Episode 26, Season 2. Chuck and Chris discuss the stiff finger and the basic concepts required in assessment of these fingers. We discuss the full range of issues from bone status to soft tissues, tendon mobility to joint contractures. This will be part 1 with a more therapy focused colleague joining for part 2.
We referenced an AAOS ICL published here: Post Traumatic Reconstruction of the Hand. JBJS 89A: 428- 435, 2007
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 26, Season 2. Chuck and Chris discuss the stiff finger and the basic concepts required in assessment of these fingers. We discuss the full range of issues from bone status to soft tissues, tendon mobility to joint contractures. This will be part 1 with a more therapy focused colleague joining for part 2.
We referenced an AAOS ICL published here: Post Traumatic Reconstruction of the Hand. JBJS 89A: 428- 435, 2007
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 really well. What about you?
Chris Dy:I'm doing pretty well. It sounds like you've got a pretty exciting trip coming up. Is that right?
Charles Goldfarb:Well, you know, it's sort of weird because I'm a little nervous. I haven't been on an airplane or traveled. I've traveled with the family by car. But I haven't been on an airplane and I want to say like 18 months or I don't know. So yes, I'm going for a fellowship reunion. I did my fellowship in a bygone era in Cincinnati, and Dr. Stern is having one of his fellowship reunions in Jackson Hole, Wyoming. And this might be the last one. So I thought it was important to attend that I'm taking my eldest son who's pre med and so we're looking forward to it.
Chris Dy:That sounds pretty exciting. Hopefully, a relaxing schedule is nothing too crazy, I'm sure.
Charles Goldfarb:Yeah, morning. conference, you know, with presentations, and it's really nice, because there is some good science. And there's also some people with a really good sense of humor. So it, I really do enjoy it and then the afternoons we'll hang out, we'll hike. You know, it'll be great.
Chris Dy:There's something about a meeting like that, where you actually get what people really think as opposed to what they feel like they should say.
Charles Goldfarb:There is no doubt there's no formality. There's no expectations. One of the stories that I'll never forget is you know, Peter Stern is known for the proximal row carpectomy, the PRC and I fellow showed a case where, sorry, where, where he had done what he called the DRC. And he had removed the trapezium in the trapezoid for severe arthritis. And that was the first time I've seen a distal row carpectomy.
Chris Dy:There you go. You never know what's going to come out of Cincinnati.
Charles Goldfarb:Exactly. Exactly. So what about you any any good cases?
Chris Dy:You know I had a really interesting case. I had one where a patient came in with just incredibly bad superficial radial nerve distribution, nerve related pain neuritis. And it was odd because 15 years prior, she had had a first compartment released through a dorsal or excuse me through a transverse incision. So I was like, Oh, for sure that's the answer. Somebody buggered her nerve, but what was weird is that it was 15 years right? So, you know, I kind of you know, tried to slow roll it and go conservative route and you know, finally, you know, we put her through a diagnostic injection for her SRN provided wonderful relief, she felt good, I felt good. I said, Alright, let's explore the nerve and I signed her up for my normal kind of might have to graft it might have to bury it might have to do both, you know, that kind of thing. And so we get to the or we do our exploration and while her her SRN branches look a little, you know, odd and a little thickened, she had this really firm, bulbous mass coming from a radiocarpal joint, and it was a cyst. So it's kind of a variant of a radiocarpal ganglion cyst more radial than dorsal and certainly not a volar cyst. So I just thought was interesting. It was clearly what could drive her symptoms, so we excise the cyst. I also released the SRN approximately at the brachioradialis exit, but I found it to be very interesting. I don't know if you've encountered that before.
Charles Goldfarb:I haven't it's sort of makes me think of the proximal cap-radiocapitellar joint and assist there which may affect the post interosseous nerve now that's super interesting. And just for the audience, and I guess my own personal sake, explain what you mean by you release the superficial branch, the radial nerve proximally what exactly do you do to the nerve or I should say to the surrounding tendons to give the nerve more room?
Chris Dy:Yeah, we've talked about this a little bit, I think on a prior episode, but you know, that nerve is going to go from deep relatively deep to superficial at the level where it goes from underneath the brachioradialis which tends to be about eight to 10 centimeters proximal to the radial styloid. So what what you can do there is perform essentially its anatomy of the brachioradialis I tend to do this, you know, under direct result visualization just distal to the musculotendinous Junction. And before releasing it, making sure that nothing on the wrist moves, nothing on the thumb moves, because clearly he don't want any additional problems. And you know, they obviously have to respect the nearby structures including the radial artery. It's an automize that ensure that the muscle retracts appropriately That the nerve is happy.
Charles Goldfarb:Perfect. Love it. Love it. Thanks for clarifying. Yeah, it sounds like an interesting case. I enjoy that. I would like to jump in if you're ready for our topic of the day actually, maybe part one of a two part topic.
Chris Dy:I think that this topic definitely deserves a guest from one of our, a guest appearance from a hand therapy expert such as Macy Stoner. So I believe for those of you that tune in for Macy, and I believe there are more than a few of you based on the reviews that have been left. Macy's coming back for the next episode on this. So stay tuned. But we'll try to set the set the stage for her.
Charles Goldfarb:Yeah, I have to say Chris and I are a little sensitive. It seems like the crowd may prefer Macy to both of us. But you know, we'll give the crowd what they want.
Chris Dy:Well, you know, we're gonna try to be better about some structure to our schedule. So don't worry, Macy won't be disappearing too much. You'll you'll get your taste every now and then.
Charles Goldfarb:Absolutely. So the topic Chris and I had decided would be interesting is the stiff finger. And it actually lends itself perfectly to a podcast format, because there's really not a lot visual required. And it's principle based. And so what I'd like to start with maybe is, you know, when I think about this, I think about two fundamental issues before I even think about why the finger might be stiff. And I'd love your thoughts. The two fundamental fundamental issues for me are one, has there been an appropriate bony reconstruction prior to the finger getting stiff? And to what is the soft tissue or envelope like? So maybe we can talk through those? But I don't know if you'd add anything to that list? Or how do you think about it?
Chris Dy:No, I think those are the prerequisites. And for those of you that are listening, and if you're a trainee, or you just want to read something really good. You know, our partner, Marty Boyer, gives us lecture every year in the fellowship. And he always points to the article that you Dr. Goldfarb wrote along with Marty and Jesse Jupiter, and it was published as an ICL in JBJS in 2007, we'll include that in the show notes. It's a great article, it outlines a very elegant way of thinking about this, you know, and those are the prerequisites, right, you want to know that the skeleton has been appropriately established and is stable, so as to allow whatever intervention you are going to perform to succeed. And soft tissue coverage being absolutely necessary as well. So having a supple soft tissue envelope, though, yeah, to start with, that, if you don't have that you've got work to do before you can start thinking about releasing contractures and, you know, freeing up tendons.
Charles Goldfarb:I love that. Two comments. One is, I think you told me you read that when it was released, but did you were in high school at the time of 2007 release, but you were ahead of the game, I think ahead of the curve.
Chris Dy:You know, this is one of they still, you know, published journals, and the only way you can get them was to go to the library, open up the leather bound mahogany, you know, library books, and perfectly get your nose in there. I actually don't even know if this exists in PDF format, I'm gonna have to scan it just for the purposes of providing it to the to the listeners.
Charles Goldfarb:Oh, it's a classic, it's got to be there. So in all seriousness, you know, I think this principle of bony reconstruct, or bony appropriate initial fixation, and gaining the proper anatomy, together with creating a soft tissue envelope that will allow for future improvement of the finger or T. And what I mean by that is, you know, the hand surgeon is always thinking about therapy, it's gonna be why it's so nice to have Macy. But when anytime I do a case, not only when I think about how am I going to take care of the fracture, or the injury, I'm already thinking about what will therapy look like. But sometimes we we get ahead of ourselves, because it is really important in these cases, emphasize that, if you don't get the bony fixation or the soft tissue fixation right the first time, then you have to go do that before you can even think about the stiff finger. So it really is an interesting, you know, it stresses the importance of thinking, always thinking ahead, but never losing sight of the critical components.
Chris Dy:Well, I mean, the, the, all the structures in the finger are so jam packed, as opposed to the forearm, or even, you know, the brachium or the thigh I mean, got a lot of leeway in the other areas, but everything is so jam packed in the finger that if you don't have, you know, if you don't have the bone appropriately stable and fixed in reasonable alignment, you just can't ask the tendons to work around that. And I think you guys give a good example in that article talking about if you have like a small like sub condylar fragment that's getting causing impingement even you know, that'll stop the joint from moving properly and it can also impinge on the tendons. So it's those small things and I agree with your point about, you know, always thinking about the therapy And that, honestly, is why we choose some of the fixation strategies that we choose is to enable, you know, therapy. And I honestly, there are days where I, I wish I had been able to provide more stable fixation, but sometimes the fracture doesn't give you that. And you really have to slow down your therapy and taper your expectations from the very beginning.
Charles Goldfarb:Right, and start talking to the family or the patient at that time. So for example, had a really interesting case today of a younger patient who essentially sheared off about 40% of the base of the middle phalanx sort of a collateral ligament injury, but it really affected the articular surface. And it was such a thin fragment, it was really tough to deal with. And in the end, I accepted that I had to pin the joint. And that's okay, for this exact reason I can deal with finger stiffness, if I can get the alignment and the bony healing the way it needs to be in. So it was a little disappointing that I couldn't accomplish all my goals, but I walked away from they are very happy with what we accomplished.
Chris Dy:So you say that we can handle stiff fingers. So say you have stable bony fixation and reasonable alignment. And you've got a supple soft tissue envelope either through, you know, local coverage, rotational coverage, whatever it is, how do you start to diagnose what the issue is.
Charles Goldfarb:So the first thing is you do want to be aware of, you know, as you think about the stiff finger and think about the role of therapy and think about the role of surgery, the first thing is, is the finger through the phase of healing, such that it's not swollen, it's not sore. Once you kind of check those boxes and say the fingers just stiff, then I think in your mind to the best of your ability, you were trying to figure out why it's stiff. And for me, I think about this is really simplistic. And this is not about imaging. It's not about ultrasound, you know, there's no MRI, this is purely a clinical examination, I think about the extensor tendons, and the dorsal capsule and ligaments, I think about flexor tendons, and the flexor sheath, and potentially the volar plate. And that's how I initially categorize things. Is that where you start?
Chris Dy:Yeah. Similarly, I mean, I think that one of the principles that you and Marty have really drilled into us as your trainees was, you don't have good passive motion, who cares about active motion, you can't even really assess it. So you clearly you know, at the end of the day, what you worry about and what you want to get as good active motion, but you can't get that unless you've got good, passive motion.
Charles Goldfarb:Exactly. And so if you have a finger that neither flexes, nor extends, it's just stuck, then really, you don't know anything about the flexor, or necessarily the extensor tendon, you just have the finger doesn't move. And so in those kind of patients, the first thing I would say is, and I'm interested to know, if you agree, I think you do agree, I have stopped trying to treat dorsal and volar pathology at the same time, instead of the words, I almost always start dorsally. If there's evidence of an extensor, tendon adhesion, and or a joint contracture, I am happy with dealing with those all at the same time, I don't honestly think it's that big a deal. And I do not then go volarly. Because what I have found, and what Marty has found, is that it can be too much for the patient, and then the patient swells. And then we know that the edema can lead to adhesions, and so becomes this vicious cycle. And so keeping it simple, minimizing swelling, addressing one side of the finger only, and for me, it always starts dorsal.
Chris Dy:So the principle here is that if you have if you're trying to assess to gain flexion, right, which usually is what we're trying to prioritize, you don't know whether that's a flexor tendon adhesion, or it's a dorsal capsular, you know, dorsal capsular contracture or unless you've addressed that dorsal issue. Now, once you free things up on the dorsal side through your capsular, release, extensor tenolysis, then you can say, Alright, well now is Arma flexor tendon stuck. But why do you start dorsally? Why dorsal as opposed to starting volarly?
Charles Goldfarb:Maybe simplicity, I think that the expectations for rehabilitation, the simplicity of the surgery, the confidence that I can accomplish my goal with limited risk. I think all of those things are true about the dorsal finger. And so let me let me link this to a topic that you and I have talked about more and more. And that's local only surgery because traditionally, when I thought about doing a dorsal release, maybe it's a Bier block, maybe it's local plus MAC, but really, it's just whatever it takes, and then I create a dorsal incision. And usually what you find in these really traumatized fingers is you inside the skin and you encounter scar tissue. So then you're creating full thickness flaps off the extensor mechanism. Maybe that's proximal phalanx that maybe that's middle phalanx as well. But you're creating full thickness flats off of the tendon. And then you're separating the tendon from the bone. And then you are releasing the dorsal capsule, and Mesa, maybe the dorsal aspect of the ligaments until you can passively flex the finger. And typically, that would be it, you wash it out, you close it up, you start therapy, and then you figure out whether the patient can demonstrate pull through and active motion. Whereas I know you've done this, when you think about a local only procedure, I would assume that you would then ask the patient to flex and see if they can demonstrate active motion.
Chris Dy:Yeah, no, I mean, I think that these are some of the more challenging ones, for obvious reasons, but they're also some of the more gratifying ones. You know, I wanted to talk to you about the use of local only and how that may change your thought process. But before we do that, I actually wanted to know whether you think it's usually the dorsal capsule, whether you think it's tightness or adhesions around the extensor mechanism, and which one you go after first? And how extensive can your tenolysis be before you start creating more of an issue?
Charles Goldfarb:Yeah, again, let's let's pretend we're focused on the proximal phalanx and may have been a bit proximal phalanx, maybe the PIP joint. First of all, I'd be curious. I make straight dorsal incisions, you know, people, some people do weird things around the dorsal joint and this is the dorsal finger is different for me than the volar finger. So I make a straight incision. And I will say that in most cases, it is extensor tendon adhesions, which are the primary issue, but releasing the PIP or even the DIP joint capsule is such a simplistic thing to do that unless it's just supple as heck, I go ahead and do it, unless I do a tenolysis and there's full passive motion.
Chris Dy:So you would start we would start with the tenolysis. And then check your passive motion if they're not awake, and then release the capsule, if they're still, if they're still not able to passively flex.
Charles Goldfarb:Yeah, so check passive motion, whether they're awake or asleep. And then you have released the capsule, if necessary, and release the dorsal aspect of collateral ligaments or even the entire collateral ligaments, if necessary to achieve easy passive motion.
Chris Dy:And you think that's that you can do that because you know, this is a stiff finger. It's not one you're worried about collateral ligament instability, that kind of thing.
Charles Goldfarb:Absolutely. No worries about collateral ligament instability whatsoever.
Chris Dy:Now I've heard you, I think it was you maybe it wasn't you, but I've heard others say that from that dorsal approach, you can then kind of sneak a freer in there and get to the release the volar, check rein ligaments, what do you think about that?
Charles Goldfarb:Yeah, to me, it's kind of a you can do that. And again, to me, it's better to try that than to make a separate volar incision, and really try to do an extensive volar release. Sure, you can put a freer in the joint and try to release the volar plate, if that seems to potentially be a problem. But in reality, you're trying to take a shortcut which you might get away with, but the primary principle for me is don't operate on both sides of the finger. And really, if you achieve your goal dorsally and get the patient to therapy, then you you're off to a great start.
Chris Dy:So does the flexor check. So to say where you essentially performing a trigger finger release in the palm, so not in the finger in the palm on the volar side, the flexor side, and do a tenolysis, a traction type of tenolysis along the FDP, does that count a surgery on both sides of the finger?
Charles Goldfarb:Excellent question. And I guess it only applies if we're not using local only, right because essentially you're trying to replicate finger flexion or maybe do attraction to license I think there is a role for attracting tenolysis. But I do think that's okay to do a traction tenolysis proximal in the palm, ideally just proximal to the one pulley and see if that demonstrates finger flexion or if there are limited adhesion as it may help break them up.
Chris Dy:It looks like it hurts. A traction tenolysis.
Charles Goldfarb:Well, we know it hurts. Here's why we know it hurts. If I do a little bit of a traction tenolysis with the trigger finger release, and I've had I had a patient come back couple weeks ago to say, you know, that was really easy, except there was this pulling sensation in my forearm
Chris Dy:Were they were they awake, or were they?
Charles Goldfarb:Oh, yeah, local only, wide awake.
Chris Dy:But why would you. Whoa, timeout. I was about to say that. I feel like a traction tenolysis has been obviated and is now antiquated in the setting of local only surgery.
Charles Goldfarb:Oh, no, it's fine. That's the first one who's complained about it.
Chris Dy:Oh, you're so mean pulling on their FDP like that. I will say I remember being your fellow and knowing that I had paid sufficient attention when I was able to twirl the small side of the ragnell retractor around the FDP tendon like a baton, to do the traction tenolysis in the way that you do it. Because it's like watching a marching band. Somebody in a marching band roll their baton to do that.
Charles Goldfarb:Yeah, well, you got to have skills it's the hand surgeon skill set, you got to be able to get your ragnell retractor around the FDS, pull on the FDP and do your traction tenolysis? Of course you do.
Chris Dy:Until you don't need to anymore because you know, tenolysis in 2021.
Charles Goldfarb:Fair enough, Dr. Dy. Fair enough. So what is your time interval? Let's say you do your dorsal tenolysis and maybe a capsular release, you're really happy with the surgery, the patient happened to be wide awake, and they could not demonstrate active motion. So for me, that means we still don't know if it's a flexor problem, or if it's a PIP, joint contracture problem, or both. But I guess my first question is, how long do you send them to therapy? Is there a time average time? Or what do you look for?
Chris Dy:I probably would do at least a month. And I think it kind of depends on you need to give them enough time to recover from the surgery to truly engage with a therapist for the therapist to try to understand kind of the personality of the finger, so to say, as well as the personality of the patient. And you know, really mean honestly, they usually have been treating the patient for a while before surgery to be honest with you. So they have a sense of what's going on. So I'd say at least a month. I guess I knew we could rely, you know, fall back on the orthopedic unit of six weeks. But.
Charles Goldfarb:Yeah, I think that's good advice. And you know what this is where the therapist is key. This is one one example of the many times the therapist is key, I think four weeks, six weeks, sometimes it's three months. But for me, it's not only the time, it's just making sure the finger looks good, the wound is healed, there's no edema, there's no obvious pain, and they've been able to maintain that passive flexion and then we turn our attention volarly.
Chris Dy:So then what do you think the steps are volarly? What are you concerned about in terms of the pathology that is stopping the finger from flexing?
Charles Goldfarb:I guess the first question is do your radiographs give you any tip off so in other words, if this was a proximal phalanx fracture, and when you went dorsally, you had a lot of adhesion, in scar tissue, dorsal to the proximal phalanx, then what I would be hoping for is a almost a spot weld situation. Volarly where the flexor tendons were adhered to the volar proximal phalanx those kind of situations are what really makes you happy, and makes you feel like this can be a home run. But the reality is, you go where you think the action is. And you do a release, you know, you do a flexor tenolysis. And we can talk about details a bit, plus minus a joint release. And you know, if your finger extends fully, which it may or may not, then you may not be worried about the PIP joint. But if you have a finger in mid flexion, and it can't extend fully and can't actively flex, then you really don't know whether this is a flexor tendon issue, or a PIP joint contracture.
Chris Dy:So how do you know where the action is? Aside from kind of your if you're in a setting where you know, fracture wise, maybe that's where it was, I mean, I've had a couple of cases where an ultrasound has been very useful showing me where the spot weld was. But that's also something that is inconsistent in terms of the person doing the ultrasound, whether they can deliver that level of detail.
Charles Goldfarb:Yeah, I would say with great comfort that I've never used MRI for this, I don't think MRI has a role. I do think it depends on your comfort with your ultrasonographer. It's not been a regular practice of mine to use ultrasonography. But I have no problem with it being done. So you look for secondary signs, you look for scarring that may affect the skin, you look for X ray signs of healing or know where your fracture or crush injury may have been. And then honestly, you go where you think the action is, and open things up and get to work.
Chris Dy:So is this a local only case for you in 2021?
Charles Goldfarb:I haven't had this situation but I think the answer is yes. With the right patient. I think it is a local only procedure for you?
Chris Dy:Yeah, I mean, I and I've had maybe less than a handful I think of flexor tenolyses that I performed for various reasons under a local only. And you This is not like local only carpal tunnel like you got to prepare the patient like this is going to be thank you for doing this because it helps me do my job. This is not going to be a short thing. We will make you as comfortable as we can. But I'll be honest with you, you know, whenever you're manipulating tendons and pulling on muscle bellies that's uncomfortable for people in ways that you can't block.
Charles Goldfarb:Yeah, so this is an interesting one for me because one of the most technical procedures that you are I will do it Maybe even more technical than nerve surgery is a flexor tenolysis. And, you know, things can really go wrong, we're trying to protect the pulley system, we're trying to either maintain or recreate a gliding surface between the two tendons, and free the tendons from bony scarring. And it can be really difficult. And honestly, that's why there are specialized tools available. You know, tenolysis knives are a thing. Now, I don't have them, I don't really use them. And I typically am a surgeon that will try to make do with whatever is there. But this is one case where you sometimes need specialized tools like a beaver blade, or like the tenolysis knives. So I think this is one where it does pay to be prepared, because it can really make a difference.
Chris Dy:Yeah, I agree. beaver blade, 11 blade sometimes for me, I don't have the tenolysis knives. It just doesn't come up that often to be honest with you where I've thought like, Oh, I really need to learn how to use a new instrument. But yeah, and I think the stakes are high. It's a hard surgery already. Having people awake makes it even more challenging to be honest with you, it adds another layer of complexity to the whole situation. So I can see why some would prefer to have patients asleep. But it I think it does help you know, diagnostically and honestly, we talked about this before about local surgery, patients see how hard you're working. And with them being engaged in the process, they're a little more invested too, because, you know, they're telling the therapist, like all we're doing all this, and you know, they're trying to try this, that and the other and I was there the whole time. And you know, it adds something, I think it's hard to quantify. And it's a little squishy, but it adds something.
Charles Goldfarb:Oh, for sure it does. But you're right, it can become awkward if you're really working hard and not seeing the success that you open expect to see. And so let's say you tackle a what you think is a spot weld over the proximal phalanx and you free the tendons and prior to doing that release, you couldn't extend the finger fully, all the sudden, you can now extend the finger fully. But you might perform a traction tenolysis or if the patient's awake, you ask them to flex. And you don't know, at this point, whether you've achieved a full release of all the adhesions. As a you don't know, if there's more work to be done, you're encouraged that you've gained passive extension by releasing whatever is tight volarly. But until you see their active flexion or pulling on the flexor tendons proximately, the palm to demonstrate flexion you don't know that you've been successful. So that's another reason why despite the challenges of local only, it really is nice to have the patient awake.
Chris Dy:Yeah, absolutely. You know, and then so then at that point, you know, what, if you are sure that the tendons are freed up is that when you're going to, you know, do your PIP contracture release to get a little bit more and how do you approach that technically.
Charles Goldfarb:So if you have a patient who cannot passively extend, but you've done a flexor, tenolysis, and the patient can demonstrate active flexion then the next step absolutely is a PIP joint release. And so this is where we, you know, hear the terminology that check rein ligament, or, you know, non pathological state is the check ligament. That's Kirk Watson's terminology. And so basically, you know, you have the volar plate, which will be very thickened, I tend to approach it proximally, I try to maintain the transverse vasculature and release the volar plate proximally, some people will do a distally I prefer doing it proximally and initially is just a transverse division of the volar plate on the neck of the proximal phalanx as the first step. And that allows you to mate to obtain full passive extension, you're done. The next step would be to release the insertion of the accessory collateral ligaments into the volar plate on each side. So you're working back and forth with your tendons to get the exposure that you need while obviously protecting your neurovascular bundles.
Chris Dy:So how do you how do you handle the tendons? Do you, you know, in terms of manipulating them to get where you need to go on the finger.
Charles Goldfarb:Yeah, I think this goes back to when we've talked about flexor tendon repair, you know, typically, or historically, I might just open the flexor sheath between a two and a four. And that's a great way to expose the flexor tendons and to allow them sufficient mobility to get out of the way for exposure of the volar plate. But if you've done a tenolysis and you know your sheath may not be what you want it to be, you have to be careful not to over release the pulley system. But let's say that's what you've done. So you have exposure between A two and A four. So if you really C one, A three and C two, you're looking at tendons, they're gliding nicely, and it's for that it's I feel like it's pretty straightforward. You retract the tendons with a ragnell retractor radially or ulnarly, and you expose your volar plate and expose either side of the Secondary collateral insertion into the volar plate.
Chris Dy:So I want to we'll get into some details with Macy on the therapy aspects. But how do you counsel people about what they're going to get at the end of this? I remember, you know, some of our partners when I was training with them kind of telling people, look, we can do all this work. It look great, probably right. After when you leave the OR, but you're not going to keep all of it. How do you navigate that discussion?
Charles Goldfarb:Yeah, you know, one of one of my lines in clinic meal, we all have our lines. One of my lines is we as surgeons cannot control the production of scar tissue, eventually, we'll be able to, I say, but we can't today. And so our only control is doing a good job in the OR in starting therapy as soon as possible. And so you're right, I don't promise a finger that straightens fully in a DPC or district Palmer crease measurement of zero. But that's what I hope for. So I tell them that I hope to not leave the OR without having full motion. But if you keep most of it, and I'm usually pretty vague, it's certainly more than 50%, I would be disappointed if I only keep 50% of the improvement. But I hope for at least 75% improvement to be maintained. And sometimes it's more, it really depends on the nature of the problem. If it truly is a spot weld, this is straightforward released. And I hope they keep it all. And I expect them to keep it all. But often, if it's more complicated, it's not going to be as good.
Chris Dy:So what's your dressing like any or after you've done the procedure you describe?
Charles Goldfarb:Yeah, it depends a little bit on how hard I work. If I work hard, I typically operate on Wednesdays for cases like this. If I work hard, I'll put them in a resting splint. And let them sit till Friday, maybe Monday. If I don't work hard, it's just a soft dressing and start therapy the next day. And the idea being let things calm down a little bit. Before we get them back into therapy. How do you how do you approach that?
Chris Dy:Yeah, I tend to go off of the all the flexor tendon kind of edema work, and I will typically have them in 48 hours afterwards, you know, at least to get the dressings down and to start the process with therapy. I think that that post operative edema doesn't really quite take a turn down until about 72 hours. But you know, it really is good to I think start the process of just re familiarizing the patient with their finger. So not that dissimilar. I try to do soft dressings when I can if I'm not trying to protect any, you know, because at this point, you're not doing any tenorrhaphies, you're not doing any osteosynthesis. So you're not really needing big bulky splints that can create their own issues.
Charles Goldfarb:Yeah, and let's be clear about one of the things I almost You know, it sounds we used to think about if we had a significant volar play contracture in a finger in a markedly flexed position. Some might have advocated for pinning the finger and extension to let the soft tissues relax for a week or two weeks. And I want to be clear, I do not do that anymore. I do not think it's helpful, I think it might be harmful. And so I personally don't believe in that approach. I like to get the finger mobilize, and let my therapy colleagues splint in different positions after those few days, you know, a couple days later, but I don't pin Do you ever? Not ever, but do you regularly pin?
Chris Dy:You know, I remember starting out in practice, and I pinned a couple of Dupuytren's, you know, that I had released and I don't really think added a whole lot to be honest with you. And it just led to stiffness, which was obviously, you know, in that particular setting, not very helpful. You know, do you think it's the trauma from the actual pin? Or do you think it's the fact that they're not moving there, that joint, and it's leading to accumulation of fluid and lack of, you know, you know, the edema being pumped out of the finger?
Charles Goldfarb:I think it's the latter. I think the earlier you get them moving, the better and just quote unquote, resting the finger is not as effective as getting it moving.
Chris Dy:So you set the stage for Macy to join us.
Charles Goldfarb:Absolutely. So Macy is going to enlighten you and me and all of us about how she approaches the recovery from the stiff finger and I'm really looking forward to it.
Chris Dy:Fantastic. Well I'll see you next time.
Charles Goldfarb:All right. Have a great night.
Chris Dy:You too.
Charles Goldfarb:Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@Handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time.