Special Aspects in Musicians

Philippe Cuénod

Abstract

Carpal and hand fractures in musicians require special consideration, not only to restore the delicate and precise movements needed to play the instrument, but also to take care of the patient as a whole. As any artist, musicians are very sensitive persons and any trauma of their hand or carpus may trigger a fear of not being able to resume their playing and therefore put their career in jeopardy. A surgeon in charge to treat a fracture in a musician’s hand should be aware of the artist’s needs to play his instruments. The requirements may be very different according to the instrument played. The movements for playing the most common instruments are detailed. The general principles of fracture treatment are the same as for other patients, except that any bone displacement that can interfere with the precise movements, should not be tolerated. Stable fracture fixation to allow early mobilization and rehabilitation is the rule. Stiffness has to be avoided at all costs. Care must be taken to plan the incision in a way to avoid the contact areas of the finger with the instruments. Mini-invasive surgery should be used, as long as it does not increase the risks. In particular, percutaneous screw fixation is useful in selected cases. When the fracture is too bad, joint fusion in a functional position is indicated.

During the whole process of treatment, care must also be taken to discuss with the patient of his or her technical needs with the instrument, to encourage and support him or her psychologically to prevent that a good surgical treatment turns into a catastrophe by emotional complications.

Keywords: musician, hand, carpus, fracture, treatment, special features

13.1 Introduction and Historical Perspective

Being artists, musicians are, by definition, very sensitive persons. Considering the importance of hand representation in the cerebral cortex, it is not surprising that any fracture of the hand, even minor, may have disastrous consequences on the artist’s playing ability. Even with a perfect functional result, such an incident can put the musician’s career in jeopardy. Musicians are as much concerned by the risk of losing the skills to fulfill a passion as by the risk of losing their job. Historically, there are plenty of examples of musicians who had to stop their career or radically change it, following a hand trauma. It is not clear what caused Schumann’s hand problem; was it an attempt to improve the agility of his left fourth finger with a device of his own, then an operation, that resulted in a cripple hand,1,2 or a focal dystonia³ that terminated his concert pianist career and obliged him to become a composer?

A missing or handicapped hand may trigger a new career, for example, pianist Paul Wittgenstein, who lost his right arm in world war I, but continued to play piano pieces, specially written for him by famous composers like Ravel, Britten, Korngold, Prokofiev, Strauss, and others.^4,5 Django Rheinhardt, used to play banjo guitar until he sustained a deep second- and third-degree burn of the hand. A retracted scar on the dorsum of the left fourth and fifth rays left him with a cripple hand. He, however, took advantage of his problem to switch to guitar and develop a particular technique to become one of the best ever jazz guitarists⁵ ( Fig. 13.1). In some instances, adjustment of the musical interface can be achieved by tailoring the instrument to the patient’s handicap.⁶

The incidence of fractures in musicians has not been reported precisely, but is probably not very different than in the general population. Musicians may be more cautious to avoid accidents and refrain from having dangerous activities, although some admit not taking any special precaution.⁷ A survey of the musicians of a symphonic orchestra is underway to try and determine the incidence and outcome of hand and carpal fractures, but collection of data is a bit tedious. Indeed, as already reported, musicians reluctantly acknowledge any hand trouble fearing to lose their job in the very competitive world of orchestras.⁸

Fig. 13.1 Django Rheinhardt’s left hand playing the guitar. Clawing of the fourth and fifth fingers by burn contracture. Drawing © Gani Jakupi. Used with permission.

The general technical principles of fracture management, however, apply to the musician’s hand. The goal is, of course, to restore the anatomy, but moreover, the function. In this regard, the progress of fracture management, with smaller implants and mini-invasive techniques, may help the surgeon to achieve this goal. It is to be kept in mind that the choice of a technique should be guided by the moto “primum non nocere.” It is of vital importance to take the time needed to expose the different treatment options for the patient, the risks, and the expected outcome. This moment is of utmost importance and may be determinant for the result. Unsatisfactory surgical results may not be the end of the musician career. A complete finger function may not be necessary to play an instrument, depending on which one is played. Therefore, the surgeon needs to have some knowledge of the movements required to play the most common instruments to determine the best treatment options or, at least, carefully ask the patient about the technical aspects, if necessary, with the help of his or her instrument.9–11

The emotional consequences of a traumatized hand in a musician must not be underestimated. An injury, even minor, may have disastrous consequences in some artists, known to be particularly vulnerable emotionally. Stiffness may prevent the musician to correctly play his or her instrument and interfere with the ability to cope with the handicap through fear, anxious feeling, and depression. On the other end, a crippled hand is not always the end of the skill to play as some musicians can adjust their game in order to continue playing.

13.2 Instruments and Movements Required to Play Them

A quick search on the internet shows that the number of listed music instruments amounts to 888.12 Most of them are unknown to the author and probably to most of the readers. The hand surgeon should, however, be aware of the interface between the wrist/hand and the most common instruments, in order to understand the needs of the artist and to correctly address his or her lesion.¹³

The standard instruments in western countries compose different types of orchestras or are played as solo. The orchestra of classical music includes four groups of instruments: strings (violin, viola, cello, and double bass), woodwinds (flutes, clarinet, oboe, and bassoon), brass (trumpets, trombones, horns, tuba), and percussion (drums, cymbals, tubular bells, xylophone). Other instruments such as the piano and celesta may sometimes be grouped into a fifth section, such as a keyboard section or may stand alone, as may the concert harp and electric and electronic instruments. The orchestra, depending on the size, contains almost all of the standard instruments in each group.

The jazz orchestra uses more or less the same instruments but in a different setting. Early ensembles were composed of clarinet, tuba, cornet, baritone, drums, and piano, as were the New Orleans bands. Then the Big Bands were predominantly wind orchestras, containing alto and tenor sax sections, trumpet and trombone sections, along with piano and drums. Later during the Bop period, the alto saxophone and trumpet were played by the major soloists, backed up by piano, string bass, and drums. With the advent of fusion, electric instruments such as the electric guitar and keyboard synthesizer became prominent.

The movements of fingers, hand, and wrist obviously differ from one instrument to another, but also from classical to jazz. It is not rare to see a jazz pianist play with a flexion of the wrist and flat fingers, which is in contradiction with the academic posture of slight wrist extension and midflexion position of the fingers. Thelonius Monk’s flat fingers on the keyboard is a well-known feature of a jazz pianist, but classical artists may also have a nonacademic posture, as the Canadian pianist Glenn Gould.² The position of the distal interphalangeal (DIP) joint can vary from tight flexion (Count Basie) to hyperextension (Jelly Roll Morton).⁹

13.2.1 String Instruments

String players’ right hand holds the bow and the important movements required are extension and flexion of the wrist as well as radial and ulnar deviation. The violinist’s left hand is positioned with a hypersupination of the forearm and a wrist flexion and needs a normal flexion of the finger joints to reach to the cords and also an ability to completely stretch the little finger ( Fig. 13.2). Viola requires more or less the same movements. As the cello is not held between the jaw and the shoulder, but in front of the body, it does not need a hypersupination of the forearm and the hand is therefore in a more direct plane. The left hand mostly plays by flexion of the proximal interphalangeal (PIP) and DIP joints while the metacarpophalangeal (MP) joints are in neutral or slightly flexed ( Fig. 13.3). Guitar is played without a bow. The fingers of the right hand play the cords in a movement including flexion at the MP, PIP, and DIP level. Jazz or rock guitarists often play with a plectrum that needs a good pollicidigital pinch. The left hand squeezes the cords in an analogous movement as the violin player, with less extreme position of the wrist ( Fig. 13.4). Double bass players’ left hand is held in flexion of the MP and PIP joints increase flexion to reach to the cords. The right hand plays with the bow or with the fingers rather straight, especially when playing jazz. The typical movement is a lateral swipe that needs some flexibility, but without too much of a flexion. The skin of the volar and radial aspects of the right fingers is specially exposed when playing that way and any tender scar resulting from a trauma or operation could interfere with proper playing.

Fig. 13.2 Left hand of a violinist. The three radialmost fingers need an excellent flexion at PIP and DIP joints. The fifth finger requires full extension too.

Fig. 13.3 Left hand of a cello player. The MP joints are in neutral or slight flexion and the PIP and DIP need good flexion.

In the contrary to the string players, a pianist does not require an important flexion at the PIP and DIP level, the finger movements taking place mostly in the MP joints, except for the thumb that needs some flexion at the MP and IP joints for the “thumb under” movement (the thumb crossing under the other fingers when playing the scale). Pianists with small joint arthritis of the hand can therefore continue to play on keyboards with some adjustments ( Fig. 13.5).

13.2.2 Brass Instruments

Trumpeter’s left hand holds the instrument with more or less straight PIP and DIP and about 45 degrees of MP flexion. The thumb just needs opening of the first web space, but can have only little flexion of the MP and IP joints, because its role is mostly static. The hand therefore does not require too much of a movement. The right hand needs little MP flexion, but more PIP flexion to get to the valves with the pulp, although, according to the size of the hand or the style of play, the PIP can be held more in extension. Once again differences of style and techniques exist between musicians, above all jazzmen.

Horn is played with the left hand on the keys, but the right hand is important to modulate the sound by placing the fist in the position of an obstetrician hand into the bell. A good trapezo-metacarpal (TM) flexion is therefore required, but IP needs to extend. The left hand needs MP and PIP motion of second, third, and fourth fingers in order to play the keys. The thumb holds the instrument in a more or less static way, but needs a good IP range of motion to activate a key ( Fig. 13.6).

In trombone playing, the right hand holds the instrument, the thumb around the bell brace, the index completely stretched to reach the mouthpiece and the other fingers flexed at the MP and IP level. The left thumb, index, and third finger hold the slide brace. Index and third finger need MP flexion and IP extension in a more or less intrinsic plus position.