Chuck and Chris are joined by a special guest, Megan Conti Mica currently at the University of Chicago. The three of us catch up a bit with a hand club discussion before diving in to a technical discussion of distal radius malunion.
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Chuck and Chris are joined by a special guest, Megan Conti Mica currently at the University of Chicago. The three of us catch up a bit with a hand club discussion before diving in to a technical discussion of distal radius malunion.
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, hey Chris.
Chris Dy:Hey Chuck, how are you?
Charles Goldfarb:It's a special day. I'm great.
Chris Dy:It is a special day is it because we have a guest
Charles Goldfarb:it is absolutely because we have guests but not just any guest.
Chris Dy:We have a guest that is very special to me. Megan Conti Mica is joining us for this episode. And well, we should talk about Megan in a little bit. You know, Megan is probably one of my favorite collaborators outside of Chuck.
Charles Goldfarb:That's, that's saying something Chris likes to collaborate as I think we all know he collaborates in research, collaborates with people like to talk about food weirdly enough, he talks he collaborates and all kinds of things. Oh, well.
Chris Dy:Before we talk about Megan, I want to talk about her husband, Mike, who I went. When I came there and visited, visited Megan, she was kind enough to let me stay at their place. And Mike made this amazing meal. And I know that Maggie can throw down in the kitchen too. It's just a great couple. I mean, this the quality of the chicken that I had, there was fantastic. And chicken is easy to mess up and it's hard to make really good.
Charles Goldfarb:You know, I was raised on a diet of chicken and rice. So I would have enjoyed that. No, I have no doubt. I have no doubt. All right.
Chris Dy:Well, you know, it's I'm thrilled that we're joined by Megan Conti Mica who is currently in practice at the University of Chicago but is going to be moving to Scottsdale for her for a new gig and a new transition. Pretty soon. She trained at Loyola and then went on to train at the world famous Mayo Clinic for her hand surgery training. Megan I've collaborated a lot and she's a dear friend of mine, currently we are in a hand travel club together, which has been super fun. But during the height of the pandemic, we were part of one of the Hand Societies' initiatives for online education which was Firsthand the masterclass in hand surgery with Peter Stern for about 14 months. We got together every month and you know, got to talk to some really great legends in hand surgery. So Megan, welcome to the pod
Megan Conti Mica:thanks everyone. I'm really excited to be here and it's super honored to have been asked to be here by you too.
Chris Dy:You're probably wondering why it took so long
Megan Conti Mica:no i you guys you guys invited me about two days ago so I'm more wondering who cancelled and I was you know F squad and that's why I got my invite
Charles Goldfarb:there was a long list of cancellations but but no you were our first choice we have a great topic to discuss a little teaser we're gonna talk about distal radius non unions and just general surgical approaches but you're honestly both Chris and my first you know first thought and I think we both have a relationship with you Chris obviously with Firsthand and travel club and and you and I were lucky enough to travel to Israel to represent the Hand Society with the joint hands society and Israeli Hand Society meeting and that was super fun to meet you know, Mike and meet your youngest and bond with you guys and my son. And it was it was really great.
Megan Conti Mica:It was really fun. I think we we definitely convinced your your oldest son who's going to medical school to maybe we aren't having children after watching us travel around Israel with a three month old.
Charles Goldfarb:I think that's true. But you guys made it look easy, even though it's not always pretty. He has made it look easy.
Megan Conti Mica:Yeah, I don't know about that. But thank you. And Chris, obviously always a pleasure to spend any time with you.
Chris Dy:It is isn't it? Yeah. Okay. All right.
Megan Conti Mica:Chris, giving you any type of problem.
Chris Dy:Oh, Megan, it's just it's so much fun. And it's always it's always very easy to talk with certain people especially. You know, it's kind of like Chuck and I do this frequently. When we were doing Firsthand. It was just such an easy conversation with you. So thank you for being a partner in crime on that one certainly had its share of ups and downs for sure.
Megan Conti Mica:It was fine. It was interesting educational all at once.
Charles Goldfarb:I have two questions. I always like to do two questions. The first I'll ask them both and then maybe each of you will take one of these. The first one is why did they cancel your show why they pulled the plug. And the second is I want to know more about that. That travel club because I'm in a travel club is a little different. So I'd love to hear more about that one, YouTube.
Chris Dy:Well, Megan, why did you get cancelled?
Megan Conti Mica:I know right canceled.
Chris Dy:I'm still on the air with Chuck.
Unknown:Oh, actually, we we chose to to stop recording with Peter Stern retired. Sorry. So it just seemed like the right thing to do. You know, it was it was just a timeline issue for us. But I, you know, in retrospect, I think we could have gone forever, right, Chris, we could have kept making video after video podcast after podcast. But I don't know if anyone would listen. So I think at some point, you know, things might have run its course. And it's time to move on to bigger and better things, which for Chris was, was this podcast and for me, it was silence.
Chris Dy:I have nothing to add, as you would say. No, I think it was a good time to transition. You know, in all actuality, we could have gone on forever and interviewed a lot of people, it would have been super fun. And very educational, especially at least for us. But you know, in reality, there was a lot of, I think, fatigue for online webinars, after, you know, two years of the pandemic, and just interest, I think, was starting to flatten for everybody involved. And I think that it was just one of those natural times, where with Peter retiring, and stepping down from a national stage it was it was the right thing to do.
Unknown:We felt right, exactly. You gotta you gotta retire on top. Right? You got to stop, stop waiting. People are still
Charles Goldfarb:interested in those royalties. And those royalties.
Megan Conti Mica:Yeah we're in syndication. I mean, it's great
Chris Dy:Yeah, we're not getting Seinfeld royalties, we, in fact, didn't even get any swag, which, which we regret. But yeah, I think it was, it was, it was a lot of fun to do. And, you know, I encourage anybody who hasn't listened to some of them, there's some just absolute pearls of knowledge that are dropped by a lot of really, really talented surgeons. And for us, it was super fun, just because he got to interview some of the Living Legends of hand surgery. So I think that's an opportunity that I will always have cherished. And about our travel club. We're kind of a small group. But you know, I think for a lot of I was actually just talking with one of our fellows who's graduating and I asked him, David Wright asked him if his generation of hand surgeons has started to form a travel club yet, because I know there are a couple clubs that have formed even after Megan and I are as a group. And it's interesting, because at least the way that I've seen it done is that it tends to be people who have kind of done fellowships within a couple of years of each other. And you get together on a, you know, annual basis and you know, get together when you're all at the hands of society and whatnot, and have a fun kind of trip. Obviously, there's some, some business involved, people bring families and you try to go somewhere where people want to go and it's a smaller kind of a casual meeting, we'd we had a lot of fun. When we got together, we've done a couple of meetings. And, you know, we talked about cases, you talked about the challenging parts of your practice, you can make it whatever you want, make it a research gathering that kind of thing, if you want to. So everybody kind of contributes, what they want, what they want to contribute. And I think there's a great mom that's built there. But what do you think, Megan?
Megan Conti Mica:Yeah, I think it's, um, it's, it's a very unique thing to hand surgery. My husband's a spine surgeon, he's super jealous. He keeps talking about doing something in the spine world, but I don't know if we can afford those types of bougie trips. But they're Yeah,
Charles Goldfarb:they probably don't like each other that much, either. That's the hand surgery versus spine surgery.
Chris Dy:Yeah, no, I think I was I was at the one dinner were where Mike picked the wine. And they were like, wow, this is the level we're all
Megan Conti Mica:I know, I know. You can't put Mike Mike food and wine, you gotta be very careful with putting him in charge, or you just had to kind of close your eyes and, and realize it's just gonna be the best of the best but, but reality is, is our travel club is I talk to you guys. I mean, on a monthly basis, that or someone I talked to, and it's for cases, it's for personal advice, you know, career advice. So it becomes, you know, it makes your world a little bit smaller, but also that you feel supported with questions that maybe you don't feel comfortable asking your partners or you just want somebody else's opinion that does these surgeries more often than you. So I mean, I've had some disaster cases, and I call up Dave Brogan, because I'm like, man, if there's so many who knows disaster cases, it's this guy. And he's given me sound advice that I've followed. And it's been really, really helpful just to send out you know, the bats, you know, the bat signal and, and see who, who responds.
Charles Goldfarb:I love it. My travel club is a little different. It's just congenital. It's in small international group and it sort of source of a different purpose. But I think I want to go back to what you said, because it's really important for those younger listeners, is when you start practice, no matter how prepared you are, you the things that seem simple and fellowship and residency are no longer simple, and the hard stuffs harder. And I told I didn't have a travel club when I started practice. I had three really good hand partners. So I would ask each of them questions intermittently, and then you feel like oh my god, I've asked Marty Boyer too many questions, send an email or call Dr. Stern, and then all of a sudden, you're asking too many questions, you're like, everyone thinks I'm an idiot, I need to find someone else to bounce questions off of, which is just the facts of life. And I think your, your points are really good one, and really helpful to hear.
Unknown:Its also the practice management issues as well, like you run into problems, and you ask your senior partners, and they're just at a different level in their career. So they, when they have to solve problems, it's just a little bit different, you know, like, they've been there for 10-15 years, they've already established a voice, and you're early in your practice, and nobody really cares about your voice, per se. And so it's learning how to navigate those types of situations and, and having somebody else who's just going through the same thing, it's, it's really valuable to have that lateral mentorship as opposed to that up and down like that superior mentorship.
Charles Goldfarb:You know, one way to gain more mentors, and I've heard this as can be really helpful, is just to move your family to a different location, and meet new people. And you can ask more questions, as anyone tried that strategy.
Megan Conti Mica:I'm in the midst of trying that strategy. And let me tell you, it's better just to make cold calls, I think there might be easier. But yes, we're in the midst of a move. This is my, I've been with the universe Chicago for eight years. So this is my first move. So I've been really, really lucky that I've had a great run, and haven't had to move practices early in my career, I really got to stick it out in build groups. But that also makes it harder to move. Because you have built routes, and you have a great practice, and you have great patient population and referrals. So it is a little scary to not only be leaving something that is really good to move somewhere else. But it's also it's a lot, it can be a little complicated. And so I'm really excited about it. We're moving back to Arizona, which is where I'm from my husband is getting a great gait, I'm getting a great gig. So fingers crossed that, you know, this is this a good long term move for us and for our family.
Chris Dy:Yeah, they're lucky to have you there in that practice. And it is obviously a loss for years. So you Chicago, because you were very involved with their fellowship and residency training and a beloved mentor for them. So they'll miss you. I know you'll keep up with your relationships with them. But you know, for the future trainees at the University of Chicago, it's you won't get the Megan coffeemaker love that everybody else has gotten. And so many people have spoken fondly of.
Megan Conti Mica:That's really sweet of you say, but they all know that I'm always a phone call away. And I we're gonna be visiting Chicago all the time, because my husband's family's here. So they already know, I've already planned to come back for graduation next year. So they can't get rid of me that quickly.
Chris Dy:And I think one more thing, before we jump into our clinical topic for today, you're kind of a big deal. You're running the annual meeting for the hand society this year with our hand club, buddy page, Fox, so let's snap in, like Chuck's done it before. I hope to not do it.
Megan Conti Mica:It's been you know, it's actually been an honor. So first of all, I get to do this with Paige Fox, who was my co Fellow at the Mayo Clinic,
Chris Dy:it's supposed to be called the world famous. That's what that's what David calls it whenever he talks about it.
Megan Conti Mica:Well, Dave, Brogan knows, I mean, I don't even need to say world famous because everybody knows it's world famous. So it's kind of almost redundant, I guess there'll
Chris Dy:be you FMC is whatever. But
Megan Conti Mica:I mean, it was a wonderful place to do fellowship, absolutely. No question about it. But she, it's been amazing to, to get to build up that bond, again, if somebody that I did fellowship with and we're actually going to be in Toronto, which is one of our other co fellow Heather bolts, or that's her stomping ground. So she's been helping us a lot with locations, restaurants, stuff like that, but it's gonna be a great meeting, it's gonna be a different meeting. Because we're back and be in the United States, we're going to be Toronto, so please get your passport in order. That is my biggest fear is that people are going to show up to the airport, and then all of a sudden realize they need a passport to go to Canada. But the meeting is gonna be great. We've done a lot of different things, there's going to be a lot of different types of debates, that we're gonna have a lot of different symposia as, you know, Masters giving lectures and, and having one on one with Master. So it's going to be a lot of new content and a lot of more diversity and voice it should be, it should be really exciting.
Charles Goldfarb:It looks great. And you know, I have been through this. It's not easy. It's a lot of time and you have done this without Angie. So the transition, I'm sure was a little more challenging at least town. And it's always easier if you know your creative thinker and I'm sure pages as well. It's just easier to do what's been done before. to branch out is hard. It's hard to create the content or the concepts, it's hard to get speakers to agree to it. So I think we're all looking forward to it. So congrats in advance and passport is good to go.
Megan Conti Mica:Yeah, it is hard it but you know, change is always scary. Definitely, we're with a new acsh group for annual meeting planning. But everybody has stepped up to the challenge, and everyone is making this the greatest meeting. So sorry, Chuck, we, we have to take that from you. And hopefully the year after us, they do even a better meeting, and that we keep building on each other.
Chris Dy:I think it's gonna be wonderful. You always bring such great energy. And I'm sure the meeting Planning Committee and the staff are very happy with that. Chuck, we should probably thank our sponsor, before we dive into this distal radius, malunion topic.
Charles Goldfarb:Absolutely. The Upper Hand is sponsored by Practicelink.com, the most widely used physician job search and career advancement resource.
Chris Dy:Becoming a physician is hard finding the right job doesn't have to be joined practicing for free today at www.practising.com/the. upper hand. And I'm sure Megan probably has looked through a lot of practice, practice resources and job searching resources as she's looked at that transition. In practice.
Unknown:It's nice to have something in one- in one place.
Chris Dy:So take a look. There you go. She's plugged into Practice Link to look at that.
Megan Conti Mica:I'm hoping you'll ask me back one day, you know, well, there's
Chris Dy:a lot of stuff that you should we should have you on to talk about. I mean, when I think, you know, in all seriousness, I think that you've done a wonderful job with advancing, advancing and academics and reputation and establishing yourself as a presence both in hand surgery in general, but also a lot of our topics about, you know, trying to establish more diverse and inclusive training environments. And you know, you've done fantastic work with that. So I guess we'll have you back.
Megan Conti Mica:I won't see how the actual content goes before.
Charles Goldfarb:Yeah, let's see me downloads we get here. No, I think I think oh, my gosh,
Unknown:I'm calling my family. And if that's what's based on downloads, I have a very, I have a Catholic side of the family and a Jewish side of the family. They will be all over it
Chris Dy:Five Star five star reviews all commenting on Mexico on TV because I do it
Charles Goldfarb:a little afraid you guys are scheming to boot me off the upper hand which
Chris Dy:firsthand?
Charles Goldfarb:I think the no brainer invitation, which which you may not feel like doing would be after the hands study, we used to do a debrief. So maybe if you have the energy and the time post hands Saturday, we could we could gather and talk about that. When I do preach that
Megan Conti Mica:I'm in. Alright, so Chuck, what you want to talk about today?
Charles Goldfarb:Yeah, you know, one topic, which I get asked about a lot, and you have a case that can be delightful. And it's also a case that can be really challenging as the distal radius malunion. And so there are different ways to approach the classic malunion. So let me paint a picture. And then we can discuss, we want to be a little technical about how we would approach things. So the picture is this. So we have a 60 year old, very active young lady who has a classic distal radius fracture. She fell while playing pickleball
Chris Dy:and I knew you're gonna say pickleball I actually saw this patient yesterday.
Charles Goldfarb:And unfortunately, she is a tough lady and kind of wanted to talk it out and you bought a splint at Walgreens and put it on and she comes in to see us five weeks later, not in any pain, but with significant deformity. So she had a classic distal radius fracture metaphyseal colles type, and she now has 35 degrees of dorsal tilt. Her you know, the relationship between the radius and the ulna, it seems like the ulna is now long. I personally have a hard time figuring that out when there's so much dorsal tilt, it's an extra articular fracture. Again, she's not having any pain, but she she comes in to see and maybe Chris, you can start with you. What's your first you know, you're having the initial conversation with her in the office. She does not have evidence of nerve issues. I know you're going there. And she just comes in with deformity.
Chris Dy:No, I feel like this is a patient that we all see and so, this is somebody who has automatically self selected to attempt at non operative treatment because sometimes this is the other way that this this kind of scenario comes up is that you try something and they They slipped into dorsal angulation. You know, sounds like based on the patient profile, you know that I would this is somebody who I would think about, you know, fixing if they had come early on anyway, fixing with surgery. So we could start some earlier rehab. You know, so I think the conversation is more about, you know, what are you looking for in terms of, you know, return to activity? I think it sounds like they want to get back quickly. I do have the conversation about the appearance of the deformity, not necessarily only for aesthetic reasons, but I found that that comes up. And I think it's important to be proactive about, you know, saying, it's going to always look like this, there's always going to be that bump on the pinky side. If we don't do something about this, are you okay with that, but I think there's, you know, pretty, pretty strong consensus in the literature that leaving somebody at this age with this desired activity level with that amount of dorsal angulation is going to have negative implications on their functional outcomes, particularly grip strength, and kind of activities of daily living. So it is a discussion about, you know, we got to break your bone again, and put it back in place and get you going. Megan, what are your thoughts?
Megan Conti Mica:Yeah, I think it's, it's a long discussion, because it is tricky, because they're not symptomatic right now, in the sense of pain, but the question is pronation, supination, are they having that block of rotation, and that's where these mal unions can cause a lot of issues. And so if she, you know, this is her thing that's keeping her mentally active, physically active, is pickleball. And she's not able to move the racket in all seriousness, that's something to discuss, yeah, maybe she needs some physical therapy or occupational therapy to get her back. Or if this is something surgically, we need to fix because there's a bony block. I think the long term conversation is, there's complications with surgery, this is not a slam dunk surgery. And when you lay everything out to the patient, they have to make a decision. Ultimately, this has to be a shared decision making situation. Because one, there is a lot of opportunity for this not to go exactly the way they want. And they have to understand that the risk is not really going to be exactly how it was before the fracture.
Chris Dy:No, Megan and Chuck, and I end up getting a little bit of an echo chamber just because of the podcasts. And then also, because of our, you know, conference interactions and stuff, what are the complications you talk about with, with this kind of patient or a distal radius patient who's coming in for an acute fracture, and you're talking about surgery versus you know, non operative treatment?
Megan Conti Mica:Yeah, um, I have seen a lot of complications, practice so far. And so it's been pretty humbling. So I don't just see fracture, fixed fracture, or see X ray of malunion. fixed value again, because I've seen what happens afterwards. And, and it can be pretty devastating. I've had, I've actually had non unions happen. And it's not fun to have a non union of this because it's, it was hard. The first time you did that corrective osteotomy. It's even harder the second time. So you know, tendon injuries, especially if you're doing a opening wedge osteotomy, that EPL can be definitely injured. It depends if you're going dorsal or volere. So the plate placement, I personally always go Buller, because I am post boilerplate invention, and so I feel more comfortable going volar. You know, so patient health, like pathology, their biology, if they're going to heal this thing. And then also their range of motion afterwards. A lot of times these patients, they go in there, they're in a cast, and they may or may not be doing early range of motion, and then they have a lot of stiffness. And they came with the word stiffness, and now they have a different type of stiffness, that can always be frustrating. So infection, I mean, I can keep going.
Charles Goldfarb:So awesome. I have a lot I want to unpack from what was said. So first of all, I think your point about rotation is really important. And sometimes, you know, if we call 80, and 80-80 degrees are pronation add supination. Normal, it's not always terrible rotation, but it's just not what they had before. And for some patients that matters, at least in my experience, for some patients, it doesn't it mattered for this lady. So that's, that's a great point. And then when we think about the appearance, I think about it in three buckets. You know, Chris mentioned the prominence of the owner, that just Oh, no, that's certainly an issue. The actual deformity of the radius is an issue. And the third one, which can be a little tricky to figure out clinically, but it's more apparent radiographically is the loss of radial inclination. And in the classic fracture, that's a big deal, maybe in this one too, and we can talk about it for corrective purposes. Because if you lose that radial inclination, as I think we all appreciate that, you know, the wrist just tilts over and it's not a functional issue at all. But it is a big appearance issue. So my question they hate that zigzag deformity, they hate it, they hate it. So my question to you both because I think you guys are in a different generation, and I think it was a dig to say I was in the post folder plate era, I was in the pre volar plate era barely
Megan Conti Mica:when dinosaurs roamed the earth. That's right,
Chris Dy:Intern in the 1890s, you wanted me to be very clear on that.
Charles Goldfarb:My question is this. We, in all seriousness, in my residency and fellowship, we talked a lot about adaptive mid carpal instability. I don't feel like we talk about that anymore. And so just and I'd love both of your opinions, but to quickly define it. This is a situation which would allegedly cause adaptive mid carpal instability, a lot of dorsal tilt, and you lose wrist flexion. And so the theory from Fernandez was, you would, quote, break in the mid carpal joint, and you'd get extra flexion and mid carpal joint your lunette would go dorsal? And I just don't know that people talk about that anymore. Am I right? Or am I wrong?
Megan Conti Mica:You are right. And I think the reason why we talk Don't talk about is we're trying to avoid it. Because I don't think we have a great solution for it, especially if you have a, an older malunion. Because that's when that happens. There's usually two types of mid carpal involvement. One is that as you were talking about the adaptive mid carpal dorsal instability, but the other one that we don't talk about is just that subluxation. And I think the subluxation is easier to fix with the osteotomy. But the studies haven't supported that the osteotomy is actually going to fix that malalignment. And that's something to think about. And that comes back to that whole thing. Your wrist is not going to be the same after your surgery.
Chris Dy:Well, I think, you know, you're getting in there. I mean, you know, five weeks is much better than six months, you know, in terms of, you know, the development of that adaptive mid carpal instability. I mean, I remember reading about that when I was in training and but not ever really seeing it, and then practice. And maybe it's seen me, but I haven't seen it, so to say,
Charles Goldfarb:yeah, it's super interesting, because when you have that dorsal tilt, sometimes the loonie goes with the distal radius, and sometimes it doesn't. But you're both right. And in this case, it's not a discussion point, because it does happen over time. And so at five weeks, you know, we're not too worried. Alright, let's jump in if it's okay. To some technical. So, Megan, you're gonna go volar. Chris, are you going? Yeah, molar?
Chris Dy:No. Dorsal?
Megan Conti Mica:Oh, my goodness. All right.
Chris Dy:No, no, have learned different techniques other than just rollerblading.
Megan Conti Mica:Okay, guys, you're poor. I know that you're only worried about nerves. But there are tendons back there. I haven't bought them as secondary surgery. Have you seen that play out afterwards?
Chris Dy:I would argue that sometimes the volume plates a little not not nice to the flexor tendons to in what?
Megan Conti Mica:You're actually very, you're Yeah, that's a really good important. And especially when you have these dorsal angulation mal unions, which are the more common ones, right, it's not usually the bowler angulation. And that prominence when you do the osteotomy can make those fixed angles, not fit, fixed angle plates not fit correctly. So your that is a very valuable point. But I'm really strong, and I can then those plates, and I can do ask the tech to me, so I'm able to make those plates fit.
Chris Dy:I like well, I mean, I liked the boiler plate, I think a lot of people will use it as a reduction aid. You know, I think that that is a really nice technique. And I've done it and you know, I think that if you're going to use it as a reduction aid, and get the plate exactly where you want it or you have to defend it, like you're saying with your very strong hands.
Megan Conti Mica:That's just, that's just a you know, an online dig on you.
Chris Dy:Well, if you have to, you know, I think before you use the plate as an aid, you really got to make sure that you're completely released on the dorsal side. So when I go volar, I end up making a dorsal counter incision for two reasons. One is to make sure that you're completely released on the dorsal side. And then the second is to look for those extensor tendons to make sure you're not going to butter them up, particularly the EPL because in a male union situation, you know, the anatomy, I think, is somewhat a little distorted. I'm probably in the minority. I saw Chuck grimacing as I talked about a dorsal counter incision, which is why I would just go dorsal.
Megan Conti Mica:Alright, so Well, I I'm excited to see what Chuck has to say because I'm feeling we both do the same thing. Alright. Of course you do.
Charles Goldfarb:I'm sure. I'm sure we do. So I think we've already heard two really important technical pearls and I think think Megan years is really, really important. And I don't think I realized it for years. So if you're going to go volar, and you're going to use the boiler plates, which are all pre contoured. And if you don't restore volar tilt, and you just accept neutral, and I'll be honest, I accept neutral all the time, then you are setting yourself up for problems later, because your plates going to be prominent, so super important that you either restore volar, tilt, or contour the plate. So I love that point. And the crisis point is also good. You don't always have to make a dorsal counter incision, but you have to be aware of the tendons, and you have to keep them safe if you go volar. So love those types of two pearls already. So Chris, since you're clearly in the minority, why don't you briefly walk us through how you approach this? dorsally?
Chris Dy:Right, yeah, so I usually end up taking the dorsal position here, when we're in conference, because everybody else except for Marty wants to go volar. So, honestly, if you could go, I would, I've done it both ways. And I think that, you know, both will work. I like going dorsal just for the reasons that, you know, I stated in terms of avoiding, you know, knowing exactly where I'm released, but then you come into the same issue of making sure that you're completely release vulnerably, I think you can, you can kind of peek around from the radial side and make sure all your bone is released. Through your approach. I think that the concern for the tendons is not as big as you know, as it was when you're using dorsal plates that were like tendons shredders, I think the plates are lower, better contoured now and have smoother edges. And as long as your screws are sitting flush in, and I'll be honest with you, I think it's dealing with an extensor tendon issue tends to be a little bit easier to dealing with the flexor tendon issue down the line. And I have not found the dorsal plates to be as prominent and bothersome as others have described. So I can't honestly remember taking you out to dorsal plates, knock on wood, but have taken out volar plates that are both I've put in and and others have put in, you know, a number of times over the years. So, you know, in terms of doing the approach, it's a pretty simple approach, pretty straightforward. Starting to move transpose your EPL, identify and move it go between two and four. And then really identify, you know, your fracture plane, just like any sort of corrective osteotomy localize it on fluoro. You know, I tend to use, depending on the case, I'll either use a saw or just an osteotome. And I think your points about trying to restore the the right amount of the volar tilt is good. Even if you're not using a hole or play, I do try to go for a roller tilt, rather than just neutral.
Charles Goldfarb:So in this case, Chris, do you use the plate as a reduction tool, but we're only five weeks out? Hopefully the reduction is not that hard to get? Are you creating your opening wedge, and then just maintaining it and putting your plate on? Do you use bone graft? Those two questions I think would be helpful to hear.
Chris Dy:So I don't think you need to use bone graft. There's a number of papers out there demonstrating that you don't have to actually like the tip that my hand Club partner and our actual Wash U partner David Brogan does, you know, after I do the wedge, I usually usually use some of those cancellous chips or croutons to help kind of provisionally hold it in place as a wedge, knowing that it's not structural truly, but it's going to help me kind of see where I want things to line up, I tend to use a provisional K wire to really help hold my reduction kind of from the styloid towards the metathesis. And really get the tilt just right, I tend not to use any pretty contour dorsal plates to be honest with you the system that I'd used before I found the plates to be rather chunky. So I ended up using a mini frag plate and usually a T type plate. And honestly, manually with my strong hands, bending the plate to dial in exactly where I want it.
Charles Goldfarb:Megan, any any questions for Chris, before we pivot to your description of a vote approach?
Megan Conti Mica:Yeah, I think we've kind of clumped all of the distal radius and all unions together. Do you change your approach when it's fuller versus dorsal? angulation? Yeah,
Chris Dy:I think so. I mean, I'd say it would depend on the deformity. And you're right, we're clumping it all together. So to be very clear, you know, this is a dorsally angulated fracture with dorsal displacement of the distal piece. There is no intra articular involvement, at least of the male union components. So, you know, we're not, you know, trying to equate everything together. But, yeah, I think I would, you know, I think that this one's easier because I go dorsal cuz that's where the deformity is.
Megan Conti Mica:Yeah, I just, the other question I have for you is, what do you do with the owner? So the owner side, if, you know, obviously, if there's still length issues, or at which this patient, I believe, had a length issue with possible the starting of carpal abutment?
Chris Dy:Well, I think that, you know, as Chuck mentioned earlier, I think it's really key to get your length and inclination, right. And I think that getting the radius out to length, you know, in this particular situation in five weeks, I'm not expecting it to be very challenging to get the radius out to length. And I think that is honestly easier from the dorsal side. And I tend to use an osteotome as a reduction tool to just kind of tease up that radial side and then pin it or wedge it exactly where I want it. I get kind of OCD about this, but I get it exactly where I want it. And then I put the plate around it as opposed to using a plate as a reduction aid because I'm going from dorsal. Chuck, what are your thoughts? I mean, I know that we've got to wrap up soon. So
Charles Goldfarb:well, I we got a few minutes, I think the great points on going door. So when I go dorsal, I like to croutons tip just as a temporary reduction aid, you know, or you can use K wires, okay, whereas they're a little cheaper. And we shouldn't be going for anatomical restoration of the distal radius, and hopefully that obviates the issue with the distal ulna. I don't love doing a distal radius osteotomy with an owner shortening osteotomy. But I think we have to be honest with ourselves in a different situation, longer standing, it may be harder to restore the anatomy. And you should go ahead and do the owner shortening if there's any doubt, right? Since we get ourselves in trouble saying it'll probably be fine. Or we can always come back and do another surgery. If you think it's gonna be an issue, and you can't really restore the length of the radius and you should shorten the owner.
Chris Dy:Do you consent for possible on the shortening osteotomy? When you have a spidey sense that it's going to be challenging?
Charles Goldfarb:I do. I still try not to do it. But I do. And the other thing, if you truly are lengthening things, let's say it's a two years out, and the illness seems really long. I hate to you know, bring nerves back in the picture. But in that case, I always do a carpal tunnel, I don't think in this patient, five weeks out, I would necessarily do a carpal tunnel release. Megan, what about you?
Megan Conti Mica:Well, I think I think we have to take a step back of going dorsal versus volar. So the dorsal you're doing an opening wedge osteotomy. Whereas if you have older, you're probably gonna be doing a closed wedge osteotomy, which decreases your length and you probably are going to have to do something with the old map. So then, so I just before I even answer the carpal tunnel question, I do think that's important to point out is that, at the end of your procedure, you really have to look at that length and see what you have and have not obtained and make a decision. From there, what you need to do with the ulna. I mean, if you know less is always more, but if you do distal over section, you can always use that. Or even if you do an owner shortening osteotomy, you can use that as bone graft, so that you can not use those bone chips and save a little bit of money. You know, we don't have the fancy WashU money on the south side of Chicago. But there's other ways of using that bone and not just throwing it away.
Chris Dy:But then just like the you know, it's like you talked to the spine surgeon local bone graft.
Megan Conti Mica:So, but the other part of it is the, the carpal tunnel, I don't think you ever lose anything by doing a carpal tunnel release. So if you like it runs through your head and makes you do carpal tunnel release, just do it. You know, it's like, it's like doing fasciotomy you're never gonna feel bad about doing it, you're gonna always feel like, well, you know, we saved ourselves from something worse. So I usually talk to the patients about it. And, you know, it doesn't necessarily mean I'm going to do it, but it's there.
Chris Dy:Especially if you've got if you're at a place where they're very efficient about preoperative blocks. You know, then then there's no, there's no way to know after they've done the preoperative block about whether there are carpal tunnel symptoms, I agree low threshold to to do a carpal tunnel release, Chuck, before we go to volere, or technique pearls. Are you bone grafting? On the regular?
Charles Goldfarb:No, not bone grafting? Almost ever. And I agree with Megan Megan's comments about carpal tunnel. It's really it really is interesting. The block point is really important, because I think about that every time I'm in, we block almost everyone. But if I'm doing any type of osteotomy, I think twice about whether to say yes to the block, or I'll do a short acting block, you know, as for a six or eight hour block, the problem becomes pain control gets really tricky in those patients. So you get pain relief for six hours, and then can they catch up and keep up? It's It's tricky, but I think you have to err on not blocking, if there's any concern for post operative challenges with swelling, which of course there would be here. So Megan, what I mean, we all know how to do a bowler approach. But how do you think about once you've done your volere approach? What are your steps to you know, create, recreate the normal anatomy?
Megan Conti Mica:Yeah, I think the biggest thing to add that you don't do the dorsal approach really is you can use the plate as part of your reduction, which is what Chris was alluding to previously. And I think that's important too. Talk about because sometimes when you're doing these open, wedge osteotomy, they become unstable. And then all of a sudden, you're you've made a hard surgery harder, because now you have two very unstable components that you're trying to stabilize. And so if you put the plate on end, you can get your distal screw holes by putting the plate on, do a couple of drill holes, some K wires, make sure you're in parallel with the articular surface. And then you take the plate off and do your osteotomy, you have at least the placement of the plate distally. And that makes at least one component. Easy, and then you can just realign that with with the shaft. So that is a pearl. That's, I think, really important to remember of pre planning for this osteotomy by making sure that you know where your play is going to go so that you're not having to unstable edges, and then all this space that you're trying to fill or not fill, making it harder for yourself.
Charles Goldfarb:Yeah, I think that's a really good point. It's what I run into trouble, maybe too strong, but I have to carefully think about the placement of that plane, especially if I'm trying to increase radial inclination at the same time. And so you have to be really precise on how you conceive of where that plane is going. But if you get that, right, the case is over. Right, you've already you've finished the case.
Chris Dy:Yeah, the carpentry and this has to be, you know, really spot on and perfect. From the get go. You know, and I think that your point about you know, taking a case, you know, that is you're taking a segment that's stable, but the forum, but then having to very unstable segments can be really frustrating and challenging. You know, so I think pre drilling on the far side is super helpful.
Megan Conti Mica:I just, you know, I forgot to mention this. Chris, one of the things that I do for that dorsal scarring is I will put a lobster claw on the radial shaft, and then I'll rotate the components away from each other. And then I feel like I can really release that scar tissue dorsally by by rotating it, I used to actually with subacute, distal radius fractures that show up to my clinic later in the game. So that's another way of not having to make that dorsal approach,
Chris Dy:you really gotta have that thing completely free dorsally. And I think the error, you know, and I've learned the hard way is that you're like, oh, it's probably fine. But I think that, you know, the probating that distal fragment or moving the shaft to is helpful just to really get to the far side of it and make sure especially as you're over, you know, just proximal to the sigmoid notch on the other side.
Charles Goldfarb:Yeah, that that's the, it's probably fine. That's going through your head, as you're doing cases, like this is always sort of the kiss of death, especially if your day is going crazy. You just can't let that happen. But I think both your points are really good. So the orb, a technique of pruning the radius out of the way is really great. But you have to make sure your dorsal release is complete, or else you will not correct the angulation that you need to correct. So super, super important. Great, I love that what other what other volere thoughts do we need to finalize.
Megan Conti Mica:So I don't, I don't want to bring up another huge topic as we're trying to wrap up. But I do want to point this out, because this is something I've learned and been burned with. I've had inter ticular disorients millions, and I'm intrigued to hear what you guys have to say, where I have done personally personalized jigs, where they take the CT and then make jigs, and you spend all this time planning out your osteotomies. And you think it's gonna be really, really easy, because it's like, make a cut here, you make a cut here, you make a cut here and you put these little jigs on step 1234. And it's almost like paint by colors, you think it's gonna be really easy. And then it's not because you have engineers who are looking at the CTS and making these jigs, but they're not surgeons, and you're starting to realize, oh, my gosh, there's a lot of scar tissue and trying to rotate this component and this component is not as easy as, as 123. And I and I've struggled with those cases before because of scar tissue.
Chris Dy:We do need to have a separate episode for this because I feel like we just had this conversation. Sorry, I we just had this conversation there a hand conference earlier this week when Lindley wall was talking about a materialized case that she did using custom jigs and the challenges of what surgeons think versus engineers and where the engineers will try to put the plate versus where a surgeon wants to put the plate.
Charles Goldfarb:Yeah, I it is a really important point. So we have our part to that we're gonna have to do
Chris Dy:it. Sorry, Chuck. I just have one more question. I think it's pertinent. Is this a standard kind of distal radius fracture rehab for you guys? Or are you immobilizing them for longer after this kind of thing? especially if you're there, you've got a wedge and you're not grafting that kind of thing? Or do you just proceed like you normally would?
Charles Goldfarb:Okay, oh,
Megan Conti Mica:check, I wanted to answer that first, but I, I'll go, um, it depends on the patient, honestly, it depends on the fracture or the osteotomy. And you know how strongly I feel like this is going to heal. So, you know, I do think you need to do a little bit of range of motion, some gentle range of motion just to keep them moving. Because you know, a lot of these guys, these guys and girls are stiff. And so all of a sudden, you splint them until they have union, and they're even more stiff. So I think it's important that they have the tendons gliding, and there is a little bit of motion. But I, again, this is going to be patient specific.
Charles Goldfarb:If you have a good plate, these plates are really strong, and the bone is reasonable. Even if you've created an open wedge osteotomy I think it's okay to start early therapy with splinting between therapy sessions and no crazy therapy. So I do I do start early. So this has been super fun. Thanks for joining us. This has been great. We definitely thank you guys. Part two, part three. Keep going. Oh,
Megan Conti Mica:I just I tried to. I'm trying. I'm just trying to like weasel my way in.
Charles Goldfarb:You've succeeded.
Chris Dy:It's been a joy. As always, Megan, good luck with your upcoming move. And we look forward to having you back either before or after the annual meeting. Yeah,
Megan Conti Mica:I'll hopefully see both of you at the meeting. Thank you guys so much. This has been an absolute blast.
Charles Goldfarb:Thank you. 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 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.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time