Hand Center Recent Publications

Brachial plexus birth injuries occur when the nerves controlling arm movement are damaged during delivery, and surgeons have long relied on the Narakas classification system to categorize these injuries and guide treatment. This study introduced a new intraoperative classification system based on direct surgical findings from 162 patients treated over 19 years, grouping injuries by which nerve roots were affected (C5–C6 through C5–T1) and how many roots were completely torn away (avulsed). Researchers tracked functional outcomes using the Active Movement Scale before and after surgery, finding that scores improved overall but declined as injury severity increased from type A to type D. Importantly, the number of avulsed nerve roots within the most severe injury group (type D) was strongly associated with differences in functional recovery, while Horner's syndrome — a marker sometimes used to indicate lower nerve involvement — did not significantly affect final outcomes once injury type was accounted for. These findings suggest that a classification system grounded in what surgeons directly observe during the operation may more accurately reflect the true range of injury severity and better predict recovery than the traditional Narakas system, ultimately supporting more informed surgical decision-making.

Radial-sided wrist pain is a common complaint that can be difficult to diagnose when symptoms overlap or are subtle, making advanced imaging sometimes necessary. This review article was designed to help surgeons better understand how to use magnetic resonance imaging (MRI) as a supplementary diagnostic tool when a standard physical exam and patient history are not enough. The authors outline the key anatomical structures on the radial (thumb) side of the wrist and describe specific MRI features that correspond to various conditions affecting that region. By providing a systematic approach to interpreting these images, the review aims to improve diagnostic accuracy and guide clinical decision-making. This practical guide is significant because it bridges the gap between radiological findings and surgical planning, potentially leading to more targeted and effective treatment for patients with radial wrist pain.

This study investigated the total financial cost that medical students face when pursuing a career in plastic and reconstructive surgery (PRS), focusing on expenses that accumulate well before the formal residency application process begins. Researchers distributed a survey to PRS residency applicants and research group members during the 2023–2024 application cycle, collecting data on education, research, conferences, away rotations, and other career-building expenses. The findings revealed that the comprehensive cost of pursuing PRS ranges from approximately $33,400 to $45,479, with major expenses including away rotations ($6,000–$9,000), conference attendance ($2,000–$3,000 for those attending more than five conferences), and unpaid research years that left over half of participants with living expenses exceeding their income. Nearly all respondents (96.6%) felt these costs were too high, yet 93.3% still believed pursuing PRS was worth the financial sacrifice. The study highlights a significant equity concern, as these financial barriers may discourage qualified candidates from lower-income backgrounds and calls for systemic solutions such as guaranteed research stipends, expanded scholarships, and broader use of low-cost application platforms.

Flexor pollicis longus (FPL) palsy — weakness of the muscle that bends the thumb — is an uncommon complication of both-bone forearm fractures (BBFFs), and its causes are not well understood. Researchers conducted a retrospective review of 29 patients who underwent surgical repair of BBFFs between 2005 and 2023, finding that 5 patients (17%) developed FPL palsy either at the time of injury or shortly after surgery, all involving fractures in the middle third of the radius. All five cases resolved on their own within an average of 33 days, suggesting the nerve was bruised rather than permanently damaged — a condition called neurapraxia. To better understand why this complication occurs, the team also performed dissections on 10 cadaver arms and found that the nerve branch supplying the FPL muscle is located between 7 and 9 centimeters from a common elbow landmark, placing it in a vulnerable position near mid-to-proximal radius fracture sites. These findings suggest that both the fracture itself and surgical manipulation — such as excessive pulling on surrounding tissue — may put this nerve branch at risk, which has important implications for surgical planning and patient counseling.

Researchers surveyed residency program directors across obstetrics and gynecology, plastic surgery, urology, and pediatrics to understand how medical training programs handle situations where resident physicians object to providing gender-affirming care. In 2023, 257 program directors completed a survey, and 62 of them provided written responses to an open-ended question about their perspectives on conscientious objection to this type of care. Analysis of these responses revealed that attitudes and policies varied widely depending on the medical specialty, the program's prior experience handling objections to other controversial procedures, personal values of program leadership, and the laws and regulations of their state and institution. Most respondents agreed that conscientious objection to gender-affirming care is an important and complex issue, but no consistent or standardized approach existed across programs. These findings highlight an urgent need for clearer, more uniform policies that also account for differences in specialty training requirements, existing frameworks for handling objections to other types of care, and the legal environment in which programs operate.

Brachial plexus injuries can cause paralysis of the arm, making it difficult to detect other simultaneous injuries such as tendon ruptures. This case report describes two patients who suffered brachial plexus injuries and were later found to have undiagnosed ruptures of the distal biceps tendon, the tendon that connects the biceps muscle to the forearm. In one patient, the rupture was only discovered six months after nerve surgery when the biceps muscle showed early signs of reactivation but could not produce normal movement; in the second patient, the rupture was found during a muscle transfer procedure. Both patients ultimately regained some elbow flexion with gravity assistance by one year after their reconstructive surgeries. The study highlights that distal biceps tendon ruptures can easily be missed in patients with brachial plexus injuries because the limb weakness masks the typical signs of a tendon tear, and the authors recommend that surgeons take a careful patient history and physically examine the biceps tendon during any operative procedure to avoid overlooking this concurrent injury.

Medical schools are increasingly attracting a more diverse pool of applicants, raising questions about what factors influence how residency candidates rank their program choices. This study surveyed applicants to an integrated plastic surgery residency program across two application cycles (2022–2024) to determine whether faculty and resident diversity influenced rank list decisions similarly to traditional program features like quality of life and perceived fit. Using a Likert scale survey, 180 of 673 applicants rated the importance of various program characteristics, including the presence of underrepresented in medicine (URiM) faculty, diversity in leadership roles, same-race resident representation, and participation in diversity, equity, and inclusion (DEI) initiatives. Female and URiM applicants consistently rated diversity-related factors as significantly more important than their male and White peers did, while all applicants prioritized quality of life and program fit. These findings suggest that residency programs seeking to attract a broader, more diverse pool of applicants should strategically incorporate visible diversity and DEI efforts into their recruitment practices.

Spinal cord injuries (SCI), particularly those affecting the cervical spine, can severely limit upper extremity function and reduce a person's independence and quality of life. This article reviews surgical strategies used to restore movement in the hand, wrist, and elbow for individuals with tetraplegia, including established techniques such as tendon transfer, tenodesis, and arthrodesis, as well as the more recently adopted approach of nerve transfer. A thorough preoperative evaluation—combining physical examination and electrodiagnostic testing—is critical to identify suitable donor tendons and nerves, with the International Classification of Surgery for the Hand in Tetraplegia (ICSHT) guiding prioritization of functional goals such as elbow extension, wrist extension, pinch, and grasp. Postoperative rehabilitation must carefully balance immobilization with movement to prevent joint stiffness, and may include cortical retraining to help patients learn to activate transferred tendons or nerves. The authors emphasize that successful outcomes depend on a collaborative, interdisciplinary team approach to evaluation, surgical planning, and individualized rehabilitation.

Spinal cord injuries (SCI), particularly those affecting the cervical spine, can severely limit upper extremity function and reduce a person's independence and quality of life. This article reviews surgical strategies used to restore movement in the hand, wrist, and elbow for people with tetraplegia, including established techniques such as tendon transfer, tenodesis, and arthrodesis, as well as the more recently adopted approach of nerve transfers. A thorough preoperative evaluation—including physical examination and electrodiagnostic testing—is critical to identify suitable donor tendons and nerves, and the International Classification of Surgery for the Hand in Tetraplegia (ICSHT) helps guide surgical planning by prioritizing restoration of elbow extension, wrist extension, pinch, and grasp. Unlike tendon procedures, nerve transfers are time-sensitive and must be performed before irreversible muscle atrophy sets in, adding urgency to early surgical referral. The authors emphasize that successful outcomes depend on a collaborative, interdisciplinary team approach that spans injury assessment, surgical planning, and individualized rehabilitation, including cortical retraining to help patients learn to activate transferred tendons and nerves.

Perilunate and lunate dislocations are serious wrist injuries that are frequently missed on initial evaluation, making timely and accurate diagnosis critical. This study tested whether a machine learning (ML) algorithm designed to automatically label the lunate bone on wrist X-rays could help physicians more accurately identify these injuries. A total of 137 participants from emergency medicine, radiology, and hand surgery reviewed 30 lateral wrist X-rays both with and without the ML tool and were evaluated on measures of diagnostic accuracy. Using the ML tool improved overall accuracy, specificity, and F1 scores across all experience levels, with the most notable gains seen in residents, who reached diagnostic performance comparable to attending physicians when assisted. These findings suggest that AI-assisted image analysis could serve as a practical safety net for reducing missed diagnoses, especially in settings where specialist expertise is not immediately available.