Season 4, Episode 6. Chuck and Chris gratefully review comments from listeners with a few listener questions sprinkled in. And, we review a few cases with some interesting perspectives on revising an ulnar nerve and lengthening bone (Different cases).
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
Please complete NEW Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Season 4, Episode 6. Chuck and Chris gratefully review comments from listeners with a few listener questions sprinkled in. And, we review a few cases with some interesting perspectives on revising an ulnar nerve and lengthening bone (Different cases).
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
Please complete NEW Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog 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 podcast.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm doing really well. It's good to see you. It's been too long.
Chris Dy:It's been good to. It's good to see you too. It's been a long time. I know that last time we teased these cases that we're going to talk about. So everybody's probably really excited about that. But we did want to share some great feedback. We did comment a couple episodes ago about how the the email inbox has been a little quiet for the for the podcast. So Ham podcast@gmail.com Make sure that email us questions and everything. But we had some really great feedback from listeners. And David Wells is one of them. He's an orthopedic NP that previously worked in foot and ankle and switched over to hand and has enjoyed listening to us on the go and while driving. So thanks, David for that very kind email. And see our next one is from a good old friend, Bob Vandermark. He's written a couple of times and thanked us for the podcast and wish us a happy new year. So he liked he liked our talk about carpal tunnel and practice guidelines. And you know, so thanks for that. Bob. And Clifford Johnson, a surgeon that's not too far from us. on the Illinois side, he sent a very nice email saying that he understands how we're going to Q two weeks he surprised it took us this long. I think Bob vandermark said about the same thing too. But yeah, so we really appreciate everything that everybody's written in you know, there was a podcast listener Nikhil Agra wall, who was at the, at the Hand Association meeting and didn't have the, quote, nerve to say hi. I wanted to write in and, and tell us how much he loved the podcast. So yes, thank you to all of you for for your kind comments.
Charles Goldfarb:So those are great. I love those. I can share a few as well. So you know, if you aren't on our upper hand podcast, email list, right in and we'll put you on the list, I promise. They're not that frequent. Sometimes there's information and sometimes it's an update, but I don't know we probably over the last year since we were you two, we probably sent out one every three or four months. So recently, we sent one out notifying all about the change in cadence to every other week. And then we've got some great responses. So I'll read a couple of those. So this first one is near and dear to my heart. This is Matthew DeWolf, who's a hand and upper extremity surgeon at Berkshire Orthopedic Associates. Now Chris, I don't know if you know where the Berkshires are, maybe do I hope you do
Chris Dy:give it sounds like there's some fancy money in that area.
Charles Goldfarb:Well, the Berkshires are where Williams College is located, which went to school so as the
Chris Dy:so I hear, just grow they grow hand surgeons on trees and Williams,
Charles Goldfarb:Western Mass beautiful part of this country. So Matt was very nice and said some really nice things and thanked us for the time and energy we put into this. I find it very entertaining and educational. And he has some suggestions including an HBr top HBr topic, which we already covered. So thanks, Matt. This will be an interesting one, I may have poured this onto you Brittany Mitchell is an occupational therapist, and really said that I still listen on my drives to work and to indoor swim lessons from my three and five year old. Most of my time recently has been dedicated studying for the CHT. But she wants us to talk more about mallet fingers, which is not the most exciting topic but there's a lot there. So I think we could have a good mallet conversation at some point for sure.
Chris Dy:Yep. Share the people aren't Chuck we got to do it.
Charles Goldfarb:Sharon. Sharon Stanley is a plastic hand surgeon at LSU New Orleans. She's early in her practice sees a lot of holly trauma and devastating upper injured upper extremity injuries. She feels that she sees a lot of CRPS more than she realized previously, and we'd love to hear our thoughts on it. Maybe we can even talk about that one. And then I think the others we can mention another time. What do you think about that? How often do you see CRPS and do you find it associated with major traumas or or what's what's your what's your experience then, Mr. Rue?
Chris Dy:Well, I think that I see it. I see it more than other people a because of my practice and be because I recognize it more. It's one of the things where You may not see it, but it'll see you. And it's hate. It's such a tough condition to treat. And, you know, I think we probably should do an episode on CRPS. And we should have our therapy friend Macy on the episode for that. Because I think that it's it's such a challenging condition that will not be treated solely by the surgeon, although surgeons certainly can have a role in treatment. But the nastiest ones are the crush injuries and the dog bites.
Charles Goldfarb:Yeah, in my in my practice, it's typically a referred patient, maybe from another hand surgeon or not. And I'm always and we should talk about this is a great a great idea for an episode, I think we've talked about talking about this, and we never did it. It's a great idea for an episode. And I think there's a lot to share. I never mind seeing those patients, but always lay out the expectations for my visit. If as a hand surgeon, I can help you, I'll do just that. If I can't, then you're better served with another physician. And I think that's an important kind of parameter to set early.
Chris Dy:Right. Right. Right. You know, it's interesting, though, our role is hand surgeons were probably the ones physician wise, where we know a lot about certain things. And if there isn't a physician that is better equipped, even if you're not providing a surgical service, sometimes I feel like we should still quarterback or run points on the situation. Now CRPS, you know, I think especially type one, you know, the pain management teams are fantastic at handling that from a very multidisciplinary manner. But, you know, I had somebody recently who didn't have a firm diagnosis. But clearly, I think what we were doing for her in terms of guiding therapy, et cetera, was helpful, and I didn't think anybody else will be able to help them out. So it's like he had just come back and I walked out the room was like, I don't know why we're having them come back. But I think we're probably the best people to take care of them. And you know, one of our former partners and mentors, Dr. Goldman would always tell me in clinic, Chris, the buck stops here. If you don't figure this out, nobody else will. I remember that every day.
Charles Goldfarb:Well, it's true. i That's another good topic to discuss, you know, what do you do when you can't figure things out? What do you order? Who do you console, there's all kinds of strategies that we've developed, I'm sure you think about things differently than I do. But ultimately owning it. And doing your darndest is is the right approach.
Chris Dy:Right? Well, thank you for for those that wrote into, in reply to the, the, the listserv about episode feedback and suggestions. I have a question that came out of the the email account if that's all right, so it is about thinking about C5 brachial plexus nerve.
Charles Goldfarb:Say it isn't so
Chris Dy:now, but it was actually spurred about by listening to the radial nerve, tendon, trans versus nerve transfer episode. And this is from Nick Coudray. Sorry, Nick, if I didn't pronounce your last name properly. He's actually an outpatient ot up in our neck of the woods. He's up in North County. So you've seen some of our patients too. And he's seen one of my Plexus patients and was just asking, in terms of timing, you know, what, what you expect in terms of the recovery timeline after for nerve transfers that I think that probably it, in theory is a little similar. But a lot of it depends on the distance to target in terms of you know, how far the nerve has to regrow to get to the muscle, and then how long it takes to mature there are certain nerve transfers that just take a longer time to mature, even once it re innovation has actually started. And that process has has begun when the nervous hit the muscle. I don't know have you noticed a big difference in terms of certain nerve regeneration over the years and when you are treating more of the traumatic nerve injuries?
Charles Goldfarb:Well, I mean, I assume my sense, I hope my sense is accurate, in that I find radio, it's not just distance in which I where I'm trying to interpret it. It's not just about distance to innovation point. It's just the nerve itself has intrinsic characteristics, which might be slower or faster. Yeah. For me, it's radial nerve, faster than median nerve faster than older nerve. But I would love to be corrected if I have that wrong.
Chris Dy:No, I think that's right. I think the one of the challenges I think with the radial nerve is that it's um, if you was actually looking at the radial nerve today during a nerve transfer case, it's such a I mean, it's so nerdy. It's it such a fascinating nerve, like when you look at it, like right at the so called spiral groove that doesn't isn't really a groove. But yeah, when you look at it there, it's just got so much fat. And it's not as it's not as nice, organized and defined set of tubes. Like the ulnar nerve is in the breaking like the media nervous into breaking them and I think that's probably why the radial nerve responds differently to ver Higher proximal repairs or reconstructions, there's something about the fat content of that nerve, the soft, the soft tissue around the nerve, the me scenario, etc. That makes a little more challenging to align that properly and probably has some implications for actual nerve regeneration. But I think as your more distal Yes, I agree with exactly what you said in terms of how nerve flow respond. But even as you you know, some of the papers that look at reconstructing and grafting radial nerves and a distal half and distal third of the brachial, they do better than people that are more proximal and that might be distances target that might be because the nerve just becomes more structured and more like the median and ulnar nerve as you get into the lower half just above the elbow.
Charles Goldfarb:So I have to ask you a question. Where are you in that? Here's what here's what I'm visualizing. Dr. Dy is in the or he's looking at the radial nerve, and all of a sudden, someone is snapping, say, Dr. Dy Dr. Dy, come back with us.
Chris Dy:I did actually say I was like, in radial nerve is so fascinating. She said that out loud. I can't believe I just said that. But yes, they had to they had to bring me back, bring me back to the moment, we talked about being present in our last episode. I was I was off in my own world, thinking about the radial nerve
Charles Goldfarb:is you know, when someone loves nerves, they love nerve and you know, we just have to accept that about you.
Chris Dy:Excited, it's a, it is something that you just got to deal with. It will say one more one more listener email.
Charles Goldfarb:We answer the question, though,
Chris Dy:I don't even remember. I think we did. I mean, Plexus is such a, you know, grab bag in terms of you know, you don't always have your routine transfers, you know, in terms of yes, sometimes you can do your classic Psalm sack triceps, the axillary and your double overland or double for circular, whatever you want to call it. Sometimes you don't have that. And you're dealing with what you what's available. And I think that's the allure and the challenge, all in one. But the lack of predictability will drive some people a little bit crazy, especially if you're in the therapy side of it.
Charles Goldfarb:That is fair, that is fair. Well said.
Chris Dy:There's one more email I wanted to go through. Dr. Sarah Shippers is a freshly minted orthopedic cancer and in first year in practice, and really enjoyed the the radial nerve, tendon versus nerve episodes, and especially the therapy episode, because now she has a podcast that she can resource she can send her therapists to, since they may not see this kind of rehab on a regular basis. So she's very happy about that. And she thanked us for our dedication to hand surgery education. So that's very kind of you, Sarah, thank you for sending that. When you did.
Charles Goldfarb:Absolutely. I thought there was a question in there. Oh, no, I
Chris Dy:just wanted to thank you for all that you've done, Chuck. Oh,
Charles Goldfarb:I love that. That's so nice. Good luck. And hopefully the upper hand Podcast is your partner in this career journey.
Chris Dy:And I agree with that. And the upper hand podcast is sponsored by practicelink.com. It was widely used physician job search and career advancement resource.
Charles Goldfarb:Nice, nice, nice. Becoming a physician is hard. Finding the right job doesn't have to be joined practice link for free today at www.practicelink.com/theupperhand, just go to the site and look at it. It's pretty impressive. I'm not telling you to switch jobs, but it's always nice to know what's out there.
Chris Dy:Yeah, let me go look. Now Chuck, good to see you later.
Charles Goldfarb:So speaking of switching jobs, can we can we digress? Is it appropriate? For me to digress and talk about the NBA trade deadline? How exciting that
Chris Dy:wow, that's yes. I was just talking with somebody about how the Brooklyn Nets you know, basically tilt their entire roster.
Charles Goldfarb:Yeah. Oh, my goodness. You know, it is interesting that there was so much excitement around the NBA during Super Bowl week, which by the time this episode drops, it's going to be long over. But in the in the NBA I really enjoy in part because it's can be so unpredictable.
Chris Dy:Yes, yes, the word shitshow often comes up is interesting. How do you feel I mean, this is not a sports podcast, or at least what actual sports but you are an expert in in basketball. So do you think these are good moves made by the teams that you know are the Suns gonna be happy or the man is going to be happy?
Charles Goldfarb:The Suns are going to be happy if everyone stays healthy, and they I would predict they'll come out of the west and play the Boston Celtics if everyone's healthy, my Golden State Warriors it's looking like an uphill uphill battle for them. Dallas and now you know with Kyrie you know, we don't want to get too detailed here that that one's gonna be a tough one. So a lot of excitement around the trade deadline which just makes the NBA more exciting. And I was thinking on my drive in as I was listening to one of my favorite podcasts aside from this one. Bill Simmons who talks about really the NFL and the NBA and and it's just there's so many characters and I was trying to think NBA characters are there those same characters in the hand society that we just don't know about?
Chris Dy:For sure. I will not tell you I think the Kyrie Irving of the hits. That thought did cross my mind. And I actually had a sense you were going there.
Charles Goldfarb:That is so funny. I'm sure we all have our little, yes, this person is x and that person's y? Because he answered you super exciting Doctor Dy, and it's just as exciting as the NBA,
Chris Dy:or nerdy or nerdy little world. So I'm gonna, I'm gonna say something, sometimes you say something out loud, hoping that it comes, you know, to keep yourself accountable. So it will come true. I'm gonna say something out loud in hopes that it doesn't come true. So in right now, my role as fourth assistant coach of the first grade basketball team of my kids team, they have, of course, put practices on Thursdays at 3pm, which means I can never ever make it like come on guys, like seriously, like, couldn't even do like an extra hour later. But, but I actually happen to make it yesterday, which was super exciting, because my son was jazz that I was there. And some of the some of the coaches and dads were talking about setting up a little pickup game, you know, on one of the weeknights, and I am totally in, but I'm gonna put it out here that I really do not want my Achilles tendon rupture, because I feel like that is the setup. I like I pride myself in being in very reasonable shape. And I can do a lot of things. But I think the sprinting and the stop, start up and down the court might be a little too much for me.
Charles Goldfarb:Oh, it's not too much your strength will be just that. If you warm up appropriately. You know, the first game, just see what happens after that the other dads are getting tired and you're gonna be going strong.
Chris Dy:Yeah, you know, I need to I need to stretch. That's actually what I need to do. But you know, we've we had a couple of really nice days here recently in St. Louis. And, you know, they're happy with myself. I went and banged out an eight mile run in the park. I kind of didn't realize I was going to do that. And I paid for it the next day for sure.
Charles Goldfarb:Wow. But that's great. Yeah, we did have some nice days. And those first few nice days are absolutely inspiring. Hopefully, others across the country are getting to experience the same but it wasn't even that warm. It was like mid 50s. But it was sunny and beautiful.
Chris Dy:Mid 50s is great. Are you kidding me? Our friends in Florida are like yeah, you suckers. So while you we talked about being workaholics and in the last episode, and I will say I'm a bit I've known to be a bit competitive. And, you know, one of our partners, Dr. David Brogan is a marathon runner and very skilled long distance runner. And I always want to tell him, like, you know, I just want to be able to tell him at any point that I could run a half marathon. So I just That's my my crazy fitness goal is to be able to say I just banged out a you know, 13 miles, you know, I still got it, David, I could catch you at some point.
Charles Goldfarb:Here's here's my life advice. Do it now. Because when you're old like I am, that ship has sailed. I've finally admitted that ship has sailed. I'd be happy to walk I happen or thought.
Chris Dy:I've gotten my feel. I think I'm done with marathons, although I may meet my midlife crisis. And you know, I had a good couple. And I think I'm good. So anyway, when we talking about some actual hand surgery before people turn this off,
Charles Goldfarb:maybe to eight. All right, why don't we want to share a case?
Chris Dy:Yet interesting case, you know, that was referred to me by one of my partners, one of our partners, a patient who had had a prior subcutaneous transposition elsewhere. crashy started as an insight to then was revised to a subcutaneous transposition and then came in with just a boatload of pain right over the chest anterior to the medial lateral condyle. Tap on that area, it drives them absolutely crazy. The nerve itself is actually functioning pretty well the ulnar nerve insensate in the posterior branch of the medial inner brachial cutaneous nerve distribution. So, I see the patient, our partner is convinced it's an ABC neuroma, and nothing else. And I kind of thought that was the case. And, you know, we get a nerve study, nerve study comes back, essentially that the ulnar nerve is working pretty darn good. Which anytime you're going into a revision surgery like oh man can only make that worse. But an ultrasound, very compelling shows just a huge honking neuroma for the SABC. So how do you approach that patient who's got a functioning ulnar nerve but has pain and you suspect that there's a neuroma in that area?
Charles Goldfarb:So you believe that irritated segment is the older nerve itself right at the right ad or on the medial epicondyle in addition to a reactive cutaneous nerve?
Chris Dy:Yeah, and I actually thought was more For the reactive cutaneous nerve, because the ulnar nerve and the motor sensory function and clinical exam was pretty good, and the nerve study was pretty good. And the nerve was not terribly enlarged on the on the ultrasound, but the MA BC was the size of the older nerve. It's like the same cross sectional area. So I actually thought it was an MVC surgery, but I was going to be right next to the ulnar nerve.
Charles Goldfarb:Right. Well, I guess my a couple of comments, you know, we have discussed this, the literature proves this a failed. Decompression is is not as easy as simply transposing the nerve. And that's why I take even more care in that decision making process today because we know from Dr. Cathy's paper that those patients just don't do as well. So that's number one. Number two, I really liked that pasture, cutaneous, or adipose flap anteriorly rather than an Eaton flap with fascia, because I think it allows you to keep the nerve more lateral and away from the middle of a condo, I don't think that nerve is happy. And you may disagree. I don't think that nerve is quite as happy when it's really far medial or near the bone. That's my second takeaway. And then my third comment regarding planning is, I would plan to go in and evaluate that medial brachial cutaneous nerve, neuro Lysaght or potentially excise it if that looks like the best indicator, of course, with preoperative discussions around numbness, and then assess the nerve. And if the nerve is scarred in and doesn't look good, then I think you have to go so muscular with it.
Chris Dy:Yeah, I agree. I think that I think the nerve does not like being right next to the medial epicondyle if it's on top of it. I think that if you're going so muscular, I think it's okay to put the nerve, you know, closer to the bone. As long as it's you get them moving early. Because if you put it closer to the bone on the anterior side of it, or you know, not, you know, where it sits inside too, but on the other side of meetup calm now closer to the median nerve. You know, that's a nice smoother course for that nerve, it is much more likely to be in a straight line and topographically it doesn't have to go up and down like it would if you did it, you know, with the subcutaneous. So if you're doing a subcutaneous, I think it is important to pull it away from the medial condyle. And I've seen some fail or have to be revised, have to as a strong term, but would benefit from revision because it was just right on the bone right on top of the bone.
Charles Goldfarb:So what did you do in this case?
Chris Dy:So we plan for revision surgery. It was mainly immediately supposed to be an MABC neuroma surgery but I said we're going to be in the area. I always have my guard up about the ulnar nerve, there's a fair chance I'll need to revise your transposition, just because I don't want anybody that ever have to come back here again, especially if your nerve is the ulnar nerve ends up being the source of your pain. So we opened everything up, obviously wide exposure on both ends. And find the ulnar nerve and it is just plastered to the flexor pronator surface really close to the middle of the condo. And it matched the preoperative tonnelle sign that we marked, which I thought was going to be more of the medial end of brachial cutaneous neuroma. And I always mark the preoptic own holding because I think it can be useful guide and it shows a patient to kind of what your plan is. And you know, lo and behold, I mean, immediately next door to it. There was a huge honkin neuroma for the meal and a breakthrough cutaneous nerve. So I'm not absolutely sure what the pain generator was, if it was one or the other or a combination of the two. But it was a it was a slog to get that nerve out the ulnar nerve out of that scar.
Charles Goldfarb:And so you neuralyzed The ulnar nerve, you excise the neuroma and the branch of the medial brachial.
Chris Dy:Yeah, so we revised your eye we did an analysis on the ulnar nerve and did a sub muscular transposition kind of the normal one left at very loose in terms of you know, the any area around the nerve that does something that I had not done in this particular situation before but I thought was interesting. You know, there was always that we always have our branches to the FCU and I found a couple of branches FCU and we ended up doing a targeted muscle regeneration from the MABC you know, neuroma branch. So we excised out the neuroma and went back to healthy fascicles. We did have to use a an Allah graft to make that TMR reach but you know, I'm not sure which part of this neuroma treatment is going to be the thing that that helps the most. Whether it's the excision of the painful neuroma, whether it's the nerve growing into the alley graft or whether it's actually making it to the to the FCU bridge.
Charles Goldfarb:Interesting. Alright, so let me just make sure I understand this. So you dealt with the ulnar nerve and it sounds like that was almost a straightforward but in the end, we understand what you did and then you didn't just excise the neuroma or bury the stump. You excise the aroma. You brought an expensive Allah graft in a suit you add it to the residual MABC and then you put that allograft into the FCU
Chris Dy:It wasn't that expensive. I mean, come on. Thank you compare it to some of the arthroscopy stuff if you use all those fancy all those fancy suture tapes I mean in this grand scheme of things it yes but that's that's yes the allograft was intercalary between the MABC and the and the FCU branch and this is something that I've done before obviously I've done TMR before and I've done TMR and painful neuroma cases. I remember one. You're gonna laugh at this. In revision Morton neuroma case. She kind of had surgery. Yeah. Yep. And did TMR. And so one of the one of the foot interossei. And it was great.
Charles Goldfarb:Do you even know what they're called
Chris Dy:Lumbrical. Interossei- some kind of intrinsic muscle in the foot that most people that die, but you know. But ya know, that was that was a very, it's nice, because for that particular situation, you know exactly where the nerve is going to go, you don't risk it dislodging out of muscle. I know the other option, obviously, and I've done this a lot before too. And so view is to implant the buried the cut end of the nerve into muscle. And that's still I think, a great go to treatment. I mean, what one of the takeaways I had from the ESPN meeting was. That doesn't mean there's no, it's not going to be always TMR or rpmi, or whatever other treatment you have for a painful neuroma, it's knowing about how to do all of them, because they're going to be some nerves in particular, that are going to respond better to each different treatment, and then some scenarios in which you're not going to have other options. So it is important to know kind of the full spectrum. But let's hear a case from you.
Charles Goldfarb:Sure, I was debating I try to some of the most interesting cases or congenital cases. And I recognize that a lot of the audience, you know, might find them interesting, but might not truly relate. So I want to share and I'm not gonna share a sports a complete sports case, but I'm going to share an adolescent case. So 15 year old male comes in with a drnj dislocation in a history of fracture. Now, if someone walked in and said that to me, or one of my colleagues said that to me, my brain would immediately go to distal 1/3 of the radius fracture. Now union only ends up dorsally. And those cases I love when those go man, I hate for the kids. But when that case walks in, I know I can make that child better by correcting the radius deformity. So really like that, and that's, that's an adolescent, you know, in someone our age or your age or my age, it may not be so straightforward, but in a younger patient, it's a great case.
Chris Dy:Is that scenario typically the one where they're going to remodel but they didn't remodel?
Charles Goldfarb:Yeah, when they're they're going to read when they're 13, and they're gonna remodel 40 degrees, and I
Chris Dy:had air quotes with my gonna remodel for those of you that are not watching on YouTube.
Charles Goldfarb:Yes, exactly. So this case was interesting because this patient had a procedure done a soft tissue procedure of some sort done near the distal ulna. And I believe the growth plate may have been affected. And so it over grew dorsally with the growth plate was still growing normally there. And that led to a dislocation of the Dr. uj
Chris Dy:kind of soft tissue procedure would bugger up the faces.
Charles Goldfarb:I think it was unusual maths of some sort, which was volar and close and I don't know the details.
Chris Dy:So this is like some kind of in the distal ulna like a volar, physeal bar, almost from some kind of trauma or surgical traumas, I think
Charles Goldfarb:that was happened to the faces was now closed. We're left with this deformity and we're left with a patient who couldn't rotate. Got it. Okay. Really interesting. And so it, I was hoping that it would turn out like it would had the radius spin the issue. And so we went in, we did a closing wedge osteotomy on the owner, and put a vor plate on, which corrected the obvious angulation asymmetry to the other side, always X ray, the opposite side played on the radius, lower plate, we did a closing wedge osteotomy on the ulna Oh, ulna, yep. And then we basically closed it down. So the the owner was sitting dorsal, and then we close it down, put the plate on, and it went right back into the DRUJ and then the or we did a DRUJ release. I don't know if we had to or not in the or we had immediate full restoration in motion. It's kind of remarkable.
Chris Dy:That's pretty impressive. So it just because it was sitting out of the sigmoid notch and you got it back into the sigmoid notch then
Charles Goldfarb:I think it's that simple. And I just it gives me you know, there's so much a remodeling potential and young patients but be just tolerance to different things. And so if we can if we can recreate the normal anatomy in a lot of these situations, the kids bounce back amazingly fast. It's really, really exciting, I think. Yeah, that's
Chris Dy:that's a crazy case. That's great. How did you pick your implant? Did you decide was this just something that the use of kind of a standard what a mini frag or a small frag player did you actually use the kind of normal on there shortening osteotomy set, which may not work for a 13 year old?
Charles Goldfarb:Yeah, it's interesting. I always struggle with implants around the distal ulna. I don't know about you. But when there's fractures of the distal ulna, for example, or in this case, where we're doing a very distal osteotomy, I never know exactly what the right plate to use is, I usually have some type of 2.0, 2.4, 2.7 plate available. And that's what I did in this case, it was, I think it was a 2.3 plate, but it was locking, which is nice to have the bone actually was pretty disappointing, I guess, because there hadn't been motion of the form for a year. And it just came together nicely. And And nowadays, with the more rigid smaller plates, I think you'd be pretty comfortable with your ability to obtain and maintain a reduction.
Chris Dy:Now, would you? Whoa, what, what's the postdoc protocol for that patient? I mean, how much are you going to protect that obviously, you want to get this thing moving, because the patient hasn't been moving their forearm in a while,
Charles Goldfarb:yeah, two weeks in a splint for me, and then two weeks and, you know, a surgically applied splint. And then I'd see them back in the office and I'll have them in a therapy fabricated splint with early active motion, nothing passive. And then hopefully, by five or six weeks, they're healed. And then we ramp up from there. So you know, it's still still the this, it's been about four weeks. So I need to see the patient back in a couple more weeks and see how they're doing. But their two week visit, they were already doing pretty well. So I'm pretty excited.
Chris Dy:Yeah, that's, that's great. I just got a clarifying question. Given what we're dealing with here. Is your post op splint that you fabricated a sugar telling and is the therapy splint going to be a monster? Or are you letting them kind of move ad lib and something below? Below elbow?
Charles Goldfarb:Yeah, I'm curious as to what you do when I operate on the radius. Or if I have a foveral TFCC repair, I tend to do a sugar tong to start and then a muenster. When I operate on the ulna as I did in this case, I think of is it as the constant unit with a radius rotating around it. So I just did a short arms on it. And I debated the longer but I just know what the short arms. How do you think about those situations?
Chris Dy:I guess the only way, the only if I'm worried about the about the DRUJ. That's when I go above elbow with the sugar tong and a muenster for purely for like an ulnar shortening osteotomy in which it's more for pain and less for stability. I'm okay with something below elbow.
Charles Goldfarb:Yeah, yeah, I agree with that for sure. The other cool case, as we wrap up, I've had two really interesting cases. And again, this is a little in the pediatric and congenital world. But as you remember, Dr. Dy Olliers disease is multiple enchondromatosis and the enchondromas can really affect growth of the bones and so I've had two of those in the last few weeks where I've lengthen the radius. And for one of them I did a osteotomy and application of an external fixture to gradually lengthen we needed more length and the other one I did a step cut. And I haven't done a lot of step cut osteotomies is where you can get about a centimeter and a half or sometimes a little more. It can be kind of fun. It's also a little harrowing because I worry about swelling when you do one stage lengthy things but thankfully all went well. But fun pays out cut
Chris Dy:it Step Cut very interesting technically is that is that something that you find very challenging aside from the consideration for the swelling but I mean getting the carpentry just right must be very challenging.
Charles Goldfarb:i It worked well. We had Jessica Billig, our fellow was there she was great. And what we did was we worked in the metathesis of the distal radius near or in the side of the income drama which usually is a good thing they tend to heal well in that area. And we essentially made a longitudinal using K whereas longitudinally, we did about a century and a half and then we exited on one side distally exit and on one side proximately put two smooth laminar spreaders in one on each side and spread and things were well aligned and we put a long enough played on that we had good security proximal and distal and then one one transverse screw as well so pretty pretty, pretty good. I mean it's got to heal but I was pretty encouraged.
Chris Dy:Sounds pretty slick. Is that is the treat that like any other osteotomy in terms of post op protocols and rehab
Charles Goldfarb:Yeah, I would go I'm done the Step Cut I would I really monitored for compartment syndrome and I think we go a little slow till we see some callus formation given that we're depending on a plate and a narrow bridge connecting bone but yeah, they're gonna heal well. The beauty is that these heal really well. Two Olliers cases, That's a lot.
Chris Dy:That is a lot. You have your boutique practice. Is there a blog post coming? Perhaps?
Charles Goldfarb:You know what there should be if I was on my social media game? I did delete Twitter, but I had to reinstall it.
Chris Dy:What what? I do have to reinstall it.
Charles Goldfarb:I just need to follow up on some stuff. And I want to get back into the Journal of hand surgery Twitter journal club in your car Twitter for that.
Chris Dy:Yes, yes, it does. Yes, it does. I think Twitter is way beyond the scope of this podcast, one of the things I listened to outside of our stuff is pivot. And we've talked about Scott Galloway before. You had a time they talk about Elon Musk and Twitter is disproportionate because a little too much. That's I know a lot of what's going on at Twitter. And I admit, I have not opened Twitter really much in the last few months because of all this craziness going on.
Charles Goldfarb:I know, I know. I'm not gonna it's not gonna be part of my daily routine to go there. I do like Instagram. You know, but I'm old. No one expects much of me on on those on those forums.
Chris Dy:But that means that you are exceeding everybody's expectation. All right. Well, you have a great rest of the day. You too. Good
Charles Goldfarb:to see you. Take care. Nice seeing you. 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 @handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is @congenitalhand.
Chris Dy:What about you? 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
Charles Goldfarb:to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time