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Updated: May 8, 2026

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery

Published on: February 17, 2018

Does the gatekeeper model work in hand surgery?

Tristan L Hartzell¹, Jonathan H Shahbazian, Amit Pandey

¹Norfolk, Neb.; Los Angeles, Calif.; and Baltimore, Md. From the Department of Surgery, Faith Regional Health Service; the Department of Orthopedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles; the University of Southern California; and the Department of Surgery, University of Maryland Medical Center.

Plastic and Reconstructive Surgery

|August 30, 2013

Summary

This summary is machine-generated.

Most patients with hand problems see a primary care provider first, but many receive incorrect diagnoses and unnecessary treatments. This suggests the current referral system may not be the most efficient for hand care.

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Area of Science:

Orthopedics
Hand Surgery
Health Services Research

Background:

Managed care plans often use a physician "gatekeeper" model for referrals.
The effectiveness of this gatekeeper system for upper extremity complaints is largely unevaluated.
Prior management of patients with elective hand disorders has not been systematically assessed.

Purpose of the Study:

To evaluate the prior management of patients with elective hand disorders presenting to a hand surgery clinic.
To assess the accuracy of diagnoses and appropriateness of treatments initiated before specialist referral.

Main Methods:

Prospective enrollment of new patients at a tertiary academic medical center.
Evaluation of prior provider, diagnosis, treatment, and complications for 125 patients.
Independent determination of actual diagnosis and appropriate treatment by two experienced hand examiners.

Main Results:

98% of patients saw a primary care provider, but only 34% received the correct diagnosis.
Nerve compression syndromes were diagnosed accurately 64% of the time; stenosing tenosynovitis only 15%.
74% of patients had prior interventions, 70% deemed unnecessary; 90% of advanced imaging was unwarranted.

Conclusions:

Primary care providers unfamiliar with hand anatomy frequently misdiagnose and mistreat common hand conditions.
The current referral system may be inefficient for delivering care for elective hand conditions.
Delays in diagnosis and unnecessary interventions led to complications in 17% of patients.