascia and its finger prolongations are removed, the metatarsophalangeal and interphalangeal joint motions can be accurately determined. Usually the metatarsophalangeal motion is complete and the proximal interphalangeal motion limited in the last 20 to 30 degrees of extension. Capsulotomy of the proximal interphalangeal joint adds little increase in motion at the time and seems to decrease the motion postoperatively as healing proceeds. The gaping skin wounds in the palm and the stretched volar skin of the fingers are disregarded in assessing the probable outcome of the procedure. If the fingers can be extended to near normal at this stage, active motion to this degree can be regained by the patient postoperatively. For this reason, it is felt that skin grafts are not indicated because they add more scar tissue to the palm and postoperative function seems to return easily without them. The fingers are allowed to flex until the skin wounds can be closed easily. Unless the procedure is unduly long, the tourniquet is not released until the wounds are closed and a massive pressure dressing is applied over the palm and fingers (Fig. 263). This dressing extends well distally to incorporate the metatarsophalangeal and proximal interphalangeal joints and terminates in the area of the middle phalanges. Such a dressing allows active finger motion in the distal interphalangeal joint and to a lesser degree in the proximal interphalangeal joint. Objection can be raised to this type of procedure and dressing because it does invite some danger of excessive bleeding and hematoma, but these have not occurred frequently. There seems to be less danger in proceeding in this manner than in releasing the tourniquet and controlling bleeding before the dressing is applied. This procedure at times requires insertion of a drain and its removal in 24 hours. The dressing is left in place for ten days. During this time active finger motions are encouraged, elevation is carried out routinely and the patient is generally comfortable. If skin healing is adequate at the end of the ten day period, a smaller type of dressing is applied and warm hand soaks and more active finger flexion can even be started. No active stretching of the fingers is begun until the skin wounds are firm. The patient can then start actively to extend the affected finger to the limits of pain. As extension increases, the posterior tongue-blade splint or splints can be used at night to maintain the extension gained. Patients have found various means to aid in gaining extension. Those who work at desk positions can learn to slip the hand
796
Howard R. Crawford
Fig. 264. a, Preoperative photograph. A dense bandlike contracture mass of progressive nature spanning the palm and extending up into the proximal phalangeal level of the ring finger had resisted all efforts to correct it. b, Condition two and one-half years after operation, showing normal extension of the ring finger.
under their buttocks and actively stretch the fingers by varying the weight on the dorsum of the hand. It is well to remember that if the fingers extended to near normal at the completion of the fascial excision, after operation the skin will usually accommodate to this by gradual stretching once the wound edges are well healed. Through this period there is diffuse swelling of the hand and fingers, especially about the metatarsophalangeal and interphalangeal joints.
Fig. 265. a, Preoperative photograph. A dense band similar to that shown in Figure 264 stretches across the palm of the hand into the base and even to the middle phalangeal level of the ring finger. b, Two years after operation. Normal flexion and residual flexion deformity in the proximal interphalangeal joint of the ring finger are shown.
Fig. 266. Severe deformity in both ring and little fingers. Note hyperextension of proximal interphalangeal joint of ring finger. This was a recurrence following excision of the palmar fascia more than three years earlier. To date correction has remained complete following a second radical excision of palmar fascia.
797
798
Howard R. Crawford
Routine measures of elevation and massage will help, but the most effective measure is continued active and passive exercises carried out by the patient. These patients are not given routine physical therapy because in the majority of cases their postoperative care can and should be managed by the patients themselves.
Fig. 267. a, The deformity of the little finger is severe and was not corrected by mUltiple subcutaneous divisions of the fascial band. This finger will be amputated at the metacarpal level. b, The ring finger of the other hand has been adequately corrected and the correction maintained.
Figures 264 to 267 show typical examples of Dupuytren's contracture, both preoperatively and postoperatively. In summary, it is well to emphasize that the palmar fascia should be adequately dissected and this dissection, must extend through the palm into the fingers, removing as much as possible of this fibrous tissue. Skin grafts have not been used routinely to bridge gaping wound defects after contracture of the fingers has been corrected. In the majority of cases
Surgical Correction of Dupuytren's Contracture
799
these hands can be restored to usefulness. By means of simple measures carried out by the patient, not only will adequate motion be regained in the affected fingers but also motion gained by the surgical procedure will be maintained postoperatively. Simple night splints also aid in maintaining finger extension. It is well to remember that correction of a flexed finger by producing extension is of little value if the finger cannot be flexed again. REFERENCES 1. Bunnell, S.: Surgery of the Hand. Ed. 2. Philadelphia, J. B. Lippincott Co., 1948. 2. Mason, M. L.: Dupuytren's contracture. S. CLIN. NORTH AMERICA 32: 233-245 (Feb.) 1952. 3. Meyerding, H. W.: Dupuytren's contracture. Arch. Surg. 32: 320-333 (Feb.) 1936. 4. Meyerding, H. W.: The treatment of Dupuytren's contracture. Am. J. Surg. 4£): 94-103 (July) 1940.