RISK FACTORS :Smoking (mean 16 pack-years, odds ratio 2.8), Increasing age, Male/Caucasian, Diabetes mellitus (one-third affected, increases with time, usually mild; middle and ring finger involved), Epilepsy, Chronic illness
Medical Care: No medical treatment has long-term value in halting or reversing the progression of contracture.
Surgical Care: The goal of surgical care is to excise or incise the diseased fascia. This treatment does not cure the disease but is meant to prevent progression to severe debilitating joint contractures.
" Indications for surgery
o Surgery is indicated with MCP joint contracture of 30Β° or more. When the MCP joint is involved, there is no rush to operate because even long-standing and severe contractures of the MCP joint are usually corrected readily at surgery and usually do not recur.
o PIP joint contractures do not have the same prognosis. Excising or incising involved fascia may not correct the joint contracture, particularly those of long duration. Proceed with surgery as soon as PIP joint contractures are observed.
o Functional disability is a subjective symptom that may sometimes be an indication for surgery, but only if the patient clearly understands the potential morbidity and that the process is occasionally exacerbated by the operation.
o In bilateral cases, the worst or dominant hand should be operated on first, allowing an interim healing period of 6-8 weeks before proceeding with surgery on the contralateral hand.
" Choice of operation
o Fasciotomy involves incising the involved fascia. It may provide short-term relief but is also associated with a very high recurrence rate. This procedure may correct an MCP joint contracture but almost certainly will not correct a PIP joint deformity. Reserve fasciotomy for elderly or debilitated patients who are unable to tolerate a more lengthy procedure.
o Extensive fasciectomy involves removing as much fascia as possible, including that which is grossly normal. Today, this procedure is not commonly performed because of the increased associated morbidity, including hematoma risk and prolonged postoperative edema and stiffness. Some authors prefer to leave the skin wound open to heal by secondary intention as a means of decreasing hematoma risk.
o Dermofasciectomy removes the diseased fascia as well as the overlying skin. Resurface the wound with a full-thickness skin graft. Recurrence rates are quite low with this approach. Because of the radical nature of this procedure, it is usually reserved for patients with recurrent or severe disease.
o Regional fasciectomy involves excising only grossly involved fascia. Although it has clearly been shown that the disease process extends into clinically normal palmar fascia, this approach has proven successful in correcting MCP joint contractures and some PIP joint contractures and carries an acceptably low morbidity rate.
" Use loupe magnification during the procedure to help identify and preserve delicate structures. Use general, axillary block, or Bier block anesthesia. Place a pneumatic tourniquet on the operative extremity. Insufflate the tourniquet after the arm has been exsanguinated with elastic wrap or elevation.
" Incisions vary and may be transverse, zigzag, or longitudinal, depending on the region involved. Elevate the skin off the underlying diseased palmar fascia. Identify all the neurovascular bundles that may be in jeopardy during dissection and subsequent excision. Each involved finger has a radial and ulnar neurovascular bundle that must be identified. Identify the bundles from proximal to distal, or vice versa, depending on surgeon preference and ease of dissection. The neurovascular bundles may be displaced, distorted, or centralized by the contraction of the components of the palmar fascia. Usually, a plane of dissection between the diseased palmar fascia and neurovascular bundles can be developed with careful blunt dissection. Immediately repair any inadvertent injury to the neurovascular bundle under surgical microscope.
" After the full course of each neurovascular bundle has been identified and dissected away from the diseased palmar fascia, excise the diseased fascia. The MCP joint is usually fully corrected by this maneuver. Manage PIP joints that have residual flexion of less than 30Β° with postoperative splinting and hand therapy. If PIP joint flexion is still greater than 30Β° following fasciectomy, consider whether further procedures would improve function. The initial step should be to release the flexor tendon sheath because the flexor tendon may become foreshortened secondary to the prolonged contracture and may be causing the residual deficit. If this fails to improve PIP extension, consider releasing the accessory collateral ligaments from the volar plate. Alternatively, consider releasing the checkrein ligaments or proximal attachment of the volar plate to the proximal phalanx. If these maneuvers fail to improve the flexion contracture, proceed to closure and use an aggressive course of postoperative splintingand hand therapy to improve function.
" Release the pneumatic tourniquet and cauterize the bleeding sites with bipolar cautery. Use meticulous hemostasis to prevent postoperative hematoma. Close the skin with interrupted or running absorbable or nonabsorbable suture material. Consider modifying skin closure with a Z-plasty or V-Y advancement to provide additional length without undue tension. If skin grafting is necessary to close the wound, use a full-thickness graft to minimize wound contracture during healing.
" Postoperatively, dress the hand and place it in a splint. Immobilize the wrist in neutral or slight flexion to relax the palmar skin and to allow MCP and PIP joint extension.
Activity: Postoperatively, maintain the hand in the original dressing and splint and strictly elevate for 2 days. At this time, follow-up care with the hand surgeon and referral to an occupational therapist is required; ideally, the patient should see both simultaneously. After removing the initial surgical dressing, fit the patient with a comfortable Thermoplast splint, which should be worn throughout the rehabilitative process. A static dorsal forearm splint with the wrist in neutral or slight flexion that permits the use of uninvolved fingers is recommended. This splint counteracts the natural tendency of scars to contract and helps overcome any residual PIP joint contracture.
" Rehabilitation is a gradual process of increasing activity and decreased splinting to achieve optimal restoration of movement. Frequent visits to the occupational therapist help to restore preoperative flexion and to maintain extension gained at the time of surgery. Patient motivation and severity of disease dictate the intensity and duration of therapy.
" The splint may be removed several times daily beginning on postoperative day 2 to allow active and passive range of motion of the digits. Provide adequate oral analgesics to promote patient comfort and therapy compliance. Activity may be increased as tolerated, and heat applied prior to therapy may improve tissue elasticity and patient comfort.
" Request the occupational therapist to regularly record objective measurements of function to monitor progress, facilitate communication with the hand surgeon, and encourage patient compliance. The patient should perform simple exercises at regular intervals every day.
" Final results are realized in approximately 6 weeks. Following this period, patients should wear the splint nightly for an additional 3-6 months, at the discretion of the occupational therapist and hand surgeon, to maintain extension and prevent scar contracture. Silastic pads, stretching, and scar massage are useful adjuncts to promote scar softening and maturation. The patient can expect to return to normal activities within 2-3 months.
POSSIBLE COMPLICATIONS :
. Post-surgery development of refl ex sympathetic dystrophy
. Postoperative recurrence or extension 46-80%
. Postoperative hand edema and skin necrosis
. Digital infarction
EXPECTED COURSE/PROGNOSIS :
. Typical
. Unpredictable, but usually slowly progressive
. Patients likely to have aggressive disease (one or more) < 40 at onset, knuckle pads, positive family history, bilateral disease involving radial side of hand
. Reports of clinical regression with continuous passive skeletal traction in extension and under a skin graft
. Recurrence rate after surgery is 10-34%
. Prognosis better for MP joint vs PIP joint after surgery
. Atypical
. Nonprogressive
. Surgery rarely needed
. Recurrence unlikely if surgery performed