CME/MOC

MOC-PSSM CME Article: Dupuytren’s Disease

William M. Swartz, M.D.
Donald H. Lalonde, M.D.
Pittsburgh, Pa., and Saint John,
New Brunswick, Canada
Learning Objectives: After reviewing this article, the participant should be able
to: 1. Describe the condition of Dupuytren’s disease in its various presentations
and severity. 2. Describe the pathologic anatomy involved in palmar and digital
contractures. 3. Understand recent elucidation of relevant pathophysiology. 4.
Be familiar with treatment options and the management of complications.
Summary: Dupuytren’s contracture is one of the most frequent conditions seen
by practicing hand surgeons. Inherited in an autosomal dominant pattern, the
disease is characterized by a nodular thickening of the palmar fascia metacar-
pophalangeal and proximal interphalangeal joints. Treatment is offered to
symptomatic patients with painful nodular or disabling contracture. The most
prevalent surgical procedure is limited fasciectomy of the involved abnormal
structures. Recurrence is common. New treatments on the horizon include the
injection of clostridial collagenase, which is now in U.S. Food and Drug Ad-
ministration phase III trials.
The Maintenance of Certification module series is designed to help the clinician
structure his or her study in specific areas appropriate to his or her clinical practice. This
article is prepared to accompany practice-based assessment of preoperative assessment,
anesthesia, surgical treatment plan, perioperative management, and outcomes. In this
format, the clinician is invited to compare his or her methods of patient assessment and
treatment, outcomes, and complications with authoritative, information-based references.
This information base is then used for self-assessment and benchmarking in parts II
and IV of the Maintenance of Certification process of the American Board of Plastic
Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather,
it is designed to serve as a reference point for further in-depth study by review of the reference
articles presented. (Plast. Reconstr. Surg. 121: 1, 2008.)

I
n 1777, Henry Cline, using cadaver dissections,
described that the palmar fascia alone was re-
sponsible for contractures in the palm. His pu-
pil, Astly Cooper, discussed this condition and
advocated fasciotomy through a small cutaneous
incision in 1822. It was Baron Guillaume Du-
puytren, however, that more fully described the
pathologic anatomy and its treatment. He dem-
onstrated the cord-like nature of the diseased tis-
sues by performing a fasciotomy without anesthe-
sia or tourniquet before a class of medical students
in 1839.1
Dupuytren’s disease is characterized by thick-
ening of the palmar fascia and often complicated
by cord-like structures that extend from the palm
into the affected fingers. In this latter situation,
there is frequently contracture of the metacarpo-
phalangeal joints and the proximal interphalan-
geal joints (Fig. 1). The disease appears to be
genetically determined and has been studied ex-
tensively among discrete populations. McFarlane
has traced the appearance of the disease among
Germanic and Celtic tribes that migrated across
northern Europe, ultimately settling in Scandina-
via and the British Isles.2 The disease is inherited
Disclosure: Neither of the authors has a financial
interest in any of the products, devices, or drugs
mentioned in this article.

From the Division of Plastic Surgery, University of Pitts-

burgh, and the Division of Plastic Surgery, Dalhousie
University.
Received for publication September 6, 2006; accepted Feb-
ruary 22, 2007.
Copyright ©2008 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000305932.46121.84
The test for the MOC-PS–aligned CME article
“Dupuytren’s Disease” by Swartz and Lalonde
is available at http://www1.plasticsurgery.
org/ebusiness4/OnlineCourse/CourseInfo.
aspx?Id_13405.

www.PRSJournal.com 1

Fig. 1. Presentation of an 80-year-old man with severe contrac-
tures of the metacarpophalangeal and proximal interphalangeal
joints. Note the pretendinous cord in the thumb-index web.
in an autosomal dominant pattern with variable
expression. In a study of 9938 patients registered
in a regional Veterans Affairs Hospital, 91.3 per-
cent were white, 4.1 percent were black, 2.4 per-
cent were Hispanic, 0.1 percent were Native Amer-
ican, and 0.8 percent were Asian. Whereas the
incidence of bilateral disease in whites was greater
than 50 percent, blacks were reported to have
bilateral disease in 14 percent. This study gives
further credence to the genetic nature of the dis-
ease process.3 Those patients with a severe expres-
sion of the gene are known as having the diathesis
of Dupuytren’s disease characterized by multidigit
and palmar involvement, knuckle pads, and plan-
tar fibromatosis in the feet (Ledderhose disease)
or less frequently other integumentary structures
such as the penis (Peyronie disease).
The biological events responsible for Du-
puytren’s disease have been studied extensively.4
New knowledge in this area resulting from the
study of the palmar nodules shows the target cell
to be the myofibroblast. In the proliferative phase
of the disease, as characterized by Luck,5 there is
a random accumulation of immature fibroblasts in
a characteristic whorl pattern. These fibroblasts
are associated with increased levels of growth fac-
tors known to stimulate fibroblasts, such as inter-
leukin-1, basic fibroblast growth factor, transform-
ing growth factor-␤1 and -␤2, epidermal growth
factor, and platelet-derived growth factor. Meta-
bolic activity in cord-derived fibroblasts was sig-
nificantly greater than fibroblasts cultured from
nodules or control flexor retinaculum from rou-
tine carpal tunnel specimens.6 Other findings in
patients with Dupuytren’s disease compared with
2
Plastic and Reconstructive Surgery • April 2008
normals include a different glycosaminoglycan
profile, further supporting the genetic predispo-
sition in these patients. These variations have been
associated with the Zf9 gene polymorphism. Pres-
ence of the G allele versus the A allele in the Zf9
transcription factor gene was associated with a
marked increase in the incidence of Dupuytren’s
contracture in a case-controlled study group of
138 patients.7 Additional studies have identified
the up-regulation of the MaFB gene in diseased
fascia, thought to play a prominent role in tissue
development and cellular differentiation.8 The
second element in the development of contrac-
tures is the presence of tension. In the involutional
phase, the fibroblasts align themselves along the
tension lines, thus creating cord-like structures
known as pretendinous cords in the palm and as
the central cord in the finger. These mechanical
forces tend to align the fibroblasts and contribute
to the differentiation of the fibroblast into the
myofibroblast. In the residual phase, the central
cords and pretendinous cords are largely acellular
and tendon-like. It has been shown that reducing
the tension on these cords allows softening of
residual nodules and thus provides a fundamen-
tal rationale for the surgical treatment of this
condition.
PATHOLOGIC ANATOMY
As described above, the pathologic anatomy of
the diseased tissues tends to form tension lines in
the palm and digits. Abnormal structures evolve
from the diseased palmar fascia beginning with
the nodule formation in the palm and leading to
cord-like structures in both the palm and finger.
In the normal anatomy, the longitudinal fibers of
the palmar fascia extend into the digits as the
digital theca. In the most superficial layers, these
palmar fibers insert into the skin and extend onto
the digit as pretendinous fibers. The second layer
of the palmar fascia runs dorsally beginning at the
level of the metacarpophalangeal joint as spiral
fibers as they travel distally and rotate dorsally to
reach the lateral digital sheet of fibrous connective
tissue (Fig. 2). In the diseased state, these spiral
fibers become the spiral cords. As the contracture
process develops, these fibers displace the neuro-
vascular bundle medially in the finger. The deep-
est layer of the palmar fascia passes vertically onto the
dorsum of the finger on either side of the metacar-
pophalangeal joints and inserts onto the interosseus
muscle fascia. In the diseased state, the structures
are known as the pretendinous cord, extending on
the palm from the midpalmar crease to the base
of the digit; the central cord, extending from the
Volume 121, Number 4 • Dupuytren’s Disease
Fig. 2. Normal relationships of integumentary structures in the
palm and digit. Reprinted with permission from Hughs, T. B.,
Mechrefe, A., Littler, J. W., and Akelman, E. Dupuytren’s disease.
J. Hand Surg. (Am.) 3: 27, 2003.
base of the digit across the proximal interphalan-
geal joint; the spiral cord, which passes dorsal to
the neurovascular bundle and then displaces it;
and the lateral cord, which is the thickening of the
digital sheet and contributes significantly to prox-
imal interphalangeal joint contracture, particu-
larly on the ulnar side of the little finger. Surgical
procedures designed to correct these contractures
must take into account each of these abnormal
structures (Figs. 3 and 4).
PREOPERATIVE ASSESSMENT
Dupuytren’s disease typically presents clini-
cally in men older than 40 years and in women
older than 50 years. When the disease presents in
younger patients, it usually has a more progressive
course and may be associated with other sites of
involvement. Dupuytren’s diathesis is used to de-
scribe patients who have early and progressive dis-
ease, with both multiple digit and palm involve-
ment. Other sites that can be involved include the
Fig. 3. Pathologic anatomy in Dupuytren’s contracture. Note
how the spiral cord draws the digital nerve medial to its normal
location. Reprinted with permission from Hughs, T. B., Mechrefe,
A., Littler, J. W., and Akelman, E. Dupuytren’s disease. J. Hand Surg.
(Am.) 3: 27, 2003.
plantar fascia (Ledderhose disease) and, less fre-
quently, curvatures of the penis (Peyronie dis-
ease). Patients with this advanced involvement
may have thickening of the tissues over the prox-
imal interphalangeal joints, known as knuckle
pads. More commonly, however, the disease pre-
sents as a nodular thickening in the palm with or
without contractures of the metacarpophalangeal
and proximal interphalangeal joints. The ring fin-
ger is most commonly involved, followed in order
by the little finger, the thumb, the middle finger,
and the index finger. Diabetes is associated with
Dupuytren’s disease. In these patients, the disease
is usually of a more mild nature. Smoking and
alcoholism are frequent comorbidities and have
been thought to play a role in the pathogenesis;
however, this has not been proven in any rigorous
fashion. In addition, patients with seizures have an
increased incidence of contractures and nodules
that may reflect the use of seizure medications
3

Fig. 4. Pathologic anatomy in Dupuytren’s contracture. Note
how the spiral cord and lateral cord structures cause progressive
proximal interphalangeal joint contracture. Reprinted with per-
mission from Hughs, T. B., Mechrefe, A., Littler, J. W., and Akelman,
E. Dupuytren’s disease. J. Hand Surg. (Am.) 3: 27, 2003.
such as Dilantin (Warner-Lambert Co., Morris
Plains, N.J.). However, a recent series of almost
3000 patients9 could not confirm a statistically
significant correlation of Dupuytren’s contrac-
ture with diabetes mellitus, severe alcohol con-
sumption, heavy smoking, or epilepsy and the
stage of the disease. The patient’s smoking his-
tory is relevant for an assessment of the potential
complications of flap or digital ischemia follow-
ing the surgical procedure. Additional risk fac-
tors for postsurgical complications include vas-
cular disease associated with upper extremity
atherosclerosis.
PHYSICAL EXAMINATION
The physical examination should make note
of the nodules in the palmar fascia and thickening
of cord-like structures over the palm and extend-
ing into the finger. Flexion contractures of the
metacarpophalangeal and proximal interphalan-
geal joints are noted, with consideration given to
the quality of the skin over these involved fascia
4
Plastic and Reconstructive Surgery • April 2008
structures. In severe contractures of the proximal
interphalangeal joint, preliminary fasciotomies
may be considered to allow the skin to be properly
cleansed before a definitive surgical procedure.
Contractures of the metacarpophalangeal joint
are caused by the pull of the pretendinous cords;
however, the metacarpophalangeal joint struc-
tures themselves rarely are secondarily affected.
In the proximal interphalangeal joint, however,
prolonged contracture may lead to shortening of
the collateral ligaments, flexor tendon sheath, and
volar plate. It is difficult to assess these structures
in the preoperative evaluation. The patient should
be informed that release of the proximal inter-
phalangeal joint may require additional surgical
maneuvers and prolonged splinting. Examina-
tion of the genitalia and plantar aspects of the
feet may help in assessing the severity of the
disease and in prognosticating the long-term out-
come. Treatment of these associated conditions,
however, is beyond the scope of this article.
Many of these patients will have a positive family
history reflecting the autosomal dominant na-
ture of this disease.
ANESTHESIA
Some authors recommend performing pri-
mary Dupuytren’s resection using the wide-awake
approach, using only local anesthetic with epi-
nephrine injected into the palm and finger with
no tourniquet.10,11 Denkler11 reported the treat-
ment of 60 consecutive digits using the wide-awake
approach for palmar and digit fasciectomies with
no digital or flap necrosis. In addition, there was
no significant difference in patient outcomes
when these procedures were carried out on an
outpatient basis compared with an in-hospital
setting.11 Lalonde et al. reported similar results in
203 consecutive cases.10 The main advantage of
the wide-awake approach is that these older pa-
tients with frequent medical problems just get up
after the operation and go home like they do when
they go to the dentist. In addition, avoiding nausea
and vomiting in up to one-third of the patients12
and avoiding unwanted admissions in 14 percent
of patients13 resulting from complications of gen-
eral anesthesia are attractive advantages.
However, most surgeons still prefer to perform
this operation under tourniquet control. A limited
procedure lasting up to 1 hour can safely be per-
formed with a distal forearm tourniquet and light
sedation, using median and ulnar nerve blocks at
the wrist and intermetacarpal blocks. Intravenous
sedation is useful to keep patients comfortable
and motionless during these procedures. Intrave-
Volume 121, Number 4 • Dupuytren’s Disease
nous Bier block anesthesia is also an effective
method of providing anesthesia to the hand and
fingers with a distal forearm tourniquet. At the
conclusion of the procedure, however, local infil-
tration with lidocaine or bupivacaine will aid early
release of the tourniquet and provide skin anes-
thesia during closure.
General anesthesia, brachial block, and supra-
clavicular blocks are recommended for patients
needing more extensive dissections and who
would be unable to tolerate the extended tourni-
quet ischemia. Those who advocate the wide-
awake approach10 also mostly prefer general an-
esthesia and tourniquet for repeat secondary
Dupuytren’s surgery, which is more difficult be-
cause of the scar dissection.
LOCATION OF OPERATION
Many patients today undergo extensive pro-
cedures in an ambulatory surgical facility on a
regular basis. A surgical facility with appropriate
equipment, lighting, and anesthesia support is re-
quired for these procedures. In patients with se-
vere contractures, postoperative digital ischemia is
a concern. For this reason, should there be any
question about the return of circulation on release
of the contracture, postoperative monitoring over-
night in the hospital may be considered. Simple
procedures under local anesthesia, such as limited
fasciectomy without vascular compromise, cord
fasciotomy, or nodule excisions only are reason-
ably performed in an office setting.
TREATMENT PLAN
Occasionally, patients may be managed with
observation only if functionally significant flexion
contractures have not developed. Nodules by
themselves need not be treated. If the nodules are
somewhat tender, however, injection with triam-
cinolone has been shown to soften these nodules.
There is an approximately 50 percent recurrence
rate between 1 and 3 years after such injections.14
A novel treatment for nodules and cords is the
injection of clostridial collagenase, an enzyme that
has been shown to lyse and rupture finger cords,
causing metacarpophalangeal and/or proximal
interphalangeal joint contractures. This treat-
ment is presently undergoing phase III efficacy
trials before obtaining U.S. Food and Drug Ad-
ministration approval for this use.15 The effec-
tiveness of this treatment indicates the role of
collagen as the fundamental composition of the
Dupuytren’s disease cords and may offer a
nonsurgical alternative to more current stan-
dard treatment.
INDICATIONS FOR SURGERY
The primary indication for surgery of patients
with Dupuytren’s disease is progressive disease
with development of metacarpophalangeal and/
or proximal interphalangeal joint contractures.
Additional indications include tender nodules,
particularly over force-bearing digits. The mere
presence of a nodule does not necessarily por-
tend the need for surgery, however. A retrospec-
tive review showed that approximately 50 percent
of patients who present with isolated nodules ul-
timately develop cords. Of 59 patients, five devel-
oped metacarpophalangeal joint contractures of
greater than 30 degrees and/or had proximal in-
terphalangeal joint contractures. They also noted
that the age of onset of 50 years or younger highly
correlated with the progression of the disease
process.16 Patients usually request surgery because
they have difficulty putting their hand in a pocket
or in a glove. A good test to decide whether a
patient is a good candidate for surgery is to have
them attempt to place their hand flat on a table.
A metacarpophalangeal contracture of 30 degrees
will be an indication that surgical correction will
be of benefit (Fig. 5).
SURGICAL TREATMENT
Since Dupuytren’s description of palmar fas-
ciotomy, a variety of surgical procedures have
been recommended, ranging from the limited re-
lease of the diseased cord to radical palmar fasci-
ectomies and skin grafting. The rationale for treat-
ment in each of the following methods is the
interruption of longitudinal forces along the di-
rection of the fibers of the palmar fascia, preten-
dinous cords, and central cords in the digit.
Fig. 5. Early contracture of the proximal interphalangeal joint
prevents the patient from placing her hand flat on the table.
5

Percutaneous Chordotomy
Simple fasciotomy (chordotomy) has been
proposed for the treatment of severe contractures
as a first step in allowing hygiene of the skin before
more definitive procedures have been pursued or
as a simple “nonoperative” procedure to buy some
time. This technique, which can be performed
using percutaneous 18-gauge needles or myrin-
gotomy knives, has the advantage of being quick
and affords modest relief in elderly patients, who
may not otherwise be candidates for corrective
surgery. These percutaneous methods carry with
them the risks of injury to the neurovascular struc-
tures which, in severe contractures, are pulled me-
dially from their more lateral position by the con-
tracted cords. In a study of 166 digits, percutaneous
fasciotomies were compared with limited fasciec-
tomy. There were no complications in the percu-
taneous group, and relief of contractures im-
proved 63 percent versus 79 percent in the limited
fasciectomy group. The authors acknowledge the
limited release of proximal interphalangeal joint
contractions and recommend the procedure for
total passive extension deficits of 90 degrees or
less.17 Although the British National Institute for
Clinical Excellence published guidance in Feb-
ruary of 2004 stating that percutaneous chor-
dotomy is safe and effective, tendon injuries,
arterial false aneurysms, and nerve injuries have
been reported.18 Another study with 32 months’
follow-up revealed a recurrence rate of 65 per-
cent after percutaneous chordotomy.19 The best
patient for chordotomy is an elderly patient with
a cord located mainly in the palm.20
Radical Fasciectomy
The opposite extreme is the radical fasciec-
tomy of the palmar fascia, including the preten-
dinous bands to all four fingers. In theory, the
diseased fascia extends into the dermis, and by
removing the skin with the fascia, recurrence is
thought to be significantly lowered. In addition,
the normal skin is interposed between the dis-
eased structures proximally and distally. In se-
verely contracted digits, release of the contracture
may require skin grafts for the shortages of skin
that may occur in the area of the proximal inter-
phalangeal and metacarpophalangeal joints. Rad-
ical fasciectomy is no longer performed, as the
recurrence rate is similar to limited palmar fasci-
ectomy, but the complication rates are signifi-
cantly higher.
6
Plastic and Reconstructive Surgery • April 2008
Limited Fasciectomy
Popularized by Hueston,21 the current main-
stay of surgical treatment is the procedure known
as limited fasciectomy. In this procedure, only the
fascia that is causing contracture is removed under
thin skin flaps in continuity with the pretendinous
cord in the palm and the spiral cord and central
cords in the digit. The incisions required for this
procedure can be performed with Brunner inci-
sions, modified to form Y-to-V advancements or
longitudinal incisions with interposed Z-plasties
(Fig. 6). In this procedure, the skin is elevated at
the level where fat joins the pretendinous cord,
and these flaps are usually quite thin. Where mul-
tiple incisions for adjacent fingers are used, the
intervening skin between the digital rays provides
the vascular basis for these flaps. The resection of
the pretendinous cord begins with division of the
cord proximally in the palm where the digital ar-
tery and nerves are always deep to the palmar
fascia. Once the neurovascular bundles have been
identified, they are traced distally to the metacar-
pophalangeal joint crease, with all diseased fascia
being removed above the flexor tendon sheath. At
the web spaces, there is a confluence of tendinous
structures which, when contracted, draw the neu-
rovascular bundles medially. The spiral, central,
and lateral cords of the finger must all be dis-
sected, with positive confirmation that digital
nerves are protected. This may necessitate a distal
to proximal dissection distal to the proximal in-
terphalangeal joint. This fascia may be removed in
continuity with progressive release of digital con-
Fig. 6. Common incisions used for palmar and digital fasciecto-
mies. In more severely contracted digits, the skin shortage is
lengthened by Z-plasties.
Volume 121, Number 4 • Dupuytren’s Disease

tractures as the diseased tissues are released. Once
the central cord has been resected, the metacar-
pophalangeal joint contracture is usually com-
pletely released. If the proximal interphalangeal
joint contracture remains, deeper dissection into
the lateral cords of the finger and spiral ligaments
must be pursued.
Some advocate full-thickness skin grafting to
decrease recurrence rates. In one study, 7 per-
cent of patients had recurrent disease after 4.4
years of follow-up when proximal interphalangeal
joint contracture was treated primarily with fas-
cial excision, no skin excision, and insertion of
full-thickness skin grafts.22 Some advocate primary
dermofasciectomy and full-thickness grafting for
younger patients with Dupuytren’s diathesis.23
Management of Proximal Interphalangeal Joint
Contracture
Once the diseased fascia and cords have been
removed, residual proximal interphalangeal joint
contractures may be addressed surgically. The or-
igins of these contractures may include the spiral
cords, flexor tendon sheath, collateral ligaments,
and volar plates. Each can be assessed and surgi-
cally released sequentially until full extension of
the proximal interphalangeal joint is achieved.
Some23 feel that the first step should be division of
the checkrein ligaments just proximal to the ar-
terial branch for the vinculum longum, which
should be preserved. Next, the accessory collateral
ligaments and then finally the collateral ligaments
of the proximal interphalangeal joints can be di-
vided sequentially until proximal interphalangeal
extension is obtained.
With these maneuvers, there is the risk of
stretching the digital nerves and arteries. The
results of proximal interphalangeal joint con-
tracture release are highly variable. The recur-
rent contracture is frequent, and full extension
long term is rarely achieved24 (Fig. 7). Some

Fig. 7. (Above, left) A 40-year-old laborer with Dupuytren’s diathesis and severe ring and little finger metacarpophalangeal and
proximal interphalangeal joint contractures. (Above, right) Palmar and digital fasciectomies were performed with proximal
interphalangeal joint volar plate, checkrein ligament, and collateral ligament release. (Below) Photographs obtained at 1-year
follow-up after extensive hand therapy. Note early recurrence of proximal interphalangeal joint contracture.

7
 Plastic and Reconstructive Surgery • April 2008

authors advise against a routine surgical joint

release, as this maneuver sometimes can also
result in decreased proximal interphalangeal
flexion postoperatively.25

RECURRENT DISEASE
The treatment of patients with difficult or re-
current disease may require the judicious use of
dermofasciectomy or the insertion of full-thick-
ness skin grafts,22 particularly over the contracted
skin of the metacarpophalangeal joint and prox-
imal phalanges. Dissection of neurovascular bun-
dles is tedious and fraught with hazard. Patients
should be doubly warned about the risk of nerve
and vascular injury, and the surgeon should be
prepared to repair or graft the nerve should such
an injury occur. Resection of the recurrent con-
tracted cord and overlying skin should result in
Fig. 8. Dynamic extension splint for early postoperative man-
relief of metacarpophalangeal and proximal in-
agement of metacarpophalangeal and proximal interphalangeal
terphalangeal joint contractures. Full-thickness
joint contractures.
skin grafts harvested from the groin provide a
generous and well-tolerated donor site; however,
alternative sites such as the volar wrist and ante-
cubital fossa are alternatives.26 Despite the sur-
geon’s best efforts, continued contractures, espe-
cially of the proximal interphalangeal joint, are
frequent. In rare situations, amputation of a se-
verely contracted digit may be required.

POSTOPERATIVE MANAGEMENT
For many surgeons, the patient’s hand is
placed in a bulky dressing with volar plaster splint-
ing with metacarpophalangeal and proximal in-
terphalangeal joints in full extension. Others let
the patients leave the operating room without a
splint after surgery. Some splint the metacarpo-
phalangeal joints in flexion and the interphalan-
geal joints in extension to help resolve central slip
attenuation, which may occur with longstanding
proximal interphalangeal joint contracture.27
Most surgeons continue to use some form of night-
time extension splinting by occupational thera-
pists to maintain extension for a number of
months after surgery.28 Although there is some
evidence that prolonged night splinting may be
valuable,29 the proof of efficacy of this treatment
is still not solid.30
In the first author’s (W.M.S.) practice, the first
dressing change occurs at 1 week, at which time
active and passive range of motion is begun. At this
time, a referral to a certified hand therapist is
made, and dynamic extension splinting is pro-
vided if there is any residual proximal interpha-
langeal joint or metacarpophalangeal joint con-
tracture (Fig. 8). Nighttime splints are also
Fig. 9. Nighttime resting splint.
provided (Fig. 9). By the end of the second week,
full passive range of motion is usually achieved, at
which time sutures are removed and more aggres-
sive therapy instituted. In situations where the
open palm technique is used, the first dressing
change is at 5 days and daily dressings are per-
formed thereafter, combined with active and pas-
sive range-of-motion exercises. Nighttime splint-
ing is continued for 6 months after surgery, and
biweekly monitoring of joint range of motion is
provided by the surgeon. By the eighth postoper-
ative week, active physical therapy can usually be
stopped. Continued dynamic splinting, however,
may be required should persistent flexion con-
tractures remain.

8
Volume 121, Number 4 • Dupuytren’s Disease

OUTCOMES 253 patients undergoing Dupuytren’s contracture

The long-term surgical outcome following pal-
mar fasciectomy and flexor contracture release is
variable depending on the age at which the pa-
tient’s disease manifested; the severity of the dis-
ease is indicated by multiple joint involvement and
whether the little finger is involved. Recurrence is
common, with up to 40 percent of patients with a
12-year follow-up requiring additional surgery.
Long-term follow-up suggests higher rates of re-
currence, from 63 to 71 percent when patients are
followed 20 years or longer. The more severe tend
to occur early.23 A recent British survey of 141
hand surgeons revealed a reported disease recur-
rence of 33 percent and postoperative stiffness of
10 percent.31 Recurrent disease is difficult to treat
and is often accompanied by nerve injuries and
sometimes amputations.
Generally, pure metacarpophalangeal joint
contractures can be completely released with good
extension results, whereas proximal interphalan-
geal joint contractures do not fare as well, with
higher residual contractures and faster recur-
rences. Patients with Dupuytren’s diathesis (pos-
itive family history, bilateral disease, early age of
onset, and ectopic multiple site lesions) tend to
have higher and earlier recurrence rates.23
COMPLICATIONS
Major complications following Dupuytren’s
surgery usually involve nerve or arterial injuries,
with impending ischemia of the digit. The surgeon
should assess the circulatory status of the finger
once the tourniquet is released, and if there is
vascular compromise, measures should be taken
to either refrain from full extension of the digit or
repair the artery, if needed. Similarly, nerve inju-
ries can be treated at the time, if noted, with nerve
repair or grafting. The patient should be made
aware preoperatively that injury to these structures
is a significant risk, particularly in the more severe
joint contractures. Transient paresthesias usually
resolve. More commonly, however, hematomas
and skin flap necrosis can occur. In an analysis of
surgery with limited fasciectomy by a single sur-
geon, Bulstrode et al. reported 46 patients with
complications (18 percent), many with more than
one complication.32 Six patients had nerve injuries
requiring repair and one had an arterial injury.
Each of these occurred in patients with proximal
interphalangeal joint contractures of 60 degrees
or more. More common complications included
digital hematoma (2 percent), wound infection
(9.5 percent), skin slough (2.4 percent), and sym-
pathetic dystrophy (2.4 percent).33 There were no
palmar hematomas when they were left open, a
finding that confirms the results of others.33 One
text cites hematoma, skin loss, or infection at 3
percent; nerve and arterial division at 3 percent;
loss of flexion at 6 percent; and complex regional
pain syndrome at 5 percent, for an overall com-
plication rate of 19 percent, not counting recur-
rence of extension contractures.34
Use of the open palm technique33,35,36 has min-
imized the risk of these complications and is ad-
vocated by many as the procedure of choice. This
technique is most useful when multiple digits are
involved in the same hand. It is prudent to obtain
hemostasis after the tourniquet is released and to
place a Penrose drain beneath the skin flaps. The
drain is removed at the first dressing change, usu-
ally at 5 to 7 days. Advocates of the wide-awake
approach feel that the incidence of hematoma is
less with this technique, as there is no tourniquet
to let down and hematomas are rare, even without
drains.10,11 When severe contractures are released,
the surgeon should be prepared to place a skin
graft in the resulting skin defect rather than risk
tension in the skin flap closure.
SUMMARY
Successful outcome following Dupuytren’s
contracture release requires meticulous tech-
nique, dissection under magnification, and vigor-
ous postoperative therapy. Most patients are grat-
ified to have a significant improvement in their
range of motion despite a less-than-perfect result.

Table 1. CPT Codes Commonly Used in Surgery for Dupuytren’s Disease

CPT Code Descriptor
26040 Percutaneous fasciotomy: The simple release of a palmar cord including local anesthesia
26045 Open partial fasciotomy: The release of diseased palmar or digital cord, limited to one incision
26121 Fasciectomy of palm with or without Z-plasty or skin graft. The resection of diseased palmar fascia
includes dissection of digital nerves and vessels
26123 Partial palmar fasciectomy with release of single digit including PIP joint
26125 Each additional digit. This code never stands alone. It must be used with 26123 as an add-on code to describe
fasciectomy of more than one digit

9

Both surgeon and patient should be aware of the
limitations of surgery for this condition, and when
reasonable expectations are expressed and met,
both will find this surgery a rewarding experience.
CPT codes commonly used in surgery for Du-
puytren’s disease are listed in Table 1.
William M. Swartz, M.D.
5750 Centre Avenue, Suite 180
Pittsburgh, Pa. 15206-3761
william.swartz@verizon.net
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