** This is the author’s opinion and does not represent the military or U.S. government. **

By Fred P. O’Brien, MD

I am an active duty orthopedic surgeon in the US Army, and I completed my orthopaedic and hand surgery training through military GME programs.  We have the privilege of caring for service members, their families, retirees and others who are seen in the military healthcare system.  In the US, our assignments can range from working at Medical Treatment Facilities (“MTFs”), comparable to large, tertiary referral centers, to smaller clinics serving local military communities.   Depending on the location, we also participate in training residents and medical students. 

Practicing in a military environment has substantially impacted my professional development. Our mix of clinical and operative cases varies depending on our domestic or overseas location.  I work in a non-trauma hospital, but have still gained an appreciation and insights from the challenges of returning soldiers to full duty after hand or upper extremity injuries, whether or not surgery was required. Some of the more rewarding moments have come from applying insights from civilian researchers and colleagues to military settings.  Scapholunate ligament pathology of varying degrees is common among soldiers (I sometimes wonder if our hospital is the world’s capital of idiopathic dorsal wrist pain). Push-ups in a hands-flat position often exacerbate symptoms, prompting a referral to hand surgery clinic.  Recent biomechanical research has shown that push-ups in this position, the commonly preferred form in the military, can result in increased pressure in the radioscaphoid fossa¹. Army policy does allow push-ups in a wrist neutral position (i.e. on knuckles) and I have discussed this research when recommending a transition to this style of push-ups. 

During deployed assignments, I have benefited from experience and shared wisdom of our civilian and fellow military hand surgery colleagues.  Like many others, I am an avid reader of the ASSH listserve.  In the second month of my most recent deployment, we were treating a patient with a severe brachial plexus injury that primarily affected his radial nerve function.   Resources for definitive care were limited, to say the least.  Dr. Andrew Nelson had previously posted a fascinating case involving a patient who had fabricated his own radial nerve palsy splint using a rigid dorsal frame and elastics (7/3/2018, ASSH listserve).  With that as my muse, I cobbled together a similar splint using fiberglass and remnants from therapy bands.  While my splint wasn’t nearly as aesthetically impressive (and probably would have wound up on the cutting room floor of a MacGyver episode), I think it gave our patient a little more function and freedom.  Thank you to Dr. Nelson and his patient!

When I look at our practice environment, I am constantly humbled by the example set by those around me.   Some have spent full careers in other areas of the military and have changed course to serve in healthcare.   I have met family members who travel long distances for care at larger centers, or who have contended with deployments that were much longer than my own.  Wounded warriors who are recovering from injuries sustained in battle are especially inspiring and remind me of the privilege it is to serve in this incredible profession.

1. Daly BT, Werner FW, Cavallaro SM, Tucci ER, Harley BJ. Effect of Push-Up Position on Wrist Joint Pressures in the Intact Wrist and Following Scapholunate Interosseous Ligament Sectioning. J Hand Surg Am. 2018 Apr;43(4):339-345. doi: 10.1016/j.jhsa.2017.10.019. Epub 2017 Nov 20. PubMed PMID: 29157783