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,

Hamish

Good enough for Warnie? Good enough for you.

Should be in the Olympics

It’s hard to know where hand therapy fits in to the lexicon of sports injury management. At first glance, depending perhaps on your background, it would seem natural that it be considered essential. Try and think of a sport that doesn't involve your hands or wrists or elbows or shoulders in some way. The Inuits seem to have a few covered, but haven’t yet taken the world stage by storm with leg wrestling and high kick competitions. There’s also the great English sport of toe wrestling, which perhaps their miserable World Cup cricketers are more suited to.

NFL Hall of Famer Ronnie Lott had the tip of his left little finger amputated
 so he could keep playing. Treatable swan neck too.

If you discount those athletic pursuits like running and jumping, any sport that demands equipment, or has a ball, also demands good to normal hand function. So why is it I still see, even in the professional sportsperson managed by an in-house rehabilitation team, severe injury that is not treated and that will almost certainly lead to long term pain and dysfunction? It’s because if you can run, you can play. “Suck it up Princess, we’ll tape that digit up and send you out after an injection or two!” 

NFL wide receiver and future Hall of Famer Torry Holt.
Can you pick which finger is stuffed? 

I can appreciate that sentiment at a professional level. I've been an advocate for returning elite sportsperson back to sport before I’d let a layperson with a similar injury return to a labouring job. In doing that, I don’t believe I am maintaining the passive aggressive ignorance that has historically governed hand injury at that level. Rather I do it because I know that that athlete has every possible diagnostic and rehabilitative process at their disposal, and that if I've done my job well, I’m confident they can play protected. It’s when these same processes are available but not utilised that I get cranky. 

The problem is compounded when school kids are encouraged to play through a recently dislocated finger having been advised by someone who doesn't know better, that they’ll be fine. Or when the manual worker, who strained his thumb ulnar collateral ligament in a weekend game of footy, doesn't seek treatment for it because his team mates tell him he’s soft, further damages it at work, and now needs surgery that puts him out of footy and without a payslip.

Making those fat digits work...

...and work again. Miss you Warnie.

By not hiding that I work with professional sports-persons, I am in no way showing off. I am teaching my weekend warrior patients and the school kids that come through after cricket, gym or basketball that their injury is legitimate, should not be ignored, and needs treatment from someone who knows what they are doing. If hand therapy is good enough for Warnie (didn't treat him, but know who did), it should be good enough for everyone else. 

Look after those fingers,

Hamish

Thumbs vs Shoulders

What a good boy!

Those therapists that have written pages of trivia about the instability of the shoulder joint need to take some time out, breathe a little less of their own self-importance, and have a look at the humble thumb. True thumb opposition is a movement unique to humans, and if that's not enough evidence as to why its' stability should rate more highly, it can also take credit for allowing Jack Horner to stuff his face with the best bit of his Christmas pie. Try doing that with your shoulder! 

The thumb carpometacarpal (CMC) joint is a saddle joint. It is capable of 360 degrees of circumduction, as well as abduction, adduction, extension and flexion. It is crucial to good grasp, and essential to pinch. Like the shoulder, it is not solely dependent upon bony congruity for stability, relying significantly upon a network of soft tissue structures. When these structures fail, the stability of the thumb's base is threatened and daily function, let alone sporting function, is significantly impacted.

Not Ivy, but can you see how the downward pressure
 of the bar could force the metacarpal anteriorly?

I see this most usually in older patients who have degenerative osteoarthritis of that CMC joint. Today I saw it in a young, female elite power lifter. At the top of the snatch move apparently, good form combined with normal shoulder bio-mechanics, dictates that the bar with all its weight, rest not in the palm transferring weight down through the arm, but across the first web space. 

For a woman with naturally hyper-mobile joints, this is not ideal. Ivy (not her real name) had developed a subtle palmar instability at the CMC joint in one hand. When under load at the top of the snatch, with the bar's pressure over the distal end of the metacarpal, the joint would feel as if it were about to dislocate anteriorly. It had become painful, and clicky with circumduction. It was perfectly stable with pinch and grip, and her global strength was unaffected, but crucially abductor pollicis longus (APL), extensor pollicis longus and brevis (EPL/B), and extensor carpi radialis brevis (ECRB) were all weak compared to the contra-lateral hand. And surprise, surprise, a national competition was two weeks away.

I did two things, well three really. The first was that I let Ivy educate me in the technique she uses to lift. We then broke down the mechanics of that, and I applied my understanding of anatomy. Based on that, I could explain to Ivy exactly what I felt was happening and why.

The second thing I did was to splint and tape the hand to provide the CMC with the support it was currently lacking. I didn't want a rigid material, so I used a flexible thermoplastic promoted with the potential to enhance joint proprioception. Whether it does or not, an impressive sentence like that is worthy of its' own blog! I then taped in such a way that the CMC had solid AP pressure. Immediately Ivy had relief.

Needs dynamic stability training ASAP.
Might need an opposable thumb first.

Finally, I set Ivy up with a strengthening program which concentrated on the thumb extensors in an attempt to rebuild some of the lost stability. I do think that a lot of why Ivy is having this difficulty is because she is a young woman whose joints are still immature and hypermobile. The problem is that the stresses of her sport have meant that abnormal stress has been placed across a joint that is no longer able to tolerate it. My theory is simple (FYI it's not really my theory. I've borrowed it from Virginia. See the reference below re dynamic stability training for thumbs). If Ivy can strengthen and tighten the muscles that provide her CMC joint with secondary stability, then she can regain control over that joint at the top of the snatch. Then she can take over the world, marry Jack Horner, and become a shoulder physio. 

Look after those fingers,

H

Ref
O'Brien, V., Giveans, M. Effects of a dynamic stability approach in conservative intervention
of the carpometacarpal joint of the thumb: A retrospective study. Journal of Hand therapy (26) 2013 44-52.

My Little Bit

The Australian Rules Football team I work for won the premiership on Saturday. Until last year I'd never been involved consistently in elite sport. I am now a very small part of one of the most successful teams in the history of this sport. Please understand, I know that my contribution to Hawthorn's success amounts to 0.0000005% and a couple of dozen custom neoprene finger stalls. I am not looking for, nor do I expect praise. Rather, I want to recognise, and thank the club and the other medical staff for their excellence and especially for including me as part of that team.

My 0.000005%

I'm about to head off to Malaysia for the International Society for Sports Traumatology of the Hand meeting. I can't recall ever being so motivated about a conference. I look forward to learning as much as I can, so that when the season starts again, I can bring new skills and help the boys go back to back to back! 

Look after those fingers, and GO HAWKS!!

Hamish

What's the matter with Jason?

Don't worry mate, we'll get this sorted

Jason Day, one of the best and most successful golfers Australia has ever produced, has a problem with his thumb. I don't know much else. I could possibly find out, but to be honest, I probably still wouldn't understand what the issue was unless I was to actually have a look at him myself. If he did come down to Melbourne, here's what I'd do. 

1. I'd get a decent history. I'd find out when the symptoms started. Did he hit a rock or a tree as suggested somewhere on the net. Has he changed his swing around that time? Did he play more around that time? Did he trial new gear around that time? There is always a reason, things don't just happen. 

   

   Seriously, don't stress. You're on the right track now!

2. I wouldn't look at any scans.
3. What has he done so far to manage it? What has helped to manage it? What has been of no use at all? What does he need to do and when?
4. I still wouldn't look at any scans.
5. I'd start assessing his hand, wrist, and arm. Sensation, strength, pain, stability, provocative manoeuvres etc. Probably look at his cervical spine and shoulder girdle too.
6. I might look at scans now. 

   

   A scan

7. I'd find out when he gets the pain. Is it at rest? Is it during his swing? His downswing? At impact? At follow through? In the middle of a round? At the start or end of training? Putting vs chipping vs driving? Fades vs power? During any non-golfing activity?
8. We might go to the range so I could watch him hit a few balls. I might video this.
9. I'd reassess his hand and wrist based on what I had seen and based on what Jase (we're mates now) had told me.
10. I would remember at all times that Jason is the golf expert and I am the hand expert. 

    

    The plan would be unlikely to include this bloke!
11. We would then develop a plan based on a thorough understanding of the injury and a complete understanding of what Jason needs his thumb to do.
12. The plan might be a period of rest, it might be splinting, it almost definitely would include strengthening, it might be surgery, it might need advice from others including swing guru's like Ryan Lumsden. It would be a plan that Jason would have to buy into completely. 

There has to be an answer. There has to be a way to getting my new mate Jase back to playing quality golf. It's all starts with asking the right questions.

Look after those fingers,

Hamish

"Tis the Season

When I worked at the public hospital, it was an unwritten rule that we shouldn't be away around Father's Day. This wasn't some Plastics / Hand therapy department scheme to downgrade the importance of this particular "Hallmark" holiday; but rather a recognition that we were about to get busy. 

Father's Day means new toys for the boys. Chainsaw's, circular saws, drop saws, hammer drills. In short, power tools with a particular ability to cut and maim would soon be in the hands of a particular demographic that has no ability to read instructions. It doesn't matter how many sticker's those Dad's had to remove that said "Don't touch blade while it is spinning", they would always find a way to touch that blade, and lose those fingers. 

Guess what happens next...

It was the same at the end of tomato season, when the Italian women would come into the hospital having lost fingertips to a blender that jammed whilst they were making bottles of spaghetti sauce. Funny how I never ate any of the sauce given to me as a thank you present. 

Right now, it's the end of the footy season. That means lots of thumb and wrist reconstructions are coming through. Cricket is about to begin, so soon, I'll be up to my neck in mallet fingers. That, and ulnar sided wrist pain in tennis players and golfers.

One particular golfer is the inspiration for this short piece. The Shark, Greg Norman. Shame it wasn't a shark that cut into his left hand; the chainsaw story just isn't as interesting. Still, it's no surprise. Next time Greg, pay someone to cut down that palm tree that is obstructing your ocean view. Oh, and if you need someone to help you get those fingers curling around a golf club again, give me a call.

Look after those fingers,

Hamish

Goth on a Rock

Me climbing.

   I really like rock climbers. I’d have to say, I have never treated a rock climber I didn’t envy to some degree. Their sport is graceful, but inherently dangerous. It demands strength, but also flexibility. For my son’s birthday recently, we spent the day at an indoor climbing gym. The kids went up and down the walls like rats up drainpipes. I was more like a turtle on a wheelchair access ramp. 

   

    If I wasn’t climbing, I was watching. One climber in particular caught my attention. She was a big woman with Goth style makeup and purple hair. There is no way that if I’d seen her on the street that I would have credited her with any athletic ability whatsoever. I don’t think I’ve ever been more wrong. Watching her focussed repetition and her rehearsed moves as she made her way up a ridiculous wall was hypnotising. And then, like I always do, I started to look at her hands. Every finger was taped.

Ruptured A2 pulley.
Note how the tendon (black line) no longer conforms to the bone.

    When rock climbers come to see me, it is usually for treatment of a finger pulley injury. Pulleys are thin bands of tissues that force the flexor tendons in the finger to glide as closely as possible to the bone, ensuring the most efficient transfer of power. When they tear, the tendon is freed, and will take a more direct path to its’ insertion. This is known as bowstringing. Depending on how bad the tear is, they do respond well to conservative management. 

Tape pre application

    In 2007, Dr Isabelle Schoffl published an article that examined the ability of several taping methods to replicate the role of a finger pulley. She was able, using ultrasound imaging, to determine that one particular method was significantly better at this than others. She called this the “H method” of taping, and I’ll try to explain it below.

• Get an 8- 10cm piece of rigid sports tape
• Split it down the middle longways, leaving a 1cm “bridge” in the middle. The tape should resemble an H now with legs of about 4cm.
• Place the “bridge”, ie the not split bit, over the palm side of the PIP joint (the middle joint of your finger.
• Wrap the ends of the tape closest to your palm around the finger below the PIP joint.
• This bit is important. Bend the finger at that PIP joint to about 30 degrees. Then wrap the remaining two legs around the finger above the PIP joint.
• This is also important. The tape needs to be firm, but not so tight that it makes your finger turn blue or go numb. If that happens, please loosen it off asap.

Finished tape

   When completed, the tape doesn't look significantly different from a circumferential tape, or a figure eight tape. Where it does differ however, is in its’ ability to provide support directly where it is required instead of simply redistributing forces. 

There are several clips on YouTube that demonstrate the technique nicely. I like the fact that the finger still bends easily with the tape on. I really like the fact that Dr Schoffl has quantified finger strength and the tendon / bone relationship with the tape on. I have now even started to adapt this method for taping PIP volar plate strains, as I find it easier than figure eight taping, whilst also being less bulky. The athletes also report that it still gives them the support they need.

Goth on a Rock

I never spoke to the Goth climber. She didn’t get my business card, nor did she get a lesson on H taping. It’s more than likely she didn’t need my help. But if she ever does need that lesson, I’ll be able to show her how to protect her pulleys, confident that science has my back. I’ll even find some purple tape to match her hair!

Look after those fingers,

H

        Refs: Schoffl, I et al. Impact of Taping After Flexor Tendon Pulley Ruptures in Rock Climbers. Journal of Applied Biomechanics 23:52-62, 2007.