Tuesday, March 20, 2007

Swan Thing or Another

I played rugby in college; that's me in the picture. We were a damn good team -- East Coast Champions a few times, played in tournaments in the Bahamas over Spring Break (yes, we did play.) The only time I got hurt was when I returned to Amherst during my freshman year in med school. It was a rugby weekend, and the opposing team was short one man, so I played for them, against my former team. Bad karma, I guess: in a desperation tackle, I collared a guy and my grip was stronger than the flexor digitorum profundis tendon on my right ring finger. After the game, when I tried to make a fist, the finger wouldn't flex. Bummer. Especially for a future surgeon. So I had it operated on.

Stupidly, rather than seeking out a hand surgeon (there were a couple there of great renown, including one with a fabulous name: Kingsbury Heiple. During one of our orthopedic exams, one of the students had written on the blackboard "Kingsbury Heiple is not a flavor of ice-cream.") I went to the student health service, who referred me to their default surgeon. And, rather than having the decency to send me on, he did the operation himself. Why not? He'd never fixed one before, and wanted to give it a shot. In my career, taking on an operation about which I couldn't honestly feel I was as skilled as anyone was something I never ever did. Back then, the concept didn't compute, and I never thought to ask the man if he knew what he was doing. He did, I found out later, ask ol' King how to go about it.

My important recollections about the peri-operative time are these: in the recovery room I must have moaned, because a nurse stabbed me in the thigh with some demerol. My thigh hurt much longer than my hand. I had one more shot of demerol the next day. It felt so good I told myself "never again!" I was casted to above the elbow, and had to take a pathology final that way: having trouble operating my microscope I asked if anyone would "come over and twist my knobs." I passed. The tendon was held in place via a wire looped through it, the finger-bone, and my nail. Removing it later hurt like hell. Probably would have been worse, had the surgeon not accidentally cut the medial digital nerve, making half my finger numb.

Which brings me to the climax: the surgeon had been so excited by the operation and the mechanism of injury that he told me he planned to publish an article about it. After the several weeks it took to get my finger mobile again, we ran into each other in the hospital and he had a look. No article ensued.

The finger, in repose.

The scar, following the course of the digital nerve.

A classic swan-neck deformity. Undesirable.

The tip is permanently bent, too. It moves, but not all the way up. Once in a while when grasping an instrument with thumb and ring finger through the holes, I have to try twice to let go of the damn thing. Not a big deal. They say you should find the good in the bad: for a long time the side-numbness of the finger bugged me bigly. I'd find myself constantly rubbing it, for some perverse reason drawn to (if that's what it was) the weirdness. When I touched that part of my finger to something else, it sort of creeped me out. A year or so later it occurred to me that I was no longer noticing. My brain had bought the feeling as normal and no longer brought it to my attention.

Which gave me a perfect demonstration to patients on whom I was planning axillary node dissection (most often for breast cancer): there's a possibility of a numb spot on the upper inner arm. It could bug you for a while, I'd tell them, but eventually you'll stop noticing. And then I'd show them my ridiculous finger, proving I knew of what I spoke.


jmb said...

Good photos and story for Dr Charles' Eschara site, except you wouldn't be anonymous, because we all saw it here first.

ditzydoctor said...

my friend has boutonnieres on all his fingers from suffering abuse as a kid - he had the door slammed shut on his fingers millions of times!

but at least you're a walking example, and really, that's the best way to put your patients at ease =D

Lisa said...

Three years aftert he mastectomy, and my body fools itself into thinking there is still feeling there. That is a very weird sensation

Guy With a Knife said...

Getting a swan-neck after FDP repair is a bit unusual. I'd more expect tendon adhesions leaving you with a flexion contracture. I'm not quite sure how your surgeon achieved that. Of course knocking out your ulnar digital nerve is a sweet trick. (at least it looks like the ulnar side) He had the good thought to do it to your non-opposition side!

Ah, hand surgery . . . queen of the disciplines . . .

Annie said...

You think you're frustrated??!!?? I had something to contribute regarding this post that now escapes me. I'm sure that it was eminently succinct and insightful.....if only I could pluck it from the nether regions of my brain. Alas, I fear it is lost forever.......On a much brighter note, I'm reading and thoroughly enjoying your book and have all but made it required reading for my nursing students!

Anonymous said...

Dr. Schwab, you did well to go on and do the wonderful work you did with a finger that wouldn't cooperate with you ... however, I'm not surprised!

Thanks for sharing this!

Anonymous said...

Hi, sorry to hear about your injury, especially as I have just received the same injury by doing a handstand! I have a splint on mine but am off to the hospital tomorrow to meet the "hand doctor" i know they want to avoid surgery, and having read your story so do I ! Being a girl, it's not a pretty sight! will let your know, cheers, Heather


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