Treatment with a variable angle locking plate can, in theory, maintain near anatomic reduction of intra-articular distal radius fractures, but it is unknown to what extent reduction is maintained as measured by computed tomography. We assessed changes in radiographic fracture position 1 year post-operatively. We included 73 patients of whom 66 patients (90%) had radiographs available for review at 1 year post-operatively. We found a small (less than 2 mm or 2°) but statistically significant change in several measures. Accounting for inter-observer variability, this is probably within measurement error. We found no difference in change in fracture position or range of motion, grip strength or patient-reported outcome between the use of one or two distal rows of screws. Our results show that minimal changes in reduction can be expected after volar plate fixation in most patients. We recommend using only one screw row routinely, limiting costs, surgical time and the risk of misplacement of screws. Level of evidence: IV

Learning Objectives: After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery. Summary: Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

Thumb hypoplasia modified Blauth III B is usually treated by pollicization or, less commonly, by toe transfer. Both procedures always result in the resection of a body part, but with good cosmesis and acceptable function. We describe an intermetacarpal I/II arthrodesis with autologous bone graft augmentation to lengthen and stabilize the loose thumb. Clinical data were collected from nine patients, median age at surgery 3 years 8 months, with more than 7 years of follow-up. The results showed a grip strength on the Jamar dynamometer of approximately 61% of the unoperated hand. The Quick-DASH score was 11. The reconstructed thumb was 0.8 cm thinner and 1.9 cm shorter. Overall satisfaction on the VAS, with an average of 1.5 out of 10, is excellent with a partially usable thumb on a hand with five rays. The described procedure is a reliable treatment option with satisfactory results. In addition, none of the patients lost pincer grip between the second and third digit, but their thumb gained new function. Especially in environments where physical integrity has a high value, thumb construction instead of replacement could be considered.

Twenty-three patients with a mean age of 52.7 years underwent pulley reconstruction using the Okutsu double- or triple-loop technique after iatrogenic or traumatic rupture of at least two adjacent flexor tendon pulleys in the finger and distal palm; mean age of injury was 4.77 years. The mean follow-up was 4.66 years after reconstruction of mostly A2 pulleys in a single surgeon setting. Outcome measures included ROM, NRS pain, satisfaction, Disabilities of Arm, Shoulder and Hand Questionnaire (DASH) and Krimmer score, Buck–Gramcko score, Jamar grip strength, pinch grip, and vigorimetry compared to the uninjured side. The median patient satisfaction score was 6.6/10. Hand function using the DASH score was 9.5. Grip strength on the Jamar Dynamometer showed only a slight reduction of 13% compared to the uninjured side. The resultant force of the operated fingers on the vigorimeter is almost 60% of that of the contralateral side, and the finger-palm distance of the operated finger was reduced from 2.2 cm to 1.45 cm. Other functional scores, such as Krimmer (82.2) and Buck-Gramcko (10.9), support these good results. The follow-up of patients more than 4.5 years after reconstruction of the A2 and A3 flexor tendon pulley using the double- or triple-loop technique showed acceptable patient satisfaction and good function of the finger in everyday life.

Introduction: Although Covid-19 and especially lockdown periods have affected our everyday live, its impact on hand traumatology is under investigated. Materials and methods: We retrospectively analyzed all patients presenting at a FESSH accredited HTRC and level 1 trauma center in Germany during the Covid-19 lockdown period and an equivalent timeframe in 2019 regarding incidence of hand trauma, injury mechanism, type of injury and hand surgeries. Results: 338 patients presented at our department with acute hand injuries. A significant reduction of work-related accidents was found during lockdown contrary to an increase of do-it-yourself related trauma. Although the incidence of hand trauma decreased during lockdown by 18%, the rate of hand surgery increased in absolute and relative numbers. Conclusions: Although Covid-19 has negatively impacting elective and semi-elective surgeries, acute hand surgery has gained in importance represented by a shift from work related to do-it-yourself trauma and an increased rate of surgical treatment. Level of evidence: IV (therapeutic).

Background: The balance of the finger is maintained through a complex interaction of intrinsic and extrinsic mechanisms that coordinate motion, stability and force transmission across the metacarpophalangeal and interphalangeal joints. Although flexor muscle mass exceeds that of the extensors, equilibrium is achieved through precisely calibrated tendon positioning, lever arms and passive restraints. This balance permits efficient motion with minimal energy expenditure and allows rapid transition between power and precision function. Physiological balance: Active balance is generated by coordinated action of extrinsic flexors and extensors with intrinsic modulators, including the interossei and lumbricals, which regulate tendon tension and joint sequencing. Passive stabilizers including the palmar plate, collateral ligaments, sagittal bands, annular pulleys and retinacular ligaments maintain tendon alignment, optimize lever arms and prevent subluxation. Balance modulation is provided by Landsmeer’s ligament and Winslow’s diamond, and the camshaft and hypomochlion effects further refine interphalangeal coordination and stability. Disruption of any component alters tendon vectors and joint moments, producing predictable deformity patterns including clawing, boutonnière, swan-neck deformity and bowstringing. Restoration of balance: Restoration of balance requires more than structural repair. Successful management depends on correcting bony alignment, restoring joint mobility and reconstructing soft-tissue relationships to re-establish physiological force distribution. Surgical options include tendon transfer, intrinsic release, pulley reconstruction, centralization procedures and nerve reconstruction, dependent on underlying pathology. Conclusion: Finger function depends on finely tuned balance of intrinsics and extrinsics. Understanding the dynamic and passive stabilizing mechanisms is essential for diagnosing imbalance and for planning reconstructive strategies that restore movement. Level of evidence: V. Narrative review.