Conversations with Baron Dupuytren

It started insidiously.  I first noticed it about a decade ago while carrying out a respiratory examination, and percussing a patient’s chest, by laying my left hand prone on the patient’s back and tapping the middle phalanx of the middle finger with the tip of my right middle finger.  I couldn’t rest my left hand flat because my little finger had developed a mild contracture and was sitting at about ten degrees of flexion.  That is in fact the acid test for Dupuytren’s Contracture – this inability to lay one’s hand, prone, flat on a surface.  The condition was described by Baron Guillaume Dupuytren (1777 – 1835), surgeon to Louis XVIII.  A thickening of the subcutaneous palmar fascia forms a cord which pulls the finger into flexion.  It’s quite common.  They say it’s down to a Viking gene that can skip generations.  I’m not sure about that, but I’m having lunch with a Viking next week so I will ask her about it.   

One pays less attention to the chronic than to the acute.  That is why the insidious is – well, so insidious.  I developed the same thing in my right hand.  Bilateral Dupuytren’s of the little finger.  But I was too busy to pay much attention; I had lots of medicine to practise, and books to write and so on.  I was deft from an early age at the typewriter, “Qwerty-adept”, but I never properly learned to touch-type so never used my pinkies.  I quietly let the thing progress. 

The first time I really had a sense of loss was when I realised, having previously been able to stretch a tenth on the piano, I couldn’t even stretch an octave.  Well I could, having a broad stretch, with thumb and any other finger, but not the pinkies.  O well, I was never a pianist, although I did like to tootle (I won’t say tickle the ivories – the ivory police will be at my door) – now and then. 

The crunch came quite recently, when I realised I couldn’t lay my left little finger down on the viola finger board.  Now the viola can lie dormant in its case for months on end.  But human nature being what it is, I thought, “This is intolerable.  I must play my viola!”  The time had come to seek the help of my erstwhile medical colleagues.

I consulted privately.  I knew that there was no way the NHS, with its current inevitable backlog in elective surgery, would prioritise Dupuytren’s Contracture. The NHS would not be aware that failure to play the viola is a medical emergency.  I phoned my GP and asked her for a referral to a hand surgeon in our local private hospital, and I emailed a couple of pictures of my hands.  I myself have often referred patients to this hospital, and although I frequently walk past its front door, I’d never previously entered.  Nice place.      

The surgeon saw me the following week, and, one week later, he carried out a needle fasciotomy on my right hand.  He just popped in some local anaesthetic and then picked the fascial cord apart with a hypodermic needle, and then pulled my pinkie into hyperextension.  The cord came apart with a resounding snap.  It was very satisfying, as much for the surgeon as for me.  Then he put a dressing on the wound and left it to heal “by second intention”.  It is a remarkable procedure, with a huge gain from minimal intervention.  I left the hospital with a straight finger, and, two days later, I could depress Middle C on the piano with my right thumb, and, with my little finger, the E of the octave above.  Honestly, it was like a miracle.

The left side was a little more complicated.  The proximal interphalangeal (PIP) joint was involved, so the surgeon opted for a subtotal fasciectomy.  I preferred to be awake throughout the procedure, so the anaesthetist put in a regional (brachial plexus) block.  It was spectacularly successful.  I lost all proprioception – the perception of a limb’s position in space.  The limb lying on the table to my left could not be mine, because I could feel my left arm, where it had previously been, resting across my tummy.  In a bloodless field the surgeon made a series of interconnected zig-zag incisions, exposed the neurovascular bundles, and excised redundant cord around them.  Then he closed up.  There was some canned music playing quietly in the background.  Michael Bublé.  Fortunately, I am a fan of Michael Bublé.

Now the stitches are out and everything is healing apace.  And I can stretch a tenth with my left as well as my right hand.  In fact, the piano has become the chief instrument of my post-op physiotherapy.  I started with Bach’s C Major Prelude from the first book of the 48.  Then I moved on to the first movement of Beethoven’s Moonlight Sonata, useful because the left hand mostly holds down octaves.  Then Mozart K 545, making sure not to be lazy but to play the arpeggios of the left hand mostly with the ring, and not the middle finger, to facilitate flexibility between little and fourth fingers. 

It’s funny; barely conscious of the matter, I’d resigned myself to a future without a piano.  The recovery of the ability simply to depress the keys has made me determined to stick with it, as much in order to stop these cursed fascial cords from reforming, as to make some semblance of music.  Use it, or lose it.  I think that’s true across the board.  Maybe we should never give anything up (with a few notable exceptions, such as cigarettes, unkindness, and minimalism).        

I’m very grateful to my surgeon, and the whole team at the hospital.  Today, I got out the Archinto Strad and played a C major scale, avoiding the open strings and using my newly revitalised little finger.  It worked.  Now that really is a miracle. 

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