Curvebeam Connect: Hand, Wrist & Elbow Injury Recovery Methods in Sports Medicine

Welcome to Curve Beam Connect. Listen in monthly as we talk with doctors and experts in the field discussing innovations and insights into orthopedic imaging. Welcome to the Curve Beam Connect podcast where we give doctors, patients, and anyone interested in health care and technology a look into how our solutions are changing medicine. I'm your host, Vinti Singh. I'm the director of marketing here at Curve Beam. Our guest this episode is heavily involved in upper extremity research and has received numerous honors and awards from the American Association of Orthopedic Surgeons and the American Society for Surgery of the Hand. Doctor Glenn Gaston is a hand surgeon with OrthoCarolina, one of the nation's leading sports medicine practices. He's based in Charlotte, North Carolina. He serves as the hand consultant for the Carolina Panthers and the Charlotte Hornets, as well as Hendrick Motorsports NASCAR team. He's also a member of the NFL Physicians Society and serves at the NFL Hand, Wrist, and Elbow Subcommittee, which is gonna be the focus of our interview today. Welcome, doctor Gaston. Thank you so much for joining us today. Thanks for having me. Great. So can we start by you explaining, how the NFL, physician society is set up and specifically the NFL Muscular Skeletal Committee. What do you do? Who are the members? Just give us a brief introduction. Yeah. Sure. So each NFL team has team physicians as well as team consultants that serve, on the NFL physician society and within it. From that, they've done a really good job of setting up various committees. It began really with the spine and head committee, and that was what was really driving a lot of the concussion research that you've heard a lot about. Subsequent to that, they developed a foot and ankle committee, that really did a good job of evaluating lower extremity injuries and looking at the effects of which shoes should you wear on which turf and things like that to really the goal, of course, being to protect the players. Mhmm. More recently, just in the last two years, we formed the hand, wrist, and elbow subcommittee. And our charge is to look at injuries that affect the hand and wrist and review. Basically, we start with reviewing all the injuries that have occurred over the last several years and trying to look for patterns and then, of course, looking towards injury prevention being the goal. So there's four of us that serve on that committee, and it's been a pleasure and honor for me to get to be one of them. So how often does the hand, wrist, elbow subcommittee meet? We have an in face meeting annually at the NFL combine. So we all go to the NFL Combine, and there, is at that time is when we have our annual NFL physician society meeting, and the subcommittees will meet then. But then we have ongoing research studies, and so we have meetings probably around quarterly by the phone, to review data and discuss our plans and our goals of our committee. And do you have a term that you're going to serve on this committee, or, how how is it decided who is who actually sits on that? You know, right now, we don't. We just formed about two years ago, and there's four of us that are on that. And, we haven't even gotten to the phase yet of determining when we're gonna roll on and off the committees. But most of the committees have been pretty open in the, past in terms of people staying on them for fairly long periods of time as long as they're making good progress as a team. So it sounds like hand, wrist, and elbow is a relatively new committee, compared to, say, the concussion team or ACL tears. Can you talk about how it was decided that there should be a special subcommittee just for hand, wrist, and elbow? Yeah. You know, I think, just because those injuries didn't get as much attention in the past, as you're aware, many injuries to the hand, people will still be able to play. They can put them in a cast, whereas if you have a ankle injury, they have more time off the game. And, of course, with concussions, even greater times off and more concern for the players' long term well-being. So I think it just took a while to appreciate that these injuries were also of importance to the players and to the teams. And it was about four years ago that we began the discussions of maybe we should form one, and the NFL player society and, physician societies were very responsive. And so four of us got together who routinely attended the combines and set this committee up. So what are the key areas that the hand wrist elbow subcommittee has focused on? What are some of the predominant injuries or trends that you're looking at? We had an interesting discussion in the very beginning of there's sort of two ways you can go. Do you go for what are the most common injuries? Even if that means they're injuries that don't miss as much playtime. So there's common things like dislocated finger joints and broken metacarpals and broken bones within the hand that we, wanted to evaluate. But then we also wanted to look at some of those injuries that may be less common but more destructive, things that would be more likely to end a player's career or result in long term arthritis or long term issues for the players. So we've sort of broken it into two parts. One, we're looking at, what are called metacarpal fractures, which are just one of the more common broken bones in the hand, and looking at how how long does it take players to recover from this. When is it safe to let them return to play? What's the optimum way of treating them? Because how we treat an NFL player is very different than how we treat the average weekend warrior. And to that end, how we treat an NFL quarterback may be very different than how we treated an NFL lineman, so if they're able to play in a cast or not. So we're trying to look at various factors for that. And then at the same time, there's some more significant injuries such as ligament tears and a bone called the scaphoid that can be broken in the wrist that if undertreated can lead to much more long term morbidity for the player. Interesting. So I was reading a little bit. I saw that the NFL medical committee, they actually do a lot of extensive injury tracking and data tracking of injuries in every game, by position, even by day, played. So Thursday injuries versus Sunday injuries. Can you talk a little bit about how that injury data is tracked and how it's, recorded and used by your subcommittee and and the entire, medical committees? Yeah. Absolutely. And I'll tell you what. It's absolutely incredible. The NFL's really done an incredible job of devoting the resources needed to track it. And you're exactly right. Every single practice, every single game, every single injury to every single player is recorded, and it's down to what type of turf. Was it raining? And they have video footage, of virtually every injury that occurs, for us to even review. So something as simple as a laceration that just needs a stitch would be recorded all the way down to someone breaking their arm. And then our committee basically takes the data at the end of each year, and we can look at it however we want. We typically break it down into, in order, what are the most common injuries to the arm that we see. And then we may choose certain injuries that we know, as I mentioned, are devastating long term and look at those specifically to see is there a trends that we can begin to identify. These injuries more often happen, in these types of place. These injuries more often happen in these types of conditions. Therefore, we can start looking towards how can we prevent them. Can you provide an example of one of those more devastating injuries, the two that we're really looking at right now are one's called a scaphoid fracture Mhmm. And one called a scapholunate ligament injury. The scapholunate ligament is a critical ligament in the wrist, very similar to the ACL in the knee. And we know that if people injure that injury and it's not treated, that it leads to long term arthritis in the wrist and loss of function. So those are two we're looking at now. And quite honestly, because of the point we're at, we still haven't gotten to the phase where I can give you a how do we prevent that yet, but that's what the real goal of the committee is. Mhmm. Now we're simply trying to put together, what's the frequency and what are the factors that seem to be associated with that injury. And then the next step would be the how do we therefore prevent it. So this data that you're collecting, all the metrics, all the statistics, it sounds like it's pretty extensive. Is there any way that I know you said there's a big difference between a professional NFL, player and the circumstances they're in in your average weekend warrior. But is there anything that can be extrapolated from this data that could be applied to a larger patient population? Yeah. I think there eventually could be several things that come up, through that. One would be we learn a lot. If you look at advances that we see in sports medicine, a lot of the things that become mainstream in the regular population were first introduced in the pro athletes. Because what you see in pro athletes is people really wanting to push the boundaries of recovery. Mhmm. One week earlier of, being recovered makes a big difference. Things like, PRP injections, which you hear a lot of now for, the the average weekend warrior who may have tennis elbow. A lot of that data was originally coming out of NFL athletes that were really pushing the envelope of trying to get healed faster. And so, athletes that were really pushing the envelope of trying to get healed faster. And so the use of PRP, the use of a lot of other biologic agents really, stems from our experience with pro athletes. Interesting. So you practice at OrthoCarolina. Is there anything that you've learned from sitting on the subcommittee that you've applied just day to day, to patients that you're seeing coming in? What I've probably applied the most is you've learned a lot just seeing how quickly are other physicians allowing their players to get back and what are the positives and negatives of that. So if we see a trend such as for this particular injury, players have been allowed to go back, as early as a week or two, but their reinjury rate was higher, then that makes me wanna hold back that injury a little bit, from getting them back too early. Mhmm. And, conversely, you learn a lot that you may be traditionally waiting about six weeks to return a player for a particular injury, but then you see in the data that there's several players that have gone back at week four and have done well. Mhmm. So that probably influencing return to play times has been one of the areas I've learned the most. Talking about return to play, and you had also mentioned scaphoid fractures earlier. So there have been studies that have shown that CT imaging could potentially show signs of bony healing if you do have a scaphoid fracture earlier than they would show up on x-ray, sometimes the difference is a matter of of weeks. And if you're an NFL player, that can make a huge difference. But even for the average person, being able to take a cast off and returning to functionality sooner is better. Can you talk about so you use the inReach, CT imaging system at, OrthoCarolina, which is the in office CT scanner for, hand, wrist, and elbow. Have you at all introduced that protocol of assessing, basically fracture healing for a nondisplaced fracture on CT? Is that a protocol that you're using, and are you seeing that you're detecting it earlier? Yeah. The in office CT has been a tremendous gain for us, and I use it a lot, in two various ways. The first is determining is something fractured or not. Because scaphoid fractures, one of the problems is the X rays right after the injury are very often normal, and you can't see the fracture line, which then you're faced with a difficult dilemma. Do you just assume it's not fractured and allow the player to play? Do you hold them out? And so the ability to write then get a CT scan and make the determination, is it broken or not, has been huge. Mhmm. And in our office, the average time from, when I just get an X-ray that's negative to when I order my CT and get that done has been about twelve minutes. Mhmm. Twelve minutes later, I have the answer as to whether or not this player has a scaphoid fracture. Mhmm. So that's been one huge area just in determining is something broken or not. Secondly, to your point, it's been hugely helpful that at around the time where you assume the fracture will be healed, exactly as you mentioned, we know that these fractures are notoriously difficult to gauge healing on plain X rays. Mhmm. So having the in office CT has been tremendous, and I can get that right away when they come and assess how much healing do they have. And most of us will use the number of about fifty percent. Once that bone's about fifty percent healed, then we feel comfortable allowing the elite athletes to return. So Mhmm. That's a determination that you really can't make without a CT scan. Additionally, a regular CT scan before we had the in office scanner took a lot more time to coordinate additional visits to do, which delays that player's return and has more radiation to them than the in office CT scans that we're having. So That's that's great to hear. So are you using that for your athletes as as well as someone who may just suffer a scaphoid injury, say, you know, from a fall? Oh, yeah. So we use it. Basically, it's become our modality of choice for determining whether or not, someone has sustained a a scaphoid fracture. And that's from exactly, as you said, the general population all the way up to the pro athlete and everybody in between. That's great. Taking it back to the research, there was an article in the American Journal of Sports Medicine in two thousand eight that looked at, comprehensive data from, NFL injuries of the hand, wrist, and elbow. And it said that eighty percent of hand injuries that pro football players suffer are finger injuries. And most of the time, you don't even hear about them because the players, return to the field pretty much next week. Can you just offer your insights and just those common finger injuries that are happening that it seems, across positions? Sure. One of the most common things we see is just a dislocated finger, and those are typically reduced on the field by the trainers. The trainers will come in and literally just pop it back in joint and typically manage them with just some buddy tape, and they oftentimes return the same game, oftentimes within a few minutes of the injury occurring. And then one tremendous advantage these pro athletes have, though, is they're getting rehab constantly. So every single day, they're going to practice. If there's an injured player, they're working with the training staff, to get back their motion, to get their swelling down. And I'm really blessed here in Charlotte. Pat Connor is our team physician, and Ryan Vermillion is our, Panthers head trainer. And those guys do a phenomenal job of just everyday working with these athletes. So one of the differing factors of them and the weekend warrior is just that. A weekend warrior may go to therapy once a week for an hour, whereas these guys are getting hours of therapy every day. Mhmm. So it's one of the reasons they're able to get back to that performance level Mhmm. So much faster than the general population. Gotcha. That that makes sense. Is there anything that the general population could do to kind of mimic that, or are you really only going to get that in that specialized setting? To that degree, you're only gonna get it in that specialized setting. However, I do stress the importance of home exercise programs to patients and explain to them that difference. Mhmm. And then you do see people spending more time at home doing the exercises they're given rather than just setting that sheet of paper to the side and only doing it when they go see their therapist. Mhmm. So I think following those therapy guidelines and, doing the home programs Mhmm. Makes a tremendous difference in how fast, people can return to the activities they enjoy. I'm personally guilty of not following those home protocols, so I'm just gonna maybe do that a little bit more now that I've heard that. So that same study, it it explained that the wrist, elbow, and forearm injuries can be a lot more severe. A forearm injury, I was surprised it can mean that somebody's benched for half a season. So just last month, Chicago Bears defensive lineman, Akeem Hicks, was placed on the reserved injured list, after his major injury. Can you play, armchair surgeon and just kind of comment on his injury and his treatment? His, I haven't actually saw. I haven't seen him, so I can't really comment specifically on his case, but, you're exactly right in terms of the generality of forearm fractures. That's an injury that's gonna take a lot longer to get over than a simple finger fracture. But a lot of the wrist and forearm injuries really come down to, player position and how much stability we can achieve when we fix them. So if it's certain positions such as take a alignment, oftentimes, after a broken bone, we typically wait at least two weeks for the skin to be healed. Mhmm. And then once the skin's healed, the bone is not healed yet. But if we can protect them in a cast, we'll do that, and we'll sometimes be able to let them play a little bit sooner in a cast. Other positions and other injuries, you simply can't. So if we're worried that the wrong hit is gonna refracture that arm, then we have to hold them until the bone's healed. Mhmm. And that bone healing typically takes about six to eight weeks, which in the context of the NFL is typically about half the season. Okay. And because, you know, the this is so their profession is so dependent on it, are you probably imaging them at more regular intervals than you would the average patient? Definitely. Particularly if you're at the point where you're deciding can they go back to play or bet or not. Mhmm. Players that are on the cusp of being able to return were imaging at least once a week Mhmm. To look for that healing. Mhmm. I think we have to mention Drew Brees and his aggressive recovery plan. I know we were mentioning a little bit earlier that players are typically on the accelerated path. What can you comment on there? Yeah. So he had and, again, I haven't treated him specifically myself, but he had something we call a game keeper's injury or a skier's thumb where there's an important ligament on the inside of the thumb, that was torn, and that was repaired. And those injuries do take he's been out about, right at six weeks now, I think. Mhmm. And he has a very accelerated program. With a there is a new technique we're adding to ligament repairs oftentimes called an internal brace, which is basically a strong suture tape that we can put over top of repaired ligament to give it some additional stability. That has allowed us to take players that traditionally would have been put in a cast for six weeks and move them into braces and get them moving their joints earlier to try and regain that motion earlier while we're waiting for the ligament to heal. Interesting. And then it gives it a little bit more strength so that we feel a little bit more comfortable as physicians allowing them to return to play a little bit sooner than we would have, in the past. And is that a relatively new procedure? The procedure of fixing the ligament's pretty much the same, but adding that internal brace or adding that, fiber tape to it to help protect it is something we've really been doing more of in just the last few years. Yes. And then just last year, Raheem Mostert of the San Francisco forty niners had what was described as a gruesome forearm break, but he's back. He played, this past week. What is the takeaway there? The takeaway would be number one, these players are incredibly resilient and incredibly impressive in terms of their motivation. And we've seen that time and time again from, quote, unquote, gruesome injuries in these athletes to where the following season they're back and having, incredible seasons and dedicated medical staff, great trainers. And, really, I like I said earlier, I think hats off to the NFL for setting up a database like this, tracking their injuries, and allowing the medical advancements to be made to help these players, not only get back to sport, but then hopefully long term in life have less long term consequences of having played the game. Just curious. Is that database, made public at all just for fans who are interested or maybe even researchers who would take that data and mine it and and try to come up with the information? Imagine, there's a lot of sensitivity behind that data, in terms of knowing Mhmm. Specific you know, there'd be HIPAA violations as well. So that's it's really only open to the researchers, that are part of the subcommittees. K. Gotcha. And then taking it a little bit more broadly, and we can even go, beyond the sports medicine realm, What is one hand injury that often gets misdiagnosed or mistreated in sports? And what advice would you give both patients and general practitioners who might be the the frontline provider who's seeing that injury for the Yeah. There's several of them. One, we already touched on, and that's that scaphoid fracture. So scaphoid bone is located if you go to the base of your thumb, between the base of your thumb and your wrist, right there is where your scaphoid's located, and it's the one that x rays are oftentimes negative. So I think one huge piece of advice would be anytime you have a player or really just any individual who has a fall or an injury to their wrist and they're sore there, even if the x rays are negative, that needs to be evaluated a second time about two weeks later, ideally, by either a hand physician or an orthopedist familiar with those injuries, so that they're not missed. Mhmm. Because the consequences of missing that is really critical. We see people all the time who come in six months, one year later, and they had presented to an urgent care and were told it was nothing. And now they've got a bone that never healed and may not even be salvageable and end up with a partially fused wrist as a result. So that'd be one big one. Another injury that's, less common, but if you have a baseball player who has a check swing and has a pain in their palm or a golfer that hits a fat shot and they have pain in their palm, there's a specific bone called the hamate, and there's what's called hamate hook fractures. And routine x rays will miss those. And, again, like the scaphoid, if they're missed, they can have significant long term problems such as nerve damage or tendon ruptures that result from nearby structures rubbing against that bone that never healed right. So So probably always better to if you're you're having pain to get it checked out and just make sure because there could be something underlying that could be missed on a regular exam. Yeah. Even to the point where if they'd had, one evaluation, say, at an urgent care or at a ER setting Mhmm. And they didn't see anything at that time, if someone's still hurting six weeks later, eight weeks later, it needs to be reevaluated. And that's where going to see either a hand specialist or at least an orthopedist with familiarity in treating hand injuries, is critical. Well, this has been extremely enlightening. I've personally learned a lot about, the NFL, medical society and what it's doing. And, I think it will be exciting to see once there's been a couple more years of of data and analysis, what we learned specifically about the hand, wrist, and elbow, and forearm, and, you know, what are the correct precautions that we should be taking and how are we changing, player safety guidelines as a result. So, it was great to get a kind of behind the scenes, look at that and then to see how that might eventually filter down to, you know, the broader patient base. So how can people, if they're interested in kinda keeping up to date on this and and following your journey, can they follow you on social media? How can they connect with you? Just go into ortho carolina dot com, and we've got links, to me and to all of our physicians, several other of which are also involved in the NFL as well. So ortho carolina dot com would be an easy way for them to get in touch with us. Any final thoughts before we sign off? You know, Vinnie, I just appreciate the opportunity to do this with you. It was great. And, hopefully, people can learn a lot about, what how players are trying to be protected at the NFL and then, like you said, the translatability of that to the general population. Thank you so much. Thank you.