Welcome to the upper hand, where Chuck and Chris talk hand surgery.
We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
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Oh, hey, Chris.
Hey, Chuck, how are you?
I'm well, how are you?
I am fantastic. Nice to see you on another nice day in St. Louis.
A little breezy, a little breezy.
Yeah, there are some things knocked over in my yard, so.
So you're well aware.
Oh, yeah. Fully aware and a rainy day yesterday, so it's nice to not have some rain.
Yeah, we are actually sitting in relative close proximity, I would give us six feet apart. But we're not doing this by zoom. It's a whole nother thing.
Well, you know, our tech director really got on my, got on my case about the zoom thing. So, you know, whoever that guy is, is, uh, you know, kind of kind of tough.
Sounds like a jerk.
Yeah. Well, yeah at times.
Well, it's good to be back. And we have I think what we're doing today is we're hitting up part three of distal radius fractures. Is that right?
Yeah. And I know everybody loves to talk about distal radius fractures, there will eventually be a part four in which we have one of our therapy colleagues come on and join us. But let's talk today, a little later on about when we don't use volar plates. But before we launch into that, why don't you share some feedback from the listener survey?
Yeah, once again, we're grateful for all reviews. And this one is unnamed. And it says, Thanks for the great podcast. I've been listening for a few months now. And I like to hear about the technical and decision making steps as well as the great banter. I even got my PA to listen, and the show has really gotten him interested in and motivated in becoming more knowledgeable about taking care of hand patients. Thanks. And yeah, thank you, we appreciate
the review. And I think this episode should hit the spot as far as the technical and the decision making.
Absolutely. And the listener survey is still open. If you want a chance to win one of those fantastic upper hand coffee mugs. Our first winner is from Brazil. So congratulations to him. And he'll be getting his mug shortly. But if you want to find the links, you can find us on social @handpodcast. Then we'll also have a link on our website, theupperhandpodcast.wustl.edu.
Perfect. Yeah, the we weren't expecting an international mailing, to be honest. And so we're not sure if this is gonna go out by the slow ship. So it might not be there tomorrow. But we'll get it to you.
You'll get it eventually. It'll be a wonderful Christmas present, I guess.
So any interesting cases you want to share?
You're gonna roll your eyes, but I'm gonna talk about another WALANT case.
Oh my god, I'm rolling my eyes. I hope the audience can see that clearly.
But the this patient was so cool about everything. I mean, you know, she I walked into holding and First off, I did discuss with her that I was going to be sharing our experience about her case on social and on the podcast, and she was cool with that. But she I walked into the holding area and I swear she is one of the only patients I've ever seen meditating. And it was a totally cool vibe. Did the block, went well. And then we went back in the operating room and she
wanted to watch her surgery. So our fellow, hello, Dr. Lauren Wessel, and I did the case together. And you know, we're switching sides back and forth and putting in core sutures and epitendenis sutures and the patient was a great participant in the whole case, it was a really honestly very enjoyable experience.
Did that patient request certain ambience music in the room? Whether like, were there? I don't know what what holistic music even is.
No, she would. You know, it's funny. There was a post about this on Twitter, I did post about the playlists that came on. I tend to play pretty safe with the music in the operating room. I think we talked about this in one of the other episodes, but I did have Pandora on and I love my Hall and Oates radio station because it's got a little bit of something for everybody. But no, like, honestly, the playlist was perfectly spot on. During the part where we were exposing the
flexor tendon in zone two. It was Air Tonight by Phil Collins. When we were putting in the core sutures, it was Under Pressure by Queen and David Bowie. And as we were finishing the repair and doing the wide awake active motion check it was Signed, Sealed and Delivered by Stevie Wonder.
That is excellent. I did see that on social media. And we should talk about that for a second. But I will say that one of my friends and congenital hand surgery lovers is Michelle James out in California in Sacramento and she has a playlist for pollicization procedures and she knows that for each particular part of the case and there are well you'd say that there are 10 steps. Now, it's not perfectly aligned that every 10 steps are the same
for every patient. But she has exactly where she should be for each case by the song that's on on the radio, which is super interesting for a case like
That that is interesting. I think the only that. variation I have on that is when I'm doing a long Plexus case, I know which radio stations I need to listen to during different parts of the case. And part of that is, you know, as one of our partners, Marty Boyer has pointed out, he's like, if you have these all day cases, and you let them take all day, and you don't intentionally push the pace on things, you will be there far longer than you need
to. So I know when the energy needs to come up, when the hip hop barbecue needs to come on, you know, right at the middle of the day when we need to really get to an end.
That's a great point. That's a great point. Speaking of social, I think we both done a little more recently, on Instagram, because we're both really young, you claim that you're a lot younger than me which by, by dog years you are, but we've opened a few new Instagram accounts.
Yeah, you know, for me, it was more reactivating an account that had been dormant for four years and actually spent some time and looked back at the last things I posted and realized I was at a very different point in my life. When I was active on Instagram. Last I had just rounded the corner from residency into fellowship, and had just started my first years in attending so life is quite different now.
For sure it is. It'll be fun to see what happens. It's definitely there's some similar faces and names and I'm using it I'm using Instagram a little bit differently than I am using Twitter. But I'll have a couple of accounts, one for sports, one for congenital, and one where I don't post but I just get feedback on different things.
I think that there're definitely different target audiences. In terms of you know, you know, what kind of content goes out there what the vibe is. And I honestly, I'm still trying to figure out the Instagram app after four years of taking off. It's very different. Now there are a lot of new features that were not there before.
I t is and it's so tied into Facebook, and I have a business account on Facebook again from my congenital work. But I don't personally use Facebook, but they are intricately linked.
That's not by accident.
That is not by accident.
The algorithms are strong, Chuck.
Yes, they know us better than we know us most likely. All right, what do you say? Should we jump in?
Yeah, so we spent the last episode talking about volar plating, which is I think, for most surgeons now the default option. And I think there's been a bit of a backlash against using other types of fixation. Although there are certainly cases in which, you know, maybe a volar plate isn't the best. So how do you think about that?
I guess I would first say that, for me, there's always been two broad categories. When do you always go volar? Or when do you consider going dorsal and we're going to hit on that difference, we're also going to consider really fragment specific approaches. And some of the volar versus dorsal is purely dealer's choice. And you can show the same X ray to a couple different people. And I think the technology of the hardware
is pretty similar. And so you can really make a choice, what we're going to hit on today are the cases that, you know, aren't so simple as just volar, or just dorsal, we're going to get on the, we're gonna hit on those cases that require a little different thought, rather than your standard volar locking plate.
Yeah, so what are the you know, what's the first type of case that comes to mind? When you know, perhaps your standard volar locking plate would not be would not be enough?
Yeah, I think well, in many of these you can prob- you might be able to get away with a volar locking plate. And that's what's so tricky, because you can be lulled into that sense of Oh, yeah, I'll just put a volar plate I'll, I'll quote unquote, throw a volar plate on that, and it'll be fine and I think that's risky. And the fracture types that we're going to point out today make it especially risky. So let's start with a radial
styloid fragment. So that quote, unquote, chauffeur's fracture, which can be, it's typically a relatively sizable fragment, it typically exits in the joint right at the SL ligament, which also for me, is of concern, for all of us it should be of a concern. And yeah, you might be able to put a standard volar locking plate on there, but it's probably not the best approach.
Yeah, I think that, you know, one of the things about the volar locking plate is that it is such an exceptional piece of technology that we can rely on it to do a lot of the things that almost violate some of the standard AO osteosynthesis principles. So, you know, for example, for a, you know, one of the standard indications I think most of us have for a volar locking plate is for a dorsally displaced
fracture. And that violates Principle number one of AO of, you know, going on preventing the side, going against the deforming force and force displacement. So, there are a lot of ways in which we can get
away with volar plates. And I think that for that particular fracture for the chauffeur's fragment, you can maybe rely on, you know, one or two, maybe three of those radial sided distal locking screws and get away with it, particularly if you have a plate that is, you know, allows you a longer screw length through that radial sided distal row. But you know, if it fails, you know, you have a good reason why.
I think that's right. And I think there are a couple of, so so I'll accept and I think you'll accept that a volar locking plate is absolutely okay for for most chauffeur fractures, but I don't know that it's my first choice. I guess it depends exactly on how big the fragment is, etc. But the other options I consider or one would be simply a limited approach from the radial
styloid. And so I'm not a big believer in one or two headless screws, but that's an option, certainly, or a radial column plate is an option, or perhaps, ideally, is simply a more fragment specific type plate on the volar radial aspect of the distal radius.
Yeah, and I think that will when we say the words fragment specific, it's important to acknowledge that we are not talking about the proprietary technology that you know a manufacturer has, but really more of approach than anything else. And you can do fragment specific type surgery without, with any type of implant. It doesn't need to be specifically designed for that.
You know it, for me, the radial styloid fractures that are worrisome are the ones with either a lot of comminution on that side suggesting a higher energy or the ones associated with the radiocarpal dislocation, again, associate, you know, making you think of a higher energy type injury that probably deserves a little more respect than a couple of locking screws.
So what is your approach regarding the SL ligament? Are we as surgeons under any specific obligation to explore the possibility of an SL ligament disruption? Let's say the X rays look normal? Do you automatically throw a scope in or make a small incision? dorsally? Do you stress the patient when they're asleep? either before or after fixation of the fracture, how do you approach it?
I think that that's probably my response to that is going to be a function of my, my limited use of arthroscopy, so I don't go to arthroscopy.
Although I certainly understand how that could be useful, because I just, you know, it's not the first thing I think about, you know, you could approach this radial styloid type fracture either through a straight radial approach, like you described, or a dorsal approach, which I think the dorsal approach gives you the advantage of being able to inspect the joint which may or may not matter based on honestly
your own work. But then also look at that SL ligament and directly inspect it, because you're there, you have to open you know, if you're going to look in the joint, you have to
open the capsule anyway. And then you can also go over and fix your radial styloid fracture through however, wherever you put the plate, whether it's dorsal radial, or straight radial, and I do like a radial column buttress plate, and I, I personally tend to design that myself, I don't use a pre manufactured or pre contoured plate.
And some would say the only negative to a dorsal approach for this fracture is the forced pronated position. Obviously, when we're treating things volarly, we're in a forced supinated position. But I agree, I think this is dealer's choice, whether you go volar, or dorsal, I would tend to go volar, or a little mini incision and something from the styloid area. But I think it's your comfort and your with the
approach. And if I did go volar and had any concerns whatsoever about the SL, then either I would look inside with the with the scope or make a small and you can get away with a really small incision to look inside the joint to make sure the SL is okay, but I don't certainly don't always do that. But it's always at the top of mind.
I think the fracture, the injury characteristics and the fracture personality are, you know, will drive me towards looking into the joint if it is truly a higher energy injury, I will I will look. But if it's a lower energy injury, and I'm not as concerned it doesn't drive me. And I think one of the points you made is, you know, trying to avoid multiple large approaches. In the heat of a tough case, it is tempting to say, all right, well, let's just open on the other side. And, you
know, take a look. Now that, it may end up making your X ray look better in the end, but it's there's a price to pay for multiple large approaches. Now I think there's a difference for the smaller kinds of, you know, look in the joints or even you know, for outside of today's talk, but you know, when I do a mal union correction with an osteotomy I put a volar plate, I do make a little small incision, get the EPL out of the way and free up the dorsal cortex that way.
Yeah, that's that's great stuff for sure. All right. Let's we briefly hit on the topic of the basically volar ulnar facet fracture, but we should probably talk about that a little more. In my mind. These come in a couple different varieties. One is the one that's obvious from from the time of the original surgery and the other is the one that may surprise us because it's not quite so obvious. So the first question is, when do you think about a CT scan? And does it
have a role? If you're just not quite certain about fracture personality? So how often do you order a CT scan for distal radius fractures? And when do you use it?
If it's, um, if I'm concerned about a subtle volar displacement from a volar lunate facet fragment, and when I say volar displacement, I mean, volar, displacement of the carpus. And it's not a large enough fragment for me to identify and feel confident that I can get it with a volar plate. Or, you know, I need to honestly measure it based on some of the work that Jupiter and harness have done, I will get a CT scan,
but it is less common. I think I have a lower threshold to perform a volar ulnar approach between the long flexors and the ulnar bundle, and honestly directly inspect it that way. I have a lower threshold to switch away from volar plate for any concerning fragments.
Yeah, I think I think that's well said, we were joking earlier about Facebook and Instagram, knowing us better than we know ourselves, the other group of people who know us better than we know ourselves, are the insurance companies. And they absolutely know what Chuck Goldfarb costs to fix a distal radius fracture. And I don't think I worry overly about that. But I do worry about cost just because I think it's my
obligation. So I don't order as many CT scans, perhaps as others, and maybe I underorder CT scan sometimes. And I think this fracture is just so dangerous. And the benefit of avoiding a second or third surgery because of this fragment is just so incredibly important. I would throw back to you that sometimes if you know that fracture is there with or without a CT scan, and it's isolated, then you definitely you know, you use that volar
ulnar approach. For me, it gets trickier when it's just part of the fracture personality. And so then maybe a standard volar approach works and you have to sneak over.
Do you think it's hard to sneak over and get to that fragment and truly assess it and capture it through a standard volar approach.
I think it's doable in most patients, some of it depends on their bulk and it may require a longer incision, both proximally and distally. Distally, you know, crossing the wrist crease and we both said we don't like that, but I do think it may require more extensive incision, but in the right patient, you can get there pretty easily. In the wrong patient, it can be a struggle.
Yeah, and I think that for me, there have been a couple, I probably had one or two cases, I remember where I went and volar ulnar and then kind of wished I had a better radial sided exposure, and I had a low threshold to make a small radial accessory incision, you know, I was able to get done what I needed to do in terms of the fracture reduction. But I, I agree, I don't like crossing the
wrist crease. And I think that, you know that that scar on the skin is very tough for patients to get over in a trauma setting. You know, they're they're already prone to stiffness, and that can be a problematic area.
Absolutely. One thing that's not acceptable, though, is to try to do an incision halfway in between halfway in between a standard FCR or volar Henry, and then a volar ulnar, because that just gets you into a world of trouble with the median nerve proper and the palmar cutaneous. So you kind of have to make a choice. Yeah. And you do that preoperatively obviously.
Yeah, and these, you know, that point is important because I my hesitation about using a standard FCR type approach for for these volar lunate facet fragments is the amount of traction on the median nerve that occurs to get all the way to that volar ulnar piece, you know, a it's a hard enough exposure to make sure you can identify the fragment, appreciate it, not strip it and fix it. And then you know, having a retractor over in that area on the median nerve can be
taxing on the nerve. And you know, I'm always thinking about the nerve. And these are cases in which I have a lower threshold to perform a carpal tunnel release as well.
Yeah, I agree with everything you said. And I joke about being, showing disdain for nerves, but I really don't. And as I think I've mentioned early in my career, I was burned with over retraction with this case and an angry median nerve afterwards and I learned my lesson but don't don't if you haven't had that happen, please don't learn your lesson the hard way. Do you have a, I'm not asking for a manufacturer. But do you have a preferred construct plate wise?
Like how do you think about that for if you if you have an isolated volar ulnar corner.
I like to take either depending on the size of the patient, a 2-0 or 2-4 standard recon type plate, usually an L or a T shaped and I will custom bend that to what I think will sit appropriately in that in that concavity it's a little more distal, you have the leeway to go a little more distal than you will with the volar plate because you're obviously trying to capture this fragment and I like having a lower profile implant out there because you know honestly it's not on the
radial side, and you're not going to catch the FPL with it. It's a plate where you can put it really distal, and not have to worry as much about irritating the tendons providing that provided that you either bend it appropriately to match that fossa or you trust the patient's bone to allow the screws to make that to make the plate sit nicely when you do that apex screw for your buttress plating.
Yeah, well said, I mean, there certainly are lots of plates out there that have even little hooks that you know, extend really far distal off the plate, or you can add them to the plate, there's all kinds of variability. The bottom line is put something pretty darn distal, and make sure you buttress or capture
that fragment. Because again, to make it very clear, for those of you who haven't seen a lot of these fractures, the danger here is that if your plate is too proximal, or you don't understand the fracture fully, when you see the patient back, and honestly, this can happen, no matter how good you are, and how many of these you've treated, that if that fragment escapes volarly over your plate, then the carpus comes with it. And that's that's difficult to deal with in a sub acute
setting. So you want to get that right the first time. Now, do you consider a dorsal supplementation with a spanning plate? If you feel like you've captured this volar ulnar corner appropriately at surgery one?
No, I don't. I know a lot of people do. And we talked a little bit about it last time, I think the dorsal spanning plate may be over utilized. You know, and I think that certainly it's one consideration, I always have in the back pocket, whenever I'm doing a radius, a distal radius it is in the surgical center. So it's there
in case I need it. But I honestly will just tend to immobilize these patients longer, I do have the same concern that you have, even if I think I captured it, well, I still am pretty paranoid about getting x rays, you know, the first few weeks just to make sure it hasn't shifted. You know, and I think that there are a number of ways you can capture that fragment, doesn't always have to be through a buttress
fragment, or buttress plate. The other ways that have been described are to use a K wire and, you know, bend it back and tuck it underneath the volar plate. So that's one way to do it. You talked about adding extensions onto a volar plate or certain volar plates that have extensions to get out there. I don't love that, because then you're still, the natural tendency is to put the volar plate a little more distal, which can obviously get into some issues with the FPL. And
the long flexors. And then the other way that's been described is to use, you know, a cannulated screw, you know, so using one of those old school screws and putting a putting a wire in first and getting it secured that way, you just want a couple of points of fixation. I think that's probably the biggest thing.
I think that's great. I totally agree. Excuse me, the other issue can be if you are having to go back to the operating room, or this is a sub acute setting, I will absolutely use that dorsal spanning plate because it is a game changer in a sa- not salvage because you can still hopefully get the patient everything they would have had. But it really neutralizes those volar forces on the carpus. So that's a great option in a subacute setting.
But I agree with you, if you're if you A, identify the fracture at the time of the original surgery, and B, able to sufficiently isolate and stabilize that fragment, there's no need for a dorsal implant.
So last question for this particular fragment. What's your post-op protocol? You know, one of the we talked in the last episode. You know, one of the standard advantages of operating for these fractures for just distal radius fractures in general is early mobilization. But I think this one may be a little different.
Yeah, I go slower with this one for sure. So my typical protocol is five to six days after surgery with a stabilized distal radius fracture with a volar locking plate or a dorsal locking plate. They go to therapy have a removable brace and start active and general passive motion. With this fracture it's immobilization for four or five weeks for me.
Yeah, same here.
Okay. All right, let's, let's jump. We have two more fracture fragments. We talked about the dorsal ulnar corner a bit, we probably don't need to rehash too much of that. But when do you worry about that dorsal ulnar corner?
This is the one where you know if there's pretty substantial dorsal subluxation of the carpus more than the standard, it looks a little bit off because of the dorsal tilt. If I think that the carpus is moving with that fragment, which is not common, that's when I would get concerned about it. And then the other situation which I get concerned is the sigmoid notch, and how you know malunion there can obviously have implications for forearm motion. What about you?
Yeah, I have to say it's not at the top of my list of worrisome fracture patterns, but I don't completely ignore it. And so the reasons you just said are exactly spot on. I worry a bit more about the DREJ and again, it's one of those fracture fragments where something just doesn't look right a CT scan can help clarify. And as we mentioned in the previous podcast, David Brogan has done good work with identifying that this can be a
substantial fragment. And we shouldn't neglect it when there are signs of concern.
Yeah. And I read, you know, we talked about David's paper, I think one of the issues with his paper, you know love the guy, but you know, this, the paper was characterizing that fragment in a population, postmenopausal females in which they had a lot of CT scans, in which maybe it didn't matter as much. I think the the the characteristics or personality of that fragment are going to be different in the younger, higher energy population, which that probably matters more.
I think you said it, right. I think you said it, right.
So what implant do you like to put over there, if you have to? Do you like using the standard dorsal plates that come from manufacturers or?
I typically use a smaller more, again, fragment specific plate, and what I mean by that is just a narrower, often that L plate you talk about whether it's just a standard 2-0 or 2-4 plate, or is something out of a distal radius set. For me, this one's a little more personality driven by the size of the fragment and, and what else I might need to do. So I don't have a standard per se, for this fracture.
And I'm with you on that, I mean, know what part of the way I was trained in residency, you know, did a lot of distal radius fractures with the trauma service there. And it was, you know, using 2-0 and 2-4 plates, and, you know, designing your own and contouring and all that kind of stuff. So I honestly, I enjoy that process. In all, in all honesty, though, the dorsal sets that I had looked at when I started in practice, those plates are
relatively thick. So you know, I think, you know, if you look back at why we started using volar plates, you know, the concern for irritation of the extensor tendons with a prominent dorsal plate was a very real one. One thing that's important, I think, when you're when you are cutting and contouring plates and stuff yourself Is that just make, watch the edges, if you do happen to cut a hole off of say, you have like a T plate, and you're cutting one hole off on
the distal part. So it fits well, just make sure that you, you know, smooth down those edges with the side of a drill or a freer or something like that.
I agree with you completely, the benefit of using a more standard plate rather than one of the smaller plates out of any any company's distal radius set is that those plates are expensive in the sets. I think that competition for cost control is around the standard volar and the standard dorsal plate. And the other plates are less, we're less concerned typically about cost. And so those are not the cheapest plates in the set. In fact, they're often the most expensive set, plates in a set.
And that's why sometimes using a more standard plate and contouring it will be more cost effective.
Yeah, fair points. So you like to, you're an arthroscopy guy, a wizard, some would say. Do you worry about you know, those, the other types of fragments that involve the joint that are impacted and kind of really pushed down?
Yeah, so I mean, some people would I mean a die punch fragment is one type of intra articular displaced fracture, and that one, the die punch implies lunate compression. So Central, central central often. And those are ones where I do think a CT scan can be beneficial. But really any combination of the articular surface, I would say, requires a direct look, in most cases. And whether you do that with an open incision, or you do that, with a scope is completely dealer's
choice. I think it is an acquired skill if you choose to do this arthroscopically. And so trying to, again, hopefully use one of the columns, ideally, the the intermediate column, the more ulnar aspect of the radius, or wherever you can stabilize to is helpful in elevation of that central depressed fragment, sometimes with bone graft beneath it. But if you have good quality hardware, you don't, I don't feel you always need that, it's totally dealer's choice. And I will say that sometimes I
use a scope. And other times I do not.
Yeah, you know, when I've had to deal with these fragments, I do like using bone graft, not because I think it's gonna make a difference down the line. It's mainly because it frees up you know, can help tamp things up, hold it there provisionally, while I get my plate on, and I don't it's one less thing I have to worry about.
I think that's exactly right. One of the I've seen you know, when we go dorsally consider a dorsal plate. And I would say that's the tried and true and accepted way of dealing with these fractures is sometimes you can lift up the dorsal distal portion of the distal radius and bring the capsule with it. And so you're not making a separate capsular incision. And then you have exposure into the joint. You can elevate the fragment, you can add some bone graft, which I completely agree makes
this a little easier. And then you can close the the fracture back down at the end and put your plate on. So there's different ways to get there. Sometimes you need a capsular incision. Sometimes you can work without it. But anything you can do to just to support the elevated fragments is really the key.
So when you're going dorsal to sort of close out this discussion, do you have any pearls in terms of the approach to help cover a dorsal plate and protect the extensor tendons from that dorsal plate down the line.
So I use a third compartment approach for all of these. And whether that's approaching the carpus, or the distal radius, I carefully incise the third compartment distally to protect the superficial branch of the radial nerve, and I incise, the compartment proximally I transpose the EPL radially. And I leave it transposed and I close the retinaculum at the end of the case with the EPL
transposed. And then I elevate, excuse me, I elevate the fourth compartment in the ulnar direction, I try to leave it closed, that'll expose your post interosseous nerve and artery. And we can talk about how we handle those and elevate as necessary the second compartment as well, with a really comminuted dorsal fragment. You know, that dorsal rim is difficult, and it can be really
thin. And that's why I say sometimes you can take it with the capsule, sometimes you just have free floating fragments there. And it just is, you have to figure out what you can do. So I think the exposure, a good exposure is key, and then you can close back over that. What about you?
Yeah, I think it's, it's included in what you described. But you know, one of our former partners and mentors, Richard Gelberman would always talk about this infraretinacular type approach, and there is a layer of tissue deep to the second and fourth compartment tendons that you can lift off and save as a layer to close over the over the plate as something that will buffer the extensor. buffer it from the extensor tendons.
Yeah, absolutely. So you are a lover of nerves. Do you sacrifice the post interosseous nerve on these cases?
I don't, you know, I don't go out of my way to do it and I've seen a lot of people do that. I think that there's a lot we could have a long debate about the merits of denervation. This is not a case where I think you need it. And perhaps that nerve could be helpful in terms of proprioception, I know that there are strong feelings on both sides of the fence for that, how about you?
I don't routinely take it for anything. I do believe that nerve serves a purpose. But I don't I'm not critical of those who do. So I don't have super strong feelings, but I don't I don't routinely take it. So to summarize this last group, open or arthroscopic approach, but directly visualizing the reduction is key. And, you know, elevation and support of the fracture fragments. And then protection of the plate as possible. On the way out,
How much do you worry about step off? I mean, so you wrote the paper on this. But you're obviously an arthroscopist. So you have, you know obviously a concern for cartilage, I mean, what's the acceptable amount of step off, you know, that you can you think patients can tolerate or that you leave the OR with.
Yah so just to be clear, a gap in the articular surface is less than ideal. And we can go way back to Jesse Jupiter's paper 30 years ago, and we talked about two millimeters. I'm not sure what the right number is, honestly. But the smaller the gap, the better. But a gap is much better tolerated, especially in the weight bearing joints, compared to a step off. And I think you really want almost no step off. I think a step off in the wrong place is going to lead to rapid
degeneration. And what's too much, I would say any significant step off is too much. Certainly more than a millimeter is too much.
There you have it.
All right. Well, this was great. And this time I guess we'll for now conclude our discussion of distal radius because I think in the near future, we'll circle back and get one of our therapy colleagues to to weigh in.
Yeah, I think it'd be good to go behind the curtain and see what happens with therapy for for radius fractures.
Yeah, I need to learn so it'll it'll be good for me. All right. Have a great day.
All right. Take care.
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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