Good afternoon, thanks for having us. When we think about the management of both metacarpal and proximal phalanx fractures, there's really been a very standard that's been set with either K-wires or with plate fixation or probably even most commonly, let me get rid of my mask, sorry. Is this legal? Or most commonly non-operative management. However, when we see a lot of these fractures, there are some fractures that are well managed with K-wire fixation. Fractures where we have a lot of comminution, soft tissue disruption, instability issues. When we see a fracture like this or a hand that looks like this, the K-wire fixation really works fairly well. However, when we have patients that have more simple fractures, maybe transverse fractures, these proximal phalanx base fractures which seem to be very common for my practice and the elderly. When we place K-wires, often that really tethers the skin, the tendons, the other soft tissue down to the bone and really limits early motion and it limits us from getting that patient back to where they want to be as quickly as possible. So this is a case of Dr. Mercer's in which this patient has two fractures, both the obvious one at the base of the small proximal phalanx but also this one at the thumb metacarpal. One of the tricks for placing intermediary screw fixation to the small tubular bones of the hand, especially here at the proximal phalanx, is to find that sweet spot of advancing the screw. How do you get the screw in? So for the proximal phalanx, one of the tricks that Dr. Mercer likes to use is to actually sublux that proximal phalanx off the metacarpal head and that can give you a nice starting point for that K-wire such that you can put a single screw or if you need to, you can put double screws in. This is that same patient with the proximal phalanx fracture at the thumb. And using the headless compression screw in a type of interfragmentary fashion. And these patients can start moving right away, limiting stiffness, maximizing ADLs. When I do these types of fractures with a single screw, often I'll just buddy tape that proximal phalanx to the neighboring. Here with the thumb, this can be treated post-operatively with a simple splint that's removable and that can allow early range of motion. So headless compression screws by nature, most of the current designs have a built-in bit of compression. And this has to be kept in mind. While we're doing these tubular bones, some of these transverse fractures, we want to get a little bit of compression and some we want to avoid over-compressing. When we see these proximal shaft fractures like this, this is a nice transverse fracture that you can use this proximal method for. And another tip and trick is to obtain a preliminary reduction and a preliminary pinning. And then after that preliminary pinning is done, use the guide wires to place a couple headless compression screws. And again, this really allows for immediate range of motion. This trick can be done with a more comminuted fracture. Once again, keeping in mind the bit of compression that you might get with your screw. And here's a more comminuted fracture. And I think one of the take-home messages for proximal phalanx fractures is to really consider what is adequate. A perfect x-ray may not be necessary to get a very reasonable hand. In fact, a perfect x-ray may be detrimental to getting a functional range of motion. So this patient has a very nice range of motion. This can be done in multiple different digits with overall very nice result. Another patient here, this screw was placed from distal to proximal allowing preservation of the PIP joint. Again, I have several more examples here with more comminuted, more displaced fractures that are treated with several different directions of those headless compression screws with a very nice clinical result. This patient had a replant and this isn't an acute fracture, but this is a late sequelae of a replant in which the patient had some thumb arthritis and that was treated with just a percutaneous screw. Non-unions can be treated with intermediary screw fixation. This patient had multiple treatments from the pediatric colleagues, different attempts at different treatments and eventually went on to have a single intermediary screw fixation. The benefit of treating non-unions, malunions with intermediary fixation is you really get rid of all that exterior to the cortex instrumentation, metal plates and screws to maximize tendon gliding. These patients can be very, very stiff from the malunion and nonunion and then placing the intermediary device can really allow immediate range of motion and get really nice stability. So here that patient is with the, this is actually a malunion. So this patient came in with the rotatory deformity of the proximal phalanx. Dr. Mercer placed the K-wire first then made small incisions to make the osteotomy and then rotated the finger around the osteotomy placing the headless compression screw, obtaining stability and alignment and the ability to really get immediate range of motion. Another patient here with a middle phalanx fracture and this patient had a significant problem with their nonunion over multiple months, eventually had the intermediary fixation with acceptable range of motion. But again, I would argue that in many of these patients putting a bulky plate and screws really doesn't get you what you're looking for. I'm sorry. I'm stealing Frank's talk evidently No Frank's doing metacarpals. All right, so I'm gonna stop here. I appreciate your understanding I was actually giving someone else's talk there, but we'll have dr. Rubio come and give metacarpals Thanks so much, dr. Mercer couldn't attend she was at orthopedic research society All right, give me a moment. My talk is not on this list. It didn't come up? No. Just give us a moment. While we're figuring this thing out, thank you very much for staying to this time. All right, thank you very much. So I'll take the torch over from Dr. Haksima and we'll continue. So these are my disclosures. So metacarpal fractures, typically they consist of one third of hand fractures, the fifth metacarpal being the most common, and this is more of a condition of younger males, sometimes of the pugilist variety, but certainly there are some implications with the demographics. Now indications for fixation are a little bit variable in the metacarpal in the sense that there are these indications, irreducible fractures, open fractures with or without soft tissue injury, which may or may not include the tendons, segmental loss from some of these blast injuries, multiple metacarpals, as you've also seen with the phalanges, articular fractures, excessive angulation, and this is interesting because there's some variability in the criteria of what we will and won't accept. Certainly we take into consideration extensor lag, et cetera. And then I think one of the most clinically significant ones are malrotation. But there's also the implication of economic indications considering return to work, and I think at the end Dr. Greer will talk a bit about sort of the rehab protocols and how we treat these postoperatively. But if you look at the fixation options, traditionally these include lag screws, plate and screw constructs, transverse pinnings to adjacent metacarpals, and percutaneous or open-assisted fixation with K-wires that then have to be retrieved. Newer methods, and newer is in quotes because these are variable in terms of how long they've been used, and these include, for example, Guy Foucher's explanation several years back now of bouquet pinnings, there have been other evolution of techniques using intramedullary devices including smooth wires, locked wires, there have been headless screws, as you've seen now with the phalanges, and locked nails. And I think this talk I'm going to focus on the screw fixation because that has really shown itself to be something that's quite versatile, and it becomes a much quicker way to fix these. Now when you look at plates versus screw fixation, there are some comparisons available in the literature. One of the meta-analyses showed that the plate complication rate is in the 30% range, and this mostly includes plate removal and tenolysis procedures. The IM screw complication rate is less. There are some implications for IM screws that are specific to those devices, but again in general it seems to be, has shown itself to be pretty reliable, relatively low complication method for fixation. Now the interesting thing is when you look at total active motion comparing the two, most studies show no significant difference, but remember the caveat there being that the final follow-up includes post-tenolysis for plates and then the rehab after that, so just something to take with a grain of salt there. So let's show some cases. So this case actually got from Dr. Mercer, and you saw the introduction from Dr. Hoxham. This is an interesting case. It's a first metacarpal base fracture, and this fracture is treated by placing these guide wires. One was used for provisional fixation, and then you see that diagonal wire, and here is being drilled over that wire for placement of a head-miss compression screw. Then she added on this 6-2K wire to offload the metacarpal base. And then on the right, I'm sorry, that image is on follow-up after the wire was removed, and this fracture and the joint remained reduced. Now here's another one. This is a little bit off topic in the sense that it's not a metacarpal fracture, it's a trapezial fracture. Just a very interesting case. You can see here there's a split of the trapezium with this fracture and a concomitant CMC dislocation. This was addressed by this construct, and this is at the two-week follow-up. So you notice two headless compression screws are placed to restore the articular surface of the trapezium, and then the CMC joint was offloaded and temporarily pinned with K-wire fixation, and then you see on follow-up with the K-wire removal. This is the patient gripping, the left side was the operative side. So for metacarpals, typically the approach is the reduction is obtained with the guide wire. We typically use these mini-open. Now there's two ways to do it. There's anti-grade and retrograde. If you go retrograde through the articular head, you're going to make a small incision to move the extensor mechanism aside. Some of the concerns are with perforating the articular surface, but two things to keep in mind there. Firstly, the entry point is dorsal, and it makes up about 5% of the A to P distance and about 8% of the medial to lateral distance, so something to keep in mind. The guide wire is placed and crossed with the fracture site. Now one of the things is you can't subluxate the CMC joints as well as you can subluxate the proximal phalanx dorsally to get the entry point if you were going proximal to distal. However, flexing the wrist will also allow you to miss the carpus on the exit if you need to exit the base to get provisional fixation and stability. And here you can see the screw is being placed over the wire, and this is the end construct with showing a nice reduction with the headless compression screw, and this is one that gets buddy taped and immediate motion. You can see here how the motion progresses. Here's another case. You can see there's a fourth metacarpal flexed approximately 80 degrees, and so the reduction maneuver here can be assisted by using a K wire. The K wire is initially placed at about 90 degrees or a little bit over 90 degrees to the long axis of the metacarpal, and then you just bring the wire dorsally down against the dorsal skin, and that will get you out of that flexion. You can then place the guide wire, a ring for the screw, and place the screw. Here's another case, multiple metacarpals. So again, as I discussed before, you can put these. This is not that case, but an example where the wire, you can either insert it retrograde, exit the carpus, and then place it anti-grade if you have a very proximal fracture at the base, or you can place it retrograde from the metacarpal head approximately. So you do also have some flexibility with the wire placement and subsequent screw placement. And here you can see in this particular case, all four were placed retrograde. Here's a segmental loss case. This is also a case from Dr. Mercer that this is a teacher who, this was an accidental self-inflicted gunshot wound, usually when you're cleaning the weapon, unfortunately, and in this case, you can see that the bone loss, there's a bone loss of that first metacarpal with obviously an open injury and an extensor tendon transection. So this fracture, she managed by placing a retrograde headless compression screw in the middle, the long finger metacarpal, and then for the proximal, I'm sorry, for the index metacarpal, this care wire was placed and a cement spacer was placed into the defect as a masculine type procedure. And here it is allowing for soft tissue healing. The extensor tendon was repaired at that time. She then went back and placed an iliac crest graft into the defect after removing that cement spacer. And then you can see here with the graft in place, the graft is then held with a retrograde headless compression screw placed over that guide wire, securing the graft in place. And this was immediately after the procedure. And then you can see on follow-up, you can see very nice integration of that graft. And here's the range of motion. So on the horizon, there's been a recent advance. These types of fractures, the main thing to consider with the metacarpals is as opposed to proximal phalanx, you have a little bit of additional stability from the interossei and from the transverse metacarpal ligaments. But still one of the problems is shortening, and there's not that much significant rotational stability with the screws. And so one of the things that have recently been developed and will be available soon are these locked intramedullary nails, which have the stability for longitudinal shortening or against longitudinal shortening, as well as rotational stability, are conferred by these implants. Thank you very much. Now, Dr. Gray. Thanks so much, Dr. Rubio. All right. So we are going to go further up the limb just by a little bit. So, again, I'm Rob Graham from the North Shore of Chicago. I'm going to talk to you about MIS fixation for carpal non-unions. Where's my, this guy? Is that working? Okay, great. So, no graph, no problems. These are my disclosures. So, scaphoid fractures and non-unions are a big problem. We're worried about AVN. You've got the not-dead-yet scaphoid. You've got the dead-as-a-dead-parrot scaphoid. And you've got the walking dead scaphoid, which continues to torment you your entire life. So, how do we deal with scaphoid non-unions and why are they difficult? First of all, how do you even diagnose it? It's not clear. Do you need a vascularized graft? Do you need any graft? Is less actually more for these injuries? So, looking at the data from our radiology colleagues, you can use an MRI. And some of the studies show reasonable results for diagnosing AVN. Some say contrast helps significantly. Some say contrast makes it worse and you shouldn't use contrast. Some say that you can look at the MRI and figure out what you're gonna find in the OR. Some say it's a coin flip. Maybe the MRI does or does not correlate with the OR findings. So, clear as mud. My favorite study on this is actually from my mentor, Alan Bishop. And he did this to prove the point that vascularized bone grafting works. It works. You can bring blood in. You can get things that were dead to heal. There's no question about it. In this study, he took the scaphoid homologue from a dog, took it out, freeze dried in liquid nitrogen to kill it dead as a doornail, coated it in methacrylate so nothing could grow into it, and had one as a control group and then plugged a vascularized graft into the experimental group. And he verified that the bone healed. But interestingly, as part of the study, he would do MRIs on these dead as a doornail scaphoid homologues, and they would look normal and vascularized on the MRI, even though you knew for sure they weren't. So MRI is not really a very successful tool for predicting AVN in my hands. So you have AVN. So what are your options? You can use some sort of distant vascularized graft, medial femoral condyle. It's my favorite surgery to do. I don't do it anymore. But it works. You get the bone to heal. It's sort of a Franken bone, but it definitely heals. Smaller, you can have a local flap, a 1-2 X-ra, a terianos flap from the dorsal side, a 4-plus-5. These all work, and you can plug that into the scaphoid to get it to heal. From the volar side, you can use a Matalan flap. I find these hard in my hands to use. I'm always worried about getting into the joint surface unintentionally. But do we even need vascularized grafting? So when I was sitting for the boards, the answer was yes, you need a vascularized graft for sure. Now, maybe you don't. So I don't think that it's vital, certainly not in all cases, to do vascularized graft even for AVN and the scaphoid. So let's look at just graft. What kind of graft do you need? Do you do a wedge? Do you do a strut graft? Well, this is a very well-done biomechanical study showing that strut grafts actually have improved stability in all planes, especially with torque, compared to wedge grafts. But the question I then have is, is it the strut graft that helps? Is there another way you can achieve this? Because that carpentry is difficult. I've tried to do it before. It is not easy. It works, but it's not easy. Maybe you could just put in a second screw. And so in my practice, rather than do any of these grafts, I just do two screws, and it tends to work, and I'll show you how and why. So there's a lot of data that shows that grafting is not necessarily needed for non-unions or even AVN of scaphoid fractures. Jim Salcedo, one of my buddies, has this paper looking at it. This is an excellent review of the literature, and it shows that you can fix established non-unions with a single screw, and they go on to heal pretty reliably. Now, in my practice, two is better than one. This is a very good study. Clinically looking at the rate of union goes up dramatically with two screws versus one screw. This is a biomechanical study kind of proving the concept. Plate and screw constructs and two screw constructs tend to be both dramatically stronger than a single screw in all planes, to torsion, to bending, in all methods. So here's Rob's rule. There's nothing I can put in a scaphoid that's better than being 20 years old. I don't care what it is. 20 wins. There's also nothing I can do to slow one of these guys down. There's no cast that's good enough. So if you're this guy, you're getting two screws. So here are some things that we tell the patients, and I was told, and it's sort of the old tale that keeps going, but I don't know how true it is. We say that they don't heal because of the bad blood supply. Well, if that's true, how come the rate of Keenbox to Pricers is 1,000 to one? It's a very rare thing to go on to spontaneous AVN of the scaphoid. It's hard for me to believe that a one millimeter gap from the trauma completely kills the blood supply. We're told the gaps at the fracture site require bone grafting. Well, we know from numerous studies that's not necessarily true. And we're told that humpback deformities require open reduction and bone grafting. I don't think that's true. Since the early 90s, we haven't really been worried about scaphoid malunion. We're worried about scaphoid nonunion. I've personally never done an osteotomy for a scaphoid malunion. Some people have experienced with it, but I would argue that it's rare. We say, Rob, I'm still worried about humpbacks. Well, first of all, they're difficult to measure and difficult to figure out, but I've got a cheat code for dealing with humpbacks. So often when we're doing these open, we put a joystick in the lunate or we pin the lunate to the radius to hold that in place and hold the proximal pole of the scaphoid through the SL ligament. But there's another way that you can do it. It's easier and more direct. So just remember the thumb is a thing. You're gonna go from the back. You're gonna flex the wrist to 90 degrees and you're gonna pull down on the thumb metacarpal. And now my middle finger is pushing up on the distal pole of the scaphoid. And that gives me complete control of whatever's going on. So even with a humpback deformity, my middle finger's on that distal pole. I put my guide wire in that proximal pole and then I extend the wrist and I push up with my middle finger a little bit and I pull out a humpback. And then I finished putting the wire across. So now I fixed my humpback. I didn't open, I didn't put any graft and I put in two screws and I go home. So here's a patient I had, a hockey player, young guy, it was a long story, but essentially he played on the, it was an eight month old injury when it was diagnosed and he had to play on it for another year. Cystic changes at the waist, no humpback, but a very established non-union of the scaphoid. So I had all the big gun options. Sorry, I don't know why that's not coming up. But I ended up going with two screws because two screws is better than anything else I can put in the. That's a bummer. He had excellent motion. He lacked about 15 degrees of flexion and 10 of extension. It's a bummer. So proximal pole non-unions. So this is one four weeks after injury, still see some cystic changes. He wasn't healing in a cast, two screws, and the fracture goes on to heal. And at just three months, not full motion of the wrist, but pretty symmetric with his other side. He has stiffened extension on both sides. No grafts, fast return. But what if it doesn't work? Well, you can still do your fancy graft later. You can do a partial wrist fusion. But sometimes, even when it doesn't work, it still works. So this is a guy came in to me nine months after injury. I tried two screws. Didn't really work. This is a non-union for sure. And so two years post-op with an established non-union, he has at least adequate range of motion of the wrist and very little pain. He's working, got the point tender a little bit, takes a little ibuprofen. That might go on to fail. I may have to revise it later. But it's been two years. Hasn't blown up yet. So we're just going to keep watching him. So he's got a little bit of pain. He's got a little bit of pain. Hasn't blown up yet. So we're just going to keep watching him. So the nitty gritty vascularity I don't think is the issue. But even if it was, maybe stripping the bone isn't the right answer. Two screws are a very strong construct in all planes. And vascularized bone grafts work. They give you a healed scaphoid and a stable painless wrist. But it tends to be stiff. And in my hand, salvage procedures give me the same thing with a lot less morbidity. Thanks again. Rob gave me the when to bail talk, which is great because I don't think there is really one list that you can come up with as to when to bail. There's a lot of surgeon preferences, whether it's significant open injuries, unable to obtain or maintain closed or minimally open reduction, or non-unions or mal-unions. But when you're thinking about doing minimally invasive percutaneous fixation of proximal phalanx fractures, metacarpal fractures, scaphoid fractures, things like that, I don't think there's one list that you really have to have as to when it's inappropriate. Because you can have some significantly mutilating injuries that you can, you know, you could pick out a couple of those metacarpals and say, well, you know, I can maybe put a screw in that. But in this particular patient, if we look at where they are clinically, this is, for me, a situation where I'm not going to do a minimally invasive type of procedure. We do a maximally invasive type of procedure, a lot of temporizing things, get our soft tissue in a good place, and then work from there. Some patients who have difficult reductions and instability, so this patient has a ring PIP joint fracture dislocation, as well as that very, very common rooted, and with soft tissue compromise, ring finger, middle phalanx, those are these types of fractures that I tend to, quote-unquote, bail and go for more of a traditional K-wire type fixation. These are the bane of my existence, gunshot wounds, usually these are self-inflicted, accidentally self-inflicted injuries to the hand, so that fracture looks like this on x-ray with a significant amount of comminution, shortening, intra-articular extension, and often with a lot of these fracture lines propagating both proximally and distally to their neighboring articular surfaces. So in these situations, it's not bad to say, hey, I'm not going to do a minimally invasive type of procedure. I'm going to do something open, I'm going to get the soft tissue in a good position, and then work later on getting stability into that phalanx. This is not the same case, but one of our concerns about doing minimally invasive procedures on these metacarpals, proximal phalanx, and middle phalanxes, with significant amount of comminution is shortening. We know that if you have even one millimeter shortening at the proximal phalanx, you can get a 12 degree flexor contracture extensor lag at that PIP joint. The hope is that with the advent of more advanced technology, we'll be able to control that shortening and that potential for malrotation. But this is back to that prior patient with the gunshot. Once those K-wires have been doing their job, maintaining alignment, rotation, allowing the soft tissue to get into a good place, I went back and did a staged procedure to replace that with an intermediary screw once we have an opportunity for that finger to be a bit more healthy. Some might say that the oblique fractures are indications for not using the smaller screws. Again, I think interfragmentary fixation is really a great way to treat these long spiral fractures. And you can even transition your usual headed type of screw to a headless compression screw and obtain a very nice result. Let's move over to the scaphoid. You know, when do you bail on your percutaneous scaphoid management? And Rob did a nice job at talking about some of those options. This is an active duty service member who's about 50 years old, comes in with this unknown history, unknown time of initial injury. And we talked to him about fixing this, because when we look at the CT scan, you really appreciate that void. And although I don't get MRIs on scaphoid non-units, I do often get CT scans, because it'll give you a significant insight into, number one, where that fracture is in relationship to the scaphoid, but also how much cavitary defect you have. And if you look at this one, this is a very, very thin distal pole. So in this situation, we decided to proceed with a distal pole excision or a Malarich type procedure. Problem, of course, with that is you do destabilize the proximal row. But if we look at the literature, distal pole excision for scaphoid non-unit has a pretty reasonable long-term result. And this is Malarich's study with up to 14 years of follow-up with 94% of these patients being satisfied. And lastly, this is a patient of mine who presented here eight months post-injury with this scaphoid fracture. He has an establishing non-union with MRI taken by somebody else. But it shows that you have an established scaphoid non-union with some early cavitary defect. Elsewhere, he went on to have an open treatment with a single screw placed and some bone graft from the distal radius. And I think this is a very reasonable way to treat early non-unions of scaphoid waist fractures. However, I think the carpentry has to be done well. And we could argue that this screw maybe could have been placed in a better position. But here, that same patient is at three months with no evidence of early healing. One year post-operatively with a significant amount of absorption at the waist. And you could say, hey, you know, the screw doesn't look that loose. Is this patient symptomatic? Do they need anything? Well, I would argue that in this 19-year-old patient, this is probably going to go on to become a problem for them. So this is my indication for a mediofemoral condyle free graft is a patient that's undergone a prior scaphoid open procedure and has failed. And this surgery is actually fairly straightforward once you kind of understand the harvest anatomy and you have some basic skills with microsurgery, which my microsurgery skills are basic. But there you see that the plugged in end-to-end for the vein and end-to-side for the artery. And here that patient is in the operating room. I used a couple supplementary K wires plus two screws. Here that same patient is two months out with this time you see really robust early healing. Six months out, looks nicely healed. And then see if my CT scan video show. There they go. So now you see that they have solid osseous fixation healing all the way across that scaphoid nonunion. And again, we know this is borne out in the literature as a very reasonable way to treat scaphoid fractures. In conclusion, I think there's evolving techniques in kind of minimally invasive treatment of these fractures. Tubular bones, adequate reduction may mean improved results. So a perfect skeleton does not equal the perfect result. We know that with soft tissue needs to be respected. But sometimes an open treatment may be necessary. Thank you. Thank you so much, Dr. Huxma. And then I just lastly wanted to touch on some of the themes behind MIS hand fracture fixation and how that might impact your practice. All right. My disclosures again. So I do think that in a lot of these hand fractures less really is more. You have different options. So the anesthesia is limited which gives you more options. In phalanx fractures, this is a local case. These patients are awake and there's no anesthesia involved at all. That allows for immediate evaluation of their motion on the table and their rotation and immediate rehab. So in pre-op, you can see that this patient's got a ring in a small proximal phalanx, stiff, mal-rotated. And then on the table, you can immediately be confident you did a good job. You know this hand works because it works. Now, they are going to go through some stiffness later on which we'll talk about, but your ability to assess your job and change it if you need to has really changed my hand fracture fixation practice. Metacarpals, I don't think local only is enough. The thumb base ones, you can do that. A local sedation is often enough for those. The other metacarpals, I usually do with a block. It may have to do something with the patient population that the wall punchers don't do well with it. It may be more than that, but these patients I usually block. And even the kind of non-union cases, you can do those with a block, limited incisions, and get them back to things. Scaphoids, I've done under straight local for sure. Local with sedation is plenty. The sedation is really to tolerate the tourniquet. You put the tourniquet up for 19 minutes, the sedation is nice. And the benefits of local anesthesia, even with anesthesia not there because they're in the wards battling COVID, doesn't matter. You don't have to worry about packing staffing issues, doesn't matter. Depending on your institution, you don't have to isolate and do testing quarantine because it's going to be a local only case. They can take a cab ride home, they can have a cup of coffee and pre-op. Post-op follow-up, you can do under remote control for these patients. You have a very small incision, you put an absorbable stitch in, there's really not a lot for you to do. So this is a college patient, I saw him post-op day three because he went back to college. It just makes things easier for you and your patients. So most phalangeal and metacarpal fractures won't need any formal therapy at all. They need a little coaching because on the table you can verify this patient has sedation, so he's a little groggy. He's got good motion, even though he's a little sleepy. And so I know that this patient is going to be able to get it back on his own. They go through a valley of stiffness though, so when they come back a few days later, don't be upset or concerned that they are stiffer than what you left him with. It will come back. And so at week three, his IP motion is great. The MCPs are still a little stiff, but this is a multiple finger fracture situation. This patient had three proximal phalanx fractures. I think it's pretty good motion for three weeks. And when you have an isolated, this guy just had one small finger, this is what you expect more often. At week three, essentially full range of motion, no therapy, no splinting. So the limited only approach with limited only, local only or limited anesthesia, little to no therapy, you can do a lot of this by remote control. You can do your pre-op and post-op through telemed, so that decreases the foot traffic in your office if you've got kind of COVID restrictions placed on you. But it also makes things easier for you and your patients to handle these injuries, which are common and by definition unscheduled. That's all I got. Thank you all so much for your time and attention. We've got a minute or two for questions if there are any. Thank you.

hand fractures

minimally invasive techniques

motion evaluation

reduced postoperative pain

phalangeal fractures

metacarpal fractures

scaphoid fractures