Chuck and Chris spend a few minutes catching up before taking a deep dive into the assessment and care of the scaphoid nonunion. We discuss general approach before discussing the technical details of fixation.
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Chuck and Chris spend a few minutes catching up before taking a deep dive into the assessment and care of the scaphoid nonunion. We discuss general approach before discussing the technical details of fixation.
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 podcasts.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm good. I feel like you and I we've seen each other a bit lately, but not in the confines of our own homes and during a podcast taping,
Chris Dy:yeah, we've had a fair bit of interaction. It's that kind of year. I mean, that time of the year where, you know, graduation season, you know, all the all the fun memories and the the welcome wings and goodbyes are in the air.
Charles Goldfarb:Absolutely. We had a wonderful graduation ceremony and graduation speaker, Val Lewis from MD Anderson came up to spend the really the weekend with us. And she was wonderful as a speaker and was there for our graduation ceremonies last night, at which time you were awarded quite a special award.
Chris Dy:It was a it was quite surprising, to be honest with you. I don't know a terrible amount about the award, except I know that there are some great people that I admire tremendously who have received it in the past but it's the I don't know if I'm gonna say this properly. But the Palma Chrironis.
Charles Goldfarb:I've always said Palma Chrironis. But basically it's yeah, it's basically Teacher of the Year in the sense of it. And that's, that's a simplistic way of saying it, but get faculty member with the greatest impact on the education of the chiefs. And it is it's a really, it really is a great honor. So that's awesome.
Chris Dy:Things that I learned in being awarded is apparently I sigh quite a bit. And I also make our trainees, especially this class of chiefs apparently draw the brachial plexus. So I think that two of my mentors, Marty Boyer and Scott wolf have had a an outsize impact on how I educate in terms of sighing and dropping the brachial plexus.
Charles Goldfarb:Marty is the king of the sigh and Scott must be the king of the drawing of the brachial plexus. But that is very funny. And it absolutely was cited in your award recognition speech. You've been traveling. Where have you been lately?
Chris Dy:Well, we you heard we did the Live episode from Singapore and, and then we I was at the AOA, the American orthopedic Association meeting in Salt Lake City in which you as the Program Chair put together a fantastic program. So I was just about to ask you to tell us about that experience and congratulate you, you know, by all accounts, just like the congenital meeting that you put together with, with Anne Van Heest and, and Michelle, this was also a great success.
Charles Goldfarb:Yeah, it's great that it's over. I think it was I was pleased with the meeting. And we had some great content. I will say that, for me, the highlight was, you know, for those who aren't aware, Preston Phillips was killed in clinic a little more than a year ago in Tulsa, Oklahoma, Preston was an impactful, ala member, member of multiple different societies. African American orthopedic surgeon, of which there are far too few. And when he was shot in clinic and killed, it really was not that we needed a wake up, but a little bit of a wake up on the role of the orthopedic surgeon in advocacy around gun violence. And it is highly controversial. And there are plenty of members of the American Academy of Orthopedic surgeons who want nothing to do with this. And in fact, I think we should, quote unquote, stay in our lane. So anyways, as a result of that, we put a symposium on about gun violence, and it was really, really good. And Anna Miller from St. Louis really used the city of St. Louis and some of our challenges as a case study, which also was an impactful part of it. So I love that one. I love them all. But that symposium for me was perhaps most impactful.
Chris Dy:Yeah, it's it's very sad state of affairs in, in the US with regards to the epidemic of gun violence, and, you know, our listeners in us know that and those that are listening and have kind of viewed the US from outside clearly know that it's very different here than it is everywhere else in the world. That being said, you know, it is it is a huge problem. And, you know, I think that the challenges that we face is that, you know, orthopedic surgeons, traditionally both, you know, you know individually but also as as a group have shied away from this, you know, one of the issues to be very frank that I've had with working on advocacy through the through the AAOS which I've done in the past, as, you know, doing lobbying, doing Washington policy fellowship, being a Government Affairs Committee Chair for the hand society interacting with ALS is that they've really stayed away from this because they're the membership of the ALS has wanted to kind of stay in our lane. As a comparison, the American College of Surgeons has jumped in on this, which I do admire tremendously. So hopefully, there'll be, you know, a sea change. And, you know, obviously, the tragic events that happened to Dr. Phillips may be contributing to that change in opinion, but it's something that needs to be addressed. You know, we've done some research here, our lab has done some work on, you know, the epidemic of gun violence, especially during the pandemic. And I'm sure Anna showed some of those slides. And it's actually an area of research that we're looking into doing some grants and everything for looking at gun violence and how it relates to nerve injuries and upper extremity trauma in general. So, yeah, that was a very impactful symposium for sure. And I think it'll, you know, stimulated a lot of future discussion.
Charles Goldfarb:Yeah, well said and great AOA meeting, I was privileged to be Wayne Sebastiannelli's program chair and happy that it went. So well. I'll segue from that to saying that it's interesting, because, you know, when I was a resident all those years ago, yes, there were cars and much of our level one trauma center work was based around, you know, motor vehicle crashes, motorcycle, and occasionally other stuff. Certainly some gun violence, but not much. Today, I would say. While we still have those, thankfully, in a weird way, we have a lot of gun gunshot wounds to deal with as an orthopedic service. And we also have a lot of infections related to drug abuse. I was fortunate recently to be the graduation speaker for University of Florida. And we learned a little bit I learned a little bit about a new, I guess, drug combination, which is wreaking havoc, and I'm not sure if you've heard of this. It's a animal tranquilizer, known as it's called xylazine. And then affectionately is wrong word affectionately known as tranq. But tranq is mixed with Bentonville because fentanyl alone apparently does not give the desired high. Or maybe it's just a little different. So if you mix the two together, the high is different or better bits. Frank is unbelievably brutal on the extremities, and often leads to a ton of dead tissue and amputations. Have you had any experience with Trank?
Chris Dy:Not in any capacity? If you're wondering, but so no, I've only deal I've heard of this, just you know, kind of listening to the general news on podcasts and everything to it's terrible. You know, and it's, it's it. It's really sad that kind of we're going through this and you know, I think the the etiology of injuries has certainly changed from when you were a resident in the 90s to where we are now. I'm just going to put that out there you are resident in the 90s. The 90s. In practice longer, longer than most people who listen to this podcast have been alive. But yeah, it's it's it's awful. I think that you know, it's going to continue to change. I can't see things getting better appreciably, but we should probably talk about something a little more lighthearted on this podcast,
Charles Goldfarb:for sure. But I also think it's something we see. And yeah, I'm not looking to solve the drug epidemic and the gun violence epidemic today with you. So let's talk about something more fun. What do you got up your sleeve?
Chris Dy:Well, I will. So I'm going to I want to make this brief because we've got some good cases to talk about. We are currently in the midst in this household of planning, our first camping trip, and no my wife is not coming because she doesn't get down with that. So it is a father son trip, a couple of families. Dr. Wall's son and her husband are coming and he's got all the gear which is good, but I just want to put a quick plug out there. If anybody has any camping tips, please feel free to share them because we're about to embark on quite the adventure. Is this July 4 weekend camping trip though it's the weekend afterwards. Wow. So you are really
Charles Goldfarb:good. You have the father's on fishing trip with Dr. Berks. And now I assume Dr. Berkes is going to join for the campaign along with Dr. Wall's family. Wow. It's
Chris Dy:it's gonna be quite the quite the trip. I think that my son has been watching too much outdoor boys YouTube channel because he knows all the product, product blogs that they have. And he wants to go to Bass Pro and just go nuts. That is the most expensive camping trip in history. But if anybody has any tips, let us know. And then please feel free to email me directly with those. But we should probably shout out our sponsor practice link before we get in these cases.
Charles Goldfarb:The upper hand is sponsored by practice link.com The most widely used position job search and career advancement resource.
Chris Dy:Becoming a physician is hard finding the right job doesn't have to be joined practice link for free today at www dot practice length.com/the upper hand. Hey, Chris. Hey, Chuck,
Charles Goldfarb:do you have any reviews to share?
Chris Dy:I do actually. We have some great reviews to share. So we've had a couple that have come in recently, we are still at 4.9 out of five. So somebody gave us one star somebody gave us two stars. So we did more five star reviews to try and drag that average up. I don't know how the iTunes systems works in terms of rounding up. But we recently got one from skating lady that says five stars great for want to bch Ts. I'm an OT, practicing in hand upper extremity rehab, preparing for the CHT I really enjoy this podcast as it gives great insight and detail into the surgical procedures I treat. She appreciates how we have we respect and appreciate our our therapy colleagues. And so thank you skating lady for that review.
Charles Goldfarb:Yea, thank you so much. We are a little bit on a therapist hiatus, given the maternity leave of one of our our wonderful therapists, but we need to get back to it.
Chris Dy:We certainly do. I think that, you know those, those episodes are always big favorites. So I look forward to having having Macy come back on and maybe even some other therapists. So the last, the next review is from pod enthused five stars and says lovely for trainees. I'm a PGY2 in ortho hoping to be a hand surgeon. These episodes have been hugely helpful for the nuances of surgical techniques that there simply isn't enough time to discuss any or also enjoys our discussion about patient factors and indications. So thank you. Thank you to pot enthuse for listening and for leaving a review and make sure that you get on there and leave a review. You can even sneak a question for Chuck in there about all of his fancy athlete work and all that kind of thing.
Charles Goldfarb:Yes, please, please, please do. And we had a great email from one of our listeners, Joe Rosenbaum, who shared with us that he was thrilled to hear us discuss Israeli baseball because Joe, I guess, was professional, or semi professional. I don't want to offend them by the wrong terminology. But I'm impressed that he played that high level baseball. It wasn't in the United States.
Chris Dy:That was really impressive. You know, baseball is baseball is hard. I've learned. You know, I think I talked about this in one of the other podcasts when I was coached pitching for my son's first grade Baseball, baseball games. And I definitely, I definitely threw the ball in a manner in which there were some children that were hit. Now I spread it out among all of the children on our team that got beaned by the coach, but I have a greater appreciation for for baseball now.
Charles Goldfarb:Baseball is hard. There is no doubt. And baseball's better this year, it's the pace is faster. It's a little more exciting. So that's good news. All right. Should we talk about maybe talking about some current trends in orthopedics and medicine using some journal club articles to further discuss,
Chris Dy:yeah, we should do the journal club articles. I want to talk about a case because we haven't talked about a case in a while. And I think this one kind of piggybacks on our last discussion about age. So I've been following a patient for probably about three or four months now, who is you know, somewhere between 55 and 65. You know, and it's somebody who uses his hands quite a bit, a young man, a young a young strapping lad, thank you, non Medicare eligible. So under 65, but uses his hands quite a bit. And doesn't like to does it cannot stomach the thought of prolonged immobilization. So when I first meet him, he comes in and he had a fall into his wrist and has a skateboard waist fracture that is displaced but not severely angulated. You know, kind of well aligned, if you gave it a chance to heal in a cast, it probably would heal in the cast, and doesn't have any arthritic change or anything like that. So it's a recent injury. And we talked about treatment options and given that he uses his hands quite a bit, you know, even if he even though he was not, you know, a very young person, I thought it'd be very reasonable to discuss surgery.
Charles Goldfarb:In today's society. The speed at which we can get patients back to activities is really important to them. And so I think it's fair to discuss surgery now. I will quibble with one thing you said or maybe it's just how it came out. You said it was a displaced fracture, at least minimally and for me that displaced fracture that one can determine on X ray really does mean it is just placed and that does decrease the chance of healing, which is in my mind yet another reason for surgery.
Chris Dy:Right, right. So I think that, you know, the amount of displacement, especially for a skateboard fracture, you know, I think that we all kind of debate about how much could heal versus you know, not heal. With a cast versus surgery, I think, especially for escape points definitely tilts you towards surgery. Do you think that for skateboards in particular, surgery speeds the recovery that much we know that, you know, surgery will shave off a lot of time on recovery for distal radius fractures. And we'll talk about that in some of the articles we discussed. But do you think that scaffolds you save a ton of time?
Charles Goldfarb:I think it depends on how you define time. So I do believe it will decrease the amount of immobilization or the time duration of immobilization. And the only article I know of, and if a listener knows of another article chrisser. Obviously, if you don't have another article, let us know. But you know, way back, the shin article bond is the first author shinza second author compared or f versus cast immobilization, and basically show that it's shaped a week to a week and a half off of the healing time. And so to me, that's not a great deal. If you're living in a gas for a while, I think you probably think it's a helpful amount of time. But I don't think it saves a ton of time for the overall healing. But it does just get you going faster, so that the way I say this to my patients is, if we can start your rehab starts your therapy safely, sooner. While it may not dramatically change the time to bony union, it'll decrease the time of overall recovery because you're healing and working on motion at the same time.
Chris Dy:Yeah, I agree with that. I think that you know, the numbers that I was taught, I remember Dr. Gelberman in clinic, talking to patients and you know, telling patients that, you know, after fixation, you know, screw fixation, you're still looking at six, eight weeks of immobilization before he felt comfortable moving the patient to the next step of motion. And, you know, with with a, you know, a minimally displaced fracture and treating it in the cast, you're looking at 10 to 12 weeks for that bone to heal, which is much longer than you know, the standard six weeks or orthopedic unit you would get for any other bone. I think that the where you can save time in terms of immobilization really depends on the surgeon's threshold for allowing discontinuation of immobilization, that's a very wordy way of saying it, but when do you feel comfortable? If you've got solid fixation? When do you feel comfortable letting letting the patient start motion?
Charles Goldfarb:I think that's exactly right. And there is no literature to guide us on this whatsoever. And so the there's a big difference in healing time between proximal pole waist and distal pole. And my interpretation literature which supplements what you said about Dr. Gelberman's protocol, essentially, a proximal pole nonsurgically has tended to our weeks, sometimes 14 weeks. Waist to me is eight to 10 is what I call it patients and six to eight for for distal kind of pole or just a waist. I have a pretty firm protocol post surgically, whether it be proximal pole or waste of about five to six weeks in a cast. And then I shift to therapy with a custom fabricated some spike IP free splint and early motion initially active and gentle, passive progressing from there. What do you do?
Chris Dy:Pretty similar. You know, we know that when you do motion for for wrist is it you said active only no passive? Do you we know that the dart throwers motion is good for the SL ligament Do you think that can be extrapolated to less stress on the scaphoid bone itself?
Charles Goldfarb:I don't I don't know that to be a fact. But I do to be very clear instructions to the therapist. And again, when you have a trust level with a therapist, it really is helpful, so active for sure. And I'm okay with some gentle passive motion to start, especially if they're doing therapy in the system that I know if they're at an outline therapist who I don't know them a little more hesitant and may do active only.
Chris Dy:Right, right. And then I guess the you said there was no literature to guys, I agree. There's no good clinical literature, I think the paper that I go back to a lot is more of a mechanical biomechanical one, in terms of looking at loads of failure on a scaphoid, you know, the intact scaphoid versus one that's got an osteotomy line of you know, you know, 50% and 75% 25%. And then with or without screw fixation, and I think that the threshold for me is if I've appreciate, you know, probably about 50% of bony healing with a screw in place, and I'm more comfortable treating it as if it was healed, even without full bony consolidation.
Charles Goldfarb:I think that's a really important point and, and number one, you got to get a CT scan to be able to quantify healing, and I've actually even dropped that number a little lower I think occasionally you'll see like 10%. To me, that's not enough. 20% probably not enough. But once you get past 30 to certainly 40% with a screw, I'll let them go and knock on wood I've never regretted.
Chris Dy:Yeah, I think that a lot of times, some of our radiology, radiology colleagues don't appreciate what we're trying to do, and we get this CT scan, and they just, they tell us that the bone isn't healed yet. And that so I tend to scrutinize these and see what I feel comfortable getting away with, I'm certainly not the best at quantifying these things. And there's probably room for improvement in our communication with the radiology team. But, you know, I've really looked at it and if I got to feel comfortable knowing that this is well on its way to healing. So yeah, that those are the concerns I have. But to bring it back to this case, I actually did recommend surgery for this patient. And he declined. So then we tried cast immobilization, which the patient did not comply with. So you know, we decided at some point to say, alright, if you're, you don't want to wear a cast, or do any immobilization, and I'm certainly not going to operate on you if you're not going to be okay with immobilization. So we're just gonna let this ride. And you know, at that age, are you okay with saying, all right, you get a snack rest when you get a snack rest?
Charles Goldfarb:Well, I was gonna say this is sort of a natural history study, because we have the we have some natural history knowledge from way back when it'd be great if you could keep us we went to podcasts is still going on and 10 years, it'd be great for an update.
Chris Dy:I don't know why. What do you think this one, do you think this maybe it's different than a SLAC risk? Maybe it's different. So escape would escape for lunate ligament injuries, leading to post traumatic arthritis versus escape with non union? You know, there's the paper, I believe the first author was Mack that described as progression to arthritis. But I think the what we still don't know is how long exactly it takes to get there. We know it's going to happen. At some point, it seems to be the progression to arthritis, to post traumatic arthritis is highly variable. And most patients eventually do get there. But you know, I don't know what that timeline is. How do you counsel patients about that?
Charles Goldfarb:Well, just to follow up once you said it was Mack it was Mack and Gelberman. And to make us all feel really old, or at least me it was 1984. And so you know that that's a lot, and I honestly think is 10 to 20 years. But I don't know, you know, thankfully, at least in my part patient population, most would choose proactive surgery. But I think it's a while and so, you know, 55 is? I think he says 55 is is not I'm not there yet, but it is young. Oh, so yeah, I think it's fine. And look, he's made his choice. And so we'll see what happens. And then if let's say he does come back and he's having pain, you know, be could be a candidate for distal pole excision only without doing a more significant operation.
Chris Dy:So he comes back. He's already back because he fell again. And his skateboard fracture is still displaced, but not angulated in the sagittal. Plane. Do you have the same conversation again? Now his wife's with him? She's, she's there to cajole him and talk to him about you know, what the options are? How do you counsel this patient? Now? He does. And he's not developed any arthritis, which of course, you wouldn't expect in such a short amount of time. But that is an important thing. He doesn't have any beekley at his styloid. He's basically got a scaphoid fracture that hasn't healed it's got a nonunion
Charles Goldfarb:when you think he came back, because somehow or another with the fall, he irritated the servant? Yeah. Yes, because his wife is with him. I give them the talk again, and I don't probably hold back too much. I would say that when we spoke before I recommended surgical intervention, because I'm concerned, you're not going to heal and that will indefinite, that will certainly lead to arthritis. I just don't know when. And then if he and his wife agree, they still don't want to do anything then. And they can go away again, I guess.
Chris Dy:So in this situation, do you if you offer surgery and you're counseling them? How long do you tell them that they've got to really back off on activities, so not just the mobilization but like know, doing all the things around the house and the yard and everything that you know, he wants to do?
Charles Goldfarb:So at this point, he has a skateboard waist fracture, which is minimally displaced, but is a clear non union,
Chris Dy:not like FDA definition of non union, but it's a non union. Yeah. And you can actually see a little bit of sclerosis on the X ray.
Charles Goldfarb:I would probably put the three month number out there because I while out and I think there's a chance there'll be healed or healing at eight weeks and I can tell you how I think about doing the surgery, but I'd love to hear what you might have done. But I would say three months that would be my answer, even though I hope it will be shorter.
Chris Dy:Good. Well, I've been trained well, because I told I told them three months. Backing off on all activities. I told him to look He had the better part of two months, if not longer for immobilization. And, you know, it's interesting, his wife quoted that number back to me. And when I was talking to her after surgery saying, remember three months, tell him three months, I was like, Okay, you tell them three months? Well, I mean, so I wanted to make sure that it wasn't a proximal pole, it was a waste. But you know, just to make very sure I got some advanced imaging, because I wanted to ensure the viability of the proximal pole. So for me, that's an MRI, although I think you could get a lot of that information on the CT, I wasn't as worried about pre op planning for bony alignment, because it was not angulated, there was no humpback deformity. So I don't think a CT was going to add a whole lot in that respect. So I got an MRI. And I don't know if you would have gotten any other imaging or just gone off with the X rays, or whether you would have gotten a CT, but the proximal pole was viable.
Charles Goldfarb:Yeah, so I would not have gotten any other imaging. And I would approach this dorsally with a small incision. And if I don't have to do any reduction, or minimal reduction, then I would have a very small one to two cent range decision. And I'd use some just raise bone graft down the drill hole.
Chris Dy:What do you take down the non union and evolution site
Charles Goldfarb:and that typically do not it would have to be fit was displaced to a visible degree than I would have to do that. And I still think you can go dorsally as long as you're proximal to the dorsal ridge with the blood supply. But if it's pretty close to anatomical or minimally displaced, or if I can manipulate it, then I would not take it down.
Chris Dy:The interesting this one was not there was not a lot of reduction, but it was gapped. So there was a pretty clear non union gap. You know, and you know, I guess I veered from the wonderful training that you gave me and made a real incision because I was going to harvest distal radius through the same incision distal radius cancellous autograft through the same incision, you know, in the absence of any you know, lack of viability, the question of viability for the proximal well I did not think doing something vascularized either paddock gold or something crazy and then that was necessary. I think there are a lot of papers demonstrating now that you can heal many things with good carpentry and and you know, not using paddock gold or vascularized graft. So this was, you know, can you tell us autographed harvested from the metathesis of the distal radius.
Charles Goldfarb:I love it. That's that's what I would have done and I'm not I'm not against a larger incision as long as you protect the blood supply, but I think you can get away with all of that through a smaller incision. I will say
Chris Dy:I want to ask you something, okay, because people love the technical stuff. So we've had some kind of quick conversations in conference about how to harvest just a radius can sell us autographed, I want to know the chuck Goldfarb, a fruit protocol of how you how you harvest the graft. And I can say if I have any differences from that,
Charles Goldfarb:for sure, I'll give you that and I'll give you a technical Pearl for the screw. So I make a very small incision again, one to one and a half centimeters, which is roughly at listeners just owner to listen to the listener so it seems a little proximal and may seem a little older, but when you flex the wrist, it's in exactly the right spot. Now through that incision I can place my que were in place my screw and I can also retract the skin easily to listeners when I harvest can sell us bone grab dorsally I make sure to stay proximal and radio to listeners are kind of right at that proximal radial corner of listers. And the reason I do that is I've seen ruptures of the EPL when that is not respected. So in other words, if you just take arranger and crunch off listers, I think you can create a little bit of a problem with your EPL so I don't do that and knock on wood. I haven't had any problems with attendance and then it's just I use a small carrot as like a drill and then a bigger caret to harvest the bone graft. So that's my bone graft harvest technique. How do you do it?
Chris Dy:Um, you know, I've heard the cautionary tales from you and Marty and Ryan and conference about you know, potential compromise of the EPL. I think it is kind of similar to the attritional rupture that you see after a distal radius fracture, you know, with disruption to the metathesis by listers and potentially a water zone area on the EPO, you know, on the EPL tendon itself. So I actually go under, I make a bigger incision admittedly and or I'll make a separate incision if I'm trying to be cute with the dorsal wrist incision. And I go under the second compartment actually make I look at the EPL course and I stay way radial to it and proximal to it. I look for my second compartment so I'm usually mobilizing my second compartment anyway to get access to my wrist. I go under the second compartment. I actually use K wires to make myself a little window. It turns open up the window. i i I found it to be add extra operative time and be a little frustrating especially if somebody else is doing the scooping and I'm having to watch them screw through a small window, a bigger window, I allow the trainee to harvest as much as I can, they can from their side, I inevitably, because I'm coming from a different angle, I remind them that I'm going to harvest more than they did, and harvest a fair bit. And then I put some gel foam into the into the area where were harvested in the metathesis, mainly for make me feel better potentially about hemostasis that tried to close the cortical trapdoor if I can not close it, but put it back down, although I don't think that's a critical part of it.
Charles Goldfarb:So listeners, this is a fundamental difference between Chris and myself. I go for simple, effective and fast. And Chris goes for expensive, time consuming and elegant.
Chris Dy:Yeah, well, I don't think that gel foam was very expensive. And I have no conflict of interest in California. I'm actually not sure what the non, the non training for gel foam is.
Charles Goldfarb:I don't know either. But I do know the cost. And you're right, it's far less expensive than I thought. And let's just say so don't get anybody in trouble. It's less than $20. For a small piece, I
Chris Dy:think it's $17.18, based on the reports that we get something, something along those lines. But you know, so then for the interested why you would only pack through there, put the graph through the screws site, because I find that to be an incredibly frustrating exercise, which I don't know how much actually gets down there. And so while I used to say that I do that, I'd stopped doing that. And actually just for this particular case, I packed it into the actual non union site.
Charles Goldfarb:So this is important, did you stop doing it because you had failure for those fractures to heal, or you simply didn't feel good. And I don't mean that in a judgmental way you didn't feel good about the fixation when you pack bone graft down the tunnel.
Chris Dy:It wasn't a fixation. I still know how much of the graft actually ended up in the tunnel versus, you know, being extruded into other non skateboard parts of the wound.
Charles Goldfarb:I don't know what to say to that. I think when I look at my eye, first of all, how do you how do you do it? Well, I think the drilling is the main thing you're doing because when you drill and especially there's a cavity, that's the main thing you're doing. And then I think, you know, the the to talk about trade names, acumen and accucheck has a little plunger, which is designed for this. And so when you once you drilled, you pack your cancellous bone graft into the tunnel and use the plunger to push it approximately, you know, to the side of the nonunion. And theoretically, it should expand there. Of course, you're right. I don't know for sure. But when you look at your X rays, if you do have a cystic lesion, and you do this technique, and then you look at your X rays, there's bone graft, which fills that cyst, so I feel pretty good about it. And I don't think there's any relationship between technique and healing of these fractures because honestly, it's typically about putting the screws in the right place. And the kind of stability one achieves as much as the bow grip may add some
Chris Dy:Yeah, I think it's a carpentry more than anything else. And the fact that you're drilling across a fracture that you know, this particular case, I mean, you think about why things go on to non union kind of basic, bony principles. This was because of lack of immobilization. This wasn't because of lack of biology, you know, kind of roughly when you look at contributors to non union. And that's usually the case for some of these, you know, skateboards that you're treating that haven't healed because of they haven't had adequate stability. do when you have to use that plunger? Do you have to take out your guide where yeah, the guide
Charles Goldfarb:were is I mean, now, if you have an unstable fracture, then you obviously need a derotation wire to keep the skateboard where you put it, but you take out the guy where and and I jump thankfully, generally don't don't find it to be a problem, especially because you hadn't taken down the nonunions, you don't have rotational instability.
Chris Dy:So this one was gapped it, but it was really kind of almost a plate where it lies if you were able to compress it. So you know, for this one, I actually put an accessory wire outside of the path of where I thought I was going to put my wire from my screw. So it would stay out of the way. And then actually, you know, like, you're saying, I was very careful not to go to the dorsal ridge or just to get onto the radial side. But I localize it on because when you have a non union, it always still looks like bone. But then, you know, if you can I use the flora to localize where to where to start evaluating the non union sites. So I was able to find the non union sites. And I actually use the curates and kind of tried to freshen things up, because I knew based on the imaging that I had some sclerosis there, and then being very careful to respect the dorsal ridge. But working underneath from that kind of window that I had to curate as much out as I could on both sides of the fracture.
Charles Goldfarb:And what I think you're saying, correct me if I interpreted incorrectly, when I think you're saying is when you look at the scaphoid you don't see the non union, right, because the cartilage cap is intact. And so you need fluoro to decide where to cut the cartilage. Is that correct? Exactly right. Yeah. And the technical pearls only stated because I've done this incorrectly, is when you think you're going to get compression and whether that be from a vulnerable What's your dorsal approach, you have to be really careful not to place a screw that's too long. Because if you place a screw that's too long and what's considered from a dorsal approach, then your screw can essentially run into the distal cortical bone of the scaphoid. Or go past it if you've drilled through it. And if you do that, you may not get compression. And in fact, you may fix it with a gap. And so it's important that you allow this screw which is compressive to compress the bone.
Chris Dy:Right, I think that's a great point. And you've mentioned before, this is not a screw, typically, where you're, you're obsessed with being center center max distance, the orientation of your screw matters a little bit more. Is that right?
Charles Goldfarb:I think it does. And I don't know whether, you know, I'd like center center and I like perpendicular fracture line. And if you can get both great, but sometimes you're kind of sort of playing both the same time,
Chris Dy:right. And I think that which one you think it's more important,
Charles Goldfarb:I probably say center center, but I'm honestly not positive. We know those oblique fractures are the toughest to get to heal. So it was funny because David Brogan shared with me some images for a talk I gave in his technique when he uses the vascularized graph from the knee. And in those cases, he is absolutely putting his screw in perpendicular with the graft and the skateboard. So it's, I kind of think center centers more important, but I don't know that I don't know that to be true.
Chris Dy:So I mean, I packed in a bunch of the graft through this non union void, while I had my, you know, essentially the rotational stability wire in place, so as to not take something that was stable and make it unstable. That's why that fret, that wire was important, I packed everything in and then put my wire in from my main screw and put my screw across, got it lined up, well, seemed to compress a decent bit. Do you ever put two screws in?
Charles Goldfarb:Oh my God, that's heresy, I would never put two screws in, tell me why you put two screws and this one.
Chris Dy:Honestly, big guy, big scaphoid there was room and, you know, I kind of had this talk with him that you know if this were to go on to not heal. And we're not going back. Because of you know, you take somebody you met you immobilize them for the better part of three months, you know, tell them not to do stuff, even if it's not healing, while you're gonna keep them mobilized a little longer, he probably wouldn't want to go on to, you know, to have revision surgery and prolong you know, basically, it's more time out of their life. And if they're gonna end up getting a snack risk, they'll deal with them. So, you know, I actually said there's room in here and you know, with the screw system I was using, there was adequate range in terms of you know, being able to sneak in a smaller screws. So I put a smaller screw essentially very close to the path of that original D rotational wire.
Charles Goldfarb:Yeah, it's nice when you get your derotation wire, it is a perfect path for a second screw. And almost always, that's the smaller version. You know, theoretically, it most most systems have three, you know, three sizes. And I typically use the middle size for my escape voids with the possibility of upsizing if there is a non union. But I love the idea of putting a really small one in what many and as your standard screws.
Chris Dy:Yeah, so I mean, you know, that case, you know, went well talk to the wife afterwards. And she was like, you know, make sure you tell him three months, like I said earlier, so interesting. I was I was sharing this case with, with our partner, David, who you just mentioned, because we were doing some other case together. And he's like, Well, I'm gonna make it really hard for that, that MFT I said, Well, there's not going to be an MFT there will be no other depths of fixation. I said, if this doesn't do it, then, you know, that's it. But I honestly, I'll feel good. Evaluating him knowing that I've got, you know, really solid fixation. And, you know, we'll obviously get the the CT scan that we had talked about, you know, when do you get that post op CT?
Charles Goldfarb:Scanning, I just had this conversation, because it's a really important question. And it turns a little bit on the patient, you know, I don't want to, you know, try to be sensitive to cause I don't want to get to CT scans. So I don't want to do it too early. But also don't want to wait too long and lose time for the patient. So for most patients is at the eight week mark, there is a great paper from from the European Journal, which described using described a protocol in which non surgical treatment was chosen. And an early CT of 46 Weeks was then obtained and if there wasn't healing, then they did surgery. And so lots of ways to think about this, but with a surgically treated patient. Eight weeks is sort of my Hallmark give or take. What about Yeah,
Chris Dy:yeah, I think that that's a very different decision making context. You know, when you've gone initially, the non operative treatment. And you know, certainly like you said, you want to make sure you're avoiding extra costs. Last and radiation, you know, with the extra CT, so I actually I, the number I was gonna put out, there was eight weeks as well, because I usually see them at the six week mark, and I'll order the CT for a couple of weeks later. So that I have a sense, you know, at the six week mark, I'll probably keep them in a cast, do the CT scan into cast, and then call them with the results of the CT. And if it if it looks okay, have them come back and have the cast removed and start therapy. If it doesn't look okay, at least we still have a cast on there.
Charles Goldfarb:Yeah, I think that's, that's, that's very reasonable. And, yeah, and then my goal is, you know, if they're healing, but not healed, then I just get a little more aggressive with therapy. So that, again, we're maximizing motion and even strengthening. While you know, fracture healing is making its way. So if we have reasonable healing, say is 25% or something like that, on the CT scan? I don't repeat the CT scan, I just continue to follow one or two more X rays and make sure they're clinically doing well make sure they're functionally doing well. And then I just let them go. Do you repeat the CT?
Chris Dy:Typically, not if we're if the first one shows, you know that we're well, on our way? I don't know if I've, my threshold is probably a little bit higher in terms of percentage healing than 25%. But, you know, in this particular case, I'm sure that fine osseous detail will be obscured by middle artifact, clinical correlation will be recommended,
Charles Goldfarb:where we're counting on that.
Chris Dy:So yeah, thanks. It's been good discussion. We've covered topics from firearm violence, that Trank to campaign to skateboard on unions are pretty sure we could save the articles for our next episode, because I think that, you know, we probably lost a lot of people on the way this far along. Yeah, I
Charles Goldfarb:think the I'm looking forward to the articles because I think they are a good segue to a more generalized discussion. So I look forward to that. And thank you. It was fun catching up.
Chris Dy:Absolutely. That wonderful day.
Charles Goldfarb:All right, you too. 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. What about you?
Chris Dy:Mine is @ChrisDyMD spelled dy. 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.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time