Introduction Isolated single-digit clubbing is an uncommon clinical finding that has been reported mainly in isolated case reports describing benign tumors of the distal phalanx, with limited characterization in the hand surgery literature. Methods A retrospective chart review was performed of patients presenting with single-digit clubbing to a tertiary referral center between 2006 and 2023. Patients with diffuse or bilateral clubbing, prior local trauma or infection, or systemic disease associated with clubbing were excluded. Medical records were reviewed for demographic information, clinical presentation, physical examination findings, imaging studies, histopathologic diagnosis, and postoperative outcomes. Results Six patients (4 women, 2 men; median age, 32 years) presented with progressive isolated clubbing and nail deformity involving a single digit, most commonly the middle finger (n = 4) and less commonly the index finger (n = 2). The median time from symptom onset to referral was 2 years (range, 1-10 years; mean, 3.2 years). All patients underwent clinical and radiographic evaluation and subsequently surgical excision, with histopathology demonstrating osteoid osteoma in five patients and enchondroma in one. Following operative treatment, all osteoid osteoma patients showed complete resolution of clubbing, whereas the enchondroma patient showed significant but incomplete improvement, with persistent residual clubbing. No complications, revision procedures, or recurrences were documented during a median postoperative follow-up of 7 years (range, 3-17 years). Conclusion Isolated single-digit clubbing is an uncommon but recognizable clinical finding that may be associated with benign distal phalanx tumors. In patients presenting with chronic pain and nail deformity in the absence of systemic illness or trauma, this physical sign should prompt evaluation for localized distal phalanx pathology. Level of Evidence Therapeutic Level V.

Background:The 2022 American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand (AAOS/ASSH) guideline discourages routine operative fixation of distal radius fractures (DRF) in patients aged 65 years or older. This study examined the impact of this recommendation on operative management patterns in this population. Methods:A retrospective, quasi-experimental before-after study was conducted, including all DRF diagnoses among patients aged 65 years or older at a tertiary medical center during 2012 to 2024. Annual age-standardized and sex-standardized DRF incidence and surgery rates were estimated. Multivariable logistic regression evaluated postguideline versus preguideline odds of surgery and model-based projection compared expected with observed postguideline surgery rates. Results:During the study period, 3,137 DRF cases were diagnosed with stable incidence. Surgery rates significantly increased among patients aged 65 to 69 years from 9% to 16% after guideline publication, whereas rates were unchanged in patients aged 70 years or older. Patients aged 65 to 69 years were nearly twice as likely to undergo operative management in the postguideline versus preguideline period. Model-based projection among patients aged 65 to 69 years predicted a postguideline surgery rate of 11%, whereas the observed rate of 16% represented a 44% relative increase. Conclusions:Despite a guideline discouraging operative management of DRF at ages ≥65 years, surgery rates did not decline, and increased in those aged 65 to 69 years, highlighting the limitations of an age-only treatment threshold. Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Large language models (LLMs) are increasingly used in orthopaedic education, but their performance on the 2025 Israeli Orthopaedic In-Training Examination (OITE) remains poorly defined. To compare the performance of two contemporary reasoning-oriented LLMs on the 2025 Israeli OITE and to identify item-level factors associated with correctness. All 95 multiple-choice questions (MCQs) from the 2025 OITE were analyzed. ChatGPT 5.1 thinking and Gemini Pro 3 thinking each answered all questions once using a standardized prompt. The primary outcome was question-level correctness according to the official answer key. Questions were annotated for question type, question stem word count, image presence, and model-reported certainty. Model-specific factors associated with correctness were assessed using logistic regression, and head-to-head comparisons were performed using the exact McNemar test and paired generalized estimating equations (GEE). Both models achieved identical overall accuracy (68/95, 71.6%), with no measurable difference on paired comparison (odds ratio [OR], 1.00; 95% CI, 0.58-1.73; P=1.000). Accuracy was substantially higher on questions without images than on image-containing questions (90.5% vs 56.6%). In model-specific multivariable analyses, image presence was independently associated with lower correctness for both ChatGPT (adjusted OR [aOR], 0.12; 95% CI, 0.04-0.40; P<.001) and Gemini (aOR, 0.08; 95% CI, 0.02-0.28; P<.001). For Gemini, longer question stem word count was independently associated with greater odds of correctness (aOR per 10 words, 1.47; 95% CI, 1.01-2.13; P=.042), and Application questions were associated with lower odds of correctness than Knowledge questions (aOR, 0.26; 95% CI, 0.08-0.85; P=.026). In the primary paired GEE model, no measurable difference in correctness was observed between Gemini and ChatGPT (OR, 1.00; 95% CI, 0.58-1.73; P=1.000), whereas Application questions (OR, 0.34; 95% CI, 0.14-0.84; P=.019) and image-containing questions (OR, 0.09; 95% CI, 0.03-0.24; P<.001) were associated with lower odds of correctness. ChatGPT 5.1 thinking and Gemini Pro 3 thinking demonstrated similar overall performance on the 2025 Israeli OITE, with identical crude accuracy and no measurable difference in paired comparative analyses. Both models were substantially less accurate on image-containing questions, and Application questions were also associated with lower correctness, particularly in Gemini-specific and paired analyses. These findings suggest that current LLMs may have value as adjunctive educational tools in orthopaedic knowledge domains, but they remain insufficiently reliable for unsupervised use, particularly in image-dependent and application-based settings. not applicable

The primary objective of this meta-analysis is to systematically evaluate and compare complication, reoperation, and hardware removal rates between volar and dorsal plating in the context of corrective osteotomy for dorsally-angulated distal radius malunions. An extensive search across the MEDLINE, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was conducted to identify studies reporting outcomes following corrective osteotomy for dorsally-angulated distal radius malunions. Coprimary outcomes included: the occurrence of major complications, minor complications, reoperation, and hardware removal rates. Meta-analysis comparing each outcome with further meta-regression model based on surgical approach to compare the odds for each outcome was built. A total of 403 patients were included; 253 patients underwent volar corrective osteotomy and 150 underwent dorsal corrective osteotomy. Mean follow-up was 30 months. Volar plating was associated with fewer reoperations (9% vs. 28%), less hardware removal (3% vs. 18%) and comparable major complications (5% vs. 6%) compared to dorsal plating. The adjusted model showed a significant reduction (approximately 85%) in the odds of reoperation and hardware removal in the volar group. There was no difference in major or minor complications between the groups. This study shows that volar plating for dorsally angulated distal radial osteotomy significantly reduces the odds of reoperation and hardware removal compared to dorsal plating, even after careful adjustment for potential confounders.

Objectives: This study investigates whether the intra-operative administration of intravenous tranexamic acid (TXA), known for its hemostatic and potential anti-inflammatory properties, affects the incidence of heterotopic ossification (HO) following surgery for elbow fracture-dislocations. Methods: Design: Prospective, randomized clinical trial. Setting: Hand and Upper Extremity Surgery Unit. Patient Selection Criteria: Patients aged 18 to 75 years with acute traumatic elbow fracture-dislocations requiring surgical management from June 1, 2016, to October 31, 2022, were eligible. Inclusion criteria included traumatic non-pathological elbow fracture-dislocations. Patients were randomized 1:1 to receive either intraoperative TXA or no additional treatment. Outcome Measures and Comparisons: The primary outcome was the occurrence of heterotopic ossification (HO), defined by new bone formation observed in radiographic exams during postoperative follow-ups. Secondary outcomes included the presence of clinically relevant HO, reoperation rate due to symptomatic HO, and time to HO reoperation. Compared were patients who received TXA with controls.

PURPOSE:The purpose of this prospective study was to evaluate the influence of perioperative glycemic control, as detected by glycosylated hemoglobin (HbA1c) levels, on clinical outcomes after open carpal tunnel release (CTR) surgery. METHODS:The demographic and clinical data of the study participants were prospectively collected prior to surgery and at one year postoperatively. Objective evaluations included grip and pinch strength, along with sensation testing over the index finger using Semmes-Weinstein monofilaments (SWMF). Subjective assessments, including pain intensity (measured by the visual analog scale (VAS)), the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the Mayo Wrist Score, were also recorded. RESULTS:The study included 50 patients, comprising 27 with type 2 diabetes mellitus (mean HbA1c: 7.49 ± 1.42) and 23 without diabetes. HbA1c levels were measured up to one month prior to surgery. No statistically significant differences were found in grip strength, pinch strength, or Semmes-Weinstein monofilament (SWMF) values pre- and postoperatively in both diabetic and non-diabetic groups. Pain intensity decreased in both groups at 12 months postoperatively, but the degree of pain improvement was not statistically different between groups. Both groups showed postoperative improvement in DASH and Mayo Wrist Scores, with no significant difference in the level of improvement between the groups. Pearson analysis showed no correlation between objective and subjective measures pre- and postoperatively and HbA1c levels. CONCLUSIONS:Elevation of perioperative HbA1c levels in diabetic patients did not negatively affect surgical outcomes compared to non-diabetic patients. Both groups demonstrated significant functional improvements, with no notable differences in recovery or postoperative hand function.

Dorsal lunate dislocation (DLD) is an exceptionally rare injury, typically resulting from high-energy trauma. Due to the scarcity of reported cases, its exact mechanism of injury is not well understood. This study aimed to present three cases of DLD treated at our institution and to perform a systematic review of the literature to evaluate the mechanisms of injury and treatment approaches for pure DLD. A retrospective review was conducted of three patients with pure DLD treated at a single tertiary care center. Data were collected through medical record analysis and radiographic review. Additionally, a systematic literature review was performed to identify reported cases of DLD. Patient demographics, mechanisms of injury, treatment modalities, and clinical outcomes were analyzed. We identified three cases of DLD, while the systematic review uncovered 17 additional cases. Overall, men represented 95% of cases, with high-energy trauma accounting for 85% of injuries. Forced wrist flexion was the most commonly reported mechanism, occurring in 55% of cases. Radiographic analysis showed concomitant wrist fractures in 55% of cases. Treatment strategies included fixation in 65% of patients, ligament repair in 45%, and lunate resection or proximal row carpectomy in 15%. The median follow-up duration was 12 months, with half of the patients achieving favorable outcomes. Notably, two of the three low-energy injury cases were associated with preexisting arthritis. Pure DLD is an extremely rare clinical entity, possibly resulting from axial loading on a flexed wrist or forced hyperflexion. Characteristic radiographic findings include disruption of Gilula's lines and dorsal displacement of the lunate on lateral radiographs. Optimal management involves initial closed reduction followed by surgical fixation and ligamentous repair when indicated to enhance outcomes and restore wrist function.

Introduction: Patients facing post-traumatic malunion or congenital hand differences often contend with functional and cosmetic issues. Traditional correction methods involve open osteotomy, marked by drawbacks like scarring, non-union risks, prolonged rehabilitation, and adhesions. We therefore introduce a novel minimally invasive technique called Minimally Invasive Corrective Osteotomy of the Hand (MICO), which can be performed under local anesthesia. MICO employs a low-speed, high-torque burr to address finger malunions and congenital anomalies. Case Report: A 49-year-old male patient, generally healthy and right hand dominant, presented with a post-traumatic left middle finger, middle phalanx malunion who underwent the MICO procedure, with a 1-year post-operative follow-up. Conclusion: Our findings suggest that MICO offers a straightforward, reproducible, and delicate solution for correcting hand malunions and congenital finger deformities, potentially mitigating the well-established disadvantages and complications associated with the traditional open approach. Although early results of MICO are promising, a larger case series is needed to evaluate the superiority of this technique compared with current open corrective osteotomy methods. Level of Evidence: IV Keywords: Osteotomy, minimal invasive surgery, finger deformity.

This systematic review and meta-analysis compare the incidences of complications, reoperations and hardware removal between anterior and dorsal plating after corrective osteotomy for dorsally angulated distal radial malunions. A total of 403 patients were included; 253 patients underwent anterior corrective osteotomy and 150 underwent dorsal corrective osteotomy. Mean follow-up was 30 months. Anterior plating was associated with fewer reoperations (9% vs. 28%), less hardware removal (3% vs. 18%) and comparable major complications (5% vs. 6%) compared to dorsal plating. The adjusted model showed a significant reduction (approximately 85%) in the odds of reoperation and hardware removal in the anterior group. There was no difference in major or minor complications between the groups. Surgeons should be fully aware of the increased risks when using dorsal plate fixation after corrective osteotomy for dorsally angulated distal radial malunions.

BACKGROUND:Surgeons disagree about the best surgical treatment for simple, displaced olecranon fractures. Although the tension band wiring technique and plate fixation are the most common surgical options for fixation, studies comparing both are limited. To date, there have been no randomized trials comparing patient-reported outcomes and complications at more than 5 years of follow-up. QUESTIONS/PURPOSES:(1) Does tension band wiring or plate fixation result in better ROM and patient-reported outcome scores for simple displaced olecranon fractures? (2) What is the risk of complications associated with each technique? METHODS:Between November 2012 and October 2017, 68 patients were treated for acute, displaced olecranon fracture in a hand and upper extremity surgery unit at a tertiary-care center. Patients 18 years or older with traumatic, nonpathologic, simple olecranon fractures who presented within 2 weeks of injury were considered potentially eligible. Based on that, 74% (50) of patients met the inclusion criteria; 16% (11) of patients declined to participate in the study, and another 10% (seven) were excluded because they did not meet the prespecified inclusion criteria. Patients were randomized on a 1:1 basis to either tension band wiring or plate fixation and were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. At the final follow-up interval, 16% (eight) were lost to follow-up: 4% (two) in the tension band wiring group and 12% (six) in the plate fixation group. The median follow-up time was 8 years (IQR 7 to 9 years). We evaluated complications at a minimum of 6 years after surgery. The primary outcome measure was the 1-year postoperative DASH score. Additional outcome measures included the patient-reported Oxford Elbow Score, ROM, and the proportion of patients in each group who reported hardware-related symptoms and had subsequent implant removal or postoperative infection. RESULTS:No differences were observed in the DASH score (tension band wiring 18 [range 3 to 65] versus plate fixation 24 [range 3 to 52], median difference -6 [95% CI -12.7 to 14.9]; p = 0.73), Oxford Elbow Score (tension band wiring 36 [range 10 to 48] versus plate fixation 39 [range 17 to 47], median difference -3; p = 0.53), or all ROM measurements (p > 0.05) between the groups at 1 year of follow-up. The odds of having surgery for symptomatic implant removal were lower for plate fixation than for tension band wiring (one of 19 versus eight of 23, OR 9.6 [95% CI 1.08 to 85.7]; p =0.02); the odds of infection, however, were higher in the plate group (three of 19 versus 0 of 23; p = 0.048). CONCLUSION:No differences were observed between the two techniques in terms of ROM or patient-reported outcomes. Surgeons should consider that although the risk of implant removal is higher in tension band wiring, patients older than 85 years undergoing plate fixation for simple olecranon fractures are at a greater risk of postoperative infection. LEVEL OF EVIDENCE:Level I, therapeutic study.

Background:Immediate postoperative pain relief following arthroscopic partial meniscectomy remains a critical contributor to improved patient experience, early recovery of range of motion, and enhanced rehabilitation. Purpose:To evaluate the effect of intra-articular versus extra-articular bupivacaine on pain intensity and analgesic intake after arthroscopic partial meniscectomy. Study Design:Randomized controlled trial; Level of evidence, 1. Methods:This was a prospective double-blind, randomized clinical trial. All patients included underwent arthroscopic partial meniscectomy under general anesthesia. Patients were randomized into 2 groups, with 20 patients in each group. At the conclusion of the arthroscopic procedure, the intra-articular group received 10 mL 0.5% bupivacaine introduced intra-articularly and 10 mL isotonic saline 0.9% infiltrated subcutaneously around the portals. The extra-articular group received the isotonic saline intra-articularly and the bupivacaine around the portals. The primary outcome was the visual analog scale (VAS) for pain. Assessments were performed 0 to 0.5, 1 to 2, 2 to 4, and at 24 and 48 hours postoperatively. In addition, analgesic and narcotic consumption was monitored. Results:There were no differences between the groups in terms of patient demographics. VAS scores for the intra-articular group were 6, 8, 3.25, 4.3, and 4.5 at 0 to 0.5, 1 to 2, 2 to 4, 24, and 48 hours postoperatively, respectively. VAS scores for the extra-articular group were 3.8, 5, 2.9, 5.2, and 5.25, respectively. No statistically significant differences were observed between the 2 groups regarding pain intensity at all time points. There was also no statistically significant difference in analgesic consumption. Dipyrone was the preferred drug by patients from the intra-articular group, while the extra-articular group preferred to use opioids and nonsteroidal anti-inflammatory drugs. Conclusion:There were no differences in pain severity and analgesic intake between intra- or extra-articular bupivacaine administration after arthroscopic partial meniscectomy.

Objectives: Frostbite refers to the freezing of body tissue which is caused by prolonged exposure to cold temperatures and results in tissue destruction. Tissue damage is due to both immediate cold-induced cell death and the more gradual development of localized inflammatory processes and tissue ischemia. A detailed treatment plan based on the current UpToDate literature is needed to decrease morbidity and mortality rates. Methods: The United States National Library of Medicine (PubMed/Medline), EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews were systematically searched to identify publications relevant to this review. Conclusion: In this review, we present the current knowledge on the diagnosis and treatment of frostbite injuries. We then provide an extended and detailed treatment plan, from first aid in the field to treatment of short and long-term complications . (c) 2022 Elsevier Ltd. All rights reserved.

Objective: To evaluate the long-term outcome in patients after radial head resection surgery for isolated Mason type III radial head fractures. Design: An observational retrospective case series. Setting: A Hand and Upper-Extremity Surgery Unit in a tertiary care center. Patients: Data were collected from files of patients who were operated between the years 1980 and 2020. Of 352 patients who underwent surgery for radial head fractures, 25 patients were eligible and were enrolled in the study. Intervention: All participants underwent radial head resection surgery and a follow-up clinical and radiographic evaluation by 2 senior orthopaedic surgeons. Outcome measurements: Objective evaluation included active range of motion of the elbow and wrist joints, ulnohumeral angle, key pinch and grip measurements, and radiographic imaging of elbow and wrist joints. Subjective evaluation included visual analog scale measurements, disability of arm shoulder and hand questionnaire, Mayo wrist score, Michigan hand outcome, and Oxford elbow score. Results: The mean follow-up was 18 years. Mean elbow range of motion and mean grip strength were lower in the operated hand, as compared to the contralateral hand. Mean proximal radial migration was 1.6 mm. Mean results of visual analog scale, disability of arm shoulder and hand, Mayo wrist score, Michigan hand outcome, and Oxford elbow score indicated good functional outcome and high patient satisfaction. Conclusions: In our study population, long-term functional outcomes after radial head resection were encouraging. Thus, this procedure may be considered as a surgical alternative when radial head reconstruction or replacement fails. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

In humans, mutations in the PIEZO2 gene, which encodes for a mechanosensitive ion channel, were found to result in skeletal abnormalities including scoliosis and hip dysplasia. Here, we show in mice that loss of Piezo2 expression in the proprioceptive system recapitulates several human skeletal abnormalities. While loss of Piezo2 in chondrogenic or osteogenic lineages does not lead to human-like skeletal abnormalities, its loss in proprioceptive neurons leads to spine malalignment and hip dysplasia. To validate the non-autonomous role of proprioception in hip joint morphogenesis, we studied this process in mice mutant for proprioceptive system regulators Runx3 or Egr3 . Loss of Runx3 in the peripheral nervous system, but not in skeletal lineages, leads to similar joint abnormalities, as does Egr3 loss of function. These findings expand the range of known regulatory roles of the proprioception system on the skeleton and provide a central component of the underlying molecular mechanism, namely Piezo2 .

Epithelioid sarcoma (ES) of the hand is a rare, aggressive cutaneous malignancy with high rates of recurrence, metastases and mortality. With an incidence rate of 0.4 cases/y per one million population, which compromise for approximately 1-1.4% of all soft tissue sarcoma, ES accounts for 10% of soft tissues sarcomas of the hand and foot. Its aggressiveness and propensity to spread and metastases without being noticed, makes it unique and potentially lethal. Missed or delayed diagnosis are often encountered as this tumor can mimic variety of different entities and due to the infrequent nature of this lesion, treatment options are still controversial. The authors provide systemic review of the current literature on epidemiology, etiology, pathogenesis, management and outcomes of this disease as well as a case presentation and a proposed treatment algorithm. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities and performance status of the patient. Emphasis on a multidisciplinary coordinated care is crucial as early diagnosis and treatment can decrease morbidity and mortality rates.

Merkel cell carcinoma (MCC) is a biologically aggressive neuroendocrine tumor of the skin. There are roughly 1500 new cases of MCC diagnosed every year in the United States, with an increased incidence over the past 15 years reaching up to 8%. Epidemiological studies show that the highest MCC incidence is seen in men older than 65 years, with a ratio of 0.23 per 10,000 among whites. Merkel cell carcinoma of the skin most commonly presents as a single, rapidly growing, flesh-colored, painless mass. Because MCC is uncommon, histopathological examination is usually delayed. Because of the high mortality rate associated with this aggressive tumor, a multidisciplinary panel is recommended to ensure high-quality coordinated care. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities, and performance status of the patient. We report a case of MCC to alert medical professionals of this potentially fatal tumor, as early diagnosis and treatment may improve morbidity and mortality rates.

Background: Lateral epicondylitis is a tendinopathy of the common extensor origin at the elbow. When traditional conservative treatment fails, more effective therapies are needed. Vergenix Soft Tissue Repair (STR) Matrix (CollPlant Ltd., Ness-Ziona, Israel) is an injectable gel composed of cross-linked bioengineered recombinant human type I collagen combined with autologous platelet-rich plasma (STR/PRP). The complex forms a collagen-fibrin matrix that promotes cell migration and tissue repair. Based on positive outcomes from preclinical trials, this study is the first clinical trial of STR/PRP on tendinopathy. We hypothesized that STR/PRP would he a safe and effective treatment for lateral epicondylar tendinopathy. Methods: Patients with chronic lateral epicondylitis underwent treatment with STR/PRP. Outcome assessment included grip strength, functional disability, and changes in sonographic tendon appearance for up to 6 months after treatment. Results: The study enrolled 40 patients. No systemic or local severe adverse events were reported. Clinical evaluation revealed an improvement in the mean Patient-Rated Tennis Elbow Evaluation score from 64.8 before treatment and showed a 59% reduction at 6 months. The 12-Item Short-Form Health Survey questionnaire showed improvement from a mean score of 30.7 to 37.7 at the final follow-up. Grip strength increased from 28.8 kg at baseline to 36.8 kg at 6 months. Improvements in sonographic tendon appearance were evident among 68% of patients. Conclusion: STR/PRP is a safe treatment that effectively induces clinically significant improvements in elbow symptoms and general well-being as well as objective measures of strength and imaging of the common extensor tendon within 6 months of treatment of elbow tendinopathy recalcitrant to standard treatments. (C) 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: Patients with peripheral neuropathy and pressure under a relatively plantar deviated metatarsal head frequently develop plantar foot ulcers. When conservative management with orthotics and shoes does not cure the ulcer, surgical metatarsal osteotomy may be indicated to relieve the pressure and enable the ulcer to heal. The purpose of this study is to evaluate the use of a mini-invasive floating metatarsal osteotomy in treating recalcitrant ulcers or recurrent ulcers plantar to the metatarsal heads in patients with diabetes mellitus (DM) related neuropathy.Methods: Computerized medical files of patients with diabetic neuropathy treated with an osteotomy during 2013 and 2014 were retrospectively reviewed. There were 20 osteotomies performed on 17 patients (mean age 58 years). The patients had a diagnosis of DM for a mean of 17 years. All ulcers were University of Texas grade 1A; mean ulcer age was 19 months.Results: After 17/20 operations, the ulcer completely resolved after 6 weeks and did not recur after a mean follow-up of 11.5 months. One patient developed an early post-operative infection with osteomyelitis at the osteotomy site (proximal shaft of the fifth metatarsal) that needed debridement and IV antibiotics. In the other 19 cases, the surgical wound healed within 1 week. Asymptomatic radiological non-union developed in six cases (30 %).Conclusions: Mini-invasive floating metatarsal osteotomy can cure resistant and recurrent University of Texas grade 1A ulcerations plantar to the metatarsal heads in neuropathic patients.

Purpose The nonspecific terms “wrist sprain” and “suspected occult bony injury” are frequently documented as diagnoses in occult paediatric wrist injuries. To date, however, no one has accurately defined their true underlying pathology. The primary objective of this study was to identify the true pathoanatomy of occult acute paediatric wrist injuries. Our secondary objective was to compare our findings with existing adult data in order to determine any population differences that might be clinically relevant. Methods We performed a single-centre retrospective case series evaluating MRI findings in acute paediatric wrist injuries presenting to the hand injury unit between 2011 and 2014. All patients underwent standardised radiographs of the wrist and, where clinically indicated, of the scaphoid. Where no bony anomaly was identified, MRI scanning was offered. Cohen's kappa coefficient was used to calculate the agreement between clinical and MRI diagnosis. Results 57 patients met the final inclusion criteria. Occult fractures and bony contusions comprised the majority of the pathologies, at 36.5 and 35.0 %, respectively. There were no cases of isolated soft-tissue injury. MRI effected management change in 35.1 % of cases. Paediatric wrists demonstrated differences in injury pattern and distribution when compared to an adult population. Conclusion This study defines for the first time the true pathology of occult paediatric wrist injuries. The current definition of a wrist sprain was not applicable to a single case and therefore appears to be inappropriate for use in the paediatric population. A precise knowledge of the likely pathology facilitates accurate information delivery whilst reducing parental uncertainty and treatment variation.