Orthopaedic surgery is the branch of medicine that focuses on movement and function. In orthopaedics, we work with bones, joints, muscles, and tendons, as well as nerves and vessels. Hand surgery is a subspecialty of orthopaedics (and also a subspecialty of both plastic surgery and general surgery) that addresses all of the same issues but focuses on the upper extremity, especially the intricate anatomy of the hand. In this age of specialization and subspecialization (and what we call super- subspecialization), there is also congenital hand surgery, the field that focuses on children born with differences in the anatomy of the hand and upper extremity.
As an orthopaedic surgeon, my first priority is always function. I seek to help children born with hand differences to be as functional as possible. Typically (but not always) that is working to “normalize” the hand and upper extremity anatomy. However, the needs of each child are different and depend on many factors including that status of the affected hand, the status of the other hand (i.e., whether it is affected or not), and the specific limitations of the child. While each child is considered independently, children born with differences in anatomy do have patterns of presentation so that we see similar birth anomalies repeated over time (this is why experience is important in your surgeon). These patterns helps us understand how to best help the child.
Typically, we think of plastic surgery as the field that is concerned with appearance. But appearance is an important concern for all physicians taking care of children born with hand anomalies. Not only do we want to help the child function better, but we also have the chance to help the child interact with the world differently. If we can improve hand appearance, we can ease the social stigma of the birth anomaly. Rarely can we make the hand look “normal”, but small changes can pay big dividends. We never perform surgery to improve appearance if it will hurt function but if we can improve both with surgery, we best meet our goals for the patient.
A couple of definitions. Cosmetic surgery (the act of improving the appearance of normal anatomy) differs from aesthetic surgery (the act of normalizing abnormal anatomy). In congenital hand surgery, we improve the aesthetics of the birth anomaly by working to make the birth anomaly of the hand more like an unaffected hand.
There are many examples of how form AND function can be improved in congenital hand surgery. One excellent example of a condition improved with surgery (both appearance and function) is cleft hand as depicted here.