Welcome to the upper hand, where Chuck and Chris talk hand surgery.
We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
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Oh, hey, Chris.
Hey, Chuck,
How are you today?
Oh, you know, I've you know, I said this with a bunch of patients today. I'm fine. All things considered. I've stopped just saying things are good things are fine. I mean, I think that everybody is really feeling it, especially here in St. Louis. Things are getting even crazier with this. I don't know if it's a second wave, third wave, fourth wave, whatever it is.
Yeah, my line is I'm okay. That's about as well as I do these days. I'm okay.
Well, some good news. I mean, last week, we hit a really great milestone with the podcast our our guest podcast with Asif was our fiftieth episode released.
It's really something I was trying to do the math, I could have sworn we started like in February, right pre pandemic. And we did a couple of extra episodes, I guess we did enough that we already hit 50.
Yeah, we had a couple of Beyonce style, you know, drop three episodes in one day kind of launch. So
Those don't happen anymore.
No, they don't. But we've had some fantastic feedback from everybody who's listening. And for those of you that have filled out the survey, all 55 of you, thank you so much, we really do appreciate it. Please go on and login on theupperhand.buzzsprout.com or theupperhandpodcast.wustl.edu. And fill out the survey. We really appreciate hearing from everybody.
Absolutely. Hey, Chris, did you have, there's a couple of reviews that have come in that. We haven't really talked about it. Have you had a good or seen a good review lately.
I saw some great feedback on the survey. So this is from a current fellow and, they wrote here I'm a current Fellow at I won't say which program because I'm not sure if you wanted us to reading that on but I have been listening to your podcast since finding out about it through the hand society email lists in early spring, I've incorporated a lot of what I've learned listening to your podcast into my own personal fellow clinic. I've also got half of the residency
listening to it as well. So thank you, and I look forward to more episodes. Thank you to the fellow who wrote that we really, really appreciate it.
Yeah, thank you and get the other half of the residency listening, come on.
So Chuck, is somebody gonna win a mug this month?
Someone needs to win a mug. I mean, we we sent one mug across the world to Brazil, kind of hoping the next winner is a little more local.
Alright, Chuck your turn to pick a number one through 53. And it cannot be the one that we picked before. And I can't remember which which number that will make the later one.
Yeah, 43.
All right, whoever you are D Baron 222. And I'll leave the rest of it off. But whoever you are, congratulations, you are the winner of an upper hand coffee mug. And just from a cost perspective from our shoestring budget, I hope you live in the US. But we still welcome anybody from from abroad filling out the survey.
Absolutely. You know, international shipping, my wife runs a business which is helpful in these situations. For sure.
So, we have a bit of a treat today, don't we?
Oh my God, we are lucky to welcome back a therapist who really has gotten a lot of accolades locally just for the care she provides. But I've loved having her on our show previously.
Well, you know, we're lucky to be joined by Dr. Macy Stonner. All right, Chuck. So let's launch into a case recently had a case 60 year old woman with a metaphyseal distal radius fracture had your standard dorsal displacement. We had the conversation about options and we opted for surgery. And this is one where a standard volar plate was used. And how would you approach therapy at this point? What's your post op protocol? assuming everything went smoothly with the plate? You love the position
of the plate? You love the reduction? Where do you go from here?
Yes, it's a super interesting conversation. I'll start by saying I try not to tell the patient this bit of information until they've made their decision. Because any rational patient who hears this is going to choose surgery meaning, if you're if you're if you really have a choice, between nonoperative care and operative care and you learn that you can go to therapy and be in a splint and start early motion. It's like it sounds like
a dream come true. So going back to your question, I if I do this surgery, I have them see our therapist at about five days and and my request is a resting splint to be removed as You know, as comfortable. I let them shower at five days. And I start early active motion and maybe even some gentle passive motion. But I'm, I feel fortunate, I leave that in the hands of our wonderful therapist.
What's with the five days? Is that just how it works with your your OR schedule and where patients can come in?
It honestly is, it's a number of convenience. I operate mostly these cases on Wednesdays, and I haven't started therapy on Monday. But before we get to our wonderful therapist who's going to enlighten us all, what do you What's your basic general protocol, Chris?
So the patients who are the straightforward ones, like we're describing here, I actually go three days, because I typically will do these on a Tuesday and get them to therapy on a Friday for the very straightforward ones and follow something very similar to what you've described. So once they're in the hands of our capable therapists, and they go upstairs across the hall downstairs, wherever it is, Macy, welcome back. How do you approach that patient?
Hi, everybody, thanks for having me. So one of these types of patients is among my favorites. Just because I have orders that say, active motion three to five days post op doesn't always mean that I do that, I'll assess that motion. But sometimes people are just too sore, and too painful to do that. So I'll just measure their motion and see how they're feeling more often than not, I will initiate motion, because they're excited to to get moving. But that doesn't mean
that I do it all the time. The biggest factor for me is finger motion, honestly. So finger mobility is key in the beginning. So I always make that the priority exercise along with edema reduction. And then I make wrist motion secondary.
So how do you, so for those of us that are surgeons and haven't spent a lot of time in a therapy suite? What do you do with the patients with regards to edema control and finger motion? What happens behind the curtain?
Sure. So we have a bunch of educational materials for patients and we go through education on what is edema? What is that fluid buildup in your hand? And what can it turn into, we want to avoid it from turning into scar tissue and getting sticky and getting stiffness in your fingers and wrists. And so we go over methods including positioning at night while sleeping, elevation, compression garments, specific exercises and massage techniques.
So go a little deeper there. When you say compression garments. Everybody doesn't get something like that, do they? I mean, maybe someone gets an isotoner glove if they're really struggling with finger swelling. What is a run of the mill patient get as far as instruction regarding edema?
I would say the importance of positioning, elevation, and motion. And then it's a subjective decision whether or not to issue a compression garment just based on their hand. There's no protocol for it. But if you see that their hand looks like a balloon, or you can't see their joint creases of their fingers. They're getting an isotoner glove.
So before we dive too far into the details of therapy, what are some of the you know, not from of course, Dr. Goldfarb or any of his partners who, who send you patients, but what are the common hiccups that surgeons have, in terms of either what we write on our prescriptions, or what we tell patients that you have to course correct.
For this particular diagnosis, I actually don't have that problem very much, because it's a pretty typical condition we treat and enjoy treating, but I would say when the script says aggressive range of motion, and the patient might see that that word scares them. And they're like, aggressive, what does that mean? Am I not progressing? Are you gonna crank on my wrist, you know, that term scares them and so to prevent something like complex regional pain syndrome from developing, I try to avoid
inflicting too much pain. I don't want patients to associate therapy with like, you know, torture, so I try to not to inflict too much pain on them.
So I really liked what you said earlier about finger motion, but you may have said it in a way that's slightly different than how I think about it. So for me, when I see the patient with a distal radius fracture in clinic, maybe five days after they were seen in the emergency department, maybe they've had a reduction, maybe they haven't. If they have great finger motion, I feel like everything's gonna work out,
everything's gonna be fine. If they come in, and they don't they have either swollen fingers or stiff fingers. To me, that's the first red flag. But I don't think that's what you indicated. That's what, that's not exactly what you were saying when we first started this conversation. I think you were saying your first priority with therapy after ORIF of a distal radius fracture is to control the edema and to get the fingers moving.
Correct. So those two things because I don't have the opportunity to meet them as early as you do. So I meet them after surgery. And my comment is always okay, you broke your wrist with the wrist fracture, we know that you're going to have some stiffness, however, you didn't break your fingers. And if you have stiffness in your fingers too [you're going to be] living your life a whole lot harder, and then they kind of get that and go from there.
So do you agree with my oversimplification of good finger motion equals good outcome?
You're talking about preoperatively?
Preoperativel yeah, or postoperatively? Just.
For sure.
Okay.
Yeah, I totally, I totally agree with that. I think that that can make a much bigger difference in many other factors.
All right, so let's say you see Chris's patient at three days, or my patient at five days, you make them one of your beautiful splints. What do you tell them about the splint? Do you tell them to wear it 24/7, except for showers and very careful motion? What's your instruction on a really well done, ORIF?
So if it's that first post op visit, I will tell them to wear it all the time, except for exercises and showers. And if they're sitting down watching Netflix, they can take it off, breathe a little bit, do some edema massage, get to know their hand because it sounds crazy but sometimes these patients are so freaked out by their swollen hand that can't move that if they wear their brace too much. I think that they kind of dissociate
themselves with their hand. So I don't always have them wear it all the time, particularly when they're seated watching TV at the end of the day.
Now Chuck, I have a question for you maybe? Who are, are there certain, not the fracture characteristics but are there certain patient characteristics that make you a little nervous about this protocol? You know, is there something about, do you not trust certain age groups are you
You know, I oversimplify my my way of know. thinking for sure. But for me, it really comes down to two groups, those that start therapy at five days, and those that start therapy at five weeks. And for me, that's generally fracture characteristics or my ability to obtain and really maintain a good reduction in the operating room. But I had this wonderful luxury that Macy provides that I know I can trust the therapist, so that I don't have to be overly granular about
how aggressive to be. Because I know that if I have a good fixation, patients aren't going to disrupt a well positioned plate with good screws, that's not going to happen. You know, if they fall, that's one thing, but doing other exercises, I feel really comfortable with it. So it's really just the early group and the late group, in my mind Macy is that too ov rsimplified?
No, I totally can appreciate that comment as well. I see that.
So say they they have they've started this protocol, they now come back for a first post op visit with you, Chuck, when would that be typically? And what's the conversation what happens then?
So to me that, for me, that's 12 days, again, a number of convenience. And if I've put in nylon stitches, they come out, I get a sense of how they're moving fingers, A1 number, you know, most important, and then their forearm and the wrist. And there's nothing that makes me happier when a patient comes in and they can already supinate you know, they can all I'm you know, pronation is usually not a challenge. Sometimes it is but they can already supinate even if their wrist motion isn't
great, I feel so good. And I feel the need to say to the patient, you don't understand how wonderfully you're doing. I just I just feel the need to contextualize it because it's just, it's just still amazing to me.
What is it about supination that, you know, seeing that restoration of supination so quickly, for those of us that don't have as much experience as you and maybe have more hair?
Well, and I'd love Macy's thoughts, I think it's generally well accepted that supination is one of the hardest, if not the hardest motion to regain. And wrist flexion is really hard to regain. Now, of all the you know, if we consider the four motion, supination, pronation, wrist extension and wrist flexion. The two that I would deprioritize would be supination and flexion. From a from a functional standpoint, right? I'd rather have good pronation. And I'd rather have good wrist
extension. But being greedy I want it all so you know if they have good supination really early again, it's just like having good finger motion right after you break your your wrist. I just feel good about it. Macy again, am I making this too simple?
No, I agree with that completely. I think that finger motion again is number one. So if they can make a full fist, I'm like you're doing amazing, even though they subjectively feel like their world has been turned around because they can't do the things that they normally do. And I always have to rest assured, hey, you're doing great, you know, give them that confidence.
But I would agree. I don't know if I think it's supination vs wrist extension, but those are the two typically that I find to be the most challenging to get back. And so supination wrist extension, yeah, are the key for me. pronation, not typically a huge issue. Wrist flexion, I'm not too worried about functionally and it comes,
it's not so much that supination helps you from a functional perspective, it's just more of a marker of how you think the patient is going to do overall,
I think both, for sure. Supination people have a hard time washing their face and opening doors and things like that. So I think it's both.
Yeah, I think that's well said. All right. So let's take the patient Macy who's doing well. You know, you see him at five days I see him at 12 days. How often do you think you need to see him in the clinic? I'm sorry, in your therapy clinic? for that patient who's really almost on autopilot? Is this a once a week thing? I know it varies from patient to patient, but just generally, the simplest patient the patient is doing as well as can be expected. What How do you think about those patients
once a week, if their edema isn't too bad, they have decent motion and not too much pain, I think once a week is incredibly reasonable. Um, if they are really swollen, fingers are stiff, can't move their wrist, twice a week for sure. Sometimes that those patients are just like I said earlier, just kind of freaked out. And they need that formal instruction, encouragement. Every, you know.
So, just a quick question, given the era that we're recording this podcast in would, for that cruise control patients, that once a week patient, would a telemedicine visit be enough?
Yes, I totally think so. That happened a lot during April and May during the height of COVID, where there would be those traumatic patients that we had to see. And you would do their initial instruction with the splint and start them on motion. And I would see them once a week or every other week through zoom and email them pictures of handouts and measure them through my camera and make sure they're progressing appropriately. They did great.
So the terminology I use again, maybe still focusing mainly on that patient who's doing well, I think we should kind of come back and revisit the patient who's struggling, but thinking about the patient who's doing reasonably well. The three terms I use, and you may tell me, I'm doing it all wrong. And you just, you know, don't want to embarrass me but I'm gonna embarrass myself perhaps, I talk
about active motion. I talk about gentle passive motion and I talk about you know, you don't like this word aggressive passive motion. So what what should I be saying?
Not passive aggressive, but aggressive passive.
Those are fine ways to look at it. And by you saying aggressive passive motion. I know Dr. Goldfarb is not pleased with their motion right now. And I need to get them moving. But I'm not going to tell the patient you have to be aggressive on your wrist or we're, you're never gonna get your your function back. That's more of a little sign to me that hey, Macy, like I feel good about this fixation. Their motion isn't where I want it to
be. Do whatever you want, give them the kitchen sink, but make sure that they're stretching?
Yeah, I think I think, again, we've worked together on and off for a long time. So I think that is how I mean it. For sure. I guess I also would be hesitant to say aggressive, passive motion at 12 days. I shouldn't be.
No, I would be, I would not administer aggressive passive motion at 12 days, I probably would not.
How about for somebody who doesn't work with the two of you routinely. So what is the difference in terms of what you do Macy when you see gentle passive and quote, aggressive passive, how what? How hard are you pushing on the patient or having the patient push.
So I always use the same spiel that my coworkers will laugh at, because they hear me say it all the time, that I want you to gently push with your, I don't want your pain levels to exceed a two to a three out of 10. And everybody's two to a three out of 10 may be different. But I just want you to understand that you're not cranking on this, it shouldn't be hard enough to where you have to go take pain medication, but I want you to feel a good stretch, a two to a three out of
10 is appropriate. And that's how I explain gentle passive.
That's interesting. I would have thought gentle passive was a five.
What does that say about you?
A five is pretty intense, like where you need to go get some meds. But again, it's such a subjective scale. I don't know.
No, I think your message is clear. I think it's a really important message. And I think that's actually good for me to hear as well.
So, is it the therapist applying the passive motion? Or is it the patient self applying the passive motion? I mean, is that where's the line between active assist by the patient?
Yeah so I think that when you first initiate the exercise, the therapist does it to show them the technique, the intensity, the frequency, and then you teach them how to do it self administered, because that's what matters. You can come to therapy twice a week and I can stretch you but that's not going to make a difference if you're not doing it every day, multiple times a day. So then I check their technique, make sure they're doing it to themselves
appropriately. Some patients every time they come in, I'll manually stretch them, maybe do some mobes, or some mobilization techniques, or something like that if they're really stiff. But sometimes you just have to teach the patient how to do it themselves, and they've got it from there. I think people's personalities are different, too. And that can be a indicator as well.
So I do want to ask, you know, the next progression in terms of you know, what the next milestone is, but just so I know, and I think maybe some other people would want to know, what happens, and what are the things that you do to stretch them out, you know, there're always these modalities that are going on these things that happen in therapy to get patients warmed up, what are the examples of things that you do,
So I will have their forearm resting on a bolster like a support and their wrist just kind of hanging off the edge, I'll keep them first, typically in a little bit of elevation. So it, you know, doesn't hurt or increases their tissue extensibility before we get going, and then I'll just manually stretch them into all four motions, I'll make sure that they know how to do that. And then I'll incorporate activity with that to augment
those functions as well. So replicating, opening a door, holding a hammer and twisting, getting back into gentle weight bearing for missed extension, is something that I do a lot because people often talk about getting back to yoga or push ups or getting up from the floor. So working on some weight bearing type activities, and then slowly incorporating, like resistance and some strengthening with those stretches.
Perfect. All right, let's go back to our simple patient, our simple patient has been seen a couple times by me, and then they've been seeing you once a week, making reasonable progress, they come back to see me it's roughly six weeks. Honestly, it's probably five weeks for me, they come back. That's my first post operative X ray. Chris, I don't know if you agree or disagree with that, weigh in in a second. And then assuming the X ray looks fine, you know, it's not obviously, rarely would it be
completely healed. But if things look encouraging, then I with therapy, support and agreement, I encourage weaning of the splintand initiation of strengthening. Is that Chris, A how you see it in Macy, what would you add?
Yeah, that's pretty similar protocol. You know, I do get a two week X ray, mainly for a silly reason that where I do the majority of these cases, the interoperative, fluoroscopy, doesn't always send reliably. So I want to have some kind of documentation of the fixation that I have. I mean, I have printouts from the interoperative fluoro. And if I really needed it, I could go find it. But I like to have that documents easier sent over from
the clinic. And then yes, I will initiate the same kind of protocol in terms of tapering off the splint, and starting some gentle strengthening, I'd be curious to know what Macy thinks gentle means in terms of the amount and how to tell talk to a patient about that.
Sure. So if that's the patient that's doing well, I will emphasize strengthening over motion because their motion is probably fine. They don't need to worry about that anymore. And I'll always start with grip strength, always always. And then from there, I'll start with like wrist isometrics, either manually or with a band and then kind of doing heavier activities around the clinic as their pain
tolerates. But if they are stiff, even though I get the orders for strengthening, and they have horrible motion, I'm not going to prioritize strengthening with them, don't waste your time on gripping, you need to be stretching. So that's kind of something that I have to talk to patients about if they are still super stiff, and they kind of have this as a window, but just prioritizing them the flexibility over the strength.
And when you say working on grip strength, and I certainly feel the same way is that putty or a stress ball? What is grip strengthening.
To me, it's putty because we have different resistances of putty in the clinic and we give them to patients. It's better than a stress ball because you can replicate different motions, you can do weight bearing on it, you can do grip, you can do hook fish, you can do pinching, you can do different types of pinching, so that putty can mold into very specific shapes and can replicate many different grip patterns and pinch
patterns. Whereas as a nerf ball or stress ball, it's just kind of grip release, grip release into this really meaningless exercise in my opinion.
And then does every patient at some point get the the bands to work on, you know, wrist extension and flexion strengthening or, or is that just if you feel like the patients needs more strengthening.
I think the latter if they need more strengthening and some of these patients will fall off our schedules if they are six weeks out and they're pain free full motion back to work. They don't need therapy anymore. They cancel because they're living their life and doing great and I think that that's fine. And sometimes they don't even get you know some of the exercises that we initiate because they're already back to living
before we get to the tough patient, I have one final question on the easy patient. Because my experience this is a question for both of you. My experience is this quote unquote, easy patient. fracture heals uneventfully, radial sided pain disappears. It is not uncommon at the 12 week visit and that's usually my next visit, that they still complain of ulnar styloid ish pain. And that's a whole nother
conversation. And to me, that's the in most patients that's what lingers far beyond what radial sided discomfort is, Chris, has that been your experience? And how do you counsel patients and work with therapy on that?
I try to be good, I agree, I try to be good early on about telling them that, you know, we're going to treat this, you know, this fracture, the radius fracture, if they have an ulnar styloid, it'll try to remember to point it out. I'll try to assess their, their ulnar carpus at six weeks, and, you know, point out to them, Look, it's going to be sore here. But usually they brought it up at that point, even at the six week mark I've seen. So I try to get ahead of the messaging on that.
And it is the the thing that lingers. And I, you know, I spend more time counseling it away than doing anything else. I think rarely I get to the point where I'm treating it, you know, A of course, unlikely to have any further surgery and B, maybe an injection.
And yeah, Macy what how do you think about it Macy do you similarly? And is that a problem you see regularly in the clinic that ulnar sided pain
It happens. But one of the things that I tell people is very emphatically this will go away. This is common, because they think, okay, I injured the radial side of my wrist why does the ulnar side of my wrist hurt. And I kind of showed them an anatomy book and kind of the mechanics of the wrist. And just very, very strongly, I look them in the eyes and say this will get better. And they are like, okay, okay, thank you. I just needed that because they didn't understand anatomically, why
that hurts. But I found the wrist widget to be marginally helpful. Another thing that I do for this is just simple activity analysis. Because we use ulnar deviations so much in our daily activities, whether it's typing or lifting weights or writing, I kind of ask them, what do you do and kind of show me how you do
it. And people use ulnar deviation functionally so much we kind of have to teach them to stop repetitively, ulnarly deviating during those tasks, and that kind of takes some of the pressure off the tfcc.
Totally agree. Totally agree. All right. I think maybe we'll, we'll kind of hit one more kind of group of questions. Let's take the difficult patient. So this the patient that you've been seeing twice a week Macy, you've been encouraged them along, and hopefully they're making at least slow progress with their edema, and their motion, they come back to see me at five or six weeks, x rays look good. And now I say that inappropriate word get aggressive. So what
does that mean to you? And a patient who seems to be healing, but it's still struggling? When do you bring in static, progressive or dynamic splinting? How do you think about the progression for the patient who's struggling, but bony wise is probably doing okay.
So I group this category into this group of patients into two categories.
Are they crps like, or are they just stiff, and not that painful, if they are the second group where they're just really stiff, I'm fine to get aggressive, I'm fine for their pain levels to exceed a four or a five while they're doing stretches, and I typically don't make static progressive splints for wrist motion, because they're so large, I would incorporate like a company to help like a jazz or a statadyne type brace, fingers, I'll make some sort of composite flexion
stretch glove or NP flexion stretch splint or something like that. For the patient who I'm concerned about crps, just by some comments they might make like, this hand doesn't feel like my own or my hand looks like a glove, I can't use it, then I'm not going to make them push through pain as much. I just want to work more so on function and get them using their hands versus the patient who is not the crps type. I'm going to focus on rote, repetitive exercise.
Now at this point, is the patient completely tapered off of the orthosis? And are they using any kind of support? Even infrequently?
I would say no splint, unless they're having ulnar sided wrist pain, and they have a little wrap on. But at this point, yeah, I would say no splint.
then say you're behind the game in terms of forearm rotation. You know, like you mentioned earlier using a commercially designed static progressive for flexion. And extensions. Similar for forearm?
Yeah, so those are commercially available splints can also help with rotation. And in clinic here at Milliken. We have designed or I don't know if we designed it, but we use it often. It's called a supination strap. So if they have a standard wrist cockup, you can apply Velcro and a bunch of neoprene and around the distal humerus, and it helps stretch them into supination. A lot simpler and a whole lot cheaper.
So, as a basic, my kids would say basic as a basic hand surgeon, is it fair to say this seems like common sense, but I've never read this to be true, that if a patient really is only limited in one of the four motions, so let's say they're lacking supination, but everything else is pretty good, that you would expect that patient to do better with a forearm like statadyne in the forearm, versus a patient who's diffusely stiff, right?
That goes without saying, if they have multiple motions, which are limited, your expectations for success of the dynamic or static progressive splint is very different.
I would agree with that.
Okay. But yet, you still would do those specialized splints, because they still can make a difference?
Correct? I would, I would just have a schedule for them and say, you know, for 25 minutes in the morning, I want you to work on wrist extension, when you get home from work, I want you to work on 30 minutes or, you know, pronation or something like that. And I would often ask them, What bugs you the most? What can't you do that's so frustrating. And whatever that activity is, whether it's washing your face, okay, I know it's supination.
It's typing. Okay, I know, it's pronation, it's reaching out to grab your coffee cup. I know it's wrist extension. So whatever bugs them the most I'm going to have them work on that motion the most.
So sorry, Chris, I know you have a question. What percentage of my patients versus Chris's need a static progressive splint? I'm just kidding. I'm not comparing. But in general, we see the gamut, right? We see easy fractures, we see hard fractures, we certainly get referred in some that are harder. But I think our practices in general, regarding distal radius fractures are probably similar to whoever's listening to this, what percent needs something fancy, like a, you know, a specialized splint.
I don't have any research to back this up. But anecdotally speaking, I would say 5% or less. To be honest, there's a gentleman right now, who needs one for supination. But the physician, one of your partners who fixed the fracture told us this is one of the top five most challenging distal radius fractures I've ever treated. So something a comment like that we know this person is going to have a hard time. And a lot of times a surgeon will say,
hey, this was a tough one. Or in that comment, I know that getting that full mobility is going to be challenging.
One of the things that I've encountered with a subset of patients is that they focus a lot on the numbers that the therapist is measuring, as opposed to function. And that's tough messaging to, to counter in the office, because if they're doing well, from a functional perspective, some people just have this personality where they feel like they need perfect symmetrical motion, or they need a certain number that I don't know if the therapist isn't putting in their
head. I never emphasize numbers in the office.
I totally agree. Totally agree. This drives me crazy. Because they'll ask, Well, what number am I? And I'm like, Well, last week, you couldn't turn the doorknob. This week could you turn the doorknob? And they said yes, like so who cares? I don't know, I don't feel like sharing this
number with you. I just have this documentation on my notes, you know, for insurance, but um, yeah, if they're getting bogged down in the numbers often do something else objective like a dash score, and show them their dash score on the first day and look at your dash score no w look how much you can do, doing functional things in the clinic and just highlighting all the good, rather than, you know, numbers that may not be changing week by week.
Or it Macy here's the million dollar question. Does every patient that has surgery for a distal radius fracture, need your expert expertise? Or can someone get away with an off the shelf brace and on their own therapy,
I would say nine times out of 10 patients will likely need at least one visit whether that include education, a splint, brief exercises, expectations, but there's that occasional patient who could probably be fine with a pre fab splint and send them on their way. They may be a low demand patient with no swelling, no pain, no stiffness, and they should be just fine. But you kind of have to read the patient.
And what percentage of patients that you see, do you really today see only once meaning, you know, do you do that regularly or do most patients leave it in your world need at least one or two follow ups.
I would say five to 10% I might see just once. This happened the other day actually, but it's typically related to distance and or insurance so they might live 45 minutes away with a busy schedule and coming over to the city is challenging, or their insurance authorization is only for one therapy session, so we kind of have to get it done in one session. And I'll just make that visit longer and more thorough.
Yes, it's a super interesting question. I mean, I recognize the expertise that you guys bring. But in this challenging era of insurance and cost controls and trying to provide value, there's clear value for some patients, there's pretty clear value for others. But you're right, I think there are the occasional patients that probably will do just fine on their own.
I agree.
When are you done? When is therapy over?
Well, it's a hard question because it can be four weeks, it can be five months, it can be I just had somebody who I discharged after 14 months, from a distal radius fracture non op who had crps. So it's so different. And I think that the patient's personality plays a role into it, because some people are more independent, where they say, I got this, I can do it on my own. I don't need therapy, and some people need that formal instruction. So I don't have an answer for you.
It can be so dependent on the patient's personality, the rigidity of the fixation, their function, their motion. It's so patient dependent.
Well Chuck, on the prescribing side of things, how much are you steering that conversation? You know, typically, I'll say, do you think that therapy is still helping?
Yeah,
I think a lot of it, like Macy said, is a patient personality thing.
You know, we have this huge built in benefit. And I don't know what percentage of hand surgeons have the luxury of really having a close relationship with a therapist, potentially even an office therapist. But my comment is the same to all patients, I absolutely ask if they think therapy is still helping. And then I absolutely try to put myself out of the middle. I don't know if that's not something I'm supposed to say.
But I try to take myself out of the middle, and let the therapist and the patient decide. But here's the danger. If you have a therapist, and I don't know any, but there could be some out there who are just trying to keep the patient in the system. They're going to keep bringing that patient back. And I'm sure that happens. I know it doesn't happen for our guys, if anything, you guys let patients go a little sooner than I would rather than the opposite.
I agree. We, I agree. We in our clinic, probably we don't oversee patients at all. Because we work in an urban setting and an academic institution with a lot of people and particularly in COVID I think that it's inconvenient to be here if they don't live in the city. And there's a lot of patients to interact with during during COVID. But I guess one of our mantras here is we teach you how to be successful to self manage this condition on your own. We're not here to take your
copay. You know, we just I want you to come see me as long as you find me helpful. And I say that to patients, they will take that advice.
I think those are words to leave this podcast on, because that is really well said and and i think you know as important as we surgeons believe we are. I think the therapy relationship post surgical is incredibly important. And having the right therapist really can absolutely be the difference between a good result and a great result.
Dr. Macy Stonner, thank you for joining us.
Thanks for having me.
Hey, Chris, that was fun. Let's do it again real soon.
Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?
Mine is @congenitalhand. What about you?
Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
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