Okay, perfect, well thank you very much for that kind introduction, Gautam, and I'm really honored to be here with such an esteemed faculty. I don't think I've ever been on a panel as esteemed as this, and it's really nice to be here with all of you to speak to you this morning. I'll just give a little update on hand and wrist sports injuries for the team physician, and I could probably talk for about four hours on each of these topics, and we're not going to get through all the hand and wrist injuries, but I'm going to try to just give you a brief summary of what I do for each of these injuries. So in terms of disclosures, here they are. Okay, so quickly, I think I have about 15 minutes, so we'll see if we can get through this all. Scaphoid fractures, as we all know, it's the most common carpal fracture. Most commonly occurs at the waist, right in the middle of the bone. Less commonly at the distal or proximal aspects, and the proximal pole fractures are obviously the most concerning because of the blood supply. This is a really nice picture, kind of looking at the blood supply of the scaphoid, a nice kind of sagittal cut through the scaphoid here. You can see the nice distal blood supply, and then the dorsal blood supply from that dorsal carpal branch of the radial artery. You can see how very little blood supply is to that proximal pole. So I think if you keep this picture in mind, you'll kind of know why now that proximal pole fractures have such a bad reputation. So typically, it's a Fuchs type injury, right? You fall on an outstretched hand, usually with a little bit of a real deviation, wrist extension, and the player is just going to tell you, listen, my wrist hurts. And maybe they can play another down or two, but they're going to come out and be like, I can't play anymore. Typically, you can see the fracture on just a series of, sorry, an X-ray of the wrist, you know, whether it's the AP, lateral, or oblique, and if you can't, you get a CT scan to confirm whether or not there's a scaphoid fracture there. Sometimes people will go straight to the MRI. I don't think you need to do that unless you're really concerned for some kind of soft tissue injury, excuse me, like a scapuloneal ligament injury or something else. And the easy decisions are, so if you have a displaced scaphoid fracture, no matter where it is, you're going to fix it, right? You're going to put it back together, anatomic alignment, put a screw down the bone. If it's a proximal pole fracture, that's another easy decision, at least for me. Even if it's non-displaced, I fix these because they have such a bad reputation, you get a nice fixation, get nice compression at that proximal pole fracture site, and I think you really improve the rates of healing. But how about, the question is always, how about these non-displaced fracture, waist fractures in athletes? What do you do? You know, we know they heal actually really well. There's about a 90% healing rate. You just put them in a cast or some special brace, and within about a couple of months, you know, 90% of these are going to heal just fine. But you know, it's different for the athlete, at least in my opinion, and my preference is to fix these. Because you fix them, you put a screw in it, it's pretty easy to do, it's basically an internal cast, and if they can play, if the sport allows them to play with some sort of splint, like a thumb spica splint, a splint plus a screw, I think they're good to go. I'm not worried at all. I haven't had any problems with that. If they can't play with a splint, I'll make sure they sit out for a little while. I've got to make sure, I'm really conservative with these, if they can't play with the splint, even with the screw. I know some of my colleagues are a little bit more aggressive, they'll get them, you know, playing within about two weeks, once this incision is healed, if they can tolerate it. But I think that's a little soon. So I've seen some bad things happen with that. So I get a CT scan at about four weeks. I usually would get a CT scan at six weeks, that's what I was taught. I said, you know, wait, I've been taught, wait until six weeks, get a CT scan, because that's the earliest you're going to see some healing of this bone, even with a screw. But that's not true. You'll see some at five weeks, or even four weeks. Four weeks is the earliest I've seen it, and I'll show an example in a second. And once I see some healing there, so partial healing with a screw, I'm good to go. I think they're good to go, start moving, and then return to sport as soon as possible. So this is a case, a 23-year-old right-hand dominant, a motocross guy. He fell off his bike. He's actually going to Tokyo this summer, presented to me with this x-ray. Ignore the plate and screws, that's an older injury. But you can see a waist fracture here of the scaphoid, non-displaced. Typically, these would heal just great, right, 90% chance within a couple months. But we talked about the options, you know, and he's like, definitely, I've got to get this fixed. I've got to use that hand on the throttle. I've got to get back on the bike and train. So we went ahead and did it. Just put a nice little screw, very easy, small incision to go anti-grade through a small dorsal incision. It doesn't really matter, anti-grade, retrograde, but I'll let you go anti-grade. And you can see here, this is a CT scan at four weeks, okay? So you see the scaphoid there, you see the screw in the scaphoid, and there's actually some healing there already at four weeks. So you know, that rule about six weeks, you know what, I don't listen to that anymore. Four weeks is, at four weeks, I get the CT scan. If I don't see any healing, I'll wait a couple weeks and get another one at six weeks. But you know, four weeks is what I do now. You know, every day, every week matters for these athletes. This is a case that was just presented to me, actually. I haven't even done the surgery yet, but I wanted to share this with you. This is an MMA fighter. Not really a team sport, I apologize, but actually maybe, I don't know, not really a team sport, I think. Anyway, he presented it to me with these x-rays and this MRI. He's got a huge fight coming up, but as you can see, proximal pole fracture, this is seven years old. And you can see on the MRIs there, he's got some AVN, he's got cystic changes. What does the textbook tell us to do? Take that bone out. Take out the scaphoid, do a partial fusion, see how he does. But in an MMA fighter, that's typically, that's actually a very, you know, wrestling is his kind of key sport, you know, can you do that? With a partial fusion, what happens? 50% less motion, 50% less grip strength. He's not gonna be able to wrestle or fight effectively. So what we're gonna do, we're just going ahead, do our best to try to fix this, put a screw down it, actually try to get it stabilized, put some bone graft in there, see what we can do. Maybe do a little radial styloidectomy. He already has a little bit of arthritis. So technically, this is, I guess, a snack wrist. But he can't, he's not gonna be able to be at his peak level with just, with a fusion. So we're gonna see what he can do with the scaphoid repair with bone graft. Okay, so quickly, I'm gonna move on to now to metacarpal and phalanx fractures, some of the most common injuries that we all see, really, whatever sport. And the player's gonna present to you with, you know, saying, hey, listen, something's not right with my hand, or, you know, my finger looks crooked, especially with a rotation like a spiral fracture of the metacarpal, you have a rotational deformity in the finger. And sometimes they're not painful at all, actually, actually, I had one myself in my left hand, and, you know, I didn't have any pain. And I'm operating again in about three weeks. Don't tell my former patients that, please. So anyway, what are the typical indications for surgery? You know, we all learn in residency, rotational deformity, step off, right, at the joint surface, open fracture, multiple fractures. But how about earlier return to play? You know, is this also an indication? Is this a reasonable indication for fixing these guys, for putting them through surgery? And I think it is. So this is a nice case, and I have his permission to present it, so I'll mention his name in a second. This is a former USC football player, 19 years old at the time, wide receiver, and he has a fourth metacarpal fracture here, and you can see that pretty clearly, but you're probably thinking, listen, that's not bad. Actually, that looks better than the fracture that I had on my left fourth metacarpal years ago that I treated nonoperatively. And anyone else, yeah, you just put them in a cast or a metacarpal brace, and you let them go, they'll heal just fine, no rotational deformity. But we talked about the options, right? So went ahead and just fixed it. And I like this construct a lot. You know, sometimes I'll see x-rays of people who are fixed, and they have these short plates or just some screws. I don't do that, never for a football player. I like to span the entire metacarpal, I call it stem to stern or base to neck, with a nice thick, nice plate. I fill every single hole if I can, especially for these plates where they're kind of scalloped. You know, I think they're weaker than these reinforced plates, which I'll show a picture of in a second. And I think the empty holes can be stress risers, so I try to fill every hole if I can. So with this, this is Juju, by the way, with the Steelers. I think some of you may know him. He was catching three days after surgery, okay? So he broke it on a Saturday, fixed him on a Monday, and he was catching three days after surgery. Of course, this guy has pretty good pain tolerance, but look at what he's doing three days out. And he didn't miss a game. He was back into a game on Saturday again. Just gave him a little pat at metacarpal brace, had a great game, eight catches, including a touchdown. So just goes to show you, fix these rigidly, get them moving quickly, and basically it's just going to be the pain that's going to determine when they can go back. So just real quickly, and kind of my experience over the years in training players of different leagues and kind of when I think, when I kind of see them go back to play, this is just kind of guidelines from my experience, but for NFL players, about a week to four weeks after fixing them, depending on their position, obviously, NBA players, three to five weeks, and MLB, a little bit longer. I'm not sure. It's because they're a little wimpier than the other sports, but about four to eight weeks with or without ORF. So and then I get, you know, GMs will call and they'll be like, listen, Steve, I want numbers, right? They like numbers for whatever reason. So I want to know, what's the risk of re-injury? You know, if they go back without, if you don't have to fix, if you don't fix them, what if they go back without surgery, what's the risk of re-injury? And I don't have any literature to support this, okay? But this is kind of what I tell them because they want numbers. They keep pressing me on it. And I say, listen, if I don't fix them, no plate and screws, I say there's a 50% chance of re-injury in three weeks, 25 at four, 10 at five. At six, there's still a chance that they're going to, of course, get re-injured if that metacarpal is not protected. I'll never say it's 0%. With the plate and screws, about three weeks, near 0%. And I've been pretty, this is kind of what I've seen over the years. And that's a reinforced plate there, which I'm sure you've all used, you know, for maybe other bones or maybe even metacarpals. Nice and thick and very, very strong. And that's the scalp, not a reinforced plate on the bottom. So here's another case. This is a proximal phalanx fracture in an NHL player. Left middle finger, proximal phalanx. You're probably thinking, where the heck is this fracture? Yeah, there it is, right? And you're probably thinking, well, Dr. Shin is crazy. He's going to fix this thing. This thing is just going to heal. This thing is just great, right? And it would. If I had this fracture, no way I'd let somebody touch me, right? This would heal just fine. But he's an NHL player, you know, playoff run. What are you going to do? So you probably know what I did already. But to talk about the options, he's like, listen, I've got to get back. And so we fixed it. Nice plate, again, kind of stem to stern there, mid-axial approach. And fixed, what do you call it, I filled every hole with a screw. Really strong. He was moving within a couple days. And he was back to play at three and a half weeks. So there's no way I would have let him go back to play at three and a half weeks without a plate on this bone. And I'm not even sure if I would have been completely comfortable at six weeks. Because he gets hit by another puck, this thing is going to break again. So I'm really comfortable with this construct, letting him go back. OK. So how about the scapholinate ligament tear? This is one of the toughest things that we treat in wrist surgery. I call it the dreaded scapholinate ligament tear. I never like seeing these injuries. But unfortunately, I see too many of them. Players, they'll tell you this during the game. They fall on an asterisked hand. And with a little bit of a bone deviation and wrist extension, they'll tell you, listen, my wrist really hurts. So usually, I find that these injuries are more painful than the scaphoid fractures. And on exam, typical swelling, tenderness, and limited motion. You get the studies, x-rays. Sometimes you'll see this. Sometimes you won't. This gap at the scaphoid interval, more than about three millimeters. You get the MRI, and it confirms your finding for a complete scaphoid ligament tear. I don't get arthrograms anymore. I think that a good MRI with a good radiologist, I don't really need arthrograms to tell me if there's a full thickness tear or a complete scaphoid ligament tear. And what are you really worried about? When you fix these, you're worried about the wrist extension. That's what they need to get back. Whatever sport, gymnastics or basketball, they need to bring their wrist back to shoot the ball. And if it's blocking in football or whatever, they need to get that extension back. That's the most important thing. It's more important for most of the sports than the wrist flexion. And that's the thing that we try to work really hard to get back after surgery. So there are a lot of different surgical options. And the reason there are so many different ones, and we hear that when you hear about a condition that has lots of different ways to treat it, either they all work or none of them work. And in this case, so far, none of them really work for the scaphoid lunate. It's unfortunate. But it works. You get lucky. You do a direct repair, capsulodesis, tenodesis, put a screw across it, and you hope that you get some kind of healing of the ligament. But in my opinion, I don't think that's the real key to why these, you know, if you see that good at that x-ray without the scaphoid lunate joint opened up, it's more because of the, I think, extracellular healing and scarring that you get around the joint. And for a lot of these players, that allows to keep that joint together. But in my opinion, you know, I've done all of these. I've had failures with all of these. And I'm not saying this is the new gold standard, but I've seen better results with this kind of synthetic construct that doesn't stretch like these collagen constructs do when I use an internal brace. So anyway, I'm going to just kind of picture kind of what I do now for my scaphoid lunates, for all my scaphoid lunates, whether they're an athlete or not. And I put this construct in there with one anchor in the lunate, two in the scaphoid, and I just use fiber tape because this fiber tape stuff, it doesn't stretch as long as it has really good purchase in the bones, really does a good job of keeping these bones together. Now, chronic scaphoid lunate injuries are a different animal, though, right? You're going to have this fixed deformity, and it's very difficult, even with a really strong construct like this, to really keep those two bones together out of that and correct that scaphoid lunate angle in the lateral view. But I still think this is better than the tendon weaves or the repairs or caps of soft tissue stuff that I used to do. I stopped probably a cast in for about two months and returned to play still about four to six months. You know, I haven't been brave enough to let them go back to play kind of sooner without an orthosis, without some kind of splint, but so this is still kind of this timeline that I have, that I use, and the same one that I used for my previous repairs. So we did a biomechanical study with Tylee, basically looking at different constructs using this fiber tape internal brace, and you can see here, there's this one kind of construct from the lunate to the proximal scaphoid at the top, and then the middle one, middle from the lunate to the distal scaphoid, and then this V construct, and it kind of makes sense, right? The V construct was the most resistant to distraction and rotation. You've got two of these strong limbs crossing the joint, and the dorsal limb of the dorsal band of the scaphoid lunate ligament is the strongest part of this ligament, so it kind of makes sense. So this is what I do now. Sometimes I'll bury some fiber wire sutures in the holes and tie them over the top of the capsule, and I've been very happy with this so far. This is just one case of an NFL linebacker that I did this in. He had no ligament really there to fix, and I did this V construct with the fiber tape. You can see how five months out now, the x-ray looks really good. There is an increased scaphoid angle there. The normal angle in lateral view is about 45 to 60 degrees. He's more about maybe 90 degrees there, but it did well, and I just like seeing that joint space nice and narrow. I know I'm going through this stuff pretty quickly, but I want to talk now about one of my favorite subjects, thumb UCL tears. When this happens, it's pretty obvious. The player will come to you on the sideline, and they'll say, listen, I think I dislocated my thumb, or it really hurts, or I can't squeeze that ball anymore, or whatever. You immediately think UCL, right? That's the most common injury at the thumb MCP joint. UCL tears are 90% of the collateral ligament tears at the MCP joint, and RCL tears are only 10%. The skier's thumb, by the way, I'm sure you know the difference in terminology, but I'll just mention it for everybody. The skier's thumb is the acute injury, and the gamekeeper's is the chronic. I know people use those terms interchangeably, but whenever someone tells me, I just have this tendency to correct somebody when they tell me it's the gamekeeper's, and it just happened yesterday. What's the indication for surgery, though, for these thumb UCL tears? If they have a complete tear, or they have a displaced avulsion fracture, and there's instability, obviously, compared to the other side. Always examine the other side, because some people are just born with some instability, just generalized ligaments laxity. They'll have some of what you think is maybe a chronic UCL tear on the other side. Traditionally, what do we do? We repair these ligaments with a suture anchor, one or two little anchors into the phalanx, get it down nice, and then you cast them for about four to six weeks. Casting is kind of the bane for us as physicians who treat athletes. They get atrophy, they get stiff. So in return to play, about six to eight weeks with a splint, sometimes longer without a splint. I used to wait at least 10 to 12 weeks. I was very, very nervous about this ligament re-tearing, which I've seen when they go back even at six or eight weeks after surgery. So I thought, OK, well, why can't we use this kind of internal brace idea for the UCL? And that's what I do now for all my UCLs. I use a little anchor in the phalanx, and a bigger one in the metacarpal, bigger bone, bigger anchor. And I have this tape that kind of goes across over the ligament after I repair it with a fiber wire. And this is a really, really strong construct. So we did some studies biomechanically, four to five times stronger with this internal brace augmentation. And the kinematics are also very similar to a normal UCL repair. So that was nice to see. So here's a case. This is a quarterback, throwing hand, had a complete UCL tear. You can see on the MRI right there. Completely torn off of the proximal base of the vulnerable base of the proximal phalanx. And I apologize, this picture is not really representative of what I saw. I'm actually pulling the ligament back out towards where it's supposed to be attaching to the vulnerable base of the proximal phalanx. But it was completely torn off and very unstable. So after discussing what to do, fixing it, add the internal brace or not, went ahead and fixed it. This is what it looks like. And just have the suture tape tails kind of coming proximally, dunking with an anchor, which is proximal and dorsal to the native attachment of the UCL on the metacarpal. Make sure I tension this in about 30 degrees of flexion at the MCP joint, right? We all learn in residency that's the position in which the proper UCL is most taught. So if you don't do that, they'll lose flexion at the MCP joint. So here's just some pictures, just showing some really good flexion there. You'll want to make sure you test this out, go to a full-on position on the left there and a good extension on the right. And this is interoperatively me testing after I've put this in, and make sure they have a really nice firm end point, really strong, really, you know, still maintain very good motion at the MCP joint. And once I see this, then I close it up and they're good to go, start moving within a couple of days. So here he is post-update two, you know, a nice little splint that we make form, leaves the CMC and IP joints free from motion, still has the stitches in place there. And you can see here that he's got a really great motion already post-update two, okay. There's no way, no way I will let an athlete without an internal brace augmentation start moving at post-update two, right? Otherwise, you just have stitches holding this together, it's going to come apart. So I don't trust the patient, I don't, to let them start moving that early. So, but with this, you know, we've demonstrated how strong it is, you know, it's amazing to get a full opposition at post-update two. So we looked at about 13 athletes, you know, who had in-season surgery, and we saw that return to play at any level was about 31 days, and at about the same level, about five weeks, just a little over five weeks. And that's kind of typically what I see now with my athletes that have this surgery with the augmentation. Okay, so I know we didn't cover, you know, all the different hand and wrist injuries that we encounter with our athletes, but I want to cover at least, you know, these kind of, these four things I see very commonly. And some take-home points for the team physician from a hand surgeon's perspective, I mean, you know, and this is maybe applicable for really any orthopedic injury, but at least specifically, especially for hand and wrist, I mean, they'll usually let you know, listen, their fingers, if they think their finger's broken, or they've got an SL injury, or something's going on, they'll let you know, you know, if something's wrong, and whether or not they can play, you know. Some of you may be very comfortable training hand and wrist injuries, but, you know, if there's any, you know, lack of confidence, or whatever, just refer to the hand specialist. You know, we're going to do our best to make all you team physicians look really good, okay? We're colleagues, and we're nice guys, and compared to, like, some of the other specialties. But make sure you discuss with each athlete the non-operative and operative treatments, and let them make the decision. I always do that. I always document it, and that's usually the right decision, okay? And finally, sometimes operative treatments, like I mentioned, for some of these injuries is preferred for return to play, but they should always make the final decision. Thank you very much.

hand surgeon

wrist injuries

athletes

scaphoid fractures

ligament tears

thumb UCL tears