Providing Care for Hand Disorders a Re-Appraisal of Need

An audit of hand surgery activity in Derby during the period 1989–1990 produced manpower and resource recommendations for the speciality per 100,000 of population per year for the United Kingdom. The decade that followed the audit has seen major changes in health care provision, including reduced service activity by trainee doctors through restricted hours of work and less unsupervised surgery. A further audit of hand surgery activity was performed during 2000–2001 to assess the effects of these and other changes. This showed that there has been a 2% rise in trauma attendances, though trauma bed utilization had reduced by 12% and surgery time by 38%. Trauma out-patient visits had also reduced by 11%. Day-case trauma surgery rates were virtually unchanged at 63%. Women attend more frequently with traumatic hand injuries than they did 10 years ago and there is arising incidence of hand injuries in the home, with a falling incidence at work. Elective referrals have risen by 36% and operations by 34%. The top ten diagnoses relate to the same conditions although their rankings have changed. Elective day-case surgery rates have risen from 64% to 94% over the decade. The 34% increase in elective operations has been absorbed within a 5% reduction in elective bed use and a 23% reduction in surgery time. Elective out-patient visits have also dropped 14% overall. This audit indicates that in 2000–2001 one whole time equivalent hand surgeon can service a population of 125,000. The national requirement for a 56 million population would be 448 whole time equivalent hand surgeons.

Proximal row transcarpal fracture from a punching injury

We describe an unusual case of a 31-year-old woman who injured the right dominant wrist when she punched an assailant's shoulder. She described a mechanism of direct compression, with the wrist in hyperextension, radial deviation and the forearm in pronation. She sustained an oblique transverse fracture of the proximal pole of the scaphoid and a coronal plane fracture of the lunate and the triquetrum. This unusual proximal row transcarpal fracture is in conflict with the Mayfield sequence and was caused by a low velocity injury.