Scientific Abstract Presentations: Hand Session 3 Friday, October 16 Fri, Oct 16 2:00-3:30 p.m. CDT

Background: Scaphoid fractures are the most common carpal injuries in young, active individuals and carry a significant risk of non-union and long-term morbidity if not properly diagnosed and treated. Although operative fixation is widely performed with predictable union rates, postoperative immobilization protocols remain poorly defined, ranging from immediate mobilization to prolonged casting [1,2]. We hypothesize that variability in length of immobilization will be due to surgeon specialty, seniority, and location of fracture.

Methods: We performed a retrospective chart review of adults (≥18 years) undergoing operative fixation of acute (≤4 weeks from injury) scaphoid fracture from 2010 to 2025 at a single institution. Patients with concomitant carpal fractures, associated perilunate dislocation, or established nonunion were excluded. Fracture characteristics, surgeon specialty, seniority, and immobilization duration were recorded. Outcomes included radiographic and clinical signs of union and complications. As immobilization duration was non-normally distributed (Shapiro-Wilk), nonparametric testing (Mann-Whitney U, Kruskal-Wallis) and Spearman correlation were used to compared surgeon specialty, fracture location, and surgeon seniority respectively. Statistical significance was defined as p<0.05.

Results: Thirty-seven patients met inclusion criteria with a median postoperative immobilization period of 6.4 weeks (mean 6.7 ± 3.1, 0.4-16.7), with immobilization duration non-normally distributed (p=0.011). Immobilization duration demonstrated a trend toward longer immobilization among plastic surgeons compared to orthopedic surgeons (mean 6.99 vs. 5.67 weeks, p=0.090), though these differences did not reach statistical significance. There was additionally no statistical relationship between fracture location (p=0.405) or surgeon seniority at the time of surgery (p=0.794). Finally, 97% (36/37) of fractures achieved union.

Conclusion: Postoperative length of immobilization following operative management of acute scaphoid fractures demonstrated substantial variability without significant association with fracture characteristics, surgeon experience, or complication risk. These findings suggest that postoperative immobilization practices vary widely and may be surgeon-dependent, further supporting development of standardized, evidence-based postoperative protocols.

References: 1. Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): A pragmatic, multicentre, open-label, Randomised Superiority Trial. The Lancet. 2020;396(10248):390-401. doi:10.1016/s0140-6736(20)30931-4

2. Simon M, Gencarelli P, Yang J, et al. Postoperative immobilization of scaphoid fractures: A comprehensive review of the literature. HAND. 2022;18(6):905-911. doi:10.1177/15589447221093675

Introduction: Lymphedema is a chronic, progressive condition resulting from lymphatic system dysfunction and represents a significant source of long-term morbidity following cancer-related sentinel lymph node biopsy (SLNB) and lymph node dissection (LND). Although lymphatic reconstruction (LR), including immediate lymphatic reconstruction and lymphovenous bypass, has demonstrated efficacy in reducing lymphedema risk, its utilization remains inconsistent. Racial and ethnic disparities are well documented across surgical and oncologic care, yet large-scale data examining inequities in LR utilization are limited. This study evaluates racial and ethnic differences in the use of LR among patients undergoing SLNB and LND in the United States and identifies patient- and procedure-level factors associated with not receiving LR.

Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2023. Patients undergoing SLNB or LND were identified using CPT codes, with LR identified through reconstructive procedure codes. Sociodemographic variables, comorbidities, operative characteristics, and anatomic site of lymphadenectomy were analyzed. Patients were stratified by race and Hispanic ethnicity. Univariate and multivariate logistic regression models were used to identify factors associated with not undergoing LR, reporting odds ratios (ORs) with 95% confidence intervals (CIs).

Results: A total of 500,603 patients underwent SLNB and 500,603 underwent LND during the study period. Overall, LR rates were lower among Black or African American patients (1.7%) compared with White patients (2.1%, p<0.001), with similarly reduced rates in Asian (1.6%), Native Hawaiian (1.4%), and American Indian/Alaska Native (1.2%) patients. In the SLNB cohort, LR rates were 1.0% in Black patients versus 1.3% in White patients (p<0.001). In the LND cohort, LR rates were 2.8% in Black patients and 3.5% in White patients (p<0.001), with Hispanic patients also demonstrating lower utilization than non-Hispanic patients (2.4% vs 3.5%, p<0.001). Disparities were most pronounced in lower-extremity LND, where LR rates were 5.7% in White patients compared with 2.0% in Black and 1.4% in Asian patients (p=0.025). On multivariate analysis, factors independently associated with not undergoing LR included age >65 years (OR 1.34, 95% CI 1.28–1.42), male sex (OR 0.60, 95% CI 0.58–0.63), Black race (OR 1.39, 95% CI 1.28–1.51), Asian race (OR 1.20, 95% CI 1.07–1.35), Hispanic ethnicity (OR 1.36, 95% CI 1.21–1.53), obesity (OR 1.62, 95% CI 1.54–1.71), smoking, dependent functional status, and LND versus SLNB (OR 0.33, 95% CI 0.32–0.36).

Conclusion: Significant racial and ethnic disparities exist in the utilization of lymphatic reconstruction following SLNB and LND, with minority populations consistently less likely to receive LR. These inequities are influenced by demographic factors, comorbidity burden, and procedural characteristics. Targeted efforts to address access, referral patterns, and systemic barriers are essential to promote equitable lymphedema prevention and surgical care.

PURPOSE: Upper extremity spasticity affects approximately 40% of stroke survivors, 65% of spinal cord injury patients, and 75% of those with cerebral palsy, causing pain, contracture, and loss of limb function (1). Because nonsurgical treatments such as botulinum toxin or baclofen provide only temporary relief and carry risk for significant complications, durable surgical interventions are needed. Contralateral C7 nerve transfer (CC7) has shown promising results; however, prior CC7 studies lacked a control group receiving C7 transection alone (2). Since all C7-innervated muscles receive overlapping motor contributions from adjacent cervical roots, we hypothesized that ipsilateral C7 neurectomy (C7N) alone would reduce spasticity through subtotal denervation of multiple muscle groups, analogous to hyperselective neurectomy (3). If effective, C7N could treat widespread spasticity through a single minimally invasive supraclavicular incision. This study evaluated the safety and early efficacy of C7N for refractory upper extremity spasticity.

METHODS: We performed an IRB-approved, single-center retrospective review of all patients undergoing C7N by a single surgeon between 2024 and 2025. Inclusion criteria were age 18 to 60, spasticity secondary to cerebrovascular accident (CVA) or spinal cord injury (SCI), and persistent upper extremity pain and functional impairment despite at least one year of rehabilitation. Patients with predominant dystonia, significant cognitive impairment, or medical comorbidities precluding surgery were excluded. Surgery was performed via a supraclavicular approach under general anesthesia. The brachial plexus was exposed between the anterior and middle scalene muscles, nerve roots were identified with intraoperative stimulation, and the C7 root was sharply transected proximal to any converging branches. All patients participated in postoperative rehabilitation. Spasticity was assessed preoperatively and at three and six months postoperatively using the Modified Ashworth Scale (MAS, range 0–4). Active and passive range of motion were also recorded.

RESULTS: Six patients (3 CVA, 2 SCI, 1 cerebral palsy) underwent C7N with minimum three-month follow-up. Prior to surgical intervention, all patients had demonstrated a prolonged plateau in functional recovery despite extensive preoperative rehabilitation. All demonstrated postoperative MAS reductions following C7N. The most pronounced improvements occurred in shoulder adductor and triceps spasticity, with MAS scores typically decreasing from 3 to 0-1. More modest improvements were observed in wrist and finger flexor spasticity. Functional gains included improved active shoulder elevation, elbow flexion and extension, and wrist extension. One SCI patient gained sufficient function to nearly bring a utensil to his mouth, with gains occurring exclusively in the operative limb despite bilateral rehabilitation, with the nonoperative limb serving as an internal control. One patient experienced transient C7 dermatomal sensory disturbance that resolved with gabapentin. No significant motor deficits were observed. Several patients received additional hyperselective neurectomies and tendon surgeries to further optimize hand and wrist function.

CONCLUSIONS: This case series suggests that ipsilateral C7N without CC7 is a viable surgical option for patients with refractory upper extremity spasticity. The broad, overlapping contributions of C7 to muscles commonly involved in spasticity make this intervention well suited to provide meaningful, durable tone reduction and functional improvement through a single surgical intervention without off-target strength or sensory deficits.

REFERENCES: 1. Martin A, Abogunrin S, Kurth H, Dinet J. Epidemiological, humanistic, and economic burden of illness of lower limb spasticity in adults: a systematic review. Neuropsychiatr Dis Treat. 2014;10:111-122. Published 2014 Jan 23. doi:10.2147/NDT.S53913 2. Hua XY, Qiu YQ, Li T, et al. Contralateral peripheral neurotization for hemiplegic upper extremity after central neurologic injury. Neurosurgery. 2015;76(2):187-195. doi:10.1227/NEU.0000000000000590 3. Leclercq C, Perruisseau-Carrier A, Gras M, Panciera P, Fulchignoni C, Fulchignoni M. Hyperselective neurectomy for the treatment of upper limb spasticity in adults and children: a prospective study. J Hand Surg Eur Vol. 2021;46(7):708-716. doi:10.1177/17531934211027499

Background: Self-harm-induced complex wrist and hand injuries require specialized repair to restore function and prevent permanent damage (1); however, national treatment patterns are poorly understood. Prior single-institution and registry studies suggest self-inflicted injuries are heterogeneously evaluated in emergency settings, and psychiatric and social factors may delay definitive hand surgery consultation or operative management (2). Whether injury severity reliably translates into operative intervention at a national level remains unknown. We hypothesized that greater injury complexity increases the likelihood of repair.

Methods: Using the National Inpatient Sample (NIS) from 2017-2023, we identified self harm admissions (ICD-10-CM X71-X83) with concurrent wrist and hand-level nerve and/or tendon injuries (ICD-10-CM S64, S66). Patients were classified as isolated nerve, isolated tendon, or combined nerve-tendon injuries. Our primary outcome was specialized repair. We performed multivariate survey-weighted logistic regression to find factors associated with surgical repair, with robustness confirmed via inverse probability of treatment weighting (IPTW) and E-value analysis. To address whether coded injuries warranted operative intervention, we performed a sensitivity analysis excluding tendon codes unlikely to require repair (S66.8: palmaris longus, FCR, FCU; S66.9: unspecified), and assessed coding validity through procedures counts, length of stay, and discharge disposition among non-repaired patients.

Results: Among 576,257 self-harm admissions, 4,920(0.9%) had complex wrist and hand injuries. Repair rates varied by injury patterns: isolated nerve 63.6%, isolated tendon 53.8%, and combined injuries 87.0%, p<.001). After adjusting for demographics and hospital characteristics, combined injuries had a 4.3-fold increased odds of repair (95% CI: 2.7-7.0) compared to isolated nerve injuries, confirmed by IPTW (OR 4.2, 95% CI: 2.6-7.0; E-value 8.1). Psychiatric comorbidity (OR 0.57, p=0.019) and substance use (OR 0.67, p=0.018) were independently associated with lower odds of repair. Isolated tendon injuries had non-significantly lower odds of repair than isolated nerve injuries (OR 0.73, 95% CI: 0.50-1.07). When restricting to clinically warranted tendon injuries, the repair disparity strengthened (combined vs nerve OR 5.4, 95% CI: 2.9-10.3). Several findings suggest true undertreatment rather than coding artifact: non-repaired patients had similar length of stay (6.8 vs 7.2 days), only 3.3% left against medical advice, and patients with more specific injury codes were significantly more likely to receive repair. Excluding transfers, we identified approximately 95 missed repair opportunities per year.

Conclusions: Combined nerve–tendon injuries underwent repair in 87% of cases versus 54–64% of isolated injuries (p<0.001). This disparity was not explained by coding, age, or injury severity and was amplified by psychiatric comorbidity and substance use, suggesting gaps in surgical consultation for isolated injuries in the self-harm population. Standardized triage and mandatory hand surgery consultation for any nerve or tendon injury could reduce disparities and prevent ~95 cases of permanent hand dysfunction annually in the United States.

References:

1. Kim JH, Yoo H, Eun S. A pilot study of 17 wrist-cutting suicide injuries in single institution: perspectives from a hand surgeon. BMC Emerg Med. 2021;21(1):40. Published 2021 Mar 31. doi:10.1186/s12873-021-00432-4
2. Gu JH, Jeong SH. Self-wrist cutting injury: a traumatologic and psychological analysis. Plast Reconstr Surg. 2012;129(4):763e-764e. doi:10.1097/PRS.0b013e318245e8c5

Purpose: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly prescribed for weight loss. Prior studies in diabetic populations suggest that GLP-1RA therapy is associated with lower rates of carpal tunnel syndrome (CTS) and improved outcomes following carpal and cubital tunnel release. In contrast, emerging case reports describe acute compressive neuropathies following rapid GLP-1RA-associated weight loss, a phenomenon termed "slimmer's palsy." The purpose of this study was to better define the association between GLP-1RA therapy and peripheral nerve compression rates in the upper extremity, specifically looking at massive weight loss patients who underwent bariatric surgery alone versus bariatric surgery with the addition of a GLP-1RAs. Methods: A retrospective cohort study was conducted using the TriNetX US Collaborative Network. Adult patients who underwent bariatric surgery between January 2015 and February 2026 were identified and stratified by concurrent GLP-1RA use versus bariatric surgery alone. Patients with prior carpal or cubital tunnel syndrome (CuTS) were excluded. Propensity score matching (1:1) balanced baseline demographics, Body Mass Index (BMI), diabetes, chronic opioid use, psychiatric disorders, Complex Reginal Pain Syndrome (CRPS), metabolic disorders, cardiovascular and renal disease, chronic pain, and musculoskeletal comorbidities. Primary outcomes included new diagnoses of CTS (ICD-10: G56.0) and CuTS (G56.2). Secondary outcomes included surgical release and electrodiagnostic testing rates. Risk ratios with 95% confidence intervals were calculated. Kaplan–Meier curves were constructed to illustrate the cumulative incidence of primary outcomes. Results: After propensity score matching, 11,158 patients were included in each cohort (bariatric surgery plus GLP-1RA vs bariatric surgery alone). Mean age was slightly lower in patients who underwent bariatric surgery and were on GLP-1RAs. (50.6 ± 12.2 vs 53.5 ± 14.3 years, SD=0.22, p<0.001), as was body mass index (39.9 ± 8.0 vs 42.6 ± 7.9 kg/m², SD=0.34, p<0.001). The median follow-up duration was 365 days, with an interquartile range (IQR) of 40 days in the combined group and 0 days in the bariatric surgery group. The combined group had a 63% higher risk of developing CTS (RR, 1.63; 95% CI, 1.26–2.10; p<0.001) and a 110% higher risk of being diagnosed with CuTS (RR, 2.10; 95% CI, 1.35–3.27; p<0.001). Kaplan-Meier survival curves further demonstrated higher cumulative incidence over time and earlier onset of CTS in the combined group. Despite increased diagnostic rates, rates of carpal tunnel release were similar between groups (RR, 1.54; 95% CI, 0.77–3.09; p=0.223). Notably, GLP-1RA users were more likely to undergo electrodiagnostic testing (RR, 1.43; 95% CI, 1.06–1.91; p=0.017). Conclusions: Among massive weight loss patients due to bariatric surgery, adjunctive GLP-1RA therapy was associated with higher rates of carpal and cubital tunnel syndrome diagnoses but did not correspond to increased rates of surgical decompression. These findings suggest that GLP-1RA–associated weight loss may increase susceptibility to peripheral nerve compression without increasing operative intervention and highlight the need for heightened clinical awareness and further investigation into underlying mechanisms.

1. Dhupati P, Kisiel SC, Unadkat K, Noland SS. GLP-1 Receptor Agonist-Associated Slimmer's Palsy: Implications for the Peripheral Nerve Surgeon. Ann Plast Surg. 2026;96(1):69-74. doi:10.1097/SAP.0000000000004570
2. Liu WJ, Jin HY, Lee KA, Xie SH, Baek HS, Park TS. Neuroprotective effect of the glucagon-like peptide-1 receptor agonist, synthetic exendin-4, in streptozotocin-induced diabetic rats. Br J Pharmacol. 2011;164(5):1410-1420. doi:10.1111/j.1476-5381.2011.01272.x
3. Muscogiuri G, DeFronzo RA, Gastaldelli A, Holst JJ. Glucagon-like Peptide-1 and the Central/Peripheral Nervous System: Crosstalk in Diabetes. Trends Endocrinol Metab. 2017;28(2):88-103. doi:10.1016/j.tem.2016.10.001
4. Seddio AE, Day W, Rancu AL, Modrak M, Joo PY, Grauer JN. Endoscopic and Open Carpal Tunnel Release in Patients With Type II Diabetes Mellitus: Influence of Preoperative Semaglutide Use on Postoperative Outcomes. J Hand Surg Am. 2025;50(12):1467-1475. doi:10.1016/j.jhsa.2025.09.003
5. Weyns FJM, Beckers F, Vanormelingen L, Vandersteen M, Niville E. Foot drop as a complication of weight loss after bariatric surgery: is it preventable? Obes Surg. 2007;17(9):1209-1212. doi:10.1007/s11695-007-9203-2

Background: Early identification of septic wrist arthritis remains clinically challenging owing to overlapping presentations with crystalline arthropathy and other inflammatory conditions. Delayed diagnosis can result in joint destruction, prolonged hospitalization, and increased morbidity. This study aimed to develop and compare machine-learning (ML) models to predict septic arthritis of the wrist. Methods: A retrospective cohort of adult patients presenting with suspected septic wrist arthritis was analyzed. Nine clinically relevant features were selected for model development: blood culture results, presence of crystals on joint aspiration, involvement of multiple joints, age, intravenous drug abuse (IVDA), history of gonorrhea or chlamydia infection, prior septic arthritis, symptom duration, and history of crystalline arthropathy. Five ML classifiers were trained and evaluated using five-fold cross-validation: L1-regularized logistic regression, random forest, extra trees, XGBoost, and LightGBM. Models were assessed using mean area under the receiver operating characteristic curve (ROC-AUC), the precision–recall area under the curve (PR-AUC), and the Brier score to evaluate discrimination and calibration. Results: A total of 206 patients presenting with suspected septic wrist were identified. After excluding cases with missing data, 184 patients were included in the final analysis, including 87 septic (47.3%) and 97 non-septic (52.7%) cases. Across all models, predictive performance ranged from acceptable to good. Random forest achieved the highest overall discrimination with a mean ROC-AUC of 0.773 ± 0.051 and PR-AUC of 0.744 ± 0.042, while maintaining good calibration (mean Brier score = 0.204 ± 0.012). L1-regularized logistic regression showed comparable performance (mean ROC-AUC = 0.772 ± 0.051; PR-AUC = 0.761 ± 0.069; Brier = 0.196 ± 0.025). Extra trees demonstrated moderate performance (ROC-AUC = 0.759 ± 0.052), while gradient-boosting approaches exhibited greater variability across folds, with XGBoost (ROC-AUC = 0.726 ± 0.075) and LightGBM (ROC-AUC = 0.745 ± 0.074) showing less stable calibration. Explainability analysis using SHAP demonstrated that the presence of synovial fluid crystals accounted for the largest relative model influence (33.2%, protective), followed by blood culture positivity (24.8%), age (15.9%), and symptom duration (10.6%). Logistic regression confirmed blood culture positivity (OR 1.89), history of sexually transmitted infections (OR 1.61), and prior septic arthritis (OR 1.32) as the strongest positive predictors, whereas crystal detection (OR 0.61), longer symptom duration (OR 0.52 per standard deviation increase), and older age (OR 0.77) were associated with decreased odds of septic wrist arthritis. Conclusions: Machine-learning models can predict septic wrist arthritis with good discrimination and calibration. Random forest provided the best overall performance, although logistic regression delivered similar accuracy with greater interpretability. While blood culture positivity was the strongest predictor, early risk estimation before culture results was primarily informed by crystal detection, age, and symptom duration. These findings support the feasibility of an ML-based clinical decision support tool to assist early risk stratification of suspected septic wrist arthritis.

Background: Thumb amputation resulting from high-voltage electrical injury presents a distinct reconstructive challenge due to the unpredictable zone of vascular injury and difficulty assessing recipient vessel reliability. Electrical burns frequently cause deep soft-tissue and microvascular damage that may not be clinically apparent, complicating decisions regarding timing and feasibility of microsurgical reconstruction. While microvascular toe-to-thumb transfer is well established for traumatic and congenital thumb loss, its application following electrical injury remains sparsely described, with limited guidance regarding vessel selection, timing, and expected functional outcomes. This study presents a focused case series highlighting successful thumb reconstruction via free toe transfer following high-voltage electrical injury.

Methods: A retrospective review of a single surgeon's experience identified two patients who sustained high-voltage electrical injuries resulting in thumb amputation, one unilateral and one bilateral, who subsequently underwent microsurgical toe-to-thumb reconstruction. All reconstructions were performed after completion of serial debridements and once wounds demonstrated stable, supple soft-tissue envelopes without ongoing demarcation or infection. Preoperative planning included computed tomography angiography and Doppler mapping of donor and recipient vessels. Intraoperatively, recipient vessels were assessed for suitability based on pulsatility, intimal appearance, vessel wall pliability, and distal perfusion after tourniquet release. Free great toe transfer was performed using standard microsurgical techniques, with bony fixation, tendon reconstruction, vascular anastomosis, and neurorrhaphy. Outcomes assessed included flap survival, sensory recovery, motion, pinch strength, donor-site morbidity, and functional use in activities of daily living.

Results: Three successful toe-to-thumb transfers were performed in two patients. All transferred flaps survived without vascular compromise, resulting in a 100% flap survival rate. Both patients achieved durable reconstruction with restoration of opposition, key pinch, and functional use of the reconstructed thumb in daily activities. Sensory recovery was favorable, with two-point discrimination ranging from 10 to 12 mm at final follow-up. One patient required staged reconstruction with a pedicled groin flap prior to toe transfer to establish a stable soft-tissue envelope. Donor-site morbidity was minimal, with one instance of partial graft loss requiring secondary grafting. At long-term follow-up (18 months to 4 years), both patients maintained stable functional and sensory outcomes without late complications.

Conclusions: Microsurgical toe-to-thumb transfer following high-voltage electrical injury is safe and feasible when reconstruction is delayed until resolution of the acute inflammatory phase and recipient vessels are carefully selected outside the zone of injury. Despite concerns regarding microvascular reliability in electrically burned tissues, excellent functional outcomes can be achieved with meticulous preoperative planning and intraoperative vessel assessment. Electrical injury should not be considered a contraindication to microsurgical thumb reconstruction, and toe-to-thumb transfer remains a valuable option for restoring hand function in this challenging patient population.

Purpose: In the debate between ulnar shortening osteotomy (USO) and wafer procedures performed for ulnar impaction syndrome, many have empirically noted that USOs seem to be less painful for patients and have an easier recovery than wafer procedures in the short- to mid-term postoperative period. We retrospectively explored whether there were any substantial differences between USO and wafer procedures for short-term postoperative (<3 months) pain and other patient-reported outcomes measures (PROMs) for patients. We hypothesized that there would be no substantial differences in early postoperative outcomes between procedures.

Methods: A retrospective review was performed of patients surgically treated for ulnar impaction syndrome at a single institution over a 15-year period. Elective diaphyseal USO and distal wafer procedures were included. Patients were excluded if preoperative radiographs indicated they would not have been candidates for the alternate procedure. PROMs included numeric rating scale pain scores; PROMIS Pain Interference, Upper Extremity, and Global Health domains; EQ-5D utility; Single Assessment Numeric Evaluation (SANE) Simple Hand Score; and a global impression-of-change scale. Outcomes were categorized as early (<6 weeks) and later (≥6 weeks) postoperatively. Primary analyses compared USO with a combined wafer cohort, with secondary analyses comparing arthroscopic and open wafer techniques.

Results: Thirty-five patients met inclusion criteria, including 14 patients treated with USO and 21 treated with wafer procedures (12 arthroscopic, 9 open). Preoperative characteristics, including ulnar variance, were similar between groups. Both treatment groups demonstrated expected early postoperative increases in pain followed by improvement by the ≥6-week follow-up timepoints. Across all PROM domains, including pain, upper extremity function, and health-related quality of life, recovery trajectories were similar, with no consistent differences between USO and wafer procedures at either postoperative interval. Global impression-of-change scores improved over time in both groups. Outcomes were also comparable between arthroscopic and open wafer subgroups.

Conclusions: Short-term pain scores and most secondary outcomes were similar for patients undergoing distal ulnar wafer resection and USO for comparable clinical scenarios. Surgeons can weigh their comfort and experience with each procedure against its relative indications/ contraindications, benefits, and risks when advising patients.

Introduction: Supracondylar humeral fractures are the most common elbow fractures in children and are classified as extension-type (~95%) or flexion-type (~5%). Extension-type fractures usually displace posteriorly and are often stabilized by a posterior periosteal hinge, which aids reduction. Flexion-type fractures displace anteriorly and have historically been thought to lack a reliable periosteal hinge, making reduction more difficult and surgery more complex. The goal of this project is to 1. Determine whether all flexion-type supracondylar fractures lack a periosteal hinge 2. Identify radiographic features that may predict hinge integrity and 3. Assess how hinge presence influences operative time and surgical approach.

Methods: A 1-year prospective study was conducted including six patients under 16 years of age with flexion-type supracondylar humeral fractures. Patients were stratified based on the presence (H) or absence (NH) of an anterior periosteal hinge, as determined on maximum-extension radiographs. Operative characteristics, including operative time and surgery type, were recorded. Radiographic outcomes assessed included flexion angulation, percent osseous apposition, coronal angulation categorized by Baumann's angle (neutral, varus, or valgus), coronal translation (mm), and sagittal translation. Outcomes were compared between groups.

Results All patients (n=10) sustained a fall onto an outstretched hand (FOOSH) or a direct elbow impact, with a mean age of 8.9 years. Most fractures (n=9) were treated with closed reduction and percutaneous pinning (CRPP), while one patient underwent open reduction and internal fixation (ORIF). Eight fractures demonstrated an intact anterior periosteal hinge and two did not. Fractures without an intact hinge demonstrated significantly reduced osseous apposition and greater translation compared to those with an intact hinge. Specifically, median lateral osseous apposition was 85% in the intact group versus 20% in the non-intact group (p = 0.049), and AP osseous apposition was 90% versus 57.5%, respectively (p = 0.046). Sagittal translation was also significantly greater in the non-intact group (10.03 cm vs 4.13 cm, p = 0.044), while coronal translation trended higher (12.08 cm vs 2.40 cm) but did not reach statistical significance (p = 0.089). Median operative time was slightly longer in fractures without an intact hinge (82 minutes vs 73.5 minutes). These findings demonstrate significant radiographic differences associated with anterior periosteal hinge integrity.

Conclusion In this series, most flexion-type supracondylar humerus fractures demonstrated an intact anterior periosteal hinge, highlighting that these injuries are biomechanically heterogeneous. The presence or absence of hinge integrity was associated with significant radiographic differences, suggesting that hinge status may influence fracture stability and surgical reduction strategy, with potential implications for operative planning and patient safety.

Background: Prophylactic fasciotomy is frequently performed during revascularization for acute limb ischemia (ALI) to prevent reperfusion-related compartment syndrome. While this approach is commonly applied to the lower extremity, its necessity in upper extremity ALI remains controversial and poorly defined.

Methods: We conducted a retrospective cohort study of adult patients presenting with non-traumatic upper extremity ALI who underwent limb-salvage revascularization at a tertiary referral center between January 2000 and December 2024. Fasciotomies were categorized as therapeutic or prophylactic based on clinical indication. Patient demographics, ischemia characteristics and duration, physical examination findings, and outcomes were analyzed. The primary outcome was development of compartment syndrome during the index hospitalization. Secondary outcomes included success of limb salvage, neurologic recovery, postoperative complications, and hospital length of stay.

Results: Fifty-six patients were included. Mean age was 66 years and 55% were female. With respect to severity of acute limb ischemia at presentation, 80.4% of limbs were Rutherford class IIa or IIb. Median ischemia duration was 18 hours (IQR, 8–48). Nine patients (16.1%) underwent fasciotomy, including two therapeutic fasciotomies for clinically evident compartment syndrome and seven prophylactic decompressions. No patient required delayed fasciotomy following revascularization. Patients undergoing fasciotomy had shorter ischemia durations (median 8 vs 24 hours, p = 0.003) and longer hospital stays (median 14.0 vs 8.3 days, p = 0.007). Overall, limb salvage was achieved in 96.4% of limbs. Two amputations occurred in the non-fasciotomy group and were attributable to irreversible ischemic injury related to prolonged vasopressor use and necrotic tissue present at presentation, rather than missed compartment syndrome. Postoperative complications were more frequent in the fasciotomy group (44.4% vs 25.5%), consisting exclusively of wound-related morbidity, whereas complications in the non-fasciotomy group were primarily vascular in nature.

Conclusions: Upper extremity acute limb ischemia is associated with a substantial rate of postoperative complications, even with timely revascularization. While fasciotomy can be limb-saving when compartment syndrome is present, our findings suggest that prolonged ischemia duration alone is not a sufficient indication for prophylactic decompression. A selective, examination-guided approach to recognition of this clinical diagnosis may minimize unnecessary morbidity without compromising neurologic recovery or limb salvage.

Introduction Studies suggest that most autoimmune disease patients receive conventional disease-modifying antirheumatic drugs (cDMARDs) [1]. While some have found that DMARDs are not associated with increased incidence of certain postoperative outcomes following orthopedic surgeries [3-4], it remains unclear whether cDMARDs confer higher risk of short- and long-term outcomes following hand surgery. This large database study sought to determine whether cDMARDs confer higher risk of acute and long-term complications following proximal and middle phalangeal fracture repairs.

Methods We identified adult patients in the TriNetX Research Network with autoimmune conditions (rheumatoid arthritis, inflammatory bowel disease, lupus, etc.) who underwent proximal or middle phalangeal fracture surgical repairs, with or without cDMARD use within 6 months prior to surgery. Patients were propensity-score matched based on demographics and comorbidities (specific type of autoimmune condition, musculoskeletal diseases, BMI, smoking, neoplasms, etc.). Acute outcomes (within 6 months) included infection, hardware complications, and DVT/PE. Long-term outcomes (within 5 years) included return to the operating room (OR) for revisions or re-explorations, fracture malunions, non-unions, and hand contractures.

Results We identified 778 phalangeal repair patients with pre-existing autoimmune disorders and preoperative cDMARD use and 5794 phalangeal repair patients with the same autoimmune conditions but no cDMARD use. After matching, there were 623 pairs for comparison. cDMARD users demonstrated significantly higher rates of phalangeal fracture malunion or nonunion within 90 days following surgery (OR=2.423; 95% CI, 1.187-4.948; p=0.0123). Within 5 years of surgery, cDMARD users continued to demonstrate significantly higher rates of malunion or nonunion (OR=2.804; 95% CI, 1.694-4.642; p<0.0001). There were no significant differences in any other postoperative outcomes at either time point.

Conclusions This represents one of the first large database studies investigating whether preoperative cDMARD use puts phalangeal fracture patients at greater risk for complications following fracture repairs. Our data suggests that use of cDMARDs may result in higher risk of fracture malunion or nonunion in the short- and long-term. Considering that some conclude that biologic DMARDs (bDMARDs) affect surgical site infections [1], further research is warranted on whether biologic DMARDs result in different risk profiles.

References [1] Imam MS, et al. A meta-analysis examining the effect of perioperative biologic disease-modifying anti-rheumatic medications on postoperative wound complications in various orthopedic surgeries. J Clin Med 2024;13(18):5531. [2] McCormick N. Which patients with rheumatoid arthritis will start biologics, how soon, and why – much to learn from a universal coverage setting. JAMA Netw Open 2019;2(12):e1917065. [3] Klifto KM, et al. The management of perioperative immunosuppressant medications for rheumatoid arthritis during elective hand surgery. J Hand Surg Am 2020;45(8):779. [4] Kiso Y, et al. The use of biologic disease-modifying antirheumatic drugs does not increase surgical site infection or delayed wound healing after orthopaedic surgeries for rheumatoid arthritis. Modern Rheumatology 2025;35(2):265-272.

Background: Acute hand compartment syndrome (HCS) is a limb-threatening emergency in which rising intra-compartmental pressure compromises capillary perfusion, leading to ischemia, myonecrosis, and potentially irreversible dysfunction. While fasciotomy within 6–8 hours of compartment syndrome onset is universally recommended, the exact time of onset is often clinically indeterminate, and existing literature is limited to case series of fewer than 20 patients. No population-level data define injury patterns, operative management pathways, or a practical timing threshold for limb loss in HCS. The largest national analysis of acute HCS was performed to systematically characterize injury profiles, operative decision-making, and the association between delay to decompression and subsequent amputation.

Methods: Adults (≥18 years) with HCS were identified in the National Trauma Data Bank (2017–2021). Injury characteristics including mechanism, fracture distribution across hand/forearm/humerus compartments, and arterial transection were systematically captured to characterize the full spectrum of HCS presentations. Operative interventions (fasciotomy, carpal tunnel release [CTR], upper-extremity amputation) were identified via ICD-10-PCS codes, and procedure timing was defined as hours from emergency department arrival to incision. Because most amputations occurred after attempted salvage rather than primary amputation, timing analyses focused on salvage cases. Prespecified delay cut points were evaluated to identify the earliest threshold at which amputation rates diverged, and delay was modeled as a continuous exposure using multivariable logistic regression adjusting for Injury Severity Score, mechanism, and arterial transection.

Results: Among 577 adults with HCS (median age 38 years; 78% male; ISS median 5), mechanisms included crush (30.7%), motor vehicle collision (19.6%), assault (17.3%), falls (15.9%), burns (3.3%), and gunshot wounds (4.3%). Fractures were present in 28.9% (hand 78.4%, forearm 39.5%, humerus 7.2% among fracture cases); arterial transection occurred in 4.3%. Overall, 65.9% underwent fasciotomy, 49.6% CTR, and 4.7% amputation. Median time to fasciotomy was 4.5 hours; to CTR was 2.5 hours. Critically, amputation occurred predominantly after attempted salvage (77.8%) rather than as primary amputation (22.2%). Among salvage attempts, 9 hours from ED arrival to first decompression was the earliest threshold at which amputation rates significantly diverged (p<0.05). In adjusted analysis, odds of amputation increased progressively: OR 1.9 at 9 hours, 2.3 at 14 hours, and 2.8 at 24 hours. Three triage-recognizable features independently predicted amputation: arterial transection (OR 31.8), burns (OR 10.8), and forearm + humerus fractures (OR 17.1), identifying patients who warrant early counseling about limb loss risk.

Conclusions: In the largest national cohort of acute HCS to date, this study provides the first comprehensive characterization of injury patterns, operative pathways, and timing thresholds in this limb-threatening emergency. Limb loss was uncommon but occurred predominantly after attempted salvage. Importantly, time to surgical intervention is associated with progressively increasing risk of salvage failure. Nine hours from ED arrival represents the first population-level, objectively measurable timing threshold specific to hand compartment syndrome, transforming abstract timing principles into a clinically actionable signal. Combined with identification of a triage-recognizable high-risk phenotype, these findings establish an evidence-based framework for risk stratification, operative urgency, and early amputation counseling in acute HCS.

Purpose: The optimal timing of nerve reconstruction in brachial plexus birth injury (BPBI) remains controversial. It is hypothesized that early nerve reconstruction results in superior long-term function compared with late nerve surgery after accounting for injury severity. This study aims to compare long-term functional outcomes among infants managed with early versus late nerve reconstruction and non–nerve-based treatment.

Methods: A retrospective cohort of infants with BPBI evaluated at a tertiary children's hospital was analyzed using available medical records. Patients were categorized by surgical management as nerve reconstruction, muscle/tendon/osteotomy (M/T/O), or botulinum toxin (Botox) only. Early nerve reconstruction was defined using three alternate timing cutoffs (≤6 months, ≤9 months, and ≤12 months), each compared against their corresponding late nerve reconstruction cutoffs (>6 months, >9 months, and >12 months). Outcomes included Mallet score, Active Movement Scale (AMS), and passive range of motion (PROM). Linear and logistic regression analyses were performed, adjusting for Narakas severity and age at initial surgery.

Results: 104 patients with a follow-up of 71.5 months were included, with 43 (41.3%) early nerve surgery at 12 months, 11 (10.6%) late nerve surgery, 33 (31.7%) MTO, and 17 (16.3%) botulinum toxin only. The early nerve group had more severe baseline injuries, with 37.2% presenting with Narakas grade IV injury versus 3.4% in the no–nerve surgery group (p=0.004). In univariate analysis, the early nerve group had lower median Mallet scores (14) compared with the late nerve (17) and no nerve groups (18) (p=0.017) and lower median AMS elbow flexion ( p=0.014). However, after adjustment for injury severity, early nerve surgery was no longer associated with worse Mallet scores or total PROM. The only scale that early nerve surgery demonstrated a protective effect in multivariate analysis adjusted for injury severity was passive shoulder motion. It reduces the odds of poor rotation by 92% compared to conservative management with Botox only (OR 0.08, p=0.028). Instead, increasing Narakas severity was the dominant predictor of progressively worse outcomes in Mallet scores, AMS, and selected PROM. Compared with Narakas grade I, higher injury grades were associated with progressively worse total AMS scores (grade II: −11.9 points, III: −37.1 points, IV: −33 points; p=0.038).

In the Narakas III and IV–restricted cohort, early nerve reconstruction at ≤6 months had improved total AMS (p=0.011) and Mallet Hand-to-Mouth at ≤9 months (3.0 vs 2.0, p=0.046) compared with late or no nerve surgery, but these associations lost significance after multivariable adjustment. M/T/O procedures remained independently associated with improved postoperative Mallet scores in multivariable analysis (+3.88 points; p=0.005) within the Narakas III and IV cohort.

Conclusions: Our findings suggest that early nerve surgery in BPBI may help level the playing field by mitigating the impact of baseline injury severity. In patients presented with less severe baseline injury, early nerve surgery did not demonstrate a significant independent improvement in functional movement recovery. M/T/O procedures demonstrated a significantly meaningful functional benefit, particularly among patients with more severe baseline injuries.