ran a little long, there were awesome talks. I mean, learning three things, I think I learned 30. So thank you guys all for giving such amazing talks and really kind of focusing on kind of what's new and what's out there on some of the controversial topics. So since we don't have much time, I just want to open it up to the floor. If anyone has any questions for these guys, questions about these cases, your own cases, anything, you know, usually no one likes to get up. But I just want to offer that opportunity. And we'll just kind of zip through some of these rapid-fire cases. We only have a couple minutes. Are there any comments you guys have? If not, I'll just kind of whip through. Probably won't get through many, but we'll start with some. This is a hand case, 24-year-old professional football player. It's a wide receiver. First week of training cap, he catches a pass, he falls down. Steve, this is what he's got. What would you do? Is this op, non-op, first game, first preseason practice? Yeah, real quick. Yeah. So, you know, right hand, middle finger, proximal phalanx, fracture. Got some interarticular, right at the radial aspect of the head of the proximal phalanx. And I'm sorry, when is this, when did this happen? It happened, you know, August 2nd. Okay. First week of training. Yeah, pretty much a no-brainer. I just go in there, mid-axial approach. I would fix that, not just with screws, but with the plate spanning the entire phalanx, just like presented in that case earlier, and getting moving right away. So, operative, he told us how you fix them. When would he get back, roughly? A return to play is really going to depend on, really, him. Well, because once I fix these with that plate and screws, again, filling every hole and spanning the entire bone, I'm very, very comfortable with how that bone is protected. So, a return to play is going to be really going to be kind of up to him. Maybe buddy tape the fingers for a little bit of extra protection, but really as quickly as he can. Sounds good. So, we followed your advice. We fixed them, and he did come back in about six weeks. So, foot and ankle case, 25-year-old professional hockey player. He's a defenseman. He injured his ankle during the game. He had a toe pick, right? So, he kind of comes down on the point of his skate and rotates. These always look like they're going to be horrible, multi-legged knee injuries, and they end up being an ankle injury. So, we splint them. He would package them home. They bring them back to Florida, deliver to us. What do you see here, Norm? What do you want to do? So, he's got a pretty classic Weber B rotational fracture. I mean, the ankle joint looks fairly well reduced there, but in a high-level athlete, it's going to need to be fixed for sure. You want any additional views or imaging, anything that you find helpful in this case? So, I tend to stress them under stress floor more than I would needs anything like an MR. So, stress horoscopy would be what I would do. Ask and you shall receive. So, you get a stress view. Does this change anything here? Not necessarily, because he was probably going to get fixed anyway, but it certainly understands. It gives you a better idea that you got medial sided injury. I scoped these in high-level or really in anybody that's young, going to get a scope. I'm going to be able to evaluate the ligament integrity arthroscopically, and so they'll get the deltoid fixed. They'll get their fracture fixed, and then you ask the question about syndesmosis. Given the amount of deltoid instability, I'm sure he's got a syndesmotic disruption too. Can you talk real quick about the medial side? Because that's something that came up a lot this year on the combine, guys not getting their medial side fixed, guys getting their medial side fixed. We used to talk about just fixing the lateral side and that medial deltoid would just kind of scar in. What's going on with the medial side of the ankle right now? Yeah. So, my threshold to fix the medial side is almost zero, meaning I open a large majority of these. I have to be fully convinced that there is no injury for me not to do it. Now, I'm scoping them, so I have a really good idea about what's going on immediately when I arthroscope the ankle. So, I have a low threshold to fix it. Most of the time, it's with a suture anchor in the anterior colliculus because you've torn the deltoid, it extends into the anterior capsule. So, I'll put a suture anchor and fix it. But if it's a mid substance, you can do it with primary suture repair. But I think it's important. Why? Even though it has good blood supply, why would you ignore it if you know it's completely torn and it's a part of the instability pattern? What about a nail versus a plate on the fibular side? This is a hockey player going in a boot. I think that's a really good question because the nail has gained a lot of favor, really, in the past five or six years. And in this case where a guy is going to be in a skate and you worry about hardware irritation, I think that is a more than acceptable way to do it. Ultimately, it's about getting a good reduction. If you can get a good reduction with a nail, I think it would be certainly an acceptable way to do it. So, he got the full Monty. I wanted a traditional approach. Our foot and ankle guy convinced me for the whole scope, nail, everything. And so, this is what he got and he's doing awesome. And in terms of this nail aspect for a hockey player, I think this is going to be kind of the way to go moving forward because we had another player two years prior, had the same type of injury pattern, has a plate. He had a fracture healed fine and the plate is driving him nuts. And the equipment guys have cut out the skate, done all this stuff. It's a nightmare. And so, I think this is a very, very interesting way and something new that's out there on the horizon. 31, spine case, Drew, you're up. 31-year-old professional football player. He's a strong safety. Just comes in complaining of neck pain, a Wednesday complaint. We're tanking. We're doing terrible. So, we're not sure. There's no trauma here. Is this because he doesn't want to practice or we don't know? So, we get standard x-rays, which actually look pretty good. And then because he's in the NFL, he gets an MRI and surprise, surprise, this is what we find. So, I put my radiology arrow there for you to help. And I think you've... I probably sent this to you. Yeah. So, I think, can you comment on why this is interesting, not just because of the big disc, but the other things that we saw on the cord? Well, so, if you look at C3-4 where your arrow is, if you look at the central picture, he's got signal in his cord there. So, signal or a T2 hyperintensity, which is also known as myelomalacia. So, to the sports guys, chondromalacia is softening of the cartilage. Myelomalacia is softening of the cord. And I promise you, that is not good. And so, he is at risk for all sorts of problems with this short-term and long-term. And so, as you see the cord coming out of the brainstem going down and you get to C3-4, you start seeing this white signal and you're starting to see some volume loss in the cord. And so, if you look at the diameter of the cord above and below it, so he's flattening it out and you can look at it in the actual presentation too probably and see it, but you see signal in the cord there, which is, that is terribly problematic and you can't play with that. Now that you know about it, he's been playing with it, but now that you know about it, you know, it's like your daughter going out with a bad guy. Once you found out, you can't go out with him anymore. So, if I remember correctly, he had pretty minimal neurologic findings, like you mentioned. You know, you mentioned operative versus non-op. If you were to fix it, what would you do and what would be the requirements to return to play? What if he was totally asymptomatic and he's cord edema resolved and he's got good motion of his neck, would you still not let him play? No, I wouldn't let him play. Okay. And if he said, okay, it's retirement or surgery, what surgery would you offer him? I would do an anterior cervical discectomy and fusion with an Iliac crest autograft. And you roll for an allograft? Not in an athlete. Not in an athlete, a cop, a fireman, rodeo guy, because these guys are total knuckleheads. They're not going to do anything you tell them to do, and so you want to make it as bulletproof as possible. How do you judge your return to play? Is it fusion on x-ray, CT, clinical findings, time, what's your requirements? So classic return to play criteria is normal range of motion, pain-free range of motion, good isometric strength, normal neurological examination, and a fusion as seen on a CT scan. Greg, 27-year-old professional hockey player. He's a goalie. Feels that acute injury pop in the groin while making a save. So there's that radiology arrow again for you. So he's got an acute injury on his right adductor. It looks like a proximal avulsion. He's had a chronic injury on the other side, as you can see. What am I doing with this guy? Has he been symptomatic on his other side? Has he had chronic groin pain, antecedent pain in both ears? He had an acute injury on the other side a couple years ago, treated non-operatively, was doing okay on the contralateral side, and then has this acute injury. Yeah, I mean, I think the hockey goalie is a unique individual. The positions he has to go into compared to somebody like a soccer player. And he also has the background of having one treated non-surgically, so he's probably going to be less likely to head down the road of an operation. So I think what we're trying to achieve with thinking about an operation with these injuries is can we prevent long-term groin pain, which some of these players have with that injury. You know, this is one I think you could go either way just because of his sport and his history with the contralateral side. So there certainly is a role for non-surgical care in a trial of biologic. Can you go back to the imaging? Sure. He's not terribly retracted. So, you know, the question would be, even if you treated him non-surgically, tried to get him through the year, could you do a surgical repair in a delayed fashion after the season if he continued to be symptomatic? And the answer with these addictors, they kind of just hang out there. So we've done some chronic several months later, although you may put them under too much tension, but that could be considered as well if he continues to be symptomatic. So I think you could go either way with this one. And there is a role for biologics, you know, as we've done with hamstrings, just injecting these and trying to rehab them back. Can you comment real quick? Because I know Bill Myers put something out about PRP in the adductor a couple of years back with HO. What are your thoughts? Yeah, we haven't had that experience. I know Bill Myers talked about it. We've used it extensively in the adductors with the Steelers, mostly with the myotendinous injuries, but also around the pubic plate. We haven't seen that. And I'm not sure. We don't really see that in other areas of the body. I'm not sure exactly what the biology with that is. I know it's been discussed, but it hasn't been our experience. I haven't seen that either. And return to play, roughly, we went non-surgical. Yeah. I mean, I think you kind of see what he does with how his symptoms evolve. I mean, you know, some of these guys, the groins tend to be a little easier in general than kind of the hamstrings, even with or without surgery. So some of these guys, you know, compensate and he might be a couple weeks and he'd be happy he didn't have surgery. I think he's just at risk. Any of these guys are at risk for kind of chronic groin pain. That's what we'd be aware of. Appreciate it. So in the interest of time, we're going to kind of wrap it up. I really appreciate it. Sorry for going a few minutes over, but I think obviously, judging by everyone sticking around, that these are really interesting topics with great, great faculty. So thank you guys for doing this.

sports-related injuries

treatments

hand fracture

ankle injury

neck injury