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We report this case of a rock climber who sustained a right ring-finger grade-III A2 pulley rupture. After failed nonoperative management, the patient underwent pulley reconstruction with ipsilateral palmaris longus autograft using a double-loop technique. The immediate postoperative course was uncomplicated, and the patient returned to painless rock climbing six months after the index procedure. One year postoperatively, the patient developed discomfort on the dorsum of the proximal phalanx which progressed to baseline pain at rest. Radiographs and MRI taken 16 months postoperatively demonstrated intact palmaris graft with underlying bone osteitis and resorption of the proximal phalanx. The range of motion remained full without bowstringing. The patient was indicated for revision A2 pulley reconstruction with ipsilateral extensor retinaculum autograft. Six months following revision pulley reconstruction, the patient was pain-free and radiographs demonstrated improvement in cortical density. The patient was able to return to rock climbing. Our case suggests pulley reconstruction with an extensor retinaculum slip sutured to the ever-present fibrous rim is a viable option with successful short-term outcomes in the setting of post-reconstructive bone resorption., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. NYU Langone Health Institutional Review Board issued approval i23-01127. The current IRB Status of your submission is: Approved. This submission was reviewed by the NYU Langone Health Institutional Review Board (IRB) referenced above. During the review of your study, the IRB specifically considered: 1. the risks and anticipated benefits (if any) to your subjects 2. the selection of subjects 3. the procedures for securing and documenting informed consent 4. the safety of your subjects 5. the privacy of your subjects and confidentiality of the data • For NIH grant funded research approved before the revised Common Rule: the IRB has found the IRB approved protocol referenced above to be consistent with the NIH grantapplication. • This approval letter serves as the approval for the abovementioned location(s) only. If your study is a multi-site study using NYU SoM IRB as the Single IRB, this approval letter does not serve as approval for participating sites. If your study is a multi-site study not requiring the use of a Single IRB, this approval does not serve as approval for any of the other sites. Each site will need to obtain IRB approval before human subjects research may commence at the site. • NYU Langone Health maintains a financial disclosure process by which researchers must disclose any personal financial interest that may be related to the research. Disclosures must be completed and submitted even if no Financial Interests are disclosed. One or more researchers on this study have not submitted disclosures and/or the Conflict of Interest Management Unit (CIMU) has not finalized its decision. Should CIMU require a new or revised Management Plan, submit a modification with the final CIMU determination to the IRB for review and approval, including any revised documents, if applicable. • A waiver of Informed Consent has been granted in accordance with 45 CFR 46.116 (f). • NYU Langone Health IRB reviewed and approved a request to waive the individual authorization requirements under HIPAA for the use and disclosure of PHI for Research under 45 CFR § 164.512(i)(2)(ii)(A-C) . Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Cerasani et al.)

This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Ulnar sided wrist pain often presents a diagnostic challenge. Creating a meaningful differential diagnosis is possible with a detailed history and systematic physical exam using provocative maneuvers. Targeted imaging studies can allow for further narrowing of the differential and ultimate diagnosis.

Background: The purpose of this study was to compare the diagnostic accuracy of a smartphone flashlight to a conventional penlight with regards to transillumination of simulated soft tissue masses of the hand and wrist. Methods: Eight participants performed transillumination assessments in a fresh frozen cadaver upper extremity model. Spheres measuring 9.5 mm were used to simulate fluid-filled or solid soft tissue masses. Two spheres were placed on the volar aspect and two on the dorsal aspect of the wrist. These were then evaluated with either a smartphone flashlight or penlight. Participants noted whether each sphere did or did not transilluminate. Each participant performed two evaluations at an interval of 3 weeks. Results: The overall sensitivity, specificity and accuracy of the smartphone were 100%, 44% and 72%, respectively. The overall sensitivity, specificity and accuracy of the penlight were 100%, 75% and 88%, respectively. The difference in accuracy between the smartphone group and penlight group was statistically significant ( p = 0.029). The kappa value, indicating intra-observer agreement, for the smartphone group and penlight group was 0.76 and 0.76, respectively. Conclusion: In conclusion, transillumination with a penlight is a viable adjunct to the examination of soft tissue masses of the hand and wrist. The use of a smartphone flashlight, while convenient, is less accurate than a penlight and can lead the examiners to misinterpret the composition of soft tissue masses. Level of Evidence: Level IV (Diagnostic).

Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal injuries. It can be a useful imaging modality for clinical correlation of physical examination findings as well as an aid for image-guided procedures. Understanding the settings in which it is a helpful adjunct will have implications on efficiency and cost utility. The objectives of this chapter are to provide a background of ultrasonography as a musculoskeletal imaging modality, provide clinical correlation for ultrasonographic findings for common upper extremity pathology, review the diagnostic efficacy of ultrasonography for image-guided procedures, and provide insight into the cost utility of ultrasonography guidance for therapeutic injections.

Background: Fractures of the radial shaft with disruption of the distal radial ulnar joint (DRUJ) or Galeazzi fractures are treated with reduction of the radius followed by stability assessment of the DRUJ. In rare instances, the reduction of the DRUJ is blocked by interposed structures requiring open reduction of this joint. The purpose of this study is to review all cases of irreducible Galeazzi fracture-dislocations reported in the literature to offer guidelines in the diagnosis and management of this rare injury., Methods: A search of the MEDLINE database, OVID database, and PubMed database was employed using the terms "Galeazzi" and "fracture." Of the 124 articles the search produced, a total of 12 articles and 17 cases of irreducible Galeazzi fracture-dislocations were found., Results: The age range was 16 to 64 years (mean = 25 years). A high-energy mechanism of injury was the root cause in all cases. More than half of the irreducible DRUJ dislocations were not identified intraoperatively. In a dorsally dislocated DRUJ, a block to reduction in most cases (92.3%) was secondary to entrapment of one or more extensor tendons including the extensor carpi ulnaris, extensor digiti minimi, and extensor digitorum communis, with the remaining cases blocked by fracture fragments. Irreducible volar dislocations due to entrapment of the ulnar head occurred in 17.6% of cases with no tendon entrapment noted., Conclusions: In the presence of a Galeazzi fracture, a reduced/stable DRUJ needs to be critically assessed as more than half of irreducible DRUJs in a Galeazzi fracture-dislocation were missed either pre- or intraoperatively.

Background: Obesity is an often-cited cause of surgical morbidity. As a result, many institutions have required screening prior to "clearing" obese individuals for surgery. However, it remains unclear whether such testing is warranted for obese patients prior to upper extremity procedures. This study reviews surgical outcomes to determine if obesity does predict operative morbidity following upper extremity surgery., Methods: The National Surgical Quality Improvement Program was queried for 18 Current Procedural Terminology codes, representing upper extremity fracture and arthroplasty procedures. Patients' body mass index (BMI) and medical histories were examined as predictors for postoperative complications. Both individual and combined incidences of complications were compared between patients stratified as normal-weight (BMI < 30); obese (BMI 30-40); and morbidly obese (BMI> 40)., Results: A total of 8,477 patients were identified over the 5-year study period; 5,303 had a BMI <30, 2,565 a BMI of 30 to 40 and 585 a BMI >40. With the exception of postoperative blood transfusions, there were no significant increases in the incidence rates of any complication event as a function of BMI class. The overall incidence of complications was 2.70 % for BMI <30; 2.74 % for BMI 30 to 40; and 1.54 % for BMI >40., Conclusions: Obesity is not a reliable predictor of complications following upper extremity surgery. Thus, requiring preoperative screening for obese patients may constitute an unnecessary burden on medical resources. Further study is needed to identify specific demographics that might serve as more accurate predictors of poor outcomes in obese patients undergoing surgery of the upper extremity.