We have probably about 12, 15 minutes here to do some cases, and then we'll take a break, and then we'll come back at 9.30, 9.35 for the next section, and that should keep us on time here. So I'll rattle through some cases that are somewhat out of my comfort zone that I had here, and I'm gonna get, feel free from the audience to ask questions, chime in. We'll ask our panelists here for their thoughts about this. So one case I thought was interesting, is one of our players from this past year, 24, defensive back, direct blow, pretty classic mechanism. It's got this distal third radial shaft fracture, possible Galiazzi type pattern. Panel's thoughts, first kind of diagnosis, what do we need to be looking at with these forearm fractures, pretty classic usually, but then we'll kind of get into some of the management thoughts. Anybody? So? So clearly radius is fractured, it's shortened, so you can't really tell about your DRUJ at that point in time, but that doesn't look good, but it's lined up on your lateral view, so for me, I'm gonna fix the radius first, or in my case, I'll have one of my trauma guys probably fix it, because they're better at it, and then we'll assess the risk and see if we need to do a repair at the top. So that's where we went, went to the operating room, the radius was plated. In this case, we were concerned that the DRUJ may be unstable, but actually once the radius was out to length, it felt stable, we didn't have to do anything there. So I think the decision making with these forearm fractures is return to play for this audience. So when are we comfortable with this, letting him get back to play? Early thoughts, I'll show you where we went with this, but what's the typical time frame for a player? Now you've fixed it, you call the coach, we heard this yesterday, I don't know if it was Mark, or somebody said, every time we called the coach, said it was a perfect surgery, but how long's he gonna be out? So, Mike, how long's he gonna be out? Well, I think that, I mean, your stabilization looks very stable, or very robust, let's say that. Yeah. You know, clearly you gotta have the wound heal. So you can't, this is not one where I'd have him go back like the following week. Yeah. But I think that with regard to the front office, you'd probably tell him, you know, at least within six weeks, but I think that within probably three to four weeks, he'd be fine. Yeah. Dr. Willis, your thoughts on this? Well, my thought is that, you know, these can be a little tricky and you gotta be careful. You really wanna see some early healing. Yeah. And you might even wanna get a CT to make sure that it actually is occurring. Yeah. Because they can re-injure, even when you think they can't, they put a lot of stress on that forearm. Yeah. So you can be surprised. And if you protect them, maybe if you get 50% bridging, your DOJ is stable, you can do that. But I would say that one technique that I've tried a few times, and I'd just like to get the panelist's opinion, a couple of my baseball players, ulnar fractures, radius fractures, where they wanna go back to play early, and it's very meaningful in terms of draft status and everything else. I mean, crazy enough to do sort of a small secondary 99 plating. So you can control the rotational stresses and that concerns me the most on these than if they're swinging a bat or doing something else. Sort of something we're looking at in terms of trying to get the strongest fixation that may allow you to go back a little earlier and not have, and control rotation better, so you may not necessarily reach the TD. That's a great point. Yeah. Yeah. Yeah, so my folks would do the same thing. They'll put the big plate on and then they'll put a four-hole mini plate to help support that, add some bone graft if they have to go back. I mean, we all know that that fracture's gonna do fine, but then if they're thinking, I wanna go back in two weeks, you can do that, which increases your comfort level, and I think actually makes it more stable. And then you can put them in a molded splint from the wrist up to the elbow, like a Munster-type splint, so you can help control your axial rotation, give them some support, and then they can play whenever they're comfortable. But you have to tell them, whether you do a CT, which is probably a good idea or not, you gotta tell them, the quicker you go back, the more your risk is of fracturing, because our obligation is to our patient first. And the GM, the agent, everybody's gonna be fussing at you about getting them back on because it's important, but by the same token, but those are things you can do to make you feel better about getting them back. Those are all great points. And I think that splint is critical. Even if you have some partial healing on the CT scan, I still would put them back in the splint as well. Yeah, no, and then you get these numbers, and the GM wants to know, is it 70%, is it 80%, what's the radiologist say? And so you get this data, and it does help you, but it's still incompletely healing. I think he probably went back in a full brace at about eight weeks for us, and we had him out, and I think the second plate discussion is really a valuable one, because that may be of value here. Yeah, and that really comes up because some of these kids, not at the professional level, are trying to make the professional level, and then they lose time. That's critical, so shared decision making, and I do think rotational stress is important control. The other thing is not just the fracture healing, but what do they look like? Some people look terrible, weak, they don't have good grip, their motion's terrible, and so I think that factors into it as well. Yeah, this guy was defensive back. At four weeks, he was like, I'm totally fine, can I play? This was the kind of classic struggle of holding him back until we had enough healing. So we talked about this. Any other role for, I don't know, BMAC or Augment's metabolic medicines, Forteo, anything else for bone healing that we're doing in any of these fractures? We would 100% put him on Forteo. Yeah. That was my question. We've had some discussion, because there are risk factors with that, and do you routinely do that? Do you do it just for your professional athletes, and high-risk fractures, when, what are your indications? That was my same question when we started doing it routinely, and the risk factors are actually pretty small, you know, with regard to tumor formation and whatnot, and it really is just the cost of it, which is why it seems to be limited to our professional athletes, but anecdotally, it seems like they heal faster, but that's the best answer I have, unfortunately. Yeah. All right, let's move on. We'll try to hit two or three of these, and then we'll take a break. So, defensive back, medial alopecia, upper extension injury, tender over the medial side, some laxity at 30 degrees, kind of classic cases that have been presented here, and then pretty normal-looking X-rays, and you have, let's see if this will play, an MRI that looks, I think Mike and Buddy both kind of covered this, but medial-sided elbow injuries in these contact athletes. It sounds like the consensus is most of them can be treated non-surgically. Any thoughts about this with defensive backs or skill players? Any role for direct repair in any of these cases, or most of these are gonna heal? So, I think the isolated medial avulsion from a hyperextension injury, if you ever look in one of these arthroscopically, the amount of damage to the elbow is actually pretty impressive, and, but for isolated one-side injuries, we usually brace them and try to get them back as soon as possible. If it goes around, and that's why you do the MRI scan, even in a younger athlete, if it goes around and it starts to involve the radial ulnar humeral ligament, lateral collateral ligament, or that outer side of the elbow, then that's probably best treated surgically. The interesting thing is you can scope that, do your lateral side arthroscopically, and ignore the medial side, and they do fine. So, I don't think isolated MCL, medial ulnar collateral ligaments need to be fixed. If you're there anyway, why not fix it? Because they're going back to high-risk sport, but I would treat this non-operatively. I've seen a few of these indications to maybe fix early, especially in younger people. I'd be curious to get your opinion. Some get this extended leg lesion, this displaced, almost flipped onto itself, a few flipped into the joint, and some flipped like a U all the way around. And so, when there's that much of a disconnect, it almost looks like it's taking a right angle. Kind of feel like there would be a role to put that down and to get that back, at least in proximity, because it doesn't really seem to have as much a chance to heal. I'd like to hear your thoughts on that. So, we actually wrote a paper on this. Michael Bryan's the lead author on acute surgical intervention for complex elbow dislocations. And what you're describing is not a simple hyperextension injury where it kind of pops a little bit and it's sitting right there and you know that's gonna heal fine with maybe one to two millimeters of laxity. Once you rip everything apart, or you get a coronoid fracture, or you move into other things, then you're moving into a triad variant. And that group, you can actually fix them acutely and get them back much faster than you can non-operatively. I like scoping elbows, so we do the vast majority of everything arthroscopically. Instead of figuring out how to do the medial side, I need somebody to teach me how to not damage the ulnar nerve when I do that. But I've only done it in cadavers. So we open the medial side, but we do everything else with the scope. But again, the amount of damage that you see when you look in there is horrendous in that more complex dislocation. I agree with the panel. I think that in general, these can all be, or the vast majority of these can be treated non-operatively. I do think that when there's a proximal avulsion of the ligament, as well as complete avulsion of the flexor pronator, those are a little bit of a different beast and they do well surgically. Yeah, so there's still distills. Sorry, Chris. I had a quick question for the panel. We've talked a lot about the position players that have a UCL injury from a traumatic part of things. There's the attritional or acute from a quarterback that we try to treat those conservatively as well. But these last couple of the season that got all the attention at the end of the year were throwers that had a traumatic injury while they were throwing. So it puts them almost in a different category. Any discussion of the thought process of we typically leave, if it just happens from throwing, I think we've had half the quarterbacks on our team don't have a UCL and have never had trouble with it. But this one where they're throwing and they have a traumatic injury, does that change the thought process here? So it was really interesting. There were some conversations about some of those. So it was interesting. My thought is still, you can treat it non-operatively. You can take the time. He's gonna get well. And you're gonna throw. He's not gonna have a problem. One reason to fix it, if you do it really acutely and you fix an acute one and you start stretching them early, and I agree with you on that group where you do an acute repair, they recover so fast that it's almost timing-wise. So if you're an established quarterback and you don't have to make your OTAs and the coach doesn't care if you make spring training if you're in college or whatever, then treat it non-operatively. If you're trying to make the team and maybe there's some competition there and you need to be back by April, if it's a January injury, I'd have fixed that the next day. And not because it has to, but because I can rehab him a hell of a lot faster and get him back throwing. We have a whole quarterback return to throw protocol I'm happy to share with any of you guys if you want it. But we would start that really three to four weeks in a brace and then eight weeks really intensely so that 12 weeks, he's back on the field trying to get the starting position. The same thing with your college quarterback where the coach says, it's the last game of the season, he got hurt. I need him back for either spring training, but I gotta have him back by June. Hell fix it. And because they come back faster, it's much more predictable than non-operatively just kind of watching and being nervous the whole time. There's tons of data on non-operative treatment of UCLs in quarterbacks, but it's all that attritional injury. Our quarterback for the last two years has struggled with medial side of pain because of some flexor pronator stuff that we've tried all the biologics and whatnot for. But there just isn't any data with this type of injury that can occur traumatically. And so I agree. I think that with modern techniques of repairs, it just makes everything so predictable, particularly if it's right at the end of the season and say it was in the middle of the season, it all has to do with if they're able to throw it on. If they can, I think that again, it's gonna be more predictive if you just repair it. It's interesting to think about the older, we faced this with our older quarterback a couple of years ago and it really was somewhat traumatic, but more actually flexor pronator driven. And how that plays into the older throwing elbow, maybe it's not just the UCL, but that can be evolved and cause problems. That goes all the way back to Jackie Perry's old study where if you have on the collateral insufficiency, then your flexor pronator doesn't work as well. I don't make any sense because it should be overworking, but what happens is it gets more stress, I think. This is a thought, not a proven fact. But I think the flexor pronator then gets more stress and it starts to degenerate. And then you can't win because you can't get the muscle better because there's just the insufficiency of the ligament at this point and they can't come forward. And even on a quarterback, when they start trying to short, then they can't throw correctly. So they can't put their arm in the right position. Then you're dealing with the flexor pronator, like you said, all the time. So if you go in, you're gonna fix it, put a stitch or do something for the UCL because it helps take some of the stress off and then it gets better biofeedback and the muscle works better. That's great. I agree that when you have a significant muscle injury, in addition, it changes the game a little bit. And based on, I quote Buddy, and based on his work in acute proximal distal avulsions, tend to do very well and predictable. And even if they both do well and I can do a little bit better, why take the chance? Yeah. Because then the parents will be like, why didn't you fix it? Yeah. That's just a great discussion. It's pretty unique. And I haven't heard Mike, your talk about the kind of traumatic elbow and foal flare. It's pretty unique set of issues that have come up here. So we really appreciate all your input. And why don't we, we'll take a break now to try to keep us somewhat on time. We'll come back at 935 for the shoulder section. And you know, audience, feel free to grab the panelists if you have discussion questions here more.

forearm fractures

medial-sided elbow injuries

athletes

surgical techniques

UCL injuries