Wednesday, 26 March 2014

Listening to Instinctive Fingers

My dog Barney was hit by a car this morning. Completely my fault. Off the lead, busy road, we are walking to school on one side, and there's a cat on the other. What's a whippet to do but trust his speed and chase? The Mercedes was quicker unfortunately. I ran him to the vet; it looks like he's a lucky dog, and we're a lucky family.

VP protective splint without tape

The thing is, that all the time he was in the vet's rooms, as she was listening to his chest, I was testing his legs. I was stressing the joints, feeling for instability, testing the integrity of the bones. I had to do something, and as ineffectual as it was, it made me feel better.

Now, I'm trying not to prostitute my dog's injuries for the sake of this blog, and it is a long bow to draw I know, but when bad things happen, we so often revert back to what we instinctively know. I've had three people through in the past few days with volar plate injuries to one of their fingers. Two went to someone else first. One listened to herself. 

VP protective splint without tape lateral
The former two came in with fingers that were swollen and angry. One finger was ramrod straight attached to an icypole stick, the other had been splinted in a flexed position for too long. They were both in pain and could barely move their fingers. The third had let her finger rest in the position it wanted to sit in, in about 40 degrees of flexion. She'd iced it, and lightly massaged the joint. There was still swelling, and there was some discomfort, but she was in a much better place because she had listened, albeit subconsciously to her injury. 

I manage all volar plate PIP joint injuries in a similar way. I splint in flexion initially, gradually extending the finger out into extension. Active flexion is encouraged within the limits of the splint. There's plenty of oedema control, and plenty of education. Sure there's a risk of flexion contracture, but with guided splinting the significance of this can be mitigated.

Two of the patients were high level sportswomen. They needed splints to play in, but also protect the injury. I used a product called Cobra Cast, and made volar splints that would limit extension but allow enough to shot a basketball, and permit enough flexion to hold a cricket bat, but still protect the avulsion fracture from impact. I can't claim either had a great game, however I am convinced that by letting the finger heal in a controlled manner, natural and instinctive recovery will occur. Just as it will with Barney.

Look after those fingers,


Wednesday, 5 March 2014

Those that can do...

Stuart Canavan is a physiotherapist that started his private practice around the same time as I started mine. We've stayed in touch over the years, as he and Kathryn Leggo morphed Rowville Physiotherapy into a giant sports medicine hub for the south eastern suburbs. 

They asked me in to chat with their physios about wrist injuries. I could have talked for days, but got an hour. Essentially my message became one of if you understand what goes where, and what does what, you can help the wrist regain the stability lost through injury. Ultimately, it is stability that is essential to the wrist above and beyond strength .

For too long, therapists and rehab professionals have been guilty of handing out static wrist curls and the like, building strength at the expense of stability; even as they prescribe exercises to maximise ankle or shoulder proprioception. In the hand therapy world, that's changing rapidly. Outside of that, the concept remains unusual, and challenging.

Ligaments need stress to be able to do their job. Their job is to tell the wrist what to do, when to relax, and when to tighten up. If they have a lay off, if they are locked up for a period of time, then they need re-education, much as the muscles do. So challenge them.

Do exercises for the wrist in unusual planes incorporating shoulders and elbows. Use balls, bouncing, rolling and catching. Swap a static weight for a dynamic one like a slosh pipe. Take the activities your patient likes to do, and include it as therapy. I had a fly-fisherman come in recently. On his first visit we got the basics under control. The second time he came by, he brought his rod and we fished for gravel in the car park. 

Anderson Hand Therapy may not have morphed into a hand therapy treatment centre megalopolis, but over the past 12 years, it has certainly allowed the part of my brain that devotes itself to hand rehab to morph into more than a one trick pony. And it all starts with what goes where.

Look after those fingers, Hamish