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i am constantly giving a toast

Well, I had my first post-we-finally-know-what-it-is-and-can-treat-it-properly-now follow-up with my orthopedist today regarding my pinkie finger. Here is the rundown.

- My A2 pulley is definitely broken, and is definitely not going to grow back. No surprise there.

- Swelling has definitely decreased, but it is still swollen, and the range of motion when flexing the finger is still significantly limited.

- Neither the doctor nor my physical therapist are willing to admit it (and I can guess why), but I am 95% certain the therapy I was doing before the MRI actually caused the previous swelling. Before we had a good look at the problem, everyone firmly believed that all of my troubles were due to scar tissue building up in the second joint of my pinkie from that cut to the inside of it, and the treatment for scar tissue buildups consists of really working the finger, especially with "therapy putty" (really, silly putty), resistance, and the whole shebang. Well, when I was trying to flex my finger against resistance with a busted-out A2 pulley, you can only imagine how much that was probably pissing off that finger’s tendon. Now that we know better, we are not doing that kind of gos-se any more, and, lo and behold, the swelling has reduced. The compression, ice, and everything else is unquestionably helping, mind you, but I have to wonder how much harm we did previously.

- Surgery is on the table as an option, but "most people" – i.e. folks who are not rock climbers, musicians, etc. – simply cope with the injury.

- Said surgery would involve finding a "spare" tendon (I apparently lack the easiest one to use – the palarmis longus tendon. Put your pinkie finger to the tip of your thumb, and curl your wrist inwards; if a little tendon bows up out of your wrist, you have a "spare" tendon. My physical therapist tells me 60% of the population has at least one; I have neither, Better Half has both. Due to this, apparently my "spare" tendon would either come from my ankle (the plantaris tendon), or be shaved off an existing one.), cutting it out (neither the physical therapist nor the doctor like it when I say "cannibalize", but that is what they are doing), and wrapping it around the bone and tendon of my pinkie finger where my A2 pulley should be, then attaching the ends to one another. The incision on my finger/hand would be about 3 inches long, from what the doctor showed, and would require "multiple months" of therapy to recover from. The finger would always have a bulge in the first segment, just due to the kitbash nature of the repair.

- We have postponed any decision until we have had more time for therapy, and until we get back from visiting my parents.

So now my thoughts on the matter.

It still hurts, and pretty much all the time, regardless of whether I am using it or not; the only variable is amplitude. I am starting to understand how/why people get addicted to pain killers – not that I am, mind you; I am only taking the WalMart knock-off of Aleve, but I can see how people end up in that rut. Worse than just my pinkie finger hurting though, my entire hand, all the way past my wrist, aches. I can only imagine this is due to the swelling, the compression I keep on the swelling (Coban is still awesome stuff), the pinkie tendon being pissed off, and the other fingers trying to pick up the pinkie’s load, but that understanding does not alleviate the pain. Push-ups are impossible, and even resting my hand on my mouse can hurt.

My right hand is weak; there is no way around that. I do not know what its strength was before my injury, but my left hand can squeeze with 110 psi of force, while my right can only manage 85… and I am right-handed. Your dominant hand is typically supposed to be able to exert 10-30% greater force than your non-dominant hand. I see this weakness present itself in all kinds of ways I had not previously considered, but the one most relevant to this site you have probably already figured out.

Shooting firearms, both pistols and long guns, is both more difficult and painful now. Think of shooting handguns – every time you do so, you are basically creating rotational force around a horizontal axis somewhere between your index finger and thumb. That force is typically counteracted by, you guessed it, your middle, ring, and pinkie fingers… and the annoying thing is that the farther out the finger is from the axis, the more important it is / the more force it will be fighting against. Hell, last time I went shooting, I actually had to close my pinkie finger around the pistol grip with my other hand, it was that bad; granted, that is the grip you are supposed to use on handguns, but still.

Speaking of, when it comes to its load-bearing properties, the A2 pulley in your pinkie is actually the third-most important one of your four fingers, per the American Association for Hand Surgery.

Honestly, "most people" do not encounter this kind of injury unless you are a rock climber or otherwise put some kind of inordinate strain on your fingers when they are held in strange fashions. I still wish, to this day, I knew what I did, mostly so I made damned sure not to do it again…

And as for surgery… I cannot say I am terribly keen on the idea of being sliced open and having to cannibalize my own body (according to my doctor, there are no suitable artificial replacements for pulleys), but this is already taking "months of therapy" to get what limited use I have back anywise, and things like this concern me:

Medical or functional treatments never allowed climbers to reach their former level. The only efficient treatment was surgical, whatever the time elapsed between injury and surgery. After this surgical procedure, five of the twelve patients improved their results, five recovered their former level and two decreased. The results are analysed and compared to other surgical procedures.

Granted, they are talking about "high-level rock climbers", but the point is there. The Germans, of course, disagree with the French, though:

Nonsurgical treatment of single pulley ruptures is recommended. The clinical outcome was good to excellent, and no long-term strength deficit for the injured finger could be observed.

When it comes to blowing out both the A2 and A3 pulleys, though, the Austrians agree with the French (squeamish warning on the pictures at that site):

Thirteen patients were treated with an extensor retinaculum graft (Group A). At a mean follow-up time of 48 months, the average PIP flexion was 97%, the power grip strength 96%, the pinch grip strength 100% and the thickening 94% of the uninjured side. Ten patients were treated with a free palmaris longus tendon grafts (Group B). At a mean follow-up time of 57 months, the average PIP flexion was 94%, the power grip strength 98%, the pinch grip strength 100% and the thickening 95% of the uninjured side.

[...]

Both techniques proved beneficial. All climbers returned to their previous standard and all non-climbers regained full finger dexterity in their previous job.

Neither of these techniques are what my doctor is proposing, mind you, but both are still surgical. I am looking into this "extensor retinaculum graft", which involves harvesting (apparently that is an acceptable word, but "cannibalizing" is not) part of the fascia that holds your hand’s extensor tendons and muscles in place, but it is still fairly "new" (they only found useful donor sites in 2001) and there is not a lot of information about it, aside from the fact that it opens up an even larger hole in my hand.

So now that you all are probably bored out of your everloving minds, two quick questions:

1. How does one search for hand surgeons on the intertubes? It is not like there are review sites out there, but I guess this is a good starting point.

2. Does anyone know if Dynarex Sensi Wrap is comparable to actual 3M Coban? I bought some not-quite-Coban stuff at Walmart, and it was, frankly, crap, but something tells me I am going to need a bit of it by the time this is all said and done.

17 comments to i am constantly giving a toast

  • Is amputation even an option? Is the pinkie finger necessary to a person’s hand if the tendon is blown out? Amputation would certainly solve the chronic pain issue. Old blues guitarists didn’t even much use their pinky fingers for fretting, being able to get by with index, middle and ring fingers.

  • Don

    Jewish Hospital in Louisville, KY has a world-class hand clinic. A couple of years ago they did the first sucessful hand transplant. My wife is an RN there and says they do excellent work. I know it’s a bit far but, they apparently the place to go. I think it’s worth a consult anyway.

  • @ Robert: I suppose it is an option, but I am not sure why I would take it when there are other options still on the table that involve actually fixing the problem…

    And it is not so much the tendon that is blown, but rather the sleeve the tendon runs through. I can still operate the finger, just with a drastically reduced range of motion and more than a fair bit of pain.

    Various football players have had their pinkies amputated rather than not be able to play for a season or big game… The end result is a loss of up to 33% of your grip strength, based on what I have read elsewhere, surprisingly enough. Not really sure I want to go there yet.

    @ Don: Any place that can reattach a hand gets credit in my book – we will look into it. Thanks for the recommendation!

  • Ben C

    Use caution on the Alieve. I took it for some tendinitis and back issues for several months, and my GI tract is still all messed up several years later. It is much better than it was, but things were pretty miserable for a while and only daily Zantac managed to get me through the day without camping out in the can.

  • Oh that sounds thrilling… Per the bottle, I have not been taking it for more than 10 days straight, but I might drop even that back some…

  • Steven

    Steadman clinic in Vail,CO. steadmanclinic.com Maybe the best in the world for orthopedic surgery. Long drive but bring your skis and I will join you for a few runs…

  • @ Robert:

    Actually it won’t solve the chronic pain issue. Ghost pains, look into them. While they come and go, they can be serious and down right vicious.

    @Linoge:
    I can tell you who Janelle has been working with in Washington for her nerve damage. He is one of the best in the world for the work she would have done if she wanted to go the surgery route on her injury. In her case it would be a tendon transfer and split to move a tendon from the underside to top side of her forearm.

    In your case though you’re probably looking for someone closer. I’ll talk to some family friends and see if we can find anyone in the area.

  • Dr. Ivy did the surgery to put pins in my ring finger after a tricky spiral break. I was very happy with the results.

    http://www.kocortho.com/phys_ivy.asp

  • Rob Reed

    I’m so sorry to hear about your injury. That really sucks and it’s amazing how what seems like a small injury at first can have such consequences.

    As far as shooting, you may want to start working on support hand only handgun shooting for awhile. Shooting with your dominant may not only be painful, but may be contraindicated during your therapy and recovery. In the meantime though you still need to be able to shoot defensively at least. I recommend you acquire a left handed holster and get some practice drawing and shooting left handed only. Even when you are able to return to two handed shooting, or strong hand only shooting, it will still serve you in good stead.

  • @ Steven: Will look into them too, thanks! And me on skis is just a recipe for even more damage to at least one hand ;).

    @ Barron Barnett: Closer would be better, but apparently our insurance is changing to allow us to see any in-network doctor without a referral in this coming year, so it is not necessarily mandatory.

    Of course, our costs are going up ~30% for that “privilege”…

    @ Brick O’Lore: He is actually the doctor I have been seeing. I like him as a doc and person, but I am somewhat… “concerned” is too strong of a word, but it gets the sentiment across, that he did not mention the other two procedures for fixing this, especially since they are lower impact on the finger. It could be that he does not like them for some reason, but I would like to know what those reasons are. Something to talk about for our next appointment, I guess.

    @ Rob Reed:I have definitely realized you never fully comprehend how important a body part is until you damage it.

    And, yeah, I may have to consider doing non-dominant hand shooting for the meantime… I guess, in the end, shooting without the use of my pinkie is not really any different than shooting snubbies or pocket guns wherein your pinkie cannot grasp the gun to begin with, but in those cases, you can still wrap your other hand around your gripping hand. Sticking out my pinkie like I am toasting with the gun? Not so useful…

  • Chris

    For Not-quite-coban, Hit a Fleet Farm or whereever and See if you can find some stuff marked “Vetrap”. 4″ X 5 yard rolls, Can probably be cut into narrower rolls if needed. If it’s not exactly the same stuff I can’t tell. 3M makes both, Probably just not so picky about cleanliness with this stuff. The price is much better. It’s also great for making stainless rifle barrels un-shiny for deer season. :)

  • We do not appear to have Fleet Farms in my area, but my PT person did indicate that farming supply stores often have Coban-like stuff that is functionally Coban, just without the name and price. I went ahead and got some of the Dynarex stuff, so we will see on that count, and when that runs out, I may investigate the animal wrap stuff.

  • DJ

    I’m gonna throw my two cents worth in here. I suggest you have your hand fixed surgically. Insert your own cliché here: bite the bullet, get it done, and so on.

    There are a number of reasons why I’m chiming in, and I’ll explain each one.

    Reason #1 – Been there, done that.

    I have had nine surgeries in the past ten years. In non-chronological order, they were: 1) Lasik; 2-5) four trigger finger releases; 6) prostate biopsy; 7) prostatectomy; 8) cardiac bypass; and 9) cervical spinal fusion. Long ago, I had three other surgeries: 1) tonsillectomy; 2) wisdom teeth removal; and 3) removal of a kidney stone from a ureter by the roto-rooter method (beats me what the technical name for this is).

    No, it’s not a hobby. Sometimes, life’s a bitch.

    The point is that I am not squeamish about surgery any more than I am squeamish about field-dressing an elk. I have been immensely impressed by the professionalism and skill of the people who have worked on me.

    Reason #2 – Been there, done that, part II.

    As I listed above, I have had four trigger finger release surgeries. To find out what this is, and to see its relevance, go read the following: http://www.webmd.com/osteoarthritis/guide/trigger-finger

    Consider the anatomy you’ve described. There is a sheath under the main knuckle of the finger, in the palm. The tendons which contract the finger pass through that sheath. If the tendons becomes damaged or inflamed, they can swell a bit, which makes it difficult for them to slide through the sheath. This difficulty causes the tendons to swell and become inflamed even further, and positive feedback sets in.

    The symptom is that the finger won’t close. As more and more force is exerted, the tendon suddenly slips, and the finger suddenly contracts, all as if a trigger is being pulled and the sear finally trips, hence the name “trigger finger”. It can be intensely painful when this happens, and it can severely limit normal use of the hand.

    This developed in the ring finger of my left hand in early 2002. As it progressed, I couldn’t quite straighten the finger and gripping anything became painful. One day in June of 2003, I dropped something (trigger finger will make that easy), and I grabbed for it in mid-air. The finger “triggered” and brought me to my knees. I had to pry the finger open, which brought me to the floor.

    Enough. I opted for surgery to fix it.

    The surgery is simple, easy, and fast. I have often joked: just give me an Xacto and a bottle of Jack Daniels and I’ll do it myself.

    All the surgeon does is: 1) open the skin over the sheath, using a 1 – 2 cm incision; 2) retract to expose the sheath; 3) cut the sheath lengthwise; and, 4) close the incision and suture it. This particular sheath is not necessary; it’s simply evolutionary baggage. Releasing it does not limit use of the hand at all, but it does eliminate the problem.

    To see the surgery itself, go see this video: http://www.youtube.com/watch?v=DISCFr0YeiM

    To date, I have had this surgery four times:

    1) Jul, 2003 – ring finger, left hand
    2) Apr, 2004 – ring finger, right hand
    3) Nov, 2006 – middle finger, left hand
    4) Dec, 2011 – middle finger, right hand

    #1 was done under local anaesthesia; I watched. Yes, really.

    #2 was done under local anaesthesia after morphine was administered by IV; I was “present.”

    #3 and #4 were done under general anaesthesia; I wasn’t even there.

    The incision healed in a week or so. Tendons heal very slowly, so recovery to full, normal use of the finger was 4 1/2 months with the first three and six months with the fourth.

    Each time, the surgery gave me back 100% use of my finger. Now, my hands work just fine. At my age (I’m 59 and diabetic), they are a mite stiff, but I have full range of motion of all four of those fingers, and a strong, healthy grip with both hands. They simply work like they are supposed to. I don’t mind recoil, and shooting a .45 ACP or a .356 Mag works just fine.

    Reason #3 – A colleague and his hand.

    A colleague of mine once worked in the tire industry, thereby experiencing a nightmare as a tire “unzipped” (exploded, in layman’s terms), thereby flaying his hand as if with a blender. It was laid open, full of broken bones, cut tendons, and so on. He described it as “hamburger”, and thought he’d lose it.

    A very good surgeon put it all back together, pinning bones, suturing tendons, and so on. His hand looks normal except for faint scars in many places. His hand works normally, too. His grip can crack walnuts – I know, as I’ve seen him do it. You’d never know he had the accident unless he told you.

    The bottom line is quite simple. A good hand surgeon can work what a layman would describe as miracles. The staff of my surgeon describe what he can do with a damaged hand as “magic”.

    You don’t need to go through life as a cripple, and that’s what you’ll do if you don’t get it fixed.

    You need have no trepidation about undergoing surgery, either. After nine in ten years, I’m no expert, but I am experienced. As the Nike commercial says, Just Do It.

    Finally, if you are serious, I can recommend an absolutely outstanding hand surgeon. Read here: http://www.southwestortho.com/mehdi-adham.html

    Yes, he’s not in Tennessee. Do you want it done right or do you want it done right now?

  • Wow. Thank you for taking the time to write all of that up… Believe me, I was very, very concerned that my tendon would start triggering as well, given that it is inflamed all to hell and back, and the pulleys on either side of the blown out one are catching more load than they were used to before. I started exhibiting those kinds of symptoms for a while, but now that we are actually treating the injury properly, it seems to be abating significantly.

    That said, trust me, we are looking into surgery… I grant that perhaps my recovery from the damage itself is not nearly at 100% yet, but I doubt I will be wholly satisfied with whatever that point turns out to be, which means the only option I have left is going under the knife. Like I said, the good news is that our insurance allows us to see more doctors starting at the beginning of next year, which will open up places like the one in OKC you recommend. I just wish there were a better way of comparing / rating / ranking doctors, so you know who to spend the time to go see.

    By the same token, I need to research how to set up appointments with folks out of the immediate area – do they want a consult, do they really care about something this trivial, do they want follow-ups, etc. etc. The good news is that the existing damage really is nothing more than “ruptured A2 pulley”, and that is about as simple and as straight-forward as you can get; plus I have copies of my MRI, so I can pass that along.

    In any case, there is no way on God’s Green and Fluffy Earth that I am going to watch any of this. I had bloody well better be out, or it ain’t happenin’ ;).

  • DJ

    You’ll be “out,” not to worry.

    Likely, to get an appointment with a surgeon for the first time, you’ll need a referral. Been there, done that.

    You’ll need an MRI and X-rays, and the doctor whom you’ve been working with will have to make the appointment and pass on his evaluation. After that, you’ll deal directly with the surgeon and his staff, even if you need a followup surgery or some such later on.

    However, you’ve done your homework. That will make dealing with the surgeon much easier, and he’ll appreciate it.

    I have used the services of some very, very good surgeons, and I don’t regret any choice I’ve made. The key thing to note is that every choice I made was the result of a recommendation by others who’d been there and done that, (oddly enough) with the single exception of the one I recommended to you. I had the first two trigger finger releases done when we lived in northern New Mexico (and note that there is a fine hand/shoulder/arm surgeon in Taos). When we moved back here, I did my homework online, went down to his office and talked to his staff, and made the choice right then and there. I do not regret that choice one iota; he is astoundingly good.

    Oddly enough, one of his staff members had Lasik done about a week before I was there. I followed up her recommendation for a Lasik specialist and had spectacular results.

    To coin a phrase, go thou and do likewise.

    Now for a short diversion. About two weeks ago, a long-time family friend (old high school chum of my younger brother), tested the sharpness of the blade on a table saw. It was his fault; he did not use a blade guard nor a push stick, and the blade was way too high, about 1.5 inches higher than the top of the board he was cutting. He clipped the blade with the first section of this right thumb, from the outside. The blade cut through the tendon on the upper side, and then cut through the bone. Luckily, it did not cut the major arteries or nerves.

    A fine surgeon (young and well-trained) pinned the bone, sutured the tendon, and put all the skin and such back in place. It looks surprisingly good, his thumb works, and his only long-term limitation will likely be due to a slight shortening of the tendon, which will keep him from closing the thumb all the way.

    It was (believe it or not) outpatient surgery. It started at 11:00 AM and he was home by 3:00 PM. We visited him that night, and he showed us his bloody floor and saw.

    So, based on mine and his experiences, I can give you an idea what to expect, presuming you haven’t had surgery. You’ll find it easy.

    You’ll arrive about two hours before surgery. You’ll be asked repeatedly, by damned nearly everyone concerned, just what procedure “we’re doing”. Be ready to rattle off the technical jargon. For example, my recent spinal fusion was an “anterior cervical two-level fusion with plate”. This is not trivial; the idea is the make sure they don’t amputate your nose instead of fixing your finger.

    You’ll undress, put on a gown and footies, and climb onto a bed. A nurse will measure everything and start an IV.

    Then you’ll wait, and wait, and wait.

    Finally, they’ll wheel you into the operating theater. You’ll transfer to the operating table, get yourself wriggled comfortably into place, all the while visiting with the people getting you prepped and thanking them for taking care of you.

    Meanwhile, the gass passer will be “arranging the IV tubing”. You won’t know it, because he’ll do it behind your head where you can’t see it, but he’ll squirt a syringe full of something into the IV. You won’t feel it or know it. He does it this way so you won’t be apprehensive about exactly when you’ll go “out.” From your point of view, you will be lying there when SUDDENLY, after the passage of no time whatever, find yourself awake in recovery. You need to be aware of this. Don’t let it surprise you.

    After that, you’ll spend time in recovery as they push IV fluids in you to flush out the anaesthesia. If it’s outpatient surgery (beats me in your case), when you’re nice and stable, coherent, clear headed, and so on, they’ll give you a set of post-op instructions, prescriptions for pain meds and such, and send you on your way. Whoever is there to drive you home needs to PAY ATTENTION, because you won’t remember these instructions.

    If you come here to do it, you’ll need to spend perhaps the rest of that day and the following two days sitting quietly in a hotel room recovering. You’ll find yourself fatigued, with little energy reserves. Eat well, drink a lot of fluids, and sleep off the effects of the anaesthesia.

    Have a soft (preferably feather) pillow to put in your lap and lay your hand on as you travel home. The idea is to get it as comfortable as you can and to limit vibrations from the vehicle; feather pillows do that marvelously well.

    Then, be patient, follow the doctor’s instructions, and heal up. Again, be patient; it’s gonna be a long recovery.

    When the time comes, I’m a wizard at using hydrocodone to control pain. I took them from May 20 through mid-July last year, 5 mg every six hours, by the clock, to keep a level 7-8 pain from my tortured spine at bay. It worked, but I was quite addicted after my surgery. The key thing to know is that I know how to get off them without the slightest withdrawal symptom. Yes, really. It was trivially easy. You shouldn’t need to know how, as likely you won’t need such pain meds for more than about four days. But if you do, I’ll tell you how I did it.

    Meanwhile, get after it. The sooner you get it done, the sooner it’ll be over with.

  • Thanks again for all of the explanations… I have had a single surgery in my medical history, but it was back when I can hardly be expected to remember the finer details ;).

    Unfortunately, “sooner” will have to be next year, and probably around the end of January, the way things are going. We are going out of town to visit my parents for the holidays, and I do not want to be recovering from being sliced open going into that. Then our in-laws are prepping for some significant surgery of their own, so Better Half at least (and possibly I) will need to help them out with that.

    Life is life :).

    That said, I think I have finally come around to the “surgery is the way to go” way of thinking… Now I just need to find someone willing to do it for me.

    Oddly, that new healthcare plan I mentioned does not require referrals starting the new calendar year, which should simplify things immensely. There are some good folks in Nashville, Louisville, and Atlanta, so we are considering those, as well as the CO place recommended above and the one you mentioned. Thankfully, the holidays will give us time to fully research them :).

  • DJ

    Sounds like a plan. Just remember my simple guideline: It’s better to get it right than to get it right now. They key is finding a surgeon whom you expect will do a (ahem) bang-up job. Spend youre efforts there, and the rest will fall into place.



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