the hand we take for granted

Monday, July 16, 2012

The hand is a marvelous feat of engineering. It can pick up the tiniest of objects or make a fist and smash something to smithereens. It can catch a football, throw a baseball or caress a violin bow. It can allow doctors to sew nerves together or a logger to hold a chainsaw. And the hand that we hold so precious is often used reflexively in emotional outbursts to gesture, to warm or to hit. Sometimes, no harm, no foul and sometimes, damage happens. If only Kyrie Irving, the reigning NBA rookie of the year, could have had a do over when he slapped a padded wall and broke his hand. Instead of practicing on the court, he may need surgery to repair the damage. Bad luck.

The hand is made up of bones, joints, muscles and tendons, which create an intricate system of pulleys, allowing the fingers to move on the brain’s command. Tendons stretch from the muscles located in the forearm and attach at various levels on the fingers, but their course is complicated. The back or dorsum of the hand is pretty easy. The tendons lie underneath the skin and slide relatively freely. The palm is a different story and the anatomy is tough. The tendons are encased in sheaths or tubes and are tethered in the palm and at the level of each joint. Blood vessels and nerves run on the palm side as well, just to complicate matters. And that’s why hand surgeons exist.

Hand and finger injuries can be tricky and they have to heal well, otherwise even minor imperfections can cause significant problems with routine activities. Imagine having a finger that is difficult to extend or straighten. Each time you tried to put your hand in your pocket, it might get stuck going in. Consider if a finger wouldn’t flex or bend, causing loss of grip strength. What if one of the fingers was off just a little bit in rotation, so that when making a fist, the next door neighbor finger got in the way. Old football receivers and retired baseball catchers can attest to the gnarled hands that were the consequences of their career choice.

Common fractures of the hand usually affect the metacarpals, the long bones just below the fingers and the phalanges, he bones of the fingers. Getting frustrated and taking a swing at a wall or other immovable object often damages the 4th or 5th metacarpal the bones below the ring and little finger and these can often heal on their own and do well. The 2nd and 3rd metacarpals are less forgiving when they are broken. They form the frame of the hand and are solidly fixed. Check your own hand. The 1st metacarpal beneath the thumb, the 4th and the 5th tend to be pretty loose. You can move them around easily and that’s a good thing since it allows the hand to cup or close. But the 2nd and 3rd are rigid. Damage either or both and the integrity of the hand is at risk.

A broken bone can take weeks to heal and it needs to be immobilized so that it can heal in anatomic alignment. But there are tendons that are exerting differing forces on the bone. The muscles that squeeze making a fist are stronger than the muscles that fan the fingers out. For that reason, the joint above and below the fracture also need to be immobilized. The decision to operate on a hand fracture depends upon whether the bones can be held in alignment with a cast or whether that would likely fail. Understanding what part of the bone is broken, in what plane and where the bone fragments are in relation to each other can help make the decision whether a cast is in the future or whether metal parts need to be put into the hand to stabilize the break.

For Mr. Irving, it’s important to remember that fractures, broken or cracked all mean the same thing. The integrity of the bone has been compromised and it needs to be repaired. While he is an elite athlete, it’s his hands that make him a basketball star. The ability to shoot, pass and catch make his situation closer to a craftsman or a musician. In reality, we’re all craftsmen from changing a diaper to using a computer keyboard, we take our hands for granted and even a padded wall can’t save our hands from our neglect.

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