Bruner zigzag incisions, Z-plasty skin lengthening, McCash open palm option · Tubiana I–IV
- The classic indication is a positive table top test (inability to place the palm flat on a surface), an MP contracture greater than 30 degrees, or any PIP joint contracture.
- The spiral cord displaces the digital nerve in THREE directions — central (medial), superficial (toward the skin) and proximal (higher than expected) — creating maximum nerve-injury risk; identify the nerve BEFORE dissecting the cord.
- Limited fasciectomy (excision of the diseased cord only) is the modern gold standard; radical fasciectomy has higher morbidity and no proven benefit for recurrence.
- PIP contractures persist in 30–50 percent from capsular contracture; release the checkrein ligaments but NEVER force full correction, or a severe flare reaction follows.
- Raise FULL-THICKNESS skin flaps including dermis (thin flaps necrose — the commonest wound complication); the McCash open palm option reduces haematoma and flare.
When & Why
Indication. Surgery is offered for a positive table top test (the patient cannot lay the palm flat), an MP joint contracture greater than 30 degrees, any PIP joint contracture (even 15–20 degrees warrants consideration), or functional impairment with grip and activities of daily living. Relative indications are rapidly progressive disease despite an MP contracture less than 30 degrees, patient request in younger patients with progressive disease, and concurrent pathology such as Garrod's pads or a web-space contracture. Contraindications are medical comorbidities precluding anaesthesia, unrealistic patient expectations (especially for severe PIP contracture), inability to comply with postoperative therapy and splinting, active infection in the operative field, and severe vascular disease compromising healing. Preoperative assessment. Examine the whole hand before committing: - Table top test — place the hand flat on a table; inability to do so is positive.
- Tubiana staging — measure the total flexion deformity (MP plus PIP) for each ray (full staging table in Background & Evidence).
- Finger involvement — ring finger most common (around 40 percent), then small (30 percent), middle (20 percent), index (10 percent).
- Skin quality — look for puckering, adherent skin and Garrod's knuckle pads over the PIP joints.
- Palpate the cords — identify pretendinous, central, spiral and lateral cords.
- Vascular assessment — Allen test, digital perfusion and capillary refill. Dupuytren's diathesis (poor-prognosis factors). Age less than 50 years at onset, bilateral disease, ectopic disease (Ledderhose plantar, Peyronie penile), family history (autosomal dominant with variable penetrance), rapid progression, and Garrod's knuckle pads. Diathesis drives higher recurrence and may shift the technique choice. Imaging is not routinely required. Plain radiographs are taken only if concurrent arthritis is suspected; MRI is not indicated and ultrasound is for research only. The decision: limited fasciectomy is the default, but choose the modality to the disease and the patient.
Excision of the diseased cord only, preserving normal fascia. The modern gold standard — low morbidity and the most durable correction (around 21 percent recurrence at 5 years in the van Rijssen RCT).
Office-based cord division with a hypodermic needle. Minimal morbidity and rapid recovery, but high recurrence (around 85 percent at 5 years). Best for elderly or comorbid patients with MP-dominant disease.
Clostridium histolyticum collagenase digests the cord, ruptured by manipulation a day later. Effective for an isolated palpable cord (best for MP), but 47 percent recurrence at 5 years (66 percent for PIP) and risks tendon rupture and CRPS.
Excision of all palmar fascia (diseased and normal) and overlying skin with full-thickness skin-graft cover. Higher morbidity and no proven recurrence benefit; reserve for severe diathesis or recurrent disease.
Incision planning. Choose before inflation: Bruner zigzag incisions (the gold standard for digits — apices at the flexion creases, 60-degree angles); Z-plasties to add skin length (a 60-degree Z-plasty adds about 75 percent); a transverse palmar incision for the McCash open palm technique; or the common combination of a transverse palm with Bruner digits. Anaesthesia. Axillary block is preferred for hand surgery; Bier's block (IVRA) is an acceptable alternative; general anaesthesia if the block is contraindicated or by patient preference; WALANT (wide-awake local anaesthesia no tourniquet) is an emerging technique. Counsel the patient honestly. An MP contracture should correct near-completely; a PIP contracture may leave 20–30 degrees of residual flexion that improves with therapy. Recurrence is 30–50 percent at 5 years for Stage III–IV disease. Nerve-injury risk is 2–5 percent (higher with a spiral cord). Recovery to full function takes 8–12 weeks. Note that routine night splinting, though commonly prescribed, is NOT supported by Cochrane evidence and may even reduce final active flexion — apply it selectively, not dogmatically.
The Operation
The goal is to remove the diseased cord while protecting the digital nerves, arteries, flexor tendons and the overlying skin, restore extension (accepting residual PIP flexion), and avoid a flare reaction. The exposure — Bruner zigzag flaps raised in the right plane — is the foundation of a safe operation, and the management of the spiral cord and its displaced nerve is the whole game.
Operative sequence
- Supine, affected arm on a radiolucent hand table at 90 degrees abduction; pad the bony prominences.
- Upper-arm tourniquet, padded, to 250 mmHg (or 100 mmHg above systolic); exsanguinate by elevation only (avoid Esmarch if the vessels are diseased). Maximum tourniquet time about 2 hours.
- Mark all incisions with the tourniquet deflated so the anatomy is undistorted.
- Loupe magnification (2.5x or 3.5x) for all cord dissection.
- Mark the Bruner zigzag with apices at the flexion creases (palmar digital, PIP, DIP) and 60-degree angles off the longitudinal axis; extend proximally into the palm as needed and avoid apices in the web space (they cause web contracture).
- Plan Z-plasties now where skin is tight — a 60-degree Z-plasty adds about 75 percent length; central limb along the line of contracture, two equal lateral limbs.
- For a McCash open palm, plan a transverse palmar incision, 3–4 cm, perpendicular to the long axis, to be left open.
- Incise with a 15 blade and raise full-thickness flaps immediately, including the dermis to the subdermal-fat junction — thin flaps are the commonest cause of skin necrosis. Retract with skin hooks, never crushing forceps.
- Begin in the palm proximal to the diseased cord where anatomy is predictable.
- Normal palmar aponeurosis is white, glistening and thin (1–2 mm); diseased fascia is thick (5–10 mm), firm, yellow and adherent.
- Establish the planes: between subcutaneous fat and fascia, and between fascia and the underlying flexor tendons, using a gentle spreading technique.
- Trace normal fascia distally to the thickened cord and separate it from overlying skin where adherent.
- Classify the cord (full anatomy in Background & Evidence): pretendinous (common, midline over the tendon, nerve position normal — relatively safe); central (midline palm); lateral (radial side of the digit); and the dangerous spiral cord.
- Decision point: if a spiral cord is identified, STOP and find the nerve before any further dissection. Use loupe magnification throughout.
- With a spiral cord the nerve is displaced in three directions — central (medial), superficial (it may lie directly beneath the skin) and proximal (higher than expected, even in the palm). Never assume a normal radial or ulnar position.
- Start proximally in normal tissue, identify the nerve with gentle spreading of fine scissors — a longitudinal yellow-white structure with striations (a vessel is smooth and may pulsate) — and trace it both proximally and distally.
- Loop the nerve and artery with vessel loops, retract gently, and maintain continuous visualization throughout.
- Excise only the diseased cord; preserve all normal fascia, the neurovascular structures and the flexor tendon sheath.
- Dissect the cord from the skin superficially and from the flexor tendons deep, spreading parallel to the nerve under direct vision.
- The spiral cord inserts on the lateral digital sheet and Grayson's ligament and wraps around the bundle — dissect it free of the nerve before excising it. Preserve Cleland's ligament (dorsal, protective); excise Grayson's ligament (palmar, involved) as part of the cord.
- Excise from normal proximal fascia to the DIP joint if involved; tag specimens if multiple rays are done for orientation.
- Reassess passive extension after cord excision.
- MP joint — usually corrects fully with cord excision alone; gentle manipulation is acceptable.
- PIP joint — often persists from capsular contracture. Release the checkrein ligaments (the accessory collateral ligaments on the volar plate) bilaterally with curved scissors; if insufficient, release the proximal volar plate from the A2 pulley, preserving the proper collateral ligaments.
- CRITICAL: do NOT force full extension. Accept 20–30 degrees of residual PIP flexion and gain it gradually with therapy — forced manipulation causes a severe flare reaction.
- Garrod's knuckle pads — if adherent to the cord, excise with the fasciectomy (the defect may need a skin graft); if independent, they may be left.
- Web-space contracture — release the natatory ligament and add a Z-plasty for skin length; preserve the web neurovascular structures.
- Thumb / first web — release the involved thenar fascia, preserve the recurrent motor branch of the median nerve, and use a Z-plasty for a tight first web.
- Release the tourniquet, wait 5–10 minutes, and achieve meticulous bipolar haemostasis away from the nerves; aim for a dry field to prevent haematoma.
- Check capillary refill, colour and turgor in every digit; if one digital artery is compromised the digit usually survives on the other.
- Consider a small Penrose drain for extensive dissection or multiple rays, removed at 24–48 hours.
- Always close digital wounds with 4-0 or 5-0 nylon, everting the edges without tension (use Z-plasties for length); sutures out at 2 weeks.
- Palmar wound: the McCash open palm technique leaves the transverse palmar incision open to heal by secondary intention in 4–6 weeks — it drains freely and reduces haematoma and flare, and patients tolerate it well. Alternatively, close primarily with a drain where there is adequate, tension-free skin.
- Reserve a full-thickness skin graft (groin or hypothenar donor, tie-over bolster) for a large defect, more commonly with dermofasciectomy.
- Non-adherent dressing over all wounds; pack any open palm with non-adherent gauze; fluffed gauze between digits and bulky padding with a soft wrap. Elevate.
- Apply a dorsal thermoplastic extension splint (not circumferential): wrist 30 degrees extended, MCPs in full extension, IPs extended or 10–20 degrees flexed if the PIP is very stiff; from mid-forearm to fingertips.
- Strict elevation above the heart for 48 hours, ice to the forearm (not directly on the hand), and neurovascular checks.
A spiral cord (originating from the pretendinous cord and inserting via the spiral band, lateral digital sheet and Grayson's ligament) spirals around the neurovascular bundle from palmar to radial and displaces the digital nerve central (medial), superficial (it may lie directly beneath the skin) and proximal (it may sit in the palm). Before dissecting the cord, identify the nerve in normal proximal tissue, trace it continuously and protect it with a vessel loop. Blind dissection here is how nerves are transected. If the nerve is injured, recognise it at once and repair it microsurgically with 8-0 or 9-0 nylon.
Raise every flap full-thickness, including the dermis to the subdermal-fat junction, and retract with skin hooks. Thin flaps (under about 2 mm) devascularise and necrose — the commonest wound complication. Avoid undermining excessively and preserve the subdermal plexus; add Z-plasties for length rather than closing under tension.
After releasing the checkrein ligaments, accept 20–30 degrees of residual PIP flexion and gain the rest with therapy and serial splinting. Forced manipulation provokes a severe inflammatory flare (a CRPS-like picture of pain, stiffness and swelling) that is worse than the original contracture and may need a stellate ganglion block and prolonged therapy.
Structures at risk — know their position and how to protect each.
Position: with a spiral cord they are displaced central (medial), superficial (toward the skin, even directly beneath it) and proximal (higher than expected). Protection: identify early in normal proximal tissue, trace continuously under loupe magnification, loop and retract gently, and never assume a normal position.
Position: they run with the nerves in the neurovascular bundle, usually palmar to the nerve, and are displaced by a spiral cord in a similar pattern. Protection: identify them with the nerves, use bipolar cautery only, and avoid blind clamping or cutting; the digit usually survives on a single artery if one is injured.
Position: proximal palm at the level of the extended thumb, about 3–4 cm distal to the distal wrist crease, superficial to the flexor tendons. Protection: identify it during proximal dissection, stay on the fascia, and use a spreading technique — never blind clamping or cutting.
Position: deep to the diseased fascia within the tendon sheath; FDS is superficial to FDP, adherent to the cord via Grayson's ligament connections. Protection: identify them in the deep plane, preserve the tendon sheath (violation causes adhesions and triggering), and spread parallel to the tendon.
Position: overlying the diseased fascia, often adherent (especially with Garrod's pads), thin and at risk of necrosis. Protection: raise full-thickness flaps including the dermis, avoid excessive undermining, preserve the subdermal plexus, and add Z-plasties for length.
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0–2 weeks | Dorsal extension splint continuous | Finger active ROM in the splint only | | 2 | 2–6 weeks | Removable dorsal splint | Active ROM out of the splint; wound and scar care | | 3 | 6 weeks–3 months | Night extension splint (selectively) | Progressive ROM, light pinch, strengthening | | 4 | 3–6 months | Night splint only if still stiff | Full strengthening, graded return to function | Open palm wounds need daily dressing changes until healed (4–6 weeks). Hand therapy (ROM, oedema and scar control, strengthening) starts at about 2 weeks, typically 2–3 times a week for 6–8 weeks. Office work resumes at 2–3 weeks, light manual work at 6–8 weeks, heavy manual work at 10–12 weeks, and contact sports at 12 weeks; maximum medical improvement is around 6 months, with lifelong monitoring for recurrence. Routine night splinting for 3–6 months is traditional, but the Cochrane meta-analysis found it does NOT improve outcome and may reduce final active flexion — prescribe it selectively. Complications
- Recognition
- Numbness, tingling or dysesthesia in the digit distribution; Tinel sign at the injury site; may be delayed
- Prevention
- Early identification of the nerve before cord dissection; loupe magnification; gentle spreading; trace the nerve continuously; never assume a normal position
- Management
- Immediate recognition — microsurgical repair with 8-0 or 9-0 nylon. Delayed — observe 3–6 months for neuropraxia, then explore and repair or graft
- Recognition
- Intraoperative bleeding; postoperative pale, cool digit with delayed capillary refill
- Prevention
- Identify arteries with nerves; bipolar cautery only; no blind clamping or cutting
- Management
- Both arteries injured — microsurgical repair ± vein graft. Single artery — observe (usually adequate); postoperative ischaemia — immediate exploration
- Recognition
- Dark, dusky or black skin edges with loss of capillary refill, evident by day 3–5
- Prevention
- Full-thickness flaps including dermis; avoid excessive undermining; preserve the subdermal plexus; no tension; Z-plasties for length
- Management
- Small areas (under 1 cm) — local wound care and secondary healing; large areas — debridement and skin graft or local flap
- Recognition
- Return of a palpable cord with progressive contracture, usually from 2–5 years; higher with diathesis, PIP involvement and incomplete excision
- Prevention
- Complete excision of diseased cord; hand therapy; realistic counselling; consider dermofasciectomy only in severe diathesis
- Management
- Mild (under 30 degrees) — observe; moderate — needle aponeurotomy or collagenase; severe — repeat fasciectomy or dermofasciectomy; rare amputation for severe recurrent PIP disease
- Recognition
- Excessive swelling, pain and a tense hand with bruising, in the first 24–48 hours
- Prevention
- Meticulous haemostasis with the tourniquet released; McCash open palm; a drain for extensive dissection; strict elevation
- Management
- Small — observe, elevate, ice; large or expanding — return to theatre for evacuation, irrigation and haemostasis; prophylactic antibiotics
- Recognition
- Severe pain out of proportion, swelling, stiffness and autonomic skin changes within weeks
- Prevention
- Avoid forced PIP manipulation; accept residual contracture; gentle technique; early mobilisation; multimodal analgesia
- Management
- Early recognition — hand therapy, gabapentin or amitriptyline, stellate ganglion block, vitamin C 500 mg daily; bisphosphonates if severe
- Recognition
- Residual flexion contracture of 20–40 degrees after fasciectomy and capsular release
- Prevention
- Preoperative counselling on realistic expectations; checkrein and volar plate release; do NOT force extension; night splinting; hand therapy
- Management
- Continued therapy and serial or dynamic splinting — may gain 10–20 degrees over months; rarely PIP fusion or amputation for severe cases
Infection. Superficial wound infection (1–3 percent), usually Staphylococcus aureus, is more likely with a haematoma or diabetes and is treated with oral antibiotics (cephalexin or clindamycin) and local wound care. Deep infection (less than 1 percent) needs surgical debridement and intravenous antibiotics, occasionally a skin graft, and rarely progresses to flexor tenosynovitis.
Viva & Exam Focus
SPIRALSPIRAL — nerve displacement by the spiral cord
TUBIANATUBIANA — staging of Dupuytren's contracture
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 62-year-old man cannot straighten his ring finger. He has a palpable cord in the palm extending into the finger with a 40-degree MP and 50-degree PIP contracture. How do you manage him?”
“During a fasciectomy you identify a spiral cord. Walk me through your management of this cord and the neurovascular structures.”
“A 55-year-old surgeon has bilateral Dupuytren's contracture and is very concerned about recurrence. He asks about radical fasciectomy. What do you tell him?”
Indication
- Positive table top test (cannot lay the palm flat)
- MP contracture greater than 30 degrees, or any PIP contracture
- Functional impairment with grip and activities of daily living
- Tubiana: I less than 45 degrees, II 45–90, III 90–135, IV greater than 135
Exposure
- Bruner zigzag incisions — apices at flexion creases, 60-degree angles
- Full-thickness flaps including dermis (thin flaps necrose)
- Z-plasty (60 degrees) adds about 75 percent length
- McCash transverse palmar incision left open
The danger: spiral cord
- Nerve displaced central, superficial and proximal
- Identify the nerve BEFORE dissecting the cord
- Loupe magnification, gentle spreading, vessel loop
- Inserts via spiral band, lateral digital sheet, Grayson's ligament
Core operation
- Limited fasciectomy — excise diseased cord only
- Preserve normal fascia, neurovascular bundle and tendon sheath
- PIP: release checkreins but NEVER force extension (flare)
- McCash open palm reduces haematoma and flare
Complications
- Nerve injury 2–5% (higher with spiral cord)
- Skin necrosis 5–10% (commonest wound problem)
- Recurrence 30–50% at 5 years (Stage III–IV)
- Haematoma 2–5%; CRPS/flare 1–5%
Alternatives
- Needle aponeurotomy — ~85% recurrence at 5 years
- Collagenase — 47% overall at 5 years (66% PIP)
- Radical/dermofasciectomy — no proven benefit, higher morbidity
- Routine night splinting is NOT evidence-based (Cochrane)
Background & Evidence
Surgical anatomy of the palmar fascia. The normal palmar aponeurosis is a central triangular structure continuous with palmaris longus, sending eight longitudinal pretendinous bands to the digits, with transverse fibres (the superficial transverse and natatory ligaments), sagittal bands (vertical septa to the skin) and spiral bands connecting the palmar fascia to the lateral digital sheet and Grayson's ligament. Of the ligaments around the neurovascular bundle, Cleland's ligament is dorsal and protective, while Grayson's ligament is palmar and is incorporated into the spiral cord. The common digital nerves divide at the web space; the proper digital nerves run palmar to the axis of rotation with the digital arteries (which usually lie palmar to the nerve). The superficial palmar arch, formed by the ulnar artery with the superficial palmar branch of the radial, sits about 3–4 cm distal to the distal wrist crease at the level of the extended thumb.
- Origin and course
- Central aponeurosis, overlying the flexor tendon to its sheath
- Effect
- MP flexion contracture
- Nerve position
- Normal — relatively safe
- Origin and course
- Pretendinous cord, spiral band, lateral digital sheet, Grayson's ligament — spirals palmar to radial around the bundle
- Effect
- PIP flexion contracture
- Nerve position
- Displaced central, superficial and proximal — maximum risk
- Origin and course
- Central aponeurosis in the midline palm to the middle finger
- Effect
- Palmar contracture
- Nerve position
- Usually not involved
- Origin and course
- Lateral aponeurosis on the radial side of the digit
- Effect
- Radial digital contracture
- Nerve position
- Usually protected
- Total deformity
- Less than 45 degrees
- Outlook
- Best prognosis
- Total deformity
- 45–90 degrees
- Outlook
- Good outcomes
- Total deformity
- 90–135 degrees
- Outlook
- Higher recurrence (30–50% at 5 years)
- Total deformity
- Greater than 135 degrees
- Outlook
- Worst outcomes, up to 50% recurrence
Key evidence. The modern case for limited fasciectomy rests on three trials and one review. van Rijssen (2012) randomised needle fasciotomy against limited fasciectomy and at five years found recurrence (a greater-than-30-degree increase in passive extension deficit) in 84.9 percent after needle fasciotomy versus 20.9 percent after limited fasciectomy — limited fasciectomy is markedly more durable. Hurst (CORD I, 2009) established that injectable collagenase reduces an isolated cord to 0–5 degrees of extension in 64 percent versus 6.8 percent with placebo, at the cost of two tendon ruptures and one CRPS. Peimer (CORDLESS, 2015) reported five-year collagenase recurrence of 47 percent overall — 39 percent for MP and 66 percent for PIP — so PIP-dominant disease is the least durable indication for collagenase. The Cochrane review (Rodrigues, 2015) found insufficient evidence that any one surgical technique is superior, and — crucially — that routine postoperative night splinting does not improve DASH or extension and significantly reduces total active flexion. Taken together, no technique is proven best, so the choice is individualised; collagenase and needle fasciotomy trade durability for low morbidity, and splinting should be selective.
References
Patterns of the diseased fascia in the fingers in Dupuytren's contracture: displacement of the neurovascular bundle
- Landmark anatomical study defining the spiral cord and its formation from the pretendinous cord, spiral band, lateral digital sheet and Grayson's ligament
- Demonstrated that the spiral cord displaces the digital neurovascular bundle towards the midline (central), superficially and proximally — the basis of intraoperative nerve risk
- Established that the nerve may lie immediately beneath the skin at the proximal digit/distal palm with PIP-level disease
Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy
- RCT of 115 hands (minimum 30-degree passive extension deficit) randomised to needle fasciotomy versus limited fasciectomy
- 5-year recurrence (greater-than-30-degree increase in total passive extension deficit) was 84.9 percent after needle fasciotomy versus 20.9 percent after limited fasciectomy (p less than 0.001)
- Recurrence occurred significantly sooner after needle fasciotomy; older age reduced recurrence; satisfaction was high in both groups but higher after fasciectomy
Injectable collagenase clostridium histolyticum for Dupuytren's contracture (CORD I)
- Multicentre double-blind placebo-controlled RCT of 308 patients with contractures greater-than-or-equal-to 20 degrees
- Primary endpoint (reduction to 0–5 degrees of full extension) met in 64.0 percent of collagenase cords versus 6.8 percent of placebo (p less than 0.001)
- Three treatment-related serious adverse events: two tendon ruptures and one CRPS; common minor events were swelling, bruising and skin tears
Dupuytren contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS): 5-year data
- 5-year non-interventional follow-up of 644 patients (1,081 treated joints) from prior collagenase trials
- Recurrence (greater-than-or-equal-to 20-degree worsening with a palpable cord or re-intervention) at 5 years was 47 percent overall — 39 percent for MP joints and 66 percent for PIP joints
- Only one treatment-related long-term adverse event (mild skin atrophy); the 47 percent overall rate is comparable with published surgical recurrence rates
Surgery for Dupuytren's contracture of the fingers (Cochrane systematic review)
- Systematic review of 13 trials (944 hands); insufficient evidence to show superiority of one surgical procedure over another (needle fasciotomy versus fasciectomy; firebreak graft versus Z-plasty closure)
- Meta-analysis of postoperative night splinting showed NO improvement in DASH or total active extension, and significantly LESS total active flexion in splinted patients
- Overall evidence quality was low (high or unclear risk of bias across trials)
Further reading 1. Becker GW, Davis TR. The outcome of surgical treatments for primary Dupuytren's disease — a systematic review. J Hand Surg Eur Vol. 2010;35(8):623-626. 2. Dias JJ, Singh HP, Ullah A, Bhowal B, Thompson JR. Patterns of recontracture after surgical correction of Dupuytren disease. J Hand Surg Am. 2013;38(10):1987-1993. 3. Grazina R, Teixeira S, Ramos R, et al. Dupuytren's disease: where do we stand? EFORT Open Rev. 2019;4(2):63-69. 4. Herrera FA, Benhaim P, Suliman A, et al. Cost comparison of open fasciectomy versus percutaneous needle aponeurotomy. Ann Plast Surg. 2013;70(4):454-456. 5. Wilbrand S, Ekbom P, Gerdin B, Kalen S. The sex difference in outcome after surgery for Dupuytren's disease is related to recurrence. J Hand Surg Eur Vol. 2018;43(9):949-956.