Percutaneous needle fasciotomy is performed in an outpatient treatment room under local anesthesia with the patient recumbent (Pess et al. 2012). The patient’s hand is prepped with antiseptic solution. Portal sites are carefully chosen between skin creases in areas of definite cords and are marked with a surgical marker. The injection sites may need to be modified after releasing the MP joint. The center of the cord is normally used as the needle entrance site, but 2 parallel insertion sites, radial and ulnar, may be used for wider cords >5 mm (Fig. 21.2; Eaton 2011).

Intradermal anesthesia is performed with <1 cc lidocaine 1 % plain injected in the area of the palmar portals, prior to the release of any cords. Only the dermis is penetrated, and injection is performed as the needle is withdrawn. Conscious sedation is an option for patients with a high level of anxiety.

A 5 cc syringe is filled with 3 cc lidocaine 1 % plain and 1 cc methylprednisolone acetate injectable suspension 40 mg (Depo-Medrol, Pharmacia & Upjohn Co., New York, NY). Corticosteroids are not used for patients with diabetes mellitus. Short 25-gauge, 16-mm (5/8-in) length needles are used exclusively (Lermusiaux and Debeyre 1979). Use of larger needles is not recommended. A tourniquet is not applied. Patients are asked to stop anticoagulation, if possible, but blood thinners are not considered a contraindication to the procedure.

Each time a portal is entered, 0.1 cc of the lidocaine/corticosteroid mix is injected into the local area, and the needle is used as a scalpel to release the cord at multiple levels. Beginning the release proximally and progressing in a proximal to distal direction are recommended. While releasing the contracture in the palm, some of the PIP joint contracture may release as well. It is easier to place the needles between the proximal digital crease and the middle finger crease once the MP joint has been extended.

A “pinch and poke” technique is employed. The cord is palpated and then pinched between the fingertips (Fig. 21.3).

The needle is aligned perpendicular to the cord. The finger is flexed and extended immediately after each needle insertion to confirm that the needle is not placed within the flexor tendon. Insertion portals are made at the areas of maximum bowstringing of a palpable cord. Areas farthest from the neurovascular bundle are selected, and the patients are constantly asked if they feel any electric shocks. Portals are spaced 5 mm apart, and skin creases are avoided. Care is taken to not push the needle in too deep. Most cords are less than 4 mm from the skin, so the needle can remain fairly superficial. The distance between hub of the needle and the skin is watched closely at all times.

To confirm a good portal site, apply traction and look for blanching (Bayat and McGrouther 2006). If the diseased cord is tighter than the skin, the skin will usually not blanch with traction. Blanching may indicate that the skin is contracted, and there may not be an underlying cord present to release. Blanching will advance distally when the underlying cord has been adequately released.

Three maneuvers are used: perforate, slice, and clear. An up-and-down perforation of the cord is performed with the needle oriented vertically. A gentle pendulum side-to-side slicing motion is used with the needle tip perpendicular to the cord’s longitudinal axis. Division of the cord progresses from superficial to deep. It can sometimes help to push the cord against the needle while slicing. The three-dimensional anatomy of the cord should be kept in mind at all times. In areas of pitting, a tangential clearing motion is employed to separate the cord and nodule from the dermis. This helps to lower the incidence of skin tears. A crackly feeling is noted as the fibers are released. The needle should be changed frequently to maintain sharpness (~8–15 fresh needles per finger). Gentle extension tension is placed on the cord during the release, and then passive extension is used to rupture the cords. A pop may be heard or felt. The finger is then manipulated in abduction, adduction, pronation, and supination to release all cords. Unaffected adjacent fingers should also be manipulated, since this can help disrupt any residual cords.

Natatory cords are released by orienting the needle parallel to the longitudinal axis of the finger, perpendicular to the transverse axis of the cord (Fig. 21.4).

The cord is then released with a slicing motion, moving proximally to distally. The released cord is massaged to help disrupt remaining deep fibers. Massaging is also useful for narrow lateral cords.

After completing the release distally, the palm and finger are assessed for residual cords. Each of these cords is released, again working in a proximal to distal direction. A PIP joint contracture may still persist even after all cords are released. There is often a non-palpable central cord preventing release of the PIP contracture. A palmar release of this cord can be performed in the midline, proximal to middle finger crease. It is critical to stay very superficial and avoid entering the flexor tendon sheath.

In patients with severe PIP joint contractures, a nerve block (wrist or digital) and/or PIP joint injection with lidocaine 1 % plain is used for supplementary anesthesia. This is performed after PNF is completed to help reduce pain during the extension procedure. After all possible cords have been released, nodules are injected with the mixture of lidocaine and corticosteroid (Morhart 2015).

A light dressing with gauze bandage is applied, and removal of the bandage is allowed that evening. A splint is fitted immediately post-procedure, and night use is recommended for three to four months. Even though a splint is recommended, there is no scientific evidence supporting the use of a post-procedure splint (Henry 2014). Patients are instructed to exercise at home 5–10 min twice a day for 4 weeks. Written instructions are provided, including specific active range of motion exercises in flexion, extension, abduction and adduction, and gentle passive stretching. It is recommended that patients avoid heavy grasping for the first 2 weeks. Therapy is not needed in most instances. Hand therapy with splinting can be ordered for residual contractures and to treat PIP joints that have regained full passive extension but have a residual active extension lag (central slip laxity) (Skirven et al. 2013).