Background: Symptomatic malunion following distal radius fracture can adversely impact wrist function. Corrective osteotomy, utilising volar, dorsal or dual approaches, is a common treatment option. This study aimed to review the literature and compare the outcomes of these different surgical approaches. Methods: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted, including studies comparing volar, dorsal or dual approaches in patients aged ≥16 years. Data on patient-reported outcome measures (PROMs), pain scores, grip strength, range of motion (ROM), radiographic alignment, graft use, union rates and complications were extracted and analysed via an exploratory network meta-analysis. Results: A total of 20 studies encompassing 517 wrists were included. All approaches demonstrated improvements in PROMs, functional outcomes and radiographic alignment. Analysis suggested comparable effectiveness of dorsal and volar approaches in improving ROM and pain. Dual approaches showed similar Disabilities of the Arm, Shoulder and Hand (DASH) scores to volar. No statistically significant differences were observed between approaches in improving radiographic alignment. Subgroup analysis revealed potential benefits of the dual approach over the volar for intra-articular malunions, particularly correction of radial inclination and ulnar variance. Conversely, the volar approach may be more effective than the dorsal in correcting ulnar variance in extra-articular malunions. Graft utilisation did not significantly impact union rates across any approach. Overall complication rates were low, but the dorsal approach exhibited a higher rate of hardware removal. Conclusions: This exploratory analysis found no definitive evidence to favour one surgical approach over another, though methodological limitations preclude firm comparative conclusions. Current evidence supports individualised approach selection based upon malunion configuration, patient factors and surgeon experience. Prospective comparative studies are needed to establish definitive comparative effectiveness. Level of Evidence: Level III (Therapeutic).

Background: Diagnosing unilateral digital nerve injuries in small or already closed wounds is challenging, as clinical tests may be unreliable. Routine surgical exploration, although traditionally recommended, can represent an unnecessarily invasive procedure in cases without nerve rupture. High-resolution ultrasonography (US) offers a potential minimally invasive alternative. This study aimed to assess the reliability of US for evaluating unilateral digital nerve injuries in cases with small or previously sutured wounds. Methods: We retrospectively reviewed 19 digits from 19 patients with suspected unilateral digital nerve injury between April 2016 and December 2024. All underwent US evaluation within a mean of 8.9 days after injury. Injuries were classified as complete, partial or no tear based on long-axis US findings. Treatment decisions were guided by the US. Surgical findings were compared with preoperative US results. Clinical outcomes were assessed by pain resolution, numbness and sensory recovery. Results: US evaluation was feasible in all cases without local anaesthesia or complications. Nine patients had complete tears, six had partial tears and four had no tears. Twelve underwent surgery, and intraoperative findings matched US findings in all cases (100% accuracy). The remaining seven patients were managed conservatively. At follow-up (mean 6.6 months), all patients achieved improvement of numbness, hypaesthesia and local wound pain. Near-normal sensory recovery was achieved in 6/10 surgical patients and 4/6 conservative patients. No patients required additional treatment at the final follow-up. Conclusions: Early US evaluation is a reliable, safe and minimally invasive method for diagnosing unilateral digital nerve injuries in small or previously sutured wounds. This approach may prevent unnecessary surgical exploration in intact nerves and provide accurate guidance for treatment selection. Level of Evidence: Level III (Diagnostic).

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).

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).

Background: Metacarpal neck fractures account for approximately half of all hand fractures; however, there is no consensus on which surgical approach should be used for these fractures. This study aimed to compare the clinical and radiological outcomes of open reduction internal fixation (ORIF) and closed reduction percutaneous pinning (CRPP) for fifth metacarpal neck fractures. Methods: A total of 71 patients who underwent ORIF or CRPP for fifth metacarpal neck fractures between 2020 and 2024 were retrospectively evaluated. Patients were divided into two groups: ORIF (n = 31) and Kirschner (K)-wire (n = 40). Patient characteristics, follow-up durations, clinical outcomes and complications were examined and compared between the two groups. Clinical outcomes were evaluated using the visual analogue scale (VAS) and Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) scores. The grip strength of the patients was measured on the contralateral arm using a Jamar dynamometer and compared between the groups. Angulation and shortening of the fifth metacarpal were measured based on preoperative and postoperative radiographs. Results: There was no statistically significant difference in clinical and functional outcomes between the two groups. Postoperative grip strength, radiological results (angulation and shortening) and follow-up duration were similar between the groups. The complication rate was significantly higher in the ORIF group than in the K-wire group. Conclusions: ORIF was not superior to CRPP in the surgical management of fifth metacarpal neck fractures. Considering the higher complication rate, the use of open reduction plate screw fixation as the first option for fifth metacarpal neck fractures is not recommended. Level of Evidence: Level III (Therapeutic).

Subcutaneous rupture of the flexor carpi radialis (FCR) tendon from scapho-trapezio-trapezoid (STT) osteoarthritis is a rarely reported and diagnosed condition. A 65-year-old female presented in the clinic with wrist pain aggravated with movement. On physical examination, there was a 2-cm soft elastic mass at the radial side of the volar wrist. There was no tenderness, but pain was elicited with range of motion. Computed tomography confirmed an osteoarthritic STT with large spurs. Magnetic resonance imaging (MRI) showed impingement on the tract of the FCR associated with synovitis. Complete rupture was noted intraoperatively. Interpositional arthroplasty with palmaris longus tendon ball transfer was done after removing the bone spurs and minimal resection of the joint. At follow-up 4 months later, the patient was pain-free after a brief period of immobilisation. We present a novel approach to STT osteoarthritis with FCR rupture, which avoids the complications and disadvantages of STT fusion, promoting early rehabilitation. Level of Evidence: Level V (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).

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: Ray amputation is an uncommon but occasionally necessary procedure in select clinical scenarios. The ray can be resected at different skeletal levels. This systematic review aimed to evaluate the outcomes following single central ray amputation, with particular attention to functional recovery, return to work and complications and compare them by bony resection level. Methods: A systematic review of the literature was undertaken, identifying 25 studies reporting on 238 patients who had undergone single central ray amputation. Extracted data included range of motion (ROM), grip strength, return to work, patient-reported outcome measures (PROMs) and post-operative complications. Results: Of those reported, 90% of patients achieved a 'full' ROM following surgery. The mean time off work was 95 days, with 71% returning to their previous occupation. Average grip strength was 69% of the contralateral hand. No technique emerged as superior for the outcomes measured. Functional tests and PROMs were infrequently reported. Complications such as scissoring, malrotation and painful neuroma were described. Conclusions: The overall quality of evidence was low, with considerable heterogeneity between studies, thereby limiting direct comparisons. The most important determinant of outcome appeared to be the degree of concomitant trauma sustained by the remaining structures of the hand. Level of Evidence: Level IV (Therapeutic).

Synovial chondromatosis commonly involves larger joints in the body, like the knee, elbow and hip. Upper extremity small joint involvement is rare and limited to case reports in the literature. Non-specific clinical and radiological features are a diagnostic challenge, often delaying accurate diagnosis. We present a series of five patients with intra- and extra-articular synovial chondromatosis of the hand and wrist treated by open as well as arthroscopic methods. The treating surgeon must consider it as a differential diagnosis for swellings around the hand and wrist. A review of literature and our experience from these cases suggests that excision/loose body removal in cases of synovial chondromatosis must be supplemented with a total/subtotal synovectomy to reduce the incidence of recurrence. Level of Evidence: Level V (Therapeutic).

Phosphaturic mesenchymal tumour (PMT) is a rare neoplasm that can occur with or without tumour-induced osteomalacia (TIO). While PMTs commonly arise in the lower extremities or head and neck, digital involvement is rare. A 70-year-old man presented with a 12-year history of an enlarging subcutaneous mass on the dorsal aspect of his left ring finger. Imaging studies suggested an organised thrombus within a venous malformation. Marginal excision was performed, and histopathological examination revealed a lesion composed of capillaries and small vessels surrounded by spindle cells with small ovoid nuclei, showing immunopositivity for somatostatin receptor 2, CD56, ERG and focally fibroblast growth factor-23 (FGF23). These findings were consistent with a diagnosis of PMT, mixed connective tissue and non-phosphaturic variant. No recurrence has been observed at 4 years and 6 months postoperatively. This report emphasises the diagnostic difficulty of PMTs in atypical locations and the utility of immunohistochemical profiling in confirming the diagnosis. Level of Evidence: Level V (Therapeutic).

Background: Acute peri-scaphoid calcific deposition (PSCD) is usually misdiagnosed as an avulsion fracture of the scaphoid. This study aims to describe the clinical presentation and radiographic features of PSCD. Methods: Twelve patients with PSCD were reviewed retrospectively. The data with regard to age, sex, side involved, history of trauma, duration of symptoms, time to presentation, symptoms and signs at presentation, pain score at presentation and final follow-up, radiological investigations, treatment and duration of follow-up were recorded. Results: All patients were female with an average age of 37.0 ± 10.1 years old. The right wrists were involved in six patients. The PSCD was found around three different locations, which were the dorsal edge, the tubercle and the radial side of the scaphoid. The average visual analogue scale at the first presentation and the last follow-up were 6.9 ± 1.1 and 0.7 ± 0.8, respectively. The patients were followed up for 5.4 ± 3.0 weeks. Conclusions: Acute PSCD predominantly affects young and middle-aged women and is most commonly located at the dorsal edge, tubercle and radial side of the scaphoid. Conservative treatment typically yields favourable outcomes. Level of Evidence: Diagnostic (Level V).

Background: To compare the amount of radiation exposure received by the surgeon during volar locking plate fixation for distal radius fractures using an image intensifier (II) and a flat panel detector (FPD). Methods: We included 40 patients who underwent open reduction and internal fixation using a volar locking plate for isolated distal radius fractures. Surgeons wore thermoluminescent dosimeter badges at six anatomical sites: both thumbs, thyroid, at eye level (to estimate the eye lens dose), chest (under the protector) and abdomen (under the protector). The badges were replaced monthly, and equivalent radiation doses were measured. Fluoroscopy time was recorded from operative notes. Sixteen cases operated using an II-equipped C-arm between August and October 2020 were classified as Group II. Twenty-four patients treated between September and November 2024 using an FPD-equipped system comprised Group FPD. Results: Operative time was similar between groups (57 vs. 56 minutes). Fluoroscopy time was 324 seconds in Group II and 239 seconds in Group FPD and air kerma per case was comparable (6.6 vs. 5.8 mGy). Equivalent dose per second was higher with FPD for both thumbs (right: 2.23 vs. 1.70 μSv/s; left: 9.57 vs. 2.07 μSv/s), with no significant differences in eye-lens or thyroid exposure. Conclusions: The equivalent radiation dose per second of fluoroscopy was significantly higher in Group FPD for both thumbs compared to II systems. No significant differences were observed in radiation exposure to the lens or thyroid between groups. Level of Evidence: Level IV (Therapeutic).