HAND最新文献

Distal radius fractures (DRFs) are common, especially in elderly populations, and often occur alongside scapholunate (SL) ligament injuries (SLIs), which can progress to scapholunate advanced collapse if untreated. There is no standardized treatment for SLIs with DRFs, with options ranging from conservative management to surgical interventions. This review aims to evaluate functional, radiographic, and clinical outcomes of surgical and nonsurgical treatments for SLIs associated with DRFs. A systematic search was conducted across PubMed, ScienceDirect, and Embase according to International Prospective Register of Systematic Reviews and Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies comparing surgical and nonsurgical management in adults (≥18 years) with SLIs and DRFs were included. Outcomes assessed included Disabilities of the Arm, Shoulder, and Hand (DASH) scores, QuickDASH scores, Mayo Wrist Scores, mean grip strength, SL gap, SL angle, and wrist range of motion (ROM). Thirteen studies involving 4315 DRF patients (423 with SLIs) were analyzed. Surgical treatment showed better functional outcomes, with lower DASH scores (P = .0011) and improved radiographic alignment, indicated by lower SL angles (P = 7.5 × 10^-20). However, wrist ROM was lower in surgically treated patients, particularly in flexion (P = .00031) and extension (P = .0080). Pain was the most commonly reported complication across both groups. Surgical treatment for SLIs with DRFs may lead to functional and radiographic outcomes similar to nonsurgical options, but is associated with reduced wrist mobility. Nonsurgical management remains effective for patients with milder symptoms. Further research is necessary to refine treatment protocols and optimize outcomes for these complex injuries.

Background: There are no large studies describing patient-reported outcomes after ulnar tunnel release (UTR). The aims of this study are to describe the causes of ulnar tunnel syndrome (UTS), the incidence of UTR, and identify factors associated with long-term patient-reported outcomes after UTR.

Methods: We reviewed the medical charts of 76 adult patients who had an UTR for UTS at 1 of 5 academic medical centers between January 1, 2003 and January 1, 2017. Of these patients, 30 completed a follow-up questionnaire including the PROMIS Upper Extremity (PROMIS-UE), Numerical Rating Scale for Pain Intensity (NRS Pain), the Global Rating Scale of Change, and a custom questionnaire about satisfaction and current UTS-specific symptoms.

Results: Approximately 3% of the patients who underwent a decompression surgery of the ulnar nerve at one of our centers between 2003 and 2017 had a UTR. The most frequent described cause of compression was ganglion cyst (16%). The 30 patients who completed the follow-up survey had a mean ± SD PROMIS-UE score of 46.0 ± 12 and a median (interquartile range) NRS Pain score of 0.5 (0-4). Twenty-five patients (83%) described themselves improved compared to before UTR. Bivariate analysis showed that patients who had a preoperative electromyography and nerve conduction velocity study (EMG/NCV) positive for UTS had a higher mean ± SD PROMIS-UE score compared to patients who had a negative EMG/NCV for UTS, respectively 48 ± 12 versus 37 ± 7.6, P = .04.

Conclusion: Diagnosis of UTS is challenging and made with substantial variation among surgeons. We observed that most patients improve after UTR, but patients with a negative EMG/NCV have a lower PROMIS Upper Extremity score at long-term follow-up.

Background: While concomitant opioid and benzodiazepine use is discouraged due to an increased risk of sedation/overdose, the extent of perioperative opioid utilization in hand surgery patients already using benzodiazepines is unknown.

Methods: Using an administrative claims database, we identified adults undergoing carpal tunnel, DeQuervain, or trigger finger release, palmar fasciectomies, ganglion/mucoid cyst removals, and hand/wrist soft tissue mass excisions from 2011 to 2021. We identified opioid-naive patients with a benzodiazepine prescription within 90 days before surgery. Outcomes included the percentage of patients prescribed opioids and the amount of opioids prescribed, new persistent opioid utilization, postoperative emergency department (ED) visits, hand therapy utilization, and opioid overdose. We used multivariable regression models to adjust for age, sex, region, insurance, procedure, and comorbidities.

Results: Patients with benzodiazepine utilization had a higher adjusted odds of perioperative opioid prescriptions, amount of opioids filled, and new, persistent opioid use compared with patients without benzodiazepine use (all P < .001). In the multivariable analysis, patients with benzodiazepine use received +30.8 (95% CI: 28.9-32.8) morphine milligram equivalents and had an odds ratio of 1.48 (95% CI: 1.44-1.52) for developing new, persistent opioid use compared with patients without benzodiazepine use. Patients with preoperative benzodiazepine use also had increased postoperative ED visits and hand therapy utilization.

Conclusions: Opioid-naive patients undergoing soft tissue hand surgery who are using benzodiazepines were prescribed opioids more frequently/at higher amounts and experienced an increased odds of developing new, persistent opioid use. Surgeons could consider reducing opioid prescriptions in patients already using benzodiazepines in favor of nonopioid pain strategies.

Background: Understanding peripheral ulnar nerve anatomy is necessary to refine surgical treatment of ulnar nerve injuries. This study topographically mapped the ulnar nerve and its distal branch points from a well-defined surgical landmark and assessed for variations in interfascicular motor arrangement and branch size.

Methods: Fifty-four cadaveric upper extremities were dissected to expose the distal ulnar nerve and its branches (dorsal cutaneous (DCB), volar sensory (VSB), and motor branches). The motor branch underwent internal neurolysis to record the topographic orientation of abductor digiti minimi (ADM) and flexor pollicis brevis (FPB) fascicles and the combined intrinsic fascicle identified by its terminal branch (first dorsal interosseus (FDI)). Using a standardized grid system, the branch point location of each terminal branch was measured relative to the hook of the hamate. Diameters of VSB, DCB, and motor fascicles were also measured.

Results: Mean branch point coordinates relative to the hook of the hamate for the FDI were 22.8 mm radial/32.1 mm distal, 13.6 mm radial/25.1 mm distal for FPB, 7.7 mm ulnar/5.2 mm proximal for ADM, and 15.7 mm ulnar/95.3 mm proximal for DCB. The diameters of the VSB, motor branch, and DCB had a mean of 2.3, 1.9, and 1.6 mm, respectively. Proximal to the hook of the hamate, the fascicular arrangement from radial-to-ulnar was VSB, FPB, FDI/intrinsics, ADM, and DCB.

Conclusions: This study provides a complete characterization and mapping of the distal ulnar nerve and its branches to assist surgeons with treatment of ulnar nerve injuries, including nerve transfer.

Background: Perilunate dislocations are severe upper extremity dislocations to the wrist involving ligamentous injury. Previous literature cites closed reduction of perilunate injuries at 25%. Herein, the technique and results of closed reductions for perilunate dislocations are described.

Methods: Chart reviews were conducted of perilunate injuries treated from 2017 to 2022. Imaging was evaluated to categorize by Herzberg stage. Reduction was performed in the emergency department (ED) and involved traction, relaxation, and manipulation. Reduction attempts and success rates were recorded as were presence and resolution of median nerve symptoms.

Results: Fifty-six perilunate injuries were included with an average age of 36 years. Forty-five (80%) underwent attempted closed reduction, of which 37 (82%) were successful. Twenty-seven (48%) were Herzberg I, 18 (32%) were Herzberg IIA, and 11 (20%) were Herzberg IIB. Two Herzberg IIB injuries were mal-reduced, with the lunate returned to the lunate fossa inverted. Scaphoid fractures were more likely in Herzberg I injuries and did not influence the success of reduction. Thirty (54%) patients presented with median nerve symptoms, of which 25 underwent attempted closed reduction in ED. Perilunate reduction resolved nerve symptoms in 92% of cases. Nerve symptoms were not more common in Herzberg II perilunate injuries. Successful closed reduction of perilunate injuries was not associated with a specific Herzberg stage.

Conclusion: Closed perilunate reductions in the ED can have a high success rate >80%. Herzberg II perilunate injuries have >70% (76%) success rate in closed reduction. Rates of median nerve symptoms were high and resolved in most cases (92%) after reduction. Closed reduction of perilunate injuries can safely be attempted in the ED and resolves nerve compression prior to surgery.

Background: Understanding the median nerve's position relative to surrounding anatomy is essential; however, there are many variations among individuals. This study assesses differences in median nerve position with or without palmaris longus (PL). We hypothesize that PL presence alters median nerve position, resulting in a greater distance to the skin volar surface, a decreased distance to the radius volar surface, and an increased distance to the flexor carpi radialis (FCR).

Methods: 1193 wrist magnetic resonance imaging (MRI) studies were retrospectively reviewed from 2019 to 2023. One hundred adults ages 18 to 50 meeting criteria were included for a power > 80%: 50 wrist axial plane MRIs (distal radial-ulnar joint level) with PL and 50 without PL. Measurements included the distance from the median nerve center to the skin volar surface, radius volar surface, and FCR center. Statistical analysis included Fisher exact tests and Mann-Whitney U Test (median, ranges), with significance at P-value < 0.05.

Results: Individuals with PL had a greater distance between the median nerve and skin volar surface. The presence of PL exhibited no discernable difference in the distance between the median nerve to the radius volar surface or the FCR center. Palmaris longus presence or absence did not affect the radial/ulnar positioning of the median nerve to the FCR center.

Conclusions: PL presence results in a deeper median nerve position within the wrist in relation to the skin volar surface. This knowledge is crucial for musculoskeletal specialists, especially during volar approach wrist surgeries and when administering anesthetic or therapeutic injections to the median nerve.

Background: Vascular malformations (VMs) are a collection of rare diseases that result from abnormal overgrowth of vascular tissue and can lead to pain, infection, disfigurement, and decreased mobility. Vascular malformations can invade or impinge on nearby structures, including nerves, causing pain, numbness, and/or functional impairment. If nonsurgical therapy fails, surgical resection is considered. However, VMs' thin walls and tendency to infiltrate and/or recur makes resection difficult or impossible. Rather than resecting, we have found that patients can still benefit from surgery in the form of nerve decompression. Here, we present a series of patients with VMs causing symptomatic nerve compression that were successfully treated with nerve decompression, with or without VM resection. It is the purpose of this study to demonstrate that VM patients with nerve pain and/or sensorimotor dysfunction should be referred for evaluation by a peripheral nerve surgeon, regardless of whether the VM is considered "resectable."

Methods: Retrospective chart review of patient undergoing nerve decompression surgery for symptoms of peripheral nerve compression (pain and/or motor/sensory dysfunction) attributable to a nearby VM (confirmed on preoperative magnetic resonance imaging), with or without VM resection.

Results: Six patients with peripheral nerve compression attributable to VM were treated with nerve decompression. One also underwent VM resection. Five of the 6 patients had undergone previous surgical intervention (resection or sclerotherapy) without clinical improvement in radiculopathy. Following intervention, all patients demonstrated improvement of their pain and motor/sensory dysfunction.

Conclusions: Patients with VM nerve pain and/or sensorimotor dysfunction should be referred for evaluation by a peripheral nerve surgeon, regardless of whether the VM is deemed resectable. Even when unresectable, patients may still benefit from surgery in the form of nerve decompression.

Background: Documentation burden is a major contributor to surgeon burnout, particularly in high-volume outpatient specialties such as hand surgery. These encounters often involve multiple concurrent diagnoses, procedural planning, and longitudinal care. Ambient artificial intelligence (AI) tools, which passively transcribe and summarize clinical encounters in real time, have the potential to streamline note generation and reduce cognitive load.

Methods: Following institutional rollout of a commercially available ambient AI tool in early 2025, the system was adopted across all outpatient visits in a hand surgery clinic. Observations were collected regarding workflow adaptation, documentation quality, and perceived cognitive impact. To assess note characteristics, 14 carpal tunnel syndrome visit notes (7 AI-generated and 7 surgeon-written) were compared by word count, Flesch-Kincaid readability score, and inclusion of social and medical history.

Results: AI-generated histories were longer and exhibited greater linguistic complexity compared with surgeon-written notes. Surgeon-written assessments were longer, more readable, and more consistent in structure and tone. Social history was documented more frequently in AI-generated notes. All AI-generated assessment and plan sections followed a structured, problem-based format.

Conclusions: Ambient AI documentation can support the creation of more structured and contextually rich clinical notes in hand surgery settings. However, successful integration requires active clinician engagement and workflow alignment to balance efficiency with clinical accuracy. These findings highlight both the promise and the practical considerations of incorporating ambient AI into surgical documentation workflows.

Background: Finger amputation is one of the most common surgical procedures conducted by hand surgeons. The purpose of the current study was to compare the incidence of painful neuromas requiring surgical interventions after finger amputation secondary to acute trauma versus chronic digital ischemia.

Methods: A retrospective chart review was conducted at a single tertiary academic medical center. Patients who underwent finger amputation due to acute trauma or chronic ischemia were identified using Current Procedural Terminology codes. The primary outcome was the incidence of neuroma formation. Patient demographics, treatment types, and postoperative complications, such as infection, residual pain, and phantom limb, were also collected.

Results: Between January 2013 and December 2023, there were 1150 patients who underwent finger or thumb amputations, 917 due to acute trauma and 233 associated with chronic ischemia. Men were more likely involved in traumatic amputations. Raynaud's disease, scleroderma, and end-stage renal disease were the common causes for ischemic finger amputation. No significant difference was found between the 2 groups in postamputation complications. Thirty-eight in the traumatic group (4.1%) and 4 in the chronic ischemia group (1.7%) developed painful neuroma requiring surgical intervention. However, the difference was not statistically significant (P = .09).

Conclusions: The overall incidence of painful stump neuroma after digital amputation was low. While there was a stronger tendency in developing painful neuromas after finger amputation due to trauma compared with chronic ischemia, the difference was not statistically significant.

Randomized controlled trials (RCTs) comparing surgical fixation versus conservative management of distal radius fractures (DRFs) among the elderly often rely on P values for outcomes despite small sample sizes, attrition, and nonsignificant findings. This study uses the reverse fragility index (rFI) and reverse fragility quotient (rFQ) to assess the statistical stability of re-intervention and complication outcomes in RCTs. PubMed and Embase were searched for RCTs between January 1, 2000, and May 2024 for RCTs that evaluated surgical management versus conservative management of DRFs in the elderly population were included. RCTs were included if they contained 2 treatment arms reporting categorical dichotomous outcomes and had an equal or longer than 1-year follow-up. Non-RCT studies, RCTs with more than 2 treatment arms, RCTs without 1 year or longer follow-up, and RCTs without DRFs in elderly cohorts were excluded. rFI were calculated as the number of outcome even reversals needed to change statistical significance for nonsignificant (P ≥ .05) outcomes. rFQ was calculated by dividing the rFI by the sample size of the study. One thousand three hundred sixty-one articles were screened, with 12 studies with 1495 patients included for final analysis. The median rFI for re-intervention was 4 (range: 1-18), with a median rFQ of 0.035 (3.5%) within all RCTs evaluated. In every trial, the number of patients lost to follow-up was higher than the rFI, suggesting fragile statistical conclusions. For fracture healing complications, the median rFI was 4, with an rFQ of 0.02 (2%). Minor and major complications had rFI of 3, with rFQ of 0.02 (2%) and 0.04 (4%), respectively. Randomized controlled trials (RCTs) comparing surgical and conservative management of DRFs among elderly patients are statistically fragile, with a median of only 4 event reversals needed to alter significance. Caution is warranted when interpreting RCT results to determine fracture management among this patient population. Authors recommend larger, well-powered trials with standardized rFI analyses to better interpret outcomes in DRF RCTs among elderly patients.Level of Evidence: Therapeutic Level III.