In severe cases of Dupuytren’s contraction, certainly when the affected digits are rigidly bent into the palm, the operations in vogue are disappointing. Whether the surgeon divides or excises the palmar fascia he cannot straighten the contracted finger by manual force, still less can he trust to splint-pressure, however prolonged. The reason generally assigned is consecutive contraction of the flexor tendons. These have often been divided in the vain hope of overcoming the resistance. But it is easy to prove that the fault does not lie in the tendons, for full flexion of the wrist or metacarpo-phalangeal joints makes no difference.

Intra-articular adhesions in the metacarpo-phalangeal and interphalangeal joints of the contracted fingers might be invoked as the cause of the resistance, especially by those who see a close relation between this condition and gout or rheumatism. The idea of the existence of these adhesions is also favoured by the grave danger of stiffening of the fingers during the splint-treatment ordinarily pursued after operation. But the X-rays show a perfectly smooth articular surface in the joints. The cause of the resistance is as follows:—Owing to the second phalanx being extremely flexed so that its base is pressed against the neck of the first phalanx, and owing to this position being kept up during many months or years, the glenoid ligament in front of this joint, as well as the lateral ligaments, become shortened and incapable of extension.

The only way to overcome this obstacle is to excise the head of the first phalanx. This is done as follows:—

1. Through a palmar incision the bands of contracted and thickened fascia are dissected out, including their prolongations in front of the first phalanx. The palmar wound or wounds are closed with the finest black silkworm-gut. The finger still remains flexed at the first interphalangeal joint.
   
2. The hand is turned over so that the dorsal surface is uppermost, a semilunar incision is made over the first interphalangeal joint, the extensor tendon divided, the head of the first phalanx cleared to its neck, the latter cut across and the head dissected out.
   
3. The extensor tendon is slightly shortened and its two ends united, preferably with fine kangaroo tendon or Japanese silk, and the small dorsal incision is then sewn up. The finger should now become perfectly straight (or nearly so) without any tension whatever.
   
4. No splint is required in the after-treatment, the gauze dressing is a sufficient support; gentle active and passive movements should be resorted to within the first few days. No digit should be allowed to stiffen. The prolonged and irksome splinting usually resorted to has been responsible for many stiff fingers and hands following the orthodox operations. It is to some extent also responsible for the tendency after them to recurrence of the contraction.—J. Hutchinson, “Lancet,” Feb., 1917.

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