Plastic surgery






Fractures of the metacarpals and phalanges are frequent injuries, representing 41% of all upper extremity fractures in the United States.1 Each patient and fracture is unique, but common principles apply.The goals of hand fracture treatment are restoration of articular congruity, reduction of malrotation and angulation, maintenance of reduction with minimal surgical intervention, and rapid mobilization. This chapter focuses on the most common types of hand fractures with an emphasis on the principles related to optimal fracture treatment.


Physical examination of the patient with a hand fracture follows a thorough history. The type of trauma provides valuable information. When inspecting the injured hand, the contralateral hand serves as an excellent reference. Swelling, tenderness, or open wounds are assessed. Gentle palpation locates tender points. Circulation and sensation of the hand and the integrity of tendons and ligaments are assessed. The patient is asked to maximally extend and flex the fingers to detect malalignment or rotational changes of the digits (Figure 75.1). It may be useful to block the fracture site with local anesthesia to facilitate motion, which may otherwise be impossible due to pain.

In the presence of an open fracture, the wound is inspected after cleansing and disinfection of the hand. Deep probing of the fracture through the wound in an emergency setting is not recommended, as this may propagate bacterial contamination from the skin edges into the fracture site.

Plain radiographs in three planes—posteroanterior, lateral, and oblique—are obtained. It is of great importance that projections are accurately directed with the central beam aimed at the area of interest. Special views will be discussed as individual fractures are presented below.


The majority of closed hand fractures can be effectively treated by closed reduction and splinting. Fractures can be identified as transverse, oblique, or spiral. Each fracture has its own “personality,” depending on the time from injury to presentation, the fracture pattern, the amount of cortical versus cancellous bone at the fracture site, and the muscle/tendon forces acting on the fractured parts. Stable, non-displaced fractures can usually be treated by splinting and/or buddy taping (taping to the adjacent digit) alone. Initially unstable fractures may be reduced, converting them to a stable position for splinting. If the reduction is not stable in post-reduction radiographs, then the position should be secured by percutaneous pinning or other means of fixation (Figure 75.2).

Once stabilized, the patient is encouraged to move all uninvolved digits and to elevate the hand to minimize edema. A follow-up radiograph is obtained after 7 to 10 days to check alignment and to rule out displacement. Metacarpal and phalangeal fractures usually require 3 to 4 weeks for clinical union. Clinical union, which is defined as a state of stability and painlessness, may precede radiographic evidence of bone healing.

Irreducible fractures are candidates for open reduction and internal fixation (ORIF)Even when performed with precise technique, a surgical procedure creates additional trauma to the damaged area; therefore, the surgeon must carefully ascertain if an indication for operative treatment exists: malrotation, instability, or multiple contiguous fractures. Furthermore, if ORIF will ultimately speed up motion and recovery, then an operative procedure may be preferable.2

For open fractures, the wound is irrigated and debrided urgently in the operating room. The fracture is treated by internal fixation or Kirschner wire (K-wire) fixation during the same session if the wounds are clean. Soft tissue defects are reconstructed prior to or at the time as definitive fracture treatment. Most skin defects can be closed with local tissue. The dorsum of the fingers requires special consideration. Due to its thin soft tissue cover, this area is vulnerable to full-thickness skin loss. Coverage with local flaps, however, is limited because of the shortage of adjacent tissue. In these cases, island flaps from the metacarpal skin that can reach the digital area such as reversed metacarpal artery flaps can be used.3 Distant or free flaps are rarely needed. Adequate soft tissue cover is essential for proper bone healing. Prophylactic intravenous antibiotics are administered.4 There is evidence that a single dose of intravenous antibiotic can reduce the incidence of infection in open fractures.5Antibiotic administration is continued for up to 72 hours in type II injuries according to the modified Gustilo classification by Duncan et al.4

FIGURE 75.1. In this sculpture by Auguste Rodin, the long finger scissors over the ring finger while all the other fingers correctly point toward the scaphoid tubercle.

FIGURE 75.2. Algorithm for fracture treatment. K-wire, Kirschner wire; ORIF, open reduction and internal fixation.


K-Wires (Kirschner Wires)

K-wires are the most versatile and the most frequently used fixation method. To minimize trauma, the wires can be introduced percutaneously under fluoroscopic guidance after closed reduction of the fracture. If closed reduction is not possible, the fracture can be reduced via an open approach and then stabilized with K-wires. One K-wire alone cannot provide rotational stability; therefore, at least two wires in different planes are necessary to prevent rotation. K-wires do not add a compressive component on the fracture. The disadvantages of this technique are lack of rigidity, possible pin loosening, pin tract infection, and the necessity for additional immobilization (Table 75.1).

Tension Band Wiring

The principle of this technique is to maintain the alignment of the fracture fragments with K-wires and to apply interfragmentary compression with wire loops around the K-wire. The forces of the strong flexor tendons also contribute to the compressive force. K-wires of 0.035 or 0.045 inch diameter are driven across the fracture line. Care is taken not to position the wire ends directly underneath a tendon. A 24G or 26G monofilament steel wire is guided in a figure of eight fashion and tightened dorsally, counteracting the natural pull of the flexor tendons. This technique provides adequate fixation for early motion (Figure 75.3).

Interosseous Wiring

The 90° to 90° interosseous wire fixation can also provide stability and compression with minimal soft tissue dissection. It is mainly used for transverse fractures of the phalanges, for joint fusion, and for osteosynthesis in replantation. The technique requires 0.045 inch K-wires, an 18G needle, and 24G or 26G dental wire. Drill holes are made using a 0.045 inch K-wire through both bone fragments, dorsal to palmar, and radial to ulnar. An 18G needle is inserted through the drill holes to serve as a temporary guide for the insertion of a 24G or 26G dental wire. After circumferential engagement of the wire, it is tightened carefully to avoid wire breakage (Figure 75.4). Alternatively, instead of using interosseous wires in anteroposterior and lateral planes, both loops can be positioned in a dorsal to volar direction.

FIGURE 75.3. Tension band wiring: K-wires provide stabilization and wire loops exert compression across the fracture line.

FIGURE 75.4. Interosseous wiring: A. Two-wire loops at 90° angles to each other (90° to 90°) or (B) parallel wires provide both stabilization and compression.

Intramedullary Fixation

The use of intramedullary fixation may be suitable for transverse fractures. Steinmann pins or multiple K-wires are used (Figure 75.5).6 The devices are completely intraosseous and their removal is not necessary. Potential disadvantages are rotational instability and pin migration. They are difficult to apply in spiral or long oblique fractures.

FIGURE 75.5. Intra medullary fixation of a metacarpal fracture with anterograde insertion of prebent K-wires. A. During placement. B. Wires are trimmed after placement.

FIGURE 75.6. Lag screw principle (compression screw): A. Drilling of hole across both fragments. B. Countersinking. C. Screw length determination. D. Drilling of glide hole with larger drill bit. E. Tightening the lag screw. F. Two or three lag screws assure stability.

Compression Screws

Compression can be applied between the fracture fragments using the lag screw principle. This is done by using screws with a small length of thread at the tip and a smooth shank between the threaded portion and the tip. Fully threaded screws can also act as lag screws if the proximal cortex is over-drilled so that the proximal hole acts as a glide hole (Figure 75.6). Compression of two bone fragments with lag screws can be applied in long oblique and spiral fractures, where the fracture length is at least twice the bone width. Proper holding of the accurately reduced fragments with appropriate clamps is essential for successful lag screw osteosynthesis.

Plate Fixation

The main benefits of osteosynthesis with plates and screws are rigid fixation and maintenance of bone length. The technique is indicated in metacarpal fractures, especially with multiple fractures, and for the reconstruction of malunion and nonunion. Compression plates are designed to provide compression across the fracture line. Tightening the screw in an eccentrically placed drill hole creates a force vector in the longitudinal direction. The screw head progressively pulls the plate along with already fixed fracture portion toward the other fragment (Figure 75.7). Due to the need for extensive dissection, plate fixation is associated with a higher rate of extensor tendon adhesion formation, often necessitating tenolysis. Despite the development of thinner plates, some bulkiness remains and plates may require removal.

External Fixation

External fixation is used in complex fractures where anatomic reconstruction is not feasible. For example, highly comminuted fractures with bone loss, gunshot wounds, and fractures with severe soft tissue damage and/or contamination may be best treated by external fixation. The external fixator bridges across the fracture, thus stabilizing the bone fragments and maintaining length until soft tissue healing occurs. As the manipulation of the fracture site is minimal, preservation of the vascular supply is possible. The high stability of external fixator systems permits early mobilization.

FIGURE 75.7. Principle of compression plates. A. The distal holes are drilled in a neutral position. B. After fixation of the LC-DC 2.0 plate to the distal bone with adequate screws, the first proximal hole is drilled eccentrically (away from the fracture). C. Insertion of the first proximal screw. D. The screw head pulls the plate proximally along with the distal fragment providing compression. E. The final screw is inserted in a neutral position.


Metacarpal Neck Fractures

The most common location of metacarpal fractures is the neck. These fractures are referred to as boxer’s fractures because they often result from a fist striking an unyielding target, quite often a human face or a wall. They occur most frequently in the fourth and fifth metacarpals. Due to the pull of the intrinsic muscles, metacarpal neck fractures are angulated with their apex dorsally (Figure 75.8). For closed reduction, proper anesthesia is very helpful. An ulnar nerve block at the wrist in addition to fracture site anesthesia facilitates fracture manipulation by paralyzing the intrinsic muscles. When reducing metacarpal neck fractures, a modification of the Jahss maneuver is applied (Figure 75.9). With the metacarpophalangeal joint of the fractured digit flexed at 90°, the middle phalanx is pressed dorsally with one hand. At the same time, the other hand creates counter pressure by pushing the metacarpal body volarly. The middle phalanx is used as a crank to reduce the displaced metacarpal head. Flexion of the interphalangeal joints as recommended in the original Jahss maneuver actually encumbers the reduction by unnecessarily tightening the intrinsic muscles.

The majority of metacarpal neck fractures can be treated by closed reduction, followed by cast immobilization in 70° to 90° flexion of the metacarpophalangeal joint. Most patients regain satisfactory flexion and extension despite some residual angulation. However, severe angulation can be associated with prominence of the metacarpal head in the palm, which can be troublesome for laborers and athletes. The loss of knuckle prominence on the dorsum when making a fist may also be an aesthetic problem.

The degree of acceptable residual angulation is controversial and varies between the metacarpals. Angulation of up to 30° after reduction can be treated conservatively without significant functional loss for the ring and small fingers. Flexor tendon function may decrease significantly when the angulation is greater than 30° and the finger is shortened.7 Index and long fingers tolerate less angulation because their carpometacarpal joints are less mobile.

If a metacarpal neck fracture is unstable after closed reduction, percutaneous K-wire fixation, either in a retrograde fashion or in a transverse manner to the adjacent metacarpal, may be necessary. The latter method has the advantage of allowing active exercise 1 week after reduction, and reports show excellent outcomes.8 An alternative to percutaneous K-wiring is intramedullary nailing (Figure 75.5).6

FIGURE 75.8. The dorsal angulation of metacarpal head fractures is a result of the pulling force of the intrinsic muscles.

FIGURE 75.9. Modified Jahss maneuver for reduction of metacarpal head fractures: The digit is pressed dorsally in flexed position of the metacarpophalangeal joint with volarly directed counterpressure on the metacarpal bone.

Metacarpal Shaft Fractures

The stability and healing of metacarpal shaft fractures depends on the fracture pattern. Transverse fractures may be unstable and slow to heal because of the small amount of cortical bone at the fracture site. Oblique and spiral fractures of the metacarpal shaft have more bony surface area for stability and healing, but malrotation needs to be corrected.

Non-displaced and stable fractures after closed reduction are treated with a short arm cast for 3 to 4 weeks. If the reduced fracture is unstable, percutaneous K-wires can be used to hold the reduction. Loss of metacarpal length can compromise extensor tendon balance. Cases of comminution, bone loss, or fractures of multiple metacarpals favor open reduction and plate fixation (Table 75.2). When performing osteosynthesis with plates, incisions should be placed off the axis of the extensor tendons to minimize postoperative adhesions. Division of the junctura tendinum may be necessary to retract the extensor tendons. After longitudinal splitting and dissection of the periosteum, the fracture is reduced utilizing bone clamps. Plates are contoured precisely, and the reduction is confirmed both fluoroscopically and by clinical evaluation of possible malrotation, before they are stabilized with screws.9 Alternatively, long oblique fractures can be stabilized with lag screws (Figure 75.10).

Multiple metacarpal fractures can lead to a critical rise of pressure in the muscle compartments. If evaluation reveals evidence of compartment syndrome such as persistent unrelieved pain disproportionate to the trauma, or pain with passive extension of the affected muscles, fasciotomy of the interosseus spaces is considered. Two longitudinal incisions are made over the second and fourth metacarpal bases. Each of these incisions allows fasciotomy of two adjacent interosseous spaces.

Metacarpal Base Fractures

These fractures are usually the result of high-energy trauma and may involve dislocation of the carpometacarpal joints. Therefore, thorough evaluation of carpal involvement is necessary. If reduction cannot be accomplished with closed reduction alone, K-wire fixation or open reduction and plate fixation is required.

FIGURE 75.10. Multiple metacarpal fractures may require ORIF. The index metacarpal was stabilized with plates and screws. For the long finger, a T-plate was used, and the comminuted fragments were held together with a cerclage wire. The spiral fracture of the ring finger was stabilized with two lag screws.

FIGURE 75.11. Multiple carpometacarpal fracture dislocations: note the significant soft tissue swelling.

Intra-articular base fractures of the fifth metacarpal are referred to as “reverse Bennett” fractures and are unstable due to the pull of the extensor carpi ulnaris tendon, which inserts onto the base of the fifth metacarpal. The dislocation of the fifth metacarpal is reduced and pinned to the fourth metacarpal and the hamate. If possible, the fracture fragment itself is reduced to the fifth metacarpal as anatomically as possible. These principles for treatment are the same as for the true Bennett fracture of the thumb (discussed later).

Fracture dislocations of the other carpometacarpal joints of the fingers may be multiple and represent high-energy injuries. It is critical to consider compartment syndrome in these cases (Figure 75.11). Accurate reduction and fixation, either closed or open, is performed. For patients with severe joint destruction, primary arthrodeses may be considered.


Fractures of the thumb metacarpal are mostly divided into shaft and base fractures because thumb metacarpal head fractures are extremely rare. Energy directed toward the head usually results in rupture of the collateral ligaments. Although thumb metacarpal shaft fractures are usually easily detected by routine radiographs, full visualization of the base of the thumb metacarpal and the trapeziometacarpal joint is obtained with the Robert’s view (PA view with hand 30° short of full pronation and maximal ulnar deviation of the wrist).

Thumb metacarpal shaft fractures are usually transverse and are dorsally angulated due to the volar pull of the thenar muscles and the dorsal pull of the abductor pollicis longus tendon proximally. Most shaft fractures can be treated by closed reduction and casting because the plaster can be effectively molded around this solitary metacarpal. Upto 30° of angulation is acceptable because of the great mobility of the carpometacarpal joint. Greater angulations require reduction, and usually closed pinning.10

FIGURE 75.12. First metacarpal base fractures: A. Bennett fracture: the abductor pollicis longus tendon pulls the main portion of the metacarpal bone dorsoradially while the fracture fragment stays aligned. B. Rolando fracture with comminuted base, here Y-shaped.

Metacarpal base fractures are much more common than shaft fractures. The intra-articular types are referred to as Bennett and Rolando fractures (Figure 75.12). Base fractures are a result of an axial load through the metacarpal shaft in contrast to shaft fractures, which are commonly caused by a direct blow.

The most common fracture of the thumb metacarpal base is the Bennett fracture, an intra-articular fracture through the volar–ulnar aspect of the metacarpal base. In these fractures, the main metacarpal bone is displaced dorsoradially by the pull of the abductor pollicis longus tendon, while the smaller fracture fragment is held in position by the volar oblique ligament. Closed reduction after traction and pronation of the thumb with percutaneous pinning is the first choice of treatment. The focus should be on realigning the main metacarpal bone. The K-wire is anchored in the trapezium and/or the base of the second metacarpal. Then, the fracture fragment is reduced as best as possible. If the resulting articular step-off is more than 1 mm, open reduction may be necessary to reduce the severity of arthritic changes. Fixation can be obtained with K-wires, lag screws, or plates. The fracture is immobilized for 4 to 6 weeks in a thumb spica cast.11

Resulting mostly from high-energy trauma, Rolando fractures are frequently comminuted and difficult to treat. They consist of at least three fragments. The typical fracture line is T- or Y-shaped. The goal is to restore both height and articular congruency. The treatment of choice is open reduction with fixation using condylar plates or K-wires. External fixation should be considered for severe cases. Even with excellent surgical technique, posttraumatic arthritis of the thumb carpometacarpal joint may result over time.


Proximal and middle phalangeal fractures have similar properties. Both can be transverse, oblique, spiral, or comminuted. As a result of the intrinsic muscles and the extensor tendons, transverse fractures of the proximal phalanx tend to angulate volarly (Figure 75.13). Stable proximal phalangeal fractures are ideal candidates for dorsal splinting with flexion of the metacarpophalangeal joint. This position causes the extensor apparatus to serve as a tension band across the transverse fracture line. This effect, which is increased when the proximal interphalangeal (PIP) and the distal interphalangeal (DIP) joints are flexed, can be used to reduce a proximal phalangeal fracture. After 3 weeks, the patient is encouraged to move the finger supported by buddy taping.

FIGURE 75.13. Volar angulation of proximal phalangeal bone fractures: The intrinsic muscles pull the proximal fragment volarly and the extensor tendon pulls the distal fragment dorsally.

The chance of secondary displacement of primarily stable fractures is low.12 Reduced fractures, which were originally displaced, however, have a high chance of redisplacement. If a secondary displacement is seen in weekly follow-up radiographs, stabilization with K-wires is considered.

Condylar fractures that are not amenable to closed treatment require an open approach. Care must be taken not to injure the collateral ligaments, as much of the blood supply to the condyle is derived from this structure. Unicondylar fractures can be reduced by a midaxial approach. Screws of 1.0 to 1.2 mm diameter are used for fixation. The goal is to achieve rigid fixation and allow early movement of the joint (Figures 75.14 A and B).

Bicondylar fractures are usually unstable and require an open approach, which is best done via a dorsal incision splitting the extensor tendon between the central slip and the lateral bands. Stabilization is achieved by K-wires, screws, or T-plates. Plating is avoided when possible because it often results in stiffness due to extensive dissection and frequently necessitates tenolysis after plate removal.

Non-displaced shaft fractures can be buddy taped to an adjacent uninjured finger. Any fracture showing rotational deformity requires operation. Whereas short oblique fractures can be treated with crossed K-wires, spiral fractures should be stabilized with interfragmentary screws. When using crossed K-wires, the level of crossing should not be at the fracture site.

Extra-articular base fractures can be treated with conservative treatment with 70° flexion of the metacarpophalangeal joints. Rotational deformities need to be treated by ORIF. Intra-articular fractures are amenable to closed treatment, if undisplaced. Cortical screws or K-wires are used for displaced fractures. Loss of motion may result after phalangeal fractures, especially after long immobilization, and joint and crush injury. Therefore, early immobilization is of utmost importance.

PIP joint fracture dislocations are complex and often result in a stiff, painful, arthritic PIP joint (Figure 75.15). The treatment is based on the size of the volar middle phalanx base fragment and the amount of subluxation or dislocation of the middle phalanx. Treatment options range from fragment screw fixation, dorsal block pinning, and dynamic external fixator placement to salvage operations, such as volar plate arthroplasty and hemi-hamate arthroplasty. Full discussion is beyond the scope of this chapter.

FIGURE 75.14. Unicondylar proximal phalanx fracture treated with screw and supplemental K-wire. A. Lateral view. B. Posteroanterior view.

FIGURE 75.15. PIP joint fracture dislocation of the ring finger with disruption of 50% of the middle phalanx joint surface and resultant dorsal dislocation.


Distal phalangeal fractures are the most common fractures in the hand. They can be classified into tuft, shaft, and base fractures. Tuft fractures are usually the result of direct trauma, and comminution is frequent. Due to the close proximity of distal phalangeal bone and the nail bed, they are frequently accompanied by nail bed injury and subungual hematoma. The hematoma is evacuated by wide fenestration of the nail using electrocautery in its proximal portion, distal to the lunula. Damage to the nail bed by this maneuver is unlikely, as the nail is separated from it by the hematoma. To avoid irregularities of the new nail, meticulous repair and splinting of the nail bed is required. An extension splint is used to immobilize the DIP joint for 2 to 3 weeks. Non-displaced shaft fractures can be treated in the same way. Displacement of transverse fractures is mostly accompanied by laceration of the overlying nail matrix, which requires repair. Bone fixation is usually performed with a K-wire. Epiphyseal disruption may present as a mallet deformity. This appearance is produced by the pull of the flexor tendon on the distal fragment, whereas the extensors act on the proximal fragment. Closed reduction is mostly sufficient with repair of the nail bed, if present. Distal phalangeal fractures may result in nonunion but they are rarely symptomatic. Distal phalangeal “mallet” fractures with detachment of the terminal extensor are discussed in the extensor tendon chapter (Chapter 78).


Treatment outcomes after hand fractures are variable because of the wide range in presentation and treatment. Excellent results are reported after screw and/or plate fixation of metacarpal and phalangeal fractures with 92% displaying more than 220° range of motion.13 Favorable outcomes also follow fixation of metacarpal and phalangeal fractures with K-wires and intramedullary rods.9 Some researchers, however, found that only 27% of unstable phalangeal fractures treated by plates and/or screws achieved excellent outcomes (at least 210° arc of motion).14 Two factors may have caused the poorer outcome in this particular study: inclusion of unstable fractures only and the high percentage of unfavorable factors, such as open fractures, soft tissue damage, and comminution. Another group reported that only 52% of metacarpal and phalangeal fractures repaired with plates and screws obtained ≥220° total range of motion.15 These studies highlight the high incidence of tendon scarring after ORIF.


Given the wide range of fracture treatment techniques, the key to success for maximizing functional outcome while minimizing complications is the selection of the best treatment modality for each given case. Choosing a conservative method will avoid hardware-associated complications such as tendon adhesions and rupture and infection at the cost of nonrigid fixation, which may lead to malunion and joint stiffness from prolonged immobilization. The surgeon must therefore be aware of the possible complications associated with the different modalities. Despite early exercise after plate fixation of metacarpal and phalangeal fractures, Page and Stern15 encountered major complications in 36% of injuries, including stiffness, plate prominence, nonunion, infection, and tendon rupture. Complications were observed more frequently in open fractures and phalangeal fractures. Similar observations were made by Pun et al.14

The primary factors influencing stiffness are soft tissue damage14,16 and the age of the patient.16 Infection is also highly associated with soft tissue injury. Whereas the infection rate in closed fractures is less than 0.5%, open fractures of the hand showed deep infections in 2% to 10% of patients. The most common bacteria isolated from open hand fractures were staphylococci and streptococci.17

Malunion is more likely to occur after closed reduction and splinting or internal fixation with one longitudinal pin. Transverse metacarpal fractures result in dorsally angulated malunion, which may cause pseudoclawing, pain with gripping due to palmar prominence of the head, and dissatisfaction with the final appearance. When correcting dorsal angulation, a corrective osteotomy with a closing wedge may be sufficient in many cases, as the loss of bone length is compensated for by the angle correction.18 Rotational malunion leads to overlapping of the digits. Correction is performed by osteotomy either at the previous fracture site or more proximally.17 Nonunion is rare after hand fractures.

The hardware used for osteosynthesis can lead to several complications. The most common is pin tract infection after percutaneous pinning. In the presence of early signs of infection, a course of antibiotics is administered. If no improvement is observed, removal is the only reasonable treatment to avoid deep infection. Despite the development of thinner and smaller material, plates and screws can cause irritation of the overlying tissues due to their prominence, necessitating their removal. Postoperative scarring may result in tendon adhesions after internal fixation. The indication for extensor tenolysis and dorsal capsulotomy is judged cautiously and should be performed after an interval of at least 3 months to allow for softening of the tissues.17


In order to achieve a functionally and aesthetically satisfactory outcome, it is important to understand not only the anatomical and pathomechanical basis of the injury but also the three-dimensional pattern of the fracture. Recent improvements in the development of osteosynthesis techniques have led to an increase in open approaches to hand fractures. It is in this context that the surgeon must critically compare the advantages of rigid fixation and the potential complications of this method for each specific case. In most cases, the simplest method that will allow adequate reduction and immobilization will have the best outcome. In addition, the period of immobilization should be kept to the minimum so that motion can be restored in a timely fashion.


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18.  Green DP. Complications of phalangeal and metacarpal fractures. Hand Clin. 1986;2:307-328.