The Upper Hand: Chuck & Chris Talk Hand Surgery

Scaphoid Proximal Pole Nonunion

July 17, 2022 Chuck and Chris Season 3 Episode 27
The Upper Hand: Chuck & Chris Talk Hand Surgery
Scaphoid Proximal Pole Nonunion
Show Notes Transcript

Season 3, Episode 27.  Chuck and Chris catch up, review some listener questions, and discuss their approaches to the scaphoid proximal pole nonunion, based on experience with literature guidance.

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Charles Goldfarb:

Welcome to the upper hand podcast 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 things hand surgery related from technical to personal.

Charles Goldfarb:

Please subscribe, wherever you get your podcasts.

Chris Dy:

And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm good. You would think I would learn.

Chris Dy:

Learn from what.

Charles Goldfarb:

I this is not our first podcast together. I don't know how many we've done together because it's a lot. And I just had a quick bite of an ice cream sandwich. And now I'm having trouble talking.

Chris Dy:

Chuck, you have to take care of yourself. I mean, you're the talent here. You're you're the one carrying this dynamic duo. You know, to stardom.

Charles Goldfarb:

Oh, that's true. That's true. I do a lot of vocal cord workouts. I hope you're doing the same just to really maximize what we got going on.

Chris Dy:

Yeah, I think that's what people are tuning in for the the timbre of your voice, Chuck, they just want you to not choke on yourself as you're recording the podcast.

Charles Goldfarb:

I my voice I've been told is good for one thing falling asleep, too. So I think that's that's a skill set. I have putting people to sleep.

Chris Dy:

Yeah, you know, the skill set I had recently is when I traveled up to Rochester to visit our friends at Mayo, they allowed me to pick the articles for the peripheral nerves journal club. So I picked articles based on the locations that I traveled, and I won't say where the article was from. But one of the articles had the dubious distinction of putting Dr. Spinner to sleep. That was he questioned the veracity of the article and said it was good because it was lasting I read before I went to bed.

Charles Goldfarb:

Hey, it happens. You know what it happens.

Chris Dy:

You can't win them all.

Charles Goldfarb:

No, for sure not. So catch me up. You've been traveling, you recently went to Rochester, you're clinically busy. Are you hanging in there?

Chris Dy:

Yeah, we talked last week about like, you know, the adding on the clinic. And you know, the more I think about it, the more I'm regretting doing it. I did the same thing for next week. So we're going out of town on Friday, and I put a little half day guy on Wednesday, because I was like, You know what might as well. And now I'm like, I really couldn't use that time. So even you know, I think I mentioned last week, the hand therapist, I work with Jamie Findeiss she was like, Yeah, remember when he just used to like, take a day off and not try to make up for it? It's like, long time ago.

Charles Goldfarb:

Well, if this makes you feel any better, I still haven't learned it. It's this constant. You know, I feel I don't know why. But I mean, I enjoy clinical care. But I'm always adding clinics, like like you just did. And I still regret it after it's done. And then the next time Guess what? I do it again.

Chris Dy:

Yeah, you know, I think the listeners are seeing our pathology and I wonder where I learned this pathology I trained with that may model this behavior.

Charles Goldfarb:

I wonder if our listeners have the same pathology or if they are, you know, they just do a better job than we did.

Chris Dy:

I think our overseas listeners are saying Why can't you Americans just take your holiday and enjoy it? We probably should I really need to for sure. I've definitely craved a self care day for sure.

Charles Goldfarb:

Yeah, I could see you in the spa with your feet up getting a massage on your self care day.

Chris Dy:

Not above it, man. But I wish I had, I'm not above admitting that I've as I've aged Chuck, as you remind me I am totally okay with owning myself and who I am. So it's out there on the pod. I wouldn't mind that for sure.

Charles Goldfarb:

Absolutely. So if anyone's looking to get Chris a gift.

Chris Dy:

Oh, man. So we've gotten some really cool emails. We're gonna go into a few of them again today just like we did last week, but I did want to share a nice email. So this is from Brad Hyatt. He's an orthopedic hand surgeon practicing about five years now little pup compared to me and Chuck I guess. And he said that it was with special interests that he listened to our latest episode, the day before he had actually undergone a carpal tunnel release himself wide awake by one of his trusted colleagues and everything went smoothly. But of course, he was probably thinking of our episode and he mentioned here, he wanted us to share our thoughts on the cause of nerve injury. So you he said one of his the least favorite parts of an open mini open carpal tunnel is the controlled glide to release the proximal aspect of the TCL distal volar antebrachial fascia. And all the technique articles describe this as being under direct visualization. Now there are times where this slide is not directly visualized, and I have occasionally extended the incision proximately but less disliked the prolonged healing and wider scar when crossing the wrist crease. So why I've been tempted to perform a scissor glide without 100% visualization. This can seem so routine and seems A few of the consequences of an error can be catastrophic. I can't help but wonder if this is what happened in the case he presented. I'm interested to hear your thoughts and any tips or tricks for the proximal release. Chuck, what do you think about the slide? I remember what you told me when I was your fellow, and I'm going to allow you to answer first and I'll recant the, recall, excuse me, what you told me.

Charles Goldfarb:

Recall so I can recant?

Chris Dy:

Exactly.

Charles Goldfarb:

Well, first of all, thank you, Brad. And it's not a good time to listen to that episode, I guess. Right before one has his own carpal tunnel released.

Chris Dy:

Right after.

Charles Goldfarb:

Oh, right after okay.

Chris Dy:

Yeah.

Charles Goldfarb:

Well, a couple of thoughts. distally, I don't think anyone tries to slide or glide with scissors didn't work. It's about careful visualization. And I've always been told that the most common injury is to the sensory branch to the third webspace. I have not seen that in the meaning of complications, I have seen it. But it's not the most common that I've encountered as a surgeon caring for the complications of others. My more common scenario is a direct injury to the nerve itself. And some certainly are related to sliding, I'll say this. I think we should always try to visualize what we're doing. But I have on occasion, slid my scissors approximately without full visualization. I'll say this, though, I do it very carefully, with aware of where the median nerve is. And the Palmar cutaneous branch is also aware of where the ulnar bundle is. And I carefully drop my hand as far as it goes to the tips of my scissors are really heading volarly, rather than any other direction. So A, am I wrong to do it that way on occasion, Chris, and B, do you?

Chris Dy:

So I remember what you told me, because I had seen others do the slide in training at other places. And it always made me nervous. I remember you told me that it was okay, depending on who was doing it. Which I always found very interesting. And then the other thing that I remember you commenting on was the way in which the orientation of your curve tenotomies. So depending on how you put them, you can either have them curved towards the ulnar vascular bundle or towards the Palmar cutaneous branch of the median nerve. Now, neither of those I want to endanger but if I had to pick one, it's definitely going to be the Palmar cutaneous branch. So even when I don't slide personally, but when I'm doing that part of the procedure a that's the part that I do, not the trainee. You know, of course, I'm there with them the entire time. But in terms of how we orient position on the table, I'm sitting in the direction where my right hand can use the tenotomies going proximately. And they are typically on the other side of the table because usually they're right handed. And I turn my tips towards the Palmar cutaneous because you have to pick one. And I like exactly what you said about making sure that you're going more volar anterior than anything else. This is clearly one in which our colleagues that use endoscopy could say well, you could just use the endoscope, and yeah, I get it. I mean, like, you know, that's that's part of the perks. Right. But, you know, if you look at the literature, one of the biggest series on locations of incomplete release, and it actually typically is noted as distal, although in practice, I've noted it to be proximal, I have not noticed it to be distal. So at least that's what's out there in terms of literature.

Charles Goldfarb:

Yeah, interesting. I agree with everything you said, I set the same direction, I think the risk is greater approximately. And that's why I want to do that proximal cut slash slide. I've said this before and I'll say it again, my technical Pearl here is from Tom Kiefhaber in Cincinnati, which is to use one Ragnell and two Senns to really create a box proximally. It gives you visualization so that the vast majority of times you can see now you can use a a larger retractor as well but that usually works and I do not cross the wrist crease. I mean today I did a distal radius fracture with a carpal tunnel release because the patient had tingling and I made a quote larger incision and it was two and a half centimeters. I just don't feel the need to make an even larger incision unless something's really really you know out of out of sorts so I think we see eye to eye on this one.

Chris Dy:

Yeah, I agree with that. And you know, I've having you guys train me in terms of the technique and the Kiefhaber box I've actually modified how I use the Kiefhaber box and I actually have started to use some baby army Navy's after I've gotten my Senns in for some of those patients, in which, when you make the skin incision, some of that ulnar neurovascular protective fat starts to make its way into your incision. And I found it very nice to just use a little baby Army Navy to get that out of the way. So that's the only modification I made from what you taught me.

Charles Goldfarb:

I think that modification is okay. I wouldn't go too crazy and do any more modifications, that would be sacrilege. All right.

Chris Dy:

So it's just a couple more things. And then we can dive into an interesting case. So here is a an email from Alexander Croog. And Alexander Croog is in practice at OrthoVirginia, and he wrote some really, really nice things about the podcast. He said he's been binge listening since only hearing about it a few weeks ago, and this was, you know, in May. And he just he saved his sanity by putting it on while folding laundry as a Mother's Day gesture. Alexander, I hope you didn't injure yourself. And he also felt very guilty about not going to the Mary Stern fellowship, Jackson Hole meeting because he had just listened to the podcasts where Chuck mentioned it many times. So he says from grandpa, Chuck his words, I've learned tons of great technical and management pearls and obviously relates due to similar fellowship training, and from young, inquisitive, Chris, I relate to the feelings not too distant, you're five years out, and the patient surgical victory seems so much sweeter, and the complications much more personally devastating. Amen to that. Thank you. And you're both great examples, ambassadors for our profession on this platform. Thank you. That is what keeps us going. So he mentioned that episode, he just finished about the tip fracture dislocations. And he passed on with his lessons from the dynamic X fix that changed his things from his practice dramatically. He used to never give local when he took off the X fix in the office, then one patient pleaded and I did after I took it off, left the room and came back. And because she was known, she was also able to demonstrate full active motion right in front of me. So now I do a digital block and four weeks from removing the pins every time just for seeing the motion immediately where I went off, but also found it will break up the occasional flexor tendon adhesion that you can hear here, Flash field, and that infrequent patient that can't fully bend after removing the poor prognostic side, wishing continued success to you both - Alex Croog.

Charles Goldfarb:

So Alex, thanks, and we missed you. In Jackson. And hopefully there'll be another reunion even though the good Dr. Stern will be retired, I'm guessing he will still host in the future. Chris could be invited as a special guest, given his long standing podcast for the hand society. Who knows?

Chris Dy:

I'm just I'm just hoping that it's kind of like a Michael Jordan kind of situation, you know, 23, 45 but maybe no wizards phase of that, you know?

Charles Goldfarb:

Maybe maybe maybe. So I it's kind of humorous. So we had a discussion, I think it was it may have been at or Lindley and I's indications or maybe it was at the main Monday morning conference.

Chris Dy:

So you're so popular that you can't even keep track of where you say things.

Charles Goldfarb:

So many conferences. Now, I don't know, I can't say that I said it, it was said, it was said by some of our partners who enjoy putting on the finger X fix for PIP fracture dislocations that sometimes they feel you might as well just hand the joint because they never have motion when the fixture comes off. And that is a little different than what Alex has related. And the truth may lie somewhere in between. I have never, ever numbed the finger to take off the fixture. But that is a really solid pearl.

Chris Dy:

Yeah, and I'm totally going to do that next time I have to do that.

Charles Goldfarb:

Yeah, I mean, some active motion, some passive motion, try to get some pull through to break up the adhesions or else just be able to manipulate a bit.

Chris Dy:

Well, I mean, I think that I remember Marty telling a story about how, you know, he would have to deal with some patients who had finger stiffness in his fellowship, and he would have to go do digital blocks every time the patient came in. To help out with that. So I mean, there's something there for sure.

Charles Goldfarb:

Yeah. Love it. We welcome all pearls, email us, tweet at us. Instagram at us. I don't know if that's the word.

Chris Dy:

But let us know. Yeah, these pearls are great. And I think that it's a great way to share your knowledge with the with the listeners. I mean, listen, our stats have been great. We've gotten you know, about 2000 downloads a week. And When many years, one sees many things and so yes, I have seen we're very, very excited about that. And that actually leads us to the crux of our episode today a great case that was sent in all the way from Greece. And, you know, Ioannis Lachanas sorry for mispronouncing that, but he did mention that, thanking us for the time and effort to deliver what is probably the best medical podcast on the internet. Now, if you had not put that qualifier and probably would have been really really happy but I love it anyway. Well now become exactly we will absolutely take it. It has now become almost compulsory for my residents to listen to you guys on their Monday commute. So I'm going to change some leave out some details here just you know in terms of privacy and whatnot, but um, you know, so we have a patient who is not exactly young, not exactly old and is a nonsmoker and was in an accident, a car accident, you know, little under a year ago, and she had radial side wrist pain and X rays were negative, she was going to the splint, lot of back and forth, and then negative X rays and a CT scan six months after injury, didn't show any bony issues and then eventually had an MRI that showed a proximal, proximal pole nonunion with a very small fragments and an avascular proximal pole, and has lots of pain. So what do you think about this case? Chuck, hear that you're the carpus maven. So how do you start to think about this case is something that has come your way along your many, many, many years? my fair share of proximal pole nonunions. So with or without vascularity. It's a really interesting topic, because I think there are some institutions and some physicians who absolutely feel it can only be treated one way. And there are other institutions that have a, you know, I was gonna say diabolically, but I guess I should say diametrically opposed point of view. So to be very clear- Or diabolically I mean, you know, you never know.

Charles Goldfarb:

Some feel you have to use a vascularized bone graft, some feel you absolutely do not. For those that do. There's choices to be made. The one to super retinacular vessel versus the more popular recent medial femoral condyle. Free, not flap, right, free flap, right? I forget the terminology. Vascularized bone graft.

Chris Dy:

It's a flap, it's a flap because we don't do it.

Charles Goldfarb:

Exactly right. So So Chris, I I'll say this strongly, I much prefer going dorsally for scaphoids, I think it's less disruptive to normal anatomy, I think is a simpler approach. I think I can put a much better screw in. For every reason I like this approach better. So further than the approach standpoint, I'd prefer a proximal pole.

Chris Dy:

Yeah, I mean, I guess I also like going dorsal, I try to go dorsal every time that I can. And I, I actually have to convince myself to consider going volar just to make a have a balanced opinion on things, because there are some cases where I was like, that's a little too much deformity. So I mean, we're not talking specifically about proximal poles anymore. But you know, a waist fracture, what's your threshold on scaphoid flexion. Before your, you'll say I find I'll go volar.

Charles Goldfarb:

Should we let's. Should we back up a step?

Chris Dy:

Yeah.

Charles Goldfarb:

We have all different ilks all different training pathways and all different you know, we have therapists and students. So to be very clear, the basic principle, which we're alluding to, is your screw ideally, should be placed so that it is entering from the smaller fragment, and we'll have a good purchase in the larger fragment. Now, sometimes the fragments are relatively equal size. But the reason one goes dorsal with a proximal pole, is to assure that you have control of that proximal pole, and the screw is going where you need it to go. Likewise, a very distal fracture, you would flip that around and go from volar. So Chris's point is a good one. So you know, most of us for nonunions that choose to that we were feel were required to go volar is to correct a deformity the humpback deformity. And you can do some correcting from dorsal, but to really correct and hold that improved scaphoid alignment most people feel you have to do something from volar I don't know what the I don't know what the right answer is Chris, for the for the waist fractures and how much humpback is okay before you feel like you have to go volar but I'm with you. I will. I will maybe skirt the issue as long as my Lunate isn't tilted too far. dorsally I might try to treat to treat a a waist fracture with mild deformity I might try to treat from dorsal.

Chris Dy:

Yeah, and I mean, a fracture is not the same as a non union. Right. So a fracture that's acute, you still got a chance to you know, so I think the concern is that if you go dorsal and you're working, you know, if you're dissecting over the waist, you're going to disrupt that very delicate blood supply Um, you know, I think there are ways in which you can work beyond distal to the blood supply and leave the blood supply intact and manipulate your distal fragment to try to get to pull it up. So you can get that distal pole out of flexion. And I've done that with success. And I've been very happy with x and it spares the volar approach, it's much easier shoot the screw down. In terms of principles, before we get back to the case that we brought up. Are you a big, you know, screw biggest screw down the central axis? Or how much are you like, we got to get it perpendicular to the fracture?

Charles Goldfarb:

Central axis almost always, unless you really have an oblique fracture line that challenges that approach, I think central central meaning screw meaning the K wire and then the screw is center on a PA and center on a lateral. And I like how you corrected me, an acute fracture may be more amenable for going dorsally with some correction of any type of impending angulation. Whereas a non union, you're less likely to be able to correct that from dorsal and more likely to be required to go bowl or I think that's well said. I hope I said it right. Just like you said it.

Chris Dy:

Yeah, no, I think that it'd be very hard to try to get any correction with something that's been, you know, a non union that flexed down or a malnion or whatever. But these are hard. And so I guess they're the way I think about the case that that Ioannis sent in, you know, there's the proximal pole fragment, then there's this kind of weird occult case that he's describing. So do you have you seen a case that's been CT negative MRI positive? And do you think that's more of a ligament issue than a proximal pole issue?

Charles Goldfarb:

Well, I'll tell you, the first thing that comes to mind is the, I guess, mixed approaches in the literature for the identification of an acute fracture, and so not to get totally on a tangent. But if a patient comes down with regular side of wrist pain with negative X rays upon presentation and negative X rays at two weeks, then most of us would agree that advanced imaging would make sense unless the patient just wants to consent for a cast. And so do we obtain a CT scan? Or do we obtain an MRI? And the bottom line is there's not a right or wrong answer both can be sensitive, meaning pick up the fracture. Both can be specific meaning if they call it a fracture is really a fracture, but both can miss. And so, you know, I honestly, I get CT scans because they're cheaper and faster and easier to obtain. I think that's probably the same thing here. I'm surprised that a non union would be missed on CT scan for me. If if it's missed, if it's not seen in a CT scan, it doesn't exist, but I applaud the fact that they went ahead because of continued pain and got the MRI, I believe it's real, I believe it's a it's a proximal pole non union, especially if the ligament looks good on MRI, but I agree with you, if I opened this dorsally to look at it, I would absolutely make sure the ligament looks okay.

Chris Dy:

Yes, so it's interesting. I we disagree. Remember early on we were told that we don't we don't disagree enough. Yes. So I disagree with you actually get the MRI at that, you know, when it's not, you know, X rays or negative continued pain and they don't just want to do a cast, mainly because I like to be able to get that bony edema pattern that so called bone bruise and and be able to tell patients Hey, there's a bone bruise here. It's not a fracture. I like having that for counseling. Admittedly, you could say you can manage both the same way but I think for a patient who is X ray negative, still having pain but as MRI negative, that comes back that's good enough for me to say look, we can go about this two ways. We can either immobilize, continue to immobilize you or we can let you kind of work through this pain with the brace and take it off whenever you want. And know that it's likely going to be okay. And I know what you're saying. You know, the sensitivity is not being perfect for either study. And I guess I'm wasting healthcare dollars in the US by getting all these MRIs doesn't come up that often. But I also remember the utility of the offering or tasks, there are some patients that just want to not deal with it. And you taught me that one.

Charles Goldfarb:

Yeah, clearly I didn't teach you everything I should have the CT scan is clearly the better choice. I'm sorry, you're picking MRI here. I'm sorry, you don't care about our Medicare debt and the fact that the banks gonna be empty in 2028 Here in the US. Now I have absolutely zero problem with getting the MRI and I think you're right. The beauty of that MRI in the acute setting is the edema pattern and that is really valuable, especially in your right ear if you want to be if you want me to be totally honest, in certain patients that will get the MRI and professional athletes would be one of them.

Chris Dy:

Well, you can always print more money for our health care system, right?

Charles Goldfarb:

Yeah, sure.

Chris Dy:

Why don't want it like putting more money into an economy always works. So anyway, I digress.

Charles Goldfarb:

Yes, yeah, you do. So I want to I want to share an article about this, which I found very interesting. It's journal of Hand surgery European 2018. So this is not new, or I admit that it wasn't at the tip of my tongue, but it was published. first author is Rancy, senior listed author is Scott Wolfe from HSS. And it's by the scaphoid, nonunion Consortium. Sounds a little ominous. And basically, they use a prospective longitudinal registry with 35, scaphoid nonunions. These were not necessarily proximal pole, all were treated with curettage, non-vascularized autogenous grafting and headless screw fixation. Some did have ischemia. 28 of 33 were found to have impaired vascularity as assessed by intraoperative bleeding, which I, by the way, don't believe in. And despite all that, 33 of 35 healed by 12 weeks. And that's impressive, because 12 weeks is not that long. So a I didn't know there was a scaphoid, nonunion consortium. And B, this consortium showed what I believe is that I don't really care about the perceptions of ischemia and bleeding, and a vascularity. I think in these cases, a screw often works just fine.

Chris Dy:

Yes, so I remember that paper, I think I was actually up there when some of that was going on. And while I have tremendous respect for my mentor, Dr. Wolfe, Scott has been fantastic to me. I personally remember the papers not being received very well, at least when it was presented on the podium, but some of the meetings, I think, and I cannot remember the exact paper details off the top of my head. So maybe a little homework assignment for me, but the definition of healing was not uniformly accepted. I will leave it at that.

Charles Goldfarb:

Yeah, and I get that you know what people get upset when they feel dogmatic about something and there's a presentation to the contrary. And that same journal of hand surgery European 2018 edition, there's a good paper out of Chicago. And Robert Wysocki is the senior author there with Mark Cohen and John Fernandez, and others. And they show the same thing, that really high rates of healing with nonvascularized cancellous graft for proximal pole nonunions. The point is, it's part of a conversation with a patient, even though ultimately, we as the physician have to make this decision. At least in my opinion, I think, you know, if you have a super educated patient in your office, then maybe you get into more details, I typically present options and then guide the patient as you and I've talked about where I think this should go. But I don't know what how do you handle these situations? What would you tell this patient? And how would you manage her one year old fracture recently identified proximal pole nonunion?

Chris Dy:

Yeah, I mean, I think that there's enough evidence, I mean, so this has not had a chance to heal because it hasn't had stability. So it's not, you know, like you're biologically, you've already tried some stability, and that's not working. And you're clearly dealing with a blood flow issue. Now, this is obviously the worst part of the scaphoid to deal with, just given that it's the furthest away from the blood supply. But I think giving it a chance at fixation is a very reasonable thing, I probably would go to nonvascularized, the only thing gives me pause is that if this doesn't work, then what am I going to do? Have I left enough options for my partners who are, you know, the microvascular surgeons. So, you know, honestly, I probably would tell the patient, I'm going to talk about it with a partner. And you know, here's what I would do, but I want to talk to somebody who has, who would be the person to take care of you after, if this didn't work. And I would find my friend David Brogan, who is a fantastic micro surgeon and ask him his thoughts. And he always volunteers to see them because he's great like that. But you know, at the very least, I want his thoughts.

Charles Goldfarb:

I appreciate that. I mean, he certainly has, as we all do his set of biases, and he's a big fan of the medial femoral condyle, I get that. I will do the one, two, because it's local, because it's straightforward. And because there are good results in the literature. But I will not go to the mat for that operation. I just sometimes question how much vascularity I'm truly bringing, I questioned whether I'm just creating scar tissue. But I don't think it's an unreasonable option in the right patient.

Chris Dy:

Is fragment excision an option here? That was brought up in the email from Ioannis.

Charles Goldfarb:

Not for me, because I don't Think you can take out a fragment This isn't. So there are the super proximal proximal poles, and there are the small proximal bolt, and there's just a proximal pole. And that super clearly everyone knows what I'm talking about. The Super proximal proximal pole is when it's really just a sliver, mainly the cartilage at the insertion of the Scapholunate ligament, those are just really hard because there's no expectation of healing, there's no real bone on the fragment. This is a fragment that has bone, I think you have to fix it. And I think you can expect it will heal. I think if you try to take this out, you will create a problem because there's simply the ligament won't have enough surface area to attach to.

Chris Dy:

So say you're bringing in your one, two, or you're not going to the mat for it and you're doing some kind of cancellous grafting. How do you fix it? How do you do the carpentry on this one? For some of the more sizable proximal pole fragments? And oh, there's some literature out of New York, I think it was combined maybe with Seattle, looking at their experience. So using very small, headless compression screws in tandem usually one or two. What are your thoughts on that technique? Or what would you do in terms of fixation.

Charles Goldfarb:

So it really does get down to the size of the fragment, but I should say strongly that I'm a Joe Slade disciple. And Joe Slade taught us that one could approach these fractures from dorsal and initially it was advocated that to be percutaneous, I don't believe in percutaneous because I don't like to wrap up all the soft tissues and tendons in the area, but very small incision, and I placed my K wire and it typically if I think is large enough from a biologist say that mini acutrak, then that's what I'll drill for. And I think that's a two five drill bit for a 3-0 screw, I think I get those confused.

Chris Dy:

I think it's two five, two eight in terms of the threads on the tail versus the leading.

Charles Goldfarb:

Okay, so So K wire, and then I drill and then I use cancellous bone graft harvested from the same incision lister's tubercle or wherever I pack it down the drill hole, I don't disrupt the cartilage and the cartilage in these cases always looks normal. So if you're going to truly open the fracture, you're going to create a lot more instability, so to speak. So I leave that alone, just drill bone grafting the drill hole placement screw. If it's not big enough for the mini and you're thinking about a micro or to micros, you either do the same thing and just try to place bone graft down the smaller screw holes, or you can create a little window I'm not a huge fan of creating a window through the cartilage to bone graft. But I do sometimes use those micro screws. And I think there's a great role there's still nice compression achieved. I do like the concept of placing too but sometimes once all you get Now, if you only get one again, going back to what Joe Slade taught us, you can also decrease the forces across the scaphoid by placing something distally. And I will often use a six-two K wire from the distal scaphoid into the capitate to decrease that lever arm forces. Some have advocated Putting a screw, you know putting an acutrak from scaphoid to the capitate and take it out six or eight weeks later. I like a K wire and I'll leave it proud and take it out for six or eight weeks. And I've been happy with that approach. I think it makes some sense.

Chris Dy:

So is that like a scaphocapitate Razzle almost?

Charles Goldfarb:

It would be, it would be, with planned removal.

Chris Dy:

That's of course you gotta put the planned removal in there. But that's intense. But you know for those that are wondering why put the pin across the SC you know, your scaphoid is going to want to flex if you don't have a lot of stability proximately so you want to stop the scaphoid from flexing. So you've got the pin across the scaphocapitate joint the hold that in place. I find that really interesting. You know, I think that these can be really super, super challenging. The carpentry is really, really important. Is this somebody that you're going to immobilize until off the bat for 10 to 12 weeks and how are you monitoring healing?

Charles Goldfarb:

So that's great point. And you know, it's interesting what I remember from my mentors, you know, some things that you know, granted I don't think I've ever said that someone's gonna remember 10 years later, but there are some things that Dr. Mansky would say about congenital or Dr. Gelberman would say about different topics and I will never forget Dr. Gelberman it was never just a statement it was always a pimp question. That was full expectation that the answer would be correct. But proximal poles take forever to heal. An average healing time for approximately all non union is 12 to 14 weeks. That is a long time. And so my general strategy and I'd love to hear yours. My general strategy doesn't change for these fractures. It is six weeks post op operative immobilization and a thumb Spica IP free and it's six weeks I get them out assuming I have some trust in the patient. And that doesn't always exist that trust. But if I do trust them, they go into removable brace, they can shower, they can do some gentle wrist motion, if there's no escape, oh capitate pen, but nothing passive, nothing aggressive, and splint to be worn essentially 24/7. And then I consider a CT scan of eight to 10 weeks to give me give me an update, especially when the X rays are inconclusive, which they always are. How does your strategy differ?

Chris Dy:

Not terribly different. I remember being on the receiving end of that pimp question. That's always fun. I was actually telling some Dr. Gelberman stories in the OR yesterday, because his his longtime scrub Nancy had come in to relieve my scrub tech when I was doing a case down there. So we're having a good time. And yeah, my protocol doesn't differ very much. I like to CT scan. I don't always agree with how the radiologists interpret it in terms of quantification of healing. But I think it's an important thing to have, it is important to pay attention to the radiologist read because that's what patients get. And that's what they see they get it in the mail or they used to now they get it in the portal. So if you have a disagreement with the radiology read, it's important to let the patient know about that. Usually I use point tenderness. This is obviously an area that's difficult to assess true point tenderness on so that's you know, one less thing that you can use. Try for it. Otherwise, protocol doesn't really differ from what you said.

Charles Goldfarb:

Yeah. Great case. I think we can do well with these. I really do. I expect them to heal as long as we are patient enough and and the patient can be patient enough. So I love the case. And I hope we learned the outcome from all the way from our friends in Greece.

Chris Dy:

Yes, please share, please share. And just to follow up on what you just said, I agree setting the stage in terms of expectations of how long it's going to take to heal and what the postoperative course is going to look like and how how much consternation you may feel about this particular diagnosis is important. You don't want to scare them, but you want to set realistic expectations, and then look like a hero at the end.

Charles Goldfarb:

Absolutely, you're playing hero ball again. I would like to close by saying I moved my office, I am back in the adult world at our main office. And I have to say, so I moved my office seven years ago to go over to Children's Hospital. And then I'm moved back to the adult office space. It is amazing how much crap one accumulates in seven years. And it was absolutely fantastic to liberate myself from some of the crap that I accumulated. But I also my one of my favorite things, I came across my file of grateful patient notes. And these handwritten notes still happen. And I still save them. And I even print them out if I haven't a good email, but most times they're handwritten. And it's kind of like the nice things people say about the podcast, which gives us fuel, though that file of cards is it's gold. And I am so grateful.

Chris Dy:

Yeah, we stopped doing our win of the week segment and thank you for reminding me of that. And on a related note, so first off, it's great to have you back in the IOH, the reason is not because you were fired as chief of peds but because the role was taken over by one of our hand surgery partners, Dr. Lindley Wall is following your footsteps and being chief of pediatric orthopedics for for our department. So congratulations to her.

Charles Goldfarb:

And she's she's going to be fantastic. We had a nationwide search. And, you know, it was it was, you know, I think we're all happy that Lindley accepted this position, and she will do great things at Children's. She's not she's still be a hand surgeon, but she's gonna be she's transitioning to just being a hand surgeon for kids, maybe a little liberal definition of kids and needs to transition because she didn't want to just abandon her patients, but it's great. I'm so excited for her.

Chris Dy:

So that brings me to the reason why I thought about the gratitude thing that you mentioned is I actually have a gratitude folder in my Outlook inbox. So my, my fantastic research coordinator, Carrie Burke, was saying some very nice things about some patient interactions recently. And I just kept dropping those emails into the gratitude folder and that is, you know, my virtual way of keeping track of some things that make me very happy. And then I still have like you do the folder in the Office of Patient notes and that is the best I mean, it's why we do it. You know, so to anybody listening, I know many of you probably already do this. Therapists surgeons trainees, it is the best to do something like that.

Charles Goldfarb:

I have to say full disclosure, I struggle a little bit more with the either single like poster size framed patient photos, and sometimes I get collages which are really cool. But then I just don't know what to do with them after you know a while. Those are super thoughtful as well but they don't store quite as easily as a nice card.

Chris Dy:

I'm waiting for the Goldfarb microfiche collection of gratitude.

Charles Goldfarb:

All right, man, it's great spending late on a Thursday night with you. I it's good to see you.

Chris Dy:

Pleasure's mine. Look forward to our next recording. Everybody have a wonderful week.

Charles Goldfarb:

Absolutely. Thank you. Happy Bastille Day, by the way.

Chris Dy:

That's a that's not an American holiday. Right. That's that's a French holiday.

Charles Goldfarb:

It's a reason to celebrate.

Chris Dy:

I do love French pastries. So I will go eat some.

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.

Chris Dy:

What about you? 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.