What's New in Hand and Wrist Surgery.

Abstract

In this update of What’s New in Hand and Wrist Surgery, we hope to have summarized appropriately the most interesting, relevant, and applicable findings mostly from The Journal of Hand Surgery (European Volume), The Journal of Hand Surgery, HAND, and the Journal of Pediatric Orthopedics primarily from October 2020 through August 2021. The intent is to serve as an update of the hand surgery literature for the practicing general orthopaedic surgeon. Carpal Tunnel Syndrome Carpal tunnel syndrome is one of the most common disorders in hand surgery. Nevertheless, the optimum method for diagnosis remains controversial. A growing body of evidence suggests that electrodiagnostic studies1-4 are not more sensitive and specific than diagnosis by ultrasound or clinical history and examination. D’Auria et al.5 examined the role of electrodiagnostic studies compared with clinical judgment and found that the utility of electrodiagnostic studies may be greatest in patients for whom a diagnosis of carpal tunnel syndrome is questionable. Even so, electrodiagnostic studies are performed in many patients with carpal tunnel syndrome6. Less expensive, office-based diagnostic tools such as the Carpal Tunnel Syndrome 6 (CTS-6), a 26-point scale that incorporates aspects of the history and clinical examination to predict the probability of carpal tunnel syndrome, and ultrasound will likely supplant the routine use of electrodiagnostic studies for carpal tunnel syndrome. Strong evidence exists for the use of night splints and corticosteroid injections for early treatment of carpal tunnel syndrome. In a comparison of the 2 treatments, 100 patients with a diagnosis of carpal tunnel syndrome were randomized to a night splint or a corticosteroid injection7. In the 95 patients who completed follow-up, corticosteroid injections were superior in terms of nocturnal paresthesias, pain, and Boston Carpal Tunnel Questionnaire (BCTQ) function and symptom domains at 1, 3, and 6 months. A novel study on hand function with decreased sensation showed that a digital nerve block to the thumb had the greatest negative impact on dexterity and a loss of sensation in the index and long fingers caused decreased grip and chuck pinch strength, thus explaining the common symptoms of decreased dexterity and strength in patients with carpal tunnel syndrome8. Several studies examined the outcomes of carpal tunnel release in specific cohorts. Stirling et al.9 reported on 460 patients who had carpal tunnel release, 119 (26%) of whom reported hand-arm vibration exposure. The group with self-reported hand-arm vibration exposure had worse median postoperative QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand Questionnaire [DASH]) scores and less postoperative improvement in the QuickDASH score than patients who did not report hand-arm vibration exposure. Zhang et al.10 reported on 24 patients with a mean follow-up of 6.9 years after carpal tunnel release who had unrecordable sensory and motor potentials on preoperative electrodiagnostic studies. Data collection via telephone of the BCTQ indicated mean BCTQ scores of 1.4 for the symptom domain and 1.8 for the function domain, and a mean DASH score of 15.2, indicating that patients with severe carpal tunnel syndrome can expect recovery of function and a decrease in symptoms in the long term with carpal tunnel release. We continue to attempt to define optimal perioperative management of carpal tunnel syndrome11. Multiple studies have shown that opioids do not yield better pain control than over-the-counter analgesics12-14. Grandizio et al.15 randomized patients to opioid or non-opioid medications after carpal tunnel release and collected data on QuickDASH scores, BCTQ scores, Numeric Pain Rating Scale (NPRS) scores, and satisfaction at 2 weeks. There was no difference in reported satisfaction, but the non-opioid group had lower NPRS and QuickDASH scores, indicating that patients had less pain and better function if they did not take opioids after the surgical procedure. The summation of the literature on this topic indicates that prescribing opioids after a carpal tunnel surgical procedure is not recommended. The debate surrounding endoscopic or open carpal tunnel release continues16. A large database study17 showed that, in >500,000 patients, endoscopic carpal tunnel release was performed in 19.3% of patients. Although the overall number of open carpal tunnel releases has remained stable, the number of endoscopic carpal tunnel releases increased threefold over the 15 years of the study period. There was no difference in complications, but endoscopic carpal tunnel release cost approximately $2,000 more per patient. Recurrent carpal tunnel syndrome remains unusual. In a systematic review and meta-analysis, de Roo et al. suggested that a simple repeat release for recurrent symptoms is adequate, rather than additional procedures to wrap or place a flap over the nerve18. Carpal tunnel syndrome in children is rare but does occur19. Velicki et al.20 reported long-term follow-up on pediatric patients after carpal tunnel release. Patients with acute and tumorous etiologies had full resolution of symptoms, and those with delayed traumatic and idiopathic etiologies such as lysosomal storage diseases often had recurrent or recalcitrant symptoms. Hand Arthritis There have been a number of articles published on silicone arthroplasty and associated complications. A retrospective review of 88 proximal interphalangeal (PIP) joint silicone arthroplasties showed no significant difference between a dorsal approach and a volar approach with respect to the final range of motion and complications. However, there was an overall rate of complications of 34% and a 16% rate of revision surgical procedures21. Another study of 114 PIP joint silicone arthroplasties also showed a high reoperation rate of 14%, with risk factors being a surgical procedure on the index finger, smoking status, non-Caucasian race, and arthroplasty performed for posttraumatic arthritis22. Several studies have been published on thumb carpometacarpal (CMC) joint arthritis reporting risk factors for conversion to a surgical procedure23-25. Perhaps the most remarkable finding from these 3 studies was the relatively low number of patients who later underwent a surgical procedure in the study period. Ostergaard et al.24 reviewed 239 patients over 9 years who had a first-time corticosteroid injection for CMC arthritis. They sought to identify the risk factors for conversion to a surgical procedure and found that advanced arthritis at presentation (Eaton stage III/IV), smoking status, and history of an ipsilateral hand surgical procedure were associated with eventual surgical treatment. Nevertheless, by Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis and requested a corticosteroid injection did not have a surgical procedure within 5 years. Gershkovich et al.23 reviewed a health system database to identify 62,333 patients who had a CMC corticosteroid injection from 2003 to 2014. Their primary outcome was a repeat corticosteroid injection or a surgical procedure, comparing the time to outcome between ultrasound-guided injections and non-guided injections. Although the mean time to a repeat corticosteroid injection was similar between the 2 groups (268 compared with 237 days), only 13% of patients who had a corticosteroid injection later had operative treatment. Finally, Schloemann et al.25 sought to identify patient and disease-related factors associated with surgical treatment. They retrospectively reviewed 1,994 patients treated at 2 institutions for CMC arthritis over 3 years. Only 170 patients (9%) underwent a surgical procedure. Factors associated with the failure of nonoperative management were younger age at presentation, a prior contralateral CMC surgical procedure, and the treating institution (4% at one institution and 21% at the other institution). They concluded that surgeon attitudes strongly influence the odds of a patient undergoing a surgical procedure. New information on outcomes and return to function after a CMC arthritis surgical procedure is available. Baca et al.26 retrospectively reviewed 121 CMC joints with trapezial excision and ligament reconstruction with tendon interposition (LRTI) over a 12-year period. They found that there was greater improvement in the postoperative QuickDASH score reported by patients who underwent LRTI within <2 years of symptom onset (an improvement of 26.2 points) compared with patients who underwent LRTI within ≥2 years of symptom onset (an improvement of 5.3 points), suggesting that an earlier surgical procedure may yield better outcomes. In attempting to answer the question of when patients return to work after a CMC arthritis surgical procedure, Kirkeby et al.27 used database information to retrospectively assess occupational hand force requirements, return to work, pain, and disability. The mean time to sustainable return to work was 14 weeks, but higher hand force requirements were associated with a slower return to work27. Long-term follow-up (mean, 17 years) after a randomized trial comparing trapeziectomy alone and trapeziectomy with LRTI showed no difference between groups in terms of pain, function, satisfaction, or strength28. Wrist Trauma Distal radial fractures are known to be associated with concomitant injuries, but the need to diagnose and treat these injuries is questionable. Okoli et al.29 prospectively followed 134 patients with distal radial fracture treated with a volar locking plate, 52% of whom also had an ulnar styloid fracture, all treated nonoperatively. There was no difference in patient-reported outcomes regardless of the type of ulnar styloid fracture or presence of osseous union. Klifto et al. prospectively followed 192 patients with intra-articular distal radial fractures with radiographic evidence of a scapholunate interosseous ligament (SLIL) injury treated with a volar locking plate30. No attempt was made to repair the SLIL in the injury group. At 12 and 24 months, there was no difference between groups with respect to reported pain or function. Fixation of a distal radial fracture is technically demanding and is associated with complications, including the penetration of screws into the joint and a flexor or extensor tendon rupture due to prominent implants. Knowledge of specialized image-intensifier views such as a 68° supinated view to assess for radial styloid penetration and a dorsal tangential view to assess for dorsal cortical penetration may help to minimize these technical errors31,32. Implant problems may not become evident in the short term either, as Moriya et al. reported on an elderly cohort in whom the mean time to flexor tendon rupture after volar locking plating was 9 years33. A few recent studies helped to inform our care of the patient with a distal radial fracture. The rate of routine bone mineral density testing in patients with a distal radial fracture remains unacceptably low despite its value34. Patients who underwent testing after a fracture had a longer fracture-free interval (819 days) compared with those who did not have testing (579 days), once again highlighting the importance of early intervention. A study conducted in Pakistan showed further evidence that surgical treatment for a distal radial fracture in the elderly population does not portend better functional outcomes than casting35. In a younger population with a distal radial fracture treated with a volar locking plate, Goyal et al. reported that 90% of patients returned to weight-bearing yoga activities at a mean of 7 months, which may be valuable in counseling patients on return to activity36. With regard to risks of the surgical treatment of a distal radial fracture, there seems to be no advantage to discontinuing antithrombotic agents in patients undergoing an outpatient distal radial fracture surgical procedure37. Unsurprisingly, smokers are almost twice as likely as nonsmokers to have a perioperative adverse event of any kind in the 30 days after the surgical procedure38. We continue to explore best practices for scaphoid fracture nonunion. A randomized clinical trial of scaphoid nonunion surgical procedures comparing corticocancellous and cancellous-only bone graft showed that union rates were not significantly different, but that malunions were higher in patients with cancellous-only graft, and QuickDASH scores were significantly better in the corticocancellous group than in the cancellous-only group. These results suggest that the correction of deformity is important and may be better with corticocancellous grafts39. Infection Several studies have addressed the treatment of acute hand infections. Analysis of acute-phase reactants in operatively treated upper-extremity infections showed that C-reactive protein was abnormal in 90% of patients, whereas the white blood-cell count was abnormal in only 54% and the erythrocyte sedimentation rate was abnormal in only 67%40. A 10-year retrospective review showed that debridement of dorsal hand infections (including hand-to-mouth injuries) performed at the bedside, compared with that performed in the operating room, was associated with significantly fewer additional debridements and shorter hospital length of stay41. However, these results could have been skewed by selection bias. A novel and perhaps practice-changing method for treating hand infections was studied by Malige et al.42. The group randomized 52 patients with acute infection requiring intravenous antibiotics either to a maceration dressing consisting of warm moist gauze, Kerlix, Webril, Ortho-Glass, and a heating pad or to similar dry dressing. Those with the moist, macerated dressing had a significantly shorter hospital stay and duration of intravenous antibiotics and decreased need for surgical irrigation and debridement. Kistler et al.43 reviewed methicillin-resistant Staphylococcus aureus (MRSA) infections from 2005 to 2014. MRSA is the most common pathogen isolated from hand abscesses. The authors found increasing resistance to clindamycin (from 7% to 31%) and to levofloxacin (from 12% to 56%); the risk factors for methicillin resistance were intravenous drug use, hepatitis C, and nosocomial infections for clindamycin and fever and a history of diabetes for levofloxacin. Although intravenous antibiotic administration has been considered the gold standard for the treatment of osteomyelitis, Henry and Lundy44 demonstrated that patients with acute, direct-inoculation osteomyelitis of the hand could be successfully treated with susceptibility-matched oral antibiotics at a dramatic cost reduction ($482 compared with $21,646 per patient). Understanding poor prognosticators may be helpful in counseling patients and treating infections. A retrospective analysis of 210 patients with osteomyelitis of the hand showed that, when arterial calcification was present, there were increased risks of polymicrobial infection, additional surgical procedures, and delayed digital amputation, and a higher mortality rate at 1 and 5 years45. Thus, early amputation in patients with arterial calcification may optimize disease-free survival. Although surgical site infections are considered a “never event” in terms of patient safety, there are some patient-inherent factors that elevate the risk of surgical site infection. In a retrospective claims database review, Zhuang et al.46 found that, in patients undergoing a soft-tissue, upper-extremity surgical procedure, there was significantly increased risk of surgical site infection with serum albumin of <3.5 g/dL, at 3.5% (compared with 0.9% for serum albumin of ≥3.5 g/dL), and hemoglobin A1C (HbA1C) of ≥7%, at 1.1% (compared with 0.7% for HbA1C of <7%). Trigger Finger Several studies evaluated methods for trigger finger treatment. Topical anesthetic cream was not more effective than placebo in alleviating pain associated with local anesthetic infiltration for a trigger finger surgical procedure47. This is in keeping with previous literature on the use of ethyl chloride spray48. Jiménez et al.49 compared a technique of corticosteroid injection that utilized an approach from the dorsal web space into the area of the A1 pulley and the typical palmar midline technique. This study showed a significantly lower mean visual analog scale score for pain of 3.6 for patients who underwent the dorsal webspace technique compared with 5.4 for patients who underwent the palmar midline technique. Roberts et al.50 reviewed 210 randomly selected patients from a 6-surgeon practice who were treated by corticosteroid injection with triamcinolone, dexamethasone, or methylprednisolone. They found that patients injected with triamcinolone had a higher rate of a repeat corticosteroid injection when compared with the other medications. Patients injected with methylprednisolone underwent surgical release earlier and more frequently than the other 2 groups. This suggests that, among triamcinolone, dexamethasone, and methylprednisolone, the optimum medication for trigger finger corticosteroid injection may be dexamethasone. Sato et al.51 looked at risk factors for PIP joint contracture associated with trigger finger. Flexion contracture of the PIP joint was positively associated with older age, previous carpal tunnel syndrome or de Quervain tenosynovitis, and a more severe clinical grade of the trigger finger. Stirling et al. found that functional outcomes of trigger finger release were similar in patients with and without diabetes at a mean of 14 months postoperatively52. The need for and appropriate timing of surgical release for pediatric trigger thumb are unclear. Hutchinson et al. followed 93 thumbs in 78 children presenting with pediatric trigger thumb over 5 years53. At the final follow-up, they were grouped into 3 categories: spontaneous resolution with <5° of interphalangeal (IP) contracture and no triggering, parental request for a surgical procedure before the 5-year completion, and incomplete resolution with >5° of flexion. Thirty-two percent had spontaneous resolution, and 43% elected to proceed with the surgical procedure at a median of 4.1 years after presentation. Twenty-five percent remained unresolved, with >5° of flexion contracture. Risk factors for failure of spontaneous resolution were presentation with >30° IP contracture and bilateral involvement. Spontaneous resolution was associated with presentation with ≤30° contracture. Up to 25% of patients with pediatric trigger thumb have bilateral involvement54. Lin et al.55 found that only 3% of patients presenting with trigger thumb later developed a contralateral trigger digit at a mean of 12 months, suggesting that when a surgical procedure is desired, the routine delay in treatment in anticipation of developing contralateral disease is unnecessary. Imaging Ultrasound has been increasingly utilized in diagnosis and management of hand conditions56. Ultrasound may be used for assessing for incomplete carpal tunnel release57, evaluating for SLIL injury58, diagnosing the failed repair of flexor tendon laceration59, and identifying larger gaps present after flexor tendon repair60. However, the utility in diagnosing a Stener lesion with ultrasound or magnetic resonance imaging (MRI) has been called into question, due to the low sensitivity and specificity found for both61. Fracture Care It is critical for surgeons to know which fractures require a surgical procedure, and which do not, to achieve optimal outcomes. Trickett et al. prospectively followed 218 osseous mallet injuries treated with custom thermoplastic splinting. The distal IP joint was congruent in 168 fingers and subluxated in 50 fingers. At the final follow-up, there was no difference in range of motion, extensor lag, or the Patient Evaluation Measure between groups. Thus, the authors recommended nonoperative management of osseous mallet injuries regardless of fragment size or subluxation62. Furthermore, osseous mallet injuries treated with a surgical procedure have a high major complication rate63. Angulated fifth metacarpal neck fractures treated nonoperatively are known to have good outcomes regardless of residual angulation64. A report of 72 patients randomized to buddy taping or closed reduction and cast immobilization demonstrated that patients with a fifth metacarpal neck fracture treated with buddy taping returned to work 28 days sooner and had fewer complications, similar functional scores, and similar residual angulation compared with those treated with casting65. There is a growing body of literature on intramedullary headless compression screw fixation for long bones in the hand. Overall, fractures heal quickly with early return to function, minimal need for immobilization, and low complication rates66-69. Kirschner wire fixation is often used for hand and wrist fractures. There is a good deal of evidence that superficial wires are associated with a high rate of infection and that burying the wires beneath the skin decreases the frequency of this complication70-72. Pediatric Fractures If malrotation is not present, extra-articular phalangeal neck fractures in children remodel and have good functional outcomes without a surgical procedure73,74. Liao et al.75 compared cast immobilization (19 patients) and hand or finger-based splint immobilization (28 patients) for phalangeal neck fractures. At the final follow-up (at a mean of 9.4 weeks), all children had the ability to make a full composite fist with a tip-to-palm distance of 0 mm. Uncertainty remains with regard to which pediatric distal radial fractures require closed reduction and which require in situ immobilization. Georgiadis et al.76 surveyed Pediatric Orthopaedic Society of North America (POSNA) members for their treatment algorithm for 28 different clinical and radiographic scenarios with a range of patient ages and displacements. Complete displacement and coronal plane angulation were significant predictors of recommendation for sedated closed reduction. However, a majority of surgeons were willing to randomize 7 of the 8 scenarios that involved complete displacement and shortening, indicating that even people who treat pediatric distal radial fractures regularly do not know which fractures benefit from surgical treatment. Furthermore, dogma has suggested that the coronal plane angulation of a distal radial fracture does not remodel. Lynch et al.77 reported on 36 patients with a distal radial fracture and a mean age of 8 years who were allowed to heal with a median coronal plane angulation of 17°. At the 6-month follow-up, the median coronal plane angulation was 3°. A report on Salter-Harris III and IV distal radial fractures showed that 12 (43%) of 28 patients had growth arrest78. Thus, children with these unusual distal radial fracture patterns should be monitored for growth arrest. The standard treatment for fingernail avulsion is to reinsert the nail into the proximal nail fold. However, Seiler et al.79 prospectively followed pediatric patients with simple nail avulsion (no laceration or displaced fracture). There were 12 patients who chose operative reinsertion of the nail and 39 patients who chose nonoperative management with simple antibiotic ointment dressing. At the 6-month follow-up, there was no difference in the appearance of the nail, calling into question the need for nail reinsertion. Peripheral Nerve There is increasing evidence that patients with spontaneous peripheral neuropathies such as anterior interosseous nerve palsy after a shoulder surgical procedure, posterior interosseous nerve palsy, or Parsonage-Turner syndrome may benefit from peripheral nerve decompression if spontaneous recovery is not present early80-83. In terms of nerve injury, a surprising number (32.5%) of complete nerve lacerations were missed on the initial evaluation84, emphasizing the need for thorough knowledge and examination of the nerve function. The risk factors for false-negative examination were injury at the elbow, a gunshot wound mechanism, physician specialty, and patient age of >71 years. Bertelli85 demonstrated a more precise way to examine strength deficits associated with an ulnar nerve injury by instructing the patient to pinch at the palmar IP joint rather than the thumb tip, thus isolating the thumb adductor. With respect to nerve repair, a multicenter study showed that a processed nerve allograft was better than a conduit in patients with small (≤14 mm) and large (15 to 25 mm) gap defects in terms of functional recovery86. Targeted muscle reinnervation, a technique for plugging terminal sensory branches into motor branches, continues to show promising results in decreasing pain after amputation, and this technique likely should be considered the standard of care in surgical amputation87. COVID-19 No review of 2021 would be complete without discussing the impact of the COVID-19 pandemic. Telemedicine has emerged as a mainstream method for caring for patients remotely88. A survey of hand surgeons internationally showed that the number of hand surgeons reporting daily use of telemedicine went from 4% prior to the pandemic to 36%89. Telemedicine may increase access by patients in remote areas90, may decrease the need for transferring patients with hand trauma91, and may allow access to hand surgeons when in-person visits are restricted. However, major concerns remain with regard to the security of the platforms used89 and the level of service billed and reimbursed for telehealth compared with in-person visits92. The boundaries of the wide-awake local anesthesia no tourniquet (WALANT) method have been pushed to new frontiers in the face of limited operating room capacity. There are reports of using local anesthesia for open reduction and internal fixation to treat distal radial fracture93, for trapeziometacarpal joint arthroplasty94, and for hand fracture fixation68, further establishing WALANT as a safe, inexpensive means for surgical care associated with a satisfying patient experience95-98. Finally, case reports have emerged with regard to digital ischemia99 and hypercoagulable states affecting the upper limb100 due to COVID-19. Equity, Policy, and Education Our profession still faces profound gender101 and racial inequity102, although slow progress has been made. McCullough et al.103 reported that the percentage of female American Society for Surgery of the Hand (ASSH) active members has increased from 11% to 14% in 4 years (2014 to 2018). Furthermore, women appear to be more engaged in society leadership than men, with women holding 17% of committee positions and 40% of the Young Leaders Program memberships. Guidelines have been suggested for how to be an equitable educator and mentor of people from underrepresented groups104,105. We continue to explore the utility and limits of patient-reported outcome measures in hand surgery. In general, a patient had similar scores on the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference tests collected for research purposes and on the same tests administered at standard-care visits106; this is useful information for practices that routinely collect data using PROMIS outcomes. The PROMIS Depression module may also be used as a screen for undiagnosed depression107. However, disease-specific measures may be needed to detect postoperative improvements108. The pandemic also forced us to explore ways to educate residents remotely, and many training programs transitioned to online didactic sessions. The ASSH Surgical Simulation Taskforce developed a Surgical Training and Educational Platform (STEP) simulation training program that has now been validated109. Board-certified hand surgeons significantly outperformed trainees on all 8 tasks, differentiating the skill levels of expert and novice hand surgeons. More information and supply lists (approximately $600) are available on the ASSH website: https://www.assh.org/s/surgical-simulation. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 4 other articles relevant to hand and wrist surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Clark DM, Piscoya AS, Dunn JC, Nesti LJ. The impact of pre-existing ulnar nerve instability on the surgical treatment of cubital tunnel syndrome: a systematic review. J Shoulder Elbow Surg. 2020 Nov;29(11):2339-46. Cases of cubital tunnel syndrome refractory to conservative management are treated with ulnar nerve transposition or in situ decompression. The decision to transpose the ulnar nerve is often based on stability or subluxation of the nerve in elbow flexion, despite limited evidence to support the superiority of ulnar nerve transposition to in situ decompression with ulnar nerve instability. In this systematic review, the effect of ulnar nerve instability on surgical management (ulnar nerve transposition compared with in situ decompression) was evaluated. In 3 of 5 studies, nerve instability necessitated treatment, and, in 1 study, prospective randomization was maintained. The overall complication rate was 8.6% (4.3% for in situ decompression and 21.1% for nerve transposition), and outcomes were similar between the 2 treatments. Despite insubstantial support from the literature, this study found that the assessment of nerve stability changes the management of cubital tunnel syndrome. Reporting nerve instability and including a subgroup analysis of outcomes for patients with preexisting subluxation will further guide providers when considering how nerve instability should affect treatment decisions. Dias JJ, Brealey SD, Fairhurst C, Amirfeyz R, Bhowal B, Blewitt N, Brewster M, Brown D, Choudhary S, Coapes C, Cook L, Costa M, Davis T, Di Mascio L, Giddins G, Hedley H, Hewitt C, Hinde S, Hobby J, Hodgson S, Jefferson L, Jeyapalan K, Johnston P, Jones J, Keding A, Leighton P, Logan A, Mason W, McAndrew A, McNab I, Muir L, Nicholl J, Northgraves M, Palmer J, Poulter R, Rahimtoola Z, Rangan A, Richards S, Richardson G, Stuart P, Taub N, Tavakkolizadeh A, Tew G, Thompson J, Torgerson D, Warwick D. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet. 2020 Aug 8;396(10248):390-401. Dias et al. conducted a multicenter randomized clinical trial of patients with ≤2 mm of displacement to investigate outcomes following surgical fixation or cast immobilization of scaphoid waist fractures. In this study, 188 patients underwent surgical fixation a mean of 10.2 days after the injury, and 214 patients underwent cast immobilization (mean duration, 44.8 days). Within the immobilization group, 17 patients (8%) underwent a surgical procedure for radiographically confirmed nonunion at a mean of 159 days (range, 68 to 358 days) after the injury. There was no significant difference in the Patient-Rated Wrist Evaluation (PRWE) scores or the union rate between the surgical fixation group and the cast immobilization group at 52 weeks. Screw penetration was identified in 65% of patients in the surgical group. Surgical patients were also 10 times more likely to experience complications of infection, nerve problems, and chronic regional pain syndrome, although they were less likely to experience cast-related complications. These results highlight important risks that should be discussed in preoperative patient counseling. Patients with scaphoid waist fractures who undergo immobilization may be able to obtain outcomes comparable with those of the surgical cohort while avoiding risks of surgical intervention. These results highlight important risks that should be discussed in preoperative patient counseling. Regardless of treatment, any suspected nonunions should be identified and treated in a timely manner. Mulders MAM, Schep NWL, de Muinck Keizer RJO, Kodde IF, Hoogendoorn JM, Carel Goslings J, Eygendaal D. Operative vs. nonoperative treatment for Mason type 2 radial head fractures: a randomized controlled trial. J Shoulder Elbow Surg. 2021 Jul;30(7):1670-78. Epub 2021 Mar 19. Mason type-2 radial head fractures are displaced and partially articular. Unlike the relatively straightforward algorithm for Mason type-1 (non-displaced or displaced <2 mm) and type-3 (comminuted and displaced) radial head fractures, there has been insufficient evidence to support surgical or conservative management of type-2 (displaced ≥2 mm) fractures. In a randomized controlled trial, Mulders et al. found comparable functional outcomes between operatively and nonoperatively managed isolated Mason type-2 radial head fractures at 1 year. Although these results add to the literature of this fracture type, a larger patient population with longer follow-up is important to draw more concrete conclusions. Stephens AR, Presson AP, McFarland MM, Zhang C, Sirniö K, Mulders MAM, Schep NWL, Tyser AR, Kazmers NH. Volar locked plating versus closed reduction and casting for acute, displaced distal radial fractures in the elderly: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2020 Jul 15;102(14):1280-8. In a systematic review and meta-analysis of several high-quality randomized trials for distal radial fracture management, Stephens et al. found a small but significant improvement in DASH scores at 3 months (score difference, −8.9) and at the final follow-up (12 to 24 months postoperatively; score difference, −5.9) after volar locking plating compared with closed reduction and casting of acute, displaced distal radial fractures in individuals ≥60 years of age. Importantly, the observed differences in the final DASH score did not exceed published estimates of the minimal clinically important difference, suggesting comparable outcomes between treatment options. The decision to proceed to a surgical procedure should involve careful scrutinization of the patient’s functional level and goals and the risk profile of treatment.