Common hand and wrist complaints, how to evaluate and treat them.

In this episode I am joined by Vanessa Smith, PA-C. She is the founder of OrthoRefresh.com an online platform with talks and videos involving evaluation, casting, splinting and treating upper extremity complaints. We have a great conversation about some common hand and wrist complaints.

Transcript

SPEAKER_00 0:07

Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Hello, everybody. Welcome back to the episode. This is a very exciting episode. Today I'm joined by Vanessa Smith. She's a PA out of the South Dakota area. She is the CEO and founder of her website, Orthorefresh.com. This website is a great resource for all providers. Including all APPs, PAs, ATCs. It helps to decipher the upper extremity regarding acute and chronic injuries and has a great section regarding splinting with PDFs that can go over different splinting techniques so you can perfect these and be able to treat the patients appropriately. Vanessa, please tell us a little bit about why you started the website, orthorefresh.com.

SPEAKER_01 1:22

Yeah, I've just seen a need for more education. I'm sure you have too regarding orthopedics specific to the hand and wrist for our first encounter providers for the PAs and practitioners and physicians that work in acute care and occupational medicine and value medicine and ER.

SPEAKER_00 1:38

I think it's a great resource and would highly recommend people go to check out the website. Working in the orthopedic uh urgent care kind of perspective, I see a lot of hand and wrist injuries. It's one of the more common things that we see. And when I have students working with me, we often discuss do I have to do special tests on everything? Um and this is one of the big things I try to get across to students is that not all acute injuries require special tests because you can get false negatives and false positives from these. So what are your thoughts on this? You know, when somebody comes in with an acute hand or wrist complaint, um, do you always do you know do all the special tests or do you kind of have a variation of how you progress with things?

SPEAKER_01 2:21

In your mind, there's got to be kind of two separate things. If this is a trauma or injury, correct x-rays and you see a fracture on first glance, you see a fracture, you you don't do special tests. You want to know what's working and what's not. Like that's those are the questions I come back to. And then um if it's a phalanx or metacarpal fracture, we look at the x-rays and the clinical exam to determine our treatment. But if it's a carpal fracture or radius fracture, we just look at the x-rays. So start to break down. You don't have a big exam for a radius fracture, but you for for phalanx and metacarpal, you have to look at the hand both with fingers extended and gently flexed to look for rotation. But yeah, just trying to map out a little bit to help them like if you don't see a fracture, okay, you can start looking, but your trauma, what's working, what's not. That's the first kind of ways I tried to help them simplify it. Because it can get overwhelming. There's just so much.

SPEAKER_00 3:16

Correct. And I I agree 100%. And I, you know, I see that all the time, even from an you know, urgent care perspective. And when I have students with me, I mean, if somebody walks in and they immediately injured their arm and they can't move their arm at all and they have a clavicle fracture, you know, why are you doing a drop arm test on them? And of course the drop arm test is going to be positive, it hurts. You know, I had a patient, I had a patient in clinic yesterday who like went to see their primary care and went to an urgent care, and both of them documented positive Finkelstein's tests. And so they came in to me for a first dorsal compartment like Dequeravanes injection, and I pushed on the first dorsal compartment. They said, No, it doesn't hurt at all. But I pushed on their CMC giant and they said, Yeah, that's where it hurts. And I'm like, Well, of course, Finkelstein's positive because it hurts to move your thumb, but you know, it's it's those kind of things where it's like, yeah, yeah. So let's jump into you know what we were talking about. Um so uh, you know, from your perspective, you know, you'd mentioned that, you know, in your area, and I think in my area as well, it's hockey, basketball, volleyball, baseball. I see some um, you know, field hockey or lacrosse uh type injuries. Um and I think one of the common things that I see and that you probably see as well is these PIP joint sprains, volar plate injuries. Um, what do you often see from a treatment perspective when you get those referred from the primary care, urgent care, um, as far as what you teach um how to splint, when to buddy to tape, how many of those require surgery indications for surgery?

SPEAKER_01 4:50

Yeah, so I'd start with uh every jammed finger needs an x-ray. Every jammed finger. You you can't tell what's going on underneath, or in other words, we don't have x-ray vision. So to look at a finger just with our eyes, we can't tell what's going on underneath. You may have something simple like a volar plate injury or nothing at all, just a sprain of the collateral ligaments and capsule, or you might have a fractured dislocation of the PIP joint. So super important to get dedicated finger films for a finger injury. Don't get three views of the hand. We want if it's the index, right index finger, get three views of the right index finger to include a true lateral. A true lateral is going to show the condyles of the proximal phalanx lined up. They superimpose over each other. Then you can really see what's going on at the joint. So if you get a lateral x-ray back and you see these two condyles, you can see both of them, then that you need to send them back to X-ray to get a better lateral. So that'd be that'd be the first couple of things is we gotta get x-rays, we gotta get dedicated finger films. Uh, if on the x-ray, usually on the laterals where you're gonna see that volar plate injury, it's a little small, uh, seemingly nothing fracture of the volar rim of the base of the middle phalanx. That is technically a fracture, but we treat it like a sprain. So you could give them a splint, which they wear for sports, but otherwise they should be in buddy loops. Please do not put somebody in a lumifoum splint and say, if this isn't better in six weeks, call hand. Under no circumstances, except for mallet fingers, should you put a finger in a splint for six weeks? No circumstances. So um so especially this PIP joint, splint for activities, maybe for sleeping. Otherwise, they're in buddy loops, not buddy loops or buddy taping so that it stays still with its buddy finger, it's a neighboring finger, but so that they move together. So those would probably be the the main points with that. Um, the other thing is underneath those swollen fingers could actually be a phalanx fracture. And you don't know until you get the x-ray. The other piece of that then is looking at finger cascade. So I have everybody put their hands on the table or kind of set them on their lap in front of them, palms up, and just let the fingers chill, just relaxing. Can you appreciate how the index finger points straight, straight down, and the middle finger starts to turn a little, and then maybe your ring finger's parallel or it turns a little more, and then your pinky turns even more. They're all pointing to the same spot, the distal pole of scaphoid. So when you look at the uninjured hand, always have the the patient do this with their uninjured hand first, that they're looking at, you're looking, assessing their finger cascade, then do the injured side. If their fingers don't line up similar to the contralateral side, then we're concerned for rotational deformity, meaning the fracture has rotated and that would need surgery. So those fingers can be tricky. It's important to get x-rays.

SPEAKER_00 7:48

Yeah, and I think those, you know, from a surgical standpoint, rotational standpoint, you're talking more phalangeal fractures or metacarpal fractures, right? That wouldn't be for necessarily these volar plate injuries or these more soft tissue ligamentous injuries.

SPEAKER_01 8:00

Correct. Yep. The other piece of that volar plate uh is is looking at the x-rays when you get them, because I have seen people think that it's a volar plate, but it's and do nothing for it, but instead it's actually an evolution of FDP tendon off the distal phalanx. And that flex line is a piece of that distal phalanx way down by the PIP joint. So the other piece of this evaluation is the dedicated finger films, finger cascade, but then also is FDS intact and is FDP intact. They won't have full motion, but are they working? So in order to do that, we isolate that finger by putting all the other fingers. It's hard to like talk about, but it's just a show, yeah. Yeah, you're gonna test. Um, I have a video about it, but you're gonna test both FDS and FDP to the injured finger. And if they're intact, then and you see that fracture at the PIP joint, it's likely just the volar plate that's fractured. Yes.

SPEAKER_00 8:59

Yeah, and I think that's a big one. And I've I've seen that before in the past where it's been an FDP avulsion, and um uh, you know, it it's definitely hard to pick up. And I've I've I I know that it's always important to test uh, you know, DIP and PIP motion, but as you said, I think with the acute injury, oftentimes they won't have full motion, but they'll have um activity within that area, which will show you that it's intact. Um as far as the splinting that you do for sports, what is there a specific one that you recommend for that?

SPEAKER_01 9:28

For the finger?

SPEAKER_00 9:30

Yeah, like if there if it was a jam finger or volar plate injury, I mean the question we always get is an athlete kind of is playing basketball, they injured their finger, PIP joint significantly swollen. They they maybe have a fleck on the x-ray, but maybe not. Maybe it's just a soft tissue injury. And you know, the first question any athlete ever asks you is when can I go back and play? Um and you you had mentioned uh splinting for sports. What what specifically do you do for that?

SPEAKER_01 9:55

We lean heavily on our our um OTs. OTs, yeah, hand therapists to custom make. Usually I just find hand-based splints stay on better than finger splints. Yeah. Um if I were a long finger PIP or ring finger PIP injury, uh bowler plate injury, it would be a hand-based ulnar gutter splint to include uh that finger with its neighboring fingers ulnarly. So ring and small, that sort of thing.

SPEAKER_00 10:25

Yeah, and I I the other the other thing that at least our hand surgeons definitely um always try to discuss and get across is that, you know, a lot of the times if you're seeing a patient in the primary care clinic or the urgent care clinic and they do have this fracture that's documented on the x-rays, a lot of providers don't feel comfortable necessarily just discharging them without a splint on. And if you do put an aluma foam splint on, I think you may or may not agree, you know, put that in flexion so they're not losing uh motion because oftentimes they'll lose, you know, a motion of that PAP joint, which is why, as you mentioned, don't splint it in an extension for six weeks. So we always advocate 30 degrees of flexion on that alluma foam splint until they can follow up with us and then we'll transition them to the OT hand-based splints and or just the buddy taping, depending on the exam and the fracture pattern.

SPEAKER_01 11:13

Sure. Yeah, I haven't uh necessarily been that specific with splinting. Usually if they get to me in a week or two and they're kids, they're not gonna be stiff in that PIP joint. But definitely if there's a dislocation involved, extension, splinting a finger in extension is not a stable position. So if there's been a reduction of a joint, then it should be splinted in at least 30 degrees of flexion, if not more, to maintain the reduction. So that's a key time that we need to be splinting and flexion for sure.

SPEAKER_00 11:42

And is it matter for you from that reduction and dislocation standpoint, uh dorsal versus palmer uh splint?

SPEAKER_01 11:49

Uh not necessarily. I I've got um we commonly will do dorsal, dorsal blocking splint so that in the splint with the finger flex, they could undo the tape and bend it. So bend it even further into the palm, but they wouldn't go into major extension. And then um just in our hand surgery clinic, then we would slowly let them extend more and more over the weeks as the weeks go. Um, but but allowing them to un take the splint down, but while in the confines of the splint, work on finger flexion. So we're kind of getting in the weeds a little bit, but um finger flexion is a stable position after a dislocation, not extension.

SPEAKER_00 12:27

Yeah. And um yeah, so I I think, yeah, exactly. As you said, um, you know, allow them to flex, allow them to move, don't create a stiff finger. I think oftentimes we're taught splint and immobilize for four to six weeks with any finger injury, and and I the the new thought process, and it's not even new, is is motion, early motion um is important to maintain that um range of motion of the joint, which is right.

SPEAKER_01 12:52

And we really face more stiffness with adults, right? Like kids don't get stiff, kids don't get stiff. So um, but definitely with adults. The other conversation we have with kids who are in sports and have an acute finger or hand injury is are you getting paid more than I think you are? Then you're not playing, right? Like it's okay to take some time off to let this finger heal because the concept too is if you don't if your hand isn't working right, then you're using your other parts of your body wrong and you could do something to your back or you could roll your ankle because you couldn't catch the ball, or and so even just just just holding on participation. I think we learn a lean a little more conservative and saying, sorry, you're not playing right now. You can still go be with the team, you can still run, you can still do sit-ups, but you're not doing ball handling or or tackling or things like that.

SPEAKER_00 13:41

Yeah, and I think it's always important to give those athletes at least some uh activity level that they can do. You know, yeah, I understand that your finger's injured and you can't do this particular aspect of the sport, but you can still maintain conditioning. As you said, you can still be part of the team, you can still learn the plays and do the activities. Uh getting into that pediatric component of these PIP joints, which is something I often see, you know, a kid comes in with a swollen finger and their x-rays are negative, but they still have growth plates in that area. Um, how do you approach that, Andrew, educate, you know, regarding that if it's a physeo-1, solitary one type injury as far as mobilization and treatment?

SPEAKER_01 14:17

Yeah, I think we still will do a mobilization for comfort. So that'll be uh an option for the parents too that hey, they go to school in this, they can sleep in it, but they can take it off to shower and bathe, and they can take it off to eat their supper. If the if the x-rays are normal, pain will be their guide. And that that goes for adults too. We don't do things if it hurts. And so the kid won't use that hand if it hurts and the splint happens to be off. Um, so I even have a kid coming tomorrow. X-rays are normal, finger got jammed in a car door, but we'll see what what it looks like. And if if they're still pretty tender and swollen, then we'll probably offer offer a splint um versus you know, even just buddy loops to protect, talking about how that protects the finger. But the kid, the tomorrow is four years old. So now that I think about it, I don't think those buddy loops will stay on. So I'll probably give a little splint or something.

SPEAKER_00 15:09

Yeah, and I I think kids are pretty resilient with a lot of things and they want to and or will work through a lot of things. And so if a kid comes in and they're favoring it significantly, I tend to immobilize it a little bit longer and/or just give them a splint, but early follow-up within five to seven days to hopefully transition out and start motion. But if they're coming in moving it quite uh a bit and their x-rays are negative, then as you said, you can kind of just buddy loop and start the early motion. So it has to be an individualized basis, I think, per each kid. And some kids can't communicate if they're young kids at two years old and they can't necessarily communicate where their pain's at. Um, those are always more difficult ones.

SPEAKER_01 15:49

And reading the parents too. What are what are their expectations and trying to give them what they want, right? Because it's about patient satisfaction too.

SPEAKER_00 15:56

And then from a phonics fracture and/or a metacarpal fracture, as you had mentioned, I've always been taught the key points are look for rotational deformity on that flexion cascade, look for angular changes. I like to, as you said, have them put their hands on their laps, resting position to see if the you know the profile that nail is rotated one way or the other. Yeah. Um, because that's the first thing, you know, when I'm texting my hand surgeons, uh, you know, uh a fracture, um, the first thing they say is, is there any rotational or angular deformity? Like what's the clinical exam? That's the first question they always ask. And so I think it's an important thing for you know all the providers to know.

SPEAKER_01 16:32

Yes, absolutely. Yep.

SPEAKER_00 16:35

You had mentioned gamekeeper's thumb as regarding UCL injuries. What, what, what's how do you treat these?

SPEAKER_01 16:41

Well, acutely, they're gonna be, they're going to be uh guarding, right? They're gonna have because of the pain and swelling, they're not gonna let you do a full exam of the ulnar collateral ligament. So acutely you have high suspicion for gamekeeper's thumb, which is an ulnar collateral ligament tear at the thumb MCP joint. If they have fallen on or while they're holding a ski pole or they are um they fell and they remember their thumb went the opposite direction and they usually point toward their forearm. My thumb went way over here. Uh, those would be concerns that we've got a UCL injury. Um the other way I initially look at it too is, and though you might not tell right away with all the swelling, is if you rest that your hand on the table with the ulnar aspect of your hand, your fifth metacarpal resting on the table and your thumbs are kind of just resting, they rest in neutral. They rest kind of in alignment with your first metacarpal and your and your radius. But if there is an ulnar collateral ligament injury, that thumb will be radially deviated and it won't rest in neutral. So just natural position of the thumb at rest is one thing to look for. And then swelling tenderness about the ulnar collateral ligament. Try to do a little stress test. It's like you would do a variety or valgus of the knee, stressing the radial and ulnar collateral ligaments of the thumb MCP joint. Um, will you're looking for pain and laxity? But initially, you probably aren't gonna be able to tell much with laxity because they're gonna be in so much pain. So do your best, document what you could what you found, and then a splint as far as a uh probably recommended and non-removable uh fiberglass splint. So, like a forearm-based thumb spica splint that supports the thumb to the tip. They don't take it off to shower until they are evaluated again. And I've known some hand surgeons to uh provide a little local anesthesia and stress that ulnar colour ligament. Uh, some will just do it without that and see what their clinical exam is, and then usually it ends up with an MRI anyway. But initially it would be a thumb spike, a splint to stabilize it and um elevate, elevate, elevate, keep that hand at the level of heart or higher as much as possible. So when they're up and walking around, this hand is across their chest. It's not by their stomach and it's not down by their thigh, it's up across their chest, and that will help with pain and swelling too.

SPEAKER_00 19:05

Yeah, and I mean we're we're mid-ski season here, so we're seeing a lot of these so-called ski or thumbs, you know, ski pole type injuries. And then as we talked about, I had a lacrosse kid come in the other day with uh a UCL injury and and uh so the big thing is immobilize, thumb spike, a splint. Um, and you said follow-up. What's your recommendations as far as follow-up there?

SPEAKER_01 19:26

Should be probably five to seven days with a hand surgeon.

SPEAKER_00 19:29

Mm-hmm. Yeah. And do you do you recommend um if they're in the primary care clinic or urgent care clinic to order the MRI or hold off and let them see the hand doc first? Because you know, getting the MRI early is that gonna change the treatment plan and or your guys' algorithm as far as surgical and non-surgical?

SPEAKER_01 19:47

Uh I I in in our area and our practice, we tend to not want primary care to order an MRI just because we might be able to determine what's needed without it, which would save five, six, seven thousand dollars, how much ever they are. Um and by just based on our clinical exam. And also we've found that some uh outlying kind of primary care MRIs don't have the best quality. So then we've spent all that money and it doesn't give us the minute detail that we need when we're looking for a stenter lesion at the ulnar collateral ligament. Yeah. So don't need to don't need to get an MRI. Definitely x-rays and splint would be the initial uh recommendation.

SPEAKER_00 20:28

Yeah, and I think that's a big one. I get that a lot where there's some you know companies in town, especially where we live, where they offer less expensive MRIs, but sometimes unfortunately the image quality is not quite as good, uh, whether it's because of their software or the thickness of their cuts. And so they may miss some of those subtle things and then see you, and then you're gonna have to send them back for a different MRI that has um a more um appropriate protocol, and that's just gonna cost them more money, which is unfortunate for the patient.

SPEAKER_01 20:57

Yep. Yep.

SPEAKER_00 20:59

And then you'd mentioned just a quick down and dirty as far as seeing somebody in an outpatient clinic from a distoridius fracture standpoint. Um, look at the x-rays, I always think is important. Uh splinting is important. Uh do you have a preference as far as splinting? Just you know, a lot of those alluma foam or you know, splints I see from the urgent care perspective, or um, do you prefer the fiberglass kind of orthoglass type splints?

SPEAKER_01 21:24

What yeah. I if you're looking at the x-rays, so first of all, when you get x-rays, um, please look at them, right? Even though the radiology report isn't back, just super important to look at them and start to to get repetition. Repetition. The more you look at, the more you're gonna realize what normal is, and then you're gonna realize wait, that's not normal. Uh unfortunately, we see a lot of people x-rays are ordered, then they are discharged and they're told we'll call you with the results.

SPEAKER_00 21:54

Yeah.

SPEAKER_01 21:54

Then they're out and about waiting to hear back. Maybe the clinic closes and they never hear back. back so they go to their chiropractor only later get to find out that they have a wrist fracture. So the best practice would be if you order x-rays, you look at them and you look for you look for a fracture of the radius. You look at you're looking at the galulas lines, you're looking at the scaphoid that can be a place right we're kind of letting our eyes pan up and as you build um repetition, you build a system of how you look at hand and wrist x-rays. And so I work proximal to distal uh with with the wrist usually as far as letting my eyes look at them. So if and then if I see the fracture I'm looking at specific measurements which it's hard to describe without visuals. But if it's I see the crack but everything seems to be lined up then I would say a non-displaced fracture and a wrist cock brace from home medical off the shelf would probably would be just fine. Uh if they are in a ton of pain and they have a ton of swelling and there's a non-displaced distal radius fracture, then I would put them in a non-removable fiberglass splint. So like a volar splint or also called short arm splint to give support. I have seen so many people have improved pain within the time from they step into the clinic to what after I put the splint on because now that fracture is supported and that helps with pain. So when we talk about multimodal pain management a proper splint is part of that. Um yeah and so as far as like if you start to see more comminution or dorsal angulation or loss of radial height so it's now ulnar positive then uh then we would or if you performed a reduction then we would do something more like a sugar tongue splint where we're going from the palm, distal palm or crease around the elbow posteriorly to the dorsal hand, but allowing for MCP joint motion. So that that would be a more robust splint that doesn't allow for flexion extension or supination and pronation but not every distal radius fracture needs a sugar tongue. So that would be my tips probably.

SPEAKER_00 23:59

Yeah and I would agree with you 100% I I feel like that happens so often where I see patients back and you know somebody hasn't looked at the x-rays andor sometimes unfortunately even the radiological I'll just miss things. They don't have the benefit of the physical exam of us going in there and pushing on the patient and maybe seeing that subtle radial styloid fracture that um you know we go in and that's where they're probably tender at and we kind of take a more in-depth look at the x-ray. And so I tend to never trust x-rays and I never trust x-ray reads because I've seen a lot of missed fractures because of that. So I try to teach the same thing even if you don't feel comfortable reading the x-rays you have the benefit of the clinical exam and you can go look at that and see if there's any subtle changes that you may treat more conservatively.

SPEAKER_01 24:44

Right.

SPEAKER_00 24:44

Yep absolutely and I mean I I think with the wrist maybe slightly different than the hand again um you can give me your expert opinion I I would more uh lean towards immobilization than not immobilizing um if that makes any sense if somebody comes in and they're kind of extremely painful and you take a quick look at the x-rays and they look relatively normal to you but they're in a lot of pain I don't think the answer is don't put them in a splint or a brace. The answer is as you said from a pain control standpoint they could probably tolerate five to seven days in some type of brace or splint just to calm the soft tissue down and then follow up.

SPEAKER_01 25:21

Yes. Yep absolutely yep whether it's a what like we talked about removable wrist cock up brace or Modabber brace um from home medical off the shelf versus one that you put on with cast padding the fiberglass one step splint and the ace bandage. Yeah either of those.

SPEAKER_00 25:39

Yeah I I think a lot of patients you know as you said will come in and and the provider will take a quick look at the x ray and it will look negative and they'll just kind of send them out with an ace bandage and say we'll call you if the radiologist read changes and then they come and see me saying they got a phone call and the radiologist says there was a fracture and you know I end up then immobilizing them. So I I think the wrist doesn't tend to get as stiff and it I better safe than sorry to immobilize those patients tend to do a lot better.

SPEAKER_01 26:06

Yep, I would agree.

SPEAKER_00 26:08

And I know I know you you got to go but one last quick you know scaphoid fractures and snuff box tenderness is always drilled into our head as like a huge and major thing but I think people that come in with acute uh wrist injuries and radiostyloid type injuries they tend to have tenderness within this area. Do you have any teaching points you know regarding this because I get a lot of patients sent to me with scaphoid tenderness, rule out navicular fracture and by the time they get to me after some immobilization their tenderness is no longer in that area.

SPEAKER_01 26:40

Sure. Yeah. Nope it's it's understanding where the anatomy is under the skin. So it in an acute injury we had a gal come today she's maybe five days out now so it's not right out right fresh um but she was not tender over the radial styloid okay and then she and then I go I go dorsal from there. She was exquisitely tender over Lister's tubercle like jumped out of her chair. So okay and then that's it there. But I go back just medical legally any foosh any fallen outstretched hand I always palpate the snuff box just so I say no snuff box tenderness so that they whoever reads this someday knows that I did look for this and that is to put my thumb in the snuff box and then I try to have them relax and I take their their hand and I ulnarly deviate. So I passively ulnarly deviate the wrist and that will make the scaphoid thump thump kind of thump un into the snuff box. You'll feel it kind of come up to hit your thumb. So that's one thing is to passively ulnarly deviate the wrist with your thumb in the snuff box and you'll be able to feel that scaphoid and you'll ask if this is causing pain. If they don't jump out of your their chair it's not fractured. The other way to get to the scaphoid is volarily uh you trace the first metacarpal or thumb metacarpal to the base so the CMC joint then go proximally the next hard bump that you feel is the distal pole of scaphoid. So by pushing on that you kind of are rocking the scaphoid and if that is painful that would make you think that the scaphoid is injured.

SPEAKER_00 28:21

Awesome. I just learned it's hard to describe without showing you but no I just learned too many great things and as you're doing that I'm sitting there trying to push on my own hand um trying to see if I can feel those changes. So um no I think that's great. And I think you you would maybe agree you know people that are acutely painful maybe you'll get a false positive of those tests just because of the acute injury do you think that exam that you just described would be the same if they're day one versus day seven or does it change for the for that particular I mean it there it it might not be tender later.

SPEAKER_01 28:53

And that's the that's the whole point of the follow-up right your yeah your your first evaluation is mostly a triage does this need to go to surgery now or does this need to calm down a little bit let the swelling calm down let's get the pain under control and have it reevaluated. So just documenting what you find um I have seen I have seen transcaphoid fracture trans no radial styloid transcaphoid fracture lunate perilunate dislocation yeah right so like there is a radial styloid fracture there is a scaphoid fracture but also the lunate is sitting out volarly in the carpal tunnel and all the carpal intercarpal ligaments have been disrupted so you're gonna see that on X-ray but that that's the only time I've really seen major like exquisite pain at the radius and exquisite pain at scaphoid.

SPEAKER_00 29:44

Yeah and I think you know uh from a hand perspective and just from an orthopedic perspective in general I always try to teach like trust your palpation you know use your palpation skills know your anatomy know what you're palpating and oftentimes especially in orthopedics you know it hurts where you push and that that use that you that usually tends to line up and so I take a lot of time as you said looking at patients in resting positions seeing if their hand is is is favoring one way or the other you know in my head I'm pushing on things and in my head and even out loud sometimes the patients would be like what are you saying? I'm saying oh no tenderness over the radiostyloid no tenderness over lister's tubercle you know no tenderness at the base of the first CMC I'm just kind of saying it out loud as I'm palpating it because if they are tender there and you know the other thing I try to get across is go look back at the x-rays. If you take a quick look before you go in the room and they're negative but you go in there and they have some palpable tenderness over an area go look at the x-rays again before you discharge them and you may see a subtle finding in that area that you didn't see initially but then you have the benefit of the palpation in that clinical exam.

SPEAKER_01 30:48

Yep absolutely and if you can pull up the x-rays in the room seeing is believing. So if a patient can see the x-rays and see what you're looking at and you're walking through okay this is normal this is this is a sesamoid bone nope that's not a bad thing. That's your hook of ham eight like the like just normal findings that we see on the radiographs walking through that and showing the other thing I talk about too with fractures not specific to scaphoid but usually metacarpals and phalanx is that the outer lining that cortex of the bone is like an eggshell. So if it's cracked it's gonna dent in it's gonna stick out typically we look for some disruption of the cortex and I you know and you're pointing out I don't see anything on any of these bones you know so walking through that out loud is a great great idea.

SPEAKER_00 31:32

Yeah I feel like it just helps me to kind of make sure I'm palpitating all the key anatomical landmarks plus sometimes it gives that patient confidence that hey this person knows what they're talking about. Right or they just think I'm talking to the voices in my head. I'm not sure which one but all right well I appreciate your time I'll let you go um uh thank you very much I think this was I'd I'd love to have you on again um you know I as you said I think you can talk for an hour just about this the radius fractures so right yeah yeah uh but yeah I appreciate your time well I hope everybody enjoyed this episode I think this was a great episode uh regarding upper extremity injuries kind of how to think about and or treat acute upper extremity injuries. Vanessa does a great job uh discussing this uh please go to her website orthorefresh.com again I think this is a fantastic resource if you're looking to update um your knowledge on upper extremity injuries and also for casting and splinting she has a great PDF that goes over what cast and splint should be used for what specific injuries thank you again for listening please follow us on social media both Facebook and Instagram uh Ortho on the go podcast uh also uh stay tuned next week next week I'm gonna have uh Laura Rennie Laura's a uh youth athletics coach uh we're gonna talk about the importance of youth athletics uh in our young population and I I think it's a great uh conversation uh I really think you guys will get a lot out of it so definitely tune in next week for this episode. Thanks again for listening. Have a good day