Jeffry T. Watson, M.D.
VanderbiltHandCenter
Clinical Interests: Hand & Upper Extremity Reconstruction
MD Degree: University of Texas Southwestern
Post Graduate Training: University of Texas Southwestern; WashingtonUniversity
Interview with Dr. Watson:1. What type of symptoms would indicate a referral to your office?
Aside from the obvious subacute industrial upper extremity trauma, we often see patients simply with progressive pain and dysfunction in their hands, wrists, forearm or elbow. This may take the form of worsening numbness, weakness or swelling.
2. What would you consider an average length of time for conservative treatment prior to initiating surgery?
Few problems require surgical treatment upon presentation, unless they have already had an appropriate workup elsewhere prior to seeing me. For patients with overuse problems such as tennis elbow, I try to delay surgery until symptoms have been ongoing at least 6 months, as most people will get over this if I give them the chance. Clearly, depending on the degree of pain and dysfunction, I have bent that rule at times. For patients with trigger digits or Dequervain’s tenosynovitis, I’ll try a trial of 1-2 injections before considering surgery, as most respond well to the shots. Finally, for carpal tunnel syndrome, the severity of the symptoms can dictate the treatment. If the patient is already demonstrating objective muscle wasting and motor dysfunction, I don’t think we should wait at all, as irreversible deficits are already setting in. However, I give everyone a trial of splinting and perhaps activity modification. One other modality I employ more than most is steroid injections in the carpal canal. If the diagnosis is at all unclear, this can be particularly beneficial at confirming the diagnosis and also offering some idea of how the patient may respond to a carpal tunnel release. Furthermore, some patients experience months of relief and return simply inquiring about another injection. Again, the results of the injections are quite variable, but I’ve seen enough benefit from them that I at least offer it to most patients. Bottom line, the nonoperative treatment time frame for carpal tunnel depends on degree of symptoms and patients’ response to the above measures. However, I rarely operate on this problem with symptom duration of less than 3 months.
3. What is your criteria for doing surgery?
As suggested above, that would depend on the particular problem and response to nonoperative measures. It is impossible to address the specific criteria for all the diagnoses we see in this document, but a few generalizations apply. Obviously, the particular disease entity and severity of pain and dysfunction dictate the need for surgery. I also have to have the sense that the patient has a reasonable chance to benefit from the operation and that they have an appropriate level of expectations and understanding. Simply put, the relative gains versus drawbacks from surgery have to weigh out so that both we both have the sense that this is an operation for the patient and not to the patient.
4. What percent of the patients that you see in clinic have surgery?
Probably 20% of new patients in the office go on to surgical treatment.
5. What treatment measures are normally indicated during the conservative treatment period?
Clearly, that also depends on the diagnosis. For most, modifications of activity, anti-inflammatory medications, splinting, and judicious use of injections help out. However, many patients have already done all this by the time I see them.
6. If surgery is indicated, at what point do your patients normally return to work with restrictions?
For smaller scale procedures (carpal tunnel release, Dequervain’s release, ulnar nerve transpositions, tennis elbow release, to name a few), I hold them out through post operative day number one or two. Even if one handed duty is available, I personally do not think it’s reasonable or worthwhile forcing them back sooner. Although they may not be using the treated limb, prolonged placement in a dependent position promotes swelling and exacerbates pain significantly. Most patients are also still taking narcotic analgesics during that time. With issues of driving and potential job site hazards, it should be obvious what problems may arise there. Finally, pushing people beyond that sets up an adversarial position for everyone involved from the start and invites a tedious convalescence and return to regular duty effort.
For larger scale procedures (crush injuries, nerve reconstructions, etc.), it clearly depends on the procedure and occupation.
7. How do you feel about returning patients to modified duty if it is possible?
My position on that is fairly simple and consistent. After getting a sense of the problem, I inform them of what I think their limitations and restrictions are and put those on the “ return to duty” form. Beyond that, it is up the employer as to whether or not they are able to accommodate those particular medical restrictions. I’m accustomed to the response, “They don’t have any light duty. I need to be completely off.” I make it clear that it is still between them and their employer whether or not the restrictions can be accommodated. If not, the employer will simply send them home. Most people get the picture once I clarify that. I try to stay out of transportation issues and other endless peripheral circumstances that can make the picture exceedingly confusing and divert attention away from what the actual medical limitations are. Case managers have historically been immensely helpful in helping out in this area.
8. How open are you to direct communication with the case management/adjustor community?
No problem. If the patient’s okay with the case manager in the room, I’m all for it. In fact, I prefer it, as it cuts down on repeating conversations to all parties involved. However, I try to verbally communicate the plan at some point before days’ end with the case manager if they cannot be present. Unfortunately, in the middle of some clinic days, it’s hard for me to have separate conversations with everyone. I may have to catch up with people at the end of the day.
- In what types of situations would you order a Functional Capacity Evaluation (FCE)?
The other situation is if I sense the patient is less than authentic in his/her description of limitations, symptoms, or disability. Some evaluators are especially perceptive at picking up on this, and I may need some objective support to point out what may really be at hand there.
As an aside, I have begun to tell most patients that the evaluators will be closely monitoring them as such. My reason for this is because I’ve had a few patients that had legitimate problems and limitations who came up looking like complete squirrels on the FCE. They may not have been feeling well or did not appreciate the importance of the evaluation. Nonetheless, not only was the test useless from an actual limitation standpoint, but it also branded an otherwise reliable patient as a potential malingerer.