Good morning, everyone, or good afternoon, or good evening, depending on where you're joining us from. On behalf of the American Society for Surgery of the Hand and the American Society of Hand Therapists, I'd like to welcome everyone to the 2022 Electives in Hand Surgery webinar. I'm Paige Fox from Stanford University, and I'm co-chairing today's program with Brandon Smitana from Indiana Hand and Shoulder Center, and Kristen Valdez from Toro University. Kristen? Good morning, everyone. I'm Kris Valdez, and I'd like to thank our esteemed faculty of hand surgeons and hand therapists for being here with us. I'm Brandon Smitana, and today's course will be divided into three sessions. They will include a mix of content in traditional lecture format and case-based discussions to maximize engagement on the Zoom platform. We encourage both participants and faculty to ask questions into the chat, which will be actively monitored. Questions will be incorporated in the case-based discussion, so please ask them during these sessions. Any remaining questions or those posed during the lectures will be highlighted during time allotted for questions at the end of each session. Our three sessions include wrist, hand, and two concurrent sessions, one covering shoulder and elbow and the other soft tissue and nerve pathologies. We have time allotted for a break in between the first two sessions, as well as prior to the concurrent session as time allows. Just a few housekeeping notes before we start the course. Your audio will be muted during the presentations, and the recording will be available to attendees one week after the course. Please engage and ask questions in the chat to the panelists, and in case of technical difficulties, please contact webinarsupport at ASSH.org. Attendees of this live virtual course can receive up to 4.5 AMA CME credits, with one hour of that being patient safety. You can claim your credits on Thursday, February 3rd, by logging into the ASSH website. To claim your CEU certificate, please contact Lucy Patilano at education at asht.org. Here's just a reminder of how to do that. Next, ASSH has some great courses and offerings coming up. Failed Nerve Decompressions and Nerve Reconstruction with Drs. Moore and Isaac will take place on Wednesday, February 23rd from 7 to 8.30 PM Central Time. The ASSH Diversity Webinar is taking place on Thursday, February 24th. Importantly, abstract submission for the 77th Annual ASSH Meeting is open. The submission deadline is February 28th, 2022. Visit ASSH.org for more information on the Annual Meeting. Specialty Day is back in person at the AAOS on Saturday, March 26, 2022 in Chicago, Illinois. And the ASSH Self-Assessment Exam is now open for registration. The meeting will begin on April 1st and close on July 31st. Lastly, please check out the ASSH Surgical Anatomy Series available in both print and e-book. Our first session will cover the wrist. And first up, we will have Dr. Amagi from Texas Orthopedics, Dr. Putnam, and I will be discussing scaphoid fractures and SNAP cases. Dr. Putnam, would you like to start us off with a little bit of background on what we're going to cover today? And then we'll turn it over to our co-chairs, Dr. Putnam and Dr. Putnam, who are going to give us a little bit of background on what we're going to cover today. and go through some of the cases as well. So for the first case, I have a 51-year-old right-hand dominant otherwise healthy male who was seen by one of my partners for bilateral wrist pain, right worse than left. He had a history of bilateral scaphoid fractures that were treated conservatively about 30 years ago. He's had increasing pain and stiffness over the last three years and finally decided to come in for evaluation. So his exam's pretty unremarkable. Both sides, his neurovascular intact. The right side, he has definitely a limited range of motion with flexion extension and pain throughout. Stiff amount of tenderness over the radial scaphoid joint. Left side, very similar, but a little bit better range of motion than his contralateral side. So here's some images to start off with. On the right side, Dr. Putnam, do you want to kind of say what you think of these? Sure. So AP and lateral view, we see evidence of a scaphoid nonunion with advanced collapse and periscaphoid arthritis. So it makes sense that this is the side you said is more limited range of motion. Right, so then we have his left side. So, you know, kind of similar findings here, but not quite as progressive as his other side. So diagnosis, just like Dr. Putnam outlined, he's got bilateral scaphoid nonunions with arthritis. So next steps, Dr. Putman, would you get any further imaging of this or what would you recommend to the patient this time? You know, I think for the left side, certainly at least a stage one, just looking at the changes in the styloid there, I don't necessarily know that advanced imaging would change my management on either of these cases, but I don't think a CT is the wrong answer. It might help you give him a prognosis for if a limited procedure, like a styloidectomy or a denervation, how much it might help him. But I don't think you have to have any advanced imaging here. Sure, so I didn't get any advanced imaging. I didn't think it would change the plans with him whatsoever, just kind of based on his exam. So treatment, you know, the options you can continue conservative treatment. You know, we talked to him, active immunizations, bracing. He's been doing that for approximately 30 years. So that's not really what his options were at this time. So that wasn't why he was coming in. So, you know, surgical stuff, you mentioned this a little bit, but an erectomy is kind of a limited intervention procedure. You could do just a pull excision, proximal carpectomy, or even a partial wrist fusion. Dr. Putnam, what would you think at this point? So I think for the left side, certainly, he has a reasonably good motion. I think you said there, he has some degenerative changes, but not as significant as the right. So on the left side, I might counsel him for a denervation and a styloidectomy. Again, lay the crepe a little. We don't know how far that further degeneration will go, but on the right side, I would think that a PRC or a four corner fusion would be the more predictable surgery for him. Sure. So I talked to him about all those options and he was not wanting to do a longer recovery. An erectomy he wasn't interested in. So I talked to him about doing a potential distal pull excision. And I said, you know, this isn't burning any bridges, but I can't make any guarantees this is going to hold up either. And he said, great, I want to get back to fly fishing, mountain biking, and everything as soon as I possibly can. So I talked to him about doing distal pull excision. So Mallory's procedure, which does have some pretty long, good long-term data, first described over 20 years ago. And then they had a new article come out in ASCH germ for hand surgery with a 20 year experience and fairly well good results of this. So on the right side, we went ahead and did the distal pull excision. So post-op for him, I splinted him for just 10 days. The transition to a Google brace for comfort. Saw him back about a month after that. And at two months out, his range of motion is simply improved. He had no pain whatsoever with range of motion. He was already back to fly fishing and he was super happy with it. And I told him, I'm happy to see you back in six weeks to check in. And he never showed up. Nine months later, he came back in. He said, my right side's doing awesome. I want you to do the exact same thing to my left side. So he came back in and requested a similar procedure. We did that, sort of the exact same thing. Splinted him for 10 days, transition to a Google brace for comfort. I think he's actually scheduled to see me next week for a new evaluation. Thank you. Looks like you've got a question here. Yeah, it looks like I got a question from Dr. Yao. Great case, is there a limit on how much the distal pole you can excise with a malwage procedure? You know, Dr. Yao, I'm happy to have you chime in on this as well. I don't know if there's a specific amount of limits. There is a concern if you take too much out of it, that you'd have some destability to the wrist. And I think that's when you're looking at doing much more of a proximal carpectomy or partial wrist fusion, like Dr. Putnam mentioned. But I'm happy to have you chime in if you have a thought about that as well. Sorry, thanks. Yeah, I don't do that procedure myself personally. So I don't have any real experience. So I was just asking whether or not there was a limit. Yeah, I don't know for sure. That on the right side, it was a little bit less. The right side, it was a lot more, but I don't have a limit myself per se. Thanks. Yep. Yeah, great case. So I got one more case before we'll switch it over to Dr. Putnam. So case number two, 17-year-old male, otherwise healthy. He was referred from one of my partners to a persistent wrist pain after a fall four months prior. Four months ago, he had an injury playing football. He presented in urgent care at the time of the injury where x-rays were obtained. He was told there was no fractures. He continued playing football. He then sustained a tibiotubercle fracture that was treated more urgently by one of my trauma partners. And during his post-operative period with his immobilization of his lower extremity on crutches, he's noted to be at persistent wrist pain. So on physical exam, neurovascular intact. He did have some tenderness to the snuff box, stiffness with range of motion, though no significant pain. These were the x-rays that were obtained by my trauma partner at that time, Dr. Putnam, do you have any thoughts on these? Yeah, so evidence of a delayed union, if not a non-union. I think you said he was four months out. It looks established to me at this point. So I would just go ahead and call it a non-union. Yeah, sounds good. So I agree, less scaphoid, delayed union, slash non-union. I think if you read textbooks, technically non-unions are six months. I don't know if that really applies to the scaphoid because I think that there's a little bit different blood supply and healing aspects here. But so less scaphoid, delayed union, non-union. Next steps on this, would you get any further imaging? Great question, in this case as well, I don't necessarily think that any advanced imaging is needed. It's an established non-union. Whether or not a CT or an MRI suggested ABN, and again, that's very controversial. It probably wouldn't change my management of this case. It's a young, healthy male. So, yeah, I agree. My partner, my trauma surgeon actually ordered an MRI. It re-showed there was a non-union there. I think evaluating blood flow on an MRI for the proximal pole is difficult. I don't think there's a lot of evidence to suggest we can. CT, sometimes I'll get these if I'm worried about collapse or hump-back deformity or something like that. But basically the x-rays here, I wasn't concerned about that. So treatment options, what would you recommend at this time, Dr. Putman? Continued conservative management, would you give him these options at this point or would you push him another way? Yeah, so like we discussed, an established non-union, those fracture edges look pretty sclerotic to me. I don't think there's any role for conservative management or hope for a bone stimulator. I'd indicate him for surgery. I agree. So surgery, what would your approach be to that one? This is why I love scaphoid fractures because it's so controversial how we're going to fix it and there's so many options and so much level four and five evidence to support those options. So my workhorse for these, you have a young, healthy patient with, it looks like robust real estate for fixation and grafting. So for me, that would be Ken Salas-Graf to add a little biology to the- I think it might just be me, so I'll go ahead and continue. So I agree. I think a treatment for this, I think a percutaneous screw is probably not going to do the trick. For this, I would typically go with a VOLAR approach, put some biology in there with some bone grafts. So I recommended an ooproductional fixation with distal radius valve bone graft from a VOLAR approach. There was a comment in the chat about seeing a lateral X-ray and Dr. Greenberg indicated that the humpback collapse preoperatively could be a significant determinant of a surgical approach. Correct. I think I had a lateral earlier. Maybe I didn't have one in this. There we go. There was the lateral there. So he looked pretty aligned here with us in the humpback, which is a time when I would get a CT potentially if I was worried about that. But in this case, I wasn't as worried about a humpback deformity. And someone, Dr. Kim has suggested perhaps a bone graft of the harvest site. Correct. So there's different harvest sites available for this. Distal radius, which is what I go to a lot of times if I'm just doing a cancellous graft because it's right there. Iliac crest is sort of your standard workhorse if you need a little bit more of a cortical cancellous graft. So this is his floral picture. So we did ooproductional fixation and scaphoid with distal radius bone graft and a headless compression screw. So post-op protocol, I think Dr. Putman looks like we got you back now. Mobilization, what would you do for mobilization afterwards? So my worry with these folks, as soon as you get them out of their splint or their cast, as soon as they get their removable brace, they never come back. So I'm pretty aggressive about transitioning my post-op splint to a cast and following that with radiographs out of the cast and recasting them until they have enough evidence of bony bridging. And until they're non-tender. And that's when I put them into a removable brace. Do you routinely use a bone stimulator for these? I do not. Not unless it's been three to four months and their progress has plateaued. Gotcha. And then how do you, do you get a CT to confirm healing at that time or is it non-tender just based on x-rays? You know, I find that I still order a CT scan the majority of the time, although recent literature would suggest that it doesn't really add to the, that there's not good reliability for that. I think that was in JHS last year. That CT scan doesn't really add a whole lot to what we already see in radiographs, but I do find myself ordering a CT scan. It sounds like, it seems like a natural progression as you and the patient get frustrated that you want to confirm that there's 50% healing before you let them go. Gotcha. And then we already kind of touched on this about when back to full activity, typically no pain, x-rays or radiographs or CT showing healing at least 50% and then range of motion and strength are better. So my post-op, he was splinted for 10 days. So kind of the same things Dr. Putman mentioned about worried they're going to disappear. I was also a little bit worried about compliance because he's a 17 year old kid who just wants to play football. So I did cast him. He came back. We've checked it a couple of times. He ended up having a cast on for just shy of two months. And I did use a bone stimulator as well. Parents had asked about it. I don't think it lost anything. And I think throwing the whole kitchen sink at this in my approach to sometimes with a young, healthy person is a reasonable application as well. So I did get a CT at two months. Patient had no pain, but kind of what Dr. Putman mentioned as well. It's a natural progression. I want to see it's healed. Makes me feel better about him before I say you get back to full activities. So these are a couple of selective sagittal images from his CT at two months out. And the radiologist reports, there is some healing across the fracture, less than 50%. I think this is actually pretty difficult to assess healing specifically at those times. But I do think that this gave me some idea of how he was progressing to heal. So I didn't take him completely out of immobilization that time because I wasn't 100% sure it was completely healed. He went back into a splint. He then disappeared for about two months. And then he came back with a new X-ray, no pain, full range of motion and got him back to full activities. Okay, wonderful. We have a, I'm coming to you from Connecticut and we have a blizzard ripping through here right now. So we're expected to get about a foot and a half of snow. So in the spirit of that, I'm just going to plow forward into a third case. What I'd like to present is a 60 year old male. Should be able to see his radiograph there now, who has a longstanding history of right wrist pain. This is a healthy 60 year old male. He's a non-smoker. Sorry, I'm not having good luck controlling those slides advancing. He doesn't have any specific injury that he recalls. He comes in just requesting whatever surgery might get him back on his motorcycle the fastest. He's already tried non-surgical management and exhausted it. So Jason, what do you think about these radiographs? Yeah, it looks like he has history of definitely some scaphoid trauma. There's definite amount of arthritic change coming through his proximal roll. Lateral gave me a little bit more idea of what his mid-carpal joint looks like as well, but it looks like that may be affecting his mid-carpal joint as well. Yeah, absolutely. So in the interest of time, I'll plow forward. We've kind of discussed surgical options for a snack wrist. Motion preserving is the wrist innervation, but we're going to consider this male to be a candidate for a PRC versus a four corner fusion. Our decision on that is going to be based off of his goals for motion. Certainly, I said he's a non-smoker. That's very important. And then at the time of surgery or based on preoperative imaging, what you think the capitate and the lunate facet are going to look like. So Jason, what do you think? What would you be telling this patient about the best surgery for him? Yeah, I mean, I think you mentioned it. Wrist innervation is a possibility. If you're going to do that, you can always do a local block in clinic and see if that gets rid of his pain. The other options are PRC, four corner fusion, potentially a total wrist fusion. I love PRCs. I think they're more predictable, more reliable, have less postoperative complications. I'm not worried about healing. The issue you mentioned right into is if there's a weird decapitate or lunate fossa. You can always make that decision interop or another thing that I've had pretty good success with is doing capsular incisions. If there's a little bit of detergent change on the capitate but not significant. So I would lean probably toward a PRC. And then the option is if that fails later, you can always go back to it if you need to. Sure. So I agree completely. That's what we did. His capitate was a little ebernated, but I felt that it was appropriate for a capsular interposition. I did approximately base flap for this patient and he was ultimately very happy. These are his images at four months postoperatively. He had 40 degrees of flexion and extension and had a grip strength that was about 75% of his non-dominant side. He was very pleased with that outcome and got back in his motorcycle. So I'll skip the overview slides and I'll say thank you so much. I think we're out of time here. Thank you so much. Next, we have Dr. Jeffrey Yao, who will be describing SL and perilunate and other instabilities. Okay. Good morning. Can everyone hear me? Yes. Thanks. Thanks everyone for the invitation to participate. I'll try to cover this massive talk in 15 minutes just by way of a context. I usually give this as a one hour talk, but I'll try to compress this down and focus primarily on scapulonate injuries. Those are the most commonly encountered and the most commonly discussed. Oh, I would be a miss in not mentioning the big game that's coming up tomorrow and support our San Francisco 49ers. Okay. Here's my disclosure slide. And okay. So we'll start by just reminding everyone that carpal instability is a massive talk. It's important to remember that malalignment alone does not equal instability. In other words, there are some patients that do have congenital hyperlaxed wrists that appear malaligned, but are asymptomatic. So instability is really the abnormal transfer of load across a carpal joint with abnormal motion. So motion should be smooth, synchronous, without sudden alterations or clunks. I think this is the most important classification that we use for classifying carpal instability was the Mayo classification. And it's classified in dissociative, non-dissociative, complex, and adaptive. And for the most part, I'll focus primarily on the carpal instability dissociative patterns. The scapulonate ligament injuries, but I'll touch on the others towards the end. So focusing on scapulonate ligament injuries is carpal instability dissociative. Remember, we're talking about the proximal row as a unit. And if there's any dissociation within the carpal proximal row, then that's what's called a carpal instability dissociative pattern. And the most commonly discussed is a scapulonate ligament injury. And I could think of this as a spectrum of disease. I took this from Kirk Watson's chapter on this topic. And I thought it was very elegant in that it's not either one or done kind of injured or not injured. It's a spectrum of disease with identifying multiple different levels of injury to this ligament. And I'll focus on that the majority of this talk. We further so classify or classify pathologic conditions of the scapulonate ligament as pre-dynamic, dynamic, acute, static versus the chronic issue, which we briefly talked about in the previous session with a SNACRIS or a SLACRIS in this scenario. I think this is a very useful classification for those of you, if you're not familiar, I would encourage you to read Mark Garcia-Elias's paper on the staging of scapulonate injuries. And this is how I like to think about these injuries. And based on the stage that we are in, will help dictate my treatment. There are other classifications. It's a Will Geisler's arthroscopic classification and then the European Risk Arthroscopy Society, now the International Risk Arthroscopy Society classification. So you can see when there's a number of different classifications, this is something that we talk about a lot. But for the purpose of this talk, I'll focus on the Garcia-Elias classification. So looking at these pre-dynamic instability patients, the patients with the partial ligament injury, these are the patients that we see all the time. Patients with wrist pain, with wrist hyperextension, doing yoga or pushups is classic, especially in this population. Dorsal central wrist pain, it's kind of big, very, very common. We see this multiple times per year. Our Mark's classification, this would be stage one where the ligament's primarily still intact. The treatment for this is usually just a period of immobilization, activity modification, avoiding the exacerbating activities. Oftentimes we'll give a cork or stair injection and ultimately if that all fails, which it rarely does or uncommonly does, then surgical, and I think arthroscopic surgery for this is very effective. Often you'll get in there and find sprayed capsule synovium which gets caught in there. If you think about your wrist as it hyperextends, that tissue gets pinched between the lunate and radius and that causes pain. So we just go in there with a shaver and quite simply just shave that out. And that's very therapeutic in and of itself. Occasionally we'll encounter a ganglion as well, where this can be either visualized at the skin level or it's not visible, what we call an occult ganglion and only identified via MRI. And we could excise that as well. And ultimately, if that also is impinging on the posterior neurostatic nerve, we'll also often do a post-neurostatic anorectomy as well. And this is what it looks like after the debridement. I do favor the use of thermal treatment for the scapulonate ligament if it's partially injured, partially stretched out. And I do think that not only helps stabilize it, but also it helps denerate the tissue as well. And we showed that in our lab where we found that the thermal treatment, it does eliminate or at least temporarily destroy the neuronal markers in the area of the treatment. Moving on to dynamic instability where the ligament's injured, but still the carpus is maintaining its position on standard x-rays, but with stress x-rays, you'll often see a gapping. This is a patient of mine, one of our football players. You could see on the MRI axial view, you could see dorsally, the scapulonate is torn, but the relationship between the scapula and lunate is still maintained. Treatment here, again, always is non-surgical first, activity modification, et cetera, mobilization. And then again, if this goes on to surgery, arthroscopic surgery, I feel is very appropriate and effective. This is what we'll often encounter arthroscopically. Will Geisler's classification classify this as probably grade two or three? Still a stage one in ORC-RCLS staging system. And based on Geisler's classification, it really, in my mind, helps determine the treatment, whether it be just debridement of the ligament, debridement plus or minus thermal shrinkage, and or all of the above plus pinning of the joint. If it's completely disrupted, then we're talking about a different animal altogether, and we'll get to that in a few moments. So again, for earlier stages, I do like a debridement with thermal shrinkage. And if it gets to stage three, I tend to do a pinning, plus or minus arthroscopic capsulodesis. Because this is the pathology we're talking about. Again, it's not completely disrupted, as on the photo on the right, with more of a delamination of the ligament or stretching of the ligament as demonstrated on the left. So, whoops. So I do think that there is a benefit of the thermal shrinkage, as I discussed earlier. Just a brief discussion of how that works. It causes a secondary fibroplasia and scarring of the ligament. And I do think there's also that denervation effect, as we discussed earlier. The results in the shoulder are poor, and that's why I got a bad wrap, but I think in the wrist, it's very effective and we've published on that as well. So this is what it would look like before and after. In this case, we did put a pin across, as you can see in the back of the right photo, for a later stage, Geisler stage, excuse me, stage three injury. And again, we talked about the denervation effect. This is the study I alluded to, where we looked back at our patients where we treated with thermal shrinkage, mean seven-year follow-up with zero of these patients needing any further surgery. And this is that particular patient. This is in the early stages of zoom, and you could see his range of motion is great, and he did very well with that treatment. Moving on to acute static instability. This requires not only a complete rupture of the scapulonate ligament, but also your secondary stabilizers. Here's where you have a statically widened scapulonate, as you can see here. Don't really need an MRI to confirm that, but this patient actually had one, and you could see the widening of the scapulonate interval. Under arthroscopy, you could see completely, this is what we call the drive-through sign, where the scope is advanced completely between the scapulonate and lunate. And you can visualize the capitate head. Now we're moving on down through the Garcia-Leal staging to the stage two injuries. When it's acute and repairable, I do think that the best treatment is still an open repair. I think it's the most robust treatment option, and just inserting a suture anchor down into the bone and repairing the ligament back down the bone is very effective. In this case, I used pins to stabilize the radio lunate, I'm sorry, the scapulonate, as well as the scapulocapitate articulations to protect the repair. A lot of talk is about the chronic irreparable scapulonate ligament injuries without arthritis. We already saw some nice cases earlier about patients who have developed a snack wrist and arthritis. At that point, the cat's out of the bag, and you're looking at mostly salvage procedures. What about this situation where the ligament's torn, but it's no longer reparable, and there's no arthritis? Now we're talking about the stage three and four of Garcia-Leal's classification scheme. And here we have a number of options. We already heard about denervation. There are many capsulodesis that have been described, many attempts at scapulonate reconstruction, and as the adage goes in orthopedics and hand surgery, plastic surgery as well, that if there's a number of different ways to treat one problem, either they all work or they all don't work, and nothing has distinguished itself from all the others as a true gold standard method of treatment. And then there are also the salvage procedures, which we already spoke about. Lastly, we're talking about the slack wrist. And we know that it follows a pattern of degeneration at the radial styloid, the radial scaphoid articulation, and then the capulonate articulation. Now this is the end stage of Garcia-Leal's classification, stage five and six. Whoops. And your options are, as we discussed earlier, for the slack wrist, the salvage procedures, PRC and the four-corner fusion, or mid-carpal fusion, I should say, are the typical options we discussed. Quickly moving along to the other underappreciated ligament of the proximal row, the lunar trapezoid interosseous ligament. Here it's basically the mirror image of the scapulonate ligament injury. And in my mind, the treatment is exactly the same as for the scapulonate, as I just discussed. Oops. We'll often identify the VZ deformity on lateral X-rays with chronic injuries. Again, same treatment as the SL, but for the chronic injuries, I do find that salvage procedures are very effective either in LT arthrodesis or in ulnar shortening osteotomy. This carpal instability, non-dissociative patterns or SIN patterns. This is an instability between the radius and proximal row or the two carpal rows. This can be seen as ulnar translocation. Moving quickly along, here's one of our patients, painful pop at 300 pounds, lifting 300 pounds. You don't see much on their X-ray, but if you compare to the other side, you can see the lunate's ulnarly translocated compared to the other side. And there's the MRI just showing multiple ligament injuries. The radial carpal and dorsal radial carpal ligaments are injured. So we repaired those ligaments, put a spanning plate on three months later, and you can see he's doing quite well. Mid-carpal instability is a whole nother ball of wax. In the interest of time, I'm going to move quickly through this. It's usually traumatic, but can be atraumatic. Treatment typically is conservative, but you can do thermal shrinkage and partial risk fusions. Moving on quickly, the perilunate complex or the carpal instability complex injuries, the perilunate injuries are classic or axial dislocations. Mayfield's continuum of perilunate instability, you can see usually starts with the scapholunate ligament and travels around the lunate. The reverse is the opposite, starting with the LT and going in the opposite direction. These are commonly missed, but the treatment typically is first closed reduction and then either pinning or open induction introversation. This can be done arthroscopic. And lastly, carpal instability adaptive or CIA. This is extrinsic to the carpus, usually seen with a disarrayous malunion. As it's dorsally angulated, it causes disruption of the capital lunate articulation, as you can see on this lateral radiograph, and the treatment is corrective osteotomy. So to summarize, I think it's very important to be aware of and use the Mayo classification carpal instability to describe these injuries, and hopefully I was good enough to describe those injuries to everyone today. So thank you very much for your attention. Thank you, Dr. Yao. So I'm Kristen Valdez, and I don't have any conflicts of interest, and I am giving this talk on behalf of Christos Keragiannopoulos. So we have some objectives, but I'm gonna kind of skip through those and we'll get right into it. So we do know that as we have already learned about the ligamentous structure of the wrist, and just to give a little bit more information, the extrinsic broader capsular ligaments have a direct blood supply, so they have a better healing potential versus the intrinsic interosseous ligaments, which really rely on the surrounding tissue for blood flow. So that makes them have a slower healing and usually more likely to repair. So as we know, this is the type of injury that happens from a high velocity and landing on an outstretched hand. And then that can cause, again, that SL injury and the ligament injury, which can cause significant wrist instability and pain. So as we've already learned from Dr. Yao that the different classifications of the SID, carpal instability dissociative, or dorsal intersegmental instability, the dizzy wrist. And so the scaphoid and the lunate and the triquetrium, when they are balanced, they are all connected together and they move as a unit. But unfortunately, when there is a tear between, in this case, the scaphoid and the lunate, the lunate, as Ken Flowers talked about, goes off and is promiscuous and runs away with the triquetrium. And so they have a tendency to go in the opposite direction of the scaphoid. So the scaphoid goes in a flexion position and the lunate goes with the triquetrium in the extension and supinated position. So there's some classification of the injury. A dynamic instability has no radiological findings, no deformity, and that's a partial tear. And most of these can be conservatively managed versus someone with static instability where they have a loss of secondary restraints. They have a full tear on radiological findings and a static deformity or dizzy wrist. And those are the people that usually progress on to a surgical management. So some of the key rehab management principles are that ligaments take 12 weeks to heal. And so that's a really important consideration as we've talked about earlier today. A lot of people have a tendency to want to get back as soon as they can, especially once their pain is under control. So we really need to reiterate with our patients the healing timeframe and that it can take that full 12 weeks to regain that ligamentous stability. So we want to avoid aggressive and extreme range of motion. A stable, non-painful wrist is always better than an unstable, painful wrist that has a lot of motion. So we want to emphasize neuromuscular control. And of course, there are some prognostic factors for recovery, including patient age and what they are intending on doing with their wrist once they get back to full motion. So typically, rather than depending just solely on weeks, we think about the progression of rehab in terms of phases. And the first phase is the protective phase where we immobilize usually somewhere between two and four weeks. And then the early mobilization phase starts between two to six weeks where we have a removable orthotic device on and we start early functional active range of motion. And then that late phase starts at six to 12 weeks and we have a gradual return to activities of daily living and sporting activities. So some of the things that we have recently learned is again, the neuromuscular control and a wrist proprioceptive program. And that's really important for the unconscious control of the wrist that people need to know where their wrist is in space to have smooth and coordinated movements. So what we also found out is that carpal ligaments can resist about 360 Newtons or 35 grams of force. And so we really want to make sure that wrists have that strong neuromuscular control so that our patients and that population can return back to their normal activity demands. So some of Dr. Haggart's key work in this area really indicated that the ligaments are not only just a passive restraint system, but they also have mechanical receptors that basically tell the muscles when to fire. And that firing of the muscles helps to give that neuromuscular control of the joint. So early sensory reeducation, and one of the ways that we do that is with joint position sense. And then later stabilization exercises are looking at a more dynamic approach, and I'll be showing some of those in a moment. So again, the wrist ligament muscle reflexes, they really fire off the antagonist and the agonist muscle, and that gives stability to the wrist. So the early phase at 2 to 8 weeks, we're really looking at functional and closed chain active range of motion with sensory feedback, maybe rolling a ball forward and back, side to side with a cloth on a table, and just gently moving in supination and pronation, but really no weighted stress at this point. One of the things to consider is dart thrower's motion, which is the functional range of motion of the wrist. The nice thing about this is that this occurs at the mid-carpal joint, so it doesn't put any stress on the radial carpal joint. So joint position sense, then this just shows a picture of someone who, when their wrist is positioned in a position and asked to replicate that, that they have difficulty. And this is very something easy to do in clinical practice, is measure somebody's joint position sense and then record the degree of error that they have. So again, some of the things that we want to be doing that could be in our toolbox at this point, even include mirror therapy, edema control, and those closed chain activity. As we move on to the later phase of rehab, which is between 6 to 12 weeks, that's when we start aggravating the wrist to a certain extent, to aggravate and get the wrist proprioceptors to fire. And so it might include like shaking the TheraBand bar, some other activities that I will show you in a moment as well. So Markecia Elias talks about the importance of that, the carpal supinators, the ECRB, the APL, the FCU, and the FCR actually protect that SL joint and the ECU destabilizes the joint. So why is that important? Well, probably because what we really need to do is when we're doing early exercises, the forearm should be positioned in pronation. And so we're working on strengthening those carpal supinators, and we can do that with a TheraBand or with active resistive exercises and with TheraTubing. Here again, there's some of the body blade, the gyroscope, or the Dynaflex bar, ball flips or catches are all part of that late phase training. So we really want to work on regaining and returning our proportion to their sports goals. We can also do initially starting against the wall and then progressing to the floor, and then even turning the BOSU ball over and make it even in more unstable surface as that patient progresses. So again, just to reiterate some of the expectations, avoid that aggressive passive range of motion. We want to regain pain-free functional range of motion, hopefully within six weeks. We want to restore the normal neuromuscular control of that joint, a gradual resumption of ADL activities and sports. Thank you so much for your attention. Thank you, Chris. Next up, Joseph Buckwalter will be discussing wrist arthritis. Okay. Hopefully everybody can hear me. My name is Jody Buckwalter. I want to thank the co-chairs and the Hand Society for putting this together. I've already learned a lot, so this is a wonderful webinar. I'm very happy to be a part of it and thank everybody for putting it together. Moving on quickly. I seem to have control over this. So I have no disclosures. Couple objectives. I'm hoping to just build on the cases that were presented earlier and the discussion of the different types of arthritis. Wrist arthritis is a huge topic that probably should take all morning. I'll try and condense it to this 12 to 15 minute period. Hopefully answer some of your questions and consolidate some of the information that we've already discussed today. So there's several different types or mechanisms that cause wrist arthritis. As many of you know, there are many joints to the wrist, so when people talk about wrist arthritis, they could be referring to many different things. There's primary osteoarthritis of the wrist. There's the post-traumatic that we discussed today. Going over several cases, there's rheumatoid arthritis, which in and of itself is a whole topic for discussion. Congenital, often forgot about, but in our clinics we see this quite often in a younger population, someone with a Madelung's deformity. And then idiopathic, such as Keenbox or Preiser's disease can also manifest. So again, going on to the types of arthritis, we've already discussed slack wrist and snack wrist. There's STT arthritis, and for those who don't know what STT is, that's the articulation between the scaphoid, the trapezium, and the trapezoid. This is often misdiagnosed, but it is a very, very common type of arthritis. DRUJ arthritis is also a type of wrist arthritis that can happen independently or is found in combination with other types of arthritis. So just to go over the slack wrist, which has already been discussed to a certain degree, this is an increase with an SL ligament injury. You have this flexion of the scaphoid, which ultimately leads to a pattern type of arthritis. DC deformity has already been discussed, and these are some of the measurements that we look for on lateral x-rays. I just briefly mentioned that a snack wrist is different. It's already been discussed today, and there is a slightly different pattern of arthritis that you might see, but in general, we can think of them as very similar patterns of arthritis. So in slack wrist, this image has already been presented, I think, in Dr. Yow's talk, but we think of this as the Watson stages of wrist arthritis. We have stage one, which is radial styloid, stage two, which is the whole radioscaphoid articulation, and finally stage three, which moves on to the capital lunate articulation. Recently there's been a discussion of stage four, which is pancarpal arthritis. I tend to stick with the initial classification, but if you see really bad arthritis, you can just call it pancarpal arthritis. Importantly, from an understanding the mechanism of how this progresses, the radial lunate joint is always spared. That is something that is often tested, but again, from the treatment options, it's important to understand that that is part of the progression, that the radial lunate is spared. These are just some further pictures, again, showing, if you can see on the left here, you see stage one with just this beaking of the radial styloid. In stage two, you see the progression to encounter the whole scaphoid facet, and then stage three, when you have involvement of the lunocapitate joint. One test, I was trying to integrate some of the clinical aspects of this. One test that we use for scapho-lunate instability is the Watson-Schiff test, or scaphoid-Schiff test. This is hard to do this test, but this can really be very useful when you're trying to determine what's going on. You can see pressure applied to the pole of the scaphoid with radial and ulnar deviation, and you get a large clunk, or hear a clunk, or a patient will have a sense of instability. I actually have this myself, but it doesn't bother me too much. Moving on to the treatments for slacked wrists, as has been said many times today, your first rule is treat the patient, depends on the stage of arthritis. You want to treat them symptomatically. Here are several of the options. I'll try and go through these in some detail. This is a kind of a flow sheet that you can follow if you're interested in things. Again, putting it all together to try to treat the patient with the stage and the symptoms is the most important thing. Starting with some of the treatment options, already been discussed, scaphoid excision, forecorner fusion. This can literally be done a hundred different ways. I just put a smattering of different examples up there of things that have been done. Most importantly, removing the scaphoid and then locking the proximal and distal row. However you accomplish that, whether it's with sprues or staples or K-wires or the plates, any of these options will work. I actually have used them all to a certain degree. Proximal row carpectomy, also discussed today. This is taking out the whole proximal row. Very important that we have a good articular surface on the capitate, although that can be managed with interposition and some other ways if there are issues with that as well. As I said before, really important to have that articular surface of the capitate and preservation of the radioscaphocapitate ligament. Again, this is something that is often tested, but very important if that is injured during the proximal row carpectomy, you'll get translocation of the carpus afterwards, which can lead to further problems down the line. So here's just some pictures from a proximal row carpectomy. Again, this arrow, if you can see this yellow arrow here, is showing the radioscaphocapitate ligament. Very important in your excision of the scaphoid and lunate that you really seek to preserve that. There's been multiple studies on the differences between PRC and four-corner fusion. In general, this becomes something that each provider looks at the literature, looks at the patient, and tries to determine what is best for those patients. I think the things that we talk about the most are grip strength and range of motion afterwards and the slight differences that have come out in some of these studies. These are very important for counseling your patients on the differences in these types of procedures. Finally, moving on to one of the more less salvaged, or one of the more complicated salvaged procedures is wrist arthrodesis. I really like this image here because it shows all the different joints that are involved in wrist arthrodesis. Wrist arthrodesis is kind of the end stage when the other options haven't worked or you've tried something and it has failed. These joints all need to be fused. Importantly, the radiocarpal joint or radioscaphoid and radiolunate, the midcarpal joint or the lunocapitate joints, and then very importantly and often forgot is the carpometacarpal joint or the joint between the capitate and the third metacarpal. The reason this is so important is because the fixation is often nowadays done with a plate from the radius all the way to the third metacarpal. If that joint is not fused properly, you could encounter hardware complications later and failure of your construct. Just a few examples of the different types of indications for wrist arthrodesis and how people have done this. I tend to use a plate, but it has been described with Steinman pins and all different types of ways of fusing the wrist. Moving on to the last option for treatment of wrist arthritis is wrist arthroplasty. This has been around now for about 50 years. There's been multiple iterations of different types of implants. The newer implants are more stable and show less complications, but this is still something that can have multiple complications. It can be difficult to get to work long-term, so your patient selection is very important. Generally an older population, lower demand population usually has about a 10-pound lifting restriction and avoiding loading of the wrist for a lifetime after this procedure. Really importantly, when you're looking at a situation where a patient may have bilateral wrist arthritis, you need to figure out what is going to be best for each wrist. You can't necessarily decrease range of motion in both wrists, so you may have to consider a wrist fusion or a partial wrist fusion in one side and a wrist arthroplasty in another. Often patients will come in with one side that's symptomatic and another side that's less symptomatic, obtaining x-rays of both sides in an effort really to plan for the future is a wise idea because you could get yourself into a difficult situation if you're not planning for the future in patients with bilateral wrist arthritis. Just some examples of wrist arthroplasty. You can see the arthritis on the left and the implant on the right. I've got my take-home points for you here, and I finished with five minutes early. Using the etiology of wrist arthritis, the common things that we've discussed today, slack and slack wrist. I did not discuss distal radius fractures, but this can lead to radiocarpal arthritis. The slack and slack wrist follow a predictable pattern staged by the Watson stages. And then surgical options include non-operative management with symptomatic treatment, proximal rocarpectomy versus intercarpal fusion, wrist arthrodesis, and finally wrist arthroplasty. I think that's it. If anybody has any questions, please feel free to get a hold of me. Thank you, Jody. Next up, we have Alexandra McKenzie from HSS, who's going to discuss rehabilitation after wrist arthroplasty. Hi, my name is Alex McKenzie, and I, yeah, I'm a hand therapist in New York. And today I'm going to talk about rehab after wrist arthroplasty. And hold on. I have nothing to disclose. So let's start talking about how much wrist range of motion is required for function and for ADLs. Because presumably someone who's going to have a wrist arthroplasty, we're trying to preserve some amount of wrist range of motion to preserve a little bit of function. So there's been a lot of studies that have looked at how much motion is required for ADLs, and the numbers are a little bit variable. And so we know that for wrist extension, we require about anywhere between 30 to 60 degrees of wrist extension. And for flexion, anywhere from 5 to 54 degrees of flexion, which is a pretty big span. A lot of that flexion is required for activities such as perineal hygiene and for feeding. And we know that we need about up to 17 degrees of radial deviation and up to 40 degrees of ulnar deviation. However, most ADLs can be done in about a 40 to 40 degree flexion-extension arc, and then about 40 degrees combined radial and ulnar deviation. However, these studies were done before we had a really good understanding of coupled motion, and now we know that most ADLs occur more in an oblique dart-thrower's plane, and that motion is occurring primarily at the mid-carpal joint. And this motion can be difficult to measure in a motion analysis lab with markers, but it can definitely be especially difficult to measure in a clinical setting. So there was a study that came out a few years ago that wanted to see how patients did after total wrist arthroplasty and how they did with function. And so they had participants perform the Solomon Hand Function Test, which looks at seven different types of hand function, so four different types of pinch and three different types of grip. And what they found was that patients who underwent total wrist arthroplasty actually had a pretty good range of motion compared to their unaffected side, and they also had pretty good strength compared to their unaffected side. However, when they compared the patients, the arthroplasty group, to normal healthy volunteers, they found that circumduction was only 17% compared to the healthy volunteers. And they also found that it took participants in the arthroplasty group, it took them twice as long to complete the Solomon Hand Function Test. And what they found was that precision tasks, the motions that require things such as lateral pinch, tip pinch, and tripod pinch, those actions actually took much longer to complete, and they took a lot more motion than just doing a power grip motion. And they found that patients in the arthroplasty group were performing tasks more in a flexion extension plane rather than in an oblique plane, and they're actually completing tasks in more of an extension ulnar deviation plane, which is the opposite of how we use our wrists with ADLs in daily life. Okay, so what do we need to know from the surgeons as therapists? So what's helpful for us to know is if we know what type of prosthesis. Was it a hemiarthroplasty, was it a total arthroplasty, was it an arthroplasty that is trying to preserve that mid-carpal joint? Were there any soft tissue procedures done? Was there a synovectomy that needed to be done? Were there any tendons that needed to be repaired? What is the status of the DRUJ? Because we know that we need to have decent forearm rotation in addition to having flexion extension and radial ulnar deviation. What is the status and integrity of just the soft tissue stabilizing structures around the joint? And how confident was the surgeon in how much motion was achieved in the operating room and just how stable did that prosthesis feel in the OR? So post-op guidelines. With other joint arthroplasties with hips and knees, we get those patients moving much sooner, but with the wrist, we just want to kind of let things gel a little bit longer, so we're going to immobilize patients typically for about 10 to 14 days. And then, so in therapy, we're going to start seeing the patient after that first post-operative visit. So the patient comes down to therapy after their stitches are removed, and we make them a custom thermoplastic wrist splint, and we start them on some gentle active range of motion. And the goal, and I usually tell people, the goal is just a little toggle of motion. We're not trying to force anything. We're not doing passive range of motion. We're just going to limit that early motion to about a 30 to 40 degree arc of motion. They can start weaning from the splint at around four to six weeks, and then full activities are permitted at around eight weeks. We know that just based on experience and multiple studies, that early motion can be really important in helping with edema control and helping prevent scar adhesions and joint contracture, but we also want to look at range of motion in the rest of the chain. We know that this population of patients, whether they have OA or RA, they may have a joint involvement more proximally, such as an elbow or shoulder, and they may need to compensate with that motion. So if someone is lacking full wrist flexion or full wrist extension, they may need to compensate with more elbow motion to make up for that lack of wrist motion. So we need to make sure that we're looking at the entire chain with their activities of daily living. And we really want to make sure that we're driving home this concept of stability versus mobility. Sorry about that. So our therapy goals after arthroplasty is first and foremost, we want to protect the surgery. We want to make sure that we're preserving that prosthesis for as long as possible. Because we don't want patients to have to go through a revision arthroplasty. And I think our biggest role in therapy is really patient education. We're going over what is the goal of surgery? And the primary goal is pain relief with some restoration of range of motion, but not full range of motion. And we want to make sure we're doing range of motion to the entire arm. We're working on edema control, scar management, and also just looking at their ADLs and how can we modify some of those activities. So what are we telling patients? We're telling them that they need to avoid repetitive forceful use, that they need to avoid lifting greater than two pounds on a regular basis and avoid lifting 10 pounds ever. They can expect to get about 30 to 40 degrees of wrist extension, 20 to 30 degrees of flexion, and maybe 30 degrees radial ulnar deviation. And that this is just going to take time. Like the motion comes back slowly. And so just for patients to just be patient. We can look at functional activities, any kind of adaptive equipment that they may need. I love Kinesio Tape for edema and scar management. This is a light touch Kinesio Tape, which is better for sensitive skin. And so people who may have been on DMARDs for a long period of time, this might be a better option. As that joint gets stronger, we can progress them to doing some light proprioceptive activities. And we also just want to be aware that we're watching for complications in therapy. I think the biggest complication I see is wrist stiffness, particularly in flexion. I think people just have a hard time getting that flexion back. And I don't know if it's because the dorsal wrist capsule may have had some preexisting stiffness, but getting wrist flexion back has definitely been the biggest challenge. And it is an important motion. I think we tend to kind of disregard wrist flexion, but it really is an important motion for people to get back. So I'm gonna end with this case study that came out of Australia recently, because it's rare that you read a paper and you're like, well, that was a feel good story. This is a patient who was hearing impaired and she used sign language to communicate and she had advanced RA. And so she had very limited wrist range of motion. And so it was really, it had a great impact on how she was able to communicate. So the surgeons decided to cast her to mimic her wrist arthrodesis to see if she would be able to sign with her wrist fused. And it just took a really long time for her and it was frustrating. And so they decided to go ahead and proceed with a total wrist arthroplasty. And you can see her pre and post-op motion. She made significant gains in range of motion and it just really improved her quality of life and her ability to communicate. And so this is just like another reason why you may wanna consider a total wrist arthroplasty compared to an arthrodesis. So, and that is everything I have. Thank you. Thank you, Alexandra. That point about the patient with RA and who needs to sign and communicate is quite interesting. Next, we'll be discussing tips and tricks for just raised fractures. Doctors Kamal Shapiro and Chris Valdez will be taking charge. Great, thanks so much for having us. So we appreciate being invited to speak here at the electives course and look forward to learning a lot the rest of the day. So we're gonna quickly talk about this raised fractures and review some cases. And I'm gonna just quickly go over a little bit of background, just some principles that can inform some of the decision-making for those cases. So wrist fractures come in all shapes and sizes, closed, open, comminuted at the articular surface or comminuted at the metadiaxial junction. And a lot of the sort of fracture pattern informs different approaches, volar, dorsal, and as well as timing of surgery. So why treat this radius fractures? We know that shortening leads to increased loads on the ulnar wrist and can lead to ulnar wrist pain. We know pretty well what normal carpal kinematics are. And there's been a number of studies that have shown us what occurs when you have abnormal angulation of the distal radius and you have then abnormal carpal kinematics, which Jeff Yao and others have spoken about before, which can lead to eventual arthritis in the wrist. And so here's some examples of, for example, what the DRUJ can accommodate for when there's either extension at the distal radius or a flexion at the distal radius and loss of rotation. Some other areas to consider in distal radius fractures is that some limitations in motion that can occur after surgery are due to the normal structures that exist, including the strong volar carpal ligaments. Here's one study by Chang from JAMA that highlighted how every degree of loss of right inclination, there was a weaker grip strength that occurred. And some of that is you can see as you begin losing inclination, you tighten up those volar radial ligaments, the radius scapulae capitate, long radial lunate, which can prevent some ulnar deviation and could lead to loss of grip strength. There's a number of theories for how to classify distal radius fractures. This is the column theory, which just identifies various columns, radial column, ulnar column, and intermediate column, as well as different types of fracture fragments that have been described as well. So some questions to ask, at least when I approach cases, are evaluating the various columns and then just sort of understanding when you see different patterns in those columns, how you might be prepared for those. So comminution in the radial column and then small fractures in the intermediate column, and then in the ulnar column, looking at the base of styloid fractures as well. So some instruments and implants to have around include some clamps, lamina spreader. I like using headless compression screws. Having threaded K-wires are oftentimes helpful, and then some more clamps. So some quick cases to review. This is a 48-year-old that had a ski injury with this displaced intra-articular distal radius fracture. I'm highlighting in this case how this fracture extends into the sigmoid notch and how there's been some literature that describes really ensuring that you reduce the sigmoid notch for rotation. And so here's a CT scan again. Here you can see on the coronals, on the sagittals, fracture that goes into the sigmoid notch. So there's been some work on this by Berger and colleagues discussing fractures that extend here in the DRUJ. This study had 33 patients. Likely it was a little bit underpowered, but nonetheless showed at least some trend towards DRUJ arthritis when there was a fracture extension there in the sigmoid notch when there were poor dash scores when there was a step-off in the coronal plane in the sigmoid notch. Again, another study looking at distal radius fractures involving the DRUJ and rotation where they were able to find some loss of rotation when there was a malreduction in the sigmoid notch. So here in this case, we did focus on reducing the sigmoid notch in addition to I think what standard we know in terms of reducing the articular surface at the radiocarpal joint. Another just tip in terms of how to do that, this is one that I like using. This is a malunion case, but the principles are the same, which is oftentimes when you have this shortening, you can see that the distal segment can slide radially and some tricks to use are to put a laminar spreader in between the radius and the ulna on the shaft that can pull the shaft and metastasial fragment radially and ulnarly translate the distal segment and can reduce any fracture that extends into the sigmoid notch. There's a lot of literature on tendon rupture and the risks that can occur with abnormal placement either too distal or too radial. There's some debate in the literature as to the significance of plate placement, but certainly it's well known that too distal plate placement or too radial plate placement can lead to tendon ruptures. And again, a number of papers that have shown some variation in how strong people believe that is. In general, the thought is that a lot of that occurs from improper plate placement in the radial column or prominence of the dislodge of the plate because of loss reduction or loss of that volar tilt of the distal radius. And so here's some pictures from prior work that shows sort of where the FPL and flexor tendons sit and how a distal radius plate is typically contoured to fit on the volar lunate facet. And if it sits too radial, you can be more prominent and create issues with flexor tendons. So here's an example of one of my cases where I think that plate placement seems ideal, but certainly there's always opportunities for improvement. This is another one of my cases where I did focus a lot on sort of articular reduction with the dorsal approach, but placed the plate too radial. And I think that could put that patient at risk for flexor tendon irritation. Lastly, I just want to touch on axial stability. Conceptually, and certainly with AO principles, we often are taught to focus on articular reduction first and convert C fractures to B-type fractures and B-type fractures to A. For my approach for these, actually the opposite in, I'll generally focus on the axial stability of these high energy comminuted fractures that extend to the shaft and work from the shaft up. And so here's some cases where we just place lag screws from the shaft up, kind of ignoring the articular fracture till the very end. And so we piecemeal these together and then place our plate and then can use our plate as a reduction tool for the articular surface. Here's another example of a high energy injury extension into the metadiaxial region. Again, we focus on fixing the extra articular fracture first and then place our plate and then begin working on the articular reduction with the plate in place. And then one last example of fracture patterns to look out for, these are ones where you see dorsal carpal subluxation. Anytime I see these, I'm typically using a dorsal approach, which oftentimes we're not using in our sort of standard approach for distoradius fractures. So here's an example of a distoradius fracture, some question of dorsal subluxation. And so for me, this is an automatic fracture and dorsal subluxation. And so for me, this is an automatic dorsal approach and dorsal plating. Another example of high energy injury that presented in an X-Fix. Here's some 3D recons of a CT scan. You can see translation of the distal segment, sort of a shear type injury, dorsally, some dorsal comminution and some concern for dorsal subluxation. So we approach this case with volar plate and provisional K wires, and then went dorsal, reduced the dorsal articular surface, and then placed a dorsal plate along with the volar plate. Thanks so much. Excellent. Thanks, Rob. My name is Lauren Shapiro. I'm currently at UCSF. I'd like to thank the organizers for inviting me to speak today. I have no disclosures. And I'm gonna walk through a couple of cases here. The first will be a couple of variations on a theme. So this is a 42-year-old female who is active, relatively healthy, fell off a bike. You can see in these X-rays here, she has a displaced interarticular distal radius fracture. And I think the important thing to catch on this one is that volar lunate facet, with a volar ulnar corner, as Rob spoke about in his talk. And we'll go through both of these cases as well. This is a similar case, a little bit different. 37-year-old male, healthy, active, dominant hand, again, with a volar ulnar corner fracture, which I think is important to recognize and treat. You can see those here. This is a nice paper from Beck and colleagues. It was prospective observational study of over 52 patients with V3 type fractures. And they noted that volar shearing fraction with separate scaphoid and lunate facet fragments, preoperative lunate subsidence, as well as the length of the volar cortex available for fixation, were significant predictors of loss of reduction. They noted that having less than 15 millimeters of the volar lunate facet available for fixation, or greater than five millimeters of initial lunate subsidence patients were at risk for failure even if the plate was placed properly. And this is a nice illustration from that paper looking at that fracture fragment. There's a couple of different ways to approach these. You can see kind of the alignment of the fracture on both of these cases here. So going back to that first case, this 42-year-old female with an intraarticular fracture, I think when there is not an isolated fracture, it's nice to kind of treat the fracture as a whole. And here, this Dennison and Moore technique using either 3-5 or 4-5K wires, putting those into the reduced volar ulnar corner fracture, you can bend these to match the volar cortex and place them under the plate. As you can see here, these are some postoperative images. And here she is healed in about three months. And these are two papers looking at outcomes. These detail about 25 patients, all of whom healed without loss of fixation or fracture fragment escape. One patient did need some hardware removed for flexor tendon irritation. So this is a nice technique to have in your back pocket when you're fixing these volar ulnar corner fragments. In this case with an isolated volar ulnar corner fragment, this is just another way to approach this. Here's a CT scan, again, demonstrating this displaced fracture. In here, this was not associated with any other fracture fragments, as you can see on this CT scan. So a nice approach for this one is, I'll let these run for another minute. You can see here. So here we actually approach this with a volar ulnar approach. And you can extend this into a carpal tunnel if you'd like, but this is essentially using the interval between FCU and the ulnar neurovascular bundle and the flexor tendons here to approach this fracture fragment. You can see clinically here, using a fragment-specific approach with this plate, intraoperative, and then postoperative films here. And so jumping into a different, I guess, type of fracture fragment, this is a 28-year-old female who is 10 years out from a previously treated fracture of an intraarticular distal radius. She was fairly active, had pain with her activities of daily living. She was in the military. You can see here, she has good range of motion, but was not able to perform the activities she would like. And here you can see an intraarticular distal radius fracture malunion. She's fairly short, has lost her inclination as well as her height and her tilt. So here are some CT scans just demonstrating that as well. And for this case, we used patient-specific cutting jigs based upon her contralateral anatomy. As you can see here, this bottom image shows the contralateral side mirrored onto the side in question. And you can see the proposed correction here to maintain her alignment as Rob was talking about in his early slides. Is this her preoperative appearance? Her passive range of motion on the table. And then this is a burr guide, actually that's placed first, and it shows you where exactly you can burr such that your plate will fit after the correction. And that's with the burr guide off, and you can see the location of the burring. And then here is an osteotomy guide that is placed on. Here's us making our osteotomy site. And then with the plate on, we're able to correct our length here. And here's a video of that. And here are these osteotomy wedge trials that are fit in, and you can take florals and see what kind of correction you're getting and how appropriate that is intraoperatively. You can fill these grafts with bone graft as well. We took some graft from the Iliac crest here, placed it in the wedge, and you can see bone graft in here with our wedge, correcting our alignment. And then here again, correcting coronal plane translation here. Filling in the rest of the bone graft. And then these are final florals intraoperatively, and then postoperatively here at about six months. And she has range of motion as well. And you can see just healing across that osteotomy wedge and some of these CT scans about six months out. I don't think it's letting me advance. There we go. And here's your clinical range of motion. So I think a nice technique to have when you have these complex multi-planar malunions. Thank you. Thanks Lauren and Rob. Great talk. Next up, we move forward into the black box of the ulnar side of the wrist with Drs. Suh and Greenberg, along with input from Alexandra McKenzie, our hand therapist. Well, good morning, everybody, and thanks for taking time out to listen to all the faculty this morning. Hope everybody's enjoying this. I have a few cases, and then Dr. Suh has some cases, and we'll let Alex chime in as well with some of her thoughts regarding therapy. Okay, so this case actually drags out for many years, which is pretty typical of kind of these challenging distal radial adjoining stability cases. But this is a 12-year-old healthy, active female who was referred to one of my partners who has since retired for ulnar-sided wrist pain. She was referred to him from a local pediatric orthopedist who we're friendly with. Her history starts actually in 2013 when she sustained, and I put this in quotes, an injury because the details of that are not very clear. Persistent pain despite conservative management prompted the referral to our practice. So in September of 2013, her exam was consistent with ulnar-sided wrist pain. She had an MRI at that point in time, which showed increased signal in her ulnar head and TFC. With the thought that this was a TFC injury in a young person, she was placed in a long-arm cast. Despite a few months of casting, she had severe pain in her ulnar carpal region. She had evidence of hypermobility of her distal radial joint and pain with stress. At that point in time, the diagnosis of distal radial joint instability was made. Here's her preoperative x-rays and realize these are 10 years old. This is from 2012. You see her lateral shows that her distal radial joint is well reduced. There's no evidence of any secondary changes in the carpus. That's an oblique. But on this PA view, you clearly see a widening of the distal radial joint consistent with instability. So now four months post-injury in 2013, she underwent an open triangular fibrocartilage repair. I apologize for this early part of the history because this is information from my partner who has retired and we just have information from the charts as well as some of the images. But I'll bring you up, the interesting part of this is her contemporary treatment. So a few months after that initial surgery, she had some persistent instability with mechanical popping, but overall improved discomfort and you see she's regained pretty functional motion although some limitations of forearm rotation. So in May of 2014, once again, recurrent symptoms of increased pain, pain with lifting and weight bearing, but at least according to the notes, a stable joint. Once again, fairly functional motion, but with the thought that she had a persistent distal radial joint instability, she now undergoes a second procedure and a reconstruction of her distal radial joint with a graft from the flexor carpi ulnaris. Reports in 2015 state that she resumed all her activities with just occasional discomfort. Let's jump now many, many years. She's now at university in Madrid, even though her family lives here in the United States and she presents to one of my partners seven years and three months following her injury. Her symptoms have recurred pain, popping, and a feeling of the joint actually dislocating and relocating and her exam at that point in time shows laxity of the distal radial joint, worsened neutral when compared to the opposite side and significantly worsened pronation compared to the other side. She has a repeat MRI, which is basically not helpful in any way. There's no triangular fibrocartilage tear, no avascular necrosis, her ECU is subluxated but not torn, no space occupying lesions. So panelists, at this point, let me, do you have any thoughts at this point in time? What's your diagnosis? Do you need any additional maneuvers or additional imaging? Nina? Yeah, so for me, typically, like I have had a patient also present very similarly like this, like she previously had like a Berger-Adams reconstruction for DRUJ stabilization and in that scenario, what happened is I sent her for an MRI just to make sure that the graft itself had not torn and in that particular scenario, the graft had torn. So that's something I would maybe think about for this particular patient maybe because she was relatively okay after her reconstruction, but now she's doing poorly again. So has there been an interval change? So I would look at that. I'd also probably get some more imaging, look at the contralateral side, look at forearm x-rays and then also the MRI. Okay, so you're thinking about imaging the other side for what reason in particular? So usually I just do it as a comparison to see if there's how much difference some females, sometimes the DRUJ looks, in this particular situation, like there's clearly abnormality sometimes in some of the females that I've dealt with, the DRUJ gap looks large on the side that's symptomatic, but it looks pretty similar to the other side. So I just like to have that as a comparison. Okay. So Alex, let me just ask you a question just very, very briefly right now. We send you a patient that we say has instability, but really not at a point where it's an operative case. What do you do? Well, I think about just what are some of the dynamic risk stabilizers at the DRUJ. So we've got ECU, peroneal quadratus. Is there anything that I can do with that? Is there any splinting or taping techniques that I can do with people? And then just looking at how they're using their wrists in their daily activities. I do think it's really challenging when you've got stiffness in the presence of hypermobility. It's a complicated thing to treat. So those are just some of the things that I would be looking at. Okay. All good thoughts. So and just to add something or to confirm what Dr. Su recommended was that, you know, she did have a repeat MRI, which didn't really show that there was any abnormality of the triangular fibrocartilage from her previous repair or loss of the graft. But now she's a year later, she can only get to the States kind of when she's out of school from Madrid. She has persistent symptoms with painful instability. And my partner who was seeing her recommended that she come to our difficult problem conference, which we have once a month for patients that are kind of a challenge. Well, because of COVID, she couldn't make it. So she came to me directly. Now she's seven years, eight months following injury. And she clearly has persistent instability. She has painful popping affects her every two weeks and which is severe, but on a daily basis, she has instability like symptoms. And in a very, very kind of detailed questioning and trying to get information that wasn't in the chart, this so-called injury that I talked about at the very, very early slides was actually a distal radius fracture that she had even before she saw the pediatric orthopedist and she was in a cast for four weeks. So she has nothing external, you know, you know, whenever you see somebody with complex distal radial joint pain, think from the outside in, she has no complex, no red flags whatsoever, but clearly has instability in pronation with stress testing. So I'm thinking now that maybe it's not something soft tissue. My partner ordered a comparative CT axial cuts, and you can kind of get a suggestion here. Well, Nia, let me ask you, what do you see here? Is this type of evaluation helpful for you? So for me, typically I do like to do the axial CTs and supination pronation and neutral gives me a nice sense of how the DRUJ is placed, sorry, the ulnar head is placed during rotation. Here I think there is a side to side difference, so I would say that this is relatively helpful just because on the side that has symptomatic side, her DRUJ shape globally is different than the other side. So I would be more cognizant about the fact about this distal radius, quote unquote, fracture that she previously had, I'd be looking for perhaps a malunion. Yeah, I think so. I think that's kind of the point here is that we sometimes, when we're presented with these cases, we sometimes box ourself in and immediately start thinking, well, there's instability, so it obviously has to be a TFC avulsion from the fovea or some abnormality of the restraining ligaments, and just to keep in mind, especially with these pediatric injuries that malunions can give you instability of the distal radial joint. So obviously, you know, the thought here now is that maybe it's not soft tissue, and actually what I recommended for her is not CTs, but well, CT augmented, a materialized evaluation. So just that case that Dr. Shapiro just showed us about using 3D printed guides to do malunion correction, I think that in some cases, it's very useful to have 3D printed, and with the help of the engineers and reviewing the CT scans, you get to see here how significant her rotational malalignment here, and I think if you look at the panel on the right, where you have the injured and the corrected side, you see the amount of deformity here, and I put the panel on the left there to show you that when you correct the models to make sure that the bicipital tuberosity is facing in the same direction, and then you look at not only the morphology of the sigmoid notch, but also the rotational position of her distal radial articular surface, you realize that this is truly malunion, and you know, in retrospect, looking back at initial treatment directed at the TFC was probably not going to fix this problem. So the treatment of choice obviously is a corrective osteotomy, and she, unbeknownst to me, she was planning to go back to Madrid, and before her first post-op visit, her mom calls me and says, oh, you know, she has to go back to Madrid to get back to school, and I said, oh, I was thinking she'd be here for at least a few weeks, but we were able to get post-op x-rays, and then I was fortunate to send her to Dr. Del Pinal, who practices in Madrid, and he's doing her follow-up, and actually, I just got this note from him a couple weeks ago, and it's, Jeff, I just saw your patient, she's doing okay, nearly full range of motion, no pain, and here's her current x-rays, so my hope here is that correction, the underlying deformity, that that should stabilize her, should stabilize her joint. So comments? No, I think I also have had good success with the materialized. It's always nice. It's hard to see on those 2D image x-rays exactly the deformity, so when you do the materialized and the engineers are able to superimpose the two, I have found it very helpful in having those guides, particularly for young patients who have deformities that are subtle, sort of, to have them, or sorry, multi-planar, I mean, to have the materialized jigs is very helpful, but the x-rays look great, I think. Yeah. Alex? Comments? No, I think this looks fantastic. Yeah. At this point in time, I think her therapy, from your standpoint, would be pretty easy, just kind of stable fixation, get her moving, right? Exactly. Okay, let me just show, this will be quick, because I want to get through Dr. Su's case, and unfortunately, when I was putting this case together, I thought I would have access to my arthroscopy images, but they were done at the hospital, and I could not get them, so hopefully I'll describe them to you. This is a 48-year-old, very, very active male, plays a lot of golf, does a lot of weightlifting. He developed ulnar-sided wrist pain while doing curls, and noted that he was unable to do the things that he liked, even driving caused symptoms. So his exam showed he had symmetric full-range motion, significant, excuse me, pain with full pronation, and pain with ulnar deviation, a little bit in pronation, and ECU completely benign. So here's his preoperative x-rays, see an AP and a PA view, a lateral, and then a grip PA view. Comments? It's slightly ulnar positive, but otherwise, like, no arthritis or anything like that that I can note. But yeah, I thought the same thing, I really didn't see much radiographic changes. So would you have gotten any additional imaging at this point in time, specifically I'm thinking the role of MRI? So it's controversial. Sometimes if you have a very good exam and things like that, like, it's, like, a patient's very reliable, but I will have to say, like, I do tend to get an MRI, and sometimes that's driven by the patient kind of wanting to know all the information, or most times, actually, like I'm currently at Emory, but actually in Canada, most times the family physician would have, sorry, the PCP would already have gotten the MRI, so they have that before seeing me as the surgeon. Yeah, that is really my experience, is that if the patient sees somebody else before me, nearly 100% of the time, they have an MRI, and this could be even with something as short as 24 hours of symptoms. It's like a knee-jerk reflex for the practitioners, wherever they're at, to order MRIs. But I mean, if, I guess, you know, in this particular case, one thing that the MRI can be helpful is to show you kind of the detail of the foveal anatomy, you know, because sometimes there are cases of instability where you will do an arthroscopy, and actually the superficial component of the triangular former cartilage will be intact, but, you know, you can kind of get a feel with your allotment test that there is something deep that's maybe not anatomically correct. And in that case, a pre-op MRI would help you, but I use a lot of my clinical findings, and if somebody is really unstable and I'm taking them to the operating room with the diagnosis of instability, even if I do an arthroscopy and the superficial component is intact, I still know that there's probably a deep tear. So I did not get an MRI in this guy. This guy is completely, completely reliable, straight shooter. And what was interesting, and I really apologize, I don't have, but he actually had two tears. He had a peripheral detachment of his TFC and a large central tear with a lunate impaction lesion. So he had a delamination of his cartilage, even though he didn't have any loose bodies and nothing in the mid-carpal joint or the radial side. And I'll just move on quickly, but what we did was just did an arthroscopy. We debrided the central portion and I repaired his peripheral TFC and did an ulnar shortening. So Nina, just comment here on your thoughts as far as ulnar shortening in the face of TFC repair. When do you, what's the situation where you consider doing something to unload the ulnar side of the wrist in the face of TFC pathology? And so I actually am a, I do actually like ulnar shortening quite a bit, like the ulnar shortening osteoarthritis. I found my patients do quite well with TFC tear, particularly if they've had any, if they have any central tear and there's certainly, if there's abutment onto the lunate, then I usually will always shorten them because yeah, initially maybe after my arthroscopy it looks okay, but then they have a recurrent problem. So I like to kind of do that all in one sitting. Yeah, I think I have a pretty short trigger as well to do an ulnar shortening in conjunction with, you know, TFC pathology. Obviously in this guy, pretty straightforward because even, I mean, I think he clearly had evidence of impaction, even though he also had, you know, instability from loss of the foveal attachment. So Alex, comments or therapy thoughts in these kinds of patients? I think the thing to consider is that these tend to take a long time to heal. And so just reiterating that with the patient and making sure, just, it takes a while for bony consolidation, but sometimes we just have to hold people back from not doing too much because they're usually feeling better, so. Yeah, when you figure out how to do that in a patient that's feeling good, I'd really like to know that. Because it doesn't happen out here very much, especially in the middle of golf season, so. Okay. Do you cast them? Say what? Do you cast them, Dr. Greenberg, for like? I mean, in this situation, I do not. I mean, for the peripheral repairs, I do hold them for about four weeks before I start protective motion. But in just the, just the ulnar shortenings, like these diaphyseal shortenings, they come for their post-op visit and then I let them go, so. Jeff, there is a quick question from the audience here. Would a wafer procedure not provide enough shortening in this instance? A wafer procedure would be perfectly appropriate here. I am personally biased towards preserving the ulnar head. And I have, you know, over the course of 30 years, have done a lot of different things to the ulna. And my, I do bias towards anything that's gonna preserve the ulnar head. Now, in this situation, you know, maybe that would have been a really quick thing to do because I did a open foveal repair. So while it was open, I could have just shaved off two millimeters of the, you know, of the pole of the ulna. There's nothing wrong with that. So, but I tend to, I tend to do more diaphyseal or even a metaphyseal type shortening, which is a closing wedge osteotomy. But that is reasonable. I tend to be as, as probably lean more towards what Dr. Greenberg does too. I'm more apt to shorten on the shaft versus to the, like within, during my arthroscopy. Okay. Nina, I guess you're up next. Oh, there it is. Okay. Just give me two seconds. Sorry about that. So I have no conflicts to disclose. So this case is just a 29-year-old male, open Galeazzi fracture dislocation during a fall from his motorcycle in a motocross event. He was treated elsewhere with, had multiple depriments and eventually had ultimately pinning, sorry, ORIF of his radius fracture with DRUJ pinning. This is actually a picture that the patient shared with me at the time of his injury. And then this was the post-operative films that were done with his initial presentation. I think I'd probably do the same. I would do a radius ORIF, clearly do multiple depriments. The one thing that probably I don't do, I used to pin all the time my DRUJ. Nowadays, I tend to not pin as much. And then if I'm doing any type of pinning or I'm worried about the DRUJ because I have been burned a couple of times where I've actually pinned it slightly subluxated. I do get a CT after my surgery just to make sure that I have adequately reduced my DRUJ. Dr. Greenberg, do you tend to pin your DRUJs? No, I don't like pinning the dysradial joint. And my feeling about it is that if I have some type of pathology where I feel like I need to pin the dysradial joint, then I personally would rather address whatever the pathology is that's making me think about pinning the dysradial joint. I'd rather fix that. Now, I will say that in this particular case where you have a huge grade three dirty open wound like you showed in that clinical picture, maybe this is a case where I would say, hey, you know, I don't wanna put any hardware in the end of that ulna like a suture anchor or something to fix his blown out TFC at this point. So this may be one of the really rare instances where even in my practice, I might say, let's pin it just temporarily or let's see how stable it is in supination. But this is a case, obviously I'd be, all the restraints at the end of the ulna are gone. You know that from just a clinical picture. So I'm assuming that even after fixation of this fracture, that there's some element of instability, but. Yeah, that's true. And then this is eventually, he had his DRUJ pins removed approximately seven weeks after the initial injury. So, and then the radius RAF healed without issue, didn't develop terrible infection either. So he was able to return to work actually, and then in April, so that was several months after. So there was actually shockingly a period of time where he was doing quite well after a surgery. He wasn't complaining of any instability. He was able to do day-to-day activities without any difficulties. And then all of a sudden he said at work, he was trying to lift a heavy object. And then he felt his distal ulna break loose. He felt a significant difference than he had pre-lifting the box. Now he presents complaining of pain associated with snapping and clicking about his distal ulna. It's aggravated by any type of lifting and activity, any type of forearm rotation. He says he feels something moving. And then he actually, if you occasionally listen very carefully, you can hear a little snap. So Dr. Greenberg, what are your thoughts at this point? Would you pursue more imaging, I would assume, or? Well, I mean, obviously I would examine him first. And I think with a lot of these instabilities, you actually can come up with a pretty accurate diagnosis, even the absence of MR. However, in this guy, I probably would get a confirmatory MR, knowing the nature of his initial injury. I'd probably want to image his soft tissues. Yeah, so he did receive an MRI and it pretty much said that he really had no TFCC. At the time of his initial injury, it does appear as though they attempted to repair some of his TFCC, but not with any type of suture anchors. Understandably, probably because of the degree of dirtiness of the wound itself. So this is, the wounds were on physical exam. Wounds while healed, fingers were well-perfused. You could actually just see the prominent distal ulna, exaggerated, of course, in pronation. His range of motion was not terrible, actually, but it was different than the other side. And you could tell that there was marked AP translation of the distal ulna in side-to-side comparison. And then this was his CT. And then clinical image just showed that that booth, like without any type of like force whatsoever, it was extremely unstable. So this patient actually received a DRUG reconstruction. And the only reason I put this case in is it's just a counterbalance for this patient didn't have like a radius malunion necessarily, or malunion. So this one received a DRUG reconstruction and he actually did quite well. He kind of went back to his regular activities and he had no complaints after that. Dr. Greenberg, any comments you would make or different to do? I think this is an excellent case. This is, you know, my experience, even in the patients with chronic instability is that the majority of them still have TFC to repair. You know, I have one very vivid. I mean, I had, you know, I took care of a college volleyball player who had been seeing a number of practitioners over two years. And when we finally made the diagnosis that she's got a TFC tear, and I took her to the operating room thinking that we were gonna have to do an Adams reconstruction. And her whole articular disc was just out there sitting in the breeze, just not attached to anything. And we just re-anchored that to the fovea after two years and she was perfectly fine. But I think in this case, this is where you really need to have this in your toolbox, because this is a case where obviously the attempts were made to repair the stabilizing elements at the time of injury. And you know that the quality of that tissue is not gonna be good. So I think this is a great indication for a ligament reconstruction, which I think for the most part, you don't really have to do this very often. Yeah, I agree. Like I would have to say, like I do not do this procedure because it's predominantly I try to focus on the TFCC. So it's one of the rare examples. So Dr. Fox, I think our time is up. So if you wanted to go to your questions. Thank you so much, Nina, Jeff and Alex for those great cases and comments. We have about eight minutes here built into our schedule before our break. If anybody has any questions, we'd be happy to answer them in that you can put them in the chat or you can put them in the Q&A. We have obviously covered all of surgery and risk therapy in two hours. So there may be some questions out there that we've missed. All right. One of the questions in the chat was, what effect does de-innervation have on proprioception? And I bet a lot of our panelists can answer this question or at least give some thoughts on that. Maybe we'll start with our therapist first. After you see a patient that has de-innervation, do you notice issues with proprioception, Alex, Chris? I would say certainly people will have issues with proprioception just from being immobilized for a long period of time. So, yeah, and I know Elizabeth Hager has done a lot of studies on de-innervation of ligaments around the wrist. There's not as many studies of proprioception around the DRUJ, but it's definitely something that's important to work on. We try and incorporate the closed chain, open chain activities that Chris was talking about in her talk, and I'll let her take it from here. Yeah, absolutely. They're just not getting as much information as they would normally. So because of that lack of information that they're getting from the de-innervation, we are seeing increased proprioceptive deficits. And so it's definitely something that we make sure that we work on in therapy, as well as make sure that we give them a home program to work on those deficits to try to regain that unconscious neuromuscular control. Do you think that has long-term effects or is that just a short-term and they really pick it back up? I've always wondered that. You know, that's really interesting. And for the most part, we still, this is an area that needs a lot more research, but what we have seen is that people with the right neuromuscular re-education actually get it back pretty quickly. And it's actually pretty easy to see the improvements because we just continually measure joint position sense over time. And so that's kind of how we gauge, are they actually making the improvements and are they back to where they need to be? And just as a follow-up, before we go on to the next question, how do patients, this is from Dr. Greenberg, how do patients manifest their proprioceptive deficits? What do you see? So typically one of the things that you see is like, for example, I asked a patient one time, I put like two little marbles in a little plastic cup and I asked her just with her wrist to just get them moving counterclockwise and clockwise. And what she does is she just does it with her entire body. And she even says, I know I'm supposed to just be moving my wrist, but I just can't help it. And so what you see is more of this kind of global motion where they just can't focus in on what they need to do to control it accurately. And they just have a tendency to have a bigger kind of where they're using the entire arm to get to complete the task. Wow, great. The next question was about proximal migration of the carpus after distal pole scaphoid excision. Maybe Jodi or Jason or Jill could tackle that. Yeah, I can take that. I mean, I think Dr. Yao brought out the point is how much do you need to leave in the proximal pole? And I don't know if there's a great specific answer for how much is enough to leave. You can get some collapse potentially, which would be, you know, further progression of the arthritis. I think that the 20 year data from the Malarich stuff shows there isn't a stiff amount of collapse on that. The downside would be that you have to go do another salvage procedure like a proximal carpectomy or sort of a partial risk fusion or total risk fusion. I haven't seen that. I haven't been a long enough to know if 10 years from now my patients have had a collapse after that, but I think it's a possibility, but it's a kind of one of the steps in the process that if you do that, it fails, you're not burning your bridges down the line. Great. And then Dr. Greenberg was also gonna comment on that. Yeah, so I think one of the things, I personally like the Malarich procedure a lot, especially for the more distal scaphoid non-unions. I worry when you kind of get it when there's the more proximal ones, you're taking out a lot more scaphoid. However, I would encourage everybody to really pay attention to the lateral X-ray preoperatively, because one of the things you will see after distal pole excision is you will see DC and you will get exaggeration of your DC deformity after you take out the distal pole. So when somebody that has a moderate amount of DC, pay attention to that because you can lead to a adaptive kind of a sin problem after a Malarich. And I have actually had to take people back. Now, the situation is actually not that terrible because your salvage for your failed Malarich is gonna either be a proximal carpectomy or a foreclone fusion anyway. So if you get that unfortunate postoperative finding where you get an adaptive sin, then you're gonna move into that salvage anyway. But just be aware that you can definitely get symptomatic mid-carpal subluxation from exaggeration of your DC after you do a distal scaphoid excision. Perfect, thank you. Okay, with our last minute, we'll answer the last question I see here in the chat, which is what amount of wrist flexion extension do you typically expect after scapholigament repair? What do you generally tell patients pre-op to guide their expectations? I think Dr. Yao is still on. Dr. Yao, do you wanna touch on that? If not, maybe Dr. Kamal or Dr. Shapiro. Hey, Paige, can you repeat the question? What amount of wrist flexion extension do you expect after scapholigament repair? What do you tell patients preoperatively? Yeah, so repair versus reconstruction. When I do reconstructions, I generally tell people that on average, they may lose about 50% of wrist motion compared to the normal side. And that's just my sort of laying crepe to the scarring that occurs. I think as our SL reconstructions begin to minimize the post-op immobilization, so some techniques that don't require K wires and eight weeks of wrist immobilization, perhaps we'll get better range of motion long-term, but I don't think that's really been decided yet in the literature. That's great. Yeah, I also tell my patients 50% range of motion. If we get more than that, I think it's great. What about our therapists, Chris and Alice? Do you guys see more or less? That's typically what I see too, about 50%. But to be honest, a lot of times because we don't push range of motion, oftentimes they're discharged by the time that we see their final outcomes because we're not pushing to try to regain that range of motion. Alex? Yeah, I would agree. I mean, the goal is stability and a stable wrist. And so focusing on just addressing those muscles that are the supinators of the carpals and just working on function as opposed to working on motion. Yeah, but we don't see these people return after a year. So I don't know what the long-term is, but yeah, I would tell people about 50%. That's great. Yeah, I think it is an exchange, right? Yeah, I think you brought that up, Alex, an exchange for a stable wrist, exchanging that for motion. Well, thank you to our participants for their questions. We're going to take a 20-minute break. So we'll be back. We'll start promptly at 11.20 Central Time, 9.20 Pacific, 12.20 East, and then wherever else you are. So 20 minutes, and then we'll start back. Thank you, everyone.

wrist arthroplasty

wrist range of motion

hand function

rehabilitation

improving

maintaining

oblique dart thrower's plane

motion pattern

case studies

distal radial joint instability

ulnar-sided wrist pain

triangular fibrocartilage complex

TFC tear

Galeazzi fracture dislocation

DRUJ reconstruction