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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.

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.