Subcutaneous fasciotomy, partial fasciectomy for dupuytren contracture

Surgical procedures commonly used in treating Dupuytren contracture are: (1) subcutaneous or percutaneous fasciotomy, (2) partial (selective) fasciectomy, (3) complete fasciectomy, (4) fasciectomy with skin grafting, (5) amputation, and (6) joint resection and arthrodesis. The appropriate procedure depends on the degree of contracture, nutritional status of the palmar skin, the presence or absence of bony deformities, and the patient’s age, occupation, and general health. The least extensive procedure, subcutaneous fasciotomy, is used in patients with well-defined cords (those with distinct pretendinous cords) regardless of age, but especially in elderly who are not concerned with the appearance of the palpable remaining disease or in patients who have poor general health. The results of this procedure are better in the residual phase, when dense, mature cords are present, than when the lesions are more immature and diffuse. Partial (selective) fasciectomy is usually indicated when only the ulnar one or two fingers are involved.

Subcutaneous fasciotomy

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Using a pointed scalpel, make skin puncture wounds on the ulnar side of the diseased palmar fascia at the following levels: (1) just distal to the apex of the palmar fascia between the thenar and hypothenar eminences, (2) at or near the level of the proximal palmar crease, and (3) at the level of the distal palmar crease. Digital nerves are more likely to be injured at the distal palm where they become more superficial and may be intertwined with the diseased tissue ( Fig. 37.1 ).
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Insert a small tenotomy knife, with its blade parallel with the palmar skin, through each of the puncture wounds. A 15- or 11-blade scalpel works satisfactorily for this purpose ; however, sterile 18-, 22-, or 25-gauge hypodermic needles may alternately be used for the same purpose of releasing the tight fascial cords. Pass the cutting instrument across the palm beneath the skin but superficial to the fascia ( Fig. 37.2 ).
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Turn the edge of the blade dorsally toward the palmar fascia and extend the fingers to tighten and raise the involved tissue. Carefully divide the fascial cords by pressing the blade onto the tense cords with gentle downward pressure over the blade or at most a gentle rocking motion; never use a sawing motion. Whenever a cord is divided, the sense of gritty, firm resistance disappears, indicating that the blade has passed completely through the diseased fascial cord ( Fig. 37.3 A , palmar fascia; B , neurovascular bundle; C , flexor tendons; D , metacarpal).
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Keep the blade in a plane parallel with skin and free the skin from the underlying fascia. The corrugated skin, although very thin at times, can be safely undermined and released as necessary with little fear of skin necrosis ( Fig. 37.4 ).
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In the fingers, subcutaneous fasciotomy is safe for a fascial cord located in the midline. Insert the blade through a puncture wound adjacent to the cord and divide it vertically.
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For a laterally placed cord, use a short longitudinal incision, and excise or divide the diseased segment under direct vision. Also enucleate larger nodules in both fingers and palm under direct vision.