This video demonstrates the technique of regional fasciectomy. Good long-term functional results are possible with regional fasciectomy and Z-plasties as seen in this patient with preoperative small and ring finger contractures, including the PIP joint of the small finger. This illustrative patient has contractures of the first web space as well as in the distal palm and extending up to small and ring fingers. Z-plasty flaps are drawn out preliminarily with attention paid so as not to have future flaps pulling against each other when they are inset. Perhaps counter-intuitively, it is unnecessary to design Z-plasty flaps so that they will fall into the natural finger skin creases as seen in the dotted lines. The thinnest part of the flap is actually right at the base at the skin crease, and if the skin crease traverses the base of the Z-plasty flap, then there is potential risk of flap necrosis. The desired flap outline is therefore shown in bold. Avoid undermining to preserve deep blood supply. This is especially important for the distally-based web space flap as seen here in the first case that we presented. Dissection starts in the distal palm, where the digital neurovascular structures are known to be deep to the transverse fascial fibers. This release of the pre-central cord in the distal palm reduces the degree of distal contracture and then facilitates more distal dissection by at least allowing some digital extension. As one proceeds distally, it becomes a neurovascular dissection, since nerves can turn sharply over the Dupuytren cord, creating potential for injury. Spiral lateral and abductor digiti minimi cords can displace neurovascular bundles superficially and towards the finger midline as seen in this spiral cord. This is a different patient, and only once the neurovascular structures are dissected is all the diseased fascia then excised. This is clearly seen in our patient with the neurovascular dissection followed then by a diseased cord excision. The tourniquet pressure is then released and checked for hemostasis. After the wounds are thoroughly irrigated, can the tourniquet be once again inflated and meticulous wound closure performed? In order to avoid excessive wound closure tension, we favor leaving palmar incisions open when necessary. A bulky dressing with the fingers immobilized in the intrinsic plus position completes the procedure. At this time, there is no need to keep the fingers in full extension, because it takes approximately five days before the collagen phase of wound healing even begins. The intrinsic plus position relaxes the flaps, prevents tenting of these flaps, and maximizes initial wound healing. Within five days, digital motion is started. We make liberal use of co-band wrapping to help reduce edema. This next video shows active range of motion at three weeks postoperatively.

fasciectomy

Z-plasties

hand contractures

neurovascular dissection

postoperative care