Mission Trips and Cases

Chuck and Chris catch up on life, travels and cases.  We discuss Chuck's recent mission trip with World Pediatrics and pivot to discuss a few cases including care of the phalanx enchondroma and pain at the pisiform.

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Transcript

Charles Goldfarb: 0:05

Welcome to the Upper Hand Podcast where Chuck and Chris talk hand surgery.

Chris Dy: 0:09

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: 0:17

Please subscribe, wherever you get your podcasts

Chris Dy: 0:20

Thank you in advance for leaving a review and rating that helps us get the word out. You can email us at Handpodcast@gmail.com. So let's get to the episode.

Charles Goldfarb: 0:30

Oh, hey, Chris.

Chris Dy: 0:31

Hey, Chuck, how are you?

Charles Goldfarb: 0:33

I'm good. I'm good. It's new for us recording on a Saturday afternoon, the day before the pod drops, right?

Chris Dy: 0:41

This is right up to the wire. Usually we kind of get things, you know, tucked away early on. But you know, we wanted to give people something super fresh.

Charles Goldfarb: 0:49

Yeah, absolutely. I feel like I hadn't seen you in person in a while, either.

Chris Dy: 0:52

Well that's because you haven't seen. We haven't seen each other in a long time. It's been a while. You know, so you've been, you know, you've been globe trotting, doing quite a bit of a work overseas. Is that right?

Charles Goldfarb: 1:04

Yeah, we should talk about that. We should talk about your travels. And yeah, I think we you and I have talked about what we could accomplish in this pod. And maybe we have a couple of interesting cases we can go through that are new and different for at least for discussion.

Chris Dy: 1:17

Yeah, no, I think we have some great cases to discuss. I'd love to hear about what you've been doing. And I just came back from somewhere about to go somewhere else. So yeah, it's really interesting that I don't know how much maybe not where you just went. But the podcast has a very far reach. And you know, there are a lot of people that really enjoy it. And, you know, I really appreciate when people come up and say how much they enjoy the podcast and what they've learned. And you know, why? Why it helps. So, I am a big as I've learned over the years, my love language, I'd like to receive his words of affirmation. So if you're out there, keep telling us how much you love it.

Charles Goldfarb: 1:55

There's so much truth to that, because we need that affirmation, because I think we're both at least somewhat busy. And it's hard to keep this card to keep the pie going. But I think it is a passion for both of us. And it the little things matter. For example, the way podcast listeners are calculated are now different than they were six months ago. And even that type of stuff kind of makes you makes you second guessed the impact that we're having. But when someone speaks to the impact, it says everything,

Chris Dy: 2:28

right? Absolutely mean literally every place that we go, I'm sure you hear to somebody who's like I see you. I'm sure you hear us all time, but we love the podcast, and it, it really does help to know that we're reaching people. So you know, we do like to hear from folks. So send us your questions, your comments. You know, we've had some really great episodes come from people emailing and writing in. And yeah, you're right. I mean, I think the metrics are changing. And, you know, maybe we should change to meet the metrics. But I think we do what we love, and we love what we do. And it is really honestly super fun once we find the time to do it.

Charles Goldfarb: 3:00

Yeah, exactly. Right. So let's start I'd love to hear first about your recent travels and your upcoming travels. You know, no food related travels, hopefully just work related travels.

Chris Dy: 3:13

I did sneak some food in but no, I was. I had the honor of being invited to the UT Houston orthopedic residency as their visiting professor. It was super fun. I did not realize how big that department has become and really how much they've changed since when I was a medical student looking at that program. I looked at the roster and saw just how many like first off how big it is and their reach and just like every academic medical center and department looking to expand their reach through, you know, through outpatient surgery centers and satellites, you know, et cetera. But then just so many people that are recognized along the way, so I had a great time. I shared some stories about how I met my wife in Houston and when we were both 17 years old and how we got married in Houston. I spent a year in Houston enjoyed going to Houston Rockets games and the Yao Ming Shane Battier era; McGrady was there too. So it was it was super fun to see everybody and you know, gave a couple of talks, got to have a really great dinner with some of the residents, one of whom just matched in the hand. So shout at the Shireen going to Philly for her hand fellowship. And, you know, we got to hang out with Hayden, who's going to be applying next year. So it was it was really fun saw some friends James Saucedo Dean Smith, it was great. It's always fun to kind of share the how we approach things in last few and you know, give it give a case presentation and try to keep things spicy for the residents during their rounds.

Charles Goldfarb: 4:37

I have two questions. I know you've missed that. Two questions. First. What are you there for the 100 mile an hour winds and this crazy storm I read about so

Chris Dy: 4:47

I got out I guess a few hours before the reason that I heard about it is that our I guess my friend James Saucedo who I met when I was way back when doing research down there. He's on faculty there now and he had texted Uh, both me and Daniel say about something. And Dan was like, Hey, how the pictures look crazy down there. I was like, what happened? I didn't see any of this. So I learned about the weather afterwards after I got back home to St. Louis. Yeah, something.

Charles Goldfarb: 5:14

And then it goes from there still power outages and yet it's 100 degrees there. So it's not a great time for Houston. Houston had some rough go with the weather. Yeah,

Chris Dy: 5:23

they had that crazy thing where all the toilets froze a few years ago. I mean, it's, it's insane. But it's got a soft spot where I had a really good time. So I really wanted to thank that program at Houston for inviting me out. They have a really great energy down there and I really enjoyed it.

Charles Goldfarb: 5:36

And what aspect forgive me if I'm wrong, what aspect of nerve surgery did you discuss?

Chris Dy: 5:42

I have a fun talk that I like to give about, you know, common issues or you could say complications after orthopedic surgeries are common with big surgeries. I feel like that's a if I was coming in and giving a grand rounds. I wanted to find something that was applicable to a lot of people, not just the hand surgeons out there. So there was all sorts of cases there's peds, you know, shoulder arthroplasty, sports arthroscopy, hip, and knee arthroplasty. It's all the issues that can come up, which I love about nerve and being a hand surgeon, you kind of get to go anywhere and do everything. So that was good talking to give another talk about controversies and ulnar nerve management, both for compressive neuropathy and for trauma. So that great case discussions and they presented some very interesting cases. And one of which was actually a case from one of our former residents. Erica Giles, who is now a tumor attending down there. So it was really fun. Ah,

Charles Goldfarb: 6:32

sounds sounds great. And where are you off to next? are you stopping to see a few patients in St. Louis? Are you just heading out again?

Chris Dy: 6:39

Oh, I had a clinic yesterday. It was it was a banger as they say. It was busy. I was doing the solo clinic life and it was uh, it was intense. But it was good. I saw a lot of patients got a lot of good follow up. You know, had a I had a good time. And then, you know, working this week, and then I'm heading to Singapore.

Charles Goldfarb: 7:01

Oh that's right now is this this is part work part family.

Chris Dy: 7:05

Yeah, so the first half is work. I was invited by the group out there a shoo in our friend. And a couple other folks invited me to do a research seminar with none other than famous hand surgeon Kevin Chung. So we're doing a two day research seminar. They are definitely getting their bang for their buck. I'm giving I think, three or four talks and having to you know, kind of workshop and mentor some people and it's gonna be exciting. It's gonna be fun. Sure, I'll be doing the majority of my work on the plane on the way there. Yeah,

Charles Goldfarb: 7:33

yeah. Well, that that's, that's great. I know, you guys will have a good time. And it's a family just staying in the Singapore specific area, you guys

Chris Dy: 7:41

just in Singapore. And that's more than enough for us and the kids are going to have a good time. We've got some family out in Malaysia, so they'll see them and yeah, it's gonna be a whirlwind trip, though. We're looking forward to it. Hopefully all the flights go okay. And so often, but before I want to hear about your recent trip, and we've got those cases to get to, but before we do that, we should probably give her a shout out to our friends at practice, Link.

Charles Goldfarb: 8:02

Absolutely. The upper hand is sponsored by practice link.com, the most widely used physician job search and career advancement resource.

Chris Dy: 8:10

Becoming a physician is hard finding the right job doesn't have to be joined practicing for free today at www dot practise lync.com/the. upper hand. Yeah,

Charles Goldfarb: 8:21

so just got back from a mission trip a week or so ago. slowly recovering. Have to say it was it was great in every way that we would hope it was also exhausting. I work with a group that is called the world pediatric project, which has recently renamed itself world pediatrics for a broader appeal. It is far from just orthopedic surgery. We focus on the eastern Caribbean and Central America, but do have some relationships outside those two regions. And so I'm involved in the board here in St. Louis, and it's a big and growing organization with multiple hubs, Atlanta, Richmond, Southern California, Miami to become a hub. And so it's great. It's great and Lindley wall and I swear to divide up the hand and upper extremity work in the Eastern Caribbean, and typically make a trip about once a year. And so this was our trip.

Chris Dy: 9:23

So that's amazing. I've heard from you and literally about those trips. And our fellows have really enjoyed participating in this trips. It's really kind of you and generous of you to to bring them and you know, have them see, see the work that you're doing, participate in it and contribute. I know they really appreciate that. I think it's great that you develop the system where it's not just a kind of drop in and do your work and then leave. I know a lot of work goes into it beforehand. Can you talk about how you've set up the system, I know that you will literally go separately and that's very intentional. And there's a lot of prep work that goes on, you know, while you're not there in the Eastern Caribbean.

Charles Goldfarb: 9:59

Yeah, well set So, the way we have done it is that you know, the group we work with has boots on the ground on in all of the Eastern Caribbean, multiple different islands. And, you know, we think about I was in St. Lucia, but we think about St. Lucia and we think beautiful beaches and fancy resorts. And that is true. But that's, you know, 2% of the island and the rest of the island. While there certainly are healthcare services, what we do is not represented on island or is not accessible. And so this trip actually, I think, required more preparation in a good way than others. And I say that because I did three telehealth clinics with different island populations, St. Kitts, Dominica, St. Vincent, and really had my surgical list pretty prepared before we ever got there. And what we do, and then then we have follow up as well. So it's not just the glamour of fly in fly out, because that is not the right way to do things. And so we arrived there, we had travel issues, but we arrived there late Saturday night, clinic all day Sunday, and then we operated for days took care of 20 kids and those great it. The one thing that I would like to be different, but it is what it is, these islands are not conducive to a significant amount of orthopedic surgery education, simply because there are not the orthopedic surgeons that are either interested or available to learn in these areas. And so that differentiates us in a negative way. I would say, anesthesia wise, there's lots of people interested in learning about the blocks Ahalya Kodali was doing and the processes but but not the orthopedic education. So that that's a I guess that's a missed opportunity, but it's not really a missed opportunity. Because, again, it's just not just, it's just not needed.

Chris Dy: 11:54

Well, I think you're playing the hand that you're dealt, right. I mean, so if you are in a place where there were a lot of people that wanted to educate, I'd be I'm sure you would be educating. I think that's probably the differentiator between that and something like what Jim Chang's evolve with with that resurge? I think is what they do. Yeah. So I mean, if there was an audience, I'm guarantee you would be teaching them how to assess and evaluate and treat these patients. But that's not what's available to you. So

Charles Goldfarb: 12:17

the I think Emily's Zoldos who came with us yeah, will never do pediatric hand surgery again, her life. I'm certain when she's in remarkable Peachtree orthopedics in Atlanta next year. But I think she had a great time and certainly had a great time with her. You know, the pathology is interesting, and I think it's relatively characteristic birth, brachial plexus palsy, secondary manifestations of bat, cerebral palsy, you know, largely untreated, post traumatic, whether that's burns, or just trauma that doesn't heal well. And then a little congenital, it's actually I think we've hit a lot of the congenital and we bring some of the more severe, more serious congenital up to St. Louis, which is part of the program. But yeah, good mix of pathologies, and you know, nice early results.

Chris Dy: 13:10

Yeah, I heard that you saw one of our postop brachial plexus free functioning or Silis patients. I was like, saw the videos like that's crazy.

Charles Goldfarb: 13:17

Yeah, so it is crazy. So the story is, you know, kind of a silent, maybe he's 18. Now silent. You know, very quiet kid comes in, and he has sort of a rope around his neck with his arm, and like a makeshift sling. And he walked in, I'm like, Hi, how you doing? And he didn't really have much to say. And then I kind of sift through some materials and realize that he had come up to St. Louis and had a pre functioning or Silis transfer. And he had been educated on therapy. We tried to connect him with therapy in St. Louis, in St. Lucia and just hadn't really happened. But what was remarkable and I haven't seen a lot of these patients in follow up. What was remarkable is that he's doing incredibly well. anti gravity, elbow flexion is really good. And he has I'm sorry, gravity eliminated. elbow flexion is really good. And anti gravity. elbow flexion is excellent as well. So the therapist who came with us, Stacy Baker, who's amazing. Spent some time with him on a couple of different days. And yeah, he's doing great. Yeah, that's

Chris Dy: 14:23

that's basically all of our fragrance illustrators for his for elbow flexion. They kind of do their own thing, no therapy. Now he is He's great. He's actually pretty early on. I don't remember the exact time but he is exceeding expectations, which is remarkable. So thank you for seeing him and I'm glad Stacey was there. She is a really a wizard with with the therapy which is so critical after that kind of surgery.

Charles Goldfarb: 14:44

Yeah, I know that mission trips are, you know, it's interesting. They there had to remind our group that this is not going to be easy. Everything's not going to go according to plan. And in some respects, that's the appeal. You have to sort of think on your feet you have to To deal with situations where you don't have anything that you want, and it's the flow is not going to be good, we were ambitious in getting 20 surgeries done, we got them done. And the group we had was amazing. So we travel with an anesthesiologist and or nurse therapist and our hand fellow, and it was a amazingly good group. And really great, but these are less than ideal situations. But that if you think about the right way, that's part of the fun.

Chris Dy: 15:30

Well, yeah, of course, you want to avoid the medical tourism aspect. And I think that you and I did talk to a wall and all of world pediatrics, they've really done a great job, as you know, to provide really a service to that community into that country. So kudos to you guys mean, if anybody wants to learn about world pediatrics, how do they learn about it, we're just getting involved in you know, that kind of work, you know, as they get into practice, either as a therapist or as a surgeon.

Charles Goldfarb: 15:57

Yeah, I would be neglectful if I didn't mention that we were supported in part by touching hands through the hands society. And so this was, you know, Scott Kosan, sort of ran with the concept of outreach as a part of the hands Saudis effort, and he, with others has elevated the outreach concept for the American Foundation for Surgery of the Hand is one of the major buckets. So there's a lot to learn from the hand society. And there's a lot of different organizations, we mentioned research, and there's many others, aside from World pediatrics doing this, but the hand study for those listeners is really a good one. And certainly, I can connect anyone with any background, whether that be ham therapy, or general orthopedics to people who are interested in doing this, but it's really it's a great thing that we have the opportunity to do this. And it's not to suggest that we don't have enough opportunities in this country. The United States has plenty of need it this is just a little bit different.

Chris Dy: 17:00

Yeah, absolutely. I mean, you see that the touch hands program also has some domestic projects. And I think that, you know, many of us are also helping patients that are underserved and underinsured in our populations. And, you know, I think that's, that's part of our professional, professional obligation. So, before we get into some cases, first off, I want to say if anybody has questions for Chuck about that hand podcast@gmail.com send him an email, send us an email and we'll make sure that he gets them and y'all should mark your calendars for October 25 and 26, or checkpoint, surgicals, next categoric course upper extremity nerve distress strategies for surgical management. Join the course faculty Dr. Fraser levers edge and Dr. David Brogan. We know those guys in Denver, Colorado is a review management strategy for commonly encountered challenging nerve injuries and conditions affecting the upper extremities. Graduated

Charles Goldfarb: 17:56

let me contribute to this, you left me a little bit to learn more about this and other educational programs, please visit nerve master.com Checkpoint surgical driving innovation in nerve surgery. So

Chris Dy: 18:08

it's funny, I was driving home today I was running with my daughters. We're celebrating my daughter's birthday today with the school party. Her birthday was actually earlier this week. And that's a whole separate story of what we did. But I was driving home from picking up all the things for this party. And there's I don't know if you've seen this chuck. But on. On Big Bend, there is this recording studio that has a sign out now for voiceover lessons. And I thought it was like hey, they often have like ads for like podcasts, recording, et cetera. And like, alright, we got that down. But I was like, Maybe I should take some voiceover lessons. Be the movie Phone Guy. Yeah, look, do

Charles Goldfarb: 18:45

you need a backup career plan? And that's a good one. You know, I have a future. I was

Chris Dy: 18:49

on a patient this year or this week about my retirement plan. And I think it is good to go to culinary school. But maybe I'll be a voiceover guy will say, yeah,

Charles Goldfarb: 18:59

so many options, so little time. All right. And we have two cases we'd like to discuss these are cases that we have or pathologies we have not previously discussed. And why don't we start with a case that you had. So throw it out there? Sure.

Chris Dy: 19:16

So this is really interesting. It's a patient who I'm going to try to remove as many details as they can, in their 40s A person who relies on their hands to make a living in terms of their a proceduralist. And they've got this insidious onset of pain at their middle finger at the base kind of proximal phalanx region was nagging was getting, you know, problematic and then had some free time so they decided to stop in and get a visit and one of our very convenient injury clinics but got an x ray and I happen to be next door and demonstrated a lytic lesion within the base of the proximal failings but no fracture and findings. We're, you know, to me at first blush and the radiologist fortunately agreed we're consistent with an N conundrum. So Chuck, how do you approach this patient? I mean, there was no actual trauma. It hurts. Not terrible, you know, they made they had some time, and they got it checked out. I mean, how do you think about these kinds of lesions within the bone?

Charles Goldfarb: 20:23

Yeah, you know, in conundrum was are relatively classic looking, they can be expensive to the bone, they have that sort of ground glass appearance. Sometimes there's calcifications, but you can generally make the diagnosis on X ray findings alone, they're often eccentric a bit. And, you know, I think once you're confident in the diagnosis, than a surgical intervention makes sense. You know, I was taught, and I'm curious as to what you were taught, I was taught that if you have a fracture related to an enchondroma, which I know this patient did not have, but if you do have a fracture, I was taught to wait, let the fracture heal, and then go back out, go and do your surgery where you curretage and bone graft or plus minus bone graft. It's not how I think about I'm curious to how you think about the patient with the fracture, and also what you did for this patient.

Chris Dy: 21:16

That's exactly how I was taught. Probably because somebody like he taught me that. But so it's interesting, because it's like, if you have a fracture, you're supposed to let it heal and like, cool off, but then you go back and do something else. Like that doesn't make a lot of sense. But that is the teaching. This patient had pain. And because of the teaching, I said, Look, you don't have a fracture. If you're cool with just watching this, why don't we just watch this, I'll get, you know, therapists can make you a splint if you want, if you need support. But honestly, if you know, you can tell me when this reaches a threshold where you're like, I need to do something. And that's initially what we talked about. How do you you said you think about things differently than the textbook. Now? How do you think about it?

Charles Goldfarb: 21:56

Yeah, for the reasons you said, it makes no sense to me to let a fracture eel and then do surgery. I do think these don't get? Well, I should say that more clearly. These don't get better, right? They're not going to go away. And I sort of wonder why that became the teaching. And I think it's because if you think of pediatric lesions, and you think of something like a unicameral bone cyst, if those fracture, they can disappear. And then con drama with a fracture does not disappear. And so my philosophy is if you have a fracture, and honestly, even if you don't, I certainly it's a patient driven decision. But I encourage going ahead with the curretage and bone graft and I bone graft most. But not all of these depends a little bit on the size. I haven't gone with either autograph from the destroy radius, or off the shelf, I don't have a strong opinion about that. I think the key is in the aggressive curretage.

Chris Dy: 22:53

taking away all the discussion points. So you just really just blew right through that topic. You know, I had a discussion with the patient, and we decided to keep an eye on it. But lo and behold, the patient, who I happen to know, contacted me and said, I had this actually really hurts. What can we do about it? So I gave them the options that you discussed. I mean, so for those of you that may not be as knowledgeable about this topic just yet. I mean, so what this is, this is a benign cartilage tumor. tumor, not necessarily cancer, of course, but it's, it's benign. The recurrence risk is there. But I think what Chuck talked about is that thorough curretage, meaning you're scraping out all of this stuff, this cartilage stuff that's sitting within the measure layer, canal, the bone. And as it kind of presses on the bone, it can, you know, thin out the cortex and eventually lead to a fracture. So yeah, I mean, the teaching to me was, you know, if it's painful bothers them, they want to do something you sure attach it. So Chuck, how do you decide where to go into the bone to cure attach it? Is this a big incision? Is it a small one? And then what's your what's your magic technique for getting all of it out? Like you talked about earlier? Yeah, I

Charles Goldfarb: 24:04

think the approach is, can be many. To me, it's whatever is simplest, and often that's dorsal, through the extensor, or adjacent to the extensor tendon, and often through the thinnest part of the lesion, if it's expands out, so the thinnest part of the bone, I open it up. You know, classically for weight bearing bones. We're taught to do that in a elliptical type fashion or a not a square, kind of perforation of the bone. I don't know that it really matters here. And then I just think it's aggressive Portage. Whoever's with me is pure dodging. I'm pure dodging. I'm irrigating. And then plus minus packing with Bhangra. What about you?

Chris Dy: 24:45

Similar? You know, I think for this particular case, we're able to go adjacent to the extensor mechanism. And yeah, really is kind of aggressive curatorial, getting your caret in there and scraping all of it out getting it from different angles. How do you know when you're done?

Charles Goldfarb: 25:02

You're done when you keep securitizing and all you're getting back is bone at least that's my take.

Chris Dy: 25:09

And is there is there is it possible to push too hard and when you're curious dodging and fracture that kind of thing or weekend cortex

Charles Goldfarb: 25:17

For sure. never happened to me but why did that happen?

Chris Dy: 25:24

It did it but I thought about it as you're doing it. You know, it's always someone to things like when you're harvesting distal radius, kids Ellis autograph, you know, the attendings got that extra move that gets, you know, tons of bone graft? I was like, if I'm gonna push hard, this is probably not the best situation to do it in.

Charles Goldfarb: 25:40

Yeah, I think the morbidity is low. So used autographed. Did you use autographed on this one? Well,

Chris Dy: 25:46

actually, I had a discussion with patient I mean, from the teaching that, you know, I remember from training and actually went looked up this topic again, just to make sure nothing had changed. Because it's been a while since I've trained. There's no difference between using an allograft versus, you know, so cadaver bone versus using somebody's own cancellous bone. So, with that in mind, and with this person who wanted to get back to using their hands and doing procedures as quickly as possible, we had a discussion, but honestly, I kind of steered her towards Allah graft. And that's what she picked to.

Charles Goldfarb: 26:17

Yeah, I think that's great. I, you know, healing time is variable. In my experience, it could be six to 10 weeks to really feel competent. But yeah, I think people get back to activities much sooner than that.

Chris Dy: 26:30

So when you when you pack this, after you've packed it with as much of the choice, you know, graft, how do you know when you're done? And then what do you do after?

Charles Goldfarb: 26:42

Yeah, you pack it till you can pack it anymore. Ideally, it's not spilling out, but you pack it nicely. radiographs, you know, mini c- arm look really great when you pack it nice and full. I tend to, in the OR, put a big, bulky forearm based splint, and then a week to two weeks later, haven't go to clinic and get something really small and removable and start moving. So we don't worry about the stiffness piece.

Chris Dy: 27:10

So when do you think they're okay to start doing things with their hand in terms of light activities and beyond?

Charles Goldfarb: 27:17

Yeah, obviously depends a little bit on how thin the cortices are. If it's a typical case, where maybe there's mild thinning, but not dramatic. I think it you know, they can obviously the light activities, essentially right away, or heavy gripping or hitting the gym or playing a sport. I do think you have to be a little careful. So probably, again, depending on the details, six weeks. Right,

Chris Dy: 27:37

right, right. So yeah, no, I think that's the balance is trying to figure out kind of what you will let them do an even little things about when you will let them sweat and shower and that kind of thing. I mean, you So you went through this recently in the past with various surgeries? I mean, what's your threshold? And actually asked this question when I was doing a case recently with our partner, David Bergen. Like, hey, when do you let people start to let things get wet? And when do you let them start to sweat? So what's just backing out of this case, but like, you know, what's your threshold for that?

Charles Goldfarb: 28:06

Yeah, I think we've talked I don't know if we have but I've gotten really what I think is liberal, for most conditions is three days if I'm gonna let them take off a splint or dressing. If I'm worried for whatever reason, it's five to seven days. As far as getting it wet. Soaking, it probably is fine at those same time at rolls, but I generally ask them to wait until they see me at the first post operative visit.

Chris Dy: 28:31

These do you feel different about getting wet versus sweating? Of course this person needs wants to run.

Charles Goldfarb: 28:37

I don't feel different at all. I think the epidermis is sealed by three days. I think they're fine.

Chris Dy: 28:43

yeah. So I've actually because of our my trip to Washington, DC and switching my wound closure, based on the advice of our colleagues, Sam moved to Terry. I've gone to three days for carpels triggers and anything that I close with subcuticular closure and double bond.

Charles Goldfarb: 29:00

Yeah, I love that. I would dermabond I get one day but hope one day, all right, one day, and then before we switch gears, you know, and this is maybe for the residents or medical students. Ali aids disease spelled Ali eres disease is a really interesting condition associated with it and Kendra was actually multiple and kendama ptosis. And these can be very different players much more aggressive. They require more significant and multiple bone procedures. And what's super interesting about this is it it affects only one side of the body. That's the that's the trivia there.

Chris Dy: 29:39

So there you go. There's your first aid for the Board's from Chuck Goldfarb. Yeah, so, so all yeas aside, how do you counsel patients with an isolated Anton drama about potential recurrence risk etc.

Charles Goldfarb: 29:52

Knock on wood, I haven't seen much I can tell them. It's somewhere between five and 10% for a typical if I feel like we've done Good job which we have for Fallon, Gio and candriam. I say five to 10%. What? What is your number?

Chris Dy: 30:07

I basically say the same thing. I think I tell them it's low, but it's not zero. So I think I use that for a lot of things if even if for the residents and fellows that have been in my clinic, because I think if you're the one, it's all relevant or so. All right. Well, that was a good discussion. Thank you for sharing your thoughts on that. And bucking the textbook. Tell me about this case that you have as we kind of wind things up. Yeah,

Charles Goldfarb: 30:30

I this is something we haven't really touched on. I had a patient a couple of months ago, that I was taken to the operating room for a presumed foveal TFCC tear. And I had seen and treated him over a couple of months, I think I'd given him a steroid injection, which helped temporarily, someone back in clinic the last visit before x rays looked fine. But not only did he have pain at the fovea, you know, just volar to the ulnar styloid. He had tenderness over the pisiform and owed by over I mean directly bowler, but also on the owner side of the piece of form. And so, you know, there are specialized X rays one can obtain to rule out easier to track which arthritis. I don't find those to be invaluable. Meaning I think people can have symptomatic pain at the pizza trick which will join even without obvious arthritis. But it's an interesting diagnosis. And so how do you think about pico trek mutual pain plus minus arthritis?

Chris Dy: 31:31

Well, I mean, I think it's certainly has to be in the differential. You know, basically, every patient who I see with on their side of wrist pain, I will examine, and palpate a piece of form and do a piece of track, which will boost tests, essentially, you're trying to really provoke the pisifrom against the track, we're trying to see if you can get some pain going there. And that's a very distinct kind of pain. So I it's certainly seen me I've seen it a fair number of times, it's probably see me more than I've seen it. But, you know, honestly, after reading a few articles, I became much more attuned to the diagnosis and started looking for more.

Charles Goldfarb: 32:04

Yeah, I think I think we have to look for it, because it's very easy to attribute that, especially if the pains more vague to whatever on the owner side of the wrist. The boost test or you know, direct pressure dorsally directed pressure on the pisiform or radially directed pressure, the pisiform also typically have them farther FCU to see if that elicits any pain. Long story short is I didn't see evidence for arthritis by MRI or X ray on this patient. Pain was absolutely consistent. And so I talked to a patient about the options and my plan was at the time of arthroscopy, a confirmed there was a folio TFC tear, so we repaired it, and one can sometimes scope the pisotriquetral joint. I and others talk about that I think it's often a long run for a short slide. So it's not a huge part of what I do. In this case, I told him that if I didn't see any other reason for pizza tracheal pain that I would perform an open open pisiform ectomy which felt a little aggressive. But in retrospect, it wasn't. And in this patient, there were a number of there was probably 15 Kandra loose bodies in the Pietro cultural trial and are visible by you know, but that's not really the point of this discussion. It's just be aware of the pisotriquetral joint.

Chris Dy: 33:31

ya know, when I see somebody who has well, who I think has pain, because of pisotriquetral synovitis or arthritis, I will typically send them for an ultrasound guided steroid injection, i Yes, I could do it in the office under fluoroscopy. To be very honest with you, it tends to be it kills workflow. So I send them for that injection. And that way I know it's exactly where it needs to be. It tends to be under ultrasound guidance, although depending on the student, they may do it under fluoroscopy. I like that I've had to do a piece of form ectomy on one patient for that reason for this condition, but most people I feel like tend to get better with with a steroid shot.

Charles Goldfarb: 34:09

Absolutely. So well said steroid shots have absolute role here. And if you do find yourself performing a piece of porn recommend, there's two things that are maybe self evident one, there's a little nerve, which is really close.

Chris Dy: 34:23

So we made a call there, we took

Charles Goldfarb: 34:25

We took care of the ulnar neurovascular bundle. And that pisiform is bigger than expected. Every single time. It's bigger than expected. In this case, there was arthrosis there were the comforter, loose bodies, so we felt very good about it. And patients don't miss their pisiform thankfully, and they tend to get better not always immediately, but they tend to get better. What do you do with the FCU I repair it back to itself. And it doesn't seem to it's not as if it loses his attachment. So I just repair it back over the top and and it still fires later.

Chris Dy: 34:57

Yeah, it's funny like you would never really see the piece of For him, because it's always covered by the FCU. You know, insertion. So I agree with you early on. Once you're taking it out, you're like, Whoa, so as long as you get the nerve Adalet okay.

Charles Goldfarb: 35:09

You got to take care of the nerve first. So those nerves centric people tell me awesome What else you got?

Chris Dy: 35:17

You know what I think we're at our point where we should wrap the case. But I think next podcast, we're gonna dive into the latest edition of What's New in hand surgery, an article that I used to write and I'm happy I don't anymore.

Charles Goldfarb: 35:29

I know that is true. Well, I look forward to that conversation. All

Chris Dy: 35:33

right, well, I gotta go because I've got to head to a T ball game. Have fun. All right. Take care.

Charles Goldfarb: 35:40

Bye. Hey, Chris. That was fun. Let's do it again real soon.

Chris Dy: 35:44

Sounds good. Well, be sure to email us with topics, suggestions and feedback, you can reach us at handpodcast@gmail.com.

Charles Goldfarb: 35:51

And remember, please subscribe wherever you get your podcast.

Chris Dy: 35:54

And be sure to leave a review that helps us get the word out.

Charles Goldfarb: 35:58

Special thanks to Peter Martin for the amazing music. And

Chris Dy: 36:02

remember, keep the upper hand come back next time