Planning of Surgical Treatment--Raoul Tubiana
PLANNING OF SURGICAL TREATMENT
R A O U L T U B I A N A , Paris SUMMARY When faced with a hand lesion even of moderate severity, whether recent or old, it is essential to prepare a rational plan o,f treatment. This will be based on a number of factors, which include the clinical examination, age and occupation o~ the patient, physical condition, and whether or not the dominant hand is involved. The examination will determine the extent to which the integuments, bones, tendons anti nerves are involved. When this has: been completed, one must assess the functional possibilities, taking into account associated lesions and relating them to the patient as a whole. GENERAL CONSIDERATIONS IN PLANNING
(1) The first aim of hand surgery is to restore [unction. This aim should never be forgotten and all surgical procedures must be planned with this objective in view. (2) T h e r e is no such thing as a routine operation f o r one condition o f t h e hand. The surgeon must never be a man of one procedure. On the contrary, he must have the experience to adapt techniques with which he is familiar to the individual problem of each patient. (3) The hand must not be considered apart from the limb or from the patient as a whole.. To quote Bunnell, "Never examine a hand through a hole in the blanket!" The choice of operation is at least as important as surgical technique; this is true both for emergencies and for elective surgery. (4) While surgery should be modified to suit the requirements of the patient, it must also be tailored to the ability of the surgeon. He should not embark on extensive emergency procedures or complex elective techniques such as pollicisation, nor attempt the treatment of neurological or congenital deformities unless he has sufficient experience. (5) Psychological and cosmetic factors must not be forgotten. The hand is constantly exposed to the eyes and to physical contacts; it is also the only part of our body which we have constantly in view. We are all aware of the plastic beauty and integrity of our own hands and it is easy to understand how any abnormality of the hand, whether of traumatic, pathological or congenital origin, may have psychological consequences. There is, however, a difference in the situations facing a surgeon about to treat an acute, open injury from that where it is necessary to restore function in a hand suffering from active disease or the effects of previous trauma. PRIMARY TREATMENT
Wounds of the hand must be treated surgically; there is no argument on this point. A wound can only be properly explored and cleaned surgically. By contrast decisions concerning the timing and the mode of repair of the skin, bones and tendons are open to discussion. The order of priority in management is as follows: (1) Relief of vascular complications: haemorrhage or ischaemia due to injury or compression of the vessels. (2) Prevention of infection. (3) Stabilisation of the skeleton. (4) Provision of skin cover. (5) Prevention of stiffness and fixed deformities. (6) Repair of nerves and tendons. The Hand--Vol. 7
No. 3
1975
223
Planning of Surgical Treatment--Raoul Tubiana
The primary operation thus involves two stages: a stage of wound cleaning and exploration, and a stage of repair. The first operation may sometimes be complete and definitive.. It is possible, in theory, to complete as many reparative procedures as possible at the first session, but when the tissues are contused and complex lesions are present, a one-stage repair may be dangerous and involve undue risks. The initial treatment must therefore aim at achieving uncomplicated healing and not attempt reconstructive procedures which may fail due to the state of the wound or to the prevailing conditions for surgery. The steps in this primary operation are first to clean and explore the wound, secondly to deal with vascular complications and stabilise the skeleton correctly and thirdly to ensure good quality skin cover. The nature and extent of the skin lesions influence the treatment of the deeper structures. Only in the presence of a clean cut skin wound, can one safely consider a primary repair of the nerves and tendons. In every case the following points are considered: Mode of closure: if the risk of sepsis is too great, closure is postponed. Swabs are taken for culture and antibiotics are prescribed on the strength of the sensitivities. A delayed primary closure is often possible. Necessary sacrifices: the assessment of viability and the decision as to which structures are worth preserving for eventual functional recovery can be difficult. When in doubt, it is preferable, as Pulvertaft (1967) has stated "to be conservative and to preserve all viable structures even if they will not contribute directly to the ultimate functional result. They may be useful later." One must be conservative, but not excessively so. A severe localised injury to one finger presents a problem quite different from an extensive wound of the hand. Early amputation of a digit which would otherwise remain stiff and insensitive may save precious time for a manual worker. One is more conservative when several digits are affected, even more so with the thumb. When the injury involves several fingers and the metacarpal part of the hand, the initial surgical treatment must be adapted to the likely requirements of later reconstruction. In particular, one should strive to maintain the length and mobility of the peripheral skeletal elements, namely the first and fifth rays, which can be put to profitable use when restoring the grip. It is also important to preserve all anatomical structures which may prove useful later as a source of ~kin, tendons, nerves and bone. RECONSTRUCTIVE SURGERY
Elective surgery carries less risk of infection and of non-viability. The surgeon therefore has better opportunity to plan treatment in relation to the functional requirements of the patient. In effect, faced with complex lesioffs; tl~e surgeon must evaluate preoperatively not only the chances of success of the intended surgical procedure, but also the future usefulness of the hand for the patient. T h e decision is n o t w h i c h procedure can be carried out on a hand, b u t rather w h a t will the p a t i e n t be able to achieve w i t h his hand.
It is not an anatomical result which is being looked for so much as the recovery of functions useful to the patient, and these must be taken into consideration as well as the therapeutic possibilities when defining objectives such as recovery of pinch grip, either lateral or terminal. In certain cases a patient requires full extension of a finger rather than full flexion, e t c . . . A particular surgical procedure carried out for one patient is not necessarily the correct one for another, even though he has an identical lesion. Even when 224
The Hand--Vol. 7
No. 3
1975
Planning of Surgical Treatment--Raoul Tubiana
technically well performed an inappropriate operation will only at best result in a marginal improvement; it may even cause functional deterioration if it is too ambitious with regard to the age or physical condition of the subject, if it disrupts a functional adaptation acquired over a long period of time, or if it involves prolonged inactivity. Long periods in hospital and multiple operations deter patients from returning to work. Only a full assessment can lead to planning based on the priorities of the patient and determine the precise order of treatment. Some patients need only one procedure, while others may require several operations. These should be spaced out according to the detailed plan formulated after examining or after surgical exploration. Bunnell and Boyes have summarised in five words the reconstructive programme for a disabled hand: position, cover, prehension, sensibility and placement. "If we observe what is lacking in these five elements, we plan our reconstruction to make up the deficits" (Boyes 1964). Position Few concepts have been more useful for saving injured hands than that of "position of function", but the many variations in the description of this position leads one to think that more than one exists. Bunnell (1948) has defined it as "the mid-position of the range of motion of each and every joint, including the wrist, and rotation of the forearm". We could say that positions of function are those that place the joints so that grasp is easy and where stiffness is less likely to occur. Finally, they are those positions where eventual stiffness will permit preservation of movements of small amplitude, in an active and useful range. "This so-called position of function has all the wisdom of parking a balky old car with a weak battery on a hill. From this position, it is easy to get it started again" (White, 1960). In practice, the term "position of function", as it is commonly used, is applied equally to different situations and it is important to distinguish between the temporary protective positions of immobilisation and the positions of fixation in a functional position. Positions o[ protection for temporary immobilisation should respect the following rules: (a) The wrist is in moderate extension and in slight ulnar deviation. (b) Flexion is predominant at the metacarpophalangeal joints at about 50°-80 °. Conversely, the interphalangeal joints are maintained in only slight flexion. In these positions the collateral ligaments are stretched. (c) The first metacarpal is placed in anteposition and slight abduction so as to keep the web fully opened. (d) The forearm is placed in semi-pronation. Immobilisation in this position aims at protecting the future mobility of the hand, in other words, a "prospective" position for mobilisation. The positions of function required for permanent immobilisation of joints differ in many ways from those required for temporary protective immobilisation. These are better called positions o[ fixation. They must be adapted to the individual patient. Ankylosis of both wrists in extension for example is a great handicap. It is essential to evaluate the movement of the mobile part of the hand each time one has to fix a digit in a permanent position. Finally, in certain circumstances the joints may have to be temporarily immobilised in non-functional positions o/relaxation to prevent excessive tension as for example after tendon or nerve suture. The Hand--Vol. 7
No. 3
t975
225
Planning of Surgical T r e a t m e n t - - R a o u l Tubiana
Skin Co,ver The skin of the hand is unique in the body for its rich sensory nerve supply and its fine fibrofatty subcutaneous layer. These characteristics vary greatly throughout the hand, matching the functional requirements. The type of skin to be used to cover the hand is thus determined by the functional requirements of the recipient area. The best skin is provided by the hand itself. Local flaps which are adjacent to the exposed area have the advantage of introducing skin of identical texture and of bringing their own blood and nerve supply. But their size is necessarily limited and the donor site usually needs a skin graft, which will be of inferior quality. When local flaps are not available, split skin grafts of the correct thickness, area and colour find many applications.. Distant flaps, either the cross-finger or the cross-arm, or from the thorax or abdomen can provide a fat-lined gliding plane for tendons, protect prehensile zones or cover a poorly vascularised defect where a free graft would not survive. Eventual preparation of these distant flaps must be included in the planning.
Gripping The term "gripping" is preferred to that of "prehension" which is a more complex mechanism involving a constant adaptation of the grip according to the sensory information it receives and to the intended use. Gripping has two components: an opening phase activated both by the dorsal extrinsics and by the synchronised contraction of the intrinsics, and the closing phase which depends essentially on the flexors. The two extrinsic muscle systems in the forearm provide the strength for opening and closing the fingers. The intrinsic muscles are indispensable for the freedom of movements of each phalanx. Gripping can be affected by a great variety of trauma and pathological processes. Its restoration may require the correction of contractions, repair of tendons by suture, graft or transfer, and nerve repair, which should be performed within one year of the injury. Depending on the severity of the lesions, one may be able to restore the precision grip and power grip, or in some cases only the more rudimentary action of the pincers or of the hook. To make precision handling possible, the minimal requirement is a thumb with as much as possible of its length and mobility and a finger against which it can actively oppose. The presence of a third mobile finger greatly increases control and precision. In power grasping, the hand wraps itself around the object and this movement requires mobile digital joints. The force of this full hand grip will depend on the width of the palm and the conservation, at least in part, of the peripheral rays. The thumb considerably increases the strength of this grip and improves control. For a simpler pincer action, two parts must be able to oppose each other, one of which must be active.
Sensibility Sensibility of the hand is essential for prehension and its restoration is an important part of any plan of reconstruction. Painful and insensitive fingers are seldom used. One can hope to restore some degree of protective sensitivity by late repairs of nerves, up to five years and may be more after micro-surgical nerve graftings.. When the skin of an important tactile surface has been lost, a sensitised skin flap can, if required, be transferred from less useful areas by advancement 226
The H a n d - - V o l . 7
No. 3
1975
Planning of Surgical Treatment--Raoul Tubiana
or rotation of adjacent integuments, or by a skin transplant, with its neurovascular pedicle.. These flaps retain a normal relationship between the nerve and the skin. Sensibility does not have the same value all over the hand. The most important areas are the pulps, but even here there is a functional hierarchy of the hemipulps which determines the priorities for repair as well as the choice of donor zone: the medial hemipulp of the thumb and lateral hemipulp of the index are the most important. On the other hand, loss of sensibility gives less disturbance on the medial aspect of the middle and ring fingers and for this reason they are the usual donor areas. The sensible zones of a finger due for amputation is the obvious choice in some cases.
Placement Located at the end of the upper extremity which serves as its vector, the hand can function efficiently only if the joints proximal to it are stable and mobile. The hand can reach any part of the body because of the mobility of the shoulder, elbow and wrist in different planes. Thus placement is one of the principles we must consider in planning the procedures for reconstruction of the hand. This may be of paramount importance in congenital anomalies of the upper limb.
Timing The order in which secondary restorative procedures will be done depends on many factors, including local conditions and evolution of lesions. In every case positioning the skeleton by splints or by surgery, soft tissue release and skin cover constitute the first steps. One should then protect or restore nerve function to prevent additional trophic changes, and finally repair the tendons, sometimes after preparing a gliding bed. When multiple operations are contemplated, a procedure requiring immobilisation must not be carried out at the same time as another after which immobilisation would be prejudicial. Physiotherapy and splintage are indicated between operations and sufficient time must elapse to allow the soft tissue induration to resolve. The programme must also take account of the social and professional rehabilitation of the patient. An injury to the hand may mean a change of occupation and retraining must not await the completion of treatment which may take a very long time, as for example in lesions of the brachial plexus. Professional rehabilitation needs help from the social services, to support the psychological wellbeing of the patient, ensure his economic security, and ease his return to work. The choice of a new occupation should also influence the plan of treatment. When the planning of treatment is complete, it should be discussed with all those involved: the anaesthetists who may need to consider several operations; the physiotherapists who must get to know the work and activities of the patient and the functional result which is aimed for. Finally, and most important, the patient must be kept informed, as his full co-operation is essential for success. REFERENCES BOYES, J. H. (1964) Brussels Les Publications "Acta Medica Belgica". Philadelphia and Montreal, J. B. Lippincott Company: p. 125. BUNNELL, S. (1948) Surgery of the Hand, Second Edition. Philadelphia, London, Montreal, J. B. Lippincott Company. PULVERTAFT, R. G. (1967) Traumatic mutilation of the hand. Severe combined mutilations of the thumb and fingers. Sicot, 1966, Paris Meeting. WHITE, W. L. (1960) Restoration of Function and Balance of the Wrist and Hand by Tendon Transfers. The Surgical Clinics of North America, 40: 427-459. The Hand--Vol. 7
No. 3
1975
227
PLANNING OF SURGICAL TREATMENT
R A O U L T U B I A N A , Paris SUMMARY When faced with a hand lesion even of moderate severity, whether recent or old, it is essential to prepare a rational plan o,f treatment. This will be based on a number of factors, which include the clinical examination, age and occupation o~ the patient, physical condition, and whether or not the dominant hand is involved. The examination will determine the extent to which the integuments, bones, tendons anti nerves are involved. When this has: been completed, one must assess the functional possibilities, taking into account associated lesions and relating them to the patient as a whole. GENERAL CONSIDERATIONS IN PLANNING
(1) The first aim of hand surgery is to restore [unction. This aim should never be forgotten and all surgical procedures must be planned with this objective in view. (2) T h e r e is no such thing as a routine operation f o r one condition o f t h e hand. The surgeon must never be a man of one procedure. On the contrary, he must have the experience to adapt techniques with which he is familiar to the individual problem of each patient. (3) The hand must not be considered apart from the limb or from the patient as a whole.. To quote Bunnell, "Never examine a hand through a hole in the blanket!" The choice of operation is at least as important as surgical technique; this is true both for emergencies and for elective surgery. (4) While surgery should be modified to suit the requirements of the patient, it must also be tailored to the ability of the surgeon. He should not embark on extensive emergency procedures or complex elective techniques such as pollicisation, nor attempt the treatment of neurological or congenital deformities unless he has sufficient experience. (5) Psychological and cosmetic factors must not be forgotten. The hand is constantly exposed to the eyes and to physical contacts; it is also the only part of our body which we have constantly in view. We are all aware of the plastic beauty and integrity of our own hands and it is easy to understand how any abnormality of the hand, whether of traumatic, pathological or congenital origin, may have psychological consequences. There is, however, a difference in the situations facing a surgeon about to treat an acute, open injury from that where it is necessary to restore function in a hand suffering from active disease or the effects of previous trauma. PRIMARY TREATMENT
Wounds of the hand must be treated surgically; there is no argument on this point. A wound can only be properly explored and cleaned surgically. By contrast decisions concerning the timing and the mode of repair of the skin, bones and tendons are open to discussion. The order of priority in management is as follows: (1) Relief of vascular complications: haemorrhage or ischaemia due to injury or compression of the vessels. (2) Prevention of infection. (3) Stabilisation of the skeleton. (4) Provision of skin cover. (5) Prevention of stiffness and fixed deformities. (6) Repair of nerves and tendons. The Hand--Vol. 7
No. 3
1975
223
Planning of Surgical Treatment--Raoul Tubiana
The primary operation thus involves two stages: a stage of wound cleaning and exploration, and a stage of repair. The first operation may sometimes be complete and definitive.. It is possible, in theory, to complete as many reparative procedures as possible at the first session, but when the tissues are contused and complex lesions are present, a one-stage repair may be dangerous and involve undue risks. The initial treatment must therefore aim at achieving uncomplicated healing and not attempt reconstructive procedures which may fail due to the state of the wound or to the prevailing conditions for surgery. The steps in this primary operation are first to clean and explore the wound, secondly to deal with vascular complications and stabilise the skeleton correctly and thirdly to ensure good quality skin cover. The nature and extent of the skin lesions influence the treatment of the deeper structures. Only in the presence of a clean cut skin wound, can one safely consider a primary repair of the nerves and tendons. In every case the following points are considered: Mode of closure: if the risk of sepsis is too great, closure is postponed. Swabs are taken for culture and antibiotics are prescribed on the strength of the sensitivities. A delayed primary closure is often possible. Necessary sacrifices: the assessment of viability and the decision as to which structures are worth preserving for eventual functional recovery can be difficult. When in doubt, it is preferable, as Pulvertaft (1967) has stated "to be conservative and to preserve all viable structures even if they will not contribute directly to the ultimate functional result. They may be useful later." One must be conservative, but not excessively so. A severe localised injury to one finger presents a problem quite different from an extensive wound of the hand. Early amputation of a digit which would otherwise remain stiff and insensitive may save precious time for a manual worker. One is more conservative when several digits are affected, even more so with the thumb. When the injury involves several fingers and the metacarpal part of the hand, the initial surgical treatment must be adapted to the likely requirements of later reconstruction. In particular, one should strive to maintain the length and mobility of the peripheral skeletal elements, namely the first and fifth rays, which can be put to profitable use when restoring the grip. It is also important to preserve all anatomical structures which may prove useful later as a source of ~kin, tendons, nerves and bone. RECONSTRUCTIVE SURGERY
Elective surgery carries less risk of infection and of non-viability. The surgeon therefore has better opportunity to plan treatment in relation to the functional requirements of the patient. In effect, faced with complex lesioffs; tl~e surgeon must evaluate preoperatively not only the chances of success of the intended surgical procedure, but also the future usefulness of the hand for the patient. T h e decision is n o t w h i c h procedure can be carried out on a hand, b u t rather w h a t will the p a t i e n t be able to achieve w i t h his hand.
It is not an anatomical result which is being looked for so much as the recovery of functions useful to the patient, and these must be taken into consideration as well as the therapeutic possibilities when defining objectives such as recovery of pinch grip, either lateral or terminal. In certain cases a patient requires full extension of a finger rather than full flexion, e t c . . . A particular surgical procedure carried out for one patient is not necessarily the correct one for another, even though he has an identical lesion. Even when 224
The Hand--Vol. 7
No. 3
1975
Planning of Surgical Treatment--Raoul Tubiana
technically well performed an inappropriate operation will only at best result in a marginal improvement; it may even cause functional deterioration if it is too ambitious with regard to the age or physical condition of the subject, if it disrupts a functional adaptation acquired over a long period of time, or if it involves prolonged inactivity. Long periods in hospital and multiple operations deter patients from returning to work. Only a full assessment can lead to planning based on the priorities of the patient and determine the precise order of treatment. Some patients need only one procedure, while others may require several operations. These should be spaced out according to the detailed plan formulated after examining or after surgical exploration. Bunnell and Boyes have summarised in five words the reconstructive programme for a disabled hand: position, cover, prehension, sensibility and placement. "If we observe what is lacking in these five elements, we plan our reconstruction to make up the deficits" (Boyes 1964). Position Few concepts have been more useful for saving injured hands than that of "position of function", but the many variations in the description of this position leads one to think that more than one exists. Bunnell (1948) has defined it as "the mid-position of the range of motion of each and every joint, including the wrist, and rotation of the forearm". We could say that positions of function are those that place the joints so that grasp is easy and where stiffness is less likely to occur. Finally, they are those positions where eventual stiffness will permit preservation of movements of small amplitude, in an active and useful range. "This so-called position of function has all the wisdom of parking a balky old car with a weak battery on a hill. From this position, it is easy to get it started again" (White, 1960). In practice, the term "position of function", as it is commonly used, is applied equally to different situations and it is important to distinguish between the temporary protective positions of immobilisation and the positions of fixation in a functional position. Positions o[ protection for temporary immobilisation should respect the following rules: (a) The wrist is in moderate extension and in slight ulnar deviation. (b) Flexion is predominant at the metacarpophalangeal joints at about 50°-80 °. Conversely, the interphalangeal joints are maintained in only slight flexion. In these positions the collateral ligaments are stretched. (c) The first metacarpal is placed in anteposition and slight abduction so as to keep the web fully opened. (d) The forearm is placed in semi-pronation. Immobilisation in this position aims at protecting the future mobility of the hand, in other words, a "prospective" position for mobilisation. The positions of function required for permanent immobilisation of joints differ in many ways from those required for temporary protective immobilisation. These are better called positions o[ fixation. They must be adapted to the individual patient. Ankylosis of both wrists in extension for example is a great handicap. It is essential to evaluate the movement of the mobile part of the hand each time one has to fix a digit in a permanent position. Finally, in certain circumstances the joints may have to be temporarily immobilised in non-functional positions o/relaxation to prevent excessive tension as for example after tendon or nerve suture. The Hand--Vol. 7
No. 3
t975
225
Planning of Surgical T r e a t m e n t - - R a o u l Tubiana
Skin Co,ver The skin of the hand is unique in the body for its rich sensory nerve supply and its fine fibrofatty subcutaneous layer. These characteristics vary greatly throughout the hand, matching the functional requirements. The type of skin to be used to cover the hand is thus determined by the functional requirements of the recipient area. The best skin is provided by the hand itself. Local flaps which are adjacent to the exposed area have the advantage of introducing skin of identical texture and of bringing their own blood and nerve supply. But their size is necessarily limited and the donor site usually needs a skin graft, which will be of inferior quality. When local flaps are not available, split skin grafts of the correct thickness, area and colour find many applications.. Distant flaps, either the cross-finger or the cross-arm, or from the thorax or abdomen can provide a fat-lined gliding plane for tendons, protect prehensile zones or cover a poorly vascularised defect where a free graft would not survive. Eventual preparation of these distant flaps must be included in the planning.
Gripping The term "gripping" is preferred to that of "prehension" which is a more complex mechanism involving a constant adaptation of the grip according to the sensory information it receives and to the intended use. Gripping has two components: an opening phase activated both by the dorsal extrinsics and by the synchronised contraction of the intrinsics, and the closing phase which depends essentially on the flexors. The two extrinsic muscle systems in the forearm provide the strength for opening and closing the fingers. The intrinsic muscles are indispensable for the freedom of movements of each phalanx. Gripping can be affected by a great variety of trauma and pathological processes. Its restoration may require the correction of contractions, repair of tendons by suture, graft or transfer, and nerve repair, which should be performed within one year of the injury. Depending on the severity of the lesions, one may be able to restore the precision grip and power grip, or in some cases only the more rudimentary action of the pincers or of the hook. To make precision handling possible, the minimal requirement is a thumb with as much as possible of its length and mobility and a finger against which it can actively oppose. The presence of a third mobile finger greatly increases control and precision. In power grasping, the hand wraps itself around the object and this movement requires mobile digital joints. The force of this full hand grip will depend on the width of the palm and the conservation, at least in part, of the peripheral rays. The thumb considerably increases the strength of this grip and improves control. For a simpler pincer action, two parts must be able to oppose each other, one of which must be active.
Sensibility Sensibility of the hand is essential for prehension and its restoration is an important part of any plan of reconstruction. Painful and insensitive fingers are seldom used. One can hope to restore some degree of protective sensitivity by late repairs of nerves, up to five years and may be more after micro-surgical nerve graftings.. When the skin of an important tactile surface has been lost, a sensitised skin flap can, if required, be transferred from less useful areas by advancement 226
The H a n d - - V o l . 7
No. 3
1975
Planning of Surgical Treatment--Raoul Tubiana
or rotation of adjacent integuments, or by a skin transplant, with its neurovascular pedicle.. These flaps retain a normal relationship between the nerve and the skin. Sensibility does not have the same value all over the hand. The most important areas are the pulps, but even here there is a functional hierarchy of the hemipulps which determines the priorities for repair as well as the choice of donor zone: the medial hemipulp of the thumb and lateral hemipulp of the index are the most important. On the other hand, loss of sensibility gives less disturbance on the medial aspect of the middle and ring fingers and for this reason they are the usual donor areas. The sensible zones of a finger due for amputation is the obvious choice in some cases.
Placement Located at the end of the upper extremity which serves as its vector, the hand can function efficiently only if the joints proximal to it are stable and mobile. The hand can reach any part of the body because of the mobility of the shoulder, elbow and wrist in different planes. Thus placement is one of the principles we must consider in planning the procedures for reconstruction of the hand. This may be of paramount importance in congenital anomalies of the upper limb.
Timing The order in which secondary restorative procedures will be done depends on many factors, including local conditions and evolution of lesions. In every case positioning the skeleton by splints or by surgery, soft tissue release and skin cover constitute the first steps. One should then protect or restore nerve function to prevent additional trophic changes, and finally repair the tendons, sometimes after preparing a gliding bed. When multiple operations are contemplated, a procedure requiring immobilisation must not be carried out at the same time as another after which immobilisation would be prejudicial. Physiotherapy and splintage are indicated between operations and sufficient time must elapse to allow the soft tissue induration to resolve. The programme must also take account of the social and professional rehabilitation of the patient. An injury to the hand may mean a change of occupation and retraining must not await the completion of treatment which may take a very long time, as for example in lesions of the brachial plexus. Professional rehabilitation needs help from the social services, to support the psychological wellbeing of the patient, ensure his economic security, and ease his return to work. The choice of a new occupation should also influence the plan of treatment. When the planning of treatment is complete, it should be discussed with all those involved: the anaesthetists who may need to consider several operations; the physiotherapists who must get to know the work and activities of the patient and the functional result which is aimed for. Finally, and most important, the patient must be kept informed, as his full co-operation is essential for success. REFERENCES BOYES, J. H. (1964) Brussels Les Publications "Acta Medica Belgica". Philadelphia and Montreal, J. B. Lippincott Company: p. 125. BUNNELL, S. (1948) Surgery of the Hand, Second Edition. Philadelphia, London, Montreal, J. B. Lippincott Company. PULVERTAFT, R. G. (1967) Traumatic mutilation of the hand. Severe combined mutilations of the thumb and fingers. Sicot, 1966, Paris Meeting. WHITE, W. L. (1960) Restoration of Function and Balance of the Wrist and Hand by Tendon Transfers. The Surgical Clinics of North America, 40: 427-459. The Hand--Vol. 7
No. 3
1975
227
