Tuesday, 5 May 2015

Surely it's not that tricky?

Come on Doc. You've had at least 6 years of study to get to where you are. The nature of the two letters that come before your name engender an immediate level of respect that no other working stiff can generate. So why is it so bloody hard for you to treat a finger volar plate injury? I just explained this injury to an eight year old, and she got it. Surely it's not that tricky a concept? 

Spot the tiny bit of bone. 

For the purposes of keeping things simple for the late referrers out there and truth be told, you're not all doctors, I'll just talk about the middle joint of the finger today, the PIP. Think of the volar plate as a bridge across the palmar aspect of the PIP joint. If this bridge is hyperextended too far, either the bridge will snap, and / or a piece of bone connected to the bridge will be pulled off. If that piece of bone is less than 50% of the articular surface, not significantly displaced or overtly unstable, the finger can heal without surgery.  

Broken bridge means bits are missing...
From here, there are only two things you need to know, so stick with me. When you splint the patient's finger in extension, the ends of the broken bridge are too far apart to join up. Do I need to say that again? I will. When you splint the patient's finger in extension, the ends of the broken bridge are too far apart to join up. 

I drew this. Brilliant right?

Point number two. If you tell the patient not to bend the finger, the finger will get stiff very quickly making my job even more difficult when you eventually decide to refer him or her on after 7 weeks of ineffectual management. Bending the finger will not stress the repairing ligament. Straightening it too far will. 

One option. But understanding the concept is everything.
If you are still with me, you should be able to understand what to do next. Right. Splint the finger in a bent position. This will approximate the ends of the bridge, allowing the natural healing process to join them up. Encourage the patient to bend the finger as tolerated as long as there is no instability. Again depending on the patient and the circumstances, next week, straighten the splint a little. 

My treatment protocol varies significantly according to the patient. Some are in a splint for 4 weeks, some more, some just 2 and then buddy taped. Some never get splinted at all. They're an easy injury to treat properly, but can quickly go pear-shaped if basic principles are ignored. What you, dear late referrer need to comprehend, is that none of my patients are ever splinted straight because although my wife tells me I need the money, fixing your mistakes is not work I enjoy. 

Look after those fingers,


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