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Male Speaker: Alright, so I'm going to bring Chris Hood back up to talk about Dancer's fractures of the fifth metatarsal. Probably better to dim the lights a little bit, yeah, perfect. Alright, again Dr. Hood is coming to us from Tennessee and going to speak about fifth metatarsal fractures.
Dr. Christopher Hood: Alright, so we're going to talk about fifth metatarsal shaft and Dancer's fractures. I kind of combine them into two. Depending on what article you read or textbook, they kind of go back and forth between the terminology. No disclosures. So we're going to go through the backgrounds, some of the classification systems, anatomy and then I really like to just kind of go through the patient workup, physical exam, stuff to look for, x-rays and then going over both conservative and surgical treatments, the sparse literature that's out there on this topic and then some case examples. So the fifth metatarsals, the most common fracture metatarsal anywhere between 40% and 70%. There is multiple classification systems for the variety of types of fractures of the fifth metatarsal, but again, specifically again we're going to be talking about that distal fracture, somewhere from the distal metatarsal to the metaphyseal diaphyseal junction area. These account for about 24% of fractures. Usually, the orientation is going to be proximal dorsal to distal plantar. They might be short oblique. There might be a spiral component to it or a butterfly component. So the different variety of fifth metatarsal fractures, we all kind of know avulsion fractures, degenerative fractures are the most common. Zone III is going to be stress type fracture just distal to the Jones area and then Dancer's and shaft fractures on the broad left area and then a stress fracture of the actual shaft.
So there was a study by Kane in 2015 where they were looking at just the incidence of the different types of fifth metatarsal fractures, again Zone I being that avulsion fracture at about 57%, Zone II, the Jones fracture at about 13%. When you combine the shaft and Dancer's fracture, where in this instance they used the two different terminologies, it equates to about 30%. So it is the second most common type of fractures you'd see in the metatarsal of the fifth. So I was trying to find the different classification systems because this was trying to be educational for the residents and there really isn't one out there for this. So we all know in school the Stewart classification system. It doesn't talk about shaft fracture, Dancer's fracture. The Torg classification system, again it's Jones fractures specific talking about either the delayed, early or nonunion situation regarding a Jones fracture but nothing to do with what we're talking about here. The kind of orthopedic mostly use Zone I, II, and III classification system, again nothing that we're talking about but just kind of showing these for completeness sake for the residents. A PI chapter on their website has a "classification that's anatomic" talking about again tuberosity, Zone I, Zone II, those Jones fracture. And then they sort of mention the segmental shaft fracture and the diaphyseal fracture but not really any sort of information, just describing it. So in 2016 in JFAS, Savoy came out with, I guess, you want to call it their own name classification system but it was more just trying to describe the different types of fifth metatarsal shaft or Dancer's fractures and the orientation. Nothing was prognostic about this. It was more just an x-ray review and trying to see if they can determine any sort of pattern. So their system came up with a grade I, II, and III being either unicortical, bicortical with greater left center than 3 mm of displacement and then one that's greater than 3 mm of displacement with a butterfly component.
So just for representation, the different types that they were talking about, but again, nothing really prognostic, not talking about how to treat it, not talking about the workup, just more or less trying to describe the fracture. So the Dancer's fracture, I couldn't really find an origin as to why it was called the Dancer's fracture though a couple of studies that we will look at are related to the dancing population and I think one of the first articles that I found talking about this was in a ballad population, so there may be some corollary there. Again, it's going to be a long oblique or spiral fracture starting usually at the lateral neck of the distal shaft and extending medial proximal throughout the diaphysis. There may be a long spike. There may be some comminution, sometimes at the metatarsal head or neck and often they are shortened and displaced medially and elevated. Little dancer there. So for quick anatomy, couple of the structures you're going to want to be aware of in that area. It's more so going to be nerve artery and vein structures because the they are the ones that's going to be overlying the incision area. There is not too much tendinous structures over the actual fifth metatarsal shaft. The peroneal structures are going to be proximal. The long extensors are going to be distal but most importantly, you're going to be want to be drawing attention for either that short saphenous vein or the sural nerve. So when the patient comes in, they are often going to have a complaint of history of stepping off a curve, some sort of twisting mechanism. They may be a dancer, Dancer's fracture. It may be some sort of sport-related soccer football, something again what we talked about this morning, those Jones fractures with the poor clits and thin clits, too much torque on the bone causing this mechanism of injury. They are going to have localized pain, swelling, tenderness along the fifth metatarsal and along that lateral column. Again, the mechanism is going to be a fall and inverted or plantar flexed foot. There is going to be some sort of twisting of the foot. There may be some blunt trauma, someone getting hit by something but again most of the time, patients are going to say, it's almost like an ankle sprain of the foot is what I tell them when they injure this area.
So on the physical exam, just going through your four different section, you're going to want to palpate that area, palpate range of motion, check the range of motion of the fifth MTP. You're also going to want to check the ankle, just how we said it's sort an ankle sprain of the foot. I've had many patients who have also had ankle injuries that have gone along with this whether it's an avulsion fracture of the lateral malleolus and ATFL injury and so forth. Neuro exam is going to be pretty benign, maybe some numbness in that area from swelling and neuropraxia of these sural nerves. Dermatology, you're going to see swelling, edema, bruising and then vascular, they are typically normal. Imaging, most of us are just going to start with the three film of the foot, AP lateral and medial oblique. Sometimes getting a lateral oblique can be helpful just to greater appreciate the orientation of the fracture, maybe gauging the fracture distance or any sort of displacement. Again, we talked about the orientation of the fracture. The MRIs and CTs are really not warranted unless there is some sort of delayed healing, nonhealing issue that you're seeing six weeks, eight weeks, 10, 12 weeks out in your concern for a nonunion, especially when you're trying to gain that evidence to possibly get them a bone stimulator. So just some different orientations, they come in all shapes and sizes but the gist is the same. So conservative treatment, if it's nondisplaced and acceptable alignment, you can just proceed with nonsurgical treatment. I kind of look through the literature in some of the studies that I read, put together a protocol and I go somewhere breaking it up about four-week segments where I try to keep them either nonweightbearing or partial weightbearing or surgical shoe or fracture boot. Moreover with the boot, if there is any sort of ankle component coming along with it, then from four to eight weeks still be weightbearing in that thing and then from 8 to 12 weeks and so forth transitioning them back into sneakers. Sometimes if I put them back in their sneakers to take some load off that area, we just talked about the padding and strapping. I put them in Powerstep or some sort of orthotics over-the-counter in their shoe.
And I will add some wedging to the outside of the heel to try to take some pressure off that lateral column. In some instances depending on how creative you are, I will say with your documentation, you can get this covered for a bone stimulator just something to help the healing process because these two have occasionally some delayed healing and so if you can get that on the front end, it can be helpful. So usually, I will see these patients about every four weeks right at our transition points and then if everything is looking okay, the pain is going down, the swelling is going down, look like there is radiographic healing, we will just progress to the next stage whether it's going from nonweightbearing, weightbearing in that DME device to back in those sneakers. So here is just different example over the course of about three months or so of different patients that I had. You can kind of see starting from left and work in right just kind of watching the grass grow, the bone healing over the course of time. So conservative treatment has some complications that can go with it. Mainly, it's going to be a delayed return to activity. It could be a nonunion or delayed union. Metatarsalgia, if there is any sort of displacement or the fracture does move throughout the course, there may be some irregularity in the metatarsal parabola. If there is any sort of shortening or elevating of the metatarsal head, you may have some callus or corn formation to the fourth sub met area or even to the fifth digit because that fifth metatarsal isn't in exact alignment and so that's going to direct the position of the toe. There has also been reported neuroma formation where that four-five interspace may have a change in the distance between and causing irritation of the nerve. So surgical treatment, typically, you're going to want to perform surgery on these if there is displacement greater than 3 or 4mm in either the sagittal or transverse plane or greater than 10 degrees of angulation. If there is transverse fracture versus more transverse, I guess I will say, versus that long oblique style, there is going to be more instability to the fracture. There is less bone-on-bone kind of interface at that fracture healing site where there may be risk for having a delayed or nonunion.
Distance between the fractures. This is what I think getting that medial and lateral oblique can be helpful. I'm just trying to estimate what's the distance between the fracture gap. If it's greater than maybe 3 or 4 mm, you might want to perform some sort of surgery to get those two sides of the bone closer to each other for healing. Any sort of comorbidities and this can go either way, whether it's diabetes, PVD, smoking, alcohol, drugs, bone health aging and so forth, that may defer you going one way or another to surgery or not to surgery or the way you're going to the surgically fix this whether it's more of percutaneous approach versus an open approach. You want to take into activity level, their age and then really just what our general tenets are for deciding surgery. So the different methods that you can use are percutaneous methods, cerclage wire, often people will use a fiber wire, independent screws whether it's a two or three screws just into the bone, plating plus or minus an interfragmentary screw. Some people I've seen ex-fix these. One of the keys I guess I will put in here is remembering that if you're going to use any sort of plating and you want to perform a cerclage wire technique, a lot of our plating nowadays is titanium and cerclage wire is stainless steel and so you don't want to mix the metals for possible galvanic corrosion situation. So that's why I will often use fiber wire as my cerclage and then the other thing you want to do is try to top that knot in that four-five interspace or trying to tuck it in one of the plate holes because that knot is not going to go away and you can get some rubbing and I've had the situation where that actually caused the breakdown in a wound. So percutaneous techniques, you can do this a couple of different ways. You want to either just start distal possibly catching the base of the fifth proximal phalanx or going in just below the head of the metatarsal and just driving that wire retrograde. You can make a small incision at the site of the fracture and drive your wire antegrade and then back retrograde.
So anyway you can kind of do it to manipulate the fracture back in the place. So some of these pictures from AO show that technique. Often the K-wire is going to be 0.62. Some recommend if you're going to do percutaneous techniques to drive the wire all the way to the base if there is any sort of osteoporosis or instability to the bone, they also recommend using two wires. Here is just example of one that I did. So not too displaced but she is wanting surgery to try to get back the things quicker. So we just kind of ran that wire down the suit, put it about three or four weeks, got her back into sneakers by about eight weeks or so. So open surgery, typically, the incision is going to be lateral or dorsolateral on that lateral column just over the fifth metatarsal, again taking care to look out for that nerve and vein in that area. So you typically have a linear incision. Often, I find myself wanting to put it more lateral than say dorsolateral. I think it's better to go a little bit higher than maybe what you're initially thinking or when I draw my incision, I always end up going just medial to it more on the foot. Two reasons is I think it gets better exposure to the metatarsal but also the more lateral you put that incision, the more it's going to be in the area where maybe more rubbing on a shoe, women who are wearing ballad flats high heels, the edge of the shoe is going to be rubbing on that area and you can have irritations, especially if you have a plate underneath it or just scar incision irritation. So once you made your incision, often you will grab the fifth toe or the distal fifth metatarsal head and use that to manipulate the fracture fragments back into place. You will clamp it with the K-wire. One of the hints that they recommend is because the bone is so small and these plates are -- I'm not going to say the larger side but you're working in a small area, is the clamp will be in the way of trying to properly place the plate and so once it's clamped, you may want to take a K-wire to then hold that fixation but it's out of the working field of where you actually going to put your plates.
So you kind of just temporarily use the clamp, get your x-ray shots, make sure it's where you want it, pin it and then start to fix it. So there is all different types of hardware out there, all different brands and companies. I find it helpful to use handsets just because of the fact that the plates are going to be a little bit smaller, they are going to be thinner, little bit more low profile than some of the "low profile metatarsal plates" that are out there for some of the other companies. You can see the top ones are going to be specific metatarsal plates by one company where below it's there hand plates. The hand plates also come in a bit more of orientation just because of the way that hand metatarsal fractures are. So you will have anything between T plates, Y plates, L plates, 45 degree angle plates as you kind of go around those different colored plates in the lower side. So one of the ways we talked about was just independent screws. So you do this by either dividing the fracture or the length of the fracture and you have thirds depending if you're going to use two or three screws. You're going to want to make sure you don't place the screws towards the distal or proximal ends of the fracture where the bones are going to be much thinner, where you're going to risk either fracturing the bone or causing the stress riser. You're going to have the screws perpendicular to the fracture. The screws should be the screw head's distance from the fracture again to make sure you don't cause any sort of stress riser reaction. And then the other thing I often will do is I will start some of the screws independently and I will have all two or all three in and then I will work my way going to each of them, so I get more of compression across the board versus putting one in -- putting a lot of stress in one area and putting a second one in. So here is just some examples of that. So again surgery, ORIF. Once we have done a clamp, you may need to bend the plate, those hand plates again are nice because they are more thin profile and you're able to bend them much easier, especially because that bone kind of like the fibula as you get higher up on, it has more of a spiral to it and so you want to make sure there is good contour.
So you can just see fixing it. Just some examples. This is one of those hand plates that has that 90 degree L. Often you're going to want to get at least two screws on either side of the fracture so that all the screws aren't just holding the actual fracture itself and so that's why some of these hand plates are nice because of that distal end being either an L or Y shape. You can have two screws that are in the same plane but you're still getting that double fixation above or below. So again just some other examples. I thought this one was interesting. I didn't do this but I saw it in a paper. So if this is [indecipherable] [0:16:36] trying to do I guess a long Jones screw, it's kind of cool. So often the treatment afterwards is if you just do percutaneous K-wire, usually you will have them weightbearing as tolerated anywhere between 0 and 2 weeks removing the wire about four to six weeks and then transitioning back into sneakers at about 8 weeks. So it's similar to that nonoperative conservative treatment. And then ORIF, it's all over the place and some of the studies we will look at have very different treatment protocols but typically I will do nonweightbearing for about two to four weeks, CAM boot weightbearing for four weeks and then back into sneakers by eight weeks or so. I feel more confident moving these people along a bit quicker, especially when we do plating techniques because I know the plates are pretty solid in there, so it should be going anywhere. So surgical complications. Again, it's a later nonunion. You may need to do a revision on this. You may need to get the bone stimulator if it was something you're unable to get initially. Sural neuritis whether it's rubbing from the plate against the shoe from the surgery itself. Painful hardware, you want to make sure if you have to take the hardware out and time is elapsed in those, so this is where maybe getting that CT may come into play. There is no documented removal rates for this sort of fixation. Important thing to remember is to remember the hardware that you use because we don't often use hand plating systems in foot and ankle surgery. So when you're going to take the hardware out, you want to make sure when you dictated that case the first time around, you put in there that you used the handset.
I will often even dictate what the size of the screws are specifically and also what the head of the screw is because they are often going to be cruciate or something else other than the hex or the star-shaped drivers and so you want to make sure if you're going to make the screw out, you've the right screw driver. And then going along with that when you're putting these screws in, you're going to want to make sure you don't strip them. So if you're doing it or the resident's doing it, really making sure you get that two-finger tightness and you're not cranking the head of the screw and stripping it, especially when you have these cruciate type screw heads where once you strip them and they are very, very thin in the depth with where the screwdriver fits in, it can be pain in the butt to get them out. Metatarsalalgia again, just like the nonoperative treatment if there is any sort of disparity in the metatarsal parabola, you didn't fix it, there is a malunion, you can get overloading of the fourth metatarsal area or even the third, callus formation, stiff fifth toe joints, then wound dehiscence infection and so forth. So there is a lot of literature out there about avulsion fractures. There is a lot of literature out there about Jones fractures but I could really only find and we will talk about a few of them, I think six articles specifically looking at Dancer's fractures specifically. So again that first article, we looked at showing that this fracture encompasses about 30% of the fifth metatarsal fractures in this large study of about 1300 x-rays. Specifically again, we talked about the shaft fracture, they found about, I think, it was 300 if my math is correct, somewhere in that range. But when they look at how many of them were actually fixed, it was six of them. So I thought that was interesting. When I was initially trying to figure out, I had one of these coming to my office and I was leaning towards fixing them more often than not fixing them, but when you look at the study, they didn't talk about displacement, angulation, any sort of the radiographic parameters but you have to assume there was a good proportion of them that we're on one spectrum or the other and they only fix six of, what's that, 350?
So are we fixing these, do we need to fix them, I guess that's kind of the question that I was sort of looking for. So one of the first things I found was this ACFS post, I couldn't find the year of it but it was some time before 2016 where they were looking at fifth met fractures and do we need to be fixing these in army population. So their retrospective review looked at 41 patients where 12 were treated surgically and about 30 were treated conservatively. Across all parameters, clinical union, radiographic union and return to activity or sport, it was quicker return in all the surgical population. The surgical group also did have less complication where there was just a dehiscence every fracture and painful hardware for conservative management went on to eight delayed unions, one patient had RSD and there was some metatarsalgia. So kind of putting a tick in the box for surgical management. O'Malley in '96 looked at Dancer's fractures specifically in ballad dancers, so this is again I think was one of the first articles I could find, so this may be where the name of the fracture came from. Four of them were treated surgically, two percutaneously and two with ORIF where the other 31 were treated with just close reduction and weightbearing and CAM boot. So in this treatment protocol, they just went right away to weightbearing as tolerated and fracture boot and once they had radiographic healing, they progressed patients along. So again thinking about how you're treating these, this is just one example of a protocol. So their results show two complications, one was the delayed union and one was the refracture. Most patients had pain-free walking at about eight weeks and they return to ballad bar training and then full ballad at about 11 and 19 weeks. So they concluded that in most instances, nonoperative treatment will get you back to your activities quicker. Thompson in 2017 looked at again fractures in this area where they had 64 patients and they split it up between a type 1 or type 2 fracture which I don't think really matter too much for what we're trying to get at here. They used quarter tubular plates and 2.7 mm screws. So again using that small frag of that handsets and their protocol which was interesting was kept the patient nonweightbearing until x-ray union, then they transition them from partial to full weightbearing.
They found that healing was about eight weeks in both instances and they had small complication where it was delayed union, nonunion, one infection and one hardware removal. So they felt that because of fifth metatarsal has a thick diaphyseal and thick periosteum, there was increased vascularity to the bone and so there was a higher rate of union. So looking at the vascular anatomy of the fifth metatarsal, gets its blood supply from three main areas. There is the nutrient arteries, the metaphyseal-epiphyseal arteries and then the periosteal arteries. And all three of these combine give the bone a pretty decent blood supply in order to get your fracture healing, unlike the Jones fracture which occurs just at the base between the junction of those long arteries and then the network at the base where blood supply is more disrupted there. It's not as good and you get those nonunion rates. So Bigsby in 2014 looked at functional outcomes in fifth metatarsal fractures. They did a questionnaire study, asking patients to respond the surveys at one month, four months and 12 months. Out of the 117 fractures about 30 of them were the type that we're looking at here. They found that there was a bit more of delay and return to activity and delay in pain and recommended telling patients you maybe have some sort of discomfort or delay in activity up to a year outside these having these type of fracture. So another one in 2013 looked at nonoperative treatment of this fracture specifically where they had about 3000 fractures, 140 where the style again that we're looking at, their postop protocol was six weeks weightbearing as tolerated in either CAM boot or surgical shoe and then transitioning to stiff sneakers afterward and back to activity. Of the 141 treated nonsurgically, they only had one nonunion, clinical healing was noted at 6 weeks and they had high foot function scores at their endpoint.
They felt that the main reason that the metatarsal is especially in these nonoperative treatments healed pretty well, healed without any sort of malunion or delayed union is because of the fact that the different columns of the foot. So we talked the other day about the Lisfranc joint and being that kind of middle column of the foot being very stable. The medial column of the foot has some motion maybe 2 or 3mm or 2 or 3 degrees in dorsi or plantarflexion where at that medial column, the keystone has less than a degree, less than a millimeter, so it's a very rigid area versus the lateral column of the foot where some people describe it as having upwards of 10 degrees or 10mm of plantar and dorsiflexion motion. It's triplane joint that some people would argue and so the fact that area can accommodate the ground can act as more of a mobile lever. There is not as much stress in that area. It could be a reason why this area tends to heal better with conservative treatment and also why the complication with conservative treatment is less in terms of that callus formation and metatarsalalgia. Even though it is a possibility, the reports are pretty low in all the studies that you look at. So just some quick case examples. So I had more in there but I cut them down. So I called this one as kind of what you want for nonoperative treatments. So a 15-year-old guy, parents didn't want surgery. So we just went through weightbearing as tolerated in a boot for 0 to 8 weeks, transitioned him from 8 to 10 to 12 weeks back into a sneaker and by three months, he was healed and back to activity. So I was just kind of looking at his x-rays from December, January, February, March. Just kind of have to coach the patients along, coach the parents along that if you're going to treat these things nonoperatively, I feel like you really don't see anything until that like really six or eight week x-ray. So at four weeks when you don't see anything and the parents or the patients likewise anything happening, well, we need to jump ship and do surgery. No, once we pick nonoperative treatment, we're going to stick with that for about 10 to 12 weeks unless something egregious is going on because you really have to wait for that eight-week mark to see the x-ray. This is what you don't want for a nonoperative treatment but postoperatively getting that end result. So this is a 64-year-old female who fell off of a horse. She worked on the farm and says she couldn't do surgical treatment, so we just put her on the fracture boot so she could maintain her lifestyle. So had this happened in November, kind of looking at the x-ray three months later, you still see the fracture. It doesn't look like it healed at all. This is one of those instances where you will get a CT scan and they read it as virtually no healing across the fracture line. So we took her in for surgery, used again one of those Y hand plates with some independent interfragmentary screws and about two or three months later, she was fine. And again because we did surgery and her kind of time restraints with her actual lifestyle because we had the plate in there, I was more willing to move quicker through the surgical recovery process because I was pretty confident that it was going to be stable even though the x-ray didn't show any sort of healing until that two or three month point. That's her endpoint. This is what you don't want operatively and postoperatively. So we all kind of have our bad cases out there. So this is a 61-year-old female. She tripped off a curve again having that sort of twisting mechanism. Past medical history of osteoporosis and breast cancer. What was really important to her was maintaining her active lifestyle, doing yoga, doing gym activities and so forth and so she wanted whatever was going to get her quickest back to her recovery. So again, we planned for operative treatment, four weeks nonweightbearing, four weeks in a boot and then back to sneakers. So in this time, my rep was telling me about this new plating system that was designed specifically for metatarsals and so I figured, hey, I will try it out which I didn't. So we could see here we fix this. So just looking at this plate versus some of the other ones that we had in the other x-rays. We can see it looks much thicker. It looks much more robust, much more stiff which I think was part of the problem here. I also think my placement was bad where I had it. If you look at the distal end of the joint, it's pretty close to that area and she did have some stiffness in the joint.
Everything was going well. So I saw her about seven weeks and then she calls me at the eight-week mark saying something happened. She has got a hole on her foot. There is fluid coming out of it. So I think the area we're just talking about the incision, you can get rubbing, you can get irritation. She ended up developing little bit of an abscess. We did a bedside and cultured it. She was on oral antibiotic for two weeks but it didn't continue to heal. So we ended up having to take her back three weeks later to remove the hardware, not put anything in, flush it, culture it, all that sort of standard tenets for infection management. Didn't grow back any sort of osteo but infectious disease still recommended six weeks of IV antibiotics. So this is just going through a healing. So she was still worried about the bone healing and so forth which I was as well. But ultimately, because of that lateral column flush that we're talking about, even if it didn't completely heal, it shifted up a little bit, I wasn't too concerned about any sort of lasting disability afterwards. So just a recap. There is not that much literature about these types of fractures even though they do make up a large proportion of fifth metatarsal fractures. Overall, there is a pretty high healing rate and high functional outcomes. Just remember the long fracture, it has a greater surface area for bone-on-bone contact to get bone healing. The thick periosteum with the good vascular supply and that mobile lateral column gives a little bit more forgiving to that area in terms of healing both operative and nonoperatively. Both conservative and surgical management are acceptable but the decision should be made each fracture dependent. There is not really a cook book for these. It's the patient. It's the fracture. It's what's really going on completely. However if there really is more than 3 or 4mm of separation or angulation, you should be erring on the side of probably fixing these. Surgical treatments can be percutaneous or open. And with that being said, the surgical treatment may allow for a quicker return but nonoperative treatments when you look at the study, it shows return to sport, return to activity just as quick as the nonoperative. I found this to be a good article. So I like foot and ankle specialist as a journal. Every quarter they put out these roundtable discussion which just pick a topic, they have a moderator and four or five people. In our field either it's DPM or MD, DO talking about a topic. And so they had one in 2016 where they discussed fifth metatarsal fracture. So again this doesn't have a lot of research to it in terms of the fracture but you can kind of get other people's ideas who are seeing a lot of these fractures. So they talk about Jones fracture, avulsion fracture, these Dancer's fractures and what their protocols are. It's a good article to read and the series is good in general where we're talking earlier about Jones fractures and I won't take it off topic but you have four different doctors with four different opinions. One guy says he will fix a Jones fracture and put athletes back by six weeks. One guy says he keeps some nonweightbearing for eight weeks when he fixes it with ORIF. So just good to sort of see what other people are doing out there. That's my references. It's a lot of them. That's it.
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