IntroductionChapter 1

The cost of hand injuries in financial and human terms is tremendous. In the year 2000, >50 million Americans experienced a medically treated injury, resulting in lifetime costs of $406 billion (Corso et al. 2006). Injuries to the hand and wrist account for approximately 20% of visits to the emergency department (Angermann & Lohmann 1993, Larsen et al. 2004). The most commonly injured body part in occupational accidents in the United States is the upper extremity, according to a report of the Center for Disease Control and Prevention. Hand injuries account for one-third of all injuries at work, one-third of chronic injuries, one-fourth of lost working time, and one-fifth of permanent disability (Marty et al. 1983). In a recent study from The Netherlands, hand and wrist injuries annually accounted for $740 million (in US dollars) and ranked first in the order of most expensive injury types, before knee and lower limb fractures ($562 million), hip fractures ($532 million), and skull–brain injury ($355 million) (de Putter et al. 2012). Although hand injuries occur in all age groups, they are most prevalent in young people, thus affecting the active and earning part of the population most severely. The consequences of a hand injury for an individual include pain and suffering immediately, possible loss of function, and earning capacity for the rest of one's life and reduced potential to live one's life to its full potential. The burden for society is therefore in the form of a drain on financial resources, along with a loss of contributions from its most active and capable segment.

Hand surgery as a specialty evolved during World War II and the treatment and care of hand injuries has progressed considerably since then. The principles of early debridement, leaving the wound open, ‘second look,’ and delayed closure, born of necessity in the combat environment, have evolved into an emphasis on primary healing by radical debridement and early coverage and composite reconstruction wherever it can be accomplished safely in civilian practice (see Chapters 6 and 13). The advent of microsurgery in the latter part of the last century had a major impact on the way hand injuries are being treated now. Replantation of the amputated parts became feasible and reconstruction by free tissue transfer made salvage of severely injured hands possible. Reconstruction of these injuries was inconceivable before the microsurgical era (see Chapters 17 and 18). Flap surgery has been completely revolutionized from the days of random pattern flaps by better understanding of cutaneous blood supply and application of microsurgical techniques. Now a myriad of flaps is available to match the reconstructive needs of an individual wound and various combinations of tissues can be transferred as composite reconstruction with minimal donor site morbidity (see Chapter 13). Results of tendon repair have improved by emphasizing primary repair when feasible, better suture materials and techniques that allow early motion, along with the evolution of postoperative tendon protocols based on a better understanding of biological principles (see Chapters 10 and 11). Modern techniques of nerve repair under magnification and emphasis on tension-free nerve repair using nerve grafts when required, as well as placement of the repaired nerve in a well-vascularized, scar-free bed have helped to improve results immeasurably from the days when the principle objective of nerve suture was simply the physical union of the cut ends at almost any cost (see Chapter 12). Nerve transfer procedures developed in last two decades, and the availability of many sensory cutaneous flaps has addressed the majority of reconstructive issues. These developments have minimized the need for secondary reconstructive procedures such as tendon transfers.

The adoption of safety measures is the best strategy to prevent hand injuries and minimize their tremendous impact. Looking at just one sector of the construction industry in the United States, the figures show that road constructors pay $48 million more for hand injuries each year than the $8.3 million it would cost them to equip all of their hazard-exposed workers with protective gloves. In the United States, 2the Occupational Safety and Health Administration (OSHA) is the key agency responsible for enforcing safety regulations and keeping the work place safe. Low- and middle-income countries often do not have a comparable regulatory prevention network such as OSHA, and thereby lack any stringent adherence to safety guidelines. As a result, hand injuries are relatively more common and their consequences are more serious. Globalization, rapid industrialization, and the push for economic development in some of these societies have outpaced safety measures in industry and farming and have magnified the impact of the hand injuries (Schaub & Chung 2006). The National Hand Societies have an important role in increasing awareness in the public and persuading their governments to implement effective safety measures. Farm workers are particularly vulnerable in these countries as most farming equipment lacks safety guards, and the farming sector is deprived of any state-sponsored social security or workplace compensation schemes.

The book is divided into four sections. The first section (Chapters 1–7) covers the nature of the problems in complex hand injuries and the principles involved in diagnosis, treatment, and rehabilitation. It also deals with the necessary contributions for comprehensive treatment of complex hand injuries from radiology, anesthesiology and hand therapy departments. Proper imaging of the hand is essential for the accurate diagnosis and treatment of hand injuries. Computed tomography (CT) scanning and magnetic resonance imaging (MRI), in addition to traditional radiographs, have added tremendously to our ability to evaluate complex hand injuries (see Chapter 4). The development of modern techniques for regional anesthesia has greatly influenced choice of anesthesia in recent years. These techniques are presented in Chapter 5. An essential role is played by the hand therapist in preventing complications of hand injuries and maximizing the potential for functional recovery. A close collaboration between the hand surgeon and therapist is therefore of the utmost importance in achieving the best possible outcome in hand injuries (see Chapter 7).