White book on hand surgery in Europe.pdf White book on hand surgery in EuropeWHITE BOO K ON HAND SURGERYIN EUROPEProduced by the European Boardof Hand Surgery - EBHS1.1. What is hand surgery ?Hand surgery is the field of medicine that dealswith problems of the hand and wrist, whether ofcongenital, traumatic, degenerative, inflammatory ortumoral origin. The aim is to restore the function ofthe hand, which should be regarded as the key organof prehension and sensibility. In this context, handsurgeons are also involved with complex problemsof the whole upper extremity, including lesions ofthe peripheral nerves and the brachial plexus. Handsurgeons are also involved in the restoration of prehensionin cases of tetraplegia and spasticity. Becauseof their special expertise, hand surgeons are alsofrequently involved in the repair of lower extremitynerve lesions.1.2. The scope of hand surgeryThe scope of hand surgery is broad and requiresa wide range of diverse operative skills necessaryto diagnose and treat, conservatively or surgically,hand and pertinent upper extremity and peripheralnerves affections.The hand surgeon masters microsurgery as wellas orthopaedic and plastic surgery techniques, as appliedto the complex and delicate anatomy of the handand upper limb. Hand Surgery considers also thecosmetic aspects of the reconstruction of the hand.A close cooperation with other specialists is required,including orthopaedic and trauma surgeons, plasticsurgeons, radiologists, paediatric surgeons, rheumatologists,anaesthetists, specialized physiotherapists,occupational therapists and other paramedics for rehabilitation,orthotics and prosthetics.The treatment of a lesion of the hand/upper extremityin the earliest phase by a surgeon trained inhand surgery offers the patient the best chances of earlyand best recovery, and also reduces the costs relatedto the disability and time-off work for society. This isparticularly true for the hand traumas, which are particularlyfrequent.This book is made by cooperation of the specialistsections of UEMS, which deal with the educationand qualification in hand surgery in EU countries,and FESSH in order to set the minimal requirementsfor a surgeon, who treats the complex problems of thehand. The UEMS Council has endorsed it in Prague,October 9, 2010.2.0. Training and Qualifica tionin hand surgeryQualification in hand surgery is based on theclinical and surgical training received after basic accreditationin plastic or orthopaedic surgery in themajority of European countries. In some countriesqualification is also possible through general, paediatricor trauma surgery; a separate specialty of handsurgery exists only in a few countries of Europe.Training includes theoretical and clinical activities.The trainee should be exposed to he followingconditions: Anatomy of hand and upper limb. Physiology of muscle, tendon, nerve and joints,blood perfusion and bone metabolism.Впервые публикуется «White book», посвященная кистевой хирургии в странах Евросоюза. Этобогатейший материал, собранный членом редакционного совета нашего журнала, профессором MassimoCeruso (Флоренция, Италия). Даны подробные данные о кистевой хирургии и ее месте в травматологиии пластической хирургии. В ряде стран кистевая хирургия стала даже отдельной специальностью.Много внимания уделяется вопросам профессиональной подготовки врачей в области кистевой хирургиииз числа травматологов и пластических хирургов. Захватывают идеи о будущем кистевой хирургии ипрофессиональных сообществах.6№ 4 (39) декабрь2011 Вопросы реконструктивной и пластической хирургииWhite book on hand surgery in Europe Conservative treatments of hand disorders includingpost injuy pain syndromes. Operative surgery, including microsurgicaltechniques. Rehabilitation and functional splinting.In addition, a certified training course in microsurgeryon laboratory animals should be included in thecurriculum.2.1. Certifica tion: EuropeanDiploma Exami nationAccording to the bylaws of EU, qualification inHand Surgery is certified nationally by the local authorities.The «European Diploma in Hand Surgery» is nota prerequisite to practice Hand Surgery: it is an addedqualification and attests the European standard of thesurgeons skill and knowledge. It is released by the EuropeanBoard of Hand Surgery; provider is the Federationof the European Societies for Surgery of the Hand.Strict conditions are required to obtain the qualificationcertified by the Diploma. The candidate is requiredto report academic records and training postsheld and provide proof of a significant number of operationsas operator or first assistant. Because of thedifferences in training which exist in different parts ofEurope, different sets of criteria will have to be utilizedaccording to the prevailing pattern of training in thecandidates own country.1. In countries where training in hand surgery followsaccreditation in Orthopaedic or Plastic Surgery,one years training with 100 % exposure to hand surgeryin an accredited centre is sufficient for the DiplomaExamination.2. In countries where training in hand surgery followsaccreditation in a major surgical specialty otherthan Orthopaedic or Plastic Surgery, two years trainingin an accredited centre with 100 % exposure isrequired, and at least one year before this time musthave been spent in either the specialty of Orthopaedicor Plastic Surgery.3. Candidates from countries in which hand surgeryis already a separate specialty in its own right,may take the European Diploma Examination withoutfurther training provided that: Their general background training (minimumduration 2 years) has incorporated exposure toorthopaedic and/or plastic surgery for at leastone year. Their specialty in Hand Surgery has been for aminimum of three years in an accredited centrewith exposure to both orthopaedic and plasticsurgery techniques, including microsurgery. They have achieved accreditation in hand surgeryin their own countries.A countersigned logbook indicating performedand assisted operations, academic records and trainingposts held is also required. The logbook contains14 subsets, including tendon, joint surgery, replantationsand congenital conditions and has a guide to therecommended number of required operations. Thecandidate should prove a significant number of operationsas operator or first assistant. If possible, thetraining must be done in an accredited hand surgerytraining center or, at least, under the supervision ofan experienced hand surgeon. At this moment the accreditationof hand surgery training centres is basedon the proposals made by national societies. It is alsoexpected that the candidates pursue a scientific activity.The candidates should also have a recommendationfrom his/her national society for surgery of thehand. If the candidate fulfils the above requirementshe may take the European Examination.The examination is open, not only to hand surgeonsfrom European member countries, but also toanyone who fulfils the above requirements and desiresto participate and receive certification in this specificcompetency, in conformity with European standards.The European Board Examination in Hand Surgery(EBHS) is intended both as a quality mark, andto help in the harmonisation of standards in EU andUEMS member countries. The European Board examinationis not an alternative to a national examination,where one exists. Passing the EBHS Examinationdoes not give the right to work in a member countryof the EU. Such rights are granted by the National Authorityin each country.The Diploma Examination is annually organizedby of the European Board of Hand Surgery andusually takes place at the site of the Congress of theFederation of European Societies for Surgery of theHand, two days prior to the event, with the participationof 10-15 volunteer examiners invited from thecountries of the examinees, with the idea of providingat least one examiner for each candidate speaking thesame native language. The examiners are proposed bythe national societies. The format of the examinationis a multiple choice questions elimination test, followedby two 40 minute oral examinations conductedby two examiners. The chairman of the ExaminationCommittee and two supervisors survey the flowof the examination to provide feedback for followingexaminations. The main topics covered in the oralsare trauma, general reconstructive surgery and othertopics, like systemic diseases, arthritis, Dupuytren,tumours and congenital malformations. The officiallanguage of the exam is English.7Вопросы реконструктивной и пластической хирургии № 4 (39) декабрь2011White book on hand surgery in Europe3.0. Ha nd surgery in EuropeEuropean hand surgeons are represented by nationalsocieties consolidated in the Federation of EuropeanSocieties for Surgery of the Hand (FESSH).At a political level they are represented through theEuropean Board of Hand Surgery (EBHS).The Federation was established in 1990 as an associationof European national societies for surgeryof the hand, to represent these societies and theirmembers at a supranational level, to rationalize andunify education and training in hand surgery whilepromoting uniformity among the different countriesof Europe, to set a qualification standard for the practiceof hand surgery within the Council of Europe, toimprove the indications for hand surgery for the benefitof the patients, to define the highest standards fortreatment of hand pathologies, and to implement andsustain study and research.At present FESSH represents 24 national handsocieties (there is no national society in Europewhich is not a member of the Federation) formedby over 4 200 surgeons, whose main interest is handsurgery. The Federation is officially represented by itsSecretary General. The Council comprises ten members:the Secretary General, the Treasurer, the Chairmenof the Committees for Examination, Training,Research, Internet, Hand Trauma, Journal of HandSurgery, European Accreditation and an Historian.The FESSH Examination Committee providesfor the yearly organization of the European Board ofHand Surgery Diploma Examination. Two delegatesfrom each UEMS Section actively involved in the activitiesof the European Board act as contributors tothe organization of the European Board Examination.The applicants are selected by reviewing the documentssubmitted, the preparation of the MCQs forthe written examination are provided and the oralsessions are organized; these are held by a group ofexaminers, mainly invited from the countries of theexaminees. The first Diploma Examination was heldin Paris in 1996.The Training Committee aims to stimulate, assistand foster training in Hand Surgery in Europeamongst young surgeons, as well as established ones.The European Federation offers through its websitea database of centres in Europe that provide trainingin all or in particular aspects of hand surgery. There,young surgeons can find details of the centre for training,fellowships or research. The centres offering theseopportunities can upload onto the database details ofthe type of experience offered, funding and contactinformation. This committee, through a web-basedapplication form, also administers the Training andTravelling Awards. Every year 8 awards, currentlyfunded at 2000 Euros each, are given to surgeons froma member society to visit other Hand Centres with thepurpose of furthering their knowledge of Hand Surgery.The Training Committee is developing a MedicalStudent Bursary to inspire ambitions to become aHand Surgeon.The Federation of European Societies for Surgeryof the Hand promotes scientifically sound basic andclinical research studies in hand surgery. As an example,the Research Committee has promoted activitiesfocused on reconstructive hand surgery in tetraplegia,by organising an internet-based survey directed towardspatients living with tetraplegia in Europe, severaldedicated courses in tendon transfer surgery, andby organising a 3-month fellowship in reconstructivehand surgery in tetraplegia.Complex traumatic lesions of the hand representa substantial chapter in hand surgery. Optimal managementof these traumas requires specific individualskills of the surgeons (microsurgery, replantation surgery)and a specific organisation of the centres (permanentavailability). For this reason the Hand TraumaCommittee is currently identifying and mappingthese centres throughout Europe.The Journal of Hand Surgery, European Volumeis the official journal of the Federation, and includesnot only contributions by European authors, butalso any noteworthy paper written by hand surgeons,from any country, which chooses to publish in theJournal.Finally, the Federation of European Societies forSurgery of the Hand works on the history of handsurgery in Europe, especially reviewing research andadvances made by European hand surgeons and collectingmeaningful pertinent documents. The historyof the Federation of European Societies for Surgeryof the Hand may be found in an article published byS. Hovius in the Journal of Hand Surgery in 2002, aswell as in the attached document and on the FESSHwebsite (http://www.fessh.com).3.1. Congress and Courses in Ha ndsurgery in EuropeThe Federation of European Societies of Surgeryof the Hand organises a congress each year.At each congress there is an Instructional Course inHand Surgery. The lectures are published as a book,distributed at the time of the course. An independentScientific Committee judges the anonymousabstracts of the free papers submitted for presentation.8№ 4 (39) декабрь2011 Вопросы реконструктивной и пластической хирургииWhite book on hand surgery in EuropeIf possible, the meetings are organised in conjunctionwith the European Federation of Societiesfor Hand Therapists. The attendance at the meetingsso far has ranged from 400 to over 1 000 registrants.In addition to its annual congress, the Federation ofEuropean Societies for Surgery of the Hand organisesBasic Hand Surgery Courses in Eastern EuropeanCountries (three in the last five years).Education is also provided by national hand surgerysocieties from yearly national meetings, localand regional meetings, instructional courses (Austria,Belgium, Finland, France, Germany, Hungary, Italy,Netherlands, Norway, Poland, Rumania, Spain, Sweden,Turkey, UK) and formal lectures, research presentationand informal discussion.The FESSH congress is granted European CMEcredits by the European Accreditation Council forContinuing Medical Education (EACCME).4.0. Multidiscipli nary JointCommi ttee (MJC) on Ha nd SurgeryThe Multidisciplinary Joint Committee on HandSurgery is a committee of the Union Europeenne desMedecins Specialistes (UEMS), whose main task is topromote the harmonization of Hand Surgical educationand training in EU countries. It was established in 1999by the initiation of UEMS Surgical Section, and all Sectionsinterested in Hand Surgery are invited to join. TheFederation of European Societies for Surgery of the Handreported its interest for collaboration. The disciplines, inwhich hand surgery is closely linked, and which were interestedin joining the Committee by their representativeswere General Surgery, Orthopaedic and Trauma Surgery,Plastic Surgery, Paediatric surgery. The function of thecommittee was activated no earlier than 2008, when thefirst meeting with representatives of UEMS and FESSHtook place on January 26, 2008 in Brussels, after whichregular meetings have been organised.4.1. European Boar d of Ha ndSurgery (EBHS)The European Board of Hand Surgery (EBHS),formed by the MJC on Hand Surgery and the EuropeanFederation of the Societies of Hand Surgery(FESSH), was initiated in 2010 and endorsed by theUEMS Council in Prague, October 9, 2010.EUROPEAN CURRICULUM FOR HAND SURGERY1. PREFACE1.1. Particular qualificationHand Surgery has developed into a particular qualificationwith practitioners derived from orthopaedicsurgery, plastic surgery, general surgery and occasionallyother disciplines such as trauma surgery, paediatricsurgery and emergency medicine. The term HandSurgery includes conditions of the hand and wrist andperipheral nerves, including the brachial plexus (primaryand secondary surgery).In Europe, different countries have different trainingprogrammes and thus different emphasis on therequirements for becoming a Hand Surgeon. In Finland,Hand Surgery is regarded as a separate specialitywith training in Hand Surgery undertaken withoutprior Orthopaedic or Plastic surgical training. In somecountries (e. g. Germany, Hungary, Sweden) HandSurgery is a particular qualification with practitionersformally trained in Hand Surgery following training inOrthopaedics, Plastics and General Surgery. In somecountries (Turkey, UK) Hand Surgery is a separatespeciality in some centres and part of plastic surgeryor orthopaedic surgery in others. In other countries,(Austria, Belgium, France, Italy, Netherlands, Norway,Poland, Portugal, Rumania, Russia, Slovakia, Spain)Hand Surgery is a particular qualification professed byan Orthopaedic, a Plastic or a General surgeon.Within countries, there are some hospitals withseparate hand/peripheral nerve surgery units andothers, which manage hand conditions within the orthopaedicor plastic surgery department. Even withinHand Surgery, there are sub-specialities such as brachialplexus, congenital differences, micro-vascularsurgery and complex wrist reconstruction.In Europe, different countries have different trainingprogrammes and thus different emphasis on therequirements for becoming a Hand Surgeon. In section4.3.2 of this document, the current status of HandSurgery in each member country is described. In onlyone country (Finland) Hand Surgery is a separate9Вопросы реконструктивной и пластической хирургии № 4 (39) декабрь2011White book on hand surgery in Europespeciality from the start of surgical training onwards;in some countries it is a particular qualification afterprevious training in Orthopaedics, Plastics or GeneralSurgery followed by specific training and examinationin hand Surgery. In some countries Hand Surgery is aself-professed speciality without formal training or examination.This is a developing picture; there is likelyto be a trend towards specific training and examination.2. INT RODUCTION2.1. Learning resourcesThe trainee in Hand Surgery has many learning resourcesavailable.2.1.1. Clinical ExperienceTrainees will learn from their present employmentpost by observation, supervised operating, discussion.This apprenticeship is a crucial part of surgical training.2.1.2. FellowshipsFurther training is gained from a Hand Fellowship.This provides concentrated experience, not diluted bygeneral orthopaedic or plastic surgical duties. SomeFellowships provide very specialised training withinHand Surgery depending on the practice and reputationof the Consultant to whom the Fellow is attached.Fellowships are available in Europe; FESSH intendsto develop a European Fellowship Directory.Overseas Fellowships are also available across theworld, which offer excellent experience.Observerships are also available, in which thetrainee can visit a centre with a particular reputationor expertise, to learn by observation rather thanpractical involvement in patient care. Constraints onsalary, time and medical registration make short observershipsa valuable.Funding is available for some fellowships. FESSHoffers Training Award and Senior Travel Awards. NationalSocieties also offer support (see individual Societywebsites).2.1.3. Reading2.1.3.1. Journals Journal of Hand Surgery, European Volume. Journal of Hand Surgery (American). Chirurgie de la Main (France). Handchirurgie, Mikrochirurgie, PlastischeChirurgie (Germany). Magyar Traumatologia, Ortopedia, Kezsebeszet,Plasztikai sebeszet (Hungary). Revista Ibero-americana de Cirurgia de lamano (Spain). Rivista di Chirurgia della Mano (Italy). Rumanian Journal of Hand and ReconstructiveMicrosurgery. Scandinavian Journal of Plastic and Hand Surgery. Orthopaedic Surgery Literature. Plastic Surgery Literature. Microsurgery Literature.2.1.3.2. Internet sourcesPubmed Medscape Web of Science.2.1.3.3. TextbooksMany are available to cover all aspects of HandSurgery in various depths and formats.2.1.4. MeetingsMeetings provide education from formal lectures,research presentation and informal discussion. Thereare verymany suitable meetings: National Hand Surgery Society Meetings. FESSH Annual Meeting- Meetings. Instructional Courses (Austria, Belgium, Finland,France, Germany, Hungary, Italy, Netherlands,Norway, Poland, Rumania, Spain, Sweden,Turkey, UK).2.1.5. TutorialsTraining programmes should be encouraged toprovide tutorials for individual or groups of traineesas a powerful tool for personal education.2.2. Learning OutcomesThe Hand Surgery curriculum should lead to thefollowing outcomes and core competencies: knowledge and Understanding; practical Skills; intellectual skills; personal Qualities; other skills.2.3. AssessmentIt is envisaged that an individuals expression of aninterest in hand surgery should be supported by formalassessment.2.3.1. Ongoing work-based assessmentA trainee should be regularly assessed by formalindividual appraisal from his supervisor or trainer.The appraisal should have a structured form so thatlearning goals are set, reviewed mid term and then reviewedat the end of training.2.3.2. Formal Examination2.3.2.1. European Diploma in Hand Surgery,released by the European Board of HandSurgery of UEMSProvider is the Federation of the European Societiesfor Surgery of the Hand (see 4.3 Certification inHand Surgery).10№ 4 (39) декабрь2011 Вопросы реконструктивной и пластической хирургииWhite book on hand surgery in Europe2.3.2.2. National Diplomas in Hand Surgery2.3.3. Other TestsExamples for self assessment include: American Society for Surgery of the Hand SelfAssessment Questionnaire www.assh.org; Journal of Hand Surgery (European) «So youthink you have read this Journal?»3. CORE COMPETEN CIESOF THE EUROPEAN HAND SURGEON3.1. Knowledge and Understanding3.1.1. Basic Science Anatomy of the hand and upper limb. Embryology of the Hand and Upper Limb. Physiology of muscle, nerve and bone metabolism.3.1.2. Principles of Hand Surgery Injured hand - wound care, management ofskeletal, vascular, tendon and nerve injuries. Treatment of fractures and malunions of thehand. Ligament ruptures and joint instabilities of thehand. Arthroscopy of the hand and wrist. Amputations in the hand. Burns of the hand. Reconstructive surgery of mutilated hand. Management of upper limb nerve injuries, includingbrachial plexus injuries. Management of tetraplegia, stroke, brain injuryand cerebral palsy. Tendon transfers. Congenital abnormalities of hand and upperlimb. Arthrosis of the hand and wrist. The arthritic hand in rheumatoid arthritis andother inflammatory arthritides, e. g. LES andscleroderma. Dupuytrens contracture. Overuse syndromes. Nerve compression syndromes. Infections of the hand. Vascular disorders. Tumours of the hand.3.2. Practical Skills3.2.1. RequirementsHand Surgery has a very large repertoire of proceduresfor which the surgeon needs detailed knowledgeof the complex anatomy of the hand and wrist, aswell as competency in microsurgery, reconstructiveplastic surgery and orthopaedics. Some proceduresrequiring specific practice and skill should be undertakenby only a few (e. g. pollicisation of the thumb,brachial plexus exploration) whereas others (e. g. triggerfinger, carpal tunnel) can be undertaken by manypractitioners with surgical qualification and basictraining; still other procedures, although complexand rarely performed, can be performed by a trainedHand Surgeon by applying familiar techniques to familiaranatomy.3.2.2. List of proceduresHerein follows a description with the operationsto be performed independently by the trainee or, foroperations of a higher degree of difficulty, as a participant.Microvascular experience is essential.Surgical procedures can be listed according to theanatomical structures involved:A) Skin and subcutaneous tissue:1. Free skin graft.2. Pedicled local flaps.3. Regional and\or island flaps.4. Free flap with microvascular anastomosis.5. Treatment of retracting scars of the handand wrist.B) Tendons:1. Flexor tendon repair.2. Flexor tendon graft.3. Flexor pulley reconstruction.4. Flexor tendon tenolysis.5. Trigger finger release.6. Extensor tendon repair.7. Extensor tendon graft.8. Extensor tendon tenolysis.9. Tendon sheath synovialectomy.10. Tendon reconstruction in rheumatoid arthritis.11. Tendon transfers (injury, paralysis, spasticconditions).12. Free muscular flap with microvascular anastomosis.C) Bone and Joints:1. Closed reduction and fixation of fracturesand dislocations.2. Open reduction and fixation of fracturesand dislocations.3. Corrective osteotomies.4. Treatment of non-union.5. Bone resections.6. Bone grafts and substitutes.7. Free bone transfers with microvascularanastomosis.8. Finger joint ligament or palmar plate repair\reconstruction.11Вопросы реконструктивной и пластической хирургии № 4 (39) декабрь2011White book on hand surgery in Europe9. Wrist ligament repair\reconstruction.10. Arthrolysis.11. Digital\wrist arthroplasty (incl. allo-arthroplasty).12. Wrist partial and total fusion.13. Hand Arthrodesis.14. Denervation.15. Synovectomy.16. Arthroscopy.17. DRUJ reconstruction.E) Nerves:1. Microsurgical repair of nerve lesions.2. Nerve grafting and neurotisation.3. Neurolysis.4. Brachial plexus repair\reconstruction.5. Treatment of nerve compression syndromes.G) Blood vessels:1. Microsurgical arterial anastomosis.2. Microsurgical venous anastomosis.3. Adve graft omy.List of procedures should also include operationsfor the treatment of complex trauma of thehand, special.A) Amputations:1. Hand level.2. Carpal or forearm\upper limb level.B) Replantation in limb amputations:1. Digital or metacarpal level.2. Carpal or forearm\upper limb level.3. Lower limb.C) Treatment of thermal burn, chemical injury,electrical trauma.D) Mangled hand treatment.E) Fasciotomy.F) Necrotising fasciitis.G) 1. Um Resection of skin and soft tissue tumour.2. Resection of bone tumour.3. Resection of tumour-like lesion.H) Dupuytrens contracture.I) Treatment of congenital malformations of thehand.3.3. Intellectual Skills3.3.1. EducationA Hand Surgeon must be able to critically assessa research article or podium presentation, to understandthe strengths and weaknesses of the materialand to apply it to his own practice.3.3.1.1. Continuing Medical EducationEducation is a life-long process; the Hand Surgeonshould take personal responsibility to use allresources to improve and update his knowledge andpractice.3.3.2. ResearchThe Hand Surgeon should undertake some researchduring his/her training, At the very least, athorough understanding of the basics of research isessential: formulating a hypothesis; designing an appropriate methodology to testthat hypothesis.3.3.3. AuditThe Hand Surgeon should review the outcome ofhis own practice. As a minimum, a log book should bekept. Procedures with uncertain outcomes or surgeondependentoutcomes such as joint replacement, scaphoidfracture fixation, tendon grafting, should be routinelymonitored for quality. Validated scoring schemesare available for example the QuickDASH, PatientEvaluation Measure (PEM) and Michigan Hand Score.3.3.4. TeachingTeaching is part of learning. Also, an individualhas a responsibility to pass on acquired knowledgeand skills so that others can benefit. The Hand Surgeonshould also teach the patient so they are betterinformed of their condition and the treatment options.3.4. Personal Qualities3.4.1. Team workingHand Surgeons work with theatre teams, therapists,nurses, junior doctors and many others whoare involved in the care of patients. The Hand Surgeonwill often be the leader of the team and shoulddevelop the necessary qualities of leadership.3.4.2. DelegationMany problems in Hand Surgery can be sharedwith others. The Hand Surgeon should developskills of delegation so that patient care can be safelydelegated to the appropriate practitioner to helpprovide an efficient, safe and cost-effective service.3.4.3. Time Managementand Stress ManagementSurgery is stressful. It requires long hours withmany competing demands on time and skill. Somedecisions are uncertain; some procedures are verycomplex with potentially serious complications anduncertain outcome. The Hand Surgeon must learnto manage time and cope with stress.3.4.4. ReferralThe Hand Surgeon must appreciate the responsibilityof asking for advice or referring to anotherpractitioner when a case is beyond his expertise orcomfort.12№ 4 (39) декабрь2011 Вопросы реконструктивной и пластической хирургииWhite book on hand surgery in Europe3.5. Other Skills3.5.1. ConsentInformed consent is important in developingthe confidence of a patient by engaging them in thechoice of treatment and avoiding medico-legal issueswith unexpected outcomes.3.5.2. DocumentationClear contemporaneous documentation is importantfor many reasons: to allow proper handover,for example post-operative instructions; to recordthe basis of clinical decisions; for medico-legal protection;to collect data for research and audit.3.5.3. Service ManagementA Hand Surgeon must be able to prioritise andalso develop the skills to manage their service withthe skills, resources and personnel available.4. ST RUCTURE OF TRA ININGOF EUROPEAN HAND SURGEONSStandards of postgraduate medical education havebeen developed (see reference list) upon which thetraining of Hand Surgeons in Europe should be based.4.1. Routes into Hand SurgeryTrained Hand Surgeons derive from four routes: An individual who trains in a country whereHand Surgery is a speciality in its own right. A trained and accredited Orthopaedic or PlasticSurgeon who develops Hand Surgery as aparticular qualification. A trained and accredited Surgeon (not Orthopaedicsor Plastics) who develops Hand Surgeryas a particular qualification interest.An accredited Orthopaedic or Plastic Surgeonwho develops Hand Surgery as a particular qualificationinterest will cover a broad range of HandSurgery and so less specific Hand Surgery trainingis required compared with an individual who hastraining, with or without accreditation, in anothermajor surgical discipline. Hand Surgery certificationtherefore has to take account of these differentroutes.4.2. AssessmentAssessment takes two forms, formative and summative.4.2.1. Formative assessmentThis is an ongoing process in which the traineehas teaching, advice and review of his/her progress.It allows the trainee to grow in knowledge and confidence;gaps are identified and filled. Regular appraisal and documentation of progress. Assessment in the workplace. Observation of histo sion taking, examination,surgical procedures. Assessment outside the workplace. Case presentations, research presentations,teaching of colleagues.4.2.2. Summative assessmentThis is a formal test of whether the trainee hasreached an appropriate standard. The requirementsfor the Diploma, which provides the summative assessment,are described below.4.3. Certification in Hand Surgery4.3.1. European Board of Hand Surgery DiplomaThis recognises the varied routes into Hand Surgeryacross Europe. Because of the differences whichexist in training in different parts of Europe, differentsets of criteria will have to be utilised according to theprevailing pattern of training in the candidates owncountry.1. Examination.2. In countries where training in hand surgeryfollows accreditation in a major surgical specialityother than Orthopaedic or Plastic Surgery, twoyears training in an accredited centre with 100 % exposureis required.3. Candidates from countries in which hand surgeryis a separate speciality in its own right, may takethe European Diploma Examination without furthertraining provided that: Their general background training (minimumduration 2 years) has incorporatedexposure to orthopaedic and/or plastic surgeryfor at least one year. Their speciality in Hand Surgery has beenfor a minimum of three years in an accreditedcentre with exposure to both orthopaedicand plastic surgery techniques, includingmicrosurgery. They have achieved accreditation in handsurgery in their own countries.A countersigned logbook indicating performedand assisted operations, academic records andtraining posts held is also required. The logbookcontains 14 subsets, including tendon, joint surgery,replantations and congenital conditions and has aguide to the recommended number of operations.The candidate should prove a significant number ofoperations as operator or first assistant. If possible,the training should be done in an accredited hand13Вопросы реконструктивной и пластической хирургии № 4 (39) декабрь2011White book on hand surgery in Europesurgery training center. At this moment the accreditationof hand surgery training centres is based onthe proposals made by national societies. It is alsoexpected that the candidates pursue a scientific activity.The candidates should also have a recommendationfrom his/her National Society for Surgery ofthe Hand.If the candidate fulfils the above requirements hemay take the European Examination.The examination is open, not only to hand surgeonsfrom European member countries, but also toanyone who desires to participate and receive certificationin this specific competency, in conformity withEuropean standards.4.3.2 Recognition of Hand Surgery and NationalDiplomas4.3.2.1 Status of each FESSH member CountryAustria. Hand Surgery is just about to become aspeciality with a three year training programme andthen an examination due to be developed. Candidateshave prior training in Orthopaedics, Trauma, Plasticsor General Surgery.Belgium. Exam administered at 4 Universities,comprising a dissertation (Universe Libre de Bruxelles,University Catholique de Louvain, Universityde Liege, Universite de Lille II). Training occurs overa period of 2 years, 4 theoretical modules and practical(dissection) per year and 1 year training in a specialisedhand centre. Details from olivier.barbier@uclouvain.beBulgaria. No details.Czech Republic. Hand surgey is not a separatespecialty and there is no examination.Denmark. No details.Estonia. No formal training.Finland. Hand surgery is a separate speciality withan examination organized by the University of Helsinki.France. Hand Surgery is not a separate qualificationbut follows training in orthopaedics or plastics. Toqualify as a hand surgeon, the orthopaedic or plasticsurgeon must spend 1 year as resident and 2 years asFellow in Hand Surgey training centres accredited bythe «College de Chirurgie de la Main» (Hand surgeyCollege). The trainee must pass an Inter University Diploma(IUD). There is a University Diploma of Surgeyof the Hand and Upper Limb in 2 years (St Antoine,HEGP, Lille, Bobigny, Versailles) and a University Diplomain Microsurgey at Bichat, Fer-a-Moulin and StLouis Hospital Paris.Germany. Hand Surgey is a particular competence(zusatzbezeichnung) after 6 years of GeneralSurgery, Plastic Surgey, Orthopaedics, Paediatric surgery,Neurosurgey. Surgeons then need a further 3years of Hand Surgey training, completed by an oralexamination in Hand Surgery.Greece. Hand surgey is not a separate specialtyand there is no examination.Holland. Hand Surgey is not a separate specialityand there is no examination. There are no set criteriaby which an individual can be classified as a HandSurgeon. Most hand surgeons have trained in PlasticSurgey, occasionally Orthopaedics.Hungary. Hand surgery has been recognized as aseparate specialty since 1994. There are two years oftraining after training in, Orthopaedics, Trauma orGeneral Surgery, as well as a practical and theoreticaloral examination. Over 80 % are trained as TraumaSurgeons.Ireland. No details.Italy. Hand surgery is not a separate speciality andthere is no examination. There are University.Masters in hand surgery: the participant should attend1500 hours of teaching (800 lectures, 700 clinical).Each of the Masters gives 60 formative credits.Hand surgeons come from orthopaedics or plasticsurgery specialties.Latvia. No details.Norway. There is a Diploma in Hand Surgeryawarded by the Norwegian Society for Surgery of theHand. To obtain the Diploma the candidate has to bea specialist in orthopaedic, plastic or general surgeryand in addition has to fill certain criteria (detailed in«the Log Book» made by the Hand Society).Poland. No details.Portugal. No details.Rumania. There is no formal training and no examination.Hand surgeons derive from Plastic Surgery.Russia. Entry is through Orthopaedic Surgery. Nospecified criteria for being a Hand Surgeon and no examination.Slovenia. No information.Spain. There is no formal training programme orexamination. Trainees can undertake a Hand SurgeryFellowship after Plastic or Orthopaedic Training.Sweden. Used to be separate but in 2007 ruleschanged. Hand Surgery is now a branch of Orthopaedics.After 5 years of orthopaedic training, there aretwo further years of hand surgery training and attendanceat 6 courses. The FESSH Diploma entitles a salaryraise of 150 to 200 Euros per month.Switzerland. Hand Surgery is recognized as aseparate specialty. After 2 years of general training inPlastics, Orthopaedics, General or Paediatric Surgery,there is a 4 year training programme in at least 2 differentcentres. The trainee must attend 6 national orinternational conferences or courses and must be the14№ 4 (39) декабрь2011 Вопросы реконструктивной и пластической хирургииWhite book on hand surgery in Europefirst author of a peer-reviewed article on hand surgery.The trainee must also give 2 oral presentationsat a hand surgical congress and complete a log book.There is a final oral examination organized by theSwiss Hand Society.Turkey. Hand Surgery has just been accepted as aparticular qualification. An examination should be developedwithin two years.UK. Hand Surgery is not quite a separate specialityalthough holding of the FESSH Diploma and appropriatetraining has led to recognition by the licensingbody (General Medical Council). The BSSH andUniversity of Manchester hold an examination eachyear. Hand Surgeons gain their board examinations inOrthopaedic or Plastic Surgery and can then specialisein Hand Surgery. At least one year as a Fellow ina recognized centre in the UK or abroad is expectedalthough there are no formal requirements for someoneto promote themselves as a hand surgeon. Furtherdetails www.bssh.ac.uk /education/diploma.4.4. TrainersTrainers will be trained Hand Surgeons who areable to provide the time, enthusiasm and resourceto support the educational needs of the trainee.The Trainer should be recognised by his or her peersas an individual with the proper attitude, reputationand credentials to train.4.5. Training CentresThere are very many excellent centres for trainingin Hand Surgery throughout Europe. Formal recognitionis a future option (see 5.)4.6. Trainees4.6.1. Personal responsibilityThe trainee has a personal responsibility to followthe curriculum. This means dedication of timeto reading and observing and to arranging time withthe trainer. Hand Surgery is diverse and an individualtrainee will have deficiencies in experience. A traineewith an orthopaedic background may need to makespecial effort to fill gaps in knowledge of the plasticsurgical aspects of hand surgery. Fellowship trainingand observerships, often meaning travel away fromhome, is usually required.4.6.2. LogbookThe trainee must keep a log book of proceduresthat have been performed or participated in. The logbookshould form a part of the ongoing formativeassessment of the Trainee, as well as a marker for entryinto summative assessment (i. e. Diploma). Anadequate range of procedures should be accumulatedto allow competent unassisted performance of manyprocedures and at least an understanding of morecomplex procedures.5. FUTURE DEVELOPMENTSEducation is a developing process.5.1. Fellowship and TrainingPost DirectoryThe FESSH website suggests a database of training,research and fellowship posts. Centres can uploadinformation about the location, experience availableand financial arrangements. The database can besearched by potential applicants. It is hoped that thedatabase will be populated by more and more centresover the next few years.5.2. Hand Trauma CentresA European network of Hand Trauma centres hasbeen developed by FESSH. These centres can provideintensive training in the management of hand trauma,as well as opportunities for audit and research (seewww.fessh.org).5.3. Joint RegistryAnatomical joint replacements are available forthe wrist, metacarpophalangeal joints, proximal interphalangealjoints, thumb base, ulna head, radialhead and elbow. New designs and biomaterials areevolving. Whereas hip and knee replacement givereliable long term results, there are few data on theoutcome of most implants in the hand. Some devicesfail early and have been withdrawn. A European JointRegistry based on a web-based proforma wouldproduce a very large database from which the bestperformingimplants can be selected and by whichpoor designs can be detected and withdrawn as soonas possible.5.4. Hand Surgery Training CentresThere are no recognised criteria at present for arecognised training centre. The EBHS plans to considercriteria, such as volume of work, exposure tospecial interests within hand surgery, emergency15Вопросы реконструктивной и пластической хирургии № 4 (39) декабрь2011

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