The Upper Hand: Chuck & Chris Talk Hand Surgery

Deep Dives on Surgical Technique: ECU Tendon

April 24, 2022 Chuck and Chris Season 3 Episode 15
The Upper Hand: Chuck & Chris Talk Hand Surgery
Deep Dives on Surgical Technique: ECU Tendon
Show Notes Transcript

Season 3, Episode 15.  Chuck and Chris discuss  ECU tendon pathology including tendonitis and instability.  We review pertinent history, physical examination including the ECU Synergy Test, and surgical techniques including transposition of the tendon for instability.

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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 ya?

Charles Goldfarb:

Fantastic. How are you?

Chris Dy:

I'm doing well. I'm doing well coming off of, you know, high Easter weekend was super fun for us. I ate a lot of food, a lot of the things that I was supposed to give up for Lent. I gave up my wife and I typically will give up sweets for Lent. And that tends to that strategy, or at least that sacrifice tends to bend a little bit towards the end. We went all in. And then this year, I also gave up bread, which was a lot harder than I expected. Because even though I don't regularly eat sandwiches, all I wanted when I gave up bread was a sandwich.

Charles Goldfarb:

Well, that resonates. I am not a particularly religious person, but I am Jewish. And so we give up bread for Passover. I'm not very good at that part of I have trouble getting by without bread.

Chris Dy:

Well, it's interesting. I was talking about I guess I was lamenting my Lenten sacrifices during clinic one day and Jamie Findeiss the therapist is in clinic with me on Fridays, she was like, well, but is giving these things up actually making you a better person? And I'm like, No, clearly not. I'm hangry. Right now, maybe I need to reconsider my strategies here.

Charles Goldfarb:

Yeah, it's funny when you talk about giving up sweets, I mean, that that's another one that's very hard for me essentially, how our family divides. My wife is really disciplined. And my two older kids are really disciplined as far as eating and and not to pick on my youngest child, but my youngest child follows my path, which is pretty good most of the time, but that's unnecessary crunches and seven m&ms in the cabinet, and they will not last long.

Chris Dy:

Oh, man. So I had I had a patient, a grateful patient who expressed her gratitude in the best way, obviously bringing in food. And she had a family that was trying to leave it very generic. She had a family member who works for a very big candy company. Comes in, just with looks like she was about to rob a bank with these two huge sacks of you know, candy, branded swag. And of course, inside it is literally the most candy I've ever seen.

Charles Goldfarb:

So let me ask before you tell, did you share it with everyone in clinic? And except that you're not taking any of this home? Did you? Did you hide it away to take most of it home? Or do you do a kind of partial?

Chris Dy:

I didn't either of those to chuck. My whole thing. My thing is that if somebody brings something into clinic to show how thankful they are, if there's any possible way to bring that home to show my children that I help somebody, and that they were so thoughtful and appreciative that they did something for me, I kind of want them to see that because I want them to understand that, you know, we're not completely transactional in this world, in the sense that you know, you pay x and you get y but people just think of you and they appreciate you and they will do something nice. And then of course I wanted to bring them to candy, but the bags are cool. So I brought home the bags, immediately showed them the bags and what was inside of them and then dumped all of the candy into a separate bag, which is stashed in the laundry room may have gotten into the stash recently. But I will admit to one thing that I did I know there's a whole line of questioning that's coming my way on this but I admit to one thing that I did very weak of me before it took the bags home and went and picked up all the peanut butter m&ms. Put them in my stash in the clinic knowing there would be a day where I would just need a whole lot of peanut butter m&ms.

Charles Goldfarb:

You got to do what you got to do. But I You know what? This is a great topic. I think most of our listeners can relate. It is really appreciated when patients do think of us in a non transactional way. And it happens some I'm pretty you know my clinic style is pretty direct. I can be warm and fuzzy, especially with the pediatric population but I'm not always the most warm and fuzzy you know that about me? And I know patients get that and either you like that and or you don't. There's benefits running on time etc. But what patients do recognize and bring in gifts on occasion I don't get gifts all the time, but when I do there, I'm grateful. I usually share them with the staff or just give them to the staff. I do agree with you though it is important is important. for our kids and family to understand these, these signs of appreciation.

Chris Dy:

Yeah, there are many, there are many things that I will share with our team given-

Charles Goldfarb:

Just not chocolate.

Chris Dy:

Well, no, no, there was there was chocolate distributed. But I really wanted them to the bags were really cool. And of course, you can't just bring on one bag if you have to. I mean, I guess I could, I should probably teach my kids a lesson in sharing. But clearly, I haven't learned it either. It's funny one of the so patients will bring stuff in. And one of our team members who shall remain nameless has a total thing about eating stuff that patients bring in that is homemade, will not touch it, which I kind of get. But I'm also a sucker. I will go for it. Do you have any strong feelings?

Charles Goldfarb:

Honestly, it depends a little on the patient. Judging that way.

Chris Dy:

But you know, I think our therapy colleagues will, this will resonate with them. Because if your therapy practices anything, like the therapy practices that I see in surrounding my practice, the therapist get all the good stuff, the therapists get all the good stuff, and rightfully so because you all spend so much time with patients. But I think I get you talking about getting a few things. I'm like you I'm not that warm and fuzzy. My soft spot is not peds. But it's the nerve patients, I spent a lot of time with them and do all of that. But I am pretty direct in clinic as well probably learned it from you. And I don't get I get a fraction, little fraction of the rewards and fun stuff that our therapy colleagues get, which is cool, because they earned it.

Charles Goldfarb:

For sure. And that you know, that is for the medical students and residents who are listening. It's different when you know hand surgery is not always life changing in a way that total joint arthroplasty, or spine surgery may be and if you're in it for the chocolate, maybe you think about those specialties.

Chris Dy:

I think that spine patients might not be chocolate, I think you're looking for spine surgeons, they may go a little bit, you know higher tier so to say, but you never know.

Charles Goldfarb:

Like wine.

Chris Dy:

Exactly. Anyway, so our topic today is sportsy. It's a detail episode on ECU tendon surgery. Now, I don't have a ton of experience with this because I have chosen not to make sports a big part of my practice, mainly because there's a giant elephant in the room that gobbles up all the sports in our group. But that's totally okay with me.

Charles Goldfarb:

You know, I don't know that I gobble it but I do enjoy it most of the time, isn't it. What's interesting about the ECU tendon is it falls into the black box of the owner side of the wrist and I'm actually doing a webinar for the AAOS and hand society in on in early early May, about this topic that is the ulnar side of the wrist and, and so people always like to talk about the TFCC. And that's sort of, you know, one of my passions, the ECU gets a little less respect, but it shouldn't because it can be the culprit. And it's tricky. There is no doubt it's tricky. And I would say that when I think about the ECU, I think about ECU tendonitis and ECU instability. And while they are, you know, potentially related, they are separate diagnoses. At least that's the way I think about it in a big picture. Do you think about it the same way?

Chris Dy:

Yeah, I think so. Yeah, I'm curious, you know, for you of the percentage of young, healthy active people who have on their side of wrist pain, so not on their styloid or TFCC related pain after distal radius fracture, but you know, and a nonfactor setting, what percentage of that ulnar sided wrist pain have symptoms that are largely driven by the ECU. Now, I know there's, you know, different kinds of ECU pathology. There's a lot of overlap between ECU and the TFCC. And other causes ulnar sided wrist pain, but what percentage is really driven by the ECU?

Charles Goldfarb:

We're talking isolated ECU, I would say, five to Max 10%. There, like you said, there's overlap, but it's a small percentage. Now, you know, I you know, it may see me but I don't always see it is one explanation why it's so low. But I think that's, that's, that's feels right to me.

Chris Dy:

But, you know, one 5%, one out of 20. I mean, you know, you see a fair number of patients a week that could be one patient a week that's ECU related, that maybe, maybe more maybe more for you.

Charles Goldfarb:

Yeah, one or two. patients a week in some form or fashion. And then it's also complicated by the fact, by two facts. I would say one. ECU tendonitis is a weird diagnosis for me because when I operate for ECU tendonitis, I'm never impressed by the tendinitis. Meaning I don't see a ton of inflammation. And it's just it can be one of those procedures that you do that can be helpful. But it's not a procedure I rushed to do because I don't always get the satisfaction of that surgery. Because that's,

Chris Dy:

You know, I'll be honest with you. I mean, I don't do a lot. I think I can count on one hand, a number of ECU tendonitis surgeries that I've done, I spent a lot of time not trying to do surgery for the reasons that you stated. Now I know we're supposed to do a detail episode, focusing on technique, but I think it's worthwhile in for this particular topic to really backpedal and talk about, you know, diagnosis, pearls on history, physical exam stuff, and why don't we start with the ECU tendonitis?

Charles Goldfarb:

Yeah, so yeah, we can probably fly through this, I think with full, you know, being fully comprehensive. So, you know, dorsal ulnar pain, I love it. When patients say that it radiates up the owner side of the dorsal forearm, that is a really helpful, subjective complaint that I like. Other than that, is that vague area of pain on the own wrist, which can be very difficult to differentiate between other pathologies. And so the subjective comment that I like to hear if it's easy to nice is radiating up the form. And I would just say that the objective feature is the ECU synergy test. I and we may have talked about that on the show. But for those of you who haven't done it, or used it, I should say, it is based on a paper, which was written a while back is from 2008 is from Robert Ruhland, and Christopher Hogan in in Virginia. And they describe this test, which makes a lot of sense. And so let me just describe it. It's a supinated, elbow bent, 90 degrees form fully supinated. And then the idea is you resume you put your, you apply radially directed force on the long finger, and only a directed force on the thumbs and the thumb. And so the patient is trying to bring their middle finger and an older direction and their thumb in a radial direction. And that requires that you fire ECU. And this paper used us used EMG to prove that point. And so when you fire your ECU that should precipitate pain related to tendinitis. And it's a really well done paper and they looked at three groups of patients. I believe one was isolated ECU tendinitis, it got better with injection. Another was coexistent ECU tendinitis and intra articular pathology. And the third was just in particular pathology and the test stood stood well, it did well. So supinated resisted thumb radial deviation resisted. Middle finger owner deviation makes you far your ECU, and that should recreate pain.

Chris Dy:

Yeah, no, I think that's an excellent summary of it. I'll be honest with you, I don't usually use the middle finger part of it, I probably should I have the patient, you know, face their palm towards their face. And then I have them spread their thumb as far away as they can from their pinky. And I push against them a little bit. And if it causes pain on the other side, that is how I use the test. So I'm not a purist. But it seems to work for me. It works in terms of at least understanding the involvement of the ECU,

Charles Goldfarb:

well said, and I totally agree. And part of it is, you know, I'm not calling patients disingenuous, but they don't think about it, right? They're messing with their thumb, not their owner setting wrist pain. And so that really precipitates a strong reaction, then I feel like it's great. And then the last thing I'll say is, you have to differentiate tendinitis from instability, right. And that's really important to do. And you can't effectively treat anyone if you don't know the difference.

Chris Dy:

So before we dive into that, are there any you mentioned that kind of subjective complaint of pain along the other side of the wrist that radiates up the door? So on their forearm? Are there any maneuvers or activities that patients tend to associate or you know that you've noticed that they describe a you know is more likely to show up as ECU tendinitis?

Charles Goldfarb:

I think no, I'm maybe I'm missing something. But I think anything that requires you fire your wrist extensors, puts that ECU tenant on stretch and can cause pain. So either firing or putting on stretch can cause pain, but there's not one specific activity like The Chair pushup test or you know that nothing like that really helps me isolate the ECU tendon versus ulnar sided risk pathology in general.

Chris Dy:

So when do your alarm bells start to go off about instability? Is that purely based on your exam? Or is there anything that comes out of the patient's mouth that makes you think of ECU instability?

Charles Goldfarb:

So first, I think we should clarify that not all instability is pathologic or painful. And so some patients will come in with instability. And you notice it, as you know, a kind of happenstance and that is, should not be overtreated. And I think that's really important. And I recall David ring, talking about that went a long time ago when I thought, Wow, is that really true, but it is absolutely true. Of course, identifying those that are symptomatic and unstable is important. So the classic maneuver is a good one. And it's an easy one. And it's I don't know if this is the official name, but it's the ice cream scoop maneuver, right, so you have your pom protonated. And actually your wrist a little bit extended, like you're grabbing an ice cream scooper. And then you go into older deviation and supination. And use a little flexion of the wrist. And if there's instability that should cause it. And so often you can feel or hear that or see that it can be subtle, for sure. So you have to look for pain or some type of participating symptom. It's not a passive positioning. It's the motion of getting there. And if the patient doesn't walk in and say this is what I'm this is what's happening, this hurts, then you can sometimes get them to show you what that maneuver.

Chris Dy:

So is there any role for blotting or, you know, feeling the ECU tendon in different form positions and seeing if you can subluxated? Or is that is it purely like you're saying an active dynamic kind of test that that adds value?

Charles Goldfarb:

Absolutely. And I'd certainly do that, I just think it's it's most often less clear cut. And so my shifting the ECU tendon out of its groove, first of all, doesn't always mean anything, because you can get an MRI and see the ECU out of a screw. And that doesn't necessarily mean that's the cause of the symptoms, it certainly can be the cause of the symptom. And you can even get a supinated MRI, you know, most MRIs are done in the Superman position. And so you're protonated, which has relevance for older variants, but also has relevance for the ECU tendon is typically a more stable position. But if you supinate the form that can put the ECU in a more risk for subluxation position.

Chris Dy:

What else are you looking on on the exam?

Charles Goldfarb:

Well, I'm also looking at the fovea and trying to rule out of coexistent TFCC pathology. I'm looking at the carpus as well. And absolutely, you can have you know, you can have multiple pathologies at once because we know the ECU sub sheath is part of the TFCC complex or TFCC complex. And we also know that there can be a communication between the two. And so when I think about diagnostic or therapeutic injections, you know, if you're doing a intra articular injection versus doing an ECU injection, sometimes the medicine crosses and you know ICU injection can affect the wrist joint as well.

Chris Dy:

So what's your what's your workout from there? So say it's a tendinitis patient, no instability on your exam or on their complaints. Are you doing any additional? Are you getting any X rays? Are you doing any imaging? And then how would you how does that change for in instability patient?

Charles Goldfarb:

If I'm treating tendinitis, I'll do the typical tendinitis things. wrist splint, resting in the position of comfort, which again should be pronation. I don't if this is an acute onset, I might consider a long arm splint but generally I do not. So short arms. Splunk often custom with a little bit of wrist extension, anti inflammatories, activity modification with the next step being corticosteroid injection.

Chris Dy:

So no imaging.

Charles Goldfarb:

No, I don't think imaging is helpful. And the reason I don't think imaging is helpful is there can be all types of pathologic appearing things in the ECU, the ECU split, so to speak, is called on MRI all the time. We don't know if that's pathologic or not, it's just gonna be if I'm worried about ECU tendonitis, to me it's a clinical diagnosis with injection as a confirmatory test and treatment unless a have to go the or which I try to avoid doing

Chris Dy:

and then how does how does your treatment change for instability?

Charles Goldfarb:

acute onset in acute onset instability can often be most effectively managed surgically in one population, right in a population that is is high level arm surgery to repair the sub sheath might make sense. Although you absolutely can also treat them in pronation long arm Splinter cast, and let the sub sheath try to heal. And so it depends on your patient and how aggressive they want to be. I would say that the vast majority of patients who come in are not acute. And the instability is chronic has failed previous treatment. And then you're looking at treatment. And to me, there's two treatment options, and eyes slash we at this institution favorite one. And certainly, other institutions treat this differently. I'll say that a lot of people like the concept of repairing the sub sheath. And to be very clear, there's two parts of what wraps around the ECU one is the dorsal retinaculum, which comes superficially all the way around bowling alley. And the second part is the what's been termed either the sub sheath or the ligamentum jugatum, which is really what holds the ECU stable. So we're pairing that with or without a deepening of the groove is one option. I don't love the idea of deepening the groove, because to me, it feels like the tenant is just going to scar into place, and lose some of its functionality. So what Dr. Gelberman taught me and us is a transposition of the ECU where you take it out of his groove shifted dorsally, it's free to glide, it's sitting in a beautiful bed over the fifth compartment. And I've been super happy with that procedure. I've written up that procedure with our experience with it. And I think it's a great option, which gives me greater confidence that the ECU will maintain its function.

Chris Dy:

It's a lot to unpack there. I can go on for that. That was great. Before we dive into the technique, parts of that, how long? How many injections? Will you give a patient with tendinitis and no instability? And then is there a role for an injection in a patient with instability?

Charles Goldfarb:

I typically only give one injection, and it is a reflection of a couple of patients that I've seen, thankfully not necessarily been a party to their treatment, where they have received multiple injections in this location, subcutaneous fat atrophy, more pain. And you can also create instability. If you inject too many times. And so-

Chris Dy:

Any ruptures?

Charles Goldfarb:

I have not seen a rupture, have you?

Chris Dy:

I have not well, not for ECU. I've seen one for fcr.

Charles Goldfarb:

Wow, yeah, that's tough. So I usually only do one. And and I guess I will say if patients pushed me hard because of a great result from a first injection on Mike, is there a second? Do you have a limit?

Chris Dy:

Yeah, I usually won't do more than one based on what I saw at the fcr. And clearly, the ECU is a much more important tendon than the fcr.

Charles Goldfarb:

Yeah. I don't know that injection of the ECU for instability is wrong. And I guess if someone was pushing to try it, but because of a time issue, I might consider it but it doesn't make sense to me. So I would not certainly not be eager to do that.

Chris Dy:

So let's let's get to the or say you've decided for a tendinitis patient, not instability, you're going to do some kind of debris bent? Or whatever it is that you do for that? What do you do?

Charles Goldfarb:

So there are reports that you cut the retinaculum, cut the sub sheath and everything will be fine. That's some of the early reports in the general orthopedic literature. I don't believe in that. And so what I took a

Chris Dy:

AKA how to create instability?

Charles Goldfarb:

It's crazy. They the reports say instability was not created, but I don't think in good conscience I can, I could do that. What I tend to do is essentially, take a small area, which would include this the deep ligament or the ligamentum jugatum and work proximal and distal to that. And so I may release the sheath, let's say two centimeters proximal to the to the tip of the styloid and then preserve the sheath over that two centimeters to the tip of the stylet and probably another two centimeters, so maybe preserve three or four centimeters of for stability, where proximal is that area, open things up or distal to that area, position the wrist in different extension or flexion postures and examine the tendon and abraded as necessary. That may be conservative. But when I've done this, I have found that technique to be effective and I hope listeners will weigh in if they see it differently or treated differently.

Chris Dy:

What is considered diseased tendon?

Charles Goldfarb:

Well, I mean by MRI, it's often intrinsic to the tendon, which again as confusing to me, I think we're looking for essentially synovitis around the tendon. I think that's diseased, like any other tendon.

Chris Dy:

Got it? And then after that's done, close, and that's it?

Charles Goldfarb:

Well, it gets to the point of a lot of this close and rest them. You know, it's forced rest for six weeks, which may be a maybe that's a little punitive. But I think that may provide as much good as the surgical intervention itself.

Chris Dy:

Cast or custom orthosis.

Charles Goldfarb:

I totally fed, I tend to cast.

Chris Dy:

So they have a lot of they've invested a lot of their energy and time into it. They want to get better, and you're arresting them. Sounds like sports.

Charles Goldfarb:

Yeah. It's kind of like tennis elbow. I don't love treating tennis elbow, I kind of put it in that category.

Chris Dy:

So then talk to me about how you address instability. You know, is this You mentioned a little bit about your philosophy. You don't like to deep in the groove? I mean, I guess if you're looking for a disk or in and not be unstable, then maybe that's a solution. Are there any cases in which you think groove deepening is the answer?

Charles Goldfarb:

Well, I think there are cases where repair of the ligamentum jugatum is the answer in a truly acute injury in one of our orthopedic colleagues, not at Wash U was playing golf, had a pop, had instability and had had a repair. Two days later, he recognized what he had done. And they put two suture anchors in the owner border, and repair that ligament or the subsheath back down. And he was kept in a position of, you know, pronation and slight wrist extension for six weeks. And he did great. Totally agree with that I would have done the same, I don't think I would have added a deepening there. I just don't believe in the deepening. I guess if it's an old guy like me, and you wanted to use that approach, you and I probably wouldn't miss my ECU, honestly. But I think in an athlete, whether that'd be a teenager, athlete, collegiate or professional, I think for some, they might.

Chris Dy:

I just don't understand how you're gonna get attended to collide by a raw bone. You can't sell a surface I just.

Charles Goldfarb:

And you immobilize them to boot. Right. So, for that reason, I love this transposition procedure.

Chris Dy:

To talk me through the transposition.

Charles Goldfarb:

I think it's technically very straightforward. So you do need a sizable incision. So I don't know four inches, going from near the base of the fifth metacarpal, proximal, you know a bit and insides through the skin, protecting cutaneous nerve branches, and release the retinaculum as far voli as you can you reflect the retinaculum up you're looking at the sub sheath, which always looks like degenerative tissue. And I released that is far own early as possible, and then examine the tenant examine, you know, just take a look at things try to get a sense of things. And then it's really simple. Once you mobilize the tenant, you simply bring it dorsally on top of the retinaculum. And then you bring the rest of the retinaculum underneath and then back over the top of the ECU and suture it in place. And you're suturing it directly over the fifth compartment. You have to be careful not to grab a the EDM. But it has a nice bed to rest in. It's a smooth gliding bed, the retinaculum heals nicely, I typically put at least 6, 7, 8 stitches in there. And again, gotten patients back to full activities. I tend to mobilize them for five to six weeks, and then they ramp up from there.

Chris Dy:

What stitches used like three with a bone or something like that, or three other bond, you got it. Yeah, I remember very vividly the description of this procedure in the Masters techniques for risk surgery, obviously, edited by Dr. Gelberman. But I, as an aside, I picked up a copy of this textbook for like 10 bucks on Amazon when I was a fellow just because I was as a fellow I was running around with my head cut off most of the time. And if I needed to read for something, it had to be like a textbook because I couldn't spend any more time looking for articles. Unfortunately, most of the textbooks are edited by our faculty. So I picked that one up and I still actually look at that. And it's got a great illustration of this exact procedure.

Charles Goldfarb:

Yeah, and that's where I learned it. And certainly Dr. Gelberman was active in the sports field for many years and did a great job and I took his advice and tried it and have liked it. It is funny about what happens to textbook and pricing because most of the procedures we do in hand surgery are changing that frequently. I bet most of that book is maybe with this set If you don't staple in a treatment, most of that books probably spot on today.

Chris Dy:

Oh, you know, the scuffle in a treatment doesn't work anyway. So sure. Any other pearls for ECU either tendinitis, surgery or instability, surgery? anything different that you've done? Have you changed your surgery over the years?

Charles Goldfarb:

I have not. I have not. I don't think there's any other pearls. I think it's something you have to actively look for. Meaning the tendinitis or subtle instability. And so making the diagnosis is the hard part. Sometimes Sometimes is the easiest part ever. And sometimes it's the hard part. So you have to think about it versus intrinsic pathology of the wrist joint. And I guess you would say lt would be part of the pathologic spectrum. But no, it's it's an interesting diagnosis. It's not an infrequent diagnosis, as we discussed earlier, but I think it's one where we can help patients.

Chris Dy:

Does anybody after a transposition of the ECU? Do they ever complain about the appearance of their wrist? Does that lump us in over the more centrally Does that bother them at all?

Charles Goldfarb:

No, I haven't heard that or honestly seen it. i It hasn't ever been totally visible to me.

Chris Dy:

Just as good of a surgeon.

Charles Goldfarb:

The wrists have support and fatty tissue which hides it.

Chris Dy:

Or you don't ask.

Charles Goldfarb:

Alright, tell me one thing you're grateful for.

Chris Dy:

I am grateful for eating bread and sweets again, and not feeling bad about it. I'm grateful for the you know, having had the chance to spend some time over the holidays, over the Easter holiday with with friends and family. And, you know, that is always fun, and I think should not be taken for granted as much anymore, given everything we've gone through in the last two and two plus years. How about you?

Charles Goldfarb:

Love that. I am grateful that I went to a meeting, I went to the pediatric hands study group meeting in Salt Lake City, Utah. Last weekend. It was great to see people it's great to socialize. It was educational. It was not COVID free. In the end, there was a couple of cases.

Chris Dy:

The old super spreader conference nice.

Charles Goldfarb:

I don't think it turned into that we did wear masks because of the rules of the university inside but with dinner and stuff we did not but man. I you know I've never been someone to say I love meetings that I still wouldn't say that. But it really felt good.

Chris Dy:

Was this your first meeting back? I know you've done some like smaller committee meeting and question writing things with those this first like academic meeting.

Charles Goldfarb:

First academic meeting. Yep. Loved it.

Chris Dy:

How many podcasts high fives that you get?

Charles Goldfarb:

You know, it's funny you asked that question. Because I know you have said it was great. I did get some. And I don't really know what to say. I say thank you. I'm so glad you're listening. Do you have ideas for topics but I got a lot.

Chris Dy:

I really did. I really did. Then you didn't give away any swag.

Charles Goldfarb:

I forgot to.

Chris Dy:

I'm sure.

Charles Goldfarb:

I have a box on my front door. I need to bring some to your house.

Chris Dy:

I'm sure they'll find out I'm sure they're gonna find you in Boston at the hand society or whatever other Oh, we need to bring something to London for the IFSSH, the guys at TSA are going to say what what are you bringing into our country? The British equivalent of the TSA.

Charles Goldfarb:

And who would want it?

Chris Dy:

Exactly like are you guys some kind of fake celebrity? I don't understand.

Charles Goldfarb:

All right. Great to see you.

Chris Dy:

Nice seeing you. See you next time.

Charles Goldfarb:

Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy:

Sounds good. Well, be sure to check us out on Twitter @Handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb:

Mine is @congenitalhand. What about you?

Chris Dy:

Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your 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