A qualified hand surgeon is a licensed surgeon who is trained to diagnose and treat injuries to and disorders of structures in the hand, wrist, and forearm. Hand surgeons treat all hand injuries, even those that do not require surgery. Most hand surgeons also diagnose and treat injuries and disorders of the shoulder and elbow as well. Hand surgeon is a general term – hand surgery is performed by orthopedic, plastic, or general surgeons with specialized training in hand injuries.
A hand surgeon may treat hand issues with physical therapy and pain management, in addition to surgical procedures when needed. Carpal tunnel, wrist pain, tennis elbow, sports injuries, fractures, and trigger finger are all examples of injuries that are commonly treated by hand surgeons. Arthritis, nerve and tendon injuries and congenital limb defects are also treated by surgeons specializing in treatment of the hand.
Anatomy of the Hand
The hand is a complex and intricate structure made of bones, joints, ligaments, tendons, muscles, nerves, skin, and blood vessels, which must all remain healthy for the hand to maintain its proper functions without pain or discomfort. A hand surgeon must have precise knowledge of hand anatomy and how each part works together. While there are many disorders that can affect the function of the hand, the most common issues occur from traumatic injury.
The hand is comprised of 27 bones, with three main nerves (median, ulnar, and radial) with their own unique sensory and motor functions, while the muscles are divided into intrinsic and extrinsic categories. The 27 bones are categorized into carpals, metacarpals and phalanges. The wrist is the most complex joint in the body, with 8 carpal bones grouped into two rows with very restricted motion between them (Wilhelmi, 2016). Because of the structure of the wrist, it is vulnerable to injuries, particularly fractures.
Bones
There are 5 metacarpal bones in the hand, and each has its own base, shaft, neck and head. The thumb is a metacarpal bone, and it is also the shortest and has the most mobility of all the hand bones. There are 14 phalanges, and each finger has 3 phalanges (proximal, middle and distal), while the thumb has only 2 phalanges.
Skin
The dorsum (top of the hand) skin is different than the skin of the palmar, or palm, region of the hand. Dorsum skin is thin and pliable, and it attached to the hand’s skeleton only by loose areolar tissue, where lymphatics and veins course (Wilhelmi, 2016). Because of the loose skin, the dorsum is susceptible to skin injuries and the creation of flaps.
The palmar surface of the hand is unique, with characteristics for special function (Wilhelmi, 2016). The skin on the under-side of the hand is thicker than the skin on the top of the hand, and is strongly attached to the skeleton of the hand by many fibers. The strongest connections are at the creases in the palm, which is important for hand surgeons, because these are the areas for incision during surgery. Palmar skin allows for stability and is perfect for grasping, and it has a high concentration of sensory nerve organs that are essential to the hand’s normal function (Wilhelmi, 2016).
Nails
The nails are specialized skin appendages derived from the epidermis, and the nail bed has a germinal matrix, sterile matrix and hyponychium (Wilhelmi, 2016). The germinal matrix produces most of the nail plate, and the sterile matrix is vascular and is responsible for the pink color under the nail plate. The sterile matrix gives the nail its strength and its adherence to the nail bed. Resisting infection is the main function of the hyponychium, and it also has a role in the strength of the adherence of the nail plate to the nail bed.
Palmar Fascia
The palmar fascia runs vertically down the top of the hand, and it is made of tough fibers and tissues that are arranged in longitudinal, transverse, oblique and vertical fibers. The longitudinal fibers originate at the wrist and spread out to the base of each of the fingers and the thumb. This design allows the movement of each digit. The transverse fibers are concentrated in the mid palm and web spaces, and they are closely associated with the longitudinal fibers and serve as pulleys for the flexor tendons proximal to the digital pulleys (Wilhelmi, 2016). The vertical fibers of the palmar fascia attach to the dermis of the palmar skin. Deep to the longitudinal and transverse fibers, the vertical fibers coalesce into septa and attach to the metacarpals, forming 8 different compartments for the flexor tendons and neurovascular bundles of each digit (Wilhelmi, 2016).
Nerves
As mentioned previously, the three nerves in the hand are the median, ulnar, and radial nerves and they each have their own unique sensory and motor functions. The median nerve is responsible for innervating the muscles involved in the fine precision and pinch function of the hand. It originates from the lateral and medial cords of the brachial plexus (Wilhelmi, 2016). The ulnar nerve originates at the medial cord of the brachial plexus, and it runs through muscles involved in the power and grasping hand functions. The radial nerve is involved in wrist extension, working to control and stabilize the position of the hand. This nerve originates from the posterior cord of the brachial plexus.
Muscles and Tendon
The intrinsic and extrinsic muscles have different locations within the hand and arm. The intrinsic muscles are within the hand itself, while the extrinsic muscles are located in the forearm, connected to the hand by tendons. Extrinsic muscles have a significant role in extension and flexion of the hand, while the intrinsic muscles work during grasping functions.
History of Surgery
The history of surgery before the use of anesthesia is a brutal one. Although it did save lives, it was extremely painful with a high risk of infection. Eye surgeries and amputations were done while the patient was wide awake, with nurses or other assistants holding the patient down. Other surgeries, such as those in the abdominal area were almost always fatal. Due to lack of anesthesia, surgeons chose speed over precision and accuracy, so there were many complications that could occur.
The crucial spark of transformation — the moment that changed not just the future of surgery but of medicine as a whole — was the publication on November 18, 1846, of Henry Jacob Bigelow's groundbreaking report, “Insensibility during Surgical Operations Produced by Inhalation” (Bigelow, 1846). In his writing, Bigelow described how a dentist administered a gas to his patients which made them insensitive to pain. The dentist, however, had patented his discovery and wanted to keep it a secret. Bigelow offered that he could smell ether in the gas, and this led to the development of ether anesthesia, which revolutionized surgery.
A New Era
Surgeons soon found, however, that anesthesia allowed them to perform more complex, invasive, and precise maneuvers than they had dared to attempt before (Gawande, 2012). Within 10 years of this discovery, the first successful hysterectomy and removal of ovarian cysts were documented, and other effective anesthetics were discovered, including nitrous oxide, chloroform and halothane, while narcotics such as laudanum were used for pain relief post-surgery.
Infection was still a major challenge for surgeons, with nearly 50% of abdominal surgeries resulting in sepsis. In 1867, Joseph Lister wrote a series of articles depicting his use of carbolic acid as an antiseptic, although it was disregarded by most. Lister based his treatment on the theories of Louis Pasteur. During this time period, surgeons may wear the same overcoat for all surgeries, and it was never washed. Hand washing and hygiene were not common. Some surgeons, however, especially younger ones, began accepting the diligence required for aseptic and antiseptic practice, which led them to unimagined treatments and discoveries (Gawande, 2012).
In 1868, the first successful gallbladder operation was performed by John Stough Bobbs using chloroform as the anesthesia. The remainder of the 18th century saw the first transabdominal resection of an infected appendix and the first thyroid removal. The first successful brain tumor was removed in 1884.
The 20th Century
By the 1920s, surgery became a dominant force in medical advancement (Gawande, 2012). Rubber gloves to help prevent infection were introduced, and burn and wound treatments became simple and less traumatizing to the patient. After World War I, national associations were formed for neurologic surgeons, orthopedic surgeons, urologists, and other specialists, and dedicated training programs were established as surgery became normalized (Gawande, 2012).
World War II led to even more advancements in surgery and other medical fields, and more soldiers were surviving what had previously been fatal injuries. In the 1940s, there were advances made in diagnostic testing, vaccines, antibiotics and other laboratory innovations (Gawande, 2012). The first successful open-heart surgery occurred in 1952 and led to the development of cardiopulmonary bypass technology. The first organ transplant surgery was soon to follow.
Modern Surgery
More than 2500 different surgical procedures are now performed across the country and the world. Current challenges for surgeons practicing today include minimizing invasiveness by using smaller incisions and lasers, to shorten recovery time, ensuring the quality and appropriateness of the procedures performed, how to ensure all patients have access to quality surgical care, and managing the immense costs (Gawande, 2012). Standardization of routine surgeries across the country and internationally and measuring surgical care and its results are also challenges faced by hand and other surgeons.
Many surgeries are done as outpatient procedures, such as gallbladder, removal of polyps and tumors, and biopsies. The increased safety and ease of surgery have produced an explosion in the volume of operations being performed — to at least 50 million annually in the United States alone (Gawande, 2012).
History of Hand Surgery
Hand surgery was one of the last surgical specialty fields to emerge as its own discipline. This specialty was founded through the combined efforts of general surgeons, plastic surgeons, orthopedic surgeons, vascular surgeons and neurosurgeons and was thought to find its beginnings in the casualties of World War II (Yale, 2017). There were numerous soldiers with hand injuries, among others, which led to a demand for surgeons familiar with acute hand injuries that lead to hand deformities.
During the early days of the war, there were no specialized units for hand injuries. Soldiers with hand injuries may be placed in a plastic, orthopedic, neurosurgical, or general surgery units. A plastic surgeon, J. William Littler, led the first hand surgery ward, and regional hand centers opened in hospitals with plastic surgeons, because they had the knowledge of wound coverage and trauma reconstruction needed to treat severe hand injuries.
There are many surgeons who contributed to the development of hand surgery, and some of the notable ones are as follows (Yale, 2017):
Dr. Alan Kanavel was a general surgeon in Chicago who published a landmark text in 1932 that led to significant reductions in the risk of infection after hand surgery.
Dr. Sterling Bunnell emphasized the importance of gentle handling of tissues, the use of the tourniquet, nerve grafts, and pollicization of the index finger.
Dr. Harold Kleinert advanced the field’s knowledge of tendon repair and healing as well as revascularization of the upper extremity.
Dieter Buck-Gramcko, Adrian Flatt and Joseph Upton are three orthopedic surgeons who have imparted invaluable experience in the care of children with congenital hand deformities.
Dr. Sumner Koch was a plastic surgeon that made advances in skin coverage, the treatment of tendon and nerve injuries as well as in the treatment of Dupuytren's disease.
Sir Harold Gillies, another plastic surgeon, made great strides in our understanding of skin flap surgery.
In hand surgery today, microsurgery and neurovascular anastomoses are used for reconstruction and replantation of the fingers and thumb, and whole muscles from other parts of the body can be transplanted into the hand. Nerve injury and regeneration has allowed hand surgeons to perform procedures on peripheral nerves that relieve nerve compression or to repair injured nerves following traumatic events (Yale, 2017). The experience with nerve injuries and paralysis has naturally led to refinements in tendon transfers to improve function in the hand and upper extremity, and better understanding of muscle physiology, nerve repair and biomechanics has enabled hand surgeons to restore function to the injured hand (Yale, 2017).
How to Become a Hand Surgeon
It takes several years of education and training to become a hand surgeon. An undergraduate degree, medical school, a residency and a fellowship must all be successfully completed for a hand surgeon to legally treat patients. A valid license must be maintained at all times throughout a hand surgeon’s career. An aspiring hand surgeon may choose plastic surgery, orthopedic surgery, or general surgery as their medical specialty field.
Medical school training includes special knowledge and skill in the design and transfer of flaps, in the transplantation of tissues, and in the replantation of structures are vital to these ends, as is skill in excisional surgery, in management of complex wounds, and in the use of alloplastic materials (ACS, 2017). Residency experiences allow for the student to develop their knowledge of arts and science and to develop into a competent, responsible surgeon with high moral and ethical character capable of functioning as an independent surgeon (ACS, 2017).
Undergraduate Degree
A future hand surgeon will get a bachelor’s degree in a pre-medical or science field such as biology or chemistry, although some choose to major in a social science such as sociology or psychology. There is no requirement for a specific undergraduate major, but most students choose science to prepare themselves for the Medical College Admissions Test (MCAT).
The MCAT must be passed to be accepted into any accredited medical school program. Medical school is highly competitive, so a high MCAT score and a high GPA will increase the chances of acceptance, in addition to participating in multiple extracurricular activities and volunteering or working at a local hospital or clinical center.
Medical School
An accredited medical school is the next step in the process in order to earn a Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.). A D.O. typically completes one year of an internship prior to completing medical school. The first two years of medical school include classroom and laboratory requirements in courses such as biochemistry, anatomy and physiology, pharmacology and medical law.
The last two years consist mainly of hands-on clinical experience in hospitals or other health care centers under the direct supervision of a licensed, experienced physician. Students gain exposure to various medical specialties such as internal medicine, general surgery, cardiology, pediatrics, and many more. Accreditation for educational programs such as medical schools and residency training programs is through the Accreditation Council for Graduate Medical Education (ACGME).
Residency and Fellowship Programs
Once medical school is successfully completed, five to six years of residency training is required. Typically, the first three years of surgery training is in general surgery and the final 2-3 years are in more specialized fields or areas, such as hand surgery. A hand surgeon may apply for residency programs in orthopedic, plastic, or general surgery. The orthopedic and general surgery programs typically last five years, while the plastic surgery residency may be up to 7 years in length.
Following completion of the residency program, a one-year fellowship begins which gives the surgeon additional training and experience working specifically on the hand or other specialized area. During the fellowship program surgeons gain experience in trauma surgery of the hand and wrist, including replantation of severed body parts, congenital differences, microvascular surgery, arthritis surgery (both rheumatoid and osteoarthritis), reconstructive wrist surgery, peripheral nerve surgery (ASSH, 2017).
License and Certification
Most hand surgeons obtain a license after completing medical school and before they begin their residency program. Licensing requirements vary by state, so the residency should be completed in the state the surgeon chooses to practice in. Most states require surgeons and physicians take and pass the United States Medical Licensing Exam (USMLE) before they are legally allowed to practice medicine and have contact with patients. The USMLE is a written and clinical examination that is separated into 4 different sections.
The American Board of Surgeons (ABS) offers certification to surgeons within all specialties, including hand surgery. The ABS offers certification in general, vascular, pediatric, critical care, and oncology surgeons as well. Surgeons may have to take a qualifying and a certifying examination to gain board certification. Board certification is not required to become a practicing hand surgeon, but many medical professionals voluntarily become certified for a variety of reasons.
Hand surgeons will take the Hand Surgery Certifying Exam after they have been certified in General Surgery by the ABS. The American Board of Plastic Surgery and the American Board of Orthopedic Surgery also offer certification in hand surgery, although only one certification from one of these organizations is needed.
Job Prospects
The Bureau of Labor Statistics (BLS) projects a 15% growth for all physicians and surgeons by the year 2026. The median annual salary for all surgeons is approximately $208,000, with over 100,000 new jobs expected to open in the near future. Nearly half of the surgeons practicing today work in private practices, while the other half work in hospitals, academia, or for the government. The salary for physicians and surgeons is among the highest compared to all other occupations.
Yale University Hand and Comprehensive Microsurgery Center. The History of Hand Surgery. Retrieved November 16, 2017 from: http://yalehandsurgery.org/history.html
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