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March 18, 1974

The "Intact" Hand After Crush and Burn

JAMA. 1974;227(11):1305. doi:10.1001/jama.1974.03230240063032

"Edema," Sterling Bunnell said, "is the mother of scar." A fecund and implacable mother, he might have added. Edema of the lower extremity has a host of genetic factors, including the law of gravity. Edema of the hand and arm, by and large, has two basic causes: trauma, including surgical trauma, from the axilla downward, and the inflammatory state, with or without infection. Crush and burn are the worst of the traumas, if we except mangling beyond hope of salvage.

The hand is a compound cylinder with a thick and tough volar skin, backed by fascial sheets and septa, with few escape hatches. The carpal tunnel has minimal room for the eight tendons and major nerve it must carry. Destructive pressure on the median nerve is common even without gross trauma; the ulnar nerve, hardly more than a centimeter away, passes through an unyielding tunnel as it divides into motor