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Abstract The fair innings argument (FIA) is frequently put forward as a justification for denying elderly patients treatment when they are in competition with younger patients and resources are scarce. In this paper I will examine some arguments that are used to support the FIA. My conclusion will be that they do not stand up to scrutiny and therefore, the FIA should not be used to justify the denial of treatment to elderly patients, or to support rationing of health care by age. There are six issues arising out of the FIA which are to be addressed. First, the implication that there is such a thing as a fair share of life. Second, whether it makes sense to talk of a fair share of resources in the context of health care and the FIA. Third, that 'fairness' is usually only mentioned with regard to the length of a person's life, and not to any other aspect of it. Fourth, if it is sensible to discuss the merits of the FIA without taking account of the 'all other things being equal' argument. Fifth, the difference between what is unfair and what is unfortunate. Finally, that it is tragic if a young person dies, but only unfortunate if an elderly person does.

Background: Scaphoid fracture fixation using a single headless compression screw (HCS) may permit unacceptable rotation at the fracture site. This study aimed to assess the biomechanical stability of a single HCS construct to fix scaphoid waist fractures., Questions/purposes: (1) Does a single HCS provide rotational stability? (2) What degree of rotation is found at the central axis of a scaphoid without fixation?, Methods: In eight fresh frozen cadavers, two parallel K-wires were placed in the scaphoid to mark rotation and an osteotomy was created at the scaphoid waist. To determine whether rotation was present between the proximal and distal poles, radiographs of the wrist at terminal range of motion (ROM) were reviewed for relative change in wire position. The fracture was then reduced, and an HCS was then advanced across the fracture; rotation was again evaluated. Rotation was quantified in the group without fixation using a sensor that measured angular rotation., Results: Before screw fixation, interfragmentary rotation was found to average 22.5° during flexion/extension, 19.0° during pronation/supination, and 34.0° during radial/ulnar deviation around the central axis. The radiographs after osteotomy demonstrated rotation in all specimens. After fixation with an HCS, radiographs demonstrated relative rotation of the two halves of the scaphoid in all ROMs for all specimens, except flexion for one specimen., Discussion: Internal angular tension was observed within the scaphoid, and rotation of 20° to 30° was noted around the central axis during simulated ROM mimicking nonsurgical treatment. A single HCS failed to prevent fragment-relative rotation at the fracture site., (Copyright © 2025 by the American Academy of Orthopaedic Surgeons.)

Background: Metacarpal neck fractures are frequently encountered by hand surgeons. Certain operative metacarpal neck fractures are amenable to both retrograde intramedullary screw (IMS) fixation and closed reduction percutaneous pinning (CRPP). The purpose of this study was to compare functional outcomes and complications following these two techniques., Methods: All patients with metacarpal neck fractures treated with either IMS or CRPP from 2015 to 2021 at a large private academic institution were retrospectively identified. Electronic medical records were reviewed for demographics, Quick Disabilities of Arm, Shoulder, and Hand (qDASH) scores, metacarpophalangeal joint range of motion (ROM), and complications., Results: A total of 113 patients, consisting of 57 in the IMS cohort and 56 in the CRPP cohort, were included. The CRPP cohort was significantly younger, otherwise demographics were similar between both groups. Both cohorts had similar preoperative (47.5 IMS vs 43.9 CRPP), postoperative (17.6 IMS vs 9.9 CRPP), and delta (35.5 IMS vs 34.0 CRPP) qDASH scores. Retrograde IMS allowed for greater flexion at 4 to 6 weeks (81° vs 65°) postoperatively. The overall incidence of complications was similar among IMS and CRPP (21.1% vs 17.9%), although IMS had significantly more major complications (8.8% vs 0%)., Conclusions: Despite earlier return to ROM, operative fixation of unstable metacarpal neck fractures with retrograde IMS may be at higher risk of major hardware complications and extensor lag., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To evaluate the proximity of the ulnar neurovascular structures to the endoscopic blade during endoscopic carpal tunnel release (CTR)., Methods: Ten fresh-frozen cadaver hands were used to perform endoscopic CTR using devices from two manufacturers. The skin was excised from the palm, and the endoscopic carpal tunnel blade was deployed at the distal edge of the transverse carpal ligament (TCL). The blade's proximity to the ulnar neurovascular bundle, deep ulnar motor branch, superficial palmar arch, and median nerve was recorded. Following release of the TCL, the device was turned ulnar to the maximal extent to determine if direct injury to the ulnar neurovascular bundle was possible., Results: The average longitudinal distance from the end of the TCL to the superficial palmar arch was 13.3 mm (range, 8.4-20.9) and to the ulnar motor branch was 10.8 mm (range, 4.0-15.0). The average transverse distance from the end of the TCL to the ulnar neurovascular bundle was 5.9 mm (range, 3.1-7.8) and to the median nerve was 3.3 mm (range, 0-6.5). In two of our specimens, the median nerve subluxated volarly over the cutting device. When placing the blade at the distal edge of the TCL, injury to the deep motor branch of the ulnar nerve, ulnar neurovascular bundle, or superficial palmar arch was not possible in any specimens using the tested devices, even when turning the blade directly toward these structures., Conclusions: There is a low likelihood of direct injury to the ulnar neurovascular bundle during endoscopic CTR., Clinical Relevance: These results suggest that injury to the ulnar neurovascular bundle is unlikely during endoscopic CTR if the distal aspect of the transverse carpal ligament can be clearly identified prior to release. Control of the median nerve is also important to prevent subluxation over the cutting device., (Copyright © 2025. Published by Elsevier Inc.)

Purpose: The purpose of this cadaveric study was to investigate the intrinsic anatomy surrounding the metacarpal head and the relationship between the interosseous-lumbrical junction (ILJ) and transverse metacarpal ligament (TML) as it pertains to saddle deformity-posttraumatic adhesions at the ILJ that cause impingement during intrinsic activation., Methods: Ten fresh frozen cadaveric arms underwent dissections, identifying the intrinsic musculature within the second through fourth webspaces. The TML and ILJ, or "true tendon," were identified. A separate area of nontendinous fibrous tissue identified proximal to the ILJ was referred to as "pseudotendon." Measurements were made within each webspace to identify distances between these structures in full finger extension and intrinsic plus position to assess for changes during simulated motion., Results: The true tendon to TML distance progressively decreased toward the ulnar digits. In the intrinsic plus position, the pseudotendon to TML distance was 0 mm at all webspaces for each specimen. When moving from neutral to intrinsic plus, the true tendon to TML distance decreased the most in the third and fourth webspaces compared with the second, consistent with the trend toward a smaller ILJ to TML gap in the ulnar digits., Conclusions: There is a fibrous pseudotendinous region proximal to the ILJ that abuts the TML in the intrinsic plus position, which may cause impingement when inflamed in the setting of saddle syndrome. Furthermore, a decreased ILJ to TML gap in the ulnar digits may be related to an increased predilection for saddle deformity in those areas., Clinical Relevance: These results suggest that there is a fibrous region present proximal to the ILJ that may be implicated in the pathology of saddle deformity. Furthermore, decreased distances found between the ILJ and TML in vivo may be an explanation for increased occurrence of saddle syndrome in the third and fourth webspaces in clinical practice., (Copyright © 2025. Published by Elsevier Inc.)

Purpose: The optimal timing for surgical treatment of open distal radius fractures remains an area of debate. The purpose of this study was to examine the outcomes of open distal radius fractures treated surgically before or after 24 hours., Methods: A multicenter retrospective review was performed on all open distal radius fractures treated over 11 years. Patient demographics, injury mechanism, and initial treatment were recorded. Fracture severity was graded by the Gustilo-Anderson classification. Comparisons were made between those treated surgically within and after 24 hours. Outcomes examined included infection, revision surgery, osteomyelitis, and nonunion., Results: A total of 230 cases met the inclusion criteria. The cohorts of early and delayed surgical intervention were similar with regard to preoperative demographics. The most common mechanism of injury was motor vehicle accident. Approximately 40% of cases were graded as type I, 40% as type II, and 20% as type III. Mean time to debridement in the group treated after 24 hours was 5 days. A mean postoperative follow-up of greater than 6 months was obtained in both cohorts. Similar outcomes were found between cohorts with respect to postoperative infection, revision surgery, osteomyelitis, and nonunion., Conclusions: Similar outcomes with regards to infection, revision, osteomyelitis, and nonunion were found between open distal radius fractures treated emergently versus those managed in a delayed fashion. Patient- and injury-specific factors are important in dictating care., Type of Study/level of Evidence: Prognostic IIB., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2025 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain., Methods: This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy., Results: Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10., Conclusions: It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Noninvasive magnetic resonance imaging (MRI) of the relayed nuclear Overhauser effect (rNOE) constitutes a promising approach for gaining biological insights into various pathologies, including brain cancer, kidney injury, ischemic stroke, and liver disease. However, rNOE imaging is time-consuming and prone to biases stemming from the water T1 and the semisolid magnetization transfer (MT) contrasts. Here, we developed a rapid rNOE quantification approach, combining magnetic resonance fingerprinting (MRF) acquisition with deep-learning-based reconstruction. The method was systematically validated using tissue-mimicking phantoms, wild-type mice ( n  = 7), and healthy human volunteers ( n  = 5). In vitro rNOE parameter maps generated by MRF were highly correlated with ground truth (r > 0.98, p  < 0.001). Simultaneous mapping of the rNOE and the semisolid MT exchange parameters in mice and humans were in agreement with previously reported literature values. Whole-brain 3D parameter mapping in humans took less than 5 min (282 s for acquisition and less than 2 s for reconstruction). With its demonstrated ability to rapidly extract quantitative molecular maps, deep rNOE-MRF can potentially serve as a valuable tool for the characterization and detection of molecular abnormalities in vivo ., Competing Interests: The authors declare no competing interests., (© 2024 The Author(s).)

Introduction The current method for determining the appropriate wrist splint size in the clinical setting relies on measuring wrist circumference, but this approach often fails to ensure optimal fit. This study evaluates additional hand features using 3-dimensional (3D) scanned data and Artificial Intelligence (AI) to improve the fit of pre-fabricated wrist splints. We hypothesize that wrist and forearm widths can provide a more accurate fitting than wrist circumference alone. Materials and methods We recruited 54 healthy volunteers to be scanned. Each volunteer was fitted with a standard wrist brace (Short Arm Brace, Ossur, Iceland), and 3D data from their hands were collected using an infrared-based 3D scanner (Einscan Pro, Shining3D, China). The 3D scanned data were then analyzed to identify and measure 14 distinct hand features. To explore the relationship between these hand features and the optimal splint size, we generated a categorical correlation map. This map identified hand features that were most strongly correlated with splint size categories (small, medium, large). Subsequently, we developed a classification algorithm to predict the appropriate splint size based on the correlated hand features. We utilized three different machine learning models for this purpose: Extreme Gradient Boosting (XGB) Classifier, RandomForestClassifier, and Support Vector Classifier (SVC). Each of these classifiers was trained and evaluated to determine their accuracy and effectiveness in predicting the correct splint size. Results Wrist width showed the highest classification accuracy (91%) for both the XGB Classifier and RandomForestClassifier. The measurements including hand wrist width, mid-forearm width, and hand crease line width also performed well with the XGB Classifier, achieving an accuracy of 90%. The SVC showed consistent performance across various feature sets, with the highest accuracy of 81% for the measurements. Overall, these findings suggest that wrist width is the most predictive feature for splint size classification, with additional features providing minimal enhancement. Conclusions Artificial intelligence, combined with 3D scanning, can accurately predict wrist splint size from a single image acquisition, enabling contactless, personalized fitting. This approach can improve patient outcomes by enhancing the fit of prefabricated splints., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Thomas Jefferson University issued approval IRB Control # 13D.432. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. 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: Ashkan Sedigh Michael Rivlin Amir Kachooei declare(s) non-financial support, employment, a patent and stock/stock options from Dimension Orthotics, LLC. Intellectual property info: 3D printing of wrist orthoses. 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, Sedigh et al.)

Purpose: Compressive neuropathies such as carpal tunnel and cubital tunnel syndrome can lead to sensation loss, muscle weakness, joint contractures, and disrupted sleep. The interplay between these conditions and the effect on patients' intimacy is unknown. The purpose of this study was to examine sexual function before and after surgery in patients undergoing carpal tunnel release or cubital tunnel release., Methods: All patients 18 years or older who underwent unilateral or bilateral carpal tunnel release and/or cubital tunnel release, performed either open or endoscopically, between January 2021 and August 2022, were retrospectively identified. An anonymous 21-question survey assessing pre- and post-operative sexual function was sent electronically to patients who were between 3 months and 2 years postprocedure., Results: A total of 47% of respondents reported that their upper extremity symptoms disrupted their sexual activity. Before surgery, various challenges were reported: paresthesia (84%), pain (61%), reduced strength (53%), and reduced motion (40%). A total of 65% of patients changed positions before surgery, most frequently by avoiding weight-bearing (79%) and using the affected arm (55%). After surgery, 61% reported an easier time engaging in sexual activity, which was most frequently attributed to diminished paresthesia (69%) and pain (67%). A total of 73% of patients resumed sexual activities within 3 weeks of surgery. Ultimately, 32% of patients were more satisfied with their sexual function after surgery., Conclusions: Sexual function is intimately tied to the physical and mental health of individuals. Surgical release improves sexual function and satisfaction., Type of Study/level of Evidence: Retrospective Case-Control Cohort, Therapeutic III., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)