1. P A R T N E R S O R T H O P A E D I C
Trauma Rounds
Case Reports from the Mass General Hospital and Brigham & Women’s Hospital
A Quarterly Case Study Volume 3, Winter 2012
Recovering From Injury
David Ring, MD, PhD idly and completely than we expect, and patients who make the
best out of their situation when the injury is severe. If we could
Some fractures frustrate us. Adverse events just figure this out and bottle it!
always affect us. But nothing takes the wind
from our sails more than a patient who has Psychologists call it self-efficacy: 2 “I can do it”; “I have got
greater pain and disability than expected. We this”; “I will be fine.” The key to health and wellness is within.
are used to having answers and knowing what The opposite is catastrophic thinking and passivity: “Someone
to do. For diagnoses like open fracture, com- needs to fix this or I will never be able to rely on my hand
partment syndrome, or an elbow that will not stay reduced, we again”. With insight, some guidance, and lots of practice, cata-
feel like we can make a difference. But when our patients have strophic thinking can be replaced with self-efficacy.3
stiff fingers, a stiff elbow, or persistent disabling pain the an- Trauma surgeons see this all the time. As patients recover, the
swers do not always come easily.1 natural protective state where our worst thoughts are convinc-
Coaching, encouragement, and reassurance can backfire. To the ing (“If I push it any more I will rip the plate out;” “I will never
injured it may seem like we are not listening, we are dismissing play tennis again”) gives way to increasing confidence in self-
their concerns, or we feel they are not trying hard enough. Tell- stretches and trust in the hand. We can all likely recognize this
ing a patient something encouraging and optimistic like, “no process in some of the rougher patches of our own lives.
pain, no gain” seems to say that we think he or
Figure 1: Dr David Ring examining a patient’s hand.
she is a wimp. Without trying to do so, we can
dig ourselves into a very deep hole.
It is tempting to give up. The bone is fixed.
My work is done. This is not my problem.
Perhaps the physical therapist, pain doctor, or
alternative practitioner will have the answer.
Unfortunately, these experts are often at as
much of a loss as we are. Giving patients
stronger narcotics, injections, or alternative
treatments often disappoint them and can seem
like a step backwards. It stinks. There must be
some hope.
On the other hand, once you have been in prac-
tice for awhile you realize that most patients
eventually figure it out and complete the re-
covery - even after many months of little or no
progress. We also are afforded the privilege to
see the patients who recover much more rap-
Trauma Rounds, Volume 3, Winter 2012
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2. P A R T N E R S O R T H O P A E D I C T R A U M A R O U N D S
One formal method for coaching and accelerating this process is make you say or do something counterproductive. Do not be
what psychologists call cognitive behavioral therapy, which is overprotective. I find therapists tend to do this almost auto-
learning to separate thought from fact.4 This is particularly use- matically or as part of their profession: “Work to pain, but not
ful for relatively intuitive people who can navigate through beyond;” “Do not overdo it, you will cause inflammation.” As
what is real and what is irrational. Those who are used to trust- we all know, you are not doing the stretch correctly unless it is
ing their gut feelings often find it particularly difficult to change uncomfortable, and the more stretching the better.
mindset. One day soon patients and providers will seek out
Recovery is not just about new bone bridging the fracture line.
this kind of fitness for their thoughts and behaviors like they
Recovery is regaining confidence in your arm or leg and know-
seek out physical fitness today. A coach or trainer can be in-
ing that things will be okay - in spite of permanent impair-
valuable.
ments. Our expertise facilitates the biological aspects of recov-
But what can we do today? It all starts with empathy. To para- ery, but we can play an important role in the cognitive and emo-
phrase Osler: Patients do not care how much you know until tional parts of recovery as well.
they know how much you care. Language that acknowledges
the patient’s thoughts and emotions is key: “Does it feel like Opportunities for Empathy
you can’t depend on the hand?” “… like you’re going to do The patient says: You say:
harm?” “... like the exercises are not going to work?” When you I have a high threshold for pain, It probably feels like the wrong thing to
get a nod, you know you have connected. but… do
It’s unbearable; It’s excruciating You’ve been through a lot;
Acknowledge how difficult and counterintuitive it is to do a Your reserves are probably tapped
painful stretch after injury. Normalize it: “This is how we are
This is as far as it will go Does it feel like your going to prevent
built. It is an evolutionary advantage to react to pain protec- it from healing or maybe pull out the
tively and prepare for the worst;” “Pain sets off the ‘alarm’ like plate?
smoke sets off the fire alarm. Just like in the kitchen, it’s usually I’m trying as hard as I can I know that you’re giving this your all.
The stretches are so counterintuitive
a false alarm.” Analogies can be easier for the patient to absorb
I’m dropping things It probably feels like you won’t be able
and seem less confrontational - even when the message is coun- to rely on your arm
terintuitive.
References
Celebrate small improvements and insights. Be patient. Ex- 1. Ring D, Barth R, Barsky A. Evidence-based medicine: disproportionate pain and
plain things that are counterintuitive, but do not try to convince disability. J Hand Surg Am. 2010 Aug;35(8):1345-7. PubMed PMID: 20684932.
2. Arnstein P. The mediation of disability by self-efficacy in different samples of
— just offer your expertise. One of the most common miscon-
chronic pain patients. Disabil Rehabil. 2000;22(17):794-801.
ceptions is that swelling blocks motion. If patients trust you 3. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculo-
and are prepared, you can encourage them in a self-assisted skeletal pain. J Bone Joint Surg Am. 2009 Aug;91(8):2014-8.
stretch and show that this is not true - particularly for stiff fin- 4. Vranceanu AM, Safren S. Cognitive-behavioral therapy for hand and arm pain. J
Hand Ther. 2011 Apr-Jun;24(2):124-30; quiz 131. Epub 2010 Nov 4. PubMed
gers.
PMID: 21051204.
Be aware of your own thoughts and emotions. Stress contagion
is when the patient’s stress transfers to the provider. It can AchesAndJoints.org/Trauma
Please share your comments online, or by email:
Trauma Faculty Michael Weaver, MD — 617-525-8088
Mark Vrahas, MD / mvrahas@partners.org
BWH Orthopedic Trauma
Mark Vrahas, MD — 617-726-2943 Yawkey Center for Outpatient Care, Suite 3C
mjweaver@partners.org
Partners Chief of Orthopaedic Trauma 55 Fruit Street, Boston, MA 02114
mvrahas@partners.org Jesse Jupiter, MD — 617-726-5100
MGH Hand & Upper Extremity Service Editor in Chief
Mitchel B Harris, MD — 617-732-5385 jjupiter@partners.org Mark Vrahas, MD
Chief, BWH Orthopedic Trauma
mbharris@partners.org David Ring, MD — 617-724-3953
MGH Hand & Upper Extremity Service
Program Director
R Malcolm Smith, MD, FRCS — 617-726-2794 dring@partners.org Suzanne Morrison, MPH
Chief, MGH Orthopaedic Trauma (617) 525-8876
Brandon E Earp, MD — 617-732-8064 smmorrison@partners.org
rmsmith1@partners.org
BWH Hand & Upper Extremity Service
David Lhowe, MD — 617-724-2800 bearp@partners.org Editor, Publisher
MGH Orthopaedic Trauma George Dyer, MD — 617-732-6607 Arun Shanbhag, PhD, MBA
dlhowe@partners.org BWH Hand & Upper Extremity Service www.MassGeneral.org/ortho
gdyer@partners.org www.BrighamAndWomens.org/orthopedics
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Trauma Rounds, Volume 3, Winter 2012