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Congenital Anomalies of the Hand

Principles of Management The difficulties in treating congenital anomalies of the hand have long been recognized. Milford observed, “a single surgical procedure cannot be standardized to suit even similar anomalies.” Treatment of a congenital hand deformity may be sought at birth or later in the child’s development. Involvement may be unilateral or bilateral; the anomaly may be an isolated condition, or it may be a single…

Hand Infections

Factors Influencing Hand Infections The clinical course of most hand infections is affected by anatomic, local, and systemic factors, in addition to bacterial virulence and the size of the inoculum. Anatomic factors that to some extent determine the ease of penetration, localization, and spread of infection include: (1) the thin layer of skin and subcutaneous tissue over the tendons, bones, and joints; (2) the closed space…

Tumors and Tumorous Conditions of the Hand

Hand masses may result from tumors and tumorous conditions, and although most of these masses are benign, they should be considered potentially problematic and managed with great diligence. Because the hand has limited free space and exquisite sensitivity, even small and histologically benign masses can cause pain and significantly impair function. However, most hand neoplasms develop insidiously without significant pain or tenderness (including those that are…

Compressive Neuropathies of the Hand, Forearm, and Elbow

Carpal Tunnel Syndrome Carpal tunnel syndrome, described by Paget in 1854, is the most common upper extremity compression neuropathy and results from median nerve compression within the carpal tunnel. The carpal tunnel is bound by the carpal bones arching dorsally; the hook of the hamate and the pisiform medially; and the scaphoid tubercle and trapezial ridge laterally. The palmar aspect, or “roof,” of the carpal tunnel…

Stenosing Tenosynovitis of the Wrist and Hand

Stenosing Tenosynovitis Stenosing tenosynovitis in the hand and wrist are common conditions resulting in significant functional impairment for which treatments usually are straightforward; symptom resolution usually is complete with appropriate management. When the extensor pollicis brevis (EPB) and the abductor pollicis longus (APL) tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician Fritz de Quervain, who described this malady…

Dupuytren Contracture

Dupuytren disease is a proliferation of previously normal subcutaneous palmar and digital tissues that may manifest as nodules and cords that may compromise hand function by the resultant finger and thumb joint flexion contractures. Other secondary changes include thinning of the overlying subcutaneous fat and subsequent adhesion to and later pitting or dimpling of the skin. The lesion activity and the ensuing deformity rate vary considerably.…

Compartment Syndromes and Volkmann Contracture

Definition and History Compartment syndrome is a condition in which the circulation within a closed compartment is compromised by an increase in pressure within the compartment, causing necrosis of muscles, nerves, and eventually the skin because of excessive swelling. Volkmann ischemic contracture is a sequela of untreated or inadequately treated compartment syndrome in which necrotic muscle and nerve tissue have been replaced with fibrous tissue. In…

Arthritic Hand

Rheumatoid Arthritis Rheumatoid arthritis is the most common idiopathic inflammatory arthritis, affecting approximately 0.8% of the population, and it is two to four times more common in women than in men. The disease is characterized by hypertrophic synovitis that leads to joint laxity from soft-tissue attenuation, which may lead to joint subluxation and dislocation. Joint cartilage destruction usually ensues and may lead to attritional tendon rupture.…

Cerebral Palsy of the Hand

Cerebral palsy is a nonprogressive, nonhereditary encephalopathy that occurs in the prenatal or perinatal period and is characterized by altered motor, sensory, and, often, intellectual function. Cerebral palsy occurs in the industrialized world with an approximate annual frequency of 2 per 1000 live births. The most common motor disability of childhood, cerebral palsy can be caused by fetal stroke, anoxia, infection, teratogens, central nervous system malformations,…

Paralytic Hand

Sensation, mobility, and strength are required for the highly adaptive functions of pinch, grasp, and hook. Positional changes and delicate movements also are made possible by the many joints of the 29 hand, wrist, and forearm bones and by the 50 muscles that act as motors and stabilizers. To be purposeful, motion must be controlled, and joints crossed by moving tendons must be stabilized by balanced…

Special Hand Disorders

Aneurysm, Thrombosis, and Embolism in Radial, Ulnar, and Digital Arteries Through the continuation of the radial artery into the hand as the deep palmar arch and the ulnar artery as the superficial palmar arch, circulation to the hand is usually sufficient to allow the digits to remain viable despite most disease and injury. The superficial arch is complete in almost 80% of hands and incomplete in…

Wrist Disorders

This chapter includes a discussion of anatomic, biomechanical, and kinematic aspects of wrist function and diagnostic methods, treatment options, and procedures for various wrist conditions. A considerable body of information on the wrist has developed in recent years. No attempt is made to resolve all controversies or to define narrowly the place of new procedures or technologies. Anatomy The wrist is the anatomic region between the…

Nerve Injuries at the Level of the Hand and Wrist

This chapter includes the essentials of treatment of nerve injuries in the digits, palm, and wrist. Although many of the principles discussed here can be applied to injuries in the forearm and arm, more detailed discussions of more proximal nerve injuries can be found in Chapter 62 on peripheral nerve injuries. Nerve entrapments and compression neuropathies also are discussed in detail in Chapter 62 . Reconstructive…

Fractures, Dislocations, and Ligamentous Injuries of The Hand and Wrist

Although general management principles apply to the hand, functional impairment may follow seemingly minor trauma from resultant secondary sensory loss, motion restriction, and weakness. When treating fractures, anatomic and radiographic perfection does not always lead to normal function and early and accurate detection of soft-tissue injuries may require more specialized and urgent treatment. Often, it is better to accept a less than anatomic fracture position and…

Flexor and Extensor Tendon Injuries

Flexor Tendons A basic knowledge of the anatomy of the flexor tendons, especially in the forearm, wrist, and hand, is assumed, as is an understanding of the essential biomechanical aspects of flexor digitorum profundus and sublimis function in the fingers. Tendon nutrition is believed to derive from two basic sources: (1) the synovial fluid produced within the tenosynovial sheath and (2) the blood supply provided through…

Acute Hand Injuries

The hand and fingers are the body parts most often injured in the workplace. In the United States, annually, more than 1 million emergency department visits are caused by work-related hand trauma. For an acutely injured hand, restoration of function is the goal of treatment. It is necessary to prevent infection, salvage injured parts, and promote primary healing. Although nerves and tendons may be repaired in…

Basic Surgical Technique and Postoperative Care

The hand is the most complex and versatile structure in the human body. Formed of 27 bones, the hand and wrist require more than 30 muscles and a vast web of ligaments and tendons to move them into the myriad postures required for the countless tasks the hand performs every day. The complexity of hand function is reflected by the large amount of brain space dedicated…

Microsurgery

Microsurgery techniques are being applied to an expanding range of orthopaedic problems. Now the term super-microsurgery , coined by Koshima et al., is used to apply to the anastomosis of submillimeter vessels that is necessary in distal replants and perforator flaps. The discussion presented in this chapter includes microsurgical procedures appropriate for surgery of the hand, including the repair of small vessels and nerves; the transfer of…

Peripheral Nerve Injuries

Peripheral nerve injuries are common. Despite numerous advances in microsurgical technique and interfascicular nerve grafting, many treatment principles obtained from World War II experiences as set forth in the cumulative works of Seddon and Woodhall are still applicable today. Current research focusing on pharmacologic agents, immune system modulation, enhancing factors, and entubulation chambers, although promising, have had little clinical application so far, and the results of…

Old Unreduced Dislocations

Any dislocation should be reduced as soon as reasonably possible. While a joint is dislocated, the metabolism of its hyaline cartilage is disturbed and synovial fluid functions are impaired. Hyaline cartilage may begin to degenerate during this brief period, and irreversible changes rapidly occur. Consequently, when old unreduced dislocations are finally reduced, normal and painless joint motion and function should not be expected. When old unreduced…