Season 4, Episode 13.
Chuck and Chris spend the first 20 minutes of this nearly hour- long episode discussing past and future travel- the meetings, the patient care challenges, etc. Then we pivot to deep dive with a discussion on a case of FPL rupture after volar plating of a distal radius fracture. While uncommon, this problem can be a real challenge and we discuss efforts to minimize, diagnosis, and treatment. Join us!
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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 13.
Chuck and Chris spend the first 20 minutes of this nearly hour- long episode discussing past and future travel- the meetings, the patient care challenges, etc. Then we pivot to deep dive with a discussion on a case of FPL rupture after volar plating of a distal radius fracture. While uncommon, this problem can be a real challenge and we discuss efforts to minimize, diagnosis, and treatment. Join us!
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:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:Really well, how are you?
Chris Dy:Fantastic. Beautiful Saturday morning in St. Louis, hoping the weather holds out for today.
Charles Goldfarb:Yeah, absolutely. At my I'll date myself, my youngest turned 18 yesterday, and with a nice celebration, which continues all weekend. So yeah, good times around the house.
Chris Dy:So she just gets a weekend, where as your wife gets a year that's really interesting.
Charles Goldfarb:18 might be equivalent to 50. And one of those the big birthday scheme of things.
Chris Dy:That's pretty awesome. So congratulations to you guys. Does this mean she's leaving the house? Come the end of the summer?
Charles Goldfarb:It does. And I'll tell you we tell you and I are looking forward to empty nest hood for sure. And you know, with FaceTime and texting you stay in such close contact is it doesn't you know it's obviously empty nested but it's not daunting, at least to us at all.
Chris Dy:I'm sure when you know, maybe if we're still doing this a few years, maybe you'll have some additional reflections on what that's like.
Charles Goldfarb:And they might look different. They might look different. We'll see. We might get tired of each other. But we've been looking forward to this.
Chris Dy:Fantastic. Well, congrats to you guys and a half and happy birthday. And I think you guys will enjoy the rest of the weekend for sure.
Charles Goldfarb:Absolutely. One of the things that this will allow us is a little more flexibility to travel. And that's one of the things we want to hit on. On this episode. There's some different travel to discuss. And I think we have a good episode planned.
Chris Dy:Yeah, absolutely. So you want to talk about any upcoming travels you have? Or do you want to go back and talk about your recent travels?
Charles Goldfarb:Well, I have two exciting trips. I almost never traveled for a full week for work. And I have two full week trips. The first is this coming week. So we're recording this on April 29. So I leave tomorrow for Israel for a week never been. There's a joint American Israeli hand surgery Conference, which is the second of its kind that first was in 1979. Yeah, so kind of crazy. There's a good good group of American surgeons going and um, you know, just really excited about the history of the country and the dynamic of the country. And I don't know that it's ever a perfect time to travel there. There's a lot of political, shall we say, discussion going on now. But I'm really excited. And my oldest to keep it in the family is joining me Jake's flying from New York to Israel. And he is able to do that because he got into medical school. So all good.
Chris Dy:All right. Well, congrats to Jake. That's huge. And then that's such a fun opportunity to do that. I think I've talked I think probably on the pot, I talked about how important pre pandemic my last international trip was doing a similar trip with the American delegation, so to say to combine meaning with the Korean society for surgery they had and went to Seoul and actually brought my father. So on a similar theme to what you're talking about just slightly different variation on it. But you will not be the only wash you Hansard and traveling Israel. Is that true?
Charles Goldfarb:Yeah. Well, Marty Boyer is one of the ringleaders for sure. With Jennifer Wolf, as the president of the Society and your close partner, and obviously mine, David brokens. Joining I don't know his travel schedule, but David's definitely going to be there.
Chris Dy:Yes, it'll be fun. What are you going to be talking about?
Charles Goldfarb:I was looking at the schedule, I seem to be the one to give two talks, which is obviously great. I'm traveling along way. I'm talking one, which was easy to put together, one actually had to put together the easy one is Rachel deficiency in the wrist, that that's I've done some modifications, because interestingly, one of the, or maybe the thought leader who helped us use soft tissue distraction for radial deficiency at the wrist was an Israeli, who described it in 1989. And said, I'm going to mention that and I don't know if the person is still alive or not. But that may be a fun discussion over there. And then I'm talking about pediatric and adolescent scaphoid fractures, which is interesting assignment. And it's been fun to put that together.
Chris Dy:That's great. Well, are you and Jacob have any time to to explore? Are you heading right back right afterwards?
Charles Goldfarb:Yeah, we're gonna have a couple days before. We get it on Monday. And we have Monday and Tuesday. And then the meeting sort of starts Wednesday night with some lecture about I think it's really a trauma lecture, which should be really interesting given their experiences. And then in the meeting is Thursday and Friday, and then we have a little time Friday afternoon and Saturday. We Have some time and come back Saturday night and Sunday respectively.
Chris Dy:That's pretty exciting. And that's the first of two week long trips.
Charles Goldfarb:Yeah. The second is Minneapolis for the world congenital meeting which we have spent this was originally scheduled. I know, we've talked about it, but it's originally scheduled in 2021 pandemic delay. You know, in retrospect, we had to let this, you know, we made a good decision, we were debating, you know, having in 2022. And we ultimately decided to delay it for two years, that was the right decision. And it's come together really nicely. There were some anxious moments on, you know, when people sign up for meetings like this, our goal was 300 attendees, and we're almost there. So the finances were a little shaky for a while, but we look good. The meeting is going to be incredible. It's actually Wednesday through for actually, for me, it's Wednesday through Sunday morning, because we have a study group after but it's really Wednesday through midday Saturday, and really a great lineup of talk. So I will be really excited to be at this meeting. What about you, you gotta be going somewhere?
Chris Dy:Well, there's there's actually a little bit I think, by the time this episode drops, since we're trying to plan ahead, since you and I are alternating our weeks of travel, it seems by the time this drops, we will I will have probably been on my way are just back from the combined Asia Pacific meeting in Singapore, which is super exciting. I think. I think I have told the story of how we slash I was invited to this to this meeting when you and I were in London at fesh. But one of the meeting organizers Shuman das de is, is in Singapore and he is a fantastic hand surgeon with an interest in your world of congenital and peds and he's actually going to be attending your meeting in Minneapolis. But he was a hand fellow when I was a resident at Special Surgery. So he and I know each other from there, and he was kind enough to invite me to come over I'm super excited to go to Singapore. Never been and very excited about that. And along the family theme, my sister's actually going to be joining me because she's able to travel and she is obviously super excited about that, too.
Charles Goldfarb:Now, is this the sister who met up with you in Vegas?
Chris Dy:Yes. Same sister. It's nice to work. It's nice to work remotely, isn't it?
Charles Goldfarb:Yeah, it's I have not been to Singapore either. I had one chance and timing wasn't right. So I look forward to hearing your thoughts. How long is that meeting?
Chris Dy:The meeting itself is four days, it will be kind of an out and back on the on the back end of Memorial Day weekend. A memorial day weekend call and then one of our partners has been kind enough to cover me for the few hours that are at the end of the holiday weekend where I have to be in route. So yeah, super excited about that.
Charles Goldfarb:Wow, that'll be that'll be that'll be great. Good. Well, we should we thank our sponsors.
Chris Dy:We absolutely should we absolutely should. Oh, man. Yeah, by the way, anybody that's listening to him, we do actually work. I think my schedule is crazy champ pack that weeks that I'm here before I leave in the weeks that I get back, but I'm sure yours is the same way.
Charles Goldfarb:Well, yeah, I think it's it. That's a really good point. Yeah, the RVU expectations out of these out of touch academic hands. Yeah, that is so not the case. And not only that, I've learned to be a little better. But you don't want the stress of all of it to like, you know, make it harder. But God missing two weeks, in a relatively short period time is unprecedented. And I'm already paying for it. And I'm going to pay for it for a while.
Chris Dy:Well, I mean, we've talked about so far on the pod about being guilty of the add on clinic to make up for lost time. I'm trying really hard to protect the time that I need to for sanity and for academic reasons. Although my medical assistant has become very savvy looking for or in clinic time to fill the gaps because it is getting a little crazy.
Charles Goldfarb:Yeah, yeah. 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 finding the right job doesn't have to be joined, practicing for free today@www.practicing.com backslash, the upper hand,
Charles Goldfarb:I think I can share what you know, we you have been talking with our friends at practice link about a new segment, which I think maybe whether or not they're involved, I think we should do it. I think it's a really cool idea.
Chris Dy:Well, let's not let's not let him off the hook entirely. I think it would be really fun to do. We had a I want to when we start the segment, I will disclose the listener email in full. But we did have a great listener who wrote an email with a segment very reminiscent of an old NPR show that I used to listen to, I guess when it was in podcast form, but many listeners who are you know old like Chuck probably listened to it when it was an actual radio show form. So I am a little bit of a an NPR nerd. So we will not give it away yet. But that's a little teaser. And I think it's going to be really fun, fun venture with our folks with our friends over practice. Like
Charles Goldfarb:I didn't never news in podcast form but they're you know, they're There's something about having a show, whether that's television or radio, it's on at a certain time that you have to try to work around to be there. Obviously, if you can't be there, you can't be there and the olden days, you know, you just missed it. Now, you don't miss anything. And you can listen or watch at your own convenience. But I remember planning my days around this particular show, and really great stuff.
Chris Dy:I mean, basically, the upper hand is going to be the equivalent of must see TV in the podcast interaction. Not really. But have you had so we talked about your amazing travel scheduled coming up? Probably you've come back from a meeting recently, I saw a lot of buzz on social media about positive.
Charles Goldfarb:You know, I actually only had a quick trip to pause and on pause, and I was in Nashville, which is about a positive by the way. Thank you. For those listeners who are blissfully unaware, the pediatric orthopedic Society of North America, which is a great group. It's a bit smaller than the hand society. And they really have two major meetings each year. This is sort of the scientific meeting. And it was in Nashville, which is four and a half hour drive from St. Louis, just far enough to to make me not drive when I was debating that for a while. But I was there for less than 24 hours. And I went down for a great pre course, sort of pre course they call it a specialty day. And we had a hand specialty segment, which was awesome.
Chris Dy:That's great. Did you wait, I didn't know they have a second meeting. Is it like a social meeting or something every
Charles Goldfarb:year? It's called I POS, which is in early December. It's really it's it's it's really good speakers. And it is designed, it's not scientific presentations. It's not awards. It's just you know, bread and butter, pediatrics orthopedic surgery in various formats for residents, for fellows, for young attendings for everyone to learn. It's in it's an intense few days of really great stuff. So that is super fun as well. But pause now is the classic scientific meeting. And it was good it was in Nashville was great. And Dr. Lindley wall, our partner co organized this session with Hilton Gottschalk, who's in Austin, and they had a great session with some scientific presentations and some case presentations, which I think was really well received.
Chris Dy:Yes, and Dr. Wall, your your partner, your partner in the congenital practice and my partner in hand surgery, we should acknowledge that she has now an endowed professor at Washington University. It's fantastic. And he's taken over your role as a pediatric orthopedic surgeon in chief at St. Louis Children's Hospital. Is that the fancy way to call over the chief of peds?
Charles Goldfarb:That sounds good to me. Yes, absolutely. Yeah, she she's doing a great job.
Chris Dy:That's pretty exciting. I saw I know, my feet is obviously biased. But I saw a very strong WashU presence at the meeting both among faculty trainees now and then alumni from, you know, various stages in their career. So congrats on all that you've done to build that legacy.
Charles Goldfarb:Well, teaser for a future episode. But, you know, building community is hard. But it's also incredibly rewarding. And we have a great alumni group of physicians, and we had a reception at paws on Thursday, and I couldn't make it. But it was incredibly well attended. And just like you and I have talked about our hand society, get together for wash your hands, wash your hand. It's so great when those things go well and and you really get to see people you care about and who've been a part of the program. And so that really is wonderful to see in peds. Ortho?
Chris Dy:Absolutely. When when you get to reflect on that, that's fantastic. So how many people do you think were in the room for the? Or where do you think were attended Posner in general?
Charles Goldfarb:I don't know the answer to that question. It's a great question. I have no idea. I don't know. 1000s. Yeah, in the 1000s, but not multi 1000s. I would guess 1000 or so. But that could be way off. Probably not fair to guess I don't want to insult anyone if I'm way off. But, you know, I know that you and I've talked about just meeting attendance in general, I don't think has rebounded, the academy talked about that the attendance in Vegas matched 2019, which I think is an accomplishment. But certainly, it's tough. And there were shy of 100. And people in the hand specially today, which is good. You know, it's not. It's never been a segment that has a huge number of people. There's competing interest. And so you get people really shouldn't hand but it's hard to pull other pediatric orthopedic surgeons away from other specialty days. So it was a good session in a good city with good friends, so it was fun. But you also have traveled and I'm really curious to learn about Chicago and what went down.
Chris Dy:Well, the reason I asked you about the number of people a positive is that you went from a meeting in You know, 1000s of people there to I organize a meeting for 20 people. That was a very different experience. I mean, so when I when we had the phone we received the funding for multicenter brachial plexus prospective cohort study the planet study, which I'm very proud of that acronym. It's probably the only acronym I will ever come up with that works. But it's the prospective longitudinal assessment of nerve trauma planning, I still remember the day that I came up with that was I was leaving the gym and going to Monday morning conference, pre pandemic, and I was sitting at a stoplight. It's like I got it. This will work because all the other orthopedic multicenter studies seem to be themed on on astronomy, so moon and Mars, etc. So that was my contribution. So our planet group, when we received our funding, we said we're going to have a study meeting, once a year in person then of course, the pandemic. So this was our first study group meeting in person. It's amazing it was that the American Society for Surgery, the hen was kind enough to host us. Chicago was the perfect location for a flying meeting, because we've got folks coming from New York, Baltimore, Charlotte, Nashville, in Chicago, on the in Gainesville on the West Coast, and Seattle, so and Indianapolis, so people are coming from everywhere. So to have a flying or driving meeting in Chicago was kind of perfect. And acsh has wonderful offices, as many who are listening who may have dropped by no great meeting spaces, and very economically efficient, I will say meeting cleaning costs. So that was also huge. So yeah, we flew in surgeon from each site. They have funds from the grant to do that. And then a member of the research team from each site in terms of a research coordinator, research assistants. And it was incredible. I mean, it was just nice to have a group of we hadn't nine brachial plexus surgeons all come together very thoughtful people who we all looked at each other and talk very honestly and openly about where what our shortcomings are. And it was amazing to have a group of surgeons of that caliber, some real names, be very honest and open and there wasn't any chest thumping of this is how I do it. This is how you should do it. It was let's try to figure out how to get better. And we had a guest speaker from the President of United UI brachial plexus network, who provided not only a great presentation, but sat in on all of our science, scientific type sessions where we're brainstorming and thinking about a new ideas and gave incredible context. And that was invaluable to the meeting. So super fun, just a dinner on Thursday night, all day kind of meeting stuff on Friday, and people are out by late Friday afternoon.
Charles Goldfarb:That is great must have taken a lot of planning to put this together and make it as an efficient and productive meeting as it sounds like it was.
Chris Dy:I am very proud of the fact that we were able to get thing, pull it off efficiently and there was no grumbling about we started too early, we started too late, we ended too late, etcetera. We kept us on time and caught some audibles during the day to kind of work, you know, go along with what the group seem to want to do. I think as the meeting organizer, my biggest faux pas was getting dinner at an Italian restaurant on Thursday night and forgetting to order a pasta dish for the group. I think reflective of the fact that I've tried to be a little better about that kind of stuff. But totally, if that's the biggest issue I have with the meeting, I think we've succeeded.
Charles Goldfarb:Yeah, that is a win. And so you have nine, you said nine surgeons attended, you have nine sites, or was everyone able to attend? Yeah, so
Chris Dy:we had once one site that had to two surgeons attend, there was one site that did not have a search intent, but had their physician assistant come who was heavily involved in both the recruitment and the execution of the study. So it was it was fantastic. I mean, we had HSS represented Johns Hopkins, ortho Carolina and Charlotte, Northwestern University, University of Florida, the Indianapolis hand to shoulder Center, our group at Wash U and the University of Washington, in Seattle.
Charles Goldfarb:And is there are there plans to enlarge the group? Or is this the size, it's, you know, get things done and can sufficiently enroll,
Chris Dy:I would love to hear your thoughts on that. And, you know, maybe a future episode about how to guys, you've done some incredible work with the kid registry. I think we're going to try to get bigger at some point. It's the group feels good right now. But I think we're obviously open to other surgeons who are thoughtful seeing these patients have an interesting approach to it. You know, it's just a matter of at the end of the day, the brass tacks or you know, getting the data in. And, you know, if you can't get the data done, then you know, even though if you're an incredibly nice person, and I like you socially, I don't like having to lean on you too much to get the work done.
Charles Goldfarb:Now, that's right. It's it's we've gone very slowly with expansion. I think it would be a great topic because I think these groups are chant, you know, have changed the face of orthopedics and orthopedic research and incredibly important so yeah, we should dedicate an episode to that for sure.
Chris Dy:But maybe we should talk about some hand surgery,
Charles Goldfarb:I guess. So we have we have a good I think you have a case you want to share and and I think we can have a really robust conversation. I'm looking forward to this.
Chris Dy:Yeah, I'm actually I think I may be tainting the well on peer review of you guys. This case that we're going to discuss is probably going to end up being some kind of case series surgical technique thing because as we talked about this, I emailed the or hand surgery group. So you know, you, Dave Brogan, Marty Boyer, Ryan, California, Marie Morris, and then they went on, I was like, Look, how many of these cases have you done because lo and behold, I've done four in the last three years, for some reason, at least, at least four with a good pictures, which there may have been a day where the case wasn't going as smoothly and I forgot to upload pictures, but FPL rupture. After attritional. FTL rupture after volar plating for distal radius fractures. It's something that is so commonly talked about as a complication of this radius fractures. The frequency rates are published with some, you know, obviously, different levels of methodological rigor. But then people say, oh, yeah, you then you, you reconstruct it, but then nobody actually, there's very little out there about how to do it, which was frustrating, because I remember doing my first couple of these and trying to look at the literature to see kind of what to do and what the experience has been and finding very little and the resident I'm working with right now. Andrew Kuhn is fantastic. He corroborated that when he I asked him, What did you read for this case? He said there was very little, so I can present the case, you know, in generalities, but you know, this is there, an older gentleman older than Chuck, who had a distal radius fracture fixed somewhere else in the St. Louis region, and even he doesn't know who fixed it, which is probably a good thing, because as you've said, If you don't know your hand surgeons name, that's probably a good thing. But he couldn't, he couldn't even remember 10 to 11 years ago. volar plates have a prior generation. And their fracture itself has healed incredibly well like almost anatomic position the plates distal though, and you and I have talked, I don't know if it's in this forum, or in conference or wherever about, you know, you put the plate where you need to get the fracture fixed, right. But if you know, you're gonna have to come back in the future, you have to remind yourself that you have to come back in the future to get the plate up and granted awareness of plate positioning and you know, risk of attritional rupture of any of the flexor tendons has gone up in recent years, but I think that was probably recognized by when this plate was going in. But it comes in, you know, randomly, you know, 10 years after his or if by somebody else and say, I can't bend my thumb didn't feel pop, I don't know what happened. And then, of course, it took him you know, three months to realize I should see somebody say, comes into the office, and we get X rays me, how do you how do you talk to this patient fracture is healed? Well, you know, the plate is distal. And it's pretty clear clinically, that he's got a ruptured FPL, Tina desus, you know, doesn't show any, any motion of the IP joint of the thumb.
Charles Goldfarb:In we talked about some of the anatomy, before we kind of talked about how this is dealt with.
Chris Dy:Absolutely. So I would love to hear your thoughts. But you know, I think that so for those of you that are kind of new to the game, or are not surgeons, you know, when you typically most people when they do the surgical approach for a distal radius, or if you're doing a boilerplate, most of us will make an incision kind of right over the fcr tendon, you incisal or sheath of the fcr, you retract the FCRA you inside the dorsal sheath. And the way that I do it, and instead of you know, kind of spending time identifying the long flexors, etc, I just kind of take a freer, and I get over to the shaft of the radius proximal to the fracture, park that free or on the radial border, the radius kind of right around where the br is going to start to flatten. And then after putting the free are in there and establishing that plan, I put a homerun over there, which is a retractor that kind of hooks underneath the dorsal part of the radius. And that keeps my radial artery out of the way. And then I just take a sponge and bluntly dissect all the long flexors over towards, you know, towards the OMA. And that shows us the pronator quadratus, which in many cases is has been traumatized, and it's almost blown apart. But you do have to inside some of that pronator quadratus, to get down to where you need to do your work for the plate. And some people early on, especially the hand weenies among us would debate on whether to repair the product or cooperate is to provide a buffer between the plate and the flexor tendons. But that's kind of where it gets interesting. So what do you maybe I mean, I know it's not the focus of this episode, maybe you get some pearls about how you do the approach.
Charles Goldfarb:Yeah, I like what you said, I go through the fcr sheath as well. You know, you do have to be careful about the Parma cutaneous branch of the median nerve, which is classically between the Palmer as long as and the fcr but can be overlying the fcr and you don't want to injure that nerve. It it's not the worst thing in the world to injure the nerve but patients don't like it and they complain about it. And then you work underneath the flexor tendons. As you said, I like your home and trick. Expose the pronator and you know people talk about how do you release the pronator D just do a straight incision. Do you leave a cuff to repair? Do you You L shape it. So you're distally going transversely across the race, I don't think it really matters. And honestly, as you mentioned it, it can be really traumatized and bad fractures. It is it is relevant for this conversation, though. So after you elevate the pronator, you fix the fracture. And I guess let's go back to premiere now. And then I want to ask you a couple of questions. I do try to fix the pronator. And there's some literature around this. But the reality is, I don't think it necessarily matters because the watershed zone, which is the area where things get a little tricky, and if your plate is really on that distal watershed area, it's probably prominent, and that prone area can't protect you. And so probate or repair make some sense to me, it's definitely not mandatory, I don't think it really keeps you out of trouble. Right.
Chris Dy:Can I add one thing about that? Yeah, I want to ask you, Is there are there ever any situations, are there any fracture types or clinical scenarios in which you say, definitely going to do this approach, like I'm going to fix the pronator, because there may be there are a couple for me. But and I started off like that. And you know, when I was a resident, Scott wolf had a nice technique where he would longitudinal instead of just transversely, releasing the BR off the styloid, he would longitudinally in size, the BR brachioradialis tendon, and leave the volar slash on their portion of that br tendon attached to the pronator quadratus and elevate that as a single sleeve, so that you could repair VR back to VR, instead of trying to repair a flat squishy traumatize PQ muscle back to somewhere on the radius or periosteum, or something I have, when I've said I'm going to go in and repair the pronator quadratus. That's the technique that I've used because I have not found muscle repair to be gratifying and enduring in any meaningful way.
Charles Goldfarb:i It is highly variable for me, it depends on the patient age, and obviously the nature of the trauma, I have variably had good success with just repairing it to the to the cough, which is left behind. But whether you inside or elevate the br You can still use the br However you do it, the br is just sitting there, and there's no negatives to using it as an anchor point for your repair. But I like that technique. It does make sense as to your question about whether there are certain fractures where I, you know, on the way in think about per, you know, repairing the br At the end, I don't know that I've thought about that way, which ones which ones do you think about?
Chris Dy:I think it's the one where I know I'm gonna have to put my plate pretty distal. I think our was actually our conversation here with Dr. On eBay in his talk about how you know, he designed his initial volar locking plate to be placed on an anatomically reduced fracture. And I think over time, because you can, quote, get away with a lot of stuff. A lot of surgeons have accepted kind of taking a fracture in neutral or slightly dorsal tilt, and then putting the plate on to hold that position, which again, ends up working out, okay, a lot of the time. But if you do that, then you're accepting a plate that is inherently going to be more prominent and potentially pressing on your flexor tendons. So, you know, I think before if I knew that I was going to kind of accept a, a non anatomic reduction for various reasons, whether it was bone quality, or you know, patient morbidity or trying to, you know, kind of move the case along to get out of the or if the patient was sick. That's when I think, you know, I would probably try to do something for the pronator quadratus. But now I think I've become much more exacting on the reduction, I will accept it at least try to get some element of bowler tilt to try to protect that plate from becoming prominent, so less picky repair for me recently, because I'm just trying to get a better reduction.
Charles Goldfarb:It's a really, really important point that bears emphasizing. So a distal radius which heals in neutral or slightly dorsal tilt is fine, I think we all would acknowledge that. But if you are whether treated surgically or non surgically, whether treated surgically or non surgically and what you know, but to your point, if you're putting a plate on which is anatomically designed, and you accept neutral or especially slight dorsal tilt, then you are almost guaranteeing that that plates going to be prominent unless you bend the plate or do something. And that's a really important point. The only thing I would say that maybe my philosophy is slightly different or my understanding is slightly different is I don't think it matters, you repair the probate in that situation because the provenance is distal to the pronator. But I think it's a really important point.
Chris Dy:Right, right. Do you think that matters? And I have some ideas on this. But do you think it matters the type of implant that you use? You don't necessarily need to say what you use or whatever. But I mean, I do think that designs matter.
Charles Goldfarb:Actually, it's funny because that was my question to you. I you know we all say that these plates are interchangeable. And I know that manufacturers don't like to hear us say that but it
Chris Dy:Unless you want to spend less you want to sponsor us, if you want to sponsor us, Chuck is willing to listen to and we could talk about how great your plate is relative to other plates. Just kidding. Not really.
Charles Goldfarb:Yeah, I mean, to certain degree plates are interchangeable, but there are subtleties. And maybe in a perfect world for, you know, we'd have a plate choice for each type of fracture or something, but there aren't differences thickness, how the screws fit, they're absolutely differences. And I do think it matters, I really do.
Chris Dy:I changed plates, I change preferred manufacturer for plates, some point in the last five years, for a couple of reasons. One was actually customer service, which that company has, that I moved away from has improved. The but I was, you know, starting at a new surgeries, you know, ambulatory site, and I needed trays to be stocked, and if the trays aren't stocked, I'm gonna start looking somewhere else. And then also the this newer plate that I've been using is thinner, which I think makes a difference. But one thing that I learned not the hard way, but just from like looking, you know, in terms of complications, but like looking at at lying in surgery, I think that some of some surgeons really endeavored to get that quote, homerun screw up the styloid. And listen, if my philosophy which is probably a bit of a hot take is that if you're relying on a single homerun screw to provide stability for your radio column and the radio column matters that much, you probably should be putting some additional fixation on the radio column. While it looks awesome on X ray to have the longest dilates current. Remember, there was a competition one of the attendings I was with in residency would, you know, remark on oval this person put a so and so length styloid screw and can you do that I'm gonna have fun now, like, that doesn't matter. I don't know what you think about that. I'd love to hear your thoughts on that.
Charles Goldfarb:That's interesting, I think we should have an episode on distributees fractures again, because some of this stuff is good. And, and we should repeat it or expand on it. I've never heard that honestly and don't have any don't put any stock in the the quote unquote, homerun screw homerun screw. For me, I think more about an electron fracture. I don't think there's a single screw that is that vital for destroyers. Now it can be important, especially in the osteopenic patient or the multi fragmentation. But that's new to me.
Chris Dy:That's so so it chiefing. That type of the point of that was that achieving that type fixation sometimes means that you're relying on the variable angle aspect that many many plate manufacturers give you. So for those of you less initiating, we should have a different conversation about this. A locking plate has a fixed angle option in which the plate you know, you take the nominal angle that so that the screw head locks in 90 degrees to the plate. Now you have a variable angle option where you can work within, for example, 30 degrees on a cone and shoot that screw in a different direction. And then the screw head will still lock into the plate. What I've learned is that for this particular manufacturer, if you do the variable angle and try to get maybe a different length angle on this different length on the screw, like a longer screw, the screw head will still lock into the plate. But it will sit more prominently. And I think for those radial sided screws, those are the ones that could potentially tickle and irritate and eventually nutritionally rupture your FPL. And I always, for me, it has been, you know, the FPL from what I've seen, and not many of the other flexor tendons?
Charles Goldfarb:Oh, I think that's exactly right. And that point is is well stated. I don't want to pivot prematurely. But I'm curious. I think we have said on this podcast that both of us in the immediate post operative period mentioned to the patients that we may have to remove this plate, your fracture required a little bit of a distal placement. Do you believe that you can monitor palpate for crappy tests or tenosynovitis all along the volar forearm and decide whether you need to remove the plate? Or is it purely the plate is placed in a position that makes you worried therefore you have to plan to remove the plate?
Chris Dy:Good question. I talked to Vashi about the potential for implant removal before surgery. And if there's a particular case in which I think that we need to remove it, I make sure to tell the family tell the patient and put it in my notes honestly to remind myself because once people start coming back at you know, six weeks, three months, etc it's kind of hard to remember some of that stuff. You know, in terms of how to monitor I don't think we can reliably do it. There are case reports from all over showing this can happen immediately after surgery versus 1015 20 or 30 years I think there's a report from I think it's from mainland China about this happening 20 years after or if so it's something that I worry about all the time and when I'm kind of discharging patients from care after just radius fracture fixation I say look, I need to know if you feel when you're I actually palpate on them and I feel over their long flexors and put my finger in there and then I put their finger there. And then I extend their wrist. And I say if you're gripping and you know, I'll do it for you to hear, but I'll put my finger right before the wrist crease on palm really. And I'll say if you're gripping and you feel anything creaking, you're crunching you need to call me because I'd rather know before it's too late, because I'd rather get that implant out when the tenant is getting irritated versus you know, tendon starting to give. Now, that being said, I've only had one patient come back recently that I remember that actually did that. And I went and took out her plate and the tendon looked completely fine. But I think the point for me on the exam is that it should be with the wrist and extension, there was a paper, I think it was an ultrasound paper. published last few years, I think we've actually talked about it on one on one of the What's New enhanced surgery episodes a few years ago, showing that wrist extension is a position that you want to check, you know, for crepiness.
Charles Goldfarb:All well said, I do the same exact thing. And when you feel it, it's impressive. When you feel that gravitas or competence, theoretically, or accurately. It's real, and you know it and it worries me. But I think you can also have that rupture without ever having felt that. And I think your point about timing is is really spot on. It's spot on. All right, we should definitely, we've been babbling for a while we should talk about how you think about reconstruction, should we? Well,
Chris Dy:let's because we kept talking about all of your extensive travels and ate up half of the episode.
Charles Goldfarb:Sure, sure.
Chris Dy:Yeah, so I don't know I struggle with this because I looked in the literature. And it really isn't, there's no definitive case series or surgical technique, or, I don't know, I'm stupid for like defaulting this idea that somebody's trying to beat a punch, by time we get this written up. But there will be a case coming from WashU at some point, whether or not it's the first one in the literature, not at this point. But Chuck, maybe we don't release this for like six months. But there's very little out there, you can I personally do not think in this nature of rupture, you're ever going to be able to repair it, I think you have to tell the patient, you're going to have to use some kind of graft. And for me, that's typically going to be an autograph. And then yeah, I've learned the hard way that you got to say, it's probably going to be back in your carpal tunnel or beyond the distal stop. So you got to be in terms of drawing out your incision, which I typically do in the office and then in pre op, just say, Look, we're gonna have to do a carpal tunnel release, I may need to go out into your thumb to find this thing. I'll make as you know, as many incisions and as big of an incision as I need. But the you know, not more than any.
Charles Goldfarb:Yeah, absolutely, you ended up with a relatively sizable incision. But as you cannot repair these and you can't repair them on the dorsal side, either for EPO ruptures, and you, you often are either exposing the entire carpal tunnel or passing a tendon graft through the carpal tunnel. So I agree with that. And that's important to lay out beforehand. So number one question. So you don't do a tenant transfer, you're like, you're not going to do an FDS. Of ring finger to Palmera as long as you're doing an inner positional graft, is that correct?
Chris Dy:If I can, because I mean, you know, so other people have asked him like, why not just do like biard FPL, because your tenants don't is going to be too far distal to reliably get into use of ers as a transfer, because that would be a relatively easy, straightforward transfer. But you know, the FPL is such a huge muscle belly. And I remember Marty Boyer, one of our partners, talking about how the FPL is a huge muscle belly, and it just like, I don't like to leave axons on the table, he doesn't like to leave any good muscle on the table. So, you know, I think that it is also independently innervated, which is huge. So I personally think that it's a better option than an FDS transfer. But I do think in FTS transfer would be a nice alternative or backup, if you, for example, got into a situation where you couldn't get this thing to, you couldn't get your tenant graph to reach for whatever reason, or you're like, This is no longer gonna glide. What do you think about it?
Charles Goldfarb:I think that's well said I have you know, no one has a ton of experience to your point. I've done in a positional graphs, and I've been happy with it. But I do think FTS, is a great backup. If for whatever reason the inner positional graft is not going to work.
Chris Dy:What's your choice of graft? Is there any role for Allah graphed here?
Charles Goldfarb:Oh, I don't think there's any role for Allah graph. There's no need for the expense. And I think there's plenty of options. So the way I think about it is Palmares is obviously easy and is fantastic. As long as it's there. I assume you agree with that? That's the first choice.
Chris Dy:Yeah, that is that is the first choice. But what do you do if Paul versus not there?
Charles Goldfarb:Yeah, I mean, certainly you have the option in those patients that have a contralateral Palmeras. To do a small incision and harvest has not really been my first choice. I usually use a portion of fcr. So I have no problem harvesting half of fcr. I think it works. I think it's right there. And you certainly have plenty of length for almost every scenario. What about you?
Chris Dy:Same algorithm, not surprising anybody? I think that most of us would make the same decision. Do you have any pearls on finding the distal stump?
Charles Goldfarb:You know, no. I haven't done enough of these to have true pearls. I, it's often in the carpal tunnel has been my experience. So you're hoping you find it, you know, right near the plate. But that's not really what I have seen. And so what I typically do is I don't typically open the carpal tunnel, because it's ultimately a great pulley in these situations. And so I go distally over, so I make an incision, usually, what I ended up doing is making an incision where we know we can find the part of the FPL just proximal to the one pulley. Because if you go to proximately, in the 13 hours, it can be tricky to find it, at least for me. So I find it a little more desolate preserving the a one pulley, and then I tried to work back towards the George, we just had a head raise, because it's because
Chris Dy:you're raising your hand on the camera. Zoom is too smart. Yeah,
Charles Goldfarb:I work back towards the chances of carpal ligament, but I like to leave the chances of carpal ligament intact. And obviously, gotta be aware of those little nerves that you care so much about. keep everything safe, but I do motor branch. Well, that and the two sensory nerves. They're all in play.
Chris Dy:Yeah, it's interesting in this case, you know, we actually, one of the points I make when we're starting the volar approach to get back in is that you got to find the median nerve from the beginning. I personally think that's important because I've gone into takeout volar plates before the median nerve was randomly subcutaneously, or, conversely scar to the plate. So in terms of making myself feel better, I find the median nerve right away so that everybody knows where it is. And then in this particular case, we actually saw the Palmer cutaneous and it had its own classic little tunnel, you know, just sitting on top of the carpal tunnel. So we kind of traced all that out. I think this is hard, because like you said, if you want it, you can it's nice to leave the carpal tunnels a pulley, but also I kind of get a nervous because I'm almost always going to have a graph sliding through the carpal tunnel. So I think it's actually my preference is to release the carpal tunnel. So I should do that from the beginning. And in this particular case, it didn't have to go on the thumb, we were actually about to make the incision to go out into the thumb. And then we did the classic like orthopedic milking maneuver where he tried to, you know, flex the thumb and kind of walk that thing down, you know, by pushing on it over the flexor sheath. And lo and behold, it picked his head out into the very dysplastic. I'm like looking down into the carpal tunnel, like put my head down. And it's just that right there underneath Athena eminence. So that was great. Because we were then able to start our weave, I started my weave distally with this case of Palmeras, I've had to use an fcr Hemi fcr in the past. Got some really nice weaves. We put some nice stitches in. And then I guess the question is, you know, we pass then pass the graft into the carpal tunnel to take the shaft or not the shaft but I guess to the non woven portion of the graft into the carpal tunnel. How do you set your tension? Because I think this is something that I guess we'll have discussion when we write this up. But you know, this is not easy.
Charles Goldfarb:So first of all, you're doing like a pullover TAF weave. Is that your goal? So you can start early motion?
Chris Dy:Yeah, we did a poll for Taft. And we're starting early motion. And I felt good, you know, we got you know, three really nice weaves, not too bulky.
Charles Goldfarb:You know, the bulk is obviously key. I think about it with wrist position. And so I tried to set my attention so that with wrist extension, the thumb is flexed and resting comfortably a little firmly but not too firmly against the middle failings of the index finger. So it hits her so it hits for pitch. So it hits for pinch. And then with wrist flexion the thumb is fully extended IP joint is hyper extended even. And you always, you know, we've talked about it's always like a little tight, but not too tight. And so it isn't art intended transfers just aren't done today as much as they used to be done. So it is a little tricky, especially when you're doing this infrequently, like we all are. That's interesting.
Chris Dy:I, I have the pleasure of reviewing our fellows case logs every month and have been different viewing case logs now for the last two or three years. And also nationally in discussion is you know, we're not doing as many tendon transfers. I mean, our fellows nerve numbers are off the charts. You know, some of that is the bias of what we do here. But it is important I tell them, you gotta go get your radial nerve tenant transfers, like, you know, when when we do them. Part of you know, the experience here is trying to provide a balanced perspective and making sure because I didn't honestly, I didn't see many tenant transfers and my fellowship here, because some of its like, kind of depends on who you work with, and when you work with them and kind of the random lottery of that, but then also just general practice trends.
Charles Goldfarb:Yeah, really true. And I think we've we've learned that that there are certain cases for whatever reason that are just not going to be seen frequently and the fellows need to be there if if they can, thankfully we have a huge volume of cases across the board. But we have our subspecialty biases, for sure.
Chris Dy:Absolutely. Absolutely. So yeah, attention and attention in a similar way. I'm not as generous of you about So checking extension with the wrist and flexion, I really do care more about, you know, what the hands what the thumb is going to do with the wrist and extension. And, you know, my, I have not done enough of these nor do I think anybody probably has to have a standard therapy protocol. But I do think, you know, we put this patient in a you know, so we also got some leaves proximately and I'm less worried about bulk, they're actually reverse the tendon so that the skinnier part of the tendon that's less mop nd because if you really get as much length on the tendon as you as you want to, you're really getting a superficial palmar fascia so that the but the skinny and cleaner part of the tendon is coming off in the musculotendinous junction. So I turned that back and use that display. So it's nice and you know, to avoid the bulk.
Charles Goldfarb:I know they only a nerve surgeon would think about reversing the tendon
Chris Dy:reversing it said, Hey, man, I'm trying to make this look good. But yeah, as they told us in India, you got to take good pictures, otherwise they won't take your good surgeon. Fixtures are good. But in then we've had in proximately got a really nice, we've set the tension after the first we've made sure we liked it or set the tension with the first reason that checked it after the first week. Dorsal blocking splint, forearm based, you know, with the rest was just a neutral. But then, you know, ran the ran the thumb portion over the top MP IP and kind of the gentle flexion that I wanted.
Charles Goldfarb:Yeah, love it. I mean, I think I don't rush to get movement in these patients. But I think either one week or the typical two week follow up, I start therapy. I do think it takes a while for this truly to incorporate. But I tend to be you know, keep them with that dorsal Boxman for six weeks, and I don't truly release them until eight to 10 weeks. But I think you can get really good results here and patients seem to be happy. And the final thing I'll say is, you know, not every patient in my experience has chosen to reconstruct these most do. But occasionally you have a patient that just says I don't think it's that big a deal.
Chris Dy:Yep, I agree with you on that. I'm trying to remember how many patients have declined, there's definitely been at least one he's like, No, I'm good. And only it was exactly in this setting of a distal radius fracture, but I think it was some random attritional rupture. And I said, No, I'm good with what I have. You know, I like the early motion within the confines of a dorsal blocking splint, mainly to get that, you know, we've gliding through the carpal tunnel. And then, you know, the Tina desus part, I think in a few weeks is very reasonable. So I'm a little more liberal than you. I'd love to hear from any surgeons, therapists, you know, their perspectives on this, because I think that it's important to kind of see if anybody else has a broad experience with this. But don't publish it before we do.
Charles Goldfarb:And then the random hand surgery eponym query here is manna Phelps syndrome vs. Rubbish. fvl.
Chris Dy:Now maybe there's something golden maybe at least will be Goldfarb syndrome, and we
Charles Goldfarb:know, thank you, no, thank you like
Chris Dy:a workman hammering his nails. You know, I guess out to close. I mean, I think that you, you want to email the group, I was like, Look, does anybody have this, like, this won't be a ground Brown, groundbreaking earth shattering contribution. But I think it would be a modest contribution. And I think you had a really nice comment saying that it's, you know, these kind of, in quotes, simple, and quote, you know, studies that, you know, can help practice.
Charles Goldfarb:Yeah, I mean, I think, God, your government taught me that right. There are some studies that will impact practice, that people will will look for and reference and this is one of those that you can make a difference in how people think about this issue. And residents in young attending search for a paper like this to help guide them honestly. And then there are other papers that have bigger goals, you know, but I think this could be a nice contribution. Hopefully, we can, you know, get some patients together and get some follow up.
Chris Dy:Yeah, let's not count our chickens before they hatch.
Charles Goldfarb:True. True. All right, fine. Fine. Thank you.
Chris Dy:Have a wonderful day. You too.
Charles Goldfarb:Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is @ congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time