Season 3, Episode 16. Chuck and Chris with a grab bag of topics including listener emails and a few very interesting surgical cases. We will discuss the placebo effect and recovery after long bone fracture + a few nerve and elbow cases.
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.
Season 3, Episode 16. Chuck and Chris with a grab bag of topics including listener emails and a few very interesting surgical cases. We will discuss the placebo effect and recovery after long bone fracture + a few nerve and elbow cases.
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, how are you?
Charles Goldfarb:I am doing well. How are you tonight?
Chris Dy:I am great. I am great. I am staring at a piece of apple pie that I'm going to eat as soon as we're done with this.
Charles Goldfarb:That is incentive to get done.
Chris Dy:It's been a staring contest. It's interesting. I am not shy when I talk in the OR about my love and appreciation for food. And she had a one of our RN first assists his wife or he convinced his wife to make an apple pie for me. Literally, the best apple pie I've ever had.
Charles Goldfarb:That is awesome. I am seriously jealous. I had a interesting day. I had a great day I have intermittently been able to ride my bike to work but I was able to do it today. It was a little chilly this morning it was around 50. But coming home, it was 75 it was I came home at like six I left at six. And it was 75 and sunny. My God. It was awesome.
Chris Dy:It was a gorgeous day. I actually came home and both of my kids were in bathing suits. And I was like did y'all get in the pool. I was like I didn't heat it up. But there must have been so nice outside that they just could not resist.
Charles Goldfarb:You and I might not have enjoyed that pool. But kids are immune.
Chris Dy:Yeah, I actually saw. I walked by our chairman's office today I saw a bike in his office too. Is it yours or was it his?
Charles Goldfarb:We do not share office. It's his. He has a very short commute, but he does ride often.
Chris Dy:Very good. Very good. Well, good for you. I look forward to seeing you out and about and riding across Forest Park.
Charles Goldfarb:Absolutely. The best path to work.
Chris Dy:My son still reminds me of that one time during the guest camera what random day it was but actually biked him to school like he was on his bike. I was on my bike and we had a good time. But it's been a while.
Charles Goldfarb:We had a little hiccup there, but I think we're back. All right. I think we're doing an interesting episode one that I'm kind of looking forward to. We're gonna do a little bit of a grab bag with a couple emails and a couple of cases. Does that sound like fun?
Chris Dy:Sounds like fun. Did you get an email from Down Under recently?
Charles Goldfarb:I did, I would say so. Richard Lawson is a great guy. He's a good friend. I don't see him enough who I first met on my Bunnell traveling fellowship when I went down to visit Michael Tonkin. And Michael kind of pawned me off on Richard, who took me to a gym to do rock climbing. And it was super fun. And I was super grateful that he was hanging out with me. And while again, we don't see each other often. He's just a really, really nice guy. So I was interacting with him about something. And he kind of threw in there casually that Oh, yeah. Broke my humerus.
Chris Dy:Wait, wait. So is he a hand surgeon?
Charles Goldfarb:Yeah, he's a hand surgeon Absolutely. In Sydney.
Chris Dy:Got it. Got it. Okay, so he how did he break his humerus.
Charles Goldfarb:I'm just gonna I asked him he gave me support. So I'm going to just read his emails not that long. And I think it's actually pretty telling so. Hi, Chuck. I love the podcast. Well done. Sarah and he's speaking of Sarah Tolerton brought to my attention and it is very good. You guys have an excellent report. Thank you, Richard. I have to carry Chris on this podcast but.
Chris Dy:Just just a workman hammering nails. Going at it.
Charles Goldfarb:All right, the story of the left arm unfortunately, not very glamorous. It was but what's what's great for me and then part of the reason I wanted to read this is just hearing an Australian put things into written form. It's very different than what-
Chris Dy:I was really hoping you were going to read this with an Australian accent. So you know, maybe we can do a take two on this one.
Charles Goldfarb:No, you can do it. The story of the left arm. Unfortunately not very glamorous. It was blowing a gale at the rowing sheds. That's I've never other than that in my life.
Chris Dy:English American English.
Charles Goldfarb:It was really windy at the pond. Probably no one should have been out some friends put their double in the water. The wind took the aluminum and cloth stretchers and one sailed into the water between our nice modern non slip Pontoon. and the neighboring not so good structure. I jumped onto this and down I went. Big jolt through the radial and ulnar nerves thought shoulder dislocation but palpation revealed a mid shaft fracture, which is said like such an orthopedic surgeon. I'm going to keep going. A very good trauma surgical friend of mine plated it post dearly, and I am pleased to say it as united with no nerve problems, lessons learned. Number one, fractures are painful. Wearing a sling from clothing is worse than a paper sling, which is worse than a cloth sling. Can't argue with that. It is interesting how we see people on the day the next day, two weeks, six weeks in three months. And in each of those time points, the patient is usually better. But the line joining those dots is not necessarily smooth. I think that is well set. long bone fractures and adults are exhausted. After the first week I went back to consulting and did three half days and just went straight back to bed after each morning. Muscles take ages to heal. I followed my surgeon's advice and avoided any rowing and weights for three months, then went back obviously to eagerly training just about every day, but I thought fairly gently. It all caught up with me. And by two weeks, I had to stop due to arm pain taking the rest of the season off. Life is better with exercises and rolling has been tough not doing the thing I love for almost five months. And there you have it try. This is sage advice, try to keep your long bones intact. As I get older, I think about that a lot.
Chris Dy:That's amazing. And I would I would say hell try to keep all your bones intact. long bones included in the bones you can swallow.
Charles Goldfarb:Yeah, keep them all intact. But the long bones I must admit I haven't had a long bone fracture, although one of our partners recently has. Let's keep them intact.
Chris Dy:Well, so two things. The first one is that actually our partner who fractured his tibia knew he fractured his tibia as soon as he did it based on the same instincts that your buddy had as well, you know, as a ski boot kind of thing. And he's like I, you know, pretty sure I've midshaft tibia like when EMS putting the cart, you know, the second thing is more serious. And I think it's super important. I think that as, as we try to teach ourselves and and teach our trainees technique, being really good about taking care of muscle, you know, I kind of make a joke about it. But you know, one of the things that Lorich what Dean Lorich was really big about was very, you know, elegant, sharp dissection with a knife with a scalpel and learning how to dissect with it. And his quote, well, all the time was don't meet, don't make dog meat out of this. And that's obviously a very callous thing to say. But I've honestly found myself saying don't make dog meat out of this when we're doing some sort of some dissections where you want to be very kind to the muscle and try to keep the fascial planes intact because of the kind of pain that you're describing, you know, the more patients you see post off, the more you hear them say, Oh, this muscle hurts or something, you know, some of the dissections that we do are deeper or more prone to having that kind of pain.
Charles Goldfarb:Oh, I think that's well said I think back to when I was a resident, I may have said this before, when there wasn't a pair of tries typical approach to the distal humerus. We went straight through the tricycle out right down the middle. And I went, it was stunning to me. And I hated it for that reason. And now I love the posterior approach to the to the humerus, because she's moved the triceps either way, it's like such a no brainer.
Chris Dy:Well, I think that's also why, you know, for a sub muscular transposition, it's fine. That surgery hurts so darn much. Is that just all of that muscle manipulation? I mean, you know that that is one reason to avoid that surgery if you can.
Charles Goldfarb:That's the reason I do is that's why it's not my first choice there. Certainly those who argue do the last surgery first, which would be a sub muscular, but I don't think it's that simple. I don't it's not my first surgery.
Chris Dy:Yeah, I think that if, you know, I think I've shared this with you before, but when I was visiting Elizabeth Hoggart, she looked me in the eye said would you have that surgery? I said not unless I had to. That was a moment for me where I reconsidered my algorithm a bit.
Charles Goldfarb:All right, I think you you received an interesting email as well this week.
Chris Dy:Yeah. So you know, thanks to those of you that send emails and it really, you know, it's helpful for us to, you know, know what questions you want to answered and also just to get your feedback so Ryan Caldwell is a hand surgery Fellow at Tufts and Ryan, thank you for the for the email and I'm gonna go ahead and read it. You He starts by saying thank you for your podcasts, you've created an entertaining and valuable resource for hand surgery trainees, like myself, and it's been very helpful to me as I start my practice. We've enjoyed doing it. So thank you for, for tuning in. And he goes on to say, I'm intrigued at the larger benefit that sham surgery shows and trials, both in and out of the upper extremity, the power of suggestion, the scripted role of the patient getting better, especially if they liked their doctor. The immobilization, the emotional validation of having a surgery, it all seems to add up to a very powerful therapeutic effect. There are also several pathologies that seem to be treated equally well with many different surgical techniques, sometimes based on fundamentally different theories of pathophysiology, such as, you know, various treatments of the lateral condyle for lateral epicondylitis, or some of the various treatments for Keinbock's disease, whether you're doing vascularized, bone grafting, shortening the radius or even a cord decompression. Again, chronic SL reconstruction like rotator cuff repair seems to produce good clinical results despite radiographic progression or recurrence of deformity, something seems amiss. The surgery for epicondylitis TSCC tears, proximal nerve compression syndromes Keinbock's, chronic SL, et cetera, help my patients apart from the placebo effect of surgery. How can I be sure? So you know, pretty straightforward, easy question, Chuck, one should take this answer in my two cents this?
Charles Goldfarb:Yeah, I'll take this one, Chris. You know, it's interesting, because all I really want is for the patient to be better. I'd like to do that in a non interventional way. I'd like to do it rapidly. I'd like to do it with low costs. And I recognize that there is a placebo effect. But our goal is to just get patients better. And many of the surgeries that Ryan mentioned, I don't love. And I'll share one brief anecdote. Early in my career. I was the designee and that's why I started to love wrist arthroscopy because no one else really wanted to do it. And that's why I started doing it. And we debris did central tears, we do breathe it radial tears, and we repaired older tears, even though we didn't recognize TFCC related instability, or at least I did not. And I always wondered if Maria and I talked about whether repairing those dorsal ulnar tears did anything. Because it wasn't a stability issue. It was just a, you were doing something and really you were mobilizing and they got better. That's an example. I think we're where I was overtreating and today, I might just read that unless it was a very large tear. Again, fovea TFCC tears are a different story. They're about stability. But I think he makes a good point. I don't like lateral epicondylitis surgery. I agree that lots of different ways to approach that. But we want to get the patient better. And many, if not all of the surgeries mentioned can help achieve that result.
Chris Dy:How much of the improvement? And Ryan thank you for getting us to a very philosophical level here. And a very nicely worded email eloquent, how many of these surgeries are deep now how much of the improvement after surgery do you think is from the other things that Ryan stated? I think it's a really important suggestion, the scripted role of the patient getting better immobilization, emotional validation of having surgery, how much of that do you think is part of it?
Charles Goldfarb:All of it is part of it. And we talked about it on our last episode about ECU tendon and maybe part of is just immobilizing the patient for six weeks after surgery. It's all a part of it. One of the reasons I like fracture surgery is you fixed you fix the broken bone is very objective and you know all this other stuff is less so
Chris Dy:I think that you know the reason why fracture one of the reasons why fracture surgery is so gratifying is that not only can you see it, the patient can see it like you can show that to them. It's very hard to show patients other things you know, effectively either because they can't see it, and it's based on how they feel or because it's just really hard to explain you know some of these concepts escaped illuminate instability, for example, that we don't even fully understand.
Charles Goldfarb:Yep, totally agree. It is interesting though, the flip side of what you just said is if you treat a patient for a fracture, and they develop a painless fibrous non union we might be okay with that but sometimes patients are not.
Chris Dy:Right and that's where I start to lay the crepe from the very beginning. Now I think they're I think they're, you know, of the surgeries you listed at the end each of those has value when done in the appropriate setting. Now of course I'm by is because we're the ones were the arbiters of what's appropriate. fair or not. But I, I've tried to take, I've tried very firmly to avoid the supply induced demand. Just because I can do something doesn't mean that I should do it. But I can see very easily how if you haven't run a good experiences with some cases, you're gonna push the limits on some stuff, and really feel like you know, in your heart of hearts, that you're doing something for that patient, and maybe they're going to do well, because of the other reasons that you stated.
Charles Goldfarb:Yeah, it's a really tough concept. And I can sit here and be judgmental of people who've gotten a great result from something I don't do. And that may not be fair. And I think it is incumbent on all of us to practice appropriate medicine, it's sometimes it's easier said than done at the patient's putting pressure on you about an intervention. And it just gets really tricky. But you know, the, you want to sleep well at night. And that is not always a way to think about it. Because if you're directionality you can get you can, you can deceive yourself about whatever you want to do. So it's not always about sleeping well, but that's my threshold. And I try to be scientific, I try to follow the literature. And I feel pretty comfortable that I don't over treat people.
Chris Dy:I try to be a good steward for, you know, testing, and you know, that kind of stuff. But sometimes, honestly, some patients just want some imaging that maybe I would not have ordered, but I actually know that just getting the fact that I'm getting something and doing something for them is therapeutic. So I'm guilty of ordering some therapeutic imaging at times,
Charles Goldfarb:for sure. And I will add, one of the best things about being an academic medicine is you have people judging each step you take you have residents and fellows questioning while you're doing something, and you can't kid yourself, and you can't deceive yourself, and you have to be able to defend yourself. Not just do it because I said to do it. They don't question you though, right? i When people come on my rotation now I don't know if they do or not. But it when people come on rotation, that's the first rule. If we are in the or if we are in the clinic, and something doesn't feel right, or you don't think I'm doing the right thing. I expect you to speak up and if you don't, and something goes amiss, I will be really disappointed.
Chris Dy:People who never gave me you never gave me that first rule. The first rule was don't sing.
Charles Goldfarb:The second rule was don't speak up Dr. Dy.
Chris Dy:That's fine. It's it on a lighter note, I remember getting sign out about your rotation. And it was so funny because like when you're an attending, people will think that you want all these things or don't want certain things and it's just this like lower that gets passed down that you know, Goldfarb wants things exactly this way every time and it's probably because like some random thing happened one time, and they just like took it to heart. But yeah, it's it's very funny to see. You know, how you actually practice in your actual preferences versus what I was told about you?
Charles Goldfarb:Yeah, I'm sure that's true. I'm sure that's true. I that was I love that conversation. There's no easy answers, as you obviously know, as we all know, but interesting conversation.
Chris Dy:Now, no, I think Ryan deserves a mug. Chuck, are there any mugs left?
Charles Goldfarb:There are a few mugs left. We should get Ryan's address. Ryan, if you're listening, send us your address, and we will send you a mug.
Chris Dy:Fantastic. And I think we also owe one of our former fellows a mug the one one of the things that we said was if they published an article from their fellow research project that they will get a mug and your mentee on this project. Dr. Jocelyn Compton recently scored a nice JHS publication on how none of us need to fix Jersey fingers anymore. So bravo. Definitely mug worthy.
Charles Goldfarb:Have we talked about that article? I think we did.
Chris Dy:We talked about it. We talked about it on the hand society wrap up when it won the award for the best. Best poster?
Charles Goldfarb:Yeah, it is a really interesting article read it everyone in journal of hand surgery. It does not say don't fix FDPs. But it does question why it's a knee jerk reaction because complications are higher, and outcomes are not clearly better for many.
Chris Dy:Now I took that as don't fix them or send them to the Senate to the senior author of Dr. Compton's article.
Charles Goldfarb:Oh, please don't.
Chris Dy:That's exactly what you want a bunch of non-op zone ones.
Charles Goldfarb:Yes, exactly. Tell me about an interesting case you've done recently.
Chris Dy:So you remember when we were talking about our radial tunnel technique? And he said, yeah, just go interior. And then I joked and said, Well, you don't like to release all of the radial tunnel. So really? Yeah. I recently, I saw patients and ended up revising a radial tunnel. And it was the exact textbook kind of distal compression. And to the point where, you know, we examined her in the Neo preop and put an exon where they were maximally tender, and lo and behold, that's where the residual supinator was. And the first surgery had been done through an anterior approach by an excellent surgeon. But you know, it's just one of those things that you just, it's really hard to see the distal end of the supinator. And I don't go dorsal very often and isolated manner. And that is a humbling approach to do when you're trying to just perfectly get the, the fascial planes and not make dog meat. As I mentioned earlier, if you're even just a planer to off a couple of clicks off, you know, that can change your whole approach and clearly obscure where you need to be.
Charles Goldfarb:I think that's well said, I like a couple of things that you said. The first is that, and I've said this over and over, I love examining and marking patients in the preoperative holding area, I mark my incisions, I mark the masses, and I mark the areas of greatest discomfort. So I love that for radial tunnel, that's a super helpful thing. And I think it can guide your approach. So love that.
Chris Dy:You know, I don't do the dorsal approach, often in isolation. The other case I'll share with you guys later, you know, I use the dorsal approach as an accessory. But a pure dorsal approach is challenging, and especially when you start to encounter a scar. And that's when it gets real and very challenging to try to free up the PIN in an area where you've got a lot of small vessels. You're around a lot of muscle. It's not exactly the easiest surgery in a revision setting.
Charles Goldfarb:Yeah, I did that. Very similar surgery for different reason. But I, I did I took a patient to the or who had proximal radioulnar sent us a proximal radioulnar impingement after radial head replacement, and removal of the radial head implant. And so with rotation, he was impinging radius on ulna. And so the first thing I did was find the radial nerve and find it entering and exiting the supinator and can't get safe. And then I created an interposition combination of Antonius and Allah graft, super fun surgery, super trying surgery. But that approach, as you just said, with scar tissue can be tricky, but feels really good when you see the anatomy as you as you describe.
Chris Dy:Now is that a dual incision approach?
Charles Goldfarb:Did not I just went sort of an extended ankle as approach really sort of where they made the previous decision, but I just made it a little bit longer.
Chris Dy:We should in the future episodes spent some time talking about proximal radioulnar synostosis. That's a tough condition to treat.
Charles Goldfarb:Unfortunately, I have experienced with both synostosis and impingement. And I really as you know, have gained, you know, really started to love elbow. So yeah, I think that'd be a fun episode.
Chris Dy:I'm glad you love elbow.
Charles Goldfarb:I've many have said that to me.
Chris Dy:But then, you know the other part that was interesting about this case is that they had come in with an ultrasound from elsewhere. And the ultrasound from elsewhere showed that the superficial radial nerve was not enlarged compared to the opposite side. But she added smells that will you know, coincided with the area where the superficial radial nerve exits from underneath the brachioradialis and she was this aesthetic in the SRN distribution, motor wise had recovered everything from her last surgery but we went ahead and did the SRN decompression and the brachioradialis anatomy and the nerve just didn't look right. And I it's totally like a squishy, very kind of anecdotal and soft call, but it just didn't look right. And I can clearly I think you could feel and see the area where the nerve was not normal. I can't say it was terribly enlarged. But I could I think maybe I'm rationalizing along maybe with what Ryan was saying in his email, but rationalizing to myself that it was the right thing to do to add that distal decompression.
Charles Goldfarb:I'm sure it was the right thing to do. Because when you're you know you have you should have more freedom to do a little bit more in a revision situation. Obviously, you want to get everything done right the first time when possible. But in revision situation, you have to be willing to do more because you want to not be back a third time.
Chris Dy:Right, exactly. And then the last thing I'll add is that in preparing for the case, I cracked open the old government Blue Book from 1993. Which I love that book, by the way. I mean, it's such a nut for textbooks as we talked about it earlier. And it talks about the total off the cuff like level five evidence but says the rate of distal decrease of distal compression meaning you know, it's at the distal edge is superior to being 5%. That number felt right to me. Maybe it's a little high. But does that number feel right to you?
Charles Goldfarb:That number feels right to me as well. Very low, but it's not zero.
Chris Dy:Right. Now, you know that Graham Lister do what he was talking about. Just a little bit.
Charles Goldfarb:Can I share something with you about a case?
Chris Dy:Yeah, absolutely.
Charles Goldfarb:It's a case that you will never do. Dr. Dy?
Chris Dy:Oh thank goodness.
Charles Goldfarb:I think? I think the discussion around it is super interesting.
Chris Dy:Let me guess, did you did you make a thumb out of something?
Charles Goldfarb:No, but that'll be part of this child's treatment. I want to leave out some of the some of the demographics in the life. But I treated a patient with ulnar dimelia, more commonly known as mirror hand. And the mirror hand part, while certainly not straightforward, pretty accepted steps for treatment. And I don't want to bore anyone. So I'm going to jump to the part which is more uncertain, and more challenging, which is the elbow. So when, and I share this map, because I want to bore people the details of how to treat mirror hand and ulnar dimelia with limited elbow motion. But I think some of the principles of what we did felt really good. But very briefly, just to set the stage, if you have two ulna bones, and may come together at the distal humerus, essentially what happens is the child can't flex. And so elbow surgery is designed to try to restore at least passive if not active, flexion to some degree, because we all know that a straight elbow is not functional, eating stuff, and many daily activities are tough. And so I my personal philosophy is to do this surgery younger to give the joint time to remodel after you do what you do. And we did the surgery, it was felt very good. But what I liked most was our planning, and the kind of the cognitive exercise around it. We got a CT scan, and 3d reconstructions on the CT scan, we got an MRI, which honestly was not as helpful as the CT. But I was curious about the muscle development, but it wasn't the best MRI. So I couldn't learn as much as I wanted. But what I did, which made me really, really happy was I got a 3d model printed of the, of the elbow. And again, it's a 3d model of the bone, which doesn't reflect the cartilage. But it is really, really helpful in strategizing how to approach the elbow, and what we might need to do. And it's a fascinating, fascinating limb development problem. And we spent a lot of time we got the result we want and we got about 80 to 90 degrees of flexion. And super fun. And I think it was a great exercise for myself, but also for the trainees and Dr. Wall partner with me on this surgery.
Chris Dy:Super, as has been pointed out before, super interesting. It's something we like to say here and around these parts. When you do that, what do you do with the model? At the end, at the end of the case? You don't just chuck it you?
Charles Goldfarb:Definitely not. There's a couple of funny things. One, I haven't worked with this particular 3d printing lab. And I said, Hey, is there any way you can make a model? It's kind of last minute and he says, No problem. I'll get it done. I'll print it over the weekend. I'll be ready for you on Monday. And.
Chris Dy:Then he's like, What the hell is this up there two ulnas?
Charles Goldfarb:No, but he's we had a little phone zoom. And we talked about things, but what was interesting was he printed it, you know, one to one to the CT scan, which was essentially life size, which was like this big. Because it was, you know, it was a young kid. And so I talked to him later on. I said, Can we just scale that next time to do it two to one he's like, of course we can't you just got to ask. Like.
Chris Dy:Maybe he just assume since you're a peds ortho surgeon is used to operating on small stuff.
Charles Goldfarb:It's true, it still was helpful. But it's sitting on my desk, I love it on my desk, it's gonna stay there forever.
Chris Dy:So is there ever any reason to get another CT scan on this child? And then could you get another model printed to show the work that you did?
Charles Goldfarb:What would be really interesting and there's really almost nothing in the literature. One of my friends from Japan actually has a pretty reasonable article which describes sort of what we did, but there's so little because it's an uncommon problem and bah bah bah, but I do think it will be interesting because the old bones are rotated. So they're not sitting directly posterior, they're both rotated around a little bit. So they're kind of sitting at 45 degrees to one another. And so that may limit in the future motion. I would love to know what the elbow joint looks like, at eight years of age or skeletal maturity, it will be fascinating, for sure.
Chris Dy:I'm wondering if there's a way to do it when, obviously, radiation conservative manner. But yeah, that'd be super interesting that there I said it again, it's very interesting.
Charles Goldfarb:Who was given us grief about that, I don't remember who it was. But it was funny.
Chris Dy:That is pretty funny. So, you know, I have one more case to share. And I don't know if you have any other ones. But, you know, we talked about it before on the podcast, and I can't remember, probably set it in other venues. But I think we vastly underestimate the amount of trauma that gunshots due to nerves. And, unfortunately, being in St. Louis, we see a fair bit of firearm violence. And we wrote about that recently and JBJS, and suddenly spiked since the pandemic. And two cases, both recently one with you know, a bullet that went through the deep perineal nerve and just skirted right by the superficial perineal nerve, like almost impossible shot. But you know, had a very anatomically matched, you know, palsy had intact e-version, kind of this aesthetic in the ESPN distribution, but you know, pretty normal, and that completely density perineal palsy. And, of course, there was a fibula fracture to same location, you can see where the bullet was, I mean, it was remarkable. And again, ultrasound saved the day, told us that there was a partial transaction of that nerve from the bullet allowed us to act sooner, and I think gives us a much better chance to make things better. And then the another related case was-
Charles Goldfarb:So how soon do you prefer to act? You saw the patient, you got the ultrasound? Is this something you want to do in the first two weeks? Or what's your goal?
Chris Dy:I think that we don't really know. And I hope that some enterprising and bright young hand surgeon or therapist will try to understand this, but we don't know how long it takes for that zone of injury to truly declare itself. And in what situation I think many of us have accepted three weeks, roughly as the amount of time it takes. So this patient, you know, we've seen in the clinic, about three weeks out from the injury, had an ultrasound done in the next week, and it was in the or before by the five week mark. And, you know, knowing that we're going to have to graft now as a very reasonable graph length and is with you know, within a very reasonable timeframe to see recovery.
Charles Goldfarb:That's awesome.
Chris Dy:And again, another gunshot wound, but a gunshot wound to the proximal form. And kudos to one of our trauma colleagues who when they were plating the approximate radius from a dorsal approach was kind enough to find the PIN and tell me that it was completely transected completely transected so helpful, because I'm not going to sit and wait and watch this one, you know, you know, didn't even need to get any imaging or anything like that got them back to the or within a few weeks. And completely through the pie. Right where you know, it was intact, kind of halfway through the supinator and towards like the distal two thirds of the supinator just blown apart. And then it for those of you that are familiar with the branching pattern of the PIN after you know, maybe about two or three centimeters after an emerges from the distal end supinator it splits into that superficial branch which tends to go towards the the fourth, fifth and sixth compartment and then a deep branch which tends to go to the thumb. So the first and third compartment and it mean the anatomy was just beautiful, but seeing how it was just transected just proximal to that bifurcation gave us a fighting chance with the graph. I also added a distal nerve transfer because there was a kind of a freebie branch to the EDC. So I took the AIN from the pronator quadratus flipped it backwards through the interosseous membrane as described by Bertelli but instead of putting it into the thumb extensors put it into the EDC because I figured there might as well give it a shot.
Charles Goldfarb:Wow, well done. I have seen two gunshot wounds right at that bifurcation at the distal end of the supinator. And that is tough. When you have small branches and a segment is destroyed that is really tough. So I do think your your patient was somewhat lucky and I think adding the nerve transfers a no brainer.
Chris Dy:Yeah, it was it was and I think it was a good example of we talked about earlier that radial tunnel surgery. It's a good example of being facile with all the approaches because in order to find healthy nerve I had to go back into your Hear and kind of do the approach at the arcade level, find a healthy nerve. And honestly, the nerve, the supinator just look like mush, even though theoretically it's innovation had already come in, just didn't look great because of all the direct trauma to it, but then found the nerve there that allowed me to work back on the dorsal side and put the grafted. And again, because we got there within a reasonable amount of time, reasonable grasp length and a decent chance of recovery across across the graph.
Charles Goldfarb:Yeah, love it. Love it. Awesome. All right, this has been fun.
Chris Dy:But yeah, a little a little grab bag episode. You know if anybody has any questions, they want to email us, you know, the the thing handpodcast@gmail.com or leave it in a review. Chuck likes positive affirmation and feedback. So please, provide that for him and me. But mainly Chuck.
Charles Goldfarb:For sure. Please do that. I'll leave you with I am grateful for spring. That's it.
Chris Dy:Yeah, I haven't lived in St. Louis that long. But you know, these up and down spring things where it's like 70 degrees one weekend, and like, 30 the next weekend with snow. I don't like it so much. I do like spring weather though. So my next thing I'm grateful for is also spring.
Charles Goldfarb:I totally agree. All right, man. It's been fun. Thank you very much.
Chris Dy:All right. See you next week.
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