Background: This study investigated the methods used to diagnose carpal tunnel syndrome (CTS) at a regional hospital and determined whether surgical wait times differed between those who had a nerve conduction study (NCS) and those who did not. Methods: This study consists of a retrospective cross-sectional review of patient records over 24 months, recording demographic information, date of initial orthopaedic clinic consult, date of surgery and diagnostic tool utilised by the assessing clinician. Patients were divided into two groups: those who had an NCS and those who did not. These two groups were statistically analysed to compare surgical wait times from the date of initial consult to the date of surgery. Results: The study determined that 117 carpal tunnel release (CTR) procedures were completed, with NCS used to diagnose CTS in 86 of the 117 patients. The remaining 31 patients were diagnosed using either provocative tests or an ultrasound study. The number of days to surgery was significantly higher amongst participants who had an NCS (median 206 days) compared to the non-NCS groups (median 73 days). Conclusions: It is concluded that the use of NCS in the diagnosis of CTS prolongs the surgical wait times of patients requiring surgery. There are some cases where an NCS is required to provide clarity in an unclear clinical picture; however, given that in many cases a reliable diagnosis of CTS can be made without completion of an NCS, the necessity of routinely completing this investigation should be judiciously considered, especially in circumstances where surgical wait times are of importance to patient outcomes. Level of Evidence: Level III (Therapeutic).
Background: Trigger digit is a common hand disorder that causes pain, limited finger motion and functional impairment in activities of daily living (ADL). Although psychosocial factors are increasingly recognised in musculoskeletal disorders, the relationship between central sensitisation (CS) and trigger digit has not been investigated. This study aimed to identify ADL impairments associated with CS Inventory (CSI) scores in patients with trigger digit. Methods: This retrospective study included 35 patients (12 men, 23 women; mean age: 64.0 ± 9.4 years) who received conservative treatment for trigger digit between October 2022 and May 2023. Quick disabilities of the arm, shoulder and hand (Q-DASH) and CSI scores were assessed. Correlations between total Q-DASH and CSI scores were analysed using bivariate analysis, and associations between individual Q-DASH items and CSI scores were examined using Spearman's rank correlation coefficient. Statistical significance was set at p < 0.05. Results: The mean Q-DASH and CSI scores were 23.6 ± 19.5 and 22.5 ± 14.5, respectively. A significant correlation was found between total Q-DASH and CSI scores (p = 0.021). Amongst the 11 Q-DASH items, Q3 (carry a shopping bag or briefcase), Q4 (wash your back), Q8 (limitations in work or daily activities) and Q11 (difficulty sleeping because of pain) were significantly associated with CSI scores (p = 0.024, 0.018, 0.033 and 0.001, respectively). Conclusions: These findings suggest that psychosocial factors associated with ADL impairment in trigger digit can be assessed using CSI scores. Specific Q-DASH items reflecting daily and social functioning, hygiene and sleep may be particularly influenced by CS mechanisms. Level of Evidence: Level IV (Diagnostic).
This technical note describes a reproducible technique for intraoperative assessment and optimisation of Zone II flexor tendon repairs using the Wide-Awake Local Anaesthesia No Tourniquet (WALANT) approach combined with intraoperative Total Active Movement examination (iTAMe). The aim is to provide surgeons with a systematic protocol to evaluate tendon glide, detect gapping and address pulley obstruction in real time, thereby improving repair integrity. The technique involves WALANT solution administration, tendon exposure via Bruner incision, four-strand core suture repair and iTAMe testing. Key steps include troubleshooting algorithms for gapping (suture reinforcement or re-repair) and triggering (pulley venting), complemented by intraoperative patient education (iPE) to enhance compliance. The principal conclusion is that integrating iTAMe into WALANT procedures enables immediate correction of repair flaws, reduces postoperative complications and empowers patients through direct engagement. This method offers a practical framework for surgeons adopting wide-awake tendon repair. Level of Evidence: Level V (Therapeutic).
Background: Transverse metacarpal shaft fractures commonly require surgical fixation, yet optimal postoperative management remains controversial. Although intramedullary (IM) Kirschner wire (K-wire) fixation allows early motion, many surgeons continue to apply postoperative splinting due to concerns about stability. We aim to determine if a single IM K-wire fixation without immobilisation yields better outcomes and faster recovery of hand function. Methods: A single-centre, prospective and randomised controlled trial was conducted between November 2024 and November 2025 involving isolated transverse fractures of the second to fifth metacarpal shafts. Twenty patients were randomised to single buried IM K-wire fixation without postoperative immobilisation (Group A) or percutaneous transverse K-wire fixation followed by 4 weeks of splinting (Group B). Outcomes included metacarpophalangeal (MCP) joint range of motion (ROM), disabilities of arm, shoulder and hand (DASH) score, healing and complications, assessed at 4, 8 and 12 weeks. Results: Group A demonstrated significantly superior MCP joint ROM and lower DASH scores at 4 weeks postoperatively, with differences exceeding the MCID threshold. After K-wire removal, no differences in ROM or DASH scores were observed at 8 and 12 weeks. All patients achieved bone union. No malrotation, loss of reduction, wire migration, infection or fixation failure occurred in either group. Conclusions: Single IM K-wire fixation without postoperative splinting is safe and provides earlier functional recovery compared with conventional transverse K-wire fixation with immobilisation without affecting the final outcomes. Early hands-free mobilisation facilitates faster restoration of ROM and daily hand function without compromising fracture healing. Level of Evidence: Level II (Therapeutic).
In cases of failure of trapeziometacarpal total joint replacements, we have chosen a different strategy than trapeziectomy for high-demand patients (or patients dissatisfied with a contralateral previous trapeziectomy), performing a trapeziometacarpal arthrodesis with an interposed corticocancellous iliac crest graft. This article aims to describe the technique and report our results in three patients. Median age at revision arthrodesis was 60 years. The stems were removed with a dorsal bone-lid, leaving a defect into which the bone graft was fitted and fixed with cortical screws before impaction of the graft into the trapezial remnant with K-wire fixation proximally. Cast immobilisation was used for 8 weeks. At final follow-up, all fusions had healed, and patients were satisfied according to strength measurements and PROMs. While further validation in a larger cohort with longer follow-up is required, we believe the technique may be of value, particularly in high-demand patients. Level of Evidence: Level V (Therapeutic).
Intra-articular coronal shear fractures of the metacarpal head in adolescents are rare and easily overlooked because the fracture plane lies parallel to standard radiographic projections. We describe four adolescent patients to define distinct clinical and radiographic diagnostic clues that support early recognition. A consistent injury pattern of axial loading across a hyperextended metacarpophalangeal joint was observed. Two patients demonstrated a reproducible mechanical click occurring during terminal hyperextension. Initial radiographs were subtle or equivocal in three patients, with metacarpal head squaring and a double shadow sign representing key radiographic signs of coronal fracture morphology. Computed tomography clarified fracture morphology when plain radiographs were inconclusive and demonstrated intra-articular incongruity requiring operative treatment. Delayed recognition in one patient resulted in symptomatic malunion. Awareness of the characteristic diagnostic clues should prompt advanced imaging and facilitate earlier identification of this uncommon intra-articular injury. Level of Evidence: Level V (Therapeutic).
Distal biceps tendon repair carries a recognised risk of posterior interosseous nerve (PIN) injury, particularly when anatomical planes and tuberosity landmarks are not precisely identified. This case report describes an acute PIN palsy in a young labourer following single-incision cortical button fixation for a distal biceps rupture. Postoperative imaging revealed proximal malposition of the Endobutton, prompting urgent re-exploration. Intraoperatively, the biceps tendon was found to have been passed radially over the PIN, resulting in stretch and compression, and fixation was non-anatomical. The tendon was re-routed ulnar to the nerve and secured to the correct radial tuberosity footprint, with full neurological recovery achieved by 3 months. This case highlights the critical importance of full forearm supination, accurate development of the brachioradialis-pronator teres interval and precise identification of the tuberosity to avoid iatrogenic nerve injury during distal biceps repair. Level of Evidence: Level V (Therapeutic).
Background: Paediatric elbow fractures are difficult to diagnose because secondary ossification centres can obscure radiographic interpretation. Emergency physicians often request contralateral elbow radiographs to improve diagnostic accuracy, although the benefit of this practice remains controversial. This study aimed to evaluate the impact of contralateral elbow radiographs and a targeted educational intervention on the diagnostic accuracy of emergency residents interpreting paediatric elbow fractures. Methods: This diagnostic study included 28 emergency residents at a tertiary hospital. Participants interpreted 23 paediatric elbow radiographic sets under 4 conditions: injured elbow only, injured plus contralateral elbow and the same evaluations after a targeted educational lecture. Diagnostic accuracy, sensitivity, specificity and confidence were analysed using paired statistical tests and regression models. Results: Mean diagnostic accuracy improved significantly after the educational lecture (median score increased from 14 to 17; p < 0.001). The addition of contralateral elbow radiographs did not significantly improve diagnostic accuracy or confidence either before or after the educational intervention. Regression analysis identified targeted education as the strongest predictor of improved diagnostic performance. Conclusions: Targeted educational interventions significantly enhance diagnostic accuracy in paediatric elbow fractures. The addition of contralateral elbow radiographs did not improve diagnostic performance in this controlled assessment setting. However, their selective use in specific clinical scenarios may still be beneficial, and clinical judgement remains essential. Level of Evidence: Level II (Diagnostic).
Amyloidosis is a disorder characterised by progressive extracellular deposition of misfolded proteins, which can result in significant cardiac and neurologic morbidity. Traditionally, haematologists and cardiologists have served as primary diagnosticians for this disease when patients present with symptomatic systemic disease. However, musculoskeletal manifestations of the disease, such as carpal tunnel syndrome, trigger finger, spontaneous distal biceps tendon rupture and rotator cuff disease, are now recognised to frequently precede cardiac or neurologic involvement by several years. With the recent development of effective disease-modifying therapies, orthopaedic surgeons and hand surgeons in particular may play an increasingly important role in early diagnosis of amyloidosis. Recognition of these associated musculoskeletal conditions presents hand surgeons with a unique opportunity to perform targeted biopsies, allowing for earlier referrals, initiation of disease-modifying therapies and thus potentially stalling a devastating multiorgan disease. Level of Evidence: Level V (Therapeutic).
Background: Brachial artery injuries are common in upper limb trauma and require timely repair to prevent ischemia and limb loss. In developing countries like India, delayed presentation is frequent due to limited access to specialised care, inadequate infrastructure and delays in multidisciplinary coordination, complicating timely revascularisation. This study aimed to evaluate limb salvage outcomes and factors influencing prognosis in patients undergoing delayed repair of traumatic brachial artery injuries. Methods: This prospective study included 30 male patients (ages 18-58 years) with traumatic brachial artery injuries treated over 2 years. All patients presented more than 6 hours after injury. Emergency surgical repair was performed using either primary anastomosis or reversed vein grafts, with the great saphenous vein used in 14 patients and upper limb veins in others. Associated nerve and tendon injuries were repaired simultaneously. Fasciotomy was performed in 20 patients. Patients were followed up at regular intervals (2 weeks to 6 months), and outcomes were assessed in terms of limb salvage, complications and secondary procedures. Results: Out of 30 patients, 26 limbs (86.6%) were salvaged, and 4 (13.4%) required above-elbow amputation due to gangrene. Most patients (20/30) presented between 12 and 24 hours, with one case successfully revascularised at 92 hours post-injury. Ten patients underwent primary repair; 20 required vein grafting. Concomitant nerve injury was found in 26 patients, primarily affecting the median nerve (16 patients). Fasciotomy helped prevent irreversible ischemic damage. Two patients developed acute kidney injury, and 10 required negative pressure wound therapy followed by skin grafting. Conclusions: Delayed surgical repair of brachial artery injuries, even beyond conventionally accepted ischemic time thresholds, can achieve high limb salvage rates. However, systemic limitations in developing countries continue to pose major challenges to achieving timely intervention and optimal outcomes. Level of Evidence: Level IV (Therapeutic).
Hajdu-Cheney syndrome (HCS) is a rare genetic connective tissue disorder characterised by progressive acro-osteolysis of the distal phalanges, pseudo-clubbing, joint hyperlaxity and generalised osteoporosis. We report the case of an 85-year-old woman presenting with infectious dactylitis of the third finger of the right hand, in whom radiographs revealed distal osteolysis in several digits. After excluding infectious, inflammatory and metabolic causes, genetic testing confirmed a heterozygous NOTCH2 mutation consistent with HCS. This case highlights the importance of recognising the characteristic radiographic and clinical findings in the hand, since its presentation may mimic rheumatologic or infectious conditions. Awareness of this entity allows accurate diagnosis, avoidance of unnecessary surgical interventions and optimised functional and preventive management. Level of Evidence: Level V (Therapeutic).
Iodinated contrast extravasation is usually self-limited; however, in confined regions such as the dorsum of the hand - especially in paediatric patients - it can progress to acute compartment syndrome. We report a 9-year-old girl who developed hand compartment syndrome following extravasation of 50 mL iohexol (350 mgI/mL) via a 22G catheter during contrast-enhanced abdominal computed tomography. Despite standard extravasation management, symptoms progressed rapidly. Compartment syndrome was diagnosed clinically based on pain disproportionate to injury, refractory to analgesics, exacerbated by passive stretch, with paraesthesia and prolonged capillary refill. Emergency decompression was performed through five incisions. Delayed primary closure was achieved on postoperative day 5 without vacuum-assisted closure or skin grafting. At 6-month follow-up, grip strength equalled the contralateral side and QuickDASH score was 0. This case emphasises that moderate-volume contrast extravasation can rapidly cause compartment syndrome in the paediatric hand, and that standard extravasation protocols become contraindicated once compartment syndrome is suspected. Level of Evidence: V (Therapeutic).
Background: Ulnar-sided wrist pain (USWP) is a frequent complaint, and triangular fibrocartilage complex (TFCC) injuries are amongst its most common aetiologies. Nonsurgical management of USWP is heterogeneous with variable periods of immobilisation. This study describes the outcome of a structured multiphase, conservative program for USWP that was clinically diagnosed as TFCC injuries in a single centre. Methods: Thirty-two individuals with USWP, foveal tenderness ± distal radio-ulnar joint (DRUJ) laxity diagnosed as TFCC injuries participated in the structured multiphase therapy program from 2020 to 2023 and were followed up prospectively. Assessments included numeric pain rating scale (NPRS), wrist range-of-motion, grip strength, weight-bearing ability, Modified Mayo Wrist Score (MMWS) and Patient-Specific Functional Scale (PSFS). The program comprised 4 weeks of splint immobilisation, 3-4 weeks of dynamic DRUJ stabiliser strengthening and 4 weeks of neuromuscular retraining. Outcomes were reassessed at 3 months and 1 year. Results: Twenty-nine patients were evaluated; 14 completed therapy, 15 defaulted and 21 were reviewed at 1 year. Amongst these 21 patients, mean NPRS decreased by 4 points and PSFS improved significantly. Completers also showed significant improvement in weight-bearing ability and were more likely to achieve excellent/good MMWS at 3 months than defaulters. All completers returned to regular work/activities at 1 year, compared with 9 of 10 contactable defaulters. None required surgery within 1 year. Conclusions: A structured multiphase therapy program for USWP clinically diagnosed as TFCC injury improved pain, function and weight-bearing ability. Completers were more likely to achieve excellent/good MMWS at 3 months, and no patient required surgery within 1 year. Level of Evidence: Level IV (Therapeutic).
Background: Wrists with scapholunate advanced collapse (SLAC) and scaphoid non-union advanced collapse (SNAC) are frequently managed using either lunocapitate fusion (LCF) or four-corner fusion (4CF). However, technical factors within the LCF may have an important influence on union and complication rates. Methods: This retrospective study evaluated the radiographic and functional outcomes of 28 patients (LCF = 19, 4CF = 9) treated between 2015 and 2023, with particular emphasis on technical observations within the LCF group. The 4CF cohort was primarily included to provide a clinical context. Results: The fusion rates were significantly lower in the LCF group (47% vs. 100%, p = 0.0098), and the reoperation rates were higher (32% vs. 0%, p = 0.136). In the LCF group, all patients treated with a single screw (3/3) or with two partial-threaded screws (3/3) developed non-union. In contrast, the non-union rate was 43.8% (7/16) in the two-screw subgroup and 30.8% (4/13) when at least one fully threaded screw was used. Both procedures yielded comparable improvements in wrist range of motion (ROM), visual analogue scale (VAS), quick disabilities of the arm, shoulder and hand (QuickDASH), modified Mayo wrist scores (MMWS) and patient satisfaction at 1-year follow-up. Although LCF is less extensive, its outcomes in this study appear to be influenced by technical factors. Conclusions: The main finding of this study was that non-union and reoperation in the LCF group were clustered in cases with less robust fixation constructs and potentially insufficient preparation of fusion surfaces. These observations imply that the outcome of LCF may depend more on the surgical execution than on the procedure itself. These findings should be considered hypothesis-generating. Larger studies are required to clarify the potential technical risk factors for surgical failure. Level of Evidence: Level IV (Therapeutic).
Background: Distal radius malunion accompanied by increased dorsal angulation tends to alter wrist biomechanics, leading to a range of carpal malalignment patterns, which may affect both the radiocarpal (radiolunate) and midcarpal (capitolunate) joints. One type has radiocarpal malalignment with an aligned midcarpal joint, and the second type has midcarpal malalignment with an aligned radiocarpal joint. Previous studies have demonstrated that corrective osteotomy tends to restore normal radiocarpal and midcarpal alignment. However, we observed that radiocarpal and midcarpal malalignment persist in a subset of patients, despite appropriate correction of the malunited distal radius. The primary aim was to assess the effects of postoperative persistent carpal malalignment on functional outcomes by comparing the Patient-Rated Wrist Evaluation (PRWE) of patients with and without persistent radiocarpal or midcarpal malalignment following a corrective osteotomy of the distal radius. Methods: For this retrospective study, we screened all consecutive adult patients who had an extra-articular corrective osteotomy between January 2019 and 2024 for a distal radius malunion. Radiocarpal and midcarpal malalignment was assessed on pre- and postoperative radiographs by two researchers. The PRWE was evaluated during the standard postoperative follow-up. Results: This study showed that PRWE scores of patients with carpal malalignment did not differ from those of patients with normal carpal alignment, both preoperatively and postoperatively. Furthermore, the prevalence of all types of malalignment decreased following the corrective osteotomy, and all patients reported improved hand and wrist function, with a median improvement of 50 points on the PRWE. Conclusions: Midcarpal malalignment is common in distal radius malunions and may exist simultaneously with radiocarpal malalignment. Despite the presence of malalignment, all patients experienced improved function after the corrective osteotomy. Therefore, we conclude that persistent radial or midcarpal malalignment following a corrective osteotomy does not have an adverse effect on functional outcome. Level of evidence: Level III (Therapeutic).
Background: The extended dorsal central splitting approach (EDCSA) in surface replacement arthroplasty (SRA) for primary osteoarthritis of the proximal interphalangeal (PIP) joint contributes to overcoming problems associated with the volar approach. However, new issues associated with the dorsal approach have become apparent. This study aimed to evaluate the time-dependent features of complications following SRA performed using the EDCSA for primary osteoarthritis of the PIP joint. Methods: This retrospective case series study included 188 patients (140 women and 48 men; 240 fingers) who underwent SRA for primary osteoarthritis of a PIP joint between 2017 and 2024 and were followed up for at least 1 year. Medical records and radiographs were reviewed to identify complications and any revision procedures performed during follow-up. Results: The mean duration of postoperative follow-up was 5.3 years. The mean active arc of motion at the PIP joint improved from 39° preoperatively to 64° at the latest follow-up. Postoperative complications occurred in 62 fingers (26%), and 33 fingers (14%) required revision surgery. Complications involving soft tissues were most common, followed by extension contracture or flexion contracture. The temporal distribution of complications revealed two distinct peaks: early complications within 6 months, which were predominantly flexion contracture, and late complications after 12 months, which were mainly extension contracture with or without swan-neck deformity. No serious new complications were identified beyond 3 years after surgery. Conclusions: SRA for osteoarthritis of a PIP joint continues to be refined, with ongoing efforts to improve outcomes and reduce the risk of complications. The EDCSA provides reliable exposure and allows early rehabilitation, resulting in favourable medium-term outcomes with respect to range of motion, but still has a non-negligible complication rate. Complications show characteristic time-dependent patterns and can be attenuated by timely intervention. Level of Evidence: Level IV (Therapeutic).
Volar locking plates become the standard treatment for distal radius fractures and are mostly applied through volar approaches that rely on the flexor carpi radialis (FCR) as a superficial landmark. Although usually straightforward, anomalous flexor musculature may complicate exposure, misdirect dissection and increase the risk of iatrogenic neurovascular injury. We report two rare anatomical variants encountered during open reduction and internal fixation: FCR brevis (FCRB) associated with anomalous insertion of the pronator quadratus, and complete agenesis of the FCR. Both substantially altered the expected surgical anatomy. The FCRB obscured the typical superficial interval and was associated with ulnar displacement of the pronator quadratus on deeper dissection. In the second case, the absence of the FCR eliminated a key landmark, with the palmaris longus becoming the most radial tendon, increasing the risk of inadvertent ulnar dissection towards the median nerve and its palmar cutaneous branch. Recognition of these variants is essential to ensure safe volar exposure and avoid neurovascular injury. Level of Evidence: Level V (Therapeutic).
Background: In recent years, there has been a growing interest in the use of shear wave elastography (SWE) to evaluate neuromuscular lesions and follow-up treatment progress. SWE is a technique used to measure tissue stiffness; however, the factors influencing the elastic modulus obtained by SWE, as well as the reliability of the measured values, have not been sufficiently examined. This study introduces a reproducible SWE protocol for assessing the ulnar nerve in healthy adults and investigates differences in elastic modulus by sex, side (left/right), measurement site and the presence or absence of ulnar nerve dislocation. Methods: A total of 48 ulnar nerves of 24 healthy adults were evaluated. The elastic modulus was measured using SWE. The elastic modulus was measured at two locations with the elbow in full extension (0°): 5 cm proximal to the medial epicondyle (ME; upper arm) and 5 cm distal to the ME (forearm). Results: The coefficient of variance for the elastic modulus was <0.05, indicating stable measurement. No significant differences or interactions were observed based on side (left/right), measurement site or ulnar nerve dislocation status. However, a significant sex difference in the ulnar nerve elastic modulus was found (F = 47.74, p < 0.001), indicating that the nerve was stiffer in males than in females. In the elastic modulus distribution, males tended to have a higher median value in the right forearm, whereas females showed significant asymmetry between the left and right forearms. Conclusions: This study established a reproducible SWE protocol and explored sex-based and anatomical differences in ulnar nerve elastic modulus, providing foundational data for future cubital tunnel syndrome (CuTS) diagnostics. Level of Evidence: Level IV (Diagnostic).
Corticosteroid injection is a widely accepted first-line treatment for trigger finger. However, it carries a potential risk of flexor tendon rupture. This complication is rare, particularly after a single injection. We present a 59-year-old woman who experienced spontaneous ruptures of the flexor digitorum profundus and superficialis tendons of the middle finger 2 months after a single corticosteroid injection for trigger finger. We review the literature and discuss underlying mechanisms for flexor tendon rupture. To minimise the risk of this complication, we recommend administering extra-tendinous injection of corticosteroids at the lowest dose and advising patients to avoid strenuous activities, such as heavy gripping, sports or lifting, for at least 3 weeks post-injection. Level of Evidence: Level V (Therapeutic).
Background: Radial longitudinal deficiency (RLD) is a rare congenital malformation that severely impairs grasp and pinching due to radial ray and thumb hypoplasia or aplasia. Standard management typically involves early centralisation to align and stabilise the wrist, followed by pollicisation when the thumb cannot be reconstructed. However, little attention has been paid to pre-pollicisation-rehabilitation strategies that might facilitate the acquisition of postoperative pinch function. This study aimed to report early functional outcomes after staged reconstruction for severe RLD, highlighting a structured pre‑pollicisation programme that establishes index-middle finger pinch after wrist centralisation. Methods: We retrospectively reviewed four children (six hands) with RLD treated between 2022 and 2024 with staged reconstruction: (1) early orthotic management, (2) wrist centralisation at approximately 1 year of age and (3) pollicisation of the index finger at 2-3 years of age. All patients underwent a structured pre-pollicisation rehabilitation programme focussing on the development of index-middle finger pinch after centralisation. Outcomes at 6-18 months after pollicisation included grasp patterns and a tape measure-based pinch test. Results: All hands achieved cylindrical and spherical grasps, and four hands demonstrated early fine motor tasks, such as scissor use and pre-writing. The mean tape measure-pinch score was 3.5 points (range: 1-4) on a 5-point scale. One hand showed poorer function, corresponding to marked preoperative hypoplasia of the index donor finger. Wrist alignment and thumb opposition posture were maintained during the short-term follow-up period. Conclusions: Staged centralisation and pollicisation produced encouraging early functional outcomes in children with severe RLD. Pre-pollicisation-training to establish index-middle finger pinch after centralisation appeared to facilitate early acquisition of post-pollicisation-pinch and grasp, and may represent a simple, practical adjunct to standard surgical care. Level of Evidence: Level IV (Therapeutic).
