INTRODUCTION:Carpal tunnel syndrome is increasingly recognized as an early musculoskeletal manifestation of transthyretin amyloidosis. Tenosynovial biopsy during carpal tunnel release may detect transthyretin amyloid deposits, but the yield of a targeted strategy remains uncertain. METHODS:We conducted a single-centre comparative before-after study of 347 patients undergoing carpal tunnel release with tenosynovial biopsy. The non-targeted cohort was recruited between October 2021 and July 2023 and the targeted cohort between October 2023 and May 2026. Targeting was based on predefined clinical red flags. Histopathological assessment used Congo red staining with confirmation of transthyretin by immunohistochemistry. The primary outcome was histopathological positivity for transthyretin amyloid deposits. Two multivariable models assessed the targeting strategy and individual clinical factors. RESULTS:Overall, 82 of 347 biopsies were positive. Targeted biopsy was associated with a higher positivity rate than non-targeted biopsy, at 37% compared with 18%. Male sex and treated trigger finger were associated with increased positivity. Diabetes was associated with lower synovial transthyretin positivity, at 12% compared with 26%, and remained inversely associated after adjustment. CONCLUSION:Targeted tenosynovial biopsy during carpal tunnel release was associated with higher detection of transthyretin amyloid deposits than non-targeted biopsy. However, because the study compared two successive periods using a historical control group, the observed difference cannot be attributed to the targeting strategy alone. Diabetes was associated with lower synovial transthyretin positivity, suggesting that biopsy yield may differ between clinical subgroups. LEVEL OF EVIDENCE:IV.
INTRODUCTION:Previous studies have identified morphological alterations in spastic muscles focusing predominantly on gross motor muscles, with specific emphasis on those of the lower limbs. There is minimal information on the morphology of spastic upper limb muscles in relation to clinical deformity. Therefore, the aim of this study was to investigate the morphological parameters of the biceps brachii and forearm muscles according to the severity of forearm and wrist and finger deformities in children and adolescents with spastic cerebral palsy. METHODS:A total of 87 children and adolescents with spastic cerebral palsy were recruited. The Gschwind and Tonkin and Zancolli classification systems were used to grade forearm pronation and wrist and finger deformities, respectively. Morphological parameters, including muscle thickness, anatomical cross-sectional area and pennation angle (PA) were assessed using a B-mode ultrasonographic device. RESULTS:Significant differences in morphological parameters were observed according to the severity of upper limb deformities. Specifically, as the severity of forearm, wrist and finger deformities increased, the muscle thickness and anatomical cross-sectional area of the biceps brachii, pronator teres and flexor carpi radialis significantly decreased. In contrast, the pennation angle of the extensor digitorum increased with the severity of forearm and wrist and finger deformities. CONCLUSION:These findings support the role of spasticity-induced morphological alterations in the development of upper limb contractures and highlight the clinical value of muscle architecture assessment in guiding targeted therapeutic interventions. LEVEL OF EVIDENCE:III.
INTRODUCTION:Wrist reconstructive procedures commonly use synthetic materials passed through transosseous tunnels to stabilize the carpus. This experimental study compared the tensile mechanical properties of common sutures and synthetic tapes across a bone tunnel edge. We hypothesized that failure would primarily occur at the cortical bone edge owing to abrasion at the suture-bone interface and that increasing strand number would increase construct stiffness and decrease failure. METHODS:Five suture materials (SutureTape, LabralTape, FiberTape, Ethibond, and Mersilene) were tested in one-, two- and four-strand configurations, with 12 constructs per group. Constructs were passed through a 2.5 mm transverse tibial bone tunnel and secured to a servohydraulic testing apparatus with knotless fixation. Testing simulated physiologic scapholunate ligament loading with 1000 cycles from 0 to 100 N at 1.5 Hz followed by ramp loading to 300 N. One-way ANOVA with Tukey post hoc analysis (α = 0.05) evaluated load at failure and percentage elongation. RESULTS:Single-strand SutureTape, Mersilene and Ethibond demonstrated greater elongation at 100 N than single-strand LabralTape and FiberTape (p < 0.001). Mersilene and Ethibond elongated significantly more than SutureTape. Increasing strand number decreased elongation, although not proportionally to the number of strands. Single-strand Ethibond and Mersilene had the highest failure rates and lowest failure loads. No single- or double-strand LabralTape or FiberTape constructs failed at the bone tunnel edge. CONCLUSION:Synthetic suture and tape constructs demonstrated differing mechanical properties and failure modes across a bone tunnel edge. Material selection and strand configuration may influence construct stiffness, elongation, and failure risk for ligament reconstruction.
INTRODUCTION:This study measured how much the carbon footprint and hospital costs could be reduced by using fewer surgical instruments and drapes in minor hand trauma surgery. METHODS:A retrospective cohort study of patients undergoing minor hand trauma procedures was carried out to compare carbon emissions between standard care and a reduced-waste protocol over a 4 month period. The size of drapes and instrument trays were reduced in the new protocol, having been identified as the most modifiable contributors to carbon footprint. Carbon emissions analysis and data on procedural costs and infection rates were collected and compared between the two models. RESULTS:One-hundred patients were eligible for inclusion. Overall, 236 kg of carbon emissions were saved in the reduced waste group in the study period. Smaller drapes reduced CO2 emissions per procedure by 71%, and streamlined trays achieved a 20% reduction. Projected over 1 year, these changes were equated to a carbon saving comparable to planting 100 trees. Mean cost savings of 40% per procedure were achieved in the intervention group. There was no observed compromise in safety or infection rates in routine follow up. CONCLUSIONS:Surgical services must take steps to reduce their environmental impact. This study provides a framework for other surgical specialties to implement climate safe practices. It demonstrates that practical, low-cost changes can yield significant environmental and financial benefits without compromising patient safety. LEVEL OF EVIDENCE:III.
Palmaris profundus is a rare accessory flexor muscle with several recognized variants. We report the incidental intraoperative identification of a type V variant during forearm surgery. This variant may have different clinical implications than the more common subtypes.Level of Evidence: V (Case Report).
INTRODUCTION:Arthroscopic techniques for treating scapholunate interosseous ligament injuries have evolved over the past decade. However, the optimal arthroscopic surgical approach for scapholunate ligament injuries of varying grades remains debatable. METHODS:A systematic literature search was carried out to identify primary studies reporting patient-reported outcomes after arthroscopic treatment of scapholunate interosseous ligament injuries, with a minimum postoperative follow-up of 12 months. A random-effects meta-analysis was carried out to assess changes in patient-reported outcome measures. RESULTS:A total of 16 studies encompassing 434 patients were included. Seven studies reported on arthroscopic capsulodesis; four assessed electrothermal treatment; three described arthroscopic debridement combined with percutaneous K-wire fixation; and two assessed arthroscopic reduction and association of the scaphoid-lunate. Of the seven studies on arthroscopic capsulodesis, six provided enough data for meta-analysis (N = 250), showing a significant improvement in postoperative patient-reported outcomes compared with baseline. CONCLUSION:Arthroscopic capsulodesis appears to offer significant functional improvement and a low complication rate in higher grade scapholunate ligament injuries. LEVEL OF EVIDENCE:IV.
INTRODUCTION:This study investigated the prevalence of amyloid deposition in tissue obtained during trigger finger release and limited fasciectomy for Dupuytren's disease and whether these procedures may allow early detection of cardiac amyloidosis. METHODS:This prospective, explorative study enrolled men aged >50 years and women >60 years undergoing trigger finger release or limited fasciectomy at two centres, excluding patients with known amyloidosis. Surgical specimens (A1 pulley or Dupuytren cord/nodule) were histologically analysed using Congo red staining. Positive samples underwent immunohistochemistry for amyloid subtyping and patients were referred for cardiological assessment. RESULTS:Among 100 trigger finger release patients (50% women; median age 67 years), 10 specimens were Congo red positive, with amyloid confirmed in five (four transthyretin, one undifferentiated). No patient showed clinical cardiac amyloidosis. Amyloid positivity correlated with pre-existing heart failure. Among 100 limited fasciectomy patients (23% women; median age 66 years), eight specimens were Congo red positive, but none were immunohistochemically confirmed, and no clinical cardiac amyloidosis was identified. CONCLUSION:Tissue obtained at trigger finger release may represent a site for early recognition of transthyretin amyloidosis, whereas tissue from limited fasciectomy appears unsuitable for screening. LEVEL OF EVIDENCE:IV.
INTRODUCTION:Carpal tunnel syndrome may occur in association with distal radial fractures, and decompression is sometimes considered at the time of fixation. The flexor carpi radialis approach used for anterior plating may allow decompression without extending the incision into the palm. This study compared intracarpal canal pressure reduction achieved through this approach and the standard technique. METHODS:Twelve fresh-frozen upper extremities were studied. Within each pair, one limb underwent carpal tunnel release through the flexor carpi radialis approach and the contralateral limb through a standard open palmar incision. A balloon-tipped catheter connected to a pressure transducer was inserted proximal to the wrist crease and advanced distally to measure pressure at 5 mm intervals. The peak-pressure site was identified and used for measurements in the neutral position and during wrist flexion and extension. Measurements were obtained before and after release. Final dissection assessed completeness of release and iatrogenic injury. RESULTS:Pressure increased distally, peaking at 114 (SD 70) mmHg approximately 29 (SD 5) mm distal to the wrist crease, near the hook of the hamate. Pressure increased with both flexion and extension, with higher values in extension (201 (SD 12) mmHg) than flexion (133 (SD 17) mmHg,). Both techniques reduced pressure in the neutral position by approximately 75-85 mmHg. Complete release was confirmed in all specimens without tendon or nerve injury. CONCLUSION:The flexor carpi radialis approach provides pressure reduction comparable to the standard open technique and may allow decompression without a separate palmar incision.
INTRODUCTION:This prospective pilot study assessed the effectiveness of two new clinical tests (Szczecin 1 and Szczecin 2) by comparing them with the All-India Institute of Medical Sciences (AIIMS) and Schaeffer's tests for detecting the presence of the palmaris longus (PL) tendon, using ultrasonography as the reference method. METHODS:A total of 370 wrists were assessed in 210 patients (107 male, 103 female) aged 18-86 years (median age: 54 years; IQR: 43 to 67), with a median body mass index of 27 kg/m² (IQR: 24 to 30). Four clinical tests were used: the Schaeffer's, AIIMS, Szczecin 1 and Szczecin 2. Tendon visibility, the difficulty of distinguishing the PL from the flexor carpi radialis tendon, the number of attempts required for correct execution and the subjective ease of the test were analysed. The presence of the PL tendon was confirmed by ultrasonographic examination. RESULTS:The sensitivity for the right hand was: Schaeffer's, 71%; AIIMS, 63%; Szczecin 1, 87%; Szczecin 2, 89%. For the left hand it was: Schaeffer's. 72%; AIIMS, 65%; Szczecin 1, 88%; Szczecin 2; 91%. Palmaris longus tendon absence in one or both hands was found in 13% of patients (or in 16% of all assessed hands). CONCLUSIONS:The two new tests showed higher sensitivity than the reference tests and may be more useful in daily clinical practice. LEVEL OF EVIDENCE:III.
INTRODUCTION:The aim of this study was to report the anatomical variations in the blood supply to the island flap harvested from the radial thumb in modified Bilhaut-Cloquet procedure for thumb duplication. METHODS:A total of 190 patients with Wassel type II-IV thumb duplication underwent the modified Bilhaut-Cloquet procedure. The blood supply to the flap was assessed and anatomical patterns were recorded based on the relative calibres of the proper digital artery and communicating branches. RESULTS:Three types of blood supply were identified: fine communicating branch type (n = 134), equal calibre type (n = 43) and coarse communicating branch type (n = 16). The coarse communicating branch type exhibited the lowest success rate, while the fine communicating branch type achieved a 100% success rate. CONCLUSION:The blood supply patterns to the island flap is crucial for improving surgical outcomes and reducing complications in thumb duplication correction. LEVEL OF EVIDENCE:IV.
INTRODUCTION:Traditional surgical treatments for wrist osteoarthritis, such as arthrodesis or arthroplasty, are invasive and irreversibly compromise joint motion. Wrist denervation offers a less invasive alternative aimed at pain relief while preserving mobility. However, its durability remains uncertain. The aim of the study is to evaluate whether wrist denervation prevents further osteoarthritis-related wrist surgery in the mid- to long-term. METHODS:This prospective multicentre study included patients with symptomatic wrist osteoarthritis who underwent wrist denervation after failed non-surgical treatment between 2012 and 2024, with a minimum follow-up of 12 months. The primary outcome was procedure success, defined as the proportion of wrists not requiring further osteoarthritis-related surgery. Secondary outcomes included visual analogue scale (0-100) scores for pain and function, patient satisfaction and willingness to repeat the procedure. RESULTS:One hundred and twelve patients (114 wrists) were included. At a median follow-up of 4 years (1-13), 86% of wrists did not undergo further osteoarthritis-related surgery after denervation. Most reoperations occurred within 2 years. Mean visual analogue scale pain score at rest significantly improved from 48 (SD 28) preoperatively to 26 (SD 29) (reduction: 22 points). Mean visual analogue scale function significantly improved from 55 (SD 26) to 69 (SD 24) (improvement: 14 points). Patient satisfaction was rated as good or excellent in 60%, and 82% were willing to undergo the same treatment again. CONCLUSION:Wrist denervation yields durable symptom relief and can, in many cases (86%), prevent further osteoarthritis-related surgery in patients with wrist osteoarthritis over a median 4 year follow-up. LEVEL OF EVIDENCE:II.
INTRODUCTION:The aim of this registry-based cohort study was to examine the impact of socioeconomic factors on the incidence of paediatric hand and forearm injuries in Stockholm County, Sweden. METHODS:Registry data from Region Stockholm's database was obtained for all children aged 0-18 years diagnosed with a hand or forearm injury between 2014 and 2019. The data included area of residence classified as low, average or high socioeconomic status, as well as age and type of injury. Incidence rate ratios were estimated using Poisson regression to compare incidence rates of all injuries and specific injury types across socioeconomic groups. RESULTS:The yearly mean incidence rate for any hand or forearm injury in children aged 0-18 years during the period was 345 per 10,000 person-years, with the highest incidence observed in children living in areas with high socioeconomic status. When types of injuries were analysed separately, burns and crush injuries were most common among children aged 0-2 years living in areas with low socioeconomic status, whereas fractures, sprains and contusions were more frequent among children aged 11-14 years residing in areas with average or high socioeconomic status. CONCLUSION:Adolescents in high and average socioeconomic areas show higher incidence rates of fractures, sprains and contusions, whereas the youngest children in low-socioeconomic areas remain more vulnerable to burns and crush injuries. These findings strengthen prior research demonstrating the association between area-level socioeconomic status and both injury incidence and type. Our results underscore the need for continued and enhanced prevention measures, particularly targeting the persistent risk of domestic injuries among the youngest children. LEVEL OF EVIDENCE:III.
INTRODUCTION:The first dorsal metacarpal artery (FDMA) flap is a well-established option for reconstructing complex thumb defects. Despite its reliability, inadequate flap perfusion remains a concern with a potential risk of postoperative ischaemia compromising outcomes. This study aimed to introduce and assess a dual-pedicle modification of the FDMA flap combined with an intraoperative perfusion testing protocol to improve flap vascularity assessment and surgical reliability. METHODS:Thirty consecutive patients with complex thumb defects underwent FDMA flap reconstruction using a dual-pedicled design incorporating a secondary fasciocutaneous random-pattern pedicle based on the radial side of the index finger. An intraoperative axial pedicle stress test was carried out using temporary occlusion with a sterile finger tourniquet to isolate and assess axial pedicle flap perfusion intraoperatively and based on the test findings, the secondary pedicle was either divided immediately or retained temporarily. RESULTS:Immediate division of the secondary pedicle was carried out in 27 patients, whereas three required temporary preservation because of inadequate perfusion during intraoperative testing. Complete flap survival was achieved in all patients with no vascular complications. The mean static two-point discrimination was 8.90 (SD 1.21 mm) and the mean Kapandji score was 8.87 (SD 0.96), indicating satisfactory sensory and functional outcomes. CONCLUSION:The proposed dual-pedicle modification, combined with intraoperative perfusion assessment, provides a practical method for estimating axial pedicle adequacy and may assist in intraoperative decision-making when flap perfusion is inadequate. LEVEL OF EVIDENCE:IV.
INTRODUCTION:Tattoos are increasingly common and may be encountered overlying planned surgical incision sites. This is particularly relevant in hand and upper limb surgery, where tattoos are frequent and highly visible. Tattoos in standard approach lines raise aesthetic and ethical considerations. Despite this, little is known about current surgical attitudes towards tattoo preservation. We assessed current practice among hand and upper limb surgeons when tattoos lie within the preferred incision. METHODS:An electronic survey was distributed to hand and upper limb surgeons trained via plastic or orthopaedic surgery programmes. Respondents reviewed a standardized scenario showing a tattoo over the anterior distal forearm incision for distal radius fixation and selected their preferred approach. Specialty, seniority and level of training were recorded. RESULTS:There were 225 responses; 175 (78%) were senior surgeons (post-Certificate of Completion of Training/consultant). Orthopaedic surgeons comprised 181 (80%) and plastic surgeons 44 (20%). Overall, 173/225 (77%) would incise directly through the tattoo. Tattoo-preserving options were less common, comprising incision along the tattoo margin 34/225 (15%) and raising a skin flap 7/225 (3.1%). CONCLUSION:Upper limb surgeons predominantly favour standard incisions through tattoos rather than preservation. Given limited commentary in the literature and potential aesthetic and psychological implications, we propose the ART algorithm (assess safety-review size-talk to the patient) to structure decision-making and support preoperative discussion of incision placement during consent.
Introduction: This study aims to explore the types of surgeries performed for radial polydactyly, complications and their associations with Wassel–Flatt classification types using a multi-centre prospective paediatric hand surgery registry. Methods: Patients with radial polydactyly in the Congenital Upper Limb Differences (CoULD) Registry who underwent surgery were reviewed for Wassel–Flatt classification, types of surgeries performed and complications. Results: A total of 247 extremities with radial polydactyly in 230 patients underwent surgical treatment at an average age of 1.4 years (ranging from 24 days to 8.4 years) for the index operation. The most common primary procedure was excision of the radial thumb with reconstruction of the dominant ulnar thumb (87%), followed by simple excision (7%). Thumbs classified as the hypoplastic subtype were more likely to undergo simple excision. The most common ancillary procedure was ligament reconstruction. Fifteen patients (7%) experienced 17 total complications including five thumbs requiring revision at an average of 3.6 years (range 2.5–4.3 years) after the first surgery. Conclusions: Excision of the radial thumb with reconstruction of the ulnar thumb is the most common procedure for patients undergoing surgical treatment for radial polydactyly, followed by simple excision of a hypoplastic polydactylous digit. Surgical complication rates for radial polydactyly surgery are low (7%) with a 2% reoperation rate at the 3 year follow-up. Level of Evidence: IV
Introduction: Trigger finger is a common tendinopathy with an increasing incidence in the aging and metabolically compromised populations. While corticosteroid infiltration (INF) remains the most frequently used conservative treatment, extracorporeal shock wave therapy (ESWT) is a non-invasive alternative with potential long-term benefits. Methods: A prospective, non-randomized comparative study was conducted including 42 patients with Quinnell grade II–III trigger finger. Patients were allocated sequentially to treatment with either ESWT ( n = 21) or INF ( n = 21). Outcomes were assessed at baseline, 6 months, 1 year and 2 years including pain, functional status, grip strength, Quinnell classification, Roles and Maudsley score, patient satisfaction and conversion to surgery. Results: At 6 months, outcomes were comparable between the groups across most assessed variables. Most of the patients in the ESWT group achieved substantial pain relief at 1 and 2 years. Functional outcomes differed between the groups at 1 year. Grip strength gains were maintained in the ESWT group. Patient satisfaction remained stable in the ESWT group and decreased in the INF group. Surgical conversion occurred less frequently in the ESWT group than in the INF group at 2 years. Conclusions: In this study, both ESWT and INF were associated with clinical improvement in patients with moderate trigger finger. Differences between treatments emerged at longer follow-up intervals, particularly in pain-related outcomes and rates of surgical conversion. These findings indicate that ESWT is a non-invasive treatment option associated with sustained clinical outcomes over time. Level of evidence: II.
Introduction: Distal phalanx fractures are commonly associated with nail unit injuries and may cause long-term nail dystrophy. However, the risk factors associated with such deformities are poorly understood. In this study, we aimed to assess the potential risk factors for nail dystrophy after distal phalanx fractures. Methods: We conducted a retrospective review of adult patients with distal phalanx fractures treated at a single hand surgery centre between January 2015 and December 2019. The patients were followed up clinically and radiographically for at least 1 year after injury. Results: We included 112 patients with 128 distal phalanx fractures. Nail dystrophy developed in 50 fingers. The significant independent predictors of nail dystrophy included nail bed injury and nonunion. Nail bed suturing, fracture location, trauma type and dorsal rim incongruence were not independently associated with nail dystrophy using multivariate analysis. Conclusion: Nail bed injury and nonunion of the distal phalanx fracture significantly increased the risk of post-traumatic nail dystrophy. These findings underscore the importance of careful assessment and management of nail bed injuries and fracture healing when treating distal phalanx fractures. Level of evidence: III
INTRODUCTION:Vascularized toe proximal interphalangeal (PIP) joint transfer restores motion after destructive finger injuries, yet outcomes are limited by a persistent extensor lag. We observed subtendinous connective tissue attachment beneath the extensor digitorum longus (EDL), from the proximal phalangeal neck to the PIP joint, that may tether the tendon to bone. We assessed whether releasing this tissue improves surgical outcomes without compromising perfusion. METHODS:We performed a retrospective matched cohort study with a 1:1 propensity score matching on sex, age at surgery, native toe passive range of motion (ROM) and follow-up duration, comparing transfers with subtendinous tissue dissection to cases without dissection. Matched cohorts included 17 dissected and 17 non-dissected joints. The primary outcome was extension lag of the transferred PIP joint at final follow-up. Secondary outcomes included active PIP joint ROM, active flexion, percentage of use (active ROM ÷ donor toe passive ROM ×100), revision incidence and number of revision procedures per patient. Early follow-up was defined as 6 months postoperatively, and final follow-up as the most recent outpatient visit. Patients with follow-up <12 months were excluded. RESULTS:At the 6 month postoperative assessment, prior to any revision procedures, the dissected group demonstrated less extension lag (15° vs. 20°, p = 0.014) and greater ROM (55° vs. 45°, p = 0.017). At final follow-up, extension lag remained less (15° vs. 20°, p = 0.032), whereas ROM, flexion and percentage of use did not differ. The revision burden was similar between groups. CONCLUSION:Donor-side release of the subtendinous tissue beneath the EDL was associated with reduction in early and final extension lag without vascular compromise. These findings should be interpreted cautiously and warrant confirmation in larger studies with longer follow-up. LEVEL OF EVIDENCE:III.
Introduction: Scapholunate instability is the most common pattern of carpal instability, yet the relative contributions of the intrinsic and extrinsic ligaments remain debated. This systematic review evaluated cadaveric studies of wrist biomechanics assessing kinematic changes following carpal ligament sectioning to clarify the stabilizing roles of individual ligaments. Methods: The EMBASE, MEDLINE, Cochrane and Scopus databases were searched from inception to June 2025. Cadaveric studies reporting scapholunate gap (SLG), scapholunate angle (SLA), radiolunate angle (RLA) or dorsal intercalated segment instability (DISI) after ligament sectioning were included. Data were extracted for cumulative and sequential sectioning patterns and synthesized qualitatively. Results: Thirty-three studies involving 406 wrists were included. With an intact scapholunate interosseous ligament (SLIL), sectioning single or multiple extrinsic carpal ligaments produced minimal changes in SLG, SLA, or RLA. Scapholunate interosseous ligament sectioning increased SLG (mean +1.7 mm), SLA (+8°) and RLA (+3°), with clenched-fist loading further elevating SLG (+0.7 mm) and SLA (+4°). The dorsal intercarpal ligament (DIC) was the dominant secondary stabilizer. Combined SLIL–DIC injury produced the greatest increases across all measures, and DISI occurred only when the SLIL and either the DIC or the scaphotrapeziotrapezoid complex was sectioned. Conclusion: Cadaveric evidence confirms the SLIL as the primary stabilizer of the scapholunate joint and identifies the DIC as the key secondary stabilizer. These biomechanical findings support early diagnosis, targeted reconstruction and the need to restore both primary and secondary stabilizers to prevent progressive scapholunate instability.
