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Contractures and Deformities

Dupuytren’s, trigger finger, and fixed flexion deformities: etiology, staging, and surgical/non-surgical management options.

107 citationsUpdated Oct 2026

Overview

Contractures and deformities of the upper extremity arise from diverse etiologies, including intrinsic thumb pathology [1], obstetric brachial plexus injury causing severe forearm supination contracture typically presenting before age 10 [6], and muscle imbalance secondary to spasticity [7]. The management of malunited hand fractures is dictated by deformity location, soft tissue compliance, tendon balance, and joint contracture status [74]. While Dupuytren’s contracture surgery aims to correct deformity rather than cure the underlying disease [10], evidence for its optimal management remains limited [36].

Non-operative strategies include passive stretching for infantile camptodactyly under three years [2] and initial conservative care for stiff digits, though results are often poorer in severe or chronic cases [9]. Conservative treatment of Boutonniere deformity may yield one to two grades of range of motion improvement, yet deformity frequently persists [26]. Surgical intervention is indicated when conservative measures fail or for specific traumatic and post-burn contractures. Elbow contracture release in pediatric and adolescent populations achieves significant range of motion improvements comparable to adults [40], with anterior approaches yielding satisfactory results and low complication rates [20]. However, post-traumatic elbow releases may require multiple procedures, and patients must be counseled on the risk of recurrence [3].

Operative outcomes for digital contractures are generally favorable. Post-burn proximal interphalangeal joint flexion contractures in children were successfully treated in 88% of digits, defined as postoperative contracture less than 20° [5]. Surgical release for posttraumatic proximal interphalangeal joint flexion contractures typically improves flexion by 25° to 30° and shifts the arc into a functional range [11]. Percutaneous accessory collateral ligament release demonstrates high patient satisfaction and a mean 64% improvement in contracture [62], while central slip facilitation devices offer a valid alternative for severe Dupuytren’s contracture [14]. Immediate postoperative active mobilization following tendon transfer for claw deformity is safe and yields outcomes similar to immobilization [52].

Anatomy & Pathophysiology

General Principles of Deformity

Joint deformity arises from multiple etiologies, including soft tissue contractures, muscle imbalances, joint instability, and bony pathology. Generalized joint hypermobility occurs in approximately 5% of people and is familial [113]. Soft tissue causes include contracture of overlying skin, typically seen with severe scarring across the flexor aspect of a joint [113], and contracture of subcutaneous fascia, with Dupuytren's contracture in the palm being the classic example [113]. Muscle contracture due to fibrosis or ischemic necrosis, such as Volkmann's ischemic contracture, causes fixed joint deformity [113]. Unbalanced muscle weakness or spasticity results in joint deformity that becomes fixed if not corrected, as seen in poliomyelitis and cerebral palsy [113].

Joint instability may present as a deformed appearance when force is applied [113], while joint destruction from trauma, infection, or arthritis may lead to severe deformity [113]. Bony deformities stem from genetic or developmental disorders diagnosed in utero, during childhood, or in adulthood [113]. Rickets in children and osteomalacia in adults affect the entire skeleton and cause bone deformity [113]. Injuries involving the physis may result in asymmetrical growth, with deformity emerging as the bone elongates [113], whereas malunited fractures can cause bone deformity at any age [113]. Paget's disease affects older people and causes bone deformity [113], and postoperative iatrogenic deformity is a recognized cause of bone deformity [113].

Neuromuscular conditions share commonalities in musculoskeletal manifestations, including muscular weakness or imbalance that may result in diminished function, contracture, deformity, gait disturbance, and scoliosis [17]. There is currently no cure for neuromuscular conditions, but advances in medical management, genetic treatment, and surgical care have increased life expectancy [17]. The orthopaedic manifestations of neuromuscular diseases are no longer confined to the pediatric population [17].

Hand Anatomy and Biomechanics

The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [50]. The hand skeleton is divided into five rays, each comprising a polyarticulated chain of metacarpals and phalanges [50]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration for grasping [50]. The thumb metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [50], and the transverse axis of the palm forms an acute angle of approximately 75 degrees with the longitudinal axis [50]. The hand presents a longitudinal and transverse concavity, giving it the shape of a cup with a palmar concavity when the thumb is placed next to the index finger [50].

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [49]. Extrinsic muscles have their origin outside of the hand and insertion on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [49]. The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [49]: * First compartment: Contains the abductor pollicis longus and the extensor pollicis brevis [49]. * Second compartment: Contains the extensor carpi radialis longus and the extensor carpi radialis brevis [49]. * Third compartment: Contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle [49]. * Fourth compartment: Contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [49]. * Fifth compartment: Contains the extensor digiti quinti [49]. * Sixth compartment: Contains the extensor carpi ulnaris tendon [49].

The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [49]. Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [49], while distal interphalangeal joint extension is achieved through the conjoined lateral bands composed of tendinous slips from extrinsic and intrinsic tendons [49]. The sagittal band fibers form a sling that allows proximal extrinsic extensor tension to be transmitted to the proximal phalanx, permitting metacarpophalangeal joint extension without a tendinous insertion onto the proximal phalanx [49]. With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [49].

The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [49]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [49]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [49].

There are seven interosseous muscles, four dorsal and three volar [83]. The dorsal interossei are abductors and lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [83]. The volar interossei are adductors and lie to the ulnar side of the index finger and the radial side of the ring and little fingers [83]. The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [83]. Each dorsal interosseous muscle, with the exception of the third, has two muscle heads: a superficial head and a deep head [83]. The superficial head of the dorsal interosseous abducts and weakly flexes the proximal phalanx [83], while the deep head flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [83].

Transverse fibers arch dorsally from each lateral band to join each other over the dorsum of the finger, flexing the proximal phalanx [83]. Oblique fibers (spiral fibers) from the lateral bands insert onto the lateral tubercles at the base of the middle phalanx to extend the middle phalanx [83]. The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [83]. The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx to extend it [83]. The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [83]. The abductor digiti quinti and flexor digiti quinti brevis are similar in structure and function to the superficial and deep heads of the dorsal interossei, respectively [83]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate and inserts onto the ulnar side of the diaphysis of the fifth metacarpal, which it flexes and supinates [83].

The metacarpal arch is endowed with adaptability due to the mobility of the peripheral metacarpals [86]. The index metacarpal is the most firmly fixed [86], while the ring metacarpal has about 10 degrees of mobility in flexion and extension [86] and the fifth metacarpal has a range of flexion–extension of approximately 20 degrees [86]. The metacarpophalangeal articulations are the keystones of the longitudinal arches of the hand [86]. The volar plates prevent hyperextension at the metacarpophalangeal joints [86]. An imbalance between the three muscular systems, especially an "intrinsic-minus" situation, results in a break in the continuity of the curves at the level of the metacarpophalangeal joint [86].

The dorsal skin is thin and has loose connections with deeper planes, allowing free gliding and full flexion at the digital joints [92]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger from extension to full flexion [92]. Flexion at the metacarpophalangeal joint alone requires an average skin lengthening of 1.25 cm [92]. The dorsal and palmar areas of skin are independent because of a system of adhesions that anchors their common boundary to the underlying plane [92].

The superficial palmar fascia covers a triangular area of the central palm, with the proximal corner facing directly proximal [93]. Four central bands of fascia extend distally from the palmaris longus tendon toward each of the fingers, with no central band for the thumb [93]. Superficial fibers of the central bands merge with vertical retinacular fibers at the dermis’s undersurface and are more often involved with nodules than other fiber groups [93]. Intermediate fibers split transversely into two sections forming the spiral band that tracks around the neurovascular bundle [93]. Deep fibers continue dorsally to merge with sagittal interosseous fascia fibers and are rarely involved in contractures [93]. Fibers dorsal to the digital neurovascular bundle are collectively called Cleland ligament, and those palmar to the bundle are called Grayson ligament [93].

The axes of flexion are arranged so that flexion of all the metacarpophalangeal and proximal interphalangeal joints causes the fingers to converge toward the scaphoid [94]. The position of each articulation depends on the equilibrium of forces acting at that level, which is subject to the position of the immediately proximal articulation [91]. The active factor in joint equilibrium is the dynamic balance between antagonist muscles, while passive factors include ligamentous restraint and muscular viscoelasticity [91]. Almost all movements in the hand are around oblique and variable axes, resulting in combined movements permitting optimal orientation of the phalanges at the time of prehension [91].

Pathophysiology of Specific Deformities

Intrinsic contracture of the hand results from adherent, fibrotic, or contracted interosseous and lumbrical muscles causing an imbalance of viscoelastic forces about the extensor mechanism [33]. Severe intrinsic contracture deforms the finger into a posture where the metacarpophalangeal joint is flexed while the proximal interphalangeal joint is extended [33]. Dislocation of the metacarpophalangeal joint may occur in rheumatoid patients with concurrent synovitis [33].

Recontracture in Dupuytren's disease is a rate (percent per year), not an event [32]. Biologic and mechanical abnormalities are widespread in healthy appearing tissues before treatment and persist after corrective procedures for Dupuytren's disease [32]. Early recontracture develops during the first three postoperative months and is due to residual secondary effects of a chronic flexed posture on tendons, ligaments, skin, and other soft tissues [32]. Incomplete correction and early recontracture are more likely for PIP contractures greater than 40 to 60 degrees, MCP contractures greater than 50 degrees, and composite contractures greater than 110 degrees [32]. Progressive recontracture is due to residual active disease, where residual intact cord fibers remain biologically active and contractile [32]. Myofibroblast-rich cellular histology at the time of a corrective procedure correlates with progressive recontracture [32]. Late recontracture begins after an initial period of stability lasting a year or more and represents new disease activity in previously quiescent tissues [32]. Regression occurs in Dupuytren's contracture [73]. Imbalances of the extensor mechanism are caused by Dupuytren's disease [78].

In spastic cerebral palsy, the pennation angle of the extensor digitorum increased with the severity of forearm and wrist and finger deformities [30]. In patients with cerebral palsy, early flexion deformity of the digits is due to muscle spasticity, while late stages are due to muscle and sometimes joint contractures [163]. Severe flexion deformity of the metacarpophalangeal joint from combined forces of extrinsic digital flexors and intrinsic muscles results in great tension in the retinacular ligaments of the extensor mechanism, particularly the sagittal bands [163]. Attenuation of the sagittal bands allows the extensor tendon to dislocate with subsequent loss of extension at the metacarpophalangeal joint [163]. When sagittal bands are disrupted, extensor tendons become unstable and may sublux or dislocate ulnarily, impairing or losing active metacarpophalangeal extension [162]. Subluxation of the extensor tendons after sagittal band injury causes the intrinsic muscles to rest in a shortened position, which eventually results in myostatic contracture and swan neck deformity [162]. Adaptive shortening of the extrinsic finger flexors is required for the development of claw finger deformity [147].

Loss of intrinsic function of the foot leads to an imbalance allowing the extensor digitorum longus to extend the metatarsophalangeal joint and the flexor digitorum longus to flex the interphalangeal joints, causing claw toe deformity [96]. When the metatarsophalangeal joint is hyperextended, the ability of the extensor hood to extend the distal interphalangeal and proximal interphalangeal joints is significantly diminished [114]. Chronic hyperextension of the metatarsophalangeal joint eventually leads to fixed flexion deformities at the interphalangeal joints [114].

Most deep dermal and full-thickness burns involve the dorsum of the hand due to the natural response to use palms to shield the face and body [46]. Postburn flexion contractures are more commonly seen in the young population [46]. Burn contractures are classified by severity: * Type I: Limited to the skin; shows more than 30 degrees passive flexion with the wrist in maximum extension but less than 30 degrees with the wrist in maximal flexion [46]. * Type II: Involves scarring of both the skin and MCP joint capsule; fails to reach 30 degrees passive flexion even with the wrist in maximal extension [46]. * Type III: The most severe; MCP joint position is fixed in extension regardless of wrist position, often including bony or articular abnormalities [46].

The most severe dorsal hand burns result in a claw hand deformity with MCP joints in rigid hyperextension and PIP joint flexion contracture [46].

Larsen syndrome is associated with dislocated joints, foot deformities, and spinal deformities, including potentially lethal cervical kyphosis [53]. In Larsen syndrome, elbows frequently demonstrate radiohumeral dislocation with lateral prominence of the radial heads [53]. The elbow may be fixed by webbing in the antecubital space with a flexion contracture varying from 60 to 90 degrees [53]. Fingers are usually long and cylindric with shortened metacarpals and a spatulate thumb [53]. Dislocation of the metacarpal joint of the thumb can occur in Larsen syndrome [53].

The modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis could detect advanced deformity earlier and was more strongly correlated with hand function [44]. Comprehensive analysis identified five deformity patterns and a progressive course in the rheumatoid hand [80]. The value of the thumb is dependent in large part upon the mobility of its web [132].

Classification

Camptodactyly: Camptodactyly is classified into three main categories: Type I (classic), Type II, and Type III [43]. Type I presents in infancy, is frequently confined to one or both little fingers, and is usually sporadic but may be inherited as an autosomal dominant trait with incomplete penetrance [43]. Type II presents in adolescence, tends to worsen with the adolescent growth spurt, and affects females more often than males [43]. Type III is associated with chromosomal disorders, craniofacial diseases, and skeletal deformities [43]. The incidence of camptodactyly is estimated to affect less than 1% of the population [43].

Tubiana and Michon: This classification system scores contracture in a complete finger regardless of the contribution of the metacarpophalangeal joint or proximal interphalangeal joint [150]. Stage 1 is defined as contraction of 0–45° [150]. Stage 2 is defined as contraction of 46–90° [150]. Stage 3 is defined as contraction of 91–135° [150]. Stage 4 is defined as contraction over 135° [150]. The system does not allow deduction of whether a finger should be treated conservatively, minimally invasively, or with open surgery [150].

Dupuytren’s Disease Severity Staging: A revised severity staging system incorporates total flexion deformity and additional clinical risk factors [108]. This system provides a more objective and precise method for assessing disease severity [108] and may predict surgical outcomes [108].

Dupuytren’s Contracture Clinical Grading: A clinical grading system sorts patients into five broad surgical categories [111]. This system takes into account predisposing factors, risk of recurrence, and sympathetic tone in the individual patient [111].

Modified Terrono: A modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis could detect advanced deformity earlier than the original classification [44]. The modified classification was more strongly correlated with hand function [44].

Sandzen: Sandzen described a mild, moderate, and severe classification system for first web space contractures [160]. Mild first web space contractures involve a localized area of skin [160].

Swanson: The Swanson Classification of congenital anomalies of the hand and upper limb was recommended by the International Federation of Societies for Surgery of the Hand Committee on Congenital Conditions [156]. It was first presented in the 1960s according to the understanding of limb development and causation of limb anomalies present at the time [156]. Increasing knowledge at a molecular level has caused some to believe that deficiencies in the Swanson system demanded a new approach [156].

Other Considerations: Congenital contracture of the ulnar digits involves the middle, ring, and small fingers [34]. It is distinguished from ischemic contracture by a bony prominence on the proximal ulna [34].

Clinical Presentation

General Principles and Neuromuscular Manifestations

Muscular weakness or imbalance in neuromuscular conditions may result in diminished function, contracture, deformity, gait disturbance, and scoliosis [17]. The orthopaedic manifestations of neuromuscular disease processes are no longer confined to the pediatric population [17]. Correct diagnosis of the etiology of deformity is imperative for successful treatment [12]. In spastic cerebral palsy, the pennation angle of the extensor digitorum increases with the severity of forearm and wrist and finger deformities [30].

Intrinsic Hand Contractures

Intrinsic contracture of the hand is a condition in which adherent, fibrotic, or contracted interosseous and lumbrical muscles result in an imbalance of the viscoelastic forces about the extensor mechanism [33]. This pathology may result from trauma, spasticity, ischemia, rheumatologic disorders, or iatrogenic causes [33]. In mild cases, the patient may perceive a feeling of weakness or tightness when attempting to grasp a large object [33]. In severe cases, the hand assumes a posture with hyperflexed metacarpophalangeal joints and hyperextended proximal interphalangeal joints [33]. Considerable disability may result from weakness in grip strength, difficulty with grasping larger objects, and troubles with maintenance of hygiene [33]. The diagnosis is generally made via history and physical examination [33]. Adjunctive imaging, rheumatologic testing, and electromyography may aid in determining the underlying cause or assessing the severity of intrinsic contracture [33].

Camptodactyly

Camptodactyly is a nontraumatic, often progressive flexion contracture of the proximal interphalangeal joint that usually affects the little finger [43]. The true incidence of camptodactyly is estimated to affect less than 1% of the population [43]. Type I, or classic camptodactyly, presents in infancy and is frequently confined to one or both little fingers [43]. Type II camptodactyly presents in adolescence and the deformity tends to worsen with the adolescent growth spurt [43]. Females seem to be more often affected than males in Type II camptodactyly [43]. Camptodactyly has been attributed to tightness of the skin, underlying fascia, and flexor digitorum superficialis tendon [69]. Many patients experience little functional impairment, especially with a mild contracture [69]. Bony abnormality of the proximal interphalangeal joint was noted in 29% of all camptodactyly patients and in 58% of those with joint stiffness [69].

Dupuytren’s Contracture

Classic Dupuytren disease and atypical non-Dupuytren disease are distinct clinical entities that differ in presentation, etiology, treatment, and prognosis [98]. Dupuytren's disease may remain non-progressive without developing contracture [57]. The relationship between severity of flexion contracture and functional disability measured by the DASH questionnaire appears to be very weak or even absent in patients with Dupuytren’s contracture [41]. Patient-rated measures should be used alongside contracture severity to assess outcomes in Dupuytren’s contracture [31]. Recurrence of the contracture is always a possibility in Dupuytren's disease [56]. Early age, Dupuytren diathesis, multifocal disease, PIP joint disease, and small finger contracture are identified as potential predictive factors for recurrence of Dupuytren's contracture [56].

Elbow and Forearm Contractures

Severe supination contracture of the forearm usually presents before the age of 10 years in obstetric brachial plexus injury [6]. Flexion contracture in obstetric brachial plexus injury is not primarily related to bony changes of the elbow [39]. Pseudo-Volkmann contracture is well described but uncommon [13]. Congenital flexion deformity with an aberrant origin of the flexor digitorum profundus may be a potentially ignored disease often mistaken for Volkmann contracture [38]. Contractures can occur in muscles subjected to frequent injections and may develop in adult life as well as in childhood [15].

Postburn and Congenital Deformities

Most deep dermal and full-thickness burns involve the dorsum of the hand due to the natural response to use the palms of the hands to shield the face and body [46]. The most severe dorsal hand burns result in a claw hand deformity with the metacarpophalangeal joints in rigid hyperextension and proximal interphalangeal joint flexion contracture [46]. Congenital contracture of the ulnar digits is a congenital flexion deformity involving the middle, ring, and small fingers [34]. Many hand and upper extremity deformities secondary to amniotic constriction bands are encountered [54]. A residual flexion contracture was described in 24% of children operated on the fingers for mucopolysaccharidoses and mucolipidoses, most often reducible and predominated in the distal interphalangeal joint [66].

Investigations

Physical Examination: A careful physical examination is essential to direct care and future testing if indicated [48]. The clinician must combine the patient history with a careful physical examination to pinpoint or at least narrow the scope of possible pathologic processes [48]. Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [48].

MRI: MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing in Dupuytren's disease [101]. It may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity, but this potential staging tool has not been investigated yet on a large scale [101]. MR assessment of Dupuytren’s is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [101].

Doppler: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, but false-negatives are possible [101].

Other Considerations: One technique does not treat all deformities uniformly, highlighting the need to determine the true etiology before surgical intervention [166]. Preoperative deformity is a significant predictor of complete intraoperative correction and complete correction at follow-up in Dupuytren’s disease [75]. Patient-rated measures should be used alongside contracture severity to assess outcomes in patients with Dupuytren’s contracture [31].

Treatment

Non-Operative

Nonsurgical management constitutes the first line of treatment for most digital and upper extremity contractures, with specific protocols dictated by etiology and severity. For posttraumatic PIP joint contractures less than 45°, nonsurgical care is the standard initial approach, aiming to apply distributed extension force perpendicular to the joint [157]. This is achieved through serial digital cylinder casts changed 2 to 3 times weekly, removable serial casting, or static and dynamic extension splinting, the latter offering ease of application and allowing passive and active movement [157]. Approximately half of the final correction can be achieved in the first 2 weeks, with reported improvements of 16° to 18° after 10 weeks to 4 months of splinting [157]. However, longstanding contractures or those greater than 45° may not tolerate extension splints due to the risk of skin breakdown from progressively transmitted forces [157]. If extensive hand therapy fails after 3 months, nonoperative management is unlikely to be successful [157].

For camptodactyly, nonsurgical care is the first line for patients with functional limitations, including serial casting and splinting [69]. In infants younger than three years, passive stretching is a straightforward, complication-free method for improving flexion contractures of varying severities [2]. A protocol of 5-minute stretches performed 20 times daily has improved mild camptodactyly from 20° to 1°, moderate from 39° to 12°, and severe from 75° to 28° in children under three years of age [109]. Dynamic splinting yields good results, though some flexion deformity may recur upon discontinuation [109]. For upper limb amyoplasia, early intervention begins with occupational therapy, stretching, and splinting [110]. Stretching exercises to achieve passive elbow flexion past 90° are initiated as early as possible to facilitate hand-to-mouth activity, while the wrist is splinted to minimize flexion and ulnar deviation deformities [110]. Passive stretching is also used to maximize finger and thumb range of motion [110].

In upper extremity cerebral palsy, nonsurgical treatment includes therapy, splinting, assisted devices, and neuromuscular agents aimed at preserving joint motion and preventing permanent deformity [100]. Static and dynamic splinting, bracing, casting, and range-of-motion exercises are critical for preventing progression [100]. Care must be taken with bracing and splinting to prevent skin complications in limbs with altered sensibility [100]. Pharmacologic agents, including botulinum toxin, benzodiazepines, gabapentin, and baclofen, are helpful for symptom management and may be administered orally, intramuscularly, or intrathecally [100]. Intramuscular botulinum toxin A is typically used for spasticity, assisting with aggressive therapy during growth periods or serving as a diagnostic tool for preoperative planning [100]. For Boutonniere deformity, nonoperative treatment can achieve one to two grades of ROM improvement, although the deformity may persist [26]. For supple congenital clasped thumbs, nonoperative treatments such as splinting or casting are preferred to allow weak extensor muscles to become functional [79]. However, nonoperative methods are not recommended for patients with agenesis or severe hypoplasia of the extensor pollicis brevis, though they may improve fixed soft tissue contractures before surgery [79]. In Dupuytren's disease, non-operative therapy includes splints, ultrasonics, physical therapy, roentgen therapy, vitamin E, and corticosteroids [158]. Hydrocortisone acetate injections into nodules have produced disappointing results, except in several early-stage, soft, actively growing nodules [158].

Operative

Indications: Surgery is indicated when conservative management fails to achieve adequate functional improvement. For the stiff digit, surgery should be considered after limited improvement following 3 to 6 months of conservative management [9]. Initial nonsurgical treatment is warranted, but results may be poorer in patients with more severe or chronic contractures [9]. In camptodactyly, surgery is considered for moderate to severe deformities (60° to 90°) or those not responding to splinting [69]. Specific surgical indications include poor response to conservative management, flexion contracture greater than 30°, or PIP joint skeletal changes noted on radiograph [59]. For elbow contractures, surgical release is indicated for extension contractures that fail to resolve sufficiently to allow hand-to-mouth activities in amyoplasia [110]. In Dupuytren's contracture, when the contracture warrants treatment, definitive treatment is surgical [158]. Surgery is performed to correct contractures, not to cure the disease [10].

Surgical Approach / Technique: For camptodactyly, the goal of surgery is to achieve a more extended resting position to allow improved grasp, not to obtain a normal digit [76]. In young children where the deformity disappears with wrist flexion, release of the sublimis tendon may correct the deformity and prevent worsening during growth; this procedure usually should be performed by 4 years of age [109]. In older children and young adults with weak PIP extension, release of the flexor digitorum sublimis muscle and transfer into the extensor apparatus is advised [109]. A volar release, including local skin flap and volar plate release, may be used before tendon transfer to allow passive correction [109]. If the flexor digitorum superficialis tendon is normal proximally, a lengthening and transposition of the insertions at a chiasma level is performed [109]. Release of the flexor tendon sheath, volar plate, or accessory collateral ligaments may also be necessary [109]. The surgeon has a better chance of achieving a good result if the flexor digitorum superficialis is sectioned when a volar soft tissue release is done [23]. Bony decompression of the irregular head of the proximal phalanx leads to poor results and should be avoided, as it has resulted in firm fibroosseous ankylosis [23]. Preoperatively detected bony abnormalities at the neck of the proximal phalanx or involving PIP articular surfaces should not be explored, as there is no benefit [109].

For elbow contractures in amyoplasia, the elbow is approached posteriorly using an extended incision [110]. The ulnar nerve is identified, mobilized, and transposed anteriorly [110]. The triceps tendon is lengthened using W-plasty or a similar technique, and the posterior capsule of the elbow is addressed [110]. For spastic elbow deformity, several techniques are often combined in a single stage to provide an improved elbow position in patients with and without volitional control [61].

Postoperative Management: The postoperative regimen for camptodactyly involves maintaining the PIP joint in extension for 4 weeks in a cast [109]. After 4 weeks, a splint allowing active-resisted flexion is applied, unless the flexor digitorum superficialis was lengthened, in which case this is delayed another 8 weeks [109]. At 6 weeks, daytime motion is allowed with splinting at night [109]. The regimen also corrects any central slip attenuation [109]. For open surgical elbow contracture release after trauma, patients must be counseled that contracture may reoccur and some may require multiple procedures to achieve functional motion [3].

Outcomes and Complications: Surgical outcomes for camptodactyly are unpredictable; 20% of patients improve with nonoperative treatment and only 35% with operative treatment [109]. Salvage procedures result in functional improvement, although a normal digit is not obtained [23]. Most arthrogrypotic hand deformity surgeries result in better outcomes if performed during the early years of life using bony and/or soft-tissue interventions [28]. For Dupuytren's contracture, postoperative outcomes for fasciectomy and fasciotomy were successful, but surgical complications were common and recurrence was likely within a few years [8]. Late follow-up showed residual contracture in 20% of the open-palm group compared to 42% of the closed-palm group following fasciectomy [42]. Conservative surgery is simple, safe, and appropriate for discrete band contractures in the palm [104]. The simple staged procedure using a central slip facilitation device is a valid alternative for severe PIPJ contracture, demonstrating reliable correction and acceptable outcomes [14]. Indications for arthrodesis in severe recurrent Dupuytren's contracture should be stringent, as only 2.8% of patients required arthrodesis [51].

Adjuncts: Collagenase Clostridium histolyticum (CCH) injection is an alternative treatment. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures [24]. Recurrence was generally less severe than the initial contracture in the MCP group [24]. Most successfully treated joints had a contracture well below the threshold for surgical intervention 3 years after treatment [35]. Despite a lower injection rate, correction of joint contracture and range of motion was similar to clinical trial findings in clinical practice [99]. Grafts should possibly not be a contraindication for enzyme treatments for recurrent Dupuytren contracture [143]. There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture [115]. The safety of Xiaflex for patients with contractures less than 20° is questioned because no published prospective trials included such patients, despite the drug's indication covering any degree of contracture [130]. Patients can be counseled before CCH treatment that older age and increased contracture correction are risk factors for skin tearing, a common complication [16]. Percutaneous needle fasciotomy for primary Dupuytren’s contracture showed a significant change in total passive extension deficit after 2 years, with the best results in correction of MCP joint contractures [107]. Thirty-four per cent of patients had no further surgery at 10 years following percutaneous fasciotomy, with a mean contracture of 57° which was less than the original contracture [4].

Other Considerations: Recontracture is the critical unsolved issue of Dupuytren care, and recontracture and retreatment complications are the prime drivers of poor long-term outcomes [32]. Biologic and mechanical abnormalities are widespread in healthy appearing tissues before treatment and persist after corrective procedures [32]. Recontracture is a rate (i.e., percent per year), not an event [32]. Different definitions of recontracture include the need for repeat treatment, loss of a defined percent of initial correction, or loss of a specified number of correction degrees [32]. Pretreatment anatomy, individual biology, and procedure each influence the risk and timeline of recontracture [32]. There are three common patterns of recontracture: early, progressive, and late [32]. Early recontracture begins 1–2 weeks posttreatment and plateaus after 6–12 weeks, due to residual secondary effects of a chronic flexed posture on tendons, ligaments, skin, and other soft tissues [32]. Incomplete correction and early recontracture are more likely for PIP contractures greater than 40 degrees to 60 degrees, MCP contractures greater than 50 degrees, and composite contractures greater than 110 degrees, regardless of treatment technique [32]. Progressive recontracture begins 6–12 weeks post-treatment and is due to residual active disease [32]. PIP contractures, severe contractures, and diffuse disease are more likely to have multiple cords affecting the same joint, some of which may escape treatment, leading to progressive recontracture [32]. Late recontracture begins after an initial period of stability lasting a year or more and represents new disease activity in previously quiescent tissues, constituting true “recurrent Dupuytren contracture” [32]. Biologic factors lead to late recontracture [32]. Currently there remains limited evidence to guide the management of patients with Dupuytren's contracture [36]. Dupuytren's disease may remain non-progressive without developing contracture, as demonstrated by case reports of individuals with palm thickening but no functional impairment over 20 to 30 years [57].

Complications

Dupuytren's Contracture

Recurrence: Surgery corrects the contracture but does not cure the underlying disease [10]. Recurrence is a constant possibility, with predictive factors including early age, Dupuytren diathesis, multifocal disease, PIP joint involvement, and small finger contractures [56]. Long-term data indicate recurrence in 67% of MCP joint contractures and 100% of PIP joint contractures, though recurrent deformities are generally less severe than the initial presentation [70]. In prospective cohorts with a mean follow-up of 3.8 years, recurrence was common [67], and postoperative outcomes, while successful, were frequently complicated by recurrence within a few years [8]. Recurrence is particularly frequent in younger patients and those with PIP contractures [63]. Initial long-term evaluations found disease recurrence or progression in 4 of 6 patients with MCP contractures and 2 patients with PIP contractures, with MCP recurrences generally less severe [24]. At 10 years, 34% of patients required no further surgery, maintaining a mean contracture of 57°, which was less than the original deformity [4]. Late follow-up demonstrated residual contracture in 20% of the open-palm group compared to 42% of the closed-palm group [42]. Most successfully treated joints remained well below the surgical intervention threshold three years post-treatment [35].

Pathophysiology and Timing: Recurrence does not usually occur within 12 to 18 months of treatment [153]. Early recontracture develops during the first three postoperative months before plateauing, driven by residual secondary effects of chronic flexed posture on tendons, ligaments, skin, and other soft tissues [32]. Progressive recontracture represents a steady worsening after the first three months due to residual active disease [32]. PIP contractures, severe contractures, and diffuse disease are more likely to involve multiple cords affecting the same joint, some of which may escape treatment [32].

Management and Prognosis: The frequency of repeated operations is significantly lower in women than men, suggesting the disease is less aggressive in women [153]. At one-year follow-up, recurrent contracture in joints previously treated successfully with CCH may be effectively managed with up to 3 injections of CCH [60].

General and Other Contractures

Functional Outcomes and Recurrence: Patients must be counseled that contracture may reoccur and that multiple procedures may be required to achieve functional motion [3]. A result is considered worse if postoperative findings include increased contracture, loss of arc of motion, or ankylosis in a less functional position [23]. In pediatric populations, a residual flexion contracture was described in 24% of children operated on for finger contractures, most often reducible and predominating at the distal interphalangeal joint [66]. Despite recurrence, the mean postoperative deformity was significantly better than preoperatively, and the majority of families subjectively reported good function [22].

Specific Deformities and Complications: Bony decompression of the irregular head of the proximal phalanx leads to poor results, with two cases developing firm fibroosseous ankylosis at 20 and 0°, respectively [23]. Swan neck deformity may progress significantly over time due to increasing DIPJ flexion contracture [47]. In one case, a patient presented with thick recurrent contracture involving flexion contractures of 90° at the proximal interphalangeal joint and 30° at the distal interphalangeal joint [19]. At 12 months, a patient had no functional problems despite a residual PIP joint contracture of 30 degrees [45]. Recurrent contracture will occur if flexor tendon moment arms are not reconstructed after the device reverses the contracture [123].

Recovery

Non-Operative Management: The duration of orthotic use in weeks is significantly associated with the extent of contracture resolution in the stiff proximal interphalangeal joint [25]. Initial nonsurgical treatment for the stiff digit may have poorer results in patients with more severe or chronic contractures [9].

Operative Outcomes and Recurrence: Patients undergoing open surgical elbow contracture release after trauma must be counseled that contracture may reoccur and some may require multiple procedures to achieve functional motion [3]. In postburn proximal interphalangeal joint flexion contractures in children, 88% of digits were successfully treated with a postoperative contracture of less than 20° [5]. Most clinical series of patients who have undergone surgical release for posttraumatic proximal interphalangeal joint flexion contractures document an improvement in flexion contracture between 25° and 30° [11]. Surgical release for posttraumatic proximal interphalangeal joint flexion contractures results in a shift of the flexion/extension arc into a more functional range [11]. In camptodactyly, sectioning the flexor digitorum superficialis during volar soft tissue release increases the chance of achieving a good result [23]. Bony decompression of the irregular head of the proximal phalanx in camptodactyly leads to poor results, with cases developing firm fibroosseous ankylosis [23]. In Dupuytren’s contracture treated with percutaneous fasciotomy, 34% of patients had no further surgery at 10 years with a mean contracture of 57°, which was less than the original contracture [4]. Postoperative outcomes for fasciectomy and fasciotomy in Dupuytren’s contracture were successful, but surgical complications were common and recurrence of a contracture was likely within a few years [8]. In Dupuytren’s disease, long-term recurrence rates suggest recurrence in 67% of MCP joint contractures and 100% of PIP joint contractures, though recurrence was generally less severe than the initial contracture [70]. Recurrence of contracture, distinct from disease recurrence, could be predicted as early as 6 months after surgery for Dupuytren disease [125]. Late follow-up showed residual contracture in 20% of the open-palm group compared to 42% of the closed-palm group in Dupuytren’s disease fasciectomy [42]. In collagenase injection for Dupuytren's disease, initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures [24]. Recurrence after collagenase injection for Dupuytren's disease was generally less severe than the initial contracture in the MCP group [24]. Recurrent contracture in joints previously successfully treated with collagenase Clostridium histolyticum may be effectively retreated with up to 3 injections at a short-term follow-up of 1 year [60]. In osteotomy of the thumb delta phalanx in Rubinstein–Taybi Syndrome, the mean postoperative deformity was significantly better than preoperatively despite recurrence [22]. The majority of patients' families subjectively reported good function after osteotomy of the thumb delta phalanx in Rubinstein–Taybi Syndrome [22]. In deltoid muscle contracture, 47 of 49 shoulders (96%) had a good clinical result after distal release of the contracture [164]. In dorsal adduction contracture releases for short congenital syndactyly, no revisions were necessary in follow-ups ranging from 6 months to 3 years [68]. In a case of Dupuytren’s contracture causing an irreducible traumatic dislocation of the proximal interphalangeal joint, the patient had no functional problems at 12 months despite a residual PIP joint contracture of 30 degrees [45].

Key Evidence

• [L5] The purpose of this article is to describe the many causes of intrinsic contracture, detail how they are evaluated to distinguish among them, and delineate the surgical and nonsurgical treatment options currently in use. [1] (10.1016/j.hcl.2011.09.008)
• [L4] It is a straightforward, complication-free method of improving flexion contracture in camptodactyly of different severities in infants. [2] (10.1016/j.jhsa.2010.07.032)
• [L4] Patients must be counseled that contracture may reoccur, and some may require multiple procedures to achieve functional motion. [3] (10.1016/j.jse.2017.10.023)
• [L4] Thirty-four per cent of patients had no further surgery at 10 years, with a mean contracture of 57° which was less than the original contracture. [4] (10.1016/s0266-7681(97)80281-1)
• [L4] Eighty-eight percent of the digits were successfully treated (postoperative contracture less than 20°). [5] (10.1016/s0363-5023(87)80022-9)
• [L3] Severe supination contracture of the forearm usually presents before the age of 10 years. [6] (10.1177/17531934221121912)
• [L5] However, selected deformities related to muscle imbalance secondary to spasticity may be corrected by appropriate surgical procedures. [7] (10.1016/s0363-5023(83)80267-6)
• [L2] Postoperative outcomes were successful, but surgical complications were common and recurrence of a contracture was likely within a few years. [8] (10.1177/1753193410397971)
• [L5] Initial nonsurgical treatment is warranted but may have poorer results in patients with more severe or chronic contractures; surgery should be considered for limited improvement after 3 to 6 months of conservative management. [9] (10.5435/jaaos-d-18-00310)
• [Textbook] Surgery is performed to correct contractures, not to cure the disease. [10] (10.1007/978-3-642-22697-7_32)
• [L4] Most clinical series of patients who have undergone surgical release document improvement in flexion contracture between 25° to 30° and a shift of the flexion/extension arc into a more functional range. [11] (10.5435/00124635-200609000-00002)
• [L4] Correct diagnosis of the etiology of deformity is imperative for successful treatment. [12] (10.1016/j.jhsa.2014.01.039)
• [L4] Pseudo-Volkmann contracture is well described but uncommon. [13] (10.5435/jaaosglobal-d-18-00031)
• [L4] The simple staged procedure is a valid alternative in the management of severe Dupuytren's PIPJ contracture, demonstrating reliable, reproducible correction of the deformity and acceptable patient outcomes. [14] (10.1177/1753193412439673)
• [L4] Contractures can occur in muscles subjected to frequent injections and may develop in adult life as well as in childhood. [15] (10.2106/00004623-197456040-00019)
• [L2] Patients can be counseled before CCH treatment that older age and increased contracture correction are risk factors for this common complication. [16] (10.1016/j.jhsa.2019.06.010)
• [L5] Treatment of intrinsic contractures is based on etiology, with hand therapy as the first line of treatment. [18] (10.1016/j.hcl.2011.10.001)
• [L4] Surgical correction of elbow flexion contractures in pediatric patients through an anterior approach leads to a satisfactory result in the majority of cases, with a low incidence of complications. [20] (10.1016/j.jse.2020.01.081)
• [L4] Despite the recurrence, the mean postoperative deformity was significantly better than preoperatively and the majority of patients' families subjectively reported good function. [22] (10.1177/1753193409354523)
• [L4] [23] (10.1016/s0363-5023(77)80072-5)
• [L4] Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. [24] (10.1016/j.jhsa.2010.01.003)
• [L2] The duration of orthotic use (weeks of treatment) is significantly associated with the extent of contracture resolution. [25] (10.1016/j.jht.2011.09.006)
• [L3] One to two grades of ROM improvement can be achieved, although deformity can persist even after dedicated conservative management. [26] (10.1016/j.jht.2025.02.013)
• [L5] Most arthrogrypotic hand deformity surgeries result in better outcomes if performed during the early years of life using bony and/or soft-tissue interventions. [28] (10.1016/j.jhsa.2021.10.027)
• [L3] In contrast, the pennation angle of the extensor digitorum increased with the severity of forearm and wrist and finger deformities. [30] (10.1177/17531934261480554)
• [L3] These results suggest that patient-rated measures should be used alongside contracture severity to assess outcomes. [31] (10.1016/j.jht.2010.07.006)
• [L5] [33] (10.5435/jaaos-21-10-581)
• [L4] Congenital contracture of the ulnar digits is a new congenital flexion deformity involving the middle, ring, and small fingers, distinguished from ischemic contracture by a bony prominence on the proximal ulna. [34] (10.1016/j.jhsa.2021.06.008)
• [L4] Most successfully treated joints had a contracture well below the threshold for surgical intervention 3 years after treatment. [35] (10.1016/j.jhsa.2012.09.028)
• [L2] Currently there remains limited evidence to guide the management of patients with Dupuytren's contracture. [36] (10.1302/0301-620x.100b9.bjj-2017-1194.r2)
• [L4] The authors suggest that congenital flexion deformity with an aberrant origin of the flexor digitorum profundus may be a potentially ignored disease often mistaken for Volkmann contracture. [38] (10.1016/j.jhsa.2015.07.012)
• [L4] This indicates that flexion contracture is not primarily related to bony changes of the elbow. [39] (10.5435/jaaos-d-17-00110)
• [L4] Elbow contracture release in the pediatric and adolescent population can provide significant improvements in range of motion similar to that achieved in adults. [40] (10.1016/j.jse.2016.09.008)
• [Textbook] The relationship between severity of flexion contracture and functional disability measured by the DASH questionnaire appears to be very weak or even absent. [41] (10.1007/978-3-642-22697-7_40)
• [L3] Late follow-up showed residual contracture in 20% of the open-palm group compared to 42% of the closed-palm group. [42] (10.1016/s0363-5023(84)80184-7)
• [L5] [43] (10.1016/j.hcl.2008.12.003)
• [L3] The modified classification could detect advanced deformity earlier and was more strongly correlated with hand function. [44] (10.1177/1753193419886719)
• [L5] At 12 months, the patient had no functional problems, although he had a residual PIP joint contracture of 30 degrees. [45] (10.1016/j.jhsb.2006.12.005)
• [L5] [46] (10.1016/j.jhsa.2014.03.018)
• [L5] The swan neck deformity in this individual progressed significantly with time because of increasing DIPJ flexion contracture. [47] (10.1016/j.jht.2009.11.005)
• [L4] The indications for this procedure should be stringent, as only 2.8% of patients operated upon for Dupuytren's contracture required arthrodesis. [51] (10.1016/s0363-5023(87)80291-5)
• [L2] Immediate postoperative active mobilization is safe and has similar outcomes of deformity correction compared to immobilization. [52] (10.1016/j.jhsa.2007.10.012)
• [L4] Many hand and upper extremity deformities secondary to ACB are encountered. [54] (10.1177/1558944717750917)
• [L4] Dupuytren's disease may remain non-progressive without developing contracture, as demonstrated by two case reports of individuals with palm thickening but no functional impairment over 20 to 30 years. [57] (10.1177/1753193416632644)
• [L4] [59] (10.1177/1558944719834654)
• [L4] At a short-term follow-up of 1 year, recurrent contracture in joints previously successfully treated with CCH may be effectively retreated with up to 3 injections of CCH. [60] (10.1016/j.jhsa.2017.02.010)
• [L5] Several techniques are often combined in a single stage to provide an improved elbow position in patients with and without volitional control of their affected extremities. [61] (10.1016/j.jhsa.2023.09.015)
• [L4] A high patient satisfaction rate of five out of six and a mean 64% improvement in contracture is sufficiently encouraging for us to extend this series. [62] (10.1016/0266-7681(86)90158-0)
• [L4] The complication rate was low, but recurrences were frequent in younger patients and for PIP contractures. [63] (10.1016/j.jhsa.2012.01.029)
• [L4] [66] (10.1177/17531934211061980)
• [L2] In prospectively collected cohorts with a mean 3.8 years of follow-up, recurrence after Dupuytren contracture treatment was common. [67] (10.1016/j.jhsg.2026.100979)
• [L4] In dorsal adduction contracture releases followed-up from 6 months to 3 years, no revisions were necessary. [68] (10.1016/0363-5023(91)90186-f)
• [L5] [69] (10.1016/j.jhsa.2009.06.014)
• [L4] Long-term recurrence rates suggest recurrence in 67% of MCP joint contractures and 100% of PIP joint contractures, though recurrence was generally less severe than the initial contracture. [70] (10.1016/s0363-5023(09)60096-4)
• [L5] [73] (10.1016/s0266-7681(05)80273-6)
• [L5] The choice of surgical approach, timing, and technique is determined by the deformity location, soft tissue compliance, tendon balance, and presence of joint contracture. [74] (10.1016/j.jhsa.2013.07.014)
• [L2] Preoperative deformity is a significant predictor of complete intraoperative correction and complete correction at follow-up. [75] (10.1177/1753193409353849)
• [L4] The goal of surgery is to achieve a more extended resting position to allow improved grasp, not to obtain a normal digit. [76] (10.1016/j.jhsa.2018.03.023)
• [L5] [78] (10.1016/j.jht.2024.12.017)
• [L4] [79] (10.1054/jhsb.1999.0203)
• [L2] Our comprehensive analysis identified five deformity patterns and a progressive course in the rheumatoid hand. [80] (10.1186/s13075-021-02448-4)
• [Textbook] Classic Dupuytren disease and atypical non-Dupuytren disease are distinct clinical entities that differ in presentation, etiology, treatment, and prognosis. [98] (10.1007/978-3-642-22697-7_1)
• [L3] Despite a lower injection rate, correction of joint contracture and range of motion was similar to findings from clinical trials. [99] (10.1016/j.jhsa.2013.08.114)
• [L4] It is simple, safe and appropriate for the discrete band contracture in the palm. [104] (10.1016/0266-7681_87_90183-5)
• [L4] The treatment showed a significant change in total passive extension deficit after 2 years, with the best results in correction of MCP joint contractures. [107] (10.1177/1753193411407245)
• [L4] The revised severity staging system, which incorporates total flexion deformity and additional clinical risk factors, provides a more objective and precise method for assessing Dupuytren's disease severity and may predict surgical outcomes. [108] (10.1007/s11552-007-9071-1)
• [L4] The classification system has been used to sort patients with Dupuytren's contracture into five broad surgical categories and takes into account predisposing factors, risk of recurrence and sympathetic tone in the individual patient. [111] (10.1016/s0266-7681(98)80045-4)
• [L1] There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture. [115] (10.1177/1558944721994220)
• [L4] However, recurrent contracture will occur if the flexor tendon moment arms are not reconstructed after the device reverses the contracture. [123] (10.1016/j.jhsa.2012.04.023)
• [L3] Recurrence of contracture (not disease recurrence) could be predicted as early as 6 months after surgery for Dupuytren disease. [125] (10.1016/j.jhsa.2013.05.038)
• [L5] The author questions the safety of Xiaflex for patients with contractures less than 20° because no published prospective trials included such patients, despite the drug's indication covering any degree of contracture. [130] (10.1007/s11552-012-9424-2)
• [L4] The value of the thumb is dependent in large part upon the mobility of its web. [132] (10.2106/00004623-195032020-00004)
• [L4] Grafts should possibly not be a contraindication for enzyme treatments for recurrent Dupuytren contracture. [143] (10.1016/j.jhsa.2013.03.063)
• [L5] These simulations suggest that adaptive shortening of the extrinsic finger flexors is required for the development of claw finger deformity. [147] (10.1016/j.jhsa.2019.05.007)
• [Textbook] [150] (10.1007/978-3-642-22697-7_28)
• [L4] [153] (10.1054/jhsb.1999.0154)
• [L5] [156] (10.1177/1753193417690965)
• [L5] [157] (10.1016/j.jhsa.2013.03.014)
• [L5] [160] (10.1016/j.jhsa.2015.06.113)
• [L4] [162] (10.1016/j.jht.2008.06.013)
• [L4] [163] (10.1054/jhsb.1998.0005)
• [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. [164] (10.2106/00004623-199802000-00010)
• [L5] It emphasizes that one technique does not treat all deformities uniformly and highlights the need to determine the true etiology before surgical intervention. [166] (10.1016/j.jhsa.2022.07.008)

See Also

• Dupuytren's Disease
• Joint Disease

References

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[19] In_Reply_S0363502313005303. n.d..

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