Hand and Upper Extremity Surgery
Core principles
- Flexor tendon zones guide prognosis and repair: zone II injuries have poorer outcomes because of the flexor sheath and pulleys.
- Nerve injury assessment includes motor and sensory distribution; early repair improves outcomes, and nerve gaps may need grafting or conduits.
- Hand compartment syndrome and severe swelling threaten perfusion; escharotomy or fasciotomy may be urgent.
- Scaphoid fractures risk nonunion because of retrograde blood supply; anatomic snuffbox tenderness warrants immobilization and repeat imaging if initial films are negative.
- Carpal tunnel syndrome is median nerve compression; night symptoms and thenar wasting guide severity and surgery.
Worked example
A 30-year-old falls onto an outstretched hand with snuffbox tenderness but normal initial radiographs. Reasoning: treat as suspected scaphoid fracture, immobilize, and arrange repeat imaging or MRI. Missing this injury risks nonunion and avascular necrosis.
Traps
Do not suture a contaminated tendon wound without irrigation and antibiotic consideration. Do not ignore open joint injury. Do not diagnose carpal tunnel syndrome without examining median nerve territory.
Key points are listed separately.