So I know hand and wrist probably isn't really the forte of most of the people in the room, but nevertheless, it does get tested on your board exam. So I'll try to hit most of the highlights. We'll do a lot of questions, and just at least get in your head the points of information that are somewhat previously tested. I don't have anything to disclose of any relevance to this course. We'll start with fractures, metacarpal and phalanx fractures. Remember that we usually classify these based on the location, so base, shaft, neck, et cetera, and the morphology of the fracture, long oblique, transverse, short oblique, spiral, factors into how we plan fixation. So I'll just go over some very brief principles there and the differences between simple and comminuted, you know. So some of the things that are frequently tested, a few take-home points. Five degrees of rotation of a metacarpal can cause 1.5 centimeters of digital overlap. Five degrees, 1.5 centimeters. It has been tested, so try to just keep that in your mind. What do we accept for a metacarpal shaft? 10 degrees in digits two and three, 20 in four, 30 in five. And the reason for that, as you may recall, is because of the increased mobility of the fourth and fifth CMC joints compared to the second and third. So they're more mobile, you can tolerate more. So 10, 10, 20, 30. And then it has been studied in the lab, seven degree extensor lag will result from about two millimeters of shortening. Now that's functionally acceptable to have a seven degree extensor lag. Somewhere around five millimeters, although it's debatable, is what's typically quoted as acceptable shortening for a metacarpal shaft. So all these numbers have been tested, so try to get these in your mind. These metacarpal shaft fractures heal typically in around four to five weeks. If we are going to fix them, usually for either long oblique or spiral fractures, using isolated compression lag screws is beneficial. For your short oblique or your transverse, those are usually very amenable to a closed reduction percutaneous pinning. There's a lot of different ways to skin the cat for those technique-wise. So no one will ever ask you what's the best way to pin a fracture, but knowing that the long obliques and spirals are best with screws for rigid internal fixation. And remember that the dorsal plate is a nice option, especially for transverse fractures, either in a light laborer, like a borderline blue collar laborer that can get back to work early, or in a non-skilled position athlete. So someone like a linebacker or a lineman in football is a great person for a plate and screws because they can play almost right away after in a cast. The boxer's fracture, the metacarpal neck fracture, those numbers I quoted before for the shaft, the 10, 10, 20, 30, basically just add 10 degrees more for each one of those. So probably 20, 20, 30, 40 is what we kind of accept when it comes to metacarpal necks for the same reason as the shaft. These are either going to get non-operative treatment. The majority of these are going to be non-operative or they can get a closed reduction percutaneous pinning with various techniques if they're displaced. And the one that occurs the most, as you know, is the small finger and 40 degrees is about the acceptable number there. Again, 20, 20, 30, 40 index through small fingers. The metacarpal base fracture can come in a couple of different varieties. So when it's seen in isolation, it's pretty easily managed. The majority of them are non-surgical, although if it's displaced and there's an extensor lag, you could consider pinning it. But the majority of isolated metacarpal fracture, metacarpal base fractures are non-surgical. Be very aware of a concomitant CMC subluxation or dislocation. What you'll see is the theme with the questions they tend to ask you guys is if something is missed when it should have been surgical and it was not. You know, the kind of thing that can get you into a lot of trouble. So you always want to, if they test a metacarpal base fracture, or if you see one, you have to look closely at the CMC joints. And if the X-ray looks like the one on the bottom where there's subluxation of the joints, that's one that's very unstable and needs to be closed, reduced, and pinned. And here's just an example of what you might see on the AP view. So if you can see over on the left, you see a perfect little joint space between the fifth metacarpal base and the handmaid, and you do not see that on the right side. No matter how you take them to fluoro or you try to find it, that joint surface is absent, which is a hint that that joint is subluxated or dislocated. The Bennett's fracture is also a CMC injury. It's just a CMC injury to the thumb. They do like to test some of the deforming force questions on this injury. So remember the APL is the deforming force for this fracture, the abductor pollicis longus. It inserts on the dorsal base of the metacarpal, and it's basically gonna pull the shaft away from the intact fragment, that volar ulnar fragment that's still there. It gets displaced by the APL. And this in most patients is a surgical injury. So I think they want you to be aware of the significance of this injury. And as long as it's recognized acutely, it can typically be pinned or if the piece is really large, you could consider screws, but usually pinning. Phalangeal fracture is obviously highly variable depending on which phalanx it is, but our tolerance for deformity, just know, is much less than it is for metacarpals. And at the same time, we hate opening these. So the answer for these is hopefully gonna be some sort of closed reduction percutaneous pinning. The principles on when to apply surgery are not all that different than in the metacarpal. If you can treat them non-surgically, you do an intrinsic plus splint in a position shown here, flexion of the MP joints, extension of the IPs, and that'll help prevent too much stiffness from occurring. And you always want to, with phalanx fractures, the answer is you splint or cast to the joint above, joint below. So if it's a proximal phalanx fracture, you can do a cast that has the DIP joints free. Just remember joint above, joint below, the kind of stuff you learn early in residency. Applies to most of these finger fractures. A common mistake is immobilizing these too long. So realize that these fractures, the literature supports three or at most four weeks of immobilization time before you start controlled mobility. And that's with a removable brace, seeing a therapist, starting motion at three or four weeks, typically active and active assist motion. These do heal quickly, and that's in a good way when you talk about return to sport, because typically within about two months, eight weeks, these people can get back to sport, maybe body taping at most. When these are fixed surgically, we try to do either percutaneous or limited open fixation. It's gonna be a lot of the same principles that we applied to the metacarpal. This unicondylar proximal phalanx fracture that you see shown here is a common injury within an athletic population, and it can either be missed or mismanaged even if identified. So these are almost always surgical. Just be kind of aware of that, because the effect of a malunion on the joint is a very negative one. So just be aware of this injury is a pretty common one. This can be treated with a closed or an open reduction and either screws or pins placed across. They do like to test these PIP dislocations as well. The majority are dorsal, but when you look through some of the questions that have been seen on your exams, they definitely test the volar one, even though it's the kind of thing I see once every year or two. They like to test it, and I think that's because of the significance of the injury, all right? So even though most of them are dorsal and they affect the volar plate and one or both of the collateral ligaments, the volar ones get tested almost more because of the effect of the injury on the central slip. So when you dislocate a PIP volarly, the central slip's gonna be violated. And the method of immobilization or rehab for that patient is entirely different than the 95%, which are just the volar plate dorsal injuries. So the volar plate dorsal injuries, they can be working on flexion right away. There's really nothing you need to protect except avoiding vigorous hyperextension, but you don't lose much. A volar one, the answer is you splint them full-time, extension for six weeks. And if you miss this and you don't do the right thing, then they get a boutonniere deformity. And if you remember much about hand surgery, one of the hardest things to fix is a chronic boutonniere deformity in a young, active patient. So again, they don't want you to miss important things. So don't be shocked if a volar dislocation shows up. And if it does, it needs full-time splinting for six weeks compared to dorsal, which is early range of motion to prevent stiffness. The dorsal fracture dislocations are often classified by how much of the volar lip is involved. So if you have less than 30% of the volar lip fractured with a dorsal PIP fracture dislocation, they don't really need anything other than just some buddy taping and they can return to play very quickly. The collateral ligaments, we know are injured with these as is the volar plate, but they never require any acute surgical intervention. And the greatest risk here is stiffness. So if there is measured stiffness, you get them into OT quickly. This range between 30 to 50% has been shown to be the at-risk range. So this is someone where you wanna under fluoroscopy or with static X-ray, bring them into some more extension and see if the joint starts to subluxate. The book answer is if the joint subluxates at 40 degrees or less, remember in full extension, it's gonna be the most unstable, most stable inflection. So if somewhere 40 degrees or more extension, they start to subluxate out, that's someone that the book answer is you treat them with extension block splinting. So you splint them at 40 degrees or so, and then over the subsequent four to six weeks, you start bringing them out into a little bit more extension. In reality, this isn't a very common clinical circumstance, but that's the way it's gonna be presented on a test. And that's gonna be your answer. If they're unstable at more than 30 or 40 degrees, like if they paint a picture, as soon as you get to 60 degrees short of extension, they're already coming out the back, that's one that's gonna be surgical. So that's your kind of, your picture of an at-risk. And then if you have a large volar lip fracture over 50%, those are typically gonna be inherently unstable and they're gonna sit in a position like you see on that top left X-ray. And this is one where if it's comminuted, they may present an option of doing like a distraction external fixator, which is a reasonable option, or if with screws or needing to sometimes go to the hemihemate. I doubt that they would make you differentiate between which of those three options is the best, but a dynamic X-fix, ORIF with screws, or a hemihemate are all options. The hemihemate is usually reserved, as you probably know, for the more comminuted, non-reconstructible volar lip ones. But those will be options for the large fragments. Late treatment of PIP, fracture dislocations like this are also decent options for the hemihemate if they happen to present that case. And there's decent literature supporting the benefit of that procedure, even within the chronic ones with a subluxated joint. So a few questions relevant to these topics. A 14-year-old male basketball player presents after jamming his thumb during a game, swelling and pain over the thenar eminence, and his radiographs are shown. What's the deforming force of the injury? All right, so this is the one we just talked about, a Bennett fracture, right? So a Bennett, it's gonna be the abductor pollicis longest. The APL is gonna be what your deforming force is. And if you just look at the X-ray and see which way the metacarpal subluxating, then you're gonna know which way it's taking the fracture. It's taking it dorsally and radially. 22-year-old starting safety on a football team is seen two days after injuring the index finger, severe pain at the PIP joint, and tenderness and swelling at the ulnar side of the PIP. Range of motion is limited, 20 to 40 degrees, and radiographs don't show a fracture, and the joint is reduced. And here's the stress radiograph. So clearly this is someone with a very unstable joint, but it's due to an isolated collateral ligament injury, as you can see. So an isolated acute collateral ligament injury is never surgical, 0% of the time, all right? So in the thumb, different story, but within the lesser digits, it's not. So the treatment for this person is simply gonna be just buddy taping them to try to protect that collateral ligament and to let them use the hand, all right? Division I cornerback comes out of the game holding the right hand after breaking up a pass. You find gross deformity of the long finger and with dorsal translation of the middle phalanx. With gentle traction, you pull it back in, it's reduced and you take him to fluoroscopy and you find a small volar lip fracture. It's non-displaced and it's 25% of the articular surface. You do find that the joint begins to sublux in less than 45 degrees of flexion. So he's almost into that at-risk zone, 25%. Remember the 30 to 50% is at risk. They're saying at less than 45 degrees, so he doesn't have to be flexed too much. Less than 45 is when he starts to subluxate. So remember, they're kind of painting the picture here of someone who should be, book answer, extension block splinting, because they start to subluxate a little at around 40 degrees or so, and it's a small enough piece that it has a chance of success. If it was a 50%, 60% piece, the answer's probably gonna be surgical. 18-year-old softball player, palmar dislocation, PIP joint. Okay, so here's that again. It's something I see once every two years, but it shows up on your guys' exams. So a volar PIP dislocation, and the answer here is gonna be that the central slip's injured. So full-time extension splinting, right? Full-time extension splinting, six weeks. High school basketball player, left hand, catches a pass, struck the ring finger, pushed it down into his palm, volar dislocation, IP joint. These are two different tests. It comes up again, a different question. The finger's reduced, and it shows that it's concentric. So what's the best treatment for the volar dislocation? Splint the PIP in full extension. All right, moving on. Soft tissue injuries of the hand. Thumb ligament injuries, they definitely like testing these, especially the pertinent anatomy gets tested the most. So radial collateral and ulnar collateral ligament injuries. The classically tested parameters are if you have greater than 30 degrees instability as an absolute number, or a 15-degree difference compared to the contralateral side, has a high suggestion of a complete injury that's at risk of a stenor lesion. And remember, we'll go over a stenor lesion, but at a high enough risk of a stenor lesion that it's likely surgical. I'll tell you, in practice, these numbers are very hard to really perceive just looking at a thumb, and people have a lot of side-to-side variability. So in practice, having fluoro and doing stress testing compared to the other side very objectively is critical. But these are your book answers, these numbers. It's also been quoted that 33% radial or ulnar subluxation or three millimeters of palmar subluxation are criteria for surgery, although to be honest, I haven't really seen those tested much, so those aren't numbers you need to memorize. With an RCL injury, especially a chronic one, they're classic for showing a big head of the metacarpal kind of staring right up at you. So if you look at someone's thumbs like this and you see the head of the metacarpal more prominent on one side than the other, there's probably a RCL injury that might be chronic. They usually present more chronic than acute, the RCLs. These definitely get tested. So this is a take-home point, although it seems like minutia. The proper collateral ligament runs obliquely. It runs between those two purple dots, okay? The metacarpal's on the right side, the proximal phalanx is on the left side. So it goes from dorsal on the metacarpal to volar on the proximal phalanx. And it's because of that orientation that it helps prevent volar subluxation of the P1. So you can imagine, it's not only constraining in the coronal plane, it's also preventing the phalanx from falling down in the sagittal plane. So the proper collateral runs obliquely. The accessory collateral runs a little more straight, less oblique, and it's more volar, all right? So you can think of it almost more like a hammock on the volar surface of the joint. It's almost part of the volar plate in a way, the accessory collateral, versus the proper digital that runs further up. So you probably need to rupture both of these to place yourself at high risk for a stenor lesion. And remember, a stenor lesion is where the whole ligament pulls off and the adductor pollicis gets wedged under it. So it has no means to flip back to where it belongs because it has soft tissue interposed. And the only way to get good healing is to get the adductor out and directly fix the collateral back down. So here's an example of a classic rupture. It usually ruptures distal off of the base of P1, and you can see the residual ligament stump right there. If we do surgery, it's typically through a midaxial incision. Again, it's usually a volzed off of the phalanx, and you want to be careful. There is a little passing dorsal sensory branch that always goes right through the surgical zone. It's fixed with a suture anchor if it's soft tissue only or occasionally a very small tension band if it's a bony fragment that's been evolved. Post-operatively, it's four to six weeks in a splint and then starting supervised range of motion and starting pinch strength typically at around eight weeks. But remember that what you'll see get tested the most, and I have sample questions, is the anatomy of those ligaments and when to test. So because the proper digital goes at the angle, just remember you test it in an angle. So that one typically gets tested with the MCP joint at about 30 degrees flexed. Easy way to remember, it runs at an angle, you test it at an angle, okay? 30 degrees flexed. The accessory collateral, because it's straight, you test it straight. So that's the one that gets tested in full extension. If it's a zero, you're testing the accessory collateral. Collateral ligament injuries to the other digits is usually manifest by local tenderness to palpation over the ligament itself or with gentle stressing of the ligament. These are the ones I mentioned are never treated acutely surgically. So it's really buddy taping to the adjacent digit to try to prevent it. And then if you have gross instability in a chronic setting where you have chronic instability of a collateral ligament injury to a lesser digit, it can become surgical. And here it's the reverse of the thumbs. The thumbs, it usually evolves off of the proximal phalanx. For the lesser digits, it usually evolves off of the metacarpal head. So it's the opposite. Mallet finger, as lame an injury as it is, get tested for you guys too, I think probably because you see them a fair amount within the athletic population. It's a DIP extensor lag from an avulsion of the extensor tendon. You always wanna get an X-ray of these, always, always, because you wanna make sure that there's not a large bony fragment because that's really your indication for surgery is a large bony fragment. The majority of them, small bony fragments, even if they look avulsed or soft tissue only, are never acutely surgical, never, never. All right, so unless it's a large bony fragment with subluxation, it's not surgical. It's six to eight weeks of full-time splinting followed by then about a month of night splinting. Reduction in pinning should be considered for DIP joint subluxation. That's the main indication, a subluxated joint. And the predictor of that is likely a greater than 50% fracture fragment. All right, so those two go hand in hand and one leads to the other. And here's an example of that. So a approximate 50 to 60% bone fragment with a joint that's subluxated. And you see that the concavity no longer matches the convexity, right? They don't fit on top of each other appropriately anymore. And that's one that should be fixed. The Jersey finger, they love testing this on your guys' tests. It really comes up a lot. So maybe more than almost anything else I'm gonna present today. And the reason is because they don't want you to mismanage. They don't want you to miss the things that are important or over-treat something that needs benign neglect and it's gonna do worse with surgery, and I'll go over that. So it's almost pathognomonic in the ring finger. It's almost never in another finger. And the Ledi classification for this is one of the classifications in hand surgery that's really most stood the test of time. So a type one is where it retracts back to the palm, okay? And these are really important points. Retracts to the palm, and you probably only have 10 days at most to fix it surgically. So they'll present someone where it's in the palm, on an MRI or on exam, and it's a month out, okay? And that person is not the person who you sign up for a repair. That's one of the few most important take-home points from today, okay? If it's in the palm and it's more than 10 to 14 days, you do not fix it. Type two is where it's gonna retract to the level of the PIP joint. The vincula typically restrains it so it doesn't go any further. Those you have about six weeks to fix because you haven't had much shortening and retraction of the muscle belly. So you have more time, probably six weeks. A type three is gonna be bony, and it's gonna be a large enough bone block that it only goes to the DIP joint. So it barely went anywhere. So those you probably have almost an infinite amount of time to fix, okay? But they don't really present those. They like to present the other ones that can more get you into trouble. So if there is a delayed diagnosis beyond those repair timing parameters, you're either gonna treat it with benign neglect where you do nothing and you leave them with a hand that comes down like this, which is okay. I mean, it's not a bad hand. Or if it's a high-level musician or someone that fits the mold, considering either one or two stage tendon grafting for that. But you never do a repair after they're past that time period for a repair. Once in a while, you'll meet someone who they don't really care about the fact that they can't bend the knuckle, but it's hyper-extensible because they don't have an FTP. Every time they go to type or do anything, the knuckle flips up because it's loose, and that bothers them. And for those people, either a capsulodesis or a fusion of the DIP joint could be a benefit to give them a solid fingertip. And there'll be some questions. We'll go over to make those points hit home. Flexor pulley rupture is seen in the population you guys tend to treat, so be aware. It's classic in rock climbers. So if they present a finger issue with a rock climber, you can bet they're probably presenting a rupture of a pulley. They can present in a lot of different ways. They can present looking like a central slip injury, looking almost like a boutonniere. PIP flexion contractures are common. You probably all remember this bow-stringing concept, but none of you really know what bow-stringing looks like, right in someone's finger. So it's usually gonna be a PIP flexion contracture is one of the first things that you see. And then when they come down to make a fist, even though they have a PIP flexion contracture, they still can't quite get it down all the way either. But their chief complaint is often the fact that they have a PIP flexion contracture. The area that's ruptured is variable. The most common is some combination of like A2, A3. Sometimes it can be all of them, A2 through A4. It's never acutely surgical, never, okay, because it's a reconstructive procedure. You're not gonna go in there and fix a pulley. So if you diagnose them even a week after the injury, you do pulley rings, you do OT to try to maximize PIP extension. And if it remains a problem six or eight weeks down the road, then you can reconstruct it. But it's early splinting, early therapy, and then later on surgical if necessary. The boxer's knuckle or the sagittal band rupture. This is gonna be someone with pain and swelling over the dorsal aspect of the MP joint. It's most commonly the radial sagittal band that gets injured because the tendon tends to go ulnarly. A way to remember this is remember the old rheumatoid hand with the ulnar drift. That's because the radial sagittal band tends to be the one that ruptures, traumatic and with rheumatoid. So radial sagittal band usually, and the tendon goes ulnarly. Sometimes it's a hard diagnosis to make early on because they just have a big swollen joint. So you gotta have a low threshold and kind of be aware of it and be closely looking how their extensor tendons track. And if you're not sure, you can get an MRI to see. Treatment, if it's recognized, within the first three to four weeks, you can try to splint them in almost full extension and then gradually over about a month, bring them into a little bit more flexion. If it's in the chronic setting, it's best treated with a reconstruction because there's not much of a role. Although I'll show a question where, I think it's a bad question, where for some reason the answer was to go in and do an acute repair. So I'm hoping you don't get that question because I don't know why that was the answer. But the answer is usually gonna be splinting early. So some questions. 19-year-old football player, right hand problem. Can't extend his thumb IP joint after he felt the pop in his wrist earlier that morning. No history of trauma, although he now does remember that he has fell on an outstretched extremity six weeks ago and initially had pain around the wrist. On physical exam, he can't extend the thumb, but passively he has full range of motion. No sensory or vascular deficit. So when they present someone who has full passive motion and limited active motion, you guys probably know what's going on here. Full passive motion, but a lack of active motion. The answer is either gonna be a nerve problem or a tendon problem. Are gonna be the only things that are creating full passive motion, but limited active. So he has a tendon problem. He has a rupture of his EPL. So remember an EPL, the classic answer for this is to do an EIP transfer. So he must've had a non-displaced distal radius fracture that was missed and then he had a nutritional rupture of his EPL. So it's a tendon transfer from the EIP. High school football player, weakness in grip. Can't bend his ring finger. So you already know what this is, right? Can't flex his ring finger. Injured it 10 weeks ago making a tackle. So they're giving you the information you need to know. 10 weeks ago, this guy got a Jersey finger is really what they're starting to present. Can't flex the DIP of the dominant ring finger, no swelling or tenderness. So it doesn't seem acute and he doesn't have pain in the palm. Pain in the palm after a rupture could be a reason for surgery to go in and excise the stump, but they're not painting that picture. Subjective weakness and grip and MRI confirms that the FTP is in the palm. What's the most acceptable treatment at this time? Okay, so for him, it is benign neglect, right? It's not going in and doing anything surgical because he hasn't really demonstrated that he needs that and it's chronic. 13-year-old flag football player, ring finger injury. Occurred while trying to pull a flag from an opponent. Has a swelling with the finger lying in slight extension. There's no active flexion at his DIP joint. They don't say the exact date of injury, which is a little bit odd, but they're certainly making it sound like it's relatively acute. So this is identifying this is an acute Jersey finger, so you go in and fix it, okay? 28-year-old boxer, right index finger, MCP joint pain and dorsal swelling. Has localized pain and swelling over the dorsal MCP joint. Full passive range of motion, but he has an inability to achieve full terminal extension. This is that kind of bad question I was telling you about where for this person, because they're fully passively correctable, if you can document on MRI or on clinical exam that the extensor ends up back where it belongs, that person probably should be splinted. But the answer for this is that, I believe, is you should do a surgical repair. So maybe the catchphrase of he has an inability to achieve full terminal extension, maybe that's why they're saying that it should be surgical, but I don't have a good answer for that. I don't know why that's the answer, but just kind of be aware that this picture they might want you to operate. We were at a local high school basketball game. Trainer calls you to see a catcher. It's the thumb of the glove hand was forced backward on itself, immediate pain, can't get it back in the mitt. He's tender on the ulnar side of the joint. No firm end point when applying gentle radial stress. So a lack of an end point suggests it might be a significant ligament injury. And remember, they say that's both in a flexed and an extended position. So when you stress it in flexion and in extension, it's loose in both, right? So remember, testing it in flexion is the proper collateral. That's the one that runs obliquely. Testing it in extension is the accessory collateral. That's the one that runs straight. What's the significance of the radial instability both flexed and extended, right? And it's both of them. It's that there's rupture of the proper and the accessory collateral ligaments, and that places you at a high risk of a stenor lesion because the whole thing is a volzed off and there's enough room for the adductor pollicis to sneak in behind the ligament. 20 year old college football player, hyperextension injury to the right ring finger four weeks ago, can't actively flex the ring finger DIP joint. Again, you're probably already getting bored with this, but you can see how the degree gets tested. Can't flex the DIP joint, has passive motion intact. The mass is palpable on the palmar aspect of the PIP joint. All right, so this is a type two. It's only retracted to the level of the PIP joint, and the injury was four weeks ago. Four weeks PIP. What's the most appropriate operative treatment is gonna be a direct repair, right? Because a type two, you have six weeks. When it's at the PIP joint, it's not as far. You got six weeks, four weeks is okay, so you fix it. Baseball player, mallet injury, non-dominant middle finger during the game in the middle of the season. What's the most appropriate treatment for this injury? They don't mention anything about a large bony fragment, so you can probably assume it doesn't have that. So it's gonna be full-time extension splinting for the six weeks, followed by at night for a month. Rugby player, type one avulsion of the FDP at its insertion on the ring finger in the fifth game of the season. What is the most appropriate treatment? So it's in the palm. So they kind of paint this picture like it's early or middle of the season. They're tempting you to say, let him keep playing, right? But they say it's type one, and you know a type one can't wait. So a type one needs it to be done right away. 32-year-old fell while skiing, complains of pain and swelling at the base of the thumb. You're assessing ligament stability of the MCP joint. What position should the thumb be held in? Here we go, same points, right? 30 degrees of flexion to test the proper collateral and full extension for the accessory collateral, all right? There's only two things to take away from this talk. It's gamekeeper's thumb and jersey finger, the things with bad eponyms. Those are the things that get tested a lot. 25-year-old skier, thumb pain after a fall, no opening of the MCP joint with radial stress and full extension, and there is laxity at 30 degrees of flexion. So they're loose when they're tested in flexion. What's most likely injured? The proper collateral, because they were testing it in modest flexion. Football player can't straighten the tip of his ring finger since he injured it six weeks ago. He can flex it without any pain. You take radiographs in the office that show no fracture. So they're painting the picture of a mallet injury at six weeks old, even at six weeks, two months, even in that range, you still try to splint a mallet and sometimes they can still correct themselves. Baseball player hit by a fastball on his left long finger knuckle, had ice and immobilization. You're seeing him one day later. Swelling dorsally at the MCP joint and there's with palpation and manipulation there is a pain, I think. There's full passive range of motion. He's able to perform active extension from a fist to MCP extension with no deformity noted and radiographs are normal. So they're painting a picture of that boxer's knuckle and I get the sense here, this is someone who they're saying he can get all the way there on his own, even though he has a boxer's knuckle. So for this person, I think they are recommending immobilization and extension. So it seems like their breaking point for making you guys recommend surgery is if they can fully actively extend on their own or if they can't and it's stuck down for testing purposes, okay? All right, moving on to the wrist. You can think of the wrist as kind of a four-sided box in a way. So radial, ulnar, dorsal and volar wrist pain or wrist problems and we'll tackle each of those groups kind of independently. Radial-sided wrist injuries. These are the main ones that you're gonna see. Scaphoid fracture or scaphoid non-union. There's arthritis of the CMC, STT or radiocarpal joints. Slack arthritis would be the classic at the radiocarpal joint. And then there is dequere veins, tenosynovitis. And the green box is where you're gonna have your CMC issues. The purple, phasing into the red, you're gonna have decrevains. STT arthritis or scaphoid problems will be at the purple, kind of around the snuff box. And definitely the only thing that should hurt that far up at the red over the radius is gonna be decrevains. So here again is a example of a scaphoid fracture, scaphoid screw across it. Scaphoid fractures, there should be a history of trauma, although once in a while you'll meet someone who really didn't remember the event, but usually it'll be a football player or someone who gets hurt a lot. The classic is that they're tender in the snuff box and there's various stress views you can get to try to make the scaphoid stand up tall and see it well. The classic algorithm is if the x-rays, including stress x-rays, are negative, then you can put them in a cast and then re-X-ray at around two weeks, kind of presuming that it could be a non-displaced scaphoid fracture, and then see them in two weeks when maybe the fracture has resorbed some at the edges and you might see the fracture better, or there's the option for the immediate MRI. And there's definitely literature supporting cost-effectiveness of an immediate MRI, especially in a working individual. It's hard to say that there's cost-effectiveness in making a high school kid who can still go to school and doesn't make any money to make that, the cost benefits not quite there in a kid, but in an adult, definitely. It used to be supported to get a bone scan, alternatively to the serial casting for scaphoids, although now, really, MRI has superseded that because it's a more sensitive and specific test. CT scan with scaphoid fractures has a role in trying to confirm that a non-displaced fracture is, in fact, non-displaced. So if it's a normal-looking scaphoid on x-ray, normal, then the MRI's the answer to try to diagnose a non-displaced fracture. And there's role because then you can get that person back to function. Because when you look at the literature, about 80% of patients who you would swear they have a scaphoid fracture, it's the right mechanism, they're the right age, you push, everything, and it hurts, but the x-ray's normal. Even 80% of those patients aren't gonna have a fracture. Only 20% of them do. So if you're over-treating 80% of people, that's a lot. And that's why there's the impetus for the earlier MRI. CT scan is good if you see a crack and you're trying to confirm that it truly is non-displaced. And my recommendation would be, for practice, every non-displaced crack of a scaphoid waste deserves a CT scan. Because you'll be surprised how often they're gapped, even a millimeter or two, and that's enough for surgery, because it places them at risk of getting a non-union. CT scan also helps define the quantity of a humpback deformity, if you're dealing with a scaphoid non-union. The indications for surgery, almost all proximal poles are gonna be surgical, so if they present a proximal pole, when in doubt, you should operate on it. Or greater than one millimeter of displacement of a waste. Most of the distal poles are non-surgical, just for your information. And there is some pretty good comparative evidence showing that there is earlier return to sport with a non-displaced fracture for a non-skilled position athlete, if you fix it with a percutaneous screw, compared to treating it with a cast. So your light laborer or your non-skilled position athlete can likely get back faster if you do a screw. Here's just some of these results that I've summarized for you, nothing to memorize here, don't really worry about this slide. Scaphoid non-union, as I mentioned, CT scan is good to show the morphology of it, the degree of humpback, the degree of cystic change. If it's a proximal pole, those are usually atrophic non-unions, where the overall bony architecture and geometry of the scaphoid's maintained, you just have a little crack that won't heal. Those usually get a dorsal approach, bone grafting to enhance the biology, and a screw for stability. For a waste fracture that's a non-union, those are usually displaced, those are usually the ones that flex into a humpback deformity. So they typically need a volar approach to jack the fracture open. Bone graft, I don't think they'll ask you structural versus non-structural, but bone grafting into the waste and then fixation typically with a screw. And just know if it gets tested, vascular bone grafting is indicated primarily for AVN of the proximal pole. Whether that's with a waste fracture or with a proximal pole fracture, they have to tell you that there's AVN of the proximal pole before a vascularized bone graft is gonna be the right answer. Moving on, decoravanes tenosynovitis. It does get tested a little bit, so just be aware of it. And it's really this anatomy, I think, that gets tested the most. The first dorsal compartment tendons are the APL and the EPB. Those are the ones that are involved. We see it a lot in frequent wrist sports like racquet sports, golf, bowling. The Finkelstein's test, as you know, is kind of pathognomonic for this condition. If they present someone with more mild symptoms that hasn't had much management, then a thumb spike, a splint, anti-inflammatories, ice, et cetera, is the way to go. Furthermore, moderate to severe disease, cortisone injections are highly effective, over 80%. It's the most successful thing we treat with cortisone in the hand and wrist. So, very high cure rate. And surgery, because cortisone works so much, surgery's not very common. But if it is done, the two main things you need to look out for are the dorsal sensory radial nerve branches that are at risk through the surgical field. They need to be identified. And then if you do a release too volar and you don't create a sling, you can get volar subluxation of the tendons when they go into flexion. So that's something to look out for. Questions, radial-sided wrist and hand pain. Competitive racquetball player, radial-sided wrist pain. Notes that there's discomfort with hitting shots. It's been present for six weeks. Has tried icing, but hasn't had any successful relief. There's a positive Finkelstein's and crepitation over the distal radius, two centimeters proximal to the styloid. What would we recommend in this case? It's a steroid shot, relative rest, home exercise program, and a splint. So your basic mainstays of non-surgical treatment of decrovanes. Female tennis player, several month history of radial-sided wrist and thumb pain, no trauma. And usually for these, if they're thinking tendonitis, they'll say no trauma, because it helps you rule out scaphoid fracture a little bit. There's been no improvement with multiple non-steroidal anti-inflammatory medications. First dorsal tenderness, positive Finkelstein's, negative CMC grind test, no degenerative joint disease. You diagnose her with decrovanes, and you perform an injection into the first dorsal compartment, what anatomic structures are present? So this huge, long question, all they're asking is what runs in the first dorsal compartment. So just try to memorize that, APL and EPB are the two. If you want a hint for trying to memorize those, if you know that there's a longus and a brevis that runs in there, you know it's not EPL, right? You probably know enough about the hand to know that EPL definitely is the one that extends the thumb IP joint, it goes on the top of the wrist. So if you know that it's a longus and a brevis, and that it's not EPL, then it's gotta be EP brevis and AP longus, right? Ulnar-sided wrist injuries, this is the low back pain of the wrist for hand surgeons, always a lot of vague things but they'll hopefully not present too vague a case for you. These are the things we're gonna talk about with the ulnar-sided wrist stuff. We'll start with TFCC tears. These patients usually have tenderness to palpation at the dorsal DRUJ and the ulnar fovea, so those are the green spots that you see there on the picture. There could be pain with passive ulnar deviation or what we call like a grind test where you kind of load the wrist axially and make them rotate, pronation and supination under axial load. One of the keys will be assessing the stability of the DRUJ, because that'll factor into some of the treatment recommendations. So hopefully they'll present one with an unstable or a stable DRUJ and maybe help you a little bit. These have been classified by Palmer into traumatic and degenerative. Just know that if they present like a chronic appearing, macerated central tearing of the TFCC, have a look if they have a long ulnar positive variance and that's someone who really would benefit most from an ulnar shortening joint leveling type procedure. But from what I've seen of the questions, most of your guys' questions fall more into the traumatic realm. So the peripheral tears tend to be acute versus the more central tears would be degenerative. In the acute setting, there's very rarely a role for surgery unless they have a blatantly unstable DRUJ or they paint a picture of like an irreducible DRUJ, but these are almost all gonna be treated acutely with splinting. If the DRUJ is stable, it can just be a wrist brace. If the DRUJ is unstable, you might wanna consider a Munster splint or a long arm splint and supination. In the delayed setting, if it's been over six weeks, that's when you start thinking about something like a cortisone injection in addition to the splint because most of the biologic healing that was going to take place will have already taken place. So you're just trying to get inflammation out at that point if there's any chance of avoiding surgery. For a tear without DRUJ instability, just a scope debridement, those patients, I think you can treat almost like a knee scope debridement of the meniscus. So you start range of motion almost right away, a wrist brace for comfort, and they can return back to sports pretty much as tolerated starting at a month to six weeks out. If you do a repair, then you need to protect your repair for six weeks. So for six weeks, it's a transitioning from a long arm splint then to a wrist brace, and it basically delays the return to sport by probably about six weeks, so looking closer to three months. And then remember that central perforation, more chronic tear that benefits from some sort of joint leveling procedure, a wafer or an ulnar shortening osteotomy. Here's just an example of one of those peripheral tears of the TFCC, and here's the type of, well, typically we do more than one, but anywhere two to three of these little horizontal mattress sutures that can be placed kind of arthroscopic assisted. This is an example of a more central TFCC tear, so you see the entire body of the TFCC has signal change in it, so it doesn't appear to just be a peripheral tear. The body of the disc itself looks more diseased. Here's an example of the ulnar positive variants just in case they were to show it. You wanna draw a line across from that volar rim of the distal radius, and the articular surface of the ulna should be equal to it. Here you see it's longer, so an ulnar shortening osteotomy was done to try to bring the distal ulna back down to be equal with the radius. And here's an example of what one of those central degenerative tears would look like, so frayed in the middle. That's actually the distal ulna that you see in the middle, so that person has worn through pretty much the entirety of their TFCC down to visualizing the cartilage of the distal ulna. So you arthroscopically try to smooth that out, but the more critical thing is to do the ulnar shortening. Moving on to the ECU, actually, even though ECU pathology's not all that common, this does get tested, and I'll have some sample questions for us to think through, but the questions here get a little bit, the ulnar side of risk questions get a little bit hazy sometimes, so if you see one, I would concentrate on it a little bit, because sometimes it's just not as clear what they're looking for. So ECU, there's a few different ECU pathologies you can have. You can have tendonitis of the ECU, where it's structurally normal and it's just inflamed. You can have ECU tendinosis, where you'll see thickening, just like the Achilles or anything else, you see these kind of thickened blobs of the ECU that have undergone actual tendinosis changes. Or you can get subluxation of the ECU, where the ECU, the tendon itself might be fine, but it ruptured out of its external sheath, and it subluxates volar around the ulnar styloid. Okay, so the ECU should be sitting as a dorsal structure, and the pathology will be that it subluxates around the side, around the ulnar side, to the volar part of the wrist, and that would be subluxation. So these are the people who are at risk of ECU problems, and the ECU is that red structure shown there. So regardless of their ECU problem, you're gonna look for tenderness over the ulnar groove, and then you wanna try to diagnose if there's subluxation occurring. So in ulnar deviation and supination is when it's gonna dislocate. So it's like the opposite of the DRUJ. The DRUJ is stable in supination, ECU's the opposite. ECU comes out in supination. So you wanna bring them into supination, and then ulnar deviation, and see if you can palpate the tendon flipping out, and you wanna do side-to-side comparisons. On the MRI, you wanna look for the ECU to be seated appropriately, like it is here. You can see how the ECU is sitting in the middle of the groove on this MRI, compared to the next one I'll show, where you'll see it's out. This could be a case more of ECU tendinitis with some tendinopathy. You see the ECU has some little kind of dots of signal change in it, and there's definitely some tenosynovitis around it. It lights up pretty white. But when you look at this MRI, for example, that yellow arrow is pointing out to an ECU that's spilled out of its groove. So now it's falling around to the volar side, and this schematic kind of shows how that happens. It's a delamination of the retinaculum that's supposed to keep it in its groove, and then it spills out and goes volar. For ECU tendinitis or tendinopathy, which is shown here, remember that MRI I pointed out could be more like a tenosynovitis, you see a lot of tendinopathy of that ugly-looking ECU there, just like an Achilles or a biceps could get. For tendinitis, it's the basic early stuff, a wrist brace plus-minus a cortisone injection. But if they paint a picture of someone with a lot of tendinopathy, a big, thickened, nodular ECU, the answer's not an injection, because that's someone who can easily rupture. So that person's probably someone you want to take a little bit more lightly. For the instability, if it's diagnosed early, you want to do some sort of a long arm or Munster splint and pronation to try to keep it in its groove where it belongs. And if that fails, then you can reconstruct the groove, or reconstruct the retinaculum with a groove deepening as needed. Here's just an example of that. I don't think they'll ever test techniques for how to do that. Dorsal tricritral fractures, very common, boring and common. So they're almost never surgical. You'll see just on the lateral x-ray, this little bone chip, if they show you that, the answer is that it's a dorsal tricritral avulsion injury, which represents a ligamentous avulsion on the top of the wrist. It'll oftentimes come after a fall, most commonly. It's six weeks of immobilization. And I think you do need to take these a little bit seriously, because once in a while, the ligament avulsion will be so big along a spectrum that they can go into a VZ collapse pattern. Remember VZ, if you remember, VZ, V-I-S-I, is due to lunar tricritral ligament injury along the scale with the dorsal extrinsic ligaments, compared to DZ, which is the slack arthritis thing. So I think these people do deserve a cast, or at least full-time splinting, to try to let whatever injured heal well and not cause a collapsed wrist. And then lastly, the hook of the hematopoietic fracture, you would see very commonly within an athletic population. It's gonna be isolated pain in the palm. It's usually a very short differential diagnosis list with this condition, because they're tender in a very specific place. So people who play racquet sports, it can sometimes be an acute on chronic condition, and you wanna look for pain reproduced by flexion of the small finger, or occasionally ulnar nerve symptoms. And occasionally, there'll even be small finger flexor tendon rupture. If it's an acute injury, six weeks in a cast, and you hope that it heals, you don't need to document healing on a CT skin, because it really doesn't matter if it's a stable, painless, fibrous union, you don't care. In the chronic setting, it's a surgical excision, which works great, and people are back to sport very quickly. You just gotta be careful of the important anatomy that's around it. But it's an excision, and then return to sport pretty much as tolerated within a month. There can occasionally be pathology within Guillain's canal, which can be an ulnar artery thrombosis, or an aneurysm, like a hypothenar hammer syndrome, or occasionally a ganglion cyst. And the classic here will be someone who presents with isolated, motor-only ulnar nerve dysfunction. And they're trying to make you fall into the trap of, say, his cubital tunnel. But if it's motor-only, then you have to look at the wrist. Probably get an MRI to see if there's a ganglion cyst, or a space-occupying lesion on the motor branch. Ulnar-sided wrist pain questions. Trail-riding cyclist, weakness of grasp in the hand, difficulty with key pinch. It was observed for six weeks. An MRI shows a cystic mass in Guillain's. So this is exactly that scenario I just described. So motor weakness secondary to a mass in Guillain's. So the answer is gonna be to open up Guillain's and get the cyst out, to take the pressure off the motor branch. Offensive lineman, two-month history of wrist pain. Now pain with past protection. It's ulnar-sided tenderness and pain with axial load, ulnar deviation, and wrist extension. So they're not really talking about a subluxating tendon. They're talking about ulnar-sided wrist pain with axial loading. The radiographs don't show any, they should say positive, don't show any substantial ulnar variance problems. So it's an MR arthrogram. Here they don't give you a non-arthrogram, but just know in case it's tested that our literature does support an MR arthrogram is better than a plain MR diagnosing TFCC problems. MR arthrogram's better. Weight lifter, ulnar-sided wrist pain and mechanical symptoms. Working out for eight weeks. Went to the PCP. The MRI showed a central TFCC tear. Come to you for treatment. There's no DRUJ instability and the patient's wrist is ulnar neutral. So what would you do next? So they're painting a picture of no mechanical symptoms, probably suggesting that the DRUJ is stable. This is someone you can try non-operative management first. Don't have to go to the operating room for this for a central TFCC tear. Golfer, right wrist pain. It's been for two weeks after he hit the ground abnormally with a club hitting out of the rough. Hasn't been able to return. It's on the ulnar side of the wrist, reproduced with an ulnar grind. An evaluation of DRUJ stability reveals increased translation of the ulna with a shuck test relative to the opposite side. So here they're kind of painting a picture of a probable TFCC tear with DRUJ instability because they're talking about increased shuck. So the answer is further imaging to get a TFCC tear, to see if there's a TFCC tear. Fly fisherman, ulnar-sided wrist pain in the dominant hand for one week since a fishing trip to Montana. On physical examination, there's a painful snap over the dorsal ulnar wrist with pronation and supination. So they're kind of painting the picture, dorsal ulnar snapping of a probable subluxating ECU. So radiographs are normal with no underlying arthritis. What's your recommended treatment? So you've diagnosed a probable subluxating ECU tendon. So it's gonna be immobilizing the wrist again in pronation, which is gonna be your stable position for the ECU and some dorsiflexion so it doesn't flex over the side. Collegiate rower has wrist pain lasting for one month since the beginning of the season. There's a pain at the ulnar aspect of the wrist and it's worsened with resistance to ulnar deviation and supination. And there is a fullness over the dorsal wrist also. So they're again painting a picture of the ECU. They don't mention it's subluxating, but they're describing tenderness over the ECU itself. So this is more your ECU tendonitis because it's not subluxating. And this would be your early supportive care. Hockey player, second opinion, had his wrist twisted. It happened three weeks ago, tried to play through it, but he couldn't. He's got exquisite tenderness along the ulnar side of the wrist. Forced wrist hyperextension and ulnar deviation increases discomfort, negative for fracture. An MRI just shows some generalized soft tissue edema in the ulnar hand. He elects to proceed to the operating room for diagnostic arthroscopy. At the time of the arthroscopy, you encounter a tear through the center of the TFCC complex, while the periphery is stable to probing. What's the treatment of choice? It's just a basic arthroscopic debridement. He doesn't have ulnar positive variance. He just has a non-structural TFCC tear without instability. So all it is is just an early debridement and then trying to get back to sports in four to six weeks. Recreational tennis player hit a low forehand shot, has ulnar-sided wrist pain, and a painful click is reproduced with ulnar deviation and supination, right? So here's ECU again. They're talking about this painful click on the dorsal form. So it's gonna be subluxation of the ECU. Competitive dart thrower, pain while throwing darts. It started after a fall onto an outstretched hand, two months prior, has difficulty throwing. The physical examination shows tenderness at the ulnar styloid and pain with passive ulnar deviation, and no tenderness over the course of the ECU or the FCU. The radiographs, including a carpal tunnel view, are negative. So what's the most likely injured structure? It's gonna be the TFCC, because they specifically said he doesn't have any tenderness over his ECU. So the main things they're gonna test over here is really gonna be TFCC, ECU, or hook of the hemate. It's probably gonna be one of those three things. So if they say he's non-tender at the ECU, that's painting a picture more for a TFC. But you can see these questions are a little bit more vague. They don't seem as obvious as some of the others, so I think you wanna read through them pretty well. Gymnast, sports medicine clinic, ulnar-sided wrist pain, insidious over three months. Can't compete due to discomfort with weight bearing. The pain's reproduced by ulnar deviation and axial compression of the wrist, and an MR arthrogram is obtained and shows a small amount of dye leakage into the DRUJ. So they're kind of painting a picture. Axial loading, ulnar-sided wrist pain, probable TFCC. At the time of your arthroscopy, there's a stable appearing horizontal tear of the TFCC just off of its radial attachment to the sigmoid notch. So what do you do for this person? Well, this is an arthroscopic debridement. I'm kind of surprised they tested portals a little bit. One maybe take-home point, we never do a 6U portal. Never do 6U, because it places the dorsal sensory and ulnar nerve at risk. So it's always gonna be a 6R. It's not gonna be a 6U portal. But it's a debridement because it's a small stable tear. All right, lastly, and we don't have too much left here, dorsal and volar-sided wrist injuries. These are gonna be some of the dorsal things. Note that the second dorsal compartment tendons, which sometimes get tendinitis, would be the purple there. The green could be scapholunate pathology or something like a dorsal carpal ganglion cyst. Intersection syndrome, that's also second dorsal compartment. Again, that's along the purple stripe. Keen box would be right in the middle of the joint, probably a little ulnar to that green box. SL injury, it can come along a whole spectrum. This x-ray shows a static deformity, so you can see it's wide there. Sometimes it takes a grip to demonstrate that, and if so, then that's considered dynamic. So it's along a spectrum from occult pre-dynamic all the way up to static or late-stage degenerative cases. You wanna test for a Watson's test. I don't think they'll ask you how to do it, but know that a Watson's is a clunk that's positive for scapholunate pathology. For acute repair in this case, you probably have somewhere around six to eight weeks to still have a chance of doing an acute repair, and maybe you add a dorsal capsulodesis if the ligament quality isn't great. But for a complete scapholunate ligament injury with a static deformity, and hopefully that's what they'll present, it's usually gonna be an acute repair. And from what I've seen, actually, SL pathology, thankfully, doesn't get tested all that much for you guys, because it does get a little hazy. So you would then pin for about six to eight weeks after the repair and then get them back to motion, knowing that there probably will be some degree of permanent stiffness, but the goal is to try to prevent arthritis. Probably three to four months at a minimum for return to play could be longer for some sports. Dorsal ganglion, well, the classic history is it can fluctuate in size. It should look very, very well-defined and nodular on the top of the wrist. They'll sometimes, you'll have these ones where someone, they can only show it to you when they do this, and that's one of those more flat-lying, almost pancake-like, occult ganglion cysts, but they'll be tender right over the scapholunate joint. It'll hurt, typically, with forced wrist extension, which would be like doing push-ups, would be the thing that would make them hurt the most. You'll see it on an MRI, as is shown here, emanating from the distal portion of the scapholunate interval, and you could also show it on an ultrasound or other advanced diagnostic testing. Splinting, aspiration, surgery would be the main goals. I haven't seen this tested much for you guys. I wouldn't pay too much attention to it. I think the treatment for this is gonna be pretty intuitive. Second dorsal compartment problems could be intersection syndrome, which is up proximal, where the arrow is, and that comes along with kind of like a crepitation, snap, crackle, pop, when they move the wrist, and they'll be tender there, or you can have an insertional tendonitis, where they're tender almost down near the second and third CMCs, where they insert. The anatomy, know that it's those same APL and EPB tendons of the first dorsal compartment that are crossing over the second when you get intersection syndrome, and it's usually due to repetitive motion of the wrists. I mentioned the snap, crackle, pop symptoms you can get, and it's your basic supportive care, rarely surgical, typically cortisone can cure it. And then Keenbox disease, which can be a whole nother lecture in and of itself, just know that it's AVN of the lunate. It can be diagnosed sometimes just because of pain with normal x-rays. There's MRI positive only, which is a one, all the way up to the various collapse patterns. Main take-home points are that if it's someone who's ulnar negative, then that means they're imparting more load through the radial lunate joint, and not enough through the ulnar carpal joint. So if they're ulnar negative, the joint leveling procedure, or radial shortening osteotomy is the way to go. All right, if they're later stage, like a 3B or a 4, which is someone who's gonna have arthritis or joint collapse, carpal collapse, DZ deformity, those people, then just shortening the radius isn't enough. So you're talking about a PRC, wrist fusion, that type of thing. So those are, and I don't think that gets tested much with you guys. And then just a few slides on volar wrist pain. Carpal tunnel always has to be in the differential. Know that you can have FCR tendinitis, which will be where that little red line is. You can have a generalized tendinitis of the digital flexors with an aching in the central portion of the volar wrist in a longitudinal pattern. You can have FCU tendinitis, which would be kind of around where that small blue circle is. I'm sorry, volar ganglion in and around where that small blue circle would be, right around the radial artery. And those are gonna be your main things volarly. Just to finish off with the last round of questions. Football player presents to you the day after the final game of the season, jammed his wrist while making a tackle, has pain and tenderness on the dorsal aspect of the radial carpal joint. He has a clunk with pressure when you apply it to the volar scaphoid. So a clunk in this situation is screaming out that it's a positive Watson's and it's a positive scapholunate problem. So his radiograph is shown here. It's a pretty crappy radiograph that they show. But they're describing really an unstable, acute scapholunate injury in a young patient, which is definitely treated with a direct repair. And remember, six to eight weeks, probably eight weeks is the time when you can do a direct repair. If they present someone who's three months out of this, you have to start thinking reconstruction. A large symptomatic volar wrist ganglion after multiple attempts that failed non-op management, she moves forward with surgical excision. What preoperative finding would heighten your concern when operating on the ganglion? And remember, these are around the radial artery. So if you have an abnormal Allen's test, abnormal perfusion to the hand, you want to be very, very concerned about what's going on. Recreational tennis player referred to you for three months duration of pain on the dorsal forum. No specific injuries. They're presenting just something insidious and onset. Received an injection somewhere near his elbow several years ago that worked like a charm. Examination shows tenorus along the dorsal distal aspect of the forum and some crepitation with wrist extension. So that's that snap, crackle, pop of intersection syndrome that they're describing. What anatomic structures are responsible for the symptoms? It's those same old friends from before. So the abductor pollicis longus and brevis as they go over the extensors. Right-hand dominant collegiate tennis player points to the dorsal radial aspect of the distal forum as a site of pain. On exam, tenorus to palpation is elicited and some crepitus with resisted thumb, abduction, and extension. So what best describes the tendons that are involved? Kind of same thing as before. Okay, the only difference here is they're also factoring in the two tendons that they're riding over. So they're describing the first and the second dorsal compartment together. Otherwise, it's similar to the other question. And that's it. Thank you.

hand and wrist injuries

fractures

ligament injuries

treatment options

case studies

ulnar-sided wrist pain

radial-sided wrist pain

mallet injury

scaphoid fractures