A Quick Bite

Lives to surf another day

Watching Mick Fanning disappear behind a couple of waves just after the world had seen him turn to face a shark in the final of a surfing contest in south Africa, my first thoughts were of Bethany Hamilton. For those of you that don’t know, Bethany lost an arm to a shark whilst surfing in Hawaii. She recovered well enough to compete and win several professional surfing titles. Mick’s encounter was the premium topic of conversation with all of my patients that day, but Bethany’s story was the one I discussed with one particular patient. 

Chicky

Ned (not his real name) wasn’t an elite sportsperson. He had rolled a car almost 20 years previously resulting in a terrible crush injury to his right arm, and the eventual amputation of his index finger at the metacarpal (knuckle) joint. His right hand had adapted really well to this, with his thumb bypassing the now gone finger, and working with his middle fingertip in order to pinch and grip strongly. Unfortunately, Ned had never attempted to increase his left hand use to compensate for his injuries. His right hand now demonstrated advanced degeneration, and he had significant pain related to muscle overuse and strain. Treatment involved supportive splinting, exercises to divert stress to under utilised muscles and away from the overworked ones, and loads of education on how to adjust activity including dirt bike riding.

Jack before...

Jack after.

Ned also wanted to know how I felt he would go if he had another amputation and I told him I believed he would adjust well albeit with a caveat. Several Australian Rules footballers have had a finger amputated and have been able to play at the top level, Daniel Chick being the first to spring to mind. My first patient ever in my career was a former champion amateur golfer with only one arm who claimed to have taught Jack Newton how to play golf again after he had walked into a propeller. The key is something called neural plasticity combined with something they all had in common called perseverance. Ned hadn’t been too keen on the latter, and was now suffering the consequences. 

My point is, that it is all very well to understand that the brain will automatically start to redirect its’ energies towards existing fingers or limbs once it recognises that it has lost fingers and / or limbs. There has been plenty of research to explain this with a good article at http://www.thenakedscientists.com/HTML/interviews/interview/1000517/ and the NOI group website http://www.noigroup.com/en/Home a good place to start learning. However, there is a disturbing tendency in my profession to put patients in front of a mirror box for half an hour and expect them to come out of the session with no pain and full movement. It doesn’t happen because even though neural or cortical plasticity is automatic, cortical retraining is not. It takes work. If patients like Ned are not prepared to put the work in, then non-dominant hands will remain non-dominant, and allowing a thumb to bypass an amputation will not be enough. 

Preachy? You bet!

I know I have simplified things almost too much. Certainly I am guilty of being too preachy. But then, that is part of my role. Using Bethany, Jack and Daniel as examples helped me explain to Ned what he needed to do. Will he do it? I have no idea. I’d back Mick Fanning in though had that shark been hungry. 

Look after those fingers,

Hamish

Don't Lay Down Sally!

Ouch

Running. It’s not just about your legs. Sure, strong hamstrings, powerful glutes, and quads can hurl you down a track, but they’re not the be all and end all of speed. In order to harness that energy, you must have control, and control is far more difficult to achieve if it’s not innate. 

Bob running at school (digitally altered image that's nothing like Bob)

When I watch runners, I watch their hands. When I run, I’m conscious of my hands especially when I’m tired. There was a good runner at my high school. Bob Moore was his name. He ran with a loping, stretched out and lazy gait that mimicked the sort of student he was. Kind of like the Dalai Lama in sneakers. I might have been smarter than Bob, but I was never going to be as fast as him. Once I’d accepted that, I decided to at least try and run like him. I worked out quickly that the easiest way to start was with my hands. 

Bob ran with his thumb lightly touching his index and middle fingers. There was no tension, just the slimmest of contacts. Somehow, this connection worked to release any tightness in his arms and shoulders, directing all energies to where they were required.  I saw Bob recently at a school reunion and we talked briefly about that. He laughed as I explained my theory, and said he just ran without wasting time about thinking how his hands were held.

I'm sure that scaphoid's gone too...

I’m sure Sally Pearson has always been a Bob Moore sort of a runner as opposed to a Hamish Anderson type. At least, I’m sure she was until she got good, really good. Because at her level, everyone is powerful, and everyone is quick. Differences are minute, and control is crucial. With her fracture of her ulnar, her radius, quite possibly the scaphoid, and the dislocation, the potential for a loss in motion is significant. 

Wrist extension, finger extension and significant loading to push off

A loss in motion means that as she runs, there is a reduction in the co-ordination of her wrist movement which in turn affects her balance as she hurdles. There is also the certainty that her starts would be affected because of an inability to weight bear through the affected hand. But would that be enough of a reason for Sally to pull out of World Championships that are 10 weeks away? 

Left wrist extended and fully pronated. Could be tricky now.

At two weeks post fracture, Sally would not yet have any idea of what her wrist would be feeling like in another two weeks, let alone ten. Her fracture on x-ray, whilst significant, isn’t going to keep her from running, but it will stop her from running well at least in the short term. It will rob her of that sense of fluidity she has always had, and the control she has developed. That affects her training, and that affects her ability to compete at an elite level. I think Sally is aware of this and I think that is why she has pulled the pin early. 

I can only hope that the surgeon who operated has been able to do so in such a way that Sally is already moving her wrist. I can only hope that the rehab staff she has have the good sense to ask for help before it is obvious that things aren’t progressing because whilst I’m sure they’re world class with hamstrings, I bet they don’t see “exploded” wrists every day like I do. Will she be able to run like Bob Moore again? Time will tell. I just hope she never runs like Hamish Anderson!

Look after those fingers,

Hamish

Playing with Plastic.

No bunny hurt in the taking of this photo

At the risk of doing myself out of a job, and incurring the wrath of hand therapists everywhere, I want to share front-line management of thumb MP joint injuries. Greg Hoy, the hand surgeon I work with, refers to tears of the radial collateral joint of the thumb as "AFL (Australian Rules Football) thumb". Tears to the ulnar collateral ligament are more commonly recognised as "skiers or gamekeepers thumb. 

GAWN

No matter what the moniker nor whether the ulnar collateral, radial collateral, volar plate, or a combination of all three ligamentous structures of the thumb MP joint are injured, taping is usually not sufficient to allow the player back to sport safely. Splinting is required. 

I find smug, self serving amusement in the fact that so many skilled therapists and doctors shrivel at the thought of using thermoplastic to support a joint. Whilst their trepidation works to my advantage, ultimately it helps no one. So here is a basic recipe.

It should look similar to this too thick, poorly fitted pre-fab thing 

1. Get a piece of thermoplastic, 1.6mm thick.
2. Cut out a pear shaped piece, long enough to extend from just proximal to the IP joint of the thumb, to just distal to the CMC joint. 
3. Put the plastic in hot water just as if you were softening a mouth guard.
4. When it has softened enough, place it over the dorsum of the thumb, working it into shape so that it contours well
5. Trim to fit, making sure it doesn't impinge over the CMC with wrist extension and radial deviation.
6. Tape on. 
7. Refer to a hand therapist for treatment (happy with that BC?)

Before something

Different players in different positions like different things about these splints. Some can't have any coverage over the thenar eminence. Some like it to wrap around the proximal phalanx. As long as it protects the MP joint, and restricts movement but permits play, it's good. 

After something

Rehabilitation after that is more involved, and here's where you need to refer to an experienced hand therapist because the splint cannot be expected to do anything more than limit more damage. If you can get that at least half right, it's a start. I can always fix up your smashed up, finger dinted thermoplastic disasters afterwards and no one needs to know but us!

Look after those fingers,

Hamish

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