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Hand therapy

Synopsis ■ Flexor tendon injuries treated with optimal repair techniques may benefit from an early active motion regimen utilizing short arc active flexion exercises initiated within the first postoperative week. ■ The use of a relative motion extension orthosis has become the standard of care for the treatment of extensor tendon repairs with evidence to support earlier functional hand use and return to work. ■ Fracture…

Aesthetic hand surgery

Access video content for this chapter online at Elsevier eBooks+ Introduction Hands are an essential part of human interaction, communication, and social integration, and apart from the face, they are the most consistently visible part of the body. Generally, the primary concern for hand surgeons is the restoration of function. However, many patients desire not only a functional extremity, but an aesthetically pleasing one, supporting the…

Upper extremity composite allotransplantation

Synopsis ■ Upper extremity allografts consist of multiple tissues of variable immunogenicity such as skin, lymph nodes, bone marrow, nerves, vessels, muscles, and bone. ■ Transplantation can restore the appearance, anatomy, and function of non-salvageable upper extremity loss by replacing “like-with-like” tissue while avoiding donor site morbidity and/or multiple reconstructions. ■ Vascularized composite allotransplantation (VCA) is not a life-saving procedure but it can significantly enhance a…

Treatment of the upper extremity amputee

Access video lecture content for this chapter online at Elsevier eBooks+ Introduction Upper extremity amputees are different from lower extremity amputees in many aspects. The patients tend to be younger, and their amputations are primarily due to trauma and tumors rather than dysvascular conditions. The patients live longer with their residual limbs, and prosthetic concerns for the two groups of patients dramatically differ. Upper extremity prostheses…

Growth considerations in the pediatric upper extremity

Synopsis ■ Skeletal growth is possible because of the presence of an active physis. ■ The physis is a temporary anatomical structure physiologically regulated by several factors. It can be hindered by congenital conditions (chondrodysplasias), direct damage, or interruption of its blood supply. ■ Regardless of its etiology, when the physis and or the epiphysis are damaged in a skeletally immature individual, three main issues must…

Congenital hand VII: Dysplasias – congenital contractures

Synopsis ■ The term arthrogryposis encompasses all congenital joint contractures. This includes arthrogryposis multiplex congenita in which multiple joints are contracted, amyoplasia which includes a characteristic pattern of upper extremity contractures, and distal arthrogryposis which is a set of 10 genetic disorders with associated hand and feet contractures. Treatment depends on the joint(s) involved and the associated functional limitations. Ensuring adequate shoulder internal rotation and elbow…

Congenital hand VI: Dysplasias – tumorous conditions

Synopsis ■ The OMT (Oberg, Manske, Tomkin) classification divides congenital tumorous conditions of the upper extremity into four broad categories based on the tissue involved: vascular, neurological, connective tissue, and skeletal. ■ While the great majority of congenital lesions are benign, many can cause local destruction, systemic dysregulation, and life-long morbidity. ■ The clinician should undertake a careful and methodical approach to evaluating, diagnosing, and treating…

Congenital hand V: Deformations and dysplasias – variant growth

Synopsis ■ In the Oberg, Manske, Tonkin (OMT) classification, “Deformation” refers to disruption of a limb that has already been formed. This category previously included constriction band sequence and congenital trigger digits, although the latter has been removed in the latest OMT update. ■ Trigger thumbs are common. Surgical correction remains the mainstay of treatment although conservative management is increasingly practiced worldwide. ■ Trigger fingers are…

Congenital hand IV: Malformations – abnormal axis differentiation – hand plate: unspecified axis

Synopsis ■ Syndactyly is one of the most common congenital differences in the upper extremity. It can be classified as incomplete (soft tissue only, not extending to the tip), complete (soft tissue only, extending to the tip), complex (with distal bony union) or complicated (with more than only distal bone fusion). The timing of surgery depends on the fingers involved and the type of syndactyly. In…

Congenital hand III: Malformations – abnormal axis differentiation – hand plate: proximodistal and radioulnar

Synopsis ■ Patients are treated from infancy to skeletal maturity and have unique needs which may change over time. ■ Comprehensive examination and appropriate workup and referrals for associated medical conditions is imperative. ■ To provide the best family-centered care, it is important to understand the family’s perspective and their goals for their child. ■ Patients tend to be incredibly resilient and functional. Many times, surgery…

Congenital hand II: Malformations – whole limb

Synopsis ■ Poland syndrome includes a wide range of anomalies that are relevant to the plastic surgeon. From a surgical point of view, priority is given here to discussing the management of the absent pectoralis major muscle, as the associated breast and congenital hand disorders are discussed in detail in other chapters. ■ Ulnar dimelia is an extremely rare congenital disorder and is usually associated with…

Congenital hand I: Embryology, classification, and principles

Synopsis ■ Consistency of terminology is necessary for optimal communication. ■ Limb outgrowth and patterning are controlled by specific signaling centers within the developing limb bud via the activation and interaction of molecular messengers. ■ Anomalies of limb development result from: spontaneous mutation of genetic material inheritance of abnormal genes subtle or gross insult to the limb bud. ■ The anomaly may be isolated or syndromic.…

The painful hand

Synopsis ■ Neuropathic pain is a common feature following traumatic injury. The pain experienced can have a profound effect on the individual; restricting their ability to carry out everyday activities and to participate in their societal roles. ■ This chapter recognizes that a multimodal and multidisciplinary approach to assessing, diagnosing, and treating post-­traumatic neuropathic pain is essential. Its structure therefore follows a typical clinical pathway. “Key…

The stiff hand

Access video and video lecture content for this chapter online at Elsevier eBooks+ Introduction Hand stiffness may result from either flexion contractures (inability to extend) or extension contractures (inability to flex) of the small joints of the hand. These limitations of either extension or flexion may be both active (inability to bring about motion through muscle activity) and/or passive (inability to move a joint with an…

The spastic hand

Synopsis ■ Spasticity is a condition characterized by muscle hypertonia, caused by a hyperactive stretch reflex mechanism, usually linked to a central neurological insult. It is responsible for various limb deformities, causing variable functional impairments. ■ Its primary treatment is non-surgical, but in selected cases, surgery may be indicated. The goal is to improve function by rebalancing the existing deforming forces, namely spasticity, muscle and joint…

The ischemic hand

Synopsis ■ Upper extremity ischemia is caused by many etiologies and may be classified into acute and chronic cases. ■ A precise understanding of arterial anatomy is pertinent to preoperative diagnosis, patient selection, and operative procedure. ■ A history of cold intolerance, Raynaud’s phenomenon and frequency of ischemic pain is important. Color changes, ulcerations, and infections are evaluated. ■ Noninvasive vascular examination includes measurement of fingertip…

Free-functioning muscle transfer

Synopsis ■ Free-functioning muscle transfer involves the transfer of a muscle from a distant location to replace a major functional deficit. ■ It is a complex procedure that requires high patient motivation and compliance. ■ The technique involves microvascular anastomoses and neural coaptation. ■ Meticulous attention must be paid to proper positioning and tensioning of the transferred muscle. Postoperatively, a structured long-term rehabilitation program is required.…

Nerve transfers

Synopsis ■ Nerve injuries are often devastating, with associated pain and impaired function. ■ Motor nerve injuries must be managed expeditiously, because regenerating axons must reach target muscle prior to degeneration and fibrosis – “time is muscle”. ■ Nerve transfers offer an advantageous method of reconstruction by delivering regenerating nerve fibers to the target end organ more quickly, thus converting a proximal injury to a more…

Tendon transfers

Synopsis ■ A tendon transfer is a reconstructive technique in which the tendon of a functioning muscle is detached, mobilized, and then reattached to another tendon or tendons of a non-functioning muscle, or into bone, to substitute for the action of the non-functioning muscle or tendon. ■ Tendon transfers in the upper limb are indicated to restore function to paralyzed muscles and tendons following nerve injuries,…