Complex Hand & Wrist Surgery

Hand and Wrist Surgery in Austin, TX

Written by Brian P. Kelley, MD — Dual Board-Certified Plastic & Hand Surgeon
‍Medically reviewed: May 4, 2026 · Last updated: May 4, 2026
Educational content. Not a substitute for individualized medical evaluation.

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Introduction

The hand is the most functionally dense region of the human body. Twenty-seven bones, more than thirty muscles, three major nerves, and a network of tendons and pulleys move within a few centimeters of skin. Small problems in the hand have outsized consequences — a stiff finger interferes with everything from buttoning a shirt to operating a phone, a numb thumb compromises grip strength, and a missed tendon injury can cost permanent function within weeks if not addressed.

I practice as a dual board-certified plastic and hand surgeon in Austin, Texas, with academic Affiliate Faculty appointment at Dell Medical School at The University of Texas at Austin and a member of the Seton Institute of Reconstructive Plastic and Hand Surgery. Hand and wrist surgery is the core of my practice, and it is also the area where my published work is densest — including book chapters in standard hand surgery references and peer-reviewed publications on fracture care, tendon healing, nerve compression, and pediatric hand reconstruction.

This page is an orientation to what hand and wrist surgery covers, when surgical evaluation is appropriate, and how the major condition categories are approached. For specific conditions, follow the linked detail pages where they are referenced.

When to See a Hand Surgeon

Addressing most hand problems starts with primary care, urgent care, or an emergency department. Surgical referral is appropriate when:

• The injury or condition has not improved with non-operative management — splinting, hand therapy, anti-inflammatory medication, or activity modification. Persistent pain, weakness, or dysfunction beyond a reasonable trial period (which varies by condition) is a reason to escalate.
• The diagnosis points to a problem that is unlikely to resolve without surgery. Some conditions — displaced fractures, complete tendon lacerations, advanced nerve compression with muscle wasting, several arthritides — have well-defined surgical indications that should not be delayed.
• Function is measurably affected. Difficulty with grip, pinch, fine motor tasks, or work-specific demands is a more useful threshold than pain alone. Pain is what brings people to a doctor; function is what determines whether surgery is the right next step.
• There is uncertainty about diagnosis. Hand and wrist anatomy is dense and overlapping, and conditions that present similarly can have very different prognoses. A hand surgery evaluation includes a structured physical examination, imaging review, and where appropriate, electrodiagnostic studies (EMG and nerve conduction studies) to clarify the diagnosis before treatment is decided.

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Categories of Hand and Wrist Surgery

The breadth of hand surgery is best organized by what is being treated rather than by individual procedures. The major categories below cover most of what I see in clinic.

Fracture and Trauma Care

Fractures of the hand and wrist range from straightforward distal radius fractures — the wrist fracture most commonly seen after a fall — to complex multi-bone injuries involving the carpus, metacarpals, or phalanges. Surgical management depends on fracture pattern, displacement, joint involvement, soft tissue condition, and the patient's functional demands. See my recent blog entry on the American Society for Surgery of Hand on this topic.

Distal radius fractures alone account for roughly a sixth of all fractures seen in adult emergency departments and represent one of the most common upper extremity injuries. Treatment ranges from closed reduction and casting for stable, well-aligned fractures to volar plating, external fixation, or fragment-specific fixation for displaced or unstable patterns. I have authored a textbook chapter on distal radius fracture management in the Michigan Comprehensive Guide to Upper Extremity Fracture Surgery.

Hand and wrist trauma also includes tendon lacerations, soft-tissue defects requiring flap coverage, and replantation of amputated digits. Soft-tissue coverage of the upper extremity — including elbow trauma — is a published interest of mine, with a Hand Clinics review on reconstructive options for elbow soft tissue defects.

Nerve Compression and Peripheral Nerve Injury

Carpal tunnel syndrome — compression of the median nerve at the wrist — is the most common nerve compression in the upper extremity. Cubital tunnel syndrome (ulnar nerve compression at the elbow) is the second most common. Both conditions are typically diagnosed clinically and confirmed with electrodiagnostic studies.

Surgical decompression — open or endoscopic for carpal tunnel, in-situ release or transposition for cubital tunnel — is offered when symptoms are severe, when there is objective nerve dysfunction (sensory loss, motor weakness, muscle wasting), or when non-operative management has failed. The threshold for surgery is informed by the natural history of the disease: untreated severe nerve compression can produce permanent damage, so the decision is not just about symptom relief.

Beyond compression neuropathies, peripheral nerve injuries from trauma, surgery, or disease may require repair, grafting, or transfer. Detailed discussion of nerve repair, nerve transfer, and Regenerative Peripheral Nerve Interfaces (RPNI) for amputation neuromas is on the [peripheral nerve surgery page].

Tendon Injuries

Flexor tendon lacerations on the palm side of the hand and extensor tendon lacerations on the back of the hand are surgical urgencies in the relative sense — outcomes are often worse with delay. The classic Zone II flexor tendon injury, sometimes called "no man's land," involves the segment of tendon that runs through the digital sheath and pulley system, where the technical demands of repair are highest and the rehabilitation protocol determines outcome as much as the surgery does. This is something that needs to be fixed operatively within a week or two, in most cases, of the initial injury.

Post-operative timing matters. My published research with the University of Michigan group, in Plastic and Reconstructive Surgery — Global Open, examined the effect of time to hand therapy following Zone II flexor tendon repair and demonstrated that early initiation of structured therapy is associated with better outcomes. Patients who skip or delay hand therapy after tendon repair generally do not achieve their potential recovery, regardless of how technically clean the surgical repair was.

Chronic tendon problems — including trigger finger (stenosing tenosynovitis), de Quervain's tenosynovitis, and tendon attrition ruptures in rheumatoid arthritis — are also treated with a combination of non-operative measures, injection, and surgical release or reconstruction. I have authored chapters in Operative Techniques in Hand and Wrist Surgery on rheumatoid tendon attrition rupture and on swan-neck and boutonniere correction.

Arthritis and Joint Reconstruction

Arthritis of the hand and wrist takes several forms, each with distinct surgical considerations.

Osteoarthritis of the basal joint of the thumb (the carpometacarpal joint) is the most common form patients seek treatment for. Surgical options range from ligament reconstruction with tendon interposition to suspension arthroplasty. Indications and choice of procedure depend on stage, hand demands, and patient preference.

Rheumatoid and inflammatory arthropathies present a different set of problems. Synovitis, tendon attrition, joint deformity (boutonniere, swan-neck, ulnar drift), and progressive loss of function require coordinated medical and surgical management. I authored the chapter on rheumatoid arthropathies in Grabb and Smith's Plastic Surgery, eighth edition, and additional procedure-level chapters in Chung's Operative Techniques in Hand and Wrist Surgery.

Wrist arthritis — whether post-traumatic, scapholunate advanced collapse (SLAC), or scaphoid nonunion advanced collapse (SNAC) — is staged and treated with procedures matched to the pattern of joint destruction, including proximal row carpectomy, partial wrist fusion, or total wrist fusion. I have authored chapters on proximal row carpectomy and total wrist fusion in Operative Techniques in Hand and Wrist Surgery.

Pediatric Hand Surgery

Children are not small adults, and pediatric hand surgery is a distinct discipline. The biology of pediatric tissue, the influence of growth, the importance of cortical neuroplasticity, and the special considerations around consent and follow-up all differ from adult care.

Conditions seen in pediatric hand surgery include congenital hand differences (polydactyly, syndactyly, radial longitudinal deficiency, thumb hypoplasia), brachial plexus birth palsy, pediatric fractures with growth plate involvement, and trauma. My published work in this area includes a first-author qualitative analysis of patient and parent perspectives following reconstruction for congenital hand differences, in Plastic and Reconstructive Surgery, and a case report on on-top-plasty reconstruction for complicated radial polydactyly, in Hand.

The pediatric population also benefits from biological advantages that adult patients do not have. Faster nerve regeneration, shorter limbs, and superior cortical plasticity make procedures like nerve transfers and brachial plexus reconstruction more tractable in young children than in adults.

Together with my partners, I service the Austin community at Dell Children's Hospital in the specialty care clinic. We see children with trauma, congenital hand differences, and nerve pathology. More information can be found at the clinic website or by calling 512-324-0137.

Tumors and Soft Tissue Reconstruction

Hand tumors — most commonly ganglion cysts, giant cell tumors of the tendon sheath, and lipomas, less commonly soft tissue sarcomas — are evaluated, biopsied where indicated, and excised with attention to preserving function. Soft tissue defects after trauma, tumor resection, or burn require reconstruction matched to the defect: skin grafts, local flaps, regional flaps, or free tissue transfer for larger defects with critical structures exposed.

The reconstructive surgical training that comes with plastic surgery board certification is the part of my background that informs this category most directly. Hand surgery without microsurgical and flap reconstructive capability has limits in trauma and oncologic cases that involve more than the tendons, nerves, and bones.

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Why Combined Plastic Surgery and Hand Surgery Training Matters

Hand surgery is one of the rare sub-specialties certified through three different pathways — plastic surgery, orthopedic surgery, and general surgery. Each entry path produces good hand surgeons, and the right surgeon for any given patient depends on the specific problem more than on the path of certification.

The plastic surgery pathway adds capabilities that matter most in trauma, tumor reconstruction, soft tissue coverage, and microsurgical work. A complex hand injury that involves bone, tendon, nerve, and missing soft tissue calls on every part of the toolkit. A patient with a tumor in the palm requires both excision and a thoughtful soft-tissue closure. A patient with a peripheral nerve problem who needs a tendon transfer because the nerve injury is too old to recover by nerve repair benefits from a surgeon who can plan and execute both operations.

This is the framing within which I practice: hand surgery first, with the additional resources of microsurgery and soft-tissue reconstruction available when the case requires them. See an example in the news of successful replantations of four fingers on a man's hand for an example of operations I have performed.
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Pain Management and Recovery

Surgical recovery in the hand is shaped by two things: the operation itself, and the rehabilitation that follows. The operation gets attention because it is dramatic and discrete. Rehabilitation gets less attention because it is incremental and slow, but in many hand surgery cases — flexor tendon repair, nerve transfer, joint reconstruction — the rehabilitation determines the outcome more than the surgery does.

Modern pain management in hand surgery emphasizes multimodal approaches that minimize opioid exposure. My systematic review of acute postoperative pain management in hand surgery, published in the Journal of Hand Surgery — American, reviewed the evidence base for non-opioid options, including regional anesthesia, scheduled non-opioid analgesics, and procedure-specific protocols. The findings support a stepped, evidence-based approach to pain that limits opioid use to where it adds genuine value.

Hand therapy — provided by certified hand therapists, often in coordination with the surgical team — is essential after most hand surgery. Splinting, range-of-motion protocols, scar management, and progressive strengthening are all part of the recovery, and the patients who do best are the ones who engage with this part of treatment as seriously as they engaged with the decision to have surgery.

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Medical References

Peer-Reviewed Publications

1. Johnson SP, Kelley BP, Waljee JF, Chung KC. Effect of Time to Hand Therapy following Zone II Flexor Tendon Repair. Plastic and Reconstructive Surgery — Global Open. 2020;8(12):e3278. PMID: 33425592.
2. Hooper RC, Cederna PS, Brown DL, Haase SC, Waljee JF, Egeland BM, Kelley BP, Kung TA. Regenerative Peripheral Nerve Interfaces for the Management of Symptomatic Hand and Digital Neuromas. Plastic and Reconstructive Surgery — Global Open. 2020;8(6):e2792. PMID: 32766027.
3. Kelley BP, Franzblau LE, Chung KC, Carlozzi N, Waljee JF. Hand Function and Appearance following Reconstruction for Congenital Hand Differences: A Qualitative Analysis of Children and Parents. Plastic and Reconstructive Surgery. 2016;138(1):73e–81e. PMID: 27348688.
4. Kelley BP, Kubiak C, Chung KC. An On-Top-Plasty Reconstruction for Complicated Radial Polydactyly. Hand. 2018;13(3):NP10–NP13. PMID: 29313380.
5. Kelley BP, Chung KC. Soft-Tissue Coverage for Elbow Trauma. Hand Clinics. 2015;43:693–703. PMID: 26498556.
6. Kelley BP, Shauver MJ, Chung KC. Management of Acute Postoperative Pain in Hand Surgery: A Systematic Review. Journal of Hand Surgery — American. 2015;40:1610–1619. PMID: 26213198.

Book Chapters

7. Kelley BP, Chung KC. Distal Radius Fractures. In: Chung KC (ed): University of Michigan Comprehensive Guide to Upper Extremity Fracture Surgery. Wolters Kluwer Health.
8. Kelley BP, Chung KC. Rheumatoid Arthropathies. In: Chung KC (ed): Grabb & Smith's Plastic Surgery, 8th edition. Wolters Kluwer Health.
9. Fujihara Y, Kelley BP, Chung KC, Waljee JF. Tendon Transfers for Low and High Ulnar Nerve Palsy. In: Chung KC (ed): Operative Techniques in Hand and Wrist Surgery, 3rd edition. Elsevier.
10. Multiple additional chapters in Chung KC (ed): Operative Techniques in Hand and Wrist Surgery, 3rd edition, including chapters on rheumatoid tendon attrition rupture, swan-neck and boutonniere correction, proximal row carpectomy, and total wrist fusion.

Specialty Society Resources

11. American Society for Surgery of the Hand: https://www.assh.org/.
12. American Society of Plastic Surgeons: https://www.plasticsurgery.org/
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Related Topics

For specific conditions, see the following detailed pages:

• Carpal tunnel syndrome and surgical release
• Acute Hand and Wrist Injuries
  
• Hand Arthritis and Chronic Hand Conditions
• Pediatric hand surgery and congenital hand differences
• Peripheral nerve surgery, RPNI, and TMR
• WALANT - Wide-Awake Surgery For Hand Problems
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Closing Disclaimer

This article is educational and does not establish a doctor-patient relationship. It does not replace individualized consultation, examination, or review of personal medical history and goals. Patients with hand or wrist concerns are encouraged to schedule a consultation to discuss their specific situation and treatment options.

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Frequently Asked Questions