COMPLICATIONS OF TREATMENT Common complications of the treatment of hand injuries The most common complication of any hand injury is stiffness, due to the collaborative effects of inflammation, swelling and immobility. Attempts at prevention of stiffness are much more effective and worthwhile than later attempts to correct established stiffness. This and other complications are less likely when the treatment follows priority based guidelines. Priorities: Management priorities are the same for severe and minor injuries: establish the extent of injury; remove the bad; reconstruct the good; involve the patient and tailor the surgery to the patient (CO). Severe upper extremity injuries with soft tissue loss have shorter hospitalization and more rapid recovery with primary reconstruction, even if this requires primary microvascular free flap surgery (DC). One conceptual approach to organizing the initial management of severe head injuries is to break down priorities as they relate to either healing or function: Healing priorities: circulation, skeleton, closure: Inadequate blood supply is the single most likely explanation for complications of delayed healing, fibrosis and infection Function priorities: nerve, joint, muscle: Nerve injuries should be approached aggressively, as there is never a better time to evaluate and to perform repairs, and the only satisfactory time to repair partial nerve lacerations is in the acute setting The first surgery is critical to the final outcome for the mangled hand. The key goals during this surgery are: Removal of devitalized tissue Removal of contamination Restoring good vascularity to the remaining tissues and replantation as required Haemostasis Achieving bony stabilization Repair and reconstruction of other tissues if the situation is suitable. Adequate soft tissue cover for the hand is an important aspect of the reconstruction. It not only provides cover for the exposed tissues, but restores the contour and appearance of the hand. Rehabilitation is also facilitated with wound healing. Good skin and soft tissue reconstruction of a mutilating injury also provides a platform for further reconstruction, for example staged tendon reconstruction or toe transfer. Once the wound is ready for cover, nerve and tendon repair or grafting can be done. Standard techniques can be used. Alternatively, nerve and tendon reconstruction may be deferred until good wound healing. If repair or grafting is not possible, reconstruction using tendon transfers, arthrodesis, or free tissue transfers are usually done later.