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Physician’s Notes
Date:
Stiffness in the Hand
Mission Statement
The mission of ASSH is to advance the science and
practice of hand surgery through education, research
and advocacy on behalf of patients and practitioners.
6300 North River Road
Suite 600
Rosemont, IL 60018-4256
Phone: (847) 384-8300
Fax: (847) 384-1435
E-mail: info@assh.org
www.handcare.org
www.handcare.org
Diagram for Physician’s use
      The hand and fingers seem to work effortlessly when healthy.
Normal joints have considerable motion, enabling us to
perform many different activities with our hands for work,
leisure, communication, and more. A variety of problems can
cause stiffness in the hand, limiting the use and function that
we often take for granted.
Figure 1:
Anatomy of finger joints
in mobility that may vary depending on the position of
neighboring joints. The muscles and tendons are also
evaluated for their action and any tightness. It is also very
important to assess the impact of stiffness on function.
PIP joint
extensor tendon
DIP joint
MP joint
X-rays are usually obtained to evaluate for arthritis and any
other distortion of the bones and joints. On occasion, other
studies may be considered, such as MRI or CT scan, for
special situations which can not be adequately assessed
by X-rays.
How do joints move?
Joints have precisely shaped matching surfaces that are
covered with a smooth layer of cartilage, like ball bearings, to
allow considerable motion. Ligaments are fibrous structures
that hold the bones together on each side of the joint, like
stout pieces of tape. They are shaped and located in such
a way that they permit motion while stabilizing the joint. The
volar plate protects the joint from hyperextension (bending
back too far), and the collateral ligaments provide stability
against side-to-side stress. Capsule is a thinner lining
that encloses the joint. Muscles provide the power and
movement to generate motion, and tendons are like cables
that transmit this movement from the muscles to the joints
(see Figure 1)
.
flexor tendon
capsule
collateral ligament
volar plate ligament
interosseous muscle
How is stiffness treated?
Conservative treatment may include stretching exercises for
the joints and muscles, as well as modalities to help loosen
them. Different types of splints or casts may be used to try to
provide sustained force to stretch the tight joints and regain
more motion
(see Figures 2, 3)
. Such measures are often
performed under the care of a hand therapist.
Figure 2:
Dynamic extension splint (to help straighten)
Surgery may need to be considered if conservative
treatment is not working. Surgery can include releasing
the tight ligaments and capsule and/or freeing up adherent
tendons and muscles. Such procedures usually require
intensive post-op hand therapy in order to maintain the
gains achieved at surgery, and the patient must be ready
to commit to such a program. Otherwise, the structures
that were released are likely to scar down again, resulting
in recurrent or worsened stiffness.
Why do joints get stiff?
Problems that affect these structures can result in stiffness.
Various types of arthritis can distort the contour of a joint,
altering its geometry so that it can’t move normally. Fractures
can also distort the smooth surface of a joint. Fractures
that aren’t even in the joint can cause adherence of nearby
structures, such as tendons and muscles. Scarring at the
site of fracture healing can tether these structures and limit
their motion, resulting in stiffness. Dislocations and even bad
sprains can injure the ligaments and capsule, causing them
to become thicker and less elastic with consequent loss of
mobility. Tendon and muscle injuries can also cause them to
get scarred down to their surroundings and thus lose some
of their usual mobility, resulting in stiffness.
Figure 3:
Web strap (to help bend)
If the stiffness is from arthritis, aggressive stretching and
surgical releases are usually not advised as the contour
of the joint may be too distorted for these approaches
to work. Adaptive strategies in the way the hand is used
may be helpful. Joint replacement or reconstruction may
need to be considered. Pain and functional impairment
are the main reasons to consider surgery. Not all stiff
joints need intervention. For example, the end joint (distal
interphalangeal, or DIP) of the finger can be stiff but still
compatible with good finger function. Sometimes joints are
even surgically fused in order to relieve pain and/or put the
finger in a more functional alignment.
How is stiffness evaluated?
Your doctor will need to know about the onset and progression
of the stiffness, its effect on use of the hand, any injuries,
other medical conditions, and any prior treatment. Careful
examination is performed to check the range of motion,
noting any difference between the active motion (motion that
you can generate on your own power) as opposed to passive
motion (motion that results from external force). Swelling
and tenderness are assessed, as well as any differences
Your hand surgeon will help you decide the best approach
to take for your individual situation. Successful outcomes
depend on the combined efforts of the surgeon, therapist,
and patient.
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