Hand Surgeons versus Orthopaedic Trauma Surgeons Coverage of Upper Extremity Injuries: Where Should the Line be Drawn?
Andrew Miller, MD; Matt Cantlon, MD; Asif Ilyas, MD
Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA
INTRODUCTION: Currently, there is no clear consensus as to which consulting service should provide care for hand and upper extremity injuries. To better understand how upper extremity injuries in the emergency department (ED) are currently triaged to specialists and to assess the current opinion among hand and orthopaedic trauma specialists as to fwho is best to triage these injuries, a survey was constructed with the hypothesis that there would be no consensus.
METHODS: The American Association for Hand Surgery (AAHS) membership and Orthopaedic Trauma Association (OTA) membership were surveyed using an online questionnaire. The questionnaire included 16 demographic questions and 12 clinical scenarios designed to elicit opinion on how upper extremity injuries should be triaged to specialists based on injury location, type, and severity. Confounding injuries in addition to the fracture were also included such as nerve injury, vascular injury, and infection.
RESULTS: A total of 103 responses from the AAHS and 114 responses from the OTA were received. Nearly 50% of respondents report no formal anatomic line as to how upper extremity injuries are currently triaged to specialists from the ED. 31% of the AAHS participants stated that hand call should begin at the level of the distal radius, followed by 20% indicating that call should begin at the level of the forearm. 51% of the OTA respondents indicated hand call should begin at the radio-carpal joint followed by 20% indicating call should begin at the carpal-metacarpal joint. There was strong agreement among respondents of both groups that trauma surgeons should be called for injuries at the level of the elbow or more proximally. Also, there was increasing agreement among respondents that complex injuries involving neurovascular compromise be better assigned to hand call regardless of location of the injury.
CONCLUSION: There is agreement that proximal to the elbow the trauma consultant should be called and distal to the distal radius the hand consultant should be called. However, there is lack of agreement between members of both the AAHS and OTA who should be responsible for call between the elbow and the hand. However, when a fracture was associated with a neurovascular injury is present there was a bias for the hand surgeon to be consulted. In order to optimize patient care, better allocate consultant resources, and minimize conflict between consultants, establishing anatomic guidelines for consultation should be considered while also taking into account available consultant resources and expertise.
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