What are the treatment options for hand contracture?

Treatment Options for Hand Contracture

The optimal treatment for hand contracture depends critically on the underlying etiology: for osteoarthritis-related contractures, start with education, exercises, and orthoses combined with topical NSAIDs; for post-stroke spastic contractures, implement daily stretching with positioning and consider serial casting or botulinum toxin injections; for Dupuytren's contracture, collagenase clostridium histolyticum injection is the preferred first-line intervention for metacarpophalangeal joint contractures ≥20°, achieving 77% success rates with minimal major complications.

Etiology-Specific Treatment Algorithms

Hand Osteoarthritis-Related Contractures

Non-Pharmacological Interventions (First-Line)

• Provide education and training in ergonomic principles, activity pacing, and assistive device use to every patient 1
• Implement exercises to improve function and muscle strength while reducing pain 1
• Apply orthoses to prevent or correct lateral angulation and flexion deformities, particularly for thumb base involvement 1
• Consider local heat application for symptomatic relief, though evidence is limited to expert opinion 1

Pharmacological Management

• Topical NSAIDs are the first-line pharmacological treatment due to superior safety profile compared to systemic agents 1
• Topical NSAIDs demonstrate equivalent efficacy to oral NSAIDs (effect size -0.05,95% CI -0.27 to 0.17) with significantly fewer gastrointestinal complications (RR 0.81,95% CI 0.43 to 1.56) 1
• Reserve oral NSAIDs for limited duration when topical agents fail 1
• Intra-articular glucocorticoid injections may be considered specifically for painful interphalangeal joints when other modalities prove insufficient 1
• Chondroitin sulfate may provide pain relief and functional improvement 1

Surgical Intervention

• Surgery should be considered when structural abnormalities persist despite other treatments failing to adequately relieve pain 1
• For thumb base OA: trapeziectomy is the procedure of choice 1
• For interphalangeal OA: arthrodesis or arthroplasty 1

Post-Stroke Spastic Contractures

Prevention and Early Management

• Position the hemiplegic shoulder in maximum external rotation for 30 minutes daily (either in bed or sitting) to prevent shoulder contracture 1
• Implement daily stretching of hemiplegic limbs, teaching patients and families proper techniques to avoid injury 1
• Standing on a tilt table for 30 minutes daily is useful for preventing contracture 1

Orthotic Management

• Resting hand/wrist splints combined with regular stretching and spasticity management may be considered for patients lacking active hand movement, though effectiveness is not definitively established 1
• The evidence is conflicting: Royal College of Physicians guidelines recommend against resting hand splints, while Veterans Affairs/Department of Defense guidelines recommend their use 1
• Early botulinum toxin injection to wrist and finger flexors combined with splinting may be beneficial 1

Advanced Interventions

• Serial casting or static adjustable splints may reduce mild to moderate wrist contractures 1
• Surgical release of brachialis, brachioradialis, and biceps muscles is reasonable for substantial established elbow flexor contractures causing pain and range-of-motion limitations 1
• Resting ankle splints used at night and during assisted standing may prevent ankle contracture in the hemiplegic limb 1

Dupuytren's Contracture

First-Line Treatment

• Collagenase clostridium histolyticum (CCH) injection is the preferred initial treatment for contractures ≥20° in metacarpophalangeal joints (MCPJs) and/or proximal interphalangeal joints (PIPJs) 2, 3
• MCPJs achieve 77% success rate (reduction to ≤5°) compared to 36% for PIPJs 2
• 94% of patients experience at least one 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
• Major nonsurgical complications are rare (0.07%), including tendon injury and anaphylaxis 2

Alternative Minimally Invasive Option

• Needle aponeurotomy (NA) represents another minimally invasive alternative 3

Surgical Management

• Selective fasciectomy is recommended once contracture has occurred and minimally invasive options have failed 4
• The "synthesis technique" combining tissue rearrangement with selective wound closure demonstrates superior outcomes compared to open palm technique 4
• Synthesis method achieves: MCP contracture reduction from 57° to 0°, PIP contracture reduction from 58° to 10°, faster healing (28 vs 40 days), and lower recurrence (0% vs 50%) 4

Intrinsic Muscle Contracture

Non-Surgical Management (Mild Cases)

• Occupational therapy with focused stretching protocols 5
• Custom orthoses to maintain corrected position 5, 6
• Botulinum toxin injections for spasticity-related contractures 5
• The "Inflatable Carrot" orthosis provides an alternative for severe flexion contractures when surgery is contraindicated, improving pulp-to-palm distance from 0 to 2 cm at 4 weeks 6

Surgical Management (Severe Cases)

• Options include soft tissue releases, tendon transfers, and release of flexor and intrinsic muscles 5, 6
• Surgical approach is dictated by the underlying cause and severity of contracture 5

Critical Monitoring and Follow-Up

• Adapt long-term follow-up to individual patient needs 1
• Re-evaluate between 3-5 days after initial treatment to assess response and distinguish partial from complete involvement 7
• For Dupuytren's contracture treated with CCH, monitor for recurrence at 6-month intervals, as 23% of successfully treated joints experience recurrence, typically within 12-24 months but sometimes as early as 6 months 2
• Arrange specialist assessment within 8-12 weeks if no improvement occurs 8

Common Pitfalls

• Avoid prolonged oral NSAID use due to gastrointestinal perforation/ulcer/bleed risk (RR 5.36 for RCTs, 2.70 for cohort studies) 1
• Do not continue ineffective treatments indefinitely—stop and reassess 8
• Recognize that PIPJs respond less favorably than MCPJs to CCH treatment (36% vs 77% success), requiring adjusted patient expectations 2
• Be aware that resting hand splints have controversial efficacy—combine with other modalities like botulinum toxin for optimal results 1
• Avoid immobilization beyond 72 hours—functional treatment with exercises is superior 7