This study aimed to develop and evaluate a convolutional neural network for identifying scaphoid fractures on radiographs. A dataset of 1918 wrist radiographs (600 patients) was taken from an orthopaedic referral centre between 2010 to 2020. A YOLOv3 and a MobileNetV3 convolutional neural network were trained for scaphoid detection and fracture classification, respectively. The diagnostic performance of the convolutional neural network was compared with the majority decision of four hand surgeons. The convolutional neural network achieved a sensitivity of 82% and specificity of 94%, with an area under the receiver operating characteristic of 92%, whereas the surgeons achieved a sensitivity of 76% and specificity of 96%. The comparison indicated that the convolutional neural network’s performance was similar to the majority vote of surgeons. It further revealed that convolutional neural network could be used in identifying scaphoid fractures on radiographs reliably, and has potential to achieve the expert-level performance. Level of evidence: III

Neural Regen Res, Official publication of Publishing House of Neural Regeneration Research China Association of Rehabilitation Medicine,China

We treated 16 patients with 17 hypoplastic thumbs (eight Type IIIB and nine Type IV) using a non-vascularized fourth metatarsal transfer with a rotational flap and multi-staged reconstruction. The average age at the first operation was 24 months. The average follow-up time was 46 months. All patients achieved reasonable hand function and were able to use the reconstructed thumb to grip small and large objects. The operated thumb achieved an average Kapandji score of 6.7 and average pinch strength of 0.9 kg. There were two cases of graft nonunion. All parents are satisfied with the function and appearance of the reconstructed thumb and donor foot. We conclude that non-vascularized fourth metatarsal transfer is a feasible reconstruction method for patients with Types IIIB and IV hypoplastic thumbs. The reconstruction allows for the preservation of a 5-digit hand with reasonable function and appearance and minimal donor site morbidity, although long-term growth of the metatarsals still need to be monitored. Level of evidence: IV

Objective: Perilunate injuries are rare but devastating carpal injuries. The treatment of perilunate injuries remains challenging and contentious. This study aims to describe a novel mini‐invasive surgical technique of arthroscopic‐assisted reduction and robot‐assisted fixation for the treatment of trans‐scaphoid perilunate fracture dislocations (PLFDs).Methods: We retrospectively reviewed patients with PLFDs after surgical treatment from February 2021 to March 2021. The patients underwent arthroscopic‐assisted precise reduction and robot‐assisted headless screw fixation. Times of guide wire placement were recorded intraoperatively. Periodic follow‐up was performed until union of scaphoid fracture was confirmed. Range of motion of the wrist, grip strength, the Visual Analog Scale (VAS) score, the Mayo Wrist Score, the Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, the Patient‐Rated Wrist Evaluation (PRWE), and osteoarthritis were evaluated at the final follow‐up.Results: Two male patients presenting with PLFDs with an average age of 24.5 years old (32 and 17 years) were included in this study. Intraoperatively, anatomic reduction of the scaphoid fracture was achieved under arthroscopic guidance. A robotic‐assisted single‐attempt guidewire insertion was performed for scaphoid fracture and lunotriquetral interval. The CT scans at 8 and 12 weeks showed the union of the scaphoid fracture. At final mean follow‐up of 13.5 months, the extension, radial‐ulnar deviation, and pronation‐supination were consistent with the contralateral side in both patients. One patient experienced mild limited range of motion with the flexion 46° of the injured wrist compared with 81°of the contralateral wrist. The VAS score was 0 and 2. The grip strength was 32 and 26 kg compared with 24 and 42 kg of the contralateral wrist. The PRWE score was 13 and 10 and the QuickDASH score was 2 and 7. The Mayo Wrist Score was 100 and 65. No sign of osteoarthritis was found at the last follow‐up.Conclusions: Arthroscopic‐assisted reduction and robot‐assisted fixation is a viable and promising alternative for the treatment of perilunate fracture dislocations. This technique allows precise reduction and accurate placement of the K‐wires/screws into the carpal bones through the optimal biomechanical paths.

Background: The predominant method for Manske type IIIB and IV thumb hypoplasia is pollicization. However, for those who are not willing to sacrifice the index finger, a method that could reconstruct a functionally capable and aesthetically acceptable thumb remains desirable. This study aimed to investigate and assess the functional and radiographic outcomes of utilizing a reversed vascularized second metatarsal composite flap for thumb reconstruction as a new alternative. Methods: From May 2014 to January 2017, 15 patients with Manske type IIIB or IV thumb hypoplasia who were admitted to the Department of Hand Surgery, Beijing Jishuitan Hospital were included in this study. An osteocutaneous flap containing a section of second metatarsal and its distal head was transferred in reversed position to reconstruct carpometacarpal joint. The donor site was reconstructed by a split half of the third metatarsal. Various functional reconstructions were commenced at second stage. The reconstructed thumbs were evaluated using the Kapandji score, pinch force, and the capacities of performing daily activities through a detailed questionnaire. Results: Among these 15 patients (seven type IIIB and eight type IV), there were ten boys and five girls with median age of 4.2 years (range: 2.0–7.0 years). There were seven right, three left, and five bilateral thumbs for whom only the right thumb received surgery. There were 14 metatarsal flaps survived (14/15). With an average follow-up of 19.2 months, the reconstructed thumbs had acceptable functional and aesthetic outcomes and the donor foot presented in decent appearance without signs of impaired function. All 15 children have improved the Kapandji score (from 0 to an average of 6.7), pinch force (from 0 to an average of 1.5 kg), with ability of grip and pen holding. X-ray indicated continuous bone growth. Patients and parents had good acceptance of the new thumb. Conclusions: Reconstruction of an unstable hypoplastic thumb (Manske type IIIB and IV) with use of a vascularized metatarsal is an effective strategy. It offers an alternative solution for parents insisting on saving the thumb.

Background: SMAD6 variants have been reported in patients with radioulnar synostosis (RUS). This study aimed to investigate the genotypes and phenotypes for a large cohort of patients with RUS having mutant SMAD6.Methods: Genomic DNA samples were isolated from 251 RUS sporadic patients (with their parents) and 27 RUS pedigrees. Sanger sequencing was performed for the SMAD6 coding regions. For positive probands, co‐segregation and parental‐origin analysis of SMAD6 variants and phenotypic re‐evaluation were performed for their family members.Results: We identified 50 RUS probands with SMAD6 variants (13 co‐segregated with RUS in pedigrees and 37 in RUS‐sporadic patients). Based on the new and previous data, we identified SMAD6 mutated in 16/38 RUS pedigrees and 61/393 RUS sporadic patients, respectively. Overall, 93 SMAD6 mutant patients with RUS were identified, among which 29 patients had unilateral RUS, where the left side was more involved than the right side (left:right = 20:9). Female protective effects and non‐full penetrance were observed, in which only 6.90% mothers (vs. ~50% fathers) of SMAD6 mutant RUS probands had RUS. Pleiotropy was observed as a re‐evaluation of SMAD6 mutant families identified: (a) three families had axial skeletal malformations; (b) two families had polydactyly; and (c) eight families had other known malformations.Conclusion: SMAD6 was mutated in 42.11% RUS pedigrees and 15.52% RUS sporadic patients.The RUS patients with SMAD6 variants exhibit both non‐full‐penetrance, variable expressivity, pleiotropy, female protective effects, and the left side is more susceptible than the right side.