Chuck and Chris catch up before and after some major travel and then dive into the impact of patient age on treatment decisions. We use scaphoid fractures and cubital tunnel as the basis of this discussion. Do we make inappropriate assumptions about young patients' healing abilities? And when we operate, do we treat patients differently- what's the evidence?
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Chuck and Chris catch up before and after some major travel and then dive into the impact of patient age on treatment decisions. We use scaphoid fractures and cubital tunnel as the basis of this discussion. Do we make inappropriate assumptions about young patients' healing abilities? And when we operate, do we treat patients differently- what's the evidence?
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
Please complete NEW Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Welcome to the Upper Hand Podcast where Chuck and Chris talk Hand Surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe, wherever you get your podcasts.
Chris Dy:And thank you in advance for leaving a review and leaving a rating wherever you get your podcast.
Charles Goldfarb:Oh, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm fantastic. We're back at it.
Chris Dy:We are and it's a lovely, it's been a lovely week in St. Louis. I know that we keep keep saying that on the air. And who probably wouldn't tell people if the weather was awful, but it's been really good. And, you know, I actually have found a new way to unwind at the end of the day,
Charles Goldfarb:I want to hear it. You mean not cooking, or
Chris Dy:this is this is after the cooking, because we did some incredible weeknight meals this week. But getting in the pool after the kids are in bed, like putting on some music just getting in the pool and just kind of sitting there because then I can't be doing anything else. And it even just like 20 minutes has been very therapeutic. He did your pool is heated pool as well, for sure it's heated because my wife and my wife won't get in even if the pool is a toasty, like 87 If it's like below 80 outside, like she's like it's just too cold. That's why I gotta get in the pool.
Charles Goldfarb:I'm with her. But kids have a remarkable ability to not be cold and water. So they don't care.
Chris Dy:But now they're impervious. But ya know, it's that's been really good. It's been a nice way. It's been a busy week. So
Charles Goldfarb:I'm, I'm a little embarrassed to say that I took advantage of the weather for the first time yesterday. And the reason I'm embarrassed is it's already the end of May. It's the first time I biked to work this year. But it was it was 60 when I rode in in the morning, and you know, the nice 80 or so on the way home Sunny, beautiful day the park was hopping. So it was awesome.
Chris Dy:Now, Chuck, I am so American that on the fly cannot convert that to Celsius for our international listeners. But that's a very pleasant, pleasant range of temperatures. Not too hot, not too cold. It's kind of kind of perfect. Yeah, I have this thing where like, just internally, if I know it's really nice outside, and if I don't get outside it for at least a little bit. I like guilt myself. I don't know. It's weird, but you know, because it's growing up in Florida. And then moving to New York. And then subsequently here, like I never had a true appreciation for seasons until you know, New York and now here because like New York and spring was glorious. August in New York was awful. St. Louis in the spring is glorious. August is pretty fast. It's a lewison time
Charles Goldfarb:there for all the listeners who do bike to work and maybe it's elective, maybe it's mandatory. There's nothing like it on the right day. It gets you going in the morning and gives you energy and then lets you as you said unwind at the end of the day. It's awesome. And I am going to get back into the groove.
Chris Dy:Nice. A friend of the pod Sam Moghateri over in DC he he posted some pictures of himself biking to work and his kiddo biking to school. I was like, that looks pretty cool.
Charles Goldfarb:So that's awesome. Hey, do we have any new reviews out there?
Chris Dy:We've got a couple of interesting emails. I had an email from a from a certified hand therapist in Iowa who was emailing me about a patient that she was referring, and her name is Michelle McMurray. And at the end of this email, she said on an outside note, I'm a huge fan of the podcast. I will admit I have been listening since the beginning. So Wow. Over three years. Thank you, and really appreciate what you're doing with this. I've listened to the podcasts over many long runs and feel like I've learned a lot of insight and information from both of you as well as your guests. I hope it continues. So thank you, Michelle for that.
Charles Goldfarb:Yeah. I think before we have a good topic to discuss, maybe we should thank our sponsors to start.
Chris Dy:Yes, the upper hand is sponsored by Practicelink.com, the most widely used physician job search and career advancement resource.
Charles Goldfarb:Becoming a physician is hard finding the right job doesn't have to be joined practice link for free today at www.practicelink.com/theupperhand, go see them. They do good stuff over practice, like
Chris Dy:Yeah, absolutely. I mean, it's, for a lot of people, the job search thing probably starts a little too late. I would encourage our listeners who are trainees, probably to start looking earlier than you think mainly to familiarize yourself with the process and the options. Yeah. You don't want to kind of freak yourself out by you know, looking too early and being too serious. But it's just good to know what what the process looks like.
Charles Goldfarb:I think that's great advice. And I would add that, you know, if you happen to know where you want to be when you're done with your training, and you can geographically geographically and in which you know there's pros and cons to that. But if you do know and potentially even know the practice, it's a huge advantage in fellowship because then you can tailor your fellowship to some degree based on the need he'd obviously want to keep your fellowship education broad based, but there are always choices and options to make. And that knowledge is helpful. So I think you know, it's not crazy to start thinking about this between your fourth and fifth years of residency, and then potentially reach out to Praxis again, if you know where you want to be. If you're flexible and open, then it's a very different search.
Chris Dy:Right, absolutely. And then I guess for those of you that listen, that are plastics, trainees, push that back by a year. Sorry. But you know, it doesn't. Yeah, you got to be inclusive.
Charles Goldfarb:Yes, so you are about to embark on quite a journey. And I've recently had two great trips, you want to tell us where you're headed. And this, this episode will drop after you're back. But I think it's the anticipation of the trip is pretty fun.
Chris Dy:Yeah, it's really great. So going to the the APFSSH trip. So it's the basically the Asian collaboration of hand societies there, which is going to be in Singapore, their for their, for their Congress this year. Super excited about that, I think that, you know, there's going to be some really interesting talks, I was just looking at the at the program, kind of circling the stuff that I wanted to go to, I'm going to share some thoughts on radial nerve reconstruction, which is going to be fun, and we're gonna, we're gonna have a small live event for the upper hand, which you may hopefully be able to join us for Chuck. Well, it's mostly,
Charles Goldfarb:it's on my calendar for this for central time in the US for this Thursday night. 11:30pm. I'm going to hopefully be watching basketball. And before I go to bed, I will, you know, have a chat with you from across the world. And we have a special guest. And I'm going to try to get that episode edited quickly and get that to drop outside of our usual sequence.
Chris Dy:That's awesome. So hopefully it works out if you're listening to the if you listen to the next episode after this one, and it's not a live interview from Singapore that you know that technically it didn't work out. Yeah, so yeah.
Charles Goldfarb:So I have to admit that the meeting was not really on my radar. But I've been traveling, and I'll give you a brief summary of my travels, and it. A lot of people that I interacted with would go into this meeting. And it's a little, you know, US centric not to be aware of this meeting, and I hope to potentially participate in the future. So I was in Israel for a week for the joint Israeli us hands Society meeting, which was the first one since 1979. It was fantastic. Both the educational content, the collegiality, which was really fun. And you know, seeing Israel for the first time with his historical sites in Jerusalem, and its modern sites, and Tel Aviv and the Dead Sea, really a great trip, but several are more than several people. Were talking about this upcoming meeting. And there was some podcast love, which was fun to fund to be a part of in in Tel Aviv.
Chris Dy:That's great. That's such a fun opportunity and incredible opportunities. I mean, culturally, I think that's a it's probably once in a lifetime, you get to do that. So you know, I that's a great year, we'll do it. Yeah, I remember going to conference that morning and realizing that half of the hand service was in Israel. The rest of us held it down.
Charles Goldfarb:It was Marty Boyer's idea. And David Brogan and myself, joined along with, I don't know, maybe there was 12 or 15 other hand surgeons from the US. So really, really remarkable. And I came back and work for a week, of course, had some flight issues. So it was late to clinic on Monday morning, but didn't make it and then worked for a week and then headed off to Minneapolis for the 2021 Delayed COVID Delayed world congenital Symposium on upper extremity malformations which we renamed, because malformations is, you know, suggest bad formation, and apparently that can be bothersome or even offensive. And so we're renaming it but that stuff aside what a meeting it was incredible. I was really proud of kind of what we put together and, and the speakers were remarkable. There were about 300 attendees from across the world. majority were surgeons, we had a great therapist showing with a therapy free course, organised by Amy Lake from Dallas. So this this meeting, Ann VanHeest was the local host and certainly the co- organizer with myself and Michelle James, and really, really great and I learned a lot I had a lot of fun. A lot of people were headed over to Singapore right after this meeting after that meeting. So it was it was really fun. I'm happy it's over. But happy we pulled it off.
Chris Dy:By all accounts, both talking to people and then seeing things on social media a resounding success. So no big tip of the cap, as we say over here to to you and Michelle and Anne for pulling off an amazing meeting, everybody was raving about it.
Charles Goldfarb:Thank you. Well, I must agree. I will say, Chris, that there was a little podcast love and a little podcast frustration from that crowd, that there wasn't more congenital discussion. And I tried to explain that. Yes, some would be good. But I struggle with making sure we keep this podcast interested, you know, interesting to as many people as possible.
Chris Dy:Well, I mean, I know that there has been some interest in congenital so I got an email from a from a colleague, I have yet to physically meet in person from the Philippines. And he was telling me that he sent a selfie with you and him and said, I told Chuck that we need more congenital and I said, you know, what, if you want this podcast to continue to be a two way street, we can't do too much congenital, or we can have somebody else on and I can fade to black and that's okay with me. Yeah,
Charles Goldfarb:we'll figure out a way to squeeze some in. But we are going to sort of touch on my population. Let's talk a little about about the impact of age and pathology and surgical decision making.
Chris Dy:Yeah, no, I think that's a super interesting comment. actually have an anecdote that made me think about that. I saw a patient in clinic at some point recently put it that way. Who had a at this point in display, scaphoid fracture skateboard race fracture, but it had been missed for about a month had seen an outside hand surgeon, the old outside surgeon, and not to be named he initially
Charles Goldfarb:that outside certainly
Chris Dy:a small, a small aside, and I may have told this already on the podcast many episodes ago, but when I was in, when I was in residency, we talked before about how my training, Lee had to make a lot of PowerPoints for conference for peds conference. And so I'm just sitting there just slogging through these PowerPoints and a medical student is there helping me and the medical scenes like, where is this? OSH where is this? They seem to spend a lot of patients that you. For those of you that aren't familiar that is outside hospital. But anyway, so this outside surgeon took x rays, initially, apparently the X rays were negative, but the patient continue that pain. So I found a way to our injury clinic. And then our Injury Clinic provider asked me to see the patient because at that point, our x ray showed that she had a display scaphoid fracture, teenager High School Volleyball player about to enter club volleyball. The initial the X rays that we had showed some displacement, but it was kind of like gay might be okay, I hit this kind of gets into the what are your preferences in terms of return to activities? Age? So how would you kind of handle that situation with a teenager who's in volleyball player, say borderline displacement, versus somebody who I don't know, say they're strapping 39 year old hand surgeon, you know, or 39 year old who was not a hand surgeon? You know, how would you handle that discussion?
Charles Goldfarb:It's funny, my one of my talks in Israel was on the adolescent scaphoid fracture. And I think
Chris Dy:I heard it was that heard? That was an incredible talk that generated a ton of discussion,
Charles Goldfarb:it was surprisingly generated a ton of discussion. But I think the interesting factor is that we, you know, what you don't want to do in certain conditions is give kids too much of the benefit of the doubt, meaning, oh, there kid, there'll be fine. And I think we do that all of us do that all of us are guilty of that. And so I've just shared a brief protocol, which is not the point of the podcast. But basically, if there's suspicion in the emergency room or urgent care, hopefully, they're immobilized. And I do it in a way that is not removable. They hopefully come back in two weeks for repeat X ray and repeat exam, if X rays normal exam was normal, move on, let them ramp up. If exam is painful, X rays are normal, then you have a choice, either put them in a cast, or you get advanced imaging. But I think the mistake we sometimes making kids is assuming that the X rays, okay, two weeks, they're fine. But as your case I presume that got that about, right? If your case is any indicator, that's not what happens. And there can be a fracture and it displaces with activity. And if it's displaced on X ray is displaced. And so you could get a CT scan. In fact, that probably would unless you're just deciding to go to surgery, of course, you know, we know there's always a little resorption as the healing starts, so that can make displacement look a little worse. But, you know, for me, I would either go to the ER or if there's any doubt about whether I had to get a good a CT scan.
Chris Dy:So first off for your algorithm is that for kind of radial side of wrist pain, and snuffbox tenderness in an adolescent. Yes. Thank
Charles Goldfarb:you for clarifying. Okay,
Chris Dy:and then when you say the exam over time, is that point tenderness over the snapdocs?
Charles Goldfarb:Yeah, because I think as you and I both know, you know, yes, if there's pain radially over the snap box, that's concerning, and it has to be asymmetrical pain, right? Because there's it's just a little bit of a sore spot to push, but that pain goes away. And scaphoid nonunions how and the pain may not be there six weeks or eight weeks or 10 weeks. And so you have to have a threshold to make sure you don't miss it.
Chris Dy:Man, I had some good training, because what you just described is exactly what I did. It's actually pushed on both snuff boxes. And for those of you, I don't know, do they still call it the anatomic snuff box and med school? I mean, because who's who's putting snuff in a snuff box? I don't know. I mean, I can't What are we in? plantation south? Yeah.
Charles Goldfarb:Good point.
Chris Dy:But so, you know, I pushed on both snuff boxes and said, This must feel different than the other side? And, you know, is it worse? And if the answer is yes, and we had the discussion, and, you know, in terms of age, because this patient really wanted to get back to volleyball, and he initially kind of said, look, I think this is displaced. But I think the best way to really quantify that and really objectively look at it would be a CT scan. You know, but again, if you, you know, I gave you the option, like, if you want to just go to surgery, we can go to surgery, because that would I think address your, your desire to get back to stuff sooner. And so, the initial plan was then to hold off on the CT, because it wasn't going to change my surgical decision making and proceed to the surgery is that pretty much if you were decided, like maybe we could treat this non operatively? Would you get the CT? And then if it was like, you know, clearly displaced on a CT, would you recommend surgery at that point, or push it a little bit not push it? But, you know, kind of steer the patient in that way?
Charles Goldfarb:Yes. So I think that, you know, I get CT scans for two reasons. One, to plan surgery, like if I really just need to better understand morphology, for example, I had a four year old now Union, in a teenager, I needed to understand the morphologic changes in the skateboard before I went to the board, that was helpful. And then sometimes I'll get it to help with the surgical decision making. But let's be honest, if a fracture looks displaced on X ray, it's only going to look more displaced on CT scan. So that could, you know, increase your your surgical indications, I doubt is going to decrease it.
Chris Dy:What are your indications? How much displacement is enough displacement, where you're gonna say you're gonna recommend surgery? And does that threshold change? Does that threshold change with with different ages, because I remember in in training, the least, the pendulum was very much in the operative camp for skateboards when I was a resident. And we would joke that, you know, there was millimeter to displacement, that that that was called to the or at least in the Upper East Side?
Charles Goldfarb:Well, I think a millimeter is my threshold, honestly. And I do think I probably have a little bit more tolerance in a kid than in a, an old person like me, but not much, it's not much different. Even
Chris Dy:how accurately, can you tell a millimeter on an x row on
Charles Goldfarb:an x ray? No. Totally fair. That's it. But if it's displaced on X ray, especially for the acute, you know, the X ray is taken in the acute phase, if it's displacement x ray is displaced, pick on a period in that story. For me, the question for me in the adolescent is what do you do with a proximal pole, like, let's say it's not super proximal, but kind of the proximal third, middle third junction, and you give those a chance to heal without going to surgery and an adolescent? And here's, here's my personal story is that my nephew lives in Denver, and I asked him to see Lou Catalano. I thought for sure, Luke, he had that fracture, I thought for sure Lou was going to recommend surgery. He said that let's give this a chance to heal Napoli. My nephew's very active. But he was okay with that. And sure enough, eight weeks later, by CT scan, it was healing probably took about 10 weeks to totally heal, but it healed. So you don't think we have to need your crush the or in proximal polls in the adolescent? And maybe we can be a little more conservative than with the adult. But I don't know. What do you think?
Chris Dy:I agree. I mean, I think that, you know, the calculus and the conversation changes in terms of how you counsel patients based on middle third versus proximal third. But I guess you have to, it really is filling out the patient and their their timeframe. I do tell people, just anecdotally, for scaffolds tend to 12 weeks if treated in non operatively in the cast in terms of healing, and earlier with surgery, but it's not like it's saving you tons of time. I mean, it's giving you a little more confidence that you can get back to stuff sooner if you've got a screw in addition to at least 50% bone healing as we've talked about in prior episodes. I guess for you like let me let me put the question a different way so you keep dodging me. So two millimeter displaced 15 year old high school athlete versus two millimeters displaced 35 year old desk warrior versus 55 year old.
Charles Goldfarb:I'm not 55.
Chris Dy:I'm not and I'm not 35. So yeah, how would you treat 15, 35, 55
Charles Goldfarb:all get surgery. It was two millimeters of displacement. I think if it's like maybe a little less than a millimeter, then maybe the adolescent gets a trial if they want of non operative care. But the other two gets harder.
Chris Dy:Okay. Very, very helpful to know. Because I think that, you know, I would probably have a discussion with each of the groups, I probably would not, for the 55 year old executive, I would have a lower threshold to proceed with non operative treatment with obviously, casting, not removal race. You know, because I think that there's a chance that that patient probably doesn't need to get back to stuff sooner rather than later. And again, I don't want to be ageist. But you also, you have to have a conversation about quickly. People want to get back because I fix a disgrace, and a 75 year old person who really wanted to play pickleball
Charles Goldfarb:Pickleball is important. I guess the thing is, hats are not fun to wear. And one of my biggest challenges in practice in general, not just with scaphoid is the idea of treating someone non surgically with the risk that they might then need surgery. And if you do that in a 15 year old, or maybe even a 55 year old and say, Okay, we're going to put you in a cast for six or eight weeks. And hopefully he'll if you don't we'll do surgery, then. That's like, to me, that's terrible. Not terrible care, because it just happens sometimes. But it's got to be terribly frustrating to hear that's a possibility as a patient.
Chris Dy:Well, yeah. So I think that that's something that I did not appreciate until I came into practice. And I see that nerve trainees, and this has nothing against them. I think it's just the the lack of kind of real world experience, because then they say, Well, why are you treating this? Why are we even thinking about treating this non operatively? All you lose this time? And I'm like, Well, time actually is quite important because of the scenario you just described. If somebody is expecting to want to get back to stuff as soon as they can, and you give them this, perhaps inflated sense that this is going to be okay without surgery, and then it displaces or it doesn't heal, and then they end up losing two to four weeks or six weeks or eight weeks, which is a valuable chunk of time in somebody's life. I mean, killing surgery, in some ways sometimes allows people to start that recovery process earlier and allows them to move on.
Charles Goldfarb:Absolutely. Can we can we do another age related case?
Chris Dy:Yeah, why don't you toss another one out, or I kind of steer that conversation. So let's take
Charles Goldfarb:a 15 year old, right hand dominant baseball player who comes in after being referred from an outside institution. Patient has medial elbow pain. He has numbness and tingling which comes and goes and the ringing long finger. He has negative nerve studies. And he's here to see you. And they said the other doctor didn't think surgery made a lot of sense, given that the nurseries were negative. But he's you know, having some trouble with baseball, he doesn't really have trouble with daily activities, because the numbness really does come and go. And I can I can give you one more exam Pearl, if you want. Or you can tell me how you would approach this kid and we'll get to the same endpoint.
Chris Dy:What position?
Charles Goldfarb:He plays outfield.
Chris Dy:Okay. All right. And then I think that where you're leading me is the stability or lack of stability of the ulnar nerve.
Charles Goldfarb:Yeah, I would tell you two things. Number one is UCL is intact, which I you know, I wasn't you don't really worry, but it's our obligation to make sure it's okay. And then I think that's the most important point is examining the stability of the nerve. And sometimes as obvious clinically, sometimes someone like you with an additional skill set can use an ultrasound to understand, but in this adolescent population, I think it's usually pretty obvious if the nervous, symptomatic and unstable. And that was this kid situation. So now you have this 15 year old, who has done non no non operative care as an unstable and symptomatic or what do you do?
Chris Dy:Well, hold on before I want to take a little detour, which I can't believe I'm asking the sports related question but in an non pitcher, but an outfielder who asked to throw how important is the UCL
Charles Goldfarb:the way I think about it, and there may be listeners who have more knowledge than I. The way obviously pitchers are pitchers and they need to UCL shortstop and third base really throw high velocity regularly. The positions that might be considered more guarded certainly first base as a lot less throwing. Second base still throws a fair amount and the outfielders throw irregularly but are required to really put a lot of velocity on the ball so outfields a little safer and less demanding than the other positions except for first base but I think still demanding and I think it could be a problem. Catcher. catcher, I would put it in the same category as not quite pitcher but probably a little more than, than shortstop and third base, just given the intermittent velocity needs.
Chris Dy:Good. So my detour here has been we've immediately lost all international listeners because nobody cares about baseball anymore.
Charles Goldfarb:Separate our Japanese colleagues and even it's right it's interesting. There's some baseball in it. Drill I learned,
Chris Dy:I'm sure I'm sure there is some. Yeah, we're not talking about the footy or anything. So I'm sorry, can you can you tell me how you examined stability of the ulnar nerve, because I thought I was doing it correctly for a while. And then I really went back and read the paper that describes the instability. And I changed how I examined because I wanted to follow what that paper described.
Charles Goldfarb:Well, this is super interesting. And obviously, I'd love to hear your take. And the way we described in the paper, we wrote, this is sort of pre ultrasound. When we did a basically an interesting idea, we tried to look at asymptomatic pediatric and adolescent patients and a large number. And these were essentially siblings
Chris Dy:of patients that it's just like the waiting room of the shrine. Yeah, yeah, exactly,
Charles Goldfarb:exactly. And so the way I do it still, to this day, I kind of became more comfortable with it was, first of all, just put my my index and middle finger on the learner, and just gently move the elbow that easily doesn't help too much. And then what I do is I flex the elbow passively maximally, and I put my fingers on the posterior aspect of the medial epic condyle. And one of one of a couple of things that will exist one, the nerves behind my fingers, ie sitting in the groove, to the nerves clearly in front of my fingers, which means subluxated, or three, it's under my fingers, which means perched. And so you still may not know that, but then as you go to straighten the elbow, that nerve will want to fall back into the groove. It's anterior. And so to me, that's, that gives me the most insight. Obviously, it varies based on body habitus, but it's, it's pretty reliable, at least without the ultrasound, how do you clinically examined?
Chris Dy:No, I think that I love that I love your description of it, and kind of how you've broken that down for subluxation versus dislocation versus a stable situation. I tell our trainees that you you know with elbow maximum flexion, you are trying to push that nerve out of the group, okay. And if you can't push it out of the groove, then that's obviously a stable nerve. If there's a little play and a little bit motion, you get into this, the situation's you described, but as you ask the patient to extend the elbow, you're trying to keep that nerve subluxated, you're dislocated. And if you can keep the nerve pinned anterior, then that's obviously a you know, dislocated, and quite an unstable nerve, if it kind of has some play, and it's moving back and forth a little bit and trying to get back in the groove that is your purchasing or subluxated situation. But I actually I don't think that's talked about enough how to properly examine for stability of the ulnar nerve when you don't have an ultrasound, etc. So i That's why I took a little second detour on this not dodging your case, but I promise,
Charles Goldfarb:what I want to kind of present to, you know, scenarios with this. So the first is this scenario that I presented, unstable nerve, electro diagnostically negative, intermittent symptoms, do you offer this patient, non operative? Pair? If so, what does it look like? And if you do or don't, then you consider surgery, what are the surgical surgical options look like?
Chris Dy:I think you offer them non operative care, but they've probably already tried it, or they're not going to be into it. So if you, you know, night, splinting is something that is going to help quiet a nerve, but it's not going to change how the nerve behaves during the activities that they want to participate in. So you know, if you tell them to modify their activities, then if they can do it and take rest, from throwing, then great. But if this is something that they're going to continue to want to do, and you can give them something to help them do that, and they have the time to recover from the surgery, then I think it's very reasonable to offer them surgery. How do you approach it?
Charles Goldfarb:Well, I have two questions, which really makes me smile, because when I was at one of these meetings, someone came up to me and goes, Chuck, I have two questions for you. And I didn't immediately know they were two things. So my first question is, when you examine the other side, do you typically find an unstable nerve? If the symptomatic side is unstable? Do you agree that the contralateral side is also typically unstable?
Chris Dy:I honestly I don't often examine the other side unless they're having symptoms. But I know that the paper you guys wrote showed that there's a subset of patients who have bilateral instability and that's kind of how they're built. Bob Hotchkiss used to say that the ulnar nerve is a design flaw from the Creator, God, whatever your beliefs are. But because that just a third of the population tends to have at least instability on one side. So I don't always examine the other side.
Charles Goldfarb:Yeah, my experience well, that's fair enough, but my experience is yes, they are generally unstable on the other side, also, but asymptomatic and then you have the discussion with the family once a nerve becomes symptomatic, unless you modify your activities. You won't give it a chance to calm down. My other question is any role for therapy? Nerve glides? I never know when to ask for that. It seems to me sometimes if there's multiple levels involved in the cervical spine, you know, sometimes nerve glides, makes sense. Why would nerve guys be appropriate or therapy be appropriate in this patient?
Chris Dy:I don't think nerve glides would help. I think it's probably looking more at mechanics and the potential involvement of something like TOS. If you've got some overlay of TOS, on top of the irritable, unstable ulnar nerve with throwing, if there are some things that could be improved mechanic wise with throwing, then perhaps there's a way to, to address this without surgery. But if it really is localizing to the unstable ulnar nerve at the elbow being irritated with throwing motion, and there isn't a whole lot else going on, I don't think therapy is it would be very helpful. Although I would welcome any of our therapy colleagues who are listening to please let us know if you've got some some tricks in your bag, because that would obviously help us because if we can avoid surgery be great.
Charles Goldfarb:I think you asked me a question before I went off on a tangent, but I don't remember what it was. But surgery, and what are you offering?
Chris Dy:Yeah, I mean, you can talk more about this tonight. Because I mean, you wrote the paper, you know, in terms of, you know, doing decompressions versus transpositions. In this particular population. You know, it was a retrospective study. And, you know, methodologically had some, you know, shortcomings, but I think it was a very helpful paper in terms of understanding, you know, that patients who only have insight to decompressions in this age group with this, you know, athletic demand, don't do predictably. Well,
Charles Goldfarb:I think that's well said,
Chris Dy:I don't Is that a fair assessment of your paper.
Charles Goldfarb:That's a fair assessment. So this patient's unstable. So we're going to transpose this patient right. Now, I like your point, because I was going to raise the same point. So we're going to transpose this patient for me, I really, really, really want to do a subcutaneous transposition, not a sub muscular in this patient. Fortunately, almost all adolescents do great with that option. So that, to me, is a good reliable result, I've gotten really much more aggressive in their rehab, I stopped dressing after surgery, sling for a couple of weeks, get their motion back. And then at five or six weeks, they are almost all doing well. And I rapidly progressive so that by seven or eight weeks, they're back in their sport, which felt, you know, feels aggressive to me, maybe listeners like Oh, I do that all the time. But for initially, I was 10 or 12 weeks before I let them get back to really throwing activity. So been happy with an aggressive postdoc protocol?
Chris Dy:Do you? I know that you've adopted kind of that adipofascial kind of broad barrier for the nerve and keeping it to the front. Do you do that also for this population? Or do you do a kind of the fascial sling that is more classically described? And does your rehab change based on which which type of transposition you do? subcutaneously I still
Charles Goldfarb:like adipofascial flap so to speak, when at all possible occasional have a really thin adolescent especially like a volleyball player, then you really worry is that repetitive trauma is subcutaneous the right move. I still think it is the right move. But you know, if they don't have good subcutaneous tissue, then the Eaton fascial sling might make sense. But I just like it less and less than like this adiofascial flap flap more and more.
Chris Dy:Does the rehab vary based on you know, because you're kind of sewing fat to sub q in some points for that added professional? So does that, you know, do you find that to be less sturdy, or?
Charles Goldfarb:I think the adipofascial flap is better. I think it heals more rapidly. And I think it just feels I feel more comfortable with it, but fundamentally it only to react changes. And then getting back to your question. I no longer do decompressions and adolescent population. So if this patient were symptomatic, but stable, I would still transpose them. I just think there's something about this age group, that makes me far less confident of a successful outcome with decompression. And we know that with decompression, you know, in the older patients, it can work really well. But we know we have to revise a decompression and from Ryan cowpeas work, then the results are going to be less optimal.
Chris Dy:Right. So what when's the inflection point on age when a young adolescent gets into what age then they become more of a candidate for a decompression alone? If they have a stable nerve on exam and on ultrasound?
Charles Goldfarb:Yeah, essentially, I don't know what your sense is. There definitely is this bimodal age distribution, but in my population, I see this and in adolescents with, you know, seriously, you know, sports related, then I tend to start seeing it in the 35 Plus aged population. I don't know that I see a lot of 20 to 30 year olds or 20 to 35 year olds with this, of course, we see some but I would say in that adolescent population, it's just one treatment. And then I consider decompression in older patients. And as we've talked about, my use of the decompression option has declined over time. I don't do it very often, to be the perfect patient. Do you agree with
Chris Dy:kind of as you Yeah, I agree with that. I mean, as you get into the mid 30s, that's when you start to think more about decompression alone. As an end. Does that change to that shift back towards transpositions in say, 55, 65 70 year old patients Yeah, with
Charles Goldfarb:more definitive considerations and possible sub muscular as well.
Chris Dy:Okay, and is that the based on the status of the ulnar nerve in terms of, you know, is it if there's advanced clinical findings in terms of, you know, atrophy or weakness or anything like that like to see you have a healthy nerve still on a nerve study, and it's stable in a, you know, 55 year old
Charles Goldfarb:decompress. What about you?
Chris Dy:Yeah, same thing. I mean, I actually don't think this, aside from the caveat of the adolescence kind of athlete, I don't think that the decision making for me changes a whole lot based on age. So it's not not like the skateboard.
Charles Goldfarb:Oh, interesting. I think we probably could have a part two of this sometime about some age related decision making, but I like this. We got a little sports. We got a little nerve. Hopefully we satisfied some of our listeners.
Chris Dy:You can continue your ages trends.
Charles Goldfarb:So yeah. All right. Well, you're on call this weekend. So go get them.
Chris Dy:Oh, yes. So excited. Good people of St. Louis. Have a wonderful weekend. You
Charles Goldfarb:have a great trip. Thanks. Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@Handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is @congenitalhand.
Chris Dy:What about you? Mine is @ChrisDyMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out. Special thanks
Charles Goldfarb:to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time