Chapter 44: Surgery of the Hand and Wrist

KEY POINTS

1. Surgery of the hand is a regional specialty, integrating components of neurologic, orthopedic, plastic, and vascular surgery.

2. Understanding hand anatomy is the key to proper diagnosis of injury, infection, and degenerative disease of the hand.

3. After evaluation and/or treatment, patients should be splinted to protect the injured digits and keep the collateral ligaments of the injured joints on tension (metacarpophalangeal joints flexed, interphalangeal joints extended).

4. Healing of an injured or diseased structure in the hand is not the endpoint of treatment; the goal of any intervention must be to obtain structure healing, relief of pain, and maximization of function.

5. If a patient managed conservatively for cellulitis does not improve within 24 to 48 hours of appropriate intravenous antibiotics, abscess must be suspected.

6. Clinical examination, particularly noting the area of greatest tenderness and/or inflammation, is the most useful diagnostic tool for hand infections.

INTRODUCTION

The highly mobile, functional, and strong hand is a major distinguishing point between humans and the nonhuman primates. The hand is an essential participant for activities of daily living, vocation, and recreational activities. The hand is even adaptable enough to read for the blind and speak for the mute. The underlying goal of all aspects of hand surgery is to maximize mobility, sensibility, stability, and strength while minimizing pain. These goals are then maximized to the extent possible given the patient’s particular pathology. Hand surgery is a regional specialty. Hand surgeons integrate components of neurologic, orthopedic, plastic, and vascular surgery in the care of patients with disorders of the upper extremities.

ANATOMY OF THE HAND AND WRIST

In order to understand any disorder of the hand, one must understand the anatomy of the underlying structures. Examination of the hand is based on demonstrating the function or lack thereof of each of these structures.

Bones

The hand is highly mobile in space to allow maximum flexibility in function. As such, a number of directions particular to the hand are necessary in order to properly describe position, motion, and so on.¹ Palmar (or volar) refers to the anterior surface of the hand in the anatomic position; dorsal refers to the posterior surface in the anatomic position. The hand can rotate at the wrist level; rotation to bring the palm down is called pronation, rotation to bring the palm up is called supination. Because the hand can rotate in space, the terms medial and lateral are avoided. Radial and ulnar are used instead as these terms do not vary with respect to the rotational position of the hand. Abduction and adduction, when used on the hand, refer to movement of the digits away from and toward the middle finger, respectively (Fig. 44-1).