Athletic Injuries of the Upper Extremity: the Adolescent to the Adult - the Amateur to the Professional Co-Chairs: R

Home , Brunelli procedure

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional Co-Chairs: R. Glenn Gaston, MD, Gary M. Lourie, MD, Thomas A. Wiedrich, MD

Program Syllabus Thursday, September 05, 2019

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 – 7, 2019 LAS VEGAS, NV

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional

The treatment of the injured athlete remains a continued challenge. The skeletally immature, the weekend warrior, the high-level amateur and the professional athlete all pose specific difficulties for the hand surgeon in treating the injury. Ultimately, however, the surgeon is nearly always faced with the goal of early return to play with minimal risk. This goal must be balanced with the chance of re-injury and lasting damage to the patient. The purpose of this pre-course is to offer an up-to-date review of hand, wrist and forearm injuries in the athlete, emphasizing pertinent anatomy, mechanism of injury, conservative and operative treatment and safe return to play. Lectures given by noted faculty will be divided into anatomic modules with attention to bone, ligament, tendon and miscellaneous topics. Case presentations will initiate each talk followed by a concise presentation on the specific topic emphasizing potential differences between the adolescent and the adult and the amateur versus the pro.

LEARNING OBJECTIVES At the conclusion of this program, the attendee will: • Manage athletic injuries in athletes of all ages and abilities. • Utilize treatment algorithms of common athletic injuries. • Apply current treatment concepts in treating athletes to any hand practice.

CME CREDIT HOURS The ASSH designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Conflict of Interest Disclosures for 2019 Program Committee and Course Faculty

Program Faculty & Disclosures The American Society for Surgery of the Hand gratefully acknowledges those who have generously volunteered considerable time and effort to plan, organize and present this CME course. The ASSH appreciates the faculty’s dedication to teaching, their support of the ASSH mission, and their significant contribution to the educational success of this program. The following is a list of disclosures for all participating faculty and program staff.

CONFLICT OF INTEREST POLICY According to the ASSH conflict of interest policy, individuals involved in continuing medical education activities are required to complete a disclosure statement. The ASSH acknowledges this fact solely for the information of the listener. Non-conflicted reviewers have examined, documented and resolved financial relationship disclosures for this course content.

Financial Disclosure – represented by ● Instructors, planners, content reviewers and managers who affect the content of a CME/CE activity are required to disclose financial relationships they have with commercial interests (i.e. any entity producing, marketing, pre-selling, or distribution health care goods or services consumed by, or used on, patients) associated with this activity.

FDA Disclosure – represented by ▲ Some drugs or medical devices demonstrated at this course may have not been cleared by the FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or medical device he or she wishes to use in clinical practice.

The ASSH policy provides that “off label” uses of a drug or medical device may be described in the ASSH CME activities so long as the “off label” use of the drug or medical device is also specifically disclosed (i.e., it must be disclosed that the FDA has not cleared the drug or device for the described purpose). Any drug or medical device is being used “off label” if the described use is not set forth on the product’s approval label.

Planners 2019 Annual Meeting Program Chairs Duretti T. Fufa, MD Consulting Fee: Medartis and Integra Contracted Research: Medartis

James P. Higgins, MD No relevant conflicts of interest to disclose

Session Co-Chairs/Moderators Gary M. Lourie, MD No relevant conflicts of interest to disclose

R. Glenn Gaston, MD Royalty: Zimmer Biomet Receipt of Intellectual Property Rights/Patent Holder: BME Consulting Fee: Zimmer-Biomet, Endo, Integra and BME Speakers Bureau: Endo

Thomas A. Wiedrich, MD No relevant conflicts of interest to disclose

Faculty Mark E. Baratz, MD Royalty: Integra Receipt of Intellectual Property Rights/Patent Holder: Integra Speakers Bureau: Integra

Michelle G. Carlson, MD No relevant conflicts of interest to disclose

Randall W. Culp, MD Royalty: Arthrosurface and Arthrex Consulting Fee: Zimmer Biomet

Rodney J. French, MD Receipt of Intellectual Property Rights/Patent Holder: Zimmer Biomet Consulting Fee: NHL, NHLPA, Calgary Flames and Nashville Predators Speakers Bureau: Bioventus and Exogen

Thomas J. Graham, MD Royalty: Zimmer Biomet

Thomas R. Hunt, III, MD, DSc No relevant conflicts of interest to disclose

Jeffrey B. Husband, MD No relevant conflicts of interest to disclose

Fraser J. Leversedge, MD Royalty: Wolters Kluwer, OrthoHelix Surgical Designs and Wright Medical Consulting Fee: AxoGen, Bioventus and Stryker Contracted Research: AxoGen

Marc J. Richard, MD Royalty: Acumed Consulting Fee: Acumed, DePuy Synthes, DJO and Medartis Speakers Bureau: Acumed, DePuy Synthes, DJO, Medartis and Bioventus

Melvin P. Rosenwasser, MD Consulting Fee: Stryker, Acumed, Zimmer Biomet and Conextions

James M. Saucedo, MD, MBA Royalty: Hely & Weber Speakers Bureau: TriMed Ownership Interest: Edge

Steven S. Shin, MD Royalty: Arthrex and Hely & Weber Consulting Fee: Arthrex

Douglas R. Weikert, MD No relevant conflicts of interest to disclose

Thomas A. Wiedrich, MD No relevant conflicts of interest to disclose

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult – The Amateur to the Professional

Thursday, September 05, 2019 – 7:00 AM – 11:00 AM

Roman Ballroom II, Caesars Palace Las Vegas Co-Chairs: R. Glenn Gaston, MD, Gary M. Lourie, MD, and Thomas A. Wiedrich, MD

Description The treatment of the injured athlete remains a continued challenge. The skeletally immature, the weekend warrior, the high-level amateur and the professional athlete all pose specific difficulties for the hand surgeon in treating the injury. Ultimately, however, the surgeon is nearly always faced with the goal of early return to play with minimal risk. This goal must be balanced with the chance of re-injury and lasting damage to the patient. The purpose of this pre-course is to offer an up-to-date review of hand, wrist and forearm injuries in the athlete, emphasizing pertinent anatomy, mechanism of injury, conservative and operative treatment and safe return to play. Lectures given by noted faculty will be divided into anatomic modules with attention to bone, ligament, tendon and miscellaneous topics. Case presentations will initiate each talk followed by a concise presentation on the specific topic emphasizing potential differences between the adolescent and the adult and the amateur versus the pro.

Learning Objectives At the conclusion of this program, the attendee will:

• Manage athletic injuries in athletes of all ages and abilities. • Utilize treatment algorithms of common athletic injuries. • Apply current treatment concepts in treating athletes to any hand practice.

PROGRAM 7:00 – 7:05 AM Introduction Gary M. Lourie, MD

7:05 – 7:59 AM Miscellaneous Upper Extremity Injuries Moderator: Thomas A. Wiedrich, MD

7:05 – 7:15 AM Forearm Fractures Fraser J. Leversedge, MD

7:16 – 7:26 AM CMC Joint Injuries Randall W. Culp, MD

7:27 – 7:37 AM Kienbock's Disease Thomas A. Wiedrich, MD

7:38 – 7:48 AM MCL Injuries of the Elbow Marc J. Richard, MD

7:49 – 7:59 AM Discussion and Questions

8:00 – 8:54 AM Traumatic Conditions of the Wrist Moderator: Jeffrey B. Husband, MD

8:00 – 8:10 AM SL Injuries Steven S. Shin, MD

8:11 – 8:21 AM Acute TFCC Injuries Jeffrey B. Husband, MD

8:22 – 8:32 AM Ulnar Impaction Syndrome Mark E. Baratz, MD

8:33 – 8:43 AM ECU Sheath Injuries Thomas J. Graham, MD

8:44 – 8:54 AM Discussion and Questions

8:55 – 9:10 AM Break

9:10 – 10:04 AM Fractures of the Hand and Wrist Moderator: R. Glenn Gaston, MD

9:10 – 9:20 AM Phalanx Fractures Rodney J. French, MD

9:21 – 9:31 AM Metacarpal Fractures R. Glenn Gaston, MD

9:32 – 9:42 AM Scaphoid Fractures Thomas R. Hunt, III, MD, DSc

9:43 – 9:53 AM Other Carpal Fractures James M. Saucedo, MD, MBA

9:54 – 10:04 AM Discussion and Questions

10:05 – 11:00 AM Tendon and Ligament Injuries of the Hand Moderator: Gary M. Lourie, MD

10:05 – 10:15 AM Skiers/Gamekeepers Michelle G. Carlson, MD

10:16 – 10:26 AM Jersey Fingers Melvin P. Rosenwasser, MD

10:27 – 10:37 AM Extensor Tendon Injuries Douglas R. Weikert, MD

10:38 – 10:48 AM Pulley Injuries Gary M. Lourie, MD

10:49 – 11:00 AM Discussion and Questions

11:00 AM Conclusion R. Glenn Gaston, MD, Gary M. Lourie, MD, and Thomas A. Wiedrich, MD

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 7:00 AM - 7:05 AM

Introduction

Gary M. Lourie, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

◼ Athletic Injuries of the Upper Extremity-The Adolescent to the Adult-The Amateur to the Professional

◼ Gary M Lourie

◼ Introduction

◼ PreCourse 12

◼ Athletic Injuries UE

◼ Treatment Injured Athlete Challenge

Skeletally Immature

Weekend Warrior

High Level Amateur

Professional Athlete

All Pose Specific/Different C

Levels of Difficulty

◼ Athletic Injuries UE

◼ Goal Elite(Any)Athlete

◼ Early Return to Play

Balance Return

Long-term Risks

Medicolegal issues

Conflict of Interest Team vs Player

◼ Athletic Injuries UE

◼ All Hand Surgeons Share Similar Goal

◼ Early Return to Play

◼ Minimal Risk Professional/Amateur/Child

◼ Athletic Injuries UE

◼ Early Return to Play ◼ Minimal Risk

Balanced

Chance of Reinjury

Lasting Damage

◼ Athletic Injuries UE

◼ Treatment Elite/Amateur

◼ No Specific Guidelines

◼ Literature Scant (Rec Scarce) Legal Issues

◼ Differences Age, Position, Level of Play, Inseason vs out

◼ Athletic Injuries UE

◼ Literature Minimal (Excellent)

◼ 1)Hand Injuries in Athletes, Strickland and Rettig 1992

◼ 2)Acute Hand and Wrist Injuries in Athletes; Evaluation and Management JAAOS, 2001

◼ 3)Athletic Injuries of the Wrist and Hand Part I and II, Rettig, AC AJSM, 2003

◼ Athletic Injuries UE

◼ Recent Literature that helps Guide RTP

“Sports Injuries of the Elbow and Hand”

Hand Clinics Editor William B Geissler 2009

“Elite Athlete’s Hand and Wrist Injury”

Hand Clinics Editor Michelle Carlson 2012

“ The Athlete’s Hand and Wrist”- A Masters Skill Publication ASSH 2014

◼ Athletic Injuries UE

◼ Purpose ASSH PreCourse 5

◼ Up to Date Review Injuries in the Athlete

Hand/Wrist/Forearm Pertinent Anatomy

Mechanism of Injury

Treatment

◼ Athletic Injuries UE

◼ Early Safe RTP

◼ Minimal Risk

Lectures Noted Faculty

Divided Anatomic Modules

Bone/Ligament/Tendon/Misc

◼ Athletic Injuries UE

◼ Case Presentations Initiate Series Talks

◼ Emphasizing

Differences Adolescent/Adult

Differences Amateur vs the Pro

◼ Athletic Injuries UE

◼ Rx Injury/Early Return to Play

◼ Plunges Surgeon Complex Interaction

◼ Player,Trainer,Manager,Owner,Agent

◼ Parents Adolescent Athlete (DIFFICULT)

◼ NO RIGHT SOLUTION

◼ Athletic Injuries UE

Treating Athlete Challenge!

◼ Goal Early Return to Play Minimal Risk

◼ Our Method Performance Based Decision Making

PBDM

Discuss General Guidelines

◼ Athletic Injuries UE

◼ Performance Based Decision Making

◼ APPLES- Acronym Helps Guide Management

◼ A- AGE

◼ P- Position ? Sport ? Dominance

◼ P- Performance

◼ L- Level

◼ E- Enhancing ?Hx PED (Perf. Enhancing Drugs)

◼ S- Season In Season vs Out of Season

◼ Athletic Injuries UE

◼ AGE APPLES

◼ 27 yo Braves

◼ 12 yo Scaphoid

◼ Athletic Injuries UE

◼ POSITION- APPLES

◼ Scaphoid Fx

◼ D1- College QB

◼ D1- OL vs LB

◼ Athletic Injuries UE

◼ Performance Level- APPLES

◼ Scaphoid Fx

◼ Starting ◼ Practice Sq

◼ Athletic Injuries UE

◼ Enhancing- ? PED APPLES

◼ HGH Anabolic Steroids

◼ Professional

◼ College

◼ High School

◼ Athletic Injuries UE

◼ PED

◼ Athletic Injuries UE

◼ PED So Rampant Use Baseball

◼ David Pursley Atlanta Braves ATC (1969-2002)

“Would be very careful operating on any baseball player that played in 80’s and 90’s”

◼ Athletic Injuries UE

◼ PED Careful OP Present/Former

Soft Tissue Procedures!!!!!!!!

◼ Failure rate high

◼ Complication rate high (Miles JBJS)

◼ Literature Supports (Inhole AJSM)

◼ Athletic Injuries UE

◼ Results- Testing showed anabolic steroids produced a stiffer tendon that absorbs less energy and fails with less elongation.

◼ Athletic Injuries UE

◼ PED

◼ Anabolic Steroids

◼ HGH, Peptide Boosters ◼ HCG

◼ Blood Doping, Erythropoietin

◼ Stem Cell

Long-term effects UKNOWN

◼ Athletic Injuries UE

◼ Injury Assessment

◼ Age

◼ Position

◼ Performance Level

◼ Enhancing Drugs Hx

◼ Season In or Out

◼ Athletic Injuries UE

◼ Season In vs Out

◼ Scaphoid Fx ND In Season (ORIF)

◼ Scaphoid Fx ND Out of Season (Cast)

◼ Athletic Injuries UE

◼ Injury Assessment- APPLES

◼ Decision to Treat

Surgical

Non-surgical

With that Decision

RTP and if so Early

◼ Athletic Injuries UE

◼ Decision Treat Early RTP ◼ Ask Myself ?

Influence pt 1 d (Healing ex Fx)

Influence pt 1 wk (Soft Tissue Heal)

Influence pt 1 y (Mal/Nonunion)

Influence pt 10 y (Degenerative OA)

◼ Athletic Injuries UE

◼ Not an Easy Answer

◼ ASSH PreCourse 5

◼ Guidelines/Recommendations

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 7:05 AM - 7:59 AM

Miscellaneous Upper Extremity Injuries

Thomas A. Wiedrich, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 7:05 AM - 7:15 AM

Forearm Fractures

Fraser J. Leversedge, MD Royalty: Wolters Kluwer, OrthoHelix Surgical Designs and Wright Medical Consulting Fee: AxoGen, Bioventus and Stryker Contracted Research: AxoGen

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Speaker has not provided a handout for this presentation Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 7:16 AM - 7:26 AM

CMC Joint Injuries

Randall W. Culp, MD Royalty: Arthrosurface and Arthrex Consulting Fee: Zimmer Biomet

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Athletic Injuries of the Upper Extremity CMC Injuries

Randall W. Culp, M.D. Philadelphia Hand to Shoulder Center Thomas Jefferson University

I. Overview a. Thumb and finger injuries are the most common upper extremity injury in competitive sports. b. Hand is least protected and at high risk of injury. II. Anatomy of the Thumb CMC Joint a. Double saddle configuration that moves in 3 planes: F/E, Ab/Ad, Pro/Sup b. Stability comes from bony geometry ligaments and joint capsule. c. Biconcave structure reported to provide 47% of stability in opposition. d. Ligaments: Volar beak (anterior oblique), intermetacarpal, dorsoradial. e. Some describe volar beak ligament as crucial for stability (Burton, JHS: 1985). f. Other studies show primary restraint to dorsal dislocation was dorsoradial ligament (Strauch, JHS: 1994). III. Images a. AP, oblique, lateral. b. Bett’s view (highly recommended) palm provided 20° from palm flat against x- ray plate; x-ray beam directed 15° proximal to distal. c. Stress radiographs (prayer view) pressing radial border of the thumbs together. IV. Thumb CMC Dislocations a. Rare (<1% hand injuries) dorsal dislocations result from axial load to flexed thumb. b. Unstable injury, most authors recommend surgical reconstruction. c. Acute dislocation in athletes: reasonable to consider reduction and cast. Must monitor closely with serial x-rays, high incidence of redislocation. d. Closed reduction and percutaneous pinning has high risk of persistent instability (50%) 1. Comparison study of CR, pin, vs Eaton-Littler: 50% failure of CR, pin Eaton-Littler: normal motion, pinch strength, no redislocation, (Trumble, JHS 1996). e. Reconstruction of anterior oblique ligament has been described with FCR (Eaton- Littler), APL. f. Repair dorsoradial ligament complex with bone anchors. g. Newer technology (swivel lock, labral tape augmentation) repair dorsoradial complex. Acute thumb CMC dislocations

Lahiji et al. 2015 6 A. Closed reduction A. Asymptomatic instability + cast (1 patient) dorsoradial B. Early ligament repair (5 patients)

Jeong et al. 2012 1 A. Closed reduction A. Asymptomatic instability (B/L) pinning (1 patient) B. Early ligament reconstruction

h. Return to play 1. As early as 2 weeks with protective splint cast in non-throwing, non- dexterous athletes. 2. Throwing or dexterous positions, may be 6-8 weeks. V. Bennett Fracture a. Thumb metacarpal fracture account for 25% of all metacarpal fractures, 80% of those occurring at the base. b. Anatomy: 1. Avulsion fracture of the volar/ulnar portion of metacarpal bone, held by anterior oblique ligament. Metacarpal shaft pulled dorsal, proximal and radial by APL, narrowing of web space by adductor pollicis. c. Classification (Gedda) 1. Fracture with a single large ulnar fragment and subluxation of metacarpal base. 2. Impaction fracture without subluxation of metacarpal. 3. Fracture with small ulnar avulsion fragment with metacarpal dislocation. d. Treatment (Rivlin, JHS 2015) 1. Closed reduction (CR) – axial traction, palmar abduction, pronation, pressure over metacarpal base. a. No consensus on relationship of malunion and poor functional outcome in non-athletic populations. Anatomic alignment is goal in athletes. 2. CR + Cast – Usually unstable to maintain reduction. 3. Percutaneous fixation – pins or screws. a. Direct or indirect fixation. b. With or without crossing the fracture. 4. Open reduction and internal fixation (ORIF) a. Advantage of anatomic reduction under direct vision. b. Dorsal or palmar (Wagner) c. Plates, screws (compression or cannulated) 5. Arthroscopic reduction and internal fixation, (Culp, Hand Clin 2017) a. Minimally invasive. b. Direct visual control of joint surface. c. Can use intrafocal pin reduction. d. Accuracy of fluoro/c-arm alone? e. Outcome 1. Intra-articular pins can cause damage to articular surface (16/21 patients in one study) 2. Acute stage – generally favorable if especially with small fracture fragments. 3. Articular step - Ok > 2mm poor prognostic factor with large fragments (Kamphuis Hand Surg Rehab 2019) f. Return to play, (Kadow Hand Clin 2017) a. Dependent on age, sport, handedness and level of play b. Pins generally removed 3-4 weeks c. Injuries to the non-throwing hand and in athletes in non- tackling positions may return to sport with protective brace at 3 weeks. Injuries to the throwing hand and players in talking positions may return to play 6 weeks. d. Unanswered questions: play with articular pins? Play with sutures still present? References:

Adi M, Miyamoto H, Taleb C et al. Percutaneous fixation of first metacarpal base fractures using locked K-wires: A series of 14 cases. Tech Hand Up Extrem Surg. 2014, 18: 77–81.

Bennani A, Zizah S, Benabid M et al. The intermetacarpal double pinning in the surgical treatment of Bennett fracture (report of 24 cases). Chir Main. 2012, 31: 157–62.

Bennett EH. Fractures of metacarpal bone of the thumb. Br Med J. 1886, 2: 12–5.

Brazier J, Moughabghab M, Migaud H, Fontaine C. Articular fractures of the base of the first metacarpal. Comparative study of direct osteosynthesis and closed pinning. Ann Chir Main. 1996, 15: 91–9.

Brüske J, Bednarski M, Niedźwiedź Z, Zyluk A, Grzeszewski S. The results of operative treatment of fractures of the thumb metacarpal base. Acta Orthop Belg. 2001, 67: 368–73.

Burdin G. Arthroscopic management of tibial plateau fractures: surgical technique. Orthop Traumatol Surg Res. 2013, 99: S208–18.

Cannon SR, Dowd GS, Williams DH, Scott JM. A long-term study following Bennett’s fracture. J Hand Surg Br. 1986, 11: 426–31.

Capo JT, Kinchelow T, Orillaza NS, Rossy W. Accuracy of fluoroscopy in closed reduction and percutaneous fixation of simulated Bennett’s fracture. J Hand Surg Am. 2009, 34: 637–41.

Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg. 2009 May-June; 34(5): 945-52.

Cullen JP, Parentis MA, Chinchilli VM, Pellegrini VD Jr. Simulated Bennett fracture treated with closed reduction and percutaneous pinning. A biomechanical analysis of residual incongruity of the joint. J Bone Joint Surg Am. 1997, 79: 413–20.

Culp R, Solomon J. Arthroscopic Management of Bennett Fracture. Hand Clinic 33. 2017: 787- 794.

Culp RW, Johnson JW. Arthroscopically assisted percutaneous fixation of Bennett fractures. J Hand Surg Am. 2010, 35: 137–40.

Diaconu M, Facca S, Gouzou S, Liverneaux P. Locking plates for fixation of extra-articular fractures of the first metacarpal base: a series of 15 cases. Chir Main. 2011, 30: 26–30.

Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973, 55: 1655–66.

Edmunds I, Trevicick B, Honner R. Fusion of the first metacarpophalangeal joint for post traumatic conditions. Aus-N-Z J Surg. 1994, 64: 771–4. References (Cont’d):

Foster RJ, Hastings H 2nd. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orthop Relat Res. 1987, 214: 121–9.

Foucher G. Injuries of the trapezo-metacarpal joint. Ann Chir Main. 1982, 2: 168–79.

Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett’s fracture in the carpo-metacarpal joint of the thumb. Acta Orthop Scand. 1952, 22: 249–57.

Ghilardi G, Parmeggiani G. Trapezio-metacarpal luxation and subluxation. Minerva Orthop. 1960, 11: 498–503.

Giesen T, Cardell M, Calcagni M. Modified Suzuki frame for the treatment of a difficult Rolando’s fracture. J Hand Surg Eur. 2012, 37: 905–7.

Greeven AP, Alta TD, Scholtens RE, de Heer P, van der Linden FM. Closed reduction intermetacarpal Kirschner wire fixation in the treatment of unstable fractures of the base of the first metacarpal. Injury. 2012, 43: 246–51.

Holzach P, Matter P, Minter J. Arthroscopically assisted treatment of lateral tibial plateau fractures in skiers: use of a cannulated reduction system. J Orthop Trauma. 1994, 8: 273–81.

Hove LM. Fractures of the hand. Distribution and relative incidence. Scand J Plast Reconstr Surg Hand Surg. 1993, 27: 317–9.

Huang JI, Fernandez DL. Fractures of the base of the thumb metacarpal. Instr Course Lect. 2010, 59: 343–56.

Iselin M, Blanguernon S, Benoist D. First metacarpal base fracture. Mém Acad Chir. 1956, 82: 771–4.

Jeong C, Kim HM, Lee SU, Park IJ. Bilateral Carpometacarpal Joint Dislocations of the Thumb. Clinics in Orthopedic Surgery 2012: 3, 246-248.

Kadow TR, Fowler JR. Thumb Injuries in Athletes. Hand Clin. 2017 Feb; 33(1): 161-173.

Kamphuis SJM, Greeven APA, Kleinveld S, Gosens T, Van Lieshout EMM, Verhofstad MHJ. Bennett’s fracture: Comparative study between open and closed surgical techniques. Hand Surg Rehab. 2019 April; 38(2): 97-101.

Kapandji A, Moatti E, Raab C. Specific radiography of the trapezo-metacarpal joint and its technique. Ann Chir. 1980, 9: 719–26.

Kapandji A. Closed reduction osteosynthesis of non-articular proximal fractures of the 1st metacarpal bone. Crossed ascending double pinning. Ann Chir Main. 1983, 2: 179–85. References (Cont’d):

Keramidas EG, Miller G. The Suzuki frame for complex intraarticular fractures of the thumb. Plast Reconstr Surg. 2005, 116: 1326–31.

Kjaer-Petersen K, Langhoff O, Andersen K. Bennett’s fracture. J Hand Surg Eur. 1990, 15: 58– 61.

Leclère FM, Jenzer A, Hüsler R et al. 7-year follow-up after open reduction and internal screw fixation in Bennett fractures. Arch Orthop Trauma Surg. 2012, 132: 1045–51.

Lahiji F, Zandi R, Maleki A. First Carpometacarpal Joint Dislocation and Review of Literatures. The Archives of Bone and Joint Surgery. 2015: 4, 300-303.

Liverneaux P. Fracture and dislocation of the thumb. In: Duparc J (ed.) Conférences d’Enseignement de la SOFCOT. Paris, Exp sci. Fr, 2006: 144–68.

Liverneaux PA, Ichihara S, Hendriks S, Facca S and Bodin F. Fractures and dislocation of the base of the thumb metacarpal. Journal of Hand Surgery (European) 2015: 40E, 42-50.

Liversley PJ. The conservative management of Bennett’s fracture-dislocation: a 26-year follow up. J Hand Surg. Br. 1990, 15: 291–4.

Lutz M, Sailer R, Zimmermann R, Gabl M, Ulmer H, Pechlaner S. Closed reduction transarticular Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett’s fracture dislocation. J Hand Surg Br. 2003, 28: 142–7.

Meyer C, Hartmann B, Böhringer G, Horas U, Schnettler R. Minimal invasive cannulated screw osteosynthesis of Bennett’s fractures. Zentralbl Chir. 2003, 128: 529–33.

Moutet F, Bellon-Champel P, Guinard D, Gérard P. Synthetic ligament reconstruction of the thumb metacarpophalangeal joint. 21 cases. Ann Chir Main Memb Super. 1993, 12: 196–9.

Oosterboss CJM, De Boer HH. Nonoperative treatment of Bennett’s fracture: a 13 year follow- up. J Orthop Trauma. 1995, 9: 23–7.

Ozer K, Gillani S, Williams A, Peterson SL, Morgan S. Comparison of intramedullary nailing versus platescrew fixation of extra-articular metacarpal fractures. J Hand Surg Am. 2008, 33: 1724–31.

Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am. 1998, 23: 827–32.

Pavić R1, Malović M. Operative treatment of Bennett’s fracture. Coll Antropol. 2013, 7: 169–74.

Péquignot JP, Giordano P, Boatier C, Allieu Y. Traumatic dislocation of the trapezio-metacarpal joint. Ann Chir Main. 1988, 7: 14–24. References (Cont’d):

Proubasta IR. Rolando’s fracture of the first metacarpal. Treatment by external fixation. J Bone Joint Surg Br. 1992, 74: 416–7.

Rivlin M, Fei W, Mudgal CS. Bennett Fracture. J Hand Surg. 2015 Aug; 40(8): 1667-8.

Sawaizumi T, Nanno M, Nanbu A, Ito H. Percutaneous leverage pinning in the treatment of Bennett’s fracture. J Orthop Sci. 2005, 10: 27–31.

Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968– 1975. Clin Orthop Relat Res. 1979, 138: 94–104.

Sidharthan S, Shetty SK, Hanna AW. Median nerve injury following K-wire fixation of Bennett’s fracture-lessons learned. Hand (NY). 2010, 5: 440–3.

Simonian PT, Trumble TE. Traumatic dislocation of the thumb carpometacarpal joint: early ligamentous reconstruction versus closed reduction and pinning. J hand Surg. 1996 Sept; 21(5): 802-6.

Soyer AD. Fractures of the base of the first metacarpal: current treatment options. J Am Acad Orthop Surg. 1999, 7: 403–12.

Stanton JS, Dias JJ, Burke FD. Fractures of the tubular bones of the hand. J Hand Surg Eur. 2007, 32: 626–36.

Stern PJ. Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN, Pederson WC and Wolfe SW (eds.) Green’s operative hand surgery. Philadelphia, Elsevier Churchill Livingstone, 5th Edn. 2005, Vol 1: 277–341.

Strömberg L. Compression fixation of Bennett’s fracture. Acta Orthop Scand. 1977, 48: 586–91.

Surzur P, Rigault M, Charissoux JL, Mabit C, Arnaud JP. Recent fractures of the base of the 1st metacarpal bone. A study of a series of 138 cases. Ann Chir Main. 1994, 13: 122–34.

Toupin JM, Milliez PY, Thomine JM. Recent post-traumatic luxation of the trapeziometacarpal joint. A propos of 8 cases. Rev Chir Orthop Reparatrice Appar Mot. 1995, 81: 27–34.

Tourne Y, Moutet F, Lebrun C, Massart P, Butel J. The value of compression screws in Bennett fractures. A propos of a series of 44 case reports. Rev Chir Orthop Reparatrice Appar Mot. 1988, 74: 153–5.

Uludag S, Ataker Y, Seyahi A, Tetik O, Gudemez E. Early rehabilitation after stable osteosynthesis of intra-articular fractures of the metacarpal base of the thumb. J Hand Surg Eur. Epub ahead of print 21 Jun 2013.

Van Niekerk JL, Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical treatment. Injury. 1989, 20: 359–62. References (Cont’d):

Vichard P, Tropet Y, Nicolet F. Longitudinal pinning of fractures of the base of the first metacarpal. Ann Chir Main. 1982, 1: 301–6.

Wagner CJ. Methods of treatment of Bennett’s fracture dislocation. Am J Surg. 1950, 80: 230–1.

Wiggins HE, Bundens WD, Park BJ. Method of treatment of fracture-dislocations of first metacarpal bone. J Bone Joint Surg. 1954, 36: 810–9.

Wintman BI, Fowler JL, Baratz ME. Traumatic dislocation of trapezium: case report and review of the literature. Am J Orthop (Belle Mead NJ). 2000, 29: 229–32.

Zemirline A, Lebailly F, Taleb C, Facca S, Liverneaux P. Arthroscopic assisted percutaneous screw fixation of Bennett fracture. J Hand Surg Asian Vol. 2014, 19: 281–6. Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 7:27 AM - 7:37 AM

Kienbock's Disease

Thomas A. Wiedrich, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Speaker has not provided a handout for this presentation Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 7:38 AM - 7:48 AM

MCL Injuries of the Elbow

Marc J. Richard, MD Royalty: Acumed Consulting Fee: Acumed, DePuy Synthes, DJO and Medartis Speakers Bureau: Acumed, DePuy Synthes, DJO, Medartis and Bioventus

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Marc J. Richard, M.D. ASSH Pre-Course 05 UCL Injuries of the Elbow

I. Overview of Relevant Elbow Anatomy

- UCL o Anterior, Transverse and Posterior bands o Anterior band – Anterior and posterior bundles - Medial epicondyle - Sublime tubercle - Medial epicondyle apophysis - Ulnar nerve

II. The Problem

- Epidemiology of UCL injury in baseball o Increasing numbers of primary and revision reconstructions in MLB o Rapidly increasing numbers of UCL reconstructions in youth players - Perspective o Accounts for more days missed than any other injury in MLB and MiLB o Outcomes of reconstruction ▪ Less velocity, higher ERA, higher WHIP, less innings pitched

III. Adult Injury Patterns

- Most commonly attritional, midsubstance tear - Requires reconstruction with allograft or autograft - Association with pathology in lateral and posterior compartments o Compression at radiocapitellar joint o Posteromedial osteophytes on olecranon

IV. Adolescent Injury Patterns

- Commonly an avulsion with a healthy ligament o May be amenable to repair rather than reconstruction - Variants/Equivalents of UCL injury related to the immature skeleton

V. Risk Factors for Injury – Adults

- Volume o Pitchers from warm climates have a higher incidence of TJ reconstruction and at an earlier time in their career o Pitch counts

- Velocity - Technique o Change in technique over last several decades ▪ Inverted “W” ▪ Flat Arm Syndrome - Other factors o GIRD o Horizontal adduction loss

VI. Risk Factors for Injury - Adolescents

- Volume o Pitch counts ▪ >80 pitches per appearance has 3.8x higher risk of injury o Youth players should take 4 months off per year ▪ 5x higher risk of injury in those who don’t - Technique o Break in kinetic chain - Velocity o >85mph has 2.5x higher risk of injury - Other o Regularly throwing with arm pain has a 36x higher risk of injury

VII. Conclusions

- Understand the kinetic chain of throwing - All youth players are referred for re-evaluation of throwing technique - Need education to understand the risks for elbow injury in throwers - Break the misperceptions about TJ surgery

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 7:49 AM - 7:59 AM

Discussion and Questions

All Faculty

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 8:00 AM - 8:54 AM

Traumatic Conditions of the Wrist

Jeffrey B. Husband, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 8:00 AM - 8:10 AM

SL Injuries

Steven S. Shin, MD Royalty: Arthrex and Hely & Weber Consulting Fee: Arthrex

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

How I Treat Scapholunate Ligament Injuries in the Athlete (Steven Shin, MD)

Spectrum of Injury

How I Treat Scapholunate Ligament Tears • Pre-dynamic, dynamic, in the Athlete static, SLAC (Watson, JHS- B 1993) Steven S. Shin, MD, MMSc • Geissler classification Associate Professor and Vice Chair Department of Orthopaedics • “Partial” vs “Complete” Cedars-Sinai Medical Center

Hand Consultant to LA Angels, Clippers, Dodgers, Kings, Lakers, Rams

The Athlete SL Injury

• Partial tear: play as tolerated, address in off- Br J Sports Med, 2013 Nov;47(17):1071-4 season • 2008-2011 • 14/15 pro male athletes (11 rugby, 2 boxing and 1 golf) • Complete tear: delayed vs • Modified Brunelli procedure immediate treatment • Mean age: 30 years (range 18-42) (multiple factors) • Mean follow-up period: 25 months (range 3-43) • 11/14 (~80%) athletes returned to play within 4 months of surgery • 9/14 (64%) athletes returned to pre-injury level of competition

Partial SL Tears Complete SL Tears • Options • Direct repair – Immobilization (how long? • Capsulodesis Cast or brace?) – Injection (cortisone, PRP, • Tenodesis stem cell?) • Screw – Arthroscopic • debridement/shrinkage Internal Brace?

1 How I Treat Scapholunate Ligament Injuries in the Athlete (Steven Shin, MD)

Internal Bracing for SL Tears Dorsal Tape Only Reconstruction • Multiple IB Techniques • Advantages – Acute: repair or reconstruction with IB augmentation – No creep – Subacute/chronic: reconstruction – Fast and easy to do • Biologic (tendon graft) only? – Avoids bicortical drill holes • Biologic (tendon graft) with IB augmentation? • IB (tape) only? • Potential Disadvantages – No primary biology – Doesn’t address volar band – Anchor pull-out, tape slippage – No outcomes data (yet)

2-Anchor 2-mm Tape Only 2-Anchor 2-mm Tape Only IB: Biomechanic Testing • Indications: – Partial (dorsal +/- central band tears) – Predynamic, dynamic

• Optional/Recommended: – Micro anchors to repair ligament – Drill holes for bleeding

3-Anchor 2-mm Tape Only IB 23 yo RHD, NHL forward • Indications: – Acute complete tears – Static

• Optional/Recommended: – Micro anchors to repair ligament – Drill holes for bleeding

2 How I Treat Scapholunate Ligament Injuries in the Athlete (Steven Shin, MD)

6 mo Post Op NFL LB: 6 weeks Post Op

NFL LB: 5 months Post Op Conclusion

• Makes sense to me • Promising in short-term • Doesn’t burn bridges • Better than what I’ve done before • Need long-term outcomes

3 How I Treat Scapholunate Ligament Injuries in the Athlete (Steven Shin, MD)

THANK YOU

4 Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 8:11 AM - 8:21 AM

Acute TFCC Injuries

Jeffrey B. Husband, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

9/5/2019

Tears of the Triangular Fibrocartilaginous Complex

JEFF HUSBAND MD

I have nothing to disclose

Objectives

Review relevant anatomy and biomechanics of the TFCC Understand the classification of TFCC tears, especially those that are related to trauma Recognize and diagnose tears of the TFCC Discuss appropriate conservative and operative treatment Present one technique for repair of ulnar side TFCC tears Post-operative management and decision making about return to play after surgery Understand and diagnose ulnocarpal impaction and review treatment options

1 9/5/2019

Injuries and Disorders of the Ulnar Side of the Wrist

 TFCC tears  Ulnocarpal impaction  DRUJ instability, osteoarthritis  ECU tendinosis and subluxation  Ulnar carpal instability  Pisotriquetral osteoarthritis  Hook of hamate fractures  Ulnar styloid fractures and non union  Ulnocarpal and radioulnar ligament injuries

Why can ulnar wrist pain be difficult to diagnose?

 Small anatomical area with numerous closely associated structures that may be affected by trauma, degenerative conditions or osteoarthritis  Biomechanically complex  The same mechanism of injury may damage different structures  Different injuries or disorders may present with the same type and location of pain with similar physical findings  Abnormalities found on MRI do not necessarily correlate with the cause of the problem

The “Black Box of the Wrist”

2 9/5/2019

TFCC Anatomy

The three functions of the TFCC

 Cushions the ulnar carpus- carries 20% of axial load across the wrist joint  Primary stabilizer of the DRUJ  Stabilizes the ulnar carpus

3 9/5/2019

TFCC- Biomechanics

Palmer Classification of TFCC tears

Palmer Classification of TFCC tears- what do we see in athletes?

 Class 1A- central perforation  Class 1B- ulnar avulsion with or without distal ulnar fracture  Class 1D- radial avulsion  Class 2- ulnocarpal impaction with varying degrees of associated pathology

4 9/5/2019

Clinical Evaluation of TFCC Tears

 Mechanism of injury- most commonly due to axial load in wrist extension and ulnar deviation or due to forced maximal forearm rotation combined with axial load.

 There is usually full ROM and no swelling

 Tenderness in the fovea distal to ulnar styloid between ulnar head, FCU and pisiform- “positive fovea sign”. Sensitive and specific for TFCC and UT ligament injury

 DRUJ instability

 Tests for other pathology- ECU, LT ligament

Imaging- MR arthrogram most sensitive

 Sensitivity between 88- 100% for central tears  For peripheral tears, DRUJ injection with contrast increases sensitivity to 80%

MR arthrogram- Type 1A and 1D tears

5 9/5/2019

MR arthrogram- Type 1B tear

MR arthrogram- Type 2C tear

 Ulnar

The Prevalence of TFCC Signal Abnormalities on MR Imaging Relative to Clinical Suspicion of Pathology Bendre et al, JHS Vol 43: 819-26, 2018

 Retrospective review of 1134 wrist MRI studies in patients with suspected wrist pathology.  Low clinical suspicion of TFCC pathology or clinical suspicion of TFCC pathology.  Overall 28% with low suspicion of TFCC pathology had TFCC changes, with 19% of 18-30 year olds having changes as compared to 64% of those over 70 years having changes.  The prevalence of TFCC changes in patients with a clinical suspicion of TFCC pathology increases up to 40 years and then decreases afterwards.  Conclusion: MRI most useful in younger patients and less helpful for non-specific wrist pain in older patients. 

6 9/5/2019

Consider other causes of ulnar sided wrist pain- look beyond the TFCC tear on MR

Conservative Treatment

 1A and 1D tears may respond to rest, immobilization- 60%  Corticosteroid injection

The Natural Course of Triangular Fibrocartilage Complex Tear without Distal Radioulnar Joint Instability Kwon, BC. ASSH Annual Meeting 2018

 Retrospective EMR review of 104 patients with a TFCC tear without DRUJ instability  Conservative treatment  VAS and PRWE evaluation  Complete recovery in 54 patients at an average of 26 weeks  At one year 40% still had pain and disability  Poorer prognosis in younger patients and in dominant hand

7 9/5/2019

1A and 1D tears- arthroscopic debridement to a stable margin- up to 90% success rate

Type 1B TFCC tears

 Peripheral tears are through vascular tissue and are therefore amenable to repair  Inside-out, outside-in, or all inside repairs  Repair to capsule, ECU subsheath  Open repair to bone  Ulnar tunnel technique  75-90% good to excellent results

8 9/5/2019

Type 1B tear- repair with all-arthroscopic technique- Yao and Lee JHS 36A, 2011

Ulnar tunnel technique for repair of 1B TFCC tears

Arthroscopic TFCC Repair

9 9/5/2019

Post-operative Managment

 Repaired 1B tears  Debridement of 1A and 1D  Sugar tong splint tears  Custom made Muenster  Soft dressing splint at 7-10 days  Dressing off at 1 week followed by ROM  Allow gentle wrist flexion and extension but no  Return to activities by 3 to 6 forearm rotation until 6 weeks as pain permits weeks.  Strengthening at 8 weeks  Unrestricted activities at 12 weeks

26 year old NHL player- “jammed” both wrists during the previous season. Ongoing pain.

Right wrist- large central TFCC tear, stable margins- debrided

10 9/5/2019

Left wrist- acute appearing central tear, no peripheral tear, stable- debrided- playing hockey and working out at 6 weeks

17 year old RHD wrestler with ulnar wrist pain after hyper-supination injury

Ulnar tunnel TFCC repair

11 9/5/2019

Ulnar tunnel TFCC Repair

 Wrestling at 3 ½ months with no pain  No tenderness on examination, no DRUJ instability

Summary

 Try to ensure you have made a correct diagnosis- look beyond the MR  Conservative treatment may work for central and radial sided tears  Debride central and radial tears (1A and 1D)- return to play as pain permits  Repair ulnar sided tears (1B)- return to play by 3-4 months

References

 1: Palmer AK. JHS 14A: 594-606  2: Cooney WP. JHS 19A: 143-1543:  3: Hermansdorfer JD. JHS 16A: 340-346  4: Sachar K. JHS 37A: 1489-1500  5: Yao J. Lee AT. JHS 36A: 836-842  6: Papapetropoulos PA. JHS 35A: 1607-1613  7: Atzei A. J Wrist Surg 4: 22-30 8: Wysocki RW. JHS 37A 509-516 9: Iwasaki N. J of Arthr and Related Surg 27: 1371-1378 10: Bendre H. JHS 43A: 819-826

12 Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 8:22 AM - 8:32 AM

Ulnar Impaction Syndrome

Mark E. Baratz, MD Royalty: Integra Receipt of Intellectual Property Rights/Patent Holder: Integra Speakers Bureau: Integra

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Ulnar Impaction Mark Baratz MD Cassidy Costello BA Defined by: • Premature growth plate closure • Radial head resection • Traumatic event • Characteristic findings o Pain exacerbated by activity o Swelling o Limitation – loss of wrist motion and forearm rotation o Ulna sided wrist pain

Who is at risk? • Athletes o Sports requiring power grip, repetitive pronation and wrist ulnar deviation. o Athletes in racket sports, baseball, and gymnastics are more at risk. • Distal radius fracture malunion with increased ulnar variance

Evaluation • Ulnocarpal stress test o Patients elbow rests on exam table with forearm perpendicular to the floor o Wrist is ulnarly deviated and forearm is rotated through a full arc while applying axial load o Positive test produces symptoms • AP radiograph • Pronated grip view o Show lengthening of ulna • MRI

Treatment • Nonoperative o Modify activities o Braces between practices & games o Taping for practices & games o Steroid injections (chronic cases) • Operative o Goal: to shorten ulna relative to distal radius o Arthroscopic Debridement – option for mid-season athlete ▪ High success rates (70-85%) & quick recovery o Arthroscopic Wafer – 2 weeks of immobilization and 6 weeks afterwards of removable splinting o USO – gold standard ▪ Diaphyseal Osteotomy options • Transverse • Oblique • Step-cut o Open Wafer – TFCC intact – same period of immobilization as arthroscopic wafer

Post-op • Splint 3-4 weeks • Work on forearm rotation • Rarely send to PT • Union 6-8 weeks

Complication Rate • Shortening Osteotomy: 30% • Open Wafer: 8% • Arthroscopic Wafer: 21%

Complications • Hardware prominence • Non-union • Residual pain @ the DRUJ

Long-term outcome of Step-Cut Ulnar Shortening Osteotomy for Ulnar Impaction • Retrospective study of 164 patients who underwent step-cut ulnar shortening • 98.8% union rate at a mean of 8.2 weeks • All patients returned to their previous work at a mean of 4 months

Summary: • Although, ulnar shortening is a successful treatment for Ulnar Impaction Syndrome, treatment should be based on the needs of the athlete. • Treatment goal: to return athlete to play in a timely and safe manner

Studies

Henderson C.J., and Kobayashi, K.M. Ulnar-sided wrist pain in the athlete. Orthopedics Clinics of North America. 2016. Vol. 47(4), pp. 789-798.

Jarrett, C.D., and Baratz, M.E. The management of ulnocarpal abutment and degenerative triangular fibrocartilage complex tears in the competitive athlete. Hand Clin. 2012. Vol. 28, pp. 329-337.

Jaworski, C.A., Krause, M., and Brown, J. Rehabilitation of the Wrist and Hand Following Sports Injury. Clin Sports Med. 2010. Vol 29, pp, 61-80.

Papatheodorou, L.K., Baratz, M.E., Bougioukli, S., Ruby, T., Weiser, R.W., and Sotereanos, D.G. Long-term outcome of step-cut ulnar shortening osteotomy for ulnar impaction syndrome. Journal of Bone and Joint Surgery. 2016, Nov. 2. Vol. 98(21), pp. 1814-1820.

Sammer, D.M., and Rizzo, M. Ulnar Impaction. Hand Clin. 2010. Vol. 26, pp. 549-557.

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 8:33 AM - 8:43 AM

ECU Sheath Injuries

Thomas J. Graham, MD Royalty: Zimmer Biomet

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Management & Rehabilitation Protocol for Injuries of the ECU & Investments

Severity Grading of ECU Injuries

Mild: Swelling in sheath, no bowstringing, no intrinsic abnormality (MRI). Moderate: Bowstringing of ECU distal to ulnar styloid, possible intrinsic change (MRI), no subluxation with pronosupination. Severe: Bowstringing of ECU distal (and potentially proximal to) the ulna styloid, intrinsic (focal vs. longitudinal) tendon embarrassment, subluxation out of ulnar sulcus with pronosupination.

ECU Treatment & Rehabilitation Program

Immobilization Phase: Long-arm splint can be considered, but short-arm usually effective. Wrist can be placed in neutral to slight flexion and radial deviation. Any cardio/leg work permitted per level of comfort. • Mild: 5-7 day initial period of immobilization • Moderate: 7-10 day initial period of immobilization • Severe: 10-14 day initial period of immobilization

[If in removable splint, may ice or perform modalities like iontophoresis. May be out for hygiene if taped around distal aspect of tendon. Consider dental bolster or elastomer mold longitudinal tendon support]

Motion Recovery Phase: After initial immobilization period, assess level of comfort. If pain and swelling persist with gentle motion, consider injection.

Start A/AAROM program to level of comfort along these guidelines: • For 2-3 days, out 3-5 X/day for motion program (ECU Taped) • For next 2-3 days, out 6-8 X/day for motion program (ECU Taped) • For next 2-3 days, out 10-12 X/day for motion program (ECU Taped) • For next 2-3 days, out 13-15 X/day for motion program (ECU Taped)

[If motion exceeds 75%, may consider start of strengthening program. If at any time during motion recovery phase that symptoms dictate, injection could be considered; typically place in immobilization for 3-5 days post-injection, then resume motion recovery protocol.]

Strength Recovery Phase: With ECU taped or splinted (Arnold Palmer-type splint), may commence strength recovery phase as directed by player experience and in collaboration with medical/training staff. When strength exceeds 75%, may start sports-specific preparation.

Sports-Specific Preparation Phase (Hockey): Obviously, this phase is largely conducted under the purview of the team’s medical/training/coaching staff. In our experience, progression through the following stages has allowed appropriate monitoring and focus for this injury: • Stick-handling • Passing & receiving • Shooting: Slap shots and wrist shots • “Battling”

Return-to-Play

Individual decisions on return-to-play are the complete purview of the player’s team. In our experience, the following guidelines can be useful in developing milestones and targets for resumption of elite level play at the NHL level.

• Mild: 25% of players typically return between 2-3 weeks, 50% between 3-4 weeks, and the remaining 25% after four weeks. • Moderate: 25% of players typically return between 3-4 weeks, 50% between 4- 6 weeks, and the remaining 25% after 6 weeks • Severe: 25% of players typically return between 4-6 weeks, 50% between 6-8 weeks, and the remaining 25% after 8 weeks.

[NB. There are a subset of players who have newly-developed tendon subluxation after embarrassment of the ECU investments and remain relatively asymptomatic. These players can typically return to elite level play with taping safely and effectively, requiring symptom monitoring only.]

Failure to Improve & Progress

The reasons we are comfortable recommending nonoperative treatment for problems of the ECU and its investments is that the same form of reconstructive surgery that we perform for acute cases is the same as we perform for remote cases. Stated alternatively, primary repair of the sheath, subsheath or linea jugata is extremely unlikely, so some form of augmentation with a retinacular flap is usually likely for cases of ECU problems, especially tendon subluxation.

Some players will not respond to nonoperative treatment for ECU. If these players have failed to return to elite level play during the season of injury, then ECU reconstruction can be entertained. Typically, even players in whom symptoms have not completely resolved can return in-season to safe and effective play – in that subset, end-of-season reconstruction remains compatible with completion of the entire rehabilitation protocol so that participation in training camp can be accomplished.

Operative Handling of ECU Tendon Pathologies

Reconstruction of the investments of the ECU tendon and/or the tendon, itself, has several germinal components to consider: • Re-establish static stabilizers of the ECU tendon that recapitulate the vector of operation of the musculotendinous unit. • Deepen, or otherwise recontour, the ulnar sulcus to either accept the ECU tendon or diminish painful subluxation of the tendon. • Assure that the dorsal limbus, or dorsal radio-ulnar ligament structure is competent or reconstructible. • Address primary tendon pathology through debridement and/or “tubularization”

Thomas J. Graham, M.D. Clinical Professor of Orthopedic Surgery Director of Strategy & Innovation NYU Langone Department of Orthopedic Surgery

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 8:44 AM - 8:54 AM

Discussion and Questions

All Faculty

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 9:10 AM - 9:20 AM

Phalanx Fractures

Rodney J. French, MD Receipt of Intellectual Property Rights/Patent Holder: Zimmer Biomet Consulting Fee: NHL, NHLPA, Calgary Flames and Nashville Predators Speakers Bureau: Bioventus and Exogen

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

19-07-28

Clinical Care of Speciﬁc Sport-Related Hand and Wrist Injuries Disclosures:Dr. Rod French

Paid Speaker for Bioventus - EXOGEN (Speaking fees, paid travel) Phalangeal Fractures in Paid consultant for NHL & NHLPA Elite Level Athletes (Consult and surgical fees, gear/apparel)

Hand & Wrist Surgeon for Calgary Flames (NHL) (retainer fee, consult and surgical fees, paid travel, equipment)

Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Hand & Wrist Surgeon for Vancouver Canucks (NHL), NHL & NHLPA Consultant Hand & Wrist Surgeon Vancouver Whitecaps (MLS), and Nashville Predators (NHL) (consult and surgical fees) Head Team Physician, Canadian Olympic Snowboard Team Assistant Professor, UBC Plastic Surgery Team physician for Canadian Olympic Snowboard Team (paid travel, equipment) Vancouver, BC

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

PEARL # 1: Ego

Mike Hayton, Wrightington, England Published March 2019

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

“Be conscious of the ego-stroke . . .

. . . then park it !” Dr. John Rizos, NHLPA

1 19-07-28

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

• Doctor First

• Business of the team is not yours PEARL # 2: Time Commitment • Fan last

Comprehensive Care of the Elite Level Athlete Comprehensive Care of the Elite Level Athlete Dr. Rod French Dr. Rod French

Challenge to the clinician: Injury sets a complex situation in motion Pearls of communication involving: • Physician With coaches, GM’s, & agents - FOUR POINTS • Athlete • Athletic trainer 1. Diagnosis • Coach / coaches 2. Recommended treatment • Manager • Owner 6 “parents” 3. REALISTIC timelines * • Agent 4. Add the ONE thing that could REALLY go wrong • Parents }

Comprehensive Care of the Elite Level Athlete Phalangeal Fractures in Elite Level Athletes

Dr. Rod French Dr. Rodney FrenchGet, MD, MEd, FRCSC,to Dip.know Sport Med. your patient !

Pearls of communication

Text messaging has greatly facilitated communication

• Group text at end of consult

• on drive home, call all parties personally

2 19-07-28

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

Get to know your patient:

• Sport

• Level – high school, college, pro

• Position

• Limitations of motion in that position

• Gloved or not gloved

ComprehensivePhalangeal Fractures Care in of Elite the Level Elite AthletesLevel Athlete Phalangeal Fractures in Elite Level Athletes

Dr. RodRodney French French , MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

Pro patients PEARL # 3: • Contract negotiations? Treat the whole patient • Contract year? (….you’re a Doctor First )

• Impending free-agency?

ComprehensiveClinical Care of CareSpeciﬁc of the Sport-Related Elite Level Athlete Hand and Wrist Injuries ComprehensiveClinical Care of CareSpeciﬁc of the Sport-Related Elite Level Athlete Hand and Wrist Injuries Dr.Dr. Rod Rod French French Dr.Dr. Rod Rod French French You are the Quarterback / CEO of their care

3 19-07-28

Experience is what you get… when you DIDN’T get what you wanted

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Goals

• Prevent stiffness !!

PEARL # 4: • Maintain alignment

Goals of Treatment for Athletes • Enable early RTP

• Minimize Risk

• ALWAYS remember:

Life AFTER sport

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

PEARL # 5: Accurate Diagnosis !

4 19-07-28

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Diagnosis Diagnosis High Index of Suspicion

• Fractures can occur after seemingly • Be thorough innocuous injuries

• Be meticulous • Undisplaced fractures require an X-Ray to diagnose…… LOW threshold to x- • Be accurate ray!!

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Diagnosis Diagnosis Clinical Imaging

From: “Sports Injuries of the Hand and Wrist”, p. 63, eds Mike Hayton et al., Springer, 2019

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

Diagnosis Imaging

• T2 fat sat image showing • ulnar positive variance • edema in lunate and triquetrum • with cystic changes in triquetrum

= ULNAR IMPACTION SYNDROME

5 19-07-28

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

PEARL # 6: Precision matters

This is not the time for “good enough”

Phalangeal Fractures in Elite Level Athletes Comprehensive Care of the Elite Level Athlete

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rod French

Pearls of surgical treatment

1. Perform ONE procedure

2. Book more O.R. time than usual

3. “The operation indicated … is the one you do best”

Phalangeal Fractures in Elite Level Athletes NOTE: Player consented to having Phalangeal Fractures in Elite Level Athletes Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. his case presented. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

23 year-old NHL forward. Nov 15 in Minnesota 23 year-old NHL forward. Nov 16 in Vancouver

6 19-07-28

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

If you don’t RIGIDLY ﬁx (ie use k-wires), then by all means apply a splint PEARL # 7: Precision Combined with The whole point of RIGID ﬁxation is EARLY MOBILIZATION…… Immediate Range of Motion = Early Return-to-Play DO NOT make incisions to apply hardware and then CAST THEM !

7 19-07-28

Phalangeal Fractures in Elite Level Athletes Comprehensive Care of the Elite Level Athlete

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rod French

Pearls of post-op care

1. Don’t ASSUME the splint is worn correctly 2. Playing splints - not necessarily joint above and below

3. Be careful of “hand therapy” in the training room

Nov 22 in Calgary 4. WRITTEN post-op instructions MANDATORY 7 days post fracture 6 days post-op

Phalangeal Fractures in Elite Level Athletes Johnny Gaudreau Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

DR. ROD FRENCH Preliminary Rehabilitation Protocol! ! Immediate Peri-operative Phase: (Week 1) - Remove splint from OR at 24-hours if possible - Ice area and apply Coban compression to control edema. START EXOGEN on day 1 - Initiate IMMEDIATE ACTIVE range of motion of all joints - use pain killers liberally if needed as PREVENTION OF STIFFNESS is paramount. - Use buddy taping only after splint removed to promote range of motion. - Use thermoplastic splint only if too much pain or needed for sleep. - May shower normally after 24-48 hours. Apply polysporin to wound. - GOAL: control edema with ice, maximize MCP joint range of motion

Motion Recovery Phase: (weeks 1-3) - Once edema is controlled, HEAT is the most important modality in finger joints to aid with mobility. Use heat baths, heat wraps etc to heat up hand - Add PASSIVE range of motion near end of first week and progress this as much as tolerated. - Scar massage starts. - SUTURES to be removed a 2.5 weeks, on approx DECEMBER 4th or 5th. - Do not neglect working on EXTENSION of finger joints. Use “place & hold” to encourage - GOAL: recover FULL range of motion by end of week 3 Sport-Specific Recovery Phase: 3-6 weeks post-op (*followup Xrays, 3 views at 3 weeks) Nov 25 in Calgary - Slow and progressive increase in resisted activities permitted in fingers. - Use pain as a guide. If fracture site non tender, okay to progress as tolerated 10 days post fracture - This phase begins when RANGE OF MOTION is FULL and PAIN IS ABSENT - Protection of the little finger in the glove is paramount. The hinges of the glove are the likely 9 days post-op gap in coverage that requires attention

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

Dec 4 in Calgary Feb 18 in Vancouver 19 days post fracture 3 months post-op 18 days post-op

8 19-07-28

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

19 y.o World Junior Hockey player, Dec 17 SURGERY Team Canada 2 days post-injury

2 NHL Drafts – undrafted

Possible 2019 ﬁrst round draft pick

Dec 15, last exhibition game before tournament

Phalangeal Fractures in Elite Level Athletes Phalangeal Fractures in Elite Level Athletes

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med.

Fracture: Dec 17 Day 0

Surgery: Dec 19 Day 2

Dec 17 SURGERY RTP (practice): Dec 22 2 days post-injury Day 5

RTP: Dec 26 Day 9

Phalangeal Fractures in Elite Level Athletes Comprehensive Care of the Elite Level Athlete

Dr. Rodney French, MD, MEd, FRCSC, Dip. Sport Med. Dr. Rod French

Plays all games in tournament Be suspicious

No man-games-lost rest of season Be thoughtful Plays in CHL Championship Be vigilant NHL Drafted June 21 Be humble Signed contract with NHL team July 11

9 19-07-28

Questions ?

Rod French, MD, MEd, FRCSC, Dip. Sport Med Plastic and Reconstructive Surgeon Specialist Hand and Wrist Surgery Ofﬁce: 778-571-HAND Fax: 778-571-4265 Cell/Text: 604-999-1766 Email: [email protected]

10 Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 9:21 AM - 9:31 AM

Metacarpal Fractures

R. Glenn Gaston, MD Royalty: Zimmer Biomet Receipt of Intellectual Property Rights/Patent Holder: BME Consulting Fee: Zimmer-Biomet, Endo, Integra and BME Speakers Bureau: Endo

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Speaker has not provided a handout for this presentation Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 9:32 AM - 9:42 AM

Scaphoid Fractures

Thomas R. Hunt, III, MD, DSc No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Speaker has not provided a handout for this presentation Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 9:43 AM - 9:53 AM

Other Carpal Fractures

James M. Saucedo, MD, MBA Royalty: Hely & Weber Speakers Bureau: TriMed Ownership Interest: Edge

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

9/3/2019

Other Carpal Fractures in the Athlete

James M. Saucedo, MD The Hand Center of San Antonio UT Health San Antonio Department of Orthopaedics ASSH Annual Meeting Boston September 12, 2018

www.handcentersa.com 1

Agenda • Background • General principles – Evaluation – Treatment – Return to play • Specific injuries • Case examples

Background • Fractures involving the rest of the carpus are – Less common – Less recognized – Less understood – Less treated • May still have adverse effects

1 9/3/2019

General Principles: Evaluation • Maintain suspicion & know the anatomy • Understand the demands of the athlete • X-rays (specialty views) – Carpal tunnel view – Various oblique views • Advanced imaging

General Principles: Treatment

• Timing considerations – Can it wait? Patient • Rule of minimization – Minimize downtime – Minimize complication Injury Sport – Minimize uncertainty

Treatment Options • Immobilization – Must consider how long it will take & how predictable is healing • Fixing – Reasonable in both displaced & non-displaced fractures • Excision – Non-essential fragments

2 9/3/2019

Treatment Options: Decisions

Displaced Non-Displaced Fractures Fractures

Essential ORIF Non-Op vs. Fragments (vs. CRPP) ORIF*

Non-Essential Non-Op vs. Excision Fragments Excision

Return to Play Decisions

Injury Features

Treatment Patient Chosen Demands

Return to Play Decisions • Non-essential fragments that are painless may be delayed – Or excised if symptomatic • Essential fragments that were fixed should be protected until healed • Positions that allow for immobilization may speed return to sport

3 9/3/2019

Specific Injuries

The “Other” Carpal Bones • Trapezoid • Rarest carpal fracture (<1%) • Trapezium • Well-protected by its neighbors • 2nd metacarpal impaction • Capitate • Associated injuries are common • Lunate • Consider CT scan • Triquetrum • Base treatment on displacement, • Pisiform essential vs. non-essential • Hamate

The “Other” Carpal Bones • Trapezoid • Body vs. ridge fractures – Body & shear fractures due to 1st metacarpal • Trapezium impacting trapezium • Capitate – Ridge fractures due to direct impact or avulsion by TCL • Lunate • X-ray with pronated AP or carpal tunnel • Triquetrum view (consider CT scan) • Pisiform • Treatment depends on displaced vs. non, • Hamate essential vs. non-essential*

4 9/3/2019

The “Other” Carpal Bones • Trapezoid • Associated injuries more common* • Trapezium • Fall on outstretched, hyperextended wrist → dorsal radius impinges • Capitate • May present with vague, low-intensity pain • Lunate • CT, MRI may be helpful • Triquetrum • Risk of AVN  • Pisiform • Consider ORIF regardless of displacement • Hamate

The “Other” Carpal Bones • Trapezoid • Rarely occur in isolation* • Trapezium • Axial and hyperextension injuries • Tenuous blood supply → advanced imaging • Capitate if suspected* • Lunate • Consider ORIF regardless of displacement • Triquetrum • Pisiform • Hamate

The “Other” Carpal Bones • Trapezoid • Three fracture types – Hyperextension + ulnar deviation → dorsal • Trapezium cortical fracture* • Capitate – Forceful palmar flexion + twisting → ligamentous avulsion • Lunate – Compression between hamate & distal ulna → • Triquetrum body fractures o • Pisiform • X-ray lateral, 45 pronated • Avulsion fractures without associated • Hamate instability → non-op

5 9/3/2019

The “Other” Carpal Bones • Trapezoid • Often direct blow from stick • Trapezium – May also be eccentric pull from FCU • <50% associated with other injuries • Capitate • Consider PT arthritis from overuse • Lunate • Carpal tunnel or supinated oblique • Triquetrum • Excision for symptomatic fractures • Pisiform – Consider release of P-H ligament to decompress Guyon’s canal • Hamate

The “Other” Carpal Bones • Trapezoid • Three major fracture types • Trapezium – Hook – Body • Capitate – Dorsal avulsion • Lunate • Carpal tunnel or supinated oblique • Triquetrum • May consider non-operative for hook, BUT…* • Treatment depends on displaced vs. non, • Pisiform essential vs. non-essential • Hamate

Case Examples (with Tips & Tricks)

6 9/3/2019

Case 1 • 20 year old RHD male with hard fall while playing basketball • Right hand pain, swelling

7 9/3/2019

Direct Dorsal Approach + Traction

Headless Compression Screw + Pins

8 Weeks (Pins Pulled @ 6 Weeks)

8 9/3/2019

Case 2 • 21 year old RHD male, collegiate baseball player • 5 months of ulnar sided hand pain • Immobilization did not relieve pain • Off-season

“Hamate View”

9 9/3/2019

Motor Branch Identified

Remain Sub-periosteal

*Different Patient...also baseball player. 29

Repair Periosteum Over Defect

10 9/3/2019

Hook No More

• Not uncommon to have ulnar sided wrist pain • Resolves with time • May return once wound healed, as tolerated • Counsel carefully to manage expectations

Summary • Maintain suspicion for other carpal fractures • Consider specialized views, advanced imaging • Treatment must consider demands of the athletes & implications of treatment – Minimize downtime – Minimize complications – Minimize uncertainty

Summary • Treatment options include – Immobilization – Fixation (ORIF vs. CRPP) – Excision • Treatment depends on – Displaced vs. non-displaced – Essential vs. non-essential

11 9/3/2019

Treatment Options: Decisions

Displaced Non-Displaced Fractures Fractures

Essential ORIF Non-Op vs. Fragments (vs. CRPP) ORIF*

Non-Essential Non-Op vs. Excision Fragments Excision

Return to Play • Depends on ability to wear brace during play • Excision – 1-2 weeks or once the wound is healed • ORIF and CRPP – 6-8 weeks out of play – May generally return at 6-8 weeks in splint – Full return at 10-12 weeks

Thank You!

12 9/3/2019

Case 1

• 22 year old RHD male vs. cement block • Right hand pain, swelling

13 9/3/2019

Traction Through Finger Traps

14 9/3/2019

CRPP

Pins Pulled at 6 Weeks

15 9/3/2019

16 Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 9:54 AM - 10:04 AM

Discussion and Questions

All Faculty

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 10:05 AM – 11:00 AM

Tendon and Ligament Injuries of the Hand

Gary M. Lourie, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 10:05 AM - 10:15 AM

Skiers/Gamekeepers

Michelle G. Carlson, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Skiers/Gamekeepers Injuries in the Athlete

Michelle G. Carlson, MD Official NBA Second Opinion Physician Consultant Hand Surgeon The New York Knicks/Liberty The New York Nets The New York Mets Iona College

Disclosures

• No relationships with commercial interests related to this presentation existed during the past 12 months.

http://www.assh.org/About-ASSH/ASSH-Store

1 Need to know • Sport • Level of Play: Pro, College, High School • Position: gloved or non-gloved • Dominant or Non-Dominant Hand • Limitations of motion acceptable for that position • Where they are in the season • Contract Negotiations

2 Collateral Ligament Injuries

• Clinically greater than 30 degrees instability, or greater than 15 degrees compared to contralateral side.

UCL Tear

• 26 yo NFL Center • “Sprained thumb” during game

3 R.A.

• Fell during game on left thumb 2/2004 • Cannot play due to pain and swelling of left thumb MP joint. • h/o UCL repair in college ‘98

MRI

4 Surgical Technique

Bone Anchor – double loaded

Internal Brace

5 Repair Site

Repair Site

Internal Brace

6 Surgical Technique

Surgical Technique • Mark dorsal aspect of MP joint • Midaxial incision • Extends from proximal aspect of condyles to 5 mm distal to joint • May need to be slightly more proximal if Stener lesion present

Surgical Technique • Protect sensory branch of radial nerve • Incise adductor aponeurosis/dorsal hood longitudinally leaving enough hood by EPL to repair • Identify UCL • Incise capsule along dorsal aspect of UCL as necessary

7 Surgical Technique

• Prepare insertion site of UCL, just proximal to tubercle. Make sure you are volar enough • Drill and fill with anchor, double loaded if possible with extra 2-0 nonabsorbable suture • Repair UCL with two sutures

Surgical Technique

• Repair dorsal capsule to UCL, and UCL to volar plate if possible • Repair adductor aponeurosis • Repair skin with subcuticular suture

Surgical Technique

• Pin or not to pin ? • No pin anymore !!!

8 Collateral Ligaments - Post-op

• Bulky dressing one week • Palm based thumb spica splint at 1 wk post-op for total 6 weeks ATC • IP Rom in splint

Collateral Ligaments - Post-op

• Thumb MP ROM at six weeks • Cut out cone splint weeks 6 - 12

Timing of Treatment

• Time in the Season • Can they play untreated and taped ? • Can they play protected ? • MRI: Stener or nondisplaced UCL tear ?

9 Return to Play

Dy, Khmelnitskaya, Hearns, and Carlson, Survey: Treatment after surgery Orthopedics 2013 RTP 2 weeks protected 3 months unprotected Ritting, et al, Clinical J Sports Med 2010 Immediately after injury in cast Unprotected at 3 months

Morgan and Slowman, JAAOS 2001 Immediately thumb spica cast 6 weeks. At 6 - 12 weeks rigid taping of MCP joint.

Johnson and Culp, Hand Clinics 2009 Incomplete injuries of UCL: 6 weeks thumb spica aplint or cast Unprotected play starts at 12 weeks

Return to Play Following Hand Injuries in the NBA

Morse KW, Hearns KA, Carlson MG. Orthop J Sports Med. 2017 Feb 16; 5(2);

Design and Methods

• NBA Transaction Report was analyzed from January 2009 – May 2014 using www.prosportstransactions.com

• Demographic information (age, position, shooting side) was identified through www.espn.com and www.basketball-reference.com

10 Results

• 137 Total Injuries Identified . 39 injuries to the hand . 98 injuries to the finger • 68 Injuries were included in the study . Metacarpal Fracture: n=26 . Thumb Ligament Tear: n=9 . Phalangeal Fracture: n=33

Conclusion: Return to Play

• Thumb ligament tears: longest RTP (67.5 days) • Metacarpal Fractures: Twice as long for fractures treated surgically vs non-surgically (56.7 vs 26.3 days) • Phalangeal fractures: no sig diff between fractures treated surgically and non-surgically (46.2 vs 33.3 days)

NCAA Rules Governing Protective Equipment

Sport Specific Cover Splints in ½ inch closed cell foam

http://www.ncaa.org/sites/default/files/SMHB%20Ment al%20Health%20INterventions.pdf

11 12 Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 10:16 AM - 10:26 AM

Jersey Fingers

Melvin P. Rosenwasser, MD Consulting Fee: Stryker, Acumed, Zimmer Biomet and Conextions

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Speaker has not provided a handout for this presentation Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 10:27 AM - 10:37 AM

Extensor Tendon Injuries

Douglas R. Weikert, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Speaker has not provided a handout for this presentation Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 10:38 AM - 10:48 AM

Pulley Injuries

Gary M. Lourie, MD No relevant conflicts of interest to disclose

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV

Pulley Rupture in the Athlete ASSH Precourse 12 2019

Gary M Lourie MD

Pulley

Treatment Elite/Recreational Athlete

Challenge Clinician

Injury Sets Complex Situation Inv

Physician

Athlete

Athletic Trainer

Manager-Owner

Agent

Pulley

Goal Treatment Elite Athlete

Return to Play Early x/o Risk

Balance Return

Long-term Risks

Day/Age Medicolegal issues

Pulley

Pulley Injury

Pertinent Anatomy

Mechanism of Injury

Dx/Rx

Emphasis Elite Athlete and Return to Play

Pulley

Pulley Rupture (Annular) RARE (*CONSEQUENCE*) Mountain climbers

Can be seen Nonclimber

Best References

1) Injuries to the Finger Flexor Pulley System in Rock Climbers; Current Concepts. Schoffl VR, Schoffl I. JHS A 2006;31A.

2) Closed Flexor Pulley Injuries in Nonclimbing Activities. Schoffl VR, Jungert, J. JHS A 2006;31A.

Pulley

3) Surgical Repair of Multiple Pulley Injuries-Evaluation of a New Combined Pulley Repair. Schoffl VR, Kupper T, Hartmann J, Schoffl I. JHS A 2012;37A.

4) Flexor Pulley System; Anatomy, Injury, and Management. Zafonte B, Rendulic D, Szabo R. JHS A 2014;39A.

5) Annular Flexor Pulley Injuries In Professional Baseball Players. Lourie GM, et al. AJSM 2011;39.

Pulley

6) Baseball and Softball Injuries; Elbow, Wrist, and Hand. Trehan SK, Weiland AW. JHS A 2015; 40.

7) Closed Traumatic Rupture Pulleys. Bowers WH et al. JHS A 1994;19A.

8) Boutonniere and Pulley Rupture in Elite Athletes. Marino JT, Lourie GM. Hand Clinics 2012;38no2.

Pulley

Pulley Pertinent Anatomy (Doyle,Blyth)

5 Annular 3 Cruciate 1 PAP

Pulley

Pertinent Anatomy-Pulley System

Described 1975-Doyle,Blyth AAOS

Many Modifications- “Synovial lined fibrosseous tunnel..pulleys fibrous tissue bands segmental fashion ….maintain flexors constant relationship joint axis motion” Pulley

Function

“To Keep the Tendons Close to the Bone as Well as Transfer the Linear Force of Muscle Contraction into an Efficient Flexion Moment at the Joints” Doyle JHSA, 1989

Pulley

A2 A4 Important (A3 Stability PIP)

Injured-Clinical Significant Findings

Tendon Bowstringing

Loss Power

Reduced ROM

Risk additional rupture

Fixed Flex contractures

Pulley

MOI- Bowers JHS ‘94

Non Climber

“ A rapidly applied extension force exerted to the acutely flexed digital system-not dissimilar FDP avulsion”

Pulley

MOI Climbers – Same Mechanism Highly Concentrated Demands Place Hand (Pulley) Risk

2 Finger Positions (Hand)

The Hanging (DIP,PIP,MP Flexed)

The Crimp (PIP Flex DIP Ext)

Pulley

Force (newtons) Pulley Studied (Variable)

599 N Pulley PIP flexed 135* (Burtscher ‘87) 450 N A2 Pulley (Bollen ‘90)

269 N A4 Pulley (Roloff ‘06) Crimp

To Rupture A2 400N vs 137N (Variable)

Forces Pulley Crimping close to Bio Tearing Force!!!!

Pulley

Forces Pulley Newton Approach Bio Tearing Force Typical History Climber

Esp During difficult passage

Esp Loss of Footing

Pulley

Clinical Findings Typical History (climber)

Acute onset of pain

Pop or snap 75 %

Heard up to 10 to 15 m away

Acute pain forces climber stop

Immediate palmar tenderness

Pulley

RF followed MF

Longest digit with full flex(Bynum)

Lumbricals RF,SF bipennate

Juncturae Tendinae cc RF (tether)

Power grip in UD (RF)

Pulley

Exam

Tenderness palmar aspect Pulley (Lateral)

Swelling/Hematoma Bowstringing Only Multiple Rupture

Isolated Resisted Flex Digit Opposition Increased Distance Palpated ?A2

Pulley

Algorithm

Schoffl ’96

MRI

Pulley

Radiographs Rule Out Fx

MRI Gold Standard

US Schoffl

JHS,2006

Cost

Dynamic

Pulley

MRI Gold Standard

T1 TBD (Tendon Bone Dehiscence) >2mm

T2 Edema Tendinitis, Flexor Tendon Rup

Flex vs Ext TBD

>2mm Rupture

Pulley

High Cost MRI-Prompted US

Dedicated MD Very Useful Dynamic

>2mm Pulley R

Pulley

Rx- Scientific Evaluation and Therapeutic Guidelines

Grading System (Schoffl Wilderness Env Med, 2003)

Grd 1- Pulley strains no increased dehiscence of the bone to tendon on MRI or US <2mm

Pulley

Grd 2- Complete Rupture A4 or partial rupture of A2 or A3 ( good prognosis)

Grd 3- Complete Rupture A2 and A3 (Prolonged Recovery-Guarded)

Grd 4- Multiple Ruptures A2/A3, A2/A3/A4 or A2 or A3 with lumbrical or CL

Pulley

Treatment Gr 1 Strain <2mm US MRI

Conservative Immobilization None

Functional Therapy 2-4 wk

Protection Tape

Return Lo Demand SSA 4wks

High Demand SSA 6 wks Taping 3 Mos

Pulley

Taping Pulley (thermoplastic)

Bollen ‘90 1.5 cm Tearing Force 500N

Warme ‘05 No diff

Schweizer ‘00 No diff

Cons Rx Excellent

Pulley

Treatment Gr 2 Rupture A4 Partial A2 Conservative Immobilization 10-14d (Splint)

Functional Therapy 2-4wks

Pulley Protection Tape vs Thermo Ring

Lo Demand SSA 4 wks

High Demand SSA 6-8wks Taping 3 mos

Pulley

Treatment Gr 3 Complete Rupture A2/A3

Conservative Immobilization 10-14d (splint)

Functional Therapy 4 wks

Pulley Protection Thermo Ring!!!!!

Lo Demand SSA 6-8wks

High Demand SSA 3 mos Taping 6 mos

Pulley

Gr 3 Complete Rupture A2/A3

PROLONGED RECOVERY

Some Advocate Surgical

Abrahms “A2 Pulley Insufficiency”

JHS ‘13 EBM ? High Demand

Conservative Gr1-3 Pulley

Pulley

Treatment Gr 4 Multiple Ruptures A2/A3/A4 or Single with CL, lumbrical

SURGICAL (Many) Immobilization 14d

Functional Therapy 4 wks Thermo Ring

Lo Demand SSA 4 mos

High Demand SSA 6 mos Taping 12 mos Pulley

Many Techniques- Widstrom Loop 1 1/2 Best

Pulley

Example Gr 4 3rd Baseman

2 Swings

L RF RCL

A2 Pulley

Pulley

Four High Perfomance Pitchers AJSM 2011

A4 rupture MF

Prodomal Sx Fastball 2-3 wks

Pop pain swelling midphalanx

MRI Inc T B D >2mm P2

Pulley

A4 rupture ppt Fastball not Curve

Rx- conservative Return 2-3 mos

Pulley

Conclusion

Rare Injury Increasing Incidence Higher Suspicion Better Dx Methods

Rx- Conservative Single Pulley

Surgical Multiple Pulley

May not be Sport Specific (Climber)

Pulley Rupture

Thank You

Pulley

Precourse 12: Athletic Injuries of the Upper Extremity: The Adolescent to the Adult - The Amateur to the Professional 10:49 AM - 11:00 AM

Discussion and Questions

All Faculty

74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 - 7, 2019 LAS VEGAS, NV