Rob Kaufman, professor of orthopedics and has a passion for reconstruction of a lot of ligament issues. So I'm going to start with, I get the easiest job and that's direct them at the app, and then if you like someone's... Thumb particularly is prone for injury because it just sticks out there and wants to be injured. Same with the small finger. You know, it's just asking for injury especially of the UCL. The anatomy of the thumb and fingers of the MP joint is very well described and I'm sure this is nothing new to any of you. Just as a point of reference though, you know, you have the proper collateral ligaments and the accessory collateral ligament attachments specifically to the volar plate. You can see they have a very specific angle of attack from proximal to distal and this has all been very well described. In extension, you know, the main contributions to stability are the accessory collateral ligament and its attachment to the volar plate. And then inflection, you have the proper collateral ligament and its attachment is the, that's the primary stabilizer to varus and valgus stress. Carlson and those in New York described well. The origins. The insertion is probably a little bit more. It's about three millimeters from the articular side as well as from the bolar side and that would be the typical central portion of the attachment of the UCL. As I mentioned, the UCL and the RCL are very similar. thicker for the UCL at the origin, a little narrow at its insertion, which is why the majority, 90 percent, will be in volts from the base of P1, whereas the RCL may be a little bit thicker at its insertion, which is why there's more avulsions from the base of P1. But in general, you know, if you, you know, the patients come in, they... Just a The anatomy of the digital MP... So, if you're interested on the app, I've got three poll questions there for you. If you want to answer them, if not, that's fine. And then feel free to send questions through the app as well. One came through about getting the bone through the tunnels. How does that work without shredding it? I'm going to have Dr. Kaufman talk about that during his talk, because he's going to talk more about the reconstructive portion. So, my talk here is about primary repair. These are my conflicts. So, Dr. Boyce kind of already talked about this slide, but it ends up being very important for primary repair. I mean, I think the whole goal of surgery is to restore anatomy, or at least to reconstruct it as close to anatomic as possible. And I think, you know, especially for ulnar clariligaments, there's a slide later talking about if you are off by just two millimeters in either direction, you start to lose range of motion and have less stability. So, I pulled this article out of the Journal of Hand Surgery, Bobby Chhabra, the senior author from UVA, and I found it interesting. And one of the questions I asked in the poll is, do you, as surgeons, typically repair the accessory collateral ligament to the vulvar plate, as this picture shows? I've actually never done that. I kind of find it interesting. I wonder, maybe my two colleagues, Dr. Boyce or Dr. Kaufman, do you routinely repair the accessory collateral? Do you think you can easily identify two different ligaments, or is it all kind of one? I mean, I find this interesting, too, if you look at the middle picture, B there, the one suture anchor is probably a lot too dorsal. Based on Dr. Goitsislav, we want to get that a lot more volar as well. So acute repair just with an anchor, I think that's probably the standard of care. We'll talk about ligament augmentation, but if you see this, as college athletes, if you play football, basically, you can go back to play in about seven weeks if you're a receiver, quarterback, running back, that type of position, if you're a lineman or non-skilled player, back to four weeks. And so that kind of gets into the debate about do we need augmentation or not. It's almost like a product looking for a place to use it, in my opinion. But this seems like most people go back to play. They get immobilized a little bit anyway, so what's the real need? A lot of research has been done. I think I have three slides in a row just talking about different biomechanical studies comparing suture anchor, which again, I think is probably the standard. You could do bone tunnels, but I think anchors are so easy, most people would use those. This suture tape augmentation or, you know, arthrix, we'll call it internal brace, or a palmaris longus reconstruction or supplementation. And if you look at just time zero, you can see in the bottom left-hand corner, the load to failure, you know, clearly adding something else, whether it's suture tape or suture or whatever you want to use, is going to have a higher load to failure at time point zero. I think the issue I have with this is that we almost aren't ever loading it completely. I mean, if we do suture tape, we're still going to immobilize people for at least three or four weeks. I think Drew Brees was the most recent example of this. You know, he tore his thumb UCL. He had surgery with suture augmentation, and he still missed five weeks, I think, he went back. And so, you know, why are we either spending the extra money or risking kind of anything long-term if there's not a real benefit to it? Another study, 24 cadaver fingers, suture anchor repair versus suture augmentation. I thought this was interesting. On the left-hand side, the load to failure actually wasn't different. But as they started cycling it, in figure three, you can see on the upper right-hand corner there, as you got that first thousand cycles, the suture augmentation had a lower deformation. And again, that makes sense. You have something that is not biologic, just, you know, a stabilization device that's going to give you more cyclic load resistance. And then just another study here, fresh frozen cadavers. Again, as you would imagine, the suture tape or the augmentation has a much higher load to failure. But again, I would question, are we really wanting to load that early on? If you gave me the story that you are doing suture augmentation and you're letting everyone return to play without restrictions at two weeks as soon as their incision heals, I think that's a different story. But I think most of us are still going to immobilize them for a fairly long amount of time regardless of whether we do augmentation or not. So this is the other end of that. You know, you've got the suture augmentation group where you're, like, basically throwing the kitchen sink at it. You're trying to make this super stiff and stable. And then you have this study out of Mayo where they had chronic UCL injuries, which I know is Rob's talk, but I'm just trying to, this distinction between max stability versus just take any kind of local tissue you have. And I think if you actually read the text, they're just kind of sewing almost capsule and not even sewing anything else. So Peter Rue walked in. These are his partners up here who are just taking local tissue to repair UCL tears. And they had 12 patients, 15-year follow-up. And you can see on the right-hand side, 100% satisfaction. I wonder if this is the Mayo magic a little bit with 100% satisfaction. And if you look down, VES pain, 0.6, dash score of 6, which is basically normal. So these patients all did very well. But I think the tricky part is if you don't restore that anatomy, look at the radiographic follow-up. And the patients that got to come back, you know, three had angulation. Dr. Goitz kind of talked about more than 15 degrees would mean it's unstable. Five had radial translation. And then the majority of them actually had arthritis. So if we're taking relatively young people, and I mean, I see a lot of these, they get missed. You know, someone gets tackled playing football. They hurt their thumb. They play the season. They just kind of tape or splint or brace. And then you see them a year later with an unstable thumb. What happens to those people long-term? Ideally, we restore that anatomy. We make it stable and prevent the arthritis. But in this series, 88% had arthritis. What about the overall outcomes? This was a nice systematic review by Julie Samora out of Nationwide Children's in Columbus. And I kind of pulled this slide up just to show that, in general, with just the standard repair techniques, we're not even talking about internal brace or any of those magic things, just look at the post-operative outcomes on the right. It's probably hard to read, but basically 100% stability, 100% good and excellent outcomes. In general, this procedure, just with suture anchors, tends to do pretty well. I think stiffness can be a big problem. My friend, Rob Kaufman, will tell you stiff is stable. That's one of his favorite lines. But sometimes stiffness is really hard to treat kind of long-term. And so what is that average stiffness? And you can see that the augmented repair actually ends up having more stiffness. Now, that's kind of talking about stiffness of the reconstruction itself or the repair, but I think the thumb itself can also get stiff after you do this with the augmentation. It's a bigger exposure. You're putting more suture in, and I think it can be an issue long-term. I'll skip that over. All right. I wanted to bring this up because, you know, we're all from Pittsburgh. Our late mentor, Freddy Fu, double bundle, used to talk a lot about that. So what if you do single bundle versus double bundle thumb UCL? I think a lot like the ACL literature, it actually doesn't really show much difference at all. And so, again, making more holes probably isn't worth it to do. This is the study that I kind of brought up earlier. You know, what about your placement? As Dr. Goit said, you want to be about 3 millimeters from the joint surface and 3 millimeters from the volar base of the proximal phalanx. So what if you place it 2 volar? That's going to increase your radial deviation. So as you stress that, it's going to be less stable by about 9 degrees. If you place it 2 dorsal, it increases your radial deviation by 7 degrees. And then if you place it 2 distal, it actually stiffens the construct. And that makes sense, right? You're going to tension that ligament a little bit more, but you also lose flexion. So I guess if you're going to air, probably try to place a little more distal because I definitely would take a thumb that's stable but has a little less flexion than a less stable thumb. Rob's going to talk about reconstructions. So I'll kind of skip over this slide. So here's just an example of one of my patients. You can see that this was kind of more of the mid-substance rupture. I think Dr. Goytz kind of fairly nicely showed the data for UCL tears. You basically had 90 percent evulsion rate from the proximal phalanx. But in this case, it was kind of more of acute on chronic type injuries. So it was a fairly large gap. And so then I did do a suture augmentation. You see I took a palmaris autograft and then did the suture augmentation with 2 anchors. And I thought that was a fairly nice kind of minimally invasive technique. What else can you do? I found this article really interesting out of Indiana Hand Center. They actually took the adductor pollicis tendon. You can see it's attached right here to the proximal phalanx base. And then they swing it around and then anchor that down to the metacarpal head which I thought was very interesting overall. They kind of show some of the data that it's about the same length and width as a UCL tendon. And then their results, these patients seem to do pretty well also. So maybe this is a better option than taking a palmaris or something of our other autograft or allograft and using local tissue instead. Switch gears, that was all about thumb ulnar collateral ligament which I think is probably most of what all of us see. Again, as Dr. Goit said, these are a little trickier about where they rupture. We think that in general on the UCL, it's almost always off the proximal phalanx. But on the radial side, it's a little bit more mixed. You can get proximal tears. That's still the majority coming off the metacarpal head. You can also get distal tears as well. And then there's some mid-substance ruptures. I put this picture kind of showing the anatomy like his study did from Michelle Carlson's group. But it's kind of interesting. The insertion site in the metacarpal is a little more dorsal than you think. That was for the thumb. Radial collateral ligament injuries of the finger. I think the index and the small finger are the two most common. We'd like to place this in three different grades. Grade 1 would be the tender but no instability. Grade 2, they have some laxity but a good end point. And then grade 3 has no end point. You can see the algorithm. If it's a grade 1, like Dr. Goit's potentially had, body taping or splinting. If it's a grade 2, you can try a cast and then a splint. And for the grade 3s, in general, the recommendation is repair or reconstruction. It's kind of funny. I pulled this right out of a journal and you can see like the R's somehow became quotation marks. Stability was restored in all of these patients. 25 subacute or chronic radial collateral ligament injuries. But look at the DASH score. You know, a DASH of 23, anything below about 16 or 12 is considered normal. So even though these patients had repairs of their radial collateral ligaments, they actually didn't get back to normal afterwards. And the average arc of motion was only about 75 degrees. So yes, we made people stable, but they still had some disability even after repair. Here's another study looking at 10 patients with 12 ligaments. This was almost kind of a stenor lesion of the collateral ligament on the finger. And on average, this group did a little bit better, maybe because they were more acute injuries. This is something I find really fascinating. Everyone, like patient-wise, you talk to patients, everybody just wants an MRI. Oh, can I get an MRI? They think that's going to solve all their problems in some ways. But this study kind of showed that MRI was only accurate in 36% of patients for finger collateral ligament injuries. I think it's probably a little bit better for thumb collateral, but for finger collaterals, really rely on your physical exam. And I know Dr. Goit's kind of led off with that. Our exam is still the key. You know, we treat patients, not imaging. So in this study, and I think it's a little bit tricky because they had seven partial tears. I'm not even sure what that means sometimes. But MRI, if you have a patient with instability on your exam, but a normal MRI, I would tell you to still think about at least exploring it and potentially repairing or reconstructing. So on the left side, here was one showing a complete tear, which I think we'd all say it was pretty obvious. There's no connection. Here's the normal ring finger. Here's the injured small finger. And then here's one that was read as normal, but ended up. Yeah, I mean, I would base a lot of it on their age. I just turned 40, so now I'm considered old, I guess. But if I had a 40-year-old that had some arthritis or ligament tear, I would probably just recommend fusion in that case, depending on their occupation. If I've got a younger patient, an 18 or 20-year-old, I probably would just try the repair or reconstruction, and then just see how things go over time. Would you think differently? Yeah, I think it does help because if you have a complete tear, I think that for most people the answer is probably a surgery. I think the harder part is the grade twos. You know when someone has a very clear exam, and you can pull them 90 degrees, I think that's kind of an easy decision for repair. I think the harder part is when they have a good end point, but they have pain. And so I usually would not get an MRI right off the bat. I would probably just immobilize those people for about six weeks, and then see how they feel. And then if they are still having pain, I would get the MRI after that. And for me, it comes down to partial versus complete. If I've treated someone without surgery for six weeks, they're still having symptoms, and they have a complete tear, I'm probably going to offer them a repair. Whereas if it comes back partial tear or normal, then I would be much more likely just to get them into therapy or maybe inject their joint. While we're waiting for this, I can just tell you that one of the issues that we all have is making the diagnosis and then establishing when we want to operate. And I think the timing of things in the physical exam, you know, is really everything. And often people, to make it even more complicated, they actually didn't have a normal thumb completely, on the radiocollateral side, but they were okay and then they had an injury and that sort of pushed the sleeping bear in the rear end and now they have symptoms that are more substantial. And so sometimes I always, you know, go into the arena telling them I might repair and I might reconstruct, particularly volleyball players and wrestlers have radiocollateral ligament injuries and then basketball and football. Most people, most sports have onocollateral ligament injuries. But I've seen so many wrestlers where they were fine and then they get injured and I'm ready to do a repair and I go in there and I find out that the ligament is not terrific. And so one of the things that you want to do is be able to do a ligament reconstruction. And that is what we're going to talk about here. And I do a method that hopefully is going to show up here that is actually very easy and it takes no more time to do a collateral ligament reconstruction and I like it so much that when I go in there and I see a ligament that's like, so it's not bad, but it's not great and perhaps it's an athlete and they don't always tell you the whole story. I have a very low threshold in general to do the ligament reconstruction. So there are a number of different options. We're not going to go through every single one and in general the ligament reconstruction with the tendon graft is the sort of standard. And it was originally described by Dr. Glickel and he makes the same drill holes that I do where basically you have two holes on the proximal aspect of the proximal phalanx and one hole at the sort of point of isometry in the metacarpal head. And what he does, however, or did I should say, because I don't think he necessarily does this now, is he would take the tendons and tie the tendons over the skin so you would have that button there. And sometimes he would then just tie the suture, but normally it was actually the tendon itself. And so that is one way to do it and then essentially this technique that we're going to talk about is an evolution of that thought. There are a number of different ways to go, but I would suggest if you're going to reconstruct and you can make bone bridges and bone bridges are easy and they're inexpensive, which of course companies aren't happy about, why do that than use a suture anchor, in this case two suture anchors, to take the palmaris and then insert it with two suture anchors. So many roads lead to Rome and what we're going to talk about here is a method that is pretty straightforward. And so it starts with essentially a drawing for the fellows and what this shows is essentially the holes that you're going to create. And there are two holes in the proximal aspect of the proximal phalanx, as you see there, in general. And it's easier said than done. In general you do want to be on the, let's see if my cursor shows up, does it, yep, good. So if this is the center line, then your first one should be more or less at the center line of the intramedullary axis and then the next one is on the bolar aspect. That way you reconstruct both the proper and the accessory components. However, there are plenty of patients whose proximal phalanx is not enormous and so if with that first more dorsal, if you will, drill hole, you're a little bit on the dorsal side because you never want to break your bone bridge, then that's quite okay too. And so in general these are the holes and then this is the point of isometry at the metacarpal head. And so this hole is a little bit bigger and then you drill a hole here and you drill a hole there. I will say that you make these holes, you don't have to connect them in general. I will take a little curette, normally a curved one, and I'll try to like just open up that area a little better. But also you can take the drill from here and drill, you can't quite go all the way through but you can create sort of an opening underneath the bone and that makes the graft passage easier. Also here, the big risk when you're trying to connect the dots with your drill is that you would drill through your bone bridge and I've done that and then what I had to do is create another hole here so don't be me and have that problem. Basically if you start drilling here and you push the drill towards the far side, depending on what you're reconstructing, then you'll have a nice bone bridge. And so pretty much that's the drill holes. Now, your incision is, and we all know this, I center it over the metacarpophalangeal joint and I find the, create nice thick skin flaps, find the sensory nerves, and then I always cut, I mean, you know, because this is really the abductor aponeurosis or the adductor aponeurosis depending on which side you're repairing. But I, for the ulnar side, this is going to be an ulnar collateral ligament reconstruction I think. Yeah, it is. I cut the adductor aponeurosis just off of the extensor mechanism but what I like to do is at the very distal end, I leave it attached. So that way I can sort of close the zipper at the end of the case. And so what you see here is that the ligament was injured pretty much on the ulnar side where it's going to be injured, which is distally, and it's intact proximally and you inspect it and you say, eh, is this a ligament that you can repair or is this a ligament where perhaps it's been a couple of months. And sometimes if you have a stenor lesion and it's rolled up on itself, even after a week or two, the ligament doesn't want to uncoil and then reattach. And so if you're going to have that ligament that almost makes it, because they're all going to almost make it, but then it doesn't really have good overlap onto the bone, just reconstruct. Because that way you sleep better, I sleep better at night. It's all from my sleep. My whole practice is that way. And because I've, fortunately, as Dr. Goitz will tell you, I have stiff patients. Generally, I don't have unstable patients. But if you have instability as your problem, then having a little bit more stiffness downstream is a better thing than to have the same problem again. That's just my opinion. So you'll harvest the palmaris longus if they have one. Sometimes when they don't, I harvest the contralateral palmaris longus, but I always check. And lately, to be honest, just the other day, I took a quarter, like 25% of the flexor carpi radialis in somebody who didn't have palmaris longuses on either side. So that's what I'll do. I don't think there's any downside to doing that. I make longitudinal incisions, and I always like to find the palmaris longus, approximately, and make sure that when I'm pulling it, I see muscle. It's just, again, another safety technique. And we have fellows, and it's just nice to know that you're cutting something that is most certainly going to be the palmaris longus and nothing else. So here you see the drill holes being made. In general, it's actually super easy to do. You could theoretically use a cannulated drill bit, but the small, it's not needed. But what you do want to do is start your holes, particularly if you're going to do this sort of, maybe you haven't done 65 of these, I would start it with a K-wire, and then the K-wire doesn't wander, because the drill, if it does wander, and then it engages, and now your hole is in a spot where you didn't love it. If you just start with a K-wire, then you kind of create an opening where then it's easy to make the drill hole where you would like it. So this is the point of isometry at the distal aspect of the metacarpal, as you can see here. And I don't know if I have a picture of the drilling of the proximal phalanx, but I always put a homin on the undersurface, because you really want to, if you're going to show yourself things, particularly the hole here, you want a homin underneath there, because you want to get as volar as possible to create the trajectory for the, essentially the accessory portion of your collateral ligament reconstruction. So here it is, and one of the questions that was just asked is, how do I pass the graft? Is that difficult? It's actually not difficult, and I wish I had a picture of this. What I do is I take a 4-0 nylon, and I grab it with my suture holder where it's sharp, so at the needle. And then I take it backwards, and I show myself the loop, and the fellow or the resident, which we have a bunch today, pulls the loop, passes the graft, and just the tip, and then pulls it across, and then you have the other side. Make sure you grab the other and put a hemostat, because what's happened is I've then pulled it through, so you don't want to do that. And then, so you start with these two limbs, and then they both have to go through the point of isometry, and so you would take your 4-0 nylon, give yourself the loop here, pull it through. Take the 4-0 nylon, give yourself the loop there, pull it through. And then when you are pulling up on those ligaments on the palmaris longus, and I think we have it here. So this is you with the two hemostats applying tension to the grafts, and when you tension the graft, you can hear it saying, thank you. And you've restored stability. It's rock solid. There's no question at all. And then you do one pulvotaph weave, and you end up normally having extra tendon, and so what you do is you just take this, and you throw it down. And it doesn't need to go there, because you have enough, but you just pretty much put it where ligament should be on the inside of the metacarpophalangeal joint. And then you close the capsule, and the capsule, which has the ligament that you didn't love to begin with, that just augments the repair, and then you close the aponeurosis. And so here you have the aponeurosis closed, and you make sure that I always do a little freer action underneath, or a hemostat, or whatever, something to make sure that all the sensory nerves are happy campers by the time you've put in all your stitches. I use all absorbable suture, which is a segue into what we're going to talk about next. Interesting. So you can do the same thing on the radial side. In fact, you can do the same thing for all fingers. The only time I do it for the metacarpophalangeal joints of the index, long, ring, or small is if they have failed nonoperative treatment, and most people will not fail nonoperative treatment. But when you do fail, then you need a reconstruction, because you don't need a repair of the collateral ligaments of the fingers, because if it could have healed, the ligaments would have been fine and they would have healed, but it's hard to repair Aunt Millie's tissue. And so then I just do a ligament reconstruction, and you can do these really quickly. I mean, this doesn't take me any bit longer than it's like, bing, bing, bing, drill the holes, pass it through, and done. And so that's how it looks on the radial side, essentially the same principle. And this is the wrestler, volleyball player, and then the other guy is sort of the more chronic basketball or football injury. So what do we see here? We see a ligament reconstruction or ligament repair that's augmented, and there is a concern that the nonabsorbable augmentation would cause to something called stress shielding. And so it is absolutely true that the internal brace adds rigidity to the ligament repair reconstruction, which is why in those cadaver studies of which you see so many, they always do better, and with cyclic loading, yes. But you're not, this is a bad evaluation because we know that if you add something versus not having something, you're going to do better in the group that you added something to. But what really matters is how do they do longer term, and are you hurting the ligament by always taking the forces away from the ligament? The ligament wants to see forces. That's how you get stronger. When you go to the gym and you work out, you're essentially ripping things so that you then heal better so that you're stronger. But if you constantly are shielding the structure that you're trying to make better, you're actually hurting people. But we don't want to talk about that because it's not good for business. So it's marketed to decrease the time required for patients to resume their desired activities, including sports, and particularly in the elbow, I'm seeing a lot of these being put in. And it has to be awesome if Drew Brees used it, and it's, I think, rather controversial. And so the non-absorbable suture, I think, would be a much better approach simply because the, I'm sorry, the absorbable suture would be a much better approach simply because it goes away. And if something, it's like the concrete forms aren't needed when the concrete is dry. If you can get rid of them, if they can dissolve, then that might be of value here. And so as we see, it's a little bit of a double-edged sword. Yes, you reduce the stress and the load seen by the ligament during the early phases, and that's absolutely true, but it ultimately can impact the final strength and composition of the reconstructed ligament. And so here you see, essentially, the value of having augmentation in the early healing because as you're healing in those early stages, it's nice to have something to take the forces away because normally you're trying to create a healing environment that doesn't see forces by immobilizing them. And so here, potentially, you could move them because the construct's not seeing forces because what you've added is making it so strong. That's true. However, over time, the stress shielding then makes that ligament compromised. And so we all know Wolff's Law, essentially the pedestal sign when we look at a total hip replacement, et cetera. That's stress shielding, the effects in total elbow arthroplasty. For instance, when you have ghosting of the condyles over nine years, even though everything went well, you have no bone. So that's Wolff's Law. The equivalent of Wolff's Law, which is much less talked about, is Davis's Law. Davis's Law is the same thing. It's basically, if you don't see forces, you're going to pay a price. And it's not as if this hasn't been shown in the literature. It absolutely has been shown. Tom Amato looked at the mechanical properties in patellar ligaments. Every ligament that doesn't see force because it's stress shielded does worse over time. And there's an article that I actually am a co-author in, written also with the late Dr. Freddy Fu, where we just looked at the stress shielding of ligaments. And I think the thumb probably doesn't matter, whether you stress shield it or not. Because I think that the forces that it sees are not as enormous. But in the elbow, I think it really does matter. And that's a huge, the market of the kid who wants to keep playing and then doesn't need a ligament reconstruction, and then the subsequent time off, away from pitching, versus a smaller procedure that just repairs the ligament and gets you back on the mound. I mean, the value is just enormous from a selling perspective, from a marketing perspective, if you can get that kid back to pitching. And the problem is, I think, that it's actually longer term going to give people problems. And it's been in the ACL, for instance, it was done quite a bit, things like that. And it's all been taken off the market because it causes problems. And so I think this is a dangerous, the non-absorbable suture augmentation. tunnels yeah great question sort of in general people are you know quite a bit different in size but an eighth of an inch is you want to sort of you can always make it bigger and so start smaller ish and again pre-drill with the K wire eventually if you do it a bunch on the metacarpal you'll just boom boom not need that because those two holes on the dorsal aspect of the metacarpal don't really matter so much where you make them there's certainly a lot of latitude here you can have them be there and there so I don't think this has to be precise this area does have to be rather precise because it's the point of isometry sometimes that bone is super hard and so I'll take a little ranger's and and even eat away just a little chunk in this area so that the drill doesn't It's time for a couple of cases. What I love about Thumbs is both these cases came in literally this last week. I probably wouldn't stress this one. I think you're just gonna displace that fragment further. All right, so I'm gonna argue differently. Why do you hate this kid? I would just... He came and saw me the next day. He's like, please don't hurt my thumb. Well, if it's in season and he or she could play in a splinter cast, I would say there's almost no downside to let them play for six weeks in the cast and then reevaluate it. I think in this age group at 16, there's actually a reasonable chance they're going to bridge some bone across that. And if the ligament is attached to it, it may be stable enough that they are okay. If they just can't tolerate the cast or don't want to try to play in a cast, I mean, it's hard if you're a basketball player, how do you shoot with a cast on? In that scenario, I would probably at least offer them excising that fragment and anchor repair. I think your oblique view is really nice, because I think sometimes when I see these, the avulsion fragment is actually relatively dorsal. And we know from all of our anatomy slides, it inserts very vulnerable. I mean, this one on the oblique looks like this is like exactly the insertion point of the UCL. Whereas I have seen some where it's more of like a dorsal fleck off the capsule, and in those ones, I think they're stable. are rather unstable but in this guy I think the proximity of the fracture fragments lets me believe that this would be stable. Once healed and I think it would heal and I would put him in a cast. One thing I don't do much of is put people in splints that are removable when you're really hoping that something heals because you just you know it falls off at night or something happens and then and then they end up not doing well. So a cast is incredibly protective particularly on the radial side. A lot of these injuries in the early going can be treated with immobilization. The owner side is less forgiving that way and so I operate on these more and I think it has a lot to do with the position that they play in. So if this is a lineman he'll be fine in a cast and it's a different story obviously if you're the quarterback then then you really are out and if you're gonna be out anyway and this is the conversation that is frequently had if you're gonna be out regardless then maybe fixing it and making sure that because what happens if it heals but with with a little bit of a gap now you do have the ligament under less tension than it was initially and if this is his throwing hand and he's you know the sophomore quarterback maybe restoring anatomy is actually the way to go. So in general I think I feel like I am rather aggressive fixing these on the owner side less so on the radial side but this guy here probably I would cast unless he's as unstable as you suggested and then that's a different story and then I would fix. It's pretty volar, this ligament attachment, as we've been talking about. How do you like to repair them if there is a bony fragment you think is fixable? So I put a poll out there for this question, how would you treat it? If you want to answer, we can talk about what everyone says. To answer your question, I think if it's a sizable fragment, and this one is a relatively small amount of the joint. You'll see some that are a quarter of the joint line, some of a third, like a really big piece. I think some of those, it is possible to get a small screw, like a 1-8 or 2-0 mini frag screw, and I've done that a few times. I think I've often treated them with small K wires, like one or two small 3-5 K wires, leave them sticking out of the skin. I used a tiny K-wire and I also put the suture in there and it's almost like a tension band construct around the pin because it's going to be a tiny piece but you can see it perfectly and then you can catch it nicely with the K-wire but then generally that's not necessarily enough stability but then if you augment that healing environment with like one or two three-ovicle sutures now it's pretty stable and and then at four So we got 22 votes, 23, 43% said non-op, 48% said early surgery, and then I gave the option of have them play the season and do it at the end of the season. And 8% said that. So that was for this particular case. Slightly more, well now it's even, more people are voting. It's exactly even on non-op versus early surgery. So, this one also came in last week, and now this one I have already treated, so I can give you a follow-up, but this is an unusual one. 22-year-old. Yeah. My first sense would be a fusion, an MCP fusion. I think your picture showing the lack of creases is problematic because if I'm now taking away MCP flexion and then she didn't have any good IP flexion, then that makes it a less functional thumb. And you talk about her being a writer, you know, is she going to be able to hold the pen or pencil as easy with that? I still think, at least in my hands, fusion be more reliable. I mean, Dr. Kaufman is a very talented surgeon. He makes those drill holes look really easy. But having tried to do them myself, it's not as easy as he makes it look. So, for me, the fusion would be more reliable and I'd probably do that. Rob, how about you? I mean, I would reconstruct. I mean, not try to fuse because the IP motion is. Are you okay? Should I hold you back? You guys aren't gonna fight, are you? Sharing, it's good. Bob, five people voted up on that. Any tips to examine the pain intolerant patient? So that young guy who you hate and you were examining his thumb with an acute UCL avulsion fracture. Any tips on someone that just will not tolerate in an office exam? Because it sounds like that's an important part of your algorithm. You know, someone comes in, you start pulling on them and they really guard. Do you do a digital block in those people? Do you just wait on imaging? Do you let them calm down for a few weeks and bring them back? Yeah, that's what, I mean, I establish. My experience is the stenor lesions actually hurt rather little and they have no stability at all. So it's almost a circus trick, you can just say, oh, look at that and it's dramatic how unstable they are given how relatively little pain that causes. But the tear that's not a stenor lesion, in other words, the adductor aponeurosis when it came back didn't push it into a different zip code, that hurts much more because it's trying to heal. It's more or less where it needs to be. And so that is the stress ligament that causes substantial discomfort. And I don't even get an MRI, if I can take the thumb and put it in a different zip code and they don't have that much pain and you can normally feel a little bit of fullness, that's a stenor lesion. You don't need to MRI. I actually don't get that many MRIs for this because it's not needed. But I mean, I don't mind it, it's just one extra cost that I think can be avoided most of the time. I mean, this is a physical exam finding. And the little lines that you draw, particularly radial collateral ligaments because these people often have lived with it, their thumb will be deviated and it kind of starts looking like a finger because it's that deviated. But the radial collateral ligament you can live with when it's dysfunctional, the owner collateral you can't because you can't grip anything because it's the post. But the radial collateral ligament then deviates, deviates, deviates and then when you draw a line and you compare it to their uninjured side and there's, you know, 15, 20 degrees of laxity and then the other side, it's 60 degrees. You don't need an MRI. They see that. They're like, oh, wow. Yeah, I didn't realize that. But that looks bad and in the chronic setting or even subacute setting, that's just not going to do well with the mobilization alone. John, do you ever inject to do the exam, the lidocaine injection? No. I mean, if they're pain intolerant, they're not going to tolerate a digital nerve block either. I mean, your case though looked a little bit subacute because there wasn't a lot of ecchymosis. There wasn't too much swelling. Do you think that person had it calmed down for a week or two before you saw them? Because sometimes people come in and they're all ecchymotic and it's super swollen. I think that's a tough exam. So the football player? Yeah. Yeah, I think he was tough and he was able to let me examine him pretty well. Any other questions that were popping up on there? Yeah, someone had asked if you have an intact accessory collateral ligament, do you think that helps the proper collateral ligaments heal non-operatively or do you think it's sometimes still they fail and go into surgery? My opinion about that one is that's one that you can. And Rob, maybe for you, someone asked, because you are good at those bone tunnels, have you ever had someone that you've done a UCO reconstruction, a younger kind of athlete, they've gone back to play and then actually fractured through the bone tunnels? And does that change your algorithm sometimes? If you know you've got a pit football running back, you're going to do the reconstruction, maybe he's going to go back next year, are you worried about those bone tunnels? Yes and no. No, I have not actually had a fracture through one of those bone tunnels yet. However, there is a person who had a fracture years later from another injury, and it sort of extended into the area where the bone tunnels would have been, and it seemed like it was quite late. It didn't seem necessarily like that was a stress riser that I had caused, although theoretically it happened. This was more of a softball hits it and explodes it. So no, I haven't, but that is always a concern. And one last thing, stiffness. I think for the most part these joints aren't that much a stiffness creator, except if you extend them fully postoperatively. So what I do, and I try to really make a point of that, I try to flex them in about 20, 30 degrees because it's a cam on the side view, and with the bigger R, the bigger radius towards flexion, and in full extension sometimes if they heal there and they have that type of healing response that really creates a lot of stiffness or just creates an amazing amount of scar, they sometimes don't overcome that initial hurdle. But if you're there already at like 30 to 40 degrees, they have no problems regaining their flexion over time, and I'm not saying they get it right away. So that's one thing that I've, because I've had a couple of people, and it's generally females, it's been so far only females, that I immobilized in extension earlier in my practice, and they didn't flex, and in one or two instances I had to reoperate, like six months later, to give them motion, and it just killed me because you're subjecting them to another surgery for that reason. But ever since then I've been flexing my MCPs in about 20, 30 degrees, and that's really worked. So I'm happy with my motion, and I don't really send people to therapy that much either. I just have them move it. But, yeah, maybe I should. Well, thank you guys for the panel, and I hope you all have a great day.

ligament issues

thumb

fingers

ulnar collateral ligament

anatomy

treatment options

immobilization

reconstruction

suture anchors

stability