0:10

Welcome to the

0:10

Upper Hand where Chuck and Chris

0:13

talk hand surgery.

0:14

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

0:16

talk about all aspects of hand

0:19

surgery from technical to personal.

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Thank you for

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subscribing. Wherever you get

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your podcasts.

0:25

And be sure to leave a

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review that helps us get the

0:27

word out.

0:28

Oh, hey, Chris.

0:29

Hey, Chuck, how are you?

0:31

I'm doing pretty well. We're getting a little fancier.

0:34

Yes, I hear that we're

0:34

now using a program that has all

0:37

sorts of fancy audio sound

0:37

clips, I think you're probably

0:41

going to start to work some of

0:41

those into the to the podcast.

0:44

Pretty exciting.

0:45

Oh, for sure.

0:45

We are we have outgrown zoom.

0:49

And I say that totally tongue in

0:49

cheek because A, I don't know if

0:51

that's really true. And B, we

0:51

may be back on zoom tomorrow.

0:54

Exactly. I will say,

0:54

you know, now that you're

0:57

officially a funded podcast, I

0:57

mean, you know, I think we're

1:00

probably funded in a way that

1:00

very little other podcasts are

1:03

by an actual grant.

1:06

This is true.

1:06

This is true. Our funding

1:08

mechanisms are limited. But we

1:08

have access some funds, which

1:12

makes it feel good.

1:13

Excellent. Excellent.

1:13

So I wanted to get to a reader

1:17

question, which was sent in to

1:17

us and I think you'll like this

1:21

one. And the subject line is

1:21

sports wrist question for Dr

1:24

Goldfarb. All right. So this i

1:24

from Paul Hovis. Thank you fo

1:28

sending in the question, Paul

1:28

Paul is an orthopedic hand an

1:31

upper extremity surgeon in Texa

1:31

and he is a consultant for on

1:35

of the major league teams an

1:35

their farm teams, which i

1:39

fantastic. So congrats on that

1:39

His question is stated, ther

1:43

has been a rash of comebac

1:43

balls hitting our pitchers i

1:46

there throwing wrists, causi

1:46

g distal ulnar shaft fractures

1:50

r ulnar styloid fractures. In t

1:50

e non high level athlete l

1:54

y person and for all ulnar styl

1:54

id fractures I adhere to

1:57

he typical literat

1:57

re recommendations consisting

2:00

of predominantly immobilizati

2:00

n. However, I was mostly wonder

2:04

ng what your opinion is on surgi

2:04

al intervention for pitchers w

2:07

th distal ulnar shaft fractures

2:07

on her throwing arm that wish

2:10

to pursue pursue surgery whet

2:10

er displaced or not, do you f

2:14

el this gets them back to p

2:14

ay faster, or at least back t

2:17

a throwing program more quickly

2:17

I know there are complex wr

2:20

st mechanics that are overloo

2:20

ed predominantly with curveballs

2:23

or sliders. And I can't say I

2:23

ve found much literature

2:26

or direction on this speci

2:26

ic patient populati

2:32

It is a great

2:32

question. I can talk, it's

2:35

interesting. I take care of the

2:35

Cardinals here in St. Louis and

2:38

some of their farm players, some

2:38

of them get cared for down near

2:41

Jupiter, Florida. But this is an

2:41

injury I haven't seen in the

2:46

last five or six years in a

2:46

baseball player. So you know,

2:49

maybe it's coming because those

2:49

balls come off the bat very

2:53

quickly, especially with the

2:53

speed pitchers are throwing

2:55

today. So in my mind, I'm

2:55

envisioning what I would call a

2:58

nightstick fracture. And, you

2:58

know, classically we are taught

3:03

not to treat those surgically

3:03

because they do heal nicely. I

3:07

will go back to the basics of

3:07

the care of the athlete. And

3:11

answer this in the sense that,

3:11

you know, the paradigm has

3:14

changed. And we've talked about

3:14

this a bit. 20 years ago, the

3:18

paradigm of taking care of an

3:18

athlete revolved around

3:21

minimally invasive care, with

3:21

attempts to go non operative.

3:26

Today, the care is more

3:26

invasive, with attempts to

3:29

minimize time away from sport,

3:29

and maximize function upon

3:34

return. And so that means more

3:34

surgery. Let's be blunt. And so

3:38

I think the question is really a

3:38

good one. And I think Paul has a

3:42

very valid point, that if you

3:42

think you can get the athlete

3:46

back playing faster, with

3:46

minimal morbidity, then it makes

3:50

some sense. And you know, a

3:50

distal 1/3 on a shaft fracture

3:55

is different than a very distal

3:55

ulnar shaft fracture, which I

3:59

think can be really tough to fix

3:59

effectively. And obviously,

4:03

that's different than an ulnar

4:03

shaft- ulnar styloid fracture.

4:05

So my answer is if it's

4:05

displaced, or if it even if it's

4:10

not dramatically displaced, if

4:10

we think we can get the athlete

4:13

back to play faster then it's

4:13

something I would consider.

4:17

Do you think that the

4:17

fractures that are minimally

4:22

very minimally displaced like

4:22

you almost can barely make it

4:25

out in an X ray is just kind of

4:25

like scaphoids where for a while

4:28

people were fixing everything?

4:30

Yeah, this I

4:30

think it would be tough for me

4:33

if it was a hairline fracture,

4:33

or very subtle, I don't think I

4:37

would treat that surgically. I

4:37

would put the put the the

4:40

pitcher in the cast and follow

4:40

it closely with the expectation

4:45

that it would heal rapidly and

4:45

well and we wouldn't miss that

4:48

much time. I think once it

4:48

becomes displaced that obvious

4:51

The next question is how

4:51

displaced is too much, but I

4:54

wouldn't be opposed to more

4:54

aggressive care with at least

4:58

some displacement.

5:00

Now when you're talking about returning to a throwing program, what do I

5:02

think what what I loved about

5:05

Paul's question was the thought

5:05

that there are some mechanics,

5:09

nuances to things like

5:09

curveballs and sliders. Now, I'm

5:12

not familiar enough with

5:12

throwing mechanics or taking

5:14

care of these high level

5:14

athletes know, perhaps what some

5:17

of those differences are?

5:18

Well, I think

5:18

it gets to the point that we

5:21

could, you know, with a plate

5:21

fixation, we could get the

5:25

athlete back working on motion

5:25

of the forearm, motion of the

5:31

wrist, and potentially start

5:31

strengthening really quickly. As

5:36

far as the throwing mechanics,

5:36

though, I don't think you get

5:39

them back until they're really

5:39

ready to go. Because I think you

5:42

risk throwing off those

5:42

mechanics, if you return them

5:45

prematurely. And I do, you know,

5:45

I, it's very fortunate that we,

5:50

you know, every sport, baseball,

5:50

as well as all the other

5:54

professional sports have really

5:54

high level training staff that

5:58

get this at a super high level.

5:58

And so I think our job as

6:02

physicians and surgeons, when

6:02

it's called for, is to kind of

6:06

give the green light. And their

6:06

job is to work through the rehab

6:10

and maximize full return to

6:10

play. And so I don't know that

6:14

the mechanics, I think the

6:14

mechanics are a real concern.

6:17

And my philosophy would just be

6:17

no throwing program, unless it's

6:22

light toss kind of stuff, until

6:22

they're really ready to go.

6:26

Yeah, I mean, this is

6:26

like total level eight evidence

6:29

right now. But for me, I feel

6:29

like probably there is some,

6:32

some torque that is different in

6:32

slowing and throwing a curveball

6:35

or slider versus a fastball. And

6:35

I would imagine that comes

6:38

through the form and through the

6:38

carpus, in terms of, you know,

6:41

pronation, supination, probably

6:41

more supination than anything

6:44

else. So I would imagine that

6:44

the threshold to operate upon

6:49

these patients who use that

6:49

particular kind of pitch is

6:51

probably much lower.

6:53

Yeah, yes. And

6:53

no, I mean, I think if you

6:55

choose non operative care, you

6:55

just have to be patient, and

6:58

make sure that you have

6:58

sufficient healing before you

7:00

start the process. There is no

7:00

doubt there's more torque,

7:03

totally agree. And so it either

7:03

it's going to slow you down on

7:07

one end or the other, whether

7:07

you're slowed down by initial

7:10

mobilization, or slowed down

7:10

before you can really go

7:12

hardcore, you're still gonna

7:12

have to be patient till you have

7:15

clear healing.

7:17

You're gonna love this because I actually had this patient within the last few

7:19

weeks.

7:21

Oh, wow.

7:22

Not a pro athlete. Of

7:22

course, not in my practice, but

7:26

an actual collegiate bound

7:26

scholarship softball pitcher,

7:30

hit by a pitch coming back at

7:30

her right on the shaft fracture

7:34

actually tried to non op it,

7:34

because it was minimally

7:37

displaced. But then I watched it

7:37

displace, the next week, he came

7:40

back. And basically dad looked

7:40

at me and said, I was wondering

7:44

why you weren't operating on her. Here we go.

7:46

Wow. So you,

7:46

you put a standard plate on?

7:51

Yeah, standard plate.

7:51

You know, what I have found

7:54

with, you know, I was trained by

7:54

one of the orthopedic trauma

7:58

surgeons that I worked with in

7:58

my residency, very much to dual

8:03

plating and orthogonal plating

8:03

was big. I think sometimes for

8:06

these, you might make them too

8:06

stiff, which would be my

8:09

concern.

8:10

Yeah, for me

8:10

that ulna bone is not the one to

8:13

be too aggressive like that, I

8:13

completely agree with you. And

8:17

this is the bone where I really

8:17

am careful about minimizing,

8:20

stripping. And really just

8:20

expose wherever I'm going to put

8:24

the plate and try to leave

8:24

everything else intact,

8:27

periosteum especially because,

8:27

you know, even if you're a

8:31

listener, and you don't do a lot

8:31

of ulnar fracture surgery,

8:34

that's probably all of our

8:34

approaches. We all do ulnar

8:37

shortening osteotomies. And that

8:37

is one where I lay a lot of

8:41

crepe about time to healing and

8:41

my typical responses eight to 10

8:44

weeks.

8:45

Why do you think that ulna bone takes so long?

8:47

You know, I

8:47

don't know the vascularity well.

8:50

Certainly, some of it comes from

8:50

the interosseous membrane. But

8:53

it's it I mean, it goes it's got

8:53

to go back to the basics of the

8:56

blood supply must be lousy. You

8:56

know, I've I've investigated

9:00

this in a very, very specialized

9:00

population that is in in the

9:06

osteoclasis patient. So,

9:06

osteoclasis for me, is in

9:10

regards to children born with

9:10

proximal radioulnar synostosis.

9:15

So congenital anomaly, and we

9:15

rotate the forearm in those kids

9:19

by creating osteotomies. And one

9:19

of our excellent previous

9:23

fellows many years ago,

9:23

basically came to the conclusion

9:26

that once a child is over age

9:26

six, healing is so unpredictable

9:32

that doing that surgery and not

9:32

putting hardware in really risk

9:37

the non union and so it's just

9:37

got to be a vascularity issue.

9:40

And, and there's so much the

9:40

cortical bone is such a great

9:45

percentage of the ulna right? So

9:45

there's just not a lot of

9:49

cancellous bone to promote healing.

9:52

Do you change your

9:52

immobilization based on the fact

9:55

that it takes so long to heal?

9:55

Is there any thought to

9:57

mobilizing people with you

9:57

including their forearm, at

10:00

least?

10:01

In a fracture?

10:04

Yes, in a fracture setting,

10:05

Yeah, I don't

10:05

go above the elbow. But I tend

10:09

to do it with like a nightstick

10:09

fracture non athlete. I just put

10:13

them in a cast for six weeks as

10:13

a starting point and then

10:15

reassess. Hopefully then getting

10:15

them into something different.

10:19

Below elbow, so not a

10:19

Munster or anything like that.

10:22

Yeah, I mean,

10:22

as I think about it, not totally

10:24

fair, but it's the radius

10:24

rotating around the ulna. But

10:27

certainly, there's torque on the

10:27

ulna during that rotation, no

10:30

doubt about it.

10:31

Yeah, I've been known

10:31

to use the Munster. But yeah,

10:34

this patient this patient got

10:34

single plate has done incredibly

10:38

well so far. And we're hoping to

10:38

get get them back ASAP. So Paul,

10:42

probably not the person you

10:42

wanted answering the question in

10:44

terms of a recent case, but you

10:44

definitely got Chuck's thoughts.

10:47

Thank you for that. Great question.

10:48

So Chris, keep

10:48

working hard. And one day, you

10:51

might graduate from nerve

10:51

surgery, and you can move into

10:54

sports, I don't want to promise

10:54

you anything. But there's hope

10:57

for you.

10:57

I'm hoping to stay where I am right now. I'm good. I'm good on that.

11:01

Alright, so I

11:01

know you have the topic that we

11:04

are going to discuss tonight.

11:04

And it's a good one. So I'm

11:06

going to give you a little special intro. I love it.

11:17

That is so awful. So I

11:17

was actually listening to the

11:22

ortho hub podcast. I think they

11:22

called see one do one now. And

11:27

actually, in one of their recent

11:27

episodes, I guess they got a

11:30

hold on one of these little

11:30

sound machine things too. So it

11:34

was used excessively in that

11:34

episode, and I'm sure you're

11:37

going to be using it more.

11:38

We're done.

11:38

We're done, I think unless

11:40

something special happens.

11:42

So today's case,

11:42

actually is what actually will

11:46

lead us into our topic for

11:46

today. So I was treating a

11:49

patient who had a couple of

11:49

fractures, one of them being

11:52

displaced distal radius

11:52

fracture, pretty run of the mill

11:55

volar plate kind of thing. But

11:55

then also had a Pilon type

11:59

fracture of the base of P two of

11:59

the small finger. So a fracture

12:05

that I groan every time I see.

12:05

Absolutely, that's a tough one.

12:11

So it got me thinking,

12:11

obviously, we're thinking about

12:13

our options. So maybe we can

12:13

talk through some of those. So

12:18

how what's your threshold to

12:18

operate on patients with a, you

12:21

know, smash, P2, fracture, and

12:21

then possibly some volar or

12:24

dorsal? More often dorsal

12:24

subluxation of the PIJ?

12:28

Well, it's a

12:28

really interesting question,

12:31

because I think as we think

12:31

about fractures, and we're

12:34

really talking about fractures

12:34

at the base of the middle

12:38

phalanx, I think about them in

12:38

really, I guess I would say,

12:42

three different groups, I think

12:42

we have what I would call the

12:44

classic fracture dislocation,

12:44

which is a volar lip fracture,

12:48

of varying size. We have the

12:48

Pilon fracture, or really kind

12:53

of a severe fracture involving

12:53

the entirety of the Joint

12:57

Service. And then we have what I

12:57

call the central slip fracture,

13:01

which you and I discussed in

13:01

within the last month or two,

13:05

with a case example. So we

13:05

probably don't need to rehash

13:08

that one. But if we talk about

13:08

the Pilon fracture, and the

13:12

volar lip fracture, I think

13:12

there's just so much to discuss.

13:16

And so I would start by saying,

13:16

and I'd be interested to hear

13:19

how you think about this, my

13:19

first goal is understanding if

13:23

there is a concentric joint

13:23

reduction. And so I don't you

13:28

know, I love standard x rays,

13:28

because they give us great

13:31

definition. But for me, that is

13:31

a C-arm, I'm lucky to have a

13:34

C-arm in my office, so I can

13:34

really profile the joint and

13:37

really understand reduction.

13:40

Yeah, I think that's that's critical, because oftentimes, your the X rays you

13:42

get are suboptimal. And it's

13:46

really hard to I think this is

13:46

when we're truly understanding

13:48

the, quote, personality of the

13:48

fracture is useful. Because you

13:53

understand the deforming forces,

13:53

you understand your end goal in

13:56

terms of what you're trying to

13:56

achieve with any sort of

14:00

stabilization. And then keeping

14:00

in mind the fact that you're

14:03

just trying to get this joint lined up and moving.

14:06

Now that's

14:06

exactly right. And so, you know,

14:08

most fractures can be thoroughly

14:08

assessed with a good C-arm

14:13

radiograph I'm not really one to

14:13

order CT scans, or certainly not

14:18

MRIs and these cases, the only

14:18

other thing I would throw out is

14:23

if it's a really bad fracture,

14:23

and if the joint is is clearly

14:27

not aligned and you know, you

14:27

have to take the patient to the

14:29

operating room, then a traction

14:29

radiograph is gold in these

14:33

patients and so but for me,

14:33

that's not done in clinic

14:35

because then you have to

14:35

anesthetize the patient. It

14:37

would I mean, you have to you know, give them an injection of lidocaine, but but in the OR a

14:39

traction radiograph can be gold.

14:43

So how would the

14:43

traction radiograph influence

14:46

your management?

14:47

Yeah, so I'm

14:47

us and I'd be interested see

14:50

philosophically how you think

14:50

about this. When I go to the

14:52

operating room, it is always my

14:52

goal, to know exactly what I'm

14:56

going to do. I don't you know,

14:56

and which is interesting for

14:59

someone like me To say, because

14:59

one of the things that appealed

15:02

to me about congenital hand

15:02

surgery is some of the general

15:06

hand surgery is figuring things

15:06

out on the fly. And that's fine.

15:10

I think in that world, I'm okay

15:10

with it in the adult world, I

15:13

really like to have a plan. Some

15:13

of that's practical, because I

15:16

run to rooms, and I really like

15:16

to be on time, and I like to

15:20

have the day run smoothly. But

15:20

this is a case where I typically

15:25

go to the operating room with a

15:25

plan A, B, and C. And that and

15:30

the ultimate choice is based on

15:30

kind of what we see.

15:36

So the traction

15:36

radiograph helps you in, helps,

15:40

maybe has you shift A, B, and C

15:40

up and down in terms of what you

15:44

know which one you're gonna try first.

15:45

Yeah, I'm a

15:45

fan of, and I think especially

15:48

keep it you know, trying to keep

15:48

this minimally invasive is

15:51

always the goal. And, you know,

15:51

this is a forgiving joint in the

15:57

sense that if you have a

15:57

reduction, and the head of the

16:02

proximal phalanx is generally

16:02

well aligned with the base, the

16:06

middle phalanx, that base of the

16:06

middle phalanx can remodel, and

16:09

even if the radiographs don't

16:09

look good, if you restore your

16:11

natural curve, then I think you

16:11

can get a really good result,

16:15

even if the radiographs don't

16:15

look perfectly, don't look

16:17

perfect, but so I go for

16:17

minimally invasive, but really,

16:21

I'm thinking about can I do a

16:21

closed reduction alone? And the

16:24

answer that is almost never. A

16:24

closed reduction with pinning of

16:28

some sort, an open reduction in

16:28

either pinning or fixation. And

16:34

then finally, a traction device,

16:34

which is can be gold, you know,

16:40

and Joe Slade taught us so much

16:40

about the traction device and

16:43

others have added to that basic

16:43

knowledge of how do you create

16:46

an effective traction device

16:46

that's tolerated, and there's so

16:49

much to it. But those are the

16:49

kind of how I'm thinking about

16:53

these when I go to the operating room.

16:56

So let's let's for

16:56

completeness sake, let's cover

16:58

the whole spectrum. So you mentioned doing closed reduction, and when that would

17:00

work. Now, typically, you know,

17:02

you're not seeing that in the

17:02

office, that's something that

17:05

you know, makes its way to the

17:05

ED or the urgent care, that kind

17:07

of thing. And it's quote,

17:07

simple, meaning there's no

17:11

fracture associated with with

17:11

it, or there's a very small

17:14

fragment. I actually had one of

17:14

these walk into the office

17:17

because they came to our injury

17:17

clinic. And I happen to be

17:20

dictating at the time. So I saw

17:20

the patient and did a closed

17:22

reduction in the in the fluoro

17:22

suite. And everybody was

17:26

obviously happy with that. After

17:26

you do a closed reduction, and

17:29

it feels really good. Do you do

17:29

a dorsal blocking splint? Do you

17:32

just buddy tape? What do you how

17:32

do you manage that?

17:34

For me, it's

17:34

always a dorsal blocking splint.

17:37

And let's say your reduction of

17:37

that dislocated joint was good.

17:41

But as you extended the finger,

17:41

you know you started to get that

17:44

V sign where the dorsal joint is

17:44

not parallel, but as V, then I

17:50

flex the finger down. I mean 60

17:50

degrees is fine. And then I

17:54

create a dorsal blocking splint

17:54

either in the office or ideally

17:57

with a therapist. With the goal

17:57

being extended 10 degrees every

18:01

week, during the healing

18:01

process. I you know that that is

18:05

a really important part of my

18:05

practice.

18:07

That's textbook right

18:07

10 degrees every week. So I got

18:10

the reduction, I put a little

18:10

alumafoam splint in the fluoro

18:13

and then actually took her right

18:13

to the to the therapy office

18:16

that was co-located an

18:16

orthopedic suite, so that worked

18:19

out really well in terms of

18:19

getting a splint made for that

18:22

patient.

18:23

Yeah, that's

18:23

that's magic. And we are

18:25

fortunate we've said this

18:25

before, we'll say it again to

18:28

have the, you know, close

18:28

proximity as well as expertise

18:31

of our therapy colleagues. And,

18:31

and you know, once you have

18:35

obtained the reduction, their

18:35

role in this is really

18:38

everything.

18:39

So then let's go to

18:39

the next scenario. Let's say you

18:41

have a dorsal dislocation,

18:41

meaning that the prox-the middle

18:45

phalanx is drifting dorsally.

18:45

And so you've got a volar lip

18:48

fragment, say it looks to be

18:48

about 20% of the joint.

18:52

Yeah, I don't

18:52

focus so much anymore on the

18:56

percent involvement of the joint

18:56

I would do with you know, I

19:01

would try to close production in the clinic, hopefully, depending, you know, on the

19:03

situation, or else I would

19:05

proceed to the operate, if it's

19:05

a week out or whatever, I would

19:07

proceed to the operating room,

19:07

assess it with traction, assess

19:11

whether a closed reduction in

19:11

flexion will reduce the joint.

19:15

And again, this is when you have

19:15

to be very critical of yourself

19:18

and your x rays. And if you're

19:18

not convinced that you really

19:22

have that anatomical alignment,

19:22

and that parallel alignment with

19:27

the head and the base of P two,

19:27

then I think you have to, you

19:31

know, move on to the next stage.

19:31

And depending on that volar

19:36

fragment and in some ways for me

19:36

a large volar fragment and we

19:40

can quibble on what large means

19:40

is fantastic because you go on

19:44

you fix it, and I think those

19:44

patients can do really well and

19:47

they get moving really quickly.

19:49

So is it is large

19:49

enough meaning large enough for

19:52

you put a screw in.

19:53

That is

19:53

exactly right of screw or two

19:57

and I can't think of too many

19:57

more satisfying cases and I

20:01

think they're uncommon that you

20:01

have that one non comminuted

20:05

volar fragment, that clearly

20:05

that buttress is required to

20:09

restore stability. And flexions

20:09

not enough. So you go in, you

20:14

get the reduction, you put two

20:14

screws in that in that fragment.

20:17

And again, to me, that is such a

20:17

satisfying case.

20:22

So walk me through

20:22

some of the technical details.

20:24

So what size screws you're

20:24

using? How do you approach it?

20:28

And then do you do anything to

20:28

keep the joint blocked after

20:31

that?

20:32

Yeah, so happy

20:32

to and certainly what your

20:35

opinion on some of these things.

20:35

So for me, it would be I when I

20:38

approached the volar PIP joint

20:38

more commonly for a joint

20:41

release than for this fracture

20:41

pattern. Specifically, I create

20:45

a V incision. So oblique

20:45

incision across the skin volarly

20:50

over the proximal phalanx, and

20:50

then oblique incision over the

20:55

middle phalanx elevator, full

20:55

thickness flap, protect the

20:59

neurovascular bundles, and

20:59

expose the sheath. And then I

21:03

simply work between a two and a

21:03

four. I retract the tendons, and

21:09

you know, you're working more

21:09

distally. You know, obviously, I

21:11

stated that often you're doing

21:11

this to expose and treat a volar

21:15

plate contracture. So in those

21:15

patients, I'm working proximally

21:18

at the checkering ligaments,

21:18

etc. In these cases, you're

21:21

working distally. And so you

21:21

have to really assess, you know,

21:25

where the insertion of the FDS

21:25

is more distal than we think.

21:29

And so it's more broad than we

21:29

think. And so dealing with the

21:33

FDS are working through FDS,

21:33

using a dental pick, hopefully

21:37

to obtain the reduction using

21:37

temporary k wires to maintain a

21:43

reduction while you check C-arm.

21:43

And then I would say typically,

21:47

it's a 1.5 millimeter screws, so

21:47

1.1 drill bit, 1.5 millimeter

21:51

screws and two of them, do you

21:51

think about it differently? Or

21:54

does that resonate?

21:56

No, I, I've done it a

21:56

handful of times. And I think

21:59

about it the same way this this

21:59

just honestly doesn't come up as

22:02

much as as much maybe as it

22:02

comes up for you. Maybe it's

22:05

some of its patient population,

22:05

that kind of thing. But you

22:08

know, you and and Lindley Wall

22:08

actually does a fair bit of

22:11

fixing these, at least from what

22:11

she said. And you know, at it,

22:16

it looks like a great, very

22:16

satisfying procedure.

22:19

Oh, it is. And

22:19

I think that led to an

22:23

evolution. So what really makes

22:23

me happy is when you watch

22:28

really smart people process, how

22:28

can we do something differently?

22:34

And how can we advance our

22:34

field. And so we've talked about

22:38

that with other episodes, and

22:38

we've had guests that have done

22:41

just that. But Hill Hastings,

22:41

who was at the Indiana Hand

22:45

Center, did that for these

22:45

fractures. And so I'm sure all

22:49

the hand surgeons out there, and

22:49

many of the residents know the

22:52

Hemi hamate arthroplasty. And it

22:52

is a really smart way to deal

22:59

with chronic vo-you know, volar

22:59

lip fractures are ones that are

23:05

not re constructible. And man,

23:05

it is really a smart procedure.

23:11

Now, how many of those Do you think you do a year?

23:13

Not many, I

23:13

would say to a year would be a

23:17

good guess. Obviously everything

23:17

comes in waves but to a year do

23:21

you do or have you? Is that a

23:21

part of your arsenal? Or is that

23:25

one you might send on?

23:27

It's a part of the

23:27

arsenal The last time I did it

23:29

was actually on somebody who had

23:29

not succeeded with other

23:32

attempts at pinning and

23:32

everything else. And honestly,

23:35

that's what did the trick and it

23:35

was wonderful. It was very,

23:39

very, very satisfying. Maybe

23:39

think I should do this more. And

23:43

maybe the patient has other

23:43

patients with this issue. have

23:46

seen me more. But I haven't

23:46

pulled the trigger on it.

23:50

Yeah. Is this

23:50

an example? And I think you're

23:52

what you just said is exactly

23:52

right. You it can be such a home

23:56

run, that you look to broaden

23:56

your indications. And I have to

24:01

say it's not always a home run.

24:01

And you know, our partner Marty

24:04

Boyer has, as he would say,

24:04

can't can't regularly make it

24:07

work. And so you have to be

24:07

careful about the indications.

24:11

And really you have to be

24:11

careful about the carpentry. And

24:15

that's what's fun about this

24:15

case, but that's also what's

24:17

challenging about this case.

24:19

Yes, definitely high

24:19

risk, high reward. I remember

24:22

the first one of these that I

24:22

booked out of training, I had

24:25

one of our partners scrub with

24:25

me on it. And I felt much better

24:29

because that partner said, You

24:29

know what, let's just do the

24:31

volar plate arthroplasty he

24:31

couldn't make it work. So it

24:35

made me feel a little better to

24:35

know that somebody who I

24:38

consider a very good technical

24:38

surgeon was also quite humbled

24:40

by this.

24:41

Yes. And that

24:41

can absolutely happen. The volar

24:44

plate arthroplasty is

24:44

interesting. And I would say

24:47

largely that's one for the

24:47

history books and I'm guessing

24:50

that most of the younger folks

24:50

out there haven't done that

24:53

procedure is not part of

24:53

residency training for most of

24:57

us or fellowship training in

24:57

That's another procedure. It's

25:01

just so interesting. When

25:01

procedures aren't done

25:03

regularly, you don't learn the

25:03

nuances. And so it becomes

25:07

harder to use it as a bailout

25:07

down the road. And so, you know,

25:11

I haven't done that many of that

25:11

procedure, and it's really not

25:15

in my arsenal.

25:17

Well, it's a procedure

25:17

you don't do until you have to

25:19

do it. Like you're saying it's a

25:19

bailout. And, you know, it's

25:22

certainly, like you I call I go

25:22

into the OR with, you know, Plan

25:26

A through F for some of these

25:26

cases, and it's certainly not

25:29

the one at the top, but

25:29

sometimes it gets pulled out.

25:32

But if you

25:32

were considering it, would you

25:35

be more likely to consider

25:35

traction device as opposed to a

25:40

volar plate arthroplasty?

25:42

I think so. But I, you

25:42

know, I, so a traction devices.

25:46

Another thing that I think we as

25:46

surgeons find is very cool. But

25:51

I'm not convinced that patients

25:51

love it as much as we think they

25:54

do.

25:55

I think that's

25:55

an understatement. I think

25:57

you've got to be held to wear

25:57

that thing for six weeks. But it

26:01

is cool.

26:03

I mean, it's it's a

26:03

technical triumph. And it's

26:05

incredible that the whole thing

26:05

costs like 30 cents. And it

26:10

works. If you purely Think of it

26:10

as stabilizing the joint

26:14

maintaining some element of

26:14

motion, I guess you could argue

26:17

as to how much people actually

26:17

move with that thing on. I think

26:21

this comes down to patient

26:21

selection. It's fracture

26:23

selection, but then also the the

26:23

has to be the right patient.

26:27

Totally agree.

26:27

That's Well said. And that's

26:29

really important. That has to be

26:29

a patient who understands what

26:32

they're signing up for.

26:32

understands that, hey, this is

26:35

probably not our first choice.

26:35

But we're picking this because

26:38

we we need to do something

26:38

unusual to stabilize this

26:42

fracture is definitely never my first choice.

26:44

Yeah, it's kind of a

26:44

weird thing to try to explain to

26:47

somebody during the preoperative

26:47

discussion. I always make the

26:52

joke that they're going to have

26:52

great TV reception. But I think

26:54

that's getting lost on my

26:54

generation and younger.

26:58

Oh, it's so

26:58

funny, because I did that. I

27:00

don't think I told you the

27:00

story. So I'm sitting at

27:02

Children's Hospital and I'm

27:02

talking to a six year old

27:05

patient and I go, yeah, we're

27:05

gonna get the fracture reduced

27:08

and put a couple pins in, it'll

27:08

look like you have an antenna.

27:11

And I go, Oh, my God, you don't

27:11

know what an antenna is. And he

27:14

goes, of course, I know what an

27:14

antenna is. I'm like, how do you

27:18

know what an antenna is? He's

27:18

like, yeah, it's on a little

27:21

bug. It's the little things

27:21

coming out of his head. I'm

27:24

like, Yes, it is. Of course it

27:24

is.

27:27

Wow, wow. Wow. That's

27:27

pretty awesome. Yeah, I've

27:32

noticed that the references I'm

27:32

making are getting lost upon the

27:36

the medical students already so

27:36

you can't you can't make

27:39

Seinfeld references anyways,

27:39

nobody gets those. It's got to

27:42

be Friends. Friends and newer.

27:43

And that's a

27:43

loss. The other one I use, and I

27:45

always kind of, kind of, you

27:45

know, tilt my head to see if

27:48

they get it is the give me a

27:48

give me a hit. You know, show me

27:51

what you do when you hitchhike,

27:51

you know, like, give me a thumbs

27:53

up like you're hitchhiking. And

27:53

sometimes I get a what?

27:57

Yeah, why would you

27:57

hitchhike when there's Uber and

27:59

Lyft and every other ridesharing platform.

28:01

Yeah that went

28:01

away when the serial killer

28:05

movies came out.

28:08

Exactly. So dynamic ex

28:08

fix. You know I found these to

28:12

be a little challenging every

28:12

time that I plan on doing it, I

28:17

want to bring the paper myself

28:17

put it up in the OR I make the

28:20

resident be ready to put it up

28:20

in the OR draw it out, have all

28:24

the wires ready and know exactly

28:24

how to do it. Because this can

28:28

be relatively straightforward,

28:28

or can be very frustrating for

28:31

like, God, I got to put the band

28:31

here and put this little s band

28:34

and that's not that's not exactly fun.

28:37

I think it is

28:37

personality driven. Some people

28:39

enjoy the fiddle factor. That's

28:39

not really my strong suit. I not

28:44

a big Fiddler. Again, it can be

28:44

a really satisfying procedure if

28:49

you're able to reduce the joint

28:49

apply the traction, and you

28:52

know, allow even motion. But I

28:52

have to say it's not one of my

28:57

top 10 favorite procedures.

28:58

How much do people how

28:58

much do people move when they

29:01

actually and this will not be

29:01

good for one of our therapy

29:03

colleagues to let us know? Do

29:03

they actually move?

29:07

I think this is a great guest episode or maybe guest and they're about

29:09

both a surgeon and a therapist

29:13

who loved this procedure to

29:13

really talk through the nuances

29:17

of applying that fixator

29:17

correctly. I think they moved

29:21

some but I think you're looking

29:21

at a limited arc of 45 degrees

29:24

or something. I don't think they're getting much more than that. But hey, it's a Head

29:25

Start.

29:28

So do you think that

29:28

they move more than if you do

29:30

just a dorsal blocking pin to

29:30

kind of stabilize things and

29:34

they just move within that arc

29:34

that the dorsal blocking pin

29:36

allows?

29:37

So we haven't

29:37

mentioned the dorsal block pin.

29:39

I'm glad you brought that up. I

29:39

mean, most people think of that

29:41

dorsal blocking pin into the

29:41

head of the proximal phalanx to

29:45

really create almost a dorsal

29:45

block splint but a little more

29:49

rigid. Most people think about

29:49

that for a mallet fracture, but

29:52

it can have a role here. And I

29:52

do think it can be appropriate I

29:56

think, you know, given the

29:56

severity of the fracture sure

30:00

that we would consider the

30:00

dynamic ex fix for, I think they

30:04

move pretty well, I'm not sure

30:04

which ones more. But I think

30:06

given again, the severity, I

30:06

think they can they can move

30:09

reasonably well in the traction.

30:09

And then once you get the fixer

30:13

off, I think we can, it can

30:13

really be a nice Head Start.

30:17

So to bring things to

30:17

a close, how do you manage the

30:19

Pilon fracture differently than

30:19

you would say, the volar lip

30:23

fracture with the associated

30:23

dislocation?

30:26

Well, I

30:26

certainly Pilons come in all

30:29

varieties, but I think it's

30:29

becomes more difficult to think

30:34

about fixation of the fragments.

30:34

So you know, if there's a dorsal

30:38

fragment and a volar, fracture

30:38

fragment, and then you have that

30:41

kind of intact central area,

30:41

traction makes a lot of sense.

30:46

And so sometimes you can get

30:46

away with a percutaneous

30:48

fixation. But I think the real

30:48

Pilon is the one for me, at

30:54

least, that makes the most sense

30:54

for dynamic traction.

30:57

So when we talk about

30:57

Pilon fractures, you know, just

31:00

for those, you know, that may

31:00

not be as familiar, we're

31:02

talking about a fracture, that's

31:02

essentially an impaction

31:05

fracture to the cartilage

31:05

surface of the base of the

31:07

middle phalanx splitting that

31:07

middle phalanx space into two or

31:12

more pieces. So like Chuck said,

31:12

a large kind of dorsal piece,

31:16

and then a large kind of volar

31:16

piece, and maybe some

31:18

combination in between.

31:19

Yeah, and I think it's really important to emphasize as much as we try to

31:21

treat these closed, because you

31:24

know, with, with multiple

31:24

fragments, you can get yourself

31:29

in a world of hurt very quickly,

31:29

if you try to go in and piece

31:31

everything back together. Now,

31:31

there's a role for piecing

31:34

everything back together. But

31:34

often, what we do, whether

31:39

you're treating this with an

31:39

traction or a couple of pins, is

31:43

you can elevate the fracture

31:43

fragment to try to create a

31:46

concentric join again, and then

31:46

support the you know, the

31:50

fracture, however you do it

31:50

again, with K wires or with a

31:53

traction setup.

31:55

Like you said that the

31:55

base of that middle phalanx is

31:57

somewhat forgiving in terms of

31:57

the remodeling. So that is

32:01

helpful. You don't have to have

32:01

it absolutely perfect. You just

32:03

need something that you can flex

32:03

around, obviously, I'd asked you

32:07

one question to close. When

32:07

you're deciding closed versus

32:12

open, obviously, the downside

32:12

potentially of opening this

32:16

finger is that you're going to

32:16

compound the swelling from the

32:18

trauma, the upside, obviously,

32:18

you can get more stable

32:21

fixation. So how do you navigate

32:21

that balance as you're thinking

32:27

about the patient and the

32:27

fracture? And that kind of

32:29

thing? Because do you look at how swollen the finger is to start that kind of thing?

32:33

Well, I think

32:33

timing is important for this

32:35

fracture, you know, you don't

32:35

want to leave a joint dislocated

32:38

for too long. But you're right,

32:38

I don't think this is the

32:41

fracture that I want to go there

32:41

are a day for when they're

32:44

maximally swollen, or when you

32:44

know, whenever they're massively

32:47

swollen. So if I don't get this

32:47

acutely, it may be one that I

32:49

wait until day seven and have

32:49

the patient home and elevating.

32:53

So that if I do need to go in

32:53

that I'm not overly worried

32:56

about compounding the swelling,

32:56

you know, for me, this gets back

33:00

to the basic principle of the

33:00

first thing we have to do as

33:04

surgeons is get the bone and get

33:04

the joint right, we can deal

33:07

with stiffness, no doubt about

33:07

it, we can deal with the stiff

33:11

tip joint, as long as we restore

33:11

the bony anatomy. If we get that

33:17

bone healed, and the PIP joint

33:17

contracts, I'm not overly

33:20

worried about that, because I

33:20

can make that better. What you

33:23

can't make better. Well, it's

33:23

more difficult to make it better

33:26

if you have a big step off and

33:26

the joint or a joint that

33:28

subluxated. And so I think the

33:28

decision making really has to be

33:32

about restoring that alignment,

33:32

even if it's not perfect, but

33:37

really the basic alignment of

33:37

the base of P2.

33:42

The fractures that I

33:42

dislike the most probably the

33:45

PIP fracture dislocation. So

33:45

thanks for thanks for talking me

33:48

through some of it.

33:49

No, I loved it. I think you bring good insights. And I hope that some

33:51

of our listeners will, will

33:55

raise some questions and

33:55

hopefully we you know, I can

33:59

give you another drumroll

33:59

though, to take us home if you

34:01

want.

34:02

Please don't. But if

34:02

there's any if there are any

34:04

therapists or surgeons that are

34:04

dynamic ex fix aficionados,

34:08

either for surgery or therapy,

34:08

let us know we'd love to have

34:11

you on.

34:12

Absolutely. And I'm going to throw a teaser out there to all of you guys. So

34:13

Chris is going on a special

34:16

adventure with his family and I

34:16

if he survives it, then we're

34:19

going to hear about it on our

34:19

next episode. Fair enough.

34:23

Yeah, the first-the

34:23

first time we're going camping,

34:25

so Filipino American guy from

34:25

Florida. This is not a common

34:30

thing. So let's see how it goes.

34:32

Good luck.

34:32

Alright, take care.

34:36

Alright.

34:37

Hey, Chris.

34:37

That was fun. Let's do it again

34:39

real soon.

34:40

Sounds good. Well, be

34:40

sure to check us out on Twitter

34:43

@Handpodcast. Hey, Chuck, what's

34:43

your Twitter handle?

34:45

Mine is

34:45

@congenitalhand. What about you?

34:48

Mine is @ChrisDyMD

34:48

spelled d y. And if you'd like

34:52

to email us, you can reach us at

34:52

hand [email protected].

34:56

And remember,

34:56

please subscribe wherever you

34:58

get your podcasts

34:59

and be to leave a

34:59

review that helps us get the

35:01

word out.

35:02

Special thanks

35:02

to Peter Martin for the amazing

35:05

music. And remember, keep the

35:05

upper hand. Come back next time