Carlson Strother, Courtney

Background: Flexor pollicis longus (FPL) palsy following both-bone forearm fracture (BBFF) is a rare complication. Methods: A retrospective review of acute BBFF treated with open reduction internal fixation by a single surgeon from 2005 to 2023 was performed. Injury and surgical characteristics of patients with documented FPL palsy were reviewed. In addition, 10 cadaveric dissections were performed to evaluate the anatomy of the anterior interosseous nerve (AIN) and its branches. The distance of these branches from palpable elbow landmarks and variability in branching pattern were evaluated. Results: Twenty-nine patients underwent surgery for acute BBFF. Of these, 5 (17%) had evidence of an FPL palsy either at the time of injury presentation (n = 2) or immediately following surgery (n = 3). All patients with FPL palsy sustained fractures in the middle one-third of the radius. All palsies resolved after an average of 33 days of observation. In cadaveric dissections, the average distance from the lateral epicondyle to the AIN takeoff and branch to the FPL was 5.5 and 7.6 cm, respectively. The AIN takeoff and branch to the FPL were never less than 4 and 7 cm from the lateral epicondyle, respectively. Conclusion: Flexor pollicis longus palsy following BBFF can occur at the time of injury or following surgery. All FPL palsies involved midshaft radial fractures and were likely neurapraxia. The etiology of FPL palsy remains unclear, but cadaveric dissection suggests the FPL motor branch may be at risk from mid-to-proximal radius fracture fragments or excessive traction during surgery.

Background: Proximal pole scaphoid fracture nonunions are challenging conditions to treat. When significant comminution of the proximal pole and avascular necrosis is present, scaphoid proximal pole reconstructive options are considered. The proximal pole of the hamate is a local autograft option; however, little has been described on the outcomes of this procedure. Methods: Patients who underwent proximal pole scaphoid reconstruction using proximal hamate autograft at 3 tertiary care centers were retrospectively reviewed. Radiographic union was classified by greater than 50% bony trabeculae across the reconstruction site on computed tomography scan. Results: Ten patients were included. Average age at the time of surgery was 27.9 years, and 60% were men. Average length of proximal hamate autograft harvested was 10 mm. All patients healed at an average of 14.3 weeks following surgery. At final follow-up, 3 patients reported no pain, 3 reported mild occasional pain, 2 reported moderate tolerable pain (1 at the hamate graft site), and 2 had no reports on their pain level. Conclusions: In small proximal pole scaphoid nonunions with fragmentation and avascular necrosis, ipsilateral proximal hamate autograft reconstruction of the scaphoid proximal pole is a viable and reproducible option with high rates of union and patient satisfaction.