Season 3, Episode 31. Chuck and Chris share exciting podcast milestone and announce a new giveaway to celebrate. And then, we get down to a new topic- capitellar OCD, osteochondral defect, aka osteochondritis dissecans. We share thoughts on diagnosis and treatment- what works, what doesn't, and so much more.
Subscribe to our newsletter: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
Please complete NEW Survey: https://forms.office.com/Pages/ResponsePage.aspx?id=taPMTM1xbU6XS02b65bG1s4ZpoRI9wlPhXnSF2MnEXxURVRNVDNBMEVSMU1CWFpIQVA4SEtMTFcyMS4u
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.
Season 3, Episode 31. Chuck and Chris share exciting podcast milestone and announce a new giveaway to celebrate. And then, we get down to a new topic- capitellar OCD, osteochondral defect, aka osteochondritis dissecans. We share thoughts on diagnosis and treatment- what works, what doesn't, and so much more.
Subscribe to our newsletter: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
Please complete NEW Survey: https://forms.office.com/Pages/ResponsePage.aspx?id=taPMTM1xbU6XS02b65bG1s4ZpoRI9wlPhXnSF2MnEXxURVRNVDNBMEVSMU1CWFpIQVA4SEtMTFcyMS4u
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.
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 podcast.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm doing really well. What about yourself?
Chris Dy:Oh, fantastic. Fantastic. Always good to be here recording again. And then we're gonna get into one of your favorite topics today.
Charles Goldfarb:We are you know, I, I love elbow. That's the teaser? And what type of elbow we're going to discuss, you'll have to just hang on and see.
Chris Dy:Is it that little bity elbow that you posted on social media recently? Or is it something more than that?
Charles Goldfarb:Did you like that? It was little bity. I didn't know when I printed the 3d model. I had to say I'd like life size, not miniatures.
Chris Dy:Objects in mirror are closer or larger,
Charles Goldfarb:or whatever is so true.
Chris Dy:So I'm really exciting stuff for the podcast. We are I guess we're a solid two years and seven months into recording and releasing episodes. Amazingly, we're still here. And I would say our podcast is thriving, because we are about to reach a very exciting download milestone.
Charles Goldfarb:It's really, I think, pretty incredible that we are by the time this podcast actually drops we will be well past this milestone of
Chris Dy:200,000 downloads.
Charles Goldfarb:Yeah. So first of all, thank you. Thank you to the listeners. And thanks to Chris. This has been super fun. And I hope we have another 200,000 is, you know enough fodder for more downloads, but I'm really proud. And I hope we can stay engaging. But we want to celebrate this.
Chris Dy:Yes, we absolutely should. I wanted to thank the goal for our children for clicking 200,000 times over the last two and a half years. I'm sure they're very exhausted now. But seriously, it is. It is a it's been a treat. Thank you Chuck for being a fantastic partner. And the listeners of course, you keep us going you keep us energized, we keep getting reviews and emails that just you know, make this a joy. To be very honest, we talked in the last episode about leadership stuff and how sometimes you just run out of gas on stuff and this is one of those things where you know, there is a little bit of inertia sometimes to kind of get things going. But once we do it feels really good. And you know, I wanted to share our view if that's okay with everybody. So we've got a great review. This one is from Joe Bisante. Joe is an OT-CHT he in New Jersey, he gave us five stars. So thank you, Joe. He says his pod our podcast is his go to for both hand surgery therapy topics. And for entertaining banter. That's clearly Chuck. I love how you collaborate with your hand therapists and how much you value. How much value you place in their expertise and experience. Both of you are unquestioned experts in disciplines, yet present present complex material in an understandable and relatable manner. So Joe, thank you. You're a established therapist in New Jersey and you work at the Rothman Institute. So we know you've got some academic chops as well. So we appreciate your writing that review. Thank you.
Charles Goldfarb:Yeah, thank you so much. And before Chris and I talked about the celebratory giveaway, I want to share the contents of another email. Because one of you, Dr. Terry Light, call this out. And we like that we know we don't always have all the answers. And we know there's got to be bloopers out there that, you know, we could laugh at and celebrate. But I made a mistake. And Terry called me on it and
Chris Dy:love others. We have a fact checking listener group. I love that.
Charles Goldfarb:Love it. So my mistake was I referenced George Kettlecamp in regard to sagittal band injuries. And the reality was a couple of things. First of all, it's not George cattle camp and if Dr. Kettlecamp as a listener, I very much apologize. His name is Donald Kettlecamp. And he was at the University of Iowa and wrote a paper with Adrienne Flatt and Robert Moulds. And it talked about sagittal banditry. So we got the generalities of the citation correct. But we made a mistake and I think the other interesting thing is Terry's follow up email where he said and I agree with this fame is fleeting. Dr. Kettle camp was on the American Board of orthopedic surgery from 1980 to 1986. He was the frickin AOA president in 1990 and some I like to think of myself as a student of history of the field screwed up his name. So my apologies. And thank you, Terry for calling me out.
Chris Dy:It's amazing. For all the things we talked about in the last episode for all the things that we strive for all the accolades that some of us shoot for, at the end of the day, only your family is going to remember making sure you prioritize that. But Terry, thank you for for pointing that out. And I'm glad Dr. Kettlecamp has been given his his shine through through an email from you, Terry. So Chuck, what should we give away to celebrate 200,000 downloads?
Charles Goldfarb:Well, I think one thing that we have, that I've been not so great about fully utilizing are books, and I read lots of books. But when you and I edit books, we typically get a copy of the book. And so I think that you and I would each like to provide a signed copy of a recent textbook that we have either edited or contributed to, and make it available for a survey winner.
Chris Dy:That Chuck, what kind of narcissistic ideas who came up with that idea? You think people are gonna want a book signed by one of us? Hey, listen,
Charles Goldfarb:it's a free book. And it wasn't. But it's a free book. So I think
Chris Dy:one of us came up with that idea. I think that'd be a fun thing to do. It's literally the only thing we have. But we still get asked about mugs. And I think there are a couple of left. So maybe maybe those will make their way out to so Chuck, how does one enter into this drawing for the textbook package,
Charles Goldfarb:I'm not going to disclose that on the air, Chris, here's what I'm going to do. If you have not signed up for our email newsletter, and I promise we will not spam me too much. I'll send a couple emails about this, go to the show notes. The signup is there. And if you sign up, there'll be more information to come in the in the weeks ahead about how to qualify for the drawing for a textbook or mug. We're also going to set up a new survey because we want to understand what you like and don't like about our podcast. And so they'll be two bits of information. And both will be available in the show notes. And we would really, really appreciate your interaction with that.
Chris Dy:Absolutely. So please, please sign up for for that on the show notes and help us celebrate a huge milestone. Now, I can't think of a better way to celebrate than to give chuck a topic that he just loves it. You know, he really tried to pull in some perineal nerve and I said, You know what, Chuck, our listeners are not ready for that yet. It's a lower extremity. It's a nerve, you're really going to push some people away. And he said we could talk about ligament injuries and stuff. I said, Okay, maybe one day, but how about we talk about something that you love, potholes in the elbow?
Charles Goldfarb:I do like potholes not in the St. Louis streets, which they have way too many. And don't let Chris valea y'all, he wants to always talk about nerve. But I think we're gonna talk about elbow OCDs, and it's gonna be a focused discussion. I know all the listeners won't necessarily like the topic, but I'll tell you this. I think there's some generalities from this, and some frustrations with this, that maybe we'll you know, everyone will appreciate. So let me share a case with you maybe as a way to get going. I have a 13 year old female who is into cheer. And that always, for me at least takes some digging to understand really what that means. You know, gymnastics is pretty easy. You know, I'm a level nine gymnasts, I do this, and that with cheer has all kinds of gradations. But she's very active, and she does tumbling as part of her chair. And she does stunning west part of her chair. So she's very active and was a previous gymnast, and she's developed right elbow pain. And her elbow actually lacks extension. So her elbow motion is 35 to 140. And her rotation is full. She does not have mechanical symptoms, but she has some pain and she can't straighten her elbow, and she's frustrated.
Chris Dy:Now, was there a specific injury traumatic episode antecedent event that led to this?
Charles Goldfarb:She had some pain or aching pain in the elbow over a couple of months, but there was not one specific event, just a realization over time that she couldn't fully straighten her elbow.
Chris Dy:How does one go that long without being able to noticing that you can't straighten your elbow?
Charles Goldfarb:I certainly would expect there was a critical event but she didn't remember it. And it didn't cause pain. And I'll say this is not the common scenario. The common scenario is full motion, maybe some mechanical symptoms like some clicking or even some catching or locking. But this is real. And this is how this young lady presented.
Chris Dy:Okay, so are you the first person she's seen for this? How many people have these patients typically seen before they get to the Tsar, the guru, The Wizard of Oz Chuck Goldfarb.
Charles Goldfarb:highly variable. But they've almost always seen at least another physician, maybe an APP, this young lady had seen a physician who recommended rest for this. And unfortunately, that that wasn't the right answer, when you really lack motion or have significant mechanical symptoms, I don't believe rest is the answer. Just to kind of go down that pathway, rest might be the answer for kids with those CDs, Once diagnosed, if there's no displacement of the OCD, and if the child is younger, especially rest, and giving the body a chance to heal can be super helpful.
Chris Dy:So rewind back for me, and let's talk about you know, the differential and how you get to the right diagnosis on your questioning because I think of you know, an adolescent athlete. And even if they're not a thrower, or maybe it is something that is more of an overuse kind of thing, and how do you distinguish an overuse kind of thing? versus kind of pain inhibition versus an actual OCD? Like, what are the questions that you are asking on your history that are going to lead you down this route?
Charles Goldfarb:It's a great point, it's a great point, you do want to understand the timing and the material, you know, kind of what happened? And then you don't always get a great answer. But that's an important part of the history. If it is a gymnast, you want to understand what level what do they do if it's a baseball player, you want to understand how many innings they're throwing, and what type of pitches they throw? Those are all super important. You understand one, understand what's been done, you know, what have you tried, have you tried rest what is rest mean? And just kind of go down those pathways. And so it's not necessarily super quick. And then you really have to do a careful exam. And so on my exam, I focused on a couple of things. Even though I might hear that there's no pain or here that pain is lateral, I still focus on the medial elbow to start, I examine the UCL moving valgus stress test, I examined the older nerve, I examined the triceps, and then I go laterally, and I examined the gutter. I want to feel the radial capital or joint, I want to make sure there's no nerve pathology. So comprehensive exam, which can thankfully be done pretty quickly. I will say I'm babbling. I will say one of the things that I found that super interest lately is this pain inhibition can be a real thing in the very young adolescent, and that often is nerve related. And the nerve findings can be subtle. And then our experience that is Dr. Wall's experience in mind, the ulnar nerve can often be the culprit. And so again, a careful exam is super important.
Chris Dy:If you just bring the nerve into this, that's great. I
Charles Goldfarb:did I do respect the nerve and those that care for nerves I do.
Chris Dy:So when you're examining what are the specific things when you're assessing ready capital or joint when you're assessing the gutters, you know, other any classic moves that are very helpful to you, or any moves that you have determined, are helpful.
Charles Goldfarb:Big palpation, for me is the main one. And so when I say when I think about the lateral elbow, I think about I started the lateral Epicon dial and just palpating directly there. And then if you if you just let your fingers slide posterior to lateral of a condo, you fall into what I call the lateral gutter, and that's the joint. And so in an old patient like me, that could indicate arthritis. In a younger patient, it could indicate synovitis and some type of intra articular pathology, you can then go back to lateral condyle and slide a little distal rotate the radial head, feel the radial capital or joint and for most with a symptomatic OCD, that's where they feel pain. And then you do have to differentiate this different populations. But if you feel that lateral a condyle and go just anterior then you're in lateral epicondylitis turf. And then if you go a little distal, as you know, we'll talk about that inward again, you can follow the radial tunnel. And so the four things I think about latterly are joint based issues, ligament based issues, tendon based issues like tennis elbow, and then finally, radial tunnel.
Chris Dy:How do you then go to work these patients up? Does every patient get radiographs? And then how often are those going to inform management for you? And then when are you moving towards advanced imaging?
Charles Goldfarb:Everyone gets a radiograph sometimes bilateral if I think it will be helpful. Usually the radiographs are helpful but they probably don't tell the whole story. So if you're really concerned about an OCD and MRI is almost always indicated in my mind, and insurance companies. Don't fight us too much on this one, although we'll get come back to insurance companies later. But the MRI usually tells detail is it is the OCD, you know, how big is it? Number one? Does it involve a lateral wall? Number two? Is there a loose fragment number three? You know, how does it guide potential treatment was the, you know the depth of the cartilage issue. So lots of information we could talk about this ad nauseam. But the MRI for me is always helpful.
Chris Dy:So before we get too far into this, can you define what an OCD is for the listeners, because we have people of varying backgrounds and training levels, etc?
Charles Goldfarb:Yeah, it I think different people use it to mean different things. So it could be a stick can drag this to seconds, or it could be osteochondral defect. And there may be some out there who are laughing at me, but I use those somewhat interchangeably. The defect obviously implies an OCD, which is using the osteochondral defect implies a bigger displays lesion in my mind, but I think people use those terms interchangeably. Both is OCD. But the reality is, this is a death of subchondral bone and subsequent pathology to the overlying cartilage. And I think most people believe there's likely a genetic component, there's a hypovascular issue. There's a trauma or repetitive trauma issue in many, and sometimes there's an acute trauma event in some. And so all those factors come into play. But ultimately, if you get an OCD, then unfortunately, it can be a difficult difficult problem for a young child, who is often very involved in athletics.
Chris Dy:What happens if the OCD goes untreated? Is it something like a like a snack or like escape one non union that we think predictably would go on to a specific pattern of arthritis?
Charles Goldfarb:I think if you have an OCD, and you don't rest, then you risk. I don't think there's any good natural history studies that I know of the best literature's from our Japanese friends who seem to have a higher incidence and incidence of this and perhaps related to, you know, baseball fanaticism. But I think it's safe to say if you have an OCD and don't rest and continue the trauma, you will, it will lead to a displaced fragment, which can cause joint problems and ultimately require treatment. Whereas early on if you rest appropriately, and what does that mean, six months, probably, some would argue even longer periods of respite that gets really hard for our population.
Chris Dy:When do you pull the trigger on the MRI, if you know, you're gonna know if the rest of them initially did? Do the rest? First, keep the clinical suspicion in your head, maybe talk about it with the family? Or do you get the MRI for the job?
Charles Goldfarb:For me, in our role as a tertiary care center, often with the patients seen several different providers before seeing us, I get the MRI at the start. And I think you kind of have to to understand what's possible. Is it possible that this will heal? Or the growth plates open to increase the chances of healing? Is there a loose body that you couldn't appreciate on the X ray, you kind of want to know all those things. And then if it's an if it's a nondisplaced, OCD, and the family is reasonable, and I would push them to be reasonable, then you give it a period of rest? And you explained that you can't promise it'll heal. But that's your hope? And I think I think it does, I think there's a good chance for for the right kind of OCD to heal. But then, obviously, you have a group of patients where it doesn't heal, or it's too late.
Chris Dy:And is it ever too big to heal? To not heal?
Charles Goldfarb:I don't know. I mean, certainly the size of this lesion matters a lot. I think many of them will heal despite their size, if they're just in the right biological situation, a young enough patient who really does respect it and stay off of the elbow. Yeah, and then so the way I think about these is, I think, pretty straightforward. If the fragment is displaced, then surgery is indicated. And if I think about surgery, and certainly there's some gray areas, but when I think about surgery, I think about can I repair the fragment? Can I stimulate a marrow response and get fibrocartilage replacement of the last hyaline cartilage? Or do I have to think about ways to bring in new bone and cartilage to get this thing to heal to give the kid the best chance of a good outcome?
Chris Dy:When you talk about displacement? Because it's death of subchondral bone? Is it just that the you have a sinking in of the area on top of which you have the subchondral bone death? Or is it actual displacement in sense of maybe it's riding high and shifting out, you know, causing an actual area for you know, point loading of that specific displace fragment or is it more point loading and barriers around it?
Charles Goldfarb:Yeah, I think it's a matter of you do get loading around it. It's just a matter of will the car village fragment break off, and typically is just that overlying cartilage which breaks off and the underlying bone just stays on healthy and sits there. And so the primary treatment, the so called to Bremen and micro fracture is simply about giving, creating channels of bleeding bone that will allow progenitor cells to populate this area and create fibrocartilage, which is can be a sufficient substitute cartilage to get get kids back back to play. So pretty cool, and really can work. And we've done a few studies in this area, and many others have done studies in this area, demonstrating that this micro fracture for the elbow really can be successful.
Chris Dy:How for those of for those listeners that have trained in orthopedics, how different are these elbow OCD lesions from the ones that are encountered in in the knee?
Charles Goldfarb:I don't know that they're fundamentally different. I think they're less worrisome because you're not theoretically, weight bearing on the elbow, at least you don't have to wait bear on the elbow. So I think they're a little bit of less stress. And we certainly learned a lot of lessons from treatment of elbow, I'm sorry, treatment of Neo CDs and shaking those lessons to the elbow. At least, you know, we haven't really taken all the lessons from the knee, but but some of the key ones.
Chris Dy:So what are the different treatment options. And you know, we've talked a little bit about rest, is there any role for you know, injections of any sort, whether that's steroid hyaluronic acid, or some disco supplementation, and then talk to me about the different surgical options and when to use those.
Charles Goldfarb:Yeah, I personally don't believe there's any role for injections. There's no literature support that I saw a great family last week who came down from few hours away, four or five hours away, and they had gotten injections in the elbow, and they felt better. And then they had these displaced OCDs and they weren't going to heal. And so it creates this artificial sense of things are better. And I think that can lead to more damage being done, honestly. So I'm not a big fan of injecting kids joints anyways, sometimes I'll do one in the right situation. But not for me, there's no injection that's appropriate for this issue. Not even PRP, not even our friend PRP, I get that one a lot. So you know, the hardest ones of these are when you have pain, failed conservative treatment. And the when you go into your elbow scope, the overlying cartilage looks intact. And then you probe it and it's loose or flakes off and you just get this sinking feeling in your stomach where you're taking away what appears to be healthy cartilage that has absolutely no support beneath it. And so you create the lesion in some respects. And then you ask the body to heal this with new cartilage but that that unsupported cartilage over the dead bone does not heal.
Chris Dy:And so you mentioned you mentioned inspection on arthroscopy is there ever is it always arthroscopy? Is there ever a role for an open surgery? Or is arthroscopy just part of the not only treatment diagnosis or confirming the diagnosis establishing prognosis?
Charles Goldfarb:I think it's, it's, it's got to be arthroscopy. I mean, you certainly could open an a&e a splitting approach. The elbow was part of what we did for this young lady. But I think arthroscopy is the tool, because you can really get information about the whole joint, you can do breed inflammation, or synovitis. And you can really assess the area of concern.
Chris Dy:So you mentioned about microfracture techniques, maybe even bringing in some, you know, a plug or something like that. How do you what are the different surgical techniques that you use? And when do you use them?
Charles Goldfarb:I would say the most common is a microfracture at least in my hands. If OCD and it's some of this is these numbers are somewhat arbitrary, because it does depend on the size of the child and, and the growth plates in the lake. But as a general principle, the lesion is less than one centimeter in diameter. In the center of the capitellum, I will try a micro fracture once it gets more laterally, and that kind of the kind of the elbow where the capitellum you know, ends. That lateral wall is really important for stability, you don't want the radial head escaping, because that creates a whole nother set of problems. And so if it's centered in the capitellum, micro and small enough lesion on microfracture is appropriate when you get more than a centimeter in size, then you have bigger problems. One of the tricks and challenges that we have is that insurance companies largely refuse to pay for an OATS procedure. So notes is when you take essentially an osteochondral autograft plug. You can do you can use an allografts. But for me I like to take a plug of bone and cartilage from the knee from the lateral proximal cartilaginous portion of the of the knee and the beauty of this approach is that it's okay, it's it heals quickly, reliably. And you can essentially take a one centimeter plug or bigger or two plugs, and you essentially put those in the capital them create a smooth surface. And what you're asking the body to do is heal the deep bone. That's why you harvest a centimeter deep blood or something like that. And you ask the body to heal the bone to bone deep, and then the cartilage stays alive on the surface. And you can It's remarkable, it's a reliable technique, it's probably the most reliable technique in my mind. It does require going to another joint insurance companies routinely fight this and often deny it. And there's literature supporting it. It's one of my greatest frustrations with interacting with insurance companies.
Chris Dy:Is that is it that they think that it doesn't work? Or they're just I mean, we can probably get into the whole thing about insurance companies, you have, have there been payers that have changed over the last couple of years and actually started to accept it?
Charles Goldfarb:To my knowledge? No, I can't say that every insurance company rejects it. But I every time I scheduled this case, it seems to be rejected. I do a peer to peer and like you said, or someone said recently, in a discussion, you have the peer to peer, but you the reality is you're just wasting your breath. Because they're gonna say, well, it's considered experimental, we can approve this. And that's what they say. And it's not experimental. And there's good orthopedic science to support it. And there's good anecdotal evidence that it works. And yet, we can't always get it approved. And so it's frustrating because it's a great, great operation.
Chris Dy:So do you typically harvest the plug on your own? Do you involve one of our sports partners? And where do you take it from the knee without it being an issue in the knee? You mentioned kind of the proximal lateral aspect, right?
Charles Goldfarb:Yeah. So you know, the first couple times I did this, I worked with my sports partners, but it's not hard. It's a lateral para patellar approach. Actually, it's not exactly accurately stated. It's a lateral approach to the patella, and then you use one of the Z retractors retract the patella. There are great kits designed for harvesting the plug in is that very proximal lateral cartilage on the anterior surface of the knee. And it's non weight bearing it doesn't have any interaction with the patella. And so, you know, occasionally, it is a fresh source of frustration for kids, but almost always is extraordinarily well tolerated. So fun surgery, effective surgery. And I really like doing it when we can, you know, make it happen.
Chris Dy:So the question, the question is, do you wear loops when you're harvesting?
Charles Goldfarb:For sure don't wouldn't you?
Chris Dy:Of course, I wear loops when I nail femur.
Charles Goldfarb:I feel naked in the operating room without my loops. And I get made fun of and I'm fine.
Chris Dy:I was doing a wrist scope recently and I had my loops on or going right. I was like, Well, you don't?
Charles Goldfarb:Yeah, it just I need that weight. I need that comfort. I absolutely wear my lips.
Chris Dy:I was gonna ask when you when you inset the plug? Is it purely interference fit? Are there any additional forms of fixation? How are you doing that?
Charles Goldfarb:Interference fit-, never had a problem knock on wood and sounds you have to contour it a little bit because you know, the capsule was curved. And this is sort of a flat piece of bone and cartilage you're harvesting. But yeah, I see the appeal of Sports Medicine. Obviously, I like wrist scopes and elbow scopes. And I like working with my sports partners. And you and I are gonna have a future episode about that. To close the book on this, maybe this topic and this patient, this young lady had a really interesting thing. She had a 14 millimeter OCD, loose fragment floating in the joint it was actually hard to get in the posterior joint because this fragment is so big and it was a massive part of her capital because she was not that big. And there was a really thin layer of bone. But because it was so massive, you know, ideally, these fragments they break off have bone on them, because if there's bone, there's hope for bone to bone healing. Cartilage itself is not going to heal but there's bone on the fragment it might heal. There was a little bone in because it was massive. We went ahead and fixed it. Which was really satisfying. But I don't know if it's going to heal. But there are different tricks and tools out there. I used what's called a micro nails made by a company called Conmed. I've never used it before I really liked it. I think there's a lot of little things out there. They are bioabsorbable I put to a minute it was very slick. I could have used a headless screw. These things have a little bitty head on them. It was really satisfying. It'll be more satisfying if the fragment heels
Chris Dy:Of course so in look thinking about that case and reflecting on her preoperative exam. Why do you think she couldn't extend her elbow all the way it was that she was you know the abnormal contact pressures. at that area right on her capital, every time she tried to extend,
Charles Goldfarb:it was a physical block because that fragment was loose. And so in the operating room, she had full motion, which is always also very satisfying. Now, this thing doesn't heal, we're gonna have to push the insurance company to approve an OATS procedure. But I'm hopeful, cautiously hopeful.
Chris Dy:So then to, to bring in our therapy colleagues into this What's your postdoc protocol after? Maybe not this case, for example, but maybe after notes or microfracture? Yeah, usually, you are just trying to get the elbow moving, I don't splint these these patients, bulky soft dressing to start, I kind of tell them to move at home. And then I see him back at two weeks, these are kids that you know, they they don't tend to get stiff. And so I check them at two weeks. If they have their motion, then I just tell them to wear a sling as a reminder, at least for the first six weeks, and try to keep their activities limited. And then at six or eight weeks, you know, I often will start to do some light strengthening, but I protect these patients for a while. So an OCD treated with an OATS is usually healed about three months and then they can ramp up their activities tolerated. And OCD treated with a micro fracture. I actually protect them for longer four to six months and usually get an MRI. Not everyone does a repeat MRI, but I often get an MRI to assess healing. And then if you fix the fragment, which for me is really uncommon, because I can't usually find the indicated you know, I can't find the fragment, it needs to be fixed. But those I go slow on also need to make sure we're healed before we go back. So not a huge therapy need for these kids. But there can be I guess I would say sports related rehab to get them ready to go back to their sports make sure their mechanics are okay, as they kind of, you know reincorporate into their favorite activity. So when do patients aged out of having OCDs? You know what, getting older guy like me versus an old guy like you? Are we gonna get OCD in our elbow?
Charles Goldfarb:I think I'm just gonna get plain old arthritis. I don't know about you. But see, I think what happens is, you know, usually if you once the growth plates close, I think it's pretty rare to see a new OCD. Now. I'll see OCD is with close growth plates. But I think those develop before the growth plates close and just persist. But I think you don't really see him above the age of 15 or 16. Or at least I don't.
Chris Dy:Okay, well, thank you for educating me, I learned a lot about OCDs more than I'm ever going to want to remember or ever need to know, because I'm just going to send them to you. But thank you, I think that that's gonna be very educational episode for many.
Charles Goldfarb:I think my I know, my penance is probably going to be two nerve topics. And I don't know what else, that's okay.
Chris Dy:Well, we'll make sure to give people what they want. And you know, that'll be part of the new survey that's going to come out. So those of us that sign up, we're going to do it on a survey, you'll enter to win the books. Maybe get some extra swag out there. And thank you, everybody for for always supporting the podcast. Really appreciate it.
Charles Goldfarb:Absolutely. We are grateful beyond belief. Hey, Chris, this was fun.
Chris Dy:This was fun. We'll see you next time,
Charles Goldfarb:man. 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 at hand podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is at congenital hand. What about you?
Chris Dy:Mine is at Chris de MD spelled dy. And if you'd like to email us, you can reach us at hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out. Special thanks to
Charles Goldfarb:Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time