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 am pretty fair. How are you today?
I'm doing all right. You know, I took a day off this week, it was awesome. Yes. Yes, I know, you missed me in conference on Monday. But, you know, a little bit of backstory. I took a day off on Monday because I realized that, you know, as great as it's been with the pandemic, not traveling so much. We talked about this a little bit in the last episode. That also meant working more, and then not having anything to disrupt the normal kind of
cadence. And I think I needed just a day to look forward to. So I took Monday off and ended up taking my son and my daughter to the St. Louis zoo. And I've been wanting to do that because my son's really into snakes right now. But I didn't want to take him on the weekend when there would be a bunch of people at the zoo. So we essentially had a private Zoo experience.
Wow. And the St. Louis zoo is something- not only is it free, but it's a pretty darn good zoo.
It is, it's a great zoo. And I wouldn't say I mean, there's no charge for admission, you and I pay for it in taxpayer dollars. And anybody who comes to St. Louis can get it on our dime. So, but it's a great zoo. It's a great zoo. There was there were more staff there than visitors. They did everything right in terms of masks and everything. And yeah, we went through the reptile house two and a half times.
I love it. So answer me two questions, please. Number one, was it a great day? And number two, were you able to not think about work on that day? Because that's the key. If you spend your day thinking about what you might have gotten done, what you could have gotten done, then it's it's not only counterproductive. Well, it's counterproductive.
Yeah, no, I completely agree with you on that. I made it a day where I couldn't think about work too much, because I had a five year old and a two year old running around me. So they didn't really let me do that. And then also after the zoo, I took I took Rafi on a hike in Castlewood Park. And so that was a good way to get outside for both of us. And then we got to do where we now developed a tradition of getting Dairy Queen blizzards after hiking, which may or may not be
a good thing. But he loves the fact you can turn the thing upside down and it doesn't spill.
Yeah, one of my kids, there's got to be a treat at the end of the effort, whatever the effort may be, and then that's okay. I think it's okay. The other two don't care as much.
This may be a dangerous precedent though. That's the only problem. The blizzards will only get bigger in size as as they progress in age, which means my Blizzard will also have to get bigger.
True. All right. What about any new exciting reviews? Are there any out there?
We do. One of our longtime listeners, Dr. Paul Inclan, also one of our residents has finally left us a review. So thank you, Paul, for leaving the review. You know what Chuck, he gave us five stars, and I will say, I've already filled out his evaluation many months ago. So there is no quid pro quo here. But he did say it's a wonderful opportunity to passively learn pearls for the trainee in a package that is entertaining to listen to. This has significantly strengthened both
my fund of knowledge. Or Paul, you wrote both but you can tell us the second thing. Anyway, the non hand episodes are useful for surgeons and health care providers from all fields. So thank you, Paul, for the review. We appreciate you listening and I basically give away every question to every every answer to every question I asked on the rotation in the podcast.
That's a teaser. Absolutely. Good stuff.
He caught onto that, he caught on to that which is good. So any, any any new cases or anything cool?
Yeah, I would. Yes, I'd love to tell you about a case. And then I actually read an interesting article which I'd like to briefly discuss. So case wise recently had a Dupuytren's fasciectomy. So as we've talked about, I'm a huge fan of the needle fasciotomy in the clinic, and it's really cut down on the number of formal open fasciectomies, which honestly is a is a loss for our fellowship, in the sense that, that that skill set is very important. It's very, it's is a technical
procedure. Experience matters. So I'm always happy when there is a a need to go to the operating room. And this patient had patient had three finger disease and classic pre-tendinous cord for the middle finger an intrinsic cord to the ring finger, and then a combination for the little finger and had previously had collagenase injection for a cord for the little finger, so the middle finger and the ring
finger went fine. And I get to the to the ring finger, which had a maybe a 30-40 degree contracture at the MP joint and a 90 degree contracture at the PIP joint. And it was fascinating because the digital bundles were encased in Dupuytren's, not you know, it was they were spiraling and all that but truly encased in a concrete like fashion, which I have not seen terribly often.
Do you think that it was the collagenase playing a role in that in terms of the scar tissue around it? Or?
I think that's an easy an easy answer. I'm not sure if it's true. I think in my mind, maybe it is. But Wow. So, you know, we we invited to the basic principles, you know, we found the bundle proximally, bundles proximally found them distally worked in between and it was it was a challenge. And then once we succeeded, everything was intact, and we deflated the tourniquet. And you can guess what we had. A white finger.
A white finger exactly. Well how much contrast how much correction Did you get?
100% correction, which was very satisfying. I've limited I've been talking about this, you may have heard me say this, I've been talking about this a lot. I rarely perform a volar plate release anymore. I have rarely found that necessary. Now sometimes I do a manipulation. But with a little manipulation, complete excision of all the Dupuytren's, which you can requires a lot of work. I did not need to touch the volar plate, finger was white, you know, there's white and there's
white. This was white, but not the deep white that truly scared me. But it made me a little nervous. So we did the usual stuff to fight spasm. And eventually the finger came around but but it took probably 15 minutes of a little bit of angst.
So for you What's the stuff that you do so obviously, you relaxed the extension posture of the finger, you've already visualized, the bundles. Are you using anything like a topical papaverine or lidocaine for spasm, anything like that?
Usually it's warm water. And patience, I can find the water but finding the patience is a little harder for me. And in this case, we got some 2% lidocaine and dribbled that on as well. We did not have the papaverine at the surgery center. But you know, the real consolation or consoling factor for me was there was no bleeding vessel. You know, once the tourniquet was down, so that gave me some confidence. But gosh, that was a long time.
So if it hadn't come back, would you have you know, relaxed the finger and pinned it in a certain position? What do you think you would have done?
I don't think I ever got to the point thinking that it wouldn't come back had I had a digital artery injury and had to repair it at a smaller surgery center, then I would have had to process more. Again, it's it's knock on wood. I've never gone down that pathway where I had to really think about salvage, so to speak. I don't pin my fingers at all anymore. I put them in a resting soft dressing, let them sit for 48-72 hours and then start therapy. I'm not sure what your
what's your protocol is. But that's worked pretty well for me.
Yeah, it depends on the case, you know, so if a Dupuytren's gets to the OR, which, as you mentioned earlier, it's not incredibly common anymore. So I like to do these awake. You know, I think that it's useful to have the patient involved in the process and actually have them visualize the correction. And sometimes it is good to hear, have them hear how we're working what we're thinking about. And I show them and say, Hey, is this enough? Do you want more I can get you
more. And it also gives me the advantage of getting them up to therapy, the day of for a splint rather than waiting a little bit longer, not that they're going to do a whole lot of therapy exercising, but I think having them get up for a nice splint right after they leave and recoveries is nice. You know, one thing that I would want to ask you is you mentioned not routinely doing any volar plate work and doing some
manipulation. How do you assess before surgery how much of it is a joint contracture kind of issue? And when is it too much surgery to do some work on the joint itself?
Well, the literature tells us and I think this is out of Baltimore, the literature tells us if you have to do a volar plate release, long term expect only about 50% improvement to that PIP joint. And obviously for those who haven't done a lot of this we're not really talking about the MP joint because an MP joint responds beautifully every time to taking out the use of the pre tendenous cord maybe an abductor digiti, digiti minimi cord for the small finger, the PIP
joint's different. But my, my experience with First of all, I don't think it's too much surgery, in my experience with purely addressing the Dupuytren's, which again can be complex, and it's about 100% Dupuytren's excision across the joint, and potentially a little manipulation is that it has been really effective and the results are better, I hope to be able to eventually look back and provide some actual follow up on that. But that's my early sense.
So if you get that much correction, what's your preferred way of dealing with, you know, any skin voids or soft tissue defects from the skin being contracted for so long? Are you the kind of person that likes a full thickness skin graft? Do you like to leave it open? You know, I remember doing a modified McCash procedure during my fellowship with Dr. Gelberman. And that seemed to be quite labor intensive for the post operative follow up.
Yeah, that that, thankfully, is not in my armamentarium. Although it is good to have seen that because you never know when you might need it. And for me, those type of considerations are about revisions of previous open surgeries. And so I for my camptodactylies is not to bring it all back to congenital but for me, that's a that's a key point, I use a rotation flap off
the side of the finger. And so that's a great option for me, especially if that PIP joint if we're really dealing with skin that that may not have support beneath it for healing. And so a rotation flap can be very helpful.
Okay, that's a great discussion. It's a nice follow up, almost part four of Dupuytren's disease there.
Yes. So so I want to briefly and I think we're all feeling a little optimism about COVID. I think, here in St. Louis, the numbers are good, actually, across the country, the numbers it is, we gotta be careful to say the numbers are good, the numbers are heading in the right direction, there are still far too many deaths and infections on a daily basis. I actually am a little worried about these
variant strains. There was a really interesting article in The Atlantic magazine, written by a Yale public health expert, and it talked about a city city called Manny- Manaus, I think Manaus in Brazil. And it's really fascinating. This city was overrun with COVID, early to the extent that all the public health folks thought the city had achieved herd immunity. You know, typically people say 70-75%, infection rates are required or immunizations are
required for herd immunity. And that was what everyone thought had been achieved in this city. And that was, you know, late spring, early summer. And the really concerning thing is that they are now overrun with a new Brazilian variant, and people are sick and people are dying. And it's just it's just a worrisome example of the fact that we we are not out of this yet at all.
Yeah, it's it's way too early to, to do any celebrating, and certainly way too early to let down, let down our guard. It's been a long time. You know, it's honestly, it's been 11 months now, since this whole thing started in earnest. And probably it's been here for about a year. So it, that's tough. And I'm just surprised you have time to read the Atlantic. I'm so impressed.
I, I thank you for saying that. I try, I try to read outside of work. And this is work related. But yeah, these kind of I don't know, I like we've talked about all the ways we can fight burnout, and fight the stress that every single one of us and all of you listening are experiencing, these are such abnormal times, that whatever, whatever gets you talking to other people, whatever kind of just makes makes you feel better. And again, reading pessimistic news may not make me
feel better. But it's reading outside of medicine, it leads to conversations in my house. And so all of those things matter. And so I do think we should, and people like me, and you especially need to fight being one dimensional, if that's a
trip to the zoo. Great. If that's, you know, going for a run great, but all of us need to continue to be aware of mental health because we know we are already in an epidemic of mental health challenges, and that's not going to get better anytime soon, either.
My current read outside of medicine is Dave Chang's memoir called eat a peach, the founder and you know, chef at Momofuku in New York City initially, and he's probably one of my favorite chefs. So the issue with me reading this book right now is I get so damn hungry. Every time I read a chapter and talking about food, but I agree with you 100% that we need to read outside of medicine and I used to read the Atlantic. I don't know what it says about my residency. I think I had time to read in my
residency. But since uh, you know, parenting and attending hood started have not found the time.
Well, we should briefly and I'll tell you what I'm reading. I may have mentioned this before. I'm getting near the end. I read multiple books at a time. I'm reading the splendid and the vile, which is a book that Eric Larson, who's one of my favorite kind of historically, historical, it's true history. But he almost makes it an easy read. This is about London, about Winston Churchill, about leadership, and about World War Two before the United States joined in the bombings, it is
incredible. I'm almost done. It's not a book. It's not an easy read.
Sounds like a light read.
Yeah. Well, the other book we should talk about is a book called f blank ck your formula. Why following rules is the worst marketing decision you'll ever make. It's by a few different people, Brian Krause, and Aaron Perlit. And the reason I bring this book up, it's about marketing. And Aaron is going to be our guest on the next episode.
That's fantastic. I can't wait to hear what Aaron has to say. I think it'll be a nice follow up to the prior week's episode on marketing and practice development. And I think at some point, we're going to round out that series by having another surgeon come on the show who has a different perspective, perhaps from private practice. So thank you in advance to Aaron for joining us and we look forward to hearing from him.
Perfect. Let's jump into we thought we had been neglecting the clinical content world. So we wanted to break up the marketing discussion with a key clinical topic. And you know, what Chris came up with, we can only come up with one dimensional topics. So Chris, tell us what our topic is.
The topic is pronator syndrome, or whatever it's called nowadays. You know, I think that it's challenging, because this is a syndrome that has changed names quite a few times. If you talk to some people, they will call it Lacertus syndrome now. So what are your thoughts, Chuck?
For me, it's still called Pronator Syndrome. And it is something that is infrequently diagnosed, but when diagnosed, can be a really important step for the patient.
So in your mind, what is pronator syndrome? I know that there are a number of different definitions out there, I actually pulled out my Dr. Gelberman Blue Book, to look up the definition. But I'll read to you that this was first described by Seaforth in 1951, who proposed that the median nerve was compressed between the two heads of the pronator teres muscle or by the FDS arch. Is that still your understanding of it in 2021, which, you know, compared to 1951, it's been quite some time?
So, you know, at washu, we have been very fortunate to have a great anatomy series. And some of those anatomy discussions have been remarkably impactful for me. And I remember as a resident, having these discussions, in which we talked about the anatomical reasons for pronator syndrome. And so we talk about the supracondylar process. We talk about the ligament of Struthers. We talk about the lacertus fibrosis, we
talked about the pronator. And we talked about the FDS arch and I will never forget Paul Mansky saying, I buy it, I buy all of those as possible explanations for nerve compression, except the lacertus. And I think he's right. And we always release the lacertus. But I think the other is really only three because supracondylar process slash ligament of Struthers, I think is one potential compression point. And I think that two
heads of the pronator. And I think that FDS arch can be can be real constriction points, but it's just amazing what sticks with you over time. And I'll never forget those discussions.
So let's before we dive into the more distal points of entrapment, let's talk a little bit about that supracondylar process and the ligament of Struthers. Have you ever seen one?
Yes, absolutely.
And was it compressive.
I have seen one. No, I've seen a couple. And yes, I have seen it be compressive. But you are correct. I mean, this is a zebra. The question becomes if you have a patient, and we obviously will get to the diagnosis part. But if you have a patient where you think there is a compression of the median nerve at the elbow, does that require an X ray?
Well, I will, I will admit when I see a patient who has had and we'll get into this a little bit I think has not done well after a carpal tunnel release. You know, usually these these folks come in they've had the release done elsewhere. They're having persistent pain. I usually end up working them up in terms of physical exam, as we'll talk about earlier, a nerve study and then on the way out, I will send them with an X ray of the elbow mainly for completion sake.
Yeah. I try to get an X ray. I try to palpate and you know, etc, I don't know, I wouldn't be critical of someone for not getting an X ray. But I do think it feels like the complete evaluation. If I'm really truly concerned about that diagnosis.
I think the psychology of the visit is different though they've come in with a failed surgery or persistent symptoms. They are in the mindstate where, and I am to where I want to make
sure there's nothing missed. As opposed to the patient who's coming in with a new complaint, a new diagnosis has not had surgery in the past, I will evaluate the median nerve in the proximal forearm, in addition to the carpal tunnel, but I won't get an X ray of the elbow, because I think that, again, it is so rare that the odds of me finding something the pretest probability, so to say, is incredibly low.
So let me I'm gonna bring up three different diagnoses. And I want you to tell me which one for you has provided a more satisfactory surgical release. So of these three diagnoses, when you end up doing surgery, which might be uncommon, which of these have you been most impressed with the compression of the nerve, you know, in discussion. So I would say, radial tunnel, pronator syndrome, and distal ulnar tunnel compressive syndrome.
Which of those three has led to the most to the most impressive clinical findings at the time of surgical decompression?
In order, pronator by far, and then I think it's probably a tie but I think ulnar motor Guyon canal, distal ulnar tunnel, and followed by the radial tunnel. And that's not to say that those surgeries are not useful and effective. I think those last few surgeries are effective, but in terms of visually being impressed by the compression, a tight FDS arch so not necessarily the lacertus I agree with with with Dr. Mansky on that, a tight FDS arch is visually and audibly satisfying
to release. What about you?
Totally agree. Although, I don't know if this will resonate with listeners, I don't do many distal ulnar tunnel or Guyon's Canal decompressions. We talk about ganglions. And this could be a whole nother topic and I don't want to belabor it, but I am never satisfied with that surgery. I never walk out of the operating room thinking and I did one yesterday actually because of a remarkable Tinel's at the elbow and at the wrist and and suggestion on nerve
studies. I never see anything. I just never walk away thinking wow, I really helped this patient even though I might have I never walk out of the operating room thinking that was really satisfying.
Yeah, the the variability in how that surgery is used is incredible. You know, there are some surgeons who release it every time they do an ulnar nerve surgery at the elbow. There are some that do it many times and others that do it very rarely. And it's while that point where the nerve, the ulnar nerve dives deep to the hypothenar fascia is impressive. It never feels particularly
tight or synotic. Almost like, for example, the median nerve at the FDS arch in that subset of population has got a really tight band. You know, I think that one thing that we're trying to study in a project that we're doing here is that theory that a nerve that is recovering from an injury or from compressive neuropathy that's been released will actually swell downstream. That's an almost dogmatic thing that's held over from lab work. And not to say that that
translation can't be made. But it has yet to be truly demonstrated in in any sort of clinical studies. There are a couple of case series in which they've released nerves that were that didn't recover completely and gotten some relief, but that's kind of an indirect conclusion.
But what's your current state of practice and we are way off topic. What's your what's your current state of practice, if you have a severe cubital Tunnel Syndrome, with or without, you know, throwing in a supercharge or anything like that? Do you feel you need to decompress the distal ulnar tunnel to give the nerve the best chance to recover?
So I think it depends on the exam. So the patient who it's kind of weird because there's this there's this middle ground where if the patient has severe atrophy or notable atrophy and has decreased CMAP amplitude on the nerve study that patient's probably getting a supercharge anyway because of you know, those findings, so they'll get a Guyon decompression as part of that.
For the patient that has kind of that moderate loss of CMAP amplitudes has some weakness but doesn't have any frank atrophy and is not getting a supercharge in my practice. I don't love a Tinel's at Guyon's canal because I think you hit the median nerve anyway. So I try to do a Durkan test or just you know, honestly pressing directly over the ulnar nerve just proximal to the pisiform. And if that reproduces a you know the classic paresthesias in the ring and small finger, I will release
that nerve. Or if there's any swelling at the wrist on ultrasound, I think the nerve studies are a little less reliable for Guyon's Canal, except if you do side to side comparisons, which we sometimes get, but don't always get. And I get the fact that I'm pushing on a nerve and I'm producing parasthesias and I'm not truly assessing the motor function, but I don't think there's a better way to do it.
Okay, I would not argue with you a bit. All right, let's refocus.
Yeah. This this podcast will be entitled, Chuck and Chris's pandemic adventures plus pronator syndrome plus Guyon canal. But anyway, so we talked about the compressive structures. You know, what do you think this really is compression by? Do you, do you think it's still lacertus? I know that Dr. Mansky said it wasn't? Do you think it's the pronator? Some people now believe it's never the pronator? What do you think it is?
Which gets to Oh, let's talk about, I'm going to answer your question in a roundabout way. I want to discuss clinical exam. So classically, we talk about, you know, examining the carpal tunnel, examining the median nerve, and I pretty much always assess for a Tinel's at the pronator. And if there's some suggestion of irritability of the nerve there, then I may do
some other tests. And so the tests that people talk about are one, extending the elbow and resisted pronation, which assess the role potentially of a pronator compressive point. And then I think people talk about resisted wrist and finger flexion as well, to talk about FDS arch. I I buy it, I think the clinical exam is helpful. And I think that the lacert- I do not believe the lacertus is a contributing feature, I think it's either the pronator, or the FDS fibers arch.
Yeah, and I think that, you know, you're right about the provocative maneuvers, in terms of how it's described. And then some people will actually, you know, use resisted elbow flexion as one of them, you know, with the thought that it is the lacertus, I've seen a couple of tight lacertuses. But more, it's not that common to see a really tight lacertus. You know, it is more common, I think, to release a lacertus on the way down to seeing a tight
FDS arch. So, you know, I think, to me, the biggest physical exam maneuver that is helpful is again, a more of a Durkan test, because I think a Tinel is a little scattershot in that area
personally. So I'd like to feel kind of that midline, lateral ridge of the flexor pronator mass, and kind of fall into that sulcus, where you know, based on the number of ulnar nerve transpositions that I've done and that you've done, you know, where that median nerve is gonna lie, just, you know, on the inside edge of that flexor pronator mass, and push in
there. And our our therapists like to, you know, tell me that patients describe my knobby fingers going in there and causing them pain, but if I push in there, I know it's gonna cause some pain, discomfort, but I want to know is if they're having paresthesias, shooting down distally. And if that comes about, then I think this is one I should release proximally as
well. Or if I'm doing my Tinel's sign at the carpal tunnel, and the symptoms are radiating proximally that also clues me into a potential other site of compression. And then lastly, I think the physical exam, just doing your standard, you know, extrinsic median nerve motor testing, but with a lot of detail can be incredibly helpful. And for that, you know, it's it's really doing a detailed exam, and you know, I
flex the wrist. So I take the tenodesis out of it, and then I will check resisted FPL resisted FDP index. And I think you can get a lot from that, because you should not be able to break somebody who's FPL or FDP index, even what their wrist flexed with one finger. And this is something where you calibrate your exam over, you know, however many people that you see over time, but you shouldn't be
able to do that. Just like you shouldn't be able to do that for the ulnar FDPs when you're checking somebody's ulnar nerve.
Yeah, I like everything you said, I want to emphasize a couple points I if the listeners like me, you guys were all palpating your forearm as Chris described, the-
I was too.
The radial aspect of the flexor pronator mass and you're right for most people, you can really feel that radial aspect, and that's where the nerve is so that's a great anatomical point for exam. The second is one that Dr. Gelberman has always emphasized is if you think about a point two centimeters, proximal and two centimeters, radial to the medial epicondyle. That's another really good anatomical point to consider for the median
nerve. So I think everything you said is right on I have to say I'm a little skeptical of proximal radiation during a Tinel's as indicating pronator compression. I don't think it's wrong, but it hasn't set off the same alarm bells for me.
Yeah and I guess I should clarify. I don't necessarily think that means pronator or proximal forearm compression it to me, it means there's another site of compression. And that could be potentially, you know, the pronator, the lacertus, whatever you want to call this syndrome. It could be a supracondylar process, it could be TOS, it could be the C spine, it just clues me in on to look a little
harder. Which actually brings us to our next thing, when are you getting any ultrasound or nerve studies for this because this is a condition that is notorious for being a, quote, clinical diagnosis.
Yeah, you know, the longer I do this, I don't know if I get any wiser, but I become a little more dogmatic in my opinions. And if I'm really thinking that there is a component of median nerve compression at the pronator, I tend to get nerve studies. I don't always do that for carpal tunnel, especially with classic findings. But if I'm thinking there's two sites of compression, I will get the nerve study with or without an ultrasound. I'll leave that up to the to the physical medicine
and rehabilitation doctor. The trick, of course, is that they still I still may make the diagnosis of pronator even with a negative nerve study. So then you say, well, what's the point? I think the point is, if it confirms the diagnosis, it's very helpful information for me.
Yeah, I think it's hard to make the diagnosis on that. I mean, I think if anything, I'll get it for completion sake, and to look at the C spine or the thoracic outlet. But I won't really use it to look at compression in the median nerve, because the thought is, is that this is all theory now that the compression there is not tight enough to actually cause a disruption of conduction. So it's just really
hard to find it there. That being said, you know, if I'm concerned about more proximal sites of compressions, I usually will get it. But this is one where I really do rely on my physical exam. You know, I'm reminded of the fact that we're, we're in a very challenging review process right now for a
journal article. And we had used the phrase clinical diagnosis and gotten so much pushback from a reviewer because, you know, essentially, that reviewer was very opinionated that whenever they see the words, clinical diagnosis, they feel like it's something that is almost construed by the physician, almost a surgeon induced demand
kind of thing. And I guess that's the other side of the pendulum from, you know, this reliance on imaging and objective studies, and taking almost the art out of what we do.
Yeah, that's super interesting. And it's it's, I guess, from an objectivity standpoint, there's some it's not an unfair comment. But it's also not a realistic comment. given some of the diagnoses that we've already talked about today, and others.
It's a tough one to address in peer review as well.
Yes, it is. So, all right, let's just talk big picture. So what percent of the time when you are performing a primary carpal tunnel release? Do you also perform a pronator decompression?
I think now, it's probably 10%. I think that as recently as two or three years ago, it was probably as high as 20-25%. And I will say I don't do a pronator decompression, I do a lacertus and an FDS decompression, because I really don't think that it's the pronator that's compressing I know that runs counter to what is described in the textbooks, etc. But I think it's, it's, that's not the compressive
point. You know, it's very rare that I will prepare a patient for a full on median nerve decompression to form including takedown of the pronator. Because it usually is either the FDS arch or the lacertus.
I would not argue and I think those who would argue that the pronator is a problem would would make the comment that it is typically a dynamic problem. And bulkier two heads of the pronator, where the median nerve is traveling in
between. And for those of you who are residents or medical students who aren't familiar with anatomy, there's nothing quite like the cross sectional anatomy of the elbow, or just distal to the elbow and watching that median nerve travel through the pronator watching a giving off the AIN branch, you know, five centimeters distal to the antecubital is really just
fascinating anatomy. But But I agree with you, as far as you know, clear compressive sites, there's no doubt that the- the leading edge of that FDS is much more impressive.
What's your percentage? You would say?
Less for sure. And I don't have as heavy a practice as you do. I would say it's it's honestly 2% something like that.
Yeah. I think that's you know, that's fair. And when we talk I think you maybe said in your training along the way you'd seen some surgeons embrace it and perhaps do too many. You know, and I think that, you know, there's sometimes I'll talk to patients say look, you know, this is a really hard thing to look for objectively Think you have it, we can just do your carpal tunnel release and see how you do. And then if we need to have you come back,
we'll come back. Other people, I feel strongly and I kind of honestly influence them one way or another. I think that's what we do as doctors, especially as surgeons, we give them our own our best clinical impression. And honestly, I haven't counted I have meant to count before because I knew you're gonna ask me that question. I meant to count before we started, because I did have a patient asked me recently, how many ulnar nerve transpositions I had ever done.
And I actually looked it up and told him he was like, oh, okay, you can do mine.
So, alright, and I'm gonna I may, I don't want to anger anybody, but I may anger some people with this question. But do you believe in therapy for pronator syndrome, whatever you want to call it? And do you believe in nerve glides as being an efficacious treatment for nerve pathology?
You know, I don't think that it works particularly well for pronator syndrome. If there's something else going on, in terms of thoracic outlet, which clearly can be the case, I think it's really effective there. I think, as you mentioned earlier, it you know, if it is truly the pronator muscle, that is the compressive pathology, then it is a dynamic process and some ergonomic adjustments would
be helpful. So I think those ergonomic tips that can be shared by our therapy colleagues, either in a visit with us if they're shadowing the clinic, or with you know, a formal therapy visit can be useful, but I don't put I don't put a lot of stock that that's the thing that's going to stop this process. So I don't routinely send people up just for that. And I think nerve glides do have benefit overall. I think some of it is patient empowerment, to be honest with
you. And then some of it is ergonomic adjustments that typically come with the instruction of nerve glides. What are your thoughts?
I think that's well said I've used it more frequently with more success in some mild cubital tunnel and some brachial neuritis, so to speak. And I think it's been helpful in those situations, I have not found much utility for other nerve compression syndromes.
So what are your if you get if this patient gets to the operating room? What's your preferred anesthetic?
I don't think this is one where I would consider a local only technique. I think with deeper procedures, more proximal procedures it's more challenging. So for me, it would not be a local only, I would consider a bier block. And because this is not a lengthy procedure, it's not a big incision procedure. But I would consider a bier block I would consider a supraclavicular block, which I use a lot. And I would certainly consider a general but it wouldn't be a local only for me. What about you?
So I kind of was clued in on doing more lacertus pronator decompressions when I visited Elizabeth Hagert in I think it was 2016 in Stockholm. And you know, she had a practice where she was doing these in essentially a procedure room under local and seeing her results. It was really impressive. You know, we were talking about the resistance, you know, extrinsic median testing, seeing on the table improvement. Now, I don't know how much of that was a parlor trick. And I actually tried to
examine them myself. And I think she was right. And I have that I have had, I think there was one trainee, I think it was Sobel, Andrew Sobel, who was with me, and I did this, like we had him test the patient beforehand, test the patient after the FDS arch decompression, and he was blown away like he was sold, or whoever the trainee was, but it doesn't happen like that that
often. And I used to do a lot of these under local but what I've realized in our in our patient population who tend to have a healthier subcutaneous envelope, to put it politely, more obese patients. It's challenging to do these under local for the reasons you stated. It's a
deeper dissection. And one difference, I think, and maybe I'm misremembering what Elizabeth taught me, but she did not routinely visualize the median nerve every time she would find the lacertus would release the lacertus and call it a day. There were times where she would check them and examine them and then perhaps release the FDS arch if they still had some weakness. But I think my personal philosophy is, you know, I'm there to decompress the median nerve, I want to see
the median nerve. And sometimes that can be a little more difficult with patients under local not impossible, but a little more difficult.
I think that's well said. And for me, just to be blunt, and we have been jabbering on now for quite a while. I make a three ish centimeter incision from the antecubital crease distally I think you can subcutaneously get a great exposure proximally if you need it. I release a lacertus, I examine the nerve as it passes between the two heads of the pronator and I trace it down toward the FDS arch and release that fascicle leading edge as as needed and and it is
it is needed every time. And so I do all three of those things even though I don't necessarily believe the lacertus is contributing, but those are the three areas I check for, in addition to palpating more proximally.
And after, after I release that FDS arch, I will continue to trace the nerve distally. And usually it's with a close tenotomy scissor, and just palpating that course of the nerve and making sure that it's not tight, and I typically am able to put my finger in there. And, you know, make sure that it's not tight as the nerve progresses into the mid portion
of the forearm. So even through, you know, a relatively small incision, you can do a lot of work and ensure you know, do it safely, obviously, and ensure that everything is decompressed. You know, I'm like you I use a little incision, that's probably you know, is the most proximal part is just distal to the antecubital fossa, it's a little s shaped incision, and kind of matches the course of that
flexor pronator radial edge. And this one can sometimes be a little tricky in terms of finding the median nerve, because I find that it's, it's sometimes hiding in plain sight. And if you're off just a click with your dissection in terms of the plane that you're coming down, it can be a little harder because it's so weird, because you're so used to looking at it, for example, during an ulnar nerve transposition from the medial side and looking kind of
over the top. And it almost shows itself immediately to you. This one can kind of be hiding in plain sight. And you know, it just takes a little longer you want to make sure obviously, you see you get it out safely.
Absolutely. And you have to make sure those big veins there are not your Nemesis and they will be your nemesis, likely, but keeping those intact is helpful. I do one thing I do like about this procedure in a way that I also like a radial tunnel decompression is the recovery is remarkably fast. And by recovery, I mean, the recovery from the surgery, patients bounce back really quickly, the wounds heal well. I use a bulky soft dressing, let them start using their hand right away.
When I see them at two weeks, I often don't see them again, unless we just need another follow up because we need more time.
Yeah, bulky, soft dressing for me down to five days, sometimes earlier depending on the calendar. And you know, I have had, I think probably one or two hematomas that have come about. So that's one thing that you always got to look out for, especially if you are using a tourniquet if the patient's asleep. But in a slender patient with a low BMI,
I will do it awake. You know, just obviously, it's one of those things where you tell the trainee, this is where technique is paramount, because awake surgery can be unforgiving in terms of how the patients perceive things. So this is really minimizing the big spreads being very locked in and technically precise the entire time. Not that you aren't during any of this surgery, but you can get away with bigger spreads when the patient's asleep.
I think that's an excellent point I did four local only procedures yesterday they were in the OR but four which was a lot for me. And it you're right when you especially when you're working on a nerve, those big spread dissections, which I favor at times are a common no go with a local only because you ding that nerve once. Even if they don't, you know even if they're anesthetic to things, they feel it.
Yeah, you know, part of part of wide awake, which I think some people don't like is the showmanship aspect of it, you kind of have to be on every cylinder, right? So you've got to lead the OR, you got to do the surgery or take a trainee
through the surgery. And you have to essentially entertain the patient, or hope that the person up top who's monitoring the patient, if you have that is also doing it and that's the biggest lesson I took from one of the biggest lessons I took from our brief stint of doing these in the office alone was that I just had to do more. It's like more mental bandwidth to do the entertaining part of it too.
I think you're right. And we know you're a showman Dr. Dy, but it is, it's harder work for sure. It really is. For sure.
Well, on that note, I think we have brought pronator syndrome, lacertus syndrome, FDS arch syndrome to a close. We haven't even talked about AIN syndrome, which is an entirely different topic.
Oh god, I thought we were done.
We'll leave that for the next nerve related potpourri day, so.
Fantastic.
Have a wonderful day, Chuck.
Good to see you, Chris. Thank you.
Take care. Bye.
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 handpodcast@gmail.com.
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