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 well, beautiful day in St. Louis. I know that we keep saying this on every episode. But it is unseasonably warm here.
It is one of those days. That is - simply spectacular. And I don't I know we don't want to talk potentially divisive politics. But we're recording this on November 7, and there was news this morning.
Really?
A little bit, a little bit.
Yeah, there were there are some breaking news, you know, something that was probably a few days in the making. Some would say longer. But
yeah, it might be interesting, not today, might be interesting to talk about maybe even with an invited guest talk about some of the implications of a Biden presidency on medicine. You know, we certainly have there is there are multiple topics to discuss regarding nuts and bolts, including potential cuts in our reimbursement, the change in clinic, or, you know, clinic visit coding, there's lots of things we can talk about like
that. Not the most exciting of topics, but we probably should delve into at least the potential implications of a Biden presidency.
And I think that it will differ for some of the health policy related issues based on how the senate turns out, because the presidency of a Biden, or the agenda of a Biden presidency may look very different based on whether the democrats have control of both chambers of Congress.
That is well said, and I know you are a health policy lover, so yeah, let's see what kind of what what pans out looks like, we're gonna be waiting till January to truly understand the makeup of the Senate. But It could be fun, I would look forward to that.
And it'll be interesting to see what what both sides of Congress tried to sneak in in a lame duck session, potentially in the next couple of weeks. So that may be somewhere where you'll see some activity. But, you know, I honestly think the pandemic should be the priority. But you know, our views are probably different than some of those in DC.
Yeah. Well, let's hope so. I mean, here in St. Louis, we have stopped allowing elective inpatient surgery scheduling, thankfully, we're still allowed urgent surgeries, and we're still allowed outpatient surgeries, but things are really bad in St. Louis right now.
Yeah, and I think that's being borne out in a lot of parts of the country, unfortunately, hopefully, we'll be able to get our act together. I know that we do have some listeners from overseas, who are probably looking at us saying what the heck is going on in the States? So
It's true, but we are certainly not alone. There are many countries and some are, you know, I think I eye enviously, those who are taking this more seriously, but, you know, we're not alone in struggling. I'm not defending the policies of this administration. But we are not alone.
Yes, yes. hearing the news of what's going on in, you know, in Europe is, it's sobering. Yeah. So on a lighter note,
yeah. Sorry. Sorry, we should just apologize and move on.
Wow. So you started off with American politics and then segwayed into the pandemic, way to go Chuck way to set the stage for a breezy podcast episode
well, for all four of you who are still listening, we'll move on.
Well, so we had a we had a great review, we're always thankful and appreciative for the reviews that our listeners leave. And this one was left a couple of weeks ago on iTunes by Court WSHR1 fantastic five star review. Thank you for that. And it says Chris and Chuck are soothing, relaxed and engaging. Glad I found this podcast and I've added it to my regular rotation. Thank you. So we have a cool feature, a listener grab
bag. So for anybody that is listening and wants to send some questions, either a follow up from a prior episode, or just a random question, you can send us an email at hand podcast@gmail.com. And this question comes from Sina Babazadeh. I hope I pronounced that somewhat correctly. A surgeon in Melbourne, Australia. So Sina is asking, is your treatment algorithm the same for both iatrorogenic and idiopathic cases of Kienbock's disease?
This was a follow up from the Steve Moran episode, or do you tackle the iatrogenic ones differently? So Chuck, what do you think?
I don't think my approach would differ. Certainly, if I recognized that I was the cause in whatever form or fashion, it does make me I think naturally feel more pressure and perhaps an inclination to treat more aggressively. But in theory, my principles would hold. If the lunate is avascular, but has maintained its shape and hasn't collapsed. I would treat it with a immobilization first. And if that failed, then I would treat it with a vascularizing
procedure. Because I don't think my principles would change even though I'd feel differently about it. How about you
I think that all roads will lead and you know, will ultimately unite here, and I agree, I wouldn't change the treatment algorithm. Clearly your discussion with the patient's a little bit different. And honestly, I, you know, one of our other listeners and colleagues, Rob Gray from Chicago, pointed this out on Twitter, perhaps with the hypercoagulability that's being seen with with COVID manifestations, perhaps we're gonna see a rush of Kienbock's disease that comes up down the
line. But I agree if the shape of the lunate hasn't changed, I'm not doing anything differently. Now, admittedly, I'm not one of those fancy scope guys like you. So my algorithm is a little more straightforward and a little a little less sophisticated. Perhaps I don't do the microsurgery of the joint as you do.
A lot less sophisticated. I guess I would say without the scope involved.
It's a good thing I have partners.
So we're on the same page. That's perfect. I would ask, before we turn to the most exciting two minutes of this discussion, which is our listener survey plug. I want to read a message from a partner. I've done this before qx MD. And this is the brief message This podcast is sponsored against sponsor implies sharing of Monetary Funds, which is not going on but that's okay. This podcast is sponsored by our
partner to qxMD. qxMD builds mobile solutions that drive evidence based medicine and clinical practice, check out Read, that is the read app, for easy access to research personalized for you. And also Calculate, which is another app, for over 500 easy to use decision support tools. So qxMD.com so and I'll be serious about this, and then let's move
on I don't want to belabor it. I am still using the Read app and I find it I find it helpful, it does help me peruse certain topics and certain journals in a really easy fashion. So I don't want to belabor it, but just wanted to share that.
Well, thank you to QX MD for, for helping to promote our podcast. And if anybody's listening and wants to support the podcast we'll certainly listen to it. I know we've talked before about conflicts of interest in the past. And that's obviously a concern for for us both. But you know, we'll listen. So we have been doing
this listener survey. And if anybody would like to help us out, we're trying to figure out how to engage those of you that have been kind enough to listen to the podcast, we love doing this. And then it makes it more fun when we know what what everybody wants out of the podcast. So if you will look on social and follow us on Twitter, it's @handpodcast, there'll be links to the listener survey. And you can also find that on our podcast website, theupperhandpodcast.wustl.edu.
And also on that website, you can find a link to a new feature that we've been doing some Journal Club content. So we've been posting the recap of the WashU hand fellowship Journal Club every month. So Chuck, and I kind of talk about the three articles that we review that morning, and kind of give our quick takes on what the articles mean, both, you know, from a methodological perspective and potentially in the greater context. So please check that out that YouTube channel is out
there. And it'd be great if anybody has any feedback about the journal articles too.
Perfect. So why don't if it's okay with you, I will summarize some of the early and I'm underlining and highlighting the word early survey results. So you know, it's interesting, our podcast, what the right word is publisher gives us basically weekly updates on our listenership. And so right now we get well over 1000, well over 1000 downloads a week, but they they try to quantify what we can expect and how many listeners we have for each podcast. And we're about
900 for each episode now. And again, the beautiful thing for Chris and I is that number continues to rise week over week and so we're grateful for those of you who are sharing. Now the disappointing part
So you're if you're if you're on the WashU promotions committee and you want to help get me promoted to associate professor. Just make sure that you account for the social media and podcasts that's in the promotions and tenure process.
You know, that is such an interesting topic, and we definitely should discuss that at some point. Definitely the concept of social media and influence that can be provided. But anyways, back on back on target. So we have 32 of 865 regular listeners who took the time and we are so grateful for those 32 of you to fill out the survey, I'm a little disappointed to say that requests for more nerve topics does outweigh slightly by a hair recount possibly necessary.
It's an expensive recount, and you might end up with less votes. so careful what you ask for.
True. True. So we'll leave it we'll leave it But anyways, I think I don't want to get into the details of the survey results now. But I would like to and Chris and I both would like to do what we've been promising to do and that is send one lucky listener and one lucky one lucky survey finisher, a mug, an upper hand coffee mug. These are unbelievable, in high demand and you can't get them anywhere. Except for here.
Yeah, no, I forgot about the line outside of your basement door, trying to get. If it weren't for that COVID pandemic. they'd all be knocking down your door trying to get it
True, true. So what we thought we would do is do this live.
Why don't you I'll pick a number and then why don't you read the first part of their email address without the domain name
Perfect.
that way but but hold on before I say the number. I want everybody to potentially pull over the car. I don't want anybody freaking out that they won the coffee mug.
It's true.
The upper hand podcast is not liable for any traffic or pedestrian accidents that may occur during the live drawing of this mug and lucky number 19.
lucky number 19 is the winner. The first part of the email address is Rodesantos. Rode Santos. Congratulations. We will send you an email and asking for your physical mailing address. And we'll get that out to you.
All right, Dr. Miss Mr. Santos, congratulations. Perfect. Or de Santos, perhaps
we did have episode feedback, which I think was helpful. There was a request for more discussion on crps complex regional pain syndrome. And Chris and I completely agree. And we had talked about timing of a therapist engaged podcast regarding crps, because we know how dependent we are on our partner therapist in the treatment of crps. So that is upcoming for sure. All right, well, let's jump into the heart of our podcast today that is
distal radius fractures. And why don't we start just talking about how we think about non-op versus surgery and all that kind of stuff. So when you think about a patient who was reduced in the emergency room and sent to your clinic, what's your general protocol as far as how often you see them? When you change them from a plaster splint to a cast? How do you think about all that?
Um, you know, I tend to think about it in terms of whether the fracture is stable or not, you know, whether it's a fracture that has a risk of displacement. And then the second thing that I think about the other big question is, will this patient tolerate, you know, inevitably, what might become a malunion? And I think that there are a lot of contributors to that second question. And that's when you have to really get to
know the patient. But if somebody comes in reduced, I typically will leave them in their post reduction splint provided that it's a reasonable, reasonable alignment, and I'll get an X ray or a fluoroscan to confirm that and then I would probably depending on how far out they are. See them back in a week? How about you?
Yeah, I think that's really well said, the whole thing. So I typically see them ideally at one week, two weeks, three weeks, and then get them out of immobilization at five weeks. So I tend to leave them in their reduction plaster splint for three weeks, and then I take it out, and then I get a c-arm and then I put them in a fiber gap fiberglass cast. And I know that's a little debatable, as I recall, you get them out of the reduction immobilization at two weeks, is that right?
Well, you know, I'll immobilize them, but you know, typically, they're coming in in some kind of sugar tong type splint that goes above the elbow to control the forearm. And what I would usually do is have our cast room Tech's cut down the above elbow parts, so it's essentially becomes a volar slab and a dorsal slab at one week and overwrap that with cast material, with fiberglass cast material, essentially converting it into a short arm cast. And that'll happen at the first
visit. And then I'll see them back a week later, get x rays in in that hybrid cast, and if it's holding steady there, I'll have them switch out to a formal cast because I don't think that, you know that small period of time where you're switching from the hybrid splint cast to a cast, a formal cast is going to lead to any displacement. And I think it's lighter and more convenient for patients.
So you think you can get them to two weeks, the fracture is sticky enough and it's safe save time. And then there's no doubt that patients like that transition. And getting out of the heavy plaster, the uncomfortable plaster into fiberglass is a game changer. I just I don't know that I've been burned in changing before three weeks. But that's my protocol. And maybe I should think about moving it up a bit.
Now certainly nobody would fault you for that. I mean, you know, that's the classic tried and true protocol. Seeing them back every week, for the first three weeks and keeping them in their post reduction immobilization. That's, you know, for anybody that's a trainee that's listening, that is the classic way of doing it. I do get, I have deviated from that because of the reasons you stated in
terms of patient comfort. And you know, there are some reasonable studies showing that if it hasn't displaced by two weeks, that probably is the point where it's going to be reasonably maintain alignment.
I as you mentioned, to start, and we'll get into some of the details here. For me, the most challenging situation I have is when you see and so what I always do when a patient comes in is first of all, I try to look at the injury radiographs and the reduction radiographs because I think you learn a lot and then I obtain new typically c-arms, but sometimes plain radiographs, at that one week visit. So one week post injury
post reduction visit. And the worst thing for me is when it looks pretty darn good in the ER after reduction, slightly worse at week one. And they come back at week two or week three, and it's just slowly gotten worse it's that, you know, we that is the physician and the patient invest in non operative care. And this slow progression of worsening is really tough to deal with.
And that's and I think I agree with the heartache that comes with that, and I've gone through it. And I think that's why it's so important to frame the discussion early on that, you know, we may change treatment options, you know, based on what it looks like, you know, when you come back, and then admitting to yourself when it is displacing because that's also a hard thing to do. Because you know, the patient doesn't, you know as already said, they
don't want surgery. But study after study, and we'll go into this in more detail have demonstrated that the advantage of surgery in many of these cases is the earlier, earlier mobilization. So as if you follow a patient for two or three weeks, you're really eating into that advantage that
they may have gotten. One question I wanted to ask you is what about the patient with a displaced fracture who comes in a day or two later, and hasn't had a closed reduction because they went to an urgent care center where they don't do that, or because they went to an ER facility where they where they don't do closed reductions, which I think is becoming more and more common as urgent care facilities have become more prevalent in the States.
Yeah, it's so true, there is a role for urgent cares, and I do have urgent cares that share patients with me. So I'm grateful for that. But it's an opportunity lost if the patient doesn't have a reduction when that patient would have benefited. And you know, worse than not doing it is what I think happens is sometimes the patient is quote unquote, reduced while the cast is being put on and I've talked to my team, and that's not a
reduction. So in other words, if a patient comes in and they haven't been reduced, then I take off whatever splint they're in for new x rays and exam, if they had been reduced, the team is under instruction, don't touch the splint. But then sometimes you get these urgent care patients and we're picking on urgent cares a little bit but you get to urgent care patients. The patient says yah well when they put the splint on they reduced me. And to me that's
total total nonsense. And I'm my guess is that that urgent care is billing for that reduction, which is non existent and is very frustrating for me to hear. So sorry, a little bit of a soapbox, I'll circle back to where we started, which is if a patient has a fracture, which would benefit from a closed reduction, how long will I you know, at what interval will I consider it. I will consider it at 48 hours, maybe even a little
longer. But ideally it's 24 hours because I think I can do a pretty painless hematoma block and relatively comfortably obtain a reduction in the right patient. So that's my general strategy. What about you?
Yeah, I think closed reduction in the office is right patient at the right time. You know, and I agree probably 24 hours is my window as well. I think you know, we I tend to be a little more lenient with things now, especially with COVID. I don't want to send a patient to the ER if I think I can get a reasonable reduction. But you know, in the office, we don't have access to anything but lidocaine, so we don't have
any oral pain medication. We clearly don't have any access to sedation or anything like that. So you got to feel pretty good about your ability to perform this reduction. And then there are the practical considerations about honestly the rest of your clinic. So if sometimes if they're okay with waiting a little bit longer, I know if I know I have a space at the end of my day, I may just do it then
Yeah, really, I totally agree with everything you said the adolescent patient is always a very interesting conversation, whether it's distal radius or whatever, where you have to have buy in from the families. But in that classic distal radius fracture, it takes a patient who really wants to stay out of the operating room, and time and ability to make it happen. So I think it's a it's a, it's a really important point. And I think an ability to give a good hematoma block is obviously critical.
So when you're looking at those pre injury radiographs, and even the post reduction radiographs, how do you make the decision about what you think is going to be stable and hold?
You know, so for me, and I think for most of us, the initial displacement tells me so much, because if that is severe, then I immediately I'm worried that whatever reduction no matter how wonderful was obtained in the emergency department that's at risk. But you know, classically, the La Fontaine criteria were have been quoted over many years. I think that was 1989. It was a relatively small study from Brussels, around 100 patients. And those criteria are
completely reasonable. They've stood the test of time now people have nitpicked at the La Fontaine criteria for an unstable fracture. Maybe we should go through them. But I think those are the basics and you can quibble with them. But those are the basics. How do you how do you think about it,
I also use them as a framework. So for the listener that may not be familiar with the La Fontaine criteria. It's a lot of the same stuff we classically talk about in orthopedics for radius fractures, but it's dorsal angulation, more than 20
degrees. Combination of that metaphyseal cortex dorsally, greater than 50%, or potentially some combination towards the joint, or the volar surface, initial displacement more than a millimeter or excuse me a centimeter shortening on the radial side of greater than five millimeters and associated ulnar fracture, it's not clear whether that's a styloid, or a neck fracture, and severe osteoporosis. So our ability to judge severe osteoporosis on a
plain film is quite limited. But I like to take some things from there. And then also, I think, another one that is typically included, I'm not sure if LaFontaine did it himself, or somebody else added it, is age. And having three or more of those factors tends to be a risk factor for loss of reduction at follow up.
Yeah, I think thanks for sharing those, I totally agree. And again, that you can't quibble with these criteria. And lots of people over the years have tried to optimize or improve, I don't know that we can do much better. It's been shown that radial shortening and dorsal combination are perhaps most associated with displacement. And others have suggested the ulna fracture, whether that be distal ulna, or styloid, are not associated. But it's impossible to quibble with those criteria.
And I think they're helpful, but like everything, and you mentioned age, everything is age dependent. I think, you know, when volar plates, and we're going to spend some time in our next next episode talking about volar plating. When volar plates first came out, the pendulum swung so far, so fast towards everybody getting a volar plate, that it was clearly too far. Now we've swung back recognizing what Colle said many, many years ago that many patients even with displacement do fine. So it's
hard. It's tough.
Yeah, I agree that many patients with displacement will do fine. But it's mainly I think these criteria are helpful in counseling patients. So saying, you know, A, you know, this has a x, you know, chance of displacing, or I think it's going to hold or I don't think it's going to hold based on the way it looks on this x ray. And what will be the implications, if it, you know, heals in this
malunited position. And some of these markers like the dorsal angulation, you know, have been demonstrated to have a negative impact on objective measures like grip strength, as well as patient reported outcomes like the dash. And one thing that I like to look at on the lateral film is whether the capitate is centered over the radial shaft
extended the radial axis. And that's been described by McQueen's group as well as examined by other groups, looking at the relevance of that, but that I think, is a good way of knowing is the carpus aligned over the forearm? And is this something that is going to be bothersome malunion? Obviously, study after study has shown that with increased age, you can tolerate more patients tolerate more.
Demand is typically less and, and patients accept more. So I guess when we think about it, I'm thinking on my feet here, I haven't really said this before, but there's really three things here, right? One is radiographic appearance. And that's where you and I may get excited, but maybe inappropriately so. The next is functional outcomes, and how that's associated with radiographic appearance is up to debate and you know, that's what
the literature's for. And the third thing is just what a patient wants, which is the trickiest of all, because that is, you know, we have to develop that patient relationship to understand. And so for me most practically, you know, we classically think about the Colle's fracture with that dinner fork deformity. And we know that deformity is well accepted by most patients, if they understand it. And when I say well accepted, I mean, well accepted functionally, we also have to make sure it's well
accepted aesthetically. But for me, the bigger one is the loss of radial inclination, which creates a bit of a radial club hand type appearance that some patients are fine with, and some patients absolutely hate.
Yeah, when they, you know, when, when we go through that initial discussion, I tell them, look at the way your wrist looks, now, some of the swelling is going to go down, but that bump, meaning the dorsal prominence of the radius, and then that bump, the increased prominence of the ulnar head, that's going to be the same, your wrist is going to look like that. And most people are accepting of it, if you get ahead of it, and tell them that ahead of time. But there are some people who say, I don't
like the way it looks. And you know, that loss of radial inclination. A lot of people don't like that. And that is one reason why patients sometimes choose to move forward with surgery. You know, I think that in terms of the, in terms of the
patient demand. You know, one way that, you know, I like to describe this to patients, and I'm not, I'm known for having very poor analogies, but this one seems to work is that, you know, treatment with a cast or immobilization versus surgery for distal radius fracture, we know that at a year, you're probably going to end up in the same place for many of these fracture patterns. But do you want to take the elevator, surgery? Or do you want to take
the stairs? Because you're going to get the advantage early on with surgery?
Well it's, it's definitely a good analogy and even weirder
For once, for once I have a good analogy
even within the surgical realm. I mean, the differences between, say, a closed reduction and pinning versus a volar plate, gets you there. And that difference is probably a little less than the non operative versus the volar plate. I think it's a good analogy. It's tricky, because patients often actually I was talking to a patient last night at 6pm, believe it or not, I'd seen him last week and they wanted to discuss something a
little further. And it was kind of right in that perfect sweet spot for me as far as I had a few minutes. And they ended the conversation with what would you do if this was you or your family. And that's tricky for these fractures, because your needs and my needs. And my 65 year old retired patient needs
are all very different. But I struggle, because as soon as we tell a patient that if we take to the operating room, and if we put a volar plate on, I'm going to have you see therapy the next week and start moving their eyes light up, because they're starting to process that wow, you mean I don't have to be in a cast for five weeks. But for me, that's not always a surgical indication. It's a surgical benefit, but not an indication. So I struggle with how to make patients aware of that benefit.
Because while it may, I may be talking in circles, but while it may be a good reason to think about surgery for a surgeon because he or she may need to get, may need to get back to the operating room, he himself or herself very quickly, for another patient. That's not a reason to do surgery, I don't think.
Yeah, I mean, I think that the I agree with you on that, I'd say that it's not an indication, but if you have a fracture that you know, radiographically is, you know, displaced and at high risk for instability. And you are able to provide that benefit. I think it influences the decision making calculus, because you should you have to share that with the patient. You, I think clearly, you know, we as surgeons can frame things, however we would like, can clearly influence
patients' opinions. And I think that's the hard part, especially if you know, for those of you that are trainees and coming out I mean, you'll realize you can steer people wherever you want to steer them for better or worse. And you have to have, you know, both the surgery person on your shoulder and like the non-op person on your shoulder kind of say, you need to tell him about both sides and what you know, this term is going to be loaded and I say it but the fair and balanced perspective.
Yeah, for sure. I guess I would say in a patient where I believe surgery is the right move. And I don't you know, you and I have talked a lot about this. I generally counsel patients to help them make a decision but sometimes the patient wants you or I to make, help them make that decision or simply to make that decision for them. And for that patient where I think surgery is the right move and the patient is not quite convinced. I will say that early motion is a huge
selling point as it should be. I mean your life post-surgically is completely altered in that first six week timeframe. It is so much easier to shower at five days to get a brace at five days and start gentle motion. And the concept of working on your motion while your fractures healing, rather than letting your fracture heal completely, and then starting motion is something that every patient can wrap their brain around.
Yeah, and I think that, um, you know, with, with surgery, and I think it's important to inform them about the risks of potentially of the complications, obviously. And I think one of the things that we talked about is risk to flexor tendons and irritation from the flexor tendons. How often do you, what do you quote patients in terms of second surgery for removal of the implant?
I think, right, so when we're talking about surgery, you know, I really honestly believe that for me, a volar approach to the distal radius, and a well placed plate is really a low risk intervention. And so the actual technical surgical risk are really low. I quote, infection rate, at least from our center of about one in 300. And I think other risks to tendons or nerves, etc, at the time of surgery are incredibly small. And so I do talk about
stiffness. And I do talk about the potential need to remove a plate and the risk of plate irritation of tendons, whether the plate is irritating them volarly, or potentially a technical issue leading to dorsal tendon irritation postoperatively, I quote patients between one in 10 and one in 20 plates needing to be removed, whether I know that at the time of surgery, or we figure that out later. What do you tell patients?
I say one in 20, but I also tell them that there are case reports of flexor tendon irritation and rupture, you know, 5-10 years after initial volar plate placement, which is the kind of scary part about it. You know, I think that, you know, as you mentioned earlier, the indications for volar plating have changed the, you know, the pendulum swings a lot. I think we sweat, settled into a
sweet spot. But you know, there were many, there are many cases where, you know, these plates were just being quote thrown in. And I think if they're used in a haphazard or slapstick fashion, it can be a problem. I mean, a volar plate is not a panacea, a volar plate is a tool, and you got to use it well, and you got to know what what you can get out of the plate, you can't use rely on the plate too much for for reduction, because when you do that, that's when it leads to
a prominent plate. And I think we'll get into that in a little more detail when we do our episode on the technical aspects of the surgery. But that's one thing where I tell people, you know, the plate may irritate the tendons way down the line. And we'll just have to hope that it doesn't. And I'll do everything in my power to put that plate in a location where it is really minimal risk for the flexor tendons.
Yeah, again, well said. The, we're gonna, we're going to have an episode on distal radius fractures and the role of therapy, because I think that is something that just is really not as straightforward as it may seem, but does every patient of yours that has a distal radius fracture, whether treated surgically or non surgically, does pretty much every patient see therapy at least once?
Mmm, you know I think it kind of it's, if they have surgery, yes. If they don't have surgery, it's dependent. Honestly, COVID has changed clinic flows a little bit, you know, we've gotten our hand therapist followers back in the clinic. And that has helped because when they are back in the clinic, I can have them see the patient who has just come out of the cast and show them
some exercises. You know, I can do that to a certain extent, but I don't have the expertise that our therapists colleagues have. But when they're not in the clinic with us, I typically do send them up for one visit, if I feel like they're not going to do it on their own. An important caveat is that patient who you are treating non operatively.
And they come back, and they've just got sausage fingers, and you see, you know, signals and red flags right away for that crps type patient, like we talked about a couple of weeks ago, that's the patient that goes to therapy right away. How about you?
Yeah, I think Well, I was gonna say something different. But I want to circle back to what you just said, when I see a patient in the clinic. And let's say they're one week out from a treatment in the emergency room with a closed reduction, and that patient is having trouble getting finger motion back. Because really, if the patient comes in at one week, and their finger motion's perfect, and I'm not assessing wrist or forearm, right, because they're immobilized, but that
finger motion is perfect. I feel good. However, if they are just doing that little tiny flex extension move, it makes me nervous immediately. And I almost turn into a jerk. And I really kind of read them the riot act about it's incredibly important that you own this, and you have to be working on not just moving the fingers. I think that's important where our instructions have to be literal. It's not just moving the
fingers. It's making a full fist and fully straightening your fingers because to me, that is a huge warning sign for a less than optimal outcome.
Yeah, I tell them they should be touching the cast. You know, I think that that's one thing that they understand. And I think that you bring up a good point as one thing that probably steers me to surgery in some patients. As surgeons, we like predictable. We like reliable. I know what what's going to happen typically after volar plating. There are more wildcards, although it is still somewhat predictable with non operative or cast management for distal
radius fractures. And in certain patients and in certain patient physician relationships, you want that reliability. Because sometimes they're, they're going to have a hard time accepting uncertainty. And sometimes I do
I think you're right. And again, it's about too. reading the patient, understanding what he or she most prioritizes. And while you know, fracture work, in some respects is easier in the clinic than a vague wrist pain patient, there's still intricacies to trying to get the information you need, in a time efficient fashion from that patient to best help them because every patient, three or four different patients may have the same fracture, and you may treat them slightly differently based on
the needs of the patient. And that's that's an art that gets to the art of medicine and and how do you develop that patient relationship and get the information out of them that you need.
Yeah, a few a few comments, as we come to a close here for what you just said, that's one of the things I tell the trainees at the beginning of the rotation. I was like, I will tell you what the board answer s when we walk out of the room, nd then I will tell you why I am deviating from the board answer because there are reasons why. And it's not always because we like to do surgery, you know, there are important things that
come in play. And one of the things that you've mentioned before is you know, people need to work. You know, and I think that sometimes, you know, especially in the COVID era, you know, if you can get somebody back to work a few months earlier, that's going to be incredibly beneficial for them. And then the last thing I would say is that, you know, many of our listeners know this, but volar plate is but one option to treat a distal radius fracture
surgically. And there are specific fractures that we will talk about in a future episode where we go either dorsal or we use fragment specific type strategies. So do you have anything to add as we close out?
Yeah, we talked about the generally widely accepted criteria, and those are important. And we could spend hours talking about those, the one fracture that gets the most has gotten the most attention over the last year or two is that volar, ulnar corner fracture, and I think both of us recognize that that is a fracture that needs to be treated surgically, and with great care. So that is something that I would add to that surgical indications or surgical
instability issue. The other one, which we didn't really hit on was intra-articular displacement, whether that's a die-punch fragment, whether it's a gap of two or more millimeters or worse than a gap, whether it's a step in the articular surface, those are all super important things. And again, we'll hit on those again, in the future, I guess I would say one of the things that has served me well, is how I counsel patients about recovery. And I say two
things to every patient. First, I say expect a year, expect a year to get as good as you're going to be now at six months or even at four months, you're gonna be pretty darn good. But you will continue to improve as far as motion and strength and overall satisfaction with this injury, whether surgical or non surgical, up to a year. So that's one point I stress from day one. And I've been super
happy to have done that. The other point I stress is that the pain on the thumb side of the wrist, ie the distal radius fracture will go away. And that'll go away at six weeks ish. The ulnar sided pain persists for much longer. And I stress that as well and those two points, simplistic as they are, and everyone's probably rolling their eyes like yeah, obviously, those have served me really well with patient education.
One other, I agree 100%, one other thing that I drop in mainly because of my bias is that with these really bad expected malunions, you know, with a lot of dorsal placement, I do counsel them about the risk of carpal tunnel
syndrome down the line. And that is a much easier thing to deal with, obviously a carpal tunnel release as opposed to a fracture surgery that can be done under local etc. But if you look in some of the tables, on some papers, you can find some reasonable, you know, incidence data and it tends to be around 15 to 20% with these, with these expected malunions. So that's just something to keep in mind.
Because if you don't tell them they may wonder why you know why they have this numbness and tingling three or six months down the line.
That's perfect. And you know, like everything with Chris it, the bony structures exists to support our nerves. And so that is a great topic to end on nerve surgery in the setting of distal radius fractures.
You're welcome, mister "I wrote all the crps articles on distal radius fractures."
All right, I know you are in hospital and you are working. So thanks for joining me this morning and have a good day.
All right take care. Bye 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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