Purpose Scaphoid fractures, the most common carpal fractures, are prone to nonunion because of their retrograde blood supply. Delayed presentation increases the risk of nonunion and progression to scaphoid nonunion advanced collapse. Social determinants of health, as measured by Area Deprivation Index (ADI), Social Vulnerability Index (SVI), and Child Opportunity Index (COI), can influence timely presentation, increasing the risk of nonunion. This study aims to develop a novel artificial intelligence model to predict scaphoid nonunion rates using socioeconomic indices alone. Methods A retrospective review identified 107 patients with suspected scaphoid fractures (January 2018–June 2025) who presented within 5 years of injury. National ADI, SVI, and COI scores were obtained. A binomial regression was used to validate ADI, SVI, and COI scores to predict nonunion status. A multilayer neural network was trained on the indices to predict nonunion status. Model performance was evaluated with area under the curve, and Youden’s J statistic was maximized to determine sensitivity and specificity. Results Higher ADI (OR = 1.029; 95% CI, 1.009–1.049) and SVI (OR = 1.020; 95% CI, 1.006–1.035), and lower COI (OR = 0.986; 95% CI, 0.974–0.998) were independent predictors of nonunion on presentation, validating their usage. The neural network had an area under the curve of 0.879, and at a threshold of 0.21 (J = 0.707), the model achieved a sensitivity of 95.7%, specificity of 75.0%, precision of 0.512, and an F1 score of 0.667. Conclusions Our artificial intelligence model predicts nonunion status based purely on social determinants of health, emphasizing their influence on scaphoid fractures. Addressing these disparities is essential to improve timely access to care for injuries such as scaphoid fractures and may be crucial to other timely orthopedic fractures. Type of study/level of evidence Prevalence IIIb.
Purpose Emerging evidence demonstrates cost savings when low-acuity hand procedures are performed in office-based settings compared with hospital facilities or ambulatory surgery centers (ASCs). However, it is unclear whether these advantages translated into broader adoption of office-based care. Accordingly, this study sought to evaluate temporal trends in procedural setting and reimbursement rates for three common hand procedures. Methods A retrospective analysis was conducted using Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary and Physician Fee Schedule datasets from 2011 to 2023. All fee-for-service Medicare Part B claims for carpal tunnel release (CTR), trigger finger release (TFR), and de Quervain release (DQR) were included. The primary outcome was the shift in the place of service: office, outpatient hospital, inpatient hospital, or ASC. The secondary outcome was the facility and nonfacility reimbursements for each procedure. Poisson and mixed-effects regression models were used to evaluate temporal volume and reimbursement trends. Results From 2011 to 2023, ASCs were the dominant setting, accounting for 44.9% of CTR, 50.2% of TFR, and 53.3% of DQR procedures. The proportion of office-based procedures increased modestly across all procedures (CTR: 3.94% to 5.55%; TFR: 7.54% to 12.31%; DQR: 4.31% to 6.78%). Furthermore, although nominal reimbursements increased over time, overall inflation-adjusted reimbursements declined consistently after 2013. Notably, inflation-adjusted reimbursements across the 12-year period significantly decreased for TFR from $586.70 ± $183.98 to $496.64 ± $178.48 and CTR from $585.11 ± $44.93 to $489.69 ± $40.60. Conclusions Despite evidence supporting the safety and cost savings of office-based hand procedures, minimal migration toward office-based care was observed for low-acuity hand procedures. The authors hypothesize that a realignment of reimbursement policy may incentivize office-based care. Type of study/level of evidence Economic/decision analysis III.
Purpose Ulnar polydactyly (UP) is a common congenital upper limb anomaly, yet prospective data on inheritance patterns, phenotypic distribution, associated anomalies, and treatment outcomes remain limited. Methods We conducted a registry-based observational study of consecutive children with UP enrolled in a prospectively maintained congenital upper limb anomaly registry at a tertiary referral center between 2018 and 2025. Data included family history, pregnancy characteristics, Congenital Upper Limb Differences database classification of phenotypes (A1–A6 and B), laterality, associated anomalies and genetically verified syndromes, and interventions. We analyzed the strength of associations between hand presentation and associated anomalies using multivariable logistic regression. Results We included 98 patients with 160 affected hands. Fifty-four percent had a non-Nordic family background, substantially exceeding the proportion of individuals with a non-Nordic background in the general population. Forty-two percent reported a positive family history of UP. Type B UP predominated (85%). Associated lower limb anomalies occurred in 24% of patients. Phenotypes A and bilateral affection showed strong associations with lower limb anomalies and genetic syndromes and/or anomalies besides the limbs. Our unit performed all surgeries without any complications, yet we reoperated many patients after inadequate ligation of type B UP in the maternity wards. Conclusions Ulnar polydactyly comprises phenotypic subgroups with differing risks of associated anomalies, supporting a phenotype-based approach to clinical assessment. We recommend genetic evaluation for all patients with phenotype A and for those with bilateral type B with associated lower limb anomalies. In contrast, unilateral and bilateral type B without lower limb involvement or associated anomalies on routine clinical examination do not require further evaluation. Type of study/level of evidence Clinical II.
Purpose Type 2 diabetes mellitus is a risk factor for compressive neuropathy. The purpose of this study was to determine whether metformin use is associated with reduced rates of compressive neuropathy, primary nerve decompression surgery, and revision after carpal tunnel release and cubital tunnel release, while controlling for concurrent diabetes medications. Methods We performed a retrospective cohort study using the TriNetX federated research network. Adults with type 2 diabetes mellitus were stratified by metformin exposure, defined as at least 10 prescriptions over 5 years. The primary outcomes were incident compressive neuropathy and nerve decompression surgery. In a unilateral revision cohort, the outcome was ipsilateral revision between 30 days and 5 years after the index procedure. One-to-one propensity score matching balanced cohorts on demographics, comorbidities, and concurrent diabetes medications. Four prespecified medication-stratified sensitivity analyses addressed insulin, sodium-glucose cotransporter-2 inhibitors, and glucagon-like peptide-1 receptor agonists. Carpal tunnel release and cubital tunnel release revision results were pooled via fixed-effect meta-analysis. Results After matching, the primary analysis included 260,823 pairs. Metformin users had lower rates of nerve decompression surgery (0.60% vs 0.72%; odds ratio, OR, 0.831 [0.776–0.889]) and compressive neuropathy diagnosis (2.78% vs 3.05%; OR, 0.909 [0.879–0.941]). The surgery-level association was stronger without concurrent insulin (OR, 0.727 [0.662–0.799]) and attenuated to nonsignificance with concurrent insulin (OR, 0.948 [0.836–1.076]), though the diagnosis-level association persisted. Among patients with unilateral carpal or cubital tunnel syndrome, ipsilateral revision was less frequent in metformin users (pooled OR, 0.711 [0.533–0.950]). Metformin users also had lower vitamin B12 levels (mean, 646.4 vs 707.4 pg/mL), consistent with sustained metformin exposure. Conclusions Metformin use was associated with reduced incidence of nerve decompression surgery and ipsilateral revision after carpal tunnel release and cubital tunnel release in patients with type 2 diabetes mellitus, with directionally consistent effects across sensitivity analyses. These findings suggest that maintaining metformin therapy may carry benefit beyond glycemic control. Prospective studies are needed to validate these findings. Type of study/level of evidence Prognostic II.
Purpose The optimal surgical approach for retrograde intramedullary fixation (rIMF) of metacarpal fractures remains unclear. We hypothesized that a percutaneous approach for rIMF of metacarpal shaft fractures would exhibit improved functional outcomes compared to an open approach without increased incidence of extensor lag. Methods A retrospective cohort of patients who sustained a closed metacarpal shaft fracture and underwent rIMF through either a percutaneous or an open approach were identified. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, total active motion (TAM), grip strength (% of contralateral) and visual analog scale pain scores were collected at 1, 2, 4, 6, and 12 weeks after surgery. Additional outcome measures included surgical time, radiographic alignment, and instances of extensor lag. Results At a single level one trauma center, 54 patients, comprising 56 metacarpal shaft fractures, were retrospectively identified. Patients treated with a percutaneous approach demonstrated significantly improved TAM (248° ± 10° vs 228° ± 19°, P < .05), grip strength (95 ± 4 % vs 75% ± 6%, P < .05), and QuickDASH scores (2.5 ± 2.6 vs 10.5 ± 4.0, P < .05) through 2 weeks after surgery, with differences dissipating by 4 weeks, and no cases of extensor lag seen. Additionally, the percutaneous approach yielded significantly shorter intraoperative times (9.5 minutes vs 18.6 minutes, P < .05). Conclusions A percutaneous approach for rIMF of metacarpal shaft fractures significantly improved outcomes including TAM, grip strength, and QuickDASH scores through the 2-week postoperative period and demonstrated lower initial visual analog scale pain scores. Additionally, the percutaneous cohort experienced no cases of extensor lag at any time point. Type of study/level of evidence Therapeutic III.
