Chuck and Chris are joined my Marschall Berkes, Chief of Orthopaedic Trauma at Washington University Orthopedics to discuss clavicle fractures. Recognizing that many hand surgeons treat the entire upper extremity including clavicle fractures, Marschall's perspective will be interesting to many listeners. We discuss indications, approach, technique, etc.
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Chuck and Chris are joined my Marschall Berkes, Chief of Orthopaedic Trauma at Washington University Orthopedics to discuss clavicle fractures. Recognizing that many hand surgeons treat the entire upper extremity including clavicle fractures, Marschall's perspective will be interesting to many listeners. We discuss indications, approach, technique, etc.
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.
See https://checkpointsurgical.com or www.nervemaster.com for information about the company and its products as well as good general information about nerve pathology.
Please complete our Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe wherever you get your podcasts.
Chris Dy:And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts. Oh, I aggress Hey, Chuck, how are you?
Charles Goldfarb:Fantastic. How are you?
Chris Dy:I'm good. It's a weeknight and we're joined by a special guest who didn't want to do it over zoom. Wanted to come over and hang out.
Charles Goldfarb:That's what a bromance looks like. I love it.
Chris Dy:Just a couple of guys drinking some Bordeaux hanging out with Chuck.
Charles Goldfarb:Some bordeaux. Wow.
Chris Dy:I have to say it's my it's probably a first in terms of drinking wine while on the air. But you know, it's kind of like Make Me Smart. The other Friday afternoons on top and for joining in.
Charles Goldfarb:Absolutely. It's perfectly appropriate. Well let you know if you get out of hand. I think it's a great idea.
Chris Dy:Absolutely. Let's introduce our guests, we're joined by Dr. Marschall Berkes, the chief of the orthopedic trauma service here at Washington St. Louis.
Charles Goldfarb:Yeah. Welcome, Marschall.
Marschall Berkes:Well, thank you guys for having me. I'm not sure what this is gonna look like. And I apologize in advance for offending your viewership. But hopefully, we can talk about some fun things and learn from each other. So it'd be great.
Charles Goldfarb:Yeah, I think you're you're the first of this category of guests that is not in the hand world. But you are in the travel world. And I think you certainly have things you can teach us.
Marschall Berkes:Well, you know, I don't know if I can teach anything. But I think we all have experience. And that's the best teacher. Right. So looking forward to going through this. Love it,
Chris Dy:Chris. And I go pretty far back. We're about to celebrate our 10 year residency, graduation anniversary, which for you, Chuck is probably 30 years ago. But yeah, so we did our training together in New York City and orthopedics. And then Marshall did that great thing and helped serve our country and was stationed in Germany as part of the United States Air Force.
Charles Goldfarb:That's incredible. I don't how did that not know you guys were residency mates. So what happens when you get older you forget what you knew, and everything seems fresh.
Chris Dy:That's the beauty of it, isn't it? But Marschall, Marshall has been here at Washington University finishing his military career and has risen to the rank of chief in the trauma service and is a trusted colleague, and essentially the go to person I think, for many of us for our orthopedic trauma needs.
Charles Goldfarb:Yeah, well said, well said, I feel luckier than ever to have him on the show.
Chris Dy:I don't want to talk him up too much. But he's one pretty much every teaching award out there at the University for our departments, many of which you have are also on Chuck. So he's here to give his perspective on things. And I have an interesting case I wanted to discuss,
Marschall Berkes:let's go for it.
Chris Dy:So there is somebody who I treated early on in practice, who had a humeral shaft treated with the plate and screwed construct by an orthopedic trauma surgeon here, who subsequently developed a radial nerve palsy. And I actually went in and exposed the nerve and did not realize this. And she did incredibly well to the point where this is one of the videos you show at a meeting like they do so well from just quote just the neurolysis
Marschall Berkes:nice, like so in clinic. It's like, Hey, hold on, let me let me get the video done. Again,
Chris Dy:if it didn't, I'm like awkward one handed iPhone video long. They don't have the resources for anything better than that. So. So yes, she does. She's doing really well. I see your back, you know, I see your back for a couple of years. And I tell her follow up as needed because she's doing so well. And then she comes back recently. So fast forward kind of five years later, has lost a lot of weight after a gastric bypass surgery. And now her radial nerve is starting to irritate her again. I'm thinking maybe this is something more like tennis elbow, she's just having pain doesn't have a frank radial nerve palsy, put her through the whole workup like our maybe it's just radial tunnel. But as part of the workup, she gets an updated nerve study showing the nerve is working reasonably well. But the ultrasound shows the nerve just kind of strumming back and forth over the plate. And I was surprised by this. I told her I wasn't sure what to do about it. I mean, have you seen anything like that and years down the line? Well,
Marschall Berkes:I you know, first of all, I would be curious to see what an ultrasound of any humerus with a plain screw looks like with the radial nerve in relationship to it. Right. I mean, you're looking at the one that okay, there's symptomatic, but similar to getting ultrasounds on asymptomatic shoulders that have surprised rotator cuff tears, like, I'm not sure how you interpret that but given the clinical context and symptoms, makes you think I suppose. Have I seen that before? No, maybe it's seen me however. I mean, you're You're a smart, observant guy and unless so, so, I don't know. I mean, that's, this was a posterior approach post your plate,
Chris Dy:posterior plates, some inner fragmentary screws. Okay? Did you run across anything like that in the past in your in your
Charles Goldfarb:practice? No, I have not. But I did take out some hardware today I was thinking of Marshall and our being our guests tonight, I took out some hardware that was placed overseas 14 years ago, play that was super fun, and made me want to be a trauma surgeon. Sounds like that's your strategy here, Dr. D, you're gonna go take that played out and take care of the nerve.
Chris Dy:So yeah, we talked about the options and said trauma surgeon has since departed WashU. And so here I am with taken out large bag screws that told our fantastic fellow Anamosa, who's plastic strings, that these are probably the biggest plate screws it's ever going to handle in his career. But he handled it with a plumb and neuralyzed to the nerve. And but it was intra operatively, it was really stuck down to the humerus. And then on the lateral side and, and posterior Lee, as expected it was, if he's to the plate, there was a little mobility there. But I was surprised as the mirror came around the distal third of the humerus on the lateral side, in order to neuralyzed that off, I've never neuralyzed nerve by preserving a cup of periosteum. So that was a challenging part of the dissection. You know, it's always interesting when you're working around the radial nerve with a 15 blade, but, you know, I figured I would leave a competition with the nerve. And that was the best all the tissue. I mean,
Marschall Berkes:that's sort of, you know, the the essence of the informed consent and like, hey, you know, how are we going to make you worse, potentially. And so I think that's a pretty deep conversation, but you need to have the patient with a eyes wide open type of approach, because, you know, you're really going to regret having, potentially currently depths, it's not that that would happen with you, of course. But it could happen, it
Chris Dy:could happen. I mean, I have the spiel down to, you know, pretty routine phrase in terms of, you know, the chances of me making worse are pretty low, then you knock on wood, but I tell him, it's not zero. So it's something that we both need to acknowledge.
Marschall Berkes:So how far out is this patient now from their last intervention,
Chris Dy:and therefore, I can't really say, not enough work and devolve understood, but post op exam, initial post op evaluation have been good. So I think we're through the woods on that part. But it's just a question of how much
Marschall Berkes:resolution right? I mean, yeah, that's, that's, I think you would know pretty quickly, right? In this scenario, whether it's okay, first point would be to better not. So we'll keep your fingers crossed. I thought.
Chris Dy:Exactly. I thought she was all better when I discharged.
Marschall Berkes:Does the crossing fingers.
Chris Dy:Hi.
Charles Goldfarb:I have two comments as I often do. The first is Marschall. I know it must catch you by surprise that Chris wanted to talk about a nerve case. I don't know how your wine drinking parties usually go but I'm sure there's nerve discussion involved. So that's point number one. That's
Marschall Berkes:Thats why we that's why we drink the wine
Charles Goldfarb:to get through it. I understand. Yeah, maybe I should be drinking wine at these little podcast sessions. The second thing is I thought that was an interesting point Chris, I have to say it's not common but sometimes when I do perform a neuro lysis I do bring periosteum or adjacent soft tissue you know trying to prevent any type of 360 degree situation with a nerve being compressed but I don't mind taking some adjacent tissue if I felt like it'd be detrimental to try to tease it off.
Chris Dy:Oh, yeah, I absolutely believe in taking adjacent tissues especially in this setting. Of course the nerve is functioning pretty well both clinically and on electrodiagnostic studies. I'm not going to disrupt it more than I have to I just hadn't I've never had to take an essentially an entire you know, three centimeter piece of curiosity with it.
Charles Goldfarb:Yeah, super interesting. Maybe we should thank our sponsors for this opportunity to talk about wine and nerves with Dr. Burks without
Chris Dy:the the upper hand is sponsored by practicelink.com The most widely used physician job search and career advancement resource
Charles Goldfarb:becoming a physician is hard finding the right job doesn't have to be joined practice link for free today at www.practicelink.com/theupperhand
Chris Dy:never thought you hear people read copy on can worlds
Marschall Berkes:magic.
Charles Goldfarb:Inspiring
Marschall Berkes:I think I'm gonna look up practicelink.com So
Chris Dy:there you go.
Charles Goldfarb:I'm not really excited about your doing any type of job search
Chris Dy:Executive Vice Chair hat
Charles Goldfarb:yes. So can we can I share a different case with you Dr. Berkes, just for maybe to talk in general principle, but also perhaps some details. I have a A 23 year old motocross rider who is highly competitive, and he flew off and has a midshaft clavicle fracture with about a centimeter and a half of overlap. And with you know shortening, the scan is not threatened but I just love to know, throw any softball. Talk to me about clavicle fractures. There's a lot of answers out there
Chris Dy:neuro status, Dr. Goldfarb.
Charles Goldfarb:I am not discussing it.
Marschall Berkes:So, and he comes to you like in the office a couple days later or whatever, whatever the case is.
Charles Goldfarb:I love cold trauma. Yes, this is four days out.
Marschall Berkes:I mean, this is this is good to know, right? Because I think a lot of the patients that we see on the trauma services are treating, you know, they're coming to the ER, and maybe they're banged up with a bunch of a bunch of other things. And amongst the laundry list, maybe sure they have a clavicle fracture. And so one thing to consider, if you're looking at X rays, like let's just start there, and then we can talk about what the patient is experiencing idea history. But you know, a lot of these extra guys are taking them supine on a stretcher. And so that first radiographic evaluation, it's a snapshot in time, right? So maybe it is wildly displace, maybe it isn't. But it's information nonetheless. So I think when they come and see you in the office, it's really useful to kind of understand what's happened over time, these of the the stability of the fracture, because I think a lot of the time, what we see is, these patients get up and start walking around, and then you know, will they get interval displacement? Now? Is that going to change your decision making? Maybe it does, maybe it doesn't. But it might change the patient's perception of, you know, Hey, this looks kind of crazy, like I have this spike of bone sticking out right near my skin, and I don't like that. So a patient just like that this morning. So that's one thing to consider. Then Then we start getting into talking to the patient. Okay, like, this guy sounds very active, young, healthy, high demand,
Charles Goldfarb:wants to get back on the bike ASAP. Sure.
Marschall Berkes:This isn't cancer, right? Like nobody has to have surgery. And sure, there was a lot of excitement. And still, as I think in terms of operating clavicles. Because surprise, most of them do very well. And so it's it's a compelling surgery to perform. Because I think, if done well, patients do really well. Do they need surgery, though? No, they don't. It's an option. It's a choice. Right? So for me thinking about indications, it begins and ends with really what the patient wants to do. And then you kind of draw in elements of how displaced is it? What do you do for a living? Do you need to get back to work? Do you need to get back to doing knuckleheads things and riding a motorbike again,
Chris Dy:riding a motorbike is work.
Marschall Berkes:They're not mutually so. So yeah, this is all part of the conversation. And I think over the course of whatever it is, 510 minutes that you're talking to the patient, you get a pretty good sense of what they want to do. And then considering you know, what it is they need to be doing? Like if, if Grandma just needs to turn off the oxygen from four to six liters. Probably doesn't need like, you know, early aggressive overhead motion. But I think, yeah, this sounds like a case where I would be more than willing to offer open reduction internal fixation and and we could talk about, you know, how you do that, whatever. But I think it does get patients back to better function quicker. And I would let them essentially pursue whatever it is that they want to do, if that's their rationale for getting this done. Right. I wouldn't operate and then say, oh, you can't go back to work for three months, because I want to pack that I had a surgery then, you know, so. So it
Chris Dy:sounds like you're like a you're like a give them the menu kind of surgeon more than anything else. Yeah.
Marschall Berkes:And some some patients that are are like, Oh, I don't I don't need surgery, and I can just have it repaired later down the road. If it doesn't feel like that's some people are totally fine with that. So I think you just let the patient kind of choose what they want to do with the best information we have
Chris Dy:I just wanted to throw out a couple of quick, rapid fire damage or you know, patient characteristic things and tell me whether you think that increases or decreases your likelihood to offer sort of good, good. You meet them in the ER for an isolated injury. versus you need them in the office four to seven days?
Marschall Berkes:I don't think that makes too much of a difference. Probably. You know, if you're talking about meeting for the first time. You know, like I said, there's been some time for potentially this to displace. And also they're seeking you out for whatever treat maybe it's not surgery, they just want whatever. But yeah, I don't know that that in and of itself is a major determining factor. But yeah, potentially, a little bit later, they may be having gone through a couple of days of misery. And they're like, I got this is as painful as this, like, do something. So male, maybe a little bit more on a couple days later end of the spectrum, but doesn't change for me, it's really up to them,
Chris Dy:assuming similar desires to return to work in terms of type of new type of work I do and timeframe. 25 years old versus 40 patterns. It
Marschall Berkes:doesn't make a difference to me.
Chris Dy:Chuck, any rapid fire questions? Yeah,
Charles Goldfarb:yes, some rapid fire? I guess it never surprises me when Chris talks about nerve and I don't want to lump you in with every other orthopedic trauma surgeon but I guess I shouldn't be surprised you started with the X ray. Discussion?
Marschall Berkes:I do.
Charles Goldfarb:Yeah, a little bit. I do. Question Do you consider and this is a hand surgery, hand surgeon weenie question. Do you consider aesthetics? Like the appearance of the shortened? clavicle? Does that matter? I don't think it matters functionally. Do you hear that? Do you deal with that?
Marschall Berkes:Well there I think in a related sense, there is some data that maybe it does matter if you're talking about like shoulder ptosis. Where Okay, yeah, the medial extent is displaced cranially. But really, it's the lateral extent that's drooping down there and of the way to the shoulder girl and a limb. So in with the short name, you know, Mickey's Canadian randomized control trials that other dashboards with repetitive motion was was worse. Now, am I going to hang my hat on saying, Well, sir, we can get your dashboard such that such and such better we repair this thing? I don't know. But I think it lends itself to the alteration of the length tension relationship of your rotator cuff and shoulder musculature. And that's not going to get better. You know, a patient comes in like, this looks kind of weird. Like, well, if we're going to treat without surgery, it's gonna look like that basically, forever, because it's going to heal on that position. And that's fine. Again, if if you are okay with that. So, I think making that clear to the patient is important.
Charles Goldfarb:Talk to us very briefly. And this could be a rabbit hole. It's not intended to be about multi trauma. So if you have an ipsilateral or contralateral femur fracture, or forearm fracture, do those really ramp up your, I guess, pushing at least a little bit for clavicle fixation?
Marschall Berkes:Yeah, for me, it does. I mean, I think you try and stack everything in their favor in terms of being able to utilize whatever it is that they have that can be as functional as possible as soon as possible. And this is something that patients feel pretty good pretty quickly after this operation compared to some other things, which that's not the case. So I think it does afford them to maybe use their learning a little bit more effectively. They have lower extremity trauma. I guess how you define poly traumas is a little bit of a question. And then there's always if you want to go rabbit hole mode, people with chest wall injuries, there's some question about, hey, if they have multiple ribs, does fixing the clavicle help with kind of chest wall architecture? And does that provide any additional benefit? That's not entirely clear or borne out, but that is thrown out there as a rationale for surgical treatment?
Chris Dy:What about a scapular fracture?
Marschall Berkes:Yeah, I think that's reasonable. It's particularly when it's displaced scapular neck or, you know, whatever the fracture pattern may be in conjunction with a clavicle. Any people have different people have different philosophies and treatments for that, but I think there's quite a bit of alignment on okay, if we start out the clavicle, then maybe there's an indirect reduction of the scapula and that doesn't need to be treated. I think they have to be considered independently, but for sure the combination of two probably just speak to the level of violence and displacement and potential benefit for early stability
Charles Goldfarb:For the the so called flooding shoulder.
Marschall Berkes:Yes
Chris Dy:I had a follow up question. That's okay. Let's you have one Oh, go ahead. Well, you know, so we do have a lot of hand therapists, physical therapists OTS that listen and you mentioned, you know, in terms of allowing somebody to go on to an expected value need which we see a lot for example, with the distal radius, fracture in our population. I've learned what to tell him about, because I've heard enough about what I didn't tell him about and follow up. So the appearance is one thing. So you touched on that. Yeah. You know, are there functional things that perhaps you've noticed over time when you treated somebody without surgery? Is it endurance? Are there particular types of shoulder? Or glenohumeral motion that they lack in terms of activities? Or what are the things that you're going to treat somebody non operatively, our listeners should make sure to talk to our patient. Yeah,
Marschall Berkes:I mean, I do mention kind of that repetitive motion thing, just in strength, just because I you know, that's really the only thing I've read that says that, yes, this may actually be true. But I haven't had in my experience is not fast. So take it with a grain of salt. But I haven't had tons of clavicle male unions coming in and complaining of, you know, massive, functional deficits. I think it's more than non union patients that you end up seeing, at least in my case. So I don't have an abundance of wealth with answering that question directly.
Chris Dy:Chris, do you take care of clavicle fractures?
Marschall Berkes:Also, I fix them all. So
Chris Dy:ah, pearl of wisdom there. You know, I don't, unless I guess if I'm in, you know, I guess the only situation is if I have a clavicle osteotomy. And I want to get access to the classes. But I have not primarily fix the clavicle fracture since starting practice. I know, a couple of our hand partners, you know, may have some flirtations with such fxation.
Charles Goldfarb:Yeah, I do treat clavicle fractures. You know, not I don't go seeking them out. But I'm happy to do it. They're fun surgeries. And we should talk a little technical. So partially, you know, sometimes Chris, especially sometimes even I get consulted to help with exposures. So for example, sorry, I cracking myself up. So for example, the perineal there when you know, we're worried about the posterolateral corner of the knee, or the sciatic nerve with the hamstring motion. Have you ever consulted Chris for the supraclavicular nerves to identify them? And keep them safe?
Marschall Berkes:Short answer? No. It's, it's, uh, I think the question trying to ask is, you know, how do you handle the nerves on the exposure? There's different schools of thought, you know, I've been involved in cases involving preserving all the nerves. I've also heard, this is all anecdotal that, you know, patients have more painful nerve type symptoms, potentially as a consequence of that, because then, you know, the stretching and irritation of the supraclavicular nerves. I have heard of, you know, people injecting the nerves and then sharply transecting them as a method to eliminate that as a possibility. I mean, obviously, that is going to result in some chest balling on us, or you can just ignore them entirely as I do. And I have not had anyone complained to them. Maybe they're all going to Chris, I don't know. But they've not complained to me directly about that. So my my personal approach and philosophy is just to basically go right through them and haven't had anybody complain of chest wall numbness and or dysaesthesias. That's not to say that No, no, no, when
Chris Dy:Nor do you ask? .
Charles Goldfarb:There may not be a second glass of wine for you tonight with all those nerves.
Chris Dy:Well, there's so when you go is it skin? And then after the skin? Is it boldly down the bone down a periosteum? Or is it night? You scalpel away?
Marschall Berkes:No, I mean, it's through skin with it. And then typically, it'll be a lot for this electrocautery dissection to the cloud.
Chris Dy:Because I think that your point of you know, having to dance around the nerves and inevitably somebody stretching them a lot. It actually is better I think if you're going to do it, just bully through them, you know, rather than project protecting them, but then subjecting them to just a ton of stretching irritation. Yeah. It's kind of like some people treat a neuroma by cauterizing it. So I actually don't think it's that lot of an argument. But I guess it depends on who's handling them.
Marschall Berkes:Sure, like, right,
Charles Goldfarb:Hey, Chris. Before we talk technical should we thank our sponsors.
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Chris Dy:It's a real The cool device I'm using a few times now and I really, I think there's a complete need for it. So we can talk more about that another episode. But let's get back to talking with our buddy Marschall. Do use the checkpoint at all, Dr Berkes.
Marschall Berkes:I do not.
Chris Dy:Okay. All right, leave it to us. We'll handle it break. Okay, I can stay in business. Sure. All right.
Marschall Berkes:So let's, let's go back to that somewhat straightforward. midshaft, clavicle, 23 year old motorcross rider. And he you and he have had a wonderful discussion and have elected to proceed with surgical intervention. And just without getting too much in the details, but also not too superficially. Just take us through how you do this. I'll ask you some questions. You know, positioning is this beach chair is it supine, is your where's your incision, is this one plate two plates. And if they're, you know, help us understand why you choose which fixation
Chris Dy:or a nail
Marschall Berkes:So my personal preference patient is supine, I'm just a radiolucent. Kind of like a diving board type table. So not any specific beach chair or positioning things otherwise, I do elevate the head of the bed probably 2030 degrees, I think it helps kind of get all the neck bat and just kind of stuff settle the way rather than working down into a hole. I don't, I used to like, you know, kind of put a bump on into the scapula or between the scapula I stopped doing that I just haven't found it to be incredibly helpful or necessary, I just do a window prep and drape prep out the whole arm again, haven't found that necessary or a requirement. I have the car. So I'll turn the bed 90 degrees and that the c-arm come in from the head. So the two views, I'll use the roll back, essentially to the bottom and c-arm hits the bed, and that's about 23 degrees roll back, which gives you kind of a good top down shot and then roll over all the way. And that'll give you a good, you know, real AP, if you will, classical itself. So that's the general setup, the approach is nothing special, you know, down to bone, I think the mistake I've seen is a lack of exposure, and a lack of awareness of the fracture, these are always more complicated than you think would be my general summary statement on that. You think you're going to go in there, and these two pieces are going to click in and it's like, you know, black screw, neutralization played done, whatever, you know that there's always multiple pieces, there's always kind of this Caudill combination that I don't personally know really pursue with dissection. Nor do I think it's a good idea, because it's going to require quite a bit of stripping of, you know, whatever's keeping that fragment alive. So the general strategy becomes using whatever reads that I can expose on the anterior and superior aspects of the clavicle. And typically you can get enough of it reconstructed that there's maybe 270 180 degrees of the two back together and the lines and how you hold it, there is a little bit of a, you know, case by case basis, I personally like kind of drilled holes in the bone and then just like a straight point to point clamp to hold that and then put a plate on the surface that the clamp is not in. So if it's on top, then I put the plate in front of I have the clamp in front of the plate goes on top. I personally have been trained in and really like the dual mini frag plate fixation. And that's typically like a sin to seven plate on a superior surface and thicker to four plate on the interior surface. And those are just contoured. Most people have pretty reasonable bone quality. So it's not like any tons or any lopping screws. caveat is when you start getting pretty lateral, the distal clavicle bone quality, even young people is not fantastic. So the last one may be a locking screw because it makes me feel better. I don't know if that's a requirement, but then the other pearl.
Chris Dy:Hold on, Tom, you got there a lot. We got to unpack some of this first for you. Okay,
Marschall Berkes:I'll stop.
Chris Dy:So do you pre contour your own plates? And do you use a pre contemplate the contour on the fly? Do you let the bone do some of the work? How do you make that decision?
Marschall Berkes:Yeah, I just these are just straight plates out of whatever mini fragments that you like. I think the ones that have longer plates are nice because, again, frequently these are more comminuted than you may appreciate just on an initial review of the plain X rays and when it's shortened and Mal aligned, so you may have to go fairly extensive all along the medial lateral aspects of the clavicle to get this thing I would think sufficiently fixed now, what that means is part of statics and religion potentially but it's You know, a good working length and something you feel like is well fixed. So yeah, some of those 16- 18- 20 hole plates, and you can just cut it to whatever length you like. And then yeah, I'll just use a plate Bender, having one that allows you to bend it on the flat in addition to sort of cranial caudal type then is going to be necessary. So there's there's different commercial flip vendors that are in most sects. So I remember
Chris Dy:for that cranial caudal plate vendor, I actually had one of the implant companies find one and get one made for me, and then somehow it ends up in your tray.
Marschall Berkes:Well
Charles Goldfarb:Well they know where their bread is buttered. I appreciate that description, I have to say you'll be proud to learn that Zach Meyer, who you know, is one of our pediatric orthopedic attendings doing a little bit of specialty trauma work, has been using your two plate model and credit you and conference and always asking, why would he waste two plates when one will do the job, but he is proudly using two plates and states that it decreases the need to take out hardware and decrease his complaints with wearing backpacks.
Marschall Berkes:So I think there is something to that. Now, the other part of this is that with these plates that are so flexible, you can do some insights you can't you know, you don't have it have to have it contoured perfectly, because it will conform to the bone not overpower the reduction, versus a thicker, thicker, pre contoured ribeye plate. Where you know, number one, unless you're a 70 kilogram Swiss man, it probably is not going to fit you. Okay, so that's one problem number one, and number two, even, you know, if it fits relatively perfectly, it is pretty bulky. And so I've taken out out of the patients that I have personally operated on with this technique, I've taken out one set of plates. And I don't know, I mean, I don't remember exactly how many but way, way more that have been fixed elsewhere, using a small frag, and they come in and they want it out. That's, I think something that goes into the rationale for doing it. But you know, sure, three, five, do they work? They work just fine. So I think whatever you're comfortable with and whatever works in practices, that's great.
Charles Goldfarb:Do you have anxiety when others are drilling to place screws in the clavicle, about the large vascular structures which are nearby? Because I hear so many people talking about this, and I don't think I have the appropriate amount of anxiety. Of course I want whoever is particularly you know, holding the drill at the time to show a proper appropriate care and not plunge, do you do anything to protect those deep structures or you just expect good surgical technique?
Marschall Berkes:Now the latter? Yeah, you know, go out of my way to do I don't know what that would involve you know, Homans underneath the bone or, you know, the opportunity presents itself. Sure, fine, but I'm not like super OCD about that other than the sense that sure, like, operate like you should, and there should be no issues.
Chris Dy:So what was the last Pearl you're going to share before we cut you off?
Marschall Berkes:Oh, yeah, as you get lateral, you're at least my ability to kind of understand exactly where the end of the clavicle is, it gets tricky. So before you go ahead and plate the whole thing, and start high fives all the way around and you discovered you have the end of the plate over the ac joint or even a screw in the ac joint. It may be worthwhile to check that earlier on in the case just because it can be tough to tell. So
Charles Goldfarb:I think that's good advice. And I will say some of the pre contoured plates, I've struggled I've used the you know, understanding what I'm doing I've used the right clavicle plate on the left clavicle and and I think your point about the contour no matter how well meaning it is it just doesn't work for every patient. So I think that's a really important point for those who liked those plates. Just be flexible in how you approach which plate you use for which patient and and be careful on that lateral clavicle Totally agree.
Marschall Berkes:Yeah.
Chris Dy:So a couple of quick questions as we wrap up. First one is are there any remaining indications that you see for use of anything other than plate screw construct
Marschall Berkes:yeah you know people have experience there's definitely you know, these flexible let's call it nailing intramedullary fixation systems or even something that's not as advanced like titanium elastic now I've seen used I've seen technique written up I think it was of a One of the army hospitals using I think, is a six, five, can't sell a screw essentially intramedullary hitting it on the straight part of the clavicle or at least that's, that's what I assume, based on the geometry of the screw itself, with the the concept that it avoided a larger incision over the area, and a plate over the area where they're carrying their rucksacks, which you know, weigh in excess of eight pounds, or whatever it is. So, you know, I think that that's a rationale, I don't personally employ that. I just, it seems like a solution to a problem that I don't currently have.
Chris Dy:Okay, well, then. And then I think the last question I want to ask you is, what does your rehab protocol for this look like? You know, how much are you? Are you limiting any shoulder motion? Initiating shoulder motion right away? Do you have any limits on activities, weight limits, that kind of thing?
Marschall Berkes:Yeah. Like, most things that I take care of, I've kind of evolved over time, just because ultimately, patients can end up doing whatever the heck they want. And most of the time works out just fine. So there's a lot of self protection, I feel like just in terms of what we say, Oh, don't do this, because that's what I was taught in residency and you know, where it is bond in that regard. But so active passive range of motion, no limits straightaway, given a slang but don't get rid of this thing, whenever you want to, you just start moving your shoulder, I don't normally prescribe physical therapy, the first three weeks until they come back, and then we kind of figure out, hey, how you doing how you feel. And most the time, they're feeling pretty good, they had pretty reasonable motion offered to them, you'd like to do physical therapy and things, you get a sense of which patients are pretty good on that and which ones are not so much. And then in terms of thing, you know, lifting, pushing, pulling, job related stuff, I'm still you know, if somebody said, I need to go out there and, you know, start powerlifting, or lifting, you know, 100 pound bags or whatever. I don't know that anything before six weeks, that'd be super enthused about that. If they said, Hey, Doc, you know, I gotta get back, or I was gonna get fired from my job. And then I think I would be willing to make that compromise. That's a pretty rare situation. But usually, this is that sort of thing where I feel like, I end up trying to potentially even like, slow them down a little bit, just because they're feeling so well. And like, want to get back out there and do something. And maybe we should I don't, I don't really know. But I think the first six weeks is some reasonable limitation just in terms of how much they're getting after it with the weight bearing. And as we mentioned earlier, like, you know, by trauma, it's kind of like, whatever you have to do to get out of bed and mobilize. Use your arm, that's fine by me. So.
Charles Goldfarb:So if you have to really kind of put you on the spot, if you have a high school football player who wants to get back a running back wants to get back and play, you fixed his clavicle, you're really happy with the fixation. And you say you can't play for six weeks come back in six weeks, I've got an x ray, do you have to see healing on that X ray, to release him at six weeks? Or is the six weeks without any negative appear? No negatives on the X ray good enough?
Marschall Berkes:I suppose it was, you know, what kind of healing? Are you going for Chuck? Because I don't know how you intend to see healing with absolute stability?
Charles Goldfarb:Well, you told me you put soft plates on
Marschall Berkes:you know, yeah, I think I would go more based on clinical finding, you know, if the X ray looked unchanged, in the sense that everything's well aligned. There's no loosening of screws, patient feels well, they're dying to get back if it's worth it to them so much that okay, yeah. Is there a risk that, you know, this may displace or whatever? Yeah, I suppose that's possible. But again, I think that's the art of the patient physician relationship and just understanding what's what's important to them. So I would, I would kind of suss it out clinically, rather than really radically the absence of any negative findings.
Charles Goldfarb:Perfect, this was awesome.
Chris Dy:Thank you for joining us Marschall.
Marschall Berkes:Thanks for the softball you guys want to talk about you know, like mangled lower extremities.
Charles Goldfarb:Y'all have a good night.
Marschall Berkes:All right. Take care. Thanks for having me.
Charles Goldfarb: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 at 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