Welcome to the DocTalks Podcast, a conversation on what’s new and relevant in the world of Canadian medicine and hospital health care. Join us for each episode, as we interview physicians, patients and caregivers to dive deep into what it’s like to treat and live with some of today’s most common health challenges. Hosted by Ian Gillespie.
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DocTalks - S3E18
Wrist injuries and ailments w/ Dr. Ruby Grewal
[00:00:00] Ian Gillespie: Hello, I'm Ian Gillespie and welcome to the DocTalks podcast, brought to you by St. Joseph's Healthcare London. You know what they say?
The radius connected to the scaphoid. The scaphoid is connected to the trapezoid. I'm sorry. I'd like to apologize for that.
I, you're probably wondering why am I singing? I'm not sure, but what am I singing about? I'm singing about bones, bones that are all part of a seemingly simple part of the body that's actually quite complex. I'm talking about the wrist, and today I'm joined by Dr. Ruby Grewal. An orthopedic surgeon from Roth McFarland hand and upper limb center at St.
Joseph's Healthcare London. And we're gonna learn a bit more about the wrist and its common injuries and conditions. Thanks for joining us today, Dr. Grewal.
[00:00:46] Dr. Ruby Grewal: Oh, thanks Ian. It's nice to meet you.
[00:00:48] Ian Gillespie: So I think a lot of us might be familiar with things like repetitive stress and carpal tunnel syndrome, which I've dealt with people who work on keyboards and so forth. That's not an uncommon thing, but I wanted to ask sort of at the outset here, are wrist injuries common?
[00:01:04] Dr. Ruby Grewal: Well, here at St. Joe's we have what we call the hand and upper limb center. So we are a tertiary unit. So we only look at arm injuries. So for us and in our group, wrist injuries are very common. And we are a catchment area for. Almost the entire western half of the province. So most complex injuries will come to us.
And also just the regular run of the mill, someone just fell onto their outstretched hand as well.
[00:01:28] Ian Gillespie: Right. I should specify that I, I guess there are sudden injuries like a, a fracture or a sprain right from a fall. And then there are more sort of long term problems, like some of the ones I was mentioning there, repetitive stress, arthritis and carpal tunnel. Let's start with the injuries like falls and strains and fractures.
Can we talk a little About that? so this, I would assume this would be commonly from what people slipping on the ice or engaging in a sports activity or?
[00:01:53] Dr. Ruby Grewal: anytime you fall as a reflex, our first. Gut instinct is to throw our hands out to protect ourselves. So typically for young, healthy patients they will injure their wrist when they're playing sports or doing activities like that. And unfortunately, as we get older and our bone quality diminishes, sometimes just a fall, even from standing height is enough to break your bones.
[00:02:16] Ian Gillespie: Oh wow. So that sort of injury, I guess, how is that sort of treated? I mean, a fracture would, is, is that usually a splint or is it surgery? It would depend, I guess, on the severity,
[00:02:25] Dr. Ruby Grewal: It depends on the severity. I'd say the vast majority can be treated with a cast and just a bit of downtime in the cast while your body does its thing and heals the bones. But in some cases, if the injury is a bit more severe or the bones can't quite be put back into position appropriately with only casting, then we need to do something a bit more invasive, and that's when we'd get involved with surgery.
[00:02:46] Ian Gillespie: and then what about the long term? Problems that we see, repetitive stress syndrome and carpal tunnel. Can, can you talk a little bit about that? I mean, is that something that we're seeing more of recently in the last decade or so, do you
think?
[00:02:58] Dr. Ruby Grewal: I think we probably are seeing more of it in general as a population. We're becoming more sedentary, we're becoming more dependent on keyboards and smartphones, and people are doing a lot of repetitive thumb. Use a lot of repetitive and sustained posturing when they're sitting on their keyboard for eight hours a day.
And I think that certainly does contribute.
[00:03:20] Ian Gillespie: And what kind of symptoms would someone who's experiencing something like that? Like carpal tunnel?
[00:03:26] Dr. Ruby Grewal: Well, carpal tunnel, what that actually is, it's the carpal tunnel is the name that's given to the bones, the shape that the bones form around the wrist, and that is a particular point where the nerve can get pinched. So when the nerve gets pinched, it's a feeling very similar to that. When your foot falls asleep, when you're getting pins and needles burning, tingling pain, that sometimes wakes you up from sleep and sometimes causes so much numbness in your fingers that people lose dexterity.
They lose their fine touch sometimes when they're grasping onto things because they don't have that sensory feedback, they often don't know how tight to grip things. So, Little things will even just slip right from their fingers
[00:04:09] Ian Gillespie: And what's, what are the sort of treatment options for someone who's having that sort of problem?
[00:04:14] Dr. Ruby Grewal: during the day. If you were to get into a funny position like that, that's pinching your nerve, we would shake it off or we'd move or we would do something. The problem comes at night when you get your wrist
into a bent position. And you could potentially be like that for six, eight hours at a time. And that causes severe compression on the nerve, and that's why people will wake from sleep because of it.
So one of the easiest things you can do is to just get any kind of a splint just from the drug store or anything off the counter, something that will keep your wrist bent backwards, away from that flexed position. And by keeping your wrist in that position at night while you're sleeping. For one, it'll prevent that nerve from getting kinked.
I always explain to patients, it's sort of like a garden hose, right? If you have a garden hose that's bent, that kink is gonna inhibit water flowing through And even if you undo that bend, the kink is still there. So if you can wear a splint quite regularly at night, that'll hopefully prevent compression and hopefully over time.
Act to kind of allow that kink to work itself out.
[00:05:24] Ian Gillespie: I've experienced that. there was a period where I was waking up and my, my hands were asleep So in that case, I mean, should people wear a splint on both wrists, or is it
[00:05:32] Dr. Ruby Grewal: I would say just whichever one is bothering you.
And it's not that cumbersome if you're doing it at night, when you're sleeping you don't necessarily have to do it during the day. But nighttime splinting is the first line treatment for carpal tunnel, and I'd say for most cases it can really make a big difference.
[00:05:49] Ian Gillespie: Wow. And then is, sorry, is that something though that it's a fairly simple treatment, I guess. I mean,
[00:05:54] Dr. Ruby Grewal: Well, that would be our first line treatment, and that works I think, for people when they have fairly early disease, mild symptoms that could be potentially enough to reverse it. But unfortunately, as the disease progresses and the nerve gets quite badly pinched, that's not gonna be enough. I think it probably still helps, but oftentimes once the pinch has been on for a long time, then people often require surgery. And what we do is we basically increase the amount of space in there so the nerve doesn't get pinched so easily.
[00:06:27] Ian Gillespie: how frequent is surgery then used as an intervention? Is that uncommon or is that, done a
lot?
[00:06:32] Dr. Ruby Grewal: It's fairly common. It works very well and it doesn't necessarily have a lot of downtime associated with it. So I think it's a pretty common surgery that we do for this problem.
[00:06:44] Ian Gillespie: Right, and the recovery process is fairly quick,
[00:06:48] Dr. Ruby Grewal: In terms of the initial recovery, it's just related to the wound healing. And once the wound is healed, the stitches are out. You can use your hand. The carpal tunnel is that area, it's just right around the heel of your hand. So that's an area that people often put a lot of pressure on and gripping and things like that.
So certain people, if they have heavier jobs or more manual type work, then their recovery would be a bit longer. So it's a bit dependent on the activities you're doing.
[00:07:15] Ian Gillespie: And then as far as people who suffer pain from keyboarding for long hours during the day. Maybe you can talk a little bit about the importance of an ergonomic desk setup. Right. Is that the key there?
[00:07:26] Dr. Ruby Grewal: Yeah. I mean, I think that it's very important to make sure your keyboard and your workstation is set up for you. We saw a huge increase in the amount of repetitive strain
activities when people shifted to working from home because they may have had a nice desk
set up at work, but now all of a sudden you've got people working on their kitchen table and their dining room table and things like that.
So we certainly saw a huge increase in those types of injuries and problems. So I think. Making sure your screen is at the right height, your keyboard is at the right position. There are a lot of different types of keyboards that are out there now, too. A split keyboard. Some people use a vertical mouse instead of the typical mouse.
And these adaptations, I think, have been really helpful for people. A big thing though, aside from the setup, is to just remember to take breaks during the day. For some people with repetitive strain injuries, we'll often tell them to put a little timer. On their phone or on their desktop so that every, two hours they get a little reminder so they can just stop and do a 32nd stretch break.
And that, that really helps to just break it up and hopefully be a bit more preventative.
[00:08:32] Ian Gillespie: and then what about other conditions like, for instance, osteoarthritis? Now, is that something that would affect mainly older patients?
[00:08:41] Dr. Ruby Grewal: Yeah. Osteoarthritis is a, Name that we give to the wear and tear arthritis. So the arthritis that happens over time as the cartilage that coats the bony surfaces wears thin. And now instead of having two smooth surfaces gliding against each other, you've got bone on bone.
[00:09:01] Ian Gillespie: That's similar to a repetitive sort of stress injury.
[00:09:05] Dr. Ruby Grewal: Typically when we talk about repetitive strain injuries, we're talking about more of the soft tissues, the tendons, the muscles, things like tennis elbow and the tendons basically getting injured. The arthritis actually affects the bones that make up the joint itself. So when the. Cartilage coating on the surface of the bone wears out, and you've got bone grinding on bone.
That's what we call arthritis,
[00:09:32] Ian Gillespie: And again, this is mainly in older patients.
[00:09:35] Dr. Ruby Grewal: typically in older patients, but we'll also see it after injuries. So if somebody has an injury that's gone into the joint and injured the cartilage of the joint itself. They will be more prone to developing arthritis. Unfortunately, we still don't have a way of regenerating or recreating that cartilage.
So you see those two groups predominantly effective.
[00:10:00] Ian Gillespie: Oh, okay. And is there a way to prevent the onset of something like osteoarthritis?
[00:10:05] Dr. Ruby Grewal: There are certain things that will predispose people to certain types of arthritis. It's basically. Wear and tear over time. So the harder we are in our joints, the more they will tend to wear out. You know, for example, knee arthritis, the heavier you are, the more quickly your knees will wear out.
So weight control is a big thing for preventing osteoarthritis. In the knees, the hand it's a little bit harder because, a lot of it has to do with the type of work people do. The type of. Activity we see, particularly in women, a lot of wear and tear arthritis at the base of their thumb, and that's just from years of a lot of pinching and gripping and sustained activities that involve that, that causes that to happen.
There's lots of different theories about it. A lot of it has to do with hormonal changes causing little more laxity in their ligaments, and then because the ligaments are a little bit looser, the joint moves a little bit more and then it can cause a bit more wear and tear.
[00:11:12] Ian Gillespie: And then are there other conditions here? I've got in my notes rheumatoid arthritis. Is that, how is that somewhat different?
[00:11:17] Dr. Ruby Grewal: So where osteoarthritis is a wear and tear over time, rheumatoid arthritis typically affects younger patients and rheumatoid arthritis is what we call an inflammatory arthritis. So what that means is the body itself is. Generating inflammation, almost attacking the joints and the lining around the joints.
[00:11:45] Ian Gillespie: Hmm. How is that treated?
[00:11:46] Dr. Ruby Grewal: That's, if you've heard of the specialists called rheumatologists. Rheumatologists do a lot of work with people with rheumatoid arthritis, and once you get a diagnosis of rheumatoid arthritis, I'd say the first line treatment is medical management. So there are a lot of medications that can help, too.
Reduce the inflammation that is being generated in your body. And I'd say for most patients with rheumatoid arthritis, they need some type of medical management of it. And, we've had a lot of advances over the years and the drugs that can help treat rheumatoid arthritis have gotten really good.
Unfortunately, though, it can attack certain joints and when it attacks certain joints, they get into the same issue with the cartilage worn out. And pain, stiffness, and particularly in the hand, there are significant deformities that can develop for people with rheumatoid arthritis.
[00:12:41] Ian Gillespie: And it sounds like, so then, is this an instance where we, we haven't really talked about wrist replacement? Is that.
[00:12:48] Dr. Ruby Grewal: Yeah. So as the joints get attacked and get damaged, eventually it will be beyond salvage. And the medical management is just not enough. And if the pain is bad enough that it's affecting people's day-to-day life, it's affecting their quality of life, then that's when we usually intervene as surgeons and we'll focus in on whichever joint is, is bothering them.
And for rheumatoid arthritis, it can be their fingers or it can be their wrist. And risk replacements are one of the things that we're offering now to these patients, which is providing them with really exceptional benefits.
[00:13:25] Ian Gillespie: I'm not sure I understand what a wrist replacement is. So are you replacing certain muscles or bones or.
[00:13:31] Dr. Ruby Grewal: Yeah, so a joint replacement typically replaces the bone, the ball and socket, so to speak. So you typically will have on one side a ball and the other side, the socket, so those are usually made of metal. And then there's a connecting piece, usually a type of High density, plastic, sort of a polyethylene type of insert that helps to connect those two pieces. Previously, the only real option we had for people with really bad wrist arthritis, with rheumatoid arthritis and, and osteoarthritis for that matter, was to fuse the wrist. And, you know, the basic thought was, well, if the bones hurt when they're grinding on each other, Let's stop them from grinding on each other, which means we stop them from moving, which works great for getting rid of their pain, but then people have a wrist that doesn't bend up and down, which people learn to make due if their pain is bad enough.
But the nice thing about the wrist replacement is it not only gives them the pain relief, but also lets them keep their movement. So that's been a real game changer for, for that population.
[00:14:38] Ian Gillespie: Huh. How, how long have have you been doing wrist replacements at the hand and upper limb clinic? There? Is that again? Is it a relatively recent development or?
[00:14:46] Dr. Ruby Grewal: It's a relatively recent development and historically, There have been risk replacements, they will sort of come up into favor and then they say, well, the long term results are not great, and then they'll fall out of favor. But in general, I would say the generation of risk replacements we have now are really quite good.
And we've been using them for, I'd say about seven years, five to seven years, with really good results. And we typically try to offer them to patients that initially, We're not gonna overuse their risks. So the rheumatoid population is an excellent one, and that's sort of where we've started, but we're moving into more of the general wear and tear arthritis as well.
[00:15:25] Ian Gillespie: Right. what about prevention? I mean, you, you've talked about a kind of a variety of, of problems that can affect the wrist. I mean, is one thing, one preventive strategy, strengthening the bones in the wrist? Is that something that a person can do
[00:15:41] Dr. Ruby Grewal: Particularly with the thumb arthritis I was talking about that often affects women There are hand exercises that you can do to help strengthen the muscles and hopefully help stabilize the joint a little bit more to help lessen the symptoms or, slow down the onset
[00:15:57] Ian Gillespie: And are there any sort of supplements like I, I think I've heard of say, calcium pills or something like that. Is, is that helpful to again prevent fractures and injuries?
[00:16:07] Dr. Ruby Grewal: Well, yeah. So in general for bone density and bone health, calcium and vitamin D are very important and those are really the building blocks. as people get older, they tend to lose bone density. So one of the most important things you can do is make sure that you're getting a lot of calcium and vitamin D, and it is thought that dietary calcium is better for you than calcium supplements.
So that's, you know, drink your milk, eat your cheese.
[00:16:33] Ian Gillespie: Well, I love cheese. And then what about I mean, for many people, if we go back to the injuries, the, the fractures and the sprains, I guess part of that is preventing a fall.
[00:16:44] Dr. Ruby Grewal: Right. So certainly the weather plays a huge role in that, in this part of the world with icy sidewalks. And snow banks and things like that. So we do see a lot of wrist fractures and wrist injuries in the winter months. Good. Footwear is really important too. You know, I had a patient recently who was said, you know, she just for a minute slipped on her husband's shoes and ran out into the yard to do something quickly and down she went.
Right. So good. Supportive shoes are very important. Being a little bit extra cautious when you're on uneven ground or slippery surfaces in the winter months. People that do like to do a lot of walking, there are spikes that you can put on the bottom of your shoes that help give you a little more traction, and those have been shown to be quite helpful.
For prevention. You know, we've been interested really in looking at osteoporosis and looking at wrist fractures and how that plays into it.
Because oftentimes people will fall and break their wrist when they're younger and active, you know, and by that I mean the 50 year old, 60 year old when an elderly person falls. Once they're in their seventies and eighties, then you're looking more into hip fractures and more serious injuries. So the wrist fracture is really a very good early warning sign to start thinking about bone density and to start thinking about your overall bone health.
So we have a program here where if somebody does present with an injury such as a wrist fracture, From a simple fall, from standing height, we will start the process of osteoporosis screening because if we can identify somebody early that may be headed in that path, intervening now when they're 50 or 60 will make a big difference 10 or 15 years down the road.
And just being aware of like what we talked about, calcium supplementation. Vitamin D, regular bone density checks so that you know if you're sort of falling on that slippery slope, because although wrist fracture is bad and can really affect people's quality of life, what we really wanna do is prevent that hip fracture which could potentially put somebody into a nursing home.
[00:18:51] Ian Gillespie: Wow. Okay. This is probably the dumbest question I can ask, but I don't know. Just because we're talking about falls, is there a strategy to fall, like you said right off the bat, people instinctively reach, their hand out when they're falling. Is there a, is there another way to fall?
Should people try not to reach forward when they fall?
[00:19:10] Dr. Ruby Grewal: Well, I think that's a reflex. And you know, that's a reflex that has developed for reason cuz you wanna protect your vital organs, you wanna protect your brain, and unfortunately, I think as we get older and we lose those reflexes is when people fall and break their hips and they fall and they hit their head and things like that.
So, you know, it's, it's there for us to help us and protect us. And unfortunately, I think it happens in. Just that split second moment that there's not often much opportunity to, to change the trajectory.
[00:19:41] Ian Gillespie: So. are there any specific supports at St. Joseph's at the hand and upper limb clinic now in place for, for people who have experienced risk problems and conditions?
[00:19:50] Dr. Ruby Grewal: Yeah, we're actually very fortunate to have a world class therapy department in our hospital under the same roof. They have been really inteGrewal in helping our patients achieve great outcomes. And we are very closely connected and patients often will see us and then go straight upstairs and see the hand therapists And they can see them right after they see us. So we really have an integrated model where we're working together because the surgery is really only half of it. The big part of it is the hand therapy that goes into it to really making sure that people get back their full function.
[00:20:25] Ian Gillespie: well drink your milk then right along with the other things and correctly place your keyboard and there's lots of other interesting strategies we've learned today. Thank you. Thanks, Dr. Grewal for joining us today on the Doc Talks podcast.
[00:20:38] Dr. Ruby Grewal: you for having me.