Expert: Mary Gordon - 2/18/2010

Question
My mother was diagnosed with Alzheimer's/Parkinsons 3 years ago, is wheel chair bound, and must be washed, fed, etc. Over the last 2 months she has developed clenched fists. It appears terribly uncomfortable, though she doesn’t seem to complain. We worry about some sort of infection due to her hands always tightly clenched – even though she is showered regularly. It is also difficult to cut her nails. Our caregivers try to gently open her hands to get in a rolled up dry wash cloth to try and help keep her hand open, but after a few minutes, my mother cries in discomfort, and or the wash cloth comes out. Wonder if there are any ideas, tips, solutions in terms of medications, products, and /or ways to gently open and keep open her hands at least some of the time. Also what type of Doctor (Ortho, Rheumatoid  Arthritis, or?) is best to see with this condition? Thank You!
Doug - Montreal

Answer
Hi Doug - you need an orthopedic hand specialist - there are specialists who provide evaluation and treatment for injuries and conditions affecting the hand and arm. They are also the ones who direct therapies and various kinds of splints. They sometimes work out of the plastic surgery clinics but their specialty is hand and arm function.

There is a hand clinic at the McGill University Health Center
HAND CLINIC (MGH CLI)
tel. (or extension): 48025 (514-934-8025)
PLACE: L9 200 Montreal General Hospital
TIME: Monday to Friday 08H00-12H00 and 13H00-16H00

I'd start with a call to them to see if you can get into see a real expert. These contractures tends to get worse and worse - to the point where it will be very hard to open her hands or cut her nails. What happens then is that it becomes extremely difficult to stop her nails from cutting into her hands, or to keep her hands dry (i.e. the skin stays moist all the time and it is very hard to clean and keep the skin in good in condition).

There are all kinds of over the counter products that may or may not help - here are some examples
http://www.regalmedical.com/whfo.htm
http://www.abledata.com/abledata.cfm?pageid=19327&ksectionid=19327&top=11845
http://www.pelicanmanufacturing.com.au/cgi-bin/store/commerce.cgi?pid=126&ppi=PI...

Obviously, you will not want to invest in these until you get some opinions from a doctor, who may prescribe a custom brace or other alternative. They also make braces that go on the outside of the hand.

One approach that has helped many - believe it or not - is botox shots. Quite often claw hand problems are related to the median and/or ulnar nerves, and some of the muscle contractions that pull the hand into a claw and in and up onto the chest come from muscle contractions above the hand itself - which is why the injections are often in the arm itself.  The specialist will be able to tell if this might help in your mother's situation.

In really intractable cases, surgery is sometimes proposed, up to and including severing nerves or tendons to relax the hand, which I know sounds extreme - but irrespective of what is done to make her more comfortable and reduce risks of infection, she is unlikely to be able to use her hands again.  If you do end up faced with a surgical recommendation, I'd tell the doctor NOT to put  her under a general anesthetic but to find a way to do it under sedation and a local. General anesthesia is really not good for people with AD - they can really go down hill from it, and often do not ever recover the ground they have lost.

Below I have stuck  a little blurb giving the medical explanation for most claw hand deformities with links below to some good diagrams of the hand so you can see what is going on inside.

The clawed hand and flexed wrist
"Flexor spasticity is frequently responsible for this deformity.  Flexor carpi radialis and ulnaris muscles act on the wrist with flexor digitorum superficialis muscle flexing the fingers at the proximal interphalangeal joints and flexor digitorum profundus muscle flexing the terminal phalanges".

Mary note: see these
http://en.wikipedia.org/wiki/Flexor_carpi_radialis_muscle - this is a muscle in the forearm that flexes the wrist
http://en.wikipedia.org/wiki/Flexor_carpi_ulnaris_muscle - this is another muscle in the forearm that flexes the wrist
http://en.wikipedia.org/wiki/Flexor_digitorum_profundus_muscle - this is the really big one in the forearm that flexes the fingers - when you look at the diagram you will see it pulls the tendons in the hand
http://en.wikipedia.org/wiki/Flexor_digitorum_superficialis - this one starts in the forearm but acts on the finger joints

Hope this helps. Give the clinic a call and see if they can get you in - and if not, ask them to recommend an alternative clinic or specialist.

Mary