Expert: Mary Gordon - 2/14/2010

Question
Mary,
  My mother has a clenched left hand which stays moist from lack of air and the skin between her fingers has started to break down/turn white and die. Do you have any experience with this, I read an answer you gave about a clenched hand and possible remedies including botox. We had a hand doctor order injections in the arm but the neurologist that gave the shots put them in her palm. Where is the best placement for the shots if you know, and do you know of any good ways to keep the palm dry when its almost impossible to open the hand. Also any medicine to help clear up the dead skin, obviously any medications that add moisture are out. We have used a little lanaseptic and neosporin on the raw places, maybe 40 percent zinc oxide desitin? We also had a moldable splint made to try to help open the hand but it fits in the palm and blocks the hand somewhat from drying, I'm going to try to get one made to fit the back of the hand instead to get more air circulation. Do you have any suggestions ?
Thanks for your time and any help you can offer.
                                                 Doug

Answer
Usually the claw hand problem is 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.

I have stuck in the official general medical explanation and I've stuck in links for some of the terms so you can look at the diagrams of how the hand works:  

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

"The lumbrical muscles flex the fingers at the metacarpophalangeal joints.  It is important to differentiate between the action of these muscle.  Good hand function is impossible with a thumb in palm deformity, i.e. an adducted flexed thumb in the palm and it is important to assess this."

Mary note:
http://en.wikipedia.org/wiki/Lumbricals_of_the_hand - these are in the hand itself, so this may have been what the neurologist was aiming for in her palm, or it could have been the below muscles in the hand that control the thumb

"The deformity is caused by overactivity in opponens pollicis muscle and thumb flexion is due to a combination of flexor pollicis longus and brevis muscle shortening.  Finally, it may be useful to note that in patients with coarse hand function, it is sometimes better to leave a flexed stiff thumb terminal digit, as this will assist pincer grip. "

Mary note:
http://en.wikipedia.org/wiki/Opponens_pollicis_muscle - this is a muscle in the hand that moves the thumb
http://en.wikipedia.org/wiki/Flexor_pollicis_longus_muscle - this is a muscle in the forearm that moves the thumb
http://en.wikipedia.org/wiki/Flexor_pollicis_brevis_muscle - this is a muscle in the hand that moves the thumb

I'm not sure why the neurologist gave injections into the palm, since the major part of the problem usually is upstream but he may have had a reason. I'm not a doctor but I really think it would be worth going to a hand specialist or another neurologist to see about trying again with Botox to see if she can't get some relaxation of the hand.

I know you know she won't likely be able to use her hand again, so this is entirely about comfort and preventing suffering. If nothing else can be done, you end up having to inquire about having the nerves or tendons cut under a local anesthetic - which is an option.

Have you tried putting a roll of loose weave gauze or cheese cloth in her hand - if you can get it in there, it will allow for some air circulation and drying. I would think the barrier creams might make things worse, given the excess moisture in the skin can't evaporate through the cream.

I wish I had more suggestions - I know this is very frustrating when you want to ensure she is comfortable and well looked after.

Mary