Season 3, Episode 49. Chuck and Chris continue with this 4 part segment on radial nerve injuries. In this podcast, Macy joins us to discuss her role in patient assessment and her perspective on both tendon transfers and nerve transfers to address radial nerve injury/ palsy.
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Listings at theupperhandpodcast.wustl.edu.
Season 3, Episode 49. Chuck and Chris continue with this 4 part segment on radial nerve injuries. In this podcast, Macy joins us to discuss her role in patient assessment and her perspective on both tendon transfers and nerve transfers to address radial nerve injury/ palsy.
Subscribe to our newsletter: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
See http://www.practicelink.com for more information from our partner on job search and career opportunities.
Please complete NEW Survey: https://forms.office.com/Pages/ResponsePage.aspx?id=taPMTM1xbU6XS02b65bG1s4ZpoRI9wlPhXnSF2MnEXxURVRNVDNBMEVSMU1CWFpIQVA4SEtMTFcyMS4u
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Listings at theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast 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 things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe wherever you get your podcasts.
Chris Dy:And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:Fantastic. Because we have another great guest tonight,
Chris Dy:we have another great guest. And I'm sure you're also excited because we're wrapping up a series on nerve and we can probably tell you at least some kind of series of sports, the kinds of things
Charles Goldfarb:you will and I think we just disparaged our guests because she's really not a guest. She's really like the third wheel kind of he or
Chris Dy:she is a recurring guest third wheel really the glue that holds us the whole show together. We don't have Basie on for a few episodes, people start to wonder what's going on. So welcome to the show. Macey.
Macy Stonner:Thank you both. I think you're giving me a little bit too much credit, but I'm happy to be here.
Charles Goldfarb:Well, you have a lot of fans out there. That is clear.
Macy Stonner:Yeah, very flattering, and really cool that you brought me on. So very appreciate
Charles Goldfarb:it. I had a great serendipitous meeting with your family this week. And I think I already mentioned it on the air. But I was down in Alabama, at the turkey trot cheering on my family because I'm too injured to run. And I met your husband who I know and your son, and most importantly, your dad and they were all awesome.
Macy Stonner:Yeah, that was so random that you ran into my family in our mutual hometown of Birmingham, Alabama this past weekend.
Charles Goldfarb:I know. I know. There was 1500 people at the turkey trot. I was a fan. I was not running. But I know that. I think your dad and is it your brother did the 10k and brother in law? Yeah.
Macy Stonner:So was it the Achilles tendinitis or the knee arthritis?
Chris Dy:Those are that's a bold proclamation.
Charles Goldfarb:So wish me luck. I'm having my knees scoped tomorrow. Oh. So hopefully we check off one problem. And then just the old age in general, be the only thing keeping me down.
Chris Dy:There's no sign of arthritis than being in arthritis denier by getting your nice coat.
Charles Goldfarb:Well, it's all about ratios. If the ratio of meniscus tear pathology is greater than the arthritis pathology, then I'm good. Let's just
Chris Dy:let it let it be told that chuck chuck practices evidence based medicine but he doesn't want any part of being signed up for a nice cup and fraying and he doesn't end up with a unicondylar knee replacement or some other craziness.
Charles Goldfarb:This is a prayer. I will say it right here and right now. But there is a meniscus tear. So let's just open it out.
Chris Dy:Tomorrow. If you ever if you ever had all of us, there'd be at least one meniscus.
Charles Goldfarb:Your ages put together probably less than mine. So I don't I don't need to talk to you guys about this.
Chris Dy:I'll stop talking junk. I operated on a patient recently who is far older than I anybody on this on this episode. And he told me he's like, When can I start to exercise again, I exercise three times a day for 20 minutes. Hey, man, that's awesome. Good for you.
Charles Goldfarb:I've told you my latest. I think I have been a lifelong hater of early morning exercise. And now I get up at a ridiculous hour to get on the bike or do something it means I'm old. What prompted the change? I can't sleep as well as I used to and I can't exercise when I'm tired at the end of the day.
Chris Dy:Got it? Well, welcome to The Club. Chuck.
Macy Stonner:The end of the day. It's like I'm done. my gas tank is on zero.
Charles Goldfarb:I know. I know. Alright, we should jump into the actual reason for our getting together. So Macy, we this is the fourth of a four part series on radial nerve injuries, radial nerve palsy. The first episode was a general discussion. And then we talked about radial nerve transfers. And we talked about 10 and transfers. And we wanted you to bring it all home and package it up for us and explain how you think about these. So Chris, I don't know if you want to start off the questions for Macy, and I'm sure you want to talk to her about nerve transfer. Really.
Chris Dy:So Macy, I'm trying to remember the exact scenario we presented a few episodes ago, but let's change the app and change the details slightly. So say you have somebody who's, you know, middle aged like Chuck states. This thing's a fall as a has a good chef humerus fracture that's closed and is treated operatively. Before the surgery, there is a noted radial nerve palsy. The surgeon did not expose the nerve as part of their surgery treated the fracture X ray looks beautiful but the patient again still has radial nerve palsy. They're in the office, they come to our complex nerve clinic that's you and I call elaborate in and say they're six weeks out now? And how do you approach that patient because inevitably, I'm going to leave the room and say, Macy, I'd love your thoughts, because you're the expert on how to help us decide what is best for this patient,
Macy Stonner:join you in a collaboration of business surgical or is not. And so if they're saying, Oh, it's getting better, it's getting better at the six week mark, correct me if I'm wrong, you might want to absorb it. But if it's, you know, you likely would order some nerve studies, and then have them come back after those are done. But I'm going to make sure that this patient is comfortable, they have some sort of splint that's going to support their wrist and support their fingers, if needed, make sure that they keep their joints supple. A lot of times these patients don't need formal therapy, at this point, just some sort of supportive splint to keep their wrist and extension, and then I would meet them again, when they come back after their nerve studies. And then you would make that call whether or not they're a candidate for nerve transfer, attendant transfer, and a lot of times we think, okay, they're more of a tenant transfer candidate, okay, they're more of a nerve transfer candidate, either personally, or physiologically.
Chris Dy:And I'm gonna, I'm gonna, I'm gonna stop you there and say, I don't make that call, we meaning you and I make that call together. Or if I'm with one of your other hand therapy colleagues, I'll make that decision with them. You know, I think that you've said it a couple of things. I'd love to know your thoughts, just your Gestalt on who you think is going to get better on their own? Because I don't think it's just me, or the surgeon who's making decision on who is a surgical candidate versus not. I think that there are a lot of clues that you as therapists pick up on to say, Hey, this is probably going to get better. I don't think that calls exclusively ours as surgeons. And then the second question of Mike, Chuck, now, when you talk about splints, are you can you tell me a little bit how you think about like a thermoplastic versus a Benick. Because I know a Benick is something that a lot of patients often benefit from,
Macy Stonner:always recommended Benik. First, for comfort, so it's softer. I think it's more functional, if it's more comfortable people actually wear it. The downside of the benek is that you have to pay out of pocket like 100, and something 120 Something like that out of pocket, and you can't get it same day. So I have to take measurements and submit some paperwork to the company. And then it comes within a few weeks. The idea of getting something the same day across the hall, but the therapist can just whip out a custom brace to support their wrist and fingers is very appealing to patients, along with the fact that that is often covered by insurance. Even though a custom one made by me or my colleagues would be more expensive than the benek. If the patient knows I can get it today. And it's likely going to be covered by my insurance that's often very attractive that as well. A lot of times patients have both, and they can alternate between the two if they have the resources.
Charles Goldfarb:So when I think of a Benick as a congenital hand surgeon Benick to me means a soft thumb spiker. What is a Benick in this situation name
Macy Stonner:is the same company as you're used to with a congenital population. But it's just a dorsal based, soft, regular palsy splint. That it's not hard, right? So it's just more comfortable. It keeps them in the same position. And it's moldable like it comes in. And then we mold it either in the microwave or on a bit of warm water, mold it to them. So it's just more comfortable because of the material. So it
Charles Goldfarb:holds their wrist in neutral is what you're saying, Does it do anything with the MP joints,
Macy Stonner:it actually holds their wrist whatever we want it to be. So I'll probably put it into 30 degrees of extension and then MP joints and thumb and full extension. And then it allows them to have active finger flexion with a little bit of passive extension when they release an object. So it's just as functional as that thermoplastic one.
Chris Dy:I do I do want an answer to the first question I asked you. But Chuck, we would be remiss if we didn't talk about our friends over at practice link before we got any further.
Charles Goldfarb:I agree and I was looking forward to sharing my my appreciation for practice link because the upper hand is sponsored by practicelink.com The most widely used physician job search and career advancement resource.
Chris Dy:Becoming a physician is hard finding the right job doesn't have to be doing practice link for free today at www.practicelink.com linkedin.com. Now Macey, I mean, it's pretty amazing that you got to hear us do that live, but I'm sure you've enjoyed that thoroughly. Let's get back to the question I want to answer to if it's possible, just Are there any clues that you get on your examination, your assessment about who early on who might get better without surgery
Macy Stonner:dependent What nerve studies show, this is just my clinical assessment in the clinic. There exam. So I have a piece of paper that has a radial nerve exam and I go from proximal to distal and I do all the manual muscle testing takes a while in detail. And then if they are starting to show that things are coming back, then sure I'm like, do you want operate on this right now? Is it going to be more optimal if we just wait for the natural recovery to come through? So it's very much based on clinical exam, starting from the top and then monitoring that from when you first see them? documenting it, and then their next follow up? Yeah, that would be like the most obvious objective clinical finding.
Chris Dy:Now you mentioned on when you talked about how we decide together about whether somebody is better off with nerve or tenant transfers, if they end up being a surgical candidate. You mentioned personality and physiologic physiologically. So can you go a little into more some detail about maybe personality, or
Macy Stonner:I want to be as politically correct as I should. But I think that there's sometimes people who get it, and people who don't, you know, and sometimes they just really understand the anatomy, they understand what's going on, they have realistic expectations of what you're telling them. And sometimes people just have an inkling that they might not be the best people to comply with that might be behaviorally socioeconomically just various person factors that you're like, would they be able to, you know, have the resources, motivation to go through the extensive nerve transfer rehab, you know, because that's a huge expense and a big commitment on the patient's end. So nerve transfers, kind of like you're in it for the long haul. Tenant transfers is as you know, a quicker fix, but also has its challenges as well. So there's no perfect, easy way out.
Chris Dy:Now, the the tendon transfers, what, for those of our listeners that are not therapists, what does that rehab look like for a tendon transfer? In terms of, you know, you mentioned things like intensity of time, like the reeducation? Part of it, like how tough is that rehab.
Macy Stonner:So I think that if patients can make it through the first six weeks following a tendon transfer, they're going to be golden. That's the hardest part, because the way I educate patients about this is, you know, your muscles have been realigned to help create this pull of the muscle and tendon unit to facilitate wrist extension and finger extension. And you really want to maintain that nice tight position for at least a month in a splint to keep it tight. If you accidentally or purposefully, let your wrist dangle, let it drop into flexion, let your fingers drop into flexion, you could lose that tension. And you might overstretch the transfer. So I always try to scare them a little bit in the beginning. So that they really buy into the idea of full time splinting for a month, because full time splinting for a month is very burdensome. And so if they buy into it, I think that there'll be fine. So anyway, it's the first month is easy in the sense of all you have to do is wear a splint, not a lot of exercises other than actively and passively flexing the finger IP joints if they're stiff, and then they come back around the month and then that's when you start attending transfer training. So typically, you would do very gentle active, wrist flexion and gravity minimize playing with attempted active finger extension. You know, gentle pronation with wrist extension simultaneously, and kind of guiding him through very gentle exercises, probably once a week for two or three weeks, and then every other week and then let them be by 10 weeks 12 weeks through done. Nerve transfers, as you know can be a year. So what's different, lengthy process go ahead.
Charles Goldfarb:Are there any factors, which you see which affect the outcome of tendon transfer, and re education or radial nerve tendon transfers, just pretty good. It gets
Macy Stonner:more difficult to get optimal positioning of the MP joints with splinting. So typically the wrist is pretty solid. But to get full MP extension, keeping the pie piece free is very difficult even for the most seasoned of splinters. And if they lose any swelling, or they put a strap on the wrong way, it can shift and then their MPs aren't supported enough. And a lot of times they fall into a little bit of flexion and then they're like that for three, four weeks and then they can't get that active zero degrees extension back. So I think that difficulties with splinting can be a problem. Page patient understanding of the diagnosis, you know, their health literacy plays a big factor in compliance with the splint all that kind of stuff. And
Chris Dy:so what It isn't about nerve transfer therapy that is so different from a reeducation perspective, aside from the frustrations of having to wait, you know, six months or four months for the lights to come on in terms of the the the signal to reach the muscle. What makes that reeducation piece so much harder? Because fundamentally, it's you know, we try to choose the nerve transfer donors based on something similar to the tendon transfer donors in terms of synergism.
Macy Stonner:Yeah, so I think that a big part of it is, again, I've said this word a lot, but patient understanding of the nerve transfer, there's countless times where I've seen patients ongoing, ongoing for months and months and months. And every time I see them, I say, what's your donor? Tell me what your donor is. And they're like, no, what? We really struggled to understand that relationship. And so I think even my, you know, quote, brightest patients really still struggle with understanding that, and it's a complex thing. And so I think that really understanding what is driving the recipient target muscle. And so once they have that, it's easy. You're just teaching them what to strengthen from a donor perspective. And then what recipient muscle you're trying to activate and coupling those two motions. So a lot of times therapists get really freaked out by nerve transfer, rehab, but if you really understand the anatomy and what the patient should be doing, it's really not that difficult.
Charles Goldfarb:So wait a second. Now you got me confused? You're telling me that, what did I say? No, no, you're telling me the patient needs to understand what Dr Dy has done with nerve transfers? Or because I don't understand, or does the patient just need to have a sense of what muscles to strengthen on both sides of the forum?
Macy Stonner:Yes, that's what it needs to happen. So I'll often write the referral and copy and paste surgeries in from the OP note in the referral. And they'll see Dr Dy's List of 17 different things that were done. And they're really overwhelmed. Like, don't worry about that. Just ignore it. Here's your donor. Here's your recipient. understand those two things, and we're going to be solid. But as simplistic as I just made that sound, it's still some difficult for patients to get.
Chris Dy:But don't they need to understand that pretended transfers anyway?
Macy Stonner:Yes. But I kind of tendon transfers as more of a like, a static transfer where like, I believe that if you have really solid splinting for a month, it's going to get there. Just keep it tight. And then yes, as tendon transfer exercises are going to augment the motion, but I don't believe that donor strengthening is as important and tenant transfer rehab as neurotransmitter rehab. This is one therapist opinion, but I feel strongly about it.
Chris Dy:Right? Well, I mean, do you see a fair, high volume of nerve injury patients between our orthopedic complex Arif clinic and all of the wonderful plastic surgery colleagues, we have WashU, who also will send their patients to Milliken. So I have a question for you. Do we ever over tighten tendon transfers?
Macy Stonner:No, no, not at all? I don't think so. In fact, I'm typically pretty conservative with my treatment of tendon transfers, meaning that I would keep them in a splint for longer, because I never really see a downfall of keeping it tight for longer. So I don't ever think that that's an issue.
Charles Goldfarb:All right, let's go back to nerve transfers, just a little slow. So you're telling me that the primary focus, and maybe I just want to be very clear, is strengthening the nerve, basically, the donor muscles because you obviously don't want those to lose strength. And secondarily, you're working on the recipients, muscles for the nerve transfer. But really, that's just a time based problem. Right? So the
Macy Stonner:visual wonderful article written by my colleague, Laura Kahn, called the Adapro approach to donor activation focus approach for neurotransmitter rehab. And so it's all about the beginning phases, flooding the donor 20 reps every hour, you know, just really giving more and more activation to the donor which will subsequently give more electrical activity to the recipient. And then in the case of MIDI into radial nerve transfers. Let's say you get a twitch of your recipient at four to five months. At that point, you start trying to do more active motion of the recipient. But in that first while while you're just waiting and waiting and waiting for the target to come back, you not only do donor strengthening but you combine donor activation with recipient target muscle activity passively. So for example, I might do like resisted wrist flexion. And using my contralateral hand, passively extend my MP joints, and then eventually just doing the recipient activation. And I think that that education is important to help patients understand that synergistic movement that has to happen together in order for the recipient to happen independently later.
Chris Dy:So when should we start the donor activation or the donor flooding? Like when should that start after a nerve transfer?
Macy Stonner:You know, a lot of the literature out there talks about a prehab appointment to really start doing that before they before surgery starts. But if I'm being honest, it never happens. Really. I think that as long as they get to that point within the first six weeks, it's great. Just even for patient understanding and patient receptivity, that first appointment is often very overwhelming, but you go through a lot of important things.
Charles Goldfarb:Does electrical stimulation play any role in the rehab of either tendon transfers or nerve transfer patients?
Macy Stonner:I would say more so with neurotransmitters, if it's tendon transfers, you know, you're trying to strengthen a muscle tendon unit versus nerve transfers, you're strengthening the nerve to go to the muscle. I don't use it that often. But I definitely think it has a role if you're struggling to find anything or, or for example, like, if patients just really can't, in quotes, find their donor like, Excuse me, find their muscle where like, it's been so long, since they have extended their wrist on their own, they just kind of really struggle to like, think about that activity, just like his loss from their brain, like the thought of wrist extension is just foreign to them. So then you put electrical stimulation on their dorsal forearm, and then it actually comes up on its own. And you're like, oh, there it is. There it is. Okay, that's what I'm trying to go for. So it's a nice patient education.
Chris Dy:So when you when you rehab our patients, after tendon transfers, you said that after about 10 weeks, they're pretty much pretty much finished. When do you think their function starts to plateau from, you know, after they've left therapy? Are they seeing a plateau and kind of got what they got by the three month mark?
Macy Stonner:Yeah, that's kind of what I was thinking like the 10 to 12 week mark, if they still haven't gotten their recipient muscle activation, and it's probably what it's going to be. I've had very few patients where the radial nerve example where they struggle getting that MP flexion back, which I don't really think is a problem, like, as long as they get their extension, I'm pretty confident that flexion is going to come back in time if they're stiff. But like for that particular patient, I don't think it's you get what you get, I think that's going to come back in time. But it's more related to the target recipient muscle activation that we're going for. So, for example, if it's 12 weeks out, and they can still only obtain negative 50 degrees of MP extension actively, I'm not so convinced they're going to continue to get it.
Charles Goldfarb:That makes sense. I would say that I share that belief. Now, to clarify, again, how this compares to nerve transfer timing. When does a nerve transfer patient like in this situation? When would you expect them to plateau? Is it? Is it 24 to 30 weeks? Or is it even longer?
Macy Stonner:I think it depends on the transfer and how long you know, that donor was to the recipient? I would say flat toe 14 to 18 months. Is Dr. Dy is that on target with what you were just thinking
Chris Dy:I was going to say 15 to 18 months? Oh, that makes. It's like we work together like we were together. You know, I saw I saw a patient recently who had a lot of physiologic things working in his favor in terms of he was younger, came to me relatively early, had the resources for therapy and even though not the most sophisticated patient intellectually you would think he was a crafty kind of guy and I think he just kind of got it even though he wasn't the most book smart guy and his result honestly, you can't tell the difference between the two sides. I mean, I very rarely hand off, you know M 5s after a nerve injury. But I almost did. But I helped my principal you could never be an M 5 after a nerve injury. So I didn't give him an empire but he looks fantastic. But it took 18 months to get there. And now he's golden. And it really is I think for patients an awful lot analogies as you know Macy being in clinic with me. But I very much like in the tenant transfers to you know, driving a Honda and the neurotransmitters saving up to driving a Mercedes or your luxury car of choice. Because you know, you're still going to get to the same place just a matter of whether you have the time and the resources to save up To get what I think is the, you know, the best possible result, but not everybody is in that, you know, even eligible for nerve transfers, which I think is the challenging part.
Macy Stonner:I think you should give yourself more credit because I heard you say that analogy the other day, and I loved it. And I told some of my colleagues Milliken, I love that. That's great. That's really cool.
Chris Dy:One on the scoreboard for me 18 For Brogan.
Charles Goldfarb:I have to say, Macy, I have heard about this same patient at least twice before. So I'm not sure how many of these almost in five nerve transfer patients are running around. But I like to hear about the same one over and over. Yeah, there are
Chris Dy:multiple videos of multiple patients. I know, we all take out our videos of our best patients, but you know, it's I think it's important. You mentioned the prehab thing, I love prehab if we can make it happen. And sometimes the prehab is just being fortunate enough to have a therapy colleague, usually it's either you or in my other clinic. You know, Jamie Findice or Kathy Dahm are losing Miyagi in the clinic with me just like, hey, I think that's good to just like this, this patient might be a good candidate, you may want to start on this now if we can.
Charles Goldfarb:So So basically, what is your I asked him this question completely? Seriously, because you may think I'm messing around. But what's your favorite thing about complex nerve clinic? Tech? What do you enjoy about? Yeah, that's
Macy Stonner:a great question. Um, well, the medical assistant that works here brings really good snacks. And so that is, primarily what keeps me here. But after that, I got as a great question. I love the way that Dr. Dy uses my services. He really values me as an OT. And I really feel like a valued member of the team, where he says, hey, this person could benefit from you. Can you please help make him better? Can you please help educate them on expectations? Thought can transfer? Can you please evaluate him from a therapy perspective and tell me what I'm missing? So I feel like every room I go into, like, what I'm coming out to share, he values a doctor broken the same. So I love feeling valued. And I really love that each patient is like a puzzle pieces like, hey, what's working? What's not? What, how can we make him better? And so I leave clinic on Thursday nights when I hit spin, but I feel good. You know? So I, I like it for a lot of reasons. And I hope that another therapist doesn't come in and slip in and take it from me.
Chris Dy:Oh, that's so thank you to both of you. That was a wonderful holiday gift. I really appreciate that. It's it's a fantastic collaboration, I can't see the clinic being any other way. You know, when we, when Dr. Brogan and I designed it, we designed it heavily on what a lot of other centers do. And I think that we're even trying to make take strides to make it even better in terms of, you know, where we can go from here, really upping our education game and improving collaboration. So, you know, this has been super fun. And obviously, all of our complex nerve clinic collaborations are fun. We'll see in a couple of days for it. But thank you for sharing your expertise with us today.
Macy Stonner:Thank you so much for having me.
Charles Goldfarb:It's been super fun. And just for the listeners may seen I grew up probably 10 miles from each other. And we sound exactly the same doorway.
Macy Stonner:Do you think that I have a southern accent? No.
Chris Dy:There's definitely a substantial amount of yours. As soon as you show up.
Charles Goldfarb:When I hang out with basically too much the accent gets a little stronger.
Macy Stonner:Oh, yeah. When I see my friends from home, it's it's real thick y'all.
Chris Dy:chuck chuck your I think you're like a chameleon because I heard when you when you were hanging out with our fellow from last year Elspeth Hill, I heard that your your British accent suddenly came out so that this all right there multiple, multiple, multiple accounts that may have happened. All right. Well, you guys have a wonderful evening. Thank you both.
Macy Stonner:Are you too? Bye, bye.
Charles Goldfarb: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 d-y. 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 podcast
Chris Dy:and be sure to leave a review that helps us get the word out. Special thanks
Charles Goldfarb:to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time