0:00

Dr. Stern, we're here with a 29-year-old

0:00

3 00:00:02,940 --> 00:00:05,490 professional athlete, throwing athlete.

0:06

And, uh, this patient experienced,

0:08

I believe, a deceleration injury.

0:10

I think his hand got caught on somebody

0:12

else's helmet in the middle of a throw.

0:15

And, um, when he walked off the field, his thumb

0:18

could just kind of droop down to the side, although

0:20

he wasn't in much discomfort at the time.

0:23

We've got, uh, coronal, what I call

0:26

UCL views with the proper angulation.

0:29

Fat-suppressed, uh, T1 anatomic image, and

0:32

then the axial, uh, water-fat-suppressed image.

0:36

And he's got a very complex, high-grade

0:40

UCL. Just to give the audience the anatomy,

0:42

here's the adductor aponeurosis, and you can see how

0:45

it's dipping underneath the ulnar collateral ligament.

0:49

Now, an inexperienced reader might think that

0:50

that was the adductor aponeurosis because of

0:52

its slope and kind of blend these two together,

0:55

but this is actually the UCL that normally

0:57

would exist under here and attached there,

1:01

and now it's sitting on top of the aponeurosis.

1:04

You can see it on the, uh, coronal T1.

1:07

Looks like kind of a yo-yo on

1:08

a string sign, if you will.

1:11

And then in the short axis view, there's this extra

1:13

nubbin of tissue that normally wouldn't be there.

1:16

That's the UCL that is sticking out

1:19

dorsally because these things retract.

1:22

They fold backwards on themselves, uh, this way.

1:26

And then they kind of lob themselves on top of the

1:28

adductor aponeurosis, which I've depicted here.

1:31

And then this is the UCL sitting well on top of

1:35

the adductor aponeurosis, which is underneath it.

1:38

So, a couple of issues on this case.

1:41

Obvious, high-grade, stenotypic, trapped UCL.

1:46

What matters in the acute stage?

1:48

And what determines what kind of

1:50

procedure you're going to do here?

1:51

Because I think this patient

1:52

has a pretty shredded UCL.

1:55

Yeah, this is, uh, even an orthopedic

1:58

surgeon could make the diagnosis here.

2:01

The ligament is completely blown out, uh,

2:04

and as you said, it flips over backwards.

2:09

And it's actually, the reason it looks like it's on

2:12

top of the adductor aponeurosis, it's actually flipped

2:16

over, approximately 180 degrees, and it's

2:21

actually just proximal to the adductor aponeurosis.

2:25

At any rate, the question is

2:28

whether or not, exactly as you've drawn,

2:31

the question is whether or not

2:34

this can be repaired.

2:37

And in these cases, from a clinical

2:41

standpoint, you really want to get

2:43

to the surgery as quickly as you can.

2:45

Sometimes the ligament is so

2:47

damaged, hemorrhagic, and edematous

2:49

that you cannot reattach it.

2:52

In that case, you would have to substitute

2:54

it with some type of tendon graft.

2:57

Again, usually the palmaris longus

2:59

is our go-to graft situation.

3:02

If you can reattach it, fine.

3:04

You can put it down with a suture anchor.

3:06

There are a number of different techniques.

3:09

This was another patient of mine,

3:12

and in this case, the patient

3:16

elected to finish out the season and we did a

3:18

reconstruction with a palmaris

3:22

graft, and he returned the following

3:25

season to have a successful career.

3:29

He did well.

3:31

Now, for the audience,

3:33

this was his non-throwing hand.

3:35

Had it been his throwing hand, there's no

3:36

way that he would have been able to continue.

3:38

He wouldn't have been able to hold the ball.

3:39

Yeah, that's correct, absolutely correct.

3:40

83 00:03:42,184 --> 00:03:44,514 But it was his non-throwing hand, and with a lot

3:44

of, uh, taping and splinting, uh, he was able to,

3:49

uh, handle the ball and finish out the season.

3:52

Question for you.

3:53

If you, if you avulse off a piece of the

3:55

base, how does that change the surgery?

3:58

Well, in gen, uh, no, it

4:01

absolutely will change the surgery.

4:03

If you think you can fix, uh, a fracture

4:07

fragment, which is, uh, certainly a variable

4:10

size, as you mentioned earlier, it can be very

4:12

tiny to, uh, you know, uh, fairly substantial.

4:17

We would always try to fix bone to

4:19

bone rather than tendon to bone.

4:21

So if we can preserve that fracture fragment and

4:25

put it down, uh, by a variety of techniques, screws,

4:29

pins, uh, pull-out buttons, et cetera, more than the

4:32

radiologist would need to know, we would do that.

4:35

Uh, sometimes, uh, however, the fragment is

4:38

small enough that it ends up being excised and

4:41

then you do a ligament to bone reattachment to

4:43

the volar ulnar base of the proximal phalanx.

4:46

In terms of timing, you mentioned, you

4:48

mentioned this when we were off camera.

4:50

You said, you know, it's important to fix these

4:52

in the acute stage if you can, uh, functionally

4:55

based on, you know, the patient's job, etc.

4:58

But one of the reasons you want to fix them early is

5:01

because if you let them go, that changes the procedure.

5:03

Could you explain that a little bit?

5:05

Over time, the, uh, the tissue, the

5:09

ligamentous tissue, the collagen just deteriorates

5:12

and becomes very edematous, uh, and almost, I

5:16

wouldn't say friable, but it's edematous

5:20

and you just cannot get a reliable repair.

5:23

So, uh, ideally, in an injury like this, if you

5:28

could repair this, and I've done this, day one

5:31

or day two, that would be the ideal situation.

5:34

But over time, the collagen kind of coalesces, becomes,

5:39

for lack of a better word, mushy, and it precludes any

5:44

type of acute reattachment, necessitating a free graft.

5:50

And this patient had, as you said, a free graft.

5:52

He's also got two of the other

5:53

findings that you alluded to.

5:55

In prior vignettes, you can see that

5:57

he is extended during this exam.

6:00

It's probably an almost full

6:01

extension, as much as he can get.

6:03

And if you look at the cortex of the metacarpal,

6:06

and then you look at the cortex of the

6:08

proximal phalanx, they're offset a little bit.

6:11

So he does have a little bit of radial deviation.

6:14

And he also has that sag sign that we talked about

6:17

before, where the proximal phalanx is moving forward

6:20

due to loss of the secondary stabilizers.

6:23

Um, any other comments before we get off this case?

6:25

No, I, I think you've described it quite well.

6:28

Great.

6:28

Dr. P and Dr. Stern, out.