Max Cohen was driving through West Orange last November when, for reasons that are still not clear, he fell asleep at the wheel. He was the only person hurt when his car struck a telephone pole, but he had multiple injuries, including a compound fracture of the right wrist.

Mr. Cohen was taken to the New Jersey Trauma Center at University Hospital, a Level 1 facility where the most serious and complex trauma cases in northern New Jersey are treated. Two surgical teams worked on the 66-year-old man: one for the broken right shin bone and calf bone, the other for the wrist, led by Dr. Virak Tan, assistant professor of orthopaedics at New Jersey Medical School and a hand and microvascular surgeon at University Hospital. Compound, or open, fractures, where the bone breaks through the skin, are considered surgical emergencies because of the risk of infection and damage to the blood vessels and nerves.

"Dr. Tan is a very gifted surgeon," says Mr. Cohen's wife, Eleonore. "He was able to reconstruct Max's wrist. Today, Max is able to swing a golf club and sail his boat, two pleasures we were unsure he'd be able to do when he was first brought to the trauma center."

Dr. Tan and Dr. John Capo, assistant professor of orthopaedics at New Jersey Medical School and chief of the division of hand and microvascular surgery at University Hospital, provide comprehensive management of conditions affecting the hands, the elbows, and the shoulders. Both doctors have engineering backgrounds and have completed residencies in orthopaedic surgery and multiple fellowships in hand and microvascular surgery. One of Dr. Capo's fellowships was in upper extremity trauma and reconstruction at the University of Bern, Switzerland. As a visiting fellow in microsurgery at the Chang Gung Memorial Hospital, Taiwan, Dr. Tan studied with one of the world's leading experts in brachial plexus surgery.

Hand and microvascular surgery is an often-complex subspecialty that, in addition to orthopaedics, combines elements of neurosurgery and plastic surgery. The hand itself, with 27 bones, is intricate, flexible, and has many moving parts. Its three major nerves, the median, the radial, and the ulnar, facilitate mobility and sensitivity, and more than 35 muscles control voluntary movement in the forearm, wrist, and hand. Patients with upper extremity conditions or injuries want relief from pain and what most of us take for granted: the ability to use their hands and arms to perform daily living tasks such as dressing, eating, and writing, and being able to work or enjoy hobbies.

Carpal tunnel syndrome (CTS) is one of the more common conditions treated by hand and microvascular surgeons. It is a disorder that, while frequently associated with keyboard use, can be aggravated by any activity in which hand and finger movements are done over and over again. Overuse can result in "compression" of the median nerve, which passes through the wrist's carpal tunnel, causing pain, tingling, and numbness in the fingers and hand. "Carpal tunnel can be severely disabling, and when not treated early on, may result in permanent nerve damage and hand dysfunction," says Dr. Tan.

Most CTS patients do not have surgery. Non-operative measures such as rest, anti-inflammatory medication, occupational therapy, splinting, and cortisone injections are tried before turning to the operating room. When symptoms persist, the transverse carpal ligament can be cut to release pressure on the median nerve. There's new research on CTS treatment, however. A recent study from the Netherlands found that 80 percent of patients who had carpal release surgery showed improvement after three months, compared to 54 percent of patients who just wore splints.

"This is a very well-designed study with good methodology. It reconfirms that carpal tunnel release is a very reliable procedure to relieve pain and symptoms of median compression in the wrist," comments Dr. Tan. "However, the study did not compare splinting and cortisone injection (the mainstay of non-operative treatment) with surgery. So, in most cases, I will continue to start with the non-operative modalities, then offer surgery if the splinting and injection fails."

Still, the lion's share of common conditions involving the hand and upper extremity can be successfully treated non-operatively with medications and/or therapy. Trigger finger, where a thickening or knotting in a tendon locks a finger in a bent position, can often be resolved with cortisone. Fluid-filled cysts on the hands known as ganglions can be aspirated. Overuse of the arm can cause tiny tears in the tendons, leading to two similar ailments, golfer's elbow and tennis elbow. Most of the time, rest, ice, and splinting are all that's needed to heal these conditions.

A Second Chance at Recovery

Then, there are more complex conditions. On August 21, 2000, Peter Troost, a television lighting director, fell when the ladder he was standing on collapsed. Among the injuries, his left elbow was "shattered like an egg." Mr. Troost had reconstructive surgery and rehabilitation, but less than one year after the accident, his range of motion was dramatically reduced to less than 45 degrees. "I could barely reach to tie a necktie," he says, "and there was a lot of pain." He was referred to Dr. Capo for corrective surgery.

And so on July 24, 2002, Mr. Troost had a second surgery on his elbow. Dr. Capo removed multiple metal plates and screws that were holding bone in place. They were no longer needed, as healing had taken place, and were beginning to cause hypersensitivity in Mr. Troost's elbow. The surgeon also removed some bone deposits and excessive scar tissue. "I ended up with a jar full of hardware," says Mr. Troost. "But Dr. Capo also went the extra mile. When I went home two days after the surgery, a machine that would very slowly bend my arm back and forth was there waiting. He arranged that for me."

Fittingly enough, the 42-year-old man went back to work the day after Labor Day. Mr. Troost's range of motion has already improved, and with aggressive therapy to break down scar tissue, it is anticipated that he'll regain optimum use of his arm.

With their specialized training, Dr. Capo and Dr. Tan are able to treat the complex cases as Mr. Troost's. A patient whose finger is severed in an accident requires microsurgery to reattach it and repair the tendons and the delicate nerves, arteries, and veins. Obstetric brachial plexus conditions, where nerves are damaged during the birth process, can cause paralysis or weakness in the baby's upper arm (Erb's palsy) or hand (Klumpke's palsy). "If these injuries don't recover on their own, surgery may be warranted. Hand and microvascular surgeons can offer a comprehensive approach that not only repairs the nerves, but addresses any problems involving the muscle, tendons, or bones," says Dr. Tan. "There could be a need for a tendon transfer, for example." A tendon is a cord of tissue that connects muscle to bone. When there is nerve damage or a loss of function, healthy tendons from another part of the body can be taken and transferred to the area where there's injury or deficit.

Through innovations in technology and surgical technique, specially trained hand and microvascular surgeons can perform total elbow replacements and total shoulder replacements. Most often, candidates for this procedure are elderly, have severe arthritis that hasn't responded well to medical treatment or other surgery, or in selected cases, have suffered a traumatic injury.

"For these patients, joint replacement can significantly relieve pain and help to restore function," says Dr. Capo. "Total shoulder and elbow replacement have been available for many years, but are performed less often than total hip or total knee replacement. Part of the reason is that we're highly selective as to who qualifies as a candidate for the surgery; there also are relatively few orthopaedists who specialize in this complex procedure." Total elbow or shoulder replacement surgery takes about two to three hours to perform, with a hospital stay of about three days. The satisfaction rate following this surgery is usually very high--about 95 percent, says Dr. Capo, because of the significant pain relief it brings.

Hands and arms are used countless times a day, and when there is pain or limited use, the whole person is affected. Dr. Capo and Dr. Tan provide patients with information to make the best choices possible and then follow through with optimal care. "The work we do encompasses more than setting bones," says Dr. Capo. "There's an intricate network of joints, tendons, nerves, and blood vessels that is involved. Beyond that, there's a person with a job to do or a hobby to enjoy. Giving him or her back the ability to do even daily living functions provides a great deal of satisfaction."

For more information about hand surgery and treatments, call (973) 972- 0763.