Thank you. Our next speaker regarding hand and wrist is Robert Wysocki from Rush. Thanks. Appreciate it. Obviously hand, wrist isn't really something always in the wheelhouse of everyone in this room. So I think in a good way you'll notice there's a certain trend towards the topics they like to ask questions about. A lot of times it's topics that have no room for debate where they're asking basic anatomy questions. So if you're going to prepare in a way, that's one of the highest yield things is looking at the basic anatomy of the conditions we discuss today because we'll discuss the ones that tend to be the most tested. And you'll really see trends in all the sample questions that I show. So just to get started, no relevant disclosures for me to let you guys know about. All right. We're going to start with fractures. And these, while it's good information to know in taking care of some of your athlete patients, they actually don't get tested all that much. You'll see within the questions. But I'll try to go through some of the most salient points. When we think about hand fractures, they're usually of any of these tubular bones of the fingers or metacarpals. Think about basic regional anatomy. Is it the base, shaft, neck? Are they intrarticular? And they factor into our management just like they do elsewhere in the body. The morphology of the fracture, the column you see on the right is going to factor into how stable they are. Are they likely to collapse? Are they not? And then also what type of fixation do we use? That's a little bit more in our world than yours, but it's just the way that we think about these injuries. And then if they're comminuted versus simple, a variable tendency for them to shift over time. Metacarpal shaft fractures. This does get tested a little bit in the orthopedic and hand literature, maybe not as much within sports medicine. But five degrees of rotation can cause a centimeter and a half of digital overlap. Bottom line is you've got to be very alert for clinical malrotation with metacarpal shaft fractures. Not as much neck. Boxer's fractures almost never malrotate. It's the shaft where you really have to worry about that. So what can we accept? Well, it's 10 degrees for the index and long finger. And remember, you can accept less because their CMC joints are very rigid. As you get over to the ring and especially the small, the CMC joints are very mobile and they can make up for bits in which a shaft fracture is off. So that's the reason why. For the ring finger, 20 degrees. And the small finger, 30 degrees, is what you can tolerate. And when I'll show neck fractures in a minute, an easy kind of cheating point is you can basically increase each of these numbers by 10 degrees for a metacarpal neck fracture. Okay. So everything goes up about 10 degrees as far as what you can accept. Other data that's been studied in the lab, a 7 degree extensor lag for every 2 millimeters of shortening in general, although there's person to person variability. So somewhere around 5 millimeters of shortening is acceptable because it's a mild extensor lag and one that's probably not going to compromise function. These usually heal in around 4 or 5 weeks. That's regardless of how you treat them. So if it's something surgical, if it's like a long oblique or a spiral pattern, it would be an open reduction, internal fixation with small screws. If it's a transverse or short oblique picture, it's usually going to be a CRPP with intramedullary pinning down the shaft of the metacarpal, but in some non-skill position athletes like football offensive and defensive linemen are the classic example. You can consider a dorsal plate and they can play in a cast and it's usually rigid enough to allow that. But healing time, 4 to 5 weeks and that's about how long we'll keep pins in if we treat it with pins, 4 to 5 weeks. Talked about the metacarpal neck. Again, you can accept 10 degrees more safely. Some people have advocated you can accept up to 70 degrees for a small finger. That's pretty aggressive, but somewhere around up to 40 degrees should be quite safe as long as you don't pick up on a major extensor lag or a pseudoclaw where they go in to make a fist and instead of being like this, the small finger kind of goes into this position. That's usually something that's going to be persistent and around 40 degrees is when it gets borderline for that. It's usually going to be a splint or a cast if it falls lower than that number. If it's higher than that number, it's a CRPP with either crossed or intramedullary pins. The metacarpal base fracture is kind of a whole different animal. These are usually axial impaction injuries, what you'd call almost a pugilist injury, like the same as a boxer's fracture, but they're usually impaction directly into the CMC joint. And these are some of the most commonly missed or at least undervalued injuries in the upper extremity. There's actually quite a bit of litigation over these injuries if they're mistreated. So if you see someone with a big swollen hand back here and it looks nodular, have a very high index of suspicion for a fourth or especially a fifth CMC dislocation or a fifth metacarpal base fracture because they can be missed because the reality is you're going to see them best on the lateral x-ray, right. Sometimes the AP x-ray can be very deceivingly almost normal appearing and on the lateral the problem is all the metacarpals are blocking each other. They're like trees in a forest. So you look and it's hard to tell that the fifth CMC is subluxated without fluoroscopy to get it in the right rotation or a CT scan. So please just high index of suspicion for those. It's common as you see pictured on the bottom there to have a coronal fracture through the fourth metacarpal base and a pure dislocation of the fifth. They basically spit out dorsally and the fifth often comes out on its own and the fourth, the volar base will often be left behind attached to the ligament so they come out dorsally. And then oftentimes there'll be an element of a hamate fracture that goes along with this and there can be impaction to the fifth base or to the hamate if it's more of an axial direction rather than a dorsal force vector. So here's an example and you can see, I mean, when you're looking at the comparison, you can probably now see the difference. When you look on the left you can clearly see an articular surface between the hamate and the fifth metacarpal base. You cannot see that on the right, okay. But you can imagine that if someone wasn't really used to looking at hand x-rays you might see that fracture of the fourth base, but not really pick up on the fact that there's something wrong with the fifth base. But you have a complete lack of a visible articular surface or a gap which should make you suspicious for a fifth CMC dislocation. Also technically a CMC fracture subluxation type injury is a Bennett fracture. So this one does get tested within your testing. So and it really from what I've seen the questions really harken back to what's the main deforming force and just something worth memorizing. It's the abductor pollicis longus, all right. So that little bony fragment that you see looks like a little sail from a sailboat is attached to the volar ligaments and that stays right where it belongs. The rest of the metacarpal starts to subluxate and shorten away from that. So the abductor pollicis longus which inserts on the base of the thumb metacarpal dorsally is going to pull it in a radial, proximal, and dorsal direction, okay. So it's pulling away from that little volar radial fragment. And these if they're identified early they can be closed, reduced, and pinned versus ORIF if it's delayed or if it's a large fragment or if you can't reduce it. Phalangeal fractures as you probably remember from your training, these come in a whole host of different flavors and it's beyond the scope of this to go through every type of phalange fracture but you're looking for a lot of the same things as the metacarpals. You're looking for some sort of skeletal deformity, malrotation, deviation, shortening. Just know that phalange fractures in general are less tolerant than metacarpals of deformity, okay. So most phalange fractures unless it's a true hairline crack it might be worth having a hand surgeon take a look because some of them can be kind of mysterious bad actors. For ones that are inherently stable we typically splint them in an intrinsic plus position just like this, making sure to immobilize the joint above and the joint below, kind of old principles from orthopedics but it still rings true. So if it's a distal phalange fracture you really only need to immobilize your DIP and then you just keep going backwards. But if it's a proximal phalange fracture, a stable little hairline, immobilize the MCP and the PIP in a splint or cast and let the DIP free from motion so your tendons don't get stuck. So joint above and joint below. They're usually sticky enough in three weeks whether you pin them or not to allow range of motion of those joints. So the ones that you initially immobilized after three weeks you can start them moving. And if you wait too long there's going to be a high risk of permanent stiffness. So three to at most four weeks really is the magic number is when you should start moving all joints with a splint just to control for a little bit of protection. These heal pretty fast so within eight or at most ten weeks from maybe heavy contact sports people can get back to their sport. Shaft fractures, when they're fixed sometimes they need an ORIF, again for your long oblique fracture pattern like is shown here. Transverse fractures, intramedullary pinning, same principles as metacarpals except we try to avoid plating these at all costs. So while there may be a linebacker who we put a plate on a metacarpal transverse fracture to let them play, there's way too much morbidity and downside to plating a phalanx to do that just for someone to get back to their sport early. So you won't really seeing us doing that with a phalanx. These intraarticular fractures, these can be bad actors. One of our primary care sports medicine fellows just earlier this morning came up to me with a 14-year-old kid with one of these unicondylar phalanx fractures. These can really be bad actors and go on to trouble AVN if they have to be opened, articular incongruity, post-traumatic arthritis. So these you have to be very, very aware of and should be taken very seriously. These are usually going to be fixed with either pins or small screws, not infrequently they need to be open as it's somewhat of a three-dimensional deformity. It looks on that APX-ray like all it is is it's slid that way, but with the collateral attachments they usually rotate in almost like a distal humerus would and a closed reduction can be very challenging and destructive. So they are ones to be taken seriously. PIP dislocations, I think this is an important topic. It does get tested quite a bit in your testing and from what I've seen, take home point, they don't want you to miss the significance of a volar PIP dislocation. Okay, they don't want you to miss the significance of a volar PIP dislocation, because that's an injury where you by nature should rupture the central slip and they need to be splinted in full extension for six weeks. It's a different... And they only make up probably 3% of these and that's the thing is they don't want you to get into trouble, you know, majorly mistreating something. So they're so different because we don't do early motion for them like we do for everything else. So just beware the volar dislocation of the PIP. The majority are dorsal with some combination of ulnar and radial, the volar plate of vulses, and the volar, as I mentioned, is going to be a different form of treatment. The number one complication of your 97% PIP dislocations is going to be stiffness. It's a volar plate contracture with a flexion contracture so they don't get all their motion back. It's not recurrent instability or arthritis or pain. The volar dislocation, different story. Your PIP dislocations, remember that they can often come with fractures of the volar rim. It is a well-validated point now that less than 30% middle phalanx, volar lip bony involvement, it should still be a stable joint, okay. Less than 30%, it still should be stable. You treat it just like a pure dislocation or a sprain. You don't really need to do anything special for it. If it's between 30% and 50%, it's at risk of becoming unstable and then beyond 50% there's a very high likelihood that that joint is going to subluxate and that's when you get into trouble is when you're missing kind of volar lip so you take more and more of it and you're stable this direction but the joint starts to fall out of the socket, in this case, head of the dorsal direction and you need that bony buttress, whether it's tamping it down and using an X-Fix or putting in a Ham-Aid or whatever you need to do to get that volar lip back to keep it in the socket. For players who have your standard PIP dislocation, they should at least try to be reduced on the field and usually it's successful and then some really simple buddy taping should be enough for the vast majority of these people if they want a little bit of added protection. A little finger orthoplast splint during like heavy contact sports could be considered but the key is buddy taping, early range of motion and a low threshold to get them into OT to get the stiffness out. This is an example of that little volar rim fracture that I was talking about. This one appears like it would be less... it would be at or less than 30% so it should be inherently stable. One that's bigger like a 30 to 50, if it's borderline, will do that extension block splinting and that may be tested at times where if they're borderline and they have a sense of instability, maybe let's say when you go beyond 30 degrees, you can splint them at around 30 to 40 degrees and gradually bring them out as the weeks go by, but in my practice that patient is few and far between. They're usually stable or not stable and it's hard to just trust extension block splinting, but it still is a reasonable tested point that an at-risk one or a borderline one that starts to dislocate as you get closer to extension, they'll say a number like 30 degrees. You know, they won't say that it dislocates at 90 degrees or else it's too unstable, but as they get out, if at around 30 degrees they start to slip out, you can do extension block splinting and that is supported. Here's just an example of that volar lip. You can see that one in the intraoperative photo. It definitely extends more than 30% of the way from volar to dorsal, so that benefits from a ORIF hopefully if it is acute. The hemihemate, as you may recall from training has been developed as a great technique for reconstituting the volar lip using an osteochondral autograft harvested from the hemate. It's really a great operation. It's probably the most revolutionary operation in hand surgery in the last 20 years, although it's a small one. There was nothing really... There was no equivalent to it until it was invented, so... But for these really comminuted volar lips that can't be reconstructed with the native bone, it's a real nice option. So for these late PIP dislocations, one like you see pictured here, you have a nice dorsal articular surface, but you're just smashed and unrecognizable volarly doing the hemihemates the way to go. So we'll fire through some questions. Fourteen-year-old male, a basketball player, jammed his thumb, swelling and pain over the thenar eminence. Radiographs are shown here and we already hit this point. What are the deforming forces of this injury? So they're showing a Bennett fracture, okay. Bennett, it's the abductor pollicis longus, which is going to be pulling and it's going to take it dorsally and radially. And the dorsal and radial part you can just even surmise just by looking at the direction it's displacing. The main point to memorize is that it's the abductor pollicis longus. Twenty-two-year-old starting safety football team, index finger two days ago, pain at the PIP, diffused tenderness, range of motion is pretty sharply limited as you can see, only a 20-degree arc. There is no fracture present and the PIP is reduced, but they show you they're stressing one of his collateral ligaments and it's widely unstable. Okay. I think it's safe to say that no PIP, collateral ligament injury in isolation acutely is ever surgical, really ever, as long as the joint is well reduced. If they show a statically subluxated joint, that would be one thing and that goes anywhere in the body, right. You can't just have a statically subluxated or dislocated joint, but assuming the joint looks concentrically reduced as they comment on, it's not going to be surgical for these people. So buddy taping, let them continue to play and then you give it six weeks of protection against side-to-side load and 99% of the time, those are going to heal fine on their own because the PIP joint has tremendous inherent stability. It's like a tongue and groove pattern and even without any ligaments, as long as you don't stress it, those ligaments will all spot well down very nicely. Division I cornerback holding his right hand after he broke up a pass. There's a gross deformity of the long finger dorsal translation of the middle phalanx related to the proximal. So they're painting a picture of a dorsal PIP dislocation, right. Gentle traction, it's realigned. You examine them under floral, you see a small volar lip fracture that measures 25% and is non-displaced. You note that the joint begins to sublux in less than 45 degrees of flexion, okay, and that's one of the important points here. So they're giving you all the information you need to know. So remember I mentioned, if they're saying you're starting to subluxate, a medium-sized bony piece starting to subluxate at 30 or 40 degrees, they're painting a picture of someone they want you to do extension block splinting for. 18-year-old softball player, palm or dislocation, long finger PIP joint, what is most likely torn? And there's numerous questions on this. For something that I probably see once a year, it's amazing how many questions seem to be on your guys' test with this. So this is like a top two or three take-home point from this whole hour. What's most likely torn, volar, PIP, dislocation, central slip. Every time, that's going to be your answer, central slip. Remember, six weeks, full-time immobilization and extension. To try to let the central slip heal appropriately. High school basketball player, left hand, catching a pass. It struck his ring finger and pushed it into his palm. Volar dislocation, PIP joint. Fingers easily reduced. And there's a concentric reduction with no fracture. See, they're tempting you to go down the road of just probably moving him early because they're painting it as being something benign, right? But again, you're going to splint the PIP in full extension because it's a volar injury. You're probably sick of hearing me say that, so I'll try to stop. Soft tissue injuries to the hand. Moving on. This gets tested quite a bit for you guys. Gamekeeper's thumb. So just be aware, especially the anatomy. When you stress ligaments in what positions, things like that. So this is another very high-yield one for you to familiarize with. The kind of classic testing point is a greater than 30 degrees of instability solo or if it's more than 15 degrees different than the contralateral side suggests a structurally significant UCL rupture that should be treated surgically. The 30 degrees absolute, I think it's hard to hang your hat on that because there's so much person-to-person variability and you probably require a fluoro to really know if you're truly seeing 30 degrees or not, but the side-to-side difference is a big one and it's probably the most reliable. There's also been other things described that are indicative of 33% subluxation. I don't know how someone's going to really measure that. I guess it's you just look for a third. Three millimeters palmar subluxation on a lateral view. It's hard to get a perfect lateral sometimes, so I would go by that kind of 15 and 30 number. That's really the most tested. For an RCL injury, and these are often understated, but RCL injuries can oftentimes lead to developing arthritis because the joint pretty heavily subluxates. So if you see someone where they show you their thumbs and it looks like there's like a huge bump on the dorsal radial metacarpal, they're going to come in saying I have a big bump on this bone right here. They don't come in complaining of an unstable joint. They just have a statically subluxated MCP joint from a chronic RCL injury. And usually once you see them it's not acute and the horse is out of the barn, but full thickness acute RCLs with subluxation are surgical. So I would be on the lookout for them and if you see them, definitely get them to one of your hand colleagues to make sure that they're not surgical. This again does get tested. So you're going to want to test the proper collateral and this is a take-home point. Proper collateral is tested in flexion and that's because it basically goes between those two purple dots. So if you want to kind of get an end on, so to speak, you flex the joint about 30 degrees and stress it that way. The accessory collateral in addition to the volar plate are tested in full extension and I'm sure this is analogous to something you guys do in the knee. I don't really know what it is, but there's probably some sort of equivalency. If you have both ruptured, meaning you're tested in both positions, that's the high likelihood of the stenor lesion, which does get tested. Remember a stenor lesion is where you have a complete pull off of the UCL off of the insertion on the proximal phalanx and it gets lodged behind the adductor pollicis, okay. The adductor aponeurosis, ADD. It's just a classic anatomy thing that may very well get tested and the reason they want you to be savvy at picking up on these is, again, it's a major conversion in treatment, right. So if you have a complete injury with a stenor lesion it's surgical. If you have a partial injury it's never surgical. So they don't want you to float someone along going in the wrong direction who should have an operation. So that's one of the reasons they want to make sure that you're very familiar with that. So this is an example of kind of a stenor lesion. So if you see on the left and the right, you have a nice visible ligament. It doesn't look like it's lodged behind anything and you have the adductor aponeurosis that's almost on the outside of it, right. So you see a little thin black line to the left in both of the two pictures with a thick meaty collateral under it. On the right side you really don't see that, right. It has a very amorphous appearance. You can't see the discrepancy between those two layers. So the one on the right would be somewhat consistent with a possible stenor lesion. Surgery for this, not that it matters too much to you guys, it's typically a suture anchor repair down to bone. There's a little sensory nerve branch that we need to protect. If it's a bony, you can do a tension band fixation for it. For post-op for these, it's six weeks in a splint and then starting range of motion of the MCP joint thereafter. If it's a non-operative, which most of these are, it's four weeks in a cast or a splint, depending on patient reliability. IP joint free to work on motion there, but just to mobilize the MCP. So about four weeks non-op, six weeks operative. And it's not until eight weeks that we start really strong pinch, because it's pinch that's going to stress that ligament a lot. The collateral ligament injuries to the other fingers. So the index through the small finger. We do see these quite a bit as partial thickness sprains. We almost never end up with something surgical or full thickness, at least to the point where it bothers someone. The treatment, just like for PIP collateral ligaments, is to buddy tape to the adjacent finger. They can be sometimes painful for months. Not uncommonly at three or four months if there's pain we'll do a cortisone shot in the joint, but they're almost never surgical, honestly. So and I don't see these tested much for you guys. One take-home point might be that it usually avulses off the metacarpal. So the thumb UCL usually avulses distally off the phalanx. The lesser digits it's almost always off the metacarpal and that's an anatomic point. That's something that they might test you on because it's pretty well known. Mallet finger, always a fun one. A DIP extensor lag from an avulsion of the extensor off of the distal phalanx. Remember it's very important to get an x-ray because if there's a large bony avulsion it's a conversion from surgery, conversion to surgery from non-op. And they're looking for you not missing those possible big treatment conversions. So be on the lookout for x-rays and mallet fingers. For ones where there's no fracture or where there's a small bony piece, typically less than 50%, you're gonna splint it full-time, absolutely full-time. They don't take it off in the shower, they don't take it off anywhere for six to eight weeks. And then after that usually they get back to speed pretty fast with a home exercise program. If there is a greater than 50% bony involvement especially with visible DIP subluxation volarly, that's gonna convert to surgery. And it's really the same principle as why a volar lip large piece renders a PIP unstable. It's just the dorsal side, it's the same thing. As you can see you're just missing the end of that concavity of the joint. And with that absent there's nothing to really prevent the flexor from pulling the rest of the distal phalanx volarly and letting it escape. And that one on the right is not a finger that's gonna do very well. The one on the left if it stays that way will do pretty well. But the one on the right basically is what happened to the one on the left after two weeks. So within two or three weeks these can really fade and as the soft tissues lose their structure it starts to subluxate. Jersey finger, they test this a ton for you guys, a ton. So I think kind of, this is probably the only hand classification that's even worth knowing I think for you folks. But I think it definitely is. The ring finger, it's almost pathognomonic. It's almost always in the ring finger. The Ledi classification's probably one of the better classifications in hand surgery as simple as it is because it really factors into treatment. So it's called the Ledi classification number one. The tendon retracts all the way back to the palm and you have two weeks at most to fix. But ideally seven to 10 days to get it fixed before the muscle shortens and fibrosis. A type two is where the vincula keeps it in place and it only goes to the PIP joint. Those you easily have probably four to six weeks at least to get to and treat. And it should be manifest with where they're tender. And it's a careful physical exam. Are they tender in the palm? Are they tender at the PIP? And it's really quite a sensitive and specific finding. It's a good physical exam finding to try to differentiate. If you're really unsure and someone wants to put off the surgery, you could always get an MRI. And then a type three, which is where there's a sizable bony avulsion, it'll probably only go to the DIP because the bone can't fit under the A4 pulley. So it lingers right at the DIP joint and you probably have almost an infinite amount of time to fix that because it's only gone three millimeters and the muscle belly's still gonna be at full length so it's really not an issue. A lot of these present delayed. It's amazing how many, especially kids, like teens and 20s, show up eight weeks after this happens somehow thinking it was gonna magically get better on its own, that they couldn't bend their finger. But for the delayed diagnosis ones, it's usually treated with benign neglect where we do nothing because any type of stage reconstruction is kind of fraught with disaster. You can do something like a fusion or a capsulodesis of the DIP if it's floppy when they go to pinch. But trying to get their flexion back for really most people's not worthwhile. Flexor pulley rupture, it's a very athletic injury. So I think it's the kind of thing that may show up on your tests. Main take-home points are it's the A2 and the A4 pulley that are the structural ones. Those are the ones that you might need to reconstruct, especially A2. So that's a major take-home point. They usually present not with complaining of bowstringing because patients don't even know what bowstringing is. Their chief complaint is usually a PIP flexion contracture. They come in like maybe three weeks after the injury, rock climbers especially, and it's a flexion contracture. It almost can look like a boutonniere. It almost has that same type of appearance. Last take-home point is there's never anything acute to do surgically. All you do is get them into therapy right away. You can have them wear pulley rings. It's like a tight rubber ring around the P1 if it's the A2 pulley to try to help hold it in place temporarily, get it stretched out. It's almost like an ACL. You kind of rehab it first, get mobility back, and once you have supple tissues, then you can reconstruct it. There's nothing to do acutely. It's just a delayed reconstruction. Boxer's knuckle, this is one I've seen tested. I think there's an example test question that we found coming up. It can be confused with MCP, joint collateral ligament sprains. It can even be confused with trigger finger, misdiagnosis of trigger finger. It's a subluxation of the extensor tendon. It's usually going to go radially because it's usually the ulners. I'm sorry, it's usually going to go ulnerly because it's usually the radial sagittal band that will tend to have attrition, and it's a classic like boxer's injury. So if they present a question for you, it's going to be a punching mechanism. I almost assure you it's going to be someone punch something and comes in with a dorsal swollen MCP joint. Sometimes it's a situation where it slightly subluxates and they have full extension. Sometimes when they go to make a fist, it's so bad, they literally can't actively extend on their own. They should be able to hold it out there because once you get the extensor tendon back on top, it should be able to stay. It's that transition point they might be missing or you'll literally see or feel the tendon subluxate. If they're identified acutely, and there's one test question coming up that I'll point out that I think is kind of a bad, excuse me, a bad question, but if it's recognized acutely, there's a role for non-operative management, especially if they present it seeming a little more mild, like you can feel it subluxate, but it immediately goes back to the top of the finger and extension, something like that. There's definitely a role for a period of extension splinting for about a month and gradually transitioning into more flexion. Chronic injuries, your only option is reconstruction. We won't go into how, but kind of reconstruction for this. There's rarely an indication to do any kind of acute sagittal band, although they do present a case here that's a little bit along that line. 19-year-old football player has a problem with his right hand. He's been unable to actively extend his thumb IP joint since he had a pop in his wrist earlier that morning. He didn't recall an acute history of trauma to the hand or wrist, but upon further questioning, he remembered falling onto an outstretched extremity six weeks ago. He had pain in his wrist. It had gotten better, didn't seek treatment, and he can't extend the thumb actively, but he has full passive range of motion. So inability for active motion, but full passive motion suggests in your world, likely a tendon injury. So in this case, it's his extensor pollicis longus. He can't extend the thumb. It's kind of a random question, but this is an extensor pollicis longus rupture with a non-displaced distal radius fracture that he probably had. And the classic teaching you probably remember from your training is a transfer of the EIP to reconstitute EPL function. High school football player. Weakness of grip. Inability to bend his dominant ring finger 10 weeks ago. So they're giving you some information here, okay. So can't bend his dominant ring finger for 10 weeks. Was going to make a tackle. Didn't want to lose his starting position. Can't actively flex his DIP. He has no palpable swelling or tenderness in his palm. He has subjective weakness in grip. MRI shows the FDP, however, to be in the palm. Okay, so 10 weeks, FDP in the palm. Too late, right? You have at most 14 days to fix that. You'll make someone tremendously worse if you go ahead and try to fix that when it's been 10 weeks. So the option here is really just gradual rehab. Grip strengthening, range of motion, and you can do some sort of DIP fusion later if it turns out he needs it. Flag football player. You're gonna see lots of these jersey finger questions. I'm telling you, it's a very high yield thing within hand and wrist for you to be familiar with. Right hand dominant ring finger injury. He was attempting to pull a flag from an opponent. Got caught in a belt. The examination shows swelling and the fingers lying in slight extension. No active flexion at the DIP joint. For these, from what I've seen, they make the diagnosis very clear. There's not going to be much doubt what it is. All right, so they're saying, what is the most appropriate treatment for this individual? So this was acute. So in this case, you're looking at a acute repair of the flexor digitorum profundus. Now, if it's within four days, it doesn't matter if it's a one or a two or a three. You're going to surgery for it. The duration starts to pan out if you're at three weeks, five weeks, eight weeks. That's when you start thinking about whether it's a one or a two or a three. But if it's acute, you're always gonna fix it. You never let it wait. 28-year-old male, boxer. Right index finger MCP joint pain and dorsal swelling. Okay, you probably already know what this is now. Localized pain and swelling of the dorsal MCP. Full passive motion, but an inability to achieve full terminal extension. This is a question that I think is not a great one. You know, they're painting a picture that it should be a repair of the sagittal band. Maybe it's because they're saying that part about how he can't achieve full extension. I don't know that I agree, but I guess take home point. If you see one that's painted as an ugly picture of a boxer's knuckle like this, like cannot achieve motion at all, then maybe they're looking for a repair. Home team's athletic trainer asks you to come and evaluate a catcher. Thumb of his glove got forced backwards at the plate. Immediate pain in the thumb. Unable to put his hand back inside. Tender at the ulnar aspect of the MCP joint. You didn't see a firm end point when trying to stress it. Okay, so you're already getting a sense that there's some laxity there. And that was inflection or extension. So remember, this individual is testing the proper and the accessory collateral, and it seems lax in both. What is the significance of the instability in both flexion and extension? So here's that point, okay? So both the proper and the accessory ulnar collateral ligaments are likely torn, and that's highly correlated with a stent or lesion. So this is kind of painting a worse picture, right? So you can see why that's the answer. Comes down to the anatomy. Collegiate football player, hyperextension injury. Right ring finger four weeks ago. Unable to actively flex the ring finger, DIP, although passive is intact. A third jersey finger question, right? It's amazing how many they have. A mass is palpable on the palmar aspect of his PIP joint, and the x-rays are unremarkable. All right, so they're really taking it through the Leti classification here. Four weeks out, it's a type two, it's at the PIP, and that is appropriate to go ahead and do a repair for. Because it's a type two, it's at the PIP joint, hasn't gone to four, too far, up to six weeks is fine. Mallet injury, non-dominant middle finger. What's the most appropriate treatment of this injury? Closed treatment with full-time extension splinting for six weeks, followed by night splinting. They don't talk about x-rays or any type of fracture subluxation, so you have to assume it's just a soft tissue mallet, and then you can treat it closed. Six weeks full-time splinting, 24-7 at night, for the next six weeks after. Rugby player, type one avulsion, FDP, here it is again, at the insertion site of the dominant hand, fifth game of the season. What's the most appropriate treatment? Now they're wanting to test you if you're gonna give in and let the guy return to play and put off his surgery, but they're painting a picture of bad omen, right? Type one, you know it's gonna be in the palm, it's five days out, you're in your window, you could treat it, so it's gotta be fixed surgically, so it gets reattached acutely. Fall while skiing, pain and swelling at the base of the thumb. This is a little more anatomy again on the MCP joint. In order to assess ligament stability of the MCP in what position should the thumb be held? Answer, what we just went over. 30 degrees flexion for the proper collateral, that's the one that runs obliquely, and then full extension for the accessory collateral and the palmar plate, both of which run more almost straight longitudinal with no obliquity. Football player, unable to straighten the tip of his ring finger, times six weeks. He can flex it without pain, and radiographs taken in the office demonstrate no fracture. And so they're painting a picture here that ring finger makes you worry about Jersey finger, but it's not, you know, it seems more like a mallet. So they said radiographs are negative, no fracture. So you know, a soft tissue mallet, even subacutely, is never surgical, never. So the answer's gonna be some sort of splinting and you know it's full time. Baseball player hit by a fastball, left long-fingered knuckle. Iced it, immobilized, you see him one day later. MCP joint is swollen, especially with palpation of the extensor. He has full passive range of motion and can perform active extension from a fist to the MCP with no deformity. So they're painting a more mild picture than that other guy, right. The other one they said he wasn't able to do extension at all. This one is. So this is a more mild boxer's knuckle. So I think in their testing, mild boxer's knuckle, they're gonna want you to do kind of protection and extension. A severe seeming boxer's knuckle, they might want a surgical answer. All right, moving on to the wrist. I think the wrist I sometimes think of almost like a four-sided box, dorsal, radial, ulnar, volar. I think it's a good way to organize things and kind of think through patients, both their pain complaints and their physical exam. So we'll start radial. Radial-sided wrist injuries, these are gonna be most of the ones you run through. I think the wrist is a great example of surface anatomy. There's a lot of things to feel. And if you know the anatomy, it can really be very helpful in making diagnoses. So for example, when you look at the green area pictured there, that can be something like CMC or STT arthritis. Purple is gonna be more towards your snuff box where the scaphoid lives. And that red over the radial styloid is gonna be where you'd see something like decorvains, for example. Scaphoid fractures, starting there. There should be a history of trauma, but occasionally there's not. It's a bone that doesn't bleed very much when it breaks. It's kind of like a TFCC tear. So sometimes people don't identify it because it doesn't bleed much, it doesn't swell much. If they're kind of tough people, they might just think it's a low-grade sprain and blow it off. They should, though, quite reproducibly have tenderness in the snuff box. That is a very sensitive and specific thing with people with scaphoid fractures. There's several ways to get a stress view of a scaphoid, which I think is out of the scope of what you guys need to know. You're gonna maybe get some tests, questions on how to manage the occult scaphoid fracture just because you're on the front line and may do advanced imaging. It used to be that someone who had a suspicion of an occult scaphoid fracture, you'd put them in a cast, presume a fracture, even if you don't see one, have them come back in two weeks, get x-rays again. If the x-rays are negative, you get a bone scan. Okay, now things have changed since then. You can still run the same option by parents and things like that, but the other option is to get an MRI right away. An MRI right away has nearly 100% sensitivity and can give you the answer sooner because the reality is in the literature about 80% of the appropriately at-risk patient, young, appropriate mechanism, tender in the right place, you'd swear on your mother's grave they have a scaphoid fracture. 80% of those people, you get an MRI and they don't. It's some sort of mild contusion or something. So you can avoid over-treating a lot of people by getting MRIs quickly if the patient and or family believe it necessary. The role for CT scan is largely to assess if a fracture's truly non-displaced. So if you see a kid and you see a crack and you wanna treat it in a cast, I would get a CT scan on every one of those, every one of them, because you'll be shocked how often on the sagittal views it's actually falling into flexion and should have surgery, because one millimeter or more is surgical, or I should say more than one millimeter. And how can you say you're seeing that every time on an X-ray, right? So I think that that's a good role for CT and then the other is for scaphoid non-unions to image how much bone loss there is, deformity, et cetera. Again, more than one millimeter is considered displaced enough for surgery and this is the classic humpback that they fall into on the sagittal CT scan as it goes into flexion. Almost every proximal pole fracture is going to be surgical. It's almost a non-debatable point because of the poor vascularity. There is data that there's earlier return to sport in a non-displaced fracture. If it's treated with a screw, certainly they can go back earlier if you can put them in a cast. Again, the football lineman is kind of the classic example. I don't know, in my mind, how much for a young high school athlete unless it's playoff time, putting them through the risk of surgery and anesthesia to get them back on the field a couple weeks faster, but it's always a conversation. Percutaneous screw versus a cast, definitely a little bit of quicker time to union. Nine versus 13 weeks if you put a screw in it. Definitely return to sport faster. It's all a matter of weighing the risks and benefits. There's a trend possibly towards a higher non-union rate in a cast, but it's a question of if all those patients were perfectly indicated for non-op. You know, were there some of those who had a millimeter and a half and were starting to flex and probably should have had surgery to begin with? So with the right indicated patient, especially these teens who a lot of these people are, it's probably no difference in union rates. I mentioned the role for CT scan for the delayed cases. The fracture morphology and where it is is gonna predict how we tackle it surgically. So a proximal pole usually isn't really displaced. It's a true failure of biology. It's an atrophic non-union. So because it's proximal and this scaphoid slopes this direction, it's gonna be a dorsal approach with bone grafting and fixation really just to get stability. If it's a waist fracture non-union, which are the most common ones we see, those are gonna fall into that humpback deformity I showed on the CT scan and typically require an open approach. You have to jack the fracture open. You're gonna have segmental loss, which you pack with bone graft and then screw fixation. They will never test vascular bone graft for you because it's too controversial. So don't even think about it. Moving on. Dequervain's tenosynovitis, extremely common. They do like to test the anatomy for this. So it's a very easy take-home point. I have it highlighted there in pink. Abductor pollicis longus, extensor pollicis brevis. Those are the two tendons in the first dorsal compartment. Those are the ones that cause you to develop dequervain's arthritis. So just something definitely worth memorizing. A lot of radial ulnar deviation like racket sports tends to be something where they have an increased incidence. Early on, very mild symptoms. Thumb spica splint, oral anti-inflammatories, low threshold to switch over to a cortisone injection also. The success rates are extremely high. It's probably the most successful thing we treat with cortisone in the hand and wrist for permanent cure. So on their test questions, you should have a very low threshold to choose cortisone shots because they're safe and highly effective for these patients. If you do surgery, it's a surgical, basically unroofing of the first row's compartment and there's a little sensory nerve to be aware of in case that gets tested. Some questions on radial-sided wrist pain. Racquetball player, radial-sided wrist pain, dominant extremity, present for six weeks, tried icing, but didn't have any successful relief. Positive Finkelsteins and crepitation over the distal radius, two centimeters proximal to the styloid. What's the best treatment? Just a side point, this question can be confusing because if they talk about radial wrist or like distal forearm pain and they say crepitation, it's very likely they're gonna be hunting for intersection syndrome, which you maybe have even never seen. I probably see it once every two years, but it's real, it's a very legitimate diagnosis. But intersection syndrome, which is a pain more probably four to five centimeters above the wrist with crepitation. And that's the classic thing is they get a snap, crackle and pop when they move their wrist. So this question was almost tempting you to go that direction, but everything else, the Finkelsteins, you know, points to decravains. So best management strategy, they already tried ice, it's been six weeks. This is gonna be a cortisone injection. And I think that's gonna be part of the correct answer with almost any decravains question for you guys, I would guess. A female tennis player, right-sided wrist and thumb pain. Pain is worsened with lifting and repetition. Has noted no improvement with oral non-steroidal anti-inflammatories. Tender in the right place. Finkelsteins, they're saying it's not the CMC because it's a negative grind test and radiographs are normal. You diagnose decravains, you do an injection. Here's the anatomy I mentioned that they like to test. So what's in that space? Abductor pollicis longus, extensor pollicis brevis. Just memorize it. Those are the two first-dose compartment tendons. The ulnar side of the wrist. This is, as you probably remember, a bit of the kind of low back pain in the world of the hand and wrist surgeon. So it's a lot of vague symptomatology that can be tough to treat, but we'll try to hit on some of the ones that are the most subjective. TFCC tears are probably gonna be your most common. The TFCC will often be tender in those green spots, okay? So the one towards the bottom of the screen on the left picture, that's your ulnar fovea. As you wind around more dorsal there, that would be your kind of dorsal DRUJ or dorsal lunar tricleteral interval, which will be other common tender spots for TFCC pathology, whether it's acute or if it's chronic, like an ulnar impaction, those will be the common spots. The red that you see there, that's the ECU tendon, runs all the way up to the fifth metacarpal base, and they can be tender anywhere along it, all the way from the groove on the ulna all the way to its insertion at the base of the fifth metacarpal. So anywhere along that corridor, it could be the ECU. On the flip side, on the palm there, where you see that red dot, that's the hook of the hamate. You wanna be very aware of that in your racquet sports athletes, especially baseball players. The little purple circle, that's your pisiform, pisotricuitral arthritis will sometimes be tender there, or tendonitis of the FCU. The FCU is that aqua structure that's drawn going towards the purple circle on the right. TFCC tears will start with tenderness, dorsal DRUJ and ulnar fovea, as I just showed pictured here. Sometimes passive ulnar deviation, or active for that matter. Them almost reaching out for the Q or the W on a keyboard is something where they'll notice it. Grip with forearm rotation, they tend to find bothers them a lot. Remember when you go into power grip, you actually ulnarly deviate a lot. No one makes a strong fist this way. If you're gonna make a really tight fist, you go into ulnar deviation. So they're having pain with tight gripping, not because it's hurting to flex their fingers, but because they're loading the ulnar side of the wrist when they do it. It's important with these patients, especially when you evaluate them acutely with an athletic injury, to assess the stability of the DRUJ. And when you see some of the questions I have, that's gonna be one of the deciding points that they suggest creates urgency versus not. Is if the person has asymmetric DRUJ instability, they're gonna lead you towards pull them out, needs an MRI urgently, probably needs a surgery, that kind of thing. Versus if they say the DRUJ is stable and it's acute-ish, it's not gonna be surgery. It's probably not gonna be a shot. It's gonna be splint, kind of modification of activity. Okay, so I think that's maybe the highest-yield TFCC topic, is to be alert for what they say about the DRUJ. Class I are the more acute traumatic injuries, and they can be anywhere on the disc, radial, central, peripheral. Same thing with these degenerative tears. Remember that the degenerative ones tend to come with ulnar-positive variants, ones which then benefit from an ulnar-shortening osteotomy as part of their treatment. The class II is degenerative. The central tears is more the degenerative type where it's just worn away from the inside out. And in general, the acute tears tend to be more the peripheral ones, off of the capsule on the side, or deep root avulsions down near the fovea, for example. In the acute phase, you're gonna, of course, start with a splint. Very important to test the stability of the DRUJ, as mentioned. And these first six weeks, I don't even really get an MRI. There's not much of a purpose to doing that, unless their DRUJ feels unstable, because you're never gonna do anything different. Because even if the MRI is negative, and they don't see a TFCC tear, if they're tender in the fovea, you have to believe that's the diagnosis. So it's six weeks of immobilization regardless. If they present chronic, like after six weeks, I think then you're pulling the trigger more for the MRI, because you're gonna look at something like a cortisone injection or a surgery. So beyond six weeks of symptoms, probably kind of a quick trip to the MRI, versus if it's acute, I would not. How do we treat them? Well, it's a different rehab for each of the surgical options. So if you simply do a scope debridement of a non-structurally significant tear, like a little bit of central tearing, a small horizontal tear, those are some of the things they'll mention in your test questions that are benign. Little horizontal tear, central tear, that's not structural, okay? So for those patients, you just immobilize for comfort for maybe a week or two at most. They get into therapy quickly, really no restrictions in doing so, and they're back to sports at six to eight weeks. For a repair, like a peripheral repair, really everything is slowed down by about six weeks, because you have to protect them for the six weeks while your repair is healing, and you phase into the same rehab. So it's like a three to four month return to sport instead. And then lastly is your central perforation ulnar positive patient. This is the class two degenerative type, where you do something like an ulnar shortening osteotomy. That again prolongs at six weeks, because you need to probably give six weeks for your osteotomy to heal. They start the same rehab, and then it's about three to four months return to sport. So here's an example of one of those peripheral tears. If you look at the MR image on the left, you'll see that you see that black triangle. That's the TFCC. But then next to it, as it gets towards its insertion, you lose some of that linear black signal. And that's the type of patient who could benefit from a repair, whether it be arthroscopic or open. No one's gonna test you on that. But this is the kind of tear that could have DRUJ instability, because you don't see the foveal insertion of the TFC on that MRI. And here's a more degenerative pattern. So you can... It doesn't look like anything's pulled away, but that black triangle, which was so well-defined on the last image, looks very white, hazy. It's like a mixed, more heterogeneous signal here. So this would be more of like a degenerative tear pattern, and the patient's a little bit ulnar positive. So here's an example of someone ulnar positive undergoes an ulnar shortening osteotomy. That'll be your classic degenerative tear pattern treatment, typically with an arthroscopic debridement. All right, ECU. We see it a lot in racket sports of any kind, tennis, golf, baseball. There's theoretical reasons as to why the leading hand or the trailing hand would get it, not something you need to know. They're gonna be tender probably anywhere along the ECU, including over the ulnar groove. A lot of it is differentiating tendinitis versus subluxation. The tendinitis is gonna be much more common than the instability, but you do wanna try to assess that. These go unstable in supination, and I think that's something, it may be, I don't recall, but I think on one of the questions they do address that a little bit. And honestly, it's a hard thing to rationalize, why when you supinate, your ECU subluxates or dislocates. So the way that I try to remember it is it's the opposite of the DRUJ. Most people kinda remember that the DRUJ, you immobilize it in supination, you know, back with your teaching of like Galeazzi's and all that. DRUJ splint in supination. And if you remember that the ECU is the opposite of the DRUJ, you'll know that pronation's good, right? Just memorize that it's the opposite of the DRUJ and don't try to rationalize anatomically why it happens. But you're gonna wanna go into ulnar deviation, supination, and then feel to see if the tendon's coming out of the groove. And it's gonna subluxate out of the groove and in a volar direction. So here's an example just of a little bit of ECU, just a little bit of ECU tendinitis. So you can see the ECU within the groove of the ulna on this axial section. It's in there well, it's not subluxated, but you can see there's a bit of a heterogeneous appearance to the tendon itself. There should be a nice black circle and definitely quite a bit of inflammation around it. So this is probably some tendinopathy and tendinitis of the ECU. ECU instability, however, what you'll see in the picture on the left, you can see how the black little oval is completely spilling out of the groove. And here's a little schematic of how it happens on the right side. So it basically serves as we think it's more of a liftoff of the sub sheath of the retinaculum rather than the retinaculum tearing in the middle over the ECU groove. The little red arc that you see there, the red rainbow, on the bottom part, it starts to delaminate and the tendon escapes under. So for our reconstruction, we usually capture all those fibers going polar to dorsal and then put suture anchors right below the groove as you look at that image to then corral the tendon and keep it there. So it's like a delamination injury of the deep part of the retinaculum. For ECU tendinitis, there can be a lot of tendinopathy that comes along with it. Here on the right is an example of a pretty bulky ECU tendinopathy. The reason that matters is because cortisone injections should, you should hold off a little bit on immediately going to cortisone injections, especially with older patients with ECU tendinitis. And that's because there's a risk of rupture, right? So if you have a kid, especially if there's an MRI that shows the tendon of normal structure, no tendinopathy, a shot's okay. But a 62-year-old patient, bulky looking out here, I often won't do a shot unless I see an MRI that shows that there's not severe tendinopathy because I've had some patients rupture from the shot. That's not really a very reconstructable rupture if it happens. It's a tough condition to manage when it's at its end stage because doing a debridement of that tendinopathy isn't a very gratifying procedure. For the people with instability, if you recognize it acutely, like over the first month, there's definitely a role for non-operative management. So it's not very fun for them, but you want to splint them in full pronation. Remember the opposite of DRUJ instability. And then if it's chronic, you do a reconstruction as I kind of described earlier. And here's just a picture of a little retinacular reconstruction done for the ECU. There's various techniques. Dorsal tricritical avulsion fractures, pretty common. They actually represent, as you would know, more of a ligamentous avulsion than they do a true fracture when you're talking to the patients about it. And for that reason, I think they need to be taken pretty seriously. If it's a high-grade injury, these are the ones that can lead to a VZ deformity. You maybe remember from residency, the DZ and VZ. And DZ is a scapholunate ligament rupture. VZ is more of a lunar tricritral type avulsion. And these are at risk of that. So I think this, although it looks small, even if they don't have much pain, I do immobilize them full time in a splinter or cast for six weeks to try to optimize healing. Because if they get VZ collapsed, there's really no solution for that. And they're not gonna be happy if it's a youngish person. Hook of the hamate fractures within your stick sports. If it's acute, there's definitely a role for immobilization. If it's chronic, really the answer is you take it out surgically. Be on the lookout either for ulnar nerve symptoms or pain with small finger flexion. You can even get abrasive rupture of the small finger flexor. So whenever you see a hook of the hamate patient, you have to ask them if they're having pain with flexing their small finger. And if they are, it's a lower threshold to go and take out the hamate and then smooth out the area so they don't rupture their flexor. If they don't have small finger symptoms, six weeks in a cast, and really whether they heal on x-ray is irrelevant. Just saw one of these people back today, and he's a very type A guy. And I told him that I don't want to irradiate you with a CT scan. You're pain-free, we'll just see how you do. But I don't know if he's gonna accept that. I think he wants to know if it's healed. But maybe he'll choose the radiation. If it's chronic, you just excise it. It's definitely an area that's kind of tiger country when you're going into that part of the hand to take it out. You got the ulnar nerve, the ulnar artery, the flexors. So it's always kind of a high sphincter tone operation. But it's actually a good operation if you get it out safely. The people tend to do very, very well. And within four to six weeks, even high-level baseball players are back playing fully. Ulnar artery, around guillanes, you can have ganglions that compress the ulnar nerve in cyclists. Just be on the lookout in the cyclist for a dense ulnar neuropathy that comes on rapidly. It's very likely to be a guillanes process. You can have hypothenar hammer syndrome in a laborer that pounds a lot, which is a vascular aneurysm that's in guillanes. So ulnar nerve isn't always the cubital tunnel. Remember to look out in those two subpopulations for guillanes. Few questions, 19-year-old trail riding cyclist. Weakness of grasp in the hand with key pinch. So they're already painting the picture. It's a cyclist, right? Weakness in grasp. Six weeks of observation has already been had. And there's a cystic mass in guillanes canal. So that's an easy one. So you have a cyst in guillanes. He's weak. This is gonna be to do a decompression of guillanes and get the cyst out. I think they'll make those pretty clear for you. Lineman, two-month history. Wrist pain, began in summer camp. He's now having pain with past protection. Ulnar-sided tenderness and pain with axial load. Ulnar deviation, wrist extension. X-rays are negative and there's no abnormal ulnar variance. So what further imaging is coming up next? Pretty straightforward. MR to look for the TFCC. That's the picture they're painting. Our literature does support arthrogram being superior to plain MR. So if it's suspicion of an acute TFCC pathology and they give you both choices, you should choose the arthrogram. Recreational weightlifter, ulnar-sided wrist pain, no mechanical symptoms, times eight weeks. MRI showed a central tear. Physical examination, no DRUJ instability and he's ulnar neutral. Okay, so again, no DRUJ instability. So they're painting a picture of a little more insidious, a little more benign course. So this is someone non-operative management and said it's no hurry on this patient. DRUJ stable. Collegiate golfer, right wrist pain. This happened more acutely. Two weeks ago, hit the ground with a club while hitting out of the rough. Can't return to play. Ulnar-sided pain. It's reproduced with ulnar grind. Increased translation of the ulna with shuck test compared to the opposite side. So different picture than the last guy. Acute, traumatic, grounded the club. DRUJ seems somewhat unstable. X-rays are okay. Next step in management is a higher index of suspicion. You know, further imaging right away to look for a TFCC tear that could be more urgent. Fly fisherman, complains of severe ulnar-sided wrist pain. Dominant hand after casting for a week. Painful snap of the dorsal ulnar aspect and pronation supination. Radiographs are normal. So snap, pronation, supination, you can imagine the ECU kind of subluxing in and out. So there's a chance that could be the DRUJ, but they're saying it's dorsal over the ulna, painting more of an ECU picture. So this is one where it's relatively acute. They said it's only been a week, right, and the tendon's snapping. It can be relocated. It's coming out. So this is one where you immobilize in a position of pronation. Collegiate rower, wrist pain lasting one month since the beginning of the season. Pain on the ulnar wrist. Worsened with ulnar deviation and supination. Fullness over the dorsal ulnar wrist. I think they're going the same direction towards ECU. So they're not talking about subluxation, but they're still describing that area. So it's more of a tendonitis of the ECU from overuse. Long question. Hockey player got injured into the boards three weeks ago. Couldn't play through it. Tender to palpation on the ulnar aspect of the wrist. MR arthrogram didn't show any discrete pathology except some edema. Decides to proceed with a diagnostic arthroscopy and you encounter tearing of the center of the TFCC with the rest remaining stable. What is the treatment of choice? So just an arthroscopic debridement with kind of an early range of motion and return, right? And I think when I talked about the algorithm earlier, we talked about that. So a simple debridement. The rim was intact. This is someone who you speed up through the rehab phase. Competitive dart thrower. Pain while throwing darts. Difficulty throwing at the release. Physical exam, tender to palpation at the ulnar styloid and with passive ulnar deviation. No tenderness over the ECU or the FCU. Imaging's negative. Most likely injured structure. I mean they're really painting a TFCC picture here. The ulnar deviation mechanism, but nothing over the ECU. I think maybe in interest of time we'll skip and just go on to, so I have two minutes remaining. Dorsal and volar-sided injuries. Dorsal you want to be on the lookout for occult ganglia and scapholunate ligament injury. We talked about intersection syndrome. The second dorsal compartment lies along that purple stripe. So anywhere along there can be intersection syndrome proximally or an insertional tendinitis of the radial wrist extensors more distally. Keen box you'll almost never see, but there's a chance it may get tested. Scapholunate ligament injuries, they range from your non-static injuries, more of like a dynamic or pre-dynamic, and then all the way up to a static deformity, and then at the end stages arthritis. Number one physical exam test you may see tested is a Watson's maneuver. You don't have to know how to do it, but if they say a Watson's is positive or there's a clunk, that's suggestive of significant SL instability and that person should be treated promptly. Okay, so look for a positive Watson's. You can do an acute repair probably anywhere less than two months, and if the tissue's not great you can add a little dorsal spot weld to the capsule, the capsule adhesives. It's a long haul for these. The pins are in at least six to eight weeks. Then they're extremely stiff. They come out of it easily four to six months to return to play or work after a scapholunate ligament repair. Your dorsal ganglion, we see a lot of these. This is like yoga wrist is a dorsal ganglion. You see a lot of these kind of occult ones where you don't really see it. Maybe they do this and there's an ever so small mound. It's gonna be pain with extension loading like pushups. If you're not sure if it's there you can get an MRI. If it's clear as day you can see it from across the room. They don't really need an MRI. It's about a 60% recurrence rate with needle aspiration. So a lot of these people, if it bothers them, will end up undergoing surgery for it. So a lot of times if they're not really willing to do the shot, straight to surgery is sometimes undertaken. This ECRB, ECRL tendinitis, the intersection syndrome as pictured there is the one I talked about. It's above the wrist crease, a good four centimeters above, in line with the second dorsal compartment. And what that is is a tendinitis actually caused by the first dorsal compartment. And I don't think we'll have time, but there's a question that asks what's causing someone's intersection syndrome and it's in the handout. You'll see it. And it's the first compartment rubbing over the second. So if you give them a shot, you give them a shot in the second, because that's where the problem has resulted but it's been caused by the first compartment. And they get a snap, crackle, and pop classically. Keen box we'll skip, because I haven't seen it tested for you folks. And then VOLR, I didn't see any test questions on VOLR stuff for you guys. These will be some of the diagnoses to look out for, but I really don't think you're gonna see any material tested there. And that was just a few questions you'll see in your packet, so I should probably stop there. Thanks. Thank you.

hand and wrist injuries

basic anatomy

fractures

management

treatment options

diagnosis

complications

TFCC tears

physical examination

rehabilitation