Common Adult Orthopaedic Injuries
Speaker 2: 01:08 Sure, I'd be happy to. Um, I'm a, uh, I'm originally from the northeast, like a lot of people. Um, I grew up actually outside Philadelphia. Um, okay. And, uh, but then even independent than I was born in New York City, so, you know, the last name is Irish. Sometimes I've got some patients coming in to see me that, uh, had this idea that with the name Tuohy that it's going to be Asian. So they're a little confused when they come in up and up and up in the northeast. It's a pretty well known OTU he kind of Irish name. Gotcha. Um, and then, uh, when I went to college, um, my parents moved from outside of Philadelphia Down to high point North Carolina. And so I originally started at University of Michigan and then transferred and finished the University Chapel Hill, which is a great place. Go to our heels. There you go. Um, and then, uh, that I, uh, spent some time working in the lab and eventually I went to wake forest, wake forest for medical school. Um, and then, uh, did most of my training back up in the northeast. I did my orthopedic residency back at Albert Einstein in Philadelphia. Um, a shoulder and elbow fellowship at Thomas Jefferson in Philadelphia and then a hand fellowship at Vanderbilt just over in Nashville. So
Speaker 1: 02:19 Cody also, um, what made you want to become a a hands, elbow shoulder doctor?
Speaker 2: 02:27 Um, well it's, it's, it's a good question. I mean most people are gonna give you the canned answer of, hey, I want a medicine cause I want to help people. And there's a lot of truth to that. It is very satisfying I think. Sure. Especially with, uh, you know, what we see now with most folks in terms of motivation, um, by folks like Daniel Pink that, um, purposes had really important thing for people. And so medicine to one of the ultimate places, it's still, that never changes. We still have great purpose in terms of what we are doing. Um, but, uh, but worth the Phoenix is fun cause you know, it's, it's you're helping people, um, enjoy life still and mo and a lot of the things we're doing, although most of them are all active, um, it people find that very satisfying to get back whatever function is that, that they were losing or lost.
Speaker 2: 03:17 Um, in particular a Rabo in hand, I was interested in doing all three of them because of the fact that they're integrated together. You know, you need your shoulder to get your, get your hand out in space. Um, you need your elbow to be able to retract your hand in and out of space. Um, and then your hand is your primary sensory organ for both to primary central Oregon to feel things in the world. But then additionally to be able to grasp things, interact with the world. The way to think about it is, you know, you have five senses, you know, sights your eyes and knows the smell, but your hand is what you do to feel and your touch into the world. And so you need all of those things to really work effectively.
Speaker 1: 03:59 Yeah. That's a real, it's a really cool way to put it actually. Nice. Um, so remind me, how long have you been here at Wake Forest Baptist now?
Speaker 2: 04:05 So I've been here for over 10 years. I came here in 2008, so, and my practice has evolved a little bit where it's kind of funny in town where, um, half the people know me as a hand surgeon and the other half and nobody is shoulder. So having the opportunity to talk a little bit, great. And let folks know that I do a little bit of everything from that point of view. Now. Now, realistically, probably about 60% of my practice is shoulder, about 10% elbow and 30% hand. Um, so cool.
Speaker 1: 04:34 Um, well speaking of doing a little bit of everything, you also like to dabble, uh, in research. One of the great things about being here at wake forest baptist health is we're an academic medical center. Um, so I don't know if you just want to touch on, uh, what you like doing a little bit of research on when you have, when you have that time.
Speaker 2: 04:50 Yeah. So I've kind of, you know, at first probably five or six years, I really was pretty focused on rotator cuff research. We did a lot of basic signs, science research and spun out of that actually. But a patent in terms of, um, some ways detention, rotator cuffs to figure out if, if you know what the appropriate appropriate level of tightness is when we're fixing things, um, that still in the process of being studied and we were collecting data for that. But, but, um, you know, that's where sort of my passion is that sort of also where, um, we, uh, we've learned a lot and things have changed a lot over the last five to 10 years. Not just what we're doing here, but you know, across the nation in terms of what, what rotator cuff things need to be addressed and why. Um,
Speaker 1: 05:36 see, I love hearing cool stuff like that. When you, when you are talking about, you know, sometimes when, when people go into great detail about research, uh, tactics and goals and objectives, it can come across to the common person as maybe not the most exciting thing. Right? But to be able to hear about how it gets transferred over to the clinical side and it's helping patients at the bedside. I think it's pretty [inaudible].
Speaker 2: 05:57 Cool. Yeah. And the other part of it too now, which is interesting, which kind of blend a little bit of what we're doing here right now, is that, um, I've gotten pretty interested in the informatics side of medicine. Um, EHR is really, or EMR is, most people kind of talk about it is sorta changed the way we approach things. And, and one of the issues we have now moving forward as getting the data out of these, um, software programs so that we can help patients better in terms of knowing exactly what they're feeling and why they're feeling it and how we can make our outcomes better. And that's been a tricky thing. So much of what we've done up until, until all of that came at wake one are epic and all these other companies, we, you know, everything that was manually done. And so there's the opportunity now to, to help collect that data in a much more efficient manner. Sure, sure. So, yeah.
Speaker 1: 06:48 Well, um, you mentioned rotator cuff, you know, with uh, the shoulder, uh, episodes that you see in clinic, cause that's still one of them. The most common injuries or ailments to people is people they come into your clinic and they had rotator cuff issues. If you just want to talk about Kinda what that is and maybe why are the main reasons that gets hurt.
Speaker 2: 07:07 Sure. Um, well one of the first I would tell you in general the number one musculoskeletal complaint that people come in for his back pain. And then knee pain used to be two in shoulder. He used to be three and it's actually shoulder and knee of flipped. So shoulders the second most complaint that folks will come in interesting in to see us. Um, and it can include a whole wide variety of issues, but, and they're usually pretty directly related to people's age. So, you know, if I have a patient that comes into 30, I don't really worry about the rotator cuff unless they had some dramatic traumatic injury. Like, sure they fell out of a tree 25 feet. But, um, but so the classic patient that comes in with a, with a rotator cuff problem that I worry about is late fifties, early sixties. And, and so what a lot of the times we s you know, I'm usually diffusing and debunking with patients is that a lot of rotator cuff problems are simply genetic and, and your rotator cuff degenerate.
Speaker 2: 08:02 It's what the analogy is, is it's like, you know, the tires on your car is that, you know, they wear out after 50,000 miles or 60,000 miles. And so your rotator cuff, because we all live so much longer than we used to, um, it degenerates in some patients and then eventually that it tears. The thing that I like to point out to folks though is that, um, you know, a lot of folks, uh, learn to live with it and it doesn't functionally affect them as much as they think. And so we work really hard in terms of making sure the patients understand that when they come in to just cause they have a rotator cuff tear doesn't mean they're going to need surgery because it's everyone's, all my patients that come in for the first time or for a couple of times, they're, you know, they're, they have had some friend who had some disastrous shoulder experience and they were never the same after that. So
Speaker 1: 08:49 That's interesting. So, um, maybe for some of the younger patients that you see if it's not cuff, um, what are some of the episodes or diagnoses that you're seeing with some of the younger patients?
Speaker 2: 09:01 So my sports medicine colleagues usually see a lot more of those patients than I do. Um, but the most common things for those folks are, um, shoulder dislocations, um, uh, collarbone fractures, uh, shoulder separations, um, and then usually labral tears. Um, and your labor is a soft tissue inside your shoulder. Um, the analogy I tell my patients when I'm talking to him about as it's soft tissue around the socket and what that does, is it essentially like a suction cup for the ball to stay stuck where it's supposed to be. Sure. When you have a tear with that one, it may just cause pain, which it can. Or if you tear in particular location after dislocation, then what happens is folks then have what we call recurrent instability or meaning they'll continue to dislocate their shoulder, um, when they put their arm in a particular place. Insurance. Yeah.
Speaker 1: 09:56 So, um, we'll uh, we'll move down the arm a little bit to the elbow, I guess next. Um, so one of the more common, um, elements I hear around the elbow a lot is tennis elbow. I don't know if that's, if that's what you hear or see a lot in clinic. Um, but just talk about, um, some of the common common, uh, elbow diagnosis, you see.
Speaker 2: 10:17 Yeah. You know, fortunately elbow, um, it's such a, it's probably, I would argue it's probably the most important joint in your arm because you can't compensate for loss of motion with it. And so, you know, if it gets stiff in one way or another, we're hurts and you don't move it, it makes life really hard cause you want to get your hand to your face and your hand to your bottom. So important to two important places for two different reasons. So, uh, but most commonly the things we see are tennis elbow, which is called lateral epicondylitis or Golfer's elbow, which is medial epicondylitis. Um, and interestingly, um, there, despite the term Itis, which implies inflammation, right? Neither one of these are inflammatory problems or their tendon degeneration problems, just like what we talked about with the rotator cuff. And so, um, they're just, they're again, something that wears out.
Speaker 2: 11:15 You classically see people come in with these symptoms, you know, in their forties. Um, and I jokingly will tell them it's, it's the gateway to middle age is what they're, they're suffering through. Um, but fortunately I tell people that their, they're self limiting processes. And they go away, but they can take six to 12 months to go away and it can be pretty, pretty hard because they affect, um, gripping significantly. And so if you have a job that requires a lot of gripping or a lifestyle that requires a lot of gripping, they can be pretty debilitating in terms of what you want to do.
Speaker 1: 11:46 Sure. So speaking of, you know, what, uh, obviously you and your colleagues are here to help people give back to their active lifestyle or their, their normal lifestyle for job duties. Um, if you would talk a little bit about what you know there, there's a whole spectrum of, of things that you can do as a doctor to help a patient. And one of the spectrum we have surgery but there's other things that are nonsurgical. So I don't know if you just want to speak to that, uh, very briefly about some of the different options and it doesn't always require going under the knife
Speaker 2: 12:18 for sure. In tennis elbow. I will use tennis elbow as an example cause it's a good good example that you know, I mentioned that it's a self limiting process, which means it goes away on its own. It doesn't need actually really any treatment at all. So all of the things we do for it are ways of decreasing your symptoms so that you can tolerate the problem until it eventually goes away. Um, it's a challenging problem because everything we do to treat it has about the exact same success rate. So if you do nothing about 85% get better. If you do some steroid injections, about 85% get better. If you do some physical therapy, about 85% get better. And then there's all kinds of other things out there in the world that, you know, people read about and they come in and things like a Holo therapy, which is not holy therapy at a pot pilot therapy I think is what it's called.
Speaker 2: 13:08 It's with water. And then people come about laser therapy and, and their surgery on there too. But what we know pretty clearly, at least for surgery is that, um, you know, I won't offer anybody surgery before they've had symptoms for six months because I know that it's going to go away. And when I first started practice it was 12 months. And that was usually generally what people agreed to, you know, the experts out there. But some of the financial analysis has shown that it's six months. It's still financially it makes sense to do surgery for certain people. You know, if your job is, you know, you're working in a factory and doing a lot of manual work, can't sit around at home for a year waiting for your tennis elbow to heal. So, so those are all the things out there. And then, you know, I'll additionally talk to people because some folks, you know, the other thing I emphasize is tennis elbow is, it's really just a pain problem and say the pain causes you problems in terms of using your hand. But until I'll try almost anything with people and you know, to keep them out of the or cause I know it all eventually get better. And a lot of folks when they know that want to try almost anything. So I'll even try other holistic things like acupuncture and things like that for folks to avoid surgery, um, moving forward.
Speaker 1: 14:22 That's interesting. Cool. Uh, well, so we'll continue our trek down the arm and we'll get to the hand. Um, so, uh, these days, what are, what are most people talking to you about in clinic with, with their hand problems? What do you see in a lot of,
Speaker 2: 14:37 well, probably two things in my practice and the two most common are clearly are carpal tunnel syndrome. Um, some times folks have done a little bit of a search on their own and the website does your, um, and they're convinced that's what they have. They, when they come in and, and because it's such a common problem, they're often right. Uh, and then probably the other most most common thing that I see is, um, is base of the thumb arthritis, which we call beige lar joint arthritis or CMC arthritis of the thumb. Interesting. Um, which is very, very common in women, about four to eight times more common in women than men. And they often come in in their 50s with a lot of thumb pain.
Speaker 1: 15:19 So is that, um, just over use or degenerative based on your age or a combination or?
Speaker 2: 15:25 So we think the reason why women are more prone to it is because they're just natural, a little more loose jointed, um, from their estrogen and hormones. And so that joint doesn't have natural stability. It's basically two saddles against each other. And so the ligaments keep everything stable. And so over time when those ligaments slowly stretch out because of the hormonal kind of things I just mentioned, shearing of the joint will cause it to develop arthritis. And so, I mean, I see folks all the time, they come in, you know, I'm looking at their hand for something else and it's very clear that they have the deformity consistent with it. Sure. Um, fortunately, you know, seven or 8% of people learned a little bit that they adapt to it. Um, it hurts. Um, and so, um, you know, they learn how to do the non non-operative kinds of things to make it, you know, tolerable. Sure. So,
Speaker 1: 16:14 well, um, one of my family members a few years back, they had, um, carpal tunnel pretty bad. They had that surgery. Right. Um, but once again, there's, there's the spectrum of, of services or treatments available. Um, so for carpal tunnel there could be surgery, but then there's, there's other things to help see if that can help get the patient better. Is that correct? Yeah,
Speaker 2: 16:37 there are. I mean, I would, I would argue that I have carpal tunnel, um, and uh, but the only time I am symptomatic consistently symptomatic cause when I'm gonna go mountain biking. So it's hard for me to justify going to have surgery just so I can go mountain bike more. Um, I get it sometimes at night. That's one of the most common things we look for is folks wake up and their hand feels numb. Um, and that has to do with how we sleep. We tend to sleep with our risk spent. Yup. Um, so the first thing we do in terms of treatment for that is we give people some splints to wear at night and that keeps their wrist straight. And so they tend not to sleep in a fetal position, which is how we all naturally want to sleep. Interesting. So, um, so that's the first thing we do that usually helps people in the earlier stages.
Speaker 2: 17:18 And then, uh, the next thing we usually consider a steroid injections, which are quite effective. They don't, in general, they're probably, we got real percentages for it, but you know, probably only about 25% of people will have steroid injections and have their symptoms go away and never come back. Um, and, uh, so in general, I would say most people that end up with symptoms, they're usually gonna end up probably going towards surgery at some point a lot of times. Um, because it simply comes down to what with that dizzy, what that disease process. You know, you have a nerve and a small tunnel with nine tenants, and so it's just a volume issue. And so if there's something affecting that volume, there's not really a way to change that. So some people, it's just anatomy. And over time that nerve gets unhappy. For some folks, um, like rheumatoid arthritis, there's inflammatory tissue that's in there.
Speaker 2: 18:14 Um, for some people that do a lot of heavy gripping activities there tend to develop a certain amount of film and inflammation around them that, and any, any guy going to volume thing like that is gonna affect it. So, um, so a lot of times people end up towards that. But what I would tell them is, and I'll say you're as well as I do, is the two happiest patients I have are a carpal tunnel. Patients that ever releases and, um, and shoulder replacements. And the reason why, and it's nothing that I do for them, the reason why their surgeries are so good and so successful was because they're reliable. They get really, they get a, they get people rid of people's symptoms reliably almost every single time.
Speaker 1: 18:51 Yeah. Um, well I have another question. So we were at an event last week, um, and we had a few people, um, in the audience at that event. Um, mentioned something about trigger finger. Um, I don't know if you could just briefly talk about what that is and um, how to treat trigger finger. I think we're hearing that a little more more frequently these days.
Speaker 2: 19:13 Yeah, it's a, it's a problem where people develop, it's the swelling, um, and attend and your tendons a rope to connect to the muscle, to the bone. And, and when your muscle pulls on the tendon or the rope, it moves down the bone that it's attached to. And so your tendons in your hand, they all sit in these really tight little tunnels and there's really no extra space in there at all. So trigger fingers essentially have to do with where that tendon starts and enters. That tunnel is right at the, about the, in your palm towards the end point of it. And uh, and so we don't really understand why it happens. And we went on, I was a chicken or egg thing, but people develop some swelling either of the tendon, which then starts causing, um, thickening and tightening of the tunnel. Or if it's the other way around, the thickening and tightening in the tunnel cause of the tenant's swollen.
Speaker 2: 20:03 But either way, the point is, is that the tenant is, it gets caught trying to enter that tunnel and it causes pain. And that's the first thing people feel, um, is they'll feel pain in their palm and don't really understand why that is. And then later they see the flicking that happens is the tendon kind of pops through. And so fortunately if there's, there's really two kind of groups of it. There's the idiopathic group, which is the run of the mill person that develops it and lots of people develop it. And then there's other people that have swelling in the tendons for other reasons, like a rheumatoid arthritis patient or diabetics have sugar deposition around their tenants that that causes the swelling and the difficulty sliding through. And so if it's a, if it's an idiopathic or no good reason of person injections, a lot of times we'll help them and get rid of their symptoms.
Speaker 2: 20:50 They don't need surgery, especially if they come in with symptoms, you know, that are less than a year. But if you have some of these other disease processes like diabetes and stuff, I tell the patients, you know, we'll try it injection. And I do it also for diagnostic reasons for the patients because they come in and you know, they want to know what they have is what they have and it still will get rid of their symptoms and diabetics. But, um, these symptoms always come back. And so, but it's a great way for the patient that tr gain a level of trust with me and see that like, oh, well this is what it is because I got this steroid injection and my symptoms went away. And so what I tell folks then is the surgery is basically a, a permanent way of getting rid of the symptoms versus the injection is going to be temporary and for something like that.
Speaker 1: 21:34 So, um, let's say that someone has, um, maybe one of the elements that we've, we've discussed and there's is at the level for which they are going to need some sort of surgical procedure. Sure. Um, generally people don't like to hear that, that they have to have surgery and someone has to cut them open and do something, um, to one of their joints. Right. Um, so I guess just if someone is that's listening might have, um, you know, problem with their shoulder or they might need surgery or on their hand, you know, what are, what's some, some things that you could talk about that would, um, I guess reassure them that the surgical process we have here at wake forest baptist is, you know, we have a good, you know, pre-op op and then post op whole whole navigation process. So I don't know if you want to talk to two that just were admitted and, and talk about, you know, what y'all do for surgical procedures and, and how you get people back to back to being healthy.
Speaker 2: 22:34 Well, the first thing I would tell you, at least in my clinic, what I really emphasize is that a lot of what I do is elective. And I try to make sure people understand that, that if you lived, we were pretty lucky. We live in a country where we can have a lot of things musculoskeletal operated on that in many other countries would not be addressed. Like you would basically be given a stick to go chew on and you'll deal with the pain and move on in life. So we're very fortunate in the United States sometimes that's, and so I really emphasize that to the patients is like, you know, this is an elective thing. Ultimately, you know, you don't have to have surgery. I mean there's, you know, if people have something that's broken, that's one thing. But sure, a lot of what they're coming to see us about are wear and tear, um, degenerative kinds of things that are going on.
Speaker 2: 23:19 Whether it's, you know, tendonitis or arthritis or some inflammatory thing like, you know, trigger fingers like we just talked about. And so that's the first thing cause I want folks to be 100% comfortable that they're, you know, that are going to have surgery. Um, I just recently had surgery and you know, it's uh, you going through it actually gives you a very good under very much better of how patients are giving up control and the trust that they're giving a surgeon to, to let somebody, you know, perform something invasively on their body. Yeah. So, um, so I'm very careful with that. You know, I would rarely ever, if for that reason to help develop a relationship with a patient, I would rarely have a patient come into my clinic and tell them, hey, they need an operation. The first time they come in. Sure. Mean if they come in with something that obviously needs to be fixed, like they broke the wrist, that's, that's one. [inaudible]
Speaker 2: 24:12 that's one different thing. Sure. But it's important that, that conversation to that they trust you in terms of what you're doing. So that, at least in my clinic, that's the way things go. Um, and the other thing that's, you know, excellent here is we have, you know, experts everywhere. And so if there's things that we're not sure about, um, you know, we can get, we can get you to the right folks to make sure that we're not missing anything. Um, make sure that, you know, folks medically are completely healthy enough to have surgery, so we're not taking any kind of unnecessary risks for the patients. Um, and, uh, and then the other thing I would just tell folks is that, um, you know, especially here we're all, we've all spent an extra year or two doing specialty training, so we're all experts in terms of what we're doing. So people can feel confident that, you know, they're getting the best possible care that they could be for their, whatever their musculoskeletal orthopedic problem is.
Speaker 1: 25:02 Yeah, that's a great point. Um, and I just want to let people know if you're listening and you're having, um, some sort of discomfort or pain in your elbow or shoulder or hand, um, you know, Dr [inaudible] or one of his colleagues, they're a great resource. Um, you know, you can reach out and they're gonna provide a lot of valuable insight for you in a, in a, an a diagnosis to help you, um, along your journey to get back to being active. Um, so a really convenient way to get ahold of them. I'll give you just a couple of options. Um, people can go to our website, wakehealth.edu/ortho, wakehealth.edu/ortho or they can call three, three, six, seven one six, wake. That's nine two five, three three, three, six, seven one six, nine two, five, three. And make an appointment with Dr Tuohy in his clinic or, um, you know, one of his colleagues.
Speaker 1: 25:56 We, we have Ortho clinics for hand and elbow and shoulder. Um, we have physicians, uh, all over the triad in northwest, North Carolina. So, um, we can, we can help people in this whole area. Um, and we're gonna wrap up here soon, Dr Tuohy. But, um, I guess just talk about, you know, if you could share just a quick story of, um, you know, have you had a patient, I'm sure you have. Um, but you know, someone who's had to have surgery but then they're back to a hundred percent health if it's a shoulder replacement or something with the hand, you know, just kind of, um, kind of having them come back and be at 100% again. What's that like?
Speaker 2: 26:38 Um, you asking for an example or how it makes me feel?
Speaker 1: 26:40 Yeah, how it makes you feel, how it makes the patient feel mean. It's,
Speaker 2: 26:44 Oh, I mean it's, it's, I mean that's part of what we do. I mean that's what makes what I do for a living. So satisfying. You know, I've had lots of great stories, both, you know, trauma wise and non trauma wise of, of folks that come to see me. Um, you know, I had, you know, one woman in particular that came to see me, I remember quite well that um, she had broken her wrist and it healed in a bad position and she had seen two other people and they had suggested based on how bad it was that she should just have her wrist views, which means basically having it heal together so it doesn't move anymore. And so, um, I told her that, uh, I said, you know, we can try, we can try to go back in and realign everything. And we did and she did far better than I ever thought she would have. I mean, she gained back almost all of her wrist motion, but you know, the best part was that over the last couple of years she always sends me a Christmas card of her and her grandkids. So it's great seeing all of that. Um, you know, when you can help somebody that way.
Speaker 1: 27:38 Oh, that's awesome. Well, you can check out Dr [inaudible] profile or any of our other orthopedic surgeons or doctors profiles on our website. And, uh, like I said, you can find out more information about our services, wakehealth.edu slash Ortho or seven, one six week to make an appointment. Also a quick reminder, you can check out wakehealth.edu/besthealth to listen to all of our podcasts, including this one. So Dr. Tuohy, once again, thanks so much for visiting us this month. I really appreciate it. Thank you. Appreciate it.
Speaker 3: 28:11 Yeah, thank you. And, um, we hope that everyone listening has a great June and, um, we'll, we'll talk to you again next month. Have a good day. Thanks for listening to this episode of the best health podcast brought to you by wake forest baptist health. For more wellness info, check out wakehealth.edu and follow us on social media, wake forest baptist health, the gold standard of health care.