Season 3, Episode 46. Chuck and Chris begin the first of a 4 part segment on radial nerve palsy. In this podcast, we discuss diagnosis, evaluation, and initial management of patients with radial nerve palsy. We plan episodes on tendon transfer, nerve transfer, and therapy in this population. Note- we apologize for some background noise (kids).
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Listings at theupperhandpodcast.wustl.edu.
Season 3, Episode 46. Chuck and Chris begin the first of a 4 part segment on radial nerve palsy. In this podcast, we discuss diagnosis, evaluation, and initial management of patients with radial nerve palsy. We plan episodes on tendon transfer, nerve transfer, and therapy in this population. Note- we apologize for some background noise (kids).
Subscribe to our newsletter: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
See http://www.practicelink.com for more information from our partner on job search and career opportunities.
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.
Listings at 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'm great. We're back at it.
Chris Dy:We are back at it. I apologize in advance. The children are running around and there's going to be in some inevitable inner interjections I should say
Charles Goldfarb:Hey, that is beautiful. That is life. And we'll get through it. Well, I
Chris Dy:My apologies in advance to the to the technical editing staff on that front.
Charles Goldfarb:That's fair. I'll do the best I can that I have for a highly paid technical expert. I want to share our case.
Chris Dy:Yeah, let's do it. It's been a while since we've done cases.
Charles Goldfarb:Yeah. So I, it's interesting case of a young woman who came in with hand pain, really centered over her third MCP joint after a minor trauma six months ago, that led to a nondisplaced metacarpal fracture. And so I got X rays, and she had a vascular necrosis of the metacarpal head. Which is not common. And I've seen a handful of times in my in my practice, but really, really interesting.
Chris Dy:How often what was the thing that led you to get the film's at this point, because sometimes, you know, if it's if you have a metacarpal fracture, you assume everything's healed? What drove you to get the film's at that point? Because honestly, I will say that I try to be pretty prudent and judicious about when I get films, you know, for a few reasons, one of which being radiation exposure, cost and clinic flow?
Charles Goldfarb:Yeah, it's a great question. First of all, I didn't treat her initially not that I would have anything would have been different. And she had swelling at the joint level. And so, you know, the question, you know, at least in St. Louis, is pretty uncommon that one can obtain an MRI, if that's what would have been best for this patient without having X rays. And so insurance companies push us to getting X rays, but I have your philosophy, I don't want to get an x ray. Unless I really have a strong reason to do so. But in this case, I did, which demonstrated the avian
Chris Dy:now, is this a fluoro in the office, or was this an actual formal radiograph?
Charles Goldfarb:So here's how I and I'd be interested to hear your thoughts, but I obtained plain radiographs rather than the far easier, far faster, far less expensive c-arm radiograph option which we have in our office, but I obtained plain radiographs when I need definition. So some carpal abnormalities, when you know the precision of a plain radiograph will offer something better assessment of healing or alignment or whatever. Or if I'm just not certain what's going on sometimes I think it can be helpful, but c-arm are beautiful and the ability to position for a c-arm is remarkable.
Chris Dy:Yeah, I agree with you on that there are some specific conditions in which I will always get formal radiographs. But then also from a documentation perspective, especially as insurers now are actually requiring some of them which is crazy or requiring actual images to be sent to their office for review prior to authorizing certain procedures now that hasn't really hit the hand surgery realm yet, but they are doing that for spine and for hip and knee arthroplasty. There's one particular insurer that requires images to be sent. Now on the other end, you're like Who the heck is reviewing that? But you know, the it's a reality coming. So I usually will use plain radiographs for something for scaphoid fractures are suspected scaphoid fractures for I'll get it for SL because there's a nice SL series that we have here. And then I think in this particular condition, I will admit I probably would have just gotten Florida scanned images. But Hindsight is 2020 So probably would have gone with plain radiographs. That's what you're telling me to condition as
Charles Goldfarb:well and the beauty of a c-arm is so quick and so easy and you can always order a radiograph after so got the radiograph new the diagnosis trivia question for you. Dr. Dy. Do you know who gets the credit for even though it may not be totally accurate? And who's what is the eponym? Around metacarpal head avian I know you're a smart guy but you Don't dabble in sports too much.
Chris Dy:You know, Chuck, I don't know. But some friend some angel left something in the chat for me. I couldn't do it, man. I couldn't do it. You know, I remember when when we did an episode of firsthand one of the last ones it was with. I won't say who but there was an episode that revolved around the elbow, in which the guest started pimping, me and my co host And it was the worst experience I've had in recent February. And it made me recall all the times where I was on the receiving end of these, this line of questioning, and gave me a little, little empathy for now that I'm on the delivering end of questions, or Sure. Dieterich disease is the deterik, Dieterich. I don't know.
Charles Goldfarb:I thought it was Dietrich disease, but it's not it is Dieterich disease, which is totally irrelevant. I think most of us have gotten away from pampering on eponyms, but there is some interest so, not to belabor this case, but lengthy discussion of the family after the MRI confirmed exactly what we thought. And we proceeded with a MCP arthroscopy. Now, it wasn't certain that would be a sufficient treatment. But sometimes I've been surprised. And so we did a joint debridement large hole in the metacarpal head. It's not one, this is not a situation where we thought that micro fractures or Bremont could really lead to healing. And indeed, it did not. And so patient comes back six months later, still with discomfort, and we had to make a bigger decision.
Chris Dy:What are the options at that point? I mean, I think the MCP arthroscopy is an interesting one, and certainly where if that's, you know, in your skill set, certainly worth offering. It's not probably where I would have gone honestly, I would have referred to you. But you know, what are your other options beyond that now?
Charles Goldfarb:Yeah, I don't think they're good. So you know, you have a young patient in this case, she was around 15 and 14, but pretty close to skeletal maturity, if not at skeletal maturity for the metacarpal. itself. So you know, an adult, you can think about fusion, you can think about arthroplasty. I guess you could think about a resurfacing arthroplasty. But really, the only thing I knew to do at this point was notes. And I've done it a couple of times before, with good but not perfect success. And I thought it would be a good option here. And that's indeed what we did. The interesting thing? Well, I think the whole thing was interesting.
Chris Dy:Before you before you go on how big is the lesion? And how, you know, we talked about, you know, my and all my knowledge of Dieterich disease? How big are these lesions? Typically? Are they the entirety of the metacarpal? Head? Are they a portion of the cartilage? You know, where does it tend to affect
Charles Goldfarb:my experience has been that they are always large, this one was 10 millimeters pretty circular. And there was a rim, a radial older and volar rim which was intact, the dorsal was gone. And so it was the large it was 75 80% of the metacarpal hit remarkable. And so again, options are lousy. And I gave the family an option, an autographed or an Allah graft oats plug. And I think wisely they chose allograft . Because she was a runner, and she was a three sport athlete. And there was some concern about harvesting an oats plug from the knee. Now I think that's, you know, those surgeries do really well, I have another one on this week. But I was happy to do an allograft and it makes for a really efficient surgery.
Chris Dy:Now, are you ordering a metacarpal head when you're requesting your allograft or you, I don't know what surface you would take from that matches that contour. And if you can get that specific when you are requesting an ally graph specimen.
Charles Goldfarb:Yeah, so essentially, here's one of the companies and I might as well say it, I don't have a relationship with them as Arthrex, they actually offer allograft plugs like you would take from the knee. And so it is just a plug and you specify the size, and they provide the plug, and you plug it in. And so it's not like you're requesting and I am in the process of requesting a capitellum because I have a massive capitellar lesion. This is different. This is literally just a plug of cartilage and bone.
Chris Dy:Does the curvature and the contour of it matter? And how do you how can you do you get a selection of things you can use and you can mix it there, you know, shave it down that kind of thing.
Charles Goldfarb:You don't, all your control is around the way you drill your hole. So basically you drill a hole into the lesion to allow it to accept a slightly larger plug and then you press fit the plug. So the way you draw your plug can help and then you have a little bit of an ability to the cartilage is pretty thick, even a little bit of an ability to contour the cartilage. In this case, it worked out really well but the fit was great and the alignment was good. It's not perfect. It's not exactly the same as a metacarpal head but we had a smooth arc of motion and and patient degrade. So really interesting to me
Chris Dy:is that the fixation is all press fit or is there any additional fixation all precedent? Really interesting, cool case. Thanks for sharing.
Charles Goldfarb:Well, I feel I feel like if I ever give in the approaching holiday season with a sports case, I have to pay the price and so my price you If I had to agree to a three part nerve series My god!
Chris Dy:You did. But it's a nerve series that every button that believe it's a nerve series you published on, Mr. Workman. But let's talk a little bit about our friends first before we before we jump in and give it away. So the upper hand is sponsored by practicelink.com, the most widely used physician, job search and career advancement resource.
Charles Goldfarb:Becoming a physician is hard. But finding the right job doesn't have to be joined practice link for free today, at WWW .practicelink.com. Visit our friends, they have a they have a huge wealth of practice information, not only helping you find a job, but just the resources they have on the website. It's really impressive.
Chris Dy:Yeah, I mean, I think seeing checking out the website will at least give you a sense of what questions you should be asking as you look for positions, you know, so because you know, whoever's listening, may be looking at as broadly as a private practice versus looking at something like an academic but at least asking the questions and seeing what's out there will certainly help you.
Charles Goldfarb:Absolutely. All right, there's a drumroll going on in my house. Tell us about our nerves series, what are we going to do?
Chris Dy:Well, I've been seeing patients, you know, I've seen a lot of radial nerve palsy patients that at various time points on the spectrum, whether it's somebody who early on, in trying to figure out whether this, you know, getting a diagnosis and trying to figure out whether to, you know, go with watchful waiting, surgical indications, that kind of thing. And then, you know, trying to figure out that if you're going to surgery, what kind of surgery to do, and then the technical details. So I think it'd be good to at least talk today talk about maybe the condition indications, and then potentially, during future episodes to talk about, you know, technical aspects of surgery, because I know that you've done a lot of tendon transfers in your years and written a lot about tenant transfers. One of the chapters I read and refer my trainees to is written by you about tenant transfers for radial nerve. So and then we could talk about the nerve stuff at some point when you are open to talking about that.
Charles Goldfarb:No, I love it. I obviously, I'm a bit old school and I do believe in tendon transfers. For many conditions in my pediatric population, especially with spastic disorders like CP I do that regularly. But yeah, I think it's great. So we'll talk broadly to start and then maybe we'll have an episode two and three, on tendon and nerve transfers, respectively, I think it'd be a great way to start winding down 2022.
Chris Dy:So let's talk about a case for example. So how, how do you think about a patient with a closed humeral shaft fracture who, you know, say they were treated, not treated surgically, they're noted to for the for the shaft for the humeral shaft, but they're noted to have a radial nerve palsy during their er evaluation, and they're referred to you about a month out from their injury. And they have a low radial nerve palsy, triceps is intact, but they've got absent sensation in the superficial radial nerve distribution, and they've got a wrist drop, and their MP joints are down.
Charles Goldfarb:Yeah, it's a great question. You know, a classic presentation. You know, there always is talk about whether it was the nerve palsy present on arrival to the ED. If the humerus was reduced that it then become identifiable, I guess, in this case, patient comes to the ED humerus fracture, radial nerve palsy, let's just say the patient was treated in a co optation splint or whatever, in my experience, and my personal practice, is to follow that patient and give the nerve time to declare itself and give us time to potentially obtain a nerve study. How do you think about it?
Chris Dy:I think that, you know, mechanism matters a lot. So if it's the kind of standing level fall, I don't get as excited as if it was a ballistic or sharp injury. And that does change how I think about the workup. Ultrasound has helped us a lot, I think, as we think about, you know, is the nerve in one piece or two pieces to put it very plainly. So if there's a ballistic component to it, or there's a sharp component, or there has been surgery involved, and we don't know whether the nerve is structurally intact, the ultrasound helps early on with answering that particular question. Because otherwise, you're waiting at least three or four weeks to get a nerve study, if you choose to get when even that early. Before you can see any signs of degeneration because valerian degeneration hasn't kicked in to the point where it can be picked up on the nurse study until about three or four weeks. So you know, I think that that so called electro diagnostic gap can be filled in pretty early with an ultrasound if you have concerns about continuity of the nerve now with a closed, you know, standing level fall type mechanism. I think it's truly very hard to think about whether the, you know, that conceivably, that the nerve could be in two pieces, so I'm less likely to act early on that.
Charles Goldfarb:Yeah, I think that's fair. And that seems like that's the situation we really Starting with soy fracture from a fall, we would assume it is a narrow apraxia and will recover. In this very specific case, probably don't do an early ultrasound, if the patient does not demonstrate clear recoveries, six weeks, and they might start showing some signs. Do you get your nerves steady of six weeks?
Chris Dy:Well, I mean, you know, ideally, it's, you know, the you see him at the six week mark, and then you get the study at six weeks. But in reality, especially at this time of the year, I'm probably thinking ahead and scheduling them for some kind of nerve study. You know, the six week study for me is a luxury. I like it because it gives me a baseline, it gives me something to work from going forward, do I truly need it? No, a lot of our decisions is going to hinge on the three month mark. So, in practicality, if this patient gets to me at six weeks, I'll examine them get a baseline and then set them up for a follow up exam and a nerve study at the three month mark and a nurse study before I see them just so I can talk to them about the results of the study, and the in reexamine them.
Charles Goldfarb:You again, there's taking this very simplistic case, do you have to have a nerve study? Or can you examine it three months? And if they demonstrate radio wrist extensor improvement? Or maybe some you know, finger extension improvement? Do you still feel you need a nerf study? Or is it just for those cases that are completely uncertain?
Chris Dy:No, I mean, I think that I think examined him again, at the three month mark is absolutely helpful. And if again, if you have the opportunity to do that, where you could quickly get the study that you want shortly thereafter, it's not going to create more issues with patients traveling in and, you know, having to come back in for another exam. And you know, you don't have any issues with patient follow up, then. Yeah, great. I get do a repeat exam in three months, and then determine whether you need to study. There are a lot of folks that will you know, if your baseline and your default is to treat these patients non operatively, I think you probably will be more apt to slow down on the nerve studies and, you know, give it a lot more time. I admit that my bias is that, you know, I'm probably more apt to discuss surgical intervention, just because of the patients that I've seen here, you know, and then the fact that if you wait, wait, wait, wait, wait, and it doesn't get better. And you're in that 10 to 20%, of, quote, Nuray practices, which by that point have declared themselves to not be neuro practices. Is it too late? If you're at the nine month mark, I mean, that's the data that was shown by Omer, with all of the ballistic injuries from the wartime experiences, and in the mid 20th century was that yes, a lot of them will get better. The problem is that if they don't get better, then you are stuck with you know, a very not a very narrow, but you have a definable set of options that do not involve nerve reconstruction, mainly tendon transfers.
Charles Goldfarb:Okay, for those of us who aren't masters of our nerve study domains, what might you see three months or four months, which would say to you, waiting no longer makes sense. And obviously, this is more than just reading the interpretation of the nursery?
Chris Dy:Well, so I'm going to assume that you've got at three months, you've still have absence of wrist extension, and absence of thumb extension and absence of MP extension of the of the digits. So if that's the case, and then you can even say if you're able to discern whether breaker radiolysis present or not, you know, so if that's the case, on my nerves study, what I'm looking for is whether there are any motor unit potentials or recruitment, with attempted wrist extension and attempted finger extension, I don't really trust the single motor unit. But if there's more than that, then I think there's a chance that could get better. And that's where I think that you know, the role of serial exams comes in, not necessarily serial EMGs. But you know, if there are few motor units, and the recruitment pattern is reasonable in terms of how it's listed on the table, then I think you may give it a chance to see if it gets better. You can look at things like C map amplitudes, I think they're a little less reliable for in this particular case, but they can be useful. And then you can look at the sensory sensory studies for this official radial nerve. But again, a lot of what you do is ultimately going to hinge on on the EMG of the affected muscles, specifically, the wrist extensors and EDC.
Charles Goldfarb:Does your interpretation of a nerve study differ in the situation of a ballistic injury? Or an open injury? Or is that more where you bring in the ultrasound or the nerves study findings are those findings and the importance of those findings similar no matter the type of
Chris Dy:trauma, it matters a little bit the type of trauma because sometimes, you know, if there's a muscle injury, the ability to like the ability to recruit and have a normal, a normal pattern is going to be different. So for example, I had a patient who I treated when I was on ortho trauma call, who had a crush injury to the forearm with both bone for fracture, and aim palsy, and then a muscular attendance injury to the EDC. So, the treated to play the book one form of fracture repaired the musculotendinous injury to the EDC, and have been following the aim. And we're not, you know, we obtained nerve studies for the aim and, you know, if we were to obtain a nerve study for that, for the EDC, not that we will get in this particular case, but that would show an abnormal recruitment pattern, not because of the nerve component to it, but because of the muscle involvement. So I think, you know, taking into account the totality of the injury is important, but in this particular case scenario that we gave, I don't think it matters.
Charles Goldfarb:So let's talk about timing. So give me a list, if you can, of indications for early intervention, and some of this is going to be self evident, maybe all of it will be self evident. But let's just, let's just keep it basic, in which situations do you intervene with nerve exploration, early,
Chris Dy:sharp, laceration or traumatic wound in the area where the radial nerve is coursing, you know, basically starting at, you know, the so called spiral groove and then distally, to the level of the elbow, and then at the radial tunnel, so if you know there's a wound in that area, and you've got a policy, that I think it's very reasonable to consider exploration. Now, an area controversy is for patients who have had surgery on their humerus, and the nerve was not directly exposed. And there's a policy after surgery, whether it was present before or after surgery is always questionable. But I think exploration of the nerve there is, I think it's helpful, although, I probably will use the ultrasound because we have it to answer the question about whether the nerve is in one or two pieces. Even if the nerve is one piece, it could be scarred down to the plate, which we've also seen, or it can be tickled by a screw, which we've seen. And that's something that I think has a poor prognosis. And there are some, there are some parts of the world, for example, in the UK, where they have very low threshold, and Britain even have guidelines saying that they shouldn't explore any of the, you know, post surgical nerve policies. I don't think we've gotten there. But I have a lower threshold to explore and get the information because I think that adds to the diagnosis.
Charles Goldfarb:I love that. I love that. That's that's very helpful. And are there any other patient factors that push you chose an earlier surgery? Aside from coexistent injury? Like you mentioned, were you going to have a hard time with a nerve study? comorbidities anything else? Or is it pretty much as straightforward as you have outlined?
Chris Dy:That's never as straightforward as that I think that there are some patients who have a little more that want a little more information. And their personality is such that they want to know what's going on. So I think that's an earlier indication for exploration.
Charles Goldfarb:Perfect, perfect. Yeah, that makes that makes a lot of sense to me. And then ultimately, indications for a late exploration, get back to ultrasound, in combination with nerves study findings, suggesting that it's more than nerve injury is more than a nerve, a proxy.
Chris Dy:Yeah, and I think that, you know, as we, as we discuss in our next episode about this, I think the timing matters. I think it's whether we go with three months versus six months versus nine months also depends on the menu of options you can give patients if you're less likely to offer something like a nerve transfer, because you don't have experience with it. That's okay. And then I think you're able to slow down your discussion. And then even you know, if you're willing to offer something like exploration and grafting at the side of the injury, plus minus neurotransmitters that also changes your your timing considerations. So I don't want to leave people with a cliffhanger, but we probably should because my family is about to erupt.
Charles Goldfarb:And that is our life stage difference. I'm sitting quietly in my basement so I don't wake up my family. You are living the family life right now.
Chris Dy:I've got Legos crawling on me and I've got my son coming in wanting to show me his hockey cards. And I've got well last
Charles Goldfarb:question in all seriousness is if you classify median, radial, and ulnar nerves, as most amenable to nerve grafting with with good recovery, where does the radial nerve fit in that it radial nerve seems to do well with nerve grafting? This is a teaser for our next episode, what's your thought on those three nerves comparatively?
Chris Dy:I agree. And I think it's largely because of distance to target but I think the radial nerve does have the best chance. And you know, one of the people that was kind enough to have me as a visitor gentleman for tele has published on that particular scenario with radial nerve grafting. So I think the regular is the best one.
Charles Goldfarb:Perfect. All right. With that, we will call it a call it an episode, and we look forward to episodes two and three on radial nerve treatment. And we'll discuss a little more on timing and how we get into the specific treatment. So, Chris, you have your work cut out for today. Enjoy it.
Chris Dy:Yes, the Dy family house is officially awake. But we could also potentially have a part 4 we can invite Macy to come on and talk about the therapy parts of it. So there we go. That might bring us to a close for 2022.
Charles Goldfarb:I love it.
Chris Dy:Let's do it. In early Hanukkah and Christmas for all. Alright, have a wonderful day. You too.
Charles Goldfarb:Bye bye. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @chrisdymd spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
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