I would think that Hand to Hand will be shaped more in perks. Like if you start advancing in a melee skill, a perk for better punching ability will become available. Finally the physic guards are no more!
I have a feeling that if at all, we'll see a New Vegas approach where you can learn Hand-to-Hand moves to make it more useful. The difference of course being that it'll be more for a "Oh *** need to stun this guy and run away" situation than general combat
And then its effectiveness would probably be determined by your strength or something to that effect... thats what I imagined when i read this anyhow. Not much of a problem for me, i dislike hand to hand unless im hunting mudcrabs that start the fight music
which makes me jump and fearful of some hidden enemy, only to find its a little itty bitty mudcrab.
(Payne Note: When typing that i almost posted that i was attacked by headcrabs :P)