Season 3, Episode 5. Chuck and Chris talk congenital hand surgery. Do you want to be the expert or do you believe that time spent learning about congenital conditions is a waste of your time. We unpack it here and emphasize why there is a great deal for all of us to learn from congenital!
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Season 3, Episode 5. Chuck and Chris talk congenital hand surgery. Do you want to be the expert or do you believe that time spent learning about congenital conditions is a waste of your time. We unpack it here and emphasize why there is a great deal for all of us to learn from congenital!
We plan a newsletter launch soon. Subscribe here: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Welcome to the upper hand, 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 aspects of hand surgery from technical to personal.
Charles Goldfarb:Thank you for subscribing wherever you get your podcasts.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Oh, Hi, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm fantastic. How are you?
Chris Dy:I am doing well. I'm excited. We're gonna talk about something that is near and dear to your heart today. So that's gonna be great.
Charles Goldfarb:Right? Well, you know, the people have spoken and is clear that they like sports podcast the best. And a distant second is nerve. No one has ever clamored for congenital and it's been hard for me to keep my lips sealed on one of my passions.
Chris Dy:So So tell me you tell me why you think that is? Do you think it's just very niche? Do you think it's just are they intimidated by the kid part of it the genetics part of it, like, tell me why this is an important thing I should at least know.
Charles Goldfarb:I believe that every hand surgeon and trainee and therapists should understand kids. I think there's many reasons. One, there are technical pearls, that are procedures done routinely in the pediatric population that translate nicely to the adult population. And so comfort level can be built. Interacting with kids and families is an acquired skill that I'm still acquiring. And I think that's incredibly valuable. And thinking about how to get the best out of surgical outcomes with kids, whether that be through therapy, or you know, just working with a family is also an important skill. And so, on the surface, some might think that, you know, it's time spent maybe in a congenital or situation that could be better spent elsewhere. I couldn't more strongly disagree. I think there are many lessons to learn in the ER. And I think, you know, there are certainly congenital cases that all hand surgeons should consider. And there's other congenital cases that most answers you should not consider. So I just spouted off a lot. But what resonated?
Chris Dy:So I mean, we talked about it a couple of weeks back when we were doing our fellowship, interview episode about, you know, how there is value in learning congenital, but you obviously if you're not going to do it, you may not want it to weigh too heavily on your schedule for a very limited and already dense year. How do you how do you conceptualize you know the learning important principles about congenital hand surgery but also for you, I also know that you guys don't really love it when people dabble in congenital, so somebody is going to learn this stuff in fellowship? Do you just want them taking the principles away? Or do you actually want them doing some of this stuff when they go out into practice?
Charles Goldfarb:Yeah, a lot to unpack. So first of all, I would say that it's a relatively saturated market. Meaning there are hand surgeons at almost every single Children's Hospital in America where that did not used to be the case. So lots of hands surgeon specializing in peds. And so to build a congenital practice is is not necessarily the goal. So Lindley and I, Lindley Wall and I made a choice years ago not to have a separate congenital fellowship, there are a few of those in the country. And I'll tell you, many of those fellowship leaders wonder whether it's the right thing to do, because there's simply not a lot of job opportunities. But I think a principle based learning of congenital is important. It's important for the history of hand surgery in general. And as I mentioned before, that there are technical things that we learn and see regularly in peds and in kids with birth differences that you just don't see in adults very often. And when you see them, and you're experienced in the treatment, it's just much easier.
Chris Dy:So let's let's, let's start a little series. I know this is gonna keep you engaged in the podcast for the rest of the season, at least let's start a little series of congenital hand surgery for the non congenital hand surgeon. So teach me some of these principles. Let's Can you pick a condition that you'd want to start with? And we'll just go from the very basics and kind of tell me what I should know or what I should appreciate?
Charles Goldfarb:Well, I think most simplistically, is in, I keep saying pediatric, I probably should have been saying congenital, but in pediatric or congenital hand surgery, is non traumatic one of the things we do all the time, is lengthen skin. And the basic reason for that is if I treat a kid at a young age, whether I'm the world's greatest surgeon Not I will create a scar. And that scar will not lengthen as rapidly as the bone will grow. And so scar contractures are common. And so Z plasties, and soft tissue rearrangement, are a frequent part of our practice. And I'm not solving those issues with free flaps or massive flaps, it's typically Z plasties as mentioned, or small, random flaps that are really vital. And we do all the time in the adult world. I don't do that very often. Do you?
Chris Dy:So well sometimes you have to do a Z plasty, you know, and then you'd rather know how to do it before you need to do it. The time that it comes up for me is, you know, after a trauma, a massive crushing crush injury to the hand, but then also potentially after a Dupuytren's release.
Charles Goldfarb:Absolutely. That's exactly right. And not the hardest concepts or, you know, procedures that we do. But just the basics are so fundamental to pedes. And so important for a trainee to understand before embarking on their career, even if they don't take care of it. So that's, that's the low hanging fruit. That's the super easy part.
Chris Dy:Well, what's it what's a Z plasty?
Charles Goldfarb:A Z plasty is a way to lengthen a linear scar, and I am not a plastic surgeon full disclosure. And most classically, I do want one of three Z plasties. So the easiest is the to flap 60 degrees, Z plasty, which lengthens by 75%, that that band, when we're performing a Z plasty, whatever variety, not only are you rearranging the skin, there's inevitably a scar tissue band beneath the skin, which view size but a two flaps the easiest, four flap Z plasties can be managed in a couple of different ways. But it gives you a nice lengthening of the soft tissues, but a less acute depth, so to speak, of the of the site of lengthening. So if you're doing in the first Web Space, for example, it may create a nicer softer closure rather than the acuity of a two flap Z plasty. And then some of the do a five flap Z plasty which has different cute names like running man or jumping man, but five flap just adds V to Y plasty in the middle of your four flap Z plasty. So those are the ones I use regularly. You know, I do use them in Dupuytren's on occasion. But mainly for me, it's the pediatric population.
Chris Dy:Now, are you the kind of surgeon that's going to draw out your Zs before you make your excision of the prior scar? And are you the kind of surgeon that's going to, you know, exercise the scar and then figure it out afterwards? I've noticed that there are some differences among plastic surgeons and orthopedic surgeons with how you approach that.
Charles Goldfarb:I think you said that right. There are definitely differences between how a plastic surgeon and orthopedic surgeon handles things. I will say if we're considering a diagnosis like radial polydactyly I excise the extra thumb then figure out how to close it without a linear scar. But when I'm doing Z plasties, I take the opposite approach. I meticulously plan out my Z plasty. I often measure to make sure each of the limbs is of the same length. And I try to shoot for 60 degrees. I don't pull up the goniometer in the OR but pretty anal retentive about getting that right.
Chris Dy:I wasn't gonna ask you if you had the sterile goniometer. You know, because I feel like that seems to be a very Chuck Goldfarb ish kind of thing.
Charles Goldfarb:We do have one I don't always use it at the shrine.
Chris Dy:Okay, got it. All right, well, so let's talk about radial polydactyly, that you mentioned, that is one condition that you treat. And that seems to be a relatively common and perhaps straightforward congenital condition. So tell me what that is.
Charles Goldfarb:So how many hours do you have? So it's interesting when treatment of radial polydactyly was first described, maybe 60-70 years ago, they just talked about taking off the extra thumb. And for most radio polydactyly is that's not good enough. Increasingly, and there's actually two papers in the literature this year that have modified the main classification. The main classification, in the literature is called the flat, I'm sorry the Wassel classification, and many of us now choose to call it the Wassel-Flat classification, because the the lore is that Dr. Wassel, was a fellow under Dr. Flat and looked up his patients and wrote a paper and did not include Dr. Flat as an author. I think we've even talked about that in the past. And so most of us called the Wassel-Flat classification, but there have been two articles in the last year in different journals that have suggested adding a hypoplastic category to the Wassell classification, with the implication that you you can then just take off that thumb. Every hand surgeon in America would be comfortable doing that as long as they have a You know, an opportunity to, to operate on young kids because that surgery can be done at six months of age or something like that. If it's more than a little hypoplastic, thumb, that's a that's a real extra thumb, then I think most of them, I would think would benefit from the precision and the kind of experience of a congenital hand surgeon.
Chris Dy:But how much how much bone do you need to make it a real thumb that somebody like you needs to take off versus somebody like me? And no, I'm not trying to do any congenital? But how much of a thumb does that does that take?
Charles Goldfarb:I think, fundamentally, you have to have essentially a normal thumb with a very small thumb attached to it. Whereas the thumbs that require more precision in their reconstruction, or are two smaller thumbs that may be well aligned, or may have angular deformity through the bone or through the joint. But if it's truly an extra hypoplastic, thumb, then it's just it's pretty obvious that the main thumb is pretty darn normal. And then the extra thumb is pretty small.
Chris Dy:How do you take off the extra thumb if you're just taking off the the small if you have a normal thumb and you got a smaller little guy next to it, what do you do is take a little rubber band and wrap it around and squeeze it real tight.
Charles Goldfarb:That's for the extra pinkies in, okay, newborn nursery. For the thumb, we probably don't do that they're not quite so hypoplastic. Just a little elliptical incision, there's usually a single nerve and a single artery and you cauterize those, you don't want a low neuroma forming, if you can help it subcutaneously but it's a it's a 30 minute operation. The exciting coding dilemma for hand surgeons like me in the O R is if you really are just taking off that extra digit. Do you bill for a very small procedure like a CPT 11200? Or is it a reconstruction of a polydactylous digit even though all you did was lop off the extra thumb. So a little tricky and a little interesting, but you know, the more complicated radial polydactylys are, there's a huge variety of them, which has made reporting difficult.
Chris Dy:So what are the what are the things that you teach our residents and fellows about kind of the more complex, radial polydactyly cases that they could potentially take into the future?
Charles Goldfarb:When we Well, first thing is when you close, you don't want a linear scar, because in a child, a linear scar in the wrong place will lead to a scar contracture over time. And so as I was joking, earlier, orthopedic surgeons take off the extra thumb, and then figure out how to close well that figuring out how to close always includes that V to Y plasty of some sort. That's the most simple message. But you know, if you think about an adult hand surgeon who may be occasionally performing a ray resection, or some type of bigger Reconstructive Surgery of the Hand, understanding racquet incisions for exposures, so superficial incisions that then lead to identification of the neurovascular bundles, the collateral ligaments and exposure of the joint. Those are principles that are easily learned and taught in the congenital space and are so uncommon in the adult space that without that congenital experience, I think is just harder to get them to get them down.
Chris Dy:So when you talk about a racquet incision, so I remember making a racquet incision for some Ray resections what's what are the pearls with that in terms of how you size that? How you think is should you just always go bigger? Because you can always trim it down later? Where should the the kind of the larger part of the racquet be as opposed to the handle that kind of stuff?
Charles Goldfarb:Yeah, so, you know, if you're doing a racquet incision for a Ray resection, for me, the key is, you want to adjust that racquet incision, so that you can, when you close, you can recreate the the web, between whatever digit is radial, whatever digits ulnar to the Ray that you excise. So if you're excising the ring finger, you have to think about your closure such that you have recreated a nice webspace the thumb is easier because it's just the thumb. And clearly you don't want to be left with a shortage of skin. And again in the orthopedic way, we save more skin and then trim the skin at the end. The classic plastic surgery way of doing this would be a racquet incision with a kind of filet flap zigzag incisions on each digit that then meet perfectly after the extra digit is excised. Yeah, as I think about the next most common congenital condition that that non congenital hand surgeons might consider would be syndactyly. And I'll say this, I don't think there are many orthopedic hand surgeons that are that are looking to do syndactyly cases. I'm guessing that most of the non congenital hand surgeon procedures like sit down actually are done by plastic surgeons who feel very comfortable with soft tissue handling. And I think that's fine. You know, some syndactyly are more straightforward than others complex activities where there's bony union, it makes it more difficult and, and the results are always less satisfying. But my thoughts are, you know, the surgeon has to have the knowledge and expertise, which I think many can have, you gotta have a great therapist to help manage the soft tissues after the procedure is over. And you got to have a system set up for these kids, it's just, it's more than just the surgeon expertise to get the best outcome.
Chris Dy:So when you're what you said, not all syndactyly are created the same. So what are the different types of syndactyly? And what are the ones that should make us a little more worried versus the ones that, you know, can be handled by somebody with little experience in this?
Charles Goldfarb:Um, you know, I would say the syndactylys that are not super tight together. So the fuse fingers, where there's a fair amount of scan between the fingers makes it more easy when there's no bony connection between the phalanges makes it more straightforward. And I would also say when there's not an associated syndromic condition, because those kids do more poorly in general. And I think the reconstruction has to be more cognizant of the general health of the child. And so I think an isolated classically middle ring finger, partial or complete syndactyly, with lots of extra skin between the digits can be pretty straightforward to handle. But most syndactyly is also need extra skin. So then you're thinking skin graft? Are you thinking skin graft substitute. And so it you know, you can get tricky pretty easily. And so, for example, when I see syndactyly, is treated in the community that come in with a groin skin graft and 2022. There's nothing wrong with it, but I don't think it's it's up to date, I really don't. The skin darkens. If it's not taken laterally enough, it's hair bearing skin. And there's just easier ways to do it, and 2022 and I think most congenital hand surgeons, for a simple syndactyly would not use groin skin.
Chris Dy:So what is the right skin to use.
Charles Goldfarb:If you choose to use a skin graft, most people use antecubital crease skin, some will use skin along the transverse incisions, leaner the wrist crease. Again, it's not wrong, but I'm just not sure it's right to use growing skin because the color match and the hair bearing issues are real. I tend to use skin grafts substitute. So use Hyla matrix, which has been really successful in our practice. So it's kind of like Integra. But in kids young enough, the epidermis can reform over the skin deficit area very nicely. And so we've been using that. And so it decreases the need for a second incision in the harvest site.
Chris Dy:As we bring this first episode of congenital for non congenitals-
Charles Goldfarb:First and maybe last.
Chris Dy:Well, what are the things that what are the conditions in brief that you think that are treated in the community that probably should be treated by somebody like you? And what are the conditions that are sent in that probably should be treated, you know, by a competently trained hand surgeon?
Charles Goldfarb:Yeah, it's, it's actually it's the right question is not such a simple question there. Because, again, if a community hand surgeon has the expertise, the interest in the systems, which includes a great therapist in place, then this can, you know, the, that's very different from a hand surgeon who has done a little bit this as a resident doesn't do things regularly doesn't have a therapist they work closely with, that's harder, but you know, the right kind of post axial polydactyly or, you know, little finger polydactylys are typically much more straightforward, as we mentioned, the radial polydactyly where the extra thumb is truly hypoplastic. That's pretty straightforward. The straightforward syndactyly is one, you know, one, one diagnosis, which could easily get grouped here is is, is congenital, which is a misnomer, but really pediatric trigger thumb. So a trigger thumb is there's nothing complex about treating a trigger thumb. The questions are about the safety of anesthesia and timing of release, and how long you watch it before you do it. But you know, paediatric trigger thumb is quite common and quite straightforward. Those are the ones that really come to mind when you get to things like radial deficiencies hyperplastic thumbs, cleft hands, symbrachydactylys. Those carry a little more complexity, at least in my mind, and it's not only the technical skills is the decision making process, the family counseling, the associated geneticists, there's just so many variables that either you have a system in place or you don't. And you know why fight that fight if it's not easy for you in your system.
Chris Dy:So what is the right timing for trigger thumb surgery, and the type of anesthetic that should be used for trigger thumb surgery?
Charles Goldfarb:There was a good paper this year by Doug Hutchison and others from Salt Lake City, which looked at a large number of trigger fingers. And Doug decided that he was trying to change trigger fingers, so one to watch and see what happens. So he looked tried to assess natural history. And basically, the conclusion was, if the trigger is, is contracted at more than 30 degrees, and if it's bilateral, it's unlikely to resolve and going ahead and doing that, you know, the trigger thumb after six months or whatever, it's totally fine, less notable trigger finger, a unilateral trigger finger or trigger thumb isn't has a chance to resolve it, the family's not interested in just the simplicity of a trigger release, then going ahead and watching it is fine. And the United States is just so simple to take care of this, and you see them once after surgery and the kids done, that most of us offer trigger releases after three to six months of non operative care. Let me let me flip this around.
Chris Dy:Can I asked one more question about the trigger thumb?
Charles Goldfarb:Yeah.
Chris Dy:I feel like there's a couple more things I don't I don't ever think we're going to talk about pediatric trigger thumb ever again on this show. So.
Charles Goldfarb:Why not?
Chris Dy:Well, so is the non operative treatment? Is it observation or is it splinting?
Charles Goldfarb:It's just observation, because you can't effectively treat that age kid with a splint. And so some would say stretch and some would say splint, that doesn't work. It's just observation.
Chris Dy:And then in terms of the timing of surgery, you know, what's the safe age for anesthesia in this particular case, and then what kind of anesthesia is it?
Charles Goldfarb:Yeah usually, you know, there's been a lot of literature and there's a lot of discussion a few years back around safety of anesthesia in the patient younger than three years of age. I think that really applies for prolonged or repetitive anesthetic exposures. But a two minute exposure for a trigger thumb, I don't think is a big deal. And typically it's a masked anesthesia, we do tend to give some Marcaine before the surgery starts, that's been proven to decrease the amount of anesthesia required, and at most it's a five minute surgery. So very simple surgery, very short anesthesia, and then rapid recovery.
Chris Dy:Now, now that the digital nerves to the thumb are quite small, even in adults at times, how much more worried are you about that in a kid?
Charles Goldfarb:No worry, the goal is simply stay midline, stay right over the A1 pulley, release A1 pulley and a trigger thumb is easy to release because you essentially start proximally and your releases done when the thumb straightens. And so you don't need to vis- I don't plan to an ever attempt to visualize the digital bundles. I just stay directly over the flexor tendon sheath. So flipping this around what nerve surgeries should not be performed by people like me?
Chris Dy:Ah, you know, I think how much time do you have? I feel like that's an episode in and of itself. We should have that episode. And it can you know, I think that nerve it I think is it can be done very well by a competently trained hand surgeon as long as you've done it in training. And there are honestly there are a lot of things that I have learned to do since finishing training just based on principles and practice and going to the lab and all that kind of stuff. I think the things to think about are you know, if it doesn't work, can you take care of the issues down the line, you know, for example, so say like an upper trunk plexus. If you if you do an Oberlin or double facicular, double Oberlin nerve transfer, and it works. It's fantastic. It's one of those gratifying surgeries we have in peripheral nerve. But if you have indicated the wrong patient, and then you have now taken that option from me, because, you know, perhaps you didn't, it wasn't just an upper trunk. And perhaps you've now used a donor nerve that I can't use for something else, or you know, there's just one, it works out great, it works out great. But it's more about making sure that you have the sound foundation in terms of the diagnosis, the treatment options, and then knowing what the options are should it should fail. And not that we ever plan for things to fail, but that's reality, you need to know your backup options. I think that's one example of you know, if, if you've been trained well, you're up on the current indications go for it. But if there's any doubt or any hesitation that probably should be sent somewhere else not because the technical parts of the surgery are that hard. You know, it's it's one of the it can be a very straightforward surgery that it's very fun to do. But more because of the all the other considerations that come around it like you were describing.
Charles Goldfarb:Yeah, it's interesting that mean, when I think about things like radial deficiency and I think about upper trunk Plexus, why would a kind of Community hand surgeon, there's no offense intended by that label, or by when I'm about to say, why would they want to treat these two conditions. And maybe it's because they're in a rural community, and they're, you know, the patient wants that wants to stay local and have that treatment. But there's there's just a lot of complexity, sometimes with the technical aspect of it sometimes with the follow up, as you said, sometimes with the necessary team approach to both of those conditions as examples.
Chris Dy:Yeah. And I think that you know, that there's a real argument to say, for some conditions, you know, why send somebody in into another center three or four hours away, if there can be cared for locally, and especially, you know, you're seeing little ripples of that, as you know, when we've gone through waves of, you know, bed crunches and stuff, not for this kind of stuff. But you know, for, for anything that would be inpatient, you know, admissions and stuff. You know, I think we tend to be a little more willing to see patients from elsewhere, because we want to be helpful, but there are probably times where patients could stay locally, but nobody wants to err on the side of of not accepting a referral, just because you think it can be treated locally, because you don't you don't know the circumstances locally.
Charles Goldfarb:Right. Now. That's exactly right. I think this is a sensitive conversation. And I'm sure that my comments may have annoyed some listeners, I hope, if I do annoy you find that you don't stop listening. But to that you write in and let us know your thoughts, because we would appreciate that.
Chris Dy:Hashtag cancel Chuck is what we're going for here. So Chuck, I think I think I know your win for the week. It's probably getting us to talk about congenital on the podcast. But do you have a win for the week?
Charles Goldfarb:Well, that is a huge win. That's exactly right. My win for the week is in the middle of COVID. And in the middle of Snowmageddon, St. Louis 2022. I was 11 for 11 for my main surgical day, not a not a cancellation.
Chris Dy:Wow. That's huge. That hasn't been the case in recent weeks has it?
Charles Goldfarb:Now I feel like we're on the downslide. What about you?
Chris Dy:Okay, good. I will say my win for the week was walking into a case recently, and surprisingly, seeing a fellow who could take the resident through a case. So it was great. I walked out like, Oh, my day just changed my morning a little different. Now I can relax a little bit more. So that was a huge win for me. I you know, it's we have a program that oftentimes doesn't have residents and fellows scrubbing together, except if it's, you know, somebody's out of town or something like that. But it was very nice to allow our fellow to really directly supervise and walk, walk a resident through a case. That was That was wonderful. You know, I did my normal thing. I kind of stayed in the room and supervised and heckled and provided me seen excuse me, provided encouragement, not heckling. It's pointed feedback.
Charles Goldfarb:You know, it's an interesting time of the year because certainly at this time of the year, fellows have been around for six months. They know what you know, they know a lot about how we do things and what we're doing. It's also the time of year where fellows get a little antsy, and they're thinking about next year. So keeping them engaged in different ways, is both helpful and productive for all sides.
Chris Dy:Agreed. Well, you have a wonderful rest of your day and enjoy the rest of Snowmageddon.
Charles Goldfarb:Thank you. Take care.
Chris Dy:Bye.
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 dy. If you'd like to email us, you can reach us at hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcasts
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