The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Hand Therapy for Finger Fractures with Macy
Chuck and Chris are joined by special guest Macy Stonner who brings her therapy expertise to the topic of finger fractures. This episode will revisit common fractures and the therapist perspective to outstanding outcomes.
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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 rating that helps us get the word out. You can email us at Handpodcast@gmail.com. So let's get to the episode.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm really, really good. It's a special night.
Chris Dy:It is a special night. Our I would have to say our favorite recurring podcast guest is with us tonight. So it's gonna be great Macy's back, Hey, she's back.
Macy Stonner:I'm happy to be here.
Charles Goldfarb:Not as happy as we are. Because I think you know, when you're on an episode like listenership goes through the roof.
Macy Stonner:You know, I don't know if you're just being polite, or if that's actually true, but I'll take it as a compliment. So, thank you,
Chris Dy:you're gonna have so many people recognizing you when they see you at the the hand therapy meeting in St. Louis later this fall. That's may see.
Charles Goldfarb:Or on the street? I mean, people may just walk up to you and say, I know you know
Macy Stonner:Thank you. It'll be interesting. Okay, let's get moving.
Charles Goldfarb:Before we jump in with Macy, we did have a podcast listener right in about our partner Ryan Nunley and our, I guess I would say like fanboy discussion of his efficiency and of his practice. And there was some concern that maybe we were overhyping it. And maybe we shouldn't be promoting practice efficiency. I don't know how you heard it, Chris, but I'd love to hear your thoughts about the concept.
Chris Dy:I don't I wasn't as pessimistic about the comment, which we certainly appreciate. You know, I think that it's, it's not that we, I think we're overly enthusiastic about it. And perhaps maybe we just shouldn't provide, you know, some more context, that there's definitely a lot of different ways to run a practice. You know, having a waiting list for surgery for six months is not ideal in terms of, you know, having to make people wait, etcetera. And folks should be able to get the care that they want slash need, perhaps earlier. But I think there are a lot of good things about the way that Ryan has structured his practice, and anybody that knows you and knows that, you know, like I said, your love language is efficiency. So I mean, if you are able to find ways to just make the most and you know, out of the time you're at work means that you can make the most out of the time you're not work. And having recently spent even more time with Ryan since the podcast recording, he lives it. And you know, he's there with his kids. She, my son had a sleepover at his house, just this past weekend. And he was fully doubled down and was hanging out. And so he's not, he's not always on the phone doing stuff when he's not at work. So I'd say I think there probably is just room for some more context. No, there's a lot of different ways to do things. But I'm I'm of the like, where if I'm at work, I want to be as maximally efficient as I can, so I can not have to worry about that stuff. When I'm not quoted at work
Charles Goldfarb:We recognize that those choices are not for everyone. And we're not here to say how to run your practice in your life. But you know, I think a good example was a couple weeks ago, I had a case cancel, a big case cancel. And so my day was not like filled to the kind of maximum extent. And so when that happens, I think all the listeners will know what tends to happen, the ORS everything slows down. And so that's fine. If mentally, I'm going to be there till five or six, because we cancelled the case, and I'm not going to get home any earlier. Or you sort of have the mentality that look, we push like we always push. And if we get done an hour early, fantastic. And that's my mentality. Because the time I spend at work is the time I spend at work, I'm at home. So that's why I am passionate about efficiency,
Chris Dy:right- And it's like, I remember when we would do these big plexus cases early on, and Marty was around Marty Boyer is around, he would come in and he'd say, look, we got to keep moving this case will take as long as you give it. So a lot of times, you know, stuff at work can be like a sponge and will expand to fill the space. So I like the ability to get things move and get things done and work at a high clip so that you can again focus on other things. There was one comment in that email about the nunley episode I thought was interesting about you know, how do you how would you feel if you were that patients and you're 12 there are fewer that surgeons 12 total joint of the day or whatever? I don't know oftentimes, when I'm kind of late in the day and just stacking all my locals at the end of the day. I do have patients ask me how many surgeries I've done that day. How do you answer that, Chuck?
Charles Goldfarb:It is a fair comment. I answer that question. You know, I don't sometimes I tell the exact number But I think, you know, we, it's a fair comment only if we let our fatigue show or let our fatigue affect our ability to provide every patient the same excellent surgery. And I had a big case then today, I had a really big case, it was a massive OCD. And we were treating it with a graft. And, you know, I think I get energy towards him today, to be honest. But it's a fair question. And I think if, if I get to the point, I actually said to my wife, when I got home that I feel like I'm getting older because when I get home, I am tired. Then I need to cut back because if I can't give that last patient the same attention, I give the person shame on me.
Chris Dy:I think it's absolutely fair. So we've kept people waiting too long. To talk with Macy, we have to make them wait a little bit longer, because we do have to thank our first sponsor, the upper hand is sponsored by practice link.com, the most widely used position job search and career advancement resource.
Charles Goldfarb:Becoming a physician is hard. Finding the right job doesn't have to be joined practice link for free today at www.practicelink.com / the upper hand?
Chris Dy:Yes Practice Link is also exhibiting at the WashU nerve course which will have just completed by the time you're listening to this. So thank you, to those of you that waited outside in the rain to get into the Washington, of course, I'm sure there are a lot of people that couldn't get it.
Charles Goldfarb:You know what I actually looked at the lineup for the first time today this morning, carefully. It's awesome. It's a really, really good agenda. So congrats in advance. And I hope and I know everything's gonna be pulled off perfectly.
Chris Dy:We'll look forward to it. So Macy, thank you for joining us again today. I think we had a really good discussion, Chuck and I did last last time about finger fractures and how we approach things. And I think finger fractures are some of the more challenging things that that hand surgeons and hand therapists can treat just because there's so much variability. So tell me, is there a one particular pearl that you can give us to open up before this?
Macy Stonner:Started tonight, I reminded you that we did a similar podcast a few years ago, and my my commentary has changed. And I think that a few years ago, you asked me which would I rather rehab pinning or plating? And my answer was pinning. And nowadays whenever I see pinning, I kind of Oh, no, because I've realized in time that I prefer plating. Interestingly, because it's changed. I've just found recently that people get scarred in or they get freaked out by the pins more. So I think I've just kind of changed my preferences for rehab for plating. But there's I don't have any pearls in general, I guess it just depends like the the arthritic patient who wants to get back to farming versus the kid who wants to get back to sports. You know, there's just so much variability. So I feel like it's hard to answer that like a case to talk about are
Charles Goldfarb:Well, thank you, we should we should do that. Maybe we'll start proximately work distally and throw out a couple of different cases. So if it's okay, I'll start with a case. I have a 23 year old male who has to displaced midshaft metacarpal fractures. And, Chris, why don't you jump in first thing, what you would do? And then we'll ask me see what she thinks about your choice, and then how she would rehab it. And so these are displaced, they're unstable. I'll say the fifth metacarpal is at 45 degrees shaft, and the fourth is about 40 degrees so markedly displaced three days old hands pretty swollen. No numbness or tingling. What's your conversation with the patient? And how do you think you would proceed?
Chris Dy:Well, I first of all, ask what was the name of the girl because typically, this is preceded by some kind of hand versus stationary objects such as wall actually last time I asked that which was in clinic this week. He's like, Yeah, I was mad at my mom. But yeah, so you're painting a picture of a patient who's probably indicated for surgery. I will say that although the textbook north of bullets and all of them say that multiple metacarpals is an automatic indication for surgery, it's not always I have treated some patients with multiple metacarpals, non operatively and been satisfied with that. I think it honestly depends on the situation. You did not mention whether there was any sort of rotational deformity or not. I'm assuming, you know, maybe there isn't one but that clearly is one that would sway in indication towards surgery. 23 year old you said probably somebody that's in the prime of their earning and is trying to provide for themselves family perhaps. I think honestly, the most predictable outcome does come with surgery. It's just a question of how to how to provide that stabilization, mid shaft and Mmm, fourth and fifth. Honestly, my go to now is probably headless compression screws to provide the stability, the upside of the stability that Macy mentioned, without the downside of the potential downside of you know, tendons that he's adding to the, to the plate etc and less surgical trauma. So that's where I'm now that's probably not where I would have been when we started recording this podcast 18 years ago.
Charles Goldfarb:That's true. 18 long years ago, we started this podcast. Yeah, I think it's a fair statement, we wouldn't have neither of us would have likely chosen headless compression to use intramedullary screws. Not that there's anything wrong with plating or even petting. Sometimes I think we've all grown accustomed to the benefits. So Macey, are we as surgeons making a good choice by choosing the intramedullary screws? Are you seeing a lot of those patients? And do you have to continue to see the seeing them? Or do they seem to do pretty well, you
Macy Stonner:know, categorize those patients in between, like you mentioned planning and the pinning. So I think that's actually something that I would really prefer to rehab actually, because they're not so freaked out from the pins, which most people don't do range of motion while they see them because it's scares them and then they don't get so at least attendance, like you said with the plate. So
Charles Goldfarb:when do you want to see him? How do you tend to provide immobilization if you provide a mobilization and what are your instructions to the patient as far as home therapy,
Macy Stonner:So if they're in a dressing, that's pretty so supportive, and their MCP joints are flexed well, then I'll probably see them between the week and week and a half, something like that maybe two weeks at the latest. And I want to ensure a few things I would put them in a hand based on our gutter splint with the rain and small finger if they're younger or not really trustworthy, I might include the middle finger to just for additional support. And I want to ensure that the MCPS are in a good flexed you know closed pack position with the IP joint awaking on IP joints are actually a free, I would have those exposed just because it's a metacarpal fracture. So those are should be fine. But the MCP joints are included. I want to look out for two things. I want to prevent MCP capsular stiffness, so being able to work on active flexion because a lot of times those get really really tight from collateral ligament shortening. And then I also want to look out for like tethering of the EDC along the metacarpal. So extrinsic tightness. So those are the two problems that I would want to watch out for. And on that first visit, I would obviously make an the splint and do wound care etc. But give them active range of motion, which would look like is this video recorded? Can people see me? Okay? Okay, so I will rejoice. Okay, great. I think one time I did this podcast, I didn't know that and I just got out the shower, my hair was soaking wet. And you were like, Okay, anyway, so I'd have them work on like active extension composite extension working on it what's called a tabletop. So full MCP flexion. With the IPS extended, that's often very difficult for them. I don't want to work on hook fisting, which is just the IP joints flexing with the MCB joints and extension. We're just going to really work on EDC excursion, going back up to full extension, and then working on a full composite fist. Sometimes I'll work on abduction and adduction as well. But just like a very basic introduction to active range of motion day one, then I'd have them come back and see where their deficits lie. Is it EDC scoring? Can they are they having a hard time with engaging their long flexors? Is it you know, scar tissue adherence or dorsal swelling? You know, what's the problem? So, I keep going on you got to stop me
Chris Dy:A couple of questions. I mean, yeah. So is that the same protocol you would use? Regardless of whether that was fixed with the intramedullary screws or with a plate?
Macy Stonner:Yes, the only thing that changes my mind necessarily is when to initiate active range of motion, and what sort of deficits I'm anticipating.
Chris Dy:And then why include the MP joints in the splint if shaft? Yeah, when I've done this for shafts that I've put into modular screws actually go with the metacarpal MPs fingers completely free. And it's cost me it's probably overkill. It's by just a reminder, like, Hey, don't do something crazy,
Macy Stonner:so well. So you would have been fine with no mobilization?
Chris Dy:Honestly, for most of these patients, if I really like the stability, yes, if I trust them, but I give them the cuff as a reminder.
Macy Stonner:Um, I guess like he's 23 I don't know, more rather than for protection. More so for positioning, because when their acts without the MCPS acts, in any flexion they're going to be kind of an extension of Pretty much all the time. So I would use it more so for keeping the collateral ligaments stretched out and avoiding them tightening up into MCP extension. That would be a decent rationale for that.
Chris Dy:Yeah, that's great. I'm just I'm just curious, because I mean, I guess, as a surgeon, I tend to protect a little bit more in most cases, I think this is one of the cases where I'm a little more liberal. Yeah,
Macy Stonner:that makes sense. I think there's a case for both, I guess I would have to feel around for the patient's personality and see if they seem likely to comply versus not,
Charles Goldfarb:you know, I have a younger population in general, 23 year old male who punch something to stain these fractures, I would, would want to brace of some sort of splint, orthosis, whatever we call them these days. And I do think a cough has a lot of value, the metacarpal cuff, and for those of you who don't know the terminology, it literally just comes on the owner side and spits across the dorsum, mainly, but also the polymer aspect of the of the hand, obviously leaves the NP joint free. So that's different than what Macy was suggesting with immobilizing, the MP joints, but you're right. I mean, with intramedullary screws, I don't really worry about tenant adhesions too much, right? It's really the capsule that I do worry about at least a little bit. But it's been pretty rare that I've seen issues, but I do send patients to you guys. And I think they all are treated as you said yes.
Chris Dy:how often are you seeing patients treated with pins? And you know, what's your How do you counsel patients through telling them that it's okay to do some motion, even though like you said, they probably aren't doing a whole lot. Yeah,
Macy Stonner:I kind of I don't scare them, but I just kind of say, hey, look like I recognize that this is, you know, difficult to see something protruding from your body. And I've seen people get quite stiff, and I don't want that to happen to you, I promise I would never give you an exercise that's going to harm your recovery or impact the integrity of your fracture fixation, and just really give them confidence that what I instruct them is okay, and very much encouraged to do frequently. And I just see with pinning a lot. Anecdotally speaking, I guess just lack of motion and like, as opposed to capsular stiffness more like yeah, flexor tendon adhesions, I would say. And honestly, my brain right now is going to like P one fractures, not necessarily metacarpals. But that's just where my brain went.
Charles Goldfarb:Yeah, let's, let's keep going. Because I think in in general, these fractures, metacarpal fractures do well, they do. And I think the intramedullary fixation is even more reliable. And you know, we are less at risk for seeing some of the complications, proximal failings, fractures.
Chris Dy:Oh, hold on, hold on. Can I ask a question before you end this part of the conversation? Sure. One comment and one question. So I guess I would just caution that I think the interventional screws are great, but they're not a panacea. And we still don't know, we know a fair bit about, you know, how much of the cartilage is compromised, and that it's not an essential part of the compromise, or a central part of the articular surfaces compromised. Tendons tend to do pretty well, from some early studies. But you know, these are, these can be really challenging if they if they get infected. You know, there are some case reports floating around of the the challenges that come about if one of these were to get infected. Now, fortunately, that has not been my experience yet. But I always think about that before I put these in. And then my question for Macy is just in general, for metacarpal fractures, when can you start doing some strengthening you
Macy Stonner:feel if I communicate with the surgeon, which I'm very grateful for that communication, collaboration where I work? And I'll say, hey, how do you feel about this fixation? And they're like, oh, it's solid, which is typically what they might say, I would say, eight weeks. Does that seem reasonable?
Chris Dy:It just seems longer than Oh, you
Macy Stonner:seem like that seems longer.
Chris Dy:I'm usually very conservative. That's funny. But I would probably Okay, six, doing, if they're moving. I usually tell people, if they're moving well, I move them, I get them started and strengthening a four to six weeks, as long as they're not tender over their fracture site. And there's no Sutton than anything, everything looks okay, on the on the flouroscan images
Macy Stonner:. Honestly, this is really good for me to hear and to learn that in this particular case, like you feel very comfortable and confident in the, you know, stability. So this is actually a great learning opportunity for me.
Charles Goldfarb:Well, and I think a couple of things. One, I see my patients for two weeks and six weeks and then may not see him again, or probably the next visit will be 12 weeks. So if if I send them back to you guys in six weeks, it would be for strengthening or any, you know, motion deficits. But I don't always send these patients for strengthening and if they've sort of graduated, they have good motion. They don't have pain. They have good healing. I don't necessarily send them for strengthening. But yeah, I think I mean, if it's an A transverse fracture with great fixation, that's one thing if it's an oblique fracture, where you're just not quite as confident, just a different situation.
Chris Dy:Fair enough. Now, why don't we move on to a proximal phalanx fracture? Did you have one in mind, Chuck? Sure,
Charles Goldfarb:sure. I'm trying to think of a reason Some case that would fit the bill. I had a, this was a 27 year old lady who had a fracture, which was essentially a long oblique proximal phalanx fracture that did enter the PAP joint. And so it was displaced enough that I was worried about both the joint and the alignment. I think it was a torque injury that caused this if some sort of finger was grabbed. And so she, you know, is swollen that I think she was four days, five days out when she first came to the office, but a fracture, which I think anyone looking at the X Ray would be concerned about, both for healing the joint and her rotational instability. So Dr. D, what do you think
Chris Dy:I always get, I always get this pit in my stomach when I see proximal failings, fractures for the most part, with the exception probably of like the you know, Metastasio base type fracture, that's transverse everything else, you're never quite sure how involved it's going to be. And when you say long oblique, I found that long oblique, so with this kind of mechanism tend to be more involved than the initial x rays make you think. So you're telling me it's splitting into the joint, you're telling me it's a long oblique fragment, or fracture line, I'm probably thinking open reduction and intervention or non interventional, inter fragmentary screw fixation. So multiple screws along the obliquity of that, of that fracture, making sure to prioritize getting the joint getting joint right, getting the fracture out to length and getting things stabilized. Temptation, sometimes it's to put that plate in, I think, the way you're describing it, maybe it's too much for pins, but if you can get away with pinning, I think that that has a lot of value. And when I say get away with I don't mean get away, I mean, I mean that you're gonna get a nice reduction, good opposition to the fracture ends and solid fixation with likely multiple pins.
Charles Goldfarb:Yeah, I think we'll turn it over to Macy in a second, I think all good points, let's just carry the O R, I F with screw fixation out a little further. For me, that means splitting the extensor mechanism longitudinally, typically 1.5 millimeter screws, I go, ideally would have three of those screws, but if it goes, the way I hope it will go would be excellent fixation with good, good solid, you know, I would have confidence in my fixation before some AC I'd like you to and then we repair the extension mechanism on the way out. So that's one scenario. The second scenario, I'm a bit biased by my partner Lindley wall, we do indications together and, and she pens a lot of these. And so especially in our younger population, she's younger population than I do, but she will obtain an anatomical reduction and sometimes using a reduction clamp without in sizing the skin, and then put two or three pins obliquely across the fracture. So Mesa found
Chris Dy:it, I found a little bit challenging to get a nice percutaneous clamp down in some of my chunkier patients. So to say, especially with all that swelling there, so that I was go into that with that being planned a and I try it and I get a little frustrated. But when it works, it's fantastic. Do you ever you mentioned splitting the sensor mechanism? Do you ever feel like you can dance around, you know, on the side of the central portion of the of the extensor mechanism and kind of working in between that and the lateral bands,
Charles Goldfarb:I usually end up splitting it in some regard. Now in this case, if I'm really worried about the joint and I may not be meaning I might not need to look into the joint. But there's any doubt about the joint reduction that would go between the central and lateral slip and truly split the extensor mechanism in
Chris Dy:how do you repair the the split that you put in that mechanism?
Charles Goldfarb:Yeah, and I'd love for listener thoughts I'd love for your thoughts. I usually use a four Oh, suture of some variety vibro sometimes monocryl, I don't know that you always have to repair it. As long as your extensors stable. We don't want that lateral band slipping over the side is why I do repair it especially if I'm going more distally but I you know, I tend to repair it on the way out. But don't always.
Chris Dy:And then do you lag those screws? Are they just purely positional screws.
Charles Goldfarb:I think I was biased by literature from long ago that basically says if you get an anatomical if you obtain an anatomical reduction, have a towel clip or reduction clamp holding that reduction, then I do not feel the need to put a lag screw in. And I think it's really important especially when one works with trainees lagging like at a 1.5 millimeter level can be very tricky because if you're two or three degrees off between your one you know, we're your 1.5 drillbit and your 1.1 drillbit, you can really cause problems and so that's part of the reason I don't lag and the other part is I think you already have compression from your clamp and you don't need it.
Chris Dy:Right. The margin for error on these screws is incredibly, incredibly small. So This is not one where you're kind of looking at a different direction while the drill is, you know, in the hands of somebody else if you choose not to have somebody else do that. Alright, I talked enough, let's hear what Macy thinks about. If you've got, you know what the certain things is solid fixation with, you know, multiple screws,
Macy Stonner:three really good screws, I'm feeling good. Like I'm feeling like I can move them five to seven days. If that seems reasonable to you, I'm thinking this person is going to be in which fingers it sorry, does it matter?
Charles Goldfarb:Little it was a little, little finger.
Macy Stonner:So hand based ulnar gutter, mcps and flexion and IP joints and full extension including the ring and small, trying to get that pap joint in full extension is often the challenge they want to be somewhat flexed. And most people end up with somewhat of a flexion contracture anyway. So getting them started five to seven days just with the same exact active range of motion program that I mentioned for the metacarpals but with a little bit of a difference. For tracks, proximal failings fracture, which is like chemotherapy, bread and butter. These are the ones we see all the time because they get really stiff or scarred in. And so I would instruct them in blocking exercise. And for listeners who don't know what that means. It means supporting the proximal failings in MCP extension and isolating that flexion force only to the PAP joint. So you're not getting a full composite fist. It's purely just blocking the FDS to the small finger if they have one, or and then blocking to the tip in isolation as well just to get more glide of those long flexors. And then I'll also instruct in what's called this is very therapist lingo. But reverse blocking. Do y'all know what that is? Ish. So reverse blocking is for working on active pap extension. So I start in some MCP flexion. And I work on forcefully extending my extension mechanism up into full PHP extension to prevent that long term flexion contracture.
Charles Goldfarb:Which one's more important, and I think we got the gist, we probably could have figured out what reverse blocking was. But which one's more important extension or flexion
Macy Stonner:Flexion by far flexion is function. That's what I tell my patients. And so people get really bogged down with a flexion contracture, like the inability to extend and I'm always like, don't worry about that, don't worry about that. Research shows that if it's more than a 30 degree flexion contracture it's functionally limiting if it's less than 30. It's cosmetic. And so I tried to talk about the importance of flexion flexion flexion. With that being said, in my schpeel as always that flexion is function during the day, we really need to be working on active fisting and grasp and really getting your tendons gliding. But at night is a really good opportunity to wear some sort of static splint to keep that pap joint in extension to help stretch boilerplate to keep your extensor in the shortened position. And then you wake up in the morning, take it off and work on flexion. Again. So that's kind of common schpeel. Below provide.
Charles Goldfarb:I mean, for some of you have questions about that protocol, or whether we ask them about the pins,
Chris Dy:I was gonna ask about pins. I do like the quote that you add flexion is function. I like that a lot. I think I may end up using that. And then you mentioned, you know, about the 30 degrees being the threshold at which, for flashing contractures where it's not, you know, it's more of a aesthetic thing. It's really hard to explain that to patients. In my experience, you know, you tell them like least for example, like in the elbow, you tell them the functional range of motion that we all quote, in patients like no, I want my elbow straight. It's like you don't need it, but I want it straight. So it's very hard, I think for patients to grasp that, at least on the brief interactions I have with them. So I'm trying to get better at my messaging, and making sure that I appreciate yes, that they've got a deficit that it appears to bother them because you have some patients who are so fixated on numbers. And you know, it becomes very, very challenging to counsel them away from trying to get a perfect score in the game.
Macy Stonner:Not being a number cruncher. I say that a lot. And you know what population just came to mind and I don't want to talk about this, but as the mallet population, they get so bogged down in the numbers not being able to fully extend and you can have to really coach them on like, Hey, I hear you. I recognize that this stinks and this isn't perfect, but you're gonna be okay. You know, it's gonna be fine.
Charles Goldfarb:personal anecdote, I am recovering from a knee replacement. And I do think therapy is wonderful. I now believe in therapy I was
Chris Dy:before Well,
Charles Goldfarb:I will say the importance of a good therapist and I was fortunate to have a really good therapist. It's really incredible. Mmm, it gives you it gives the patient confidence. It is motivating. You don't want to disappoint your therapist. It was really it's been an interesting ride. Of course, I cancelled my last couple of therapy visits, but I'm doing pretty well. But yeah, and I am not super focused on the numbers, but I absolutely can see why some would be, especially with a knee replacement, like how much flexion do I have, you know, like you just get fixated on the numbers I get. Now, same patient, but instead of three screws buried, you have three oblique K wires exiting on the older side of the proximal phalanx. What do you do with this patient? Do you want to see them at the same timeframe? Would you rather us keep them a little longer before we send them down to you? What's your strategy?
Macy Stonner:I gotta be honest, my treatment for that person might not change a whole lot. Five to seven days would be great. I'm not really seeing these patients, five to seven days. I'll be honest, when I worked in the OSI and Chesterfield I feel like I did where I work. Now. I feel like they kind of come at the two week mark after they get their postdoc dressing off, and you'll be fine. But I'd like to seem a little earlier. So yeah, two weeks at the at the latest, I'd say for this
Chris Dy:patient, your recommendations don't change. But probably what changes is their ability and or willingness to do what you're
Macy Stonner:exactly, exactly. So this person, they're just I think they might be more swollen or freaked out and their frequency of active range of motion at home is less. And I'm thinking, again, anecdotally that these get more like scarred in, like their long flexors can't glide. So like their fists might be like a six or a five to the DPC, but then I passively stretch them in and it's like a one. So there's a big discrepancy between active and passive flexion indicating scar tissue adhesions along their FTS FTP, which is somewhat more of a challenge sometimes just working on a lot of like, active tendon glides a little bit of resistance to challenge those tendons to glide further. personal anecdote which I wanted to make sure that I said, not personal but as a therapist for certain patients, I've had maybe two or three, maybe four patients lately that have had proximal failings pins skid scarred in a full passive, very limited active, and the surgeon has injected them for classic trigger finger. Perfect, full motion, canceled all the therapy appointments. Because literally, I don't know what it is, but it's like an hour an experiment for me. I'm like, let's do it a career injections the algos and they're like, good to go. How interesting is that?
Chris Dy:You would think that it's not for trigger symptoms, but there do you think it's like the hydrodissection perhaps down the sheet that is opening up some of these adhesions if they're putting their injection in machine?
Macy Stonner:No, I think that like at least two of them did have some tenderness alone that one pulley so you could provide a rationale for doing it. I don't know. I really don't know if it warrants more people for doing this. But I think it is something that's now in the back of my head like let's try that can't hurt better than a Tino ISIS.
Chris Dy:You know, you heard it first on the upper hand. Breaking news.
Macy Stonner:That's your goal for him. I think he's rolling his eyes right now.
Charles Goldfarb:I'm seriously rolling wise. I don't know. But hey, I trust you. So I am gonna look for it.
Macy Stonner:Again. It's experimental.
Chris Dy:I have a question I want to ask you but before I ask you that I do want to thank our other sponsor, checkpoint surgical. So the upper hand is sponsored by checkpoint surgical, a provider of innovative solutions for peripheral nerve surgery. As a hand surgeon and as a head therapist, you know that nerves matter. It's why checkpoint surgical is singularly focused on elevating the clinical practice of nerve surgery with innovative technologies that help improve patient outcomes.
Charles Goldfarb:That is quite a sentence checkpoints. surgicals portfolio includes a range of handheld interoperative nerve stimulators, nerve cutting instruments, and biomaterials To learn more visit www dot checkpoint surgical.com Checkpoint surgical driving innovation and nerve surgery.
Chris Dy:There you go. There you go. And checkpoint did exhibit and was a premier sponsor for our nerve course. So thank you to checkpoint for for supporting that. So basically, the question I wanted to ask you is, as surgeons, after we've placed pins, would you prefer that we bend or not bend the K wires after they've exited the skin?
Macy Stonner:I don't really care. Okay. Whatever, whatever you want to do.
Chris Dy:Well, I don't know sometimes it gets the way that the pins are, you know, position could get in the way of you know, wound care. And I clearly tried to make a point to make sure it's not going to get in the way of any. Any motion of the of the adjacent
Macy Stonner:Yeah, the only thing I can think of is sometimes like the pin cap is If it's a thick one, if it goes in the webspace, it drives him crazy. And it's uncomfortable for splinting, and just at rest, it just kind of like rubs on him. But that's the only circumstance where I think it's the position is annoying, but you might not be able to avoid that.
Charles Goldfarb:Presumably, for the index finger and the little finger you would prefer the pins to exit on the radio side or owner side, respectively. I assume that's a big deal. You can't really control with the middle and ring. Is that fair? Yes, that's fair. Sometimes easier than others, but I think it's a goal.
Macy Stonner:Yeah, that's fair.
Chris Dy:Chuck. Chuck, do you bend your pins? I can't remember.
Charles Goldfarb:I do not bend my pens. I use pen caps because they're inexpensive. Right?
Chris Dy:Right. No, I sometimes bend pins and I use Jergens balls, because they're slightly more expensive and to get underneath Chuck's skin. No, but I've had patients get kind of freaked out about the regular pin caps just kind of falling off so it's just one less phone call.
Charles Goldfarb:Totally Drew. may see Yes. coming to a close. We got to know what's your least favorite fracture to see is it a mallet fracture? Is it multiple falen geo fracture That's it.
Macy Stonner:That's it right there. So multiple multiple p one fractures, whether it's two three P one, fractures are difficult in general, but when there's more than one, I find that that's a huge indications for a more difficult recovery. Especially in an older patient.
Charles Goldfarb:Amen. I totally agree. And those patients get stiff they get frustrated i That's my least favorite scenario.
Chris Dy:Can I ask you a question? My multiple p one experience has been colored by a number of dog leashes injuries do I feel like those are the worst that has had those been a problem and you know, both of your practices in terms of you know, the the mechanism is challenging tons of swelling. They just seem to take longer.
Charles Goldfarb:I think it's true. doggedly people do not understand that dog leash danger is should come with the dog should come with a warning like, or the leashes should come with a warning. This happens all the time. It's like the equivalent of the trampoline for kids.
Macy Stonner:I'm thinking more about like a fall or something like that. But that's where a lot of the cases I'm thinking of with multiple fractures, but yeah, they're not fun.
Chris Dy:Okay, and Can I ask one last question Macy.
Macy Stonner:Yes, of course,
Chris Dy:if people have a dynamic External Fixator, of Slade frame, so to say they actually move in therapy.
Macy Stonner:Um, while I'm watching them and like telling them to do something short. But do they do it at home? Probably not. If that's what you're asking, Are you saying like, do they actually do the exercise? Or is their joint actually moving? Well, we
Chris Dy:call it a dynamic ex fix. And I feel like it's much less dynamic and more of a static ex fix for a lot of people. I've, it's almost like, honestly, it's like one of the fellows favorite favorite procedures to indicate when they come through. And then after having done it a few times, I've just been not impressed with their ability to move. Now ultimately, they do is as good as any of these patients can do, I think, yeah, I just don't think they're moving a whole lot. While they've you know, while you've taken the very high amount of time to put together that Erector Set with the rubber bands.
Macy Stonner:I have a relatively recent case from Dr. Brogan and he did great. He had a DPC of one or less, you know, negative 10 degrees of extension at the end did great, super swollen and his pap joint has always I think it'd be somewhat enlarged compared to the other ones. But he was like 17 and healthy. But an again, an older patient, I think that they would have like some chronic stiffness for sure.
Chris Dy:I guess I'm sending all those to Dr. Brogan.
Charles Goldfarb:He enjoys them. He enjoys them. Macy. Thank you as always, that was great educational for us and hopefully for our listeners. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to email us with topics, suggestions and feedback, you can reach us at hand podcast@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.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember,
Chris Dy:keep the upper hand them back next time.