OBJECTIVE:Postoperative hand therapy is important for recovery and enhanced functional outcomes following hand surgery. Access to this essential care is limited in Alabama, however, particularly for vulnerable populations in rural areas where public transportation is scarce. These challenges are further amplified for patients who are unable to drive due to their injuries. This study aimed to quantify disparities and barriers to certified hand therapy access in Alabama. METHODS:Certified hand therapists in Alabama were identified through the Hand Therapy Certification Commission directory. Practice addresses were geocoded and paired with county center coordinates to calculate travel distances from each county center to the nearest certified hand therapist. These distances were then converted into one-way travel costs using Internal Revenue Service standard mileage rates. Counties were categorized by rurality using Rural-Urban Continuum Codes (RUCC) and assessed for social vulnerability using the Social Vulnerability Index (SVI), which considers socioeconomic, housing, and transportation factors. Statistical analyses, including t tests, χ2 tests, and multivariate regression, were used to evaluate patterns and predictors of travel costs. RESULTS:Alabama counties had a mean SVI of 0.67 ± 0.195-significantly higher than the national mean of 0.50 (P<0.0001). More than 80% of Alabama counties rank in the most vulnerable 50% of US counties, with Shelby County being the only county in the least vulnerable quartile (SVI 0.116). In addition, 36 counties (53.7%) are classified as rural (RUCC 4-9). Both SVI and RUCC independently correlated with increased travel costs. Multivariate regression modeling revealed that each unit increase in RUCC was associated with a $3.43 increase in travel costs (P<0.0001), and each 10% increase in SVI corresponded to a $1.64 increase in travel costs (P=0.006). These factors explained 56.4% of the variability in travel costs. Heatmaps visually highlighted higher travel costs in rural, socially vulnerable areas. CONCLUSIONS:Rural and socially vulnerable populations in Alabama face significant travel barriers to accessing certified hand therapy. The combined impact of geographic isolation and social vulnerability underscores the need for targeted interventions to ensure equitable access to postoperative care.

Purpose:Performing tenosynovial biopsy during carpal tunnel release (CTR) has emerged as a promising diagnostic tool for systemic transthyretin amyloidosis cardiomyopathy (ATTR-CM). Early detection is critical because therapies, such as Tafamidis, have been shown to significantly improve outcomes when initiated prior to heart failure. The Val122Ile mutation (V122I) of the transthyretin (TTR) gene causes hereditary ATTR amyloidosis (hATTR), is found almost exclusively in people of African descent, and is underdiagnosed. The importance of diagnostic feasibility of transverse carpal ligament (TCL) biopsy is critical in the African American population, who often have poorer outcomes from delayed treatment. Methods:We reviewed 22 studies published between 2017 and 2025 and conducted a retrospective cohort study of patients who underwent CTR at our institution between 2021 and 2025. Intraoperative TCL or A1 pulley specimens were routinely biopsied. All samples were analyzed for the presence of amyloid using Congo Red staining. Demographic data were extracted from the medical record. Results:Our literature review found that 10% to 30% of CTR specimens contained amyloid deposits, mass spectrometry was the superior analytic modality, and biopsying the TCL in high-risk patients had greater diagnostic yield. At our institution, 89 patients (61.8% African American and 38.2% Caucasian) underwent CTR with concurrent tenosynovial biopsy between 2021 and 2025. The mean age was 55.36 ± 12 years and 32.6% were men. All specimens were analyzed with Congo Red staining. Amyloid deposits were not identified in any specimens. Conclusions:Our negative findings with the largest studied African American population to date underscore the importance of further investigation to refine selection criteria, standardize sampling, and clarify the role of TCL biopsy in early detection of ATTR-CM. Type of study/level of evidence:Therapeutic III.

Introduction Current management via open dissection for cubital tunnel syndrome is efficacious; however, it can lead to lengthy recovery. Sonography can be utilized in open dissections for cubital tunnel syndrome to minimize incision lengths, but it has garnered interest in cadaveric studies for achieving entirely minimally invasive decompressions. Objective This study aimed to examine the feasibility of sonography in diagnosing cubital tunnel syndrome and propose a minimally invasive approach to decompression using a commercially available ultrasound-guided device, leveraging its success in carpal tunnel syndrome management. Methods Dissections were performed on three cadaveric arms. Presurgical mapping of the ulnar nerve was performed via ultrasonography, identifying the ulnar nerve traversing muscular and bony landmarks through the elbow. Operating bidirectionally via a single site at the level of the cubital tunnel, the carpal tunnel release system was utilized under ultrasound guidance, rigidly simulating surgical operation regarding time, technique, and care of dissection. Postoperative confirmation of decompression was achieved via open dissection. Results In all three specimens, successful fascial release was confirmed. There was no injury to the ulnar nerve itself or any motor branches, and there was no identifiable subluxation of the nerve with complete ranging of the elbow. Conclusions This study demonstrates the feasibility of in-office cubital tunnel decompression, addressing the growing demand for minimally invasive interventions. By adapting techniques from carpal tunnel syndrome management, this approach offers an alternative to traditional open surgery, particularly relevant amid limitations on operating theater access. Such innovative strategies hold promise for expanding surgical options and meeting the evolving needs of patients, emphasizing the importance of adapting established techniques to address emerging challenges in patient care.

Current management via open dissection for cubital tunnel syndrome is efficacious; however, it often leads to lengthy patient recovery. Sonography can be utilized in open dissections to minimize incision lengths, but it has garnered interest in cadaveric studies for achieving entirely minimally invasive cubital tunnel decompressions. Dissections were performed on three cadaveric arms. Pre-surgical mapping of the ulnar nerve was performed via ultrasonography, identifying the ulnar nerve traversing muscular and bony landmarks through the elbow. Operating bidirectionally via a single site at the level of the cubital tunnel, the carpal tunnel release system was utilized under live ultrasonographics, rigidly simulating surgical operation in regards to time, technique, and care of dissection. Post-operative confirmation of decompression was achieved via open dissection. In all three specimens, successful fascial release was confirmed. There was no injury to the ulnar nerve itself or any motor branches, and there was no identifiable subluxation of the nerve with complete ranging of the elbow. The operation itself was characterized by a quick learning curve as the final release was completed in seven minutes as compared to the 14 minute procedure time of the first operation. This study demonstrates the feasibility of in-office cubital tunnel decompression, addressing the growing demand for minimally invasive interventions. By adapting techniques from carpal tunnel syndrome management, this approach offers a safe and efficient alternative to traditional open surgery, particularly relevant amidst limitations on operating theater access. Such innovative strategies hold promise for expanding surgical options and meeting the evolving needs of patients, emphasizing the importance of adapting established techniques to address emerging challenges in patient care.

BACKGROUND:Traction neurectomy (TN) remains the standard of care for digital nerve management in partial and ray digital amputations but is associated with both neuroma formation and chronic postoperative pain. The purpose of this study is to evaluate if digital nerve coaptation (DNC) is associated with lower postoperative pain and complication rates compared to standard TN. We hypothesize that patients undergoing digital amputations with DNC will demonstrate lower postoperative complications, reduced rates of persistent pain, and fewer reoperations for nerve-related pain. MATERIALS AND METHODS:A retrospective cohort study was conducted, analyzing 95 patients who underwent partial or ray amputation at a single institution from 2019 to 2024. Patients were stratified by nerve management technique: DNC (n = 26) vs TN (n = 69). Primary outcomes included postoperative pain scores and complication rates including neuroma formation, infection, wound dehiscence, persistent pain, and functional stiffness. Pain scores were assessed using the Neuropathic Pain Scale (NPS, 0-100) and a numerical pain rating scale (NPRS, 0-10). Of the 95 patients, 48 (TN = 33, DNC = 15) were successfully contacted for postoperative pain assessment. Statistical comparisons were made using independent t tests, Mann-Whitney U tests, and chi-square analyses, with significance set at P  < 0.05. RESULTS:Patients with a digit amputation that underwent DNC experienced a lower percentage of complications compared to traction neurectomy (26.9% vs 55.1%, P  = 0.030). Furthermore, although not statistically significant, patients undergoing DNC reported lower average NPS (36.1 vs 43.8, P  = 0.263) and NPRS (3.79 vs 4.20, P  = 0.590) scores compared to neurectomy alone. This trend of decreased pain scores reported by patients who received DNC was true regardless of whether the amputation was due to acute injury or other causes. Similarly, patients described reduced pain at all amputation levels except the middle phalanx. CONCLUSIONS:These data indicate a positive observable outcome when comparing patients' postoperative pain and rate of complications with DNC vs TN at the time of amputation. Though a larger sample size is needed to solidify these results, these findings do suggest that DNC is a potentially superior alternative for nerve management in digital amputations, with the potential to improve long-term pain control and patient outcomes.

OBJECTIVES:Access to a certified hand therapist (CHT) plays a crucial role in enhancing postsurgical functional outcomes and reducing morbidity in complex hand surgery and trauma cases. Unfortunately, the availability of CHTs is uneven across regions, particularly in less populous states such as Mississippi. The financial and time-related burdens of traveling to a CHT to receive appropriate rehabilitation care affects patients recovering from hand surgery and hand trauma. This study investigated the accessibility of CHT services in Mississippi by analyzing physical proximity to CHTs and assessing the resultant economic implications, specifically focusing on transportation costs. METHODS:County-level distances to the nearest CHT were mapped and evaluated. The associated cost of personal vehicle transport was calculated using 2024 Internal Revenue Service standard mileage rates of $0.67/mi. Distance from a CHT and travel costs were stratified based on published 2023 Rural-Urban Continuum Codes. RESULTS:One-way analysis of variance revealed a significant difference in both the distance traveled to CHTs and the associated travel costs when stratified by Rural-Urban Continuum Codes (P < 0.05). On average, the distance to a CHT in Mississippi is 27.6 mi or 55.2 mi round trip, incurring a cost of $36.98 per visit. Residents of the farthest county from a CHT travel 86.4 miles or 172.8 miles round trip, however, resulting in a financial burden of $115.78 per visit to a CHT. CONCLUSIONS:This heightened cost for individuals residing farthest away poses substantial geographic, economic, and time-related barriers to accessing CHT services. Moreover, these barriers have a pronounced impact on the well-being of patients and their families, considering the frequency of required visits for adequate rehabilitation and functional recovery, typically occurring once or twice per week over several months. This study emphasizes the urgency of addressing disparities in CHT access to ensure equity across the state.

INTRODUCTION:Current management via open dissection for cubital tunnel syndrome is efficacious; however, it can lead to lengthy recovery. Sonography can be utilized in open dissections for cubital tunnel syndrome to minimize incision lengths, but it has garnered interest in cadaveric studies for achieving entirely minimally invasive decompressions. OBJECTIVE:This study aimed to examine the feasibility of sonography in diagnosing cubital tunnel syndrome and propose a minimally invasive approach to decompression using a commercially available ultrasound-guided device, leveraging its success in carpal tunnel syndrome management. METHODS:Dissections were performed on three cadaveric arms. Presurgical mapping of the ulnar nerve was performed via ultrasonography, identifying the ulnar nerve traversing muscular and bony landmarks through the elbow. Operating bidirectionally via a single site at the level of the cubital tunnel, the carpal tunnel release system was utilized under ultrasound guidance, rigidly simulating surgical operation regarding time, technique, and care of dissection. Postoperative confirmation of decompression was achieved via open dissection. RESULTS:In all three specimens, successful fascial release was confirmed. There was no injury to the ulnar nerve itself or any motor branches, and there was no identifiable subluxation of the nerve with complete ranging of the elbow. CONCLUSIONS:This study demonstrates the feasibility of in-office cubital tunnel decompression, addressing the growing demand for minimally invasive interventions. By adapting techniques from carpal tunnel syndrome management, this approach offers an alternative to traditional open surgery, particularly relevant amid limitations on operating theater access. Such innovative strategies hold promise for expanding surgical options and meeting the evolving needs of patients, emphasizing the importance of adapting established techniques to address emerging challenges in patient care.

PURPOSE:Access to a certified hand therapist (CHT) enhances postoperative functional outcomes and reduces morbidity in complex hand surgery and in traumatic injuries that necessitate targeted rehabilitation. However, CHTs are unequally distributed across regions, resulting in access disparities. This study investigated the accessibility of CHT services in the United States by analyzing physical proximity to CHTs and estimated associated personal ground transportation costs. METHODS:County-level distances to the nearest CHT were mapped and evaluated. Transportation costs were calculated using 2024 US Internal Revenue Service standard mileage rates ($0.67 per mile [$0.42/km]). Counties, selected as the geographic unit because of national data availability, were classified as Urban (1-3) or Rural (4-9) based on 2023 Rural-Urban Continuum Codes (RUCCs). Independent t tests compared travel distance in rural and urban counties. Multivariable analyses were performed to evaluate the association of RUCC with distance to nearest CHT. RESULTS:Distance traveled to nearest CHT provider and travel costs differed significantly between urban and rural counties. On average, individuals in rural counties must travel 38.75 miles (cost of $26.00) to reach a CHT, compared with 13.55 miles (cost of $9.10) for those in urban areas. Rural-Urban Continuum Code is a predictor of travel distance, with each increase in RUCC corresponding to a 4.77-mile increase in travel. CONCLUSIONS:Geographic disparities exist in access to CHTs across the United States, creating potential barriers to optimal rehabilitation outcomes. CLINICAL RELEVANCE:Limited access to CHTs places a substantial physical and potential economic burden on patients given the frequency and duration of rehabilitation. Further investigation into sociodemographic factors may help identify actionable solutions to improve equitable access nationwide.

Background: Though mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma (CTCL), it has no curative treatment. The aim of current topical and systemic treatment is centered around relieving symptoms and optimizing disease-free time. The use of surgical management to achieve the same goals of symptomatic reduction is not well described in the current literature.Methods: We present a case of refractory MF that failed chemotherapy, radiotherapy, and UV light therapy. Despite medical management, the tumor burden progressed to significant compression neuropathy of the ulnar and median nerves.Results: To reduce tumor burden and attempt to provide symptomatic relief, a surgical plan was developed to include radical resection of the tumor of the left upper extremity (LUE) with release of the cubital tunnel, carpal tunnel, Guyon canal, and coverage with split-thickness skin graft. The patient reported decreased symptomatology interfering with her daily activities and, overall, a better quality of life postoperatively.Conclusion: Surgical intervention, in addition to established medical standards of care, for symptomatic relief of compression neuropathy from tumor mass effect for refractory CTCL should be considered to achieve quality of life goals for patients.

Coverage of exposed tendon and bone in upper-extremity injuries presents a reconstructive challenge, often requiring staged procedures or complex microsurgical reconstruction techniques. We present a case series using a single-stage approach with intact decellularized fish skin graft laminated with a simultaneous split-thickness skin autograft. This technique aims to reduce the number of surgeries and decrease time to complete healing. Two cases are reported: a dog-bite forearm injury with exposed extensor tendons devoid of peritenon and a work-related crush injury of the hand with exposed metacarpal fracture. Following definitive debridement, both cases ultimately achieved successful wound healing with simultaneous placement of decellularized fish skin graft laminated with split-thickness skin autograft without further interventions.

Background:Incidence and prevalence data for congenital upper extremity anomalies in the literature are scarce due to lack of reporting requirements, absence of a centralized database, and insufficient referral networks. As the state's only pediatric hospital and congenital hand clinic, the University of Mississippi Medical Center (UMMC) is uniquely positioned to report the per capita rate of congenital upper extremity anomalies. Methods:Pediatric patients presenting from 2015 to 2020 were identified using International Classification of Diseases codes in the UMMC electronic medical record. Exclusion criteria included age older than 18 years at presentation and defects secondary to trauma. Diagnoses included polydactyly, syndactyly, reduction defects, club hand malformations, and syndromes with upper limb anomalies. Demographic data were collected including age, race, sex, maternal age, family history of extremity anomalies, geographic location, and insurance status. Geographic trends were identified, and results were presented in incidence of disease per 10,000 births. Results:A total of 477 pediatric patients presented with a congenital upper extremity anomaly from 2015 to 2020. The average rate of congenital upper extremity anomalies in Mississippi was 21.5 per 10,000 births. The 3 most common upper extremity anomalies were polydactyly (13.1 per 10,000 births), congenital trigger thumb (2.67 per 10,000 births), and syndactyly (1.66 per 10,000 births). The polydactyly group was further divided into preaxial (1.98 per 10,000 births) and postaxial (10.9 per 10,000 births) polydactyly. There was a male predominance in presentation with 60.4% (n = 288) of patients being male. Conclusions:In the past 5 years, only New York State has published similar findings delineating the incidence of congenital hand anomalies through their Birth Defect Registry. The prevalence of upper extremity defects presenting to UMMC from 2015 to 2020 was 21.5 per 10,000 births; however, 5 specific counties had a significantly higher prevalence, ranging from 53.65 to 63.97 per 10,000 births. To develop effective programs to comprehensively treat these pediatric patients, accurate reporting and data collection mechanisms are critical.

Tumoral calcinosis (TC) is a rare condition defined by the accumulation of calcium salts in soft tissues surrounding joints, most commonly large joints. Chronic joint inflammation in the setting of local hyperphosphatemia leads to interruption and dysfunction of tissue repair and generates breakdown products that subsequently calcify and accumulate. We present a case of a 42-year-old man with a history of end-stage renal disease on dialysis presenting to the clinic with a painless digital mass of his right long finger at the proximal interphalangeal joint. Our initial impression was a splinter abscess based on presentation and patient history. Although our patient’s presentation of traumatic, painless TC of the hand secondary to end-stage renal disease is rare, the pathogenic mechanisms behind TC support this presentation. The authors recommend including TC within the differential of presentations similar to that of chronic abscess or giant cell tumor, especially when their medical history includes end-stage renal disease.

Background Mercury, an element with threats of severe toxic insult to humans and no biological function, has a surprisingly extensive record of human exposure. Regardless of hesitancies toward its harmfulness, it has been historically identified with an almost supernatural power to provide protection from evil and sickness, give good fortune, lend aid in athletic undertakings, or even allow one to achieve immortality. Mercury poisoning is an iatrogenic disease even today as people attempt to achieve these effects through volitional injections into their body by practitioners. Although an uncommon practice in the United States, awareness of patient presentation after volitional injections of elemental mercury is necessary for appropriate treatment of these patients. We aim to increase awareness of the cultural practice of subcutaneous injections of mercury, as it is uncommonly seen in the United States, to contribute a broader understanding to the patient's medical presentation and describe an approach and the impact of medical and surgical intervention. Methods In this report, we describe a rare case of elemental mercury poisoning secondary to volitional subcutaneous injection to the arm. Initial management of care through chelation therapy and monitoring of renal and serum mercury levels in addition to symptoms of systemic spread was overseen by an internal medicine physician and poison control. Surgical intervention via full-thickness excision of the visible mercury to the right arm followed by local flap and skin grafting reconstruction was performed. Conclusions Mercury poisoning from intentional subcutaneous administration is an uncommon patient presentation in the United States; however, knowledge of management of this rare condition is important for effective management of iatrogenic mercury toxicity.

Background:Studies comparing carpal tunnel release with ultrasound guidance (CTR-US) to mini-open CTR (mOCTR) are limited. This randomized trial compared the efficacy and safety of these techniques.Methods:In this multicenter randomized trial, patients were randomized (2:1) to unilateral CTR-US or mOCTR. Outcomes included Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), numeric pain scale (0-10), EuroQoL-5 Dimension 5-Level (EQ-5D-5L), scar outcomes, and complications over 1 year.Results:Patients received CTR-US (n = 94) via wrist incision (mean 6 mm) or mOCTR (n = 28) via palmar incision (mean 22 mm). Comparing CTR-US with mOCTR, the mean changes in BCTQ-SSS (-1.8 versus -1.8; P = 0.96), BCTQ-FSS (-1.0 versus -1.0; P = 0.75), numeric pain scale (-3.9 versus -3.8; P = 0.74), and EQ-5D-5L (0.13 versus 0.12; P = 0.79) over 1 year were comparable between groups. Freedom from scar sensitivity or pain favored CTR-US (95% versus 74%; P = 0.005). Complications occurred in 2.1% versus 3.6% of patients (P = 0.55), all within 3 weeks postprocedure. There was one revision surgery in the CTR-US group, and no revisions for persistent or recurrent symptoms in either group.Conclusions:CTR-US and mOCTR demonstrated similar improvement in carpal tunnel syndrome symptoms and quality of life with comparable low complication rates over 1 year of follow-up. CTR-US was performed with a smaller incision and associated with less scar discomfort.

Purpose: The purpose of this study is to determine the public's perception of the scope of practice for oculofacial plastic and reconstructive surgeons (OFPRS). Methods: A 49-question survey was distributed by Qualtrics((R)) to a panel similar to the US demographic composition. Responses collected underwent bivariate statistical analysis. Result: A total of 530 responses were obtained, with most respondents being white, female, over the age of 35, from the Midwest, and with at least a college education or above. Most respondents did not think ophthalmologists or optometrists were surgeons, and only 158 people (29.8%) knew the primary specialty of OFPRS was ophthalmology. Board certification was preferred by 98.87% of respondents, and 95.28% preferred ASOPRS-trained OFPRS. Conclusions: Our study highlights the gap in knowledge about OFPRS as a field, the qualifications and training required, and the scope of practice. Notably, even for OFPRS-specific procedures, PRS remained the leading subspecialist chosen for interventions such as orbital decompression (58.5% vs. 71.5%), orbital reconstruction (57.9% vs. 74.2%), enucleation/evisceration (48.1% vs. 53.4%), optic nerve-related surgery (39.8% vs. 43.4%), orbital cancer resection (42.8% vs. 46.8%), and tear duct surgery (41.9% vs. 52.5%). Additionally, most respondents did not feel that facial fillers, laser skin resurfacing, eyelid cancer removal, or cataract surgery were within the OFPRS scope of practice.

Background: There are various anatomical descriptions of the pulley system of the fingers and thumb. The A0 pulley, often referred to as palmar aponeurosis of the fingers, is of keen interest, especially regarding surgical release of the A1 pulley for trigger finger; however, there has been no anatomical description of the A0 pulley in the thumb. Methods: Twenty-four cadaveric thumbs were dissected to expose the entire pulley system. Each structure, including the A2, Aob, Av, A1 pulleys, and any proximal transverse elements, were cataloged. Results: Three distinct transverse elements were identified proximal to the A1 pulley including: (1) the named ligament of Grapow; (2) the proximal commissural ligament and associated transverse fascial tissues; and (3) a definable A0, identified in 10/12 (83.3%) cadavers and 15/24 (62.5%) thumbs. Ten A0 pulleys occurred bilaterally, while 5 occurred unilaterally. Conclusions: The presence of an A0 pulley in greater than 80% of the studied thumbs serves as an important anatomic finding that should be considered in surgical treatment. An additional finding of importance is that the pulley system anatomy demonstrated variability in laterality. Based on these anatomic findings, not only can the A0 pulley be defined as a unique anatomic structure of the thumb, but its repair also has implications for successful surgical treatment of thumb pulley system pathologies.

Purpose Currently, no comprehensive database detailing topography and axon counts exists. This study aims to review the axon counts and topography of the major peripheral motor nerves of the upper extremity to allow for optimal surgical planning for peripheral nerve reconstruction via neurotization. Methods Peer-reviewed journal articles were identified through PubMed, ScienceDirect, Google Scholar, and CENTRAL. Studies were included for review based upon the identification of the described topography or axon count of any upper-extremity peripheral motor nerve. Animal research, laboratory studies, and unpublished studies were excluded from our review. A total of 43 studies were identified, and 38 of these met the inclusion criteria. Statistical analysis was performed to determine axon count averages for all upper extremity motor nerves identified in the included studies. Results Thirty-eight studies were reviewed, giving insights into the topography and axon counts of the major peripheral nerves of the upper extremity, including the brachial plexus and its terminal branches as well as common donor nerves such as the spinal accessory nerve and intercostal nerves. Studies showed considerable variability in reported axon counts. Conclusions Existing data were relatively weak and included several case reports and series. Taking this into consideration, we posit that there is a need for further studies of upper-extremity nerve axon counts that include large study populations and more consistent methods of nerve specimen analysis. Clinical relevance Understanding the topographical anatomy of donor and recipient nerves, as well as appropriately matching the motor axon counts for each donor and recipient, is helpful in upper-extremity nerve reconstruction.

Anatomical variations within Guyon's canal such as an accessory abductor digiti minimi are described as causes of ulnar nerve compression. Here we present a unique case of delayed ulnar neuropathy following treatment of left fourth metacarpal base fracture with percutaneous pinning fixation and an uncomplicated two month postoperative course. He returned with new ulnar sensory loss and motor weakness. EMG demonstrated nerve compression with CT identifying an accessory abductor digiti minimi in Guyon's canal. Following Guyon's canal release with partial accessory muscle resection, there was immediate sensory and progressive motor recovery with resolution of clawing. Delayed compression by an accessory abductor digiti minimi following trauma has not been described, suggestive of double-crush phenomenon. The accessory muscle was an asymptomatic variable (first "crush") and with the second "crush" of post-surgical changes resulting in pathological nerve compression. With delayed onset ulnar neuropathy after trauma, surgeons should consider possible accessory structures.

Thumb reconstruction following a traumatic injury challenge depends on the extent of the injury. Ideally, reconstruction should restore thumb length and position and retain thumb stability, mobility, and strength, while preserving sensation and aesthetics. Achieving these outcomes can be especially challenging in severe cases of soft tissue and bony loss. The authors present a case of a 20-year-old right-hand dominant female involved in a motor vehicle accident who sustained severe crush injuries and burns to her right hand. Her injuries included soft tissue and bony defects extending from the thumb to the distal radius, namely avulsion of the thumb and significant loss of the distal radial and carpal column, resulting in severe wrist instability. We employed a three-segment vascularized osteocutaneous fibula flap to reconstruct the thumb and wrist to restore bony construct, carpal support, and soft tissue coverage. Thumb motion could not be achieved, but this technique offered a sensate, functional post for opposition and the appearance of an anatomic hand. Because of this surgery, the patient was enabled to graduate from college and pursue full-time employment. The authors hope that this report will add to the fund of knowledge and surgeon armamentarium for similar devastating injuries demanding thumb and wrist reconstruction.

Total scalp avulsion is a time-sensitive, catastrophic injury requiring quick, complex decision-making. Traditionally, these injuries were treated with split-thickness skin grafts. With advancements in microsurgery, treatments evolved to scalp replantation, becoming the standard of care in scalp reconstruction. Although the integrity of the scalp’s blood vessels is pivotal for successful replantation, the authors believe that scalp replantation should be considered at all costs. In the presented case, a 54-year-old female presented to the emergency room following an incident with an auger that completely avulsed her scalp. She was taken back to the operating room, where scalp replantation was performed. Following replantation, scalp necrosis led to serial debridings in the operating room, and eventually, all of the scalp was debrided down to healthy tissue. Surprisingly, the galea survived despite this, which provided a healthy base for skin grafts. Before definitive coverage was placed, it was decided to utilize a bilaminar acellular dermal matrix along with negative pressure wound therapy to create a more robust bed of granulation tissue. After three weeks of this treatment plan, the patient returned to the operating room, where a healthy, viable bed of granulating tissue was revealed beneath the dermal matrix. Split-thickness skin grafts were taken from her thighs bilaterally and sewn together in a quilt-like fashion to cover the wound bed. The entirety of the graft healed without complication except for one small area that required full-thickness skin grafting in an outpatient setting. Even though the replantation ultimately failed, it allowed the galea to survive, which saved the patient from undergoing a free tissue transfer and allowed her scalp to be reconstructed with split-thickness skin grafts. Even in the setting of polytrauma, the authors hope that anyone treating a scalp avulsion would consider scalp replantation at all costs.