The Upper Hand: Chuck & Chris Talk Hand Surgery

My Toughest Case: Scleroderma

August 22, 2021 Chuck and Chris Season 2 Episode 34
The Upper Hand: Chuck & Chris Talk Hand Surgery
My Toughest Case: Scleroderma
Show Notes Transcript

Episode 34, Season 2: Chuck and Chris bring back "My Toughest Case" and Chris discusses a patient with scleroderma including evaluation and treatment options including sympathectomy.

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.

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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:

All right, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm good. I'm good. It's good to see on a nice Sunday morning.

Chris Dy:

It's nice to see you. How's your weekend been going?

Charles Goldfarb:

Good, good to be with the family I, it's about to be a very different household. Maybe by the next time we record. I will have to in college and junior in high school and the landscape is changing.

Chris Dy:

Goodness, that is absolutely crazy. We're still, we're still camping out in our friend's basement. But we do have a closing date in sight. So we're hoping by the end of the month, we are up and out.

Charles Goldfarb:

Oh, wow. Congrats. That's super exciting.

Chris Dy:

It is exciting. We did a you know, kind of walk through the house last weekend. It looks amazing. We're very excited about it. But certainly it's come with a fair bit of stress to get there. So very exciting. Very exciting. So hopefully, next time we record will be closer to the end.

Charles Goldfarb:

Well, if if you need any help on moving day. I'm happy to call Dr. Boyer for you.

Chris Dy:

I thought you're about to assign a medical student or resident to me.

Charles Goldfarb:

Now I am more than happy to lend the hand. I really am.

Chris Dy:

I appreciate it. Thank you. I may just be parking my kids at your pool.

Charles Goldfarb:

That's an option too.

Chris Dy:

So, a couple of great reviews I want to share one actually has a question. So this would be really useful for us to address. So this is from either Matt Rode or Matt Rod-e. I can't. I'm not sure how to pronounce exactly but five star review. subject is a fountain of information. It says Hi, my name is Matt. I'm a second year medical student at Mayo Clinic. I've heard of that place. And hopefully a future orthopedic hand surgeon. You've got plenty of excellent model role models up there at Mayo for you to to work with. The podcasts are so full of great information, I have to pause to make notes or flashcards. That is a first and that is awesome. Keep it up. I was wondering if you could discuss your differential diagnosis for a patient with catching slash snapping of fingers. And do you have any pearls for differentiating a trigger finger from a sagittal band rupture? Sincerely, Matt. So first off, Matt, thank you for that awesome review. It's it's amazing to hear that you're making flashcards from it. That is fantastic and definitely invigorating for us. Chuck, do you have any thoughts about the question?

Charles Goldfarb:

Well, it's a good question. Because we and I would I would think all hands surgeons have the potential to fall into this trap. can get lulled into this sense of everything that pops is trigger finger. And we know one thing and this is one of Dr. Boyer's teaching points is that, you know, hand pain is often trigger finger even when you don't think it is mean that vague pain and you try to push on the A1 pulley, it's obviously a different category. So trigger finger can be more than we think it is. But when we hear catching the finger or popping the finger, all of us immediately think of trigger finger. True?

Chris Dy:

Yeah. It's, you know, the rule, the MIB rule of hand surgery is it's always a trigger finger.

Charles Goldfarb:

And that's what happens.

Chris Dy:

But then I think that I think I think the asterisk is not everything that pops is a trigger finger.

Charles Goldfarb:

I think that's right, and not all of us have that population that he has. Um, so I think of a couple of different things. First of all, I always palpate the A1 pulley and ask the patient to demonstrate their triggering A, the palpation may be painful, and B, obviously feeling the trigger can be 100% diagnostic. And then I do think about sagittal band ruptures, especially with a weird mechanism born acute onset. And I think it's a matter for me, and I'd love to hear your thoughts as well. It's a matter of turning the hand over, asking the patient to make a fist and watching that extensor mechanism palpating the extensor mechanism palpating for pain typically over the radial sagittal band and typically the middle finger. That was a classic article by Kettlekamp that taught us that is almost always the middle finger and it's almost always the radial sagittal band is ruptured. And then lastly, check and see if they can actively extend the finger, which again doesn't really differentiate it. But passive extension is different, right? You can passively extend a ruptured sagittal band, you can't passively extend without a pop. A lock trigger finger. So those are my Brief thoughts.

Chris Dy:

Yeah, I think that the the nature of the snapping catching is different. And you won't appreciate that unless you turn the hand over. So you're saying turn the hand over, meaning inspect the dorsum, as opposed so we're used to, you know, inspecting patients, Palmar volar surfaces? I think, Matt, you're ahead of a lot of people just because you're recognizing the fact that this could happen. And, you know, one of the, one of the pearls that I heard in residency a lot is that the, the eye does not see what the mind does not know. So, you know, I think it's fantastic that you're, you know, able to, you know, recognize that this entity exists. I agree with what Chuck said, in terms of, you know, the a typical trigger finger. You know, I think that it's the pain kind of going shooting, we're not shooting but you know, referred maybe to the PIP joint. But then when you palpate the PIP joint, there's no actual effusion or tenderness at the joint itself. And I've seen that in kind of the, quote, early stages of triggering and I think that's described as kind of the maybe phase one or stage one of that condition or pre stage one. Before there's any frank triggering.

Charles Goldfarb:

Yeah, I love that. The other comment I will make is that the other trap that I should just not speak for all hand surgeons I'll just speak for myself is that when I see a patient, and I make a diagnosis, it does set me up for future problems. And what I mean by that if I see a patient, and I call it trigger finger, while before the resident or fellow goes in the room, then next time the patient comes back, they're going in with the mindset of trigger finger. Before I go back in the room on that second visit, I'm thinking trigger finger. And so if I miss diagnose the patient the first time, I definitely know it increases the chances of continuing that misdiagnosis moving forward. And where that's important here is what the failed corticosteroid injection. So if I miss diagnose a trigger finger, and give the patient a steroid injection, and the patient comes back four to six weeks later and says, Doc, that did not help at all. The the compounding of the error is saying, Well, let me give you another injection, or let me take it to the operating room and fix that trigger finger. I don't know why that steroid injection doesn't work. steroid injections literally, almost always work. They just don't always last. thoughts on that?

Chris Dy:

Yeah, I actually was thinking about that the other day, because I had a, quote, atypical presentation of triggering. And I went ahead and gave her the injection in pretty much every time when I'm making this small talk about the injection, I give them the same spiel, you know, in most people kicks in within two or three days, I've seen it take up to two weeks, which I've only seen it take that long one time. But I do tell patients, I've seen it take up to two weeks for it start to work. And if it's not working by two weeks, call, let me know. So you can come back and make sure that we're you know, that we got the diagnosis, right. So that's something that typically comes out of my mouth when I'm talking to patients about an injection. And the question I had for you is kind of a weird one. But I mean, in terms of when you're listing a diagnosis in the EMR, for the atypical presentation of triggering, at least when I'm dictating a note, I typically will say, you know, a very typical, but I think this is triggering in the assigning a diagnosis, do you just put finger pain? Or do you go ahead and commit and put trigger finger?

Charles Goldfarb:

I commit, it's interesting, because my mind goes in a different direction. I mean, in response to your question, I commit and say trigger finger in for my diagnosis code. However, for my assessment plan, I might say trigger finger, but somewhat atypical, I would just put a little, you know, I would back off a little bit in my actual note, the flip side of that, of course, is carpal tunnel. I don't call a carpal tunnel into if I'm sending a patient for a nerve study. I don't call a carpal tunnel to have my nerve say results back. Maybe that's just I don't know, probably doesn't matter. We're probably talking about something that the audience is rolling their eyes at. But I wait a little bit on the carpal tunnel diagnosis, unless it's just crystal clear. Unless I'm skipping nerve studies and planning for surgery.

Chris Dy:

I guess I Yeah, probably a little eye rolling from some of the audience. But there probably are some that to care about, get you know how we document things in the EMR, because then if you list the diagnosis that it becomes part of the problem list and then it carried into you're talking about is compounding of issues and perpetuating and I think that it's probably more more of an issue if you put it listen in your actual billing diagnosis. But anyway, Matt, thank you for the great question. And that didn't think that we could talk that long about trigger finger. I don't think we've committed an entire episode to it, nor do I really want to.

Charles Goldfarb:

No, agreed and the last thing just in closing just to be complete, there can be intra articular pathology at that MCP joint. It's pretty rare. But you can have an intra articular reason for popping it but it's just different. It's more pain and occasional popping. But I just want to close the loop there. Awesome. Thank you for the review.

Chris Dy:

Yes. And please, everybody, get on the iTunes and leave us the only option of five stars. And then you can ask Chuck a question. And we'll address it just like we did for Matt. So thank you, Matt. We love it. And, you know, good luck with the rest of the academic year. I think you're just starting off.

Charles Goldfarb:

Absolutely. All right. I think today we are going to talk about a really difficult case, the segment you have entitled, my toughest case.

Chris Dy:

Yeah, it's my turn. It's my turn. And this one's funny because it's um, it's a case that I did not see in my fellowship training. But now I've done a few. And I think they're really challenging. So this is a this particular patient is actually somebody who's come to see me a couple of times, and I've operated on twice now. And they have a condition called diffuse systemic scleroderma. And how, you know, with a with Raynaud's now, and ischemic pain, and a definite difference in the feel, and the turgor of the fingers, but no, frank ulcerations as of right now, but when they first saw me, they did have alterations, and they've tried all sorts of medical management, you name it from sildenafil to obviously nitro paste, and they've tried everything else. And they don't have enough relief. How do you approach that? scleroderma? Raynaud's patient, Chuck, what what's your treatment algorithm and they admittedly get to us late in the game. So?

Charles Goldfarb:

Well, I'll be happy, very honest about a couple things. The first is that for most Raynaud's, patients, I send them to rheumatology for treatment. with the caveat that I'm happy to see them back, you know, patients get sent to us for all kinds of non surgical reasons. And I think early in one's career, my general approach personally, and also, I think it's just reasonable is to see all comers take good care of them, understand what you can treat and what you're not the best person to treat, and build your name and your community build your reputation. At this point in our career, seeing a patient with scleroderma, or maybe with Raynaud's, I might not be the best person to see them. Now, I know where you're going with this case, I think. But I would say that for like a typical Raynaud's patient who's coming in for finger color changes in pain and cold weather relatedness, I would send them to rheymatology. Now for this patient, I agree with kind of is what it sounds like you started with you started with the basics, you know, keep the fingers warm mittens on a cold day. But more importantly, try to open up the blood vessels. And so use of nytro paste, and consider a systemic calcium channel blocker, I would do those things for certain. Before jumping to considering surgical options, I would also think about Botox, and I don't know the literature as well as I could or should, and you probably have a better sense than me. But Botox has been demonstrated to be one reasonable treatment option. Do you have any experience with it?

Chris Dy:

You know, only to send patients for it. And then obviously, it's sending them to their back to the rheumatologist if they haven't tried that, but you know, this patient doesn't come come into my clinic very often, to be honest with you. And it's usually they are sent by their rheumatologist and they're done with all of the non surgical treatments by the time they see me and this is just one of the things for you, if you don't have this in your practice, you know, some but somebody may come to your office and you know, you haven't really assessed this patient before.

Charles Goldfarb:

Well, that's the perfect scenario. And so you know, there's we've talked a little bit about relationships and, and what kind of relationships you can have with other physicians, other medical providers and how they can help build your practice. And I've talked a lot about athletic trainers being one perfect example, obviously, primary care physicians, concierge care doctors, there's lots of good examples of how you can build your practice. This is a perfect one, you know, there absolutely should be a back and forth with rheumatology, not as robust as it used to be when when they rheumatology patients and those when we try arthritis really needed surgery regularly. But this is great. So this patient walks in, he or she has been maximally medically managed and they're coming to you for a solution. So paint a little bit more of a picture of what the hand looks like please.

Chris Dy:

So the pain is index and middle alterations at the very tip kind of at the hyponychium of the index and middle the index and middle feel different they're all not completely would eat are petrified but they feel firmer, they don't have the same kind of balance in the skin turgor and the the ring and the smaller okay and the thumb is totally Fine. And then on the clinical exam, very easily palpable radial pulse, not a great owner pulse. And actually, I forgot that I have Doppler in my clinic, I think I'd seen a couple of these patients. And the last time I saw him, I didn't have doppler in my clinic. So I made a big stink, and I got a handheld Doppler in my clinic. So now I've actually went and used it. And you can hear the radial obviously, is great, because it's palpable, the ulna is a little thready, but it's there. And you can kind of hear in a superficial arch, but you got to work for it. And then the radial and ulnar to the proper digital arteries to the index and middle are not great. The radial is, again, you got to work for it on the index. And then basically that second webspace branch is not fantastic. And then the ulnar portion of the middle is okay. So I'm kind of in a jam. And, you know, I don't know how you counsel patients about, you know, what surgery is like and what to expect, and you know, things like that?

Charles Goldfarb:

Well, it's a great, it's a great case. And in the in the right patient, I would consider a surgical intervention. And I have you know, it's interesting, it does raise the question of in a group like ours at a referral center like ours, should Chuck and Chris and basically, should all six of us do cases like this that are uncommon? Or should we, you know, have our micro partners do it. And obviously, you do micro a lot, I do micro some, and I certainly think it's highly appropriate for both of us to do it. And so I would, you know, if I chose to handle this case, rather than referring it, I would consider a sympathectomy. And when I've done those in the past, A, it can be fun, although it's not always a fun case. And B, you can make a big difference for this person.

Chris Dy:

This goes into the it's all good till it's not the kind of case because the friability of those arteries is real. I mean, they're not normal arteries.

Charles Goldfarb:

So tell. So lay lay all your cards on the table. So you decide you're seeing the patient, you decide, yes, the sympathetic sympathectomy makes sense. You talk to the patient, you schedule the case, how does Chris Dy prepare for a case that he doesn't do all the time?

Chris Dy:

You're actually getting a I won't? I won't answer that, Chuck. Because that's actually a topic for the wheel of hand surgery that we're going to record for next week, preparing for new cases. So I will sort of answer it, but I won't give you the full, I won't spill all the tea here. So you know, I think that in, it's kind of hard, because you're having to think on your feet in clinic. Because you have to tell the patient what to expect after surgery, but you yourself haven't had a ton of time to do the reading in the literature, you rely on your base of knowledge that you have for fellowship, so you're somewhat non committal to the patient, you know, you tell them what you remember the success rates to roughly be? No, so I talked to her say, look, you know, the the very last option here, which I think is why you're here to see me is to, you know, try to reinvigorate those blood vessels, what we do is that we, we think that there's essentially some spasming in the blood vessels coming from the nerve supply that goes to that feeds into those blood vessels. And we're just going to separate the nerve endings from the blood vessel, and then also try to open up some space for those arteries. I tell them that they can probably expect some element of improvement, at least in the short term in the pain and hopefully some healing of the ulcers. But I think the recurrence rate is the thing that I worry about.

Charles Goldfarb:

Yeah, well said Well said, I do think it'd be fun to talk about preparing for cases. I look forward to spinning that wheel. What's going to be you're gonna roll your eyes. I know you are. So my 16 year olds, 16 year old daughter talks a lot about the tea, which is like, the gossip. And so I love that you work that in. So correct me if I have the origin of this expression wrong. To me, it's it started with kind of reading of the tea leaves, which I you know, kind of thought, I really I don't know if I really understood what the tea leaves were. And then I was watching I don't watch a lot of TV, but I was watching Peaky Blinders maybe six months ago. And they actually I guess it was a thing where you people actually read the tea leaves in the tea cup and can kind of help understand the future. So I don't know if I'm taking this analogy too far. But that's what I thought of and I'm sure there are listeners who love Peaky as much as I do.

Chris Dy:

You are absolutely taking it too far. I have no idea what you're talking about. I do know that the kids talk about the tea, and it is a gossip. That's about as far as it goes for me.

Charles Goldfarb:

Alright, sorry about that.

Chris Dy:

So what's been your experience in terms of how these patients do after a successful so And we'll get into the technical parts of it in just a minute. But

Charles Goldfarb:

I think your your summary was a good one. I think, you know, certain patients, this can be a home run, maybe not lifelong, but you can really dramatically improve their situation. You can get the ulcers to heal, you can help the pain and set them on a on a different course, I do agree the risk of recurrence is very high. But that's why I say it is a procedure that I did I don't mind doing that, because the results are reliable. And so I think you did the right thing for sure.

Chris Dy:

So when you book them for a sympathectomy, what do you what does that mean to you? Well, what are you intending to do and to which arteries?

Charles Goldfarb:

So first of all, I book it on the main campus with a microscope. I don't I don't know that's 100% mandatory but for me, it is. And I book it for, you know, again, I'm not in the or everyday doing micro, but I probably do book it for two hours, and I'm part of that is just set up and the microscope and, and so I did two hours and two hours in the room, two hours in the room. Okay. And for me, that's a longer case. But again, I don't want to be in a two room day trying to do a case like this, and I need to have a microscope. And then I would plan on addressing the radial artery and the ulnar artery, at least examining them in the distal forearm, and I'd follow the radial artery distally. And then I certainly would address the digital arteries from the arch heading distally. Now, for the radial index finger, obviously, that may be a branch from the princeps. So may may look a little different. But I would address all four arteries, focusing on the ulnar digital artery to the index and the radial digital artery to the to the middle. But it's a big case for me.

Chris Dy:

So would you book it on the main campus? Say, for example, see your surgery center had a microscope? Would you just do it there on a day where you're not as busier at the end of the day? Or is you doing it at the main campus? Because you want access to other things? Other people maybe?

Charles Goldfarb:

No, I don't think I would worry about it. That's a good? That's a great question. I wouldn't worry about risks. I wouldn't worry about meeting a partner, I don't think I would get into that kind of trouble. It's just a matter of being able to take my time and do the right thing. In this case, I'm not worried about admission. So yeah, if my surgery center had a microscope, and I could put it at the end of the day or under protected time, I would do it there. I have no idea about reimbursement or things like that. But absolutely, I would do it, I would do it in an outpatient environment, if I could find the right environment.

Chris Dy:

So and then would you get an angiogram ahead of time?

Charles Goldfarb:

I would not, I tend not to do that. I'm sure many would. And if any of our listeners have experienced with this, we would love for you to share your thoughts with us. But I would at the beginning of the case really doing more in depth Doppler exam than you did. So when the patient's on the table, I would plot things out, it would help guide my planning. But I would still plan on addressing distal forearm. And also the digital vessels.

Chris Dy:

I though my Doppler exam was pretty thorough, but that's okay. So, so would you go into the finger? You know, you mentioned working on the arteries to the finger at the level of the distal palm, would you cross at Palmar digital crease?

Charles Goldfarb:

I guess it would depend a little bit on what the vessels look like but I traditionally have not. I work on the arch. And I go out to the Palmar digital priests, I don't typically go into the fingers and less a I'm not making progress. And be it seems like the vessels are more problematic distally.

Chris Dy:

So this is actually a case that I did a few years ago. And now shape have now re operated upon but the patient at that at that point we did what you described out at the level of the distal palm and found those four arteries that you discussed. I did the you know the sympathectomy and then I did adventitial stripping for probably about a two or three centimeter segment for each of those and did go out into the fingers and I can't remember exactly now why I did that but I'm pretty sure it was based on like you're saying the description. She did Oh and I did it as surgery center because I have a microscope at my surgery center. And and honestly that was a little bit of a fight to get that scope at the beginning but it has opened up a lot of opportunities for me to do things with a lot of comfort out there.

Charles Goldfarb:

Oh, that's so interesting. Well, I'd love to talk more about that. Keep going though. You should we should.

Chris Dy:

So she did great. She loves me for that. And also healed, pain was gone. This was three years ago, she comes back recently sends a few messages in the chart saying I'm not doing so great, we get her into the clinic. And, and the fingers are back to where they were no ulcerations. But you know, it hurts, it hurts a lot. I mean, she's like, you know, start saying the a word, you know, that you don't want to hear as a hand surgeon. For those that aren't initiated the, when a patient brings up amputation, you have to really pause a bit and realize that it's really bothering them. So we have the same talk about, you know, how challenging This is. And now, if you've done this sympathectomy, you there really is no reason for, you know, spasm to be part of it. But all that scar that it's encased in can, you know, choke off and scar those blood vessels and make it difficult for blood to follow through. So you know, the plumbing really gets messed up. So this time I actually, because it was a revision case, I emailed one of our partners, and David Brogan was kind enough to share some insights and he suggested an angio because he had a case where a patient had an odd thrombosis and an unexpected location. And with that information, he had planned to do some vein grafting or arterial grafting versus vein grafting for that thrombosis segment. So we got the angiogram, angiogram came back with no thrombosis, but an incomplete arch, great flow through the radial and not great flow through the owner. So with that in mind, we went back to the OR. And this was hard, you know, the, the radio and the owner part, you know, sympathectomy and you know, adventitial stripping, that all went really well, obviously, because that's a bigger, those are bigger pipes went to the superficial palmar arch. And you know, those look fine, you know, that arch looked okay, but then getting out to the radial index and to the honor index, and to the radial middle, those were really diminutive and really caught up in a ton of scar. So that was really challenging and almost felt like in a weird way kind of felt like a dupes.

Charles Goldfarb:

And you do this with David?

Chris Dy:

No, David was around, fortunately, but I did not need David. David was gonna be there, it was gonna we are just going to move with David's OR we thought we're gonna have to do the grafting if there was a thrombosis. But we kept it in mind. Just because, you know, logistically is a little bit easier because there was no plan to do any grafting. Although I did talk to the patient, it was on the consent about possible grafting even in the absence of a thrombosis, just because you never know how those vessels are going to handle.

Charles Goldfarb:

Yeah, and the you know grafting is really tough. Because even if you can, you know, put it into the arch, for example, where do you tighten distally? If you have four vessels all the way? So it's tricky, and obviously not a situation you want to be in. Yeah, I revision sympathectomy is not something I've undertaken, probably not something I would undertake, honestly. And do you have any type of results from operation number two?

Chris Dy:

Very, very short term, we're happy. Nothing, nothing, nothing yet. And I think that the proof will be in the pudding there in terms of you know, as a follow up comes and we've had this discussion that we're probably going to be in the same boat in terms of you know, we're battling a systemic condition. And you know, this probably will recur. And we're again, running out of options, and prepping for this case, and looking into literature, there was a really nice case series of revision sympathectomy is that fortunately, our colleagues at Wake Forest have published in the European Journal with, you know, good measured, you know, but good results. So I think that that is reassuring. And that's a really hard case. slogging through scar is one of those days that you come home, just physically and mentally exhausted. Because, you know, you're like cracking your neck to get into different angles, we did it all under the scope in terms of the sympathectomy. I mean, the gross dissection we did on loops, but the sympathectomy part on the the scope, but the gross dissection was challenging, you're obviously working through tissue plans that are not normal. So then you're just you're, you're on edge, I think a lot for a lot of it. And it's a you know, obviously really small structures,

Charles Goldfarb:

You probably had a very skilled set of hands to help in that, in that experience, fellows, I'm guessing. But these the kind of cases that even if you don't technically need your partner, doing a case like this with a partner really can be a game changer, in the sense of, you know, two minds working together on how to address things, how aggressive to be tactically, you know, you're going to bring excellence with one of your partners, and just the interaction. You know, we don't you are, I think we are both fortunate, because we both operate with partners, not infrequently and I know that we As I say, you know, speak to the audience, many people do not. And that is while Yes, there are financial costs to working together. There's nothing like it. I mean, it is really one of the joys of my practice when I get to operate with my partners.

Chris Dy:

Yeah, I think I think it's fantastic. And, you know, I enjoyed, you know, every big Plexus reconstruction, David and I will do together. And then I've been fortunate enough to that Lindley's asked me to come help her with some of the the birth plexus. And it's just fun, even if Yeah, technically, you can absolutely do the case on your own. And, you know, very beginning of my career, I did the Plexus cases on my own, you know, and then obviously had some help from, from like Marty, when he would come in. So remember asking Marty to harvest or all nerve and still hearing about that story. still hear about that now. But you know, even if it's not for the the technical things that David brings to the table in terms of being able to do the free functioning, muscle transfers, etc. But just like you're saying, bouncing things off of each other, what do you think about this? Do you agree with that, in real time, it can be tremendously useful. So maybe we should do it more in terms of partners. But it is, it is something that when it happens, it is absolutely worth it.

Charles Goldfarb:

Right, there's an opportunity cost. But again, playing the long game, it makes cases can make cases like that, or other cases a lot more rewarding, and just builds that camaraderie which I think we are so fortunate to have in our relationships, but good job sounds like sounds like a homerun for the patient.

Chris Dy:

Yeah, yeah, we'll see. I mean, you know, we gave it everything. So, you know, revision sympathectomy. For sympathectomy. I think that in fellowship, I just, I don't know if it's because of the way that the cards fell, but I didn't see it at all. I did it pretty early on in practice, one or two times. And now, you know, first revision, but I think that the principles, you know, in terms of technique and everything, try to pick them up somewhere along the way. And if you're a fellow and you see these, if these are not cases that are common at your institution, and you scan the schedule, and you see somebody with it, go check it out, or even a resident like me, because I still remember cases for my residency that I didn't get to see during fellowship. So you never know. You rather you rather be somebody else's patient first.

Charles Goldfarb:

It's true. I joke about you know, not doing much micro and I prefer when my micro is elective. I don't know that I would prefer that this case be my elective micro.

Chris Dy:

Yeah, you probably will send that to one of our partners so.

Charles Goldfarb:

I most definitely will.

Chris Dy:

Alright, well, great. Let's get together again soon. I think the wheel of hand surgery's going to be calling us.

Charles Goldfarb:

The wheel of hand surgery. All right. I look forward to it. Have a good day.

Chris Dy:

Take care.

Charles Goldfarb:

Hey, Chris. That was fun.

Chris Dy:

Let's do it again real soon. Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb:

Mine is@congenital hand. 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.