The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Talk Hand Surgeries for the Non Hand Surgeon

April 17, 2022 Chuck and Chris Season 3 Episode 14
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Talk Hand Surgeries for the Non Hand Surgeon
Show Notes Transcript

Season 3, Episode 14.  Chuck and Chris discuss a listener suggestion for an episode: hand surgeries for the non hand surgeon.  We discuss common procedures for the non hand surgeon and provide our opinions on these cases.

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Charles Goldfarb:

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, how are you?

Charles Goldfarb:

Fantastic. Super duper. How are you?

Chris Dy:

Oh, I'm, I'm just okay. I'm fine. I'm fine. Super excited. Today's episode was requested by one of our residents, Dr. Paul Inclan, who is not going into hand but somehow was still listening to the podcast. I guess he just loved his rotation with me that much. But is currently applying to sports medicine fellowship. He requested that we have a talk about five ish surgery, hand surgeries that non hand surgeon should know how to do so that'll be today's topic. But before we launch into that, I wanted to read a review if that's okay.

Charles Goldfarb:

Please do and I thank Paul for his suggestion of topics and we are always interested in your, the listeners, suggestions for future and podcast topics. But please read the review.

Chris Dy:

Well, this review is from Sarah. She's a CHT in Texas. And thank you for leaving a wonderful five star review. And it says I'm not a podcaster but your podcast is something I look forward to each week on my drive home from clinic. I admire each of you and appreciate your time and effort on this endeavor. My CHT brain loves every single minute I learned valuable tidbits in each episode. My passion for ham therapy leads me to grow and learn and your podcast is perfect for me. I appreciate hearing your rationale for certain procedures. And most importantly, appreciate your respect to the current as well as past research, which Chuck has written all of. I added that. Thank you so much for all you do for your patients and your community. And she was kind enough to share information about the podcast with her favorite hand surgeon in the great state of Texas. So Sarah, thank you for the review. Thank you for listening, and for spreading the word.

Charles Goldfarb:

Thank you, Sara super kind, and we appreciate your writing in as well as being a listener. Chris, I heard through the grapevine that you had an interesting, fellow centered dinner on Friday night, I'd love to hear more.

Chris Dy:

We did it was with a local financial services company, I guess I should say. And interestingly enough, the way that we got connected is that the gentleman who reached out used to be a hand surgeon, I guess once a hand surgeon always a hand surgeon, but he's no longer practicing. And he practiced in our community here in St. Louis and was an incredibly well respected surgeon knows our partner Marty Boyer fairly well. And I guess he had reached out to Marty and they were talking about financial planning. He in this stage of his career as a vice president of this company, name is Plancorp. And he works for Plancorp. And he wanted to reach out to our fellows about just talking about personal finance, and kind of all the things that we touched upon in our prior episode. He actually listened to our episode and I actually don't remember exactly everything that I mentioned, and you mentioned in that. But there were some good suggestions that we also got in follow up emails that we should go through as well. But we had a dinner. It was really interesting. Coincidentally one of our non operative sports medicine doctors Kayla Daniel is married to one of the Plancore advisors so I got to hang out with Kayla at dinner. It was great.

Charles Goldfarb:

Yes, I love it. I love it on a couple of for a couple reasons. One, Kayla and I were talking yesterday and that's how I knew about this discreet dinner I didn't get an invitation to add just kidding. I love that we have in the last few years. For a long time I've been giving coding and personal finance lectures to the fellows and plan to continue Marty join me last year for that and and we'll probably continue to do that and and there's no one recipe but it's just so important you know that when you are a trainee you are hopefully locked in on one thing, and that is learning your craft and the other stuff is incredibly important and can't be neglected. And this is it's really great that you guys did this and hopefully the fellows all appreciated it.

Chris Dy:

Yeah and I appreciate the way that Bob at that Plancore set this up. There was it was pretty free flowing conversation clearly there obviously points that they wanted to address. But it was good because I think it just gave our fellows and myself as well and stuff to think about. You know many of them, I think already have kind of their setup, but doesn't mean you can't reexamine your philosophy and the services that you use So it was it was a nice, nice dinner. And it was made better because they asked me to talk about the podcast a lot.

Charles Goldfarb:

I love it. I know you said look, I carry the podcast, Goldfarb's not at dinner because he doesn't carry his share of the weight.

Chris Dy:

Because Goldfarb Goldfarb is editing the podcast. That's actually why he's not at dinner.

Charles Goldfarb:

What I think actually what you just said, is interesting not to get too waylaid by this topic, but I think it's interesting. So I, and I believe you have used one financial services company for a long time. And I've been very happy with them. They're conservative, but not ridiculously conservative. But interestingly, I have reexamined what I'm doing in the last year or so I've started to do some different things in addition to that. And so you're right, it's not something that should be inflexible, and not, you know, different companies have different principles and how they handle things. And so just to put your head down and say, Oh, my finance guys habit, that's not you, and so continually re examining the process and how you and your family handle it is really important.

Chris Dy:

Yeah, and we've had listeners, right in saying that, you know, you don't need to have somebody do that for you, you should totally do it yourself. And everybody's got their own perspective, I personally don't have the bandwidth for it. You know, as we discussed in the last episode, I really don't even have the bandwidth to look at my codes. So I can't keep an eye on all that stuff. But yes, I mean, you are paying, you know, a fair bit of money to have somebody manage your money. And in many cases, you get what you pay for. But there are many surgeons, I think, and therapists that are able to do this on their own and more power to you.

Charles Goldfarb:

Yeah, I think that's right. And again, my my whole principle is, don't be egotistical about this. You know, we as surgeons, and therapists are not smarter than our financial colleagues, they have spent more time are able to spend more time daily on this. And so yes, we can choose to do this ourselves. But if you choose that route, you know, you need to take the time to do it. Right. So I haven't I really enjoy this aspect of life, but I do generally have others handle it for me.

Chris Dy:

So let's get to Paul's topic. So Paul suggested five hand surgeries that non hand surgeon should know how to do what comes to mind.

Charles Goldfarb:

Yeah, I think it's a really interesting topic. And you and I are both we're probably going to come off a little snobbish here.

Chris Dy:

No, just you.

Charles Goldfarb:

Just the usual just me. So let's start with a nerve surgery because nursery's aren't that special, right? Let's start with carpal tunnel. I think a carpal tunnel can be done by those and other fields. I, you know, the hand surgeon approaches or carpal tunnel release with respect, and really a principled approach. And as long as others who may choose to do this procedure do the same, I think good outcomes can be expected, perhaps a little bigger incision, which is fine, perhaps a little different post operative protocol, which is fine, but it can't be a slash and burn technique, so to speak, it's got to be done with respect, and good outcomes should be and, you know, really expected and I think they absolutely can be obtained. So I think any well trained hand surgeon, plastic surgeon, general surgeon, and some might say neurosurgeon, because there are plenty of neurosurgeons doing carpal tunnel releases can do this procedure.

Chris Dy:

Do you think they need to do it with loupes?

Charles Goldfarb:

No, I don't think so. I mean, I can't do a femur fracture without loupes. And so that's one end of the spectrum. No, I don't think you need loupes. You know,

Chris Dy:

I think that, you know, from an access to care perspective, yes, this surgery should be done by any board should be able to be done by any board eligible board certified orthopedic surgeon, plastic surgeon, theoretically general surgeon a neurosurgeon to because there are going to be many practice settings in which you're the general and not to exclude plastics or anything, but you know, you're the general orthopod for the community. And you should know what to do carpal tunnel release, because it's a common procedure with reliable and predictable outcomes. So yes, I think that a carpal tunnel should be should be on that list for sure.

Charles Goldfarb:

Yeah, the only caveat I would say is, if you are a surgeon, who does this procedure intermittently, you know, some hand surgeons will do five or 10 a week. And if you're doing one or two a month, I might argue and again, some will disagree with me. I might argue it shouldn't be done into scopic. Lee, I would argue that into scopic may have a higher risk. I personally believe it does. The literature doesn't necessarily confirm that. But I would say if you're intermittently doing this procedure, do it with an open technique or mini open technique. Do you agree with that?

Chris Dy:

Yeah, but I I think I have my bias of not having spent a lot of time with endoscopic, as we talked about in a prior episode of looking at using an ultrasound guided one. But again, that also is not a procedure that should be done if you don't know how to do a solid open carpal tunnel release. Because you don't appreciate what you're seeing unless you have a healthy respect for the open anatomy. And again, not like you're seeing all these structures when you're doing a mini open carpal tunnel release, but you need to respect them.

Charles Goldfarb:

Yeah, I think that's a good pivot to another procedure. And the reason I say it's a good pivot is part of meeting patient expectations is setting patient expectations. So carpal tunnel is not foolproof, and not every patient has a perfect result. Part of is making the diagnosis and, and confirming the diagnosis. And while trigger finger is simpler in every respect, many of us fall into the trap of making 100% of trigger finger releases will do perfectly. And while the vast vast majority do, there can be scar tissue, there can be recurrence and, and so that's another procedure I think a generalist can and should do. But again, with at least a modicum of respect for the procedure.

Chris Dy:

Right. Where when do you think trigger fingers go south? When do you think that? Is it an inter operative thing? Is it just how patients respond to the scarring, who is unhappy after a trigger finger release?

Charles Goldfarb:

You know, I believe David Ring tried to look at this. And as I recall, it was like 2% of patients were not happy after I think that feels about right, I usually tell patients, one out of 20 will not get the result that they want, or I want and I usually believe it's related to scar tissue. I try to be very, you know, regimented in how I do it and what I release. I don't think it's about that. You know, it's one of those deals, same approach, same retraction, same sharp release every time. But But ignoring complications, I think there's a very small percentage that makes scar tissue and don't do great. I will say what I've become convinced of is if you're doing three triggers, I won't say two. But if you're doing three or four triggers, I think the risk of that scar tissue less than perfect outcome markedly increased.

Chris Dy:

You mean scar tissue around the tendon or scar tissue at the the incision?

Charles Goldfarb:

Both. What do you think?

Chris Dy:

Um, yeah, I mean, I, I caution patients, mainly, that I think that the scar, the painful scar is probably the biggest thing. And it's going to feel sore and tender for quite some time. And most people are over that by a month. But there is the occasional patients. And it's uncommon. But if you're that one matters a lot that, you know, still have soreness there. And I have one patient in my mind who, you know, kind of sticks out as having that issue. In however many years I've been doing this, you told me I'm not allowed to call myself young anymore.

Charles Goldfarb:

Someone else someone else said that. Not me, but I agree.

Chris Dy:

Right. Right, right. Yeah, I don't know. I mean, I think that I think this is one of the surgeries where there is such an advantage to having people awake, in terms of being able to assess for any areas where the tendon may not be completely released. And there's still some triggering. Now, it's uncommon that, you know, when I have the patients move their finger that there's any triggering or catching, but it comes up once every few months. And then that's enough for me to say Thank God I do he's awake.

Charles Goldfarb:

I think that's really well said, and I totally agree with you, even though I don't do all of them, I do the vast majority now awake, same with my carpal tunnels.

Chris Dy:

So what's the third procedure that you think a non hand surgeon a generalist, so to say, should know how to do?

Charles Goldfarb:

You know, distal radius fracture, and you know, distal radius fractures are really a bread and butter procedure for all hand surgeons. But we also have come to respect the injury and respect the challenges. And again, it gets back to being able to predict possible complications and doing what we can to minimize those. So you know, a simple quote unquote, simple colles fracture with a volar plate can have complications. And so do you draw both cortices and where do you put your plate, all those things matter? But having said all that, I think for the not crazy convoluted multiple fragment, intra articular fracture, I think that is a procedure that many others can do and do well.

Chris Dy:

And then many do, I mean, you know, there are tremendous regional and institutional variations and who takes care of distal radius. At some places, it's the trauma service, some you know, so I mean, I remember in training when I was a resident trauma service would take care of all the acute distal radius fractures. And you know, I think the things that they care about are different than the things that hand surgeons care about. And I was looking back at my binder of fluoroscopy, for when I was a trauma when I was on the trauma service as a resident, and I looked at some of those constructs, and like, I would not have done that this way. And I would not have accepted this. But there were also some very thoughtful things that, you know, there's trauma surgeons that just different approaches and different priorities, I think, what are two? Conversely, what are the distal radius fracture patterns that you think should be handled by only hand surgeons?

Charles Goldfarb:

Well, one that may have an accompanying ligament injury, although some would argue that it for example, if you're concerned about an SL injury, do we address at the same time, although some would argue ignore it?

Chris Dy:

Some good literature out there suggesting that.

Charles Goldfarb:

Yep, a die punch. fracture, I think is one that probably probably would benefit from a hand surgeon approach. I would say I'm one with an accompanying DREJ instability, for certain, but a colles fracture? Again, quote unquote, simple two part fracture. I think those are far fine. What about you? What did I miss?

Chris Dy:

Um, I think that's my, you know, I think radiocarpal dislocations. Any injuries along that spectrum probably should be treated by a hand surgeon just because we're probably the ones that are going to take them across the finish line. But, you know, I bet there are lots of cases that are treated well, that we've never seen. You know, I think one difference that I've noticed and it's in the literature as well as the the threshold to perform adjunct procedures like a carpal tunnel release at the same time. You know, I've done I do a fair bit of carpal tunnel release when I'm fixing it as a radius. Now, it's not common, but I definitely do it more than what I noticed when I was in training because the trauma service would never do it. Because it just didn't either didn't cross their minds or it just didn't come up as part of the injury. You know, for that patient.

Charles Goldfarb:

Yeah, well said really important. I did one this week where distal radius fracture with some early numbness and tingling in the fingers and and while not dramatic to me, if there's any signs of anything, I go out and do the carpal tunnel, really. So really good point.

Chris Dy:

I mean, one of our peds ortho partners sent me a patient a few months ago, I was so pleased that they had done a carpal tunnel release at the same time as their distal radius. Or if I was so happy that they had done it, the patient is going to be great.

Charles Goldfarb:

Yeah, I think I know what you're talking about. And I agree with you completely. And that's because Lindley and I preached that in the in the comp our indications conference.

Chris Dy:

Our residents are so good that they can do it.

Charles Goldfarb:

Well, that is certainly true. That is certainly true. All right, what's next? We've got what we talked about carpal tunnel trigger distal radius.

Chris Dy:

I don't know about this one. But I think I think it's probably true. I think generalists should know how to fix metacarpal fracture.

Charles Goldfarb:

Yeah, I agree. The trickier part might be which metacarpal fractures need fixing, but I agree with that. I mean, especially someone who does a lot of trauma can handle it, handling the tendons dorsally matters. Newer slicker techniques might not might not be used, but newer slicker techniques might not end up being, you know, the be all and end all. So I agree with that. I mean, again, once you're getting into articular, head of the metacarpal, that's different, but a metacarpal, especially shaft fracture or boxer's fracture that might be treating. I agree with you completely.

Chris Dy:

Yeah, I mean, from an access to care perspective, I mean, those things come up, they should be fixed. You know, now when when you start to get to the proximal phalanx, that's when I think things start to get a little bit tougher. There are much many more considerations in terms of the soft tissues. But yeah, I think the metacarpal should, should be able to be fixed. Is there anything else on this list as we bring things to a wrap?

Charles Goldfarb:

Yeah, you know, the one I was thinking about is the one I am not so certain about, and I hope our listeners will weigh in, I don't know about cubital tunnel patients and some of our shoulder and elbow partners historically have done that, and I'm in no position to tell someone to or not to do a procedure. But again, the problem is indications for procedure management after and ideal techniques in and sure there are plenty of cubital tunnels that can be decompressed. Or the nerve might be transposed that you can expect a good outcome. But in my mind, when the procedures predicted rate of success, lowers, you know, some maybe 80% that people do great or 70% of people do great. That's more of an indication for a specialist to handle it. And so, I do wonder whether cubital tunnel should be regularly performed by others.

Chris Dy:

Well, you know, in actuality, I agree with you, but they are being done by others and many, many others. You know, and I think that the variability in results after cubital tunnel surgery is coming Turning. Also the variability in which surgery you do. You know, we don't agree even as a community of hand surgeons what the right thing to do is, but I think that you know, for this particular surgery, you should know how to take somebody across the finish line. So what do you do if your first surgery doesn't go? Well? Are you able to perform the revision and do it well, and take care of the patient? That's the way that I think about it. You know, for example, it's not exactly the same. But I mean, somebody asked me like, what, what would you want done whether if you had cubital tunnel and you were had failed non operative treatment? Would you want a decompression or a transposition and if I had a stable nerve, I probably would want a decompression done by a surgeon who knows how to do a really good transposition. Because if something doesn't go well, and I'm part of that, somewhere between seven to 20%, that needs a revision surgery I want, I would like to stay with the same surgeon, I want to know that surgeon knows how to handle a transposition.

Charles Goldfarb:

Yeah, well said, for sure. And yeah, and I don't mean to suggest that others shouldn't, or can't do these procedures, I just, they make me a little nervous. Nervous is the wrong word. But they, you know, I just, again, it goes back to predictability. And I, I know that there are really skilled surgeons out there who are not Hansard, and you do a great job with this procedure, no doubt about it. But I just don't think it's a procedure that one should perform once or twice a year. And like you said, without the ability to handle what may happen after?

Chris Dy:

Well, it's a way to end it on a high note there. We'd love to hear I mean, for our listeners, you know, hand therapists or their surgeons that, you know, or their surgeries that you've seen non hand surgeons do and do it well, or maybe not. So well love to hear your feedback on that. And then for our, you know, practicing surgeons and trainees, what do you think? Because, you know, if you're a trainee, you got to learn how to do this stuff. And if you're a practicing surgeon, I bet we have some generalists who listen, and want to give us their thoughts. So please feel free to either send an email, social media, whatever works best, but yeah, let us know.

Charles Goldfarb:

Yeah, I appreciate that. And I think that's a really good point. And therapists know all and they they they see outcomes, they objectively can quantify outcomes. And so nothing's more flattering than getting referrals from a hand therapist, but they do have a very unique perspective.

Chris Dy:

Oh, it's total flattery. It's like when you get the when the PACU nurses and OR nurses start coming to see you. I remember you talking about that is that when I was your fellow, and seeing that, and patients referred from him, therapists are seeing him therapists themselves as patients is, you know, it's, it's flattering, for sure. Yeah. So any any wins for the week.

Charles Goldfarb:

So my win for the week, is I'm starting to prepare for a couple of meetings. And, you know, I, you know, I'm not one who wants to travel all the time. But, you know, once a month, every other month, I think that's fine. And I have three or four meetings coming up, and I'm starting to prepare for them. And not that I love the preparation part. But I'm looking forward to it. It feels like again, one other indicator that we're getting things back to normal. What about you?

Chris Dy:

You know, I was just thinking more of a slides on the plane and slides in the hotel the day before kind of guy. But you clearly have it together much more. You know, I'm really excited. I'm going to I'm going to make some fried chicken this this afternoon. And cheeseburgers. My daughter is in love with cheeseburgers. And it's the only way that she will eat protein, apparently. So I'm gonna fire up the grill today. And you know, and then also do some fried chicken. So I'm super excited about that. It's not a win yet. I hope it ends up being a win, but it's a win in my mind already.

Charles Goldfarb:

Well, growing up in Alabama, the careful fried chicken creation process is is uh, you know, I'm interested to see how it comes out. Good luck.

Chris Dy:

Oh, yeah, I'm the big big buttermilk guy. I'm gonna go put those guys in some buttermilk now. So enjoy the rest of your day. And good luck with your meeting prep.

Charles Goldfarb:

Thank you. Take care. 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. 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 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