DUPUYTREN’S CONTRACTION.
Dupuytren’s contraction presents the most serious and insidious appearance of slow but almost irresistible contraction of fibrous elements which the human body presents. It is produced by contraction of the palmar fascia, with its numerous minute prolongations, rather than by flexor tendons. It is seen in the hands of men who from the nature of their occupations are subject to much irritation of the palmar surface. It begins nearly always in the fourth or fifth fingers, but may spread to and involve all the digits and even the thumb. The view held by Adams and others that it is a chronic hyperplastic inflammation, with scar-tissue contraction of the palmar fascia and of the adjoining connective and fatty tissue, which does not involve them evenly, but only at certain points, is correct, at least when small nodules may be felt in the palm which are the precursors of the disease. Either hand may be affected, but generally both are involved. It is found in from 1 to 2 per cent. of those who depend upon their hands for their support. Deformity may proceed to pressure dislocation and finally to ankylosis. Its causation then is very obscure; it is rarely the result of definite injury, but follows continued irritation of the surface. It seems to have a local origin, and yet it is frequently associated with the gouty diathesis to such an extent that the prolonged use of alkalies will relieve some cases. The first significant sign of the condition is the formation of small nodules in the palm of the hand, as stated, and this usually precedes the finger contraction by a year or two.
Fig. 110
Dupuytren’s contraction. (Adams.)
Fig. 111
Dupuytren’s contraction of palmar fascia, showing contracted fingers. (Burrell.)
Treatment.
—There is considerable difficulty in treating these cases satisfactorily. Cooper advised subcutaneous division of the tense bands and forcible stretching of the fingers; this rarely proves sufficient. Adams advocated multiple sections made with a small tenotome, which is more effective. The best method is that of Kocher, which consists in excision of the fascial bands by longitudinal incisions along the cords, and the dissection of the skin from the underlying fascia. The cord is carefully dissected, with its prolongations and then completely removed, while the margins of the skin wounds are closed with sutures. The more thoroughly the dissection is performed the more satisfactory the result. The fingers should be straightened and kept from contraction by the use of a mechanical device. In desperate cases the entire skin of the palm has been removed, with the diseased fascia, and a plastic operation made with skin taken from the thigh or the chest, the flap being sutured in place but not detached completely for ten to twelve days.