Yelena Bogdan, MD, FACS, FAAOS🦴🧚🏻♀️
@InvictaOrtho
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orthopaedic trauma surgeon | educator | associate professor @EinsteinMed | wife & mother | 🧡my rescue dog | @BUOrtho @HSpecialSurgery alum | immigrant | 🇺🇸 |
Bronx, NY
Joined October 2018
It's time to unveil one of my labors of ❤️! Astrid is my world. I want her to live forever, even in the hearts of those who never met her. Perhaps this book will inspire you to adopt a rescue pet. Perhaps you just like bones. Or dogs. Or both!.Buy here:
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Not exactly my usual “technical trick,” but if you have long hair and haven’t seen this already. you can turn any hospital glove into an emergency hair tie. Learned this in residency and definitely still use it. (And yes, you can tear the glove instead of cutting it, haha)
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I get questions about “pie-crusting”/fenestration technique for fasciotomy wound closure, and how it heals. Here it is, 8 months later. Pie crust scars heal very well from the inside out. you can barely see them now (the little white lines).
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stole this meme pic and made my own. this is my life 😂😂
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Every year my hospital has a Christmas show. This year I did “Have Yourself a Merry Little Christmas.” 😊🎄
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From early on, I printed & saved every case I did in training. This creature (The Binder) grew to monstrous proportions. In it are fluoros,templates,drawings, & technique notes. I still add to it occasionally. In digital age, would still recommend this exercise to every resident.
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🥰 I’ve been working on something very important…say hello to Sam 🥰
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Normally I’d say happy Sunday but I’m admitted for presumed sepsis from the gastroenteritis I had. Fortunately feeling better with fluids and antibiotics so I think it’s still considered a happy Sunday. We will resume regularly scheduled Twitter programming on Monday hopefully.😘
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Based on a recent discussion about how we don’t get formal lectures on stuff we use in the OR, I made this PowerPoint for medical students to learn about basic instruments of ortho trauma. Please share with anyone who you think might benefit!
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This month’s JAAOS: the “pooping duck sign” of a triquetrum fracture. Treated nonoperatively in vast majority of cases. And now you’ll never look at it the same way again. :)
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Last time I missed the OTA it was because I was working on an important project (my son’s birth)… well this time I have to miss it again for a followup study. Welcome Ellie, 🌸 I am so glad you’re here.
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Don’t be fooled by the seemingly lined up medial cortex here (yellow). This fracture is in varus (blue line should cross the center of the head, instead it’s at the top), and the nail is inside the fracture (red)—this is called the wedge effect.
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As a half Russian, half Ukrainian, this encompasses my feelings on the situation. He is Stalin 2.0 and since he was KGB he runs the country the same way, with fear. Murderer. (Muting comments because I don’t want them to stress me out. We still can’t reach my uncle in Ukraine.)
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@ManMilk2 The patient had a bad fracture of the tibia (the bigger bone). The fibula was likely cut out and used as bone graft for bone loss in the tibia. This is called a vascularized bone graft. Fortunately the tibia is our main weightbearing bone, so most of the fibula is expendable.
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One of the hardest parts of being a surgeon is the inability to be alone with personal grief because you are needed by someone else, right now. And you owe them your 100%, so your pain takes backseat. Work has been my savior many times & I’m grateful to it, but it takes its toll.
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Guidewire in fracture site. You have to be more proximal & more medial than this. If you ream/nail like this, will create wedge effect seen in pic from this paper ( and have issues. Either clamp and get better start point, or DHS, but don’t nail like this.
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I made sure to get a formal pic with intact makeup early… shortly after this, my lil brother walked up to the chuppah ahead of his bride and I started bawling. 🤣😭
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[1/18] Kicking off the new year with some tips of how I do a short cephalomedullary nail for an intertrochanteric fracture. The cases I use here are not all the same and aren’t always “perfectly done” but I try to showcase the best example of the technique itself.
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[1/2] There are many ways of doing Poller screws. One simple technique is described here ( in which you draw a line down anatomic axis of metaphyseal/short piece, then a line along fracture, and put the screw in the acute angle. I find it works well.
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[1/11] JBJS March 2009: classic instructional course lecture titled: “intertrochanteric fractures: ten tips to improve results” by Haidukewych. I strongly urge anyone who hasn’t read it to do so in full, but I will share the tips in this thread, drawing on own cases and internet.
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I have to say, out of all the awards I have ever received, this might be the closest to my heart and what I truly love— education. Thank you. ❤️
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Sometimes I still feel like I need to pinch myself because I live in a dream.
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[1/11] I believe that surgeons should show mistakes as well as the good stuff. I don’t show that as often for the bread & butter cases because errors there not as common, but here is one where I messed up and how I fixed it. No distal extension in this fracture, pure nail case.
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My book is now at our local library. And thus, a childhood dream of mine has been realized. 💜🙏🏻
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An excellent trick to find the radial nerve in posterior triceps split approach, from paper by Frank Liporace: 2 fingerbreadths or 4cm proximal to where triceps aponeurosis meets septum between long and lateral heads of triceps. It’s neat; it has worked every time for me so far.
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Today at library: .Me: “hi, you did not have this book by @NikkiHaley so I bought it myself. I read it, and now I would like to donate it.”.Librarian: “oh thank you!! I like her a lot.”.Me: “me too. Now more people get to read what she has to say.”👩🏽💼🇺🇸💪🏻.@FFL_of_America.
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How posterior starting point causes extension deformity in distal femur. My residents asked me to explain how I think of start point deformities in general; this is what I showed them. I treat the fragment that is away from start point (on other side of fracture) as “stationary.”
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This doesn’t happen outside the OR often due to patient discomfort, but the best way to do a short leg cast is with the patient prone. That way, the gastroc is relaxed so the foot can dorsiflex more easily, and gravity helps you into dorsiflexion rather than working against you.
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Since my prior post stirred up hornet’s nest of “this should never happen,” I’m here to assure everyone that with enough time in OR, all kinds of things happen. Many tricks I post meant to prevent “happening.” So, even if your residents swear “it’s in bone” make them get lateral.
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A view at about 70° showing perfect lateral with neck concavity on both sides, screw centered & lined up with head, neck & nail. This is view that should aim for in ITs. (If anyone wondering re: TAD, I use calTAD and so my screw is low on AP which is why not close to joint here)
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A piriformis nail start point. On the AP the wire should overlap the bone because the fossa is behind the bone, and on the lateral it should be posterior, in line with the shaft as shown here.
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As a followup for what the final result looks like:.
I get questions about “pie-crusting”/fenestration technique for fasciotomy wound closure, and how it heals. Here it is, 8 months later. Pie crust scars heal very well from the inside out. you can barely see them now (the little white lines).
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A retractor pushing on the femoral neck to reduce a flexed intertroch. It’s important to keep this reduction until the cephalic screw is in. You can usually bypass the nail jig by keeping the incision slightly anterior (arrow; the drill for cephalic screw is shown more distal).
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Honored to receive the @otatrauma Mentorship Award. A highlight in my life, not least because it was presented by my own mentor and friend, former OTA President Heather Vallier. To have the very person who offered to mentor me at this meeting years ago do this makes me 🥹
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[1/9] Open pilon saga. The wound is a Gustilo Anderson Type IIIA, starting medial and going anterior. Skin quality ok but not great. Patient middle age, no significant comorbidities so this is one of those times when you prepare them for the long haul in the first conversation.
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Trick I use sometimes when fracture too short to hold reduction w/clamp: reduce it, manual hold clamp, fire wires into proximal & distal fragments, bring wires out tibia (plateau style), then will hold & can plate etc. Just remember to remove wires before tightening plate screws.
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Got the covid vaccine. In other news, texting your family “I got shot” immediately after, when you work in a level 1 trauma center in NYC, is not smart. 😆.
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Ha! I am apparently the top Twitter influencer in ortho. I may not have the most followers from that list, but I have the top engagement score(?) While I hate idea of influencers & just set out to teach/share tips and tricks, it’s still kind of cool.
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It’s not unusual for a patella clamp to be perfect on one side and gap articular side. For that reason I often use 2 clamps, one superficial & one deeper (with poke through tendon), then fiddle around until it’s perfect (left pic wasn’t final reduction, but wanted to show clamps)
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The best talk I ever had with my mentor:.Me: “I just wish I wasn’t so scared of messing up all the time.”.Him: “Why are you afraid of fear? Fear is good. I’m often afraid.”.Me: 🙄“Yeah right.”.Him: “Really. Let it keep you honest. If you stop being afraid, you’ll stop learning.”.
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My partner took this pic of me reading between cases 🙃
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I don’t sleep well before big cases so I plan, and plan.
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“Ladder fixation” in a severely osteoporotic, diabetic patient. There was a small posterior mal. Medial mal left alone due to bad skin. Fibula fracture extended from joint to just above depth gauge. Remember, the more severe the osteoporosis/diabetes, the more fixation you need.
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How did this happen? Biomechanically, I have no idea. Loosening I understand, but bending upward like that, no clue. It just goes to show that patients do not always follow textbooks. I find that fascinating. “The more I learn, the more I realize I know nothing.”
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People ask me about rule for skin bridges. I drew it out. Line A is your first incision. As long as line B (skin bridge length) is half of line A or longer, it does not matter how long line C is. The skin bridge will survive. I have never had an issue. Now to wash off my arm 😂
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My example of how bell clapper screws help prevent translation deformity. Fracture aligned with clamp but when released it coronally translated (red). Reclamped & used bell clapper screw (blue) that narrowed proximal canal, allowing no more shift. Paper:
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Fun little intraop video showing lag by design in action.
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I was showing PA examples of total hips online and saw this. The following conversation occurred:.Me: “. is that a tail?? does that person have a tail!?”.PA: “Dr Bogdan, that’s a dog.”.😂😂😂I laughed so hard I cried—this is why laser focus is bad. I thought it was dysplasia🤦🏼♀️
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One way to help coronal translation and reduction without opening is to pass a threaded K wire into the fragment and pull it outward until you get close enough to pass the nail, and push with your finger on the other fragment to help meet it.
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The correct clamp placement to reduce fracture dislocation (moore type plateau). The important caveat is that lateral column must be intact, which it typically is in Moore type 1 or 2. When you exfix these your hands should be in same places as clamp. Translation, not pulling.
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[1/2] Removing a stuck ring when cutters not available/patient refuses. Thread umbilical tape on the volar surface (usually more give), wrap it tight distally and secure/hold at end (green), then unwind tape (blue). The ring will slide on the tape and come with it.
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One of my favorite quotes from the last few years came from Game of Thrones: “Any man who must say, ‘I am the king,’ is no true king.” -Tywin Lannister. I think of it every time I come across this one person at work….
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My residents took this action shot of me today, showing why a left sided IT fracture is at risk for proximal fragment flexion. In their words, “this is going in the chief presentation” ….This is also not my first time jumping on furniture for demo/teaching purposes🤣
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I was surprised with this amazing cake (worthy of the great British baking show) on my last day in the OR! My favorite scrub tech Devin held onto that surprise the whole day haha. Look at that little mini plate, it makes my heart happy. Thank you! ☺️☺️🥰
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When doing long nails for your hip fractures, always check the knee. This patient’s osteoporosis was so bad the guidewire just yeeted itself out of the bone without any significant pushing. CT scan postoperatively showed no occult fractures, only the hole the guidewire made.
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Patiently threading a guidewire into multisegmental tibia using multiple tricks: pushing with mallets, bending guidewire (but not too much or will mess up nail endpoint), small incision to lever with freer, & good old hands (lead gloves). Distractor/Schanz pins are other options.
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Kanavel signs of flexor tenosynovitis: finger held in flexion, pain along flexor tendon sheath, fusiform swelling (“sausage digit”), pain with passive extension. Treated by various methods; hand partners taught me 2 incisions, proximal & distal, & threading angiocath into sheath.
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[1/2] Wire redirection trick. I liked my start point here but didn’t like my trajectory, thought it was aiming too lateral and too posterior. Rather than change wires or use the honeycomb, I maintained original start…
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My labor was tough. Epidural didn’t work, had episiotomy and tear. Not being able to sit, let alone work out, was hard. But a month later, my ortho genes kicked in and I was like f*** it, I’m gonna get after it. 35 lbs down, 15 to go 💪🏻🤱🏼 (dog cameo extra) #DEFCOR @jockowillink
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If your guidewire is going anteriorly on lateral, it’s at risk for cortical perforation during reaming. To avoid going down same path, leave first wire in, and put (bent) second wire aimed more posterior (arrow). Then pull first wire and voilá, good position! Just don’t overbend.
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Joint replacement surgeons, you will find this hilarious. Steve Carell describing his hip replacement… we sometimes forget that what is normal to us seems like an alien world to laypeople… 🤣
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Posterior mal steps I was taught by my mentor. I reduce spike & pin it first. Then I address gap (yellow) with lag screw outside plate, often with washer. Often the lag is long after this (blue) & changed at the end. Then plate. I get good reduction consistently w/this technique.
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Patella fracture, treated nonop in cylinder cast with immediate weight bearing, xrays 5 weeks apart. The retinaculum was clearly intact here & patient could do straight leg raise. The slight gap in joint space healed nicely. I don’t think I could do better with plating or screws.
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Bosworth fracture dislocation. Proximal fibula is stuck behind incisura. Closed reduction won’t work. I treated this by placing Hintermann (wires in red areas), distracted it enough so I could then lever fibula out w/Freer; it pops back in place. Then treat like normal ankle fx.
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I use “pie crusting” mostly for fasciotomy wounds, but it was described by @FractureDoc in 2007 for the feet as well. I use it in the setting of tight dorsal foot wounds if I do a midfoot or Lisfranc type injury to increase my comfort level with the skin. They heal great.
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Due to the rotation of the ilium outward (purple) (can also see more of the lesser trochanter than usual- green), the right leg is externally rotated (blue). Once the iliac wing is fixed, the rotation of the legs is comparable. I love fracture work because it makes sense.
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The beauty of a colinear clamp (helped along in this case by bone hook initially for fine tuning reduction). It is one of my favorite things for spiral fractures, mostly subtroch & femur shaft. Keep it on throughout nailing and reduction stays when taken off. I don’t use cables.
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A piece of family history. I wrote this letter after immigrating to the US, asking her to help my dad get into residency. He ended up getting in on his own, btw.☺️ I love how on the side of the page I try out the word “license” & eventually give up and write “examination” 😂
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My first YouTube educational video!! --How to read a shoulder Xray, and some dislocation/fracture basics. Meant for ER and primary care, and also any orthopedic surgeon who has time to kill. If you guys like it, I will make more! :) via @YouTube.
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After my absolute shit of a day yesterday, I came home today to a homemade carrot cake. My takeaways:.1. There’s no crying in orthopaedics. 2. Marry someone who complements you and has abilities you don’t. In my case, the ability to produce edible food.
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The dangers of improper short-segment fixation. Note also how there was only one screw proximally. Metaphyseal bone, toggle, and new fall, equals badness. (Callus because the re-injury was missed until pain worsened). Curious what my fellow trauma folks would do with that callus.
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A deformity like this often doesn’t reduce fully with traction. You still have to ream the proper starting point, but before that you have to reduce it. Usually, I use a clamp. Here, one of my residents was using a ball spike pusher.
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Suture fixation of patellar avulsion. I do it the same way as patellar tendon: two fiberwire sutures in 4 limbs, 3 holes in patella (peripheral 2.5 and central 3.5). Peripheral holes take one suture limb each, central hole takes middle two limbs. Tie over the top.
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[1/17] A story. The talk about death yesterday reminded me of my patient from years ago. Mary (not her real name) was 95, in great health, active in the community and all mental faculties at full strength. She fell and had a hip fracture for which I had to do a hemiarthroplasty.
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“They use the term compound fracture!!” 😂😂 bless you @DGlaucomflecken.
Thanks feelings bro . #orthotwitter #DangerSquiggles #ICanManageDiabetes #medtwitter @DGlaucomflecken
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Demonstration of healing in a basicervical femoral neck fracture treated with a DHS. Controlled collapse has occurred at the site with callus formation (green arrows), with expected protrusion of screw laterally (yellow). Patient has no pain.
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K wires (red) going from fibula into tibia & talus to hold length reduction in comminuted fibula w/poor bone where clamps not staying. Then I place plate and do screws above (green) & below (blue) fracture to suck plate down. The blue later exchanged for shorter locking screw.
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I know posters etc are counted as research item, but this arms race is unrelated to resident competence & saturates the field w/meaningless literature. If it were up to me, every application would have max of 3 slots for research and would be judged on intent/content, not number.
Saw this on IG. Is this correct? How can you complete medical school while also generating 37 publications?
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OTA 2023 poster 13: while this medial approach seems cosmetically preferable, I am very concerned about the distal fixation and how short the screws would need to be.
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When I do open syndesmotic reductions, as here, my incision is in green. The oblique wire pins the syndesmosis in place once I have the reduction; the most distal wire controls fibular rotation for fine tuning. Paper:
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As I pass the 8K follower mark (wow, thank you for enjoying my trauma world!), I am happy to announce that I am now an official @AAOSmembers social media ambassador. My scrub tech asked if that meant I was now going to do “break the internet” magazine covers. Well, pass the 🍾 😂.
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Less is more sometimes. This pt broke elbow 50 years ago as a child and has managed to live and work with it. The only complaint was bone starting to stick out of skin and had an infection. I cut as much of the humerus back as I could (right). Wound healed, super happy patient.
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External fixation is in my mind still great option for distal radius. The problem is that people flex wrist instead of translate, causing problem with finger motion. But if done right, people can use their fingers well. My residents haven’t seen one before—is this a dying art?
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Oldie but goodie. How to do tip apex distance measurement, and a case example of very low TAD (purple). Original Baumgaertner article shows increased cutout in posterior inferior zone, here:
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Crying. From senior general surgeon at my hospital. I will miss him, and all my friends and colleagues at Geisinger. But it is time to move on. Proud to announce I am joining @MilanSenMD’s team in the city that was my first USA home and has always held my heart, NYC! 💔&❤️
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If you drill perfect circle & feel yourself hit nail, here’s a trick: stop, take driver off & see where you’re at. Here you’re too distal/lateral(A). Lean drill manually to aim more proximal/medial(B), tap with mallet until feel it go through nail(C), then finish with driver(D).
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What’s wrong with this fluoro? 4 things at least: to make a good starting point judgment you need perfect lateral (red) and you don’t have that; starting point needs to be proximal/closer to cartilage (blue); sleeve not down all the way (yellow); and trajectory too steep (green).
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[1/9] My mentor once said “if you can understand ankles, you can understand all of orthopaedics.” You can tell this ankle will be trouble due to fibula comminution. On lateral can see great example of how fibula (red) travels with posterior mal (yellow) because they’re attached.
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Pre-flight liquid courage! (I’m deathly afraid of flying.) See y’all at @aaos1 annual meeting in a few hours! Expect some highlights from the trauma papers and the exhibit hall. 👍🏻✈️
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