Okay. So we'll move on, then, perhaps, to our next speaker, who is Claude Williams. He's going to speak to us about PRP fracture dislocations. And we'll discuss this one about what to do with the next one. Is that okay? Thank you. So Glenn Gasson has briefly already touched on this topic, and we've gone over a few of the considerations on these injuries. We talked about the incidence in injuries. And I think this is a big problem with these injuries, is they're so common to have finger injuries in athletes, particularly collision sports, that the trainers often are busy dealing with other injuries. They see these commonly. They're often innocuous injuries. And so they're often ignored. So what I try to do early on in the season is proactively talk to the trainer so they remember two things. One, some of these injuries can come back and bite you, as we know, if it's a fracture dislocation that goes unrecognized. And number two, if it is unrecognized, it's not the kind of injury that you can repair at the end of the season and have a similar outcome. It's a completely different path that you've gone on if you're dealing with a reconstruction of these injuries. And so if they keep that in mind, then they maybe have a little higher attention to these injuries when they come off the field. I would tell the trainers, first of all, they're the ones typically going to be on the sidelines or the team physician. Ask the player about the mechanism, any injury that has to be brought back out straight or a hyperextension type deviation injury. If there's any malalignment to the finger, of course, have them check the range of motion and particularly lateral stability. If there's pain with any of this the next day or if there's any limitation of range of motion, you have to consider boutonniere deformities or bony injuries and x-rays. All these injuries certainly would deserve x-rays if you meet those criteria. So what we look for when we see an x-ray, we all know about the V sign. Basically what we're trying to determine is the stability of the fracture because that's really going to dictate the treatment and when the player can return to play. So in terms of stability, we can get that on the physical exam, but by the time we see these athletes, we've got radiographs to evaluate and we need to make sure they're good radiographs and a dead true lateral of the PIP joint so we can make a determination in terms of the congruity of the joint because we know it can be fooled. Roughly 25 to 35, 40 degrees in there may be in the tenuous range. Anything certainly more than 50 percent is going to be unstable and this injury that we see here on the right certainly meets those criteria. You can see the V sign, more than 50 percent of the articular surface involved. And so this is an injury, we've talked about a lot of finger injuries and I think even the agent that spoke mentioned that finger injuries are different than knees and ankles because you can often play through it and deal with it at the end of the season and a lot of players are going to even with these injuries. All you have to do is look at the coaching staff, maybe some veterans and all their fingers as we mentioned are all swollen and deformed often and they've had a lot of missed injuries. But I think you owe it to the players to explain to them exactly what they're dealing with up front and that they really have two paths. So an injury like this, they really have a choice of either correcting it right in the beginning or it's a different operation later in the season and those decisions are going to depend of course on where they are in the season and the position that they play. So in terms of stability, when you have a fracture involving the volar lip, you've disrupted the constraints, dorsal subluxation and then you've got the deforming forces that are really all in play. Not only the central slip, but even the sublumus tendon is going to act to shorten the middle phalanx and dorsal subluxation. So an unstable injury really requires more than just a splint to prevent those deforming forces. Stable injury is what most players expect with injuries to the middle joint is that they can just play through it, they can tape it, buddy tape it and that's true with a small volar injury. I like some of these buddy loop straps or buddy taping in the glove depending on the position. And I think with this, the obligation is just to watch it very closely, to x-ray them maybe once a week for the first three weeks to make sure it stays reduced. But the problem typically is going to be more stiffness than recurrent instability with a small volar like a bulge and so encouraging range of motion. I think buddy taping not only prevents hyperextension but also encourages them to move the finger. Options for the unstable PIP joint, fracture dislocation, we've already discussed some of these, pin fixation, open reduction, internal fixation and traction devices. Splinting for the tenuous fractures, but that is difficult I think in an athlete who is going to be playing but there are, I have had some linemen who have had somewhat tenuous fractures that have been able to be stayed reduced in a flexion splint and they can play with something that's very flexed. A ball handling position wouldn't be able to do that. I've been happy with fractures that are fixed with pins that have adequate bone stock like this one and certainly we've seen some good results. This is from Dr. Strouch who described this technique. In my opinion this doesn't have a lot of place in a professional athlete or football player because it's a large enough piece. I prefer to fix it internally. External pins may be a problem with even just working out and sweating. So I try to go with internal fixation if at all possible on those fractures. Thereby allowing protective motion and it's just easier to splint and protect during play even if they have to, even if you need to protect them. Maximum protection splinting six to eight weeks on these fractures though in the early and you can risk displacement but it depends on the position of when they can return to that. Traction devices, I won't go into all of these, but these are basically season ending if you're dealing with one of these and the player has made a decision to treat a comminuted pylon fracture and they want to get it right. These traction apparatus I think are helpful but obviously not able to play with. The last thing I'll just say about salvage procedures is the vulvar plate arthroplasty and hemiamate arthroplasty I would just certainly make sure that the athletes understand it's a different operation. They're not going to get the open reduction internal fixation two months later and the trainers and the players need to know that ahead of time and I think that's probably our legal obligation is to tell them ahead of time that it's a different result because I have certainly had many of these fractures show up at the end of the season, now the player is ready to get it right, he wants to get an x-ray because his finger is still hurting and that's a very different path. So lastly in terms of return to play in the different positions I would protect them until there's healing and stability of the joint. That doesn't mean they can return to play at that time. What their functional limitations are really depend on the position. Thank you.

PRP fracture dislocations

athletes

finger injuries

treatment options

return to play timeline