The surgeon who knows the most about hands: "Rafa Nadal, surely his doctors advised him to stop earlier"

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His resume is as impressive as his speech is passionate when he talks about the member of the human body that has made his name a medical reference in half the world: the hand. Head of the Orthopaedic Surgery and Traumatology Service and the Hand Surgery and Microsurgery Unit of the HM Montepríncipe University Hospital and director of the European Institute of Reconstructive Surgery (IECR), Pedo J. Delgado is the Michael Jordan of hand surgeons, and it is because he leads what he himself defines as a kind of Dream Team : the board of directors of the Spanish Society of Surgery of the Hand (Secma), which will preside until 2025.

In Spain, there are just over five hundred super-specialized hand surgeons and, among them, he says, some of the world leaders in this field. His next challenge (and he assumes many) is to place the Secma in the place he believes it deserves for the "very high qualification" of the directive and its partners, and to ensure that the diploma of accreditation in Hand Surgery taught by the society achieves official recognition.

From the anonymous patient, who comes to him for an ailment in the hand, to the athlete (front row or lower categories) who can not pick up the racket or the hockey stick, Delgado pampers everything that falls into his hands (never better said), because "there is no small pathology". You cannot cover the sky with your hand, says the proverb, but listening to him talk about his hands with such passion, solvency and scientific basis, one inevitably ends up looking at his own... And he sees them capable of anything.

Due to the number of members and the specificity of its discipline, the Secma is somewhat unknown within the large number of medical societies in Spain. Sell me the benefits of the society that will preside until 2025.Look, I place you a little in context. The Secma was created no less than in 1969, together with the British Society of Hand Surgery, and is, in Spain, the second oldest in our field of action, after the Spanish Society of Orthopedic Surgery and Traumatology (Secot). Our scientific society began with hardly anything, with 16 surgeons who came together and founded it, and in its 54-year history it has had 29 presidents, many of them very prominent figures, nationally and internationally, of hand surgery. Come on, the Secma is not as pipiola as its size might make you think... Let's see, we are relatively young compared to historical medical societies in other countries, but I think ours is one of the societies that has grown the most in recent years. When I joined the society, 10 years ago, we were 360 members and today, in the last assembly we did, we already had 540, and every day they knock more members at the door. Just over half a thousand, then. Are there many more hand surgeons in Spain? I am referring to specialists who are off the radar of Secma. Well, I would say not many more than those 540, because surgeons need a backup, a group to lean on, to serve as an umbrella. Put that in Spain there can be, in round numbers, a total of 600. In any case, it's not all about size. From Secma's relatively modest numerical position, what goals does the board of directors you chair have in mind for the next two years? Look, we have a society that is increasingly present internationally, and not only in Europe, but in the United States and in America in general. We have partners who are very, very recognized outside of this country. With these members, we have constituted a board of directors with four very clear objectives: training, accreditation, leadership and communication. It sounds as ambitious as it is generic... I explain, I explain. This directive will work for society, not the other way around. Fortunately, those who are on the board are people with so much prestige that they do not need society to further cement that prestige and, therefore, they are going to turn to the Secma. All also have a strong vocation for service, teaching and training. We have assembled a team as if it were the Dream Team of the NBA of Barcelona 92. Until now, the society accredited the training that the members did on their own, and now we are also going to do our own courses, not only the one that is already done at the end of the year, but many more, and some local, online, with videos, with discussion forums ..., so that everyone, whether resident or a specialist with a lot of experience, Have training options. If you captain that Dream Team, do I interpret you as a kind of Michael Jordan of hand surgery? [Laughs]. I'm a little old to play in the NBA, but you understand me. Any NBA team that has played in the Olympics has been the best, and it is a way of valuing the enormous potential that the Secma has in its own thing: we have gathered the best surgeonsWe of the moment, nationally and internationally, to form an unbeatable team. Undoubtedly, many young surgeons have these people among their professional references, and they will also dedicate two years of their lives to work for society. I assure you that being able to count on them is a luxury. Listening to him it seems that we are a European and world power in hand surgery. How good are you and your colleagues? In certain areas, we are a very clear reference, and it must be said with great pride. For example, in wrist arthroscopy, we are true international leaders; In microsurgery, reconstructive surgery, plexus surgery... And then there are other areas that have had a lot of tradition in Spain, such as carpal trauma or distal radius fracture. And another very important thing that I said in the last assembly: we have to be the leaders that we wish we had when we started in this. Now that we have brought together a leading world group, we have the responsibility to give here, in Spain, the training that we, many times, had to look for abroad. Now that it speaks of the youngest, the Secma has created a specific vocalia for the young surgeon. What is the scenario of a professional when he arrives at the exercise of this discipline? Look, societies usually grow and evolve more slowly than the members who are part of them. Our goal is to try to open a channel of communication so that young surgeons can channel their problems and concerns, which are different from those of senior surgeons. The profile of the surgeon has changed a lot in recent years: we are talking about much more prepared people at an earlier age than we had; They also have much closer references, unlike us, which cost us much more to reach, and communication channels are now much more fluid, almost immediate with social networks. As if that were not enough, some also accumulate a lot of experience, which they have acquired earlier and thanks to the possibility of working hand in hand with some of those senior references. In short, we want their concerns to have a presence in the Secma and, in addition, to exchange experiences with the group of young surgeons of the European Society. Excuse me, he also told me about the accreditation of training as another key objective for Secma. Yes, yes, very important. About three years ago, the Secma created the Spanish Diploma of Hand Surgery, which is taught for two years, with a theoretical part, another practical, and that, once achieved, accredits, with the endorsement of the Secma, that you are a hand surgeon. We want more and more specialists to have it, so that the patient, when he needs it, knows that he can expressly look for a hand surgeon. Many people, when they come to my practice, are surprised that there are specialists in this discipline, and we are talking about something fully recognized already in three countries in Europe: Germany, Switzerland and Sweden. Having the diploma of the Secma is, therefore, an added value, like that of the European Society of Hand Surgery, which also gives it, and you can perfectly have both. And Spain, at the moment, does not officially recognize either of the two? No, and that is one of the problems we face. In Spain, the only official titles recognized, at the moment, are those of Plastic Surgery and Orthopedic Surgery, but not There is a specific degree. Saving the distances is as if you intended to drive a truck or a bus with the B2. Can you drive it? Yes, but, in theory, it is not the same. Sure, an orthopedic surgeon can operate on your hand, but if complications arise that go beyond their expertise, what happens? In fact, there are already many services that have hand units, but now they need to be accredited and integrated by hand surgeons who are officially recognized for the academic effort they have made to train. I said before that the Secma is the second oldest society in Spain within the area of Traumatology. Isn't it somewhat paradoxical that people with such awareness of their superspecialty, who saw the need to associate more than half a century ago, still do not have a diploma that officially recognizes them? Totally agree. Look, the previous board of directors already tried and, in fact, the Government has had that request on its table for a long time, but, for one thing or another, it seems that it has not yet seen the time to do it. We are a scientific society that is there to help the Administration and to help patients, and that, in addition, already accredits a training that, in my opinion, should be recognized, as is the training accredited by other societies. He also spoke of the need to assume a certain leadership as a scientific society. What do you mean? Very simple. We have a very important group of people and we have to continue commanding many areas worldwide in which we are already absolutely leading, such as microsurgery, wrist arthroscopy... And that links with what I also told you before about communication. The Secma, a society made up of absolutely altruistic people and at the service of the profession, training and accreditation in hand surgery, must necessarily be the first interlocutor in all issues that have to do with our discipline, from patients who demand information, to editorial or institutional advice, through the relationship with the Public Administration, for the elaboration of guides, training protocols for residents... Tell me a secret. How does a small scientific society move in the midst of so much corporate giant, and so historically rooted? How can they make their voices heard and claim their role as a key interlocutor in their specialty? I assure you that we surgeons are aware of this difficulty, because, in fact, the dialogue with the Administration is complicated. It is also true that whenever we have knocked on their door they have received us, so there is recognition. However, I understand that, for certain requests, the problem, rather than recognition of the entity of your interlocutor, is one of budget. In any case, I insist on the message: the health of the hand is vital, not only for patients, but even because of the high cost that these pathologies can have for companies and for the Administration itself. Another doubt that assails me. With a base of training in general traumatology, with such a wide field of action in principle, how does one come to look at the hand? What led you, for example, to become interested in that seemingly small member? Look, in the United States and in many countries in America, residents make a orgeneral rtopedia and then have the obligation to specialize in a certain area; When they finish, they are specialists in hand, knee, hip, shoulder ... And that's where his professional career begins. In Spain, you do your 5 years of residency, you are an orthopedic surgeon and you can start working on whatever you want, or what you can, come on. Now, in reality you are not a superspecialist of anything and the training to achieve it is, to a large extent, self-taught. You are looking for life, go: either you are lucky enough to enter to work in a specific team or you have to go looking for your place, little by little. Hence, I insist a lot on the importance of the diploma given by the Secma, because it is a regulated training and channeled by society with the parameters that we consider that a hand specialist should have, and also in full consonance with the training that is given in Europe. Apart from this formative helplessness, I said before that the ordinary citizen often does not even know about the existence of hand surgeons. Do I understand that this will also be a very important handicap? Yes, because sometimes patients come to the consultation resigned to the fact that no more can be done for them. And that does not mean that things have been done badly until then, eye, but that surgery sometimes goes well and sometimes not so much, and there have nothing to do with the surgeon or the technique that has been used. In any case, when they find an expert in their ailment, many times a world opens up to them, and that is why it is vital that they know our work. Also, not everything is done with surgery; Even if we are surgeons, it does not mean that we operate on everything. The good thing about an expert is that he makes the diagnosis well, from the exploration itself to the imaging tests and treatment, with a much more specific vision. How far does that specific vision go? Do you see hand, wrist and the entire upper extremity or are you limited only to the hand? Depends on. Normally, the surgeon sees hand, wrist and, in many cases, can reach the elbow. And then any pathology that requires microsurgery, such as nerve injuries or limb coverage injuries, which do not have to be only at the level of the forearm. Now, the central pathology is hand, wrist and elbow (the latter, as I say, not in all cases) and any general surgery with microsurgery, nerves and coverage surgery. Why is the hand so important from a medical point of view? What implications can not treat a pathology in the hand well or in time can have? Look, I answer you with an idea that the French writer Paul Valéry already captured in his famous Address to the Surgeons. He said that the hand is the only instrument that is valid for many things: it is valid to defend oneself; It is also valid to relate, to communicate, to eat, to work, to play an instrument, for a blind person to express himself, it is valid to feel... What instrument do we have in the body that does all these functions? When the sensory and motor regions of the brain are profiled, the hand occupies 30% of the space we use for these functions. In addition, the sequelae that a hand injury can leave us are not only visible, but can limit the patient's ability to work, to relate or to exercise basic functions of daily living, such as dressing or eating.Do you think people are aware of this importance? Do you not have the feeling, with all the quotation marks you want to put on it, that the hand suffers a certain discredit with respect to other members? I understand that you, as a professional, pamper it, but aren't you somewhat undervalued? You can't even imagine how many patients tell me, "Doctor, I had no idea how much hands mattered." Even among orthopedic surgeons themselves there is a kind of underestimation of the hand: they usually say "a little finger" or "I have left you a doll", when nobody says "a little girl" or "an ankle". Look, a finger has the same structures as a femur, with the difference that it is much smaller and we cannot make mistakes, because they are one-shot surgeries. If you don't get it right the first time, it doesn't work. I'll give you an example: a fracture of a phalanx near the joint is almost as complex as a tibia and the sequelae it can leave are even greater. In short, we are watchmakers, we work on a small scale, but the dimension of what we do is just as big as with any other element, member or organ. What implications has the brutal and accelerated transition from homo analógicus to homo digitalis had for your specialty? All, of course, because the evolution of the pathology of the hand has been equal to that of history. One of the first occupational diseases, in quotation marks, that was documented in the world was the famous tendinitis of Quervain, better known as sprained wagtails, those women who went to the river to wash with the board. From there, there have been many injuries and occupational traumas due to repetitive movements at different times. Now, with the daily use of the keyboard and mouse, tendinitis and tendonitis are becoming more frequent; the carpal tunnel, due to the posture of the hand on the keyboard, and the increasingly common tendon injuries, with the proliferation of online violence games. And among younger and younger people, even rizarthrosis proliferates, due to the devilish speed at which they write with the keyboard of their smartphones. The use of new technologies has multiplied the appearance of pathologies that were previously much less frequent or that appeared much later. Well, prevention campaigns on the use of new technologies seem to tiptoe over the possible effects of their abuse on the hands. Elaborating a little on the idea of undervaluation that we mentioned before... Well, big mistake. In any emergency department, and even in any consultation of Family Medicine or Occupational Medicine, the hand represents about 30% of consultations, and many of them related not only to trauma, but to the misuse or overuse of those hands, both at work, sports or at home. Hence the importance of prevention and citizenship education campaigns, and hence, again, the importance of the Secma, which can do a fundamental job in these education and prevention campaigns. I know it's an extreme case, but professional e-sports players can add up to 10,000 clicks mouse in an online match. That, repeated day after day, doesn't sound very healthy for hand health. No doubt. Any repetitive act, without control and, moreover, with such high precision and speed can result in serious injuries. Over time, the tendon can become inflamed, thicker and can dilate the entire digital channel, so that the movement is even less precise, because the pulleys themselves can also be affected. And so, 25,000 more things that can happen. What we have said before: new technologies and new online sports bring with them a hyperactivity in the hand that did not exist before and that, sooner or later, will take their toll. So many clicks in such a short time and so continuously is very likely to give rise to a process of any kind, as it is not good to be pressing the mobile all day with your thumb. The million-dollar question: is elite sport bad for hand health? Sport is bad for patients and good for surgeons [laughs]. No, seriously: there are, in fact, many injuries associated with the practice of sport, and not only in the elite, but at all levels. Whenever we think of sports injuries, we think of the big figures, but the problems usually start in the lower categories, and among younger and younger people. There are young people who coach football three or four times a week; tennis and paddle tennis, practically every day; To handball and basketball, day yes, day no... And all that implies many injuries, which can mark their evolution as athletes, but also their daily lives, and even limit their professional career. We need to get closer and closer to sports federations and societies directly related to the hand to foster synergies, prevent injuries and help those boys and girls avoid having more significant injuries in the future. Tennis will be the big bogeyman for a hand surgeon, right? Well, look, lately we have many, many injuries with the paddle. There are many tennis players who have migrated to paddle tennis, which is not a sport as easy as it seems and that, for the hand, is an even greater challenge than tennis itself. That is why it is essential to re-educate these recycled tennis players, and I am not only talking about young people, but athletes with a lot of experience in tennis. Now you sell yourself a little. Don't you think that every elite athlete who practices a discipline directly related to the hand should have a family hand surgeon? I do not know if it is a bedside, as you say, but I know that all elite Spanish athletes who have had, or have, a hand problem have been treated by surgeons of the first line. Having said that, I also tell you that prevention has not existed. Traditionally, the physical trainer, physiotherapist or occupational therapist has been trusted more than a specialist. Obviously, an athlete, no matter how elite he is, cannot have at his service a specialist in each area, but in the case of hand sports it would be convenient not to resort to the specialist only when the injuries appear, but that the contact was habitual, to explain how to take care of yourself and how to prevent the injury before that.and intervention is needed. You say that sports injuries occur at younger and younger ages. Carlos Alcaraz, 19 years old, 6 major injuries in a year and a half. Do not tell me that this is normal, no matter how high the demand to which you are subjected. Yes and no, and let me explain. Carlos has around him an exceptional medical team, which is very much on top of him, but the problem is that the sporting demand and his schedule of commitments are very demanding. He and any top-notch figure. There is an obvious dissonance between medical health and sports commitments. Many times, the difference between a top-level athlete and another is not technical, because they all have a comparable technical level, but lies in their capacity for suffering. If an international sports figure is characterized by something, it is precisely by his capacity for suffering, and many go to the limit. Well, that, and the demand to which, many times, their environment subjects them, right? Or self-demand, in many cases. We cannot lose sight of the fact that tennis players, no matter how elite they are, are autonomous, and have to continue working, and do it a lot and at a very high level of demand if they want to reach and stay at the top of the ranking. Thus, of course, it is very difficult to maintain a balance between activity, professional needs and the body's own biology. Returning to Alcaraz, I know that he is a person with an impressive physical capacity, who has a spectacular medical team and who will surely know how to stop in time to gather strength, because that team is advising him perfectly. Maybe I force him to get very wet, but maybe Rafa Nadal should have stopped earlier? His doctors probably told him to stop earlier and maybe he wasn't the one who didn't want to. Nadal is a superman, the perfect example of that brutal capacity for suffering that I spoke of before, and he also has an extraordinary medical team, which he carries very well. But if the athlete does not want to, it is very difficult to stop him, and Nadal has a very high level of demand with himself and with his country. How can you stop a torrent with Nadal's abilities, not only physical, but mental, heart and level of self-demand? I know that he is perfectly advised in everything related to his health, but it is Rafa who decides, ultimately, when and how. Beyond his obvious consideration as an elite athlete, 20 serious injuries throughout his career, including several inflammations in the hands, breaks in both wrists ... all that has to pass an inevitable bill in the future, right? Are we talking about possible lifelong sequelae? Unfortunately yes, because the overloads suffered by those knees, those hips, that foot, those wrists ..., and not only Rafa Nadal, but modern tennis itself, which has undergone a barbaric evolution: it has changed the way of grasping the racket, the way of playing itself, which is much more physical, more intense. Traditionally, there were two types of players, the technicians and the physicists, but today, all of them, combine both virtues, and that continuous intensity ends up paying in the form of injuries. Hence the enormous importance of good physical preparation and a medical environment with a preventivist vision. But that at all levels, right, since the depoRte base up to the elite? Yes, yes, of course, that's what I meant before with the importance of permanent medical supervision to protect children from the beginning. Nadal we have one, Alcaraz we have another, but, of course, we would like more to reach that level. How many athletes, no longer from Spain, but from all over the world, have improved the top 20 in recent years? Very few, because they do not arrive, arrive destroyed. Obviously, the technical demand they have is very high and, obviously, that will also be paid for in the future, with an overload, but, from the medical point of view, we have to help them so that they can arrive in the best possible conditions. I insist, however, that the balance between medicine and sport is very complicated. Benzema's bandaged hand has already become almost an icon of the player and of Real Madrid itself, but the fact is that he has been wearing that bandage for more than 4 years. Or is that injury eternal or did it heal badly at the time and now it has become chronic? Benzema's case is a paradigmatic example of the difficult balance that I previously told him between the sporting needs of a club and the biology of the person. There was a certain moment when he could not be treated surgically, which could have solved or not his pathology, and a conservative treatment was chosen. The final treatment may have been delayed excessively, but, obviously, it has not gone badly, because, despite the bandage, he has performed well professionally, he has won the Ballon d'Or and the Champions League. And the bandage itself has become, in effect, a kind of talisman for the player and almost an icon for the Champions League. It is evident that Benzema's injury is not approached in the same way in an outfield player as in a goalkeeper, who, practically without any doubt, would have needed an urgent operation. I never tire of repeating the same thing: in elite sport you have to make a good balance between injury and sports needs of the professional. As much as a striker does not score goals with his hand, I do not know if the decision of the club or of Benzema himself would have been different if the injured member was someone else. Doesn't this abound a little in the idea we mentioned earlier about the relative undervaluation of the hand? This is like everything, a matter of balance and the circumstances of each one. Imagine the impact a hand, wrist or finger injury has on a pianist; What not to say about a painter or a professional who makes precision techniques: a simple finger can lead to a permanent work disability. In short, each hand is different and the needs, circumstances and specific situation of each patient are also different. What I always tell my residents is that it does not matter if the patient comes with a minor injury or another that requires microsurgery and transposes, for example, a toe to the hand; Whatever you do, you have to do it well, from the simplest to the most complex, and always think about what each patient needs, be it little or a lot. Family Medicine often says that what is not known is not chosen, and that its specialty should have more presence in the university. Does hand surgery have enough presence in the early formative stages of the doctor to instill the bug for it? Well, look, I'm an associate professor [at San Pablo CEU University] And, within the subject, we have several topics related to hand pathology. He would be struck by the number of students who approach you later, ask you questions and are interested in the subject, among other things, because they did not think that the hand was so important, nor that everything related to it, from the medical point of view, could be so beautiful. In fact, we have some residents who have been specifically trained in Orthopedic Surgery because he discovered the hand and liked it a lot. We also talk about a pathology that involves direct contact, a closeness with the patient, who ends up opening up and confiding his concerns to you. In the case of MIRs, there is also the handicap that not all hospitals offer specific rotations in hand surgery... More and more hospitals have specific hand units, but it is true that there are still not all of them. During residency, training is mandatory in all areas and many residents who do not have powerful hand units in their centers, or who do not have them at all, seek this rotation in other hospitals. Almost all hand surgeons in Spain have residents who come from very different hospitals to train specifically in hand or to improve their knowledge in it. So there is interest, and growing. In fact, the latest requests for new Secma members have been from residents with an interest in hand surgery.

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