What are the current treatment options for managing contractures in the hands?

Current Treatment Options for Hand Contractures

For managing contractures in the hands, a comprehensive approach including orthoses, exercises, topical treatments, and botulinum toxin injections is recommended, with no specific new medications developed exclusively for contractures. 1, 2

Non-Pharmacological Interventions (First-Line)

Physical Interventions

• Daily stretching exercises should be performed multiple times daily to maintain joint mobility and prevent worsening of contractures 1, 2
• Exercises to improve function and muscle strength are strongly recommended (Level 1a evidence, Grade A recommendation) 1
• Regular range of motion exercises help maintain joint mobility in affected hands 2
• Proper positioning of the hand to counteract deforming forces 1, 2

Orthotic Devices

• Orthoses/splinting should be considered for symptom relief, particularly for thumb base contractures (Level 1b evidence, Grade A recommendation) 1
• Resting hand/wrist splints may be considered for patients lacking active hand movement (Level IIb evidence, Class C recommendation) 1
• Serial casting or static adjustable splints may reduce mild to moderate wrist contractures (Level IIb evidence, Class C recommendation) 1

Pharmacological Management

Topical Treatments

• Topical NSAIDs are the first pharmacological treatment of choice for hand contractures due to osteoarthritis (Level 1b evidence, Grade A recommendation) 1

Systemic Medications

• Oral analgesics, particularly NSAIDs, should be considered for limited duration to relieve symptoms (Level 1a evidence, Grade A recommendation) 1
• Chondroitin sulfate may be used for pain relief and improved functioning in hand osteoarthritis (Level 1b evidence, Grade A recommendation) 1
• Muscle relaxants for spasticity-related contractures:
  • Tizanidine is effective for chronic spasticity without significant loss of motor strength 2
  • Oral baclofen is effective but may cause sedation 2
  • Dantrolene should be considered when cognitive side effects need to be minimized 2

Injectable Treatments

• Botulinum toxin injections are the first-line therapy for focal hand dystonia and can be beneficial for managing spasticity-related contractures 2, 3, 4
  • Effective for spastic lumbricals at doses of 10-15 units per muscle 4
  • Can significantly reduce tone and clonus in injected muscles 4
• Intra-articular glucocorticoid injections may be considered for painful interphalangeal joints in osteoarthritis (Level 1b evidence, Grade A recommendation) 1

Advanced Interventions for Refractory Cases

Surgical Options

• Surgery should be considered when other treatments have not been sufficiently effective (Level 5 evidence, Grade D recommendation) 1
  • Trapeziectomy for thumb base osteoarthritis 1
  • Arthrodesis or arthroplasty for interphalangeal joint contractures 1
  • Surgical release of brachialis, brachioradialis, and biceps muscles for substantial elbow contractures (Level IIb evidence, Class B recommendation) 1

Education and Supportive Care

• Education and training in ergonomic principles, activity pacing, and use of assistive devices (Level 1b evidence, Grade A recommendation) 1
• Regular follow-up adapted to individual patient needs (Level 5 evidence, Grade D recommendation) 1

Important Clinical Considerations

• Early intervention is crucial as 60% of stroke patients develop joint contractures on the affected side within the first year 1
• Wrist contractures occur most commonly in patients who do not recover functional hand use 1
• The presence of spasticity within the first 4 months after stroke is associated with elbow contracture development 1
• Contractures can cause pain and make self-care, including dressing and hygiene, difficult 1

Treatment Algorithm

1. Begin with daily stretching exercises and proper positioning
2. Add orthoses/splinting for symptom relief
3. Consider topical NSAIDs as first pharmacological treatment
4. For spasticity-related contractures, add muscle relaxants (tizanidine, baclofen, or dantrolene)
5. For focal spasticity, consider botulinum toxin injections
6. For persistent pain, consider oral NSAIDs for limited duration
7. For structural abnormalities with persistent symptoms despite conservative management, consider surgical intervention

Remember that prevention of contractures is preferable to treatment of established contractures, which can be challenging 5.