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Proper care of the pediatric hand requires a careful, systematic history, and physical examination, and is facilitated by recognizing common disease patterns, making it easier to determine which conditions require specialty referral, and the timing of those referrals. The article outlines pertinent details of examination and discusses diagnosis and treatment of a number of common diseases entities of the hand.

Establishing soft-tissue coverage adequate to retain an injured digit (preserve length) is not always possible or advisable. Careful evaluation combined with the skillful application of various reconstructive procedures (at the expense of length) may salvage the function and aesthetics of the injured hand.

The primary treatment goal for Kienböck's disease remains decompression of the lunate. Although a number of treatment options are available, scaphocapitate fusion is our first choice in many cases of Kienböck's disease. Scaphocapitate fusion mechanically decompresses the lunate and prevents progressive carpal instability. When compared with STT fusion, it has been shown to result in equal or relatively less loss of wrist motion and thumb basilar joint motion. For disease in earlier stages and with ulnar-minus variance, joint leveling procedures have been shown effective; but ulnar-neutral and ulnar-positive wrists would cause one to favor scaphocapitate fusion to prevent postoperative ulnocarpal abutment.

Reconstruction of the traumatically or congenitally amputated thumb presents a significant challenge. The individual needs of the patient must be matched with the armamentarium available to the surgeon. Metacarpal elongation via the distraction-lengthening technique, which uses local tissue without sacrificing any adjacent digits or toes, is a reliable means of increasing thumb length by 3 to 3.5 cm. The optimal situation for performing this procedure is the presence of an amputation in the perimetacarpophalangeal joint region. Although neo-osteogenesis has been shown to be useful in pediatric patients, bone grafting is recommended in those individuals aged 25 years and older with gaps of 3 cm or more. The patient must be carefully observed during the distraction period because of the potential problems that may arise from the use of an external fixation device.

Selection of the most appropriate operations for a patient is as important as technical expertise in performing the procedures. Web deepening may be performed alone or in addition to tissue augmentation and should be planned in conjunction with bone lengthening. Skeletal augmentation is useful if fingers are missing or inadequate, and it is necessary to add bony tissue. In general, in order to grow, skeletal transfers must be performed on very young children or must include vascularized physes; complex cases may require microvascular composite toe-to-hand transfer. Distraction-lengthening for intercalary skeletal enhancement is indicated for patients with multiple hypoplastic, aplastic, and missing digits, but the cosmetic result is limited. The major procedures should be started by age 2 years and finished by age 4; unfortunately, it is most often not advisable to perform microvascular surgery at such an early age. Modification of functional patterns, even though they are abnormal or the result of incomplete anatomy, should be avoided in the older child or adult because tinkering does not lead to significant benefits. For a cooperative, and often difficult, staged venture to be maximally successful, physicians and parents must share realistic expectations of aesthetic and functional results.

The motivated patient with symptomatic post-traumatic PIP joint stiffness and discomfort has the potential for significant functional improvement. The specific treatment will depend on many factors, including residual joint architecture, alignment, and condition of the soft tissues. The careful surgeon will review all physical and roentgenographic data with the patient and involve her/him in the treatment plan. The function achieved eventually will depend as much on the motivated patient in the hands of a skilled therapist as on the surgeon's meticulous technique.