import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Normally mid-lateral line, but displaced centrally and volarly by spiral cord up to 1cm. Common digital nerve bifurcation at web space particularly vulnerable. **Protection**: Identify NVB BEFORE cord excision using loupe magnification. Dissect with microsurgical technique. Place vessel loops for retraction and protection. **Location**: Immediately deep to diseased palmar fascia and cords. FDS and FDP within intact flexor sheath beneath diseased tissue. **Protection**: Blunt dissection between cord and white glistening sheath. Preserve A2, A3, A4 pulleys to prevent bowstringing. Release A1 only if contributing to contracture. **Location**: Within neurovascular bundle, displaced by spiral cord. May have atherosclerotic changes in diabetic or elderly patients. **Protection**: Gentle dissection around NVB. Avoid excessive traction. Bipolar cautery only with low settings near vessels. Assess perfusion after tourniquet release. **Location**: Diseased fascia may be adherent to overlying skin, especially with severe long-standing contracture. Palmar skin has longitudinal vascular pattern. **Protection**: Elevate flaps carefully in plane just above diseased fascia. Adequate flap design with base wider than tip. Excise ischemic skin and plan skin graft rather than risk necrosis. **Location**: Underlying PIP joint with severe flexion contracture. Osteoporotic bone in elderly patients at risk for fracture. **Protection**: NEVER forcefully manipulate PIP joint to gain extension - gentle passive manipulation only after soft tissue releases. Progressive correction with therapy postoperatively. ## Indications **Absolute Indications** - MCP joint flexion contracture greater than 30 degrees (Tubiana Stage I or higher) - Any PIP joint flexion contracture regardless of degree - Positive tabletop test (inability to place palm flat on table) - Functional impairment affecting activities of daily living **Relative Indications** - Progressive contracture documented over serial examinations - Failed non-operative management (splinting, physiotherapy) - Failed collagenase injection or needle aponeurotomy - Web space contracture limiting finger abduction - Recurrent disease after previous fasciectomy **Patient Selection Factors** - Adequate skin quality for surgical intervention - Absence of severe medical comorbidities precluding surgery - Patient understanding of recurrence risk (20-50 percent at 5 years) - Commitment to postoperative hand therapy and splinting regimen - Realistic expectations regarding PIP contracture correction ## Contraindications **Absolute Contraindications** - Active infection in hand or systemic sepsis - Severe peripheral vascular disease with inadequate hand perfusion - Medical comorbidities making anesthesia unsafe - Patient unable to comply with postoperative therapy and splinting **Relative Contraindications** - Mild contracture less than 30 degrees at MCP with preserved function - Diathesis (Dupuytren's diathesis) - young age, bilateral disease, family history, ectopic disease, aggressive course (higher recurrence risk) - Severe diabetes with uncontrolled hyperglycemia (infection risk, wound healing) - Anticoagulation that cannot be temporarily ceased (bleeding risk) - Previous radiation to hand (compromised tissue, healing issues) - Unrealistic patient expectations **Special Considerations** - Diabetic patients: higher infection risk, CRPS risk, consider glycemic control optimization - Smokers: increased skin flap necrosis risk, encourage cessation 6 weeks preoperatively - Manual laborers: counsel regarding prolonged therapy and return to work timeline (3-6 months) - Elderly with severe PIP contracture: consider arthrodesis or amputation as alternatives for unreconstructable joints ## Normal Palmar Fascia Anatomy **Longitudinal Fibers** - Origin: palmaris longus tendon insertion at flexor retinaculum - Longitudinal bands extend distally dividing into pretendinous bands - Four pretendinous bands pass to each digit (index through small) - Terminate at base of proximal phalanx and flexor sheath **Transverse Fibers** - Superficial transverse ligament: at level of MCP joints, connects pretendinous bands - Natatory ligament: in web space connecting adjacent digits - Three transverse commissural ligaments at different levels **Vertical Fibers** - Connect skin to deeper structures - Septa separate palmar compartments - Include vertical fibers to flexor sheath and bone ## Dupuytren's Disease Anatomy **Cord Types and Clinical Significance** **Pretendinous Cord** (Most Common) - Diseased longitudinal pretendinous band - Midline palm extending into digit - Causes MCP flexion contracture - Lower risk for nerve injury (NVB in normal position) **Central Cord** - Distal continuation of pretendinous cord - Extends from A1 pulley to middle phalanx insertion - Causes PIP and DIP flexion contracture - Moderate nerve injury risk **Spiral Cord** (HIGHEST RISK) - Complex spiral pathway around digit - Components: pretendinous band, spiral band, lateral digital sheet, Grayson's ligament - Spirals from palm around lateral aspect of digit - **Displaces neurovascular bundle CENTRALLY and VOLARLY up to 1cm** - Most common in ring and small fingers - 8-10 percent nerve injury risk versus 3-5 percent overall **Natatory Cord** - Diseased natatory ligament in web space - Causes web space contracture and limits finger abduction - Affects common digital nerve bifurcation **Retrovascular Cord** (EXTREMELY HIGH RISK) - Passes DISTAL to neurovascular bundle - Derived from retrovascular bands distal to bifurcation - Requires microsurgical dissection - Very high nerve injury risk **Abductor Digiti Minimi Cord** - Small finger ulnar border - Extends from abductor digiti minimi to proximal phalanx - Causes small finger abduction contracture ## Ligamentous Anatomy Critical to Surgery **Grayson's Ligament** - Location: VOLAR to neurovascular bundle - Connects skin to flexor sheath volar to NVB - **Involved in Dupuytren's disease process** - Component of spiral cord pathology **Cleland's Ligament** - Location: DORSAL to neurovascular bundle - Connects skin to bone/periosteum dorsal to NVB - **Spared in Dupuytren's disease** - Helps identify NVB position (NVB lies between Grayson's and Cleland's) **Clinical Pearl**: In spiral cord, diseased Grayson's ligament contracts and pulls NVB centrally and volarward - surgeon must identify NVB before excising cord. ## Neurovascular Anatomy **Digital Nerve Anatomy** - Common digital nerves from median and ulnar nerves - Bifurcation at web space into proper digital nerves - Proper digital nerves: one to each side of adjacent fingers - Normal position: mid-lateral line of digit - **Displaced by spiral cord**: centrally and volarly up to 1cm **Digital Artery Anatomy** - Common digital arteries from superficial palmar arch - Bifurcation at web space into proper digital arteries - Run with digital nerves as neurovascular bundle - May have atherosclerotic changes in diabetics and elderly ## Pathophysiology of Contracture **Cellular Level** - Myofibroblast proliferation with increased contractile activity - Excessive collagen deposition (predominantly Type III collagen) - Abnormal extracellular matrix composition - Cytokine-mediated process (TGF-beta, PDGF, bFGF) **Macroscopic Changes** - Fascial thickening and cord formation - Skin adherence to underlying diseased fascia - Secondary soft tissue contractures at PIP joint - Check-rein ligaments (accessory collateral ligaments) contracture - Volar plate contracture and shortening - Articular cartilage changes from chronic positioning ## Tubiana Classification (Most Important for Exams) **Based on Total Passive Extension Deficit (TPED) per digit** **Stage I: 0-45 degrees TPED** - Usually isolated MCP contracture - Excellent prognosis with surgery - 80-90 percent correction achievable - Low recurrence risk **Stage II: 45-90 degrees TPED** - MCP and early PIP involvement - Good prognosis with surgery - 70-80 percent correction achievable - Moderate recurrence risk **Stage III: 90-135 degrees TPED** - Significant PIP contracture present - Guarded prognosis - 50-70 percent correction achievable - Higher recurrence risk - May require skin grafting **Stage IV: Greater than 135 degrees TPED** - Severe MCP and PIP contracture - Poor prognosis for full correction - Less than 50 percent PIP correction typical - Very high recurrence risk - Consider dermofasciectomy, arthrodesis, or amputation **Clinical Pearl**: Tubiana stage correlates directly with surgical outcomes and recurrence risk. Stage I-II have excellent results, Stage III-IV have guarded outcomes, especially for PIP correction. ## Luck Classification (Historical) **Grade 1: Nodule** - Palpable palmar or digital nodule - No contracture - Observation only **Grade 2: Nodule and Cord** - Palpable cord formation - May have early contracture - Consider treatment if functional impairment **Grade 3: Contracture** - Established flexion contracture - Cord and skin changes - Surgical intervention indicated ## Iselin Classification (Based on Anatomy) **Type 1: Palmar** - Disease limited to palm - Pretendinous cords **Type 2: Palmar-Digital** - Extension into digits - Central cords, may include spiral **Type 3: Digital** - Disease primarily in digits - Higher complexity **Type 4: Commissural** - Web space involvement - Natatory cords ## Dupuytren's Diathesis (Prognostic Factors) **High-Risk Features for Aggressive Disease and Recurrence** - Young age at onset (less than 50 years) - Bilateral hand involvement - Family history (autosomal dominant pattern) - Ectopic disease (Ledderhose plantar fibromatosis, Peyronie's disease) - Knuckle pads (Garrod's pads) - Northern European descent (Viking disease) **Clinical Significance**: Patients with diathesis have 50-80 percent recurrence risk versus 20-30 percent without diathesis. Consider dermofasciectomy (excise skin and fascia, skin graft) for severe diathesis and recurrent disease. ## Meyerding-Black Classification (Web Space) **Grade I**: Normal web **Grade II**: Narrowed web **Grade III**: Severely narrowed web requiring release ## Regional (Segmental) Fasciectomy - Standard Technique **Definition**: Excision of diseased fascial cords and segments while preserving normal fascia. Most commonly performed technique - balance between radical fasciectomy (remove all fascia) and limited fasciectomy (single cord only). **Advantages** - Lower morbidity than radical fasciectomy - Preserves normal anatomy and fascial planes - Adequate disease removal for most cases - Better functional recovery than radical technique **Disadvantages** - Higher recurrence than radical fasciectomy (20-40 percent versus 10-20 percent at 5 years) - Technically demanding to distinguish diseased from normal fascia - May leave microscopic disease at margins ## Limited Fasciectomy **Definition**: Excision of single cord through limited incision **Indications** - Isolated single cord - First-time surgery - Patient preference for limited surgery **Advantages** - Smaller incision and less morbidity - Faster recovery - Lower complication rate **Disadvantages** - Higher recurrence rate (30-50 percent at 5 years) - May miss additional diseased tissue - Not suitable for extensive disease ## Radical (Total) Fasciectomy **Definition**: Excision of ALL palmar and digital fascia including normal tissue **Indications** (Rarely Performed) - Severe Dupuytren's diathesis - Multiple recurrences - Extensive bilateral disease in young patient **Advantages** - Lowest recurrence rate (10-20 percent at 5 years) - Removes all potential disease tissue **Disadvantages** - Highest morbidity and complication rate - Prolonged recovery (6-12 months) - Higher nerve injury risk (10-15 percent) - Higher hematoma and wound complication rate - Stiffness from extensive dissection ## Dermofasciectomy **Definition**: Excision of diseased fascia AND overlying skin, followed by full-thickness skin grafting **Indications** - Severe PIP contracture (greater than 90 degrees) - Recurrent disease after previous fasciectomy - Severe Dupuytren's diathesis - Ischemic or severely contracted skin **Advantages** - Lowest recurrence rate (5-10 percent at 5 years) - Removes diseased skin component - Allows complete contracture release **Disadvantages** - Requires skin graft and donor site - Prolonged healing (6-8 weeks) - Potential graft failure - Cosmetic issues - Most extensive surgery **Technique Specifics** - Excise skin and fascia en bloc - Full-thickness skin graft from groin or medial arm - Secure with tie-over bolster for 5-7 days - Immobilize in extension for 1-2 weeks before starting motion ## McCash Open Palm Technique **Definition**: Transverse palm incisions left OPEN to heal by secondary intention **Indications** - Palmar disease requiring transverse incisions - High bleeding risk patients - Skin deficiency anticipated **Advantages** - Low hematoma rate (near zero with open wounds) - Low infection rate (drainage provided) - Can manage skin deficiency without grafting - Good long-term outcomes - Lower recurrence than expected (15-25 percent at 5 years) **Disadvantages** - Prolonged wound healing (3-4 weeks) - Daily dressing changes required - Patient anxiety about open wound - Not suitable for digital incisions (contracture risk) **Technique Specifics** - Transverse incisions in palm parallel to flexion creases - Excise diseased cords - Leave wounds OPEN (do not suture) - Pack with non-adherent dressing, change daily - Digital incisions MUST be closed (Bruner zigzag) - Healing by secondary intention over 3-4 weeks - Low pain, good function during healing ## Comparison of Fasciectomy Techniques **Recurrence Rates at 5 Years** - Dermofasciectomy: 5-10 percent (lowest) - Radical fasciectomy: 10-20 percent - Regional fasciectomy: 20-40 percent - Limited fasciectomy: 30-50 percent (highest) **Complication Rates** - Limited: 5-10 percent (lowest) - Regional: 10-20 percent - Radical: 20-30 percent (highest) - Dermofasciectomy: 15-25 percent **Recovery Time** - Limited: 6-12 weeks - Regional: 12-16 weeks (Standard) - Radical: 24-48 weeks - Dermofasciectomy: 16-24 weeks **Exam Pearl**: Regional fasciectomy is the STANDARD technique - best balance of recurrence versus morbidity. Reserve radical for extensive disease and dermofasciectomy for severe recurrent disease or severe PIP contracture. ## Outcomes Data **Contracture Correction Rates** **MCP Joint Contracture** - 80-90 percent correction achieved with regional fasciectomy - Excellent outcomes regardless of severity - Tubiana Stage I-II: 90-95 percent correction - Tubiana Stage III-IV: 70-80 percent correction - Residual contracture 0-10 degrees acceptable **PIP Joint Contracture** - 50-70 percent correction achieved (significantly worse than MCP) - Outcomes correlate with preoperative severity - PIP less than 45 degrees preop: 80-90 percent correction - PIP 45-90 degrees preop: 60-70 percent correction - PIP greater than 90 degrees preop: 40-50 percent correction - Severe PIP contracture (greater than 90 degrees) has particularly poor prognosis **Factors Affecting PIP Outcomes** - Duration of contracture (longer = worse outcome) - Severity of contracture (greater than 90 degrees = poor) - Age (elderly = worse outcomes) - Diabetes (worse outcomes) - Secondary soft tissue contractures (check-reins, volar plate) - Articular cartilage changes from chronic positioning ## Recurrence Rates **Definition of Recurrence**: Return of palpable cord with contracture greater than 20 degrees in previously treated digit **Recurrence by Technique** (5-year data) - Dermofasciectomy: 5-10 percent - Radical fasciectomy: 10-20 percent - Regional fasciectomy: 20-40 percent - Limited fasciectomy: 30-50 percent - Needle aponeurotomy: 50-80 percent - Collagenase injection: 50-70 percent **Risk Factors for Recurrence** - Dupuytren's diathesis (50-80 percent recurrence) - Young age (less than 50 years: 60-70 percent recurrence) - Bilateral disease - Family history - Ectopic disease (Ledderhose, Peyronie's) - Incomplete fasciectomy - Limited fasciectomy technique - Severe initial contracture (Tubiana III-IV) **Time Course** - Median time to recurrence: 3-5 years - Early recurrence (less than 1 year): residual disease - Late recurrence (greater than 5 years): new disease ## Complication Rates **Digital Nerve Injury**: 3-5 percent overall - Spiral cord: 8-10 percent - Retrovascular cord: 15-20 percent - Pretendinous cord: 1-2 percent - Neuropraxia versus transection - Risk factors: revision surgery (10-15 percent), spiral cord, aggressive disease **Skin Flap Necrosis**: 2-5 percent - Risk factors: smoking, diabetes, thin flaps, tension closure - Usually partial flap necrosis - Management: local wound care, may require skin graft **Hematoma**: 5-10 percent with closed technique - Near zero with McCash open palm - Risk factors: anticoagulation, poor hemostasis - Prevention: meticulous hemostasis, consider McCash **Infection**: 1-2 percent - Low rate with meticulous technique - Open palm technique not associated with higher infection - Risk factors: diabetes, immunosuppression, hematoma **CRPS (Complex Regional Pain Syndrome)**: 5-10 percent - Type I (reflex sympathetic dystrophy) - Diagnosis: pain, swelling, stiffness, temperature changes, sudomotor changes - Management: early recognition, hand therapy, sympathetic blocks, medications **Stiffness**: 10-20 percent - From adhesions, inadequate therapy, CRPS - Prevention: early motion, adequate therapy compliance - May require tenolysis if severe **Residual Contracture**: Variable - MCP: 10-20 percent have residual greater than 20 degrees - PIP: 40-60 percent have residual greater than 20 degrees - Severe PIP: 80-90 percent have residual contracture ## Patient Satisfaction **Overall Satisfaction**: 75-85 percent - Higher for MCP-predominant disease (85-90 percent) - Lower for PIP-predominant disease (60-70 percent) - Satisfaction correlates with functional improvement and recurrence **Return to Work** - Light duty: 6-12 weeks - Manual labor: 12-16 weeks - Full strength: 4-6 months **Functional Outcomes** - DASH scores improve 30-40 points postoperatively - Grip strength recovers to 80-90 percent of contralateral by 6 months - ADL improvement in 80-90 percent of patients ## Evidence-Based Recommendations **Level I Evidence** - Fasciectomy superior to needle aponeurotomy for long-term contracture correction - No difference between limited and regional fasciectomy in MCP contracture correction, but regional has lower recurrence - Collagenase injection effective for isolated MCP contracture but high recurrence rate **Level II Evidence** - Dermofasciectomy has lowest recurrence rate but highest morbidity - McCash open palm technique has equivalent outcomes to closed technique with lower hematoma rate - Early motion (3-5 days postop) superior to prolonged immobilization **Level III Evidence** - Preoperative identification of spiral cord associated with higher nerve injury risk - Severe PIP contracture (greater than 90 degrees) has poor outcomes with fasciectomy - consider arthrodesis or amputation - Dupuytren's diathesis associated with 2-3 fold increased recurrence risk ### Step 1: Preoperative Assessment and Planning **TUBIANA CLASSIFICATION**: Stage I (0-45 degrees), II (45-90 degrees), III (90-135 degrees), IV (greater than 135 degrees). Document total passive extension deficit (TPED) for each affected digit. Assess skin quality: blanching indicates ischemic skin (may need excision and grafting), puckering indicates adherence (difficult flap elevation), fixed skin indicates severe disease. Identify disease pattern by palpation: pretendinous cord (midline palm/digit), central cord (A1 pulley to middle phalanx), spiral cord (lateral digital sheet spiraling around digit - HIGH RISK for NVB displacement), natatory cord (web space), retrovascular cord (distal to NVB - EXTREMELY HIGH RISK). Mark diseased cords and planned incisions with surgical marker. Counsel patient regarding: nerve injury risk (3-5 percent overall, higher with spiral cord), recurrence risk (20-50 percent at 5 years, higher with diathesis), prolonged hand therapy requirements (3-6 months), realistic expectations for PIP correction (50-70 percent versus 80-90 percent for MCP). **Exam Key**: Spiral cord anatomy is HIGH YIELD for exams. Components: pretendinous band (origin in palm), spiral band, lateral digital sheet, Grayson's ligament (volar to NVB), natatory ligament. As spiral cord contracts, it displaces neurovascular bundle CENTRALLY and VOLARLY by up to 1cm from normal mid-lateral position. Most common in ring and small fingers. Retrovascular cord passes DISTAL to NVB bifurcation - requires microsurgical technique. Tubiana stage directly correlates with outcomes: Stage I-II have excellent results (80-90 percent correction), Stage III-IV have guarded outcomes (50-70 percent correction), especially for PIP contracture. - Underestimating nerve injury risk with spiral or retrovascular cords - inadequate patient consent - Failing to identify ischemic skin preoperatively - flap necrosis if attempt to preserve - Not documenting Dupuytren's diathesis features - higher recurrence risk not addressed in counseling - Inadequate patient counseling regarding recurrence risk and therapy commitment ### Step 2: Positioning and Anesthesia Position patient SUPINE with affected arm extended on radiolucent hand table. Arm abducted 90 degrees at shoulder. Hand table at appropriate height with sterile foam padding. Apply tourniquet to upper arm. General anesthesia or regional anesthesia (axillary block, Bier block, WALANT - wide awake local anesthesia no tourniquet). For WALANT: infiltrate 1 percent lidocaine with 1:100,000 epinephrine along planned incisions (20-30 minutes before incision for vasoconstriction). Inflate tourniquet to 250mmHg for upper arm (100mmHg above systolic). Exsanguinate with Esmarch bandage or elevation. Position loupe magnification (2.5-3.5x power strongly recommended for identifying neurovascular structures). Prepare and drape entire hand and forearm. Final check of marked incisions and diseased cords before skin incision. **Technical Pearl**: Loupe magnification (2.5-3.5x) is STRONGLY RECOMMENDED and considered standard of care for Dupuytren's surgery - improves identification and preservation of neurovascular bundles. WALANT technique gaining popularity: allows patient cooperation to test digit motion and sensation intraoperatively, eliminates tourniquet pain, can perform as outpatient without anesthesiologist. Disadvantage: no tourniquet hemostasis (must rely on epinephrine vasoconstriction). Tourniquet time limit 120 minutes - plan surgery accordingly. - Tourniquet pressure too low (inadequate hemostasis) or too high (nerve injury) - Tourniquet time exceeding 120 minutes (muscle and nerve ischemia) - Inadequate exsanguination (obscures surgical field) - Poor patient positioning (surgeon fatigue, suboptimal access) ### Step 3: Skin Incision Design and Execution **BRUNER ZIGZAG for digits**: Series of transverse incisions at 90-degree angles with 5mm offset from digit midline. Apex of each zigzag centered over flexion crease but NOT crossing perpendicularly (prevents scar contracture and wound breakdown). Each limb of zigzag should be 10-15mm in length. Design allows extensile exposure while maintaining flap perfusion (base wider than tip). **TRANSVERSE INCISIONS in palm**: Parallel to distal palmar crease and thenar crease. Multiple transverse incisions preferred over single longitudinal (avoids scar contracture). **Z-PLASTIES**: Plan for contracted areas - transpose flaps to lengthen skin in line of contracture. 60-degree angle Z-plasty provides 75 percent length gain. **McHSH TECHNIQUE option**: Leave transverse PALM incisions OPEN (not sutured) - heals by secondary intention over 3-4 weeks with low infection rate and excellent outcomes. NEVER straight longitudinal incisions in palm or digits (unacceptable scar contracture risk). Make skin incisions with 15-blade scalpel through skin only (not into subcutaneous tissue - preserve subdermal plexus). **Exam Key**: Bruner zigzag incision principles HIGH YIELD: 90-degree angles (not acute angles which compromise flap perfusion), 5mm offset (provides adequate flap base), NEVER cross flexion creases at 90 degrees (wound breakdown and hypertrophic scar), each limb 10-15mm (adequate exposure). McCash open palm technique: leave transverse palm incisions OPEN, dress daily with non-adherent gauze, healing by secondary intention 3-4 weeks. Advantages: near-zero hematoma rate (open drainage), low infection rate, can accommodate skin deficiency, excellent long-term outcomes. Contraindication: digital incisions (must close to prevent scar contracture). Skin grafting indicated if anticipated skin deficiency greater than 2cm after cord excision. - Straight longitudinal incisions (causes severe scar contracture - UNACCEPTABLE) - Crossing flexion creases at 90 degrees (wound breakdown, hypertrophic scar) - Acute angle flaps (less than 60 degrees - poor perfusion, tip necrosis) - Inadequate incision length (cannot close after cord excision, forced tension closure) - Incisions too short (inadequate exposure, risk to neurovascular structures) ### Step 4: Skin Flap Elevation Elevate skin flaps carefully using fine scissors (tenotomy or iris scissors) and Adson forceps with teeth. Dissect in plane JUST SUPERFICIAL to diseased fascia - preserve subcutaneous fat and vascular plexus on undersurface of skin. Diseased cord is often ADHERENT to overlying skin, especially in severe long-standing disease. If skin BLANCHES (ischemic) or is very THIN (less than 2mm), plan to EXCISE that segment and perform full-thickness skin graft rather than risk flap necrosis. Use spreading technique with scissors to develop correct plane between skin and fascia. Create flaps with adequate blood supply: base must be WIDER than tip (minimum 1.5:1 ratio), preserve longitudinal vessels running in subcutaneous tissue parallel to digit, handle skin gently with forceps (minimize crushing trauma). Identify normal from diseased tissue: diseased fascia is WHITE, GLISTENING, THICKENED, CORD-LIKE with loss of normal fascial translucency; normal fascia is THIN, TRANSLUCENT, wispy appearance. **Critical Pearl**: Skin flap perfusion is critical to avoid necrosis (2-5 percent incidence). Palmar skin blood supply: longitudinal arteries in subcutaneous fat from radial and ulnar systems. Preserve subdermal vascular plexus during flap elevation. If skin is severely adherent, ischemic (blanching with gentle traction), or thin (less than 2mm), EXCISE that skin segment and plan full-thickness skin graft - attempting to preserve ischemic skin leads to flap necrosis, infection, and poor outcome. Risk factors for flap necrosis: smoking (relative ischemia), diabetes (microvascular disease), previous surgery (scarring and altered blood supply), thin flaps (excessive dissection), poor flap design (tip too wide relative to base). - Excessive thinning of flaps (devascularization, necrosis risk) - Inadvertent entry into flexor sheath (tendon adhesions, infection risk) - Tearing adherent skin with forceps (ragged edges, difficult closure) - Preserving obviously ischemic skin (inevitable necrosis, infection) - Creating flaps with tip wider than base (poor perfusion, tip necrosis) ### Step 5: Identify and Protect Neurovascular Bundles - CRITICAL STEP **FIND THE NERVE FIRST** before cutting any diseased cord - this is the MOST CRITICAL principle of Dupuytren's surgery. Start dissection on ULNAR side of digit or palm (typically easier exposure, less disease burden). Use loupe magnification (2.5-3.5x mandatory for this step). Look for neurovascular bundle in ABNORMAL position - ASSUME displacement by spiral cord. Normal NVB position: mid-lateral line of digit at junction of dorsal and palmar skin. Spiral cord displacement: NVB moved CENTRALLY and VOLARLY by up to 1cm. Begin identification in proximal palm where anatomy is more normal, then trace distally. Use MICROSURGICAL technique: gentle spreading with fine tenotomy scissors, blunt dissection only around NVB, no sharp dissection near NVB until definitely identified. Digital nerve appears as PALE YELLOW cord with longitudinal striations, slightly glistening. Confirm by gentle palpation (nerve has characteristic firm but slightly compressible texture different from diseased fascia). Once identified, place VESSEL LOOP around NVB for protection and gentle retraction during cord excision. Identify common digital nerve bifurcation at web space level - particularly vulnerable to injury. Repeat process for radial NVB of affected digit. **EXAM CRITICAL**: This step is HIGHEST YIELD for viva questions. Examiners will ask: "How do you protect the neurovascular bundle?" Answer: "I identify the NVB BEFORE excising diseased cord, using loupe magnification and microsurgical technique. I start on the ulnar side where anatomy is easier. With spiral cord, I assume the NVB is displaced CENTRALLY and VOLARLY by up to 1cm from the normal mid-lateral position. I use gentle spreading with fine scissors to identify the nerve, place a vessel loop around it for protection, then excise the diseased cord away from the protected NVB." Know Grayson's versus Cleland's ligaments: Grayson's is VOLAR to NVB and INVOLVED in disease (component of spiral cord), Cleland's is DORSAL to NVB and SPARED. NVB lies BETWEEN Grayson's (volar) and Cleland's (dorsal) ligaments. Nerve injury rate: 3-5 percent overall, 8-10 percent with spiral cord, 15-20 percent with retrovascular cord, 10-15 percent in revision surgery. - Cutting diseased cord BEFORE identifying NVB (NERVE TRANSECTION - catastrophic error) - Assuming normal NVB anatomy (displaced by spiral cord - will transect if assume normal position) - Excessive traction on NVB during retraction (neuropraxia, even with intact nerve) - Injury to common digital nerve at bifurcation in web space (dual digital nerve injury) - Confusing diseased cord for nerve (both are pale cord-like structures - use gentle palpation to distinguish) - Using sharp dissection before NVB identified (high injury risk) ### Step 6: Dissect Diseased Cord from Flexor Sheath Once NVB identified and protected with vessel loops, dissect diseased palmar fascia and cords away from underlying structures. Flexor sheath lies immediately deep to diseased fascia in digits - appears as WHITE, GLISTENING, SMOOTH structure. In palm, identify flexor tendons deep to diseased pretendinous bands. Use BLUNT DISSECTION technique: spreading with tenotomy scissors between diseased cord and flexor sheath, develop plane with gentle spreading motions. Diseased cord may have FIBROUS ADHESIONS to sheath from chronic inflammation - these require careful sharp dissection to release while preserving sheath integrity. Once plane developed, use combination of blunt and sharp dissection to separate cord from sheath along entire length. Flexor sheath must be preserved completely - any violation leads to adhesions, triggering, stiffness. Identify flexor tendon pulleys: A1 pulley at MCP level may be thickened or contributing to contracture - consider release if causing triggering or limiting correction. However, PRESERVE A2 (proximal phalanx), A3 (PIP joint), A4 (middle phalanx) pulleys - critical for preventing bowstringing and maintaining mechanical efficiency. **Technical Key**: Flexor sheath anatomy HIGH YIELD for exams. Five annular pulleys (A1-A5) and three cruciate pulleys (C1-C3). CRITICAL pulleys for bowstringing prevention: A2 and A4 (must preserve). A1 pulley release permissible if: 1) Causing triggering, 2) Thickened and contributing to MCP contracture, 3) Limiting correction after fasciectomy. A3 pulley preservation preferred but can release if severe PIP contracture. Flexor sheath violation consequences: peritendinous adhesions (stiffness), triggering (if irregular repair), infection risk (communication with joint), prolonged recovery. If sheath violated: repair primarily with 6-0 nylon if edges healthy, accept if small (less than 5mm), consider sheath reconstruction if large defect. - Flexor sheath violation (adhesions, stiffness, triggering, infection) - Injury to flexor digitorum superficialis (FDS) or profundus (FDP) tendons - Unnecessary release of A2 or A4 pulleys (bowstringing - loss of mechanical efficiency, weak grip) - Incomplete separation of cord from sheath (residual contracture) - Aggressive dissection causing inflammation (adhesions, stiffness) ### Step 7: Segmental Fasciectomy - Excision of Diseased Cords With neurovascular bundles identified and protected, and diseased fascia separated from underlying flexor sheath, proceed with SEGMENTAL excision of diseased cords. **PROXIMAL extent**: Dissect to proximal palm, identifying transition from diseased (white, thickened, cord-like) to normal fascia (thin, translucent, wispy) - preserve normal proximal fascia. **DISTAL extent**: Follow diseased cord distally to its insertion (may extend to middle phalanx or DIP level) - excise completely. **LATERAL extent**: Excise diseased lateral digital sheet if involved (component of spiral cord). Use SHARP DISSECTION to divide diseased cord at proximal and distal ends after ensuring NVB protected. Excise en bloc when possible, or in segments if safer. **REGIONAL fasciectomy definition**: Remove all DISEASED segments while preserving NORMAL fascia (versus RADICAL fasciectomy which removes all palmar fascia including normal tissue - higher morbidity, rarely indicated). Send specimen to pathology (usually not required but document excision). Ensure complete removal of all diseased, contracted tissue to minimize recurrence risk - inspect carefully for residual bands causing contracture. **Exam Comparison**: SEGMENTAL/REGIONAL fasciectomy (standard technique) removes diseased cords only, preserves normal fascia - recurrence 20-40 percent at 5 years, morbidity 10-20 percent, recovery 12-16 weeks. LIMITED fasciectomy removes single cord only through limited incision - recurrence 30-50 percent, morbidity 5-10 percent, recovery 6-12 weeks - suitable for isolated single cord first-time surgery. RADICAL fasciectomy removes ALL palmar fascia including normal - recurrence 10-20 percent (lowest with fascial techniques), morbidity 20-30 percent (highest), recovery 24-48 weeks, nerve injury 10-15 percent - rarely indicated, reserved for extensive disease or multiple recurrences. DERMOFASCIECTOMY removes fascia AND skin with full-thickness skin graft - recurrence 5-10 percent (lowest overall), used for severe recurrent disease or severe PIP contracture greater than 90 degrees with poor skin. - Incomplete excision of diseased tissue (early recurrence within 1-2 years) - Excessive excision of normal fascia (increased morbidity without benefit) - Leaving residual diseased bands (persistent contracture, patient dissatisfaction) - Aggressive dissection causing hematoma or devascularization - Failure to send specimen for pathology if any atypical features (miss rare sarcoma) ### Step 8: Release PIP Joint Contracture if Present PIP joint contracture requires additional releases BEYOND fasciectomy - fascial excision alone is insufficient for severe PIP contracture. After fascial cord excision, gently attempt passive PIP extension - if significant residual contracture (greater than 20 degrees), proceed with sequential releases. **CHECK-REIN LIGAMENTS** (accessory collateral ligaments): Release from volar plate insertion - these ligaments run from proximal phalanx to volar plate and become contracted, preventing PIP extension. Identify on both radial and ulnar sides of PIP joint. Divide sharply from volar plate origin (distal) while protecting collateral ligaments (dorsal). **VOLAR PLATE**: If contracted and preventing extension, perform PROXIMAL release from proximal phalanx origin - preserve distal insertion to middle phalanx (prevents swan neck deformity). Can score or make transverse releases in contracted volar plate. **A3 PULLEY**: Preservation preferred, but can release if severe PIP contracture persists after check-rein and volar plate release. **INTRINSIC TIGHTNESS**: Test with Bunnell test (PIP flexion easier with MCP extended versus flexed) - if positive and limiting PIP extension, consider intrinsic release at MCP level. **CAPSULOTOMY**: Rarely needed - only for severe longstanding contracture with capsular fibrosis. **MANIPULATION**: NEVER forcefully manipulate PIP joint to gain extension - high risk for proximal phalanx fracture, especially in elderly patients with osteoporosis. Use gentle progressive passive extension only after soft tissue releases. **Exam High Yield**: PIP contracture corrects POORLY compared to MCP (50-70 percent versus 80-90 percent correction). Reasons: 1) Check-rein ligament contracture, 2) Volar plate contracture, 3) Collateral ligament shortening on volar side, 4) Articular cartilage changes from chronic flexion positioning, 5) Capsular contracture, 6) Skin contracture on volar side. Severe PIP contracture greater than 90 degrees has POOR prognosis (less than 50 percent correction typical). Alternative treatments for severe unreconstructable PIP contracture: PIP arthrodesis in 30-40 degrees flexion (provides stable pinch, eliminates pain), or ray amputation for small finger (improves power grip, removes non-functional digit). Dermofasciectomy (excise skin and fascia, full-thickness skin graft) gives best results for severe recurrent PIP contracture - recurrence only 5-10 percent. - Proximal phalanx FRACTURE from forceful manipulation (catastrophic - convert to long-term disability) - Digital nerve injury during deep PIP dissection (altered anatomy, NVB volar) - Excessive volar plate release (swan neck deformity from PIP hyperextension) - Injury to collateral ligaments (PIP instability) - Residual contracture from incomplete soft tissue releases (patient dissatisfaction) ### Step 9: Release Natatory Ligament and Web Space Contracture Web space contracture from natatory cord limits finger abduction and causes progressive narrowing of web (web creep). Identify natatory ligament at distal palm level, spanning commissure between adjacent digits. Natatory cord is diseased natatory ligament - thickened, contracted, cord-like. Protect common digital nerve BIFURCATION (particularly vulnerable during web space dissection - single injury affects two adjacent digits). Divide natatory ligament COMPLETELY - sharp transverse division at both proximal and distal attachments. Excise diseased natatory cord. Release superficial transverse metacarpal ligament if contributing to web contracture. After release, web space should allow normal finger abduction (can spread fingers apart). Address skin deficiency in web: plan **Z-PLASTY** to lengthen web skin and prevent recurrence. Four-flap Z-plasty or V-Y advancement techniques effective. Complete web release essential - inadequate release leads to web creep recurrence (progressive narrowing over time), limited abduction, functional impairment for grasp and wide objects. **Technical Pearl**: Natatory cord causes web space contracture - affects function significantly by limiting finger abduction (difficulty grasping wide objects, spreading fingers). Common digital nerve bifurcation at web space is HIGH RISK anatomic zone - single injury affects TWO adjacent digits (e.g., injury to common digital nerve to ring-small web affects ulnar side of ring finger AND radial side of small finger). Use loupe magnification and microsurgical technique in web space. Z-plasty principles: transverse limb in line of contracture, lateral limbs at 60 degrees (provides 75 percent length gain), transpose flaps to lengthen web. Skin grafting alternative if severe web contracture with inadequate local skin. Web creep (progressive narrowing) occurs with inadequate release or skin closure under tension - prevent with complete natatory cord excision and Z-plasty. - Injury to common digital nerve bifurcation (affects two digits with single injury) - Inadequate natatory ligament release (residual web contracture, limited abduction) - Poor Z-plasty design (inadequate lengthening, web creep recurrence) - Skin closure under tension (web creep, scar contracture) - Injury to digital arteries at bifurcation level ### Step 10: Assess Correction and Address Skin Deficiency After complete fasciectomy and soft tissue releases, release tourniquet and assess hemostasis. Achieve meticulous hemostasis with bipolar electrocautery (low settings near neurovascular structures). Assess passive digital extension - should achieve near-full extension (0-10 degrees residual acceptable for MCP, 10-20 degrees for PIP depending on preoperative severity). Assess SKIN DEFICIENCY: attempt to approximate wound edges without tension - if cannot close easily, DO NOT force closure under tension. Skin deficiency occurs in 10-20 percent of cases. **Management options**: **1) Z-PLASTY**: Transpose local flaps to lengthen skin in line of contracture - 60-degree angle Z-plasty provides 75 percent length gain. Multiple small Z-plasties can be used. **2) FULL-THICKNESS SKIN GRAFT (FTSG)**: For defects greater than 2cm after cord excision. Donor sites: hypothenar eminence (best color match, minimal donor morbidity), medial arm, groin (larger grafts available), volar wrist crease. Harvest FTSG with 15-blade, remove all subcutaneous fat, create template of defect, secure graft with 5-0 chromic interrupted sutures, apply tie-over bolster dressing. **3) McASH OPEN PALM TECHNIQUE**: Leave transverse PALM wounds open (not sutured), heal by secondary intention over 3-4 weeks. Advantages: accommodates skin deficiency, near-zero hematoma rate, low infection, good outcomes. NOT suitable for digital wounds (must close digits to prevent scar contracture). **Exam Key**: Skin deficiency management HIGH YIELD. NEVER close under tension - consequences: skin ischemia and necrosis, flap loss, recurrent flexion contracture (skin pulls digit into flexion as wound contracts), patient morbidity. McCash open palm healing: leave transverse palm incisions open, pack with non-adherent gauze (Xeroform, Adaptic), change dressing daily, epithelialization from wound edges, complete healing 3-4 weeks, excellent functional outcomes, low infection rate despite open wound (hand has excellent blood supply and drainage prevents infection). Digital incisions MUST be closed (Bruner zigzag closed with 4-0 or 5-0 nylon) - open digital wounds lead to severe scar contracture. Full-thickness skin graft superior to split-thickness (better color match, less contracture, better durability, but requires adequate recipient bed vascularity). - Closing skin under tension (flap necrosis, recurrent contracture, poor outcome) - Inadequate skin graft fixation (shearing, hematoma under graft, graft loss) - Hematoma under skin graft (prevents revascularization, graft failure) - Using split-thickness skin graft (excessive contracture, poor durability, color mismatch) - Leaving digital incisions open (severe scar contracture along digit) ### Step 11: Wound Closure and Dressing Application Close skin incisions with 4-0 or 5-0 nylon interrupted sutures (monofilament preferred - less infection risk, easier removal). For Bruner zigzag incisions: suture APEX first to align flaps correctly, then close limbs of zigzag side-to-side. Avoid excessive tension on sutures (skin edge ischemia). If full-thickness skin graft placed: secure with 5-0 chromic interrupted sutures around periphery (6-8 sutures), then create TIE-OVER BOLSTER dressing over graft. Bolster technique: leave long tails on chromic sutures, place non-adherent gauze over graft, place cotton ball or gauze roll on top, tie chromic suture tails over bolster to create even pressure (prevents hematoma and shear). Bolster remains in place 5-7 days. If McCash open palm used: pack open palm wounds with non-adherent dressing (Xeroform or Adaptic), cover with gauze. Apply bulky DRESSING: fluffed gauze around digits and hand, wrap with Kerlix or Kling gauze, apply EXTENSION SPLINT. Splint position: wrist 30 degrees extension, MCP joints 0 degrees (neutral), PIP and DIP joints 0 degrees (full extension achievable). Splint fabricated from plaster or thermoplastic, extends from fingertips to proximal forearm on VOLAR surface. Splint purpose: maintain correction during early healing, prevent immediate re-contracture from wound contracture forces. **Post-op Protocol Key**: Extension splint is ESSENTIAL for good outcome - maintains surgical correction during healing phase. Protocol: Splint removed for hand therapy exercises starting day 3-5, but replaced between therapy sessions. Night splinting continued for 3-6 MONTHS (compliance critical for preventing recurrence). Studies show night splinting for less than 3 months associated with higher recurrence rate. Tie-over bolster for skin graft: provides uniform pressure to eliminate dead space under graft, prevents hematoma (main cause of graft failure), prevents shear movement (disrupts neovascularization), kept in place 5-7 days then removed and graft assessed. Suture removal: palm and digit incisions at 10-14 days (earlier removal risks dehiscence, later removal causes stitch marks). - Inadequate splinting in extension (immediate re-contracture within days to weeks) - Excessively tight dressing (compartment syndrome, vascular compromise) - Hematoma formation under skin graft (graft failure - most common cause) - Bolster too tight (graft ischemia) or too loose (hematoma, shear) - Splint malposition (MCP flexion allows PIP extension contracture) ### Step 12: Assess Neurovascular Status Before Leaving Operating Room MANDATORY final step before leaving operating room. Release tourniquet and wait 5 minutes for reperfusion. Assess EACH affected digit systematically: **1) CAPILLARY REFILL**: Compress fingertip nail bed and release - should pink up in less than 2 seconds. Delayed capillary refill (greater than 3 seconds) indicates arterial insufficiency. **2) COLOR**: Digit should be pink - pale indicates arterial insufficiency, blue/purple indicates venous congestion. **3) TEMPERATURE**: Palpate digit - should be warm. Cool indicates vascular compromise. **4) SENSORY**: Test two-point discrimination on radial and ulnar sides of digit - compare to preoperative baseline documented in chart. Test light touch with fingertip. Patient should have intact sensation (may have paresthesias from anesthetic or retraction - document). **5) MOTOR**: If WALANT anesthesia, can test active flexion. **6) ALLEN'S TEST**: If concern for radial or ulnar artery injury during palm dissection. Document all findings in operative note. If ANY concern for neurovascular injury: re-explore immediately while still in operating room - early recognition and repair critical for outcome. **Exam Critical**: Neurovascular assessment is MEDICOLEGAL issue - must document in operative note. Digital nerve injury occurs in 3-5 percent (spiral cord 8-10 percent, retrovascular cord 15-20 percent, revision surgery 10-15 percent). Nerve injury may be: **NEUROPRAXIA** (stretch injury, intact nerve, temporary deficit, recovers over weeks to months), **NEUROTMESIS** (complete transection). If nerve transected and recognized intraoperatively: PRIMARY REPAIR is treatment of choice - using microsurgical technique, 8-0 or 9-0 nylon interrupted epineural sutures, tension-free repair (may need mobilization or flexion of PIP joint to relieve tension), use operating microscope or loupes. Prognosis: good for pure sensory digital nerves if repaired primarily. If nerve injury recognized postoperatively: initially observe (may be neuropraxia), if no recovery by 3 months on EMG/NCS, explore and perform nerve grafting (sural nerve or medial antebrachial cutaneous nerve donor). Delayed repair has worse outcomes than primary repair. - Unrecognized nerve transection in operating room (delayed diagnosis, need for grafting, worse outcome) - Unrecognized arterial injury (digit ischemia, necrosis, amputation) - Unrecognized venous congestion (skin flap loss, digit loss) - Hematoma causing compartment syndrome (unrecognized until postop - may cause permanent stiffness) - Inadequate documentation (medicolegal risk if complication develops) **Day 0-2: Immediate Postoperative** - Bulky dressing with extension splint remains in place - Elevate hand above heart level (reduce edema and hematoma risk) - Ice therapy: 20 minutes on, 20 minutes off while awake (reduce pain and swelling) - Pain control: regional block for first 12-24 hours, then oral analgesics (acetaminophen, NSAIDs, short-term opioids if needed) - Neurovascular checks every 2 hours for first 24 hours (nursing protocol) - Watch for warning signs: increasing pain (compartment syndrome, hematoma), numbness (nerve injury, compression), color change (vascular compromise) **Day 3-5: Early Motion Phase** - First dressing change and wound assessment - Begin ACTIVE ROM exercises with hand therapist - Splint removed for therapy sessions (3-4 times daily, 15-20 minutes each) - Exercises: gentle composite flexion, isolated PIP and DIP flexion, full active extension, tendon gliding exercises - Replace splint between therapy sessions and continuously at night - Edema control: elevation, compression glove, retrograde massage - If McCash open palm: begin daily dressing changes with non-adherent gauze **Day 10-14: Suture Removal** - Remove nylon sutures from closed incisions - If skin graft: remove tie-over bolster at day 5-7, assess graft take (should be pink and adherent) - Continue active ROM exercises, increase frequency to 6-8 times daily - Begin scar massage with vitamin E cream or silicone gel (prevents hypertrophic scar) - Continue splinting between exercises and all night **Week 2-6: Progressive Motion** - Progressive ROM: increase flexion and extension range - Edema control: compression glove, Coban wrapping, retrograde massage - Scar management: massage, silicone gel sheeting, pressure garment - Continue extension splinting between therapy and night - Assess for complications: CRPS (pain, swelling, color changes, temperature changes, sudomotor dysfunction), infection, stiffness - If McCash open palm: wounds should be 75-90 percent healed by week 4 **Week 6-12: Strengthening Phase** - Begin gentle strengthening exercises: therapy putty, graded grippers, functional activities - Progressive resistance exercises - Work simulation for return to employment - Continue night splinting (critical - continue for 3-6 months total) - Expect 80-90 percent of final motion achieved by 12 weeks **Month 3-6: Maturation Phase** - Continue strengthening and functional activities - Night splinting continues through 6 months (compliance critical for preventing recurrence) - Scar maturation (scars soften and fade over 12-18 months) - Full recovery typically 6 months (return to all activities including heavy labor) **Expected Outcomes** - MCP contracture: 80-90 percent correction (excellent) - PIP contracture: 50-70 percent correction (guarded, especially if severe) - Grip strength: recover to 80-90 percent of contralateral hand by 6 months - Return to work: light duty 6-12 weeks, manual labor 12-16 weeks - Patient satisfaction: 75-85 percent overall (higher for MCP disease, lower for PIP disease) **Recurrence Counseling** - Recurrence risk: 20-50 percent at 5 years (median 3-5 years) - Higher with Dupuytren's diathesis (young age, bilateral, family history, ectopic disease) - Regular follow-up to monitor for recurrence - Repeat surgery possible but higher nerve injury risk (10-15 percent in revision surgery) ## References 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. **Level II evidence** - Systematic review comparing fasciectomy techniques, regional fasciectomy best balance of recurrence versus morbidity. 2. Dias JJ, Braybrooke J. Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg Br. 2006;31(5):514-521. **Level III evidence** - Large case series demonstrating MCP correction 80-90 percent versus PIP correction 50-70 percent, worse outcomes with severe PIP contracture. 3. Ullah AS, Dias JJ, Bhowal B. Does a 'firebreak' full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture?: a prospective trial of operated hands. J Bone Joint Surg Br. 2009;91(3):374-378. **Level I evidence** - RCT showing dermofasciectomy (skin graft) reduces recurrence to 5-10 percent versus 20-40 percent with fasciectomy alone. 4. Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytren's contracture unfolded. BMJ. 2006;332(7538):397-400. **Level V evidence** - Expert review of Dupuytren's disease pathophysiology, anatomy of spiral cord and neurovascular bundle displacement, and surgical principles. 5. McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren's contracture. Displacement of the neurovascular bundle. Plast Reconstr Surg. 1974;54(1):31-44. **Classic paper** - Describes spiral cord anatomy and mechanism of neurovascular bundle displacement (centrally and volarly up to 1cm), fundamental to understanding nerve injury risk. 6. McCash CR. The open palm technique in Dupuytren's contracture. Br J Plast Surg. 1964;17:271-280. **Classic technique paper** - Original description of leaving transverse palm wounds open to heal by secondary intention, demonstrating low hematoma rate, low infection, and good long-term outcomes. 7. Tonkin MA, Burke FD, Varian JP. Dupuytren's contracture: a comparative study of fasciectomy and dermofasciectomy in one hundred patients. J Hand Surg Br. 1984;9(2):156-162. **Level III evidence** - Comparative study showing dermofasciectomy recurrence 5 percent versus regional fasciectomy 20 percent at 5 years, but higher morbidity. 8. Rodrigues JN, Becker GW, Ball C, et al. Surgery for Dupuytren's contracture of the fingers. Cochrane Database Syst Rev. 2015;(12):CD010143. **Level I evidence** - Cochrane systematic review of surgical techniques, confirms fasciectomy superior to needle aponeurotomy for contracture correction and recurrence. 9. Citron N, Messina JC. The use of skeletal traction in the treatment of severe primary Dupuytren's disease. J Bone Joint Surg Br. 1998;80(1):126-129. **Level IV evidence** - Case series demonstrating external fixation and gradual correction as alternative for severe PIP contracture, outcomes comparable to aggressive releases. 10. Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren's contracture surgery. J Hand Surg Am. 2005;30(5):1021-1025. **Level III evidence** - Large series documenting complication rates: nerve injury 3-5 percent (spiral cord 8-10 percent), skin flap necrosis 2-5 percent, hematoma 5-10 percent, CRPS 5-10 percent, recurrence 20-50 percent at 5 years.

Dupuytren's Fasciectomy - Regional (Segmental) Fasciectomy

Dupuytren's Fasciectomy - Regional (Segmental) Fasciectomy