Advice and resources : Hand contractures

About the condition

Hand contractures are commonly seen in patients with a neurological condition or advanced dementia.

The most frequent cause is due to lack of use, and subsequent shortening/tightening of the muscles and tendons over time.

The following advice and resources were designed for use in care homes, but can be used in other situations, such as caring for a friend or family member in their home.

If you think your resident/ the person you care for may have a hand contracture, this is a checklist of things to look out for:

• spending much of the time with a clenched fist
• unable to fully open hand and stretch out fingers, even with help
• fingernails starting to press into palm of the hand
• hand starting to become odorous and difficult to clean
• expressing pain when you try to open out their hand

If you are a care home worker and suspect a patient has a hand contracture, please refer them to the Care Home Support Team (CHST) for an assessment. In other situations, please raise the issue with a healthcare professional involved in their care.

The best outcomes can be achieved if the hand contracture is identified early on.

Daily hand care

Whilst awaiting an assessment, these are some things to consider.

• Are they in pain during hand hygiene?
• Do they need pain relief prior to personal care? (If nothing is prescribed, do you need to liaise with the GP about a medication review?)
• Could you use something like a rolled-up flannel between fingers and palm (even a baby flannel if the gap is small) to stop the fingers digging into the palm?

It is vital to adequately manage this condition to prevent pressure sores and skin breakdown to the palm and fingers. It is also important to stretch and move the hand as much as tolerated to prevent further deterioration and pain from stiff joints and tight tendons.

Effective nail care is important to prevent injury and infection. Download 'Resource 12 - Fingernail care' below or visit our advice page.

• Read about fingernail care

Hand hygiene principles

Hand hygiene is important as wet/sweaty skin changes the normal skin barrier and can lead to skin breakdown, sores, and infections.

Once a hand contracture is present, movements can be uncomfortable and difficult, therefore it is essential to maintain adequate hand hygiene and there are important principles to consider.

• Consider pain relief prior to hand hygiene and ensure the person has had ‘breakthrough’ pain relief within an appropriate amount of time prior to starting the hand hygiene.
• Your hands must be clean prior to engaging in hand hygiene and gloves should be considered as per protocol.
• Always involve the person and check that they are ready to start.
• Use a bowl of water to soak the hand, but only if the positioning of the hand enables this.
• Be aware the muscles in the arm/wrist may be tight, so use slow, gentle, but firm, movements to allow the hand to be in the best position to clean. Do not force the hand open. A light touch may also be necessary if the person has sensory issues.
• Be aware that touching a person’s hand may cause it to become tighter. Talking to them and drawing their attention away from the hand may help.
• Ensure to clean the palm, between all the fingers, between the webspace of thumb and finger, and back and side of hand as tolerated.
• Check for any skin breakdown as you clean.
• Ensure soap is low pH (acidic) and do not use anything scented.
• The towel should have a lot of absorbency. Consider microfibre towels and or small baby flannels (which are absorbent).
• Keep their nails short to prevent future problems.
• Ideally, the hand must be dry following the wash.

If the hand is very tight or if after the above steps have been taken and the patient is experiencing ongoing odour of the hand, refer to a healthcare professional for advice.

Pain relief

People with hand contractures may experience pain at rest and if force is used to open a hand, e.g. for hand hygiene, this may be painful.

People who have difficulty communicating may struggle to express pain and it may be difficult to assess their pain. The Abbey Pain Scale may be useful for determining a resident’s level of pain and response to pain relief. For those who can express pain verbally, a number pain scoring tool may be useful, e.g. x out of 10.

If the person you care for is experiencing pain from hand contracture(s), consider the following.

• Good communication between nurses/senior carers, carers, and GPs, and full care plan records, are important to ensure that effective care and pain relief is provided.
• Discuss the need for pain relief with their GP who will decide the level to be used (usually starting with paracetamol as required, then regularly if needed).
• Pain relief may only be needed before hand hygiene is attempted or all the time, depending on severity.
• If paracetamol is ineffective, the next step may be codeine, morphine, or another suitable alternative on a ‘when required’ or regular basis. The dose or type of medication may need to be adjusted if it does not work or if there are side effects.
• Make sure their pain is reviewed regularly to ensure pain relief is effective and act if it isn’t. Using a pain scale and recording pain levels at different times of the day can be useful (see example of an Abbey Pain Scale on the following page).
• A body map may be helpful if there are multiple areas of pain to assess and treat.
• If pain relief is needed before hand hygiene, give it at least 30 minutes before and check it is working before starting (an instruction can be added to the prescription and their medication administration record (MAR) to ensure this happens).
• Record the effect of any pain relief on the relevant MAR chart section (see example on p3).
• Check and report any side effects of the medication to the GP, e.g. if morphine is used, drowsiness, confusion, or constipation may occur.

Download 'Resource 3 - Pain relief for hand contractures' from the section below to view an example Abbey Pain Scale and medication recording chart.

Interventions

Ask a healthcare professional for further advice regarding a trial if you feel any of these options may be suitable.

Resources

Download our complete hand contractures resource pack: