The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Discuss Claw Hand

January 15, 2023 Chuck and Chris Season 4 Episode 2
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Discuss Claw Hand
Show Notes Transcript

Season 4, Episode 2.  Chuck and Chris return after one week off to catch up and begin a discussion on claw hand. We describe presentation and etiology and start to discuss surgical treatment.  More to come on this topic.

Referenced manuscript: Goldfarb CA and Stern PJ Low Ulnar Nerve Palsy  Journal of the American Society for Surgery of the Hand, Feb 2003, 3:14-26

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Charles Goldfarb:

Welcome to the upper hand podcast where Chuck and Chris talk Hansard.

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:

Oh, quite well, it feels like it's been a minute.

Chris Dy:

It has been, well welcome to 2023. I know that we I don't know- we have savvy listeners. I don't think you had a podcast and then we took a week off last week. And then we had an episode that we recorded before. And love that listeners picked up that that was recorded before the New Year. give them enough credit. Dr. Dy. Yeah, we can't get one past them. So. So yeah. Welcome to 2023.

Charles Goldfarb:

Yeah, yeah, it's off to a good start. How was your holiday season?

Chris Dy:

Well, you know, we were supposed to go to Estes Park, Colorado for a little family trip. And then I'm sure many of our listeners also got caught up in the whole Southwest cancellation. snafu. More than a snafu. It's our trip was canceled and that we decided to take it an alternate route. And because we were supposed to travel with my family from Florida, and nobody was flying anywhere. We drove and met them halfway in your home former hometown of Birmingham, Alabama.

Charles Goldfarb:

I was so excited to hear that you went to see my birthplace. How was Birmingham?

Chris Dy:

You know what, we had a fun time. You know, so we're not skiers, so it's just gonna be mainly like hanging out inside anyway, to be honest with you with some snow activities for the kids. So we got to do all those things, minus the snow activities, but in warmer weather. So you know, the kids had a good time with their cousins. And you know, me and my wife and my sisters and my brother in law, we had a good time. So there was some cooking. There was a fair, we ate our way through Birmingham. I've got a bunch of spots, some of which you recommended others in which we branched out a bit from, and we didn't really get time.

Charles Goldfarb:

So you are not staying in Birmingham Central and is the Birmingham that I recall got rural pretty quick outside the city limits

Chris Dy:

we were in, Was it Mountain Brook? Is that the that's where you recommend. So we were in Mountain Brook and I was talking to somebody they asked where we were staying. And I told them and so when walk around outside there.

Charles Goldfarb:

That's why he got such a good deal on that.

Chris Dy:

Well, it was a last minute Airbnb. So. So yeah, we had a really good time. It was a wonderful place. The kids had a good time. We had fun, all good. How was your holiday?

Charles Goldfarb:

We also were struck by Southwest. Although it all worked out, we lost we were gonna go to California for five days, just to you know, get out of town and get the kids together and have them a little bit captive. And Jake made it out. No problem flying from New York and the rest of us got our flight canceled. We lost two days. But we still weren't you know, we only ended up being there for two and a half days. But we kind of had to go because Jake was there. It was fun. It was a great time highlighted by some time spent with our wonderful fellow David Wright and his family. And it's kind enough to take us out and a tour of San Diego Bay on his beautiful boat. So there was definitely a highlight. The kids loved it.

Chris Dy:

Awesome. That sounds great. Yeah, I saw the picture. And I also heard from a birdie that David may have hosted Jake for Christmas dinner.

Charles Goldfarb:

Yeah, well, yes, we were. We had a call you had a great trip plan. And Jake got out there on Christmas Eve and we did not and David was kind enough to invite him over in the event. His family even gave him a nice gift.

Chris Dy:

Wow, I thought it was gonna be like the Plaza from Home Alone where Jake was just sitting there eating rooms, watching movies, but I guess he's a little older than that.

Charles Goldfarb:

Well, we joked about that because he was in a nice spot. And he you know, there are worse places to be stuck alone.

Chris Dy:

I'm sure I'm sure that his accommodations were were adequate.

Charles Goldfarb:

Yes, for sure. Sure your practice didn't slow down on the holidays at all, because mine was out of control. Yeah,

Chris Dy:

it's I mean, our friends from overseas are gonna laugh at the American healthcare system. But the end of the year, I met my deductible, suddenly urgent carpal tunnel situation and many other chronic conditions. You know, that became real. I started hearing that refrain in September as I'm sure you did, too. And, you know, like for many procedure lists or surgeons in the US, it's a very busy November, December and maybe an exhale in January.

Charles Goldfarb:

Yeah, mine's carried over into January. I feel like I still haven't caught up but I mean, it's good. It's a nice way to end the year. But it's nice to take a few days off as well,

Chris Dy:

Well, you know, I've got the Monday Friday clinic schedule. And because of the way the holidays fell this year, I paid a substantial penalty. So every clinic in January thus far has been absolutely bonkers with patients. You know, and it's, it's been busy. But busy is good. A lot of learning, as the residents that I'm working with now said, a lot of learning and learning quickly.

Charles Goldfarb:

So a little teaser, I think maybe next episode, I don't want to lock us in. But I'd love to talk some about the adolescent elbow which, which hopefully would appeal to a wide audience. As I've mentioned on this podcast, it's remarkable to me what I am seeing someone who- I don't even know if m name is out there as an adolescent elbow person- but I do a ton of it, and increasing complexity of challenges. So I'd love to share some thoughts and pick your brain just on kind of developing somewhat of a niche practices. I've always had an each practice and other areas, but not this. So could be an interesting conversation.

Chris Dy:

Yeah, no, I think that that's it's amazing. That's a practice niche that did not exist, even as recently ago when I was in training, which was probably just like two or three years ago. But that that didn't exist, and that was not, quote, a thing. And I think that it'll be interesting to hear you talk through how that's developed for you. And where you envision that going. While you clearly I have developed a niche in other areas, including congenital and pediatric hand, and as well as the sports practice in general, I think the landscape has changed and something that's even as hyper focused as adolescent elbow, you know, we'll be it'll be different to try to develop that in 2023 and beyond.

Charles Goldfarb:

That's exactly right. Today, we have a great topic. But maybe before we jump in, we should thank our sponsors.

Chris Dy:

Yes, the upper hand is sponsored by Practicelink.com. And yes, they are still sponsoring us. The most widely used physician job search and career advancement resource, becoming a physician is hard. Finding the right job doesn't have to be

Charles Goldfarb:

joined practice link for free today at www.practice.link.com/the upperhand. So it is a it is a service they provide, which is really interesting. And after speaking to some of our residents, it there's no easy resource. And so maybe maybe it's a it's an option for some hopefully, I'm not looking for a job anytime soon. But just in case.

Chris Dy:

You never know. You know, I think that at the very least, it's somewhere to start and how to start thinking about the questions to ask as you look at offers, and so much of the that market is think it's still highly, I guess, unregulated. So putting some structure around it and knowing how to approach a process is good. And apparently you have to use this link, otherwise, we will not get credit.

Charles Goldfarb:

Please, please go often and time

Chris Dy:

And hit refresh. And login to many VPN from different countries.

Charles Goldfarb:

It's actually interesting, we probably could have an interesting episode talking about job search, because I've learned a lot not necessarily because of this relationship. But just it's an it is a really interesting process for

Chris Dy:

sure. Hearing hearing our residents and fellows go through it. I think you pick up pearls about how the process has changed and honestly how individual it is. But I think that having having an understanding of how to think about it even know where to start, I think can be very useful. Yeah.

Charles Goldfarb:

And when does it start? You had a good idea for a topic today, which may end up being a two parter, but we thought we would jump in and why don't you you want to start by telling us about a case?

Chris Dy:

Well, yeah, I mean, so I saw, I saw a patient with advanced ulnar neuropathy. And this was, you know, the completely burnt out and cold all ulnar nerve. So no way of salvaging that with any transposition and supercharge. And you know, there was not a substantial pink opponent. So really, you really were left with a functional issue of claw head and the classic claw hand. And, you know, I think that thinking about the claw hand was always really challenging to me because I didn't see that patient as a resident very often. And I saw some of it as a fellow but I think that what you see as a as a fellow in clinic and an OR is very subject to waves in practice and you know, who's coming in on what they did some of it's very random. So, you know, I didn't get a lot of exposure to thinking about the claw hand you know, but then I read this great article by a young Dr. Goldfarb when he was in training with Peter Stern that was published in the now defunct Journal of the American Society for Surgery of the Hand.

Charles Goldfarb:

I love that I feel some pride in having published in but not contributed to the end of a journal which was review Journal. Arnold Peter Weiss really led that effort. It was a very good journal, I'm not sure exactly why it's no longer present. But that was that review article on low nerve palsy really had a good deal of information on it. And there's not a lot new. So 20 years ago, we was about the same as it is today, actually, maybe even worse.

Chris Dy:

I mean, I think that that that review article, somehow advanced the field. But it's been disseminated as part of the Stern classic readings in the in the folder there. So I think a lot of people have read it. And for good reason, it's a really good article. And what I love about it is it very clearly breaks down the reasons for a claw. On top of that, it goes into all of the physical examination findings that that are commonly discussed. So you know, I think it is a really solid read for any medical student, resident, fellow Hand therapist, who wants a fundamental understanding, because I think you can build a lot of knowledge after you've read that article,

Charles Goldfarb:

or attending who doesn't see this very often. And I think that's most of us, you know, I, and I'd love to go into detail. I recently been treating a family with Charcot Marie Tooth, and they present like ulnar nerve, chronic ulnar nerve, and it's really fascinating to see them and think about, it's the same situation, how do you reconstruct them to improve their function, especially when you're not dealing with pain, and then you're not going to recover sensations intact for this group. So it's the same conversation just with a very specialized group.

Chris Dy:

So I mean, I think that one of the challenging parts about just, you know, these complex patients, and this aspect nerve is just trying to break down what's going on, and what needs to be done. And I think that, you know, I was seeing a run of complex like, kind of weird cervical radiculopathy, double crush kind of patients in clinic, do they? And I was reminded of the quote, you know, "how do you eat an elephant?" One bite at a time. So you got to start somewhere, right? So you know, this was not going to be a cooking reference. But it's, I think that understanding the lesion and then understanding what drives the lesion from a purely anatomic or physiologic perspective, and then figure out what you can do to functionally make a difference is the way to go

Charles Goldfarb:

and understanding what each patient is bothered by. And that'll be interesting part of this conversation. So, so how do you want to start?

Chris Dy:

Well, I mean, I think that maybe you could tell us a bit about, you know, why if in the classic isolated ulnar neuropathy patient, why they get a claw deformity, you know, so what's going on at each of the joints, because if you break it down at that level, then I think the rest of the process of treating it follows.

Charles Goldfarb:

Yeah, I think really simplistically, you lose the function of the intrinsic muscles of the hand. And that includes the interossei, and the lumbricals, especially ulnar sided interossei. But that varies from patient to patient. And once you this, essentially what we're talking about is you're losing the extension of the PIP joints, the way I think about it, you may think about it differently. And this is just me processing the visual, is when you lose your ability to actively extend the IP joints. And again, mainly the PIP joint, your body attempts to compensate. And you end up over firing your extrinsic extensors, your EDCs and your extensor digiti minimi. And over time, especially in some more lax individuals, you get marked hyperextension of the ring and little finger especially. And then you get a flexion posture of your ring and little and maybe your middle fingers. So that's the simplistic overview on the owner side of the hand. What did I miss?

Chris Dy:

None of the I mean, obviously, that's That's it right? I mean, you wrote the article, right. So, but I think it is the absence of on their intrinsic function in the setting of maintained radial(nerve) extrinsic extension of the fingers. So you still have something that is going to try to pull on both the MP and PIP joints into extension, the radial nerve with the EDC, the EDM and the EIP. But you lack the ulnar, the ulnar nerve intrinsic function of flexing the MP joints and extending the PIP and DIP. So you have an imbalance now, and you know, I think one of the key so that's the straightforward one where you don't have any crazy radial nerve involvement. And then the thumb I want to leave for a separate discussion because I think that's a little bit harder to tackle. So, if you have somebody that's got clawing, first off when you see the patient, I think one of the important things to check for is maintenance of supple, supple joints. So means making sure that this is a passively correctable claw deformity because As I think it becomes a much harder issue to deal with, if things are not passively correctable,

Charles Goldfarb:

and that's our job. And I'm sure Macy would, would educate us both. But that's our job as physicians and therapists, is early recognition in the setting of trauma. So if there's a gunshot wound to more proximal or nerve, for example, even if you supercharge reconstruction, I think you have to act as if you expect there to be a risk for claw. And I do two things in those patients. One, I asked therapy to educate on passive extension, to not lose it and to use some type of lumbrical bar to keep the MP joints flexed, which allows the patient to actively extend the IP joints. So those are my two early steps early intervention.

Chris Dy:

Yeah, absolutely, completely agree with that. And, you know, that mentioned of the lumbrical bar is very helpful, because you know, that flexion of the MP joints is an important concept to understand in terms of your options for correction of a claw deformity. So in a claw deformity, as you've mentioned, I'm just going to say it differently, just in case people are going to hear it differently to your MP joints want to extend your and then your PIP and DIP joints essentially want to flex, and especially for the ring and small finger. So what you've got to do to try to get those, those ring and small fingers into extension at the PIJ in particular, is get those MP joints into flexion. And I think that's the biggest thing to assess, you know, and the physical exam maneuver that I like the most is the Bouvier maneuver. And that's where you hold the MP joints in flexion. And then you ask the patient to straighten their fingers. And to me that's it's a big decision node there, whether they can straighten or extend their PIP joint. If the MP joint is held in flexion, did I summarize that correctly?

Charles Goldfarb:

You did that I think that's important to understand as a clinician, not only because it helps you better process and discuss with the patient, but frankly, it drives the surgical decision making process as well.

Chris Dy:

Right. So what's your decision making process? I mean, so you think about all the different things that you could do with the underlying principle of wanting to get the MP joints into flexion? With the goal of using the extrinsic extensor, extensors to then drive PIP extension, how do you think about different ways to get that done?

Charles Goldfarb:

Well, the first in my mind, the first step is how do you control the MP joints? So there's two issues. One control the MP joints and for some patients, that's sufficient. And then the second decision making is, do you want to try to power PRP extension? So if they the Bouvier test is positive, meaning they can't do that, then you have to decide? Do I want to try to power finger IP joint extension? And do I want to use a classic finger flexor to do that? Or do I want to use another muscle group altogether? Like the ecrb or ecrl, extended with a four tail graft? And so those are I think that's it really for the owner of the hand reconstruction? Those are the decisions.

Chris Dy:

Right, exactly. So if you if you do the Bouvier maneuver, and the MP joints are held in flexion, and you're able to get active extension of the PIP joint. Do you think that that's enough to rely on holding the MP joint and flexion and go with what is called many would call a static kind of transfer? And do you think that the only indication for a dynamic type transfer is if you don't get active extension of the PIP joint with the Bouvier maneuver MP joins held in flexion.

Charles Goldfarb:

So I certainly am rapidly becoming one of the elderly senior statesman on the hand world in the sense that I've been doing this 20 years now. But and I'm at a you know, a big tertiary quarternary type referral center, but no one does a lot of this no one. And so, you know, leprosy taught us a great deal about this problem, but those surgeons are just not around anymore. So no one has a huge personal experience. My personal belief is that I really do still like a capsulodesis but I don't think it's sufficient because it will stretch out over time and most patients I don't believe in bony blocks are some of the other historical things. To me, it's very simple. You Well, nothing's nothing simple, but you do I do a volar capsular thesis and essentially through the same incision, I add a Zancolli lasso. So how do you think about it?

Chris Dy:

So I mean, the principle is to keep the MP joint in flexion and there are a number of different ways to do that. And you've listed a couple of them. You know, the first way to get the MP join flex would be to as you're talking about advanced the MP joint volar capsule and in an advancing that, that's going to hold the MP joint in flexion. Another way to do that would be to intentionally bowstring at and essentially do a an aggressive release of A1 and A2 in order to get MP joint in flexion. And that can be done in combination with the capsulodesis. And then you mentioned I might be missing something else. But you mentioned one of the other ones, which is the Zancolli FDS lasso, in which you find the FDS tendons slips as they insert distally, or wherever you choose to take them, release them distally, so they're no longer flexing the PIP joint. And then in there a number of different ways to do this, but then loop them back on top of themselves. So you've got them on top of the A1 and A2 pulleys volar to the A1 and A2 pulleys, and then sutured back to itself proximal to the A1 pulley. Can you think of any other static kind of procedures that would hold the MP to an inflection?

Charles Goldfarb:

No, those are the main ones I like, again, historically, people put a bone block in the joint. I mean, you confuse the joint if you want. But that doesn't make any sense to me. So I think in my mind, you've summarized it very nicely, including the technique. And I think there are different ways to do Zancolli lasso. But they're all about the same in my mind, whether you go over A1 and A2 and there are different ways to do it, but accomplish the same goal, a dynamic transfer, that when the patient fires tends to flex the MP, and they may be able to extend the IP joint more easily.

Chris Dy:

Wait a minute, this is a static transfer this is statically, holding the MP joints in flexion. Right,

Charles Goldfarb:

the capsulodesis, but Zancolli adds a dynamic component when they're pulling on their FDS

Chris Dy:

Okay, gotcha. That's okay. I see what you're saying. And then do you when do you think that the volar capsulodesis is enough? Because, you know, when I've, whenever I've done that I've been unimpressed with the amount of correction and the maintenance of correction. And I don't know whether I'm fooling myself. Yeah,

Charles Goldfarb:

it's hard. I don't know the perfect population, I would say a bit of an older patient, maybe with a more robust volar plate. Now those are the patients that may not get so much hyperextension the MP if they ever really, like a burly type worker may not get as much MP joint hyperextension. But the flipside is, if they do get some they have a more substantial volar plate to work with. It's the same question we deal with when we're talking about the thumb CMC joint, like how do you control the MP joint of the thumb in a straightforward way in his capsulodesis enough? So I don't know the answer. But I do like it because it immediately places the MP joint in flexion. It's one more check. And I think, in general supplementing it with something else. Makes sense.

Chris Dy:

First of all, I don't want to gloss over a really good point that you made. The big working hand tends not to get a claw, just because the MP joints tend to be tight. And they tend to have a bit of an MP joint contraction which stops them from going into this, you know, if you have lakhs and if you have more laxity, you're more prone to get into this hyper extended MP posture. And I remember reading when I was a resident reading the chapter on older neuropathy and Green's operative hand surgery, talking about how the ulnar nerve is a luxury to the laborer. And for a number of reasons, but one of them being that you know, the cloth just doesn't happen as much in that big burly hand. Now, that is clearly an overgeneralization. But it's a good concept to think about.

Charles Goldfarb:

Absolutely. And it's fact I mean, you'll see it in your clinic and you worry less about that worker with an older injury than you do with a, you know, a 15 year old adolescent female. It's just different population.

Chris Dy:

So then I think we're going to have to have another episode on this because we're probably running close to time. But you know, do you ever pin the MP joins to keep them in the flexed position temporarily?

Charles Goldfarb:

I am absolutely not against pinning- I've pinned less and less fingers in these situations whether it be the PIP joint after release or the MP joint the situation. I think again, if you have substantial volar plate to work with and you feel comfortable with your capsulodesis and you can capture a dorsal splint to block extension I am comfortable not pinning. But the flipside is also true if you need to pin your MP and you know what, you pin for six weeks and they're they're gonna get stiff.

Chris Dy:

So we'll talk about the technical aspects of the Zancolli as well as other dynamic transfers when we meet again, but when you have somebody who in whom you've done a volar capsulodesis alone and advanced it and you've gotten them in good position, what's your postop protocol for that? And are you also intentionally bowstringly at the same time?

Charles Goldfarb:

I always release obviously A1 because that is your access point to the volar plate. I have not done that. It's a smart trick. I've not tried it. Meaning and I think what would be required would be to release A1 and A2. I haven't done that I might consider in the future. I think for me this volar plate capsulodesis would again be a, the right patient and b, the right injury. I wouldn't do that in a Charcot Marie Tooth patient or in a chronic ulnar nerve that we're not hoping recovers. But if it is a younger patient with an order of repair plus minus supercharge, that had been clawing prior to surgical intervention where you are hopeful for recovery. I think that's the perfect patient to do a capsulodesis alone, because if you recover if your nerve regeneration works, you're not going to need it.

Chris Dy:

Do you think that down the line that you having? I think you think it'll stretch out in with enough time that it'll coincide with your eventual recovery of intrinsic function that you amazingly get?

Charles Goldfarb:

Absolutely, its always perfect timing.

Chris Dy:

Well done. Well done. Um, that one, then I guess, before I forget to ask technically, how do you secure your advancement of the capsule?

Charles Goldfarb:

Yeah, I tend to take a segment out of the volar plate. And I don't use suture anchors, although again, not against them. But I'd take a wedge segment out of the volar plate, flex the finger and use a pretty substantial like a 2-0, braided nonabsorbable suture to bring the edges of the boiler plate back together. That's part one. Part two is a mobilization for six weeks.

Chris Dy:

Now, it was very hard for you not to say the the brand name of that feature he just received

Charles Goldfarb:

a- I don't know why I didn't say the right brand name, you always need to correct me when I do. And b- it was very hard to say it that way.

Chris Dy:

I like I like to use a generic suture anchor. Because that's, that's what I saw when in the limited portions that I saw in training. But I again, I probably like to spend more money than you.

Charles Goldfarb:

Maybe you do, maybe. So when you do that you put the suture anchor in the base of the proximal phalanx? Do you excise any of the volar plate or you just use that suture anchor to grab some of the volar plate ?

Chris Dy:

I put the anchor in the metacarpal. And use that at the kind of the neck region because I think you're getting dicey, the further out you go and then use the braided nonabsorbable suture and essentially crack out one limb up and then bring that same limb down and then hold the MP joint down. And I think that if you're limited in terms of the, if you don't have anybody that can hold it or you know, usually you're the attending and you're flexing the MP joint down and somebody else is doing the stitch, that can be very tight area to put a stitch in, and also the slide that not properly, which can lead to some points of frustration. So sometimes it is more helpful just to at least provisionally pin the joint, which I try not to pin if I don't have to. And then I also think well if I've got it pinned what not, leave it pinned. But if I can avoid pinning it, I avoid pinning it if I need to just from a logistical perspective I will. And then just really this is the knot where the knot tying skills matter and sliding not not all the all the way down and securing it properly. It holds really well I'm very happy with that. It's just obviously like anything will stretch over time,

Charles Goldfarb:

I think we need to create a new scale, we'll call it the "F-bomb generating scale" of procedures, this would be high on the list of generating F bombs. Because you have a relatively small area you're working in, you have the flexor tendons in your way you're trying to retract the flexor tendons, keep the MP flex, put some sutures in and look smooth doing it. And I'm sure you do Dr. Dy, but I let them fly during that case,

Chris Dy:

I'm just gonna say that this is an excellent time

Charles Goldfarb:

I like that I would also for those of us who to reinforce knot tying skills. So, so yes, we can go into more detail about other aspects. I think probably we need to alternate and you know, let you have your adolescent elbow have made it to the end of this episode, my request would be moment. Next and then we'll get back to two different types of tendon transfers for anti claw of alternate nerve ish and sports. send us your F bomb generating cases, I think those will be of good fodder for discussion. I may even email the group to ask for those.

Chris Dy:

This, look at this 2023 And a new lesson of listener engagement. So thank you to those of you who have made it to the end. And now that you you know, Chuck's pearls for F bomb generating cases.

Charles Goldfarb:

Perfect. I love it. Good to see you, Chris. Have a good long weekend.

Chris Dy:

You too. Hey, Chris,

Charles Goldfarb:

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