The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Finger Fractures
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Chuck and Chris answer a few listener- submitted questions and then take a deep dive into their approach to finger fractures with a specific focus on Kirshner wires, k-wires.
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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 Goldfarb:Please subscribe, wherever you get your podcasts
Chris Dy:And thank you in advance for leaving a review and rating that helps us get the word out. You can email us at Handpodcast@gmail.com. So let's get to the episode.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:Fantastic. It's gonna be a great day. It's beautiful St. Louis, I think it's gonna be reasonable temps all good. Absolutely.
Chris Dy:So today is the day where my daughter has decided she wants to take bike riding lessons. She is strong willed, I think is the way to say it. And so for her birthday, last year, I went out of my way to go down to the bike store and you know, get her a real quote, big girl bike because she was turning five. And it was time for her to learn how to ride and she just looked at it and then refuse to get on it. So but for some reason, like last weekend, she's like, next weekend, we're doing bike lessons. I was like, okay, and you know, fortunately, my wife has been the one that teach our children to ride a bike. So I think it's because I'm the one who actually takes them out once they learn how to ride. So yeah, it's a big day in St. Louis, we were just talking about the weather when I went upstairs. So that's
Charles Goldfarb:so awesome. It's funny. My wife is the one to teach my children how to drive that's more recent for us than the bike riding. We are first to learn to bike ride in a traditional fashion. And honestly, neither have loved it. So we really didn't do a lot of bike rides and found my third kid did like riding and during the pandemic, we rode all over, which was super fun. But she learned to ride on a what's it called a glider where there's it's basically it's just simulates bike riding, and you kind of use your feet, it actually was cool. She learned to balance way sooner than the other two. But then you get used to using your feet to break and it causes all kinds of problems on the regular bike. Well,
Chris Dy:I will say that my son did use the balance bike. And he he's great bike rider and we did ride a lot during the pandemic. You know, I remember a lot during the pandemic, early stages, but my my daughter is not not was not as keen on the balanced bike. And to bring it to something closer to you. My wife has already told me I'm not allowed to teach them how to drive which is great. I'm very happy about that.
Charles Goldfarb:Absolutely. It's not fun at all.
Chris Dy:I don't think I drive. I don't think I drive aggressively. I just drive defensively and to drive defensively. We have sometimes had to drive aggressively. Well
Charles Goldfarb:said I like that. I like that a lot. Yeah, I don't you know, I remember learning to drive. But back in the day, of course, especially in my family, we are learning to drive on a manual transmission. And so it was a old CJ7 Jeep with what they say three on the floor, the big long bang, and it was three years and that Jeep would balk. And it was crazy. But it was my mom and taught me.
Chris Dy:That is the most Alabama thing I've ever heard you say. I actually I My first car was a manual transmission. And God I miss it. I should still put my hand when there's a most cars now don't have an actual like gear knob even for an automatic but if there's a car like a rental car, and there's a gear knob I like put my hand on it still I don't I'm just used to putting my hand there.
Charles Goldfarb:Absolutely. But I'd say and we've talked too much about it. But one more anecdote is that Thank God, I don't have a clutch as I wouldn't be stuck at home with my recovery. I have my left knee done, I can drive to work I would be it would be a problem.
Chris Dy:Oh man, you're right about that. You're right about that. But whenever so we were on a vacation last year, and we were in Italy and I loved getting the stick shift. I mean, it's was crazy such throwback, so to say but yes, we have talked way too much about that topic. But we should. We have some really interesting cases to discuss to kind of grab bag of emails and whatnot. But the upper hand is sponsored by practicelink.com, the most widely used physician job search and career advancement resource.
Charles Goldfarb:Becoming a physician is hard. Finding the right job doesn't have to be joined practice link.com for free today. And you can actually specifically look for the URL www.practicelink.com/ theupperhand, I, as maybe we have many have discussed, I have many roles in the department. One is that I head up our neurorehabilitation program and I was really happy to hear that a candidate for our program found this on practicelink.com. So I have nothing to do with where our jobs are posted. But we post on practicelink.
Chris Dy:awesome, awesome. Well, you know, practicelink also going to exhibit at our WashU nerve course, which is about 10 days away. So we're really excited about that. It's gonna be a superfund course. So if you haven't signed up yet, if there's still spots, go check it out. Be there may there may not be and I did confirm if you just Google Wash U nerve course you will find our course website
Charles Goldfarb:Thank goodness because I've been trying to find it to register this.
Chris Dy:I'm sure I'll save you a spot check, don't worry. So we we've got some interesting emails, I think the first first one we got was from Matt Tomaino who is a practicing hand surgeon in Rochester and has written some good papers. And so you may know his name. But we he emailed us about our keinbocks episode from, you know, a little bit ways ago, and we said that, you know that steroid injections were not advised in general unless the patient needs to delay surgery and does not change the course of the disease. And Matt was kind enough to let us know his perspective. And he says that his experience has been different. In patients with stage two or Keinbocks he thought that the acute development of pain may be more synovitis related, as opposed to coming from the bone itself, and that a cortisone shot can really help with with pain relief. You know, he routinely opposite thinks there's probably little downside more like offering an injection for somebody with a small cuff tear that's painful without weakness can make a symptomatic patients asymptomatic. So that's his first point. He did bring us a second point. But Chuck, what do you think about that?
Charles Goldfarb:So first of all, if Matt's listening, thank you. And I've known Matt for a long time, and he has a lot of interesting things to say. And at some point, he could potentially be a really good guest on the program. He's 100%. Correct. And you know, it's interesting, you and I, when we first started podcasting, we worried that what maybe we still do, maybe you still do, we worry that what we say gets memorialized. And we're like, if I say something stupid, we out there forever. And I'm sure we've said our shares stupid stuff. And I don't think this is a stupid thing. But we just start a conversation. And sometimes, I don't know if it's misinterpreted or doesn't come out the way we want. I 100% agree with Matt in one sense, but I probably still disagree in another. So I use steroids, you can't you
Chris Dy:can't 100% agree. And then in some senses, like 95% agrees.
Charles Goldfarb:So I do use steroid injections. And my my speech to the patients is very similar. So I explained that if I'm giving a wrist injection, whether it's for Keinbocks or for potential TFCC pathology, I'm giving the injection not to fix the problem not to cure the problem, but to take away the associated synovitis. And hope that the pain goes away, short term and long term. But I don't know if it will. So it's both it is not really a test, because we likely know there's methodology, but as a treatment for the setup is not the problem. What I don't like to do is repetitive injections, especially in younger patients, because I think we know that they can be detrimental to the good cartilage in the joint, the restaurant is obviously complicated. So I appreciate Matt writing it. I agree with him. But ultimately, it likely requires more than just an injection in the setting of Keinbocks. That's my take what's yours?
Chris Dy:No, same thing. I mean, I think steroids are a useful thing. And I will do radiocarpal injections for patients with Keinbocks in an attempt to try to quiet things down, you know, because I agree that it is likely synovitis related that I very carefully talk to patients for pretty much everything with the exception maybe of trigger finger, that steroids are not curative. You know, steroid injection is not going to stop this process from going on, it's gonna make you feel better might buy some time. But with the exception of trigger finger meant Aquarians. I think, you know, this is not going to fix it. And I'm very careful with my language. I think we talked about this before that we can't fix people, in many ways.
Charles Goldfarb:Yeah, I totally agree. And, you know, like for tennis elbow, I don't promise a quote unquote, cure or a fix for carpal tunnel. I certainly don't promise. In fact, I say that. I don't know what your we've talked about this, but I don't remember your response. I tell people for carpal tunnel, a classic carpal? Well, you know, we give injections, I give injection for carpal tunnel into into settings. One, if someone just doesn't want surgery, yet, they're a surgical candidate because they have classic carpal tunnel or they want to delay surgery. And then I sometimes give it as a diagnostic test. But if I'm giving it as a treatment, I tell patients that I expect less than 20% will still be improved one year later, to the point that it's almost never a cure. Yeah,
Chris Dy:no, I think you know, when we had our we did, we reviewed an article a large artists large series from Scandinavia probably about two years ago in journal club. And the take home was that 85% of people who had a steroid injection for carpal tunnel, still had surgery within a year. And that's the number that I quote. Now, our residents and fellows have heard me quote that and I think that's really good. So if you tell somebody like this will kick the can down the road. You know, clearly, our experience and our interpretation of the literature is biased because we read surgical literature, and we are surgeons. So there is a number, a vast number of papers out there that would support the use of corticosteroid injections to treat carpal tunnel perhaps definitively. It's just not my experience that it works definitively.
Charles Goldfarb:Right, right. Yeah. So again, goes back to the basics. So have just, you know, conversation with the patient. And it's been fun. My, as I mentioned, my son is a first year med student. So he's on a clinical rotation now, for the first time. And so in the first year they get into clinic, and really not the clinic onto the floor. And it's just amazing like, and it's actually rejuvenate is the wrong word. Because I don't even rejuvenate. But it's inspiring, sort of to kind of see the world through a first year medical students eyes. It's amazing. Like what we do, what we have the opportunity to do is amazing. And watching him soak all this in and learn and have perspective is is awesome. And so some of these things about fixing and about perspective and about really talking to the patient actually means more to me today than it did before he started med school. med school. Yeah, absolutely.
Chris Dy:I mean, I think if once you get the appropriate perspective of what we get to do, as surgeons, you're like, you're meeting somebody, sometimes literally right before you take them to the operating room, you are cutting into them. I mean, for lack of better term, it's a very intimate relationship, especially for somebody doing hand surgery. So like literally holding their hand in the preoperative examination. It's It's incredible what we get to do. You know, and I think that getting to see that perspective as as your son goes through it, as you appropriately like, you know, gives you the right perspective in terms of what we get to do.
Charles Goldfarb:Yeah, and I think it is for him, it's been fun, because it sort of has started to demystify what I do. And also, you know, just make it more real, like with complications and with challenges is really interesting.
Chris Dy:Yeah, normally, he gets to respect that a bit more see what dad does, or
Charles Goldfarb:less, I keep telling him to look at other specialties, but he keeps coming back to orthopedic surgery. And we have so many examples in our department and in our world. This but we know orthopedics and plastics, and, you know, the therapy life, which one of my kids might pursue is we're all lucky.
Chris Dy:Well, I mean, it's pretty cool. We get to do to be honest with you. I mean, you don't have to, you know, you're not dealing typically in orthopedics with in plastic surgery, life and death, although there are the you know, I remember the neck fascia case I did as a fellow. And actually, I think that's probably the only time I have saved the life was with the neck fashio case. But other than that, it's you're dealing in different margins. So yeah, I mean, actually, your point about your son in surgery, and that kind of thing is really interesting, because we had a response, an email from Bob Vandermark. And Bob is a great friend of the podcast and, you know, mentioned that we talked a little bit about doing deep trance surgery a couple of episodes ago. How do you feel about Jupiter in surgery awake? Because that's Bob was trying to tell us that doing wide awake for this has some advantages that I think clearly it does. And he sent us a nice article from Don Lalonde's group about kind of pearls about doing wide awake surgery for dupes.
Charles Goldfarb:Yeah, I I in the right setting in the right patient with the right kind of dupes. I totally agree. And I see the benefits, you know, you have less bleeding. Yeah, it's a it's a procedure that can go quite smoothly and be quite predictable. My concern is that sometimes these are, and maybe Bob's not suggesting we do these for all cases. But it can be a longer case, it can be a more challenging case. It's just in our setting. It's not been easy to do. But I will say I read the article. Thanks, Bob. And thanks for writing in. And I think it's a fair, fair suggestion. And for the right, the right for the right patient in the right practice setting. I think it makes all the sense in the world. What about you?
Chris Dy:no, I've actually done some one week dups. And it's not my default. But I mean, I think as if I'm doing a dups and somebody who's clearly at risk for having anesthesia related issues, at least from my rudimentary understanding of that, I do it. You know, so it's, it's not something to be brutally honest, it's just harder for me, like, just like, I can do it, I can do it. Well, it's just more stressed. Because you're, you know, dupes can be stressful, as we talked about, like, you know, like, I think I said on the last episode that, you know, it's, it can be a very humbling, humbling disease process and a formidable foe in surgery. Because just when you think you understand do patricians disease, it throws you for a loop. So and I don't want to be thrown for a loop all the patients awake, especially if you're heavily involving a learner.
Charles Goldfarb:Well, that was my point. And I think that's exactly right. We there needs to be verbal interaction, comfortable, verbal interaction with a resident or fellow in what you're seeing and what you're doing. And, and that can be tricky in these situations. And so that's the balance. I think, if I was not in a situation where I was teaching, it might even make more sense if I was working with a, you know, a PA, for example. Yeah,
Chris Dy:no, absolutely. And I think that, you know, so this article that that Bob forwarded us is in PRS Global Open so people can go download it for free. It's called tip tricks and tips, tricks and pearls for a superior patient inserted experience for wide awake SuperTrend surgery. first author is Natasha Barone. And the second author is Don Lalonde. Yeah, I, again, like if this was like a, you know, I'm doing three cases in a day, and I've all the time in the world. And I could just sit and let the block setup for half an hour. And I'll say, it's actually really challenging when you're to be honest, running to rooms, and you're kind of bopping back and forth, etc. Like, for me, like, when I'm doing my normal to room flow, and our learners will attest to this, I'm actually going out and blocking patients between cases, because I'm doing that in holding, so it can set up for a reasonable amount of time. So to then incorporate a block that is admittedly going to be a little more involved and take more time to do, then a carpal tunnel or trigger block is a bit of a logistical challenge. And I know that practice settings are different in different environments, both in Canada and in the US. And ultimately, we do what's right for the patient. But if there's a margin where it's not going to make a terrible amount of difference to the patient, and I have the choice between doing it under anesthesia, general anesthesia versus local, I may just pick general for a lot of things.
Charles Goldfarb:Yeah. So I think that's again, good, good points. And I completely agree, especially with the blog, the way our system works, and when I block the patients, so I hope that I am blocking them 20 minutes in advance of the surgery, because what we all know is the Lidocaine is going to take effect, but the epinephrine may not. And of course, the dupa trends is more important that you have a bloodless field that if you do fantastic, but you know, there have been some carpal tunnels where I didn't have enough time to let it set up appropriately. And of course, everything was fine, and it was safe and etc, etc. But, but for dupa trends, you got to get it right. And maybe that patient comes in a little earlier, you block a little earlier you can get around it, but just another hiccup to kind of the busy day for some of us,
Chris Dy:ya know, there's some really good pros in here. You know, perhaps my favorite one is using the lightning late night FM DJ voice and manner to reassure them with your soothing voice, cheering to surgery. But they do talk a little bit about some of the logistical things about how having somebody checking their blood pressure and hearing the beeps of the anesthesia machine when they're checking vitals. I cannot agree more. It is super annoying. And when patients complain about the most is the darn blood pressure cuff. And I cannot get out get it out of our system because I think the the A O RN has a recommendation that vitals be monitored routinely for patients who are having procedures in the operating room, whether it's under local or not. And I just can't get her way around the policy.
Charles Goldfarb:So we had a good conversation yesterday, we had some folks come in to consult about our what we call the OC one of our outpatient centers, looking at efficiencies, and one of their recommendations which Ryan Calfee and I certainly agree with is, should we and as you have done, it's your facility, use our procedure rooms for hand surgeons and have a day or have a balanced room where you can do local only procedures in crank. And there are certainly stories out there of getting 20 cases done of cartels and triggers and simple things. And, and I know those are true, it's a beautiful thing. Our system, as we've talked about is a little different. But one of the things I said is that, you know, yes, that could work, if I gave one of my rooms to a partner kept one of my rooms and had a procedure room as a local only room that could absolutely work. The problem is our pre post area would be filled with people even if they don't stay long our current process is you know, they have their procedure, they go recover for 10 or 15 minutes even, they don't need to recover. And then they get dressed and they go home. And I said if we're gonna do that, then we have to change our process, which I don't know if we can write they need to wear their street clothes. And they need to as this article says get up and walk out the door, not beyond the stretcher taken back for even a brief recovery in the recovery room. So the article does have some nice pearls.
Chris Dy:Ya know, I think if you were to redesign the system, so if there's somebody out there that's about to start their practice and says this is how I want to do well on surgery, clearly follow the pearls in here about room setup and everything that alone follows. I mean, I remember a camera where they saw him talk about this or read it, like he'll have somebody else he'll have everybody come and he'll have five or six people that get blocked by somebody else, and they just sit there in the waiting room until it's their turn. And that's just not the flow in our particular practice setting. And I would imagine most large academic centers. Yeah,
Charles Goldfarb:yeah, exactly. Exactly. So the other thing we had with these consultants was I really like and I think it's just such a truism that we you know, we all say that politics, you know, all politics is local. All healthcare is local, and it is all in its hyperlocal you know, our center is different from a center across the street based on the hospital system in so many different factors that that, yeah, all of these recommendation from experts or want to be experts is very dependent on your setting.
Chris Dy:Yeah, absolutely. I mean, I think that's even going between, you know, south or two of our different centers and I go to South County you're in Chesterfield. I mean, there are differences when I when I go to different places.
Charles Goldfarb:Yes, absolutely. Um, why don't we thank our other sponsor?
Chris Dy:Yeah, absolutely. Our sponsor checkpoint surgical is a corporate sponsor of the upcoming Mayo Clinic International Symposium on surgery of the spastic upper limb on June 4, the sixth in Rochester, Minnesota. The course is a comprehensive multidisciplinary program directed by Dr. Peter Ree, and Dr. Michael Weinberg on the procedural and surgical management, this spastic upper extremity, Peter, great guy, I'm sure it's gonna be awesome for us
Charles Goldfarb:to learn more about the course and other upcoming educational programs supported by Checkpoint Surgical, including our very own program here at Wash U coming up soon, please visit nervemaster.com. That's
Chris Dy:right. As we mentioned, the course is about 10 days away, or WashU course and spots are going to be you know, really maybe hard to come by me. And I think we'll have some standing room opportunities. But it's really cool. I mean, the cadaver lab is going to be really decked out technologically. You know, we spend a lot of our funds trying to get the appropriate television screens and cameras set up. It's gonna be really cool. So yeah, I'm sure that and I know the Mayo Clinic doesn't really nice course, too. I've been up to their brachial plexus course, back in 2018. I think the last time they had it, and it was great. So yeah, check that out. Thank you to checkpoint for for supporting that course and for supporting us. Absolutely.
Charles Goldfarb:Absolutely. We had a couple of I'm not sure if we have any other. I don't think we have any other questions or mail to discuss. We had some cases we thought might make some sense.
Chris Dy:Yeah, absolutely. Let's get on to some cases. All right, which one you want to use talked a little bit about pinning. You know, I think we haven't talked about pinning fingers in a while. And you know, I think that, you know, in general, how do you approach you know, pinning versus more stable internal fixation? I guess we could probably start just in general with metacarpals versus flanges. I remember an old Marty Boyer quote is plate metacarpals and pin phalanges. Is that still true in 2024? Yeah,
Charles Goldfarb:I mean, that was a that was again, that was a truism. And that was absolutely our approach here at Wash U. And that is not what I would say is that is the case in 2024. Here, watch, you think to some technological advances. So essentially, I just saw an x ray of a relatively transverse fourth metacarpal, fracture markedly displaced. It actually had an extension, a long extension all the way to the joint that was completely non displaced. And kind of debating what the best approach for that is. And when I'm taking care of kids, Lindley wall is my my partner, this child may come to the shrine as early adolescent. And the question becomes, and Dr. Wall is, I would say, a master painter, and does a huge number of these type of cases, and she pins everything, he does it very well and has really good results in the price is right. For metal carpals. You know, as we have talked about on this podcast, I increasingly try to stay away from big open incisions from plating at all. And I've used a lot of retrograde, screw fixation, non competitive or compressive, depending on the fracture pattern. And so I think that's absolutely my go to, for most of these, but some require, you know, a lot of thought and preparation.
Chris Dy:So yeah, I think those are really interesting points. And I think a lot of us are going to headless compression screws or non compression, just headless screws, or in intramedullary fixation, I think is the right term for metacarpal fractures, I think there's certain patterns that are more amenable to that and some that are, you know, that are, would not permit it at all. And I've learned the hard way. You know, so what are the patterns on metacarpal is that you think, Hey, this is going to be great for intramedullary fixation versus ones you're like, I'm gonna stay away from that. Well,
Charles Goldfarb:first of all, I don't think the availability of this surgical technology and these intramedullary fixation options should necessarily change our general treatment. So, whether that be surgical or non surgical, there is an argument to be made like in many spots about early fixation and getting patients out of immobilization and that can make a lot of sense, but you know, shaft fractures in general are you know, we can tolerate less deformity classically Apex dorsal, we can tolerate less of that. And shaft fractures are typically transverse or close to transverse and those are perfect indications and I think with a great reduction, a compression screw can still make a lot of sense. And I haven't seen a difference between compression screws and non compression screws in shaft fractures as the first category.
Chris Dy:Yeah, no, I agree with that. I mean, it's nice when you add a transverse fracture in a shaft. I think where I've gotten where I've had to do a little more troubleshooting is, you know, when the obliquity of the fracture has led, I there was one case recently where the obliquity of this is a fourth and fifth metacarpal shaft fracture. But the fourth, the fifth, had a little bit of obliquity which led the guidewire to, you know, to go outside, you know, to deviate away from the fracture. So, like not Phil was in the fracture, or in the distal part, you know, but then as we're introducing the wire, he just kind of propagated out of the fracture instead of getting into the proximal part of the metacarpal shaft. So, that was a bit tricky. And clearly, we spent some time troubleshooting that and it went really well. And we got all the benefits of the intramedullary fixation. But I think the obliquity can sometimes be tricky. And I've also seen that happen and you know, proximal failings, factors when I've tried to use headless compression screws, instead, in essentially as collateral recessed pins without having them stick out of the skin. You know, so I think there can be some, you know, there definitely some pearls there. I think the big concern that people have about using these central mentally fixation in the metacarpal is, what if you, God forbid, what if it gets infected? What happens there? Like, you know, what are you dealing with then, and I think that that's a very reasonable concern. It's
Charles Goldfarb:a reasonable concern. And that goes to the point of don't Overbury, ideally, so that you can find the screw and take it out knock on wood, I've never had to do that I have sent some seen some bent screws. But ultimately, I've never had to really dig to remove a screw and I don't overly worry about the cartilaginous entry point, you know, what happens to the cartilage there? I just think there's plenty of evidence. First of all, it's pretty dorsal, I don't worry about it. Going back to your original question, and building on what you already stated, it is the distal fractures that provide the most challenge, I think, yes, these can be transverse. But in my experience, at least the ones I've struggled with, both recently in in the past had been those oblique fractures, which are super interesting, because number one, they often go really distally. So they're not ideal for plating either, because they go into the basically into the joint with you when you think about the capsular reflection. And I have a really low threshold for just using a pointed reduction clamp, whether closed or open to secure the fracture. And then once you secure the fracture, you put your non compressive intermaxillary screw in, and I think you're done. And it actually takes it simplifies a really difficult fracture pattern. And I've been really happy with some of those.
Chris Dy:Yeah, no, I think that's, that's well stated. And I think that is the distal kind of neck head fracture that, you know, that can be really challenging to try to address or the plate that I used to go to pick a painting for, you know, so not to doing that as much because I think that the technique you described with an intramedullary fixation can be very
Charles Goldfarb:useful. I think we should for many of those who have never heard of bouquet pinning, and we should probably describe it because I learned that fellowship. And I would say technically, it's not always easy.
Chris Dy:No, it's not easy. It's actually a really good technical exercise to be honest with you, for our learners. And for our for us. I mean, yeah, so you're basically you're pre bending some K wires and inserting them into the base of the metacarpal kind of reel, just after the joint surface and you're introducing them in a manner in which you're shooting them, you make a small little opening in the metacarpal with an awl and you're introducing these pre bent pins, kind of like flexing nails, I guess, is the most appropriate analogy like for a peds case. And you're putting these pre bent pins in and shimmying them up the shaft across the isthmus and then splaying them out and turning them in a way that props up and reduces your supports your distal fracture, so a neck or a fracture that's kind of at the head neck function. It can work beautifully, it's awesome fixation, and oftentimes, you do have to remove them, but sometimes you don't. And it gets you really solid fixation, especially if you have you know, two or three, you know, pins and K wires in there that are supporting and splaying out and providing multiplanar instrumentally fixation. Isn't that appropriately stated?
Charles Goldfarb:Yes, really good. So I before we had the well accepted option of the intramedullary screws, I did a lot of pinning of metacarpals in an effort especially in the adolescent population, in an effort to avoid being a plates and screws for all the negatives they have. And just to be very clear about the negatives not only is it a bigger surgery, but you have a real risk of creating scar tissue and Missing function and having to go back and Tina lice and or take off the plate. But the antegrade haywire, especially for the fourth and fifth metacarpal is something I struggled with a lot. And there's no II, you know, the fourth in some ways could be easier depending on the patient's individual morphology. And what I did on more than more than a few occasions was bury as to your ladder, you know, to your point, bury a single big K wire down the shaft or the fourth metacarpal at the set that we aim for the owner base of the fifth metacarpal sort of right adjacent to the insertion of the ECU is tricky. It's tricky to hit, it's tricky to expand. And so this retrograde options are far superior,
Chris Dy:right? Absolutely. If we were to have like a you know, technical trial thing for people practicing hand surgeons like a, you know, Olympic trial kind of thing I would put bouquet pinning is one of the things like you know, you got to repair a nerve, you got to repair a vessel, you got to do book a pin, you got to you know, but it just always played on like, you know, it's a technical challenge. I think it's it's a really good one to do. And then one way in which you can separate the grownups from the kiddos. So to say,
Charles Goldfarb:my Hansard Olympics, I like that. I will say a few weeks back. I had a day, shortly after my surgery where I was coming back and I asked for just a half day and I had some great pediatric and congenital cases, and then Dr. Wall must not have been available. So I kept adding on fractures. And I ended up with four or five fractures and one of them and they were, you know, they were found geo fractures or metacarpal fractures, I pinned them all. And one of the metacarpals I pinned and I think in a young adolescent, often with a boxer type fracture young adolescent male who punches something. I don't I don't know that that situation necessarily benefits from a screw. And I think putting k wires in for four weeks is well tolerated. And you know, putting a cast on or however you want to handle it. I think it's very appropriate treatment.
Chris Dy:Yeah, I think for metacarpal is I think people will move their fingers with pins for a metacarpal I'm less likely to see people move their fingers with pins for a failing geo fracture. Do you agree that in general that that holds
Charles Goldfarb:100%? And it's interesting, it's very patient dependent, obviously, but I totally agree. Right? So you can get away with early motion of the IP joints, typically, and hopefully of the MP joint with a painting of a metacarpal. It is tricky, especially with younger patients, when you get into the balance you'll fracture. So what has your experience been with? We've seen some marketing about the headless screws as mandatory screws for Fangio fractures, have you done it often have you done it at all?
Chris Dy:I have, I wouldn't say do it often. I like it is if if you can, you know we talked about with a say like a you know, relatively transverse, proximal phalangeal fracture at you know, sort of sort of the base that's extra articular that you would typically use a collateral recess pin for so introducing a pin essentially at the insertion of the collateral ligaments at the base, and then shooting your pins distally in typically a you know, antegrade crossed pattern, ideally crossing distal to the fracture. I've used headless compression screws as a substitute for collateral resuspend. So essentially act as internal fixation. You know, obviously, you get the benefits of percutaneous fixation percutaneous approach with the benefit of internal fixation in the right pattern. That's awesome. Because it really works well. And you know, I think people are on social media and stuff, there are some surgeons that are pretty, pretty good about posting their different constructs and seeing all the kinds of options and that's where having a range of sizes on your head, the screws can be useful. But sometimes it doesn't work out. And then you're left with, you know, you've already kind of made a big hole and you're dealing with, you know, sometimes the pattern is such where if it does have an intra articular extension, and you don't recognize it, it can be super challenging.
Charles Goldfarb:Absolutely. So I just looked up the ones we use and I do have a conflict of interest, but not about this particular product. These are the ones we're referring to are the X Men nails, and for the metacarpal they are called the innate for those who are not familiar and for the Fallon Gio fractures, they're called the inframe. And I say that I work with acne men on other things, but not not on this and this product was developed by an external company and it was acquired by by, by Oh my god. This product was acquired by alphabet. So I
Chris Dy:want to say before he before we go into that I mean, I you can use, clearly you can use other headless compression screws, just a lot of these companies because I don't use the the intimate products, I don't use those. So there, there are other companies that make headless compression. So there's clearly there are just there are fewer versions that are not compressive. Just straight intramedullary fixation without your threads that are going to compress. Yeah,
Charles Goldfarb:well said and really important. Absolutely. Because you're right, we don't have these on the shelf. And so if I want to use it for a metacarpal, or wherever, and to me, again, the most important time to use the non compressive is an oblique fracture where you don't want to compress. Good point. Yeah, I think I have done these a few times, I have to say, I've just may not be seeing enough and doing enough to be facile. I typically use K wires Occasionally, I'll still open and do multiple, you know, small fragment or modular hand type screws. But But I think, you know, if you have to observe the basic principles, right, you want a stable reduction, that allows early motion. And that can look a lot of different ways and be effective. And you have to consider cost time and the or all those things matter. In the pediatric population, what I do see, perhaps more than you, gamers are using the answer. And the difference being and this is super important. All the therapists will recognize this is super important for the simple reason that kids are less likely not not, it doesn't, it does happen, but they're just likely less likely to get stiff, they're also less likely to participate in early motion. So it's just a it's just interesting facts.
Chris Dy:Yeah, no, I think that proximal phalanx, fractures and PIP, fracture dislocations are some of the most humbling fractures that that we have. And I've seen former presidents of the hands society at multiple institutions be humbled by failing to fractures, you know, so and, you know, I've, I've challenged I've been really challenged by some of these, I remember recently, there was an Anamosa. Remember this, there was a day where I did a full clinic. And then there's a proximal feliz fracture that I tried to be cute and add on at the end of clinic in the O R, and it was much more challenging than we than we thought and, you know, it ended up looking great. And we're happy with how it went. But it was not certainly not playing A, B or C in terms of the the the final fixation strategy. But like you said, like you've told me on multiple occasions, you got to be happy with how things look, when you leave the car, and we were happy with how things looked. We just wish we had gotten there much sooner. As as we bring this to a close, I'm going to ask you, how do you handle your pins? So how do you think about, you know, cutting your pins externally, whether you bend them before you cut them? What kind of caps you put on the pins, what you tell patients about the pins, because these little things I think can matter sometimes for our trainees, or learners Excuse me.
Charles Goldfarb:Yeah, so super important question. I want to get to that I want to say something that that is important along that conversation. You know, the thankfully, if you do use pens on phalanx fractures, and you put the pens in in a way where it's safe, you can choose to leave the pin proud at the insertion site, or you can choose to drive the pin in, you know, whether it's integrated or retrograde and have the pin exit at the at the other side of the phalanx. And that's a nice trick to keep to stay aware of, because it can help you manage the patient postoperatively. And so Dr. Wall has taught me and again, this is Lindley wall, who is one of our Hansard partners who is really focused on pediatrics. So we in the pediatric population, there's an entity called a sub condylar fracture, which is essentially just below the proc typically proximal phalanx condors and they typically just tipped backwards. And so they're unstable. So you reduce them and you put pins and you can choose to leave your pins out distally. And then it can be a little bit problematic, they also bind the collateral ligament, or you can drive your pins in in a retrograde direction, and have them come out approximately, in which case they're less problematic and potentially bind the joint less. And so I'm not suggesting that works for every fracture, because there are benefits to having your pen long on the smaller fragments side, if that makes sense. But just be aware that external placement of the pins, you can have choices no matter what your fracture looks like. So that's the first thing I would like to say. Yeah,
Chris Dy:I don't think that's well suited. You know, I think that we had to use that technique in this fracture I was talking about after our clinic recently, so yeah, totally agree.
Charles Goldfarb:Yeah. So the second thing is I do not bend pins typically I will sometimes especially if I think it helps me move the pen away from the skin so it feels like the skin is going but two other pens can put too much pressure on the skin. I will use too. needle drivers and carefully then the pan away from the skin, but I don't routinely do it. And my whole one of my most important concept to think about with pinning is not to violate the far cortex go too far, and then have to pull your pin back. Because then I think you have an unstable or potentially unstable pin and and you have bigger problems. So I hopefully emphasize to learners that were carefully engaging the far cortex and taking a lot of care not to go too far. Yeah,
Chris Dy:tell them to park it in the far cortex. Yeah, yeah. One thing that I learned and fellowship from Ryan Calfee was that, you know, you want to take your knee, if you're going to bend the pin, you want to take your needle driver and hold it proximal I guess, to where you're going to bend the pin, to make sure that that stays nice and stable. Because you know, I think theoretically, and I've seen it happen, bending the pin can displace your, your, your pin itself and affect your fracture. And I usually hold it proximately there with to where I'm bending it with a heavy needle driver. And then I use a Fraser tip suction, suction thing, and I put that put the pin inside of that and use that to bend because gives you a nice lever arm for that I have when I put pin pin caps on and I use I've gotten away from using kind of the less expensive pin caps and use going to Jurgen balls, mainly because I've had some patients and the Dragon Ball. So not terribly expensive to be honest with you. Mainly because I've had patients kind of get freaked out by the fact when the pin caps just dislodge during like routine care. It just kind of freaks them out. So like all right, like the Jergens balls are less likely to come off during that process.
Charles Goldfarb:Yeah, all well said I tend to use pen caps just because they're a little cheaper. And I think yeah, to your point, you want your heavier needle driver as close to the skin even pushing the skin in a little bit. And either been with the Fraser tip or been with another needle driver Totally agree. And you're right, you can displace a fracture with with non careful bending of the pen. Super, super important. How long do you have any hard and fast rules about how long you leave the pins in? I have some thoughts but I'm curious two years,
Chris Dy:however long I can get from the pins typically. So that tends to be somewhere between four to six weeks. So younger kid who would the you know predilection to heal quicker, probably four weeks. But, you know, in an adult that usually ends up being six weeks. If I can get six weeks out of it. I counseled them pretty routinely that you know, a pin site infection is a pretty common thing. And we usually treat that with some oral antibiotics. And if I can get six weeks out of a pin, I will try to get six weeks out of a pin.
Charles Goldfarb:Yeah, I think that's well said. So for adults with proximal metacarpals. Those are always six weeks, and they're big K words, six twos, often, four fives at least or five fours. These are the American system. Yeah,
Chris Dy:as I say like, you know, we actually have a chart in my or in South County with like conversion of like, four or 55462 into millimeters. Because you know, the reps I'll come in talking about like, especially if we're gonna do like headless compression screws. I asked them what size the wires are that you use the guide wires, and they tell me a millimeters and like what's that and American. We have a chart for this particular situation.
Charles Goldfarb:It's so true for distal metacarpals. I typically use the point oh four fives. And those stay in typically five weeks. And then Fangio fractures depends a little bit on exactly where they are, but in adults is typically four to five weeks and in kids is typically three to four weeks. Because I think you can safely take things out and kids much earlier which then untethered things and lets them start moving because many kids will just not move at their pens in and and I don't even try a lot of them. I just put them in a cast and the or see him back at three to four weeks, take the cast off, take the pens out and then go. Do
Chris Dy:you. What do you use as your markers to say when a fracture is healed and ready to remove or at least healed enough to remove pins? Are you going fluoroscopically? Are you going by tenderness? Like what's your guidance?
Charles Goldfarb:Yeah, I wish there was a hard and fast rule for me there is not I think time is probably the most important thing. In a reliable patient pain at the fracture site can be helpful with that patient. I do think callus visible which is often the case for metal carpals is less commonly the case in adults with phalanx fractures, kids will show callus but in my experience, adults don't. And so you kind of have to just go with your gut and go with the time, right
Chris Dy:and if you're getting floor scan images, it's easy to show the patient in real time it's helpful for me that they're if they're non tender or minimally tender to say, alright, we're on our way to healing, but you have to counsel them that they're the fracture line in terms of disappearing like you would see in a long bone that takes a long time to happen in the upper extremity. And I think that the clinical or biologic healing is in advance of the radiographic signs of healing. And I think getting in front of that messaging is important, particularly if you're sending them to radiology for formal X rays in which they will We'll see the radiology reports saying that the fracture is killing as opposed to killed. But if they're quote, healing, and they're non tender to me that's healed. Absolutely
Charles Goldfarb:agree. Absolutely. Yeah, I think to bring this to a close, I do think pinning of fingers is a skill set. Like many things in surgery, some people are have that three dimensional sense, they can do it. Immediately other people have to develop that. It is an acquired skill set for most of us. But it's a really important one for the answer. I
Chris Dy:will I will bring this to a close by saying by repeating a story that I had in my fellowship year, that's I tell often tell our residents and fellows that when I scrubbed with you, early on in the year, when I was a fellow, and there have been numerous trainees or learners that have come from my residency to this fellowship. And we repinning a finger fracture. And you looked at me with such frustration and exasperation, and said, You residents from this program never know how to pin fingers looked at you like because nobody ever let me do that. Thank you. Thank you for that educational opportunity, Chuck, when I was a fellow
Charles Goldfarb:doesn't sound like me at all.
Chris Dy:There might have been an F bomb in there, too.
Charles Goldfarb:I've grown so much since that time, My patience has expanded so much.
Chris Dy:Yes. Now because your son's a medical student. So you're starting to feel like what your son would be like as a resident, so I get you. Anyway, that was fun. I didn't think we've talked that long about pinning stuff. But I know there's clearly more we didn't even discuss. So. All
Charles Goldfarb:right, love it. Thanks. Have a great day. All right, you too. Hey, Chris. That was fun. Let's do it again real soon. Sounds
Chris Dy:good. Well, be sure to email us with topics, suggestions and feedback, you can reach us at hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast. And
Chris Dy: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
Chris Dy:remember, keep the upper hand come back next time