Hand Surgery Specialists Research Articles

The Burden, Challenges, and Prospects of Hand Surgery Practice in South Eastern Nigeria

Abstract Background: Hand injuries sometimes cause significant loss of function with psychological and functional consequences. The national status on dedicated specialised hand surgery units, hand surgery fellowship programmes, and outcome of operative hand surgery cases is generally lacking. Aims: To determine the current state of hand surgery practice in south eastern Nigeria and identify the major challenges to its practice and proffer realistic solutions. Methods: This was a prospective and cross-sectional study conducted amongst accredited hospitals for plastic surgery training in south eastern Nigeria amongst plastic surgery senior residents. Data were collected using a well-structured online questionnaire validated by a panel of investigators created as a Google form. Data analysis was carried out using Statistical package for Social Sciences by IBM, version 22. Ethical approval was obtained from the health, research, and ethical committee of the University of Enugu Teaching Hospital, Enugu, Nigeria. Results: There was a 70.59% response rate with 24 residents filling and submitting the questionnaire. Lack of fellowship training opportunities in hand surgery represents the most important challenge of hand surgery practice, followed by lack of appropriate facilities in government institutions in contrast to a lack of funding in private ones. Other major challenges include lack of adequate funding, lack of facilities, late presentation of cases, and lack of appropriate follow-up physiotherapy protocol. Availability of competent hand surgery specialists was significantly correlated with the frequency of hand surgery cases in the facilities (P = 0.000; χ2 = 20.400). Conclusion/Recommendation: The current state of hand surgery practice in south eastern Nigeria is not yet optimal. The creation of more hand fellowship trainings and courses bagged first place in recommended solutions by nearly half of the respondents. Provision of modern facilities, creation of dedicated hand surgical units, and better funding to the specialty were other suggestions.

Consultations for Poland Syndrome: The Essentials for a Thoracic Surgeon.

Poland syndrome (PS) is a rare congenital musculoskeletal entity occurring in approximately 1 in 30,000 newborns that manifests with variable symbrachydactyly, ipsilateral costochondral deformities, an absence of pectoral muscles, and breast underdevelopment. These have potential impacts on social, somatic, and psychological functionality, often leading affected individuals to seek expert opinions on corrective surgery. Due to phenotypic variability, strict management guidelines are lacking, with treatment decisions often based on the specialist's personal experience rather than published evidence. Comprehensive imaging with CT and MRI with 3D reconstruction is crucial for providing a descriptive assessment of musculoskeletal defects. Management is multidisciplinary, involving thoracic, plastic, and pediatric surgeons and hand surgery specialists, as well as psychologists and developmental growth specialists. Surgery should achieve both structural and cosmetic correction to reverse the psychological and social impact and achieve patient satisfaction. We aim to provide thoracic surgeons the essential answers for sharing with affected adult individuals during consultations focusing on chest surgical correction.

International Experience with Glomus Tumours: An Algorithm to Improve Diagnostic Accuracy

Background Glomus tumours are benign tumours which most frequently affect the upper extremities, often the subungual regions of the digits. The classic triad of presenting symptoms include cold hypersensitivity, point tenderness and paroxysmal pain. The absence of a visible lesion or a lack of a complete triad of symptoms, renders these lesions notoriously difficult to diagnose. The aim of this study is to analyse the referral pathways and misdiagnosis rates in relation to management of upper limb glomus tumours at our institution and compare this to the international experience. Methods We conducted a retrospective review of all glomus tumours treated at our institution over a twenty year period. Medical records, radiological imaging and histopathology reports were reviewed to identify patient, disease and treatment-related factors. A literature review of published case series of upper limb glomus tumours was performed to assess referral pathways, management and misdiagnosis rates. Results Twenty three upper limb glomus tumours were treated at our institution between 2000 and 2022. The mean age of diagnosis was 52.56 years (27-63 years) with a male preponderance 17/23 (74%). The overall rate of misdiagnosis was 70% based upon histological request forms at the time of surgery. The lowest rates of misdiagnosis were associated with management by hand surgery specialists. Eight published case series were identified in the literature with misdiagnosis a common phenomenon. Referral to hand surgeons appears to improves diagnostic accuracy. We present an evidence-based algorithm to recommend optimal management which may guide clinicians and improve patient outcomes.

Plastic Surgeon versus Orthopedic Surgeon: Where Would You go for Your Hand Injury? A Cross-Sectional Study in Saudi Arabia.

Background Hand surgery has become a well-established medical specialty in recent years, with many highly trained hand surgeons practicing in various cities throughout Saudi Arabia. It is crucial to assess the public's knowledge and awareness regarding hand surgery specialists and to identify the existence of bias in the public's perception of plastic and Orthopedic surgeons. Methods A self-administered questionnaire was designed and disseminated to adults in Saudi Arabia via Google Forms. The questionnaire addressed participants' knowledge about which type of surgeon they would consult for various hand-related issues. Results A total of 716 participants were surveyed. Most believed Orthopedic surgeons were more qualified for hand surgeries than plastic surgeons. Furthermore, the public seemed to feel safer with Orthopedic surgeons regarding complications. There was a misconception regarding plastic surgeons' qualifications, with only 24.4% recognizing that all plastic surgeons could perform hand surgery. The majority also held misconceptions regarding Orthopedic surgeons' qualifications for hand surgery. Gender and educational level influenced the responses, with females and those with bachelor's degrees or higher showing slightly more knowledge. Conclusion There is a need for increased public awareness and education regarding the qualifications and capabilities of both plastic and Orthopedic surgeons in hand surgeries. Both specialties are well-trained and competent in this area, and the choice should be based on the specific needs and circumstances of the patient.

The Effect of Timing Between Traumatic Flexor Tendon Injury of the Hand and Surgical Intervention on Repair Failure Rates.

Flexor tendon injuries of the hand, especially in zone II, pose a challenge for hand surgeons because of the region's intricate pulley mechanism and local avascularity, and post-surgical complications such as repair failure are not uncommon. One proposed predictor of outcomes following flexor tendon repair has been timing of surgery from initial injury. However, the effect of the timing of flexor tendon repair on failure rates remains controversial and understudied. The purpose of this study was to compare the failure rates of zone II flexor tendon repairs in patients at various time intervals from onset of injury. A retrospective chart review was conducted using data from hand surgery specialists at our level 1 trauma center from January 1, 2010, through May 31, 2020. This retrospective review included 407 zone II flexor tendon repairs. The primary outcome was failure of repair. Among 407 flexor tendon repairs, there were 12 reported repair failures. The failure rate was 2.9%. In the non-failure group, the mean number of days between the date of injury and the date of surgery was 7±13 days. For the failure group, this value was 14±17 days. Repairs occurring within 14 days had a failure rate of 2.3%, while repairs occurring beyond 14 days had a failure rate of 7.7%. This study demonstrates that there is a benefit to repairing the tendon within a 14-day window, as evidenced by a lower failure rate. More research is required to determine if other complications and overall health of the hand are also improved when a repair is performed in a more expedient manner. [Orthopedics. 2024;47(2):113-117.].

Trends in Open vs. Endoscopic Carpal Tunnel Release: A Comprehensive Survey in Japan.

We analyzed trends in open and endoscopic carpal tunnel release (CTR) from 2014 to 2019 using the National Database of Health Insurance Claims and Specific Health Checkups in Japan (NDB). Japan has a universal health insurance system and more than 95% of all claims are searchable in the NDB open data repository. The results revealed that nearly 40,000 CTRs were performed annually in Japan, and open CTR was performed almost 4 times more often than endoscopic CTR. The crude annual incidence of CTR in the general population among people 20 years of age or older was 32.2 per 100,000. The incidence of open CTR peaked in the 80–84 age range for both males and females. The incidence of endoscopic CTR peaked at 80–84 years in females and at 75–79 years in males. There was a mild correlation coefficient between the endoscopic CTRs and the number of hand surgery specialists by prefecture per population (r = 0.32, p = 0.04). However, the number of hand surgeons per capita by region and open CTR per capita was not correlated (r = 0.06, p = 0.67). There were about twice as many outpatient as inpatient surgeries, reflecting a trend toward ambulatory treatment.

A National Survey of Hand Surgeons: Understanding the Rural Landscape.

Twenty percent of the US population is described as being rural and may have limited access to hand surgeons, especially on an emergency basis. Little is known about case type, call hours, employment status, and other relevant details of rural hand surgery. We surveyed members of the American Society of Surgery for the Hand to begin to describe the problem. There were 471 responses from 2256 members surveyed with 387 completing 100% of questions asked. Ninety (19%) identified themselves as primarily located in a rural population and 381 (81%) in a metropolitan region. In our study, rural hand surgeons were more likely to be employed by a community hospital, followed by independent private practice, multispecialty group, academics, and then locum tenens. Rural surgeons' practices were 80% solely hand surgery, while metropolitan surgeons' practices were 89% (P < .01). Metropolitan surgeons felt that of the transfers from rural facilities, 46% did not need emergency hand care and that 60% of the time, there was not actually a need for specialty hand surgery care. Our survey begins to shed light on the details of rural hand surgery practice. We found that rural surgeons are more likely to be employed in community hospitals and take more call. When available, hand surgery specialists could prevent unnecessary transfer of patients to metropolitan areas. More work needs to be done to describe the differences between rural and metropolitan hand surgery practices as well as create rural hand surgeons.

Treatment of acute injuries of the hand

Treatment of acute injuries of the hand Abstract. Injuries to the hand are a common presentation in primary care units. When accurately assessed, many open injuries may be handled in the emergency department without referral to a hand surgery specialist. We would like to give some recommendations on how to treat the most frequent injuries like lesions to the nail and nailbed, fingertip amputation as well as burns, infections and bites. But first, we highlight the different methods of local anesthesia and discuss the use of a tourniquet or vasoconstriction with adrenalin - WALANT - instead.

Factors Influencing Bone Union in Finger Distal Interphalangeal and Thumb Interphalangeal Joint Arthrodesis.

Background: Finger joint arthrodesis is a common operation which has many indications including acute trauma, post traumatic condition, osteoarthritis, and rheumatoid joint deformity. The objective of this study was to evaluate factors which may influence bone union in arthrodesis of the distal interphalangeal (DIP) joint of the fingers and interphalangeal (IP) joint of the thumb. Methods: A total of 310 arthrodesis (221 finger DIP and 89 thumb IP joint) were analysed retrospectively. We used variables related to the patient and to the operative technique in univariable and multivariable regression analysis. Outcome events were bone union within 90 days, established non-union, infection and re-operation. Results: Of the 310 operations 280 resulted in a favourable outcome while 30 resulted in bone non-union. In the univariable analysis the most important negative predictor variable for bone non-union was an operation done by other than hand surgery specialist (OR = 3.75, 95% CI = 1.727-8.140, p = 0.001), which also predicted the indication for re-operation (OR = 4.705, 95% CI = 1.563-14.163, p = 0.006). Because of insufficient event rate of bone non-union multivariable analysis was not possible for bone non-union. In the multivariable analysis rheumatoid arthritis had negative influence on bone union within 90 days (OR = 0.45, 95% CI = 0.219-0.925, p = 0.03) and none of the variables predicted infection. Conclusions: In our cohort finger DIP and thumb IP joint arthrodesis generally resulted in favourable outcome in terms of bony union regardless of the underlying medical condition or technical details of the surgical operation. Overall the results emphasize the importance of adequate surgical skill and practice even with a simple surgical operation.

The Patient and Observer Scar Assessment Scale: Translation for portuguese language, cultural adaptation, and validation.

Evaluating scars is fundamental to analyse the outcome of treatments that include surgical intervention. Scales facilitate this type of assessment, but most of these measuring instruments are in different languages. The Patient and Observer Scar Assessment Scale (POSAS) is one of the most robust instruments available in the literature for the evaluation of scars, although there is no validated version in Brazilian Portuguese. The aims of this study were to culturally translate and validate POSAS for the Portuguese language of Brazil and to test its reproducibility, face validity, content, and construct. Following the methodology proposed by Beaton DE, Bombardier C, Guillemin F, Ferraz, MB, Spine 2000, 25, 3186, the questionnaire was translated and adapted to the Brazilian culture. The reproducibility, face, content, and construct validity were then analysed. In all, the scale was applied to 35 patients with postoperative scars (patient version) and 35 hand surgery specialists (version for the observer). The internal consistency was tested by Cronbach's alpha, and construct validation was performed by correlating the translated instrument with the Brazilian Portuguese translation of the Vancouver Scar Scale (VSS). The cultural adaptation of POSAS Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP) was confirmed. Both subscales showed strong internal consistency (Cronbach's α = 0.77-0.93), demonstrating reliability. The reproducibility was excellent, and the adapted scale demonstrated significant intra- and inter-observer reproducibility (r > 0.9) (P < 0.05). The validity of the construct was significant and showed good sensitivity between POSAS EMP/UNIFESP and the VSS. This study confirmed that POSAS EPM/UNIFESP can be used to evaluate patients with surgical scars in the Brazilian population. It has proven to be useful for clinical and research purposes, lending itself to capturing medical opinions and those of the patients themselves.

A Tablet-Based App for Carpal Tunnel Syndrome Screening: Diagnostic Case-Control Study.

BackgroundCarpal tunnel syndrome (CTS), the most common neuropathy, is caused by a compression of the median nerve in the carpal tunnel and is related to aging. The initial symptom is numbness and pain of the median nerve distributed in the hand area, while thenar muscle atrophy occurs in advanced stages. This atrophy causes failure of thumb motion and results in clumsiness; even after surgery, thenar atrophy does not recover for an extended period. Medical examination and electrophysiological testing are useful to diagnose CTS; however, visits to the doctor tend to be delayed because patients neglect the symptom of numbness in the hand. To avoid thenar atrophy-related clumsiness, early detection of CTS is important.ObjectiveTo establish a CTS screening system without medical examination, we have developed a tablet-based CTS detection system, focusing on movement of the thumb in CTS patients; we examined the accuracy of this screening system.MethodsA total of 22 female CTS patients, involving 29 hands, and 11 female non-CTS participants were recruited. The diagnosis of CTS was made by hand surgeons based on electrophysiological testing. We developed an iPad-based app that recorded the speed and timing of thumb movements while playing a short game. A support vector machine (SVM) learning algorithm was then used by comparing the thumb movements in each direction among CTS and non-CTS groups with leave-one-out cross-validation; with this, we conducted screening for CTS in real time.ResultsThe maximum speed of thumb movements between CTS and non-CTS groups in each direction did not show any statistically significant difference. The CTS group showed significantly slower average thumb movement speed in the 3 and 6 o’clock directions (P=.03 and P=.005, respectively). The CTS group also took a significantly longer time to reach the points in the 2, 3, 4, 5, 6, 8, 9, and 11 o’clock directions (P<.05). Cross-validation revealed that 27 of 29 CTS hands (93%) were classified as having CTS, while 2 of 29 CTS hands (7%) did not have CTS. CTS and non-CTS were classified with 93% sensitivity and 73% specificity.ConclusionsOur newly developed app could classify disturbance of thumb opposition movement and could be useful as a screening test for CTS patients. Outside of the clinic, this app might be able to detect middle-to-severe-stage CTS and prompt these patients to visit a hand surgery specialist; this may also lead to medical cost-savings.

HOW DO BOARD-CERTIFIED HAND SURGEONS MANAGE CARPAL TUNNEL SYNDROME? A NATIONAL SURVEY.

ABSTRACTObjective:To evaluate tendencies in the planning, diagnosis, and treatment of carpal tunnel syndrome (CTS) by Brazilian hand surgery specialists. Methods:This cross-sectional study was performed at the 36th Brazilian Hand Surgery Congress. We prepared a questionnaire about preferences in the management of CTS, and board-certified hand surgeons that attended the congress were asked to fill out the questionnaires. A total of 174 questionnaires were analyzed. Results:Electromyography examination is used by most surgeons. Night splinting is the most commonly used conservative treatment option. Half of the surgeons utilized prophylactic antibiotics. Most of the interviewees conduct inpatient surgery in the operating room and prefer intravenous regional anesthesia. Most of surgeons use the standard open technique associated with proximal release of the antebrachial fascia and do not perform neurolysis. Compressive dressings are most commonly used for 7 days. Conclusion:The approach to CTS among Brazilian hand surgeons with regard to pre-, intra-, and post-operatory conduct is consistent with the international literature. However, there is a need to reflect and conduct new studies on non-surgical treatment involving local corticosteroid injection, use of prophylactic antibiotics, hospital admission, and type of anesthesia in order to provide more cost-effective approach to surgical treatment for CTS. Level of Evidence V; Expert opinion.

Nerve Grafting is a New Treatment Option for Stroke Patients

Recently, New England Journal of Medicine published an article by the famous hand surgery specialists, Yudong Gu. The important medical achievements of Gu's team include transposition of C7 nerve root of the unaffected side on the upper limbs in stroke hemiplegia, changing the brain central dominance region, and rebuilding the function of hands with spastic paralysis. These achievements are admirable because worldwide medical problems, such as stroke sequela hemiplegia, require long-term arduous efforts for any progress to be made. Any result that improves the survival quality of patients has significant social value. Their success has enabled me to feel that I am no longer alone in my years of exploration, and I am grateful to them from the bottom of my heart. At this time, I am reminded of the 40 years of my experience in this field. It has taken the efforts of many people to make this happen: Limb sequelae of stroke, especially spasmodic paralysis of upper limbs, often result in patients losing their ability to self-care, which can cause a great burden to their family and society. The need to rebuild and improve functions in such patients is urgent.

Plastic surgeons as hand surgery specialists: determinant factors of public's perceptions

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Nerve grafting is a new treatment option for stroke patients

Recently, New England Journal of Medicine published an article by the famous hand surgery specialists, Yudong Gu. The important medical achievements of Gu's team include transposition of C7 nerve root of the unaffected side on the upper limbs in stroke hemiplegia, changing the brain central dominance region, and rebuilding the function of hands with spastic paralysis. These achievements are admirable because worldwide medical problems, such as stroke sequela hemiplegia, require long-term arduous efforts for any progress to be made. Any result that improves the survival quality of patients has significant social value. Their success has enabled me to feel that Ⅰ am no longer alone in my years of exploration, and Ⅰ am grateful to them from the bottom of my heart. At this time, Ⅰ am reminded of the 40 years of my experience in this field. It has taken the efforts of many people to make this happen: Limb sequelae of stroke, especially spasmodic paralysis of upper limbs, often result in patients losing their ability to self-care, which can cause a great burden to their family and society. The need to rebuild and improve functions in such patients is urgent.

A case study and literature review of surgical treatment for brachial plexus pain caused by Pancoast syndrome

&lt;span&gt;This study reports the diagnosis and treatment of brachial plexus-associated intractable pain cause&lt;/span&gt;&lt;span lang="EN-MY"&gt;d&lt;/span&gt;&lt;span&gt; by Pancoast syndrome, along with the associated literature review, based on a patient we attended to in April 2011. A full examination was performed after his admission, and neurolysis was conducted on the right brachial plexus of lower trunk. Follow-ups and treatment evaluations were carried out 1, 2, 3, and 6 months after the initial neurolysis procedure, which was followed by a radiation therapy two months later. The patient’s pain symptoms were relieved and he partially regained sense awareness and movement of his right hand. We found that early clinical manifestations of Pancoast syndrome are atypical and are sometimes difficult to detect. It is very similar to brachial plexus injury-related pain, and the patient must be referred to an orthopaedics or hand surgery specialist for treatment. Therefore, improving medical practitioners’ general understanding &lt;/span&gt;&lt;span lang="EN-MY"&gt;of&lt;/span&gt;&lt;span&gt; this disease is essential in order to avoid potential misdiagnoses.&lt;/span&gt;

Medical Student Perceptions of Plastic Surgeons as Hand Surgery Specialists

Plastic surgeons are often not perceived as hand surgery specialists. Better educating medical students about the plastic surgeon's role in hand surgery may improve the understanding of the field for future referring physicians. The purposes of this study were to assess medical students' understanding of hand surgery specialists and to analyze the impact of prior plastic, orthopedic, and general surgery clinical exposure on this understanding. An online survey including 8 hand-related clinical scenarios was administered to students at a large academic medical center. After indicating training level and prior clinical exposure to plastic surgery or other surgical subspecialties, students selected one or more appropriate surgical subspecialists for management of surgical hand conditions. A response rate of 56.4% was achieved. Prior clinical exposure to plastic, orthopedic, and general surgery was reported by 29%, 43%, and 90% of fourth year students, respectively. Students generally chose at least 1 acceptable specialty for management of hand conditions with improvement over the course of their training (P = 0.008). Overall, students perceived orthopedic surgeons as hand specialists more so than plastic and general surgeons. Clinical exposure to plastic surgery increased the selection of this specialty for nearly all scenarios (22%-46%, P = 0.025). Exposure to orthopedic and general surgery was associated with a decrease in selection of plastic surgery for treatment of carpal tunnel and hand burns, respectively. Medical students have a poor understanding of the plastic surgeon's role in hand surgery. If plastic surgeons want to continue to be recognized as hand surgeons, they should better educate medical students about their role in hand surgery. This can be achieved by providing a basic overview of plastic surgery to all medical students with emphasis placed on hand and peripheral nerve surgery.

Hand Injuries in the State of Florida, Are Centers of Excellence Needed?

Hand injuries are common and costly. The need for hand surgery specialists is undeniable. In the state of Florida, the availability of specialty services in hand surgery is limited. Florida ranks 4th in population and 32nd in hand surgeons per 100,000 state residents. Recent media reports highlight these limitations among hand surgeons and other specialists in the state. To evaluate the need for hand surgery centers of excellence in the state, we performed a retrospective review of data collected from the Agency for Health Care Administration database of hospital inpatient admissions from 1997 to the second quarter of 2007. Demographic information, details of the injury, and outcome data were evaluated in patients with amputation injuries. Amputations of the thumb, fingers, and hand/wrist/forearm were counted and factors associated with these injuries were recorded. Place of occurrence and injuries caused by machinery were evaluated. A regression analysis was performed to evaluate trends in the number of amputations and replantation procedures. We identified 4,858 patients with amputations in this time period. There were approximately 462 amputations per year. The trend in finger amputations appeared to be increasing yearly, whereas the trend for replantation surgery was decreasing. Six percent of the hospitals recording admissions with the Agency for Health Care Administration performed 68% of the replantation surgeries in the state. We also noted an increasing proportion of patients being admitted and treated outside of their own county and region. With fewer replantation surgeries performed and patients traveling farther for treatment we conclude that there is a need for coordinated evaluation, triage and treatment of patients with hand injuries requiring specialized hand surgery services at centers of excellence in Florida.

Are distal radius fracture classifications reproducible? Intra and interobserver agreement.

Various classification systems have been proposed for fractures of the distal radius, but the reliability of these classifications is seldom addressed. For a fracture classification to be useful, it must provide prognostic significance, interobserver reliability and intraobserver reproducibility. The aim here was to evaluate the intraobserver and interobserver agreement of distal radius fracture classifications. This was a validation study on interobserver and intraobserver reliability. It was developed in the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina. X-rays from 98 cases of displaced distal radius fracture were evaluated by five observers: one third-year orthopedic resident (R3), one sixth-year undergraduate medical student (UG6), one radiologist physician (XRP), one orthopedic trauma specialist (OT) and one orthopedic hand surgery specialist (OHS). The radiographs were classified on three different occasions (times T1, T2 and T3) using the Universal (Cooney), Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF), Frykman and Fernández classifications. The kappa coefficient (kappa) was applied to assess the degree of agreement. Among the three occasions, the highest mean intraobserver k was observed in the Universal classification (0.61), followed by Fernández (0.59), Frykman (0.55) and AO/ASIF (0.49). The interobserver agreement was unsatisfactory in all classifications. The Fernández classification showed the best agreement (0.44) and the worst was the Frykman classification (0.26). The low agreement levels observed in this study suggest that there is still no classification method with high reproducibility.

Limited-Incision Carpal Tunnel Release

Hand Surgery Specialists, Ltd., Richmond, Virginia, U.S.A. (BOWERS) Greenstein, Baitch, Saltzman, Matz, P.A. Pikesville, Maryland, U.S.A. (BERNER) Address correspondence and reprint requests to Dr. William H. Bowers, Hand Surgery Specialists, Ltd., 7650 East Parham Road, Richmond, Virginia, 23294, U.S.A.