Difficult Phalanx Fractures

Chuck and Chris briefly review challenges with the US healthcare system but spend most of the episode discussing difficult hand fracture cases.

Meyer ZI, Goldfarb CA, Calfee RP, Wall LB. The Central Slip Fracture: Results of Operative Treatment of Volar Fracture Subluxations/Dislocations of the Proximal Interphalangeal Joint. J Hand Surg Am. 2017 Jul;42(7):572.e1-572.e6. doi: 10.1016/j.jhsa.2017.03.030. Epub 2017 May 3. PMID: 28476538; PMCID: PMC5510930.

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The Upper Hand Podcast is sponsored by Checkpoint Surgical, a provider of innovative solutions for peripheral serve surgery. To learn more, visit https://checkpointsurgical.com/.

As always, thanks to @iampetermartin for the amazing introduction and concluding music.

For additional links, the catalog.  Please see https://www.ortho.wustl.edu/content/Podcast-Listings/8280/The-Upper-Hand-Podcast.aspx

Transcript

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Charles Goldfarb (You):  Oh, hey, Chris.

Chris Dy:  Hey, Chuck. How are you?

Charles Goldfarb (You):  I'm great. We're doing the pod. How can I be better?

Chris Dy:  Loving the pod. Super fun. Uh, I got a lot of fun, uh, cases to talk about today.

Chris Dy:  Uh, excited to have, uh, the opportunity to share them with you. I hear that you've had some, uh, some interesting experiences recently with the American healthcare system.

Chris Dy:  You want to share?

Charles Goldfarb (You):  Yeah, yeah. This will be great for our overseas colleagues to share how things work. And, you know, if you go on social media, you'll see some—sometimes people record these interactions, which I think is really interesting.

Charles Goldfarb (You):  I kind of wish I'd recorded this one, but, you know, the American healthcare system is so difficult in so many different ways. And so I had a patient with a, um, malunion—talking about our fracture cases we're going to discuss later—but this is a patient I didn't treat.

Charles Goldfarb (You):  Came to me six, nine months after, um, fracture of the second and third and fourth metacarpal necks, uh, that healed in a malunited, united posture, but it didn't look terrible on X-ray. Um, it wasn't joint-based pain.

Charles Goldfarb (You):  I really couldn't identify the source of pain, but pretty reliable guy. And so I'm like, well, let's get a CT scan to better understand the malunited position.

Charles Goldfarb (You):  And, um, which I don't order a lot of tests like that. I just don't.

Charles Goldfarb (You):  But in this case, it wasn't clear to me, do I need—do I need to address any of them? Do I need to address all the malunions?

Charles Goldfarb (You):  What should I do? So I requested a CT scan and was told by the insurance company that it was declined and that I should get an MRI instead.

Charles Goldfarb (You):  And I'm like, what? You want me to spend more money, um, and get the test that's going to help me less?

Charles Goldfarb (You):  And the—sometimes I'm just like, screw it, I'll get the MRI. But this time I was like, no, out of principle.

Charles Goldfarb (You):  So I ended up, you know, they—they said I had to do a peer-to-peer. My nurse called me, like, in the middle of surgery and said, "You got to do it now."

Charles Goldfarb (You):  I'm like, okay. So I—you know, the nurse dialed the phone.

Charles Goldfarb (You):  Of course, I sat on hold for five minutes waiting for my peer, um, to get on. The peer, of course, was not an orthopedic surgeon.

Charles Goldfarb (You):  And the person gave me grief for needing a CT. "Why would you need a CT scan?

Charles Goldfarb (You):  Why don't you just do an MRI?" So I explained the logic.

Charles Goldfarb (You):  And then I was put on hold for five more minutes before they came back and said that it was approved. It's just crazy.

Charles Goldfarb (You):  I think it's the goal of any service industry. When you make a phone call, your power company, your water company, your phone company, and they just put you on hold hoping you'll hang up.

Charles Goldfarb (You):  I think that's the goal.

Chris Dy:  Yeah, that's super interesting. I think I've had nothing but frustration with peer-to-peers. Although occasionally you'll get somebody who—and then for those of you that are listening and not watching, when Chuck said peer, there were super air quotes going on.

Chris Dy:  Um, but, uh, occasionally you get somebody, even if they're not your peer, uh, they understand and they're checking a box. Uh, and as long as you are affable and provide a reasonable clinical, you know, uh, reasoning for it, they're usually okay.

Chris Dy:  What pisses me off—excuse me—what ticks me off is when they're combative with you and they don't have the experience you have. And it's not, you know, oftentimes it will be an orthopedic surgeon, not a hand surgeon, or it's an orthopedic surgeon who doesn't know how to take care of nerves, just because that's not part of their training, etc.

Chris Dy:  And I'm frustrated with them. Uh, and I'm not trying to beat my chest saying I'm this amazing person, but it's like, I know I do this more than you do.

Chris Dy:  Like, you don't know about this. You might be asking Gemini what to do with it, but I know what to do with it.

Chris Dy:  And it's—I've almost lost it on some of those. I usually get everything approved, but it can be a super frustrating experience.

Charles Goldfarb (You):  Yeah. And, you know, honestly, the system sets us up for confrontation because after being told I had to talk now or I had to reschedule when there wasn't anything scheduled, being told that, uh, I'm going to wait five minutes before I get to talk to my non-peer, not even an orthopedic surgeon, um, I'm already frustrated. And I try not to be.

Charles Goldfarb (You):  Anyways, I don't want to vent too much, but the United Healthcare System—uh, United States Healthcare System—is super flawed. And this is one example of trying to, uh, dictate care from people that probably shouldn't be doing that.

Chris Dy:  The closest parallel I can have for our younger listeners who are still in training, it's like getting these calls from the ED PA and then the ED attending, and you're on orthopedics and you're like, this patient is, you know, clearly not a candidate to be on orthopedic inpatient service, yet you want them to have somebody who has no real medical training in terms of managing complex inpatient internal medicine issues to be the one in charge of them. Probably not a good idea. But this is where you

Chris Dy:  have—you get those same kind of feelings. It brings it back a little bit.

Charles Goldfarb (You):  Yeah. Yeah. Well, you know, we are fortunate to be doctors in the United States.

Charles Goldfarb (You):  There are many advantages to where we practice and how we practice and institutionally, and there are many flaws of our healthcare system. But, you know, overall, I think when patients can access care in the United States, uh, generally excellent care is provided.

Charles Goldfarb (You):  Our system falls down with access.

Chris Dy:  Um, one question I wanted to ask you is that when patients come in saying they want a certain thing, uh, some kind of advanced imaging, how hard do you fight them now? Like, I've—I'll be admitted, I don't fight them as much anymore. I just say, "All right, your insurance company is probably going to say no, but if you want it, uh, it's not going to change what I do, but if it'll make you feel better, we can go ahead and put the order in."

Chris Dy:  And I hate admitting that.

Charles Goldfarb (You):  Yeah, I have to say, sometimes I—I don't fight the fight either. But I was recently made privy to some data, and there's—there's third parties out there that aggregate data in a way, uh, in 2026 that I've never seen it aggregated before, to the extent that they know the cost of care to the dime for Chuck Goldfarb, uh, for X case, and can compare it effectively to my peers. Now, hand surgery is not total joint arthroplasty, where it's so clear-cut and there's so much variety

Charles Goldfarb (You):  in what we do. So it's—it's going to be, you know, it's just—it's always going to be harder in our world. But for a joint surgeon, the cost of care numbers are really, really good, and we are increasingly being compared physician to physician along those lines.

Charles Goldfarb (You):  And so saying no to that patient who demands an MRI is probably important, but sometimes it's just too hard to do it.

Chris Dy:  Yeah. I'm—I'm, uh, one of my many flaws, I'm somebody who, uh, hates saying no to people, uh, just in every part of my life. And, uh, this is just one where I'm not going to fight that battle.

Chris Dy:  It's not that I'm going to die on with this patient. Unless I tell them, like, that's just not the right test, uh, how about this or something.

Chris Dy:  You can find some other way to make them feel better, but it's the joys of practicing medicine. So, uh, I have a few cases I want to present, but first, uh, we should thank our sponsors, so PracticeLink.

Charles Goldfarb (You):  Yeah, the upper hand is sponsored by PracticeLink.com. It was widely used position, job search, and career advancement resource.

Chris Dy:  Becoming a physician is hard. Finding the right job doesn't have to be. Join PracticeLink for free today at www.practicelink.com/theupperhand.

Charles Goldfarb (You):  All right.

Chris Dy:  So I've—I've had this kind of interesting run of, you know, potpourri of, uh, fracture cases that have come in, uh, and I just wanted to kind of get your sense of, you know, high level what you would do and kind of talk through some of these things. The first one that I want to talk about is somebody who's your age and, uh, so strapping young, healthy person rides their bike into work, you know, etc. Unfortunately, it was in a motor vehicle accident, was T-boned, and

Chris Dy:  finger versus, uh, dashboard. And, um, initially had a DIP dislocation in addition to a fracture at the base of the middle phalanx involving the PIP joint. The DIP was reduced at the urgent care and then comes in with a reduced DIP, but a pilon fracture of the middle phalanx base.

Chris Dy:  So not a dorsal fracture dislocation, not a central slip volar fracture dislocation, but a straight-on pilon. The finger is swollen and angry, um, but you've got the base of the middle phalanx is essentially splayed, and you've got a step-off at the PIP joint at the base of the middle phalanx and kind of that central articular third.

Chris Dy:  How do you start to approach something like this? I mean, these are the fractures where you walk in, you're like, "Ooh."

Charles Goldfarb (You):  Yeah. So, uh, great hand surgery case. Um, it's interesting because, you know, some—I think these cases is, you know, it's an example.

Charles Goldfarb (You):  If you're in a large group of hand surgeons, there's probably one or two hand surgeons that just love these. And as I get older, I get more and more willing to share these cases with partners who might be excited by it.

Charles Goldfarb (You):  Because when you think about it.

Chris Dy:  For the record, I'm not excited. I'm happy to take care of the patient there in my clinic, but it's not something I'm excited about.

Charles Goldfarb (You):  Right. No, I totally agree. Um, I mean, the bottom line is you have to decide.

Charles Goldfarb (You):  You have to make your initial decision is, does it need surgery or not? Sounds like it does with a displaced pilon fracture base of the middle phalanx.

Charles Goldfarb (You):  Your next question is, is this something that I can treat with a closed reduction and pinning, uh, an ORIF, or am I best served with some type of external fixation setup? And, and that, then you have to decide, do I like the—and I'm trying to remember all the names—the Suzuki frame, uh, that which uses rubber bands.

Charles Goldfarb (You):  Um, the Joe Slade force coupler also uses rubber bands. The banjo splint, the hinged fixtures.

Charles Goldfarb (You):  There's all kind of things that can be done. And the bottom line is hopefully you get good at one of those techniques.

Charles Goldfarb (You):  But getting good, what does that mean? Once a year?

Charles Goldfarb (You):  Twice a year? These are hard.

Chris Dy:  Yeah, these, uh, complex PIP injuries don't come in that often. I think that the dynamic X-fix is a thing that's discussed so much, uh, and just so rarely done, I think, in most places, just because, you know, these cases don't always come in with a lot of frequency. Uh, and maybe that's at least our practice here in St.

Chris Dy:  Louis. Um, for me, this was not one where I wanted to, uh, consider a dynamic frame just because I didn't have a specific vector in the sagittal plane that I was trying to control.

Chris Dy:  This whole thing was just splayed apart. So I thought this was one where, you know, if I tried, I didn't want to pin the joint, um, because, you know, I think that I still would have a displaced articular piece to deal with, whether I pin the dorsal side to the proximal phalanx head or the volar side, and then I wouldn't get the benefit, potential benefit of trying to get the patient moving to get the swelling down and keep the joint supple.

Chris Dy:  This did not seem like one where I would feel comfortable just trying to get it pinned, um, you know, uh, percutaneously. Um, because I think with these fractures, and I haven't treated a ton of these pilons, but it's hard to truly appreciate how, for lack of a better term, how smashed that joint surface is without any advanced imaging.

Chris Dy:  And I don't know if advanced imaging would have changed what I would have done. I knew I wouldn't be able to get this perked.

Chris Dy:  So is it, uh, how do you think about, do you open this? Is this something where you're not, you've got an angry finger, just like a lot of fractures, but this one in particular, given the direct axial loading, which leads to that pilon type component of an injury.

Chris Dy:  And for those of you that aren't orthopedically trained, a pilon fracture for us is typically, um, referred to as a fracture of the tibial plafond because there's been an axial load of the hindfoot straight up into the base of the tibia and just creates a huge impaction. So how do you think about, um, you know, opening this?

Charles Goldfarb (You):  Yeah. Um, and these are cases. I'll start by saying there are certain cases when you can be very, um, confident in how long a surgery will take, or if, you know, you can speed up or, you know, if you need to, to get a case done.

Charles Goldfarb (You):  This is not that case. This is a case where you have to carefully plan and carefully execute, because if you choose to open it, um, and that very well sounds like the right decision, you have to be meticulous in your execution of your surgical plan.

Charles Goldfarb (You):  And so this is a case that requires more planning than most. Um, it's a case that requires, you know, carefully choosing volar or dorsal, occasionally both, um, and then how you elevate fracture fragments to recreate the joint surface, how you support the fracture fragments.

Charles Goldfarb (You):  And so, uh, you know, I think either direction can work. It really depends on the fracture pattern and the fracture personality, as they say.

Chris Dy:  Right. Uh, this was definitely a case that I said last case of the day because I didn't want to think about anything else going on after this. Um, and I booked it with enough time to plan to open, um, even if, you know, I was going to, you know, assess them while they were asleep.

Chris Dy:  Um, ended up doing an open approach, uh, split the extensor mechanism, was very mindful to preserve the central slip, um, and did a dorsally based plating. Um, I'm happy with the fixation.

Chris Dy:  I think one of the kind of take-homes for these screws, anytime you're putting a screw in the phalanx, I look at the person across the table from me and say, this is a one-chance screw. Um, you've got one shot, and this is where I'm not afraid to take the take the drill.

Chris Dy:  If I don't think, if A, if I think I have a better angle, B, if I don't have the most confidence that they're going to be able to put this where it needs to be, or as they can drill it and I'm tightening the screw down because you're watching these little comminuted fracture fragments, are you excessively loading this? If you tighten it too much, you get a propagated different fracture line.

Chris Dy:  This is where the OCD part of the hand surgeon comes in, and it's just about getting it right the first time because you do not get a second chance most of the time on these screws.

Charles Goldfarb (You):  Yeah, well said. All that's well said. I, uh, I recently also went dorsal on a fracture like this and, uh, really, and, and, and we had, we had done, I think, what we could do for elevating the joint surface.

Charles Goldfarb (You):  And sometimes I'll take a little K-wire and use the blunt end to try to tamp up, uh, a fracture fragment that may not be the dorsal fragment or the volar fragment, but that central fragment, and then you're sort of trying to put a screw down to support that fragment. We had done all of that very carefully and successfully with one-chance screws.

Charles Goldfarb (You):  Um, and I still pinned the joint. And out of principle, I don't like to pin the joint, but I have to be confident that I have stabilized things to the degree that I don't worry about it.

Charles Goldfarb (You):  In this case, I still worried about it. And so, you know, Marty Boyer, our partner, loves to give a lecture.

Charles Goldfarb (You):  He gives a great lecture about joint stiffness. Um, the key thing is you have to restore the bony architecture correctly.

Charles Goldfarb (You):  We can deal with a stiff joint. What we can't deal with, uh, as easily is a malunited fracture.

Charles Goldfarb (You):  And so I agree with you wholeheartedly. We try to avoid pinning the joint, but if you have to do it, do it and don't think twice about it.

Chris Dy:  Yeah, I agree. I mean, you got to get the bone right. You can deal with the stiff joint later.

Chris Dy:  Uh, in an ideal world, you get the bone right and you can move. Um, and this patient is doing well with PIP motion.

Chris Dy:  I think he's having a little bit harder time with DIP motion. I'm not sure how much of that is gliding of the extensor mechanism over the plate versus in his initial DIP dislocation and the trauma that comes to the soft tissues with that.

Chris Dy:  Um, but, you know, I think we've been working pretty aggressively on therapy because, you know, I think one of the things that, uh, stabilization with, um, either interfragmentary screws or a plate and screw construct is that it allows you the confidence to say, all right, I've got good stability. I can get, get things moving a little quicker.

Chris Dy:  Um, which I think is harder with pins. I mean, I think pins have their role for sure, but, you know, having hardware exterior to the skin, I think, can be very challenging for some patients.

Charles Goldfarb (You):  Yeah, that's right. And I assume, so for those dorsal approach middle phalanx fractures, you know, you're preserving the central slip, but your plate can be right up abutting the central slip insertion. Um, and then a T-plate or one of those little curvilinear plates that extends distally.

Charles Goldfarb (You):  Is that what you did in this examination?

Chris Dy:  That is what I did.

Charles Goldfarb (You):  Nice. Yeah.

Chris Dy:  So I wanted to ask to present another case to you, uh, but before we do that, uh, this episode is going to be coming out the week of the Hand Society meeting, which is super exciting. So I want to make sure everybody knows that we're going to have a live podcast, uh, at the Hand Society meeting on Friday, September 18th at 4:00 PM. Uh, but if you're attending the ASSH annual meeting in Boston this week, be sure to add this educational session to your schedule.

Chris Dy:  Checkpoint Surgical is proud to host Advancing Upper Limb Spasticity Care, a case-based discussion exploring how nerve-based surgical techniques are transforming the treatment of upper limb spasticity.

Charles Goldfarb (You):  Here are practical insights, challenging cases, and expert perspectives from Dr. Wee Lam, Dr. Carolyn Leclerc, Dr.

Charles Goldfarb (You):  Peter Rhee, and Dr. Sammy Tufaha join Checkpoint this Thursday, the September 17th.

Charles Goldfarb (You):  Uh, Thursday, September 17th at 11:30 AM and visit booth 1831 in the exhibit hall. So, um, looking forward to a great meeting.

Chris Dy:  Yeah. So check out that meeting and then check out our live podcast. Bring questions.

Chris Dy:  Uh, be prepared to heckle Chuck. Uh, we'll have a good time at, at the Hand Society in Boston.

Charles Goldfarb (You):  Yes, we will. Yes, we will.

Chris Dy:  So my next case is not that far off, but a different nature of a fracture. So this is a patient who, as I was talking about in the last episode, I was packing up my bags in the after finishing my dictations, and then one of the, uh, very kind orthopedic injury clinic providers says, "Hey, would you mind just taking a look at this X-ray?" And, uh, I looked at the X-ray and then immediately your heart kind of goes, and it's a central slip fracture, um,

Chris Dy:  of the middle phalanx. So also a base of middle phalanx intra-articular fracture, but not a pilon like the other one. And this one, uh, looking at it on the, we harped on radiology recently about getting really good laterals.

Chris Dy:  So I think this patient actually went back and forth a couple of times to get a good lateral. Um, but the lateral shows that the volar portion of the middle phalanx is not subluxated, but there is a chunk of dorsal middle phalanx base that's approximately 45% of the entire joint surface that is just floating in debris dorsally.

Chris Dy:  Um, I actually brought the patient over to fluoro and extended the PIP joint. And, you know, as expected, there was no chance of getting that dorsal piece approximated to the volar piece, the volar joint surface.

Chris Dy:  How do you think about this case? Because on exam, because this has just happened, she was still having some active extension through her PIP joint, uh, presumably through the lateral bands, just kind of knowing where that, you know, um, uh, central slip fragment was displaced.

Chris Dy:  So how do you think about this case?

Charles Goldfarb (You):  Yeah, these are great cases. These are very, very challenging or can be. Um, we have shared our experience with these and how challenging they can be, um, in the literature.

Charles Goldfarb (You):  Um, for me, um, I'm not afraid to open these. I think getting a closed reduction in the clinic is impossible.

Charles Goldfarb (You):  Getting a closed reduction and pinning that fragment is possible in the OR. It depends on the specifics of the fracture fragment.

Charles Goldfarb (You):  Um, but this is a case where I almost always pin the joint to our recent discussion, uh, to preserve the ability to get this to heal in an anatomical position. Sometimes these fragments are big, sometimes they're small, sometimes you can use a suture anchor, sometimes you can, you know, pin or put a couple of screws in the fragment.

Charles Goldfarb (You):  So much variability is based on the fragment itself, but you have to get this right because the joint does not tolerate this fragment being displaced.

Chris Dy:  So you mentioned the paper that you wrote. I remember I had a central slip fracture dislocation, which just for everybody, this is different than your kind of volar PIP fracture dislocation where you have like a volar base fragment and the joint itself goes dorsally. This is the opposite.

Chris Dy:  You got a dorsal base piece and the joint potentially goes volarly. Your paper saved me during board collection because I had one of these that, you know, these patients, this patient didn't do well.

Chris Dy:  It had some issues with follow-up too and, you know, adherence to therapy recommendations. Um, but the fact that you guys wrote that paper, I think Zach Meyer might have been the lead author.

Charles Goldfarb (You):  I think so.

Chris Dy:  Dr. Wall were the, uh, the faculty on there. That helped me a lot in collection and made me realize that, you know, as much as I want my patients to do well, this is just a nasty actor, um, this fracture.

Chris Dy:  So do you think it behaves differently if the joint has not subluxated? Do you treat it differently than if the joint is clearly volarly subluxated?

Charles Goldfarb (You):  Yeah, totally agree. The joint is subluxated volarly, which essentially is, you know, not what happens if the middle phalanx dislocates volarly. One or two things has to happen.

Charles Goldfarb (You):  Either the central slip tears or you have a central slip fracture. Um, and so one of those two things has to happen.

Charles Goldfarb (You):  And in that case, the instability issues are more significant. In your case, I guess it was something short of the joint dislocation or subluxation.

Charles Goldfarb (You):  So you're really just dealing with that fracture fragment. So yeah, more stability, less concerned about the joint, but you still have to get the anatomical reduction.

Chris Dy:  And that's the thing is that it made me, it made the decision-making a little bit harder because then it's like, well, the joint's volarly subluxated. Yes, of course, we're going to surgery. Then it was, all right, so this is a big piece.

Chris Dy:  What do I do with it? Uh, I can see it playing out in a couple of different ways.

Chris Dy:  I was going to try to perk this piece, which was not the biggest piece. And in the process of perking the piece, you know, putting a percutaneous pin into the piece and then trying to reduce it and get it across, destroys that piece, which makes me super nervous.

Chris Dy:  And I can see that ending in heartache. Um, so because I could see that playing out, I went ahead and just made the decision to open, um, which I think gets me, makes me feel better about my ability to identify and secure the piece, although you do pay the penalty of opening somebody's finger at the PIP joint.

Chris Dy:  Um, and just to move things along, um, we opened and it was really interesting. I mean, it was literally a central slip fracture.

Chris Dy:  And, you know, putting a pin across it and kind of looking underneath, the central slip is clearly attached there. There's a cancellous base.

Chris Dy:  You can see where it goes. Um, so I ended up pinning it, um, back to the, uh, the remainder of the base of the middle phalanx.

Chris Dy:  And then, uh, I buttressed it, uh, because I wanted some stability. And I knew that I had a little, this was, I think, a 2.8 K-wire.

Chris Dy:  And that piece was still just barely bigger than a 2.8 K-wire, which, um, trying to remember the metric size of a 2.8 K-wire, I think it's a 0.8 millimeter. Um, so I put a, I custom plated a, I custom cut a plate and buttressed it into the apex screw at the, you know, first and then went distally in the shaft.

Chris Dy:  And then I was trying to figure out, do I try to fix into this piece? From an orthopedic perspective, I'm really happy.

Chris Dy:  I've got my buttress. The proximal flange of the plate is sitting on the piece, uh, you know, had the K-wire kind of sitting through one of the screw holes.

Chris Dy:  Um, and then just made the decision not to try to fix into the piece, put a couple of locking screws on both sides of the piece just to keep the construct there. Um, but this was like, the people that work with me know the difference between type one fun and type two fun.

Chris Dy:  Do you know the difference, Chuck?

Charles Goldfarb (You):  I do not.

Chris Dy:  Type one, type one fun is like fun the whole time. It's fun while you're doing it. It's like fun afterwards.

Chris Dy:  Type two fun is awful as you're doing it. You're like, this is, this is the worst.

Chris Dy:  And then you look back, you're like, oh yeah, that was great. So this case was type two fun because like the entire time, uh, I feel like if you had, uh, a 12-lead EKG on me, my STs would have been elevated at several points during the case.

Chris Dy:  I asked the nurse to send troponins on me just to get a trend. It was just so nervous the entire time.

Charles Goldfarb (You):  So a couple of interesting cases. Some people are thinking probably to themselves, well, what's the difference between the fracture you describe and a mallet fracture? And you could argue not much, but I would say there are a couple of critical differences.

Charles Goldfarb (You):  Number one, the DIP is very different than the PIP joint. First of all, I don't care that much about the DIP joint.

Charles Goldfarb (You):  Um, yes. Not as much as I care about the PIP joint.

Charles Goldfarb (You):  Yes. Uh, number two, there's so much more resilience to the DIP joint than the PIP joint.

Charles Goldfarb (You):  So if you have a malunion of that, uh, terminal tendon fragment, so to speak, the mallet fragment, you'll be fine. Uh, but the PIP joint's not like that.

Charles Goldfarb (You):  And, uh, you know, they do make, I don't think I've ever used one, a hook plate for these where you kind of like you would do for a volar ulnar corner of the distal radius, but, uh, I haven't used those. Sounds like your solution was, dare I say, elegant?

Chris Dy:  I'd like to think it was elegant. It was stress-inducing for sure, but, uh, you know, fortunately, I think everything came together really nicely. And then stressing the joint, you know, passively flexing down, no displacement.

Chris Dy:  I was very happy with it, um, towards the end of the day, but I agree. It's, it's, you know, the DIP is a different beast.

Chris Dy:  You can, and nobody loves this, but you can fuse the DIP with relative impunity for most of the, most of the joints, um, you know, with some implications for grip if you do the rigid small, but you can deal with that issue. This is a much harder, the sequela of a PIP fracture, intra-articular fracture, much harder to deal with than those of a DIP fracture.

Charles Goldfarb (You):  Yeah, absolutely. Maybe we have time for one more fracture, either yours or mine, either way.

Chris Dy:  I've got one more. I mean, this has just been a run of fractures recently. So, um, so this was interesting.

Chris Dy:  So going outside slightly of the realm of the normal hand surgery, an injured worker comes into the clinic, um, working as a mechanic, had some kind of thing fly off his machine and hit him directly in the ulnar shaft. Just huge mechanical impact and has a displaced ulnar shaft fracture.

Chris Dy:  Um, so it's not a radial shaft fracture. There could potentially be a role for some non-operative management.

Chris Dy:  How do you kind of unpack that as you think about the care of the injured worker?

Charles Goldfarb (You):  Yeah, I mean, in some ways, I think about caring for an injured worker like I think about caring for an athlete. Obviously, they're different, but there's some overlap for certain getting back to work matters and like getting back to play matters. You know, the classic night stick fracture for those outside the United States, although I think this is universal, but.

Chris Dy:  They have to think about night sticks. I've seen movies in the UK where, you know, they're carrying night sticks around.

Charles Goldfarb (You):  Is it the Bobbies? Is that what they're called? Yeah, the night stick fracture is you hold your arm up to protect you, you get hit by the baton and you break your ulna.

Charles Goldfarb (You):  And as I recall, the literature is if it's more than 50% displaced, fix it. If it's less than 50%, don't.

Charles Goldfarb (You):  I generally abide by that, but, you know, this may be a case to try to get them moving more quickly and back to work more quickly.

Chris Dy:  Yeah, and that was the biggest thing. It was like, well, you know, hey, we can treat this without surgery. You'll be, you know, immobilized for a while.

Chris Dy:  It's going to take a little longer. You're going to stay off of work longer.

Chris Dy:  Um, but you're a young person. I think that you will do well with the surgery.

Chris Dy:  Uh, you know, do we go ahead and open it up and fix it? And, you know, to move the conversation along, we did.

Chris Dy:  Um, so what's your current, uh, so I put an interfragmentary screw across the main fracture line, uh, and then put a neutralization plate on the volar aspect of the ulnar shaft. Uh, very happy with the fixation.

Chris Dy:  Uh, I guess the question I have for you and for, you know, this may be of interest to our therapy colleagues as well, what's your post-op protocol for something like this? I mean, I know some of our trauma colleagues will put it in a soft dressing and let them go.

Chris Dy:  Uh, how do you manage this?

Charles Goldfarb (You):  Yeah, I've never had the audacity to do that. I don't think it's crazy at all. I always immobilize.

Charles Goldfarb (You):  Um, it's just like a distal biceps. I always immobilize at least for a short term.

Charles Goldfarb (You):  For this, I would probably put a plaster splint on, have them see therapy within five to seven days for a removable brace. Um, it just makes me feel better.

Charles Goldfarb (You):  And I think especially if someone's trying to resume activities, it just gives me an extra element of comfort. What about you?

Chris Dy:  So plaster splint, do you mean a volar forearm baseball or resting splint or a sugar tong splint?

Charles Goldfarb (You):  Yeah. And that's for post-operative comfort, but not a sugar tong. I would not immobilize the elbow.

Chris Dy:  Is the sugar tong really immobilizing the elbow?

Charles Goldfarb (You):  I think it is.

Chris Dy:  I wanted to, I mean, just as a, just to make it easier, uh, I just went ahead and did a sugar tong because I wanted to control forearm rotation. Um, but we, to your point, I mean, you know, I'm very happy with the fixation. Do I really need it?

Chris Dy:  No. Um, but I think it sends a message, gets everything to quiet down, and then we're going to get them into therapy, uh, three or four days post-op, uh, to have a custom splint made and work on some gentle forearm motion, elbow motion, wrist motion, but no loading, no strengthening.

Chris Dy:  So that's our protocol for him. I've, you know, I even have a couple more fractures we could share, but I know we're out of time.

Chris Dy:  I'll save them for the next episode.

Charles Goldfarb (You):  I love it. You have a fracture practice.

Chris Dy:  The nurse is giving up nerves. Exactly. The nurse is down there at the surgery center where it's going to kill me because I've changed the schedule multiple times to accommodate all these fractures and there are all these, uh, osteosynthesis sets that were floating around and we made it work.

Chris Dy:  So shout out to the nurses down at the South County Cam for tolerating me.

Charles Goldfarb (You):  Yes, absolutely. It's, uh, I had a slow day this past week because it's back to school week and it happened to be back to school week and I was at the children's surgery center and, um, just like, oh my God, you've got to be kidding me.

Chris Dy:  Make, make, make the most of your found time. I'm sure you found something to do.

Charles Goldfarb (You):  Exactly. Yes, I did. Yes, I did.

Charles Goldfarb (You):  All right. This was fun as usual.

Charles Goldfarb (You):  Thank you.

Chris Dy:  Oh, thank you. For those of you listening, check us out at the Hand Society meeting live podcast, September 18th, Friday at 4 p.m. and email us at handpodcast@gmail.com.

Charles Goldfarb (You):  Done. All right. I'm going to jump on my call.

Charles Goldfarb (You):  Thank you. Have a good day.

Chris Dy:  You too. See you. Bye.

Charles Goldfarb (You):  Bye.