By Mary Carpenter
Read anything good lately? We have, and that’s why we’re pumped to publish this occasional series inspired by our favorite recent reads. This week Mary’s inspiration was The Covenant of Water, by Abraham Verghese.
“YOUR hands are a super important part of how you interact with the world and do the activities you love,” states MyClevelandClinic. In The Covenant of Water, the hand injuries of two characters stop them from doing the work they love: in the case of a doctor, that is surgery—due to scarring after a fire; and for the other, an artist, leprosy slowly diminishes her abilities. Although leprosy is rare in the U.S., several of the most common hand conditions occur predominantly in women.
Base-of-thumb arthritis afflicts women 10 to 20 times more often than men—most frequently over age 50— although no one is sure why, according to Duke Health hand surgeon David Ruch. Although the thumb has an impressive range of motion, over time dexterity can wear away the bone-cushioning cartilage and result in pain as well as displacement of the thumb. What is also called thumb arthritis or CMC (for carpometacarpal joint) may respond to NSAIDS, splints and steroid injections, and surgical options may help prevent serious permanent impairment.
Trigger finger is also more likely to occur in women, also more commonly in women over age 50. Tendons along the front of the hand that slide in order to flex the fingers can thicken and catch—most commonly affecting the thumb and ring finger—and in advanced cases cause fingers to lock and need assistance to unbend. According to Cheltenham Hospital orthopedic surgeon Ewan Bigsby, when the triggering becomes “troublesome”— for some, producing a clicking sensation—cortisone injections may help, but surgery provides the best long-term solution.
Carpal tunnel syndrome (CTS) is a compressive neuropathy that also afflicts more women, in this case at three times the rate of men—with peak incidence between ages 45 and 54. Irritation of the wrist’s median nerve — most often linked to repetitive professional work, such as typing — can cause pins and needles, with discomfort often impeding sleep. Early symptoms, such as reduced feeling in the fingertips, can proceed to constant numbness of fingers and weakness in the hand, and ultimately damage the hand muscles, especially at the base of the thumb. Initial treatment can involve wrist splints worn at night, but surgery offers rapid improvement in symptoms and can allow the nerve to fully recover.
Ganglion cysts, sac-like structures often filled with liquid that can occur in almost anyone, develop along the tendons and joints of hands and wrists and can range in size from tiny nodules to an inch in diameter. Most cysts have no clear cause and are harmless, but they can restrict mobility and can cause pain if pressing on a nerve. Infection—often resulting from at-home attempts at removal, such as hitting the cyst with a hammer, closing it inside a heavy book and sticking it with a sharp object in the hope of popping it —can require surgery.
Essential Tremor (ET), which most often affects the hands, is the most common movement disorder—with Katharine Hepburn a famous sufferer. “To drink without using both hands” was the greatest wish of one man, who’d had ET since age 9. The condition can look like Parkinson’s disease (PD) but is not linked to dopamine depletion and causes handwriting that is large and tremulous, rather than the slow and very small scribbles of PD. For sufferers of both, tremors can be made worse by anxiety, stress, fatigue, physical exertion and fever.
Finally, Dupuytren’s contracture is slightly more likely to affect men; is the most common connective tissue disease; and is often inherited. Thickening of tissue in the palm or fingers —most likely first to affect the ring or fourth finger—can cause the hands to contract and fingers to bend inwards. Conservative treatment using splints at night can prevent worsening. And needle fasciotomy, using a needle to perforate thickened tissue, can offer relief but because the condition has a high rate of recurrence, surgery to remove diseased tissue is the most established treatment.
The disfigurements of Dupuytren’s contracture can be, though to a much lesser degree, similar to those caused by leprosy or Hansen’s disease: for a case described in JAMA, ring-shaped rashes led to numbness and tingling patches on the skin—and after four years, hands “slowly bending like a claw,” according to metro.co.uk. With leprosy, nerve damage leads to joint deformity, but loss of sensation can also make sufferers unaware of limb injuries, such as burning.
While uncommon in the U.S., leprosy has been on the rise, notably in Florida; and with 159 new cases reported in 2020, some experts consider the disease “endemic.” In the U.S., armadillos appear to be the common reason for local transmission, either consuming them or working in soil that has been contaminated. But leprosy, usually contracted via airborne droplets from an affected individual, is not highly transmissible: almost 95% of people exposed to the bacteria never develop the infection.
For my hands, I’ve had mild essential tremor since childhood. Then in my 30s, breaking a glass led to stitches and a persistent painful, red lump over one joint —the occasion for my first encounter with a “hand doctor,” who told me the tiny fragments of glass that remained would emerge on their own in a month or two. Decades later, after performing all of the ill-advised at-home treatments on a ganglion cyst at the end of one finger, I developed an infection that required surgery.
Over the years, I also developed CMC arthritis that caused my thumbs to appear lumpy and out of place: without surgery, a doctor warned, I might lose the opposable thumb function. Ligament reconstruction surgery—removing and replacing the damaged ligament using a piece of tendon from the wrist—on my left, nondominant hand made that thumb look less displaced and lumpy. But weakness that remained helped me decide to leave the right hand alone.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
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