Season 2 Episode 47. Chuck and Chris discuss an FPL rupture case and respond to a listener requested segment: 3 Influential Mentors. Each of us share 3 mentors including why each was so influential to us.
Sign up for The Upper Hand Podcast Newsletter: http://eepurl.com/hH5qfT
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.
Season 2 Episode 47. Chuck and Chris discuss an FPL rupture case and respond to a listener requested segment: 3 Influential Mentors. Each of us share 3 mentors including why each was so influential to us.
Sign up for The Upper Hand Podcast Newsletter: http://eepurl.com/hH5qfT
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.
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 great. It's Wednesday morning. I'm here talking with you before a big OR day. What could be better?
Chris Dy:I know, we're recording during the daylight hours. So which is kind of an odd thing for us at times. But you know, it's nice. It's a nice way to start the day.
Charles Goldfarb:Yeah, you were trying to get me to record last night and it was getting late. And I'm old and was getting tired and need that need to bring the energy.
Chris Dy:Well, I mean, I was solo parenting last night. And it was just a constant, constant struggle, I kept losing the the time limits, I'd set on myself to get the kid make dinner and get the kids fed and get them bathed, and, and tucked in. And that honestly is quite tiring. Because by the time that I finished getting them down, I'm ready for a nap. And it's either I'm going to go to sleep at that point. I'm going to rally and stay up for another couple of hours. So even though we didn't podcast last night, I did get some other stuff done. So.
Charles Goldfarb:Excellent. Excellent. So what's going on?
Chris Dy:Interesting case, I had a case recently that reminded me of one from a couple of years ago. So I patient at a couple years back that presented with a with an FPL rupture, after a volar plate. And I know we talk about this a lot. And we talk about how it can happen. We don't really know how often it truly happens. And we also know that the timeline, you have it happen pretty quickly words can be many years. Now when I was talking to them about the reconstruction, because it was clear on examination that they had ruptured the FPL, I was looking into literature and didn't see a lot of true technique articles, or mentions about how to actually repair the tendon or reconstruct the tendon. There are some articles that talk about how people did but they didn't go into much detail about how they did the surgery. So how would you approach that case?
Charles Goldfarb:It's interesting, because that has recently come up in discussion. And I'll be vague just because it's one of our partners. And, and it actually wasn't one of their cases, but it's just, it's timely. And you know, the options, as you all know, are, first of all, one could choose to address the thumb and say fus the IP joint, I haven't ever really taken that approach. Because I do think the FPL certainly does more than just flex the IP joint. But that can be a reasonable and pretty straightforward option. I've always chosen to try to provide the FPL function. And to me, there's two ways to do that. One is tendon transfer and the others interpositional graft. I'll give you my bias in general, I do like the interpositional graft is not something we do very often. And it does depend on what you have to work with. Typically, the rupture is pretty proximal, so you have plenty of tendon to tie into. That's my general approach. Happy to talk in more detail. How did you think about this one?
Chris Dy:Same thing. You know, obviously, the, to me the graft is appealing. The interpositional graft is appealing because you know, just like I talked about not leaving axons on the table, Marty talks about not leaving this huge FPL muscle belly on the table. Because the muscle belly is still good, the tendons rupture, but it's a huge muscle. And as you were saying it's an important muscle slash tendon in many ways. So I like trying the graft in the limited number of cases in which I've had to do this. I guess the graft considerations, what do you use as your donor?
Charles Goldfarb:Well, the no brainer is a Palmaris longus at present. It certainly is a bit smaller in most patients, but doable. And you can perform a nice pulvertaft weave or you can do an end to end depending on size match. If that is not available, I also think is completely reasonable to use a portion of FCR It is literally right in your field, you can take the whole FCR we know that clearly from other procedures. I think either of those are acceptable and can be expected to have a good outcome.
Chris Dy:So in this case, a few years back there was no Palmaris and then I decided to use the entire FCR and you know hadn't done that before and it was actually turned out a lot smoother than I thought I always have a healthy respect for how much scar can form around the even just a standard removal of volar plate without the FPL consideration. But you know, carefully dissecting that away even the palmar cutaneous branch because that was visible In the field, and then harvesting the whole FCR. And doing it interpositional graph actually end up doing a pulvertaft on both ends and went very slow with the rehab splinted them down with a dorsal blocking splint at the radial side of them spike essentially with the thumb component going over the IP joint and a little bit of flexion and then initiating some basically treating it like a flexor tendon, like, you know, dorsal, blocking, initiating some gentle active motion eventually. But I left them in that dorsal blocking for quite some time and ended up fantastic result very happy. But it was a little harrowing, just kind of figuring out how to deal with it, because it was something I hadn't had to treat before.
Charles Goldfarb:Oh, that's awesome. So two questions. Of course, there's always two. The first is I assume you released the carpal tunnel, instead of jamming this FCR tendon through the carpal tunnel? And second, how did you tension it? Did you use tenodesis. And check the position of the thumb and do you over tension at slightly just talk briefly through that.
Chris Dy:I had to do a carpal tunnel release to get the tendon. So you know, even though the site of rupture is at the base of the of the watershed region where the volar plate is put in, it's just hard to go get it there. And then because everything is scarred in, and then I just get nervous about kind of working in that area at the at the wrist crease without seeing what I need to see. And even you know, when we opened the carpal tunnel, it was pretty apparent where it was. And it wasn't all the way retracted back. But it would have been hard to get there without releasing the carpal tunnel. So in this case, I actually, it was kind of neat. From an anatomy perspective, I found the palmar cutaneous branch found its little path adjacent to the carpal tunnel, not in the carpal tunnel and release that and just to get it out of the field. And then yeah, the it's a bulky thing to put in. And it's adjacent to the median nerve. And it makes me worried that of course, you know, we know that releasing the carpal tunnel will increase the volume in that area. But it still makes me worried because it's a bulky repair. And I tried to make it as you know, tapered and smooth as we could. But we all we also know it's going to scar and it's not going to look like it does at time zero. So that was part of the impetus for doing at least some early active motion to get things gliding so they don't at ease down. And then tensioning wise, yes, tenodesis, wrist back and then thumb down and IP flexion. And I did put it a little tighter, because we know it's going to loosen over time. And we are going to be pushing it a little bit early on with the rehab.
Charles Goldfarb:Yeah, love it. Love it. Yeah, you know that degree of quote unquote over tightening kind of depends on how long the rupture has been there because we know that that proximal stump will retract and the muscle somewhat, I don't wanna say fibrosed that sounds permanent, but we'll tighten as well. And so I do a little interoperative longitudinal distraction on the proximal stump to try to loosen some of that up how effective that is. I'm really not sure. But I like what you said.
Chris Dy:Yeah, it'll be it'll be interesting to see if we if, if there aren't any good technique, things out there, we should probably put one together next time this comes up. Because you know, it might be a nice little illustrative case thing. And if anything, it will be published in a journal of the upper hand.
Charles Goldfarb:I like that, I like that. Speaking of which I have some ideas are on our newsletter, which is gonna is so far has been over promised and under delivered. So I need to get to work on that.
Chris Dy:Well, we'll talk shortly in our next episode about our holiday hiatus. And maybe that'll be our little project to keep us busy, although maybe we don't want to be busy. So some really cool, cool listener feedback. You know, it's been great. We've had some wonderful emails come in, and we'll save some of them for the future episodes. But this is a great email from Minnie Mao. She is a hand therapist. It looks like she's out at Stanford, based on her email. But you know, thank you for this email. Everybody can email us at handpodcast@gmail.com. And she wrote in saying how much she loves the podcast, saying that at least Chuck is engaging educational entertaining. She actually said both of us but you know, we'll give you that. And she loves a deep dive episode. She says a hand there as a hand therapist. I don't have as many opportunities as I'd like to be in the OR with our docs. So the descriptions of the surgeries from approach to technique and troubleshooting really helps me to visualize and understand what each surgery entails and helps guide my rehab. He both have a great sense of humor and seem to be humble, thoughtful and articulate surgeons. Have been listening since episode one. And congrats on the 100th episode, which we will talk about in the next episode. But yes, we have reached 100. So Minnie sent in some fantastic ideas, and I want to incorporate many of them, but one that I thought would be great since we are in the season of festiveness and gratitude. She liked the Thanksgiving episode. And she was wondering if we could do a follow up then we could start with at least one of these topics, a list of threes, three people that influenced your career. Three patients or cases you will never forget. And three things you would tell your younger self So we can start with at least one of them. And, Chuck, I will let you pick which one since I know we got to get you to the OR shortly.
Charles Goldfarb:Yeah, well, I think we should go as far as we can. And Minnie I want to say thank you for the very kind comments. And for the great suggestion. You know, we started early on with sevens. We talked a lot about sevens. But I like this a lot. Why don't we just start where Minnie started when you want to talk about people who influenced our careers?
Chris Dy:Absolutely. You have to start since you had a longer career. To put it nicely.
Charles Goldfarb:Yeah, well, this is this is, I guess, in some ways too easy. I'm going to talk about my three mentors. And I certainly could find another 30 People probably who have positively impacted me, and taught me different things. You know, that's the beauty of this. And for those who are residents or fellows, you know, one of the things I thought about when I was applying to residency and then applying to a fellowship is trying to find a person who could serve as that mentor figure for years to come. And so I've been really lucky for my fellowship. While I had great mentors across the board, Peter Stern, obviously stands out. What Dr. Stern taught me is just an unbelievable commitment to education doesn't have to be formalized, although in his program it was. But just day in day out, from beginning to end of the day, education is foremost. And I think that is incredibly important. It's easy to lose sight of and slip away from. But my first one is Dr. Stern, who I fortunate to still keep in touch with and see not infrequently. So thank you, Dr. Stern. And maybe I'll flip it back to you for for your first.
Chris Dy:Well, I want to make a comment. The I've gotten to know Dr. Stern more recently through doing firsthand with him and it's incredible. I mean, his focus on education is apparent. I mean, that's why he was a natural choice for firsthand and, and really eminent that the development of that came from the Stern classic articles which I guarantee you pretty much every hand fellow in America has seen that list and is participated in some journal club based on that list. So you know, incredible contributions to hand surgery both in his, you know, his writings, which are real and valid and are useful in practice and then also in educating one of our former fellows and a listener, Shohbit Minhas, has always egged me on to try to get you to do a Mount Rushmore of hand surgery. And I haven't gotten you to do it yet. And we maybe we will in the future. But I was at of course, recently, and I was sitting around with a group of hand surgeons have different levels of experience. And we were we were doing the after dinner cocktails, and I pitched this idea of the Mount Rushmore of hand surgery, and Dr. Stern's name came up more than once. So, you know, it will be a good episode for us to do at some point. But yes, I can absolutely see how, how influential Dr. Stern has been for you.
Charles Goldfarb:The Mount Rushmore will take some preparation, it's almost like we need to start with a NCAA style bracket of whatever the number is 32 Maybe we could find and then and then bring it down to the Mount Rushmore level of four.
Chris Dy:You realize we may not have many friends in hand surgery after this.
Charles Goldfarb:We'll have to have strict criteria.
Chris Dy:Exactly, there must be data to drive this. Um, so I think the first person I think of just in terms of starting my career outside of my father, obviously, in terms of influencing my career choice would be Ann Ouellette in Miami, and she is a hand surgeon down at Miami. And at that time, she was at the University of Miami. Those of you that are listening in South Florida probably know her pretty well. She had trained at Seattle for orthopedic residency and an afterwards train with Buckwalter. And you know, she was at at the University of Miami when I was a medical student. And I was looking to do research and at that point in the department, it was not easy to do research down there. And maybe she was the one who turned me on to hand surgery because I ended up doing a bunch of cadaveric studies in the with her in the lab that led to several publications and kind of got me interested and got me the I think the research credit I needed to be a competitive orthopedic applicant at that time, led to me taking a year off to do research because I liked it so much. And she helped continue position continue to position me for my career. I remember asking her about residencies after interviewing and feedback. And she was really encouraging of me to look into the, into the program at HSS and was really encouraging about, you know, when I was making my rank list, and I still talk to her. Every time I see her in a meeting or sometimes when I do make it down to South Florida, I make sure to see her. So yes, she's been incredibly influential just from getting me started perspective and showing me that a lot of things are possible even when you're when you're coming from a place that didn't have a ton of resources at that time.
Charles Goldfarb:I love it. I love it.
Chris Dy:I still I don't know if I can convince you to use the Herbert sling though. You know, to stabilize the the ulnocarpal joint but one day maybe.
Charles Goldfarb:Yeah, maybe we'll keep talking. Number two also is a pretty obvious choice for me. That is Paul Mansky. Dr. Mansky was one of my residency educators. And then when I came back after a fellowship, I would say he was my closest partner simply because we did congenital together. And, you know, the whole process of education about congenital hand surgery is could be a topic of an entire episode. But the fact that I could work with Dr. Mansky for 10 years, until he passed away, was a remarkable opportunity for me, helped guide my continuing congenital education, and really made me quite comfortable with anything and everything that could walk through the door. Obviously, I saw things for many years exactly as he saw him those things and those conditions. I've evolved, certainly, as I hope we all do. But while I feel very fortunate to have considered Dr. Mansky a mentor, an educator, and obviously a friend as well, so really important to me.
Chris Dy:I keep seeing, you know, every now and then there'll be in a former doctor, Mansky patient that comes in, and they're just almost always completely through the roof about him. But you know, it's funny, there's one patient who came in who I want us to do a thumb CMC injection on, and she almost talked me out of it, because she had had such a tough experience with an injection by Dr. Mansky. And I was like, Wait, this is literally only not positive thing I had heard. And we all know that everybody has a hard time with injections, regardless of who's doing the injection. I was like, are you sure it was the right Dr. Mansky?
Charles Goldfarb:That is funny.
Chris Dy:But she loved the injection. So it worked out, okay. But it did take a little bit of words, some words to calm her down and get her going. So so I know our number three is going to be the same. I'm fairly confident on that. So I will go with my number two. And I'm not sure honestly, I didn't think a lot about how to word this. So I'm just gonna kind of go with it. But it's Dean Lorich, at at HSS. And he was an orthopedic trauma surgeon. And you know, he was not a perfect man by any means. But he was an incredibly influential educator. He was certainly not an educator that was for everybody, in terms of he was not to their liking in terms of how he taught. But for me, what I took away the most from him was an incredible appreciation for surgical technique for discipline. And I think that, you know, preparation for cases holding all of us to incredibly high standards, whether it was Floor Care, ER management, or the OR itself. And being a mirror, like he was not afraid to tell you when you did not do well. And yes, he could have handled that in many better ways in terms of how he told people that. But I think there were many of us that responded to that, for better or worse, and he pushed me to be a better surgeon, and I still use a lot of his techniques, at least in terms of anatomic dissection, I still think about how he thought about anatomic dissection. And I've honestly never prepared for a rotation more than the PGY three rotation for on trauma. I mean, I would do so many cadaveric dissections just to get ready. And I think that that appreciation for anatomy that appreciation for discipline and preparation is something I try to pass on as much as I can to our trainees.
Charles Goldfarb:I think that's really well said, the, you know, what I think about often is, in this age of resident education, sometimes that what might be perceived as hard nose perspective can get lost. And I think it's critically important to hold people accountable, to praise the good and challenge the bad. And that's I think it's more challenging. Maybe I'm just speaking about myself, because I know I struggle with this. But really nice to hear. And super important.
Chris Dy:I agree. I think it's hard to do that in this era. And that's nothing against the current generation of learners. It's just, it's just harder to do. It doesn't mean that you don't do it. I certainly think that the trainees that I've talked to appreciate it, when we tell them very fairly and squarely on what to work on and tell them how they need to improve. It's much easier to tell somebody good job, pat them on the back and have them move on. But I think it's our responsibility for things that deserve greater attention to give greater attention.
Charles Goldfarb:It is it is again, not easy, remains important. And just one of those things that is our responsibility, really.
Chris Dy:So let's go with your number three.
Charles Goldfarb:Yeah, I'm sure number three is the same. So Richard Gelberman is was my basically when I started as a resident that was his first year as chair of the department. He built the department he really literally Built the department. And that's a remarkable opportunity he took advantage of it created a great department taught me many, many things. Details matter, that's probably if I just say one thing, it would be the details matter that's in our knowledge of anatomy, it's in our interactions, it's in our ability to understand and quote, the literature is in our manuscript writing, and the detail with wordsmithing. And Dr. Mansky, taught the same as editor journal hand surgery, but so many things I could mention about Dr. Gelberman, but details I think, is my foremost.
Chris Dy:Yeah, he has, um, he was incredibly, incredibly into the details, I mean, to the point where you really have to wonder, you know, why am I trying to learn this number? That I think at least when he was teaching me, and I can only speak to, you know, my experience as a learner with him, he was pushing me to connect the dots. And there, what I appreciated about working with him as a learner was the accountability. You know, still I know that he, I think, earlier on was much harder on his trainees. And I think he was still very much, you know, he was tough on us, but it was it was coming from a good place. And I think that's the important part. And I learned a ton from him. And I think for me, the biggest thing was the career development path in terms of what I wanted to do as an academic surgeon, and seeing the path to being an r1 funded surgeon and seeing what it took the fire in the belly, the grit, the focus, the determination, all those things that make them fill entire podcast with the lessons that he taught me just in that realm. But yes, our Number three's are the same. And I think that, you know, we probably at some point we keep talking about, we got to have him on the pod. I know that, you know, his the format is different than what he's used to. But I think it'd be great.
Charles Goldfarb:I think you would, to which the story you told about Dean Lorich and your preparation for the OR does make me think about Dr. Gelberman and preparation for anatomy session. So just to frame it briefly. You know, anatomy used to be every single week, with the fellows and the residents on service. Now we do it once or twice a month. And it was incredibly intense. There was an expected format for delivery, there were no notes allowed. And, you know, so you're scouting for memory with an incredible amount of detail. You know, when I was a PGY, four, I was the chief on the hand service, and it was the chief who did the presentation. So wasn't usually a PGY four. And so I remember cramming for hours. I remember sitting in the shower, you know, at 4am, the day of the presentation, reciting out loud the presentation I was about to give, but you know what, I'm better for it. I'm better for it.
Chris Dy:I think that you're right, that was a recital. But you know, it's a it's like the thing, you have to practice it so much that doesn't sound practiced. And once you cross that threshold, then you've achieved the mastery of the anatomic presentation.
Charles Goldfarb:That's exactly right. I mean, again, I still remember those details today. So I love this. I do think on our next pod. Hopefully we can find time to talk about Minnie's additional suggestions. But this was great.
Chris Dy:I love it too. And you know, I think let's talk about meetings, additional suggestions. Let's celebrate 100 episodes on our 100 and second episode. And you know, it'll be fun. It'll be a good way to head into the holidays.
Charles Goldfarb:Perfect. I love it. Good to see you have a good day.
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 dy. 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 podcasts.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand, come back next time.