The deformities of the fingers and toes

by William Anderson

The therapeutical measures now eligible may be briefly enumerated:

Non-operative treatment.—There is no doubt that in the milder cases and when the morbid process has come to a standstill, a considerable improvement may be effected by massage and persevering extension. I have seen in a patient of seventy the fourth and fifth fingers brought from an angle of 90° with the palm nearly to a straight line within a year, but the contraction relapsed completely in three months, when a severe illness made it necessary to suspend the treatment.

We have heard much of the wonders effected by hypnotism during the latter days, but the surgeon hardly expected to be told that Dupuytren’s contraction, of all diseases, could be cured by “suggestion.” Yet in a recent volume of one of our medical journals we find a practitioner gravely claiming a successful result for this treatment in a case of the kind; a curious demonstration of the survival, at the end of the nineteenth century, of the peculiar mental condition that brought patients to the feet of Greatrakes and Perkins in a bygone generation.

The Operative measures may be divided into three classes: subcutaneous, open, and plastic.

The Subcutaneous method deserves the first place. Mr. Adams’s operation consists in the subcutaneous division of all the contracted bands of fascia which can be felt; “the bands to be divided by several punctures with the smallest fascia knife passed under the skin and cutting from above downwards, followed by immediate extension to the full extent required for the complete straightening of the fingers when this is possible, and the application of a retentive, well-padded, metal splint from the wrist along the palm of the hand and fingers; the fingers and hand to be bandaged to the splint. When the full extension cannot be safely made, it must be carried as far as possible without tearing the skin.” This plan I have followed, with slight variations, but I have found it easier, after making the preliminary puncture (which should be longitudinal in direction to prevent gaping during the subsequent extension), to pass the knife beneath the band and to cut from within outwards, except in places where the deep surface of the skin is very tightly adherent, and the little wounds are sealed with cotton wool impregnated with collodion and dusted over with iodoform. The sensation conveyed to the operator by the division of the round palmar cords is very similar to that experienced in tenotomy, and the effect of each section is immediate and encouraging. In some examples, however, the morbid tissue has become so firmly blended with the corium, especially over the proximal phalanx, that a satisfactory division is difficult, or even impossible; and if the extension be carried too far ominous fissures begin to appear in the rigid integument. When this happens the surgeon, if wise, will be satisfied with whatever he has been able to achieve, without proceeding further at the time. The splint extension may be immediate or deferred. Where the skin has held good there is no reason why the fingers should not be put in position at once and fixed in place by a splint of plaster of Paris or other material; but if it be evident that the integument at any point has been severely strained, it is desirable to wait for a few days before the parts are put on the stretch, and there is no reason to believe that the delay will be attended by any disadvantage. The operation may with benefit be preceded by careful washing of the hand and packing with a weak solution of perchloride of mercury solution or other antiseptic, and antiseptic dressings should be applied until the incisions are completely healed.

The after-treatment consists in the use of splints of various forms. The palmar splints of Mr. Adams are very convenient, but in the early periods plaster of Paris is equally satisfactory, and renders the intervention of the instrument-maker unnecessary. Whatever form be adopted it should be worn day and night for two or three weeks, and then be replaced by a well-moulded front splint of sheet iron, to be applied at night only, and kept in use for several months. The hand once set free during the day the patient is to be urged to practise friction, with passive extension and active movements of the joint, at every possible opportunity; and it is only by strict attention to these rules that permanency of the improvement can be ensured. In private practice the instructions are usually carried out with a good will, and hence relapses are exceptional. Mr. Adams and Mr. Macready estimate them as less than ten per cent. But in hospital practice the case is different. The artisan has seldom much leisure or inclination for unpleasant manipulations for which, despite the assurances of the surgeon, he sees little immediate necessity, and he frequently allows the hand to drift into a condition, which, if not worse, is at least little better than before.

The Open operations may be placed under two separate headings—one in which the bands are merely divided in one or two places, and the other in which the morbid tissue is excised as far as possible. The first of these, however—the original method of Goyrand—may now be held as superseded, since it has neither the safety of the subcutaneous method nor the thoroughness of the more radical measure. We need therefore only discuss the latter. The cutaneous incision may be either longitudinal and linear, as practised by Goyrand, Kocher, and others, or V- or Y-shaped, after the method of Busch, Madelung, and Richer. In any case the reflected skin should be very gently dealt with, and the wound carefully closed after the removal of the diseased bands. In most instances the simple linear incision gives all that is required, but the other varieties are useful when the distal end of the band branches or expands. The isosceles flap of Busch is made with the base opposite the metacarpo-phalangeal joint, the apex at the distal extremity of the hollow of the palm. ([Fig. 4.]) When the hand is extended after section or excision of the contracted tissue the apex of the flap is drawn away from the angle of the incision, and the wound when closed assumes a Y-shape. A Y-incision, with the fork over the first phalanx, and the stem corresponding to the palmar cord, is of advantage where the fibrous band spreads out broadly and becomes adherent to the skin beyond the metacarpo-phalangeal joint, the reflection of the angular flap within the fork allowing the safe removal of the diseased tissue. In any of these operations the anatomical relations of the vessels and nerves should be carefully borne in mind. Fortunately the morbid tissue seldom encroaches upon the nerve tracts in such a way as to expose them to danger. The best rule for the surgeon is to confine his dissection as far as possible to the tissue overlying the axes of the flexor tendons, and not to make any further lateral excursion than is absolutely necessary. Extreme care, however, will always be needed in excising cords which run towards the inter-digital web, as these lie directly over the nerves. The tendons are quite safe in the palmar incisions, as they lie much deeper than the fibrous cords, but the diseased tissue is closely related to the thecæ in the fingers. The after-treatment is similar to that recommended for the subcutaneous operation, but for obvious reasons the necessity for antiseptic precautions is more vital in the open method. No drainage is required.

Fig. 4.

Diagram showing Incisions for Open and Smaller Plastic Operations.