Carpal fractures and injuries of carpal ligaments are commonly seen as consequences of severe combined hand injuries. Adequate initial surgical management is essential for optimal functional outcome. Early repair of functionally relevant carpal structures is advocated and even partial or complete wrist arthrodesis might be indicated in this phase. Also, repair of injured blood vessels, nerves and tendons as well as reconstruction of soft tissue defects that might accompany the carpal injury is mandatory. Ideally, the initial surgical management allows for early physical therapy. These severe injuries should be primarily referred to specialized centres that also possess adequate facilities for physical and occupational therapy. Occupational rehabilitation after severe combined hand injuries is of great importance and requires specialized counselling.