Jason Strelzow

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.

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Objective: Depth‐gauge measurements can be time‐consuming and prone to technical error. The aim of this study is to evaluate whether “anatomic zones” along the distal femur can be used to help estimate distal interlocking screw length during femoral intramedullary nailing. Methods: A retrospective “anatomical control” cohort was used to establish anatomic zones along the length of the distal femur and estimated screw length within each zone. Estimated screw lengths for each zone were based on mean cortex‐to‐cortex length at each zone as measured on computed tomography (CT). A validation cohort was prospectively enrolled to evaluate agreement between these estimated screw lengths and depth‐gauge measurements for each zone. Agreement was evaluated using mean differences between estimated screw lengths and depth‐gauge measurements, an intraclass correlation coefficient (ICC), and Bland–Altman analysis. Results: The retrospective cohort of 56 patients was used to establish eight anatomic zones. Screw length estimates derived from CT‐based measurements ranged between 42.1 mm in the most proximal zone to 80.2 mm in the most distal zone. The validation cohort included 74 patients (126 screws), was 63.51% male ( n = 47), with mean age 44.2 ± 24.7 years, mean height 173.2 ± 12.7 cm, and mean BMI 28.5 ± 10 kg/m ² . The mean absolute value difference between zone‐estimated screw lengths and depth‐gauge measurements was 3.9 mm ±2.9 mm, ranging 2.7 mm‐5.6 mm depending on zone. The ICC was 0.94 (95% CI [0.91, 0.96], p < 0.01). Bland–Altman analysis revealed a bias of −0.86 mm with limits of agreement at +8.6 mm and −10.3 mm. Conclusion: Anatomic zone‐based screw length estimates derived from CT data show strong agreement with depth‐gauge measurements and are a potential adjunctive strategy to reduce operative time and errors in screw length selection without the need for additional equipment or technology.

Background: Bone density can impact treatment decisions for orthopaedic conditions. While ad-hoc intraoperative surgeon assessment of bone quality is common, the accuracy of such evaluation remains unknown. The primary purpose of this study was to determine whether orthopaedic surgeons’ intraoperative assessment of bone quality closely correlated with validated measures. Methods: In this prospective cross-sectional study, we enrolled adult patients undergoing orthopaedic surgery at a Level-I trauma center. Eligibility required an opportunistic computed tomography (CT) scan of the lumbar spine, glenoid, wrist, pelvis/femur, proximal tibia, or calcaneus. Seven surgeons, blinded to objective measures of bone quality, provided intraoperative bone-quality assessments using a 10-point Likert scale and categorized bone quality as normal, osteopenic, or osteoporotic. Hounsfield units (HUs) were measured on CT using a previously published technique. All images were reviewed by a single orthopaedic surgeon, blinded to intraoperative bone-quality assessments. Results: Of the 229 patients enrolled, 215 had available CT data and were included in the study. The average age of these patients was 44 years (range, 18 to 95 years), with 40.5% being female. Over half of the patients (61%) were Black or African American, while a quarter of the patients (25%) were White. The most common surgical sites included the femur (39 patients, 18.1%), ankle (31, 14.4%), and acetabulum (26, 12.1%). A positive linear relationship between HU and surgeon bone-quality assessments was observed (r = 0.66; p < 0.0001), which was consistent across surgical anatomic sites. Abnormal bone quality was correctly identified by surgeon assessment with 84% sensitivity and 97% specificity. Conclusions: This study demonstrated that surgeons can reliably detect abnormal bone quality through intraoperative assessment across numerous surgical sites. Intraoperative assessments may provide actionable and reliable feedback regarding bone density without additional cost or radiation in cases when opportunistic scans are not available. This information can inform intraoperative decision-making and presents opportunities for bone-health interventions. Level of Evidence: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.