ifssh
ezine

www.ifssh.info VOLUME 3 ISSUE 3 AUGUST 2013

Journal Highlights
Member Society Updates
Upcoming Events

CONNECTING OUR GLOBAL HAND SURGERY FAMILYIFSSH ScientificCommittee Report on the
Anatomy of the Hand
THERAPEUTIC EXERCISE IN WRISTREHABILITATION PART 2

THE EPONYMOUS SWANSON LECTURE
BY PROFESSOR WAYNE MORRISON

Angular stable fixation of ulna
shortening osteotomies.
LCP Ulna Osteotomy System 2.7.
Optimized Plate Design
The low profile plate with tapered ends reduces the risk of soft tissue irritation and hardware related
patient discomfort. The plate is available in two lengths: 6 and 8 holes.
Precise Instrumentation
System specific instrumentation like Parallel Saw Blades and Drill Templates allow to perform a secureand accurate osteotomy cut, for transverse cuts as well as for oblique cuts between 2 and 5 mm width.
Freehand Technique
Additionally available Compression / Distraction Instrument to facilitate freehand technique application
especially in shortenings more than 5 mm.

For further information please contact
your local Synthes representative:
www.synthes.com

August 2013

Contents
4 Editorial

By Professor Ulrich Mennen, editor of the IFSSH ezine
Letters to the editor

6 Executive news

• Newsletter from the Secretary-General:
Marc Garcia-Elias• Message from outgoing Secretary-General:
Zsolt Szabo

8 Member society updates• The Asian Paciﬁc Federation Societies for Surgery of
The Hand (APFSSH)• Australian Hand Surgery Society• News from the Brazilian Society for Surgery of theHand

12 Special features:• The Eponymous Swanson Lecture by Professor
Wayne Morrison, given at the 11th Congress of the
IFSSH in India, March 2013
• The Turner Institute in St. Petersburg, Russia

16 Pulse

26 Hand therapy

Therapeutic Exercise in Wrist Rehabilitation Part 2

30 Research Roundup• Innovations in treating skin defects of the hand
• Free vascularised medial femoral condyle autograft
for challenging upper extremity nonunions• Modern tendon repair techniques

33 Pioneer profiles
Robert Carroll
Nils Carstam

36 Journal highlights

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

39 Upcoming events

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

IFSSH Scientiﬁc Committee Report on the anatomy of
the hand

IFSSH ezine AUGUST 20133

editorial

Editorial
The IFSSH ezine has become the oﬃcial communication tool of the IFSSH. It also has become popularamongst our Members, judging from the constant ﬂow of new subscriptions and the huge number ofsubmissions.

To reiterate, the tagline of the Ezine is:for the Members, by the Members!
Therefore every Member is invited and encouraged to use this medium:1. to share interesting and educational information
2. to advertise upcoming activities
3. to share humerus incidents (humorous!)
4. to give an opinion, controversial or debatable
5. to send photos which tell more than words
6. to get or give advice on diﬃcult cases

This issue contains the following special features:
1. The Eponymous Swanson Lecture by Professor Wayne Morrison, presented at the 11th Congress of the
IFSSH in India, March 2013.
2. The Turner Institute in St. Petersburg, Russia.
3. A new section for Member society updates and related Federations. Delegates are encouraged to use
this platform to uniform colleagues worldwide about their activities.
Be a communicator!
With sincere regards
Ulrich Mennen
Immediate Past-President:International Federation of Societies for Surgery of the Hand
Editor: IFSSH ezine

IFSSH disclaimer: The IFSSH ezine is the official
mouthpiece of the International Federation of Societies
for Surgery of the Hand. The IFSSH does not endorse
the commercial advertising in this publication, nor thecontent or views of the contributors to the publication.
Subscription to the IFSSH ezine is free of charge and theezine is distributed on a quarterly basis. To subscribe,
please click here. Should you wish to support thispublication through advertising, please click here.
4

IFSSH ezine editorial team:

Editor: Professor Ulrich Mennen (Immediate Past President of the IFSSH)
Deputy Editor: Professor Michael Tonkin(President of the IFSSH)

Publication coordinator:
Marita Kritzinger (Apex ezines)
Graphic Designer: Andy Garside

O THE
SUBSCRIBE T

ifssFRhEE
ezine

FOR

IFSSH ezine AUGUST 2013letters to the editor

Dear Member
I am trying to draw together a comprehensive archive. At the
moment Belinda Smith (IFSSH Administrative Secretary) and I areconcentrating on the Executive Committee Meetings over theyears. I think the International Federation was set up in Januaryof 1966 and have the inaugural Minutes. However, at present
we have nothing from January of 1966 until some Minutes
dated the 6 March 1971. After that we have no Minutes until the
24 February 1981. We have no Executive Committee Minutes
from 1982 -1986 or 1997 - 2000 (inclusive). If you have a copyof any of the Executive Committee Minutes that are missing I
would be grateful if you would scan them and send them toBelinda in the Secretariat (email: administration@ifssh.info). We
would be extremely grateful. Minutes are very valuable data
which trace the development of the International Federation
and a comprehensive set would be a very valuable resource forarchivists in years to come.
I think we should also start to develop the same process forthe Delegates’ Council Meetings. At this stage the only question I
have relates to the date that Delegates Meetings started. We have
all the Delegates Minutes from 2001 onwards and know that there
was a Delegates Meeting in Barcelona of June 2000 (although we
do not have those Minutes currently).
I do hope you will be able help us with the missing Executive
Committee Minutes and/or information concerning the inaugural
Delegates’ Council Meeting and any Delegate Minutes from theoutset to the year 2000 inclusive.
Frank Burke
IFSSH Historian

IFSSH ezine AUGUST 2013

Living Textbook of
Hand Surgery:an update
At the IFSSH Congress in Delhi, with theenthusiastic support from Ulrich Mennen andRaja Sabapathy, great interest and cooperationfrom the Hand Surgery family was shown for The
Living Textbook of Hand Surgery. More authors,
reviewers and members for the editorial board
have come forward to participate. However, somechapters are still missing authors! The editorial
team welcomes everybody who is interested totake part as an author. Do not hesitate to contact
us if you are interested in participating in this very
exciting venture.
The team has been working backstage todevelop the software. The intended interactive
web design for the book is completely diﬀerent
from standard ebooks and published PDFdocuments, and therefore has to be generated asa new concept.
We are also in contact with Wikimedia andopen access networks, to adapt the book,from the beginning, to deﬁned concepts ofopen educational resources, like the UNESCO,
who developed a system especially for higher
education.
The Living Textbook of Hand Surgery will be
introduced and discussed at the OER-Congress
and Barcamp of Wikimedia in Berlin, in September
2013 to gain technical and conceptual ideas.
You are invited to follow the progress at thewebsite: handbookhand.com. A timetable offurther developments will be published soon.
Thank you all for your support and interest,
Richarda Boettcher
Handchirurgie Weltweit e.V.
richarda.boettcher@hand-ww.de5

executive news

Newsletter from theSecretary-General
Dear Friends
It is only four months since I embarked
on this magniﬁcent cruise, called
IFSSH, and yet I know that I will
enjoy this trip. So far, membershipcooperation has been superb; the crew
(Belinda, Santosh), incredibly eﬃcient;and the captain (Michael Tonkin), an
expert sailor, one of the best, indeed!
Yes, our ship is in good hands, andwith the help of those who precededme (Thank you, Zsolt and Ulrich) I haveno concerns. If I ever thought thatlife as a secretary-general would bequiet, it is time to say that I was wrong.
This is a ship where things happen
constantly. Paraphrasing Rod Steward,
I would say that “there is never a dull
moment” in our Federation. Let me tell
you what is going on.
For those who are still basking in
the glow of that “incredible India” we
had the chance of visiting, rememberthat thousands of photos were taken
during the congress, and that they areavailable through our website (http://
ifssh-ifsht2013.com/gallery1.php). The
pictures are in web/screen resolution.
To obtain high resolution copies forprinting purposes, please send amessage with the code number given
below each photo to the webmasterat info@krithitechnologies.com, and hewill mail them to you.
The IFSSH sponsored theregistrations of 20 surgeons to attend

6

the triennial congress in Delhi, as
well as recently providing funding
for IFSHT projects and assisting theAmerican Association for Hand Surgery
with ﬁnancial support to teach handand microsurgery to a Mongoliandelegation.
The Committee for Educational
Sponsorship (CES), along with the
Executive Committee, presented a
new set of guidelines for educationalbursaries and grants to the Assemblyof National Delegates. They wereapproved, with four main categories of
educational sponsorship support:• Speciﬁc education projects withthe oversight of a society/memberof the IFSSH (e.g. fellowship
programmes at underdeveloped
institutions, educational DVDs andbooklets, etc);• Society congress/courses organisedby societies, with support available
for speakers, registrants and/or
equipment;• Regional courses, such as theEastern European Hand Surgery
course; and• IFSSH congress registration (i.e.
support to attend the congress
for those from areas of need –IFSSH membership is not requiredfor individuals to apply for thiscategory).
The method of application andacceptance was simpliﬁed to make theprocess much faster and allow more
projects to receive timely funding.
Delegates are asked to read theguidelines on the website (www.ifssh.
info) and encourage applications fromtheir societies.
Excellent news comes from
Buenos Aires about the possibility of
having both the IFSSH and the IFSHT
congresses in the same venue, apossibility that was initially discarded.
Although not yet fully decided, thelocal organising committee is working
full speed in this. The 2016 IFSSH
Congress will be held on October
10-13, 2016 in one of most attractive
areas of Buenos Aires, Puerto Madero.
IFSSH ezine AUGUST 2013

executive news

Message from outgoing
Secretary-General:
Zsolt Szabo
Further information may be obtainedat www.ifssh-ifsht2016.com. In thisregard, new, more detailed guidelines
on how to organise an IFSSH congress
have been presented for discussion to
the ExCo.
Aside from these initiatives, theadministration keeps its routine:
control of banking transactions,sending receipts to the membership
who paid theirs annual dues, website
updates, committee reports, and so on.
We have started preparations for
the National IFSSH Delegates Council
meeting which will be held in Paris
during the meeting of FESSH, June
18-21, 2014 (www.fessh2014.com/en/
welcome).
Frank Burke is doing a great job
in reorganising and completing ourarchives, a badly needed task thatﬁnally appears to see an end.
A process of discussion has been
started in order to update the IFSSH
charter, a modiﬁcation project that isneeded to adapt our legal status to the‘changing times’.
I wish you the most relaxing
summer vacation!
Marc Garcia-Elias
Secretary-General, IFSSH
Email: secretary@ifssh.info

IFSSH ezine AUGUST 2013

As the Secretary-General during thelast three years, I have realised how
important it is to be a member of
an international community. I havebeen always told, but now I knowthat we, the hand surgeons from allaround the word, we are a little bit
special. Our enthusiasm and friendship,
our involvement in teaching andeducation activities, combined withhigh quality social activities makes
hand surgery diﬀerent to otherspecialties. The Executive Committeeof the IFSSH led by its President did
his best for the ﬁnal goal of every
hand surgeon: a better outcome
for our patients. All our activities,
projects and work are dedicated tothis and for success we really need
your contribution. The best leader
is worth nothing without a devoted
and enthusiastic army. Changing theleaders from time to time brings fresh
ideas, new methods and diﬀerent
ﬂavours, but the continuity, the realvalue is always represented by theactive membership of a Society anda Federation. It was an honour anda great satisfaction to work with you
during the last three years. We haveachieved much.
A new Executive Committee has
been elected. The personalities andthe devotion of the new oﬃcers area guarantee of continuity and thedevelopment of new ideas, activities

and projects. I would like to thank you
for your involvement, for your support
and your active participation in thelife of our Federation and I would
like to introduce the new Executive
Committee:
President: Michael Tonkin
President Elect: Zsolt Szabo
Secretary-General: Marc Garcia-Elias
Secretary-General Elect: Daniel Nagle
Historian: Frank Burke
Immediate Past-President:
Ulrich Mennen
The new Nominating Committee is:
Chair: Ulrich Mennen(Immediate Past-President)
Members: Jim Urbaniak,
Arlindo Pardini,
Moroe Beppu – Member-at-Large
Zsolt Szabo
President Elect, IFSSH

7

members news

Member society updates
Australian Hand Surgery Society
The Australian Hand Surgery Society(AHSS) is a relatively small organisationof 150 members, the majority beingfrom orthopaedic or plastic surgery
backgrounds. Over the past four
decades the Society has evolved froman informal interest group into a much
more structured organisation withclose links to The Royal AustralasianCollege of Surgeons (RACS), and to theparent speciality bodies, namely The
Australian Orthopaedic Association(AOA) and The Australian Society of
Plastic Surgeons (ASPS). The Hand
Society has always run a vibrant andcomprehensive Annual Scientiﬁc
Meeting which attracts the majority ofthe membership, and also organises
a number of other workshops andtraining activities for both members
and orthopaedic and plastic surgicaltrainees.
In recent years there has beenstrong support towards establishinghand surgery as an independent
speciality in its own right, as present
in a number of other countries.. For
many reasons, some political, someorganisational, this has been resisted
by our College of Surgeons, who
do not wish to expand the numberof speciality groups beyond the8current 9 established specialities. It
has become clear over the years thatextra training in hand surgery, outside
the normal fellowship requirementsof orthopaedic and plastic surgery
training, is required to develop
expertise in hand surgery. In past
years, this has usually meant surgical
graduates take up fellowship positions
either overseas or within a handfulof local fellowship jobs available inAustralia. There has been no formal
recognition of this extra training which
has occurred in an ad hoc manner,
although it has served our handsurgery community well. It is wellrecognized that there are considerable
diﬃculties in ﬁnding overseas
fellowship positions due to increasing
political and bureaucratic obstructions
to the free exchange of doctors andsurgeons between overseas training
centres.
The Australian Hand Surgery
Society has been actively involved inpromoting post fellowship training in
hand surgery, and has pursued waysof improving training in a more formal
and structured manner through The
Royal Australasian College of Surgeons(RACS). In the past few years the RACS,
with input from a couple of othersub-speciality groups, has developed apost fellowship education and training
programme (PFET) in a number ofsuper specialities. These currently
include spinal, colorectal and handsurgery.
At the beginning of 2013 the
AHSS appointed the ﬁrst new post
fellowship trainees into a structured
PFET Programme. This has involved
an enormous amount of work inestablishing agreement between
all the interested parties (RACS,
AOA, ASPS), deﬁning a curriculum,
developing mechanisms for trainee
selection and the accreditationof training centres, and all of theadministrative processes to assist in
management. Although it has justcommenced, we are very enthusiastic
that the PFET programme will expand
quite rapidly as our orthopaedic andplastic surgical trainees with interestsin this area seek more formal training
within Australia.
There have already been a number
of PFET Training Centre positions
accredited to take on the expected
increasing numbers of specialist
trainees, and we look forward to ﬁnetuning and improving our programme
as it matures over the next few years.
Randall SachPresident AHSS
July 2013www.ahssociety.org.au
IFSSH ezine AUGUST 2013

members news

Brazilian Society for Surgery of the Hand

The 33rd Congresso Brasileiro deCirurgia da Mão (Brazilian Meeting ofHand Surgery) and the 14th Congresso
Sul Americano de Cirurgia da Mão(South American Meeting of Hand
Surgery) were held between April 25thand 27th in Rio de Janeiro, also known
as the Wonderful City.
On April 24th, a Pre-Meeting Course
was held and organized by Dr Don
Lalonde, President of the American
Association of Hand Surgery. Many
American hand surgeons came with Dr
Lalonde, and they all paid for their own
expenses.
IFSSH ezine AUGUST 2013

The meeting had more than 700
participants, including Argentinean,
Chilean, Ecuadorean, Peruvian and
Venezuelan, German, Brazilian,Canadian and American Hand
Surgeons. During those four days, we
had an intense scientiﬁc schedule.
Three rooms held courses, lectures,debates, presentations of thirty oral
papers and eighteen e-posters.
Dr Monteiro, SBCM’s President, and
Dr. Sobania, SSCM’s President, duly thanksthe involvement of all contributors.
Carlos Henrique Fernandes
SBCM’s TreasurerStanding: Hilton Gottshalk (USA),
Randip Bindra (USA), José do Carmo (Brasil), Carlos
Fernandes (Brasil), Peter Murray (USA),
Mark Rekant (USA)
Sitting: Cherrie A. Heinrich (USA),
Julie Adams (USA) Donald H Lalonde (PresidentAAHS), Anderson Vieira Monteiro (President of
33o Congresso Brasileiro de Cirurgia da Mão),Alejandro Badia (USA)9members news

Bolivian Hand Society
The Bolivian Hand Society recently
appointed its new council.
Dr Juan Carlos Suárez López (President),
Dr Alfonso Soria Galvarro Bort (VicePresident), Dr Julio César Irigoyen Suárez(Secretary General), Dr Kenyi Nitabara
Koga (Secretario de Hacienda), Dr Jorge
Arredondo Saucedo (Secretario de Actas),
Dr Omar E. Lizarazu Jaldin (Vocal), Dr
Juan Carlos Mendieta Rojas (Vocal).

Asian Pacific Federation Societies for Surgery of the Hand
The 9th Congress of the Asian Paciﬁc
Federation Societies for Surgery of
The Hand (APFSSH) in conjunction
with The 5th Congress of the Asian
Paciﬁc Federation of Societies forHand Therapy (APFSHT) was heldfrom October 10 – 13, 2012 at theGrand Hyatt Hotel in Bali, Indonesia.
This was the annual scientiﬁcmeeting for hand surgeons and handtherapists in Asia as well as otherphysicians that are interested in the
management of hand injury,
trauma, congenital and otherdisorders of the hand. The
9th APFSSH in conjunction
with the 5th APFSHT
included approximately
1,000 participants from allover the world. The scientiﬁc
committee arranged a stateof the art program including
all the latest developments

10in the ﬁeld consisting of 4 plenary
lectures, 1 memorial lecture, 12 masterclasses, 6 panel discussions, 30 satellite
symposia, 15 keynote lectures, postcongress instructional courses andworkshops, as well as free paper
sessions consisting of both oral andposter presentations.
The 10th Congress of the Asian
Paciﬁc Federation Societies for Surgeryof The Hand (APFSSH) in conjunction
with The 6th Congress of the Asian

Paciﬁc Federation of Societies for Hand
Therapy (APFSHT) will be held from
October 2nd – 4th, 2014 at the Hilton
Kuala Lumpur Hotel, – Le Meridien in
Kuala Lumpur, Malaysia.
The Society President is Moroe Beppu,
The Congress President is S. Roohi
Ahmad,The Congress Vice-President is Ranjit
Singh,and the Congress Secretary is Shalimar
Abdullah.
For further information,please check the homepageof the Congress at http://
www.apfssh2014.org/index.
html.
We look forward to seeing
you all in Kuala Lumpur,
Malaysia.
Moroe Beppu MD
President of APFSSH
www.apfssh.org
IFSSH ezine AUGUST 2013

Angular stable fixation of ulna
shortening osteotomies.
LCP Ulna Osteotomy System 2.7.
Optimized Plate Design
The low profile plate with tapered ends reduces the risk of soft tissue irritation and hardware related
patient discomfort. The plate is available in two lengths: 6 and 8 holes.
Precise Instrumentation
System specific instrumentation like Parallel Saw Blades and Drill Templates allow to perform a secureand accurate osteotomy cut, for transverse cuts as well as for oblique cuts between 2 and 5 mm width.
Freehand Technique
Additionally available Compression / Distraction Instrument to facilitate freehand technique application
especially in shortenings more than 5 mm.

For further information please contact
your local Synthes representative:
www.synthes.com

special features

Swanson Lecture
IFSSH Meeting, Delhi, 2013

Wayne Morrison
Professorial Fellow University Melbourne and Australian Catholic University
Director O’Brien Institute,
Plastic surgeon, St Vincent’s Hospital, Melbourne.
Thank you for the honour ofpresenting the IFSSH Swanson lecturefor 2013. I can only assume your choice
was inspired by my former fellows andthe charming Indian characteristicof politeness and deference to yourelders. Many of these fellows are now
illustrious alumni on the world stage ofhand surgery. This parental relationshipreminds me of Louis Vasconez an
esteemed plastic surgeon when
delivering a similar prestigious lecture
told the story of how he was asked
to give a talk at his son’s school andhis son pleaded with him “dad please
don’t make a fool of yourself in front of
all my friends.” Here’s hoping!
Let me ﬁrst say something of Al
Swanson. This lecture is named inhonour of Alfred Swanson. No name ismore identiﬁable in hand surgery than
Swanson as a result of his “Swansonsilicone” joints that have proved theirworth and popularity over almost
50 years. Given that each person has
10 ﬁngers with the potential for 30
ﬁnger joint replacements, who in thehistory of surgery, would have had
a greater inﬂuence on hand surgery.
These were developed during the

12

1960’s and marketed in 1969 during
a period of hand surgery revivalthat could be described as theHigh Renaissance of hand surgery.
Concurrent developments were
occurring in tendon and nerve repair,congenital deformities, microsurgery
and carpal mechanics. Swanson’s
other great contribution was in hisrole as chairman of the Nomenclaturecommittee of the IFSSH where heintroduced a classiﬁcation for thecongenital hand that allowed outcome
studies of the various reconstructive
procedures to be critically evaluated.
He succeeded my mentor, Bernard
O’Brien, as president of the IFSSH andO’Brien presented him the Federation
medal which many do not know wasa gift of the Australian Hand Club.
It is somewhat ironic that our newpresident Michael Tonkin is now taking
it back.
I started plastic and hand surgery
training in 1972 at St Vincent’s Hospital,
Melbourne, with Bernard O’Brien
when Al Swanson was at the heightof his fame. The era of microsurgery
had just begun and the excitement
and expectations were palpable.

Mutilating hand injuries were thenorm before the current standards ofhealth and safety were introduced andthe opportunity for replantation andimaginative secondary reconstructions
abounded. For me, this was the ideal
hand surgery paradigm, a plasticorthopaedic hybrid of aesthetic
and functional challenges, andreconstruction of the mutilated handbecame my major interest.
The groin ﬂap was the graveyardof many a budding microsurgeon. The
vessels were small, sometimes absent
and recipient size match unfavourable.
Failure was common. Anaesthetists
and theatre staﬀ were hostile anda thick hide and strong belief wereprerequisites for self - survival. In
1972, Bernard O’Brien commenced anoverseas fellowship training program
and we were fortunate to always havethem to blame.
In 1976, in the ﬁrst article of theﬁrst issue of the American Journal ofHand Surgery, Bill Littler published “100Years of Making a Thumb” charting themilestones and characters involved.
This accurately paralleled the ﬁeld ofhand reconstruction as a whole during
IFSSH ezine AUGUST 2013

special features

this period. His centenary begins in
1874 with phalangisation by Hugier; 1888 - staged cross ﬁnger transfer(Guermonprez); 1900 - toe transfer andosteoplastic thumb reconstruction(Nicoladani); 1946 - pollicisation basedon the neurovascular pedicle (Gosset,
Hilgenfeldt); 1957 - neurovascularisland ﬂap (Moberg, Littler andTubiana); 1960 - microvascularanastomosis (Jacobson); 1965 –
digital replantation (Tami); 1967 - freemicrovascular toe transfer (Buncke,
Cobbett, O’Brien).
Not mentioned in Littler’s
pantheon, was the Australian, Arthur(Ben) Murray, from Tasmania who in
his youth had lost a leg and sustained
an ulnar nerve palsy but subsequently
went on to train in orthopaedics. Whilein the UK at the outbreak of WorldWar II, he was not selected for military
service but was sent to Edinburgh
IFSSH ezine AUGUST 2013

where he established the ﬁrst
dedicated hand surgery service which
has become the prototype modelfor hand surgery services aroundthe world. In 1946, before Gosset,
he described the true pollicisation
technique on the neurovascular
pedicle that is essentially employed
today. He also performed cross ringﬁnger transfers and long before
Swanson, performed the ﬁrst ﬁnger
joint replacement which he designed
from metal. This was reported in 1946.
Two plastic surgery pioneers ofWorld War 1 laid the foundationsof reconstructive surgery on which
many of the subsequent hand surgery
developments progressed. Harold
Gillies, a New Zealander working in
England introduced the tube pedicle
for transfer of large amounts of tissue
and Johannes Esser, a Dutch surgeon
and Gillies’ equivalent working in Berlin

treating the German war injured, used“biological ﬂaps” based on arterial
pedicles.
In 1974 I had the good fortune oftraining at Canniesburn Hospital in
Glasgow, then a hotbed of creativity
and mecca for international visitors.
McGregor had recently describedthe “groin ﬂap” and rediscovered andarticulated the concepts of arterialbased ﬂaps practised by Esser. Tom
Gibson with Medawar had pioneered
the concepts of immunology forwhich Medawar won the Nobel
Prize. Graham Lister and Bob Acland
were at Canniesburn during thisfertile period. From Glasgow, I went
to Paris with Raoul Tubiana whotaught me hand surgery with an
orthopaedic focus under the oneon-one patron-apprentice format, aunique opportunity and a mentor
to whom I owe a great debt. On

13special features

returning to Melbourne in 1976, I
rejoined the team with Bernard O’Brien
and Allan McLeod at St Vincent’s
which was a lively place with fellows
attracted from all around the world.
Many fascinating cases including afull face and scalp replant aﬀorded
us the experience to develop suchtechniques as microvascular cross ringﬁnger transfer, vascularised tendon
transfers, wrap-around toe ﬂaps andmajor microvascular reconstructions.
The Microsurgery Research Centre,
subsequently to become the O’Brien
Institute, was evolving and became aleading centre for microvascular, hand
and reconstructive surgery research
including transplantation.
Although many saw theopportunity for limb transplantation as
the ultimate in hand and upper limb
reconstruction, few believed that thecurrent status of immunology, nor the
results from animal research, justiﬁed
the long term risks involved. Despite
this in 1998, a single hand transplant
was performed by Dubernard in
Lyon, France, soon followed by
Louisville’s case pioneered by Warren
Briedenbach. It was not however
until 2000 in Innsbruck, a bilateral
hand transplant was performed by
Piza-Katzer and Ninkovic that many
sceptics including myself wereconverted seeing the beneﬁts versus
risks ratio shift substantially in favourof the patient in the bilateral limb case.
Although late starters, we performed
our ﬁrst hand transplant in 2011 on
a patient who had lost both hands
and both feet from pneumococcal
septicaemia. This patient was aged 66,
the oldest so far recorded transplant
and the results 2 years later have been

14

“Althoughmany saw theopportunity
for limb
transplantation
as the ultimate
in hand andupper limb
reconstruction, few
believed that thecurrent status of
immunology, nor
the results fromanimal research,justified thelong term risks
involved”

excellent.
Exciting progress is currently being
made with robotic hands including
mind-activated and no doubt this ﬁeld
will progress.
At the O’Brien Institute in
Melbourne, our current researchinterest is in Tissue Engineering basedon the concept of encouraging ourown tissues to regenerate rather thanheal by scar and avoid the necessity
for donor tissue and its associatedmorbidity. The ultimate expressionof this of course would be limb

regeneration. There are examples
in nature which make this concepttantalising feasible. Tadpole tails,salamander limbs and the human liverare examples. Children’s ﬁngertips
and tendons sometimes are observed
to apparently partially regeneratefollowing injury. We have developedmodels of tissue engineering in small
and large animals testing the capacityof cell therapies to survive anddiﬀerentiate into speciﬁc tissues andhave been able to generate pseudoskin ﬂaps, muscle and bone tissues,and organ tissues such as beatingheart and insulin-secreting pancreas.
Fat injection is a form of cell therapy
which no doubt incorporates fat cell
precursor or stem cells which have thecapacity to survive and diﬀerentiate
or initiate self-repair through growth
factor and cytokine release. This
technique has been applied forrevascularization of tissue and digits,
reversal of radiation injury and in
Dupuytren’s contracture in the belief
that recurrence will be diminished.
Much of the science behind celltherapy remains to be elucidated but
we are again entering an exciting
era, perhaps a new renaissance akinto the period when Al Swanson andhis contemporaries inspired us at theend of Bill Littler’s centenary of ideas.
It is now almost 150 years from the
beginning of his cycle and it could
be said that during this time we haveseen surgery advance from Macrothrough Micro to the Molecular.
It has been a great honour todeliver the Swanson lecture and I
sincerely thank our hosts and thescientiﬁc committee for giving me thisunique privilege.
IFSSH ezine AUGUST 2013

special features

The Turner Scientific and ResearchInstitute for Children’s Orthopaedics
By Dr Olga Agranovich
The Turner Scientiﬁc and ResearchInstitute for Children’s Orthopaedics inSaint-Petersburg is a leading medical
establishment in Russia dealing withorthopaedics, traumatology and therehabilitation of children with boneand joint diseases and injuries.
In 1890 a shelter for children withorthopaedic diseases was establishedin St. Petersburg by the founderof Russian orthopedics, Professor
Genrih Turner. In 1932 the shelter wastransformed into the Turner Scientiﬁcand Research Institute for Children’s
Orthopaedics.
The aim of the Institute is toorganise and improve the orthopaedic
and trauma management of children
and adolescents with congenital andacquired disorders of the locomotor
system, as well as the developmentof scientiﬁcally based methods
for the prevention, treatment andrehabilitation of disabled children.
The Institute consists of a complex
of modern buildings, operating rooms
and laboratories equipped with thelatest technology, including modern
microsurgical and neurosurgicalfacilities. The Institute has 500 beds,
divided amongst the following 10
departments: general bone pathology,
spine and neurosurgery, hip pathology,
foot pathology and systemic diseases,
cerebral palsy, hand pathology and
IFSSH ezine AUGUST 2013

microsurgery, rheumatology arthritis,
arthrogryposis, maxillofacial surgery, as
well as a rehabilitation and outpatient
section. The Institute also has a schoolfor the children.
The Arthrogryposis department
was started in 2010, and is theﬁrst specialized department forchildren with arthrogryposis in
Russia. It has 50 beds. There areseveral rehabilitation rooms in thedepartment. From 2010 to 2011 , 120
patients with arthrogryposis werealready treated. Being a specialized
department, the focused treatment
methods and improved overallmanagement have a dramatic eﬀect
on the results. One of the goals of
this Arthrogryposis Department isalso to give assistance to patients andtheir families to adapt to home andsocial life. Patients are seen from theﬁrst month after birth up to 18 yearsof age. Surgery is performed fromage 5-6 months. One of the research
projects is spinal cord stimulation asa part of the rehabilitation of thesepatients. Locomotion therapy (Armeo,
Locomat).is used extensively postoperation to restore function of theupper and lower limbs

15

Pulse: Committee Reports

IFSSH Scientific Committee
Report on Anatomy Of The Hand
Chairman: Eduardo R. Zancolli III
Committee: Carlos Zaidenberg, Diego Piazza, Hernan Iriarte

Knowledge of anatomy of the hand is
the basis for understanding pathology
and for precise application of surgical
techniques.
This committee has selected towrite a report on the TFCC anatomy but
believing also that it will be extremely
useful for hand surgeons to have a brief
actualization of the most signiﬁcant
new papers on hand anatomy.
Since the last IFSSH Committee
Reports (November 2010), a lot of
papers on hand anatomy have been

published, many conﬁrming what isalready known but some adding new
knowledge on the already known
structures. This last group mainlyrefers to anatomical variations thatneed to be known in order to diminish
surgical surprises and to imagine how
to deal with them.
We are conscious that due tothe huge amount of bibliographicalsources we might have missed some
important papers and we apologize
for it.

Committee Report on Anatomy of
the TFCCThe Triangular Fibrocartilage wasinitially described by Weitbrecht (1742)
as intermedia triangularis cartilage. In
modern literature Palmer and Werner(1981) introduced the term TriangularFibro Cartilage-Complex (TFCC) to
describe these structures.

C. Zaidenberg dissection
Figure 1. R: radius, UH: ulnar head, S:
styloid insertion, F: foveal insertion, UCL:
ulnar collateral ligament. 1: Superficial
aspect of TFCC (styloid), 2: deep
insertion (foveal)

16

Anatomical description
The TFCC is a structure running fromthe medial border of the radius to
the styloid area of the ulna and witha distal volar expansion to the carpus.
This ﬁbrocartilage-ligament complex
stabilizes the distal radio-ulnar andulno-carpal joints, distributing load
between the carpus and ulna, andallowing smooth wrist ﬂexionextension, radial-ulnar deviation andforearm pronation-supination.
Other structures also intervene
in stability: musculotendinous
structures, the bony anatomy and theinterosseous membrane.
The TFCC diﬀerent components are:
• Articular disc
• Dorsal and palmar distal radio-ulnar
ligaments• Meniscus homologue• Capsule• Extensor carpi ulnaris subsheath
The articular disc is a cartilaginous
avascular structure that has twowide insertions in the radius having
as functions, load transmission(approximately 20% in normal
conditions) and prevention of
deformity during rotations of the radioulnar ligaments.
Dorsal and palmar radio-ulnar TFCC
portions arise from the medial borderof the distal radius and insert on theulna at two separate and distinct sites:
the fovea at the base of the ulnar
styloid and to the ulna styloid itself.
The peripheral portion of the
IFSSH ezine MAY 2013

Pulse: Committee Reports

Figure 2. Dorsal attachments of the superficial fascicle of the dorsal RU ligament. A: dorsal view. B: Oblique view. C: Volar view.
From radial to ulnar, its 3 different ulnar insertions A,B,C. (from EA Zancolli´s paper)

articular disc of the TFCC is thicker thanthe central part and has longitudinallyoriented collagen ﬁbres. This
thickening has been described as thedorsal and palmar distal radio-ulnar
ligaments. Both of them containing a
superﬁcial and a deep portion. Dorsal
and palmar deep portions insert on theulna’s fovea (conjoined ligamentous
insertion).
Superﬁcial portion of dorsal RU
ligament inserts proximally in three
diﬀerent sites, according to Zancolli EA
descriptions (2008), A-radial border of
ECU groove; B-deep in the ECU groove;
C- dorsal aspect of the styloid process.
Figures A, B, C. (Figure 2).
Superﬁcial portion of palmar RU
ligament inserts distally in the volar
surface of lunate and triquetrum bonesby two separate fascicles (ulno-lunate
and ulno-triquetral ligaments). These
ligaments are considered to connect
the ulna to the carpus through thepalmar foveal origin of the radioulnar
ligament. (Figure 3)
Anatomical and histological studies
have shown that only the proximal
ligamentous component of the TFCC
connects the radius directly to the ulna
(Nakamura et al 1995, 1996, 2000).
IFSSH ezine MAY 2013

The deep components of the
TFCC have been referred by wrist
investigators as the Ligamentum
Subcruentum. In his landmark 1975
article on the “Articular disc of thehand”, Kauer gives credit to Henle andFick for describing a vascularized ﬁssure
between the superﬁcial and deep
components of the TFCC, which theycalled the “ligamentum subcruentum”,
technically not a ligament at all. Overthe past 20 years, however, the term
Ligamentum subcruentum has cometo represent the deep ﬁbers of the
TFCC (inserting into the fovea) andis now used commonly by many
investigators as interchangeablewith the term “deep TFCC radioulna
ligaments”.

Nakamura & Makita (2000)
suggested that the ligamentum
subcruentum is merely the expressionof a vascular intrusion into this defectbetween the superﬁcial and deep
laminae of the TFCC.
The meniscus homologue, asmooth synovium-like membranous
structure which extends from thediscoid section of the TFC to thetriquetrum, was ﬁrst described by
Lewis (1970) as a distal-volar expansionthat extends from the dorsal-ulnar
aspect of the distal radius to thepalmar-ulnar aspect of the triquetrum.
It works like a hammock supportingthe carpal ulnar border, highly
vascularized with loose areolar tissue.
There is a cavity adjacent to the ulnar

C. Zaidenberg dissection
Figure 3. TFCC components:
AD: articular disc; DRUL:
dorsal radioulnar ligament;
PRUL: palmar radioulnar
ligament; ECU-SS: extensor
carpi ulnaris subsheath; MH:meniscus homologue; UTL:
ulnotriquetral ligament; ULL:
ulnolunate ligament.

17

Pulse: Committee Reports

styloid that communicates with theulnocarpal space, called the prestyloid
recess.
Garcia Elias, based on histologicalstudies, considered the tissue which
continued from the TFCC to the carpal
bone as a meniscus homologue which
is diﬃcult to separate from the TFCC.
Others authors (Ishii, Palmer& Werner 1998) redeﬁned three
conﬁgurations of the meniscus
homologue and the prestyloid recess,based on how the prestyloid recesscommunicates with the ulnocarpal
space: 1- narrow opening type; 2- wide
opening type; 3-no opening type.
Diﬀerent studies have shown that
there are variations in the attachmentof the TFCC to the triquetrum.
Hogikyan & Louis subdivided thepatterns of its attachment to thetriquetrum into four types: a small,thin structure and focal attachment(group 1: 28%); a small, thick structureand focal attachment (group 2: 39%); a
thick structure and broad attachment
to between one-third and one-quarterof the triquetrum (group 3: 28%); and abroad attachment covering the entire
triquetrum (group 4: 5%).
Nishikawa et al. also performed astudy for the meniscus homologue’s
attachment to the ulnar side of thetriquetrum (79 joints) obtaining
diﬀerent results than those fromprevious studies. They found that thesection attached to the triquetrum issmooth and that in almost all cases
the site of attachment is on the ulnar
articular side of the triquetrum (Figure4). In about 10% of cases, the meniscal
homologue was found attached to
the ligament of the lunotriquetral
ligament, obscuring the articular

18

Figure 4: Photographshowing the TFCC broadly
attached to the triquetrum(group 4). The TFCC attachedto the lunotriquetral ligament
and the joint surface of thetriquetrum was covered by
the TFCC. (*TFCC broadly
attached on the triquetrum).
(from Nishikawa´s paper)

C.Zaidenberg dissection
Figure 5: Photograph showing cadaveric wrist dissection. R: radius; 6thCompartment; UH: ulnar head; S: Styloid; T: triquetrum; H: hamate; ECU: extensor
carpi ulnaris. ECU-SS: subsheath; AD: articular disc.

surface of the triquetrum.
The capsule attaches to the ulnaalong the anterior and posterior
margins of the styloid process, andto the radius along the anterior andposterior borders of the sigmoid
notch. Distally the DRUJ capsule isincorporated into the TFCC.
The thickened ulnar joint
capsule originates from hyalinelike ﬁbrocartilage on the tip andmiddle portion of the ulnar styloid,and coalesces with the meniscus
homologue to constitute the ulnar
wall of the TFCC. (Nakamura & Yabe,
2000). The ulnar collateral ligament iscomposed of the ﬂoor of the extensor
carpi ulnaris sheath and the thickened

joint capsule.
The Extensor Carpi Ulnaris (ECU)
tendon courses through the sixth
dorsal compartment of the wrist,
passing dorsal on the lower end of theulna through a small ﬁbro-osseous
tunnel. The tendon is held tightly inthe ulnar groove by a thin subsheath,a proper relatively rigid retinaculum,
attached on the margins of the ulnar
groove and ensuring its stability
during pronation-supination. It is apulley described by Bourgery et al as“petit arcade ﬁbrose” which prevents
ECU tendon subluxation. The ECU
retinaculum is separate from thedorsal or extensor retinaculum andcovered by expansions of the extensor
IFSSH ezine AUGUST 2013

Pulse: Committee Reports

retinaculum, which plays no stabilizingrole with regard to the ECU tendon.
The extensor carpi ulnaris (ECU)
subsheath has a ﬁrm connection to
the dorsal edge of the ulnar fovea
through Sharpey’s ﬁbers. Based on
its histological composition, it isconsidered that the ECU subsheathis an important ulnocarpal stabilizer.
(Figure 5)

Innervation of the TFCC
Gupta et al (2001) studied theinnervation of the TFCC. Central andradial aspects of the TFCC do not haveany nerve fascicles or ﬁbers present.
The volar portion of the TFCC is
innervated by a branch of the ulnar
nerve and the dorsal sensory branch of
the ulnar nerve.
The ulnar and dorsal aspects of
the TFCC are more variable in theirpatterns of innervation. Branches of
the ulnar nerve and the dorsal sensory
branch of the ulnar nerve innervate theulnar aspect of the complex. Branchesof the posterior interosseous nerve andthe dorsal sensory branch of the ulnar
nerve innervate the dorsal aspect of
the TFCC. (Figure 7)
Cavalcante ML, Rodrigues CJ, R.
Mattar Jr (2004) went futher andstudied mechanoreceptors and nerve
endings. The free nerve endings,(Figure 8) responsible for sensing pain,
predominate in the ulnar and dorsal
areas. The Vater-Pacini corpuscles
predominate in the radial and dorsal
area, promoting perception of the

Biomechanics in short
The distal radioulnar joint (DRUJ)
has been deﬁned as a diarthrodial
trochoid articulation formed by thehead of the ulna and the shallow
sigmoid cavity of the lower end of
the radius. The curvatures of the two
articulating surfaces are not equal.
The radius of the ulna is about two
thirds the length of the sigmoid
notch concavity. This results in a
relatively unstable articulation with

C. Zaidenberg dissection
Figure 6. Vascular supply patterns

Figure 7. Low-power view of preserved
and sectioned TFCC showing sampled
regions including central/radial (c),palmar (p), ulnar (u), and dorsal (d).
(from Gupta´s paper).

Figure 8. Free nerve endings (arrows)
in the fibrocartilaginous tissue at the
peripheral area of the TFCC. (from R.
Matta Jr´s paper)

Vascular supply of the TFCC
There are two clearly deﬁned areas, 1)
the central is avascular nourished bysynovial ﬂuid, 2) the periphery of the
TFCC is supplied by branches of theulnar artery and also from the anterior
and posterior interosseous arteries.
This has important implicance in thehealing potential of future repairs.
(Figure 6)

IFSSH ezine AUGUST 2013

onset or cessation of movement
and mechanical stress change. The
Golgi-Mazzoni corpuscles were more
frequent in the ulnar and ventral areas,
linking these areas to function of slow
adaptation and sensation of extreme
movements. The propioceptivefunction receptors were found in
all areas of TFCC because Ruﬃni
corpuscles have homogeneous
distribution in it´s ﬁbrocartilaginous
tissue.

19

Pulse: Committee Reports

reduced area of contact between
the two bones. To overcome this,diﬀerent stabilizing structures exist:(a) the TFCC, composed of the discus
articularis, the palmar and dorsal
radioulnar ligaments, the ulnocarpal
ligaments, and the ECU sheath; (b) the
pronator quadratus muscle; and (c) theinterosseous membrane.
The concave radius-of-curvature of
the sigmoid notch is greater than thatof the ulna head (Figure 9).
Full congruity of two articulating
surfaces is therefore not possible. This
incongruity of articular surfaces createsa geometrically non-constrained
articulation at the DRUJ, subject totranslational dorsal and palmar instability.
In the extremes of forearm rotation,<10% of the ulnar head may be incontact with the sigmoid notch.
Thus for complete function inpronosupination, a longitudinal axis
that passes through the center of theradial head proximally and through the
foveal sulcus distally. (Figure 10)
The radioulnar ligaments arise froma broad area in the ulnar fovea andfrom a rather narrow area at the ulnar
styloid. Considering the larger area oforigin and the close relationship ofthe fovea to the rotation axis of theforearm, it is likely that the foveal origin
is the more important. (Nakamura
2001)

C.Zaidenberg
dissection
Figure 9. Different
radius-of-curvature
between distal
radius and ulna.

DRUJ Stability
With inherently unstable, nonconstrained articular surfaces,
anatomic stability of the DRUJ is
also achieved through extrinsic
extracapsular structures.
Extrinsic stability is provided
principally by dynamic tensioningof the ECU as its tendon crosses
the distal head of the ulna, thesemirigid sixth dorsal compartment
itself, constraining the ECU tendon,
dynamic support provided by thesuperﬁcial and particularly the deep
heads of the pronator quadratus
and the interosseous membrane.
These extrinsic DRUJ stabilizers areof relatively minor consequence torotational forearm stability, comparedwith the more biomechanicallyeﬀective intrinsic radioulnar
components of the TFCC.

Classification of TFCC ruptures
Palmer (1989) divides TFCC lesions
in two groups according to etiology(traumatic or degenerative) andlocation. He describes four main
traumatic ruptures. (Figure 11)
A diﬀerent rupture was also
described by Zancolli EA (2008), who
added a ﬁfth injury: superﬁcial dorsal
avulsion, referring mainly to the twomore radial insertions of the superﬁcial
fascicle of the dorsal radioulnar
ligament, (Figure 12) which heconsideres is the main cause of dorsal
ulnar instability.
Based on clinical, radiographic, andarthroscopic ﬁndings, Atzei et al (2011)
deﬁned a comprehensive classiﬁcationthat refers to the diﬀerent types of
peripheral (Palmer class IB) TFCC
lesions. With a guideline for speciﬁc
treatment modalities. He deﬁned six
diﬀerent classes. (Figure 13)

C. Zaidenberg dissection
Figure 10. Longitudinal
axis that passes throughthe center of the radialhead proximally andthrough the foveal
sulcus distally.

20

IFSSH ezine AUGUST 2013

Pulse: Committee Reports

Figure 11: Palmer Classification. I: Traumatic TFCC
injuries. 1A: central tear. 1B: peripheral avulsion fromulnar styloid. 1C: volar ulnocarpal ligaments tear. 1D:
radial attachment tears.

Figure 12: A and B, traumatic injuries of the TFCC: 1.superficial dorsal
avulsion ( arrows); 2.deep ulnar avulsion (foveal); 3. Central perforation;
4. Radial avulsion; 5. distal avulsion: frequently associated withlunotriquetral interosseous ligament tear (6). (from EA Zancolli´s paper)

Figure 13: Atzei Classification. He defined 6 different classes of peripheral TFCC tears.

REFERENCES

1. Adams BD, Berger RA. An anatomic
reconstruction of the distal radioulnar
ligaments for posttraumatic distal
radioulnar joint instability. J Hand Surg
2002;27A:243–251.
2. Af Ekenstam F, Hagert CG. Anatomical
studies on the geometry and stability ofthe distal radio ulnar joint. Scand J Plast
Reconstr Surg 1985;19:17–25.
IFSSH ezine AUGUST 2013

3. Af Ekenstam FW, Palmer AK, Glisson
RR. The load on the radius and ulna
in diﬀerent positions of the wrist andforearm: a cadaver study. Acta Orthop
Scand 1984;55:363–365.
4. Atzei A, Luchetti R. Foveal TFCC tearclassiﬁcation and treatment. Hand Clin2011 263-272
5. Bednar MS, Arnoczky SP, Weiland
AJ. The microvasculature of thetriangular ﬁbrocartilage complex:
its clinical signiﬁcance. J Hand
Surg1991;16A:1101–1105.
6. Bourgery JM, Bernard C, Jakob NH. Traite
complet d´Anatomie de l´homme. Vol.2.
Paris, 1852 m
7. Cavalcante ML, Rodrigues CJ, R. Mattar Jr.
Mechanoreceptors and nerve endings ofthe triangular ﬁbrocartilage in the humanwrist. J Hand Surg (Am) 2004 29: 432–435;

21

Pulse: Committee Reports

discussion 436–438.

New York: McGraw-Hill, 1996:667–709.

R, Cooney WP, Linscheid RL, Chao
EYS. The distal radioulnar ligaments:a biomechanical study. J Hand Surg
1991;16A:1106 –1114.

8. Fick RA.Handbuch der anatomie
und mechanik der gelenke unter
bercksichtigung der bewegenden
muskeln. Vol 1. Anatomie der gelenke.
Jena: Fischer, 1904.

18. Kleinman WB, Graham TJ. The distal
radioulnar joint capsule: clinical anatomy
and role in posttraumatic limitationof forearm rotation. J Hand Surg 1998;
23A:588–599.

9. Garcia Elias M. Anatomy of the wrist. The
Wrist, edited by HK Watson. Philadelphia
2001

19. Lewis OJ, Hamshere RJ, Bucknill TM.
The anatomy of the wrist joint. J Anat
1970;106:539-552.

28. Schuind F, An KN, Berglund L, Rey
R, Cooney WP, Linscheid RL, Chao
EYS. The distal radioulnar ligaments:a biomechanical study. J Hand Surg
1991;16A:1106 –1114.

10. Garcia Elias M. Soft tissue anatomy andrelationships about the distal ulna. Hand
Clinic1998;14:165-76

20. Lewis OJ, Hamshere RJ, Bucknill TM.
The anatomy of the wrist joint. J Anat
1969;106:539-52.

29. Stuard P, Berger R, Linscheid R, An K.
Dorso Palmar Stability of the Distal Radio
Ulnar Joint. J Hand Surg 2000, 25A : 689-6

11. Gupta R, Nelson SD, Baker J, Jones
NF, Meals RA. The Innervation of the
Triangular Fibrocartilage Complex. Plast
Reconstr Surg 2001; 107: 135-9.

21. Nakamura T, Yabe Y, Horiuchi Y. Functional
Anatomy of the Triangular Fibrocartilage
Complex. Journal of Hand Surgery 1996.
21B. 5: 581-586.

30. Spinner M, Kaplan EB. Extensor carpi
ulnaris: its relationship to stability of the
distal radioulnar joint. Clin Orthop Relat
Res 1970;68:124–128.

12. Hogikyan JV, Louis DS. Embryologic
development and variations in the
anatomy of the ulnocarpal ligamentous
complex. J Hand Surg1992;17A:719-23.

22. Ono H, Gilula LA, Marzke MW,
Obermann WR. Bicompartmentalizationof the radiocarpal joint. J Hand
Surg1996;21A:788-93.

13. Henle J. Handbuch der bänderlehre
des menschen. Braunschweig: Friedrich
Vieweg, 1856.

23. Palmer AK, Werner FW. The triangularﬁbrocartilage complex of the wrist:
anatomy and function. J Hand
Surg1981;6:153-62.

31. Thiru-Pathi RG, Ferlic DC, Clayton ML,
McClure DC. Arterial anatomy of thetriangular ﬁbrocartilage of the wrist
and its clinical signiﬁcance. J Hand Surg
1986;11A:258– 263.

14. Hagert CG. Distal radius fracture andthe distal radioulnar joint – anatomical
considerations. Handchir Mikrochir Plast
Chir 1994;26:22–26.
15. Ishi S, Palmer AK, Werner FW, Short WH,
Fortino MD. An anatomic study of theligamentous structure of the triangularﬁbrocartilage complex. J Hand Surg Am.
1998;23(6):977-85.
16. Kauer JMG. The articular disc of the hand.
Acta Anat 1975;93:590 – 605.
17. Kleinman WB, GrahamTJ. Distal ulnar
injury and dysfunction. In: Peimer CA, ed.
Surgery of the hand and upper extremity.

24. Palmer AK, Werner FW. Biomechanicsof the distal radioulnar joint. Clin Orthop
Relat Res 1984;187:26–35.
25. Palmer AK. Triangular ﬁbrocartilage
complex lesions: A classiﬁcation. J Hand
Surg(Am.) 14: 594, 1989.
26. Pogue DJ, Viegas SF, Patterson
RM, Peterson PD, Jenkins DK, Sweo
TD, Hokanson JA. Eﬀects of distal
radius fracture malunion on wrist joint
mechanics. J Hand Surg 1990; 15A:721–
727.
27. Schuind F, An KN, Berglund L, Rey

32. Viegas SF, Pogue DJ, Patterson RM,
Peterson PD. Eﬀects of radioulnar
instability on the radiocarpal joint:a biomechanical study. J Hand Surg
1990;15A:728–732.
33. Weitbrecht J. Syndesmologia sive Historia
Ligamentarum corporis Humani, quam
secundum observations Anatomicas
Concinnavit, et Figuris and Objecta
Recentia Adumbratis Illustravit. Academyof Sciences, Petropoli, 1742.
34. Zancolli EA. Etiopatogenia y tratamientode la inestabilidad dorsal del extremo
distal del cúbito consecutiva a la rotura
traumática del ﬁbrocartílago triangular.
Rev Asoc Argent OrtopTraumatol2008;
73(3):2-23.

Latest Papers on Hand Anatomy
I. LIGAMENTS
The insertion points of the thumb`s
MP joint collateral ligaments has been
described with some precision. The
ulnar collateral ligament (UCL) has ametacarpal origin 4.2 mm from thedorsal surface and 5.3 mm from thearticular surface. The center of thephalangeal insertion of the UCL was

22

2.8 mm from the volar surface and3.4 mm from the articular surface.
The volar aspect of the phalangeal
insertion extended up to 0.7 mm fromthe volar edge of the phalanx.
The radial collateral ligament(RCL) inserts at the metacarpal,
having its center at 3.5 mm from thedorsal surface and 3.3 mm from thearticular surface, the dorsal aspect
being 1.5 mm from the dorsal edgeof the metacarpal. The RCL`s center atphalangeal insertion was 2.8 mm fromthe volar surface and 2.6 mm fromthe articular surface, being its volar
aspect 0.5 mm from the volar edge ofthe phalanx. This data is relevant forsuccessful repair and reconstruction.
IFSSH ezine AUGUST 2013

Pulse: Committee Reports- J Hand Surg Am. 2012 Oct; 37(10):2021-6
Anatomy of the Thumb
Metacarpophalangeal Ulnar and Radial
Collateral Ligaments.
Carlson MG, Warner KK, Meyers KN,
Hearns KA, Kok PL.

II. NERVESThe TMC joint has been described as
innervated by the radial nerve (maininnervation), the lateral antebrachial
nerve innervation and the median
nerve. Even though denervation’s
based on these structures not always
lead to good results. A new study on
19 cadaveric specimens shows that58% had superﬁcial radial nerve, 47%
had median nerve innervation fromthe motor branch and 47% had ulnar
nerve innervation from the motor
branch. This paper supposed to speak
for the ﬁrst time that ulnar innervation
may also be present for the TMC joint. Iowa Orthop J. 2011; 31:225-30.
Ulnar nerve component toinnervation of thumb carpometacarpal
joint. Miki RA, Kam CC, Gennis ER,
Barkin JA, Riel RU, Robinson PG, Owens
PW.
Deep palmar communications
between the ulnar and median nerves
have continued to be studied. (50hands, 25 cadavers). In 16% of thehands communicating branches were
found - Clin Anat. 2011 Mar; 24 (2):
197-201.
Deep palmar communications
between the ulnar and median nerves.
Marios Loukas, Sharath S Bellary, R
Shane Tubbs, Mohammadali M Shoja,
Aaron A Cohen Gadol
Another paper also describes thata connecting third common palmar
digital branch of the median nerve
IFSSH ezine AUGUST 2013

with the fourth common palmar andproper palmar digital branches of themedian nerve presented a plexiform
nature. - Anat Sci Int. 2013 Jan 17.
A rare anatomical variation of
the Berrettini anastomosis and third
common palmar digital branch of themedian nerve. Sirasanagandla SR, PatilJ, Potu BK, Nayak BS, Shetty SD, Bhat
KM.
The median nerve branches for the
pronator teres have been studied in
one paper. All specimens (20 upper
limbs) showed to have a branch fromthe median nerve long enough toreach the radial nerve in the cubital
fossa in potential for neurotization
cases. - J Neurosurg. 2011 Jan; 114(1):253-5.
Median nerve branches to thepronator teres: cadaveric study
with potential use in neurotization
procedures to the radial nerve at the
elbow. Tubbs RS, Beckman JM, Loukas
M, Shoja MM, Cohen-Gadol AA.
The sublime bridge is thetendinous arch connecting the radialand humeral heads of the ﬂexorum
digitorum superﬁcialis muscle. Locatedat the mean distance of 8.1 mm fromthe medial epicondyle, it was foundto be tendinous in 75% and muscularin 25% of the specimens. As known, it
is a potential factor for median nerve
compression at the proximal forearm. J Neurosurg. 2010 Jul; 113(1): 110-2.
The sublime bridge: anatomy
and implications in median nerve
entrapment. Tubbs RS, Marshall T,
Loukas M, Shoja MM, Cohen-Gadol AA.

III. MUSCLESThe ﬂexor carpi radialis brevis muscle isa muscular variant that can be present
as much as 3.95 % in cadaveric studies.

On volar approaches for distal radius
fractures it may be found as a separate
tendon running between the FCR andthe radial vessels (inserting distally at
the FCR tunnel) and superﬁcial to thepronator quadratus. - Hand Surg. 2011;16(3): 245-9.
The ﬂexor carpi radialis brevis
muscle - an anomaly in forearm
musculature: a review article. Ho SY,
Yeo CJ, Sebastin SJ, Tan TC, Lim AY.
The Palmaris Profundus variant
when present (incidence 1/530 limbs)
may prohibit endoscopic carpal tunnel
release. It was found inserting onto theundersurface of the transverse carpal
ligament. - J Hand Surg Am. 2012 Apr;
37(4): 695-8.
Palmaris profundus tendon
prohibiting endoscopic carpal tunnel
release: case report. McClelland WB Jr,
Means KR Jr.

IV. TENDONS
A new study of the ﬂexor tendon
sheaths shows high incidence ofvariations (33% in 12 cadavers), whichhave communication between theradial and ulnar bursae. This might
explain variations to the classicalpresentation of spread of infection
through the digital ﬂexor sheaths. - J
Hand Surg Eur Vol. 2009 Dec; 34(6):762-5.
An anatomic study of ﬂexor tendon
sheaths: a cadaveric study. Fussey JM,
Chin KF, Gogi N, Gella S, Deshmukh SC.
The extensor pollicis brevis (EPB)
tendon has been determined to run
through a separate sheath in the ﬁrst
dorsal compartment in 28% (50 wrists,
25 cadavers) - J Hand Surg Eur Vol.
2012 Feb; 37(2): 155-60.
Accuracy of intrasheath injection
techniques for de Quervain’s disease:23

Pulse: Committee Reports

a cadaveric study. Mirzanli C, Ozturk
K, Esenyel CZ, Ayanoglu S, Imren Y,
Aliustaoglu S.
Accessory abductor pollicis longus
tendons have been studied once
more (78 cadaveric upper limbs) witha presence of 85%. This paper speaksof the potentiality of the tendons as
a graft source for TMC osteoarthritis.
- Clin Orthop Relat Res. 2010 May;
468(5): 1305-9.
Anatomic study of the abductor
pollicis longus: a source for graftingmaterial of the hand. Bravo E, Barco R,
Bullón A.
The sheaths and tendons of theﬁrst dorsal compartment were alsostudied in 124 cadavers.
A unique compartment was foundin 63.4%. In 32.1% two complete orpartial separate compartments wereobserved, while 4.5% specimens
showed no extensor pollicis brevis in
the ﬁrst dorsal compartment. - Anat
Sci Int. 2010 Sep; 85(3): 145-51.
Anatomical variations in the tendon
sheath of the ﬁrst compartment.
Motoura H, Shiozaki K, Kawasaki K.
The accessory tendon slip from theextensor carpi ulnaris (ECU) has also
been studied in 54 specimens with anincidence of 5.6 %. Originating fromthe ECU, they ended in the extensor
apparatus of the ﬁfth ﬁnger, running
ulnar side of extensor digiti minimi
tendon.
The mean width was 1.4 +/- 0.01
mm. This slip must be considered incases of ECU tenosynovitis and MRI
images of longitudinal split of ECU.
- Acta Orthop Traumatol Turc. 2012;46(2): 132-5.
Accessory tendon slip arisingfrom the extensor carpi ulnaris and24

its importance for wrist pain. Pınar Y,
Gövsa F, Bilge O, Celik S.

V. MYOTOMESIn brachial plexus dissections (38 arms,
19 cadavers), branches from the lateral
cord to the ulnar nerve or medial cordhave been identiﬁed in 13.1%. Flexor
carpi ulnaris (FCU) in electrodiagnostic
studies (in cases of C6, C7 and C8
radiculopathies) showed abnormal
ﬁndings in 46.2% of C7 radiculopathies,
76.5% in C8 radiculopathies and 0% in
C6 radiculopathies.
This study shows that the FCU canalso be aﬀected in C7 neuropathies(not only in C8 cases as classicallymentioned). - J Korean Med Sci. 2010
Mar; 25(3): 454-7.
Anatomical andelectrophysiological myotomes
corresponding to the ﬂexor carpi
ulnaris muscle. Pyun SB, Kang S, Kwon
HK.
VI. VASCULAR
The persistent median artery has
been addressed in three papers. In
one of them giving an incidence of
4%. It´s relations, superﬁcial to thethird common digital nerve and theextraligamentous recurrent thenar
motor branch of the median nerve
have been determined. - Clin Anat.
2011 Jan 12.
Persistent median artery: Cadaveric
study and review of the literature. EidN, Ito Y, Shibata MA, Otsuki Y.
The other addresses the palmar
type of the persistent median artery(PMA) with an incidence of 15.4%(42 cadavers, 84 limbs). In 11.9% of
the 15.4 % the PMA took part in theformation of the superﬁcial palmar

arch. - Hand (N Y). 2010 Mar; 5(1): 31-6.
Palmar type of median artery as
a source of superﬁcial palmar arch:a cadaveric study with its clinicalsigniﬁcance. Nayak SR, Krishnamurthy
A, Kumar SM, Prabhu LV, Potu BK,
D’Costa S, Ranade AV.
Another study on 60 upper limbs
demonstrated a 6.6 % persistent
median artery. - J Clin Diagn Res. 2012
Nov; 6(9): 1454-7.
Prevalence of the persistant medianartery. Singla RK, Kaur N, Dhiraj GS.
A study about the arteries of thethumb (30 hands) showed that the
princeps pollicis artery was present
in all specimens and was the originof the radial and ulnar digital arteries
in 73.3 %. The dorsal ulnar artery waspresent in all cases and also originatedin the princeps pollicis artery in 73.3%.
The dorsal radial artery was present
only in 66.7% of dissections as a direct
branch of the radial artery. Several
anastomoses were found between
the radial and ulnar digital arteries andbetween dorsal and palmar systems. Plast Reconstr Surg. 2012 Mar; 129(3):468e-476e.
Arteries of the thumb: descriptionof anatomical variations and reviewof the literature. Ramírez AR, Gonzalez
SM.

IFSSH ezine AUGUST 2013

NEW SUBSCRIBERS: Take 20% off
A quarterly peer-reviewed periodical covering all aspectsof wrist surgery and small bone surgery of the hand

Journal of Wrist Surgery
Editor-in-Chief: David Slutsky
2013/Volume 2/4 issues p.a./ISSN 2163-3916

USA and Canada
Individuals: $176.00 $141.00
Institutions: $462.00
Contact customerservice@thieme.com
For institutional subscriptions, contact esales@thieme.com
Mexico, Central and South America
Individuals: $192.00 $154.00
Institutions: $478.00
Contact customerservice@thieme.com
For institutional subscriptions, contact esales@thieme.com

ORDER TODAY

Africa, Asia, Australia and Europe
Individuals: €136.00 €109.00(Please add handling charges: €36.00)
Institutions: €348.00
Contact customerservice@thieme.de
For institutional subscriptions, contact eproducts@thieme.de
Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka
Contact customerservice@thieme.in for all subscription
rates in INR.

http://www.thieme.com/jws

Special introductory rates are only valid for new subscribers and are limited to the first year of subscription.
Only qualified professionals and students are eligible for individual subscriptions. Orders from individuals
must include the recipient's name and private address, and be paid by private funds.

Become a fan at www.facebook.com/thiemepublishers.

Follow us @ThiemeNY

hand therapy

Therapeutic Exercise
in Wrist Rehabilitation
Part 2
By Jennifer Blenkinsop
This article is the second of two
articles dealing with rehabilitationof the wrist after injury. The ﬁrst
section CLICK HERE TO READ PART
1 dealt with speciﬁc exercises using
isometric and isotonic exercises. In thissection, plyometric exercises, reactive
muscle activation, mirror therapy andapplication of speciﬁc exercises in daily
life are discussed.

Plyometric exercises
Plyometric exercises cause amuscle to rapidly stretch (eccentric
contraction) prior to contraction(concentric contraction). The prestretch eccentric contraction stores
elastic recoil potential energy (muchlike a spring) which allows muchgreater force generation in theconcentric contraction phase (1).
This is used in many daily tasks likethrowing an object, digging, hitting aball, ﬂipping a pancake, hammering,pushing something away (eg pushinga child on a swing) etc. The need forplyometric exercise as part of therehab process is largely dependent on
the functional needs of the patient, as

26

they are an advanced form of exercise
and require adequate strength and areasonable degree of both conscious
and unconscious neuromuscular
control/ proprioception.
Plyometric wrist exercises may
involve throwing and catching a ballagainst a mini-trampoline or to atherapist. The exercise may easily be
graded. Initially the ball may begin
as a medium to large, light ball andprogress to a small medicine ball. The
hand position for throwing may utilise
the DTM or may use a number ofdiﬀerent grips, which can be tailored tothe patients’ pathology and functional
requirements. Initially the task may bebilateral and symmetrical, which is lessdemanding in terms of motor control,and may be graded to unilateral
simple throwing and catching, to fullarm throwing and catching using theentire upper quadrant and full body
kinetic chain.

Reactive muscle activation
This focuses on reconstructing theunconscious activation of muscles
to restore joint balance (2). It aims to

restore the normal neuromuscular
reﬂex patterns in the muscles
around a joint, and the unconscious
activation of agonist and antagonist
muscles in response to changing/
unexpected requirements. This is
critical to both high level function
and injury prevention, and may bevery important in ligament injuries
as well as in hypermobility related
wrist problems. By the time theclient is engaged in plyometrics andreactive muscle activation exercise,the therapist must now consider
involvement of the upper quadrant,
rather than focusing on the wrist
IFSSH ezine MAY 2013

hand therapy

joint only in order to normalise thewrist’s role in global upper extremity
movement and function.
Some examples of therapeutic
exercises that may be used include:

Powerball: The NSD Powerball,when spinning, produces multidirectional centrifugal forces. The
patient is required to control the ball ina smooth, circular motion, against themultidirectional forces of the ball. The
higher the speed of the inner spinningball, the more control required by
the patient. This exercise has beenshown to signiﬁcantly increase muscle
endurance of the forearm (ie wrist)
musculature (3). It requires a highdegree of neuromuscular control.
Initially larger circular motions areencouraged with slower ball speeds(less resistance but requires controlled,smooth motion), and graded to more
controlled, smaller circles, but witha higher ball speed. Patients should
begin with short periods (eg 3 X
30 sec) and slowly build their time.
Overuse/ over exercising can produce
pain at the common extensor tendon,
and therefore careful monitoring ofsymptoms and speed of progress isrequired by the patient and therapist.
Many patients have diﬃculty with the
IFSSH ezine MAY 2013

motion initially, and may need to try
with the unaﬀected hand ﬁrst before
achieving the correct motion on theaﬀected side. One of the beneﬁts ofthe power ball is that only a small
amount of wrist ROM is needed tosuccessful master the technique.
Ball stability exercises: In thisexercise a medium to large ball isstabilised by the patient (the amountof weight-bearing and position of thewrist is determined by the pathology),
while the therapist tries to move theball in diﬀerent directions and degrees,at increasing speed. This is very similar
to the ball exercise described in thesection on Isometric exercise, exceptthat the speed and amplitude of the
disturbance in increased.
Wobble Board/ Balance Board:
In this exercise the patient holds the
opposite lateral sides of the balanceboard. The amount of wrist extension
is dependent on the pathology andthe goals of the exercise. The therapist
holds the board anteriorly andposteriorly. The therapist then tries to“The hand isrepresented on
both the motor
and the sensory
cortices. The brain
is continuously
remodelling itself
in response tochanges in sensory
input.”

move the board in diﬀerent directions,while the patient tries to stabilise
against the movement.
Another option is that the patient
is in four-foot kneeling, holding thebalance board on the ﬂoor in front
him. He then ‘walks’ the wobble board
forward a distance and then back.

The patient may also be in a fourfoot kneeling position, while weightbearing through the wrist which ison the centre of balance board. The
unaﬀected wrist is not involved. The
patient is required to maintain balanceon the unstable surface of the balanceboard. A ball may also be used insteadof the balance board, allowing greater
ﬂexibility in terms of wrist position.

27

hand therapy

Rubber Bar Exercise or similar:
This involves holding the bar at thebase and ‘shaking’ it in either anantero-posterior direction or in acircular motion. The Theraband bar
is reasonably short and therefore thestabilisation requirement is reasonably
low. There are exercise apparatus withlonger and more ﬂexible lever arms
that make controlling the motion
more challenging.

Mirror Therapy“Surgical procedures of the hand arealways accompanied by synaptic
reorganisational changes in the brain
cortex and the outcome of many
hand surgical procedures is to a large
extent dependent on brain plasticity”(4). The hand is represented on boththe motor and the sensory cortices.
The brain is continuously remodellingitself in response to changes in sensory
input. Reorganisational changes
may be activity dependent based onalterations in hand activity and tactile
experience (4). Over-use, lack of use

About the author(ie diminished sensory and motor
input) and minor injuries will also
alter representation (5). Activationof ‘mirror neurons’ in the premotor
cortex can occur by simply observing a
movement (6), not only by movementof the injured part itself. Imagining
a movement or viewing a picture ofhand activity can stimulate neurons
in the somatosensory cortex which
may serve to limit the reorganisationalchanges, and thus it is thought toimprove proprioception and motor
control, as well as modulate pain
responses particularly the locationof pain stimulus has become more
centralised.
Mirror therapy may therefore behelpful in improving co-ordination(7), motor control, proprioception
awareness, kinaesthesia and reducing
pain. It is also used as part of a sensory
re-education programme where
needed.
Altschuler (8) wrote an interestingarticle on their use of mirror therapy
to assist a patient regain active wrist
motion following distal radius fracture,
where the patient had greater passive
than active ROM. In this instanceElectrical Stimulation was applied to
the wrist extensors of the aﬀected
hand, which was obscured fromvision, and when the stimulus was felt
the patient was required to extend

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

28

the unaﬀected wrist, while viewing
this in the mirror. This was gradedto active-assisted movement of theaﬀected wrist at the same time aselectrical stimulation, to concurrent
active movement without theelectrical stimulation. The result wasa signiﬁcant increase in active ROM
than pre-treatment. Thus use of mirror
therapy can be integrated during
the application of other therapeuticmodalities.

Other applications include
observing the unaﬀected hand in
the mirror in various hand positions
and trying to reproduce this with theaﬀected hand (joint position sense),and performing diﬀerent movements
which may include functional tasks,use of tools etc. Another option is
performing a functional task with the
unaﬀected hand while observing it in
the mirror, while trying to reproduce
the same functional task with the
unaﬀected, obscured hand. Tactile
stimulation may also be performed aspart of a sensory re-education whereappropriate.
According to Butler, ‘smudging’ ofrepresentations in the sensory andmotor cortices and elsewhere are
best avoided by return to normal
activities. The brain is the ultimate ‘use
it or lose it’ machine. It seems clearthat functionally meaningful and goal
IFSSH ezine AUGUST 2013

hand therapy

directed inputs will be better acceptedby the brain processing…clearly themore functional the movement andthe more it links to desired activity andachievable goals, the better” (5).
Speciﬁc, targeted exercises
are practical (including all thosementioned above), often measureable
and cost eﬀective in our current
time, cost, and outcomes driven
healthcare systems and lives. However,
perhaps we need to consider how toincorporate more creative activities
into our programme so that ourtherapy includes the whole person ina more bio-psycho-social approach.
For example throwing actual darts forthe dart throwing motion, or using
computer games such as Nintendo
Wii and X-box sporting games so that
motion can be done without needing
all the structure of a sporting activity,
and without resistance and impact.
Speciﬁc therapy-related computer
programmes are commerciallyavailable, but not always easily
accessible or aﬀordable in somecountries. An excellent option, if
available is equipment such as the
BTE or LIDO work simulators, which
may simulate a number of work tasks
and tools, while at the same time thetherapist can adjust the resistance andtime of the task.

IFSSH ezine AUGUST 2013

Wrist extension may be achieved
through woodwork and baking
tasks. Reactive muscle activation
for wrist motion within a short arcof motion can be achieved ﬂying
stunt kites, or the dart throwers
motion may be progressed by ﬂyﬁshing. Wedging of clay for pottery
is an excellent plyometric task, andworking the clay on a wheel enhances
bilateral co-ordination, mobility andproprioception, with tactile, visualand proprioceptive input. The listof activities is endless and of course
culture speciﬁc. All this activities
are not only important for motion,
strengthening, proprioception andfunction, but also enhance a person’s
sense of accomplishment, self-esteem
and conﬁdence, while at the sametime reducing fear of using their hand.
In this way more normal movement
patterns will develop within the
conﬁnes of the pathology/injury,
and conscious and unconscious
proprioception will improve. Betterneuromuscular control will most likely
result in more smooth, controlled
and co-ordinated use of the upper
quadrant, and cortical representation
should be normalised more rapidly.
Added to these are the emotional andpsychological beneﬁts of participation
in meaningful activities at work, homeand leisure. Not all of these aspects
can be accurately measured, but
without doubt the therapy will bothmaximise recovery in outcomes andtime (meeting the needs of funders)
while also being very client-centered(meeting the needs and goals ofpatients and therapists).

Useful reading and references:
1. Mc Neely & Sandler. Power
Plyometrics: The Complete
Programme. Meyer and Meyer
Sport. UK. 2007
2. Hagert, E. Proprioception of theWrist Joint: A Review of Current
Concepts and Possible Implications
on the Rehabilitation of the Wrist.
Journal of Hand Therapy . January
2010, 23 (1): 2-17.
3. Balan SA, Garcia-Elias M. Utility of
the Powerball in the invigorationof the musculature of the forearm.
Hand Surgery. 2008; 13(2):79-83.
4. Lundborg,G. Brain Plasticity and
Hand Surgery: An overview.
Journal of Hand Surgery Br. 2000
June . Vol 25(B): 3: 242-252
5. Butler, DS. The Sensitive Nervous
System. Chapter 2. Noigroup
Publications. Adelaide, Australia.
2000.
6. Lundborg, G and Rosen, B. Hand
Function after Nerve Repair. Acta
Physiol 2007: 189, 207-217
7. Rosen,B & Lundborg,G. Training
with a Mirror in rehabilitationof the Hand. Case Report.
Scandinavian Journal of Plastic andReconstructive Surgery and Hand
Surgery. 2005: 39: 104-108
8. Altschuler EL, Hu J. Mirror therapy
in a patient with a fractured wristand no active wrist extension.
Scand Journal of Plastic andReconstructive Hand Surgery. 2008;
42(2):110-29

research roundup

Innovations in treating skindefects of the hand
USA

Dr Andrew Watt from the
Department of Orthopaedic Surgery& Sports Medicine at the University ofWashington, wrote an overview paperthat investigated advances in treating
skin defects of the hand, particularlyskin substitutes and negative-pressure
wound therapy.
“I became interested in the useof dermal substitutes and negative
pressure wound therapy out ofsheer necessity,” Dr Watt explained
about his interest in the subject. “I
am a reconstructive microsurgeon
and generally believe that native
tissue reconstructions oﬀer superior
functional and aesthetic outcomes inthe setting of complex hand injuries.
With that bias in mind, however,there is a sub-set of patients who,by virtue of their injury, are notviable candidates for local tissue or
free tissue reconstructions. Thesepatients have generally sustained
severe crush or blast injuries to thehand, have incomplete arterial archesor have tenuous vascular supply
or underlying vascular disease,” hecontinued, adding that for thesepatients, dermal substitutes oﬀer the
potential for reconstruction without
relying on microvascular techniques
or local tissue reconstruction. These
techniques come with a cost, however.
These alternative reconstructions often

30“Negative pressure
wound therapy isa useful adjunct inthe managementof hand injuries
as both a bridge
to definitive
reconstruction
and as a highly
effective bolster
dressing whichallows forcontact withthe anatomicalirregularities
inherent in thehand”
require longer healing times and as aconsequence, often result in longer
periods of immobility for the hand.
Watt believes the most importantﬁndings of this paper are that dermal
substitutes provide a reliable anddurable reconstructive option whenlocal tissue and free tissue transfer
techniques are not feasible. In addition,

feasibility may be related to patient
factors including the mechanismof injury and vascular status of
the hand as well a health system
factors including the availability of
microsurgical techniques.
“Negative pressure wound therapy
is a useful adjunct in the managementof hand injuries as both a bridge
to deﬁnitive reconstruction and asa highly eﬀective bolster dressing
which allows for contact with theanatomical irregularities inherent in
the hand. Negative pressure therapy
as a deﬁnitive management should
be avoided given wound contracture
and prolonged immobility limiting
functional recovery,” he continued.
For Watt, it is important that readersof the paper understand that while
plausible and reliable reconstructive
methods, the use of negative pressure
wound therapy and dermal substitutes
should not be regarded as a ‘ﬁrst line’
reconstruction. “These techniques areuseful adjuncts and act as deﬁnitive
reconstructions only when local andfree tissue transfer techniques are notfeasible. Immobility is often prolonged
while awaiting dermal substituteincorporation and granulation via
negative pressure wound therapy
resulting in increased stiﬀness,” heexplained. He continued that whenembarking on this reconstructive path,
IFSSH ezine AUGUST 2013

research roundup

Modern tendon
repair techniquesUSAthe surgeon and therapist should pay
particular attention to splinting andshould consider motion at all available
joints that do not absolutely require
immobilisation during the healing
process.
In terms of the future, Watt said
he will continue to employ dermal
substitutes and negative pressure
wound therapy in his clinical practice.
“I have found negative pressure
therapy as an almost indispensable
adjunct to placement of dermal
substitutes and as a bolster for skingrafts. Future endeavours are focusedon minimising immobilisation while
maintaining successful dermal
substitute incorporation. I am also
looking to compare functional
outcomes in patients with comparable
injuries treated with microsurgicalreconstructions (free fascial andfasciocutaneous ﬂaps) and with thosetreated with dermal substitutes,” heconcluded.

JOURNAL REFERENCE
Hand Clinics, Volume 28, Issue 4 ,Pages 519-528, November 2012

IFSSH ezine AUGUST 2013

Dr Steve K. Lee, from the Hospitalfor Special Surgery at Weill Cornell
Medical College in New York recently
published a paper on the topic ofmodern tendon repair techniques in
Hand Clinics. Digital tendon repair
is one of the most common issues
in hand surgery and also one of themost vexing. A repair must withstandthe forces imparted on it during
early motion. The article evaluatesmodern tendon repair techniques andearly clinical experience using suchmethods have shown clinical successof improved motion and no known
ruptures.
“My interest was sparked when
I was faced clinically with treating
patients with these problems. I did
not feel that there was an adequate
solution for hand tendon repairs.
Either the repairs were too weak or
too bulky. Early range of motion witha repair that glided well in the pulleysystem was a diﬃcult goal to achieve. I
therefore embarked on several studies
to investigate this problem,” Dr Lee
explained.
For Lee, surgeons reading thearticle should understand that tendon
repairs are technically demanding
procedures where every single detailmatters. Exactly what suture material
is used, where the suture is started,
how far of a suture span, the suture“tendon repairs
are technicallydemanding
procedures where
every single detailmatters”
conﬁguration, how many knots areused, etc. all play an important role inits biomechanical performance. “Themodern repairs are extremely strong
and have very limited gapping during
active motion. For zone II repairs, they
can also have a very low amount offriction imparted to the pulley system.
These all lead to potentially improved
surgical results,” he added, concludingthat his future research will be in thelong term clinical evaluation of thesepatients who had such repairs.

JOURNAL REFERENCE
Hand Clinics, Volume 28, Issue 4 ,Pages 565-570, November 201231

research roundup

Free vascularised medial femoral
condyle autograft for challenging
upper extremity nonunions
USA
Dr Alexander Shin, from the Divisionof Hand Surgery, Department ofOrthopedic Surgery, Mayo Clinic,
recently authored a paper on the topic
of free vascularised medial femoral
condyle autograft for challenging
upper extremity nonunions, publishedin Hand Clinics.
“The inspiration for the use of themedial femoral condyle for scaphoidnonunions comes from our evaluationof the results of the 1,2 ICSRA
vascularised bone graft for scaphoidnonunions,” Dr Shin explained, addingthat when his group initially describedthe dorsal distal radius vascularisedbone grafts in 1995 and published theinitial series in 2002, they had a 100%
union rate of scaphoid nonunions.
However, favourable outcomes were
not universal and other authors were
publishing signiﬁcantly poorer results.
“In 2006, we critically evaluatedthe outcomes of the 1,2 ICSRA
vascularised bone graft in 47 patientswith 48 nonunions and found that
we had a 71% union rate. Criticalevaluation of this cohort, revealed thatpatient and fracture selection wereimperative for optimising outcomes,”
he continued. “In particular, patientswith carpal collapse (with humpback
deformity) and proximal pole AVN,
had a signiﬁcantly high failure rate. To
address this speciﬁc type of scaphoid32“there are
solutions forsome very difficultand challenging
upper extremity
nonunions”
nonunion, we recognised that weneeded a large graft to restore thenormal geometry of the scaphoid andalso need a graft that was vascular.
We had a good experience withthe corticoperiosteal ﬂap from themedial femoral condyle and took theexperience with this and considered its
use as a structural vascularized bone
graft,” he said.
According to Shin, a cadaver study
performed in our lab demonstrated
that there were excellent vascularperforators to the distal inferior
quadrant of the medial femoral condylewith consistent anatomy. “Dr Allen
Bishop and I performed the index
procedure in 2005, and we have hadoutstanding success with the graft in
the patients with AVN, scaphoid waist
nonunions with carpal collapse,” he said.
For him, the most important
outcome of this study is that they
are able to achieve union in thesevery diﬃcult scaphoid nonunions.
Additionally, the results have been
replicated across the hand surgery
community. “Our original series
reported in 2008 had 100% union rates.
Anectdotally, since the original report,
we have performed close to 55 surgeries
and have only 3 failures to date,” he said.
“The most important take away
message is that there are solutions forsome very diﬃcult and challenging
upper extremity nonunions. There isno simple panacea for some of thesenonunions. The surgery is exacting
and can be diﬃcult. It is importantfor hand surgeons to know that there
is a role of microvascular surgicalprocedures to address these nonunions.
Critical evaluation and a discussion ofoutcomes, risks and beneﬁts to thepatient are necessary as well as having
the technical ability for the surgeon to
perform these surgeries. Currently weare critically evaluating the outcomesof our procedures with longer follow
up and look forward to report theseat the next international meeting,” heconcluded.

JOURNAL REFERENCE
Hand Clinics, Volume 28, Issue 4,
Pages 493-501, November 2012

IFSSH ezine AUGUST 2013

remembering our pioneers

Pioneers in Hand Surgery
Robert E Carroll, MD
Dr Carroll was well known for his
educational eﬀorts in the teaching of handsurgery, not only in the United States, but
throughout the world. He established oneof the early formal training programs forhand surgery in the United States. During
his career he has visited and taught inmany countries throughout the world.
Physicians from these countries, as well as
many others, have experienced a formal
training program with him in New York City
as Visiting Fellows. Some 150 doctors frommany countries that have an active Hand
Society, have worked in his department.
Graduating in medicine from Yale
University, New Haven, Connecticut, hereceived training in general surgery andorthopaedic surgery at the Massachusetts
General Hospital in Boston where he cameunder the tutelage of Dr Henry C Marble.
For a brief period of time he taught atthe Harvard Medical School, Cambridge,
Massachusetts. Following service in theSecond World War in the Paciﬁc theatre, hemoved to New York City. A year was spentin studying with Dr Sterling Bunnell in San
Francisco, California, and with Drs Sumner
L. Koch, Michael L. Mason and Harvey S.
Allen in Chicago, Illinois. Returning to the
New York Orthopaedic Hospital, a divisionof the Columbia-Presbyterian Medical
Center, he established the Division ofHand Surgery where he remained as Chief
until 1986. During this tenure Dr Carroll
had helped develop the use of silicone
IFSSH ezine AUGUST 2013

tendons for hand surgery reconstruction.
The Hand Service has been known for
its large experience in congenital handdeformities, as well as tumours and muscle
transplantation.
Dr Carroll has been honoured bymembership in the Hand Societies of 16
countries throughout the world. He wasconsultant to the United States Navy,
United States Air Force, the Veterans
Administration and the United States
Public Health Service during his years ofactive practice. He has been Presidentof the Association of Bone and Joint
Surgeons. He was one of the founders andsubsequently a President of the New York
Society for Surgery of the Hand, as well as aVice President of the American Society for
Surgery of the Hand.

33

remembering our pioneers

Professor Nils Carstam, MD
Dr Carstam, a native from Vaxjö, Sweden, graduated fromthe University of Lund Medical School. He trained ingeneral surgery at the University of Lund, Sweden from1942 to 1949. He was ﬁrst introduced to hand surgery
by Erik Moberg in 1949. He came to the United States in1950 to study hand surgery under Sterling Bunnell in San
Francisco, California, and Sumner Koch, Michael Mason
and Harvey Allen in Chicago, Illinois. He continued his
hand surgery studies with his many colleagues from theAmerican Society for Surgery of the Hand and the British
Hand Club. He worked with Graham Stack on a Hand
Surgery Bibliography prior to the institution of Medline.
In 1951, he was a Founding Member and Secretaryof the Scandinavian Club for Hand Surgery which was
initiated by Erik Moberg. Dr Carstam later succeeded him
as President. He became Head of the Section of Hand
Surgery of the Department of General Surgery at the
University Hospital, Malmö, Sweden in 1951. His graduation
thesis, “The Eﬀect of Cortisone on the Formation of
Tendon Adhesions and Tendon Healing – an Experimental
Investigation in the Rabbit,” was presented in 1953.
Dr Carstam became Associate Professor in Hand Surgery
at the University of Lund in 1954. In 1962, he became theHead of the ﬁrst separate Department of Hand Surgery
organised in Scandinavia at the University of Malmö.
Dr Carstam has been very involved in the organisationof hand surgery in Sweden, where it became a recognised
specialty in 1969. He was the Scandinavian delegate to theconstitutional meeting of the International Federation ofSocieties for Surgery of the Hand held in Chicago in 1966and served on several of its committees.
Dr Carstam was appointed Honorary Professor by the
Swedish Government (1980), Honorary Member of theAmerican Society for Surgery of the Hand (1971) and of the
British Society for Surgery of the Hand (1982).

34

After retirement from his hospital position, Dr Carstam
continued to be actively involved in private practice of handsurgery at the Malmö General Hospital in Sweden.

IFSSH ezine AUGUST 2013

ifsshezine

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

For the membersby the members…

The IFSSH ezine is created with the intention of engaging the global hand surgery
community and to promote the profession through the sharing of knowledge.
In order for the IFSSH ezine to remain relevant and topical,
we rely on you, our readers, to:■ Subscribe to receive the ezine
FREE OF CHARGE 4 times per year
■ Submit letters to the editor■ Provide us with feedback about the ezine

RE
CLICK HEETE A

TO COMPL VEY
R
5 MINUTE SU E
ABOUT THIFSSH EZINE

journal highlights

Journal Highlights
Below is a selection of contents pages from the latest issues of the following leading hand surgery journals.
Hover your mouse over each article heading and click to go to the original abstract page of the article.

Journal of Wrist Surgery Volume 03 · May 2013
■ The EWAS Classiﬁcation of Scapholunate
Tears: An Anatomical Arthroscopic Study

Ligamentous Repair in the Treatment ofChronic Scapho-Lunate Ligament Tears■ Dorsal Capsuloplasty for Dorsal
Instability of the Distal Ulna

■ Scapholunate Ligament Reconstruction■ Anatomical Description of the Dorsal
Capsulo-Scapholunate Septum (DCSS)—
Arthroscopic Staging of Scapholunate
Instability after DCSS Sectioning■ A Minimal Wrist Arthroplasty for Early
Wrist Osteoarthritis■ Radiographic Evaluation of Chronic
Static Scapholunate Dissociation Post Soft
Tissue Reconstruction■ Anatomy and Clinical Relevance of the
Ulnocarpal Ligament■ Current Role of Open Reconstruction of
the Scapholunate Ligament■ Arthroscopic Volar Capsuloligamentous
Repair■ Arthroscopic Management of
Scapholunate Instability■ Scapholunate Instability: Proprioception
and Neuromuscular Control■ Arthroscopic Dorsal Capsulo-■ Dorsal Wrist Capsular Tears in
Association with Scapholunate Instability:
Results of an Arthroscopic Dorsal
Capsuloplasty■ Causes of a Block to Forearm Rotation
after Distal Radius Fractures■ Management Distal Radius and Distal
Ulnar Fractures with Fragment Speciﬁc
Plate

Hand Volume 8 – Issue 2, June 2013
■ Identiﬁcation of three movement
phases of the hand during lateral and pulp
pinches using video motion capture■ Resolution and recurrence rates
of idiopathic trigger ﬁnger after
corticosteroid injection■ Validity of the Patient Speciﬁc Functional
Scale in patients following upper extremity
nerve injury■ A radiological sign in chronic
collateral ligament injuries of the thumbmetacarpophalangeal joint■ A systematic review of outcomes ofrevision amputation treatment for ﬁngertip
amputations■ Suture button suspension following
trapeziectomy in a cadaver model■ Scapholunate ligament injuries: a review
of current concepts■ Carpal coalition■ Resident selection of Hand Surgery
Fellowships: a survey of the 2011, 2012,
and 2013 Hand Fellowship graduates■ Tennessee emergency hand care
distributions and disparities■ The range of movement of the thumb36■ Anatomical evaluation of a corticalbutton for distal biceps tendon repairs■ Fluoroscopy-assisted stress testing of
the thumb metacarpophalangeal joint toassess the ulnar collateral ligament■ The comparison of paper- and webbased questionnaires in patients withhand and upper extremity illness■ Prevalence of the palmaris longus
muscle and its relationship with grip

and pinch strength: a study in a Turkish
pediatric population■ Partially ossiﬁed iliac crest graft for thereconstruction of the pediatric thumbproximal phalanx■ Acute closed dislocation of the second
through fourth carpometacarpal joints:
satisfactory treatment with closed
reduction and immobilization■ Extension disturbance of the little ﬁnger
in amateur piano players: two case reports■ Irreducible dorsal epiphyseal fracture
dislocation of the distal phalanx: a casereport■ Bilateral spontaneous ﬂexor digitorum
profundus tendon rupture of the ﬁfth digit:
case report and literature review

IFSSH ezine AUGUST 2013

journal highlights

Hand Clinics Latest issue is: Volume 29 • Issue 2 May 2013
■ Gliding Resistance and Modiﬁcationsof Gliding Surface of Tendon: Clinical
Perspectives■ Tendon Healing, Edema, and Resistanceto Flexor Tendon Gliding: ClinicalImplications■ Current Practice of Primary Flexor
Tendon Repair: A Global View
■ Primary Flexor Tendon Surgery: The
Search for a Perfect Result■ Wide-awake Flexor Tendon Repair and
Early Tendon Mobilization in Zones 1 and 2■ Uncommon Methods of Flexor Tendon
and Tendon-Bone Repairs and Grafting■ Two-stage Reconstruction with theModiﬁed Paneva-Holevich Technique■ Diagnosis and Treatment of Finger
Deformities Following Injuries to the
Extensor Tendon Mechanism■ Flexor Pulley Reconstruction■ Complex Flexor and Extensor Tendon
Injuries■ Tendon Reconstruction with AdjacentFinger Hand Tendon■ Current Flexor and Extensor Tendon
Motion Regimens: A Summary■ Outcomes and Evaluation of Flexor
Tendon Repair■ Intrinsic Tendon Healing and Staged
Tendon Reconstruction: Reﬂection ofLegends■ Current Methods and Biomechanics ofExtensor Tendon Repairs

Journal of Hand Surgery (European Volume)
July 2013 J Hand Surg Eur Vol 38, Issue 6■ Complex regional pain syndrome:observations on diagnosis, treatment anddeﬁnition of a new subgroup■ Commentary on complex regional pain
syndrome: observations on diagnosis,
treatment and deﬁnition of a new
subgroup by Zyluk and Puchalski■ A comparison of the accuracy of two
sets of diagnostic criteria in the early
detection of complex regional pain
syndrome following surgical treatment of
distal radial fractures■ Complex Regional Pain Syndrome: areview■ Carpal tunnel syndrome diagnosed
using ultrasound as a ﬁrst-line exam by thesurgeon■ Commentary on Lange. Carpal tunnel
syndrome diagnosed using ultrasound as aﬁrst-line exam by the surgeon

long-term follow-up of treatment withcorticosteroid injections in patientswith carpal tunnel syndrome. When are
multiple injections indicated?
■ Value of anatomic landmarks in carpal
tunnel surgery■ Carpal tunnel release: a randomized
comparison of three surgical methods■ Neurostenalgia as a cause of pain after
tendon and nerve repair at the wrist■ Abnormal muscle of the distal anterior
forearm presenting with compression on
the median nerve■ The eﬀects of 5-ﬂuorouracil on ﬂexor
tendon healing by using a biodegradable
gelatin, slow releasing system:
experimental study in a hen model■ Assessment of volar angulation andshortening in 5th metacarpal neckfractures: an inter- and intra-observer
validity and reliability study■ The eﬀect of metacarpal shortening on
digital ﬂexion force■ Cost analysis and related factors inpatients with traumatic hand injury■ The long-term follow-up of treatment
with corticosteroid injections in patientswith carpal tunnel syndrome. When are
multiple injections indicated?

■ Proximal interphalangeal joint
replacement with an unconstrained
pyrocarbon prosthesis (Ascension®): along-term follow-up■ Commentary on Berger et al. The■ Iatrogenic injury to the ulnar nerve

IFSSH ezine AUGUST 2013

during primary repair of medial ulnar
collateral ligament in complex elbow
fracture dislocations

37

journal highlights

Journal of Hand Therapy
Volume 26, Issue 3, July - September 2013
■ Eﬀectiveness of cast immobilization incomparison to the gold-standard selfremoval orthotic intervention for closed
mallet ﬁngers: A randomized clinical trial■ Clinical commentary in response to“Eﬀectiveness of cast immobilization incomparison to the gold-standard selfremoval orthotic intervention for closed
mallet ﬁngers: A randomized clinical trial”■ A descriptive study on wrist and handsensori-motor impairment and function
following distal radius fracture intervention■ Measurement properties of the PatientRated Wrist and Hand Evaluation: Raschanalysis of responses from a traumatic hand

injury population■ A retrospective cohort investigation ofactive range of motion within one weekof open reduction and internal ﬁxation of
distal radius fractures■ Hand impairment and activity limitations
in four chronic diseases■ Preference of lid design characteristics byolder adults with limited hand function■ Involuntary contralateral upper extremity
muscle activation pattern during unilateralpinch grip following stroke■ Evaluation of the Korean version of thepatient-rated wrist evaluation■ Design and construction of custommade neoprene thumb carpo-metacarpal
orthosis with thermoplastic stabilization forﬁrst carpo-metacarpal joint osteoarthritis■ Patterns of research utilization among
Certiﬁed Hand Therapists■ A systems change: Leading the way tomeeting health needs■ A hand therapy protocol for thetreatment of lunate overload or early
Kienbock’s disease■ A simple distal radioulnar joint orthosis

Journal of Hand Surgery: American volume
Volume 38, Issue 7, Pages A1-A28, 1285-1468 (July 2013)■ The Eﬀect of Night Extension Orthoses
Following Surgical Release of Dupuytren
Contracture: A Single-Center, Randomized,
Controlled Trial■ The Thompson Procedure for Chronic
Mallet Finger Deformity■ Distal Interphalangeal Joint Arthrodesis
With the Reverse Fix Nail
■ Fingertip Reconstruction With
Simultaneous Flaps and Nail Bed Grafts
Following Amputation■ Annular Ligament Reconstruction Using
the Distal Tendon of the Superﬁcial Headof the Brachialis Muscle: An Anatomical
Feasibility Study

Ligament Reconstruction■ Histopathological Characteristics ofStenosing Flexor Tenosynovitis in Diabetic
Patients and Possible Associations With
Diabetes-Related Variables■ Eﬀect of Capitate Morphology on
Contact Biomechanics After Proximal Row
Carpectomy■ Validation of Phone Administration of
Short-Form Disability and Psychology
Questionnaires■ In Vivo 3-Dimensional Analysis of Dorsal
Intercalated Segment Instability Deformity
Secondary to Scapholunate Dissociation: A
Preliminary Report■ 3-Dimensional Deformity Analysis of
Malunited Forearm Diaphyseal Fractures■ Traumatic Proximal Interphalangeal Joint
Reconstruction With an Autologous HemiToe Osteochondral Graft: Case Report■ Single-Stage Surgery Combining Nerve
and Tendon Transfers for Bilateral Upper
Limb Reconstruction in a Tetraplegic
Patient: Case Report■ Comparison of In Vitro Motion andStability Between Techniques for Index
Metacarpophalangeal Joint Radial Collateral■ Identifying the Location and Volume of
Bony Impingement in Elbow Osteoarthritis
by 3-Dimensional Computational Modeling38■ Semiconstrained Total Elbow Arthroplasty
for Posttraumatic Arthritis or Deformities of
the Elbow: A Prospective Study

IFSSH ezine AUGUST 2013

upcoming events

Upcoming events
68th Annual Meetingof the American
Society for Surgery of
the Hand
October 3-5, 2013
Moscone West Convention Center,
San Francisco, CA, USA
www.ASSHAnnualMeeting.org
Annual Meeting program chairs Michael
Hausman, MD and Fraser Leversedge,
MD look forward to a robust program at
the 68th Annual Meeting of the ASSH.
REgISTRaTIon FoR ThE
68Th annual mEETIng IS now oPEn!
Discover the latest strategies, techniques andpractice management tips; exchange ideas
with your contemporaries from across theglobe; and explore all corners of the field fromindustry exhibits to outreach opportunities injust a few days' time.
This year, ASSH introduces the International
Bring a Young Surgeon Program. This
program will allow surgeons who practice
medicine outside of the United States tosponsor a young (age 35 or younger) surgeon
for a FREE 2013 ASSH Annual Meeting
registration. Visit us online to learn the details
about this exciting opportunity!

EvEn moRE good nEwS: You will get
50% more scientific content with 100% lessmaterials to carry around. How? All of thecontent for this year’s paperless meeting will beaccessible through our free mobile app and our
website, so log in and explore.
ThIS YEaR wE havE:• Invigorating general sessions.
• 52 instructional courses.
• 12 pre- and post-courses, including two
hands-on skills courses.
• A bustling exhibit hall and various industry
forums highlighting the latest products.
• Inspiring and thought-provoking keynote speakers.

68Th annual mEETIng oF ThE aSSh

EducaTIon
TEchnologY
throughocToBER 3-5, 2013

San FRancISco

ShaRE YouR knowlEdgE – lEaRn nEw SkIllS – BE PaRT oF ouR gloBal communITY

JoIn YouR collEaguES aT ThE 2013 aSSh annual mEETIng
www.aSShannualmEETIng.oRg

IFSSH ezine AUGUST 2013

3rd Annual RAMSES Multispecialty Robotic
Microsurgery Symposium
8-9 November 2013 | Strasbourg, France | www.roboticmicrosurgeons.org
The only multi-specialty microsurgical gathering of its kind—with microsurgeons
from varying ﬁelds, including: hand, plastics, reconstructive, ENT, urology,
gynecology, ophthalmology, vascular, orthopaedics, pediatrics and peripheral nerve.

4th Annual Congress of the Orthopaedic
Department at Sohag University incollaboration with the Egyptian Society for
Surgery of the Hand and Microsurgery & Pan
Arab Hand & Microsurgeons
Hurghada, Egypt | 20-22 November 2013www.handsurgery-sohag.org/
On behalf of Hand & Reconstructive Microsurgical Unit of Orthopaedic
Department, Sohag University, Egypt, we have the pleasure to invite to participate
and share your experiences in the 4th annual congress of the department incollaboration with the Egyptian Society for Surgery of the Hand and Microsurgery(E.S.S.H.M.) & Pan Arab Hand & Microsurgeons which will be held in Serenity
Makadi Heights Hotel, Makadi Bay, Hurghada, Egypt from November 20-22, 2013.
The congress invited TOP ﬁgures of Hand & Reconstructive Microsurgical ﬁeld
in the world whom their presence will enhance the scientiﬁc program with latest& advanced techniques and procedures.
Hurghada is a coastal city located in the eastern coast of Egypt on the Red Sea
and has a great and magniﬁcent weather and nature. You will see the pure waterand the magniﬁcent creature in the sea from types of ﬁshes to the coral reefs.
Serenity Makadi Heights Hotel is located in Makadi Bay, a 5-star hotel deluxe
hotel built in the west bank of the Red Sea. It is easily reached from HurghadaInternational Airport (36 km) to the south. The resort surrounded by large gardens
and located directly on the Red Sea oﬀering spectacular views over the turquoise
water and an amazing experience of a luxury life style combined with the warmthof true Egyptian hospitality and very possible features to make your stay enjoyable
We are looking forward to seeing you to share this wonderful scientiﬁc &social event.

39

upcoming events

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

Società Italiana di Chirurgia della Mano

Preliminary Programme

COURSE OF
ARTHROSCOPYANDARTHROPLASTYOF THE WRISTArezzo - Italy

21st - 23rd November 2013

Coordinators:
Riccardo Luchetti
Andrea Atzei
FACULTY

Manel Llusa
Paolo Arrigoni
Riccardo Luchetti
Andrea Atzei
Augusto Marcuzzi
Alejandro Badia
Pierpaolo Borelli Christophe Mathoulin
Jane Messina
Massimo CerusoFrank Nienstedt
Maurizio Corradi
Giorgio Pajardi
David Espen
Sandra Pfanner
Marcus Gabl
Mario Igor Rossello
Marc Garcia-Elias
Max Haerle Jorg Von Schoonhoven
Jeffrey Yao
Elisabet Hagert
Giulio Lauri

3rd European
Symposium on
Paediatric Hand
Surgery andRehabilitation
13 - 14 January 2014
London, United Kingdom
http://www.bssh.ac.uk/education/
courses/3rdeuropeansymposiumon
The British Society for Surgery of theHand are delighted to host the 3rd
European Symposium on PaediatricHand Surgery and Rehabilitation
which will be held at the Institute ofChild Health in London on 13th - 14th
January 2014.
Submission of abstracts is now open
and will close on 31st August 2013. The
full programme and further information
will be published in September 2013.

Second International
Symposium on
Arthrogryposis
17-18 September 2014
St Petersburg, Russia
http://amc-2014.org/
We have pleasure in inviting you tojoin us to the SECOND INTERNATIONALSYMPOSIUM ON ARTHROGRYPOSIS«UPDATES FROM AROUND THE
WORLD» which will be held in SaintPetersburg, Russia on 17th and 18th
September 2014.
The faculty will consist of seniorclinicians from all over the world withparticular expertise in the managementof all aspects of the care of children
and adults with Arthrogryposis
including, geneticists, neuromuscular
pediatricians, surgeons andrehabilitation experts. This is a unique
opportunity to discuss the diﬃculties ofmanaging this complex condition.
One of the world’s most beautiful
cities, St Petersburg has all the
ingredients for an unforgettable
travel experience. The city oﬀers an
extraordinary history and rich cultural
traditions, which have inspired andnurtured some of the modern world’s
greatest literature, music, and visualart. From the mysterious twilight of theWhite Nights to world-beating opera
and ballet productions on magicalwinter evenings, St Petersburg charms
and entices in every season.
We look forward to welcoming you
to Saint-Petersburg.

LECTURES AND HANDS-ON SESSIONS FOR THERAPISTS
Tutors: Marc Garcia-Elias, Elisabet Hagert, Manuel Llusa

40

IFSSH ezine AUGUST 2013

upcoming events

IFSSH ezine AUGUST 201341

ifsshezine