Orthogate Subspecialty Journal Scan: Hand and Wrist
Curated critical appraisals of recent high-impact trials and practice-changing studies across hand and wrist, structured using the SBAR framework for immediate surgical and clinical application.
- 1. Comparing Conservative and Surgical Treatment of Acute Nondisplaced Fractures of the Scaphoid Based on Fracture Location - The Journal of the American Academy of Orthopaedic Surgeons Level I
- 2. Superior compared with anteroinferior plating for mid-shaft fractures of the clavicle - The bone & joint journal Level I
- 3. What Is the Probability of Radial Nerve Recovery After Surgical Repair of Humerus Fractures Accounting for Time Since Injury? - Clinical orthopaedics and related research Level I
1. Comparing Conservative and Surgical Treatment of Acute Nondisplaced Fractures of the Scaphoid Based on Fracture Location: A Systematic Review and Meta-Analysis.
Authors: Hawkins S, Al-Kharabsheh Y, Li J, Leary E, Nuelle J et al. | Journal: The Journal of the American Academy of Orthopaedic Surgeons (Aug 2026) | View Source / DOI
Situation
ed to report the nonunion risk in nondisplaced scaphoid fractures when stratified by both treatment type and fracture location. We searched PubMed, SCOPUS, CINAHL, SportsDiscus, HAND , Journal of Hand Surgery , and Plastic and Reconstructive Surgery for outcome studies of nonsurgical or surgical treatment of acute, nondisplaced scaphoid fractures. Meta-analyses were conducted for the pooled proportion of fracture nonunion of each fracture location and treatment modality. We screened 2019 articles, and 29 were included in the final data analysis. The pooled proportion of scaphoid fracture nonunions was higher among those treated nonsurgically than surgically, although prediction intervals were overlapping and significance was not established. We found that, regardless of the treatment method, proximal fragment fractures have the highest rate of nonunion. When evaluating only proximal scaphoid fractures, the proportions of nonunion were similar between nonsurgical and surgical subgroups. Our review indicates that surgical treatment
Background
Treatment of nondisplaced scaphoid fractures with either nonsurgical or surgical methods ideally involves shared decision making. To date, no meta-analysis has explicitly reported differences in healing rates between fracture locations and treatment choices, making this conversation challenging. We aimed to report the nonunion risk in nondisplaced scaphoid fractures when stratified by both treatment type and fracture location.
Assessment & Findings
- Study Design & Methodology: We searched PubMed, SCOPUS, CINAHL, SportsDiscus, HAND , Journal of Hand Surgery , and Plastic and Reconstructive Surgery for outcome studies of nonsurgical or surgical treatment of acute, nondisplaced scaphoid fractures. Meta-analyses were conducted for the pooled proportion of fracture nonunion of each fracture location and treatment modality.
- Primary & Secondary Findings: We screened 2019 articles, and 29 were included in the final data analysis. The pooled proportion of scaphoid fracture nonunions was higher among those treated nonsurgically than surgically, although prediction intervals were overlapping and significance was not established. We found that, regardless of the treatment method, proximal fragment fractures have the highest rate of nonunion. When evaluating only proximal scaphoid fractures, the proportions of nonunion were similar between nonsurgical and surgical subgroups.
Recommendation & Practice Takeaway
Clinical Pearl: The results of this study can be used to inform shared decision making when discussing treatment for a nondisplaced scaphoid fracture.
2. Superior compared with anteroinferior plating for mid-shaft fractures of the clavicle : a meta-analysis.
Authors: Boutros M, Awad G, Adio A, Lawand J, Boufadel P et al. | Journal: The bone & joint journal (May 2026) | View Source / DOI
Situation
of this meta-analysis was to evaluate the clinical outcomes, complications, and complication-related outcomes following superior compared with anteroinferior plating of mid-shaft fractures of the clavicle. A comprehensive search was conducted in PubMed, Scopus, Cochrane Library, and Google Scholar until 22 August 2025. Randomized controlled trials and observational studies comparing superior and anteroinferior plating techniques for mid-shaft clavicular fractures in adults were included. A total of 13 studies met the inclusion criteria, including 1,433 adult patients with these fractures. The outcomes which were assessed included the Constant-Murley score (shoulder function), Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, neurological injury, implant removal, postoperative pain (visual analogue scale), time to union, the rates of nonunion and infection, and operating time. Anteroinferior plating yielded significantly higher Constant-Murley scores compared with superior plating (mean difference -1.91 (95% CI -3.25 to -0.57); p = 0.005). Anteroinferior plating was also associated with a significantly lower risk of minor neurological injury compared with superior plating, with a risk ratio of 3.69 (95% CI 1.03 to 13.25; p = 0.050). There were no significant differences in the mean DASH score (p = 0.110), implant removal (p = 0.350), postoperative pain (p = 0.620), nonunion rate (p = 0.250), infection rate (p = 0.600), time to union (p = 0.520), or operating time (p = 0.580) between the groups. Anteroinferior plating provides significantly better shoulder function with a significantly reduced risk of minor neurological injury compared with traditional superior plating. These
Background
Contemporary surgical practice requires high-level comparative evidence to guide implant selection, technique optimization, and complication mitigation in hand and wrist.
Assessment & Findings
- Study Design & Methodology: A comprehensive search was conducted in PubMed, Scopus, Cochrane Library, and Google Scholar until 22 August 2025. Randomized controlled trials and observational studies comparing superior and anteroinferior plating techniques for mid-shaft clavicular fractures in adults were included. A total of 13 studies met the inclusion criteria, including 1,433 adult patients with these fractures. The outcomes which were assessed included the Constant-Murley score (shoulder function), Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, neurological injury, implant removal, postoperative pain (visual analogue scale), time to union, the rates of nonunion and infection, and operating time.
- Primary & Secondary Findings: Anteroinferior plating yielded significantly higher Constant-Murley scores compared with superior plating (mean difference -1.91 (95% CI -3.25 to -0.57); p = 0.005). Anteroinferior plating was also associated with a significantly lower risk of minor neurological injury compared with superior plating, with a risk ratio of 3.69 (95% CI 1.03 to 13.25; p = 0.050). There were no significant differences in the mean DASH score (p = 0.110), implant removal (p = 0.350), postoperative pain (p = 0.620), nonunion rate (p = 0.250), infection rate (p = 0.600), time to union (p = 0.520), or operating time (p = 0.580) between the groups.
Recommendation & Practice Takeaway
Clinical Pearl: Anteroinferior plating provides significantly better shoulder function with a significantly reduced risk of minor neurological injury compared with traditional superior plating. These findings support the growing adoption of anteroinferior plating as a safe and effective alternative for the surgical treatment of mid-shaft fractures of the clavicle.
3. What Is the Probability of Radial Nerve Recovery After Surgical Repair of Humerus Fractures Accounting for Time Since Injury?
Authors: Krijnen N, Comerci A, Head L, Legerstee I, de Klerk H et al. | Journal: Clinical orthopaedics and related research (May 2026) | View Source / DOI
Situation
Investigating clinical outcomes, surgical technique efficacy, and patient recovery profiles in this targeted cohort.
Background
Radial nerve injury after operative treatment of humeral shaft fracture usually improves, but a subgroup of patients does not recover. Understanding the probability of recovery over time is important in deciding on watchful waiting, nerve exploration, or tendon or nerve transfer. Bayesian analysis is helpful in estimating such probabilities. This type of analysis is predicated on estimating the probability that an event will occur and subsequently updating that estimate as new information becomes available-for instance, when nerve recovery does not occur over time.
Assessment & Findings
- Study Design & Methodology: Between January 2002 and November 2014, we treated 375 patients with open reduction and internal fixation (ORIF) for a traumatic diaphyseal humeral fracture at six urban hospitals (two Level 1 trauma centers, two Level 2 trauma centers, and two community hospitals). From this previously studied cohort, we lost access to one hospital's data, leaving us with 295 records to screen for eligibility. We considered patients with an isolated preoperative or postoperative radial nerve palsy, defined as an inability to extend the wrist against gravity (Medical Research Council grade < 3), as potentially eligible. Based on that, 24% (72 of 295) were eligible; of those, 2.8% (2 of 72) were excluded because a nerve disruption was repaired during ORIF. Another 24% (17) had incomplete data sets, leaving 74% (53) for analysis here. Patients with incomplete data sets did not differ from analyzed patients with respect to demographics or injury characteristics. The median (IQR) age was 43 years (25 to 61), and 49% (26 of 53) of patients were male. Most palsies presented preoperatively (83% [44]). Motor recovery was defined as the ability to extend the wrist against gravity (Medical Research Council grade ≥ 3). We conceptualized the probability of radial nerve recovery over time as two conditional probabilities: (1) the probability that the nerve injury is recoverable (neuropraxia, or recoverable axonotmesis), and (2) the probability that it did not recover at a certain point in time. We used a Bayesian network analysis to model these two probabilities. We based our estimate of the probability of a recoverable nerve injury on the largest systematic review, in which 90% (438 of 488 [95% confidence interval (CI) 87% to 92%]) recovered. To reflect uncertainty, we repeated the analysis for the upper and lower limits of its CI. To estimate the probability that recovery did not happen yet at a certain point in time, we used the timing of recovery from the patients in our cohort. We used Cox proportional hazards analysis to examine associations between time to recovery and demographic and injury variables, including age, sex, fracture type and location, vascular injury, type of fixation, and timing of palsy (preoperative versus postoperative).
- Primary & Secondary Findings: If a nerve has not recovered by 7 months, the probability of nerve recovery by 18 months was still better than chance, at 56% (range 48% to 62%). If the nerve had not recovered by 1 year, then the probability of recovery was 17% (range 13% to 21%). No variables (such as age, fracture location, vascular injury, or fixation type) were associated with timing of radial nerve recovery.
Recommendation & Practice Takeaway
Clinical Pearl: Providers can use our findings to counsel patients on the expected probability of nerve recovery, which might reduce anxiety while patients await recovery. These probabilities can aid in the decision whether and when nerve reconstruction, nerve transfers, or tendon transfers may be beneficial. Because the probability of recovery remains relatively high for at least 7 months after injury, early surgery is unlikely to be beneficial in patients with radial nerve motor injury after surgical fixation of humerus fractures. Future studies can provide more specific recovery probabilities by including findings on electrodiagnostic studies and patients treated nonoperatively.
