Firework Injuries and Journal Club

Chuck and Chris discuss the 4th of July and fireworks injuries.  We review the most common presentations and treatment including acute and delayed.  We then pivot to review three interesting and recent publications.

Bulstra and the Machine Learning Consortium, "A Machine Learning Algorithm to Estimate the Probability of a True Scaphoid Fracture after Wrist Trauma."  J Hand Surg 2022: 47: 709-718

Schmidt, et al, "Association between radiographic and clinical outcomes following distal radius fractures". J Bone Joint Surgery 2023; 1-12

Loewenstein, et al "Ulnar wrist denervation..."  J Hand Surg 2023; 48: 544-552

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Transcript

Charles Goldfarb: 0:03

Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.

Chris Dy: 0:07

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: 0:15

Please subscribe, wherever you get your podcasts.

Chris Dy: 0:18

And thank you in advance for leaving a review and leaving a rating wherever you get your podcast.

Charles Goldfarb: 0:24

Oh, Hi, Chris.

Chris Dy: 0:25

Hey, Chuck, how are you?

Charles Goldfarb: 0:26

Fantastic. How are you?

Chris Dy: 0:28

I'm good. It seems like you're probably recovering from what was probably a very busy holiday weekend.

Charles Goldfarb: 0:34

You know, it's funny, because we discussed recording this episode last night, which would have been July 5. And I'm like, I'm too tired. I'm bold. I'm recovering. Let's do it. This morning, which is early in the morning of July 6. So Thursday, two days after Fourth of July. And I woke up that I wasn't sure I made the right decision. I always wake up before my alarm. And then my alarm goes off. And there's one of those I don't know where I am. I don't know who I am. You know, this experiences. It was crazy.

Chris Dy: 1:05

Yes, I'm sure and I think we're going to talk a little bit about your Fourth of July weekend here in St. Louis. We were actually a way and I had a similar experience in well, similar but very different experience yesterday when I woke up in my own bed on Wednesday morning not knowing exactly where it was because I was so used to sleeping in the bed at the vacation home we were at in Georgia. So it's very different experience of disconcerting nonetheless,

Charles Goldfarb: 1:31

yeah. So you Was this just you and your wife or was the whole family.

Chris Dy: 1:37

Family, whole family took the weekend off? My wife is I think my mate mentioned this on the pod in the past but my wife is on the 50 states with the kids before they're out of the house. Band. So you know right now I think that was number 16 That we checked off the list going to St. Simons Island off the coast of Georgia, flew into Jacksonville and drove an hour and we had a great time it was really fun.

Charles Goldfarb: 1:59

That counts for Georgia. That is so not Georgia. You're just like this letter of the law.

Chris Dy: 2:05

It was very Georgia tell you that. I'm gonna leave it at that but it was very Georgia.

Charles Goldfarb: 2:10

You know, be careful. I'm an Alabama boy.

Chris Dy: 2:13

I was it was more Georgia than many would say Atlanta is.

Charles Goldfarb: 2:17

Well, that is true. That is very true. Well good. I'm glad I'm glad it was a good trip. I do want to mention I'm on a new kick. Before I tell you what is overnight oats which I am not new in fact I am very late to it is so good. I don't know what took me 10 years it's so good.

Chris Dy: 2:37

It's probably Jessica Billy rotating on your on your service with all of her overnight oats that I think already Boyer would would gently tease her is her mush

Charles Goldfarb: 2:49

it I look I was looking for a new breakfast that filled me up and this is awesome. So for all those What is this socially disconnected people like me? overnight oats is awesome.

Chris Dy: 3:01

So is this like you're one of those guys that does like the batch prep like for the whole week or you like definitely set it the night before and then

Charles Goldfarb: 3:09

yeah, night before my milk, my Chia my oats and add a little sweetener in the morning little fruit maybe Ah, my God, it's good stuff.

Chris Dy: 3:18

I will say as a texture guy. overnight oats has fantastic texture. I just have never gotten there. Maybe one day, maybe one day.

Charles Goldfarb: 3:27

Well, I realized you had gotten there because I haven't seen it on Instagram. So if it's not

Chris Dy: 3:34

there already overnight oats enthusiasts are overnight. It's makers that want to sponsor us let us know because apparently Chuck is going to be on the date,

Charles Goldfarb: 3:43

at least for the next week, at least

Chris Dy: 3:46

Fourth of July call what does that like? Certainly, as we talked about, and maybe a little less, lighthearted way, on the last episode, we see a lot of ballistic injuries here in St. Louis, this is certainly ballistic injury of a different sort that is quite seasonal.

Charles Goldfarb: 3:59

You know, I first of all, I like how we do our call. So in other words, our goal with call on these long weekends is to give everyone except for the person on call time to do what they would like with so I was on call from June 30 through July 5, which is great. And I'm being very serious when I say that because it really does give every other person time although Monday was a normal workday. So you know, in quotes because not much of the department was working. But it's getting us nice get away you know, it really is a nice opportunity, so called Thank goodness for David Wright, who is one of our remarkable fellows who was incredibly good. We did not get absolutely obliterated with firework trauma, but we had enough to you know, keep it interesting. The I have to say Marty Boyer usually does the Fourth of July or likes to and he likes all hands on deck everyone around you It was just a normal call weekend for us. And we didn't know extra fellows were called in. But all firework injuries are kind of the same to me. They the pictures look terrible. And the reality is in the ER, there's usually not all that much to do. And it's a matter of typically the first webspace often gets blown apart, maybe some distal amps, depending on the size of the explosives, and often some burns. Ophthalmology is usually involved before we can go the or so interesting, but we you know, we had three or four of those to a significant degree and, and thankfully, all came together nicely.

Chris Dy: 5:44

Two things. Classic, nice,

Charles Goldfarb: 5:46

nice, nice,

Chris Dy: 5:47

I thought I thought the first thing you're gonna say about how you like how we do calls that we split it with plastics. But as your partner, I appreciate what you said about how we've done our call schedule, I think much more thought has gone into it in recent years in terms of making sure to rotate the calls in a way that works for everybody. And you know that that's clearly helps with families and people with young kids. So as your as your junior partner, I appreciate that. So thank you for taking Fourth of July call my son's birthday is on July 8. So every year, we're typically out of town. I'm sure I'll in my when I get to my my queue every seven years for Fourth of July, it'll be off to my son, we're staying in town. But my second thing is, you know, asking, Does your threshold for replantation change with this kind of injury versus mono, say this standard kind of tablesaw industrial accident? Not An avulsion. But does it change it all over this weekend?

Charles Goldfarb: 6:49

In response to your two points? I'll give you two back?

Chris Dy: 6:53

Of course, of course. Very Own branded?

Charles Goldfarb: 6:55

Yes. Number one, I don't, I think these are almost never replaceable. And there can be An avulsion type injury, which there certainly was for us in these cases. So one of the patients, you actually may be seeing at some point who Avulsed we save the thumb, but the digital nerves are both evolves proximately. Not that there's anything you can do for it, but you can be creative. And so I think replants are almost never the situation, I can't think of ever having done a replant. And in these situations, for me, probably the single most important technical consideration is the first webspace. And so if someone's holding the firework, if it's a Roman candle, it's a little bigger, those usually are more burns than explosions. But obviously, our fireworks industry is not regulated. So those can be explosions as well. With the first webspace gets blown apart. And I think the temptation is just to close it, you know, everything close, close it down. And what happens is you have a markedly contracted first webspace and no one's happy. And so we do a lot of painting of the first webspace I don't think this is particularly novel, but we do that. But I think it's really important that we do that one of our patients had a CMC fracture dislocation. And so we pin that, and the first webspace to let the soft tissues heal. So yeah, it's a lot of that just soft tissue work, which is fine. And, you know, got to monitor people as they heal.

Chris Dy: 8:19

So I think you're probably downplaying your expertise in this area with regards to the first webspace. I've learned a lot from you along the years in how to evaluate and treat, you know, that part of the injury. Do you have any technical pearls about you know, the pinning itself? Like what size pins to use? How many pins What's your in, like, what's your configuration? And then also, you know, in terms of coverage, are you doing any rotational flaps at the time to bring in some local tissue, whether it's, you know, pedicle to random pattern to try and get some kind of tissue in that void? Or are you setting things up for later reconstruction?

Charles Goldfarb: 8:57

Thank you kind words. I would say that no immediate, soft tissue, you know, rotational flaps, etc. I'm a big fan of dorsal advancement flaps. That's because of my congenital bias. If those are if the dorsal soft tissues are unaffected by the blast injury, that certainly can be an effective way to deepen the first sweat face if it does contract. But honestly, I think if he needs skin and support, I think you're looking at either a groin flap or a forum flap of some variety. So in these cases, it was simply primary closure. And then we'll see what happens. You know, thankfully, infection in my experience has not been a common issue here, but I think we just want to get through the initial trauma and then reevaluate and as far as penny goes, I go big on these pens. For five at a minimum, but typically six to I placed my pens proximately at the between the first and second metacarpals I Um, and I think if he plays it dislike, it just creates more scarring potentially. So proximately and one of the pearls and anyone who's done enough hand surgery, knows if you take a six to k where, and, and keep firing and keep missing, and I will say it's not easy to go from the first metacarpal to the second metacarpal. His sounds crazy, even if the wound is open, it can be a tricky thing to do. Similarly, going from the fifth metacarpal to the fourth metacarpal for say, if that CMC fracture dislocation can also be tricky, and you cannot fire and fire and fire and all of a sudden you've you've perforated or postage stamped the metacarpal. And it can break later. And I've seen it. So that's the only technical consideration or worry that I have with that technique.

Chris Dy: 10:47

So postage stamp, many of our younger listeners may have never handled the postage stamp. But I think you're talking about perforations around the entire periphery, is that correct?

Charles Goldfarb: 10:58

So that was a new term to me, when I use potions, stamping, you know, the little dots when I do most of my osteotomies. And so I'll take a K wire, and I prefer to cortex and then use an osteotome to complete the osteotomy to minimize heat to maximize healing. But yes, if you're if you're multiple perforating a bone, you weaken it, obviously. And that's the intent when you're performing an osteotomy. It's not the intent when you're performing a painting. It's funny, though, along those lines, we were talking the other day about a couple you know, a bunch of old people were sitting around the table talking about generational gaps, and someone made the motion of rolling down their window with a manual roller. You may not even remember what that

Chris Dy: 11:42

oh, yeah, remember that?

Charles Goldfarb: 11:44

And know what you're talking about? Yep.

Chris Dy: 11:46

But still up. It's still people get the thing with the phone. When you put your like you're, you're someone you're thinking, even though many people have never held the phone in that way.

Charles Goldfarb: 11:55

That's true. That'd be I don't know that all kids do. Like I asked my kids that very question. It was for me, it was more of this, like, what's this? And it was kind of like, what are you holding your fist up to

Chris Dy: 12:05

see those of you that are only listening on audio and are missing the live the YouTube feed are missing all these wonderful gestures that Chuck has made us all is him scarfing down these overnight oats. Before we move on, I want to ask you, so it's two pins, are they largely oriented in the transverse manner? Yes. And then how do you position the thumb in terms of where it is relative to the plane of the palm?

Charles Goldfarb: 12:28

Yeah, so I prefer a Well, I think antic position with maximum radial and Palmer abduction is one way to do it. And certainly that's appropriate. I don't mind if it's just radially abducted either. So in the plane of the fingers, I think is okay, as long as we're putting the skin on tension, and you actually put it a little more tension, I think when you're maximally radially abducted.

Chris Dy: 12:53

And I think one point that you mentioned, and you know, should be reinforced is the importance of debridement. Yeah, I think getting a really good to breed mentor, as Marty would say, to breed mount is critical with this, because, you know, I think the last thing we want to do is leave a night just for infection. You know, and unfortunately, a lot of my experience with firework injuries is that not all of them have the ability to follow up locally. Since, you know, given the nature of our center, we see a lot of people that are transported in sometimes unnecessarily flown in for a revision amputation. Because nobody knows what to do with these. And they're very intimidating based on the pictures, as you alluded to, everybody has this kind of shock factor. I remember Fourth of July as a fellow just, you know, having a nice day. And then it started like in Italy in the late afternoon and I got to the hospital, I didn't, I hope nobody from the ACGME is listening. But you know, I didn't leave the hospital for a solid 30 hours, because there was so much work to do it so we had to, it was just a busy time. But a lot of there were a lot of transfer calls. And you know, triaging those can be challenging, because it's very intimidating, you know, if you're already doing, we were doing some microvascular work at that time, and you know whether to accept something when you're already doing a Micro Case is one thing, and that's probably a topic for another day. But then also just moving through the line of revision amputations trying to ferret what could be done in the IDI what needed to be done in the ER because of the treatments, all that kind of stuff.

Charles Goldfarb: 14:21

Yeah, all really good points. And it goes back to your previous question slash point you made about, you know, what do you do immediately versus what do you do in a delayed fashion and you know, we want to do the right thing for the patient, but a patient who has trouble traveling and may not be able to come back for follow ups in St. Louis. That's a real trick and should we be more aggressive with immediate flaps if potentially necessary? And that's it's a fair question. I don't think there's a right or wrong answer personally.

Chris Dy: 14:48

Absolutely. We should have an episode some point about, you know, non microsurgical flaps that hand surgeons can do including that growing flap, which is a nice, nice technique to pull out of the bag every now and then certainly one that is A little bit of a shock to patients if they wake up with their hand sewn to their crotch, but we should talk about that in a day. I'm sure there are a lot of guests we could have on to talk about that. We should think we should thank our sponsors.

Charles Goldfarb: 15:12

Absolutely. The upper hand is sponsored by practice link.com, the most widely used physician job search and career advancement resource.

Chris Dy: 15:20

Becoming a physician is hard finding the right job doesn't have to be joint practice link for free today at www.practicing.com/the. upper hand. So I wanted to thank all the listeners for for writing in we've had some fantastic emails come in about prior episodes a lot about the FTL reconstruction episode, great pointers. I do want to save those for another episode, we've had a great email about our scaphoid discussion from from our last episode with with a little bit of contention, which is great good to discuss. So I think there's a lot of good stuff in there. There's a nice P IP case. So we'll save those for another day. But I do want to thank everybody for writing in. We get them we get the emails we love. It gives us great stuff to talk about. So if you have any questions, suggestions, cases, etc. Hand podcast@gmail.com.

Charles Goldfarb: 16:13

Yes, love it. And really, it's so helpful to have that fodder for discussion, because it means that people are interested and engaged in there's really good topics. And yes, you and I discussed the head to discuss this morning. Where do we start? But we're starting with a little journal club. Yes,

Chris Dy: 16:31

we did talk at the end of the last episode about how we wanted to do journal, we got kind of caught up in that skateboard case. So speaking of skateboards, there was a really interesting article from the Machine Learning Consortium, which is, you know, all over the place, but really headquartered in the, in the Netherlands and Australia. So, machine learning for scaphoid fractures. So you know, there's that always that clinical conundrum about, you know, the occult, scaphoid fracture. And in this this the first article, the first author on this article was last name Bill strap, and this was in the journal a hand surgery, the American edition last month. So, Chuck, what did you take home from this? I mean, you know, they looked at 117 fractures that were confirmed on CT scan MRI, and on X ray, you know, among 422 patients with radial wrist pain after I recited trauma, and then use machine learning algorithms, which they did not disclose the algorithms because I think they're still being refined, so to say, but interestingly enough, you know, I think they're getting closer to trying to find some kind of decision aid for the occult, scaphoid fracture.

Charles Goldfarb: 17:42

Yeah, and you and I have discussed on the pod the how we each approach these in the sense that, you know, when do you immobilize, when do you get advanced imaging, etc, etc. So the point of this study is, can we accurately predict the probability of a fracture? And can we decrease the number of patients who have advanced imaging to rule out scaphoid fracture? And I have to say, I don't know that, you know, in any way, this changes our current treatment, it has the potential to change our future treatment, but it is pertinent because machine learning is all over the place. And I think this is coming as an adjunct to our clinical acumen, and it will make all of us a little bit better. Because we, you know, this just makes every decision a little more scientific, or I should say, it will make every decision a little more scientific.

Chris Dy: 18:37

Yeah, no, I think it's interesting, because, you know, when I think of machine learning in this context, I think about, you know, a lot has been said about the potential for machine learning and quote, AI in a very kind of broad term about replacing radiologists in many ways, in terms of pattern recognition on imaging. So this I think, is interesting because it goes beyond just the radiographs and looks at some of the clinical factors, you know, in terms of locations of tenderness, age, mechanism of injury, that kind of thing, and factors in essentially doing a moderate version of something like the audible ankle rules, like you know, the rules for like a decision, you know, simple score for like, if you come in with ankle pain, and whether you have an ankle sprain whether you should get X rays or not to look for a fracture. Now, clearly, you know, sending somebody for a CT scan or an MRI, you know, one of the advanced imaging modalities is much bigger deal than getting X rays, you know, so this algorithm was able to cut down had 100% sensitivity, although, you know, which is good because it didn't miss a fracture, but it probably over called some because their specificity was quite low. And they said that they were able to cut down advanced imaging by 36%. So within the confines of a, you know, a system in which you have finite resources, which all healthcare systems do, and we're trying to be good stewards of this. This has the potential to really help cut costs and drive value. The discussion that we had in our in our Hands service conference on Journal Club was really derived from Where's machine learning going to go. And I think what's going to happen is that you're going to see some of these, you know, machine learning algorithms get in the hands of, of insurance companies and payers, and it really drive, you know, the prior authorization processes, essentially. And I think that can be a bit I worry about where that's gonna go.

Charles Goldfarb: 20:23

Yeah, I think that's well said. And the other factor is, you know, what mattered to their algorithm to their, the ability of the machine learning algorithm to predict things and, you know, male sex, the previous talks about sex and age and mechanism and areas of tenderness. And so I think they did a good job of trying to simplify the number of factors that actually mattered. So I think, look, we're gonna see a lot more of this as we should, and it is going to affect how we care for patients. I don't think it's there yet. But it's not far away.

Chris Dy: 20:58

I haven't finished in one day, you know, with some kind of intake form and use of EMRs. So you know, their figure that they show, figure two in terms of, you know, typing in all the factors and getting your risk of a skateboard fracture is super interesting. It's kind of like, this may have been past your training. But when we use the FRAC score for osteoporotic fractures, and you would go on a website, and you would type in all the demographics, and you would tell the patient their risk for fragility fracture in the next five years, super useful for counseling, so you can type all the factors in for this patient and say, Look, your risk of having a skateboard fracture is not zero, but it's only 20 something percent. So I think us getting imaging at this point is probably advanced imaging is probably overkill. But if your number meets a certain threshold, 70 80%, you know, let's go ahead and get the advanced imaging because the numbers show that there's a good chance that the that the fracture is there, some would argue why don't you just treat the fracture, if it's radiographically, occult by just go ahead and putting it into cast?

Charles Goldfarb: 21:54

Yeah, it's really interesting to think about this. And one of the reasons you and I want to discuss this article is how it impacts our clinical care. Again, today, not really, when this tomorrow began, I don't know. But, you know, is this gonna be something else we have to pay for as clinicians or as hospital systems to access to these machine learning algorithms. And it is really going to be fascinating to see how it plays out. And all I can say is, I hope that many of us get involved in this type of research, because I think that will, will speed the process, but also make it more accessible to all I would predict.

Chris Dy: 22:27

Certainly agree, I think it's something that you know, AI is coming in all facets of our lives, as well. You either push the elephant or you ride the elephant is one of the other.

Charles Goldfarb: 22:37

I did read did read this morning that access to like chat, GPT is down like 50% since it first popped on the scene. And the cynical say, that's just because you know, it's summer, and students are not using Chat GPT for their essays. But I think some of the excitement, of course, wears off. But this isn't going anywhere.

Chris Dy: 22:59

I read I one of the podcasts I listened to semi regularly is the daily from the New York Times. And some of the topics I mean, they cover stuff incredibly well. And I was drawn to the one recently on chat, GPT, which I think is fantastic. And it talks about how students are using it. So I'm using it for a very obvious ways in terms of generating a paper some using it in a very interesting way to do kind of background research and then write on their own or using it in, you know, oh, that doesn't sound like what I would write check. GPT here's something that I wrote make this sound like me. And then they also get the perspective of professor, you know, kind of a Liberal Arts professor who just talks about how it's sad how, you know, his students don't want to write and engage in the same way that he wants them to. But realizing the chat GPT is here to stay in this kind of thing is going to be something we have to deal with. It'll be super interesting to see what kind of orthopedic residency essays check GPT generates in the next few years. I think that's, it's coming. And I think we need to be fully aware of because as we all know, the there are very few personal statements that stand out. You want to stand out in the right way, but for most people, it's okay to just have a very average statement.

Charles Goldfarb: 24:13

Yes, that is true. And and I think there are there are those who can allegedly detect and tools that can help you detect an AI generated essay or, you know, personal statement, but certainly you and I don't have that skill set. I don't think we may detect something feels weird about an essay, but we're not going to be able to say that's generated by

Chris Dy: 24:37

I guarantee you one of us has read in AI generated thing at some point in the last year, whether it's an essay for for one of our programs, or even a paper. It's interesting in the last few months now for each journal if submitted to that you have to submit an affirmation if this was not generated by chat GPT the game has changed and it will forever be changed. Why don't we move on maybe squeezing One or two more articles, I'll let you pick I thought the distal radius one was interesting. I always thought the ulnar wrist pain one was interesting to you. So where do you want to go next?

Charles Goldfarb: 25:08

Let's do those two. So the distal radius paper first author is Schmidt It's based out of various hospitals in Sweden. It's a prospective. One year follow up study of 366 patients managed either with reduction in cast immobilization or surgical intervention. And we can talk about what surgery means. And they looked at a variety of different outcome measures, including radiographs, quick dash, range of motion, grip strength, etc. And,

Chris Dy: 25:40

This was in the May 12 2023 edition of The American Journal of the joint surgery. So jbjs 2023, may, if it did those following at home,

Charles Goldfarb: 25:52

yes, perfect, perfect. Thank you. And, you know, I guess I would say, not surprisingly, but demonstrated in a nice way, they really showed to cut to the crux, and we can again, elaborate as you wish, clinical outcomes declined, starting at five degrees of dorsal tilt. But really, it's not until you get to 20 degrees of dorsal tilt, that things really started to matter. So that's my simplistic takeaway. I'm sure you can add some nice flavor to that.

Chris Dy: 26:26

Well, I mean, I don't think that you know, any of these prospective cohort studies are incredibly difficult to do take a lot of work, you know, both you and I are living this right now with our different prospective cohort slash new aka registry type studies, which not really registries but you know, it's, so it's things where it got a ton of work goes into it, and you kind of have to see where the data takes you, even though you have you heard a priori said kind of hypotheses. You know, so a lot of effort goes into this kind of thing I, I struggle with, you know, these continuing distal radius fracture papers, you know, we saw such a rush of it, you know, in the last decade of, you know, do you operate, do you not operate, what kind of surgery, you know, that kind of thing in there, the pendulum keeps swinging back and forth. In terms of non operative management, one of our partners, one of is, quote, aggressively non operative, as one of our residents described, you know, for treating these, and I think others have a lower threshold to offer surgery, I tried to give patients, you know, data driven counseling based on kind of age displacement and what to expect. And this lines up very well with, you know, the work that, you know, the McQueen group has done in the UK, in terms of, you know, you look at displacement, and it's stuff like grip strength and a dash, it starts to fall off as you get more dorsal displacement.

Charles Goldfarb: 27:42

Yeah, all well said, again, another golden opportunity for AI or machine learning to help us because, you know, we bring our own biases to this to this decision making process. And, you know, Linley and others are working on decision aids, which really will help, because it's really not only about our perspective, on what we can expect from a patient focused outcome, it's also about what the patient wants, what their thoughts are on surgery, what their thoughts are on the aesthetics, because that matters a lot to some people. And in a perfect world, we wouldn't think about that kind of stuff, we would just do the best thing for the patient, but all that matters. And so it's, this is a really good paper, this will allow us to counsel patients more appropriately, or at least I believe it will, for me, it doesn't fundamentally change the way I think about things, it does reinforce how I think about things, it doesn't change it.

Chris Dy: 28:34

It this I think reinforces a lot of the work that's already been out there. It's important to have it out there. You know, it's not completely novel, but it's important to demonstrate it. And certainly, I think there are differences in terms of acceptability among different cultures, but it's hard to argue with grip strength and a dash to be honest with you, I think that translates pretty well across cultures. You know, the article that we covered in our journal club that we're not gonna get to discuss today was, was that a Rochester and Warren hammered screw up before he left there? And it was interesting, looking at kind of how they evaluated patient preferences, essentially, I think one thing that, you know, where this could go eventually is, you know, the personalized medicine aspect and, you know, having, having some kind of system where the computer knows your preferences, your personality, and says, Okay, well, you know, Chris is really interested in getting back to X, Y, and Z. And based on his fracture displacement, and his timeline, he should have surgery, or he shouldn't. So I think that that's probably where it's going to go. But I think the patient preferences and the counseling are key, because every patient is different in terms of what they want, what matters to them. I had somebody who had treated with, you know, with case management for distal radius fracture, and her displacement is completely acceptable. radiographically and I told her about the likelihood of having a prominence of her own her head, the bump on the pinky side of your wrist, it's most likely going to be there. It's not going to change it's going to be like that. And at every follow up visit, that is what this patient fixates on and I said, I could break your wrist again. And we can put a plate on there and make that better or we can cut up that bone. And that, of course is unacceptable to them. But they don't like the fact they've got a bump on the wrist. So, again, like you said, I think it's all the brothers in the counseling, and I don't think a computer is going to counsel patients for us, but I think a computer can provide data, data driven approach, which will help the right patient.

Charles Goldfarb: 30:23

Yeah, really well said and and the gap between the counseling that we do, and not what patients hear it, but how they incorporate what we say into the way they think about their issue is really super interesting. And again, every patient does it differently. And I have that same patient that you do that. We've had the discussion 10 times, but it doesn't change. There are several writing on the particular issue, which was predictable.

Chris Dy: 30:50

Right, right. So yeah, why don't we move on to our final article? I think this one marries her to Pinterest. So this is what the first article is. The first author is Scott Lowenstein, this is on their wrist innervation articular, branching pattern selective blockade of the dorsal branch of the ulnar nerve. This came out of, you know, consortium of places really out of Wisconsin, but I know this concept has been really driven by Dr. Li Delon, who has been on the podcast before, and his academic appointment is at Johns Hopkins, although I know he is recently retired. And Lee did discuss this with me, you know, when I visited with him, when we had our, our interview, so super interesting article about on the wrist innovation. You know, I think the anatomically, they described kind of a pattern of innovation on the older side of the wrist, and then did a simulated block with staining of that would simulate kind of where lidocaine would go, and how often that would affect the selectively hit the ulnar articular branches and not affect the sensory or motor components of the ulnar nerve. So I think this is interesting, because it's, it's not novel in terms of the anatomy. It's not novel in terms of doing a block. But the way that they did this, they wrote this paper very well, in terms of positioning it for an engineer so that somebody would be interested in reading it. So I think there's a bit of gamesmanship, that's probably not the right term in your games person ship, in terms of how to write this article and to, to get a paper published.

Charles Goldfarb: 32:26

Yeah, there's a lot of different ways to go with it. I like how you said that last piece about, there's not a lot of new information here. But it was packaged in a way that is interesting. And, you know, when I when I have papers that maybe don't, aren't accepted to the first journal, I submit them to, and the reviewers make comments, sometimes I wonder how I could have packaged the information differently. And this is just well done. Right. It is interesting, I am glad to have read it. From the technical message, there's nothing new here. But it does make me think about things. So would you consider using the information provided in this manuscript? For potentially considering an innovation procedure for the owners of the wrist? especially focusing on that dorsal sensory branch?

Chris Dy: 33:14

Yeah, well, 100%, for sure. And you know, when I think both of us just to make it very clear, when both of us make the comments about packaging of this article, we're not saying that in a negative way. I think that's just reality of getting an article into a journal and doing a project that's interesting. Maybe not necessarily novel, but the way you package is how people are going to interpret into corporate into their clinical practice. So the way this is packaged, made me say, you know, I think this is something I could be interested in doing. And I have had that thought in the past, but reading, it kind of makes me feel better about doing it.

Charles Goldfarb: 33:43

Yeah, definitely not in a negative light, honestly, you know, in a very positive light, because I don't think anyone's doing anything inappropriate. They're just presenting the information in a way that will be most, you know, attention grabbing. We talk about that specific thing all the time when we're submitting abstracts for podium presentation, because for those of you who haven't gone down this road before, you know, if you are a reviewer for a major meeting, you are often reviewing at a minimum 50 and sometimes hundreds of abstracts, depending on your role in the process to decide what is accepted for podium presentation, what might be accepted for poster presentation and what might be rejected. And you have a short amount of space to make your case that you have interesting, compelling information. And we talk about packaging it all the time in that process. We talk about it less for actual scientific manuscripts, but it's the same process so I admire what they've done here and it did grab me absolutely. Now I don't know if I would do it helped me understand one thing. If the dorsal sensor branches older nerve is potentially a cause allergy of nerve or nerve that leads to pain if injured. How can you just cut it and expect that the wrist pain will go away and there won't be any nerve mediated pain?

Chris Dy: 35:02

Great question. So you need to be very selective in which portion that you cut. So they were very clear not to get the sensory component that went to the dorsal owner side of the hand. So that's the call centric nerve that we're always looking for when we do any approach to the other side of the wrist as you get towards the on the carpool reading just because of what you know, the paper that Ryan Calfee wrote, you know, she was cited by many, including at the publisher onis graduation ceremony, which as a quick aside, I will say I acknowledged on the last episode how honored I was to join the group that got it and I realized that you also received it, I thought you had I want to like give it to you if you know, but yes, and trying to Google about like what honestly, the award was and what it means. Your name came up repeatedly. So congrats to you on your, on your publisher on US residents education and mentoring award. But yeah, but getting back to discussion. So yeah, you have to be sure that you're going just for these articular branches and not for the sensory component that comes out at component. You know, so I think that that's where the rub is. But the idea here is that what you can do in the clinic, either clinically, which many people the more than more slender, you can actually palpate or roll that nerve, you know, as it's just proximal to the to the owner neck and block that nerve. And now clearly you're gonna get sensory loss on the on the dorsal ulnar aspect of the hand, probably not on the the owner sensory distribution proper to the ring and small finger and you shouldn't get an older motor block, but just blocking that nerve, if it helps with their owner sided wrist pain. That's I think the point of this article, it says that patient would be a good candidate for generation in which in the actual surgery, you would go for the articular branches alone and leave that dorsal owner sensory branch otherwise alone.

Charles Goldfarb: 36:45

Yeah, that was my attempt at a softball for you to hit out of the park, which I think you did. And you're right. I mean, we just to be again, really clear, which I think you were, we I take great care. I mean, every arthroscopy potentially puts that nerve at risk. And there's often a transverse branch that goes right near my six, our portal that we really don't want to injure. So it's just those articular branches that we don't really talk about that are the goal here, if you were to consider that selective denervation,

Chris Dy: 37:13

right, I'm not I'm not an arthroscopy, but I stay away from doing six you for this exact reason of trying to avoid damaging that cause out of nerve and I think that's why many of us, novice arthroscopy will do six are as opposed to going more older, because once you as Ryan showed us, once you get more towards that mid axial portion of the of the other side of the wrist, that's when you're putting the sensory component at risk. You know, I think this is interesting. I think that, you know, my concern still remain with the narration in terms of the proprioceptive loss, I think Elizabeth hoggets group has done a lot of work on that I struggle with, you know, the huge upside is that if you block a patient, and they do well with this, and then you do a degeneration and they do well, they're really happy because you've spared them a surgery, a different kind of surgery, that probably has a longer recovery. And then, you know, particularly like the total wrist innovations that the mayo group has published about, you know, for them, it's done really well for slack and snack riffs, it lasts them a certain period of time, it buys them time before they have to have a more palliative or salvage type surgery. The question is, you know, is your patient the right one he's going to be happy with? Wow, that's great. That got me a year or two before I had to have X y&z procedure with a three month recovery.

Charles Goldfarb: 38:23

Right? And then what's the effect of the previous generation on the recovery and ultimate function after that secondary procedure? That's the question. I totally agree. And that's why I'm not early to jump on on the denervation. option. But again, we clearly don't have the answer to all the problems. And sometimes our options for patients to consider for big risk problems are big risk surgeries, which are not always exciting for patients to hear. So this kind of work is again, very, very important. As much as I hate to praise nerve surgery studies.

Chris Dy: 38:56

Well, this is the, you know, nerve harming surgery part of it, where you're just going after the innervation. So I think it's interesting, I think it certainly has already influenced how I talk to patients, you know, I've talked to patients about you know, using this kind of approach, and some people are really gung ho about it. I think it's all about, again, patient selection, which is a very, you know, catch all term. But honestly, it's probably one of the harder parts of our job.

Charles Goldfarb: 39:20

Absolutely. All right. I'm off polymerization on the books today, which is exciting. I have another super interesting case as well on a kid that came up from Central America. So good day.

Chris Dy: 39:32

All right. Well, you have a lot of work to do. I've got some abstract writing to do. And then I've gotten out of clinic so very different days, but I'm gonna go package things very well for this. ASP and abstract deadline.

Charles Goldfarb: 39:42

Awesome. Have a good day. See you later. Hey, Chris. That was fun. Let's do it again real soon.

Chris Dy: 39:48

Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb: 39:53

Mine is @congenitalhand.

Chris Dy: 39:55

What about you? Mine is @ChrisDyMD spelled d-y and if you'd like to eat Email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb: 40:04

And remember, please subscribe wherever you get your podcast

Chris Dy: 40:07

and be sure to leave a review that helps us get the word out. Special thanks

Charles Goldfarb: 40:11

to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next week