Treatment Approach for Bilateral Contracted Hands
The treatment of bilateral contracted hands requires immediate implementation of daily stretching exercises, joint protection education, and assistive devices, with topical NSAIDs as first-line pharmacological management, progressing to occupational therapy with splinting, and ultimately surgical release if conservative measures fail after 3-6 months. 1
Initial Conservative Management
Non-Pharmacological Interventions (First-Line)
Education and ergonomic training should be initiated immediately, focusing on joint protection techniques, pacing of activities, and proper use of assistive devices to maintain function while preventing further contracture progression 2, 1
Daily stretching exercises are essential to improve range of motion, reduce pain, and strengthen muscles, with the goal of counteracting deforming forces through gentle, sustained pressure over time 2
Positioning and splinting strategies must address the 24-hour management approach: use resting wrist/hand/finger splints to prevent hypoextensibility in long flexors, ensure even weight distribution during functional activities, and avoid prolonged end-range positioning 2
Occupational therapy should focus on grading activities to increase affected limb use with normal movement patterns, engaging patients in tasks promoting proper alignment and weight-bearing, and teaching energy conservation techniques 2, 3
Pharmacological Management
Topical NSAIDs are the preferred first-line pharmacological treatment due to superior safety profile compared to systemic options, particularly when multiple joints are affected 2, 1
Oral NSAIDs or acetaminophen (up to 4g/day) should be considered for limited duration when topical treatments provide insufficient relief, though systemic agents carry higher risk profiles 2, 1
Intra-articular corticosteroid injections may provide short-term relief for painful flares in interphalangeal joints, though evidence shows efficacy lasting only 1 month rather than sustained benefit 2
Advanced Conservative Interventions
Specialized Therapies
Botulinum toxin injections can be considered for adult patients with severe contractures who have failed conservative therapies, though this requires tolerance of the injection procedure and further research is needed 2, 3
Orthotic devices should be carefully considered, as prolonged immobilization risks muscle deconditioning, learnt non-use, increased pain, and paradoxically worsening symptoms through increased attention to the affected area 2
Critical caveat: Serial casting for fixed contractures has been associated with worsening symptoms and development of complex regional pain syndrome, so removable splints with regular monitoring are preferred if splinting is necessary 2
Surgical Management
Indications and Timing
Surgery should be considered when structural abnormalities persist and conservative treatments have failed to adequately relieve pain or restore function after 3-6 months 2, 1
Surgical options include contracture release with skin grafting, bilateral side-finger flaps with full-thickness skin grafts for severe flexion contractures, or selective procedures based on underlying pathology 2, 4
Surgical Outcomes
Trapeziectomy alone is as effective as combined procedures (trapeziectomy plus ligament reconstruction and tendon interposition) for thumb base involvement, with fewer complications (RR = 2.12,95% CI 1.24-3.60) 2
Early soft-tissue release procedures are recommended for addressing toe and finger contractures, equinus and cavus deformities, though long-term recurrence is likely due to disease progression 2
Condition-Specific Considerations
Dupuytren's Contracture
- Collagenase clostridium histolyticum injection achieves 59% overall success rate across all treated joints, though recurrence occurs in 23% of successfully treated joints within 12-24 months 1
Inflammatory Causes
- Systemic corticosteroids should be considered when contractures result from inflammatory conditions like systemic lupus erythematosus with flexor tenosynovitis, as MRI-confirmed tenosynovitis may respond rapidly to immunosuppression 5
Post-Burn Contractures
- Metacarpus and phalanx traction using Kirschner wire fixation for 2-7 weeks followed by traction frame with rubber bands for 2-6 months can lengthen contracted tissue and restore function without immediate surgery 6
Monitoring and Follow-Up
Long-term surveillance should be adapted to individual patient needs, assessing for recurrence tendency within 1-2 weeks post-treatment and monitoring scar formation using the Vancouver Scar Scale at 1,3, and 6 months 2, 6
Functional assessment using Total Active Movement (TAM) method and Jebsen Test of Hand Function should be performed before treatment and 1 month after to objectively measure improvement 6
Important pitfall: Avoid conventional or biological disease-modifying antirheumatic drugs for hand contractures related to osteoarthritis, as evidence does not support their use 2