The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Hand Injuries in Rock Climbing
Chuck and Chris discuss rock climbing injuries. We review general hand and wrist injuries but focus on the classic injuries to the fingers and flexor tendon sheath.
We refer to
Upper Extremity Injuries in RockClimbers: Diagnosis and Management byLaura A. Sims, MD. J Hand Surgery 2022; 47:662-72
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Chuck, 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, and thank
Chris Dy: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 great. It's Saturday morning talking to you. What could be better? Yeah,
Chris Dy:well, it could be better for outside. It's actually pretty nice morning, from what I understand.
Charles Goldfarb:It was a nice morning. I had an early coffee, and now we're chatting and yeah, hopefully it's gonna be a great
Chris Dy:day. I think it's a nice reprieve from the triple digit Fahrenheit weather we've been having. I think this weekend will be nice, but it's back into the upper 90s and close to 100 next week.
Charles Goldfarb:It feels weird to say, but I think we haven't had a bad summer heat wise. I mean, it is getting there now. In August is always the worst, but compared to much of the country, St Louis has not been so terrible.
Chris Dy:Yeah. I mean, I think that there have been days where we've had monsoons, so the humidity has risen, which has been challenging. But to your sage advice, a few years ago, we decided to no pun, totally intended. But I mean, take the plunge and put in the pool, and that's been paying dividends in terms of having some ability to cool off.
Charles Goldfarb:It's great when your kids use the pool. I have a pool that no one ever gets in, and yet I clean it every week, and it kills me every day.
Chris Dy:So you got you, you do the cleaning yourself now.
Charles Goldfarb:No, let's
Chris Dy:see, I think I told you this, and one of our partners in the peds ortho division feels similarly. I like the night swim. It's actually a really nice way to just relax, unwind, no devices, put on some music, and just spend 1520 minutes in a pool. It's very relaxing for me, and it makes me feel like I'm getting return on investment.
Charles Goldfarb:I need some of that. Sorry. I have a post viral syndrome, as I've been told, that's been going on for three weeks. But this is post work.
Chris Dy:This is like, post work. Kids in bed after dinner, like everybody's like, usually at that point my wife is is working out. Because I'm the morning workout person. She's the evening. So I try to, you know, unwind, stay up a little longer so we can hang out if she's done working out, and then some in the pool, just hanging out a little bit. I
Charles Goldfarb:love it. I love it. That is, that is great. I have to consider that. Because, I
Chris Dy:mean, as soon as I as soon as I lay on the couch to watch TV, I'm out. So it's true.
Charles Goldfarb:It's true. Usually my evening reprieves are reading, and it's usually trying to read something mindless, but lately it's been B school reading, which doesn't have the same effect. Yeah,
Chris Dy:you're you're quite busy. You know, we can talk more about your B School experience in a future episode, but I fear you've had a recent trip up north. Is that right? Yeah,
Charles Goldfarb:I went to be the graduation speaker for Mayo's Fellowship, which was really a treat. Had a great trip, saw a lot of friends connected. You know, what's really nice about these is the ability to connect with the fellows. So we had a nice dinner, just the fellows and myself. The whole rest of the the next day was spent my giving talks, their giving talks. We spent about two hours in the lab together doing dissections, very similarly to what you have established here, where the fellows request each of us to do a dissection and and we just did different things. And I told, told the fellows of mayo, just like we tell our fellows here, kind of how we think about things. Yeah, I gave the talks I think are interesting, and we can discuss that briefly. And then had a nice graduation dinner where I thought it was kind of cute the mayo attendings write a limerick about each fellow and share those. So that was creative and cute. And came home. So it was very nice. The Mayo Clinic is a really impressive place. And not that anyone would ever doubt that they have, they have a really amazing facilities. And it was, it was fun to see it, it's, it's different than what we have. I wouldn't say better in any, in any form or fashion. It's just different.
Chris Dy:Yeah, no, I've gone up there. I went up there when, you know, I think when I was relatively new attending, and attended their brachial plexus course, which they which was great course, international faculty, fantastic. A lot of what we've done with the Washington course was modeled after how they've structured their course. And, you know, went up there as during my government travel, government scholarship travels a couple years ago and really enjoyed it. So it's, it's a fantastic place, I think, you know, like you said, there's a lot of differences. It makes you appreciate those differences and different approaches. Yeah,
Charles Goldfarb:it is. It is a lesson to residents and fellows who may be listening and medical students who may be listening, and that there's a lot of different. Ways to run a practice and have a how one exists in relation to the care they provide and and it's really important to understand those I you know, to some degree in residency, although that's not the primary goal in residency and fellowship, you know, I think you learn a lot in addition to hand surgery, if you look carefully. So I think it does matter for fellowship. Obviously, it matters for life, and you're going back up there in February. I don't know in what capacity, but as a visiting professor in some way.
Chris Dy:Yeah, it was. It's a tremendous honor. But I was invited to be the Morton spinner visiting professor and in peripheral nerve surgery. So that's named after Robert spinners, Father Morton spinner, who is a well known hand in peripheral nerve surgeon, and Rob is a one of the elite neurosurgeons in peripheral nerve and you know, honestly, their their Plexus team, which is Rob, Alex shin and Alan Bishop. That team is the the standard at which, you know, I have tried to establish the practice that David and I are working on in terms of nerves. So huge honor to be invited to come up. I believe it's sometime in February. Very excited to do that visiting professorship, give a talk at ortho Grand Rounds. I think it'll be really fun. So thank you to the Mayo team for inviting me to come back. I will probably end up mentioning it during my talk up there. But I did apply for residency. Didn't get an interview. I did apply for hand fellowship, didn't get an interview. So this feels really good to go back and be invited to do this. So yeah,
Charles Goldfarb:I heard they usually hold that that visiting professorship in May, but in special honor for you, they moved it to February so that you could enjoy the Rochester winter.
Chris Dy:Oh, yeah, of course, of course. And you know, I kind of feel like, you know, you Michael Jordan got cut from the, you know, the freshman high school team. Caitlin Clark didn't make the Olympic squad. My chance to show that I can, I can, I can hang with the guys up there, but and the gals, but it's, I mean, honestly, their nerve team is amazing, and we're, we're doing our best to to really emulate what they've been able to do up there. So, um, well, we did send off our fellows since the last time we recorded. And I know our last episode was focused on pearls for our graduates, it's been interesting to welcome our new fellows. We've got three new fellows on board, and you talk about differences even one day in the or half day in the or a half day in clinic with with a new fellow, and then a full day in clinic the next day, just differences and exam and approach. And, you know, it is, it's going to be a fun year. I think,
Charles Goldfarb:yeah, it's going to be a fun year. And I've, you know, I've gotten a little started, you know, our fellowship began on Thursday, which was August 1, and this a little time with fellows. And yeah, it'll be fun. I am working with a plastic surgery fellow first, which will be great for two months. And look forward to it. You know, there's certain things that plastics fellows are interested in, and a lot of that tends to be bread and butter, hand rather than flaps, because most of them are are skilled in that domain, they tend to be less interested as a generalization, and things like elbow arthroscopy, which is easy to understand, but, yeah, it's always super fun and the process, and let's be honest, you and I learn as well.
Chris Dy:Yeah, absolutely. I learned a lot, you know, from our different trainees, you know. So one of the, one of our, the new fellow that's on my rotation right now was quoting some literature I hadn't read before. He's like, I'll send it to you. I said, send it to you. I said I probably won't read it, but actually said it to me, no, I think it's it's been great. Dan's been fantastic on service. And then Nick colado, who you're mentioning, did come to our nerve clinic in the afternoon on Thursday, and I enjoyed having him there. So So here's to the new academic year before we jump into today's topic, which I think will be of relevance to a lot of people who are seeing patients who are rock climbers. We should thank our sponsors at practice. Link,
Charles Goldfarb:absolutely, the upper hand is sponsored by practicelink.com, the most widely used physician. Job search and career advancement resource. Becoming
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Charles Goldfarb:So we are. I mean, we could probably start with the case, but I would say that there's rock climbing indoor and outdoor around St Louis. I don't know that I would describe us as a hotbed, but I think as much as I know we are as our community is active in rock climbing as much as any other
Chris Dy:Well, I think it's a, it's a it's an activity that has really exploded in popularity. I mean, I remember, this was late 90s, when I was finishing high school, the prep school that I went to had just put in a rock climbing wall, which was like a huge deal. But I think they're everywhere now, and people are climbing indoors and outdoors still, generally terrifies me to do anything that that risky, as we've talked about before. I'm pretty risk averse, but my son loves going rock climbing. They've got one at their school, of course. And then, you know, one of the things that he requested to do on his day, where I hung out with him on his birthday, was to go rock climbing. So we've gone. Couple of times, there's some really cool gyms in St Louis, and it's, it's, I'd love to do a little more of it myself when we're in there, because a very safe environment. But a lot of times I'm just watching him just scamper up the wall. I mean, it's amazing, like, the kid gets, like, 40 feet in the air. And I'm like, I probably should be more concerned. We actually went with one of our partners kids, and he was like, aren't you? Are you a little worried? I'm like, no, they're strapped in. I feel like they're fine. But
Charles Goldfarb:it's the it's the stage of life where you're, you know, nothing can hurt me. You know, when you're a young kid and you're you're not completely they're not completely wrong in thinking that way. I love the risk averse. Chris, as as you have shared with us some of our listeners, including myself. Honestly, I never went to a school, and yes, there was rock climbing when I went to school, but I never went to school where they had their own rock climbing gym or a wall. So you grew up and went to a school that had a rock climbing wall. And of course, the apple, as my mom used to say, The apple doesn't fall far from the tree. Nobody
Chris Dy:here knows me from high school, but I was, my habitus was, I think, quite a bit different in high school, there was no way I was climbing a rock climbing wall tell you that. So things have changed, and, you know, hopefully for the better. But yes, I was fortunate enough to go to a school that was, let's just say, well, resourced and and I'm fortunate enough to be able to provide that for for my children? Yeah, absolutely,
Charles Goldfarb:as my wife always said, you know, if you could afford the the excellent private school education, why would you not do that? And I always, you know, we had a Marty and I met with the fellows before they left a couple days before, just talk about life finances. And we do a little financial work. We talk about coding, of course, but outside of that, and I, one of my favorite things to say is the greatest, and I do believe this, the greatest gift my parents gave me was education, and it was great education, and I did not have medical debts. I meant not medical debts. I did not have school debts to pay. And that's an incredible gift and and certainly that is a goal for my children as well.
Chris Dy:Right? I was told I was going to have the same gift for medical school, and then the stock market crashed right when I was in medical school. So I am happy to pay off my loans like everybody else, but I'm almost there. The interest rates so damn good. Why would you pay it off right away? So at least it was a full time. So the today's episode was actually originated by an email that we got from a listener, and he I asked Dr Christopher McMullin, who is a physiatrist and the associate PD for the pm and our residency at the University of Washington up in the northwest, in Washington State, he emailed me a question about hydro, hydro dissection for nerves. And we exchanged some emails, and he said that he does listen to the podcast. And I was very excited about that. And I asked Chris if there was something that he was interested in hearing about, and he did say that he sees a number of rock climbers and looking for ways to brush up on his hand knowledge. So that's why I started listening to the podcast. And some of the more technical discussions are a little bit outside of what a pm and our doc would would typically take home a lot from but he did ask about to us to talk about climbing injuries, pulley ruptures, but any other kind of injuries that are relevant to rock climbers, which was perfectly timed because we actually had recently read an article in JHS center. It was a current concepts review on on rock climbing injuries. Thank you, Chris, for writing that in. And I think Chuck, if you have a case that we could talk about that'd be super helpful.
Charles Goldfarb:First of all, I should say that, you know, we you and I brushed up on things that we like to make sure we don't miss any of the obvious issues. And so Laura Sims from the University of Saskatchewan had a good article in 2022 in general hand surgery entitled upper extremity injuries and rock climbers, diagnosis and management. I'll put this in the show note, show notes. And what was interesting about this article is it did emphasize other things besides finger issues. And I think those are all the pretty logical ones. Whether it's TFCC from a rotational injury hook of the handmade, uh, elbow issues, like tendonitis, shoulder issues, those are all in play. But what most of us really think about with rock climbing is clear it's the flexor tendons from crimping, etc. So let me give you a case, and we'll use it as a jumping off. So I have a 32 year old, fit young man who is an avid rock climber, not his job. He has a desk job during the day. He climbs three days a week plus, and came in with sort of an acute on chronic injury. Had some middle finger pain, which was sort of at the base the finger, by his description. And it got worse. He denied any sense of tearing. He had a little bit of swelling. Had maintained full mobility, but had pain, which prevented him from rock climbing. And when you get to the prevention stage, obviously that leads to the doctor's visit. Um. So how do you think about these things? What's running through your head? What testing Do you consider?
Chris Dy:Well, first off, I mean, I when I read the article, I saw all the different grips, and I was like, Man, I'm like, not gripping things properly when I'm doing my kind of twice a year rock climbing indoors. But, yeah, no, I think that the you know, the first thing you think about, because of the way that, you know, we've been taught, is you think about, is there a pulley rupture? And, you know, the classic, you know, vignette for a polypter Is somebody feels a pop or a sensation of tearing, and they swell and they can't make a full fist. Now, somebody doesn't have to, kind of meet the classic vignette to have an injury like that, but that's the first thing I'm thinking about. And then, honestly, I learned a lot in reading this article about some of the other different things that could happen in terms of, you know, when the lumbar cool shift, which was very interesting. I think it depends on what kind of grip the patient's using. And we can talk about that in more detail, about how to think about that, how to assess that. I think, you know, the exam is critical. So feeling, seeing where you know if there's any clinically visible lack of motion, you said, Yes, full motion. If there's any areas where there's distinct ecchymosis or swelling or tenderness, I think tenderness is probably the biggest thing for me on exam, and then during that exam, excluding other potential issues, something more proximal, or something like a collateral ligament issue or a joint sprain, or something like that, which doesn't seem to be the case here. So, and then we could talk about imaging in a moment. But what is there anything else you think about on the exam? I think
Charles Goldfarb:this will be a good video podcast for those who want to join us on YouTube, and we can talk about certain things I would love to know, and I really honestly, I would love to know, hopefully our listeners will as well. How do you examine in these situations? What are you testing? How do you look for bow string? How do you test FDS versus FDP? How do you palpate those kind of things? I think would be helpful to discuss and demonstrate. Maybe.
Chris Dy:Yeah, so, I mean, I am. I don't have a great exam specifically for bow stringing, aside from tenderness along the suspected areas. I mean, I think the classic, you know, rupture is going to be at a two, you know, but that's not always the case. I mean, there's tons of pressure also over the PIP during a lot of these grips. So could be a three as well. But seeing where they're tender, whether where it is based on from the, you know, in the area between the Palmer digital crease and the PIP crease, and then trying to differentiate. So, yeah, if we're doing video, so between the palm digital crease and the PIP, and then really trying to isolate the FDS. So, you know, because of the common, shared muscle belly, oftentimes we'll kind of get the fingers out and then try to get the PIP flexing here and see if, if that, if that elicits any sort of limitations in motion compared to the adjacent fingers, and then you can isolate the FDP by blocking the FDP as well. So seeing how the motion in those and if there is differential glide, the odds of there being anything crazy with like a jersey finger or something like that, you got to make sure. But I think that's less likely in this particular situation. Yeah,
Charles Goldfarb:I think that's well said, and for the younger listeners, I'm just going to make that hopefully maybe it was clear enough, maybe, maybe, maybe not. So what Chris was saying is, if you want to test FDS, if you keep the other fingers extended. So if you're going to test FDS and middle finger, you extend the other three fingers and ask the patient to flex, because the FTP is a common muscle belly isolated flexion of, say, the middle finger, which I have flexed here, is done only by the FDS. And so it's a great way to isolate the FDS, and you can do that for each finger. And then, as Chris said, test the FTP. This is not only applicable for rock climbing. It's also applicable for give a laceration in the palm and you're trying to figure out what may be injured, and what gets tricky in this case and in a laceration case, is, what if you nick the sheath, you know, does that cause pain? What if you Nick a tendon and have a partial tendon injury? And so you're not only looking for the ability to flex, you're looking for pain with flexion. And I'll say one other thing before I turn it back to you this article I thought was really helpful to test for bow stringing. Which, which we, you know, is not the easiest thing to test for. It often is seen on imaging more easily is basically it's resisted PIP flexion and potentially palpable. I honestly can't say I've ever palpated bow stringing in this kind of situation and a patient that didn't feel a pop. I'm not sure we're really worried about both training, but it's something you want to test for.
Chris Dy:Yeah, and I think that's, that's well said. And, you know, I think that as you're examining the other thing that tends to be in differential is more of a generalized flexor Tina synovitis kind of thing, not necessarily along the lines of trigger finger, but probably in this similar family and that, I think would be diagnosed with kind of palpate pain with palpation, a little more proximally than what we've been talking about so near the distal Palmer crease, proximal to the Palmer digital crease would get you, give you a good sense of that, but I completely agree. I think the bow string is probably more more readily diagnosed on imaging. Probably would get a fluorescing image just. For exclusion sake, but not necessarily. Sometimes, if you're going the MRI route, having a plain film type image is helpful for authorization in the United States, but I think ultrasound is really helpful in this particular situation. Yes,
Charles Goldfarb:totally agree. I mean, MRI can be utilized, and it's institution dependent. How good are your ultra stenographers? Are you the hand surgeon doing ultrasound? But ultrasound is my first choice. I know you do some ultrasound. Is this something you would feel comfortable ultrasounding yourself? Or do you send this out?
Chris Dy:I don't. I mean, I think if I worked at it a bit, I could do it. But to be honest, from a practical perspective, we don't have a probe small enough in the clinic where I work to do it, so the small footprint probe tends to live in the two other locations where I don't go. So it just, honestly, it's just, I think, easier for me, and I feel more confident sending it to one of our partners in our pm and our department division that do this quite readily. And obviously we have radiologists who are skilled as well. Perfect,
Charles Goldfarb:perfect. Yeah, we are in a very enviable situation where we have multiple different providers who can put providers who can provide this service. So you see the patient, they have some vague discomfort, let's say near the palm of digital crease, no palpable bow springing, no ganglions, some mild discomfort with resisted flexion, but nothing dramatic. But you know the guy said that, hey, I haven't climbed in two weeks. It feels a little better, but I still have pain, and so is your next step in ultrasound? Or would you consider an injection on that first clinic visit? Or what do you
Chris Dy:do? I wouldn't necessarily go straight to an injection. I think if I was, you know, I think if they're rock climbers, tend to be a different breed. They love rock climbing, and they're very apt to continue climbing through a lot of stuff. But if it says a lot, if this patient can't climb one thing that we didn't talk about, but you know, if, if this was not the middle finger, but if it was the ring or the small, I think the differential changes a bit to talk about hook of handmade issues, and with the FDP ring and small running over the hook of the handmade and with that kind of repetitive grip through the FDPs that can really put a lot of pressure on the handmade. And if your your suspicion is more for a stress reaction or eventually a non displaced hookah handmade fracture, then there might be a role for a straight up cast immobilization, which obviously would keep them out of climbing for quite some time. But I think my counseling would probably be with this middle finger patient to say, why don't you stop climbing for a bit? Let's see if things quiet down even before jumping to an ultrasound or an MRI. I may just give them the option of activity modification and a pulley rig, because even if it's not truly a pulley injury, that might make them feel a bit better, and I think that's something that can be readily accomplished by our therapy colleagues, or pulley rings can also be purchased. You know, on the on the interwebs, I love
Charles Goldfarb:all that. I want to, I want to follow up on a couple of those things. First of all, I'll start by saying many of these experienced climbers will take their fingers in advance, or will take their fingers in an effort to control discomfort and create their own pulley rings with tape. We all know the limitations of tape, though tape is uh, it feels good when you first put it on, whether you're taping your ankle or taping your fingers, but it doesn't tend to do much over time, especially with sweat. So pulley rings make sense and can be helpful, along with the typical non operative modalities like anti inflammatories, etc. The other thing you said, which is interesting, which I totally agree with, is the hook of the hand, and so I have traditionally, and this is a little bit of a side, but not really diagnosed, hook of the hand, just by palpation, right? So you go about two centimeters distal and radial to your PISA form. PISA form is always at the risk crease and hoping the handmade is distal. And typically, it's an easy diagnosis, so to speak. I love this test, which I honestly haven't been doing for that many years, where you ask the patient to only deviate the wrist, even though I don't think that's vital, you extend the wrist a little bit, and then resist, you know, flex their fingers. And I resist them. If they have a hook of the hand manufacturer, they jump off the chair. It is really, really impressive. It's a super helpful test, yeah.
Chris Dy:And in addition to what Chuck has shown us here on the video, I mean, it's, it's nicely laid out in this article, you know, the other way to increase the sensitivity of that test will be to palpate on the hook, as you're doing that resisted FDP for the ring and small. And again, I think that's a really interesting and great test, and probably can help you quite a bit without any imaging. Yeah.
Charles Goldfarb:And just to be clear, I think we glossed over it a little bit, and this article will help but crimping. For those who aren't familiar with it. You know, there's different there's open crimp, closed crimp, and there's all kind of different hand positions. And I'm not a climber, so just the concept of crimping in general is a little bit of MP flexion, typically maximum PIP flexion, 9200 degrees, and the dips are usually extended. So it's just an unusual force. Load on the fingers, which really puts pressure on the FDS and the a two pulley, as you mentioned.
Chris Dy:Yeah. So they mentioned, they also showed, in one of these crimping pictures, that the thumb is, you know, the thumb is pressing down and applying additional pressure over p2 which again, will extra load that, that Pip, kind of a two, a three, kind of pulley area on the index finger. And then for the for the hook of the handmade thing. I mean, it was interesting. They had these. They showed this really weird grip, which I would have never thought about, but this under cling grip, which is like, you know, flexion of the wrist and ulnar deviation, and then pulling through the FDP ring and small, like the exact setup you would need for a hook of the handmade stress reaction.
Charles Goldfarb:Yeah, all kind of, all kind of unusual dynamics. So would you have injected
Chris Dy:this patient? You mentioned that you asked that to me, and I said, No, but yeah, I
Charles Goldfarb:would not. And maybe there's if the listeners out there would do it. Maybe, if you live in Boulder, Colorado, and you have a huge population, maybe you are injecting on the first visit. I always hesitate to inject on a first visit for a lot of reasons, including the fact that the path understanding the pathology, I think, is helpful in these situations. Giving it a chance to calm down without jumping to an injection is just my preference. So I send it for an ultrasound.
Chris Dy:Yeah. And I think practically, just for a number of conditions. I'll tell our learners when they're with me, it's like, I try not to put needles in people the first time I meet them, try not to book surgery the first time I meet them. And just I usually say, Listen, if it's really bugging you, we can consider an injection, but we might want to keep that in our back pocket for a future visit if things don't quiet down. So I would have gotten an ultrasound too. Plain films any use for you, or you skip that step,
Charles Goldfarb:I think what you said is really important. I don't think they're necessarily useful. And if I'm going to get them, I probably do a mini CRM, just because it's quick and not terribly costly. But if you're considering an MRI, you almost always have to have a playing films before our insurance companies in the US will pay for it. So there's that factor. Before I share the results of the ultrasound, I know you're dying to know what we found. I'd like to thank checkpoint surgical, yes,
Chris Dy:the upper hand is sponsored by checkpoint surgical, a provider of innovative solutions for peripheral nerve surgery as a hand surgeon and a hand therapist or a pm and our doc, or anybody that to his listening to his podcast. You know that the nerves matter. It's why checkpoint surgical is singularly focused on elevating the clinical practice of peripheral nerve surgery with innovative technologies that help improve patient outcomes.
Charles Goldfarb:Checkpoint surgical portfolio includes a range of handheld intraoperative nerve stimulators, nerve cutting instruments and biomaterials. To learn more, visit www.checkpointsurgical.com checkpoint surgical driving innovation and nerve surgery.
Chris Dy:There are nerves around the police too. So you know, it's not something we talked about for this particular condition, but they did mention that carpal tunnel syndrome could be something that you see transiently in climbers, just given all the all the stress on the lung flexors as they enter the carpal tunnel.
Charles Goldfarb:That's exactly right. So, you know, I hate to, you know, build up the suspense around what was the outcome of the ultrasound? And I have to say, this is, not uncommonly, the outcome. It didn't show much. It was, you know, the pulleys were intact. And I think in general, we have a sense of when the pulleys were ruptured, whether there's bow stringing or just that more sudden traumatic event with Audible popping or tearing, and there was inflammation, and that's all we found. So there's inflammation on the ultrasound. Patient remains sore. He's tried anti inflammatories, he's tried taping. And so I, as we've talked about, I call my patients with test results and then decide where to go with it. If I'd called him, he was better, I'd say, you know, tape and try to get back to climbing. But I called him and he wasn't better. So I say, come back to the office. How do you handle that?
Chris Dy:Similarly, I tried to be better about calling and try to get a sense of that, you know, whether it's a patient I want to call her and whether I think that's going to be an effective conversation, or whether they're the kind of person that's better off coming in back. I think in this particular demographic, he probably wanted you to text him, but you wouldn't do that, so you call them instead. Yeah, so I agree. I think that, you know, oftentimes it is not a poly rupture, although that is what we want to diagnose. I think some of our I think our residents or fellows may have heard me tell the story, but I remember one time in the fall, it was like the first month or six weeks of my hand surgery fellowship. I was, of course, on Dr galbians rotation to start, and we were in his clinic, and I saw a patient who felt a pop and couldn't move his finger very well. And he wasn't a rock climber, but he was a manual laborer, and, you know, was pulling something heavy off of his truck. And I came out of the room, and I very nervously presented to Dr gelberman, and said, you know, Dr gelberman, I think this patient has a pulley rupture, you know, how would you like us? You know, I would plan on getting some additional imaging. And then he just looks at me. He and says, Chris, do you think he actually has a poly rupture? I said, Yes. And he looks over as medical assistant says, Tiffany, have I ever diagnosed a polypter in clinic? And Tiffany's like, no, of course not. Dr government. He looks over at Rhonda, Hand Therapist that's in clinic, says, Rhonda, have I ever diagnosed a polyruptor in clinic? Said, of course not. Dr galberman, and he looks at me and just walks into the room as if he had a trigger figure. So that's awesome. It got better. Oh, it's funny, this time of the year always brings about such fond memories of the beginning of my fellowship, and some of which I've already shared with our new hand fellows during their onboarding. But so yeah, oftentimes it's not a pulley rupture. We've talked a lot about this concept of bow stringing, and I think it probably would be good to unpack that a bit for the people that are a little less experienced. But you know, the pulleys are, they're series of very tight, tight bands, essentially that run around the bone throughout the finger, and really hold the flexor tendons tightly adherent to the bone, so that they can actually work across the joints and lead to the flexion of the of the PIP and dip. And if you have a pulley rupture, that ring opens up, and then it's no longer holding those tendons down to the bone, and you see something called bow string. And now in the setting, we would see it more commonly, would be if you had a trauma to the finger and you had multiple pulleys that were opened up, either from the trauma or from the process of repairing the tendons. Then the tendons don't stick down to the bone, and they come off of the bone, and then they're less. They're not as their biomechanical efficiency to flex the joints is less because they're further away from what they're trying to move. So that's the concept of bow stringing. And then if you were to image that either on ultrasound or an MRI, what you're looking for is to see the distance from the and this is helpful on MRI just because you have the adjacent fingers in the same cut, but you can clearly do it on ultrasound. You'll see the flexor tendons floating more vulnerably. There's more space between the bone and the tendons at the area of the suspected injury, as opposed to either proximal, distal, on the finger or on the adjacent fingers.
Charles Goldfarb:Really well explained. I have two additions. The first is that, number one, we think about this a lot as we consider flexor tendon repairs, and we've made this point repetitively, if we're going to open a finger and do a flexor tendon repair, we try to work between the key pulleys being a two and a four, but only open what we have to because while the a two and a four are clearly the most important pulleys, if we have to sacrifice one or one has been injured, if we have the a three and the c2 and the a four intact, well, the likelihood of bow stringing is decreased. So that's super important. The second point is that while everything you said is true and you lose the mechanical advantage provided by the pulleys when they are injured, so flexion, strength and work reflection may be affected clinically. What you see is a lack of full extension, and Marty Boyer taught me that many years ago, and at first I just had a hard time wrapping my brain around it, but it's true, if you injured a two pulley, you may develop a pip flexion contracture. Now it's not going to be a huge contracture, but you just don't have full extension. That's really interesting.
Chris Dy:I think that's a really good point, and I think that's not stuff that's in the textbook. So thank you for bringing that out. I think that there are people that would want to know what how we would approach this surgically, if it actually was a surgical case, but I will share a couple of vignettes about surgery for this. I don't know how many you've done in practice. I've probably I can count it on one hand, and that would maybe be generous. But interestingly enough, I was asked by a faculty member during my residency to to help write a review article about flex or pulley reconstruction. And I said, of course, being a resident, but wanting to go into academics, I think I was applying for hand surgery, you know, soon as needed to kind of get some productivity. I said, of course. And I asked this faculty member if they had any, uh, cases to share. No cases, at least, documented with pictures. And I asked around the faculty, and there was not a whole lot of responses. So it's just and not that's nothing against the people that I worked with in residency. We actually ended up doing an article, a separate article, because of that, looking at in New York State, how many pulley reconstructions hand surgeons had done. It is very, very small. So this is not a surgery that's coming up often, at least in New York State. I don't know how many rock climbers there are. Maybe it's more, more coming up more often in places where there's a higher incidence of rock climbing, but it's just not a common operation. That's what I'm trying to
Charles Goldfarb:say. Oh for sure, I don't know that I've done. I don't think I've ever done one in a rock climbing situation. So I've done them, of course, for chronic flexor tendon issues. And, you know, stage reconstruction, that's the only setting. And I've done that maybe low double digits, if that, but probably between five and 12 or something. So really low numbers. There's nothing technically all that challenging about a lot is made in the hand surgery textbooks about how you wrap the reconstruction like the Palmaris, around the bone, under over the extensor tendon. But yeah, haven't done a lot of it. And because number one, but the pulley ruptures are rare in the rock climbing population. And two, if you have a sorry. I keep saying flex chicken, if you have a pulley rupture, usually it's one pulley, and you do fine. And in a situation like the case I presented, the patient either gets better or you give them a cortisone injection and they get better and they move on. Yeah,
Chris Dy:I think that's I think that's true. You know, I think for the people that are taking tests, still, there are, it's a testable topic, just because hand surgeons like to talk about it. You know, there are a couple of different ways to do the reconstruction of the pulley, like Chuck was mentioning, if they supposedly, there's a quote ever present rim of pulley that remains after a rupture that you can use to to to weave a Palmers through. So essentially recreating that pulley, or you can take a Palmaris or any sort of other graft, and actually, instead of weaving into that, wrap it around the bone and use that to help keep the tendon down, you just need to make sure, as you're wrapping it around that you're not catching the extensor tendon on the other side, on the dorsal side of the bone. So you need to make sure your your loop passes underneath the extensor tendon, adhered to the bone, and then goes on top of the flexor tendon to keep it snug to the bone. And, you know, there are a lot of different ways to secure that kind of loop. There's a whole There are way too many ways to do something that isn't really that common.
Charles Goldfarb:Yeah, that's right. There's, you know, hand surgeons like, there's an academics bent and an anatomical bent to a lot of this stuff. And so sometimes topics get magnified out of proportion to prevalence. And this has been one, and
Chris Dy:it says that this is why I wrote two papers on flexor pulley ruptures. And look at you today. So that was fun, you know. Thank you to Chris for sharing that suggestion. Hopefully, that helps elucidate some things. And if there are any questions that you have about that, or clarifications or pearls you want to share from your practice, please email us the same thing to any listener hand podcast@gmail.com
Charles Goldfarb:Yeah, we would welcome some pearls. And again, Chris and I have admitted this is not something that we see despite our sports population, as much as others may so please share any any tidbits or any recommendations you have with us, and we'll share them with the audience. So thank you very much. Yes and
Chris Dy:absolutely. And in the therapists that are listening, you may see a lot of these patients too. So please send us your pearls of wisdom, and we're happy to share them on the air until next time.
Charles Goldfarb:Fantastic. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to email us with topic 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. Special,
Charles Goldfarb:thanks to Peter Martin for the amazing music,
Chris Dy:and remember, keep the upper hand. Come back next time you