Madness in the Time of Corona

Hates a microphone!

Six weeks ago, I wrote about how things change. I was diving back into private practice after 3 years of mostly working at a public hospital. The Corona virus was on the radar then, but it didn't appear to be influencing anybodies plans unless they lived in Wuhan, and it certainly wasn't shaping mine. For me it was full steam ahead. Loving being back at the Hawthorn footy club, and relishing the challenges associated with working with the Carlton AFLW team. I was also at the pointy end of having been the co-convenor for the, wait for it, triennial combined meeting of the Asia Pacific Society for Surgery of the Hand, and the Asia Pacific Federation of Hand Therapists here in Melbourne. 

Do they miss me as much as I miss them?

We were expecting well over a thousand registrants for this conference. As we got closer to the event date of March the 10th, those numbers started dropping. First the Chinese delegation pulled out, then Singapore, Korea, and much of Japan. When the Grand Prix wasn't cancelled, we took this as a green light to continue. At the same time, we spent a lot of time arranging video presentations, and the schedule took a massive hit. 

The conference went extremely well. Minimal contact, but not nearly to the extent we have now. A challenging program amidst a backdrop of impending doom. The call to cancel the final day was made at three o'clock on Friday the 13th. Apt perhaps. There was disappointment, but no complaints that I was aware of, and I can only thank the delegates for that. The gala dinner went ahead, and as Alison Taylor said, it was kind of like the last party on the Titanic. It was certainly the last party I'll be at for a while. 

Ripping tune

I've now lost my contract at the footy clubs and my practice has shrunk to half of what it was. I still have people coming through the door, but I'm restricting that as much as possible to post-operative cases. I've read comments about how we should shut our doors completely or just offer tele-health, and I can appreciate where they are coming from. However closing the door on a person just after surgery and having them rely on surgical advice to "just start moving when you feel like it" is likely condemning them to a crap result. Tele-health is great for some and I've used it to reinforce & adjust programs, but it can't work for everyone. So I'm still open. 

But it's weird isn't it? It's surreal. Streets are empty. Toilet paper has made a return, but you can't buy more then two tins of vegetables even if you mix the types, and there's nothing in bulk. Spotify is chockers with Corona Isolation playlists. The memes that are flying around are mostly hilarious, although I get the impression that the edge to them is getting darker and nastier.

For a positive sporting fix

When I'm not working on the business I'm watching anything on Netflix I can that's sport related. Just finished "The English Game". Acting was ordinary, but the story was fascinating. There's a series of ESPN documentaries called "30 on 30" that I'd love to work through, and I've found several podcasts one of which, "The Howie Games" is a surprising stand out. I'll do some exercise, go for a run, hit the lonely speed ball, and have a kick with my son. I'm also working on a passable version of "I Useta Love Her" by the Saw Doctors. Classic happy space song. It could be worse, and so it's not me I'm worried about. 

Here's where a blog that is determinedly light-hearted and irreverent becomes sombre. I worry for those who don't have my resources. I worry for Mum and Dad. I worry for the mental health of so many. I worry for the long term implications of this virus: socially, financially, and physically. I worry for my friends working on the front-line in public health both here and overseas. I don't worry for the dickheads who think they are above it all and can do whatever they want. Karma will get them.

So stay safe, look after your fingers, and I'll see you on the other side of this madness. 

H

It's all about me now!

So as you may have noticed, I never fulfilled that promise to complete the triathlon series, nor did I update the blog as regularly as I should have. 2019 was a year of massive upheavals for me and mine, and things certainly got away from me. I did however complete the same triathlon this year. I was faster this time, and I’ve emailed the race organiser Adam Beckworth (www.beckworthracing.com) to get his 10c worth on triathlon and hand injury. Hopefully that will all work out! 

In the meantime, with the unashamedly self-centred goal of self-promotion, I’m going to use this blog to discuss my rationale associated with diving back into the perils of full time private practice after three years of working predominantly in the public sector.

Thanks again to Hoggie of Andrew Hogg design

When you are solely responsible for bringing food to the table and can’t just expect to be paid for showing up, a whole host of issues aside from the ability to fix fingers arise. You have to understand marketing. You have to understand budgets. You have to understand relationships with referrers. You may not want to admit it, but because your relationship with your patients is fee for service, sometimes your role becomes mercenary. These conditions are what you sign up for. The reason I went to work at Austin Health as their senior clinician in hand therapy, was because 15+ years of mostly independent private work had worn me out. 

At Austin Health I had a great team of therapists to lead and teach. I also learnt from them all, regardless of their experience. I got paid regardless of whether a patient showed or not. I could manage my time to include extra projects and research and was supported to do so. I enjoyed my three years there because of the people, both the other therapists, and the patients. Ultimately, the reason I left the financial safety of a permanent position, was because Austin Health could never give me the career control I had when I was my own boss.

Go the Blue Baggers!

Within two weeks of leaving Austin Health, I was consulting with a wheel chair athlete at the Australian Open. I also took the opportunity to work directly and regularly with the Carlton AFL womens team, in a very similar role to what I do at the Hawthorn footy club. I got busy establishing three new clinics. Two of these are in busy sports physio practices; one is in a rock-climbing gym! I am chasing provider numbers, new equipment, and new stationary, not to mention new patients. I am writing to potential new referrers. I am working on “establishing a social media presence”. I am getting control back. 

I am getting control back by doing what I love to do, in the manner in which I love to do it. Yes there is a financial risk; I don’t anticipate I’ll be flying first class anywhere anytime soon. But I’m challenging myself again much as I challenged myself in the Barwon Heads triathlon last weekend. Life is simply too short to doubt yourself or your ability to do what you want to do.

Until next time, look after those fingers,

Hamish

Triathlon & Hands

Matt Hopkinson. Ordinary triathlete, elite dancer!

I was recently chastised in a nice way by my “landlord” Matt Hopkinson. Matt is the owner and principle physiotherapist at “Glenferrie Sports and Spinal” which is where I work every Monday afternoon. Matt, and Ben Holland the peoples’ podiatrist, had just returned from a weekend in Sydney on practice management, and in particular, the use of social media. Matt had a crack at me for not keeping my presence on social current. He’s right of course, it has been 10 months since my last blog, and so I promised him I would get something down. 

The something that has been buzzing around in my head is the result of a triathlon I completed in February. Around the same time, I saw an elite triathlete, who had had an extremely nasty injury to her wrist after a fall from her bike. The injury, whilst it didn’t necessarily stop her from training, certainly impacted on how she trained and what she could do.

Triathlon is a sport that demands different things from the body at specific times. There are things that are similar between the disciplines, eg cardiovascular fitness; and there are things that are different such as the demands on upper body in swimming that are not there in running. I would argue, and I will argue, that a wrist or hand injury can impact all three; swimming, cycling, and running. 

I first saw triathlon on the Saturday afternoon TV show “Nines Wide World of Sports”. The Hawaiian Ironman. This race began in 1978 when Judy and John Collins proposed combining the three toughest endurance races in Hawai’i—the 2.4-mile Waikiki Roughwater Swim, 112 miles of the Around-O’ahu Bike Race and the 26.2-mile Honolulu Marathon—into one event. 15 people raced that year, 2400 last year in what is now a qualification only event (1).

It really is that colour. Swimming through goose poo.

My first triathlon was in 1985 around the Kew Boulevard. We swam in the Yarra River which is revolting now I think about it, and I was 296^th out of the water in a field of 300. Jumped on my trusty but rusty 10 speed Lawrencia bicycle with its pack rack still attached and rode my guts out. Did okay in the run and ended up in the First Aid van with cramp at the end. A fantastic morning and whilst the experience never led to a lifetime of racing, I’ve always loved the sport.  

In the next blog (and it will be up very soon), we’ll talk about swimming, my least favourite leg but an important one for fingers!!

(1) http://ap.ironman.com/triathlon/events/americas/ironman/world-championship.aspx#ixzz5onGPe21q

One screw or two?

It's getting towards the end of the Australian rules football season. It always seems around now that I see more people with hand and wrist fractures than I did at the start of the year. maybe it's the cold, maybe it's fatigue, maybe it's that the games become more desperate with finals around the corner. Surely someone knows?

Better in brown & gold! Scaphoid 2016.

In any case, this week I have seen 4 footballers with scaphoid fractures. All were simple non-displaced waist fractures. Two were casted, two had surgery. One of these had one screw inserted to repair the bone, the other two. A physio I really respect asked whether the two screw thing was new, and why would the surgeon opt for what appears on the outside to be much more difficult surgery to a small bone that already has a poor reputation for healing. The surgery and the science weren't new to me, but a translation of their impact was obviously required so let's start at the start. 

Facts about the Scaphoid (1,2)

Scaphoid fracture through waist. One screw, result at 4mths. Not my patient.

• Most commonly injured carpal bone
• Frequently diagnosed late if at all, with high rates of bone non-union
• Best assessment indicator remains pain on palpation of scaphoid in radial snuffbox (below thumb)
• The part nearest your wrist (proximal) has poor blood supply, often lost with a fracture of the middle section (waist)
• Casting can be required for 2-6 months
• Surgery appears to have better outcomes in the short term
• It appears thumb immobilisation is unnecessary in a cast (3) (but I still include the thumb at least initially because I definitely don't trust young, male footballers!). 

Not an option in Aussie rules footy!!

If I am just talking about athletes, then they are looking at the quickest possible return to their sport. This makes a fracture during the season more likely to be addressed with surgery in spite of the real risk of complications. There remains a risk though. Surgery will ensure good bone compression and stability, but the bone still requires protection in a splint, and active movement outside of the splint is not always encouraged such is the reputation of this poor little bone (1,2). 

The reason surgeons started looking at two screw fixation was that they wanted earlier movement at the wrist to reduce concomitant weakness, and there have been significant improvements in available hardware since development of the Herbert screw in 1984(5). There was also a recognition of the potential benefit of permitting controlled stress across the joint to augment bone growth. 

Cupcake bouquets. Who knew they were a thing?

Keen students of previous blogs will be aware that the scaphoid is a tricky little beast, not always moving in a singular plane. The problem with a single screw, was that it still permitted rotation of the scaphoid. Proponents of the two screw method argued that torsional stability of the bone would be enhanced with two points of fixation (4,5). This makes sense to me. One toothpick in a cupcake bouquet and the cupcake will slide off. Two toothpicks and it can't. Simple! 

Obvious complications are that inserting two screws is technically very difficult, it effectively doubles the likelihood of malpositioning, and it is more expensive (4). It is a new technique; one that is not available to all patients, and one that is not yet supported definitively. Rehabilitation protocols specific to this surgery have not yet been established. 

Notwithstanding the risks, and relative newness of the research, the biomechanical theory comparing one vs two screws is promising. Both lab based and clinical results do indicate a better stability, stiffness and energy absorption compared to a single screw. Whilst these studies concentrated on scaphoid fractures involving non-union or displacement, the implications are that an earlier introduction of mobilisation, loading and strengthening may be tolerated (4,5); possibly even an earlier return to play... just in time for finals!

Look after those fingers,

Hamish

References

1. Rambau GM et al. Evaluation & management of nondisplaced scaphoid waist fractures in the athlete. Operative Tecniques in Sports Medicine 2016 24:87-93
2. Winston, M., Weiland AJ. Scaphoid fractures in the athlete. Curr Rev Musculoskelet Med 2017 10:38-44
3. Buijze, GA. et al. Cast immobilisation with and without immobilisation of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: A multicentre, randomised, controlled trial. JHS Am 2014; 39(4):621-627
4. Mandaleson, A. et al. Scaphoid fracture fixation in a nonunion model: a biomechanical study comparing three types of fixation. JHS Am 2018;43(3):221-228
5. Garcia RM. et al. Scaphoid nonunions treated with two headless compression screws and bone grafting. JHS Am 2014;39(7):1301-1307

Low to High Hamma, Low to High

John Egan; back 2 back 2 back winner of the
Cannons Mark of the Year
Gary Coleman Cup

My mate Jumping Johnny Egan is one of the best marks of a footy that I have ever seen. As he launches himself towards the ball, his hands move from down by his waist into the air above his head before snapping open with wrist extension just before the ball smacks into his palms. Conversely, and keen readers of this intermittent blog will know exactly where I am going with this, I am one of the worst marks of the footy I have ever seen. At least, I used to be.

The local junior footy club (Go Sharks) began to run training nights for Dads. There was no game, just an excuse to run hard and do circle work. One night, in the middle of another ball dropping performance beyond belief, the bloke running the show pulled me aside and asked if anyone had ever taught me how to mark a footy. Before I’d even had a chance to realise that he wasn’t taking the piss, Jacko proceeded to outline exactly what I needed to do. I needed to be more like Johnny. 

Talk about "Low to High" Poppy!!

When Johnny marks the ball, his hands aren’t coming up from below the ball’s trajectory. Instead they are coming towards the ball but in such a way as to offset the trajectory and speed of the ball so as to give his hands as much time as possible to grasp it. Now that’s not what Jacko told me, but it is what he meant when he said “Low to high Hamma. Low to high mate”. It is however what an Italian neuro-physiologist found in a mind numbingly involved article with the disarmingly simple title, “Grasping and Catching” (1). 

Catching is a combination of predicting the velocity and path of the object, adjusting proximal structures in such a way that grasp of the object is possible. Experience helps which probably is one reason the recent explosion in girls playing footy has seen a similar explosion in finger injuries within that cohort. What also helps is visuo-spatial ability, which is a little more difficult to train up if you haven’t been gifted with it to the same ability as Jumping Johnny. 

Above: Mind you, a sticky glove helps too... right Clokey?
Below: I don't need one says Roughy!

Whilst the article is at pains to point out differences in catching ability between professional and amateur sports people, it does indicate that a combination of training, technique and experience can make a difference. It is all about maximising the time you have getting your hand into position before it needs to grasp the ball to hang on to it which may be why an over hand catching technique proved more reliable. This technique may not be transferable to Australia’s greatest game in every instance, but the concept is, and getting your hands into position is the best way to start. 

Look after those fingers,

Hamish

(1) Cesqui, B. et al. Grasping in one-handed catching in relation to performance. PLoS OneJuly 2016

The Stress is Killing Me

A lot of trees have been sacrificed in the name of better understanding bone stress injuries to the lower limb. Brukner and Khan’s latest edition of Clinical Sports Medicine devotes a whole chapter to their management... in feet.  Admittedly with good reason; they are debilitating and difficult to treat.  However, at the risk of being seen to harp again on my favourite theme of “what about the hand”, what about the hand? If B & K don’t mention them, and do they even exist? 

The answer is of course yes, it’s just that they are rarer. A Spanish paper in 2010 reported that only 12 cases of stress fractures to the metacarpals had ever been written up. The authors of that paper then published a case series of 7 tennis players with stress fractures of a metacarpal. All were adolescents, and all had altered their training or some aspect of their game prior to this injury (1). Volker Schoffl, that rock-climbing, x-gaming hand surgeon in Germany also published a paper on bony oedema in climbers (2). Aside from that there are a few case studies, but not a lot.

I've got almost too much in common with this guy!

So if they’re not talked about much, are we talking about the same thing? Well, essentially yes. B & K devoted a chapter to this subject; I’m going to try to paraphrase them in 150 words. Actually, I’m just going to copy what Stuart Warden wrote because it’s nice and succinct… (3) “A bony stress injury (BSI)represents the inability of bone to withstand repetitive mechanical loading, which results in structural fatigue and localised bone pain and tenderness. It occurs along a pathology continuum beginning with a stress reaction, which can progress to a stress fracture, and ultimately a complete bone fracture”. Thank you Stuart. Of course there is a lot more too it, and his chapter is a good read so get into it if you want to know more. 

Should be obvious.
MRI stress #. Not my patient
(4)

“Treatment then is what?” I hear you protocol driven fiends out there screaming. Rest and controlled load says Stuart, among other pearls. But let me make this a bit more personal, this is what I did...

·    Tennis player, bone pain in second metacarpal, had come on strongly over the period of a clay court tournament but had likely been festering for some time. Essentially the pain was so severe he could no longer hold his racquet and hit a forehand with any force. Stress reaction confirmed on MRI, dorsal interossei inflamed also which made anatomical sense. 

·         -Weeks one to two, rest in hand forearm orthosis overnight, hand based radial metacarpal joint immobilisation orthosis during the day, coming out for gentle range, modalities and very light massage only. Pain with turning on tap.
·         -Week three initiate very light isometrics to the interossei. Shadow racquet swings with large diameter light cardboard roll – NO PAIN. Decreased splint use, taps almost ok. Continue overnight splinting, stop day splint.
·         -Week four introduce light grip vs theraputty, continue to build load. Roll ball on racquet head. Grip rolled up towel.
·         -Week five to six, continue to build load, isometrics well tolerated now, introduce graded hitting ie soft balls, no forehands just yet. Progress putty density, light gym weights.

At this point, I passed him back to the tennis physios as the interossei were now pain free to heavy loading, although forceful grip was uncomfortable especially when hitting, and he still had pain with palpation of the second metacarpal. However my outcome measures had all been met, and it was felt he needed to focus on the tennis side of things.

Not my patient btw. Just a funny photo.

It is now 4 months since he last hit a tennis ball in anger, but he has finally been given the green light to resume competition. That’s a long time off for something that was initially seen as a short term reaction to increased activity. The time frame does does however, fit published case studies (1,4). It’s also likely that this stress reaction was in fact a fracture. I can absolutely guarantee that if any of the team involved with this injury come across any similar injury that occurs in another tennis players metacarpal will be taken just as seriously as if it had occurred in a metatarsal. “What about the hand” indeed! All part of my cunning plan. 

Look after those fingers,

Hamish

(1)    Balius, R. et al. Stress fractures of the metacarpal bones in adolescent tennis players: a case series. American Journal of Sports Medicine 2010 38:6 pp 1215-1220

(2)    Hochholzer, T., Schoffl, V. Overuse bone marrow oedema of the hands in sport climbers. Sport Orthop Traumatol 2013 29:3 pp 219-24

(3)    Warden, Stuart. “Sports Injuries: Overuse” in Brukner, P & Khan, K. Clinical Sports Medicine 5^th ed. 2017
(4)    Duarte, M. Metacarpal stress fracture in an amatuer tennis player; an uncommon fracture. Revista Brasilera de Orthopedia June 2017.

If a tree falls in the forest...

Nothing wrong with those fingers Dennis

I have often said in this forum and in others, that injuries to the hand are often neglected by patients, especially it seems, in an athletic population. For that I think we have only ourselves as therapists to blame. In spite of best intentions, these injuries are regarded as less important and less crucial. The only real way to change this perception is through researching the impact and incidence of hand injuries within a sporting population. 

For many years, Dr John Orchard has been compiling injury reports in elite cricket. On the back of these papers, a great deal of good work has been done to address hamstring, groin and back injuries at all levels of cricket, with particular attention to fast bowlers and the development of appropriate workloads. 

In a recent publication, Dr Orchard revisits injury incidence within an elite cricket population, and updates the injury definitions. The article is well constructed, discussing at length the most common injuries and whether rule changes might make a difference. What stood out for me having been alerted to the article via Twitter by Alex Kontouris, the Australian cricket team physio, was that in spite of ranking third for incidence and fourth for most affected body part over a ten year period, wrist and hand fractures were not discussed at all.(1) 

Does "!" make him soft?

To be fair, the article was written to address the rise in hamstring injuries in connection with the rise in Twenty20 cricket becoming a the most popular cricket format. I also accept Alex's comment that most fractures occur in situations which cannot be controlled in the manner that a soft tissue injury can be. Yet if a maintained incidence rate at an elite level is not commented on, if those injuries aren't considered worth commenting on at an elite level then the perception of laypersons become that the injuries aren't worth taking seriously even though those of us who treat elite athletes know that isn't the case. 

Getting amateur sports persons to take wrist, hand and finger injuries seriously before they become chronic is an issue I face every day in my clinic. I need someone to show me how to make Dr. Orchards' research have an impact in my clinic for the everyday athlete. Any takers? 

Look after those fingers,

Hamish

Refs:    (1)  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5167453/