Phalangeal fractures of the hand are common and potentially debilitating. The majority of these fractures may be treated conservatively. Surgery may speed recovery and avoid complications such as malunion and arthrosis in selected cases. A variety of procedures offer either relative or absolute stability. A review of the management of phalangeal fractures will be presented. Treatment options, rehabilitation and common complications are discussed. Early mobilization of the fractured hand is emphasized since soft tissue recovery can be more problematic than that of bone.
 

Introduction
With the advancement in surgical techniques and arthroscopic instrumentations, minimally invasive hand surgery has become the most popular treatment options for most common hand diseases. It has proven to have faster patient recovery and lower morbidity. These can be divided into arthroscopic surgery, endoscopic surgery and percutaneous soft tissue surgery.
Arthroscopic surgery
- Proximal interphalangeal joint (PIPJ) and Metacarpophalangeal joint (MCPJ) arthroscopy: indications include synovectomy for inflammatory arthritis, removal of loose bodies and osteophytes.
- Thumb carpometacarpal joint (CMCJ) arthroscopy: indications include synovectomy for inflammatory arthritis, assisted reduction in fracture fixation, hemi-trapeziectomy and fusion for osteoarthritis.
- Wrist arthroscopy: it has become the gold standard for detecting intra-articular pathology, including the cartilage status, ligament injury, and the triangular fibrocartilage complex (TFCC). It also has an important role in the treatment of intra-articular distal radius fracture and other carpal bones fracture.
Endoscopic carpal tunnel release
Endoscopic carpal tunnel release has become the current trend in treating carpal tunnel syndrome. Its advantages include: reduced postoperative pain, faster recovery and earlier return to work and fewer wound-related complications such as scar tenderness.
Percutaneous soft tissue surgery
1) Percutaneous trigger finger release - Percutaneous technique by using a needle can accomplish the same surgical result as traditional open surgery with faster recovery and better surgical outcome.
2) Percutaneous fasciotomy for Dupuytren’s contracture - Percutanous fasciotomy for Dupuytren’s contracture can be performed by using a needle under local anaesthesia. It has a lower incidence of nerve injury and reflex sympathetic dystrophy. It also has a faster recovery and less wound complications.
Advantages of Minimally invasive surgery
Advantages include: 1) less post-op wound pain, 2) faster rehabilitation and recovery, 3) less surrounding soft tissue adhesion, 4) better preservation of surrounding vascularity and 5) better cosmesis.
 

Scaphoid, being the ‘keystone’ of the carpus linking up proximal and distal carpal rows, is the most commonly fractured carpal bone, with the peak incidence in young active individuals. Its peculiar anatomy, blood supply and orientation create challenges in the diagnosis and treatment of its fracture. Malunited or non-united fractures alter wrist kinematics, resulted in continued wrist pain, stiffness, and early arthrosis.
Most clinical tests showed very high sensitivity but lack specificity individually in diagnosis of scaphoid fracture. Radiographs can sometimes be difficult to interpret due to the orientation and shape of the bone. Early use of advanced imaging like CT or MRI in suspicious cases has been shown to be cost effective when analysing societal cost.
For acute non-displaced fracture, cast immobilisation remained effective, with union rate approaching or exceeding that attained with operative intervention. Evidence support equal outcome when using a short arm or long arm cast with or without the thumb spica component.
Operative treatment is indicated for unstable, displaced or proximal pole fracture. Clinical and biomechanical data support both volar and dorsal approaches as safe and effective. Location of the fracture therefore dictates the surgical approach. Implants providing rigid fixation have evolved from the original solid screw and jig as described by Herbert and Fisher, to various designs of cannulated headless compression screws, or even plates. Anatomic rigid fixation has been shown to lead to faster time to union, reduced risk of non-union, improved functional outcome and earlier return to work.
Minimal invasive techniques, including percutaneous and arthroscopy-assisted techniques, have been developed to better preserve the local vascularity and ligamentous integrity around the scaphoid. Arthroscopy-assisted technique allows better assessment of reduction, fracture stability, vascularity of fracture fragments, associated ligament injury and cartilage status, which can guide subsequent treatment. Bone grafting of reducible non-union can also be performed with such technique.
Various local and free vascularised bone grafting techniques were developed since the 1980s, particularly to address non-unions associated with proximal pole avascular necrosis or failed previous attempted surgical treatment. The use of computer-assisted navigation and robotic assistance for more accurate placement of screw has also been investigated in recent years. However, evidence for recommending these techniques is not strong.

Most of the wrist pain following injuries are actually related to injuries to ligament rather than fractures. So most of them may not be revealed on conventional plain x ray. Careful history taking about mechanism of injury and physical examination is he clue to diagnosis and interpretation of MRI need to correlated with physical signs. Without proper diagnosis and treatment the ligament injury may become chronic and develop symptoms caused by carpal instability. The two most common instabilities: scapholunate and distal radioulnar joint instability will be discussed in the lecture.
 

Replantation is a surgical process to re-attach a separated body part by microsurgical techniques, aiming to re-establish circulation for survival of the detached part. Since the first replantation was being done in 1963 by Chinese Pioneer Dr Chen Zhong-Wei, there has been a lot of development. 1. Indication: With advancement in technology in surgical instrumentation and magnification, indications for replantation surgery may extend to very distal fingertip amputation, crushed injury or avulsion injury. 2. Refinement in surgical techniques: with better understanding of the anatomy, replantation is more easily to be done as those anatomical structures can be more easily identified. Use of volar veins improved the chance of success. One may also use artery to vein anastomosis in very distal replantation. Other adjunct procedures, such as venous flap or cross finger flaps may also improve survival rate. 3. Ectopic banking: It is a technique used for temporary nourishes the amputated part in a nonanatomical position when immediate replantation is not possible. It is hope later reconstruction is feasible after optimizing the wound condition. 4. Replantation Centers: There are well-established replantation centers in some countries. These established replantation centers would be more equipped with the necessary support for replantation surgery, from transport, post-operative monitoring and rehabilitation. These will also improve outcome of replantation surgery. Hong Kong may consider the development in this direction.
 

Hand injuries, especially hand fractures, are known to have a very high incidence rate amongst the other body parts. Being a specialized unit for manipulation, support, sensation perception and communication, hand injuries have a significant impact on patients’ physical as well as psychosocial functions.  Along with the advancement of physiology understanding and evolution of operative techniques, different treatment approaches and stronger reduction are developed to restore the hand anatomy.  Yet complications such as pain, stiffness are not uncommon.  

The role of occupational therapists in hand rehabilitation is to maximize the patients’ hand function and capacities to facilitate resumption of their life roles.  Various treatment modalities are employed to restore motion, strength and functions.  The application of these techniques will be discussed in the presentation with case illustrations.