Chuck and Chris have a brief discussion about Chuck's Executive MBA program and then take a deep dive on a laceration in the distal forearm- the so- called spaghetti wrist. We talk details including the technical aspects of the procedure and patient expectations.
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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.
Chuck and Chris have a brief discussion about Chuck's Executive MBA program and then take a deep dive on a laceration in the distal forearm- the so- called spaghetti wrist. We talk details including the technical aspects of the procedure and patient expectations.
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. Please
Charles Goldfarb:subscribe, wherever you get your podcasts. And
Chris Dy:thank you in advance for leaving a review and leaving a rating wherever you get your podcasts. Oh,
Charles Goldfarb:hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:I'm great. You seem to be pretty busy nowadays. You know, obviously, you've got your full time job. And you've also got your your Billy Madison hat. You're going back to school?
Charles Goldfarb:Yeah, yeah, this was a B School weekend. So that for that. It's Thursday, all day, Friday, all day, Saturday all day. So I we're recording on Sunday the 29th. And we'll be dropping this episode in a couple of weeks. But yes, schools really great.
Chris Dy:So as to people in the Executive MBA program actually call it an EMBA. Because people have told me that Chuck is going after his EMBA. I'm like,
Charles Goldfarb:it's funny. You asked the question. They do call it the m bar, which I never I always call it an executive MBA. But I guess that's too much too much of a mouthful. So they call it the EMBA. Well, I
Chris Dy:mean, I give some of our trainees a hard time if they come in saying "ORIF" . FOOSH is the other one. I am not a fan of FOOSH. That's actually one of the things you can't say my clinic there are a few phrases, some of which I can't say on air, that you're not allowed to say in my clinic. futian over if are two of them.
Charles Goldfarb:I have a feeling that this is gonna resonate with some listeners. Yeah, I am not an ORiF, or ORIF or FOOSH. I don't like those things. I mean, I don't know why O.R.I.F is better, but it is, it's clearly better.
Chris Dy:I thought you'd have feelings about this. We're either going to people, it's gonna be polarizing, they're gonna be with us or against us. It's fine. Sorry, you're wrong. If you actually say.
Charles Goldfarb:Yes, this is schools. It's kind of crazy, as I think I don't know if we talked about on the air. But I've wanted to do this forever. So I am a little bit older. I'm not the oldest, but I'm older and in the class, but it's great. So this these last three days, basically, the way it works here at Wash U Olin School of Business is you have a foreign half hour class in the morning and a four and a half hour class in the afternoon. You do that for three days. And they go beyond one weekend. So this weekend, we did accounting. And we also did business analytics, which is really looking at HBr cases, and learning how to know what to analyze, and then how to do the analysis. The hard part is not doing the analysis is figuring out what to analyze and how to gather disparate pieces of information and bring them together for a statistical assessment. It's very cool.
Chris Dy:Now is your NBI. One that has a specific focus like a healthcare focus, or is it any more generalized? You know? You're You're shaking your head? No.
Charles Goldfarb:Yeah. Well, I was gonna verbalize that too. Yeah. I did not want to healthcare focus, I wanted the kind of the whole thing. And so this fall, it's those two classes, its marketing, and marketing, accounting, business analytics. Yeah, those those three classes for the fall. And so far, it's been been really awesome.
Chris Dy:And they have you found it hard to, to get into the assignments, given that they don't have a healthcare focus. I mean, because obviously, we're talking about industries and spaces that you have not had a particular professional interest in.
Charles Goldfarb:Yeah, they so far, they're all 100% applicable, like marketing is obviously applicable accounting clearly. And then the business analytics is really, you know, obviously, we're not you and I aren't reading HBr articles at work, but the concepts of kind of how to think about things, how to apply mathematical assessments, and then how to take what you find and present it and share it and convince people is really great. And so I think that everything I do will be applicable. And, you know, it's just, it's just interesting stuff to me.
Chris Dy:Are you the only clinician in the program? No,
Charles Goldfarb:I am not. There are two other two other full time conditions, one neurosurgeon at Wash U. And one plastic surgeon, there's a internal medicine doctor does a lot of research. And there is a two full time PhD like research folks. There's some clinical grant managers and so there's probably probably a quarter of the class is about 3033 34 people in the class and about a quarter of the class. Maybe a little less has some type of medical tie. Then
Chris Dy:of the I guess maybe the surgeons , what's the timing of this and their careers and kind of their overall intentions? Don't obviously don't say names, but you know, what's their? What's their goal?
Charles Goldfarb:They're definitely younger. I think they're both in their early 40s. I think it's kind of a, it's a source of interest. I don't know that either of them have specifically stated that they thought this would take their career in a different direction. maybe help them in their current status, maybe give them something to reengage with? Yeah, I actually haven't asked that specific question. That question gets asked to me all the time. But I haven't specifically asked that question. But it's, it's really an interesting thing, I don't think. And I'll know more as I go along or develop stronger feelings. I don't think an MBA is for every doctor, obviously. But just the learning process. At my age, you know, when you get old, is fantastic. Like, it's, it's amazing. It's really great. Sounds
Chris Dy:fun. I always joke about wanting to do it. And Tiffany, you better not actually do this. Just you wait. But is there anything in particular that you thought about in terms of timing? You know, I don't know whether it was more of where you were professionally, or kind of the, you know, the situation with your kids, or? Yeah,
Charles Goldfarb:it all sort of came together. I've been looking at this particular program, probably for five or six years. And it just felt like I couldn't pull it off in the past I, I'm an empty nester. Now, as we talked about, that definitely helps. My wife was in agreement for a lot of reasons. So that helps. I honestly think, mid to late ish. 40s is probably the right age, which is older than a lot of my classmates, I'm certainly not trying to say anything negative of my classmates. But there is for this particular program, the executive program, there is a critical life experience that I would that brings a lot to the class. And you know, hearing different people in different industries, talk about their challenges, their opportunities, their competition, is part of the great, vino, what's so interesting about it. And so I think you got to have done enough to know the problems of your industry, and to know what you want to accomplish to really get the most out of it.
Chris Dy:Well, it sounds like an amazing experience, I look forward to seeing you go through this journey and hearing your reflections on it. You know, it's going to it's going to be a lot of fun.
Charles Goldfarb:Yeah, I have a big accounting test that I need to get done. It's, it's it's open book. Because you know, individual, there's an honor code, the professor estimated 15 plus hours to get that done that that's the test and you know, there's homework and there's a marketing assignment. So it's gonna keep me occupied, which I guess is good.
Chris Dy:15 plus hours, or 15 hours for you is probably the assignments 15 hours for you. That's probably what, six hours you know, between running two rooms and having me
Charles Goldfarb:It's funny, I don't know, I think an average accounting students. So it'll be really interesting to see,
Chris Dy:I don't think you've ever been average in any Chuck's for a while here,
Charles Goldfarb:here's one for you. And I've been given advice on this. So for this particular test, there's part of the test, which is to go for a pass this pass fail, which is the right way it should be pass fail. So you can do 80% of the test and get a pass. Or you can go for a high pass. There's no honors or anything. So it's just pass, high pass low pass, you can go for a high pass and do significantly more work another five to 10 hours. And intrinsically, I'm like, of course, of course, I'm gonna go for the high pass. And the practicality is need to modulate reality. And I don't think I can do it. I'm still toying with it, because it feels wrong not to. But that's really interesting. Like, it's kind of it's not who I am. Well,
Chris Dy:I don't know, if it's one of those things where you know, the the people who get who get the high pass, maybe their names get passed on to other employer, you know, like, if you were maybe not somebody who was in the position you're in, and it might matter, like, you know, but I guess P equals m, but at the end of the day, right? That's
Charles Goldfarb:true. But as you know, I've talked about it and I know you're not suggesting otherwise it is. It's not just about the letters right, I am doing this because I am super interested in there's no doubt that the exercise of doing the work makes you better. And then there's the cognitive dissonance. I think that's the right expression in which I'm feeling by even thinking about not doing it and judge me if you will, listeners that's that's just reality. But
Chris Dy:I guess we'll check in and see which one you got. Which assignment you completed. Before we were gonna do with details episode today about a topic that I think a lot of people have encountered. But before we do that, why don't we jump in and thank our sponsors at practice, like
Charles Goldfarb:the upper hand is sponsored by practicelink.com The most widely used position job search and career advice estimate resource. Becoming
Chris Dy:a physician is hard finding the right job doesn't have to be joined practice link for free today at www.practicelink.com/theupperhand.
Charles Goldfarb:All right, I think we have a great case to discuss
Chris Dy:Well, yeah, no, I think the case is good because it leads into a pretty good details type episode. I know that when I, when we saw people in Toronto, people have asked for more kind of technical detail episodes, and I think this one is chock full of them. So this is somebody who's, you know, somebody who is in their kind of, let's say, 30s, or 40s, had a very large piece of glass, you know, come down on their forearm, and you've got a laceration that's five centimeters proximal to the wrist crease, transverse stays on the volar side doesn't go anything dorsally no fracture remarkably on X ray, and lacerated everything and the volar aspect of the forearm, every tendon, including the palmaris, which was present. And then, you know, for the purposes of this case, you know, it was patient actually had a revascularisation at an outside facility, and then ended up with me. So that's one wrinkle we could talk about. But, you know, fortunately the fingers are perfused has a good attitude, good support. How do you kind of think about this? Well, we call it America spaghetti wrist and when I'm told you call an India, a full house, from my experience there. How do you think about this injury as you see this patient either if you were to get called from the ER or whether it's, you know, this patient never comes to the office, but this time actually came to the office? Yeah,
Charles Goldfarb:well, that was gonna be my first point is I It's interesting what occasionally, we do electively but the vast, vast majority of the time is not an elective procedure. And this one certainly fits that category. I recently did a pair illuminate electively that was reduced and an outside hospital came to see me like 10 days later. And that's that obviously is done electively if the reduction is accomplished in the ED
Chris Dy:did it stay reduced,
Charles Goldfarb:it stayed reduced. Yeah, well, they reduced it actually, what was interesting about that case, not to go on a tangent. But what's interesting about that case is it was more so I got to it about two, two and a half weeks later, it was challenging to get this case limited reduction, where I wanted, it wasn't a simple maneuver. So that felt like more work than I would typically have seen. But otherwise, look, it was nice doing it electively for sure. So this is fascinating. So it sounds like probably not a hand surgeon, maybe a vascular surgeon at a smaller emergency department may have taken care of this and done the revamp, ask and that brings a whole nother bag of worms, I guess because you really have to make sure you take care of that. Obviously, you're going to but but that has to be priority number one, not that you can't redo the repair. But, but that's really important.
Chris Dy:Yeah, so you know, this patient had revascularisation, radial and ulnar arteries, both with interpose saphenous vein graft, and it looked great. Certainly was more stressful to dance around that. And I opted to not use a tourniquet just out of an abundance of caution, which added another element to this case. You know, so if that was not in the picture, say this hand, it was, you know, say the hand is vascularized. Your fingers look good in terms of their pink, they refill? Well, what's your timing on this is if this is an ER, and the hand is perfused, maybe one arteries out? Maybe the radials out the owners it or vice versa? Is this something that you're just taking right away to the ER? Are you waiting until your next elective day?
Charles Goldfarb:So really interesting. So first of all, I would say I don't recall the last time I had a spaghetti wrist or a full house, I love that. That was complete, meaning everything vole early, and far more commonly it is one of the vessels is intact. And so if one of the vessels is intact, and it's a clean knife, or glass type cut, I typically will repair the other vessel. But I certainly don't think is mandatory if there's there's good capillary refill. I think that was to your to your point. And timing. I have always done these acutely, either that night or the next day. But there's no reason it needs to be acute. I mean, you don't want the most you don't want to wait three weeks I don't think because you don't want too much retraction. You know, it's interesting I was as you were talking I was thinking you know, where do these happen like where proximal distal wise to these happen? They they happen in a relatively narrow range and I guess it's just the the nature of our anatomy and the our susceptibility of trauma. But yeah, they're happening sort of and I'm for those on YouTube. You can see But it's kind of distal one quarter from the wrist crease a little approximately, you know, maybe three or four centimeters. That's where they all happen in my experience.
Chris Dy:Right? Yeah, I mean, because at that point, that's when you're dealing with actual tendons, right? Like you get a little more proximal, that you're dealing with musculo musculotendinous junction or actual muscle injuries, which, for some reason, don't ever end up either happening there don't end up being as complete, so to say. So yeah, no, I agree with you. For some reason, they all end up being in this kind of distal quarter of the of the form. And yeah, and I can't remember the last time I actually had everything out, you know, as it was, in this case,
Charles Goldfarb:it is since why vein grafts were chosen. I don't think that would be my initial, you know, plan unless I encountered difficulties with vessel we approximation. Yeah,
Chris Dy:I mean, looking at the you know, I guess we'll get into the details. But looking at all this, this is the case where if I was feeling a little gutsy, I probably might have been able to primarily repair the nerves. But Adam an abundance of caution in the fact that the other considerations for rehab, I ended up using nerve autograft. But I think he did us whoever the surgeon was, they did us a favor, by making sure that there was some redundancy in their vascular reconstruction. Because perhaps if they had, you know, really mobilized everything and got those the arteries together, but they were a little tight that might have limited what I could have done in terms of motion afterwards. And I'm not sure what the decision making process was, I don't know if I, I guess I would have thought to prep the leg for for Searl. But I again, it wouldn't have been my thought to prep the leg for saphenous. Like in the thigh saphenous.
Charles Goldfarb:Right, right. Right. What about how did you decide where to do it? Would you have done this as an outpatient? Did you feel like you had to be in the hospital or outpatient with microscope availability? What's your thought for spaghetti wrist?
Chris Dy:So, for me, it's just microscope availability, I think it's fine to do as an outpatient. I think this never comes up as an outpatient. I think it's a unicorn that I saw here. You know, I think there was an expectation that the patient had, that was kind of relayed to them that there was some urgency to this, which is not wrong. But they were in fact traveling from quite a distance. And we were able to pull something off where we're able to do it on an outpatient basis. But at a play at a facility that had a microscope. To me, I think I'm personally I would prefer microscope, although I think certainly this could be done without one. You know, should should you feel so inclined, in terms of your magnification with loops. But I do like this under a microscope much better.
Charles Goldfarb:So two other questions. Number one, when you got to the operating room, how many days? Was it? postinjury? Roughly?
Chris Dy:Six.
Charles Goldfarb:Okay. And then my second question is, What did you ask for? To have available? So you said microscope? And did you know before you went in that you are going to be doing a nerve graft? And how did you know that? And then the last question is, what type of suture Do you ask for in these situations?
Chris Dy:Yeah, so my inclination was that we're gonna have to do an earth raft mainly because we're, it's not, you know, times zero, or, you know, Day Zero Day One after the injury. So, my sense was that there probably was going to be some retraction of the median and ulnar nerves, which would make it difficult to to get them primarily repaired and collapsed to the floor, I'd be comfortable moving the fingers and having something glide past the fingers and thinking in the future, you know, in the first six weeks about wanting to get some tDCS going for the fingers. Because I didn't have any of the components of this injury, the fingers are probably the most predictable ones. And although I like to prioritize the nerve stuff, just because of what I do, the nerves still have more guarded prognosis. And at the very least, you don't want to compromise what you do with your fingers in order to don't want to compromise the outcome I can get with composite flexion from the flexor tendons, because I'm trying to protect the nerves, because the nerves still are, it's less consistent. I don't know if that's a mouthful, and there's a lot to unpack there. But that's at least how I think about it.
Charles Goldfarb:So well, we can Well, we can jump into expectation. So for those who don't do a lot of tendon repairs, and certainly a therapy perspective here would be fascinating. You know, spaghetti wrist or while they can be at the wrong time of day, that is middle of the night, and it can take a while to do all the things that Chris is going to share with us. I think they do pretty well from a nerve. I'm sorry, from a tendon standpoint, what are we so meaning I would hope wrist and finger motion are are close to full, I wouldn't expect completely full there will be some strength issues. Likely What's your expectation with your nerve repair? So you were you were going to address presumably the median nerve and the older nerve plus minus superficial branches radioulnar
Chris Dy:right. So that's our end is intact, which actually plays into the ring construction plan for me, which is a nice thing. But Palmer cutaneous is out of it was not visible anywhere in the wound. And it's interesting to talk about therapy component because in preparation for this episode, I dug out an email from my fellowship year, that wow, I spent, I spent some time with our head therapists. And I would you know, when I would do cases, as a fellow, I would often ask for their input about, you know, rehab. So I dug out an email from a now retired ham therapist, spent a lot of time in our division. And she emailed me back, say, Hey, Chris, I know there's next to nothing in the literature on the rehab perspective for spaghetti risk. But I love this diagnosis. Because it's one, it's one where doing the right things early almost always means a happy outcome. And waiting too late to start can cause a little extra misery. Since we're not in Zone Two, early active motion isn't as critical. However, if nerves are cut, it's almost always essential to start early digit active range of motion to preserve as much of the brain handling as possible. So that's just the beginning of email. And I still go back to the female because it's actually how I base my protocol for for spaghetti risk with or without nerve. So I just chuckled, because that was, you know, almost 10 years ago now. That
Charles Goldfarb:is awesome. And if we were a little more sophisticated podcast people, and that that's on me, not you, there would be a little ding that would happen. So imagine our musical like, wake up and listen for a second, if you are a fellow or even a resident, you know, and I don't care if it's hand or sports, have a relationship with therapists you trust and during your training year, during your specialization year, it's not just surgical indications. It's not just surgical techniques. It is understanding what the therapist can bring to the table. Absolutely.
Chris Dy:I mean, it's funny all the all the the fellows seem that the end of the year are scrambling for all the protocol, various conditions, which I can say I was heavily involved in developing some of my protocols, because I work with, you know, Athletica, more than then the Milliken Hand Center just because of the nature of my practice, which was very good for me to learn about kind of how to make these decisions. And I have not thought about them as much because my partners in therapy are so skilled and communicate so well that I don't have to like sit there and think about a protocol that often. Yes,
Charles Goldfarb:and I had to, you know, I've written a book about therapy protocols for congenital, I haven't thought about sports protocols, but did end up having to write some which thankfully had been adopted, it's just easier when we all think about the same way. And we've had those conversations that as a group of seven, we hopefully we're pretty aligned on how we handle therapy, just because it's better for the patient and for uniform better for therapy. And, and I think we we as a group had been been pretty good about doing that. Yeah,
Chris Dy:absolutely. So I mean, to that point about the tendons, you know, it is one where I do want to get some, some passive motion on those fingers ASAP. And then your your question about expectations for the nerve. I think in general, anytime you're involving a nerve graft, you probably have about based on literature, somewhere between 70 and 80% chance at getting meaningful clinical recovery. And typically, that's motor, but for obviously, these nerves, this is both motor and sensory. So that's a general broad number that I use for patients, I think it sets appropriate expectations, this page was actually very upfront with what they were looking to do in terms of their future, I won't say specifically what it is, for obvious reasons. But you know, they were more concerned about, you know, being able to grip and grab as opposed to, you know, in their mind kind of a sensation aspects to it. And then the dexterity part of it, which obviously, fortunately, this is their non dominant hand. But I know they haven't, the patient has no idea how devastating this injury is going to be to the use of their hand. So I'm trying to paint a picture of what a you know, a hand without the good phenol and good intrinsic owner function looks like for that patient. But you obviously don't want to be too much doom and gloom. So I think it is definitely a very challenging situation to counsel somebody in. Oh,
Charles Goldfarb:for sure. Alright, so I want to know, how long have you booked the case for? And I want to know what suture you asked for both for the nerve and the tendons. So
Chris Dy:I committed the sin of booking it for as long as they had
Charles Goldfarb:well done. I
Chris Dy:needed to get the case done. And but yeah, so I I booked the case as two and a half hours. And it probably took a little longer than that. But I think you know, this is a this was a place where that she already had overtime for me set aside and for whatever reason that different case cancelled and I was planning on going to that facility anyway. So they were happy that I use the time. And it took a little longer than expected to get in the room and get started because I don't work there all the time. But, you know, they they were great when I got there. They were very, very helpful, wonderful team. It's always hard when you're doing a big case with the team you've never worked with, but they were incredible. So then, you know in terms of I booked it for two and a half I probably should have booked it for three days. Knowing I didn't have to do arteries was really helpful or not anticipating having to redo the vascular part was helpful. You know, I asked to prep the leg because I anticipated harvesting Searl. So in terms of positioning bump out of the hip nonsterile tourniquets, and I did not put a tourniquet on the arm because I didn't want to be tempted to use it, just given how fresh the vascular reconstruction was. And there's really no evidence actually did it search quickly trying to figure out if it was okay or not, because it would move the case along faster. But, you know, I also asked for some lidocaine with B to get through some of the skin parts of it. And then knowing I was going to have to do a carpal tunnel release and Qian canal release. I just went ahead and put that LIDAR without being for that part of it right away in terms of just to make the initial approach a little bit easier. And I asked for a bunch of sutures. So for me depending on where that is, it's going to be either a three or a three Oh, braided nonabsorbable suture. Oh, caliber of the same variety. Then I asked for my standard micro sutures, which for me are nano nano monofilament. And I also asked for some fibrin glue, which is off label for those listening for use and nerve computations. But I think it's a common practice. Okay,
Charles Goldfarb:so before we jump in on the technical which will include order of operations, I'd love to hear how many strands you know you consider for your tendons, how you think about that in the forearm, and then exactly what you did with your nerves but let's think checkpoint surgical.
Chris Dy:So the upper hand is sponsored by checkpoint surgical, a provider of innovative solutions for peripheral nerve surgery. Checkpoint surgical is always striving to elevate the clinical practice of peripheral nerve surgery by providing surgeons with new technologies to help improve patient outcomes. Checkpoint
Charles Goldfarb:surgicals newest intraoperative nerve stimulator the Gemini bipolar nerve stimulator does just that. With a bipolar stimulation pro Gemini provides finely controlled stimulation even at the secular level, allowing surgeons to take actions based on the most precise information available to learn more visit www.checkpoint surgical.com. Checkpoint surgical driving innovation and nerve surgery. Wow, that is good copy. Yeah.
Chris Dy:They have been very great about providing us the coffee that they would like. So thank you to the checkpointing for that. The nice thing about the Gemini is that you don't, there's no chance of stabbing yourself by putting in that grounding needle. But it does have and this is not an episode about the Gemini. But it does have different features that make it very helpful. And I do like using it for for the different features and less risk of stabbing yourself or somebody else
Charles Goldfarb:I need. I need all that I actually was doing. I do a fair number of sciatic nerve decompressions for chronic hamstring avulsions with my sports partners, and I had a six month old one and I actually considered asking for the checkpoint, but it ended up being fine. So I don't use it with any regularity once a year maybe but I know it's important for your practice, okay.
Chris Dy:But you didn't use a thing that our sponsor.
Charles Goldfarb:I'm not a nerve guy. I do nerves, I use it. And when I use it, I enjoy it. But I'm being real here, Dr. D.
Chris Dy:That's great. Yeah, but this, this was not a case in which I used that device. It'd be interesting to use a stimulant handheld stimulator really early on after the injury to see if you can separate some of your stimulate your distal side before valerian degeneration hits. And I've done that for Super acute injuries because it's helpful if you're trying to differentiate motor sensory parts. So that anyway, that's an aside, but yeah, so for me, and I'd love to hear your thoughts, you know, what the order of operations are exposed what you can see right away and for I needed to I actually ended up doing the carpal tunnel release pretty quickly because it was clear to me that somehow these tendons were cutting and retracted back into the carpal tunnel, at least the the FDS is in the FTPS and it was it was kind of a challenging, kind of weaving the tendons back back and forth. But the way it generally approach it is you know, I had to expose these arteries protect both of the arteries get a sense of what that reconstruction look like. And then, you know, wanted to get a sense of the tendons and where the nerves were and what I was gonna have to do so that as soon as I could, I'm fortunate enough to work in an academic place like you are where I have an assistant that I can send down to the leg start harvesting circle, which was nice so as soon as we got the tendons sorted out, you know and we were in a good place for it was just kind of sewing tendons sewing tendons, asked our fantastic resident to go down to the leg. It's our harvesting circle. So
Charles Goldfarb:love that and agree with everything you said I don't routinely release the carpal tunnel although some might advocate for that just I guess with nerve swelling, so to say. But it clearly if you have to release it, you release it no second thoughts. I liked the cons. After putting in a core stitch, not that I think you absolutely have to in this location, and sort of using a tag of some sort to identify the distal and proximal tendons. So that's where the time is spent identifying, doing your best to confirm you have the right tendon and and putting your core stitch in. And then once you have all that, then you're just tying knots. Right.
Chris Dy:So I mean, that's the challenges case is that my, my FPL was pretty apparent that was not hard to to get going. But fcrn FC were out. And you know, I did repair those on the way out, you know, and I'd love to know your thoughts about whether both of those are necessary or not. But I went ahead and did it did not do the Palmeras. But as soon as I could find my FPL, that was the, that was the easiest stuff to find outside of fcrn FCU. But then all of the flexors for the fingers had retracted back into the carpal tunnel, distally, they were pretty apparent proximately It wasn't hard, I saw immediate nerve pretty quickly. And I think one pearl that I was taught and that I was telling our residents was that it's tempting, as soon as you see all the anatomy, you know, kind of cut and hanging out to like dissect it out all nicely and separate it but you can't because you actually need those surface cues of the median nerve at that level is just right underneath the epimedium of the FDS. And that's a super important clues. So you know which ones are FDS is, and which ones are FTPS. And then you're relying at your carpal tunnel level of kind of the classic, you know, where your tendons are lying in the carpal tunnel. So and then obviously, you have the accuser use, like pulling on the individual tendons to see which fingers are moving. But, you know, going crazy and dissecting out everything proximately it will actually hurt you in the end.
Charles Goldfarb:Really, really important point. And then depending on your level, you can choose to repair each of the FTP tenants individually or as a group, given the fact that they typically have one common muscle belly, there are exceptions to that as well. But I think that's right, you don't want to over dissect this. And so that's that's why I like you know, just going in putting your core stitches in and usually, uh, you know, sometimes I use a stereo chip with labels, but whatever you want to do, just try to leave as much as you can alone and then start deep work superficial nerves within that order of operations. Yeah,
Chris Dy:to me, it's much it. It's, I think I remember Jim Chang presenting about this. I do like the nerdy part of me wants to do the labels and all this stuff. Practicality wise repairs you go. If you can repair as you go, like you're saying, putting in your course stitches, at least like that is super helpful. Just get things checked off the list, because this case will take up as much time as you give it. You know, so if you want to move this along efficiently, you need to kind of get things going as quickly as you can in terms of knocking some of the repairs out. Yeah,
Charles Goldfarb:I liked the way you said that. Because I know that when fellows first encounter this in the middle of the night, it can be a really long case. And this is one where you can do a great job, you can do it efficiently, but you have to really focus and go and so clearly you did that. When you evaluate your nerves, were you it was clearly I mean, it must have been apparent that you needed some some length, how much time how much, how many strands, and how much length did you do for your cable grafting,
Chris Dy:the challenge of where this nerve was cut is where the median nerve starts to go for more and more tubular structure to start to fan out to a flatter nerve. So this ended up being I could have primarily repair this nerve if I really wanted to keep the wrist a little bit of flexion. But that was not what I wanted to do. Because I wanted to make sure that I could get a get tendons gliding past it and be getting a decent going for the tendons. So actually measured my gap, I turned back to healthy fast skulls measured my gap with the wrist, extended over a bump in the fingers and extension. So I would be super sure to know what my median and ulnar nerve gaps were going to be. An immediate nerve gap was not big and ended up being about a centimeter and a half the owner of gap was about two and a half centimeters. So not huge, but you know, so the ulnar nerve ended up being like a really nice kind of three cable size from several. And the median nerve, just based on the width was five, I could have gotten four, but I liked five, and that that's bigger than I typically would use. But just because the nerve is fanning out at that point, I wanted to provide a lot of tubes for that, for that nerve to grow down. The tricky part about this one is that you know, I did leave the location and laceration was proximal enough where I didn't coincide with my carpal tunnel incision. And also the gowns cannot release. But the you know, there's a skin bridge and of course the tendons had to come underneath the skin bridge, they're attracted back in the carpal tunnel. So I ended up putting some sutures in the tendons where I could find them in the carpal tunnel and then pulling those underneath the skin bridge into the proximal wound in shuttling them and in the process of shuttling them that kind of disrupted the contents of my the topography of my carpal tunnel. So now my median nerve took this like weird turn down Deep. So then I had to do the same thing and essentially reorder the carpal tunnel, so that the median or was sitting was sitting vole early again. So again had to put a put a like a little six Prolene in the epithelium before trimming back, and then shuttling that underneath the skin on top of the tendons that are shuttled through, it was so painful, but in at the end of day, I was happy that taken those little things, because then the nerve has a much smoother course along the way. And then repairing attendance, I'd love to know what you do, I was using up being a little bit of a kind of a modified, which was government at that point as being modified casters maybe reinforced with the horizontal mattress, just getting really good stitches, at least four strands, and each of them it's not zoned to, but you still want to get stout repairs.
Charles Goldfarb:Yeah, I agree with everything that you know those tendons can be variable size in that part of the forearm, depending on which team you're talking about. And so I agree it's four to six strands if you can, don't mind it all the external horizontal mattress, I think that's a nice way to get a little more strength. And three over to me feels completely fine. I have to say, I don't know that I would have done any shuttling I probably would have just opened things up. But Bravo. And yeah, it's it's a good case. When When do you and maybe we should close this episode down. But what do you tell the patient six months a year for quote unquote, full recovery?
Chris Dy:Um, you know, I'd expect to get the attendance kind of where, where they should be by about six to eight weeks. You know, that's a little aggressive on the timeline. And then the nerves take, I always tell people just nerves take the better part of a year, just pretty generically. You know, I won't get into these details. But I did add a sensory nerve transfer from the radial side, the the radial distribution on the radial side of the index dorsum to the proper index, digital nerve on the radial side, and then for the thumb on the other side, for the dorsal owner thumb to get some pinch surface going. And that I think, is just the way to get things moving earlier, in terms of recovery, because I have really had no options to do nerve transfer stuff for 13 hours or for for the other intrinsics. So I'm relying on the grafts for that. But yeah, overall the nerves I tell them, you know, better part of the year and then hopefully we'll get things moving along with therapy pretty quickly within the first few months. And
Charles Goldfarb:you send them to therapy, how quickly do you start therapy,
Chris Dy:I'm going to see him back pretty soon. And we're going to do therapy within the first week for finger range of motion, left DLR and a dorsal blocking splint, you know, for the wrist, forearm based dorsally blocking the wrist and neutral that we did the the nerves in extension. And then also extending with outriggers for the thumb and the fingers just to keep them in a position of comfort. So then we'll start some some passive motion for the fingers pretty soon.
Charles Goldfarb:Love it. Love it. Okay. I'm sure we it's interesting that you and I probably underestimated how much there was to talk about here, but I think we got most of it covered. We could certainly that sensory transfers are interesting, but maybe for another episode. Yeah,
Chris Dy:it's super nice, super nerdy. We can definitely talk about it all the time. But yeah, and I loved I love this case. Yes. Was one things. It's fun to do while you're doing it. You just don't want it to take too long because then it becomes less fun.
Charles Goldfarb:Yeah, that's exactly right. All right. Well, this has been fun, and I look forward to talking next time. All right, catch you next time. 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