2. History

2.1 The Middle Ages

Medical historians have not identified any condition of the hand resembling Dupuytren's disease in exhaustive examinations of the medical writings of the Greeks and Romans (Whaley et al.; 1993). The identification (Whaley et al., 1993) of four miracle cures in the Icelandic sagas, which constitute a large part of the written tradition of mediaeval Scandinavia, in which the condition of the hand which was healed bears a resemblance to Dupuytren's disease suggest that the Norsemen may have suffered from the contracture and conceivably that their ecclesiastical surgeons practised some form of treatment.
There appears to be no mention of a palmar retraction in the fragmented Anglo-Saxon and early Gaelic medical literature, nor in that of Scandinavia in the 13th and 14th Centuries though the monks recorded treatments for other hand conditions. Even the well-researched and more extensive medical literature of medieval Europe before 1614 contains no evidence of the condition (Elliot, 1988a; Whaley et al., 1993). The omission of any reference to contracture of the palmar fascia may simply be the result of the fragmentary nature of the record which has survived. It may also be that when life expectancy was short the incidence of this disease of late middle age may have been small and the problem considered trivial.

Predicator hand
Figure 2-1: La Main de Dieu adorns the third edition of the G.E.M. monograph on Dupuytren's disease

Even though illustrations of Dupuytren's disease by the hands of a saint are common, this relationship is unlikely since there is great variation of hand postures recorded in religious art throughout the ages (Elliot, 1988a). Indeed the exact positions of the ring and little fingers differ considerably, sometimes being more suggestive of the clawed hand of ulnar palsy.

2.2 The beginnings

From the exhaustive study of the early history of the contracture of the palmar fascia made by Elliot (1988a, 1990), it appears that the first surgical reference to the retraction of the palmar aponeurosis that will be known as Dupuytren's disease dates from 1614. That year, Felix Plater of Basel describes, in the third volume of his observations, the case of a master mason with an irresistible drawing into the palm of the ring and little fingers and a ridging of the palmar skin. He believes the tendons to have contracted and pulled out of their sheaths, so raising the palmar skin as they bowstring across the palm, an interpretative error which was to persist for two centuries.

The anatomist surgeon of the late 18th century have revolutionised surgery by their determination to explain the normal and abnormal bodily functions by cadaver dissections.

Henry Cline Senior (1750 - 1826), one of John Hunter's (1728 - 1793) pupil, first dissects a hand with a retraction of the palmar aponeurosis in 1777 (Cline, 1777), the year of Dupuytren's birth. He writes:

"The contractions of the fingers which so frequently happens in laborious people, arises from a thickening and shortening of the fascia in the palm of the hand, without any alteration in the muscles and tendons. This has been seen in dissecting two subjects , in one all the fingers were contracted, but upon cutting through the fascia they were immediately extended. In the other the ring finger only was contracted, which was found to arise from a thickening and shortening of that portion of ligament, which is inserte into that finger. It appeared from the last case that the fascia is not blended with the skin of the fingers, but inserted into the phalanges distinctly, by the side of it".

He thus recognises the contracture as a disease of "laborious people" and the role of the palmar aponeurosis in contrast to Plater's description. He describes the treatment of the contracture by palmar fasciotomy soon later (Cline, 1787). He emphasises again the role played by the aponeurosis and, echoing Platter's description of the mason's hand, demonstrates his error by excluding the involvement of the flexor tendons in the genesis of the disease. He also suggest a relation between heavy manual work and the development of the disease.

Leçons orales
Figure 2-2: Excerpt from Leçons Orales, page 479, 1839 edition

Cooper (1822) confirms that the disease develops after heavy manual work and is due to the retraction of the palmar aponeurosis but considers that fasciotomy can only be applied on narrow bands in the palm. His discussion of the treatment of the condition will be misquoted in the French literature (Elliot, 1988a), first by Dupuytren (1839), then by those who followed him, as a statement that the disease is incurable (fig. 2).

Although many of the surgical texts written in France during the 18th century discuss surgery of the hand, the bias being, as one would expect at a time when surgery was performed without anaesthesia, towards the emergency treatment of infection and trauma, no reference can be found to contracture of the palmar fascia. Alexis Boyer (1826), personal surgeon to Napoleon Bonaparte and first patron and teacher of Dupuytren, describes what he calls a "crispatura tendinum" that he attributes to a drying, hardening and stiffening of the flexor tendons and the overlying skin. He warns against surgical treatment by division "of the flexor tendons".

"Les doigts, et particulièrement les trois derniers, sont sujet à une flexion permanente, involontaire à laquelle on a donné le nom de contracture, et que certains auteurs ont appelée en latin crispatura tendinum. Cet état est souvent une infirmité de la vieillesse; on l'observe quelque fois chez les adultes, jamais chez les jeunes sujets. Les doigts se fléchissent peu à peu, et on perd la faculté de les étendre à volonté: les tendons des muscles fléchisseurs soulèvent la peau qui se fronce en travers..."
"La nature de cette affection n'est pas bien connue: toutefois en considérant attentivement ses phénomènes et la manière lente et graduée dont elle se forme, on est porté à croire qu'elle dépend moins de la contraction spasmodique des muscles fléchisseurs que d'une espèce de déssèchement, d'endurcissement et de rigidité du tendon et de la peau..."
"On a conseillé de mettre le tendon à découvert, de le couper en travers, d'en retrancher même une portion, d'étendre le doigt et de le maintenir alongé au moyen d'une attelle. Mais le succès d'une telle opération est trop incertain..."

2.3 Baron Dupuytren

On 12 June 1831, Dupuytren, then senior surgeon of Hôtel-Dieu in Paris, operates a wine merchant whose left ring and little fingers are completely flexed and drawn into the palm (Dupuytren, 1839). The disease seems to have started twenty years before after strenuous manual work. The finger contracture dictates to make several transverse incisions in the palm and on the first two phalanges (fig. 3).
Leçons orales On 5 December 1831, he presents his observations on the retraction of the palmar aponeurosis and illustrates his lecture by the case, now famous, of a 40-year-old coachman. He dismisses any association with inflammatory conditions, with rheumatic disorders or with trauma of the ligaments, joints or bones (fig. 4). He firmly associates the disease with chronic local trauma (fig. 5). He emphasises the clinical course of the disease, including the predilection for the ring finger, the spread to adjacent fingers, especially the little finger, and the progressive lifting of the palmar skin into folds over the contracting subcutaneous bands as they pull the fingers into the palm definitely eliminating a tendinous origin (fig. 6). He stresses the normality of the joints, none of which showing evidence of ankylosis. He demonstrates that the skin is bound intimately to the palmar aponeurosis by dense fibrous tissue, in which there is little fat and that, to correct the retraction, the aponeurotic bundles, that have insertions on the proximal phalanges and into the deep transverse metacarpal ligament, have to be divided.

He finishes his lecture by an operative demonstration on the coachman. He corrects the contracture by several palmar and digital fasciotomies and gives warning that it is immediately below the retracted bundles that the nerves and arteries enter the finger. He also stresses the role of postoperative splinting. Moreover he maintains that the normal function of the palmar aponeurosis is not only to contain the deeper structures but also to brace the fingers in a state of flexion and that, consequently, the disease could be considered as an exaggeration of a normal state.

Figure 2-3: Excerpt of the description of the first operation performed on the wine merchant (Leçons orales, 1839)

Subsequent compilations of the "Leçons orales" of Dupuytren (1832, 1839) will further discuss the differential diagnosis that must be considered: section of an extensor tendon, scarring of the flexor tendons, shortening of palmar cutaneous scars, joint stiffness, paralysis of the ulnar nerve and even post-traumatic retraction of the flexor muscles (which could well be a description of Volkmann's syndrome before Volkmann).

Leçons orales Leçons orales
Figure 2-4: Excerpt from Leçons orales, 1839 Figure 2-5: Excerpt from Leçons orales, 1839


Leçons orales

Figure 2-6: Excerpt from Leçons orales, 1839

Very soon after the "Leçons orales" criticisms of Dupuytren's opinions appear (Elliot, 1988c). In particular, Goyrand demonstrates that the bands holding the fingers in flexion cannot be the distal prolongation of the palmar aponeurosis and that new tissue is present in the fingers. He also questions the theory that palmar trauma is responsible for causing the condition and raises the possibility of a hereditary predisposition. His communication to the Academie was a matter of controversy for many years.

Nevertheless Dupuytren's contribution to the description of the contracture that now bears his name was fundamental. He was first to give a detailed account of its evolution and treatment even if other surgeons had analysed some of its signs before him and if many aspects of the disease were more intricate than he suspected.

2.4 Evolution of surgical management

The primitive anaesthesia techniques of the early 19th century implied limited and swift surgery. Dupuytren himself suggested simple fasciotomies through small transverse incisions staged in the palm and on the first phalanx.

As advances in anaesthesia and wound management made more sophisticated surgery possible, the limited surgery of the beginnings became more complex. Many different patterns of skin incisions associated with more or less extensive fasciectomies have been described the choice of the skin approach being influenced by the extent of the planned fascial dissection.

2.4.1 Fasciotomy

Simple release of the contracted fascia can result in prolonged or permanent release of the contracture as has been demonstrated by the correction of the contracture after trauma (Grace et al., 1984). Historically open and closed wound approaches have been used for fasciotomy (McGrouther 1990d). Open wound release was performed among others by Dupuytren. Closed fasciotomy was advocated by Sir Astley Cooper (1822) by the subcutaneous division of a band with a pointed bistoury introduced through a small wound in the skin; a splint was then applied to maintain the finger in a straight position.

As the frequency of recurrence became apparent, simple fasciotomy was progressively given up except by some surgeons if the band is well defined and bow-stringing (Colville 1983, 1990) or for the division of bands proximal to the distal palmar crease (Rowley et al. 1984).
Gonzales (1971, 1985, 1990) has advocated either a fasciotomy or a limited fasciectomy in the digits with interposition of Wolfe grafts. The operation of fasciotomy and graft (McGregor 1985) requires division without dissection of the retracted cords.

2.4.2 Radical palmar fasciectomy

Goyrand has been credited with the first fasciectomy. As for simple fasciotomies, the concept of limited fasciectomy was to become unpopular because of the likelihood of recurrences.
Radical palmar fasciectomies were proposed at the turn of the 20th century when more extensive operations became technically possible and when it was realized that recurrences were frequent after less extensive operations. The technical details of this type of operation were clearly explained by McIndoe & Beare (1958). They proposed a single transverse palmar incision with a very wide undermining in direction of the wrist and of the finger. The proposed excision was really very radical since even the natatory ligaments were removed in the block dissection. The fingers were approached through Z incision centred on the digital midline. The entire palmar fascia was removed in a single block extending into the finger by undermining. Great emphasis was placed on dressings to prevent haematoma formation.

2.4.3 Limited fasciectomy

Hueston (1961) emphasized that the then poor reputation of operations for Dupuytren's disease had largely arisen from complications and that the radical palmar clearance which was then in vogue was particularly responsible. He defined his operation, 'limited fasciectomy', as 'the excision of the palpably thickened fascia with a narrow margin of normal aponeurosis'. Hueston approach can be considered as a near total fasciectomy in the involved rays extending from the mid-palm to the base of the second phalanx (McGrouther 1990d). Hueston's article in the Plastic and Reconstructive Surgery journal was to establish the ground rules for the next quarter century. The advantages perceived by Hueston were a simpler operation than radical fasciectomy with a simpler return of normal function. He found no difference in the rates of recurrence or extension compared with the more radical approaches.

Many other authors moved from radical to limited fasciectomies following the principles stated by Hueston. Further technical refinements were described by Skoog (1967, 1985) who introduced an anatomically precise operation preserving the transverse fibres of the aponeurosis which are not involved by the disease.

Another approach was proposed by McCash (1964) who felt that the impaired vitality of the palmar skin after limited fasciectomies made through zigzag incisions or straight incisions converted to Z plasties was the source of many problems. Those skin flaps were thus undesirable. Skin grafts impose the immobilization of the hand and he also felt that they should be avoided. His approach was to make incisions in the transverse skin creases and to move the undermined skin bridges so that the skin shortage is transferred to the distal palmar crease incision which remains wide open. Only the diseased fascia has to be removed. The open wound is dressed at weekly interval. The wounds generally close in 2-5 weeks and since they remain open, there is no possibility for an haematoma to collect. A disadvantage of the open palm technique is that the patients are apprehensive about the open wound. The great merit of the method is its safety. Nevertheless, it only partially solve the problem of the finger contracture.

Figure 2-7: Hueston's (left) and Skoog's approaches


2.4.4 Dermofasciectomy

The elective excision of skin involved in recurrent Dupuytren's disease was proposed by Hueston (1962). His belief was that the palmar dermis exerts some form of control on the disease process and that the simultaneous excision of the diseased aponeurosis and of the overlying skin at the proximal segment of the digit from one neutral line to the other, could prevent recurrences.
Smaller skin grafts have also been proposed by Gonzales (1971, 1985, 1990) and McGregor (1985) to break up the contracture line.

2.5 Conclusion

Dupuytren's contribution to the description of the contracture that now bears his name was fundamental even though other surgeons had analysed some of its manifestations before him and many aspects of the disease were more intricate than he suspected. His presentation and the passionate discussions that ensued raised many questions that are not yet answered today:

Without clear answers to these questions, the surgical approach of Dupuytren's disease has swayed from the very simple closed fasciotomy to the very aggressive radical palmar fasciectomy. The less traumatising techniques were often found insufficient to correct the contracture and to bring a lasting improvement. The more aggressive operations were developed on the unfounded hope that recurrences could be avoided. This has never been proved and these techniques were responsible for a great number of complications.

Two intermediate approaches are currently in favour: the limited fasciectomy proposed among others by Hueston and further refined by Skoog (fig. 7) and the open palm technique of McCash.