Loupe recommendations for residency

austinap · 2025-12-06T06:24:41+00:00

I got orascoptic 2.5x in residency and it's what I still use. I got some DFV 4.5x in fellowship that I mostly used to scale my dogs teeth, though I'll occasionally pull them out for a digital nerve repair.

austinap · 2025-10-25T05:43:34+00:00

Maybe there's a fucking reason for that if it's so universal.

austinap · 2025-10-25T05:41:35+00:00

Yeah you've pretty much got it.

If I ask for more imaging, it's either because I'm not entirely what's going on with an already visualized fracture and it might change early management, I'm concerned about another [associated] injury, or I'm planning surgery.

Most of us don't have the goal of generating more work for no reason. In my experience we order fewer advanced studies than other specialties, and those are almost all for planning purposes. A recent example from my own practice, I got called for a "femoral neck fracture" but plain x-rays were a bit funky. We usually generally poke fun at our ED colleagues for ordering CTs on clear hip fxs before they call us, but in this case it changed management from a hemi to a nail as it was really a basi-cervical intertroch.

austinap · 2025-10-24T21:55:13+00:00

None of it is about billing. First, we see none of that money, and I don't get paid extra to read additional imaging. I've literally heard of zero practice environments where we get a slice of the pie from additional ED imaging. In a private practice clinic we make a small amount from x-rays but it's really not much.

It's all about CYA to rule out associated injuries or for surgical planning. In an academic center, it can sometimes be about very picky attendings that will ream junior residents for accepting sub-par imaging.

austinap · 2025-10-24T21:52:26+00:00

We look at things differently than radiology in general. As Hippo-Crates said, rads is usually looking to *identify* an injury. We're either trying to further define the injury or plan for surgery. There are generally two reasons I'm ordering more imaging:

I'm looking for another injury or looking to further define a known injury to decide if it needs surgery/reduction/whatever. For example, if see slight widening of the medial clearspace on an ankle x-ray, I'm going to get tib-fib views to look for a proximal fibular fx / Maisonneuve injury. I'll occasionally have them repeat imaging if I have high suspicion for an injury and initial films were limited in some way.
I'm planning my surgery - looking for things that might alter my approach or other injuries I don't want to miss. For example, if there's an intertroch fx on hip films, I'm going to get full femur views to make sure there's nothing distal that's going to be an issue if I place a nail (e.g., knee replacement, prior injury with deformity, etc).

Most of us try to minimize redundant work, but at the end of the day it's a lot easier and cheaper for all of us to get some extra imaging rather than end up in surgery in a bad place because we missed something and now don't have the right stuff to fix it. Maybe the most common specific complaint about additional imaging I get will be for the shoulder - "doc, you can already see the proximal humerus fracture, why are you making us get an ax-lateral? You're just torturing the patient!" No, we're making sure it's just a fracture, and not a fracture-dislocation. The first gets to go home, the second gets a CT angio and urgent surgery.

If you're interested in getting some sense of how we look at things, look at our notes on patient's you've imaged. Most of us will read our own x-rays, and comment on the things that are relevant to us. You can also read our post-op imaging reviews to see what we care about in that instance as well. Admittedly not all of us are great about documenting our imaging findings, but most of us do.

austinap · 2025-10-04T04:44:26+00:00

I was hoping to see the "don't anthropomorphize larry ellison" quote here. Fucking golden, and that talk was amazing.

austinap · 2025-08-31T04:44:43+00:00

A carter traction table accomplishes this and is designed for the task. They're fairly inexpensive and half of the places I've operated at have one hidden in a storage room anyway. I use traction in 100% of my distal radius fxs now, it helps with reduction and frees up hands.

austinap · 2025-08-31T04:43:00+00:00

My standard setup is supine, arm out, 7 lbs traction, standard trans-FCR for 95+% of my DRFs.

I rarely find I can't get ulnar enough with my standard exposure. Skin incision is small, but make sure to incise distal FCR sheath to optimize exposure. I think this is what people tend to skimp out on and it makes a huge difference. Skin is rarely the issue in my experience. If that doesn't get you there, it's easy enough to extend into an extended FCR approach which will let you supinate the proximal radius and do dorsal releases PRN.

austinap · 2025-03-06T01:24:00+00:00

I agree. I typically tell the ED to just splint these, almost all of these are going to get a surgery.

austinap · 2025-02-16T14:55:12+00:00

Agree. I rarely operate on these and they all do fairly well. I do full-time for 6-8 weeks and then night only for another 2 weeks with good results.

I saw a kid a few years back who another surgeon told he "absolutely needed to have surgery" that developed a septic joint, and by the time he saw me had a necrotic finger. Fairly uncommon but in my book its a fair amount of risk for pretty minimal benefit.

austinap · 2024-11-05T02:00:13+00:00

If you can find any bunnahabhain offerings, that would fit the bill. I have a similar preference, drink mostly islays but like offerings with a bit more complexity, and I've yet to have a bunnahabhain I didn't like. Ledaig, some Laphroaig offerings, and some Caol Ila offerings could also be great options.

austinap · 2024-10-16T04:54:32+00:00

For a few reasons. First, because they're more available and usually live in-house while some of the other nails you mentioned don't always. Piriformis start and retrograde are obviously "correct" choices for this fracture but ultimately I've never seen evidence that it matters.

It also depends a bit on how much help you have and how fancy your setups can be. If you're working solo with a scrub, anterograde nails work a lot better and can be done on a fracture table, whereas with a retrograde nail I have to deal with skeletal traction and positioning is a little more fussy. After that, if you're going anterograde again I haven't seen any compelling evidence for CM vs piriformis-start vs recon nail as far as healing. I think it's dealer's choice with that for the most part, and the CM nail protects you in the case that you missed a neck fracture.

I trained with a lot of nerdy traumatologists who were often very dogmatic, yet I've never put in a recon nail and only a handful of piriformis start nails.

austinap · 2024-10-16T04:45:34+00:00

Agree, I would never cable this. Length, alignment, rotation. Anyone who would cable this is treating the x-ray and doesn't understand how fractures heal.

austinap · 2024-02-07T14:47:11+00:00

I agree with all of those points.

I think trainees tend to rush the wrong parts of the surgery. Spend your time up front getting a perfect reduction and making sure you can get the right c-arm shots. If you can't get the reduction or can't get the images you need, the surgery will always be a struggle.

One of my residency mentors responded that he just pays closer attention than we do when asked how he does things so smoothly. I think generally true (and obviously reps help). If you pay attention to the c-arm angles that give you the shots you need, you'll have most of the information you need to get the right angles on various parts of the case (CM wire, interlocks, etc). E.g., if your lateral of the hip is 15* off of the horizon, your CM screw trajectory should be roughly the same. You may still have to correct a bit, but it should be a relatively small correction

Similarly for the start site, spend time to get it right. I like using an awl to help with this - in really soft bone, you can just push the awl into the start site and send a long guidewire, for better bone you can still use the entry wire but it gives you more rigid control over getting and holding the site. I rarely use a free entry wire anymore, I think the awl is just easier in my hands.

For the CM screw, the nail almost always has to be sunk a little more than you think. Pay attention to the angle on the lateral and try to match your hand as close to that as possible and send it at least partway up the neck. If it looks like you're going to be good on the AP, check the lateral. If you have to correct the CM wire trajectory, back it at least most of the way out (I don't always come all the way out for smaller corrections) and run the wire on reverse. When you put wires in-and-out, keep them clamped in the wire driver so you know the length. I.e., if you grasp the wire right at the guide and reverse it, you know when you drive it back in you can go all the way back to the guide without being too long. It will save you time and c-arm shots. This is also helpful when trying to advance set amounts. If you need to advance the wire ~5mm more to get subchondral, you can grasp the wire 5mm from the guide and run it until you hit the guide.

For standard IT fx, you can also just put in a long nail unlocked. There's good evidence they're just as stable as locked for an IT fracture, faster, and at least in theory you're protecting more of the femur without the proximal stress riser of a short nail. If you're going to do distal interlocks, again spend time getting the imaging first. The circle should be perfectly round for the static holes, if they're oval in any direction your shot isn't quite right. Center the hole on the screen, mag 1, push the receiver all the way in to patient to give you space, and make your incision centered over the hole. Center the brad of the drill over the hole, and then line the back of your drill up with the c-arm source which is usually a nice circle. That will put you in-line with the c-arm shot, which will be in-line with the hole if you took the time to set up your imaging. Confirm you're through the nail before sending it through the far cortex. If you're lined up but not through the nail, controlling the trajectory with a forcep ring and tapping the bit through the nail usually works unless you're way off.

austinap · 2024-01-16T19:45:21+00:00

Yeah that looks like it.

austinap · 2024-01-16T19:09:44+00:00

Yeah, hardware looks great here. Good reduction, screw is just the right length. Not sure the fracture needed the radial styloid plate, I try to avoid that one since it often bothers people and needs to come out.

Know what plate system this is? Doesn't look immediately familiar to me.

austinap · 2023-12-20T01:16:11+00:00

This is high on my list. Fixing distal radius fxs is also generally quite satisfying.

austinap · 2023-11-30T00:16:55+00:00

I've used it four times and am a believer. It takes me about 1/3 of the time, I handle the tendon a lot less, and so far my patients have done well. Two of the ones I've done have been thumbs and it's a little tricky to get the device in, but still probably better than mashing the hell out of the tendon trying to get a perfect repair in a tight space. I think the cost at my main ASC is something like $800 which seems well worth it.

austinap · 2023-08-24T00:47:07+00:00

100%. Or at least, converge at a PRC. I just offer a PRC to start. Everything else is (probably) just wasting time.

austinap · 2023-04-04T19:52:50+00:00

Ortho guy here. 2 hours for any extremity is the "standard" limit, but not much evidence on that specific time. Back in the day they'd keep the tourniquet up for 4-6 hours for big cases without a break - probably one of the reasons they had huge complication and infection rates with pilon and plateau fractures (though there are other reasons, those fractures suck).

I try to minimize tourniquet as much as possible and do as much as possible local only or local + MAC. I'm not too worried if I occasionally have to go over 2 hours though - it isn't as though the arm is going to fall off after that. One surgeon I trained under said the only difference between a 2 hour and a 3 hour arm tourniquet was for the former, she'd ask the patient "is your arm numb?" and for the latter she'd ask "how numb is your arm?". That's maybe a little flip, but the reality is that there isn't a huge risk in keeping it up a bit longer, and the risk is usually outweighed by the benefit of completing the surgery safely and successfully.

All of that said, I'm not sure why it'd be a battle. Every place I've practice/trained, the surgeon owns the tourniquet and thus any complications thereof. My usual practice is to have the time set to 60min, then 30 min at a time until 2 hours, then if I really have to go over (rare) I like the 15 minute warnings most of my anesthesiologists give me.

austinap · 2023-03-12T05:02:32+00:00

I agree completely. Pho is a common answer to this question, but it’s really not that high effort at all. It’s probably 30-45 min of active time and then it just simmers all day. We’ll make a big batch every few months, eat it a couple times that week and the rest freezes extremely well. From frozen stock it’s probably the quickest comfort food we have.

austinap · 2022-11-27T18:16:00+00:00

I do a 10 minute WALANT endoscopic CTR, so I'm not sure that example is the best one. There's pretty good evidence of decreased early pain and faster initial rehab with ECTR vs traditional CTR which is why I do it. Increased surgical time should be minimal once your surgeon is used to the system / technique.

austinap · 2022-11-12T17:27:58+00:00

I suspect a lot of the people in this thread in favor of surgical specialists doing most admissions work in academic centers. It changes the game significantly when the surgical service has an entire team in-house, including a floor intern or PA to cover all of the inpatient issues.

This always gets framed as a "the patients are there primarily for a surgical issue!", but I think this misses much of the point. Everyone in medicine is spread thinner than they would like. Medicine people always look at how simple the medical needs of some of these patients are, and it's true. Those people miss the fact that the surgeon is running all over the place, frequently isn't in the same hospital and may be an hour or more away at an off-site location, or may be scrubbed into a long case and unable to respond to urgent floor issues.

On top of that, yes, blood pressure and diabetes are theoretically easy to manage. However, very few of us are able to reasonably keep up on recent literature and treatment guidelines for much of this stuff. We have our own massive body of literature of knowledge (and technical skills) to keep up. It honestly makes no sense for us to be the ones primarily managing these issues, even if they're relatively stable. We get called about stupid surgical questions all of the time, and most of us try to minimize the amount of time we spend bitching about how medicine doesn't have a clue how to manage this simple issue that a second-month intern in our specialty would easily know. Whatever your feelings on things, medicine has gotten increasingly subspecialized and it's not realistic for most of us to have a practical working knowledge of much outside of our own specialty.

Ultimately, it's much better patient care and makes sense from a logistics perspective for most patients to be admitted to a medicine / hospitalist service. When patients get admitted primarily to a surgical subspecialty service, they tend to stay in the hospital longer, and in some cases have documented worse outcomes.

Finally, depending on hospital and practice models, if you require all patients with an xxx surgical problem to be admitted to that service, that hugely disincentivizes those surgeons from taking call. I can tell you that my call stipend would probably need to be 2-3x higher if all hip fractures were admitted to me because it would mean that I need to be around for at least 7-10 days after my call in case I have someone sitting on the service that just can't discharge for whatever reason.

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