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Hand Trauma and Injuries

Hand trauma: high-incidence, costly injuries requiring nuanced management of fractures, soft tissue, nerves, and vascularity.

Overview

Hand traumatic injuries are resource-intensive and often require treatment outside the surgical global period to achieve optimal functional outcomes [1]. These injuries frequently involve accompanying pathologies in the hand and foot that must be addressed during diagnosis and management [2]. While the majority of hand fractures can be managed nonoperatively, surgery offers distinct advantages in properly selected cases [4]. Athletes sustaining hand and wrist injuries require specific understanding of diagnosis, management, and return-to-play guidelines to maximize treatment results [3].

Fracture outcomes vary significantly according to fracture type, surgeon experience, and patient compliance [25]. Injuries to the thumb and index finger are associated with a higher likelihood of unplanned reoperation [11]. Nonvascularized autogenous bone grafting can restore good hand function in severe injuries involving substantial phalangeal bone loss [5]. Although finger fracture indications for surgical treatment are more clearly defined and operative techniques continue to evolve, the published randomized controlled trial evidence for hand fractures and joint injuries remains narrow in scope and of generally low methodological quality [8, 25].

Pediatric closed hand fractures are predominantly treated nonoperatively with few complications [10], yet referral patterns are inefficient, with roughly half of cases initially presenting to outside providers [10]. Many pediatric cases are evaluated by multiple providers before reaching a hand surgeon [10]. Surgical needs in children range from simple injuries requiring a single operation to complex injuries needing two surgeries, while major injuries demand a significantly greater number of procedures [45]. Incorporating disability outcome measures into evaluation regimens may help clinicians adopt more individualized, activity-of-daily-living–oriented treatment strategies [20].

Anatomy & Pathophysiology

Osseous and Articular Mechanics

Management of hand fractures requires balancing the prevention of stiffness through early motion with the avoidance of deformity via adequate reduction and stabilization [47]. Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [17]. Carpometacarpal fractures and dislocations represent the most frequent motorcycle crash thumb injury, likely due to the mechanics of gripping handlebars and high-energy force directed into the palm against the metacarpal base [54]. Patterns of peri-articular finger injuries differ significantly between the three finger joints, a variation explained by the mechanism of falling and local biomechanical forces [28]. Biomechanical stability during simulated active motion protocols does not differ in simulated proximal phalanx fractures treated with two versus three lag screws [53]. Non-surgical treatment of spiral and oblique metacarpal shaft fractures with metacarpal shortening results in statistically significantly reduced finger strength, though the clinical relevance of this deficit remains unclear [32]. Nonvascularized autogenous bone grafting is capable of restoring good hand function in severe injuries involving substantial phalangeal bone loss [5].

Ligamentous and Capsular Structures

Recent reviews focus on the anatomy, physiology, and biomechanics of the ligamentous joint capsule of the MCP, PIP, and DIP joints to inform new clinical approaches for these common problems [49]. Biomechanical analysis reveals that a steer pulling on the thumb during team roping generates force and pressure several times larger than that of a ring avulsion injury [46]. Thumb ray dysfunction in sensibility and mobility remains the primary functional disability following exploded hand syndrome, despite generally good overall outcomes [6].

Neuromuscular and Functional Kinematics

Fundamental muscle-tendon-joint mechanics studies enable single-stage surgical reconstruction of hand function and early postoperative activity-based training in patients with cervical spinal cord injuries [43]. Targeted surgical intervention and undefined therapy interventions appear to have little influence on activity and participation in hemiplegic cerebral palsy, although wrist and finger biomechanics and active range of motion do improve [42]. Limited surgical procedures improved finger, thumb, and wrist positions at two-year follow-up in cases of upper limb congenital muscular hypertrophy and aberrant muscle syndrome in children [22]. Mirror hand-ulnar dimelia typically involves the entire upper limb, requiring treatment plans that consider predictors of function at each limb segment rather than morphology alone [52]. Improved strength of thumb reconstructions and a reduced need for secondary surgery were observed in posttraumatic hand reconstruction using toe-to-hand transfers [44]. Touch screen technology has become increasingly relevant to hand function in modern society for children with normal hand formation, congenital differences, and neuromuscular disease [50].

Infection and Soft Tissue Pathology

Optimal outcomes in the acute surgical management of hand burns require meticulous surgical technique combined with preoperative and postoperative hand therapy to preserve function and prevent contracture [64]. Function and appearance of the hand remained normal at the three-year follow-up evaluation for Mycobacterium monacense infection of the hand [19].

Classification

AO/OTA (Adapted): The adapted AO classification for hand fractures demonstrates good inter-observer agreement for bone identification, substantial agreement for bone segment coding, and moderate agreement for fracture type [34].

PNB: The PNB classification separates fingertip injuries into their effect on the pulp, nail, and bone, providing a three-digit number that accurately describes the injury for documentation, treatment instructions, and referral indications [61].

Other Considerations: Hand traumatic injuries are resource-intensive and may require treatment outside the global period to obtain the best functional outcomes [1]. Hand and foot fractures have many accompanying injuries that require attention during diagnosis and treatment [2]. Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury [7]. The published randomized controlled clinical trial evidence for hand fractures and joint injuries is narrow in scope and of generally low methodological quality [8]. The majority of hand fractures can be treated without surgery, though surgery offers distinct advantages in properly selected cases [4]. While general outcomes were good for exploded hand syndrome, thumb ray dysfunction in sensibility and mobility remained the main functional disability [6]. Nerves primarily sutured following types of trauma commonly seen in civilian life provided a definitely higher grade of motor reinnervation of the intrinsic muscles of the hand than did the secondarily sutured nerves [55]. Hand surgeons should understand the pathophysiology and appropriate management of various types of radiation injury, including acute and chronic forms resulting from fluoroscopy, nuclear accidents, or weapons, as the hand is the organ most frequently affected by ionizing radiation [9]. The COVID-19 pandemic and consequent restrictions of activity have had substantial impacts on the patterns of hand trauma and its management, resulting in a decrease in overall presentations, particularly elective cases, and alterations in injury type and mechanism [13].

Pediatric Patterns: Fractures of the forearm, wrist, and hand are the most frequent skeletal trauma in the pediatric age group [58]. Many pediatric forearm, wrist, and hand fractures can be successfully treated nonsurgically with excellent functional results [58]. Early identification of injury type and potential instability is key to good outcomes in pediatric forearm, wrist, and hand trauma [58]. The frequency, pattern, and treatment of pediatric hand fractures vary among different age groups [65].

Athletic and General Context: Athletes commonly sustain injuries to the hand and wrist, and an understanding of diagnosis, management, and return-to-play guidelines is important to maximize treatment outcomes [3]. This study presents detailed information about the various types of finger fractures which can be used as point of reference in clinical work and for future studies [60].

Clinical Presentation

Hand traumatic injuries are resource-intensive and often require treatment outside the global period to achieve optimal functional outcomes [1]. These injuries frequently involve accompanying pathologies that must be addressed during diagnosis and management [2]. In the United States, hand-related conditions significantly contribute to emergency department volume, with open wounds being the most common presentation, predominantly affecting young adults [24]. The COVID-19 pandemic and subsequent activity restrictions have substantially altered injury patterns, resulting in decreased overall presentations and shifts in injury mechanisms [13].

Mechanism-based assessment: Radiographic evaluation for hand wounds should not be systematic but must be directly related to the mechanism of injury [7]. Accurate diagnosis and management of fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility [17]. While general outcomes for exploded hand syndrome were good, thumb ray dysfunction in sensibility and mobility remains the primary functional disability [6]. Severe injuries, such as those from Samurai sword assaults, can cause devastating loss of function [14].

Patient-specific considerations: Athletes commonly sustain hand and wrist injuries, requiring specific knowledge of diagnosis and return-to-play guidelines to maximize outcomes [3]. Upper extremity trauma, particularly involving the hand, first ray, and fingers, is a significant source of morbidity for professional football players [29]. Pediatric closed hand fractures are mostly treated nonoperatively with few complications, yet referral patterns are inefficient, with roughly half of cases initially presenting to outside providers and many evaluated by multiple providers before seeing a hand surgeon [10]. Fingertip injuries in children are common, result in significant burden, and are mostly preventable, with most occurring at home in doors or windows [30].

Complications and comorbidities: Nearly one-third of hand-injured patients meet diagnostic criteria for PTSD, depression, or both, negatively affecting general health status [15]. Self-reported cold sensitivity is frequently observed in traumatic hand injuries and is particularly apparent in patients with hand-arm vibration syndrome [16]. Early diagnosis and prevention are the only methods to halt the progression of hypothenar hammer syndrome, which can lead to permanent impairment [12]. The unusual presentation of sequential traumatic bilateral extensor pollicis brevis rupture highlights the need to consider this injury during post-traumatic examination [23].

Evidence limitations and specialized contexts: The published randomized controlled clinical trial evidence for hand fractures and joint injuries is narrow in scope and of generally low methodological quality [8]. Current evidence regarding the diagnosis of hand compartment syndrome relies mostly on case reports and small case series with varying etiology, lacking a consensus reference standard or reliable diagnostic criteria [27]. Hand surgeons must understand the pathophysiology and management of radiation injuries, including acute and chronic forms from fluoroscopy, nuclear accidents, or weapons, as the hand is the organ most frequently affected by ionizing radiation [9].

Investigations

Plain radiography: While routine PA and lateral views are often insufficient for diagnosing lesser sesamoid fractures, oblique views are recommended [74]. Radiographic assessment for hand wounds should not be systematic but must be related to the mechanism of injury [7]. Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures [77]. Intra-operative fluoroscopic imaging provides an accurate assessment of articular step-off and displacement compared with radiographs and direct visualization, making it an adequate tool for treating hand fractures [73].

MRI: MRI provides important preoperative information for surgical decision-making and planning in patients presenting late with closed flexor tendon injuries of the hand [56]. Advanced imaging should be considered when evaluating posttraumatic ulnar-sided hand pain if the I-S IMA or the L-S IMA is greater than 10° [78].

CT: Computed tomography is recommended over plain radiography alone for trapezoid fractures, which may be underdiagnosed on standard films [72]. Whole-body CT is a valuable diagnostic tool for detecting hand fractures in polytrauma patients [75].

Other Considerations: Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [17]. Understanding diagnosis, management, and return-to-play guidelines is important to maximize treatment outcomes for athletes sustaining hand and wrist injuries [3]. The majority of hand fractures can be treated without surgery, although surgery offers distinct advantages in properly selected cases [4]. Nonvascularized autogenous bone grafting is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss [5]. While general outcomes for exploded hand syndrome are good, thumb ray dysfunction in sensibility and mobility remains the main functional disability [6]. The role of surgery for mallet fractures of the thumb remains unclear due to their uncommon nature and favorable radiographic findings [79]. Hand and foot fractures frequently present with accompanying injuries that require attention during diagnosis and treatment [2]. The hand is the organ most frequently affected by ionizing radiation, and surgeons must understand the pathophysiology and management of acute and chronic radiation injuries from sources including fluoroscopy, nuclear accidents, or weapons [9]. Samurai sword assaults can cause devastating loss of function in hand injuries [14]. The unusual presentation of sequential traumatic bilateral extensor pollicis brevis rupture highlights the need to consider this injury when examining the post-traumatic hand [23]. Combined dislocation of the trapezoid and finger carpometacarpal joints can result in nearly identical wrist injuries with good short-term functional outcomes when injuries are quickly recognized and appropriately addressed at initial surgery [76].

Treatment

Hand traumatic injuries are resource-intensive and often require treatment outside the surgical global period to achieve optimal functional outcomes [1]. While the majority of hand fractures, including most pediatric closed hand fractures and metacarpal fractures, are managed nonoperatively with few complications [4, 10, 40], surgery offers distinct advantages in properly selected cases [4]. Operative indications for finger fractures are more clearly defined as techniques and implants for osteosynthesis continue to evolve, with results varying based on fracture type, surgeon experience, and patient compliance [25].

Non-Operative

Conservative Management: Most pediatric closed hand fractures and unstable displaced pediatric phalanx fractures are treated nonoperatively with splinting and hand physiotherapy, yielding good outcomes [10, 57]. A non-surgical protocol is appropriate for isolated proximal phalangeal fractures without uncorrectable rotation or angulation exceeding 25 degrees in the sagittal plane or 10 degrees in the coronal plane following closed reduction [35]. Nonsurgical treatment with early unrestricted mobilization is noninferior to surgical treatment for displaced metacarpal spiral fractures at midterm follow-up [68]. Many acute closed sagittal band injuries of the metacarpophalangeal joint can be managed nonsurgically with extension splints [41]. Conservative management of tendinous mallet finger injuries neglected for 2 to 4 weeks achieves outcomes comparable to early presentation with low long-term complication rates [51]. Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes [33].

Pharmacologic and Adjunctive Therapy: The success incidence of corticosteroid injections for trigger finger and thumb may be as high as 69%, with efficacy increasing when treating the thumb compared with other digits [18]. Hand therapy plays a critical role in coordinating edema control, pain management, and functional recovery for upper extremity injuries [39].

Operative

Indications: Surgical intervention is indicated for unstable, displaced pediatric phalanx fractures [70]. Injuries to the thumb and index finger are more likely to undergo unplanned reoperation following phalangeal fractures requiring vascular reconstruction [11]. Age alone should not be an absolute contraindication to finger replantation [38].

Surgical Approach / Technique: Percutaneous elastic intramedullary nailing of metacarpal fractures results in good hand function with few complications [21]. Unstable, displaced pediatric phalanx fractures require surgical management, preferably closed reduction and percutaneous pinning [70]. Nonvascularized autogenous bone grafting is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss [5]. Early debridement, antibiotic treatment, reconstruction, and rehabilitation offer the best chance for full functional recovery following gunshot wounds to the hand [37].

Adjuncts and Specialized Care: Autologous skin cell suspension (ASCS) is safe and effective in treating hand burns [31]. The management of thumb tip injuries has evolved with an expanded armamentarium of versatile flaps and less donor site morbidity [66]. Conservative treatment with semi-occlusive dressings has gained ground for thumb pulp injuries, yielding excellent results in contour and sensibility restoration [66]. The treatment of acute burns to the hand and upper extremity remains an evolving process with an emphasis on the restoration of function [36].

Outcomes and Limitations: The published randomized controlled clinical trial evidence for hand fractures and joint injuries is narrow in scope and of generally low methodological quality [8]. Regardless of the treatment chosen for limb-threatening injuries, long-term studies show that patients sustain significant disability [62]. Optimal management of subacute or chronic closed sagittal band injuries of the metacarpophalangeal joint remains undefined [41]. The inclusion of disability outcome measures in the evaluation of hand trauma regimens might help to expand the clinician's view to more individualized, activity-of-daily-living–oriented, treatment regimens [20].

Complications

Wound complications: Smoking is associated with increased wound complications in hand and upper extremity surgical patients [48]. Open wounds are the most common cause of hand-related emergency department presentations, mostly occurring in young adults [24]. Nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both [15]. PTSD, depression, or both have a negative effect on general health status after hand injury [15].

Infection: Function and appearance of the hand remained normal at the 3-year follow-up evaluation for Mycobacterium monacense infection of the hand [19].

Nerve palsy: Approximately 75% of infants with brachial plexus birth injury will recover, leaving up to 25% with long-term deficits [26]. Early diagnosis and prevention of hand trauma is the only way to stop the progression of Hypothenar Hammer Syndrome, which can lead to permanent impairment [12].

Stiffness / Arthrofibrosis: Cold sensitivity is frequently seen in patients with traumatic hand injuries and is particularly apparent in patients with hand-arm vibration syndrome [16].

Other Considerations: Hand traumatic injuries are resource-intensive and may require treatment outside the global period to obtain the best functional outcomes [1]. Hand and foot fractures have many accompanying injuries that require attention during diagnosis and treatment [2]. Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury [7]. The hand is the organ most frequently affected by ionizing radiation, requiring surgeons to understand the pathophysiology and management of acute and chronic radiation injuries [9]. Most pediatric closed hand fractures are treated nonoperatively with few complications [10]. Referral patterns for pediatric closed hand fractures are inefficient, with roughly half of cases initially presenting to outside providers and many evaluated by multiple providers before seeing a hand surgeon [10]. Injuries sustained in the thumb and index finger are more likely to undergo unplanned reoperation [11]. The COVID-19 pandemic resulted in a decrease in overall hand trauma presentations, particularly elective cases, and alterations in injury type and mechanism [13]. Samurai sword assaults can cause severe hand injuries with devastating loss of function for the victims [14]. At long-term follow-up, the success incidence of corticosteroid injections for trigger finger and thumb may be as high as 69% [18]. Efficacy of corticosteroid injections for trigger finger and thumb increases when treating the thumb compared with other digits [18]. Percutaneous elastic intramedullary nailing of metacarpal fractures results in good hand function with few complications [21]. Limited surgical procedures for upper limb congenital muscular hypertrophy and aberrant muscle syndrome improved finger, thumb, and wrist positions at 2-year follow-up [22]. Hand-related conditions contribute significantly to emergency department volume and consume a growing quantity of health care resources in the United States [24]. Smoking produces deleterious local and systemic effects that negatively affect the outcome of hand and upper extremity surgical patients [48]. Smoking is associated with delayed bone healing in hand and upper extremity surgical patients [48]. Smoking is associated with reduced replantation viability in hand and upper extremity surgical patients [48]. Palmar plates offer faster functional recovery compared to dorsal fixed-angle plates in AO C-type fractures of the distal radius [67]. Palmar plates are associated with lower complication rates compared to dorsal fixed-angle plates in AO C-type fractures of the distal radius [67]. The incidence of hand fractures in children was more than twice as high at the end of the 1970s compared to the 1950s [69]. No significant change in the incidence of hand fractures in children could be found after the end of the 1970s [69]. Awareness of risks and factors associated with hand injuries during hand surgery and adopting intraoperative measures are important strategies for preventing these potentially serious and life-threatening accidents [71].

Recovery

Light activity (weeks): Patients may resume desk work, driving, and light activities of daily living once the initial healing phase allows, though the specific timeline varies by injury type. For metacarpal fractures in the National Football League, involvement of lesser digits lessens return-to-play time compared to other fractures [81], while operative intervention for thumb metacarpal fractures also lessens return-to-play time [81]. In cases of delayed replantation, results comparable to immediate replantation can be achieved even when surgery is delayed overnight [80].

Full activity (months): Return to full manual work and sport depends on the specific pathology and surgical intervention. Percutaneous elastic intramedullary nailing of metacarpal fractures results in good hand function with few complications [21]. For upper limb congenital muscular hypertrophy and aberrant muscle syndrome in children, limited surgical procedures improved finger, thumb, and wrist positions at the 2-year follow-up [22]. In infants with brachial plexus birth injury, approximately 75% will recover, though up to 25% will have long-term deficits [26].

Complete recovery / outcome plateau (months): Functional and psychological outcomes stabilize over extended periods. Function and appearance of the hand remained normal at the 3-year follow-up evaluation for Mycobacterium monacense infection of the hand [19]. At long-term follow-up, the success incidence of corticosteroid injections for trigger finger and thumb may be as high as 69% [18], with efficacy increasing when treating the thumb compared with other digits [18]. Nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both, which have a negative effect on general health status after hand injury [15]. Cold sensitivity is frequently seen in patients with traumatic hand injuries and is particularly apparent in patients with hand-arm vibration syndrome (HAVS) [16].

Rehabilitation protocol: Early mobilization is critical for optimal outcomes in flexor tendon repairs. Outcomes for primary repair of Zone 2 flexor tendon injuries depend on proper surgical methods, the surgeon's experience, and early mobilization [83]. The time elapsed between injury and surgery is not an important risk factor for a good outcome in primary repair of Zone 2 flexor tendon injuries with up to five-week delay [83]. For open hand injuries, delaying surgery by 4 days does not appear to increase the risk of surgical site infection [84]. Nonvascularized autogenous bone grafting is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss [5].

Functional milestones: Clinicians should incorporate disability outcome measures to expand their view to more individualized, activity-of-daily-living–oriented treatment regimens [20]. Injuries sustained in the thumb and index finger are more likely to undergo unplanned reoperation [11]. Hand traumatic injuries are resource-intensive and may require treatment outside the global period to obtain the best functional outcomes [1].

Other Considerations: Early diagnosis and prevention of hand trauma is the only way to stop the progression of Hypothenar Hammer Syndrome, which can lead to permanent impairment [12]. Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend [85]. New institutions and providers can expect anywhere from a 10% to a 60% increase in hand trauma burden without a significant change in the severity of the trauma cases after joining the ASSH Hand Trauma Center Network [82]. The duration of banking before secondary thumb reconstruction via ectopic banking of bony phalanges from a nonreplantable amputated thumb should be no more than 2 weeks [86].

Key Evidence

  • [L2] Hand traumatic injuries are resource-intensive and may require treatment outside the global period to obtain the best functional outcomes. (10.1016/j.jhsa.2025.06.017)
  • [L4] Hand and foot fractures have many accompanying injuries that require attention during diagnosis and treatment. (10.1186/s12891-024-07407-z)
  • [L5] The majority of hand fractures can be treated without surgery, though surgery offers distinct advantages in properly selected cases. (10.1016/j.jhsa.2013.02.017)
  • [Case_report] The technique is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss. (10.1016/j.jhsa.2008.04.025)
  • [L4] While general outcomes were good, thumb ray dysfunction in sensibility and mobility remained the main functional disability. (10.1177/1753193412468577)
  • [L3] Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury. (10.1177/17531934231211566)
  • [L1] The published randomized controlled clinical trial evidence for hand fractures and joint injuries is narrow in scope and of generally low methodological quality. (10.1177/1753193419865897)
  • [L5] Hand surgeons should understand the pathophysiology and appropriate management of various types of radiation injury, including acute and chronic forms resulting from fluoroscopy, nuclear accidents, or weapons, as the hand is the organ most frequently affected by ionizing radiation. (10.1016/j.jhsa.2008.01.035)
  • [L3] Most pediatric closed hand fractures are treated nonoperatively with few complications, but referral patterns are inefficient, with roughly half of cases initially presenting to outside providers and many evaluated by multiple providers before seeing a hand surgeon. (10.1177/15589447211008590)
  • [L3] Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up. (10.1177/15589447221109635)
  • [L4] Early diagnosis and prevention of hand trauma is the only way to stop progression of this disease, which can lead to permanent impairment. (10.1177/03635465000280052101)
  • [L4] The COVID-19 pandemic and consequent restrictions of activity have had substantial impacts on the patterns of hand trauma and its management, resulting in a decrease in overall presentations, particularly elective cases, and alterations in injury type and mechanism. (10.1177/15589447211028918)
  • [L4] This case series demonstrates the extent and severity of hand injuries that can be caused by sword assaults with devastating loss of function for the victims. (10.1177/1753193410381576)
  • [L2] Nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both, and these conditions had a negative effect on general health status after hand injury. (10.1016/j.jhsa.2008.11.008)
  • [L3] It is frequently seen in patients with traumatic hand injuries and particularly apparent in patients with HAVS. (10.1186/1471-2474-11-89)
  • [L4] At long-term follow-up, the success incidence may be as high as 69%, with efficacy increasing when treating the thumb compared with other digits. (10.1016/j.jhsa.2014.09.006)
  • [L4] Function and appearance of the hand remained normal at the 3-year follow-up evaluation. (10.1016/j.jhsa.2007.10.016)
  • [L3] The inclusion of disability outcome measures in the evaluation of hand trauma regimens might help to expand the clinician's view to more individualized, activity-of-daily-living–oriented, treatment regimens. (10.1016/j.jhsa.2006.05.017)
  • [L4] The general outcome was good hand function with few complications. (10.1186/1749-799x-6-37)
  • [L4] Limited surgical procedures improved finger, thumb, and wrist positions at 2-year follow-up. (10.1177/1753193418774459)
  • [Case_report] The unusual presentation highlights the need to consider this injury when examining the post-traumatic hand. (10.1016/j.jhsa.2007.02.007)
  • [L3] Hand-related conditions contribute significantly to ED volume and consume a growing quantity of health care resources in the United States, with open wounds being the most common cause of presentation mostly occurring in young adults. (10.1177/1558944717695749)
  • [L5] Fractures of the fingers are better understood, indications for surgical treatment are more clearly defined, and operative techniques and implants for osteosynthesis are continuing to evolve and improve, though results vary according to fracture type, surgeon experience, and patient compliance. (10.1054/jhsb.2002.0889)
  • [L5] Current evidence regarding the diagnosis of hand compartment syndrome is based mostly on case reports and small case series with varying etiology, lacking a consensus reference standard or reliable diagnostic criteria. (10.1016/j.jhsa.2015.01.034)
  • [L4] The patterns of peri-articular finger injuries differ greatly between the three finger joints, explained by the mechanism of falling and local biomechanical forces. (10.1177/17531934251381203)
  • [L4] Upper extremity trauma, especially injury to the hand, first ray, and fingers, is a significant source of morbidity for professional football players. (10.1177/0363546508318197)
  • [L4] Fingertip injuries in children are common and result in significant burden, yet are mostly preventable, with most injuries occurring at home in a door or window. (10.1177/1558944716670139)
  • [L4] ASCS is safe and effective in treating hand burns. (10.1016/j.jhsg.2021.03.001)
  • [L4] Finger strength was statistically significantly reduced, but its clinical relevance remains unclear. (10.1186/s12891-025-08776-9)
  • [L4] Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes. (10.1016/j.jhsa.2017.10.004)
  • [L4] The adapted AO classification for hand fractures demonstrated good inter-observer agreement for bone identification, substantial agreement for bone segment coding, and moderate agreement for fracture type. (10.1177/1753193409355256)
  • [L4] A non-surgical, conservative protocol can be used for patients with isolated proximal phalangeal fractures without uncorrectable finger rotation or fracture angulation exceeding 25 degrees in the sagittal plane or 10 degrees in the coronal plane following closed reduction. (10.1177/1753193419881086)
  • [L5] The treatment of acute burns to the hand and upper extremity remains an evolving process with an emphasis on the restoration of function. (10.1016/j.jhsa.2010.03.019)
  • [L4] Given the current evidence related to management of gunshot wounds to the hand, early debridement, antibiotic treatment, reconstruction, and rehabilitation offer patients the best chance for full functional recovery. (10.1016/j.jhsa.2013.02.011)
  • [L3] Age alone should not be an absolute contraindication to finger replantation. (10.1016/j.jhsa.2011.01.031)
  • [L5] Hand therapy plays a critical role in the treatment of upper extremity injuries by coordinating edema control, pain management, and functional recovery. (10.5435/00124635-201008000-00003)
  • [L5] The majority of metacarpal fractures are managed nonoperatively. (10.1177/17531934231184119)
  • [L5] Many acute injuries can be managed nonsurgically with extension splints, while optimal management of subacute or chronic injuries remains undefined. (10.5435/jaaos-d-13-00203)
  • [L4] The targeted surgical intervention and undefined therapy intervention seemed to have little influence on activity and participation, although wrist/finger biomechanics and active range of motion improved. (10.1197/j.jht.2008.01.001)
  • [L5] The authors present fundamental muscle-tendon-joint mechanics studies that allow for single-stage surgical reconstruction of hand function and early postoperative activity-based training in patients with cervical spinal cord injuries. (10.1177/1753193419827814)
  • [L4] Improved strength of thumb reconstructions and reduced need for secondary surgery was also displayed. (10.1016/j.jhsa.2011.04.010)
  • [L4] Most pediatric hand injuries requiring operative intervention are simple injuries that generally require only 1 surgery, while complex injuries typically require only 2 surgeries, and major injuries require a significantly greater number of surgeries. (10.1177/1558944719893037)
  • [L4] Biomechanical analysis showed a huge amount of force and pressure, several times larger than that of ring avulsion injury, results when a steer pulls on the thumb. (10.1177/03635465030310051601)
  • [L5] Management of hand fractures involves balancing the prevention of stiffness through early motion with the avoidance of deformity via adequate reduction and stabilization. (10.1016/j.jhsa.2016.03.007)
  • [L5] Smoking produces deleterious local and systemic effects that negatively affect the outcome of hand and upper extremity surgical patients, including increased wound complications, delayed bone healing, and reduced replantation viability. (10.1016/j.jhsa.2012.08.018)
  • [L5] This review focuses on recent information regarding the anatomy, physiology, and biomechanics of the ligamentous joint capsule of the MCP, PIP, and DIP joints with a view to new clinical approaches for these common problems. (10.1016/j.jhsa.2017.08.024)
  • [L3] Touch screen technology has become increasingly relevant to hand function in modern society. (10.1016/j.jhsa.2014.12.028)
  • [L3] Conservative management of tendinous mallet finger injuries that have been neglected for 2 to 4 weeks can be treated as well as those injuries in patients presenting within the first 2 weeks of injury with low long-term complication rates. (10.1016/j.jhsa.2014.06.140)
  • [L4] Mirror hand-ulnar dimelia typically involves the entire upper limb, and treatment plans should consider predictors of function at each limb segment rather than just morphology. (10.1177/17531934221116960)
  • [L5] Biomechanical stability during simulated active motion protocol did not differ in simulated proximal phalanx fractures treated with 2 lag screws or 3. (10.1016/j.jhsa.2015.02.012)
  • [L4] Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base. (10.1177/1753193415620186)
  • [L4] MRI provides important preoperative information for surgical decision-making and planning in patients who present late with closed flexor tendon injuries of the hand. (10.1054/jhsb.1999.0306)
  • [L4] Operative management is rarely indicated in paediatric hand fractures, as good outcomes are reported with conservative management of splinting and hand physiotherapy. (10.1177/1753193412475045)
  • [L2] The study identified substantial treatment variability in common paediatric hand fractures, providing information and insights for future research directions. (10.1177/17531934241258862)
  • [L3] This study presents detailed information about the various types of finger fractures which can be used as point of reference in clinical work and for future studies. (10.1371/journal.pone.0288506)
  • [L5] The PNB classification separates fingertip injuries into their effect on the pulp, nail, and bone, providing a three-digit number that accurately describes the injury for documentation, treatment instructions, and referral indications. (10.1054/jhsb.1999.0305)
  • [L4] The study provides a comprehensive analysis of hand injuries in sports, identifying specific sports with high injury rates and injury patterns to inform prevention strategies. (10.1186/s12891-020-03807-z)
  • [L5] Optimal outcomes require meticulous surgical technique combined with preoperative and postoperative hand therapy to preserve function and prevent contracture. (10.1016/j.jhsa.2014.07.032)
  • [L4] The frequency, pattern, and treatment of pediatric hand fractures vary among different age groups. (10.1177/1558944719900565)
  • [L5] The management of thumb tip injuries has evolved with an expanded armamentarium of versatile flaps and less donor site morbidity, while conservative treatment with semi-occlusive dressings has gained ground for pulp injuries, yielding excellent results in contour and sensibility restoration. (10.1016/j.jhsa.2014.09.028)
  • [L1] The advantage of palmar plates is a faster functional recovery with lower complication rates. (10.1186/1749-799x-7-8)
  • [L2] Nonsurgical treatment with early unrestricted mobilization remains noninferior to surgical treatment at the midterm follow-up. (10.1016/j.jhsa.2025.06.018)
  • [L3] The incidence of hand fractures in children was more than twice as high in the end of the 1970s compared to the 1950s, where after no significant change could be found. (10.1186/s13018-019-1248-0)
  • [L5] Management is based on injury severity, with nondisplaced fractures treated via splint immobilization and unstable, displaced fractures requiring surgical management, preferably closed reduction and percutaneous pinning. (10.5435/jaaos-d-16-00199)
  • [L4] Awareness of the risks and factors associated with hand injuries during hand surgery and adopting intraoperative measures are important strategies for preventing these potentially serious and life-threatening accidents. (10.1177/1753193408090125)
  • [L4] These fractures may be underdiagnosed, and computed tomography is recommended over plain radiography alone in case of clinical suspicion. (10.1016/j.jhsa.2012.02.046)
  • [L5] Intra-operative fluoroscopic imaging provides an accurate assessment of articular step-off and displacement in comparison with radiographs and direct visualization, making it an adequate tool for use in the treatment of fractures of the hand. (10.1177/1753193412468565)
  • [L4] Routine PA and lateral hand radiographs may be insufficient for diagnosis, and oblique views are recommended. (10.1016/j.jhsa.2013.06.039)
  • [L3] This study shows that whole-body CT is a valuable diagnostic tool for hand fractures in polytrauma patients. (10.1186/s12891-020-3068-0)
  • [Case_report] Both cases demonstrate similar mechanisms resulting in nearly identical wrist injuries with good short-term functional outcomes when injuries are quickly recognized and appropriately addressed at initial surgery. (10.1016/j.jhsa.2010.06.005)
  • [L4] Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures. (10.1177/1558944717733278)
  • [L3] When evaluating posttraumatic ulnar-sided hand pain, advanced imaging should be considered if the I-S IMA or the L-S IMA is greater than 10°. (10.1016/j.jhsa.2012.05.042)
  • [L3] The role of surgery for mallet fractures of the thumb remains unclear due to their uncommon nature and favorable radiographic findings. (10.1177/1558944716672192)
  • [L4] The results of delaying replantation of digits overnight give results comparable with those of immediate replantation in selected cases. (10.1016/j.jhsa.2018.03.047)
  • [L4] The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. (10.1016/j.jhsa.2022.01.011)
  • [L4] Based on our findings, we believe that new institutions and providers can expect anywhere from a 10% to a 60% increase in hand trauma burden without a significant change in the severity of the trauma cases after joining the network. (10.1016/j.jhsg.2023.06.011)
  • [L4] The time elapsed between injury and surgery is not an important risk factor for a good outcome; rather, outcomes depend on proper surgical methods, the surgeon's experience, and early mobilization. (10.1177/17531934211024435)
  • [L2] Delaying surgery for open hand injuries by 4 days does not appear to increase the risk of surgical site infection. (10.1177/1753193420905205)
  • [L4] Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend. (10.1016/j.jhsa.2011.08.003)
  • [L4] The duration of banking before thumb reconstruction should be no more than 2 weeks. (10.1016/j.jhsa.2022.06.027)

See Also

References

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[2] Clinical analysis of 1301 children with hand and foot fractures and growth plate injuries. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07407-z

[3] Chapter 9 Hand and Wrist Injuries. 2019.

[4] Hand Fractures: A Review of Current Treatment Strategies. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.02.017

[5] Nonvascularized Autogenous Bone Graft for Extensive Phalangeal Bone Loss: Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.04.025

[6] The exploded hand syndrome: a report of five industrial injury cases. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412468577

[7] Recommendations for radiographic assessment of hand wounds. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231211566

[8] Treatment interventions for hand fractures and joint injuries: a scoping review of randomized controlled trials. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419865897

[9] Radiation Injury and the Hand Surgeon. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.01.035

[10] Presentation and Referral Patterns in Pediatric Closed Hand Fractures. HAND. 2021. DOI: 10.1177/15589447211008590

[11] Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation. HAND. 2022. DOI: 10.1177/15589447221109635

[12] Hypothenar Hammer Syndrome in a Golf Player. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280052101

[13] The Impact of COVID-19 on Hand Trauma. HAND. 2021. DOI: 10.1177/15589447211028918

[14] Severe hand injuries resulting from Samurai sword assaults: a Dublin case series. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410381576

[15] Posttraumatic Stress Disorder and Depression Negatively Impact General Health Status After Hand Injury. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.11.008

[16] Self-reported cold sensitivity in normal subjects and in patients with traumatic hand injuries or hand-arm vibration syndrome. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-89

[17] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[18] Long-Term Effectiveness of Corticosteroid Injections for Trigger Finger and Thumb. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.09.006

[19] Mycobacterium monacense: A Mycobacterial Pathogen That Causes Infection of the Hand. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.10.016

[20] Impairment and Disability After Severe Hand Injuries With Multiple Phalangeal Fractures. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.05.017

[21] Percutaneous elastic intramedullary nailing of metacarpal fractures: Surgical technique and clinical results study. Journal of Orthopaedic Surgery and Research. 2011. DOI: 10.1186/1749-799x-6-37

[22] Upper limb congenital muscular hypertrophy and aberrant muscle syndrome in children. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418774459

[23] Sequential Traumatic Bilateral Extensor Pollicis Brevis Rupture: A Case Report. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.02.007

[24] Burden of Hand Maladies in US Emergency Departments. HAND. 2017. DOI: 10.1177/1558944717695749

[25] Treatment of Fractures of the Fingers. What’s New?. Journal of Hand Surgery. 2003. DOI: 10.1054/jhsb.2002.0889

[26] Chapter 21 Brachial Plexus Birth Injuries. 2020.

[27] Acute Compartment Syndrome of the Hand. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.01.034

[28] Is there a difference in the types of injuries occurring around each finger joint after a fall?. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251381203

[29] Upper Extremity Injuries in the National Football League. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508318197

[30] Fingertip Injuries in Children: Epidemiology, Financial Burden, and Implications for Prevention. HAND. 2016. DOI: 10.1177/1558944716670139

[31] Use of Autologous Skin Cell Suspension for the Treatment of Hand Burns: A Pilot Study. Journal of Hand Surgery Global Online. 2021. DOI: 10.1016/j.jhsg.2021.03.001

[32] Impact of metacarpal shortening on finger strength following non-surgical treatment of spiral and oblique metacarpal shaft fractures. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08776-9

[33] Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.10.004

[34] Reliability of a Classification of Fractures of the Hand Based On the AO Comprehensive Classification System. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409355256

[35] Non-surgical management of isolated proximal phalangeal fractures with immediate mobilization. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419881086

[36] Acute Management of Burn Injuries to the Hand and Upper Extremity. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.03.019

[37] Management of Gunshot Wounds to the Hand: A Literature Review. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.02.011

[38] Adverse Events Following Digital Replantation in the Elderly. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.01.031

[39] Therapy After Injury to the Hand. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201008000-00003

[40] Metacarpal fractures. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231184119

[41] Closed Sagittal Band Injury of the Metacarpophalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-13-00203

[42] Pre- and Postsurgical Evaluation of Hand Function in Hemiplegic Cerebral Palsy: Exemplar Cases. Journal of Hand Therapy. 2008. DOI: 10.1197/j.jht.2008.01.001

[43] Reach out and grasp the opportunity: reconstructive hand surgery in tetraplegia. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419827814

[44] Posttraumatic Reconstruction of the Hand—A Retrospective Review of 87 Toe-to-Hand Transfers Compared With an Earlier Report. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.04.010

[45] The Epidemiology of Operative Pediatric Hand Trauma: A Retrospective Chart Review. HAND. 2019. DOI: 10.1177/1558944719893037

[46] Thumb Amputations from Team Roping. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310051601

[47] Hand Fractures: Indications, the Tried and True and New Innovations. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.03.007

[48] Smoking and Hand Surgery. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.08.018

[49] The Collateral Ligament of the Digits of the Hand: Anatomy, Physiology, Biomechanics, Injury, and Treatment. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.08.024

[50] Hand Function With Touch Screen Technology in Children With Normal Hand Formation, Congenital Differences, and Neuromuscular Disease. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.12.028

[51] Soft-Tissue Mallet Injuries: A Comparison of Early and Delayed Treatment. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.140

[52] Mirror hand-ulnar dimelia: a single centre experience with 13 patients. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221116960

[53] Two Versus 3 Lag Screws for Fixation of Long Oblique Proximal Phalanx Fractures of the Fingers: A Cadaver Study. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.02.012

[54] Motorcyclist’s thumb: carpometacarpal injuries of the thumb sustained in motorcycle crashes. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415620186

[55] Median and Ulnar Nerve Suture: AN EXPERIMENTAL STUDY COMPARING PRIMARY AND SECONDARY REPAIR IN MONKEYS.. The Journal of Bone and Joint Surgery. American Volume. 1968.

[56] The Role of Magnetic Resonance Imaging in Late Presentation of Isolated Injuries of the Flexor Digitorum Profundus Tendon in the Finger. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0306

[57] Paediatric hand fractures. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193412475045

[58] Chapter 54 Pediatric Forearm, Wrist, and Hand Trauma. 2020.

[59] Anatomical distribution and treatment of paediatric hand fractures: a multi-centre study of 749 patients in the Netherlands. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241258862

[60] Finger fractures: Epidemiology and treatment based on 21341 fractures from the Swedish Fracture register. PLOS ONE. 2023. DOI: 10.1371/journal.pone.0288506

[61] A New Classification for Fingertip Injuries. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0305

[62] Chapter 15 The Mangled Lower Extremity. 2021.

[63] Hand injuries in sports – a retrospective analysis of 364 cases. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03807-z

[64] Acute Surgical Management of Hand Burns. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.032

[65] Frequency, Pattern, and Treatment of Hand Fractures in Children and Adolescents: A 27-Year Review of 4356 Pediatric Hand Fractures. HAND. 2020. DOI: 10.1177/1558944719900565

[66] Management of Thumb Tip Injuries. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.09.028

[67] Palmar and dorsal fixed-angle plates in AO C-type fractures of the distal radius: is there an advantage of palmar plates in the long term?. Journal of Orthopaedic Surgery and Research. 2012. DOI: 10.1186/1749-799x-7-8

[68] Nonsurgical Treatment Versus Surgical Treatment in Displaced Metacarpal Spiral Fractures: Extended 4.5-Year Follow-Up of a Previously Randomized Controlled Trial. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.06.018

[69] Hand fracture epidemiology and etiology in children—time trends in Malmö, Sweden, during six decades. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1248-0

[70] Pediatric Phalanx Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-16-00199

[71] Hand Injuries During Hand Surgery: A Survey of Intraoperative Sharp Injuries of the Hand Among Hand Surgeons. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408090125

[72] Trapezoid Fractures: Report of 11 Cases. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.02.046

[73] Accuracy of fluoroscopy in the treatment of intra-articular thumb metacarpal fractures. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412468565

[74] Fractures of the Lesser Sesamoids: Case Series. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.06.039

[75] Detection of fractures of hand and forearm in whole-body CT for suspected polytrauma in intubated patients. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3068-0

[76] Combined Dislocation of the Trapezoid and Finger Carpometacarpal Joints—The Steering Wheel Injury: Case Report. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.005

[77] The Utility of Plain Films for Nonoperative Fifth Metacarpal Fractures: Are Follow-up Radiographs Necessary?. HAND. 2017. DOI: 10.1177/1558944717733278

[78] The Intermetacarpal Angle Screening Test for Ulnar-sided Carpometacarpal Fracture-Dislocations. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.05.042

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[82] The Effect of Joining the ASSH Hand Trauma Center Network on the Volume and Severity of Pediatric Hand Trauma Transfers. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2023.06.011

[83] Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211024435

[84] Time to surgery for open hand injuries and the risk of surgical site infection: a prospective multicentre cohort study. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420905205

[85] Patients Lost to Follow-Up After Metacarpal Fractures. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.08.003

[86] Secondary Thumb Reconstruction via Ectopic Banking of Bony Phalanges From a Nonreplantable Amputated Thumb: A Follow-Up Study. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2022.06.027

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2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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