Percutaneous Fasciotomy in the management of Dupuytren"s contracture. Although PCF is associated with chances of recurrence but when done properly it gives excellent results with less number of complications.

1. Ansarul Haq
MS Orthopaedics
Senior resident GMC Srinagar

2. Who should Manage these patients?
Orthopaedic Surgeon
OR
Plastic Surgeon

3. Introduction
Dupuytren’s contracture (DC) is a benign
fibroproliferative disorder of the fascia of the hand and
fingers, resulting in progressive thickening and shortening
of the palmar fascia. This results in the formation of cords,
flexion deformities of the digits, and ultimately loss of
range of motion, especially loss of finger extension.
Albin R, Brickly D et al : Dupuytren’s contracture: an active cellular process, J Bone Joint Surgery 57A;726,1975
An HS, Southworth SR, Jackson T, et al; Cigarette smoking and dupuytren’s contracture of hand, J Hand Surg 13A:872,1988

5. Van Rijssen AL, Werker PMN. Percutaneous needle fasciotomy in Dupuytren’s disease. J Hand Surg. 2006;31B(5):498–501.
Weinzweig J. Plastic surgery secrets. Philadelphia: Elsevier; 1999, p. 554–9.
The lesion usually begins
in line with ring finger at
the distal palmar crease
and progresses to involve
the ring and little finger,
these digits being more
frequently involved than
other digits.

6. Although the cause of Dupuytren disease is unknown,
a family history is often present. Males are three times
as likely to develop disease and are more likely to
have higher disease severity. Male predominance may
be related to expression of androgen receptors in
Dupuytren fascia.

7. It has been associated with smoking and
chronic alcoholism and with several medical
conditions, notably diabetes mellitus, liver
cirrhosis and epilepsy, as well as acute injuries
such as fractures, penetrating wounds, and
lacerations of the hand.
Shaw RB, Chong AKS, Zhang A, Hentz VR, Chang J. Dupuytren’s disease: history, diagnosis, and treatment. Plast Reconstr Surg.
2007;120(3):44–54.

8. Progression of the disease process

9. Continued...

10. Tubiana’s staging of dupuytren’s contracture

11. Management
There are different treatment options for the
management of dupuytren’s contracture. In the
absence of contractures treatment usually is not
indicated because nodules and cards usually are
painless. Rarely is the presence of a palmar nodule
alone an indication for surgery.

12. Continued...
In 1952 Baxter et al, introduced injection of steroids into
nodules. This has allowed softening of the nodules but it failed
to induce regression of the contractures. Ketchum and Donahue
studied the modification of dupuytren’s nodules by intra-
lesional injection of triamcinolone acetonide, after an average
of 3.2 injections per nodule 97% hands had softening or
flattening of nodules. Although complete resolution of the
disease was rare, only half of the patients had nodule
reactivation within 3 years after the injection.
Ketchum LD, Donahue TK: The injection of nodules of dupuytren’s contracture with triamcinolone acetonide. J Hand Surg 25A:1157,2000

13. Nowadays, there are still no clear indications for surgery.
However a flexion contracture of 30° or more at the
metacarpophalangeal (MCP) joint and any contracture at
the proximal interphalangeal (PIP) joint result in
significant impairment of the hand.
Ketchum LD, Donahue TK: The injection of nodules of dupuytren’s contracture with triamcinolone acetonide. J Hand Surg 25A:1157,2000

14. Surgical options for Dupuytren’s contracture
1. Subcutaneous fasciotomy
2. Partial (selective) fasciectomy
3. Complete fasciectomy
4. Fasciectomy with skin grafting
5. Amputation
6. Joint resection and arthrodesis

15. Percutaneous Fasciotomy
 Three puncture wounds are made on the ulnar side of
diseased palmar fascia at three levels-
 First one just distal to the apex of the palmar fascia between
the thenar and hypothenar eminence, second one at level of
proximal palmar crease and last one at the level of distal
palmar crease.
 Through these puncture wounds a small tenotomy knife is
inserted below skin but superficial to the palmar fascia. Fingers
are extended to tighten the involved tissue.
 The fascial cords are divided by gently pressing the blade
onto the tense cords with gentle pressure over the blade

16. 65 years old patient with dupuytren’s contracture involving dominant hand

17. At 1 year follow-up

18. 50 yrs old male patient with dupuytren’s contracture of left hand involving only little finger
Pre-op Post-op

19. 57 years old patient with Dupuytren’s contracture
Pre-op Post-op

20. Rowley DI, Couch M, Chesney RB, Norris SH. Assessment of percutaneous fasciotomy in the management of Dupuytren’s contracture. J Hand
Surg. 1984;9B(2):163–4.
Rowley (1984) performed PCF on 107 fingers that were
divided into two groups: fingers with dominant MCP joint
contracture and fingers with dominant PIP joint contracture. In
both groups, PCF was deemed unsatisfactory for PIP joint
contracture, and there was a rapid deterioration to the
preoperative level. However, early surgery in PIP dominant
disease favoured some improvement most likely because
secondary joint contracture of the capsule and collateral
ligaments had not yet formed. On the other hand, PCF leads to
satisfying improvement at the MCP joint in both groups, and in
its own group, the improvement is marked and sustained.

21. Rowley DI, Couch M, Chesney RB, Norris SH. Assessment of percutaneous fasciotomy in the management of Dupuytren’s contracture. J Hand
Surg. 1984;9B(2):163–4.
This difference in results between MCP and PIP joints
was attributed to the fasciotomy being restricted to
proximal to the distal palmar crease in order to
decrease the risk of neurovascular injuries. Therefore,
it was concluded that PCF should be performed for
fingers with MCP dominant disease, especially if PIP
joint contracture was recent and mild. Postoperative
complications were limited to skin tears

22. Cheng HS, Hung LK, Tse WL, Ho PC. Needle Aponeurotomy for Dupuytren’s contracture. J Orthop Surg. 2008;16(1):88–90.
Cheng (2008) performed PCF on eight Chinese patients. A
splint maintained the finger in extension for 8–12 weeks.
Immediately postoperatively, there was a 100% improvement
of the mean flexion contracture at the MCP joint, whereas at
the PIP joint, the improvement was 76%. After 22 months, the
retained improvement was 70% at the MCP joint and 41% at
the PIP joint. No patient had undergone further surgery at the
22-month follow-up. This could be due to the fact that patients
of Asian ethnicity seem to present milder forms of Dupuytren’s
disease that seldom require surgical intervention.

23. Although PCF is associated with chances of recurrence
but when done properly it gives excellent results with
less number of complications.