The History of Hand Surgery

The specialty of hand surgery developed during World War II. Battle-induced injuries to bones, joints, nerves and arteries required expertise from several surgical disciplines. Yet in the press of war, the gathering of so many specialists in one place was not practical. The need for a select group of surgeons to care for all components of the arm quickly became obvious.

Enter Dr. Sterling Bunnell, a consultant to the U.S. Army who created a training program teaching interested surgeons the multiple skills required to fulfill that need. Dr. Bunnell's program was the progenitor of the modern hand surgery specialty.

Current training for hand surgeons requires completion of a program in Orthopedic, General or Plastic Surgery, and then passing the certifying board of that specialty. Aspiring hand surgeons must next complete a yearlong Hand Surgery Fellowship in which they receive intensive training in the diagnosis and treatment of arm problems. They become certified when they pass a final exam: the Certificate of Added Qualifications in Hand Surgery.

The historical context for the three qualifying fields is that both plastic surgery and orthopedic surgery are more recent branches off the general surgery main trunk. Modern hand surgery began in World War II as a military planning decision. US Army Surgeon General, Major General Norman T. Kirk, knew that hand injuries in World War I had poor outcomes in part because there was no formal system to deal with them. Kirk also knew that his civilian general surgical colleague Dr. Sterling Bunnell had a special interest and experience in hand reconstruction. Kirk tapped Bunnell to train military surgeons in the management of hand injuries to treat the war casualties, and at that time hand surgery became a formal specialty. Orthopedic surgeons continued to develop special techniques to manage small bones, as found in the wrist and hand. Pioneering plastic surgeons developed microsurgical techniques for repairing the small nerves and arteries of the hand. Surgeons from all three specialties have contributed to the development of techniques for repairing tendons and managing a broad range of acute and chronic hand injuries.

Hand Surgery Around The World

Hand surgery is an interface specialty which has received contributions and incorporates techniques from orthopaedics, plastic surgery, general surgery, neurosurgery, vascular and microvascular surgery and psychiatry. It is a complex, fascinating specialty. There is Increasing recognition that a well-rounded grasp of biomechanical concepts, functional needs, and the necessary background skills in soft tissue handling (plastic), bone and joint handling, and microsurgical and microvascular reconstructive skills are critical in optimizing outcomes in the management of hand injuries and afflictions.

Hand surgeons perform a wide variety of operations such as fracture repairs, releases, transfer and repairs of tendons and reconstruction of injuries, rheumatoid deformities and congenital defects. They also perform microsurgical reattachment of amputated digits and limbs, microsurgical reconstruction of soft tissues and bone, nerve reconstruction, and surgery to improve function in paralysed upper limbs.

The field of hand surgery deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or upper extremity (commonly from the tip of the hand to the shoulder).

Hand Surgery in Singapore

In a few countries such as Sweden, Finland and Singapore, Hand Surgery is recognized as a clinical specialty in its own right with a formal four to six years hand surgery resident training program. Hand surgeons going through these programs are trained in all aspects of hand surgery, combining and mastering all the skills traditionally associated with "Orthopedic hand surgeons" and "Plastic hand surgeons" to become equally adept at handling tendon, ligament and bone injuries as well as microsurgical reconstruction such as reattachment of severed parts or free tissue transfers and transplants.

Specialist Hand Surgery units were established in Singapore as early as 1985, and formalized hand surgery training programs and specialist accreditation in Hand Surgery began in 1991, administered by the Ministry of health, Singapore.

To be registered as a Hand Surgeon in Singapore, candidates must have completed at least 4 years of well-rounded basic surgical training and 4 additional years of specialist training to pass a rigorous certifying examination.

History of Microsurgery

Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves (typically 1 mm in diameter) which have allowed transfer of tissue from one part of the body to another (transplantation) and re-attachment of severed parts (replantation).

The advances in the techniques and technology that popularized microsurgery began in the early 1960s. The first microvascular surgery, using a microscope to aid in the repair of blood vessels, was described by vascular surgeon, Jules Jacobson, of the University of Vermont in 1960. Using an operating microscope, he performed coupling of vessels as small as 1.4 mm and coined the term "microsurgery."[1] Hand surgeons Kleinert and Kasdan performed the first revascularization of a partial digital amputation in 1963.

Nakayama, a Japanese cardiothoracic surgeon, reported the first true series of microsurgical free-tissue transfers using vascularized intestinal segments to the neck for esophageal reconstruction after cancer resections using 3-4mm vessels.

Contemporary reconstructive microsurgery was introduced by an American plastic surgeon, Dr. Harry J. Buncke. In 1964, Buncke reported a rabbit ear replantation, famously using a garage as a lab/operating theatre and home-made instruments. This was the first report of successfully using blood vessels 1 millimeter in size. In 1966, Buncke used microsurgery to transplant a primate's great toe to its hand.

During the late sixties and early 1970s, plastic surgeons ushered in many new microsurgical innovations that were previously unimaginable. The first human microsurgical transplantation of the great toe (big toe) to thumb was performed in April 1968 by Mr. John Cobbett, in England. In Australia work by Dr. Ian Taylor saw new techniques developed to reconstruct head and neck cancer defects with living bone from the hip or the fibula.

These many advances, now commonplace, developed in tandem with the development of the Zeiss Operating microscope, fine micro-instruments, and fine suture materials.

History of Replantation

Replantation is the reattachment of a completely detached body part. Fingers and thumbs are the most common but the ear, scalp, nose, face, arm and penis have all been replanted. Generally replantation involves restoring blood flow through arteries and veins, restoring the bony skeleton and connecting tendons and nerves as required.

Initially, when the techniques were developed to make replantation possible, success was defined in terms of a survival of the amputated part alone. However, as more experience was gained in this field, surgeons specializing in replantation began to understand that survival of the amputated piece was not enough to ensure success of the replant. Functional demands of the amputated specimen are paramount in guiding which amputated pieces should and should not be replanted. Additional concerns about the patients ability to tolerate the long rehabilitation process that is necessary after replantation both on physical and psychological levels also became important. So, when fingers are amputated, for instance, a replantation surgeon must seriously consider the contribution of the finger to the overall function of the hand.

In this way, every attempt will be made to salvage an amputated thumb, since a great deal of hand function is dependent on the thumb, while an index finger or small finger may not be replanted, depending on the individual needs of the patient and the ability of the patient to tolerate a long surgery and a long course of rehabilitation.

However, if an amputated specimen is not able to be replanted to its original location entirely, this does not mean that the specimen is unreplantable. In fact, replantation surgeons have learned that only a piece or a portion may be necessary to obtain a functional result, or especially in the case of multiply amputated fingers, a finger or fingers may be transposed to a more useful location to obtain a more functional result.