Season 4, Episode 10.
Chuck and Chris take a deep dive into Deborah Bohn's What's New in Hand Surgery in JBJS, part 2! Chuck also drops some news on a new endeavor.
JBJS 2023; 105:428-34
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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 10.
Chuck and Chris take a deep dive into Deborah Bohn's What's New in Hand Surgery in JBJS, part 2! Chuck also drops some news on a new endeavor.
JBJS 2023; 105:428-34
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 podcasts.
Charles Goldfarb:Hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm doing okay, I'm doing okay. It's, it's gonna be a nice day here in St. Louis, and get some podcasting done trying to learn a new editing software program. But I'm good.
Chris Dy:I your skill set is so unbelievable. If you would, if you were to tell people that there was this amazing hand surgeon who can do congenital and pediatric adolescent hand surgery, he can also fix things and elite athletes can also be the executive vice chair of a department and is really good at Logic Pro. Like,
Charles Goldfarb:like, You flatter me. Here's the real story. I am getting older and I'm afraid of obsolescence. And I'm trying to stay relevant. Technological.
Chris Dy:I'm glad that you didn't jump on the tic toc bandwagon. No. So I had a really interesting experience. I just gave a talk to our PGY to resident class on a weekend, which is a little bit odd. But it was fun. We did we have a nice session about grant writing, which our partner David Brogan is in charge of the resident research curriculum. And he asked me to give them a talk about that. And, you know, I gave a bit of a lecture about the process, but really kept it short. And then I asked them to do some elevator pitches about the research ideas. So they had a time to 60/62 pitch. They gave some great pitches, they all stayed on time. And, you know, I asked the the other participants, you know, what, you know, what they're, you know, seeing what their partners were trying to study, and you know, whether it was important and whether they could do it. And it was a fun session. There's some really great ideas out there.
Charles Goldfarb:It's that first of all, that's awesome. And it is unusual for us to do a Saturday session and we're trying to consolidate on Tuesday evenings and but wow, what an opportunity to for them to hear from you. And I'm sure David chipped in. And the elevator pitch is super interesting. It it is a skill set to be able to pitch in that fashion. And my wife did the I don't wanna say the ultimate, but did no ultimate elevate.
Chris Dy:Let's be real. That is the ultimate elevator pitch. Yeah,
Charles Goldfarb:when she was on Shark Tank, but this is cool. That's, that's great. That must have been super fun.
Chris Dy:Yeah, it was fun. And it was good to see them kind of I think it's, you know, in terms of, you know, a didactic session on grant writing, it's probably the easiest way to get them involved in everything. Because, you know, like, we were using it as an example of an aims page. If you can convey something in an elevator pitch, your aims page is essentially a paper elevator pitch. And, as you stated, that elevator pitch skill is important for a lot of other reasons outside of research, you know, say you're looking for a job or you know, you're pitching on Shark Tank, etc. So, fun session.
Charles Goldfarb:Yeah. So Chris, I have two thoughts. Of course, my first thought is I want to share with you one thing I did recently, which I'm doing a little book club with some of the department administrators. And we read this book is a Disney book called br guests, or I think it's called br guest. And it's sort of the end, we've all heard about the Disney model like the Ritz Carlton model of customer service. It's pretty cool. So we met for coffee yesterday afternoon and kind of talk through some of the lessons, I think there's gonna be some tangible takeaways about kind of how we do training and orientation and stuff like that. It was it was pretty fun.
Chris Dy:Yeah, I think that Disney is getting a little beat up right now in Florida. But their model of their model hospitality is one that stands the test of time. I mean, it's experience, right. And so much of how we're shifting, I think we talked about in one of the HBr sessions before, so much of the process now is just about experience. And that's how we that's how we compete with others is providing an experience that is better and beyond what others can do, not only from the lens of you know, actual patient care, but from like, hey, I really enjoyed going to that. That doctor's office.
Charles Goldfarb:Yeah, it's right. And it is there are no easy solutions, especially with the way healthcare works, but that's exactly right. That's what I'm competing against. All right. So my second is going to be news to you, I think. And your your segue of the HBR article is important. I am going to business school.
Chris Dy:Wow. Okay, so yeah, there's a lot there. How the heck are you Gotta do that. And why are you doing it? I mean, I know that you don't take any decision lightly. And I'm sure it probably took you a long time to come to that conclusion, and it's a pretty penny.
Charles Goldfarb:So you have no idea how long, I'll give you a sense of how long I took the GMAT. And during medical school, that was the first time I was interested in
Chris Dy:business, not surprised, not surprised at all.
Charles Goldfarb:And then I took it again, maybe five or seven years later, and then Doctor good for it doesn't you don't need it anymore. It's so
Chris Dy:like, any standardized test, you don't need it to.
Charles Goldfarb:And then I, you know, back in the aughts, you know, 2007, or so I talked to Dr. Government, and he basically said, you don't need it, you're gonna get a hands on business experience with our outpatient center and the like. And to some degree, that's certainly true. I'm sort of doing it for three reasons, not two, but three. First, I just need to shake things up a little bit. I'm very happy with what I do. And I love what you love our department, my partners, but I need to do something a little differently. And this has been something I've always wanted to do. And I've talked to a whole lot of people, and I think you're gonna get a lot out of it. So that's the first thing. The second thing is, you know, they're potentially I would consider a chair job at some point in my career, although, you know, I'm not young, but that's potentially in the cards down the road. And I think this will make me a better chair and make me more marketable. And the third thing is, I'm not afraid of a pivot I, you know, I talked to Ken Yamaguchi, one of your mentors, and one of my partners and friends. And he had only really great things to say about both the business school experience and his pivot to, you know, leading Centene from a medical standpoint, so I talked to a lot of people, I did not jump into this. Regis is supportive, and it's an Executive MBA Program, and I'll be able to share some lessons with you and the crew.
Chris Dy:I can't wait. I'll be learning from a professional in a different realm to assist me. Great. Well, congratulations to you on coming to that conclusion. And for acceptance and step program. I know that's not an easy thing to do. Are you going to be here at Wash? U?
Charles Goldfarb:Yes. You know, first of all, I think wash is great, Olin School Business is great. But, you know, I did consider other options. Some of them have a little more of a healthcare focus, which obviously wasn't sure I wanted, but some of us just practical, you know, just easy being here.
Chris Dy:And I guess you have a sense of what's the time commitment, like for someone excited, because I'm sure a lot of our listeners, you know, might be in the healthcare leadership space, either in or outside of academia. I know, there are a lot of health. A lot of physicians that are involved in you know, private practices that are huge, and you know, multi specialty groups. And, you know, this is something that might be of interest to them, too.
Charles Goldfarb:Yeah, for sure. It's it's the way this program works is there's what they call go week, which is in residence seven days, kind of get back into the academic groove, which I think for some participants will be very different. I'm not I haven't been in class in a long time.
Chris Dy:But I think you have to stay on campus because you live closer to campus than most on campus.
Charles Goldfarb:Yeah, I do for one week. And then I can't wait to see the pictures of that. And then it's Thursday, Friday, Saturday, once a month for 20 months. And there's a couple of trips, one advocacy, advocacy trip to DC and then one an international trip, which I think around five days. And that's it. And I think it's 10 to 15 hours of coursework a week, studying and catching up and stuff. So my clinical schedule and my administrative schedule have to change. That's the one promise I made. My wife can't add this on, which of course is correct. I cannot add this on. So we'll see. We'll see how that shakes out.
Chris Dy:Okay, well, podcast listeners, let's let's hope that he still has some time for us. Speaking of the podcast, we should thank our sponsors.
Charles Goldfarb:We should we are so fortunate. The upper hand is sponsored by practice link.com, the most widely used physician job search and career advancement resource.
Chris Dy:Becoming a physician is hard, especially if you choose to get your MBA, finding the right job doesn't have to be a fact join practicing for free www.practicelink.com/theupper hand.
Charles Goldfarb:All right, should we jump in or any questions? I
Chris Dy:think the practice like folks might need to watch out because you're gonna come out of business school is this master negotiator and you're gonna know all about marketing and all these skills that many of us never learned along the way except maybe the hard way. So yeah, we should jump back in. We jump back into what's new in hand surgery. Part two.
Charles Goldfarb:Yeah. So you know, we said in case the listeners didn't listen to part one, please do. And I think we had a good conversation about some really interesting topics. And Deb Bohn from University of Minnesota has done a great job summarizing that pertinent hand surgery literature over the last year. And we had, we talked about duper trends and we're going to Jump into the trauma section, I believe,
Chris Dy:yeah, we're gonna get right into the distal radius sections. So this was an interesting study that the first one she highlighted and talking about, you know how reliable it is to look at X rays on your phone. Because I think that many of us do that already. And it's kind of reassuring to know that we can make some pretty good calls without pulling up packs on our computers and whatnot. And, just by judging what essentially is a screenshots of X rays.
Charles Goldfarb:Yeah, you know, Dr. Gelberman used to talk about you want to do some, I don't want to mischaracterize what he said, but the way I took it was, you want to do some studies that are very practical and very germane, and it will appeal to a lot of large audience. This is that for sure other studies can get into the weeds on something you're passionate about. But this is how you impact hand surgery. It's a simple study, but it's an important message that, you know, phone or computer screen, you can make the same judgments.
Chris Dy:I can I can actually see this coming and helpful from a medical legal perspective, to be honest with you to have some cover. So thank you to the authors for writing that paper.
Charles Goldfarb:Yeah, absolutely. And then, and then Deb, references, study looking at older variants, which is pretty interesting, because most of us think about assessing owner variants on a PA radiograph. And with a distress fracture, especially with altered dorsal volar tilt. The the message was that when variance was assessed, on a lateral view, only only 5% of the fractures of the distal radius had true owner positive variance, compared with an apparent variance of 32%. On the PA view, which is really interesting to think about.
Chris Dy:Yeah, I know that it, it's interesting to think about, I think that to be honest with you my take home from this doesn't change is that I still counsel the patient based on the way the on their head looks. And you know that deformity and I tell them that for the beginning, that is not going to change. And it's hard, you know, because oftentimes, you are treating these patients non operatively. And it's just another thing, you got to talk through it, I've learned the hard way that you need to talk about that for visit one, and need to keep talking about that during the subsequent visits. And honestly, a lot of patients are separate on it. And then you say, well, I could fix it by you know, breaking your bone again, and operating on you and putting a plate on there. Oh, no, no, no, that's not a big deal.
Charles Goldfarb:Right? Exactly. No, I don't think it changes how I practice or how I communicate with patients, which is obviously most important. And then what was me we pivot back to nerve?
Chris Dy:Yes, we do. And I you know, I think this is a study that has been, you know, similar to findings that have come out in the last few years, but I become much better about counseling patients about delayed onset carpal tunnel after a distal radius fracture, non operative treatment, particularly as we go more towards the pendulum is shifted back towards treating these with, you know, expected expected male unions. So when I see a patient in this group that I know is going to get a male union, I know they're going to be dorsal and tilted, I do tell them, you know, one of the issues is that you're probably going to develop or you have a chance of developing carpal tunnel syndrome. At some point in the future, we might need to address that. But that's a very different surgery than if we were fixing your bone.
Charles Goldfarb:Yeah, I mean, this this, the swinging of the pendulum, towards operative treatment for everyone destroys fractures now away from operative treatment for elderly with disabilities fractures is really interesting. And I think we're learning more about the ramifications of some of those decisions. And certainly the potential for the development of carpal tunnel syndrome in this patient population is highly relevant and needs to be discussed.
Chris Dy:Does one out of nine feel right to you? They said 12% of the patients in their retrospective, you know, review of 216 patients treated non operatively 12%, developed sub acute carpal tunnel, so one out of nine,
Charles Goldfarb:I don't think it's lower. I don't I think it feels about right to me, honestly, it could be slightly higher than that.
Chris Dy:Yeah, no, I think it's probably too. I'm just I guess I'm thinking about the number of patients I've treated, the percentage of patients I've treated for malunion or let develop a male union that have undergone a carpal tunnel, I think it's lower, or the percentage of my carpal tunnels that have had this race factor at I think it probably is a little bit lower in my practice, but I think it depends on who you're seeing.
Charles Goldfarb:Yeah, for sure, for sure. Interesting study nonetheless, just emphasizing some of the things that we need to consider when when treating these patients. But what was one
Chris Dy:thing that was helpful for counseling is that the meantime the diagnosis of the carpal tunnel was three months which does feel about right to me. And importantly is as Deb points out here, that's usually the juncture in which you're not seeing them anymore. You may not have seen them anymore at that point. So it is you know, kind of the wrap up Spiel I give people does include a warning about you know, if you develop any numbness or tingling you know, we know that the anatomy or if your wrist has changed and sometimes that can lead to some pressure on the carpal tunnel that's something we can address just tell me if you develop that comeback or call if you develop that. No, that's
Charles Goldfarb:exactly right. And and I don't think this is misdiagnosis requiring three months to make the correct diagnosis. I think it's just as gradual onset of symptoms that maybe is a really a subacute, carpal tunnel that doesn't come on overnight. And then patients, you know, might downplay the symptoms, given that they're healing from a significant trauma.
Chris Dy:Right. And it is something that's addressable. So Chuck, would you treat this carpal tunnel any differently? Would you do your standard mini open carpal tunnel release? Or is this an indication for an extended carpal tunnel release,
Charles Goldfarb:it is an indication for my standard carpal tunnel, which is a mini open. But the trick, of course, is that as one proceeds proximally with the release of the proximal fibers of the transverse carpal ligament and the distal end of brachial fascia, I think you have to be careful, because the way the district is typically heals, and with dorsal tilt, the nerve is going to be pushed more volar. And you might put the nerve at a little more risk if you're not careful.
Chris Dy:I do have a lower threshold to go into an extended although I don't always for this nerf studies ultrasound, given our last week's discussion.
Charles Goldfarb:Well, no, probably neither. My guess is these are going to present in a classic fashion with CTS, CTS being you know, elevated, so probably not necessary again, as long as you recognize the correlation.
Chris Dy:Yeah, and you've known these people for a while at that point, too. So you typically have a relationship, which makes a little bit easier to kind of talk through some of the nuances. Yeah, so we're getting closer with sports to your topic here. metacarpal fractures.
Charles Goldfarb:Very, very exciting. Although no one would claim boxers fractures are the pinnacle of excitement. But yeah, but it's an interesting topic, because it's so you know, it's just a hard patient population to follow up on. So it's a hard patient population to do a study on.
Chris Dy:Yeah, absolutely. And so, you know, dogma or prior tenants would have it that, you know, we would operate for, or suggest surgery for patients with pretty severe angulation of dorsal angulation of fifth metacarpal, fractures, Apex dorsal. And this, there is a nice study here in which they looked at a small group of patients that healed with an apex dorsal malunion of over 70 degrees, and half of whom are laborers. And of their 15 patients 12 them as 80% scored zero on their dash meaning no disability. Do you believe that?
Charles Goldfarb:is incredible? I mean, I believe it because I trust the authors. This is, I don't know, Dr. France, but this is Fraser levers edge. And so I do believe it, but it does strike me as surprising. 70 degrees is a lot.
Chris Dy:What's your threshold on on considering surgery in an isolated fifth metacarpal neck or shaft fracture?
Charles Goldfarb:I become uncomfortable with 50 degrees. And so if it's less than 30, I don't think twice about saying an operative 30 to 50. It's a conversation more than 50 it's still a conversation, but I might have a lower threshold 70 degrees to me is a lot.
Chris Dy:And do you think this is a function of them truly not having issues or a function of the dash?
Charles Goldfarb:Well, I don't think the dash is the best tool to assess this population that is very, very true.
Chris Dy:By these the click dash to but Yeah, same, similar.
Charles Goldfarb:It's just that is the metacarpal head in the poem that, you know, if you grab a steering wheel or grab a baseball bat, or you know, just any of those activities, I think it would be bothersome, but you know, I do trust Dr. liversedge.
Chris Dy:I think he's just got a resilient group of laborers out in Colorado that will just kind of do it. Do it. But you know, I think it is it is nice to see obviously that, you know, our, you know, these values can be tolerated well, but I think that it's important for you know, what I take home from this is that it is a discussion.
Charles Goldfarb:That's right. The next study is interesting to I don't know, this group is Pagani at all, is published in hand in 2022. Looking at performance outcomes and return to sport following metacarpal fractures in Major League Baseball players, which is, you know, the hand that's affected matters, right, the bottom hand on the baseball bat, it takes more forces, but essentially, they showed a couple of really important things. The first is that treating a patient surgically does not necessarily get the patient back to play faster. That is a misconception. I completely agree with that it applies to multiple areas. That's not always the quickest way back and they demonstrated that and you know, consider non operative management.
Chris Dy:Yeah, and I think it's a good one but I think your point about getting it does matter to get in the weeds on this one in terms of which sport which obviously this one's all homogenous with baseball but which hand in which position and I you know, having not read the full paper I don't know for sure how they handle that you know that the these return to sport studies are always interesting because you know, as, as a medical student or as a resident, you're piling through fantasy baseball stats and like, you know, looking at you know, when people get back to play, which is fun to do, but I think not every baseball position is created equal.
Charles Goldfarb:Yeah. And then the next study, one of the next studies they're referencing is discussions of retrograde intramedullary nails for metacarpal fractures. Your good friend, Dr. Content mica is one of the authors of one of the studies and it I have to say, I have been becoming more enamored with the approach the intramedullary layer approach. And I have to say I did my first patient with a screw, similar type screw the extra med screw in a phalanx this week. And those who use that technique, swear by it, and I'm beginning to understand why I think for the metacarpals I'm very comfortable. I like it, I get it. For the phalangeal fractures. I think there's a real indication in certain patients.
Chris Dy:Yeah, I'd be interested your thoughts? You know, we have I have no financial ties to estimate I'll do I do a little consulting work for j&j. And Cynthia's? Yes, I, I typically use this in these headless compression screws just because I like there. I like the various sizes. And I like the length, which, you know, I think have become an issue when I've tried to use other kind of more traditional headless compression screws in the metacarpal. I've done some in the phalanges, and I've learned the hard way, what works well, and what doesn't work? Well. You know, the patient's all did fine. It was just more of like how the surgeon that as they would say, the Goldfarb F bomb index surgeon an alternative for the surgeon frustration index. But you know, it's, I think there's a role for it, and I can definitely see it, I've just become, I think better recognizing the fracture patterns and orientations of the fracture lines for both metacarpals and flanges in which I would use it. But you know, the study that that Megan did, and the first author was actually our incoming hand fellow for next year, Andrew Shizu. Ski, you know, basically demonstrated that the, the issues, the perceived issues with articular damage, are not likely to really pan out, you know, even though you are by, in theory, violating that cartilage, it's not so much a part of the metacarpal head that matters.
Charles Goldfarb:Yeah, and it's a little easier to violate that cartilage, at least for me and the metacarpal, it becomes a little more challenging when one considers the challenge to fractures and some people are going down the pike with proximal phalanx retrograde or distal phalanx retrograde, that's harder for me, I haven't pulled the trigger. I've done some oblique screws. But you know, we need longer term follow up, but the early indications are pretty positive.
Chris Dy:Yeah. And I think that the, you know, not not for these particular studies. But you know, I think that using those screws as almost like our collateral or recess pins can be very helpful. But you got to have just the right fracture pattern in order to do that.
Charles Goldfarb:Absolutely. Absolutely.
Chris Dy:And then your study is next.
Charles Goldfarb:Yeah. Dr. Competence study, that
Chris Dy:the award winning study, some of you may remember when we did the the hand society podcast from 2021, I guess, when we were in San Francisco, and well in the wildland metal that year.
Charles Goldfarb:Yeah, it's a good study. So for those who aren't familiar, I'm ashamed of you, first of all, but you may not have read it. We looked at repair and non repair of the flexor digitorum profundus tendon with avulsion injuries in the setting of an intact fts. And this flawed study, retrospective, the groups aren't exactly the same blah, blah, blah. But the message is that repair of the FTP should not be automatic. It is there are complications, many more complications with repair versus non repair. And there's simply challenges there's a huge requirement for therapy, it just puts the non surgical option on the table. And there's some data that supports thinking, you know, thinking about that option.
Chris Dy:I think I love having the data. I think this is something that a lot of hand surgeons kind of came to on their own evolution of practice. I think you told me that this concept was kind of bounced around on the hand surgery listserv, and many people said, Yeah, that's what I do. Anyway. So it's great to have it in the literature. So thank you for putting that forward. And I know that Jocelyn put a lot of work into that and she was a fellow with us a few years ago.
Charles Goldfarb:Absolutely. We can briefly review this hand arthritis study, if you like. Basically, the author's report using CBD cream to treat non non surgically CMC arthritis. And this was a safety and efficacy study looking at twice a topical application. And basically, it worked.
Chris Dy:Yeah, now I think this is something that it does come up in practice, at least in good old Missouri even but especially those coming from the Illinois side. It works and it works for some patients. I don't have a firm grasp on in whom it works and whom it doesn't work. I'd love to see a you know, some kind of comparative study against, you know, something we typically use like a diclofenac, you know, the Voltaren gel and see if it matters for that. I don't know how much of it is the therapeutic act of applying something, although the comparison to the placebo would suggest that it's not just that. So there's some there's something there. And, you know, I know that there are some groups that are studying this. I know one of our colleagues, Brenda George, out at UVA is looking at this pretty heavily. It's going to be a useful tool. I just don't know how we're going to end up using it.
Charles Goldfarb:That's exactly right. I like this section on infection, because it has affected my practice. And what they did was they looked at the rate of surgical site infection or wound complications. For CMC, arthroplasty, carpal tunnel, there's been a number of studies trigger releases, looking at the timing of this last steroid injection, versus the surgical intervention. I think it's a really important concept.
Chris Dy:Yeah, absolutely. I think that, you know, there, there are a couple of studies in the last year that I wrote this, this update section, that kind of extended that window beyond the traditional six weeks that we use, and put it out to more of a three month timeframe. And I tend to quote that for patients now. Now, honestly, the the incidence of a surgical site infection after a trigger finger release, or carpal tunnel release are actually pretty low. Usually what it is, is probably an overhaul and my experience is that it's an overhaul in terms of you have some redness, probably from where the sutures are made, because they've been using it a little bit much. And we call it antibiotics to try to nip it in the bud if it is and honestly to make the patient feel better. I'm guilty of it. I don't
Charles Goldfarb:know. That's right. That's absolutely right. I think the take home for me is that for and this is, as Deb phrased it, she said strong consideration should be given to avoiding ipsilateral hand surgery within 90 days after a corticosteroid injection. And I want to be clear, I do not think that is a hard line. And I still often do use six weeks. And I'm comfortable with that. But in a patient that may have predisposing factors, risk factors. immunosuppressive therapy, then I think that that's 90 day number becomes even more critical.
Chris Dy:Yep, absolutely. And you're such a busy surgeon. I'm sure you're booking out 90 days. So maybe you can give them that one steroid shot before they actually get their surgery and still be okay.
Charles Goldfarb:I don't know patients are needy. We know we're gonna go to V
Chris Dy:school, you know, picking up the book out six months in advance. Yes, I kid I kid. We're very good about access here. I promise. So this the next study was about prophylactic antibiotics for clean hand surgery. You know, this is something that honestly, I think Ryan Calfee study bias because it came from here, but I haven't really changed my practice after Ryan's study came out. And I learned it from him, you know, typically, especially now that I'm doing a lot of these awake, there's no antibiotics, but for patients that have an IV access, and you know, if they're, they're healthy, if they're not obese, BMI, if they're non smoker, no diabetes, they're not getting antibiotics.
Charles Goldfarb:No, I don't I just don't do it. i We see such a low rate risk of infection, that I haven't second guessed that I just don't give antibiotics unless I'm using hardware, occasionally for joint base procedures. But for the bread and butter stuff we do that are soft tissue just it's a no go for me.
Chris Dy:Yeah, you know, I think for some of the bigger soft tissue exposures, you know, for some muscular transposition, and that wounds open a little bit longer. I'll do that. Now I'll be clear if they have an existing arthroplasty like a total hip or a total knee or they spine hardware, and they were told to have it about it's that kind of thing. I think it's reasonable to even without the other risk factors to give IV antibiotics prophylactically but you know, that we talked about this as a service, you know, recently like if you're doing Milan to do you need to give oral antibiotics for this kind of thing. I don't think there's any, any consistent agreement.
Charles Goldfarb:Right, right. And one of the huge benefits of a lot is there's no ID and so we certainly wouldn't want to do that. Right? Let's bring it home with the pediatric section, which I don't you know, understanding our audience, I don't want to get too much in the weeds here.
Chris Dy:took up so much space on the page. It's almost it's almost a full page.
Charles Goldfarb:I know. I know. I'll summarize quickly. So number one for kids with buckle fractures. Now the key here is accurately diagnosing a buckle and not missing a really a fracture this larger than a buckle. So what's a buckle to you then a buckle to me means buckling of one cortex with completely intact other cortex and you don't want to miss that fracture that may have that buckled dorsal distal radius cortex, but extend voli and violate the cortex voli also, because those fractures can displace and it's the bottom line is we should all consider using removable braces for the true buckle. But it's not easy. It's you know, it's families don't trust their kids. heads in cast seem while annoying, safer. And I think it's reasonable and the true buckle to do it. And that's the take home of this study.
Chris Dy:What age do you think that a cast becomes? Is there an age threshold in which a cast becomes preferred over a brace or vice versa?
Charles Goldfarb:I don't think so. You could argue that once a kid gets slightly older, they're more in control and more likely to wear the brace. But there's so much it's just the child him or herself. That has to be considered i don't i As long as it's a true buckle, I don't really think about age too much. But I do always I still offer the cast for sure.
Chris Dy:I don't see many of these. Usually, it's like as a favor to the person in the injury clinic across the way just because of the nature of my practice, but I do leave it up to the parents, I say, look, there's good literature, the good papers to support, you know, treating these with a brace but you tell me if your kid's gonna wear the brace? If not, then you know, we'll do a cast? Or if they're younger, I'll just say which one do you want casting will make it a pain in the butt in terms of bathing your small child. I know that now. I don't know if I want to recognize that without being a father, to young kids at this point. But yes, I kind of incorporate the parents into the discussion. How long do you have to immobilize them for?
Charles Goldfarb:If it's in the well, I guess for any age, it's really three weeks, you know, you're going to have cows for three weeks. If they're going back to sports, then I typically do four to five weeks, depending on the age, the older child waits a little bit longer. Okay,
Chris Dy:let's talk about these displaced and overriding disarray is fractures in patients under 10.
Charles Goldfarb:Yeah, it's always hard as a an orthopedic surgeon or any hand surgeon, when you see up to 100%, displaced fracture. Even if we understand that the remodeling potential, especially in the plane of motion, that is flexion extension, that remodeling potential is through the roof. It's hard to observe that as and the risks are compounded. When we think about operative intervention for those fractures that involve the growth plate, because manipulation, that growth plate carries a risk that the growth plate will shut down. So we are often better served to avoid surgery. But it is not easy. It's not easy to have a conversation with the family and and you have to fully trust and know that remodeling is going to happen in order to convince the family and it's hard. It's just hard, right?
Chris Dy:Absolutely. So when you say surgery, do you mean like open surgery? Are we talking like close reduction in ED? Like where does that fall into the spectrum of treatment?
Charles Goldfarb:I think most of us would, you know, try a close reduction in the IDI or potentially one close reduction in the or I think for me, the question becomes, okay, now you're seven days out, or 10 days out, there's early healing, and you're 100% displace, what do you do then? And I think this study is really interesting. So it looked at a cohort of reduction in casting, and a historic cohort of insight to casting 50 patients in each and it final couple of guts and cycle casting. My God. If final follow up, there was significantly worse angulation in the reduction group in both the sagittal and coronal planes. In addition, patients who had a close reduction spent more than six hours longer in the emergency department. And that double the charges. Crazy.
Chris Dy:Yeah, you know, it's it's counterintuitive, to be honest with you, you would think that a close reduction would lead to because these are both unstable, pay cohorts with unstable completely displaced fractures, you would think that the close reduction would not be worse. So I want to read this paper a little more to be honest with you. You know, but, you know, the question is, you know, whether you subject the patient to having sedation for the clothes reduction procedure itself, the trauma that does to mainly the parents, to be honest with you cited the anesthetic risk to the child. And then, you know, the cost as well. You know, I don't know, I think that the it's an interesting question, but I think your point about, you know, banking on the remodeling, just remember these are, these are kids under 10.
Charles Goldfarb:Right, exactly right. So the details do really matter in a study like this. Let's skip and discuss ganglion cysts, if that's okay.
Chris Dy:Oh, that every ma that works in my clinic knows how much I adore ganglions who have to torture me by putting a ganglion
Charles Goldfarb:Yeah. So this study looked at 315 patients, which is obviously a huge number that you neither you nor I would like it's a multicenter study. And essentially, they concluded that the the effort and the expense of aspiration or a wrist orthosis is not warranted and that either observe these with the hope that they resolve, or we consider surgery for patients who have functional limitations or pain. And there's also surgery are good, but maybe not as good as the adult population with dorsal risk ganglions. But the results of surgery are good. But they're not perfect.
Chris Dy:No, is this paper? Are these findings good enough for you to go to a parent and say, you know, the chances of, if we put a needle in this, the chances of it coming back are high enough where we should go straight to surgery, or we should just observe it. It's that's kind of a hard discussion to have. Because, you know, traditionally, you know, they're gonna wonder why you can't just put a needle in, especially if they've had prior experience with it, and they look up stuff on the internet, they're not going to see the latest study.
Charles Goldfarb:Yeah, you know, kids and needles don't often mix. So that was one mitigating factor against a huge desire for needles is, as you know, I like to give options, and the options are observation, aspiration, or surgery, I don't usually offer a splint because that my experience has been that they don't help. And this study bears that out. I would say a high a very small minority of patients and families request the aspiration. And when they do they understand the real risk of recurrence, but it's so easy to do. And and for those selected patients where it works, obviously, they're very happy.
Chris Dy:Yeah, yeah. So I'm not I don't see this a lot in the in the adolescents. But honestly, my counseling is pretty similar for adults, although obviously, the threshold to use a needle in terms of aspiration is different than an adult versus a child. Yep,
Charles Goldfarb:that's exactly right.
Chris Dy:So I want to wrap up, let's talk about this. There's an interesting study here about driving for lunch. And Deb opens it up by saying that's one question that has made many surgeons uneasy is whether it is safe for patients to drive after Wilmont actually doesn't make me uneasy. But maybe it's actually it's one of the things I taught tell patients that you can drive yourself, your drive yourself home, but you know, because all the times they're already known when they're driving. But it gave me pause in this study this looking at this as timely because one patient was very well meaning and was giving me some feedback on my preoperative counseling, and told me that I should not tell people that they can drive themselves home, because she said it just was too uncomfortable. And she could she didn't want to do it. And that's one patient out of I don't even know how many will on surgeries I've done now. But it's been, you know, four or five years. But it did give me pause. And it's helpful to know that this study exists.
Charles Goldfarb:Yeah, I think it's to some degree, you know, in the state of Missouri patients decide if they can drive or not. But I do it is part of my preoperative conversation to say that if you have a trigger, if you have a carpal tunnel on one side, you can drive yourself home. So you may not want to, and that's certainly up to you, and you will have a bandage on. But many people do drive themselves home. And I think it's an important point.
Chris Dy:Yeah, so this this study that they looked at Pino was a first start the author, but you know, 39% of patients admitted driving to and from their surgery, their will on surgery. And then prospectively, you know, they looked at that 30 patients anonymously before they drove the day of surgery, and that 51% had reported returning to driving on day one. So I think that patients largely can and will do it, I based on that patients feedback, I did alter my counseling a little bit. Instead of saying you can drive yourself to drive yourself home, I do say, you know, but you might want to have somebody available just in case.
Charles Goldfarb:I think that's the right advice. And obviously, we want safety and my line to patients is, you know, you never need that second hand when driving until you really need that second hand when driving and then you want to have it available. So that's, that's part of the decision making that they need to make.
Chris Dy:I remember your one of your driving lines was, you know, to practice in a church parking lot, which, you know, I don't know why the church
Charles Goldfarb:still still as a church, and I don't know why either because they're big, or at least in Alabama growing up, those were the biggest parking lots. Go figure.
Chris Dy:Yeah, there you go. Like it's you can't say a Walmart parking lot, because that was probably hazardous anyway. So. Sure. So that brings us to the end of what's new enhanced surgery for 2023.
Charles Goldfarb:Thank you. It was fun talking about Deb's article, I think it was a great whirlwind tour through hand surgery. And look, it emphasizes how, what kind of impact we can all make on the field of hand surgery. And I look forward to seeing what comes out in 2023.
Chris Dy:Absolutely. i These articles are always fun, because you know, when we have residents who say I want to do research, like I usually tell them go read what's new, and so and so, and try to see what you know, the the author, you know, has four ideas of things, you know that that could be next. So, yeah, you know, those of you that are doing research, maybe look at that.
Charles Goldfarb:Yeah, don't don't. Your goal shouldn't be to change the world, because we're not going to do it in hand surgery, but incremental progress can be really satisfying.
Chris Dy:Yeah, absolutely. I have a wonderful day. You too.
Charles Goldfarb:Thank you. 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@congenital hand. 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