Decisions regarding reconstructive surgery of the hand and upper limb start and end with function. Will you be able to make your patient more functional? In the short term? In the long term? Are the risks worth the investment of time and energy through healing and rehabilitation? It is important to be certain you, your patient, and their family are well informed and prepared to do all that is necessary to maximize outcome.

The definition of function gets more refined in considering goals of surgery depending on the following: (1) The overall medical condition of your patient—is their problem a single-organ system musculoskeletal disorder involving 1 or many joints, or are there are extensive medical comorbidities? (2) Geographic distribution of the pathoanatomy—is it localized to 1 region (shoulder, elbow, forearm, wrist, hand)? Or involving most or all of the upper limb and hand? And, (3) simply, how good is their brain function? Equally important, how adaptive and resilient is the child and family? Of course, the child’s age and developmental skills matter. The more complex the situation, the more precise the surgical reconstruction. But even simpler single-region orthopedic surgeries require extensive planning and skilled technical care to achieve the desired result of significantly better function.

The primary function of our shoulders is to (1) place our hand(s) in space and then (2) stabilize our hand(s) for gross and fine motor work. The evolutionary anatomists inform us that our elbows evolved for us bipedal humans to bring food from where we gather it to our mouths for sustenance. Of course, our biceps with elbow flexion and forearm supination gives us great lifting strength. Our forearms add complexity to our abilities to work our hands more precisely in tight spaces moving from strength (supination) to fine motor (pronation) activities seamlessly. Our wrists work (1) in harmony with our digits. Wrist tenodesis illustrates the connectedness of wrist flexion with digital extension; and wrist extension with digital flexion. Depending on need, we can vary strength and precision almost seamlessly; (2) in harmony with our forearms by forearm pronation, wrist flexion and ulnar deviation (dart throwing, spear chucking, ball throwing) as well as with our shoulders and eyes (hand-eye coordination). I doubt I have to say much about the exquisite coupling of cascading interphalangeal motion with grasp and release hand function, or the magnificent sophistication that thumb opposition and lateral 3-point precision pinch abilities bring to all our lives, especially us surgeons. In summary, operations for our patients have to improve their abilities to perform these activities both in isolation and in combined movements from the shoulder to digits.