Speaker A
Hello, good evening. Welcome you all to the hand ledger. Hi. Hi. Hi. So today we are also joined by Dr.
Discussion on hand surgery challenges, tendon injuries, nerve function, and best practices in trauma and post-op care.
Key Takeaways
- Thorough knowledge of tendon and nerve anatomy is crucial for accurate diagnosis and treatment.
- Small cuts can cause significant tendon injuries that patients and clinicians often miss.
- Avoid passing K-wires through joints to prevent long-term stiffness and damage.
- Shared decision-making with patients improves treatment outcomes and satisfaction.
- Peripheral settings need tailored approaches due to resource constraints but must maintain quality care.
What the video covers
- Dr. Samat shares a stressful surgical experience involving a difficult radial nerve repair during a forearm injury.
- The podcast discusses the importance of precise tendon and nerve function examination in hand trauma cases.
- Commonly missed tendon injuries such as EPL, EIP, FDP, and FDS are highlighted along with patient and clinical factors.
- The risks and limitations of certain surgical techniques like K-wire pinning across joints and DRUJ stabilization are debated.
- The importance of proper splinting techniques to avoid joint stiffness and preserve function is emphasized.
- Challenges faced by peripheral hospitals with limited resources and staff in managing complex hand injuries are acknowledged.
- The discussion touches on the need for thorough radiological assessment and patient-centered shared decision-making.
- The podcast stresses the importance of clinical experience in diagnosing and managing hand injuries beyond surgery.
- The speakers caution against common pitfalls in emergency and trauma care related to hand injuries.
- Overall, the episode provides practical insights and expert opinions on improving hand injury outcomes.
Chapters
- 00:00Introduction and Guest Introduction
- 01:31Stressful Surgical Experiences and Nerve Harvesting
- 03:07Importance of Thorough Hand Examination in Trauma
- 04:46Commonly Missed Tendon and Nerve Injuries
- 06:06Discussion on Avocado Hand Injuries and DRUJ Stabilization
- 07:28Best Practices for K-wire Use and Splinting
- 08:58Challenges in Peripheral Settings and Resource Limitations
- 10:54Radiological Assessment and Shared Decision Making
- 12:50Summary and Final Thoughts on Hand Injury Management
Full Transcript — Download SRT & Markdown
Speaker A
Samat. Hi. What was the most difficult or most stressful experience in the OT? Stressful surgery or stressful situation? That can be two different things.
Speaker A
Every case is stressful. But one case, as I am remembering right now, is a forearm cut injury or something. There was a radial nerve cut, which was also cut. So I could not find the
Speaker A
radial nerve for some reason for almost one and a half hours. I was just searching for the radial nerve at night, midnight, 2:00 a.m. or something. So you know it is there but still you are not able to find it.
Speaker A
Funny that you should say radial nerve because I also operated on a radial nerve last week. I found the radial nerve. I found the radial nerve at the medial septum. I found the medial nerve at the lateral septum. I found the
Speaker A
medial nerve through the triceps but in between I couldn't find it. I had to dig, dig, dig proximal, dig distal, half an hour, 45 minutes, no nerve stimulating, nothing is working. So that was the latest stressful case that I had
Speaker A
encountered. The first time I harvested, you know there is only one shot that you have because the hand that you're operating on has only one hammade. One wrong cut and there is no bailout.
Speaker A
Every single cut that you're taking on that is trying not to sweat on the table. Now that we know that the distal capitate also can be used, would you be a little more easy in your harvest? No, but maybe because it
Speaker A
didn't make that much sense to me, particular bone fitting in there and I know we should overstuff the hammade graft but maybe as a bailout, as a worst-case scenario bailout, but I would not want to rely on
Speaker A
that as a first choice or while harvesting the hammade for that. I think the hammade has worked for all these years. Happier sticking to that than the distal capitate. As of now, I'll stick to hammade.
Speaker A
His boss favorites dialogue just because you know you can do it. How about something you would want people to remember while examining any hand condition? One thing that you would want people to not miss out on while
Speaker A
they examine a patient. People, I would divide that into two, like say anyone who is in a medical site and other sector patient site. Whenever the patient comes to a casualty, the first person is going to see the med
Speaker A
casualty medical officer or some resident or someone. But what really happens is majority trauma in hand are not just single fracture or you know it's always big RTA who has head injury who has spine or lower
Speaker A
limb femur and then also hand and tendon. So what I really felt, like my personal experience or maybe a majority of them, sometimes it's not like their fault or something but what is important, head is important rather than hand. I
Speaker A
think everyone agrees to it. So when these types of things, you know, examining has a set of life-threatening injuries but I think hand is also injured. These types of things, they come to us quite later stage. I try to tell the
Speaker A
whoever is there on call and so try to examine each tendon. In my personal experience, the most commonly missed tendons are EPL, EIP, and FDP, also FDS sometimes. What about you, sir? So interesting you said about puncture wound missed EPL injury.
Speaker A
Exactly. Exactly. I had a patient, we saw a patient, Dr. Karthik and I, we saw a patient which was referred to us from neuro and ortho for a sudden thumb drop with a sudden onset of sharp electrical shock pain, something
Speaker A
like that around the thumb and radial border of the wrist. Immediately thereafter she had a thumb drop. She had been seen by our ortho and neuro colleagues, examined well and was referred to us.
Speaker A
Classic drummer's palsy. Asked the history and she had a trauma a month or so back treated conservatively but when we see the X-ray, the radial styloid was a little more hyperopic or radiopaque. We can feel the distal and the proximal
Speaker A
parts of the EPL missing out the history and missing out proper examination and just focusing on what the initial symptom was is something that is very, very often missed. If the patient had an electrical shock, something nerve related, usually it is
Speaker A
not if examined well and a history is taken properly. What do you think? If you don't know what the tendon does, you can't really examine for its function.
Speaker A
If you don't know what the nerve does, you can't examine for its function. It happens quite often when you have residents examining who are the first line of treatment for patients that reach the emergency. Radial nerve injury with a humerus shaft that we
Speaker A
had. I get a message saying midshaft radius fracture neurovascular intact. A little later a video comes across saying patient is able to extend all fingers and patient was able to extend all the IPs but not extend the MCP. That was
Speaker A
considered as neurovascular intact. A patient with a clear radial nerve. So the understanding that active MCP hyperextension must be examined needs to be driven into the residents also. I was telling about the patient factor, right? There was a patient I
Speaker A
think maybe a half cm cut injury at this level, zone 2. He just left it. He thought it was a sickle cut. He just went to a regular local doctor and he just tried a bandage but his finger is
Speaker A
straight. So people do miss out for a very small sick or a knife or a glass.
Speaker A
These cuts, even though they are small, they tend to cut the tendon but the patients do miss it. I do get patients after a month that my finger is not working, my finger is not moving. So I just wanted to mention that even there
Speaker A
is a patient factor in this rather than not just hospital and ground stuff.
Speaker A
Abishek, have you started seeing avocado hand injuries yet or we haven't advanced that much?
Speaker A
No, no, I haven't. What is that? They hold an avocado and they cut it.
Speaker A
For me, it is always when there is DRUJ instability or something. They do wire from ulna to radius. Everyone should stop doing it because it's going through the DRUJ and it is the most, you know, it is going to
Speaker A
damage the joint. How about people who pass it a bit proximal to the DRUJ to stabilize a post-Galazy who say we will avoid the joint but we will still pass that wire between both the forearm bones? People do say, did say that to me
Speaker A
but you're still obstructing the joint. You're not just because you're not. Will you do the same thing for the knee or a hip? I don't think so. Right. So yeah, same way you don't obstruct the joint. You don't do that.
Speaker A
And then I don't think you're really solving the issue. Also, when you're splinting a joint that is unstable where the ligament is not going to pinning, it isn't going to allow the ligament injury to heal.
Speaker A
So when you said pinning everything, don't keep the finger straight. Don't give a full straight finger splint.
Speaker A
Don't pass a K-wire from the fingertip all the way to the MCP joint. Don't keep it straight.
Speaker A
Textbook. Don't do the so-called Wolverine K-wire. Just leave the joint be. Even if it's unstable, just give it a little flexion.
Speaker A
It'll be happy. The patient comes with a pointing index is very difficult to treat later. That's one thing that should really be avoided.
Speaker A
Splinting or keeping the wire right across. What about you, Aishi? Unstable elbows that people take up for close reductions, bar, open reductions and decide for some reason I don't feel like repairing the ligaments. I will pass a very thick K-wire that goes
Speaker A
from the ulna all the way up the humerus immobilized in 90°. That's again doing nothing for the ligament, leaving a joint that is going to become stiff because of the injury in a worse condition than we started out with
Speaker A
without much of a bailout after a wire is out. Any experience with this procedure? Anybody seen this happen? Yeah, stiff stable joint. I think this problem is not just here. It is all over the world in peripheries all over the world. They
Speaker A
do face this even wrist everywhere. We think it.
Speaker A
hand surgeons. In a like you said in a peripheral setting where resources are less and they don't have enough time, experienced staff, no assistance. It makes a lot of sense to try to do the most with the least resources we have. But eventually
Speaker A
we should start not doing it. I think elbow quite reduced comparative to the wrist and fingers. I feel fingers are like you know left and right. It is the ideal treatment till date. wrist also maybe some people might not do or you
Speaker A
know it's it's still yeah but elbow it is more or less I mean according to my experience but fingers it is the standard treatment for heel you forgot the heel so it is the standard treatment for every every finger fracture any part
Speaker A
just wire it straight maintain the length what x-ray radiology ology is commonly very commonly wrongly taken be it the finger wrist elbow shoulder what do you see commonly that you wish they hadn't done for an x-ray so in my
Speaker A
experience for anything anything below wrist it's always a oblique AP oblick that may be thumb index ring or anything pap specific specific. No, it's always this and this.
Speaker A
Especially the okay. Especially the okay thing which I am absolutely I cannot I I I don't I I don't like that view at all. For some reason even though if I want to take that view I I'll not take that view
Speaker A
only. So I'm I'm so irritated with this this sign or this symbol. Okay. Oblique view of a hand. So for you know for thumb you know there are a lot of views like thumb AP oblate lateral and if you
Speaker A
want to see for CMC you take Robert's view also for for CMC aton view all this for only in hand there are so many views you know which gives better um you know uh to assess what is there in the uh
Speaker A
what what is the pathology before Abishek jumps in uh I specifically write uh for my hospital PA and lateral I also write the 9090 and give them and still they'll take the okay they just can't resist taking this
Speaker A
oblique view as you said I still no one can understand when they are taking wrist PA to you know make make the patient sit 90° you know I how muchever I tell I I send specific picture there is an X-ray
Speaker A
WhatsApp group all the X-ray technicians and me I send that photo also sometimes still I don't get that it's always okay it's always okay go down I've gone down to the X-ray room told them please from now on get the PA
Speaker A
view of the wrist with the shoulder abducted and elbow flexed that day in the evening I'll get an AP of the wrist or a for a wrist for a risk.
Speaker A
Okay. Okay. For a risk. Okay. One more that really gets on my nerves is um sometimes from the emergency we have uh some patient came in with uh wrist pain and elbow pain. I have shared the x-rays and this x-ray is a fulllength
Speaker A
x-ray from the fingertip till the elbow and nothing is in a nothing will be in lateral also. doing it lateral also. There are there are two oblique views from the fingertip up to the elbow and they expect the diagnosis
Speaker A
out. You cannot see any joint. The X-rays go in a cone. How to explain this? I can't see the ends.
Speaker A
It is a photo of the forearm, not an X-ray of the forearm. And very often it is difficult to convince the radiology team or the patient to get another X-ray. That is a hassle.
Speaker A
Sir, you can see the wrist. No, you can see the wrist. How but how important is positioning for taking a wrist X-ray? Like when we do a PA, when we do do a lateral, when we do do a clench fist,
Speaker A
the PA feel is so important because assessing one carpal instabilities requires a true PA. Assessing if the ALNA alna variance requires a true PA view, alna siloid fractures, you cannot the with the supernated AP view is going to just obscure the styloid. There are
Speaker A
so many things that we just miss out on without a proper PA view of the wrist.
Speaker A
And so what about a clench fist? Clench fist you usually do when you have scaffoldate uh instability or you suspecting scaffold uh instability you try to take clench fist.
Speaker A
One more thing is uh uh dynamic druj impingement. Whenever we clench the alna translates distally.
Speaker A
So that's one more cause for alnar sided wrist pain that we should uh also look for and clench fist they'll send PA when I don't want.
Speaker A
No my my my thing is like you know we are talking for uh all this regarding this. How can we correct it? Is there any way that we can you know keep talking to the radiology team explain to the patient themselves that
Speaker A
this is the position I want you to do it? I do I I I specifically tell patients if they tell you to keep like this don't keep like this. I want this finger lateral and I mark with my pen tell
Speaker A
whoever is taking X-ray to do this. But you know on a daily basis I don't know how far this will be. How many how many how many times does the patient come back to you and said sir I told them to
Speaker A
take it like this way but they told me to keep my hand like this in in 10 times at least three to four times I'll get this it happens enough times yeah enough problem yeah I thought is there any better way you guys have that
Speaker A
you know we can solve this I I don't know if you have noticed that the views that we write down when the X-ray technician clicks on that view on his system there is a feature that shows osed how it's supposed to be positioned.
Speaker A
So I I don't think the problem is lack of access to knowledge. No, no, no. So I have seen not everyone. I don't know. I don't say PA view. It shows with the patient sitting down not like this.
Speaker A
It just shows the wrist and the forearm like that. It doesn't show the position.
Speaker A
There is discrepancy between what a hand surgeon asks for radiology versus what a orthopedic surgeon or a plastic surgeon wants for radiology. The same x-ray wrist will more often than not the even a hand will be written x-ray a by our
Speaker A
own colleagues. So it has to start there that uh proper radiology should be standardized unless there is a specific view specific condition where you need that X-ray all risk should be PA neutral PA and a true lateral specified otherwise
Speaker A
unless specified otherwise so you can't just blame the radiologist also because there are so many things and nobody asks for the same thing. What is the risks with remote consultations and hand surgery? What's one case that really made you feel like you were lucky you
Speaker A
didn't give a just a digital consultation for this X-ray? Um, this is uh because I remembered one of the posts that had put up a couple of weeks back. Now, the X-ray looked absolutely normal. If you you don't zoom
Speaker A
in enough, you can't even notice the fracture in the metacle. But you see the patient and you have the little finger pointing towards the thumb. Now if it was just looking at the X-ray and very superficially looking at
Speaker A
an X-ray, you would one miss a fracture, two, you would miss a fracture with the rotational deformity. Those are kind of things that people need to also understand that just an X-ray might not suffice especially in the metacarpal.
Speaker A
However well you do your okay X-ray you might really miss that metacarpal fracture and miss the need need for surgery need for correction of the rotational deformity. The other thing is uh the ability for us to zoom on an
Speaker A
X-ray, for us to take a picture on a mobile and zoom it and see it really makes the patient understand what we are looking at so that it's easier to explain and not an abstract where the p the x-ray is on the radiology window and
Speaker A
we are pointing something something there and they are exactly I was about to say that one thing patients or other colleagues should know how to send the X-ray first, you know. Exactly. They'll window sunlight. Sometimes some people are
Speaker A
walking behind and with an X-ray. A very scenic a very scenic river and grass behind an MR film.
Speaker A
uh scenery obstructing the MRI. all the all the images of the MRI with scenery behind you should know how uh to send to a doctor how properly the image should be first and second I not you just mentioned one or two but for me almost
Speaker A
it's like a daily or every alternate day because the place where I am staying it's like from all periphery or local not just orthopetics even general surgeons do refer for even uh pediatrician or anyone in anyone who is
Speaker A
working in a you know tier three cities or tire three towns or small villages who who has a small clinic they'll take an X-ray and they'll send I will ask them if I sometimes you know they are 100 kilometers away I can't see any
Speaker A
fracture in PIP I'll ask him if there is a swelling he's unable to flex send him because even though I tell him to take a true lateral or something it's you know they don't take it or sometimes If they
Speaker A
take it, yeah, if they don't take it, I'll ask two things. Swelling. If he's unable to move his fingers, send him.
Speaker A
I'll examine and then, you know, take her other view if possible. And in majority cases, the PIP fractures or other filing fractures were missed. When Balaja spoke about that taking an image and zooming in and how much of a
Speaker A
difference that makes. Did we not see this during our fellowship training and how how important it is for uh current day residents and people who want to learn any any sub specialtity to understand how important it is to be in the OPD
Speaker A
with your mentor and cuz this is something I saw everyone's looking at the same MRI but everyone's not understanding the same thing. He he took a picture of an X-ray or a CT, zoomed in and showed what is the problem
Speaker A
to the patient and you could see now the patient understood. You you could try and explain you can point at those little images on the on the viewbox and say that this is where the problem is.
Speaker A
He's not seeing the problem. It it it took you 15 years to figure out that there is a problem. He's not going to figure it out in 15 minutes.
Speaker A
And another uh segue, this is where seeing patients matters. It's not just operating and taking post-operative care. It's the ability to diagnose.
Speaker A
Diagnosis comes from seeing the patient. That is something that uh we should really emphasize and that comes with sitting with your mentor in the OPD long as agreed. But they are worth it. Not just to diagnose but to know what to
Speaker A
tell the patient. True. Very true. Yeah. You understanding that doing a proximal roarctomy or a partial restion is going to give you back about 70 80% of range of motion and a diminished grip strength. That makes sense to you.
Speaker A
And but you saying these words did not make sense to the person you're speaking to. So figuring out a way to convey these things in in that would understand what you're saying. Now what is a 70% reduction in what is a 30% reduction in
Speaker A
range of motion? So will I be able to move your wrist? Yes, but less how much less? How do you get them to understand that you're not moving your wrist at all? Now you'll be move able to move it a little bit more but it won't
Speaker A
be as good as the other wrist. So that made more sense than saying you'll have a 30% reduction from the normal range of motion to a person who doesn't know what the normal range of motion is.
Speaker A
True. What Abishek told is 100% true. I feel we are fortunate enough to you know be trained by you know someone who taught us this not just surgeries you know not just doing surgeries these things you know do matter a lot
Speaker A
and how this that is where we realize that uh there is something called shared decision making when we share knowledge with the patient and we have seen our mentor skip treatment plan on a heartbeat Just because the patient said something
Speaker A
that aligns with what the patient wants and like what Abishek Samrat said, just because you can do it doesn't mean that's what the patient wants.
Speaker A
Exactly. Segue into part two of why distal radiuses fail to understand people. Maybe we should add a tagline for hand surgery. Not just for us like entire hand surgery. Hand surgery is something that we're not treating uh the problem. We are treating
Speaker A
the function. To treat the function, you need to see the patient. Focusing on the function rather than just the fracture.
Speaker A
Horrible stage three B. You see the X-ray the wrist is gone. But the patient will have reasonably good painfree movement. Only maybe grip strength may be painful. Extreme ranges may be painful. Loading the wrist may be painful. We're not just treating the
Speaker A
radiology. We are treating the patient. So it's not just a case, it's somebody's livelihood. So their risk doesn't move.
Speaker A
Their way to earn is gone. The way to taking care of their family is gone. So that should really be explained.
Speaker A
No, that that kind of situation keen box collapse lunate you know it's not going to get revascularized but reasonably preserved range of motion still try to buy the patient more time. Would you still go ahead with the salvage
Speaker A
procedure or would you maybe think of a radial shortening and co- decompression and still wait till he progresses further?
Speaker A
You know what I will do? I'll first ask boss favorite question. What what do you want? If he's painless, he's happy. I'll tell come back when you have pain.
Speaker A
Simple. Then I'll think of options. Kiss principle. Not how easy is it to miss a scaffoid on a regular X-ray and a lateral that is really not lateral. How many times has a patient with a scapoid fracture come to
Speaker A
you with the initial assessment having true PA lateral scapoid view pronated oblique view almost never exactly almost never and then almost just for our happiness it's never never and I I have a very low threshold for a patient with enough fox proximal polar
Speaker A
distole tenderness to send them for an MRI with C I would rather overdiagnose than I would rather get it done and be sure there is nothing there then figure out 3 weeks or 4 weeks later that oh there's a fracture line and again that's
Speaker A
where informing the patient that this fracture might need serial X-rays in different points of time progressing on to CT or without MRI really makes sense it's just not take the initial X-ray even if it's the wrong images X-ray
Speaker A
looks normal you're fine not the case patient has persistent 3 to 6 weeks of radial this pain take another radiology series and the proper one this time would you wait would you wait for 3 weeks and then advise the MR or would
Speaker A
you if the patient is willing get the MR done on day one if the patient is willing yes but then again if we have a so-called bone bruise or a undisplaced scaffoid at the initial x-ray or initial MRI CT are we going
Speaker A
ahead with pinning or do we wait undisplaced weight undisplaced waste still wait do you cast short thumb spa cast or I think I feel better go for fixation what was the paper by Dr. Dr. Sep Sebastian on uh the cost on the
Speaker A
healthare system on SC because of scoid non-unions. Agreed. I I I understand the gist of what you're about to say. But again, coming back to boss's question, if it was your wrist, would you wait?
Speaker A
If it was my wrist, I wouldn't wait. Same. Secondary procedures. not really very happy with a scaffoid fracture treated with a perccutaneous screw seem to seem to do just so much better than a skoid non-union treated with bone grafting in
Speaker A
a true most fractures just more pronounced in this case what about we jump into CTMR taking an MRI or an elbow suspected elbow dislocation within 24 to 48 hours of the injury and all we see is Eddie man blood and
Speaker A
convincing the patient, explaining to the patient that they'll need another MRI. Usually patients are referred with already an MRI taken where you can't see anything.
Speaker A
It's all hematoma and edema. So, looks like these all are complaints rather than in an ideal world. This won't happen.
Speaker A
But our world is not ideal. Welcome to the hand ledger. Three hands are just rant about everyday practice.
Topics:hand surgeryradial nerve injurytendon injuryEPL tendonK-wire pinninghand traumasplinting techniquesDRUJ instabilityshared decision makingperipheral hospital challenges
