ifssh
February 2018www.ifssh.info

ezine

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

VOLUME 8 | ISSUE 1 | NUMBER 29 | FEBRUARY 2018

RESEARCH ROUND-UP:
DISTAL RADIO-ULNAR JOINT

HAND THERAPY:SPORTS INJURIES OF THE HAND & WRISTADVANCES IN REHABILITATIVE TREATMENT

The Handand
Neurology
CHECKLIST FOR HOLISTICMANAGEMENT

CLASSIFICATION OF QUESTIONSUPCOMING EVENTS
1

www.ifssh.info

February 2018www.ifssh.info

VOLUME 8 | ISSUE 1 | NUMBER 29 | FEBRUARY 2018

contents
4

6

EDITORIAL
Checklist for Holistic Management• Distal radio-ulnar joint- Ulrich Mennen• Triangular Fibrocartilage Complex Repair

OBITUARY• Adrian E Flatt• Ridvan Ege

8

LETTER TO THE EDITOR
Some stories of Adrian Flatt (1921 - 2017)

10 SECRETARY-GENERAL REPORT

1226 RESEARCH ROUNDUP• Radial Nerve Excursion at the Brachium

30 MEMBER SOCIETY NEWS• American Society for Surgery of the Hand
• German Society for Surgery of the Hand
• Mexican Society for Surgery of the Hand andMicrosurgery• Romanian Society for Surgery of the Hand
• Philippines Association of Hand Surgeons

IFSSH Newsletter• Italian Society for Surgery of the Hand

- Daniel J. Nagle• Dutch Society for Surgery of the Hand

PIONEER PROFILES• Geoffrey Raymond Fisk
• Wael Mansour Fahmy

14 REPORTS AND UPDATESThe Hand: a Neurologist’s perspective- Johan A. Smuts

22 HAND THERAPYSports Injuries of the Hand & Wrist
Advances in Rehabilitative Treatment- Mojca Herman• Japanese Society for Surgery of the Hand
• Polish Society for Surgery of the Hand
• Korean Society for Surgery of the Hand

39 ART
40 PEARLS OF WISDOMClassification of Questions- Michael Tonkin- Andreas Fox

42 HAND SURGERY EVIDENCE
43 UPCOMING EVENTS
List of global learning events and conferencesfor Hand Surgeons and Therapists

2

3

EDITORIAL

www.ifssh.info

EDITORIAL

February 2018

As a hand surgeon who has been in medical practice forThis is not a flow chart, or flow diagram but a mental

48 years, I found the following 10 point mental check list

check list to ensure that all the important bases haveinvaluable to insist me in an attempt to reach a honest

been covered.

diagnosis in the first place, and only then, to offer aholistic management plan for my patients:“A correct diagnosis will help in reaching the most
optimal management, but an incorrect diagnosis

Have I listened to my patient’s complaints?

will lead to an incorrect management”(not the opinion of others, for example
physiotherapists, relatives or colleagues)

All the very best for an enjoyable and meaningful 2018 !

Do I have all the relevant background

Ulrichinformation? (e.g. work, hobbies, sports, musicetc.)

Checklist for Holistic
Management

Have I physically examined my patient?
Have I made a provisional clinical diagnosis?
Do I really need further investigations toconfirm my clinical diagnosis? (will this add
more information)
If so, which ones are realistic? (sonar, X-rays,
electro conductions, bloods, MRI, scans)

For a very long time I have struggled to find an answer

We are trained to make a diagnosis; and (any)to a concerning trend, which seems to become morediagnosis we will make! But this is often where we

frequent.

miss the point; it is in choosing the right, holistic

Have I, in simple objective terms, explained

option for the patient sitting right in front of me at thisthe diagnosis to my patient? (using models,This trend becomes more obvious the more patientsmoment, which can only be based on an honest anddrawings, diagrams, scan images)

I see for so-called “second opinions”, as well as

correct diagnosis.
Have I discussed all the management options,complicated cases that are referred to me.
Why are we in medicine neglecting a very simple

including the possible risks? (observations,

The issue is that one sees an increasing number

method to help us avoid unnecessary mistakes orointments, medicines, appropriate modalities ofof patients who have been “over serviced”, oroversights, which other professions have used forhand therapy, splints, surgical options)inappropriately treated.

many years?
Have I explained the difference between “aThe challenge was to identify the cause or reason for

Pilots use check lists as an essential necessity toserious condition” (something needs to be done)

this inappropriate handling of these patients’ ailments.

ensure the safety of the aircraft and passengers. The

and “an annoying condition” (no urgency to dobuild environment (eg. architects, quantity surveyors,

anything)?

It became clear that the answer was indeed simple.

builders) cannot design, plan or build any construction

The problem mostly does not lie in a lack of training,

without check lists. All successful venture capitalists

Am I sure my suggested management willknowledge or skill, but in not seeing the bigger picture,use check lists before investing in start-up enterprises.

benefit the patient, even with the known

Ulrich Mennen

evaluating the odds against the benefits and/or

possible complications? (scarring, stiffness,

Editor: IFSSH Ezine			deciding what is best for a particular patient.

implant failure, infection, rehabilitation etc.)

www.ulrichmennen.co.za

45OBITUARY

www.ifssh.info

Adrian E Flatt

OBITUARY

February 2018

Ridvan Ege(1921 - 2017)(1925 - 2017)

ifssh
ezine

CONNECTING OUR GLOBAL HAND SURGERY FAMILYIFSSH DISCLAIMER:
The IFSSH ezine is theSurgery (American) from 1980-1991.

Dr. Flatt and I corresponded and

He trained 50 hand surgery fellows

spoke often over many years. He

in Iowa City, Norwalk, Connecticut,

was always encouraging, upbeat

From 1967 – 1993 he was theSocieties for Surgery of theand Dallas, Texas.

and insightful. He often nudged

Chairman of the Department

Hand. The IFSSH does not

me to write more and share myof Orthopaedic Surgery andendorse the commercial

He was named a Pioneer in Hand

thoughts with others. We are all

Traumatology at Ankara University

advertising in thisSurgery by the International

the better since he so willingly

Medical School before his retirement

publication, nor the content

Federation of Societies for Surgery

shared his knowledge with us all.

in 1993or views of the contributors(TSSH).

official mouthpiece of theInternational Federation ofof the Hand in 1992.

to the publication.
His inspiring teaching of hand

Prof Ege was honoured as a ‘Pioneer

Subscription to the IFSSH

As a high school student, I read

anatomy to medical students atof Hand Surgery’ at the 6th IFSSH

ezine is free of charge andan article in Time magazine about

Texas Southwestern Medical School

Congress in Helsinki, Finland, inthe ezine is distributed on a

Dr. Adrian Flatt’s work at theearned him the Teacher of the Year

1995.

quarterly basis.

University of Iowa where he hadhonors on 7 different occasions.

Still full of energy after his

Adrian Flatt was born in Englanddeveloped metal MCP joints. I used

and raised in India. While

the Time article as the basis of ahe attended medical schoolat Cambridge University, heRidvan Ege was born in Denizli,

retirement, he established the Ufuk

Should you be interested toMany years ago, Dr. FlattTurkey in 1925. He qualified as a

University in 1999.

advertise in this publication,science project, never supposing

anonymously contributed a

Medical Doctor in 1948 and received

that our paths would cross.

substantial sum to an AFSH

the General Surgery Board Certificate

Ege published 92 books on Hand

fund that has underwritten thein 1955. He then completed his

Surgery and Orthopaedic Surgery, as

please contact the Editor:ezine@ifssh.info

Hospital in London during the blitz

As a resident, I read his books on

costs associated with the ASSH

Orthopaedic Surgery residency in thewell as 304 scientific articles.

IFSSH EZINEEDITORIAL TEAM:

bombing in WWII. After training in‘The Care of Minor Hand Injuries’,

Residents and Fellows Conference

USA between 1955-1959.

He was the chairman and organiser

EDITOR:

orthopaedic and plastic surgery in‘Care of the Arthritic Hand’, andfor many years. After several yearsof the 8th IFSSH Congress in 2001 in

Professor Ulrich Mennen

England, he became a physician‘The Care of Congenital Handof prodding, he reluctantly allowed

Dr Ege then became the Director of

Istanbul.

(Past President of the IFSSH)

in the Royal Air Force parachuteAnomalies’. Each was practical andthe ASSH to add his name to the

Orthopaedic Surgery in the Gulhane

Still not done, at the age of 80,

rescue team in Sri Lanka. He madehighly readable by the novice.

conference title.

Medical School between 1959-1967.

he was Chairman of SICOT

DEPUTY EDITOR:

18 parachute jumps as a young

He became famous for his

Between 1963 and 1964 he did a Hand

(International Federation ofProfessor Michael Tonkin

physician. He first came to the US

technique of making molds of

He was a remarkable man who lived

Surgery Fellowship at the New York

Societies of Orthopaedic Surgery and(Immediate Past President ofon a Fulbright Scholarship. He

hands of children with congenitala full life by any measure.

Columbia University under Dr. Robert

Traumatology) in 2005.

the IFSSH)

assumed a faculty position at thehand disorders. He also madeUniversity of Iowa in 1956.

numerous hand castings of

Adrian E Flatt passed away on 14

Prof. Ridvan Ege passed away in 8

GRAPHIC DESIGNER:

accomplished individuals (October 2017 at the age of 96 years.

June 2017

Tamrin Hansen

volunteered at the Royal London

E. Carrol.
Back in Turkey, he established theDr. Flatt became an ASSH member

presidents, athletes, artists, medical

in 1958. He served as ASSH

colleagues, etc) which now fill

Terry Light, MD,

Surgery and Traumatology in 1964 .

Haluk Ozcanli M.D

TO SUBSCRIBE GO TO:

president from 1975-1976 and was

the lobby of the Baylor University

Past ASSH President

In 1967 Dr Ege founded the Turkish

On behalf of the Turkish Society for

www.ifssh.info/ezine.html

the Editor of the Journal of Hand

Hospital in Dallas.

Society for Surgery of the Hand

Surgery of the Hand

6

Turkish Society of Orthopaedic

7

LETTER TO THE EDITOR

www.ifssh.info

Some stories of
Adrian Flatt (1921 - 2017)

LETTER TO THE EDITOR

February 2018upon the Queen Mary for the United

published.

sauntering with a broad-based mid-

States that Sir Reginald realised thatAs an editor, Adrian was alsoWestern country stride. They were as

Mr Flatt had disobeyed him, behaviour

responsible for telling us that ourdifferent as chalk and cheese. At nowhich he could not countenance, nor

profound and worthy efforts should

stage during this meeting, nor during

understand. Sir Reginald, as an older

be placed in a drawer for a number ofthis walk, did one try to outdo theman, was also known for fracturing

weeks, then re-examined for the manyother - the elegance and confidence

his pelvis during a game of “Oswestry

faults which would become apparent,of two talented men. At least, until

When the ASSH meeting was held

Terry Light, ASSH Past-President has

Richard Smith, without condescension

billiards” at the Robert Jones andbefore submission.

they reached the environs of the pub.

in Chicago in 2003, Dan Nagle and I

written a wonderfully moving accountand in perfect English, the meaning

Agnes Hunt Orthopaedic Hospital

On receiving criticism from reviewers,

I heard Harold say to Adrian in his

were asked to talk about the History ofof his associations with Adrian Flatt.

of my question. I was a very grateful,outside Oswestry in Shropshire.

we should follow the same process.

laconic, American drawl “In what year

Chicago Hand Surgery. We spent the

Others will provide factual details ofyoung trainee.

He certainly anticipated the current

were you born Adrian?” “I was born insummer editing photos and videos

his remarkable life. What follows is a

In this game the protagonists placetendency for many to respond in anger

1921. I am 82” was the reply in a precise

and refining our text. A rehearsal theseries of “Adrian Flatt stories”, some

During that meeting I learnt of “twotheir hands on a billiard table. A nameand immediately, through email orand clipped English accent. “I am also

day before our presentation, while

undoubtedly apocryphal. Those instories” which have entered folklore.

is called and that person must taketwitter, when criticised. The time in a82” said Harold. A silence followed.

the stage was being constructedwhich I was involved are true, at least

The first we all know. Wassel, atpossession of a moving billiard ball,drawer, and the time it took to write aThen, this : “Well, in what month werearound us, was judged “boring.” We

to a fading memory.

the completion of his Fellowship

which has been propelled at speed

letter in response was enough time toyou born?” asked Harold. “I was bornin Iowa City, was approached byagainst the cushion of the table, before

allow immediate resentments to pass.

in August” replied Adrian. “Well, I

needed to shorten our presentation.
We were despondent. Overnight weI first met Dr Flatt at the Derby Hand

Dr Flatt who questioned whether

the ball comes to a stop, whilst being

What an outstanding piece of advice

was born in October” said Harold,edited out several minutes of video

Course conducted by Frank Burke inhe had contributed anything of

prevented from doing so by the otherthis was, insightful, understanding and“which means that you are older and,and text. Our final rehearsal of thethe UK, in 1981. He and Richard Smith

worth to hand surgery during his

players, who may move around thegentle.

therefore, you should enter the hotel

new script was held at 6 AM on theformed a formidable teaching duo at

Fellowship. In the following week hetable whilst keeping their hands inmorning of the opening ceremony.

this week of intimate learning for an

produced the Wassel classification

contact with the table. Their aim is

In 2004, Adrian Flatt and Harold

Adrian,” I appreciate your courtesy”.

When we finished our presentation

audience of 50 or so, of which I wasof thumb duplication, a classification

to prevent the named player from

Kleinert attended another hand

Without batting an eye and with not

to an empty auditorium, we heard aone. Richard Smith, metaphorically,

which remains in use today. To myretrieving the moving ball. A thrust

meeting in Derby, this time to celebrate

so much as a slight upturn of the lips,

lone individual applauding. When

amputated both my index and little

knowledge, Wassel made no otherfrom one right hip sent Sir Reginald,

the retirement of Frank Burke. Frank

Harold then informed Adrian that as

we realized that it was Adrian Flatt,fingers as a punishment for answeringsignificant contributions to the world

whose name had been called, tumbling

had spent Fellowships with both inhe was entering the hotel firstly, hewe were ecstatic. He said that hethat my little finger was the leastof hand surgery. Some would prefer

into the, fortunately unlit, fire place.

the US. They were his teachers as

was responsible for buying the firstenjoyed our presentation very much.

useful and the one which I could mostthe naming of this classification to be

The culprit remains nameless.

they were mine. At the time of Frank’sround of drinks for everyone. That was

At that point, I felt that if Adrian Flattdo without. If I was not embarrassed

altered to Flatt’s classification of thumb

Certainly not Adrian Flatt. I suspectretirement, both were still working.

the only round of drinks we had before

liked it, I didn’t care what anyone

and humbled enough, he then feigned

duplication. (My apologies to Wassel ifthat the game is rarely played now.

Harold Kleinert presented a talk “Mydinner. Nevertheless, Adrian was his

else thought. We confidently went

to misunderstand my question as

I have unintentionally caused offence).

first 50 years of hand surgery”. Adrian

normal gracious self.

forward with our show at the opening

to whether there was an increase

ceremony in front of 1500 attendees.

in degenerative changes in those

The audience vigorously applauded

first”. “Well thank you. Harold” said

My next involvement with Adrian

Flatt’s topic was “My life as a medical

Before this, during his training as an

Flatt was in 1985, when as editor of

student in London during the Blitz”.

Our paths have crossed many times.

born with a congenital scapholunate

orthopaedic registrar in the UK, Adrian

the JHSA, he returned a manuscript

The audience was enthralled by both

There are too many stories to tell. He

the final presentation – I was mostor lunotriquetral synostosis. This

Flatt had been Senior Registrar to Sir

I had offered for publication, alongmen. In the evening, with England’s

has been a teacher, mentor and friend

pleased that Adrian liked it.

in response to a discussion of theReginald Watson-Jones, one of thewith scathing comments from thesummer smiling, a group of us, led

to me, as he has been to so many. We

prevalence of such changes following

more famous orthopaedic surgeonsreviewers. Of course, I took offenceby Adrian and Harold, headed to thewill miss him.

surgically performed intracarpalof that time. Such was his power

to this and responded with a long

nearby local pub for refreshments

arthrodeses for carpal instability. Itthat when Mr Flatt apologeticallyexplanatory letter to Dr Flatt. His reply

before dinner. I was following

was fun enough and effective for the

informed the great man that he waswas a delight. He informed me that if

immediately behind the two and what

purpose of teaching. However, Adrian

moving to Iowa City in the United

my manuscript had been as elegantly

a sight they offered. One, upright,

Flatt noticed my discomfort and spoke

States, Sir Reginald forbade him. It

and pithily written as was my letter,almost rigid with the gait of a soldier,

to relieve it. He proceeded to explain to

was not until Adrian had embarked

undoubtedly it would have beenor an English gentleman; the other

Terry Light, MD, Past ASSH President

8

Michael Tonkin

9

SECRETARY-GENERAL REPORT

www.ifssh.info

SECRETARY-GENERAL REPORT

February 2018

I encourage the hand surgeons of our member societies to take the time to peruse the IFSSH Ezine.
This quarterly communication is unique and serves as a conduit for the exchange of information
within the world hand surgery community. The Ezine contains informative articles on clinical issues
as well as updates on the many accomplishments of our member societies. We sincerely appreciate
the member societies’ contributions and of course we are indebted to Professor Ulrich Mennen for his

IFSSH
Newsletter

Editorship of the IFSSH Ezine. By the way, if you do not already receive the Ezine, please subscribe(free of charge) via the website - http://ifssh.info/ezine.html.
Once again, I encourage you to take advantage of the many educational program funding opportunities
offered by the IFSSH.
On behalf of the IFSSH Executive Committee I wish you a Happy New Year.
Future Meetings:
Triennial IFSSH Congresses
XIVth IFSSH – XIth IFSHT Congress – Berlin, Germany
17-21 June, 2019www.ifssh-ifsht2019.com

I am pleased to report the IFSSH continues to grow. We are now a Federation of 59 societies from 57
nations and we look forward to welcoming many more hand surgery societies into the IFSSH family.

XVth IFSSH – XIIth IFSHT Congress – London, United Kingdom
2022 (Dates to be confirmed)

The IFSSH is dedicated to promoting the dissemination of hand surgery knowledge around the world.
The IFSSH is uniquely positioned to pursue this goal given the financial health of the organization

National and Regional hand surgery meetings

and the breadth of its membership. One way the IFSSH can help educate hand surgeons is through the

Please see announcements in the Ezine and listed on the IFSSH website.

Harold Kleinert Visiting Professorship. The IFSSH Committee on Educational Sponsorship (CES) has
funds available to underwrite a visiting professorship to interested hand surgery units and is anxious
to receive applications. This Professorship provides funding for hand surgery centers to bring a wellknown hand surgeon to their unit. I strongly encourage our members to consider this opportunity.
The IFSSH Committee for Educational Support (CES) also looks forward to receiving applications
for financial support of other educational endeavors such as regional courses, outreach programs
including education and medical missions, grants for fellowships and attendance at the IFSSH
Triennial meetings.
Full details are available on the IFSSH website - http://ifssh.info/fellowship-grants.html
Speaking of the website, we continue to work on the website upgrade. The upgrade will make thewebsite more user friendly, increase its functionality and contain more IFSSH archival information. We
will keep you informed as this upgrade process evolves.
This year the 2018 Delegates’ Council Meeting will be held in conjunction with the FESSH congress
which will take place June 13-16 in Copenhagen. We will forward the full details of the IFSSH

Daniel J. Nagle MD

Delegates’ Meeting to all delegates in the near future.

Secretary General IFSSH

10

11

PIONEER PROFILES

www.ifssh.info

Geoffrey Raymond Fisk
MRCS; LRCP; MB BS; FRCS Ed; FRCS Eng; MPhil

1916 – 2007

PIONEER PROFILES

February 2018

Wael Mansour Fahmy
MCh(Orth) , FRCS(Eng)1928 – 2003

Geoffrey Fisk was born

Fisk has been honoured by being appointed Hunterian

Wael Fahmy was born in

Professor Fahmy has participated in numerous societyinGoodmayes,

Essex

Professor at the Royal College of Surgeons (London) on

Cairo on 3 August 1928,

activities. He is Founder Member and Secretary Generalon 26 May 1916.

He

three occasions (1951, 1968 and 1978) during his consultant

to Mansour Fahmy, aof the Egyptian Hand Club. He served as Council Member

studied medicine at St.

career, and his discourse in 1968 dealt with carpal

philosopher, and Insafof the Egyptian Orthopaedic Association for over 15 years,

Barholomew’s Hospitalinstability and the fractured scaphoid, describing wedge

Serry, an educator.

In

and was elected President in 1992. During this period, hein London and later

grafting for non-union. He has lectured widely and written

1952, he graduated fromsupported the expansion of audio-visual facilities for sub-continued postgraduate

extensively on the biomechanics of the wrist joint and the

Ein-Shams

Medicalspecialized fields, including hand surgery. Meanwhile hetraining there.

history of development of Hand Surgery. He has shared

School, Cairo, Egypt. He

upgraded his private service to an Institute level wherein the training of senior registrars on the Bart’s Rotation

received a diploma of

trainees and researchers frequently utilized the library andTraining Programme and on his retirement in 1981 some

surgery in 1956, and a

microsurgical laboratory facilities.

thirty trainees had obtained consultant appointments.

diploma of orthopaedic

Shortly

after

the

outbreak

of

World

War II, he was posted

surgery in 1959.

In

In 1980 he formed, with dedicated expatriates, the Egypt &to Addenbrooke’s Hospital in Cambridge to assist in the

After retirement from consultant practice he took up the

1963, he earned the Fellowship of the Royal College ofEastern Mediterranean Society for Surgery of Hand, for theestablishment of an Accident Centre for the treatment ofstudy of Anthropology and obtained his MPhil at Darwin

Surgeons of England ( FRCS Eng), and a master’s degree

purpose of joining the IFSSH. Since that time he has been

military and civilian casualties. He later joined the Royal

College in Cambridge University.

While studying atin orthopaedic surgery from Liverpool in 1965. During thisthe Editor of the Eastern Mediterranean Hand Bulletin, a

Air Force Medical Branch at Northallerton where he came

Witwatersrand University, he described a severely fractured

time, he received his initial training in hand surgery at

newsletter that also provided a computerized data base forunder the influence of Guy Pulvertaft. There he designed

calcaneus partly united to the talus in a 22 million year old

Harlow-Wood Orthopaedic Hospital, in Nottinghamshire,

hand problems. In later years his focus was on computer

the “Lead Hand” for securing the hand on the operating tablefossil Australopithecine hominid from Sterkfontein, Southby Guy Pulvertaft.

programming methods to join together management rules

during surgery. This device is used universally although its

Africa.

origin is often not known by the user (Lancet 1948).

by weights of confounders. The weights were derived
General W. M. Fahmy served the Egyptian Medical Corps

by linear regression of age, duration, type and location of

Fisk (originally spelled Ffyske) had many interests,

until 1983. During that time, he conducted Hand Surgery

lesion. He was simultaneously verifying by meta-analysis,

His first consultant appointment was to the Seamen’s

including gardening and classical music . He owned aclinics at the Helmiah and Maadi Military Hospitals

the linear correlation.

Hospital in Greenwich, London where he established a Hand

copy of the first editions of Andreas Vesalius’ Fabrica (1543)

whereService. In 1952 he was awarded a Fulbright Fellowship at

as well as Adrian Spigelius’ Opera (1645). He died on 10

revascularization in dogs during the early seventies.

St. Louis, Missouri, in Professor J. Albert Key’s Service. He

November 2007 at the age of 91.

was later appointed orthopaedic surgeon to the Harlow

heexperimented

withintermediate

vesselHe organised the Satellite Congress to Egypt before the 4th
IFSSH Congress in Tel Aviv, Israel in 1989.

Dr. Fahmy was then appointed Professor of Orthopaedic

Group of Hospitals setting up a Hand Service there also. He

Geoffrey Raymond Fisk was awarded the “Pioneer of Hand

Surgery at the Military Medical Academy in Cairo, where

designed a camera for use in the Accident Department.

Surgery” title in 1998 at the Seventh International Congress

he established a microsurgical laboratory for small animalsof the IFSSH in Vancouver, B.C., Canada.

with the purpose of conducting workshops that would help

At the Seventh International Congress of the IFSSH in

He was an early member of the curiously named Second

surgeons from all over the region to develop skills in the

Vancouver, Canada in 1998, Wael Mansour Fahmy was

Hand Club, the precursor of the British Society for Surgery

fields of their applications. He devised twin microscopes

honoured “Pioneer of Hand Surgery”

of the Hand (BSSH). Fisk was a Founder Member of thewith separate foot pieces to allow two surgeons to work

BSSH and its President in 1981.

simultaneously on cases of multiple re-implantations.

12

Wael Fahmy passed away on 29 December 2003.

13

SPECIAL FEATURE

www.ifssh.info

The Hand:a Neurologist’s
perspective
JOHAN A. SMUTS MBCHB, MMED(NEUROL), LLB
PRETORIA, SOUTH AFRICA
JASMUTS@GMAIL.COM

SPECIAL FEATURE

February 2018

The brain-hand link

Spinal cord lesions

Many conditions affecting the central nervous system find

Depending on the level and completeness of spinal cord

unique expression in the hand. Lesions of both the brain

lesions a mixed upper and lower motor neuron weakness

and spinal cord will produce uniquely recognizable handpattern can be observed in the hand.

posturing.

Radicular pathology from the C6-T1 roots affects the hand.

Spasticity

1.

Cervical Myelopathy				Central nervous system (CNS) damage can induce

Cervical myelopathy can be caused by various

deformities of the limbs due to muscle spasticity and thenpathological processes resulting in compression

tendon retractions. The intrinsic muscles of the hand ie.

of the spinal cord. The clinical picture varies

the interossei muscles, the adductor digiti minimi, and toaccording to the level of cord involvement. Patientsa lesser degree the lumbrical muscles are mainly involved.

present with neck pain and paraesthesia in aThis often leads to a wrist flexion. The position of thenon-dermatomal pattern but also weakness in thefingers is variable. The fingers can be flexed, making aupper extremities combined with loss of motor

tight fist around the thumb.

control due to weakness and often spasticity in thelower extremities, resulting in gait impairment.
In advanced disease, there may be global wasting

Table 1
“Often the hands
will solve a mysterythat the intellect has- Carl G. Jung		

- Radiculopathy

as a diagnostic area in clinical evaluation of a patient has
great significance for the neurologist. It also presents alink between neurology and various other specialities.

dysaesthesia in a dermatomal distribution. This

• Neuropathy- Generalized neuropathy				- Entrapment neuropathy• Trauma• Brachial plexus
pathology

guidelines as in table 1 can be helpful.

trauma will not be dealt with in any detail. Each of themain headings encompass large volumes of information;
just broad outlines will be discussed.

Cervical radiculopathy (CR) causes dysfunction• Anterior horn cell pathology (ALS)

evaluation of the hand must be done but generalrheumatological causes of hand pathology including

Cervical Radiculopathy				of a spinal nerve root, presenting as pain and

There is no clear scheme according to which neurologicalwhile others such as primary orthopaedic and2.

• Movement disorders

		In this paper, neurological aspects will be highlighted

ulnar 2 or 3 digits (3). 					(brain-hand link)- Myelopathy		

depending on the medical speciality involved. The handposturing of the metacarpophalangeal joints in the• Brain: Upper motor neuron pathology 		• Spinal cord:

this is often viewed from a specific vantage pointinterphalangeal joint extension, and flexed

Conditions affecting the handstruggled with in vain.”

Many pathological processes will affect the hand andof the hand intrinsic muscles, loss of active		- Trauma		- Brachial plexus neuritis		- Thoracic outlet syndrome

can be due to degenerative cervical spondylosis or
Spastic hand secondary to ischaemic brain damage

foraminal stenosis, cervical disc herniation, andtraumatic or degenerative instability. The seventh

There are multiple causes of spastic deformation of thecervical nerve root is most commonly involved,

hand but cerebral palsy (CP) (1) and stroke are the most

followed by the sixth cervical nerve root (3).

common. The functional and structural changes that take								place are due to adaptive plasticity of the CNS to offset

2.1 C6 radiculopathy can cause pain and• Vascular pathology

or improve functions compromised by the pathologicaldysaesthesia radiating from the neck to the• Myopathy

insult. Early detection and classification of handanterior arm, the lateral aspect of the forearm,abnormalities in CP can guide therapies.

the first dorsal web space, and into the thumb• Systemic diseases- Auto immune pathology		affecting the hand

- Vascular pathology				- Arthritic disease• Orthopaedic conditions• Psychogenic disorders

and index finger. It normally does not cause
From a therapeutic perspective, the spastic hand issignificant motor problems in the hand (4).

significant because of the option to treat with Botulinum
toxin (2). EMG guided injections of Botulinum toxin often

2.2 C7 radiculopathy may cause dyasesthesia

alleviate the symptoms and facilitate remedial therapy.

radiating from the neck into the back of theshoulder and arm, the dorsal forearm, and the
mid dorsal hand. Patients may also exhibit

14

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SPECIAL FEATURE

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February 2018

Metabolic causes including diabetes.

weakness of wrist flexion, and finger extension

Dystonia

and T1), and FDI and ADM, which are differentially(4).

In primary dystonia, the best-known example is theaffected, are both ulnar nerve innervated. The reason

2.3 C8 radiculopathy can cause dysaesthesia

task specific dystonia such as writer’s cramp (5). In

for this dissociated pattern of weakness is not wellneuropathy

radiating down the medial borders of the arm

this condition, the hand posture becomes abnormal

understood.

Exposure to poisons 		

and forearm and into the ulnar digits.

while performing a specific task while under all otherToxic substances including heavy metals or chemicals

The sensory disturbance can mimic ulnar

circumstances the hand is completely normal both

Medications 		

nerve entrapment at the elbow; but would affectin physical evaluation but also in function. In writer’s

Especially chemotherapy, can cause peripheral

the forearm which is preserved in patients

cramp, the patients tend to have an abnormal gripneuropathy

with ulnar nerve entrapment. Loss of intrinsicof the pen and abnormal posturing of the hand andmuscle strength in the ulnar nerve distribution

arm when writing. Treatment of focal dystonia of the

Infections		

as well as weakness in the median and anterior

hand is very difficult and although Botulinum toxininterosseous nerve distributions can bedoes provide relief for some patients, it can induce

observed in patients with radiculopathy (4).

unwanted weakness compromising other handfunctions (6).

Movement disorders

Up to 50% of diabetics develop some type ofViral or bacterial infections, including Lyme disease,shingles, Epstein-Barr virus, hepatitis C, leprosy,
diphtheria and HIV
The split hand syndrome in amyotrophic lateral sclerosis(Photo: The split hand syndrome in amyotrophic lateral

Hand function can be compromised due to lesions ofTremorsclerosis Eisen, Andrew and Kuwabara, Satoshi Journal of

the basal ganglia. Various conditions can affect the

Various causes for hand tremors are recognized.

neurology, neurosurgery, and psychiatry volume 83, monthbasal ganglia including cerebral palsy and primary

Hand tremors can vary from being mildly bothersome

11, 2011, pages 399-403) Internet photo

movement disorders.

to incapacitating. The most frequently occurring

Inherited disorders		
eg. Charcot-Marie-Tooth disease
Trauma or pressure on the nerve
Acute neuropraxia and chronic irritation eg. bangles
and watch straps
Tumours		
Includes neuromas and pressure on nerves due tohand tremors are essential tremor and Parkinsonian

Neuropathy

Cerebral palsy

tremors. Studying the tremor in relation to activity,

Neuropathies affecting the hand may be classified

In cerebral palsy, the predominant motor abnormality

frequency and muscle groups involved can be of help

somewhat arbitrary into generalized and focal

paraneoplastic syndromeis spasticity; but can include dyskinetic (dystonia orin diagnosing the underlying illness.

traumatic neuropathies which include entrapment

Vitamin deficiencies 		

neuropathy.

Especially Vitamins B-1, B-6 and B-12 and Vitamin E

choreo-athetosis) and ataxic cerebral palsy (2). Thiscan make treatment very difficult since therapy should

Anterior horn cell pathology

be aimed at reduction of the spastic elements as well

Amyotrophic lateral sclerosis (ALS) usually causes

as the abnormal movements.

and niacin
1.

Generalized neuropathies			

Bone marrow disorders

insidious loss of function or gradual, slowly

Neuropathies can affect the hand in many ways.

These include myeloma (monoclonal gammopathies),

progressive, painless weakness in one or more regions

In generalized peripheral neuropathies, thelymphoma and amyloidosisof the body, without sensory disturbances.

distal appendages are often affected early on and

In lower motor neuron (LMN) involvement,

therefore the feet and hands are involved. Peripheral

Other diseases		fasciculation may occur early on.

neuropathy, a result of damage to peripheral nerves,

Patients with upper motor neuron (UMN) involvement

causes weakness, numbness and pain (8). Peripheral

generally have increased reflexes. As ALS progresses,

neuropathy can result from multiple causes

muscle atrophy becomes more apparent, and spasticity

some of which are listed in table 2. Many of theCompressive neuropathies are common conditions

may compromise function. Muscle cramps areneuropathies, however, remain idiopathic.

(9). Some of the compression syndromes are listed(radial) hand’, including the abductor pollicis brevis(APB) and first dorsal interosseous (FDI) muscles.
There is relative sparing of the hypothenar muscles(the abductor digiti minimi (ADM)). This dissociated
A Patient with writes cramp. Note the wrist extension,

atrophy of the intrinsic hand muscles is termed the

support of the arm with the other hand and the abnormal‘split hand’ (7). The muscles involved in the split hand

grip of the pen.

are innervated through the same spinal segments (C8Renal disease, liver disease, connective tissue
disorders and hypothyroidism
2.

Entrapment syndromes			

in table 3. The symptoms can range from sensory

common. The hand muscle wasting affects the ‘thenar

16

tumours in the area and polyneuropathy due toTable 2 Causes of peripheral neuropathies
Autoimmune diseases		
Including Sjogren’s syndrome, lupus, rheumatoid
arthritis, Guillain-Barre syndrome, chronic
inflammatory demyelinating polyneuropathy andnecrotizing vasculitis

abnormalities, paraesthesia, and pain early on,
to motor disruption and permanent sensory
loss. Carpal tunnel syndrome is very prevalent
but other compression syndromes affecting thehand include entrapment of the Median, Ulnarand Radial nerves (10). Although diagnostic
techniques such as radiologic imaging have17

SPECIAL FEATURE

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SPECIAL FEATURE

February 2018

been developed to diagnose nerve compression

stimulator and the generated action potential is

Brachial plexus pathology

injuries; electro-diagnostic studies are still usedrecorded by 2 electrodes on the skin, along the length

Brachial plexus injuries have many causes, such as

widely. Sonography has become sophisticatedof a nerve. For purely sensory nerves, recording

falls, traumatic traction, crushing, penetrating injuries,

with high definition images and visualisation ofelectrodes are commonly placed proximally along theobstetric complications, thoracic outlet syndrome,

inflammation, so that accurate measurements

nerve, toward the spinal cord, yielding a sensory nerve

tumours and aneurisms (13). Patients often lose handof the surface diameter of nerves inside andaction potential (SNAP).

function, if the lesion is at the level of C7 and lower.

outside of the compressed area give an accurate

In assessment motor function, sensory dermatomal

indication of the compression. This helps the

In motor nerves, the recording electrodes are placed

surgeon in planning the extent and nature of the

distally on the belly of the target muscle, yielding a

decompression procedure.

compound muscle action potential (CMAP).

Diagnostic evaluation

Information obtained is about the amplitude, latency

1.

Table 3 Compression syndromes of the upper limb

distribution, and reflexes must be evaluated.

(delay in response following stimulation), andRadiology						This can include a standard AP chest X-rays, toconduction velocity (latency divided by distance) (11).
Common entrapment syndromes		

Values of recorded responses (in a patient with carpal

rule out first and second rib fractures potentially∙ Carpal tunnel syndrome (CTS)		

tunnel syndrome)indicating damage to the overlying brachial plexus.

∙ Ulnar neuropathy at the elbow (UNE)		

Various techniques are available to make the diagnosis

A neck X-ray should also be obtained to exclude∙ Radial nerve syndrome at the brachioradialisof nerve entrapment (12) but standard practice for thecervical transverse process fractures, which

tendon (Wartenberg syndrome)(RNS)		
∙ Posterior interosseous nerve syndrome at thesupinator muscle (PINS) ∙∙∙ Thoracic Outlet Syndrome

diagnosis of carpal tunnel syndrome would include:

2. Electro-myography (EMG)

may indicate root avulsion. Magnetic resonanceMedian sensory nerve peak latencies are measured

EMG studies analyse the integrity of muscle function

imaging (MRI) is very useful for imaging the post-

and compared to either the ulnar or radial sensory

by studying the electrical activity in the muscles

ganglionic brachial plexus, and for evaluating

peak latencies in the same hand. (usually orthodromic

during rest and contraction. EMG studies are

benign and malignant tumorous lesions. It also

particularly important to determine whether axonal

provides excellent evaluation of any oedema or

damage has occurred.

fibrosis of the brachial plexus (13).				

responses over a short distance, typically 8cm) In
Rare entrapment syndromes		borderline results additional testing is used.
∙ Anterior interosseous nerve syndrome		∙ Pronator syndrome			∙ Ulnar neuropathy in Guyon’s canal

If the median sensory response is absent, the median

EMG studies involve insertion of a needle electrode inmotor onset latency in comparison to the ulnar motor

a muscle. Then, the needle is moved around within a

EMG can assist in diagnosis of brachial plexus

onset latency can help localize the problem.

muscle to check for fibrillation potentials (indicating

injury, localise the level of the lesion, help estimate

loss of innervation).

the severity of axon loss and eliminate other

Electrodiagnosis of Chronic Nerve Compression

2.

Electromyography (EMG)				

conditions from the differential diagnosis. Repeat

Injuries
Patients are often referred to neurologists with the

Next, the needle is kept in a single place to check for

EMG studies, combined with repeat physicalrequest to perform diagnostic nerve conduction

fasciculation.

examinations should be done to document

studies. The broad principles for diagnosis of nerve

progression of recovery (14).

entrapment will be outlined. The specific entrapment

Finally, motor unit potentials (MUPs) are recorded (11).

syndromes have specific diagnostic criteria but only

By selective comparison of muscles innervated by theTreatment

the diagnosis of carpal tunnel syndrome will besame nerve but different nerve roots, and conversely,

Treatment of brachial plexus injuries is either

discussed in detail.

a single root expressed by different nerves, a picture

conservative or operative. The use of EMG will allowof nerve pathology regarding the anatomical location

the clinician to ascertain if the damage is degenerative.

Two types of electrodiagnostic studies are commonlyof damage can reasonably accurately be established.

If this is the case then conservative treatment isused: nerve conduction studies and EMG.

Various patterns of the motor unit can also be used toindicated. In this period neurologists are often called

establish re-innervation and thereby to some degree

upon to help provide adequate pain relief, to minimise

severity of injury and indirectly the prognosis.

discomfort and maximise physiotherapeutic potential.

1. Nerve conduction studies				
These are very useful in diagnosing compressive

If surgical intervention is deemed necessary close

neuropathies.		

Median sensory nerve recording and graphs of recorded

cooperation with the surgeon is needed to decide the

A sensory nerve is stimulated with a handheld

responses

precise nature and localization of the injury.

18

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SPECIAL FEATURE

February 2018

6. Botulinum toxin therapy of writer’s cramp. Das

16. Distal myopathies. Udd B Curr Neurol Neurosci Rep.

Myopathy

Psychogenic disorders

Myopathy generally tends to affect proximal larger

Psychological disorders can present with neurologic

CP, Dressler D, Hallett M. Eur J Neurol. 2006 Feb;13

muscles. Welander described a distal arm myopathy

symptoms or signs, but have no identifiable structural

Suppl 1:55-9. Review.					and since then many well-characterized distal

or functional neurological aetiology. These conditions

myopathies have been described. In Welander

can mimic almost any organic disease (18). Presenting

myopathy the symptoms have a late onset affecting

hand syndromes can include pseudo-paralysis,

sclerosis. Eisen A, Kuwabara S. J Neurol Neurosurg

the hands and gradually distal muscles of the lower

pseudo-sensory syndromes and psychogenic

Psychiatry. 2012 Apr;83(4):399-403.			

extremities. The most-affected muscles are the long

movement disorders syndromes. To distinguish these

extensors of the hands and feet (15). Distal myopathies

from organic disease the examiner must observe signs

share the clinical features of preferential muscle

and symptoms or elicit test responses that are non-

Diagnosis and Symptom Management. Watson JC,

weakness in the feet and/or hands. These are aphysiologic and incompatible with organic disease.

Dyck PJ. Mayo Clin Proc. 2015 Jul;90(7):940		

clinically and genetically heterogeneous group ofTreatment falls in the realm of psychiatry.

disorders (16).

2014 Mar;14(3):434.						17. Distal myopathies Mazen M. Dimachkie, Richard J.

7.

The split hand syndrome in amyotrophic lateral

Barohn, Neurol Clin. 2014 August; 32(3): 817–842		
18. Hysterical conversion and brain function.
Vuilleumier P. Prog Brain Res. 2005;150:309-29

8.

Peripheral Neuropathy: A Practical Approach to

9. Evaluation and Treatment of Upper Extremity
Conclusion

Nerve Entrapment Syndromes Eric E. Floranda,

Other neuromuscular disorders that are importantExamination of the hand in neurology has great

Bret C. Jacobs, Prim Care Clin Office Pract 40 (2013)

to recognize as they display prominent distal limb

significance since this is often revealing of pathology

925–943							weakness can include Myotonic dystrophy (DM)elsewhere in the nervous system. As mentioned earlier

Facio-scapulo-humeral dystrophy (FSH), Inflammatory

hand pathology often forms a nexus between neurology

myopathy and various other myopathic conditions.

and various other specialities.

10. Compressive neuropathy in the upper limb.
Mukund R. Thatte and Khushnuma A. Mansukhani
Indian J Plast Surg. 2011 May-Aug; 44(2): 283–297.

Investigations can include serum CK,

References

electromyography and muscle biopsy as well as

1.

Management of the Spastic Wrist and Hand in

11. Compressive Neuropathies of the Upper Extremity:muscle imaging (17). Based on the combination of

Cerebral Palsy. Nels D. Leafblad, BS, Ann E. Van

Update on Pathophysiology,			age at onset, mode of inheritance, pathology andHeest, MD. J Hand Surg Vol. 40, May 2015			

Classification, and Electrodiagnostic Findings

muscle imaging, the list of possible underlying genetic
disorders can be narrowed down allowing for specificMinal Tapadia, JD, MA, Tahseen Mozaffar, MD,
2.

genetic testing.

Diagnosis, Treatment, and Prevention of Cerebral

Ranjan Gupta, MD J Hand Surg 2010;35A:668–677		

Palsy in Near-Term/Term Infants T. Michael O’Shea,
MD, MPH. Clin Obstet Gynecol. 2008 December ;51(4): 816–828.						12. Diagnosing carpal tunnel syndrome--clinicalcriteria and ancillary tests. Wilder-Smith EP, Seet
RC, Lim EC. Nat Clin Pract Neurol. 2006 Jul;2(7):366-

3.

Cervical Radiculopathy and Myelopathy:

74.								Presentations in the Hand Alan J. Micev, MD, Andre
D. Ivy, MD, Sandeep K. Aggarwal, MD, Wellington K.

13. Brachial plexus injuries Christopher Bonham andHsu, MD, David M. Kalainov, MD. J Hand Surg Am. r

Ian Greaves Trauma 13(4) 353–363				

Vol 38, December 2013					14. Electrodiagnostic assessment of the brachial
4. Neck pain, cervical radiculopathy, and cervicalmyelopathy: pathophysiology, natural history, andplexus. Ferrante MA. Neurol Clin. 2012
May;30(2):551-80.						clinical evaluation. Rao R. J Bone Joint Surg Am.
2002;84 (10):1872e1881.					Ahlberg G, Anvret M, Edström L. Neuromuscul

Hands of a patient with Welander’s myopathy 		(Internet photo no reference)

15. Welander distal myopathy--an overview. Borg K1,

5.

Writer’s cramp. Goldman JG. Toxicon. 2015 Dec

Disord. 1998 Apr;8(2):115-8.

1;107:98-104. Epub 2015 Sep 21.			

20

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Sports Injuries ofthe Hand & Wrist

ADVANCES IN REHABILITATIVE TREATMENT - MOJCA HERMAN

HAND THERAPY

February 2018

psychological readiness forand communicated in the context

treatment session content, patient

successful return to sport.

of the athlete’s sport and individual

tolerance, and planning fortimelines. The therapy goals andsubsequent sessions. The mostThe second progression

rehabilitation process must be

crucial relationship is with theencompasses the need torelayed and executed in a way thattherapist and athlete. The athletecommunicate in a sports minded

the athlete understands the needneeds to teach the hand therapist a

vocabulary when rehabilitating

to continually protect the healing

language that is unique to them as

athletes in a hand therapy setting.

tissue during rehabilitation. The

they describe the sport from their

Learning to speak the athlete’scoach is the sport expert who is able

perspective. The athlete will further

language within the scope of their

to communicate the nuances of theprovide insight to how their injury

Hand and wrist injuries in athletes

therapists have largely adopted analso report after injury (Covassin,

sport specific needs is criticalsport while describing sport specificis impacting normal hand/arm

are common, counting for as

evidence-based practice approach to

Beidler, Ostrowski, & Wallace, 2015).

for successful rehabilitation andfundamentals and milestones

use within their sport. There is amany as 25% of all sports injuries

clinical rehabilitative management

These negative psychologicalultimate return to sport. Thisneeded for the athlete’s safe return.

natural synthesis of dialogue as the(Rosenbaum & Awan, 2017). Athletes(MacDermid, 2004). The

responses affect adherence, recovery

requires a unique dialogue that is

The level of unique and detailed

therapist introduces therapy termsof all different levels representing

progression on this current handin rehabilitation, confidence,

weaved between the physician,sport and medical communication

to the athlete, the athlete infuses

numerous types of sports aretherapy practice is consideration ofincrease risk of injury, moreover,coach, hand therapist and athlete.

is ongoing and frequent between

the therapist with sport language,referred to our hand clinics every

an additional framework for sport-

can decrease the likelihood ofThat is, the ‘team’ of experts

the therapist, physician and coachand the physician and coachyear. Hand therapists need to beoriented rehabilitation referred to as

successful return to sport (Ivarsson,

surrounding the athlete must be

while discussing rehabilitation

impart their expertise. This willable to confidently rehabilitate an

psychologically-informed practice.

Tranaeus, Johnson, & Stenling,able to universally communicate

athlete who has sustained an injury

Psychologically-informed practice2017). A simple suggestion forin a streamlined sports minded

to the hand or wrist and returnis a framework that takes into

assessing psychological readinesslanguage to ensure the athlete

them to their sport as fast and safe

account a patient’s psychologicalis the utilization of a questionnaire

returns medically healthy andas possible. The challenge is in

makeup, including thinking,administered during various phases

psychologically ready. Specifically,

designing tailored therapy programs

emotions, personalities and pastof rehabilitation. An example of

the referring physician is theto meet the athlete’s sport specificexperiences (Johnson & Haigh,such a questionnaire is the injury-

medical expert guiding treatment

physical needs while adhering to the2010). This framework can provide

psychological readiness to return tobased on decisions on tissue

healing tissue timelines. In a typicalimportant insight to an athlete’s

sport scale (I-PRRS) (Glazer, 2009). It

healing parameters. The physician

hand clinic, it is rare that therapy

perspective, in turn, be a valuable

is a straightforward six question tool

will determine the timelines

sessions factor in psychologicaland necessary rehabilitation tool forthat rates the athlete’s confidence

for the initiation of therapy,

readiness, communicate in a sports

successful return to sport. There islevel from 0 (no confidence) to 100

frequency of therapy sessions,minded language, or incorporate

ample research that has explored(complete confidence) on return toand the formal clearance forgraded sport specific movement

the psychological responses in

sport participation after injury. The

sport reintegration. The medical

patterns. Yet these concepts areathletes associated with return toreported information gathered is

terminology imparted by thefundamental for successful return

sport after injury (Arden, Taylor,useful to inform the therapist on thephysician needs to be translated

to sport after injury. It is the goal ofFeller, & Webster, 2013). Despite theathlete’s self-perceived readiness

into an understandable language

this article to introduce these threeoverall emotion being positive as theto return to sport, furthermore

for the athlete’s commitment to theconcepts as progressions on current

rehabilitation process progresses,

help guide treatment planning

medical recommendations. The

hand therapy practice for sport-

one of the most prominentand intervention throughout

hand therapist is the rehabilitation

oriented rehabilitation.

emotional responses for return tothe course of rehabilitation.

expert who performs a detailed

sport after injury is the fear of re-Embedding hand and wrist therapy

assessment of the upper extremity

The first progression encompasses

injury. Additionally, there are otherin a psychologically-informed

deficits, as well as screening forthe guiding framework for informed

negative emotions such as anxiety,practice treatment approach is

psychological readiness. The

clinical practice decisions. Hand

stress and depression that athletes

useful for enhancing an athlete’s

evaluation needs be interpreted

22“This challenge can be
successfully met by designing
creative programs thatincorporate automatic gradedsport specific movement
patterns, advancing theathlete’s rehabilitation both
physically and psychologically,
all while communicating ina unique and detailed sports
minded language”

23HAND THERAPY

www.ifssh.info

HAND THERAPY

February 2018ensure mutual trust and a positive

In some cases, the athlete’s healing

therapist ask the athlete to bring in

introduction to evidence-based

psychological environment for thetissue is ready to start performing

their sports equipment, and together

practice for hand therapists.

athlete to thrive.

sport simulation as part of thecollaborate in designing the ‘best fit’

Journal of Hand Therapy.

treatment like having the arms

orthosis (Fig 3).

2004;17(2):105-107.

The third progression encompasses

simulate swimming strokes, orthe need for incorporating

swinging a golf club or a tennis

Acute hand injuries in athletes.

automatic sport specific movement

racket (Fig 1).

Physician and Sports Medicine

7.

patterns directly into the treatment

Rosenbaum Y.A., & Awan, H. M.

Journal. 2017;45(2):151-158.

sessions. Therapists are skilled at

In other cases, the healing tissue

activity analysis when creating a

is ready to tolerate incorporating

About the author.

rehabilitation environment thatthe athlete’s sports equipment in

Mojca, “MO”, is a former Olympic

is challenging yet successful. The

therapy like dribbling a basketball,

Swimmer and graduate of USC’s

obvious challenge is in creating

throwing a baseball on a rebounder,

Occupational Therapy Program.

a tailored therapy program thator practicing hockey stick handlingFig 3. An example of a carefully

She has over 20 years of clinicaladheres to healing timelines while(Fig. 2).

fabricated custom thumb orthosis

experience and is currently insimultaneously honoring thethat protects the healing tissue whileathlete’s desire to return to sport

simultaneously allowing the athlete

at an uncomfortably fast pace.

to use their hand in waterpolo ball

graded sport specific movement

Journal of Sports Medicine.

private practice, Mo also provides

The easiest way to accommodate

handling skills

patterns, advancing the athlete’s

2015;34(2):199-212.

therapy to elite and professional

Glazer, D. D. Development andathletes including: LA Clippers,

this transition for the athlete-

Fig 4. Volar and dorsal views of the wrapped custom waterpolo thumb orthosis

her 14th year of private practicein Torrance, California. In her

rehabilitation both physically3.

patient is to incorporate graded

The ability to incorporate a custom

and psychologically, all while

preliminary validation of theLakers, Kings, Dodgers, Anaheim

sport simulation into the therapy

orthosis into the rehabilitation

communicating in a unique andinjury-psychological readiness

Ducks, Angels and the LPGA. Mo

programming. Having the ability forprocess is an empowering tool

detailed sports minded language.

to return to sport (I-PRRS) scale.

is currently a member of the ASHT

an athlete to engage in sport related

for quicker and successful sport

Incorporation of these components

Journal of Athletic Training.

Board of Directors, has co-authoredintegration (Fig. 4)

in the currently accepted

2009;44(2):185–189.

several chapters on a variety oftasks will increase adherence andFig 2. An example of incorporating

confidence, lessen return to sport

the athlete’s sports equipment whiletimelines and ensure a safer reentry

practicing graded sport specific

Of note, it is also critical toaide in facilitating sport oriented& Johnson, U., & Stenling,

guest lectures at both USC andwith less risk of injury.

movement patterns with a hockey

continuously educate the patient

rehabilitation, as well as safe and

A. Negative psychological

CSDUH Graduate Occupational

stickregarding the risks involved, thus

successful return to sport for the

responses of injury andTherapy Programs in the Los

requiring excellent communication

injured athlete.

rehabilitation adherence effects

Angeles, California area.

practices of hand therapy will

4. Ivarsson, A., & Tranaeus, U.,In other scenarios, the healing

and reciprocal trust in this phasetissue warrants further protectionof the rehabilitation. Enabling an

References

athletes: a systematic review

before engaging in sport specificathlete to start graded sport specific1.

Arden, C. L., & Taylor, N. F., &and meta-analysis. Open Accesstasks. The natural and obvious form

movement patterns earlier thanFeller, J.A., & Webster, K.E. (2013).

Journal of Sports Medicine. 2017;of protection in this scenario istraditionally considered, is a very

A systematic review of the

8:27-32.

incorporation of a custom fabricatedpowerful clinical intervention.

psychological factors associatedon return to play in competitive

orthosis. A carefully fabricated5.

Johnson, R., & Haigh, R. Social

with returning to sport following

psychiatry and social policy

orthosis that serves the purpose

Rehabilitation of hand andinjury. British Journal of Sports

for the 21st century – newof protecting the healing tissue

wrist injuries in athletes can be

Medicine, 47(17), 1120-6.

concepts for new needs: theFig 1. An example of the athlete

while simultaneously allowing

challenging for hand therapists.

Covassin, T., & Beidler, E.,‘psychologically-informed

performing sport simulation by

the athlete to start graded sportThis challenge can be successfully& Ostrowski, J., & Wallace,environment’. Mental Health andpracticing the arm motion in freestyle

related activities can be extremely

met by designing creative programs

J. Psychological aspects ofSocial Inclusion. 2010;14(4):30-35.

swimming

beneficial. It is suggested that thethat incorporate automatic

rehabilitation in sports. Clinical24

hand therapy topics, and annually2.

6.

MacDermid, J.C. An

Mojca Herman

25

RESEARCH ROUNDUP

www.ifssh.info

RESEARCH ROUNDUP

February 2018

“CHRONOLOGIC AND GEOGRAPHIC TRENDS OF TRIANGULAR FIBROCARTILAGE
COMPLEX REPAIR”‘HAND CLINICS’ NOVEMBER 2017 VOLUME 33, ISSUE 4, P593-605“DISTAL RADIO-ULNAR JOINT: FUNCTION, ANATOMY INCLUDING PATHO-MECHANICS”
JOURNAL HAND SURGERY’ (EUROPEAN) MAY 2017, VOLUME 42, ISSUE 4, P338-345

1. What were your main reasons for3. What should all hand surgeons

writing this article?

(and or hand therapists) reading

Recently, the anatomy of TFCC has

your article understand about the

been described in detail, especiallyfindings of your research?

the ulnar side which consists of

A number of treatment methods

two portions: superficial portion

for TFCC tears have been reported,(styloid insertion) and deep portionand the treatment strategy of TFCC

(foveal insertion). The strategy oftears have changed. In particular

TFCC repairs on the ulnar side has

the treatment for ulnar sided tears

thus changed and is well accepted.

should recognise the importance of
foveal attachment.

what I’ve been presented at many

(and or hand therapists) reading

However, the treatment strategy

meetings/congresses throughout

your article understand about thefor other portions of TFCC injuries,

the last few years. Richard Berger isfindings of your research?

such as radial side tears is still

the one who taught me “everything”

I think the most important thing toabout the DRUJ. Martin Langer is aunderstand is that the stability of

the chronologic and geographic

colleague with exceptional talents

the DRUJ is complex. If the DRUJ is

trend of the repair methods basedin illustrating, thus the combination

unstable, there are many different

on published articles which discussof the three of us I thought would be

structures that should be addressedvarious TFCC repair methods. This is

fruitful.

(TFCC, UC lig complex, ECU, PQ, IOM,

the reason why I wrote this article.

Taichi Saito

controversial. I wanted to describe

the bony structure and the capsule).

Jan-Ragnar Haugstvedt

2. What are the most interesting/Thus you need more than one tool

2. What is the most interesting/important results and conclusions

in your toolbox to address DRUJ

important result and conclusion ofof your article?

instability.

your article?

For me, it was important to realize,

Most articles published demonstrate

when I performed my studies, that

4. Will you be conducting further

the repair of ulnar TFCC tears. In

the foveal insertion of the DRU

research/publishing further work

particular, the reports focus onligaments is the most importanton this topic? If so, what will it

repairing the TFCC by attachment to

1. What were your main reasons forelement in DRUJ stability.

entail?

the fovea. It indicates the importancewriting this article?

“Everyone” knows this by now,

We have during the last yearthat the foveal reattachment has

My doctoral thesis, built on work

but not at that time. I also thinkpublished on 20 years follow up

being recognized.

from the BioMechanics Lab at Mayo,

it’s important to understand thatof TFCC injuries. If more work

was on DRUJ. I’ve often been asked

ligamentum subcruentum, theis to be published, it will be on

to give talks about the anatomy andfoveal insertion, has fibers coming

clinical results of different surgicalbiomechanics of the DRUJ. Henkfrom many different structures. The

procedures.

Coert, the co-editor of JHS(E) asked

anatomy (and biomechanics) is moreme to write this review article forcomplex than was thought of fromthe special DRUJ issue, and by

the beginning.

doing so I was able to put in a paper

3. What should all hand surgeons

26

27

RESEARCH ROUNDUP

www.ifssh.info“ANATOMICAL FACTORS CONTRIBUTING TO RADIAL NERVE EXCURSION AT THE
BRACHIUM: A CADAVERIC STUDY”
WAYNE A. CHEN, T.DAVID LUO, MICHAEL D. WIGTON, ZHONGYU LI
JOURNAL OF HAND SURGERY (AMERICAN), PUBLISHED ONLINE: NOVEMBER 2017
1. What were your main reasons forwriting this article?

vascularity, nervous, and connective

We are interested in looking at theRadial nerve palsy is common after

tissue ratio. Therefore, we believe

incidence of radial nerve palsy

prolonged pressure to the nerve suchthe main cause of the vulnerability

after open reduction and internal

as in Saturday night palsy, bluntof the radial nerve to compression

fixation of humeral shaft fractures.

trauma associated with humeral

and traction injuries is extraneural

We do not have clinical data to

shaft fractures, and closed or open

tethering mainly at the lateralsupport the notion that releasing the

reduction of humerus fractures.

intermuscular septum. A second

lateral intermuscular septum has a

The mechanism of this relativeinteresting finding is that elbow

protective effect on the radial nerve

vulnerability of the radial nerve to a

position affects the strain on theduring humeral fracture reduction

traumatic insult remains unknown.

radial nerve. Flexing the elbow fromand fixation. A randomized controlled

Some authors believe extraneuralneutral to 90° doubled radial nerve

study comparing humeral fracture

factors such as the nerve crossing theexcursion. Further releasing the

fixation with or without radial nerve

spiral groove limiting its excursion islateral intermuscular septum tripleddecompression would help us toresponsible. Others think intraneuralradial nerve excursion.

further understand if releasing

factors are likely to blame as thethe lateral intermuscular septum

radial nerve is “anatomically

3. What should all hand surgeonsprovides protection to the radialdifferent” in comparison to the(and or hand therapists) reading

nerve during the procedure.

median and ulnar nerves. The main

your article understand about thereason for this study was to identify

findings of your research?

the extraneural vs. intraneural factors

When we perform humeral shaftthat contribute to the vulnerability offracture fixation, prophylactic release

the radial nerve at the brachium.

of the lateral intermuscular septum
nerve palsy. Elbow positioning isimportant results and conclusions

important in changing the excursionof your article?

of the radial nerve. When performing

The most interesting finding fromclosed reduction of humerus

this study is that the radial nerve has

fractures, shoulder manipulation orless excursion than the median andreduction, or nerve gliding exercises,

ulnar nerves at the brachium, making

flexing the elbow to 90° reduces theit more vulnerable to traction injury.

tension to the radial nerve.

Wayne A Chen

4. Will you be conducting further

excursion up to 38%. Compared toresearch/publishing further work

the median and ulnar nerves, theon this topic? If so, what will it

radial nerve is similar in terms ofentail?

Dr. Anne Wajon, IFSHT President and guest
speaker, joined the executive committee meeting as an advisor. Mr. Hercy Li (Hong Kong) was
elected as APFSHT President for 2018-2020 and
Mr. Yazid Ahmad Jus (Malaysia) was elected as
the President-Elect. The next conference is in Melbourne, Australia in 2020.

The Guatemalan Association of Hand Therapists(AGTMANO), founded in 2004, became a memberof IFSHT in 2015. Lynn Bassini, CHT and the Guatemala Healing Hand Foundation sponsored the Association. The Association works closely with the
Guatemalan Hand Surgery Association to organize
an annual joint congress.

AMERICAN SOCIETY OF HAND THERAPISTS MEETING 2017

Anne Wajon, IFSHT president, discussed IFSHT
activities with ASHT President Gary Solomon andshared IFSHT news with attendees.
Dr. Wajon and Dorit Aaron (US), co-convener ofthe scientific program with Beate Jung (Germany),
discussed the upcoming Triennial Congress plans. Therapists in the audience wereencouraged to volunteer tobe involved in congress planning and to attend the congress. Maureen Hardy and
Peggy Boineau, IFSHT EXCO
members, assisted in searching for potential speakers forthe congress among those
speaking at the ASHT meeting.

L to R: Carolina Tejeda, Otty Chin (Members-at-Large), Ileana Aguilar (Secretary
General/Founder, Gladys Mendez (Education), Lynn Bassini (Founder), Marta
Beatriz Pineda (President/Founder), Maria Del Carmen Sierra (Treasurer), Dr.
Gustavo Lopez (Founder), Karla Aceituno (Founder)

ASIA PACIFIC FEDERATION OF
SOCIETIES FOR HAND THERAPYIFSHT INTERNATIONALTEACHING GRANT

The IFSHT International Teaching
Grant has increased to US $1500 to provide support
to experienced hand therapists who provide handtherapy training in developing countries. For more
information visit: www.ifsht.org/page/international-teaching-grants-O.

IFSSH EZINE

L to R Front: Seiji Nishimura (Japan); Kent Chang (Taiwan); Hercy Li, President(Hong Kong); Jose Ramos (Philippines); Casie Chan (Hong Kong); Back: Cecilia Li(Hong Kong); Yazid Ahmad Jus (Malaysia); Kris Tong (Singapore); Tan Eng Wah(Malaysia); and Chen Min (Japan)
David Tianyi Luo28

SPOTLIGHT ON IFSHT MEMBERSOCIETY: GUATEMALAJohn Li-Zhongyu

Releasing the lateral intermuscular
septum significantly improves nerve

VOL 12 NO 1 | JAN 2018

The 7th APFSHT Conference was held with the 11th
APFSSH Conference 7-10 November, 2017 in Cebu,
Philippines with more than 100 attending. Jose
Ramos (organizing chair) worked with the newly
formed Philippine Hand Therapists Society and Dr.
Seiji Nishimura, APFSHT President (Japan), to prepare the two-day scientific programme. Workshops
held after the conference covered Taping of Hand
and Upper Limbs by Ms. Charlie Tan (Malaysia) and
Hand Splinting sponsored by Orfit Inc.

may reduce the incidence of radial
2. What are the most interesting/February 2018

The IFSHT contribution to the IFSSH November
2017 EZINE is “Early Active Vector Adjustable Skin
Traction (EAVAST) for Phalangeal Fractures” by
Jason Fairclough, a physiotherapist and certified
hand therapist from Sydney, Australia. The paper
describes a traction method for phalangeal fractures using simple splinting principles: http://www.
ifssh.info/pdf/issue28_november_2017.pdf.
For hand therapy educational events, go to “National/International Education Events” under “Education” at www.IFSHT.org.

Michael Wigton

1 1 t h Tr i e n n i a l I F S H T Co n g re s s|Berlin, Germany|

J u n e 1 7-2 1 , 2 0 1 9|i f s s h - i f s h t 2 0 1 9 . co m 29

MEMBER SOCIETY NEWSwww.ifssh.info

Member Society NewsAMERICAN SOCIETY FOR SURGERY
OF THE HAND

MEMBER SOCIETY NEWS

February 2018

GERMAN SOCIETY FOR SURGERY OF
THE HAND (DGH)

will prepare and organize the scientific program. Next to
the traditional scientific sessions, lectures and courses,
there will be new formats like an educational day on the

The German Society for Surgery of the Hand (DGH)

Monday prior to the official opening ceremony.

held its 58th annual congress combined with the 22nd
annual meeting of the German Association for Hand

We finally succeeded in integrating the European

Therapy (DAHTH) from the 11th to the 14th of October

FESSH Congress into the IFSSH/IFSHT Congress and are

Young International Membership dues are $200 per year2017 in Munich. It was an exceptional meeting with 677

looking forward to a combined instructional course on

Become a Member of the American Society for Surgery

and applications are accepted any time throughout theparticipating surgeons and 224 hand therapists.

“Distal Radius Fractures and Carpal Instabilities” andof the Hand. Apply by 16 March 2018

year. To learn more and apply, visit http://www.assh.

ASSH is pleased to invite all surgeons trained in theorg/About-ASSH/Join-ASSH/Become-a-Member/Young-

The British Society for Surgery of the Hand was thehand and upper extremity to apply to be an ASSH

International-Member!

guest Society. Apart from the speakers from the United•subscriptions to all ASSH newsletters; and more!

the resulting instructional congress book edited by Paco
Pinal from Santander,Spain.

Kingdom, presenters also came from Germany, Austria,

The official website http://ifssh-ifsht2019.com/ is online

If you have questions or need assistance completing an

Switzerland, China, Sweden, Romania, France and Italy. It

now, and will shortly present the major topics of the

As an International Member, you will receive:

application or obtaining supporting materials, please

was a vivid and high-quality scientific meeting covering

congress. So far the following important dates:•

a subscription to The Journal of Hand Surgery;contact Mary McCarthy at mmccarthy@assh.org

all aspects of hand surgery in 210 presentations, 9•March 1st 2018 - Start Abstract Submission•access to Hand-e (the ASSH education website withworkshops, 9 instructional courses, 8 lunch-workshops, 2•

March 1st 2018 - Start Online Registration

courses on sonography of the hand and 2 courses on the•

September 30th 2018 - Abstract Submission Deadline

osteosynthesis of fractures of the hand. Impressions of•

February 28th 2019 - End of Early Bird Registration

International or Young International member.

thousands of recorded lectures, technique videos

Join us in Boston!

and more);•••discounts on books, courses, and our Annual

Members and nonmembers alike are invited tothe congress as well as of the enjoyable congress dinner

We greatly enjoy preparing an inspiring and memorable

Meeting;

attend the 73rd Annual Meeting of ASSH in Boston,party can be found at: https://flic.kr/s/aHsmaGwJgY

congress in 2019 and to host surgeons and theirwonderful opportunities for networking and

Massachusetts, 13-15 September 2018. The meeting

The German Society for Surgery of the Hand is very

accompanying partners, family members and friends

collaboration;

features high quality scientific programming,

active in planning the 14th IFSSH and 11th IFSHT

from all over the world and are looking forward to a great

subscriptions to all ASSH newsletters; and more!

networking opportunities and a very special event:

Triennial Congress 2019 in Berlin. Please note that there

number of abstract submissions.

was a final change of the congress date. We are delighted
International Member applications must be received

ASSH WELCOME EVENT AT FENWAY PARK

that we are now able to host our international guests in

Organizing group consisting of the IFSSH presidential

by 16 March 2018. International Membership Dues are(INTERNATIONAL RECEPTION)*

Germany from June the 17th to 21st 2019.

congress group from the German Society for Hand
Surgery (DGH), the president of the German Association$350 per year. Apply Now at http://www.assh.org/AboutASSH/Join-ASSH/Become-a-Member/International-

ASSH Goes to Fenway! All international attendees are

The DGH council has decided not to nominate a single

for Hand Therapy (DAHTH) and members of theMember!

invited to the ASSH welcome event at Boston’s historic

congress president but a presidential group withprofessional congress organization “Intercongress” (PCO)

Fenway Park on Thursday, 13 September 2018, featuring a

different responsibilities for each member. Prof. Max

The ASSH Young International Membership category

baseball game between the Boston Red Sox and Toronto

Haerle will mainly be responsible for the scientificis open to international surgeons who have completed

Blue Jays (game starts at 7:10 PM). Enjoy food, drinks

program, Prof. Andreas Eisenschenk will mainly bea post-graduate program in disorders of the upper limb

and the game while gathering with your colleagues.

responsible for the local organization in Berlin andwithin the last 5 years. You will enjoy benefits like:All registered, international attendees will receive one

Prof. Jörg van Schoonhoven will be responsible for the•a subscription to The Journal of Hand Surgery;ticket, included with registration (until event sells out).

communication and coordination with the IFSSH and the•access to Hand-e (the ASSH education website with

Registration opens in early April! Tickets are limited so

IFSHT and together with the PCO (Professional Congress

thousands of recorded lectures, technique videos

please register early to reserve your space!

Organization) for the exhibition of the industry. Within
the PCO (“Intercongress”) Mrs. Denise Schuler will be

and more);••discounts on books, courses, and our Annual*Note: This event will replace the traditional

responsible for the organization of our congress.

From right to left: Isabell Faad (PCO), Max Haerle (DGH),

Meeting;

international reception that has been hosted at past

After having defined the major topics of the meeting we

Denise Schuler (PCO), Andreas Eisenschenk (DGH), Antje

wonderful opportunities for networking and

ASSH conferences.

contacted every Member Society of the IFSSH to suggest

Wellbrock-Wicking (PCO), Jörg van Schoonhoven (DGH),

members for the international scientific committees who

Natascha Weihs (DAHTH)

collaboration;

30

31

MEMBER SOCIETY NEWSMEXICAN SOCIETY FOR SURGERY OF
THE HAND AND MICROSURGERY

www.ifssh.info

Some of the procedures performed were open carpal
tunnel release, syndactyly surgery, tumor excisions,February 2018

JOURNAL HIGHLIGHTS

ROMANIAN SOCIETY FOR SURGERY
OF THE HAND

surgical release of scared skin contractures in patients
Sociedad Mexicana de Cirugía de Mano y Microcirugía, S.C.

MEMBER SOCIETY NEWS

Romania, who shared their knowledge and experience
with the Romanian colleagues and the younger
generation of residents. Their presentations, founded onwith burn sequelae, trigger finger release, different kinds

The year 2017 was very busy and productive for theyears of practice, and their insightful comments openedof flaps and correction of congenital differences.

Romanian Society for Surgery of the Hand (RSSH). The

the ground for discussions and were very well received

The follow up of the operated patients was done by a

RSSH presently has 65 active member.

by the congress participants.

couple surgeons who performed the surgeries, ensuring

In January, the RSSH was the Invited Society to the

During this national event, the Society changed its

correct postoperative care.

American Association for Hand Surgery (AAHS) Annual

President: Professor Alexandru Georgescu handed theMeeting, held in attractive and exhilarating Waikoloa,

torch to Associate Professor Zorin Crainiceanu from

Hawaii. Members of the RSSH were invited to participate

Timisoara, Romania.

as Instructors in various highly interesting andappreciated Instructional courses, in order to present
their expertise and discuss Romanian and American
techniques and tactical criteria.
The Mexican Society for Surgery of the Hand and

The Romanian participants were plastic surgeons (since

Microsurgery (MSHSM) is actively involved to help

in Romania hand surgery is mainly performed by plastic

people with limited resources all over Mexico.

surgeons), but also a pediatric orthopedic surgeon anda hand therapy specialist, who presented their points of

In coordination with the Hand Surgery division at theview. Their presentations were highly appreciated and

AAHS President Dr. Murray and RSSH President Dr.

Instituto Nacional de Rehabilitación (INR) in Mexico City,

triggered lively discussions, during the sessions andGeorgescu

which is part of the National Health Institutes as well

At the last meeting of 2017, the MSHSM was honored

especially after them, creating new connections andas the government of the Mexican State of Campeche,with the attendance of the Secretary of Health of thegreat friendships.

another pro bono campaign was recently launched.

State of Campeche, who also witnessed the launch of our

The surgery campaign took place in several stages.

new website.

In response to the American warm welcome, the RSSH
invited the AAHS in April 2017 to Cluj Napoca, Romania,
as guest of our Society’s congress: the 11th National
Congress of the Romanian Society for Surgery of theHand, held together with the 12th National Congress of
the Romanian Society for Reconstructive Microsurgery,the National Conference of Romanian Association of

Dr. Geoffrey Hallock (USA) and Dr. Magdy Nabil Morsy

Plastic Surgeons and the 1st Cluj Napoca International(Egypt) during the Flaps dissection Course

Course on Perforator Flaps. During this joined scientificevent 47 faculty members from Egypt, Finland, Greece,
Italy, Moldavia, Poland, Serbia, Switzerland, Turkey, andthe USA participated, as well as 33 Romanian guest
Patient selection was done on 30 November to 2

lecturers.

December. Of the 50 consultations, 17 patients wereselected for 24 surgical procedures which were done

These activities encourage also other members of our

Before the congress, Professor Alexandru Georgescu,

from 6-9 December 2017.

Society to continue with future outreach campaigns in

the President of RSSH, co-organized together with Julie

Mexico which is one of the main goals of our Society.

Adams, Josh Abzug and Peter Murray (AAHS President)

The medical staff was composed of orthopedic residents,

another interesting scientific event, the AAHS Pre-

hand surgery fellows and hand surgeons from different

congress Course: Advances in Hand Surgery. To this(Greece) and Dr. Bumbasirevic

areas, working together in 4 surgical teams.

course were invited 18 hand surgeons from USA and(Serbia)32

Dr. Windell Merrit (USA)Dr. Georgescu, Dr. Soucacos

33

MEMBER SOCIETY NEWSASSOCIATION OF HAND SURGEONSOF THE PHILIPPINES

www.ifssh.info

February 2018

JOURNAL HIGHLIGHTS

Thomas Kiefhaber, John Capo, Scott Kozin, Don Lalonde,

The President-Elect of the Society is Bruno Battiston,

Plastic Surgery - with 120 hours of practice - again in

Diego Fernandez and Marc Garcia-Elias.

Head of the Hand and Upper Limb Department in Torino

three weeks during the year;

Trauma Center (CTO) and a new council has been voted
It is with great pleasure that I introduce the Association

Members of the AHSP would like to welcome 2018of the Hand Surgeons of the Philippines (AHSP). The

and wish the IFSSH more power. We look forward in

AHSP was established in 1984 as a small group of handparticipating and establishing closer ties with IFSSH

surgeons dedicated to the care and surgery of the hand.

Member Societies in the future.

The AHSP was also one of the founding societies of
the APFSSH (Asian Pacific Federation of Societies forSurgery of the Hand). Since then, the membership of

MEMBER SOCIETY NEWS•

under President Roberto Adani from Modena.

2-3 Hand and Microsurgery Fellowships of 1 year
are available in recognized Hand Surgery Centers in
Italy.

From 2017, the Society offers an “International Travelling
Fellowship in collaboration with the ASSH” to visit

ITALIAN SOCIETY FOR SURGERY OF
THE HAND

prestigious centers in the USA and participate in the
Annual Congress of ASSH.

the Society has been increasing, as more surgeons
take an interest in the art and science of hand surgery.

(Società Italiana di Chirurgia della Mano) (SICM)

SICM organizes two more dissection courses per year

At present, the AHSP has 31 members, mostly with an
orthopedic surgery background.

for more experienced surgeons with an International
The Italian Society for the Surgery of the Hand,

Faculty that joins the Italian Faculty: these twofounded in 1962, includes 12 Honorary Members, 835“advanced” courses are in English and last three days.

The past year (2017) was a historic year for the AHSP.

full registered members, and 40 young members. The

Fig 1: Dr Bruno Battiston (President-Elect) (left) and Dr

In 2018, we will organize the following two courses inThis was when the AHSP hosted the 11th APFSSH (Asian

majority of the Italian members are Orthopedic Surgeons

Roberto Adani (President) (right) during the official

Verona:Pacific Federation of Societies for Surgery of the Hand)

while Plastic Surgeons are a substantial minority.

ceremony of the Italian Congress.

1.

Congress in Cebu City 7-10 November 2017. This occasion

Elbow Surgery (Anatomy and Clinical experiences- Topics on Anatomical approaches, Arthroscopy,

marked the first time that the AHSP has hosted an

The Society Secretariat is based at:

The new SICM council (in office to the end of 2019)

Arthroplasty and Prosthesis, Soft tissues andinternational event. The congress was led by Ida Tacata

PLS - Via della Mattonaia, 17 - 50121 Firenze FI

develops the education program for residents andNerves);(Congress President) and Emmanuel Estrella (Congress

Tel. 05524621 Fax. 0552462270

surgeons, which is one of the main goals of the Society.

Chair and AHSP President). Four hundred forty three

sicm@promoleader.com(Fig 2)

registered participants attended the 11th APFSSH

Web Site: http://www.sicm.it

Congress from 25 countries (Figure 1).

2.

Hand Surgery (Surgical techniques in hand surgery:
Ligaments, Tendons, Fractures and Arthroplasty).

Training and education of surgeons:

These courses are popular with participants coming

The Society Journal is “Chirurgia della Mano” and is

The Italian Society organizes for young surgeons (duringfrom all over the world. The programs are available on

A total of 119 talks were delivered with 26 Plenary Talks

the official Journal since 1963 (C.G. Edizioni Medicothe residency program) 3 main courses per year

www.sicm.it

and 93 simultaneous session talks, covering various

Scientifiche s.r.l.)•

topics in hand, wrist and microsurgery. Among the

http://www.cgems.it/Cgems-Prodotti-Elenco.

course organized into three modules (one week each;Every year a National Congress is held in a Center ofdistinguished guests of the Congress were Peter Stern,

asp?Categoria=21

anatomy, orthopaedic/hand surgery, plastic/hand

Hand Surgery and in 2017 the chosen city was Modena,

surgery);which was a great success. The title “Look to the past - toAdvanced Course in Microsurgery - organized in

see the future” allowed us to explore all the topics in thecollaboration with the Societies of Microsurgery andfield of hand surgery.

•

The participants of the 11th APFSSH in Cebu City, Philippines 7-10 November 2017.

34

Anatomy and Surgery with cadaver dissection

Fig 2: The new Council (2017-2019) of the Italian Society of Surgery of the Hand (SICM)

35

MEMBER SOCIETY NEWS

More than 500 people joined the congress including
therapists and residents. Many international colleagues

www.ifssh.info

DUTCH SOCIETY FOR SURGERY OF
THE HAND

enriched the program: A. Bhatia (India), H. Buerger(Austria), M. Calcagni (Svizzera), J. Chang (USA), F.

MEMBER SOCIETY NEWS

February 2018

Brigitte van der Heijden
President of the Dutch Society for Surgery of the Hand

POLISH SOCIETY FOR SURGERY OF
THE HANDIFSSH representative of the Dutch Society for Surgery of
Nederlandse Vereniging voor Handchirurgie (NVvH)

the Hand

Polskie Towarzystwo Chirurgii Ręki(Francia), R. Kebrle (Repubblica Ceca), D. Lalonde

During last ten years the Dutch Society for Surgery of

Most of the activities of the Polish Society for Surgery(Canada), L. Nagy (Svizzera), O. Reigstad (Norvegia), M.

the Hand has grown to a multi-disciplinary society

JAPANESE SOCIETY FOR SURGERY
OF THE HAND (JSSH)

Rizzo (USA), L. Scheker (USA), J.B. Tang (Cina), Z. Wangof almost 250 members including hand therapists,(Cina)

general surgeons, orthopedic surgeons, plastic surgeons,

The history of JSSH was published in the February 2017

the new ideas during this event was to hold a session

rehabilitation physicians and an anatomist. The Dutch

issue of the IFSSH Ezine (#25, p37-38)of the live oral EBHS (European Board of Hand Surgery)del Piñal (Spagna), K. Fukumoto (Giappone), A. Gilbertof the Hand are connected with its meetings. This year
we had the IXth National Meeting in Krakow. One ofsociety organizes scientific meetings twice a year. In

examination which was conducted by Martin RichterMay 2017 all “ins and outs” about hand fractures were

61th Annual Meeting of the JSSH

(Chair of Examination Committee) and Piotr Czarnecki

discussed with, among others, Prof Nagy from Zurich.

Date and time: April 26-27, 2018

(Polish Member of Examination Board). It was positively

Place: Tokyo

evaluated by participants as an excellent example of

In November 2017 the Dutch Society celebrated its 45th

President: Professor. Katsunori Inagaki, Showa

how the examination looks and works.

anniversary in Utrecht, which was a great success.

University School of Medicine

A variety of presentations about innovations in hand

URL: http://www.congre.co.jp/jssh2018/index.html

Dr Mariusz Bonczar,

surgery were done by international speakers like Prof

President of PolishFig 3 Some guest speakers at the 55° SICM Congress held

Bindra, Prof Verstreken, Prof Lindau and Prof Liverneaux

Secretariat for Japanese Society for Surgery of the Hand

Society for Surgery ofin Modena in 2017 			

and by Dutch experts like the anatomist Prof Bleys,

address: c/o Congress Corporation, Kohsai-kaikan

the Hand opens theP. del Piñal, JB Tang, R Adani, J Chang, M Innocenti

radiologist Prof Maas and Plastic surgeon Dr Strackee.

Building, 5-1 Kojimachi,

National Meeting which

Chiyoda-ku, Tokyo 102-8481, Japanwas held this year in

The Dutch Society is much honored that it was elected

TEL: +81-3-5216-5569

Krakowat the FESSH Congress in Budapest to organize the 2021

FAX: +81-3-5216-5552

FESSH Congress, which will be held in Amsterdam.

E-mail: office@jssh.or.jp

During this national meeting new elections were held.

URL: http://www.jssh.or.jp/

Dr Mariusz Bonczar is now the President of the Polish

The Dutch society is working hard to create aSociety. During the evening social meeting, two handcertification “subspeciality in handsurgery”. In thesurgeons, Prof. Jerzy Jabłecki form Trzebnica andNetherlands, hand surgery is practiced by various

Prof. Jan Skowroński from Białystok, received special

physicians like trauma surgeons, orthopedic surgeons

recognition from the Society for their contribution to

In 2018 SICM has been invited as guest Society during

and plastic surgeons. It is believed that recognition ofPolish and international hand surgery.

the Congress of the American Association for Hand

hand surgery as a subspeciality will improve the care

Surgery (AAHS) and of the American Society for Surgery

for the patients with a hand problem. The certificate canof the Hand (ASSH).

be obtained if the specialist fulfills the set requirements

JB Tang, D Lalonde, R Adani, Z. Wang

in the field of knowledge, experience and practice. The
All society information and entry criteria are available

certification of the American Society for Surgery of theonline: http://www.sicm.it.

Hand (ASSH), the European Diploma in Hand Surgery

Current Board Members of the Japanese Society forand the “White Book” of the Federation of European

Surgery of the Hand

Pierluigi Tos MD, PhD

Societies for Surgery of the Hand (FESSH) have been

International Delegate at the IFSSH ofused as guidelines when drawing up the requirements.

The Italian Society for Surgery of the Hand (SICM)

In 2015 the framework for the certification was approved

Microsurgical training during “Academy of Hand Surgery”

pierluigi.tos@unito.it

by the members of the Society. The implementation and– periodical courses supported by the Polish Society forcontrol system is currently being drafted.

Surgery of the Hand

36

37

MEMBER SOCIETY NEWSwww.ifssh.info

February 2018

ART

Seoul, from 15-17 June 2017. At this exciting event, recent
advances in the hand, micro and reconstructive surgery
were discussed by experts from 72 countries.

Poster Session during Xth International Poznan Course
in Upper Extremity Surgery. This is a well recognized

9th Congress of the World Society of Reconstructive

event every year in Poznan and is attended by over 450

Microsurgery (WSRM) 15-17 June 2017

surgeons from many countries.
The annual congress of the KSSH took place in November,
Besides the national meeting there is an ongoinga time when the autumn leaves are at their mosteducational project and supported by the Society viz

beautiful. The most recent congress (35th) was held as“Academy of Hand Surgery”, consisting of 3-4 meetings

the second iteration of the international meeting from 3-5

per year and directed mostly to young residents

November 2017, and was chaired by Dr. Sang Hyun Woo.

improving their skills in microsurgery and general

Two outstanding hand surgeons, Professor Kevin Chungknowledge in hand surgery. It organized by Prof. Tomasz

from Michigan University (USA) and Professor Michael

Mazurek (Past President of the Society) and his team

Sauerbier from Frankfurt University (Germany) werefrom Gdańsk.

invited and gave inspirational key-note lectures about
the most recent advances in the field of hand surgery. In

One of the most important courses had its anniversary

addition, seven travelling fellows from Taiwan, Japan,

last year. The Xth International Poznan Course in

Malaysia, Hong Kong, Singapore, and Russia presented

Upper Extremity Surgery was organized in Poznan byinteresting topics from their own countries and practices.

Prof. Leszek Romanowski and dr Piotr Czarnecki withThe 2018 KSSH Annual Congress will take place from 3-5

the team from the Department. It attracted over 450

November 2018, in Seoul. We will ensure that this meeting

participants, with 35 speakers, 11 sessions, 5 workshops,

is educational and interesting for our internationalcadaver pre-course and poster session. The course keeps

participants. The new chairman of the KSSH, beginning

its international character and every year invites also

in 2018, is Professor Hyun Dae Shin.

surgeons from Eastern Europe.

KOREAN SOCIETY FOR SURGERY OF
THE HANDThe Korean Society for Surgery of the Hand (KSSH)
was established in 1982. The KSSH has successfully
held international hand society meetings, which have35th Congress of the KSSH 3-5 November 2017

included the 4th Congress of the Asian Pacific Federationof Societies for Surgery of the Hand (APFSSH) in 2002

On behalf of our chairman and the many KSSH members

and the 11th Congress of the International Federation

who will participate at the FESSH 2018 Congressof Societies for Surgery of the Hand (IFSSH) in 2010.

(Copenhagen, Denmark) and the ASSH Congress 2018

In addition, the 9th Congress of the World Society of(Boston, USA), we look forward to sharing our expertise

Reconstructive Microsurgery (WSRM) was held in COEX,

and passion for hand surgery.

38

Art exhibit #2:
Wooden chair (H730 x W400 x D470 mm)
Artist: unknown
Collection: Ulrich Mennen
39

PEARLS OF WISDOM

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Pearls of Wisdom

PEARLS OF WISDOM

February 2018“

Classification of Questions

both the trainer and the trainee. The trainee with an

Type I –A good questionawareness of the classification is more likely to think

The seniorauthor decrees thatthe teacher has
absolute right ofdetermination of not
only the appropriateclassification of aparticular question
asked, but also the
response to thequestion

Type II –A good question asked at a

before asking a question. It encourages the traineecharacterise that which makes a good question.2

to consider whether the question will be answered in

Similarly, Sarti also discusses the benefits of asking goodtime or whether it should be asked at all, thus avoiding

questions and helps to clarify these.3 The MIT Teachingunnecessary questioning during surgery, clinic, orand Learning Laboratory, which aims at strengthening

ward rounds. It also forces the trainee to be moreeducational efforts in a variety of spheres, defines a goodthoughtful of the topic, read in advance and consider

question as relevant, short, clear, and unambiguous.4

References:

how else knowledge can be gained. It is too easy to keep

Emphasis in the education literature tends to focus on

1. Lyon PMA. A model of teaching and learning in theasking questions resulting in an unstructured learning

how a teacher can best ask questions. We believe that

operating theatre. Med Educ 2004; 38:1278-87.

experience, and is indicative of a lazy mind.

focusing on how the student should ask better questions

2. Lyon PMA. Making the most of learning in theon Questions in Surgery
Many would consider surgical training as a form of an

The senior author decrees that the teacher has absolute

apprenticeship. To that effect, the relationship between

right of determination of not only the appropriate

teacher and student is an important one. The quality

classification of a particular question asked, but alsoof the interaction between surgeon and trainee in thethe response to the question. A Type I question may

operating theatre has been linked to the quality of theelicit an erudite, pithy, and informative response.

learning experience. Through decades of involvement in

Type II questions tend to be met by abrupt, grumpy

surgical teaching and education, the senior author has

answers or silence. The response to Type III is erratic

observed a pattern in the questions posed by his trainees.

and unpredictable and the teacher may well resort to

These observations have allowed the formulation of aexpletives.

1classification for the questions asked by trainees which ispresented below.

Although there is a humorous side to this classification,
there is benefit in its more serious consideration by

bad time
IIa – The answer will become clear if 		the trainee waits for the next step in a 		procedure
IIb – The question is asked at a particularly 		
difficult time during a procedure
IIc – The teacher is in a bad mood and any 		
question asked is at a bad time
IId – The question is asked to show off		is equally valuable. Leading surgical educationalists1,4,5
are in agreement that the quality of a learning
opportunity within the surgical environment is a bilateralprocess between trainer and trainee. The quality ofquestions asked by both parties is of crucial importancein maximising this learning experience.
We would commend this classification as a means ofimproving surgical education. The junior author also
finds it of benefit as a tool to use in an effort to avoid
irritating the trainer. The senior author believes thatthe trainer’s changing response to questions over time(especially if a larger percentage of questions are beingclassified as Type II and Type III (Figure 1) may be a usefulrule of thumb in deciding when to retire; unless it isobvious that the questioner is an idiot.

”
5

Michael Tonkin – Trainer

Andreas Fox – Trainee

operating theatre: student strategies and curricularFrom the point of view of the trainer, this classification

initiatives. Med Educ 2003; 37: 680-8.

has several benefits. It allows a swift and broad

3. Sarti R. Question: What makes a good question?

impression of the type of trainee and an insight into their

11/03/2008. Clomedia.com/articles/view/question_what_

learning style. It also allows monitoring of progress:

makes_a_good_question/1

one would hope for a trainee that asks far fewer Type II

4. Breslow L. Lessons learned: findings from MIT*Some may query this sub-classification as a Typeand Type III questions and far more Type I questions at

initiatives in educational technology. Journal of Science

II question. However, “bad timing” refers to thethe end of their placement compared to the start. Sucheducation and Technology 2007; 16(4): 283-97.

understanding that at some time the questioner would

observations can form part of the subjective assessment

5. Eckhauser FE. The surgeon as teacher of medical

not have had the knowledge and that at certain timesof the trainee.

students. In: Bartlett RH, Zelenock GB, Strodel WE, Harper

ingratiation through sycophancy is entirely acceptable to

Lyon argues that any academic process needs theML, Turcotte JG, Editors. Medical Education: a surgicalthe trainer.

formulation of analytical questions, and goes on toperspective. Chelsea, Missouri: Lewis; 1986. 47-51.

knowledge and not to gain it, or to 		ingratiate the questioner*
Type III –40

A bad question41

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UPCOMING EVENTSPARIS•FRANCE

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Chairmen:
Christophe Mathoulin
Mathilde Gras

International Symposium

Institut de la Main

WRIST ARTHROSISGENERAL ORGANIZATION

www.symposium-institutdelamain.com
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44 bd. Périer - 13008 MarseilleTel.: +33 4 91 94 54 72
Fax: +33 4 91 58 54 94
contact@symposium-institutdelamain.com

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