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On Hand: Deep Knowledge Enables Effective Treatments to Preserve Crucial Function


Nancy McRay has played the piano since she was a small child, not just for her entertainment, but as a professional. Often her jobs required her to play for hours at a time.

Nancy McRay was just three years old when she sat down at her family's piano and began to play, naturally and easily and with great joy. She also had a knack for sight-reading, looking at the printed notes set before her and immediately playing them, as if she'd already practiced them many times before. By the time she was 14, word had gotten around about that skill and she became the official accompanist for a regional musical theater company.

McRay kept playing, earning an undergraduate degree in music performance, and then a master's degree. She taught piano, she directed musical productions and she never stopped accompanying, sometimes playing for hours on end in the course of a rehearsal.

Then, one day about 15 years ago, McRay felt something different when she spread her left hand out wide to cover a big distance between one note and another−it was a little pain between her thumb and her fingers. "I knew my mother had had arthritis, and I wondered if it could be that," she said.

Use, time and genetics

She was exactly right. McRay, like two in three post-menopausal women, was experiencing the first signals from a basal thumb joint beginning to lose its protective buffer of cartilage. With each pivot of the thumb, each outreach, each grasp, the cartilage between the thumb joint and its partner bone, the trapezium, grew thinner and thinner, more and more painful. After years of medication, splints and acupuncture, McRay finally found her way to Stanford Hospital & Clinics orthopaedic hand surgeon Amy Ladd. Also a pianist, Ladd understood McRay's dilemma better than most.

I knew my mother had had arthritis, and I wondered if it could be that.

-Nancy McRay, Stanford Hospital hand patient

After hand surgery at Stanford Hospital & Clinics, Nancy McRay can play the piano again, without pain. She's learned new playing techniques to help her avoid extra stress on her hands.

Ladd borrowed from one part of McRay's body to repair the thumb joint's worn edge. Carefully picking her way through the network of nerves and muscles to reach a tendon in McRay's forearm, Ladd removed a small piece of it, coiling it into a plate-like shape and placing it as a new padding between the thumb joint and the trapezium.

"I can't sing Stanford's praises high enough," McRay said. She had thought about having the surgery for more than two years, and knew it would mean a year of carefully-paced recovery before she could venture another try on a piano. But now, when she comes for a follow-up appointment, she and Dr. Ladd work hard to find a few minutes to sit down to play some simple duets. She's also learning jazz piano with a teacher who almost immediately identified how McRay could change her playing style to protect her repaired thumband its mate from further damage.

Architectural challenge

The first sign of trouble for Nancy McRay was pain in the base of her left thumb.

The human hand is a tricky piece of engineering, especially the thumb joint. "We're looking for ways to better understand it," Ladd said. Anatomists call the thumb joint−the trapezial-metacarpal joint−a saddle joint. It is the only one of its kind in the body."

The saddle joint looks very much like its name, and it is the key to the thumb's ability to work in opposition to each of the fingers.

Stanford hand surgeon Amy Ladd, MD, restored McRay's ability to play by placing a piece of tendon from McRay's forearm in the joint as a buffer.

Essential and multipurpose

The motion of the basal thumb joint acts like a ball and socket, similar to the hip or shoulder joint.  However, Ladd said, "This saddle joint is much more complicated. It's more like two spoons loosely cupped together. Sometimes one rolls on the other like a snowboarder on a half-pipe, sometimes they grind like a mortar and pestle."  And compared to the hip, shoulder, or knee, she said, "It's a tiny little joint much harder to study with imaging techniques and motion studies."

Nancy McRay's hand surgeon, Amy Ladd, MD, couldn't have been a better fit for her. Ladd is also a pianist who understood the mobility and strength needed to play.

Ladd and her Stanford colleagues at the Robert A. Chase Hand & Upper Limb Center take a collaborative and comprehensive approach to patient care, combining research and clinical practice of three fields of surgery−plastic, orthopaedic and general surgery− as first established by Chase, the Center's founder. An early pioneer in hand surgery, Chase established Yale University's Plastic Surgery section and then came to Stanford in 1963 to chair its surgery department. From 1977 to 1992, he was chief of the Division of Human Anatomy. He is the co-author of the Handbook of Hand Surgery and a founding member of the American Society of Hand Surgeons. He remains at Stanford as an active teacher and physician. His interest in the hand began when he served as a military doctor, treating soldiers wounded in the Korean conflict in the early '50s. Then, there were just two centers in the U.S. who offered specialized care of the hand.

I'm a great believer in not expecting something like this is going to make everything perfect again. I am trying to do everything I can to take care of it.

-Nancy McRay, Stanford Hospital hand patient
  • Sprains, fractures or other injuries to the bones in the hand raise the likelihood of osteoarthritis. So can repetitive motions in certain occupations-- construction workers who hold jackhammers damage the cartilage from the harsh vibrations of that kind of equipment. When possible, wear protective gear.
  • Keep scissors handy to get through some of the tough packaging that seems impossible to open by hand-- and can cause injury.
  • Use jar openers whenever possible. Twisting while grasping puts heavy strain on the thumb and wrist.
  • Ask about an ergonomic keyboard for work on a computer. Posture and proper chair are also important tools to reducing the stress of hours of typing.
  • Consider stretching and light weightlifting to keep flexible and build strength in the muscles of your joints.
  • Self-massage of the hands can also loosen tightness after hours at work.
  • Monitor how long and how tightly you pinch or grasp an object. More stress on the joint means faster breakdown.
  • Electric can openers, food processors, oval-shaped rubber handles, gel pens and ergonomically-shaped knives can all reduce the work load on the thumb joint.
  • Listen to your body. If you are using your hands and the activity is painful, your body is trying to tell you something. Ignoring the pain allows the damage to continue. Ask yourself if there is a different way you can do an activity with less stress to your hand.

Compared to other parts of the body, Chase said, the hand is a tightly-packed labyrinth of bone, muscle, tendon, ligament and nerve. Its ability to perform its tasks combines the need for brute force and minute manipulation. The muscles and joints are a pulley system with flexibility that enables an unmatched diversity of movement. The hand's architecture also can control an extreme range of intensity of motion and force–as fist or as coordinator of such fine motor skills as sewing, writing and playing musical instruments.

And then, there's the way the hand, and its skin, interacts with the brain. The brain devotes as much of its real estate to movements of the hand as it does to the arms, trunk and legs together. The hand's sensory function are also dense−that's how we can recognize an object just by holding it. Chase likes to tell the story of a patient whose badly injured thumb was replaced with a finger. A few months later, seeing the patient using the new digit just as he would have his thumb, Chase asked him about it. The patient was quite happy with the restoration of function. "It feels like a thumbger!" he told Chase."

Array of repair options

Ladd and others have ideas about what might work to prevent the kind of deterioration that, for someone like McRay, ends in surgery. The need will be great: millions of Baby Boomers are getting to that age when they will likely develop the same kind of osteoarthritis McRay has. The next generation will have grown up typing on keyboards for hours on end from an early age or texting hundreds of times daily on cell phones. That kind of heavy use could produce repetitive stress injury. It's already showing up in popular parlance as ailments like cell phone elbow and Guitar Hero wrist.

Implants are in development, Ladd said, as are studies to pinpoint the mechanisms at play in thumb joint breakdown. "This little saddle joint is a sloppy one, with built-in vulnerabilities," she said. "We think micromotion could be the key to why it fails."

It's a tiny little joint much harder to study with imaging techniques and motion studies.

-Amy Ladd, MD, Stanford Hospital, Robert M. Chase Hand and Upper LImb Center

The surgery that McRay had is not for everyone. Some patients may opt for another of the surgical approaches that stabilize the thumb joint. What finally made McRay decide to go forward was the degree of pain that had become constant and its impact on her ability to do the many small tasks required for daily life - to open jars, grasp a door knob, put away dishes or walk her dog.

The surgery and the months of postoperative hand therapy have made her far more selective about how she uses her hands. She definitely stays away from the kind of intense, rapid piano playing she once did so often. But play she does, and loves it as much as she ever did. "I'm a great believer in not expecting something like this is going to make everything perfect again. And I am trying to do everything I can to take care of it."

About Stanford Health Care 

Stanford Health Care, located in Palo Alto, California with multiple facilities throughout the region, is internationally renowned for leading edge and coordinated care in cancer, neurosciences, cardiovascular medicine, surgery, organ transplant, medicine specialties and primary care. Stanford Health Care is part of Stanford Medicine, which includes Lucile Packard Children's Hospital Stanford and the Stanford University School of Medicine. Throughout its history, Stanford has been at the forefront of discovery and innovation, as researchers and clinicians work together to improve health, alleviate suffering, and translate medical breakthroughs into better ways to deliver patient care. Stanford Health Care: Healing humanity through science and compassion, one patient at a time. For more information, visit: StanfordHospital.org.