Okay, great. That was a great talk by Drew. Great to be here everybody. Nice to meet you all and I'm going to be talking about hand and wrist injuries. Obviously we don't have that much time but I'm going to focus on four injuries that are pretty common. These are my disclosures. Scaphoid fractures, scapholigament tears. One of my favorite topics is thumb UCL tears and I'll finish off with something fun, some metacarpal fractures and some cases. So let's start off with scaphoid fractures in the athlete. So this is the most common fracture in the wrist. I'm sure we've all encountered these in all of our athletes, usually from a fallen outstretched hand, a little slight radial deviation. But sometimes the athlete thinks, hey, you know what, I just got a sprained wrist or the team physician says it's a sprained wrist, they don't really follow through. But you know, if they have that tenderness in that snuff box, as you all know, you know, get some x-rays. If you don't see it on the x-rays, they still have that tenderness. Get the CT scan or maybe the MRI. And these can be tough to manage, you know, because as we all know, the blood supply is very precarious to the scaphoid. And so we don't know if these things are going to heal. I've seen the most non-displaced waist fractures not heal, right? Even with mobilization, bone stem, whatever, they don't heal. When it comes to scaphoid fractures, kind of what are the easy decisions, right? So if you have a displaced fracture, okay, that's easy, right? You want to fix it. Put a screw in it, you're good. Proximal pole fractures, again, because the blood supply to that part of the bone is the least, you want to fix those as well to try to improve the chances of healing. But how about that non-displaced waist fracture in the athlete, right? There's some good literature out there that says, yeah, just put him in a cast. They got a 90% chance of healing, all right, within about three months. It's kind of a long time, but 90% chance. So if I had a non-displaced waist fracture of my scaphoid, I'm not going to have surgery, okay? Unless maybe if I'm an athlete. But I'm going to mobilize it. I'm going to see, follow it closely, with x-rays or a CT scan, and maybe, you know, every four to six weeks and then see if it's healing. You know, there's another study here, this is from JBJS, Bond et al in 2001, kind of an older study, but a really good one. They compared screw fixation to immobilization only. And they saw that it was much faster, seven weeks versus 12, if you put a screw in it. And this is in, I think, it was a Naval Center study. So my approach to scaphoid fractures in the athlete, if they have it, fix it, okay? You got to get them back on the field, get them back to play. You're going to increase their chances of healing. Putting a screw in it is not that big a surgery, okay? It's usually a small incision, whether you go anti-grade or retrograde, it doesn't really matter, okay? But if you want to give the athlete the best chance of getting back on the field and healing, then you want to go ahead and just put a screw in it. If they can play in their position or their sport with a little playing splint, go for it, okay? If they can't, then you got to watch them closely. And I get a CT scan. I usually get a CT scan at six weeks post-surgery, and if there's about 50% healing with a screw, I let them go, okay? They're good to go. And I, but now I've kind of gone earlier and earlier. Now I do it about four weeks, because I found in a lot of these young, healthy athletes, they'll show this 50% healing even earlier. If they don't have it, I'll wait a couple of weeks and get another CT scan and kind of watch it every two weeks. But that's kind of what I do now. And people talk about putting one screw in it versus two screws. You might've seen some x-rays of some of your athletes now that get two screws for a scaphoid. I don't really understand that. I think you get really great fixation with one. If you put two in it, in my mind, you're just basically taking that bony surface area for potential healing and replacing that with metal. So I don't really understand that. I even heard of some surgeons wanting to do a third screw. So man, it's basically replacing the bone with metal. So this is just an example of an antigrade screw going through a small dorsal incision. Okay, so here's a case of a 23-year-old right-hand-dominant motocross athlete. He's from Australia, fell on an asterisked hand, obviously off his bike. You can see the obvious scaphoid fracture right there. You don't need a CT scan. You don't need an MRI. You can see it right there, but relatively non-displaced, about a millimeter. This is mine. I'd probably try to let it heal. It has very, very good alignment, but he's getting ready for the Olympics, wants to go, wants to be in the Olympics. So what we did after some discussion, put a screw in it, anti-grade screw, very easy to do. And this is a CT scan at four weeks. So hopefully this will work here. Okay. So yeah, so you can see, okay, coronal cuts, and you can see right here, there's a screw. You can see the fracture line, but he's got some great healing going on right there. Okay. So that's at least 50% healing. So four weeks, I let him go. And doing this for several years, they do just fine. So you don't need 100% healing if you have a screw in place. Okay. And if they don't see you right away, this is what happens, right? This is an ugly looking X-ray, ugly looking MRI. They develop something called a SNAC wrist, right? So what does SNAC stand for? Scaphoid Non-Union Advanced Collapse. And you can see that it's got some arthritic changes there on the MRI, at the areta scaphoid joint, actually on the X-ray as well. And when this happens, you know, you kind of, you know, it's hard. It's hard to do anything. You try to repair it. They're still going to have pain even if you get the scaphoid to heal because of the arthritis. So you actually have to do a salvage procedure. Okay. And these are two types of salvage procedures. On the left, this is something called the scaphoid excision, four-corner fusion. You can do it with screws. You can do it with plates. You can do it with pins. You can do it with whatever. I like doing it with screws. And, you know, this has worked well. On the left, sorry, on the right, this is something called the proximal row carpectomy. You remove the scaphoid, lunate, and tricuitrin bones. You basically give them a new radiocarpal joint, radiocapitate joint. And we used to think that, you know, just you have to do a partial fusion for NFL players or contact athletes, gives them the best grip strength, whatever. But the thing is, I've actually seen a lot of PRCs now. For whatever reason, maybe the surgeon's more comfortable with a PRC. And these guys actually do pretty well. You know, the outcomes are the same, you know, about 50% range of motion and the grip strength. And so, you know, if you do a four-corner fusion, then you have to think about, oh, man, are they going to fuse? How long are you going to wait? Actually, this guy on the left is a professional, he's a linebacker. And x-rays look pretty good there, right? I thought there was some good fusion. I got really cocky, didn't get a CT scan. And actually, it was a nonunion. So I ended up going in there and he had to screw that back down, took out the screw. But actually, I didn't do anything for the nonunion. He was actually asymptomatic. He had a fibrous union of his four-corner and just left him alone. So anyway, you can see both of these NFL players and it depends on their position what they can do. Okay, how about scaphoid ligament tears? So we just talked about the most common fracture in the wrist. This is the most common ligament injury in the wrist and the pain in the ass. For me, for a lot of hand surgeons, you know, it's really because nobody has a great answer for how to treat these, right? You can get a partial tear of this and, you know, that's kind of a complicated picture up there on the upper right. But there's three parts of the ligament. There's a dorsal band, which is the strongest part. You got your central and membranous band, the middle part. You got your boa band, which is kind of the middle in terms of strength. The dorsal band is the most important. But, you know, you can have a partial tear of any of these bands or you can have a partial thickness tear that can cause pain. The thing is, these ligament injuries in the wrist, they don't really heal very well. Why? Just like in other joints, you've got the synovial fluid bathing the ligament tear, the ligament, and it just don't heal very well. So if you have a partial tear, you know, it doesn't mean you have to actually operate on them, but the goal is pain control. However you can do that, you know, whether it's with immobilization, with anti-inflammatories, maybe a cortisone injection. I don't like doing too much of that. But the goal is just kind of pain control. And if they don't, if that doesn't work, then yeah, you can go scope the wrist and maybe do a little debridement, thermal shrinkage, denervation, whatever you want to call it with your wand, some magic, try to decrease that pain. Okay, if they have a complete tear, you can see the obvious widening there on the lower x-ray on the right. You know, that's called a Terry Thomas sign, David Letterman sign, whatever. Whoever has a gap in their mouth, you can call it that sign. You got to repair it. You got to fix it, do a reconstruction. But, you know, there's so many different procedures that have been described for this injury and none of them work very well. Okay. So that's kind of why I'm doing this, another technique. I don't have any long-term results. I'll tell you, I do this internal brace thing, but I'll show you that in a second. But, you know, with any of these techniques, you're going to get some scarring, you're going to get some stiffness, and you're going to sacrifice some motion for stability. Okay. A stable wrist is kind of the goal with these. I'm not going to really go through this too much. This is all the different options for fixing a scaphoid ligament. Like I said, there are tons of different ways to do it. You can do a direct repair. You can weave a tendon through the bones, try to keep them together. Those usually stretch out over time. You can do a ligament reconstruction, bone, ligament, bone, you know, kind of like, you know, your ACLs with your, you know, BTBs or, you know, people have actually done this for the scaphoid ligament, just for the dorsal band. You can put a screw across it. That doesn't really make too much sense to me. You're keeping two bones together. You're basically saying, listen, you're not going to have any more motion at that joint. So I don't really do that. I've seen some problems with screws too. And obviously if they're arthritic, you've got to do one of those procedures that I mentioned before, one of those salvage procedures. So, you know, just because none of these really work, I'm thinking, man, there's got to be something better that we can do for this. And, you know, anytime we use some kind of collagen-based construct, whether it's, you know, just repairing it, and by the way, once this ligament tears, you're never going to get the same strength back. So until somebody discovers Benchtop, how to like replace this ligament and get that strength back, you know, you're not going to be able to do that with surgery. And so, anyway, this is a case, you can see the complete tear right there, sorry, the dorsal band right there. And what I do is I do, for this, you know, they still have the voluminous central bands intact. I do this two-anchor internal brace. It really, you know, kind of helps keep the two bones together dorsally. And you can see that it really brings the ligament down to the bottom, make some drill holes, get some bleeding, try to get some healing. But this has worked very well for me. And some people will say, ah, it's just a dorsal band tear. It's a partial tear. Leave him alone. Well, I've seen these progress to complete tears, and especially in athletes. So I'm pretty aggressive with these. So just interoperatively, you can see, yeah, some limitation of wrist extension right there, but the reflections are pretty good. And we did some biomechanic testing. Again, complicated side. Basically, I just want to show you that, you know, the repair only at time zero is on the left, repair with the internal braces in the middle, and the intact scapula ligament is on the right. And, you know, even the internal brace, this doesn't come anywhere near as close to strength as an intact ligament, okay? It's just really hard to replicate that. But it's about three times stronger, maybe, than just a simple repair at time zero. And obviously, you hope there's going to be some kind of healing over time. But like I said before, it's difficult to get healing with this ligament. And then we did a study looking at three different constructs with this internal brace. And we found that, hey, if you can use two anchors, why not do three? Okay, it's different from the scaphoid, right? If you can do one screw, don't do two or three. But here, maybe you can do three and kind of, like, really reinforce that dorsal band. We did a three-anchor fiber tape. We looked at this three-anchor fiber tape reconstruction and found that it was the strongest construct and the most resistant to distraction and rotation. So here's just an example of this. This is what I do now for all my complete tears. I do, and you can see the suture tape tail is kind of coming out there from the scaphoid. But it really helps keep the dorsal, you know, reinforce the dorsal band and keep these two bones together. You can see the holes there on the PA view. The scaphoid angle is pretty good on that lateral view. And here's an example of a football player. I think it was a lineman, yeah, six weeks, just after a three-anchor fiber tape only reconstruction. And yeah, you know, not perfect, but it looks pretty good. The scaphoid joint is pretty well maintained there. And that wire, by the way, is just from an exospray. And they were kind enough to send me x-rays five months later. You can see, again, that the scaphoid joint is pretty well maintained. A little bit increase in the scaphoid angle there on the lateral view. But again, not bad. He was doing fine. And I was very, very happy with his result, given all the failures that I've seen with other techniques. Okay. So that was a lot on scaphoid, scaphalunate. Thumb UCL, one of my favorite topics, very common injury. And, you know, the question that I get, you know, again, when do you fix these, right? Partial tear, you don't have to fix those. Okay. Even actually a complete tear with no instability, you can give them a chance at trying to heal with immobilization. Obviously, if you have a high-level athlete that needs to get back to play, you need a much more predictable result, not a what, you know, not just kind of wait and see what happens after six weeks. You want to fix those, even if they don't have instability. But a regular person, even if they have a complete tear, you can immobilize them for about six weeks and they can heal. As long as the ligament's kind of hanging out in that area. But if you need to have an athlete, then I recommend fixing them for the most predictable result. So the traditional surgery for this is go ahead and just put an anchor in the phalanx, right? Usually these ligaments are torn off the possible phalanx base and bring the ligament back to fight right down the bone, get some bleeding from the bone, get some healing. Works great. You cast them for about four to six weeks and get them moving. Return to play is generally about six to eight weeks, but I'll always give them a splint, all right? I don't want them to go back without a splint until about 10 to 12 weeks with the surgery. Literally just having like a, it's just a little suture, kind of a little knot trying to hold this bone together. We're hoping that the body is going to get, get some good healing right there. So I'm a little cautious in terms of return to play with the traditional surgery. But, you know, and this is what I do now. I add a little internal brace and here's a professional quarterback who was on his throwing hand. You can see the UCL tear right there on this coronal view, coronal cut. It's UCL again, almost always torn off the phalanx, not the metacarpal site. Complete tear, instability, a lot of pain. And what I'm doing here, it's not a very dramatic picture. I should have taken a more dramatic picture, but I'm holding the end of the UCL with my adsent forcep and bring it back to kind of where it should attach to the proximal phalanx base. So what I did for this, went ahead and just put an anchor in there, you know, with some suture tape and the suture. Use a suture, just repair the ligament, okay? Just like you would a traditional surgery, but you know, just add the suture tape, bring it back, acts like a seatbelt for this UCL repair. And just one extra little anchor in the metacarpal, right? To kind of back it up. And we've done the, and then here he is. All right, sorry, intraoperatively. You know, you may want to make sure it's not too tight. You have good flexion, opposition, good extension at the joint. And you want to make sure that there's some, you know, really firm endpoint right away, okay, with your repair. And I'm making sure that the patient has really good motion there. If I feel like it's too tight or whatever, and you know, there's different ways to tension this. I'm not going to get into it, but if I feel like it's too tight, I'll just go in and take that anchor of the metacarpal and redo it, okay? So I want to make sure they're real good before you leave the OR. So post-op day two. So with the traditional repair, no way in hell that I'm going to let them start moving at two days after surgery, okay, with a traditional repair. You got this little one little knot trying to hold this ligament down to the bone. No way. But with this, I've gone earlier and earlier. And with these, with a lot of patients now, if they need to get back to their sport, they start earlier, post-op day two or three, okay? Take off the splint and dressings, get them moving. And so here he is, post-op day two. You can see here, this is from my therapist. And I mean, it's amazing. I mean, post-op day two, they can do this. And you know, with traditional, if you cast these things for four to six weeks, you've seen these patients. They're stiff as hell, right? Your therapists hate it. And it's hard to get their motion back, get their strength back, and certainly delay in terms of return to place. So post-op day two, able to do this. Again, with that internal brace backup, that seatbelt, I'm very confident with these. So I've been very, very happy with these. So we did some studies looking at this. You can see there's two studies here. In the upper right, you can see that with the repair with the internal brace at time zero, again, about four to five times stronger than a repair alone. We did a kinematic study with Ty Lee just to make sure that the kinematics weren't altered versus an intact ligament, or did the traditional repair, and they were all very similar, no difference. We did a return to play study and some athletes, professional and collegiate, very high-level athletes. And again, busy slide. Here's a table to kind of focus on. This is a mean return to play for patients undergoing thumb UCL repair with this internal brace. And in-season surgery, about 13 athletes in this study. And you can see return to play at any level. So that includes like a rehab assignment for a major league baseball player or whatever, about 31 days. That's not bad. But at the same level, basically back on the main roster and playing, whatever, about a little over five weeks. Okay, so that's really, really fast compared to the traditional return to play. And some of you may have athletes, oh man, they have a UCL tear, but they don't hurt too bad. You wanna let them keep playing, don't have surgery and miss part of the season. That's fine. Now with this, you can go ahead and let them play as long as their pain allows it. Okay, because now with chronic UCL tears, I've had some UCL tears where that ligament is so balled up, you can't get it back to the bone. But as long as I can get some collagen there to make me feel better that I'm doing something, I'll put this little internal brace in. I have two anchors now in the phalanx, kind of a double band or kind of thing. And this is very strong. And this patient at six weeks had full motion and able to go back to work. Actually, I'm sorry, this is not an athlete, but able to go back to all of his activities without any problems. So I don't get scared now of a UCL tear during the season. And the team physician asked me, oh man, does he really need surgery now? Or not, even if it's a stenosis, I'm gonna say, I say no. Or you can wait and deal with it in the off season. Okay, so that's some soft tissue stuff. I'm sorry, the UCL tears. And let's talk about some metacarpal fractures. Because here's a case, I wanna show some of these cases because there's kind of a new approach now, relatively new approach to treating metacarpal fractures, especially as transverse or short oblique fractures in the metacarpals. You can see here, this is a 23-year-old professional boxer. And you can see obviously that he's got these transverse mid-shaft fractures of the fourth and the fifth metacarpals. And what we do traditionally for a professional contact athlete for this, put a plate and screws on it, right? But that's a lot of dissection, okay? It's a big incision, especially for this, try to get to both metacarpals. And so what we do now is go ahead and put, and this was a perfect case for this, put intramedullary screws. And we go retrograde through the head, through a tiny little hole. And this one actually had to open a little bit to get a good reduction on the fourth. But this is all you have to do. And it's growing in popularity. I think this is great. It's a long bone, like the tibia or the femur. Why not put something intramedullary in there? Jury's still out though, in my opinion, and whether or not to do this in high-level athletes. As you can see, there's these two little holes in the metacarpal right there, especially boxers or MMA fighters, which I see a ton of, they're punching. You got this axial load going right at those holes, right at the knuckles. And I'm thinking, oh man, that's gonna be a stress riser. He's in a fracture right there at the metacarpal head. Now, I haven't heard of that yet. I don't, I never want to see that, but I haven't, I'm really, really nervous about that. So this is the only boxer I've ever done this in, just because he had two fractures. But, oh, sorry, only professional boxer. I'll show you a case of a non-professional boxer, amateur boxer. But anyway, jury's still out. I think it's a great technique. There's some anecdotal stuff about hypertrophic non-unions, maybe, if you don't get a really good intramedullary fit with these screws. But this is definitely growing in popularity. Possible complications, you gotta make sure you bury that screw, okay? You can see that on the left, that screw head is right at that joint surface, right? That thing, if that goes into the joint, you're now just, you're just messing up cartilage in the joint, and you gotta be real careful. And you can see on the actual way on the right, these things can bend too. And that thing, it would be a pain in the butt to take out. Thankfully, this wasn't my case. You see all that healing there? The only way to do that would be to actually go in and, you know, if it's bothering the patient, you go in, break the bone, and break the screw to take out both pieces. It would be a total pain in the ass. So anyway, please don't send me these cases. All right. All right. You know, at this stage in my life, I don't think I'm old, but I mean, at a point in my career where I just wanna do easy stuff. So I'm happy to give opinions, but I'm not really sure I'm gonna operate on your complications. Okay, anyway, so here's a case. Now, they even do it for phalanges too. And yeah, the lateral view looks pretty darn good, right? Pretty good alignment. On the APA, you know, the surgeon sent me this, and I didn't do this one, and they sent me this, and they were so proud of it. Oh man, you know, intramedullary screws, it's the rage now. Look at this, great, great, great reduction. I'm like, that's not a great reduction, especially on the AP view right there. It's not a great reduction. It's not good intramedullary fit. I would not be surprised if that didn't heal. And also that spike that you got on the radial side right there, that's gonna be very, very annoying for the patient, and the athlete's not gonna be happy. And so, you know, with this, probably what I would have done instead was maybe add some lag screws, and you know, if they have some time to heal, and really get that fracture closed up, or maybe even a little plate and screws, if they, you know, depending on their sport. Just from a mid-axial approach, it's a really nice approach. But yeah, I'm not really, I don't think I would have accepted this in an athlete. All right, here's another case. 26-year-old, right-hand dominant. I put boxer in quotes because he's not a professional boxer, and he's also, and I don't really know what an influencer is, but you know, I guess it's a pretty good occupation to make tons of money, and that's a great career, I guess. Anyway, oh, where's the sound here? I did exactly what you said. I told you, and now my hand, bro, my hand. David, look at it, bro. Oh! Okay, so this guy is an influencer that tries to box, and a really, really nice guy, and I have his permission to show all this stuff. So he was in a bar in Germany, and they had these boxing machines, as you saw, and he punched right through the bag and hit the back wall. That's stupid. And anyway, he's like, oh yeah, bro, bro, oh, bro, you know. And so anyway, flew back to L.A., and flew back, and you know, he wanted me to fix it, so you know, ended up with this third menocarpal fracture. Pretty, pretty combinated. It's hard to really appreciate that on the X-ray, but that's where it is. He obviously lost knuckle prominence and had a lot of combination, and so what I wanted to do for this, you know, so close to the joint, I didn't want to put a plate and screws there. It's gonna interfere with the tendon function and everything like that, and again, I'm a little bit worried about, you know, about the screws, but that's what I did for this one. I thought it was a great, great indication for it. I didn't want too much metal near the joint, and so what I did was I went ahead and just put a little screw in it, made sure it was buried there, and he actually healed very well. I always tell these guys, listen, you're gonna lose your knuckle prominence due to some shortening, but he did very well, and he's trying to get ready for another fight, and I really hope he doesn't fracture through that hole at the metacarpal head, and it's kind of funny. This is just last month. I don't know. I think I was prepared for this talk. This was in the mirror. He kind of, you know, of course he had to, like, show this off on Twitter or whatever he does, and it was an article in the mirror, which I'm not sure how respected that is, but I wanted to show you this. All right, here's another fracture. Here's a case of a professional quarterback, okay? I'm not gonna tell you who this is, but a professional quarterback with a very bad PIP joint injury, throwing hand, middle finger, and you can see here, very common in the interarticular, and I was like, oh, man, this is the worst injury I've ever seen. I'm not sure what to really do for this, and, you know, sometimes, we don't usually get these the next day, but I was like, you get down here now, and I'm gonna do this tomorrow. I was, like, even sick with something, and I just did it anyway, because, you know, the advantage that you have doing it early is that you can go ahead and, you know, actually mobilize these pieces. Oftentimes, we'll see these fractures kind of two weeks, a week later, two weeks later, whatever, and you can't really mobilize it, so a little blurry fluoro shot here, but I'm trying to show is I use the K-wire to kind of get those articular, get that impacted articular piece back down and try to get the best reduction that we could. I put three K-wires in to get some stability and want to make sure, like, okay, is it stable with these three K-wires? I was moving the joint back and forth, and I'm like, oh, wow, it's pretty stable. That's great, so then I had to replace each K-wire, no new holes, just each K-wire, put a screw in each K-wire hole, and it turned out to do pretty well. Pretty close to the joint there, but obviously, I made sure it wasn't in the joint, and this is him at three and a half weeks at post-op and returned a little earlier than I had asked him to, but, yeah, I guess he's still playing, doing okay. So, anyway, I just wanted to show you this case of a very, very bad injury on a throwing hand of a quarterback that, you know, and he actually got multiple opinions. One of them was, oh, man, he screwed, you know, just give him four weeks to get some healing, however it's gonna be, and whatever he's got, he's got. Another surgeon said, okay, put an external fixator on that, and let's see, and that's it, right? But I was like, oh, man, I think we can do something better and, you know, got away with these three screws. Okay, that's it, thank you very much. I just gotta show you this. I was having a really, really bad day one day in clinic, some angry patients, and I guess I was making them wait too long, and then I have a patient that comes in, the last patient comes in and gives me this. I just wanted to show you, pretty cool, coolest gift I've ever gotten, you know, picture of a hand on a bottle of Armenian cognac with my name on it, and I was like, oh, man, you just made my day. So, anyway, just wanted to show you that. All right, thank you very much. Thank you.

hand injuries

scaphoid fractures

scapholunate tears

thumb UCL tears

metacarpal fractures

surgical intervention