The Hand - Dupuytren Foundation

The Hand 

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Dupuytren's Contracture−−The Role of Fasciotomy 

J. COLVILLE 

Hand 1983 os-15: 162 

DOI: 10.1016/S0072-968X(83)80008-4 

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Dupuytren's Contracture-- The Role of Fasciotomy 

J. Colville 

DUPUYTREN'S CONTRACTURE--THE ROLE OF FASCIOTOMY 

J. COLVILLE, Belfast 

SUMMARY 

This paper summarises the results obtained in 95 patients treated by 

fasciotomy, defines the indications for this procedure and describes the operative 

technique. During a period of seven years a total of 95 patients with 137fingers 

affected by Dupuytren's' Contracture have been treated by fasciotomy. The 

minimum follow-up is two years. The oldest patient was 79 years and no patient 

younger that 50 years was accepted for this form of treatment. 

With lengthening active life span increasing numbers of elderly people now 

present for correction of Dupuytren's contracture, In many cases it is interference 

with a sport or hobby which stimulates this. After treating a number of these 

patients by fasciotomy alone it became apparent that in a proportion of cases the 

results were outstandingly good. It seems reasonable to offer suitable patients this 

simple procedure which does not involve risk and which causes minimal 

inconvenience. 

INDICATIONS FOR FASCIOTOMY 

The following factors are considered important in deciding whether or not this 

line of treatment should be adopted:-- 

Type of band: This must be disposed in a linear,direction and preferably cord=like. 

Any lateral extensions such as seen in the plaque type of Dupuytren's involvement 

found in epileptics or more common in the younger age group is a definite contraindication. 

Extensions from the main band to the deeper structures of the palm 

prevent bow-stringing of the band and the absence of bow-stringing is therefore 

considered a contra-indication. Conversely the appearance of a well-marked bowstringing 

indicates an absence of deep nattachments and is a favourable indication. 

Overlying skin: Ideally the skin should be separated from the band by subcutaneous 

fat which is not affected by the Dupuytren's process. Extensive attachment between 

the skin and the underlying band prevents an effective fasciotomy and contraindicates 

the procedure. A limited degree of adhesion between the band and the 

overlying skin can be corrected at the time of the fasciotomy and does not contraindicate 

the procedure. Occasionally a band may be suitable for fasciotomy at the 

palmar level but because of skin adhesion in the proximal phalanx it may not be 

suitable at this level. 

Age or infirmity: Because of the progressive nature of the disease our general policy 

is to perform fasciectomy on those under the age of sixty years unless the 

Dupuytren's bands are particularly ideal for fasciotomy. Dupuytren's contracture in 

young adults and epileptics must be dealt with by fasciectomy. Some very elderly 

patients had fasciotomy in spite of having a type of Dupuytren's band that was not 

really suitable for such a procedure. This was relatively indicated in view of the 

simplicity of the procedure and the expectation of modest benefit. 

J. Colville, F.R.C.S. The Ulster Hospital, Dundonald, Belfast, Northern Ireland 

162 The Hand-- Volume 15 No. 2 1983 



J. Colville 

Fig. 1. Enlarged view of modified No. 11 blade. 

Preliminary to Fasciectomy: In some hands, with severe contracture, and where 

there is a shortage of palmar skin there is some advantage in a preliminary 

fasciotomy to stretch the skin in preparation for a definitive removal of the 

Dupuytren's tissue by fasciectomy. It should be stressed that the fasciectomy 

performed after such a fasciotomy is somewhat more difficult although the skin 

closure is facilitated. This was done in three patients not included in the series. 

OPERATIVE TECHNIQUE 

The operation is carried out as an out-patient procedure. A tourniquet is not 

necessary. The skin in the area of the hand to be released is infiltrated with 2 per cent 

plain Lignocaine. Three areas of release are usually employed. The first is proximal 

to the distal palm crease, the second proximal to the web crease and the third 

proximal to the proximal interphalangeal joint crease. A number 11 surgical blade 

which has been modified as shown on the accompanying diagram is inserted into the 

skin lateral to the band. The blade is held horizontally and by a series of sweeping 

arcs the skin distal to the proposed point of fasciotomy is freed from the underlying 

band. There is no point in freeing the skin proximal to the point of the fasciotomy. 

In some instances the skin has corrugated over the contracted bands and this is a 

particularly favourable situation since the corrugations open out to provide an extra 

supply of skin when the band is divided. At each level of division, having satisfied 

oneself that there is sufficient mobility of the overlying skin, the fasciotomy is then 

undertaken. The blade is turned vertically and gently applied to the band which is 

held in tension. The sense of cutting through this band is more a scratching process 

rather than a cutting process and the band tends to cut itself against the lightly 

applied point of the blade rather than a purposeful incision movement of the blade. 

A gratifying snapping can be felt and sometimes heard when the band has been 

successfully divided and the retreat of the distal end of the divided band under the 

freed skin can sometimes be observed. The procedure of freeing the skin and 

division of the Dupuytren's band is repeated at the distal palm crease level and then 

if necessary at the proximal phalangeal level. The finger is extended until the skin 

tension is the limiting factor. Occasionally, where the skin has been locally adherent 

to the band and has been separated it may rupture and a small transverse wound so 

caused may, under tension, become longitudinally orientated producing what could 

be described as a 'Diamond-plasty'. A single transverse suture across the diamondplasty 

may be used to close this small wound although this is not essential. Various 

types of Fasciotomes have been tried but I have reverted to the modified Swann 

Morton No. 11 Blade. This has the advantage of rigidity and the operator retains a 

feeling of contact with the cutting part of the blade. This contact with the cutting 

The Hand-- Volume 15 No. 2 1983 163 



J. Colville 

end of the instrument is less well appreciated when using a more flexible and slender 

fasciatome. The orientation of the cutting edge can be a problem if there is nothing 

to indicate this on the handle, but this is not so when using the conventional scalpel 

handle and No. 11 Blade. 

Following the release of the contracture the hand is dressed conventionally and 

immobilised in a plaster-of-Paris gutter slab retaining as much extension 

improvement as possible. The patient is next seen one week later when the dressings 

are removed and the wound is invariably dry and healed. A fresh lightly padded 

plaster-of-Paris slab is again re-made and applied snugly to the bare arm and 

forearm with the fingers in as much extension as possible. When this has become 

sufficiently rigid it is removed and carefully placed in a bag with one or two crepe 

bandages. The patient does not require any further dressing and is given the new 

splint to take home carefully and is instructed to bandage this to his hand and 

forearm each night before retiring. The patient is also instructed to report if either 

the plaster becomes damaged or if further extension is achieved requiring a more 

closely fitting splint. One patient, a female with 120 ~ contracture which had 

improved to a 45 ~ contracture position reported three weeks later with her finger 

almost completely extended. Splintage is normally discarded after a period of three 

months. Invariably the patient can immediately start using the hand after the plaster 

has been removed at the first post-operative attendance. There has rarely been any 

cases of hand swelling or other cause for morbidity. 

In this series and in all other patients who have had fasciotomy performed there 

has not been any instance of haematoma or infection and nor has there been 

evidence of permanent damage to digital nerves. Some patients mention tingling of 

the fingers for a number of weeks presumably due to stretching of the digital nerves, 

but this invariably recovers. 

RESULTS 

TABLE 1 

AVERAGE OF ALL CONTRACTURES IN 137 FINGERS EXPRESSED AS DEGREES OF 

EXTENSION DEFICIT FROM THE PLANE OF THE METACARPAL 

1tamed. 

3 Years 

Pre-op Post-op 3 months 6months 1year (For 107Fingers) 

102 ~ 45 ~ 31 ~ 50 ~ 56 ~ 75 ~ 

The improvement of an average of 14 ~ from the immediate post-operative 

improvement to the three month position is due to the fact that in some cases there was 

quite a marked improvement obtained by the splintage which was regarded as an 

essential adjunct to operation. The three year follow-up was chosen since beyond this 

period many elderly patients did not wish to attend. The results in this column appear 

somewhat disappointing but this is exaggerated because those whose hands were 

satisfactory tended not to re-attend and those whose hands were less satisfactory were 

more inclined to report for further follow-up. 




J. Colville 

TABLE 2 

TWENTY CASES WITH THE BEST RESULTS (29 digits) 

Average Average Average Average Average Average 

Pre-op Pos~op 3months 6months 1 year 3 years 

104 ~ 26 ~ 23 ~ 23 ~ 30 ~ 32 ~ 

Nine of the total had less than 20 ~ extension deficit three years after their 

fasciotomy. The twenty cases with the worse results had all relapsed within one year. 

DISCUSSION 

It is rather surprising to find that there are only a few published references to 

fasciotomy when one considers the numerous publications on fasciectomy. In 

discussion with colleagues I get the impression that many hand surgeons 

occasionally perform a fasciotomy but there does not seem to be any attempt to 

establish the indications for this procedure. There is undoubtedly a place for such a 

procedure in selected patients and a permanent recovery of effective extension is 

expected. 

Since all patients were warned at first consultation that the procedure might 

have to be repeated within two or three years there was no disappointment in those 

who required a repetition of the fasciotomy after such a period, although where the 

indications were ideal this was seldom required. There was also a number of patients 

in this series whose indications for fasciotomy were not ideal but these patients were 

accepted for this procedure because of concomitant medical or surgical problems 

that contra-indicated fasciectomy. In this category there were three patients with an 

uncertain prognosis due to neoplasm elsewhere and there was also a number of 

patients particularly in the more elderly group, who had heard of such a procedure 

and who were willing to submit themselves to a minor operation only, in spite of 

having been warned that, in their particular case, this might not be very successful. 

Recurrence of the contracture is an accepted penalty for such a simple 

operation. The repeat fasciotomy is not so satisfactorily performed but nevertheless 

has a useful place in treatment and certainly the patients accept this more readily 

than the prospect of a more complicated operation requiring hospitalisation. 

It is paradoxical that the more contracted the finger, the shorter the 

Dupuytren's band and the smaller the block of Dupuytren's tissue causing the 

contracture. Once this band has been divided and its attachments freed, it is not 

difficult to envisage an excursion of 2cm, distal progression of the divided band. A 

student of tendon mechanics in the hand will realise that this represents about 180 ~ 

of finger joints range. 

Historically Sir Astley Cooper (1823) and Dupuytren (1832) also recommended 

fasciotomy and at a later date Adams in 1878 and McCready 1890 referred to this as 

a useful procedure. Since that time there have been incidental references to the 

procedure and most authors, in dealing with the subject of Dupuytren's contracture 

have paid lip service to the place of fasciotomy. Apart from suggesting that this is a 

reasonable procedure in the elderly there has not been any attempt to define its 

precise indications. 

Luck (1959) in his article on fasciotomy advocated removal of the nodule as 

well as division of the band as an essential part of the operation. I was not aware of 

his recommendations until my own results were apparent and since these seemed 

The Hand-- Volume 15 No. 2 1983 165 



J. Colville 

satisfactory without nodule excision, I could not therefore recommend converting 

what was a very simple procedure into one that would have been much more 

complicated. Luck also advised that the subcutaneous fasciotomy should be restricted 

to the palm but I have no hesitation in advocating fasciotomy in the proximal phalanx 

pro vided the band is well de fin ed and bo w-stringing. Th ere are many instances in which 

fasciotomy is contra-indicated in the proximal phalanx and I can well appreciate 

Tubiana's (1974) recommendation that fasciotomy is contra-indicated at this level. 

Gonzalez (1974) emphasised the value of the inter-position of a full thickness skin 

graft as a means of preventing the divided ends of the Dupuytren's band from becoming 

reattached. However, I would suggest that where the band is reasonably surrounded by 

uninvolved fat, if the separated ends can be maintained in this position for a reasonable 

time this fat will serve to separate permanently the ends of the band provided no other 

unyielding tissue, such as scar or further Dupuytren's tissue, re-approximates these 

ends. 

I have not personally used the enzymic fasciotomy first described by Bassot (1965) 

and later by Hueston (1974). I doubt if this can improve on what would be more simply 

achieved by subcutaneous fasciotomy, in the manner described in this article. It is my 

opinion that about 10~ of patients develop a type of Dupuytren's tissue which 

progresses to a situation where the contracting band is very similar to a tendon. If this is 

found or if a similar situation can be created and if there is soft uninvolved fat available 

to fill the gap between the distracted ends of the divided Dupuytren's band and if these 

can be kept separate for a sufficient length of time there is a good prospect of a 

permanent and useful recovery of extension. 

CONCLUSION 

I am confident that there is a limited place for fasciotomy to supplement the well 

established procedure of fasciectomy in the treatment of Dupuytren's disease of the 

hand. If the indications for this are met, then there is a reasonable expectation of 

recovery of useful extension which, even if not permanent may only require a further 

similar treatment after a number of years, If the surgeon is ultra-selective, results as 

good as fasciectomy are possible in a small percentage of all cases presenting. 

REFERENCES 

ADAMS, W. (1878). Contraction of the Fingers (Dupuytren's Contraction) and Its Successful 

Treatment by Subcutaneous Divisions of the Palmar Fascia and Immediate Extension. 

British Medical Journal 1: 928. 

BASSOT, J. (1965). Traitment de la maladie de Dupuytren par ex6rbse pharmacodynamique isol6e 

ou compl&6e par un temps plastique uniquement cutan6. Lille Chirurgical 20, 38. 

COO/~ER, ASTLEY. A Treatise on Dislocations and on Fractures of the Joints. London, Longman, 

Hurst, Rees, Orme and Browne, 1823. 

DUPUYTREN, GUILLAUME: Lecons orales de clinique chirugicale faites a l'Hotel-Dieu de Paris. 

Vol. I. Chap. 1. Paris. Germer Bailli6re. 1832. 

GONZALEZ, RICHARD I. Open Fasciotomy and Full Thickness Skin Graft in The Correction 

of Digital Flexion Deformity. Dupuytren's Disease. Hueston J. T. and Tubiana R. Churchill 

Livingstone (1974) 123-127. 

HUESTON, JOHN T. Enzymic Fasciotomy. Dupuytren's Disease, Hueston J. T. and Tubiana R. 

Churchill Livingstone. 1974 141-143, 

LUCK, J. N. (1959). Dupuytren's Contracture. A New Concept of the Pathogenesis Correlated with 

Surgical Management. The Journal of Bone and Joint Surgery. 41A: 635-664, 

MACREADY, J. (1890). On the Treatment of Dupuytren's Contracture of the Palmar Fascia. 

British Medical Journal I: 411-414. 

TUBIANA R. and THOMINE J. M., Surgical Treatment of Dupuytren's Contracture: Technique of 

Fasciotomy and Fasciectomy. Dupuytren's Disease. Hueston J. T. and Tubiana R. Churchill 

Livingstone 1974 85-92.

The Hand - Dupuytren Foundation

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