Approaches to Distal Upper-Extremity Trauma: A Comparison of Plastic, Orthopedic, and Hand Surgeons in Academic Practice

C LINICAL P APER Approaches to Distal Upper-Extremity Trauma A Comparison of Plastic, Orthopedic, and Hand Surgeons in Academic Practice Chanukya R. Dasari, MD, Manjot Sandhu, BS, David H. Wisner, MD, and Michael S. Wong, MD Background: Hand trauma call duties at university medical centers are tradition- ally split among plastic surgeons and orthopedic surgeons, frequently without ad- ditional fellowship training in hand and upper-extremity surgery. Differences in operative approach between these groups have never been specifically described. The University Health Consortium—Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual, billing and coding data from 90 academic medical centers in the United States and can be used to characterize the practice patterns of various academic surgical specialties. Objective: To characterize and compare the clinical experience of academic plas- tic, orthopedic, and hand surgeons in addressing traumatic distal upper extremity injuries (using the Faculty Practice Solutions Center data set). Methods: Annual data for CPT defined procedures related to traumatic injuries of the nail bed, finger, hand, wrist, and forearm performed by plastic, orthopedic, and hand surgeons during calendar years 2010 to 2013 were included in the study. Results: From 2010 to 2013, the experience of fellowship-trained hand surgeons in treating traumatic distal upper extremity injuries was consistently greater than that of plastic surgeons and general orthopedic surgeons across all categories. In- juries of the nail bed were repaired more frequently by plastic surgeons than or- thopedic surgeons (average 1.3 annual procedures per surgeon for plastic surgeons compared with 0.3 for orthopedic surgeons). Fractures and dislocations involving the phalanx and metacarpal were repaired equally by both groups, with plastic surgeons using predominantly percutaneous (38%) or open methods (45% of repairs), and orthopedic surgeons using mostly closed reduction (59% of re- pairs), splinting, and casting. Fractures and dislocations involving the carpal bones, radius, and ulna were more frequently repaired by orthopedic surgeons (average 23.2 procedures versus 2.6 for plastic surgeons), whereas tendon repairs in all segments were performed more frequently by plastic surgeons (average 13.7 procedures versus 2.5 for orthopedic surgeons). Replantation and repair of neurovascular injuries were exceedingly rare (less than 1 occurrence) in all groups for all years and are not specifically reported in Table 1. Similarly, inci- sion and drainage procedures and decompressive fasciotomies of the distal upper extremity were uncommonly performed and also not included (Table 1 displays the mean annual procedures per surgeon by grouped CPT coded procedures, with overall averages displayed to the right. Figure 1 displays the proportions of intra- articular and extra-articular bony hand injuries treated by closed, open, and per- cutaneous methods by each specialty). Conclusions: A large degree of variation exists in the treatment of distal upper extremity injuries, based on specialty service. Hand surgeons, not surprisingly, have the most robust clinical experience, whereas plastic surgeons and orthopedic surgeons each display varying strengths and weaknesses, perhaps a consequence of their respective training. Key Words: upper extremity hand injuries in trauma, plastic, orthopedic, hand, academic surgery practice, FPSC, faculty practice solutions center, AAMC, CPT, RVU (Ann Plast Surg 2016;76: S162–S164) H and trauma call duties at university medical centers are traditionally split among plastic surgeons and orthopedic surgeons, frequently without additional fellowship training in hand and upper-extremity sur- gery. Fellowship-trained hand surgeons, who typically share backgrounds in plastic, orthopedic, or occasionally general surgery, also participate. Differences in operative approach among these groups have never been specifically described. In a recent survey, fellowship-trained hand surgeons from ortho- pedic and plastic surgery backgrounds reported differences in the com- position of their clinical practices, perhaps a reflection of clinical exposure during residency. 1 Without fellowship training, plastic and or- thopedic surgeons who treat hand trauma, may be at a disadvantage when addressing certain injuries. OBJECTIVE The objective of this article is to analyze practice patterns of gen- eral plastic surgeons, general orthopedic surgeons, and hand surgeons addressing distal upper extremity injuries in academic medical centers, using the Faculty Practice Solutions Center (FPSC) database. The Uni- versity Health Consortium—Association of American Medical Colleges maintains the FPSC database which contains de facto coding and billing data from 90 academic medical centers, encompassing all procedures performed at these facilities for all payer types in both inpatient and outpatient settings by individual specialty. Previously, the FPSC da- tabase has been used to characterize practice patterns of various surgical specialties. 2–4 METHODS Annual data for CPT defined procedures that address distal up- per extremity trauma performed by university plastic, orthopedic, and hand surgeons during calendar years 2007 to 2013 were included in the study. No specific designation of prior specialty training in plastics, orthopedics, or general surgery is given for hand surgeons in the data- base. However, based on a recent survey of the American Association for Hand Surgery, and American Society for Surgery of the Hand, most respondents from academic practices were from orthopedic back- grounds (63% orthopedics, 47% plastics). 1 The FPSC database values are reported as the average annual procedures per surgeon (pps). RESULTS Received June 30, 2015, and accepted for publication, after revision February 12, 2016. From the Division of Plastic Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA. Conflicts of interest and sources of funding: none declared. Reprints: Michael S. Wong, MD, University of California Davis Medical Center, Department of Surgery, Division of Plastic Surgery, 2221 Stockton Blvd., Suite 2123, Sacramento, CA 95817. E-mail: mswong@ucdavis.edu. Presented at the 65th California Society of Plastic Surgeons Annual Meeting. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7605-S162 DOI: 10.1097/SAP.0000000000000804 S162 www.annalsplasticsurgery.com From 2010 to 2013, the total experience of hand surgeons in treating traumatic distal upper extremity injuries was greater than that of their general plastic surgery and orthopedic surgery counterparts, across all categories for all years. Table 1 displays the mean annual pps by grouped CPT coded procedures, with overall averages displayed to the right. A comparison of plastic surgeons to orthopedic surgeons shows slight predominance of plastic surgeons performing nailed repairs, al- beit in relatively low volume, ranging from 0.8 to 2.0 pps annually for plastic surgeons and 0.1 to 0.6 for orthopedic surgeons. Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.