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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.

Background: A timely assessment of nerve damage is needed for early clinical decision-making. Second Harmonic Generation (SHG) microscopy visualizes collagen. This study investigated: Can SHG imaging distinguish collagenous substructures in human nerves? Can SHG imaging detect structural damage in human nerves following destructive stretch injury?

Methods: Six human upper extremities were equally divided into 2 groups: A no-injury and a load-to-failure (LTF) group. The median, radial, and ulnar nerves were surgically exposed. Arms were placed on an Instron material testing system. Eight centimeters of each nerve was secured under 2 pins. A hook was raised from beneath the nerve until complete nerve transection occurred. After the experiment, LTF nerves were excised along their full length. No-injury and LTF nerves were placed in isotonic saline under an FVMPE-RS Multiphoton Microscope using a laser wavelength of 900 nm to induce an SHG signal. Z-stack images were acquired using a wavelength of 45 nm. Nerves were then harvested for histology.

Results: Histology sections of NI nerves exhibited normal peripheral nerve architecture. All collagenous substructures visible on histology were clearly identifiable and distinguishable on SHG images of uninjured nerves. In LTF nerves, epineurium rupture and exposed fascicles were clearly identifiable on SHG imaging. Epineurial collagen of LTF nerves appeared heavily disorganized, with short fiber fragments following no clear trajectory. Findings were consistent among nerve types.

Conclusions: This is the first study to visualize human nervous tissue using SHG microscopy. Second Harmonic Generation imaging offers detailed visualization of all collagenous substructures of peripheral nerves and detects structural damage, like epineurial collagen-disorganization, and exposure of individual fascicles in unprecedented detail.

Medial epicondyle fractures account for 11% to 20% of pediatric elbow fractures. While most are managed conservatively, ulnar nerve palsy, present in up to 16% of cases, is an accepted indication for surgical treatment. Neurologic symptoms may begin in a delayed fashion and, in rare cases, persist or progress despite surgical intervention. In adults, distal nerve transfers such as anterior interosseous nerve (AIN) to ulnar motor branch transfer have demonstrated promising outcomes, but their role in pediatric patients remains limited. We report the case of a 13-year-old, right-handed gymnast who developed delayed progressive ulnar nerve palsy after a nondisplaced right medial epicondyle fracture managed conservatively. Despite undergoing anterior ulnar nerve transposition at 8 months after injury, she exhibited persistent motor and sensory deficits, with a QuickDASH score of 90.6. At 31 months after the injury, she underwent further surgery, with ulnar nerve decompression and submuscular transposition, ulnar nerve decompression at Guyon's canal, and supercharged end-to-side (SETS) AIN-to-ulnar motor nerve transfer. Eight months postoperatively, she showed substantial recovery of hand strength, fine motor coordination, and ulnar nerve-mediated sensation. At 4-year follow-up, QuickDASH score was 6.8, indicating near-complete functional recovery. To our knowledge, this is the first reported pediatric case of SETS AIN-to-ulnar motor nerve transfer after failed decompression of the ulnar nerve, following a late ulnar nerve palsy complicating a medial epicondyle fracture of the humerus. Distal nerve transfer may offer a viable strategy for enhancing intrinsic hand function in a pediatric chronic ulnar neuropathy, even beyond the conventional reinnervation window.

We report a unique case of carpal reconstruction for capitate deficiency in a child. The patient is a 15-year-old girl who had a destructive giant cell tumor involving the capitate and hamate. To the author's knowledge, this is the first case in which Achilles tendon interposition allograft was utilized to fill the bony void left behind by capitate and partial hamate excision. Arthrodesis was used as an adjunct for stabilizing the second and third proximal metacarpals. This resulted in a great functional and radiographic outcome with 7-year follow-up. In conclusion, when treating a carpal defect from capitate deficiency, if excision of the bone in its entirety is indicated, consideration for tendon allograft as an interposition graft may be given.

Background: Postoperative outcomes for Dupuytren's disease (DD) of the proximal interphalangeal joint (PIPJ) are highly variable, and the condition often proves refractory to correction. The aim of this study was to summarize the best available evidence on the treatments for DD of the PIPJ.

Methods: A systematic review and network meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Cumulated Index in Nursing and Allied Health Literature (CINAHL), Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science were searched for randomized controlled trials (RCTs) comparing treatments for DD of the PIPJ in adults.

Results: A total of 19 RCTs were included in this study. Based on network meta-analysis of operative techniques, limited fasciectomy resulted in significantly lower total passive extension deficit compared with collagenase injections and percutaneous needle fasciotomy in the short (1-12 weeks) and long term (>2 years). Limited fasciectomy also had the lowest rates of recurrence in the long term when compared with percutaneous needle fasciotomy and collagenase injection. Collagenase injections led to significant clinical improvement compared with placebo. Triamcinolone injections in conjunction with needle fasciotomy were more effective in correcting contracture than needle fasciotomy alone. Postoperative splinting, timing of manual manipulation after collagenase injections, use of dermofasciectomy, and incision type for limited fasciectomy had no impact on correction or recurrence of DD of the PIPJ.

Conclusions: While DD of the PIPJ is often refractory, limited fasciectomy provides better and more long-lasting contracture correction compared with collagenase injections or needle fasciotomy. More RCTs are needed to effectively compare treatment techniques for this condition.

Background: Pyrocarbon metacarpophalangeal (MCP) arthroplasty is associated with high rates of recurrent deformity and reoperation in patients with rheumatoid arthritis (RA). We sought to determine the impact of preoperative hand grip strength (HGS) on implant survivorship in these patients.

Methods: We included primary pyrocarbon MCP arthroplasties in patients with RA at our single institution from 2000 to 2022. Cox proportional hazard models with restricted cubic splines were used to model the continuous relationship between HGS and hazard for revision, all-cause reoperation, and development of any complication, accounting for multiple joints per patient and adjusting for sex. Kaplan-Meier estimates were used to report survivorship at 2, 5, and 10 years.

Results: We included 75 joints in 27 patients with an average preoperative HGS of 8.6 kg (11.1 years of follow-up). There were 16 (21%) total revisions, most commonly for recurrent deformity, along with 8 nonrevision reoperations, most commonly for tendon/ligamentous repair. There was a significant, J-shaped relationship between HGS and hazard for revision (P = .001) and all-cause reoperation (P < .001). Patients with HGS below 5.5 and 5.3 kg had an increased risk for revision (hazard ratio [HR]: 13.5) and all-cause reoperation (HR: 9.8) compared with patients with sufficiently high HGS. The 10-year revision survival was 93% in patients with HGS >5.5 kg and 63% in patients ≤5.5 kg. Hand grip strength did not significantly affect hazard for developing a first complication.

Conclusion: Very low preoperative HGS is associated with worsened implant survivorship following pyrocarbon MCP arthroplasty in patients with RA.

Fingertip injuries are common, and the thenar flap is a well-described technique used to maintain digital length. However, its use in patients aged 30 years and above is generally discouraged due to concerns regarding postoperative joint contracture. The purpose of this review was to evaluate whether these concerns are substantiated. A search of PubMed, Embase, and SCOPUS (1947-2025) identified 15 studies involving 519 flaps. Case reports and studies lacking functional outcome data were excluded. Bias was assessed using the Methodological Items for Non-Randomized Studies instrument, and results were synthesized using Microsoft Excel. Joint contracture occurred in 32.4% of cases, all of which involved only the distal interphalangeal (DIP) joint. Active range of motion (AROM) at the metacarpophalangeal and proximal interphalangeal (PIP) joints remained near normal and comparable with contralateral finger values. Distal interphalangeal joint AROM was reduced by 14.1° compared with contralateral fingers. Patients older than 30 years demonstrated a 3° greater PIP joint AROM than younger patients (P = .02). Our analysis of the literature shows that there is an elevated risk of DIP joint contracture after thenar flap reconstruction of a fingertip injury, but this risk was not significantly different in patients above 30 years. Further investigation with larger studies and standardized outcomes assessment is recommended.

Background: Scaphoid proximal pole fracture with avascular necrosis is a surgical challenge, particularly in patients with high functional demand. An option is the pyrocarbon adaptive proximal scaphoid implant (APSI), replacing the necrotic proximal pole.

Methods: A long-term follow-up study of the early cases treated in our department was conducted. Thirty-six patients with a median follow-up time of 19 years (range, 11-25) were included in the analysis, performing clinical and radiological evaluations.

Results: Clinically, significant improvements were observed in mean pain Numeric Rating Scale (from 6.8 [SD 2.1] to 2 [2]), range of motion, grip strength measured with the Jamar dynamometer (from 18 [8] kg to 24 [9] kg), Disabilities of the Arm, Shoulder, and Hand score (from 66 [6.5] to 13.7 [6.4]), and Patient-Rated Wrist Evaluation score (from 73 [10] to 28 [12]). Radiographs showed good implant stability. No patient required implant removal.

Conclusion: The APSI prosthesis proves effective long term in relieving pain, improving function, and preventing carpal collapse through stable biomechanical integration.

Background: The objective of the study is to characterize factors associated with radiographic union and pain at final follow-up in surgical repair of scaphoid nonunion.

Methods: Patients who underwent scaphoid nonunion repair at our institution between 2005 and 2024 were retrospectively reviewed. Demographic and surgical factors were abstracted. Preoperative, immediate postoperative, and final follow-up scapholunate (SL) angles were measured. Radiographic union (>75% healing) and patient-reported pain at final follow-up were assessed. Associations between SL angle measurements, patient characteristics, and surgical variables with union and pain were evaluated using unpaired t tests and χ² tests.

Results: Fifty-five patients met inclusion criteria with persistent nonunion occurring in 17 patients (30.1%). Patient sex was significantly associated with union (P = .045) but not pain at final follow-up (P = .399). All other demographic factors (smoking status, diabetes, prior surgery) and surgical factors (fracture location, surgical approach, implant type, graft type, and use of adjunct Kirschner-wire) were not significantly associated with union or pain at final follow-up (all P > .05). Among SL angle measurements, only a lower final follow-up SL angle was significantly associated with higher union rates (P = .038). No SL angle measurement was associated with pain at follow-up (all P > .05).

Conclusions: Patient sex was associated with union. No other demographic or surgical variables were associated with union or pain at final follow-up. A lower SL angle at final follow-up was independently associated with successful union, suggesting that correction of carpal alignment may contribute to improved healing in scaphoid nonunion repair.

Background: Over the last few decades, hand surgeons have described a variety of wounds resulting from opioid use disorder (OUD). In the Philadelphia region, fentanyl mixed with xylazine has risen as a substance of choice. Our primary focus is to report and compare the upper limb wound morphology in patients using fentanyl/xylazine with patients using heroin.

Methods: A retrospective cohort study was performed by reviewing charts of patients seen in consultation in a single plastic surgeon's private practice for upper limb soft tissue infections associated with opioid use from September 1, 2019, to November 30, 2023. Seventy patients were included and stratified based on wound morphology.

Results: We identified 70 patients (36% male, 64% female). In the heroin group, the most common wound was abscess (50%). In the fentanyl/xylazine group, it was full-thickness wound (55%). Chi-square analysis revealed a significant relationship between substance used (heroin or fentanyl/xylazine) and wound severity (mild/moderate or severe), χ² (1, N = 70) = 42.06, P < .0001.

Conclusions: There is a paucity of medical literature about the spectrum of wound manifestations in OUD. Our data suggests that heroin use more commonly causes unilateral soft tissue injuries, which is likely a result of site-specific infection with intravenous administration. Patients using fentanyl/xylazine had a higher rate of bilateral upper limb injury and presented with more severe wounds than patients who used heroin. Hand surgeons must be informed on the spectrum of wound morphology with OUD and nuances between substances to best manage them in their practice.