15 May, 2022

Univ.-Prof. Dr. med. Justus Beier is Director of the Clinic for Plastic Surgery, Hand and Burn Surgery at the Uniklinik RWTH Aachen. Justus is also an old school friend. We did our a-levels together and since then, since 1995, have seen each other at least once a year when we arrange to meet with two other classmates, Horst and Kristof, and Winfried, our German teacher. When, after my return from France, I woke up in the night of 13 to 14 May because of two numb fingers, the index and the middle fingers of my right hand, I decided to e-mail Justus a few questions. He got back a few hours later despite it being a Sunday and one of his daughters celebrating her birthday. He really is a doctor through and through!

On Thursday, 12 May, I labeled around 1000 bottles of wine, i.e. I handled around 1000 bottles of wine, with my right hand, occasionally with my left hand, but mainly with my right hand. I fixed the bottles with my thumb, index finger and middle finger, placed the bottles in the labeller and then in boxes. Two nights later, back in Berlin, I woke up, slightly stressed and terrified, because those three fingers mentioned above were numb. Could the reason be the labeling? The handling of so many bottles? Something similar happened to me before, this year. In January and March, namely, when I helped Thomas, the winemaker, with whom I apprentice from time to time, with the pruning. The first time I woke up, at night, startled, it was the middle three fingers of my right hand that felt numb. When I told Thomas about it the next morning, he confirmed that he felt the same way, from time to time. »But one gets used to it. It’s not nice though, no.« There would be electric pruning shears, he said, but they would make annoying noises and, more importantly, would not cut quite as precisely. Justus, could you please explain to me what happens when certain fingers become numb at night due to a activity repeated umpteen times? I didn’t actually prune that many vines because I took my time and had to concentrate. I was waking up at night because of my numb fingers continuously, for about a week.

What you describe corresponds most closely to the symptoms of a so-called carpal tunnel syndrome (CTS). The so-called median nerve, one of the three main nerves for the hand, is constricted in an anatomically very special place, the carpal tunnel. This is on the flex side at about wrist level and is bounded on one side by the bones of the wrist and on the other side by a non-yielding, very tight band, the so-called carpal ligament. The problem now is that in addition to the median nerve, the nine flexor tendons of the long fingers and thumbs also run through there. If you now use your fingers and thumbs to repeatedly clench your fists, as you did with manual pruning, and use the so-called flexor tendons, which are sliding sheaths that surround each tendon and swell up a little, then at least it will be for the nerve temporarily too tight and it is more or less ›squeezed‹ until the swelling of the tendon sheaths has been reduced. The symptoms you describe, i.e. that painful numbness of the index-ring finger – often the thumb is also affected – reflects the supply area of the median nerve. The little finger is always spared, since it is fed by another of the three main nerves of the hand, the so-called ulnar nerve. If, like in your case, there is a triggering cause that you at least can temporarily avoid and when, with a certain latency, freedom from symptoms occurs again, you don’t have to do anything. However, if the symptoms persist and do not go away spontaneously, surgical relief of the nerve should be considered, the so-called carpal tunnel release, as otherwise there is a risk of irreversible damage to the nerve in the medium term, including complete loss of feeling from the thumb to the ring finger.

Have you ever treated winemakers? People who work in the vineyard? What are generally typical injuries or illnesses that can occur in relation to the hands when people use their hands to carry out certain, repetitive activities?

During my early days as an assistant doctor at the Universitätsklinik Freiburg, we very often treated winegrowers from the nearby Kaiserstuhl in particular. Typically, in addition to hand surgery symptoms such as the carpal tunnel syndrome described above, as plastic surgeons we also often have to treat skin tumors on the face and scalp as well as on the hands and forearms, which can be traced back to the UV exposure in sunny areas and the associated UV exposure during the work of the winegrowers in the vineyard. In the field of hand surgery, bacterial soft tissue infections of the hands – which are mostly due to minor traumas that are not considered further, such as small pieces of wood entering the skin – can often take a really bad course, which can only be treated by emergency surgery, if the start of treatment is delayed. This is all due to the special anatomy of the hand, mainly its flexor tendon sheaths. In addition, there are of course always many activities in a winery, including heavy machinery, which are carried out by the winegrowers themselves as in any other agricultural operation, and which involve serious hand injuries when working with a circular saw or electric shears (e.g. electric grass, shrub or pruning shears). Since harvesters were increasingly being used in some of the less steep slopes of the Kaiserstuhl and the Markgräfler Land south of Freiburg, injuries of the forearm / hand by crushing took place, due to e.g. overturning machines.

Can you train hands? I always look admiringly at the hands of winemakers. My impression is that they all have much stronger hands than me, who only types on a computer keyboard all day long. Their hands usually also appear thicker, but in any case stronger.

Of course you can train hand strength, especially clenching strength or bending the middle and end joints of the long fingers. The most extreme example of this are professional free climbers who are able to carry several times their body weight or to bend their long fingers repetetively against resistance to an extreme extent. Well-trained muscles on the forearm and hand are also developed in jobs that require frequent, very powerful clenching of the fist. Even if this is basically a (not at all intended) phenomenon that can be advantageous for stabilizing the wrist etc., there is no good reason to do it as an end in itself, in particular it is not a prophylactic measure to avoid the carpal tunnel syndrome discussed above, i.e. that regardless of this, it occurs both in people ›independent of stress‹ who only work on the computer, but also in people who are manually heavily stressed, regardless of whether they are trained – like the winegrowers you observed – or untrained, as one must realistically assume in your case.

Your hands are your most important work tool. Are you insured? What do you do to protect them, to care for them?

I found out that the unrestricted function of my long fingers and thumb is essential for some activities that have to be carried out without instrument support, in particular the surgical one-hand knot, as a result of a racing bike accident in which I fractured the middle joint of my index finger, among other things. It took several months before I was again able to perform this particular sequence of movements, which a surgeon can practically do in his sleep, almost without restrictions. The same was true – less problematic than at work, but almost as frustrating – when playing the piano. Unfortunately, insurance only helps to a limited extent. Nevertheless, when I took out my disability insurance, I made sure that I included a so-called specific waiver of referral, which means that, for example, if there is a threat of incapacity to work as a surgeon due to an injury to my hands, I could not, only because I am a licensed doctor, simply continue to work in another field, e.g. psychiatry, in which the requirements for handedness are not quite as special. In addition, I took out a private accident insurance in my first year of work, which pays a one-off amount in the event of permanent damage being determined as a result of an accident. I took out an extra higher limb fee for the hands. But I continue to hope that I will never have to use either of them, I enjoy my job far too much for that – and the loss of my hand in everyday life, in leisure activities and so on, could not even come close to compensating for it. In order to protect my hands from acute injuries, I avoid ball sports that are typically associated with an increased risk of finger injuries, e.g. hand-, volley- or basketball – apart from the fact that I don’t master these anyway and have always been too small for the latter two anyway. Due to exposure to skin disinfectants several times a day, whether umpteen times ›briefly‹, before and after each patient (= 30 seconds for hygienic hand disinfection) or for operations (= 90 seconds for surgical hand disinfection), I try to care for the skin of my hands as consistently as possible with moisturizing. One of the ›special products‹ recommended by my fellow dermatologist friend, or simply an unscented hand cream, will do.

Labeling, using a labeler to attach both front and back label. Sound on!