Jeffrey G. Stepan

The increasing incidence of civilian firearm-related injuries has placed a growing burden on hand surgeons to manage complex ballistic trauma. Periarticular hand fractures caused by firearms present a particularly difficult treatment challenge, characterized by articular comminution, bone loss, and concurrent soft tissue injury. These features frequently render standard fixation options, including plate fixation, wire pinning, and external fixation, either technically infeasible or prone to complication. This manuscript describes our technique of dorsal trans-articular bridge plating as a salvage option for gunshot-related periarticular fractures at the metacarpophalangeal and proximal interphalangeal joints of the hand. Originally developed for severely comminuted intra-articular distal radius fractures, bridge plating achieves relative reduction through ligamentotaxis while providing a robust, length-stable construct with minimal additional soft tissue disruption. We present a retrospective case series of 14 patients treated at a level 1 urban trauma center between 2021 and 2023. Nine underwent trans-articular bridge plating at the MCP joint and 5 at the PIP joint. Of the 11 patients with available postoperative data, 91% achieved radiographic fracture union. Mean pain scores improved from 5.6 of 10 at initial follow-up to 1.4 of 10 at final follow-up (mean 6.7 mo after hardware placement). Postoperative stiffness was encountered in all patients, reflecting the severity of the underlying injury. Trans-articular bridge plating is a technically reproducible salvage option for severely comminuted gunshot-related periarticular hand fractures, offering reliable restoration of digital length, alignment, and rotation with acceptable early outcomes.

There is a paucity of literature on clinical outcomes of suture anchor repair for zone 1 flexor digitorum profundus (FDP) injury. The purpose of this study was to summarize the clinical results and complications of suture anchor repairs for zone 1 (FDP) tendon injuries across available peer-reviewed literature. A systematic search in October 2025 was conducted following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to screen for peer-reviewed randomized controlled trials, retrospective and prospective studies, and case series reporting outcomes and complications of patients who underwent zone 1 flexor tendon repair with suture anchors. Eight articles (5 retrospective cohort studies, 3 case series) met inclusion criteria. A total of 161 patients underwent FDP repair with suture anchor fixation. Complications and poor outcomes were reported in 44 (27%) cases. Postoperative stiffness or decreased range of motion was the most common complication, confirmed in 27 (17%) cases. Infection, anchor migration/exposure/protrusion, nail deformity, and tendon repair failure occurred in 7 (4%), 4 (2%), 2 (1%), and 4 (2%) cases, respectively. Suture anchor repair of FDP avulsion injuries demonstrates lower rates of nail deformity and infection than those of pullout buttons; however, it still presents complications that are both familiar and unique compared with classic techniques. These results can be used to help counsel patients on the risks of surgery via suture anchor fixation.

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Background: As electronic patient portals (EPPs) continue to gain popularity and systems transition to online tools for scheduling, communication, and telehealth, patients without access or skills to use these tools may be overlooked. Objective: This study analyzed patient and neighborhood-level factors, including eHealth literacy level and the Area Deprivation Index (ADI), that may limit EPP access for orthopedic surgery. Methods: A cross-sectional, survey-based study was performed at a single urban tertiary academic medical center in the United States across foot and ankle, hand and upper extremity, and orthopedic trauma subspecialty clinics from June 21, 2022, to August 12, 2022. Survey responses (N=287) provided information on sociodemographic characteristics; barriers to EPP use and frequency of EPP use; the eHealth Literacy Scale; and the ADI, which is an address-generated national census measure of neighborhood-level disadvantage. Barriers to EPP use were inductively coded into barrier types, classified as physical access, technology discomfort, or preference. The primary outcome measure was patient-reported barriers to EPP use, which was treated as a binary outcome (1=barrier; 0=no barrier). Bivariate analyses and multivariable binary logistic regressions were performed. Results: The percentage of patients who self-reported barriers to EPP access was 43.2% (124/287), which related to physical access (13/124, 10.4%), technology discomfort (55/124, 44.3%), and preference (78/124, 63.0%). In the adjusted regressions, only low eHealth literacy and older age predicted barriers to EPP use (low eHealth literacy, adjusted odds ratio [AOR] 1.32, 95% CI 1.13-1.54; P <.001; older age, AOR 1.007, 95% CI 1.003-1.009; P <.001), including barriers of technology discomfort (low eHealth literacy, AOR 1.25, 95% CI 1.11-1.40; P <.001; older age, AOR 1.004, 95% CI 1.002-1.007; P <.001) and preference (low eHealth literacy, AOR 1.33, 95% CI 1.17-1.51; P <.001; older age, AOR 1.004, 95% CI 1.00-1.01; P <.01). Patients with physical access–related barriers as opposed to technology discomfort or preference barriers had the lowest median eHealth literacy scores (17.0, IQR 12.0-14.0 vs 27.0, IQR 16.0-32.0 vs 27.0, IQR 20.0-32.0, respectively) and roughly a quartile higher median ADI (73.0, IQR 41.0-92.0 vs 53.5, IQR 31.2-76.0 vs 58.0, IQR 38.8-83.8, respectively). Conclusions: Low eHealth literacy was the most significant determinant of overall barriers to EPP use for orthopedic surgery, followed by older age. Neighborhood-level disadvantage as measured through the ADI had no mediating effect on patient-reported barriers to EPP use when adjusting for eHealth literacy level. While patients with physical access barriers had higher ADIs, overall, few patients reported physical access barriers compared to barriers related to technology discomfort or preference. Patient preference for EPP versus non-EPP communications should be documented. Point-of-care screening using the eHealth Literacy Scale may also identify patients who require follow-up outside of the EPP during critical perioperative periods.

Background: Cannabinoids are a diverse group of compounds under investigation for various medical purposes, including analgesia. Given the evolving landscape of cannabinoid use, we aimed to analyze their prevalence and effect in pain management among urban orthopedic hand patients. Methods: An electronic survey was administered to 122 new patients presenting to the orthopedic hand clinic of a major urban academic hospital. Demographic data, numerical rating scale pain scores, cannabinoid usage, and other concomitant pain regimens were recorded. Results: Approximately half of the new patients were dissatisfied with current pain management for their hand pathology. Prescription (Rx) and over-the-counter (OTC) pain medications were used by 58% (71/122) of patients, while cannabinoids were used by 15% (18/122) of patients. Compared with pre-usage pain scores, both cannabinoids and Rx/OTC medications induced significant reductions in pain associated with patients’ hand pathologies (Cannabinoid: Δ4.4, P = .002; Rx/OTC: Δ3.0, P < .001). Cannabinoids induced a larger analgesic effect, but this difference was not statistically or clinically significant ( P = .06). Subjectively, cannabinoid users either preferred their cannabinoid over Rx/OTC medications or liked both equally. Opioid use was higher among cannabinoid users (22.2% vs 12.5%), although this was not statistically significant ( P = .28). Conclusion: Approximately 15% of new urban hand patients use cannabinoids for pain control, and these compounds have similar analgesic efficacy in hand pathologies as Rx/OTC medications. Cannabinoids are equally liked or preferred relative to traditional medications in this cohort, and they may play an important role in pain management for hand patients.

» Gunshot injuries to the upper extremity (UE) have high likelihood for causing peripheral nerve injury secondary to the high density of vital structures. Roughly one-fourth of patients sustaining a gunshot wound (GSW) to the UE incur a nerve injury. Of these nerve injuries, just over half are neurapraxic. In cases of surgical exploration of UE nerve injuries, nearly one-third demonstrate a transected or discontinuous nerve. » Existing literature regarding surgical management of nerve injuries secondary to GSWs comes from both military and civilian injuries. Outcomes are inconsistently reported, and indications are heterogeneous; however, reasonable results can be obtained with nerve reconstruction. » Our proposed management algorithm hinges on 4 treatment questions: if there is a nerve deficit present on examination, if there is a concomitant injury in the extremity (i.e., fracture or vascular insult), whether the injured nerve would be in the operative field of the concomitant injury, and whether there was an identified nerve lesion encountered at the time of surgery by another surgeon? » Early exploration rather than continued expectant management may offer improved recovery from GSW nerve injuries in particular situations. When an UE nerve deficit is present, establishing follow-up after the initial GSW encounter and early referral to a peripheral nerve surgeon are pivotal.