Read the transcript of Dr. Scott Schaaf on IRG Health Talk radio or listen here
Tom: Welcome to IRG Health Talk. I'm Tom Huntler along with Shannon O'Kelley, physical therapist and president of IRG Physical & Hand Therapy. And, our guest, Dr. Scott Schaaf, orthopedic physician from The Everett Clinic.
Shannon: Hey, you're an orthopedic surgeon and you spend a lot of time kind of treating people's bones and fractures and sometimes with these fractures you'll use metal devices to stabilize those fractures. Can you describe to the listeners how that decision is made?
Dr. Schaaf: Well, a lot of it depends on the type of fracture. Certain fractures in certain areas, like around the ankle, just don't take a cast well or a cast won't hold the break where it needs to be, and then it's better treated with a plate and screws or other type of metal implants.
Shannon: When you talk about metal implants, because patients always ask, "What type of metal did the doctor put in?" "Did they use screws?" These are metal implants designed for specific procedures and specific fractures in the body. Is that right?
Dr. Schaaf: That's true. It has become so specialized now that plate and screws could be used just for the wrist or just for the elbow. Most of them are made out of titanium. Some of them are still made out of stainless steel. The exciting stuff down the road are the plastics, things that are being made out of plastic, bioabsorbable-type implants.
Shannon: I had a patient the other day that talked about a bioabsorbable anchor that was put into their surgical shoulder. Bioabsorbable, what does that mean?
Dr. Schaaf: It means that your body actually absorbs the implant over time, so there's no metal left over. No need for another potential operation to take it out.
Shannon: So, in a year or so if you were to look in there or x-ray that joint that absorbable anchor or plate would be gone.
Dr. Schaaf: It would be completely gone. You would never see it on x-ray, and, if you went in and looked surgically you would never find it.
Shannon: Wow, that's amazing. I'm gonna bring Jeremy Cornwell in. He is a physical therapist and he and I both see patients that have undergone surgery and had metal implants. I'm sure he has some questions.
Jeremy: The main question a lot of my patients who have had an open reduction, internal fixation, the question is, "Is this thing going to stay in my body the whole time, and what are the risks involved, and how bad is it going to be to recover from having it removed?.”
Dr. Schaaf: More times than not, you do not have to take the plate and screws or any other metallic implant out. Most of the time it's for patient convenience. There are some areas of the body that are just so prominent under the skin that an implant will bother you. The most common I see is the ankle. We more commonly take those implants out, again at the request of the patient, if it is bothering them.
Shannon: I would imagine when you're talking about these plates, this is on the outside of the bone. But, I know that you use rods at times, and you put rods down in the middle of the bone, basically. Explain that. Why would you use a rod?
Dr. Schaaf: Usually the way I describe it is that our bones, especially our long bones, like your thigh bone, your shin bone, are hollow, like a ham bone. When you go and buy a ham there's a round center bone in the middle. The metal rod actually goes down the center part, into where the bone marrow is, and that rod then acts, can stabilize a fracture just through the hollow part of the bone. The nice thing about it is there's no plate that people can feel, or no screws that people can feel rub against their shoes or pants, or whatever. The downside is that they are incredibly hard to get out if they should have to have them out. We even take rods out less frequently than we do plates or screws.
Jeremy: Where are some of the common areas that you are using rods versus a plate?
Dr. Schaaf: The femur, the thigh bone and the tibia bone are the most common. But, we can rod upper arm bones, the humerus. We can rod the radius and ulnas. Sometimes, in metacarpal fractures in the hand, I will use a bigger pin, like a rod, so the same premise. It goes down the middle of the bone to stabilize the fracture.
Jeremy: I've had some skiers who have come in with tibial plateau fractures with that rod and/or a plate, and one of the big questions is, "When can I get back on the slopes?". "What are my risk factors?' And, "What am I not supposed to do?". After the implant, after some recovery.
Dr. Schaaf: If removing the implant, I usually will caution people not to do higher level of activity such as skiing, that type of thing, for about six weeks. The holes that are left by removing those implants are weak areas of the bone. We call them stress risers, and with the right amount of force you could actually break through a screw hole. It's one thing if you're just walking or doing something basic, but if you're doing something more strenuous like skiing, playing basketball, something that puts more force on the bone, there is that risk. I usually caution them not to do that for about six weeks.
Shannon: My patients usually ask, "Will I set off the alarm when I go through the metal detector at the airport?", and that's a real question they ask all the time, so how do you answer that?
Dr. Schaaf: I usually tell them be prepared for it to set it off. In other words, wear loose-fitting clothing that you can easily show the TSA that you have a scar. But, I'll be honest with you, it depends on the airport. I walked through Tampa and my belt buckle set it off, and you can walk through other airports and have a pocket full of change and it won't set it off. So, it just depends on the airport.
Shannon: As a surgeon, I would imagine, these are decisions that you're making at the time that you're performing the procedure based on your skill and knowledge. How do you decide what size of metal plate or rod? How do you make those decisions? Because, that's kind of fascinating.
Dr. Schaaf: That's a good question. Oftentimes, based on x-ray or other studies such as CT scan or MRI we get an idea of what the flavor of the fracture is, so to speak, how many pieces are there. Then, from that, we can get a rough idea of the type of implant that we would use. Oftentimes, we won't know the exact size until we get in there and get everything kind of put back together.
Shannon: I'm sure, depending on the patient's age, there are decisions to be made, the potential for growth. Isn't it true that if that growth plate is disrupted by some type of fracture that bone might not grow like the opposite side, basically?
Dr. Schaaf: That's very true. Fractures that involve the growth plate, there is a risk that that bone will not continue to grow. We tend to put less metal in kids for a couple of reasons. Number one, no one likes to operate on kids unless you absolutely have to. Secondly, kids are still growing. You can accept a lot more of an angle or tilt in a break, a slight offset of the break in kids because odds are they will not only heal the fracture but they will straighten themselves out in a matter of a few months. We put a lot more implants in adults and elderly people just because, especially in elderly folks where osteoporosis could be a concern, you need even more to be able to stabilize that fracture to make sure that it stays where it belongs.
Jeremy: Now, that's something we see a lot of, elderly patients come in who have fallen, who are trying to be independent, but are taking risks, and end up with a hip fracture and a surgery. What are some other common areas that you are likely to see for this kind of procedure?
Dr. Schaaf: In the elderly, we tend to see a lot more wrist fractures. People not only falling on an outstretched wrist and then will end up breaking the wrist as their bones are weak or brittle to begin with. Ankle fractures, where a twist of their ankle, where a younger person would maybe just sprain their ankle, they may be more prone to break it, and those types of ankle fractures often require metal implants.
Shannon: You know what I've noticed Jeremy, and I'm sure you've noticed this in your practice too. When I was a kid growing up it seems like there were always two or three kids at school that always had some kind of plaster cast on. I just don’t see any casts anymore. I hardly ever see a patient come in that says, "I just got out of a cast", or, "I fractured my leg and I was in a cast for 6-8 weeks." Are you still doing casts, or has the metal kind of taken over? Because you talk about internal casting with metal.
Shannon: Are plaster casts still commonplace?
Dr. Schaaf: Not as commonplace. I think you're right, Shannon. There still is a lot of utility for plaster casts because you can mold it, you can hold it like clay and make sure that, especially in a kid, that that fracture stays right where it belongs. So, we will still use them, but between modern bracing, fiberglass casts, it seems that we often have alternatives, even if it doesn't mean surgery.
Jeremy: Are you seeing better compliance with activity limitations by using the internal fixation, the braces, versus the braces or a cast?
Dr. Schaaf: Certainly, they are using surgery or other type of bracing. There is a better level of forgiveness if someone is more active than they should be. With that said, I still would not recommend them doing more than what we tell them to do because there still is that risk that the metal will not hold the fracture. The metal is not designed to hold your weight. The metal is designed just to hold the fracture in place until it heals. Kind of a misconception is the walking cast. Everyone who breaks an ankle thinks, "Can I have a walking cast?" It's not a function of the cast. It's a function of the break. Sometimes, you can walk on them, some you can't.
Shannon: Wow, there you go. Dr. Schaaf answering all those questions that we have regarding metal implants and fractures. Hey, if our listeners wanted to ask you a question or get a hold of you, what's the easiest way to kind of contact you at your workplace?
Dr. Schaaf: I work for The Everett Clinic. My address is 3927 Rucker Ave. in Everett. We are right in downtown Everett, and my office phone number is 425-339-5447.
Shannon: And, is it the everettclinic.com.
Dr. Schaaf: It is the everettclinic.com.
Shannon: Perfect. Thanks for your time. Good job.
Dr. Schaaf: Thank you.
Tom: If you would like more information on this topic, as well as how to contact Dr. Scott Schaaf, go to irgpt.com and click on the "For Health" tab. Or, go to IRG Physical & Hand Therapy's Facebook page.