When it comes to hand injuries, do you know what to tackle yourself, when to call the orthopedist or general plastic surgeon, and when to call a hand surgery specialist? ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with hand surgeon Scott D. Lifchez, MD, FACS, to shed some light on these questions and to explore the professional relationship between emergency physicians and hand surgeons.
Dr. Lifchez is associate professor of plastic surgery and orthopedic surgery, program director of the Johns Hopkins/University of Maryland plastic surgery residency program, and director of hand surgery at Johns Hopkins Bayview Medical Center in Baltimore. He’s also a member of the American Society for Surgery of the Hand (ASSH), the biggest national organization of hand surgeons in the United States, with about 2,500 to 3,000 active members who are certified in the subspecialty of hand surgery.
Here are some highlights from their conversation.
KK: What is the short list of those things that really need your level of expertise that can’t be handled by the general orthopedist or the general plastic surgeon?
SL: The obvious lead one would be digital amputations. For the most part, the generalists don’t do that or wouldn’t feel comfortable doing that. Some things that might be better treated by a hand surgeon are necrotizing infections of the hand and compartment syndromes of the hand. While in theory a hand surgeon might be better at handling them, the acuity may not allow enough time for the patient to get to the hand surgeon or the hand surgeon to get to the patient. Mangling injuries involving multiple tendons and/or multiple bones of the forearm, wrist, or hand are things that typically the general plastic surgeon or orthopedist is going to correctly say, “That’s beyond what I can do.”
KK: What about other specialized types of fractures, like Bennett’s or Rolando’s?
SL: Those often do not need to take a helicopter ride in the middle of the night. Those of the carpometacarpal (CMC) joint, Bennett, Rolando, perilunate injuries, and scaphoid injuries are probably best served by somebody with hand expertise. It gets a little contentious when we start talking about the distal radius. Hand surgeons generally believe that we do the best job, but orthopedists, or especially orthopedic traumatologists, will rightly say, “We take care of the most of these in the US, and we do a good job.” There’s some overlap, but I would agree that certain carpal bone injuries, especially those needing surgery and CMC joint injuries, often do need a hand surgeon.