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Background: This study was designed to compare the 1-year outcome among the groups with different low-dosage triamcinolone acetonide (TA) injections for trigger finger.

Methods: In the study period, trigger digits were initially injected with 2, 4, or 8 mg TA. We checked whether they had a second injection or surgery during the following year by either patients' revisit or telephone interview. The groups with different injections were compared according to recurrence and symptom relief period. We also assessed the 6-week outcome to confirm the short-term improvement.

Results: One-hundred ninety-eight digits were enrolled. About 60% of the injected fingers required additional treatment in each group without significant difference. The interval between the initial injection and additional treatment in the recurrent cases averaged 5 months in the 2 and 4 mg TA groups, being significantly extended for a short term of 1.5 months in the 8 mg TA group. All the groups showed a significant improvement of the patients' clinical severity at 6 weeks after injection without any difference among the groups. There was no adverse event.

Conclusions: Low-dosage TA injection for trigger finger within 8 mg yielded satisfactory results, not being inferior to those with higher dosage up to 40 mg in comparison with previous reports. Our findings implied that increasing TA dosage might bring short-extended symptom relief, however, not reduce the recurrence. While not offering great benefit, lower dosage TA injection for trigger finger can be chosen, aiming for cost-effectiveness, safety, and small injection site pain.

Background: There are various anatomical descriptions of the pulley system of the fingers and thumb. The A0 pulley, often referred to as palmar aponeurosis of the fingers, is of keen interest, especially regarding surgical release of the A1 pulley for trigger finger; however, there has been no anatomical description of the A0 pulley in the thumb.

Methods: Twenty-four cadaveric thumbs were dissected to expose the entire pulley system. Each structure, including the A2, Aob, Av, A1 pulleys, and any proximal transverse elements, were cataloged.

Results: Three distinct transverse elements were identified proximal to the A1 pulley including: (1) the named ligament of Grapow; (2) the proximal commissural ligament and associated transverse fascial tissues; and (3) a definable A0, identified in 10/12 (83.3%) cadavers and 15/24 (62.5%) thumbs. Ten A0 pulleys occurred bilaterally, while 5 occurred unilaterally.

Conclusions: The presence of an A0 pulley in greater than 80% of the studied thumbs serves as an important anatomic finding that should be considered in surgical treatment. An additional finding of importance is that the pulley system anatomy demonstrated variability in laterality. Based on these anatomic findings, not only can the A0 pulley be defined as a unique anatomic structure of the thumb, but its repair also has implications for successful surgical treatment of thumb pulley system pathologies.

Background: The purpose of this study is to analyze the relationship between discharge opioids after operative treatment of carpometacarpal (CMC) arthritis and patient-reported outcomes (PROs) over a 6-month episode of care.

Methods: A total of 172 patients met inclusion criteria for this study. Patient-reported outcomes including patient-reported wrist/hand evaluation (PRWHE), single assessment numeric evaluation, and PRO measurement information system (PROMIS) global-10 questionnaires were collected prospectively and stored in an electronic data capture system until review for the purpose of this study. Morphine milligram equivalents (MMEs) were calculated using a Centers for Disease Control and Prevention-published opioid conversion table.

Results: Of the 172 patients who met inclusion criteria for this study, 121 (70.4%) were female. The average patient age on the day of procedure was 63.6 ± 7.4 years. All patients received a prescription pain medication upon discharge with an average of 191.3 MMEs (range: 40.00-800.00 MMEs) prescribed per patient. Overall, there was no correlation between the amount of pain medication prescribed in MMEs and change in PROs between baseline, 6-weeks, 3-months, and 6-months (r < .14).

Conclusion: Surgeons should feel confident limiting postoperative opioid prescription for patients after CMC arthroplasty without jeopardizing outcomes.

Background: Lawn mower-related injuries (LMIs) represent a complex spectrum of pathology with significant public health ramifications. The purpose of this study was to analyze the epidemiological factors associated with lawn mower upper extremity amputations.

Methods: The National Electronic Injury Surveillance System (NEISS) database was queried from 2014 to 2023. National case estimates were established for upper extremity amputation events secondary to lawn mowers using diagnostic and injury-specific coding parameters. Documented cases from NEISS-participating hospitals were evaluated and injury data surrounding individual amputation events were analyzed.

Results: An estimated 17 509 upper extremity amputations occurred from 2014 to 2023 secondary to LMI in the United States. Annual case estimates and incidence rates remained relatively uniform across the 10-year study period. Most injuries were estimated to occur in 50- to 59-year-old patients. Case record review from pooled participating NEISS hospitals yielded 469 cases of upper extremity amputation directly associated with LMI from 2014 to 2023. Ninety-one percent of cases occurred in men, and most events involved the amputation of a finger (97%). Most cases of lawn mower-associated injury involved the amputation of the middle digit (41.6%) in isolation (64% of cases involved amputation of 1 digit).

Conclusions: Despite advances in product safety and consumer education, the estimated frequency and incidence rate of upper extremity amputations secondary to LMI has remained largely unchanged over the past 10 years. When these events did occur, 40- to 60-year-old men were most often involved, most commonly leading to amputation of the third finger in isolation.

Background: Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use has demonstrated positive effects on bone metabolism and pseudoarthrosis following fusion surgery. There is, however, little evidence regarding the preoperative use of GLP-1 RAs in patients who underwent arthrodesis in the upper extremity. Thus, the objective of this study was to examine the effect of preoperative GLP-1 RA use in patients who underwent small joint arthrodesis of the hand.

Methods: This study utilized a global, federated health research network to identify patients that underwent arthrodesis of the interphalangeal (IP) or metacarpophalangeal (MCP) joint. The experimental group consisted of patients that were prescribed a GLP-1 RA within 1 year prior to surgery; the control group had no previous GLP-1 RA exposure. One-to-one propensity matching balanced the groups based on baseline demographic characteristics and medical comorbidities. Rates of pseudoarthrosis and postoperative infection were assessed at 1 year following index procedure.

Results: This analysis returned 237 matched pairs. After balancing, the GLP-1 receptor agonist exposed group consisted of 68.4% female and 65.0% White patients. There was no difference between the 2 groups with respect to pseudoarthrosis at 1 year (RR = 0.700, 95% CI [0.362, 1.353]). Furthermore, similar rates of postoperative infection were observed (RR = 1, 95% CI [0.424, 2.358]).

Conclusions: Preoperative GLP-1 receptor agonist use was not associated with decreased rates of pseudoarthrosis in patients who underwent IP or MCP arthrodesis. This may suggest that successful union of small joint arthrodesis procedures is more attributable to local biomechanical factors and surgical technique rather than systemic metabolic status.

Background: There are no studies about the biomechanical behavior of ligamentous reconstructions in the trapeziometacarpal (TM) joint. The aim of our study was to analyze the stabilizing effect of 2 different dorsoradial ligament reconstructions of the TM joint: (1) monofascicular ligament reconstruction; and (2) bifascicular ligament reconstruction.

Methods: Ten fresh-frozen human cadaveric upper extremities were used. The dorsoradial dislocation of the thumb metacarpal (MC1) after applying a dislocating force was measured in 4 different situations using a 3-dimensional motion tracking system: (1) with the dorsoradial and ulnar ligaments intact; (2) after their section; (3) after dorsal ligament reconstruction with the bifascicular technique; and (4) after reconstruction with the monofascicular technique. The data were further analyzed and considered statistically significant at P < .05.

Results: The MC1 moved dorsoradially 0.36 cm (standard deviation [SD] 0.19 cm) with the intact ligaments. After sectioning the ligaments, the displacement was 0.64 cm (SD 0.24 cm). With the bifascicular technique, the MC1 moved 0.31 cm (SD 0.16 cm), and with the monofascicular technique, it moved 0.57 cm (SD 0.19 cm).

Conclusions: The monofascicular reconstruction technique seems to be insufficient to stabilize the TM joint. Dorsal ligament reconstruction with the bifascicular technique restores the original stability of the TM joint. Moreover, it is not necessary to reconstruct the ulnar ligament to restore the dorsoradial stability of the TM joint after bifascicular reconstruction.

Background: Simultaneous carpal tunnel release (sCTR) with emergent forearm fasciotomy in the setting of acute compartment syndrome (ACS) has been reported, but the national incidence and cost of delayed carpal tunnel release (CTR) remain unknown. This large database study aims to evaluate how often sCTR is performed, the frequency of delayed CTR when not performed simultaneously, and the associated costs.

Methods: The PearlDiver Mariner database was queried for patients who underwent forearm fasciotomies between January 1, 2015, and October 31, 2022. Patients were grouped based on CTR timing: simultaneous, within 2 weeks, 2 weeks to 1 year, 1 to 5 years, or no CTR. Reimbursement data were collected, and patient numbers and costs were analyzed across cohorts.

Results: More than half of patients undergoing emergent forearm fasciotomy received sCTR. Among those who did not, 31% required CTR within 1 year and 35% within 5 years. The total cost was highest when CTR was performed within 1 year but not on the same day as fasciotomy. After 1 year, the additional cost of CTR was similar to that of patients who never underwent fasciotomy.

Conclusions: This large database study shows that over one-third of patients who did not undergo sCTR at the time of emergent forearm fasciotomy required it within 1 year, incurring significantly higher costs. Including sCTR during initial fasciotomy may reduce delayed care and associated expenses. While these findings suggest that including sCTR during initial fasciotomy may reduce delayed care and expenses, the retrospective design precludes definitive recommendations, and clinical judgment remains essentialLevel of Evidence:4.

Background: An estimated one in four cases of cervical radiculopathy will indicate decompressive surgery. Around 7% of patients will develop motor dysfunction following such procedures. This study aims to demonstrate the utility of nerve transfers for cervical spine pathologies, including postoperative palsy and cervical radiculopathy with motor dysfunction refractory to decompressive surgery.

Methods: This study represents a retrospective case series of peripheral nerve transfer for palsy of cervical spine etiology at a single institution. A CPT code query was used to identify all cases of nerve transfer, and instances where the transfer was performed for cervical spine pathology were manually identified from this list. The identified cohort consisted of 8 patients: 5 cases of postoperative palsy and 3 cases of radiculopathy. Preoperative and postoperative physical exam results were gathered via chart review.

Results: Postoperatively, 6/8 cases resulted in at least M3 strength in shoulder abduction, with 4 instances of M4 function or better by final follow-up. All but 1 patient showed improvement in elbow flexion following nerve transfer, with 5/7 patients showing at least M4 function by final follow-up. Patients who underwent nerve transfer within 6 to 7 months of symptom onset appeared to experience superior results.

Conclusions: Peripheral nerve transfer represents a viable treatment option for patients demonstrating upper-extremity motor weakness of cervical spine etiology lasting greater than 4 to 5 months without significant improvement. Coordination between spine and upper-extremity surgeons should serve to optimize outcome through timely referral for nerve transfer once spontaneous recovery appears unlikely.

Background: Avascular necrosis (AVN) of the proximal pole is a well-known complication of scaphoid fractures. Avascular necrosis is poorly understood, including the transition from ischemia to necrosis, optimal treatment, and why some AVN heals but others do not. The primary purpose of this study is to evaluate patient-related factors that are associated with healing outcomes in individuals with proximal pole AVN following scaphoid fractures.

Methods: This is a retrospective review of all patients diagnosed with scaphoid proximal pole AVN secondary to a fracture from 2018 to 2024 in a single center. Patient baseline characteristics and comorbidities at time of diagnosis were collected. If the patient underwent surgical management, procedural factors were collected. The primary outcome was AVN healing after 4 months of follow-up.

Results: A total of 62 patients met inclusion criteria. Thirty of 62 (48.4%) went onto proximal pole AVN resolution. Hyperlipidemia (P = .030), advanced age at time of diagnosis (P = .038), and elevated body mass index (BMI) (P = .026) were independent factors associated with lack of AVN healing. For patients who underwent surgical management, there was no significant difference in healing outcomes between use of a nonvascularized, or no graft, and use of a vascularized bone flap (P = .115, P = .886, respectively).

Conclusions: Hyperlipidemia, elevated BMI, and advanced age are patient factors negatively associated with scaphoid proximal pole AVN healing-key information for accurately assessing patient prognosis. For surgical management, the choice of a vascularized bone, nonvascularized bone graft, or no graft does not significantly impact AVN healing.

Background: While clinical examination for carpal tunnel syndrome (CTS) is the first-line diagnostic method, its accuracy can vary, particularly among clinicians without specialized training. The CTS-6 questionnaire and ultrasound measurement of the median nerve's cross-sectional area (CSA) are two widely studied diagnostic methods. Combining these tools may provide a more reliable and standardized approach to CTS diagnosis.

Methods: A review was conducted of patients aged 18 years or older screened for CTS from June 2023 to Sept 2023. We combined scores using the formula (CTS-6 score + 2 × CSA) based on a previous study by Kimura et al. We then used the Index of Union and positive likelihood ratio (PLR) to analyze the optimal cutoff values for the combined score.

Results: A total of 142 hands were analyzed. The combined score had the highest sensitivity, while the CTS-6 alone had the highest specificity. The accuracy of the combined score with a cutoff value of 31.25 was equal to that of the CTS-6 score alone. Per the Index of Union, the optimized cutoff for the combined score was 27.68. Maximizing the PLR, the combined score cutoff was found to be 34.08.

Conclusions: Combining the CTS-6 and median nerve CSA offers the most accurate method for diagnosing CTS. A lower cutoff value (27.68 vs. 31.25) improved the sensitivity of the combined score, demonstrating a strong diagnostic performance for CTS as a screening tool. Alternatively, using the PLR-optimized cutoff (34.08), this becomes a highly specific confirmatory test.