Episode 25, Season 2. Chuck and Chris review PIP joint injuries, focusing on fracture/ dislocations and pilon injuries. These are challenging injuries with a multitude of treatment choices.
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
Episode 25, Season 2. Chuck and Chris review PIP joint injuries, focusing on fracture/ dislocations and pilon injuries. These are challenging injuries with a multitude of treatment choices.
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
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'm doing pretty well. We're getting a little fancier.
Chris Dy:Yes, I hear that we're now using a program that has all sorts of fancy audio sound clips, I think you're probably going to start to work some of those into the to the podcast. Pretty exciting.
Charles Goldfarb:Oh, for sure. We are we have outgrown zoom. And I say that totally tongue in cheek because A, I don't know if that's really true. And B, we may be back on zoom tomorrow.
Chris Dy:Exactly. I will say, you know, now that you're officially a funded podcast, I mean, you know, I think we're probably funded in a way that very little other podcasts are by an actual grant.
Charles Goldfarb:This is true. This is true. Our funding mechanisms are limited. But we have access some funds, which makes it feel good.
Chris Dy:Excellent. Excellent. So I wanted to get to a reader question, which was sent in to us and I think you'll like this one. And the subject line is sports wrist question for Dr Goldfarb. All right. So this i from Paul Hovis. Thank you fo sending in the question, Paul Paul is an orthopedic hand an upper extremity surgeon in Texa and he is a consultant for on of the major league teams an their farm teams, which i fantastic. So congrats on that His question is stated, ther has been a rash of comebac balls hitting our pitchers i there throwing wrists, causi g distal ulnar shaft fractures r ulnar styloid fractures. In t e non high level athlete l y person and for all ulnar styl id fractures I adhere to he typical literat re recommendations consisting of predominantly immobilizati n. However, I was mostly wonder ng what your opinion is on surgi al intervention for pitchers w th distal ulnar shaft fractures on her throwing arm that wish to pursue pursue surgery whet er displaced or not, do you f el this gets them back to p ay faster, or at least back t a throwing program more quickly I know there are complex wr st mechanics that are overloo ed predominantly with curveballs or sliders. And I can't say I ve found much literature or direction on this speci ic patient populati
Charles Goldfarb:It is a great question. I can talk, it's interesting. I take care of the Cardinals here in St. Louis and some of their farm players, some of them get cared for down near Jupiter, Florida. But this is an injury I haven't seen in the last five or six years in a baseball player. So you know, maybe it's coming because those balls come off the bat very quickly, especially with the speed pitchers are throwing today. So in my mind, I'm envisioning what I would call a nightstick fracture. And, you know, classically we are taught not to treat those surgically because they do heal nicely. I will go back to the basics of the care of the athlete. And answer this in the sense that, you know, the paradigm has changed. And we've talked about this a bit. 20 years ago, the paradigm of taking care of an athlete revolved around minimally invasive care, with attempts to go non operative. Today, the care is more invasive, with attempts to minimize time away from sport, and maximize function upon return. And so that means more surgery. Let's be blunt. And so I think the question is really a good one. And I think Paul has a very valid point, that if you think you can get the athlete back playing faster, with minimal morbidity, then it makes some sense. And you know, a distal 1/3 on a shaft fracture is different than a very distal ulnar shaft fracture, which I think can be really tough to fix effectively. And obviously, that's different than an ulnar shaft- ulnar styloid fracture. So my answer is if it's displaced, or if it even if it's not dramatically displaced, if we think we can get the athlete back to play faster then it's something I would consider.
Chris Dy:Do you think that the fractures that are minimally very minimally displaced like you almost can barely make it out in an X ray is just kind of like scaphoids where for a while people were fixing everything?
Charles Goldfarb:Yeah, this I think it would be tough for me if it was a hairline fracture, or very subtle, I don't think I would treat that surgically. I would put the put the the pitcher in the cast and follow it closely with the expectation that it would heal rapidly and well and we wouldn't miss that much time. I think once it becomes displaced that obvious The next question is how displaced is too much, but I wouldn't be opposed to more aggressive care with at least some displacement.
Chris Dy:Now when you're talking about returning to a throwing program, what do I think what what I loved about Paul's question was the thought that there are some mechanics, nuances to things like curveballs and sliders. Now, I'm not familiar enough with throwing mechanics or taking care of these high level athletes know, perhaps what some of those differences are?
Charles Goldfarb:Well, I think it gets to the point that we could, you know, with a plate fixation, we could get the athlete back working on motion of the forearm, motion of the wrist, and potentially start strengthening really quickly. As far as the throwing mechanics, though, I don't think you get them back until they're really ready to go. Because I think you risk throwing off those mechanics, if you return them prematurely. And I do, you know, I, it's very fortunate that we, you know, every sport, baseball, as well as all the other professional sports have really high level training staff that get this at a super high level. And so I think our job as physicians and surgeons, when it's called for, is to kind of give the green light. And their job is to work through the rehab and maximize full return to play. And so I don't know that the mechanics, I think the mechanics are a real concern. And my philosophy would just be no throwing program, unless it's light toss kind of stuff, until they're really ready to go.
Chris Dy:Yeah, I mean, this is like total level eight evidence right now. But for me, I feel like probably there is some, some torque that is different in slowing and throwing a curveball or slider versus a fastball. And I would imagine that comes through the form and through the carpus, in terms of, you know, pronation, supination, probably more supination than anything else. So I would imagine that the threshold to operate upon these patients who use that particular kind of pitch is probably much lower.
Charles Goldfarb:Yeah, yes. And no, I mean, I think if you choose non operative care, you just have to be patient, and make sure that you have sufficient healing before you start the process. There is no doubt there's more torque, totally agree. And so it either it's going to slow you down on one end or the other, whether you're slowed down by initial mobilization, or slowed down before you can really go hardcore, you're still gonna have to be patient till you have clear healing.
Chris Dy:You're gonna love this because I actually had this patient within the last few weeks.
Charles Goldfarb:Oh, wow.
Chris Dy:Not a pro athlete. Of course, not in my practice, but an actual collegiate bound scholarship softball pitcher, hit by a pitch coming back at her right on the shaft fracture actually tried to non op it, because it was minimally displaced. But then I watched it displace, the next week, he came back. And basically dad looked at me and said, I was wondering why you weren't operating on her. Here we go.
Charles Goldfarb:Wow. So you, you put a standard plate on?
Chris Dy:Yeah, standard plate. You know, what I have found with, you know, I was trained by one of the orthopedic trauma surgeons that I worked with in my residency, very much to dual plating and orthogonal plating was big. I think sometimes for these, you might make them too stiff, which would be my concern.
Charles Goldfarb:Yeah, for me that ulna bone is not the one to be too aggressive like that, I completely agree with you. And this is the bone where I really am careful about minimizing, stripping. And really just expose wherever I'm going to put the plate and try to leave everything else intact, periosteum especially because, you know, even if you're a listener, and you don't do a lot of ulnar fracture surgery, that's probably all of our approaches. We all do ulnar shortening osteotomies. And that is one where I lay a lot of crepe about time to healing and my typical responses eight to 10 weeks.
Chris Dy:Why do you think that ulna bone takes so long?
Charles Goldfarb:You know, I don't know the vascularity well. Certainly, some of it comes from the interosseous membrane. But it's it I mean, it goes it's got to go back to the basics of the blood supply must be lousy. You know, I've I've investigated this in a very, very specialized population that is in in the osteoclasis patient. So, osteoclasis for me, is in regards to children born with proximal radioulnar synostosis. So congenital anomaly, and we rotate the forearm in those kids by creating osteotomies. And one of our excellent previous fellows many years ago, basically came to the conclusion that once a child is over age six, healing is so unpredictable that doing that surgery and not putting hardware in really risk the non union and so it's just got to be a vascularity issue. And, and there's so much the cortical bone is such a great percentage of the ulna right? So there's just not a lot of cancellous bone to promote healing.
Chris Dy:Do you change your immobilization based on the fact that it takes so long to heal? Is there any thought to mobilizing people with you including their forearm, at least?
Charles Goldfarb:In a fracture?
Chris Dy:Yes, in a fracture setting,
Charles Goldfarb:Yeah, I don't go above the elbow. But I tend to do it with like a nightstick fracture non athlete. I just put them in a cast for six weeks as a starting point and then reassess. Hopefully then getting them into something different.
Chris Dy:Below elbow, so not a Munster or anything like that.
Charles Goldfarb:Yeah, I mean, as I think about it, not totally fair, but it's the radius rotating around the ulna. But certainly, there's torque on the ulna during that rotation, no doubt about it.
Chris Dy:Yeah, I've been known to use the Munster. But yeah, this patient this patient got single plate has done incredibly well so far. And we're hoping to get get them back ASAP. So Paul, probably not the person you wanted answering the question in terms of a recent case, but you definitely got Chuck's thoughts. Thank you for that. Great question.
Charles Goldfarb:So Chris, keep working hard. And one day, you might graduate from nerve surgery, and you can move into sports, I don't want to promise you anything. But there's hope for you.
Chris Dy:I'm hoping to stay where I am right now. I'm good. I'm good on that.
Charles Goldfarb:Alright, so I know you have the topic that we are going to discuss tonight. And it's a good one. So I'm going to give you a little special intro. I love it.
Chris Dy:That is so awful. So I was actually listening to the ortho hub podcast. I think they called see one do one now. And actually, in one of their recent episodes, I guess they got a hold on one of these little sound machine things too. So it was used excessively in that episode, and I'm sure you're going to be using it more.
Charles Goldfarb:We're done. We're done, I think unless something special happens.
Chris Dy:So today's case, actually is what actually will lead us into our topic for today. So I was treating a patient who had a couple of fractures, one of them being displaced distal radius fracture, pretty run of the mill volar plate kind of thing. But then also had a Pilon type fracture of the base of P two of the small finger. So a fracture that I groan every time I see. Absolutely, that's a tough one. So it got me thinking, obviously, we're thinking about our options. So maybe we can talk through some of those. So how what's your threshold to operate on patients with a, you know, smash, P2, fracture, and then possibly some volar or dorsal? More often dorsal subluxation of the PIJ?
Charles Goldfarb:Well, it's a really interesting question, because I think as we think about fractures, and we're really talking about fractures at the base of the middle phalanx, I think about them in really, I guess I would say, three different groups, I think we have what I would call the classic fracture dislocation, which is a volar lip fracture, of varying size. We have the Pilon fracture, or really kind of a severe fracture involving the entirety of the Joint Service. And then we have what I call the central slip fracture, which you and I discussed in within the last month or two, with a case example. So we probably don't need to rehash that one. But if we talk about the Pilon fracture, and the volar lip fracture, I think there's just so much to discuss. And so I would start by saying, and I'd be interested to hear how you think about this, my first goal is understanding if there is a concentric joint reduction. And so I don't you know, I love standard x rays, because they give us great definition. But for me, that is a C-arm, I'm lucky to have a C-arm in my office, so I can really profile the joint and really understand reduction.
Chris Dy:Yeah, I think that's that's critical, because oftentimes, your the X rays you get are suboptimal. And it's really hard to I think this is when we're truly understanding the, quote, personality of the fracture is useful. Because you understand the deforming forces, you understand your end goal in terms of what you're trying to achieve with any sort of stabilization. And then keeping in mind the fact that you're just trying to get this joint lined up and moving.
Charles Goldfarb:Now that's exactly right. And so, you know, most fractures can be thoroughly assessed with a good C-arm radiograph I'm not really one to order CT scans, or certainly not MRIs and these cases, the only other thing I would throw out is if it's a really bad fracture, and if the joint is is clearly not aligned and you know, you have to take the patient to the operating room, then a traction radiograph is gold in these patients and so but for me, that's not done in clinic because then you have to anesthetize the patient. It would I mean, you have to you know, give them an injection of lidocaine, but but in the OR a traction radiograph can be gold.
Chris Dy:So how would the traction radiograph influence your management?
Charles Goldfarb:Yeah, so I'm us and I'd be interested see philosophically how you think about this. When I go to the operating room, it is always my goal, to know exactly what I'm going to do. I don't you know, and which is interesting for someone like me To say, because one of the things that appealed to me about congenital hand surgery is some of the general hand surgery is figuring things out on the fly. And that's fine. I think in that world, I'm okay with it in the adult world, I really like to have a plan. Some of that's practical, because I run to rooms, and I really like to be on time, and I like to have the day run smoothly. But this is a case where I typically go to the operating room with a plan A, B, and C. And that and the ultimate choice is based on kind of what we see.
Chris Dy:So the traction radiograph helps you in, helps, maybe has you shift A, B, and C up and down in terms of what you know which one you're gonna try first.
Charles Goldfarb:Yeah, I'm a fan of, and I think especially keep it you know, trying to keep this minimally invasive is always the goal. And, you know, this is a forgiving joint in the sense that if you have a reduction, and the head of the proximal phalanx is generally well aligned with the base, the middle phalanx, that base of the middle phalanx can remodel, and even if the radiographs don't look good, if you restore your natural curve, then I think you can get a really good result, even if the radiographs don't look perfectly, don't look perfect, but so I go for minimally invasive, but really, I'm thinking about can I do a closed reduction alone? And the answer that is almost never. A closed reduction with pinning of some sort, an open reduction in either pinning or fixation. And then finally, a traction device, which is can be gold, you know, and Joe Slade taught us so much about the traction device and others have added to that basic knowledge of how do you create an effective traction device that's tolerated, and there's so much to it. But those are the kind of how I'm thinking about these when I go to the operating room.
Chris Dy:So let's let's for completeness sake, let's cover the whole spectrum. So you mentioned doing closed reduction, and when that would work. Now, typically, you know, you're not seeing that in the office, that's something that you know, makes its way to the ED or the urgent care, that kind of thing. And it's quote, simple, meaning there's no fracture associated with with it, or there's a very small fragment. I actually had one of these walk into the office because they came to our injury clinic. And I happen to be dictating at the time. So I saw the patient and did a closed reduction in the in the fluoro suite. And everybody was obviously happy with that. After you do a closed reduction, and it feels really good. Do you do a dorsal blocking splint? Do you just buddy tape? What do you how do you manage that?
Charles Goldfarb:For me, it's always a dorsal blocking splint. And let's say your reduction of that dislocated joint was good. But as you extended the finger, you know you started to get that V sign where the dorsal joint is not parallel, but as V, then I flex the finger down. I mean 60 degrees is fine. And then I create a dorsal blocking splint either in the office or ideally with a therapist. With the goal being extended 10 degrees every week, during the healing process. I you know that that is a really important part of my practice.
Chris Dy:That's textbook right 10 degrees every week. So I got the reduction, I put a little alumafoam splint in the fluoro and then actually took her right to the to the therapy office that was co-located an orthopedic suite, so that worked out really well in terms of getting a splint made for that patient.
Charles Goldfarb:Yeah, that's that's magic. And we are fortunate we've said this before, we'll say it again to have the, you know, close proximity as well as expertise of our therapy colleagues. And, and you know, once you have obtained the reduction, their role in this is really everything.
Chris Dy:So then let's go to the next scenario. Let's say you have a dorsal dislocation, meaning that the prox-the middle phalanx is drifting dorsally. And so you've got a volar lip fragment, say it looks to be about 20% of the joint.
Charles Goldfarb:Yeah, I don't focus so much anymore on the percent involvement of the joint I would do with you know, I would try to close production in the clinic, hopefully, depending, you know, on the situation, or else I would proceed to the operate, if it's a week out or whatever, I would proceed to the operating room, assess it with traction, assess whether a closed reduction in flexion will reduce the joint. And again, this is when you have to be very critical of yourself and your x rays. And if you're not convinced that you really have that anatomical alignment, and that parallel alignment with the head and the base of P two, then I think you have to, you know, move on to the next stage. And depending on that volar fragment and in some ways for me a large volar fragment and we can quibble on what large means is fantastic because you go on you fix it, and I think those patients can do really well and they get moving really quickly.
Chris Dy:So is it is large enough meaning large enough for you put a screw in.
Charles Goldfarb:That is exactly right of screw or two and I can't think of too many more satisfying cases and I think they're uncommon that you have that one non comminuted volar fragment, that clearly that buttress is required to restore stability. And flexions not enough. So you go in, you get the reduction, you put two screws in that in that fragment. And again, to me, that is such a satisfying case.
Chris Dy:So walk me through some of the technical details. So what size screws you're using? How do you approach it? And then do you do anything to keep the joint blocked after that?
Charles Goldfarb:Yeah, so happy to and certainly what your opinion on some of these things. So for me, it would be I when I approached the volar PIP joint more commonly for a joint release than for this fracture pattern. Specifically, I create a V incision. So oblique incision across the skin volarly over the proximal phalanx, and then oblique incision over the middle phalanx elevator, full thickness flap, protect the neurovascular bundles, and expose the sheath. And then I simply work between a two and a four. I retract the tendons, and you know, you're working more distally. You know, obviously, I stated that often you're doing this to expose and treat a volar plate contracture. So in those patients, I'm working proximally at the checkering ligaments, etc. In these cases, you're working distally. And so you have to really assess, you know, where the insertion of the FDS is more distal than we think. And so it's more broad than we think. And so dealing with the FDS are working through FDS, using a dental pick, hopefully to obtain the reduction using temporary k wires to maintain a reduction while you check C-arm. And then I would say typically, it's a 1.5 millimeter screws, so 1.1 drill bit, 1.5 millimeter screws and two of them, do you think about it differently? Or does that resonate?
Chris Dy:No, I, I've done it a handful of times. And I think about it the same way this this just honestly doesn't come up as much as as much maybe as it comes up for you. Maybe it's some of its patient population, that kind of thing. But you know, you and and Lindley Wall actually does a fair bit of fixing these, at least from what she said. And you know, at it, it looks like a great, very satisfying procedure.
Charles Goldfarb:Oh, it is. And I think that led to an evolution. So what really makes me happy is when you watch really smart people process, how can we do something differently? And how can we advance our field. And so we've talked about that with other episodes, and we've had guests that have done just that. But Hill Hastings, who was at the Indiana Hand Center, did that for these fractures. And so I'm sure all the hand surgeons out there, and many of the residents know the Hemi hamate arthroplasty. And it is a really smart way to deal with chronic vo-you know, volar lip fractures are ones that are not re constructible. And man, it is really a smart procedure.
Chris Dy:Now, how many of those Do you think you do a year?
Charles Goldfarb:Not many, I would say to a year would be a good guess. Obviously everything comes in waves but to a year do you do or have you? Is that a part of your arsenal? Or is that one you might send on?
Chris Dy:It's a part of the arsenal The last time I did it was actually on somebody who had not succeeded with other attempts at pinning and everything else. And honestly, that's what did the trick and it was wonderful. It was very, very, very satisfying. Maybe think I should do this more. And maybe the patient has other patients with this issue. have seen me more. But I haven't pulled the trigger on it.
Charles Goldfarb:Yeah. Is this an example? And I think you're what you just said is exactly right. You it can be such a home run, that you look to broaden your indications. And I have to say it's not always a home run. And you know, our partner Marty Boyer has, as he would say, can't can't regularly make it work. And so you have to be careful about the indications. And really you have to be careful about the carpentry. And that's what's fun about this case, but that's also what's challenging about this case.
Chris Dy:Yes, definitely high risk, high reward. I remember the first one of these that I booked out of training, I had one of our partners scrub with me on it. And I felt much better because that partner said, You know what, let's just do the volar plate arthroplasty he couldn't make it work. So it made me feel a little better to know that somebody who I consider a very good technical surgeon was also quite humbled by this.
Charles Goldfarb:Yes. And that can absolutely happen. The volar plate arthroplasty is interesting. And I would say largely that's one for the history books and I'm guessing that most of the younger folks out there haven't done that procedure is not part of residency training for most of us or fellowship training in That's another procedure. It's just so interesting. When procedures aren't done regularly, you don't learn the nuances. And so it becomes harder to use it as a bailout down the road. And so, you know, I haven't done that many of that procedure, and it's really not in my arsenal.
Chris Dy:Well, it's a procedure you don't do until you have to do it. Like you're saying it's a bailout. And, you know, it's certainly, like you I call I go into the OR with, you know, Plan A through F for some of these cases, and it's certainly not the one at the top, but sometimes it gets pulled out.
Charles Goldfarb:But if you were considering it, would you be more likely to consider traction device as opposed to a volar plate arthroplasty?
Chris Dy:I think so. But I, you know, I, so a traction devices. Another thing that I think we as surgeons find is very cool. But I'm not convinced that patients love it as much as we think they do.
Charles Goldfarb:I think that's an understatement. I think you've got to be held to wear that thing for six weeks. But it is cool.
Chris Dy:I mean, it's it's a technical triumph. And it's incredible that the whole thing costs like 30 cents. And it works. If you purely Think of it as stabilizing the joint maintaining some element of motion, I guess you could argue as to how much people actually move with that thing on. I think this comes down to patient selection. It's fracture selection, but then also the the has to be the right patient.
Charles Goldfarb:Totally agree. That's Well said. And that's really important. That has to be a patient who understands what they're signing up for. understands that, hey, this is probably not our first choice. But we're picking this because we we need to do something unusual to stabilize this fracture is definitely never my first choice.
Chris Dy:Yeah, it's kind of a weird thing to try to explain to somebody during the preoperative discussion. I always make the joke that they're going to have great TV reception. But I think that's getting lost on my generation and younger.
Charles Goldfarb:Oh, it's so funny, because I did that. I don't think I told you the story. So I'm sitting at Children's Hospital and I'm talking to a six year old patient and I go, yeah, we're gonna get the fracture reduced and put a couple pins in, it'll look like you have an antenna. And I go, Oh, my God, you don't know what an antenna is. And he goes, of course, I know what an antenna is. I'm like, how do you know what an antenna is? He's like, yeah, it's on a little bug. It's the little things coming out of his head. I'm like, Yes, it is. Of course it is.
Chris Dy:Wow, wow. Wow. That's pretty awesome. Yeah, I've noticed that the references I'm making are getting lost upon the the medical students already so you can't you can't make Seinfeld references anyways, nobody gets those. It's got to be Friends. Friends and newer.
Charles Goldfarb:And that's a loss. The other one I use, and I always kind of, kind of, you know, tilt my head to see if they get it is the give me a give me a hit. You know, show me what you do when you hitchhike, you know, like, give me a thumbs up like you're hitchhiking. And sometimes I get a what?
Chris Dy:Yeah, why would you hitchhike when there's Uber and Lyft and every other ridesharing platform.
Charles Goldfarb:Yeah that went away when the serial killer movies came out.
Chris Dy:Exactly. So dynamic ex fix. You know I found these to be a little challenging every time that I plan on doing it, I want to bring the paper myself put it up in the OR I make the resident be ready to put it up in the OR draw it out, have all the wires ready and know exactly how to do it. Because this can be relatively straightforward, or can be very frustrating for like, God, I got to put the band here and put this little s band and that's not that's not exactly fun.
Charles Goldfarb:I think it is personality driven. Some people enjoy the fiddle factor. That's not really my strong suit. I not a big Fiddler. Again, it can be a really satisfying procedure if you're able to reduce the joint apply the traction, and you know, allow even motion. But I have to say it's not one of my top 10 favorite procedures.
Chris Dy:How much do people how much do people move when they actually and this will not be good for one of our therapy colleagues to let us know? Do they actually move?
Charles Goldfarb:I think this is a great guest episode or maybe guest and they're about both a surgeon and a therapist who loved this procedure to really talk through the nuances of applying that fixator correctly. I think they moved some but I think you're looking at a limited arc of 45 degrees or something. I don't think they're getting much more than that. But hey, it's a Head Start.
Chris Dy:So do you think that they move more than if you do just a dorsal blocking pin to kind of stabilize things and they just move within that arc that the dorsal blocking pin allows?
Charles Goldfarb:So we haven't mentioned the dorsal block pin. I'm glad you brought that up. I mean, most people think of that dorsal blocking pin into the head of the proximal phalanx to really create almost a dorsal block splint but a little more rigid. Most people think about that for a mallet fracture, but it can have a role here. And I do think it can be appropriate I think, you know, given the severity of the fracture sure that we would consider the dynamic ex fix for, I think they move pretty well, I'm not sure which ones more. But I think given again, the severity, I think they can they can move reasonably well in the traction. And then once you get the fixer off, I think we can, it can really be a nice Head Start.
Chris Dy:So to bring things to a close, how do you manage the Pilon fracture differently than you would say, the volar lip fracture with the associated dislocation?
Charles Goldfarb:Well, I certainly Pilons come in all varieties, but I think it's becomes more difficult to think about fixation of the fragments. So you know, if there's a dorsal fragment and a volar, fracture fragment, and then you have that kind of intact central area, traction makes a lot of sense. And so sometimes you can get away with a percutaneous fixation. But I think the real Pilon is the one for me, at least, that makes the most sense for dynamic traction.
Chris Dy:So when we talk about Pilon fractures, you know, just for those, you know, that may not be as familiar, we're talking about a fracture, that's essentially an impaction fracture to the cartilage surface of the base of the middle phalanx splitting that middle phalanx space into two or more pieces. So like Chuck said, a large kind of dorsal piece, and then a large kind of volar piece, and maybe some combination in between.
Charles Goldfarb:Yeah, and I think it's really important to emphasize as much as we try to treat these closed, because you know, with, with multiple fragments, you can get yourself in a world of hurt very quickly, if you try to go in and piece everything back together. Now, there's a role for piecing everything back together. But often, what we do, whether you're treating this with an traction or a couple of pins, is you can elevate the fracture fragment to try to create a concentric join again, and then support the you know, the fracture, however you do it again, with K wires or with a traction setup.
Chris Dy:Like you said that the base of that middle phalanx is somewhat forgiving in terms of the remodeling. So that is helpful. You don't have to have it absolutely perfect. You just need something that you can flex around, obviously, I'd asked you one question to close. When you're deciding closed versus open, obviously, the downside potentially of opening this finger is that you're going to compound the swelling from the trauma, the upside, obviously, you can get more stable fixation. So how do you navigate that balance as you're thinking about the patient and the fracture? And that kind of thing? Because do you look at how swollen the finger is to start that kind of thing?
Charles Goldfarb:Well, I think timing is important for this fracture, you know, you don't want to leave a joint dislocated for too long. But you're right, I don't think this is the fracture that I want to go there are a day for when they're maximally swollen, or when you know, whenever they're massively swollen. So if I don't get this acutely, it may be one that I wait until day seven and have the patient home and elevating. So that if I do need to go in that I'm not overly worried about compounding the swelling, you know, for me, this gets back to the basic principle of the first thing we have to do as surgeons is get the bone and get the joint right, we can deal with stiffness, no doubt about it, we can deal with the stiff tip joint, as long as we restore the bony anatomy. If we get that bone healed, and the PIP joint contracts, I'm not overly worried about that, because I can make that better. What you can't make better. Well, it's more difficult to make it better if you have a big step off and the joint or a joint that subluxated. And so I think the decision making really has to be about restoring that alignment, even if it's not perfect, but really the basic alignment of the base of P2.
Chris Dy:The fractures that I dislike the most probably the PIP fracture dislocation. So thanks for thanks for talking me through some of it.
Charles Goldfarb:No, I loved it. I think you bring good insights. And I hope that some of our listeners will, will raise some questions and hopefully we you know, I can give you another drumroll though, to take us home if you want.
Chris Dy:Please don't. But if there's any if there are any therapists or surgeons that are dynamic ex fix aficionados, either for surgery or therapy, let us know we'd love to have you on.
Charles Goldfarb:Absolutely. And I'm going to throw a teaser out there to all of you guys. So Chris is going on a special adventure with his family and I if he survives it, then we're going to hear about it on our next episode. Fair enough.
Chris Dy:Yeah, the first-the first time we're going camping, so Filipino American guy from Florida. This is not a common thing. So let's see how it goes.
Charles Goldfarb:Good luck. Alright, take care.
Chris Dy:Alright.
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 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