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  • The field of hand surgery has evolved via the integration of surgical disciplines specific to bone, tendon, nerve, vessel, and skin.

  • A careful inventory of each of these components must be made in every patient to plan treatment and anticipate expected functional recovery of the traumatized hand and upper extremity.

  • Assessment of tissue viability should occur through a careful vascular and neurologic examination, both pre- and intraoperatively.

  • The skeleton represents the foundation of any reconstruction of the upper limb; a plan for temporizing and/or definitive fixation in every fracture must be established prior to finalizing any other repair.

  • A plan for soft tissue coverage should be made early when the skin envelope is compromised.


The origins of hand and upper extremity surgery in the United States as a surgical specialty can be largely attributed to Major General Norman Kirk, MD (Fig. 43-1), the first orthopedic surgeon to be appointed as surgeon general of the armed forces.1 With his significant experience in treating veterans of World War I and World War II,2 he appreciated that injuries of the hand and upper extremity commonly involve joint, bone, vessel, tendon, and nerve, and optimal treatment required familiarity with each.


Major General Norman Kirk, MD. (From U.S. National Library of Medicine.

In an effort to improve the outcomes related to the care of the hand and upper extremity, Sterling Bunnell3 (Fig. 43-2), a friend and contemporary of Norman Kirk, was charged with founding the first group of specialized military training centers for hand surgery.3 These programs have evolved into the current modern hand fellowships.


Sterling Bunnell, MD.

In 1989, recognizing that surgery of the hand requires a specific skill set for optimal outcomes, the American Boards of Surgery, Orthopaedic Surgery, and Plastic Surgery4 initiated a specialty examination process culminating in a Certificate for Additional Qualifications for Surgery for the Hand, now called Subspecialty Certificate in Surgery of the Hand. This certification represents the pinnacle of training and aspirations of clinicians committed to caring for those afflicted with trauma or malady of the hand and upper extremity. This chapter is a reflection of the basic tenets and a brief overview of the current state of this specialty.


The approach to the treatment of the trauma victim must follow the standardized, thoroughly investigated, and well-established protocols of basic and advanced life support in the field, as well as Advanced Trauma Life Support (ATLS). Many would agree that the severed or mangled hand, forearm, or arm can be a disturbing sight, ...

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