Good afternoon. We realize it's the end of a long day, so we're going to respect all of you who are here on time, and we're going to start on time with a master. Dr. Lee Osterman is going to tell us how to prevent stiffness and finger fractures, the dreaded complication. They all heal. The problem is they get stiff. Don, thank you. And as he pointed out, stiffness is an absolute problem. Al Swanson, one of the presidents of this organization, I think actually kind of set the bar when he said that hand fractures can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness from poor treatment. No less illuminary than Sir John Charnley noted, the reputation of a hand surgeon may stand as much in jeopardy from treating a phalangeal fracture as from any fracture of the femur. Peter Stern, who you're going to hear from, talked about complications in his series. So here's one of the masters who reported complications as high as 57% and pointed out phalanges were worse than metacarpals, open was worse than closed. Faraki also looked at complications around pinning of phalangeal fractures with the complication rate that you see there. Many, if not all of these complications were adhesion, stiffness that rendered the finger less useful. Well, why are adhesions so common? Well, everything but bone heals by scar and everything around the bone heals to the bone by scar. And remember the hand is a precision machine, has moving parts, it demands excursion, it demands alignment. There's small bones that need protection and the constrained joints, particularly the PIP joint is a bad actor as we all know. So it is also a major determinant of functional outcome, how your PIP joint does. You can have stiffness of your MP, but if you have a lot of stiffness of your PIP, it's like a bad dupatrance. Factors that influence stiffness are injury factors, patient factors, and management factors. We really can't control injury factors. We know that poorer outcomes are going to happen if they're interarticular, comminuted, unstable, displaced, and obviously if there's associated injury, be it tendon or skin. We can't control patient factors. They come to us as they come to us. And so if they have associated diseases, diabetes, immunosuppression, if they smoke, we know that younger patients do better given the same injury than older patients, and then we have socioeconomic issues about insurance coverage, accessibility to therapy, et cetera. Management factors, understanding the injury, managing the soft tissues, reducing and maintaining the fracture, proper timing of immobilization and managing complications, that's where we really have to influence the outcome. And I like the caveman principle. How would a patient do without treatment? Would he in fact be better than opening him up and putting a small plate on his proximal phalanx? Remember Hippocrates, first do no harm, and remember that casts and splints themselves can cause stiffness and cast disease, and operative intervention has its complications. And so a distal phalanx fracture immobilized like this or a fifth metacarpal fracture non-displaced, that's immobilization disease. Remember motion is lotion and keep moving parts moving. If surgery, you're going to hear from Don, I'm sure, about the use of local anesthesia so you can test your construct. How stable is it and through what arc of motion? And that I think has been one of the major advances that we have, particularly in treating finger fractures. A middle phalanx fracture like this treated with pens seem to be stable at surgery, can be treated moving and sparing the DIP joint to allow the extensor tendon to move and also allow the MP joint to move, so early active motion. I thought I'd mention about metacarpal fractures because I think this is a perfect paradigm and we have I think a treatment now that has changed the dynamic and moved it forward. Remember most fractures are going to be functionally stable, outer rays most often injured and the goal is to get them moving early and to maximize stability. And the least invasive intervention that will achieve that goal and one has to anticipate often compliance and its complications. And so here we have this fracture, short spiral. It has no rotational malalignment and so we're going to just put it in a metacarpal bar. Here we are at three weeks and here's the patient at 10 weeks, obviously somewhat happy if not giddy. The classic surgical indications are going to be malrotation and here we want to get the finger moving but we're not going to accept when they're particularly two-digit fractures or malrotation and so here we have a fracture displaced with malrotation and treated quite simply with reduction and a pin. Remember if you have a pin site then release the skin so you can move the joint around it and I never leave a pin more than three weeks across any joint with the exception of maybe the DIP joint and here's six weeks after treatment. And as I said, the new darling on the block in terms of metacarpal fractures is the intermedullary screw. Just a caveat, remember that your ring metacarpal, it has a narrower isthmus than your fifth metacarpal and there is evidence that people do well with this. There's multiple papers now that have come out in the last six months showing almost a return to normal function and so a 19-year-old dude who punches a wall and comes in with this closed fracture with some rotational issues is treated by this, inserted under local, allowed to move it right away and here he is in the recovery room right after he gets his anesthesia off. And here he is at his first office visit at six weeks. About a week from inmate, do extension, do flexion, any pain? No pain. That's good, isn't it? And here he is healed at his last visit and never to be seen again. And often these patients do have compliance issues. But nothing's risk-free and here we have a 20-year-old sophomore linebacker, comes in with that fracture with significant angulation and some rotation again and perfect candidate to put the intermedullary screw in. First postoperative visit, moving his hand well, screw looks good, rotation is good. He decides to impress his girlfriend and proceeds at two weeks to pound away to show his strength of his injured paw and now he comes back. He said, it's a little sore. I hope I didn't do anything. And so now he has bent the screw and the pin which caused some consternation as to how we were going to get that out and we subsequently decided that before we tore apart the finger that we would try and re-cannulate and bend the pin and that's what we did. We were able to re-cannulate it, re-bend the pin straight and he functionally went on to heal with a normal examination and back to football. But there's nothing that is perfect. It's the principles that are important. Finally, even when you have a bad crush injury like this, comminuted open with malrotation, often some bone loss, if you open this, again, my belief is if you put a plate in, that's when you've got to move sooner rather than later. You want to get that stability and so here we are with bone graft in place, grabbing that metacarpal head and there's certainly a lot of metal there one would think for this, but here he is at three months with an excellent range of motion and near normal function. So in summary, just remember to respect the soft tissues and remember to consider the patient you are treating. Thank you. That was great, Dr. Osterman, just awesome. And for our next speaker, we've got Dr. Peter Stern from Cincinnati who's another giant in hand surgery and such a pleasure and a privilege to have Dr. Stern speak to us today. Thank you, Don. Thank you, Don. Thank you for including me in the panel. I'm going to kind of be a sequel to Dr. Osterman's presentation and talk a little bit about stiffness after phalangeal fractures, causes and management. So this is an old, old case, but it is fairly illustrative of some of the things that I'm going to talk about. This 36-year-old healthy laborer presented to me when he caught one of his fingers in the fan blade of a car. He had no volar injuries, flexor tendons, digital nerves, the circulation were all intact. His clinical photo and radiographs are depicted. He had a dislocated PIP joint, a bicondylar interarticular fracture of the head of the proximal phalanx and his dorsal apparatus as seen was shredded. He was taken to the operating room and the questions that I might ask were what would be the anticipated outcome, what would be the choice of stabilization and how do you manage a shredded dorsal apparatus? Here's what I did. I took him to the operating room, did inter-frag fixation of the P1 fracture. I pinned the PIP joint in a small amount of flexion and I kind of piecemealed the dorsal apparatus with a non-absorbable suture. Six months later, he returned. His fracture had healed. The PIP joint was symmetrically aligned and he had a stiff finger, probably like four centimeters pulled to distal palmar crease. So we'll come back to this case later. How do I think about a stiff finger? So the question is, you know, what am I going to do to try to improve his digital flexion? And the way I think about it is that there's really two restraints to preventing finger flexion. There are static restraints and there are dynamic restraints. The static restraints are basically three things if you exclude the skin. One is the dorsal capsule. A PIP joint, particularly if it's held in extension, the dorsal capsule becomes tight. Similarly, the collateral ligaments become tight and do not allow flexion. And finally, oftentimes adhesions occur in Drucker's space. Other static restraints involve the boner joints. So as illustrated on the cartoon in the lower left, that joint's dislocated and in most cases, dislocated joints do not bend well. The other restraint to flexion, always take an x-ray, is if there was a interarticular fracture leading to incongruity, et cetera, et cetera. So you can't really fix or get a joint that is incongruous or dislocated moving unless it's congruously and symmetrically reduced. Then there are dynamic restraints. So static restraints we talked about. Dynamic constraints are essentially the extensor tendons, which would include the dorsal apparatus. And oftentimes with PIP fractures, since the fracture itself is circumferential, there are adhesions of the flexor tendon system to the fracture. So even if you can loosen up the dorsal side of the finger, you may have to go palmerly. So here is a list of considerations if eventually you recommend tenolysis. So most patients will send to our hand therapy colleagues and we want active and passive motion to have plateaued. And secondly, and absolutely critical, is the soft tissue needs to be pliable. I think it's a disaster to operate on a swollen finger. The fracture itself needs to be healed, of course, and the joints need to be congruous. I think you'll hear next from Dr. Lalonde and Wallant, particularly for finger fractures, really easy to do and something I recommend because you can see and the patient can see in the operating room how she's done in terms of gaining motion. Next, timing. I'm not a big believer in intervening too early. Again, I get very concerned about soft tissue edema and I'll usually wait in an adult at least four months before I'll consider a tenolysis. Next, I want to make sure that I have maximum passive flexion. I want to make sure that I've plateaued in terms of passive range of motion. It's going to make your surgery easier. This is in the operating room. So we've gone in. We've done an extensor release. We've done a dorsal apparatus tenolysis. We released the collateral ligaments. We've released the dorsal capsule, et cetera. And then at that point, you want to ask the patient to actively flex her finger. So what do you do if there's good passive PIP flexion but active flexion is lacking? Well, then you have to make a decision. I'll turn the patient over and do a traction tenolysis either at the level of the wrist flexion creases or more commonly at the distal palmar crease. At that time, if there are not terrible adhesions between the flexor tendon system and the proximal and maybe middle phalanx, the show's over. You have lysed the adhesions by traction. Ask the patient to flex her finger. Things are good. You're done. The big question is if after you do a traction tenolysis proximal to the fracture, that is in the palm, the finger still doesn't bend actively through traction or through the patient bending the finger, are you going to go up into the finger? In general, in my experience, if you operate in the same operation on the top and bottom of a finger, it may very well end up being stiff. So most of the time, I will not do a formal flexor tenolysis if I have previously or during the operation also operated extensively on the dorsal apparatus. Next, once you've finished your procedure, I will send the patient for therapy, very, very important, and some type of pain control. Back to our case, this patient we opened up through a dorsal approach. And the dorsal apparatus, although some of it was missing, was more or less in continuity, probably with some scar tissue. We freed the dorsal apparatus from the underlying proximal phalanx, released pretty much all of both collateral ligaments and dorsal capsule. Passively, we were able to get the finger down pretty far, but actively, actively, I'm sorry, we, the dorsal apparatus, as I said, had partially reconstituted, asked the patient to bend his finger and was able to touch the palm. This is not a home run, but now the patient can get the finger down to the palm. Note that the DIP joint, which was not injured, does not bend very much. My experience has been that trying to go up and release any adhesions or capsular contracture of the DIP joint is not very fruitful. So we ended with a reasonably decent result, a little bit of an extensor lag of the DIP joint, not full flexion, but able to touch the palm, and the patient was happy. And I'll stop, oh, no I won't. A few comments regarding flexor tenalisis. Again, I mentioned this before. If after your dorsal release, that is an extensor tenalisis, dorsal PIP capsulotomy collateral ligament release, if passive motion is greater than active motion, flexion that is, then you go to the palmar side and you do a traction tenalisis pull up on the flexor tendons, profundus and sublimus, and hope that those adhesions will be broken up. If no improvement, you can consider going all the way out on the finger. The disadvantage, again, is that that's a lot of surgery, and patients are not always happy. Here is another patient in the operating room with the two of us together, and you can see the smile on his face, and he's making a nice fist. And I'll stop there. Thank you very much. Great pearls there, I totally agree. The tissues have to be really, really soft for me to want to go and do a tenalisis, and I frequently will wait even six months or more. It's just got to be soft on the outside, or it's not going to be soft on the inside. It's kind of like the polar bear that eats the igloo, you know, hard on the outside, chewy on the inside, you know, it's. Good afternoon. Thank you very much for the invitation, Don. It's an honor for me to come here and present some of my tips. I work in Porto Alegre, in the southern part of Brazil. This is our university hospital. So, as it was said here before, stiffness the most common sequela of finger fracture, and even if it's just one finger, it hurts the whole hand. And the way to prevent it is to allow fingers to move as soon as possible. But that's difficult, because you have to, you need immobilization to heal the bones. So, you have forces pulling both sides, and you have to equilibrate that to be successful in your treatment. So, we usually treat patients, the fractures, conservatively. And in some, we can start early range of motion. And you see in the bibliography, and we see in our practice, that it's less likely to have stiffness in conservative treatment than in surgery. I agree, but I would say that it depends on what surgery, sometimes. So, this is a paper that was published some years ago, very interesting, and the authors were very happy in their idea of treating the patients with functional casts, long and short, for phalangeal fractures. The thing is that they were very strict in their requisites for the patients, and even for the stable initial reduction, they used local anesthesia for every finger they were treating. And they committed the patients to come for weekly visits in the first weeks. That's very important for conservative treatment in these cases. But at the end of the paper, they will say, well, maybe in demanding patients, some Kirchner wires or surgical treatment would be good, too. And I would say to you that I, in some cases, I discuss with the patients minimally invasive surgery. So, you want the patient to commit to the conservative treatment, to come to weekly visits so that it doesn't end up like this. So, first tip would be conservative treatment is very good, but you have to keep watching your patients, like weekly, in the first weeks for sure. If not, this is a good way of treating with K-wires. You may go with safe corridors. There's some papers about that, that you don't get your tendons and soft tissues entrapped. And you can move right away, just as this little boy, 15 years old, with rotational deformity, went to the operating room, wide awake surgery. And you can see we have full range of motion, almost full range of motion, but stability at the fracture, that's very important. So, that he can keep moving at home. So, this is home therapy. And you see he loses a little bit of motion, but this is three and a half weeks post-op, and four and a half weeks post-fracture. And you take out the K-wires, and in eight weeks he comes back like this. So, another tip about minimally invasive fracture with K-wires would be to use safe corridors, stimulate active range of motion, and you may take out the K-wires in three or four weeks. You should take out the K-wires in three to four weeks and stimulate range of motion. Some cases, some patients, they don't come early enough. So, like this patient, five weeks, we couldn't do a close reduction. So, but still we wanted minimally invasive surgery. So, a small incision, approximately, and to start the caloclasia, distally, we did the caloclasia like percutaneously with the K-wire, as you see in this slide here, I'll show this slide here. And then reduction and fixation and start moving. So, another tip would be keep minimally invasive. So, less dissection, less scar. And as it was said here, my Dr. Osterman brought the subject. So this intramedullary screw, for me, it's a, I like it very much. It's a very good way for minimally invasive surgery and very stable. You have all these reasons that you see here to make it a good stability in your fracture. I like to use the 18 gauge needle. It helps me a lot. I put the needle in the intramedullary canal. It helps to reduce the fracture and stabilize it. And then I pass the K wire and engage it to the distal cortex. And then it's just to pass the screw and test it, test the surgery, test the stability. You can go from distal to proximal. You can go both ways when you want to put more than one screw. Or you can go dual integrated, as was already published, when you have a very small proximal fragment. So the fourth tip would be to keep intramedullary. And my exclusive tip here would be using the 18 gauge needle. It makes it a lot easier to get the reduction and the guide pin. And you can go distal to proximal, proximal to distal. And anticipating the next slides, I would say, Walnut, as was said here by Dr. Stern, too, you can test range of motion and stability. So you're all aware of Dr. Lalonde in the second edition book. You can learn a lot about why the wake for fractures. And you can talk to the patient and reemphasize the importance of hand therapy in the post-operative period. So I would strongly recommend to use Walnut in these fractures. What about our first patient? So she needs an osteotomy. Again, I try to go minimally invasive, like a dorsal osteotomy, crack the bone, and then put a screw in and test with Walnut. And here's another case, another complication. Two weeks, infection. I had to take out the KU iris and do some debridement. And when he was clear from infection in 12 weeks, I went on to put a small plate and screws and bone graft. And I'm not a great fan of plate and screws in the proximal phalanx, in the phalanx. But in this case, I thought it would be the best method of stabilizing and starting range of motion right away. So managing complications, you keep the same focus on fracture stability and avoid stiffness. And you always have to know about all your bone fixation options. So I would say a take-home message here is that early motion, as you all know, is extremely important to avoid stiffness. In conservative treatment, you have only to watch carefully the patients. And always minimally invasive would be an option, is an option for me. And when you talk about surgical treatment, choose adequate fixation. Try to be minimally invasive. So remember less dissection, less scar. Wallet is very important so that the patient can see. And that helps a lot in the postoperative therapy and for sure hand therapy in the postoperative period. Thank you very much. APPLAUSE Thank you so much for a great talk from Brazil, Dr. Celso Folberg. And our next speaker is from Spain, Dr. Ana Carreño. And it's a pleasure and a privilege to have her join us as well. Thank you, Dr. Lalonde. Thank you, Dr. Lalonde, for your invitation. I think I will repeat many concepts. I want to talk about my favorite tips to decrease stiffness in finger fracture management. And as we have seen previously, stiffness after hand fractures has long worried hand surgeons because sometimes they are difficult to manage. And the first tip is to prevent it. How? Sometimes avoiding treatments that are inappropriate or even harmful and fighting our enemies, the edema and the lack of movement. Preventing stiffness requires early motion, adequate fracture stability, optimal pain management and good patient communication and rehabilitation programs to control the edema. And let's see some cases. In this diaphysis stable fractures with good alignment, we indicate conservative treatment. The hand is in a spleen with MCP inflection, as we have seen in the previous presenter, and let the PAP and DAP join to move. The light use of the hand is permitted. And active tendon gliding exercises are encouraged since the first week. Here we can see the fractured heel. And the full use of the injured finger usually is allowed by six weeks. But when conservative treatment is not indicated, as in these examples, unstable, unproductive, multiple dysplasias, sometimes horrible fractures, if we have to operate a fracture, we prefer the less the better. Local anesthesia instead of general anesthesia or axonary block, close reduction whenever it's possible and minimal contact of the material to the extensor tendons. The close reduction and percutaneous pinning has less risk of adhesion of extensor tendons, but a period of immobilization was typically required, and stiffness was not rare. But if you use local anesthesia, you can check. Sorry, it's changed the video, sorry. You can check under the fluoroscopy if the fracture is stable enough. And the most important, the patient realizes that he can move, safely move the finger, and he will remember. We try to adapt the pain to the movement. Dr. Lalonde has introduced the concept of pain guide, the early protective movement. And I used to tell the patient, when you reach the border of the pain, don't cross it. And usually they understand this concept. We wish to share the video with the patient and the therapist, if they agree. And this is helpful to involve them in the treatment. Here is the movement in five days. And we remove the key wires at three or four weeks, as Celso has told previously. We have also used intramedullary screw for some patterns like this, retrograde with local and early protective movement, or another case, retrograde or also anterograde, as we have seen previously. I seldom use place for finger fractures, as the stiffness is common. But if we decide to use it, we should try to avoid, if we can, the contact to the extensor tendons. I remember this patient was under therapy for months and months. For open fractures, we can use external fixation and sometimes absorbable suture, like this case, to approach the fracture fragments. For joint fractures, we keep the most anatomical reduction possible. And, of course, early mobilization. Here in the surgery room, we are teaching the patient how to move. And after three weeks, the patient was playing tennis against me. But fortunately, the fracture didn't complicate it. For articular displaced fragments, it's very useful the local anesthesia, as in this case. This fragment was disturbing the gliding of the flexor tendons. And after the fixation, we can check that the movement is completely normal. And it's very important the close follow of the patient. And we also use this bandage, the coban bandage, to try to avoid the edema. And here's the final function. In displaced articular high-energy injuries like this, we always need open reduction, keyword fixation. But in this case, he was a physiotherapist. And when we were operating, he told me, we will see here for the tenolysis, doctora. Maybe not, but in this case, it was a very important affectation of the soft tissues and the stiffness was previsible. And after taking the keywords, three months after taking the keywords, we performed the tenolysis. And here we can see the patient is working and is very happy. I would like to dedicate the last minute to the PIP joint because it's prone to stiffness. And immobilization will result in permanent loss of motion. We look for men reduced joint, early range of motion with of compromising instability. And sometimes the quality of the reduction is not correlated with clinically relevant post-traumatic arthrosis in the PIP joint. As we can see in this case, a young lady, volleyball player with this fracture, dislocation. The X-ray is not really very good, but the patient now is playing. It's in competition. I don't know what is going to happen with this joint because it's very young, but he has no pain now. And this is the last case that I would like to present you. It's a young rheumatic patient who falls into the hand with the extensor fingers and presented off with this proximal metaphyseal fracture, the proximal phalanx from the third to fifth fingers, and PIP fractures of the second to fifth fingers. And you can see here that the patterns were different. And in this case, we tried to tell each finger different treatment. And for the second finger, we decided extensor block pinning, but it was a very convenient fracture. We decided transarticular for three weeks, not more than three weeks, I agree, immobilizing the joint. And as index finger tolerates, it's the finger that better tolerates the stiffness. For the third fingers, we had to decide a hematoreconstructional for plastic external fixation for the four-finger palin fracture. And after check that the gliding was concentric in the three fingers, we decided conservative treatment. The edema was very important in this finger. In these cases, we used corticoid treatment, intraoperative and a few days postoperative. And all the measures, elevating compression, protecting motion. And fortunately, two years later, she has not perfect room, but painless and functional hand. So, to take home. To sum up, to decrease stiffness in finger fractures, we prefer the less the better, less immobilization, local anesthesia, minimize soft tissue injury, less hardware in contact to tendons, adequate fracture stability tested during the surgery, preferably by Wallen, and early motion protocols avoiding edema and pain. And important, good communication with patient and therapist. We need to work in team. Let's remember that our final goal is functional hand in happy patient. And so, thank you very much for your attention. countries, I'm going to take a little bit of a different spin on it. And I'm going to focus a little bit on what words I use with wide-awake patients. Because I find that intraoperative education is probably one of the more important things that I do instead of, you know, talking to the nurses about their kids or listening to rock and roll. I like to talk to the patients, and over the years I've developed patterns of words that seem to be effective, and I'd like to share those with you. You know, we love to open these things and look inside. The anatomy is so pretty. But every time we do that, that space fills with blood, and blood turns to callus and scar. And every time I open a fracture like that, I know I'm going to have at least three more months of stiffness, no matter what kind of fixation that I use. So I try to avoid that. And to avoid it, I use a lot of K-wires. I try to do things percutaneously. There's two tips for teaching residents how to more easily insert K-wires. The first is, with your C-arm, just put the K-wire over top and then draw it so that the surface anatomy of where the pin needs to go is a little easier for the residents. And then the second thing that I do, and you can see me drilling a K-wire, or my resident drilling a K-wire through a 16-gauge needle. So part of the problem when you're putting a K-wire on the side of the fingers, that it tends to slide off. So if you bite the cortex with a 16-gauge needle, and if you're lucky enough to have an assistant, the assistant can hold that needle, and you can see with your fluoro exactly where the needle is, and then you can fire the wire, and it doesn't slip off. And I'd like to thank Alex Shin for teaching me that. On Friday, we're going to start what's called Early Protected Movement with Pain-Guided Healing. So what that means is, that Amanda, you're going to have zero Advil, zero Tylenol. And you're going to move it just a little bit so it doesn't get stuck. If you move it this much, that's enough tending gliding that you're not going to get stuck. If you don't move it at all, everything in there turns to like jello with fruit in it. Like everything gets stuck to everything else. You'd like the tendons to keep moving, but you'd like the bone to stay together. If you don't do what hurts, the bone will stay together. When it starts to hurt, it's because the bone's coming apart. It's going to talk to you. It's going to tell you. And so if you just move the last joint a little bit, and even the middle joint, you can move as long as it doesn't hurt. Pain-Guided Healing. If it hurts, you can't do it. If it doesn't hurt, you can do it. Does that make sense? Makes sense. Perfect. And we're going to do that starting on Friday. But between now and then, what are you going to do? Tell me what you're going to do. Just keep my hand up. Right. Don't move it. Right. No walking around like this. No. And none of this. Perfect. All right. Great. And tonight, you can take 800 of Advil, and half an hour later, if that's still sore, you can take Tylenol. And never give narcotics for these. And I tell every patient, the pain of the break, if you keep it up and quiet like a sleeping baby over the weekend, by tomorrow or the next day, the sting of the break is going to be gone. And you're going to be into the pain of, gee, doctor, now it only hurts when I put my hand down or when I do stuff. As soon as you get into the pain of, gee, doctor, now it only hurts when I put my hand down or when I do stuff. That's when you quit taking painkillers and listen to your body and don't do the stuff that hurts. We didn't spend two billion years evolving pain because it's bad for us, and most patients will nod wisely. I say, your pain is your body's only way to say to you, hey, would you quit that? I'm trying to heal in here, and you're screwing it up. Stop that. And that's a little voice in your head you want to listen to, I think, but you can't hear it with Advil or Tylenol in your ears. And every one of my patients in every operation I do gets that little sermon on the mount, and it works. Most people who are reasonable will respond to that. Being able to get out of the cast has been nice. Yeah, so four days in this splint and took Advil maybe six times, and now we're going to start pain-guided movement and pain-guided therapy. Oh, that feels good. It does feel good, doesn't it? So you can wiggle your little finger as long as it doesn't hurt. I've been doing it all week. Good. A little bit inside, right? Just a little bit inside the cast. Yeah, just like I asked you to. I told him he could wiggle it a little bit inside the cast, and he hasn't had any Advil since yesterday morning. There's no Advil on board right now, so we can start moving it a little bit. You can tell that he's had his hand up the whole time, and he's listened, even though he's been working, because it's not swollen. It's like a report card. So I know that he's a good patient, and he's going to do everything I ask him to do. So at this point, what I want you to do is just put your finger right there, right? Hold it like that on either side. The other way. Yeah, right. And just wiggle the tip a little bit. That doesn't hurt? No. Okay. Well, if you look at the x-ray, too, you can see that I've broken the top of this before. Yeah, right. So do that again, but this time, just hold it. That felt funny. Yeah, don't do what hurts now. Back like you were doing. Just pull it in a little bit, and hold, and count to ten this time. Don't just wiggle it. Right. Okay. What you do is you take it to pain, but not past pain, and hold it and count to ten. And you do that at least ten times a day. And then move it down and do it to the next knuckle. Now, the next knuckle, you're not going to be able to move as much, because it's going to be sore. But just a little bit. Is it ever? Then don't do it. Then back off. I can do that a little bit. Yeah. Okay, and that's it. You only take it to pain, never past pain. Does that make sense to you? Yep. Beautiful. That's called pain-guided healing, pain-guided therapy. And over and over again, I say all you want it to do is not get stuck. And we treat these the same way we treat flexor tendons, for the same reason. A stiff finger is a useless finger. And we know they can do a full fist during surgery, so we know they can do up to half a fist without worry at all. You just want to keep the tissues gliding so they don't get stuck. It's exactly the same principle as flexor tendon treatment. It's the same anatomy. The day we took you out of your cast and put you into this splint that you now take off and on, right? Yes. You take it off to get in the shower. Just put it on so we can see what it looks like. It's off more than on. And that's fine. Fantastic. And can you move your finger inside it? Yeah. And does that hurt at all? No. Actually, it's helping. Just because of this being cut away. Yeah. At least I can get some movement out of it. Fantastic. It's more for protection. Okay, go ahead and show me a fist and straighten out. Fantastic. Do it again. We had a mallet before of that little finger. It's been like that forever. And turn it the other way and show me. Right. Does that look crooked to you or not? No. Okay, bring it in more. Right. Does that look crooked to you? No. Okay. Can you straighten it out? Right. So up higher than your heart for three or four days. A little Advil tonight or tomorrow and then nothing. Okay. Nothing because you can't start moving it if you're on Advil or Tylenol because you don't know what hurts when you're on Advil or Tylenol. Okay. When you're totally off Advil or Tylenol in two or three days, you can start to wiggle it a little bit. Thank you. Because if these all heal, the problem is they get stiff. And so if you're moving it a little bit, it's not going to get stuck. You don't want it to get stuck. Okay. But you can't do what hurts because if you do what hurts, you might get infection around your pins or you might take the fracture apart. If you don't do what hurts, you will not take the fracture apart. You will not get infection around your pins. Does that make sense to you? Okay. So we're two weeks from K wiring, correct? Yes. And you go ahead and show me the movement that you just did. So beautiful MP movement, beautiful DIP movement, and beautiful PIP movement. And that's all we need to do. If she does more than that, it hurts, right? It does. But doing that much does not hurt, correct? No. And you're totally off Advil or Tylenol? Yes. My kind of woman. This is what's called a perfect patient because this is not going to be stuck. She's not going to have stiffness. And I don't have a religion about how many weeks do I pull out the pin. I pull the pins out when it's clinically healed, and it's clinically healed when you press on it and it doesn't hurt. It's healed. If you go in there to fix a maluniting fracture, if you press on it and it doesn't hurt, you're going to need a freer elevator or dynamite to get that apart. So I know that when it doesn't hurt, it's clinically healed, I can pull the pins out. If that's two weeks or three weeks, fine. If it's devascularized, like a wood splitter injury or like an open reduction where you've taken away the blood supply, now it's going to take longer. So you're probably better off doing percutaneous screws if you're going to open it. So I think that testing the stability with full fist flexion really makes me comfortable about doing up to half a fist. And this concept of you press on the fracture and it doesn't hurt anymore, that's when you pull out your pins, enables you to take out K wires earlier. I took her K wires out at two weeks because it wasn't hurting when I pressed on it anymore. It's not a time thing, it's a healed thing. Obviously, if somebody has nerve injuries, then that's out. If they're numb, it doesn't count. This was a very difficult PIP fracture, and you see the before and after pinning x-rays. We used this percutaneous K wire guided bone clamp to reduce the fracture. And what this did was to hold the fragments in place. And move that just a little bit. We're now two weeks. There we go. Beautiful. That's all you need. You don't need any more than that. And that doesn't hurt, right? No, a little. Yeah, let's not go there. Great. And just flex it. And straighten. It's not stuck. It's moving. And as long as it's moving, I'm happy, right? Yes. But she's not doing what hurts. And so the two pins that you can see there are not infected because she's doing pain-guided healing. And extend it. Slowly flex it. And none of that's hurting, eh? It's pulling. It's pulling, but not hurting. And straighten. Pulling's okay. Hurting's not okay. Here she is 10 days after we started pain-guided movement. At eight weeks, we pulled out the K-wires. You can see the two K-wires sticking out of the skin there. And look at how little inflammation and no infection there is because the patient doesn't do what hurts. And she's not taking painkillers. So she knows what hurts. We removed the K-wires eight weeks after pinning because the fracture was no longer sore to palpation, clinically healed. Here's the result at 10 weeks. When I was a young surgeon at 10 weeks, they used to be so stiff. So because it was an unstable PIP fracture, I waited longer to start early protected movement. You gotta get it sticky enough. You know, and it takes 10 to 14 days for fractures to get sticky. And also, you know, she's 72 years old. So it took a little longer for clinical healing to happen, which is why I waited so long to take the pins out. That's a long time for me to take pins out. But she was still sore. It was still unstable. So I gotta have the patients talk to me and I gotta listen to what their bodies tell me. So I'm gonna stop my slides there, but I am going to invite the panel up to come up and look at a couple of cases. Dr. Stern may not be able to stay the whole time, but Lee and Anna and Celso, can you come up? Well, maybe you wanna stay there and look at the x-ray. I don't know. And yeah, well, and here, maybe we can give you a. There we go. No, I think we can come. That's all right, I'm fine. Well, obviously it's scissoring. And the question is, and it's a long of like, so for me is, I think everybody showed one of these. You're looking at a couple of pins brought in from the side, restoring, and then I would start, maybe it's because Americans are wissier, but they just don't have the stoicism, nor can I trust them to say, don't move it between pains. So interesting enough, I asked Peter, at least in our country, Advil didn't fracture at all. Pardon me? Advil or Motrin and fractures has sort of gotten this reputation. It's like smoking cigarettes. Inhibits the inflammatory phase. Now you're personally taking one or a couple during the first day, and that probably makes no difference. But if you prolong Advil over the healing, it does delay the healing, at least in animal studies. You sure that's not a little like adrenaline in the finger, Lee? I'm just telling you. I've never had a problem with Advil and fractures, never. Huh? I've never had a problem with Advil and fractures. Well, but you don't have a lawyer when it didn't heal, and you gave him Advil 800 three days a week, and he pulls out the article, and I just say, well, you know, rabbits are rabbits. Yeah, but they're only doing Advil one or two nights. In your country, in my country, they're doing it, they started on Advil before they broke it, and they're running Advil after for all the other aches and pains they've got. Well, this is fun, because we're gonna find out what they do in Spain and Brazil. So, Ana, get up and talk about what do you do. I'm completely angry with you. What's that? It's, it's, it's mal-rotated, the finger, because she's soaring, so. Yeah, no, talk to us about what you do for pain. Ah, for pain? Yes. Oh, okay, sorry, sorry. For pain? Sorry, Dr. Osterman just said that he does not give Advil because he's worried about inflammation and decreasing healing. Do you use ibuprofen for fractures in Spain? Yeah, we use ibuprofen for fractures in Spain. Okay, and the second thing is, do you? We use ibuprofen and paracetamol, alternative paracetamol and ibuprofen. Acetaminophen and ibuprofen, that's what I do, too. And the second question I have for you is, do you ask your patients to get off all painkillers before you do early protected movement? Yes, they have to get the painkillers for the pain, because- Well, you give them painkillers. I give, sorry? Sorry. Do they come off of painkillers to move early, or do they stay on painkillers to move early? I used to say, the first day, have pain, first two day, maybe first two days have painkillers, and if you start to move the third, fourth day, you don't have pain. You can take one painkiller, another, not all the painkillers the same day. Okay. They are taking out- So you slow them down, but not off. Not one day, not- Not completely off. All the treatment, to zero treatment. Maybe in Spain, people don't want to feel pain, and I don't know, it's the similar here. Right, right. I don't know if there are Spanish people here. Or Peter. No. For the counter, you don't need a prescription for them. Celso, what about in Brazil? We have lawyers in Brazil, too, and I went for a search for anti-inflammatory in fractures, and there are a lot of articles saying that you can use. You're allowed to use, so you have a defense on that. But I use painkillers. I'm not- You're not like me. My patients are not like yours. I use painkillers. So it's not just Americans. I guess we have this problem. Peter, come on up. Do you guys want to stand up here, or what do you want to do? Just do what you want to do. Come on up if you want. One thing to mention is that when you look at these X-rays, it's a pretty benign-looking fracture, and one of the things with phalangeal fractures is that you really need, as Don's given away here, you need to treat the injury rather than the radiograph. So a little trick for American patients that don't like pain is to, if they won't bend their finger pre, first time you see them, do a metacarpal block. That'll provide anesthesia, and then ask them to flex their finger, and by doing that, you can very easily see that there's malrotation or no malrotation. If there's no malrotation, I wouldn't do any surgery, but if there is malrotation, which is very poorly tolerated, I think some type of fixation, I also prefer K-wires. Yeah, that's a great trick, Peter. Thank you. So four days ago, we put freezing in your finger and put pins in. How sore was the freezing? Um, it wasn't too bad. No? No. Then we put K-wires in your finger, and you've been keeping your hand up. Now today, are you on Advil or Tylenol or nothing? Nothing. Perfect. Most important rule here. So in her case, you know, we ended up, and maybe Canadians are tougher than other people, but I don't think so. I think Canadians are just as wussy as Americans. I have to disagree with Lee about that. Beautiful. Nice, straighten out. Anyway, we did okay. So the second case, this is a PIP fracture with a dorsal dislocation, and I know there's several ways to skin this cat. Why don't we start with Dr. Stern, because so far, his body's still here, so. Okay. So again, I think that radiographically, this is unacceptable. The one thing that I am having a little trouble deciding is whether there is a fracture of the, where the extensor tendon inserts into the dorsal lip of the middle phalanx. Is the dorsal cortex intact? It is. Okay, so you could start out in the office under anesthesia, do a closed reduction, test active flexion and extension. If the joint does not clinically or radiographically pop out, you could treat the patient non-surgically in some type of extension block splint. If the fracture is determined unstable, and in general, if there's more than about 30 or 35% to the base of P2 that's fractured, the chances are it's gonna be tenuous. More than 50%, we generally say, very much unstable. So then, there's a whole host of treatments. If you wanna be minimally invasive, I think a good technique, actually, is extension block pinning, which is not that popular in our area, but I think it works fairly well. The problem is, potentially, is getting pin track infections. You wanna be, another thing would be using dynamic external fixation, which works most of the time. And of course, if you wanna open it up, I think many people would consider a hemihemate replacement. That's a technically difficult operation, but potentially provides a home run. More recently, actually, with a less comminuted fracture, but an unstable PIP injury pattern, people have started using very small plates and screws, much as we would do with a distal radius fracture, and that's another possibility. The use of palmer plate arthroplasty, as advocated by Dr. Eaton and others, has kind of fallen off of popularity in the states. Great, I'm just gonna carry on and show what we actually did. So we reduced it, it was unstable, and I put in two pins, because it was two weeks old, and it really wanted to pop back out of there. And we started moving at four days, and she ended up with a good result. So dorsal blocking splints, which was your first choice, is exactly what I did. And I gotta say that before I started early protected movement with pain-guided healing, before I did the pain-guided healing, I used to get infected K-wires all the time. And since I've been pushing on patients to get off Advil, Tylenol, and follow pain-guided healing, the infection K-wire rate is way lower. Now, all bets are off when I'm talking to drug patients, right? Like, if you got people who are drug addicts or whatever, you just can't do any of this kind of stuff. I'm talking about if anybody in this room had a problem, and a lot of Canadians are reasonable people who aren't drug addicts. And for those people, it works quite well. But if they're not, then you just can't do it. And so, go ahead, Lee, did you wanna make a comment about last night? I mean, I would treat the same way Peter did, but there are two things you saw that Anne gave you, is Coban is your friend early on. Do you use Coban, Don? You don't mention it. I use Coban for everything. It's like that commercial. I put that on everything. Yeah, Coban gives stability to the area. It also allows them to move, and it decreases swelling. And the other thing I use, particularly as they get a little later on, and assuming they're reasonable, is buddy strapping it to the other digit to move it. And so, buddy straps and Coban are two simple common things that I use on almost every finger fracture at some point. Yeah, no, that's a great tip. It reminds me of one other tip, and that's called steering wheel therapy. So, whether it's a flexor tendon or a finger fracture, if it's stiff, I tell them, you're driving, right? Yeah, I'm driving. Okay, here's what I want you to do. Every time that you put your foot on the brake, as soon as your foot hits the brake till the time it comes off, I want you to try to touch the tip of all of your fingers, including that one, onto the steering wheel. So, when you hit your brake to slow down for the stop sign, you're doing it. And as soon as you take it off to leave, you're off it, and you do it for every red light, every stop sign. I drove four hours to see you, Dr. Lalonde. I can't believe that my finger's so much better than it was. And steering wheel therapy helps. People have to not stop living to exercise. They have to exercise while they're living. That's kind of Gwen Van Streean talking to me in my head there. So, anybody want a bite on this one? You're doing a closed reduction, and you look at the x-ray and you go, ooh, I don't know if I want to bite that or not. Should I open it or not? Celso, are you going to open that one? Come on up here. I would try closed, but if I couldn't reach a good reduction, I would open. Yeah, yeah. Minimally, but I would. Yeah, it's a hard one, eh? Because you don't really know. Ana? Difficult, but if concentric, I will try to open. Yeah, so let's pretend he's awake, right? And he does it, and it seems to move pretty well. You going to go for it, or are you going to open it? I think. You're going to go for it? You're going to leave it be? I leave. Yeah, do it conservatively. Peter or Lee? Yeah, the beauty of Volantis is that you can ask the patient to move her finger, and this is actually reasonably well-reduced if you kind of draw a line tangential to the dorsal cortex of P1 and P2. They're more or less collinear. So my inclination would be that if the patient was flexing his or her finger pretty well, 70 to 90 degrees, I would not do anything more. So I would not open it. Yeah, Lee, same thing? Yeah, the enemy of this is perfection, right? Right, the enemy of good is perfect, yeah. And really what it boils down to is, do you want a perfect X-ray that's going to give you X more weeks of swelling and stiffness, or are you going to risk later arthritis and pain maybe? And really that's the devil in the deep blue sea that you're playing. So anyway, here was my devil in deep blue sea. I did him with Wal-Mart, and he was moving very well. So go ahead and move, bud, thank you. So he ended up with a good range of motion, because even though the X-ray was not perfect on the table with his movement, he was good. Now he may come back with arthritis later on. Thank you so much, Peter, yeah. He may come back with arthritis later on, but anyway, in the short one, we decided to do that. So perhaps the panelists could come up, and we could take questions from the people in the audience if there are any. We've got four minutes left. Dr. Stern had to leave. If there are any questions for the audience, or if you'd like to tell me that I'm full of it, because Canadians are, you know, tough and all that, I'm good with that. Yeah? The message is, avoid plates at all costs. The question is, avoid plates at all costs. Lee, you want to? Again, plates are not my go-to, but I showed my last case, that metacarpal that was basically scrambled eggs on the wall. There's no way to fix that with K-wires. And so I use plates, but plates, if I get it on, I move them early, and they're spending a little more time in therapy than some of the relatively simple fractures that you've seen. I mean, if you look at the opposite side, if you take an elbow, we always teach our fellows, you get your alignment, if they get stiff, we'll go back and do a contracture release. And that does pretty well for some bad elbows that you've had to stabilize, but not in the fingers. So I move them early and often, and if I put a plate on, I make sure that they can move it. The other thing I would emphasize is, there's certain fingers, an index finger that Dr. Stern showed early on, he got a great result, because your index finger, you don't use in full flexion. But you're wringing small fingers, you're spending a lot of time holding onto the rope, or you're driving the steering wheel with those fingers. And so your goal there is gonna be to get more motion. You can accept less motion in the index. And finally, if you really get stuck, I always pin a finger in extension. You give me a finger in flexion, I don't care if that reduces it. I'll never get that finger to straighten through the cobweb of a central slip. So I can always get some flexion. The flexor tendons are six times stronger than my extensors, so I can always, at some point, get some flexion. If I don't have extension, if they're 90 degrees contracted in the PIP, it's often a very lonely uphill battle, and I'm the one that starts taking pain meds. Dr. Folberg, do you try to avoid plates in fingers? Well, as I said, in that case, as I presented, I thought the plate would be the best way to go and put a bone graft, but in the rest, I try to be minimally invasive. So plates are the lowest. Dr. Carreño? The concern is not avoiding completely the plates, but when I was young, we played all the fractures in the fingers. We played fractures, proximal, middle, even distal fracture. I think that we have to don't use the plates for all the fractures, because the stiffness is really important here. You have to decide depending on the fracture. Yeah, and I think the same. I used to plate finger fractures, and I've had the same discussion with Peter Stern, and he's moved away from plates in general. So the gentleman in the back, and then the gentleman in the front. Dr. Lalonde, how long are you cutting your K wires over the skin? Does it change if you're doing it around the metacarpal head? And what are you telling your patients to take care of them, cover, skin, Band-Aid, whatever? Yeah, so shower, daily shower, and a little Vaseline around the pin. But most, if they're out, but most of the time they're in. Most of my pins are buried, and I put a little freezing in to take them out. So that's what I do with those. Yes? Yeah, two questions. For the people that use the intramedullary screws, for a P1, do you see any difference between putting it through the MCP versus going through the PIP joint? And then number two, Dr. Lalonde, if you do use the intramedullary screw, are you a little bit more free in what you tell them to do in their post-op rehab? Right, I must say I'm not a screwer. I am a K-wire-er. My condolences. So I'll let my co-panelists take that. So Dr. Folberg, do you prefer anti-grade or retrograde in the P1? It's easier to put from distal to proximal. It's easier, but you can go either way, I think. Distal, sorry, distal to proximal, you have the risk of the central band of the central apparatus, so you have to be very careful. Medicarpo's, I think, Medicarpo's, for me, distal to proximal. Proximal phalanx is proximal to distal. I mean, nobody's really studied what the defect we're creating in that proximal phalanx articular surface. You have a little bit more give in the medicarpo, but I worry about a big hole in the PIP joint, even though I agree with my colleagues it's an easier shot that way. But there are some new techniques with smaller screws doing double screws particularly for that basal proximal phalanx fracture that gets displaced dorsally or is rotated. And that's the reason I'm not a screwer is because I'm waiting for the long run, what's gonna happen to that PIP joint. So the last questions and then we'll wrap it up. Sir, that's you, yeah. So I was just gonna ask, Dr. Stern referred to the fact that if you get to the point where you're gonna do a tenolysis and you recognize that they need it on both sides, maybe you shouldn't do all that at once. So I just wanted to pull the panel on, what do you do then? How long do you wait before you go back and you tackle the other side and what are you doing with them in the meantime? Yeah, so if you do the volar side or the dorsal side, it's still stuck and are you gonna go in and do the volar side? If not, how long are you gonna wait? You know, my preferred thing, I don't do a lot of those because I just for some reason don't seem to be that unlucky. But I would rather not tackle a finger more than I have to. I think I'd have to individualize that. I'm not sure even how to answer that. Can you guys answer that? My answer, I agree with Peter. If you go in top and bottom, you get a finger that's a sausage and no matter how much you try, you just get enough scar and enough edema that you're really pushing that stone up the hill that I let off with things. But I will, again, I always address the extensor mechanism which is always my bane. I will, proximal to the A1 pulley, particularly if they've just had a fracture and there's no surgery done on the volar side, there's gonna be scar but I think you can break that. So I make an incision proximal to my A1 pulley. I take an Alice clamp and I roll those tendons up in the Alice clamp and I start pulling like crazy. With one exception where I actually pulled hard enough to rupture the flexor tendon, you actually can break up some of those adhesions and particularly if the patient's actively pulling with you. Yeah. We are three minutes over. Is it a burning one? It's a quick one. Okay. Maximum size of K wire and proximal phalanx and better to use multiple small wires or bigger ones. Quickly, I'm a 3-5-2-8 kind of guy and the proximal phalanx, I almost never use a 4-5. Anna, what size of K wires? 1.5. You don't use a one millimeter or what? Yeah, 1.5 millimeters, she says. Lee? I'm a 4-5 in the proximal portion and 3-5 in the distal half. Yeah, I use 1.2 millimeters usually. 1.2? In the proximal phalanx. Okay. Is that a 3-5 or a 4-5? 4-5. 4-5. See, plastic surgeons tend to use 3-5s, orthopedic surgeons tend to use 4-5s. On that note, have a great evening, guys. Thank you.

hand surgeons

preventing stiffness

finger fractures

early motion

fracture stability

conservative treatment

minimally invasive surgery

fracture fixation

complications

patient compliance

rehabilitation programs