The Upper Hand: Chuck & Chris Talk Hand Surgery

Resolutions and Cases

January 23, 2022 Chuck and Chris
The Upper Hand: Chuck & Chris Talk Hand Surgery
Resolutions and Cases
Show Notes Transcript

Season 3, Episode 2.  Chuck and Chris share personal and work New Year's resolutions.  Then we share two interesting cases, one an unexplained nerve issue and the other a difficult PIP joint fracture.  Join us!

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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.

Charles A. Goldfarb:

Welcome to the upper hand podcast 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 things hand surgery related from technical to personal.

Charles A. Goldfarb:

Please subscribe, wherever you get your podcasts.

Chris Dy:

And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts.

Charles A. Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are ya?

Charles A. Goldfarb:

Fantastic. I'm excited to be recording another pod with you.

Chris Dy:

Me too. I'm sitting in our study right now. Because nobody's home and it's the only time I could sit in here. My wife refuses to put a door on this study because it says it'll make the room look smaller.

Charles A. Goldfarb:

Well, super interesting. I have to say as a as a parent of young children. There cannot be many times when you are home alone.

Chris Dy:

Yes, it's it's actually kind of neat. So yes, I'm supposed to be out of town right now. But I'm not took the kids to school today. Drop them off, came back home raced home to meet with you and do the podcast episode. You know, I already worked out this morning. I might do a two day today just because I love doing it. And you know, I may put on some virtual content from the meeting. Just kind of pedal along. That's honestly, people joke about this. But like, if I'm on my peloton, when we're when we're meeting it means I'm actually trying to pay attention to you. Because otherwise I'm doing emails or checking social or anything else.

Charles A. Goldfarb:

Right. That's so interesting. So what's the what's your typical morning workout is always peloton.

Chris Dy:

Yeah, it's usually something through them. I've, it's a combination of the cycling plus something else. I don't like running as much in the morning anymore. I used to run in the morning. Prior to the pandemic, I used to do a treadmill based bootcamp class. But I don't know it's kind of hard to drag myself down there to run I get on the bike for some reason. But the running is seems harder to me

Charles A. Goldfarb:

is super interesting. Yeah, I just try to mix it up. And you know, when you get old at, everything gets a little harder.

Chris Dy:

But yes, I'm actually, you know, after the cycling stuff I've tried, I'm trying the boxing program right now. And it's very humbling, because I realize how uncoordinated I am for boxing.

Charles A. Goldfarb:

I grew up doing a little of that. And I have a heavy bag at home and I have a speed bag at home. And they're super fun, for sure.

Chris Dy:

And how often do they get

Charles A. Goldfarb:

used very often not like they should.

Chris Dy:

I'd like theboxing thing and the thing that I'm doing now is all kind of shadow boxing stuff and learning technique, I could definitely see the merits of having a heavy bag in a speed bag at home.

Charles A. Goldfarb:

There is no workout like a boxing workout, which is why as we all know, there's all kinds of gyms around that. You can go to a boxing workout because it's It's impressive how much you can get you.

Chris Dy:

So we're talking about health right now, which is a great segway it's a new year. So it's 2022. And we're back for for a third season of the podcast. Now, I was thinking it might be good to kick this episode off with maybe some resolutions. I mean, everybody loves resolutions, and everybody loves mocking people who don't keep them. So let's start with maybe one personal resolution and one practice resolution or a professional resolution.

Charles A. Goldfarb:

Okay, I can go first with the personal, you know, it really is parenthood is a super interesting thing, because of its demands on our time, in a world where we're already super busy with work and so making the time to take care of oneself, you do a good job at it. And honestly, I think it's the right approach because if you take care of yourself, you can do all your other duties to to a better degree, life gets a little less complicated as kids start leaving home. And so especially when your third child is also rarely home my Macy's my youngest and she is in 11th grade and she's very social and so she's not home as much and I do try to be careful not to you know, I'm not home enough to I just have to be very careful about how I spend my time at home but I've been able to exercise more and that is my goal for 2022 is to continue this kind of reborn interest in working out on a regular basis and multi training and all those kind of things so I'm super excited about it and looking forward to it being a great year.

Chris Dy:

Now, how do you envision kind of keeping track of this or you know, because usually people's resolutions in January come down to health stuff is there a strategy is there a you know an accountability partner is there all sorts of stuff or is just standard Chuck Goldfarb put your head down do the work.

Charles A. Goldfarb:

I don't believe in all that junk I was just gonna work out and it honestly it started and I've got I've been pretty good over the last couple years actually but I if I can, and you may laugh at this as being less than ideal, but if I can get four to five days a weekend it's a huge accomplishment weekends are easy. And usually, sometimes on Fridays I can escape. I have a hard time getting up early to work out occasionally I can do that. But I think from various different ways I can. I think I can get four to five days a week and doing different things whether it's running biking, peloton, or even using the rower or the heavy bag in the basement.

Chris Dy:

Oh, man row, I love rower. So, whenever I feel back into pre pandemic, when he would travel to a meeting, and the hotel had a rower, I was always so excited.

Charles A. Goldfarb:

Yeah, I like it is quite a workout. And the other thing I've been doing, and this is going to feed into the second part of this pod is that I've been doing a lot of push ups. And so we had a heavy interview day recently where we interviewed 38 outstanding resident applicants. And I made a point that five times during the day I broke out did push ups between interviews, and it was a great way to both get a workout and stay awake and stay, you know, engaged.

Chris Dy:

Oh, man, I'm totally gonna hold you to that during our fellowship interviews. That's awesome. It was good. No, you know, who's a sneaky sneakily, really incredibly fit person. Ryan Calfee?

Charles A. Goldfarb:

Oh, I know he is. Yeah,

Chris Dy:

I guess it's not sneaky, then. But, you know, in his clinic, he seems to sneak in some feats of strength with our trainees.

Charles A. Goldfarb:

Yeah, they are all engaged in the nurses and Ma's as well. All right, what's your resolution?

Chris Dy:

You know, my, my resolution is, and I can have a separate professional one too. But I think, you know, personal and professional kind of blend together in this one, I noticed that, you know, in times where I get a little bit stressed, I'm not the best at treating people like people, and really understanding kind of where everybody's coming from, and I can get a little transactional. And I certainly don't want I think that's honestly, it's a it's a generational thing. But I don't want to put blame on that. I think it's my personality of always trying to kind of like move to the next thing. I don't think everybody sees the world the same way that I do. And I tend to get trapped in just this, like, you know, how can you do your job so that I can continue to do my job thing. And I need to get better at that I need to understand where people are coming from their perspectives that you're gonna laugh at this, that not everybody is there to help me achieve what I want to do. Which is so so hard as a surgeon? Because you just assume that everybody has your interests in mind, which is not always the case.

Charles A. Goldfarb:

Well, that's it's really well said, and I think all of us can do better. You know, what, what the pandemic and the pandemic or related challenges of our workforce have shown me is that, you know, we have to be aware of different people's priorities, different people's goals, and trying to engage our nurses and amaze, in particular for outpatient care and our nurses for surgical care. And, you know, our workforce is suffering. So it's just incredibly important. We're, I don't think we're ever going to lose sight of that in the future. But I think we've taken that for granted for too many years.

Chris Dy:

Yeah, absolutely. And, you know, I think that the way that I'm going to try to operationalize this resolution is to actually try to talk to people more and slow down a little bit. And really, because I, you know, for example, like the our team that I work with the Street Bridge routinely, I mean, I kind of know what's going on, I kind of know them, but I actually want to get to know them as people because I think that's the the temptation especially as a young surgeon, trying to be busy and trying to get things done and, and rightfully so at times focused on patient care and cases, I don't really get to know people as well. And I think that's my personality. That's, that's something that I need to work on. So I'm going to try to get to talk to you more to get to know people more, you know, who worked with me. And so maybe you can check in with me and make sure I'm doing a good job on that one.

Charles A. Goldfarb:

I definitely well, I like that. All right, come back with one work resolution.

Chris Dy:

Um, I went well, I mean, this is gonna sound bad, but I want to get more efficient with my motion during surgery. I feel like there's still some wasted motion and I want to be as efficient as I can and try to be better about engaging the trainees about their efficiency. I tried to show wasted motion I tried to show point out to them when there is wasted motion but I think that I'm not as good at that myself. Like I've I've kind of like the the way that I do things but I think there's definitely room for improvement. So I during cases I want to say how could I have done this case even just a little bit faster, or a little more efficiently and maybe even better.

Charles A. Goldfarb:

I like that. And I know you know, teaching surgical technique is always a very interesting proposition it, you know, you have to feel very comfortable with your own technique before you're going to feel comfortable with teaching technique. But it's, you know, it's, it's what we need to do. And we have to do it at a high level. And therefore, self examination of how we get through cases is incredibly important. So I love that. Love that.

Chris Dy:

Now, is there anything that your your practice and you know, is probably a well oiled, finely tuned machine at this point? Everything's on cruise control? Is there anything you're trying to make a little better either in the practice realm or the admin leadership realm?

Charles A. Goldfarb:

There's too many things to mention, I think, what I need to do a better job of and yeah, I know you do this? Well, because we've talked about it a five year plan or, or kind of a longer range planning. I think, for me, it's about that I need to do a better job of sitting down with my wife and talking through things, as well as you know, really kind of re examining my goals, I'm at that point in their career where I need to understand what I want out of the rest of my career instead of as, as we joke, kind of just putting my head down and, and continuing what I'm doing, which is very rewarding, and you know, all good, but I think I need to be a little self reflective, I've never had a coach, I don't think I want to get a coach, but sort of have that conversation. My wife is my wife is a social worker and, and specializes in counseling, and is really good. So I think we'll have to sit down and have some conversations, which will be important.

Chris Dy:

Interesting, you say that about, you know, not wanting a coach, I kind of think I want to coach, you know, in terms of talking. So I when I was at one of the, you know, seminars, workshops that I was helping with on clinician scientists, several of the faculty members were talking about how important it was to have a leadership coach. And, you know, that's something that I don't think is typically available through our institution, for people that aren't chairs. But I think at other places is more widely available.

Charles A. Goldfarb:

But let me be very clear, I in no way would judge ever anyone with a coach and a negative light. In fact, I appreciate it. And maybe that's why I said that. I'm just, it would have to be exactly the right person. And that's what makes me nervous. Right, right. And how do you figure that out? I don't know. Cuz I don't think it's something you can interview someone for. I think it's a relationship thing. And maybe it'll happen one day.

Chris Dy:

Yeah. I'm not surprised that Chuck Goldfarb is very specific with how he wants to be coached. I'm not I'm not surprised. Do you? Maybe Maybe, I don't know, as a basketball player. Were you hard to coach? Were you that specific back then?

Charles A. Goldfarb:

I think I was very hard to coach as a child simply because I was headstrong and didn't do a great job listening. Hopefully, those those things have changed. Maybe not.

Chris Dy:

I did I do know a couple of people in the kind of orthopedic leadership room who are very Chuck Goldfarb like that do have coaches so they can exist, it's just a matter of finding them.

Charles A. Goldfarb:

I think that is well said. Well said. All right. I have a case for you. Okay, okay. I have a middle aged well, you know, what's crazy is, the patient is me is and we'll get to, but I'm sitting in clinic yesterday, and I take this adorable little 17 month old child to get a mini CRM, and I have to enter their date of birth and their medical record number. And their date of birth was July 24. Night. Damn, sorry, July 24 2019. Is that right? Now? 2020. So the child is 17 months old. And exactly 50 years younger than me, and I was like, Oh my God, for some reason that like hit me like a hammer. Okay, so I mean, 50 years younger than me.

Chris Dy:

The math just works. Somehow chuck the math just works.

Charles A. Goldfarb:

So the parents are sitting there I kind of pause. They're like, look at me, like what's going on? And I was like, I'm having an existential crisis. I'm sorry, excuse me for 30 seconds.

Chris Dy:

They're like this old man just have a stroke like.

Charles A. Goldfarb:

So, alright, I told you about in a lot of push ups. Not that anyone would notice. But it may or may not be related to my newest symptom, which is I have no constant numbness or tingling in my fingers. I have no provocative peripheral nerve signs. But occasionally, when I reach for something, and it's not necessarily Ford is not only said abduction of the shoulder, but I'll go to bed and reach for something. And I will get a clear, sharp nerve pain to my index finger, period, end of story. And if it's an impressive enough reach that can linger for five minutes or so. And it's the tip of the finger in the dorsal aspect of the finger, I have no neck symptoms whatsoever. What do you think?

Chris Dy:

So, dorsal aspect only.

Charles A. Goldfarb:

It feels more dorsal, but I think it is pulp and kind of radiating some dorsally

Chris Dy:

terrible patient, terrible patient. Terrible. So, you know, I guarantee you there's a therapist or various students, hand surgeon listeners probably gonna nail this before I do. But you know, I think that a lot of times patients can have symptoms that are related to their cervical spine, even if they don't have Frank radiating radicular type symptoms. So that's probably the first thing I would think of, you know, is just some irritation of one of your nerve roots. Probably see six based on the way you're describing it. You if you're saying it's more dorsal than anything else, and you know, maybe it's some irritation of the radial nerve, but I think that's highly unlikely to be honest with you, I would suspect, more cervical irritation before I would suspect anything involving the radial nerve. When you said index, I was starting to think kind of lateral cord, you know, contributing to the median nerve but it's kind of unlikely to pick just that off. So I think common things being common, I would probably peg it more towards the neck. But this is the challenge right is trying to figure out kind of where things are coming from and then finding weakness. And you know, I've diagnosed a few people in my clinic have come in for rollout carpal tunnel, etc, with you know, C six and stuff in it and there is some subtle weakness and things like elbow flexion when you really push on people now you're not going to find it if you're doing a cursory examination. But you know, one of the things that I learned from Elizabeth Hoggart was you, you really got to push on people. You know, and I think people are surprised with how, how vigorously I will examine some patients. But, yeah, sometimes you'll you'll find some cervical stuff. I don't know, what do you think?

Charles A. Goldfarb:

Well, I certainly that's why I was trying to do a self furlings and all the, you know, cervical assessments, for sure.

Chris Dy:

I hope there's a video of you trying to do a self Spurling, so I'm not gonna do it here. Anybody who's not watching the YouTube channel, Chuck, this tried to Spurling himself, and he looked like somebody in a headlock.

Charles A. Goldfarb:

It's true. So in a patient like this, do you start with who's minorly impacted? Couple times a day feels a symptom like this, and maybe as part of the patient centered care, but do you start with sending them to therapy and work on nerve glides and stretching? Or do you start with either a nerve study or, or a referral to someone else?

Chris Dy:

I probably wouldn't start with, with, with getting any testing at this point, it's still early on. If I was able to find some other finding that would corroborate suspicion for cervical spine, I honestly would probably just start you on, you know, either, you know, some oral anti inflammatories, if you're able to do that, or a short course of an oral steroid, which can sometimes just wipe things out entirely. But it's probably more time than anything else. If symptoms become a little more frequent and bothersome, then I think that of course of therapy can be very useful.

Charles A. Goldfarb:

When you think about nerve glides, I've always wondered, does that make any sense at all? And maybe we should invite our therapist superstar Macy back. But when you think about nerve glides, what how do those work? And what how do you think about nerve glides?

Chris Dy:

So in brief, I mean, I think the goal with the nerve glide is to try to I mean, it's in the name, but keep the nerve gliding, and keep the the tissue around the nerve, nice and compliant, so that it's not getting stuck anywhere. The the rub with nerve glides, though, is that there are only as when they're done well. And when they're done to the appropriate duration, they can work very well. I think that the the challenge is getting patients to understand exactly how much they need to push in the amount of discomfort they should be feeling and not to cross that threshold. Because if you have somebody who is an overachiever, and over does it, they can actually be set back by the nerve glides. So I think it's it's something where with the proper instruction, it can work quite well.

Charles A. Goldfarb:

Excellent. Thank you. Thank you for your thoughts. Hopefully, I'll not be really seeing you as a patient but just this informal consultation.

Chris Dy:

I'm sure I couldn't find some weakness in Utah. So So I have a challenging case last week that reminded me of a prior challenging case I had a couple of years ago. So I had a patient who You know, a few years ago had a PAP fracture dislocation. And the classic pattern, you know, kind of a dorsal dislocation with a small hole or fragment that by definition based on the categorizations, small piece like 10 15%, but just was grossly unstable. I tried to dorsal blocking splint that was not satisfactory, as soon as we took the splint off, even with closely monitoring on X rays by incremental relaxation of the, the blocking was still unstable. So I was trying to figure out what to do for this patient. What's your next step in that stage? So say you've got a small fragment 10 15% of the volar lip of the base of the middle phalanx, but you have continued subluxation of the joint.

Charles A. Goldfarb:

Yeah, those cases are interesting, because it doesn't really fit, right, you think we're about a fragment that size? Is that fragment really contributing to the instability? Or is it more of the soft tissue envelopes? Nonetheless, eat at the fragment may not be the reason this patient's unstable fixation of that fragment, could be considered as a role to reconstruct that door that that buttress that volar buttress. So for me, it would depend on what I thought about the fragment. And if I thought that fixation of it would would increase the stability, that would be my first choice, because I prefer that over any type of traction, situation, or distraction of the tip joint. Others might consider placing simply a dorsal block splint, I'm sorry, a dorsal block pin to function in the same way that a splint does, but you know, can be a little more effective. I don't love that treatment. So that's not my first line. My first line is if I think the fragment is reducible, and can hold a screw, that would be my first choice with a distraction setup as the second choice.

Chris Dy:

So like 1315 Screw situation.

Charles A. Goldfarb:

Yeah, absolutely. Where I typically release the volar plate from the fragment. So we're gonna leave the volar plate attached proximately. Free, so let me back up. So Bruner, type incisions, a V shaped incision centered on the volar tip joint, protect the neurovascular bundles on either side, open between a two and a four and retract the flexor tendons and go down to the volar plate working a little more distally that we typically do, I typically approach things from proximal, but this is approaching it from distal. So working on the fragment should be easy to identify, elevate the volar plate insertion off of this bony fragment, and then try to reduce it anatomically. Usually what I do is I put a K wire in on one side. And typically that's a 0.035k wire. And then on the other side, I've gotten the reduction, then I'll put a screw in. And then I'll remove the K wire and put a screw with a K where I used to be, again, if the fragment allows it. I'm not sure what your sense was about that fragment? Yeah,

Chris Dy:

I mean, not for this particular case. But having had the, the opportunity to explore small fragments, I find that the more you mess with the fragment, you know, it's diminishing returns. So caution for those that are taking on what Chuck is describing, yeah, if you can get some screws in a fragment and have that act as a proper buttress to joint dislocation or subluxation. Great, but you know, those are one chance pins and one chance screws,

Charles A. Goldfarb:

I think that is really well said and what we as the surgeon need to be super careful of is properly identifying those fractures that will that will allow this because if there is combination of the fragment or dorsal to the fragment, so further combination along the joint line, this will not only not succeed, it can make a difficult situation more difficult. So I you are 100% Correct. And I agree with that caveat.

Chris Dy:

So you know, you're saying if you can't do that your next option would be attraction, dynamic experts kind of thing. I mean, you're there. You've already got the approach. Are you are you doing a little boilerplate advancement, a little boilerplate arthroplasty while you're there? No,

Charles A. Goldfarb:

no, I'm not. I guess if they'll be exception, so many of our listeners will have never seen a volar plate arthroplasty. And again, not to keep harping back to my training where things have dramatically changed but overplayed arthroplasty used to be the treatment for these volar fragment volar fractures with joint instability and it was popularized in New York and I think in the right hands can still be an effective treatment but most of us don't do it well and so volar played arthroplasty where the vote plays advanced into the site of the fracture has not been a tool for me.

Chris Dy:

I think it's a good surgery and know how to do to bail yourself out If you get into a situation where fixation doesn't work, you maybe have not talked to the patient about a dynamic X fix or in the case of a Hemi hammock gone awry. You know, that is one option. So say you've gone to the dynamic experts. In this particular case that I'm describing from a couple years back, the dynamic exe fix was actually where I went directly. I did not try to fix the fragment, I thought it was too small. And perhaps I was not enlightened by you. And I know that our partner Lindley wall also likes to fix the small fragments. But I went to a dynamic ex fix. They want great patient, it was a little bit awkward on the finger, but it it looked good patient actually moved with it because he was working with this therapist. I know that the the knock on that is, although it's a dynamic ex fix. Patients don't actually move. But yeah, they were they were doing great from that. So we did the dynamic ex fix, and we left it on for I think probably six or eight weeks or something like that. And time came for the ex fix to come off. And we were happy with it looked rock solid on the the office floor scan next week, unstable, right back out. Not a good feeling. What do you do now?

Charles A. Goldfarb:

And now you're in trouble? You know, the bailout at this point is I think you have to try to understand why, you know, obviously, why did it fail? Was there something about your construct? It doesn't sound like it, especially if you're getting good motion with your fixer is probably not the construct? Is there some unrecognized additional soft tissue injury, which again, should have healed? Is the volar fragment larger than expected and not healed and therefore contributing to continued instability? I think you have to be just carefully examine all the variables to see if you can identify why it failed. And you might not not be able to.

Chris Dy:

Yeah, I think we thought pretty critically about it. And to me, it just came down to the fact that it wasn't a strong enough bony buttress. So we went to the next level, and at this point, are you the only other option I'm aware of that would work in this situation is a Hemi Hemi.

Charles A. Goldfarb:

So I am a fan. Not everyone is as you know, one of our partners does not like or believe in the Hemi handmade because he doesn't believe he can make it work. You know, I did my training in Cincinnati and Cincinnati and Indianapolis and Louisville had a annual meeting. And in the impact of Hill Hastings certainly was felt in Cincinnati. And there was some research done about the MMA technique while I was in Cincinnati. And I think it would be a really good technique. It is one of those procedures that I do think requires meticulous workmanship of the fragment. So harvesting the right fragment conjoining, the fragment to the right specifications and satisfactory fixation. So it is not a simple slam dunk guarantee great outcome, but I think it can, it can be really, really good.

Chris Dy:

Yeah, I agree. I think it's one of the more technically demanding carpentry jobs that we have to do in hand surgery, if not the most, to be honest with you, because I think it's not just harvesting the graft appropriately. But it's also getting your recipient bed ready so that it can receive it appropriately. And I think that's honestly the biggest challenge of that surgery is making sure that your graft is shaped appropriately tilted appropriately, to act as a buttress. And for those listeners that are unfamiliar with this concept, you know, the at the CMC joint, the distal aspect of the handmade, has a very nice articular surface that matches essentially what the base of the middle failings has. And it's that kind of where the fourth and fifth metacarpal base articulate with the handmade that's very similar to that condylar ridge that's present at the base of the middle failing. So you essentially, look at your defect that you have if you have an irreparable base of middle phalanx fracture, look at your defect, go look at your me hand or your handmade harvest a portion of the handmade with a saw kind of chiseling it out and then bring it on to your to your middle phalanx and then using that to recreate that concavity and that lip of the base of the middle phalanx.

Charles A. Goldfarb:

Yeah, well said and hopefully the listeners can visualize that they are not already familiar with the technique. It can be a game changer, I mean, it can salvage that tip joint, you know, when I have not always had great outcomes, and I think sometimes arthritis can set in more quickly than we might expect and the head of the proximal phalanx might not be as good as we hope that can be one limitation. And, again, as you said, the carpentry matters but In the right setting, you can take a finger, that's not really salvageable. And you can get a great long term outcome.