What is the appropriate workup and treatment for a patient presenting with hand stiffness?

Workup and Treatment for Hand Stiffness

The appropriate workup for hand stiffness should begin with radiographs of the affected hand, followed by a targeted treatment approach based on the underlying diagnosis, with osteoarthritis being the most common cause requiring a combination of non-pharmacological and pharmacological interventions. 1

Initial Diagnostic Workup

Imaging

• First-line imaging: Plain radiographs of the affected hand and wrist 1
  • Views should include posteroanterior, lateral, and oblique projections
  • A true lateral radiograph is essential to assess distal radioulnar joint alignment if wrist involvement is suspected 1
  • Advanced imaging (MRI, CT, ultrasound) should only be considered after radiographic evaluation if diagnosis remains unclear

Clinical Assessment

• Evaluate for specific patterns of joint involvement:
  • Osteoarthritis: Look for hard tissue enlargement of distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, and/or trapeziometacarpal joints 2
  • Assess for joint tenderness, which correlates strongly with pain severity 3
  • Check for joint deformity, which correlates with functional impairment 3
  • Evaluate grip strength using a dynamometer 3

Treatment Algorithm Based on Diagnosis

1. Hand Osteoarthritis (Most Common Cause)

Non-pharmacological Interventions (First-line)

• Education and ergonomic training on joint protection techniques 1
• Exercise program to improve function and muscle strength 1
  • Include both range of motion and strengthening exercises
  • Consider referral to occupational or physical therapy 1
• Orthoses/splints for symptom relief, especially for thumb base OA 1
• Thermal modalities (particularly heat application before exercise) 1
• Assistive devices to help with activities of daily living 1

Pharmacological Treatment (Step-wise approach)

1. Topical treatments (preferred first-line pharmacological option) 1

   • Topical NSAIDs (first choice) 1
   • Topical capsaicin 1

2. Oral medications (if topical treatments insufficient)

   • Acetaminophen (up to 4g/day) 1
   • NSAIDs at lowest effective dose for shortest duration 1
   • Tramadol for refractory pain 1
   • Chondroitin sulfate may be considered 1

3. Intra-articular injections

   • Glucocorticoid injections may be considered for painful interphalangeal joints 1
   • Not generally recommended as first-line therapy 1

2. Post-Traumatic Stiffness

• Active finger motion exercises should begin immediately after diagnosis of distal radius fractures 1
• For stiffness after hand trauma:
  • Early intervention with hand therapy 4
  • Pressure therapy to reduce swelling 4
  • Corrective splinting applying low-load stress for prolonged periods 4
  • Consider surgical release if conservative management fails 5

3. Functional Neurological Disorder

If no structural cause is identified:

• Focus on gross rather than fine movements 1
• Encourage optimal postural alignment 1
• Avoid splinting if possible as it may worsen symptoms 1
• Address contributing factors like anxiety, pain, and fatigue 1

Special Considerations

• Avoid splinting in functional disorders as it may increase focus on the area and lead to muscle deconditioning 1
• Elderly patients (≥75 years) should use topical rather than oral NSAIDs 1
• Surgery should only be considered when:
  • Other treatment modalities have failed to relieve pain
  • Structural abnormalities are present 1
  • Options include trapeziectomy for thumb base OA or arthrodesis/arthroplasty for interphalangeal OA 1

Monitoring and Follow-up

• Regular reassessment of symptoms and function
• Patients with unremitting pain should be reevaluated 1
• Long-term follow-up should be adapted to individual needs 1

Remember that hand stiffness can significantly impact quality of life, and early intervention is key to preventing progression and permanent disability.