0:10

Welcome to the

0:10

upper hand where Chuck and Chris

0:13

talk Hand Surgery.

0:14

We are two hand surgeons at Washington University in St. Louis here to

0:16

talk about all aspects of hand

0:19

surgery from technical to personal.

0:22

Thank you for

0:22

subscribing. Wherever you get

0:24

your podcasts.

0:25

And be sure to leave a

0:25

review that helps us get the

0:27

word out.

0:28

Oh, hey, Chris.

0:29

Hey, Chuck, how are you?

0:31

I'm doing really well. How are you today?

0:33

I am well it is. I'm

0:33

visiting family in Houston,

0:37

Texas. And it is god awfully

0:37

humid here. It is very different

0:42

than St. Louis.

0:43

Summer in

0:43

Texas. And people think St.

0:45

Louis is hot.

0:47

Yeah, no, but I have

0:47

been spending some nice quality

0:49

time at the at the pool with the

0:49

kids. My son is essentially a

0:53

fish now. He can swim on his

0:53

own, which as you remember is

0:56

very different than last summer.

0:56

So now I'm working on a three

0:59

year old.

1:00

I love it.

1:00

Well, we have a really special

1:02

guest today who can absolutely

1:02

relate to hot because she was

1:08

born in the really warm climate.

1:08

I think she was born in

1:13

Birmingham, Alabama. I know she

1:13

grew up there. So we are lucky

1:17

enough to have Macy Stonner back

1:17

with us.

1:19

By popular demand.

1:21

By popular

1:21

demand for sure. Welcome back.

1:25

Thank you so much for having me back. It's a pleasure.

1:27

So Macy, for

1:27

those of you who maybe have

1:30

tuned in and hadn't caught all

1:30

the back episodes is a wonderful

1:34

occupational therapist. And it

1:34

really we should be addressing

1:38

her is Dr. Stonner.

1:40

That's definitely not necessarily.

1:42

Her parents are

1:42

probably like, Yes, of course.

1:44

Why would you not call her Doctor.

1:45

They actually

1:45

would say that. But no, not for

1:47

me.

1:48

Oh, Chris wants me to call him Dr. Dy and I just had I don't know, I don't

1:50

know.

1:53

Well, Macy thank you

1:53

for joining us. We're gonna do a

1:56

nice follow up on our prior

1:56

stiff finger episode. But before

1:59

we get rolling, if you let us

1:59

just kind of read a review and

2:03

maybe bring up a case

2:03

presentation that I think will

2:06

start the discussion. So thank

2:06

you to BrittMitchOTRL for this

2:10

great review that you left five

2:10

stars The only way to do it, and

2:14

she actually left questions, so

2:14

we have to answer them on the

2:16

air. But says Chris, and Chuck,

2:16

I am an OT who is working in a

2:20

hospital based orthopedic hand

2:20

clinic, I am two years into my

2:23

journey to become a CHD. That's

2:23

awesome. Good for you. I've been

2:27

a practicing OT for five and a

2:27

half years. I want to thank you

2:30

all so much for taking the time

2:30

to have a podcast dedicated to

2:33

hand surgery. I listened to your

2:33

podcast every time I'm driving

2:36

into work and taking my young

2:36

kids to their swim lessons.

2:39

There you go. I've done that

2:39

swim lesson thing many times.

2:42

Now. Hopefully you're not

2:42

getting in the pool like I have

2:44

to. I have found it so helpful

2:44

for my studies and for

2:47

treatment. You are all awesome.

2:47

I do have a couple questions if

2:51

you don't mind answering them. So let's take the first one, Chuck, how often do you

2:53

communicate with your hand

2:56

therapists? Do you round with

2:56

your hand therapist? If so what

2:59

do you recommend on how to

2:59

implement rounding and or more

3:02

frequent communication? I find

3:02

it difficult to speak with the

3:05

hand surgeon I work with due to

3:05

them being so incredibly busy.

3:09

Let's start with that.

3:11

Well, first of all, I'm not sure what this rounding thing is. I believe

3:12

that's a reference to the

3:16

hospital which I try to stay out

3:16

of. But seriously, it is a

3:21

really good question. So I am

3:21

fortunate enough to a couple

3:26

times a month work with Macy.

3:26

And weekly I work with Stacy

3:30

Baker. And we obviously

3:30

communicate during those times

3:34

we are in clinic together. But I

3:34

would say honestly, in some form

3:39

or fashion, I have communication

3:39

with a therapist every day,

3:42

whether that's by email, by

3:42

phone or in epic, we communicate

3:47

and so to me, while I guess some

3:47

might consider it an investment

3:52

of time, it is a no brainer.

3:52

Because the therapists are

3:56

working towards the same goal

3:56

that I am, which is, you know,

3:59

outcomes. Is that Is that how

3:59

you think about it, Chris or and

4:02

then maybe Macy could chime in.

4:04

Yeah, I mean, I you

4:04

know, I don't spend much time in

4:07

the hospital with regards to

4:07

inpatient care, just by the

4:10

nature of the practice. I have,

4:10

you know, whenever we do have

4:13

somebody either you know,

4:13

somebody who's a trauma patient,

4:17

or a Plexus post op who stay in

4:17

the hospital, we do communicate

4:21

with our inpatient occupational

4:21

therapists, like Chuck, I work

4:26

in a model where I'm fortunate

4:26

enough to have had therapists in

4:30

our clinics at all times. So

4:30

that's been really useful in

4:33

terms of not only the expertise

4:33

that they bring to the clinic

4:37

sessions themselves, but also

4:37

the, the communication. It makes

4:42

it they're an extension of my

4:42

practice, in essence, although

4:45

you know, they are they're

4:45

definitely a distinct entity on

4:47

their own. It makes people think

4:47

that we are just this great

4:51

team, which we are, but

4:51

obviously, the optics of that

4:55

are super important. I guess in

4:55

terms of advice, you know, what

4:58

I on the surgeon side, what I

4:58

Tell all of our graduating

5:01

fellows is check out the hand

5:01

therapy environment where you're

5:04

going to start working. And if

5:04

you can try to find a way to

5:07

have a hand therapist seeing

5:07

patients with you in the clinic,

5:10

it's obviously an investment on

5:10

their end in terms of time that

5:15

they're not in the office, so

5:15

called opportunity cost. But the

5:18

relationships and the referrals

5:18

that come out of that I think

5:21

are super useful. Macy, what are

5:21

your What are your thoughts

5:24

about the communication aspect of it?

5:27

Well, I am

5:27

incredibly spoiled, because the

5:30

only job that I've ever had is

5:30

at the Milliken Hand center

5:32

where we collaborate very

5:32

strongly with the physicians

5:35

next door. And so I have been

5:35

very spoiled with that

5:39

relationship. And I really value

5:39

it. One thing that I really love

5:42

is, as you mentioned, the

5:42

fellows Skye Halverson and Sandy

5:46

Gephardt if you're listening, I

5:46

love it when I get phone calls

5:49

from old fellows to our to our

5:49

hand center, and they're like,

5:53

Hey, we're now have our own

5:53

practice now. And we don't have

5:57

a hand therapists on staff or I don't know them very well, can you tell me what you do for

5:59

tendon transfers for XYZ or

6:02

whatnot. And so it's just kind of fun.

6:04

So let's go to

6:04

question number two. So

6:06

regarding the podcast about

6:06

nerve reps, what has been your

6:09

experience was with placental

6:09

graphs for wrapping nerves

6:12

successful or not successful in

6:12

reducing adhesions? I will say

6:17

I've read about this. But I have

6:17

not used placental grafts,

6:21

mainly, because I think I have

6:21

some better options. I typically

6:25

in some of these cases will go

6:25

with a autologous vein wrap as

6:30

opposed to a commercially

6:30

available wrap. And I know that

6:33

that's going to generate some

6:33

controversy, and we have some

6:35

sparring partners with regards

6:35

to that. But I haven't had to go

6:39

to placenta. Yet, as Marty Boyer

6:39

says, never say never, never say

6:44

always but I don't ever envision

6:44

myself using that. Chuck, do you

6:48

ever see yourself using placenta?

6:49

Well, I you

6:49

know, conceptually, the placenta

6:53

is kind of held up. Like some of

6:53

the injections are held up as

6:58

the cure all for anything and

6:58

everything. I obviously have no

7:02

experience with that. But you

7:02

know, we are we are just at the

7:06

beginning of understanding the

7:06

processes of scarring and

7:09

solutions to scarring. And so I

7:09

certainly have an open mind but

7:12

no experience.

7:14

So thank you so much

7:14

for that review. We love it. We

7:18

love getting questions from

7:18

everybody. So please get on to

7:21

Apple iTunes. And leave us a

7:21

review five star review. If you

7:25

feel like it. Well really should

7:25

the only option to be a five

7:28

star review, and then leave a

7:28

question or a comment and we'll

7:31

read it on the air. And Chuck,

7:31

why don't you set us up for

7:34

today's discussion.

7:36

Perfect,

7:36

perfect. So let's present. Maybe

7:38

we'll take two case scenarios

7:38

and ask Macy's wisdom and her

7:44

thoughts on how she handles a

7:44

patient like this. So let's just

7:47

start with maybe a simplistic 25

7:47

year old who has a have. Let's

7:56

start with a simplistic 25 year

7:56

old who has an oblique fracture

8:00

of the proximal phalanx which is

8:00

displaced and shortened. The

8:04

surgeon takes the patient to the

8:04

operating room obtains a near

8:07

anatomical close reduction and

8:07

places to K wires 0.045 For this

8:14

example, so good solid k wires,

8:14

caps those K wires, places them

8:19

in a splint and sends them to

8:19

Macy for care. So the first

8:25

question I have may see is when

8:25

would you most prefer to see

8:30

that patient post op? Do you

8:30

want to see him day two? You

8:32

want to see him day 10? When

8:32

would you like to start?

8:37

I guess this is somewhat arbitrary. But I guess in my head, I always have five

8:39

to seven days. That's typically

8:42

when I would start moving them

8:42

actively. I feel like a week is

8:48

a little bit on the later end,

8:48

two days is definitely early. I

8:52

think pain might get in the way.

8:52

Five to seven days is pretty

8:55

standard.

8:56

So you're

8:56

looking for a time where you

8:58

know I'm gonna put the patient

8:58

in this example it says a little

9:01

finger and an ulnar gutter

9:01

splint. Hopefully, any

9:04

discomfort calms down, any

9:04

swelling might calm down. So

9:08

you're looking for a time when

9:08

the situation is good to start

9:12

motion. Okay, and then

9:12

reasonable patient, you believe

9:20

this patient will be compliant.

9:20

talk through kind of what type

9:24

of resting splint you consider

9:24

and how you start the patient

9:27

moving.

9:29

Sure, so day one,

9:29

I would do a lot of education,

9:32

edema management, wound care

9:32

type stuff, make them a custom

9:37

orthosis ensuring that their PIP

9:37

joint is in perfect extension.

9:41

those nasty keloid fractures get

9:41

an extensor lag or PIP flesh and

9:45

traction are pretty easily so

9:45

adequate splinting is key for

9:49

that. And then in terms of

9:49

flexion teaching them active

9:54

tendon glides to start just

9:54

something very standard very

9:57

simple. And then I would see

9:57

them back weekly, twice.

10:00

Depending on the patient's

10:00

personality, depending on how

10:02

stiff they are, depending on

10:02

their insurance, depending on

10:04

how close they are to therapy,

10:04

all these different factors, and

10:07

I would reevaluate them, if

10:07

they're still really stiff, I

10:10

would start them on, oh gosh,

10:10

isolated joint blocking,

10:14

potentially passive flexion. If

10:14

the surgeon allows it, and if

10:18

they tell me that the fixation

10:18

is solid, and depending on pain,

10:22

you know, if their pain level is

10:22

above five, I'm not gonna do

10:25

passive motion. So there's no

10:25

protocol, that word is very, I

10:30

don't know, I don't follow a

10:30

protocol just kind of depends on

10:33

the surgeon, the patient

10:33

surgery, the therapist, it's

10:36

kind of all altogether.

10:39

So you mentioned all

10:39

the various things that help you

10:42

decide how frequently you see

10:42

patients. What are the red

10:46

flags? Like? What are the things

10:46

that when a patient comes in,

10:48

that you assess, they're like,

10:48

Ooh, this patient either needs

10:51

to come in more frequently, or I

10:51

know that this patient is going

10:53

to have a really hard time.

10:56

Let's see. So the

10:56

way that I decided I need to

10:59

come in more frequently is if

10:59

they seem as though they're

11:01

going to be non compliant, or

11:01

they might not have understood

11:04

my instructions. So they require

11:04

repeated instructions, just to

11:08

understand simple active range

11:08

of motion. If they seem like the

11:13

type that's going to be non

11:13

compliant with their splint, or

11:17

the activities that they choose

11:17

to do, I might have them come a

11:20

little bit more frequently. And

11:20

if they come in with total

11:22

active motion of 10 degrees, 20

11:22

degrees, and it's just very,

11:26

very stiff. I'm going to say,

11:26

Oh, you need to send me again

11:28

next week early. So there's just

11:28

a lot of different factors at

11:32

play. And

11:33

So a comment

11:33

and kind of follow up. So first

11:36

of all, I assume, would more

11:36

than typical swelling, be

11:40

another reason that you would be

11:40

concerned and maybe bring them

11:43

back or take extra care with

11:43

them?

11:46

Yes, for sure.

11:46

Particularly because as their

11:49

swelling goes down, their splint

11:49

is not going to be comfortable.

11:52

And they're going to slide around in that splint, maybe their PIP joint might flex a bit

11:53

in that ulnar gutter until they

11:57

might get a lag. So definitely

11:57

edema plays a factor there. And

12:01

I would have to come back earlier.

12:02

Perfect. So

12:02

let's let's get a little more

12:05

detailed. You threw out some

12:05

terms, which are great, which I

12:09

you know, I assume I understand.

12:09

But let's be real, I may not.

12:13

Oh my gosh, what did I say?

12:15

Well, no, you

12:15

just I think some people will

12:17

not be familiar with the term.

12:17

So tendon glides, you start them

12:20

on some tendon glides. And you

12:20

said that kind of at the clinic

12:23

of visit number one, be very

12:23

specific. What do you mean by

12:26

tendon glides?

12:27

Sure so a tendon

12:27

glide is something that enables

12:30

the FDS and the FDP tendons to

12:30

glide freely. So I might have

12:35

give them a very simple handout

12:35

that has a picture of somebody

12:38

making a fist, somebody making

12:38

what's called a hook fist, where

12:42

their MP joints are an

12:42

extension, their PIP and DIP

12:45

joints are in flexion. And then

12:45

a photo of what's called a flat

12:51

fist or a straight fist with our

12:51

MP joints or flex their PIP

12:55

joints are flexed but their DIP

12:55

joints are straight, and that

12:58

enables FDS excursion or PIP

12:58

joint flexion. So it's a lot of

13:05

hand therapy buzz lingo. But

13:05

it's something that is somewhat

13:10

simple for somebody to

13:10

understand just to get active

13:13

movement trying to facilitate a

13:13

functional fist before we get

13:17

fancy into any other thing. So

13:17

that's kind of where we started

13:20

initially.

13:21

Let's talk about

13:21

blocking exercises. What does

13:24

that mean?

13:25

So blocking

13:25

blocking is where well, let me

13:28

backtrack a second, tendon

13:28

glides is when all four fingers

13:31

are moving in unison. If you do

13:31

blocking, that's where you do

13:35

each finger moves in isolation.

13:35

So if you're really stuck in the

13:39

scar, or you need a little bit

13:39

more advanced movement, you

13:41

might have them do isolated PIP

13:41

joint blocking when you have the

13:45

opposite hand support the

13:45

proximal phalanx to encourage

13:49

FDS glide, and then you move

13:49

distally you block the middle

13:53

phalanx when you have them do

13:53

isolated DIP flexion. And so it

13:57

just enables more advanced

13:57

movement of the joint if they're

14:02

not getting enough excursion of

14:02

their tendons.

14:06

Do you have

14:06

you know, you are very careful

14:09

about stating you splint with

14:09

the PIP joint and extension. If

14:14

you and therefore the patient is

14:14

good about wearing the splint, I

14:19

assume therefore, your primary

14:19

concern then is working on

14:22

flexion. Is that is that

14:22

generally the issue, flexion?

14:28

Yes, if you catch

14:28

them early, if you catch them

14:31

early, and you ensure good

14:31

splinting early and they do not

14:34

have a flexion contracture.

14:34

Sure, flexion is the thing that

14:39

we're working towards, you know,

14:39

we realistically we don't always

14:43

catch them five to seven days

14:43

after surgery, and they might

14:45

have already developed this

14:45

gnarly, 40 degree, either

14:49

flexion contracture or lag and

14:49

so you're working on exercises

14:54

to regain extension through

14:54

active range through night

14:58

splinting, along with Working on

14:58

their flexion. So kind of just

15:03

depends.

15:04

Are there ever any

15:04

situations in which it's

15:06

advantageous to leave the PIP

15:06

joint free in terms of

15:10

splinting, if we've got secure

15:10

stable fixation with the goal of

15:14

trying to maximize the amount of

15:14

flexion, that you could obtain?

15:17

Absolutely. Only

15:17

if they don't have a PIP

15:23

function interaction or lag,

15:23

because if they have their PIP

15:26

joints free, they're going to be

15:26

sitting in this PIP flexed state

15:30

all day. So unless they have

15:30

good extension, it's not

15:34

something that I would

15:34

necessarily encourage. And also

15:37

if their fracture is relatively

15:37

proximal, I think it's okay.

15:41

When I don't

15:41

have maybe, maybe if you're not

15:44

around or say something around, and I'm in clinic, and I'm talking to a patient about edema

15:46

control. You know, I guess I'd

15:52

love for your thoughts on how

15:52

you instruct the patient on need

15:56

to control the very specific

15:56

instruction you give them to

16:00

minimize swelling or to address

16:00

a patient who already has a

16:03

swollen finger. What do you tell him?

16:07

It's a great question, because people are very concerned about swelling I

16:08

hear often, I can't move my

16:12

finger right now I'm still

16:12

swollen. In fact, Dr. Goldfarb

16:15

the other day in your clinic,

16:15

somebody told me that. And so

16:18

it's just a myth. And so I like

16:18

to say, you know, if you wait

16:22

until your team is down to start

16:22

moving, your finger is going to

16:26

be so stiff already. So in fact,

16:26

the best way to get rid of edema

16:29

is by movement. So keeping those

16:29

fingers moving, you've been

16:32

elevated and keeping it

16:32

compressed. So just simple coban

16:36

wrapping distally to proximally

16:36

can really help control digital

16:40

edema. And that's a very simple

16:40

way for people to understand the

16:44

edema control. So I often teach

16:44

that pretty early on.

16:47

So I have a question

16:47

when when we put in pins, we

16:53

think we put them in the best

16:53

position and bend them in a

16:55

certain way to keep them out of

16:55

the way. What are some of the

16:58

more boneheaded things that

16:58

surgeons have done to make it

17:02

harder on you in terms of the

17:02

way that the pins are bent? Are

17:05

there any pearls for that you

17:05

can teach us about where to

17:08

place the pins and how to keep

17:08

them out of web spaces, all that

17:11

kind of stuff?

17:12

Or, or what

17:12

frustrates you, when you see

17:14

pins whether maybe every time we

17:14

put it in a pin, you get

17:17

frustrated, but any thoughts and

17:17

maybe a random question about

17:20

it. I like I liked the question.

17:22

I guess what you

17:22

mentioned about the web space,

17:26

so ensuring that it's not no

17:26

right in the web space to where

17:31

they get masturbation in their

17:31

fingers or where they have a lot

17:35

of pain with their splint. If

17:35

it's obviously pinned through

17:40

the joint, then that provides a

17:40

lot more difficulties long term.

17:45

What What if

17:45

you know sometimes when I pin

17:48

say, if I retrograde pin a

17:48

metacarpal there are times when

17:54

I feel like the extensor

17:54

mechanism is caught up in the

17:56

pin. And that may be okay

17:56

because the fracture looks

18:01

great, does that end up

18:01

frustrating you or you're not

18:04

too worried about it because

18:04

when the pin comes out, you're

18:07

confident you can regain motion.

18:09

They're not gonna

18:09

worry about it because I I work

18:11

with great surgeons and so I

18:11

trust that they are going to

18:13

make the right clinical call in

18:13

the OR that is going to maximize

18:17

fracture fixation stability long

18:17

term and I'm just going to work

18:20

with what I can. But I just

18:20

educate them a lot on scarring

18:24

and the anatomy involved in

18:24

fractures and tendon adhesions.

18:27

And I educate them on the

18:27

exercises to do so a metacarpal.

18:31

That's been pinned, I talked

18:31

about the EDC and I talked about

18:36

an exercise called and EDC

18:36

glide, which is again is a hand

18:40

therapy term. But it really

18:40

encourages extensor tendon

18:44

excursion through the pin. And

18:44

yeah, I trust that the surgeons

18:49

are making the right call and I

18:49

don't think that frustrates me.

18:51

But I know that what has to be

18:51

has to be done.

18:55

A question Chuck for

18:55

you. When you cut your pins

18:58

exterior to the skin, say for

18:58

example, this one where I'm

19:01

assuming we have a couple of

19:01

crossed antegrade wires into the

19:05

proximal phalanx? Do you bend

19:05

them before you cut them? Or do

19:10

you just leave them straight?

19:13

I tend to

19:13

leave my pin straight. Well, let

19:15

me back up a step. So the first

19:15

thing is when I'm having a

19:17

trainee with me, when I placed

19:17

the pins obviously want the pin

19:21

place to appropriately address

19:21

the fracture. To me one of the

19:25

keys is not plunging through

19:25

that second cortex and having to

19:29

pull the pin back then I worried

19:29

about pins, then I worry about

19:32

pin stability. As long as that's

19:32

not a worry. I cut the pins cap

19:39

them, don't bend them. Do you?

19:39

Do you bend them?

19:42

I bend them but I've

19:42

started to become I've started

19:44

to question whether I should be

19:44

bending them. There are some

19:47

situations in which, you know, I

19:47

think the bend can create more

19:50

of a hassle than it's worth. And

19:50

I don't know Macy do you think

19:54

that bending the pins is bad or

19:54

good or helpful? I mean, you

19:57

know, ideally it doesn't affect

19:57

us to do it so would you rather

20:00

have just Is it easier to advise

20:00

patients to take care of pins

20:03

that aren't bent?

20:05

No, it's never

20:05

crossed her mind ever until you

20:07

just mentioned it, I don't think

20:07

that it affects my job or their

20:11

job in terms of pin care or

20:11

range of motion. I don't think

20:14

that's and people might disagree

20:14

with me. But I don't think

20:17

that's something that really is

20:17

a big determinant of outcome

20:20

from a therapy perspective.

20:22

Do patients actually

20:22

move their finger their joint

20:25

when it's been like I we have

20:25

some partners to say nobody

20:28

really moves when they're pinned?

20:30

Sure. I think so.

20:30

I think that it depends on the

20:33

patient's personality. People

20:33

have some people have more fear

20:37

than others, and people are just

20:37

more careful. But I think that

20:43

they do just fine. If you tell

20:43

them it's okay. If you look them

20:45

in the eyes and say, it's okay

20:45

to move this, your doctor said

20:47

it was fine. Nothing that I'm

20:47

going to teach you right now is

20:50

going to harm you. It might hurt

20:50

a little bit, but it will not

20:53

harm you. And that always gives

20:53

a lot of confidence to the

20:57

patient if you say that.

20:59

I like that. And I think that's a good question, Chris, because I have

21:00

heard that before. So before we

21:04

jump to discussion of an open

21:04

reduction, internal fixation of

21:08

a similar fracture, perhaps with

21:08

the playing screw before we jump

21:11

to that similar case, I am lazy.

21:11

And so I often say to the

21:17

patient, go to therapy, they'll

21:17

take your surgical dressing off,

21:21

they'll make you a beautiful

21:21

custom fabricated splint, and

21:24

they will teach you how to care

21:24

for those pins. What do you tell

21:28

my patients when you teach them

21:28

how to care for those pins?

21:31

We get little

21:31

Dixie cups of 50% hydrogen

21:35

peroxide 50% water, instruct

21:35

them and pin care with a Q tip

21:41

is they do this once a day if

21:41

you have little crusties at the

21:45

base of your pin, sometimes they

21:45

don't even need to do anything.

21:48

If they're clean and dry. No

21:48

signs of infection, no pain, no

21:50

tenderness, no redness, you're

21:50

fine. So it kind of depends on

21:54

what they look like.

21:55

I agree and,

21:55

and I am fine with my patients

21:57

showering and I you know, I like

21:57

them to share actually getting

22:02

their pins wet. And just using

22:02

soap and water around the pins

22:07

in the shower. And then I love

22:07

what you said, I don't think you

22:10

and I've ever had a discussion.

22:10

But I appreciate what you said.

22:13

I guarantee I

22:13

guarantee you there's a little

22:16

index card floating around the

22:16

Milliken hand Therapy Center

22:18

with all the Goldfarb pin

22:18

preferences from when you first

22:21

started and you probable didn't even know it's out there.

22:24

We have a file

22:24

folder of every surgeon we work

22:27

with. And it says wound care

22:27

preferences for each doctor. And

22:30

we just go through however now

22:30

we kind of have everybody

22:33

memorized. So.

22:34

The reason I know that is because I remember having to answer these questions when I

22:36

was about to start and be like,

22:38

Oh shit, just do what Goldfarb does.

22:42

Well, is

22:42

totally fair. And we have a

22:44

group of six surgeons and four

22:44

of us regularly performed wrist

22:46

arthroscopy as an example. And

22:46

so Lindley Wall was trying to

22:50

help our therapy partners by

22:50

trying to consolidate a couple

22:54

of protocols. And it was really

22:54

tough. I mean, we just, you

22:58

know, if we've done it this way,

22:58

for three years, why would I

23:02

change and so those

23:02

conversations are tough, but it

23:05

is not particularly fair that

23:05

six surgeons have six different

23:08

pin site, you know, care

23:08

preferences, it's crazy. It's

23:11

crazy.

23:12

So I will say this

23:12

episode's gonna drop in July.

23:16

And that means that there are a

23:16

lot of fellows that are about to

23:19

move institutions and graduate,

23:19

you probably already know this,

23:22

but you should be scrambling to

23:22

get every protocol you can, from

23:26

something as simple as how does

23:26

the type of needles you need to

23:30

set up an injection in the

23:30

clinic to as complex as somebody

23:34

wound care protocols, their

23:34

their clinic templates, as well

23:38

as all their therapy protocols.

23:38

And a lot of that's available in

23:41

epic now through dot phrases and

23:41

whatnot. But make sure you're

23:44

grabbing all that stuff now before you leave.

23:47

That is That

23:47

is very true. And we know what's

23:49

happening. It's already started

23:49

happening here, as you certainly

23:52

know, Chris. Alright, may see

23:52

let's go back to that 25 year

23:55

old. And let's pretend that I

23:55

was unable to obtain a

24:01

satisfactory closed reduction. I

24:01

made an incision dorsally over

24:05

the proximal phalanx, I split

24:05

the extensor mechanism. And

24:10

let's say I needed to put a

24:10

small plate and screws in so I

24:13

put a 1.5 millimeter plate in

24:13

with five screws was really

24:19

happy when I left the or I re

24:19

approximate the extensor

24:22

mechanism, close the skin.

24:22

Splint it for four days and sent

24:27

them to you number one, are you

24:27

happier that I did an ORIF

24:31

versus a pinning? Does it make

24:31

your life easier or harder? And

24:35

how would you address this

24:35

patient differently if at all.

24:39

I have had great

24:39

outcomes with both it's kind of

24:41

hard to say I think on my for

24:41

her pinning because of that

24:46

gnarly PIP extensor lag.

24:46

Whenever I have a plate fixation

24:52

of a p one fracture I get

24:52

immediately concerned about PIP

24:56

extension just because you have

24:56

more swelling and more scarring

24:59

along that zone three extension

24:59

mechanism. And so reverse

25:04

blocking again therapy term to

25:04

get active tip extension is an

25:08

exercise that I would implement

25:08

earlier. So like I said, it kind

25:13

of dodged your question, but I

25:13

guess I'll prefer pinning.

25:15

So wait, hold on a

25:15

question for both of you then.

25:17

So if, if this is truly a

25:17

shorter oblique fracture, maybe

25:20

if it was a longer oblique

25:20

fracture, what if we had fixed

25:24

it with three or four screws

25:24

still done the same approach

25:27

maybe or kind of danced around

25:27

the extensor mechanism? So

25:31

there's still some concern for

25:31

scarring around the extensor

25:34

mechanism, but there's no plate

25:34

physically sitting dorsally.

25:38

There are inner fragmentary

25:38

screws or perhaps lag screws

25:42

that are holding that fracture

25:42

together really solid. Chuck,

25:45

would you send that prescription

25:45

over any differently than Macy?

25:48

Would you? I don't know if you

25:48

would actually end up knowing

25:51

what type of construct was in

25:51

there. But would that change

25:53

your your optimism or pessimism

25:53

about the extensor? mechanism?

26:00

Again, great

26:00

question. I think when I do an

26:04

ORIF and I have solid fixation

26:04

and feels feel really good about

26:08

what I have, I guess I always

26:08

thought that Macy would have

26:11

been happier with me then then

26:11

if I can, just because you're

26:14

not fighting the pins per se,

26:14

but but I hear her loud and

26:18

clear about the concerns about

26:18

an extensor lag. If I have

26:23

really good fixation, operate on

26:23

Wednesdays primarily, I would

26:28

say that I would send them over

26:28

for Monday. Really not

26:32

considering pins played or

26:32

screws, but I don't think it

26:35

changes my referral. I guess it

26:35

changes my optimism on how

26:39

aggressive Macy can comfortably

26:39

be. But but maybe not.

26:43

Do you write in your

26:43

prescription to be different in

26:46

terms of how aggressively Macy

26:46

or any of our therapy colleagues

26:50

can be if it's pins, plate and

26:50

screws or independent screws?

26:57

If I'm

26:57

interacting with an external

27:00

therapist, and there we look,

27:00

let's be clear, St. Louis is

27:03

blessed with a number of really

27:03

good therapists, you know, that

27:07

I know of and I'm sure there's

27:07

others, but I am much more clear

27:11

about what I would like when I

27:11

send them to Oh, gosh, maybe

27:17

this is not okay. But when I

27:17

send to Macy, or to Stacey, I am

27:21

I guess less clear, I will state

27:21

you know, early active motion,

27:25

gentle passive motion, but I

27:25

trust that they will progress

27:28

along. But I'm perhaps not as

27:28

clear as that could be.

27:34

We just are

27:34

spoiled and we know your

27:36

preferences. And so we don't

27:36

really need you to be clear. And

27:39

so we appreciate that, that you

27:39

trust us enough to guide the

27:42

patient a lot. And so you're

27:42

right, if it was plated, I do

27:46

feel like I can progress to

27:46

passive earlier because let's be

27:49

honest, a few one fracture that

27:49

was fixed is going to need

27:51

passive motion at some point, if

27:51

they were pinned, and I'm not as

27:55

convinced of the fixation as a

27:55

different approach, I might wait

28:00

on passive and because I'd be

28:00

fearful of instability, I guess.

28:04

But yes, a plate I feel like I

28:04

can be much more quick with

28:09

passive motion but you know ask

28:09

other people my colleague Emily

28:12

potassium hope she's listening

28:12

will always prefer an ORIF of a

28:17

P one fracture versus a pin

28:17

because she's convinced that if

28:20

you're pinned you're not going

28:20

to move like we had talked

28:23

earlier. And so if you don't

28:23

have visually a pins coming at

28:26

your finger, you're gonna move a

28:26

lot better. So I think it

28:29

depends on the patient depends

28:29

on the therapist. Can't go wrong

28:33

either way.

28:33

Did did Emily

28:33

brainwash her collaborative

28:38

surgeon or did her collaborative

28:38

surgeon brainwash Emily?

28:42

That's a great question. It's probably the latter.

28:48

No, no comment. I

28:48

really don't know. I've seen

28:52

Emily with her collaborative

28:52

surgeon in clinic and Emily is

28:55

Emily's smart as a whip and very

28:55

open to expressing opinion. So I

28:59

think that's, that's great.

29:01

Yeah she'll always prefer an ORIF.

29:03

So, I had a question

29:03

before we switch to say a case

29:06

where we have some stiffness in

29:06

any way that the fracture is

29:10

fixed. When do you start to add

29:10

some resistant work in terms of

29:14

putty and eventually

29:14

strengthening? Is it when we

29:18

asked you to or are there points

29:18

in the therapy course of

29:21

therapy? were like, Oh, this

29:21

patient's like, ready for the

29:23

next step?

29:25

Oh, great question. Definitely after they're healed, and that can be

29:27

very different for every

29:31

patient. But I would say once

29:31

they're healed, I'm pretty free

29:35

game with any passive motion

29:35

that I want. And then once they

29:39

start passive, wherever that

29:39

point may be, whether that's two

29:42

weeks, whether that's eight

29:42

weeks, and they're relatively

29:45

pain free at rest, I can start

29:45

some strengthening shortly

29:49

after. So that's a bad answer,

29:49

because I'm not giving you a

29:52

specific week. It totally case

29:52

dependent, but I go off pain. I

29:58

go up when they started Passive

29:58

and when they're healed,

30:04

But is there like a

30:04

specific value for total active

30:07

motion or DPC where you say

30:07

okay, now we can start to do

30:11

some strengthening.

30:13

I think that if

30:13

joint stiffness is the concern,

30:18

strengthening is definitely not

30:18

my prioritizing treatment plan.

30:24

Because I say, Hey, I get this

30:24

soapbox every time like, Hey,

30:28

you have your whole life to

30:28

regain strength, you can always

30:32

gain muscle mass, you have more

30:32

of a limited opportunity or

30:36

limited time to regain motion,

30:36

you have this nice window, and

30:41

fingers do not tolerate trauma

30:41

well, so let's really work on

30:45

stretching. Because if you have

30:45

sickness in the finger, it

30:49

doesn't just naturally get

30:49

better with time. It gets

30:52

naturally better with stretch.

30:52

So let's really stretch.

30:57

I was I was

30:57

recently at a an informal

31:00

meeting. And I guess I'll leave

31:00

the names out of it. Hopefully,

31:04

that's okay. Were they the

31:04

presenter stated, gave really a

31:09

presentation about why I hate

31:09

the squeezy ball. He basically

31:14

showed the example of if you

31:14

have a squeezy ball and you're

31:18

squeezing, and you're going from

31:18

the DPC the distal palmar crease

31:21

measurement. For those who don't

31:21

use that term of say, six

31:25

centimeters to three

31:25

centimeters, you're actually not

31:28

fully arranging the fingers. And

31:28

it may be counterproductive for

31:31

regaining motion at a time when

31:31

you need to focus on motion, not

31:35

strength. But it was pretty

31:35

insightful.

31:37

Completely agree with that. I love whoever said that. Was that Dr. Boyer?

31:41

It was not. No

31:41

reason to love Dr. Boyer.

31:45

I agree with that

31:45

completely. People have this

31:48

incomplete flexion arc when they

31:48

do it stressful. So we do a lot

31:53

of therapy putty, which has

31:53

different resistances. And that

31:57

we encourage people to do it's a

31:57

full arc of flexion to get all

32:01

the way to a DPC of zero. So I

32:01

agree with whoever made that

32:05

comment.

32:06

Well, that's the

32:06

reason why every time we open

32:09

one of those slings that has the

32:09

stress ball included, I toss the

32:12

stress ball out. Patients see

32:12

that they're going like, Oh, I'm

32:15

supposed to be using this like,

32:15

nope, no way.

32:19

Yeah, that's great.

32:19

I see that all the

32:19

time with somebody who's two

32:22

weeks out from a central slip

32:22

repair and they're like

32:25

squeezing a stress ball because they think that that's what's going to make them better. And

32:26

I'm like, Oh gosh, please don't.

32:29

So don- so donjoy USA,

32:29

if you're listening, make those

32:32

splints, or the slings and you

32:32

include the stress ball save

32:35

yourself some money man, don't

32:35

even put them in.

32:38

They're cute

32:38

and all but alright, let's

32:41

finish up the show and talk

32:41

briefly about the patient will

32:45

give you the scenario. patient

32:45

is now eight weeks out of that

32:50

initial oblique p one fracture

32:50

that we pinned. We pulled the

32:55

pins at about five weeks and

32:55

radiographs, you know look fine.

33:00

And they're back today is now

33:00

eight weeks out they've been

33:02

seeing you may see and making

33:02

some progress, but not as much

33:06

as we would like another eight

33:06

weeks out. And let's say their

33:10

Extension has been good. They've

33:10

been good about wearing the

33:12

splint, but they just don't have

33:12

active motion or sufficient

33:20

active motion. So as they

33:20

attempt to flex, they are

33:24

limited to a DPC of you know

33:24

four centimeters and we can talk

33:27

more specifics. But how do you

33:27

think about that patient? And

33:30

what do you do with them?

33:32

Oh, wait, wait, wait,

33:32

hold on, Chuck. Just so follow

33:34

up on our prior episode, we we

33:34

should know what's the passive

33:38

motion before we can talk about

33:38

the active. So give us that

33:40

info.

33:41

Thank you. So

33:41

in this patient, they have good

33:45

active and passive extension.

33:45

And they have good passive

33:50

flexion. To a DPC of zero but

33:50

when I asked him to actively

33:56

make a fist, they are limited.

33:58

Okay, so this

33:58

patient, if they have a passive

34:01

DPC of zero, I wouldn't consider

34:01

that a stiff finger. I would

34:05

consider that as tendon

34:05

excursion problem. So active

34:08

active active motion, a little

34:08

bit of resistance to encourage

34:12

your tendons to glide through

34:12

some stress, encouraging full

34:16

functional use of the hand using

34:16

it for every daily activity. But

34:20

does that person need a static

34:20

progressive splint? No, because

34:26

they're not passively limited.

34:26

They're actively limited. So

34:30

active motion all the way.

34:32

So then just to keep

34:32

breaking down terms, what is a

34:36

static progressive split.

34:38

So a static

34:38

progressive splint is a type of

34:42

orthosis or splint that has a

34:42

component on the finger like a

34:46

tab where you pull on it with

34:46

your opposite hand to provide

34:51

external or passive motion. So

34:51

it's something that you don't

34:55

have to think about the

34:55

technique involved in a manual

35:00

She just kind of passively place

35:00

your finger in a device, a

35:05

torture device that a lot of

35:05

patients describe. And it just

35:08

kind of takes you into the

35:08

motion you need to have. And you

35:12

can think about other things,

35:12

watch a show or whatever in

35:15

order to really maximize motion.

35:15

And so if it's a truly stiff

35:19

finger stiffness, meaning

35:19

passively limited, that's where

35:23

we typically go. But in the case

35:23

that you described, I wouldn't

35:27

think that that would be

35:27

necessary.

35:30

So what you're

35:30

hoping for, in the case that I

35:34

described where we have a flexor

35:34

tendon adhesion? Is that that

35:38

adhesion will break up with

35:38

daily activities or just the

35:42

active motion or even strengthening?

35:45

Sure.

35:45

When do you

35:45

apply e-stim it because that

35:48

would be the next step I assume

35:48

for you? Or when does e-stim

35:52

come in?

35:53

So I ever you

35:53

asked me this question in our

35:57

flexor tendon podcast in the

35:57

fall. And it kind of depends on

36:02

the therapist, some therapists

36:02

really value that and others

36:05

might not. I am, I have a lot of

36:05

colleagues that use it. And I

36:09

think there's definitely a role.

36:09

I don't use it a ton. Because I

36:13

think that that's an external

36:13

force that's doing the movement.

36:16

And that's not sustainable,

36:16

necessarily, if they let's say

36:19

that they're PIP flexion is, 40,

36:19

actively, and then you put some

36:22

e-stim on there, and they can

36:22

get 70. That's great. But if

36:27

they can't maintain that, every

36:27

day, as they're using their

36:30

hand, I'm not so sure that it's

36:30

totally doing what it needs to

36:34

do. I'm not against it, but it's

36:34

just not my first treatment

36:38

strategy.

36:39

So the case that Chuck

36:39

gave you is one that I don't

36:45

often see, what I typically

36:45

would see is active DPC of four

36:48

and passive DPC of two. Right,

36:48

let's work through that

36:52

scenario.

36:53

So I think in that

36:53

scenario, you still continue the

36:56

treatment strategies, as

36:56

mentioned. So active tendon

36:59

glides, joint blocking, using

36:59

the hand as much as possible,

37:03

light strengthening with the

37:03

addition of some potential

37:07

dynamic or static progressive

37:07

splint use, which I mentioned

37:12

earlier, is just an external

37:12

type of orthotic which can

37:15

stretch your finger passively,

37:15

as you go about doing other

37:19

things.

37:20

Now that dynamic

37:20

splint, very different from a

37:22

static progressive splint,

37:25

Kind of so static

37:25

progressive splint is one where

37:27

you would strap this device on

37:27

your finger, pull a tab on your

37:31

PIP joint, and it's kind of

37:31

anchor the mechanism to your

37:36

forearm. And you just kind of

37:36

let it sit there. You reassess

37:40

your pain after three to five

37:40

minutes, let's say your pain

37:43

initially is a three. After a

37:43

few minutes, if your pain goes

37:48

down to a one or a zero, that's

37:48

great. That means that your

37:52

joint is kind of accommodating

37:52

well to the stretch. So static,

37:56

progressive, meaning you can

37:56

progress this motion even

37:58

further. But it's a static

37:58

stretch. Again, a lot of

38:03

therapists will be listening to this thinking, Oh, yeah, this is all therapy lingo that they

38:05

know. And then a dynamic brace

38:10

would be one that is kind of

38:10

like you're familiar with an LNB

38:14

or something like that, that's

38:14

just like a constant stretch, no

38:17

matter what you can't adjust the

38:17

tension per se. It's just like a

38:20

constant level of stretch. I

38:20

think they both have a role, you

38:23

just kind of have to take a case by case.

38:26

Yeah, and that's certainly one where I differ 100% to the experience of

38:28

the therapist that I'm working

38:32

with. And let's be clear, what

38:32

we're talking about here is

38:35

potentially adhesion adhesions

38:35

on the flexor side, but more

38:40

importantly, that lack of

38:40

passive full motion, we're

38:43

talking about either extensor

38:43

tendon adhesions, which are

38:46

preventing that finger from

38:46

flexing, or a DI I'm sorry, or a

38:50

PIP, joint contracture which is

38:50

preventing that passive flexion.

38:55

Do we all agree on that?

38:58

Yeah, that's what I

38:58

had one question for you. I

39:01

mean, I remember Dr. Boyer

39:01

talking about when he was a

39:04

fellow in Indiana having to go

39:04

up and you know, as a fellow,

39:09

put some local anesthetic

39:09

injections in people's PIJ. so

39:12

that they could keep working

39:12

with therapy. Now we know of the

39:15

our graduation sphere taught us

39:15

about the effects of those local

39:18

anesthetics, at least the longer

39:18

acting ones on cartilage. Do you

39:22

still see a role of using, you

39:22

know, an adjunct to like a local

39:25

anesthetic if it's short acting

39:25

to help get patients through the

39:29

pain part of their therapy?

39:32

Yeah, and let's just be very clear, our graduation speaker Constance Chu

39:33

was suggesting that any intra

39:37

articular injection is damaging

39:37

to cartilage. And not I wish I

39:42

could say I was smart enough to

39:42

not inject for that reason, but

39:46

I don't inject in these cases. I

39:46

do not use any local anesthetic

39:49

to facilitate therapy. I guess I

39:49

don't think it's crazy, but I

39:54

haven't done it. I haven't done

39:54

it. may see. When do you say

39:59

uncle and I have no idea why

39:59

that expression exists? When do

40:02

you say therapy has not

40:02

succeeded? And regaining motion

40:07

is time for a surgical tenolysis

40:07

joint release whatever is is

40:13

there a magic number? Or is it

40:13

simply, the patient has

40:16

plateaued and I can't get them over now.

40:20

The second thing

40:20

you said it depends on the

40:23

patient. But if I'm seeing them

40:23

consistently, twice a week, and

40:28

I look at my range of motion

40:28

measurements every week, and in

40:32

my assessment, I continued to

40:32

write no changes this week, he

40:36

continues to demonstrate

40:36

significant joint stiffness. And

40:39

I haven't been able to type

40:39

anything different, I get

40:42

concerned that each session,

40:42

there's no change. So I'm going

40:45

to send an email or an in basket

40:45

through epic to the surgeon to

40:48

let them know. And I kind of

40:48

look in the system to see where

40:50

they're seeing the doctor,

40:50

again, to let the patient and

40:53

the physician have that

40:53

conversation about surgery. But

40:56

to dance around your question,

40:56

there's no magic date, and kind

40:59

of just depends on how they're

40:59

progressing therapy.

41:02

So to bring us to a

41:02

close, Macy, can you give us

41:05

either one Pearl, you know, that

41:05

would make us better at

41:11

communicating with our

41:11

therapists about this, you know,

41:15

these kinds of patients are one,

41:15

you know, constantly frustrating

41:19

thing that you noticed that

41:19

surgeons do that. That makes

41:23

your life a little harder.

41:26

No, I don't think

41:26

there's anything that your

41:28

surgeons are doing that makes

41:28

our life harder. I think that

41:31

it's really important when you

41:31

go to therapy to have a one on

41:35

one session, I'm really spoiled.

41:35

And at Milliken, we always have

41:40

one therapist, one patient per

41:40

session. And particularly with

41:45

digital stiffness, that's

41:45

important to address one on one,

41:48

if you have multiple patients at

41:48

once. And I know that different

41:52

employers are, are different and

41:52

require that it's just it's just

41:56

challenging to really address

41:56

stiffness. It's a very manual

42:01

type of session. And so I think

42:01

that having that one on one is

42:04

important, and really educating

42:04

them that this does not just get

42:08

better naturally with time it

42:08

gets better naturally with

42:10

stretch.

42:11

Basie, thank

42:11

you. Your insights are gold to

42:14

surgeons who don't understand

42:14

therapy as well as we would

42:19

like. And I know it's not even a

42:19

question. I know that our

42:22

listeners are going to love

42:22

this. And thank you.

42:26

Thank you for having me.

42:28

Thanks for joining us, basically, we look forward to having you on for another

42:29

session soon.

42:33

Hey, Chris, that was fun. Let's do it again real soon.

42:35

Sounds good. Well, be

42:35

sure to check us out on Twitter

42:38

@hand podcast. Hey, Chuck,

42:38

what's your Twitter handle?

42:41

Mine is

42:41

@congenital hand. What about

42:43

you?

42:44

Mine is @ChrisDyMD

42:44

spelled d y. And if you'd like

42:47

to email us, you can reach us at

42:47

hand [email protected].

42:51

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42:51

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42:55

and be sure to leave a

42:55

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42:57

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42:58

Special thanks

42:58

to Peter Martin for the amazing

43:00

music. And remember, keep the

43:00

upper hand. Come back next time.