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Management of stiff hand: an occupational therapy perspective

Article  in  Hand Surgery · January 2003

DOI: 10.1142/S0218810402001217 · Source: PubMed

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 Hand Surgery, Vol. 7, No. 2 ( December 2002) 261–269
© World Scientific Publishing Company

MANAGEMENT OF STIFF HAND: AN OCCUPATIONAL

THERAPY PERSPECTIVE

Josephine M. W. Wong
Department of Occupational Therapy, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

ABSTRACT
Joint stiffness, resulting from a variety of complications after hand injuries, remains a common problem. Prolonged swelling,
scar formation and shortening of soft tissue after prolonged period of immobilisation are the major causes leading to the loss
of joint range of motion. Treatment used to improve the joint stiffness should be integrative and problem-focused. Pressure
therapy, active and passive mobilisation through remedial activities and corrective splinting should be started as soon as problems
arise. Applying low-load stress through prolonged periods of time onto the shortened tissue at its maximum tolerable range is
the main principle in restoration of passive joint range of motion. The greater the joint limitation becomes, the longer the time
the splint should be applied. Therapists should understand the process of tissue healing and different functions of splints before
a correct and effective splint can be prescribed properly.

Keywords: Joint Contractures; Mobilisation; Serial Splintage; Low-Load Stretch.

INTRODUCTION CAUSES OF JOINT STIFFNESS

Joint stiffness remains a common phenomenon subsequent to
severe traumatic hand injuries. It is not the immediate com-
plications of trauma, but the secondary consequence of afflictions
of the skin, fascia, tendon, tendon sheath, muscle or retinacular
ligaments which limit joint motion for a prolonged period of
time.13 Even though edema and immobilisation factors at the initial
stage have been removed, shortening of joint capsule or collateral
ligaments, restrictive scar formation, tendon adhesions and
myostatic muscle contracture dominate the later stage of recovery
if the start of therapy is delayed. The severity of which depends
on the severity of trauma, modes of injury, and its associated
complications such as infection, haematoma or successive
operative procedures. The resultant impaired joint ranges of
motion and grip strength usually impose adverse effects on normal
hand functions and hence, the performance of daily work and
household activities. Splintage, pressure therapy and active
mobilisation are the treatment modalities that occupational
therapists utilise to improve patients’ hand functions.
Loss of motion of the fingers and wrist may be due to prolonged
retention of edematous fluid, scar formation, prolonged period
of immobilisation, and a combination of all.
Edema is the immediate reaction of the hand to injury. The
extent of edema is probably related to the severity of the injury to
the involved tissues altering the capillary permeability. During the
acute phase, the lymphatic fluid fills the interstitial spaces,
interfering with the normal gliding of tissues. When the edematous
process continues, protein-rich fluid overflows from the interstitial
space, and pitting edema is observed externally.5 Collagen is then
deposited along the collateral ligaments as well as the flexor and
extensor tendons, which become bound to the surrounding
immobile structures. Restricted active and passive movements
result with consequent gradual loss of motion of the finger and
hand.13
Scar formation takes place not only on the injured tissues, but
also on those tissues distant to the injured site due to the effects
of chronic edema. Moreover, scars resulting from the healing of

Correspondence to: Ms. Josephine M. W. Wong, Occupational Therapist, Department of Occupational Therapy, Prince of Wales Hospital, Shatin, New Territories, Hong Kong,
Tel: (+852) 2632-3236, Fax: (+852) 2648-4132, E-mail: pwhjoe@netvigator.com

261

00121.p65 261 01/13/2003, 10:14 AM

 262 J. M. W. Wong
contiguous tissues may also result in the formation of adhesion
that limits tendon excursion.13 Conditions are much worse when
the tendon injury is complicated by bone fractures at the same
site. Tendons may be adhered to the non-yielding fracture callus,
further reducing the amount of possible active motion and
restricting the passive range of movement. It is not uncommon to
find that extensor tendon injury at zone IV with proximal phalanx
fracture will result in decreased range of flexion and extension of
the proximal interphalangeal (PIP) joint. The repaired tendon
was adhered to the fractured site. Similar conditions can be seen
on the palmar side when flexor tendon is adhered and it limits
either the active flexion or extension of the finger joint.
A prolonged period of immobilisation is another contributing
factor of joint stiffness. Peacock11 demonstrated on a canine
model that joint stiffness was the by-product of a period of
immobilisation following trauma. He also showed that the primary
tissue involved in joint stiffness was the periarticular connective
tissue — specifically, the ligament and capsule that were placed
in a shortened position during the period of immobilisation. Apart
from this, any pressure point produced by the dressing or cast
can also lead to edema and swelling of the injured or
postoperative hand.8 Therefore, a properly fitted cotton dressing
is preferred. Most of the time, the muscles may become involved
and the resulting myostatic contraction may occur due to
prolonged immobilisation.13 It happens when the tension within
a skeletal muscle is completely removed for a period of time,
and the muscle belly is shortened at this retracted length. If the
muscle is kept shortened for a certain period of time, to restore
it to its original length may become difficult. Extreme stress may
lead to damage of muscle fibres.
To minimise the severity of complications led by tendon
adhesions and to prevent further joint stiffness, efforts including
early joint motion through active and passive mobilisation
programmes and serial splinting are indispensable. The ultimate
goal is to provide beneficial biological effect on adhesion
formation around the healing tissues and their adjacent structures.
DIFFERENT TYPES OF JOINT
STIFFNESS
The most common post-traumatic joint contractures are the
metacarpophalangeal (MCP) joint extension contracture, PIP joint
flexion contracture and extension contracture, and thumb web
contracture. These are the positions that patients find to be most
comfortable for resting their hands after injury.
00121.p65 262
MCP Joint Extension Contracture (Fig. 1)
As the collateral ligaments of the MCP joint are eccentrically
placed, coupled with the configuration of the metacarpal head,
the collateral ligaments are lax with the joint in full extension and
tight with the joint in flexion.13 Usually injury or prolonged edema
around the joint will lead to deposition of the collagen fibres
around the ligaments in their slacken positions allowing them to
shorten and contract. The flexion range will be decreased
progressively. Moreover, direct trauma to the joint or extensor
tendons, joint immobilisation in a more extended position as well
as patients’ not using their hands due to pain can cause thickening
of the dorsal joint capsules, scar formation of the dorsal skin,
and obliteration of the palmar synovial pouch.
PIP Joint Flexion Contracture (Fig. 2)
It is one of the most common complications of trauma including
tendon injuries, fractures, and soft tissue injuries such as post-
joint dislocation ligamentous lesions. Chronic edema and
immobilisation always put the joint in a flexed position, with
subsequent contracture of the palmer volar plate of the capsular
ligament, and the adherence of the collateral ligaments. Flexor
tendon adhesions and palmer skin scarring also play important
roles in contributing to joint stiffness.8
PIP Joint Extension Contracture
Limitation of flexion of the PIP joint may be due to the impaired
anatomical structures in the finger after dorsal skin laceration or
direct trauma to the joint. These structures include (1) scarring
of the dorsal skin and joint capsule, (2) adherence of the central
extensor tendon, (3) contracted interosseous muscle or adherent
interosseous tendon, and (4) contracted capsular ligament,
particularly the collateral ligament. The consequent immobilisation
may also contribute to the resulting joint stiffness.8
Thumb Web Contracture
Prolonged edema, web laceration and secondary stiffening of the
carpometacarpal (CMC) joint usually lead to the scarring of the
fascia or musculature of the first web space, resulting in adduction
deformity of the first web. This contracture can also be due to
simple scarring of the skin between the thumb and the index
finger. Distention of the dorsal first web skin is brought about by
the edematous fluid coupled with the myostatic contracture of
01/13/2003, 10:14 AM
 Management of Stiff Hand 263

edema and early active mobilisation are important to prevent

further development of joint stiffness. In addition, splinting plays
an important role in correcting joint stiffness and restoring the
joint range of motion.

Edema Control (Figs. 3a and b)

“Internal” edema can be detected easily through the following
observations: (1) loss of normal small skin wrinkles; (2) tautness
of the dorsal finger joint creases; (3) loss of metacarpal head
Fig. 1 The MCP joints extension contractures and first web contracture in
definition; and (4) obscurity of the dorsal finger extensor tendons
a hand with Volkman’s Ishaemic Contracture.
over the hand dorsum.5
Palpation of the hand gives more details in differentiating
between “movable” pitting edema and “fibrotic” edema.5 Acute

Fig. 2 A flexion contracture of the PIP joint of little finger.

Fig. 3a Unable to fully flex fingers.

the first dorsal interosseous and adductor pollicis muscles.13 It is
commonly found in denervated hands where the motor functions
are temporarily or permanently impaired. Therefore, for patients
suffering from such injuries as brachial plexus injuries, hand
amputation and peripheral nerve injuries, they should be provided
a hand resting splint for positioning the hand and wrist in
functional position at the early stage of rehabilitation. The thumb
should be positioned in the mid of radial and palmer abduction
and the first web in its widest space. Serial first web spreader
using dynamic and static splints should be provided to widen the
formed contracture in the later stage of rehabilitation.

Management of Stiff Hand

It is important to understand the factors causing joint stiffness so
as to provide correct and early intervention. Early control of Fig. 3b Unable to fully extend fingers.

00121.p65 263 01/13/2003, 10:14 AM

 264 J. M. W. Wong

“movable” pitting edema (Fig. 4) can be felt to “give way” when
direct pressure is applied by the finger tips over the edematous
area, making the finger and hand “tight and full”. The joint
appears inflamed and swollen, and the passive range is limited by
the tension created by the edema but creating a soft feel to the
end range. “Fibrotic” edema is usually a by-product of chronic
edema. Swelling no longer dominates over the fingers and hand,
rather, edema has been replaced by adhesion, and the fibrosis is
limiting the gliding of the tissue. The mobility of the tissue is
hence limited, and the passive motion of the joint becomes tight.5
Elevation, active mobilisation of involved joints as well as the
adjacent uninvolved joint, manual massage and compression by
elastic wraps or pressure garment can effectively reduce the acute
pitting edema. Patients should be instructed clearly that the
combination of all these methods make up the most efficient way
to reduce edema. Elevation of the involved limb above the heart
level can facilitate the flow of the edematous fluid from distal to
proximal parts of the body.8 Gentle active mobilisation activities
should be given to guide patients to flex and extend their involved
limbs within their pain tolerance, thereby gradually pumping away
the “extra fluid” that originally fills up the space. Massage to the
hand should be used frequently: both distal-to-proximal massage
to reduce edema, and local massage to the deep layers of tissues
in the hand to stimulate blood flow and increase mobility of the
tissue layers.5 Compression on the edematous site with elastic
bandage or pressure garment can effectively reduce edema.
Constant pressure has to be ensured at individual wrap during
the application of elastic bandage to avoid uneven distribution of
pressure over the involved limb or fingers. Tailor-made pressure
garment can provide gentle and circumferential pressure which

Fig. 4 Pitting oedema.

(a) (b)

Fig. 5 Compression techniques through gentle and circumferential pressure can help to reduce edema. (a) Cotton type elastic finger stall over the middle
finger and the elastic self-adhesive bandage over the index finger. (b) Pressure garment over the fingers and hand.

00121.p65 264 01/13/2003, 10:14 AM


Fig. 6 A dorsal/volar type night resting splint positions the hand and wrist
in safe position and by well-distributed dorsal and volar pressure swelling
can be assisted to be reduced.
can be evenly distributed over the generalised swollen hand and
wrist (Fig. 5b). Cotton type elastic finger stall is a good choice
for swollen fingers (Fig. 5a). Light dressing gauze is still necessary
to cover up the mildly oozing wound. All these compression
methods can be allowed off during the mobilisation activities to
avoid restriction on the range of motion.
The objective of splinting the edematous hand is to maintain
the optimal length of tissues and prevent the loss of range of
motion through rest and compression (Fig. 6). It is important to
preserve the length of the MCP and interphalangeal (IP) collateral
ligaments by keeping these tissues taut. This is achieved by
positioning the MCP joints in full flexion and the IP joints in full
extension. To maintain the length of the flexor tendons, MCP
flexion should be balanced with wrist extension to take up the
slack in the flexor tendons.10 A dorsal/volar slab-type splint is
suggested to be used on the heavy swollen hand and wrist, since
it is effective in gaining optimal positioning as they conform
intimately and provide well-distributed dorsal and volar pressure
to assist in swelling reduction.5
Active and Passive Motion Through
Mobilisation Activities and Passive
Stretching
Active movement of the hand encourages pumping action of the
muscle and the subsequent gliding of the soft tissue structures,
which is important in restoring the normal strength of the motor
unit of the hand, while at the same time getting more space for
the joint to flex and extend through gradual decrease of edematous
00121.p65 265
Management of Stiff Hand 265
fluid. Active movement should be sustained at the maximum range,
and in the early stages, conducted in an elevated position to
facilitate edema control. Quick, repetitive motions are only easy
motions that most patients feel capable to perform, but this can
hardly help improve the range of motion and muscle strength of
the hand. Movement should be done through patients’ focused
effort in achieving a targeted range of motion through strong
muscle pull.5 For instance, it is difficult for patients to flex and
extend their injured finger especially when it is very swollen. MCP
flexion dominates while trying to flex the fingers. To train the
flexion of the IP joints, blocking the MCP joints from full flexion
through activities or splinting while encouraging flexion of the IP
joint can transmit the global effort of the finger flexors into specific
gliding of IP joints (Fig. 7).
Passive movement is the movement of a joint by an external
force. Correct passive movement of the joint can encourage tissues
to reach a maximum available length.5 It is important to know
that resistance from the tissues must be respected during the
passive motion, and the resultant pain elicited during the
movement has to be carefully handled and cared. No aggressive
passive motion which may induce severe pain is allowed since
this may cause tissue damage rather than tissue stretching. This
is similar to Dr. Paul Brand’s4 description of his experience in
correcting club foot deformities of Indian teenagers (published
in 2002): “I felt that we had to be slow, and we also had to be
gentle. I hoped that we could achieve this by a gentle contact
manipulation keeping within the limits imposed by pain, and then
Fig. 7 This swollen index finger, being crushed with resulting communiuted
fracture of the middle phalanx, was surgically reduced by a traction device.
A MCP joint blocking splint was then applied to facilitate flexion and extension
of the IP joints by blocking the MCP joint in extension.
01/13/2003, 10:14 AM
 266 J. M. W. Wong
by using total contact plaster casts to hold the partially corrected
position for a week or so … I hoped that the improvement gained
by moderate correction at the beginning of the week would loosen
up and allow further improvement that would be maintained by
the next cast …”.4 No joint should be passively flexed without
accompanying traction to the joint, allowing room for one joint
surface to glide over the other without friction. One prolonged
hold will allow the motion to be repeated actively and more
effectively than many repeated quick stretches. It is best illustrated
by the place and hold exercise of the flexor tendon programme.
Therapists first place the involved finger(s) into maximum flexion,
usually in touch-palm position, and are followed by patients’ active
hold of the fingers in the same place for a prolonged period,
attempting to restore the maximum gliding of the flexor tendon
to achieve finger flexion at their maximum length. After several
attempts, patients will find improvement in finger flexion which is
more effective than quick and forceful stretches.
Splinting
(1) Types of splints and their application
in the different phases of tissue healing
Before we can decide on the appropriate splint to be applied on
patients’ hands, different functions of each type of splint should
be understood. Moreover, in order to facilitate tissue healing and
preserve motion, splints of different designs can provide different
amount of “stress”, which is needed by the tissues in order to
induce remodelling of the scar tissue at different stages of wound
healing.6 In other words, biological stages of tissue healing help
define the different types of splint design5 (Fig. 8).
Static Progressive Splinting
Dynamic Splinting
Serial Static Splinting
Static Splinting
Inflammatory Stage Proliferative Stage Chronic Stage
Fig. 8 Different types of splints and their combinations are effective in
different stages of healing process.
00121.p65 266
Static splint is the one molded and applied directly onto the
hand to maintain the tissues in one position. It immobilises one
or more joints; (1) support the healing tissue at the initial stage
after injury or surgery, (2) relieve pain and provide rest to
inflamed tissues, and (3) maintain tissue length to prevent
contractures.10 It may be removed periodically for short periods
for specific exercises. It is usually used during the inflammatory
stage of tissue healing when the inflamed tissue needs to rest by
immobilisation. Application of stress by splint at this stage should
be minimal depending on the specific injury or surgical
procedure.
Serial static splint is similar to the static splint, i.e. it is molded
in a stationary position. Apart from its function in providing
support to the healing tissue, it can also be applied to correct
contractures and improve the passive range of motion of the joint
by applying a gentle, prolonged stretch to promote growth of
contracted soft tissues.10 With the tissue being stretched at its
maximum tolerable length, the splint has to be worn for longer
periods of time so that the tissue adapts to the new position. After
the healing tissue adapts the position of the old splint, the old
splint is re-molded or a new splint is applied to hold the tissue
at its new maximum length. These serial adjustments of the splint
position upgrade the length of the tissue to its maximum length
regaining joint motion. Serial static splints can be applied
throughout all stages of tissue healing because of its ability to
both rest tissues and gain motion effectively.
Dynamic splint applies a passive pulling force to a specific
joint in one direction while permitting active motion in the
opposite direction, using energy-storing materials such as
theraband, rubber band, springs and spring wire10 (Fig. 9). It
Fig. 9 A dynamic PIP joint extension splint effectively restores the extension
of the PIP joint.
01/13/2003, 10:14 AM
 Management of Stiff Hand 267

involves dynamic components on top of the static splint base. It

aims to: (1) facilitate early motion to a newly repaired tendon
to minimise tendon adhesion and enhance tendon gliding,
(2) provide a passive assist to substitute for weak or absent motor
function due to a peripheral nerve lesion, (3) apply gentle,
prolonged stretch to correct contractures when early signs of
joint stiffening or tendon adhering is taking place. While the
patient wears the splint, a constant and dynamic force is applied,
and even if the joint motion improves, the force of the splint
continues. During the proliferative stage of tissue healing, healing
cells are multiplying at a rate greater than normal, and the cells
are re-aligning themselves. It is during this stage that a correctly
applied stress can be most beneficial in preventing long-term
stiffness. When a tight joint responses to manual stretch and is
able to reach its maximum passive range, dynamic splinting is
hence efficient to provide intermittent stress balanced with active
motion to maintain the passive range of motion of the joint.5
Static progressive splints consist of inelastic components such
as hook and loop tapes, adjustable hinge, screws or a turn-buckle
to apply torque to a joint in order to statically position it as close
to end range as possible, and thus increase passive range of
motion12 (Figs. 10a and b). The progressive adjustments in the (a)
inelastic components are made according to the improvement of
the joint position as the passive range improves without changing
the structure of the splint. The shortened tissue is positioned at
its maximum tolerable length. As the tissue lengthens in response
to the tension applied, the therapist or the patient adjusts the
joint position, allowing re-positioning of the tissue to the new
maximum tolerable length. This type of splint is especially effective
for stiff joints when there is significant loss of passive range of
motion during the chronic stage of tissue healing process. During
this stage, the sheer bulk of the dense scar may create physical
blocks to motion, limiting the excursion of tissue and is resistant
to lengthening and has less viscoelasticity.12 (b)
Night static splint plays an important role in maintaining the
tissue length being stretched at greater force through intermittent Fig. 10 Static progressive splint with inelastic components to stretch the
shortened tissue to its maximum tolerable range. (a) Rubber bands to
active movement and passive splinting force during the day. At
stretch extensor tightness. (b) Turnbuckle to stretch flexor tightness and
the same time, it keeps the tissue at its maximum length overnight joint stiffness
and creates the potential for maximum active motion during the
following day, since the inactivity of sleep decreases the pumping
assistance of the muscles, and less tension is required at night so (2) Effects of splinting on scar remodelling
as not to constrict blood flow. For instance, extension splint is and tissue lengthening
generally better tolerated during the night than any flexion splint, The only acceptable clinical method we have of accelerating the
and night flexion splint should then be applied with a lesser force modification of scar tissue is the application of stress to the scar.
than would be applied during the day.5 Stretch through stress represents a passive action which results

00121.p65 267 01/13/2003, 10:15 AM

 268 J. M. W. Wong
in elongation of the elastic elements of various tissues.3 Splints
are applied to provide low-load prolonged stress — a mechanical
stimulus that causes the scar to biologically re-model into a form
conducive to motion.12 As what Arem and Madden1 had stated in
1976, living tissue, including scar, will re-organise and change in
response to stress. The stress stimulus of tension triggers an
increase in the length of the tissue. Either static or dynamic splints
are designed to maximise the amount of stress applied to the
offending scar while minimising damage to normal hand tissues.14
The application of stress to injured hand tissues should be directed
towards minimising the inflammatory response and maximising
the biological re-organisational response. The force applied should
be small and constant within a given period of time. As what
Light et al. reported in 1984, low-load prolonged stretch was
more effective than high-load brief stretch in the treatment of stiff
knees in human subjects. Based on the data reported from Light
et al., together with the results derived from their study in 1994,
Flowers and LaStayo found that increase in passive range of motion
in stiff joints is directly proportional to the time the joint is held
at the end range. This further supports Brand’s concept that the
tissue will grow after it is held in a moderately lengthened position
for a significant time.2 Therefore, the key elements in increasing
passive range of motion are high time doses of low-load stress
adequate to position the shortened tissue at or near the end
of its currently available length.12
A Static Progressive Splinting Regime in
Managing Chronic Stiff Joints
To design a splinting regime is a mutual agreement between the
therapist and the patient. The therapist should understand clearly
the patient’s conditions, including acuteness of injury, time since
surgery or trauma, stage of wound healing, pain tolerance,
sensation, general health status, cognitive status as well as
motivation before the splint is fabricated. The patient should also
be clear about their conditions and the goal of the splinting
programme.
Initially, the patient may wear the splint for a brief trial period
to decide on the tolerance. In the meantime, the therapist should
focus on the patient’s feedback on the fit of splint, line of pull as
well as amount of tension. The duration of splint compliance may
become progressively extended once the patient can tolerate well.
As a general guideline, the splint might position the joint
approximately 5° beyond readily available end range, which means
the range of motion that is easily achieved without dramatically
00121.p65 268
increasing joint torque. Or, to position the joint by “feel”, i.e. to
the position that patients feel slight resistance.12
It is important to explain carefully the concept of low-load
prolonged stress to patients in order to avoid overstress to the
tissue. They should understand that the use of too much tension
will not increase passive range of motion faster. Rather, high force
will re-injure the tissue, producing more scars and increasing
the time before the joint moves.
As the static progressive splint allows patients to control the
tension by themselves, the amount of adjustment and the timing
of adjusting the inelastic component of the splint should be
explained clearly. It must be pain free and able to maintain the
maximum tolerable length of the tissue at the longest period of
time in order to improve the passive range of the joint more
quickly. According to Schultz-Johnson’s clinical experience,
patients with contracted joints that have a soft end-feel may wear
the splint for three to four hours a day and obtain rapid positive
results. However, patients with well-developed hard end-feel
contracture may need to wear the splint for the whole day and
remove it only for hygiene.12
SUMMARY
Stiff hand is an unwanted but common consequence of a variety
of complications after injuries. It is evident when the trauma is so
severe that the biological responses of the injured tissue become
difficult to manage. Sometimes, minor trauma to the involved
finger can also result in stiff joints if the patients are extremely
withdrawn and cannot manage due to some psychological worries.
Therefore, to manage the stiff finger joints or hand is not only a
matter of “competition between the pace of prioritised treatment
and the growth of scar tissues, but it is also a matter of
psychological reassurance to the patients, and the close relation-
ship between the therapist and patient as a whole.”
Intermittent regimes of active and passive mobilisation together
with the application of splinting seem to be the vital measures.
Unless the swelling of the hand and fingers are under control,
beneficial effects from mobilisation and splinting can hardly be
maximised. In order to watch for joints stiffening, patients’
progress should be well documented and regularly reviewed.
Objective review such as the range of motion and the severity
of swelling, especially during the acute phase, provides the
information on how fingers respond to gentle active mobilisation
programme and swelling control measures. However, only manual
manipulation of the involved joint(s) gives the clearest feedback,
01/13/2003, 10:15 AM

thus indicating the need for passive stretching and splint applica-
tion. Choice of splinting should be problem-focused at different
stages of tissue healing. Alternative day and night splints can
maximise the work done for the whole integrative mobilisation
and splinting programme. The more the joints become stiff, the
longer the time the tissues should spend at their end ranges
through static progressive splints in order to improve the passive
range of joint motion.7 Apart from these, accurate judgments,
flexible attitude as well as prompt actions are needed to tailor
make the specially designed treatment programme to every
individual patient. Moreover, good communication between
therapist and surgeons as well as between therapist and patients
are important to ensure the best efficacy of treatment. It is logical
to modify any treatment plan when patients’ conditions are not
improving well and contingent actions have to be made in order
to restore the best results.
References
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noncyclical tension. J Surg Res 1976; 20: 93–102.
2. Brand PW. Clinical Mechanics of the Hand. St. Louis, MO: Mosby, 1993.
3. Brand, PW. The forces of dynamic splinting: Ten questions before
applying a dynamic splint to the hand. In: Hunter JM, Mackin EJ,
Callahan AD. Rehabilitation of the Hand: Surgery and Therapy,
4th ed. USA: Mosby, 1995.
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Management of Stiff Hand 269
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