We've had some fun talks, we probably have about 15 minutes to go through some cases here so we're going to kind of get going through here, welcome our panelists up, I think we have enough chairs for everybody. So this is the wrist and the elbow session, so we're actually going to start with a wrist case, there's at least three of us on this podium that have had some wrist fellowship experience. So this is a very active 36-year-old female, very active, three months of right wrist pain, volleyball, softball, kind of patient that we all would potentially see. Very active, young, 36-year-old lady, pain of the dorsal wrist, decreased grip and strength. She came initially, x-rays there, I'll just say it doesn't look too bad there at all, not much going on, but it's enough, six months later she comes back, worsening pain, a little bit less function, mainly pain. And now you can see her x-rays here, and focus on the lunate and the angle of the scapho-lunate angle you can see there, and it just shows some images here, you can see the lunate, draw your attention to the lunate on the CT in the bottom right, and MRI showing that lunate's not looking too good. So what treatment, I'll go back, what treatment should we have for this young, active, softball player, wants to use her wrist, wants to continue, going on canoe trips up north in Minnesota, PRC, lunate excision, vascularized grafted lunate, wrist scope debridement, radial shortening, SCT, whatever, I'll go back to some of the injures, so, I don't know who I'll pick on the panel, maybe I'll start with Buddy, who's used to, does a lot of wrist arthroscopy I think, still a little bit. So, mid-stage climb box, in a young athlete, that's a tough, tough to make the next jump, I think, so I tend to at least do a scope first with the debridement, and a little tiny microfracture, might think about putting some graft in, some of the knee guys are using some different calcium phosphate materials, and you can kind of sneak it in a little bit and fill it up, but I don't have a great solution, but I would start as conservatively as possible rather than jumping into much of the realignment. David, your thoughts? Yeah, I'm a little concerned with the fragmentation that you can see in the lunate, especially on the sagittal fuse, so I think scoping it first to get a better idea of what's really going on with the lunate would make a lot of sense. And it's interesting, if you look at most of the keen box studies, even the successful patient, the rare patient treated non-operatively, the condition of the lunate really doesn't dictate how the patient's doing clinically. It'll look like a horrible looking shrunken region, but the patients can be saying, I'm doing, whether you've done a scope, a vascularized graft or such. When she's an active lady, I didn't want to do some of the more exotic things. Actually, I sent this case out to a lot of hand surgeons I know, and they said take out, do a PRC. I'm like, wow, take out the whole front row. It's like taking out the front row of your teeth on this very active 36-year-old. So I didn't do that, so I searched around for some techniques that maybe are a little bit out there. So I called the scrambled egg procedure. I did a dorsal rectangular osteotomy of the radius. Did an AIN-PIN resection, so partial anorectomy. And then maximum, I probably could use PRP, but I put allograft bone into the distal humerus and then put the coffin lid back on the distal radius without fixation. So there's the approach. It's a rectangular, so I can get my curette down in there. I put the graft on the back table for a moment and then got my curette in there and just started scrambling the whole metathesis down there. Reaching over radially, ulnarly, and then I added the allograft, put the coffin lid back on, no fixation, just tapped it back in place after the PIN-AIN resection. For fun, I got a bone scan, intense uptake at the distal radius and lunate, so this is what I'm hoping for, that we're stimulating something going on down there, some inflammatory healing response. Fifteen months later, she was pain-free, back to sports, reasonable range of motion, feeling fine. Now, how long that's going to last, I don't know. She's actually about almost 20 months, I think, now. So she kept her front row of teeth and she's back to sports and doing well. So I don't know if that's the answer, but there's a lot of answers for Keenbox. So you put the graft in the lunate? Yeah, not in the lunate. No. I didn't approach the wrist joint at all. I just cleaned out. Just stayed proximal. Yeah, just stayed inside the radius. Put in crunched up croutons for an energetic response of some sort, and you get lucky sometimes. But there is some data on that, similar technique from Argentina. And this one, they make an osteotomy, put a plate on, a little bit more extensive. They actually go after the ulna also with very good follow-ups. This is where I got the idea from, but in mine, there was no plate and we didn't violate the ulna. So that's our risk case for the day so far. Now we'll move on to the elbow. So there's an 11-year-old, I'm not kidding you, a female Greco-Roman wrestler. Her two older brothers are very good and she's highly rated. I don't know much about Greco-Roman wrestling and little 11-year-old girls, but she's also an avid athlete, softball, volleyball, track. And she fell to pop on a hyperextended elbow while she was Greco-Roman wrestling and competitively. And she's canoeing with pain. So there's initial x-rays, then MRI outside facility, and you can draw your attention to what we see over here. And here kind of a lax, obviously there's a proximal lesion of the UCL here in its entirety it looks like. And then she came to see me, actually my wife, Dr. Adams, also. Eight months, continued pain in her elbow, pain with valgus, stress testing. She just had a bit of a pronation rollout, painful over there. What should we do now in this 11-year-old, very active Greco-Roman wrestler, she hasn't been active, she hasn't been competitive for eight months now. Jeff, do you think this might be a candidate for a suture-type repair? And the question a lot of us have is when we see those patients, you had some several great series of bone formation on the ulna, commonly. But also we sometimes see this heterotopic bone forming in the area of the ligament or ligament pulled off with some proiosteum in a young patient. What are your thoughts? So my first thought is that if I had had a chain, you know, you saw this eight months post-op of my post-injury, but my first thought would be I wish they'd had it fixed when they had it initially. My second thought is I don't like the idea of putting a suture tape or an internal brace across this because of her growth potential, the tape construct is obviously not going to grow with her. And should she outpace it, I imagine she would lose some, potentially lose some motion. So if she was not healthy or not happy at eight months, I don't think there's any force of nature that's going to get that better non-surgically. So my preference would be to excise that little piece of bone and do just a simple suture repair. But I would not span that with the internal brace at her age. And that's quite one question that I have is often when you go after that bony piece, you have a defect. And then those are the more of the adult, you know, 20-year-old, then I always feel I have to do reconstruction. Yeah, I do too. And I feel like, geez, I've taken some of the ligament away. So sometimes I wonder whether I should just ignore the bone if there's still some ligament still there. I think if this was a 20-year-old, I'd definitely do a reconstruction. I think that for her, I would try to, and a wrestler, I'd try to just repair it. I think Kevin has a question. Kevin. Kevin Murray, Northern California. Great talks. Thanks to the panel. That was my question. I have a 19-year-old college pitcher that medial elbow pain for two years off and on. And MR arthrogram does not show a tear in the UCL. But there's about a 7-millimeter well-cordicated ossicle in just about that position. Any thoughts about what to do? So our experience with that has been that you have bone functioning in a tension mode. So the pain is likely because it's not supposed to be there. And it's not a suitable ligament replacement. So we've reconstructed those. And we've kind of stuck to that in the repair era, I guess, for lack of a better term, for the last few years. We've kind of stuck to that because we've really tried to say, if you have a tissue deficiency, whether it's quality or quantity, you're better off replacing that with tissue rather than tape. So I would say in that pitcher who's probably throwing the ball pretty hard and could generate some real force, that person's going to have a tissue deficiency when you take out that ossicle. I would still reconstruct that. So it's different in yours than in this one. For sure. So sometimes in this one, 11-year-old, that piece was actually part of the growth plate that came off at the original injury. And sometimes you can preserve that in a 9, 10, 11, even a 12-year-old, and repair that back and get bone-to-bone healing. And they do really well. That's the apothecial injury that the bad actor is the one where there's a distal tear and the ligament comes off. And your kid, that's probably been there a long time. And he's been doing fine. And now as his competition level gets up, now he's having trouble. And that one, you still have to graft. That's the mid-substance rupture. I haven't quite jumped to that level with Jeff's internal brace. In turn, it's expanded my repairs dramatically. But that one particular case, like your pitcher, that's different than Scott's case here. And Tony, your thoughts on the young patient? She's actually 12 now by the time she came to see me. So she's 12. It's been eight months. Would you agree, or would you do a reconsideration? So I agree with everything that Buddy and Jeff just said. I pretty much follow the same philosophy. I think what you would do here is you would expose the site and see what you have. And if it looks like the tissue is mobile enough and it has enough, I saw the MRI, it looks like it's pretty good tissue, then I would try to do a repair. And see if I could get away with that with her. And I wouldn't do a reconstruction. I wouldn't want to put those tunnels around this at this time. You know, just for completeness sake, I'd get an x-ray of her opposite elbow just to see where she's at in terms of her growth cycle. I know where she's, you know, 12 now. And so she's not too far away. But I'd still be a little nervous and probably try to do some kind of suture repair. And I would do a repair and see if I could get away with that with her. And I'd still be a little nervous and probably try to do some kind of suture repair if I could. And Luke, do you think eight months, do you think some of the non-operative, she really hasn't been treated much. She's been braced when she came to see me. She was taken out of her activities. So she has been somewhat treated non-operatively. Do you think PRP on this young lady would be effective or any other non-operative measures you can think of? No, I think that the ship has sailed. I agree with the panelists that for gymnasts, wrestlers who put a high valgus torque on their elbows, these patients actually do best when treated operatively at the first presentation. And we got extras the other side. When I spoke to her PEDS guy, she had almost no growth left, they felt, in that area. So I think, though I agree, I'm not going to make tunnels all over the place in a 12-year-old. I felt safe proceeding with the surgery. So it was, of course, torn off on the homer side. And so I did do a suture technique using the smaller anchors. And Jeff and I have discussed this in the highly traumatic automobile accident type patient. I used a bigger anchor, bigger peak anchor. But for most of the athletes, and certainly small people, I used the smaller athletes and repaired part of the ligament. But I was careful. I didn't want to take out a bone and destroy what was left. So I was able to repair back part of it. But essentially do that technique now. I just saw her a week ago, actually. She's three months out. And what I did is I splinted her in a cast for six weeks. That's a little unusual. But I was concerned. I did the repair. And it wasn't a whole lot of tissue. It's been eight months. But I went to repair, and I splinted her carefully. And the thing that was interesting, you would think that in these young people, I think if you put someone in a cast for six weeks after surgery, they're going to be stiff. Now, yes, when I took the cast off at six weeks, she was stiff. But her motion now, as you can see, is minus 5 to 150. This is her just last week. You can see a little bit of hyperextension, great flexion. And she comes out. So these patients can get their motion back, the young patients. But again, so she's three months out. I guess I can ask for a little bit of advice. I'm still going to hold her back from softball and gymnastics and Greco-Roman wrestling, for sure. And would Pamela agree with that? Or do you think at three months, we can let her fly? She feels great. Larry, what do you think? Yeah, I agree with you, Scott. I think it's premature. I would discourage her. She's obviously an aggressive athlete. And I think a young person like that, you give them an inch, and I think they're going to take more. So for me, it would probably be a six-month window to get back to those type of activities you described. OK. I think I'll show one more case that we just finished up, so I won't go over too much. This, I think, is an interesting case. This is a wild kid who's a 16-year-old. As we like to say back home, trauma is not random. So he fell. He was doing donuts. That's not really him, but it's close enough. Had a huge hyperextension injury to his left elbow at a relatively high speed. Initial x-rays, after he was reduced, it's dislocated. You can see the swelling medially. He also had a significant tearing of brachialis. I mean, he was just falling out. But notice the radial head is up anteriorly and also pulled over to the medial side. And so the only humeral looks OK on this view, right? But the radial head is up. You can't tell, but it's also pulled over medial. And this is him in the scanner. You can tell he's obviously loose because even though he's reduced, he's dislocating again in the scanner. And you get an idea of what's torn on the medial side. And again, that persistence on that lateral side of the radial head being pulled up and over and almost tight on that lateral side. Everything's kind of rotating around that lateral side in the scanner, even though it's dislocated. So something's tight over there. So you always want to get x-rays of the opposite side. Some people just have funny elbows, right? And they were born with their radial head subluxed. And you're scratching your head. But actually, that's them. But unfortunately, his right elbow is fine. So it's probably not some congenital thing. So back to his elbow. That MRI was interesting. If you go through the MRI on it, I'm not going to go through all the scans. You see a fold of tendinous-looking tissue with the solid arrow, whereas the dotted arrow is the biceps. The biceps is going where it's supposed to go. And there was no comment from the radiologist if you follow that tissue that's coming off of the brachialis down. And so we did a lateral approach. And I think this repeats itself. But doesn't that look just like the biceps? I think it'll repeat. We did a lateral approach because there is possibility. Look at that tendinous tissue, right? Boom. That had to have been the biceps, right? So there are a lot of case reports in literature of one or two patients of biceps wrapped around the neck of the radius. But they never talked that they followed that tendinous tissue down to where it's supposed to insert. Well, I did. And that tendon went to the ulna and not the neck of the radius. If you think about it, it would be hard to actually get the biceps to wrap around them. I mean, it's attached to the radius. How does it wrap around? Well, I went to the anatomy lab. It takes a lot. I proved to myself you could do it. But it's a lot easier to get the lateral tendon edge of the brachialis, which is a real tendon. We've all been doing distal biceps repairs. I'm sure Larry's seen this too, where the fellow says the tendon's intact, but they're actually looking at the lateral superficial edge of the brachialis. And so we popped them back in, repaired his medial side also. And he was doing fine. He actually went on to break his clavicle. Again, trauma's not random. I fixed that too. But here you can see a nice anatomic study of the superficial head of the brachialis. And it's tendinous and looks a lot like the biceps. And so in the anatomy lab, this is me in the anatomy lab. This is the biceps. OK, it's more distal. And here's the superficial head of the brachialis. And the key thing to me is you always see muscle because it's torn off the majority of the brachialis. It's more medial. So when you see this on the side, and it's right at the neck, it ain't the biceps. It's the superficial head of the brachialis. So I learned that over the past couple years. That's not something I come up with. And of course, my partner, Sean O'Driscoll, tuned me into that this is a real injury. So any comments from the panel? Anybody that's seen this in their practice? I'm always on the lookout for it. I have one other case that came in, and I was like, this is it. But it wasn't. At least I'm cognizant of it. So anyway, I think we'll stop there. Is that OK for the moderators? We'll stop there. And I want to congratulate everybody for coming. I think we had some good talks today. I want to congratulate the panel. Thank you very much.

wrist pain

lunate bone damage

scrambled egg procedure

elbow injury

UCL ligament