Transcript
josh MacDonald: Hi, I'm Josh McDonald.
Miranda Materi: And I'm Miranda Matieri and we are Hand Therapy Academy.
josh MacDonald: So let's talk a little bit about when we should send our patients back to sports. I had a situation actually today in the clinic where we had two kids in the in at the same time and when to send especially our pediatric patients back to the the playing field can be a little little tricky.
Miranda Materi: Yeah, and what do you do, especially if they're not professional athletes, right? You're like, well, Do you jeopardize them having another injury or something that could be more long-term? And so I guess I'd be curious as to what you did and what those cases look like.
josh MacDonald: So, yeah, it's it's tough because sometimes the kids take it more seriously than adult pros, right? Like these kids, like it is their entire world and sometimes their parents' world too. Yeah.
Miranda Materi: Unfortunately, yes.
josh MacDonald: Right, right. So we had two 15-year-old boys in the clinic at the same time, one with a fifth metacarpal fracture for punching a block wall um after missing a lift in the gym. And he is two weeks out for what at the time was a pretty unstable 40-ish degree angle metacarpal distal neck fracture, excuse me, distal shaft fracture. um And he's in an ulnar gutter splint.
josh MacDonald: The other patient is 15-year-old who fell during basketball practice and had a small finger P1 fracture that was pinned. It was pinned for two weeks. Pins were removed. And then two weeks later, sent to therapy and said, at four weeks post-operative, you can go back to basketball. Just be careful. Don't fall while you're running.
josh MacDonald: And so the The metacarpal fracture, the doctor said like nothing, nothing, don't plan on doing it. He had just made the basketball team when this happened. And he was told, um you're not going to play basketball this season.
josh MacDonald: Like don't plan on it.
Miranda Materi: Thank
josh MacDonald: You're not you're making mountma basketball season. Where that fracture could heal and he might have the capacity to play towards the tail end. But doctor just said, write it off. It's gone. Move on. The other kid, this doctor is sending him back four weeks with two of those in pinning.
josh MacDonald: on a P1 fracture saying, don't fall. Like, I don't know if this doctor knows how basketball practices and games work, but he's going to get a shooting hand whacked. He's likely going to fall down the kid.
josh MacDonald: these I mean, these' fifteen is he's 15. He's a baby giraffe and he's falling all the time during wind sprints. He's going to fall. So it's just this, like, how do doctors decide when they send kids back? And then we've got to like back up those decisions. It's tough.
Miranda Materi: that's very tough. And then like, does the kid have pain at his fracture? So I don't know. Does he have pain at the fracture site? Is there like good heal? You know,
josh MacDonald: Yeah. Yeah. Neither of these kids have really any perceivable pain. They talk about the worst is like two out of 10. If they bump it on something in their splint or something like that, they both feel fine. They're both highly motivated to get back.
josh MacDonald: And so we're telling this one kid that's going back to play back to practice basketball. We're telling him, you got to be careful. Like if you fall again, this is catastrophic, but I'm asking a 15 year old without a prefrontal cortex development to make good choices about when his buddies are all sprinting hard and he's got to tell the coach, I can't run hard.
josh MacDonald: Well, then you're not going to play in the game, right? Like what's the point of all this? He's just going to keep his mouth shut and do what he's going to do.
Miranda Materi: Right, exactly. And I think the the thing is, is that they're 15. So I think, you know, as as a parent and as a parent of an athlete too, I think I would still be like, we're going to wait longer, right?
josh MacDonald: Yeah.
josh MacDonald: Yeah. Yeah.
Miranda Materi: And, but then, I mean, what do you say when the doctors that, you know, I guess we know, cause we have our background in orthopedics, but if the doctor's saying it it's okay, I mean, what are you going to say?
josh MacDonald: Yeah. And the doctor that gave the approval after four weeks with only two weeks of pinning, I've asked follow-up questions of in the past, and it was not well received.
josh MacDonald: It was the the the physician's assistant when I said, hey, are we sure we should be moving this patient already? They're only two weeks out after a fracture and pin's out. Like, are you sure you want the aggressive range of motion listed in the script? Yeah. Yeah. That's what we said.
Miranda Materi: Yeah.
josh MacDonald: Okey-doke. All right.
Miranda Materi: Well, yeah, I think it's interesting too, because I think we know physicians like that. We know physicians that will send a distal radius, no splint after surgery, get them moving, move on their way, be aggressive. And then we know people that will wait six weeks to take them out of their splint.
Miranda Materi: It's, it's such a huge variance.
josh MacDonald: Yeah. Yeah. And the the forces and loads in a sport, in in high school sports for 15-year-olds, even if it's not a contact sport, you know baseball whatever, it's still like you get tagged with a ball on that hand.
josh MacDonald: Yeah. And ah you know a rough slide into second. There are a lot of forces at play. And I just think the risk-reward is just not there.
Miranda Materi: Yeah, as opposed to waiting a couple even just a couple more weeks, right.
josh MacDonald: Yeah. Yeah.
Miranda Materi: Then, okay, so then let me ask you this. Do you, so what I always say to my team is we have to ah trust the captain of our ship, right? And so in that case, it's the physician, that's, it's the surgeon that did the pinning.
Miranda Materi: Are you trusting the captain of your ship or like, what are you telling the parents?
josh MacDonald: So yeah, yeah, I try in those situations.
Miranda Materi: Are you like going for it or what?
josh MacDonald: i I will never say, i will never recommend that they be more aggressive than the surgeon. I might, Hint, suggest and talk around, you know, maybe it's not a bad idea to wait a little bit because there's some risks involved with this. The doctor gave you permission. So it's, you know, if he thinks it's OK, but I might have my kid wait a little longer. I might I might talk around being more conservative, but I'd never talk around like, oh, you're totally fine to play. I don't know what he's thinking.
Miranda Materi: Yeah.
josh MacDonald: Yeah.
Miranda Materi: Yeah.
josh MacDonald: The risk to our liability is too high.
Miranda Materi: Or I mean, yeah, I think but too, like if the parent has concerns, I'd say, Oh, why don't you, you know, I, I think those are valid concerns. Why don't you bring them up with the doctor?
Miranda Materi: You know, which I think like you, you said though, like most of the time when someone's advancing them that quickly, when I've done that too, I've been done it with um a patient that had nerve transfers, it was a baby for a brachial plexus. And remember calling the doctor with some concerns that we were doing, you know, shoulder abduction too early, but they were like, nope, that's what we want. You do it, you know, and you're like, okay.
josh MacDonald: Yeah. Yeah. I've also had like a senior who hurt his hand like very beginning of the season. Didn't get to play any any games, wanted to be, wanted to dress and play his final season, you know, last game of his high school career, desperately wanted to play. And I said, all right, we've got to get these markers down before you can return. And then your doctor has to give you official permission. So you schedule a visit to see that doctor before your last game and get the x-ray as late as possible. And so we work with patients and try to make sure. But yeah, it's tough when you've got providers giving vastly different timelines on things.
Miranda Materi: Yeah. And I always think, you know what, like, yes, I want to trust this provider, but I'm going to verify, like, did you mean to say this? You know, I may ask the parents to verify because sometimes the parents tell us something different too, right?
Miranda Materi: Like the parents could be like, yep, they said two weeks. But when we go back and read the chart, we talked to the doctor, like, no, that we said two months. Right. So it's always like like verifying the order.
josh MacDonald: Yeah. Yeah.
Miranda Materi: And sometimes it's not even the doctor writing the order. It's an MA putting in the computer.
josh MacDonald: Yeah. yeah There can be typos on there. There can be errors. There can be, yeah. So it's not bad to verify, but you've got to know your, your referring provider and their receptiveness to that. And,
josh MacDonald: I don't want to make it about liability and just washing your hands and saying like, well, it's on the doctor because I want to, you know, be a good person and say like, Hey, maybe this kid shouldn't be going back in the football field with a scapho loonate injury six weeks later with no protection.
Miranda Materi: Right. Yeah.
josh MacDonald: Yeah.
Miranda Materi: And what can we do to get that kid safe, you know, to play? I think are all good questions.
josh MacDonald: Yeah.
Miranda Materi: I think good to verify. Trust, but verify. That's what one Hansard and i work with. He's like, I trust you, but I'm going to verify with you as well.
josh MacDonald: Yeah, yeah. I think that's good. and And trying to approach that conversation with the surgeon or the PA in that sense of like, hey, just wanted to clarify, make sure this is we're all on the same page and this is this is what you're looking for. Yeah.
Miranda Materi: Yeah, I think even saying something like the facts came through is a little blurry. i wanted to make sure, we're you know, like, it doesn't always have to because I think sometimes people think we're like confronting, especially surgeons, they don't want to be like confronted or told what they're thinking is or being questioned, right?
josh MacDonald: Yeah. Yeah.
josh MacDonald: yeah
Miranda Materi: It's just more like I'm there. And like some surgeons don't care. We know that. But some are like, no, that's what I said. And that's what I want. Don't you dare ask me questions about it.
josh MacDonald: Right. Which I definitely don't get that vibe from PAs very often, but we've definitely got one here that she doesn't, that yeah, it's it's usually the fact is blurry. Can't tell. Can you tell, can you tell, can you confirm for me, please?
Miranda Materi: He let me know.
josh MacDonald: Yeah. Yeah.
Miranda Materi: Yeah.
josh MacDonald: Well, it's not always super clear, but hopefully you can get some sense of clarity with talking with the patients and find a way to balance that return to sport in a safe way for your patients. So If you have any questions, reach out to us via email info at handtherapyacademy.com or on our social media platforms, Hand Therapy Academy.
