The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Talk Nerve Injury During Carpal Tunnel Surgery

May 08, 2022 Chuck and Chris Season 3 Episode 17
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Talk Nerve Injury During Carpal Tunnel Surgery
Show Notes Transcript

Season 3, Episode 17.  Chuck and Chris discuss academia and education.  We also take a deep dive on a listener submitted case on nerve injury during carpal tunnel release.  We share insights on workup and surgical technique.

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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:

I'm good. It's always good to be back with you on the pod.

Chris Dy:

I know. It's so fun. It's so fun. Nothing, nothing like starting early on a Saturday morning.

Charles Goldfarb:

Absolutely. Just so easy to find the time to do this.

Chris Dy:

Exactly, exactly. Well, you know, I just finished rounding and you know, the joy of doing that. That was fun. And, you know, I'm excited to talk about a couple of cases I have.

Charles Goldfarb:

I'm looking forward to these, you've given me a little bit of a teaser. And you know, what's better than talking about nerve. I did hear, I should say to you, unfortunately, I missed your resident interactive on Thursday morning, unfortunately, I'm always double booked and so rarely get to those. But I heard that it was outstanding, not not surprising. And when I said, Well, what was the topic, I said that only tongue in cheek, because I knew what the topic was.

Chris Dy:

You know, when you so for those of you that are not familiar with how we do our curriculum, here, we have core lectures which are didactic. So you know, the faculty will give a talk about carpal tunnel syndrome, or nerve injury or something along those lines. And then that's complemented by, I think, maybe 50/50, maybe not exactly 50/50. But interactive sessions where the faculty will just present cases. And it is a Socratic, I guess, is a nice way to say it.

Charles Goldfarb:

Friendly.

Chris Dy:

It's interactive. I mean, so you can, you know, I think some of us have a little more fun with that than others. But I love giving interactives because it makes me obviously one of the, anybody that's trained with me knows that I take a lot of pictures. And this is the reason is that the pictures and you know, the X rays make a huge difference in how these cases are presented. So I'm glad you heard it went well, because actually, that's one of the cases we're going to talk about today.

Charles Goldfarb:

I love it. Before we do that, let me share my experience from yesterday, which was different. As you know, I'm an academic guy. I've been in academics my whole life, usually fortunate to have at least one trainee, and honestly, I don't, as we've discussed, I don't like more than one trainee, I just like to be a bit. But sometimes we have more than one trainee and I, it's a great, it's a great model. And we're a little short, so to speak, right now with trainees for a variety of reasons. And so I operated solo with what I thought were a couple of pretty straightforward cases at Children's Hospital, and then I had another one where one of the more senior residents came over and join me who I've not been currently working with. But the children's cases were interesting, because they weren't straightforward. And it was me and an ENT nurse who was scrubs/assisting using a drill. And, you know, those are challenges that in academics we don't usually face. And it was it was interesting end result, great for both cases, frustration level moderate. But it just reminds me of how fortunate I am in many respects and how much I like what I do. I know private practice would be great. And certainly there's resourcing your private practice, which can be really good, but it was just a it was a it was an eye opening experience.

Chris Dy:

Right, right. When you're used to having either you yourself being able to do the retraction and having somebody else do the more technical or mechanical parts of the case. Or, you know, having somebody retract for you while you do the more technically challenging parts. It's definitely different. I mean, I think that when, when I started as faculty, I wondered why there were certain times in the week where nobody had clinical commitments typically. So like Friday afternoon, our fellows have their clinic and our you know, that they primarily staff and we go there now, but in the residence go to but I wondered why nobody would have clinic on Friday after you would have surgeries on a Friday afternoon and I realized why. But you know, I do so I do my clinic on Friday afternoons alone. And I keep telling myself I need to change a template so that there aren't as many new patients because I'm sitting there seeing all these tons of new patients on my own on Friday afternoons and obviously I'm with a therapist, and that's fantastic but no trainee which means all dictations go to me and all the kind of first wave of seeing the patients and all that kind of stuff and it's great patients love Friday afternoon appointments, which is why I keep doing it. But now I realize why nobody else sees patients Friday afternoon.

Charles Goldfarb:

Two things, Chris. Two things. First, for the for the students and residents and fellows listening, that is a pearl. Friday afternoon clinics are gold, and I did one for 10 years. There are obviously some negatives to it, but patients love it and you will get busy on Friday afternoon now Monday and Tuesday have their benefits as well from weekend falls, etc. That's gold briefly because I know people don't want to just hear about about nerve. But let me tell you briefly what the cases were because they were kind of both cool. So the first one was a, you know, adolescent who was in an altercation missed his punch, it hit the wall. And essentially to make a long story short had a non dislocated but significantly subluxated thumb MCP joint with a Radial collateral ligament avulsion from proximally. So it was impressive not treated at an outside hospital. Got to me and brought to the OR, and you know, very satisfying result. I did pin the joint, which I don't usually do with the collateral ligament, but this was a very different type of collateral ligament.

Chris Dy:

That is weird. I'm just trying to think mechanically how that happens in terms of when you miss a punch, but I mean.

Charles Goldfarb:

I guess he must have struck the radial part of his thumb against the wall.

Chris Dy:

Yeah. Wow. That's a crazy injury.

Charles Goldfarb:

Yeah.

Chris Dy:

Let me guess suture tape augmentation as well?

Charles Goldfarb:

No, actually not I pinned the joint. As I said, I'll leave that in for five weeks. And I got a great suture anchor repair of a robust ligament for the metacarpal head. And again, for those of you who don't do a lot of these, you know, on the ulnar side, it's literally almost always from distal base of P1. From the radial side, Lou Catalano, demonstrated it's about a third, a third, a third and this was one of the proximal avulsion. So great repair, I think that you know, he'll do great. The second case was even harder for those who do any peds. You know what the sub condylar P1 fracture is, it's really the distal proximal phalanx fracture right below the joint surface. And what typically happens is they tilt a little dorsally. And, you know, some of them have a chance to remodel, some don't. But the reduction is no big deal. You get it back in place, but a couple of pins and patients do great. This one was off about 120 degrees. So it had it was unbelievable how displaced it was. And it had been out in that position for 10 days. And it was really challenging to get back in place. And part of the challenge is the risk of a avascular necrosis of that fragment and so detaching soft tissues is a no no. Which was really tempting to do to try to ease the reduction. You know, and the ENT nurse did a great job. And we got through it. And all that matters is it looks good now.

Chris Dy:

That's those are tough. I, my stomach turns every time I see those cases. And I really hope that you're in town or Dr. Lindley Wall's in town when those cases come up, like, you know, I think this might be better off with one of our peds specialists. How real is that risk of a vascular necrosis? The fragment having not I know, I know, it's a concern, having not seen it go south. How often does that happen if somebody comes in from outside?

Charles Goldfarb:

You know, what's interesting is more and more. And this goes for supracondylar humerus fractures and little fractures like this. These are not taken care of by people who don't know what they're doing, which is, again, I'm biased, but that's the right thing and resourcing and travel and all those things matter. I think it's one of those situations, where is the magnitude of the complication, so to speak, rather than its frequency that scares the heck out of me. I've seen it once in my career. And, you know, it's just there's no fix for it. There's no fix for it. It's devastating in a young patient to have that fragment died. So I have not seen it. I guess I've maybe seen it more than once. But I think once was on a patient I'd operate on maybe 15 years ago, and I don't know what I did wrong, if anything. But tough outcome.

Chris Dy:

Once is enough.

Charles Goldfarb:

Once is enough. Alright, I know you're itching to talk nerve. Hit me.

Chris Dy:

Hey, you know, it's interesting. I've been in this run of I think I have four presentations to give in 10 days. And I don't know how that happened. But I had I gave I had to make a new talk for for our sports colleagues. So it was nerve injuries and athletes which I really didn't want to have to make a completely new talk but I also don't like phoning it in on presentations. So I put the time into make In that talk and then I gave the presentation that we talked about before for the California and therapy group, which was really fun to do, presented alongside my therapy colleague, Jamie Findeiss. So that was another talk to put together, those are literally back to back days back to back mornings. And then I had this resident interactive to put together for this week, and then I'm co presenting our core lecture on brachial plexus with Linley Wall on Tuesday. So it's just a lot of presentations. But this case was really fun because it happened to come in pretty timely. Maybe we could talk a little bit about when patients don't do well after carpal tunnel release. So.

Charles Goldfarb:

Super fun topic.

Chris Dy:

Right, right. Right. Well, because everybody does love the carpet tunnel right? Slam Dunk, it's a layup. Yeah. So, I mean, because this surgery should go well, 100% of the time, which is a very high bar for a carpal tunnel release. So this patient came in in his 50s found his-

Charles Goldfarb:

Sorry, let me interrupt you. I think I guess in the back of my mind, I agree this surgery should go well, 100% of the time, depending on checking a lot of boxes and reasonable expectations. I would never say that to a patient.

Chris Dy:

Oh, no. Yeah, I agree. I would I never tell that to a patient. But I think in my mind, if you're going to do a carpal tunnel release, the expectation is that technically, you're going to execute it perfectly every time. Now, you may it may take a little longer to get there you everybody does it differently, etc. But yeah, I agree with you on that. So patients in his 50s came to me, about a year out from his original surgery. He had a carpal tunnel release done elsewhere. And he said, it took a while but about you know, two or three weeks later, he started having just this worsening kind of shooting pain. And he said it was like an icepick in, you know, to his middle and his ring finger. So how do you start to think about that patient?

Charles Goldfarb:

So I'm sorry, tell me exactly when it started.

Chris Dy:

So it started two weeks after his surgery.

Charles Goldfarb:

So initially, he was fine.

Chris Dy:

Initially, well he didn't come, he didn't mention it to anybody. Let's put it that way.

Charles Goldfarb:

Okay. And.

Chris Dy:

And this is the history that he gave us as a couple of weeks later, it just, you know, really, really hurt. And, you know, it's burning and shooting and, you know, ice pick kind of pain, middle and ring finger.

Charles Goldfarb:

Yeah. So interesting. You know, I, I do some medical legal review. And we've talked about that. And I do think it's important for us to be involved in that community. And therefore, I've had the chance to review some different reports of patients with nerve injury after carpal tunnel, in my experience has been most of them have an immediate, clear lack of a good result, when they wake up from surgery. Or at that first post operative visit, it is obvious that something's not right swelling, pain, shooting pain, numbness, it runs the gamut. This is a little different, but but it is what it is. You know, reports suggest that the most common injury and a carpal tunnel is to the common digital nerve to the ring and middle and gosh, this sounds sort of like it.

Chris Dy:

Yeah, no, I Well, that's, you know, obviously, the alarm bells start going off when you hear that, but the timeline just sounds weird, right? It's not. And then again, like, not everybody reads the textbook. So that's the thing I started to think about. And then he's got a tinel sign. And his tinel sign is so yeah, it's the He's, uh, you know, kind of a bigger hands, they had a reasonable size incision, and it was not a mini open and it was an open carpal tunnel release. So a healthy sized incision. But, you know, it didn't really get, you know, very far between, like, you know, beyond the distal aspect of that thenar, hypothenar confluence. So, incision ended here, he had a tinel sign here. So when I'm pointing for those of you that aren't on YouTube, it's about, you know, right around the DPC area, probably about two centimeters proximal to the, to the third webspace.

Charles Goldfarb:

So, I'm scratching my bald head. And so you pointed to the incision, ending in an appropriate spot relatively, you know, close to the superficial palmar arch, and yet his tinels begins, at least a centimeter if not two centimeters distal to that.

Chris Dy:

Correct, correct.

Charles Goldfarb:

Whoa. All right. So, I guess my initial thought is, well, that couldn't have been an injury from surgery is just too far away.

Chris Dy:

Right. I mean, because no matter your technique, I mean, nobody's reaching that far through that incision. And obviously the palmar arch is in between. So if you're going to injure something, you probably would have injured the Palmer arch along the way too. So then, his two point his so his thenars are perfect. No atrophy. His two point discrimination is elevated, it's greater than 15. For the for, of course, the third webspace distribution. So again, that is consistent with what you would think a third webspace nerve injury. But here's the other thing on his exam. So he's got at the proximal end of his incision, just proximal to the incision, his incision ends at the Palm at the wrist crease on the Palmer side. He's got a very hot Durkan's test or compressive provocative test there. If you tap on it, it obviously hurts it but if you push on it. It reproduces his symptoms in his ring in small or his middle and ring finger.

Charles Goldfarb:

Still confusing, but I guess that would make a little more sense that, and I would be suspicious of a nerve nerve injury at that level with a weird, distal radiation of symptoms. That would be my takeaway. And I can keep going. But I'll stop there and see see where you want to take me on this journey.

Chris Dy:

Yeah, so I mean, I think that the way that I think about this, there's a nice review article that was written by some of our plastics colleagues here, Tommy Tung and Susan MacKinnon, I think was in the early 2000s. And the way that they think about symptoms after carpal tunnel releases that don't go well. And are the symptoms persistent? Are they recurrent? Are they new or worsening? And if the symptoms are persistent, then maybe you had the wrong diagnosis or was an incomplete release. So wrong diagnosis, not necessarily that they didn't have carpal tunnel, but maybe there was something you missed approximately. So either in the forearm, less likely a thoracic outlet, and then obviously, the cervical spine is the thing that I think about so. And then if it's recurrent, you worry about maybe it either the transverse carpal ligament reformed, or it wasn't a complete release again, that also falls in there. Then if, as you stutely mentioned, if the symptoms are new or worsening, then you worry about a nerve injury. So median nerve and the proximal forearm was not provocative. C spine was fine. I actually got into the habit of just getting a single AP view of the elbow to make sure there isn't a Supracondylar process and a ligament of Struthers just.

Charles Goldfarb:

Damn, you are an academician.

Chris Dy:

Hey, because when I see it, I really want a great picture.

Charles Goldfarb:

I'll share it with you.

Chris Dy:

I am searching. There's there is a, there is a I think the only time that I've actually seen it is an iPhone picture of an x ray that a fellow took in your clinic.

Charles Goldfarb:

My gift to you will be a beautiful picture of a supracondylar process, I'm gonna find one.

Chris Dy:

The thing is, the thing is it can't it's not the same one, I have to say this picture is from Chuck Goldfarb. It's gotta be mine.

Charles Goldfarb:

Yeah, fair enough. Fair enough.

Chris Dy:

So then on his exam, as you go into the mid, so you know, going from the mid forearm and distally the Tinel's doesn't really pick up until kind of right proximal to the incision. So I'm thinking what you're thinking, what testing would you get at this point, you've done an exam. You've got pretty compelling findings on your exam, would you get any additional testing? Are you going straight to the OR how do you talk to this patient?

Charles Goldfarb:

No testing, straight to the OR, sooner rather than later. I think time is not our friend here. Scarring is not our friend. The chances of an MRI or ultrasound showing something helpful is just not that good. In my opinion. I'm not against those tests. But if they show something you're going to the OR if they don't show something, you're going to the OR and I plan, I would go straight to the OR sooner rather than later.

Chris Dy:

Does it change your counseling or your surgical planning? Or your surgical booking? If you have additional information?

Charles Goldfarb:

No.

Chris Dy:

So how long, how long, what are you going to tell this patient you're going to do? And then how long are you booking the case for and where are you booking it?

Charles Goldfarb:

Well, yeah, those are all really good questions. But let me back up. Because I stood on my soapbox really tall and said, straight to the OR. It is-

Chris Dy:

Like a stack of boxes you have behind you. It looks like you're moving in Chuck.

Charles Goldfarb:

Or moving out careful. I think it's really important. If it's my patient. And I think I did everything well. I'm probably doing testing just being totally honest. Right? It is far easier to go to the operating room if it's not my patient.

Chris Dy:

Right, right.

Charles Goldfarb:

So that's number one. Number two, this is not a case I do in the midst of my normal, crazy busy surgical primary day. This is a case booked separately. Booked generously. And I guess for this one, I would probably book it for an hour and a half to two hours have an operating microscope available and you know, look forward to interesting, challenging case.

Chris Dy:

So when I presented this, the slide says you know to that as a resident conference, the slides says carpal tunnel done at OSH. And it is easier when it's done it. OSH and I remember as a as an intern, we were presenting cases in trauma conference or something. And one of the medical students was like, Where is this OSH? Everything happens at OSH.

Charles Goldfarb:

It's a bad place.

Chris Dy:

Outside hospital, outside hospital never go to the outside hospital. I agree with your the threshold for testing is different if it's your own patient, and you you know, I don't remember every carpal tunnel release. But we typically have a sense of when things aren't, you know, what you would expect the intraoperatively? Would you get a nerve test? Because I think a lot of people, if you pulled them, we'd get some nerve studies. Would they help you in this setting?

Charles Goldfarb:

I don't think they help me. And again, I think time is my enemy. So I would not, would you?

Chris Dy:

You mentioned you mentioned medical legal work. Would you do you think that a nerve study is necessary in the setting of you know, because some people get nerve studies before surgery just for this reason. If things don't go, well, they have something to fall back on. Would you get the nerve study postop? Is that helpful? And somebody's not doing well?

Charles Goldfarb:

Well, there's a couple of factors. One what's the timing of the nerve study compared to the potential injury, obviously. And I will say the medical legal questions, not wrong. I've seen a case where the initial surgeon blamed the revision surgeon for the injury, which is fascinating. But no, I think a careful clinical documentation of your exam preoperatively and supplemented with a careful documentation of interpretive findings, potentially with pictures is what I would do in this short timeframe. If it's six months out, it's a very different story. And in that point, I definitely would get nervous days but in a more acute setting where I'm really want to get to where I would not.

Chris Dy:

So I mean, he is almost a year out from his initial surgery and actually came in with nerve studies done elsewhere. Which guess what showed moderate carpal tunnel syndrome? So, you know, I don't expect the nerve sites to normalize. I didn't push, you know, trying to get new studies, it would not have changed one thing for me. MRI, I think imaging the nerve. I disagree. I think imaging the nerve is useful because we've got a tunnel sign that is distal in the webspace. But you got a provocative test somewhere else. So in this particular case, I think imaging is useful.

Charles Goldfarb:

What? Listen, I'm not here to question your your knowledge of MRI and nerve. But why? You're going to see nothing, you're gonna see scar.

Chris Dy:

So you've got a tinel out here, and you've got a test, provocative test in the palm, are you going to cut them open the entire length, or are you only going to go to one place first and then try to figure out where else to go.

Charles Goldfarb:

I'm starting with an extended carpal tunnel release. But honestly, this guy probably does deserve a longer incision and exploration of both sites.

Chris Dy:

So I wanted an ultrasound mainly to query for the third webspace branch, because he's got a tinel's there. Now I think it's almost impossible to get to the third website, the area where it's tunnel is from the distal end of his incision. But I've been I've, you never know. So to me, an ultrasound was helpful there to ensure that there wasn't any enlargement of that nerve at a focal point in the distal aspect of the palm, because we're talking it's distal to the where you would make a trigger incision. So I want to make sure I was gonna have to go there because I think the nerve was going to, My thought was that the nerve was injured at the base of the, at the base of the palm, or there was a or there wasn't a complete release. So that to me, helps inform what I do in the operating room. So we got a, oh go ahead.

Charles Goldfarb:

So ultrasound, not MRI.

Chris Dy:

Ultrasound, I think ultrasound is way better.

Charles Goldfarb:

I agree with that.

Chris Dy:

It's a better assessment, it's, you know, cost less, I think it's better for everybody. It's a dynamic assessment too.

Charles Goldfarb:

And, drumroll.

Chris Dy:

So bifid median nerve, which we can talk about that maybe on another episode about how that may change what you do. Third webspace branch totally fine, everything distal to the incision, totally fine. So that helps me because then I can focus my efforts in surgery and then counseling the patient on working in his prior incision and just proximal so agree. The other thing, the bifid median nerve, the radial side was completely fine. It was uniform in its diameter, you know, from the distal forearm into the incision, but the ulnar side had focal enlargement, which is super interesting. So the ulnar side was four centimeters in the distal forearm. And then as you go distally it's 18 so it's enlarged. So clearly, there's something going on there. You know, the it was called or 18 millimeter excuse me, not 18 centimeters, but it was it was called as a huge, one of your carpal tunnel patients.

Charles Goldfarb:

Macrodactyly.

Chris Dy:

Syndromic folks. So and they called the consistent with a neuroma. So that to me is super useful in terms of councilling super useful in terms of surgical planning.

Charles Goldfarb:

I agree. For the record. You are right.

Chris Dy:

No, no. That's okay. You can go about just booking your surgery and hoping you know, so that you're gonna finish early, you'll have found time I bet you'll be kicking yourself that you finished earlier and couldn't put on another case or whatever. But I mean, your booking is absolutely right. In terms of you know, but I can send it in for a revision, carpal tunnel release a median neurolysis and a possible nerve allograft. Would you have talked to him about an autograft?

Charles Goldfarb:

Yeah, this is the discussion I had with the trainee who loved your lecture. I don't know the answer that you you have great confidence with allograft. You use it regularly, the science seems to support it. I still hesitate. I guess just because of my biases, and I would lean towards autograft.

Chris Dy:

I want you in a cut this guy's leg open?

Charles Goldfarb:

Sure, do it.

Chris Dy:

Or do you like MABC in this setting? I mean, I don't like taking nerves that tend to be provocative in terms of CRPS type things or, you know, causalgic nerves, so to say.

Charles Goldfarb:

Yeah, I, I would not I would go the lower extremity and use sural if I thought it depends on what the deficit look like. And other factors I like, you have taught me that allograft is a very effective option. And so I would certainly strongly consider that I might lean in this case towards an autograft.

Chris Dy:

Yeah, I mean, I think that the literature supports in a gap that is under five centimeters in a sensory only nerve, which we believe it is it is the ulnar side, maybe there's some integration to the lumbricals. But usually that comes off on the radial side. To me, this is a nice case for an allograft. So while I saved money on the ultrasound, I spent money on the allograft. So when we get in there, it was enlarged, as you would expect. It was thick. And it didn't handle like a normal nerve. And it was definitely a zone of transition on that nerve, proximal compared to distal. And I didn't think it looked right. I was like, maybe this is just, you know, a nerve injury and continuity, maybe it's an excellent emetic injury. But let's just be sure, let's get the microscope out and do an internal neurolysis of that component of the ulnar side. We got the scope out. And it was like this. You know, there was definitely a clear discontinuity of the nerve, which, to me, it's like, well, all right, I guess I'm glad we got the microscope. And I'm glad we did it. I was really hoping obviously, it's easier to not have to do something like that. But then we started cutting back and you know, cutting back to healthy nerve was kind of a big thing for this. For this patient, we had to cut back more than we thought.

Charles Goldfarb:

Yeah, that to me is the hard part. Right? I mean, you have to be, you know, obviously protecting the good part of the nerve, which may have been easier if this was truly a laceration the entire ulnar bifid portion. But when it's not, you're protecting the good part of the nerve, you're cutting back on the damaged part of the nerve. And you know, it's a little easier if you already know you need a draft. But it That's tricky. And you want beautiful bulging fascicles.

Chris Dy:

So yeah, it was ended up being just under a three centimeter gap. I think it's interesting. I don't know how many of the surgeons that are listening have used the acellular nerve allograft, many of us it's made here by Axogen. The way that they what size would you have asked for just out of curiosity in terms of diameter?

Charles Goldfarb:

And you said entering the carpal tunnel is four millimeters. So it's you're not going to there's still going to be edema and enlargement, distally, even after you do your resection. So I would have had a couple available. I guess I would have had a four centimeter I mean, a four millimeter, but probably double or triple that as well. I don't know. I don't know.

Chris Dy:

Yeah. So I mean, the one that was available to me, I had asked for two to three, just before the ultra because I booked the case before the ultrasound was back. And it's interesting the diameters can vary greatly, because it is a two to three. So you could be getting like a 1.9 or you could be getting a 3.5 or you know, a 3.9 It ended up being that we just I got I booked for a longer graft just because Dr. McKinnon taught me that, you know, the incremental cost of the graft is not that big. If so if you end up needing a seven, I usually just have sevens in the freezer in terms of length, and so we ended up using a two to three but then cutting it in half and using you know, double segments, which technically is a bit of a pain in the butt. I wish I just booked for a larger one, but that's what was available. So we ended up using using that and doing the repair. To me, I tried to do this with the wrist and the fingers and slight bit of a wrist and a slight bit of extension just to make sure that you have some redundancy. And I put the fingers out and then obviously check it after after doing it.

Charles Goldfarb:

Excellent. That's awesome. So talk a little bit briefly about your postoperative protocol and what you tell the patient.

Chris Dy:

So I mean, I told him what we found, obviously, the ultrasound helped because in the pre op area, we I told him, I think that this is what's going on. So everybody in patient's family was there. So everybody's kind of aware of what the possibility was. And, you know, we're gonna have to follow, follow this over time, I do protect the wrist in terms of extension for the first three weeks. So this was a dorsal blocking splint. So dorsal based on the dorsal forearm and wrist, so that they can't extend and fingers are free, though. Because I think that's super useful in terms of, you know, avoiding stiffness, etc. And I'll protect it for three weeks. And then from there, do some gentle active extension, no aggressive passive extension for an additional three weeks.

Charles Goldfarb:

And you tell him to expect normal two point discrimination? And

Chris Dy:

Oh, hell no. Are you kidding me? Well, I mean, you know, I think that it's one of those things where you're hoping to just get rid of the pain. You know, fortunately for him of any portion of the median nerve to injure This is the one because people use their webspace as a donor for a nerve transfer. And then I should mention that during the surgery, the radial side looked good. We took up the checkpoint, I was super sure that the recurrent motor branch was on the radial side, nothing funny going on in terms of anatomy. And I honestly just wanted to have another video of using the stimulator recurrent motor branch, and you will, you will rest easy that we did isolate the palmar cutaneous branch with the median nerve, and it was okay. I know you're losing sleep over that one.

Charles Goldfarb:

Be a deep exhale. Thank you. Thank you for sharing that critical version. Well, you know, I do like talk and learning and talking about nerve. Must have been a great session. Thanks for Thanks for sharing the case.

Chris Dy:

Well, yeah, I mean, it worked out that you weren't there. Because then you would have known all the answers. So that worked out pretty well. But have a good day.

Charles Goldfarb:

All right. Great to see you. You too. Glad you got to round early for the team.

Chris Dy:

Oh, yeah.

Charles Goldfarb:

All right. 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