Episode 27, Season 2. Chuck and Chris are joined by OT Macy Stonner to discuss therapy after finger fracture and therapy for the stiff finger. Macy shares various tips and pearls to maximize patient outcomes.
We referenced an AAOS ICL published here: Post Traumatic Reconstruction of the Hand. JBJS 89A: 428- 435, 2007
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
Episode 27, Season 2. Chuck and Chris are joined by OT Macy Stonner to discuss therapy after finger fracture and therapy for the stiff finger. Macy shares various tips and pearls to maximize patient outcomes.
We referenced an AAOS ICL published here: Post Traumatic Reconstruction of the Hand. JBJS 89A: 428- 435, 2007
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
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 doing really well. How are you today?
Chris Dy:I am well it is. I'm visiting family in Houston, Texas. And it is god awfully humid here. It is very different than St. Louis.
Charles Goldfarb:Summer in Texas. And people think St. Louis is hot.
Chris Dy:Yeah, no, but I have been spending some nice quality time at the at the pool with the kids. My son is essentially a fish now. He can swim on his own, which as you remember is very different than last summer. So now I'm working on a three year old.
Charles Goldfarb:I love it. Well, we have a really special guest today who can absolutely relate to hot because she was born in the really warm climate. I think she was born in Birmingham, Alabama. I know she grew up there. So we are lucky enough to have Macy Stonner back with us.
Chris Dy:By popular demand.
Charles Goldfarb:By popular demand for sure. Welcome back.
Macy Stonner:Thank you so much for having me back. It's a pleasure.
Charles Goldfarb:So Macy, for those of you who maybe have tuned in and hadn't caught all the back episodes is a wonderful occupational therapist. And it really we should be addressing her is Dr. Stonner.
Macy Stonner:That's definitely not necessarily.
Chris Dy:Her parents are probably like, Yes, of course. Why would you not call her Doctor.
Macy Stonner:They actually would say that. But no, not for me.
Charles Goldfarb:Oh, Chris wants me to call him Dr. Dy and I just had I don't know, I don't know.
Chris Dy:Well, Macy thank you for joining us. We're gonna do a nice follow up on our prior stiff finger episode. But before we get rolling, if you let us just kind of read a review and maybe bring up a case presentation that I think will start the discussion. So thank you to BrittMitchOTRL for this great review that you left five stars The only way to do it, and she actually left questions, so we have to answer them on the air. But says Chris, and Chuck, I am an OT who is working in a hospital based orthopedic hand clinic, I am two years into my journey to become a CHD. That's awesome. Good for you. I've been a practicing OT for five and a half years. I want to thank you all so much for taking the time to have a podcast dedicated to hand surgery. I listened to your podcast every time I'm driving into work and taking my young kids to their swim lessons. There you go. I've done that swim lesson thing many times. Now. Hopefully you're not getting in the pool like I have to. I have found it so helpful for my studies and for treatment. You are all awesome. I do have a couple questions if you don't mind answering them. So let's take the first one, Chuck, how often do you communicate with your hand therapists? Do you round with your hand therapist? If so what do you recommend on how to implement rounding and or more frequent communication? I find it difficult to speak with the hand surgeon I work with due to them being so incredibly busy. Let's start with that.
Charles Goldfarb:Well, first of all, I'm not sure what this rounding thing is. I believe that's a reference to the hospital which I try to stay out of. But seriously, it is a really good question. So I am fortunate enough to a couple times a month work with Macy. And weekly I work with Stacy Baker. And we obviously communicate during those times we are in clinic together. But I would say honestly, in some form or fashion, I have communication with a therapist every day, whether that's by email, by phone or in epic, we communicate and so to me, while I guess some might consider it an investment of time, it is a no brainer. Because the therapists are working towards the same goal that I am, which is, you know, outcomes. Is that Is that how you think about it, Chris or and then maybe Macy could chime in.
Chris Dy:Yeah, I mean, I you know, I don't spend much time in the hospital with regards to inpatient care, just by the nature of the practice. I have, you know, whenever we do have somebody either you know, somebody who's a trauma patient, or a Plexus post op who stay in the hospital, we do communicate with our inpatient occupational therapists, like Chuck, I work in a model where I'm fortunate enough to have had therapists in our clinics at all times. So that's been really useful in terms of not only the expertise that they bring to the clinic sessions themselves, but also the, the communication. It makes it they're an extension of my practice, in essence, although you know, they are they're definitely a distinct entity on their own. It makes people think that we are just this great team, which we are, but obviously, the optics of that are super important. I guess in terms of advice, you know, what I on the surgeon side, what I Tell all of our graduating fellows is check out the hand therapy environment where you're going to start working. And if you can try to find a way to have a hand therapist seeing patients with you in the clinic, it's obviously an investment on their end in terms of time that they're not in the office, so called opportunity cost. But the relationships and the referrals that come out of that I think are super useful. Macy, what are your What are your thoughts about the communication aspect of it?
Macy Stonner:Well, I am incredibly spoiled, because the only job that I've ever had is at the Milliken Hand center where we collaborate very strongly with the physicians next door. And so I have been very spoiled with that relationship. And I really value it. One thing that I really love is, as you mentioned, the fellows Skye Halverson and Sandy Gephardt if you're listening, I love it when I get phone calls from old fellows to our to our hand center, and they're like, Hey, we're now have our own practice now. And we don't have a hand therapists on staff or I don't know them very well, can you tell me what you do for tendon transfers for XYZ or whatnot. And so it's just kind of fun.
Chris Dy:So let's go to question number two. So regarding the podcast about nerve reps, what has been your experience was with placental graphs for wrapping nerves successful or not successful in reducing adhesions? I will say I've read about this. But I have not used placental grafts, mainly, because I think I have some better options. I typically in some of these cases will go with a autologous vein wrap as opposed to a commercially available wrap. And I know that that's going to generate some controversy, and we have some sparring partners with regards to that. But I haven't had to go to placenta. Yet, as Marty Boyer says, never say never, never say always but I don't ever envision myself using that. Chuck, do you ever see yourself using placenta?
Charles Goldfarb:Well, I you know, conceptually, the placenta is kind of held up. Like some of the injections are held up as the cure all for anything and everything. I obviously have no experience with that. But you know, we are we are just at the beginning of understanding the processes of scarring and solutions to scarring. And so I certainly have an open mind but no experience.
Chris Dy:So thank you so much for that review. We love it. We love getting questions from everybody. So please get on to Apple iTunes. And leave us a review five star review. If you feel like it. Well really should the only option to be a five star review, and then leave a question or a comment and we'll read it on the air. And Chuck, why don't you set us up for today's discussion.
Charles Goldfarb:Perfect, perfect. So let's present. Maybe we'll take two case scenarios and ask Macy's wisdom and her thoughts on how she handles a patient like this. So let's just start with maybe a simplistic 25 year old who has a have. Let's start with a simplistic 25 year old who has an oblique fracture of the proximal phalanx which is displaced and shortened. The surgeon takes the patient to the operating room obtains a near anatomical close reduction and places to K wires 0.045 For this example, so good solid k wires, caps those K wires, places them in a splint and sends them to Macy for care. So the first question I have may see is when would you most prefer to see that patient post op? Do you want to see him day two? You want to see him day 10? When would you like to start?
Macy Stonner:I guess this is somewhat arbitrary. But I guess in my head, I always have five to seven days. That's typically when I would start moving them actively. I feel like a week is a little bit on the later end, two days is definitely early. I think pain might get in the way. Five to seven days is pretty standard.
Charles Goldfarb:So you're looking for a time where you know I'm gonna put the patient in this example it says a little finger and an ulnar gutter splint. Hopefully, any discomfort calms down, any swelling might calm down. So you're looking for a time when the situation is good to start motion. Okay, and then reasonable patient, you believe this patient will be compliant. talk through kind of what type of resting splint you consider and how you start the patient moving.
Macy Stonner:Sure, so day one, I would do a lot of education, edema management, wound care type stuff, make them a custom orthosis ensuring that their PIP joint is in perfect extension. those nasty keloid fractures get an extensor lag or PIP flesh and traction are pretty easily so adequate splinting is key for that. And then in terms of flexion teaching them active tendon glides to start just something very standard very simple. And then I would see them back weekly, twice. Depending on the patient's personality, depending on how stiff they are, depending on their insurance, depending on how close they are to therapy, all these different factors, and I would reevaluate them, if they're still really stiff, I would start them on, oh gosh, isolated joint blocking, potentially passive flexion. If the surgeon allows it, and if they tell me that the fixation is solid, and depending on pain, you know, if their pain level is above five, I'm not gonna do passive motion. So there's no protocol, that word is very, I don't know, I don't follow a protocol just kind of depends on the surgeon, the patient surgery, the therapist, it's kind of all altogether.
Chris Dy:So you mentioned all the various things that help you decide how frequently you see patients. What are the red flags? Like? What are the things that when a patient comes in, that you assess, they're like, Ooh, this patient either needs to come in more frequently, or I know that this patient is going to have a really hard time.
Macy Stonner:Let's see. So the way that I decided I need to come in more frequently is if they seem as though they're going to be non compliant, or they might not have understood my instructions. So they require repeated instructions, just to understand simple active range of motion. If they seem like the type that's going to be non compliant with their splint, or the activities that they choose to do, I might have them come a little bit more frequently. And if they come in with total active motion of 10 degrees, 20 degrees, and it's just very, very stiff. I'm going to say, Oh, you need to send me again next week early. So there's just a lot of different factors at play. And
Charles Goldfarb:So a comment and kind of follow up. So first of all, I assume, would more than typical swelling, be another reason that you would be concerned and maybe bring them back or take extra care with them?
Macy Stonner:Yes, for sure. Particularly because as their swelling goes down, their splint is not going to be comfortable. And they're going to slide around in that splint, maybe their PIP joint might flex a bit in that ulnar gutter until they might get a lag. So definitely edema plays a factor there. And I would have to come back earlier.
Charles Goldfarb:Perfect. So let's let's get a little more detailed. You threw out some terms, which are great, which I you know, I assume I understand. But let's be real, I may not.
Macy Stonner:Oh my gosh, what did I say?
Charles Goldfarb:Well, no, you just I think some people will not be familiar with the term. So tendon glides, you start them on some tendon glides. And you said that kind of at the clinic of visit number one, be very specific. What do you mean by tendon glides?
Macy Stonner:Sure so a tendon glide is something that enables the FDS and the FDP tendons to glide freely. So I might have give them a very simple handout that has a picture of somebody making a fist, somebody making what's called a hook fist, where their MP joints are an extension, their PIP and DIP joints are in flexion. And then a photo of what's called a flat fist or a straight fist with our MP joints or flex their PIP joints are flexed but their DIP joints are straight, and that enables FDS excursion or PIP joint flexion. So it's a lot of hand therapy buzz lingo. But it's something that is somewhat simple for somebody to understand just to get active movement trying to facilitate a functional fist before we get fancy into any other thing. So that's kind of where we started initially.
Chris Dy:Let's talk about blocking exercises. What does that mean?
Macy Stonner:So blocking blocking is where well, let me backtrack a second, tendon glides is when all four fingers are moving in unison. If you do blocking, that's where you do each finger moves in isolation. So if you're really stuck in the scar, or you need a little bit more advanced movement, you might have them do isolated PIP joint blocking when you have the opposite hand support the proximal phalanx to encourage FDS glide, and then you move distally you block the middle phalanx when you have them do isolated DIP flexion. And so it just enables more advanced movement of the joint if they're not getting enough excursion of their tendons.
Charles Goldfarb:Do you have you know, you are very careful about stating you splint with the PIP joint and extension. If you and therefore the patient is good about wearing the splint, I assume therefore, your primary concern then is working on flexion. Is that is that generally the issue, flexion?
Macy Stonner:Yes, if you catch them early, if you catch them early, and you ensure good splinting early and they do not have a flexion contracture. Sure, flexion is the thing that we're working towards, you know, we realistically we don't always catch them five to seven days after surgery, and they might have already developed this gnarly, 40 degree, either flexion contracture or lag and so you're working on exercises to regain extension through active range through night splinting, along with Working on their flexion. So kind of just depends.
Chris Dy:Are there ever any situations in which it's advantageous to leave the PIP joint free in terms of splinting, if we've got secure stable fixation with the goal of trying to maximize the amount of flexion, that you could obtain?
Macy Stonner:Absolutely. Only if they don't have a PIP function interaction or lag, because if they have their PIP joints free, they're going to be sitting in this PIP flexed state all day. So unless they have good extension, it's not something that I would necessarily encourage. And also if their fracture is relatively proximal, I think it's okay.
Charles Goldfarb:When I don't have maybe, maybe if you're not around or say something around, and I'm in clinic, and I'm talking to a patient about edema control. You know, I guess I'd love for your thoughts on how you instruct the patient on need to control the very specific instruction you give them to minimize swelling or to address a patient who already has a swollen finger. What do you tell him?
Macy Stonner:It's a great question, because people are very concerned about swelling I hear often, I can't move my finger right now I'm still swollen. In fact, Dr. Goldfarb the other day in your clinic, somebody told me that. And so it's just a myth. And so I like to say, you know, if you wait until your team is down to start moving, your finger is going to be so stiff already. So in fact, the best way to get rid of edema is by movement. So keeping those fingers moving, you've been elevated and keeping it compressed. So just simple coban wrapping distally to proximally can really help control digital edema. And that's a very simple way for people to understand the edema control. So I often teach that pretty early on.
Chris Dy:So I have a question when when we put in pins, we think we put them in the best position and bend them in a certain way to keep them out of the way. What are some of the more boneheaded things that surgeons have done to make it harder on you in terms of the way that the pins are bent? Are there any pearls for that you can teach us about where to place the pins and how to keep them out of web spaces, all that kind of stuff?
Charles Goldfarb:Or, or what frustrates you, when you see pins whether maybe every time we put it in a pin, you get frustrated, but any thoughts and maybe a random question about it. I like I liked the question.
Macy Stonner:I guess what you mentioned about the web space, so ensuring that it's not no right in the web space to where they get masturbation in their fingers or where they have a lot of pain with their splint. If it's obviously pinned through the joint, then that provides a lot more difficulties long term.
Charles Goldfarb:What What if you know sometimes when I pin say, if I retrograde pin a metacarpal there are times when I feel like the extensor mechanism is caught up in the pin. And that may be okay because the fracture looks great, does that end up frustrating you or you're not too worried about it because when the pin comes out, you're confident you can regain motion.
Macy Stonner:They're not gonna worry about it because I I work with great surgeons and so I trust that they are going to make the right clinical call in the OR that is going to maximize fracture fixation stability long term and I'm just going to work with what I can. But I just educate them a lot on scarring and the anatomy involved in fractures and tendon adhesions. And I educate them on the exercises to do so a metacarpal. That's been pinned, I talked about the EDC and I talked about an exercise called and EDC glide, which is again is a hand therapy term. But it really encourages extensor tendon excursion through the pin. And yeah, I trust that the surgeons are making the right call and I don't think that frustrates me. But I know that what has to be has to be done.
Chris Dy:A question Chuck for you. When you cut your pins exterior to the skin, say for example, this one where I'm assuming we have a couple of crossed antegrade wires into the proximal phalanx? Do you bend them before you cut them? Or do you just leave them straight?
Charles Goldfarb:I tend to leave my pin straight. Well, let me back up a step. So the first thing is when I'm having a trainee with me, when I placed the pins obviously want the pin place to appropriately address the fracture. To me one of the keys is not plunging through that second cortex and having to pull the pin back then I worried about pins, then I worry about pin stability. As long as that's not a worry. I cut the pins cap them, don't bend them. Do you? Do you bend them?
Chris Dy:I bend them but I've started to become I've started to question whether I should be bending them. There are some situations in which, you know, I think the bend can create more of a hassle than it's worth. And I don't know Macy do you think that bending the pins is bad or good or helpful? I mean, you know, ideally it doesn't affect us to do it so would you rather have just Is it easier to advise patients to take care of pins that aren't bent?
Macy Stonner:No, it's never crossed her mind ever until you just mentioned it, I don't think that it affects my job or their job in terms of pin care or range of motion. I don't think that's and people might disagree with me. But I don't think that's something that really is a big determinant of outcome from a therapy perspective.
Chris Dy:Do patients actually move their finger their joint when it's been like I we have some partners to say nobody really moves when they're pinned?
Macy Stonner:Sure. I think so. I think that it depends on the patient's personality. People have some people have more fear than others, and people are just more careful. But I think that they do just fine. If you tell them it's okay. If you look them in the eyes and say, it's okay to move this, your doctor said it was fine. Nothing that I'm going to teach you right now is going to harm you. It might hurt a little bit, but it will not harm you. And that always gives a lot of confidence to the patient if you say that.
Charles Goldfarb:I like that. And I think that's a good question, Chris, because I have heard that before. So before we jump to discussion of an open reduction, internal fixation of a similar fracture, perhaps with the playing screw before we jump to that similar case, I am lazy. And so I often say to the patient, go to therapy, they'll take your surgical dressing off, they'll make you a beautiful custom fabricated splint, and they will teach you how to care for those pins. What do you tell my patients when you teach them how to care for those pins?
Macy Stonner:We get little Dixie cups of 50% hydrogen peroxide 50% water, instruct them and pin care with a Q tip is they do this once a day if you have little crusties at the base of your pin, sometimes they don't even need to do anything. If they're clean and dry. No signs of infection, no pain, no tenderness, no redness, you're fine. So it kind of depends on what they look like.
Charles Goldfarb:I agree and, and I am fine with my patients showering and I you know, I like them to share actually getting their pins wet. And just using soap and water around the pins in the shower. And then I love what you said, I don't think you and I've ever had a discussion. But I appreciate what you said.
Chris Dy:I guarantee I guarantee you there's a little index card floating around the Milliken hand Therapy Center with all the Goldfarb pin preferences from when you first started and you probable didn't even know it's out there.
Macy Stonner:We have a file folder of every surgeon we work with. And it says wound care preferences for each doctor. And we just go through however now we kind of have everybody memorized. So.
Chris Dy:The reason I know that is because I remember having to answer these questions when I was about to start and be like, Oh shit, just do what Goldfarb does.
Charles Goldfarb:Well, is totally fair. And we have a group of six surgeons and four of us regularly performed wrist arthroscopy as an example. And so Lindley Wall was trying to help our therapy partners by trying to consolidate a couple of protocols. And it was really tough. I mean, we just, you know, if we've done it this way, for three years, why would I change and so those conversations are tough, but it is not particularly fair that six surgeons have six different pin site, you know, care preferences, it's crazy. It's crazy.
Chris Dy:So I will say this episode's gonna drop in July. And that means that there are a lot of fellows that are about to move institutions and graduate, you probably already know this, but you should be scrambling to get every protocol you can, from something as simple as how does the type of needles you need to set up an injection in the clinic to as complex as somebody wound care protocols, their their clinic templates, as well as all their therapy protocols. And a lot of that's available in epic now through dot phrases and whatnot. But make sure you're grabbing all that stuff now before you leave.
Charles Goldfarb:That is That is very true. And we know what's happening. It's already started happening here, as you certainly know, Chris. Alright, may see let's go back to that 25 year old. And let's pretend that I was unable to obtain a satisfactory closed reduction. I made an incision dorsally over the proximal phalanx, I split the extensor mechanism. And let's say I needed to put a small plate and screws in so I put a 1.5 millimeter plate in with five screws was really happy when I left the or I re approximate the extensor mechanism, close the skin. Splint it for four days and sent them to you number one, are you happier that I did an ORIF versus a pinning? Does it make your life easier or harder? And how would you address this patient differently if at all.
Macy Stonner:I have had great outcomes with both it's kind of hard to say I think on my for her pinning because of that gnarly PIP extensor lag. Whenever I have a plate fixation of a p one fracture I get immediately concerned about PIP extension just because you have more swelling and more scarring along that zone three extension mechanism. And so reverse blocking again therapy term to get active tip extension is an exercise that I would implement earlier. So like I said, it kind of dodged your question, but I guess I'll prefer pinning.
Chris Dy:So wait, hold on a question for both of you then. So if, if this is truly a shorter oblique fracture, maybe if it was a longer oblique fracture, what if we had fixed it with three or four screws still done the same approach maybe or kind of danced around the extensor mechanism? So there's still some concern for scarring around the extensor mechanism, but there's no plate physically sitting dorsally. There are inner fragmentary screws or perhaps lag screws that are holding that fracture together really solid. Chuck, would you send that prescription over any differently than Macy? Would you? I don't know if you would actually end up knowing what type of construct was in there. But would that change your your optimism or pessimism about the extensor? mechanism?
Charles Goldfarb:Again, great question. I think when I do an ORIF and I have solid fixation and feels feel really good about what I have, I guess I always thought that Macy would have been happier with me then then if I can, just because you're not fighting the pins per se, but but I hear her loud and clear about the concerns about an extensor lag. If I have really good fixation, operate on Wednesdays primarily, I would say that I would send them over for Monday. Really not considering pins played or screws, but I don't think it changes my referral. I guess it changes my optimism on how aggressive Macy can comfortably be. But but maybe not.
Chris Dy:Do you write in your prescription to be different in terms of how aggressively Macy or any of our therapy colleagues can be if it's pins, plate and screws or independent screws?
Charles Goldfarb:If I'm interacting with an external therapist, and there we look, let's be clear, St. Louis is blessed with a number of really good therapists, you know, that I know of and I'm sure there's others, but I am much more clear about what I would like when I send them to Oh, gosh, maybe this is not okay. But when I send to Macy, or to Stacey, I am I guess less clear, I will state you know, early active motion, gentle passive motion, but I trust that they will progress along. But I'm perhaps not as clear as that could be.
Macy Stonner:We just are spoiled and we know your preferences. And so we don't really need you to be clear. And so we appreciate that, that you trust us enough to guide the patient a lot. And so you're right, if it was plated, I do feel like I can progress to passive earlier because let's be honest, a few one fracture that was fixed is going to need passive motion at some point, if they were pinned, and I'm not as convinced of the fixation as a different approach, I might wait on passive and because I'd be fearful of instability, I guess. But yes, a plate I feel like I can be much more quick with passive motion but you know ask other people my colleague Emily potassium hope she's listening will always prefer an ORIF of a P one fracture versus a pin because she's convinced that if you're pinned you're not going to move like we had talked earlier. And so if you don't have visually a pins coming at your finger, you're gonna move a lot better. So I think it depends on the patient depends on the therapist. Can't go wrong either way.
Charles Goldfarb:Did did Emily brainwash her collaborative surgeon or did her collaborative surgeon brainwash Emily?
Macy Stonner:That's a great question. It's probably the latter.
Chris Dy:No, no comment. I really don't know. I've seen Emily with her collaborative surgeon in clinic and Emily is Emily's smart as a whip and very open to expressing opinion. So I think that's, that's great.
Macy Stonner:Yeah she'll always prefer an ORIF.
Chris Dy:So, I had a question before we switch to say a case where we have some stiffness in any way that the fracture is fixed. When do you start to add some resistant work in terms of putty and eventually strengthening? Is it when we asked you to or are there points in the therapy course of therapy? were like, Oh, this patient's like, ready for the next step?
Macy Stonner:Oh, great question. Definitely after they're healed, and that can be very different for every patient. But I would say once they're healed, I'm pretty free game with any passive motion that I want. And then once they start passive, wherever that point may be, whether that's two weeks, whether that's eight weeks, and they're relatively pain free at rest, I can start some strengthening shortly after. So that's a bad answer, because I'm not giving you a specific week. It totally case dependent, but I go off pain. I go up when they started Passive and when they're healed,
Chris Dy:But is there like a specific value for total active motion or DPC where you say okay, now we can start to do some strengthening.
Macy Stonner:I think that if joint stiffness is the concern, strengthening is definitely not my prioritizing treatment plan. Because I say, Hey, I get this soapbox every time like, Hey, you have your whole life to regain strength, you can always gain muscle mass, you have more of a limited opportunity or limited time to regain motion, you have this nice window, and fingers do not tolerate trauma well, so let's really work on stretching. Because if you have sickness in the finger, it doesn't just naturally get better with time. It gets naturally better with stretch. So let's really stretch.
Charles Goldfarb:I was I was recently at a an informal meeting. And I guess I'll leave the names out of it. Hopefully, that's okay. Were they the presenter stated, gave really a presentation about why I hate the squeezy ball. He basically showed the example of if you have a squeezy ball and you're squeezing, and you're going from the DPC the distal palmar crease measurement. For those who don't use that term of say, six centimeters to three centimeters, you're actually not fully arranging the fingers. And it may be counterproductive for regaining motion at a time when you need to focus on motion, not strength. But it was pretty insightful.
Macy Stonner:Completely agree with that. I love whoever said that. Was that Dr. Boyer?
Charles Goldfarb:It was not. No reason to love Dr. Boyer.
Macy Stonner:I agree with that completely. People have this incomplete flexion arc when they do it stressful. So we do a lot of therapy putty, which has different resistances. And that we encourage people to do it's a full arc of flexion to get all the way to a DPC of zero. So I agree with whoever made that comment.
Chris Dy:Well, that's the reason why every time we open one of those slings that has the stress ball included, I toss the stress ball out. Patients see that they're going like, Oh, I'm supposed to be using this like, nope, no way.
Charles Goldfarb:Yeah, that's great.
Macy Stonner:I see that all the time with somebody who's two weeks out from a central slip repair and they're like squeezing a stress ball because they think that that's what's going to make them better. And I'm like, Oh gosh, please don't.
Chris Dy:So don- so donjoy USA, if you're listening, make those splints, or the slings and you include the stress ball save yourself some money man, don't even put them in.
Charles Goldfarb:They're cute and all but alright, let's finish up the show and talk briefly about the patient will give you the scenario. patient is now eight weeks out of that initial oblique p one fracture that we pinned. We pulled the pins at about five weeks and radiographs, you know look fine. And they're back today is now eight weeks out they've been seeing you may see and making some progress, but not as much as we would like another eight weeks out. And let's say their Extension has been good. They've been good about wearing the splint, but they just don't have active motion or sufficient active motion. So as they attempt to flex, they are limited to a DPC of you know four centimeters and we can talk more specifics. But how do you think about that patient? And what do you do with them?
Chris Dy:Oh, wait, wait, wait, hold on, Chuck. Just so follow up on our prior episode, we we should know what's the passive motion before we can talk about the active. So give us that info.
Charles Goldfarb:Thank you. So in this patient, they have good active and passive extension. And they have good passive flexion. To a DPC of zero but when I asked him to actively make a fist, they are limited.
Macy Stonner:Okay, so this patient, if they have a passive DPC of zero, I wouldn't consider that a stiff finger. I would consider that as tendon excursion problem. So active active active motion, a little bit of resistance to encourage your tendons to glide through some stress, encouraging full functional use of the hand using it for every daily activity. But does that person need a static progressive splint? No, because they're not passively limited. They're actively limited. So active motion all the way.
Chris Dy:So then just to keep breaking down terms, what is a static progressive split.
Macy Stonner:So a static progressive splint is a type of orthosis or splint that has a component on the finger like a tab where you pull on it with your opposite hand to provide external or passive motion. So it's something that you don't have to think about the technique involved in a manual She just kind of passively place your finger in a device, a torture device that a lot of patients describe. And it just kind of takes you into the motion you need to have. And you can think about other things, watch a show or whatever in order to really maximize motion. And so if it's a truly stiff finger stiffness, meaning passively limited, that's where we typically go. But in the case that you described, I wouldn't think that that would be necessary.
Charles Goldfarb:So what you're hoping for, in the case that I described where we have a flexor tendon adhesion? Is that that adhesion will break up with daily activities or just the active motion or even strengthening?
Macy Stonner:Sure.
Charles Goldfarb:When do you apply e-stim it because that would be the next step I assume for you? Or when does e-stim come in?
Macy Stonner:So I ever you asked me this question in our flexor tendon podcast in the fall. And it kind of depends on the therapist, some therapists really value that and others might not. I am, I have a lot of colleagues that use it. And I think there's definitely a role. I don't use it a ton. Because I think that that's an external force that's doing the movement. And that's not sustainable, necessarily, if they let's say that they're PIP flexion is, 40, actively, and then you put some e-stim on there, and they can get 70. That's great. But if they can't maintain that, every day, as they're using their hand, I'm not so sure that it's totally doing what it needs to do. I'm not against it, but it's just not my first treatment strategy.
Chris Dy:So the case that Chuck gave you is one that I don't often see, what I typically would see is active DPC of four and passive DPC of two. Right, let's work through that scenario.
Macy Stonner:So I think in that scenario, you still continue the treatment strategies, as mentioned. So active tendon glides, joint blocking, using the hand as much as possible, light strengthening with the addition of some potential dynamic or static progressive splint use, which I mentioned earlier, is just an external type of orthotic which can stretch your finger passively, as you go about doing other things.
Chris Dy:Now that dynamic splint, very different from a static progressive splint,
Macy Stonner:Kind of so static progressive splint is one where you would strap this device on your finger, pull a tab on your PIP joint, and it's kind of anchor the mechanism to your forearm. And you just kind of let it sit there. You reassess your pain after three to five minutes, let's say your pain initially is a three. After a few minutes, if your pain goes down to a one or a zero, that's great. That means that your joint is kind of accommodating well to the stretch. So static, progressive, meaning you can progress this motion even further. But it's a static stretch. Again, a lot of therapists will be listening to this thinking, Oh, yeah, this is all therapy lingo that they know. And then a dynamic brace would be one that is kind of like you're familiar with an LNB or something like that, that's just like a constant stretch, no matter what you can't adjust the tension per se. It's just like a constant level of stretch. I think they both have a role, you just kind of have to take a case by case.
Charles Goldfarb:Yeah, and that's certainly one where I differ 100% to the experience of the therapist that I'm working with. And let's be clear, what we're talking about here is potentially adhesion adhesions on the flexor side, but more importantly, that lack of passive full motion, we're talking about either extensor tendon adhesions, which are preventing that finger from flexing, or a DI I'm sorry, or a PIP, joint contracture which is preventing that passive flexion. Do we all agree on that?
Chris Dy:Yeah, that's what I had one question for you. I mean, I remember Dr. Boyer talking about when he was a fellow in Indiana having to go up and you know, as a fellow, put some local anesthetic injections in people's PIJ. so that they could keep working with therapy. Now we know of the our graduation sphere taught us about the effects of those local anesthetics, at least the longer acting ones on cartilage. Do you still see a role of using, you know, an adjunct to like a local anesthetic if it's short acting to help get patients through the pain part of their therapy?
Charles Goldfarb:Yeah, and let's just be very clear, our graduation speaker Constance Chu was suggesting that any intra articular injection is damaging to cartilage. And not I wish I could say I was smart enough to not inject for that reason, but I don't inject in these cases. I do not use any local anesthetic to facilitate therapy. I guess I don't think it's crazy, but I haven't done it. I haven't done it. may see. When do you say uncle and I have no idea why that expression exists? When do you say therapy has not succeeded? And regaining motion is time for a surgical tenolysis joint release whatever is is there a magic number? Or is it simply, the patient has plateaued and I can't get them over now.
Macy Stonner:The second thing you said it depends on the patient. But if I'm seeing them consistently, twice a week, and I look at my range of motion measurements every week, and in my assessment, I continued to write no changes this week, he continues to demonstrate significant joint stiffness. And I haven't been able to type anything different, I get concerned that each session, there's no change. So I'm going to send an email or an in basket through epic to the surgeon to let them know. And I kind of look in the system to see where they're seeing the doctor, again, to let the patient and the physician have that conversation about surgery. But to dance around your question, there's no magic date, and kind of just depends on how they're progressing therapy.
Chris Dy:So to bring us to a close, Macy, can you give us either one Pearl, you know, that would make us better at communicating with our therapists about this, you know, these kinds of patients are one, you know, constantly frustrating thing that you noticed that surgeons do that. That makes your life a little harder.
Macy Stonner:No, I don't think there's anything that your surgeons are doing that makes our life harder. I think that it's really important when you go to therapy to have a one on one session, I'm really spoiled. And at Milliken, we always have one therapist, one patient per session. And particularly with digital stiffness, that's important to address one on one, if you have multiple patients at once. And I know that different employers are, are different and require that it's just it's just challenging to really address stiffness. It's a very manual type of session. And so I think that having that one on one is important, and really educating them that this does not just get better naturally with time it gets better naturally with stretch.
Charles Goldfarb:Basie, thank you. Your insights are gold to surgeons who don't understand therapy as well as we would like. And I know it's not even a question. I know that our listeners are going to love this. And thank you.
Macy Stonner:Thank you for having me.
Chris Dy:Thanks for joining us, basically, we look forward to having you on for another session soon.
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@hand podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenital hand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at hand podcast@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.