Scientific Abstract Presentations: Hand Session 2 Thursday, October 15 Thu, Oct 15 5:00-6:00 p.m. CDT

Background: Pediatric phalangeal neck fractures have traditionally been viewed as unstable injuries when displaced, with operative fixation recommended to prevent secondary displacement, malunion, and functional impairment. However, emerging evidence suggests that some displaced fractures may remain stable with immobilization alone, though clinical data remains limited. This study evaluates radiographic outcomes of displaced phalangeal neck fractures in children treated exclusively with nonsurgical management and to determine whether significant progression of angulation or translation occurs during healing.

Methods: We performed a retrospective review of pediatric patients treated at a single tertiary care center between 2020 and 2025. Patients aged 13 years or younger with radiographically confirmed displaced phalangeal neck fractures of the proximal, middle, or distal phalanx were included. All fractures were managed nonoperatively with immobilization under the supervision of a fellowship-trained pediatric hand surgeon. Open fractures, intra-articular injuries, and patients lacking adequate radiographic follow-up were excluded. Demographic variables included age, sex, fracture laterality, involved phalanx, involved finger, and mechanism of injury. Fracture displacement was characterized by initial angulation (degrees) and/or translation (percentage of shaft width). Follow-up radiographs obtained after immobilization were reviewed to determine final angulation and translation. Secondary variables included time from injury to definitive immobilization and time between initial and follow-up radiographs. The primary outcome was change in radiographic parameters between initial presentation and follow-up imaging.

Results: Twenty-four pediatric patients met inclusion criteria. Mean at injury was 4.5 ± 3.04 years, and 58.3% were female. Fractures were most common in the proximal phalanx (70.8%), and the small finger was most affected (45.8%). Mechanisms of injury were broadly distributed, with "Other" and "Unknown" each comprising 20% of cases, and sports- and fall-related injuries comprising 16.7% each. The mean initial angulation was 14.8 ± 4.2, which improved to 9.8 ± 4.2 at follow-up (mean radiological interval of 27.7 ± 9 days), representing a statistically significant mean decrease of 5.0 (p= <0.001). The mean duration from date of injury to definitive immobilization by our hand surgery team was 6.3 ± 4.3 days. There was a significant inverse correlation between initial angulation and magnitude of angular improvement (r= -0.53, p= 0.02), indicating that fractures with greater initial angulation demonstrated greater remodeling during nonsurgical management.

Conclusions: Despite being traditionally viewed as unstable injuries requiring surgical treatment, displaced pediatric phalangeal neck fractures in this cohort demonstrated significant radiographic improvement with nonsurgical immobilization alone. Greater initial angulation was associated with greater angular correction, underscoring the remodeling capacity in younger children. These findings suggest that select displaced fractures may be managed nonoperatively without progression of deformity and raise the possibility that current angulation thresholds for surgical intervention in young patients may be more conservative than necessary. Prospective studies are warranted to further define safe radiographic parameters for nonsurgical management.

Introduction Open metacarpal fractures are often fixed with Kirschner wires (K-wire) due to their contaminated or dirty nature. K-wires are associated with infection rates of 7-25% (1) and typically do not allow early motion protocols, as they are non-rigid constructs. Intramedullary (IM) screw fixation provides minimal soft-tissue disruption and favorable functional outcomes in closed injuries (2), but its role in open fractures remains unclear. This study compares infection, union, and functional outcomes between percutaneous K-wire pinning and IM screw fixation in open metacarpal fractures.

Methods A retrospective study was conducted on patients who underwent fixation of open metacarpal neck or shaft fractures at a single Level I trauma center between January 2024 and January 2026. Demographics, injury, surgical, and clinical data were collected for each fracture. Thumb fractures, intra-articular fractures, fracture-dislocations, and patients with less than 6 weeks of follow-up were excluded. Univariate logistic regression assessed associations between patient and injury characteristics with fixation method.

Results A total of 18 patients with 30 metacarpal fractures were included; 23 were treated with IM screws and 7 with K-wires. Clinical union was achieved in 100% of IM screw fractures compared to 85.7% (6/7) of K-wire fractures (p = 0.23). Total active motion (TAM) did not differ significantly between IM screw (mean 141.6°, SD 29.4°) and K-wire (mean 155.0°, SD 35.4°) fixation (p = 0.56). Three complications occurred: one superficial infection in the IM screw group (successfully treated with oral antibiotics), one non-union in the K-wire group (revised to IM screw with subsequent union), and one extensor tendon tenolysis. Univariate logistic regression showed no significant associations with fixation method for age (OR 1.05, 95% CI 1.00-1.10), sex (OR 0.47, 95% CI 0.05-4.47), smoking (OR 0.28, 95% CI 0.05-1.65), mechanism of injury (OR 1.20, 95% CI 0.66-2.18), contamination level (OR 1.43, 95% CI 0.54-3.78), or mangled hand status (OR 3.25, 95% CI 0.52-20.37).

Conclusions Intramedullary screw fixation appears safe and effective for open metacarpal fractures, with a lower complication rate (4.4%) compared to K-wire fixation (14.3%). All IM screw fractures achieved clinical union, and the single non-union in the K-wire group was successfully revised with IM fixation. Despite trends towards more severe injuries in the IM screw group - including higher-energy mechanisms, greater contamination, and mangled hand status - outcomes remain favorable.

References 1. Lutsky KF, Edelman D, Leinberry C, Takei TR, Kwok M, Gallant G, Beredjiklian P. A Prospective Evaluation of Complications after Use of Exposed Pins in the Hand and Wrist. Plast Reconstr Surg. 2019 Sep;144(3):659-664. doi: 10.1097/PRS.0000000000005921. PMID: 31461022.

2. Supichyangur K, Tananon T, Sripakdee SA, Chunyawongsak V. Prospective comparison of the early outcomes of headless compression screw and percutaneous K-wire fixation in metacarpal fractures. J Hand Surg Am. 2023;48(9):950.e1-950.e9. doi:10.1016/j.jhsa.2022.02.010

Background: Cannabis is one of the most widely used psychoactive substances in the United States, yet clinical research examining its effects in surgical settings remains limited. As legalization and social acceptance increase, cannabis is often perceived as having analgesic properties, but its impact on postoperative pain perception and analgesic requirements is not well established. In particular, the influence of cannabis use disorder (CUD) on postoperative pain management and medication utilization remains poorly understood. This study investigates whether patients with CUD demonstrate increased postoperative analgesic requirements following surgical treatment of hand fractures. Methods: A retrospective cohort study was conducted using TriNetX, a global federated health research network. Patients undergoing closed reduction percutaneous pinning (CRPP) for metacarpal or carpal fractures were grouped by presence or absence of CUD (ICD-10: F12). Propensity score matching (1:1) was used to control for demographics, comorbidities, and fracture characteristics. The primary outcomes were 30-day postoperative use of opioids, non-opioids, and NSAIDs, quantified by the number of distinct days each medication class was recorded. Results: A total of 1,092 matched patients (546 per group) were included. Patients with CUD had significantly higher odds of opioid (OR = 3.00, 95% CI: 2.06–4.55), non-opioid (OR = 3.67, 95% CI: 2.76–4.93), and NSAID use (OR = 1.83, 95% CI: 1.27–2.63). CUD patients also initiated analgesics earlier and had greater usage frequency, with significant differences in opioid and non-opioid use (p < 0.001). Conclusions: Cannabis use disorder is associated with increased postoperative analgesic utilization following CRPP of hand fractures. These findings underscore the importance of cannabis-specific preoperative screening and support the need for individualized, multimodal pain management strategies to optimize postoperative care in this population.

Background: Forequarter amputation (FQA) and related shoulder-girdle ablative procedures produce extensive composite defects, often in previously irradiated or surgically compromised fields. The free fillet upper-extremity (FFUE) flap applies a "spare-parts" principle, recycling amputated tissue to provide large-volume, donor-site–sparing reconstruction. Despite theoretical advantages, outcomes remain incompletely defined due to reliance on case reports and small series.

Methods: A PRISMA 2020–compliant systematic review and meta-analysis was conducted. PubMed, Scopus, and Embase were searched from inception through January 2025. Studies reporting microvascular transfer of an upper-extremity fillet flap for reconstruction after FQA, interscapulothoracic amputation, or shoulder disarticulation were included. Primary outcomes were complete flap survival, any postoperative complication, and reoperation. Random-effects meta-analyses of proportions were performed using generalized linear mixed models with logit link; heterogeneity and 95% prediction intervals were reported.

Results: Seventeen studies comprising 44 patients were included. Mean age was 56.3 years (range 16–81), and 63.6% were male. Most reconstructions followed FQA (86.4%) for malignancy, predominantly soft tissue sarcoma (47.7%) and bone sarcoma (22.7%). Prior multimodal oncologic therapy was common, with over half receiving radiotherapy. Defects frequently involved the chest wall (47.7%), shoulder (45.5%), and axilla (34.1%), often spanning multiple regions. Musculocutaneous flaps were most common (59.1%), followed by fasciocutaneous and osteomyocutaneous variants. Complete flap survival occurred in 43/44 cases, yielding a pooled survival of 97.0% (95% CI 88.8–99.3). No total flap losses were reported. Any complication occurred in 29.5% of patients (pooled 31.2%, 95% CI 18.7–47.3), and 25.0% required reoperation (pooled 26.0%, 95% CI 14.6–42.0). Necrosis was the most frequent complication (pooled 16.1%, 95% CI 7.7–30.7), followed by thrombosis (6.8%, 95% CI 2.5–17.3) and wound dehiscence (6.9%, 95% CI 2.5–17.9). Prediction intervals were wide, reflecting heterogeneity and small study effects.

Conclusions: FFUE reconstruction demonstrates near-universal survival despite extreme defect burden and frequent prior oncologic therapy. Although complications and reoperations are not uncommon, outcomes appear acceptable in the context of high-risk forequarter-level ablation. Standardized reporting and multi-institutional collaboration are needed to refine patient selection, operative technique, and evaluation of patient-centered outcomes.

Background: Brachial plexus birth injury (BPBI) affects 0.5-2.6 per 1,000 live births. While functional outcomes are well-described, the association between BPBI and broader neurodevelopmental outcomes remains unclear. No large-scale, propensity score-matched study has examined this relationship. This study aims to evaluate the risk of developmental delays in children with BPBI compared to matched controls.

Methods: Using the TriNetX US Collaborative Network (70 healthcare organizations), we identified children diagnosed with brachial plexus disorders (ICD-10: G54.0) before age 1 year. Controls were children without brachial plexus diagnoses. The index event for both cohorts was the first well-child visit before age 1 year. We performed 1:1 propensity score matching on 22 characteristics including demographics, prematurity, birth trauma, hypoxic ischemic encephalopathy, congenital malformations, and cerebral palsy. Primary outcomes were neurodevelopmental disorders within 10 years: global developmental delay, motor delay, speech/language delay, autism, and ADHD.

Results: After matching, 426 BPBI patients and 426 controls were analyzed (mean follow-up: 4.2 years in both groups). BPBI was associated with significantly increased risk of motor delay (12.9% vs 4.0%; RR 3.24, 95% CI 1.91-5.48, p<0.001) and global developmental delay (23.2% vs 12.4%; RR 1.87, 95% CI 1.38-2.54, p<0.001). Kaplan-Meier analysis demonstrated earlier onset of motor delay (HR 3.04, 95% CI 1.76-5.23, p<0.001) and global developmental delay (HR 1.82, 95% CI 1.31-2.55, p=0.001). No significant differences were observed for speech/language delay (RR 1.29, p=0.062), autism (RR 1.64, p=0.186), or ADHD (RR 1.06, p=0.867).

Conclusion: Children with BPBI have significantly elevated risk of motor delay (3-fold) and global developmental delay (2-fold) compared to matched controls. Importantly, this association persists after controlling for hypoxic ischemic encephalopathy and other perinatal brain injuries, suggesting BPBI-specific developmental impact rather than confounding by concurrent neurological insults. These findings support incorporating routine developmental screening into BPBI follow-up protocols beyond standard upper extremity assessments. Early identification may enable timely intervention and improved long-term outcomes.

Introduction It was recently reported that 35% of patients treated for peptic ulcer disease are taking proton pump inhibitors (PPIs) beyond the approved treatment duration [1]. Nonetheless, it remains one of the most frequently prescribed medications in the U.S. PPIs have interestingly been linked to sub-optimal bone health and delayed fracture healing, perhaps due to effects of acid suppression on mineral absorption [2-3]. The first large database study investigating PPI usage in the context of hand surgeries sought to determine whether preoperative PPI use results in adverse short- and long-term postoperative outcomes following surgical treatment of metacarpal fractures.

Methods A retrospective cohort study was performed using the TriNetX Research Network to identify adults who underwent closed, open, or percutaneous treatment of metacarpal fractures, with or without pre-existing PPI usage. To control for demographics, BMI, and comorbidities (including gastritis, reflux, esophagitis, etc.), propensity-score matching was performed to yield comparable cohorts. Short-term outcomes included dehiscence, infection, and osteomyelitis within 6 months of surgery. Long-term outcomes included return to OR for relevant secondary procedures, hardware complications, and tendon or joint complications within 5 years of surgery.

Results After matching the identified PPI-using patients and non-using patients who underwent metacarpal surgery, there were 5423 matched pairs for comparison. PPI users demonstrated significantly higher rates of postoperative infection, sepsis, DVT/PE, osteomyelitis, return to OR (all p < 0.0001), death (p = 0.001), hematoma (p = 0.0007), and dehiscence (p = 0.0012) within 6 months of index surgery. In the long-term, PPI users also demonstrated significantly higher rates of OR return, hardware complications (both p < 0.0001), tendon-related complications (p = 0.0063), and postoperative osteoarthritis or contractures (p = 0.0042).

Conclusions This represents the first large database study investigating PPIs' effects on postoperative complications following metacarpal fracture surgical repairs. Our data suggests that PPI use may be associated with several acute and long-term adverse events, ranging from infection to poor joint healing. Further research should investigate the exact mechanism of PPIs' effects on bone healing following orthopedic surgeries, as well as whether or not these potential risks warrant standardized perioperative counseling on PPI consumption.

References [1] Villars JA, et al. Proton pump inhibitor use exceeding the U.S. Food and Drug Administration approved treatment duration for patients with peptic ulcer disease: A retrospective cohort study. Pharmacoepidemiol Drug Saf 2025;34(5):e70152. [2] Lespessailles, et al. Proton pump inhibitors and bone health: An update narrative review. Int J Mol Sci 2022;23(18):10733. [3] Ito, et al. Association of long-term proton pump inhibitor therapy with bone fractures and effects on absorption of calcium, vitamin B12, iron, and magnesium. Curr Gastroenterol Rep 2010;12(6):448-57.

Purpose Upper extremity arteriovenous fistula (AVF) is the preferred hemodialysis access, but AVF creation can lead to downstream hand ischemia, tissue loss, and nerve dysfunction. AVF complications are usually described from a vascular access perspective using access centered endpoints, such as steal syndrome or access revision, rather than hand and upper extremity endpoints, such as infection, finger, hand, upper extremity necrosis, nerve compression etc. In plastic surgery literature, these outcomes are primarily described in case reports or series. As a result, the population level frequency, timing, and operative burden of hand morbidity after AVF creation remain poorly defined. This study aims to quantify AVF related complications that require surgical intervention. n and identify baseline comorbidities associated with these outcomes. Methods A multi-institution retrospective study was conducted using the TriNetX network, including 57 healthcare organizations. Adults undergoing upper extremity AVF creation from 2016 to 2024 were identified using CPT codes. A non-AVF dialysis control cohort was defined using dialysis ICD-10 codes with peritoneal or catheter-based access CPT codes. Surgical endpoints were defined using the CPT code sets and included upper extremity amputation (finger, hand, wrist, and forearm), infection related hand surgery (abscess or bursa drainage, tendon sheath or joint drainage, osteomyelitis bone debridement), and nerve decompression (carpal tunnel release and ulnar nerve decompression at the wrist or elbow). Incidence of surgical endpoints was compared between the AVF cohort and the peritoneal/catheter controls using propensity score matching. Time from AVF creation to the surgical endpoint was evaluated using Kaplan Meier curves and Cox proportional hazards models. Baseline comorbidities were identified from ICD-10 diagnosis codes, and surgical endpoint risks were summarized across comorbidity profiles. Results The AVF cohort included 50,604 patients (mean age 60.3 years, 56.7% male, 47.7% White, 33.6% Black, 6.4% Asian). AVF creation was associated with higher rates of amputation (0.75% vs 0.51%, RR 1.47, p<0.001), infection related hand surgery (0.35% vs 0.23%, RR 1.54, p<0.001), and nerve decompression (0.65% vs 0.31%, RR 2.06, p<0.001). The median time from AVF creation to amputation was 15.6 months (IQR 8.2 to 24.6), to surgery for hand infection was 16.7 months (IQR 9.6 to 28.9), and to nerve decompression was 18.8 months (IQR 9.4 to 28.9). Within the AVF cohort, surgical outcomes were more concentrated in patients with comorbidities. Amputation risk was highest among patients with prior limb loss (3.9%, RR 8.1, p<0.001) and peripheral arterial disease (1.8%, RR 3.6, p<0.001). Infection-related hand surgery was most common in patients with peripheral arterial disease (0.73%, RR 2.4, p<0.001) and long-term insulin use (0.70%, RR 2.9, p<0.001). Conclusions Although downstream hand operations after AVF creation were uncommon, a multi-institution database allowed population level estimation of their incidence and timing. Upper extremity AVF creation was associated with higher rates of downstream hand surgical morbidity than peritoneal or catheter dialysis, including increased risks of amputation, infection-related hand surgery, and nerve decompression. Downstream risk was concentrated within baseline comorbidity profiles, identifying patient subsets in whom targeted surveillance and earlier referral may be most impactful.

Background Bier block or intravenous regional anesthesia (IVRA) is commonly used for short hand and forearm procedures. Various adjuvants added to lidocaine may enhance analgesia, optimize block characteristics, and reduce postoperative analgesic use. Understanding the additive effect of these adjuvants has implications for operating room turnover, PACU patient flow, and discharge timing.

Purpose To compare the relative efficacy of various Bier block adjuvants on block onset, recovery time, and time to first analgesic request, in order to optimize operating room workflow.

Methods A systematic search in PubMed/MEDLINE, Web of Science, and Embase identified RCTs comparing lidocaine-only Bier block to lidocaine plus various adjuvants in patients ≥18 years undergoing minor upper extremity procedures distal to the elbow.

Primary outcomes were sensory block onset time, motor recovery time after tourniquet release, and time to first analgesia. A random-effects component network meta-analysis (cNMA) was conducted to elucidate the additive effect of each analgesic when multiple analgesics were used. Data analysis is ongoing and groups may be altered.

Results We included 58 RCTs (3,176 patients) and eight adjuvant groups: α-2 agonists, acetaminophen, corticosteroids, ketamine, magnesium, nitroglycerin, NSAIDs, and opioids. Procedure time [mean±SD (minutes): 43.26±13.54] and study design were similar across RCTs.

For motor recovery time, Bier block with acetaminophen, corticosteroid, NSAID, corticosteroid plus NSAID, or opioid adjuvants did not show significant differences compared to standard Bier block (lidocaine alone). Bier block with acetaminophen may be associated with a faster motor recovery [mean difference (95% CI): -4.25 (-8.84, 0.34)]. Bier block with α-2 agonists, ketamine, magnesium, or nitroglycerin had significantly longer motor recovery times.

Fastest sensory onset was with magnesium [-3.56 (-4.40, -2.71)]. Sensory onset was also faster with corticosteroid plus NSAID [-1.69 (-2.98, -0.39)] or opioids [-1.80 (-2.60, -1.01)] as adjuvants compared to standard Bier block-as with α-2 agonists, ketamine, and nitroglycerin. Other adjuvants did not show significant differences.

Time to first analgesic request was significantly prolonged corticosteroid plus NSAID [161.72 (82.52, 240.93)] or opioids [83.51 (42.42, 124.60)] as adjuvants compared to standard Bier block-similarly with α-2 agonists, ketamine, magnesium, or nitroglycerin. Other adjuvants did not show significant differences.

Conclusion Acetaminophen showed comparable sensory onset and duration of analgesia to the control but allowed faster motor recovery. In short procedures such as carpal tunnel release, this may improve discharge efficiency without compromising early pain control.

Opioids and corticosteroid + NSAID adjuvants added to lidocaine were associated with faster sensory onset and prolonged pain control compared with standard Bier block without delaying motor recovery times. However, despite no effect on motor recovery, opioids may still delay discharge due to sedation or respiratory effects.

Corticosteroids inhibit phospholipase A₂ upstream in the arachidonic acid cascade, while NSAIDs inhibit downstream COX enzymes. Dual-pronged inhibition may provide broader anti-inflammatory coverage. While higher corticosteroid doses may prolong motor blockade, NSAID co-administration may permit lower steroid dosing. Further research is needed to optimize combination dosing to balance analgesia and speed of recovery.

Introduction: The use of ketorolac, a potent nonsteroidal anti-inflammatory drug (NSAID), has been largely avoided by hand surgeons following operative repair of fractures given concern for an increased risk of nonunion. Recent studies looking at scaphoid and distal radius fractures have demonstrated equivalent bone healing outcomes with and without short courses of NSAIDs. Given these findings, we hypothesized that postoperative ketorolac administration within five days of operative treatment for metacarpal fractures would not show an increased rate of nonunion or revision surgery.

Methods: A retrospective cohort study was performed using the TriNetX database. Adult patients who underwent operative treatment of a metacarpal fracture from 2015 to 2025 were included. Cohorts were defined based on postoperative ketorolac use within five days of the index surgery. After propensity score matching, incidence of nonunion and nonunion revision surgery within six months of the index surgery was determined and compared with odds ratios (ORs) and 95% CIs. Statistical significance was reported as an alpha error of < 0.05.

Results: A total of 12,822 matched patients (6,411 ketorolac; 6,411 no ketorolac) were compared. There was not a significant difference in nonunion rate or nonunion revision surgery rate between the ketorolac and the no ketorolac groups (2.23% vs 2.24%; OR, 0.993 [95% CI, 0.786, 1.255] and 0.78% vs 1.08%; OR, 0.722 [95% CI, 0.501, 1.041]).

Conclusion: Postoperative ketorolac use within five days of operative treatment of metacarpal fractures does not significantly increase the rate of nonunion or nonunion revision surgery. This contributes to the growing evidence that short courses of postoperative ketorolac may be safely used in the ambulatory hand surgery setting.

Purpose: The role for prophylactic antibiotics in closed reduction percutaneous pinning (CRPP) following pediatric hand fractures is not well-established nor standardized in practice. As antibiotic administration is not without risks, we sought to investigate the role of pre-operative antibiotics in decreasing the incidence of post-operative infection in the pediatric population.

Methods: PearlDiver, a large national insurance claims database, was queried to identify pediatric patients 18 years and under undergoing CRPP following hand and wrist fractures or dislocations. Patients with a history of cancer or any other surgery within one year of CRPP were excluded from the study. Patients who received pre-operative antibiotics (administration of intravenous cefazolin, vancomycin, or clindamycin the same day as surgery) and patients who did not were propensity-score matched for age, sex, geographical region and past medical history including diabetes and obesity. The primary outcome was post-operative surgical site infection (SSI) diagnosed within 90 days of the initial surgery. Secondary outcomes 30- and 60- day infection incidence and incidence of osteomyelitis.

Results: A total of 34,752 patients were included in the study with 17,376 in each arm. The overall incidence of post-operative SSI within 90 days was 0.87% (N = 303). There was no significant difference in infection rate between the prophylactic antibiotics group (N = 162, 0.93%) and control group (N = 141, 0.81%). The overall 90-day incidence of osteomyelitis was 0.06% (N = 21). There was no difference in incidence of osteomyelitis between patients who received prophylactic antibiotics and those who did not (0.004 vs. 0.08%). These findings remained unchanged in evaluating individual procedures and anatomical regions at 30-, 60-, and 90-day intervals.

Conclusion: Post-operative infection following CRPP for pediatric hand fractures is uncommon, and the incidence of osteomyelitis is exceedingly rare. We found no association between prophylactic antibiotics and the incidence of post-operative infection after surgery, suggesting that it may be unnecessary in such cases.