Welcome to the Upper Hand, where Chuck and Chris talk hand surgery.
Chris Dy :We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
Charles Goldfarb :Thank you for subscribing. Wherever you get your podcast
Chris Dy :Be sure to leave a review that helps us get the word out.
Charles Goldfarb :Oh, hey, Chris.
Chris Dy :Hey, Chuck. Good morning.
Charles Goldfarb :Good morning. It is early in St. Louis.
Chris Dy :It's early but these are the best times to do it.
Charles Goldfarb :It is true we are at work so family is not a factor and this is a little before the day starts so we got a lot to cover. We should probably jump right into it.
Chris Dy :Yeah, absolutely. I'm looking forward to today's death by zoom. I've got three hands society presentation, sir corn today,
Charles Goldfarb :nice.
Unknown Speaker :So I'm glad to kick it off with the
Charles Goldfarb :Perfect. All right. Well, our topic today is radial sided wrist pain. We do really have a lot to cover. It's not a topic. You know, it's always interesting at Hand Society meetings and in other places, there's a lot of conversation about ullnar sided wrist pain, and you and I've covered that, more than you may have liked.
Chris Dy :Definitely more than I would have liked
Charles Goldfarb :Radial sided wrist pain is the stepsister that doesn't get much play. But yet, it's, you know, pretty darn common.
Chris Dy :But I think that, you know, while there are some nebulous conditions that fall into this category, there are some where you can really help people in a much more standardized way than ulnar side pain. But before we dive in, why don't we do what we've been doing the last few episodes and want you to take a stab at reading a review for us?
Charles Goldfarb :Yeah, so again, we are grateful for commentary, reviews, questions, suggestions, anything but here's a nice review from Drew, 'I am very grateful to have found this podcast. I'm an occupational therapist and a certified hand therapist. I appreciate the intricacies of the surgical interventions and the examinations discussed here. I have definitely been able to advance aspects of my care based on this podcast. It's great'. So nice.
Chris Dy :That's fantastic. You know, thank you Drew for the feedback. I'm glad you found us. I gave a talk to a group of hand therapists last week. And it was great, just speaking very candidly about our areas of overlap and how we can help each other and I always find doing those sessions to be incredibly helpful in so many ways.
Charles Goldfarb :What was- I hesitate to ask- but what was your recent and therapy session on? What did you discuss
Chris Dy :Everything median nerve, everything from carpal tunnel to revision carpal tunnel to proximal compression after a prior carpal tunnel release, double crush, median nerve trauma treated with median nerve trauma treated with tendon transfers median nerve trauma treated with a nerve transfer so it was a tour of the median nerve and it was all case based which was a lot of fun just to showcases and fortunately I've been able to be in practice now long enough to accumulate videos and all that stuff to show outcomes on top of you know the really neat surgery pics that I take probably way too much time to to accumulate.
Charles Goldfarb :So yeah, I did a recent case based learning with a group of therapists here in St. Louis as well. It was also super fun. And we talked about a far more interesting topic Dupuytrens disease and I'm sure the listeners will agree with me and not you.
Chris Dy :Yeah, that's that's one where we like to spend a lot of money now, apparently. So that's that for the next set of episodes.
Charles Goldfarb :Exactly. But what this reminds me is no matter how long you've been in practice, there is a continuous need to record what we do, whether that's still pictures or video, it just makes a talk come alive if you have at least a little video to include.
Chris Dy :Well, I mean, I think that when you're in my residency, I had to make a lot of presentations and a lot of PowerPoints and, in residency in early in practice, I feel like it was more about the literature because you just didn't have enough experience. You didn't have enough of your own cases. But then as soon as you're able to step into that role, where you know, things become yours, you can see things through, that's where you can use stories, to really give a talk as opposed to making it purely about the literature. I mean, I when I give a talk to some of the residents about this, you know, I think it's important to show what you can do. A, so you have credibility. B, because you can connect with that much better. If you're out there. Just citing everybody else's work and showing things that you haven't done. It's a lot harder to connect and land, and one really good case, one really good story, we'll do that for you.
Charles Goldfarb :Its true. You know, the other thing I struggle with you raise an interesting point is that if you read in the business literature, just the use of PowerPoint in general has become more frowned upon. And certainly, the PowerPoint slide with eight bullets and 20 font because you want to get it all on one slide is just crazily ineffective. And so, as you said if you can tell a story with minimal words, now in medicine, we have to impart some basic principles on a PowerPoint slide, but it really is so nice not to have those slides filled with letters.
Chris Dy :Occasionally I'll pull up a talk that I gave in residency you know, all see the big difference between how I construct slides then are constructed sites and and how I do it now. And like many things, you know, one of our, you know, mutual former mentors, Dr. Gelberman was probably ahead of his time on that kind of thing, because I remember, you know, while he did have slides that had a decent amount of text, he would always have these great interpretive pictures. And he would start the cases by just showing a picture. I vividly remember looking at one of his brachial plexus talks and just seeing the classic crps type picture, you know, have a hand with the betadine dripping off of it and seeing the difference in the sweat patterns, etc. And that's something that's sticks, right. So, you know, anyway, I guess I digress. But yes, this talk that I gave a couple of weeks ago, it was definitely more case based than anything else.
Charles Goldfarb :Awesome. Love it. Alright, let's jump in. So we have a 37 You giving the scenario A 30, upper you know, I don't know how old he is, but he's really good luck. You're gonna he's athletic and he has a young family. Maybe he's 37 ish and he was doing something he doesn't do enough of which is which is help around the house. He was trying to hang a couple of pictures. And it wasn't going so well. He was using that hammer a ton. And
Chris Dy :He must not use a mallet at work at all.
Charles Goldfarb :No, he does fine, fine work at his job and so he woke up the next morning, and his wrist hurt on as he said, the thumb side and he really doesn't know what's next.
Chris Dy :Well, I'm glad that he saw your care. You're really trying to seek the upper hand there. And well, let's talk about the questions to ask. So patient you know, clearly says it's on the medial side, which in my experience in practice, they don't always do they just kind of point in general to 18 different areas on the wrist. But it's good that you're able to narrow it down to the thumb side. Any numbness or tingling anything along with that?
Charles Goldfarb :Yeah, he says sorry, I should have given you a little bit more so he denies any numbness or tingling. He did buy a splint at his local drugstore and it was a wrist splint, not a thumb spica splint and he said it maybe it helped a little bit but he didn't love wearing it. In fact, he tried to tighten it a lot and that seemed to make things worse, and so no numbness it's pain especially when the wrist is moved especially when the thumb has moved. It's just not getting better. It's been been three weeks and he hasn't touched a hammer in the house since
Chris Dy :It's probably by design. I like to call the adjustment of the of the prefabricated wrist orthosis the Wartenberg strap, because it certainly creates the issues that you described. So you know for me this once I've excluded common conditions presenting in a typical ways like you know, by doing it to Tinels, etc. This boils down to point tenderness on exam and you know, within two inches of longitudinal distance on the radial side of the wrist, you've got five or six different conditions that can show up. And, again, it's all about point tenors. So what I'll typically do is to avoid going to the area where it hurts the most as we've talked about in prior podcasts. I'll start at the thumb CMC joint, even though this young strapping 37 year old, there's no way he has arthritis. I'll go to the thumb CMC joint and then just march thumb, CMC to STT to styloscaphoid, and start there.
Charles Goldfarb :Perfect, perfect. Well, let's, let's start broad. I like how you describe the point tenderness aspect. Just back up for one second. And I think we'll hit all these whether in this podcast or potentially a follow up podcast, just throw out all the things you think about, because I think you're right, we think about ulnar sided wrist pain being so intricate. And there's so many different possible pain generators. It's no different on the radial side there is so just throw some out there, though. All of that you can think about there.
Chris Dy :Yeah, so the ones I just mentioned. Thumb CMC, STT, styloscaphoid. I think SNAC and SLAC can fall into that category of you know, radial sided wrist pain, although they do present a little differently FCR tendonitis, volar SL injuries, as you've taught me, occult volar ganglion cysts, intersection intersection syndrome de Quergains , and then Wartenberg. paraesthesia kind of situation. Did I miss anything professor?
Charles Goldfarb :I thank you got it, I mean I guess you could theoretically have a second compartment not an intersection syndrome but a second compartment tenosynovitis but know that that that
Chris Dy :Oh lets not forget LABC neuritis for all of our nerve fans out here. That is incredibly common, but has happened
Charles Goldfarb :it's true. Now you got to think about it. You just hope you don't see it. Got to think about me. What a terrible diagnosis that one is.
Chris Dy :I'm sure Dr. Goldfarb it's seen you but you have turned
Charles Goldfarb :Turned the other cheek. Yeah, you know
Chris Dy :I know a guy.
Charles Goldfarb :Alright, so let's say for this, you know, fascinating case we're discussing that the pain localizes over the first compartment, and you're thinking this is de Quervains means I was taught, I'll just cut to the chase, because I don't know that we want to belabor de Quervains for listeners too much. I was taught by Peter Stern, there are three necessary ingredients for the diagnosis of de Quervains. The The first is localized tenderness or point tenderness. The second is visible swelling, you know, compared to the other side, and I often ask the patient sometimes, it's not obvious to me, but I will ask the patient, and the third is a positive Finkelstein test. And I think that is a great list. And of course, it's not perfect, but it's darn close to perfect and I really almost require maybe a little strong, all three to make that diagnosis.
Chris Dy :To you what is a Finkelstein's test? Because I feel like this is one of those tests, eponymous test that has been misconstrued throughout the literature and means a lot of different things and a lot of different people.
Charles Goldfarb :Yeah, I hesitate to ask because I'm ready to answer I may get it wrong. To me. I ask the patient I have them in neutral forearm rotation, I ask them to put their thumb in their palm, which usually takes about 60 seconds to get it there and, and describe - true. You could just show them
Chris Dy :Make a '4' then roll your fingers around.
Charles Goldfarb :This is my takeaway for all from today. Um, once they have accomplished that mission, I ask them to ulnarly deviate the wrist. So it's an active, patient driven process. And that's what I call the Finkelstein What do you call it?
Chris Dy :I 100% agrees I was really hoping to disagree with you, but I want 100% agree with you on that. But You know, if you watch a trainee do a Finkelstein's typically, or you ask them to describe it. For them, it is a passive maneuver. And then, you know, the work that you've done a few years ago, I think Dr. Gelberman, did this study with a couple of medical students, you know, when you put their thumb down into the palm and have them make that four position, that puts a lot of stress on the thumb CMC joint. And I think that that is one thing that you can get a little confused. Now know. Classically, those are different demographics of patients. So you have a sense and you know that the thumb CMC patient is not typically the de Quervains patient, but sometimes it overlaps, especially in the history of somebody with recent excessive overuse, maybe somebody who should have hired somebody to do things like hang pictures.
Charles Goldfarb :Absolutely, or just develop that skill set
Chris Dy :Or develop the skills of how to swing a hammer properly. I mean, maybe that's why that person became a hand surgeon.
Charles Goldfarb :That's true.
Chris Dy :Anyway, so yeah. That's that's what, that's what a Finkelstein's means to me. I agree with you. But honestly, now that I just tried to avoid stressing the thumb CMC joint. So I will have the patient actively ulnarly deviate with their thumb kind of in and outside of the palm, and then I'll passively do it too. And then that I think, helps me differentiate. So I deviate a little bit from you and Doctor Stern on that.
Charles Goldfarb :That's fair enough. And I you know, certainly we do other things, I agree with you, the patient my age, much older than this, this strapping young patient, you do have to think about both diagnoses and you know, hopefully clinically, they can be distinguished and user they can but not always in the patient that doesn't provide the best history or description of where the pain is, and that's where I personally use differential injections, but that's jumping ahead a little bit. So. Alright, so this patient has de Quervains, your positive of it. What's next? What do you offer the patient treatment wise? What's your algorithm for care?
Chris Dy :It's only been a couple of weeks, right?
Charles Goldfarb :It has been three weeks, three terrible weeks, I mean,
Chris Dy :Confined to the couch.
Charles Goldfarb :Yeah, it's not lifting a hand around the house. It's been terrible. In fact, his significant other really suggested that he be seen for this because it's getting old.
Chris Dy :Definitely can't relate to this guy. So I'd be interested in your take on this. I think I pay lip service to oral anti inflammatories. I think in my practice, I've shifted away from that especially now that a topical option is also over the counter. To me getting topical diclofenac used to involve lots of pharmacy approvals because insurance wouldn't cover it unless you specifically said that they had done over the counter and said in your note, that's become a lot easier now that topical diclofenac is over the counter. And also like the manufacturer of that now has lots of coupons for that because there's trying to push this product and then change I think even the last like six months. So I will typically ask if they've done early anti inflammatories, I'll give it a try. I switch a lot earlier to topical anti inflammatories and to me, this patient falls into two categories or, yeah, one of two categories. They either have pain that is substantial enough to warrant an injection and skipping that topical anti inflammatory, or it's just not that bad. We'll do the topical anti inflammatory and they'll get the thumb spike brace.
Charles Goldfarb :Yeah, I think that's fair. I would say the majority of patients who make the trek to the office have tried something. But I agree if it's really mild, and I had a patient like this last week, if it's really mild, if I'm going to do an anti inflammatory, whether it be topical, which I don't honestly use that often. Maybe I should be interested to hear your experience. Maybe I should do it more. But I typically use an oral anti inflammatory and a thumb spike this brace my experience has been not very good enough. The brace works when you have it on, you take it off, it stops working. And it's that simple
Chris Dy :oral anti inflammatories, your go to are you starting people with over the counter stuff? Are you going to something stronger prescription?
Charles Goldfarb :Yeah, I usually asked them to use over the counter Aleve, and double the recommended dose of one pill in the morning, one pill evening. So it ends up being, you know, almost a Naprosyn dose prescription strength, and I'd give them precautions. And I asked I you know, keep it really simple two pills in the morning to build an evening, two weeks if that bothers your stomach Stop it. And it's just a very simple message that I think people appreciate.
Chris Dy :So do you think that you know, people who prefer things like ibuprofen does that you think that matters, although it's something that comes up?
Charles Goldfarb :I don't think it matters at all. But I do think it's hard to take three pills three times a day. I mean, the literature is clear, not the orthopedic literature, but the literature is clear that people don't do it. They just don't do it. And so if you can simplify it with a one or two, you know, two times a day I just think it makes sense.
Chris Dy :Yeah. And that's that is the thing about also doing a prescription naproxen which you know, so what you're saying is two tablets over the counter and approximate which gets you to 440 milligrams in the US at least. Compared to doing just a naproxen 500 milligrams. Some people like having a prescription with a bottle on it that tells them exactly what to do and I give them that option, whether that's silly or not. Do you ever do anything stronger like a Meloxicam or somewhat toxic or anything like that?
Charles Goldfarb :I don't not for any particular reason. It's just not my algorithm. If a patient requested it specifically, I would but I don't. Do you.
Chris Dy :If they've, if we want to do orals, you know, stepping outside of just this condition, but if we want to do orals and they've tried the over the counter and approximation, and even that lower dose and approximate will typically go to Meloxicam and I use Meloxicam for every post op patient that can tolerate it you know, unless they have GI issues or you know, something like that or throwing a blood thinner to help in that effort to Help, you know narcotics and opiates, that kind of thing.
Charles Goldfarb :Great. All right, so let's say this patient has a low pain threshold the kiss of death, but you know, no one ever says that, of course. This guy--yeah, this guy says I have a really high pain threshold, but this is killing me. And I need to do something and I'm not gonna wear a splint, I'm really active and, and I can't wear a splint and I'm trying to anti inflammatories. What else you got doc?
Chris Dy :So you know, I actually, you know, honestly, I try to avoid sticking people needles the very first time I meet him, but there are I say that sort of half joking, but you know, there are certain conditions in which you think that you can pretty much hit a home run. And for me, there are two conditions, its trigger finger, and it's the de Quervains. Now for triggers, I tell them not to do anything at all until it hurts them until the trigger hurts them because otherwise it's just a cool party trick. But for requirements, I think you can make a big difference and I think the literature would bear that out. There's been some papers in the last few years from the Boston groups that have demonstrated very high success rates. and dare I say even a cure with one injection. So that's, that's where I go to next. what's what's your threshold for offering an injection?
Charles Goldfarb :I will offer an injection on the first visit. After a careful discussion. I give everyone the option of the anti inflammatory and the brace. But I don't--
Chris Dy :Do youreally sell it?
Charles Goldfarb :No, I don't because I don't think it works. I mean, I just don't think it provides what people are looking for. But you know, for certain people, that's an easy option, and they don't mind coming back and four weeks or six weeks, they're not better. Other people never want to see me again. You'd be the judge of what that means. And I think an injection for those people is a great option.
Chris Dy :I think it totally gets into reading the room. And we're the textbook isn't always right. And you know, our partner, our partner, Marty Boyer likes to talk about, you know, how things are framed. And you can, you know, as a physician, you can clearly steer the discussion, wherever you want to take it. Because they are there to see you.
Charles Goldfarb :Absolutely and I steroid injection for de Quervains is not a is not a bad injection it's not a trigger injection the pain is is much different in my experience and so I like to do it. So let me ask you this if you decide to do a steroid injection, any tips, tricks pearls too? We talk a lot about the technique for this objection whereas for trigger finger we say you know, put it anywhere near the sheath, but what do you do for a de Quervains injection?
Chris Dy :Well, so, I mean, you know, I look at the area maximal tenderness and swelling as you mentioned, and it tends to line up with anatomically where the roof of the first dorsal compartment is. And I know based on the anatomy stuff that the end or distal end of the first compartment roof is just shy of the radial styloid. So I'll basically start there, you know, aseptic technique, etc. And then I will start my injection at that area and then I typically will on the way out at the end of my injection angle a little bit dorsally to try to get into a separate sub sheath for EPB. I need to get better probably at consistently doing that, you know, metacarpal MP extension tests that the New York guys described to look at, you know, people who may have a separate sub sheath, but honestly, it doesn't really change practice. Anyway, I will give everybody that the second, you know, that second part of the injection angling out, do you do it any differently?
Charles Goldfarb :No, I think I'd do it. Similarly, I aim- is really a distal to proximal injection, not necessarily dorsal or volar to dorsal. And I try to get in the sheath with the first pass of the needle. And I absolutely try to hit the second EPB compartment. We know from the original Gelberman studies and subsequent studies that patients who do come to surgery certainly have a higher percentage of having that separate EPB compartment. And I don't know if it matters No one's ever convinced me that we, you know, either a) we can hit that compartment or b) it fundamentally changes the likelihood of this being a successful injection. But I absolutely think it's the right thing to try.
Chris Dy :Do you? I'll put you on the spot here because I get this a lot from patients do you use the cold spray the Ethyl chloride?
Charles Goldfarb :I- if a patient demands that I will do it. Otherwise I don't buy it. I don't think it's that big a deal? I don't think it is. It's just one of those things that some patients think matters. I'm not convinced it matters. So if they requested I'll do it otherwise, I don't offer. You?
Chris Dy :Same. Yeah. And I think that the experience that, you know, being in clinic with Dr. Gelberman as a trainee and seeing how he would do a separate, you know, lidocaine injection and then come back in five minutes later and do the actual steroid injection. Yes, that's ideal. But from a clinic logistics and flow perspective, it can really slow things down. And I think most patients for this per injection in particular will tolerate this really well.
Charles Goldfarb :Yeah, this funny it makes me think of a previous study, which I think was before your time. But, again, Dr. Boyer got very interested in the concept of using vibration to decrease the pain of injection. And so we went through that process with results that didn't change any of our practices. Let's leave it at that.
Chris Dy :We're working so hard on that study. I know that you
Charles Goldfarb :Absolutely. Alright, so what is your algorithm? If you give an injection and let's say they have a great result, but not here, they get six months of relief. They come back to your office, what what's the conversation at that point?
Chris Dy :I'll be honest, I'll offer a second injection. You know, the, I don't love giving too many injections- two is pretty much the most I will give curious to hear your thoughts because of that possibility of the subcutaneous atrophy in that area, which can then make surgery that much harder, should it come to that, but I'll offer them the option have surgery versus injection at that second visit if it really is six months later, but if they had a good response with the first injection got six months out of it, then I probably would steer them towards an injection. It's different to me if they had a much if they had an equally as good but much shorter response to the first injection. You know, so that says says to me that maybe it is that's, you know, second second sub sheath of EPB. that's bothering them. What do you do?
Charles Goldfarb :Yeah, absolutely could not agree more. I'll throw in the board question of the new mom or dad, typically mom, who has a six month old that comes in the office with de Quervains those patients I expect to cure with an injection
Chris Dy :The pandemic bumpy patch. I 've seen it a couple of times I'll be very honest with you,
Charles Goldfarb :that is awesome, I have not seen a pandemic puppy victim, but I'm sure they're out there.
Chris Dy :I think they're just in my cash money. As opposed to yours, and I pushed on to two things about injections. Yeah. So what do you tell people about flares? And then do you follow have them follow up with a brace for two weeks? I asked you the second point, because I know that our group I think it was Ryan Calfee, who led the study. Although you probably participated, you know, looked at you know, how to study demonstrating that wearing the brace for two weeks may help prolong the effect of that ejection. Do you buy that?
Charles Goldfarb :I don't. So my my things are number one, I do warn every single patient about the flare. It doesn't eliminate phone calls with flare reactions to the steroid injection, but I think it does decrease phone calls. The science is not necessarily supportive of icing, but I recommend icing the site a couple of times and taking a dose of anti inflammatories. I do offer a brace but I don't push a brace after an injection. And some people like the concept of resting it for a couple of days. I do recommend they not over exert themselves. I tell them don't go to the gym today and work out. I think that theoretically seems to have some relationship with the development of a flare. But this is all just, you know, hearsay. I don't truly understand why people get a flare. I've done a study on it, which didn't help clarify anything in my mind. So I don't know what how do you think about it?
Chris Dy :Well, I think your study was helpful to characterize the frequency of the flare. Yeah, so it really is about one- third. But I like you, I tell everybody that they're going to get a flare reaction. I stole the line from Ryan. That you know, 'you're going to hate me tonight'. You're not gonna like me you like me better in the morning. But I tell him like I tell everybody to ice I do use the I tried I tell them to wear a thumb spica embrace as much as they can for the first two weeks after the injection, mainly to try and get some more mileage out of the injection. I don't know whether it is because it truly add something to the to the effect of the injection. If it's purely just decreased activity because they're in a brace, it's probably a little bit of both.
Charles Goldfarb :Yeah, that's probably right. My line is I tell them, they're going to get the flare tomorrow. And I say, if you have a flare, you will absolutely curse my name tomorrow. And then you have to stop once the flare goes away. Which they like.
Chris Dy :Because I tell them, I tell them, they're gonna get the flare the night that they get home. So put some ice on and take whatever you normally take for a headache, which I think is also Ryan line. It's really good at that kind of stuff. People get that like headache, you know that they understand that? Yep,
Charles Goldfarb :yep. All right. You do your second injection and unfortunately, our hero comes back a third time. It's now been a year since the fateful day that he decided to hang pictures. And
Chris Dy :Poor guy that's 30 pounds heavier
Charles Goldfarb :And his marriage is on the rocks because he's just sitting on the couch So, you got you make the you make the decision to proceed with surgery. First of all, what do you tell a patient about the prospects of surgery and two any surgical tips tricks or pearls?
Chris Dy :Um, you know, I think surgery has, this is one of the surgeries when it comes to it when you're actually you actually take a patient in the surgery, they do incredibly well. It's highly reliable. And it's very gratifying for all parties involved. That's my take on it. That being said, this is not a surgery I do commonly. And I was surprised by that when I, you know, I reviewed a paper for JHS, I think it's like two or three years ago. And they were talking about the numbers of surgeries that, you know, patients who are having surgery and I looked at the number of years they had collected data on the number of surgeons the number of cases, I said, Wow, they aren't really doing that many. And then we think of this as a very common condition that I looked back and thought about my practice and I really don't do this case that much. Is that your experience?
Charles Goldfarb :Oh my god. I do it. I'd be guessing, but I probably do it less than five times a year
Chris Dy :Now, I think the reason why I like the surgery is that it's all about the nerve.
Charles Goldfarb :Of course, of course, it's not about the tendon problem it's about the nerve
Chris Dy :There is one job in this case, it's true. The first job is to get that nerve out of the way. And I'll be honest, it's a great case to teach a trainee how to handle the nerve. Because they're, you know, if they don't do it, well, if they don't, if they don't know the anatomy, if they don't know how to dissect the nerve and handle it with care, this can become a nightmare. You know, and it's maybe that's something that's been ingrained in me from training. But, you know, this is a case where, you know, if you don't get the exposure, right, if you don't get that nerve or you're not aware of where you should be that anatomic branching patterns, variability, etc. The case quickly becomes one where everybody's happy to win where everybody's miserable.
Charles Goldfarb :That is very fair. So there used to be a I guess a widely held sentiment that you do not make a transverse skin incision despite the fact that it may feel better that it is for Bowden to make a transverse skin incision. So what type of skin incision do you make? After you protect the nerve? How do you approach the sheath? What do you what do you do? Where do you cut it? And what's your kind of how do you think about it?
Chris Dy :So I do an oblique incision, I don't do a transverse incision. You know, I've played around with different things kind of a semi s shaped incision versus an oblique and I basically we use an oblique incision that follows the course of the fall of the course of the tendon sheath. I don't think it matters to be honest with you. That's just my preference. And then you know, when you make that incision, you have to realize that the SRN the superficial radial nerve will be crossing that almost not directly perpendicular but almost like an x in terms of coming up in oblique To the to the way that you've made your skin incision. So, it is purely you know, I make the skin incision alone and then it is taking its anatomy bluntly spreading in line with the expected course of the superficial radial nerve, and typically identifying the nerve of that step. But if you haven't seen nerve, which should be lying right over the fascia, if you haven't seen the nerve of that point, then you bluntly dissect, you know proximally within your skin window and look for the mirror. And then once you find the nerve, you don't do too much dissection on it, but you'd want you just protect it, get it out of the way and then you finish the rest of it. I will ask it do you do this? What what type of anaesthesia Do you use for this?
Charles Goldfarb :I will do anything. I have not yet done a local only for this procedure. I absolutely would. But I haven't like I've done a quarter of things in quite a while. But uh, typically I'd say I've done Bier blocks historically.
Chris Dy :Yeah, yeah, no, I'm the same way I have done Bier blocks. I've done a couple under local, they're great. And this is the I mean, it's one of the perfect procedures for it.
Charles Goldfarb :It's interesting what you said made me think about a conversation I had in the operating room yesterday. I was- you brace yourself- I was taking off several large osteochondromas from the distal femur. I don't know if you remember where that is.
Chris Dy :Wait, were you operating around the knee? Again? I thought you just took cartilage from there for your for your elbow.
Charles Goldfarb :Yeah, well, we do that too. But I do find the knee interesting. And I was at the Shriners Hospital and I love taking care of kids with osteochondromas and I was and it started with a very simple posterolateral osteohcondroma, I think there's a nerve near there, but I might be there might be. And then of course, I got to see the patient before and he's like, what about this massive one on the inside of my knee? And yeah, we took off another one. And but it led to an interesting conversation which gets back to what you just said, which is that are you a surgeon? I think I now know the answer- that needs to know where the potentially pertinent nerve or vascular anatomy Is or are you a surgeon that is satisfied with knowing that your target in the surgery is safe from that vulnerable neuro vascular anatomy.
Chris Dy :I am 100% in the former camp, the first camp I want to know, I mean, if it's, you know, I'm not gonna go you know, if I were ever treating, you know, a, you know, if I was doing shoulder surgery that wasn't related to the nerve, I don't know if I'm gonna dissect the Plexus put it that way. Nor do I want our sports partners doing that sports colleagues doing that, but it's in the field, it's a known complication, I'm gonna go find the damn thing. You know, it's like for every like for every insight to on the nerve decompression. Yes, there is a chance that you make your skin incision and because of anatomic branching patterns, that MABC is not going to be there. In that particular case, I'm not going to go hunting for that nerve. But if I'm going to make sure within my field that I have, that it's not there, but for this particular case, I think you got to see it. curious to see where you landed this
Charles Goldfarb :Within a couple of centimeters at most of my, you know osteochondroma lie, lies the parody owner, I did not look for it yesterday. And we had the conversation and I knew that what we were doing was safe. And I do I go back and forth. Honestly, I'm not firmly in one camp or the other. But I feel like if I know exactly what I'm doing, and I've exposed as I need to expose, I do not have to find the pertinent anatomy, whether that be the radial artery for a CMC arthroplasty case I do not have to see it. I do typically. But I do not have to see it. It's just an interesting philosophical choice because I was taught by Dr. Gelberman, that even if, even if that key anatomy point was not right next door, you go find it.
Chris Dy :It's funny because I you know, you just said that, and I go find that artery every time I do a thumb CMC. Yeah, it doesn't getting beat up at some point during the case sometimes. But, you know, I go find it, I just I feel better and that's, that's where the personality thing comes into play. You know, I feel better knowing I looked at it and then I saw him that I, you know, don't necessarily need to, you know, dissect it out protected, etc. But knowing exactly where it is helps me. And especially I think in a training situation, I bet most surgeons who are listening probably fall into your camp things.
Charles Goldfarb :I don't know. Hopefully they'll write in and tell us all right, I can't believe Yeah, true. I can't it's a good Twitter poll. I Alright, we have been quite verbose about this topic that we thought would be like pulling teeth. I want to make two final points on de Quervains and I briefly want to hit intersection syndrome. So my two final questions I guess I would say on de Quervains veins are number one. Do you make it a point to release the first compartment and possibly sub compartment dorsal as possible, because that's what I do. I've, you know, I think that the thinking is it creates a little bit of a flap to decrease the chance of instability to tendons. And number two, do you place the patient in a thumb spike a splint for two weeks afterwards? Or how do you handle the patient after surgery?
Chris Dy :Short answer is yes to both. When I do my release, I release it as dorsal as possible for the concern that you stated. And then I also will make a point to see make sure that I see the EPB. And you know, it's always a fun anatomy question in terms of how you know it's EPB versus APL and seeing the muscle belly of the EPB is the classic kind of thing. And then also being aware of multiple slips of the APL, that kind of thing. So just because you've released that first compartment doesn't mean you're done. I have to see muscle belly to know that I'm done. And if I I know that you're gonna hate me for doing this, but there's a funny story from Dr. Stern, I interviewed for his fellowship and you interview for the fellowship and you go into the OR with him. So it's me and two other candidates. And he's asking me these questions. And then he asked me this question about the first compartment and potential dislocation of the tendons. And I got it right things like, you know, who describe that. And I was like, No, he's like, he's one of your mentors. Like, sir, I don't know. He's like, it was Andy Weiland. So of course, that's the part of it I got wrong.
Charles Goldfarb :Yeah.
Chris Dy :So, so yeah, I do immobilize after surgery. I put them in a thumb spike a splint I leave the IP joint free, and that comes off at two weeks. I will typically walk them down with a brace, a prefab kind of thing. And then they do not go to therapy for this condition. How about you?
Charles Goldfarb :Yeah, that's what I do as well. I just had been had been occasionally not putting a splint on in the operating room and instead using a bulky soft thumb spike with an ace bandage, which seems fine. I think it's risk that I'm going to get burned at some point or a patient's going to have unstable tendons. I do think the thumb spica split makes sense at the time of surgery.
Chris Dy :Well, I mean, I think you know you and I'd love to hear if it works out for you that way because I would probably change to that just doing a bulky dressing that they I don't know if I'd let him take it off. To be honest with you, you know, two things. A plaster splint is heavy, patients don't like heavy but plaster splint does provide some structure to the dressing and keeps it looking and feeling somewhat the same. I feel like a softer dressing loses its structure in form and that sometimes bothers patients it gets a little a little sloppy down the line.
Charles Goldfarb :Yeah, and let's face it, it's more of a sympathy dressing and this is not a big surgery and I try to provide my patients every advantage and if I can get them more sympathy at home, especially this 37 year old with a year history.
Chris Dy :So why don't we leave? Why don't we do intersection syndrome for the next for another episode. But tell me one thing that, you know, you have learned in the last few years that has changed how you approach this?
Charles Goldfarb :I don't know. Well, I don't worry, I'll just say this. I don't worry overly about steroid injections at the first compartment causing subcutaneous fat atrophy, or necessarily causing skin discoloration in darker skinned patients, because I do really put this injection deep, and I do not put it subcutaneously. And I think that's different than, say, an ECU injection where you are putting a subcutaneous, almost by definition, even if you're putting it on the bone. So I think it's important that we think about those things. But for me, this injection is a little less worrisome in that regard. What about you?
Chris Dy :I think that my physical exam has changed. I mean, I know that this is considered a somewhat simple condition to diagnose. But reading that Gelberman paper I think helped me clarify exactly how I want to differentiate between different diagnoses. So that's why I pretty much don't use a Finkelstein's test. Inevitably, the resident or fellow comes out and has documented a Finkelstein's but I really don't even use it.
Charles Goldfarb :Excellent. All right. So let's wrap this up. You gave a fantastic comprehensive list of radial sided pain generators. And what I'd like to do, and I hope you'll come back with me it is let's do this in another podcast, and we'll speak more briefly about, I don't know, seven or eight different diagnosis.
Chris Dy :Yeah, we're only going to talk about Wartenbergs. So that's the only one it's interesting.
Charles Goldfarb :I don't know what you're talking about. It's been fun. Thank you.
Chris Dy :There. We'll be talking about footsteps on freshly fallen snow,
Charles Goldfarb :I love that.
Chris Dy :We'll get to that. I love it. All right.
Charles Goldfarb :Thank you.
Chris Dy :Alright, see you then. 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?
Charles Goldfarb :Mine is @congenitalhand.
Chris Dy :What about you? Mine is @ChrisDyMD spelled d- y. And if you'd like to email us, you can reach us @handpodcast@gmail.com.
Charles Goldfarb :And remember, please subscribe wherever you get your podcasts
Chris Dy :and be sure to leave a review that helps us get the word out.
Charles Goldfarb :Special thanks to Peter Martin for the amazing music and remember, keep the upper hand come back next