Karan Desai, MD

10/17/2023

This is a 30 YO M who presented about 2 months out from “jamming” his finger. His PIP joint of the small finger had only about 10 degrees of active flexion. Lateral view shows an impacted volar middle phalanx fracture with PIP subluxation dorsally. You can see the classic “V-sign” dorsally on the lateral X-ray. We explored him and found a fibrous impacted joint that we really couldn’t improve much after 2 months of healing. We performed a hemi-hamate autograft. Some key technical points that are seen in the pictures 1) Save all the tendon sheath from A2 to A4 and save it as flap for later coverage over the bone. 2) a penrose around the tendons is key to easily retract when doing cuts and placing the graft. Otherwise they will always get in your way and increase your operative time 3) Resect the damaged section with a micro saggital saw and created “box defect”. When doing this try to create a slight slant in the coronal cut to leave more more proximally that distally on the middle phalanx. 4) There is a lot of debate on which direction to harvest the hemihamate from. I like to put osteotomes from distal to proximal for the final deep cut rather than created a trough in the proximal hamate to get the osteotome low enough. The 4th and 5th metacarpals can be shifted very easily volarly. 5) Carpentry is everything for the piece. A little prominence volarly on the graft is okay since the FDS doesn’t really glide in this area anyways. Just get the joint perfect with recreation of a volar lip by angling the graft slightly proximally as you get the most volar. 6) Meticulous soft tissue closure with repair of volar plate to the collaterals and use of the tendon sheath flap under the tendons.

09/02/2023

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04/26/2023

Galeazzi with DRUJ unstable after initial radius fixation but great stability after styloid fixation

02/09/2023

Young volleyball player with a bad fall who presented with an intraarticular distal radius fracture. Seemingly innocuous fracture on PA view but the lateral view tells a spookier story. CT scan showing a significant step off extending into radoiocarpal joint and sigmoid notch due to a large displaced dorsal ulnar corner piece. Some may choose to do this all with a volar plate, but at 2 weeks out I think going dorsal as well volar to ensure the joint is absolutely reduced is well worth it. I added a hook plate to provide a dorsal buttress and also confirmed with a dorsal radoiocarpal arthrotomy. Volar plate was added to capture the volar rim and styloid. Therapy begins one week out

10/28/2022

40 YO F with distal radius malunion treated with low energy osteotomy from dorsal approach. I prefer to go dorsal for opening wedge for correction of dorsal tilt. She lacked 25 degrees of terminal supination that corrected on the table likely from better alignment of sigmoid notch with ulnar head. I prefer to fill these with iliac crest cancellous autograft. Data is pretty convincing on not needing structural graft especially if you’re hinging on the volar cortex.

07/20/2022

Double screw fixation of P1 fractures is gaining in popularity due to the minimal invasive surgical method / minimal soft tissue stripping unlike plating and immediate range of motion unlike K wires. Two screws create a stiff construct that will not cower to rotational deformities that may be present with one screw down the pipe. There are few configurations using the two screws that work. In small digits and especially in those with smaller hands, a Y-type configuration works best with the two screws resting on each other to make a stable construct, but its can be a bit tricky. In this patient, I tried to place the radial base wire first and use it as the longer screw in the Y construct. You can see it leads to significant displacement and deviates the finger ulnarly. To correct this, I instead made the ulnar based screw the longer screw down the pipe and then rested the radial base screw on this as the shorter screw. You can see the alignment is significantly better with this construct. Sometimes you have to play around with this technique to get it just right. This patient got two poke holes and a soft dressing to immediately start range of motion.