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Live Surgery Tuesday - 3rd and 4th Proximal Phalanx Open Reduction Internal Fixation
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Live Surgery Tuesday - 3rd and 4th Proximal Phalanx Open Reduction Internal Fixation
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Language: EN.
Segment:0 .
All right. So we're with our illustrious motorcycle police officer who's now been a patient of mine twice. And this time this had to go, not at work. So he had the luxury of not having to follow the system. I've already fixed one of his phalanx fractures. You can see there and you can see the other. You can see the other.
There is a fracture. So here was a fracture. Now we fixed it, and now we're going to do the same to the ring finger. So you got here just in time for the second digit. All right, knife please. So these fractures oftentimes are the same very similar pattern in both fingers and sort of twisting injury.
The wonderful case I'd love to post if people are interested about what not to do. I had a patient that went to one of the hospitals, was seen by the person on call who was a plastic surgeon, which is fine, but if they're not particularly trained in hand, it can be a disaster. And you cannot fix that kind of fracture with pins. It needs it needs compression screws.
So my colleagues who are listening know that these are called lag screws, please [inaudible] I believe he was driving a golf cart when it happened. Yeah Yeah. You'd be surprised how many, I had a guy once who was from flew in from Dubai had a horrendous fracture to his little finger, which people think, oh, that's not a big deal.
So pinkie, you know, we call it the pinkie. Your football coaches tell you pull on it or his jam. And I absolutely hate that because let me tell you, you have a problem with your little finger. All the strength in the hand, comes from these two fingers. These are for microsurgery or threading a needle. Right knife please and. I can tell you that.
If these fractures are not fixed correctly, this is extremely disabling. His fingers were rotated. I think we have pictures that we can post, but his two fingers were rotated, facing the other direction. So you know, hand surgery is one of those things where people don't think about it much until they have it.
Think so we're all old pros here because we just did the same thing on the other finger. It's really the same exact fracture pattern. What is the rehab like after? He'll start a little bit next week just to start gently moving. But, you know, the problem is a fracture doesn't heal for correctly.
The fracture doesn't heal for about four weeks. So during that time, you're depending on the little mini screws. So this is all hematoma, blood within that's within the fracture site. And that's going to keep us. So we're going to irrigate some of that out now.
You see? So the problem with, that makes this tricky is that there's what we call a butterfly fragment. So it's not just two pieces. There's a little third piece here, and that often interferes with the reduction. Reduction means putting the bone back in place. So you can do closed reduction like you might do with a minor fracture in a wrist that hopefully will hold or what we call open reduction.
So this is, in orthopedic terms, is called ORIS. Open reduction internal fixation because we're fixing it internally. Irrigation one more time, please, and then I'll need the dental instrument. I will tell you, my dental colleagues are the ones who kind of invent everything in orthopedics. First, they did the first little mini radial x-rays already, titanium implants we use.
They all started in the dental world. So kudos to my dental colleagues. But there's a piece to it. If I don't get these little pieces of hematoma and bone fragments out then I can't get a good reduction because it'll be blocking it. So us hand surgeons often say that these are some of the actually toughest cases there are.
To get a really perfect result. It requires a lot of experience. He's lucky he was our patient previously and already knew how to find you. Now he's going to be at the orthopedic conference with a cast to share his other story. Yeah so we actually are, one the because it is because of the case that some of you may have seen where he broke his collarbone, this same arm.
He broke that collarbone and tore the ligament on the opposite thumb. And he's a motorcycle police officer here for City of Miami. So he's going up with us to Orlando. We're going to get this award, which is nice. You know, it's the injured worker award, but he didn't do this at work. So it's a little bit of a different category, but same thing.
He's going to be looking to get back on a motorcycle to keep all of us safe. Right OK. Let's have that reduction reduction clamps. Let's see if we can get this in there. You can slide out. Very good.
Get in right now. Nail him and lift up the tendon. That's it. There are all sorts of instruments designed. This was designed by a surgeon, actually, this by a company called Innomed. You see how tough to, remember on the last finger, I want you to pull on this.
We're going to pull and rotate. There you go. So you see how the rotation is really what reduces it. Problem is, is that butterfly fragment, which fits right in there. So now if this is good, we are set and these screws will stay there.
It's not necessary. No, no. I have a friend, a buddy of mine is a big jujitsu guy and he broke his, gosh 25 years ago, and I see him all the time and I forget to even ask him. Can't even see, the can't even see the little scars anymore. But he's got the screws in his finger.
Just a scratch. No, I got him. Hopefully that. OK so that looks it looks pretty good. OK,now what's important, you see this finger?
So we judge a rotation by looking at the nails. So the nails are in the same plane. Now same thing. We've got to really pronate them. Your viewers are commenting. Great job. Carry on. All right.
So this time I'm going to put the middle one first just because I have put them a little more. There you go. OK Thanks. Yes Thank you. So so as the surgeons know listening, we lag this, means that this screw we all withdraw this cortex.
So that. So that the screw actually compresses. So the screw is not really grabbing the near cortex, it's grabbing the far cortex and pulling it. So that's we call that a lag screw. Yes I'll share the pre-op X-ray in one second.
Yeah, as soon as we put this through, we can then. So you. We'll go with the 12. One more. I probably I'll probably use an 11 for the next one.
[inaudible] So the screw falls right into that hole because it's the same size. And they didn't follow the same trajectory. So that's. There you go. Got to be very precise.
OK all right. I have a question for you, Dr.B. For a lag screw, are you using a differential drill bit? Or is it screw partially threaded? Very good question. No, it's a fully threaded screw. But this drill bit, you can see it's short. So it's not going to go all the way through the fracture. It's going to go through the near cortex and it's a little bit larger diameter.
So the screw will glide through this cortex and then and then grab the far cortex and compress it. Whereas that's a very good question. So sometimes we might use the same drill bit. [inaudible] Yeah, I'm. Yeah, see, there's the, the lag scew.
The, hold on a second, it's a little dicey part. She's got that, dental instrument, please. She's got that. But this is just a sliver of bones, so I can't really do much with this. Let's get flow in here a minute just to see if this looks OK.
OK think so. [inaudible] These are not disposable. OK OK.
Thank you. This one's a little bit, this screw, just because of that lag. So I'm putting the screw really right next to the other one. I'm just going to do it a little divergent. OK let's get an 11 here and then we'll remove the clamping and put another screw.
11. I believe this is a fellow commenting that says, I feel the lag screw should be directed more perpendicular to fracture sites as pattern is long oblique. Yep yeah, I agree. But sometimes, you know, when you're in here, you kind of do what you can. But I don't have an argument with that right now.
Right now. Right here? Right but see here, we have a good reduction. You see, now, the question is, do you do anything with that little shell of a. You know, I may do something with that little, you know. Let me see.
Because I don't want that moving. I'm going to I'm going to actually, which is unusual, I'm going to counter sink this. OK we're going to go we're going to put a screw in the actual. So this is, gentle here, [inaudible] So but we're doing the same thing.
So go ahead and give me the, so I'm actually going to put a screw in the butterfly fragment because it's so large. I don't want that floating around. So I think that it is underneath the extensor, so I'm going to counter sink it.
We're probably just touching up against the other screw, but they got it past. OK, I have a question. Can that small piece of bone, can it be put anterior posterior direction? The slither of bone? Yeah I'm putting it where it belongs. I mean, it's just there's no other place to put it. It's just, I'm afraid, because it's so big.
OK. So what I'm going to do, though, is counter sink because its sitting right under the extensor. [inaudible] Yeah OK. I'll take the nine. I'm going to go a little on the short side because the tip is going to be running into the flexor tendon.
I was hoping this would be a good lesson for laypeople to understand what fixing a fracture entails. Do you want to comment? Yep so we're going to counter sink. No, it's OK. The little bit of screw head sits a little bit into that fragment. So these are the size of the screws. So now you know why they cost a little more than what you get at Costco or Home Depot.
All right. That's good. That sucking in nicely. OK, that's nice. OK, let's. [inaudible] [inaudible] Yep yeah, this is good.
OK, so let's go here and see what happens. OK you can't do that. You need to reach him and do that. You go. Yeah if you can just. Yeah, you can just hold that down like that just for a moment.
Oh, Yeah. [inaudible] [inaudible] But wait for every time. Let me know when you're ready for another question, doctor. Er yes I'm ready. OK, so for the approach, did you splint, sorry, split the extensor tendon.
And if not, what is your opinion? Should we split or go laterally and retract? Yeah, I'm going laterally. He's retracting the extensor now. I'll show it to you. The time I split it is when I'm putting a dorsal plate, which anybody who knows me knows that I can. I avoid that at all cost.
I'm not a fan of plates in the [inaudible] because you often have to remove them and the scars. Whereas with this it's I almost never have problems but to get the right, to get the plate you don't have room here so you do you do split the extensor, which I'll show now. Your colleague says that he personally feels that it damages the blood supply.
Yeah but, you know, fortunately in the hand, it's so robust. Let me have a go back to the last 12 that we'll see now. Yep let's just go to 12. It's when you get to things this small.
The depth gauge just to me is not always that accurate. No OK. So, the lags drive right in. You see it fell right in. And now, now the threads are grabbing and bam. There we go. Now, maybe I should have listened to myself. This this is not grabbing. Now, I hope it's not in a fracture site.
I don't think so. But let me have another actually. Let me see. No, no, I'm going to, let me see the X-ray for a second. Yes, yes, yes, yes. That should be good. It should be good.
Let me let me try it. I know the problem is the slightest of tips. So I'm going to drill it proximally, clamp it to me, take the screw out. I'm going to redraw the screw a little bit. It's so I'm not able to see the other side. I need a regular clamp. You know, and then let me have the same drill [inaudible] OK, here's the pre-op X-ray.
[inaudible] [inaudible] [inaudible] Since we're done with this one [inaudible] Because the other one was a little. Yes right help me here.
I'm going to direct it. Greetings from Indonesia. Oh, we, we have a great relationship with our Malaysian colleagues and Indonesia and I plan to go to Borneo. [inaudible] OK OK. Thank you.
I have a question for you, Dr. B. Yes? What do you think about headless, cannulated screws for this fracture? I don't think they're necessary. You know, these are low profile. This is metal artists and these are great and this is great Swiss technology. Let me tell you, this is now. All right, I'll take that same screw.
[inaudible] [inaudible] [inaudible] [Spanish] I believe you see some of our patients. [inaudible] Please, please. OK Nope.
I don't like it. I don't like it. I'm drilling a whole new drill. Let's start the whole process over. I don't like it. It's probably at the tip. There's a little bit of fragmentation. Are these AO screws and how many millimeters?
No, this is mid-august. Which which is? These are 1.5 millimeter. But that screw wasn't holding, so we'll use the same screw. I'm just going to drill a hole. So let me see which direction.
You have it right here? Yeah, [inaudible] right. Problem is it was in the fracture. Screwdriver in the tub. Can you repeat the company for the screws Dr. B? Novartis. We'll show you the tray afterwards.
[inaudible] [inaudible] [inaudible] physiotherapy is commenting on the team. He said, you have the best team. There you go and hope to see you in Ecuador again. Well, I'm going the first week of October, but I'm going to keep I will stop for sure. Drill bit.
So I changed directions. Folks, I'm on the edge. I'm not crazy about this, hold that? Sometimes, same screw. OK OK. Loading, here we go.
OK that's much better. All right. So for the question about the extensor, about the approach. So here's the extensor. That was a very good question. So I don't disturb the epitenon, which is these little fibers that give blood supply to the tendon.
So I go in on the lateral side, you see. So, so this should not this should not the therapy will be directed at gaining full extension. So we have, Gigi from my office is here to put on our new type of splint which we put on pre operatively. Now she's going to remold it so we can let her know. She's outside. OK, now get her watching us live.
She knows. Oh, so we're working with a company from Finland, a new type of splinting. So we splinted them in the, in the, in the office. Now we're going to heat up the splint and I'm going to put on actually as I'm putting the dress on, we'll heat it up and now it's going to be better molded. And then he'll start therapy next week. We'll actually make them we'll probably make him a thermoplast.
OK, so you start next week. All right, let's see. Let's get the floor vertical if you think you can do that. Oh, you got to unblock it, right? Oh OK.
So so important thing is, print please. We look here, all the fingers, all the fingers point to the skate point tubercle. So that's, that's what we want, looking at it this way. So that's why the proximal phalanx is so critical. Even though that ring finger fracture was a lot more difficult. OK irrigation, please.
The splint is made out of recycled wood material and we don't use a heat gun, we actually use an oven. I can show it to you in a minute. You know what? Let me get one last lateral. You printed that?
There's a question about the proximal screw. Is it very near the fracture site? Would that be an issue? Well, you know what? Your beggars can't be choosers. And and, you know, I'm happy with it. It's just, you know, when these fractures are fragmented like that, you know, it's a problem. So you know, the enemy of good is better.
And every surgeon knows that. You know, I'm not I'm not treating the X-ray. What what I'm happy about is the rotation of the finger. The fracture is stable. So there's not a lot of, there's just not a lot of, you know, real estate there to be putting you can see theres multiple screws. But it's very it's stable so. Right that's perfect, Picasso.
Greetings from Rome. From Rome? Who is it? Dr. Lucien Markovici. Oh, my He's always. For how long? I will be in Rimini next year, as my friend is the president of the European Congress next year in Rimini, Italy.
I wouldn't miss it for the world. Yeah that was your final thought? Yeah your fellow [inaudible], who commented on the screws and the fracture site, said he agrees the functional outcome is what we should bother. And greetings from India.
[inaudible] Who's in India? Your fellow who was commenting on the screws being close to the fracture site. Oh, [inaudible] Oh, OK. Well, that's the fellow's job is to bust my balls, so I like having them here, they have good questions.
So we use, as everyone knows, who's been with us, I've been doing it for gosh, almost 30 years, like a repeat patient is like... And Dr. Lucien said I use this technique and it's great, over 100 cases. I applaud them for knowing how many cases I have. That has always been a problem.
I have. You've lost count. I just know. I just. Well, I don't list, my fault. I don't document very well. But, you know, you can tell everybody the last thing you want is for Badia to give you a yet another task. So we just, I just realized a long time ago we're documenting the voter plates.
That's true. We did. So we're using and we're using two different Bowler plates. Then they give me, as we're about to publish a paper or say submit for publication on a plate that corrects the voler, tilt with the lever arm that sits under the subchondral bone and that, you know, hopefully it's accepted.
I'm not going to say what Journal because I don't want to unduly influence them, although I will say I was a reviewer for 12 years on that Journal. But that's enough. Sit on that. OK let me just [inaudible] Irrigation, please. More. What's nice about the repeat is you can evert the skin edges and you don't have to worry about difficulty of removing because you don't you're not removing a stitch.
Whereas if you did this with nylon, sometimes it's kind of stitched. And to be a little difficult to remove. So we have a shoulder with a subpectoral bicep tenodesis in the other room that they're just about ready for me. They're ready?
We have a little bit of sterile cast padding. We won't put much because your UCAST splint has enough padding that with the finger and those little screws holding it. Anybody going to Boston? Listening? We're waiting.
Oh, I have a question about fellowship, though. Do you provide fellowship short term or long term? No, they're short term because, you know, unfortunately, Thanks to ridiculous rules that society continues to impose on us is the Fellows aren't allowed to scrub with me and they used to be able to. So it goes to show that in our society where we're literally letting you know, no worries, because obviously I accept all the liability, but we're so obsessed with liability.
And the worst part about this is that we're exporting. The US is exporting this nonsense to Europe and all of a sudden all this compliance bullshit is, you know, is more important than, you know, patient care and learning and education. And it's really sad. But, you know, it doesn't matter because I'm not at this point in my career, but it's unfortunate. So the answer is no, we don't do long term policy because, you know, the surgeons really don't get to operate.
So Dr. Divanshu said, I really want to work under your guidance. I have completed my master's in orthopedics from Mumbai, India, and I'm interested in hand surgery. Can I email you? Absolutely my website is just DrBadia.com. I answer myself. The link is in our bio. [inaudible] So hold this like this.
Dr. Divanshu Sure you can find the link in the bio to the website www.drbadia.com and you can click on Ask me a question to send him an email and he answers those himself. [inaudible] Dr. Silva. Dr. Silva is watching you from Chile.
She's preparing the cast. [inaudible] [inaudible] [inaudible] [inaudible] After this surgery, we would be done going live and we'll go live again next Tuesday.
Dr Badia's in, I'll post the schedule. We usually go live on Tuesdays. Today was just a special case, so we decided to go live Thursday as well. [inaudible] [inaudible] Wednesdays are Sundays at Kava.
That was an ice cream company. What? I remember. Yeah ice cream cake. So now you'll see the splint. I will put it on. Not always at this time.
It varies on the case. So we'll select the case on Monday and post on Monday. What time will be going live on Tuesday? If you guys can share the hashtag but a live surgery tuesday? Yeah well, either way, she's coming in now with the splint, so.
So we'll keep you guys posted on this case. And on his recovery. Thank you so much for watching. We can post the splinter. OK all right. Here's our UCAST splint from recycled wood material. It's warm, so she's able to mold it to the patient.
OK Dr. Badia, a great reduction. [inaudible] [inaudible] And yes, it does get hard and stiff in about two or three minutes it will be hard.
It starts to harden now. [inaudible] I'm right behind you. Thanks I know he wanted to show, its still live, he wanted to show the tray of the screws.
Which one is it? Medartus, Aptus. This is the material inside. Wonderful thank you. Thank you guys so much for watching. Look out for Mondays.
We'll share when our next live surgery will be. Usually on Tuesdays, time will to be announced. Thank you.
Segment:0 .
All right. So we're with our illustrious motorcycle police officer who's now been a patient of mine twice. And this time this had to go, not at work. So he had the luxury of not having to follow the system. I've already fixed one of his phalanx fractures. You can see there and you can see the other. You can see the other.
There is a fracture. So here was a fracture. Now we fixed it, and now we're going to do the same to the ring finger. So you got here just in time for the second digit. All right, knife please. So these fractures oftentimes are the same very similar pattern in both fingers and sort of twisting injury.
The wonderful case I'd love to post if people are interested about what not to do. I had a patient that went to one of the hospitals, was seen by the person on call who was a plastic surgeon, which is fine, but if they're not particularly trained in hand, it can be a disaster. And you cannot fix that kind of fracture with pins. It needs it needs compression screws.
So my colleagues who are listening know that these are called lag screws, please [inaudible] I believe he was driving a golf cart when it happened. Yeah Yeah. You'd be surprised how many, I had a guy once who was from flew in from Dubai had a horrendous fracture to his little finger, which people think, oh, that's not a big deal.
So pinkie, you know, we call it the pinkie. Your football coaches tell you pull on it or his jam. And I absolutely hate that because let me tell you, you have a problem with your little finger. All the strength in the hand, comes from these two fingers. These are for microsurgery or threading a needle. Right knife please and. I can tell you that.
If these fractures are not fixed correctly, this is extremely disabling. His fingers were rotated. I think we have pictures that we can post, but his two fingers were rotated, facing the other direction. So you know, hand surgery is one of those things where people don't think about it much until they have it.
Think so we're all old pros here because we just did the same thing on the other finger. It's really the same exact fracture pattern. What is the rehab like after? He'll start a little bit next week just to start gently moving. But, you know, the problem is a fracture doesn't heal for correctly.
The fracture doesn't heal for about four weeks. So during that time, you're depending on the little mini screws. So this is all hematoma, blood within that's within the fracture site. And that's going to keep us. So we're going to irrigate some of that out now.
You see? So the problem with, that makes this tricky is that there's what we call a butterfly fragment. So it's not just two pieces. There's a little third piece here, and that often interferes with the reduction. Reduction means putting the bone back in place. So you can do closed reduction like you might do with a minor fracture in a wrist that hopefully will hold or what we call open reduction.
So this is, in orthopedic terms, is called ORIS. Open reduction internal fixation because we're fixing it internally. Irrigation one more time, please, and then I'll need the dental instrument. I will tell you, my dental colleagues are the ones who kind of invent everything in orthopedics. First, they did the first little mini radial x-rays already, titanium implants we use.
They all started in the dental world. So kudos to my dental colleagues. But there's a piece to it. If I don't get these little pieces of hematoma and bone fragments out then I can't get a good reduction because it'll be blocking it. So us hand surgeons often say that these are some of the actually toughest cases there are.
To get a really perfect result. It requires a lot of experience. He's lucky he was our patient previously and already knew how to find you. Now he's going to be at the orthopedic conference with a cast to share his other story. Yeah so we actually are, one the because it is because of the case that some of you may have seen where he broke his collarbone, this same arm.
He broke that collarbone and tore the ligament on the opposite thumb. And he's a motorcycle police officer here for City of Miami. So he's going up with us to Orlando. We're going to get this award, which is nice. You know, it's the injured worker award, but he didn't do this at work. So it's a little bit of a different category, but same thing.
He's going to be looking to get back on a motorcycle to keep all of us safe. Right OK. Let's have that reduction reduction clamps. Let's see if we can get this in there. You can slide out. Very good.
Get in right now. Nail him and lift up the tendon. That's it. There are all sorts of instruments designed. This was designed by a surgeon, actually, this by a company called Innomed. You see how tough to, remember on the last finger, I want you to pull on this.
We're going to pull and rotate. There you go. So you see how the rotation is really what reduces it. Problem is, is that butterfly fragment, which fits right in there. So now if this is good, we are set and these screws will stay there.
It's not necessary. No, no. I have a friend, a buddy of mine is a big jujitsu guy and he broke his, gosh 25 years ago, and I see him all the time and I forget to even ask him. Can't even see, the can't even see the little scars anymore. But he's got the screws in his finger.
Just a scratch. No, I got him. Hopefully that. OK so that looks it looks pretty good. OK,now what's important, you see this finger?
So we judge a rotation by looking at the nails. So the nails are in the same plane. Now same thing. We've got to really pronate them. Your viewers are commenting. Great job. Carry on. All right.
So this time I'm going to put the middle one first just because I have put them a little more. There you go. OK Thanks. Yes Thank you. So so as the surgeons know listening, we lag this, means that this screw we all withdraw this cortex.
So that. So that the screw actually compresses. So the screw is not really grabbing the near cortex, it's grabbing the far cortex and pulling it. So that's we call that a lag screw. Yes I'll share the pre-op X-ray in one second.
Yeah, as soon as we put this through, we can then. So you. We'll go with the 12. One more. I probably I'll probably use an 11 for the next one.
[inaudible] So the screw falls right into that hole because it's the same size. And they didn't follow the same trajectory. So that's. There you go. Got to be very precise.
OK all right. I have a question for you, Dr.B. For a lag screw, are you using a differential drill bit? Or is it screw partially threaded? Very good question. No, it's a fully threaded screw. But this drill bit, you can see it's short. So it's not going to go all the way through the fracture. It's going to go through the near cortex and it's a little bit larger diameter.
So the screw will glide through this cortex and then and then grab the far cortex and compress it. Whereas that's a very good question. So sometimes we might use the same drill bit. [inaudible] Yeah, I'm. Yeah, see, there's the, the lag scew.
The, hold on a second, it's a little dicey part. She's got that, dental instrument, please. She's got that. But this is just a sliver of bones, so I can't really do much with this. Let's get flow in here a minute just to see if this looks OK.
OK think so. [inaudible] These are not disposable. OK OK.
Thank you. This one's a little bit, this screw, just because of that lag. So I'm putting the screw really right next to the other one. I'm just going to do it a little divergent. OK let's get an 11 here and then we'll remove the clamping and put another screw.
11. I believe this is a fellow commenting that says, I feel the lag screw should be directed more perpendicular to fracture sites as pattern is long oblique. Yep yeah, I agree. But sometimes, you know, when you're in here, you kind of do what you can. But I don't have an argument with that right now.
Right now. Right here? Right but see here, we have a good reduction. You see, now, the question is, do you do anything with that little shell of a. You know, I may do something with that little, you know. Let me see.
Because I don't want that moving. I'm going to I'm going to actually, which is unusual, I'm going to counter sink this. OK we're going to go we're going to put a screw in the actual. So this is, gentle here, [inaudible] So but we're doing the same thing.
So go ahead and give me the, so I'm actually going to put a screw in the butterfly fragment because it's so large. I don't want that floating around. So I think that it is underneath the extensor, so I'm going to counter sink it.
We're probably just touching up against the other screw, but they got it past. OK, I have a question. Can that small piece of bone, can it be put anterior posterior direction? The slither of bone? Yeah I'm putting it where it belongs. I mean, it's just there's no other place to put it. It's just, I'm afraid, because it's so big.
OK. So what I'm going to do, though, is counter sink because its sitting right under the extensor. [inaudible] Yeah OK. I'll take the nine. I'm going to go a little on the short side because the tip is going to be running into the flexor tendon.
I was hoping this would be a good lesson for laypeople to understand what fixing a fracture entails. Do you want to comment? Yep so we're going to counter sink. No, it's OK. The little bit of screw head sits a little bit into that fragment. So these are the size of the screws. So now you know why they cost a little more than what you get at Costco or Home Depot.
All right. That's good. That sucking in nicely. OK, that's nice. OK, let's. [inaudible] [inaudible] Yep yeah, this is good.
OK, so let's go here and see what happens. OK you can't do that. You need to reach him and do that. You go. Yeah if you can just. Yeah, you can just hold that down like that just for a moment.
Oh, Yeah. [inaudible] [inaudible] But wait for every time. Let me know when you're ready for another question, doctor. Er yes I'm ready. OK, so for the approach, did you splint, sorry, split the extensor tendon.
And if not, what is your opinion? Should we split or go laterally and retract? Yeah, I'm going laterally. He's retracting the extensor now. I'll show it to you. The time I split it is when I'm putting a dorsal plate, which anybody who knows me knows that I can. I avoid that at all cost.
I'm not a fan of plates in the [inaudible] because you often have to remove them and the scars. Whereas with this it's I almost never have problems but to get the right, to get the plate you don't have room here so you do you do split the extensor, which I'll show now. Your colleague says that he personally feels that it damages the blood supply.
Yeah but, you know, fortunately in the hand, it's so robust. Let me have a go back to the last 12 that we'll see now. Yep let's just go to 12. It's when you get to things this small.
The depth gauge just to me is not always that accurate. No OK. So, the lags drive right in. You see it fell right in. And now, now the threads are grabbing and bam. There we go. Now, maybe I should have listened to myself. This this is not grabbing. Now, I hope it's not in a fracture site.
I don't think so. But let me have another actually. Let me see. No, no, I'm going to, let me see the X-ray for a second. Yes, yes, yes, yes. That should be good. It should be good.
Let me let me try it. I know the problem is the slightest of tips. So I'm going to drill it proximally, clamp it to me, take the screw out. I'm going to redraw the screw a little bit. It's so I'm not able to see the other side. I need a regular clamp. You know, and then let me have the same drill [inaudible] OK, here's the pre-op X-ray.
[inaudible] [inaudible] [inaudible] Since we're done with this one [inaudible] Because the other one was a little. Yes right help me here.
I'm going to direct it. Greetings from Indonesia. Oh, we, we have a great relationship with our Malaysian colleagues and Indonesia and I plan to go to Borneo. [inaudible] OK OK. Thank you.
I have a question for you, Dr. B. Yes? What do you think about headless, cannulated screws for this fracture? I don't think they're necessary. You know, these are low profile. This is metal artists and these are great and this is great Swiss technology. Let me tell you, this is now. All right, I'll take that same screw.
[inaudible] [inaudible] [inaudible] [Spanish] I believe you see some of our patients. [inaudible] Please, please. OK Nope.
I don't like it. I don't like it. I'm drilling a whole new drill. Let's start the whole process over. I don't like it. It's probably at the tip. There's a little bit of fragmentation. Are these AO screws and how many millimeters?
No, this is mid-august. Which which is? These are 1.5 millimeter. But that screw wasn't holding, so we'll use the same screw. I'm just going to drill a hole. So let me see which direction.
You have it right here? Yeah, [inaudible] right. Problem is it was in the fracture. Screwdriver in the tub. Can you repeat the company for the screws Dr. B? Novartis. We'll show you the tray afterwards.
[inaudible] [inaudible] [inaudible] physiotherapy is commenting on the team. He said, you have the best team. There you go and hope to see you in Ecuador again. Well, I'm going the first week of October, but I'm going to keep I will stop for sure. Drill bit.
So I changed directions. Folks, I'm on the edge. I'm not crazy about this, hold that? Sometimes, same screw. OK OK. Loading, here we go.
OK that's much better. All right. So for the question about the extensor, about the approach. So here's the extensor. That was a very good question. So I don't disturb the epitenon, which is these little fibers that give blood supply to the tendon.
So I go in on the lateral side, you see. So, so this should not this should not the therapy will be directed at gaining full extension. So we have, Gigi from my office is here to put on our new type of splint which we put on pre operatively. Now she's going to remold it so we can let her know. She's outside. OK, now get her watching us live.
She knows. Oh, so we're working with a company from Finland, a new type of splinting. So we splinted them in the, in the, in the office. Now we're going to heat up the splint and I'm going to put on actually as I'm putting the dress on, we'll heat it up and now it's going to be better molded. And then he'll start therapy next week. We'll actually make them we'll probably make him a thermoplast.
OK, so you start next week. All right, let's see. Let's get the floor vertical if you think you can do that. Oh, you got to unblock it, right? Oh OK.
So so important thing is, print please. We look here, all the fingers, all the fingers point to the skate point tubercle. So that's, that's what we want, looking at it this way. So that's why the proximal phalanx is so critical. Even though that ring finger fracture was a lot more difficult. OK irrigation, please.
The splint is made out of recycled wood material and we don't use a heat gun, we actually use an oven. I can show it to you in a minute. You know what? Let me get one last lateral. You printed that?
There's a question about the proximal screw. Is it very near the fracture site? Would that be an issue? Well, you know what? Your beggars can't be choosers. And and, you know, I'm happy with it. It's just, you know, when these fractures are fragmented like that, you know, it's a problem. So you know, the enemy of good is better.
And every surgeon knows that. You know, I'm not I'm not treating the X-ray. What what I'm happy about is the rotation of the finger. The fracture is stable. So there's not a lot of, there's just not a lot of, you know, real estate there to be putting you can see theres multiple screws. But it's very it's stable so. Right that's perfect, Picasso.
Greetings from Rome. From Rome? Who is it? Dr. Lucien Markovici. Oh, my He's always. For how long? I will be in Rimini next year, as my friend is the president of the European Congress next year in Rimini, Italy.
I wouldn't miss it for the world. Yeah that was your final thought? Yeah your fellow [inaudible], who commented on the screws and the fracture site, said he agrees the functional outcome is what we should bother. And greetings from India.
[inaudible] Who's in India? Your fellow who was commenting on the screws being close to the fracture site. Oh, [inaudible] Oh, OK. Well, that's the fellow's job is to bust my balls, so I like having them here, they have good questions.
So we use, as everyone knows, who's been with us, I've been doing it for gosh, almost 30 years, like a repeat patient is like... And Dr. Lucien said I use this technique and it's great, over 100 cases. I applaud them for knowing how many cases I have. That has always been a problem.
I have. You've lost count. I just know. I just. Well, I don't list, my fault. I don't document very well. But, you know, you can tell everybody the last thing you want is for Badia to give you a yet another task. So we just, I just realized a long time ago we're documenting the voter plates.
That's true. We did. So we're using and we're using two different Bowler plates. Then they give me, as we're about to publish a paper or say submit for publication on a plate that corrects the voler, tilt with the lever arm that sits under the subchondral bone and that, you know, hopefully it's accepted.
I'm not going to say what Journal because I don't want to unduly influence them, although I will say I was a reviewer for 12 years on that Journal. But that's enough. Sit on that. OK let me just [inaudible] Irrigation, please. More. What's nice about the repeat is you can evert the skin edges and you don't have to worry about difficulty of removing because you don't you're not removing a stitch.
Whereas if you did this with nylon, sometimes it's kind of stitched. And to be a little difficult to remove. So we have a shoulder with a subpectoral bicep tenodesis in the other room that they're just about ready for me. They're ready?
We have a little bit of sterile cast padding. We won't put much because your UCAST splint has enough padding that with the finger and those little screws holding it. Anybody going to Boston? Listening? We're waiting.
Oh, I have a question about fellowship, though. Do you provide fellowship short term or long term? No, they're short term because, you know, unfortunately, Thanks to ridiculous rules that society continues to impose on us is the Fellows aren't allowed to scrub with me and they used to be able to. So it goes to show that in our society where we're literally letting you know, no worries, because obviously I accept all the liability, but we're so obsessed with liability.
And the worst part about this is that we're exporting. The US is exporting this nonsense to Europe and all of a sudden all this compliance bullshit is, you know, is more important than, you know, patient care and learning and education. And it's really sad. But, you know, it doesn't matter because I'm not at this point in my career, but it's unfortunate. So the answer is no, we don't do long term policy because, you know, the surgeons really don't get to operate.
So Dr. Divanshu said, I really want to work under your guidance. I have completed my master's in orthopedics from Mumbai, India, and I'm interested in hand surgery. Can I email you? Absolutely my website is just DrBadia.com. I answer myself. The link is in our bio. [inaudible] So hold this like this.
Dr. Divanshu Sure you can find the link in the bio to the website www.drbadia.com and you can click on Ask me a question to send him an email and he answers those himself. [inaudible] Dr. Silva. Dr. Silva is watching you from Chile.
She's preparing the cast. [inaudible] [inaudible] [inaudible] [inaudible] After this surgery, we would be done going live and we'll go live again next Tuesday.
Dr Badia's in, I'll post the schedule. We usually go live on Tuesdays. Today was just a special case, so we decided to go live Thursday as well. [inaudible] [inaudible] Wednesdays are Sundays at Kava.
That was an ice cream company. What? I remember. Yeah ice cream cake. So now you'll see the splint. I will put it on. Not always at this time.
It varies on the case. So we'll select the case on Monday and post on Monday. What time will be going live on Tuesday? If you guys can share the hashtag but a live surgery tuesday? Yeah well, either way, she's coming in now with the splint, so.
So we'll keep you guys posted on this case. And on his recovery. Thank you so much for watching. We can post the splinter. OK all right. Here's our UCAST splint from recycled wood material. It's warm, so she's able to mold it to the patient.
OK Dr. Badia, a great reduction. [inaudible] [inaudible] And yes, it does get hard and stiff in about two or three minutes it will be hard.
It starts to harden now. [inaudible] I'm right behind you. Thanks I know he wanted to show, its still live, he wanted to show the tray of the screws.
Which one is it? Medartus, Aptus. This is the material inside. Wonderful thank you. Thank you guys so much for watching. Look out for Mondays.
We'll share when our next live surgery will be. Usually on Tuesdays, time will to be announced. Thank you.
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