Patients Transferred for Upper Extremity Amputation: Participation of Regional Trauma Centers

Epidemiology of adult hand injuries presenting to a tertiary hand surgery unit: a review of 4216 cases

This study investigates the pattern of hand injuries presenting to a UK regional tertiary centre. All referrals to our Hand Surgery Unit in 2019 were reviewed. Subgroup analyses of sex, deprivation, occupational injuries and assault cases were carried out. Over the study period, 4216 cases were referred. Most were male (70%), with a median age of 36 years and from a deprived area (75.2%). Soft tissue injury was documented in 53.6% and bone injury (fracture/dislocation) in 52.4%. Surgical management was required in 2214 (52.5%) cases. Work-related injuries accounted for 16.7% of cases and were more likely to require surgery. Assault-related injuries accounted for 8% of cases, with a male preponderance. Our findings can help facilitate service provision and guide regional and national prevention policies.Level of evidence: III.

The Effect of Joining the ASSH Hand Trauma Center Network on the Volume and Severity of Pediatric Hand Trauma Transfers

Purpose

The purpose of our study was to evaluate how the volume and severity of pediatric hand trauma is affected after enrollment into the American Society for Surgery of the Hand Trauma Center Network.

Methods

We performed a retrospective review using the patient database from our affiliated level-I pediatric trauma center. With this patient database, we compiled all emergent hand trauma transfers from February 2018 to January 2022. We compared the monthly volume, Injury Severity Score, and quarterly payor status between hand trauma transfer patients before and after enrollment into the Hand Trauma Center Network in February 2019.

Results

The average number of monthly transfers increased after joining the Hand Trauma Center Network compared with the years after February 2019. Additionally, the percentage of patients using commercial insurance increased after joining the Hand Trauma Center Network when compared with that before February 2019. Lastly, the percentage of patients using Medicaid decreased after February 2019.

Conclusions

Based on our findings, we believe that new institutions and providers can expect anywhere from a 10% to a 60% increase in hand trauma burden without a significant change in the severity of the trauma cases after joining the network.

Type of study/level of evidence

Prognostic IV.

Advanced Dupuytren Contracture: Approach to Management

Dupuytren disease is a common pathologic condition that can be especially challenging to hand surgeons in recurrent or severe contractures. Recurrence risk may be reduced with a variety of techniques, including skin grafting, external fixator application, radiation, and many others described in this article. Management of recurrence requires special attention to anatomy at risk. Adjuvant therapy may help to prevent the progression or recurrence of severe disease.

Approach to Complex Upper Extremity Reconstruction

The management of complex upper extremity trauma can be overwhelming in its urgency and complexity. Having a systematic approach that maintains a clear set of priorities focused on hand and upper extremity function, operative efficiency, and long-term planning for future operations allows the reconstructive extremity surgeon to effectively treat these complex injuries. This article addressed these overall clinical considerations and details the approach taken at the Buncke Clinic including replantation and revascularization as well as osseous and soft tissue reconstruction.

Hand Trauma Network in the United States: ASSH Member Perspective Over the Last Decade

PURPOSE

Upper extremity trauma is common, however the provision of emergency call for hand trauma can be challenging for hospital systems and hand surgeons. Over the past decade, the American Society for Surgery of the Hand (ASSH) has developed the Hand Trauma Network and an Emergency Hand Care Committee to refine care for hand trauma patients.

METHODS

The ASSH administered surveys to members about the provision of emergency hand call in 2010 and 2019. Demographic information was collected including surgeon age, years in practice, board certification, practice setting, and ACS trauma level. Other survey questions included willingness and obligation to take call, as well as barriers to providing emergency call. Financial aspects of call were also queried.

RESULTS

Survey responses were obtained from 672 surgeons in 2010 and 1005 surgeons in 2019. There was a decrease in surgeons with obligatory hand call from 2010 to 2019 (70% vs 50%, P < .05) and an increase in the number of surgeons not taking hand call in 2019 (34%) compared to 2010 (18%, P < .05). In both surveys, the main barrier for providing hand call was "lifestyle considerations," 39% (2010) and 47% (2019). There was no change in the percentage of surgeons working at facilities that provide 24/7 emergency hand call services or the percentage of hand surgeons paid to take call.

CONCLUSIONS

Certain aspects of providing emergency hand surgery care have not changed substantially in the past decade, including the number of centers that provide emergency hand coverage. A greater number of surgeons are not taking any hand call. Further efforts are required to promulgate advances in hand trauma call by the ASSH.

CLINICAL RELEVANCE

The development of the ASSH Hand Trauma Network has not yet resulted in substantive improvement in the number of facilities that provide emergency hand coverage or the number of hand surgeons providing emergency hand care.

Comparing Plastic Surgeon Versus Orthopedic Surgeon Outcomes Following Distal Upper Extremity Amputations: A Study of the National Surgical Quality Improvement Program (NSQIP) Database

BACKGROUND

Both plastic and orthopedic surgeons manage care for urgent/emergent hand conditions. It is unclear if surgeon specialty affects patient outcomes of these cases. The purpose of this study was to evaluate differences in 30-day perioperative outcomes between plastic and orthopedic surgeons following distal upper extremity amputations.

METHODS

Patients who underwent distal upper extremity amputations between 2005 and 2016 were identified within the National Surgical Quality Improvement Program (NSQIP) database using Current Procedural Terminology (CPT) codes. Differences in operative procedures, patient demographics, patient comorbidities, and 30-day perioperative complications were compared between orthopedic and plastic surgeons by univariate analysis. A Bonferroni correction was applied to account for multiple comparisons of complications.

RESULTS

A total of 1583 cases met inclusion criteria. Orthopedic surgeons performed 981 cases (62.0%) and plastic surgeons performed 602 cases (38.0%). Finger amputations comprised the majority of procedures for both orthopedic and plastic surgeons (95.5% and 94.4%, respectively). Orthopedic surgeons had a lower operative time (41.7 ± 36.2 minutes vs 47.1 ± 40.9 minutes, P = .008). There were no differences in proportion of emergency surgery, inpatients, or wound class. There were no differences in age, gender, or body mass index. The most common indications for amputation were trauma, gangrene, and osteomyelitis. There were no differences between surgical specialties in 18 30-day perioperative complications assessed, including death, reoperation, surgical site infection, or wound dehiscence.

CONCLUSIONS

Plastic and orthopedic surgeons achieved equivalent outcomes comparing 30-day perioperative complications following upper extremity amputations. These results support that both orthopedic and plastic surgeons provide similar quality distal upper extremity amputation care.

Efficiency in Replantation/Revascularization Surgery

Digital replantation and revascularization have evolved significantly since the first published reports in the 1960s. Advances in techniques and instruments have made these once formidable procedures a routine part of hand surgery training. Despite this, the frequency of successful outcomes for replantation may be on the decline in the United States. This review summarizes key mechanisms and innovations used to maximize efficiency when presented with a digital replantation, from the moment the patient arrives in the emergency department until the time of discharge.

A Decade of Progress Toward Establishing Regional Hand Trauma Centers in the United States

Although upper extremity amputations have become less common in the workplace because of improvements in safety and equipment, the American health system's ability to provide emergent microvascular care for these injuries remains highly fragmented, inconsistent, overburdened, and at times unavailable. Over the past decade, hand surgeons have worked to improve this disparity within health systems. This article discusses the need for emergent microsurgical treatment, barriers encountered in improving access to care, and a description of current and future efforts of developing a sustainable network of highly specialized regional hand trauma centers.