ifssh
ezine

www.ifssh.info VOLUME 3 ISSUE 2 MAY 2013

Pioneer profiles
Incoming IFSSH
Presidential address
Journal highlights

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

2013 IFSSH-IFSHT
Triennial Congress
overview

EVALUATION AND OUTCOME TOOLS FORASSESSMENT OF UPPER EXTREMITY FUNCTION
IN CEREBRAL PALSY IFSSH REPORTTHERAPEUTIC
EXERCISE IN WRISTREHABILITATION PART 1

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May 2013

Contents
4 Editorial

By Professor Ulrich Mennen, editor of the IFSSH ezine
Obituaries: James Roth

9 Letters to the editor
10 Members news
IFSSH Presidential Address
IFSSH-IFSHT Congress overview

19 Pulse

31 Journal highlights

Tables of Content from leading journals such as The
Journal of Wrist Surgery, The American Journal ofHand Surgery, Journal of Hand Surgery Asian Volume,
Journal of Hand Surgery European Volume and the
Journal of Hand Therapy.

34 Upcoming events

List of global learning events and conferences forhand surgeons and a surgical fellowship opportunity
in India

Evaluation and outcome tools for assessment ofupper extremity function in Cerebral Palsy
IFSSH Report

24 Hand therapy

Therapeutic Exercise in Wrist Rehabilitation Part 1

28 Pioneer profiles
Joseph H. Boyes
Mario Gonzalez-Ulloa

IFSSH ezine MAY 20133

editorial

12th IFSSH and 9th IFSHT
Congresses, New Delhi,
India, 4 – 8 March 2013
The triennial IFSSH Congresses serve a number ofimportant purposes. Apart from sharing new informationand personal experience, we also interact, to form newacquaintances. Furthermore, we catch up on the doingsof the Federation, and get updated on the current state ofHand Surgery and Hand Therapy worldwide.
Since its inception in 1966, the IFSSH has grown fromeight Member Societies, to 55 presently. Four regional
Hand Surgery Federations have come into existence viz.
the European, the South American, the Asia Pacific, and theNorth and Middle American Federations. Most importantly
however, we have formed an essential and integrated
working relationship with the Hand Therapists throughtheir Federation, hence the combined triennial Congressof the International Federation of Societies for Surgery of
the Hand, and the International Federation of Societies forHand Therapy.
Apart from all the activities by these five Federations,and their National Member Societies, it is indeed
heartwarming to see more and more Hand Surgeons

IFSSH disclaimer: The IFSSH ezine is the official
mouthpiece of the International Federation of Societies
for Surgery of the Hand. The IFSSH does not endorse
the 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.
4

and Hand Therapists all over the world working untiring,
through outreach programmes, and personal sacrifice,giving so much of their time and expertise, to better thecare and welfare of patients’ hands.
During my term as President of the IFSSH, my aim
was to further advance this Federation as the ‘integratingorganisation’ for Hand Surgery internationally. Somechanges were made, to improve mutual understanding,sharing and standardisation. Let me mention only three:Firstly, we wanted to improve communication amongst
all our Members, including the Hand Therapists, andeven non-medical persons who have an interest in thewell-being of the Hand. The IFSSH ezine, an electronicmagazine, was launched in February 2011. It is published,
free of charge every three months, and sent to over
10,000 individuals and organisations. It contains all kindsof helpful and relevant information, as well as the Reports
from the Scientific Committees. The aim of the Ezine is tobe a communication tool for our members, and by ourmembers, in order to share common interests. So please

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 Garside

O THE
SUBSCRIBE T

ifssFRhEE
ezine

FOR

IFSSH ezine MAY 2013

editorial

feel free to write and contribute to your magazine. All
National Delegates receive the Ezine, and are requested
to forward this magazine to all their individual Society
Members. But, any person who still does not yet receive
this electronic publication is of course welcome to
subscribe on an individual basis. This will ensure that you
will receive your copy immediately and directly from thepublisher.
Secondly, the Scientiﬁc Committee System was radicallyoverhauled with the help of President-Elect Michael Tonkin.
New guidelines have been set. Many more Members
are now involved, producing more, specific and relevant
Reports, not only every three years, but on an ongoingbasis. Once these Reports are submitted to the President,
they are published in the IFSSH ezine, and then posted on
the website. Since they represent the views of a panel, thecontents could be seen as representative of the current‘state-of-the art’ of hand surgery and therapy. Presently,
more than 25 Committees are working on allocated topics.
We thought that since so much good and dedicated work
is being put into these Reports, hard copies for futurereference is prudent, and will be made available at future
Congresses.
The third development, is the establishment of
the Committee for Educational Sponsorship under the
Chairmanship of Secretary-Elect Marc Garcia-Elias. OverIFSSH ezine MAY 2013

the years, especially under the leadership the previous
Secretary-General and President James Urbaniak, thefinancial position of the IFSSH is such, that it has now
accumulated enough funds, to enable the establishmentof Financial Sponsorships. Guidelines for applications
are being finalised, and will be available on the IFSSH
website. Members are encouraged to make use of thesegenerous grants. These Educational Sponsorships can takemany forms. For example, a recent project was a Lecture
and Cadaver Workshop in Hungary, which involved 130
surgeons from 14 countries.
With these and other changes we have noticed more
integration amongst our members internationally. We
know more about each other’s activities worldwide, andare therefore more exposed to new and helpful ideas,
exciting innovation, and by engaging in these activities,
pushing Hand Surgery standards constantly to new levels.
When the IFSSH was established, the emphasis wasvery much on Hand Surgery, being performed by Hand
Surgeons. However, a welcome and mutually beneficial
change has occurred during recent times regarding theirrevocable realisation that surgery is not the only method
to manage hand conditions. Optimising the managementof ailments and differences of the Hand, involves a morecomprehensive approach. Hand Therapy has added a new
dimension to regain form and function. Splinting, and5

editorial

all manner of rehabilitation, has become a highly skilled
specialty, hence our close working relationship with Hand
Therapists.
It may be discerning to remember the wise wordsof Christian AT Billroth (1829-1894), Professor of Surgery
in Vienna, Austria who defined a surgeon: “A surgeon isa doctor who knows when not to operate”. This attitude
should always be in the back of our minds when seeking asolution to a clinical problem. All ailments and differences
cannot, and will not necessary, be solved by surgery.
Nowadays we have so many more modalities to fulfill theaims of the our Charter. It may therefore be more correct tocall ourselves Hand Specialists, rather than Hand Surgeons!
Our Historian, Frank Burke has done sterling work insoliciting archival material of the IFSSH. Currently he isselecting relevant documents to be scanned and stored
electronically on the website. The advantage will be thatanybody can then access the historical information. He
will also seek a permanent location, for some important
artifacts of historical significance.
Secretary-General Zsolt Szabó has been running theFederation efficiently and professionally. His energy has
been second to none and this, while also running FESSH,
amongst others, and organising the very successful Eastern
European Hand Course mentioned above.
I would like to use this opportunity to sincerely thankall the Executive Members, for their unselfish, enthusiastic
and willing contributions during the past three years, tomake our International Federation work smoothly as adynamic organisation. Each one covered his task withnotable distinction, and their portfolio Reports will betabled at the Delegates Council Meeting. Of course, many
more willing volunteers contribute to the successes of the
IFSSH. In particular I would like to mention all the Scientiﬁc
Committee Chair persons and their Committee Members. We
all know the substantial amount of work it takes to prepare
a Report. Thank you so much.

6

Our Federation is now a well-oiled organisation, andwhich is still gaining momentum. Having a permanent,
centralised Administrative Oﬃce, adds to the professional
functioning of the Federation. Our administrator, Belinda
Smith, is indeed exceptional, not only for being efficient,capable and innovative, but also so pleasant to work with!
Thanks, Belinda.
And finally a very sincere word of thanks to Professor
Raja Sabapathy, and his amazing team, who have worked
so hard to get everything ready for the 12th IFSSH Congress
in New Delhi, so that we, the participants, could enjoy
an exciting, and an enriching hand surgery, and culturalexperience. The fact that the registrations have reached arecord number, speaks to their tremendous organisational
effort. You have done a phenomenal job. Congratulations!

Ulrich Mennen
Immediate Past-President:International Federation of Societies for Surgery of the Hand
Editor: IFSSH ezine

IFSSH ezine MAY 2013

editorial

Obituaries
Dr. James H. RothDuring the night of January 31-February
1, 2013, Dr. James H. Roth unexpectedly
passed away.
Jim Roth graduated from the Universityof Western Ontario Medical School in
1975. During his University days, Jim
played football for the University’s
Mustangs and was a feared andcompetitive athlete. He graduated from
Western’s School of Medicine in 1975
and continued his clinical orthopaedic
training in London. During his orthopaedic
surgery residency he spent one year as
Dr. J.C. Kennedy’s research resident. Postresidency Fellowship was completed in
Hand and Microsurgery at Duke University
Medical School prior to starting practiceat Victoria Hospital in London, Ontario on
January 1, 1982.
In 1988, he became a full professor atWestern. In January of 1992, Jim moved
to St. Joseph’s Health Centre in London
and together with Dr. Bob McFarlane, heestablished the Hand and Upper Limb
Centre (HULC). Under Jim’s guidance andmentorship, HULC has grown into thelargest upper extremity surgical centre
in Canada and mostly because of Jim’s
vision, the unit was able to establish itself
as one of the premier centres in the world
for upper extremity clinical care, research and teaching. Jim
trained countless residents and since 1992 has trained morethan 80 Fellows who are practicing all around the world.
Jim authored more than 150 scientific papers and bookchapters and has treated tens of thousands of patients.
The IFSSH will always owe Jim for the hard and dedicatedeffort he has put into organizing the Seventh Triennial
Congress of the IFSSH in Vancouver, Canada, in 1998.
IFSSH ezine MAY 2013

Jim leaves a legacy of excellence in clinical care,teaching, research and academic administration. He waslong-time married to his wife Barbara and a proud father tofour fiercely independent and successful daughters. His two
grandchildren gave him immeasurable pleasure.
Jim was the epitomy of success in his personal, athletic,organizational and academic pursuits.

7

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letters to the editor

Letters to the editor
EDITOR: In the previous IFSSHezine we asked you to send us analogies orways how you would describe in layman’s terms, conditions or procedures
to patients. The following letter was received from a reader:

Dear Editor,
Symptom intensity and magnitude of disability correlatemost strongly with coping strategies (e.g. mindset), so it’s
important to use analogies that give patients optimism
and self-efficacy, overcoming the natural tendency forprotectiveness and preparation for the worst in response
to symptoms, pain in particular. In that spirit, I use somedifferent analogies than those that were listed.
• De Quervain’s: “We have many tunnels to hold tendonsand nerves in place. Just like loose joints and tight joints,
some of us have tighter tunnels. If you have a tighttunnel eventually the nerve develops problems.”• Tennis Elbow: “Tennis elbow is like the graying andthinning of my hair-expected with age. But unlike
arthritis, this will not hurt forever. It tends to run its
course in about 12 months plus or minus 6 months.”(The graying and thinning analogy is good for rotator
cuff tendinopathy and trapeziometacarpal arthrosis aswell).
• Ganglion Cyst: “Since 50% of normal wrists have aganglion cyst, we can consider these little pockets aslittle side effects of the normal process of lubricating a
joint”.

IFSSH ezine MAY 2013

•

•

•

Scar Tissue: “Think of the scar tissue like this piece ofcloth. If I pull it long enough, the fibers will relax to alonger length.”
Arthritis: “Arthritis of the base of the thumb is like grey
hair-everyone gets it. My hair isn’t graying and thinningbecause my hat is too tight or my pillow is faulty - it’s thenormal development of the human body”.
SLAC and SNAC wrist: “The scaphoid is the keystone to
the wrist and when it fails the entire wrist collapses.” “Thewrist is like a set of ball bearings. If one is a little out ofplace the joint may wear a little quicker.

David Ring, MD PhD
Read the previously published list of analogies here
Can you think of more analogies? Send them to us atezine@ifssh.info

9members news

Address of Incoming
IFSSH President

Michael Tonkin
Closing Ceremony, IFSSH Congress, Delhi 2013
Photo: Michael Tonkin

Ulrich, Ladies and Gentlemen,
I am honoured and daunted by theprivilege you have bestowed uponme. In this address I have threetasks, the first of which is a delightfulpleasure – that being to acknowledge
the contribution of IFSSH President,
2010-2013, Ulrich Mennen. No
previous IFSSH President has been
more determined, more involved,
or demonstrated greater leadershipduring his term of office. His close
associations with Secretary-General
Zsolt Szabo, the IFSSH Executive
Committee and Secretariat have led
to an optimal coordination of IFSSH
activities. The establishment of the
IFSSH ezine is entirely due to theefforts of Ulrich. This has become
a communication vehicle for theFederation, reaching over 10 000
subscribers, and is perhaps one of themost effective methods of bringing
the hand surgery world together. He
has revamped the IFSSH Scientific

10

Committees, leading to an orderlypresentation and publication of thesecommittee reports, and establisheda structure ensuring the worth andcontinuity of reports with publicationin the ezine, on the IFSSH website,
and within a special booklet to be
produced at each IFSSH Congress.
Ulrich, along with Zsolt, established arelationship with the Russian Society
for Surgery of the Hand which led
to the successful application of theRussian Society as a member society.
The Bolivian Society has also joined ourfamily and the combined Scandinavian
Society is now represented by its
individual four societies: Denmark,Finland, Norway and Sweden.
Ulrich gave of his time to instruct ininvaluable regional courses in Hungary
and Russia, fulfilling a basic tenet of
our Charter.
Ulrich, South African by birth, hasbeen a contributor at all levels, local
hospital and district, national andinternational levels. He is a serious andstudious man but despite the worth of
his contributions, these alone do not
define the substance of the man: tounderstand him is to know Ulrich thesportsman, to know the humour of theman, the friendship of the man andthe devoted family man, husband of Jo
and father of three impressive children.
Ulrich steps down from the
Presidency but as Immediate Past
President he remains an active
member of the Executive Committee.
He chairs the Nominating Committee
and, as for Napoleon after any
successful campaign, the challenges
remain ahead. Ulrich, thank you
and please accept this certificate
in acknowledgement of your termas President of the International
Federation of Societies for Surgery of
the Hand.
My second task is to announce the2013-2016 Executive Committee.
Zsolt Szabo is our President Elect,
IFSSH ezine MAY 2013

members news

having completed a very impressive
term as Secretary-General in a
successful partnership with President
Ulrich Mennen. Zsolt is as enthusiastic
and energetic a person as theconvenor of our current Congress, Raja
Sabapathy – few have such energy. As
Secretary-General, he managed the
day to day affairs of the Federation
with minimal fuss and maximal
efficiency, organised the Eastern
European Hand Surgery Course in
Hungary, joined Ulrich in meetingwith the Russian Society and teachingat Russian Society courses, and has
been instrumental in establishing thefuture official framework of the IFSSH
as a charitable organisation with its
IFSSH ezine MAY 2013

“These teachers,
amongst manyothers, inspireda passion forteaching and itis this which I
believe I can offerto the International
Federation as
President over the
next three years”

bank account housed in Switzerland.
He is a very worthy President Elect. I
am delighted to present Zsolt with his
official certificate to acknowledge his
contribution as Secretary-General.
Marc Garcia-Elias moves to theSecretary-General position. No
President could wish for a bettercolleague as Secretary-General.
Although the sophistication of thetasks of Secretariat and Executive
Committee members have increased,
the Secretary-General position remains
the engine room of the Executive
Committee of the Federation.
Daniel Nagle, a past President of theAmerican Society, joins us as SecretaryGeneral Elect.

11members news

Ulrich Mennen moves to theposition of Immediate Past-President.
We are fortunate that we retain
the wisdom and common sense of
our IFSSH Historian, Frank Burke, who
has been responsible for collecting,collating and documenting thearchives of the Federation andcommitting them to an electronic file
– a substantial undertaking.
Lastly, I would welcome Moroe
Beppu from Japan to the appointmentof Member-at-Large. This is an
important position, providing as it
does a member from the Delegates’
Council to assist the three mostrecent Past-Presidents in their roles
as members of the Nominating
Committee, responsible for theassessment of nominated Pioneers
and the nomination of Executive
Committee members.
My final task is to address you
as incoming IFSSH President. This isdifficult. I looked to the experiencesof the five previous IFSSH Presidents:
Yasuo Yamauchi (Japan, 1998-2001),
Guy Foucher (France, 2001-2004),
Arlindo Pardini (Brazil, 2004-2007),Jim Urbaniak (USA, 2007-2010) and
Ulrich. These are all dignified, elegant
and impressive men. In comparison,
I feel wanting. My wife has informedme that no matter what form ofdress, no matter how I comb my hair,or even if bald, I will never appear
either dignified or Presidential. In
considering the geographic spread of
the previous five Presidents, perhaps
there is an improved symmetry to theworld map if an Australian is invited
to the position of IFSSH President
and our Federation is reintroduced tothe exotic residents of Australia – the12“we areresponsible fordisseminatingknowledge of handsurgery; we should
support thedevelopment ofhand surgery inunderdeveloped
countries; andwe should foster
friendship between
nations andindividuals.”

kangaroo, the platypus, the koala
and kookaburra amongst others. I say‘reintroduced’ as Bernard McC. O’Brien
from Melbourne was IFSSH President
from 1980 to 1983. He was a towering
figure in the worlds of hand surgery
and microsurgery and one who waslost to us at far too young an age, as hehad so much more to contribute.
In anticipating the course of myterm of office, I ask myself what I
have to offer. I considered the recent
contributions of Jim Urbaniak and
Ulrich Mennen. Here I pause toacknowledge the outstanding serviceof Jim Urbaniak to the IFSSH. He has
been part of the Executive for 18
years and, during that time, he has
become the current father of the
IFSSH, the one to whom we all turnfor advice, particularly when there
are ticklish problems confronting us.
These problems are always met withwise words and a gentle smile. Jim
achieved a remarkable feat during
his Presidency, that being to produce
a magnificent book entitled “HandSurgery Worldwide” which contains
the history of each of the 50 member
societies of the IFSSH, along witha number of classical clinical andscientific articles. Jim will remain withus as a member of the Nominating
Committee and we welcome his
continued presence. I have discussed
the achievements of Ulrich Mennen.
In comparison with these two, I regretthat I don’t have a single project which
will define my Presidency, a mission
or a vision. I feel a little like the boy, or
one of the two dogs depicted in thispicture in which the three are isolated
on a seat in the centre of a ﬂooded
river.
IFSSH ezine MAY 2013

members news

I reﬂect upon the IFSSH Charter.
Article 3 describes the aim of theFederation, the chief purposes ofwhich are detailed in 11 principles.
I summarise these in the following
manner: we are responsible fordisseminating knowledge of handsurgery; we should support thedevelopment of hand surgery inunderdeveloped countries; and weshould foster friendship between
nations and individuals.
The first of these purposes teaching - caused me to remember
my own teachers. Bill Lennon, an
orthopaedic surgeon from Sydney,will be unknown to most in this room.
However, it was he who first inspired
my fascination with and devotion
to the field of hand surgery. FrankBurke continued this during my handsurgery fellowship in Derby. One of his
teachers, Adrian Flatt, was a teacher
from afar through his writings and I
covet the memorable occasions on
which we meet. I spent 12 months
in Louisville in 1984 at a time of great
excitement during the development
and application of microsurgical
techniques to hand surgery. I am
indebted to Harold Kleinert and his
group. Specifically, Graham Lister was
the most superb didactic teacher I
have encountered. The precision of
Dieter Buck-Gramcko’s teaching ofcongenital hand surgery drew me tothis field of hand surgery, for which I
am ever grateful. I consider Eduardo
Zancolli Sr to be one of two geniusesof orthopaedic surgery whom I havemet, the other being Sir John Charnley.
His knowledge of anatomy andapplication of an innovative mind to
the surgery of patients aﬄicted with
IFSSH ezine MAY 2013

cerebral palsy, rheumatoid arthritis andtetraplegia were the basic pillars of myhand surgery learning.
These teachers, amongst manyothers, inspired a passion for teaching
and it is this which I believe I canoffer to the International Federationas President over the next three
years. It may also be applied tothe second purpose of supporting
the development of hand surgery,particularly in underdeveloped
countries. The IFSSH Executive
Committee, through its Committee
for Educational Sponsorship, has
identified the following four areas
worthy of receiving both financial andteaching support:
1) Special education projects, suchas the production of the IFSSH
Terminology booklet and the“Making a Thumb” DVD; the fundingof fellowship projects such as thatat Baragwanath Hospital in South
Africa; and the support of affiliatedgroups such as the International
Federation of Societies for Hand
Therapy.
2) The second component of support
is that for individual society
congresses and courses, throughprovision of speakers, supportof registrations, and provision ofequipment where appropriate.
3) Thirdly we can assist in theorganisation of regional courses
such as the Eastern European Hand
Course held in Hungary in 2012,
through the provision of teachers
and the support of registrants’ fees.
4) Fourthly, we will continue thefinancial support for financiallydisadvantaged surgeons to attend
IFSSH Congresses.

I commend these projects to you.
All societies should consider how they
may be involved.
Finally, the third purpose: we are
not isolated as individuals or as standalone societies. Our international
friendships allow us to understandand assist in solving the problems ofothers. The triennial congress and theinteraction between societies throughthe ezine, the website and projects
listed above, allow people from allparts of the world to communicate
and to contribute. I look around at
the members of this audience andam appreciative of what a wonderfulprivilege this is.
Ladies and gentlemen, we haveattended a marvellous congress.
We should be grateful to theIndian Society, Raja Sabapathy, hiscommittees and all included in
the congress organisation, for an
outstanding achievement. I encourage
all of you to support Eduardo Zancolli
Jr and the Argentinian surgeons andtherapists by joining together again in
Buenos Aires in 2016.

13

members news

IFSSH-IFSHT Triennial
Congress overview
The 12th IFSSH and 9th IFSHT Congresses took place in New Delhi, India, from 4 – 8
March 2013. The IFSSH ezine asked a number of delegates to share their experiencesof the Congress with the readers. In addition, we also include a selection of photos
that capture the essence of the Congress.

It was a pleasure seeing everyone in the meeting. A big thumbs-up to theorganizing committee for a well organised meeting. I would especiallycommend to the organisers of the programme for having a good balance ofpioneers and innovators of the field. I went home with more questions thananswers, which is always a good feeling. My only regret was missing some talks
because I had to choose among several good ones.
As a young practitioner, I have everything to gain in attending the IFSSH
congresses. I will definitely encourage more colleagues to join me in the future.
Nathaniel S. Orillaza Jr., MD, Clinical Associate Professor at the College ofMedicine at the University of the Philippines in Manila.
The brotherhood of hand surgeons worldwide still consistsof a relatively small group of people, especially whencompared with other medical specialties. No wonder thatover the years more than a professional friendship has
developed among many colleagues! The triennial congressof the IFSSH is a unique opportunity to come together
and collect stimuli how to improve one’s own practiceand discuss new ideas. The cycle of three years between
meetings ensures that true changes in knowledge become
apparent in the contributions.
The IFSSH Congress is a great opportunity tocommunicate with colleagues of the world, but also tomeet old friends and make new ones. As in former years,
the officers of the Federation and especially the local hosts
had to invest a tremendous amount of work to make thisyear’s congress in New Delhi as informative and, at thesame time, as pleasant as it was. The work of all of them ishighly appreciated and we all express our sincere thanks.
The fact that the meetings are held in different cities inmany different countries also gives us the opportunity to14learn more about the country, its people and cultures. So
far and in the next future the location of the congresses
were spread over all continents of the world – except
Africa and Antarctica. Save the latter, an African city should
be seriously considered for one of the future meetings.
Ulrich Lanz, Munich, Germany
Ulrich Lanz (centre) Awarded “Pioneer of Hand Surgery” in Delhi
with wife, Heide, and Prof Gus McGrouther (UK)IFSSH ezine MAY 2013

members news
RIGHT: Dr Raja
Sabapathy, Chief
Organiser of the
IFSSH Congress
lights the
symbolic candle“As a young practitioner, I have everything to gain in attending
the IFSSH congresses.” Nathaniel S. Orillaza Jr, Philippines“The meeting provides a great venue for not only education,
but also gives you the rare opportunity to interact and form
relationships with surgeons from many other countries.”
Scott Oishi, USA

IFSSH ezine MAY 201315

members news

The IFSSH congress was a great opportunity to catch
up with friends and colleagues from the other sideof the world. The symposia, in particular, gathered abroad range of experts with different viewpoints on
many of the difficult problems in Hand Surgery.
David McCombe, Royal Children’s Hospital, Melbourne
and Victorian Hand Surgery Associates, Australia
Along with the joy of returning to a congress
to meet up with overseas friends, there areinvaluable learning opportunities. At the Delhi
meeting, the sessions were all of a good quality.
Exceptionally entertaining was the congenital
hand session, in which acknowledged Hand
Surgeons ‘battled’ on several subjects. Theirthoughts will be very valuable in decision
making for daily practice. The dinner after the
opening ceremony was very enjoyable, not only
because of the food, but especially because of
the ease in which you could meet colleagues.
I would absolutely encourage colleagues toattend the IFSSH Congresses. It has an easy
accessible atmosphere where experts in theirfield are willing to have good and constructive
conversations.
Christianne van Nieuwenhoven, Erasmus MC,
University Medical Center, Rotterdam, The Netherlands

I would
definitely
encourage
hand
surgeons fromall countries to attend the IFSSH
Triennial Congress. The meetingprovides a great venue for not only
education, but also gives you therare opportunity to interact andform relationships with surgeons
from many other countries.
Scott Oishi, Texas Scottish Rite
Hospital for Children, Dallas,
Texas, USA

16

The overall quality of the scientific programme was excellent, withgreat speakers that made you want to get out of bed early in themorning and lively discussions until the end of the day.
I enjoyed the congenital debate session the most. I felt that the
problems were presented in a comprehensive way by all speakers, they
were clearly and concisely answered by the respective debate-partners
and Professor Tonkin did a terrific job as moderator by capturing theessence of every discussion in a critical question or a precise summary.
The evening dinners were the best. Nice ambiance, great service
and the food was simply delicious!
Everyone interested in hand surgery should visit the IFSSH Congress.
It is a great opportunity to get updated on the state of the art, shareideas, develop new collaborative projects that push present boundaries
and enjoy the company of colleagues in a non-clinical setting.
Robert Dijkman M.D., Dept. Plastic and Reconstructive Surgery and
Hand Surgery, Erasmus MC, University Medical Centre, Rotterdam, The
Netherlands

Indian travel tip – Ulrich Mennen
After the successful 12th
IFSSH Congress in New
Delhi in March, we travelledsouth to visit places ofinterest. In Mumbai wetreated ourselves by having
Indian cuisine in a smart
and upmarket restaurant
run by a well-known chef
who published his own
cookbook.
We ordered Lamb Curry.
After placing ourselected dish, the following
conversation took place

between myself and thewaiter:“Could I ask you aquestion to clarify anuncertainty? What is thedefinition of the words“mutton” and “goat” inIndia? I ask this question
because I have seen bothon the menus all overIndia”“Same thing, Sir”
“You mean, if I orderlamb, I may get goat?”“Most certainly, Sir”

“Why?”“Because in India sheep
is very rare. In India sheep isgoat, and goat is sheep.
It’s like chicken, Sir, it
could also be duck. Same
difference.
But, Sir, you will findit very tasty and soft,
because we only use thesmall ones.
And, Sir, the spices
compliment the taste.
I am sure you will enjoy
your food”

IFSSH ezine MAY 2013

members news

“The overall qualityof the scientificprogramme was
excellent, with great
speakers that madeyou want to get outof bed early in themorning and lively
discussions until
the end of the day.”Robert Dijkman, theNetherlands

LEFT: Professor
Wayne
Morrison from
Melbourne,
Australia,presented
the honorary
SwansonLecture“The symposia, in particular, gathereda broad range of experts with different
viewpoints on many of the difficult
problems in Hand Surgery.” David
McCombe, Australia“It has an easy accessible atmosphere
where experts in their field are willing tohave good and constructive conversations”
Christianne van Nieuwenhoven

IFSSH ezine MAY 201317

members news

“The cycle of three years
between meetings
ensures that truechanges in knowledge
become apparent in thecontributions.”
Ulrich Lanz, Germany

Putting young
hands to work
In the lead up to the IFSSH-IFSHT
Triennial Congress an art competition
was held for school children around
India. Themed ‘The Magic of Hands’
the competition invited schools to
submit paintings on this topic. Over
2000 schools submitted 4250 entries.
The top 50 paintings were selected
and compiled into a coffee table book.
The winning painting, titled: ‘A lump ofclay in the potter’s hand is tomorrow’s
earthenware’ was painted by Master
Midhun P.P., Class IX, Azhikode School,
Kannur, Kerala, India.

18

IFSSH ezine MAY 2013

Pulse: Committee Reports

Evaluation and outcome tools forassessment of upper extremity
function in Cerebral Palsy
IFSSH Report

Cerebral Palsy Scientific Committee:
Ann Van Heest MD, Michelle James MD, Michelle Gerwin Carlson MD

Cerebral Palsy is a group of disordersof development of movement andposture that cause activity limitations
attributed to non-progressive
disturbances of the developing fetal or
infant brain (1). The primary problem
in cerebral palsy is a central nervous
system (CNS) insult which leads to

IFSSH ezine MAY 2013secondary muscle imbalance, resulting
in joint malpositioning and functional
impairment of the upper limb. This canlead to tertiary problems of muscle
contracture, joint contractures andskeletal deformity.
This report examines the evaluationand outcome tools for assessment ofupper extremity function in cerebral
palsy. Evaluation of upper extremity
function includes defining the degreeof disability in use and function of
the upper limb. The World HealthOrganisation (2) defines disability

19

Pulse: Committee Reports

as causing bodily impairment,
activity limitations, and participation
restrictions. Impairment is a problem
in body function or structure. An
activity limitation is a difficulty
encountered by an individual in
executing a task or an action. A
participation restriction is a problem
experienced by an individual in
involvement in life situations. Thus,
disability is a complex phenomenon
interaction between features of aperson’s body and the features ofthe society in which he or she lives.
Disabilities encountered in children
with cerebral palsy encompass
impairments of bodily function,
activity limitation and participation
restrictions. Assessment of upper
extremity function ideally would
measure disability in all three realms,
in addition to the dimension of qualityof life. Traditionally, assessment has
primarily focused on bodily function,
but more recently assessment has also
included activity limitations and tosome extent, participation restriction.
Assessment of the upper extremityin cerebral palsy always includes

measures which are used for standard
upper extremity function assessment
including active and passive rangeof motion as well as grip and pinch
strength testing. Hand function
tests that are not specific to cerebral
palsycan be used for assessment ofhand function, such as the JebsenTaylor hand function test, the 9-holepeg test, and the box and blocks test.
For the higher functioning child, eachof these can be useful for assessmentof unilateral hand function. This report
would like to outline those assessment
tools which are specifically designed
for cerebral palsy and provide
references for the practitioner desiring
more in depth testing information.
The House upper extremity
assessment (3) is a 9-point scale that
describes the use of the affected
arm during activities (Table 1). This
classification was designed specificallyfor cerebral palsy and describes use of
the limb ranging from “does not use”
(level 0), to full spontaneous use (level8). More recently, the Manual Abilities
Classification System (MACS) has been
designed as a classification of manual

ability (Ref 4) in children with cerebral
palsy age 4 – 18 years. MACS assesses
the child’s ability to handle objects
in important daily activities such asplay, leisure, eating and dressing.
As shown in Table 2, MACS scores achild as level 1 (handles objects easily
and successfully), to level 5 (doesnot handle objects and has severe
limited ability to perform even simple
actions). The MACS gives an overall
picture of the child´s ability to use
the hands in daily life, including theinﬂuence of cognitive problems. The
classification supplements the Gross
Motor Function Classification (5) ingiving a general description of motor
function in the child with cerebral
palsy. Similar to the House scale, theMACS classification system provides a
general description of upper extremityuse during activities of daily living.
The Shriners Hospital Upper
Extremity Evaluation (SHUEE) (6)has been used specifically forassessment of the upper extremityin cerebral palsy. This test has fivesections, including: active and passive
range of motion, activities of daily

Table 1: House Upper Extremity Functional Use Classiﬁcation
Class Designation

Activity Level

0

Does not use

Does not use

1

Poor passive assist

Uses as stabilizing weight only

2

Fair passive assist

Can hold onto object placed in hand

3Good passive assist

Can hold onto object and stabilize it for use by other hand

4

Poor active assist

Can actively grasp object and hold it weakly

5

Fair active assist

Can actively grasp object and stabilize it well

6

Good active assist

Can actively grasp object and then manipulate it against other hand

7

Spontaneous use, partial

Can perform bimanual activities easily and occasionally uses the hand spontaneously

8

Spontaneous use, complete

Uses hand completely independently without reference to the other hand

20

IFSSH ezine MAY 2013

Pulse: Committee Reports

living, spontaneous use functional
analysis, grasp and release, anddynamic positional analysis. The
range of motion measurements
include shoulder, elbow, forearm,wrist, hand, finger and thumb aswell as an assessment of modified
Ashworth scale (0 – 4) for tone
analysis during range. The activities
of daily living section analyses sevenactivities and grades the patient as
independent, dependent or assist.
The spontaneous functional analysis
is an examination of nine different
activities, assessing spontaneous useof the affected arm using a modified
House scale (6-point scale, from “doesnot use” to “spontaneous use”). The
dynamic positional analysis analyses
five different segments (thumb,finger, wrist, forearm and elbow)
and describes the position of thesegment during 16 different activities.
For example, the thumb segment is
described as either across the palm,
closed, next to the index finger, or
open. The finger segment is assessed
as in ﬂexion, neutral or extension
and similarly the wrist segment in“recent advancesin cerebral palsy
have included
development
of disease
specific validated
evaluation andoutcomes tools”

ﬂexion, neutral or extension, and theelbow segment in extreme ﬂexion or
extension, while the forearm section isextreme pronation, pronation neutralor supination. The grasp and releaseanalysis looks at the ability to grasp
and release the object when the wrist
is in three different positions: ﬂexion,
neutral and extension.
Other methods of functional
assessment specific to cerebral palsy
include use of video analysis. First

validated by Waters (7), observationof daily activities have been shown tohave both intra- and inter- observer
reliability. Additionally, Carlson (8)has shown that changes were madeto initial pre-surgical plans on over
70% of patients after video tapeevaluation. This was most common
for surgical procedures addressing thewrist, digit and thumb, pointing to
the fact that these can be dynamicallyassessed using video analysis and that
this video analysis leads to different
conclusions than that which may beseen in an office setting.
The Melbourne Assessment of
Unilateral Upper Limb Function (9)is a validated, standardised test formeasuring affected limb function
in children aged 5-15 years withunilateral cerebral palsy. Children
are videotaped performing 16 test
activities of grasp, release, reach, andmanipulation. The videotapes arescored for qualities of movement
range, accuracy, ﬂuency, and dexterity.
More recently, a modified Melbourne
assessment for ages 2-4 has beendeveloped (10).

Table 2. Manual Ability Classiﬁcation System (MACS)
MACS Level
of Ability

Description

Level I

Handles objects easily and successfully.
At most, limitations in the ease of performing manual tasks requiring speed and accuracy.

Level II

Handles most objects but with somewhat reduced quality and/or speed of achievement.
May avoid some tasks or use alternative ways of performance.

Level III

Handles objects with difficulty; needs help to prepare and/or modify activities.

Level IV

Handles a limited selection of easily managed objects in adapted situations. Requires continuous support.

Level V

Does not handle objects and has severely limited ability to perform even simple actions.
Requires total assistance.

IFSSH ezine MAY 201321

Pulse: Committee Reports

Further elaboration of use of thevideo has been described by Van Heest(11). Using motion lab facilities withthe use of split screen videos, biplanarassessment of dynamic deformity canbe assessed. Additionally, dynamic
electromyographic assessment ofmuscle function can be simultaneously
collected to further evaluate
deforming forces of spastic or ﬂaccid
or dystonic muscle patterns. The
patterns of muscle firing can be used
for assessment for tendon transfer
surgery.
Many of the functional analyses
examine the affected hand in cerebral
palsy with forced unilateral function
in a controlled test situation. The

Assisting Hand Assessment (AHA) isa major advancement in upper limb
assessment in CP because it allows
grading of the ability of the affected
hand to serve as an assist for bimanualtasks in spontaneous activities (12).
The AHA was designed for unilateralconditions such as brachial plexus
birth palsy and unilateral cerebral
palsy. The AHA evaluates how
effectively the affected hand and arm
is used in bimanual performance andthe assessment is made by observing
the child’s spontaneous handling oftoys in a relaxed and playful session.
In summary, recent advancesin cerebral palsy have included
development of disease specificvalidated evaluation and outcomestools. These assessment tools are
specifically designed for upper limb
involvement due to cerebral palsy,
and provide the hand surgeons themeans to evaluate extent of disease
for specific individuals, as well as
outcomes of treatment interventions.

REFERENCES
1. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April
2005. Dev Med Child Neurol 2005;47:571–576.
2. http://www.who.int/topics/disabilities/en/
3. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in-palm deformity in cerebral palsy. J Bone Joint Surg
1981;63A:216-225.
4. Eliasson AC, Krumlinde-Sundholm L, Rosblad B, Beckung E, Arner M, Ohrvall AM, et al. The Manual Ability Classification System(MACS) for children with cerebral palsy: scale development and evidence of validity and reliability. Dev Med Child Neurol
2006;48:549–554.
5. Palisano, R., Rosenbaum, P., Walter, S., Russell, D., Wood, E., & Galuppi, B. (1997). Development and reliability of a system to classify
gross motor function in children with cerebral palsy. Developmental Medicine & Child Neurology, 39, 214-223.
6. Davids JR, Peace LC, Wagner LV, Gidewall MA, Blackhurst DW, Roberson WM. Validation of the Shriners Hospital for Children Upper
Extremity Evaluation (SHUEE) for children with hemiplegic cerebral palsy. J Bone Joint Surg Am 2006;88:326–333
7. Waters PM, Zurakowski D, Patterson P, Bae DS, Nimec D. Interobserver and intraobserver reliability of therapist-assisted videotaped
evaluations of upper-limb hemiplegia. J Hand Surg [Am] 2004;29:328–334
8. Carlson MG, Spincola LJ, Lewin J, McDermott E. Impact of video review on surgical procedure determination for patients withcerebral palsy. J Hand Surg Am 2009;34:1225–1231.
9. Randall M, Carlin JB, Chondros P, Reddihough D. Reliability of the Melbourne assessment of unilateral upper limb function. Dev Med
Child Neurol 2001; 43:761–7.
10. Randall M, Imms C, Carey L. Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children
aged 2 to 4 years. Dev Med Child Neurol. 2012 May;54(5):424-8.
11. Van Heest AE. Functional assessment aided by motion laboratory studies. Hand Clin. Nov 2003;19(4):565-571.
12. Krumlinde-Sundholm L, Holmefur M, Kottorp A, Eliasson AC. The Assisting Hand Assessment: current evidence of validity, reliability,
and responsiveness to change. Dev Med Child Neurol. Apr 2007;49(4):259-264.

22

IFSSH ezine MAY 2013

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hand therapy

Therapeutic Exercise
in Wrist Rehabilitation
Part 1
By Jennifer Blenkinsop

This article is the first of two dealing
with rehabilitation of the wrist after
injury. The first section deals withspecific exercises using isometric andisotonic exercises. The next section, tobe published in the August edition of
the IFSSH ezine, will cover plyometric
exercises, reactive muscle activation,
mirror therapy and application of
specific exercises in daily life.

Introduction
The goals of rehabilitation of the wrist
vary significantly depending on the
injury/ pathology, surgical procedureand patients’ functional requirements.
Generally for fractures without
ligament injuries, the goal is full rangeof motion (ROM), and a strong, painfree wrist capable of performing thenormal functional tasks as previously
performed by the patient. However,where ligament injuries or instabilities
are present, a limited ROM withmodified activity and functional
expectations may be preferable
or vital to achieving the goals of a24strong, stable, pain free wrist. Patient
education, and often re-education, ispivotal in these situations.
The exercise principles that follow
can be applied to most wrist injuries
that do not include ligament injuries(or repairs) and/or instabilities, andwhere hypermobility is not a concern.
However in cases of ligament injury(or repair) and/or instability andhypermobility an understanding of
carpal kinematics and the specificpathology are essential to selecting
the appropriate exercise as well as
the timing of the exercises. Some ofthe exercises mentioned may need
to be modified or omitted altogether
for certain injuries. Unfortunately therange of possible wrist pathologies(along with the modified programmes)
cannot be individually addressed,
but some of the more common
pathologies will be discussed.

Isometrics
Isometric exercises are very useful inthe early stages of rehabilitation as theamount of resistance and the ROM(if any) can be carefully controlled by
the therapist (1). It also provides an
early stage of proprioceptive input
from muscle spindles and Golgi
tendon organs (2), and later frommechanoreceptors in the carpal
ligaments when the angle of the wrist
joint is increased. The resistance may
be applied manually by the therapist
or the patient (as part of their home
programme), and the position of
the joint may be carefully selected.
For wrist isometrics no gripping isnecessary by the affected hand andtherefore no axial loading need occur
through the SLIL, making it a safe
exercise for SLIL injuries and following
surgical repair particularly in varying
degrees of motion in the DTM plane.
Because FCU, ERCL and APL appear
to have a protective function towards
the SLIL (3,4) isometric strengtheningof these muscles in a protected,
pain-free position may well be helpful
following SLIL injury or repair. Researchby Salva and Garcia-Elias (4,5,3) note
IFSSH ezine MAY 2013

hand therapy

that isometric contraction of FCR and
ECU is detrimental to the SLIL where
the SLIL is disrupted or significantly
injured, however isometric contractionof the FCR in the intact SLIL actuallyassists in providing joint stability.

Isometrics may initially be
performed with vision, and thenwithout, and also as part of a mirror
therapy programme. Researchby Kotlyn et al (8) showed that	
  submaximal (~20-50% of maximum)
isometric exercise resulted inboth ipsilateral and contralateralhypoalgesic responses. This may even
add to the ‘mirror neurone effect’of pain reduction, proprioceptive
re-education and normalising
cortical representation when used in	
  conjunction
with the mirror box.
Another method of utilisingisometrics is using a small- to mediumsized ball. The patient is seated with thewrist in neutral, and the hand lightly

In instances on mid-carpal
instability isometric exercise of FCU
and ECU, particularly together with
exercising the hypothenar muscles
provide increased dynamic stability to
the ulna wrist, according to Lichtman(6), while FCU and the hypothenars
may be important dynamic stabilisersin cases of lunotriquetral instability (asnoted by Garcia-Elias) (7).

IFSSH ezine MAY 2013	  “Isometric
exercises arevery useful in theearly stages ofrehabilitation as
the amount ofresistance and the
ROM (if any) can be
carefully controlled
by the therapist”

gripping the ball (which is resting ona table) with a very wide grip. The
therapist then attempts to rotate theball in different directions while thepatient isometrically resists. Again thetherapist can control the positioningof the wrist and the ROM according
to the type of injury. This is initiallydone slowly	
   with vision (and auditory
cues if needed), and then graded toincrease the speed to quicken themuscle reaction time to changing
demands (early stages of what has
now been called reactive muscle
activation). Another method of grading
the exercise is to begin with the wristin neutral, and then to slowly progress
to greater degrees of wrist extension
depending on the injury. It may also bedone with vision and then without.

	  Isotonic exercises
These exercises carried out against a
constant or variable load as the muscle
lengthens or shortens through anavailable range of motion. They may
be concentric, eccentric or both, and

25

	
  

hand therapy

focus mainly on improving dynamic
strength, muscle endurance andpower (1). Most daily living activities,
including sports and creative activities
include both concentric and eccentricmuscle contractions and these may
therefore need to be included as partof the complete approach to wrist
rehabilitation.
Eccentric exercises require a
relatively higher muscle force (thanconcentric exercises)), but with alower energy requirement. They arealso important in preparation forplyometric exercises which are usedin the late stage of rehabilitation ofwrist injuries in those patients withhigher functional requirements of
their wrists and upper quadrants.
Eccentric exercise have often been
associated with causing injury,
however their careful and judicious
use can significantly increase strength,
power and the “spring characteristic”
of muscle required for many daily
and athletic activities (9). This may
not only enhance performance andmotor control, but may also assist
in prevention of injuries caused bysudden unanticipated loading. The
protective mechanism may well be
a combination of enhanced muscle
function as well as proprioceptive
input from muscle spindles, Golgi

About the author

tendon organs and mechanoreceptors
in joints stimulated by motion andjoint position. According to Leger andMilner (10) following sub-maximal
eccentric wrist extension exercises(to exhaustion of the wrist extensors),co-activation of the wrist ﬂexors wasnoted when attempting to extend
the wrist thereafter. This may berelated to antagonists attempt toprovide protection and global stability
to the wrist when the risk of injury
is increased. This may indicate theadditional proprioceptive benefit ofeccentric exercises.
Wrist curls, using free weights or
products like resistive elastic/ rubbers
bands can produce both concentricand eccentric isotonic contractions inthe same exercise, and are commonlyused in the clinic as well as part of ahome programme post-distal radius
fracture and those wrist injuries that
do not include ligament injuries or
instabilities. They may be done inpure ranges of motion ie. wrist ﬂexion,
extension, RD and UD or in moreanatomical planes of motion (eg. DTM)
depending on the pathology. Assistingwith the unaffected hand can limit thetype to either concentric or eccentric
contraction only if needed.

Jennifer Blenkinsop runs a Private Hand Therapy Practice inJohannesburg, South Africa. Her qualifications include BSc (OT), Certified
Hand Therapist (CHT), Complex Lymphoedema Therapist (Casely-Smith),
Guided Imagery and Music Fellow (FAMI- Bonny Method). Please direct
all comments and enquiries to Jennifer at jblenkinsop@tiscali.co.za

26

	
  

Rubber bars eg. Theraband Exercise
Bar may be used for wrist ﬂexion/
extension as well as supination andpronation. The additional benefit
is that the exercise is bilateral andreciprocal in the case of ﬂexion/
extension and symmetrical in thecase of supination and pronation.
Asymmetrical bilateral co-ordination
is more challenging in terms of motor
control than is symmetrical bilateralco-ordination (2). Therefore the useof this exercise form can be gradedfrom symmetrical to asymmetrical, if
needed, as motor control improves.
The ‘Physiociser’ consists of two rods
with a long piece of strong elastic in
between. The patient stands on the
one rod, and with an asymmetrical,
reciprocal motion winds up the elastic.
IFSSH ezine MAY 2013	  

hand therapy

Useful reading and references

Initially there is no resistance, which
may be useful for ROM. However,as the patient continues the action
the resistance becomes greater andgreater, requiring isometric holdand concentric contractions as theresistance increases. If the bar is slowly
released there is an isometric hold andeccentric contraction. The reciprocal
motion is important in neuromuscular
control and proprioception.

1. Kisner & Colby. Therapeutic Exercise:Foundations and Techniques. Second
Ed. F.A.Davis. Philadelphia. 1990.
2. Magill, R. Motor Learning and Control:
Concepts and Applications. Mc Graw
Hill. New York. 2007
3. Hagert, E. Proprioception of the Wrist
Joint: A Review of Current Concepts
and Possible Implications on the
Rehabilitation of the Wrist. Journal ofHand Therapy. January 2010, 23 (1):2-17.
4. Salva-Col et al, The Effect of Forearm
Musculature of Carpal Stability. Journalof Hand Surgery European Volume(published online) May 2011: 1-7

	
  Exercises may be graded from
simple exercises involving the wrist
and hand only, to those involving
the upper quadrant in functional
movement patterns or patterns
specifically related to the functional
demands of the patient. An example ofthis would be slowly imitating portionsof a tennis stroke using a Theraband ora weighted pulley system, or imitating
the motions requiredby work tasks	  with resistance provided by freeweights or resisted rubber bands.
These are performed slow, controlledmanner.
Again these exercises may be
performed using a mirror box toimprove sensorimotor control andwork towards normalizing corticalrepresentation and pain modulation.
Motor control may also be improvedby activation of mirror neurons.

IFSSH ezine MAY 2013

5. Salva-Col et al. The Role of Flexor
Carpi Radialis Muscle in Scapholunate
Instability. Journal of Hand Surgery
2011: 36A: 31-36
	  6. Lichtman DM, Gaenslen ES, Pollock
GR: Midcarpal and proximal carpal
instabilities. In: Lichtman DM,
Alexander AH, ed. The Wrist and Its
Disorders, 2nd ed. Philadelphia: WB
Saunders; 1997

7. Lundborg, G and Rosen, B. Hand
Function after Nerve Repair. Acta Physiol
2007: 189, 207-217
8. Kotlyn KF, Umeda M. Contralateral
Attenuation of Pain after Short-duration
Submaximal Isometric Exercise. Journalof Pain. 2007 Nov; 8(11): 887-892.
9. La Stayo P et al., Eccentric muscle
contraction: their contribution to injury,
prevention, rehabilitation and sport,
Journal of Orthopedic and Sports
Physical Therapy 2003 Oct. 33(10):557–
571,
10. Eldger, A & Milner, T. Muscle
functioning at the wrist after eccentric
exercise. Medicine and Science inSports and Exercise. Vol 33, No 4, 2001.
Pg 612-620.

27

remembering our pioneers

Pioneers in Hand Surgery
Joseph H. Boyes
1905-1995
Joseph H. Boyes was born in Hebron, Nebraska
USA on the 31st March 1905. He studied medicine
at Stanford University, graduating cum laude MD
in 1930. After an assistantship in Hand Surgery
with Sterling Bunnell from 1934 to 1938, he set up
practice in Los Angeles. Between 1942 and 1946,
he did Army service in China and Burma. After the
war he resumed his practice and offered a Hand
Surgery Fellowship, which produced 125 handsurgeons.
Joseph Boyes was a founding member of theAmerican Society for Surgery of the Hand, andserved as its first Secretary. In 1954 he became thePresident of the ASSH. After the death of Bunnell,
Boyes edited Bunnell’s ‘Surgery of the Hand’. He
was also the Editor-in-Chief of the American
Journal of Hand Surgery from 1976 to 1982. It wasBoyes who encouraged speakers to follow his own
advice when presenting a lecture, namely to “bebright, be brief and be seated”!
In 1977 Joseph Boyes was awarded an
Honorary Fellow by the Edinburgh College ofSurgeons. Boyes was known as a master surgeon,
being precise, accurate and rapid because of his
economy and unnecessary movements while
performing an operation. It was because of his
surgical skills, his superior command of the English
language, his clear and to the point lecturers, hismany contributions to hand surgery and as rolemodel that he was honored as ‘Pioneer of Hand
Surgery’ by the IFSSH at its third Congress in 1986
in Tokyo, Japan.

28

IFSSH ezine MAY 2013

remembering our pioneers

Mario Gonzalez-Ulloa
1913-1995
Mario Gonzalez-Ulloa was born in Chihuahua, Mexico. In
1929 he started his medical training in Mexico City. He thentrained for three years in the United States. From 1939 until
1942 he worked as a plastic surgeon in the Cancerology
Service of the General Hospital in Mexico City. During
World War II, he practised reconstructive surgery in militaryhospitals in Great Britain. In 1948 he founded and wasthe President of the Mexican Society of Plastic Surgery.
In 1954 he became a member of the American Collegeof Surgeons and in the same year he was President of
the Latin American Meeting of Plastic Surgery. He was an
associate member of the Royal College of Medicine, as wellas member of the American Cleft Palate Association and
the American Society of Aesthetic Plastic Surgery. GonzalezUlloa was instrumental in the formation of the International
Society of Aesthetic Surgery, was elected President in 1973
and played a key role in organising the 1975 international
meeting in Mexico City. During his career he authored over
50 publications on reconstructive and aesthetic surgery.
He was a keen proponent of humanistic and philosophicalissues and has written a number of papers on these topics.
He published a book entitled: “Daring to Live”, in which hegives his reﬂections on loving, laughing and getting old.
Mario Gonzalez-Ulloa was indeed a man of many
talents, a well-loved lecturer and teacher and incorporated
his medical career into the larger picture of life. He wasregarded by his students as a father figure, a philosopher
and a spiritual guide. It was for all these contributions that
the Mexican Society for Surgery of the Hand proposed
Mario Gonzalez-Ulloa to be honored as ‘Pioneer of Hand
Surgery’ by the IFSSH at its third Congress in Tokyo, Japan in
1986.
He was married to Ruth and together they had fivechildren. Mario Gonzalez-Ulloa died on 3 March 1995.

IFSSH ezine MAY 201329

ifsshezine

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

For the membersby the members…

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journal highlights

Journal Highlights
Below 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 2 (February 2013)■ Resection Interposition Arthroplasty for
Failed Distal Ulna Resections■ Radiographic Parameter Analysis on
Modified Sauvé-Kapandji Procedure■ Ulnar Head Replacement and Related
Biomechanics■ The Sauvé-Kapandji Procedure■ Semiconstrained Distal Radioulnar Joint
Prosthesis■ Opening Wedge Osteotomy for
Distal Radius Malunion: Dorsal or Palmar
Approach?

■ Thumb Carpometacarpal Ligaments
Inside and Out: A Comparative Study ofArthroscopic and Gross Anatomy from theRobert A. Chase Hand and Upper Limb
Center at Stanford University■ Translunate Perilunate Injuries—ASpectrum of This Uncommon Injury■ The Value of 3.0-Tesla MRI in Diagnosing
Scapholunate Ligament Injury■ Carpal Tunnel Cross-Sectional Area
Affected by Soft Tissues Abutting the
Carpal Bones■ Chronic Scaphoid Nonunion of 28-Year
Duration Treated with Nonvascularized
Iliac Crest Bone Graft■ Subluxation of the Palmar Radioulnar
Ligament As a Cause of Blocked Forearm
Supination: A Case of DRUJ Locking■ Distal Ulna Hook Plate: Angular Stable
Implant for Fixation of Distal Ulna
■ The Distal Oblique Bundle of the DistalInterosseous Membrane of the Forearm■ Acute Distal Radius Fracture: PAF
Analysis

Hand Volume 8, Issue 1 (March 2013)■ Gaps in exposure to essential
competencies in hand surgery fellowshiptraining: a national survey of program
directors■ Characteristics of emergency
department transfers for hand surgery
consultation■ Wyndell merritt immediate controlled
active motion (ICAM) protocol following
extensor tendon repairs in zone IV–VII:
review of literature, orthosis design, andcase study—a multimedia article■ Long-term outcomes for Kienböck’s
disease■ Vascularized bone grafts for thetreatment of carpal bone pathology■ Clinical diagnosis and wide-awake
surgical treatment of proximal median
nerve entrapment at the elbow: aprospective study■ The patient’s perspective on carpal
tunnel surgery related to the type of
IFSSH ezine MAY 2013

anesthesia: a prospective cohort study■ The effect of time after shear injury on
the subsynovial connective tissue andmedian nerve within the rabbit carpal
tunnel■ Carpal tunnel syndrome with thenar
atrophy: evaluation of the pinch and grip
strength in patients undergoing surgicaltreatment■ Clostridium perfringens infection
following carpal tunnel release■ Decreasing the pain of finger blockinjection: level II evidence■ Factors associated with incomplete
DASH questionnaires■ Sequelae of foreign bodies in the wrist
and hand■ Kienbock’s disease and scapholunate
dissociation after acute wrist trauma■ A biomechanical analysis of treatment
options for enchondromas of the hand

■ Ulnar nerve ligation after removal of
Norplant: a case report■ Spontaneous rupture of a ﬂexor
digitorum profundus tendon at two levels
in zones II and III in a child■ Successful surgical management of
keratoderma hereditaria mutilans■ Acute proximal row carpectomy to treat
a transscaphoid, transtriquetral perilunate
fracture dislocation: case report and reviewof the literature■ Avascular necrosis of the scaphoidfollowing a scapholunate screw: a casereport■ Posttraumatic distal ulnar physeal arrest:a case report and review of the literature■ Bilateral Kienbock’s disease concomitantwith bilateral Legg–Calvé–Perthes disease:a case report31journal highlights

Journal of Hand Therapy Hand Surgery (Asia Pacific)
Volume 26 Number 2 (April-June 2013)

Volume 18 Number 1 (2013)■ Neural plasticity and implications for handrehabilitation after neurological insult■ Applying principles of motor learning andcontrol to upper extremity rehabilitation■ Assessment of upper extremity impairment,function, and activity after stroke: foundations
for clinical decision making■ Discriminant validity of a new measure of selfefficacy for reaching movements after strokeinduced hemiparesis■ Stroke survivors talk while doing:
Development of a therapeutic framework forcontinued rehabilitation of hand function post
stroke■ Effect of intense functional task training
upon temporal structure of variability of upper
extremity post stroke■ Effects of a dynamic progressive orthotic
intervention for chronic hemiplegia: A caseseries■ Management of upper extremity dysfunctionin people with Parkinson disease andHuntington disease: Facilitating outcomes
across the disease lifespan■ Insights into upper limb kinematics and trunk
control one year after task-related training inchronic post-stroke individuals■ A meta-analysis of the efficacy of anodal
transcranial direct current stimulation for upper
limb motor recovery in stroke survivors■ Effects on bone union andprevention of tendon adhesion
by new porous anti-adhesive
poly l-lactide-co-ε-caprolactone
membrane in a rabbit model■ The recall dash score — a novel
research tool
■ In-vivo measurement of distal
radio-ulnar joint translation■ The beauty of stability: distal
radioulnar joint stability inarthroscopic triangular fibrocartilage
complex repair■ Intercalated bone peg in thetreatment of non-united scaphoid
fractures■ Nonunion of the scaphoid distal
pole■ Predicting successful outcomes ofwrist and finger ganglia■ Short versus long-acting local
anaesthetic in open carpal tunnel
release: which provides better
preemptive analgesia in the first 24
hours?
■ Additional method for diagnosisof carpal tunnel syndrome: value ofthe second lumbrical-interossei test
(2l-int)■ Improved patient awareness andsatisfaction using procedure specificconsent forms in carpal tunnel
decompression surgery■ Comparison of clinical results
between elderly and younger
patients following endoscopic carpal
tunnel release surgery for idiopathic
carpal tunnel syndrome■ Risk factors for re-recurrent
carpal tunnel syndrome inpatients undergoing long-term
hemodialysis■ Evaluation of the first metacarpal
proximal facet inclination as aprognostic predictor following
arthroplasty for osteoarthritis of thethumb carpometacarpal joint

32■ Treatment of rolando fracture bycapsuloligamentotaxis using mini
external fixator: a report of 16 cases■ Primary repair of zone I ﬂexor
tendon injuries■ Finger ﬂexion contracture
due to muscular involvement ofsarcoidosis■ Spontaneous rupture of the left
extensor pollicis longus-, extensor
digitorum- and extensor digiti minimi
tendons: a case report■ Intraoperative findings of
necrotizing fasciitis of the handcaused by staphylococcus aureus
infection■ Non-surgical management of anavulsion fracture injury of extensor
carpi radialis brevi■ An unusual complication
after suspensionplasty with theabductor pollicis longus tendon for
osteoarthritis at the carpometacarpal
joint of the thumb■ Rotatory subluxation of themetacarpophalangeal index finger
joint: a case report■ Bony mallet thumb■ A large extraskeletal chondroma
in the hand of an elderly patient — acase report■ Palmar well differentiated spindlecell liposarcoma: presentation of arare tumor at a rare site
■ Angioleiomyoma of the superficial
palmar arterial arch
■ Single patent vessel over anembedded ring: a case report■ Application of a trans-web
approach to plating technique for an
extra-articular fracture of the proximal
phalanx■ Longitudinal melanonychia:
detection and management of nailmelanoma

IFSSH ezine MAY 2013

journal highlights

Journal of Hand Surgery (European Volume)
Volume 38 Issue 3 (March 2013)■ Clinical findings in C5-C6 and C5-C7 root palsies with brachial
plexus traction lesions■ Posterior approach for accessory-suprascapular nerve transfer:
an electrophysiological outcomes study■ Results of surgical techniques for re-innervation of the triceps
as additional procedures for patients with upper root injuries■ Characteristic radiographic features of the central ray in Apert
syndrome■ Commentary on Kim et al. Characteristic radiographic featuresof the central ray in Apert syndrome■ Arthrography in thumb polydactyly with bifurcation at theinterphalangeal or metacarpophalangeal joints provides practicalinformation at surgery■ Correction of Wassel type IV thumb duplication with zigzag
deformity: results of a new method of ﬂexor pollicis longus
tendon relocation■ Long-term aesthetic outcome of fingertip reconstruction incomplete syndactyly release■ Modified Ilizarov technique for the treatment of forearm
deformities in multiple cartilaginous exostoses: case series andliterature review■ Macrodactyly — options and outcomes■ Intravascular papillary endothelial hyperplasia of the digit: MRIfeatures with histological correlation■ Analysis of failed Van Straten LPM proximal interphalangeal
prostheses■ An objective assessment of safety to drive in an upper limb cast
■ Trigger finger caused by anatomical variation lumbrical muscle■ Adverse effect of repeated corticosteroid injections for trigger
finger on ﬂexor pulley system■ Volar wrist ganglion presenting as trigger finger■ A case of basal cell carcinoma on the dorsum of a finger■ Primary cutaneous ganglioneuroma of the finger mimicking
verruca vulgaris: a case report■ Amputation for pain in a thumb: not an advisable treatment

Journal of Hand Surgery: American volume
Volume 38 Issue 4 (April 2013)■ Minimal Clinically Important Differencesof 3 Patient-Rated Outcomes Instruments■ Benchmarking Changes in Symptom
Intensity and Magnitude of Disability■ The Minimal Clinically Important
Difference After Simple Decompression for
Ulnar Neuropathy at the Elbow■ Comparison of the Effects of
Subcutaneous Anterior Transposition and
In Situ Decompression on the Histologic
and Electrophysiologic Properties of theUlnar Nerve: An Experimental Study in a
Rabbit Model■ Effect of Partial, Distal Epicondylectomy
on Reduction of Ulnar Nerve Strain: A
Cadaver Study■ An Experimental Study Comparing
Active Mobilization to Passive Flexion–
Active Extension–Active Flexion After
Flexor Tendon Repair in Zone 2■ Analysis of a Knotless Flexor Tendon
Repair Using a Multifilament Stainless Steel
Cable-Crimp System
IFSSH ezine MAY 2013

■ The Effect of a Therapy Protocol
for Increasing Correction of Severely
Contracted Proximal Interphalangeal Joints
Caused by Dupuytren Disease and TreatedWith Collagenase Injection■ Vascularized Medial Femoral Trochlea
Osteocartilaginous Flap Reconstruction of
Proximal Pole Scaphoid Nonunions■ Scaphoid Waist Nonunion With
Humpback Deformity Treated Without
Structural Bone Graft■ Radioscapholunate Arthrodesis
With Excision of the Distal Scaphoid:
Comparison of Contact Characteristics tothe Intact Wrist■ Changes in Contact Site of theRadiocarpal Joint and Lengths of the
Carpal Ligaments in Forearm Rotation: An
In Vivo Study■ Relationship of Serum Relaxin toGeneralized and Trapezial-Metacarpal Joint
Laxity■ The Carpal Insertions of the Transverse

Carpal Ligament■ Proximal Interphalangeal Joint Injection
Through a Volar Approach: Anatomic
Feasibility and Cadaveric Assessment of
Success■ Macrodactyly in the Settingof a Plexiform Schwannoma in
Neurofibromatosis Type 2: Case Report■ Extensile Surgical Exposures of theRadius: A Comparative Anatomic StudyA Comparison of the Long-Term Outcomeof Partial Articular (AO Type B) andComplete Articular (AO Type C) Distal
Radius Fractures■ Essential Hand Surgery Proceduresfor Mastery by Graduating Orthopedic
Surgery Residents: A Survey of Program
Directors
The Overutilization of Resources in Patients
With Acute Upper Extremity Trauma andInfection33

upcoming events

Upcoming events
Advanced Derby Hand 68th Annual Meeting
Courseof the American
23-24 May 2012
Society for Surgery of
Derby, United Kingdom
the Handwww.pulvertafthandcentre.org.uk
The Pulvertaft Hand Centre, Derby, UK
is hosting this comprehensive twoday conference for Hand Surgeons,
including: Case based discussions,tips and hints on technique from theexperts, current concepts in handsurgery, controversial management
issues. Leading national andinternational Faculty will debate topics
including: Dupuytrens Contracture, theWrist, trauma, ﬂexor tendons, peripheral
nerves, joint replacement, CMCJ thumb.

October 3-5, 2013
Moscone West Convention Center,
San Francisco, CA, USA
www.ASSHAnnualMeeting.org
Annual Meeting program chairs
Michael Hausman, MD and Fraser
Leversedge, MD look forward to arobust program at the 68th Annual
Meeting of the ASSH.

3rd Annual RAMSESMultispecialty
FESSH Congress 2013 Robotic Microsurgery
Symposium
29 May – 1 June 2013
Antalya, Turkey
www.fessh2013.com
The 18th FESSH Congress will beheld at the capital city of the Turkish
Riviera, Antalya between 29 May and
1 June 2013. Antalya is located on
the southwestern coast of Turkey.
The region is famous for its historical
heritage, blue sea, warm weather andis accessible with direct ﬂight from
European cities. Detailed information
about the congress is available on
www.fessh2013.com.

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8-9 November 2013
Strasbourg, France
www.roboticmicrosurgeons.org
The only multi-specialty
microsurgical gathering of its
kind—with microsurgeons fromvarying fields, including: hand,plastics, reconstructive, ENT, urology,
gynecology, ophthalmology, vascular,
orthopaedics, pediatrics and peripheral
nerve.

Arthroscopy andarthroplasty of thewrist

22-23 November 2013
Arezzo, Italywww.sicm.it/norme_editorialien.
html
The course is designed for specialists
in hand surgery, orthopaedics andplastic surgery who want to improvetheir technical skills in the diagnosis
and treatment of wrist disease. Experts
will take lectures and presentations
followed by arthroscopic and open
surgical techniques on anatomical
specimens. Sessions will consider
clinical diagnostics for each form of
instability or other pathologies of
the wrist. Open and arthroscopic
techniques will be presented in details
with their specific indications. Eachparticipant will bring clinical cases todiscuss with experts and will have atleast one anatomical specimen.

LEARNING OPPORTUNITY
only 4 places available

Synthes Fellowship in
Hand and Reconstructive Microsurgery
Ganga Hospital, Coimbatore, India
6-8 weeksThis fellowship is an educational
initiative of the Department of
Plastic and Hand and Reconstructive
IFSSH ezine MAY 2013

upcoming events

Microsurgery department of Ganga
Hospital, Coimbatore, India andSynthes to promote Hand andReconstructive Microsurgery. Fourfellowships are available every year.
This enables the selected fellows tospend 6 to 8 weeks in the department
and take part in all the academic andclinical activities of the unit.
Ganga Hospital, situated in South
India is a 450 bed hospital, exclusively
catering to the two specialties of Plastic
and Hand Surgery and Orthopaedics.
The department has a busy trauma
reconstructive surgery load in
addition to undertaking all aspects
of Hand Surgery and the lower limb
reconstruction work provides ample
opportunities for microsurgery. The
department has a good microsurgery
training laboratory, which regularly runs
week long microsurgery courses.
The fellowship provides free
comfortable accommodation for theperiod of stay in the Hospital apartment
and an allowance of Rs 35000 to Rs
40000 (depending upon the exchange
rates) for incidental expenses. The
fellowship also includes the fees (US $750) to undertake the one week longfull time Microsurgery course in the
Ganga Microsurgery Laboratory.
We would like to choose candidates
with a professed interest in Hand andReconstructive Microsurgery. While
experience in the field is preferred, it
is not essential. The sponsors of the
fellowship are keen that candidates
should be working in an environment
where they will be able to utilise
the experience gained for better
patient care. Both Plastic Surgery andOrthopaedic trained Hand Surgeons
are eligible to apply.
IFSSH ezine MAY 2013

How to Apply?
Interested candidates are requested
to send in their CV with two referees,a photograph with a note about how
the fellowship will be useful to them.
Please send it to DR S Raja Sabapathy,
Chairman, Department of Plastic

Surgery, Hand and Reconstructive
Microsurgery, Ganga Hospital,
Coimbatore, India at rajahand@vsnl.
com. Applications are invited for 2014
and the applicants are requested toalso specify the preferred period ofstay.

“Anyone who stops learning is old, whether at twenty or eighty.
Anyone who keeps learning stays young.” — Henry Ford
Stay young through learning the latest in the field, andcontinue your educational journey by joining ASSH in
San Francisco at our most technologically advanced
meeting ever.
To celebrate the importance of collaboration in learning,
we are offering a special discount for international
attendees: Register yourself, and get free registration
for a colleague! Visit www.ASSHAnnualMeeting.org for
more details about the offer.
All of the content for this year’s paperless meeting will
be accessible through our free mobile app and throughour website, so login and explore.

This year we have:• A welcome reception dedicated tohonoring our international attendees.
• 52 Instructional Courses.
• 12 pre- and post-courses, including
two hands-on skills courses.
• A bustling exhibit hall and various
industry forums highlighting thelatest products.
• Inspiring and thought-provoking
keynote speakers.

SHARE YOUR KNOWLEDGE • LEARN NEW SKILLS • BE PART OF OUR GLOBAL COMMUNITY
JOIN YOUR COLLEAGUES AT THE 2013 ASSH ANNUAL MEETING.

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ifsshezine