Season 3, Episode 6. Chuck and Chris talk baseball injuries with a focus on the wrist. While the season may be delayed, its starting to feel like Spring Training! We touch on the elbow but focus on three common wrist issues in baseball: hook of the hamate fractures, ECU tendon, and the TFCC.
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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.
Season 3, Episode 6. Chuck and Chris talk baseball injuries with a focus on the wrist. While the season may be delayed, its starting to feel like Spring Training! We touch on the elbow but focus on three common wrist issues in baseball: hook of the hamate fractures, ECU tendon, and the TFCC.
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, hey, Chris.
Chris Dy:Hey, Chuck. That's a little low energy from you over there. What's going on?
Charles Goldfarb:No, plenty of energy. I was going deep, deep.
Chris Dy:How's it how's your morning, been? We're recording on a Saturday morning.
Charles Goldfarb:You know, my morning has been pretty good. I had a long week a lot going on. And I woke up I do I get up early, despite my best intentions and got some work done. And then I was just sitting in reading and having a delightful morning and then I got the text.
Chris Dy:Okay, so what does a weekend of work look like for you? Like what kind of work are you knocking out on the weekends?
Charles Goldfarb:It's usually a combo I try to make it a combo. It's not clinical. I you know, my thing is, I don't like to leave any particular day without clinical work done. That means all dictations all phone calls all MRI reviews. So I'm pretty good about that. And then weekends are for admin, mainly. department work, I guess I should say and, but also research, I feel. I don't like it if it gets tilted too much toward administrative work, and not enough research work. So it's usually a combo. Okay, what about you?
Chris Dy:Well, so we just finished doing our annual cadaver, brachial plexus lab and peripheral nerve lab. You know, the folks at Axogen were kind enough to bring in a guest speaker. And since I think probably last five years, we've actually taken this as an opportunity to bring in a torso specimen and today's case, a whole body specimen, which we're incredibly grateful for, because the opportunity to do dissection around the neck and fully around the shoulder without the shoulder being disarticulated is really helpful because those are all the nooks and crannies of the anatomy that are very tough to get at otherwise, that for obvious reasons. It's very difficult to secure those specimens. So we had a great time in the lab this morning.
Charles Goldfarb:So you dissected obviously both sides, big Plexus dissection. Wow, that's awesome. And it was you I'm guessing Brogan and our three fellows.
Chris Dy:Yeah, yeah. So one of our fellows couldn't make it. Had a family emergency. But otherwise, yeah, we had a great time. And several of our residents came and they were working on the working on extremity specimens, and one of our hand therapists came. So it was just a fun time. And, you know, it was interesting shout out to Jamie Findeiss who does a lot of our brachial plexus therapy and she works with Athletico. And she took it on her, you know, she took the initiative and came into the lab. And, you know, we actually did a free function and gracilis of sorts, David harvested the gracilis, I inset it in there. And then she's has a newer appreciation for the surgery, which was really cool that she came into the lab and hung out with us.
Charles Goldfarb:You know, cool on many levels that first of all labs like that are priceless. And I'm sure I know, you already said you appreciate it. I know our trainees did as well. And Jamie as well. And that's the second part is having great therapy partners, we've said over and over and over is priceless. And yet another demonstration.
Chris Dy:Yeah, and we were we've been rehabbing, more nerve transfer patients together. And you know, I showed her some of the nerve transfers that we were doing for radial nerve palsy. And I think just seeing having her see the anatomy is super useful. And just fun all around. So yes, it was a wonderful lab. And I hear that you've been in the labs who recently?
Charles Goldfarb:I have you know, I don't do you know, big brachial plexus work. But I am intrigued by a new in this topic, carpal tunnel tool, called the carpal clip, that friend of mine helped develop and I've been wanting to try it and I have to say, I walked away impressed, did five cadavers. It was quick, it felt incredibly safe. Visualization was excellent. So next step will probably be the setup a few of these on patients. I give full disclosure in these situations to the patient. Pros Cons my experience and probably do a couple more cadavers you know, right before and give this thing a shot. It really is quite nice.
Chris Dy:It's interesting. You say that because I am also in the midst of trying a new type of carpal tunnel release technique. And it's using ultrasound guidance. And so I have done two labs now have a third lab scheduled and just trying to get more reps with the ultrasound and using that guidance. And it's interesting, I think next week, we're gonna have a discussion about you know, the What's New In Hand surgery article and it includes some discussion about endoscopic versus open and the pros and cons. But yes, of course, obviously Making sure that we feel comfortable with the new techniques, disclosing it to patients, the pros, the cons, and then seeing where it goes from there. I don't I'm not I don't know for sure if I'm going to, to use it. I obviously have to feel comfortable before I make that decision.
Charles Goldfarb:Yeah, absolutely. We have to be 100% comfortable and there's an absolute requirement to be upper, you know, to be forthright with our patients about this process. So we should both report back and whatever it is three months or something like that and share how what if anything has happened?
Chris Dy:For sure. So what are we talking about today?
Charles Goldfarb:You know, I keep hearing whispers that we need more sports.
Chris Dy:Especially after last week's congenital episode.
Charles Goldfarb:And I agree we need more sports.
Chris Dy:Gotta come back strong and get people going again.
Charles Goldfarb:So you know what, despite of a lockout, baseball is hopefully around the corner let's let's talk about some basic baseball injuries and, and concepts around them. What do you think?
Chris Dy:Well, I think so. Cuz I mean, St. Louis is a baseball and hockey town now. You know, we're recording this the weekend of the Super Bowl. And I guarantee you, there are very few people in St. Louis cheering for the Rams.
Charles Goldfarb:That that is right. My eyes. The whole playoffs. All I've been about is that the Rams not make the Super Bowl. So one thing's for sure. I'm cheering for Cincinnati. This weekend? No, yeah, no doubt. But I would add one thing to what you said we are about to be a Major League Soccer city. We were supposed to start in March of 2022. But because the pandemic got pushback, but the organization is awesome. And it's been been very enjoyable, interacting and kind of watching them grow. And so I'm looking forward to, to that, for sure.
Chris Dy:For everybody else, we're recording this the weekend of the Super Bowl. So Chuck, do you have any predictions because this episode's gonna drop after the Super Bowl? So what's the score gonna be? What's is how's the halftime show? Gonna be?
Charles Goldfarb:Yeah, it was a couple of remarkable things. One is just the gambling around the legalized gambling going on. This is stunning. And as most of the listeners know, I don't personally have any experience you can wager on anything. The length of the national anthem to you know, anything you can think of the over under the first touchdown, everything. i I'll be honest, I don't follow the NFL as much as I follow college football, or the NBA. But I hope and I actually do believe Cincinnati is gonna win. Win by a touchdown.
Chris Dy:Okay, well, that's, I mean, Cincinnati, you live there for a year. So I, I'll give you that. I would love it. If Cincinnati won. I don't think it's gonna happen. You know, it's funny. I was writing what the AFC Championship I was when they were playing the Chiefs. I was writing an email to the group. And I jokingly said, you know, when you're done watching the Bengals come from behind victory, take a look at this and it actually came true.
Charles Goldfarb:Came true, I loved it, loved it.
Chris Dy:So I think the Rams will pull it off, even though I truly do not want them to. So yeah, we'll see who was right. This episode will drop the weekend after.
Charles Goldfarb:You're probably planning a feast of some sort for this event. If I know you.
Chris Dy:Oh, yeah, there's gonna there's gonna be all the things. And for better or worse, I'll be preparing my waistline. So we'll see how it goes. So yeah, baseball. So tell me. So what are the most common? Like, what are the three most common hand injuries that occur with baseball? And do you have to distinguish, you know, batting injuries versus pitching injuries or throwing catching that kind of thing?
Charles Goldfarb:Yeah, you know, I think for this audience, and certainly we could dive deeper and we can even have a guest on which might be fun. You know, when we think about throwing injuries is predominantly pitchers obviously shortstops and third baseman getting can put a lot of torque on their arms. But obviously, we're talking about the repetition and the velocity of pitching, I vote, let's save that for another episode and have a guest on that can be fun, what might intrigue you is how often I'm addressing and maybe you are as well, but I work with our sports partners. And it's not uncommon that we work together on a medial elbow where the UCL is reconstructed, and the nerve is transposed. The goal, of course, is not to need to transpose the nerve. But if the nerve is irritable or unstable, then it in my mind is the right thing to do you have any thoughts on that?
Chris Dy:Well, do you see, do you see mechanical irritation of the ulnar nerve in these athletes with in the setting where they don't have medial ligamentous issues?
Charles Goldfarb:Yes, and that is, especially in the adolescent population. And this is my theory. And you may have different thoughts on this. But my theory is that, you know, we think about a third of the population has older nerve instability. And we looked at that previously, and there's been some ultrasound studies on that as well, which are certainly more accurate than clinical exam studies. I believe What happens if for whatever reason the nerve gets irritable and if it is irritable and it is unstable, I do not find that those resolve very often. And so especially an athlete who is hesitant to take time off, to get it to calm down. So I think once it becomes stirred up even if the UCL is stable, addressing that owner becomes a priority if the need is to get back to play.
Chris Dy:How long and what kind of non operative treatment will you give them? Is this kind of like going along lines of pitch counts? Or is it night splinting the normal stuff that we do.
Charles Goldfarb:If we're going to truly try to calm this down, it is an absolute no throw for six weeks, nighttime splint, daytime motion, but no throwing anti inflammatories, that's that's my, that's my regimen. If they are making progress into the six weeks, I will extend it for another six weeks and see what happens of course, now there's a big difference between reconstructing the UCL where you're looking at a year or more, and transposing ulnar nerve where honestly, by eight to 10 weeks, you can be back throwing full force. So I don't want to be knife happy by any stretch. But also in a high level athlete. I don't want to just immobilize way to mobilize weight when the reality may not be so positive.
Chris Dy:Do you see any role for nerve studies or ultrasound diagnostically in that particular population?
Charles Goldfarb:Absolutely not opposed to it? I don't believe it's always necessary or helpful, you know, an unstable nerve. Again, love to hear your more technical thoughts, and then stable nerve without hand based symptoms that is normal sensibility normal strength? I don't you know, it's unlikely to test positive based on the, you know, the basics of EMG and nerve conduction sensitivity. So I don't rush to do a nerve study.
Chris Dy:Yeah, I guess the way I would think about is that if it if it's going to change what treatment I offer, then yes, I would get it. And I would want to know what your particular transposition or maybe it's just a decompression but what your particular treatment would be. Because for me, if I would probably still use my current algorithm of an unstable mechanical irritable nerve without any signs of innovation is going to get a subcutaneous transposition with a nice added professional fat pad flap kind of transposition like the guys from Colombia described. Its signs of deactivation, and anything in more advanced on the nervous side, I probably am going submuscular. But I don't treat the throwing population as much. So how does that affect what you do?
Charles Goldfarb:First of all, I would like to say thank you, because I have been for many years an advocate How did you do this? How did you turn this podcast into a nerve discussion?
Chris Dy:You did, you did actually.
Charles Goldfarb:Not intentionally and not. But will will go down this garden path. I was a an Eaton flap guy. So I raised the fascia from the flexor printer mask to prevent the nerve from subluxation. Posterior Lee liked it but never loved it. Because what I think happens is the nerves, scooches and that's a nerve term that Chris likes to use a lot, the nerves scooches medially and rubs up against the medial condyle. And so I've played with different techniques, but I've never loved it, I now use that fasciocutaneous flap, as long as there is sufficient fasciocutaneous tissue and love it, I think the recovery is faster, I'm more apt to get them moving without limitations faster, which speeds an athlete's recovery. I really don't do decompressions in this population, I just don't think it has a role with the forces etc. And I don't like some muscular for I guess somewhat obvious reasons I'd rather not cut the muscle and ask it to heal and achieve the same strength that I had previously, even though it probably will. My preference is subcutaneous.
Chris Dy:Yeah, I think the key with the subcutaneous and again, we'll get off of the nerve stuff, but it is making that a very broad pillow. You know, and making sure that you're not doing anything that's going to be small and tight. I think that's my main beef with some of the, you know, subcutaneous transpositions that use a fascial sling is that it? I've seen people do it and it ends up being a very thin band of tissue that looks a little bit like a transverse carpal ligament to be honest with you once you put it in. Then clearly it works in many situations. But I've also had to revise enough where I appreciate having a very broad area because obviously a broader area is going to distribute the forces more evenly the tension more evenly across the nerve that's been transposed.
Charles Goldfarb:Yeah, that is well said so when I do this eaten flap so to speak, it is now extraordinarily wide. It's probably half the width of the fascia of the flexor pronator mass and so it's much wider than I think I did I use when I started and I agree with you it can become a problem especially if you're not cognizant of where your skin incision lies. So do you get suture that flap anterior to the anterior skin flap to the posterior skin flap. But with the fascia, cutaneous, you have this great fat, that essentially you're laying right on the nerve. And again, you want to be careful not to constrict the nerve. But you're laying it right on the nerve and what better tissue on which to, you know, have a nerve resting?
Chris Dy:Yeah, exactly that came up in discussion. This week when I was working with one of our residents, Liz Graesser, who I'm slowly but surely assuring her that she will be a hand surgeon. But she's wonderful. And it's more about learning different techniques. Because you never know when you're in a revision, you'll have to pull out different types of techniques to use because sometimes your go to procedure isn't going to be available, which is what happened to us recently in a revision so. So thanks for the nerve talk. Let's talk about other other injuries that occur in the sports population baseball in particular.
Charles Goldfarb:Right, so I think the first if we're talking about hitters, and maybe we'll just make this about hitters, there's a few injuries, which I think we should discuss. But the first is just a basic discussion, which I don't think anyone ever explained to me not that I'm some rocket scientist or figuring out I wasn't a baseball player. But if listeners are not baseball people, hopefully this setting the stage helps. So if you're a right handed batter, what that means is, your left hand is below your right hand on the bat. And you're standing at the plate. And when you swing, it's really all about your left hand, your right hands on the bat to stabilize it. But when you swing and then when you follow through, you end up ulnar deviating the wrist at the final follow through. It's all left hand or non dominant hand depending on on factors. But a right handed batter is at risk for left wrist issues. And I think we can briefly discuss three somewhat common issues one is going to have a fracture to his TFCC. And we don't need to go into detail, and three is the ECU tendon. Those are the three that immediately jumped to my mind. I don't know if you have general comments before we dive in.
Chris Dy:I mean, it's the first thing that came to mind with that kind of follow through and the ulnar deviation, obviously is ECU does the first compartment ever getting irritated the first source of compartment with that repetitive ulnar deviation moment?
Charles Goldfarb:No, it seems to be resistant? I haven't I haven't experienced that. I'm trying to think of I've ever even seen radial side of issues. Of course I'm sure I have. But they just regular sided issues are uncommon in general.
Chris Dy:So let's talk about that hook of the hamate fracture is that with specific types of impact, or is it a repetitive kind of stress to the bone?
Charles Goldfarb:To me, it's a repetitive stress to the bone, there is evidence, it's actually pretty good that the handle of the bat, I'm sorry, the knob of the bat, which you know is the very bottom of the bat impacts this and there are bats that have a different shape knob that seem to decrease the risk of this repetitive stress on the hook of the hamate. And if you see a a hitter, who's been in the cage a lot, they'll have calluses right over the open to me. And so you're getting repetitive force. And I do believe this is a repetitive issue. And then at some point, you get the fracture the hook or the hamate. And when that happens, you can't swing anymore. So I don't think it's usually everything's fine, everything's fine. And then you break instead, I think it's micro trauma, micro trauma, micro trauma, and then ultimately the fracture. And we know that it's at this area of poor blood supply, where the hook meets the body of the hamate, ultimately it breaks. And I think it's become more clear to be direct in our approach to treatment.
Chris Dy:So what's the what's the calculation there? Do you just excise it, pluck it out? And you're done? Can they get back to batting after that? Or do you have to fix that thing?
Charles Goldfarb:So surgical repair of hook of the hamate in my mind is a no go. It doesn't make any sense for a couple reasons. One, you're trying to get a poorly vascularized area and small area of bone to heal to doesn't seem like anyone ever misses the hook of the hamate, even with high level performers, such as baseball players, and so you can cast somebody if you want. And again, hold your breath and hope hope hope but to me, that doesn't make sense. Even if it's a non traditional, we're gonna have a fracture meaning and acute trauma in a non baseball player. I just don't think it has much of a role. And so for me it is hook of the hamate excision is a very satisfying surgery.
Chris Dy:So is it that you mentioned after they have this kind of repetitive stress injury to the hook of the hamate that they can't bat anymore? Is it because of the pain from the fracture that they can't bat so you know excising the hook of the hamate once they get over the surgical pain is that is there any role of mechanical support against the hook of the hamate in terms of the bat?
Charles Goldfarb:No, I think once you well, you know, once you treat it and take it out, you're done. And it's just a matter of when they get back to batting. And so, you know, we shared our experience, Doug Carlin and I and Doug was a fellow here, way back maybe 20 years ago. And he has helped take care of the race for many years. And then there's been a couple other papers recently a paper out of Phoenix with a large series as well. The message is the same people, you know, players do well with vocal damage decision, the question is risk of complications and return in timing of return to play. I think an experience hands the risk is low. But sometimes the nerve gets irritable after surgery, I would say that's the biggest risk. And the second issue is return to play. And so I tell people to expect six to eight weeks, but it is highly variable. I think some players are back, batting at two to three weeks and playing full bore by four weeks, and rarely get someone who takes longer. So that's the part that's hard to predict. But it's based on pain and tolerance.
Chris Dy:Assuming everything goes the way you expect it to in surgery and the wound heals. When will you allow them to start batting the test things out?
Charles Goldfarb:Yeah, easily at three weeks, I'll say if you want to take a lightweight bat, and do some light hitting off a tee I'm fine with it or even you know, swinging a wiffle ball bat or something like that, and then go to you know, progress from there. But some people look at me like there's no way that's happening in two to three weeks and other people's will say at their first post visit. Hey, I've been taking swings and doing fine.
Chris Dy:Is it the weight of the bat or the velocity of the effort?
Charles Goldfarb:I think it's a combination. That's why the lighter swings and the lighter bat help.
Chris Dy:I got to ask you, you mentioned nerve before I did the you routinely decompresses zone two of Guyon's canal as you do this, or do you just make sure you visualize the nerve.
Charles Goldfarb:So I mean, that is obviously the risk I believe in fully exposing the nerve, careful retraction. And that means a little bit wider decompression so that you don't retract it at one little point and not over retracting, which is going to cause you know, potentially some tingling in the finger thereafter. And obviously that's the risk of the surgery. And so, yes, I suppose I protect and that's the only thing you know, it's if you think it's a really small little piece of bone and you make a small incision, you take it out, not really my approach. Still a palm only incision. I don't like to cross the wrist crease because that wrist crease crossing incision gets irritable. But find the nerve expose the nerve, gently retract the nerve, take out the hook.
Chris Dy:If anybody out there repairs these and has adequate experience repairing hook of the hamate fractures, let us know, Chuck is saying that the literature would point to otherwise. But if that's your experience, please let us know.
Charles Goldfarb:Absolutely. And I'll say one thing before we switch topics. Don't get fooled by thinking the hook of the hamate is always the only issue. So two comments there one, the physical exam is pretty classic, right? You feel the piece of form, you go about a centimeter, centimeter and a half, distal and radial. And you put your finger on the hook. And most people are most painful there. And if there's no other pain, great. The other test you can do is resisted little finger flexion. And you know, you can think about the flexor tendons wrapping around the hook that will be painful, and often positive. But sometimes it's just a little vague. And some people have pain dorsally or overly over the over the hamate bone itself. And some people a little approximately at the fovea. So I just the warning is don't be too quick to say this is absolutely hopefully hamate and nothing else is going on. Try to make sure nothing else is going on.
Chris Dy:Are there cases in which you're getting advanced imaging like an MRI and looking for edema pattern or anything like that in the hook? And if you see that, are you going to stop them and mobilize them and slow them down before? Obviously you're not going to take out a hook that's not broken? Or will you?
Charles Goldfarb:Yeah, so carpal tunnel view is the X ray of choice. No other x ray has the potential to show this if the X ray is not confirmatory, despite a strong clinical suspicion than either MRI or CT can be helpful. If it's broken, you deal with it even if it's non displaced in my mind. The question of course is when it is not broken and you do try to rest you try to let them rest and I don't like to take out non broken hooks but edema is highly concerning and you gotta you have to get that to resolve or else you're gonna be back talking to this player in another three months.
Chris Dy:I can just see you in there with your osteotome chipping out that hook of the hamate tinkling the recurrent motor branch or the deep motor branch, so don't do that.
Charles Goldfarb:Definitely not definitely not.
Chris Dy:So you mentioned TFCC as the next kind of group of issues. Next in a group of issues for batters. How is is the pathology different there compared to any other TFCC injury?
Charles Goldfarb:I don't think so. And there's not a pattern that I've seen over and over. Meaning it's, there's not a, for example, it's not always central tears or, or volar, or dorsal tears or foveal tears, it can be pretty much anything. And often it's an inflammatory issue, right, a lot of synovitis develops and, and there may not be a prominent tear. But you know, I start with DREJ examination to make sure the DREJ is stable. Check for foveal discomfort. And these are patients that if I really think it is there's a stable DREJ and focal discomfort, I don't mind doing a steroid injection as a one time intervention for both diagnostic and therapeutic purposes, and see what happens. And I've been happy that sometimes you know, you treat it and patients don't come back.
Chris Dy:And are you typically, what's your threshold for say you've done, you know, therapy, different types of supports braces orthosis, and you've tried an injection, what's your threshold to go to surgery?
Charles Goldfarb:Again, it's all about the athlete and the family if it's a younger patient and their patients. And I'm not one who preaches patients beyond reason, you know, we need to be, I feel like we as physicians need to understand priorities. And so if I have immobilized for six weeks, which I will do with an acute event, concert with concern for TFCC, if I have done anti inflammatories and some therapy to try to calm things down, if I have done a steroid injection with temporary improvement, but recurrence, I'm offering arthroscopic assessment at that point in agreement.
Chris Dy:So you mentioned immobilization is that the true old school above elbow kind of monster situation? Or are you more kind and perhaps allowing a little motion at that TFCC and staying below the elbow?
Charles Goldfarb:If someone walks in the office that has what I believe is an acute TFCC tear, focal pain, perhaps a suggestion of instability, or an MRI that shows the finding, I will put it above elbow cast and neutral rotation. However, that doesn't happen. It just doesn't happen. You don't see patients acutely, almost ever, but if they do, then that's what I push for sure.
Chris Dy:How long do they you have them wear that for four weeks? Six weeks?
Charles Goldfarb:Six weeks, Munster.
Chris Dy:How much do they hate you at six weeks?
Charles Goldfarb:They liked me because I take it off.
Chris Dy:That's right, that's right. We've mentioned this in the past podcast. And then round us out with the ECU. I think this is something that is somewhat sometimes nebulous to diagnose. So tell us how you how you evaluate that patient.
Charles Goldfarb:I would say ECU instability happens for sure. And it's one of those things that some people would tell you well, you know, you can have an unstable ECU and it's not a problem. Well, it's a problem if the patient's coming in for it. If it's a problem that this snapping is painful, and so making that diagnosis usually is not that tough, but the classic is the patient will come in with their with the form and pronation the wrist extended and they're happy. And if you like the ice cream scoop maneuver, then that ECU become unstable and we'll pop again, in an acute setting with an acute tear of the ECU sub sheath, which does happen. Repair makes sense. You could also argue that casting in a pronated extended position makes sense that would be a munster as well. But in high level athlete, it would be an acute repair. Most of the time, these are a little more chronic diagnosis isn't an issue. And in those patients. I'm a strong believer in transposing the ECU more dorsally although a lot of what you'll read talks about reconstructing the sheath or deepening the groove that just has never worked particularly well or made sense to me and we've shared our results which are pretty good.
Chris Dy:How do you think about this in batters? Is it different is ECU, are ECU issues in batters different than general population? Joe Schmo, Jane Schmo ECUs.
Charles Goldfarb:You know, I think it's just the forces they put on their wrist and you can see the batters that make it look easy and smooth. And you can see batters who just the forces that go across that wrist are incredible. And so I don't think it's any different is just kind of how they get there. And either have the uns- in my mind is very simple. You have an unstable ECU tenant, or you have ECU irritability, ECU tendinitis, so to speak. Checkmate can be a little more difficult to diagnosis and it can be a little more difficult to treat. But ultimately, it's a mobilization anti inflammatories plus minus one and one only steroid injection that location for me.
Chris Dy:Obviously, the risk with a steroid injection is a rupture of the ECU and that would not be good because because obviously how powerful the force that is, and the point that this patient in particular really needs on their deviation as the many of us, but what are your pearls for injection? If one were to try this?
Charles Goldfarb:So I, thankfully knock on wood, I've never had a rupture, which you'll see in patients, this is probably the worst area in the body. And you You certainly have an opinion on this. But I think the subcutaneous fat atrophy in this location, is riskiest, for whatever reason, certainly, you can see it me too. You can see it regularly at the first compartment, you can see it over the ECRB origin for tennis elbow, but for me, this is the area that has little tolerance. That's one of the reasons a single injection is all out typically do. I inject about a centimeter proximal to the DREJ, I don't want any diagnostic confusion. So if I'm giving an ECU injection, I want to know that it worked at least temporarily helps me confirm that this is ECU problems and not something else. And I typically obviously don't want to inject into the tenant, I eject adjacent to the tenant and use the ulna, the dorsal ulna as kind of a landmark.
Chris Dy:When you're inserting your needle, how do you know that you're at the right depth? Are you feeling tendon walking? And then kind of pulling back? Are you kind of adept enough now with knowing kind of layers you're working through before you get to the tendon?
Charles Goldfarb:Well, I'm not. I'm not an old stone guy. But certainly this is an area where ultrasound could be helpful. I think you are, you know, thankfully, it's not very hard to palpate, typically. So you can palpate, the ECU, and I usually use the bone as my as my landmark. I'm not going down trying to stab the bone because I think that's cool, but aiming for the tendon, usually going just beneath it and injecting there. How do you do it?
Chris Dy:Pretty similarly, I've only had to inject a few. You know, I think at this point, honestly, I would use ultrasound either I would do it myself with ultrasound. If I felt confident with that. Or if the anatomy was more challenging, I would I would send it to one of our partners for ultrasound. It's super convenient to have the ultrasound in the clinic, but also to have our physiatry partners who are so good with the ultrasound to I've learned so much just watching them scan too.
Charles Goldfarb:Yeah, I have no doubt. So, you know, I think baseball is a fun sport to be involved with. Certainly hand surgeons have a role. Some of it's really silly, you know, when a pitcher gets a blister, that's a major problem. But there's all kinds of hand and wrist and forearm issues in baseball, which I think can be very fun. And certainly we can dive deeper in some other areas, like I said, maybe have a guest on to talk UCL at some point.
Chris Dy:I think that'd be great. Now remember, the thing that we're doing this season is that we're closing with one win. So can you do you want to share a win that you have? Or should I go first?
Charles Goldfarb:I have one but you go first.
Chris Dy:Uh, you know, we got to see the brachial plexus and all of its glory this morning. And that, to me is a huge one. Honestly, the opportunity to have the, you know, the categoric specimens to do that it is honestly one of the things I love the most, during the academic year is getting to do this lab and hearing our trainees, maybe they're just saying it for me, but they really appreciated it. And I know they did. So that was a big one for me.
Charles Goldfarb:And that is why is a beautiful thing that we are partners, because looking at that brachial plexus just brings flashbacks, my wind is the receding nature of omicron. And the fact that optimism is is is here. And as the weather warms up, I think those two factors together, especially if we don't get hit with another wave, but something really feels good. There's just so much going on right now. And so many challenges that this feels like a really big directionality change. I went to my wife as an entrepreneur, and we went to dinner to support budding entrepreneurs. And you know, we had our mask on and we knocked on the door, you know, relatively small group and walked in there was not a single mass to be seen. You know, I had a moment of panic. And then we took off her mask. And you know, few days later, we're fine.
Chris Dy:Okay, I'll see you. Maybe I won't see you at work this week. But okay. Yeah, I think what's one thing that's interesting about Omicron and COVID, in general, is that you really see people's individual appetites for risk. And I don't say that in a negative way. I just say that in a very kind of factual way. Like everybody's got their own calculus of who they're willing to hang out with, and in which capacity and it's very interesting.
Charles Goldfarb:Yes, it's very interesting. And you factor in mental health. I mean, there's so this is really an interesting time. It's good to live in interesting times, Chris.
Chris Dy:Absolutely. Well, you have a wonderful week. I'll see you next time.
Charles Goldfarb:Thank you. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled dy. 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 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 time