Chuck and Chris discuss the adolescent medial epicondyle fracture and a group of patients with a challenging outcome. This deep dive into the pathology and the technical considerations for treatment help us better understand the fracture, the relationship of the ulnar nerve, and more
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Complete podcast catalog at theupperhandpodcast.wustl.edu.
Chuck and Chris discuss the adolescent medial epicondyle fracture and a group of patients with a challenging outcome. This deep dive into the pathology and the technical considerations for treatment help us better understand the fracture, the relationship of the ulnar nerve, and more
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.
Charles Goldfarb:Oh hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:I'm great. It's a festive time of the year and honestly is one of my favorite times of the year. I really do enjoy it. So you know, it got got a lot lined up for this weekend. A little some youth sports. Some kids outings, another youth sports event. That's just Saturday. So how about you? What do you got going on?
Charles Goldfarb:Well, sometimes this this, I don't know what the proper term is. between seasons of sports can be nice. You can have a little shutdown. I was talking to one of our partners who said exactly that like there's a couple of weeks weekends here in a row where there's no youth sports, but you obviously didn't get that break.
Chris Dy:No, definitely not. I'm just happy to be in town. It's nice. You know, I've had had to do a fair bit of work related travel. You know, in having a few weekends in a row being home has been awesome.
Charles Goldfarb:Yeah, I I've cut back on my travel as you know, because of the MBA. We were I think my next trip actually, we're gonna do a quick trip around Christmas go to Charleston, South Carolina, which love to discuss at some point. But yeah, the the upcoming nonwork team building event is our group's going to play paintball. I'm sorry that you won't be able to make it but you know, it does hit my Alabama roots a little bit. My wife was invited and she looked at me like I was crazy.
Chris Dy:You know, I really I have played paintball before. I'm sad to be missing out on it. I just I'm trying not to be over scheduled, although I do love team building morale type events, and I'm quite competitive. But I also asked when so our partner David Brogan. Medical Assistant Tracy is organizing it saying it's great. I did ask her if we were going to be following Zoolander rules because I clearly this is my moneymaker up here. And I said Zoolander but really its Anchorman rules. Were no touching the hair.
Charles Goldfarb:So funny. Yeah, obviously don't worry about that quite as much. It's a good time of year because you have plenty of it's a little chilly and so I'll be wearing plenty clothes, so there shouldn't be any physical pain other than me trying to run that'll be the only physical thing there is. You
Chris Dy:just need to be as a sniper strategic positioning because I don't think running is in your best interests right now.
Charles Goldfarb:Oh my god. No, it's not speaking of holiday season. I have do have a date for my uni computer navigated knee replacement. And I did skip around the holidays. My wife thinks I'm a lunatic. But I'm like I can't miss time in December. I gotta push this off in January but it can be busy too
Chris Dy:You have met your deductible. You're just like every other American patient. So are you gonna do the insane thing of because I remember when you were on the schedule for a nice scope. You did it at the end of your own or day. That's insanity by the way, but I guess you're probably NPO anyway jury your day.
Charles Goldfarb:So funny. I actually have no regrets. I handled that one. I thought that was pretty proud of how it worked. And I think a knee replacements is a little different. Also had asked our Surgeon my surgeon to drive me home at the end of the day because my wife was out of town coming back that night. So yeah, I'm doing a knee replacement a little differently. Although my wife thinks I'm gonna work too quickly. But I got you got to be careful. I think I don't want to compromise results here.
Chris Dy:Yea absolutely. I remember when you pulled off the day of cases and then had your own surgery. I thought that was quintessential Goldfarb. Let me that was the anybody that's worked with you as a resident or fellow knows that you have threaded that needle so many times. And when I think I'm having a highly efficient day, I realized that you probably had a more efficient day.
Charles Goldfarb:You are kind that is music to my ears. But definitely I'm learning all the time in preview for sure. It's It's fascinating what's happened to my or schedule. And this is a brief tangent, I apologize. I used to start every day when when you way back when when you were a fellow, there would be a few carpal tunnels, a few triggers a few games that would have be how we warm up our day. It doesn't work that way at all anymore. First of all, I don't do many of those cases anymore. But they're all at the end of the day. And I become more and more that insistent because I'm not insistent, but more and more pushy for all the little cases to be at the end of the day local only. And so this week I had for at the end of the day, and it was great. I've had to shift how I think about things but it's been really nice.
Chris Dy:It's interesting surgeon approaches to how they schedule their days are different because you know you have how you used to do it in terms of warmup cases and they get into your bigger cases. And then there's always the Rick Wright model of downhill skiing, knock out the big ones. My problem with the downhill skiing model is that sometimes there's a lot of variability and how long those cases will be, which can throw off your entire day. And so I've moved my scheduling model to when I run my two rooms actually have a, I do one local case at the very beginning of the day, so that both rooms can push back essentially, at the same time the anesthesia room is getting going, the general anesthesia rooms getting going while I'm doing a local case, and I just flip and by the time I'm in that other room, everything's ready to go. But now I've had to, to ensure that I keep both rooms with two full staffs, including the anesthesiologist or the CRNA, I now have to book I can't have like a local in the room that flips in quickly in and out of, I have to book the right number of cases for sequencing. And I've gotten to know how you would do like actually having to set my own lineup personally, as opposed to relying on somebody else to do it. And it reminds me of how you used to do that painstaking process every Monday of coordinating your Wednesday schedule.
Charles Goldfarb:Yes, I still do. I don't, it's not that I don't trust anybody to do it. I mean, no one's volunteered really, because they know I it really matters a lot. And you not only have to know what the case is titled, but you have to know what is likely to happen. And that's what drives me so crazy. If I come in and someone's messed with it, I sort of, you know, lose my mind. But hopefully not verbally or, or visually.
Chris Dy:I had a moment of bad behavior one time a few years ago that I did lose my mind, and I verbalize it when somebody mess with my schedule. And I don't think I lost one heart one mind that day.
Charles Goldfarb:Hey, it's what it takes to do what we do. Because we as you said, we are threading a needle every day. And obviously, we have to make sure that we take do the right thing and take great care of patients. But we need to do it in the most efficient way possible. It's just a requirement of medicine in the United States and 2023.
Chris Dy:I think so. And that was you know, speaking recently to somebody Yeah, and one of the clinician scientists, forums about you know, how to be, you know, effective as a clinician scientist, and I think you have to be, you know, ruthlessly efficient on your clinical days, if you want to protect academic time or for you, your admin, your leadership, your MBA time, you have to be very, very efficient on all the other ones and the other all the other times, so that you can maintain clinical excellence, clinical volume, but then also, you know, be present when you have your protected time for whatever it is that you're protecting.
Charles Goldfarb:Absolutely, yeah, it's interesting. I have am also still trying to find time, not to your degree, but for research, because this stuff continues, you know, my projects continue. And I've actually had a weird issue where there's a lot of people, whether they're actually some medical students, residents and fellows I'm trying to work with, it's just not enough hours in the day and some of the research concepts are great.
Chris Dy:Yeah, you turn you turn to somebody I sent to you down, you're gonna work with this. But I understand year, there's only so many hours in a day. And I think that you, you know, if you can't be if you can't deliver at the level that you're used to deliver it, then you should say No, I mean, you've earned your stripes clearly. So Well,
Charles Goldfarb:it's interesting, the department has established Diversity, Equity and Inclusion grant process. And I had a medical student who was sent to me to discuss a project and I, you know, on the one hand, I was kind of like, Oh, my God, I don't know that I can take this on and guide the medical student appropriately. She was She knows she seems she she had things together. And so I agreed to do it, thinking it wouldn't be a lot of time. And you know, what's a lot? It's more time than I hoped. But it's also pretty cool. And so trying to find some time.
Chris Dy:Yeah, I was, I was thinking about my wish list does include another day in the week and another couple of hours in each day. So Santa is listening. Yeah, why don't we thank our sponsors that Practice Link. The upper hand is sponsored by practicing.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 www.practicelink.com/theupperhand.
Chris Dy:So exciting episode today, it sounds like people want episodes about details on both clinical workup and surgical technique. And it sounds like you have a good thing for us to discuss today.
Charles Goldfarb:Yes, on the surface, it may come across as too niche. I don't think it is. And I think it'll bring up a lot of important points. And in fact, we could go too deep on this. So I think it'd be an interesting balance. Let me share a case scenario with you. Which again, on the surface, I don't know may seem like nothing. So I have a 12 year old female who first presented to my office three months ago, with a minimally displaced medial epicondyle fracture at the elbow. And you know she came in one week after a gymnastics injury. So she was doing a triple back, lots handspring cartwheel something. And what
Chris Dy:the hell's that? That sounds like you incorporated figure skating some some other kind of tumbling maneuvers like what are we talking about here like just kind of turning over like putting a lot of pressure or axial loading and yes, backflip?
Charles Goldfarb:Yes, I'm sure everyone on the call who actually knows anything about gymnastics. But in all seriousness, she was doing some kind of back handspring round off immediate pain in your elbow and was seen through urgent care appropriately diagnosed with a medial epiocondyle fracture, I saw her the next week, minimally displaced fracture we discussed options which you and I can discuss and we elected for non operative care now
Chris Dy:she feel pop when this happened or is immediate pain and what is the pop mean if anything, and there's a lot of bias recall bias with you know, how patients describe things and how we ask about them. Yeah,
Charles Goldfarb:interesting. I hear the quote unquote pop more when this happens for baseball players actually throwing in this case she just felt pain in the medial elbow.
Chris Dy:Is this similar to the gentleman and not a peds person? But is this kind of like an aphoitis type of deal where there's a stress over repetitive use, like in the throwers adolescent throwers, or is this different than that? Yeah, I think
Charles Goldfarb:in this case, it was different. But I do appreciate that line of inquiry, because a lot of these are, you know, a prophecy of inflammation, stress risers and eventual injury. Of course, that couldn't be the case here, but she denied any prodromal symptoms, just a one event.
Chris Dy:Got it. So she was seen in urgent care was diagnosed, got to you a week later is at the appropriate timing. For
Charles Goldfarb:sure, for sure. And we had a good conversation, you know, the peds literature, you know, goes way in depth as it should regarding diagnosing and best understanding the amount of displacement of the medial epicondyle and according to literature, there's plenty of leeway, you know, up to a centimeter displacement is fine. Some people say five millimeters. This was four millimeters. So it was, to me not even really great. And I, I've had some interesting experiences with me up a condo fracture. So I think this was a stoic kid as gymnast often are, and minimally displaced fracture, it wasn't hugely controversial to avoid surgery. So
Chris Dy:is this the kind of case where is this a long arm cast for however long? And then typically, how does the non operative treatment go from there?
Charles Goldfarb:Yeah, so for me, I usually start moving at three weeks. So if she was a week out, put her in a cast for two weeks, brought her back, let her started moving, let her start moving. And that was okay. She didn't have a lot of specific medial epicondyle pain, but I asked her to come back in a month. We discussed the pros and cons of therapy. family wanted to go to therapy once and to do a home program.
Chris Dy:So this is your plan. You had her comeback. She'll be six weeks out when she comes back doing home stuff on her own, I'm assuming and I have to ask no nerve symptoms.
Charles Goldfarb:Okay, yeah, good point. So at this point, no nerve symptoms, minimal pain, reasonable family, and you know, in all regards, but yeah, she wasn't come back at six or seven weeks post injury. And I fully expected Now I understand that these can run the gamut. But I fully expected her to be near full motion. And I expect her X rays to look pretty good.
Chris Dy:So during that time, where you're taking her out of the cast, you're three weeks out now from the injury itself, what activity limitations were you giving them as they were kind of getting out of the cast doing their home program for exercises? Yeah,
Charles Goldfarb:so she was not allowed to do any gymnastics, loading, no push ups, light activities, typing, Writing, Reading video games running. And the ultimate question which happens every single time, can I be in the gym, doing things where I don't use this elbow fitness and doing the no arm or one arm back handspring. And I usually look at the parents and say, if she can do it safely, she can do it.
Chris Dy:Yeah, and not to distract too much from this case. I did have a kid who really wanted to play in his hockey tournament with his recently injured finger and I'm like, I kind of get it now as a dad, my kids not you know, at that level, but it's probably okay. But you obviously have to catch it. So I think I look at the parent and like, what do you think this is up to you? You're putting, you know, there's some risk here and everybody's got different appetite for risk.
Charles Goldfarb:Yeah, I deal with this every single day as you do as most and surgeons and orthopedic surgeons do, my philosophies evolved, I just had this conversation with one of our wonderful nurse practitioners. And more and more, I am willing to let first of all, I feel like I've always been lenient in encouraging of kids going back to sports. But I do get pushed where I'm not 100% comfortable. And I verbalize that. I try to do things to be protective. And I document that, that there that there's a risk of injury and not that I live in the fear of being sued, because that's not my word had that I hadn't had that happen, especially in these situations, but I think it is about the conversation.
Chris Dy:Absolutely. So tell me more about how this case unfolded.
Charles Goldfarb:So she comes back in six weeks, and her motions terrible. Her range is 45 to 120. She had full rotation. And what was interesting, whether it was this visit or the next share we did in the meanwhile, there are a couple of things that were interesting. One as we started, you know, it's hard to figure out why is your motion so bad, you know, there's no x rays look fine. It's always hard to see healing at the hypothesis with minimal displacement. But x rays look like things were progressing. And she just seemed to develop discomfort at the end range.
Chris Dy:So you're lacking 45 degrees of extension? And assuming is your active arc same as a passive arc?
Charles Goldfarb:Yeah, so sorry, let me clarify. I do like the elbow, I do a lot of elbow, I was taught how to measure elbows and shit and verbalize the measurements back in fellowship, but not everyone does it the same way. So when I say motion was 45 to 110. So that means full motion will be zero. So full extension to 145. Typically, that's full flexion. And in this case, it was 45. So she lacked 45 degrees of extension, and she flex to 110. And yes, active equalled passive. And so that raises a super interesting question, does active equal passive because she's developed a contracture of the joint, which has been quick, but not not impossible? Or is there something else going on?
Chris Dy:Yeah, it's interesting, because it could just be kind of her gardening for lack of a better term. And then it would be really quick to develop an actual contractor. But like you said, Not impossible. So how do you first so how do you address this with the family? You know, and the patient? And then what do you do? Yeah.
Charles Goldfarb:The family, you know, was frustrated, honestly, and and I shared that I'm frustrated as well, but also share that I've, unfortunately had experience with this. It doesn't happen very often. It always happens in 10 to 12 year old girls, with some rare exceptions, but literally, every time it's incredible. And
Chris Dy:is this like a well known entity, or this is we're getting into Chuck Goldfarb level five, like, you know, everybody gather around the fireplace. Let's learn something from the guy that hasn't published it yet.
Charles Goldfarb:Well, a couple of interesting things. Thank you for that very fair comment. Lindley. And I did just published this, and I don't know if it's out yet, it was a small series as it might be expected, but it's one of those situations where once you have thought about something and written about something, you start to see it more and more. And so we, and I think it's in general a hand surgery go or will be shortly, but 10 to 12 year old females, medial epicondyle fractures, something happens, and you're gonna like what we think that something is. But what happens is, these patients start to develop co contractions, which is a term that we discussed at length with our wonderful therapy colleagues. And so it's in now I look for that every time so essentially, when she goes to extend, she's not only firing her triceps, she's firing her biceps, and when she goes to flex, she's also firing her triceps. So she's fighting against herself because something's going on with the ulnar nerve, even though she doesn't complain about her nerve symptoms. That
Chris Dy:is super interesting. And now you have piqued my interest. First off, congratulations on publishing that as a listener pointed out a couple of years ago Chuck Goldfarb, just a workman hammering nails, just finding all the nails and hammering them. And I applaud you for getting it out. Because a lot of people don't take that extra step. And you know, they think about something they put it as part of their practice they tell their colleagues but they don't necessarily get it out there literature so congrats on that. Now before we dive into the nerve part, which I'm super excited about, we should thank our next sponsor. So the upper hand is sponsored by checkpoint surgical, a provider of innovative solutions for peripheral nerve surgery. As a hand surgeon and as a hand therapist or an orthopedic surgeon genio that nerves matter. It's why checkpoint surgical is singularly focused on elevating the clinical practice of peripheral nerve surgery with innovative technologies that help improve patient outcomes. Checkpoint
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Chris Dy:nerve surgery hand surgery, you will get you just mixing up the copy there. Sorry, Becca, both of us riffs on the coffee. So tell me how this how this evolved in terms of the nerve stuff and tell me more about this patient and also what you found in your series. Yeah,
Charles Goldfarb:I think let's you and I have discussed previously, the concept of the ulnar nerve and throwers with UCL injuries. And what we share then in case the listeners don't recall is that, you know, both you and I, I think me a little more frequently work closely with our sports partners. And one of our partners, Matt Smith is amazing and particularly focused on the UCL does a lot of reconstructions. And we team up regularly because it is quite frequent that the owner nerve is irritated as well. Now, if the owner is not irritated, I'm not involved. But if it is at all, or if the nerve is subluxated, then I go ahead and transpose the nerve. But what we find in those surgeries, it's fascinating. The medial elbow soft tissues are not normal. There's scar, there's hyperemia. And the vasculature is really robust. And it's just it's very, very different from the idiopathic X. And these are the throwers or your these are the throwers. And then sortition.
Chris Dy:Let me let me ask you one question on that first. So you mentioned that the ulnar nerve if it's irritable Now, typically my experience with these younger patients that their nerve studies come back as quote normal, because those normal values on nerve study are based on an older population. So is it something on examination that clues you into that the nerve is irritated? Yeah, it's not subluxated Yeah,
Charles Goldfarb:and if the patient is seen and has UCL problem, I don't order nerve studies. It's a clinical exam by Dr. Smith and myself. And that exam evaluates for you know, certainly 10 nails or elbow flesh compression test, nerve stability, and patient complaints in the thrower, they often complain of medial elbow pain, and sometimes they complain at the distal radiation and occasional numbness and tingling. But as it seems to be not only the ligament causing pain, but also the nerve. So
Chris Dy:what's your go to treatment for the thrower who's having UCL surgery of some sort? Yeah,
Charles Goldfarb:and again, this is adolescent young adult population. I don't believe in decompression in those patients. So these are transpositions, subcutaneous fascia, cutaneous flap, early motion, and we you know, usually what happens is we're protecting them because of the UCL whether it's a repair, whether it's an internal brace, whether it's a true reconstruction, so Matt likes hinged elbow braces. And we get a moving pretty early, but fascinating is flat, I do not go so muscular. It's I think that comes with a cost.
Chris Dy:Definitely a cost in that throwing athlete for sure. Um, so tell me about the gymnasts. Yeah,
Charles Goldfarb:so we recognized and discuss this concept of how it's likely her owner nerve is contributing to these co contractions and her failure to regain motion. I stressed the importance of therapy and got our therapy colleagues more involved to try to work with that. Clinically, she did not have clear evidence of an owner at that moment, meaning nowhere to build it.
Chris Dy:Can you tell me more about why the ulnar nerve might be causing contractions just because I don't typically think that the ulnar nerve is providing any innervation to the biceps or to the triceps or the brachialis. Yes,
Charles Goldfarb:I don't either. I is a pain reaction of some sort is a subclinical pain reaction, and the patient is somehow another guarding against motions that stress the nerve you would think especially flexion. But it's extension as well. I don't understand and there is some literature out there on on the concept of contractions. Because we looked into it for this paper we use wrote, but the literature doesn't fully explain it to me so I don't know the answer to that question. But there's no doubt in my mind that it's an angry older nervous the culprit.
Chris Dy:So for any residents or fellows listening if you want an easy research project, you can definitely build on Chuck's work here, and put some needles in there and try to figure out what's going on.
Charles Goldfarb:It is it is an interesting topic, right? You do some niche work. This, you know, when Lindley and I were talking about this and recognize the problem, and our therapist recognized the problem, you kind of like, Well, should we publish this? Is it? Is it a big enough deal? And I think the reality is that we've seen in I think our case series was 12. But since then, in the last year, I've probably seen 10 more kids. It's out there, and you just wonder whether people will find this work. But if you don't publish it, then one thing is for sure, no one no one will, you know, everyone will be reinventing the wheel there
Chris Dy:and say what you will about, you know, I think the traditional academic model is that something that is open access is not considered as high prestige factor, but it's when people read it, people can get that around the world, both people who are patients, families, etc, but also other practicing surgeons and therapists. I've had people come in and print out articles that are open access in their mind, and they print out the Open Access ones and not the ones that are brought in to paywall. So there's definitely something there about the scholarship part of it. So kudos to you for getting it out there.,
Charles Goldfarb:Yea for sure. I don't think we've talked about this, but it definitely relates- 10 years ago, more than 10 years ago, when Nate Van Zeeland was a fellow. Nate was the first author in a paper I wrote with Don Bae from Boston, sharing our experience with intra articular radial head fractures. very uncommon. But we had noticed a trend of catastrophic results when those radial head fractures were underestimated. So wrote about it. And I really think it was 2012. It was published. And it was one of those deals saying exactly the thing is this, it didn't feel that impactful, rare situation. But what's happened, and I reviewed the literature, because I had to present on it recently is there's been a lot more work done in that area, and an increased recognition of the danger of that fracture, which felt really good. It felt really good. And maybe this, this is something similar. But the message here is, if you see a clinical problem, others are seeing it too, right?
Chris Dy:I mean, because you've seen 12 of them in your case series, you've seen 10 More, multiply that by the number of people that are out there, and you know, so I'm glad that I'm sure this has seen me, but I have not seen it. And it's probably seen a lot of other people in practice
Charles Goldfarb:Yeah, I assume so. So our approach with this patient was more therapy under more close therapy guidance. So go into therapy twice a week, which is no easy thing. I mean, the more I when I when I talk to families about copays, and it's unbelievable. I mean, there's some patients who have 75 to$100 copay is to see me and 50 to $75 copay see the therapist, and you're asking him to go twice a week. No one everyone flinches at that. But I still think in this situation with the hope to avoid surgery, it was the right thing to do.
Chris Dy:Yeah, absolutely. I, when I'm debating whether to continue therapy, I ask them, Is it convenient? Does it cost a lot? And it's, you can tell the people that don't mind going because it's close to home, and there's no out of pocket? But you know, for other people, clearly, it's something that we need to consider. Well, is there any thought to Botox in the biceps
Charles Goldfarb:Yeah, great question. There was thought I haven't done that yet. I think it's it's in play. Obviously, in an active kid, where you might get six months of biceps dysfunction might not be the ideal approach. But it's in play. Because if you ended up doing if you end up doing therapy for a couple of months, and then surgery and recovery, you're at six months anyways. And so it's a really interesting thought. And I think it's a fair thought.
Chris Dy:I mean, you still have your brachialis and your BR that are going to help flex the elbow. So I mean, I don't know if it'd be a complete loss of elbow flexion. But it certainly would help the home team in terms of your goals. Yeah,
Charles Goldfarb:it's just it to your point. Yeah, I don't think she could could get back to gymnastics without her biceps. But if it allowed you to kind of stop this process, then it would be a huge win.
Chris Dy:So what do you what do you do? You've tried to therapy? I'm guessing this is leading towards a surgical case, but were you able to salvage it with all of your non operative efforts? No,
Charles Goldfarb:and I don't know how successful in general we've been with therapy. So we ended up we did go the operating room. Actually, a little while back I had to the exact same patient back to back in the or same exact case. So medial EPA condo, what I was calling a non union, but I don't think that was the primary issue. I just don't think I can go the or and not address the medial epicondyle while I'm addressing the owner. So concept was treat the middle upper condyle non union and transpose thinner.
Chris Dy:So what do you what do you tell the family about what to expect in terms of you know, this is a nerve thing now in were suspecting that there is this is essentially an ulnar neuritis in the setting of a recent medial elbow bony injury. And a neuritis is driving some kind of guarding type reaction that's causing co contraction of the biceps and the triceps. Is that accurate? So yeah, what well said exactly. So then what do you tell him what we're going to do in terms of how to address the nonunion? And what you're going to do with the nerve? Sounds like you're gonna go for some kind of transposition, not just a decompression load, right? Yeah,
Charles Goldfarb:definitely. Again, the young patients, I don't believe in terms in decompressions, I tell the family three things. One, we're going to transpose the nerve. And I think that's the critical step of this procedure to we should fix the medial Appa condo. And we can talk about that. And then lastly, I always discussed the possibility of a joint release. Because if there had now you know, by the time he gets the oarsmen three to four months. And thankfully, what I've met, what I have seen happen is the patient goes to sleep, maybe things are a little bit better for motion. But then once you get in there, and you deal with some of the scar tissue that is, is kind of the reason I brought to UCL is a very similar pathology, there's a lot of scarring, there's a lot of hyperemia, and you work to transpose the nerve. And even before you fix the fracture motion is better, it may not be perfect, because I do think muscle tightness develops that don't believe this is typically a joint contracture. And if we can get them closed, I have to I have faith that therapy can get them all the way back.
Chris Dy:Yeah, no, I think that's that's my experience with this is limited, but you know, I've found that it's typically once you've addressed everything else, in this timeline, there isn't gonna be a lot of contracts. I mean, what do you think ends up being the type thing that limits elbow extension? I
Charles Goldfarb:think it's the biceps. And I think there's some contracture of the muscle fibers that just need to be stretched out over time. And whether or not there truly is a joint component. I don't know we have done joint releases. And they've been very unsatisfying in this in this situation. And so I do think it's muscular and that's why I think therapy can make a difference in therapy can be effective once you've removed the pain generator, which is the nerve.
Chris Dy:So clean up the non union, what a single screw like what are you doing some fancy Yeah,
Charles Goldfarb:and I know if any listeners have different thoughts, I would welcome them. What we have done here is we the patient is supine, which you know a lot of people prefer a prone position for acute medial epicondyle fractures. I typically do them all supine, I make a small incision anteriorly use or for your elevator in the mini CRM to identify the non union make a small incision, charrette, the what is the hypothesis or what we may call the growth plate as it is closing because that's what's happening here, the both plate is closing as a weak point to fracture. And then I take a little destroyers bone graft, I pack it in, and I put a cannulated screw. And that part is generally insight to not necessarily trying to reduce it. Because typically, these are not wildly displaced. You
Chris Dy:need the bone graft always there. Do you? Can you do you think that you? This is a fracture that it hasn't healed? Because of lack of any sort of stability? Not necessarily biology? I'm assuming? Or is that that's kind of how I think about nonunions. In general, is that different for the prophecy type fracture?
Charles Goldfarb:Yeah, these are fibrous unions. So I don't know that we have to fix them. But I feel like we should because we would hate to have to do another surgery. And we're not adding much to the surgical intervention is one of those which is sort of lame, the way I just said it. But But I think it's the right approach.
Chris Dy:I do enjoy heckling the trainee, I mean, encouraging the trainee as they're harvesting disarrayed histographs. So that was one of my favorite parts of the day,
Charles Goldfarb:for sure. And what I've learned in these situations, you know, you want to harvest your bone graft from a location that is zero risk honestly, or as low risk as possible from either tendons being irritated or nerves being irritated. And then so I tend to come proximal to the open destroyers growth plate, I tend to sort of work over near the second compartment. And then sometimes you just don't find a lot of motivation.
Chris Dy:And I go, I go deep to the second compartment, I think because of the lessons that you have, you and our other partners have taught me. So we're radial, your radial to Listers, we were underneath the second compartment. Because I don't want to mess with anything dealing with the EPL and putting that at risk, then you know, you tend to find enough and then usually the attending finds more. That's always a fun part of it. So anyway, you've stabilized the bone. You've transposed the nerve at a professional transposition, I think is your go to. What's your postdoc protocol for this is different Are you splinting them in extension, immediately after surgery? Are you splitting them at all you want to work on with therapy Day Zero, day one, day three. What's your protocol?
Charles Goldfarb:Yeah, typically, you know, we It brings up a question which I'll circle back to, but I typically try to give them a period of rest different than my other nerves different than my older owner, other owners. So I typically splint them for a week or so and then have them start therapy without necessarily needing a splint after surgery, as long as I trust them. Occasionally families want that split long arm split after surgery, but to get them moving. And I think that period of rest can be helpful because I'm trying to break that cycle. And I think transposing the old nerve is part of breaking the cycle, but just, I'll take anything I can get.
Chris Dy:And then you're splinting an extension. Yeah,
Charles Goldfarb:I mean, if, if I was going to splint at the time of surgery, for a limited period of time, it would be an extension, it's always an extension when you have a flexion contracture. And again, this is a little different. So I don't feel that after splint an extension. And then going back to the point I previously made some question, you know, that hand surgeon perspective on these Peri articular, joint fractures and kids is getting moving, right? We don't want to stiff elbow, get them moving, the pediatric orthopedic surgeon perspective is shut them down for three, four weeks and then get them moving. And so sometimes I wonder whether trying to move kids early, which is always the trend can contribute to this nerve reactivity issue, and a slower approach might be beneficial, right.
Chris Dy:And an adolescent elbow is different than an adult elbow in terms of, you know, predilection for stiffness for developing a joint contracture, especially if you've addressed what you think was the contributing cause to her limited motion. Right,
Charles Goldfarb:exactly, exactly. So we, you know, whether we splint or not for a brief period of time we start early therapy. And it's I wouldn't say these are like homeruns, immediately perfect motion. I think there is some work involved. But I think we, every time I've done this, we've seen clear gains, if not perfection, clear gains.
Chris Dy:So as we bring things to a close, can you just summarize for me how you think these patients do overall sounds like they do pretty well and kind of what the arc of recovery or the timeline looks like.
Charles Goldfarb:Yeah, one final point. And I'll answer that, that question. It's not always those treated non operatively. So some patients who have an ORIF of the medial epicondyle, acutely can develop this issue, which is sort of reinforces the the ulnar nerve, because, you know, almost no one transposes the ulnar nerve in that situation that they're fixing the medial lateral condyle. And I think is just that that precipitates more scarring. And so what's going on the ulnar nerve, it's not the fracture, it's the ulnar nerve. And so I always and I encourage all listeners to always examine for the old learner, but not just once. So you do it at that two week or six week mark, and the owner may seem quiescent, but it'll change. And
Chris Dy:how long does it take people to get better after your surgery think?
Charles Goldfarb:I think three months and then things will maybe still improve a bit more, but you're pretty plateaued at three months.
Chris Dy:Okay, well, you know, now that I've been thinking about a prior case that I've addressed with our partner David Brogan actually had, I think she was a late teenager early 20s. Very painful, medial inner brachial continues through Roma, who actually had a similar co contraction situation of the biceps and the triceps. And David did a very elegant neuroma, certain painful neuroma surgery. And that situation was fixed. And I think it's analogous to what you're describing. Now, we didn't go so far as to publish it. It is on our department website, patient successful patient case series. So you can I guess we can we can we can show that off. But that's a great case. Thank you for sharing that. And hopefully people have, you know, will learn from this or if you've encountered this before, and you have a similar different experience. Let us know. Send us an email and podcast@gmail.com Yeah,
Charles Goldfarb:I love that. Have a good busy month of December and I look forward to catching up again soon.
Chris Dy:It is a day full of activity. Take care.
Charles Goldfarb: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 and be
Chris Dy: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