In Part I of this paper an attempt was made to extricate the topic of congenital hand malformation from the tangle of nomenclature currently in use and to consider it in terms that can be more clearly understood. Possible causes of these malformations were mentioned on a purely conjectural basis.

In the treatment of the crippled hand, our inclination has been to accept the cosmetic appearance of the hand as we found it—to improve the utility of the hand if possible, but otherwise to leave it alone. Although we appreciate the intricate functions a normal hand performs as an organ of perception and movement, we have restricted our discussion of the functions of the crippled hand, before and after surgery, to such elemental act-ivities as pushing, pinching, or grasping. In evaluating the usefulness of the hand, even in the performance of these elemental activities, we have used as a gauge the degree to which the hand is subservient to the brain. At the same time we have kept in mind the functional dependence of the hand on the segments which connect it to the body and on the integrity of its own nerves and muscles. As a corollary of these considerations, we have concluded that only children who have sufficient intelligence to use their hands purposively and who have good sensibility and muscular control in the malformed hand and stable action of the arm and forearm can he considered eligible for reconstructive surgery.

In our discussion of the surgical treatment of the congenitally malformed hand, we have stressed the importance of performing any necessary surgery early, even in infancy. The fingers should be freed from cramping attachments and placed in good functional position before fixed contracture, stiffness of the joints, muscle atrophy, and adhesion of the tendons can develop. If the surgery is performed in early childhood, hot only will the results be better than those which could be obtained later, but also fewer operative steps requiring less time will be necessary.

Ten cases have been illustrated. In the first four cases (Part I) pedicled skin grafts were not used, but in the last six (Part II) these grafts were of paramount importance. Toward the end of Part I, we discussed the diversity of approach possible in the treatment of confluent digits. We stated that if only two fingers are hound together, it is feasible to use local flaps and free skin grafts. In the treatment of multiple syndactylism or of webbing associated with other anomalies, however, we definitely favor pedicled grafts.

In both parts of the paper, the reconstructive procedures are discussed in terms of the discrete functions, such as pinch, grasp, or thumb action, which they are intended to procure. It was not our intention, however, to imply that we have designed particular sets of procedures to accomplish specific functional ends. The procedures we have described—deepening of the interdigital cleft, widening of the web space, derotation or angulation osteotomy, digital shift, ostectomy, or arthroplasty—are to be regarded as tools which the surgeon can vary, amplify, curtail, or alter as he wishes in his efforts to give to a crippled limb a measure of the usefulness of a normal hand.