The Upper Hand: Chuck & Chris Talk Hand Surgery

Pediatric Phalanx Fractures

March 28, 2021 Chuck and Chris Season 2 Episode 14
The Upper Hand: Chuck & Chris Talk Hand Surgery
Pediatric Phalanx Fractures
Chapters
The Upper Hand: Chuck & Chris Talk Hand Surgery
Pediatric Phalanx Fractures
Mar 28, 2021 Season 2 Episode 14
Chuck and Chris

Episode 14, Season 2.  Chuck and Chris talk about Goldman Sachs work schedule, Chris' recent accomplishment, NCAA basketball and, oh right, pediatric phalanx fractures including extra octave fractures, subcondylar fractures, and Seymour fractures (amongst others).


As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.  And thanks to Eric Zhu, aspiring physician and podcast intern.

Survey Link:
Help Chuck and Chris understand better what you like and what we can improve.  And be entered for drawing to win a mug!  https://bit.ly/349aUvz

Show Notes Transcript

Episode 14, Season 2.  Chuck and Chris talk about Goldman Sachs work schedule, Chris' recent accomplishment, NCAA basketball and, oh right, pediatric phalanx fractures including extra octave fractures, subcondylar fractures, and Seymour fractures (amongst others).


As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.  And thanks to Eric Zhu, aspiring physician and podcast intern.

Survey Link:
Help Chuck and Chris understand better what you like and what we can improve.  And be entered for drawing to win a mug!  https://bit.ly/349aUvz

Charles Goldfarb:

Welcome to the upper hand 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 aspects of hand surgery from technical to personal.

Charles Goldfarb:

Thank you for subscribing. Wherever you get your podcasts.

Chris Dy:

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

Charles Goldfarb:

Oh, Hi, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

Doing great. How are you?

Chris Dy:

Great. It's a beautiful weekend in St. Louis. I've been enjoying the weather. It's been fantastic. How about you?

Charles Goldfarb:

Oh, it's been great. And as we have discussed the nice weather. And I feel for those out there who may not yet have enjoyed nice weather, although I think much of the of the US at least is getting there. It really is. You know, spirits are, are doing well. And I just think it is remarkably positive.

Chris Dy:

So yesterday, I did something that I have not done in at least three or four years. A shot I shot around, play played basketball for an extended period of time.

Charles Goldfarb:

Wow, what prompted that?

Chris Dy:

Well, we were you remember, you used to live near Flynn park here in St. Louis. So the kids were there. And they were having a good time and there was nobody on the blacktop and they needed to go home to get a snack. So I said, we're gonna go home to get a snack because it's only a five minute walk. I'm gonna get my basketball and I'm going to see if they will let me shoot around while they eat their snack at the park and do their nature hunts as they call it. So we got the snacks packed up, got everybody back in their little radio flyer wagon. And my son my five year old wanted to pull his two year old sister along so then I got to dribble all the way to the park. I realized my handle is sorry, compared to what it used to be. It wasn't that good before, let's be honest. But the the action of dribbling a basketball. It's been a long, long time since I've dribbled a basketball. You know, just in general. Yeah, so I got to play for a little bit tonight. I got to shoot around. Still got the shot. It took a while to get it back.

Charles Goldfarb:

I miss playing basketball but I am enjoying watching basketball. A couple interesting things. I think. First of all, I watched the vast majority of UConn versus Iowa in the women's sweet 16 game yesterday. And it's interesting essentially for a couple reasons. One I just love basketball, any and all basketball and the women's game in some ways is so much more fundamentally sound and fun to watch. If you enjoy a passing game, not just a one on one game, and it's really was great and UConn you know, is the pinnacle. And they have a great team top to bottom. And they have a freshman who's a superstar. This guy, this guy this this girl Bueckers and they played Iowa who has a superstar freshmen of their own, who actually is the leading scorer in the nation. And so there's a lot of promotion around, you know, the freshmen at UConn and the freshmen at at Iowa. This is super interesting. It was a great game, and UConn won and you know, neither freshmen had the game they hoped they would have, but they were both really still good. Draymond Green, who I really liked for the Golden State Warriors, who was outspoken, commented on, you know, equity in sports, and his comments on Twitter generate a little bit of a buzz. Because basically, he said, and I'm gonna oversimplify it that, that the women's sports in the women's game need to do more to promote their own to generate the buzz. And he got a little bit of pushback in a very positive way, not a not a pylon way from prominent women, saying, look, we've tried that, we need help. But what's interesting for me Sorry, and I'll stop jabbering on. What's interesting for me is the reason I watched that game, because there was that human element of this freshmen versus freshmen, which is a way oversimplification of a lot of great women on the court. But it was really fun to watch. And it's just a really interesting conversation.

Chris Dy:

I think it's human nature, though, for people to like stories and people to like narratives. I mean, Last Dance, was a huge hit, you know, 10 months ago, because people wanted to hear the story. Jordan was a huge, you know, draw the entire time because he was the story. And just like everything that we do, including our research, you know, when we're trying to pitch for grants, etc. Like it's all about storytelling. It you know, writing a good paper is, you know, storytelling, because you want to be, you need to capture people. And you know, no matter how many times you talk about your data in a highly technical way, unless you tell a compelling story. It's not going to sink.

Charles Goldfarb:

I like I like how you frame that and that's exactly right. And with today's media world with so much segmentation in the world, grabbing someone's attention and then having it translate to watch a full basketball game just doesn't happen that much anymore and sports have a leg up over everything else but but it was really effective and i can tell you I will continue to watch UConn all the way through and pull for them when i really hadn't watched them all season and the women's game in some ways has become at least equally if not more compelling than the men's game because there's so many teams I don't know anything about in the men's tournament this year which is exciting but.

Chris Dy:

Different game though right you know it's especially if you compare you know women's hoops to the nba and watching somebody like james harden play it's completely different.

Charles Goldfarb:

Yeah and i think that hits the nail on the head for me personally I don't enjoy watching james harden I don't enjoy the one on one game now james harden is an amazing passer when he wants to be but watching the women's game all the women look for the pass first, it's just a very cohesive sport.

Chris Dy:

Well I look forward to seeing who takes home the championship so we're recording this on March 28 and this is going to come out i think a week later so we'll have some, we'll have some updates.

Charles Goldfarb:

our listeners have followed this story and you know Goldman is a well known financial institution and i don't know about your college but a lot of my friends from college went from undergrad to Goldman and firms like Goldman understanding that they would be really well compensated and they would work incredibly hard and it would launch their careers and so the the news was 13 interns which is a small number and I understand they were all from the San Francisco office which may be interesting as well put together essentially a powerpoint it sounds like and based on a survey saying how miserable their lives were how much it was affecting their lives and the fact that most of them would not continue the process because it was so ridiculously crazy and it just it was a little bit of a media firestorm but I know anyone in medicine relates to this story and it's very different than medicine but I want to know if you had any quick takes on the story.

Chris Dy:

Well I mean the way you describe the Goldman experience you know you're going to right out of you know school you're going to work incredibly hard for very long hours for little pay knowing that it would set you up for the rest of your career I mean you could have just described residency in a nutshell there right. You know I did find it really interesting you know the number of hours they were working you know that the slide that was in the article you sent me said the you know this past week this person worked 105 hours and their average was 95 hours they go to sleep at 3am they have five hours of sleep on average and that means that they're getting less sometimes I mean you know it's it's how residency used to be right and I only know the residency that I went through and i've heard the tales from others and i've heard the tales from my father and I know that it was much more of a grind and was a much more difficult process than even when I went through it and now it's even more different but yeah the story resonates for the obvious reasons with regards to surgical training in particular.

Charles Goldfarb:

Yeah the difference of course there's several differences but the one difference is most people are going to somewhere like Goldman to learn a skill set, establish their name, make better money than we make as residents let's be clear for those first few years, and then make better money than most doctors could ever you know dream of that may be a little bit of an exaggeration and they're not saving lives and their and their and their sharpness, their ability to process at all hours is not the same requirement as it may be for a doctor but it's just I think that's why it grabbed me because it did resonate with what we went through with a change to the 80 hour workweek but it also makes me wonder about it what part of this is generational you know you're a millennial, I'm a Gen X-er i think and it's just various, there are real philosophical differences.

Chris Dy:

Yep I 100% agree the way that millennials approach life and work life balance or integration or whatever you want to call it is different than even your generation and even gen z will approach things differently than millennials do and I think that while the older generations can tend to gripe about the newer generations if you don't recognize that you can't change that generation you honestly have to go with it and if you don't change you're going to be left behind

Charles Goldfarb:

that's exactly right it actually sounds like a good topic for a podcast i don't know that our listeners would appreciate it but I will never forget Peter Stern's ASSH presidential address was on generational differences. He talked about this is way back when he talked about the mailbox, what it meant to him, you know, the physical mailbox when he used the AOL example for his daughter, they AOL mailbox and how you know, just so different that was, but I love the topic and it could be it could be fun to explore.

Chris Dy:

Shout out, shout out to Peter Stern, I got something really nice in the mail from him, like the actual physical mailbox, he sent me the most updated version of selected readings, which I love the fact that it's on a flash drive, it's got its own little imprinted, you know, label on the flash drive. And I'm sure I know, the reason why he just doesn't distributed electronically, because there are obvious copyright considerations there. But it's such a great collection of articles. I remember interviewing for fellowship and getting a version on a CD ROM. And I kept, I still have it, to be honest. Now I've got the USB, which is great. So but it came with a really nice note. He had read the What's New in hand surgery and commented on that. And, you know, what an incredible, incredible gesture. And such a great person, a little time capsule there.

Charles Goldfarb:

For sure. You know, when I was at his fellow back in 2001, thankfully, still in the 21st century, or else you'd give me-

Chris Dy:

Was it on a floppy disk, then?

Charles Goldfarb:

It was handwritten, typed manuscripts. No, but it was I don't know when he started that process, but it felt early in the process. And it has evolved and become widely recognized. I don't know how widely it was recognized 20 years ago, literally 20 years ago, I can tell you, I think you are aware of this. And I would say this honestly, to the listeners that Lindley Wall and I have put together a congenital selected readings which we update as we go. And it is for the basis of our congenital journal club once a month. And it's a great review process. And there may be a little selection bias favoring some of the work we've done here. But anyone who wants that just drop an email, and I'd be happy to share the list with you not the articles, but I'll share the list.

Chris Dy:

Yeah, no, I think that's a, a, what we so many programs have done over the years is adopted the, quote, Stern articles into their curriculum, because it's already a curated list of articles. It's great, and I think that if anybody wants to incorporate the congenital readings, I think that why recreate, reinvent the wheel?

Charles Goldfarb:

Yeah, I'm often you know, I love our congenital journal club. And we are getting way off topic, but I love the congenital journal club. And it ends up being the Socratic teaching method of myself and Dr. Wall and a few fellows and often a few residents. And I often say Should we just open that out and have whoever wants to join it? I think it would lose something. I think the small group really matters, but the readings are the basis of it. And the readings are easy to share.

Chris Dy:

I will say now that I enjoyed it, but I did not enjoy it all the time. When I was prepping for it. It was it felt like you know, you know preparing and you know, it was like you said Socratic, so it was a little bit stressful. But you know, it is a great session, I still have my notes. And I know that some of our former fellows, I remember when I was interviewing our former fellows for some fellowship promotion stuff. Brinkley Sandvall talking about opening up her notes from congenital journal club and still talking to you about cases and everything. So clearly it it's an effective educational conference, and especially with those inclined to go into that area, it really resonates. So we have a great review, I wanted to read a review from Clayton Nelson, that he kindly left this for us on iTunes about a week ago. So he gave us five stars, which is pretty much the only option right? Incredible resource for surgeons, therapists and patients. As a young hand surgeon, I have found these to be a valuable tool in my continuing education. I truly look forward to my commute so I can catch another episode. And that's from Dr. Clayton Nelson Clayton, thank you for listening. Thank you for leaving the review and we are glad that you have found it so enjoyable and useful.

Charles Goldfarb:

Absolutely. Thank you so much. Thank you so much. Do you have a case? I have been on vacation this week? It's weird. I've had a great week. And you know, I don't know if everyone experiences life I think I'm probably a little bit of an outlier. But first few days of vacation. You know, I kept up with email. And then a couple days later, I didn't and you know I check once or twice a day that's me not keeping up with email is checking once or twice a day and then the last couple of days I've been working to be honest with you. But it has been a very nice week. So I did not operate this week. Did you do anything especially exciting?

Chris Dy:

Um, you know, I had a an interesting follow up that came into the office. And he actually has signed a bunch of consents for marketing, social media, etc. But there was a case that I did back I think in the fall and actually I talked about it on the podcast earlier doing a wide awake you know, first compartment tendon repair from a traumatic laceration and then doing a superficial radial nerve repair and he was my first wide awake nerve repair the guy's done fantastically well you know it's so uncommon to get you know excellent motion from some types of traumatic lacerations, got great motion of his thumb and his SRN is completely grown back it's fantastic he loves it and it was great watching a distal Tinel sign he loved being part of the surgery and I am more and more convinced that you know patients know what we do is hard but they don't really know how hard what some of what we do is and the different you know, on the fly decisions that you're making. I mean we make so many consequential decisions on the fly kind of like what we talked about last week with you know when you're thinking fast thinking slow and you know not overthinking things but what I love about teaching residents and fellows and students is that you're talking through these decisions and honestly i'm talking through it i'm become more confident as a surgeon now that i've been practicing longer to incorporate the patient into these discussions and even a wide awake case that i did this week where we're doing a you know some, a reconstruction of some sort, I won't say what kind but for hipaa reasons but the engaging the patient having to be part of it whether or not they want to see the bloody stuff or not it's never it's bloodless but it's it's been fantastic so yes a great update on that case it's incredibly rewarding.

Charles Goldfarb:

Love that thank you thank you maybe maybe one last thing to do put you on the spot and perhaps embarrass you a little bit I just want to say in this forum congratulations it so Chris for those of you who aren't following us on twitter recently had a award finalized by NYAM switches his brachial plexus work so he is now a clinician scientist in the highest level at the highest level, with an RO1 funding his brachial plexus research and there are not many maybe you have a sense of how many but there are not many orthopedic clinician scientists funded at your level so A, congratulations and B, you got to feel great.

Chris Dy:

Well thanks I appreciate it, thanks for saying that, little embarrassing but you know it's been a lot of hard work and you know a lot of steps I actually wrote an email to the hand society leadership kind of thanking them for the investing in me for 10 years now. So, I went to the clinician scientist development program that the academy in the ORS and the ORAF run in 2011 sponsored by the Hand Society when I was a resident and that kind of showed me the pathway to getting where I am now in terms of whether I wanted to dedicate time to research whether I wanted to do a career development award, a K award. How to do that and then what you need to you know apply for an RO1 eventually you know why why would you apply for an RO1 all that kind of stuff and it's, you know the process has been long but you know the hand society has kind of stood by me the whole way multiple grant writing workshops you know from the US bone and joint initiative to the ORS and it's led to this and i'm really proud and really happy, but it does take a village so you know a lot of collaborators and mentors along the way. What we're going to be doing is studying, sounds simple but studying brachial plexus, adult traumatic brachial plexus patients using the same outcome measures at the same time intervals prospectively and those outcome measures are going to be patient centered so using you know plexus specific instrument that was developed at HSS when I was a resident I helped out Scott Wolfe and Steve Lee with that and now we're taking it broader to five different centers across the us and hopefully continuing to expand beyond that. It's it's been a great process it's been a lot of fun a lot of stress. I've wrote the grant back this time last year actually is when I started. Submitted it in July, got scored in the fall and then they make you wait really really long to find out whether you're actually going to get funded we found out this week.

Charles Goldfarb:

Well it's incredible and we are all certainly proud and looking forward to you know your findings as we move forward and I know it's gonna be a lot of years before we really know the outcome in the way that you want to share but amazing really amazing.

Chris Dy:

Thank you and shout out to all you US taxpayers thank you for the for your hard earned money.

Charles Goldfarb:

Absolutely.

Chris Dy:

You never, you never watched congressional budget stuff as closely as when you are waiting for a grant to come through and you're hoping that the government doesn't shut down so.

Charles Goldfarb:

That has got to be the case. All right, let's jump into our topic so we've had some requests to talk more pediatric and more congenital that certainly is one of my strong areas of interest we do a lot of nerve here we've talked a fair amount of sports but we haven't done a lot of kids talk, and perhaps starting with something pretty straightforward with a hopefully a broad interest will work. So we decided to talk today about pediatric phalanx fractures. And we're keeping it pretty specific because this is a, you know, hand fractures are it's a big topic and we want to be direct and just have the conversations need to have does that. Does that sound like a reasonable plan?

Chris Dy:

Absolutely. I mean, there's so much to cover with even just phalanx fractures and kids. And these are things that you know, people see commonly They come in all the time any orthopedic surgeon, plastic surgeon, hand surgeon, hand therapist is going to see these. And I think having a great understanding of what you know, an expert like you, who has treated lots of these and written a lot about them, you know, went to what's routine, what's not routine, what are the bad actors, that kind of stuff would be great. So I think we get into it, and why don't you start with, let's start anatomically, from proximal, distal, let's go to the proximal phalanx and start at the base. So what are the common fractures that you see? That can be problematic? Here? We know classically, the extra octave is one that gets talked about a lot.

Charles Goldfarb:

Yeah, I think the extra octave is is is the place to start, just to define that term. Typically, the extra octave fracture is a Salter-Harris two, or it can be a periphyseal, and I'll discuss the difference, fracture at the base of the little finger proximal phalanx. The finger becomes abducted or ulnarly deviated. And the name comes from the ability to theoretically reach an extra octave on the piano. And it's a common fracture. And of course, it can happen in other digits, it can happen in multiple digits, but that is very common. And so those kids thankfully, respond almost always to a close reduction. I don't know how many of these you see in your clinic, but I think I see them back from the ER, typically if they come to our ER they've been reduced, and then I have to follow them. Do you I assume that would be similar for you?

Chris Dy:

Yeah. So I actually, you know, I don't see a ton of these in follow up. Because you know, we have such great partners, you and Dr. Wall have been great about, you know, wanting to see kids with fractures, particularly Lindley. And I think that that's something that she enjoys, and is part of her practice that she wants to continue to grow. But I do remember treating these a lot as a resident and as a fellow. So there are a couple of textbook maneuvers that are talked about. And I want to get your sense of, you know, if I'm an orthopedic or plastic surgery trainee that is listening right now, how do you reduce these fractures and do it well? Is it like the textbook said, so you put a little pencil or something in between in that web space and use it as a lever? Or what's the chuckle for preferred reduction maneuver?

Charles Goldfarb:

Yeah, so first of all, I would say is in the ER, and sometimes in clinic, if you have the right kid, if you have a mature seven or eight year old with this fracture, and let's be clear this fracture happens, can happen from a major trauma or a less severe trauma, as the growth plate weakens as it nears closure. And so you know, it can happen in a 9, 10, 11 year old as the child's physes mature. But if you have the right kid, you can numb them up in clinic and take care of this, although it's a little trickier, it's easier to do in the ER, and the ER can truly be a block or could be some sedation and a block. The pencil technique where you put a pencil between the fourth and fifth fingers, sounds good. But the reality is, if you look at your own hand, to get the pencil far enough proximally, it has to be a really small pencil. And I don't really use that technique. And so what I do in those fractures is I grabb the finger, and I, I tend to flex it beneath the other fingers, and really just radially deviate it firmly and it tends to come back in place pretty easily. And then you have to check the cascade. And so for me that's checking the child's hand, you know, with the fingers extended with the fingers in a resting posture. And then I simulate flexion with tenodesis, that is extending the wrist. And then I add to that by squeezing the forearm, which causes the fingers to flex. And so it's really understanding as much as you can about all those positions. And if the child is wide awake, you can ask them to bend doesn't always work very well. But reduction itself is not that hard. assuring your reduction is good is really important. And then the immobilization piece.

Chris Dy:

So a couple of things before you get into those last two areas about immobilization or checking your reduction and immobilization. So if anybody's listening and wants to actually see the reduction maneuver, we're putting more video content up on YouTube. So Chuck just demonstrated exactly how to do the reduction and exactly how to do the tenodesis maneuver to check it. Are there any things that you mean? Do you ever use a fulcrum? Are you just using your jedi kind of you know, I remember as a resident you're always like, Oh, yeah, I read about this. It's exciting. Let's go put something down in the web space. But I guess skinny pencils aren't really that common anymore.

Charles Goldfarb:

Yeah, I think it's hard to create the fulcrum I really do, I think you're more likely to succeed grabbing, because you can grab more proximally than you can get that fulcrum in. And that's a whole nother topic on my syndactyly reconstructions. But I think it's grabbing and it's not a hard reduction, you just have to get it right.

Chris Dy:

Okay, do you put your thumb kind of in that space there and use that to lever over instead?

Charles Goldfarb:

Either i'd just radially deviate the inflection. Or I do try to actually grab the finger and deviate it that way. And you can try both. And you got to be careful not to over reduce some of these because the periosteum provides a supportive environment. And so you don't want to overdo it. And, you know, I think it's an acquired skill. And I think by the time most of our residents are halfway through their PGY 2 year they have this fracture down because it's so common.

Chris Dy:

How long do you think you have to do a close reduction before you know, it starts to get sticky in that angulated position?

Charles Goldfarb:

Yeah, probably a week to 10 days, I think by a week to 10 days, it can be harder. And sometimes those patients are better served in the ER, I'm sorry, in the operating room, even if it's just for closed reduction. Although my typical protocol is if I go to the OR, I typically add a pen, unless it's just an incredibly stable reduction. To finish the ER conversation, my personal protocol is I put a two by two after the reduction, I put a two by two between the fingers, I buddy tape the ring and small finger and I put an ulnar gutter splint or cast on, and then I give it three weeks. Because at three weeks, we know that the fracture is sticky, if not well on its way to being healed. And depending on the kid, I'll bring him back to the office may offer a therapy fabricated splint, although that adds cost and some would question the value of that process. I may get him a removable brace in the clinic, or depending on the amount of healing, I may just let them go with buddy tapes.

Chris Dy:

Now are you checking your reduction radiographically at all, with like a fluoroscan or something in the ER because I know a lot of our residents because now that's more broadly available. Will do a fluoroscan as opposed to a formal X ray, are you getting a formal X ray visit before after the splint is on? How do you do that?

Charles Goldfarb:

Yeah, it's tricky. So our residents I think would be lost without the mini C arm in the ER, I mean, it's really remarkable how much they depend on it now. And it does allow a greater degree of confidence in one's reduction. It is tricky when I see them back in the office, which may be in one week, what do you do with them, then, you know, if their buddy taped, then that does allow you to remove a splint and transition to a cast pretty safely. Or you can try to image through the cast. Now, if I try to image through the cast, it is done with the mini C arm because I don't think you can send a patient to radiology and expect them to have much luck with a static radiograph. But I think the mini C arm is really helpful.

Chris Dy:

So are there any extra octave fractures that are bad actors? Is there any concern for you know, when is it not straightforward.

Charles Goldfarb:

Yeah, I have to I have three comments that for first comment is that most are not bad actors at all. And they just need a good reduction. And they do great. Second is that, you know, adult orthopedic surgeons, plastic surgeons, generalist in any form or fashion get scared off by the fact that the physis is involved with this fracture. And thankfully, knock on wood, I don't think I've ever seen a growth plate arrest after base of P one or P two fracture ever. And so yes, the physis may be involved, but it's rarely a problem. And then the third thing is that this can be a periphyseal injury, they don't all involve the growth plate. And I don't think that changes anything practically about how we handle it. But they're not all truly a Salter-Harris type fracture. So again, the key is get the sagittal alignment correct. So bring it back towards the middle and ring fingers. And two get the rotation correct. Dorsal volar is rarely an issue. It's really about rotation and deviation. If you get those right, then you're good. The last thing I'll say is to me the worry about bad actors is when you have multiple fingers affected because it indicates a higher level of energy and typically a less stable pattern. And so those often but not always, often require surgery.

Chris Dy:

And is that almost like have like a windswept appearance of the hand where they've kind of come all across.

Charles Goldfarb:

Yeah, exactly. That's exactly right. And then you know, the the final point maybe on these before we bore our audience to death is that when you go the OR. Well you go to the OR if A it's a delay in you're seeing them but you do have to be careful because you don't want to traumatize the growth plate too much. But more commonly, you see them acutely or subacutely and they're just not acceptably aligned. And then you have to go to the OR and as I mentioned, I often put pins in almost always put pins and just because my, The scenario of go in the OR getting a close reduction, having the patient come back and have the deviation recur is really not palatable. So unless it's super stable, I will put one or 2 K wires and from proximal to distal, I think it's safe, well tolerated and the pins don't stay in long.

Chris Dy:

Now, one question that probably applies to the rest of the fractures that we'll talk about today, but when do you do you have the conversation about physeal involvement potential for arrest with all of these factors? Or maybe not so much with this fracture and more with others?

Charles Goldfarb:

Yeah, I really, most families come in and understand the growth plates involved, I actually tell them and I feel pretty comfortable saying this that, like I shared earlier, it's just almost never a problem. So I usually don't bring it up, if they don't bring it up. Because I just like I said, I've never seen it. And so anything's possible, but I've never seen it.

Chris Dy:

It's interesting, because I bring it up for even things like buckle fractures, you know, that was like, it's close. It's close to the growth plate. I don't think the growth plate's involved. But you know, and I think that's, that's because I just don't have the same level of comfort, you know, in reps and volume in treating, you know, pediatric fractures.

Charles Goldfarb:

Well, the distal radius is a different thing, because it doesn't even have to involve the physis till we do a subsequent growth plate at least radiographically. So the distal radius is a little bit trickier, you're certainly not wrong to bring it up, never could be faulted for bringing it up and have parents aware of it. And maybe I have seen it and just hadn't recognized it. But I just think it's super uncommon, whether that be base of P one, or base of P two now with Seymour fractures, and we're probably not going to talk too much about Seymour fractures. That's the open, you know, nail plate injury. And distal phalanx fracture, it ends up looking a little like a mallet finger. Those I have seen growth arrest with I've also seen infections with and so we treat those aggressively with irrigation, often pinning and nail plate repair. But I just haven't seen it really, for P one and P two.

Chris Dy:

Well, we should get back to Seymours though because I think that's something that there is some controversy, some new literature out there. But let's stick in the proximal phalanx for now. Go a little more distal. So let's talk about some of those subcondylar fractures. And I think this is a topic that you have published on recently, was in the last 10 years or so. Can you tell me a little bit about these subcondylar fractures, you know, are they, you know, what makes them a little more challenging to deal with? And what can be the issues?

Charles Goldfarb:

Yeah, so the subcondylar just to define them carefully. Those are the fractures that can be either the proximal phalanx and I use the abbreviation p one, but not everyone likes that abbreviation but can be of the proximal phalanx or middle phalanx p one or P two, that's just below the head, or the condyles of that particular bone. And it's often almost always a transverse fracture. By definition, it doesn't split into the joint. So it's not a unicondylar fracture. It doesn't involve a joint. But the danger with these fractures is that the blood supply is precarious. And because a lot of the fracture fragment distally is covered with cartilage, there's no blood supply coming in there. The blood supply largely comes from the collateral ligaments. And we know that a trauma alone or a trauma plus surgery can lead to avascular necrosis of these fractures. And so we tread really carefully. And so we have to think about that as we consider treatment for these. I'll keep babbling. So the classic presentation is again, little finger quite commonly, and the distal fragment translates and angles dorsally and may angle A little bit ulnarly as well. And so those fractures have the potential to do fine, but we try to treat them carefully. We try to reduce them anatomically, and often pin them to hold them in place. And we really, really try not to do an open reduction.

Chris Dy:

So when you say it translates dorsally, and angulates dorsally, is that an apex volar type of angulation? Just to make sure that everybody's on the same page, because I know there are different ways of describing fractures and you're using the classic orthopedic terminology. But.

Charles Goldfarb:

Yeah, so I'll try to say it as clearly as this how I think about so the actual distal fragment shifts dorsally and also the joint surface angles dorsally. So that, to me is the most straightforward way to describe it. I guess that is Apex volar. Because there's more of a prominence volarly and the prominence volarly is the problem. So if this is untreated, number one, it'll heal. For sure. Like almost everything else in a kid's hand, it will heal the problem becomes-

Chris Dy:

But not not in a good way.

Charles Goldfarb:

Not necessarily in a good way. And the problem becomes Yes, there can be some angulation of the finger like I mentioned in the ulnar direction, but the other problem is you can lose finger flexion at that PIP joint because you know the shape of the head and the morphology allows for that middle phalanx with PIP flexion to really engage at the neck level of the proximal phalanx and if you have a malunion you will lose flexion of the PIP joint, not the end of the world but in a kid you know you want to restore normal anatomy and maximize function.

Chris Dy:

So your goal is a closed reduction and pinning is that what kind of pin configuration is that like retrograde cross pins you know do you go or do you go the other way antegrade and what kind of size of pins are you using?

Charles Goldfarb:

Theoretically these can be closed reduced alone but again as you said we typically pin these for security to make sure it doesn't have a problem the goal is a closed reduction often flexion of the finger can accomplish a lot of your reduction but sometimes that's not enough we typically use 35, 0.035 Kirschner wires sometimes two eight Kirschner wires typically retrograde from the condyles so crossed k wires and that's that's the typical format proximal to distal wires are easier to place but it's very difficult to get a proximal wire all the way into the condyle and to have it grab enough bone to secure it and that's the beauty of the retrograde wire because the pins that are left outside the skin can be capped outside the skin and you have more security for the small distal fragment.

Chris Dy:

I apologize to our overseas listeners we are still stuck in the British system I will blame our British friends. So that's 0.028 inches which i don't know what the millimeters are i'm sure we can find a translation or conversion.

Charles Goldfarb:

Yeah isn't like a 0.062 inch K wire, I think it's 1.1 millimeters but i have no idea what the others are i'm embarrassed to say. Oh lord. Yeah and so the the other caveat which Peter Waters taught us and Roger Cornwall from Cincinnati expanded upon is if there is early healing and it's not a minimal to a true closed reduction than an osteoclasis procedure which i think i mentioned on our last podcast can be really helpful we're using a wire to break up the healing and that can be great and again the key is really try to avoid an open reduction because you don't want to do anything as a surgeon which would further risk the blood supply.

Chris Dy:

Sure and that osteoclasis is that something that you would typically do with fluoro guidance making sure obviously not to compromise that fragment that very tenuous fragment too much right?

Charles Goldfarb:

Absolutely, absolutely. Yeah and then this can be a proximal phalanx this which is far more common it absolutely can be middle phalanx. The middle phalanx probably gets underestimated for this severity just because it's the middle phalanx and we tend to you know think it's less severe and you know for those who are in training you know what a couple of major points. This fracture while it's not physically that distant from the growth plate because the phalanges are small bones is about as far from the growth plate as you can be because all the growth plates are proximal in the in the phalanx and so it's distant from the growth plate so remodelling potential is less although in a really young child it might remodel from a sagittal and coronal perspective but there is zero expectation from any rotational malalignment and so we don't assume remodeling in these kids we might hope for it if we see a kid late that has a lot of healing but we don't assume remodeling we tend to intervene to try to decrease the chance of future problems.

Chris Dy:

So why don't we close this episode with with condylar fractures of the proximal phalanx for example and how you approach those because these are ones that involve the joints you know what's your what's your what are the considerations you have in your algorithm for for decision making?

Charles Goldfarb:

So the condylar fracture and a kid is typically an older kid because it's just not the typical growth plate centered or subcondylar fracture pattern so i think about them honestly like i think about condylar fractures in adults i think the need to assure anatomical reduction in my mind is a little higher because it's a kid and what i see in practice is malunions of these fractures when they are again underestimated. Oh it's a kid it'll be fine well that's totally false so a condylar fracture is not going to remodel if you have a joint step or gap deformity is not going to fix itself and so i end up treating those malunions not infrequently because they are underestimated and so these have to be treated like one would treat an adult with an articular malalignment. And they have to be anatomically reduced. I think this is one of those situations that we've talked about where that your comfort level you the surgeon's comfort level has to come into play, I often make a small incision to examine the joint to assure that joint surface is anatomically aligned, others feel more comfortable with their ability to obtain and maintain a closed reduction. And we I typically use pens, rather than screws, although again, depends a little bit on the age of the child would consider screws like I would consider an adult. How do you think about unicondylar fractures, whether they be adult or pediatric?

Chris Dy:

I follow the same principles, you know, I have a lower threshold. And because I treat more adults, I think in these cases, I have a lower threshold to use screws because I want that that finger moving in an adult. And you know, like you said, it depends on your comfort level as a surgeon, if you feel like you can get stable fixation through pinning with obviously the benefit of not having to, you know, add more trauma. But oftentimes, I feel like I can perform the reduction and plate some screws to hold everything together with confidence so that we can get the patient moving in therapy, but a completely different ballgame in terms of motion and therapy and adults versus kids though.

Charles Goldfarb:

Yeah, I think a couple of comments. I think that's perfectly summarized. Number one, where's two advantages in kids, the first advantage is they heal faster, no one would dispute that we believe that's periosteum related, but they will heal faster. And number two, they just don't tend to get as stiff as adults do. And so when a young kid, I may pin for three weeks. In an older kid and maybe four or five weeks. But in an adult, you may end up pending for six weeks. And then all of a sudden, they hate the pins, you hate the pins and they're going to be stiff. And that that's tough. I will say with an adult, the same caution goes for a small unicondylar fracture, about protecting the collateral ligament. Because exposure wise it can just seem so easy and so straightforward on that, you know collateral ligament, but don't take it down maintain that collateral ligament.

Chris Dy:

Yeah, can't strip the fragment you'll want, you don't want to watch it disappear either in real time or in six weeks. That's not a fun thing.

Charles Goldfarb:

No, alright, let's finish up with just hitting the highlights of the Seymour fracture again, because this of all these fractures, this is the one that in some ways has the most risk.

Chris Dy:

So you describe what a Seymour fracture is. But for those who who aren't as familiar with these, we know that these are technically open fractures because the there has been compromise to the cuticle seal. So the you know, while there may not be you know, exposed bone when they come in, they did probably have a nail bed laceration. And, you know, it's just, I guess, more pattern recognition, looking at the X ray saying that just looks like you know, might have been a Seymour fracture. And then historically the concerns are, you know, things like infection and growth plate issues. So in 2021, what's your algorithm?

Charles Goldfarb:

So the classic clinical presentation and this is classic, but doesn't always happen is the nail plate is avulsed, and lays on top of the dorsal nail fold. And so when you see that together with a fracture that goes through the physis of the distal phalanx, that's a Seymour fracture. Sometimes the nail is still sitting underneath that dorsal nail fold and then it becomes trickier. But I would say the vast majority of the time if you see a Salter Harris fracture, which is typically Salter Harris two. If that distal phalanx looks flexed like a mallet fracture, you have to assume it's a Seymour fracture. And there has been some good good work looking at the risk of infection and what you do. You know, Julie Samora from nationwide has published on this and it's helpful it's helpful to understand the role of washing out in the ER, the role of oral antibiotics. To me for most kids, this still is treated not universally in the OR, but certainly every kid gets antibiotics. Every kid gets a wash out and most kids do deserve a trip to the OR for, often for pinning.

Chris Dy:

Do you think that these kids need to go on prolonged antibiotics or say they're in the OR they get a single dose of IV? Is that good? Or in the ED they get single dose of IV? Is that enough?

Charles Goldfarb:

Yeah so my protocol is if they're seen in the ED, they're washed out the finger is stable and able to be reduced. I put them on seven days of antibiotic. If they go to the OR for formal wash out for a K wire. A single shot of antibiotics in the OR is sufficient with that degree of washout and cleaning out the the open fracture.

Chris Dy:

Do you have you considered having anybody do pins in the ED?

Charles Goldfarb:

We are not set up to do that. I absolutely have no problem with that in the right emergency department set up so it during my fellowship in Cincinnati, at least for adults, that was certainly possible and kids potentially but yes i think that's highly appropriate to take care of in the ed with the right setup with the right kid.

Chris Dy:

And I think probably the only point i would make since i don't i'm not an expert in this area by any means but you know not all washouts are created equal you know i think that the sprinkling of holy water in the ED is probably not sufficient to call it a wash out. You really want to make sure that you got everything nice and clean.

Charles Goldfarb:

Yeah and I remove the nail plate in all of these kids I do a horizontal mattress repair of the very proximal aspect of the germinal matrix which is not your typical nail bed repair it's also not a nail bed repair to consider with glue and then i put adaptec under the dorsal nailfold, you could replace the nail plate under the dorsal nail fold and again the nail plate is helpful because it provides some stability but if you're adding a k wire in the operating room i don't think you need the nail plate and so i think that's generally accepted protocol but again not every kid has to be treated exactly the same way and i would also make the point you go to the OR you do all the above it doesn't remove the possibility of an infection and by infection we typically mean osteomyelitis it just decreases that chance which again is is a complication we don't want to see.

Chris Dy:

Well let's come back next week and well why don't we talk about adult phalanx fractures or we can continue on any other pedes finger fracture topic that that you'd like to educate everybody about.

Charles Goldfarb:

I hope this translates again maybe the video on youtube would be more helpful i hope it does translate for the listeners and also i think the therapy aspect of this these injuries will be helpful as well so maybe we can convince Macy to come on i know she's still out on maternity leave but maybe we can get her to join us either for the next podcast or the one subsequently.

Chris Dy:

Well because we know that podcast is not work, the podcast is fun.

Charles Goldfarb:

Amen and when it stops being fun you know what happens.

Chris Dy:

Exactly exactly it'll go into the time capsule well all right go enjoy your day i'm gonna go mow the lawn.

Charles Goldfarb:

Awesome enjoy it, take care.

Chris Dy:

All right, take care bye.

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 [email protected]

Charles Goldfarb:

And remember please subscribe wherever you get your podcasts

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.