I'm going to talk about hand and wrist injuries in sports. I've given some version of this talk many, many times. Today I decided to show you a bunch of cases. I think that's really the most fun way to go. And please, if you have any questions at the end, grab me. I'm happy to talk to you. If you disagree with anything, some of this stuff is controversial, happy to talk to you. All right. Let's get going here. So here's the first case. This is a D1 offensive lineman who thought he just had a wrist sprain, but then he presented to me about a month after the injury, the team trainer calls me, and I take a look at him. And he got these x-rays, and yeah, it looks like a pretty bad proximal pole fracture, right? It's just a bad fracture of the scaphoid. It's not your typical waist fracture that heals about 90% of the time with non-operative care, although in our athletes, we'll almost always put a screw in these for proximal pole fractures as well. We want to put a screw in these to try to maximize the chance of healing, but as we all know, the blood supply is poor, right? It's a very unique blood supply, and these often go on to non-union. So here's a CT scan. You can see a pre-op here. You can see the proximal pole fracture right there. Not too displaced, but again, because it's a proximal pole, we want to try to get some compression and rigid fixation and maximize the chance of healing. So we did this. This is him three months post-op. Unfortunately, I don't have earlier x-rays, but three months post-op, you can see the screw in there. It's a little micro 2.5 millimeter screw, and you can see that, eh, that doesn't look too great. I've used some distal radius bone graft at the same time. This is a month out, and I just want to pack with some of his own bone, and not looking too good. So here's a CT scan. We got non-union, persistent non-union, bony resorption. There's just no healing there, but we had the discussion. Three months out, you want to wait some more? You want to give this another three months? Give this a year? Well, how long do you want to give this before you play again? And he was like, you know what, Doc, I can't waste any more time. I'm going to just play. I'm going to play with brace and see how it goes. And this is about a year ago. I haven't heard from him, so hopefully he's doing okay. But I just want to show this case, because not everything always goes the way you want it to go, especially with these fractures. And so you just have the discussion about the pros, cons, risks, benefits, everything, and then you let the player make the decision. You document everything, and then you hope that they don't end up with arthritis in the future. If they do, if he does, he's going to need some sort of salvage procedure. So anyway, I just wanted to show you a case where, you know, it didn't really work out the way I planned it to. This is an older case. This is a D1 wide receiver who injured his right hand while throwing a block during a game. This is several years ago. You probably will recognize him. I have his permission to show this case. And if you look at these x-rays here, it happens obviously on a Saturday. College games are on a Saturday, and the red circle will show you that there's something going on with the fourth metacarpal. But you know what? I had the same fracture on my left hand. Never had surgery. Doing just fine. Lost my knuckle. Can't be a hand model, but I'm still operating, right? Doing just fine. So I told him, listen, you don't have to have this fixed, but if you want to play next Saturday, you got to have this fixed, or in two weeks, whenever his pain allows him. He's like, Doc, I can't sit out for six to eight weeks letting this heal. Let's fix it. So went ahead and fixed it. I put a plate and screws on it. I think this is a very, very popular way of fixing these in these high-impact sports, players in high-impact sports. And so I put a plate and screw to dorsally place to just kind of span almost the entire metacarpal with lots of little screws, and very rigid. And so two days later, on Wednesday, I told him, OK, start really moving those fingers. Get that range of motion going. And this is his idea of really getting those fingers moving. And here's him on Thursday. Pretty amazing, though. Three days after surgery, OK, with rigid fixation, he's able to catch a ball. Maybe he's a little grimacing inside. It hurts a little bit, but he's able to catch. He's able to even throw the ball back to the guy through the trainer. And he didn't miss a game. Back the following Saturday, a little padded metacarpal brace. One of his best games. It was really remarkable. But I think this is the way we treat metacarpal fractures now for our football players, whether they're a collegiate or a pro, and with very, very low risk of nonunion or problems. So that being said, this is a very popular... Oh, I'm sorry. Let me just go back to... Sorry. Here we go. That being said, there's another way to fix metacarpal fractures now that many of you may be aware of. And this is a case of a professional boxer. And as you can see, he's got fourth and fifth, mid-shaft metacarpal fractures, angulated, displaced, definitely needs surgery. But what's the best way to fix it? I just told you a plate and screws is a really good way to fix these for impact sports. But this is multiple fractures. It's a lot of dissection. It can get into a lot of scar tissue if you try to put plates on both of these things. So as you probably know, we treat a lot of these now with intramedullary screws. It's a very easy way to do it. Just a very small incision over the knuckles. And you just put this down like an IM nail for a tibia without the interlocks. And it's really easy to do. Obviously, you have to watch rotation of the fingers. Jury's still out for me as to whether or not this is a good way to go for football players. I don't know how well this is going to hold up. I've seen these screws bend. And it's very, very difficult to remove if you want to do that. Also, these little holes at the metacarpal heads are stress risers. So especially for a boxer that needs to hit, they're going to hit right there. Are they going to get a metacarpal head fracture? I don't know. Thinking about trying to do a biomechanics study to look at that. But anyway, it definitely has its advantages. For single metacarpals, I think this is a good way to go. Sorry, for multiple metacarpals, I think this is a good way to go. Single metacarpals, I'm not so sure yet in a contact athlete. Here's another case. I just told you about IM screws. This is another case of fixing a proximal phalanx fracture. This is a right-hand dominant linebacker with a middle finger P1 fracture. Put a screw down there. Not the perfect reduction, probably. Another option would have been just to make a small incision, put some lag screws across it, or a plate and screws. But again, very minimally invasive. And get them moving right away. And he was back within a few weeks with a padded cast. Here's a hockey player. And now you're probably thinking, oh, Dr. Shin only treats the easy fractures. And that's true. Don't send me any hard consults, please. You probably think, where the hell is this fracture, right? And here it is. You know, again, probably could have left this non-operative, treated this non-operatively. They were in a playoff run. And I was like, listen, you can sit out for six to eight weeks. You go back earlier than that. You get hit again. You're probably going to re-fracture. He's like, no. Can't do that. So went ahead and fixed it. And put a lot of little screws in there, mid-axial approach. And just excise the lateral band and get them moving right away. And he was able to return in three and a half weeks, which for him, for the team, was huge. So as far as I know, he's still doing okay. Hasn't asked me to take out the plate and screws yet. Here's a case of a right-hand dominant NFL quarterback. This is a very, very bad injury. PIP joint injury. Right middle finger. PIP joint injury. You can see right here, as an impacted fracture, or accommodated with a central impaction fragment. And pretty bad. He also had a mallet finger, by the way. And so with this, it happened on a Thursday night. I get a call Thursday night. He's flying down the next morning with additional studies. And what I thought was, okay, you know, usually we see these injuries in our office weeks, like a week or two weeks later, right? And you can't do what I just did here, which is basically take a K-wire, and I tried to manipulate these fragments because it was so fresh. So I was able to get a K-wire in there, disimpact that central fragment, back down, reduce it, and then reduce it with that little pointed reduction clamp, put three K-wires in there, and then I was testing the motion. Is it stable? Is it moving as one unit? And I got lucky. It was. So I just replaced each K-wire with a little screw. And again, really testing it out and praying to God that afterwards he wouldn't fall apart later. Had a little pin in there for the mallet. And then he was able to actually do pretty well. He's three and a half weeks. So here's three and a half weeks post-op. Screw's in good position. And actually, he had about 90 degrees of motion by this point. He was working every single day, lots of therapy, and able to go back to a game shortly thereafter. Of course, you're having a discussion. You may re-injure this, okay, and then things may fall apart. But he's like, I get it, doc. I get it. He recommended everything, and he did okay. So anyway, let's move on to an injury that I think is one of the hardest things that we as hand surgeons treat. And you probably see this a lot in your athletes. These are scapholunate ligament tears. This is probably the bane of my practice, of my existence. And you can see here the obvious Terry Thomas sign, obvious widening between the scaphoid and lunate. And I'll tell you right now, there is no good answer for this injury, especially the chronic ones, but the acute ones. Lots of different smart surgeons have tried to fix these, lots of different ways, and there's really no great answer for this. So anyway, this is what I do now. You know, I get the call, and you get the MRI or X-ray, and then you can see here, and then I decide to do surgery because it hurts too much. If they're not that symptomatic, I'll actually let them go. I'll be like, you know what? Try to play with this. Try to live with this because the surgeries don't work that great. What I do now, what I like the best now, is this internal brace procedure, capsulodesis, adding an internal brace. You can see on the left there, the big gap there between the scaphoid and lunate. I have this V-type construct there with some anchors. And then you see the capsulodesis. I brought the capsule down, suturing that on the right side picture, and you see the floor shots down there at the bottom. Over time, what you may see is some osteolysis around these anchors and a little bigger holes. But for me, that's just an X-ray finding. If that happens, if this fails, they're going to need a PRC or a scaphoid excision, four-corner fusion anyway. So anyway, this is what I do now, and I've been pretty happy. For this particular athlete, he did okay. Not bad. The scaphoid joint space seems to be pretty well-maintained there, and the scaphoid angle is pretty good. So this is my go-to procedure now. Of course, I have the lay of the crepe and have the discussion, but yeah, this is what I do now for these. Here's a case of a right-hand dominant professional cornerback, and you look at that X-ray on the left, and you're thinking, oh, that's not too bad. You know, what's wrong with that? But you can see some of this disruption in those gallulose arcs or lines. You guys remember that from residency, right? But on the lateral, I'm sorry, it's a little bit whited out here, but you can see something doesn't look right. Things are just not lined up there, okay? And so we get the, of course, they get an MRI. Probably didn't really need it, but everybody gets an MRI. And you can see, especially on this sagittal cut here, that spilled teacup sign, right? The capitate bone is just not sitting where it's supposed to be in the lunate. So this is a mid-carpal dislocation, and these are a surgical indication. So what we did, what I do for these is just open them up dorsally through a longitudinal incision. You can see the scaphoid there on the left ends, that ding in the cartilage there, a complete tear of the scaphoid ligament, and he doesn't have a tear of the LT ligament as well. And again, for this, I think the internal brace for this works very, very well. And this is what I do here. I put a lunate, an anchor into the lunate, have the fiber tape go to the scaphoid, and also to the triquetrum, anchor those in. It's very quick and strong, kind of provides internal stability. And then I bring the capsule down for a dorsal capsulodesis, and I actually get them moving pretty quickly, around a couple weeks afterwards. Sorry, here's some intra-op florals. You can see the holes there for the anchors, and it's a really nice way to keep these bones in position. I don't use K-wires for this at all, and these scar pretty quickly, so that's why I get them moving pretty quickly. Here he is six weeks at post-op. Again, you can kind of see the holes there, and he eventually returned to play around three months. Actually, this happened right at the end of the season. He basically took his time during the off-season to get back. But significant injury that always requires surgery, but this is a nice technique for addressing these. Here's another right-hand dominant professional quarterback, and this is a common injury that you guys probably see as well. This is a thumb UCL tear. Hopefully you never see it in the dominant hand of your quarterback, but I've certainly seen my share of these. And you can see this is a complete tear of the UCL, almost always off the proximal phalanx, and obviously unstable. On the right there, not a very impressive picture. I should have taken a more impressive one with it kind of flipped out and everything, but I'm actually drawing the ligament back to where it belongs. This is a complete tear and very unstable, and so he needed to have surgery. The question was what type of surgery was he going to have, and he received multiple opinions and then finally decided to go ahead again with this internal brace type procedure. I brought this up a few times now. This is kind of a really great way to address different injuries in the hand and wrist, so I fixed it with this. And really, it is four to five times stronger than the traditional, just simple suture anchor repair at time zero. So it gives me the confidence to get them moving very quickly, make sure they have full range of motion before I cut the tape tails there and close it up. Okay, nice smooth motion, and you want to make sure they have great stability, especially to radial stress. And once I'm happy about with that, then I just close it up and then let them go. And what I do with these guys is let them start moving very early, like literally within two or three days after the surgery. They can start. You don't have to wait for the incision to heal. You just get them moving. And I think that's where we save a lot of their time in terms of getting back to play. And this particular gentleman was able to go back around five and a half weeks postoperatively. You can see here, this is post-update two. And there's no way with just a little suture knot there with a traditional repair, let them start doing this two days after surgery. So this has been a game changer for me and my athletes with these injuries. And I think this is almost, maybe almost, I hate calling anything I do the gold standard, but I think this is almost close to the gold standard for thumb UCL injuries. Stenor lesions. Okay, these are really bad ones, right? These are the UCLs that are flipped backwards, and they're never going to heal because the adductor aponeurosis, I don't know if you guys remember that stuff, but it's caught in between. So it's never going to heal anatomically, so we got to fix these. And for chronic stenor lesions, which I see a lot of in athletes, they just kind of play the rest of the season, and it gets all scarred in, you got a huge scar ball there, you can't unroll it to get it back to where it belongs, at least in the fashion that you want. So I do whatever I can to kind of get some tissue to cross the joint, and I have some kind of substrate there. And then I add this internal brace construct, but this is a little bit more involved than my regular UCL one for acute injuries. I bring the tape back to the phalanx, and I have, again, this V-type construct, very, very strong. I have never been happy with tendon reconstructions, so I like to do this now, and it's very strong and get them moving pretty quickly after a few weeks, and I've never had to do a tendon reconstruction since I started doing this type of procedure for this. All right, and so here's a case of a Division I right-hand dominant cornerback. He was fixed up in the Pacific Northwest for this Bennett fracture, but he had a recurrent fracture shortly thereafter. I personally think these screws are a little bit small, but maybe he could have gotten away with it, but he didn't. So he has a recurrent fracture here, and it comes down to LA, and I went ahead and told them, okay, we should fix this or you're going to get arthritis almost right away. I mean, you're going to get arthritis, but let's try not to delay it as long as possible. So I went ahead and fixed it again with some bigger screws. I was able to get the tips of three screws across that fracture and into that Bennett fragment, and that itself is very stable. What we're taught in residency is that that Bennett fragment there is in the anatomic location, and you fix the rest of the metacarpal back to it, it should be stable, right? That's what we're taught. That's dogma for us. But as you can see in the little kind of fluoro video here, I fixed it. That thing is still, whoo, it's going in and out. That thing is not stable, right? So I think we should revise our textbooks, at least our hand textbooks or chapters regarding that. So what I had to do at the same time before I closed it up was I added a little internal brace there dorsally, and as you can see here, it's very, very stable. So some people have used many tight ropes for this as well. You already have three screws in there, so I didn't want to have too much going across the base of the first metacarpal to the second. So I just did this dorsal internal brace, and I've been very happy with this for my athletes for immediate stability. And this guy returned to play within about three weeks. I think this is my last case. Here's another NFL player, wide receiver, and he has his left small finger. He's right-hand dominant, but left small finger, PIP joint, radiocollateral ligament tear. He had a surgery four years ago somewhere else, and I think it worked out well initially, but obviously being a wide receiver in the NFL, not surprised it failed. And he has his recurrence comes in with this, almost a 90-degree deformity at the small finger. He's like, Doc, I can't play with this. I'm like, my first instinct was, all right, we're fusing that thing, and you can get back out there again. He's like, Doc, I'm a wide receiver. I'm not a linebacker. So I can't play with a fused PIP joint. I got to be able to grip and stuff. And so I'm like, okay, well, we can try a revision surgery. I'm not sure if this is going to work. All right, it may fail, and you're going to come back to me for a fusion. He's like, that's fine. Let's try it and see what happens. So you can't really see much in these pictures, but this is the best pictures I have. I'm sorry. So on the left, you can see I have a hole there where the old anchor used to be. I had to kind of core it out, take it out. I put another anchor in there and secured the suture tape and fiber wire sutures. In the middle picture, I found whatever tissue I could. The ligament was crap, but I found some crappy tissue and repaired it, brought the suture tape tails distally to the middle phalanx and secured it there. So again, a repair with his internal brace. And you can see the two anchors there. These are very small anchors to do this procedure, and he was quite stable afterwards. He had some arthritis there, too, but who cares, as long as he's able to not have that severe deformity and play. That's all I cared about. And here he is about two months post-op. And you can see the video here on the right that, yeah, I'm just testing him out and pretty stable for this recurrent deformity that I probably would have fused at any other time in my career. But done pretty well. You can see his motion is really good. And he'll be, this is not that long ago, but he was able to return to play at about three months post-op, and we'll see how he does. So anyway, that's all I got for you guys. Conclusion, there's some innovative surgical techniques out there for hand and wrist injuries now that may allow for earlier return to play. And this is my email address. If you guys have any questions about problem cases, I got this email address really early so I don't have to have any numbers or weird symbols in it. So it's very easy, orthohand at gmail.com. I grabbed it so early, it's probably one of the first ones. Anyway, email me if you have any questions or, you know, about anything. And thank you very much for listening.

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