The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Bennett Fractures, Rolando Fractures, and Guest Lecturer Sam!
Chuck and Chris discuss Bennett Fractures and Rolando Fractures as well as a few mailbag topics including central TFCC tears (and the role of ulnar shortening) and more on bowstringing from Sam Moghtaderi.
A few citations courtesy of loyal listener Joe McLaughlin.
1) Hulsizer, et al. Ulna- shortening osteotomy after failed arthroscopic debridement of the TFCC. JHS, 1997
2) Nishizuka, et al Simple debridement has little useful value on the clinical course of recalcitrant ulna wrist pain. The Bone Joint Journal, 2013
3) Kim and Song, A comparison of ulnar shortening osteotomy alone vs combined arthroscopic TFCC debridement and ulnar shortening osteotomy for ulnar impaction syndrome. Clinics in Orthopedic Surgery, 2011
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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, and thank
Chris Dy: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:Oh, hey Chris,
Chris Dy:Hey Chuck. How are you?
Charles Goldfarb:I'm fantastic. How are you?
Chris Dy:I'm good. I'm good. It sounds like you've been busy. You've had a busy morning, had a good case to do, and I'm excited to do a podcast with you today. Absolutely,
Charles Goldfarb:you know, as I say, fantastic. And one of the reasons I'm excited is I, you know, I live for the NBA, and we're getting closer and closer to the launch of the season, and when the pod drops, when this pod drops, we're probably pretty close to tip off.
Chris Dy:That's an exciting time. I wish we had a team here in St Louis. I mean, who? I mean St Louis is not a basketball city. I would say, I mean, I love going to St Louis University, Billikens games. It's a super fun way to spend time with the kids, and it's not terribly expensive. But who does who St Louis is root for? From an NBA perspective,
Charles Goldfarb:I think it's all over the map. You know, if you want to go to a game from St Louis, you have three, three easy options and one, relatively you can drive to Memphis, you can drive to Indy, you can drive to Chicago. None of those excite most people, but now you can spend a little more time in the car and go to Oklahoma City and see one of the best teams in the NBA.
Chris Dy:That's right. But, you know, I've always thought that if I was going to cheer for a team from St Louis, it would be the Pacers, because it is just not hard to get to and it's not crazy when you get there. And I've spent a little bit of time in Indianapolis, and really liked it. On the bucket list is doing the final four when it's there, when you're perhaps bringing the kids. I think that'd be really fun.
Charles Goldfarb:Yeah, I agree. I've done one Final Four in St Louis, so watch North Carolina win it all. But that's been a few years
Chris Dy:now my stomach, yeah, might be a pain point for some of our listeners watching UNC take it all. But yeah, that's exciting. NBA. Who are you just so it's, you know, we have receipts. Who is your pick to go all the way this year?
Charles Goldfarb:Oh, it's a tough, tough question. Great question. I think I would have to this is, may not be a popular take either. I think that the East is top heavy, but, you know, the weaker conference the West, I think is pretty good, probably one through 10. I think if I had to pick, I'd pick the Celtics. To repeat, what about you?
Chris Dy:Whoa. Well, I mean, again, I'm more of a casual NBA fan now, so I don't, don't know the ins and outs, but I'm just going to cheer for the st louis guy, Jason Tatum. I'm going to go for, go for the Celtics again. Dan Hong, our current fellow and Celtics diehard fan is going to be very happy with that, I mean, but Tatum's not even good enough to play for Team USA, apparently. So, ouch,
Charles Goldfarb:yep, yep. There's, there's, there's some truth there. Oh, my God, it's Steve Kerr's a ball movement coach, so that's probably part of it.
Chris Dy:Well, he won't be coaching next time around, from what I understand. So why don't we jump in? You have an interesting case you want to present us?
Charles Goldfarb:I do, I do, I do. We. We have a lot of interesting things to talk about. So I've had two cases. These are both college football players. They came to me in the last few weeks. Both of them were billed as Bennett fractures, so bases of thumb fractures, and both of them turned out to be a lot more. And I don't think we've touched on this topic, and I think it's an interesting one.
Chris Dy:Okay, well, we should jump in, but before we do that, we should probably thank our sponsors@practicelink.com
Charles Goldfarb:the upper hand is sponsored by practicelink.com the most widely used physician job search and career advancement resource.
Chris Dy:Becoming a physician and fixing intra articular thumb at a carpal fracture is hard. Finding the right job doesn't have to be enjoying practicelink for free today at www.practicelink.com/the upper hand. Alright, so
Charles Goldfarb:I'll just sort of merge these cases. And I'm a little worried about the rule of threes, because I've had two really, really challenging fractures, and I'm waiting for the third to walk in the door.
Chris Dy:So the this was a high JFC to JC ratio. Case, sorry. Dr Boyer would say,
Charles Goldfarb:I don't know that. Oh, I got you. I was trying to figure out the JFC reference. Yes, don't know that. We can expound on that on air. Can we?
Chris Dy:Now? We can't. This is a, this is a family friendly podcast. We can't talk about these kinds of things. But frustrating case nonetheless, I imagine email
Charles Goldfarb:us if you'd like us to explain more. So wait before we
Chris Dy:get into it like let's define the terms so Bennett fracture, and I think the term that we're also going to go into is a Rolando fracture. So these have particular significance. So let's unpack what a Bennett fracture is. Yeah.
Charles Goldfarb:So my definition of a benefracture is an intra articular fracture the base of the thumb metacarpal in which there is a constant fragment, which is a smaller fragment attached by the anterior oblique ligament. So the ligaments intact, the fracture fragment is sitting where it's supposed to, but the rest of the thumb metacarpal is out of position, pulled out of position by the abductor polysis, longest tendon. And so it's a pretty classic, easily testable injury. Yeah, it
Chris Dy:is, it is classic, and it is easily testable. I am totally showing my lack of orthopedic surgery knowledge because I cannot remember where the constant fragment is in other orthopedic there's, there's another orthopedic injury that has a constant, constant fragment, right? I get what you're saying, but I'm trying. I'm totally blanking, and hopefully a listener will email us and correct me, since I'm on a mea culpa run recently.
Charles Goldfarb:Are you looking for another example? Whether there's something like this or, yeah, there's a term there.
Chris Dy:The term is used in a different orthopedic fracture, and I'm so embarrassed that I can't remember it, and I'm going to avoid the temptation to quickly google it. Why?
Charles Goldfarb:Why are you avoiding that division? Because I focused
Chris Dy:on our podcast. So, yeah, the APL is pulling on the rest of the thumb metacarpal, and it's causing that classic deformity that you see where you have the fragment on the ulnar side of the thumb metacarpal that stays where it's supposed to stay, and then the rest of the thumb metacarpal, with the rest of the thumb is pulled proximally and radially by the APL. Is that an accurate another way of saying what you said,
Charles Goldfarb:that is, and in the emergency department, you can try reduction technique, which can be successful. I would say, in my experience, not generally successful, but again, testable and videoable if you're on video, is longitudinal traction, dorsally, dorsally directed pressure. I'm sorry, dorsally applied pressure to the thumb, metacarpal, and you also pronate, although, to be honest, I supinate or pronate, but technically, you pronate the thumb, and hopefully it kind of keys into place. Now it's probably still unstable, and that's the tricky part, and you can try to splint it, and if it's reasonably aligned, great. Generally, in my experience, these don't stay where you put them with a closed reduction. But occasionally you
Chris Dy:get lucky. It would be nice if you had the ability to pin in the ER, you know, some places do, and some places have a procedure suite in the office where you can do that, because it would save a lot of consternation for all involved. But I agree. I think it's highly unlikely to actually stay just because you still have the APL pulling on the rest of the thumb metacarpal,
Charles Goldfarb:exactly. And then how would you define a Rolando fracture?
Chris Dy:Rolando is different in the sense that it's not only a B type it's so a Bennet is a B type fracture, a particulate, if you're talking about ao, but a Rolando is like that. It looks like a Y. It's like splitting into the splitting the articular surface into more than one piece. So you've got extension, you know, you've got the fracture line is different to the configuration is different. You've got both a radial and ulnar articular component, right?
Charles Goldfarb:And so those are always surgical, because you have an articular surface disruption, and it's usually not just a little disrupted. And the bene fracture might be surgical, I would say probably a surgical, although the approach is different. Typically, I think you would agree with the bene fracture. It's a closed reduction in penning, where you're trying to get things well aligned and use a K wire to hold carpool itself back into a good position, and we can talk about details, whereas Rolando is almost always an O, R, i, f, yeah.
Chris Dy:So before we dive into how you would achieve those outcomes, if you're doing a close reduction, somehow you get it to stay in a close approximation. What's an acceptable amount of step off or articular, articular gap for the thumb? CMC, yeah, and
Charles Goldfarb:especially when you're talking about younger patients, often those who sustain these fractures, I think a gap of a millimeter or maybe even two millimeters is okay. A step off is different. And I would say, minimize the step off, because that's your real risk for arthritis, rather than a gap deformity. And some people scope these, you know, put a small scope in, and you can really assess your alignment, and then that can help you in the operating room, if you're there with a pen. Do you agree? Or are you more tolerant for displacement?
Chris Dy:No, I'm not more tolerant for displacement. I mean, I am more tolerant for displacement, but in terms of I don't like, I don't like to step off, but I like, I'm okay with the gap. I guess I took a long way. It took me a long time to say what you said. I think scoping is probably overkill. When you say, some people. Are you part of those some people, or are you, you know, a reasonable hand surgeon and not
Charles Goldfarb:a scope? Listen, what's your definition putting of reasonable hand surgery, Mr. Nerve transfer, so I
Chris Dy:MFE, MFE for all, right
Charles Goldfarb:I have scoped these, but I do generally think it's a triumph of technology over reason. I think c-arm is a satisfactory way to assess your joint alignment.
Chris Dy:So if we're, is there anything in particular you want to touch on regards to expectations for this? How do you counsel about potential post traumatic arthritis before you take the patient to the operating theater?
Charles Goldfarb:Yeah. Yeah. I mean, I think that my big conversation piece with both of these types of fractures, although more with a Bennet. It's not considered a huge fracture, but it often, I would say, in my hands, almost always keeps the player off the field. And the reason why is I don't let players go back with K wires then even cast it. And so that's the pre operative conversation is I can probably treat this closed if the fragment is small enough. There's not really even an option to treat it with anything other than K wires. And so you can't go back and play until the pins are out. That's my rule. If I put a plate and screws in and then I can cast, I'll let players go back and play with a cast, but not with pins
Chris Dy:so then it's interesting because, you know, sometimes that fragment, that constant fragment, is juicy enough to want to put a screw in there. Would you consider doing either a perk, percutaneous, or a limited, open approach to secure this internally with, you know, one or multiple screws, and then allow them to return, because they don't have pins 100% and
Charles Goldfarb:I think for the athlete in season is demanding to get back quickly, and is okay with the limited or otherwise, or if then, I think putting screw or screws in makes all the sense in the World. Other patients and families would would hear that option and still choose for a K wire. K wires, usually four weeks, and then they could play in a cast. And again, these are just, this is just the way I think about it. I don't think many people, though, let you play with pins and they could break. Do
Chris Dy:you ever bury the pin and then you're okay with it? You still have the same risk of it breaking.
Charles Goldfarb:I think in this fracture, you still have the same risk. I think there are some fractures where I have I just don't feel super comfortable.
Chris Dy:If this pin breaks, is just a disaster. You have to it's just really hard to get to the far end of that pin. If we're talking about pinning, do you ever pin the CMC joint as part of stabilization for this? Are you only fixing pinning across the fragment? Yeah,
Charles Goldfarb:I generally do include the CMC joint, because I think you're trying to balance the distraction forces of the APL. And so especially with a really small fragment, pinning the fracture site, so to speak, maybe less than satisfactory. And so taking the taking all the forces off with a CMC pin makes some sense to me. What about you? Do
Chris Dy:you even need to pin across a fracture? Well, if you just get the thumb metacarpal back where it's supposed to be, get the CMC joint where it's supposed to be, and just pin across the CMC,
Charles Goldfarb:100% agree. Or some would pin across the first second metacarpal interval. The challenge there is, do you want to pin across your first web space? Could that create scarring? That's the that's the urban lore, is that that can create scarring in the first web space. Although, knock on wood, I've never seen it. But I generally pin the CMC, not the first second space. And
Chris Dy:I also like to avoid transverse paths through metacarpals, multiple metacarpals with the pin. Just we've seen what can happen with tightrope type situations when that was used more commonly for thumb CMC, arthropody. So, yeah, I agree with you. You know, largely I tend to pin across the CMC. I think the CMC is the game, although it's really tempting as a hand surgeon to try to get something across the fracture. Yes.
Charles Goldfarb:And so these were comminuted rolandos, so I was
Chris Dy:so they weren't Bennetts. They were billed as Bennetts. And did your initial fluoro assessment make you think they were Bennetts, or were they what ways you think that they they had, how did they end up being more than Bennetts?
Charles Goldfarb:Yeah, I think someone was just throwing around an eponym. And so they were called Bennetts because they are indeed based upon metacarpal fractures. And not only were they not Bennetts, they weren't really rolandos either, other than they did involve combination at the base of the metacarpal. And so each of these patients had four or five articular fragments and and that gets really tricky, really fast. And for me, and we can talk about the operative exposure, there's nothing to it, but they these were complicated cases. Did
Chris Dy:you try with the closed reduction at first? So you knew this was more than a Bennett from the jump,
Charles Goldfarb:I always try, but didn't try very hard or very long, because there was just no way it was too many articular fragments, and so I ended up making a longitudinal incision directly over the base. I don't think you need a huge exposure. You know, in some ways, you need a bigger exposure if you're having trouble with a Bennett fracture. Because you sort of have to come around with a Wagner approach, and getting to the deep part of the fracture with a Bennet can be very tricky. If you can't just get it sort of closed or or mini open. With these fractures, you're just concerned about the articular surface, so you just need the CMC joint open, really, right? Yeah,
Chris Dy:trying to pursue the Bennett constant fragment is very hard. It's vulnerable. You're not going to get it from a dorsal approach. So I agree with that, and having tried that in the past, it is is nothing that is easy before we dive more into we should acknowledge a nerve sponsor. So the upper hand is sponsored by checkpoint surgical, a provider of innovative solutions for peripheral nerve surgery. Checkpoint. Surgical is most known for their intraoperative nerve stimulators, but did you know that they offer a full portfolio of nerve care products to help improve patient outcomes, including a novel biomaterial called neuroshield.
Charles Goldfarb:Neuroshield is a Oh, my God, You did this to me on
Chris Dy:perfect cytosine. Cytosine polysaccharide membrane. Chitosine
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Chris Dy:That's awesome. Well done. It's interesting. I at this at the recent clinician scientist program I ran into, obviously, as you know, more people that listen to the podcast, since Chuck is so well known, and the comments about the 1.5 speed became speed. Thing came on. So it'll be interesting to hear how that that copy comes across for checkpoint at either one or 1.5 speed. So
Charles Goldfarb:wait a second. Let me get this straight. Even those serious scientists who gather once a year at a fancy hotel in Chicago listen to the pod. First
Chris Dy:off, it's, it always saddens me a bit to come to fly to O'hare and not really go to Chicago, because I love Chicago and I love eating in Chicago, and I'm in Rosemont, Illinois, which is a great suburb in and of its own right. But it's, it's not really Chicago, but I did meet one very serious resident at the Harvard combined orthopedic program. I'm going to mispronounce her name, but I believe it's affiliate, and she is doing a research here, and she's interested in hand surgery, and she actually knew Agnes when Agnes was a fellow there, and mentioned the 1.5 speed thing. So yes, even the serious, the most serious clinician scientists are into the upper hand, and there are a lot of hand surgeons here. There's three on the faculty. And then there's also, I think at least eight or nine that are interested in hand. So we're representing,
Charles Goldfarb:wow. Nicely done. We didn't mention last podcast. We talked about the as HT meeting. There was some podcast love there. I was flattered.
Chris Dy:Yes, they all, they all want to get a get a moment with the famous Dr Cole farm of the upper hand podcast fame. There's nothing else that you've done in your career. This is the last thing like I see impact. So to say, that's the impact, all right, so the exposure we talked about. So how do you put together these puzzle pieces for the more complex ones?
Charles Goldfarb:You know, I would say at the risk of offending some of our plastic surgeon colleagues. This is the orthopedic part of the procedure, and it's as orthopedic as it gets. It feels like it's a classic comminuted articular fracture, and you have to put it back together, put the puzzle pieces back together. Generally, I try to open things up first, which is sort of done for you. Actually. On this last case, I pulled a piece out, put it on the back table. It was probably a good centimeter and a half by centimeter and a half piece, and then I worked on the periphery, and then at the end I was able to put that piece back. And in both cases, I used K wires, only, probably 5k wires, and didn't love it, but it's just so many pieces. I didn't think I could hold things the way I wanted without K wires. And thankfully, I think K wires are sufficient, and they can allow the joint surface to heal and move on. So K
Chris Dy:wires. And then did you also go across the CMC for this one? Or did you leave things with the metacarpal only construct? Yeah,
Charles Goldfarb:I went across the CMC with a single, larger K wire. I think it was just a four or five for both fractures, just a single K wire across the CMC, and then the other K wires were holding the fracture fragments in place. If
Chris Dy:you have a Bennet, a classic Bennett, which size wires are using, either across the CMC or into the fragment, if it's a normal sized human,
Charles Goldfarb:yeah. So if you get in the NFL size, humans, you're using something different, like a six two. But for normal, it's a four or five and often two four fives. For me, in this case, it was mostly four or 5k wires as well. When you get to the six two size, especially if you're making multiple passes, and it can especially, especially if you're going. From the first to the second. Metacarpal multiple passes can lead to metacarpal fracture. I've dealt with that recently, knock on the wood, and thankfully, not my own patient, but a metacarpal fracture after percutaneous panning.
Chris Dy:That's not fun. Yeah, I'm a little more permissive of the six two wire in across the CMC, if, honestly, if I'm the one putting the wire in, but then the four or five for the piece. So when you're doing these complex intra articular ones, I mean, I think the goal is to, just like, for example, a bigger bone and distal humerus that's intra articular, you're just trying to take the C type and turn it into a B type and just try to stabilize the fragments you have and work systematically, these are super challenging. Have you ever just used kind of a tea plate and just tried to once you've gotten the fragments aligned and avoided any flagrant articular step offs, just use that to help neutralize everything.
Charles Goldfarb:That was my plan in both of these cases and in neither of these cases was I successful. I was really hoping to address the two larger fragments in the classic Rolando, you know, schematic. It just didn't allow it, unfortunately. But that's the right approach. I think that's my preference in a more simple, non football crush type Rolando that would have worked. Does
Chris Dy:that end up typically being like a one, five or two Oh size plate or, yeah,
Charles Goldfarb:I think it's more commonly a 2o plate. Just 2o on metacarpal, seems to be the number. But occasionally it could be smaller, again, depending on the patient, depending on the fracture fragments. But and I could have supplemented my K wires with a plate, I just didn't think it added anything in either of these.
Chris Dy:Now, did you what? How are you going to plan on for these really complex ones, immobilizing afterwards. How, how are you doing it? And how long? Yeah,
Charles Goldfarb:like, you probably a plaster splint for two weeks, and then check out the pen sites, check out the wound, and then cast for three additional weeks. At five weeks, pull the pens, and then they can play, assuming we see some callous in a cast, or and, or we get them in therapy with removable grace. So I love the concept of a playing cast. I use it all the time, but only in a situation where I believe the injury is stable. So a playing cast I put on in the office. It's heavy duty. And whether it's a whether it's a mitten cast, where your fingers are clasped and you're just casting the whole thing, or a thumb Spiker, and then cut it off, hand it to the patient. It can be taped on for games, and then those patients go to therapy and get a removable brace. And so I think the concept of playing cast, whether it you know, day zero or five weeks, can make some sense when a fracture is not completely healed. I've
Chris Dy:never heard that term before, and I was going to ask you how to define it, but thank you for very clearly defining the What a play in cast is clearly those business school classes have taught you a lot about communication. Well,
Charles Goldfarb:I would say that our cast texts feel tortured by me for two particular casts, I now use a ton of Munster casts.
Chris Dy:Oh boy. They hate those.
Charles Goldfarb:They hate those, and those I use regularly because for my phobial TFC repairs, I two weeks I put them in a Munster to give them back their elbow motion, but still prevent rotation and the playing cast, same thing. It's just a little bit more annoying than most casts.
Chris Dy:I'm sure they love you for that, and then ultimately, outcome wise. I mean, you know, have you, knock on wood, have you really seen a lot of issues with post traumatic arthrosis after these kinds of fractures?
Charles Goldfarb:I haven't. You know, I, Chris, I have not been in practice for 50 years, so I I might see them later, but at the 20 year mark or so, or plus or minus, a few have not yet seen that. Did I tell you my personal story on Bennett fractures you have done. So when I was so I was when I was just turned 18, I was preparing for my freshman year of college. I was a soccer goalkeeper, and I was basically I went to training camp at another college where my uncle was the coach, and was playing tons of soccer, trying to get ready for my freshman year. And I had a benefactor and and I didn't the terminology meant nothing to me at the time, and I went to a sports surgeon, a reputable sports surgeon, who said, it's a little fragment. I really remember this. You'll be fine. Let's get you a little removable brace. He said, In 20 years, you might you could have a problem, but you'll be fine. And so I never had a cast. I was never reduced. I was putting a little removable splint. And that's how I went to college. It did impact me. It didn't really matter, because there was a senior who was all American ahead of me. So I watched mostly anyways, during games, but I practiced with that. And knock on wood, my mom seems he doing still okay,
Chris Dy:now have you fluoroed your own thumb and taking a real look?
Charles Goldfarb:I have, and I think I can see it. But you know, I haven't done a CT or that sports
Chris Dy:surgeon just went in the day. There very impressive. Any other points you want to make about Bennett Rolando before we get to a couple of grab
Charles Goldfarb:bag items? No, I think we've beaten it. I have faith that the audience is going to love this topic and and send some questions or follow ups or personal experiences. So I look forward to that at www, dot what?
Chris Dy:Good lord. Hand podcast@gmail.com yes boy. So as many of you have learned, because we've mentioned that. You know, we are on YouTube, and for we have a great comment on the What's New in hand surgery episode from at James dash MW four, sh, so James dash, MW four, sh, writes as a hand therapist, I often see patients after a trigger finger release who are unable to achieve full active PIP extension, passive is not a problem. Is it possible that the surgeon released too many pulleys, causing flexor tendon both streaming?
Charles Goldfarb:That's a great question. Thank you for for writing in I would say that is not the common scenario. The common scenario is active and passive extension are limited, even after a release. Is that what you typically see more commonly? Yeah,
Chris Dy:and I think it's because we don't recognize that they have limited they probably have a pip contracture, subtle, likely before surgery, which is the most advanced grade of trigger finger and portends, of course, prognosis, as I think we discussed during that episode. So that's what I typically see, is I didn't realize that they had a subtle PIP contracture, and then they comment to me that they can't get their knuckle all the way straight
Charles Goldfarb:right. And then I think the question slash point that James is making is the right one, if a surgeon were to release the A one and the complete a two, I think they would lack active extension. I don't think it would be dramatic, but they would lack 1015, degrees of active extension. I think that's fair. I hope that doesn't happen very commonly, but I think it could.
Chris Dy:Yeah, no, I have not personally seen that, but I'm sure if I start looking for it. Maybe I will. So yeah, thank you for that comment, James. Really appreciate it. If, if anybody listening has any different experience on the therapy side or as a surgeon, please let us know we
Charles Goldfarb:had a friend of the podcast write in and send us some voice notes on his theory and explanation of bowstring and so maybe if you want to say a little bit more, then we're just going to insert his comments because they are good and it's a different way of thinking about it. We're going to insert his comments shortly. Yeah. So
Chris Dy:Sam Moghtaderi from the George Washington University in Washington, DC. Again, friend of the pod has sent us his comments, and I really like them. Anybody who spent any time with me in the clinic knows I'm terrible at analogy, so I won't even try to create an analogy for bowstring, but I really like Sam's analogy with the latter as it was explained to him. So when Sam sent this in, I said, All right, well, we'll try to figure out a way to splice this in. I will defer to chuck, because he is the tech expert. Otherwise, I can just hold my iPhone up and play it. But Chuck assured me that this will work, so we'll let Sam take it away from here.
Charles Goldfarb:Yes, my God, I can picture it now. You would be holding your iPhone up to the computer, and Sam's voice would be like,
Chris Dy:it's like the current version of say anything, right? So,
Charles Goldfarb:all right, we can do better. We can do better.
Sam Moghtaderi:Hi, Chuck and Chris. I have really enjoyed your recent discussion about bow stringing and how it actually affects finger function. It's a topic that I think can be really counterintuitive, and I don't claim to have a great understanding of it myself, but after your follow up from your listener, I thought I would share how I think about it and how I try to teach it to our trainees. I think it's counterintuitive, because, as your listener feedback said, I think Bose stringing actually does improve the efficiency of flexion in a weird way, and that trips people up. So an analogy I like to think about, which I'm not going to take credit for. I don't remember, though, who I learned it from. Imagine you have a ladder laying on the ground, and you want to lift this ladder up off the ground. Now, imagine you tie a rope to the top rung of the ladder, which is farthest away from you, and you want to lift this ladder up off the ground by pulling on this rope. It's pretty intuitive that you're going to get the best mechanical efficiency if you hold onto your rope, let's say while you're standing up next to the ladder, because you're pulling it up from above, and that's a better angle, you have a better moment arm, which is your height off the ground, to pull on this rope. Now, compare that to pulling on the rope from a ground level parallel to the ladder. Well, you'll eventually lift it up, especially if you stabilize the base of the ladder, but that has a lot less mechanical, efficient. And see. And this is how the flexor tendon and the phalanges work. When you bowstring and your flexor tendon comes up off the hand. It actually has better mechanical advantage in lifting the finger up off the flat surface. And I sort of present it this way to trainees, to lead them astray a little bit and purposely confuse them, because then understanding it brings them back. The counterintuitive thing is, this only works at the beginning of flexion, when your hand is flat on a table and you're trying to initiate flexion. A little bit of bow stringing does actually give you more mechanical advantage, and that's why it's confusing. I think when your listener said that bowstringing improves mechanical advantage, that's probably the situation. But your finger is not a ladder, and you're not just trying to lift it off the flat surface. You're trying to get full composite flexion, which is to curl it all the way into a full fist. To do this, you have to keep changing the direction that you're pulling the bow strung tendon can't do that. Once it's gotten the finger efficiently off the table, then it's sort of done all of its work and used up all of its excursion to just do that, you need to then pull the finger proximally, and then you actually have to push the finger downwards towards the palm, which a finger, which a tendon or a rope that's in the air, can't do anymore, and that's when bow stringing prevents you from completing your flexion into a full fist. A tendon that's held against the bone always keeps pulling towards the bone, which, while initially less efficient, maintains that efficiency throughout the whole flexion arc. Anyway, that's just how I think about it. Hopefully that's helpful for some people. Thanks for the show. Take care.
Chris Dy:And then I think the last one I wanted to get to in terms of listener. Listener, grab bag is from Joe McLaughlin. He is a hand surgeon in Morrisville, Vermont. First off, he wrote us a very nice email and said, Gentlemen, hey, I hope the amusement park was good and that you did all the crazy rides with your son. It's important to show him that you've still got it. This Six Flags was awesome. I went on every ride that he wanted to go on. He talked a big game about the big Screaming Eagle, and we did it. And then all of a sudden he's like, I don't want to do it again. My stomach hurts. And our partner, Dr, Alexander Alim brought his child, and they did more adventurous rides than we did, but I did get my son back on the Screaming Eagle at least one more time. I bribed him with an IC but I figured that was the parental move that needed to be made in order to get him back on the horse.
Charles Goldfarb:The icy was before or after the ride. Oh, come
Chris Dy:on. Come on, Chuck. It's gotta be after.
Charles Goldfarb:It's gotta be after. That would have been a rookie parenting move to give him IC right before you got on. You would
Chris Dy:you would love this. I did my best to win at the game of shooting a but that essentially was a free throw to try to win some ridiculous oversized stuffed animal. And they even say on the sign that these hoops are not regulation size. They could draw that they're oval, and they tell you that the rims are very hard. And I shot what, honestly, they were 10 really good balls, like would be, would be bottom of the net, at least eight of them, if it were not for these ridiculous rules slash setup, came away empty handed. It was really disappointing for somebody who did play it not as much ball as you growing up, but played a fair bit of ball.
Charles Goldfarb:Well, I hope your son's vision of his father as an athlete has not been forever tarnished. It might be, might be. No it clearly.
Chris Dy:It clearly is. But he was very kind. He had a better reaction than Dr Lee's son. Just put it that way. But everybody got over it. There was no other no additional ICS were purchased. But to Joe's actual email, his second point feedback on the shortening scope conversation. So he says that he sees debridemont of the central TFCC tears as a much less useful surgery than ulnar shortening. Look at that hot take, and from his understanding of literature, it seems that ulnar shortening osteotomy has a much higher chance of attaining satisfactory outcome compared to TFCC debridement. Also, in his humble opinion, when doing a scope plus uso, it's really the ulnar shortening that helps minimize the number of clinical failures when the diagnosis is on their impaction and the patient has no evidence of peripheral tear producing DRA instability. I don't scope and just do the on their shortening. Caveats are that I don't enjoy managing ulnar sided wrist pain. And although talented in other areas, I am, at best, an average wrist arthroscopist. I like Joe. I connect with Joe. I relate to Joe, and Joe closes before we get into your thoughts that he appreciates the podcast and thanks for doing it. Joe trained under Bill Kleiman and our stories of government make him laugh, as they seem cut from the same cloth in regards to writing slash teaching slash encouraging the fellows I may have editorialized that last part. So thank you, Joe for writing in I want to hear Chuck's. Comments and reactions to all of the above.
Charles Goldfarb:First, I really appreciate the comments, and I think Joe hit the nail on the head, using Chris's analogy about a nail and a workman, a
Chris Dy:workman hammering nails. Somebody else's analogy about you,
Charles Goldfarb:but Joe's Listen, Joe's obviously well trained, and I appreciate his comments. He does make a self deprecating comment that he's a non famous community hand surgeon in Vermont, first of all, living out. Well, that's what I'm hoping for him. If he wants that, if he wants that, Joe's point is 100% on target. It really is exactly true that an own I think I've said this before. I know I've said this before. Ulnar shortening osteotomy is one of my favorite operations, because it is so effective in addressing ulnar side of wrist pain and even addressing instability. I personally enjoy arthroscopy. I won't comment whether I'm above or below average, but I do a lot of it, and
Chris Dy:you're an expert,
Charles Goldfarb:and I think assessing and debriding central tears has a role, but it's not nearly as important and shortening when you truly have impaction. I do think you have to look out for foveal tears. I do think other issues can exist. But my God, if i had to rate my best surgeries, ulnar shortening osteotomy, would be near the top.
Chris Dy:It's a great surgery. Fantastic. I totally agree with it. And I like how when Joe sent us this email, he did include three papers, one from the brown group Peter Weiss at ackleman, as well as two different groups from Japan and Korea demonstrating for the first two, showing that ulnar shortening osteotomy is honestly it's probably the thing that changes and improves the patient's outcome more than the scope debridements. And then the last one, being that simple debridement is not effective treatment of all their side of wrist pain. So we can put some of those in the show notes. But Joe, thank you for sharing those opinions, your opinion, and providing literature. You must have known that you're emailing Chuck Goldfarb, the executive vice chair of a famously successful orthopedic department, so you knew he was going to want evidence. Well,
Charles Goldfarb:I don't know Joe, but I'm going to give him grief, and I hope if this hits wrong, Joe, talk to me at the next meeting that you come to. I love your the three papers you cited, they're each at least 10 years old. I think there probably is a little more recent evidence, just to give you a little grief, but they are all good papers, so thank you for including them
Chris Dy:that the problem didn't solve. No need to look at it again. I mean, you know, like, why are people just still scoping risks in this sitting but I think that it's hard. I think because patients come in with an MRI report a lot of times showing that they've got a tear. And while it's easy, I think it's appropriate for us in certain settings, to say, look, we know that that's there, but we're going to do this instead. It actually is kind of hard to counsel patients saying we know there's a tear there, we're not going to go there, because some people kind of expect that,
Charles Goldfarb:right? And you know, we are. We've talked about this before, whether it's an emergency room doctor, another orthopedic surgeon, a therapist, they sort of have an outsized influence on the patient and their expectations before they ever get to us. And so you have to manage that, and you have to bring a level of confidence in your ability to solve a problem if you're not going to go down the path that everyone expects you to go down. And so I don't know that that may be a little much for this issue. And I think shortening they all know without scoping is widely accepted as appropriate. But if you're if the patient has been set up to expect they're going to have a scope, then you just have to manage that preoperatively. Totally
Chris Dy:agree. Well, thank you, Joe. And then if anybody has any other comments along those lines, or wants to send any other questions feedback, hand podcast@gmail.com that's a little too much for Chuck to handle at this point in the day. I starting. He started sundown, so we've got to move on.
Charles Goldfarb:All right, it's been fun as usual. Have a good day. 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 topic suggestions and feedback. You can reach us at handpodcast@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 you