Welcome to the upper hand, where Chuck and Chris talk hand surgery.
We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
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Oh hey, Chris.
Hey, Chuck, how are you?
I'm doing really well. How are you?
I am good. I am in full training mode. It is the day before the surgeons versus chef pumpkin war for St. Louis magazine.
You know, I am a veteran or an alum of that competition. And I went in a little naive in my expectations. And I don't mean to have you lose sleep. But this is a serious competition.
Good. Well, you know, commensurate with the amount of days I've given, been given to prepare. I'm sure I'm going to do exceedingly well. So what's the key here? How do you do well, at this competition, given that I haven't carved a pumpkin in 13 years.
Well, that's that's not a good Harbinger for success. Those who do well here have a multitude of tools such as the standard pumpkin carving tools, but they also typically bring Dremel tools. And it's it's really a it's more than this simplistic pumpkin as you might expect. I went with an emoji approach, which got some appreciation, but was so simplistic compared to those who both carved a pumpkin and had the various colors using the Dremel tool. Some went with just
a pumpkin face. My year there was a ob, for example, who had a whole pumpkin with a fetus inside a uterus. So it's not just pumpkin faces.
That's special. Okay. Yeah, so I've gotten some design inspiration scrambling during clinic yesterday, our fantastic hand therapist showed me several designs, you know, kind of played to my strengths as a hand surgeon. I'm hoping that the carpus Does, does us an honor here. But you know, I'm excited. I went out and purchased some tools got some practice, pumpkins have turned it into a father son event. So you know, zoom has given us a lot of
freedom here. So you're, I'm sure people are gonna be seeing the Dy family on display tomorrow.
Yeah, it is interesting. Doing it by zoom is both better and worse, it was fun in person, but it was a little more stressful. And I think that if your kids are part of your Prop, then you could win. Because they're pretty cute.
Well, you know, it sounds like, you know, the bar is quite low for the orthopedic hand team in the past. So I appreciate that. We are not going to go with just a face. So we'll see what happens I will probably take this opportunity to fail publicly, like I have with many other things. So
I welcome that. And I know that you'll fail on Twitter, indeed. So I look forward to seeing your pumpkin shared with all
Listen, if I'm gonna fail, everybody's gonna see it. So the question people have been dying to know the answer to, Chuck, how do they get a hand? Oh, that's a good pun. How did they get their hands on one of the sweet upper hand coffee mugs?
Well, these are limited edition. We've only done one mug printing. And I think they're stored in both my basement and yours. And they're sweet, I have to say. And we've struggled with the best way to share these mugs. And I think we've come up with a really good win win. What do you think?
I think so. Um, so what we've done is we've established a listener survey, which will help us make sure that we're talking about what everybody wants us to talk about. You know we try to predict what what would be, you know, good episode topics and format things. But we're certainly open to suggestions. So this is a great way for, for listeners to give us suggestions. So how do they access the listener survey Chuck,
it will be a link and we will put it in the show notes for this episode. And we're going to leave the survey the initial plans to leave the survey open for one month, and then tabulate the results we'll share the results as well. And our goal will be to to award a mug a month. And so we're gonna have to think about exactly how to do that. Certainly emails with show ideas are still welcome. We would love to have
your reviews. So there's multiple ways to get in good with the creators and proprietors of the upperhand podcast. it's a limited group.
I feel like you made it transparent, but it's also transparent that this is a very opaque process. So handpodcast@gmail.com for show ideas, please leave a review. Apparently that's gonna grease the wheel for Chuck when he is doing the blind drawing. But then also take a look in the show notes for the listener survey.
Well, I'm not just suggesting that only good reviews and good comments have a chance to win I, we want honest feedback, we want to know what we can do better.
100%. And you know, if you if you take a picture of yourself listening to the upper hand or telling a colleague about the upper hand in a creative way, I think that may deserve a mug too. We'll see.
Yeah, listen, Chris just wants to hand out mugs to everybody. I'm trying to be a little responsible with this process. So we'll see what happens.
So we have, I got some fantastic feedback. I didn't explicitly ask this trainee if I could read it. So I will not divulge their name. But a plastic surgery resident who is hand fellowship bound, who is currently in studying for their boards, they mentioned that they are in full exam study mode these days, and your podcast has been a great resource. So thank
you, you know who you are. And thank you to every all the trainees who are listening in, we hope that we're a great resource, we hope we're staying close to the board answers, you know, and not veering too far from them.
Well, that's great, because you know, study time is got to be really deeply valuable. In other words, if we're giving out one pearl for every hour of listening, it's probably not worth your time. So hopefully, we are, you know, really discussing topics in a way which can be helpful. So that really is a generous review, for sure. Thank you.
So Chuck any good cases recently?
You know, I did have a good case recently, which was unusual, and that's why I'd like to share it and so I had a referral in which the patient had relatively normal looking x rays, but something just didn't look right with the
scaphoid. So we got a CT scan, and the CT scan showed a markedly displaced scaphoid fracture, but displaced in a way that on the PA and the oblique you could kind of make it out on the lateral a good lateral would have shown it but it was that classic situation where the lateral wasn't good, I didn't repeat it, I still would have gotten a CT scan. So no regrets but it does emphasize to me the need to have standardized
radiographs. These were outside radiographs, you and I've discussed how we're fortunate to have wonderful radiography, you know, access. So I got the CT scan, and it showed a widely displaced scaphoid fracture with the distal fragment displaced volarly. And it just struck me as odd. And there was a couple of fragments in the capitolunate joint, and the capitolunate joint didn't look quite right either. But everything else looked great. So normally, I would simply approach that with
an open volar. And it was a waste an open volar approach and fixation. But I decided to approach this arthroscopically because I thought there was a chance I could reduce the scaphoid arthroscopically and put a screw in from dorsally. And also just had a little sense that something wasn't right. And one of the things I think is interesting for all of us to consider is I did not put that that case on my busy day.
Because cases like that are tough, you can't predict how long they're gonna take, I might have been too quick to pull the pull the trigger to get rid of the scope and bring in the open part of the surgery. And so those cases, for me are best done on my non busy surgical day. And I don't do that very often. And you do more of it. So I'll stop there. How do you approach that? I mean, do you try to do uncertain cases in a day where you're running back and forth doing lots of surgery?
Or do you reserve those type of cases for different days?
Well, there is, um, for example, you know, the Plexus stuff, you have a sense of what you're going to do when you go into it. And I've gotten pretty facile with it, I kind of know how long it's gonna take me to do a lot of this stuff, especially if I'm not exploring to Plexus and I'm going directly
to distal nerve transfers. And I had a couple of months ago, I had two weeks where I had back to back spinal accessory to Super SCAP and triceps to axillary nerve transfers, and I was going to do them posteriorly and, you know, be out of the zone of injury. And I could have done both of them in one day. But I also knew that emotionally for me, that would have been a whole lot just because you never know. And I don't want to feel
like I'm rushing at all. And I finished both of them before noon and had some time to do other things. But I told the resident that I was with, I said, look, I think we could probably knock both of these out in one day. But I think you never quite know and it's not the case you want to rush on not that you want to rush on any
surgery. But there are some cases where you know, there's gonna be you're gonna need a lot more headspace on and you're gonna need a lot more emotional reserve just in case things are a little trickier than you expect.
I think that's well said for me on my busy surgical day. I spend actually a fair amount of time designing the day. I run two rooms, I overlap cases but I am physically present for Almost the entirety of every case, and it works and the surgery center trust me, because I do spend time thinking about this and I have a lot of goodwill built it, you know, built up, but a case like this can wreck it. And so I
did it on a different day. And I'll tell you briefly I don't want to go into too much detail. But there was cap there was severe capitolunate arthrosis. There was not a complete but there was probably a Geisler grade three LT tear and this widely displaced scaphoid, so I don't really know what was going on. I do think the scaphoid was likely acute, but it felt more like a perilunate situation.
Although the mechanism didn't fit, he punched a punched a wall and unfortunately, the wall where he punched it had a stud behind it. And so it wasn't ideal for him. So it was just a very unusual situation. I was unable to reduce the scaphoid arthroscopically so I did end up having to open it, which was fine. Just a really interesting case for me. And it reiterated a couple of the points we've we've hit on.
So why why- How did you how are you going to proceed in terms of you know, the capitolunate issues and lunotriquetral issues going forward? Obviously, you fixed the scaphoid now.
Yeah, so we use the the arthroscopic assistance to debride and pin the LT. And that was you know, pretty straightforward. We cleaned up the capitolunate joint, but did not do anything with it. And then we fix the scaphoid. And my thought process was the capitolunate has to be chronic. And so let's see what happens over time.
As I'm reminded of King George in the wonderful musical, Hamilton, you'll be back.
Oh Lord, that that reference would have been well well received by my family but I have not seen it.
Oh, well people listening are gonna judge both of us for what just happened, you for not watching Hamilton, me for quoting it
Exactly right. If you have to take sides you'll know which side to take now.
Alright, so we enjoy our reader grab bag. And that's actually the source of today's topic. So thank you to everybody who has left questions for us and episode suggestions. And we're happy to answer any questions feel free to leave them for us in hand podcast@gmail.com send them over Twitter or send them over in the reviews. And we will consider them as topics for episodes or even just answer the question one off like we've been doing
the last few weeks. So today's topic is about a topic that is near and dear to many surgeon's hearts complex regional pain syndrome. And many surgeons will treat this issue but joke that they don't like to publish about it. And because patients tend to find them and not always ones that they can help. Now Chuck has published on this topic extensively, or at least has the landmark paper in the hand surgery literature, and now has a podcast episode about it. So I think this is a twofer for you.
So congratulations.
Listen, I think it's an interesting topic. And I actually it's not all doom and gloom for my future because our partner Lindley Wall has shown interest as well. And she's looking into carpal tunnel slash crps in the setting of distal radius fractures, which is a super interesting topic. And I mean that legitimately. So more to come in that area. Let's Why don't we start with a few definitions. So I'll go first. So complex regional pain syndrome is the quote unquote,
newer diagnosis. And there's two types. There's, there's type one and there's type two. And so type one used to be known as reflex sympathetic dystrophy or RSD. And essentially, it is a pain syndrome of unknown etiology. I think most of us believe that it is mediated by small nerve fibers, perhaps c fibers, but there's no major nerve injury major or minor nerve identified as being
injured. And so that's the one that a hand surgeon likely is unable to be of help for treating what is in your mind crps type two.
So crps type two, in my opinion, or at least from my understanding of it is neuropathic pain or nerve related pain that emanates along a specific and identifiable peripheral nerve distribution. Now, that may not necessarily be for example, the median nerve, it could be something like the medial cord of the brachial plexus, but it follows an
anatomic distribution. And it makes sense to us as hand surgeons and peripheral nerve surgeons to to be able to help these people because they are suffering and unfortunately, a lot of patients with crps or formerly known as RSD causalgia. They get lumped into the you know, difficult patient category and they get bounced around a lot. And you know, I think that, as well intentioned as many of us are both on the surgery side and the therapy side, these patients often are neglected.
And it's difficult to differentiate who you can help and who you don't think you can help even within that crps type two category.
I think that's right. And All right, so let's, let's, I guess, talk through how we think about the diagnosis, and how we use therapy, how we may use additional studies to confirm a diagnosis, and how we think about treatment. So, first of all, etiology in my mind, we don't always know the etiology, it can be a surgery, and there's some crazy stats that suggest up to 1% of surgeries can be associated with crps. That seems
way too high to me. But there is no doubt that a certain percentage of patients with surgery run the risk of developing crps.
And I think you're right about that. And, you know, I think that's why many of us are extraordinarily particular about protection of cutaneous nerves, the ones that are, you
know, so called causalgic. So, for example, if you're doing any surgery on the medial side of the elbow, or the forearm, being concerned about the medial and tuberculoid cutaneous nerve, doing any bicep surgery being concerned about the lateral inter brachial cutaneous nerve, there's an incidence of about 17% for LIBC issues after distal biceps repair. So that's real.
It's just a matter honestly, whether you're looking for them as a surgeon, or as a therapist, and then, you know, I think the palmar cutaneous branch and the superficial radial nerve are the other ones that get a rap for being causalgic nerves and you know, we've sparred with our partners on some of this and I think you and I fall on the same side of the aisle on this one, you know, quote, they're just
skin nerves. And maybe we're a little too paranoid about dissecting and protecting etc. but all it takes is one.
Yeah, it's if you if you, for example, don't take proper care of the medial, brachial or antebrachial cutaneous nerves in the approach for treatment of cubital tunnel, the patient may be fine, and maybe that patient's fine 19 out of 20 times. But if you have one patient that develops a severe pain after a surgery like that, that's one too many. And that's why I take as much care as possible in preventing injury to those nerves. So, alright, so surgery is definitely a risk
factor. trauma, be it big or small paper cut can lead to crps, or major trauma can lead to crps. Those are kind of the two groups I think about but it really can be anything.
Yeah, no, I mean, those are the types of patients that come in for us, you know, either the acute traumas, you know, the big, the high mechanism, fractures that are associated with nerve injuries. But even you know, honestly, standing level falls can have distal radius fractures that have, you know, acute carpal tunnel syndrome that you would not expect. And sometimes these are nerves that are have been chronically affected, and probably just get kind of tipped
over. I don't think anybody knows the true, you know, whether that's truly a risk factor or not. But I think that we don't really see many other patients. You know, in my clinic, I see occasionally, you know, there's always that Parsonage-Turner category, which is separate from this topic, we can talk about it a different time. There are all sorts of weird etiologies that are proposed for that one, too.
I think that's right. I think that's right. And that does fit in at least some of our black boxes. And I think what will be helpful is we present a few patients scenarios, but let's go through some basics. So if I were to think about a patient with potential crps, what type of studies do you consider in affirming the diagnosis?
Well, I mean, you know, by and large, almost like a nine to one ratio, the people that come into my office are in that type two versus type one category. Because you know, those are the people that that get get in honestly, there's a lot of bias in how we screen patients coming in, or screen themselves and how they're referred. But the physical exam
is so critical. I mean, it's looking for the subtleties and we talked about this before on our prior episodes, but the subtleties of the exam, you know, being very in tune to what normal is in terms of strength but you know, specifically sensation obviously two point discrimination is a mainstay, but comparing side to side sensibility, to light touch, sometimes that's all it takes.
It's uncommon, but occasionally the patient with the, you know, the, the classic appearance of the trophic patterns on their hand, the abnormal sweat patterns, all that stuff, those, you know, those are classic cases, which are worthy of noting, but it doesn't always come across that way. And then very sensitive cutaneous distribution. So the allodynia
First of all, we should clarify that this is a subjective diagnosis. And so making the diagnosis is there are criteria out there but honestly, those are not terribly
helpful for me. And so it is based on talking to the patient, examining the patient and potentially A few studies which we'll get to, I like what you said, I agree with what you said, I would categorize it as additionally, pain out of proportion to what we would expect, and clinical findings out of proportion to what we'd expect decreased motion, hypersensitivity, swelling, discoloration, extra sweat, not
You know, even with the patients that come in with, enough sweat, any of those things that just don't make for example, distal radius fractures, or other hand crush sense. And the more objective findings that are there, rather injuries, like crush injuries, in particular, are like the crps than just complaints, the easier it is, for me to be comfortable type one diagnosis that I see the most. And I'm sure you know, making a diagnosis.
that comprises a large part of what you see too, but it's the hand that just doesn't look right after a couple of visits, you can tell it's, it's a little too swollen, it doesn't have the right feel to it, the patients
are guarding a lot. And that's when you know, if I recognize as soon as we recognize that, nd sometimes that's at their first visit, we go up to ther- I send them to therapy right way, because this is something t at I want our therapists to g t on top of, and to start devel ping an alliance with the pat ent, because I don't want to s t on that
Totally agree. And and I do want to circle back to therapy just to finish the train of thought. The other test I consider, which can be helpful. And I would say can being the key word in that sentence would be nerve studies, it would include three phase bone scans, which honestly I don't use very often. advanced imaging can sometimes be helpful. But again, I'll go back to what we both have said is the history of physical, which are most helpful for us.
I'll be honest, I'm not, I'm usually not getting those studies, you know, I have not found them to be tremendously helpful in establishing a diagnosis. Let's be clear, you and I are not pain management specialists. And I think anybody listening who has more experience in that area is probably going to think that we're overly simplistically looking at this, because there's a lot of sophisticated and rigorous research going on in this area. But you know, this is this is what we see in practice.
And even if a nerve study comes back, normal, I'm not convinced that that patient, you know, I'm not going to change what I do, because, as you mentioned, it's those smaller pain fibers that are the ones that are, you know, being irritated, in, you know, crps type two, and those pain fibers are not the ones that are going to show up the most on, you know, easily on a nerve conduction study, because the nerve conduction study will pick up those larger and myelinated
fibers, whereas the nerve, those pain fibers tend to be smaller and non myelinated. So, you know, while I, honestly I wouldn't even, I wouldn't rely on it. And in for example, if we had a case of a patient with a distal radius fracture who we were suspicious of type two crps, I probably wouldn't get the study to be honest with you.
I think that's very fair. And those are those are really important thoughts. So let's talk about a couple of cases. And we can talk about how we think about patients, how we conceive of the role of therapy versus surgery, and when the time comes to not be the patient's primary provider and send the patient on. So let's talk about a but go back to what
you said before. So we have a 47 year old female who comes with, comes in with a distal radius fracture she's been seen in the ER, reduced, comes to see you and has a mildly displaced distal radius fracture by radiograph. She's in her er placed splint, which is a sugar tongs splint. And on examination, well in discussion first, she's in a lot of pain. It's been seven days since her injury, she's in more pain than we would expect the dressings not too tight. And so how do you
what do you do exam wise? What do you do and then just kind of talk me through it?
Well, you know, usually in that setting, when they're in that much pain, the splint is much more egregiously wrong than what you described.
It's the splint that goes out all the way to the tips of the fingers, not to knock our ER colleagues but I just see this enough where people come in from non orthopedic providers who are well intentioned want to immobilize a fracture but just don't have the training or the wherewithal to know that they need to leave the fingers free so their fingers have not been
moving for a while. You know, even in sometimes it is to tight and the patients had to unwrap and rewrap it themselves and then you get get the splint off. That's the first part and then just get a sense of the character of the extremity. And that sounds soft and squishy.
But I think that's you know, honestly, that'll tell the story you can tell the patient is going to be miserable, and they're not going to do well, regardless of what the radiographs look like purely based on the appearance of the hand in my opinion.
I love that so taking the splint off almost consequences be damned because leaving the splint on in that setting. Yeah, you may maintain the reduction that was obtained, but at what cost and so taking the splint off. Examine the patient getting a sense of swelling, getting a sense of motion, getting a sense of nerve function with two point and maybe muscle function even, all are critical steps.
Yea muscle function is often hard in this setting, you know, honestly, in a setting of a recent fracture, all I'm looking for are the thenars firing or not, because I really can't push on him too much. And that's where you rely a lot on your sens-you know sensibility exam. And, you know, I'll be honest, because of efficiency considerations, I'm not doing Semmes-Weinstein's, I will do two points. You know, I think you can do that pretty
efficiently. And effectively, as long as the patient cognitively understands the test. And I always check against the opposite side and make sure that they get what we're asking, because guessing does not help in that situation.
Totally agree. And I am a fan of data, whether that'd be grip strength, in other patients two point, whatever I can get, I will say without a doubt, in any patient, the one thing I look for any patient with a distal radius fracture who comes in a week later, the most important physical exam finding for me is finger motion. And it's not even
close. Because if that patient comes in with good finger motion, despite a fracture, which could be severe, in my, in my experience, they will do well, they may need surgery to get things realigned, but those patients do well. If a patient comes in that won't move their fingers just one of these like little twitch when you ask them to make a fist, I'm immediately concerned. And so those patients get a careful nerve exam, they absolutely get sent to therapy, even if surgery is being
planned. And I'm worried Honestly, I'm worried I do my best stern discussion with the patient how important it is to work on motion, I kind of I warn them, I may sound like a jerk. But this is really important. And I try my best to emphasize to them just in case, they're not trying to move their fingers that they need to understand how important that is.
What's your threshold to send for additional studies at this point, either a nerve study or even to go to surgery for in this example, a displaced distal radius fracture with a reasonable reduction, but a hand that doesn't quite look right, and maybe some altered sensibility findings and paresthesias in the median distribution.
Right, so my threshold, I do not need nerve studies, I don't want that to slow down the time to surgery, I will absolutely do a carpal tunnel release for me, and that this may differ between us and it probably differs with some of our partners, the degree of swelling doesn't necessarily push me to do a carpal tunnel release at the time of treatment of distal radius fracture, although it does a lot of swelling does raise my concern for needing a carpal tunnel.
It's about any complaints of numbness or tingling, anything that sounds or looks fishy, that's when I think about doing a carpal tunnel release, I don't think it adds much to risk of surgery, it is safe, it is quick, and it can be a game changer to have done it rather than to have not done it.
Yeah, I think it's one of those, you know, your personal comfort with the procedure you're offering will affect your threshold to offer it. So it's out there, you know, the literature demonstrates that trauma surgeons are less likely to do carpal tunnel releases compared to hand surgeons. And that's probably is due to
familiarity. I mean, you know, at the institution where I trained all of the, for residency, all of the acute distal radius fractures were being fixed by the trauma service, and I didn't release one carpal tunnel, you know in all of that, and, and there probably were some patients who probably could have benefited from it. But, you know, we never
did one. And in terms of in a setting where I'm a little worried, but the patient doesn't have a physical exam that purely corroborates that, you know, it kind of depends on the fracture characteristics, you know, the volar lunate facet fragment, because I'm typically using a
fragment specific approach. And I can do that through an extended carpal tunnel type approach, I'm going to release the carpal tunnel, because that could just be a one incision kind of surgery, as opposed to if I'm it's a fracture, where if I was to fix it, it would be with the volar plate. That tends to be a two incision surgery, and I'm not as concerned about swelling right underneath the median nerve, you know, if I'm not fixing a volar lunate facet fragment.
So let's say you see the patient, the pain's, a little out of proportion, finger motions a little bit lousy, but there's no clear evidence of nerve pathology on your exam. So you take them to the OR you treat their fracture, and they come back to see you seven days later, and their fingers are still not moving. And you're a little bit uncomfortable with that. I assume that you send them to therapy. Do you order any testing at that point?
Probably not because of that. I'll be honest with you in the demographic that we're talking about, in the you know, it isn't a patient of kind of moderate to advanced age. I'm gonna offer them a carpal tunnel under local anyway and my threshold to offer that surgery is lower than before when I was doing it under anesthesia, so I'm probably going to offer them surgery, if I think that that's going to be helpful, there are some patients where I don't think a carpal tunnel release is
going to be helpful. Because, you know, if they have crps type one, it's not going to help.
Well, people have asked for disagreement, and I'm going to give you some, I would not proceed directly to surgery, even with the option of a local only, unless I was darn sure that it was acting as an acute carpal tunnel. So I probably in this situation, would order nerve studies, or would consider the option of a steroid injection. But I understand your rationale, and it does make some sense. Now, in a patient who may not have worsening of symptoms, what's the role of therapy
Our therapy colleagues are so incredibly helpful with modalities such as you know, and techniques such as graded motor imagery, and a lot of the, you know, even apps that you can use now, to help with that process. And meter box and things like that.
Yeah, and loading that they do in the therapy clinic in different, you know, working hard on motion, obviously, hard on edema control, stress loading, when it's appropriate, all are important. I mean, for me, they have to have some clinical evidence of nerve pathology, to think about going and doing a carpal tunnel release, if they have no clinical evidence. You're right, you're kind of between a rock and a hard place. And we depend on our therapy
colleagues. And sometimes I've found that there is a later presentation of carpal tunnel, which can be found. So just because pre op or first visit post op, there's no clear evidence of pathology, it can show up later. And I think we have to be aware, based on a lousy overall clinical exam.
So for those trainees and surgeons that are listening, you know and I was joking earlier, but you know, Chuck really did write the paper on crps type two in the setting of distal radius fractures in the utilization of a carpal tunnel release, which I think has been incredibly influential, you know, in helping a lot of patients in terms of, you know, giving surgeons leeway to say, Hey, this is what's going to work. You know, Chuck, do you have any thoughts on that paper?
Well, I think the beauty of that paper, it was a paper written with Dr. Gelberman, it was his kind of initial idea. And I couldn't understand why he was so eager for me to be first author. And granted, I did most of the writing. I was younger. And I was like, Okay, great. We joked about it afterwards. I think the lesson is simple. And I think about this lesson in light of even a couple other examples, but the lesson is simple. carpal tunnel release is never going to
be the problem. And there was some dogma, hitting back to a previous episode, or urban legend that doing a carpal tunnel release in certain situations can make it worse. I think the lesson for me from that paper is carpal tunnel surgery, or whatever nerve surgery is part of the answer. And so no fear if you think there is a compressed or compromised nerve, releasing
that nerve makes sense. So for example, Dupuytren's surgery, it used to be forboden to do a carpal tunnel release at the same time as you do a fasciectomy. Well, that's crazy to me. And I do that not to say all the time, because not every Dupuytren's patient needs it. But if there's evidence to both diagnoses, I don't hesitate to do a carpal tunnel release at the same time as a fasciectomy.
I think one important point for anybody listening who does the surgeries. You know, a lot of times these are not patients that had carpal tunnel syndrome ahead of time. So oftentimes, the transverse carpal ligament is not as thick,
it's not as "stenotic". And as ou're doing the approach for the surgery, that's somethi g to consider because we all kno that that part of the surgery is a tactile part of the surgery where you're really feeling with the tip, or the belly o your blade, however you do it i order to make that initial pass to divide the transve se carpal ligament. So that is one important thing to conside
. And then for me persona ly, what I've noted in the set ing of a fracture, I do like an extended carpal tunnel release type incision with a Bruner igzag across the wrist crease eading away from the palmar utaneous branch of the median erve. Because in the trauma etting, I've noted that that vo ar antebrachial fascia tends t
be super tight. And that is one area where I had one patient where I thought I had done an adequate release, but it was tha just a couple of thick fibers f that fascia that were that we e problematic.
I think that's fair. And that's an important point. You know, I love the centimeter and a half incision for an elective carpal tunnel release. But when I do a traumatic carpal tunnel release, always cross the wrist crease, but often I do and it's a it's a more significant exposure. I do think we need to emphasize that it's not always the median nerve and it's not always carpal tunnel. I've treated a patient who had a tendon transfer had an EIP opposition transfer for a
thumb motion. And in the passing of the tendon transfer, the ulnar nerve was compromised at the wrist and so We had to address that and move the move the tendon that was previously transferred around the nerve. And so there's a variety of things that can happen. It's just about being aware and looking for possible ideologies. Because the alternative is, we can't help the patient. But
that's what I enjoy. You know, if a patient comes in who's had a serious problem for a long time, and I can examine a patient and identify a possibly compromised nerve, and offer treatment, I'm not going to cure that patient with crps, type two, but we can make them
significantly better. And the flip side is, if I can't, if I don't identify a compromised nerve, and I can't find something that I can do to help the patient, I'm not going to waste their time, by having them come back repetitively, I'm going to send them on to pain management. And that's my simplistic approach. And I like it.
Yeah, and I think patients will value getting a diagnosis and being told something, I mean, the number of people that we see being at a referral center, you know who have been run around for a long time, and just want answers, regardless of whether you can help them or not, they just want to be told, here's what you have, here's what to expect, here's what I can do, here's what I don't think I can do for you. Patients really appreciate
that. You know, and the other way that crps type two tends to show up in my office, you know, aside from like a traumatic brachial plexus injury would be, you know, nerves that are irritated by surgeries, for example, superficial perineal nerve after an ankle fracture, you know, after a standard lateral approach for an ankle fracture, we talked earlier about the medial antebrachial cutaneous nerve in a setting of medial elbow surgery like
cubital tunnel surgery. And those are patients that you can really help and you know, it's a whole lot different episode to talk about, you know, specifically the surgical treatment of pain in that setting. Because there's a lot of different ways we can do it, including targeted muscle reinnervation, regenerate peripheral nerve interfaces, you know, people want more nerve talk, Chuck, so we can hold totally have a big nerve day talking about those things. But you know, those are patients
that you can help. And we talked about diagnostic workup earlier. And I like doing a diagnostic
injection. And I don't do it myself, I have somebody do it on ultrasound guidance for a lot of these for a specific, you know, peripheral nerve that is potentially a culprit for crps type two, because sometimes the treatment does involve resection of the nerve and intramuscular transposition or you know, quote, road to nowhere type surgery, it helps me understand the diagnosis that they have, it helps the patient understand, hey, this really was the problem
this you know, nerve. And sometimes we take the drastic step of cutting the nerve and leaving them with expected a known area of numbness. But a lot of times these patients are more than happy to make that trade given how severe and how prolonged their symptoms have been.
I think that's all well said. And I know that you are clamoring for more nerve, I'm just not convinced that the entire audience wants more nerve discussion, maybe, maybe
Check the review buddy, check the review.
I think about one patient that I had in the work comp system, you know, work comp, patients get labeled very quickly. And they get labeled Mullingar someone who's working the system. And this guy was a really nice guy. And I do fall for, you know, nice patients. But he had a superficial branch of the radial nerve that had been traumatized. And I initially found a segment that was injured. And we decided to basically excise the nerve. And
he is thrilled. He has a large area of numbness along the dorsal thumb and hand and could care less. His pain, which had been present for nine months is gone. He's back to work. And so it's just about, you know, not having preconceived notions walking into the room, and doing our best as diagnosticians to rule out crps, or rule out nerve mediated pain and do what we can to help those patients.
And let's be real, it's not all sunshine and roses all the time, when I see these patients, you know, there are patients that I cannot help. And these are the crps type one patients largely, and you know, they come to me because they were told that, you know, they're seeing a nerve surgeon and you know, somebody can help
them. And you know, it's frustrating to be able not to help somebody and as much as a lot of patients appreciate you know the Straight Dope and being told what's going on and here's a referral to people that might be able to help you. A lot of times they've seen pain management already. And they've seen probably some inferior pain management doctors for the people that are coming in from
outside of our facility. And it's frustrating for them and you know, there are often maybe a patient a month or so that just kind of zaps the energy out of me in clinic and just kind of sets the tone in the wrong way because I can't help them, they don't like that I can help them and they're not shy in venting that I can't help them.
The I would say that the longer I practice, it has become easier for me to be straightforward and honest with patients and tell those who I can help how I can help them and share with those that I don't have a way to help them that too. And like you said, most people appreciate that, but some don't. And you know what? I think that's just the facts of life with being a doctor. Unfortunately, those patients are often the ones that go find review sites and leave negative reviews. But you know that
again, that's part of it. And but it is easier, the longer you do this, to be direct with patients, you know, show empathy, show understanding to the best of our abilities, show that you care, but be honest and help them move on or find the right doctor to treat them.
Absolutely. And before we close, I mean, there are a lot of obviously a lot of other modalities to treat patients with crps. You know, we haven't paid enough attention to some of the therapy modalities and it'd probably be a good episode to have with one of our therapists, and also the pharmacologic treatments, you know, gabapentinoids things like gabapentin, pregabalin, while they are awful medicines to be on, you know, having had a
relative on it. And then also having had multiple patients tell me how awful they are to take, they can be useful. And then there are a lot of other medications that can be used off label or as secondary agents to help with nerve related pain. So it's not all therapy, all surgery there. This is a hugely deep topic that we could, that we could spend more time on. But, you know, this is at least our perspective.
Yeah. And you know, spinal cord stimulators, and nerve stimulators, all that stuff, I would say the one important thing for all of us to think about is that if you have a patient and for the sake of continuity, let's say it's that distal radius patient, you know, those are the patients when you take them to the OR it's even more valuable to consider a block from our anesthesia colleagues, and potentially an indwelling catheter in that
segment of the population. So I use that even more than I typically would because I think there's long lasting benefit to that approach.
Agree so everybody, you know your patients with complex regional pain syndrome. Send them along to Dr. Goldfarb. Actually, I'm just kidding. I do love seeing this patient population, they, as challenging as it can be, they end up being the patients that give you hugs, pre covid, of course, and end up being your satisfied patients who want to help, you know, spread the word, you know, Facebook groups, etc. You know,
they're out there. So this is a challenging, but rewarding patient population to treat.
Absolutely. So in six months, we'll circle back and get another nerve podcast going but until then.
Wait this didn't count as one of the nerve topics did it?
Alright, everyone have a good day, Chris. It's been fun, as usual.
Fill out that listener survey so you can get one of those mugs.
Absolutely. Hey, Chris. That was fun. Let's do it again real soon.
Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?
Mine is @congenitalhand. What about you?
Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at hand podcast@gmail.com.
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