Location of Dupuytren's disease on the radial aspect of the hand

The fibrous elements of the radial side of the hand, i.e., index, first web space, and thumb, have not previously been fully described. However, involvement of this area may be significant, as seen in patients with a malignant form of Dupuytren's disease known as Dupuytren's diathesis, and adequate surgical removal depends on knowledge of the anatomy. Using cadavers, four major fibrous elements are defined: (1) the fibrous skeleton of the thenar eminence; (2) the radial longitudinally-oriented fibers of the palmar aponeurosis; (3) the distal transverse commissural ligament of the first web; and (4) the proximal transverse commissural ligament. These fibrous elements correspond with the four major locales of contracture seen in patients with radial sided involvement and can produce a variety of contractures: metacarpophalangeal and interphalangeal flexion, abduction/opposition and/or adduction of the thumb. Surgical management, designed to correct deformity and prevent extension and recurrences, can be achieved by extensive excision of involved tissue and skin grafts. This can be accomplished by zig-zag incisions over isolated contractures of the fibrous elements or in combination with Z-plasty if the involvement is more extensive. Besides extensive aponeurectomy, tendon sheath releases and capsulotomies may be necessary. Use of skin grafts helps prevent recurrences. Full or thick split-thickness grafts should be used with discretion avoiding major sensory areas or open tendon sheaths.