The purpose of this clinical rotation is to learn a comprehensive approach to the diagnosis and treatment of problems related to the hand and upper extremity. Exclusive experience is offered in adult and pediatric hand and wrist surgery. Training is based primarily at Barnes-Jewish Hospital, but also involves other Washington University affiliated hospitals including St. Louis Children's Hospital, St. Louis Shriners Hospital for Children, the Veterans Affairs Medical Center and the new Outpatient Orthopedic Center in Chesterfield, MO.
Hand faculty members include:
Martin Boyer, MD, FRCS(C), Chief of service
Ryan Calfee, MD
Richard Gelberman, MD (Chairman)
Charles Goldfarb, MD
Paul Manske, MD
Residents work with the entire upper extremity faculty in the care of operative and non-operative hand, wrist and elbow disorders which present to the orthopaedic service at Barnes-Jewish and the various hospitals. This includes participating in the care of patients in the clinical office practice of the attending surgeons, assisting in the operating room and performing surgery under the direction of the upper extremity surgical attending staff and contributing to the overall educational program.
The upper extremity service consists of five attending physicians who exclusively practice wrist and hand surgery and two attendings that exclusively practice surgery of the shoulder and elbow.
The junior (PGY-3) resident assists with pre-operative workups, management of in-house patients, and surgery. Junior residents take the rotation twice during their initial year, being exposed to basic hand, wrist, elbow and shoulder surgery.
The senior resident is a PGY-4 level trainee. He/she serves as a senior or chief resident on the service. The chief resident rotates on the upper extremity service for a period of approximately eight to ten weeks. The chief resident spends half of his/her time in the operating room and the other half in the out-patient clinic. The chief resident on the Upper Extremity Service also serves as the residency program's administrative chief resident.
The clinical practice includes a variety of general hand, wrist, elbow and shoulder problems and includes approximately 2000 surgical cases, with approximately 700 shoulder and elbow procedures and 1300 hand and wrist procedures. In the clinical offices of the surgical faculty , there are well over 10,000 patient visits per year. There is a weekly hand clinic at the Shriners Hospital that residents attend. Surgery is performed on a weekly basis at this institution as well.
In the clinic, residents and fellows see patients initially, performing a history and physical examination. They evaluate laboratory data and x-rays and then present the patient data to the attending. The attending asks for a diagnosis and for a proposed treatment plan. The attending then evaluates the patient, demonstrating key points in the history and physical examination. The x-rays are discussed and a treatment plan agreed upon.
Both the senior resident and fellow are in charge of dictating office notes and providing any necessary referrals for those patients seen by them in the clinic. The attending also dictates a separate note. If changes are made to the original dictation, the resident or fellow receives a copy for reference. The attempt here is to help instruct the senior residents on how to dictate an office note and provide an appropriate referral letter. Residents see approximately 100 patients on the hand surgery service and 80 patients on the shoulder and elbow surgery service on a weekly basis. As the senior resident is on the service for approximately 10 weeks, he/she is very often involved in the initial preoperative evaluation, operative treatment, and early follow-up. The chief resident is the primary contact person for hand surgery trauma call. Residents call the fellows from the emergency room for all cases that go to the operating room for consultation on all upper extremity cases. Attending faculty are available for all operative cases.
In addition to the four hours of weekly departmental orthopaedic conferences, fellows and residents on the upper extremity service attend one additional hour of conferences weekly that are specific to hand, wrist, shoulder and elbow surgery. These include a one-hour Journal Club (for the discussion of articles from both the current Journal of Hand Surgery and the "classic" hand surgery literature) alternating with a weekly, one-hour Upper Extremity Anatomy Dissection Program on. A Surgical Indications conference is held prior to each operative day by Drs. Gelberman and Manske. Both biomechanical and biochemical/genetic research laboratories are available for use by the residents and fellows.
Organization of the monthly Journal Club conferences includes 3 hand-oriented conferences and 1 shoulder/elbow-oriented conference. Included in the hand-oriented conferences is a monthly review of the Journal of Hand Surgery. Additionally, "classic" articles from the hand surgery literature are reviewed and salient points are discussed. In the Shoulder and Elbow Conference, a specific topic is chosen by the residents and the most recent, pertinent articles are obtained to comprehensively review the topic.
The Upper Extremity Anatomy and Dissection Program is a structured, organized program rotating every 12 weeks. The entire upper extremity from the fingertip to the brachial plexus is dissected. For each dissection there is a list of pertinent references and an outline organized to guide the residents and fellows for discussion.
The Surgical Indications Conference is held prior to each operative day. In this conference the junior or the senior resident is asked to present the history, physical findings and x-rays for each operative case. Specific operative indications and options for treatment are reviewed. Original articles or text readings are then assigned as preparation for the next day. All residents are instructed to evaluate the Same Day Surgery patients in the holding area prior to surgery. At this time the residents participate in the operating room for 4 surgical days per week. Typical operative volume would be 18-20 cases per week. As a general rule, the senior resident and fellow consult to determine who will cover selected cases. With the exception of difficult revision cases, the senior resident generally is given first choice to be the primary surgeon. All cases are supervised with the attending. The junior resident operative experience is generally observational for the major cases, but introductory for simple cases such as carpal tunnel release, trigger finger, etc. Depending on coverage choice by the senior resident, the junior resident will have the opportunity to perform minor hand surgery cases and 2-5 arthroscopy cases on the shoulder and elbow service for the rotation. The operative exposure on the upper extremity service is quite comprehensive. Residents and fellows will be exposed to approximately 4 pediatric hand cases, 12 adult reconstructive hand, and 6-8 shoulder/elbow cases per week.
On the postoperative day, each patient is seen by the house staff, fellows and attending physician during formal rounds. Operative findings and specific rehabilitation concerns are discussed during this time. Postoperatively the junior resident is responsible for the majority of the ward work under the supervision of the chief resident and attending.
At the end of each resident's rotation there is an exit interview. The residents are given frank, constructive feedback regarding the strengths and weaknesses of their rotation performance. In turn, the residents are asked to constructively criticize their upper extremity rotation so that improvements can be made as necessary. In summary, the service experience is designed to be a challenging, interactive, hands-on experience for residents and fellows. The extensive didactic, outpatient, emergent care and surgical experience is interactive with discussion among the attendings, fellows, and residents alike