Michael Smith, MD (Host): Welcome to Meaningful Medicine, a podcast by Novant Health. I'm Dr. Mike. And with me today is Dr. Eric Angermeier, an orthopedic surgeon specializing in hand and wrist care. We're discussing today Spring Into Safety: Top Hand and Wrist Injuries During Warm weather. Dr. Angermeier, welcome to the show.

Eric Angermeier, MD: Thanks for having me.

Host: So, it is warming up outside. That's nice, right? People are start getting outside more. They start getting their activities going. A lot of people maybe haven't been that active for a while getting out there. So, what are some of the most common hand and wrist injuries that you see this time of the year?

Eric Angermeier, MD: Certainly, the ordinary chronic hand and wrist problems don't take a break in the spring. They're year round. But the things that we see that are particularly in the category of injuries do peak in the warm weather, because people are just out and more active. So, the most common general thing we see are injuries due to falls. People slip and fall at the pool or they're visiting our lovely downtown here in Charleston, is where my practice is. We have the nice historic cobblestone that likes to trip up tourists, and they end up coming to see me if they land a little too hard with a broken wrist or a broken finger. Even things as simple as getting out and walking the dog more, believe it or not, one of the most common, hand injuries I see is people walking their dog, dog sees a squirrel and takes off. The leash is wrapped up around their fingers, and they end up with a broken finger or they fall and break the wrist. So, all the things you might imagine with people getting out and being more active certainly ramp up as the weather gets nicer and people are outside and doing things.

Host: So obviously, prevention's key. We teach that throughout all of medicine, right?

Eric Angermeier, MD: Prevention, sure.

Host: What are some strategies you have for preventing injuries when people are about to return to some of that stuff? And I'll use myself as an example. I love to golf, but I only golf during the warm months. And sometimes when I first get out there and I go to the driving range and stuff, you know, wrist, shoulders, stuff start to hurt. What should I be doing to prevent that?

Eric Angermeier, MD: I think that a very great example of this, a lot of people now are familiar with pickleball, although, you know, five ten years ago, it like barely existed. And so, believe it or not, the number one sports injury that I see as a hand and wrist surgeon are injuries related to pickleball. No one would ever believe that, they view it as more of like a casual sort of sport. And to some extent, that's why we see these injuries.

Host: It's not casual. I got friends that go crazy with that sport, Dr. Angermeir.

Eric Angermeier, MD: Yeah, it's gotten pretty intense, as people have gotten into it and the competition is ramped up, but it really highlights the point that I think you've eloquently made here is that pickleball really appeals-- it's got a low barrier of entry. In other words, folks that maybe aren't peak athletes, or maybe they think they're peak athletes, but they're not quite there yet, and it's a sport that they can get out there and start doing. And they're not conditioned. They're not stretched out. Their balance is not where it should be to get out and pull off the moves they're trying to pull off out on the court. The cutting, the pivoting, the dashing for that ball that's about to go by them, and they end up losing their balance and falling, or they end up overexerting themselves and spraining a ligament in their wrist or any number of injuries that can be due to this general idea that, you know, if you're not in great shape, if your joints are tight, if your muscles, particularly like core muscles aren't strong, it's going to set you up for an injury. You really need to pay attention to your overall musculoskeletal health prior to, you know, really getting out there and doing these things.

Now, it's a bit of a Catch-22. How are you supposed to get in shape if you don't get out there and do these things to begin with? But I think a program of joint mobility, of stretching, you know, in layman's terms, keeping limber, particularly the calf muscles. My colleagues and Foot and Ankle Surgery see a lot of Achilles ruptures from folks that are just getting out after a long winter, their calf muscles are tight and they get out there and play golf or tennis and rupture an Achilles.

And the same is true for your hands and wrists. You know, a program of stretching and loosening up those joints will put you less in harm's, way less at risk of having an injury and indirectly, again, like balance and mobility. So, just remaining active as you can through the cold weather months, whether that's on a treadmill or doing some core work so that your core is nice and stable and you're not going to get out of balance and have a fall or have an awkward motion that may strain or sprain or break something.

So, it's really a-- as much as you can a year round-- process of staying in shape. But if you have gotten behind, like I know I do in the cold weather, I don't like to get out there and exercise as much as I should, particularly when it's chilly out, just ramp back up. Slowly sort of get back to that 100% maximal effort, diving-for-the-ball kind of level of activity. If you do that right out of the gate, you're asking for trouble.

Host: So, we're talking about hands and wrists. So when it comes to stretching, can you give us an example, what's a good wrist stretch?

Eric Angermeier, MD: You know, it's tough to remember a whole regimen of things, and there's lots of very dialed in particular things for particular injuries and particular joints that may be stiff. But one of the best stretches you can do to kind of warm up for a sport is some people call it the carpal tunnel stretch. Extending your arm and pulling the fingers back and, you know, hold that for 30 seconds with a little bit of stretch to it.

Host: I feel that.

Eric Angermeier, MD: Yeah. And it's a great stretch if maybe you got a little carpal tunnel symptoms going on. That's a pinched nerve in your wrist, makes you go numb and tingly. But it's really stretching out the forearm, you'll feel that, and it's gliding those tendons through the carpal tunnel. It's starting to promote some blood flow to all those ligaments in the wrist. You can do the opposite of that stretch, which is to stretch it down. This will help to stretch out the extensor muscles of your forearm. A lot of people get what's called tennis elbow. We probably ought to rename it pickleball elbow nowadays with so many people playing that. But that pain you get that's right up here in the elbow, if you kind of bend the wrist down and stretch that out, stretch it back this way. And then, just making a fist, simply making a fist maximally flexes your fingers, and then stretching out the fingers straight and just repeat that several times. That might prevent you from a jam or, you know, a sprain to one of the fingers if you have your fingers limbered up and ready to grip that racket or that club, you know, whatever it is that you may be participating in. That's a good way to get warmed up, get the blood flowing.

Host: Boating and water sports, I think we overlook these a lot. Are there any particular-- I guess, because when people think of swimming, they don't think how they're going to hurt your hands or your wrist? But are there risks? Are there things we should be more conscious about?

Eric Angermeier, MD: Absolutely. And, again, living in Charleston, getting out and on the water is a part of lifestyle down here. So if you're talking about pools, that applies anywhere. It's the old lifeguard yelling at you telling you not to run. You know, most of the pool injuries we see is a slip and fall. You know, there's water everywhere. It's slippery. That's sort of common sense, but that's the number one pool injury we see. And of course, you know, diving in shallow water can cause some really serious injuries to your neck. And we occasionally see, you know, broken wrist or a jammed finger from hitting the bottom. Not many pools have diving boards anymore, but that used to be a big generator of all sorts of injuries. And if you're in an area, if you're lucky enough, like I live in an area where you have the opportunity to go on boats, for us boating safety is a really important thing in terms of all sorts of injuries.

One of the ones I see, unfortunately, really frequently is that boat is approaching the dock. And at least around here, we've got a lot of currents and wakes and waves and so forth. And the tendency, you got inexperienced or young passengers on your boat, and they reach out to grab the dock and the boat. The dock pinches the hand, you get a sort of a crush injury to the hand or wrist, that can be really bad depending on how badly it gets pinched.

Same thing with boat trailers. Those winches and pulleys and things like that are under a lot of tension. And there's a lot of momentum going on with all that, taking the trailer off the hitch, a lot of smashed fingers related to boating. And also, boats are another area where it's slippery when you're underway. And if you're in some rougher, choppy water, you hit a boat wake and you go flying and go to catch yourself on an outstretched hand, you can break something. So, all the standard boating safety applies. Remain seated when it's underway. You know, be sure you've got some firm footing. You know, hold onto a grab rail. All those things are important.

And one of the most devastating injuries we see related to the water is boat prop injuries. You know, the kids like to go tubing, so do adults. And climbing back on board, be sure that that prop is turned off, because that thing will certainly cause a terrible, life-altering injury if you're not careful getting back on the back of the boat.

Other sort of water-related injuries we see around here relate to fishing. So, my partner recently took care of a guy, hand surgery partner, Dr. Kokko, that got his finger bit by a barracuda down in the Caribbean. That's a little bit of an unusual one. But we see shark bites. Trying to get the hook out of a creature with sharp teeth is a common pattern of injury. It can, you know, injure a tendon or a nerve if it gets you in the right spot. Sticking your hands with hooks, infections from that sort of thing. Falling onto a oyster bed down here is a big thing. Those oysters are razor sharp and have a lot of bacteria on them. And, you know, lacerations to the hand. You might fall off a paddleboard. You don't realize you're in shallow water with some sharp stuff underneath you is a common thing we see as the weather warms up.

Host: So with all this going on, you got people on boats, you got people swimming, you got people playing pickleball and getting out there with their dog and wrapping their hand with that leash too much and something happens, and it's inevitable things are going to happen, at what point does somebody need to seek medical attention versus "I'll take care of this tonight at home with some heat and cold off and on"?

Eric Angermeier, MD: Yeah, sure. So, one of the common myths that we see a lot is, "If I can move it, it's not broken." You might see someone two months after an injury to their finger, their finger's massively swollen and still stiff and painful. You get an x-ray, and there's a broken bone in there that I could have fixed two months ago, and now it's a real challenge to get that patient feeling better two months later. And it's just a myth that seems to be out there. I'm not sure how it got out there that, if you can move your finger, it's not broken. That's just simply not true.

And oftentimes, I was at a pool party just last weekend and a little kid got his fingers slammed in the car door, you know, "Help! We need you." And I don't get that a whole lot as a hand surgeon where I'm the sort of doctor they need in a public situation like that. But the short answer is I don't know if it's broken either without an x-ray. Sometimes it's quite obvious, you know, the finger's sideways or something. But oftentimes, it can be more subtle.

So, my advice there is, you know, for any injury that you're concerned about, there's a lot of bruising, there's a lot of bleeding, there's numbness, anything more than just, you know, a minor abrasion, any pain that lingers more than just a few days, any major deformity of the wrist or the finger, that's something that you ought to get checked out within the week would be a good idea and sooner, obviously, if it's clearly an emergency, if there's active bleeding or something.

I think another common misconception is that doctors get angry at patients for wasting their time if there's not some serious injury. And that just can't be further from the case. I always love to be able to put people's mind at ease when they come in. And they're worried something might be wrong, they weren't sure if they should come in or not. You know, we'll do an exam, we'll get an x-ray if we need to, right there in the office. And it makes my day to be able to tell them, "Hey, good news, nothing's broken. This should be better, you know, within a week or two." And it doesn't hurt my feelings at all. I'm glad they came in and got it checked out. I'd much rather see that patient than the one that waited too long. And there are some injuries in the hands, particularly tendon injuries, like if you can't move your finger properly after, you know, a slice in the kitchen or something with a sharp knife, or if something's numb.

And there's a lot of, you know, entertaining that goes on this summer, so that ramps up too. You know, you're getting ready for that barbecue and slice some watermelon and you accidentally come through a little fast and hit the hand. And now, suddenly, you got a finger that's stuck out straight and you can't bend it. You know, that's something that we need to fix just as soon as possible. You know, the results are so much better if you get to those quickly. Same with nerve injuries. If you cut your hand in the kitchen and you can't feel one side or both sides of your finger, that's something that you really need to come in soon for. And we can get you feeling a lot better, have a lot better results if we see a sooner than later.

Host: Fantastic. I'm a radiologist, so I may be a little biased here. But I always tell people the only way to know if something's really broken is you need a picture. So if something really happens bad, go in, get that picture. Let's confirm what happened. That's what I do.

Eric Angermeier, MD: Yeah. And you know, a lot of offices, ours included, have x-ray right in the office. So, you can get an answer almost immediately. You don't have to guess and go off of old wives' tales to know if you've got a fracture. We can tell you for sure.

Host: When somebody is then diagnosed with a significant injury, you know, maybe they need some pain management for this, right? A lot of people are very nervous about opioids and stuff like that. What do you think about opioid-sparing techniques where maybe a little opioid with an NSAID or something, that kind of combination? Do you use that a lot in your practice?

Eric Angermeier, MD: I sure do. I certainly always try to minimize the amount of opioids. I think most of us are aware now with all the news and movies and documentaries on just how bad opioid pain medications can be, not even just in terms of addiction, although that's one of the primary concerns. But even in small amounts, the side effects can be pretty nasty: constipation, nausea, et cetera. Unfortunately, it's just not really great medications. And also, unfortunately, we don't have a lot to offer that's stronger than narcotics, but we do have things that can minimize the need for narcotics.

So if you break your wrist, for instance, most people are going to need at least some opioids for that. Some people are tough and don't need any. But what we can do is supplement those with other medications. There are medications that modulate the nervous system a little bit to dial down the sensitivity of the nervous system, things like Neurontin, things like Lyrica that can help to augment the pain management program. And just simple things that perhaps by themselves might seem too weak for the injury you got. Things like Motrin, Aleve, Advil. I'm a huge fan of Voltaren gel. I think everyone should have that in their medicine cabinets. It's topical anti-inflammatory that, particularly for the hand and the wrist, it doesn't have to absorb that far. And by not ingesting the medication, you're not tearing up your stomach. But things like anti-inflammatories, occasionally some of these nerve-modulating agents, things like topical lidocaine patches.

And then, things that aren't medication at all, things like therapy, bracing and minimally invasive surgical techniques play a role here. You know, as our surgeries have required smaller and smaller incisions and less bleeding, less trauma to the tissue to fix fractures or to fix problems in the hand and wrist, there's just less of a need for the narcotics, which has been a really great thing. It gets people recovered quicker with fewer side effects, fewer risks of all the problems that come along with the opioids. So certainly, I employ everything short of opioids prior to recommending an opioid. And when we do have people on opioids, it's for a very short amount of time.

Host: In your practice, do you find yourself doing more of these minimally invasive procedures than some of the old-fashioned surgeries of the past?

Eric Angermeier, MD: Yeah. I mean, almost everything has shrunken down in terms of how much trauma there is to the soft tissue. Almost all the common procedures we do, whether that's carpal tunnel release or we do a common reconstruction for thumb base pain, that's another that we see a lot of. At baseline, it might act up in the winter when the weather gets cold, but it certainly acts up when you're gripping a racket or a club a lot as the weather warms up. That pain that women in particular get the base of their thumb. And that procedure has gone from-- just in my career, I started practice back in 2013. And at that time, we were doing three incisions, two of them in the forearm to harvest a tendon and one at the base of the thumb to reconstruct that joint that have worn out. And now, we've gotten that down to just one incision and a much quicker sturdier technique and procedure implant that goes in there. So, that's just a couple of examples. But almost everything, over the past decade or so, has become more minimally invasive than it was prior to that.

Host: So, I've been discussing warm weather hand and wrist injuries with Dr. Eric Angermeier. Dr. Angermeier, any last words, summary statement about hand and wrist injuries as it warms up when we start getting excited and we get out there? Any last words for that?

Eric Angermeier, MD: First of all, congratulations on getting out there. As you know, as an orthopedic surgeon, one of our primary goals is to get you active, get you out there. There's been a lot written about grip strength. And that's such a highly reliable indicator of your overall health and your longevity. And that's no surprise to me. You have to have healthy hands and a healthy musculoskeletal system to get out there and stay healthy and enjoy things, enjoy life in general. I'm happy to see people out there and doing things. If you get out there gradually, don't jump head first into it. And if you do have an injury, don't be reluctant to come see a specialist or even just your primary care doctor if you're not sure who to go to so that they can point you in the right direction, and we can get you feeling better.

And a final plug, 4th of July isn't too far around the corner, but that's the worst day of the year for most hand surgeons. . Firework safety is important. And don't drink a drive, that's another big one, you know, as people are celebrating things outdoors this summer.

Host: Fantastic information. Thanks for joining me today.

Eric Angermeier, MD: Yeah. Thanks for having me. This has been great.

Host: For more information, you can visit novanthealth.org. If you like this podcast, please share it on your social channels and explore our entire podcast library for more health-related topics. This has been Meaningful Medicine with Novant Health. Thanks for listening.