Iranian Journal of Orthopedic Surgery

Abstract Introduction: Carpal tunnel syndrome (CTS) represents the most prevalent form of compressive neuropathy. Although electrodiagnostic assessments (EMG–NCV) are routinely used for diagnosis and demonstrate good accuracy, they are invasive procedures and can sometimes produce false‑negative outcomes. In recent years, high‑resolution ultrasonography has gained attention as a noninvasive, widely available, and cost‑efficient diagnostic option. The purpose of this study was to investigate the usefulness of sonographic evaluation in diagnosing CTS and to examine how its findings relate to clinical symptoms and electrophysiological results.
Materials & Methods: In this cross‑sectional diagnostic study, individuals with a clinical suspicion of carpal tunnel syndrome were assessed. Each participant underwent both EMG–NCV testing and bilateral wrist ultrasonography. Sonographic variables, including the cross‑sectional area (CSA) and the width of the median nerve at various points along the forearm and within the carpal tunnel, were compared among electrodiagnostic severity categories classified as normal, mild, moderate, and severe. The sensitivity and specificity were determined for chosen CSA and nerve‑width cutoff values.
Results & Discussion: 60 patients with the mean age of 49.5±10.4 years and mean BMI of 26.8±3.6 kg/m² being 90% female and 80% with bilateral involvement were studied. Age was not significantly associated with CTS severity (P=0.344), whereas higher BMI correlated with greater severity (P=0.01). Median nerve CSA width increased parallel with disease severity. In the right hand, a CSA cut off of 8.5 mm² at the carpal tunnel yielded 87.5% sensitivity and 81.7% specificity; in the left hand, a CSA cut off of 8 mm² provided 70% sensitivity and 95.5% specificity. Nerve width ≥ 5 mm showed high sensitivity but lower specificity.
Conclusion: Ultrasonography—especially assessing the cross‑sectional area of the median nerve—serves as a dependable, noninvasive, and precise complementary tool alongside EMG–NCV for both identifying and grading the severity of CTS.

Abstract Introduction: Pillar pain is one of the common sequelae after carpal tunnel release (CTR), presenting as deep pain or tenderness upon pressure on the thenar and hypothenar regions. It potentially interferes with return to work and patient satisfaction. This narrative review was conducted with a focus on the etiology, emerging therapeutic approaches, and a practical management algorithm for pillar pain.
Materials & Methods: A structured search of PubMed and complementary sources was performed from 2018 up to December 2025. Clinical trials, systematic reviews and meta-analyses, cohort studies, and high-quality narrative reviews addressing pillar pain, risk factors, pathophysiology, or post‑CTR treatments were identified and categorized.
Results & Discussion: The evidence suggests that pillar pain is a self‑limiting condition, and approximately half of the patients may experience it, with most cases resolving within 3 to 6 months. The etiology is multifactorial and includes biomechanical alterations of the carpal arch after division of the transverse carpal ligament, soft‑tissue inflammation or scarring, irritation or neuroma of the palmar cutaneous branch of the median nerve, and central mechanisms. Non‑surgical treatment is the mainstay of management and encompasses patient education and reassurance, occupational hand therapy modalities (desensitization, massage, graded exercises), non‑opioid analgesics and anti‑inflammatory medications. In refractory cases, minimally invasive options such as extracorporeal shock wave therapy (ESWT) and photo biomodulation may be used. Emerging evidence on fractional CO₂ laser therapy for treatment‑resistant pillar pain is promising but still limited. From a preventive standpoint, minimally invasive techniques and appropriate choice of skin closure method may influence short‑term pillar pain.
Conclusion: Pillar pain after CTR is usually benign and transient but requires a stepwise, multimodal approach. Combining patient education, targeted rehabilitation, and non‑opioid pain strategies, with selective use of minimally invasive interventions in refractory cases, offer safe and efficacious treatment.

Abstract Abstract Infected nonunion of both forearm bones presents significant therapeutic challenges. Conventional methods often involve prolonged stabilization or complex grafting techniques with variable functional outcomes. A 49-year-old diabetic female presented with purulent drainage and failed union after two prior surgeries for open forearm fractures. Radiographs confirmed infected nonunion with retained hardware. A staged protocol was performed as such: (1) Radical debridement, ulnar plating, and antibiotic-cement spacer placement in the radial defect; (2) After interim antibiotics, spacer wasremoved and radius reconstructed with tricortical iliac crest autograft, fixed with screws, and augmented by cancellous grafting. At 24-week follow-up, radiographic union was achieved with no infection recurrence. Approximately 90% of contralateral forearm range of motion was restored, with no donor site complication. This approach—combining immediate ulnar stabilization with staged radial reconstruction using the Masquelet technique—effectively resolved infection and restored function in complex both-bone nonunion. It represents a strategic balance of mechanical and biological principles for challenging upper limb reconstruction.  

Abstract Abstract Introduction: Distal radius fractures are the most common fractures in the upper limb, and many studies have been conducted on its treatment. There is, as yet, no consensus on which treatment method is preferable. This paper compares the use of plate alone with plate + external fixator in this fracture. Materials & Methods: In a randomized clinical trial (RCT), patients with type C2 and C3.1(AO/OTA classification) distal radius fracture, were randomly divided into two groups of fixation with locking plate alone (control) and fixation with plate and additional external fixator (intervention). Then patients were evaluated in terms of radiographs and clinical outcomes  in first, third and, sixth weeks, and also 6 and 9 months after surgery by Quick Disabilities of the Arm, Shoulder and Hand questionnaire (qDASH) and visual analogue score (VAS). SPSS software was used for data analysis. Informed consent was obtained from the patients. Results & Discussion: 52 patient (26 in each group) were enrolled in the study. The mean age was 42 years in the control and 41 years in the intervention group. The qDASH score in the control group was 35 and 38 in the intervention group and this difference was not significant between the two groups. No significant difference was observed between the two groups in terms of pain level according to the (VAS) score either. Also, the radiographic criteria including radius height and palmar tilt, did not differ significantly between the two groups (p<0.05). Conclusion: In general, with similar results of plating, and plating with addition of external fixator in fixation of distal radius fracture, the method of “plate alone” is preferred.

Abstract Abstract
Introduction: Bone grafting is the main treatment of scaphoid nonunion. In this study, we intend to evaluate the radiographic results in patients with non-vascularized bone graft in scaphoid nonunion with or without AVN.
Materials & Methods: In a cross-sectional study, patients with scaphoid nonunion were chosen in a census sampling method and were followed up and immobilized with plasterfor four weeks. Then a radiography was taken and the patients were followed till the union were seen in radiography. Data were analyzed by SPSS 24.
Results & Discussion: In this study, 43 patients were admitted. The mean total age of patients was 29.91 ± 8.58 years.13 patients had complications, 6 reported limited mobility and 7 reported pain. Fifteen patients (34.9) had avascular necrosis. All patients were able to perform daily activities with hands, and none complained of inactivity. The mean duration of first incision to the end was 49.16 ± 5.98 minutes. The mean time elapsed from scaphoid fracture to surgery was 36.59 ± 47.42 weeks. The mean time from surgery to complete recovery was 145.79 ± 73.85 weeks. The mean time from surgery to the first evidence of healing was 36.59 ±47.42 days which resulted in scaphoid union in all patients.
Conclusion: This study demonstrated that non-vascularized bone grafting resulted in radiographic union of the scaphoid in all patients, including those with avascular necrosis. All participants regained the ability to perform daily hand activities without functional complaints. Complications occurred in 30.2% of cases, mainly presenting as mild pain and minor limitations in hand motion. These findings suggest that this technique is a safe and effective option for treating scaphoid non-union.

Abstract Abstract
This article is the second part of a comprehensive review focusing on the anatomy, physiology, and treatment of distal radius fractures. This injury is among the most common skeletal traumas. The first part provided a historical overview of the condition and outlined the advancements in its recognition and management. It was noted that the treatment of this fracture requires a precise understanding of the anatomy of the radius and the wrist joint. The importance of standard imaging modalities such as radiography and CT scan for fracture evaluation and surgical planning was emphasized, and various classification systems used in managing this fracture were also discussed. Since the primary goal of treatment is to restore wrist function to its pre-injury level, the first part highlighted the critical role of key parameters such as articular step-off, dorsal tilt, and radial length in clinical decision-making. Now, in the second part, surgical methods including pin and plaster, percutaneous pinning, the Kapandji technique, fragment-specific fixation, external fixators (both bridging and non-bridging types), locking plates (fixed-angle and variable-angle), and spanning plates are examined. The complications associated with each method, such as infection, radial nerve injury, and tendon-related problems, are also discussed. Postoperative pain management, follow-up care, and the importance of precise imaging—particularly the facet view—are among other key topics addressed in this section. Ultimately, it is emphasized that the choice of surgical method should be based on the characteristics of the fracture, the patient’s condition, and the surgeon’s experience.

Abstract Abstract
Introduction: Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent and painful condition that limits shoulder mobility. A strong association exists between diabetes and this condition. This study aims to investigate the inflammatory risk factors involved in the development of adhesive capsulitis in diabetic patients.
Materials & Methods: In a descriptive-analytical study, individuals diagnosed with adhesive capsulitis were evaluated over three years. Among these patients, those with a confirmed diagnosis of diabetes who were undergoing treatment were identified and included in the study. They were compared to non-diabetic individuals. A pre-defined questionnaire was used to collect demographic data, diabetes duration, treatment type, and laboratory findings, which were then analyzed for associations with this condition.
Results & Discussion: A total of 53 patients were examined, with the prevalence of concurrent diabetes and adhesive capsulitis being 47%. Hyperlipidemia and hypercholesterolemia showed a significant association with the co-occurrence of diabetes and adhesive capsulitis. The mean duration of diabetes was 4.43 ± 2.22 years in patients receiving oral medication and 4.55 ± 2.60 years in those on insulin therapy (P = 0.26). The mean HbA1C level was 7.72 ± 1.01 in the oral medication group and 6.71 ± 0.48 in the insulin therapy group, indicating a significant association between treatment type, diabetes duration, and the development of adhesive capsulitis.
Conclusion: Based on the findings of this study, the coexistence of hyperlipidemia and hypercholesterolemia with diabetes plays a significant role in the development of adhesive capsulitis.

Abstract Abstract
Avascular necrosis (AVN) of the capitate is extremely rare and leads to chronic wrist pain. Currently, there is no standard treatment protocol for AVN of this wrist bone. Due to the rarity of these cases, limited experience exists regarding treatment methods. This report presents a 30-year-old male patient with AVN of the capitate. The patient was treated with a vascularized bone graft. After one year of follow-up, the symptoms have resolved, and there has been no progression of capitate necrosis.

Abstract Abstract
The brachial plexus block is a regional anesthesia technique primarily used for upper limb surgeries. This method involves injecting local anesthetics near the brachial plexus, a network of nerves that innervate the arm, temporarily blocking sensation and motor function in the affected area. It serves as an alternative or adjunct to general anesthesia, particularly benefiting patients with significant comorbidities or those at risk of complications associated with general anesthesia. Regional anesthesia plays a crucial role in orthopedic and outpatient anesthesia advancements by providing both intraoperative anesthesia and postoperative analgesia. Furthermore, with the advent of ultrasound technology, newer upper limb block techniques have been introduced for targeted anesthesia. These various approaches allow anesthesiologists to tailor pain management strategies based on the individual needs of patients and surgical requirements. Continuous improvements in ultrasound technology have enhanced the safety and efficacy of these blocks, making regional anesthesia a standard technique for pain management in upper limb surgeries.

Abstract Abstract
Carpal Tunnel Syndrome (CTS) is the most common idiopathic neuropathic compression syndrome in the upper extremity, with a reported prevalence of 2.7% in the general population. Trigger Finger (TF) is a common upper limb disorder characterized by the painful locking of one or more fingers. A review of the literature, and personal experiences of the authors indicates that the occurrence of Trigger Finger after Carpal Tunnel Syndrome surgery is significantly higher in patients with CTS compared to those without CTS, though this increase in incidence has not definitively been linked to the surgery. In most studies, thumb has been the most commonly involved finger in association with CTS; however, in some cases, the third finger was more common. In contrast, when TF occurs alone, the fourth finger is typically the most frequently affected finger with triggering in the fourth one.

Abstract این شکستگی یکی از رایج ترین اسیب های دست است. بر طبق ارزیابی سال ۱۹۹۸ در امریکا؛ سالیانه ۶۴۳۰۰۰ مورد مشاهده شده است. ۳۷۲۰۰۰ مورد مربوط به افراد ۶۵ سال ببالا بوده است.تعداد شکستگی ها با بالا رفتن سن افزایش می یابد.نوشتجات در مورد این شکستگی زیاد هست؛ تا جولای ۲۰۲۲؛ بیش از ۱۸۰۰ مقاله را مشاهده می کنیم؛۶۲۸ مقاله مقدم به دوازده ماه اخیر بوده است.
این شکستگی قبل از عصر ۱ACL (رباط صلیبی قدامی) ردیف اول شکایت های پزشکی قانونی را از آن خود داشت. بنظر می آید اکنون شکایات بیهوشی و ACL در ردیف اول قرار دارند.
در زمان جالینوس و بقراط[(۱۳۱-۲۰۱ قبل از میلاد) آنرا در رفتگی مچ میدانستند. پوتو Pouteau از فرانسه در سال ۱۷۸۳ این سنت را شکست و آنرا بنام شکستگی پوتو در نوشتجات ثبت کرد.جو سیاسی قرن هیجده اروبا طوری بود که دنیای انگلیسی زبان ؛فرانسه زبانان را به رسمیت نمی شناخت.مبادلات علمی بین آنها وجود نداشت.
ابرهام کالیس جراح ایرلندی این شکستگی رار سال ۱۸۱۴ در مجله Edinburgh Medical Surgical Journal چاپ کرد.شرح و بیان این شکستگی فقط بر پایه معاینات کلینیکی و بسیار درست بود. ناگفته نماند کالیس آنرا ۸۱ سال قبل از ظهور رادیو گرافی شرح داده بود. رادیو گرافی در سال ۱۸۹۵ اختراع شد.

Abstract Aims:
Distal radius fracture (DRF) has the highest rate among pediatric fractures. The management of distal radius fractures in children has to be as non-invasive as possible, which requires definitive care for proper reduction and stabilization. This study was designed to evaluate the short-term complications of pinning radius fractures in children, help the surgeon make an appropriate decision according to the situation of patients, and also look for solutions to reduce complications.
Methods:
In this cohort study, patients diagnosed with distal radius fracture aged 3-15 years who visited Shahid Madani Hospital in Karaj were evaluated. Demographic characteristics and type of fracture of patients who underwent pinning of distal radius fractures, were collected after obtaining their consent. Then the complications of patients were evaluated based on Clavien-Dindo-Sink, and dahl scores four and five weeks, and three and six months after the surgery.
Findings:
According to the Clavien-Dindo-Sink score, 96 cases had no complications, 35 cases had complications of grade 1, 27 cases had complications of grade 2, 9 cases had complications of grade 3, and 1 patient had complications of grade 4. In the examination of the DahlPin operative site complication score, 108 cases had no operative site complications, 30 cases had complications of grade 1, 22 cases had complications of grade 2, 6 cases had complications of grade 3, and 2 cases had complications of grade 4. Four cases had transient neurapraxia and 20 cases had limited range of motion.
Conclusion:
The results obtained from this study create a more comprehensive understanding of the complications and weaknesses of the percutaneous pinning treatment method for distal radius fracture patients.

Abstract Investigating the relationship between ultrasound findings and the results of repair of Madin nerve tears in Imam Khomeini Hospital, Urmia

Abstract:
Introduction:
Median Nerve-traumatic injury is seen in 2.8% of trauma patients. Electrodiagnostic tests cannot provide the needed information about extent of healing, neuroma or scar formation following repair to help prognosis or decision -making on time for intervention. Sonography ,as a cheap, easily accessible tool might be helpful.


Materials & Methods: The median nerve traumatic injuries during one year in a teaching hospital were entered into a retrospective study. The cases with diabetes mellitus and systemic illness, congenital neuromuscular conditions, cervical discopathy were excluded. The cases underwent clinical , electro-diagnostic and ultrasonographic assessments three months post surgical repair.

Results:
within a one-year period ,21 patients -12 male and 9 female , with 20-55 years age range ,were evaluated 3 months post median nerve laceration repair.
The volume of neuroma formed at the site of repair was clearly less in cases with complete recovery than in patients with partial recovery. Also, the volume of neuroma formed at the site of repair was clearly lower
in cases with electromyographic results of nerve regeneration than in patients with severe
axonal injury, but with no statistical significance . All patients with injury at the carpal tunnel level had complete recovery after surgery, but without statistically significant relationship .
Conclusion: Ultrasound can be used as a low-cost and non-invasive method in the study of post -repair evaluation of peripheral nerve damage.

کلیدواژه‌ها / English median nerve, neuroma, ultrasound

Abstract 1-Abstract
Metacarpal fractures are common hand injuries that often require surgical intervention for significant displacement or instability. Various fixation methods such as Kirschner wires, plates, external fixators, and intramedullary screws are used, each with potential complications. Understanding the anatomy and biomechanics of the metacarpal is crucial for successful management. We present a case of a 36-year-old man with a second metacarpal fracture following a motorcycle accident. After initial pinning failed, open reduction with internal fixation was performed, later replaced by an intramedullary headless screw. Subsequent physiotherapy led to a successful outcome with normal function and union. Surgical techniques for metacarpal fractures include pinning, plating, and intramedullary devices, each with specific indications and considerations. While pinning is cost-effective and minimally invasive, plating is preferred for certain fracture patterns, and intramedullary devices allow early mobilization. In our case, the intramedullary screw proved effective for delayed Union treatment after previous failures. Larger studies are needed to validate its efficacy and explore potential complications. This case highlights the importance of individualized treatment strategies in complex metacarpal fractures.

Abstract Background: Pulley is a synovial tissue that attaches the flexor tendons to the dorsal portions of the fibro-osseous tunnel near the tendon attachment. Pulley type A with ring structure is one of the most important pulleys in fingers. Two-stage reconstruction by silicon is the common treatment in damaged tendon which has long recovery time and the tendency of the repaired tendon to adhere to the fibrous-bone tunnel around it. Accordingly, the one-stage reconstruction by synthetic pulley is a promising approach to resolve the mentioned problems. Methods: In the present research, the polyurethane (PU) nanofiber scaffolds have been designed for synthetic pulley applications, and their mechanical and structural properties have been evaluated. Results: The structural properties of nanofiber scaffolds show similar properties to protein and polysaccharide fibers in the extracellular matrix (ECM). The Fourier transform infrared spectroscopy (FTIR) results confirmed the functional groups of PU without any unwanted reactions. The amount of stress (3.19 ± 0.54) and Young's modulus (1.20 ± 0.39) in PU nanofiber scaffolds show similar mechanical properties to natural pulley. Conclusion: The obtained results showed that the PU nanofibers scaffolds can be proposed as a suitable candidate for fabrication of synthetic pulley in flexor tendon injuries.