What is the treatment approach for a patient with a contracted hand?

Treatment Approach for Contracted Hand

The treatment approach for a contracted hand depends critically on the underlying cause: if this is Dupuytren's contracture with metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint contracture ≥30°, collagenase clostridium histolyticum injection is the preferred first-line treatment, while hand osteoarthritis requires a combination of topical NSAIDs, joint protection education, and splinting for thumb base involvement. 1, 2, 3

Diagnostic Clarification Required

The term "contracted hand" encompasses multiple distinct pathologies that require different treatment algorithms:

• Dupuytren's contracture: Fibroproliferative disorder causing progressive flexion contractures, typically affecting MCP and PIP joints 4, 5
• Hand osteoarthritis: Degenerative joint disease causing pain, stiffness, and secondary contractures 3
• Intrinsic muscle contracture: Results from trauma, spasticity, ischemia, or rheumatologic disorders 6
• Shoulder-hand syndrome: Post-stroke or post-injury condition with pain and contracture 7

Treatment Algorithm for Dupuytren's Contracture

Indications for Treatment

• Operative management is appropriate when MCP or PIP joint contracture exceeds 30°, as this threshold indicates functional impairment 4
• Contractures <30° can be observed with patient education 4

First-Line Treatment: Collagenase Injection

Collagenase clostridium histolyticum (CCH) injection is now the primary treatment for Dupuytren's disease due to its safety profile and effectiveness 1, 2, 5

Treatment protocol:

• Average 1.2 injections per patient and 0.8 injections per joint 1
• Success defined as contracture reduced to ≤5° at 12 months 1, 2
• MCP joints achieve 77-80% success rates, while PIP joints achieve only 36-39% success 1, 2

Expected outcomes:

• 59% overall success rate across all joints treated 1
• 94% of patients experience ≥1 treatment-related adverse event, most commonly peripheral edema (64%), extremity pain (53%), and contusion (51%) 2
• Major surgical complications occur in only 1.0% of patients 2
• Recurrence occurs in 23% of successfully treated joints, typically within 12-24 months 2

Surgical Management

Surgical fasciectomy should be considered when:

• CCH treatment fails or recurs 5
• Patient preference after informed discussion of risks 4
• Severe contractures, particularly in patients with Dupuytren's diathesis 4

Surgical approach:

• Volar zigzag Brunner incision provides reliable exposure 4
• Full-thickness skin grafts may help prevent recurrence in high-risk patients 4
• Early active-flexion range-of-motion exercises postoperatively to restore grip strength 4
• Nighttime extension splint for several months to maintain correction 4

Treatment Algorithm for Hand Osteoarthritis

Non-Pharmacological Management (First-Line)

All patients with hand OA should receive:

• Evaluation of activities of daily living (ADL) ability and provision of assistive devices as needed 3
• Education on joint protection techniques to avoid adverse mechanical factors 3
• Instruction in thermal modalities (heat application, paraffin wax) for pain and stiffness relief 3
• Splints specifically for trapeziometacarpal (thumb base) joint OA 3

Pharmacological Management

Step 1: Topical treatments (preferred first-line):

• Topical NSAIDs are preferred over systemic treatments for mild-to-moderate pain, especially when few joints are affected 3
• Topical capsaicin is an effective alternative 3
• In patients ≥75 years, topical NSAIDs should be used rather than oral NSAIDs 3

Step 2: Oral analgesics (if topical treatments insufficient):

• Acetaminophen (up to 4 g/day) is the oral analgesic of first choice due to efficacy and safety 3
• Oral NSAIDs at the lowest effective dose for the shortest duration if acetaminophen inadequate 3
• In patients with increased GI risk: non-selective NSAIDs plus gastroprotective agent OR selective COX-2 inhibitor 3
• In patients with increased cardiovascular risk: COX-2 inhibitors are contraindicated; use non-selective NSAIDs with caution 3

Step 3: Additional options:

• Tramadol for refractory pain 3
• Intraarticular corticosteroid injection for painful flares, especially trapeziometacarpal joint OA 3

Avoid:

• Opioid analgesics are conditionally recommended against 3
• Chondroitin sulfate and glucosamine have small effect sizes with unclear clinical benefit 3

Surgical Management

Surgery (trapeziectomy, arthrodesis, or arthroplasty) should be considered when:

• Structural abnormalities are present 3
• Other treatment modalities have not sufficiently relieved pain 3
• Marked pain and/or disability persist despite conservative treatment failure 3

Treatment for Shoulder-Hand Syndrome

Immediate Non-Pharmacological Interventions

• Active, active-assisted, or passive range of motion exercises should be implemented immediately, emphasizing external rotation and shoulder abduction 7
• Avoid overhead pulley exercises as they may exacerbate symptoms 7
• Local heat application before exercise 7
• Splints for thumb base involvement 7

Pharmacological Management

First-line: Topical NSAIDs or topical capsaicin 7

Second-line: Acetaminophen up to 4 g/day, then oral NSAIDs at lowest effective dose 7

For persistent symptoms:

• Early course of oral corticosteroids: 30-50 mg daily for 3-5 days, then taper over 1-2 weeks 7
• Botulinum toxin injections into subscapularis and pectoralis muscles for spasticity-related pain 7
• Subacromial corticosteroid injections for subacromial inflammation 7

Critical Pitfalls to Avoid

• Do not delay treatment of Dupuytren's contracture beyond 30° as outcomes worsen with progression 4
• Do not expect equal success rates between MCP and PIP joints with CCH—PIP joints have significantly lower success rates 1, 2
• Do not use COX-2 inhibitors in patients with cardiovascular risk factors 3
• Do not prescribe opioids for hand OA given lack of evidence and safety concerns 3
• Counsel patients about 23% recurrence rate with CCH treatment, typically within 12-24 months 2