The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck, Chris, and Macy Discuss the Thumb CMC Joint, Part 1

June 05, 2022 Chuck, Chris, and Macy Stoner Season 3 Episode 21
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck, Chris, and Macy Discuss the Thumb CMC Joint, Part 1
Show Notes Transcript

Season 3, Episode 21.  Chuck and Chris welcome hand therapist Macy Stoner back to the show to discuss the CMC joint.  Macy shares her thoughts on the role and specific modalities for nonsurgical care as well as thoughts on recovery post CMC arthroplasty.

Article referenced: Outcome of a Hand Orthosis and Hand Therapy for Carpometacarpal Osteoarthritis in Daily Practice: A Prospective Cohort Study.
Tsehaie J, Spekreijse KR, Wouters RM, Slijper HP, Feitz R, Hovius SER, Selles RW.
J Hand Surg Am. 2018 Nov;43(11):1000-1009.e1. doi: 10.1016/j.jhsa.2018.04.014.
PMID: 29776723

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Charles Goldfarb:

Welcome to the upper hand, where Chuck and Chris talk hand surgery.

Chris Dy:

We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.

Charles Goldfarb:

Thank you for subscribing wherever you get your podcasts.

Chris Dy:

And be sure to leave a review that helps us get the word out.

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm good. I'm happy to be back at it with you.

Chris Dy:

Oh, it's always good. It's always good. I feel like you know, it's it's the right time for a podcast episode, especially one with our friend and hand therapy expert colleague Macy.

Charles Goldfarb:

Welcome, Macy.

Macy Stonner:

Hi, thank you so much for having me back again.

Charles Goldfarb:

Well, it's not like we had a choice. I mean, the people when the people clamor for a guest we have to deliver.

Macy Stonner:

Man that is so flattering, but I'm glad to be here.

Chris Dy:

Macy are you podcast famous.

Macy Stonner:

Dr. Dy. Don't make me embarrassed. But yes. I recently have been identified from a surgeon in Chicago, which I was very flattered by. And yeah, I appreciate the publicity.

Chris Dy:

We're happy to make you even more famous than you already are.

Macy Stonner:

Thanks.

Charles Goldfarb:

Absolutely. And Macy did you know and you must, because I think you maybe jumped in the shower before the episode, but we do we do put this. We do put this on YouTube. We are going to video. So thank you for-

Macy Stonner:

Oh, well, that's good, because my hair is wet tonight. But sorry about that.

Charles Goldfarb:

No, no complaints. I'm just telling you. YouTube is growing in popularity. And we have our channel. And so hopefully you're okay with that.

Macy Stonner:

Actually did not know that. But I'm fine with it.

Chris Dy:

Wow, informed consent huh Chuck. Is that how it goes?

Charles Goldfarb:

That's how it goes. So I want to share with you guys I just did a little mini mission trip. And it was pretty great. Lindley Wall and I work with the world pediatric project, which is really a fantastic group. They are based in St. Louis and Richmond but also expanding across the country. And we did something a little different. It's a little crazy. But I flew down with Eric Gordon, one of our pediatric partners along with a nurse Melissa, and a hand therapist extraordinaire, Lauren, and also an orthotist. And we flew down for the weekend to Barbados now, Barbados is not next door. But we made the trek when we made the trek. We left super early Friday morning. We saw a ton of patients on Saturday, and we flew home on Sunday. So it's a little whirlwind. But Barbados is an amazing Island and there was there's a lot of unmet need. And so it was really great. And it was super fun to work closely with Lauren. We basically the two of us were in the same room from a little before 8am till about 6pm Just seeing patient after patient after patient. So it was awesome.

Macy Stonner:

Talking about our Lauren, Lauren Leone.

Charles Goldfarb:

I am I am.

Macy Stonner:

Oh, man. I did not know she was there. That sounds great.

Charles Goldfarb:

Yeah, it was it was perfect. And then she embarrassed me on our runs because I can't keep up with her. So.

Macy Stonner:

That sounds about right. Is it your knee arthritis or your Achilles tendinitis this time?

Charles Goldfarb:

Oh, well, how much time do you have? I'll tell you about all of my ailments. You youngsters don't know what happens after 50.

Macy Stonner:

I'm just kidding.

Chris Dy:

Chuck I did like day over the weekend and I completely regret it. I really need to stop listening to my wife that I need to work on my legs. But that's my current ailment.

Charles Goldfarb:

Yes, indeed.

Chris Dy:

So Chuck, Chuck, two things.

Charles Goldfarb:

Oh, alright.

Chris Dy:

One, how was it hanging out with Rihanna? And then to what are the greatest unmet needs you think and from just pure pathology perspective? What conditions were you seeing down there?

Charles Goldfarb:

What was cool about this trip is that WPP partnered with this called the Sandy Lane Charitable Trust and for anyone who knows anything about Barbados, Sandy lane is a super high end hotel where we did not stay but we did stay in an associated villa, there's a golf course and there's beautiful homes, including I think Rihanna's and Simon Cowell's so we it was really it was really nice and we did have brunch invited by the head of this trust there. And so it's it was really cool. The what we predominantly saw were patients with untreated upper extremity CP and birth brachial plexus palsy. And we I think we need to just streamline things because we didn't see a lot of congenital we didn't see a lot of trauma which we could have and should have. Maybe we needed one more day of clinic and the whole goal of this trip was to I set things up for more of a surgical trip in the future. So that was great. I'll tell you, Chris, I saw one thing that will make you excited because we have to always talk about nerve you and I understand the ground rules. And so basically, and I'll give a shout out to Scott Kozin, he had seen one of these children, and the child had no active elbow flexion. And I don't know exactly what he did, because I didn't have the Op Report. But essentially, he didn't some type of intercostal nerve powered transfer. And the kid had, like, incredible active elbow motion. It was awesome. Even I who don't love any of that was super impressed.

Chris Dy:

I think it goes to show you, me and intercostals are, they're reliable transfer, they're a pain in the butt to do. They're not always an option. They're less sexy than a double overload or double fascicular transfer. But, you know, even the pooled analyses and literature still show they've got pretty good success rates a lot better than some of the other stuff we do on a routine basis for brachial plexus. So actually, since we have Macy on the on the episode, I wanted to ask Macy, what do you think are the tricks to nerve transfer reeducation for intercostals? I mean, clearly, it's it's a little bit easier in the child, I would think, you know, in terms of them figuring out how to use it, but how do you approach that in an adolescent and young adult or an

Macy Stonner:

I agree with you about the children. I feel like older adult? for them, it's a little bit more intuitive. I don't see a ton of that with kiddos, because I feel like a lot of times formal therapy may not be as crucial in terms of consistent therapy as some of the adults. So they kind of just figure it out. But I think for the adults, teaching them a lot of exercises in supine, and kind of interweaving nerve reeducation with some bed mobility type things as you're already laying in bed and incorporate some exhalation, some abdominal stuff, breathing techniques, in terms of coordinating that with elbow movement as well.

Chris Dy:

I remember when I visited David Chuang in Taiwan, where they use both intercostals routinely, but also the phrenic. They would just have their patients go on hikes, all the time. All sorts of aerobic activity, especially in you know, higher, higher altitudes.

Charles Goldfarb:

That is cool. But I'm going to say that we're not going to hijack this episode and talk about nerve.

Chris Dy:

Okay. Wait, I got I got one thing to add, though. So we got so since our last episodes, we've had some great listener email. And this is one where I think we could piggyback on a prior episode, that the one where we talked about nerve injuries after carpal tunnel release. And I just want to read one question from a listener and maybe you could give me your thoughts since you taught me how to do a carpal tunnel release.

Charles Goldfarb:

Okay, I'm a little nervous, but shoot.

Chris Dy:

And then we'll jump in with Macy and we'll talk about our therapy episode. So Brad Hyatt writes us he's an orthopedic surgeon says he loves the podcast. So thank you, Brad, for listening and for telling your friends and for emailing us. He's an orthopedic hand surgeon practicing about five years. He said, It's a special interest, I listened to your latest episode, the day before I had undergone carpal tunnel release myself. Fortunately, I underwent a wide awake procedure by a trusted colleague and friend, everything went smoothly. I'm wondering if you might be willing to share your thoughts on the cause of the nerve injury that you described. One of my least favorite parts of an open or mini open is what I call a controlled glide technique to release the proximal aspect of the TCL slash distal volar interbrachial fascia. All the technique articles and videos described as being performed under direct visualization. There are times when this glide is not quite directly visualized. I have occasionally extended the incision proximally but dislike the prolonged healing and wider scar when crossing the wrist crease. I have been attempted to perform a scissor glide without 100% visualization. This can be so routine and seems safe that the consequences of an error can be catastrophic. I can't help but wonder if this is what happened in the case you presented. I'm interested to hear your thoughts of a ticks or tips or tricks for the proximal release. So Chuck, can you help enlighten Brad?

Charles Goldfarb:

Well, I don't think I could have said it any better than Brad wrote it. I really liked how he outlined that. I do agree that I would expect that many if not most of the nerve injuries with carpal tunnel are related to scissor you know, sliding or gliding or whatever you want to call it, which also comes to the point of an endoscopic release, because that's what you're doing with an endoscopic release. But Brad is right. You have to visualize so I was taught to do a carpal tunnel by Tom Kiefhaber in Cincinnati, and he really uses three instruments and three, three retractors and that is two Senn rakes and a ragnell. And I love his technique. And as Chris says, you know two of my partners who also trained in Cincinnati use exactly the same technique. And when we dissect proximately, we created simply a little box, three sides of a box where two of the retractors are. One is pulling them from the ulnar side, one is pulling from the radial side, and one is pulling from the volar side. And so you have basically three sides. And that the bottom of the box is the interbrachial fascia or proximal transverse carpal ligament, and then you you have visualization. Now, I think in the right setting where you have visualization, occasionally I will slide a little bit but I think, you know, you have to be super careful. And you can flip that around and go the other direction. Now. I never slide just aiming distally. I think that is controlled cutting. And I think as I recall from your previous description of the case, it was a distal, I think it was a distal injury, the nerve, but I think the most common injury, oh, your case was proximal. But as I recall, the most prominent injury with carpal tunnel release is distal is the common digital nerve to the ring and middle. So I think the lesson is don't don't slide even if 99 times out of 100. It's safe. That's my take.

Chris Dy:

Yeah, I agree with you entirely. I mean, it's it's just such a surgery that should go well. And I think anytime you introduce any variability in that, like, I try and train with somebody else who did the slight technique and residency, and it will always worked, then, but what if it doesn't? And you know, I think I agree with Brad and what you're saying, Chuck, the fit that was probably the cause of this injury, did another case pretty recently with like four revision surgeries in the same day, and I don't know what I was thinking when I booked them. But it was an incomplete release. So it was the other side of it. It was that same tissue that wasn't released. I use the key fob or box technique. I modified it a little bit, but I think it's no sliding all under direct visualization. Because if you're tenotomies catch on something here tenotomy blade isn't sharp and you're pushing more than you are, than you want to you're going to catch something in your in the bottom time of your tenotomy. And that can be very, very, very bad. I remember reading an article that was written by a group of hand therapists who mentioned the the potential risks or the advantages, the pros and cons of open versus endoscopic carpal tunnel. And yes, the endoscopic patients anecdotally in their experience tend to get back quicker. But what if you have that one injury, that's a catastrophic and devastating injury to the nerve? And you clearly don't want to be that one patient, even if it's less than 1% for that one patient that really matters.

Charles Goldfarb:

Yeah, well said, Macy. Have you dealt with a lot of or seen? Hopefully not many? Have you seen many, many nerve injuries with carpal tunnel release?

Macy Stonner:

Yes, I have two on my schedule. Right now. Unfortunately, were both endoscopic. And both of the surgeons unfortunately, lacerated the ulnar of one of them was the ulnar nerve one of them was a median nerve. So they've had a much more complex journey. So in that particular case, sure, I've met them and we'd get to know each other well, because they have a long journey ahead of them. But and more of the standard. Are you talking open or endoscopic I'm sorry.

Charles Goldfarb:

Either way.

Macy Stonner:

Either. So endoscopic, only there's a complication for sure. Open. Not often, but typically, if they have a little bit more of a high demand job, or they're concerned about strength or getting back to a particular activity, or job, or they have a particularly high proclivity for scarring.

Chris Dy:

Well, Brad, thank you for sending in that email. And if anybody else has some thoughts about the proximal release technique, please, please, please email us. Let us know. Chuck, did you have something you wanted to add?

Charles Goldfarb:

Well, only Yeah, thank you to Brad. We're we always welcome comments and questions. It's just great fodder for discussion. We are this close to what you're all waiting for that is Macy expounding on the CMC joint because that is our topic. But Chris and I are doing something super fun. We will both be in London for the IFSSH in on Wednesday, late afternoon, I believe it's 530 or 545. We're going to do a live taping of the upper hand at IFSSH. So we hope that if there's a few listeners who might be willing to join us, Chris is going to bring some swag, I hope and it'll be it'll be super fun. And it might just be Chris and I talking in a big room. And that's fine, too.

Chris Dy:

It'll feel like conference many years ago. But so yeah, it'd be really fun. I think if anybody wants to join us, well, it's going to be in the meeting program. And we'll send out some promos and stuff. I think it'd be great if you guys wanted to join us. Show us some UK and International Love and pick up some swag. So and Chuck will be signing autographs on any textbook that you bring him that day. Promise.

Charles Goldfarb:

As usual, alright, Macy. Yes, we want you to teach us tonight and honestly, this will be an education for at least me. I don't want to speak for Chris, about how you conceive of care of the CMC joint. And I think we should really probably focus primarily on non operative care of CMC arthritis, the role, your success, what you think is important. And then we if we have a little time, we can also discuss how you think about post operative care of CMC join after various surgeries. So you up for that?

Macy Stonner:

Yeah, that sounds great.

Charles Goldfarb:

Okay, which patients? Well, let me just let me give a case scenario. We have a young, vivacious 54 year old male, older than me, who has Eaton stage two CMC arthritis, so not terrible. His no dramatic subluxation of the CMC joint, no contracture. His MP joint is stable. This is his dominant hand. He says that, you know, sometimes he's okay, it does seem to flare now and again, opening jars is tough, he has to ask his kids or his wife to help. And he just wants it to be how it used to be. And so he was sent to you. What do you do with them? What do you tell him? Can you fix what ails him?

Macy Stonner:

Sounds fun. Okay, first of all, I think this patient has the perfect opportunity to actually improve in fit conservatively in therapy with this diagnosis. First of all, it's moderate severity, as you describe, is a guy, anecdotally speaking, I just feel like men do better, they have stronger hand, stronger joints, dominant hand. So I would if I'm in your clinic, I would write on the referral the following. Please see in therapy, two to four times, or as needed for up to eight weeks, etc. And then I would not necessarily say strengthening, I would say please instruct in activity modification, joint protection, education, orthotic needs as needed. And then what I would write as a Miliken therapist would be in stabilization exercises. So in a way, that is considered strengthening, but it's not strengthening, like one would think with weights or bands or therapy putty or anything like that. So anyway, I would meet this gentleman, on the very first day get a history of how long this has been going on. Have you had any injections, what are your goals, what hurts, and then I would evaluate him if he doesn't have any obvious deformity, no subluxation, he doesn't have a zigzag posture. He doesn't collapse as the MP joint with pinching. I'll go straight into showing him the anatomy book and kind of highlighting the beak ligament. And what happens is kind of what the posture that we're trying to avoid and kind of, I always kind of show this picture of like, advance CMC arthritis so like the zigzag. So like, this is what we're trying to avoid, you have a really good opportunity now to prevent it. And as a hand therapist, we all know that I can't take away your arthritis, but I can offer you something. So since the problem is, you know, your ligament that keeps your CMC joint stable, I kind of describe it in layman's terms, like, it's not really holding everything together as tightly. And so when you pinch something, that's where you feel pain, I can't tighten up your ligament, necessarily, but I can potentially fabricate you a splint that's going to keep that CMC joint somewhat suspended, keep you from having repetitive motion. And really, it's for pain relief. So for pain relief. It's to keep your thumb in a good position. And in theory, I guess it would be to, you know, tighten up your ligament I guess, because there's no magic exercise that tightens ligaments. It's short of immobilization. So that would be one of the main things I do is educate them on what a splint can do. I don't ever force it on them. I explain. This is what it could do feel free. I can make you one today or think about it in the future. Um, do you have a question?

Charles Goldfarb:

Well, yeah, I mean, I think we can break it down and ask kind of what you said a lot of really, really.

Macy Stonner:

I know I have. I'm particularly passionate about this subject. So you got to stop me. So.

Charles Goldfarb:

Chris, you go first.

Chris Dy:

I'm so happy that we have two people on the podcast that are experts and passionate about thumb CMC arthritis, Macy and Chuck. So when you talk about joint stabilization, what exactly does that meet? And then, you know, you mentioned What was the other the? I'm trying to remember the other term that you use. I thought that was interesting. It was regarding.

Macy Stonner:

Was it activity modification?

Chris Dy:

No, I think I understand that one, it was one of the first things you stated.

Macy Stonner:

Joint protection?

Chris Dy:

Joint protection. That's it. So tell me about joint stabilization, joint protection, what those are and how they're different.

Macy Stonner:

Great. So joint stabilization, is what everybody thinks of when I think of therapy, physical therapy, like occupational therapy, exercise based treatment. So the classic pattern of deformity that we would see would be CMC, flexion, and knee joint hyperextension. And so we explained that this is maladaptive. This is not going to contribute to a healthy posture long term, you're gonna have pain. So we want to try to encourage the opposite motions. So we want to help encourage CMC extension, and MP flexion. And so there's an exercise and if this is truly going to be on YouTube, with my wet hair, here, I can demonstrate for the camera. So I can make my thumb collapse, if you can see the lighting, my CMC joint flexes, and my MP joint hyperextends, somewhat mild. And so a lot of people come into the clinic, and that's what they do. And then I always start with saying, Okay, make an O make an O with your thumb and index finger. And then sometimes they can't do it, it looks like a D, or like this, and they cannot rotate that first metacarpal to make it Oh. And so I tried to help encourage them to work on this motion, whether you know, actively with what we call the therapy lingo, like a place and hold or you passively pull your CMC joint back into extension, let go and hold it. A lot of times, that's very, very difficult for patients to do. An exercise is also to hold on to a pen, pretend like you're writing and that helps encourage really good mechanics of the CMC joint. So anyway, I explain make an O with your thumb and index, transition that O into a C. O into a C, and it really helps activate, you know, EPL, EPB, all those things that are helping bring that CMC joint into extension. And then trying to help keep their MP joint flexed. And then I always say, so why does this matter? Why are we doing this exercise the same silly. And then I shows we have a little booklet at our clinic that kind of shows somebody's thumb's doing various things, opening a jar squeezing toothpaste, with good posture and with bad posture. And we go through it together in a booklet and say like, which one looks good, which one looks bad, this exercise matters, because long term, it's going to help encourage more healthy thumb mechanics. You know, like I said before, I can't take your arthritis away, but in a way, I can kind of re educate your muscles and beef up the muscles that surround the joint to give some sort of dynamic stability to the joints and you have less pain long term to maybe prolonged your need for an injection prolong your need for surgery, just give you a little bit more of a healthy thumb posture. So anyway, our exercise handout says make an C, make a C, lift your index finger that activates your first dorsal interosseus. So we're trying to really activate you know your opponents, your first DI working on that nice, healthy posture of the thumb.

Charles Goldfarb:

I love that and I assume this is an hour long visit your first visit with them.

Macy Stonner:

Depends on which therapist you're talking about. For me, it would be an hour, sometimes it can be 45 minutes, depending on if I have to make a splint or not. And some patients just kind of get it quickly. And they really really understand the anatomy you're talking about. Sometimes patients you can tell they're not really grasping at all and you can have to just be a little bit more simplistic with your language. But definitely 45 minutes to an hour.

Charles Goldfarb:

So describe the splint that you custom fabricate for patients. And then I guess more importantly tell them tell us, teach Chris and I how you instruct the patients on wear. When should they wear it? How long should they wear? When should they not wear it? I'm sure we all have our own anecdotes but just tell us what you tell them.

Macy Stonner:

So I will fabricate a very low profile, I think, some Spica splint with this thin material that has aerated holes in it. It's not as robust as what I would make for somebody who had a wrist fracture, and I fabricate it on them and kind of push their CMC back into a little extension, a little bit of palmar abduction and then MP flexion their wrist and thumb IP joint are excluded. And then it kind of mirrors that same shape of the O that we've been trying so hard to you know work on with the exercise. And I often will say where as much as you can tolerate for two weeks, especially if they had injection. And then after that, as needed, if you have pain only at work or while you're doing things around the house, wear during those activities to prevent, you know, repetitive thumb movement to help give you a little bit more support. You know, that would be my preference. A lot of people can't tolerate it all day because it is somewhat restrictive. But I always say it's restrictive intentionally. So some people can only tolerate wearing them at night. That's still a win for me, because they're getting some sort of support. But I would probably, you know, go from two weeks full time except for hygiene or you just need a break, to just during functional daily activities, and then just PRN.

Chris Dy:

How do you have them. I was gonna say, how do you have them alternate between something like that custom orthosis? When you say thumb Spica. I'm assuming you mean something that's forearm based. Versus can it be a hand based splint? Or? I've seen patients come in raving about comfortable braces, push braces, what's the role for those kinds of things?

Macy Stonner:

Sure. So I actually only wear fabricate the forearm based ones if they have carpal tunnel as well, for nighttime or if it's a post operative case. So in the standard CMC, conservative management, I always make it hand based. The comfort cools, man, you're asking the wrong therapist, because all my colleagues adore them. I think they have a role, but I'm not a huge fan of them. I just, they're more functional because you can move better, but they don't support the CMC as well. And patients anecdotally say they don't have as much pain relief, but they have more function. So that makes sense to me. But I will give them out. On the rare occasion if somebody needs them for yoga, or for cycling or for gardening, and they just can't use their custom plastic one because it's too restrictive. I wish we had the push ones, as you describe. We don't I actually like those pretty well for the CMC joint because I feel like that helps support them and pushes them into extension a little bit. But it doesn't do anything for the MP joint. So they have an unstable MP joint that collapses anytime you pitch something. I don't necessarily think the push splint is for that person.

Charles Goldfarb:

Why don't we stop there? This has been incredibly informative. And I know you have a lot more to share about that thumb CMC joint. But this has been really good.

Chris Dy:

Yeah, thanks, Macy. I turned I learned a ton and I look forward to hearing more from you on our next episode. And just a reminder, if anybody wants to email questions to Macy, or to Chuck or to me, but really Macy, you can hit us up at handpodcast@gmail.com.

Charles Goldfarb:

All right. We're back next week and we'll dive deeper on the CMC. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy:

Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb:

Mine is @congenitalhand. What about you?

Chris Dy:

Mine is @ChrisDyMD spelled Dy. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your podcasts.

Chris Dy:

And be sure to leave a review that helps us get the word out.

Charles Goldfarb:

Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time.