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.
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.
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.
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."
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.
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."
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."