History and structure

The Swedish Society for Surgery of the Hand’s recommended levels of structure and care of Hand Surgery in Sweden 

History

The Swedish Society for Surgery of the Hand was constituted in 1973. One year after the constitution, a committee of hand surgeons (Drs. Carstam, Mattson, Sälgeback) were assigned the task of establishing guidelines for the practice of hand surgery, in relation to other closely related specialties (plastic surgery, orthopedic surgery, general surgery). The guidelines were accepted and established at the Swedish Society for Surgery of the Hand’s annual meeting in 1975.

The first recommended levels of structure were amended by the Board of the Swedish Society for Surgery of the Hand in 1989 (Drs. Lindström, Engkvist, Lundborg, Nylander, Nachemson) and accepted by the members at the annual meeting in Stockholm, 1989.
A final structural revision was suggested and accepted at the annual meeting in 1996, as a result of recent surgical and technical advances in hand surgery.

General information

Hand surgery is a regional specialty in all of the seven health care regions in Sweden (Stockholm, Göteborg, Malmö/Lund, Linköping, Örebro, Umeå). The recommended levels of structure and care of hand surgery presuppose an established collaboration between the various hospitals in each region and the regional department of hand surgery.

The recommendation also entails an educational responsibility, where the orthopedic/general surgeon residents should be allowed to participate in a hand surgical rotation during their training. It’s also recommended that any privately practicing hand surgeons should reach an agreement with the regional hand surgery department, with regard to the above-mentioned recommended levels of structure.

Tendon injuries

All flexor tendon injuries and reconstructions at the level of the wrist/hand are hand surgical cases.

Isolated extensor tendon injuries in the forearm, on the metacarpal level or over the DIP joints may be handled by orthopedic surgeons, if proper qualifications and experience exists.
Extensor tendon injuries on the level of the proximal phalanx – PIP joint – middle phalanx require a higher degree of knowledge, in particular in the instance of associated tissue defects, and should, therefore, be referred to a hand surgeon. Multiple tendon injuries and secondary reconstructions are also cases for the hand surgery dept.

Nerve injuries

Nerve stem injuries (median, ulnar, radial, musculocutaneous) in the arm/hand are cases for hand surgical care. Simple digital nerve injuries can, in most cases, be sufficiently expedited at the local orthopedic department.

Secondary nerve reconstructions, including delayed nerve sutures, nerve transplantations and tendon transfers, after trauma or cerebral palsy, are all cases for the hand surgery dept. The only exceptions to this are the obstetrical brachial plexus injuries and the proximal nerve injuries, including the traumatic cases resulting in tetraplegia. Due to the rarity of these cases, the Swedish Society for Surgery of the Hand has agreed to recommend a centralization of the surgical care. (Obstetrical brachial plexus – Stockholm, tetraplegia – Göteborg).

Nerve entrapments

Common nerve entrapments, such as CTS and ulnar nerve entrapment in the elbow/wrist, may be handled at by orthopedic surgeons. In cases of uncertain entrapment level, other proximal nerve entrapments or where symptoms persist/recur after decompression, the regional hand surgery dept should be consulted.

Endoscopic CTR requires particular training due to the increased risk of complications. These cases should, therefore, be treated by specialists trained in the technique.

Skin – Burns

Skin grafting using small free skin grafts to cover minor defects, may be treated locally. Simple scar corrections, i.e. Z-plasty, may also be handled locally. Larger skin lesions, injuries with poor skin viability and skin defects combined with deeper injuries are usually cases for the regional hand surgery dept. The same applies to most cases requiring flap surgery.

Partial thickness burns, at most second degree burns, may be treated locally. Full thickness burns and larger burns, are usually cases for the regional Burn/Plastic Surgery Unit. However, in cases with extensive involvement of the hand, collaboration between plastic surgeons and hand surgeons is presumed to be the treatment of choice.

Bone/joint

Many of the fractures and simple ligament injuries in the hand may be treated by orthopedic surgeons.

The exceptions include carpal dislocations and ligaments injuries, with regard to both primary treatment and secondary reconstructions. Many of these require arthroscopic diagnosis/treatment, which should be regarded as a case for the regional hand surgery dept.

Multiple fractures, displaced intraarticular fractures and unstable phalanx fractures, may also be cases for the specialist hand surgery unit.

In the case of prolonged, chronic cases or cases in need of secondary reconstructions (osteotomies, non-unions, joint reconstructions with/without implants) a consultation at the hand surgery unit is to be recommended.

Osteoarthritis may be treated by orthopedic surgeons, in the instance of arthrodesis in the finger joints, including the thumb MCP and CMC I joints, as well as interposition arthroplasties of the thumb CMC I OA. Total wrist arthrodesis with bone transplant takes an intermediary position, and may be considered both at an orthopedic and a hand surgery dept. Total wrist implants or other implant surgery should be cases for the hand surgery dept.

For Rheumatoid Arthritis, see separate heading.

Complex hand trauma – amputations

Complex hand traumas, with combined nerve, tendon, bone and skin injuries, are cases for immediate hand surgical care.

Total or partial amputations that may replantation/revascularisation, are cases that should be discussed immediately with the regional hand surgery dept, in order to determine whether microsurgery is indicated and how the patient should be transported to the regional clinic.

Pressure injection injuries

These injuries are frequently associated with substantial soft tissue injuries, and should, therefore, be referred immediately to a hand surgery dept.

Infections

Acute paronychia, finger pulp infections, pyogenic flexor tenosynovitis and pyogenic arthritis are all cases that the orthopedic surgeon should be able to treat locally. Chronic infections, occult infections or complications (i.e. osteitis), should be referred to the regional hand surgery dept.

Rheumatoid arthritis

The most common surgical interventions in rheumatoid patients, such as wrist arthrosynovectomies with or without ulnar head resection, dorsal tenosynovectomy, elbow synovectomy with radial head resection and finger joint arthrodesis, including MCP/IP joints of the thumb, may be treated by orthopedic surgeons with the proper training and experience.

It is recommended, however, that cases involving volar flexor tenosynovectomies, larger grip reconstructions and tendon transfers, are treated at the hand surgery dept. MCP II-V joint arthroplasties and wrist arthrodesis may be considered intermediate cases, which may be considered both at an orthopedic and a hand surgery dept.

Dupuytren’s contracture

Primary surgery in simple cases of Dupuytren’s contracture may well be treated by orthopedic surgeons. In cases of advanced, complex contractures in the MCP and/or PIP joints or recurring contractures after previous surgery, referral to the regional hand surgery dept is recommended.

Congenital deformations

Just about all congenital hand cases should be referred to the regional hand surgery dept.

Tumors

Wrist ganglia (both volar and dorsal), tendon sheath ganglia and mucous cysts should all be handled at the local orthopedic dept.

Malignant tumors, as well as expansive benign tumors, should be treated at the regional hand surgery dept, in collaboration with the tumor orthopedic specialists.

Communication with the regional hand surgery dept

The aforementioned levels of structure and care should be regarded as guidelines to the handling of hand surgery both locally and regionally. Strict rules are impossible to impose, and there will always be cases where the level of care is intermediary. In cases of doubt, it is recommended that the orthopedic surgeon contacts the regional hand surgery dept to discuss continued treatment and handling of both traumatic and elective hand cases.