August 2013.pdf - American Society for Surgery of the Hand

ifsshezineCONNECTING OUR GLOBAL HAND SURGERY FAMILYwww.ifssh.info VOLUME 3 ISSUE 3 AUGUST 2013Journal HighlightsMember Society UpdatesUpcoming EventsIFSSH ScientificCommittee Report on theAnatomy of the HandTHERAPEUTIC EXERCISE IN WRISTREHABILITATION PART 2THE EPONYMOUS SWANSON LECTUREBY PROFESSOR WAYNE MORRISON

Angular stable fixation of ulnashortening osteotomies.LCP Ulna Osteotomy System 2.7.Optimized Plate DesignThe low profile plate with tapered ends reduces the risk of soft tissue irritation and hardware relatedpatient discomfort. The plate is available in two lengths: 6 and 8 holes.Precise InstrumentationSystem specific instrumentation like Parallel Saw Blades and Drill Templates allow to perform a secureand accurate osteotomy cut, for transverse cuts as well as for oblique cuts between 2 and 5 mm width.Freehand TechniqueAdditionally available Compression / Distraction Instrument to facilitate freehand technique applicationespecially in shortenings more than 5 mm.For further information please contactyour local Synthes representative:www.synthes.com

August 2013Contents4 EditorialBy Professor Ulrich Mennen, editor of the IFSSH ezineLetters to the editor6 Executive news• Newsletter from the Secretary-General:Marc Garcia-Elias• Message from outgoing Secretary-General:Zsolt Szabo8 Member society updates• The Asian Pacific Federation Societies for Surgery ofThe Hand (APFSSH)• Australian Hand Surgery Society• News from the Brazilian Society for Surgery of theHand12 Special features:• The Eponymous Swanson Lecture by ProfessorWayne Morrison, given at the 11th Congress of theIFSSH in India, March 2013• The Turner Institute in St. Petersburg, Russia16 PulseIFSSH Scientific Committee Report on the anatomy ofthe hand26 Hand therapyTherapeutic Exercise in Wrist Rehabilitation Part 230 Research Roundup• Innovations in treating skin defects of the hand• Free vascularised medial femoral condyle autograftfor challenging upper extremity nonunions• Modern tendon repair techniques33 Pioneer profilesRobert CarrollNils Carstam36 Journal highlightsTables of Content from leading journals such as TheJournal of Wrist Surgery, The American Journal ofHand Surgery, Journal of Hand Surgery Asian Volume,Journal of Hand Surgery European Volume and theJournal of Hand Therapy.39 Upcoming eventsList of global learning events and conferences forhand surgeons and a surgical fellowship opportunityin IndiaIFSSH ezine AUGUST 20133

editorialEditorialThe IFSSH ezine has become the official communication tool of the IFSSH. It also has become popularamongst our Members, judging from the constant flow of new subscriptions and the huge number ofsubmissions.To reiterate, the tagline of the Ezine is:for the Members, by the Members!Therefore every Member is invited and encouraged to use this medium:1. to share interesting and educational information2. to advertise upcoming activities3. to share humerus incidents (humorous!)4. to give an opinion, controversial or debatable5. to send photos which tell more than words6. to get or give advice on difficult casesThis issue contains the following special features:1. The Eponymous Swanson Lecture by Professor Wayne Morrison, presented at the 11th Congress of theIFSSH in India, March 2013.2. The Turner Institute in St. Petersburg, Russia.3. A new section for Member society updates and related Federations. Delegates are encouraged to usethis platform to uniform colleagues worldwide about their activities.Be a communicator!With sincere regardsUlrich MennenImmediate Past-President:International Federation of Societies for Surgery of the HandEditor: IFSSH ezineIFSSH disclaimer: The IFSSH ezine is the officialmouthpiece of the International Federation of Societiesfor Surgery of the Hand. The IFSSH does not endorsethe commercial advertising in this publication, nor thecontent or views of the contributors to the publication.Subscription to the IFSSH ezine is free of charge and theezine is distributed on a quarterly basis. To subscribe,please click here. Should you wish to support thispublication through advertising, please click here.IFSSH ezine editorial team:Editor: Professor Ulrich Mennen (Immediate Past President of the IFSSH)Deputy Editor: Professor Michael Tonkin(President of the IFSSH)Publication coordinator:Marita Kritzinger (Apex ezines)Graphic Designer: Andy GarsideSUBSCRIBE TO THEezineifsshFOR FREE4 IFSSH ezine AUGUST 2013

letters to the editorDear MemberI am trying to draw together a comprehensive archive. At themoment Belinda Smith (IFSSH Administrative Secretary) and I areconcentrating on the Executive Committee Meetings over theyears. I think the International Federation was set up in Januaryof 1966 and have the inaugural Minutes. However, at presentwe have nothing from January of 1966 until some Minutesdated the 6 March 1971. After that we have no Minutes until the24 February 1981. We have no Executive Committee Minutesfrom 1982 -1986 or 1997 - 2000 (inclusive). If you have a copyof any of the Executive Committee Minutes that are missing Iwould be grateful if you would scan them and send them toBelinda in the Secretariat (email: administration@ifssh.info). Wewould be extremely grateful. Minutes are very valuable datawhich trace the development of the International Federationand a comprehensive set would be a very valuable resource forarchivists in years to come.I think we should also start to develop the same process forthe Delegates’ Council Meetings. At this stage the only question Ihave relates to the date that Delegates Meetings started. We haveall the Delegates Minutes from 2001 onwards and know that therewas a Delegates Meeting in Barcelona of June 2000 (although wedo not have those Minutes currently).I do hope you will be able help us with the missing ExecutiveCommittee Minutes and/or information concerning the inauguralDelegates’ Council Meeting and any Delegate Minutes from theoutset to the year 2000 inclusive.Frank BurkeIFSSH HistorianLiving Textbook ofHand Surgery:an updateAt the IFSSH Congress in Delhi, with theenthusiastic support from Ulrich Mennen andRaja Sabapathy, great interest and cooperationfrom the Hand Surgery family was shown for TheLiving Textbook of Hand Surgery. More authors,reviewers and members for the editorial boardhave come forward to participate. However, somechapters are still missing authors! The editorialteam welcomes everybody who is interested totake part as an author. Do not hesitate to contactus if you are interested in participating in this veryexciting venture.The team has been working backstage todevelop the software. The intended interactiveweb design for the book is completely differentfrom standard ebooks and published PDFdocuments,and therefore has to be generated asa new concept.We are also in contact with Wikimedia andopen access networks, to adapt the book,from the beginning, to defined concepts ofopen educational resources, like the UNESCO,who developed a system especially for highereducation.The Living Textbook of Hand Surgery will beintroduced and discussed at the OER-Congressand Barcamp of Wikimedia in Berlin, in September2013 to gain technical and conceptual ideas.You are invited to follow the progress at thewebsite: handbookhand.com. A timetable offurther developments will be published soon.Thank you all for your support and interest,Richarda BoettcherHandchirurgie Weltweit e.V.richarda.boettcher@hand-ww.deIFSSH ezine AUGUST 20135

executive newsNewsletter from theSecretary-GeneralDear FriendsIt is only four months since I embarkedon this magnificent cruise, calledIFSSH, and yet I know that I willenjoy this trip. So far, membershipcooperation has been superb; the crew(Belinda, Santosh), incredibly efficient;and the captain (Michael Tonkin), anexpert sailor, one of the best, indeed!Yes, our ship is in good hands, andwith the help of those who precededme (Thank you, Zsolt and Ulrich) I haveno concerns. If I ever thought thatlife as a secretary-general would bequiet, it is time to say that I was wrong.This is a ship where things happenconstantly. Paraphrasing Rod Steward,I would say that “there is never a dullmoment” in our Federation. Let me tellyou what is going on.For those who are still basking inthe glow of that “incredible India” wehad the chance of visiting, rememberthat thousands of photos were takenduring the congress, and that they areavailable through our website (http://ifssh-ifsht2013.com/gallery1.php). Thepictures are in web/screen resolution.To obtain high resolution copies forprinting purposes, please send amessage with the code number givenbelow each photo to the webmasterat info@krithitechnologies.com, and hewill mail them to you.The IFSSH sponsored theregistrations of 20 surgeons to attendthe triennial congress in Delhi, aswell as recently providing fundingfor IFSHT projects and assisting theAmerican Association for Hand Surgerywith financial support to teach handand microsurgery to a Mongoliandelegation.The Committee for EducationalSponsorship (CES), along with theExecutive Committee, presented anew set of guidelines for educationalbursaries and grants to the Assemblyof National Delegates. They wereapproved, with four main categories ofeducational sponsorship support:• Specific education projects withthe oversight of a society/memberof the IFSSH (e.g. fellowshipprogrammes at underdevelopedinstitutions, educational DVDs andbooklets, etc);• Society congress/courses organisedby societies, with support availablefor speakers, registrants and/orequipment;• Regional courses, such as theEastern European Hand Surgerycourse; and• IFSSH congress registration (i.e.support to attend the congressfor those from areas of need –IFSSH membership is not requiredfor individuals to apply for thiscategory).The method of application andacceptance was simplified to make theprocess much faster and allow moreprojects to receive timely funding.Delegates are asked to read theguidelines on the website (www.ifssh.info) and encourage applications fromtheir societies.Excellent news comes fromBuenos Aires about the possibility ofhaving both the IFSSH and the IFSHTcongresses in the same venue, apossibility that was initially discarded.Although not yet fully decided, thelocal organising committee is workingfull speed in this. The 2016 IFSSHCongress will be held on October10-13, 2016 in one of most attractiveareas of Buenos Aires, Puerto Madero.6 IFSSH ezine AUGUST 2013

executive newsMessage from outgoingSecretary-General:Zsolt SzaboFurther information may be obtainedat www.ifssh-ifsht2016.com. In thisregard, new, more detailed guidelineson how to organise an IFSSH congresshave been presented for discussion tothe ExCo.Aside from these initiatives, theadministration keeps its routine:control of banking transactions,sending receipts to the membershipwho paid theirs annual dues, websiteupdates, committee reports, and so on.We have started preparations forthe National IFSSH Delegates Councilmeeting which will be held in Parisduring the meeting of FESSH, June18-21, 2014 (www.fessh2014.com/en/welcome).Frank Burke is doing a great jobin reorganising and completing ourarchives, a badly needed task thatfinally appears to see an end.A process of discussion has beenstarted in order to update the IFSSHcharter, a modification project that isneeded to adapt our legal status to the‘changing times’.I wish you the most relaxingsummer vacation!Marc Garcia-EliasSecretary-General, IFSSHEmail: secretary@ifssh.infoIFSSH ezine AUGUST 2013As the Secretary-General during thelast three years, I have realised howimportant it is to be a member ofan international community. I havebeen always told, but now I knowthat we, the hand surgeons from allaround the word, we are a little bitspecial. Our enthusiasm and friendship,our involvement in teaching andeducation activities, combined withhigh quality social activities makeshand surgery different to otherspecialties. The Executive Committeeof the IFSSH led by its President didhis best for the final goal of everyhand surgeon: a better outcomefor our patients. All our activities,projects and work are dedicated tothis and for success we really needyour contribution. The best leaderis worth nothing without a devotedand enthusiastic army. Changing theleaders from time to time brings freshideas, new methods and differentflavours, but the continuity, the realvalue is always represented by theactive membership of a Society anda Federation. It was an honour anda great satisfaction to work with youduring the last three years. We haveachieved much.A new Executive Committee hasbeen elected. The personalities andthe devotion of the new officers area guarantee of continuity and thedevelopment of new ideas, activitiesand projects. I would like to thank youfor your involvement, for your supportand your active participation in thelife of our Federation and I wouldlike to introduce the new ExecutiveCommittee:President: Michael TonkinPresident Elect: Zsolt SzaboSecretary-General: Marc Garcia-EliasSecretary-General Elect: Daniel NagleHistorian: Frank BurkeImmediate Past-President:Ulrich MennenThe new Nominating Committee is:Chair: Ulrich Mennen(Immediate Past-President)Members: Jim Urbaniak,Arlindo Pardini,Moroe Beppu – Member-at-LargeZsolt SzaboPresident Elect, IFSSH7

members newsMember society updatesAustralian Hand Surgery SocietyThe Australian Hand Surgery Society(AHSS) is a relatively small organisationof 150 members, the majority beingfrom orthopaedic or plastic surgerybackgrounds. Over the past fourdecades the Society has evolved froman informal interest group into a muchmore structured organisation withclose links to The Royal AustralasianCollege of Surgeons (RACS), and to theparent speciality bodies, namely TheAustralian Orthopaedic Association(AOA) and The Australian Society ofPlastic Surgeons (ASPS). The HandSociety has always run a vibrant andcomprehensive Annual ScientificMeeting which attracts the majority ofthe membership, and also organisesa number of other workshops andtraining activities for both membersand orthopaedic and plastic surgicaltrainees.In recent years there has beenstrong support towards establishinghand surgery as an independentspeciality in its own right, as presentin a number of other countries.. Formany reasons, some political, someorganisational, this has been resistedby our College of Surgeons, whodo not wish to expand the numberof speciality groups beyond thecurrent 9 established specialities. Ithas become clear over the years thatextra training in hand surgery, outsidethe normal fellowship requirementsof orthopaedic and plastic surgerytraining, is required to developexpertise in hand surgery. In pastyears, this has usually meant surgicalgraduates take up fellowship positionseither overseas or within a handfulof local fellowship jobs available inAustralia. There has been no formalrecognition of this extra training whichhas occurred in an ad hoc manner,although it has served our handsurgery community well. It is wellrecognized that there are considerabledifficulties in finding overseasfellowship positions due to increasingpolitical and bureaucratic obstructionsto the free exchange of doctors andsurgeons between overseas trainingcentres.The Australian Hand SurgerySociety has been actively involved inpromoting post fellowship training inhand surgery, and has pursued waysof improving training in a more formaland structured manner through TheRoyal Australasian College of Surgeons(RACS). In the past few years the RACS,with input from a couple of othersub-speciality groups, has developed apost fellowship education and trainingprogramme (PFET) in a number ofsuper specialities. These currentlyinclude spinal, colorectal and handsurgery.At the beginning of 2013 theAHSS appointed the first new postfellowship trainees into a structuredPFET Programme. This has involvedan enormous amount of work inestablishing agreement betweenall the interested parties (RACS,AOA, ASPS), defining a curriculum,developing mechanisms for traineeselection and the accreditationof training centres, and all of theadministrative processes to assist inmanagement. Although it has justcommenced, we are very enthusiasticthat the PFET programme will expandquite rapidly as our orthopaedic andplastic surgical trainees with interestsin this area seek more formal trainingwithin Australia.There have already been a numberof PFET Training Centre positionsaccredited to take on the expectedincreasing numbers of specialisttrainees, and we look forward to finetuning and improving our programmeas it matures over the next few years.Randall SachPresident AHSSJuly 2013www.ahssociety.org.au8 IFSSH ezine AUGUST 2013

members newsBrazilian Society for Surgery of the HandThe 33rd Congresso Brasileiro deCirurgia da Mão (Brazilian Meeting ofHand Surgery) and the 14th CongressoSul Americano de Cirurgia da Mão(South American Meeting of HandSurgery) were held between April 25thand 27th in Rio de Janeiro, also knownas the Wonderful City.On April 24th, a Pre-Meeting Coursewas held and organized by Dr DonLalonde, President of the AmericanAssociation of Hand Surgery. ManyAmerican hand surgeons came with DrLalonde, and they all paid for their ownexpenses.IFSSH ezine AUGUST 2013The meeting had more than 700participants, including Argentinean,Chilean, Ecuadorean, Peruvian andVenezuelan, German, Brazilian,Canadian and American HandSurgeons. During those four days, wehad an intense scientific schedule.Three rooms held courses, lectures,debates, presentations of thirty oralpapers and eighteen e-posters.Dr Monteiro, SBCM’s President, andDr. Sobania, SSCM’s President, duly thanksthe involvement of all contributors.Carlos Henrique FernandesSBCM’s TreasurerStanding: Hilton Gottshalk (USA),Randip Bindra (USA), José do Carmo (Brasil), CarlosFernandes (Brasil), Peter Murray (USA),Mark Rekant (USA)Sitting: Cherrie A. Heinrich (USA),Julie Adams (USA) Donald H Lalonde (PresidentAAHS), Anderson Vieira Monteiro (President of33o Congresso Brasileiro de Cirurgia da Mão),Alejandro Badia (USA)9

members newsBolivian Hand SocietyThe Bolivian Hand Society recentlyappointed its new council.Dr Juan Carlos Suárez López (President),Dr Alfonso Soria Galvarro Bort (VicePresident), Dr Julio César Irigoyen Suárez(Secretary General), Dr Kenyi NitabaraKoga (Secretario de Hacienda), Dr JorgeArredondo Saucedo (Secretario de Actas),Dr Omar E. Lizarazu Jaldin (Vocal), DrJuan Carlos Mendieta Rojas (Vocal).Asian Pacific Federation Societies for Surgery of the HandThe 9th Congress of the Asian PacificFederation Societies for Surgery ofThe Hand (APFSSH) in conjunctionwith The 5th Congress of the AsianPacific Federation of Societies forHand Therapy (APFSHT) was heldfrom October 10 – 13, 2012 at theGrand Hyatt Hotel in Bali, Indonesia.This was the annual scientificmeeting for hand surgeons and handtherapists in Asia as well as otherphysicians that are interested in themanagement of hand injury,trauma, congenital and otherdisorders of the hand. The9th APFSSH in conjunctionwith the 5th APFSHTincluded approximately1,000 participants from allover the world. The scientificcommittee arranged a stateof the art program includingall the latest developmentsin the field consisting of 4 plenarylectures, 1 memorial lecture, 12 masterclasses, 6 panel discussions, 30 satellitesymposia, 15 keynote lectures, postcongress instructional courses andworkshops, as well as free papersessions consisting of both oral andposter presentations.The 10th Congress of the AsianPacific Federation Societies for Surgeryof The Hand (APFSSH) in conjunctionwith The 6th Congress of the AsianPacific Federation of Societies for HandTherapy (APFSHT) will be held fromOctober 2nd – 4th, 2014 at the HiltonKuala Lumpur Hotel, – Le Meridien inKuala Lumpur, Malaysia.The Society President is Moroe Beppu,The Congress President is S. RoohiAhmad,The Congress Vice-President is RanjitSingh,and the Congress Secretary is ShalimarAbdullah.For further information,please check the homepageof the Congress at http://www.apfssh2014.org/index.html.We look forward to seeingyou all in Kuala Lumpur,Malaysia.Moroe Beppu MDPresident of APFSSHwww.apfssh.org10 IFSSH ezine AUGUST 2013

Angular stable fixation of ulnashortening osteotomies.LCP Ulna Osteotomy System 2.7.Optimized Plate DesignThe low profile plate with tapered ends reduces the risk of soft tissue irritation and hardware relatedpatient discomfort. The plate is available in two lengths: 6 and 8 holes.Precise InstrumentationSystem specific instrumentation like Parallel Saw Blades and Drill Templates allow to perform a secureand accurate osteotomy cut, for transverse cuts as well as for oblique cuts between 2 and 5 mm width.Freehand TechniqueAdditionally available Compression / Distraction Instrument to facilitate freehand technique applicationespecially in shortenings more than 5 mm.For further information please contactyour local Synthes representative:www.synthes.com

special featuresSwanson LectureIFSSH Meeting, Delhi, 2013Wayne MorrisonProfessorial Fellow University Melbourne and Australian Catholic UniversityDirector O’Brien Institute,Plastic surgeon, St Vincent’s Hospital, Melbourne.Thank you for the honour ofpresenting the IFSSH Swanson lecturefor 2013. I can only assume your choicewas inspired by my former fellows andthe charming Indian characteristicof politeness and deference to yourelders. Many of these fellows are nowillustrious alumni on the world stage ofhand surgery. This parental relationshipreminds me of Louis Vasconez anesteemed plastic surgeon whendelivering a similar prestigious lecturetold the story of how he was askedto give a talk at his son’s school andhis son pleaded with him “dad pleasedon’t make a fool of yourself in front ofall my friends.” Here’s hoping!Let me first say something of AlSwanson. This lecture is named inhonour of Alfred Swanson. No name ismore identifiable in hand surgery thanSwanson as a result of his “Swansonsilicone” joints that have proved theirworth and popularity over almost50 years. Given that each person has10 fingers with the potential for 30finger joint replacements, who in thehistory of surgery, would have hada greater influence on hand surgery.These were developed during the1960’s and marketed in 1969 duringa period of hand surgery revivalthat could be described as theHigh Renaissance of hand surgery.Concurrent developments wereoccurring in tendon and nerve repair,congenital deformities, microsurgeryand carpal mechanics. Swanson’sother great contribution was in hisrole as chairman of the Nomenclaturecommittee of the IFSSH where heintroduced a classification for thecongenital hand that allowed outcomestudies of the various reconstructiveprocedures to be critically evaluated.He succeeded my mentor, BernardO’Brien, as president of the IFSSH andO’Brien presented him the Federationmedal which many do not know wasa gift of the Australian Hand Club.It is somewhat ironic that our newpresident Michael Tonkin is now takingit back.I started plastic and hand surgerytraining in 1972 at St Vincent’s Hospital,Melbourne, with Bernard O’Brienwhen Al Swanson was at the heightof his fame. The era of microsurgeryhad just begun and the excitementand expectations were palpable.Mutilating hand injuries were thenorm before the current standards ofhealth and safety were introduced andthe opportunity for replantation andimaginative secondary reconstructionsabounded. For me, this was the idealhand surgery paradigm, a plasticorthopaedichybrid of aestheticand functional challenges, andreconstruction of the mutilated handbecame my major interest.The groin flap was the graveyardof many a budding microsurgeon. Thevessels were small, sometimes absentand recipient size match unfavourable.Failure was common. Anaesthetistsand theatre staff were hostile anda thick hide and strong belief wereprerequisites for self - survival. In1972, Bernard O’Brien commenced anoverseas fellowship training programand we were fortunate to always havethem to blame.In 1976, in the first article of thefirst issue of the American Journal ofHand Surgery, Bill Littler published “100Years of Making a Thumb” charting themilestones and characters involved.This accurately paralleled the field ofhand reconstruction as a whole during12 IFSSH ezine AUGUST 2013

special featuresthis period. His centenary begins in1874 with phalangisation by Hugier; 1888 - staged cross finger transfer(Guermonprez); 1900 - toe transfer andosteoplastic thumb reconstruction(Nicoladani); 1946 - pollicisation basedon the neurovascular pedicle (Gosset,Hilgenfeldt); 1957 - neurovascularisland flap (Moberg, Littler andTubiana); 1960 - microvascularanastomosis (Jacobson); 1965 –digital replantation (Tami); 1967 - freemicrovascular toe transfer (Buncke,Cobbett, O’Brien).Not mentioned in Littler’spantheon, was the Australian, Arthur(Ben) Murray, from Tasmania who inhis youth had lost a leg and sustainedan ulnar nerve palsy but subsequentlywent on to train in orthopaedics. Whilein the UK at the outbreak of WorldWar II, he was not selected for militaryservice but was sent to EdinburghIFSSH ezine AUGUST 2013where he established the firstdedicated hand surgery service whichhas become the prototype modelfor hand surgery services aroundthe world. In 1946, before Gosset,he described the true pollicisationtechnique on the neurovascularpedicle that is essentially employedtoday. He also performed cross ringfinger transfers and long beforeSwanson, performed the first fingerjoint replacement which he designedfrom metal. This was reported in 1946.Two plastic surgery pioneers ofWorld War 1 laid the foundationsof reconstructive surgery on whichmany of the subsequent hand surgerydevelopments progressed. HaroldGillies, a New Zealander working inEngland introduced the tube pediclefor transfer of large amounts of tissueand Johannes Esser, a Dutch surgeonand Gillies’ equivalent working in Berlintreating the German war injured, used“biological flaps” based on arterialpedicles.In 1974 I had the good fortune oftraining at Canniesburn Hospital inGlasgow, then a hotbed of creativityand mecca for international visitors.McGregor had recently describedthe “groin flap” and rediscovered andarticulated the concepts of arterialbasedflaps practised by Esser. TomGibson with Medawar had pioneeredthe concepts of immunology forwhich Medawar won the NobelPrize. Graham Lister and Bob Aclandwere at Canniesburn during thisfertile period. From Glasgow, I wentto Paris with Raoul Tubiana whotaught me hand surgery with anorthopaedic focus under the oneon-onepatron-apprentice format, aunique opportunity and a mentorto whom I owe a great debt. On13

special featuresreturning to Melbourne in 1976, Irejoined the team with Bernard O’Brienand Allan McLeod at St Vincent’swhich was a lively place with fellowsattracted from all around the world.Many fascinating cases including afull face and scalp replant affordedus the experience to develop suchtechniques as microvascular cross ringfinger transfer, vascularised tendontransfers, wrap-around toe flaps andmajor microvascular reconstructions.The Microsurgery Research Centre,subsequently to become the O’BrienInstitute, was evolving and became aleading centre for microvascular, handand reconstructive surgery researchincluding transplantation.Although many saw theopportunity for limb transplantation asthe ultimate in hand and upper limbreconstruction, few believed that thecurrent status of immunology, nor theresults from animal research, justifiedthe long term risks involved. Despitethis in 1998, a single hand transplantwas performed by Dubernard inLyon, France, soon followed byLouisville’s case pioneered by WarrenBriedenbach. It was not howeveruntil 2000 in Innsbruck, a bilateralhand transplant was performed byPiza-Katzer and Ninkovic that manysceptics including myself wereconverted seeing the benefits versusrisks ratio shift substantially in favourof the patient in the bilateral limb case.Although late starters, we performedour first hand transplant in 2011 ona patient who had lost both handsand both feet from pneumococcalsepticaemia. This patient was aged 66,the oldest so far recorded transplantand the results 2 years later have been“Althoughmany saw theopportunityfor limbtransplantationas the ultimatein hand andupper limbreconstruction, fewbelieved that thecurrent status ofimmunology, northe results fromanimal research,justified thelong term risksinvolved”excellent.Exciting progress is currently beingmade with robotic hands includingmind-activated and no doubt this fieldwill progress.At the O’Brien Institute inMelbourne, our current researchinterest is in Tissue Engineering basedon the concept of encouraging ourown tissues to regenerate rather thanheal by scar and avoid the necessityfor donor tissue and its associatedmorbidity. The ultimate expressionof this of course would be limbregeneration. There are examplesin nature which make this concepttantalising feasible. Tadpole tails,salamander limbs and the human liverare examples. Children’s fingertipsand tendons sometimes are observedto apparently partially regeneratefollowing injury. We have developedmodels of tissue engineering in smalland large animals testing the capacityof cell therapies to survive anddifferentiate into specific tissues andhave been able to generate pseudoskin flaps, muscle and bone tissues,and organ tissues such as beatingheart and insulin-secreting pancreas.Fat injection is a form of cell therapywhich no doubt incorporates fat cellprecursor or stem cells which have thecapacity to survive and differentiateor initiate self-repair through growthfactor and cytokine release. Thistechnique has been applied forrevascularization of tissue and digits,reversal of radiation injury and inDupuytren’s contracture in the beliefthat recurrence will be diminished.Much of the science behind celltherapy remains to be elucidated butwe are again entering an excitingera, perhaps a new renaissance akinto the period when Al Swanson andhis contemporaries inspired us at theend of Bill Littler’s centenary of ideas.It is now almost 150 years from thebeginning of his cycle and it couldbe said that during this time we haveseen surgery advance from Macrothrough Micro to the Molecular.It has been a great honour todeliver the Swanson lecture and Isincerely thank our hosts and thescientific committee for giving me thisunique privilege.14 IFSSH ezine AUGUST 2013

special featuresThe Turner Scientific and ResearchInstitute for Children’s OrthopaedicsBy Dr Olga AgranovichThe Turner Scientific and ResearchInstitute for Children’s Orthopaedics inSaint-Petersburg is a leading medicalestablishment in Russia dealing withorthopaedics, traumatology and therehabilitation of children with boneand joint diseases and injuries.In 1890 a shelter for children withorthopaedic diseases was establishedin St. Petersburg by the founderof Russian orthopedics, ProfessorGenrih Turner. In 1932 the shelter wastransformed into the Turner Scientificand Research Institute for Children’sOrthopaedics.The aim of the Institute is toorganise and improve the orthopaedicand trauma management of childrenand adolescents with congenital andacquired disorders of the locomotorsystem, as well as the developmentof scientifically based methodsfor the prevention, treatment andrehabilitation of disabled children.The Institute consists of a complexof modern buildings, operating roomsand laboratories equipped with thelatest technology, including modernmicrosurgical and neurosurgicalfacilities. The Institute has 500 beds,divided amongst the following 10departments: general bone pathology,spine and neurosurgery, hip pathology,foot pathology and systemic diseases,cerebral palsy, hand pathology andIFSSH ezine AUGUST 2013microsurgery, rheumatology arthritis,arthrogryposis, maxillofacial surgery, aswell as a rehabilitation and outpatientsection. The Institute also has a schoolfor the children.The Arthrogryposis departmentwas started in 2010, and is thefirst specialized department forchildren with arthrogryposis inRussia. It has 50 beds. There areseveral rehabilitation rooms in thedepartment. From 2010 to 2011 , 120patients with arthrogryposis werealready treated. Being a specializeddepartment, the focused treatmentmethods and improved overallmanagement have a dramatic effecton the results. One of the goals ofthis Arthrogryposis Department isalso to give assistance to patients andtheir families to adapt to home andsocial life. Patients are seen from thefirst month after birth up to 18 yearsof age. Surgery is performed fromage 5-6 months. One of the researchprojects is spinal cord stimulation asa part of the rehabilitation of thesepatients. Locomotion therapy (Armeo,Locomat).is used extensively postoperationto restore function of theupper and lower limbs15

Pulse: Committee ReportsIFSSH Scientific CommitteeReport on Anatomy Of The HandChairman: Eduardo R. Zancolli IIICommittee: Carlos Zaidenberg, Diego Piazza, Hernan IriarteKnowledge of anatomy of the hand isthe basis for understanding pathologyand for precise application of surgicaltechniques.This committee has selected towrite a report on the TFCC anatomy butbelieving also that it will be extremelyuseful for hand surgeons to have a briefactualization of the most significantnew papers on hand anatomy.Since the last IFSSH CommitteeReports (November 2010), a lot ofpapers on hand anatomy have beenC. Zaidenberg dissectionFigure 1. R: radius, UH: ulnar head, S:styloid insertion, F: foveal insertion, UCL:ulnar collateral ligament. 1: Superficialaspect of TFCC (styloid), 2: deepinsertion (foveal)published, many confirming what isalready known but some adding newknowledge on the already knownstructures. This last group mainlyrefers to anatomical variations thatneed to be known in order to diminishsurgical surprises and to imagine howto deal with them.We are conscious that due tothe huge amount of bibliographicalsources we might have missed someimportant papers and we apologizefor it.Committee Report on Anatomy ofthe TFCCThe Triangular Fibrocartilage wasinitially described by Weitbrecht (1742)as intermedia triangularis cartilage. Inmodern literature Palmer and Werner(1981) introduced the term Triangular-Fibro Cartilage-Complex (TFCC) todescribe these structures.Anatomical descriptionThe TFCC is a structure running fromthe medial border of the radius tothe styloid area of the ulna and witha distal volar expansion to the carpus.This fibrocartilage-ligament complexstabilizes the distal radio-ulnar andulno-carpal joints, distributing loadbetween the carpus and ulna, andallowing smooth wrist flexionextension,radial-ulnar deviation andforearm pronation-supination.Other structures also intervenein stability: musculotendinousstructures, the bony anatomy and theinterosseous membrane.The TFCC different components are:• Articular disc• Dorsal and palmar distal radio-ulnarligaments• Meniscus homologue• Capsule• Extensor carpi ulnaris subsheathThe articular disc is a cartilaginousavascular structure that has twowide insertions in the radius havingas functions, load transmission(approximately 20% in normalconditions) and prevention ofdeformity during rotations of the radioulnarligaments.Dorsal and palmar radio-ulnar TFCCportions arise from the medial borderof the distal radius and insert on theulna at two separate and distinct sites:the fovea at the base of the ulnarstyloid and to the ulna styloid itself.The peripheral portion of the16 IFSSH ezine MAY 2013

Pulse: Committee ReportsFigure 2. Dorsal attachments of the superficial fascicle of the dorsal RU ligament. A: dorsal view. B: Oblique view. C: Volar view.From radial to ulnar, its 3 different ulnar insertions A,B,C. (from EA Zancolli´s paper)articular disc of the TFCC is thicker thanthe central part and has longitudinallyoriented collagen fibres. Thisthickening has been described as thedorsal and palmar distal radio-ulnarligaments. Both of them containing asuperficial and a deep portion. Dorsaland palmar deep portions insert on theulna’s fovea (conjoined ligamentousinsertion).Superficial portion of dorsal RUligament inserts proximally in threedifferent sites, according to Zancolli EAdescriptions (2008), A-radial border ofECU groove; B-deep in the ECU groove;C- dorsal aspect of the styloid process.Figures A, B, C. (Figure 2).Superficial portion of palmar RUligament inserts distally in the volarsurface of lunate and triquetrum bonesby two separate fascicles (ulno-lunateand ulno-triquetral ligaments). Theseligaments are considered to connectthe ulna to the carpus through thepalmar foveal origin of the radioulnarligament. (Figure 3)Anatomical and histological studieshave shown that only the proximalligamentous component of the TFCCconnects the radius directly to the ulna(Nakamura et al 1995, 1996, 2000).IFSSH ezine MAY 2013The deep components of theTFCC have been referred by wristinvestigators as the LigamentumSubcruentum. In his landmark 1975article on the “Articular disc of thehand”, Kauer gives credit to Henle andFick for describing a vascularized fissurebetween the superficial and deepcomponents of the TFCC, which theycalled the “ligamentum subcruentum”,technically not a ligament at all. Overthe past 20 years, however, the termLigamentum subcruentum has cometo represent the deep fibers of theTFCC (inserting into the fovea) andis now used commonly by manyinvestigators as interchangeablewith the term “deep TFCC radioulnaligaments”.Nakamura & Makita (2000)suggested that the ligamentumsubcruentum is merely the expressionof a vascular intrusion into this defectbetween the superficial and deeplaminae of the TFCC.The meniscus homologue, asmooth synovium-like membranousstructure which extends from thediscoid section of the TFC to thetriquetrum, was first described byLewis (1970) as a distal-volar expansionthat extends from the dorsal-ulnaraspect of the distal radius to thepalmar-ulnar aspect of the triquetrum.It works like a hammock supportingthe carpal ulnar border, highlyvascularized with loose areolar tissue.There is a cavity adjacent to the ulnarC. Zaidenberg dissectionFigure 3. TFCC components:AD: articular disc; DRUL:dorsal radioulnar ligament;PRUL: palmar radioulnarligament; ECU-SS: extensorcarpi ulnaris subsheath; MH:meniscus homologue; UTL:ulnotriquetral ligament; ULL:ulnolunate ligament.17

Pulse: Committee Reportsstyloid that communicates with theulnocarpal space, called the prestyloidrecess.Garcia Elias, based on histologicalstudies, considered the tissue whichcontinued from the TFCC to the carpalbone as a meniscus homologue whichis difficult to separate from the TFCC.Others authors (Ishii, Palmer& Werner 1998) redefined threeconfigurations of the meniscushomologue and the prestyloid recess,based on how the prestyloid recesscommunicates with the ulnocarpalspace: 1- narrow opening type; 2- wideopening type; 3-no opening type.Different studies have shown thatthere are variations in the attachmentof the TFCC to the triquetrum.Hogikyan & Louis subdivided thepatterns of its attachment to thetriquetrum into four types: a small,thin structure and focal attachment(group 1: 28%); a small, thick structureand focal attachment (group 2: 39%); athick structure and broad attachmentto between one-third and one-quarterof the triquetrum (group 3: 28%); and abroad attachment covering the entiretriquetrum (group 4: 5%).Nishikawa et al. also performed astudy for the meniscus homologue’sattachment to the ulnar side of thetriquetrum (79 joints) obtainingdifferent results than those fromprevious studies. They found that thesection attached to the triquetrum issmooth and that in almost all casesthe site of attachment is on the ulnararticular side of the triquetrum (Figure4). In about 10% of cases, the meniscalhomologue was found attached tothe ligament of the lunotriquetralligament, obscuring the articularsurface of the triquetrum.The capsule attaches to the ulnaalong the anterior and posteriormargins of the styloid process, andto the radius along the anterior andposterior borders of the sigmoidnotch. Distally the DRUJ capsule isincorporated into the TFCC.The thickened ulnar jointcapsule originates from hyalinelikefibrocartilage on the tip andmiddle portion of the ulnar styloid,and coalesces with the meniscushomologue to constitute the ulnarwall of the TFCC. (Nakamura & Yabe,2000). The ulnar collateral ligament iscomposed of the floor of the extensorcarpi ulnaris sheath and the thickenedFigure 4: Photographshowing the TFCC broadlyattached to the triquetrum(group 4). The TFCC attachedto the lunotriquetral ligamentand the joint surface of thetriquetrum was covered bythe TFCC. (*TFCC broadlyattached on the triquetrum).(from Nishikawa´s paper)C.Zaidenberg dissectionFigure 5: Photograph showing cadaveric wrist dissection. R: radius; 6thCompartment; UH: ulnar head; S: Styloid; T: triquetrum; H: hamate; ECU: extensorcarpi ulnaris. ECU-SS: subsheath; AD: articular disc.joint capsule.The Extensor Carpi Ulnaris (ECU)tendon courses through the sixthdorsal compartment of the wrist,passing dorsal on the lower end of theulna through a small fibro-osseoustunnel. The tendon is held tightly inthe ulnar groove by a thin subsheath,a proper relatively rigid retinaculum,attached on the margins of the ulnargroove and ensuring its stabilityduring pronation-supination. It is apulley described by Bourgery et al as“petit arcade fibrose” which preventsECU tendon subluxation. The ECUretinaculum is separate from thedorsal or extensor retinaculum andcovered by expansions of the extensor18 IFSSH ezine AUGUST 2013

Pulse: Committee Reportsretinaculum, which plays no stabilizingrole with regard to the ECU tendon.The extensor carpi ulnaris (ECU)subsheath has a firm connection tothe dorsal edge of the ulnar foveathrough Sharpey’s fibers. Based onits histological composition, it isconsidered that the ECU subsheathis an important ulnocarpal stabilizer.(Figure 5)Vascular supply of the TFCCThere are two clearly defined areas, 1)the central is avascular nourished bysynovial fluid, 2) the periphery of theTFCC is supplied by branches of theulnar artery and also from the anteriorand posterior interosseous arteries.This has important implicance in thehealing potential of future repairs.(Figure 6)Innervation of the TFCCGupta et al (2001) studied theinnervation of the TFCC. Central andradial aspects of the TFCC do not haveany nerve fascicles or fibers present.The volar portion of the TFCC isinnervated by a branch of the ulnarnerve and the dorsal sensory branch ofthe ulnar nerve.The ulnar and dorsal aspects ofthe TFCC are more variable in theirpatterns of innervation. Branches ofthe ulnar nerve and the dorsal sensorybranch of the ulnar nerve innervate theulnar aspect of the complex. Branchesof the posterior interosseous nerve andthe dorsal sensory branch of the ulnarnerve innervate the dorsal aspect ofthe TFCC. (Figure 7)Cavalcante ML, Rodrigues CJ, R.Mattar Jr (2004) went futher andstudied mechanoreceptors and nerveendings. The free nerve endings,(Figure 8) responsible for sensing pain,predominate in the ulnar and dorsalareas. The Vater-Pacini corpusclespredominate in the radial and dorsalarea, promoting perception of theonset or cessation of movementand mechanical stress change. TheGolgi-Mazzoni corpuscles were morefrequent in the ulnar and ventral areas,linking these areas to function of slowadaptation and sensation of extrememovements. The propioceptivefunction receptors were found inall areas of TFCC because Ruffinicorpuscles have homogeneousdistribution in it´s fibrocartilaginoustissue.Biomechanics in shortThe distal radioulnar joint (DRUJ)has been defined as a diarthrodialtrochoid articulation formed by thehead of the ulna and the shallowsigmoid cavity of the lower end ofthe radius. The curvatures of the twoarticulating surfaces are not equal.The radius of the ulna is about twothirds the length of the sigmoidnotch concavity. This results in arelatively unstable articulation withC. Zaidenberg dissectionFigure 6. Vascular supply patternsIFSSH ezine AUGUST 2013Figure 7. Low-power view of preservedand sectioned TFCC showing sampledregions including central/radial (c),palmar (p), ulnar (u), and dorsal (d).(from Gupta´s paper).Figure 8. Free nerve endings (arrows)in the fibrocartilaginous tissue at theperipheral area of the TFCC. (from R.Matta Jr´s paper)19

Pulse: Committee Reportsreduced area of contact betweenthe two bones. To overcome this,different stabilizing structures exist:(a) the TFCC, composed of the discusarticularis, the palmar and dorsalradioulnar ligaments, the ulnocarpalligaments, and the ECU sheath; (b) thepronator quadratus muscle; and (c) theinterosseous membrane.The concave radius-of-curvature ofthe sigmoid notch is greater than thatof the ulna head (Figure 9).Full congruity of two articulatingsurfaces is therefore not possible. Thisincongruity of articular surfaces createsa geometrically non-constrainedarticulation at the DRUJ, subject totranslational dorsal and palmar instability.In the extremes of forearm rotation,

Pulse: Committee ReportsFigure 11: Palmer Classification. I: Traumatic TFCCinjuries. 1A: central tear. 1B: peripheral avulsion fromulnar styloid. 1C: volar ulnocarpal ligaments tear. 1D:radial attachment tears.Figure 12: A and B, traumatic injuries of the TFCC: 1.superficial dorsalavulsion ( arrows); 2.deep ulnar avulsion (foveal); 3. Central perforation;4. Radial avulsion; 5. distal avulsion: frequently associated withlunotriquetral interosseous ligament tear (6). (from EA Zancolli´s paper)Figure 13: Atzei Classification. He defined 6 different classes of peripheral TFCC tears.REFERENCES1. Adams BD, Berger RA. An anatomicreconstruction of the distal radioulnarligaments for posttraumatic distalradioulnar joint instability. J Hand Surg2002;27A:243–251.2. Af Ekenstam F, Hagert CG. Anatomicalstudies on the geometry and stability ofthe distal radio ulnar joint. Scand J PlastReconstr Surg 1985;19:17–25.IFSSH ezine AUGUST 20133. Af Ekenstam FW, Palmer AK, GlissonRR. The load on the radius and ulnain different positions of the wrist andforearm: a cadaver study. Acta OrthopScand 1984;55:363–365.4. Atzei A, Luchetti R. Foveal TFCC tearclassification and treatment. Hand Clin2011 263-2725. Bednar MS, Arnoczky SP, WeilandAJ. The microvasculature of thetriangular fibrocartilage complex:its clinical significance. J HandSurg1991;16A:1101–1105.6. Bourgery JM, Bernard C, Jakob NH. Traitecomplet d´Anatomie de l´homme. Vol.2.Paris, 1852 m7. Cavalcante ML, Rodrigues CJ, R. Mattar Jr.Mechanoreceptors and nerve endings ofthe triangular fibrocartilage in the humanwrist. J Hand Surg (Am) 2004 29: 432–435;21

Pulse: Committee Reportsdiscussion 436–438.8. Fick RA.Handbuch der anatomieund mechanik der gelenke unterbercksichtigung der bewegendenmuskeln. Vol 1. Anatomie der gelenke.Jena: Fischer, 1904.9. Garcia Elias M. Anatomy of the wrist. TheWrist, edited by HK Watson. Philadelphia200110. Garcia Elias M. Soft tissue anatomy andrelationships about the distal ulna. HandClinic1998;14:165-7611. Gupta R, Nelson SD, Baker J, JonesNF, Meals RA. The Innervation of theTriangular Fibrocartilage Complex. PlastReconstr Surg 2001; 107: 135-9.12. Hogikyan JV, Louis DS. Embryologicdevelopment and variations in theanatomy of the ulnocarpal ligamentouscomplex. J Hand Surg1992;17A:719-23.13. Henle J. Handbuch der bänderlehredes menschen. Braunschweig: FriedrichVieweg, 1856.14. Hagert CG. Distal radius fracture andthe distal radioulnar joint – anatomicalconsiderations. Handchir Mikrochir PlastChir 1994;26:22–26.15. Ishi S, Palmer AK, Werner FW, Short WH,Fortino MD. An anatomic study of theligamentous structure of the triangularfibrocartilage complex. J Hand Surg Am.1998;23(6):977-85.16. Kauer JMG. The articular disc of the hand.Acta Anat 1975;93:590 – 605.17. Kleinman WB, GrahamTJ. Distal ulnarinjury and dysfunction. In: Peimer CA, ed.Surgery of the hand and upper extremity.New York: McGraw-Hill, 1996:667–709.18. Kleinman WB, Graham TJ. The distalradioulnar joint capsule: clinical anatomyand role in posttraumatic limitationof forearm rotation. J Hand Surg 1998;23A:588–599.19. Lewis OJ, Hamshere RJ, Bucknill TM.The anatomy of the wrist joint. J Anat1970;106:539-552.20. Lewis OJ, Hamshere RJ, Bucknill TM.The anatomy of the wrist joint. J Anat1969;106:539-52.21. Nakamura T, Yabe Y, Horiuchi Y. FunctionalAnatomy of the Triangular FibrocartilageComplex. Journal of Hand Surgery 1996.21B. 5: 581-586.22. Ono H, Gilula LA, Marzke MW,Obermann WR. Bicompartmentalizationof the radiocarpal joint. J HandSurg1996;21A:788-93.23. Palmer AK, Werner FW. The triangularfibrocartilage complex of the wrist:anatomy and function. J HandSurg1981;6:153-62.24. Palmer AK, Werner FW. Biomechanicsof the distal radioulnar joint. Clin OrthopRelat Res 1984;187:26–35.25. Palmer AK. Triangular fibrocartilagecomplex lesions: A classification. J HandSurg(Am.) 14: 594, 1989.26. Pogue DJ, Viegas SF, PattersonRM, Peterson PD, Jenkins DK, SweoTD, Hokanson JA. Effects of distalradius fracture malunion on wrist jointmechanics. J Hand Surg 1990; 15A:721–727.27. Schuind F, An KN, Berglund L, ReyR, Cooney WP, Linscheid RL, ChaoEYS. The distal radioulnar ligaments:a biomechanical study. J Hand Surg1991;16A:1106 –1114.28. Schuind F, An KN, Berglund L, ReyR, Cooney WP, Linscheid RL, ChaoEYS. The distal radioulnar ligaments:a biomechanical study. J Hand Surg1991;16A:1106 –1114.29. Stuard P, Berger R, Linscheid R, An K.Dorso Palmar Stability of the Distal RadioUlnar Joint. J Hand Surg 2000, 25A : 689-630. Spinner M, Kaplan EB. Extensor carpiulnaris: its relationship to stability of thedistal radioulnar joint. Clin Orthop RelatRes 1970;68:124–128.31. Thiru-Pathi RG, Ferlic DC, Clayton ML,McClure DC. Arterial anatomy of thetriangular fibrocartilage of the wristand its clinical significance. J Hand Surg1986;11A:258– 263.32. Viegas SF, Pogue DJ, Patterson RM,Peterson PD. Effects of radioulnarinstability on the radiocarpal joint:a biomechanical study. J Hand Surg1990;15A:728–732.33. Weitbrecht J. Syndesmologia sive HistoriaLigamentarum corporis Humani, quamsecundum observations AnatomicasConcinnavit, et Figuris and ObjectaRecentia Adumbratis Illustravit. Academyof Sciences, Petropoli, 1742.34. Zancolli EA. Etiopatogenia y tratamientode la inestabilidad dorsal del extremodistal del cúbito consecutiva a la roturatraumática del fibrocartílago triangular.Rev Asoc Argent OrtopTraumatol2008;73(3):2-23.Latest Papers on Hand AnatomyI. LIGAMENTSThe insertion points of the thumb`sMP joint collateral ligaments has beendescribed with some precision. Theulnar collateral ligament (UCL) has ametacarpal origin 4.2 mm from thedorsal surface and 5.3 mm from thearticular surface. The center of thephalangeal insertion of the UCL was2.8 mm from the volar surface and3.4 mm from the articular surface.The volar aspect of the phalangealinsertion extended up to 0.7 mm fromthe volar edge of the phalanx.The radial collateral ligament(RCL) inserts at the metacarpal,having its center at 3.5 mm from thedorsal surface and 3.3 mm from thearticular surface, the dorsal aspectbeing 1.5 mm from the dorsal edgeof the metacarpal. The RCL`s center atphalangeal insertion was 2.8 mm fromthe volar surface and 2.6 mm fromthe articular surface, being its volaraspect 0.5 mm from the volar edge ofthe phalanx. This data is relevant forsuccessful repair and reconstruction.22 IFSSH ezine AUGUST 2013

Pulse: Committee Reports- J Hand Surg Am. 2012 Oct; 37(10):2021-6Anatomy of the ThumbMetacarpophalangeal Ulnar and RadialCollateral Ligaments.Carlson MG, Warner KK, Meyers KN,Hearns KA, Kok PL.II. NERVESThe TMC joint has been described asinnervated by the radial nerve (maininnervation), the lateral antebrachialnerve innervation and the mediannerve. Even though denervation’sbased on these structures not alwayslead to good results. A new study on19 cadaveric specimens shows that58% had superficial radial nerve, 47%had median nerve innervation fromthe motor branch and 47% had ulnarnerve innervation from the motorbranch. This paper supposed to speakfor the first time that ulnar innervationmay also be present for the TMC joint. -Iowa Orthop J. 2011; 31:225-30.Ulnar nerve component toinnervation of thumb carpometacarpaljoint. Miki RA, Kam CC, Gennis ER,Barkin JA, Riel RU, Robinson PG, OwensPW.Deep palmar communicationsbetween the ulnar and median nerveshave continued to be studied. (50hands, 25 cadavers). In 16% of thehands communicating branches werefound - Clin Anat. 2011 Mar; 24 (2):197-201.Deep palmar communicationsbetween the ulnar and median nerves.Marios Loukas, Sharath S Bellary, RShane Tubbs, Mohammadali M Shoja,Aaron A Cohen GadolAnother paper also describes thata connecting third common palmardigital branch of the median nerveIFSSH ezine AUGUST 2013with the fourth common palmar andproper palmar digital branches of themedian nerve presented a plexiformnature. - Anat Sci Int. 2013 Jan 17.A rare anatomical variation ofthe Berrettini anastomosis and thirdcommon palmar digital branch of themedian nerve. Sirasanagandla SR, PatilJ, Potu BK, Nayak BS, Shetty SD, BhatKM.The median nerve branches for thepronator teres have been studied inone paper. All specimens (20 upperlimbs) showed to have a branch fromthe median nerve long enough toreach the radial nerve in the cubitalfossa in potential for neurotizationcases. - J Neurosurg. 2011 Jan; 114(1):253-5.Median nerve branches to thepronator teres: cadaveric studywith potential use in neurotizationprocedures to the radial nerve at theelbow. Tubbs RS, Beckman JM, LoukasM, Shoja MM, Cohen-Gadol AA.The sublime bridge is thetendinous arch connecting the radialand humeral heads of the flexorumdigitorum superficialis muscle. Locatedat the mean distance of 8.1 mm fromthe medial epicondyle, it was foundto be tendinous in 75% and muscularin 25% of the specimens. As known, itis a potential factor for median nervecompression at the proximal forearm. -J Neurosurg. 2010 Jul; 113(1): 110-2.The sublime bridge: anatomyand implications in median nerveentrapment. Tubbs RS, Marshall T,Loukas M, Shoja MM, Cohen-Gadol AA.III. MUSCLESThe flexor carpi radialis brevis muscle isa muscular variant that can be presentas much as 3.95 % in cadaveric studies.On volar approaches for distal radiusfractures it may be found as a separatetendon running between the FCR andthe radial vessels (inserting distally atthe FCR tunnel) and superficial to thepronator quadratus. - Hand Surg. 2011;16(3): 245-9.The flexor carpi radialis brevismuscle - an anomaly in forearmmusculature: a review article. Ho SY,Yeo CJ, Sebastin SJ, Tan TC, Lim AY.The Palmaris Profundus variantwhen present (incidence 1/530 limbs)may prohibit endoscopic carpal tunnelrelease. It was found inserting onto theundersurface of the transverse carpalligament. - J Hand Surg Am. 2012 Apr;37(4): 695-8.Palmaris profundus tendonprohibiting endoscopic carpal tunnelrelease: case report. McClelland WB Jr,Means KR Jr.IV. TENDONSA new study of the flexor tendonsheaths shows high incidence ofvariations (33% in 12 cadavers), whichhave communication between theradial and ulnar bursae. This mightexplain variations to the classicalpresentation of spread of infectionthrough the digital flexor sheaths. - JHand Surg Eur Vol. 2009 Dec; 34(6):762-5.An anatomic study of flexor tendonsheaths: a cadaveric study. Fussey JM,Chin KF, Gogi N, Gella S, Deshmukh SC.The extensor pollicis brevis (EPB)tendon has been determined to runthrough a separate sheath in the firstdorsal compartment in 28% (50 wrists,25 cadavers) - J Hand Surg Eur Vol.2012 Feb; 37(2): 155-60.Accuracy of intrasheath injectiontechniques for de Quervain’s disease:23

Pulse: Committee Reportsa cadaveric study. Mirzanli C, OzturkK, Esenyel CZ, Ayanoglu S, Imren Y,Aliustaoglu S.Accessory abductor pollicis longustendons have been studied oncemore (78 cadaveric upper limbs) witha presence of 85%. This paper speaksof the potentiality of the tendons asa graft source for TMC osteoarthritis.- Clin Orthop Relat Res. 2010 May;468(5): 1305-9.Anatomic study of the abductorpollicis longus: a source for graftingmaterial of the hand. Bravo E, Barco R,Bullón A.The sheaths and tendons of thefirst dorsal compartment were alsostudied in 124 cadavers.A unique compartment was foundin 63.4%. In 32.1% two complete orpartial separate compartments wereobserved, while 4.5% specimensshowed no extensor pollicis brevis inthe first dorsal compartment. - AnatSci Int. 2010 Sep; 85(3): 145-51.Anatomical variations in the tendonsheath of the first compartment.Motoura H, Shiozaki K, Kawasaki K.The accessory tendon slip from theextensor carpi ulnaris (ECU) has alsobeen studied in 54 specimens with anincidence of 5.6 %. Originating fromthe ECU, they ended in the extensorapparatus of the fifth finger, runningulnar side of extensor digiti minimitendon.The mean width was 1.4 +/- 0.01mm. This slip must be considered incases of ECU tenosynovitis and MRIimages of longitudinal split of ECU.- Acta Orthop Traumatol Turc. 2012;46(2): 132-5.Accessory tendon slip arisingfrom the extensor carpi ulnaris andits importance for wrist pain. Pınar Y,Gövsa F, Bilge O, Celik S.V. MYOTOMESIn brachial plexus dissections (38 arms,19 cadavers), branches from the lateralcord to the ulnar nerve or medial cordhave been identified in 13.1%. Flexorcarpi ulnaris (FCU) in electrodiagnosticstudies (in cases of C6, C7 and C8radiculopathies) showed abnormalfindings in 46.2% of C7 radiculopathies,76.5% in C8 radiculopathies and 0% inC6 radiculopathies.This study shows that the FCU canalso be affected in C7 neuropathies(not only in C8 cases as classicallymentioned). - J Korean Med Sci. 2010Mar; 25(3): 454-7.Anatomical andelectrophysiological myotomescorresponding to the flexor carpiulnaris muscle. Pyun SB, Kang S, KwonHK.VI. VASCULARThe persistent median artery hasbeen addressed in three papers. Inone of them giving an incidence of4%. It´s relations, superficial to thethird common digital nerve and theextraligamentous recurrent thenarmotor branch of the median nervehave been determined. - Clin Anat.2011 Jan 12.Persistent median artery: Cadavericstudy and review of the literature. EidN, Ito Y, Shibata MA, Otsuki Y.The other addresses the palmartype of the persistent median artery(PMA) with an incidence of 15.4%(42 cadavers, 84 limbs). In 11.9% ofthe 15.4 % the PMA took part in theformation of the superficial palmararch. - Hand (N Y). 2010 Mar; 5(1): 31-6.Palmar type of median artery asa source of superficial palmar arch:a cadaveric study with its clinicalsignificance. Nayak SR, KrishnamurthyA, Kumar SM, Prabhu LV, Potu BK,D’Costa S, Ranade AV.Another study on 60 upper limbsdemonstrated a 6.6 % persistentmedian artery. - J Clin Diagn Res. 2012Nov; 6(9): 1454-7.Prevalence of the persistant medianartery. Singla RK, Kaur N, Dhiraj GS.A study about the arteries of thethumb (30 hands) showed that theprinceps pollicis artery was presentin all specimens and was the originof the radial and ulnar digital arteriesin 73.3 %. The dorsal ulnar artery waspresent in all cases and also originatedin the princeps pollicis artery in 73.3%.The dorsal radial artery was presentonly in 66.7% of dissections as a directbranch of the radial artery. Severalanastomoses were found betweenthe radial and ulnar digital arteries andbetween dorsal and palmar systems. -Plast Reconstr Surg. 2012 Mar; 129(3):468e-476e.Arteries of the thumb: descriptionof anatomical variations and reviewof the literature. Ramírez AR, GonzalezSM.24 IFSSH ezine AUGUST 2013

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hand therapyTherapeutic Exercisein Wrist RehabilitationPart 2By Jennifer BlenkinsopThis article is the second of twoarticles dealing with rehabilitationof the wrist after injury. The firstsection CLICK HERE TO READ PART1 dealt with specific exercises usingisometric and isotonic exercises. In thissection, plyometric exercises, reactivemuscle activation, mirror therapy andapplication of specific exercises in dailylife are discussed.Plyometric exercisesPlyometric exercises cause amuscle to rapidly stretch (eccentriccontraction) prior to contraction(concentric contraction). The prestretcheccentric contraction storeselastic recoil potential energy (muchlike a spring) which allows muchgreater force generation in theconcentric contraction phase (1).This is used in many daily tasks likethrowing an object, digging, hitting aball, flipping a pancake, hammering,pushing something away (eg pushinga child on a swing) etc. The need forplyometric exercise as part of therehab process is largely dependent onthe functional needs of the patient, asthey are an advanced form of exerciseand require adequate strength and areasonable degree of both consciousand unconscious neuromuscularcontrol/ proprioception.Plyometric wrist exercises mayinvolve throwing and catching a ballagainst a mini-trampoline or to atherapist. The exercise may easily begraded. Initially the ball may beginas a medium to large, light ball andprogress to a small medicine ball. Thehand position for throwing may utilisethe DTM or may use a number ofdifferent grips, which can be tailored tothe patients’ pathology and functionalrequirements. Initially the task may bebilateral and symmetrical, which is lessdemanding in terms of motor control,and may be graded to unilateralsimple throwing and catching, to fullarm throwing and catching using theentire upper quadrant and full bodykinetic chain.Reactive muscle activationThis focuses on reconstructing theunconscious activation of musclesto restore joint balance (2). It aims torestore the normal neuromuscularreflex patterns in the musclesaround a joint, and the unconsciousactivation of agonist and antagonistmuscles in response to changing/unexpected requirements. This iscritical to both high level functionand injury prevention, and may bevery important in ligament injuriesas well as in hypermobility relatedwrist problems. By the time theclient is engaged in plyometrics andreactive muscle activation exercise,the therapist must now considerinvolvement of the upper quadrant,rather than focusing on the wrist26 IFSSH ezine MAY 2013

hand therapyjoint only in order to normalise thewrist’s role in global upper extremitymovement and function.Some examples of therapeuticexercises that may be used include:Powerball: The NSD Powerball,when spinning, produces multidirectionalcentrifugal forces. Thepatient is required to control the ball ina smooth, circular motion, against themultidirectional forces of the ball. Thehigher the speed of the inner spinningball, the more control required bythe patient. This exercise has beenshown to significantly increase muscleendurance of the forearm (ie wrist)musculature (3). It requires a highdegree of neuromuscular control.Initially larger circular motions areencouraged with slower ball speeds(less resistance but requires controlled,smooth motion), and graded to morecontrolled, smaller circles, but witha higher ball speed. Patients shouldbegin with short periods (eg 3 X30 sec) and slowly build their time.Overuse/ over exercising can producepain at the common extensor tendon,and therefore careful monitoring ofsymptoms and speed of progress isrequired by the patient and therapist.Many patients have difficulty with theIFSSH ezine MAY 2013motion initially, and may need to trywith the unaffected hand first beforeachieving the correct motion on theaffected side. One of the benefits ofthe power ball is that only a smallamount of wrist ROM is needed tosuccessful master the technique.Ball stability exercises: In thisexercise a medium to large ball isstabilised by the patient (the amountof weight-bearing and position of thewrist is determined by the pathology),while the therapist tries to move theball in different directions and degrees,at increasing speed. This is very similarto the ball exercise described in thesection on Isometric exercise, exceptthat the speed and amplitude of thedisturbance in increased.Wobble Board/ Balance Board:In this exercise the patient holds theopposite lateral sides of the balanceboard. The amount of wrist extensionis dependent on the pathology andthe goals of the exercise. The therapistholds the board anteriorly andposteriorly. The therapist then tries to“The hand isrepresented onboth the motorand the sensorycortices. The brainis continuouslyremodelling itselfin response tochanges in sensoryinput.”move the board in different directions,while the patient tries to stabiliseagainst the movement.Another option is that the patientis in four-foot kneeling, holding thebalance board on the floor in fronthim. He then ‘walks’ the wobble boardforward a distance and then back.The patient may also be in a fourfootkneeling position, while weightbearingthrough the wrist which ison the centre of balance board. Theunaffected wrist is not involved. Thepatient is required to maintain balanceon the unstable surface of the balanceboard. A ball may also be used insteadof the balance board, allowing greaterflexibility in terms of wrist position.27

hand therapyRubber Bar Exercise or similar:This involves holding the bar at thebase and ‘shaking’ it in either anantero-posterior direction or in acircular motion. The Theraband baris reasonably short and therefore thestabilisation requirement is reasonablylow. There are exercise apparatus withlonger and more flexible lever armsthat make controlling the motionmore challenging.Mirror Therapy“Surgical procedures of the hand arealways accompanied by synapticreorganisational changes in the braincortex and the outcome of manyhand surgical procedures is to a largeextent dependent on brain plasticity”(4). The hand is represented on boththe motor and the sensory cortices.The brain is continuously remodellingitself in response to changes in sensoryinput. Reorganisational changesmay be activity dependent based onalterations in hand activity and tactileexperience (4). Over-use, lack of use(ie diminished sensory and motorinput) and minor injuries will alsoalter representation (5). Activationof ‘mirror neurons’ in the premotorcortex can occur by simply observing amovement (6), not only by movementof the injured part itself. Imagininga movement or viewing a picture ofhand activity can stimulate neuronsin the somatosensory cortex whichmay serve to limit the reorganisationalchanges, and thus it is thought toimprove proprioception and motorcontrol, as well as modulate painresponses particularly the locationof pain stimulus has become morecentralised.Mirror therapy may therefore behelpful in improving co-ordination(7), motor control, proprioceptionawareness, kinaesthesia and reducingpain. It is also used as part of a sensoryre-education programme whereneeded.Altschuler (8) wrote an interestingarticle on their use of mirror therapyto assist a patient regain active wristmotion following distal radius fracture,where the patient had greater passivethan active ROM. In this instanceElectrical Stimulation was applied tothe wrist extensors of the affectedhand, which was obscured fromvision, and when the stimulus was feltthe patient was required to extendAbout the authorJennifer Blenkinsop runs a Private Hand Therapy Practice inJohannesburg, South Africa. Her qualifications include BSc (OT), CertifiedHand Therapist (CHT), Complex Lymphoedema Therapist (Casely-Smith),Guided Imagery and Music Fellow (FAMI- Bonny Method). Please directall comments and enquiries to Jennifer at jblenkinsop@tiscali.co.zathe unaffected wrist, while viewingthis in the mirror. This was gradedto active-assisted movement of theaffected wrist at the same time aselectrical stimulation, to concurrentactive movement without theelectrical stimulation. The result wasa significant increase in active ROMthan pre-treatment. Thus use of mirrortherapy can be integrated duringthe application of other therapeuticmodalities.Other applications includeobserving the unaffected hand inthe mirror in various hand positionsand trying to reproduce this with theaffected hand (joint position sense),and performing different movementswhich may include functional tasks,use of tools etc. Another option isperforming a functional task with theunaffected hand while observing it inthe mirror, while trying to reproducethe same functional task with theunaffected, obscured hand. Tactilestimulation may also be performed aspart of a sensory re-education whereappropriate.According to Butler, ‘smudging’ ofrepresentations in the sensory andmotor cortices and elsewhere arebest avoided by return to normalactivities. The brain is the ultimate ‘useit or lose it’ machine. It seems clearthat functionally meaningful and goal28 IFSSH ezine AUGUST 2013

hand therapydirected inputs will be better acceptedby the brain processing…clearly themore functional the movement andthe more it links to desired activity andachievable goals, the better” (5).Specific, targeted exercisesare practical (including all thosementioned above), often measureableand cost effective in our currenttime, cost, and outcomes drivenhealthcare systems and lives. However,perhaps we need to consider how toincorporate more creative activitiesinto our programme so that ourtherapy includes the whole person ina more bio-psycho-social approach.For example throwing actual darts forthe dart throwing motion, or usingcomputer games such as NintendoWii and X-box sporting games so thatmotion can be done without needingall the structure of a sporting activity,and without resistance and impact.Specific therapy-related computerprogrammes are commerciallyavailable, but not always easilyaccessible or affordable in somecountries. An excellent option, ifavailable is equipment such as theBTE or LIDO work simulators, whichmay simulate a number of work tasksand tools, while at the same time thetherapist can adjust the resistance andtime of the task.Wrist extension may be achievedthrough woodwork and bakingtasks. Reactive muscle activationfor wrist motion within a short arcof motion can be achieved flyingstunt kites, or the dart throwersmotion may be progressed by flyfishing.Wedging of clay for potteryis an excellent plyometric task, andworking the clay on a wheel enhancesbilateral co-ordination, mobility andproprioception, with tactile, visualand proprioceptive input. The listof activities is endless and of courseculture specific. All this activitiesare not only important for motion,strengthening, proprioception andfunction, but also enhance a person’ssense of accomplishment, self-esteemand confidence, while at the sametime reducing fear of using their hand.In this way more normal movementpatterns will develop within theconfines of the pathology/injury,and conscious and unconsciousproprioception will improve. Betterneuromuscular control will most likelyresult in more smooth, controlledand co-ordinated use of the upperquadrant, and cortical representationshould be normalised more rapidly.Added to these are the emotional andpsychological benefits of participationin meaningful activities at work, homeand leisure. Not all of these aspectscan be accurately measured, butwithout doubt the therapy will bothmaximise recovery in outcomes andtime (meeting the needs of funders)while also being very client-centered(meeting the needs and goals ofpatients and therapists).Useful reading and references:1. Mc Neely & Sandler. PowerPlyometrics: The CompleteProgramme. Meyer and MeyerSport. UK. 20072. Hagert, E. Proprioception of theWrist Joint: A Review of CurrentConcepts and Possible Implicationson the Rehabilitation of the Wrist.Journal of Hand Therapy . January2010, 23 (1): 2-17.3. Balan SA, Garcia-Elias M. Utility ofthe Powerball in the invigorationof the musculature of the forearm.Hand Surgery. 2008; 13(2):79-83.4. Lundborg,G. Brain Plasticity andHand Surgery: An overview.Journal of Hand Surgery Br. 2000June . Vol 25(B): 3: 242-2525. Butler, DS. The Sensitive NervousSystem. Chapter 2. NoigroupPublications. Adelaide, Australia.2000.6. Lundborg, G and Rosen, B. HandFunction after Nerve Repair. ActaPhysiol 2007: 189, 207-2177. Rosen,B & Lundborg,G. Trainingwith a Mirror in rehabilitationof the Hand. Case Report.Scandinavian Journal of Plastic andReconstructive Surgery and HandSurgery. 2005: 39: 104-1088. Altschuler EL, Hu J. Mirror therapyin a patient with a fractured wristand no active wrist extension.Scand Journal of Plastic andReconstructive Hand Surgery. 2008;42(2):110-IFSSH ezine AUGUST 201329

esearch roundupInnovations in treating skindefects of the handUSADr Andrew Watt from theDepartment of Orthopaedic Surgery& Sports Medicine at the University ofWashington, wrote an overview paperthat investigated advances in treatingskin defects of the hand, particularlyskin substitutes and negative-pressurewound therapy.“I became interested in the useof dermal substitutes and negativepressure wound therapy out ofsheer necessity,” Dr Watt explainedabout his interest in the subject. “Iam a reconstructive microsurgeonand generally believe that nativetissue reconstructions offer superiorfunctional and aesthetic outcomes inthe setting of complex hand injuries.With that bias in mind, however,there is a sub-set of patients who,by virtue of their injury, are notviable candidates for local tissue orfree tissue reconstructions. Thesepatients have generally sustainedsevere crush or blast injuries to thehand, have incomplete arterial archesor have tenuous vascular supplyor underlying vascular disease,” hecontinued, adding that for thesepatients, dermal substitutes offer thepotential for reconstruction withoutrelying on microvascular techniquesor local tissue reconstruction. Thesetechniques come with a cost, however.These alternative reconstructions often“Negative pressurewound therapy isa useful adjunct inthe managementof hand injuriesas both a bridgeto definitivereconstructionand as a highlyeffective bolsterdressing whichallows forcontact withthe anatomicalirregularitiesinherent in thehand”require longer healing times and as aconsequence, often result in longerperiods of immobility for the hand.Watt believes the most importantfindings of this paper are that dermalsubstitutes provide a reliable anddurable reconstructive option whenlocal tissue and free tissue transfertechniques are not feasible. In addition,feasibility may be related to patientfactors including the mechanismof injury and vascular status ofthe hand as well a health systemfactors including the availability ofmicrosurgical techniques.“Negative pressure wound therapyis a useful adjunct in the managementof hand injuries as both a bridgeto definitive reconstruction and asa highly effective bolster dressingwhich allows for contact with theanatomical irregularities inherent inthe hand. Negative pressure therapyas a definitive management shouldbe avoided given wound contractureand prolonged immobility limitingfunctional recovery,” he continued.For Watt, it is important that readersof the paper understand that whileplausible and reliable reconstructivemethods, the use of negative pressurewound therapy and dermal substitutesshould not be regarded as a ‘first line’reconstruction. “These techniques areuseful adjuncts and act as definitivereconstructions only when local andfree tissue transfer techniques are notfeasible. Immobility is often prolongedwhile awaiting dermal substituteincorporation and granulation vianegative pressure wound therapyresulting in increased stiffness,” heexplained. He continued that whenembarking on this reconstructive path,30 IFSSH ezine AUGUST 2013

esearch roundupModern tendonrepair techniquesUSAthe surgeon and therapist should payparticular attention to splinting andshould consider motion at all availablejoints that do not absolutely requireimmobilisation during the healingprocess.In terms of the future, Watt saidhe will continue to employ dermalsubstitutes and negative pressurewound therapy in his clinical practice.“I have found negative pressuretherapy as an almost indispensableadjunct to placement of dermalsubstitutes and as a bolster for skingrafts. Future endeavours are focusedon minimising immobilisation whilemaintaining successful dermalsubstitute incorporation. I am alsolooking to compare functionaloutcomes in patients with comparableinjuries treated with microsurgicalreconstructions (free fascial andfasciocutaneous flaps) and with thosetreated with dermal substitutes,” heconcluded.JOURNAL REFERENCEHand Clinics, Volume 28, Issue 4 ,Pages 519-528, November 2012IFSSH ezine AUGUST 2013Dr Steve K. Lee, from the Hospitalfor Special Surgery at Weill CornellMedical College in New York recentlypublished a paper on the topic ofmodern tendon repair techniques inHand Clinics. Digital tendon repairis one of the most common issuesin hand surgery and also one of themost vexing. A repair must withstandthe forces imparted on it duringearly motion. The article evaluatesmodern tendon repair techniques andearly clinical experience using suchmethods have shown clinical successof improved motion and no knownruptures.“My interest was sparked whenI was faced clinically with treatingpatients with these problems. I didnot feel that there was an adequatesolution for hand tendon repairs.Either the repairs were too weak ortoo bulky. Early range of motion witha repair that glided well in the pulleysystem was a difficult goal to achieve. Itherefore embarked on several studiesto investigate this problem,” Dr Leeexplained.For Lee, surgeons reading thearticle should understand that tendonrepairs are technically demandingprocedures where every single detailmatters. Exactly what suture materialis used, where the suture is started,how far of a suture span, the suture“tendon repairsare technicallydemandingprocedures whereevery single detailmatters”configuration, how many knots areused, etc. all play an important role inits biomechanical performance. “Themodern repairs are extremely strongand have very limited gapping duringactive motion. For zone II repairs, theycan also have a very low amount offriction imparted to the pulley system.These all lead to potentially improvedsurgical results,” he added, concludingthat his future research will be in thelong term clinical evaluation of thesepatients who had such repairs.JOURNAL REFERENCEHand Clinics, Volume 28, Issue 4 ,Pages 565-570, November 201231

esearch roundupFree vascularised medial femoralcondyle autograft for challengingupper extremity nonunionsUSADr Alexander Shin, from the Divisionof Hand Surgery, Department ofOrthopedic Surgery, Mayo Clinic,recently authored a paper on the topicof free vascularised medial femoralcondyle autograft for challengingupper extremity nonunions, publishedin Hand Clinics.“The inspiration for the use of themedial femoral condyle for scaphoidnonunions comes from our evaluationof the results of the 1,2 ICSRAvascularised bone graft for scaphoidnonunions,” Dr Shin explained, addingthat when his group initially describedthe dorsal distal radius vascularisedbone grafts in 1995 and published theinitial series in 2002, they had a 100%union rate of scaphoid nonunions.However, favourable outcomes werenot universal and other authors werepublishing significantly poorer results.“In 2006, we critically evaluatedthe outcomes of the 1,2 ICSRAvascularised bone graft in 47 patientswith 48 nonunions and found thatwe had a 71% union rate. Criticalevaluation of this cohort, revealed thatpatient and fracture selection wereimperative for optimising outcomes,”he continued. “In particular, patientswith carpal collapse (with humpbackdeformity) and proximal pole AVN,had a significantly high failure rate. Toaddress this specific type of scaphoid“there aresolutions forsome very difficultand challengingupper extremitynonunions”nonunion, we recognised that weneeded a large graft to restore thenormal geometry of the scaphoid andalso need a graft that was vascular.We had a good experience withthe corticoperiosteal flap from themedial femoral condyle and took theexperience with this and considered itsuse as a structural vascularized bonegraft,” he said.According to Shin, a cadaver studyperformed in our lab demonstratedthat there were excellent vascularperforators to the distal inferiorquadrant of the medial femoral condylewith consistent anatomy. “Dr AllenBishop and I performed the indexprocedure in 2005, and we have hadoutstanding success with the graft inthe patients with AVN, scaphoid waistnonunions with carpal collapse,” he said.For him, the most importantoutcome of this study is that theyare able to achieve union in thesevery difficult scaphoid nonunions.Additionally, the results have beenreplicated across the hand surgerycommunity. “Our original seriesreported in 2008 had 100% union rates.Anectdotally, since the original report,we have performed close to 55 surgeriesand have only 3 failures to date,” he said.“The most important take awaymessage is that there are solutions forsome very difficult and challengingupper extremity nonunions. There isno simple panacea for some of thesenonunions. The surgery is exactingand can be difficult. It is importantfor hand surgeons to know that thereis a role of microvascular surgicalprocedures to address these nonunions.Critical evaluation and a discussion ofoutcomes, risks and benefits to thepatient are necessary as well as havingthe technical ability for the surgeon toperform these surgeries. Currently weare critically evaluating the outcomesof our procedures with longer followup and look forward to report theseat the next international meeting,” heconcluded.JOURNAL REFERENCEHand Clinics, Volume 28, Issue 4,Pages 493-501, November 201232 IFSSH ezine AUGUST 2013

emembering our pioneersPioneers in Hand SurgeryRobert E Carroll, MDDr Carroll was well known for hiseducational efforts in the teaching of handsurgery, not only in the United States, butthroughout the world. He established oneof the early formal training programs forhand surgery in the United States. Duringhis career he has visited and taught inmany countries throughout the world.Physicians from these countries, as well asmany others, have experienced a formaltraining program with him in New York Cityas Visiting Fellows. Some 150 doctors frommany countries that have an active HandSociety, have worked in his department.Graduating in medicine from YaleUniversity, New Haven, Connecticut, hereceived training in general surgery andorthopaedic surgery at the MassachusettsGeneral Hospital in Boston where he cameunder the tutelage of Dr Henry C Marble.For a brief period of time he taught atthe Harvard Medical School, Cambridge,Massachusetts. Following service in theSecond World War in the Pacific theatre, hemoved to New York City. A year was spentin studying with Dr Sterling Bunnell in SanFrancisco, California, and with Drs SumnerL. Koch, Michael L. Mason and Harvey S.Allen in Chicago, Illinois. Returning to theNew York Orthopaedic Hospital, a divisionof the Columbia-Presbyterian MedicalCenter, he established the Division ofHand Surgery where he remained as Chiefuntil 1986. During this tenure Dr Carrollhad helped develop the use of siliconetendons for hand surgery reconstruction.The Hand Service has been known forits large experience in congenital handdeformities, as well as tumours and muscletransplantation.Dr Carroll has been honoured bymembership in the Hand Societies of 16countries throughout the world. He wasconsultant to the United States Navy,United States Air Force, the VeteransAdministration and the United StatesPublic Health Service during his years ofactive practice. He has been Presidentof the Association of Bone and JointSurgeons. He was one of the founders andsubsequently a President of the New YorkSociety for Surgery of the Hand, as well as aVice President of the American Society forSurgery of the Hand.IFSSH ezine AUGUST 201333

emembering our pioneersProfessor Nils Carstam, MDDr Carstam, a native from Vaxjö, Sweden, graduated fromthe University of Lund Medical School. He trained ingeneral surgery at the University of Lund, Sweden from1942 to 1949. He was first introduced to hand surgeryby Erik Moberg in 1949. He came to the United States in1950 to study hand surgery under Sterling Bunnell in SanFrancisco, California, and Sumner Koch, Michael Masonand Harvey Allen in Chicago, Illinois. He continued hishand surgery studies with his many colleagues from theAmerican Society for Surgery of the Hand and the BritishHand Club. He worked with Graham Stack on a HandSurgery Bibliography prior to the institution of Medline.In 1951, he was a Founding Member and Secretaryof the Scandinavian Club for Hand Surgery which wasinitiated by Erik Moberg. Dr Carstam later succeeded himas President. He became Head of the Section of HandSurgery of the Department of General Surgery at theUniversity Hospital, Malmö, Sweden in 1951. His graduationthesis, “The Effect of Cortisone on the Formation ofTendon Adhesions and Tendon Healing – an ExperimentalInvestigation in the Rabbit,” was presented in 1953.Dr Carstam became Associate Professor in Hand Surgeryat the University of Lund in 1954. In 1962, he became theHead of the first separate Department of Hand Surgeryorganised in Scandinavia at the University of Malmö.Dr Carstam has been very involved in the organisationof hand surgery in Sweden, where it became a recognisedspecialty in 1969. He was the Scandinavian delegate to theconstitutional meeting of the International Federation ofSocieties for Surgery of the Hand held in Chicago in 1966and served on several of its committees.Dr Carstam was appointed Honorary Professor by theSwedish Government (1980), Honorary Member of theAmerican Society for Surgery of the Hand (1971) and of theBritish Society for Surgery of the Hand (1982).After retirement from his hospital position, Dr Carstamcontinued to be actively involved in private practice of handsurgery at the Malmö General Hospital in Sweden.34 IFSSH ezine AUGUST 2013

ifsshezineCONNECTING OUR GLOBAL HAND SURGERY FAMILYFor the membersby the members…The IFSSH ezine is created with the intention of engaging the global hand surgerycommunity and to promote the profession through the sharing of knowledge.In order for the IFSSH ezine to remain relevant and topical,we rely on you, our readers, to:■ Subscribe to receive the ezineFREE OF CHARGE 4 times per year■ Submit letters to the editor■ Provide us with feedback about the ezineCLICK HERETO COMPLETE A5 MINUTE SURVEYABOUT THEIFSSH EZINE

journal highlightsJournal HighlightsBelow is a selection of contents pages from the latest issues of the following leading hand surgery journals.Hover your mouse over each article heading and click to go to the original abstract page of the article.Journal of Wrist Surgery Volume 03 · May 2013■ The EWAS Classification of ScapholunateTears: An Anatomical Arthroscopic Study■ Scapholunate Ligament Reconstruction■ Current Role of Open Reconstruction ofthe Scapholunate Ligament■ Arthroscopic Volar CapsuloligamentousRepair■ Arthroscopic Management ofScapholunate Instability■ Scapholunate Instability: Proprioceptionand Neuromuscular Control■ Arthroscopic Dorsal Capsulo-Ligamentous Repair in the Treatment ofChronic Scapho-Lunate Ligament Tears■ Anatomical Description of the DorsalCapsulo-Scapholunate Septum (DCSS)—Arthroscopic Staging of ScapholunateInstability after DCSS Sectioning■ Radiographic Evaluation of ChronicStatic Scapholunate Dissociation Post SoftTissue Reconstruction■ Dorsal Wrist Capsular Tears inAssociation with Scapholunate Instability:Results of an Arthroscopic DorsalCapsuloplasty■ Dorsal Capsuloplasty for DorsalInstability of the Distal Ulna■ A Minimal Wrist Arthroplasty for EarlyWrist Osteoarthritis■ Causes of a Block to Forearm Rotationafter Distal Radius Fractures■ Anatomy and Clinical Relevance of theUlnocarpal Ligament■ Management Distal Radius and DistalUlnar Fractures with Fragment SpecificPlateHand Volume 8 – Issue 2, June 2013■ Identification of three movementphases of the hand during lateral and pulppinches using video motion capture■ Validity of the Patient Specific FunctionalScale in patients following upper extremitynerve injury■ A systematic review of outcomes ofrevision amputation treatment for fingertipamputations■ Scapholunate ligament injuries: a reviewof current concepts■ Carpal coalition■ Resident selection of Hand SurgeryFellowships: a survey of the 2011, 2012,and 2013 Hand Fellowship graduates■ Tennessee emergency hand caredistributions and disparities■ The range of movement of the thumb■ Resolution and recurrence ratesof idiopathic trigger finger aftercorticosteroid injection■ A radiological sign in chroniccollateral ligament injuries of the thumbmetacarpophalangeal joint■ Suture button suspension followingtrapeziectomy in a cadaver model■ Anatomical evaluation of a corticalbutton for distal biceps tendon repairs■ Fluoroscopy-assisted stress testing ofthe thumb metacarpophalangeal joint toassess the ulnar collateral ligament■ The comparison of paper- and webbasedquestionnaires in patients withhand and upper extremity illness■ Prevalence of the palmaris longusmuscle and its relationship with gripand pinch strength: a study in a Turkishpediatric population■ Partially ossified iliac crest graft for thereconstruction of the pediatric thumbproximal phalanx■ Acute closed dislocation of the secondthrough fourth carpometacarpal joints:satisfactory treatment with closedreduction and immobilization■ Extension disturbance of the little fingerin amateur piano players: two case reports■ Irreducible dorsal epiphyseal fracturedislocation of the distal phalanx: a casereport■ Bilateral spontaneous flexor digitorumprofundus tendon rupture of the fifth digit:case report and literature review36 IFSSH ezine AUGUST 2013

journal highlightsHand Clinics Latest issue is: Volume 29 • Issue 2 May 2013■ Gliding Resistance and Modificationsof Gliding Surface of Tendon: ClinicalPerspectives■ Tendon Healing, Edema, and Resistanceto Flexor Tendon Gliding: ClinicalImplications■ Current Practice of Primary FlexorTendon Repair: A Global View■ Primary Flexor Tendon Surgery: TheSearch for a Perfect Result■ Wide-awake Flexor Tendon Repair andEarly Tendon Mobilization in Zones 1 and 2■ Uncommon Methods of Flexor Tendonand Tendon-Bone Repairs and Grafting■ Two-stage Reconstruction with theModified Paneva-Holevich Technique■ Flexor Pulley Reconstruction■ Tendon Reconstruction with AdjacentFinger Hand Tendon■ Outcomes and Evaluation of FlexorTendon Repair■ Current Methods and Biomechanics ofExtensor Tendon Repairs■ Diagnosis and Treatment of FingerDeformities Following Injuries to theExtensor Tendon Mechanism■ Complex Flexor and Extensor TendonInjuries■ Current Flexor and Extensor TendonMotion Regimens: A Summary■ Intrinsic Tendon Healing and StagedTendon Reconstruction: Reflection ofLegendsJournal of Hand Surgery (European Volume)July 2013 J Hand Surg Eur Vol 38, Issue 6■ Complex regional pain syndrome:observations on diagnosis, treatment anddefinition of a new subgroup■ Commentary on complex regional painsyndrome: observations on diagnosis,treatment and definition of a newsubgroup by Zyluk and Puchalski■ A comparison of the accuracy of twosets of diagnostic criteria in the earlydetection of complex regional painsyndrome following surgical treatment ofdistal radial fractures■ Complex Regional Pain Syndrome: areview■ Carpal tunnel syndrome diagnosedusing ultrasound as a first-line exam by thesurgeon■ Commentary on Lange. Carpal tunnelsyndrome diagnosed using ultrasound as afirst-line exam by the surgeon■ The long-term follow-up of treatmentwith corticosteroid injections in patientswith carpal tunnel syndrome. When aremultiple injections indicated?■ Commentary on Berger et al. Thelong-term follow-up of treatment withcorticosteroid injections in patientswith carpal tunnel syndrome. When aremultiple injections indicated?■ Value of anatomic landmarks in carpaltunnel surgery■ Carpal tunnel release: a randomizedcomparison of three surgical methods■ The effects of 5-fluorouracil on flexortendon healing by using a biodegradablegelatin, slow releasing system:experimental study in a hen model■ Assessment of volar angulation andshortening in 5th metacarpal neckfractures: an inter- and intra-observervalidity and reliability study■ The effect of metacarpal shortening ondigital flexion force■ Cost analysis and related factors inpatients with traumatic hand injury■ Proximal interphalangeal jointreplacement with an unconstrainedpyrocarbon prosthesis (Ascension®): along-term follow-up■ Iatrogenic injury to the ulnar nerveduring primary repair of medial ulnarcollateral ligament in complex elbowfracture dislocations■ Neurostenalgia as a cause of pain aftertendon and nerve repair at the wrist■ Abnormal muscle of the distal anteriorforearm presenting with compression onthe median nerveIFSSH ezine AUGUST 201337

journal highlightsJournal of Hand TherapyVolume 26, Issue 3, July - September 2013■ Effectiveness of cast immobilization incomparison to the gold-standard selfremovalorthotic intervention for closedmallet fingers: A randomized clinical trial■ Clinical commentary in response to“Effectiveness of cast immobilization incomparison to the gold-standard selfremovalorthotic intervention for closedmallet fingers: A randomized clinical trial”■ A descriptive study on wrist and handsensori-motor impairment and functionfollowing distal radius fracture intervention■ Measurement properties of the Patient-Rated Wrist and Hand Evaluation: Raschanalysis of responses from a traumatic handinjury population■ A retrospective cohort investigation ofactive range of motion within one weekof open reduction and internal fixation ofdistal radius fractures■ Hand impairment and activity limitationsin four chronic diseases■ Evaluation of the Korean version of thepatient-rated wrist evaluation■ Patterns of research utilization amongCertified Hand Therapists■ A hand therapy protocol for thetreatment of lunate overload or earlyKienbock’s disease■ Preference of lid design characteristics byolder adults with limited hand function■ Involuntary contralateral upper extremitymuscle activation pattern during unilateralpinch grip following stroke■ Design and construction of custommadeneoprene thumb carpo-metacarpalorthosis with thermoplastic stabilization forfirst carpo-metacarpal joint osteoarthritis■ A systems change: Leading the way tomeeting health needs■ A simple distal radioulnar joint orthosisJournal of Hand Surgery: American volumeVolume 38, Issue 7, Pages A1-A28, 1285-1468 (July 2013)■ The Effect of Night Extension OrthosesFollowing Surgical Release of DupuytrenContracture: A Single-Center, Randomized,Controlled Trial■ The Thompson Procedure for ChronicMallet Finger Deformity■ Distal Interphalangeal Joint ArthrodesisWith the Reverse Fix Nail■ Fingertip Reconstruction WithSimultaneous Flaps and Nail Bed GraftsFollowing Amputation■ Annular Ligament Reconstruction Usingthe Distal Tendon of the Superficial Headof the Brachialis Muscle: An AnatomicalFeasibility Study■ Traumatic Proximal Interphalangeal JointReconstruction With an Autologous Hemi-Toe Osteochondral Graft: Case Report■ Comparison of In Vitro Motion andStability Between Techniques for IndexMetacarpophalangeal Joint Radial CollateralLigament Reconstruction■ Histopathological Characteristics ofStenosing Flexor Tenosynovitis in DiabeticPatients and Possible Associations WithDiabetes-Related Variables■ Effect of Capitate Morphology onContact Biomechanics After Proximal RowCarpectomy■ In Vivo 3-Dimensional Analysis of DorsalIntercalated Segment Instability DeformitySecondary to Scapholunate Dissociation: APreliminary Report■ 3-Dimensional Deformity Analysis ofMalunited Forearm Diaphyseal Fractures■ Single-Stage Surgery Combining Nerveand Tendon Transfers for Bilateral UpperLimb Reconstruction in a TetraplegicPatient: Case Report■ Identifying the Location and Volume ofBony Impingement in Elbow Osteoarthritisby 3-Dimensional Computational Modeling■ Semiconstrained Total Elbow Arthroplastyfor Posttraumatic Arthritis or Deformities ofthe Elbow: A Prospective Study■ Validation of Phone Administration ofShort-Form Disability and PsychologyQuestionnaires38 IFSSH ezine AUGUST 2013

upcoming eventsUpcoming events68th Annual Meetingof the AmericanSociety for Surgery ofthe HandOctober 3-5, 2013Moscone West Convention Center,San Francisco, CA, USAwww.ASSHAnnualMeeting.orgAnnual Meeting program chairs MichaelHausman, MD and Fraser Leversedge,MD look forward to a robust program atthe 68th Annual Meeting of the ASSH.REgISTRaTIon FoR ThE68 Th annual mEETIng IS now oPEn!Discover the latest strategies, techniques andpractice management tips; exchange ideaswith your contemporaries from across theglobe; and explore all corners of the field fromindustry exhibits to outreach opportunities injust a few days' time.This year, ASSH introduces the InternationalBring a Young Surgeon Program. Thisprogram will allow surgeons who practicemedicine outside of the United States tosponsor a young (age 35 or younger) surgeonfor a FREE 2013 ASSH Annual Meetingregistration. Visit us online to learn the detailsabout this exciting opportunity!EvEn moRE good nEwS: You will get50% more scientific content with 100% lessmaterials to carry around. How? All of thecontent for this year’s paperless meeting will beaccessible through our free mobile app and ourwebsite, so log in and explore.ThIS YEaR wE havE:• Invigorating general sessions.• 52 instructional courses.• 12 pre- and post-courses, including twohands-on skills courses.• A bustling exhibit hall and various industryforums highlighting the latest products.• Inspiring and thought-provoking keynote speakers.68 Th annual mEETIng oF ThE aSShEducaTIonthroughTEchnologYocToBER 3-5, 2013San FRancIScoShaRE YouR knowlEdgE – lEaRn nEw SkIllS – BE PaRT oF ouR gloBal communITYJoIn YouR collEaguES aT ThE 2013 aSSh annual mEETIngwww.aSShannualmEETIng.oRg3rd Annual RAMSES Multispecialty RoboticMicrosurgery Symposium8-9 November 2013 | Strasbourg, France | www.roboticmicrosurgeons.orgThe only multi-specialty microsurgical gathering of its kind—with microsurgeonsfrom varying fields, including: hand, plastics, reconstructive, ENT, urology,gynecology, ophthalmology, vascular, orthopaedics, pediatrics and peripheral nerve.4th Annual Congress of the OrthopaedicDepartment at Sohag University incollaboration with the Egyptian Society forSurgery of the Hand and Microsurgery & PanArab Hand & MicrosurgeonsHurghada, Egypt | 20-22 November 2013www.handsurgery-sohag.org/On behalf of Hand & Reconstructive Microsurgical Unit of OrthopaedicDepartment, Sohag University, Egypt, we have the pleasure to invite to participateand share your experiences in the 4th annual congress of the department incollaboration with the Egyptian Society for Surgery of the Hand and Microsurgery(E.S.S.H.M.) & Pan Arab Hand & Microsurgeons which will be held in SerenityMakadi Heights Hotel, Makadi Bay, Hurghada, Egypt from November 20-22, 2013.The congress invited TOP figures of Hand & Reconstructive Microsurgical fieldin the world whom their presence will enhance the scientific program with latest& advanced techniques and procedures.Hurghada is a coastal city located in the eastern coast of Egypt on the Red Seaand has a great and magnificent weather and nature. You will see the pure waterand the magnificent creature in the sea from types of fishes to the coral reefs.Serenity Makadi Heights Hotel is located in Makadi Bay, a 5-star hotel deluxehotel built in the west bank of the Red Sea. It is easily reached from HurghadaInternational Airport (36 km) to the south. The resort surrounded by large gardensand located directly on the Red Sea offering spectacular views over the turquoisewater and an amazing experience of a luxury life style combined with the warmthof true Egyptian hospitality and very possible features to make your stay enjoyableWe are looking forward to seeing you to share this wonderful scientific &social event.IFSSH ezine AUGUST 201339

upcoming eventsArthroscopy andarthroplasty of thewrist22-23 November 2013Arezzo, Italywww.sicm.it/norme_editorialien.htmlThe course is designed for specialistsin hand surgery, orthopaedics andplastic surgery who want to improvetheir technical skills in the diagnosisand treatment of wrist disease. Expertswill take lectures and presentationsfollowed by arthroscopic and opensurgical techniques on anatomicalspecimens. Sessions will considerclinical diagnostics for each form ofinstability or other pathologies ofthe wrist. Open and arthroscopictechniques will be presented in detailswith their specific indications. Eachparticipant will bring clinical cases todiscuss with experts and will have atleast one anatomical specimen.Paolo ArrigoniAndrea AtzeiAlejandro BadiaPierpaolo BorelliMassimo CerusoMaurizio CorradiDavid EspenMarcus GablMarc Garcia-EliasSICMSocietà Italiana di Chirurgia della ManoPreliminary ProgrammeCOURSE OFARTHROSCOPYANDARTHROPLASTYOF THE WRISTArezzo - Italyst rd21 - 23 November 2013Coordinators:Riccardo LuchettiAndrea AtzeiFACULTYManel LlusaRiccardo LuchettiAugusto MarcuzziChristophe MathoulinJane MessinaFrank NienstedtGiorgio PajardiSandra PfannerMario Igor RosselloMax Haerle Jorg Von SchoonhovenElisabet HagertJeffrey YaoGiulio Lauri3rd EuropeanSymposium onPaediatric HandSurgery andRehabilitation13 - 14 January 2014London, United Kingdomhttp://www.bssh.ac.uk/education/courses/3rdeuropeansymposiumonThe British Society for Surgery of theHand are delighted to host the 3rdEuropean Symposium on PaediatricHand Surgery and Rehabilitationwhich will be held at the Institute ofChild Health in London on 13th - 14thJanuary 2014.Submission of abstracts is now openand will close on 31st August 2013. Thefull programme and further informationwill be published in September 2013.Second InternationalSymposium onArthrogryposis17-18 September 2014St Petersburg, Russiahttp://amc-2014.org/We have pleasure in inviting you tojoin us to the SECOND INTERNATIONALSYMPOSIUM ON ARTHROGRYPOSIS«UPDATES FROM AROUND THEWORLD» which will be held in Saint-Petersburg, Russia on 17th and 18thSeptember 2014.The faculty will consist of seniorclinicians from all over the world withparticular expertise in the managementof all aspects of the care of childrenand adults with Arthrogryposisincluding, geneticists, neuromuscularpediatricians, surgeons andrehabilitation experts. This is a uniqueopportunity to discuss the difficulties ofmanaging this complex condition.One of the world’s most beautifulcities, St Petersburg has all theingredients for an unforgettabletravel experience. The city offers anextraordinary history and rich culturaltraditions, which have inspired andnurtured some of the modern world’sgreatest literature, music, and visualart. From the mysterious twilight of theWhite Nights to world-beating operaand ballet productions on magicalwinter evenings, St Petersburg charmsand entices in every season.We look forward to welcoming youto Saint-Petersburg.LECTURES AND HANDS-ON SESSIONS FOR THERAPISTSTutors: Marc Garcia-Elias, Elisabet Hagert, Manuel Llusa40 IFSSH ezine AUGUST 2013

upcoming eventsIFSSH ezine AUGUST 201341

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