Season 3, Episode 42. Chuck and Chris talk about two topics, completely unrelated! First, we discuss an important reader- submitted comment regarding fellowship interviews. And second, we discuss how we handle the common issue of finger injuries and potential amputations.
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.
Season 3, Episode 42. Chuck and Chris talk about two topics, completely unrelated! First, we discuss an important reader- submitted comment regarding fellowship interviews. And second, we discuss how we handle the common issue of finger injuries and potential amputations.
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 podcasts.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I am well. How are you today?
Chris Dy:I'm fantastic. It's a beautiful fall day in St. Louis. It got frigid there for a minute. And now it feels like the end of summer early fall that we were all hoping for
Charles Goldfarb:is really delightful. We tell you I had dinner outside last night at a nice restaurant and nice walk today. So yeah, it was great.
Chris Dy:Yes, it's we are we've been outside most of the day. My son had a soccer game. So we went and did that. And then the the grade organise a trunk or treat, which is kind of new to us. I don't know how much of a St. Louis thing that is, or just a family thing that is but super fun. We're all hopped up on sugar right now.
Charles Goldfarb:So when is Halloween because this episode is going to drop on the 30th. So in St. Louis, I think Halloween is gonna be celebrated on Monday night, don't you think? Yeah,
Chris Dy:I think it will be much to the chagrin of every parent out there and any t shirts for the Tuesday? Yeah, I'm sure that I don't know, maybe you you and Talia had some specific regulations for sugar intake among the children, you guys seem like a healthy family, we try and then we fail. Usually,
Charles Goldfarb:We try. I mean, I've learned a couple things about Halloween. One is that as a parent, it really is a fantastic celebration, because stealing from your children in the middle of the night is is a worthwhile pursuit, because it's really helping them not to eat too much sugar. So I like that. And then St. Louis has a great Halloween tradition. I don't know if we talked about on this show. But I really like when kids come to the door, you don't just hand them candy. They literally they really have to tell a joke. And it can be a stupid joke, which usually is like a dad joke. But I love that tradition.
Chris Dy:I think it's great. I didn't have to do that growing up in Florida. You know it, it makes it very fun. And you know, having the kids practice their jokes ahead of time is always entertaining. So, yes. And, you know, we've learned that there are certain things that belong to mom and dad out of the candy out of the candy bag. And I've been known to keep a substantial stash in my office for writer's block to help me get through.
Charles Goldfarb:I love it. I love it. Well have a good Halloween. And we have some interesting things to talk about today.
Chris Dy:We do so we have. We do have a really interesting email that came in from a listener. And you know, we recently had the Live episode where we were asked about, you know what, what we look at when we look at fellowship applications. And one thing that I said was that I look at the letters of recommendation more than anything else. And this listener, I think, in a very respectful and thoughtful way challenged me a bit on that, and said that I openly espouse the old boy network as my primary way of evaluating fellowship applications, stating that me looking at the letters was a discriminatory and myopic way of evaluating potential fellows, essentially exclude anybody not fortunate enough to go to med school or residency with one of my friends. And there could be many reasons why an applicant failed to work with one of your friends from family or cultural economic situations to just plain bad luck. So a wise person evaluating applications would look not only at their friends residents, but also those who attended institutions without big research names. And, but still showed a pension for doing the work winning small grants, publishing small journals presenting research at local meetings. These are the ones who will be overlooked by people who think the way you recommend, but have been grinding and deserve a chance you will benefit by finding overlooked candidates and they will benefit by not being overlooked because of factors beyond their control. So, Chuck, what what what's your initial take on that? I have a pretty interesting take on it. But you know, I'd love to hear your thoughts.
Charles Goldfarb:Yeah, I, first of all, we are we're grateful for the candid feedback, Chris and I have long said we, you know, when we say something on the pod, especially when it's the live pod, we are sort of, you know, putting it out there, and I appreciate this listener calling us on this, but I don't know that I can say I fully agree. And I think the it was a direct challenge which again, I appreciate. But I think it deserves conversation both a about what you meant when you said that and be what we do as we choose fellows and maybe a see what the true landscape is. So before we dive in, give I'd love to hear you've thought more about this. I think that I have but tell me what your what your thoughts are.
Chris Dy:Well, you went to a b and c which is way beyond the two Chuck Goldfarb things I'm used to You'll have to remind me what a, b and c are. After we addressed the firstborn, forgotten. Yeah. So I, it's interesting, because I, you know, when what you I guess the first one was what I meant when I originally said that, and I honestly would have to go back and listen to exactly what I said, because I don't remember all of it. But, you know, I guess my intention is that, you know, I think that it's not necessarily the letters of my friends, because I don't count many of the people who write letters, my friends, because I'm still pretty Junior. And it's usually much more senior people that are writing letters, but then I know them in terms of I know who they are and where they work. And I will say that, you know, even now looking at residency applications, which I think both of us have done recently, and we're going to do more of as we head into residency interview season, I look at letters for from, from applicants that are coming from places that aren't as well known, if that person is literally stated as the best medical student anybody has ever worked with, or the best medical student in their class, even if I have no idea where they're coming from, and no idea who wrote the letter, that statement in and of itself is pretty, pretty strong. And I will take that over, you know, I read a fair number of letters from the usual players. And you start to read between the lines for better or worse, and tried to parse the details from what you remember from prior years about how people looked in that letter than versus how they actually looked at the interview. So I will say, a superlative truly superlative letter from a person I've never heard of, and a place that I've never heard of, probably says a lot more than an average letter from somebody who was well known at a well known institution.
Charles Goldfarb:Yeah, I think that's very true. Here's how I mean, fellowship and residency are very different. And so when I think about fellowship applicants, we're, you know, in, you'll be really owning this process, we, we use a few criteria, but the hard thing is, in residency, the residency applications are going to go through the same thing, there aren't a lot of hard criteria. So we don't have any cut offs. And we don't look at you know, oh, IITs, you know, fine, if as long as you do reasonable, we don't really think about that. So then we're looking at how can one distinguish himself or herself? And we'll certainly the interview and how well, you know, they do and articulate themselves and how well they, you know, share their thoughts and their future goals. That's important. Personal Statement, honestly, for fellowship is not one of my top criteria. Letters really do matter. But like you said, I mean, I know a lot of people. They're not necessarily all my friends. And that's not it. I mean, that's not the goal, we're trying to figure out. We're trying to look for someone feeling passionately about the applicant. And it doesn't matter if they're from the best residency in the country, or less well known residency in the country, as long as there's passion behind the letter writers words, then that's what moves me. And that's what impacts man, how much research certainly can matter. But we absolutely talk about what people have accomplished from situations which are not research our houses. And so letters matter. They do. But it's not it's not a it's not an old boys network. And in my opinion,
Chris Dy:I could see how, you know, I think that it can come across as an old boys network, if you know if the way that my statement was interpreted was that I only looked at letters and yeah, I kind of get that. It's interesting that because I came from, you know, from going from medical school to residency, I went to University of Miami, which at that point, had placed only one other resident at HSS, before for residency. And so for me to match their relied a lot on letters that I think, you know, having had the ability to go back and look at my residency application, because it was given to me when I applied for other stuff. They were letters that I think were pretty strong, and were very personal and people felt very strongly about me. So, you know, I think that I benefited from having people that felt strongly about my application that helped propel me maybe to kind of out kicking my coverage in terms of residency, but certainly my residency application had a lot of other boxes checked in terms of you know, you know, doing a lot of research and coming from a place that didn't do a lot of research. So I think that, you know, it is a number of things that you look at, certainly residency applications are different and fellowship applications. And then with fellowship, you kind of see that, you know, places are going to be looking for very tailored things as opposed to a broader five year experience for residents.
Charles Goldfarb:Yeah, listen, I went to medical school, the University of Alabama, in Birmingham. And so when I'm coming out of medical school, when I'm looking for a residency, I needed someone to be okay with UAB as my medical school, and thankfully Once University was, and I do I maybe I, maybe I didn't state it very clearly, I do believe that there is a risk if one is overly dependent on letters, specifically overly dependent on letters from your peers and the people, you know, well, but I think we, you, me and everyone else here at WashU. When we think about hand fellowship applicants, it is not about who the letter is from, or it's not only about who the letters from, it is about the quality of the letter and how well that letter captures, or grabs us to kind of intrigue us about this applicant from, as the writer says, from a place we may not know as well.
Chris Dy:Well, we certainly think the listener who obviously took a lot of time to write that email, so thank you, to you for, for sharing your thoughts and inviting us to have this conversation. And, you know, it's, it's always good for us to think about it if anybody else has any thoughts on what, what their opinions are, please feel free to share.
Charles Goldfarb:Yeah, we're gonna say some, as we fear, we, you're gonna say some stupid stuff. And I have to say, when I edit is not really to edit out stupid comments, it's to, you know, make it sound better. So we're gonna say some things which, you know, may not age well or may not represent exactly our thoughts. And that's the risk we take with a podcast. But, but and I like you, I appreciate the writers comments, I think it's an absolutely important point, and one that we talk about and think about, not just in response to that person's letter, let's talk about a case,
Chris Dy:I've had a couple of interesting cases. And I remember, you know, whenever I would present cases as a fellow and as a junior attending, basically where everybody on the call, or in the conference would know it's heading towards an amputation, no matter whether it's now or in three or six months. One of our partners, Ryan Calfee would say, you know, wait until, in most situations, wait until the patient recognizes and realizes and even asked for an amputation. You know, so I have had a couple of interesting cases recently, which it's come to the point where patients have asked me for amputations is, is that something that happens frequently in your experience?
Charles Goldfarb:Well, yes, I mean, it certainly happens. It actually hasn't happened in the in the recent past for me. Let me let's before we get to there to that point, maybe we'll back up just a second and say that, you know, fingertip injuries, or more than fingertip injuries are tricky. And a lot of them are cared for in the emergency department, as a service to patients and trying to minimize that need to come back multiple times. I think an emergency department revision, amputation can be an outstanding procedure. And then sometimes it's better done in the operating room. And so that's a tricky place to start. But many, many, many patients do well from initial treatment and never did anything else. But absolutely, I have a handful of patients, you know, always on the docket, that that are not thrilled with their amputation. And you're either trying to coax them through it as I am now with a couple of patients, especially as we head into winter, or we're talking about that neck surgery, the revision.
Chris Dy:So let me paint let me give you one of the two scenarios. And one of them is a patient who had a, an open central slip injury. And that I, you know, subsequently saw in the office a few days later, and did a repair and actually did it awake, because I thought it was helpful to me and patient wanted it that way. And, you know, talk to them about, you know, the technique and what we were doing what we were seeing, and I felt good about it. But that said patient returned to activities sooner than I think I had wanted anticipated. And eventually, I think got to the point where his finger was very swollen. There was concerns about the wound. And as it continued to unfold, you know, suture started spinning, and it wasn't the nylons at the skin. So we all kind of knew where this was going. And then on multiple visits, you know, we kind of talked about the options. I said, I think we should wash this out. And he said no. And then eventually, you know, we kept pushing it kicking the can down the road. And you eventually came in and said you know what, I don't even use it. Why don't you just cut it off? And it was it was an index finger.
Charles Goldfarb:Yeah, that was my next question. Which finger because that really does play a role. So let's go back to your repair so you didn't a wide awake Central slipped prepare from an open injury. Which, you know, certainly that deserves an open repair doesn't sound like you pan the joint getting up in, which I might have. So you are depending on the patient? And do you what are you trying to immobilize that pap joint for six weeks,
Chris Dy:not six weeks, I was going to try to go three or four, because I felt really good about the repair. And probably, maybe foolishly so but you know, we had the conversation. And you know, I told him what I expected of him and was trying not to lose too much motion by pinning the joint. So I can't say I in retrospect, I would pin it this time around because probably would have fractured the pin.
Charles Goldfarb:Yeah, yeah. Good point. So now he's back is the index finger is interesting being the index finger, because for the index finger, while we all recognize and, and for those of you who haven't had this conversation, clearly the index finger is the one you can lose most easily and can get in the way. And so in an amputation, the index finger is totally reasonable, and patients don't miss it. But it's also the one that would be most successfully treated with PRP joint fusion. Because you know, you are depending on the index finger to function and extension, the IP joints do best with fine pinch, and even with large grasp and relative extension, whereas the ring and small finger are more needed for grasp and, you know, flex pap fusion is doable, but not quite as smooth.
Chris Dy:What about if the patient's already kind of come in bypassing their index finger pinching against their middle? Do you still think about going to an arthrodesis for the PIJ?
Charles Goldfarb:I think it's the conversation piece. And there, you know, I think most patients will not be, you know, don't jump to asking for the amputation and some in some respects, I appreciate that. Because it means they've thought through this. And if it does come to amputation, you and I know that patient will do wonderfully. But if they're not really convinced, then I will tuck them into a PIP fusion in this situation, I think
Chris Dy:now, I guess in my situation where I have some concerns about adherence to recommendations, I think we're not supposed to use the word compliance, but adherence to recommendations, would you still trust that you could get a VIP joint to fuse in somebody who may not listen to what you're asking them to do?
Charles Goldfarb:I think so. I don't know. There's different techniques. I'm a big fan of the tension band technique. Still, I recently revised a patient who had been fused with two small headless screws. I think that's tricky and an index finger, especially given the positioning. So I'm a big fan of tension band, I think you can get a very solid, strong repair that should do well, long term. So yeah, I mean, again, the patient needs to own part of this, but I think we could get a deal.
Chris Dy:So when patients have this particular situation, say you don't go to the fusion, but you follow their request for an amputation, what's the level in which you would shorten the digit?
Charles Goldfarb:Yeah, that's that's the question. And I think that is actually maybe harder for a patient to conceptualize. Now, the good thing about the index finger is you're not gonna have a hole in your hands, so to speak, always talk about dropping m&ms If you amputate the ring finger at the MP joint. That's not people don't do well with that. But for the index finger, I think you really have two choices. If it's truly about breadth of the hand and strength and less about appearance. I think you can do it mid proximal phalanx, but if it's truly about appearance, you can make a beautiful hand and no one will notice with a mid metacarpal Ray resection, I mean, you can have a great first webspace you can have an incision that looks beautiful, and a highly functional hand. So that's the tricky part but in a like a male labor not to you know generalize overly. Maybe it's maybe it's through the proximal phalanx.
Chris Dy:How do you decide if you're say you're shortening? You're not saving the proximal failings? How do you decide between an MP disarticulation and the trans metacarpal re amputation?
Charles Goldfarb:I don't think an NP dislocation looks good. It's easy to do. It's fast. But it ends up looking like in congenital Hansard. We talk a lot about situations where you kind of get an L shaped deformity whether that's with a extra thumb reconstruction, or whatever, and patients hate that, right. There's no l shapes in the in the normal anatomy of anything. And so that's what you get when you do an MP disarticulation So I generally push patients to let's not maybe do it at the joint even though there's nothing wrong with it. Let's go back a little more proximately. If it's distal 1/3 of the metacarpal, that's still fine. And I do a little obliquity. So I'm taking more on the radial side, and less on the owner side, just because you avoid that bump and you avoid that deformity. How do you how do you think about that?
Chris Dy:Well, I mean, I think there's the dogma about expose cartilage being a night is for infection. Do you believe in that? I've been told that a couple of times, I don't think it actually has borne out in my limited series. So I think that's one consideration I have.
Charles Goldfarb:I think the only thing I suppose college does is create bulk, whether it's head of a proximal phalanx or distal phalanx or head of a metacarpal. So when I do take cartilage, I do it without thoughts about the impact on infection, because I don't think it has a role either.
Chris Dy:And then do you do anything special? This is my nerve portion. Do you do anything special for the nerves traction direct to me, is there anything else?
Charles Goldfarb:So with initial operation, I do traction direct dummies. And I'm very curious as to what you do. And there is a limited handful of patients, as we all know, that will not be happy and will have nerve pain, it does absolutely tend to happen more commonly in the worker, and not accusing anyone of secondary gain issues, but and I think is legit, it can absolutely be legit. So it's very tricky. But the initial for me is attraction neurectomy, sharp cut with a 15 blade done carefully. But that's my approach, what's your approach?
Chris Dy:And pretty similar, I'll add the crush injury proximal to the neurectomy site. You know, to order it basically enable a level four crush injury proximal to your level five neuro medic injury in the hopes that it won't even regenerate past the level four if it does get to the level five so that it will become symptomatic. But you know, I think there's a lot of different ways to do and don't do anything special beyond that in terms of my primary surgery. Now if it becomes a secondary surgery, and then I start to pull out some of the tricks, but
Charles Goldfarb:I will tell me some of the tricks
Chris Dy:I've used, I don't I think central central coaptation is an interesting technique. I think that cortically that's probably pretty confusing. To be honest with you. I've, if you can do it in a way where it doesn't create a point of
Charles Goldfarb:corruption. You're just talking about sewing that Irvin's together, correct. Okay.
Chris Dy:Correct. And then I think the other technique you could use potentially is implanting it in some muscle, or in some bone bone is tricky, just because you can create a point of constriction. But if you do have an open canal in there, and you can tuck it away nicely, that's an easy way to do it. That's much it's facilitated if you use something like an alga graft as an extension cord, essentially. I've done TMR in some of these situations, because if you've got an expendable lumbar call or something like that, and you find a nice branch, that's been nice. I've done that in the hand occasionally and then once in a foot after a recurring Morton neuroma. And that worked really well. I'm trying to think of any other tricks. I haven't done the full on starfish, that our friends, Glenn Gaston and Brian Lofleur and OrthoCarolina have described that's obviously a for a much more extensive injury than a single, single digit amputation.
Charles Goldfarb:Yeah, I really like just the resection traction resection, I agree with implantation and muscle. Probably as my next step, depending on the level, I have done digital nerve to digital nerve coaptation. And I have to say it's generally worked. I do think it's silly to just think you can keep coming back further and further with attraction neurectomy Because that's I think, in the patients that have this happen, is going to likely or potentially keep happening. And thankfully, it's just not everyone.
Chris Dy:So let me get your thoughts on a slightly different case. Yeah, so this there's a patient who I treated them and as scleroderma, very bad scleroderma and it's failed all medical management. And a few years ago, it got to the point where we tried salvage kind of procedures, meaning we tried to do pretty extensive, you know, digital sympathectomy, ease and, and then did the arch and did the radial ulnar artery all under the microscope to save a finger and ultimately ended up losing a finger. And then a couple years goes, I mean, the guy is really happy with the end result. Couple years goes by and he comes in, I see his name on the schedule, I'm worried about what's going on. And it's his other side. And he's got the ulcerations going on and middle fingertip. And you know, I tried to Doppler him in the clinic and see what kind of flow we have and I'm not quite sure what's going on in the finger. So I sent him for arterial studies, just to get a much more detailed and objective view of the flow to the finger. And the studies actually come back showing that there is something reasonable in terms of the are the brachial index, or the digit index going to the finger. So I haven't come back to discuss those, like, look like we could try to save your finger. Like, I think there's a chance here, you know, we could do the sympathectomy, etc. And then he says no, like, this is just going to end up the way that the other one ended up, just take it now and it's his middle finger. So what would you do in that situation?
Charles Goldfarb:So that is clearly a very different situation, I would be grateful for this patient's perspective, because I would agree with it. And while you could certainly try something more heroic, I think his approach is very practical. And I would say I would do the amputation, you know, this would be without a tourniquet, it would not be true a lot in this situation, I think it's dangerous if you're going to use epinephrine in lidocaine in a patient who's avascular path. And so that could be a situation where you do the injection, and you could lose tissue. So it would be straight lidocaine. And I would simply try to take the finger is to keep the finger as distal as possible, and wait till I had some type of blood flow to confirm that we could get the skin edges to heal what is or was your approach.
Chris Dy:So I, I used a tourniquet, but I use it very low. You know, because I thought that the surgery would go much faster and more efficiently with it on and honestly, we had done it on his other side, and it turned out fine. So you know, so I took the, you know, I'd love your thoughts on this. But you know, we did a re resection at the level of kind of mid metacarpal. But in doing so we were also very careful to do as much as we could to preserve the intimate of the deep transverse inter metacarpal ligaments. And I'm curious as to how you manage trying to close that gap between the index and the ring finger metacarpals, so as to keep the you know, the strength of the hand, so to say, and to minimize kind of diastasis at that, at that level?
Charles Goldfarb:Well, I'll start by saying I love the transposition, I love taking the index finger, and transposing it to the middle finger obviously creates a bigger surgery, with more risk for healing with a patient with poor blood supply. But honestly, he would probably heal this. So I love that operation, it does create an arrow. And when I just do a ray resection without any type of transposition. You know, I don't do anything specifically to try to narrow that space, I think it's very hard to accomplish that goal. I've not been successful when I tried, I think you could Imbricate, the transverse metacarpal ligament. Or certainly you don't want to divide it inadvertently. But to some degree, you're going to have two ends of it because you're taking out the metacarpal in the middle. So at least repairing it if not trying to tighten it a bit makes a lot of sense. How did you approach it?
Chris Dy:I imbricated. A bit I don't I agree, I don't think you can really, truly close the gap, you can do your best to stop it from getting bigger. You know, he had we talked about the transposition, interestingly enough for his other side. And he said, Just keep it as simple as you can. And because I had the luxury of knowing how he did on the other side, we just kind of went with that as a template. But I've done the transposition in the past and a couple of patients in which this has come up and you know, they've done really well. So I totally get what you're saying. You know, for those of those listeners that are uninitiated, can you describe a little more technically about what you do when you take the index and move it over to the middle?
Charles Goldfarb:Yeah, let me say this I one of the things I talk about a lot and whether it's a Monteggia fracture or missed montelucia Whether it's a cleft hand that we're reconstructing, when you try to use soft tissue to make up for bony mal alignment, I think you will fail. And so you can't create a new Alienware ligament to hold the Radiohead in place. Even if you can achieve that in the operating room, eventually, that's going to fail. And I would say the exact same thing about a cleft hand or an amputated array, because you have to get the bony alignment, right. And then you don't have to worry about the soft tissues. When I and then getting to your question is, you know, this is what I do in kids a lot. If they have a cleft hand, we are constantly moving that index finger over to was hopefully there's a bit of residual middle finger metacarpal to both widen the first webspace and narrow the cleft, which is sort of what you're doing here. And so it's really a great operation, you try to maintain the length, and then you essentially are centralizing that cut metacarpal of the index onto the residual metacarpal of the middle finger, and I fixated with a good two over 2.4 plate and I've been really, really happy with that?
Chris Dy:And do you do anything in particular for their rehab? Is it? Do you mobilize them at all?
Charles Goldfarb:Yeah, I go slowly with them. And this again, these should heal. Sometimes it takes a while if it's a Metastasio area and again, especially in someone who may be avascular, Pap, it can take a while to heal, but if you have good fixation, it should heal. So good strong plate. And usually, after two weeks of kind of post operative dressing, that I'm usually doing a removable splint to get the MCP joints moving, but really limited to activities until we see healing.
Chris Dy:So then you bring it to a close one thing that I always try to make sure I do is when I make my skin incisions for these, if it's just a ray and not a transposition, making sure that I don't have to make a webspace later. So making sure I mark my incisions after that there's a book that I they were giving it away in the resident at the VA one year they were cleaning out the library when I was in residency, and it's a Atlas of amputations, which has been great for the times where I've had to do an amputation, talks all about skin incision, planning and everything. And I really make sure that I don't have to go in and create a webspace, which I think is can be very challenging for an orthopedic surgeon at least.
Charles Goldfarb:That's exactly right. Plastic Surgeons probably don't struggle with that. But you and I do. And we have to think a lot about it. So if you don't have to do it, you are certainly better off. Awesome. Well, this was fun. Yeah, you
Chris Dy:know, it's never fun to talk about cutting stuff off that you spend hours trying to put back on and other situations. But, you know, again, if that's what the patient wants, especially if they come requesting it, it can be a very straightforward solution and make everybody's lives better. As we
Charles Goldfarb:close, I will say that. Earlier this year, the fellows convinced me to replant an ablest thumb, which in a work or an injured worker, and I was like this is never going to work. And the patient is happy as a clam, the thumb is alive. Sensation might be an issue for the patient, which we may be consulting you on. But, you know, these are super interesting injuries. And really, the work we do either in the middle of the night or six weeks later can be really impactful.
Chris Dy:No two are alike. That is for sure. All right. Have a great day. You too.
Charles Goldfarb:Hey, Chris, that was fun. Let's do it again real soon. Sounds good.
Chris Dy:Well, be sure to check us out on Twitter at Han podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDYMD spelled d- y and if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your 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