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 fantastic. What about you?
You know, I'm okay. Some pandemic, pandemic related fatigue, I guess, but doing okay, I had a couple of nice cases this morning and have some found time, because I had a cancellation. So I'm happy to hop on and record an episode with you.
Yeah, I'm glad it worked. I'll be honest with you, my fantastic was probably a little overstated. But you know, it is entering the confluence of the pandemic, which doesn't feel like we're, you know, we're clearly all of us feel a little optimism that we're heading in the right direction now, but, and then St. Louis has been brutally cold. And so I'll admit, I think I have seasonal affective disorder or something
like it. And so the shorter days, which are getting better, and the cold weather, both are just tough, just tough.
I mean, we tried, we've tried as much as we can to counteract the colder weather by at least layering and bundling and going outside and doing hikes and stuff. But a couple things have come up, it's become very apparent that my wife who is from Texas, and I, hailing from the Sunshine State of Florida, are woefully prepared for this kind of weather for ourselves, which is one thing, but specifically our kids. They
don't have the right gear. And I think I don't remember what the saying exactly is that there, you know, there's no such thing as bad weather, just bad gear, bad planning or something. And we definitely fall in that camp. Then the second thing that's holding us back from going out, you know, aside from the bone chilling cold is the fact that my son told me, I don't like cold hikes. He automatically puts a stop on that now.
Fair enough? Well, it's funny, because, you know, I grew up in Alabama, so I'm right there with you. And I tend to leave for work early, I get some work done at work before the zoom meetings start in the morning before the clinical care starts in the morning. And, you know, we had a dusting of snow on Tuesday and Wednesday. And I feel lame even saying this, but I'm just I'm an Alabama driver. And it stresses me out to drive even in a small
amount of snow. And so I'm like, gripping the steering wheel with all my might, and it's like it exhausted me.
You know, it was no accident that as soon as I we moved here I got, I got a four wheel drive SUV with traction control. There was no messing around Florida boy does not know how to drive in this stuff. Nor do I want to learn the hard way.
Yes, that's exactly right. That is exactly right. Good. Well, let's jump in. Um, can I share a review?
Yeah, I think that'd be great.
Perfect. So this one is from capsular 1243. from Great Britain. Awesome. This was in response to a nerve repair episode it said, great podcast, fun, informative, honest, a great online resource for hand, plastic and peripheral nerve surgeons, physios and tissue engineers, thumbs up, and five stars. Thank you, again, that that kind of review really, really is appreciated. And, you know, thank you very much.
Fantastic. Well, thank you for that. And you know, it's that time of the month where we're at that time on the podcast where we should probably do a drawing.
Let's do it.
So, pick a number. And I'll see which who's getting a mug?
I think I went low last time. Let's go number 50, 5-0.
All right. Okay, if your email address starts with San Jueswaran,
That was really helpful.
50, but you are you are the winner of a mug, and we're gonna get that one out to you soon. Thank you for doing the survey and then anybody that wants to be entered in the chance to win a mug Chuck is going to promise to go very high next time. As we pick our our next mug. So please do the survey. The survey is listed in the show notes, I believe. And also on our website at the upper hand podcast, Wu stl.edu. We
love getting the feedback. We also love hearing from anybody that wants to email us at handpodcast@gmail.com. And remember, Chuck and I will answer any question if you leave it on a five star review on iTunes.
Absolutely. And yeah, for the name that Chris just read out. Just you know, email us please. And I will say Chris, that I did shout you out on Twitter recently because I was reviewing the poll results. And I think You deceived me at one point where you had me believing that the audience was begging for more nerve. And what what I learned instead was the audience was begging for more sports.
You know, I think the results are in the eye of the beholder. Clearly the system, the system was rigged. You know, I think those are our two most popular topics, for obvious reasons. But we will sneak in a little nerve today, don't worry,
I've no doubt I'm guessing when I next ask you to talk about a case, it's not going to be a sports case.
It is not going to be a sports case. You know, one thing that I think is really interesting how sometimes things come in spurts in practice. And I'd say that, you know, a thing that's come up for me a few times in the last month or so is doing superficial radial nerve decompressions at the Wartenberg point, essentially at the fascial exit near the brachioradialis. I don't do that many, because it honestly, it
doesn't come up that often. You know, and I had a couple of them recently, and I thought they were really interesting cases. At the conclusion of the case, I said, You know, I should just do this under local, because I'll be honest, it's such a superficial dissection, that, you know, patients probably better served with an under local, what do you think?
Wow, well, yeah, I agree with you, in my years of practice. I would say if I've done five, that would be a generous number. And it is interesting. So while we're on the topic, so I presumed these are non traumatic irritations may- you know, maybe bracelet wearing or tight watch or something, but not a blunt trauma, injury to that superficial branch of the radial nerve, truly a compression point.
Yeah, so one, one compression point, I literally tried everything that I had not to operate on him in terms of non operative modalities. And then the other one was interesting, it was a radial tunnel release that had been done elsewhere, had continued numbness in the SRN distribution, and we waited a long time and, you know, kind of had an honest discussion with the patient gave gave them options, and they wanted me to do it, which I think, you know,
is a reasonable thing. We talked a little bit about shared decision making in a prior episode. And also, we talk about it in journal club and stuff. And, you know, it wasn't a formal process. But you know, I like to give patients options. I like to and they inevitably will ask me what I would do. And then I tell them that that's an unfair question, because I don't live with this, you know, I don't live with the condition they've been living with, I don't know their decision making
calculus as well as they do. But I try to spend a little extra time and try to be empathetic about it. And, you know, just say, here are your options. And then leave the room.
Totally agree, especially in something like this. And I will say when I have proceeded down this pathway, it has been successful. And I agree with you, it could be just fine under local only because you have a defined segment where you're working, and I think getting appropriate. analgesia should be, you know, something we could accomplish under local.
There were a couple of interesting points, teaching points about the case that I was pointing out to our trainees, you know, the two things I think both of them were described by Delon and MacKinnon in the 90s. But, you know, the overlap between the lateral and brachial distribution and the superficial radial distribution is very real. But also the physical proximity of those two nerves is
very real. And, you know, unless you see the nerve emerging from underneath the brachioradialis, you could potentially confuse the LABC for the superficial radial nerve, because in one of the cases, they were literally on top of each other, you know, in, you know, we were pretty proximally. And we weren't, we weren't down by the wrist level, where it could be the volar and dorsal branch of the SRN. So I thought that was one interesting
point. And then the other interesting point was whether or not to add a brachial radialis tenotomy, to the procedure, in the efforts of trying to minimize any chance of the symptoms recurring. Do you ever did you? And you said, you don't do a ton of these, but did you? Do you add that typically, or?
I have not, but I certainly would not be against it. I have traditionally marked out the area of maximum discomfort and made a relatively small I'm not talking one centimeter but relatively small incision, maybe three centimeters. But maybe I'm not being robust enough with that.
Yeah, I think that you can certainly, I mean, you could do this inci- you can do this surgery through a transverse incision, if you you know, look at that maximum tinels and if it matches anatomically, where you know, it typically would be but I enjoyed the dissection I keep it as small as I can, but you know, I think it ends up being a four or five, you know, curved,
s shaped incision. And then I find the brachial radialis tendon essentially right after the musculotendinous Junction, and then I divide it under direct visualization of course, and I remember I did Did one of these SRN decompressions, a few years ago, and I was making small talk with Dr. McKinnon in the surgeons lounge, and she said, What well did you do the tenotomy? I was like, What? No,
no, why? Why would I do? And then she looked at me like you missed the boat, you should have been doing a tenotomy the whole time. And the patient was totally fine. It did totally did well. But you know, that was a point that I was like, You know what, I'm there. It doesn't add anything to the surgery. And if it has some benefit, I think it's worth doing.
Yeah. Agreed. Agreed. All right. Oh, interesting. So how many of those have you do you think you've done in the last, you know, in your, say, five years?
Probably less than 10. You know, there's some cases in which I'll decompress the nerve in the setting of trauma, as you mentioned earlier, you know, there's that belief that a nerve that's been traumatized, whether it's, you know, an injury or a nerve that's recovering from a nerve graft, or some kind of surgery on the nerve is going to swell distal to the site of, you know, it's going to swell as it's recovering and
regenerating. You know, that's, I think that's still falls into dogma camp, you know, it's based on some laboratory research, you know, that. And then it's kind of spread on the podiums. And there are a couple of case series that have tangentially I'll say, supported it. But I think that most peripheral nerve surgeons do subscribe to that belief that if you have a recovering nerve, there's little harm in decompressing it. And I think that's probably related to our comfort with doing those
surgeries. And some of it and this might be a little controversial, is keeping the patient in the game and giving them continued hope, you know, down the line that you know, okay, we do this. And we do that, and you'll continue to get better and better.
I'm not completely sold on that probably for the reasons you say, I would probably need to be more convinced with some literature about the benefits.
We're trying to, you know, we're trying to do a study where we ultrasound, nerves after injury before a decompression distally at known points of entrapment. So hopefully, we'll be able to get an answer within the next couple of years enrollment's been a little slow. But the literature that that assertion is based on is that, you know, there were a series of radial nerve injuries, for example, and a few didn't get better. So then they went and decompressed them, and
magically, they got better. You know, so it's, it's a case, it's almost a, a subgroup within a case series. And that's at least the best literature I could find on that. And then there's one more case series that came out. So it's kind of low level evidence. But again, most people subscribe to that. And if, if you're a listener, and you feel strongly about it, please let us know. Because I'd love to be educated more.
Absolutely. Before we jump into our main topic of the day, I did want to shout out Jim Chang, who was our guest, or visiting professor really, last couple of days, it was virtual. And you know, Jim, for those of you who don't know him is the chief of plastic surgery at Stanford University.
And he is a renaissance man in every respect, really has done a lot in every domain from President of the hand society to Chief Medical Officer of research, which does international work to being a well published, well funded, basic science researcher to being an outstanding clinician. So it was great to have Jim and we asked him to talk about leadership. So he's invited as part of the Washington University Department orthopedic surgery leadership series, and
he really did a great job. And I don't want to belabor this point, but I did order. Not exactly the book he recommended, but he made a book recommendation, which I had not heard of, by Bill Burnett and Dave Evans called designing your life how to build a well lived joyful life, actually ordered the subsequent book in that series, which is, I believe, called designing your work life. And it's a little more instructional, apparently,
versus aspirational. But it reminds me My daughter is going to Yale next year, and I guess one of the most popular courses if not the most popular courses on the Yale campus is about happiness. And so I think the you know, this is all these topics have to resonate with each of us especially in the middle of a pandemic, but I look forward to reading this book.
In classic Chuck fashion, I'm gonna answer with your the way you typically answer everything, two things.
Just two?
The number of emails I have from you with the subject two things. You didn't know that did you?
Did not.
So two things. First one is that I almost got as far as you did. I actually had it pulled up on Amazon and did not get to add to cart yet, but I will add to cart maybe we'll do a little book club kind of situation, either on the podcast or off air. I think that'd be good. And I didn't realize there. There is actually a second installment. So I look
forward to that. And the second thing is that I think I've heard about the happiness class course at Yale, and I I think some of those lectures are available as TED talks or online somewhere. I remember during the beginning part of the pandemic, there, they were actually offering I think that same Yale course as an open access kind of deal. I may have to do a little digging on that one, but I think it was available.
I think you're, I think you're correct. I'm gonna what I'm going to say next is going to make half of the audience roll their eyes and the other half is going to fist bump. Alright, so and this is all Talia, this is all my wife. So I went to Amazon first and I looked at the book and I don't remember what it was 15 bucks or something. And I almost put it in my basket. And then I'm like, I should really order locally from from a local St. Louis
bookstore. Because my wife has been pounding that in my head so I go-
Did you drive down the left bank books or did you just order online
I ordered online from left bank books, and you know, it cost me 10 bucks more. It's not gonna be here for a week, which is fine, but I do feel better doing that. I really do.
You know, if they do curbside, I may go to Left Bank books and then pick up some Jenny's ice cream is just a dangerous thing. Some some listeners may be familiar with Jenny's. I think it's from Columbus, Ohio. And they have multiple outposts. But man that's the dangerous part about being at left bank books for me. And then you've got you know, that wonderful pie pizzeria caddy corner. So that's a dangerous corner down in the Central West end.
It is and they actually have the book in stock. And they do curbside so no reason to follow through on your Amazon order.
Okay. So one question for you after Jim Chang's lecture. He had some wonderful leadership pearls, a lot of practical advice too about how to integrate, I think it's probably the way to say it, some of your work and family considerations. He mentioned bringing his bringing one child to to an academic meeting once they've turned 10. Have you ever done that? Obviously, it depends on the meeting. And he did say that and you know, or would you
ever do that? In retrospect, would you wish you'd done it?
Yeah, you know, I, others have recommended the same. And it really does depend on the meeting. So for example, the hands society, definitely for me, and I assume for you would be not a great idea, because we're so busy all day and all evening. For me, the Academy, the Orthopedic Academy would be fine, because I'm not that busy at The Academy, I've talked about it. For me, it's always been my kids are in sports, and they don't want to miss sports, and it's just never
worked out. I love the idea. I think it's a great bonding opportunity. And I can definitely see you doing it. And I can see me babysitting when you're busier than I am at the meeting.
The funny thing is, is that before the the AAOS the academy meeting was canceled for March 2020. I was actually planning on bringing my five year old to the meeting, he's was four at the time. And we were going to we were going to stay at one of the Universal Orlando hotels, you know, with all like the pool and all that stuff. And I had a light schedule relative to every other
meeting. And I was, actually the Brogans one of our partners they were going to watch over my son for a little bit I had arranged a cadre of babysitters from former co residents and co partners to to watch Rafi while while I was at doing the minimal amount of meeting stuff that I needed to in terms of either I was actually giving a lecture or I was in a committee meeting. That all you know, obviously those plans changed. I'm not
ruling it out for the future. I don't know if I'm gonna wait until 10 years old, I probably will try to take advantage of it sooner. But I will say one. One remix that I did on that was when we though I think one of the last international trips I took before the pandemic was going to Korea going to Seoul in November of 19. And, you know, Marty Boyer kindly invited me and David Brogan to join him as part of the ASSH delegation to the Korean society for surgery of the Hands annual meeting. And
I never been to Seoul. I asked my wife if she wanted to come and she was couldn't make it work in terms of work. But I then asked my dad to come and that was awesome. You know, I had a different workshop I was going to in Toronto right before
going to Seoul. And he joined he met me in Toronto, and we hung out there for a night or two and then flew to Seoul and had a ton of fun and the meeting, there were meeting obligations of course, and he explored Seoul in part on his own but we had a lot of time together and like you're saying it's not just the you know, the highlight sightseeing stuff. It's the mundane, that becomes very memorable.
Love that. Love that. And I don't you know, I think our wives are busy and and I haven't had an opportunity to, Talia just chooses essentially not to come to medical meetings and I don't know that that'll change. Maybe it will when the kids kids are out of the house which is not that far distant but even that would be fun for me. But the kids is a whole nother level, I can see that working well for you, for sure.
You're like, you're not very busy at these meetings. You're not actually working while our department pays for you to be away. Well anyway, we probably should talk about a clinical topic, we've spent now two episodes were rambling. 20 minutes before actually getting to the topic. So a topic that's closer to the sports world, certainly, any general hand surgeon or orthopedic surgeon, plastic surgeon, and therapists
will see these issues. We want to wanted to talk about, you know, Bennett Rolando fractures and also the corollary the reverse or baby Bennett, you know, ulnar sided CMC issues. So should we start with the, with the Bennett fracture?
Yeah, let's talk about Bennetts. I I'm not an eponym person. I don't know about you, but I think most of us that's all you have to say you say Bennett and you know that there's a single fragment, you say Rolando, you know, multiple fragments? And and, you know, we think about the deforming force being primarily the abductor pollicis longus, but these are sports injuries, certainly they happen in car accidents, and they happen in random situations, but we see them commonly in sports.
Yeah, I mean, I think that this is a good fracture, to think about for a number of reasons. You know, from a trainee perspective, anatomically, it's a fracture that makes a lot of sense. Like, once you get in your mind that the volar beak ligament is going to keep a small portion, but important portion of that thumb metacarpal in place, and the rest of the thumb is going to displace based on the deforming forces that you described, then it all kind of makes sense.
Right? You know, and I think that it's, it's, it's very testable, it comes up on a lot of in training exams. And I know that when you gave your most recent interactive lecture for our residents, I think that you spent a little bit of time on this fracture too.
Yeah, for the reasons you say it is, when we, you know, every we should try as surgeons, and certainly, all listeners should try to understand the personality of fractures. And I think when I first started out, I kind of rolled my eyes when people said that, but the more we work to understand the fractures, whether they are of the thumb, metacarpal, or of the distal radius, I think the better we can be at treating those fractures successfully. And the Bennett fracture is just it's
not that hard to understand. I will say, when we talk about the reduction maneuver, we talk about traction, we talk about direct pressure on the metacarpal. And then we tend to talk about rotation. And the rotation part is the part that I sometimes I will supinate it, I will pronate it I will do whatever I can to get the reduction, but I think the traction and the direct pressure, downward pressure on the metacarpal are the two most
important parts. And I just try to get to key and with rotation.
Yeah, I agree with you. 100%. That's where I think that you know, there's certainly a book answer. And then there's the real world, you know, how you actually take care of it. You know, so what is an acceptable amount of displacement for this fracture? Is there an acceptable amount of displacement for this fracture, and I'll say, not necessarily for the articular surface, because that's an entire little subtopic, we could talk about, but just for the thumb in general.
So when I was 17, heading off to college, I played soccer goalkeeper in college, and I was training and I sustained a Bennett fracture about two weeks before I was to report to my first camp.
Is that your first fracture?
I had an ankle fracture prior to that, but that this one was impactful in a different way, just because I was, you know, going to college and you know, expected to play soccer. And this was challenging. I remember the sports surgeon i saw i didn't see a hand surgeon Go figure. And he said, Oh, you'll be fine. You could have problems later. Well, laters now because I'm hurt. And I'm too scared to x ray it. So I haven't looked at it lately.
Come on, you have never you've never run in under the C arm?
I have not. I have not, maybe I will but I have not.
Your disability insurance agent is probably not listening.
True. But you know, I went through a phase where I would scope these to get to the actual the articular part. I just don't think that's an efficient use of resources or typically necessary. And it is for me all about the articular surface. And I think that it needs to be a millimeter or less. I think it really does. And I don't think that's typically very hard to get closed. But there are opportunities when we open it.
So we this is probably one of the fractures where I think there's some controversy as to how much step off in gap you could potentially accept at the articular surface. So you seem to think it's a millimeter Do you fault anybody that says you know, you can just get in the ballpark, it'll be okay.
Like many things, I focus more on step and less on gap. And so a step off deformity to me is definitely more concerning if someone's-
So then for somebody who's not familiar with that concept. So why is a step worse than a gap?
I think with a gap deformity So literally, the articular surfaces is well aligned, but it's just separated. I think that the forces traveling across the thumb down to the trapezium are still evenly dispersed. When there is a literal step off where part of the articular surface is closer to the trapezium than the rest of the articular surface, the forces are magnified on a certain part of the joint, which is not tolerated well.
Pressure divided by area.
Thank you. Well said. So yeah, so I think if you had a two millimeter gap, I wouldn't think it's crazy. If it's a three, four or five millimeter gap, very different story. I don't know how much depth is okay. But I would hope it would be less than two millimeters for sure.
Well, so you mentioned that it's a lot easier to to make the articular surface as perfect as you would like to make it if you open when do you treat these closed versus when do you treat them open? And you know, say you've got a good and acceptable, but not perfect articular reduction with with closed means when do you decide to open?
Well, I think there's there's variable factors, as we might expect, age related for sure, I have, you know, in my age group, I would have more of a tolerance for displacement. But when you think about the sports population, I think there's another reason to open if your fragment is big enough, I would prefer to put a couple of screws or a small plate and screws and create a construct that's stable without pins external to the skin, because it totally changes
return to play. So pins have increasingly become well that won't make sense, but increasingly become less desirable in taking care of the athlete, the high level athlete, whether it's professional, or college, or high level, high school, whatever you want to
call it. Because when someone has pins in, you have to be careful about even sweating, and you certainly have to avoid contact and the risks go up if someone has a plate or good screws, and the wound is close, you know, within a few days, usually three to five days Max, I'll let them sweat and do cardiovascular. And so staying in shape is easier, and then potentially get back to play with a little external protection much faster. And so I am giving a long winded answer.
But I for a standard non athlete, where I can get a good reduction closed, pinning is fantastic. But there are reasons even in that population to open if you just simply are not satisfied with your reduction.
How often when you're doing this closed, do you go after the volar ulnar beak ligament fragment? Do you try to pin into that? Are you basically pinning the joint around the fragment?
I think you one can do either. And in our you know, in our setting where we have assistants and and various factors about how a procedure may be done. It doesn't really matter does it? I think as long as we can secure the metacarpal to that beak ligament fragment, I think we've
done our job. And if usually I put two pins in, I love it if what I'm just for aesthetics of the X ray, I love it if one of them crosses the fracture and secures the fracture, and the other one may actually go from the metacarpal to the trapezium. I don't like pins going across the first webspace. So a pin mid metacarpal or distal going to the second metacarpal there's a role for that pin, but not here. I don't want to scar the first dorsal interrosseus and scar the
first webspace. So I don't put that in in this fraction.
Yeah, I will say and this is probably not the appropriate thing to say. But I do like the marksmanship aspect of trying to get something into that volar beak ligament and I think it's an excellent training exercise for our trainees. That being said, another incorrect politically incorrect thing to say, I don't like excessive X ray masturbation, I think that you know, spending so much time on that defeats the purpose and
potentially does some harm. And I can say that word masturbation because your friend is the one who said it first on our podcast last week. So I just want to make that very clear that we have expanded the lexicon of upper hand words because of Aaron Perlut last week.
So so that that podcast is gonna drop on this Sunday, and I was gonna cut it out but now I'm just gonna leave that in.
You gotta own it man, you gotta you gotta keep it.
Look where physicians, it's a medical term.
Feels like that whatever Dr. Drew's show was in the 90s, the controversial one on MTV about dating with Adam Carolla. Okay, I think it was loveline back in the day.
Yes, that is back in the day, for real.
Back to our topic. So if you if you are putting a screw and you're trying to secure a screw from the main, you know, metacarpal portion into the volar ulnar beak ligament fragment, what size screw is it usually obviously I know it depends on the size of the fragment. But what's your typical go to?
Yeah, if I really want security, I'll put a small plate, and ideally two screws in the fragment. And then typically a 2.0 plate and screws, I think feels right most of the time. And that's not for the tiny little fragments, it just isn't, if that's the professional athlete with that fracture, the tiny fragment, it is what it is, then you pin them, and you do what you can to get them back playing as soon as possible. So it is it is a
little tricky. In the true, you know, you know I'm from Alabama, I don't pronounce anything correctly. But the Wagner approach or spelled Wagner it's not a small approach, because you have to take down the thenar musculature to really look around the metacarpal and at the fragment and so it is a much it's not only less invasive from a skin perspective to just pin these, but the muscle take down to truly work for an anatomical reduction is not insignificant.
Well, let me ask you, I'm thinking back to kind of the AO fracture kind of principles. If you don't have if this isn't a Rolando, meaning there's no Y split? Why do you put the plate? Is it not is essentially acting as a big washer? Do you think it strengthens your construct compared to your inner fragmentary screws?
Yes, absolutely. Especially with the larger fragment a larger plate multiple screws, I think just gets the athlete back to doing their thing faster. As we you know, as you and I have, I think discussed on this podcast, we certainly stress I don't think it speeds healing necessarily, probably a little bit but not enough to make it the reason to do the surgery. But it speeds recovery.
Yeah, absolutely. And then when do you do you ever, ever lag these fragments, either by design or by a technique?
I don't. I have, there was a study out of Indianapolis many years ago looking at Synthes modular hand screws or obviously it doesn't matter the company but but modular hand small screws 1.5 2.0. And looking at lag technique versus simple fixation techniques, and there was no benefit demonstrated with lag
techniques. And because of our setting, I don't see the advantage, it can be really tricky to lag with a 1.5 millimeter screw 1.1 drill bit so you're drilling with the what for those who don't do this often, if you're going to place a 1.5 millimeter screw, you initially drill with a 1.5
millimeter drill bit. And then you drill small, smaller hole 1.1 millimeter drill bit such that you have to place your it has to be perfect drill, drill holes, and then you place your screw and you bring the fragment together with some compression. I think you can obtain your compression with a clamp in most cases. And then you just hold that compressed reduction with screws or screws in place.
Yeah, I think one of the things that you told me when I was your fellow is that if you're not ready as the attending to hold the reduction until that fixations in you're not the you can't be an attending. And that's probably be the reason you said that is because I was probably taking too long and your thumb CMC arthritis is starting to set in.
Sounds about right.
But in all seriousness, I mean, I think that in hand because of what you mentioned, with the, with the small caliber of the drill and the small caliber of the implants, you know, if you if you have any technical missteps, either with the over drilling, or with establishing the path for the screw, you know, on the far side, or with insertion of the screw, that's it, your chance is gone. Like it's not like a femur, like he had a lot
of chances on a femur. And that's nothing against trauma colleagues or it's not like a humerus like you know, or even even metacarpals to be honest with you. But anything outside of a metacarpal I think is much more unforgiving.
That's right, that's right and and, and unforgiving and I don't know that the benefit is is worth the the potential challenges of trying that technique is that is the bottom line.
So and the only other thing I'll add is that you know I like getting a little dental pick around that volar ulnar beak fragment and using that to hold I have not typically you know, taking a point reduction clamp and put it around there. But I think if you have the exposure and dental picks a nice way to secure that fragment without any excessive stripping.
I think that's well said and so my first choice in general is close reduction and pinning but it with a bigger fragment with a higher demand athlete. I have no problem putting a plate and screws on there or two screws or whatever. But these fractures do well and Patients, you know, very quickly typically heal because the robust blood supply, and I'm not, knock on wood, seeing many of any complications or, or delayed presentation complications. So I like treating these they do well.
It's just a question of how quickly can you get them back to the activities they want to go back to.
Now what about the ulnar side? So you know, CMC issues for the ring and small finger, the fourth and fifth metacarpals?
Yeah, I've had a couple of these recently interesting. So not truly the baby Bennett, which is a fracture of the base of the fifth metacarpal in which the ECU tendon is the deforming force, the ones I've had recently have been true fracture subluxations at the fourth fifth CMC joint where the dorsal handmade is sheared as well.
And, you know, those are those are high impact injuries, often punching and honestly, I don't know that I understand the biomechanics of when one may get a Bennett fracture, I'm sorry, when one may get a boxer's fracture, versus a base of the, you know, fourth and fifth CMC joint fracture injury. But it's a it's a high energy trauma, for sure.
Now, one thing that I think this comes up on tests, but these can be a little difficult to diagnose if you're not looking for them. And you know, using a straight hand PA, and the straight lateral view, can be deceptive. And I really think that this is where having that, you know, oblique or Semi Pronative, you can be super useful. And even you know, having live mini C arm fluoroscopy can be useful if you're concerned if you have a high index of suspicion for this fracture.
Yes. So again, focusing on that four or five and handmade fracture, it can be difficult to confirm that radiographically a couple of thoughts, as you said this, the live fluoroscopy can be really helpful. A perfect lateral can be really helpful. And there was a there was an article out of the Mayo Clinic 10 or so years ago, which looked at flexion of the fourth and fifth
metacarpals. And so if those metacarpals flex, that's a secondary indicator or problem proximately And that, to me has been really useful when I'm not when I know to look for that. That's a great indicator, there could be a bigger problem. And a CT scan ultimately, is often I don't wanna say required, but it's often helpful. I don't know that I need it for preoperative planning, because the fracture pattern is predictable of that
dorsal hamate. But if you're uncertain about whether it's needed based on alignment, a CT scan can be really helpful in making the decision about whether surgery is necessary or not.
So if you're operating, what's your preferred tactic, do you just pin the CMC joints after reducing them and then call it a day?
I think this is debatable but I do not know good literature to guide us if there is a real fracture a substantial fracture of the hamate I fix it and so I will make a small incision clean out the fracture site reduce the dorsal hamate to the rest of the hamate and put two screws in obviously careful with the volar position of the screws and they certainly the screws can go in the hook of the hamate you can feel really good if you get a 30 millimeter screw and they don't
they need not to go into the hook of the hamate they simply can't but you have to be careful with the drill because we all know the proximity of the ulnar nerve.
See brought back to nerve.
Dammit.
Well so if you you said substantial and then I was going to ask you what the substantial mean and then you went on to say put two screws. So does it mean that it is a fracture that is big enough for two 1.5 or 2.0 screws?
Yeah, I think two 2.0 screws is what I try to do and yes I do not have a specific size criteria for for
making that decision. But when there is a fracture which looks robust enough to hold the screws, I then reduce the CMC joint hold it with a 6-2 K wire and fix the fracture as well I feel better about doing both of those one could argue if you're fixing the hamate Do you need to secure the CMC joints with a K wire and that's k wire for me typically goes from five to four to three or more commonly five to four to the capitate and it
one or two k wires. I feel better with both I think the K wires unload the healing hamate and that makes me feel better.
What about your athlete though? So you mentioned the fancy sports surgeons disdain for external wires. So say you have you know to 2.0 screws in there. You have your provisional six two pin from five to four into the capitate does it remain provisional? Does it get pulled out or mean does it stay and do you leave it exterior to the skin Do you cut it deep with the plan on coming back under local or in the office?
That pin stays in. But I'll get it out more quickly. So probably stays in for four weeks till we feel comfortable that the hamate is at least starting to heal. And then I start the rehab process without heavy gripping or pushing until probably six weeks in a non athlete or someone where we're not, we don't feel as rushed. I will leave the pin in for six weeks, and then I pull it without much concern about anything.
Do you leave it buried? Or do you leave it out of the skin for in both situations?
In both situations I leave it out. What do you do?
You know, I'm not fancy. I'm not a sports guy. So I have no problem leaving external pins on people. Just for simplicity's sake, but I guess with you know, WALANT, etc, I've been doing some local or even just taking it out in the office, which I know some of our partners do. Just burying pins just deep to the skin. I just, I don't like going halfway on it. And then one thing I'll say about that, you know, capturing into the hook of the hamate. It's dangerous, right?
So you know, when you're drilling, you know, there, there was I pulled some data when I was giving a talk a few years ago, and there was a really interesting paper that came out of one of David Ring's, many labs, and they looked at they took CTs and did 3D reconstructions of the hamate. And then if you look at the tightest part of the hamate, you know, in the hook, you know, the diameter of that, you know, is about four or five millimeters.
You can have quite a long length on it if you want, but it's a really narrow corridor. And I think the last thing you want to do here is be in out in with your drill, and you know, confuse yourself those of us that have trained in orthopedics. Remember that with pedicle screws. Did they have pedicle screws when you were training? Chuck, I don't think they.
No, just we just had plaster. Those athat saw us just got a big cast o their back
Scully cast. That's right. But yeah, it's kind of like doing a pedicle screw, you gotta be perfect. You know, and so the alternative is not good.
It is technical, right? If you if you are comfortable with your ability to palpate with a drill while you are drilling, I think it's safe. But you can't fool yourself and you can't feel cortical. You know, you just can't confuse yourself. And you have to be honest with yourself. So you're right, it is not necessary. It does feel good if you make it happen, and it can be safe, but it you know, you just have to have to do it right.
Last question. I'll ask you on those dorsal hamate fractures. I've seen some people use plates here. Essentially, the plate is a washer. Do you like that concept doesn't add a whole lot for you.
It depends on the quality of your screws. To be honest, I do not mind that concept at all. I think it's typically overkill. typically not necessary. Two good screws, I think are fine in that fracture. But there's no doubt that if you if you want a little more substance and just spread the compression forces out a small plate can be helpful, it's not typically in my routine.
Okay, well, we snuck in some sporty kind of stuff for you there.
Thank you.
We have sustained you for another six nerve episodes, which I know is what do people really want.
Probably. All right. Have a good rest of your day. You too. 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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