The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Talk Radial Tunnel Syndrome: Myth or Reality

June 06, 2021 Chuck and Chris Season 2 Episode 23
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Talk Radial Tunnel Syndrome: Myth or Reality
Show Notes Transcript

Episode 23, Season 2.   Chuck and Chris discuss radial tunnel syndrome.  They both believe in the diagnosis although find it uncommon.  We discuss diagnosis, conservative care and surgery.

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, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I am great. This is an impromptu session.

Chris Dy:

I know, I'm excited. Well, you know, I had the whole day blocked off for the research management committee meeting for the hand society in which we review all of the basic science and clinical grants. So usually, I'm told it's an in person meeting with a fun series of events planned around it, but the only ones that I've gone to have been zoom all day.

Charles Goldfarb:

You know, I've had a few of those all days in meetings replacing a fly in fly out. And then there are advantages because there's no fly in fly out. But it is tough, I think to sit and converse, especially on something like grants.

Chris Dy:

This is a committee where I think this would have been much better in person. But you know, we're still in trying to figure out who can travel and when people are comfortable traveling. So hopefully the next meeting is back in person.

Charles Goldfarb:

How big a group?

Chris Dy:

Looks like it was about 20 to 25 of us.

Charles Goldfarb:

Oh, wow.

Chris Dy:

It seemed well maybe it felt like that it's a pretty big committee.

Charles Goldfarb:

Well, I'm sure everyone associates grant writing with fun people so of course it is.

Chris Dy:

I guess it takes one to know one. Any What do you been up to?

Charles Goldfarb:

Oh, nothing, it's uh, you know, summer's here. It's getting busier. As far as the you know, the my pedes world practice is getting busier. The hand world practice is pretty busy. And, you know, the administrative life is got me down a little bit. Just a lot of you know, it never stops. There's always a challenge, which is both good and, and sometimes frustrating. But my to do list never ends. But I think I speak to everyone in our audience what I say, Does anyone's To Do List ever end?

Chris Dy:

Well, we all we all talk about getting to that inbox zero. And the the one was that we had that episode about the one thing right, so maybe you'll get there one day, Chuck.

Charles Goldfarb:

I'm gonna keep trying. That's all we can do. Any good reviews out there.

Chris Dy:

Yes, we had a great review. And it actually has a question for Chuck. So this is from username m checker one and thank you for the five star review on Apple iTunes, says Hi guys, I'm an occupational therapist, PhD in Green Bay, Wisconsin. I took a new position six months ago with a longer commute three days a week and your podcasts have made it so much more worthwhile. I truly enjoy the variety of topics, good humor and up to date research in our world of hand surgery and therapy. Keep up the good work. Question for Chuck, feel free to answer too Chris, what is the most important thing about hand that hand therapist needs to know when working with hand surgeons. Thanks again. And this is from Megan. Thanks.

Charles Goldfarb:

Yeah, totally. Thank you, Megan. And I don't know if Megan or other hand therapists are coming to St. Louis in October for the ASHT meeting, which I unfortunately, I was super excited to be a part of and my middle child is heading off to college and it's parents weekend. And I don't always show for all the things that I should show for so I'm going to be at that parents weekend. So Chris and I are going to try to do something creative around the upper hand podcast. And I think that's going to be my only contribution. But that meeting will be great. And Megan, if you're coming into town, you know, look up, Chris, for sure he'll be there. And thank you again for the comment. You know, it's interesting, what my answer to the question was just because I babbled on so long, I should repeat is what are what's kind of one thing that hand therapists You know, when working with hand surgeons, it'll be interesting to see what Chris's answer is, I think don't overestimate our knowledge about the hand therapy world. Especially the further we get it, you know, when I have a super close relationship with different therapists, and we work on things and develop protocols together. And then what I like to do for the majority of things is just turn over the patient's care to the therapist, and I'm lucky that that's worked well. I guess I don't always know as much as my therapist thinks I know. And I mean that for real. And that's why I depend so heavily on a really experienced therapist, so don't overestimate my knowledge.

Chris Dy:

It's funny for a while there. I thought you were saying that you didn't want the hand therapists to think that you knew too little about hand therapy, but I guess you don't want them to think that you know too much. Is that right? clarification?

Charles Goldfarb:

Yeah, sorry. It was confusing. Yes, I know less than you think I know about hand therapy.

Chris Dy:

You know, I remember starting right after fellowship and being like, wow, I really don't know much about hand therapy. So this actually brings us to a point where I'm toying with a new project idea. And I'm gonna say it on the record here. So I actually do it Goldfarb style, hopefully better outcome than the Spanish.

Charles Goldfarb:

Say it out loud. My wife always says it say that out loud in front of friends and family, Chris.

Chris Dy:

Or you know, 1200 downloads a week. So have you ever seen the Netflix series comedians in cars getting coffee?

Charles Goldfarb:

I have seen a couple episodes with Jerry Seinfeld, it is so friggin funny.

Chris Dy:

So I'm not Jerry Seinfeld, but I love the conversational format. Just you know, we're here to talk about one thing. And I really think there's a space for us hand surgeons and orthopedic and plastic surgeons to learn about what the hell goes on at hand therapy. And so we're going to launch a series, a little YouTube video series called hand therapy for hand surgeons, maybe we'll come up with a better name. But I already have a list of topics that I came up with, and a list of local St. Louis therapists that I want to go to their clinic. And I want to be a patient and I want to learn what the hell goes on there.

Charles Goldfarb:

And that would be with YouTube, because the video component would be important. I mean, no one wants to see your face, or maybe they want to see your face, and they don't want to see my face. So I think the podcast medium is good for us. But it would not be good for that.

Chris Dy:

Well, this, this will just be my hands being on camera. Because honestly, like I have, I think I've gotten a much better sense as my practice has come along. And we've been fortunate enough to have hand therapy collaborators and colleagues in our clinics in our model. And I've learned so much from just that alone. But I really do want to know more about what happens there. So you know, coming to a YouTube screen at some point in 2020, to watch out for hand therapy for hand surgeons.

Charles Goldfarb:

Well, and we've been accused of being too agreeable. But I will agree with you. This sounds like a great idea a little challenging, of course, to find the time. But that's a great idea. And I you know, we could all learn something.

Chris Dy:

You just you just heard that our Executive Vice Chair just gave me protected time to make a YouTube series.

Charles Goldfarb:

After you write a few more grants, you got it.

Chris Dy:

Exactly. So Chuck off, first off, Megan, thank you for that review. And yes, Chuck and I will have a presence at the ASHT meeting. I know it's a hybrid meeting. So please check us out. I'm thinking I'm doing some some pre course, cadaver dissection, which I'm very excited about. And then we're fortunate enough to have one of our sessions selected for the opening portion of the meeting. And it's gonna be really cool. It's gonna have some patient advocates, some patients, hand therapists, pain management specialists, and I'll provide the surgical perspective.

Charles Goldfarb:

Yeah, and then the session I had to bow out of which ultimately will be a good thing for all the ASHT attendees is on sports in the hand and Lindley Wall is going to fill in on Saturday morning for that one. So it really looks like a great meeting. So I'm so excited is here in St. Louis, and look forward to hearing great things.

Chris Dy:

You know, I will say that Dr. Wall filling in might be an upgrade. I don't know.

Charles Goldfarb:

There's no doubt no doubt. We agree on that, too.

Chris Dy:

So any interesting cases, Chuck?

Charles Goldfarb:

You know, Chris, I did have an interesting case. It was interesting for a couple of reasons. And, you know, Chris can see my smile. I think this one gave me a little angst, which is, which is why I think it was enjoyable. And it was challenging a little bit. So I had a adult patient with macrodactyly, primarily affecting only her thumb. And for that adult patient, she had had a number of previous surgeries, I essentially had a large thumb that was insensate and had a little motion and caused pain. So you can check all the boxes about what good is a thumb and you kind of cross off all the usual stuff. And so even as a post it wasn't particularly helpful. And so we proceeded with a ray resection of the thumb and index finger pollicization, and that it is an outpatient, sort of in the middle of my normal busy two room day. But certainly this is one case you can't rush on. And it went really well. And thankfully, viability was not an issue. A little bit of a size mismatch, because we use the base of the thumb metacarpal, maintaining that CMC joint. So we had to, you know, think about length and rotation and position and we use some of the thenar muscles, and we save the adeductor. So a lot of the principles that we utilize for a, what I would call congenital pollicization, which is the vast majority of what we do, didn't necessarily apply. So it really was a nice mental exercise. And certainly, you know, there's a long way to go for outcome and, but I really think this patient's going to be happy.

Chris Dy:

That's great. I mean, I can only imagine how satisfying it is to do that procedure. And you can obviously really change somebody's life with that procedure. You know, we did a lot The last firsthand that we did was with Terry Light. And we talked about, you know, Adrian Flats and pollicization. And Dieter Buck-Gramcko and has your technique varied a lot from what was described by Buck-Gramcko? Or do you still mainly stick with those principles? I know, some, some of the finer details may have changed.

Charles Goldfarb:

Yeah, you know, first of all, I would say that the pollicization procedure is the hallmark procedure for general hand surgeons for good reason. And really, for two good reasons. One is functionally a home run. And two is aesthetically a home run. So it's a great procedure. And it's that procedure that I was fortunate to have a mentor that I could work with for years on this procedure, because while there, you know, Paul Mansky wrote a 10 step guide, and Scott Kozin actually sort of modified that. But basically, there is a stepwise way to approach this. But I think once you do enough of these, and we do about 10 a year, which is a lot. And by we I say Lindley Wall, and I do almost all of them together, which is wonderful. And it's just a procedure that is fun to do, because you recognize the impact it can have. And Dieter Buck-Gramcko who is considered one of the fathers of the general hand surgery from Germany, established the basic principles, they've been modified slightly, but I would say in large part, the procedure today looks like it looked, you know, 50 years ago, it's about right when, when Dr. Buck, or professor Dieter Buck-Gramcko described it. So really just a cool thing, I think.

Chris Dy:

If it ain't broke, don't fix it.

Charles Goldfarb:

Yeah. And like everything, people have described, subtle differences, a different incision, and a different this and a different that, but the fundamental aspects of it are really great. And, and that's another example of a procedure where therapy, collaboration is just incredibly important. How you manage the patient after surgery, really determines, you know, how successful your procedure will be.

Chris Dy:

So, Chuck, I have a burning question for you. That brings us to today's topic.

Charles Goldfarb:

Awesome. I love that you have a topic for today.

Chris Dy:

It's called it's called myth or fact, radial tunnel syndrome.

Charles Goldfarb:

Ah, yeah. You know, I think it's a fact I think it exists. Nerve pain syndrome, which is really what we're talking about is a little hard to swallow sometimes. But it's real. And I don't think it's common, I'll be interested to know how common you think it is in your busy clinical practice. But if I look at my practice, I would say I do five radial tunnel decompressions a year out of seven or 800 cases. So not many, and I would say a fair number of those are workers comp. And certainly some of those are tennis elbow associated radial tunnel syndrome. But what do you think? What's your, what's your experience?

Chris Dy:

I think it's real, and I do less than five a year. I try to steer these patients away from surgery, mainly, because a lot of them not because of the surgery is not effective. And I don't think that I can deliver a consistent result. But mainly because a lot of them will get better without surgery, whether that's through observation, waiting for natural regression to the mean. Or because they they improve with the strategies that our therapy colleagues work with them on. So I don't think it's as common as a lot of people think but I do think it's real like like you, you and I completely agree with you on the frequency, the concomitance with lateral epicondylitis. And you know, whenever I assess a patient for one I assess them for both, and it probably probably is present most of the time and both of them, it's just a matter of them both, both of those conditions getting better with kind of the same treatment.

Charles Goldfarb:

Alright, so let's talk briefly, I think we want to get a little into the technical, but let's talk briefly, I'll give you one test, what is the one test that you utilize with greatest confidence in making a diagnosis of radial tunnel syndrome?

Chris Dy:

I'll tell you, it's all relative for greatest confidence with radial tunnel syndrome, but it's point tenderness. So you know, and it's it's hard to do that kind of anterior at the most common site where we talk about the fibrous leading edge of the supinator being the most common culprit, it's difficult because, you know, jamming your thumb in that area is kind of painful for a number of reasons. But I do like dorsally kind of walking my way up from the mid portion of the forearm almost at that, you know, almost like you would be doing a posterior approach. And just walking up from the mid form dorsally trying to get between the EDC and the wrist extensors and feeling in there where you supposedly will be on the distal edge of the supinator and kind of walking in because if you start too proximally over the lateral epicondyle, you'll get your tennis elbow pain there. So I always will start with that palpating from distal to proximal, and that will tell me how much of this is radial tunnel versus how much of this is lateral epicondylitis? Or both. How about you?

Charles Goldfarb:

I? Well, I first thought I totally agree. And people talk about, you know, resistance supination and different manipulative tests. But to me, it is all about point tenderness, I think it is really important to test the other side, because you're right, you can have native, it is native soreness, but it really is not soreness, it's just an uncomfortable area to be palpated. And, for me, it's like five to seven centimeters distal to lateral epicondyle, in that inter muscular. It's really between probably ECRL and EDC. And I think you just get used to where to push and it can really recreate the pain, I think it's a very effective test.

Chris Dy:

Now, that being said, I still do the other exam maneuvers, mainly just because it's not hard to do. So you know, pain with the resistant middle finger extension is something I still do and see if it comes up. But I think the diagnostic yield on it is somewhat low. It's just been ingrained in me as to something to do. So I typically just do it quickly.

Charles Goldfarb:

I do that. And I certainly go through my lateral epicondylitis testing. And I don't inject. I know there are people listeners, I'm certain who feel like a lidocaine injection can be helpful. I've just never found it helpful. So I don't inject.

Chris Dy:

Yeah, there are a lot the classic teaching is what you you got to have a wrist drop, in order to know your injection was in the right place. I think that's playing with fire man. I think that's crazy. But you know, I, I just I've seen that anatomy way too many times to respect the variability of that anatomy. And I think my ability to do that based on, you know, surface anatomy, landmarks and palpation is not perfect. And I will use an injection as part of my diagnostic and early treatments algorithm in some select cases. And I'll send him for image guided injection.

Charles Goldfarb:

So when that is done, are you asking the our physical medicine rehabilitation colleagues, I presume to inject at the radial tunnel or inject the radial nerve slightly more proximally?

Chris Dy:

I typically will do it at the radial tunnel, you know, and I'll have them a lot of times it is just a diagnostic block, because I don't love the idea of steroids in that area. But occasionally, depending on the patient, I'll use some steroids. I don't like any more than two injections in terms of either diagnostic and or steroids.

Charles Goldfarb:

And what is the role of nerve studies and the diagnosis of radial tunnel syndrome?

Chris Dy:

I don't really think they have a role because it oftentimes come comes back as negative ultrasound has been helpful. I've had some cases where patients have gone for the ultrasound guided injection, and I've asked them to ultrasound the the PIN as it enters the supinator. And while you know, it oftentimes will come back as normal, when it is positive is incredibly helpful in terms of counseling and gives you a little more confidence that you're you're going to help this patient if the nerve is swollen compared to the opposite side.

Charles Goldfarb:

I love it. I love it. So before we jump into the meaty, exciting part, which is the surgical technique, explain to listeners how you think about therapy, I have to admit, I don't know that I've been as successful as you have with the use of therapy. I certainly believe in therapy for lateral epicondylitis. Don't get me wrong, but I don't know for isolated radial tunnel. I've been very successful. So what are any pearls on how to how to discuss this with a therapist or what what techniques are most important?

Chris Dy:

Why, you know, certainly this is an area where we could have one of our hand therapy colleagues joining us but I mean, you know, I think it is mainly about activity modification and adjustments in terms of ergonomics. You know, they end up doing a lot of the stretching and eccentric strengthening as part of you know, the therapy protocol for lateral epicondylitis. But it's really the activity modifications and getting things to quiet down as much as you can. I do think that oral anti inflammatories are useful here. I haven't really used topicals here, although it's much easily much more easily available now that diclofenac gel is over the counter. So that's somewhat easy thing to try. But I don't have any secrets or pearls for therapy. I trust our colleagues enough, as you've mentioned, to to let them do their thing. But I do have that listed as a topic for the upcoming video series hand therapy for hand surgeons.

Charles Goldfarb:

Oh my gosh, I love how you work that back in again. And I'm a I'm a I'm always intrigued by the concept of nerve glides for our therapists doing nerve glides and nerve stretching. But again, I'm not sure it's the right technique for this location. I will say that iatrogenically we can create a radial tunnel. Usually it does get better but the counterforce brace which is Believe in for lateral epicondylitis and provide a kind of a standard user to counter force brace. Sometimes they use a cockup wrist brace, but the counterforce brace incorrectly applied can really reproduce these symptoms.

Chris Dy:

I have not encountered that. But I absolutely see how that can happen. So from your perspective, which patients are going to surgery, how long do you try your conservative or non operative treatments?

Charles Goldfarb:

Why don't we speak about the isolated radial tunnel rather than the combo? I will try anti inflammatories, activity modification, and maybe some therapy which I generally don't laugh or just said, yeah, it will be an evaluated treat therapy, modalities, stretching, and are probably give it three months would be my general approach. I wouldn't make it six months. I think three months is a reasonable time course.

Chris Dy:

So how are you talking to patients about radial tunnel? When they come in? You send them to therapy? Would you not see them back for three months? What do you say, you know, when you come back, I think you're going to be better or you're going to be slightly improved. And if you're not better, then we'll talk about other options. And do you yourself incorporate steroid injection or anything like that in the treatment protocol?

Charles Goldfarb:

Yeah, so I don't believe in sending patients away for three months for anything. And so I mean, certainly I have my annual follow up for some of the congenital stuff. But if the patient has an active problem, sending them away for too long feels like the wrong thing to do. And so usually, for something like this, or for tennis elbow is probably six weeks, I would see them back check in, just kind of take the temperature of the room as far as whether they may be a little improved, whether they're more frustrated, and go from there. I'm not a steroid injection believer, so I wouldn't do that. So it's really just a matter of anti inflammatories, therapy, and process whether they are showing any signs of improvement.

Chris Dy:

So what do you think is the real point of compression here?

Charles Goldfarb:

Oh, you know, we can name the the five points of compression, but it's the leading edge of the supinator. I mean, it to me, there's no doubt that, and of course, it may not be 100%. But for me, it is darn close to 100%. And so if the patient is frustrated, and if their symptoms and signs are reproducible, I think you can, you can with very low risk, very little morbidity and a relatively rapid recovery, you can decompress the radial nerve. So to me, I think it's a safe, effective surgery.

Chris Dy:

So when you see these patients, and you're doing the surgery, and you release the leading edge of the supinator, do you make an effort to see the entirety of the supinator? Or in released the nerve throughout the entirety of the supinator? And see an exit or emerge? Or do you not just but do you only release the leading edge?

Charles Goldfarb:

Yeah, my you know, I have done these both with an anterior approach. And we should talk about this and a dorsal approach. And I don't believe that I don't want to release the entire supinator. Because I think that does add some morbidity. But I don't, I don't want to release the whole thing. And so it for me, it's about the leading edge and I you can get a sense of what's going on in the supinator. But not I don't want to release the whole thing.

Chris Dy:

See, this is where my bias comes in. As the person who sees the recurrent, you know, referral cases or questionable recurrence of radial tunnel, I know that you can't get the entirety of the supinator in all patients from an anterior approach. And that was demonstrated nicely in a cadaver study from the HSS group. So I just worry about, you know, releasing the leading edge alone, knowing that that's going to be the case 95% of the time as the compressive point, but not seeing the distal edge and then having to come back on my own case. And that's a pride thing, I guess. But I agree with you entirely, that this releasing the entirety of the the entirety of the supinator does add morbidity. You know, I think that, you know, I'm young in my career, but I've noted that you know, the things that really hurt patients in terms of post operative pain, it's whenever you do work on bone in terms of drilling, but then also a large amount of intramuscular dissection hurts.

Charles Goldfarb:

Both fair points, I would say and you may disagree, which I kind of hope you do just for a little spice. I would say that I believe I can differentiate proximal nerve compression where the nerve enters the supinator and distal nerve irritability, where the nerve exits the supinator based on my physical exam now, whether I have great confidence in that, I don't know. But I think if it's a classic examination, then I am very comfortable releasing the leading edge and you know, gently palpating and visualizing a little more distantly and understanding that I'm not going to completely release the exit point. But if it's a distal point of discomfort. I think it's very different. So that's how I think about it.

Chris Dy:

Wait, so timeout. Hold on, you said earlier that on your physical exam, the most important thing is, you know, starting distally and walking your way in from seven centimeters distal to lateral epicondyle and seeing where there's pain, and is that the area where you think there's compression? Or do you think that's just an irritable nerve?

Charles Goldfarb:

No, you're here, you're conflating what you said and what I said. You're putting your words in my mouth. No, I said, seven centimeters, distal five to seven centimeters distal to the lateral epicondyle is that point, which is the classic leading edge, and it's more distal in the forearm and pointing to kind of halfway down the forearm, then I think, and I don't know that even in me, not very muscular, but somewhat thin. I don't think I can feel that exit point. But it's just a very different location. I absolutely believe that I've had patients that have pain at the exit point, not the entrance point.

Chris Dy:

So you think that at five to seven centimeters distal to lateral epicondyle, that's the entrance point of the the PIN and deep to the supinator?

Charles Goldfarb:

Correct.

Chris Dy:

Is that when you're, are you palpating? That dorsally or volarly slash radially?

Charles Goldfarb:

Dorsally, dorsally. Yeah, that dorsal soft spot. Yep.

Chris Dy:

Okay, I can't say I agree with that.

Charles Goldfarb:

I love it. I would have been disappointed if you did. So what is your favorite approach? Do you always go dorsal always go volar do you modify?

Chris Dy:

Um, you know, I think that, you know, there are a lot of ways to get there. Right. So, you know, just in terms of clarifying for those that are listening who may not be familiar with the surgical approaches, the ones that are classically described, you know, for an anterior approach to the radial tunnel, that would be between the brachioradialis in the brachialis. And enter a lateral approach would be between the ECRL and the brachioradialis. And then a posterior approach would be between the ECRB and the EDC, I think they're, the first two are a lot easier to accomplish from a surgical perspective, I think you can accomplish the first two for sure through the same skin incision, you know, so one skin incision, different surgical windows, I typically will start by, you know, kind of more anterior than anything else working underneath the brachioradialis because you have your SRN as a guide to help you walk into the radial tunnel. So you start a little bit distal to the radial tunnel, you find your SRN, you dissect proximally. And you find where the the the PIN is coming off. And that I think is the most reliable and easiest, perhaps you don't need that extensive of a dissection. But I think that especially working with trainees, that's a very reliable approach. So I typically will start with an anterior and then see how distal I could get. Because in you know, when you go with a straight anterior approach, you probably will leave some of that supinator behind. And if your goal is to decompress the entirety of the supinator muscle, you may need that anterior lateral even a posterior surgical approach. How do you think about this?

Charles Goldfarb:

Marty Boyer, one of our partners, always goes anteriorly. And I have to say, I started my career by always going anteriorly and the pearls I have are you know your dissection, your incision point is just on the older side of the BR, the brachioradialis. You protect the LABC. And you work in that interval as Chris described. And then you will always encounter the arcade of frohse. And I typically would either use the clip applier or I would tie those with 2-0 silk ties, and then expose the nerve. As you said, the best way to find the nerve is to find the superficial branch, the radial nerve, trace it proximally and then trace the the motor nerve more distally. It's a very elegant approach. I think it heals beautifully. And I think patients do well. For me, it's a soft dressing and a rapid recovery. I'm trying to think what other pearls I have, I think that as long as you handle those vessels appropriately, as long as you protect the lateral antebrachial cutaneous nerve, I think you have a beautiful exposure of the majority of the nerve as it enters the muscle, as you eloquently stated, you don't see the nerve distally and therefore, if you're worried about the nerve distally you have to consider other options.

Chris Dy:

And and you being the astute clinician, you are essentially, you know, Sir Oastler, yourself can tell it is a distally compressed nerve. I will say it is but I can actually I think in a recurrent case that is spot on. But I think you're just you're right, because you're playing the odds, because most of the times it is the fibers leading edge of the supinator. And that can be a really tight band. And I think that just in terms of you know, for the anatomy, you know, nerds out there. It's really cool anatomy in that area. There's all sorts of variability. So you just need to be aware of the variability because oftentimes you can have branches innervating, the ECRB coming off of the SRN coming off of the radial nerve, you know that bifurcation of the SRN and the PIN or even coming off more proximally. So just things you need to be aware of. And there are these little wispy nerves that power the supinator, which are super important to us nerve nerds, because you can use that as a nerve transfer in some cases that you just need to be aware of. And I think the biggest variation that that surgeons need to be aware of is that the textbooks say that the PIN is going to stay deep to the superficial head of the of the supinator muscle, and then it won't. It'll exit, you know, kind of staying between the deep and superficial heads. But there are some variations in which it will poke through the superficial head. And if you are hell bent on decompressing the entire thing or even getting to that distal quarter of it. You can see that nerve come through superficially, you just need to be aware that you need to see the nerve at all times Keep it down keep the superficial portion of the supinator up during the decompression.

Charles Goldfarb:

Yeah, well said I mean, we could do a whole episode about my really refined physical exam techniques such as checking your hemoglobin by the beefy red color of your inner gums which of course I check for every every patient. And what is this about supinator motor branches? Are those the ones I cut right through?

Chris Dy:

Those are the ones where you can actually hear the supinator gasping as you cut it. I guess you're cutting the muscle anyways, and why does it matter? Right?

Charles Goldfarb:

Absolutely. So I will say in all seriousness, as we wind down the, when I go dorsally often it is in combination with a lateral epicondylitis procedure and you can make a slightly larger incision have good exposure. What is really interesting about that approach is that when it goes well, meaning when you find that nice interval, as you said, between ECRB and EDC. It's a beautiful exposure of the nerve. Now you can't get super far proximally with that approach. But it's a beautiful exposure. But there is a risk, there's a risk that developing that interval can be tricky for some patients. And if it's tricky, you just have to make a bigger incision, and you find the appropriate interval. But that's the hesitation and that's why for for a younger surgeon just starting out, you might choose to go volarly because it's just more more reliable anatomy.

Chris Dy:

Yeah, I think that you know, so I actually did a variation of this case, you know, so I do a fair bit of radial tunnel decompression when I'm doing nerve transfers. Anyway, I guess I didn't count that in my tally earlier but did a case like this recently where I was trying to find the deep branch of the PIN as part of a nerve transfer strategy. So I used it, I started with an anterior approach but you know, as part of this newer nerve transfer, you go dorsally as well because you're going to flip the AIM back to transfer to the deep branch of the PIN and we can talk about that in a separate episode. This is a really cool concept but essentially you have to do a dorsal approach to and nothing brings me more joy in doing some of these cases then perfectly nailing that interval and doing it largely with honestly a knife and a freer and it is beautiful anatomy and you know you I guess you're using the Goldfarb dissector there too.

Charles Goldfarb:

Oh yeah, the finger dissect I mean, what's this with a freer elevator just use the finger.

Chris Dy:

You know i think that it's just much more elegant and you got you got a freer I use my finger a fair bit, it's you know, things are gonna give you better tactile feedback. We had an attending in my residency who would call it the we call it the light in blade because his last name was light he's like get the light and blade in their shine the anatomy.

Charles Goldfarb:

We all have our favorite dissectors whether it be finger or rascally elevator for me or whatever. I will ask one additional question, maybe a final question. I have attempted the brachioradialis splitting approach for this technique and found it to be extraordinarily frustrating. And maybe I just chose the wrong patient with the beefy brachioradialis. But I would not do that again. Have you done that approach?

Chris Dy:

No, I don't like to be our approach splitting BR if you're there, you might as well go between ECRL and brachioradialis. You know, there's a really nice interval there. And McKinnon has a really Dr. McKinnon excuse me has a really nice video on this, in which you can see a cutaneous nerve running in that plane. And even the muscles themselves you can see the difference in the color of the muscle because the fascias stick around one of them. So it's a beautiful plain to expose. So if you're thinking BR splitter you might as well just go between BR and ECRL for your true anterolateral approach. I do have a couple of technical questions I want to ask you to bring it to a close. Let's do it. So two things do when you are dividing the superficial head of the supinator muscle. Do you do that with tenotomies with a knife with a bipolar with something crazy like a bovie? And then do you let your tourniquet down before you close the wound?

Charles Goldfarb:

I think for me the second question is easier. This is one of the cases and I would be interested, I think there's two cases that immediately come to mind where I always let the tourniquet down. This is one of them. And the other is this CMC arthroplasty. Especially if we are in close proximity to the radial artery, which we pretty much always are. Those the two cases that I routinely let the tourniquet down. Does that resonate with you?

Chris Dy:

Yeah. And there are cases, you know, sometimes I'll let the tourniquet down. And I'll, I'll do what I call flash a tourniquet. You let it down for a good 15-20 seconds, see if there's anything arterial, and if not, reinflate the tourniquet to allow for closure. Some would argue that you've already lost kind of your seal. And it doesn't do you much good. But I do find that to be helpful. And then I you know, I'll answer my question first, and then you can give your input, I tend to take the supinator down with bipolar. You know, I do like the hemostasis that that provides, but I'd use a bipolar on kind of a lower setting. And obviously, the bipolar doesn't have as much scatter as a bovie.

Charles Goldfarb:

So let's be clear for our audience. When you talk about the superficial and deep heads of the supinator you're talking about muscle origin, from the either distal humerus or proximal ulna, is that correct?

Chris Dy:

Well, you know, not so much origin, I'm going right over the nerve. I want to create a path for that nerve. So I'm not taking it off of the bone. I'm actually taking it in the middle of the muscle belly, which is why I asked the question of you know, I guess maybe if you do it differently, but you know hemostasis does matter at that point, because you don't want to create a large hematoma because obviously, that muscle is gonna lose.

Charles Goldfarb:

I guess I think about it differently. I really don't think about the muscular heads, you know, superficial, deep, whatever, I simply think about the leading edge that fibrous leading edge of the supinator I released that as distally as I believe it needs to be released such that you're not fighting that fibers edge. And typically, therefore I use scissors because you're cutting tendon really. And then bluntly spreading there after trying to palpate now I don't really believe I can palpate compression distantly but trying to palpate a smooth, sufficient space for the nerve.

Chris Dy:

Got it. Yeah, I think I'd take it a little bit further and probably maybe I'm doing too much. But you know, I will release the you know the fibers edge with the tenotomy scissors and I'll go after the muscle with a bipolar.

Charles Goldfarb:

Perfect. Alright, this has been fun.

Chris Dy:

I think it's been fun. And you know, thank you for making me commit. I committed myself to doing something new. So we'll see how this Youtube series goes.

Charles Goldfarb:

I love it. Alright, have a good evening.

Chris Dy:

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 hand podcast@gmail.com.

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.