0:03

Welcome to the

0:03

Upper Hand Podcast where Chuck

0:06

and Chris talk hand surgery.

0:07

We are two hand surgeons at Washington University in St. Louis here to

0:09

talk about all things hand

0:12

surgery related from technical

0:12

to personal.

0:15

Please

0:15

subscribe wherever you get your

0:17

podcasts.

0:18

And thank you in

0:18

advance for leaving a review and

0:21

leaving a rating wherever you

0:21

get your podcast.

0:24

Oh, hey Chris.

0:25

Hey Chuck, how are you?

0:27

It's a special day. I'm great.

0:28

It is a special day is

0:28

it because we have a guest

0:31

it is absolutely because we have guests but not just any guest.

0:35

We have a guest that

0:35

is very special to me. Megan

0:38

Conti Mica is joining us for

0:38

this episode. And well, we

0:42

should talk about Megan in a

0:42

little bit. You know, Megan is

0:46

probably one of my favorite

0:46

collaborators outside of Chuck.

0:51

That's, that's

0:51

saying something Chris likes to

0:53

collaborate as I think we all

0:53

know he collaborates in

0:55

research, collaborates with

0:55

people like to talk about food

0:59

weirdly enough, he talks he

0:59

collaborates and all kinds of

1:02

things. Oh, well.

1:03

Before we talk about Megan, I want to talk about her husband, Mike, who I went. When

1:05

I came there and visited,

1:09

visited Megan, she was kind

1:09

enough to let me stay at their

1:11

place. And Mike made this

1:11

amazing meal. And I know that

1:15

Maggie can throw down in the

1:15

kitchen too. It's just a great

1:18

couple. I mean, this the quality

1:18

of the chicken that I had, there

1:22

was fantastic. And chicken is

1:22

easy to mess up and it's hard to

1:26

make really good.

1:27

You know, I

1:27

was raised on a diet of chicken

1:30

and rice. So I would have

1:30

enjoyed that. No, I have no

1:33

doubt. I have no doubt. All

1:33

right.

1:35

Well, you know, it's

1:35

I'm thrilled that we're joined

1:38

by Megan Conti Mica who is

1:38

currently in practice at the

1:41

University of Chicago but is

1:41

going to be moving to Scottsdale

1:44

for her for a new gig and a new

1:44

transition. Pretty soon. She

1:48

trained at Loyola and then went

1:48

on to train at the world famous

1:52

Mayo Clinic for her hand surgery

1:52

training. Megan I've

1:55

collaborated a lot and she's a

1:55

dear friend of mine, currently

2:00

we are in a hand travel club

2:00

together, which has been super

2:02

fun. But during the height of

2:02

the pandemic, we were part of

2:06

one of the Hand Societies'

2:06

initiatives for online education

2:09

which was Firsthand the

2:09

masterclass in hand surgery with

2:13

Peter Stern for about 14 months.

2:13

We got together every month and

2:17

you know, got to talk to some

2:17

really great legends in hand

2:21

surgery. So Megan, welcome to

2:21

the pod

2:26

thanks everyone. I'm really excited to be here and it's super honored

2:27

to have been asked to be here by

2:32

you too.

2:34

You're probably wondering why it took so long

2:36

no i you guys

2:36

you guys invited me about two

2:42

days ago so I'm more wondering

2:42

who cancelled and I was you know

2:47

F squad and that's why I got my

2:47

invite

2:50

there was a

2:50

long list of cancellations but

2:53

but no you were our first choice

2:53

we have a great topic to discuss

2:58

a little teaser we're gonna talk

2:58

about distal radius non unions

3:00

and just general surgical

3:00

approaches but you're honestly

3:04

both Chris and my first you know

3:04

first thought and I think we

3:08

both have a relationship with

3:08

you Chris obviously with

3:10

Firsthand and travel club and

3:10

and you and I were lucky enough

3:13

to travel to Israel to represent

3:13

the Hand Society with the joint

3:15

hands society and Israeli Hand

3:15

Society meeting and that was

3:18

super fun to meet you know, Mike

3:18

and meet your youngest and bond

3:23

with you guys and my son. And it

3:23

was it was really great.

3:26

It was really

3:26

fun. I think we we definitely

3:32

convinced your your oldest son

3:32

who's going to medical school to

3:36

maybe we aren't having children

3:36

after watching us travel around

3:40

Israel with a three month old.

3:43

I think that's true. But you guys made it look easy, even though it's not

3:45

always pretty. He has made it

3:48

look easy.

3:49

Yeah, I don't know about that. But thank you. And Chris, obviously always a

3:51

pleasure to spend any time with

3:54

you.

3:55

It is isn't it? Yeah.

3:55

Okay. All right.

3:58

Chris, giving

3:58

you any type of problem.

4:02

Oh, Megan, it's just

4:02

it's so much fun. And it's

4:05

always it's always very easy to

4:05

talk with certain people

4:08

especially. You know, it's kind

4:08

of like Chuck and I do this

4:11

frequently. When we were doing

4:11

Firsthand. It was just such an

4:14

easy conversation with you. So

4:14

thank you for being a partner in

4:17

crime on that one certainly had

4:17

its share of ups and downs for

4:20

sure.

4:21

It was fine.

4:21

It was interesting educational

4:23

all at once.

4:24

I have two

4:24

questions. I always like to do

4:27

two questions. The first I'll

4:27

ask them both and then maybe

4:30

each of you will take one of

4:30

these. The first one is why did

4:33

they cancel your show why they

4:33

pulled the plug. And the second

4:37

is I want to know more about

4:37

that. That travel club because

4:41

I'm in a travel club is a little

4:41

different. So I'd love to hear

4:43

more about that one, YouTube.

4:46

Well, Megan, why did you get cancelled?

4:48

I know right canceled.

4:50

I'm still on the air with Chuck.

4:53

Oh, actually, we we

4:53

chose to to stop recording with

4:59

Peter Stern retired. Sorry. So

4:59

it just seemed like the right

5:01

thing to do. You know, it was it

5:01

was just a timeline issue for

5:06

us. But I, you know, in

5:06

retrospect, I think we could

5:09

have gone forever, right, Chris,

5:09

we could have kept making video

5:13

after video podcast after

5:13

podcast. But I don't know if

5:16

anyone would listen. So I think

5:16

at some point, you know, things

5:19

might have run its course. And

5:19

it's time to move on to bigger

5:22

and better things, which for

5:22

Chris was, was this podcast and

5:27

for me, it was silence.

5:32

I have nothing to add,

5:32

as you would say. No, I think it

5:37

was a good time to transition.

5:37

You know, in all actuality, we

5:40

could have gone on forever and

5:40

interviewed a lot of people, it

5:43

would have been super fun. And

5:43

very educational, especially at

5:46

least for us. But you know, in

5:46

reality, there was a lot of, I

5:49

think, fatigue for online

5:49

webinars, after, you know, two

5:53

years of the pandemic, and just

5:53

interest, I think, was starting

5:56

to flatten for everybody

5:56

involved. And I think that it

5:59

was just one of those natural

5:59

times, where with Peter

6:02

retiring, and stepping down from

6:02

a national stage it was it was

6:06

the right thing to do.

6:08

We felt right, exactly.

6:08

You gotta you gotta retire on

6:12

top. Right? You got to stop,

6:12

stop waiting. People are still

6:15

interested in

6:15

those royalties. And those

6:17

royalties.

6:18

Yeah we're in

6:18

syndication. I mean, it's great

6:21

Yeah, we're not getting Seinfeld royalties, we, in fact, didn't even get any

6:23

swag, which, which we regret.

6:27

But yeah, I think it was, it

6:27

was, it was a lot of fun to do.

6:30

And, you know, I encourage

6:30

anybody who hasn't listened to

6:33

some of them, there's some just

6:33

absolute pearls of knowledge

6:36

that are dropped by a lot of

6:36

really, really talented

6:39

surgeons. And for us, it was

6:39

super fun, just because he got

6:42

to interview some of the Living

6:42

Legends of hand surgery. So I

6:45

think that's an opportunity that

6:45

I will always have cherished.

6:49

And about our travel club. We're

6:49

kind of a small group. But you

6:53

know, I think for a lot of I was

6:53

actually just talking with one

6:55

of our fellows who's graduating

6:55

and I asked him, David Wright

6:58

asked him if his generation of

6:58

hand surgeons has started to

7:01

form a travel club yet, because

7:01

I know there are a couple clubs

7:03

that have formed even after

7:03

Megan and I are as a group. And

7:09

it's interesting, because at

7:09

least the way that I've seen it

7:11

done is that it tends to be

7:11

people who have kind of done

7:14

fellowships within a couple of

7:14

years of each other. And you get

7:17

together on a, you know, annual

7:17

basis and you know, get together

7:22

when you're all at the hands of

7:22

society and whatnot, and have a

7:25

fun kind of trip. Obviously,

7:25

there's some, some business

7:28

involved, people bring families

7:28

and you try to go somewhere

7:31

where people want to go and it's

7:31

a smaller kind of a casual

7:33

meeting, we'd we had a lot of

7:33

fun. When we got together, we've

7:36

done a couple of meetings. And,

7:36

you know, we talked about cases,

7:39

you talked about the challenging

7:39

parts of your practice, you can

7:42

make it whatever you want, make

7:42

it a research gathering that

7:44

kind of thing, if you want to.

7:44

So everybody kind of

7:47

contributes, what they want,

7:47

what they want to contribute.

7:51

And I think there's a great mom

7:51

that's built there. But what do

7:53

you think, Megan?

7:54

Yeah, I think

7:54

it's, um, it's, it's a very

7:57

unique thing to hand surgery. My

7:57

husband's a spine surgeon, he's

8:00

super jealous. He keeps talking

8:00

about doing something in the

8:04

spine world, but I don't know if

8:04

we can afford those types of

8:08

bougie trips. But they're Yeah,

8:12

they probably don't like each other that much, either. That's the hand surgery

8:13

versus spine surgery.

8:17

Yeah, no, I think I

8:17

was I was at the one dinner were

8:20

where Mike picked the wine. And

8:20

they were like, wow, this is the

8:23

level we're all

8:24

I know, I

8:24

know. You can't put Mike Mike

8:27

food and wine, you gotta be very

8:27

careful with putting him in

8:30

charge, or you just had to kind

8:30

of close your eyes and, and

8:33

realize it's just gonna be the

8:33

best of the best but, but

8:36

reality is, is our travel club

8:36

is I talk to you guys. I mean,

8:41

on a monthly basis, that or

8:41

someone I talked to, and it's

8:45

for cases, it's for personal

8:45

advice, you know, career advice.

8:50

So it becomes, you know, it

8:50

makes your world a little bit

8:53

smaller, but also that you feel

8:53

supported with questions that

8:56

maybe you don't feel comfortable

8:56

asking your partners or you just

8:59

want somebody else's opinion

8:59

that does these surgeries more

9:03

often than you. So I mean, I've

9:03

had some disaster cases, and I

9:07

call up Dave Brogan, because I'm

9:07

like, man, if there's so many

9:09

who knows disaster cases, it's

9:09

this guy. And he's given me

9:13

sound advice that I've followed.

9:13

And it's been really, really

9:16

helpful just to send out you

9:16

know, the bats, you know, the

9:19

bat signal and, and see who, who

9:19

responds.

9:24

I love it. My

9:24

travel club is a little

9:27

different. It's just congenital.

9:27

It's in small international

9:29

group and it sort of source of a

9:29

different purpose. But I think I

9:32

want to go back to what you

9:32

said, because it's really

9:34

important for those younger

9:34

listeners, is when you start

9:37

practice, no matter how prepared

9:37

you are, you the things that

9:41

seem simple and fellowship and

9:41

residency are no longer simple,

9:44

and the hard stuffs harder. And

9:44

I told I didn't have a travel

9:47

club when I started practice. I

9:47

had three really good hand

9:50

partners. So I would ask each of

9:50

them questions intermittently,

9:54

and then you feel like oh my

9:54

god, I've asked Marty Boyer too

9:57

many questions, send an email or

9:57

call Dr. Stern, and then all of

10:01

a sudden, you're asking too many

10:01

questions, you're like, everyone

10:03

thinks I'm an idiot, I need to

10:03

find someone else to bounce

10:05

questions off of, which is just

10:05

the facts of life. And I think

10:09

your, your points are really

10:09

good one, and really helpful to

10:12

hear.

10:13

Its also the practice

10:13

management issues as well, like

10:15

you run into problems, and you

10:15

ask your senior partners, and

10:19

they're just at a different

10:19

level in their career. So they,

10:22

when they have to solve

10:22

problems, it's just a little bit

10:24

different, you know, like,

10:24

they've been there for 10-15

10:28

years, they've already

10:28

established a voice, and you're

10:30

early in your practice, and

10:30

nobody really cares about your

10:33

voice, per se. And so it's

10:33

learning how to navigate those

10:37

types of situations and, and

10:37

having somebody else who's just

10:41

going through the same thing,

10:41

it's, it's really valuable to

10:43

have that lateral mentorship as

10:43

opposed to that up and down like

10:48

that superior mentorship.

10:50

You know, one

10:50

way to gain more mentors, and

10:53

I've heard this as can be really

10:53

helpful, is just to move your

10:56

family to a different location,

10:56

and meet new people. And you can

11:00

ask more questions, as anyone

11:00

tried that strategy.

11:03

I'm in the

11:03

midst of trying that strategy.

11:06

And let me tell you, it's better

11:06

just to make cold calls, I think

11:10

there might be easier. But yes,

11:10

we're in the midst of a move.

11:14

This is my, I've been with the

11:14

universe Chicago for eight

11:16

years. So this is my first move.

11:16

So I've been really, really

11:23

lucky that I've had a great run,

11:23

and haven't had to move

11:28

practices early in my career, I

11:28

really got to stick it out in

11:32

build groups. But that also

11:32

makes it harder to move. Because

11:35

you have built routes, and you

11:35

have a great practice, and you

11:37

have great patient population

11:37

and referrals. So it is a little

11:41

scary to not only be leaving

11:41

something that is really good to

11:47

move somewhere else. But it's

11:47

also it's a lot, it can be a

11:52

little complicated. And so I'm

11:52

really excited about it. We're

11:55

moving back to Arizona, which is

11:55

where I'm from my husband is

12:00

getting a great gait, I'm

12:00

getting a great gig. So fingers

12:03

crossed that, you know, this is

12:03

this a good long term move for

12:08

us and for our family.

12:11

Yeah, they're lucky to

12:11

have you there in that practice.

12:13

And it is obviously a loss for

12:13

years. So you Chicago, because

12:17

you were very involved with

12:17

their fellowship and residency

12:20

training and a beloved mentor

12:20

for them. So they'll miss you. I

12:25

know you'll keep up with your

12:25

relationships with them. But you

12:29

know, for the future trainees at

12:29

the University of Chicago, it's

12:32

you won't get the Megan

12:32

coffeemaker love that everybody

12:35

else has gotten. And so many

12:35

people have spoken fondly of.

12:39

That's really

12:39

sweet of you say, but they all

12:42

know that I'm always a phone

12:42

call away. And I we're gonna be

12:44

visiting Chicago all the time,

12:44

because my husband's family's

12:47

here. So they already know, I've

12:47

already planned to come back for

12:49

graduation next year. So they

12:49

can't get rid of me that

12:53

quickly.

12:54

And I think one more thing, before we jump into our clinical topic for today, you're

12:56

kind of a big deal. You're

12:59

running the annual meeting for

12:59

the hand society this year with

13:02

our hand club, buddy page, Fox,

13:02

so let's snap in, like Chuck's

13:06

done it before. I hope to not do it.

13:10

It's been you

13:10

know, it's actually been an

13:13

honor. So first of all, I get to

13:13

do this with Paige Fox, who was

13:16

my co Fellow at the Mayo Clinic,

13:20

it's supposed to be

13:20

called the world famous. That's

13:24

what that's what David calls it

13:24

whenever he talks about it.

13:27

Well, Dave,

13:27

Brogan knows, I mean, I don't

13:30

even need to say world famous

13:30

because everybody knows it's

13:32

world famous. So it's kind of

13:32

almost redundant, I guess

13:35

there'll

13:35

be you FMC is

13:35

whatever. But

13:40

I mean, it was

13:40

a wonderful place to do

13:43

fellowship, absolutely. No

13:43

question about it. But she, it's

13:48

been amazing to, to get to build

13:48

up that bond, again, if somebody

13:52

that I did fellowship with and

13:52

we're actually going to be in

13:56

Toronto, which is one of our

13:56

other co fellow Heather bolts,

13:59

or that's her stomping ground.

13:59

So she's been helping us a lot

14:03

with locations, restaurants,

14:03

stuff like that, but it's gonna

14:06

be a great meeting, it's gonna

14:06

be a different meeting. Because

14:10

we're back and be in the United

14:10

States, we're going to be

14:13

Toronto, so please get your

14:13

passport in order. That is my

14:17

biggest fear is that people are

14:17

going to show up to the airport,

14:20

and then all of a sudden realize

14:20

they need a passport to go to

14:22

Canada. But the meeting is gonna

14:22

be great. We've done a lot of

14:26

different things, there's going

14:26

to be a lot of different types

14:29

of debates, that we're gonna

14:29

have a lot of different symposia

14:33

as, you know, Masters giving

14:33

lectures and, and having one on

14:38

one with Master. So it's going

14:38

to be a lot of new content and a

14:42

lot of more diversity and voice

14:42

it should be, it should be

14:45

really exciting.

14:48

It looks

14:48

great. And you know, I have been

14:51

through this. It's not easy.

14:51

It's a lot of time and you have

14:54

done this without Angie. So the

14:54

transition, I'm sure was a

14:58

little more challenging at least

14:58

town. And it's always easier if

15:03

you know your creative thinker

15:03

and I'm sure pages as well. It's

15:08

just easier to do what's been

15:08

done before. to branch out is

15:11

hard. It's hard to create the

15:11

content or the concepts, it's

15:15

hard to get speakers to agree to

15:15

it. So I think we're all looking

15:18

forward to it. So congrats in

15:18

advance and passport is good to

15:22

go.

15:24

Yeah, it is

15:24

hard it but you know, change is

15:26

always scary. Definitely, we're

15:26

with a new acsh group for annual

15:33

meeting planning. But everybody

15:33

has stepped up to the challenge,

15:37

and everyone is making this the

15:37

greatest meeting. So sorry,

15:42

Chuck, we, we have to take that

15:42

from you. And hopefully the year

15:46

after us, they do even a better

15:46

meeting, and that we keep

15:49

building on each other.

15:51

I think it's gonna be

15:51

wonderful. You always bring such

15:54

great energy. And I'm sure the

15:54

meeting Planning Committee and

15:57

the staff are very happy with

15:57

that. Chuck, we should probably

16:02

thank our sponsor, before we

16:02

dive into this distal radius,

16:05

malunion topic.

16:07

Absolutely.

16:07

The Upper Hand is sponsored by

16:09

Practicelink.com, the most

16:09

widely used physician job search

16:12

and career advancement resource.

16:15

Becoming a physician

16:15

is hard finding the right job

16:17

doesn't have to be joined

16:17

practicing for free today at

16:20

www.practising.com/the. upper

16:20

hand. And I'm sure Megan

16:26

probably has looked through a

16:26

lot of practice, practice

16:29

resources and job searching

16:29

resources as she's looked at

16:33

that transition. In practice.

16:37

It's nice to have

16:37

something in one- in one place.

16:39

So take a look. There

16:39

you go. She's plugged into

16:43

Practice Link to look at that.

16:45

I'm hoping you'll ask me back one day, you know, well, there's

16:48

a lot of stuff that you should we should have you on to talk about. I mean, when I

16:50

think, you know, in all

16:53

seriousness, I think that you've

16:53

done a wonderful job with

16:55

advancing, advancing and

16:55

academics and reputation and

17:00

establishing yourself as a

17:00

presence both in hand surgery in

17:03

general, but also a lot of our

17:03

topics about, you know, trying

17:07

to establish more diverse and

17:07

inclusive training environments.

17:10

And you know, you've done

17:10

fantastic work with that. So I

17:14

guess we'll have you back.

17:16

I won't see

17:16

how the actual content goes

17:18

before.

17:21

Yeah, let's see me downloads we get here. No, I think I think oh, my gosh,

17:25

I'm calling my family.

17:25

And if that's what's based on

17:27

downloads, I have a very, I have

17:27

a Catholic side of the family

17:31

and a Jewish side of the family.

17:31

They will be all over it

17:34

Five Star five star

17:34

reviews all commenting on Mexico

17:37

on TV because I do it

17:40

a little afraid you guys are scheming to boot me off the upper hand which

17:45

firsthand?

17:50

I think the no

17:50

brainer invitation, which which

17:52

you may not feel like doing

17:52

would be after the hands study,

17:55

we used to do a debrief. So

17:55

maybe if you have the energy and

17:58

the time post hands Saturday, we

17:58

could we could gather and talk

18:01

about that. When I do preach

18:01

that

18:04

I'm in.

18:04

Alright, so Chuck, what you want

18:06

to talk about today?

18:07

Yeah, you

18:07

know, one topic, which I get

18:09

asked about a lot, and you have

18:09

a case that can be delightful.

18:14

And it's also a case that can be

18:14

really challenging as the distal

18:17

radius malunion. And so there

18:17

are different ways to approach

18:21

the classic malunion. So let me

18:21

paint a picture. And then we can

18:25

discuss, we want to be a little

18:25

technical about how we would

18:29

approach things. So the picture

18:29

is this. So we have a 60 year

18:33

old, very active young lady who

18:33

has a classic distal radius

18:40

fracture. She fell while playing

18:40

pickleball

18:44

and I knew you're gonna say pickleball I actually saw this patient yesterday.

18:47

And

18:47

unfortunately, she is a tough

18:55

lady and kind of wanted to talk

18:55

it out and you bought a splint

18:58

at Walgreens and put it on and

18:58

she comes in to see us five

19:02

weeks later, not in any pain,

19:02

but with significant deformity.

19:06

So she had a classic distal

19:06

radius fracture metaphyseal

19:11

colles type, and she now has 35

19:11

degrees of dorsal tilt. Her you

19:17

know, the relationship between

19:17

the radius and the ulna, it

19:20

seems like the ulna is now long.

19:20

I personally have a hard time

19:23

figuring that out when there's

19:23

so much dorsal tilt, it's an

19:26

extra articular fracture. Again,

19:26

she's not having any pain, but

19:30

she she comes in to see and

19:30

maybe Chris, you can start with

19:33

you. What's your first you know,

19:33

you're having the initial

19:37

conversation with her in the

19:37

office. She does not have

19:40

evidence of nerve issues. I know

19:40

you're going there. And she just

19:45

comes in with deformity.

19:47

No, I feel like this

19:47

is a patient that we all see and

19:50

so, this is somebody who has

19:50

automatically self selected to

19:53

attempt at non operative

19:53

treatment because sometimes this

19:56

is the other way that this this

19:56

kind of scenario comes up is

19:58

that you try something and they

19:58

They slipped into dorsal

20:01

angulation. You know, sounds

20:01

like based on the patient

20:05

profile, you know that I would

20:05

this is somebody who I would

20:08

think about, you know, fixing if

20:08

they had come early on anyway,

20:11

fixing with surgery. So we could

20:11

start some earlier rehab. You

20:15

know, so I think the

20:15

conversation is more about, you

20:18

know, what are you looking for

20:18

in terms of, you know, return to

20:22

activity? I think it sounds like

20:22

they want to get back quickly. I

20:25

do have the conversation about

20:25

the appearance of the deformity,

20:29

not necessarily only for

20:29

aesthetic reasons, but I found

20:32

that that comes up. And I think

20:32

it's important to be proactive

20:35

about, you know, saying, it's

20:35

going to always look like this,

20:38

there's always going to be that

20:38

bump on the pinky side. If we

20:40

don't do something about this,

20:40

are you okay with that, but I

20:43

think there's, you know, pretty,

20:43

pretty strong consensus in the

20:47

literature that leaving somebody

20:47

at this age with this desired

20:50

activity level with that amount

20:50

of dorsal angulation is going to

20:53

have negative implications on

20:53

their functional outcomes,

20:55

particularly grip strength, and

20:55

kind of activities of daily

20:59

living. So it is a discussion

20:59

about, you know, we got to break

21:02

your bone again, and put it back

21:02

in place and get you going.

21:06

Megan, what are your thoughts?

21:08

Yeah, I think

21:08

it's, it's a long discussion,

21:10

because it is tricky, because

21:10

they're not symptomatic right

21:13

now, in the sense of pain, but

21:13

the question is pronation,

21:17

supination, are they having that

21:17

block of rotation, and that's

21:22

where these mal unions can cause

21:22

a lot of issues. And so if she,

21:27

you know, this is her thing

21:27

that's keeping her mentally

21:30

active, physically active, is

21:30

pickleball. And she's not able

21:34

to move the racket in all

21:34

seriousness, that's something to

21:37

discuss, yeah, maybe she needs

21:37

some physical therapy or

21:40

occupational therapy to get her

21:40

back. Or if this is something

21:44

surgically, we need to fix

21:44

because there's a bony block. I

21:48

think the long term conversation

21:48

is, there's complications with

21:52

surgery, this is not a slam dunk

21:52

surgery. And when you lay

21:57

everything out to the patient,

21:57

they have to make a decision.

22:01

Ultimately, this has to be a

22:01

shared decision making

22:04

situation. Because one, there is

22:04

a lot of opportunity for this

22:08

not to go exactly the way they

22:08

want. And they have to

22:10

understand that the risk is not

22:10

really going to be exactly how

22:13

it was before the fracture.

22:17

No, Megan and Chuck,

22:17

and I end up getting a little

22:19

bit of an echo chamber just

22:19

because of the podcasts. And

22:21

then also, because of our, you

22:21

know, conference interactions

22:23

and stuff, what are the

22:23

complications you talk about

22:27

with, with this kind of patient

22:27

or a distal radius patient who's

22:30

coming in for an acute fracture,

22:30

and you're talking about surgery

22:33

versus you know, non operative treatment?

22:36

Yeah, um, I

22:36

have seen a lot of

22:38

complications, practice so far.

22:38

And so it's been pretty

22:43

humbling. So I don't just see

22:43

fracture, fixed fracture, or see

22:47

X ray of malunion. fixed value

22:47

again, because I've seen what

22:51

happens afterwards. And, and it

22:51

can be pretty devastating. I've

22:54

had, I've actually had non

22:54

unions happen. And it's not fun

23:00

to have a non union of this

23:00

because it's, it was hard. The

23:03

first time you did that

23:03

corrective osteotomy. It's even

23:07

harder the second time. So you

23:07

know, tendon injuries,

23:11

especially if you're doing a

23:11

opening wedge osteotomy, that

23:16

EPL can be definitely injured.

23:16

It depends if you're going

23:20

dorsal or volere. So the plate

23:20

placement, I personally always

23:24

go Buller, because I am post

23:24

boilerplate invention, and so I

23:29

feel more comfortable going

23:29

volar. You know, so patient

23:35

health, like pathology, their

23:35

biology, if they're going to

23:38

heal this thing. And then also

23:38

their range of motion

23:42

afterwards. A lot of times these

23:42

patients, they go in there,

23:45

they're in a cast, and they may

23:45

or may not be doing early range

23:50

of motion, and then they have a

23:50

lot of stiffness. And they came

23:54

with the word stiffness, and now

23:54

they have a different type of

23:56

stiffness, that can always be

23:56

frustrating. So infection, I

23:59

mean, I can keep going.

24:02

So awesome. I

24:02

have a lot I want to unpack from

24:05

what was said. So first of all, I think your point about rotation is really important.

24:07

And sometimes, you know, if we

24:11

call 80, and 80-80 degrees are

24:11

pronation add supination.

24:14

Normal, it's not always terrible

24:14

rotation, but it's just not what

24:18

they had before. And for some

24:18

patients that matters, at least

24:21

in my experience, for some

24:21

patients, it doesn't it mattered

24:23

for this lady. So that's, that's

24:23

a great point. And then when we

24:26

think about the appearance, I

24:26

think about it in three buckets.

24:29

You know, Chris mentioned the

24:29

prominence of the owner, that

24:33

just Oh, no, that's certainly an

24:33

issue. The actual deformity of

24:37

the radius is an issue. And the

24:37

third one, which can be a little

24:40

tricky to figure out clinically,

24:40

but it's more apparent

24:43

radiographically is the loss of

24:43

radial inclination. And in the

24:47

classic fracture, that's a big

24:47

deal, maybe in this one too, and

24:50

we can talk about it for

24:50

corrective purposes. Because if

24:53

you lose that radial

24:53

inclination, as I think we all

24:55

appreciate that, you know, the

24:55

wrist just tilts over and it's

24:58

not a functional issue at all.

24:58

But it is a big appearance

25:01

issue. So my question they hate

25:01

that zigzag deformity, they hate

25:05

it, they hate it. So my question

25:05

to you both because I think you

25:08

guys are in a different

25:08

generation, and I think it was a

25:11

dig to say I was in the post

25:11

folder plate era, I was in the

25:15

pre volar plate era barely

25:18

when dinosaurs

25:18

roamed the earth. That's right,

25:22

Intern in the 1890s,

25:22

you wanted me to be very clear

25:25

on that.

25:27

My question is

25:27

this. We, in all seriousness, in

25:34

my residency and fellowship, we

25:34

talked a lot about adaptive mid

25:37

carpal instability. I don't feel

25:37

like we talk about that anymore.

25:41

And so just and I'd love both of

25:41

your opinions, but to quickly

25:43

define it. This is a situation

25:43

which would allegedly cause

25:47

adaptive mid carpal instability,

25:47

a lot of dorsal tilt, and you

25:51

lose wrist flexion. And so the

25:51

theory from Fernandez was, you

25:54

would, quote, break in the mid

25:54

carpal joint, and you'd get

25:58

extra flexion and mid carpal

25:58

joint your lunette would go

26:00

dorsal? And I just don't know

26:00

that people talk about that

26:03

anymore. Am I right? Or am I wrong?

26:07

You are right.

26:07

And I think the reason why we

26:10

talk Don't talk about is we're

26:10

trying to avoid it. Because I

26:15

don't think we have a great

26:15

solution for it, especially if

26:17

you have a, an older malunion.

26:17

Because that's when that

26:21

happens. There's usually two

26:21

types of mid carpal involvement.

26:27

One is that as you were talking

26:27

about the adaptive mid carpal

26:33

dorsal instability, but the

26:33

other one that we don't talk

26:37

about is just that subluxation.

26:37

And I think the subluxation is

26:42

easier to fix with the

26:42

osteotomy. But the studies

26:47

haven't supported that the

26:47

osteotomy is actually going to

26:49

fix that malalignment. And

26:49

that's something to think about.

26:52

And that comes back to that

26:52

whole thing. Your wrist is not

26:55

going to be the same after your surgery.

26:58

Well, I think, you know, you're getting in there. I mean, you know, five weeks is

27:00

much better than six months, you

27:03

know, in terms of, you know, the

27:03

development of that adaptive mid

27:06

carpal instability. I mean, I

27:06

remember reading about that when

27:09

I was in training and but not

27:09

ever really seeing it, and then

27:13

practice. And maybe it's seen

27:13

me, but I haven't seen it, so to

27:17

say,

27:18

yeah, it's super interesting, because when you have that dorsal tilt,

27:20

sometimes the loonie goes with

27:23

the distal radius, and sometimes

27:23

it doesn't. But you're both

27:26

right. And in this case, it's

27:26

not a discussion point, because

27:29

it does happen over time. And so

27:29

at five weeks, you know, we're

27:34

not too worried. Alright, let's

27:34

jump in if it's okay. To some

27:37

technical. So, Megan, you're

27:37

gonna go volar. Chris, are you

27:42

going? Yeah, molar?

27:43

No. Dorsal?

27:46

Oh, my goodness. All right.

27:49

No, no, have learned

27:49

different techniques other than

27:51

just rollerblading.

27:52

Okay, guys,

27:52

you're poor. I know that you're

27:54

only worried about nerves. But

27:54

there are tendons back there. I

28:00

haven't bought them as secondary

28:00

surgery. Have you seen that play

28:03

out afterwards?

28:04

I would argue that

28:04

sometimes the volume plates a

28:07

little not not nice to the

28:07

flexor tendons to in what?

28:12

You're

28:12

actually very, you're Yeah,

28:15

that's a really good important.

28:15

And especially when you have

28:18

these dorsal angulation mal

28:18

unions, which are the more

28:22

common ones, right, it's not

28:22

usually the bowler angulation.

28:26

And that prominence when you do

28:26

the osteotomy can make those

28:32

fixed angles, not fit, fixed

28:32

angle plates not fit correctly.

28:36

So your that is a very valuable

28:36

point. But I'm really strong,

28:41

and I can then those plates, and

28:41

I can do ask the tech to me, so

28:46

I'm able to make those plates fit.

28:48

I like well, I mean, I

28:48

liked the boiler plate, I think

28:51

a lot of people will use it as a

28:51

reduction aid. You know, I think

28:54

that that is a really nice

28:54

technique. And I've done it and

28:57

you know, I think that if you're

28:57

going to use it as a reduction

28:59

aid, and get the plate exactly

28:59

where you want it or you have to

29:03

defend it, like you're saying

29:03

with your very strong hands.

29:08

That's just, that's just a you know, an online dig on you.

29:12

Well, if you have to,

29:12

you know, I think before you use

29:15

the plate as an aid, you really

29:15

got to make sure that you're

29:17

completely released on the

29:17

dorsal side. So when I go volar,

29:20

I end up making a dorsal counter

29:20

incision for two reasons. One is

29:24

to make sure that you're

29:24

completely released on the

29:27

dorsal side. And then the second

29:27

is to look for those extensor

29:30

tendons to make sure you're not going to butter them up, particularly the EPL because in

29:32

a male union situation, you

29:35

know, the anatomy, I think, is

29:35

somewhat a little distorted. I'm

29:38

probably in the minority. I saw

29:38

Chuck grimacing as I talked

29:41

about a dorsal counter incision,

29:41

which is why I would just go

29:44

dorsal.

29:45

Alright, so

29:45

Well, I I'm excited to see what

29:48

Chuck has to say because I'm

29:48

feeling we both do the same

29:51

thing. Alright. Of course you do.

29:53

I'm sure. I'm

29:53

sure we do. So I think we've

29:56

already heard two really

29:56

important technical pearls and I

29:59

think think Megan years is

29:59

really, really important. And I

30:02

don't think I realized it for

30:02

years. So if you're going to go

30:06

volar, and you're going to use

30:06

the boiler plates, which are all

30:09

pre contoured. And if you don't

30:09

restore volar tilt, and you just

30:14

accept neutral, and I'll be

30:14

honest, I accept neutral all the

30:16

time, then you are setting

30:16

yourself up for problems later,

30:20

because your plates going to be

30:20

prominent, so super important

30:23

that you either restore volar,

30:23

tilt, or contour the plate. So I

30:27

love that point. And the crisis

30:27

point is also good. You don't

30:31

always have to make a dorsal

30:31

counter incision, but you have

30:34

to be aware of the tendons, and

30:34

you have to keep them safe if

30:37

you go volar. So love those

30:37

types of two pearls already. So

30:41

Chris, since you're clearly in

30:41

the minority, why don't you

30:43

briefly walk us through how you

30:43

approach this? dorsally?

30:48

Right, yeah, so I

30:48

usually end up taking the dorsal

30:51

position here, when we're in

30:51

conference, because everybody

30:54

else except for Marty wants to

30:54

go volar. So, honestly, if you

30:58

could go, I would, I've done it

30:58

both ways. And I think that, you

31:01

know, both will work. I like

31:01

going dorsal just for the

31:04

reasons that, you know, I stated

31:04

in terms of avoiding, you know,

31:07

knowing exactly where I'm

31:07

released, but then you come into

31:09

the same issue of making sure

31:09

that you're completely release

31:11

vulnerably, I think you can, you

31:11

can kind of peek around from the

31:14

radial side and make sure all

31:14

your bone is released. Through

31:17

your approach. I think that the

31:17

concern for the tendons is not

31:21

as big as you know, as it was

31:21

when you're using dorsal plates

31:24

that were like tendons

31:24

shredders, I think the plates

31:26

are lower, better contoured now

31:26

and have smoother edges. And as

31:31

long as your screws are sitting

31:31

flush in, and I'll be honest

31:34

with you, I think it's dealing

31:34

with an extensor tendon issue

31:37

tends to be a little bit easier to dealing with the flexor tendon issue down the line. And

31:39

I have not found the dorsal

31:42

plates to be as prominent and

31:42

bothersome as others have

31:45

described. So I can't honestly

31:45

remember taking you out to

31:48

dorsal plates, knock on wood,

31:48

but have taken out volar plates

31:52

that are both I've put in and

31:52

and others have put in, you

31:55

know, a number of times over the

31:55

years. So, you know, in terms of

31:59

doing the approach, it's a pretty simple approach, pretty straightforward. Starting to

32:01

move transpose your EPL,

32:04

identify and move it go between

32:04

two and four. And then really

32:08

identify, you know, your

32:08

fracture plane, just like any

32:11

sort of corrective osteotomy

32:11

localize it on fluoro. You know,

32:15

I tend to use, depending on the

32:15

case, I'll either use a saw or

32:19

just an osteotome. And I think

32:19

your points about trying to

32:22

restore the the right amount of

32:22

the volar tilt is good. Even if

32:28

you're not using a hole or play,

32:28

I do try to go for a roller

32:30

tilt, rather than just neutral.

32:34

So in this

32:34

case, Chris, do you use the

32:37

plate as a reduction tool, but

32:37

we're only five weeks out?

32:40

Hopefully the reduction is not

32:40

that hard to get? Are you

32:43

creating your opening wedge, and

32:43

then just maintaining it and

32:46

putting your plate on? Do you

32:46

use bone graft? Those two

32:49

questions I think would be helpful to hear.

32:51

So I don't think you

32:51

need to use bone graft. There's

32:54

a number of papers out there demonstrating that you don't have to actually like the tip

32:55

that my hand Club partner and

32:59

our actual Wash U partner David

32:59

Brogan does, you know, after I

33:02

do the wedge, I usually usually

33:02

use some of those cancellous

33:05

chips or croutons to help kind

33:05

of provisionally hold it in

33:08

place as a wedge, knowing that

33:08

it's not structural truly, but

33:12

it's going to help me kind of

33:12

see where I want things to line

33:15

up, I tend to use a provisional

33:15

K wire to really help hold my

33:18

reduction kind of from the

33:18

styloid towards the metathesis.

33:22

And really get the tilt just

33:22

right, I tend not to use any

33:25

pretty contour dorsal plates to

33:25

be honest with you the system

33:28

that I'd used before I found the

33:28

plates to be rather chunky. So I

33:31

ended up using a mini frag plate

33:31

and usually a T type plate. And

33:36

honestly, manually with my

33:36

strong hands, bending the plate

33:41

to dial in exactly where I want it.

33:45

Megan, any any

33:45

questions for Chris, before we

33:47

pivot to your description of a

33:47

vote approach?

33:50

Yeah, I think

33:50

we've kind of clumped all of the

33:55

distal radius and all unions

33:55

together. Do you change your

34:00

approach when it's fuller versus

34:00

dorsal? angulation? Yeah,

34:06

I think so. I mean, I'd say it would depend on the deformity. And you're right,

34:08

we're clumping it all together.

34:10

So to be very clear, you know,

34:10

this is a dorsally angulated

34:13

fracture with dorsal displacement of the distal piece. There is no intra

34:15

articular involvement, at least

34:17

of the male union components.

34:17

So, you know, we're not, you

34:21

know, trying to equate

34:21

everything together. But, yeah,

34:23

I think I would, you know, I

34:23

think that this one's easier

34:25

because I go dorsal cuz that's

34:25

where the deformity is.

34:29

Yeah, I just,

34:29

the other question I have for

34:31

you is, what do you do with the

34:31

owner? So the owner side, if,

34:37

you know, obviously, if there's

34:37

still length issues, or at which

34:41

this patient, I believe, had a

34:41

length issue with possible the

34:46

starting of carpal abutment?

34:49

Well, I think that,

34:49

you know, as Chuck mentioned

34:51

earlier, I think it's really key

34:51

to get your length and

34:54

inclination, right. And I think

34:54

that getting the radius out to

34:57

length, you know, in this

34:57

particular situation in five

34:59

weeks, I'm not expecting it to

34:59

be very challenging to get the

35:02

radius out to length. And I

35:02

think that is honestly easier

35:05

from the dorsal side. And I tend

35:05

to use an osteotome as a

35:10

reduction tool to just kind of

35:10

tease up that radial side and

35:13

then pin it or wedge it exactly

35:13

where I want it. I get kind of

35:17

OCD about this, but I get it

35:17

exactly where I want it. And

35:19

then I put the plate around it

35:19

as opposed to using a plate as a

35:22

reduction aid because I'm going

35:22

from dorsal. Chuck, what are

35:26

your thoughts? I mean, I know that we've got to wrap up soon. So

35:29

well, I we got

35:29

a few minutes, I think the great

35:33

points on going door. So when I

35:33

go dorsal, I like to croutons

35:38

tip just as a temporary

35:38

reduction aid, you know, or you

35:40

can use K wires, okay, whereas

35:40

they're a little cheaper. And we

35:45

shouldn't be going for

35:45

anatomical restoration of the

35:48

distal radius, and hopefully

35:48

that obviates the issue with the

35:51

distal ulna. I don't love doing

35:51

a distal radius osteotomy with

35:57

an owner shortening osteotomy.

35:57

But I think we have to be honest

36:00

with ourselves in a different

36:00

situation, longer standing, it

36:04

may be harder to restore the

36:04

anatomy. And you should go ahead

36:07

and do the owner shortening if

36:07

there's any doubt, right? Since

36:10

we get ourselves in trouble

36:10

saying it'll probably be fine.

36:12

Or we can always come back and

36:12

do another surgery. If you think

36:16

it's gonna be an issue, and you

36:16

can't really restore the length

36:19

of the radius and you should shorten the owner.

36:21

Do you consent for possible on the shortening osteotomy? When you have a

36:23

spidey sense that it's going to

36:25

be challenging?

36:26

I do. I still

36:26

try not to do it. But I do. And

36:30

the other thing, if you truly

36:30

are lengthening things, let's

36:33

say it's a two years out, and

36:33

the illness seems really long. I

36:39

hate to you know, bring nerves

36:39

back in the picture. But in that

36:42

case, I always do a carpal

36:42

tunnel, I don't think in this

36:45

patient, five weeks out, I would

36:45

necessarily do a carpal tunnel

36:48

release. Megan, what about you?

36:52

Well, I think

36:52

I think we have to take a step

36:54

back of going dorsal versus

36:54

volar. So the dorsal you're

36:57

doing an opening wedge

36:57

osteotomy. Whereas if you have

37:00

older, you're probably gonna be

37:00

doing a closed wedge osteotomy,

37:04

which decreases your length and

37:04

you probably are going to have

37:06

to do something with the old

37:06

map. So then, so I just before I

37:12

even answer the carpal tunnel

37:12

question, I do think that's

37:15

important to point out is that,

37:15

at the end of your procedure,

37:19

you really have to look at that

37:19

length and see what you have and

37:22

have not obtained and make a

37:22

decision. From there, what you

37:25

need to do with the ulna. I

37:25

mean, if you know less is always

37:28

more, but if you do distal over

37:28

section, you can always use

37:33

that. Or even if you do an owner

37:33

shortening osteotomy, you can

37:37

use that as bone graft, so that

37:37

you can not use those bone chips

37:41

and save a little bit of money.

37:41

You know, we don't have the

37:44

fancy WashU money on the south

37:44

side of Chicago. But there's

37:48

other ways of using that bone

37:48

and not just throwing it away.

37:52

But then just like the you know, it's like you talked to the spine surgeon local bone

37:54

graft.

37:59

So, but the

37:59

other part of it is the, the

38:02

carpal tunnel, I don't think you

38:02

ever lose anything by doing a

38:04

carpal tunnel release. So if you

38:04

like it runs through your head

38:07

and makes you do carpal tunnel

38:07

release, just do it. You know,

38:11

it's like, it's like doing

38:11

fasciotomy you're never gonna

38:13

feel bad about doing it, you're

38:13

gonna always feel like, well,

38:16

you know, we saved ourselves

38:16

from something worse. So I

38:20

usually talk to the patients

38:20

about it. And, you know, it

38:23

doesn't necessarily mean I'm

38:23

going to do it, but it's there.

38:26

Especially if you've got if you're at a place where they're very efficient about

38:28

preoperative blocks. You know,

38:31

then then there's no, there's no

38:31

way to know after they've done

38:35

the preoperative block about whether there are carpal tunnel symptoms, I agree low threshold

38:37

to to do a carpal tunnel

38:40

release, Chuck, before we go to

38:40

volere, or technique pearls. Are

38:44

you bone grafting? On the

38:44

regular?

38:46

No, not bone

38:46

grafting? Almost ever. And I

38:51

agree with Megan Megan's

38:51

comments about carpal tunnel.

38:55

It's really it really is

38:55

interesting. The block point is

39:00

really important, because I

39:00

think about that every time I'm

39:02

in, we block almost everyone.

39:02

But if I'm doing any type of

39:06

osteotomy, I think twice about

39:06

whether to say yes to the block,

39:09

or I'll do a short acting block,

39:09

you know, as for a six or eight

39:11

hour block, the problem becomes

39:11

pain control gets really tricky

39:15

in those patients. So you get

39:15

pain relief for six hours, and

39:18

then can they catch up and keep

39:18

up? It's It's tricky, but I

39:21

think you have to err on not

39:21

blocking, if there's any concern

39:25

for post operative challenges

39:25

with swelling, which of course

39:29

there would be here. So Megan,

39:29

what I mean, we all know how to

39:35

do a bowler approach. But how do

39:35

you think about once you've done

39:39

your volere approach? What are

39:39

your steps to you know, create,

39:43

recreate the normal anatomy?

39:47

Yeah, I think

39:47

the biggest thing to add that

39:49

you don't do the dorsal approach

39:49

really is you can use the plate

39:54

as part of your reduction, which

39:54

is what Chris was alluding to

39:57

previously. And I think that's

39:57

important too. Talk about

40:00

because sometimes when you're

40:00

doing these open, wedge

40:04

osteotomy, they become unstable.

40:04

And then all of a sudden, you're

40:08

you've made a hard surgery

40:08

harder, because now you have two

40:11

very unstable components that

40:11

you're trying to stabilize. And

40:15

so if you put the plate on end,

40:15

you can get your distal screw

40:21

holes by putting the plate on,

40:21

do a couple of drill holes, some

40:25

K wires, make sure you're in

40:25

parallel with the articular

40:28

surface. And then you take the

40:28

plate off and do your osteotomy,

40:34

you have at least the placement

40:34

of the plate distally. And that

40:39

makes at least one component.

40:39

Easy, and then you can just

40:43

realign that with with the

40:43

shaft. So that is a pearl.

40:48

That's, I think, really

40:48

important to remember of pre

40:52

planning for this osteotomy by

40:52

making sure that you know where

40:56

your play is going to go so that

40:56

you're not having to unstable

41:00

edges, and then all this space

41:00

that you're trying to fill or

41:04

not fill, making it harder for

41:04

yourself.

41:08

Yeah, I think

41:08

that's a really good point. It's

41:12

what I run into trouble, maybe

41:12

too strong, but I have to

41:15

carefully think about the

41:15

placement of that plane,

41:18

especially if I'm trying to

41:18

increase radial inclination at

41:21

the same time. And so you have

41:21

to be really precise on how you

41:25

conceive of where that plane is

41:25

going. But if you get that,

41:28

right, the case is over. Right,

41:28

you've already you've finished

41:31

the case.

41:33

Yeah, the carpentry and this has to be, you know, really spot on and perfect. From

41:34

the get go. You know, and I

41:38

think that your point about you

41:38

know, taking a case, you know,

41:41

that is you're taking a segment

41:41

that's stable, but the forum,

41:45

but then having to very unstable

41:45

segments can be really

41:48

frustrating and challenging. You

41:48

know, so I think pre drilling on

41:51

the far side is super helpful.

41:53

I just, you know, I forgot to mention this. Chris, one of the things that I

41:56

do for that dorsal scarring is I

42:00

will put a lobster claw on the

42:00

radial shaft, and then I'll

42:04

rotate the components away from

42:04

each other. And then I feel like

42:08

I can really release that scar

42:08

tissue dorsally by by rotating

42:12

it, I used to actually with

42:12

subacute, distal radius

42:15

fractures that show up to my

42:15

clinic later in the game. So

42:20

that's another way of not having

42:20

to make that dorsal approach,

42:24

you really gotta have

42:24

that thing completely free

42:26

dorsally. And I think the error,

42:26

you know, and I've learned the

42:30

hard way is that you're like,

42:30

oh, it's probably fine. But I

42:32

think that, you know, the

42:32

probating that distal fragment

42:35

or moving the shaft to is

42:35

helpful just to really get to

42:37

the far side of it and make sure

42:37

especially as you're over, you

42:40

know, just proximal to the

42:40

sigmoid notch on the other side.

42:43

Yeah, that

42:43

that's the, it's probably fine.

42:45

That's going through your head,

42:45

as you're doing cases, like this

42:48

is always sort of the kiss of

42:48

death, especially if your day is

42:51

going crazy. You just can't let

42:51

that happen. But I think both

42:53

your points are really good. So

42:53

the orb, a technique of pruning

42:58

the radius out of the way is

42:58

really great. But you have to

43:03

make sure your dorsal release is

43:03

complete, or else you will not

43:07

correct the angulation that you

43:07

need to correct. So super, super

43:10

important. Great, I love that

43:10

what other what other volere

43:15

thoughts do we need to finalize.

43:17

So I don't, I

43:17

don't want to bring up another

43:20

huge topic as we're trying to

43:20

wrap up. But I do want to point

43:23

this out, because this is

43:23

something I've learned and been

43:25

burned with. I've had inter

43:25

ticular disorients millions, and

43:31

I'm intrigued to hear what you

43:31

guys have to say, where I have

43:35

done personally personalized

43:35

jigs, where they take the CT and

43:41

then make jigs, and you spend

43:41

all this time planning out your

43:43

osteotomies. And you think it's

43:43

gonna be really, really easy,

43:47

because it's like, make a cut

43:47

here, you make a cut here, you

43:49

make a cut here and you put

43:49

these little jigs on step 1234.

43:53

And it's almost like paint by

43:53

colors, you think it's gonna be

43:55

really easy. And then it's not

43:55

because you have engineers who

44:01

are looking at the CTS and

44:01

making these jigs, but they're

44:04

not surgeons, and you're

44:04

starting to realize, oh, my

44:07

gosh, there's a lot of scar

44:07

tissue and trying to rotate this

44:10

component and this component is

44:10

not as easy as, as 123. And I

44:16

and I've struggled with those

44:16

cases before because of scar

44:20

tissue.

44:21

We do need to have a separate episode for this because I feel like we just had

44:23

this conversation. Sorry, I we

44:25

just had this conversation there

44:25

a hand conference earlier this

44:28

week when Lindley wall was

44:28

talking about a materialized

44:31

case that she did using custom

44:31

jigs and the challenges of what

44:35

surgeons think versus engineers

44:35

and where the engineers will try

44:37

to put the plate versus where a

44:37

surgeon wants to put the plate.

44:40

Yeah, I it is

44:40

a really important point. So we

44:44

have our part to that we're

44:44

gonna have to do

44:48

it. Sorry, Chuck. I

44:48

just have one more question. I

44:51

think it's pertinent. Is this a

44:51

standard kind of distal radius

44:54

fracture rehab for you guys? Or

44:54

are you immobilizing them for

44:58

longer after this kind of thing?

44:58

especially if you're there,

45:01

you've got a wedge and you're

45:01

not grafting that kind of thing?

45:04

Or do you just proceed like you normally would?

45:07

Okay, oh,

45:08

check, I wanted to answer that first, but I, I'll go, um, it depends on

45:09

the patient, honestly, it

45:14

depends on the fracture or the

45:14

osteotomy. And you know how

45:18

strongly I feel like this is

45:18

going to heal. So, you know, I

45:22

do think you need to do a little

45:22

bit of range of motion, some

45:25

gentle range of motion just to

45:25

keep them moving. Because you

45:28

know, a lot of these guys, these

45:28

guys and girls are stiff. And so

45:32

all of a sudden, you splint them

45:32

until they have union, and

45:36

they're even more stiff. So I

45:36

think it's important that they

45:40

have the tendons gliding, and

45:40

there is a little bit of motion.

45:43

But I, again, this is going to

45:43

be patient specific.

45:48

If you have a

45:48

good plate, these plates are

45:50

really strong, and the bone is

45:50

reasonable. Even if you've

45:54

created an open wedge osteotomy

45:54

I think it's okay to start early

45:56

therapy with splinting between

45:56

therapy sessions and no crazy

46:00

therapy. So I do I do start

46:00

early. So this has been super

46:04

fun. Thanks for joining us. This

46:04

has been great. We definitely

46:07

thank you guys. Part two, part

46:07

three. Keep going. Oh,

46:10

I just I tried

46:10

to. I'm trying. I'm just trying

46:15

to like weasel my way in.

46:18

You've succeeded.

46:21

It's been a joy. As

46:21

always, Megan, good luck with

46:23

your upcoming move. And we look

46:23

forward to having you back

46:26

either before or after the

46:26

annual meeting. Yeah,

46:30

I'll hopefully

46:30

see both of you at the meeting.

46:33

Thank you guys so much. This has

46:33

been an absolute blast.

46:36

Thank you.

46:36

Hey, Chris. That was fun. Let's

46:40

do it again real soon.

46:41

Sounds good. Well, be

46:41

sure to check us out on Twitter

46:43

@handpodcast. Hey, Chuck, what's

46:43

your Twitter handle?

46:46

Mine is

46:46

@congenitalhand. What about you?

46:49

Mine is @ChrisDyMD

46:49

spelled d-y. And if you'd like

46:53

to email us, you can reach us at

46:53

[email protected].

46:57

And remember,

46:57

please subscribe wherever you

46:59

get your podcast

47:00

and be sure to leave a

47:00

review that helps us get the

47:02

word out.

47:03

Special thanks

47:03

to Peter Martin for the amazing

47:05

music. And remember, keep the

47:05

upper hand. Come back next time