Season 4, Episode 11.
Chuck and Chris welcome Macy Stonner back, our good friend and friendly hand therapist extraordinaire! Macy will lead our discussion on mallet fingers. She will share tips and tricks and we will all share our thoughts about this 'routine' but sometimes challenging diagnosis.
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Season 4, Episode 11.
Chuck and Chris welcome Macy Stonner back, our good friend and friendly hand therapist extraordinaire! Macy will lead our discussion on mallet fingers. She will share tips and tricks and we will all share our thoughts about this 'routine' but sometimes challenging diagnosis.
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 am really good. How are you?
Chris Dy:I'm great. You know, it's, we're at the end of March now. We've been we're gonna be you know, heading into April. Pretty soon. Spring is coming. The weather in St. Louis certainly reflects that. Oh,
Charles Goldfarb:my God. It is I am. I do suffer from seasonal affective disorder. Although I should say that carefully. I don't really suffer. And I'm sure there are people who do but I need sunny weather soon.
Chris Dy:Yeah, absolutely. Well, you know, we've decided, so I didn't realize this was a thing until we moved to St. Louis. The pool opening and closing thing didn't happen in Florida. The pool was always open in Florida, before it was cold or hot. But we decided to open the pool on May 1. And I'm really super excited about that. So it's kind of like a countdown to that that's at least what's going on in our house.
Charles Goldfarb:Yeah, the other reason I'm excited is we you know, we heard I heard once that someone didn't think our audio on our podcast was top notch. And I think it's pretty good. And no one's ever complained about it, except for one person said that. But we have seriously upped the game and I have to share with you but I'm using a new mic. I got the sweet new headphones. So I'm feeling pretty professional right now.
Chris Dy:Well, you know, being a boss will will step it up like that, you know, I think that and you're the kind of person that you know, you'll take that one bad patient review and change things to make it better. So one thing that was kind of interesting this week, I had my first clinic yesterday without wearing a mask. totally weird.
Charles Goldfarb:Yeah. And we and we have a guest here, maybe we should just loop her in because she's feeling the same way. So our favorite and most recurring guest is back by popular demand, I should say, By popular demand. I think in fact, they may want to vote one of us out off the island and just keep Macy hear me back.
Macy Stonner:Hi, everybody. I'm glad to be back. And I agree about the masks.
Chris Dy:So our institution just went to mask or switch was what's the word situational masking or masking at the request of the patient? Basically, at the request of the patient based on obviously different clinical scenarios, you should be wearing one. But, you know, I think I wore masks for one patient. And it's because I felt weird not wearing one because they were wearing one and they said it was fine. I just put one on anyway. How was it for you may see.
Macy Stonner:So at first I was a little weary about it and decided to keep wearing one. And then I was in Dr. Goldfarb clinic on Thursday. And I noticed that he wasn't wearing one and I thought oh, I'll just give it a shot. I loved it, I really felt like this deeper connection I'm able to make with patients just being able to play off each other's reactions. And I don't know, I just felt more connected to each patient's and loved it. So I'm gonna I think I'm gonna keep going.
Charles Goldfarb:I still been I've been traveling a little bit, even after Vegas where Chris and I recorded a couple of pods that traveled last weekend. I still wore a mask in the airport and on the plane, but man it is it is very few people with masks on traveling.
Chris Dy:I will I will say this. Partially joking, but I will use situational masking perhaps when I'm on the plane and I'm wet anyway see my mouth open and I'm sleeping.
Charles Goldfarb:There's trouble there. There's truth.
Chris Dy:And I'm realizing a couple of things about yesterday's clinic that first off, like, I have known some of these people for like three years and have never seen their face. I mean, it's amazing. And they've never seen my face. So it's, it was quite odd to like see people's faces, and especially people that you know, whom you've operated upon. And you know, that's a for lack of a better word, a pretty intimate relationship to be operating on somebody. I've never seen their face. So that was that was interesting. And you know, I think that was a nice connection. It felt really good, you know? But then I realized halfway through my clinic that I could not show all of my expressions like if I had a mask on like a patient the downside of what you're talking about Maisie like hearing a patient say something I couldn't purse my lips I couldn't be like oh my god because I'm used to keeping it okay from like, you know, eyes nose up, but uh yeah, I have to I have to remind myself it's kind of like getting getting back on a bike right?
Charles Goldfarb:Yeah, you know it's a Macy's probably experiences little kids are interesting because you really connect with them with a big smile and and but I think they also can realize just like we can read eyes, we can see smiling eyes and I think all of us are gonna be a little more perceptive about subtleties and facial expressions. But I'm also a little worried about getting sick. Like I haven't had a comma Cold and three years, and I know they're gonna start coming back. And that's one huge benefit that was really nice.
Chris Dy:Well, Macy knows Macy knows that life as well in terms of the the daycare slash Elementary School germs that both of us have been fending off for the last, I guess since the school year started. So that's we're ahead of the curve there for you. Hopefully won't spread anything to you.
Charles Goldfarb:So we have a topic, which on the surface may not sound like the most exciting topic, but
Chris Dy:it's definitely not the most exciting topic. I'll tell you that right now. But
Charles Goldfarb:it's filled with controversy. And you know, people really feel strongly so we're gonna talk about mallet fingers, which you
Chris Dy:do, uh, you do have to talk about it. Like, that's thing is that like, there's a conversation in this conversation that comes up frequently.
Charles Goldfarb:Yeah, there's no therapist or hand surgeon out there who doesn't deal with this problem regularly.
Chris Dy:Well, before we get into it, we should thank our sponsors.
Charles Goldfarb:You are so good. We definitely should thank our sponsors.
Chris Dy:The overhead is sponsored by practice like.com, the most widely used physician job search and career advancement, advancement resource.
Charles Goldfarb:Becoming a physician is hard finding the right job does not have to be joined practice link for free. Today at WWW dot practice. lync.com backslash the upper hand. And, you know, I've enjoyed our conversations with practice, Link. I think you and I owe the founder coffee and discussion one morning, but it's a good it's a good group.
Chris Dy:Right, right. Absolutely. You know, what's funny is I was talking with somebody about the podcast and the sponsorship thing. And he asked like, Hey, do you guys just like record that and just like insert it every time. And I think how we just flubbed that. That copy totally shows that we do not just inserted every time
Charles Goldfarb:now from the heart from the heart. All right, well, let's, let's how should we start this?
Chris Dy:Well, here, let's let's do a case. Right. So you know, say you've got a a young investigator eligible under 40 type dad, who is playing ball,
Charles Goldfarb:are you still under 40?
Chris Dy:I got the award, buddy. So now it's funny because I've been walking through the hospital like I apparently it's been like, people have been told in the south county or one of our satellite centers. So people are like, you're still under 40. I'm holding on for a few more months. But say it's, you know, a young dad who is playing ball with their child, and, you know, his daughter throws the ball quite hard. And, you know, he tries to catch the ball. And it's been a while since he's played ball. And there's a sudden, hyperflexion moment to his middle finger. And he comes in and you can't, he can't straighten out his finger happened. I don't know a month or Yeah, it happened. Let's say a week ago, he went to an urgent care center got X rays, X rays were negative. And they put him in and Illuma foam splint from the palm extending past the tip of the finger. It's all co Bandha. He has moved his finger in a week. So Macy, how do you because sometimes, you know when we're collaborating with you in clinic, sometimes you'll see patients for us. So how do you approach that discussion? And kind of what are the other history points you want to take?
Charles Goldfarb:Can I before you answer Can I Can I say one thing? So for those of us for those in the outside world who don't have the benefit of working with Macy or someone like Macy, it's like the best possible situation because often will have a resident or fellow who goes in and they may or may not understand all the issues and they may or may not get it right. Macy always gets it right. Like she's been doing this a long time. And when she comes out and says something I
Chris Dy:know not that long track. Not that long. Okay.
Charles Goldfarb:She's under 42. You're also in a special state. Can we talk about that for a second? How do you feel?
Macy Stonner:I feel good, I feel good. For those who are listening. I'm three weeks out from having a child and I feel good. It's like this pregnancy is a little harder because I have a toddler to run around and chase after but overall feeling good feeling ready. feeling grateful for all the things that come with it.
Charles Goldfarb:Yeah, well, I'm glad we snuck snuck this part in I don't know why I felt like I hadn't seen you in a while. And maybe we missed a clinic or something. But you were in clinic with me on Thursday. And I was like, Oh my god.
Macy Stonner:You definitely saw me your eyes got bigger. You're like, whoa, what difference?
Chris Dy:We should do a public congratulations to Macy. This will get to a baby shower on the upper hand.
Macy Stonner:Thank you. Do you want me to continue to talk about mallet or do you I'm gonna keep talking about other things.
Chris Dy:Well, I think Chuck was talking about how awesome it is to have you in clinics, the price should finish and then we should get back to well, y'all are very
Macy Stonner:sweet. Thank you. But regarding that patience. I feel like one of the first things I want to address is like, Hey, isn't to not say, Oh, you've been doing this wrong, you need to be moving these joints and your splints wrong. And you know, you're mismanaged in some way, I'd say, Nice job, you've been splitting for a week full time. But you know, we really want to customize that splint a little bit more, give you more freedom at some of the more proximal joints, support your tip of the finger a little bit better. So we're probably going to send you over to therapy today to have a different brace made and kind of go through some specific education and instructions on what to do for the next, you know, six weeks or so. And kind of educate them a lot on the anatomy. Because a lot of times I've been taught that
Chris Dy:it's like totally Birmingham nice the way the teachers Well, good job on splitting for a week. But I love that I'm sorry to interrupt you, but how would you educate them on the anatomy?
Macy Stonner:Sure. So I'm just gonna give my spiel a little bit, I'll take out our anatomy book, and I'll sure it shouldn't like the extensor tendons on my hand, and describe it like, you have a rubber band on the back of your finger that got jammed or overstretched. And if you have a hair tie or rubber band that gets stretched out, it's hard to get back to that tight tension than it once was. And so then I kind of showed them my finger and explain if we got to keep this really straight for six weeks or so through dedicated splinting, because as it heals in that straight position, think about a lot of scar tissue that gets built up on the back of your finger and it tightens up in a good way. And then after six weeks, you take a splint off, and hopefully it magically stays straight like that. And I explained it like it's splitting with a commitment. Because if you take it off for showers or for intermittent activities, you have likely let your finger droop. And we want to keep it tight for six weeks. So it's definitely a commitment. And we'll kind of go through some strategies of how to take it on and off to clean your hand to monitor for laceration without letting your finger droop. That's kind of like a little bit of my schpeel.
Charles Goldfarb:Your Spiel is great. There's a lot we have a lot of different angles, or leads we need to pursue. Sure. So number one, Chris, does every patient deserve an x ray?
Chris Dy:No, but I think that Nova in terms of decision making, and what to do, yes, in terms of, dare I say therapeutic, or XR t in terms of showing them like a lot of times patients will think like they didn't even do an x ray. So and that honestly contributes to kind of patient satisfaction. So I think getting an x ray, especially one that can be done quickly, and with very low radiation in terms of the floor skin is beneficial in terms of the relationship, but I don't need it to make the diagnosis and to guide management pretty much every time unless I have a high suspicion for a bony mallet. You know, so that I think is what how I think about how do you think about it?
Charles Goldfarb:I think every one of these patients should have an x ray. And part of it is for the reason you said and part of it is occasionally I'll be surprised there'll be a larger than expected fragment, there might be joint subluxation. And I had this conversation with jazz on Thursday that, you know, sometimes, you know, you come to the orthopedic surgeon at a at a big referral center and you just kind of get the X ray, even if you don't really need it like CMC, arthritis is another example, you know, from across the room, whether they have CMC arthritis, and sometimes you just gotta get the X ray.
Chris Dy:Yeah, I think there there certainly isn't expectation, you know, going off topic for the CMC thing. I think we've talked about this before, I usually will get the X ray for getting the surgical planning. But I tell the patients specifically why I'm not getting an x ray. And that's part of the initial counseling spiel for that particular condition. may see I love the rubber band analogy. I have not heard that. And I will probably start using it. You know, in terms of how I counsel patients, I love that especially the tension part of it and everything.
Charles Goldfarb:So Macy, I think, Chris and I feel strongly that the splints that you custom make for patients are perfect, you know, are really good and they make sense. I think some of our listeners probably don't send their patients to a therapist for a custom spine. And they get by with a Luma phone or fax but or stack splint. Exactly. Can you and I'm asking you to sell your services a little bit. Can you explain why you think a custom splint matters? And can you describe the splint or splints that you may design for a patient?
Macy Stonner:Absolutely. So in clinic Thursday was in your clinic I there was a little boy that had a mallet injury, he had a little foam splint to the poem just like you described. And when I went in there, I evaluated the positioning of this finger in that splint. His tip was in hyperextension and his tip was in a little bit of flexion and you know I think that it requires a hand surgeon softserve his eyes to monitor that and to ensure a remote you know, lateral view looking in the splint that everything is positioned perfectly and you know you can get by with a prefab, resplendent or other things but The details of a finger can be so different for everybody. And I think that being able to customize something is important. So for example, I will ensure that the PAP joint is exposed for free. That's difficult to do with the prefabricated splint. Because I don't want them to start Swan decking or get stuck there. And a lot of times, they're really swollen, and we have them come back at, you know, seven to 10 days and have it remoulded to accommodate for those changes in swelling. Because oftentimes, you put them in the splint and you haven't been a little bit of tip hyperextension have them come back, their swellings down, they've kind of shifted in their splint a little bit, and then they're in a little bit of flexion on accident, and they go to the next five weeks in flexion. Or, you know, kind of takes quite a bit of understanding. Health literacy might be a good term for this diagnosis to be successful. Because sometimes people will come back and they're spot on upside down a lot of times, and they're being positioned inflection. So I guess I'm getting at, you know, the importance of a follow up to ensure everything's going okay. But the splint going back to that is something that can be volere, to push them up into a little bit of hyperextension. Not too high on the sides, because sometimes that allows the finger to droop down, we have to be very careful with your strapping system to make sure that they're supported. Well. This is all kind of hand therapist lingo. And then we always make two at our clinic, at least one on the bowler side and one on the dorsal side to distribute pressure over six weeks and prevent, you know, skin breakdown and too much pressure on one side. So they have options to go from one to the other. But it's definitely one that I feel strongly that you can't really get a prefabricated off the shelf one to support you. Well.
Chris Dy:I love that. And you know, I think the multiple splints is key, I think it's probably the biggest advantage among all of the ones that you described, I didn't realize that you had patients come back for a visit, I kind of thought it was a one time deal. So can
Macy Stonner:be for some patients like you kind of feel out the patient. And you know, I had this physician the other day, he just needed a splint. And I was like, No, normally we come back in seven to 10 days. And he was like, No, I'm good. Like I get it, you know. But typically, that visit is really important because you just make sure that they are well equipped with all their splinting needs, you give them a little bat and velcro and different types of devices Cauvin or whatnot, to ensure that they are set with all their stuff for six weeks to accommodate for changes in swelling or an older one and the dorsal one and nine times out of 10. They hate the lower one and they just want the dorsal one. So I end up making a second dorsal one for them. And so just kind of making sure that they understand the program I document that I can I watched them transition from one splint to the other without breaking precautions or without laying the finger droop because some people just don't get it. They'll put on one splint, like they're in the shop like to mimic that they just come out of the shower and it's all wet. And then I'll have them show me they can put the other one on. And then they let their finger rest up supported. And then they droop. So it's a lot of reinforced education. Sometimes the people just really aren't getting it, you know, those people that come back, you know, three or four times, but typically it's two visits.
Charles Goldfarb:All right, I love it. I have one comment and two questions. My comment and Chris and and Macy, I'm curious as to your thoughts. I see a lot of athletes, and this is one that's hard for me because I don't know of many sports that you can play during the healing process with a mallet splint on. So for I'm trying to think of an exception, but this is one of the ones that frustrates me and I know it frustrates families and patients and athletes. I generally don't let people play with a mallet injury because I don't think we can keep the splint on effectively. We can try and we can tape it on but it comes with risks. Is that a fair statement? Or do you guys disagree?
Macy Stonner:Doctor, did you want to go first or do you want to go first?
Chris Dy:You should go first place?
Macy Stonner:Okay. I think I agree. For the most part, I think there's a few cases that could probably be okay. Depending on the sport, I guess and how protected the finger is. But if it's a small finger, and there's not a lot of real estate there and those are really tough to splint. And I feel like the splint comes off a little bit more frequently if it's a long finger and it's, I guess, thinking like a guide as a really long hand and it's pretty solid on there and I koban it really well to his finger and piece comfortable and so I think there's probably a case where like that would be okay. But I think it would require the right person who gets it, I guess.
Chris Dy:Yeah, I kind of just tell them you can do whatever you want in the splint. Just make sure the splint stays on and it's your risk. And I don't see the I'm not as fancy as you in terms of seeing the elite athletes, or just many athletes. I mean, I see some kind of a high school kind of amateur kind of thing. But, you know, I guess the next I'd love your thoughts on that, Chuck. But then also, I'd love to ask you like, what if it was a surgeon, and they needed to scrub? Are you just going ahead and pinning the joints? And do you think that's reliable? And would you ever do that in an athlete, but because of the pin breaks? That's a problem?
Charles Goldfarb:Yeah, I think it's a good point. And in general, I just tell them that if it's a elite high school athlete or a college or professional athlete, I think they're just down unless they get it pinned. And I do think painting is reasonable. And sometimes you go with a larger pen, because I don't think the forces across that DAP joint are all that great. And I would try to have them wear a splint. But even the the weekend warrior who just can't imagine wearing that splint, I have pinned and you know, it's a fine line. I do bury the pin, I leave it in for six weeks. I try to insert it under a local only anesthetic. And I try to leave it proud enough that I can take it out in the office. But it's a great solution. But it does have problems may see.
Macy Stonner:Did that patient ever get stiff with Tip flexion? Was that ever an issue regaining movement?
Charles Goldfarb:It's not I'm not seeing that issue? Yeah, I haven't either
Macy Stonner:up the conservative route. So I was just wondering,
Charles Goldfarb:my two questions not to belabor this too much. Number one, when do you include the PRP in one of your splints? And I say it carefully because I think usually when we have a splint that includes the PAP joint, we also have one that does not. And the second in our colleagues from across the seas who are listening are probably curious cost in our system doesn't manage cost well, and it's not inexpensive to send a patient. So you may say,
Macy Stonner:unfortunately, you were right. And I wish that I had a say in that. So cost. I don't even know if I'm allowed to say this on the air. But I'm going to at our clinic, we do not charge for mountains. They're not free. But we like when we submit our time, I mean, our charges, we submit how many minutes or like the time it took to take it. So it's like called initial orthotic management. So it's not an L code, meaning you don't get charged hundreds and hundreds of dollars. So that's something that's changed over the years, we've kind of modified our fee schedule. I can't speak for every clinic on that.
Chris Dy:But I mean, just before you go on, there are some health systems where this injury is initially evaluated and completely managed by hand therapists. I think that happens in the UK.
Macy Stonner:And then the other question was, oh, pap. So there's two cases in my mind, I'm thinking why am I going to pap number one is if they are a little bit further out from their injury, or they've got a lot of laxity in their swan neck and quite a bit. So I will make a splint for nighttime or as needed during the day that keeps our tip joint and a little bit of flexion and the tip joint and hyperextension. So that's one reason why I'll make a tip included when the other one is if it's a pinkie, like I mentioned earlier, there's not a lot of real estate. And so if you have a tip on the splint, a lot of times the patient doesn't feel secure, or they feel like it's going to fall off. So I'll make an additional one about that goes to the entire length of the pinkie with the caveat that, hey, don't wear this all the time. You know, I don't want your Pap joint to get stiff, but at night, when you feel like it's gonna fall off, or you're going to be doing heavy activity, feel free to wear this big one because you feel more comfortable in it. And then I put them in that and like, Oh, this feels so much more supportive. And then they kind of alternate back and forth between the two.
Charles Goldfarb:I think that's well said. And just to be clear for maybe some less experienced listeners, part of the goal of a good D IP joint immobilizing splint is maintaining the PAP joint. Because I say this to patients all the time, I don't really care about motion at the tip joint in I'd like you to regain full motion. But I really care about motion at the PAP joint. And so the beauty of this system is that you can keep your PRP moving and not worry too much about the DAP. What Chris, how do you think about so let's say six weeks comes up or eight weeks comes up and the patient comes back and and you say okay, now it's time to get rid of this one? What do you tell them? And I'm curious what you tell them? What may see my time and whether we are the same? Sure. I
Chris Dy:mean, so you know, I guess from the beginning of the initial conversation, I tell them we're going to split this for six weeks. And I guess we could ask like why six weeks? Why eight weeks? I think it's total orthopedic. You know, dogma, six weeks should be enough, right? And I tell him at the beginning that everybody ends up with a droop. We're going to do this for six weeks and let it scar tissue build up. But I remember every time and in Ryan Kalfas clinic just him kind of showing them everybody ends up with just kind of comes down to your startup here. After you come out of your splits then you'll end up just with about a maybe a 15 to 30 degree extension lag and he calls it a droop and people get that so you No. And I think that that's something that you got to tell people from the jump. So you know, when we have the initial conversation, I tell them that when they come back to the office, I love asking them, Hey, how's it gone? How's it split? Ben, show me your finger. And I know who's been wearing their splints properly, and who has not the awareness been properly because the guy who just goes, Oh, there you go, it just rips it off, clearly has not been properly wearing their splint, then there are the patients who are wonderful, who appropriately like on the little hand table that we have will take out their hand and put it on the edge and appropriately take off their splint. And when, and then when you ask them to move it, they're like, really want me to move it? That's the right patient. And you could totally tell where this this is gonna go. And I put that into my note that you know, when patient took off the split and took off the split didn't seem to follow precautions and whatever. But then I'll tell them well, you know, at this point, I want you to I have them wear the splint for another two weeks at night. And I don't know why that was one of the faculty that was Ryan does that too. And he may not still do it. But he did it when I was in training. And then I tell them kind of get back to using things where it at night or when you're doing heavy activities for two weeks. If you feel comfortable, keeping them more comfortable keeping your arm when you're playing sports or whatever, go do that, too. You'll probably end up with a little bit of a droop. Usually most people don't have a problem with that. But if you do, let me know. How will you check what's your spiel?
Charles Goldfarb:Well, most feels the same. I do like the concept of two weeks at night, two weeks with sports. I just think it feels better to the patient. Rather than okay is six weeks you're free. See you later. You know you've been wearing this splint religiously for six weeks now you're free. The one other thing I tell them and make a big deal about this is no passive flexion of the DLP joint. Oh, yeah. Because and I just say, Look, don't worry about getting your flexion back, you will get it back, I promise. Just use your hand, don't push down on it, you'll get your motion back. And before we hear from AC The one other thing, I think that's really important is your point about conversation, initial conversation. And expectation of a droop is super important. Because there will be patients that are unhappy. And it doesn't matter what you tell them, but at least if you tell them when you start, you've told them and if you did, if you don't tell them when they start that they may have a little droop, it increases the risk of frustration, even if it's irrational frustration, may see how to Chris and I do with our therapy recommendations in care recommendations post six weeks of splinting
Macy Stonner:totally agree, I typically say between two and four weeks, depending on your desire and like how tight they look like if they show me their finger and they look so rock solid and extension. Yeah, I think two is great. If they're a little sore, a little bit more flexible, and they kind of drip a little bit and might say, you know, this is up to you. If you're satisfied with this, you can live your life like this, it's fine. But depends on what your desires are. And I think two to four weeks is great still wear it during heavier activities. Or if you're nervous during something, I totally agree. I have them maybe make a slip a few slow fists open and close just to kind of help loosen things up. But again, no forceful gripping no passive flexion, that kind of thing.
Charles Goldfarb:So I love it. And I love the fact that this conversation has been primarily about non surgical care, we should touch on surgery. It's a huge minority of patients, they ended up going to the ER, Chris, I'll put you on the spot. What are your surgical indications for soft tissue or bony mallet?
Chris Dy:I very rarely have a surgical indication, I don't think I've ever operated for a soft tissue mallet. You know, we talk about the kind of the person who will not tolerate or cannot tolerate the splints for various reasons. So the surgeon, the athlete, you know, so I guess that'd be a reason to pin. You know, I have not primarily repaired the extents of the terminal tendon back to the base of the distal failings based on how I was trained, and a number of studies that have demonstrated, you know, no substantial difference in any outcomes. I do tell patients from the initial counseling when we're dealing with a soft tissue now that there is no good surgical solution that's going to make this better than if we treat you in a splint. And I think that's important because they're coming in to see a hand surgeon. So like when they come in for that that's their expectations. The first thing and you totally wouldn't score points when you're like, It's great news. You don't need surgery. Right? Yeah, really gets the conversation off to the right on the right tone. And then in terms of indications for bony mallets I think that you know, there was a lot of talk and then in the literature and the class of teaching about the size of the fragments, but I think more papers have demonstrated recently, including some meta analyses. I think Julie's some more did one looking at it's more, it's not so much about the fragment size, it's really more subluxation of the tip joints. So that volar subluxation of p3 or the distal phalanx relative to the middle failings. How about you?
Charles Goldfarb:Yeah, I like what you said I don't recall the last time I repair the terminal tenant back to the distal phalanx. I don't that's not really indicated in my hands very often, if ever, I will occasionally pin joined for the reasons you stated. So then it gets down to really bony mallets? And what are the surgical indications? And I don't think there's anything less clear in my world than that question. Dr. Wall and the wall, who's my partner sees a ton of adolescents. And that population may be a little different, maybe a little more forgiving, and she really almost never operates even some mild subluxations, I believe she'll skip the surgery. For me, the absolute indication is a subluxated joint. And I do get nervous based on the size of the fragment and the displacement, whether that's rational or irrational based on the literature or not. If I have a fragment, that's 50%. And I think most of our listeners will say, 50%, I would definitely fix that. I still hem and haw a bit, especially when there's a gap at the joint. And and when you treat that surgically, you feel pretty good about it. But I don't I just don't know that it's the size of fragment, as you said, I'm just not sure that's a real surgical indication.
Chris Dy:Well, so let's say you have a 50% fragment, but the joint is not subluxated will really still go after it
Charles Goldfarb:depends on the age depends on the family depends on the car, but you know, it's just there's a lot of factors. It's not an automatic yes or no would be my would be my lousy answer.
Chris Dy:So then when you treat this surgically, are you primarily just pinning across the joint? Are you going after that tempting, juicy fragments?
Charles Goldfarb:And I'd love Macy's thoughts on a couple of things. I'm about to say number one, yes, I'm hopefully going to reduce the fragment pen across the joint. It's a bit of a pipe dream to put a longitudinal K wire through the fragment. So usually, you're just paying the join, and sort of trying to get that fragment down. I will sometimes use a dorsal block pen to try to improve the positioning. But I hate leaving that dorsal pin in because my experience has been those the most likely to get infected and most likely to drag the patients crazy. Sometimes I'll just manipulate the fragment with a pen. But I don't like to leave dorsal pens in. Chris, I don't know what your thoughts are on dorsal pens versus just the joint immobilizing pen and Macy, I'd love to hear your thoughts on those dorsal pens.
Chris Dy:My thoughts will be quick. So I'll go first. I love the little joystick to help get everything lined up. Make sure the joints perfect. So dorsal pin in the fragment I've I don't think I've ever left a pin in. I know there might be some are tempted to put a little screw in there. It's probably overkill, you blow apart the fragment don't do it. So Mesa, your thoughts?
Macy Stonner:Sure, I think that Emily honestly treated a handful of these before. And I think my feedback is that they endure. Anecdotally speaking, they probably at the end, maintain a little bit more rock solid extension, but lose a little bit of reflection I would imagine. But I think that any patient that has pins in are freaked out to move their finger, whether it's a P one fracture or metacarpal fracture whatever it might be. So then they're a lot more worried about moving the Pap. And sometimes I think that like just by default, it gets a little bit stiffer and they're just a little bit more freaked out. But overall, I really don't have a ton to say about this population because I treat the majority 99% I would say non operatively.
Charles Goldfarb:My last point for this conversation and you both may have other points you want to close with. When a patient has a chronic untreated mallet that's resting in 45 degrees of flexion and they are unhappy. They often have accompanying hyperextension of the PAP joint. And my favorite treatment for that and it's not even close is to ignore the DAP joint as long as it's flexible meaning as long as we can passively move the DAP joint. I love a central slept anatomy. I think it rebalances the dorsal finger, and it's simple. It's effective is one of my favorite surgeries. Of course they don't see that many patients that need it, but it is one of my favorite surgeries.
Chris Dy:Then you do that under Local. Right you were doing that under Local fire before the Woodlawn stuff started right.
Charles Goldfarb:I was and I and I will. And patients tolerated really well. Yep. Yeah, there's
Chris Dy:one. There's one surgery that Dr. Marty Boyer always talks about in in our anatomy labs. When we talk about the extensor mechanism session, he always mentioned that you're the one that that showed him the way instead of doing the oblique retinacular ligament reconstruction.
Charles Goldfarb:Yeah, that is crazy. And obviously not my surgery has been around for 50 years. But it is a good one. And yeah, for those who think about an O RL reconstruction, oh my god, don't do it. Macy. Take us home.
Macy Stonner:Yeah, I think that those surgeries are fun to rehab as well. There's kids. It's very satisfying, like you mentioned, and I think that it works out well. I've only treated a handful of those. I also think maybe from you and Dr. Cathy and maybe, but I don't think that there's any issues that I've seen with them and yeah, that's pretty much it. Thank you so much for having me again.
Charles Goldfarb:We're grateful you're here. I think we've taken a boring topic and made it super exciting, right.
Chris Dy:Hey, Chuck, I do have one more question just the closed loops just for the listeners. So you have your pin in the joint across the joint. How long do you leave it in? And what's your postdoc protocol after the pin?
Charles Goldfarb:So the pen, this is one of those six weeks. You know, again, why I don't know but six weeks is the number. I see to pay. I do the surgery, I had them go to therapy to get a custom splint post surgery to cover the pin. I see them back in the clinic at six weeks. I do get a mini CRM, but I don't really care what it looks like. I removed the pin and it's exactly the same protocol. active motion only no passive motion of the DLP joint.
Chris Dy:Is that kind of work right away or?
Charles Goldfarb:Good question? Probably not probably two more weeks and then back to sport.
Chris Dy:Yeah, I think for me back to sport usually is when you can make a full fist of it. It's just a general goal for you know, a lot of the hand stuff.
Charles Goldfarb:Yeah, Macy's heard me say this, I think my I have three criteria for return to sport in general number one full motion. So your point is well taken. Number two strength which is good and symmetrical, hopefully to the upside, or at least pretty close. And three is no pain. Those are my three criteria for most things as far as return to sport.
Chris Dy:I cannot believe we just talked for 40 minutes about mallet fingers.
Charles Goldfarb:Let's do it again sometime.
Chris Dy:Definitely. Thank you, Macy for joining us. Always fun.
Macy Stonner:Thank you very much. See you next time.
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 at hand podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is at congenital hand. What about you?
Chris Dy:Mine is at Chris de MD spelled dy. And if you'd like to email us, you can reach us at hand podcast@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