The Transverse elements of the Palmar Aponeurosis in Dupuytren's Contracture: Their pathological and Surgical Significance

Abstract

Some original observations on the anatomy and pathology of the transverse elements of the palmar aponeurosis are reported. The transverse palmar ligament forms a continuous band, strictly limited to the midpalmar region with deep attachments at each end merging with the paratendinous septa bordering the compartment on the radial and the ulnar sides. Throughout its length the transverse band is intimately related to the underlying paratendinous septa and together they form a well defined fibrous tunnel system. The function of this separate anatomical structure is discussed, and related to observations on hands following its removal. In all stages of Dupuytren's contracture it was noticed that the transverse palmar band was not involved in the pathological process, this being confirmed as a constant feature in more than 300 consecutively operated hands. In marked contrast the transverse fibers of the interdigital ligaments were frequently the site of pathological changes, resulting in contracted bands.

In the surgical treatment of Dupuytren's contracture selective aponeurosectomy is recommended, i.e. the transverse palmar ligament is separated from the contracted tissue and left intact together with the paratendinous septa. In doing so the function of this fibrous tunnel system has been preserved; no recurrences were noticed at this site; healing time was reduced compared to that required following more radical procedures; and the functional restoration of the hand was also quicker. The principles for exposure of the contracted palmar aponeurosis are briefly discussed and a pattern of incisions is suggested to facilitate the dissection and to reduce the need for undermining of the skin.

The striking difference in pathological respect between the interdigital ligaments and the transverse palmar ligament is obviously imcompatible with most theories proposed on the etiology of Dupuytren's contracture. Considering the anatomy of these bands the difference in functional strain on their fibrous structures offers, however, a reasonable explanation. The observations made are regarded as additional clinical evidence in support of the author's previously expressed view, that Dupuytren's contracture develops as the result of ruptures of fibrils in the aponeurosis, affecting individuals with a general predisposition in their connective tissue. The pathological process itself is based on the fundamental principle of scar formation and contracture.