The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Mailbag and Hand Society Preview
Chuck and Chris discuss a number interesting listener submitted questions including comments around our SL ligament episode and the rock climbing episode. We even take a (brief) deep dive into biomechanics! We also share out plans for the ASSH Annual Meeting in Minneapolis.
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Chuck, 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 a 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:Hi Chris,
Chris Dy:hey, Chuck, how are you?
Charles Goldfarb:I'm good. How are you?
Chris Dy:I'm good. It's Friday morning. We're recording, and we're both excited about a fun day of activity and fun weekend coming up.
Charles Goldfarb:Yeah, what you got going on today?
Chris Dy:I'm doing a clinic, and then we're traveling for the weekend. It'll be fun. I'm excited about it. But you know, my my wife, is on this amazing thing of wanting to do all 50 states before the kids graduate high school. So we'll be checking off Nevada this weekend.
Charles Goldfarb:Oh, my God, that's so funny. So you guys will get out there, hike around, see, see the sights, and get back on a plane. ,
Chris Dy:Yeah, basically. But you know, I'm not making them do a PowerPoint at this point. So let me take a play out of the Goldfarb playbook at some point in the future and make them sing for their supper. So to say,
Charles Goldfarb:one day, but that was only for major international excursions.
Chris Dy:OK, that's good to know. Okay, now, next time we go international, I'll let them know. So you're you're busy with school today and tomorrow. Yep, school,
Charles Goldfarb:Thursday, Friday, Saturday, So day two today, which is Friday, the 30th before Labor Day weekend, and this episode will drop on the eighth of September. So yeah, school another school day, and continue to enjoy it and power
Chris Dy:through. Excited about today's episode, we're gonna we've gotten some great listener email so please continue to email us your thoughts and ideas and feedback and corrections, including something that we'll talk about today. So hand podcast@gmail.com speaking of corrections, I was called out by our fellows for misquoting some anatomy numbers in conference. Were you there on that day? I think you were talking about the absence of an FDS and a small finger, and I had a number in my head that turned out to be incorrect. The number that our fellows found was also incorrect. So a shout out to our fellows, Dan Hong, Nick colada and Eric Jang for calling out their fellowship director for misquoting something. So I actually had to go back and I screencapped my fellowship notes from when I was a fellow. I was like, I consider that to be the standard, the source, the arbiter of truth is from when I really knew the numbers as a fellow. The point was not everybody has an FDS to the small finger,
Charles Goldfarb:and what is the number of those who do not the number
Chris Dy:I have is 20% an actual anatomic absence. Now there's a in that book that you co edited, and it's a lovely book. Every hand fellow should have a copy of it. I received no royalties from shouting out Chuck's book.
Charles Goldfarb:I received barely, I received barely any royalties.
Chris Dy:I dont see that book listed on your disclosure, by the way. Dr Goldfarb, Primus manis. It's an awesome anatomy resource. I believe it was you, Marty and Fraser Leversedge, fantastic anatomy book. Our fellows and residents know about the Word documents that have all the numbers. All the numbers typically come from that book, or the book has all the numbers from the anatomy handouts, either way. But in that book, it's listed as up to 75% may have a discrepancy in being able to functionally differentiate the FDS from the FTP to the small finger. Up to 75% Yeah, I believe it's 75 or 70. I can't remember exactly previous manners, cool, so functional versus anatomic, but all that matters is that if you go in there and you don't see an FDS to small figure, don't freak out.
Charles Goldfarb:That's right, and be prepared for that when you're exploring a small finger, the small fingers are the one that we wince a little bit if we have an isolated tendon laceration just because the size. But sometimes, if it's an isolated FTP, it's a little bit easier and a little bit less concerning, at least in my mind, for work of flexion after repair. Yeah, and it's speaking
Chris Dy:of flexor tendons. A bit of a grabback episode anyway. I mean, I remember talking about a an FTP zone one a few episodes ago, I let the patient keep the button. He very, very much wanted to keep the button to give to his granddaughter. He did amazingly well so far, knock on wood. But everything has gone well. So just to close the loop on that, I think we talked about that a few episodes back, yeah,
Charles Goldfarb:you know that the whole keeping the stuff continues to be a question for patients. And I get it to some degree, whether it's removed hardware, which is harder than ever at our institution, although, you know, sometimes it happens. And I we took out a mass a couple weeks ago, which is just a fibroma, and the patient really wanted the mass, and they. Their their logic is, it's my body, it's my math. Why can't I have it? And I just have to say, because you can't.
Chris Dy:It's gross, man. You can have it after the WashU pathologist looks at it, at least
Charles Goldfarb:it won't look that good on the shelf.
Chris Dy:You know, what confuses me at times is how much they want to keep the implant. But again, I guess they've paid for it. And, you know, honestly, a recon plate makes a really sweet bracelet. I've seen it done in New York. So, hey, teach their own.
Charles Goldfarb:Yeah, I think the hardware removals that get a little bit more, but the stuff, and I think we may have talked about this long time ago, in kids, sometimes, if the kid gets older and the family chooses to wait to allow the child to determine whether to remove an extra digit. Sometimes the child will want the digit, and that is freaky to me.
Chris Dy:Yeah, that's that's something I do, like showing people things that are removed if they're awake. You know, I do a fair number of foreign body removals of various varieties, and honestly, it took out a huge Splinter that was lodged in a very uncomfortable place. And it was very gratifying, and I think fulfilling for the patient to know that she was like, not making this up, like it was not a crazy thing. Absolutely, 100% let's move on to the episode. Why don't we go through some of the grab bag and we can talk about what we'll be doing at the hand society coming up, but first, we should thank our sponsors of practicelink,
Charles Goldfarb:absolutely be afraid and sponsored by practicelink.com the most widely used physician job search and career advancement resource,
Chris Dy:becoming a physician and reading copy, they're both hard. Finding the right job doesn't have to be join practice link for free today at www.practicelink.com/the upper hand, that is two episodes in a row where I struggled with the practicing copy. Dan Hong told me I could read it my sleep. I completely flubbed it a lot.
Charles Goldfarb:Yeah, it should not be getting harder. Um, we heard from Rob Gray friend of the pod.
Chris Dy:Yeah, friend of the pod. So Rob, we shouted him out last time when we talked with Sanj about the SL ligament, and he said that he just listened to the pod that morning. Said, great to hear my buddies getting all nerdy about a ligament that I'm not sure exists. Hot take Rob. Hope you guys have a great day. Keep fighting the fight.
Charles Goldfarb:You know, that's gonna rub some people the wrong way, although I kind of hear him it's, it's when you have an acute tear and you go to put a stitch in that ligament, it is just super flimsy, and I never feel like that's an effective treatment.
Chris Dy:Yeah, I would probably say the same thing. But, you know, I'm not there enough to I don't know if repairable tears actually exist. Of a ligament which, therefore, of that ligament, which makes you think, is it truly a ligament? But it is a fiber structure that connects two bones. So I'll give it that
Charles Goldfarb:absolutely all right, we have another one, which is a great question. We only have a handle, rather than a name. Let me read that.
Chris Dy:Let me read this one, because I want you to answer it. Okay, so for those of you that don't know, the upper end is also on YouTube, so make sure to check it out, because this actually is our first comment that we're going to shout out from a YouTube from the YouTube channel. So this is from at James dash, M, w4, sh, thanks for your great show. As always, here in Cincinnati, the big question is, Will Joe Burrow perform at the same level or better since he had his SL repaired? Can you comment on rehab and expectations for athletes who have their SL ligament repaired? Thanks and go Bengals a number of emojis. This is relevant, not only for Bengals fans, but also fantasy football is upon us. So what do you think sports expert, Dr Goldfarb,
Charles Goldfarb:yeah, well, I think, first of all, thanks for the question. I think it's a really good one. And in my mind is this is one of the more serious sports injuries. And the answer to the question, unfortunately, I think, depends on the details. Was this an isolated SL tear? Was it a partial SL tear? Was an SL tear in addition to the other surrounding ligaments. So the degree of the separation, the degree of the injury, really, really matters when someone has a SL tear that leads to marked displacement of the scapegoid with flexion and gapping. It is a big deal repair, which, at a minimum, leads to some wrist stiffness, and at a maximum, leads to other problems. Now the good news about the SL, I think most of us appreciate, is that problems typically develop far down the road, and that is arthritis, and so usually in the short term, you can regain motion, regain strength, and may have a little bit of a nagging injury, but not dramatic, but it's. Problem, and I think the degree of the injury ultimately will determine how well Joe burrow performs this year.
Chris Dy:Got it Okay, so, great dodge, great evasion. Well, invasive tactics, almost like mahomes in the pocket.
Charles Goldfarb:It also, of course, I mean, I assume this is his throwing in because, well, that was actually
Chris Dy:my question. I don't know if it's historian or not. And how does the football throwing motion. How does that impact the, you know, prognosis, the rehab that you do? And then we haven't really talked about Darth throwers, you know, in the past. Is that something that you think is pertinent to this?
Charles Goldfarb:Oh, I do think it's pertinent. And so, and I'm not an expert on the Dart throwers rehab protocol, but I believe that was popularized out of HSS with Scott Wolf. And essentially the concept is, if one goes from dorsal, I'm sorry, from extension in the radial direction to flexion in the owner direction, it is a non stressful motion that allows you to work on motion quickly without stressing any type of repair. That's my take on it. And I think we use the dart thrower rehab protocol, but we're not quite as focused on it here in St Louis as other sites might be. Yeah,
Chris Dy:no. And I wonder how much you know the functional demands on the wrist of if it is a stirring hand, you know what? What implications that has. And it's always interesting. You know, these kinds of injuries are hard for athletes to come back from. I remember there was a wave of papers and knockoff papers and knockoff papers, of knockoff papers, using fantasy football stats to evaluate return to play among NFL players. Same thing with fantasy basketball, etc. And we all know, just anecdotally, like, you know, Kobe was never the same after his Achilles, you know. So, like, it's stuff like that that really gets to you. Now, I think the, like, you said, the devil's in the details, I think for this one,
Charles Goldfarb:yeah, and I just did a quick search, it was, indeed, is throwing, throwing wrist. And so I'm sure he was doing a little, a little bit of start throwing rehab protocol, and he's had he's had time, so we'll see kind of how he does the the injury that worries me, obviously even more is the periluate, and I have seen peri lunates in careers, although, again, it depends a lot on other factors, such As what position and throwing or, you know, skilled arm or not, but that's a really big injury that we tend to see in NFL.
Chris Dy:Yeah, no, I would imagine that's awful. I mean, just outside of the sports population. I mean, paralymates are like the pilons of the hand and wrist. You know, they just don't do well. And Pilon being a distal tibial impaction fracture involved in the joint. Those patients just tend not to do well,
Charles Goldfarb:yeah, yeah. Anyways, great question. Obviously, love talking about sports. We hadn't had a sports topic in a while, because we seem to always be talking about nerve, but
Chris Dy:talking about nerve in quite some time, to be honest, really interesting. Yeah, we've been doing a lot of other things, talking about your knee, et cetera. So we have one one shout out quickly and then some great feedback from another listener. So this is from Bob Vandermark. Bob is a friend of the pod. Been listening for a long time. So thank you, Bob. Chris and Chuck. Look at that. Not Chuck and Chris. Chris and Chuck.
Charles Goldfarb:Come on.
Chris Dy:Just finished the SL podcast with Sanj. Chris, you were so right. It was a masterclass on the topic. You could do a few more episodes, for sure. Thanks for sharing. And I think I completely agree, if people want to hear more, especially if you want to hear more from Sanj, let us know, and we'll get that guy back on the podcast. I feel like we barely scratched the surface on that topic.
Charles Goldfarb:For sure. He. The problem with Sanj is he, he make he sounds really smart because the damn accent and he makes us both sound less intelligent. So I don't know if we want to have him back on. I
Chris Dy:am not threatened by his accent. I feel like, you know, our American accent resonates, perhaps overseas in a very different way.
Charles Goldfarb:Yeah, a very different way. Is exactly right. It's exactly right. Well, you we have a so that that's all the comments I believe that we have on SL, and we have a bunch on the rock climbing episode.
Chris Dy:Yeah. So this came from our listener, Chris, out in Washington. He actually suggested doing the rock climbing episode. So thank you to Chris for for suggesting that. So he said that pull eruptors Definitely come up in the climbers that he see, but it's usually it's isolated to a six it's isolated to a single pulley and get them back to climbing with non op approaches. So I guess you know pearls that he's mentioned, just in general, from a more rehab focused perspective and less surgical, is that it's hard to get climbers to rest because they really need to get them to rest, but they really do need to do that in order to heal. Thermoplastic ring splint. Some available online, or having a hand therapist make one seem to be quite helpful. This is interesting. So a full at rupture might take three months to get back to full climbing, though easy climbing on big holds with an open hand grip can start sooner. Now, have you been able to hold a rock climber down for three months? Chuck,
Charles Goldfarb:definitely not, although it depends. I. I think people who've had even smaller injuries before understand that this is going to take a while to get back. Occasionally, people will wait, but usually they sort of just power through, and ultimately, I think they do fine. I don't think it changes the ultimate outcome. It's just how uncomfortable it is to get there, right,
Chris Dy:right? And I, I appreciate Chris giving me that number, just because I think that, you know, for the occasional climber, I see it's useful to have some somebody who have with some expertise, kind of telling them, Hey, this is going to take a while. It's not going to be quick. And then he also mentions the key of finding a PT or hand therapist that works specifically with climbers, you know, in terms of having them work on areas of relative weakness and climbing technique, because sometimes climbers rely too much on crimp grip, and it might be weak through the rest of the kinetic chain. So I found that very interesting. I don't have a lot of knowledge of that, but I think if you are seeing these folks, maybe reaching out and seeing who in the community, in your therapist community, does have experience working with these types of patients.
Charles Goldfarb:Yeah, it's a really good point. Like many things we do in hand surgery, we have to depend on our therapy colleagues to, you know, consider other factors that may lead to over dependence on, in this case, the crimping technique or or other strategies to overcome weakness. And then his final point is also a good one, which I have absolutely seen he made. Chris makes a comment that that there is a potential for fractures in the skeletally immature so classically Salter hair is three classically based in the middle phalanx, and that can be acute. That can be chronic, overuse. X rays typically tell the story along with a careful clinical exam. Chris makes the point that sometimes an MRI can be helpful. I don't recall getting an MRI for that purpose, but I think it's absolutely fair, and those again, just need rest to do well. I
Chris Dy:think those are great points. You know, something I would not have thought of just as I don't see that population as much, so I appreciate the education from Chris McMullen. Thank you for that. A great discussion. And if anybody has any other pearls on climbing, please feel free to send those in, because it feels like something that people see a lot of, but it's not generally discussed too much in the literature. Aside from that really nice recent article, we review article that we covered. Nick we have one more comment from a friend of the podcast about rock climbing. So I think this is your our buddy, but me, you know him better. Kevin Lutsky, yeah.
Charles Goldfarb:So Kevin was a fellow here in at Wash U initially he was at Rothman in Philadelphia, and he has since moved up to Vermont at the university, and is thrilled to be there. Still has, I think he still maintains his academic bent, but very different lifestyle and happy that Kevin landed where he did. Kevin's email was, I really liked your rock climbing discussion, because I'm a climber, and I also recently gave grand rounds on the topic. I agree. It's interesting that we spent a lot of time focused on pulley injuries, which are characteristic, but so rare. So hand surgeons agree, we just don't see that many of these. Kevin said, on the other hand, overuse or semi traumatic injuries like flexor tendonitis, lumbrical strain, capsular and pulley sprains et cetera, are way more common, but get a lot less focused. These may be prevented by attention to proper technique. And he says slow accommodation to harder grades, avoiding closed crimps, Spider Man pocket grips and not climbing through pain preventative taping does not seem to help in Kevin's experience. And he closes by saying, Great discussion. He references a paper that he was a part of, which is published open access and curious. 2021 time to improvement after corticosteroid injection for trigger finger. And I think this is relevant for the treatment of climbers. And again, Kevin loves the podcast, and I definitely will see him in Minneapolis. Yeah. No. I
Chris Dy:think those are really helpful pearls. Nothing like having a surgeon who and or not only surgeon, but also from Chris McMullen, a rehab doc, both who are very keen into climbing, be able to give expertise, not only from professional and personal perspectives. And I like the article we sent about trigger finger injection because I also found that helpful, because we've had, we had that discussion during the What's New enhance surgery, about how long it takes to get over an injection. And now that I've told patients, kind of two weeks, I feel like some others have been like, oh yeah, it took a couple of weeks to kick in. I was like, oh, okay, good to know. I've also had a lot of people say their trigger got better with observation, because it took four months to get in. There's that too, and I think I should, we should mention that Kevin does a really great job with the hand society perspectives newsletter. It is a very different take on life as a hand. Urgent, and you get a lot of international participants too. So I enjoy reading that, and I really wanted to thank Kevin for leading that effort and for and all the people that contribute to that, because it's more of the, you know, from not the technical, but the personal. So to say, to rip off the tagline for our podcast. But thank you, Kevin for doing that.
Charles Goldfarb:Yeah, Kevin's been doing that for a lot of years, and he has maintained a great a great effort. And it really shows those are always super fun to read, along with timing for improvement. And this article, I think, even said three weeks is the average, and that is, again, longer than some of us might expect. A friend had was emailing me yesterday morning and just was really uncomfortable with decquar veins, and had previously had an injection. I wasn't available because I was in school, so I sent her to one of our partners. She got an injection, and was sort of, you know, mentioned that, yeah, occasionally people have flares where they have more pain. And what was interesting was that started six hours after the injection, and was miserable from a very reasonable person. It was miserable. And I, you know, I gave the standard counseling, you know, and we think ice helps, I definitely would take anti inflammatories. This will pass, but I can't tell you when. I hope you wake up tomorrow morning and feel great, but it could last 48 hours.
Chris Dy:Yeah, those are, those are rough. And I know that, you know, we did a nice paper out of here before I got here. The group from here did a really nice paper looking at the the frequency of flare reactions. And it's not 100% clearly, and I it's usually, you know, I think 20, 30% but I usually tell everybody they're going to get a flare, just in case.
Charles Goldfarb:Yeah, I absolutely warn every patient. And if it doesn't happen, even better, even better. So we have one last, I believe, one last email, which I think was super interesting and and really helpful. I maybe I'll start with it, because, yeah,
Chris Dy:well before, before we do that, I would love you to take the lead on this. But I would love to shout out our sponsor checkpoint, surgical so please join our sponsor checkpoint at the hand Society meeting in Minneapolis in September. They will host an Industry Forum on September 20,
at 12:15pm where Dr Amy Moore and Matt wood PhD will review key foundational studies and current translation of research into therapy, therapeutic use of electrical stimulation to accelerate nerve regeneration.
Charles Goldfarb:They will discuss new advancements in the field and ongoing clinical research efforts aimed at bringing this novel therapy into clinical practice. You can register on assh website or stop by their booth number 419 to learn more about the session and the exciting things going on at checkpoint.
Chris Dy:Excellent. There is some great stuff going on. We were fortunate enough, David and I, David Brogan and I, to be part of the one of the centers and Dr Moore's prospective cohorts to RCT on electrical stimulation intraoperatively for patients with advanced cubital tunnel syndrome. And we now have our own prospective cohort of patients who are undergoing therapeutic, brief electrical stimulation for traumatic nerve injury. So we're excited about that, and wanted to thank checkpoint for supporting that last effort for us. So he has really cool stuff going on. I think Amy and Matt will give a great presentation. So go check that
Charles Goldfarb:out. Our final email is from Long Beach, California, and I apologize if I mispronounced your name, but the director there is Korash Kolahi, and I don't believe I've had the pleasure of meeting korash in person, but I look forward to it, so I'll read his email, and then we can discuss his excellent point. First of all, thank you both so much for the time and effort it takes to put together the podcast. Thank you for recognizing that. Korash really appreciates it, and I know other hand jurges Do as well. I think you're doing a great service. I have a minor correction from the recent rock climbing episode that I thought might be of interest. You had referred to pulleys as increasing mechanical advantage by keeping the tendons close to the bone. However, pulleys decrease mechanical advantage for this very reason, both streaming. I'm kind of laughing at myself, because you and I talk all the time about saying something stupid or being on the record, and we are grateful when people point this out, because we're all we're all learning and reminding ourselves. So, I mean, I'll go and I'm
Chris Dy:pretty sure I'm the one who said this. So yeah, thank you for the correction you
Charles Goldfarb:had referred to police as increasing mechanical advantage by keeping tenants close to the bone. However, pulleys decrease mechanical advantage for this very reason. Bowstring, although of course, not desirable, increases mechanical advantage by increasing the moment arm of the tendon in relation to the axis of the joint. The further the tendon is away from the joint, the more force it can exert on it. Although pulleys decrease mechanical advantage, they provide other more important benefits, including keeping the fingers slender and therefore. Or more versatile and dexterous increasing range of motion, ie getting into a full fist, maintaining a constant mechanical advantage throughout the entire arc of motion, as opposed to a variable mechanical advantage with bow strung tendons. And therefore control is easier. And then he references clinical mechanics of the hand by Paul brand and Ann Hollister, which, of course, is a classic, so really important point. And we can dive deeper, if you like.
Chris Dy:I think we should. I mean, I agree. I think there are some important pearls in there, and I would love to know how you would respond, given that I think you have far more expertise in this area than I do.
Charles Goldfarb:I love how you definitely pass that one on. I don't think either of us would consider ourselves biomechanics experts, but, but
Chris Dy:I like the exchange though. I think this is good. That was fantastic. Sure, there's been other stuff that we've said on the pod where people are scratching their heads saying, is that right? That's not what I see. So please continue to let us know.
Charles Goldfarb:So in doing a little research to respond, I want to emphasize some of the points that korash raised. First for power, the greater the moment arm, the greater the leverage, or the multiplication factor that translates tendon tension force into the moment resisting external load, such as pension grass force. And so the formula, for those of you want to geek out on this is moment equals force times distance, which is the moment arm. And so the example that I found, and I don't, I don't have, I didn't cite this, I apologize, but the example is, if the tenon moment arm is 10 millimeters, then 10 millimeters of excursion will yield 60 degrees of joint motion. But if the moment arm increases to 20 millimeters, it takes 20 millimeters of excursion to yield the same 60 degrees of motion. So there is a limit to the degree of of excursion that we have to regain to gain motion. And so in addition to this work of flexion, which is probably not the right term exactly, but is increased the greater the moment arm. And so I think the point is that the details of this matter, especially if you're taking exams, and pulleys are critical for finger function by decreasing mechanical advantage and decreasing the moment arm.
Chris Dy:Yeah, I don't know if there's, you know, I would love to, you know. I remember when I was studying this, when I was a resident fellow, really getting into the weeds about work reflection, which I think is a concept that was popularized very much in the 90s, and I know that. Think it was Dr manski here that did a lot of work on work reflection, as well as Dr brand. I agreed the details are important with regards to test taking, and it is a balance between providing actual strength, but then leading to excursion in terms of each of the joints, so not focusing on one individual joint, but what the implications are in a pulley system, not looking at things in isolation.
Charles Goldfarb:Yeah, and for the younger listeners, when I was in training, certainly I would say the decade of the 90s,
Chris Dy:1900s
Charles Goldfarb:back, in 19 the end of the last century, which is not that long ago, I think you were born
Chris Dy:in the prior century, when Chuck was in training. Well, I was gonna
Charles Goldfarb:say something smart, and now you totally ruined the moment in the last century, if you had to say what was the predominant research focus? I think we would agree it was absolutely tenant and flexor tendon repair. And two of the leading people in the country happen to be here at WashU, Richard Goldman and Paul manski. And then what's been interesting is our and it's a collective hour, although there are certainly those who remain highly interested in flexor tendons, and we are grateful to those people, our attention has shifted in other directions. And there is no question that at this moment, it's nerve. It's all about nerve.
Chris Dy:I think I there's a lot to be said about that. I mean, I think that, you know, Dr Gelberman had the longest continuously running NIH grant and hand surgery ever for studying flexor tendons. And obviously that grant moved on after he decided to to put his jersey into rafters. So, you know, we talked before about how he's asked probably each of us to take on the grant, and that was a hard thing to say no to. But tendon was just not my passion, and I think it is nerve for a number of reasons. I don't know how much of that is the clinical topic. It's exciting. People kind of get it. It's, I think it's the barrier to entry on nerve is lower than on tendon, in some ways, both from a, I don't know, I don't think, from a basic science perspective, but from a clinical perspective, I think it's something that we just see a whole lot. And, you know. It's the results are variable enough. Clinically, where you're you can clearly see there are gaps in what we understand from a basic perspective, from a surgical perspective, and from a rehab and psychosocial perspective, and that's coming from somebody who, I mean, I obviously have dedicated my career to this, and I don't know how much of it is, also like the people who decide to do some of these things. Is it the interest of the people that are chasing grants and big kind of projects like could that you're you and Lily are doing? I mean, is it the people who are influencing the interest, as opposed to the topics themselves? Because, I mean, basically, you're a hand surgery influencer chuck with your work in adolescent and pediatrics and sports and, you know, maybe they're, they're listeners, uh, younger than us, saying, hey, I want to be like Chuck Goldfarb, yeah,
Charles Goldfarb:I don't think anybody's saying that. It is, no,
Chris Dy:it used to be like Mike, and it's like Chuck the we were
Charles Goldfarb:talking recently in our group about how rare scape lining ligaments are, and you just don't see that many injuries. And therefore it's hard to get for me to get too excited about the research. To your point, the clinical application is just harder, and it's harder to find patients to follow over time, which emphasizes the importance of working collaboratively at different centers. But that was also the problem with flexor tendons, and we just don't see that many flexor tendons as well. Despite being a major center that gets many, many referrals, of course, my passion really is congenital has the same limitations. Now, patients with congenital anomalies often will travel, whereas nerve injuries and flexor tendon injuries and ligament injuries less commonly do so, but the numbers just aren't there, which brings us back to your point, which is well said. You know, nerve injuries are everywhere, and they are quite common. They vary tremendously in location and mechanism and and, you know, combined injuries, but I think that is a big contributor. And for whatever reason it is hot at the moment, I expect it'll stay that way for a while. For
Chris Dy:whatever reason, you just clearly elucidated all the reasons why it's hot.
Charles Goldfarb:I still don't understand, nor am I passionate like you. It's okay. You
Chris Dy:can just send them to David and me. It's okay. Just go ahead. We've got, we've got research stuff going on. So I think before we bring it to a close, I think you've got to run off the off the school and I've got to get some breakfast ready for the kiddos. We should talk about what we're each doing at the hand society. I know that both of us are very excited to join David way, the podcast that hand P is doing, and so we'll end up hopefully releasing that as a bonus episode for for our listenership as well.
Charles Goldfarb:Yeah. So that is a great point. David and I talked a long time ago, and I am really happy with what he has led for the business of hand surgery podcast. I think they're doing a great job. For those of you who hadn't seen it, we don't consider it competition. It's just another hand surgery podcast which is super interesting. Yeah, my, my isn't the other interesting, I hate to overuse that word. The other interesting thing about this meeting is the organizers, who have done a wonderful job, did try to limit the number of presentations or involvement for individuals, which is fantastic. It's better for everyone. There's new people on the podium, and so I have a great week, but it's not overwhelming. What about
Chris Dy:you? Yeah, no, I think that Nina and Nina sue a friend, a friend of mine and Eric Wagner, also a friend, have done an amazing job putting this together. And, you know, it's hard to follow Paige and Megan, and they've done a great job. And you know, I agree with, I think the focus on limiting commitments for each speaker has started with Paige and Megan, and I think they've done it really well this year doing the same thing, because I remember, it's like two or three meetings ago, just and it's a combination of my inability to say no, as well as my procrastination, literally just non stop for four days because I didn't make my slides in time. So I was either talking or in the speaker ready room or meeting with people. And just It was exhausting. It was a sprint. I survived, but it was a sprint. And, you know, I have some talks to give. They're talks that I'm really excited about, and I know I was pulled off of some other things. So sort of thankful for that, although I do love, you know, obviously getting out there and talking about our experience here in St Louis. So, yeah, no, I think for me, the week is starting with being a speaker at the young surgeons at boot camp. So hopefully, think there might still be some slots available. It's really, really economically priced. Well, I think it's under 100 bucks. And I'll be talking about metacarpal and proximal failings fractures, which will be fun our one of our partners, David Bergen, will also be a table instructor there for one of the for one of the implant companies. So I'm excited to join that awesome
Charles Goldfarb:so my so I have a lot of council obligations which will take up some time and actually prevents me from participating in the congenital pre course. That Lindley wall and Deb Bohn are running, which is unfortunate, because I'd like to go and learn. But my first presentation is on distro radius fractures at pre course 13 from Tamara. So that will be Tamara Rosenthal. That will be great. And I'll briefly run through a couple other things, and then I have a pediatric elbow ICL, which I think will be wonderful as well. We were fortunate to be awarded the lynchey Dobbins excellent and excellence in wrist award last year, which leads to an ICL the following year. This is our work on interobserver reliability for identifying TFCC tears and so that ICL I'm excited about, and then I close out the week with a dissection.
Chris Dy:Yes, sold out. Sold out dissection. Sold out dissection. Can't get a ticket, sorry. You might be able to scalp it. StubHub. You might be looking at some other resources. Stand outside, stand outside and look once and it's sold out. On the on the website, I was checking you out. Man, I was looking at the program,
Charles Goldfarb:so all six people signed up. That's awesome. It's all
Chris Dy:that matters that it's sold out. Chuck,
Charles Goldfarb:anyways, I'm going to do a politicization, which is amazing. Obviously it'll be adult cadaver arm, but I think we can reproduce the mechanism of that process, and so looking forward to that on Saturday afternoon. This is a really
Chris Dy:cool session that they're doing. I think this, this series, is really cool. I think that Eric and Nina have put a lot of thought into how to structure various types of sessions to get people both kind of the big auditorium style learning, but then also the intimate kind of surgical dissection and pearls and tips and tricks that you get only when you're next to somebody in the or in a cadaver lab. So they've got a number of these. You know, my time with the Masters sessions, and I think it was an appropriate choice to have Chuck do that session. So that's that's super exciting. Shout out to one of our partners, David Brogan. He's got the number one spot in terms of podium presentations, so he'll be in the the top five, leading off, proudly representing our group.
Charles Goldfarb:Absolutely not his first time,
Chris Dy:not his first time in the top five. You know, very impressive that that guy, Brogan, I'm glad we brought him over. I'm doing a pre I'm doing a pre I'm chairing a pre course on brachial plexus. I'm super excited, especially because I don't have to give a talk. I'm just sharing. That's the good that's the amazing part about being a co chair is that you can decide whether you're giving a talk or not. And honestly, I did that because I figured somebody would back out at some point and I would have to sub in. So I still might have to do that. But Macy Stoner, our friend of the pod, and our frequent guest is is given going to be giving a great talk about the rehab and psychosocial considerations for brachial plexus patients, in addition to a star studded, All Star International lineup of speakers. So I think it's going to be awesome. You might be able to get a ticket still you talk to me, could probably find a way to get you in. But no, that's going to be super fun. And then I've got, I've got some stuff on Saturday morning. I've got a presentation to give on Saturday morning about some of the psychosocial and considerations for patients with nerve injuries. So that'll be fun. Brent George from UVA invited me to be part of a really cool ICL. So excited about that. And we've got our WashU hand reception. It's gonna be really nice to see everybody from, you know, residency and fellowship in the past, and that'll be Friday night with the rest of the handclub meetings. Yeah,
Charles Goldfarb:looking forward to that. It has gotten better and better each year under your leadership, it has grown and it is a place to be. We even occasionally have friends come by that aren't related or, you know, have no relation to the fellowship. But I really do look forward to seeing everyone and looking forward to hand study in Minneapolis is a great town. Be a great time of year to be there. It's pretty easy for us personally to get there, so checking all the boxes,
Chris Dy:yeah, absolutely. I've filled up all of my I've done a lot of research culinary situation. Got a hand therapist I work with down in the our south county office. Lizzie Westland is from Minneapolis, so that has helped my selections, as well as probably too much online research. So looking forward to it very good calorically as well.
Charles Goldfarb:That's the fundamental difference between us. At least one of them. I haven't thought about food in Minneapolis. One question
Chris Dy:for you. So anybody listening, who knows Minneapolis food knows that they are famous for one thing. Do you know what the Minneapolis cuisine is famous for?
Charles Goldfarb:Cheese curds?
Chris Dy:No. Close, though, close. It's called a Juicy Lucy. It is a thick burger with the cheese on the inside, which I have not had yet, and I'm pretty sure I might just be like on the way to the airport. So don't feel gross the whole week.
Charles Goldfarb:Yeah, you may pay the price on the airplane, though. Okay? Of
Chris Dy:former presidents have eaten and gotten a Juicy Lucy at the originator, I believe it's Matt's bar. So I mean, you know, it's one of those things where you're probably on the probably somebody on the campaign tours trying to look folksy and relatable and goes and gets the cardiac platter. So anyway, looking forward to it. If you're at the Hansen site meeting in Minneapolis, please come up and tell Chuck and I about what you want to hear on the podcast. As you know, you're probably going to have to get in line to talk to Chuck, because a lot of people want to talk to him. Just come up to me whenever. I mean, I'm pretty casual guy, so
Charles Goldfarb:I love it. All right. Well, this was fun, and have a good day.
Chris Dy:All right. You too. Take care. Bye.
Charles Goldfarb:Hey, Chris, that was fun. Let's do it again real soon
Chris Dy:sounds good. Well, be sure to email us with topic suggestions and feedback. You can reach us at handpodcast@gmail.com
Charles Goldfarb:and remember, please subscribe wherever you get your podcast,
Chris Dy:and be sure to leave a review that helps us get the word out. Special,
Charles Goldfarb:thanks to Peter Martin for the amazing music, and remember,
Chris Dy:keep the upper hand. Come back next time you.