Well, good afternoon, everybody. In the interest of staying on time, we'll go ahead and get started. My name's Glenn Gaston. I'm in Charlotte, North Carolina, North Carolina. Mike Hayden is supposed to be running this, but he couldn't get here from England, so he asked if I'd do the, so. Unfortunately, you'll miss his wonderful accent until it's at least his talk, but you'll miss it for the intros, so. Megan Contemica's gonna start us off with acute thumb and P-joint ligament injuries. All right, perfect. Hi everyone. My name is Megan Konamika. I'm at University of Chicago. Thank you for being here and thank you for having me. So my topic is acute thumb MCP joint injuries and the ligaments around it. So I have no disclosures. And this is a book that I read to my kids at night and I always am humbled by the last page and the last line is always, why make big problems out of little problems? And I feel like this is appropriate. I'm not going to make this more complicated than it needs to be. So the basic anatomy of the MCP joint of the thumb is it's not really a hinged joint. There is a component of the flexion extension, but there's also rotational component and an abduction and adduction. So this is really important that the static and dynamic restraints around the joint is allowing it to move in an ability to make flexion, pinch, grip, etc. So that's why collateral ligaments, a static restraint, is really devastating when they happen. Basic things of anatomy that you really need to know is that the origin on both sides of the two parts of the collateral ligament is the same. It's an insertion that's unique. The first is the proper and that's going to be inserting on the proximal phalanx where the accessory is going to be on the buller plate. Due to this insertion, its stability changes. So for proper, it's going to be inflection and accessory is going to cause extension stability. And again, this stability is for not only a lateral stability, but the dorsal stability as well. And then the MCP range of motion is really important to understand is that it's very, very variable. The numbers are all over the place. So there's no point of memorizing range of motion, just compare it to the contralateral side. And then talking about the actual stability of the ulnar and radial collateral, they're not the same even though the anatomy looks the same. It's because of the dynamic stabilizers that are around the thumb. The majority of these injuries are the ulnar side. And the thing to really remember is that the adductor aponeurosis is buller to the joint. And that's why you get those stentor lesions. You do not get stentor lesions on the radial side or there are some case reports of it, but it's very rare. And that's because the adductor aponeurosis is actually dorsal. And so it still stabilizes that collateral ligament, whereas the adductor makes it more vulnerable. The other thing to remember is that the dynamic stabilizers on the radial side are weaker. So this becomes important when we start talking about the X-ray configurations. So ulnar collateral ligaments, these are, again, more common. And it's really from an abducted position with a valgus force. And it'll cause it to have a rupture on the proximal phalanx. And this is where those stentor lesions can occur, where the distal component of the ligament will flap up dorsally and proximal to that adductor aponeurosis and get stuck there. So it's not able to be flush with the proximal phalanx, making them a surgical indication. Again, these are a spectrum of injury. So don't just expect it to just be a collateral ligament. This can be a tendinous injury, and it can be also a dorsal capsule injury. So there's more components to it. So it's to remember this for your surgical indications. Radial side, less common. Again, this will be an adducted with a varus force that'll cause on the contralateral side now is going to be on the metacarpal. So that's important to remember. It's on the proximal phalanx for the ulnar side. And it is on the metacarpal head on the radial side. And that's a huge generic term, because you will see that there are some distal and mid-substance tears. So that's, you know, I don't want you to hang your hat on that. You definitely need to examine the collateral ligament when you're fixing it. But that's just a generalization to kind of remember. And again, this also has a spectrum of injury. On clinical exam, we could spend hours talking about, look at, is there ecchymosis? Is there instability, et cetera? Really what you want to know, is the ligament torn? And is it a complete tore? Because that's where you're going to decide, is this going to be a nonoperative treatment or is this going to be an operative treatment? And the way that, besides obviously, you know, looking, touching, is going to be your stress exam. And this can be varus and valgus. So it's the same for the radial and collateral side. Obviously that becomes the difference is your varus and valgus stress. So you hold the metacarpal stable. And then you'll do your stressing of the proximal phalanx, either an abduction or adduction depending on which collateral you are stressing. You'll do it first in extension. And again, this is because your accessory inserts onto the vular plate versus 30 degrees of flexion. And that will be testing your proper. Once you've tested this, you can always use the contralateral side as your control. And what makes it positive is this 35 degrees of laxity or 15 degrees of laxity when compared to the contralateral side. I usually check for endpoints. That's really important. That helps me in deciding if this is a partial versus complete tear. And this again can be done under fluoro exam. Imaging, if you get x-rays of the thumb, you can see with the UCL that it looks normal. You won't see any type of subluxation in acute settings. Whereas the RCL, you can see ulnar translation and palmar abduction. Now with that palmar sag or palmar's translation, that can be normal. So it's not pathognomonic, meaning if you see that sag, it means for sure there's some type of tear. Look for that on the PA, that ulnar translation. That's AB normal. And then also another thing that you can look at x-rays is for your avulsion fractures. They're non-displaced. This generally can be an incomplete fracture displaced and rotated. That becomes more of a surgical indication. Advanced imaging, I do not get MRIs. If you have a fluoro scan in the clinic, stress exam's totally reasonable. There's been enough studies that show there's a high correlation between physical exam and operative findings. So you do not need an MRI. I've pushed with a partial tear that has some type of equivalent exam where I'm kind of waxing and waning. That would be for me an indication to get an MRI. And if you're early in your practice, you know, when I first started until I felt like I really trusted my exam, I started with MRIs. And since then I've stopped using them. Non-operative options, these are going to be your patients that have an incomplete tear. So if you wanted to do, for those who need the classification, that's a grade 1 or grade 2 tears, and they're being treated with immobilization. Or if there is a avulsion fracture, it's a non-displaced avulsion fracture, and that's when you can think about non-operative treatment. Thumbs spike up for four to six weeks. And I usually do it hand-based. A lot of times people will include the wrist. I don't think it's necessary. I think you're going to end up sending patients to therapy if you do too much immobilization. And then after that, I generally don't send them to therapy. But if you do, sometimes they need it for strengthening afterwards. So let's talk a little bit about operative options. I always do an S-shaped incision, the same for radial or ulnar collateral ligaments. I base it over the MCP joint, and then I make sure that I'm dorsal, proximal at the metacarpal, and then volar along the proximal phalanx. And this has to do with the orientation of your collateral ligament. The first thing I'll do is once I get through that incision, I will dissect and be very, very careful of the sensory branches. The sensory branches here love, love to get sensitive. So I actually don't dissect them out, which you kind of see in this picture that I stole from the AO. Do not do this. Do not put any type of tension onto these nerves. I see the fat, and I just take it as a whole fat bundle and bring it up dorsally so it's out of the way. It's in its nice little bed of soft tissue, and you give it a chance of it not getting any type of hyperesthesias. And then I get to the extensor hood, and I'll make a longitudinal incision with a little bit of cuff of tissue along the extensor tendon. And then I will bring that apereinosis down palmarly. It's really important that you start with that incision dorsally, because that way you can peel off the apereinosis from the capsule, especially when you get to these injuries. Sometimes it can start getting scarred in, and you don't know your layer. And then all of a sudden, you're actually just taking out that collateral ligament. So start dorsal, and then you can peel it off, and you know your anatomy, and you can get a really good dissection. And then once you have taken that apereinosis down, you should be able to find the collateral ligament. I usually will isolate it out, getting the scar tissue off, and then I will make sure that there's not a secondary tear. I've been hosed once or twice where it's been brought off of the bone, and it's also a mid-substance tear. It's very rare, but you're there. It takes two more seconds. So get the whole collateral ligament in whole, and make a decision from there. And then for fixation, there's a couple of options. I generally just do a suture anchor, as long as it's an avulsion off of the bone. If it's a mid-substance, I'll do a non-absorbable suture, and then if it's an avulsion fracture, this is when I'll do my K-wire fixation with a 4-5 K-wire after doing an open reduction, cleaning out that fracture site, and then using a dental pick to keep it in a good position, and then fire that K-wire across. You can also use the K-wire, put it into that fracture fragment piece, and use it as a joystick to reduce it, and then shoot the K-wire across as well. And then after that, I fix the aponeurosis back to the extensor tendon with that little cuff of tissue I left, and that's when I usually will test my repair to make sure that it's stable, because sometimes you need that dynamic stability to augment your repair. Sometimes people talk about doing a 4-5 K-wire across the joint. I don't do that. The biggest indication is for RCL repairs, like we talked about before. When you have an RCL tear, the proximal phalanx likes to go bully, and then also with ulnar translation, so sometimes people feel like they need to get it up, reduce it first, and then fix their RCL, so that they don't have the RCL heal in some type of length, and then it becomes loose later. This is just showing a picture of how to do those displaceable bulging fractures. I leave those K-wires out of the skin, and I'll remove those K-wires approximately four to six weeks, depending on their exam. And then rules of four for post-operative care. For those who've had surgery know, as being a patient, it is really hard to follow your post-operative instructions. So keep it as simple as possible, because everyone who has these really hard, complex therapy protocols, they don't get followed. So I just tell everyone, it's the rules of four. Four weeks of a splint, four weeks of range of motion, four weeks of strengthening, and then they're done. Complications. This should not be done in the face of arthritis, they're going to continue to have issues. Recurrent instability, at that point, that's when you think about reconstruction and fusion, which will be in future talks. And then, what we talked about before, with the hyper seizures, with the radiosensory branch, and again, joint stiffness. I usually say it's better to be stiff and stable than loose and loose. And that's it. Thank you guys so much for your time. You don't need to hear Mike Hayden's northern English accent. It's not that well refined. No, I'm joking. I'm joking. It's a shame that they're not here. Okay, so Megan gave a wonderful overview on acute ulnar collateral ligament and radial collateral ligament injuries of the thumb. I just wanted to sort of give you what I do in 2021. My disclosures are on the website. So a couple of cases to sort of kick things off. So this is an 18-year-old pitcher who comes in with a chronic radial collateral ligament injury. And as you heard from Megan, these injuries on the radial side tend to occur proximally because the ligament is wider distally than proximally, and that's the converse for the ulnar side. So do you repair or do you reconstruct? So most of us see more ulnar collateral ligament injuries rather than radial, so we'll start on the ulnar side and then we'll flip to the radial side because there are some sort of nuances with them. And so essentially in terms of treating a chronic ulnar collateral ligament, I've sort of listed the gamut of different options available, and I would love to give you sort of prospective randomized study information. As you'll see from the literature, many of them are retrospective level 4 or 5 studies with pretty good outcomes, so it's hard to sort of tease what to do, and that's why I sort of wanted to share what I do in 2021. Now, can you primarily repair a chronic ulnar collateral ligament? This is a study that we did on patients 15 years after a primary repair, and chronic was described at greater than 6 weeks. And the take-home point of this study was if you can repair them, functionally they actually did okay, but there was a high rate of radiographic arthritis, so they didn't go on to subjective poor outcomes, but radiographically they actually didn't do that great, but functionally it was okay. So knowing that, what would you do with this patient? So comes in with a 6-month history of ulnar-sided wrist pain after skiing, was point tender of the ulnar collateral ligament with no end point. An end point is a very subjective thing. I think it depends on how hard you push. Some people put lidocaine into the joint to get rid of the pain and then test it, so I think it's very subjective. And so we did get an MRI. I personally find it hard to feel for stenolesions, how the textbook tells you what a stenolesion is. Sometimes I think in some patients, unless it's really balled up or there's scar there, I find it actually hard to do. So you can get ultrasound. There's good data showing ultrasound for ulnar collateral ligaments, so we got an MRI. Megan showed how to examine the thumb in full extension and then in 30 degrees of flexion because you're tightening up different things. So in 30 degrees of flexion, what are you tightening up? You're tightening up the dorsal capsule and the true ulnar collateral ligament, and in full extension, it's the volar plate and the accessory ulnar collateral ligament. So my approach is I think it doesn't really matter. I tend to make this sort of V. The key thing is that the point of the V needs to be as volar as you can so you can tease out and get as volar as you can on the proximal phalanx because, remember, on the ulnar side, it tends to come off the proximal phalanx. And also you can get to the volar plate, so you can actually repair the collateral ligament into the volar plate, which is the anatomy, and you can retract the digital nerve out of harm's way. And so here I think the critical thing when I'm doing this is looking at the articular cartilage, and it's important going into this and ascertaining from your patients, especially a chronic injury, because even if there's some degenerative changes, the textbook answer is to fuse them. But if they haven't had many much problems, it's a hard cell. So I'll note that in my operative note, and the key thing here is to rotate the proximal phalanx to get as volar as you can so you can pop your anchor in. And so the question that I ask myself is, can I get that ulnar collateral ligament down to bone? And if I can, I'll repair it. And I'll show you a high-level athlete that that was a question in consideration. And so for me, here I could. So I put a suture in the ligament, and then I drill away from the joint, so cheat as volar as you can, drilling away from the joint. And then here you can see you're drawing that sort of suture into the bone tunnel. And then remember I said to go as volar as you can, so now I can actually repair the collateral ligament to the volar plate. That was one of the sort of teachings of Dick Berger that stuck with me. And then you repair the dorsal capsule. And so you can see here how volar those anchors are. So that's a sort of repairing. But sometimes you get in there and you can't repair it, and you have to do a stabilization using tendon grafts. And there's a myriad of different ways that you can do it. I'm not going to go into those. I'll just tell you what I sort of do. You know, you can drill holes and sort of make it like dowel and like a V. I worry about the bone bridge on that, and so it's not something that I tend to do. So this is a patient that comes in with a chronic injury as a stenolesion. And if you've never seen a stenolesion, this is what it classically looks like. So you can see that the actual collateral ligament is what the arrow is pointing at. And because it's such a violent deviation, the sort of other area, this black area here, is the capsule. Now, this is a different patient, but this is actually what a stenolesion looks like in the operating room. So I wanted to share this with you because invariably you just see MRIs. So there I'm deviating it, and you can see the ligament. I'm going to pick it up with the pickups in a minute. It's actually outside. So there's the ligament. And so you can see how that sort of adductor aponeurosis is a mechanical block, so now if I put the ligament underneath it, then that would heal. So that's what a steno lesion actually looks like in real life. So in this patient, I opened up the patient, and you can see that there is really no ligament. There's a proximal ligament over here, but there's no way that this is gonna reach down to there. So in my mind, this was a reconstruction. So remember the picture that Megan showed on the origin is more dorsal in the metacarpal head. The insertion is more volus, so you put your K wires in that fashion, and then you take, for this case, was a palmaris graft. It can't be more than two to 2.5 millimeters wide. You wanna put a big piece of collagen in this, you try and get as big a graft as you can. It won't fit the bone tunnel, so it's two to 2.5 millimeters maximum. And so the drill holes have been made, and then what I do is whip stitch the graft, and you push it from ulnar to radial. And so you can see on the far side, I'm pulling it into the drill hole like a docking technique, and then place these biotinodesis screws. The reason why I like these screws is because they have a central cannulation, and you can put suture through those to further imbricate and support it. So it's tethered distally, and there you can see I've whip stitched it proximally, and then this will then be docked into the graft, and you can then pop your screws in. What I try and do with these is I'm actually pretty aggressive in getting them moving early, and so I like to put a sort of suture or tape through the cannulations and tie it on the other side, so you've got like a box reconstruction. And so this is the patient 12 months post-op. As I said, I could have picked many studies. This is a simple study of 38 patients who were casted for quite a while and immobilized. You know, you can see nine weeks, but they did okay. The failures went on to arthritis and went on to an arthrodesis. So one of the things in 2021 is can we move our patients earlier? We were always taught that suture anchors work well, and they do, but you tend to sort of cast them or immobilize them for about six weeks, even if that's in a removable splint. There's some articles in the Journal of Hand Surgery that's come out. Steve Shin is a big proponent of this, of using some form of augmentation to your repair so you can start moving the patients earlier. So how can you do that? So this is an NBA player who comes in shooting hand. These are difficult because it's their shooting hand. They want to get back as soon as possible, and it's in the season. So one of the things is to learn to read your own MRI. So you get an MRI here, and what I'm showing you is Megan showed about the volar subluxation. That's that dorsal capsule that's been ripped off. But look at the image on the left. Now, when you look at that collateral ligament, that is not an acute injury. You can see it's rather gray through and through. So you have to know that going into the operating room because if you're telling the patient this will just be a simple repair, and you bail to do a reconstruction in a professional athlete, and you take a graph from their shooting hand, right, there's many factors going on in that athlete that you have to think about. So this patient had gross instability. Like Megan said, I actually do find the nerve, and I actually do trace it proximally and distally. I don't sort of skeletonize it, but I do want to know where it is. I'll tell the patient after surgery they will be numb, but it does come back. So I leave it in its soft tissue envelope. I then open up the adductor, leaving a few millimeters dorsal so you can repair to it. And now this was a sort of decision point for me in terms of the tissue quality. You can see how it's balled up proximally. Now, do you repair, or do you reconstruct that? And so one of the things that I've learned in our profession is to have good friends who do a lot of these and talk to them, and speaking to some of my colleagues, if you can get that ligament down to bone, if you can get collagen down, you can repair it. So ordinarily, a few years ago, I would have jumped to a reconstruction on this case. And it's not black and white. You're in the operating room. You're thinking, what should I do? And so that's what I ask. I say, can I get this down after mobilizing it down to bone? So that was a sort of decision point for me, and you can see I can get it down there. And so the anchor is placed as volar as I can, away from the joint. It's humbling. You can think, if you turn that angle, you think you're way away from the articular cartilage. You're actually pretty close. So that's why I drill away. And then I was able to repair this down. I repaired the volar plate as well, and then you can see I'm using that tape to further augment this. When you're doing this, a technical trick is before committing to it, flex the MP joint to about 30 degrees. Otherwise, if you put the graft in or the tape in with the thumb in an extension, they're gonna get extremely stiff and extremely tight. And then you close the adductor. So the whole goal of this is to get the patients moving early, and so can you do that? So this is an article in our Journal of Hand Therapy. This is Steve Shin's protocol, where you can see he moves them pretty aggressively, essentially at seven to 10 days, they're doing active and passive range of motion, getting back to play at about five to six weeks. And remember, these are professional athletes, but I think we do treat our patients also in that way, trying to get them moving earlier. So that's ulnar collateral ligament. What about radial collateral ligament? We heard from Megan that the anatomy is different. It's different in a couple of ways. Number one, the APB is wider than it is on the adductor on the radial side. So because of that, steno lesions are rare on the radial side, but still possible. And number two is that you have to take into account the pull of the adductors and the EPL. That's a tremendous force on the radial side. So if you look at the literature, radial sided injuries don't do as well as the ulnar side because of the strength of the adductor and the EPL. In addition, the radial collateral ligament is wider distally than proximally, hence you get more injuries proximally rather than distally. So that's a tremendous force on the adductor and the EPL, but not all the time. So go back to that case of this patient. Eight months old, so chronic, not acute. But you can see the injury there. It's ripped off, it's off the bone, but it's pretty close. I think this is one we can repair. So here I did, I repaired this and put in that tape and you can see the anchor on this one. If I'm gonna be critical, that anchor is a little bit more dorsal than I would like, but I want it to be in bone. So this is him six weeks post-op. And you'll see he has excellent motion. You can see the one on the right is the one that I fixed. So him at six weeks, really getting him moving very early. So I thought a lot about this. So what are the deviators? It's the adductor and the EPL. They're pulling on your repair. So what can you do to try and minimize the pull of the adductor? And this is an article, this was just a case report of Botoxing the ADductor. That comes back after three months, but it goes for an ultrasound scan. The adductor is Botoxed. It's not pulling on your repair and you can get them moving earlier. Finally, arthrodesis. I think very rarely do I do this. I think if I am doing this, it's more when I'm doing thumb CMC surgery and they got an arthritic MP joint. Rarely am I doing this in an arthritic patient. This is the indication. But even if somebody comes in with an arthritic joint, if they haven't had much pain in the joint and they've ruptured their ulnar collateral or radial collateral ligament, most of them want to have a repair because the joint, even though it's arthritic on x-ray, wasn't causing them a problem. I think even though thumb MCP joint fusions do well, in general, patients want motion. So I think in summary, when I'm treating these patients, the questions that I ask is, is the joint arthritic or not? I think it's an important discussion with patients. Can I get their tissue back down to bone? And if I can, I will repair them, irrespective of the chronicity. If not, I will do a reconstruction. And for the radial side, I do Botox the adductor. And then finally, as I said, if it's arthritic, discuss with your patients. Most of them still want motion. But if they are okay with an arthrodesis and if they've been symptomatic ahead of time, then I'll fuse them. Thank you very much. Thank you. Let's see, I think Kate's talk is gonna be preloaded. Let me see. Yeah, so Kate Brown is from England, but she's not able to be here. So she has kindly preloaded this. So we'll hear her talk. Thanks very much, Mike, for giving me the opportunity to talk to you about fight-bite injuries. My name is Miss Kate Brown. I'm a consultant hand surgeon at the Pulvitaft Hand Centre in Derby, England. I have no disclosures. Joint injuries sustained from the result of a clenched fist striking an opponent's incisor's tooth has been known as the cancer of the hand. This was first described by Hortgen in 1910. And in the pre-antibiotic area, they could be fatal. Although the visible wound may be innocuous, there is often a crushing of the tissue and a ragged laceration. So this injury occurs with the joint inflection. When the fingers are subsequently extended, the wounds to the skin, tendon, and joint capsule realign. And this results in a sealed-off, closed inoculation of the mouth flora into multiple layers, each layer of which is surrounded by this crushed, debitalised tissue. And this demarcates the difference between a human bite, whereby the track to the wound doesn't close off. So they're certainly not the same thing. These injuries tend to occur more frequently in the male population and often are alcohol-related. Because of this, there may be a delay in the presentation and the patients may not always be candored about their mechanism of injury. So consequently, an inexperienced assessing clinician may underestimate the severity of these injuries, especially if they do present early and the injury still looks relatively innocuous. So the onus is on us as hand surgeons to educate all frontline clinicians, not just in the ER, but for example, in walking clinics. This patient group tends to be unreliable and a significant proportion will not give the correct history. And there's a high chance there will be a delayed presentation and they are more likely to default from the follow-up. It's important to note the joint is frequently perforated with damage to the articular surface. There've been multiple reports. For example, Fehr and Quinton noted that 18 of the 29 joints that they explored were perforated and Patzarska et al reported an incidence of up to 67%. More worryingly and more recently, the group from Cardiff, Shuring's group, reported up to 95% of MCPJs and 100% of the PIPJs were perforated. Important to note that this latter study was a prospective study and so they were certainly more aware of what was going on. This photograph beautifully demonstrates on the right-hand side an injury in its early stages within 24 hours, whereas on the left, it's in its much later stages and clearly it's already looking pretty bad. They should be treated urgently as a septic arthritis, even if it hasn't yet become apparent. Certainly, the later the presentation, the more chance they're going to get complications and this has been frequently reported. It's key in the ED not to assume. Immediate admission for empirical antibiotics, IV, either Coamoxiclab or if there are any allergies, potentially clindamycin or erythromycin. Plain radiographs should be taken and although there are very few true hand emergencies, this is definitely one of them. They need to be planned for an urgent incision, drainage and lavage, certainly not one to let the sun set and we will come back to this later in terms of whether to irrigate or not to irrigate. This is one of the controversies and if you're not the boss, it's important that you do tell the boss. The typical organisms here are Staph aureus, strep and enterococci, but there are also the unusual ones typical to the mouth flora, such as eichenella and MRSA is also a factor. As I said, complications are frequent and have been reported in up to 50% of patients. Previously, there have been several papers that have outlined the basic management, but this paper beautifully described the actual description of the in-theatre management. These patients were admitted for a minimum of two debridements. All of the expirations were carried out in the operating theatre and they were done under general anaesthetic with a tourniquet. The actual skin wound called by the tooth was excised and extended, swabs were taken. In the MCPJ joint injuries, the extensor mechanism was exposed. If there was a rent in the sagittal band caused by the tooth, this was left alone and the extensor tendon was open longitudinally down the midline in line with the fibres. The capsule was inspected and if it hadn't been breached, it was left, but if it had been breached, then the joint was opened and washed out with a minimum of one litre of normal saline. The two halves of the tendon were then provisionally opposed using a non-absorbable suture and the extension of the bite wound were also loosely opposed. At this point, the hand was rested on a Palmer slab in the intrinsic plus position and a further inspection and lavage was carried out in theatre 48 hours later using exactly the same procedures as described above and once there was no more purulent fluid, then it was formally closed. When it was formally closed, running 4-0 absorbable sutures were used and the skin was closed with interrupted sutures. If there was a tendon repair that was required, that happened much later down the line once the infection had been completely resolved. Should PIPJ access be required, this was between the central slip and the lateral bands. These patients need to be followed up with a hand therapist. Like I said, there'll be a big default but they need to be closely monitored. So what are the outcomes? Well, it's not uncommon to get a reduced range of motion and complications can be up to 50%. Typically, these are local skin infections, lymphangitis, septic arthritis, consequences of the joint destruction as demonstrated in this radiograph, tenosynovitis, tendon injuries, osteomyelitis or even more uncommon systemic complications such as endocarditis, meningitis or bacteremia. Like I said, the chronic infections can cause this terrible joint destruction with an overlying severe soft tissue infection. So these patients need counselling. Long-term, they may need amputation or even salvage procedures such as infusion. It's also important to note that there is a link between recurrent and indolent infections with the use of non-absorbable sutures. So I did mention earlier about controversies and this is one of them. This paper was published in 2020 and it is a retrospective chart review. The authors compared expectant management of these injuries with antibiotics versus a formal IMD in theatre in terms of the rate of complications. And overall, they claim that there was no significant difference between the two arms. But for me, there was some significant drawbacks in this paper. The patient population was described both as true fight-fight injuries but also a bite to the hand which as we've already discussed are not the same. There was also no indication as to why patients were treated expectantly or had the formal washout. Which ones were the worst of the two? And one would expect that the worst injuries ended up having a formal washout compared to the ones that weren't as bad. The authors also had a third group where they did bedside irrigation and it's not clear where they fitted in. So I wasn't overly convinced by this paper. Unsurprisingly, patients that presented later tended to do worse. This is an interesting paper where the authors looked at patients who were managed purely with local anesthetic and field sterility for their first washout. The approach that they used in terms of the joint exposure was exactly the same as Shuring's group. And the results were similar to Shuring's group. So it's not unreasonable to do the washout outside of the OR, but as long as you've done a thorough irrigation of the joint. I'm going to leave you with this video. This is a patient of ours who was a very classical patient for these injuries. Poor compliance with therapy and with treatment. Very difficult to manage. Required eight washouts in the end of his joint and had a complete destruction of the extensor tendon apparatus as well as complete destruction of the joint. So this was his final review. This video has been released with his consent. What you can see is that despite the terrible injury to his finger, he's actually not done too badly with respect to his final function. And so we have decided to delay any further reconstructive procedures depending on how he gets along. Many thanks. Okay, so now we're going to take on a little bit different topic. I'm charged with finger MP collateral ligaments, and unlike everybody else who had more literature than they could shake a stick at, we could cover all the literature in about 45 seconds on this one. So, this is going to be a little bit more of a less evidence-based and more just experience-based talk. So, here's my disclosures. You can see here, probably the one that's the most relevant is the very bottom. One of my all-star fellows this year, Mike Geary, helped kind of pull some of the pictures and background for this talk. This is actually a friend of mine. So, this is a hand surgeon, a member of ASSH, he's 50 years old, five years ago, felt a pop on his left non-dominant index MP joint. On exam, has complete laxity in his tender, and it's about two hours old right now. So, just show of hands in the room, if this was your hand, and you tore your non-dominant index RCL completely. How many people would have it fixed? And how many would non-op it? It's about 50-50. Okay? We'll come back to it. I'll show you what he did. So, this has already been mentioned. The index MP anatomy and the finger MP anatomy is very similar to that of the thumb. You've got the proper and ulnar collateral ligaments that we've already talked about. They run at about a 30-degree angle for the proper and about a 90-degree for the accessory. And the cam shape of the metacarpal head, as we've already mentioned, tightens with flexion, therefore, further flexion. So, this is a hand surgeon, a member of ASSH, he's 50 years old, felt a pop on his left non-dominant index MP joint. I think this really goes to what Sanj was saying earlier about where these anchors should be. When you looked at his drawings, I think he was spot-on. So, just remember the proximal side, so the metacarpal head, you should be in the dorsal third. And if you're on P1, you should be in the volar fourth. And that's really volar, just like Sanj said. I think when you naturally go in and put a K-wire on what you think is palmar, you're usually about halfway home. So, it's much more than you think, and so rotating the digit, as he alluded to, I think is very helpful. And you can see the metacarpal starts about almost a centimeter proximal to the joint, so it's much more proximal than the other side, which, as he alluded to, is about four millimeters. So, much closer distally than you are approximately. Approximately tends to be right on that shoulder of the metacarpal where you want to be. The index radial collateral is even probably the most important of all, because of its critical role in pinch. You don't have stability from the transverse endometric carpal ligament, and you do get some stability from the first DI, though, which is inserting, of course, 100 percent on to the base of P1. In terms of testing for stability, 30 degrees is the classic. I think it's also actually helpful to test them at 90. You get a real sense of additional further degrees of injury, and we kind of graded these as tender without instability, then laxity, but with an end point, which I agree with what was said earlier. Sometimes defining whether or not there's an end point has a lot of variables. And some people kind of pronate supinate more when you test them, so you kind of get a false sense when you test their index MP joint. They'll kind of pronate or supinate around, and other people don't have as much of that rotational component, so it makes it a little bit even harder to tell. X-rays. Good first line. They're usually normal, but you can definitely see subluxation, like you see in the image on the bottom. Evulsion fragments, of course, can be seen, and as Megan said, stress radiographs can be helpful if you're sort of on the fence as to whether or not this one's really completely torn, especially if you compare it to the contralateral side. MRI for the fingers has pretty poor sensitivity, as you can see, but at times you can really pick up a significant displacement, like you see in that Dennison photo there, that may sway your treatment once you know to the degree to which it's displaced. So similar to Sonja, I actually do get MRI on the majority of my personal ones, but you can see when Kevin Lutzky looked at his series 22 complete tears intraoperatively, they went back and looked at the MRIs, and seven out of eight were read as a partial tear. One out of eight is no tear when they all had complete tears, so not overly good. I think ultrasound is an option. I don't have any personal experience, so I can't really comment as to it. I don't use it in my practice. Stenile lesions. You can get the same thing in the fingers, and this is a great picture. I don't have any quite this good, but I have come across them, and basically it evolves as distillate and comes either through the sagittal band, or it can actually herniate almost proximal to the sagittal band and get stuck there. So be on the alert for those clinically and or, again, I think an MRI scan at times can help those if they've got no end point at all. In terms of treatment options, certainly nonoperative treatments, the majority of finger collateral ligament injuries, I think really almost all grade ones and twos can be effectively managed nonoperatively. Grade three is where it gets tricky. There's not good literature, and I'll show you what's out there. When I have ones that I am going to fix, I use a suture anchor, of course, if it's just the ligament itself, and if it's got an avulsion fraction, then I tend to fix that. It's either a K-wire, or if it's a large enough piece, then some of these smaller screws can work really well. You can see two techniques below that that I don't personally use, arthroscopic repair has been described, and then sort of this blocking technique where you put it in from the side, and then hinge it over, sort of like you would do, but kind of a lateral version of the extension block pinning that we do, that's been described, I don't have any experience with that either. For the chronics, very similar to what Sanj said for the thumb, so there's kind of two main ones, the tunnel techniques, or an interference technique, and I started out practice doing the tunnels, and it was super finicky, getting those little bone tunnels and trying to pass the graft through there. Two interference screws makes this a million times easier, so that's what I switched to, and I really have not looked back, and the biomechanical studies showing that really show no difference in strength, and actually the tunnels had a decreased MP flexion, so interference screws are technically easier, and it seems like biomechanically, perhaps even a little bit better. There are some augments that I haven't used, but I think these are good options in the case like Sean showed about what do you do when the ligament's there, but it's not great tissue, so it's been shown you can take a strip of first DI, and leave that distally based, and swing that up proximately to augment, and or reconstruct, and that's probably the one I would use, although I haven't, and this has also been described using A2 pulley, I don't know that I'd really want to go use that as my personal choice, but that's out there in the literature for you, and then MCP fusion as was mentioned earlier for chronic unstable with degenerative change, sometimes that's the way you have to go, but I don't think that's what we're typically looking for, and then how do these do, so this is a series we wrote up back in 2006 on 14 patients, these were all isolated RCL tears of the index finger, and what we found was the ones that were grade one and two all did fine, and they did great, and this was a combination of buddy tape, and temporary splinting, and then when you looked at the grade threes, the 10 that we had, two were repaired early and did very well, and then eight of them were done in a delayed fashion, and really all of those did poor, four of the delayed, you can see two of them went on to even late fusions, and the four that got non-op in a delayed fashion got treated all did poor as well, so we kind of found that early on they did well, but if you got to them late, that was a problem, and that's really kind of been substantiated in some other ones as well. Assuring study, 18 avulsion fractures from the metacarpal heads, now this is not just index radial collaterals, this is kind of all comers, and you see seven that were even non-displaced, three of them went on to symptomatic non-union, so only half of those healed non-displaced fractures, and the displaced ones they treated early, and again, look at their early results, seven out of 11 did very well and had full motion in three months, so treated early, these displaced ones seems to do good, but late seems to be a problem. Long study, very similar, 25 fingers, you can see they got to them late, about 14 weeks out, and if you look at their results, fairly suboptimal, so again, delayed fashion repairs were just not doing as well. I think what that unfortunately did though is it prompted some of these newer studies to start fixing a lot of these early, so this is kind of an admixture in the first study of thumbs and fingers, they used a suture anchor, they didn't break them out by which ones were fingers and which ones were thumbs, but no laxity and only one patient had loss of motion, so again, early treatments seem to do well for the grade threes. And this is one of the larger studies, this Max Wheeler study in PRS a couple of years ago, 46 grade threes on either exam or ultrasound for their diagnosis, treated early with a suture anchor, you can see the motion, 77 degrees, good grip, good dash, and all stable and pain free. David Ring did write a commentary in this that he felt these authors were fairly aggressive with their indications for surgery, they did include a lot of central digits, which I think a lot of people would probably treat non-op, but we really don't have great data for that. So here's our surgeon friend, he elected to have his fixed, you can see here's the ligament, the ligament evolved approximately, just like Sanj told us we should see on an RCL, and it ended up with a direct repair, augmented with a suture tape, just like Sanj described, and this was done under a wallant to allow watching the motion, so we could see that intraoperatively he had, well it's a little slow to get going, still kind of waking up, but intraoperatively he ends up having nice motion and good stability. He was able to get back to his office practice at two weeks and was back operating at week three, and he's currently five years out and doing great, and not having any issues with the hand. So this is my current algorithm, again there's not a lot, that's all the studies that are out there that I just showed you, so grade ones for border digits I tend to buddy tape, grade twos I cast for three weeks and then I buddy tape, and then grade threes for the most part I'm repairing them on index finger and small finger, and that's really in part because there's not good data on what happens to grade threes that are casted, we know the ones that are quote delayed don't do well, so I don't like to really trust it to that. But then central digits I tend to go the other way, I buddy tape grade ones, and then I cast most of the grade twos and grade threes for central digits, if it's got a large displaced bony piece that is one I'll go in and fix, or if I think there's a stinner like lesion that I see either on exam or MRI, then I would fix it, but otherwise I'm treating these pretty much non-op. I'll tell you for the approach for the central digits, I've only actually done one of those, actually going volar is a much easier approach, it would seem like you'd want to go dorsal, but sometimes if it's a vol, that avulsion piece tends to be a real palmer on P1, remember it's inserting on the volar quarter of the bone itself, so going volar and just doing like a trigger finger release and coming around the side, you're right on it, they have a good angle to put that screw, it's actually hard to put that screw on it if you go dorsal. Thank you. All right, and now we're going to go on to Mike Hayden on extensor hood injuries. Again, our last two speakers are both from England, so they're joining us virtual. Hi, my name is Mike Hayden from Wrightington Hospital in England, and I'd like to talk to you about extensor hood injuries, and this would be a typical sort of presentation of hood injuries. The one on the left you can see was an old repair which actually survived this bruising and this impact, and the one on the right didn't have any significant injury, and these both settled pretty well. But this is the dramatic sort of bruising that you can see in boxers. So I'd like to thank Richard Toste from Philadelphia for this excellent kind of a dissection when I was over there at the Philadelphia Handcourse. You can see that the extensor hood sort of holds the extensor tendons centrally, and the splits can occur on the radial side, on the ulnar side, or in the cases of the index finger down between the two tendons, and the same with the little finger can split down between EDC and EDQ. Now most injuries do occur in boxers where it's an impact and they get these tears, but very occasionally they can occur in the non-combat community where it's more of an attenuation or occasionally a tear in a otherwise perhaps weakened extensor hood. So here's a typical boxer. This has got instability of the extensor tendons, but not all have instability in the traumatic tears, and I'll actually say that the majority don't have instability. It's very subtle if they do, but this one has got gross instability of his extensor tendon from making a fist. Now this is a non-boxer, or at least she told me she wasn't a boxer, and you can see she locks her MCP joint because the extensor tendon becomes a flexor rather than extensor, and that's actually quite painful for her. You can see I had to manually straighten her. In these situations, we often trial non-operative routes with a yoke splint, and if that fails, then we look at surgical explanation, but we'll discuss that later. So here's the sort of tear that you get along the side of the extensor hood, and it's relatively straightforward to repair, but it should be repaired in flexion, and I'll come on that in a minute. So it's usually the trailing hand in my experience, so that's the fist that's behind the body. It's a finger away from the opponent, which is usually the big power shots, and it's more often in the index and middle finger, which are the two striking digits, rather than the ring and little finger, although they can also be affected. We do image these. Ultrasound's probably the best. It's dynamic, and you can see this edema just to the side of the extensor tendon, and also on flexion, occasionally, the extensor hood will sublux, but you can often see that clinically anyway. So I think it's the edema on the ultrasound. On MRI, particularly the axials, you can often see a tear, and this was an arthrogram, which kind of leaks everywhere, but I don't tend to do MRI anymore. It's usually ultrasound, but some of the athletes I look after can't really afford the imaging, and I think if it's a boxer with a very high index of clinical suspicion, localized tenderness over the extensor hood, then I would just explore the MCP extensor hood and warn them that it might be normal, and I've got quite a few where I have done that. It's turned out to be completely normal, and we've simply closed them up, and they've gone back to competing at sort of six to eight weeks after the wound had healed, and they've been fine. Now, whether that was a period of forced rest, or whether we're doing some kind of a neurectomy to the extensor hood, I don't know, but luckily, they've been okay. So I do warn them that it might be normal. As we've talked about, it's usually the index and the middle finger. Here's a relatively recent traumatic. You can see this hemorrhage distally. He's torn off the extensor hood and an underlying capsular. This is a left middle finger with the fingers to the left of the screen. This is more of a chronic situation with a rolled up extensor hood and to the side of the tendon, and this, again, we could repair with a primary technique, and this boxer returned back to his previous level. And this is a little finger where they split down between EDC and EDQ. So the vast majority of boxers can't tolerate a non-operative route, and it's highly likely that they would just re-tear. So I'd really recommend that operative in boxers, and then consider yoke splints in non-boxers, and if that doesn't work, then you can surgically explore them. The incision is usually a curved incision around the side of the knuckle, just so that you're not going to scar over the back of the knuckle. And in cases, which is quite rare, where it's two knuckles potentially affected, I use this sort of lazy H-type incision. When we do surgically explore them, and I do all these now wide awake, this one patient's asleep, you'll often find this pseudo bursa that's just on the top, and that's removed, and then you see the underlying extensor hood tear, plus or minus a capsular injury. I do these wide awake, under wallowns, it's very straightforward, and we often get a direct repair. If, however, it's not possible to do a direct repair, then you can either get an adjacent jink churi, or go to the back of the wrist for an extensor retinaculum, and again, that's very straightforward to do under wallown surgery. I think it's really important that you do all your repairs, both of the extensor hood and also of the capsule, in full flexion. You'll always be able to repair the extensor hood in full flexion, but the capsule may not be able to, and in which cases, you leave them. I'm going to come on to that in a second. This is a boxer with no capsular injury, and that was a very simple case of just repairing the extensor hood, sorry about the focus, repair that with, in this case I've used 4L-PDS, but now I tend to use something a little bit stronger, perhaps a 3-0 PDS. My knots are usually buried. And here's a boxer with a split down between the little finger, EDC and EDQ, and again all the repairs are done in full flexion. Now this is a capsular injury, it's a straight split, you can see the extensor tendon above, and again we flex them to 90 degrees and use buried sutures to repair the hood. But if the capsule's not repairable, and I've got a few that I've had like crab meat, and you just can't get a stitch in them, don't worry about that, they will still do okay even if you don't repair the capsule. So repairing the capsule's not absolutely essential, and I've got quite a few patients in that scenario. And again, just flexing it down at 90 degrees, and I can't sort of stress that enough, it's really important that this repair's in 90 degrees. I do these now under a wallet, and you can see here that the extensor hood is off to the side, very thickened capsule, 90 degrees, and we're just going to repair that down to the side. And what happens with the two knuckles, you can see it's that lazy H incision, the suturing just looks a little bit agricultural perhaps, but that's because I was looking for the best possible tissue, and that was using a 3-0 PDS with buried stitch with a running locked suture. Now what happens when you open it up and the extensor hood's intact? Well it may be that they've actually got no structural injury, but it is worth checking the capsule, and my apologies for not having a video of this, but what I now do is I inject some local anesthetic through the intact hood into the MCP joint. I then lift my thumb off the syringe barrel, and if it refills back into the syringe, I know that the capsule's intact because I've been injecting into a confined space. If however there's no backfill, then one would imagine that the capsule's torn, and then I need to explore that, incise the hood, repair the capsule as needed, or not if it won't be repaired, and then repair the hood that you've now incised. Our rehabilitation has changed over the years. We now don't put them in a splint, we get them going pretty early. We do give them a yoke or relative motion splint if we don't perhaps trust them as much as what we might, and here you can see this yoke splint for a two-digit repair. Rehabilitation, they get back to full contact somewhere at about five months post-injury, and there's a range of movement that way you can see, getting to 90 degrees, and we've got lots of these now in our series. We had one re-rupture that had a cortisone injection some six weeks prior to my surgery, and we now really would advise waiting quite a long time after a cortisone before doing that. We revised that repair, and well he's now a couple of years after that re-repair, and he's back competing. So my tips for you in the last 30 seconds are delay surgery for at least three to four months after a previous cortisone, try and do it under wallant, repair the capsule at 90 if possible, but if it's not repairable then leave it alone, and repair the hood at 90 degrees. Please feel free to direct message me or email me mikehayden at gmail.com if you require any further information, and thank you and I hope you enjoy the rest of the conference. And then to finish this off, and then we'll do questions from you guys as soon as we get this last talk by Dr. Sood playing. Ladies and gentlemen, my name is Manav Sood. I'm a hand surgeon working at the St. Andrews Center for Plastic Surgery in Chelmsford in the United Kingdom. I'm delighted to be with you for this instructional course, although sadly not in person, and I'm very grateful to Mr. Mike Hayden for the invitation to be part of the faculty. My remit is to speak to you about soft tissue cover of the MP joint of the thumb. I have no disclosures. Since this is an instructional course, we must have learning outcomes, and I hope that at the end of this lecture, and having read the articles that I've given you in my handout, you will be able to select the appropriate flap from the list that is on the slide. If you have a small defect over the MP joint, which has adequate soft tissues over critical structures, then it is possible to treat this conservatively with moist dressings and allow it to epithelialize, or else to use a full thickness skin graft to prevent a contracture, and I will not discuss these further in this talk. When we discuss skin cover for the thumb MP joint, we should be aware of the difference between dorsal and bowler defects due to the specialized nature of the skin on the bowler aspect. But let's start with the dorsum. The first flap to consider is the dorsal V to Y flap. This is a very useful flap for smaller defects on the dorsum of the thumb, and it has the advantage of limiting the surgery to the one injured digit, if possible. It is particularly useful in cases where the other digits are injured. For example, in this case, you can see the index finger is damaged, and therefore the first dorsal metacarpal artery flap may not be available to resurface the thumb. The other great advantage of this flap is in replantation and revascularization because this flap can be advanced with the veins, and those veins can then be anastomosed without needing a vein graft. By virtue of converting the V to a Y, we also do not need to put a skin graft into the donor side of the flap, making it a much more aesthetic reconstruction. The next flap we consider is the first dorsal metacarpal artery flap, initially described by Guy Fouché in 1979. Michael early looked at the vascularity of this flap and also the range, where he showed that it is more than adequate to cover both the dorsum and the bowler aspects of the MCP joint of the thumb. So here's an example of a complex defect on the dorsum. A primary tendon graft for the EPL has been done, and a flap has been marked on the dorsum of the index finger on the proximal segment. But please note that we also have a tail of the flap. The flap is elevated with the adipofacial tissue, which contains the blood vessels, the origin of which is in the first web from the radial artery. Once the flap has been completely elevated, it can be transposed into this defect, and this can be done by the tunneling underneath the skin or by dividing the skin and insetting the tail of the flap, as we show in this case, to prevent compression of the pedicle due to edema from trauma and surgery. And here is the early postoperative picture showing a well-heeled flap and a skin graft. The flap is equally useful on the bowler aspect. Here's a patient with a bowler contracture, and I've done an on-top boneplasty. But as you can see, this flap more than adequately reaches the MP joint and all the way up to the tip of the reconstructed thumb. There are other variations of perforated flaps from the radial artery on the dorsum of the forearm, as in this paper by Demiri with an elegant reconstruction, and also by Dr. Bakash. But I do have reservations about these two flaps because they're raised from areas where the superficial branch of the radial nerve needs to be handled and protected, and this can lead to neuritis and pain in this area. Bowler defects of the MP joint require glabrous skin for reconstruction, ideally, and my colleague Mr. Ibagbu described the use of the supra flap, the superficial branch of the radial artery flap, for this kind of a defect. So here is an open MCP joint, and the plan here, as shown in this schematic, is to use the superficial branch of the radial artery and create a flap based around this. The vessel can be palpated and dopplered, and the flap is then centered over the vessel and the thenar crease, ideally so that it can be closed primarily. The superficial branch of the radial artery is identified going into the flap, and the dissection is then carried out at the fascial level to ensure that the vessels remain within the flap. As you can see here, the flap has been transposed and the donor side has been covered with a full thickness skin graft, as this is a rather large defect. The flap can also be used as a reverse pedicle option, and you can see here an adherent skin graft on the thumb for which a distally-based flap has been marked. This will be based on the perforating vessels distally, and this proximal vessel will be ligated, and as you can see here, this is a nice result with good labrous skin on the thumb. The next flap for us to consider is the posterior interosseous artery flap. This is a septicutaneous perforator flap. It has a reputation for being somewhat difficult to raise, but if you follow the principle of identifying the vessel between the extensor digiti minimi and the extensor kappa alnaris distally, and then tracing the septum proximally, it is quite easy to raise. Costa et al. in their paper in 2007 described 102 such flaps used for hand injuries, some of which were for thumbs, and as you can see in this picture here, that's the main vessel with the perforating vessels going up along the septum. So here's a patient of mine in whom I've marked the perforators, and it's possible to be more precise in how we plan the flap by mapping these perforators with a Doppler, and you can see that they're quite easily visible on the Doppler itself. The posterior interosseous flap has several advantages. It can provide a sufficient quality of skin for relatively large defects. It is raised from the same limb, so therefore it can be done under regional anesthesia, and there is no microsurgery involved. The flap in itself is also quite thin and pliable, and it contours quite nicely, and if you have a smaller flap, the donor side can be closed primarily. Here's another example of a volar defect on the thumb, a relatively large flap, well-padded and vascularized, and a good result. The groin flap is very versatile in its use for hand injuries, and my colleagues, Mr. Tara and Mr. Ramakrishnan, described a mini groin flap for finger resurfacing. The technique consists of identifying the superficial circumflex iliac artery with a Doppler and elevating the flap from lateral to medial, but what is particular to this technique is that the flap is primarily thin on the table, quite radically taking care not to damage the pedicle. And here you can see a thumb with the MCP joint and the athena eminence of one-stage reconstruction, which is not just functional but also quite aesthetic. And another example of a patient with an exposed MCP joint with a similar flap of one-stage reconstruction. And this is just to give you an idea of how thin this flap can be. This is over the PIP joint of the finger, and no subsequent revisions were required. The next flap to consider is a venous flap. I first became aware of this from the work of Mr. Mark Pickford at the Queen Victoria Hospital in East Grinstead in the UK. Venous flaps are of three types. They can be flow-through flaps, they can be arterialized, or they can be shunt-restricted. Due to limitations of time, I cannot discuss the technical aspects of these, but I will show you some examples, and you can read the literature later. So here's a paper by Mallory Lee, which shows a flap with three veins, one for arterial input, two for venous drainage, and a nice result. An important paper by Dr. Wu and colleagues of 154 patients, which is worth reading because they've classified the flaps on various criteria. A very nice schematic, which shows the concept of antigrade and retrograde flow and the selection of vessels, which is in that paper and Baird's study, and it's more easily seen in this paper by Wally. And a paper by Dr. Kang and colleagues, which shows how to select parallel veins in the forearm for flaps of this nature. Finally, a reverse-flow shunt-restricted flap. The shunt itself causes flap necrosis, so therefore putting a ligature across this increases the chance of flap survival. As a final technique, I want to introduce you to the use of acellular dermis, which is a bilaminated sheet and allows for establishment of a neodermis, which can subsequently be grafted. So here's an example of a prosteontosis flap, which failed because the patient was a smoker. The defect was debrided with exposed bone and tendon. A bilaminated sheet is applied. Three weeks later, the silicon is removed, a skin graft is applied, and it heals well. And as we know from the literature, this technique can give rise to good results with nice, pliable skin. And finally, a small plea. Patients do prefer flaps that are well-contoured with inconspicuous donor sites, and we should try to achieve this for them. Thank you for your attention. All right. I think we can take some questions from everybody. I'll lead off with Megan. One thing that's interesting, it sounds like you fix all your grade threes regardless. So our group is, interestingly, split right down the middle. So half our surgeons will fix every grade three, period. The other half tend to do, which I'm kind of in, get an MRI and see how close is the ligament to bone. And if it's within about two millimeters, I'll non-opt those. And actually, start it. I don't know if you do as many of these signs because it happens during season for a lot of these football players. And they're like, well, I don't want to stop the season, so I'm going to cast it at the end of the season. If you're still unstable, we'll go back and do it. But is yours kind of across the board? All you guys do it the same way? I like to get to these early just because it makes it easier to fix them. I mean, obviously, you give people the option. I would never for the UCL. This is only, I'm assuming, for the RCL. UCL as well, as long as you know it's non-displaced. I generally try to fix these just because it gets these patients moving quicker. They get back to work quicker. Because if they fail, then you're going back. And it's a bigger surgery for them. So I've just found that giving them the options, more times than not, they'll just get it fixed and they can move on with their life. Yeah, I think that would be a good study to do, Glenn, to see the natural history of these. Because I agree with you. I'm pretty conservative, to be honest. I mean, the technology's out there to get them moving early. And if they want to do that, then so be it. I mean, personally, I would go in a cast for four to six weeks and see how I did. But I individualize it. I think there is no good algorithm out there unless there's a stent and you have to do it. Athletes, I agree with you. Basketball players, they're just challenging. There's so much demand. You can put little splints and tape them or put co-band wraps. They don't like it. They can't feel appropriately. So I find them challenging. But that's the athletes that I see most of them in. Yeah, and there's a little splint for your athletes when they get to around that four-week mark and they want to get back to your point and feel that they can make that is all dorsal and it kind of has little wings, if you will, that extend palmar to the MCP and kind of back up. And it sits all dorsally, so they've got to actually open it, assuming you guys use that as well. I think that would be interesting to look at because the soft tissue after two to three weeks, it just isn't the same. So I'm intrigued to see what long-term, if you had compared the two of them, about their range of motion and the strength of that repair. Yeah, and the point that you made, Glenn, about those fractures being volar, those avulsion fractures, Alex Shin has a nice paper out there that shows the technical aspects of it. And it's one of those things that now it's obvious, but if you're not thinking about it and you go dorsal, then you've taken an operation that is relatively straightforward to do. It's very hard to get that angle. So that's the good sort of article showing that. Audience questions? Good. That was a good ICL. I enjoyed the talks, and Mike Hayton is always good entry value. But Kate's talk and Dr. Seuss' talk were great. Thank you, guys. We'll get my two minutes back, and we'll be up here for any questions. Thank you.

fight-bite injuries

clenched fist

tooth

severity of injuries

prompt treatment

complications

study limitations

finger injuries

surgical techniques

soft tissue coverage

finger collateral ligaments