ifssh
ezine

www.ifssh.info VOLUME 5 ISSUE 2 MAY 2015

Executive news
Member society updates
Upcoming events

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

Update on Hand Surgery
in Tetraplegia

A COHORT STUDY EXAMPLE ON THE
SWING TRACTION METHOD FOR COMPLEXINTRA-ARTICULAR PIP FRACTURES

THE ROLE OF NERVE TRANSFERS
IN THE TREATMENT OF NEONATAL
BRACHIAL PLEXUS PALSYMay 2015

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4 Editorial• Editorial by Professor Michael Tonkin, IFSSH President• Living Textbook of Hand Surgery update• Surgical reticence and balanced advice, Frank Burke

8 Executive news

Newsletterfrom the Secretary-General: Marc Garcia-Elias

10 Member Society Updates
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IFSSH Scientiﬁc Committee Reports• Neonatal Brachial Plexus Palsy: the role of nerve
transfers• Spinal Cord Injuries: Update on hand surgery
in tetraplegia

39 Hand Therapy

A cohort study example on the swing traction
method for complex intra-articular PIP fractures

42 Research roundup• Re-repair of ruptured primary ﬂexor tendon repairs inZones I and II of the ﬁngers in children• The non-operative management of hand fractures

46 Pioneer Profiles• Ridvan Ege, MD• James M Hunter, MD

48 Journal Highlights

Tables of Content from leading journals such as• The Journal of Wrist Surgery• Journal of Hand Surgery American Volume• Hand Surgery (Asian-Paciﬁc)• Journal of Hand Surgery European Volume• Journal of Hand Therapy

52 Upcoming Events

List of global learning events and conferences forhand surgeons and therapists

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IFSSH ezine MAY 20153

editorial

letter to the editor

IFSSH Support for Worldwide
Hand Surgery Education
Programmes
The improved ﬁnancial position of the
IFSSH has allowed the distribution ofﬁnancial assistance to hand surgery
education programmes throughout
the world, particularly for thosecountries and participants who are
ﬁnancially disadvantaged. This is oneof the major roles of the Federation.
The Committee for Educational
Sponsorship (CES) was formed by
the Executive Committee with theSecretary-General Elect as Chair andincorporating two other members- the Chair of the host committee
for the next IFSSH Congress and theNominating Committee Memberat-Large. Therefore, the make-upof this committee changes three
yearly at the time of the triennial
congress. Marc Garcia-Elias chaired
the ﬁrst committee with the supportof Raja Sabapathy (host of the 2013
Delhi Congress) and Goo Hyun Baek
(Nominating Committee Member-at-

Large). Currently the CES is chaired
by Dan Nagle, the current IFSSH
Secretary-General Elect, who is joinedby Eduardo Zancolli (host of the 2016
Buenos Aires Congress) and Moroe
Beppu (Nominating Committee
Member-at-Large).
Details of the responsibilities of
the CES and its aims and the IFSSH
Educational Sponsorship Guidelines
may be found on the IFSSH website(www.ifssh.info). The application
processes are well detailed. There
are four main groups of educational
activities which may qualify for
IFSSH ﬁnancial assistance althoughapplications which appear to falloutside the following descriptions
may also be considered. The four
categories are:
1. IFSSH Congress Assistance
Grants: These are intended forsurgeons who would be unable toattend an IFSSH Congress without

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.
Should you wish to support this publication throughadvertising, please click here.
4ﬁnancial support. Allocation of
grants is limited to a total sum of
US$20,000, the distribution of which
is determined by the chair of theOrganising Committee of the IFSSH
Congress. It remains the responsibilityof the Organising Committee Chair
to distribute this money to worthy
applicants. Assistance was provided
to 18 surgeons to attend the Delhi
congress in 2013. A further US$4500
was distributed to the International
Federation of Societies for Hand
Therapy (IFSHT) to sponsor theattendance of therapists at the Delhi
congress - three from Argentina, twofrom India, one from the US, one fromthe UK, one from Canada and one
from the Netherlands.
2. IFSSH Bursaries and Grants:
These are intended to assist theeducational programmes ofsocieties and society individuals, aswell as those activities of our allied

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
To subscribe go to:www.ifssh.info/ezine.html

O THE
SUBSCRIBE T

ifssFRhEE
ezine

FOR

IFSSH ezine MAY 2015

colleagues such as the European
Federation of Societies for Surgery of
the Hand (FESSH), the Asian Paciﬁc
Federation of Societies for Surgeryof the Hand (APFSSH), the SouthAmerican Federation for Surgery of theHand (FSCM), Wrist and Biomechanics
International (HWBI) and the IFSHT.
The criteria both of application andselection are broad. In 2012, the IFSHT
was awarded $4,500 to support theeducational activities of six therapists
in underdeveloped countries as partof the IFSHT-IFSSH International Hand
Therapy Teaching Grant.
An individual application,
supported by the Polish Society,provided $2,000 for Dr Piotr Czarnecki
to attend educational programmes
in the United States. The awarding ofsuch grants is contentious and the CES
has indicated that any further support
for these activities would need to bestrongly supported by the appropriate
society and should return beneﬁts
to that society. A similar application
was supported by the American
Association for Hand Surgery (AAHS)
to assist the travel of two Mongolian
hand surgeons to the United States.
Those surgeons attended the annual
meetings of the AAHS and theAmerican Society for Reconstructive
Surgery and visited a number of US
centres including the Mayo Clinic.
The intent was to beneﬁt Mongolian
hand surgeons through the expertise
gained from the exposure within the
United States. A grant of $12,000 was
provided for this purpose.
3. Regional Courses in Hand
Surgery: These are designed topromote hand surgery education indeveloping countries with limited
IFSSH ezine MAY 2015

economic resources. The IFSSH will nottake responsibility for the conduct ofsuch courses, nor for the full funding,but will provide, according to need
and availability, up to a maximum of$20,000 for each course. This money
may be used to provide reduced
registration for worthy registrants, tofund faculty or to fund the structural
costs of conducting the course.
A number of successful courses
have received IFSSH funding. The
ﬁrst was a course supporting theregistration costs of disadvantaged
surgeons from Eastern Europe toattend a hand surgery trauma course
in Hungary in 2012. A number of IFSSH
members acted as lecturers and tutors
in this course, providing their own
funding.
A further Eastern European courseis planned for 2015. This course is
to be organised in Eastern Hungary
as a collaboration between Daniel
Herren from Switzerland, Kevin Chungfrom the United States and Zsolt
Szabo from Hungary. The theme of
the course is Hand Reconstructionin Trauma and Rheumatoid Arthritis,
and the organisers have accumulated
an impressive faculty. Assistancein funding is intended to allow
registration of 30-50 registrants at nocost. All faculty members will be selffunded or receive a minimal amountfor travelling. The CES is currently
assessing this application.
In August 2014, the IFSSH
supported the Australian Hand Surgery
Society and Orthopaedic OutreachGroup in an upper limb mission which
was undertaken in Phnom Penh,
Cambodia. The visiting team consistedof surgeons from Australia, theUnited States and Thailand and handtherapists from Australia. Teaching
programmes were undertaken in
two afternoons with lectures at the
University of Health Sciences, teaching
the national cohort of surgeons in
training. Tutorials and patient careevaluations were undertaken by
the therapists. Over 100 patientswith varying hand conditions were
evaluated, 35 of whom underwent
operations during the week inconjunction with the Cambodian
surgeons. This is an ongoingprogramme of regular visits to
Cambodia with the aim of developing
hand surgery services in that country.
For this mission, the IFSSH provided$19,350 in funding.
The CES has agreed to support
the IFSSH - South Asian Regional
Course in Hand Surgery to be held in
Coimbatore, India, in July 2015. Thisis a three day workshop consisting of
lectures and operative demonstrations
with $20,000 of IFSSH funding
supporting the organising committee’s
ﬁnancial commitments - faculty
costs and structure of the course. The
registration fees for over 100 surgeons
from the region will be kept to aminimum.
4. IFSSH Harold Kleinert Visiting
Professorship: This award honours
the contribution of Dr Harold Kleinert
to the distribution of hand surgery
knowledge throughout the world. It is
designed to fund a Visiting Professor
to an educational hand surgery courseorganised by an IFSSH member
society. The society should provide
details of the course and programme
and nominate three surgeons. The CES
will select the Visiting Professor from5

editorial

editorial

these three nominations and provide
the invitation through the organisingsociety. We would encourage allsocieties to consider an application toreceive a Visiting Professor.
The involvement of the IFSSH in
educational programmes is expanding.
Of course, all applications must fulﬁl thecriteria that have been outlined in theguidelines, speciﬁcally those relating toour aim of providing ﬁnancial support
to those in underdeveloped countries toimprove the teaching and developmentof hand surgery within those countries.
Of course, funds remain limited and,
therefore, the applications are ofnecessity assessed on a competitive
basis. Nevertheless, we encourage allsocieties and their members to consider
how best to use IFSSH funds for the
distribution of hand surgery knowledge
throughout the world.
Michael Tonkin
President : IFSSH
Deputy Editor:
IFSSHezine

6

Surgical reticenceand balanced advice
I spoke at a friend’s funeral recently;
a lady who was well respected inour community. She was wise andkind and calm, but also had thathighly sought after virtue, reticence.
The dictionaries deﬁne reticence asa disposition to say little, a person
who is reserved and disinclined to
speak freely (or perhaps over freely).
It is a trait in life, in general, that isunder considerable pressure as aconsequence of social media whichallows friends, or anyone, to share
their thoughts however trivial andmundane they may be. To datesociety has been slow to recognise
the risks of imprudent messaging;perhaps with time society will
adjust and reticence will once again
be appreciated as a virtue.
Is there a role for medical
reticence? I think there is. I have justread Atul Gawande’s excellent book
‘Being Mortal’ on the care of theterminally ill. It describes the art ofﬁnding out what the principal fears
and desires of each patient might
be and moulding treatment tomeet those needs. I have had theopportunity to see hospice care in
hospital and in our home recently
and was enormously impressed bywhat can be done.
I do not doubt there is value inthe toxic treatments (radiotherapy
and chemotherapy) available indeveloped countries to deal withterminal cancer, but I wonder

whether doctors are striking
the right balance between risk
and beneﬁt. Perhaps at present
such treatment is oﬀered simply
because it is available and might
help, when it simply blights theremaining time for the patient witha minimal chance of beneﬁt. Careof the terminally ill could well be anarea where therapeutic reticencewith toxic interventions should be
encouraged.
But what of hand surgery? Does
every trained surgeon, launched
onto an unsuspecting public,
have the necessary judgement toknow when not to operate; I fear
not. I should imagine we may all
be able to think of examples ofsurgeons, not always young, whosethreshold for ‘trying’ surgery as an
option is disturbingly low. There
will always be a role for innovative
and, rarely, speculative surgery, butthese would be uncommon. Any
surgical intervention comes with aﬁnite risk. It is one of the perverse
beneﬁts of a long hospital waiting
list for elective surgery that patientswith speculative operations are
rarely booked; there are too manyother cases with more obvious
surgical justiﬁcation.
In my practice it was notuncommon to see patients intheir sixties with an elective handcondition who were desperate toremain at work for another two or
IFSSH ezine MAY 2015

three years so they could get their full
pension. An obvious and common
example would be someone withsymptomatic osteoarthritis to thebasal thumb joint. There is of course
a whole spectrum of non-operativeinterventions, including for us,
acupuncture, which would be oﬀered
before surgery. We will assume that all
non-operative treatments have been
exhausted and the surgeon might beconsidering trapezial denervation or
trapezial excision. For the purposesof this discussion I will leave trapezial
replacement out of the argument.
The dilemma for the hand surgeon
is not so diﬀerent from the oncologist;
identifying the patients greatest
worries and needs. In this case it
would be ‘not to be made redundant’,“Any surgicaland he may be better soldiering onsurgery until retirement. I
intervention comes without
wonder how often my interventions
with a finite risk.” lead to a patient never returning toand to work the ﬁnal three years toretirement. Trapezial denervation,even if it produced no beneﬁt, would
be unlikely to force a worker into
retirement, but a trapezial excision
quite possibly would. If a trapezial
excision is being contemplated, howlikely is it that the worker will achieve
his primary objective of continuing
employment if his duties at work aredemanding on the basal thumb joint?
If the chances are low the patientneeds to know the surgeon will be
unlikely to deliver his primary objective

work; there are bound to be some,but I hope there have not been too
many. I regret that I never audited myoutcomes in this way.
Surgery always needs to be
applied carefully with the patient’s
very speciﬁc desires and fears cateredfor. ‘I do trapezial excision for OA baseof thumb’ does not necessarily covera patient’s needs. The therapeutic
dilemma for oncologists is currently
widely discussed, but in some areas ofhand surgery perhaps we have similar
challenges.
Frank Burke
Derby, United Kingdom

Living Textbook of Hand Surgery
The Living Textbook of Hand
Surgery is online with the ﬁrst
chapter covering the topic of
Dupuytren´s Disease. Hand
surgeons from around the world
have already seen the website,with over 16 000 visits logged
since January.

What is new in 2015?
We expect to include three
more chapters to the bookwithin the next months. In
Milan at the FESSH Congress,
the next authors meeting isplanned for Friday, 19 June
2015. Everybody interested totake part is cordially invited toattend. Details of the venue and
IFSSH ezine MAY 2015

time will be announced on thewebsite www.hand-ww.de or
can be requested by email toricharda.boettcher@hand-ww.
deA ﬁrst update of the website
is expected for September 2015.
It will include the optimised
reviewer process, responsive
design including availability
for e-book readers andimplementation of social media
are planned for the second
update.
Visit the website at
handbookhand.com
Richarda Boettcher
Handchirurgie Weltweit e.V.
richarda.boettcher@hand-ww.deA view of the book: The chapter concerning Percutaneous Needle
Fasciotomy by Paul Werker includes numerous videos. Note thecitation note with separate Doi and the direct PubMed research.

7

executive news

executive news

Message from the Secretary-General:

Marc Garcia-Elias
Dear friends
As the organisation of anotherannual Delegates’ Council meeting
commences, it is timely to list
opportunities that your society might
be interested in pursuing. Pleaseconsider these, discuss with yoursociety’s executive and members, andcontact the IFSSH secretariat if you
require more information.
We look forward to receiving
applications and meeting again in Seattle.
2015 IFSSH Delegates’ Council
Meeting
This year’s annual IFSSH Delegates’
Council Meeting will be conducted in
Seattle in September, in conjunction
with the annual meeting of theAmerican Society for Surgery of theHand. Further details will be provided
in the next newsletter.
IFSSH Membership
The IFSSH currently consists of 55
member societies. We welcome
applications from hand surgery
societies to join the IFSSH. The
requirements for membership are:
1. The applying society must be a bonaﬁde organisation whose individual
members have a major interest insurgery of the hand,
2. The applicant society shall havebeen in existence for at least two
years,

8

3. The society shall submit a listof oﬃcers and members, itsconstitution (or Bylaws) and therequirements for admission ofmembers,
4. Each applicant society shall besponsored by three Council
delegates.
Applications are considered by the
IFSSH Executive Committee andDelegates’ Council at the annual
meeting. In 2015, this meeting will beheld in Seattle in September. Societies
interested in applying for membershipshould contact the IFSSH secretariat:
administration@ifssh.info.

2022 IFSSH Congress Host Society
The IFSSH Executive Committee hasrecommended that member societies
from the European region* be invited
to host the 2022 triennial congress.
This main scientiﬁc event of the IFSSH
will be celebrated every three years
in a member society country thatis in good standing with the IFSSH,
including payment of their annualdues.
The society hosting the event
will be selected from applications six
years before at the annual Delegates’
Council meeting. Those societies fromcountries which also have a handtherapy association/society should
discuss the possibility of hosting a
combined meeting. The societies

which are applicants must submit
a formal petition to the Secretary
General at least three months aheadof the Council meeting. The same
documentation should be sent toeach member country delegate and
IFSHT representative for evaluation atleast three months before the Council
Meeting.
Therefore, any European member
society that is interested in hosting
the 2022 IFSSH Congress should
inform the IFSSH Executive of theirintentions and ensure that the fullbid is forwarded, as detailed in the
instructions above, by July 24th 2016,
for consideration at the Buenos Aires
meeting.
Information regarding theapplication process is on the
IFSSH website:
http://ifssh.info/guidelines.html*The IFSSH member societies
have been geographically grouped
according to United Nations data.
The IFSSH “European” region consistsof: Austria, Belgium, Bulgaria, Czech
Republic, Denmark, Finland, France,
Germany, Greece, Hungary, Italy,
Lithuania, Netherlands, Norway,
Poland, Portugal, Romania, RussianFederation, Slovakia, Spain, Sweden,
Switzerland, Turkey, United Kingdom.
For the purposes of the IFSSH
congress rotation system, the two
IFSSH member nations that lie within
IFSSH ezine MAY 2015

the African region - Egypt and South
Africa - have been aligned with theEuropean region and are therefore alsoable to bid for the 2022 Congress.

Pioneers of Hand Surgery
The IFSSH awards “Pioneer of Hand
Surgery” status to a person who excels
exceptionally, beyond what is normally
expected, in the ﬁeld of hand surgery.
These honours are awarded at each
IFSSH triennial congress.
A call for nominations will be sent
to the delegate of each IFSSH society
in January 2016.
The nomination must come froma member society, not an individual,
and should be reserved for those withoutstanding achievements. Details of
the criteria and nomination process areavailable on the IFSSH website:
http://ifssh.info/pioneers.html
The deadline for submitting
nominations for the Buenos Airescongress is April 24th, 2016.
Educational Sponsorship / IFSSH
Harold Kleinert Visiting Professor
The IFSSH invites applications forfunding assistance of educational
projects. These may be worthy
education projects of any description
and are awarded funding on acompetitive basis, after assessment by
the IFSSH Committee for Educational
Sponsorship.
IFSSH ezine MAY 2015

In addition to the general funding
available, speciﬁc grants are alsoavailable to:❚ provide ﬁnancial assistance tothe organisation of Hand Surgery
regional education courses;❚ assist hand surgeons from poor ordeveloping communities to attend
an IFSSH triennial Congress throughthe provision of IFSSH Congress
Assistance Grants; and❚ promote the international exchangeof hand surgery knowledge bysponsoring an IFSSH Harold
Kleinert Visiting Professor to an
appropriate hand surgery education
programme.
General applications can be submitted
for assessment at any time throughout
the year, but should be received atleast three months in advance of when
the funding is required. Full details of
the application process, and further
information regarding the speciﬁcgrant categories, are on the
IFSSH website:
http://ifssh.info/fellowship-grants.html

Future Meetings
A detailed list of national and regional
hand surgery meetings is available on
the IFSSH website.
The triennial IFSSH Congresses are
as follows:
XIIIth IFSSH – Xth IFSHT Congress
Buenos Aires, Argentina
October 24-28, 2016www.ifssh-ifsht2016.com
XIVth IFSSH – XIth IFSHT Congress
Berlin, Germany
May, 2019
Marc Garcia-Elias
Secretary-General, IFSSH
Email: secretary@ifssh.info

9member society updates

member society updates

Member society updates
American Association forHand Surgeryn
In 2013, the American Association forHand Surgery adopted a new mission statement: Working together toadvance global hand care and education. Since then, the Hand Association
has made a concerted eﬀort to fulﬁll its
mission through focus on its existing
programs and developing new initiatives geared towards an international
audience. Some of the ways the AAHS
is working to advance global hand careand education include:❚ Granting the Miguel Vargas
International Hand Therapy Teaching
Award each year to a therapist who
travels to an underserved country
to care for patients and educate thehost country on hand care.
❚ Energising the Association’s Hand
Surgery Endowment throughthe HANDS AT WORK capitol
campaign so that the Endowment
can regularly provide international
volunteer grants and scholarships
to hand surgeons, therapists andancillary medical staﬀ.
❚ Collaborating with aﬃliatedsocieties, such as the Brazilian
Society for Surgery of the Hand
(SBCM), Argentine Society for
Surgery of the Hand (AACM), andthe British Society for Surgery of
the Hand (BSSH), on the Hand
Association’s journal, HAND,
coordinating joint programming at
AAHS annual meetings, and hostingcourses at aﬃliate society meetings.

10❚ Developing a new FREE webinar series focused on providing education
online to improve hand care, globally. 3 webinars have been held todate with another scheduled for thespring of 2015. To access archived
webinars, visit http://handsurgery.
org/education/webinar.cgi
The Hand Association continues towork to advance global hand care andeducation through partnerships andcollaboration, and looks forward to sharing news on additional programs it adds
to its repertoire with the international
hand community in the near future.
For more information on the AAHS,
please visit http://handsurgery.org/

British Society for Surgeryof the Hand
The British Society for Surgery of theHand (BSSH) continues to make important contributions to the ﬁeld of handsurgery through research and in training. BSSH hold twice yearly congresses
with prestigious international guest
speakers. Each meeting is attended by
200 -300 delegates.
BSSH is one of the founder
members of the Healing Foundation,a national fundraising charity
championing the cause of people
living with disﬁgurement andvisible loss of function, by funding
research into pioneering surgical andpsychological healing techniques. This
month sees the advertisement of a
Clinical Associate Professor in Hand
Surgery, based in Nottingham andintending to take a leading role insetting up a Centre for Evidence Based
Hand Surgery Research. The post isfunded by BSSH and will be managed
by the Healing Foundation.
BSSH is developing a national
research network to facilitate theconduct of national multi-center clinical
trials. Several of these, coordinatedby BSSH, are in progress, which will
hopefully shed light on some of thecommon dilemmas in hand surgery.
The Journal of Hand Surgery(European Volume) is the oﬃcial
journal of the Society and continues toﬂourish. Initially linked to the American
Journal of the same name and more
recently adopted as the oﬃcial
IFSSH ezine MAY 2015

European journal, it has long been
established as one of the foremost
publications on the subject. The
Journal is run through a committeewith European and wider international
representation and is also the oﬃcial
journal of FESSH.
The “Instructional Courses in
Hand Surgery” continue to run
in Manchester over a constantly
updated 3- year cycle. These provide
advanced teaching at a senior traineeor consultant level in hand surgery,with authorities in their specialist ﬁelds
invited from all continents. The entire
spectrum of hand surgery is covered
over the period and the courses areopen to trainees and consultants
across the world.
BSSH in collaboration with the
University of Manchester has, since2007, established a Diploma in Hand
Surgery, using the content of thecourses as the basis for a syllabus.
Surgeons in the fellowship programme
take a modular course of face-to-facetuition with tutorials and projects withworkplace assessments and a ﬁnal
external examination. This year also sees
the commencement of an MSc course
in Hand Surgery, recently approved by
the University of Manchester.
From 1992 BSSH instituted
a national system of Interface
Fellowships in Hand Surgery, taken
after training in one of the two parent
specialties. Each post provides training
in both orthopaedic and plastic
surgery elements of hand surgery.
To date over 200 surgeons havecompleted this programme.
BSSH has developed a national
web-based hand surgery audit tooland employs a full-time database
IFSSH ezine MAY 2015

administrator to undertake most of thedata collection and entry. This allows
surgeons to audit their outcomes
and compare their own results withthe aggregated results from all BSSH
members. Surgeons can use theiroutcome data to inform their own
appraisal and continuing professional
development.
The Society has been funding visitsof hand surgery teams to developing
countries to undertake programs ofwork in Sierra Leone and Nepal. In
Sierra Leone this has been done incollaboration with ReSurge Africa,
which is sponsoring the training of
local surgeons. The ultimate aim of the
project is self-sustainability.
Next year sees the 60th anniversary of the “2nd Hand Club”, founded
by Guy Pulvertaft and Graham Stack,which evolved into the BSSH. Celebratory events are planned to mark this.
Finally, our bid to host IFSSH in
London 2022 will be submitted in
Buenos Aires in 2016. The pedigree of
the BSSH in the ﬁeld of hand surgery
and our track record in organizing
successful meetings puts us in a strong

position to host this.
We call on the rest of the world tolend us your support!
David Shewring
BSSH Delegate to IFSSH
PS: The University of Nottingham isseeking to appoint a Clinical Associate
Professor in Hand Surgery withaccreditation in either Trauma andOrthopaedic or Plastic Surgery to playa leading role in setting up a Centre forEvidence Based Hand Surgery Researchin Nottingham in conjunction with the
British Society for Surgery of the Hand
(BSSH). The post comes with substantial
start-up funding from the BSSH which ismanaged by the Healing Foundation.
The post holder will be based
within Academic Orthopaedics,
Trauma and Sports Medicine andthe Nottingham Clinical Trials Unit,
University of Nottingham. The post has
5 PAs of University time. Clinical work
(5PAs and 1 APA) will be at Nottingham
University Hospitals NHS Trust.
For full details: http://
www.nottingham.ac.uk/jobs/
currentvacancies/ref/MED064515

11

member society updates

Swedish Society for Surgeryof the Hand
The Swedish Society for Surgery of
the Hand was founded in 1973 andhas approximately 150 members. The
society is a section of the Swedish
Society of Medicine and the Swedish
Medical Association and a member of
the Federation of European Societies
for the Surgery of the Hand (FESSH) as
well as the Scandinavian Society for
Surgery of the Hand.
Hand Surgery has been an
autonomous speciality in Sweden
since 1969. To our regret, in 2006 theSwedish National Board of Health andWelfare decided to give Hand Surgery
the status as a branch speciality to
Orthopaedics, with the consequenceof prolonged time of education for
specialised hand surgeons and an
impaired possibility to the interchange
of knowledge with Plastic Surgery.
After many years of dialogue, theSwedish National Board of Health andWelfare, ﬁnally decided to re-establish
Hand Surgery as an autonomous
speciality as from May 1st 2015. The
board of the Swedish Society for
Surgery of the Hand therefore recently
established new guidelines for the
specialist training in hand surgery. In
cooperation with the departmentsof Hand Surgery at the University
hospitals in Sweden, we have started aseries of instructional courses in handsurgery, covering the entire spectrumof surgery of the hand and upper limb.
National quality registers arecommon in Swedish health care. On
the initiative of the Swedish Society for
Surgery of the Hand, in 2010 a national
quality register for hand surgery (www.

12

HAKIR.se) was started. The aim withthe register is to collect of data thatcan provide a basis for continuous
improvement of care and research.
Through standardised and continuous
follow-up, including patient reported
outcomes as well as functional
outcomes, this quality register canpromote standardisation of hand
surgical methods and postoperative
treatments, which can help to optimise
hand surgical care. Since 2014 all sevenspecialised hand surgery departments
in Sweden are reporting to theregister and so far more than 40,000
procedures have been registered.
Anna Gerber Ekblom MD, PhD
Chair of The Swedish Society for
Surgery of the Hand

member society updates

The Venezuelan Society for
Surgery of the Hand
The Venezuelan Society for Surgeryof the Hand (SVCM) was foundedin Caracas in 1974 as a medical,
scientiﬁc, and trade union organisation,
whose main objective is the study
and diﬀusion of the knowledge ofHand Surgery and reconstruction of
the upper limb. Dr Ricardo Sánchez
Beaujon established the groundwork
for building a society that today brings
together all the specialists in Hand andReconstructive Upper Limb Surgery in
our country.
In 1981 the Venezuelan Medical
Federation (FMV) recognised Hand
Surgery as a specialty and our society
expanded in to the ﬁeld of the study of

XXX Meeting SVCM, November 2014
First row: left to right; MDs Magally Ortiz (past president SVCM), Rosa Torrealba, Leslie Medina, MD
Rodolfo Contreras Gamboa (Founder and Past President SVCM), MD Antonio De Santolo Ricciardelli(Founder and Past President SVCM and Honorary pioneer in surgery of the hand IFSSH 2010), and
MDs Aloha Isea (General Secretary SVCM), Himilse Mendez. Second row: left to right; MD Gaetano
De Santolo (Secretary of Sectional SVCM), MD Jochen Gerstner (Guest Colombia), MD Carlos
Zaidenberg (guest Argentina).
IFSSH ezine MAY 2015

diseases of the hand and upper limb.
In 1983 the SVCM was welcomedin to the International Federation of Societies for Surgery of the Hand (IFSSH),
and in 1996 the SVCM joined the SouthAmerican Federation of Societies forSurgery of the Hand (FSSCM).
During the past 40 years, numerous
Presidents - Doctors Rodolfo Contreras,
Antonio De Santolo (Honourary Pioneer,
11th International Congress: Seoul,
Korea, 2010), José Camarillo, Fiesky Nuñez, Nelson Socorro, Maggali Torrealba,
Rafael Brunicardi, José Guerrero, Alberto
Urquiola, Miguel Guédez, Ramiro Morales, Magally Ortiz, Ricardo Tobio, Álvaro
Aguilar, Leonardo Briceño and currently
José Vicari - have worked hard to create
a new generation of Venezuelan handsurgeons with three years of postgraduate studies and approval of the postgraduate programme by our principals,
universities and government. Currently
in Venezuela we have seven hospitals
dictating postgraduate studies: UCV,
LUZ, MPPS and IVSSS.

XXX Meeting SVCM, November 2014
First row: left to right;
MD Jochen Gerstner (Guest Colombia),
MD Nelson Socorro (Past President SVCM),
MD Alberto Urquiola (Past President SVCM),
MD Ramiro Morales (Past President SVCM)
and other participants.
IFSSH ezine MAY 2015

We have organised and participated in many academic activities overthe past years. In 2015, we will hold the
XXXI Conference (10-12 June, in Caracas, Venezuela) in honour of Dr Rodolfo
Contreras Gamboa.
Delegate IFSSH-SVCM:
Dr Igor Indriago
President SVCM: Dr José Vicari

Spanish Society for Hand
Surgery
1. New Board of the SECMA: The
new board of the Spanish Society will
be constituted during the national
meeting in Murcia in May 2015. The
new President will be Dr Angel Ferreres
and the General Secretary will be Dr
Luis Aguilella. The rest of the Council
members will be elected by thegeneral assembly.
2. SECMA & RICMA (The IberoAmerican Journal of Hand Surgery).
The new online version of the “Revista
Iberoamericana de Cirugía de la Mano
(RICMA)”, the Ibero-American Journal ofHand Surgery, has contracted Elsevier
to be the new Editorial company.
A new editorial manager website
will help the authors to submit theirmanuscripts to RICMA. The editors,
Dr Fernando Corella and Dr Pedro J.
Delgado, have carried out tremendous
work on this project. http://
revistaiberoamericanamano.org/
3. SECMA & FESSH. The Spanish
Society participated in the FESSH
foundation in Konstanz, December
2014. The foundation of FESSH took
place on 11th December 2014 in St.
Gallen at the Bachman Notary Oﬃce

with three members representing
FESSH. National Societies joined FESSH
in signing the foundation document.
SECMA was represented by its
international delegate Dr R S Rosales.
4. SECMA AND OTHER HAND
SURGERY SOCIETIES. The American
Society for Surgery of the Hand has
selected the Spanish Society of Hand
Surgery (Sociedad Española de Cirugíade la Mano “SECMA”) as the 2015
International Guest Hand Society at the70th ASSH Annual Meeting (September 10-12 2015 in Seattle, Washington,USA). The Spanish Society will collaborate in the scientiﬁc program with
two instructional courses and poster
presenters at the international guest
society poster section.
On behalf of the SECMA, I thank the
IFSSH for the opportunity to present thisupdated news report of our society.
R S Rosales, MD, PhD
International Delegate of the SECMAThe Swiss Hand Surgery
Society

The Swiss Hand Surgery Society grewin 2015 to now include 225 ordinaryand extraordinary members. The
council changed for 2015/16, with a
new President (Michaël Papaloïzos,Geneva) and Vice President (Mario
Bonaccio, Frauenfeld) and Claudia
Meuli-Simmen (Aarau) as the past13

member society updates

president. The annual Congress is
to be held in Fribourg on November
5-6, including the main topics of joint
fusions and CRPS alongside manyother activities and free papers(http://de.sgh-sghr-kongresse.ch/zukunftige-kongresse).
The main work of the council(www.swisshandsurgery.ch) in 2014/15
involved the change of our training
program. As of January 1st 2015,
Hand Surgery is a fully acknowledged
specialty by the Swiss Medical
Association (FMH). Trainees whocomplete the structured und veriﬁed
postgraduate training may carry thetitle “Handchirurgie FMH” - a title
which is recognised in most European
countries. The council, in accordancewith the FMH, has the responsibility tosupport all training centers to adapt
to the new training program and its
regulations.
As mentioned in earlier news
updates, the new oﬃcial training starts
with a common trunk of two yearsof General Surgery that is completed

14

by an examination of surgical basics.
After passing this exam the trainee canenter the specialised training in Hand
Surgery and in Surgery of Peripheral
Nerves. This training takes four years
in at least two diﬀerent institutions.
There are diﬀerent training centers inthree categories (5 University Hospitals:
Basel, Bern, Lausanne, Geneva, Zurich;
2 Center Hospitals: Aarau, St.Gallen; 10
smaller Hospitals or Clinics: Geneva,
Sierre, Chur, Bruderholz, Liestal, Luzern,
Münsterlingen/Frauenfeld, Solothurn/
Olten, Schulthess Zurich, Winterthur;
5 private practices: Biel, Fribourg,
Geneva-Meyrin, Nyon, Rüti).
The training ﬁnishes with an oral
and written examination. With the newprogramme we will share the written
and oral examination with the FESSH,
obtaining the FESSH Diploma as the“Swiss Hand Diploma”. After passing
this exam and fulﬁlling a deﬁned
logbook, the trainee receives the Swiss
Hand Diploma (FMH certiﬁcate) at theend of six years of training.

member society updates

Taiwan Society for Surgeryof the Hand
Prof. Tang-Kuei Liu was one of thepioneers who started the handsurgeries in Taiwan. He was theFounding President of the Society
for Surgery of the Hand Taiwan ROC
in 1990. The Society was renamed
as “Taiwan Society for Surgery of theHand” (TSSH) in 2009. The Society was
mainly comprised of orthopaedic andplastic surgeons, and the President
was elected from the two societies
alternating every second year. Prof.
Ming-Ting Chen, one of the pioneers
in plastic surgery, was the second
President of TSSH (1992-1994).
TSSH joined the IFSSH when Prof.
Sheng-Mou Hou was the Presidentof TSSH (1994 and 1996), and also
became one of the founding societiesof APFSSH. The subsequent Presidents,
including Fu-Chan Wei (1996-1998),
Der-Yang Wu (1998-2000), HungChi Chen (2000-2002), Gau-Tyan Lin(2002-2004), Hsian-Jenn Wang (2004-

IFSSH ezine MAY 2015

2006), Yuan-Kun Tu (2006-2008), David
Chwei-Ching Chuang (2008-2010),
Alvin Chao-Yu Chen (2010-2012),
and Chih-Hung Lin (2012-2014),
devoted themselves in the services,
investigations, and educations of
TSSH. The current President, Chih-Hao
Chang, continues the missions, leading
the hand surgeons in Taiwan andconnecting to the world societies.
Several senior TSSH hand surgeons
have completed their fellowshipperiods abroad and were inspiredby the masters from diﬀerent
centers. Their hard work madethem outstanding in the ﬁelds of
toe transfers, brachial plexus andperipheral nerve reconstructions,congenital hand reconstructions,microsurgical reconstructions forthe mutilated upper extremities, andminimally invasive surgeries. After they
became the masters, they continued
contributing to the hand society in
Taiwan and the international societies,
providing lectures in continuing
medical educations and instructionalcourses to pass on their experiences.
Live surgery courses during
international conferences also
impressed the participants. Cadaver
dissection courses and arthroscopy
courses were introduced to TSSH
by Ircad Taiwan, established in2008. These workshops provided
a more lively form of education
to the younger generations.
Advanced shoulder, elbow, and wrist
reconstructions can be performedby this generation. Innervated toe
and vascularised joint transfers aredeveloping in this country.
Hand surgeons in Taiwan takepart in and support international
IFSSH ezine MAY 2015

activities. Prof. Yuan-Kun Tu hosted
the 8th APFSSH in Kaoshiung, Taiwan,
when Prof. Chuang was the Presidentof TSSH. More than 500 participantsjoined this conference in 2009. Prof. Tu
is currently the President of APFSSH.
With this enthusiasm and friendship,
TSSH will continue to participate in theinternational societies.

The Turkish Society ofHand and Upper Extremity
Surgery
The Turkish Society of Hand andUpper Extremity Surgery was founded
in 1977 by the Honorary President,
Prof. Ridvan Ege. The society is amember of IFSSH and FESSH and has
255 active members.
The 2001 IFSSH triennial congress
and the 2013 FESSH meeting wereorganised by the society and held
in Turkey. The Turkish Hand Society
also organises national basic andadvanced hand courses every year
in diﬀerent cities of Turkey. Between
these, the dedicated course of Prof
Dr. Ridvan Ege is traditionally very
important for our Society.
The IX. Prof Dr. Ridvan Ege basic
course of traumatic hand and upper
extremity surgery, was successfully
held at the Congress Centre of the
Gulhane Military Hospital in Ankara
on 3-4th of April 2015 organised by
Turkish Hand Society. The coursecommenced with the attendanceof Dr. Ege. Basic knowledge ofthe traumatic hand was given toparticipants by the faculty, with 100
participants in attendance from
diﬀerent cities of Turkey.
We would like to thank to Prof.
Ridvan Ege for his great contribution to
Turkish Hand Surgery.
Turkish Hand Society
Sadan Ay, M.D. Assoc Prof
Delegate of IFSSH

15

committee reports

committee reports

IFSSH Scientific Committee on
Neonatal Brachial Plexus Palsy

Table 1: Commonly described nerve transfers for NBPP
Donor nerve

Nerve type

Intraplexus

MotorMedian and/or ulnar to biceps and/or brachialis

Motor

Radial triceps branch to axillary anterior deltoid branch Tri-Del

Motor

Medial pectoral nerve to musculocutaneous

MPN-MSC

Mixed Motor and Sensory

Ipsilateral C7

iC7

Motor

Spinal accessory to suprascapular nerve

SAN-SSN

Mixed Motor and Sensory

Intercostals to musculocutaneous

ICN-MSC

Mixed Motor and Sensory

Contralateral C7

cC7

Chair: Howard Clarke (Canada)
Committee: Raymond Tse (USA), Martijn Malessy (The Netherlands), Scott Kozin (USA)

Extraplexus

Report submitted August 2014

The Role of Nerve Transfers in the Treatment of Neonatal Brachial Plexus Palsy
Abstract
Nerve transfers have gained popularity
in the treatment of adult brachial
plexus palsies, however, their role in
the treatment of neonatal brachial
plexus palsies remains unclear.
The purpose of this article is tocritically review the current literaturesurrounding the use of nerve transfers
for neonatal brachial plexus palsy.
The relative merit of nerve
transfers as a primary strategy fornerve reconstruction for Erb palsy is
still unclear. In the cases of extended
Erb palsy and more severe palsies,
the current complement of nerve
transfers is inadequate to satisfy all
target muscles. Given implications ofdenervation on limb function, growth,and the possibilities for secondary
musculoskeletal reconstruction,
maximal re-innervation should remain
the primary goal of reconstruction.
Without direct comparative studies
and given the lack of consensus inmethods of reporting results, futurestudies should consider using a wellestablished outcome measure andshould clearly deﬁne how outcomesare assessed.

16

Introduction
Neonatal brachial plexus palsy (NBPP)
occurs in 1 in 1000 newborn infants1,2.
Although most infants recoversatisfactory function spontaneously,
10-30% beneﬁt from surgery3-6.
Interposition nerve grafting
has been the mainstay of surgicaltreatment 4,5,7-9. In the case of nerve
root avulsion(s), distal targets areprioritized in the following order:
hand (if aﬀected), elbow ﬂexion, andshoulder 3.
Nerve transfers take functioning
donor nerves/branches/fascicles
to innervate non-functioning distal
targets. The donor may be part ofthe brachial plexus on the aﬀectedside (intraplexus) or may originate
outside of the aﬀected brachial plexus(extraplexus); it may be motor, sensory,or mixed motor and sensory.
Nerve transfers have gained
popularity in the treatment of adultbrachial plexus palsy10 and many
have been applied to NBPP (Table1). For example, the combination ofmedian and/or ulnar to biceps and/or brachialis (M/U-Bi/Br), radial triceps
branch to axillary anterior deltoid
branch (Tri-Del), and spinal accessory

to suprascapular nerve (SAN-SSN) canbe used to treat upper trunk palsy11-14.
Although a recent systematic review
suggests that nerve transfer may
produce superior outcomes to nerve
grafting in adults15, treatment of
NBPP diﬀers greatly: the mechanisms,
patterns, severity, extent of injury, andscar tissue formation are disparate;
infants have a much greater potential
for recovery; and the inﬂuences of ashorter limb (with shorter distances
for axons to reach targets), growth,and development (with potential for
central nervous system adaptation)must be considered. The purposeof this report is to review the current
literature and evidence surrounding
the use of nerve transfers for thetreatment of NBPP. This review will
focus primarily on re-innervation of
distal motor targets.
We performed a Medline Search forliterature documenting results of nerve
grafting, nerve transfer, or both in thetreatment of NBPP.

Outcome measures
Given the variations in reporting motor
function, we tabulated outcomesaccording to common validated
IFSSH ezine MAY 2015

systems including MRC scale, Active
Movement Scale (AMS) 16, and Malletscore17. Some authors have simpliﬁedreporting their results by using thepercentage of patients achieving“useful function” deﬁned as an AMS
score of 6 or more18-20. When a
modiﬁed MRC scale was used, we
examined whether it allowed a similardeﬁnition to be assumed.

The available literature
Only two studies directly compare
the results of nerve transfer to nerve
grafting for NBPP in a robust side-byside manner21,22. All other studies
are case series and reports that vary
greatly in patient age, palsy type,surgical indications, adjunctive/
concomitant procedures, and followup duration (Table 2). In addition,
we found variations in surgical
technique that may have signiﬁcant
implications: results of M/U-Bi/Br
may be better when performed as a
double fascicular transfer comparedto single fascicular transfer19; posterior
approach for SAN-SSN decompresses
the nerve through the suprascapular
notch whereas the anterior approach
does not23; the donor for Tri-Del
IFSSH ezine MAY 2015

Abbreviation

may be the nerve branch to any of
the 3 muscular heads and potential
denervation of the donor was notuniversally investigated24,25. Given
the inconsistencies in clinicalcircumstances, ﬁndings from one
study are diﬃcult to compare toanother.
The diﬀerentiation of Erb/Type 1
from Extended Erb/Type 2 palsy is of
speciﬁc interest in the setting of nerve
transfers given that the triceps nerve
branch may be abnormal for the
Tri-Del transfer. However, only a few
studies provided enough description
to make this distinction possible5,25-28.
Table 2 summarises the available data
for elbow ﬂexion with presentation“The relative meritof nerve transfers
as a primarystrategy for nervereconstruction for
Erb palsy is still
unclear”

M/U-Bi/Br

grossly divided between “Upper palsy”(C5-6 +/- C7) and “Total palsy” (C5-8+/- T1)29.

Outcomes
1. Primary reconstruction of
Erb palsy
Although there are no studies that
directly compare results of nerve
transfers to nerve grafting (Table 2),
two studies describe outcomes using
each approach in patients with similar
clinical circumstances. Lin reported
results of nerve grafting in a group of48 patients with Erb palsy who were
evaluated according to the algorithm
developed in Toronto4, that includes
the Cookie test administered at 9months of age18. Ladak reported
results of nerve transfers (M/U-Bi/
Br, Tri-Del, and SAN-SSN) in a similargroup of 1025. Although the durationsof follow-up varied, mean AMS scoresfor shoulder abduction, shoulder
external rotation, elbow ﬂexion, andforearm supination were similar(Table 2).
Given that, in most of the otherstudies, the available outcomes arecontained in case series and reports
with widely varying circumstances,

17

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committee reports

TABLE 2: RESULTS OF NERVE GRAFT AND NERVE TRANSFER FOR ELBOW FLEXION
Reported outcome

Approach/Author

Palsy

N

Clinical situation/Indications

Average age(range) (months)

NERVE GRAFTING
Lin 2009
Lin 2009
El-Gammal 2010
Boome 1988
Waters 1999

U
T
T
U
U, T

48
44
18
22
6

Toronto algorithm
Toronto algorithm
Pan plexus at 3 months
No C5/6 recovery at 3 months
No biceps function at 6 months

9.4 ± 2.1 (SD)6.1 ± 2.3 (SD)
10.8 (3-60)
5.3 (3-20)
N/A (N/A)NERVE TRANSFER
Intraplexus - Pure motor transfer
M/U-Bi/Br
Ladak 2014U
10
Little 2014
U
31

% functional(AMS≥6 or equivalent)Pre-opPost-op

Mean AMS Score
Pre-opPost-op

MRC ScorePre-opPost-op

12.5
0
0
-

3.6
0.7
-

N/A
-

100
86.3
72
-

6.6
6
-

78% MRC≥3-

Mallet (hand tomouth) or other
Post-op

Follow up(Years)33% Mallet 2,
33% Mallet 3,
33% Mallet 444
4.2 (2.5-7.3)
N/A

Donor morbidity

3.8

Failed “Cookie Test”
Late presentation, dissociative
recovery, avulsions, orfailed reconstruction
Late presentation
Late presentation, avulsios,or failed reconstruction
Late presentation
Dissociateive recovery
No elbow and shoulder ﬂexion
Dissociateive recovery
No elbow ﬂexion andshoulder abduction

N/A (10-18)
8.4 (3-20)

0

87

3.7
1 (0 to 3)*

6.3
6 (5-7)*

-

-

-

2
1.5

No changes in wrist ﬂexion
3% transient AIN palsy

16 (13-19)
12.9 (4-26)

0
N/A

90
65

0.8
-

6.2
-

-

-

-

1.5
2.6 (1.6-5.4)

15.4 (9-24)
13 (12-14)
10 (N/A)
12 (N/A)
8 (N/A)

0
0
0
0

100
100
100
100

0
0
0
-

7
7
7
-

N/A
0
0

71% MRC≥3
MRC 5
MRC 5

-

1.6 (1.1 to 2.5)
0.4
5
1.5
3.3

No detectable donor deﬁcits
No changes (hand x-ray or
Al-Qattan hand score)
Not speciﬁed
Not speciﬁed
No ﬁnger or wrist weakness
None
None

80% had ability to 1.8 (0.8-7)
bring hand to mouth
8% Mallet 2,
5.8 (SD 2.9)
16% Mallet 3,
72% Mallet 4
3.7 (0.9-8.2)**

Al-Qattan 2014
Siqueira 2012

U
U, T

10
17

Noaman 2004
Al-Qattan 2002
Estrella 2012
Al-Qattan 2010
Shigematsu 2006

U
U
U
U
U

7
2
1
1
1

MPN-MSC
Wellons 2009

N/A

20

Not Speciﬁed

7 (5-10)

-

-

-

-

-

-

Blaauw 2003

U25

Not Speciﬁed

5.28 (3-10)

-

-

-

-

-

68% MRC≥3

Pondaag 2012

U

25

Pan plexus at 3 months orpoor shoulder and biceps
at 4-6 months

5.8 (3-11)**

-

-

-

-

-

92% MRC≥3

None
Not speciﬁed

None

Intraplexus

18

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committee reports

TABLE 2 CONTINUED: RESULTS OF NERVE GRAFT AND NERVE TRANSFER FOR ELBOW FLEXION
Reported outcome

Approach/Author

Palsy

N

Clinical situation/Indications

Average age(range) (months)% functional(AMS≥6 or equivalent)Pre-opPost-op

Mean AMS Score
Pre-opPost-op

MRC ScorePre-opPost-op

Mallet (hand tomouth) or other
Post-op

Follow up(Years)Donor morbidity

MIXED MOTOR AND SENSORY TRANSFER
iC7
Romana 2014
U
1
EXTRAPLEXUS- Mixed motor and sensory transfer

Not Speciﬁed

5 (N/A)

N/A

100

N/A

7

-

-

-

8

Not speciﬁed

5.8 (3-11)**

-

-

-

-

N/A

82% MRC≥3-

3.7 (0.9-8.2)**

No donor deformity noted

5.8 (3-14)

-

-

-

-

0

93% MRC≥3-

5.2

No donor deformity or
dysfunction
100% atelectasis; 4.3%
pneumonia

ICN-MSC
Pondaag 2012

U, T

17

Kawabata 2001

U

30

El-Gammal 2008

U, T

31

Pan plexus at 3 months or poor
shoulder and biceps at
4-6 months
No biceps at 3 months andavulsions on exploration
Not speciﬁed

14 (4-24)**

N/A

93.5

-

-

-

-

-

4 (1-7.2)**

Luo 2011
cC7
Lin 2011

U, T

12

Avulsions or dissociative recovery 5.7 (3-11)

N/A

100***---

100% MRC≥3-

4.3 (3-5.5)

U

15

Avulsions

7.5 (3-15)

N/A

73***

-

-

-

60% MRC≥3-

3.9 (3-5.2)

Lin 2010

T

9

Avulsions (≥4)

4 (3-6)

N/A

78***

-

-

-

78% MRC≥3-

4.2 (3.7-5.2)

Chen 2007

T

4

Avulsions (≥4)

9.75 (6-14)

N/A

75***

-

-

-

75% MRC≥3-

3.8 (3.2-4.6)

80% synchronous
contralateral movement
66% synchronous
contralateral movement;
11% transient loss of
abduction
100% synchronous
contralateral movement;
25% transient loss of
abduction

N/A = Not Available or Not Specified, U = Upper, T = Total* Expressed as median**Age and follow-up are for the entire study group*** Assumes author defined MRC 2+ (Lin 2011, Lin 2010, Chen 2007) or MRC 3 (Luo 2011, Little 2014) is equivalent to AMS 6 or greater

20

IFSSH ezine MAY 2015

IFSSH ezine MAY 201521

committee reports

committee reports“The role of nerve
transfers as asole strategy
for primaryreconstruction of
Nerve grafting
brachial plexus
Few studies report the results of nerve
palsy is unclear
grafting in isolation and in a mannerthat speciﬁcally assesses elbow ﬂexion. given the lack
Lin found 86% of patients with total
plexus palsy and 100% of patients with of comparative
upper plexus palsy attained AMS≥6 .
studies with nerve
grafting.”
Nerve transfers: Extraplexus
these are summarised below
according to target movements.
1. a) Elbow flexion
There are no direct comparisons ofnerve grafting to nerve transfers andall studies are in the form of case series
or report (Table 2).

18

donorsIntercostal nerve transfer (ICN) is
most often used as an adjunct in thesetting of nerve root avulsions30-32.
The percentage of patients obtaining
functional elbow ﬂexion (AMS >6 orequivalent) has been reported at 82 to
100%. ICN transfers can be undertaken
safely in infants if the ipsilateral phrenic
nerve is functioning normally. The
sacriﬁce of ICNs risks alterations inchest growth and breast development.
In addition to potential pneumothorax,
El-Gammel reported atelectasis in all
patients and pneumonia in 4.3%33.
Transfer of the contralateral C7(cC7) via a vascularised ulnar nerve
graft has been described for pan
plexus palsy with 4 or more avulsions.
Lin and Chen respectively report78% (N=9) and 75% (N=4) achieving
active movement against gravity (>½
range) 34,35. Lin also reported using cC7transfers via sural nerve grafts to theupper trunk for Erb palsy with C5-6 orC5-7 avulsions with similar outcomesfor elbow ﬂexion 36. Voluntary control

22

was not speciﬁcally assessed, however,transient decreases of donor limb
shoulder abduction were reported34,35
and most to all patients had somedegree of synchronous contralateral
movements34-36.

Nerve transfers: Intraplexus donors
Medial pectoral nerve to
musculocutaneous nerve (MPNMSC) has been used as an adjunctfor more extensive brachial plexus
reconstruction30,37 or as a sole strategy
for recovery of elbow ﬂexion38.
Pondaag reports 92% with MRC≥330
while Blaauw reports that 68% had
ﬂexion against gravity37.
More contemporary strategies
of intraplexus nerve transfer have
involved fascicles of ulnar nerve,
median nerve, or both with either
the biceps branch (single fasciculartransfer) or both biceps and brachialis
branches (double fascicular transfer)of the musculocutaneous nerve as
recipient(s). Results of single fasciculartransfer were reported by Ladak in
a homogeneous group of patients
failing the Cookie test at 9 months
with a mean AMS improvement of
3.7 to 6.325. Other reports using thistransfer have been in the setting of latepresentation19,28,39,40, isolated deﬁcit19,28,
root avulsions19,40, or failed primary
nerve graft reconstruction19,40.
Siqueira reported the lowest
percentage attaining functional elbow
ﬂexion (AMS ≥6) at 65%, however 30%
of patients had a previously failed
primary nerve graft reconstruction
portending to a lower chance of
success40. In contrast, Little included
only 2 patients (6%) with failed primary
nerve graft reconstruction and had
87% patients attain functional elbow
ﬂexion19.
Al-Qattan reported on a groupof 10 patients who presented late,
without prior reconstruction, andunderwent median fascicle to biceps
branch transfer at 13 to 19 months ofage39. No other procedures were noted
and 90% attained functional elbow
ﬂexion (AMS ≥6). Given that age atnerve reconstruction is thought tobe an important factor in treatment
success, Al-Qattan’s results suggestthat nerve transfer is a good option
for patients presenting late. Results ofnerve grafting at a similar age are notavailable for comparison.
Patients with “isolated” deﬁcits ofelbow ﬂexion may be at a relative
functional advantage given that motor
control of the rest of the extremity
may be intact or mostly intact. This
group of patients with “dissociative”
recovery may have other motors, suchas brachioradialis that contribute toelbow ﬂexion. The merits of isolated
IFSSH ezine MAY 2015

nerve transfer in this situation are
diﬃcult to determine.
In the instance of C5 and C6
avulsions, nerve transfer is the only
option. Siqueria and Little reporton 5 and 10 patients respectively
who underwent M/U-Bi/Br transfer
for elbow ﬂexion in the case of root
avulsions19,40. All patients in Little’s
study achieved functional elbow
ﬂexion19 suggesting that this is an ideal
indication for this transfer.
1. b) Forearm supination
Few studies report outcomes of
forearm supination and there are no
direct comparisons of nerve graftingwith nerve transfers.
The mean AMS scores reported
by Ladak following M/U-Bi/Br weresimilar to those reported by Lin
following nerve grafting for primaryreconstruction of Erb palsy.
1. c) Shoulder abduction
There are no direct comparisons ofnerve grafting with nerve transfers andall studies are in the form of case series
or report. Given the many confounders
and paucity of data, inferences on
relative merit of each approach are
limited.
1. d): External rotation
Comparison of suprascapular nervereconstruction with either nerve
grafting from C5 or SAN-SSN transfer
has been reported21,22. Although eachstudy looked at diﬀerent outcome
parameters, both studies found no
signiﬁcant diﬀerence in outcome withnerve grafting or transfer.
2. Primary reconstruction of Type
2/3/4 NBPP
Several authors have reported nerve
transfers for extended Erb palsy (Type2), however, only motor outcomes
IFSSH ezine MAY 2015

related to the speciﬁc transfers
performed were described andfunction of the unaddressed targets
was not described19,27,39.
Nerve transfers for pan plexus palsy
have been described in the settingof 4 or 5 avulsions where proximal
nerve roots are limited or unavailable
for nerve grafting34,35. A vascularised
ulnar nerve was used in cases of cC7
transfer, however, sacriﬁce of the ulnar
nerve precludes any intrinsic handfunction, one of the primary goals ofreconstruction in these situations.

Discussion
The role of nerve transfers as a sole
strategy for primary reconstruction ofbrachial plexus palsy is unclear given
the lack of comparative studies withnerve grafting.
Nerve transfers do have an“Surgeons who
commit to care of
infants with NBPP
need to avoid anover-reliance on
nerve transfers
and should havethe capability andinclination forbrachial plexus
explorationand nerve graft
reconstruction.”

important role to play in speciﬁc
circumstances including inadequate
proximal roots (ie. multiple avulsions),
failed primary reconstruction, latepresentation, and isolated deﬁcits.
Surgeons who commit to careof infants with NBPP need to avoid
an over-reliance on nerve transfers
and should have the capability
and inclination for brachial plexus
exploration and nerve graft
reconstruction. While multiple nerve
transfers (M/U-Bi/Br, Tri-Del, and
SAN-SSN) can be used to address
all of the targets of isolated Erb/
Type 1 palsy, in the case of more
severe palsies (Type 2 or greater),they leave targets unsatisﬁed. Thisnot only leaves persistent deﬁcits, it
limits motors available for secondary
musculoskeletal reconstruction andmay have implications on growth.
Maximal re-innervation may involve
both nerve grafting and nerve
transfers.
In spite of the advantages of nerve
transfers, the associated morbidity is
not clear. Direct donor dysfunction,in an already compromised limb,
has signiﬁcant implications andthe eﬀect of partial denervation on
musculoskeletal growth is unknown.
Although few adverse outcomes havebeen reported (Table 2), few studies
have examined morbidity rigorously
and long-term eﬀects on growth are
not available.

References
1.

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23

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long or lateral head branch to axillary nerve. The
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BTH.0b013e31812714f3.
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16. Curtis C, Stephens D, Clarke HM, Andrews D. The
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17. Bae DS, Waters PM, Zurakowski D. Reliability of
three classiﬁcation systems measuring active

24

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motion in brachial plexus birth palsy. J Bone Joint
Surg Am. 2003;85-A(9):1733–1738.
18. Lin JC, Schwentker-Colizza A, Curtis CG, Clarke
HM. Final Results of Grafting versus Neurolysis in
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PRS.0b013e318199f4eb.
19. Little KJ, Zlotolow DA, Soldado F, Cornwall R,
Kozin SH. Early Functional Recovery of Elbow
Flexion and Supination Following Median and/or
Ulnar Nerve Fascicle Transfer in Upper Neonatal
Brachial Plexus Palsy. J Bone Joint Surg Am.
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20. Clarke HM, AL-QATTAN MM, Curtis CG, Zuker
RM. Obstetrical brachial plexus palsy: results
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82– discussion 983–4.
21. Tse R, Marcus JR, Curtis CG, Dupuis A, Clarke HM.
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PRS.0b013e3182131c7c.
22. Pondaag W, de Boer R, van Wijlen-Hempel MS,
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PRS.0000146871.94229.91.
24. McRae MC, Borschel GH. Transfer of triceps motor
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antigravity shoulder abduction in pediatricbrachial plexus injury. HAND. 2012;7(2):186–190.
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25. Ladak A, Morhart M, O’Grady K, et al. Distal Nerve
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27. Estrella EP, Mella PM. Double nerve transfer for
elbow ﬂexion in obstetric brachial plexus injury:
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28. Noaman HH, Shiha AE, Bahm JR. Oberlin’s ulnar
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29. Zafeiriou DI, Psychogiou K. Obstetrical Brachial
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doi:10.1016/j.pediatrneurol.2007.09.013.
30. Pondaag W, Malessy MJA. Intercostal andpectoral nerve transfers to re-innervate thebiceps muscle in obstetric brachial plexus lesions.
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31. Kawabata H, Shibata T, Matsui Y, Yasui N.
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33. El-Gammal TA, Abdel-Latif MM, Kotb MM, etal. Intercostal nerve transfer in infants withobstetric brachial plexus palsy. Microsurgery.
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35. Chen L, Gu Y-D, Hu S-N, Xu J-G, Xu L, Fu Y.
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NEU.0000073420.66113.66.
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IFSSH ezine MAY 2015

IFSSH Scientific Committee on
Nerve – Spinal Cord Injury
Chair: Ann Nachemson (Sweden)

Committee: Jan Fridén (Sweden), Andreas Gohritz (Switzerland)
Report submitted November 2014
Funding for this project was provided by the University of Gothenburg and Sahlgrenska University Hospital.
The authors have no financial disclosures.

Update on Hand Surgery in Tetraplegia
ABSTRACT
Patients with cervical spinal cord
injury (SCI) suﬀer from paralysis of all
four extremities (tetraplegia). Their
foremost goal is to regain autonomy
and mobility. Surgical restoration of
key functions, such as elbow and wrist
extension or hand grip control has
tremendous potential to restore criticalabilities, e. g. eating, personal care andself-catheterisation and productive
work in at least 70% of tetraplegicpatients. Tendon and nerve transfers,
tenodeses and joint stabilisations
are time-proven and reliably provide
improved arm and hand usability,
reduce muscle imbalance andpain in spasticity and prevent joint
contractures. Recently, innovative
concepts such as single-stage
combined procedures have derived
from basic scientiﬁc research andclinical studies and have been provento oﬀer considerable advantages overtraditional approaches. A combinationof seven operations, termed theAlphabet procedure, provides
simultaneous active key pinch andglobal ﬁnger grasp, together with
passive hand opening and intrinsic
IFSSH ezine MAY 2015

function. Immediate activation oftransferred muscles is necessary to
reduce the risk of adhesions after thisextensive surgery, facilitates relearning,
and avoids the adverse eﬀects ofimmobilisation on functional recovery.
Transfers of redundant fascicles takenfrom the axillary, musculocutaneousand radial nerves from above the SCI
level have been eﬀective and are apromising option to enhance motor
outcome and sensory protection after
SCI, especially in groups with very
limited resources. Further researchshould be directed at combining
traditional algorithms with these new
approaches. Improved communication
between the medical disciplines caring
for these patients, their relatives, andtheir therapists, should in future help
so that more patients can beneﬁt
from these advances and could
enable many thousands of tetraplegic
individuals “to take life into their own
hands” and live more independently
again.
Key words: Spinal cord injury –tetraplegia – tendon transfer – novel
concepts – immediate activation –combined procedure – nerve transfer

PART I:
PRINCIPLESBACKGROUND
Incidence of tetraplegia
The global incidence of spinal cord
injury has been estimated between 10
and 80 new cases per million annually.
This means that 250-500,000 people
worldwide become newly paralysed
every year 1. The patient population
represents mostly young, healthy, andactive individuals in their productive
years between the 2nd and 4th
decades of life. More than 50% of all
SCIs occur at the cervical level leading
to tetraplegia 2. The causes of injury
diﬀer between countries but the mostcommon aetiologies of traumatic
SCI worldwide are motor vehicle
accidents, falls, violence and sports
and leisure activities. Besides, many SCI
occur due to non-traumatic causes,
e.g. neoplastic tumours, infection,degenerative or vascular disorders – itcan happen to every one of us any day
3, 4
!

25

committee reports

Tetraplegia hand surgery
Although spinal cord injury remains
incurable, surgical rehabilitation of
the arm and hand in tetraplegia is
a powerful tool to restore upper
extremity functions, e.g. the ability
to groom, self-feed, self-catheterise,lift objects, write, swim, and drive.
Reconstruction of elbow extension
improves reaching capabilities andstabilises the elbow, allowing for
further reconstruction of grasping
3, 5-8. Restoration of hand function
can eliminate the need for adaptive
equipment, allow patients to regain
meaningful roles and productive work,
markedly improve autonomy andspontaneity and thus enhance selfesteem for persons with tetraplegia 9-11.
Clinical outcomes
Clinical results have been reported
as very positive. In several recent
studies, patient perceived outcomesdemonstrated major improvementof both satisfaction and performanceof preoperatively prioritised dailyactivity goals 12-15. A meta-analysis of
the literature from over 500 cases in
14 studies was recently presented

committee reports“Although spinal
cord injury remains
incurable, surgicalrehabilitation of
the arm and handCurrent utilisationin tetraplegia
Regrettably, this kind of hand surgery
is a powerfulis profoundly underutilised, althoughoutcomes are rated overwhelmingly
tool to restore
positive. For example, in the United
upper extremity
States with a population of overfunctions, e.g. the 100,000 citizens living with tetraplegia,
fewer than 400 upper extremity
ability to groom,reconstructive procedures are
performed per year, indicating that lessself-feed, selfthan 10% of appropriate candidates
catheterise, lift
receive optimal treatment of their
upper extremities . The reasons forobjects, write,
underutilisation of proven surgicalswim, and drive.” thistechniques are varied and complex.

Table 1: Muscle function according to British Research Council system
MuscleStrength Grade

Muscle Function

M0

No active range of motion, no palpable muscle contraction

M1

No active range of motion, palpable muscle contraction only

M2

Reduced active range of motion – not against gravity,
no muscle resistance

M3

Full active range of motion, no muscle resistance

M4

Full active range of motion, reduced muscle resistance

M5

Full active range of motion, normal muscle resistance26

and revealed a mean increase of
Medical Research Council scorefor elbow extension from 0 to 3.3
after reconstruction and a mean
postoperative pinch strength of 2kg, which markedly improved upper
extremity usability 16.

Table 2: International Classification of Surgery of the Hand in Tetraplegia– with addition of sources for nerve transfers
Group

Spinal Cord
Segment

Possible Muscle Transfers

Possible Axon Sources for Nerve Transfers

0

≥ C5

No transferable muscle below elbow

Musculocutaneous nerve branches
to coracobrachialis and brachialis muscle

1

C5

Brachioradialis (BR)Axillary nerve branches to deltoid and teresminor muscles

2

C6+ Extensor carpi radialis longus (ECRL)

Radial nerve branches to supinator muscle

3

C6+ Extensor carpi radialis brevis (ECRB)

4C6+ Pronator teres (PT)5

C7

+ Flexor carpi radialis (FCR)

6

C7+ Extensor digitorum

7

C7+ Extensor pollicis longus

8C8+ Flexor digitorum9

Lacks intrinsics only

10 (X)

Exceptions

17

Many patients are lacking adequate
information about the possibility ofupper extremity reconstruction 18.
After patients shift from acute care
into long-term non-surgical care,
our fractionated health care system
is poor at transferring them backinto the surgical realm for non-acuteconditions. It was suggested that “thebiggest barrier to increased use of
these procedures is the inadequate
referral network between surgeons
and physiatrists” 19.

OBJECTIVE
This paper summarises the key
elements of surgical restoration of armand hand function in tetraplegia.
1. PATIENT EVALUATION - Anatomy
and Clinical Examination
IFSSH ezine MAY 2015a. Muscle Testing: Surgicalplanning depends on preoperative
sensory and motor evaluation of
the upper extremity and includes
muscle strength tests according to
British Research Council system andInternational Classiﬁcation of Surgeryof the Hand in Tetraplegia (ICSHT) 20(Tables 1 and 2). The donor muscle
must be healthy and of adequate
strength (M4), preferably not injured
or re-innervated. With limited available
donor muscles, a weaker muscle(M3) may be considered for transfer.
Optimally, it should be similar inarchitecture, synergistic and have anadequate soft tissue bed along theroute of transfer 21, 22.
b. Joint Range of Motion: Passive
joint motion, above all in the key joints- shoulder, elbow, wrist, MCP and PIP- is a prerequisite for reconstruction. A
tenodesis eﬀect during wrist extension
IFSSH ezine MAY 2015

(hand closure) and ﬂexion (handopening) and joint stability (primarily
the thumb CMC joint) is preferable but
not required for reconstruction.
c. Sensibility Testing: Sensory
examination focuses on cutaneousaﬀerents of the hands with a 2-point
discrimination, which should be
10 mm or better in the thumb for
cutaneous control (Cu). Otherwise
ocular control (O) is required 10, 20.
d. Special aspects: Other aspectsof neuromuscular examination include
identiﬁcation of brachial plexus
lesions and entrapment neuropathies,
paralytic spine deformity, thoracoscapular stability, spasticity,
contractures, stiﬀness and instability ofjoints 23, 24. Pain and swelling are relative
contraindications to surgery and need
to be treated before reconstruction.
e. General goals of tetraplegia
surgery: To take better advantage ofremaining shoulder, arm and handfunctions, various philosophies have
evolved. Reconstruction of upper limb
motor functions in tetraplegia involve
multiple surgeries (Tables 3 and 4)
but it is always necessary to keep inmind the goals of the surgeries i.e., toprovide the individual with a better
ability to perform activities in daily life
3, 13, 14.

2. PLANNING OF
RECONSTRUCTION
The main goals of reconstruction
are to provide:
1. Elbow extension,
2. Grip function (ﬂexion phase),
3. Opening of the hand (extension
phase) and4. Intrinsic hand function.
The most frequently used proceduresto achieve patients’ ability goals andalgorithm for surgical reconstruction27

committee reports

based on International Classiﬁcation
are presented in Tables 3-5.

Prerequisites
In tetraplegia, the following

committee reports

requirements must be met before
starting functional operations:
1 Neurological functional plateau –no further recovery expected
2 Emotional Stability - accepting theconsequences of injuries
3 No open wounds or pressure sores(decubitus), no infections (e.g.
bladder)
4 Motivation and ability of theTable 3: Summary of possible surgical procedures (excluding nerve transfers) to achieve patients’ ability goals
Ability goal

Functional goal

Procedure

Rehabilitation

Stabilizing elbow in space,reaching overhead objects,
pushing wheelchair,stabilizing trunk

Elbow extension

Reconstruction of Triceps
Function

4 weeks cylinder cast withelbow fully extended

Posterior Deltoid-Triceps

4 week orthosis

Use of utensils, handwriting, pushing wheelchair

Grip

Biceps-Triceps
Reconstruction of grip
Reconstruction of passive
key grip

4 weeks arm in cast with ﬂexed
thumb and wrist

BR-ECRB

4-10 weeks active exercise

patient to take active part in aftertreatment
5 Treatment plan based on clinicalexamination and counselling of thepatient
6 Available donor muscles (muscle
strength grade ≥ M4)
7 Free passive joint mobility 3, 8, 10, 25

ICgroup Recommended surgical procedureICgroup Recommended surgical procedure

05• BR-to-FPL• ECRL-to-FDP 2-4• ELK procedure• House intrinsic procedure• CMC 1 fusion• EPL-tenodesis6• BR-to-FPL• ECRL-to-FDP 2-4• ELK procedure• House intrinsic procedure• EDM-to-APB transfer• EDC-to-EPL

7• BR-to-FPL• ECRL-to-FDP II-IV• ELK procedure (if required)• House intrinsic procedure• EDM-to-APB or EIP-to-APB

8• BR-to-FPL• ECRB activated ADPB
• Opponens plasty (EIP, EDM, FCU)
• Active Zancolli lasso procedure (ECU)• House intrinsic procedure

9• House intrinsic procedure

10• Pathological postures (MP joints ﬁxed in
hyperextension, lack of any functioning intrinsic
muscles, wrist ﬁxed either in ﬂexion or
extension etc.)• Release of contracted muscles, joint capsules,
tendon lengthenings

CMC 1 arthrodesis

BR-FPL

4 weeks in orthosis with active
key pinch but restriction ofwrist extension• BR-to-ECRB for active wrist extension• Moberg’s key pinch procedure• ELK procedure2• BR-to-FPL (active key pinch)• CMC 1 fusion• ELK procedure• EPL tenodesis to dorsal forearm fascia

3• BR-to-FPL• ECRL-to-FDP 2-4• ELK procedure• House intrinsic procedure• CMC 1 fusion• EPL-tenodesis

Split FPL-EPL tenodesis
Opening of the hand

Reconstruction of thumband finger extensors
Passive opening
CMC I arthrodesis

4 weeks wrist and thumb incast

EPL to extensor retinaculum
attachment
Active opening
PT-EDC and EPL/APL
Thumb stabilization
ELK procedure, CMC 1
arthrodesis
Reconstruction of intrinsics
Zancolli-Lasso tenodesis
House tenodesis
EDM-APB

28

4 weeks wrist, ﬁngers andthumb in cast
6 weeks splint for IP / CMC 1
joint with free thumb tip
4 weeks of immobilization in
intrinsic plus position Thumb
actively exercised 1st postop
day
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• Abducted shoulder (anterior deltoid muscle
transfer)• Flexion contracture of the elbow (biceps
tendon Z-tenotomy)• Supinated but not contracted forearm(Zancolli biceps rerouting - check presenceof supinator muscle!)• Fixed supination contracture - osteotomyof radius

1

CMC I arthrodesis
Reaching for objects e. g.
cup or glass positioningof thumb and ﬁngers for
improved grasp control

tetraplegia. Early hand rehabilitation
has many advantages, such as faster
reintegration. Often, however, ﬁnancial,family or work-related problems
must be solved ﬁrst. In incomplete
tetraplegia, functional recovery may
occur even a long time after the
injury (about two years). On the other
hand, a reconstruction using tendon

Table 4: Surgery according to International Classification (IC) – excluding nerve transfers

FPL-Radius
Reconstruction of active
key gripTime management
The above-mentioned conditions areusually achieved only after completingthe ﬁrst rehabilitation, yet a strict timerule (e.g. no operations before one
year since injury) is not appropriate.
Some patients achieve a stableneurological level after 3-6 months,
especially in cases of complete

4• BR-to-FPL• ECRL-to-FDP 2-4• ELK procedure• House intrinsic procedure• CMC 1 fusion• EPL-tenodesis

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committee reports

Table 5: Surgical management of spasticity in the tetraplegic upper extremity
Spasticity
Affected muscles
Surgical procedure
Function

Figure 2: C6 tetraplegic patient holding knife 4
weeks post grip reconstruction by transferring
the BR to the ECRB and FPL tenodesis to theradius (Moberg procedure)

Forearm

Pronator teres

ReleaseSupination possible

Wrist

FCR, FCU

Tendon lengthening

Wrist extension possible

Thumb

FPL, AdP

Tendon lengthening

Thumb extension and opening of 1st web space possible

Fingers

FDS / FDP

Tendon lengthening

Hand opening

Fingers

Interossei

Release

Reduction of intrinsic tightness, better grip

transfers may remain meaningfuleven decades after the spinal cord
injury. Predictability is reduced inincomplete SCI with asymmetry
and spasticity, so that a treatment
plan should be developed only after
nerve regeneration is complete andspasticity is under control 26.
Nerve transfers require a diﬀerent
perspective. Paralysed muscles
in SCI can be categorised into 1.
functional muscles innervated by
the supralesional segment and still
under voluntary control, 2. muscles
innervated by neurons at the lesion
level with damaged anterior horn cells
resulting in a lower motor neuron
denervation 3. muscles innervatedby infralesional segment which areparalysed. Preservation of the anterior
horn cells results in an upper motor
neuron paralysis of these muscles.
The nerves to the ﬁrst group ofmuscles represent potential donor
nerves, the nerves to the latter twogroups are potential recipients fornerve transfer surgery. Early surgery(optimally within a year) is criticalregarding the denervated muscle
group as neuromuscular end platedegeneration will make the muscle
refractory to eventual reanimation.
If a muscle is paralysed by an upper30

motoneuron lesion, neuromusculardegeneration will likely be slowed
and this may extend the time limit
for successful reanimation with nerve
transfers 27, 28.

PART II:OPERATIVETECHNIQUES
1. Reconstruction of Elbow
Extension
Elbow extension is critical foroverhead activities, weight shifting
and transfers, greatly improves
wheelchair propulsion and increases
the workspace of the hand in space.
Elbow reconstruction should precede
grip reconstruction because❚ Use of a hand that cannot reach out
is very limited.
❚ Elbow extension helps to stabilise
the patient’s trunk in the wheel chair❚ Stability itself is a factor for more
controlled use of the hand
❚ Function of distal tendon transfers
are improved, e.g. brachioradialis
muscle function (as a donor) requires

a counteracting and stabilisingaction from its antagonist i.e. elbow
extension.
Two surgical options are advocated torestore active elbow extension
a. Muscle transfer by❚ Posterior deltoid-to-triceps
transfer 9, 29-31 or❚ Biceps-to-triceps transfer 32
Posterior deltoid-to-triceps transfer
reliably restores lost elbow extension
in patients with C5/6 tetraplegia.
Patient candidates for biceps-to-triceps
transfer usually demonstrate intact
and functional brachialis and supinatormuscles, biceps activity and an

Figure 1: C5-C6 tetraplegic patientdemonstrates her elbow extension after
bilateral posterior deltoid to triceps
reconstructions.
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elbow ﬂexion contracture exceeding
approximately 20°. Both techniques
are time-proven and provide thetetraplegic with improved arm control
for many daily activities 31-32 (Fig. 1).
b. Nerve transfer using axons
from the axillary nerve
Alternatively, triceps reanimationis possible by nerve transfer. Possible
donors are nerve branches of theposterior portion of the axillary nerve(to posterior portion of deltoid or teresminor muscle) or the brachialis branchof the musculocutaneous nerve 33-35.

2. Reconstruction of Forearm
Pronation
A supination contracture can bedeﬁned as an inability to stabilise thehand in pronation due to an imbalance
between the functional supinatormuscles, mainly the biceps brachii
and supinator, and the hypotonic
or paralysed pronators. Initially asupination contracture can be reducedwith abduction and internal rotation of
the shoulder, but over time it becomespermanent as the biceps brachii andthe interosseous membrane contract.
Apart from looking ‘odd’, a supination
contracture seriously impairs handfunction, which albeit rudimentary,is very important to the tetraplegicpatient. A supination deformity
increases the risk of developing agravity-induced extension contractureof the wrist. Correction of the
IFSSH ezine MAY 2015

supination deformity enhances theusefulness of any remaining functional
muscles by enabling key-pinch. It
is generally agreed that functional
surgery should aim to restore thepronated position of the forearm andsurgical options include: 36
a. Distal Transposition of Biceps
Tendon (rerouting), if necessary withinterosseous membrane release .
b. Dorsal Transposition of theBrachioradialis during BR-to-FPL
transfer to achieve simultaneous
thumb ﬂexion and forearm pronation
37, 38.
c. Derotation Osteotomy of theRadius 36.

3. Reconstruction of Wrist
Extensiona. Tendon Transfer (BR-to-ECRB):
Reconstruction of active wrist
extension is of utmost importancedue to the wrist-related tenodesis
eﬀect. If wrist extension is absent (ICgroups 0 and 1), the brachioradialis(only IC group 1) can be transferred
for wrist extension to the ECRB toobtain a wrist extension without radialdeviation, and stable wrist-extensiondriven key pinch can be provided by
FPL tenodesis to the radius (Moberg
procedure) (Fig. 2) 39, 40.
b. Nerve transposition fromabove the elbow: Active wrist motion
enabling a tenodesis grip is a key
function in high level tetraplegia.
However, antigravity wrist extension
is absent in C5 tetraplegia and thisrenders inability to perform eventhe simplest activity of grip, sensory
functions and human contact. The
basic passive key pinch cannot be
restored by traditional transfers inpatients with no available donor
muscles below the level of elbow.
A tenodesis grip can be restored by
the transfer of the brachialis motor
nerve to the ECRL motor nerve,
combined with tenodesis of the FPL
to the radius41. This group forms a
relatively large proportion of theoverall tetraplegia population. In larger
series, IC groups 0 and 1 are relatively
frequent and correspond to 28% of
222 patients from our center 42.

31

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4. Positioning and stabilisation of
the thumb
Flexion of more than 60° in theinterphalangeal (IP) joint signiﬁcantly
disturbs thumb function in patients
who have preserved or reconstructed
extrinsic ﬂexor function (by ﬂexor
pollicis longus muscle), but haveparalysis of antagonistic intrinsic
or extrinsic thumb muscles due toperipheral nerve lesions, spinal cord
injury or neuromuscular diseases.
The preferred operation is currently
the EPL knot (ELK) procedure43 which
is a duplication of the EPL tendon
at the level of the IP joint to prevent
hyperﬂexion. A V-shaped incision ismade over the extensor hood, the EPL
tendon is elevated with a hook and aloop is formed and anchored with twosutures at its basis. The loop is thenfolded proximally on the EPL tendon
and ﬁxed with sutures along its threesides while IP joint is extended.
5. Reconstruction of Grip Function
Tetraplegic patients usually have aspontaneous weak pinch between the
thumb and index ﬁnger, depending

committee reportson the presence of a wrist extension– tenodesis grip. To produce a usefulgrip, preoperative planning must
be based on the patient’s goals andwishes and thorough testing of muscle
function, sensibility and spasticity of
the hand. In IC group 2 patients, active
extension of the wrist depends only
on the ECRL muscle, therefore thismuscle must not be used for a transfer
in this group of patients. In IC groups
3 and higher, where active extension
is provided by both the ECRL and
ECRB, the ECRL can be used for active
transfers 3, 42.
a. Reconstruction of Key Pinch- Lateral pinch, termed key grip, isbased upon the fact that hand opens
by passive or active wrist ﬂexion andcloses by wrist extension, whereby the
thumb pulp ideally should meet theradial side of the middle phalanx ofindex ﬁnger. Prerequisites for passive
key grip are wrist extension, minimum
strength grade 3, forearm pronation
and an acceptable relationshipbetween thumb and index/longﬁnger. Stabilising procedures are
the ELK distal thumb tenodesis andFigure 3: Intraoperative view of ECRL-to-FDP tendon transfer for restoration of finger flexion.

32

CMC I arthrodesis. Active key pinch
is preferably achieved by a BR-FPL
tendon transfer 44.
b. Reconstruction of Power Grip ECRL-to-FDP tendon transfer - Active
whole hand closure is powered by
an ECRL tendon transfer to the deepﬁnger ﬂexors of index, middle and ringﬁngers, excluding the little ﬁnger toprevent hyperﬂexion (Fig. 3) 44.
c. Nerve transfer to Restore
Interosseous Anterior Nerve
Function - Transferring the brachialis
motor branch of the musculocutaneous
branch to the anterior interosseous
branch of the median nerve can beused to reanimate ﬁnger and thumb
ﬂexion 45, 46.

6. Reconstruction of Intrinsics
The purpose of interossei/lumbricalreconstruction is to obtain MCP
joint ﬂexion and PIP and DIP joint
extension. Key pinch can be achievedby positioning the index ﬁnger sothat it is suﬃciently ﬂexed to meet the
thumb and is also supported by digits
3-5. Secondly, extension of the PIP
joints is essential for grasp and releaseand provides a more normal openingof the hand than reconstruction of
EDC function which gives an intrinsic
minus manner of opening. The House
procedure has proven superior to theformerly used Zancolli lasso plasty
in our experimental and clinicalexperience 47, 48.
a. Passive Interossei Function of
the Fingers using Passive Tenodesis
by Tendon Grafts in the Lumbrical
Canals – House procedure 49.
b. Reconstruction of Active
Interossei Function by Tendon
Transfer, e.g. FDS 4 with 4 Tendon
IFSSH ezine MAY 2015

Slips in the Lumbrical Canal – Brand
Procedure
Active intrinsic hand function may
be reconstructed by using a motor
muscle with 4 tendon slips inserted
into the lumbrical canals as developed
by Brand, primarily for leprosy patientswith combined median and ulnar
nerve palsy.
c. Restoration of Palmar
Abduction of the ThumbThumb palmar abduction canbe restored by transferring extensor
digiti minimi (EDM) to the insertionof abductor pollicis brevis (APB).
Notably, for this reconstruction M3
power of the EDM is usually suﬃcient
to increase ﬁrst web space opening
and to position the thumb optimallyalongside the index ﬁnger 50.

7. Reconstruction of Hand Opening(Extensor Phase)
Reconstruction of hand opening isnecessary to facilitate the ability of
the ﬁngers to surround an object inorder to grasp (Table 3). Many of thetetraplegic patients do not have thisRewrite as “ability from the tenodesis
grip which occurs with wrist extension,
due to adhesions of the ﬁnger ﬂexors
and insuﬃcient extension of the
ﬁngers even with good passive wrist
ﬂexion. Improvement of the openingof the hand is particularly necessary
in patients with ﬁnger ﬂexor spasticity
where gravity or remaining ﬁnger
extension strength cannot overpower
the ﬁnger ﬂexion spasticity 51.
a. Passive Opening of the 1st
Commissure by EPL tenodesis toextensor retinaculum or forearm fascia(powered by active or passive wrist
ﬂexion).
IFSSH ezine MAY 2015

“If a muscle
ﬂexion and extension and lack ofulnar deviators, especially in groups
is paralysed
0 and 1, in which only the ECRL is
by an upper
strongly present. By suturing of aloop onto the ECU tendon
motoneuron lesion, tendon
itself, the gripping force, in comparison
neuromuscularwith an unbalanced hand with the
motion, doubles. Because
degeneration will sameof ergonomic hand function, thelikely be slowedshoulder does not externally rotate
when the wrist is radially deviated.
and this may
This can reduce the shoulder pain that
extend the timeoccurs often in quadriplegics .
limit for successful
Additional Procedures to Reduce
reanimation with 9.Spasticity
A common observation over thenerve transfers.”
53

b. Active Opening by Tendon
Transfer by transferring PT to EPL, APL
and EDCc. Nerve Transfer of theSupinator Motor Branches (C6) tothe Posterior Interosseous Nerve(C7-8) – Bertelli S-PIN Procedure- Bertelli described the possibility ofusing the fact that supinator is always
C6-innervated and is redundant when
biceps is intact, while the ﬁbers of theposterior interosseous nerve roots are
C7-8-innervated. By transferring theexpendable supinator motor branches
to the posterior interosseous nerve,ﬁnger and thumb extension as well as
ECU function can be reinnervated 34, 52.

8. Alignment of wrist position by
ECU tenodesis
Often there is a radial deviation of
the wrist due to the limited active

past years is the increasing numberof incomplete tetraplegics. Thesepatients present a somewhat new
conﬁguration and a more complex
functional loss than that of thosepatients with complete tetraplegia,
and often demonstrate various
degrees of spasticity and musclejoint deformities 51. Muscle stiﬀness,
imbalance and deformity canfrequently be corrected by muscle
release and/or tendon lengthening
procedures (Table 5) 51, 54.
Mild deformities in the hand
primarily aﬀect the PIP and DIP joints
while the MCP joints are usuallyspared. Severe deformities may
aﬀect all ﬁnger joints. Certain surgical
techniques have proven successful intreating spasticity:a. Littler Release - In many casesa partial resection of the obliquepart of the extensor aponeurosis isenough. The insertion of the interossei
on the proximal phalanx remains.
The operation time is short and thisproduces an immediate result 55.

33

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Table 6: Advanced Balancing Combined Digital Extension Flexion Grip (ABCDEFG) Reconstruction
Order Procedure

Type

Motor

Function

Effect1

Tenodesis

Active 1

Stabilize IP joint

Prevent hyperﬂexionof IP joint,

ELK procedure

Increase contact surface to index
2

Free tendon transplant(FDS4, PL, Plantaris) extensor
hood digits 2-3 and 4-5

Tenodesis

Passive 2Interossei 3

Opening hand3

CMC 1 joint stabilisation

Arthrodesis

N/A

Fusion of base of thethumb and correct
deformity

Secure thumb’s approachagainst index during
key pinch

4

BR-to-FPL

Tendon Transfer

ActiveThumb ﬂexion

Key pinch5

ECRL-to-FDP 2-4

Tendon Transfer

ActiveFinger ﬂexion

Power grasp

6

EPL-to-dorsal forearm fascia

Tenodesis

Passive 2

Extend thumb

Opening hand

7

ECU-to-ulnar head

Tenodesis

Passive

Prevent radial deviationof wrist

Balance hand positionat all types of grips

1 powered by BR-to-FPL, 2 powered by wrist flexion, 3 MCP joint flexion, PIP / DIP joint extension

b. Tendon Lengthening of theExtrinsic Finger Flexors (FDS/
FDP) - Tenotomies of the ﬂexors are
performed about 5 cm proximal to the
carpal canal using a step-cut incisionof 6-8 cm in length. This allows aparallel sliding of both tendon stumps
and subsequent prolongation of 2-3
cm 51.
c. Additional Procedures - Insome cases other procedures may berequired, such as releases of muscle
insertions, e.g. the adductor pollicis orpronator teres or a teno-myotomy of
the wrist ﬂexors.

INNOVATIVE CONCEPTS
1. Combined Procedures - Active
Flexor and Passive Extensor Phase with
Intrinsic Reconstruction 56
Traditionally, operations for ﬂexors
and extensors were separated, yet
we have successfully combined

34

procedures for active key pinch andﬁnger ﬂexion together with passive
opening of the hand as a one-stage
operation. This reconstruction includes
7 individual operations performedin the following order: 1) Split FPLEPL distal thumb tenodesis, 2)
Reconstruction of passive interosseous
function, 3) thumb CMCJ arthrodesis
4) BR-FPL tendon transfer, 5) ECRL-FDP
tendon transfer, 6) EPL tenodesis, 7)
ECU tenodesis. This reconstruction

is termed the Alphabet or ABCDEFG
procedure, abbreviation for Advanced
Balanced Combined Digital Extensor
Flexor Grip reconstruction (Table 6).
To reduce the risk of adhesions after
this extensive surgery and to facilitate
relearning, the activation of transferredmuscles with new functions requires
early active postoperative training.
One-stage reconstruction canreliably provide grip, grasp andrelease function in persons with C6

Figure 4: Patient with C6 tetraplegia shows hand-writing technique before (left) and 4 weeks after(right) one-stage complete grip reconstruction (Alphabet procedure 56,57).
IFSSH ezine MAY 2015

Figure 5: BR-to-FPL tendon attachment siteusing double-sided running sutures back andforth with 5 cm overlap.

tetraplegia (Fig. 4). Patient complianceand satisfaction is high. Overall, thissimultaneous reconstruction saves
time, limits the need for immobilisationand the eﬀort of patient and caregivers
are less compared to the standard
2-stage reconstructions. The incidenceof complications is comparable withother published treatment methods 57.

2. Immediate Activation ofTransferred Tendons
The most remarkable and eﬀective
strategy of improving function has
been the consistent and immediate
activation of transferred muscles
after surgery. Early active training of
new motors not only prevents theformation of adhesions but facilitates
the voluntary recruitment of motors
powering new functions, beforeswelling and immobilisation-induced
stiﬀness restrain muscle contractions.
Additionally, the patient will
experience an early, spectacular andinspiring eﬀect of the reconstruction,
which will help motivate training
during the demanding and sometimes
painful initial postoperative period58.
Early activation of the transferredmuscles requires reliable tendonto-tendon attachments. We haveaccumulated experience of hundredsof side-to-side attachments using
running sutures back and forth along
both sides and with a minimum of 5
cm overlap (Fig. 5) 59.
This technique has provenextremely safe for allowing early active
training, even in cases of donor and
IFSSH ezine MAY 2015

recipient tendon mismatch, and is now
standard in our unit 3, 60. Tendon force
measurements have conﬁrmed theassertion that the elbow joint need not
be immobilised when the BR is used
as a donor muscle in tendon transfer
to the FPL, as the maximum passive
tendon tension was only about 20 N
in our cadaveric model and the failure
strength of this speciﬁc repair was over
200 N 59. We suggest that it is possible
to perform multiple tendon transfers
in a single stage, avoiding the adverse
eﬀect of immobilisation. Brieﬂy, theday after surgery a removable splint
replaces the cast and intermittent
exercises commence. Trainingemphasises the activation of donor
muscles with slight external resistance.

3. Nerve transfers
Additional reconstructive options
could be achieved by nerve transfers,
i.e. extra-anatomical short-circuit
between expendable donor nerve
fascicles from above the level of the
spinal cord injury and the motor
branch of a paralysed muscle below it.
Nerve transfers have been establishedin recent years, especially in brachial

plexus lesions, but are rarely applied in
tetraplegia 61-63. Ideally, the coaptationof an expendable pure motor axon
donor with the recipient branchshould be over the shortest possible
distance 41. Theoretically, suitable
donor nerves include:❚ Axillary nerve (C5/6) branches to theposterior deltoid and teres minor to
restore elbow extension 34, 52❚ Radial nerve branches to thesupinator (C6) or ECRB (C7) 46, 47 for
thumb or ﬁnger extension❚ Musculocutaneous nerve branches
to coracobrachialis or brachialis
muscles for elbow extension, wrist
extension or ﬁnger and thumb
ﬂexion 41, 45, 46, 60❚ Superﬁcial radial nerve (C6) or lateral
antebrachii cutaneous nerve (C5/6)
for sensory restoration of the median
nerve (1st web space) in patients
categorised as 0 (ocular control) 63
Theoretically, nerve transfers in SCI
may even be more eﬀective comparedto peripheral nerve injury because
recipient muscles with intact lower
motor neurons preserve reﬂex arcs.
They should not become refractory toreinnervation / external stimulation

35

committee reports

after 18-24 months as occurs after
peripheral palsy. Axon transfer fromthe intact donor nerve may allow
highly selective neurotisation by
intraoperative fascicle stimulation of
the intact recipient nerve, minimising
the distance between donor andrecipient and, therefore, regeneration
time. Furthermore, natural
biomechanics, the force and excursionof the original muscle are preserved,
and scar-induced motion restrictions
are prevented without the need forextended immobilisation – a primaryfactor why appropriate candidates
refuse muscle transfers. Axon transfers
may provide options for patients not
amenable to conventional tendon
transfers, including IC group 0 3, 41, 45, 46.

Combining tendon transfers andnerve transfers
Further research should be directed
at combining traditional algorithms
with these new approaches, such as
in the case reported by Bertelli and
Ghizoni 64, restoring elbow extension,
ﬁnger extension (MCP joint), thumbextension and pinch, which is a ﬁne
example of the potential restorationof upper limb function that canachieved by combining tendon andnerve transfers in one surgery. Bothtechniques, muscle and nerve transfer,need to be carefully considered andindividualised according to theiradvantages 65. For example, theBertelli S-PIN procedure (supinator toposterior interosseous nerve transfer)
may achieve better hand opening
compared to pronator to EDC tendon
transfer. This nerve transfer reanimates
not only the ﬁnger extensors, as does
the tendon transfer, but also allows

36

committee reports“Many patients
who undergo
tendon transfer
procedures
have sustained
devastating, lifechanging injuries
and they should
be consideredfull members of
the rehabilitation
team. Their input
is required in
the preoperativeplanning so
the patientunderstands
operative options
and alternatives,and appreciates
the commitment
required forsuccessful
rehabilitation.”

independent thumb extension andabduction and ﬁrst web opening
by reinnervating the APL, and wrist
centralisation by also reinnervating
the ECU muscle. On the other hand,the classical BR-to-FPL tendon transfer
almost immediately provides strong
pinch, which may exceed the power
achieved by a nerve transfer to restore
anterior interosseous nerve function
after a lengthy regeneration period.

TEAM APPROACH
Tendon transfer procedures are
optimally undertaken with a teamapproach, using the assistanceof an occupational and a hand
physiotherapist as well as a surgicalnurse. The essential hand therapist
performs the “other half” of thesurgical procedure, rehabilitation
and retraining of the transferredtendons. The hand therapist promotes
functional restoration, assists
with oedema control, contracture
prevention, and muscle activation andstrengthening. Many patients who
undergo tendon transfer procedures
have sustained devastating, lifechanging injuries and they should
be considered full members of therehabilitation team. Their input isrequired in the preoperative planning
so the patient understands operative
options and alternatives, andappreciates the commitment required
for successful rehabilitation 3.

IFSSH ezine NOVEMBER 2014

CONCLUSION
Every person who sustains a cervicalspinal cord injury with tetraplegia
should be examined, assessed andinformed concerning the optionsof possible reconstruction of motor
function of the hands and arms. It
is of course a long way before thisambitious goal can be achieved but
the resolution put forward by theleading experts in this ﬁeld certainly
stresses the necessity of increasing
the awareness and improving theinfrastructure to meet patients’demands of informed discussionsof options for improvement of handfunction. Many patients are now better
informed about the beneﬁts of surgery
probably because of easy access tocomprehensive web pages on theInternet, a trend that will likely increase
the demands for more surgicalreconstructions in the future. The
overall goal of treatment is to improve
motor functions in order to achievea higher degree of independence
for the individual with tetraplegia.
Individuals with stable non-traumatic
SCI, though diﬀering from traumatic
SCI regarding demography and injury
patterns, can beneﬁt similarly fromsurgical rehabilitation of their upper
extremities.

IFSSH ezine NOVEMBER 2014

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14. Wangdell J, Fridén J. Activity gains afterreconstructions of elbow extension in patientswith tetraplegia. J Hand Surg Am. 2012, 37: 10031010.
15. Wangdell J, Fridén J. Satisfaction andperformance in patient selected goals after grip
reconstruction in tetraplegia. J Hand Surg Eur Vol
2010, 35: 563-568.
16. Hamou C. et al. Pinch and elbow extension
restoration in people with tetraplegia: asystematic review of the literature. J Hand Surg
Am 2009; 34: 692-699.
17. Curtin CM, Hayward RA, Kim HM, Gater DR,

Chung KC. Physician perception of upper
extremity reconstruction for the person withtetraplegia. J Hand Surg Am 2005;30:87-93
18. Curtin CM, Gater DR, Chung KC. Upper extremity
reconstruction in the tetraplegic population, anational epidemiologic study. J Hand Surg Am
2005;30:94-99.
19. Curtin CM, Wagner JP, Gater DR, Chung KC.
Opinions on the treatment of people withtetraplegia: contrasting perceptions ofphysiatrists and hand surgeons. J Spinal Cord
Med 2007;30:256-262.
20. McDowell CL, Moberg EA, House JH. The
second International Conference on Surgical
Rehabilitation of the Upper Limb in Tetraplegia(quadriplegia). J Hand Surg Am 1986;11:604-608.
21. Fridén J, Lieber RL. Clinical signiﬁcance of skeletal
muscle architecture. Clin Orthop Relat Res
2001;383:140-151.
22. Lieber RL, Fridén J. The physiology of tensioningin tendon transfer surgery. In: van Heest A (ed).
Tendon transfer surgery of the upper extremity:
A master skills publication. 2012. Am Soc Surg
Hand, p. 23-33.
23. Landi A, Mulcahey MJ, Caserta G, Della Rosa N.
Tetraplegia: update on assessment. Hand Clin.
2002;18: 377-389.
24. Landi A. Update on tetraplegia. J Hand Surg
2003;28B:196-204.
25. Hentz V, Leclercq C. Surgical Rehabilitation of
the Upper Limb in Tetraplegia. New York: WB
Saunders, 2002.
26. Hentz VR, Leclercq C. The management of theupper limb in incomplete lesions of the cervicalspinal cord. Hand Clin 2008;24:175-184
27. Van Zyl N, Hahn JB, Cooper CA et al.Upper Limb
Reinnervation in C6 Tetraplegia Using a Triple
Nerve Transfer. J Hand Surg Am 2014; 39:1779183.
28. Coulet B, Allieu Y, Chammas M. Injured metamere
and functional surgery of the tetraplegic upper
limb. Hand Clin 2002;18:399-412.
29. Fridén J, Ejeskar A, Dahlgren A, et al. Protectionof the deltoid–to-triceps tendon transfer repair
sites. J Hand Surg Am 2000; 25: 144-149.
30. Fridén J. Reconstruction of elbow extension. In:
Fridén. J (Ed.) Tendon transfers in reconstructive
hand surgery. London: Taylor & Francis, 2005, p.
91-102.
31. Kozin SH, D’Addesi L, Chafetz RS, Ashworth
S, Mulcahey MJ.Biceps-to-triceps for elbow
extension in persons with tetraplegia. J Hand
Surg Am. 2010 Jun;35:968-975.
32. Leclercq C, Hentz VR, Kozin SH, Mulcahey MJ.
Reconstruction of elbow extension. Hand Clin
2008; 24: 185-201.
33. Bertelli JA, Ghizoni MF, Tacca CP. Transfer ofteres minor branch for triceps reinnervation in
tetraplegia. J Neurosurg 2011:1457-1460.
34. Bertelli JA, Ghizoni MF. Nerve transfers forelbow and ﬁnger extension reconstruction in
midcervical spinal cord injuries.J Neurosurg
2014;24:1-7.

37

committee reports

35. Bertelli JA, Ghizoni MF. Transfer of nerve branch
to the brachialis to reconstruct elbow extension
in incomplete tetraplegia: case report. J Hand
Surg Am 2012;37:1990-1993.
36. Coulet B, Boretto JG, Allieu Y, Fattal C, Laﬀont I,
Chammas M. Pronating osteotomy of the radius
for forearm supination contracture in high-level
tetraplegic patients: technique and results. J
Bone Joint Surg B 2010;92:828-834.
37. Ward SR, Peace WJ, Fridén J, Lieber RL. Dorsaltransfer of the brachioradialis to the ﬂexor pollicis
longus enables simoultaneous powering of key
pinch and forearm pronation. J Hand Surg Am
2006;31:993-997.
38. Fridén J, Reinholdt C, Gohritz A, Peace WJ, Ward
SR, Lieber RL. Simultaneous powering of forearm
pronation and key pinch in tetraplegia using asingle muscle-tendon unit. J Hand Surg Eur Vol
2012, 37:323-328.
39. Freehafer AA, Peckham PH, Keith MW, Mendelson
LS. The brachioradialis: anatomy, properties, andvalue for tendon transfer in the tetraplegic. J
Hand Surg 1988;13:99-104.
40. Fridén J, Albrecht D, Lieber RL: Biomechanicalanalysis of the brachioradialis as a donor
in tendon transfer. Clin Orthop Rel Res
2001;383:152-161.
41. Fridén J, Gohritz A. Brachialis-to-extensor carpi
radialis longus selective nerve transfer to restore
wrist extension in tetraplegia: case report. J Hand
Surg Am 2012, 37:1606-8.
42. Ejeskär A. Reconstruction of grip function in
tetraplegia. In: Fridén. J, ed. Tendon transfers inreconstructive hand surgery. London: Taylor &Francis, 2005, p. 103–120.
43. Fridén J, Reinholdt C, Gohritz A. The extensor
pollicis longus-loop-knot (ELK) procedurefor dynamic balance of the paralyzed thumbinterphalangeal joint. Tech Hand Up Extrem Surg
2013,17:184-186.
44. Ejeskär A, Dahlgren A, Fridén J. Clinicaland radiographic evaluation of surgicalreconstruction of ﬁnger ﬂexion in tetraplegia. J
Hand Surg 2005;30A:842-849.
45. Krasuski M, Kiwerski J. An analysis of the resultsof transferring the musculocutaneous nerve onto
the median nerve in tetraplegics. Arch Orthop
Trauma Surg, 1991;111: 32-33.
46. Mackinnon SE, Yee A, Ray WZ. Nerve transfers forthe restoration of hand function after spinal cord
injury. J Neurosurg 2012;117:176-185.
47. Arnet U, Muzykewicz DA, Fridén J, Lieber RL.
Intrinsic hand muscle function, part 1: creating afunctional grasp. J Hand Surg Am 2013, 38:20932099.
48. Muzykewicz DA, Arnet U, Lieber RL, Fridén J.
Intrinsic hand muscle function, part 2: kinematiccomparison of 2 reconstructive procedures. J
Hand Surg Am 2013,38:2100-2105.
49. McCarthy CK, House JH, Van Heest A et al.
Intrinsic balancing in reconstruction of thetetraplegic hand. J Hand Surg Am 1997;22:596604.

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50. Fridén J, Gohritz A, Turcsanyi I, Ejeskar A.
Restoration of active palmar abduction of thethumb in tetraplegia by tendon transfer of theextensor digiti minimi to abductor pollicis brevis.
J Hand Surg Eur Vol 2012,37:665-672.
51. Fridén J, Reinholdt. Current concepts inreconstruction of hand function in tetraplegia.
Scand J Surg 2008;97:341-346.
52. Bertelli JA, Tacca CP, Ghizoni MF et al. Transferof supinator motor branches to the posterior
interosseous nerve to reconstruct thumb andﬁnger extension in tetraplegia: case report. J
Hand Surg 2010;35A:1647-1651.
53. Reinholdt C, Fridén J. Rebalancing the tetraplegic
wrist using extensor carpi ulnaris-tenodesis. J
Hand Surg Eur Vol 2013,38:22-28.
54. Fridén J, Lieber R: Spastic muscle cells are shorterand stiﬀer than normal cells. Muscle Nerve
2003;27 :157-164.
55. Reinholdt C, Fridén J. Selective release of
the digital extensor hood to reduce intrinsic
tightness in tetraplegia. J Plast Surg Hand Surg.
2011, 45: 83-89.
56. Fridén J, Reinholdt C, Turcsanyí I, Gohritz A. A
single-stage operation for reconstruction ofhand ﬂexion, extension, and intrinsic function in
tetraplegia: the Alphabet procedure. Tech Hand
Up Extrem Surg. 2011,15:230-235.
57. Reinholdt C, Fridén J. Outcomes of single-stage
grip-release reconstruction in tetraplegia. J Hand
Surg Am 2013; 38:1137-1144.
58. Fridén J, Shillito MC, Chehab EF, Finneran JJ, Ward
SR, Lieber RL. Mechanical feasibility of immediate
mobilization of the brachioradialis muscle after
tendon transfer. J Hand Surg Am 2010;35:14731478.
59. Brown SH, Hentzen ER, Kwan A, Ward SR, Fridén J,
Lieber RL. Mechanical strength of the side-to-side
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Surg Am 2010, 35: 540-545
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mechanical strength of side-to-side tendon repair
with mismatched tendon size and shape. J Hand
Surg Eur Vol. 2014 Jan 10. [Epub ahead of print]
61. Benassy J. A case of transposition of the musculocutaneous nerve upon the median nerve.
Paraplegia 1965; 3; 199–202
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for Spinal Cord Injury. World J Neurosurg
2013;80(6):e319-326
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Tetraplegia using Innovative Methods from
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ABBREVIATIONSAPB
Abductor Pollicis Brevis
APL
Abductor Pollicis Longus
BR
Brachioradialis
CMC Carpo-Metacarpal
DIP
Distal Inter-Phalangeal
ECU
Extensor Carpi Ulnaris
EDC Extensor Digitorum Communis
EDM Extensor Digiti Minimi
ECRB Extensor Carpi Radialis Brevis
ECRL Extensor Carpi Radialis Longus
EPL
Extensor Pollicis Longus
FDP
Flexor Digitorum Profundus
FDS
Flexor Digitorum Superﬁcialis
FPL
Flexor Pollicis Longus
MCP Meta-Carpo-Phalangeal
PIP
Proximal Inter-Phalangeal
PNI
Peripheral Nerve Injury
PT
Pronator Teres
SCI
Spinal Cord Injury

A cohort study example on
the swing traction method
for complex intra-articular
PIP fractures
Lisa O’Brien, PhD
Post Doc Research Fellow, Faculty of Medicine, Nursing and Health Sciences, Monash University
B App Sc OT, M Clin Sc (Hand & Upper Limb rehab), Graduate Certificate: Clinical Research Methods

Ideally, a study comparing two
interventions would be conducted
as a randomised controlled trial(RCT), the most scientiﬁcally rigorous
research methodology. The main
advantage of this design is that random
assignment tends to make the groups
comparable both in terms of measured
characteristics and characteristics thatwere not (or could not) be measured.1
If groups are comparable at baseline,
we can be conﬁdent that diﬀerences inoutcomes after intervention reﬂect thetrue eﬀects of the intervention. A major
disadvantage of RCTs is the ethicalissue associated with conducting anexperiment where patients do not get
to choose their preferred treatment.
Trials are also resource-intensive,
costly, and time consuming. They canalso be diﬃcult to implement whenpractitioners have strong preferences
for a particular intervention.
When it is not ethical or feasible
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to conduct an experiment (e.g. theintervention is possibly risky, thecondition is rare, or outcomes takea long time to become evident) it ispossible to directly compare the resultsof diﬀerent treatment regimens using
a cohort study. 2 This is referred to ascomparative eﬀectiveness research(CER).3 Whilst these observational
studies lack the statistical purity of
randomised controlled trials, results canbe both scientiﬁcally rigorous and more
relevant to clinicians than a standard
clinical trial providing key variables incomparison groups are either matchedat baseline or controlled for in analysis.
Cohort studies also have the advantage
of being able to examine multiple
outcomes from exposure to the same
treatment or risk.
To give an example, our research
unit recently completed a multicentre cohort study to compare
long-term outcomes in two groups

with similar characteristics and injury
types (complex intra-articular Proximal
Inter-Phalangeal (PIP) fractures of 2nd4th digits). 4 We hypothesised that
there is no long-term (i.e. > 12 month)diﬀerence between swing traction
and no-traction (with or without
surgical ﬁxation) in terms of motion,
pain, function, patient satisfaction, or
treatment cost. Adults with a historyof complex PIP fractures aﬀecting ≥30% of articular surface injury at least
12 months prior were identiﬁed fromdatabase searches at three public
hospitals and a private clinic andinvited to participate. X-rays (see Figure
1 for example) taken at the time of
injury were graded by two blindedassessors (hand surgery registrars)
and participants attended a clinic formeasurement of range of motion(ROM) and self-reported function, pain,
and satisfaction by a trained assessor
who had not treated the patient.

39

hand therapy

Participant data were then grouped bytreatment provided. One group (N=17)
was treated with swing traction witha forearm based orthosis – either thevolar design by Kadelbach5 or the dorsal
design by Murray and McIntyre6 andthe other group (N=14) had no-traction,with or without surgical ﬁxation.
The volar design is shown in
Figures 2 and 3. A single K-wire isplaced perpendicularly throughthe bone distal to the injured joint,
and rubber bands or springs areattached from the K-wire to a frame
to provide a distraction force. The
orthosis has a forearm component
for counterbalance and to prevent
distal slippage of the device, whichis then worn for up to six weeks.
The beneﬁts of the swing design,
according to its creators, is that it issmaller than arcuate designs (such as
the Banjo or Schenck) thus minimally
impacting on daily routine, allowing

Figure 1 example of patient X-ray

40

hand therapy“Whilst theseobservational studies
lack the statisticalpurity of randomised
controlled trials,
results can be bothscientifically rigorousand more relevant
to clinicians thana standard clinical
trial providing
key variables incomparison groups
are either matched atbaseline or controlled
for in analysis.”

Figure 2 Patient with volar swing design traction
orthosis, with PIP in flexion

for easy compliance and pain-freerehabilitation. This assumption was,however, challenged in a qualitative
study of twelve people who had
undergone the traction protocol,7most of whom reported very highlevels of pain on commencement of
motion.
RCT methodology was considered
unfeasible given the rarity of the injury
and strong surgeon and therapist
preferences for particular treatment
protocols at the respective centres. We
chose an observational cohort study inwhich treatment was provided at theindividual’s own centre, however weensured that assessors not involved in
the treatment measured the outcomes.
This allowed us to conduct a measureof individual eﬀectiveness in a method
similar to that used in studies oftreatments for other rare injuries or
diseases.8 This comparison is “unbiased
if the groups have the same prognosis

Figure 3 Patient with volar swing design traction
orthosis, with PIP in extension
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at baseline and are treated similarly
during follow-up (except for diﬀerencesthat are a direct consequence of
whether the patient started regimen Aor B)” 9,p372

Results
In our study, the primary outcome
was combined motion of the PIP anddistal inter-phalangeal (DIP) joints,
expressed as Total Active Motion(TAM). Strickland’s original systemfor classifying ﬁnger movement
was then used to categorise therange of movement outcome.10 This
simpliﬁcation of the TAM system
was originally designed to evaluate
outcomes post ﬂexor tendon injuries,
but has been used for intra-articular
PIP fractures.11 It does not include
motion of the metacarpo-phalangeal
joints, as this is usually not aﬀected in
PIP fractures and could therefore bias
the measurement of the functional
result. In this system, the total ﬂexion
minus the extension deﬁcit (calculated
as above) is then compared with atheoretical ﬁnger in which this value
would be 175°. Results are classiﬁed(from a percentage score comparedwith 175°) into four categories:
excellent (85-100%) good (70-84%) fair(50-69%) and poor (≤49%). Strickland’s
system is useful as it provides
comparison with a norm, and theavailability of a normal contralateralﬁnger is not a prerequisite for themeasurement.12
Secondary outcomes were physicalfunction and symptoms as measured
by the Disabilities of Arm, Shoulder
and Hand (DASH), patient satisfaction,
pain, complication rates, and cost oftreatment (based on mean resource
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consumption per group). Mean timesince injury was 32.6 months in theswing traction group and 39.7 months
in the no-traction group.
The mean combined range of
motion of the PIP and DIP in the swing
traction group was 141.9°; in the notraction group it was 100.8° (meandiﬀerence= 41.1° 95% CI 11.28;70.92;
p=0.008) and clinically important as
it was double the mean CID of 20°.
Strickland score means were 80.1%(categorised as a good result) for
the swing traction group and 57.6%(categorised as fair) for the no-tractiongroup (mean diﬀerence=22.5% 95%
CI 6.56;38.48; p=0.007). There were nodiﬀerences in DASH scores, pain orsatisfaction. Complications (swan-neckdeformity, cold sensitivity, malunion,
infection, or adhesions) occurred inover half of both groups. During thetreatment phase, the swing tractiongroup attended hand therapy anaverage of 13.3 times, and the notraction group attended 11.7 times.
Average costs for swing traction wereless than for surgical ﬁxation with notraction.
As with all non-randomised studies,
however, the major disadvantage ofour design was the inability to ensurethat groups were equal at baseline on
variables not measured, and that all
treatment variables (other than thepresence of swing traction) were strictly
controlled. In the no-traction groupespecially, there was a variety of surgicaltreatment provided compared to thetraction group.
In summary, the cohort study
methodology allowed us to complete
the study without the complications
and expense associated with random

allocation to treatment, including
diﬃculties imposing non-preferredtreatment on surgeons, therapists andpatients.
It was completed on a modest
budget, thanks to small grant funding
from Victorian Occupational Therapy
Trust.

REFERENCES
1.

Cox DR, Reid N. The theory of the design ofexperiments: CRC Press; 2000.
2. Rosenbaum PR. Observational studies: Springer;
2002.
3. Kay LG, Bundy AC, Clemson LM. Predicting ﬁtness
to drive using the visual recognition slide test
(USyd). Am. J. Occup. Ther. 2008;62(2):187-197.
4. O’Brien LJ, Simm AT, Loh IW, Griﬃths KM. Swing
traction versus no-traction for complex intraarticular proximal inter-phalangeal fractures. J.
Hand Ther. 2014;27(4):309-316.
5. Kadelbach D. Swing design dynamic traction
splinting for the treatment of intra-articular
fractures of the digits. J. Hand Ther. Jan-Mar 2006
19(1):39-42.
6. Murray K, McIntyre F. Active traction splinting forproximal interphalangeal joint injuries. Ann. Plast.
Surg. 1995 35(1):15-18.
7. O’Brien L, Presnell S. Patient experience ofdistraction splinting for complex intra-articularﬁnger fractures. Journal of Hand Therapy.
2010;23(3):249-259.
8. Maybaum S, Mancini D, Xydas S, et al. Cardiac
improvement during mechanical circulatory
support a prospective multicenter studyof the LVAD working group. Circulation.
2007;115(19):2497-2505.
9. Oﬃce of the Superintendent of Motor Vehicles.
British Columbia Driver Fitness Handbook for
Medical Professionals. In: Justice Mo, ed. Victoria,
BC2014.
10. Strickland J, Glogovac S. Digital function
following ﬂexor tendon repair in Zone II: A
comparison of immobilization and controlled
passive motion techniques. The Journal of handsurgery. 1980;5(6):537-543.
11. Debus G, Courvoisier A, Wimsey S, Pradel P,
Moutet F. Pins and Rubber Traction System for
intra-articular proximal interphalangeal joint
fractures revisited. Journal of Hand Surgery(European Volume) 2010;35(5):396-401.
12. Stegink Jansen C, Watson M. Measurement ofrange of motion of the ﬁnger after ﬂexor tendon
repair in zone II of the hand. The Journal of Hand
Surgery. 1993;18(3):411-417.

41research roundup

Journal of Wrist Surgery

Re-repair of ruptured primary
flexor tendon repairs in Zones I
and II of the fingers in children

Now Indexed
In PubMed
Central

Saudi Arabia

A paper published in the European
Journal of Hand Surgery by Professor
M Al-Qattan from the Division of
Plastic Surgery, King Saud University
in Riyadh, looked at the aetiology,
management, and results of acuterupture of primary ﬂexor tendon
repairs in Zones I and II of the ﬁngers
in children. The study reported on a
personal series of 10 children treatedover a period of 13 years.
Professor Al-Qattan was prompted
to conduct this particular study due
to the fact that re-repair of ruptured
primary ﬂexor tendon repairs in Zones
I and II of the ﬁngers had not beenpreviously investigated in children.
Previous reports only focused on
adults.
Al-Qattan highlighted the threemost important points about his study
and its results:
1. The aetiology of tendon rupture
is diﬀerent when compared to adults:
children less than 5 years of age usuallyrupture their primary repairs whilst thehand is completely immobilised in acast; while teenagers usually rupture
their tendons when falling down while
playing
2. Direct re-repair is possible

42

without lengthening at the musculotendinous junction if the re-repair isdone within 3 weeks of the primary
repair
3. Do not expect excellent results“The study revealed that the results
were worse than other paediatricseries of primary ﬂexor tendon repairs.
Since the results are not excellent,the ﬁndings of my study raises
the question regarding the mostappropriate management particularlyin those with signiﬁcant tension acrossthe re-repair since two-stage tendon
reconstruction in children is known toyield excellent or good results in the
majority of cases,” he added.
In terms of future research on
this topic, Al-Qattan and his teamare working on a prospective multicenter study comparing the resultsof re-repair versus two-stage tendon
reconstruction.

“Children lessthan 5 yearsof age usuallyrupture theirprimary repairs
whilst the handis completely
immobilised
in a cast; while
teenagers usuallyrupture theirtendons whenfalling down while
playing”

The Journal of Wrist Surgery covers a range of issues relating to the investigationand treatment of disorders and injuries of the wrist. In addition to originalpeer-review articles, this quarterly periodical provides details on emerging surgical
techniques and new technologies, special focus sections and case reports.
The journal also oﬀers the nouvelle concept of peer-reviewed surgical videos.
Why publish in the Journal of Wrist Surgery?
• Rigorous peer-review by top wrist specialists • International editorial board• Rapid online publication • Web-based manuscript submission
We look forward to receiving your submission.
Manuscripts must be submitted electronically.

http://www.editorialmanager.com/jws

JOURNAL REFERENCE
J Hand Surg Eur Vol March 2015
vol. 40 no. 3 271-275
http://jhs.sagepub.com/
content/40/3/271.abstract

IFSSH ezine MAY 2015

For author instructions and further information about publishing inor subscribing to the Journal of Wrist Surgery, email jws@thieme.com

research roundup

research roundup

The non-operative
management of hand fractures
UK

Professor Grey Giddins from the Royal
United Hospital, Bath, UK, recently
undertook a review that was publishedin the European Volume of the Journalof Hand Surgery, with the aim toestablish which hand fracture injuries
are unlikely to be improved withsurgery. The intention was to prevent
unnecessary surgery, concentrate workon ﬁnding the sub-groups that may
beneﬁt from surgery and to establish
which injuries do so well with nonoperative treatment that the only
valuable clinical research in future
will be large cohort studies of nonoperative treatment or randomised
controlled trials comparing operativeand non-operative treatments.
The optimal treatment ofmany fractures, such as proximal
interphalangeal joint fracture
subluxations or spiral phalangeal
fractures, is unclear. Other relevant
fractures are spiral metacarpal fractures,transverse metacarpal shaft and neck(boxer’s) fractures, base of proximal
phalanx avulsion fractures, thumbmetacarpophalangeal joint ulnar andradial collateral ligament injuries andbony mallet injuries. For the majorityof these injuries, current knowledge
suggests that the outcome of nonoperative treatment cannot reliably be
improved upon with surgery.

44“I think that most hand fractures
are not operated on by most handsurgeons, but there is a cohort of cases
where I would not operate and others
would. There will be a range of reasonsfor this, some better than others. For
some surgeons their practice will be
diﬀerent with the patients perhaps
being less likely or able to come forfollow-up and therefore may be better
suited to surgical stabilisation. Theremay be speciﬁc instances of people
needing to return to work or sport
more quickly, in which case surgery
may be of value. There are times whenas surgeons we treat the radiographs(x-rays) perhaps more than we treat
the patient and we worry about
getting perfect ‘bone alignment’ rather
than recovery of function, which canoften be achieved non-operatively. I
think there is also a particular problem
of subset bias. Thus many, if not mostof us, are inﬂuenced by one or twocases we have seen where one lineof treatment has not worked and wehave been discouraged by it; that may
be because for some injuries which
generally do well with a particulartreatment, there is be a subset which
do not do well. I suspect we have not
identiﬁed those as we have either not
looked carefully or cleverly enough at
the cases we have seen.

There will also be cultural aspects
with some patients ‘demanding’surgery and then there may be greaterﬁnancial rewards for surgeons who
operate. I do not believe it is my role
to try to judge what surgeons do.
Rather I wanted to identify some of
the common injuries we treat where
surgery is often recommended in
the literature, but a careful review ofpublished work suggests that nonoperative treatment gives very reliable
results so there is at most only a very
limited role for surgery,” Professor
Giddins explained.
When asked what should all handsurgeons and therapists reading thearticle understand about this study
and its results, Giddins said:“The ﬁrst message is the same asgiven by our predecessors that mostclosed hand injuries can be treatedsuccessfully non-operatively. I want tostress that we need to be clear about
the natural history of any injury, i.e.
how will it do with appropriate nonoperative treatment. Only then can we
decide whether it is likely that surgery
might help. With these data we will
also establish a baseline from which toassess any surgical intervention. If, as
shown with some of these injuries, theoutcome is typically very good with
non-operative treatment, then the
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chances of surgery reliably improvingon that are so small that surgery will
rarely be indicated.
That does not mean that in
the future new, hopefully better
techniques, will not be developed andit may be that these will give evenmore superior results. Given the goodresults that are achieved with the nonoperative treatment of the majority ofthese injuries however, this is probably
not the best area to research newtechniques; rather we should look forsubgroups which respond diﬀerently
to our expectations and at thetreatment of those conditions which
do less well non-operatively thanoperatively.”
In terms of continued researchin this area, Giddins is undertaking a
number of studies, including further
systematic reviews of the outcome oftreatment of common injuries, as well
as further studies looking at the natural
history of non-operative treatment ofvarious conditions.
“I think there is a rich vein ofopportunity in trying to identify
subsets of various injuries. Our researchin the past has been hampered bymixing up injuries that were not thesame. Thus a fracture subluxationof the PIP joint is diﬀerent to a pilon
fracture. It may present in a similar way,
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the treatment options may be similar,
but these are two diﬀerent injuries
and should be assessed separately. Bycollecting larger series of cases withdetailed observations, I think we will
start identifying subsets of conditions
which do less well (or better). We may
identify which subsets of a particular
problem need surgical treatment. This
could explain much of the variability inpractice whereby some surgeons arelooking at one end of the telescope,e.g. seeing that the majority ofperhaps thumb metacarpo-phalangeal
joint ulnar collateral ligament bony
avulsions do well non-operatively andso they treat them all non-operatively,
accepting occasional poor results.
Other surgeons may be looking at
the other end of the telescope andhave recognised that there are somepatients with ulnar collateral ligamentbony avulsions who do poorly andtherefore they tend to treat all of them
surgically to avoid those poor results.
Unfortunately in the latter group many
patients will have unnecessary surgery.
If we could identify the important
subsets of any one condition wewould hopefully become better at
identifying which ones need surgery
and which do not,” he concluded.

“most closed hand
injuries can betreated successfully
non-operatively”

JOURNAL REFERENCE
J Hand Surg Eur Vol January 2015
vol. 40 no. 1 33-41
http://jhs.sagepub.com/
content/40/1/33.abstract45

remembering our pioneers

remembering our pioneers

Pioneer profiles
Ridvan Ege, MD
Dr Ridvan Ege received his
medical degree and generalsurgery training at Gülhane
Medical School in Ankara,
Turkey and was Board certiﬁed
in 1955. From 1956 to 1959,
he trained under Dr David
Bosworth in orthopaedic
surgery in Boston and received
his Board Certiﬁcation in 1960.
In 1961, he established the ﬁrst
Department of Orthopaedic
Surgery and Traumatology
in Turkey at Gülhane Military
Medical School and was
appointed Director. He wasalso Associate Professor at the
University of Ankara. Dr Ege
later returned to the UnitedStates and worked as a Fellow
with Dr Green at the Children’s
Hospital Department ofOrthopaedic Surgery in Boston
and with Drs Stinchﬁeld andCarroll at the Columbia Presbyterian Hospital in New York
City. He was then promoted to Professor and Chairman of
the Department of Orthopaedic Surgery and Traumatologyof the Ankara University, a position which he held until
1993. He also founded the Ankara University School of
Nursing and acted as Director for eight years. Dr Ege
received a Fulbright Scholarship (1967-68) and completed
his hand surgery training with Dr Carroll in New York, Dr
Flatt in Iowa and Dr Boyes in California.
In 1959, there were nine Board Certiﬁed Orthopaedists
in Turkey and thirty in 1969. Dr Ege established the TurkishSociety for Orthopaedic Surgery and Traumatology in1970 and has served as President for many years. Due to

46

James M Hunter, MD
his organised eﬀorts, Turkey has
now 1 600 trained orthopaedists
and he is considered the ‘father
of modern orthopaedics’ in his
country. Dr Ege established theMediterranean and MiddleEastern Society of Orthopaedics
and Traumatology in 1970 and
was President for 12 years during
which time he organised sevencongresses. He organised theﬁrst Hand Injury Symposium in1970 in Ankara where Drs Carroll,
Brooks, Ege, Fahmy, Omer andSwanson were lecturers. Thatsymposium stimulated manycolleagues to receive handsurgery training in USA, France,
Germany and Italy in addition
to 70 trained in Turkey. He
established the Turkish Society for
Surgery of the Hand in 1977 andhas been its President for 18 years.
Dr Ege established the Turkish
Journal of Bone and Joint and Hand Surgery and served
as its ﬁrst Editor. He has published upwards of 300 articles
and more than 100 books on Traumatology, Spine, Hip
and Hand Surgery. He is also a member of 16 International
Societies. The Ufuk University Doctor R Ege Hospital isnamed in honour of his immense contributions. Dr Ege was
the organiser of the 8th IFSSH Congress in Istanbul, Turkey,
in 2001. In July 1995, at the 6th Congress of the IFSSH(Helsinki , Finland), he was honoured as a Pioneer of Hand
Surgery.

IFSSH ezine MAY 2015

Dr Hunter was born in
Merchantville, New Jersey in1924. His college education
was interrupted by service inthe US Army during World War
II. He ﬁrst served in the Field
Artillery. While caring for the
wounded as operating room
Staﬀ Sergeant at the 1st General
Hospital in Paris, France, he saw
medicine as his future career.
He returned to Dickinson
College and later graduatedfrom Jeﬀerson Medical College
in Philadelphia. His interest in
hand surgery developed during
his orthopaedic residency at
Jeﬀerson’s under Dr Anthony
DePalma. He became Dr Robert
Carroll’s ﬁrst Hand Fellow
at Columbia-Presbyterian
Hospital in New York in 1958.
He returned to Jeﬀerson andestablished a Division of Hand
Surgery in Dr De Palma’s Orthopaedic Department. During
his 25 years as Chief of Hand Surgery, he trained 109 handsurgery fellows.
Dr Hunter introduced his concept of an artiﬁcial tendon
at the Tendon Symposium organised by Ramsay Straubin New York in 1964. His work was proclaimed a major
breakthrough in tendon reconstruction by Leo Mayer and
Guy Pulvertaft.
Dr Hunter has been honoured by membership in the
Hand Societies of countries throughout the world. His
many clinical appointments include consultant in Hand
Surgery to the Philadelphia Naval Hospital during the
Korean War, to the Valley Forge General Hospital during
IFSSH ezine MAY 2015

the Vietnam War and the State
Hospital for Crippled Children in
Elizabethtown for 25 years.
Dr Hunter’s vision of theimportance of the surgeon,
therapist and patient working asa team to get ideal results was
the impetus for the yearly Hand
Rehabilitation Symposium heldin Philadelphia since the early
70’s and attended by more thanﬁfteen thousand therapists andsurgeons from around the world.
The textbook, “Rehabilitation of
the Hand: Surgery and Therapy”,
has had numerous editions. He
has also published numerous
articles and lectured at meetings
worldwide.
Dr Hunter served as Professor
Emeritus of Orthopaedic Surgery,
Division of hand Surgery, at
the Jeﬀerson Medical College
and was named “Distinguished
Professor in Orthopaedic Surgery” in 1990. He was active
in developing new techniques to manage complications
following peripheral nerve and brachial plexus injuries. Dr
Hunter’s enthusiasm for teaching has won him the respectof his many colleagues, fellows, residents and students.
On 29 January 2013, James M Hunter passed away at
the age of 88 years. He was bestowed the title of Pioneerof Hand Surgery by the IFSSH at the 6th Congress of theFederation at Helsinki in July 1995.

47

journal highlights

journal highlights

Journal Highlights

Hand Volume 9 – Issue 4, December 2014

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

Journal of Hand Surgery (European Volume)
February 2015 J Hand Surg Eur Vol 40, Issue 2❚ Collagenase clostridium histolyticumin patients with Dupuytren’scontracture: results from POINT X,
an open-label study of clinical andpatient-reported outcomes❚ Early outcomes of a sequential seriesof 144 patients with Dupuytren’scontracture treated by collagenase
injection using an increased dose,
multi-cord technique❚ Safety and tolerability of collagenase
Clostridium histolyticum andfasciectomy for Dupuytren’scontracture❚ What patients want from thetreatment of Dupuytren’s disease— is the Unité Rhumatologique desAﬀections de la Main (URAM) scale
relevant?
❚ A review of the classiﬁcation of
Dupuytren’s disease❚ Dynamism in Dupuytren’scontractures❚ Genetic and environmental inﬂuencesin Dupuytren’s disease: A study of
30,330 Danish twin pairs❚ Commentary on Larson et al. Genetic
and environmental inﬂuences in
Dupuytren’s disease: A study of 30,330
Danish twin pairs❚ Single versus repetitive injection

48

of lignocaine in the managementof carpal tunnel syndrome – arandomized controlled trial❚ Commentary on Akarsu et al.
Single versus repetitive injectionof lignocaine in the managementof carpal tunnel syndrome – arandomized controlled trial❚ Outcome of carpal tunnel release –Correlation with wrist and wrist–palm
anthropomorphic measurements❚ Supraretinacular endoscopic carpal
tunnel release: surgical technique withprospective case series❚ Commentary on Ecker et al.
Supraretinacular endoscopic carpal
tunnel release: surgical technique withprospective case series❚ The Korean version of the Carpal
Tunnel Questionnaire. Cross cultural
adaptation, reliability, validity andresponsiveness❚ Stuck on me – Dupuytren’s diseaseof the ﬁnger presenting as complete
synechium of the ﬁnger to the palm
❚ The value of diﬀerent inﬂammatory
markers in distinguishing deep closed
hand infections from non-infective
causes❚ Surgical rehabilitation for correctionof severe ﬂexion contracture of theproximal interphalangeal joint by
modiﬁed Ilizarov method❚ Anatomic course of the medial
antebrachial cutaneous nerve: acadaveric study with proposed clinicalapplication in failed cubital tunnel
release❚ Multiple subungual glomus tumours
associated with neuroﬁbromatosis
type 1❚ Finger tourniquets: a review of
National Patient Safety Agency
recommendations, available devices
and current practice❚ Avoiding extensor tendon rupture
after the use of palmar locking plates
for distal radial fractures❚ Objective results of median nerve
decompression and tenosynovectomy
for carpal tunnel syndrome in patientswith mucopolysaccharidoses Types I
and II❚ Intraoperative migration of a foreign
body within the tendon sheath of the
ﬂexor pollicis longus❚ Involvement of hand surgeons
in research on the genetics andpathogenesis of congenital upper
limb anomalies

IFSSH ezine MAY 2015

❚ An open-label comparison of local

anesthesia with or without sedation forminor hand surgery❚ Distal humeral hemiarthroplasty:
indications, results, and complications.
A systematic review❚ A quantitative study of vibration injury
to peripheral nerves—introducing a
new longitudinal section analysis❚ Non-surgical treatment of lateralepicondylitis: a systematic review of
randomized controlled trials❚ Postapproval clinical experience in thetreatment of Dupuytren’s contracturewith collagenase clostridium
histolyticum (CCH): the ﬁrst 1,000 days
❚ The incidence of postoperative ﬂarereaction and tissue complications in
Dupuytren’s disease using tension-free
immobilization❚ Median nerve compression at theﬁbrous arch of the ﬂexor digitorum
superﬁcialis: an anatomic study of thepronator syndrome❚ Surgical management of the wrist
in children with cerebral palsy andtraumatic brain injury❚ Long-term follow-up of ﬁrst metacarpal
extension osteotomy for early CMC
arthritis❚ Anomalous ﬁrst thoracic rib as a causeof thoracic outlet syndrome with upper
trunk symptoms: a case report❚ Radiographic interpretation of distal
radius fractures: visual estimations
versus digital measuring techniques❚ Evidence for safe tourniquet use in
500 consecutive upper extremity
procedures❚ The Meniscus Arrow® as a ﬁxation
device for the treatment of mallet
fractures: results of 50 cases❚ Diﬀerences in response rates between
mail, e-mail, and telephone follow-up in
hand surgery research❚ Intraoperative evaluation of dorsal
screw prominence after polyaxial volar
plate ﬁxation of distal radius fracturesutilizing the Hoya view: a cadaveric
study❚ Volar locking plate ﬁxation of distal
radius fractures: use of an intra-

operative ‘carpal shoot through’ view to
identify dorsal compartment and distal
radioulnar joint screw penetration❚ Curvatures of the DIP joints of the hand
❚ Treatment preferences for trigger
digit by members of the American
Association for Hand Surgery❚ The treatment of extensor lagof the middle ﬁnger following
crushing–penetrating injuries of themetacarpophalangeal joint: case series❚ Integra® dermal regenerative template
application on exposed tendon❚ Upper Extremity Orthoses Use in
Amyotrophic Lateral Sclerosis/Motor
Neuron Disease: Three Case Reports❚ Anomalous muscles within the ﬁrst
dorsal extensor compartment of thewrist❚ Carpal tunnel syndrome secondary
to an accessory ﬂexor digitorum
superﬁcialis muscle belly: case reportand review of the literature

Journal of Wrist Surgery Issue 03 Volume 04 · November 2014
❚ Carpal Tunnel Syndrome❚ Routine Imaging after Operatively

Tenosynovitis

Pathophysiology: Role of Subsynovial
Connective Tissue❚ Biomechanical Role of the Transverse
Carpal Ligament in Carpal Tunnel
Compliance❚ The Transverse Carpal Ligament:
Anatomy and Clinical Implications❚ Carpal Tunnel Release: Do We
Understand the BiomechanicalConsequences?

Repaired Distal Radius and Scaphoid
Fractures: A Survey of Hand Surgeons❚ The Utility of the Fluoroscopic Skyline
View During Volar Locking Plate
Fixation of Distal Radius Fractures❚ Proximal Migration of Hardware in
Patients Undergoing Midcarpal Fusion
with Headless Compression Screws❚ Intraneural Ganglion in Superﬁcial
Radial Nerve Mimics de Quervain❚ Ligamentous Radiocarpal Fracture-

IFSSH ezine MAY 2015

Dislocation Treated with WristSpanning Plate and Volar Ligament
Repair❚ Avascular Necrosis of the Hamate:Three Cases and Review of the
Literature

49journal highlights

journal highlights

Journal of Hand Surgery: American volume

Hand Surgery: Asia PacificVolume 20, Number 1❚ Triangular Fibrocartilage Complex❚ Delineation Of Extensor Tendon Of

Tears

The Hand By Mri: Usefulness Of “SoapBubble” Mip Processing Technique❚ Surgical Outcomes Of Fifth Metacarpal
Neck Fractures — A Comparative
Analysis Of Dorsal Plating Versus
Tension Band Wiring❚ Factors Aﬀecting The Functional
Results Of Open Reduction And
Internal Fixation For FractureDislocations Of The Proximal
Interphalangeal Joint❚ Hemi-Hamate Arthroplasty
Versus Transarticular Kirschner
Wire Fixation For Unstable Dorsal
Fracture-Dislocation Of The Proximal
Interphalangeal Joint In The Hand
❚ Amniotic Constriction Bands: A
Case Series And Proposed New
Classiﬁcation System❚ A Retrospective Review Of Troubled
Replantations❚ Postoperative Voluminal Flap
Reduction After Fingertip
Reconstruction Using The Reverse
Digital Artery Island Flap
❚ A Case Report Of Acute Cubital
Tunnel Syndrome Caused By Venous
Thrombosis❚ Complete Closed Brachioradialis
Tendon Rupture: A Case Report❚ Closed Traumatic Rupture Of The
Flexor Pollicis Longus Tendon In Zone
T I: A Case Report❚ Closed Traumatic Rupture Of The
Flexor Pollicis Longus Tendon In Zone
T I: A Case Report❚ Irreducible Volar Subluxation Of
The Proximal Interphalangeal Joint❚ A2 Pulley Integrity And The

Strength Of Flexor Tendon Repair: A
Biomechanical Study In A Chicken
Model❚ Inﬂuence Of Diﬀerent Length Of Core
Suture Purchase Among Suture Row
On The Strength Of 6-Strand Tendon
Repairs❚ Cross-Cultural Adaptation, Validation,
And Reliability Of The Michigan Hand
Outcomes Questionnaire Among
Persian Population❚ The Greek Version Of The Hand20
Questionnaire: Crosscultural
Translation, Reliability And Construct
Validity❚ Neuropathic Pain In Brachial Plexus
Injury❚ Impact Of Phrenic Nerve Paralysis On
The Surgical Outcome Of Intercostal
Nerve Transfer❚ The Tricipital Aponeurosis — A
Reliable Soft Tissue Landmark For
Humeral Plating❚ Clinical Radiographic Features Of The
Wrist Without Osteoarthritis And Its
Relations To Age And Sex In Japanese❚ Radial Nerve Lacerations — The
Outcome Of End-To-End Repairs In
Penetrating Trauma❚ Biphasic Motion Of The Median Nerve
In The Normal Asian Population❚ Patient Related Functional Outcome
After Total Wrist Arthroplasty: A Single
Center Study Of 206 Cases❚ Hand And Wrist Injuries In Professional
County Cricket

50

Volume 40, Issue 2, (February 2015)
Due To Radial Collateral LigamentInterposition: Case Report And Review
Of Literature❚ A Rare Case Of Multiple
Subungual Glomus Tumours In A
Neuroﬁbromatosis Type 1 Patient❚ Surgical Correction Of Ulnar Deviation
Deformity Of The Wrist In Patients With
Birth Brachial Plexus Palsy Sequelae❚ The Use Of Bmp-2 And Screw
Exchange In The Treatment Of
Scaphoid Fracture Non-Union❚ New Technique “Graft Reposition On
Flap” In Allen Type Iv Amputation: A
Report Of Six Cases❚ Total Proximal Interphalangeal Joint
Arthroplasty For Osteoarthritis Versus
Rheumatoid Arthritis — A Systematic
Review❚ Current Management Of Hand
Enchondroma: A Review

IFSSH ezine MAY 2015

❚ Force Variations in the Distal Radius❚ The Eﬀect of Prosthetic Radial Head

❚ Pullout Wire Fixation Together With

and Ulna: Eﬀect of Ulnar Variance andForearm Motion❚ Load Transfer at the Distal Ulna
Following Simulated Distal Radius
Fracture Malalignment❚ Long-Term Functional Outcomes After
Bilateral Total Wrist Arthrodesis❚ Biomechanical Evaluation of 4-Strand
Flexor Tendon Repair Techniques,
Including a Combined Kessler–Tsuge
Approach❚ Longitudinal Split Tear of the Extensor
Pollicis Brevis Tendon: Report of 2
Cases
❚ Anatomy of the Flexor Digitorum
Profundus Insertion❚ Computed Tomography Arthrography
Using a Radial Plane View for the
Detection of Triangular Fibrocartilage
Complex Foveal Tears❚ Functionality After Arthroscopic
Debridement of Central Triangular
Fibrocartilage Tears With Central
Perforations❚ Temperature in and Around the
Scapholunate Ligament During
Radiofrequency Shrinkage: A CadaverStudy❚ Functional Outcomes of Replantation
Following Radiocarpal Amputation❚ Incipient Malunion of an Isolated
Humeral Trochlea Fracture TreatedWith an Elbow Hemiarthroplasty: Case
Report❚ The Eﬀect of Using a Cement
Gun With a Narrow Nozzle on
Cement Penetration for Total Elbow
Arthroplasty: A Cadaveric Study

Geometry on the Distribution andMagnitude of Radiocapitellar Joint
Contact Pressures❚ In Vivo Kinematics of theTrapeziometacarpal Joint During
Thumb Extension-Flexion and
Abduction-Adduction❚ Dual Mini TightRope Suspensionplasty
for Thumb Basilar Joint Arthritis: A Case
Series❚ The Eﬀect of Humerus Diaphyseal
Shortening on Brachial Plexus Tension:
A Cadaver Study❚ A Systematic Review of Outcomes
Reporting for Brachial Plexus
Reconstruction❚ Short-Term Electrical Stimulation to
Promote Nerve Repair and Functional
Recovery in a Rat Model❚ Transfer of the Radial Nerve Branch
to the Extensor Carpi Radialis Brevis
to the Anterior Interosseous Nerve to
Reconstruct Thumb and Finger Flexion❚ Biomechanical Characteristics of HemiHamate Reconstruction Versus Volar
Plate Arthroplasty in the Treatmentof Dorsal Fracture Dislocations of theProximal Interphalangeal Joint❚ A Modular Surface Gliding
Implant (CapFlex-PIP) for Proximal
Interphalangeal Joint Osteoarthritis: A
Prospective Case Series❚ The Eﬀect of an Educational Programon Opioid Prescription Patterns in
Hand Surgery: A Quality Improvement
Program❚ Dorsal Distraction Plating for Highly
Comminuted Distal Radius Fractures

Distal Interphalangeal Joint Kirschner
Wire Stabilization for Acute Combined
Tendon and Bone (Double Level)
Mallet Finger Injury❚ Nuts and Bolts: Dimensions ofCommonly Utilized Screws in Upper
Extremity Surgery

IFSSH ezine MAY 201551

upcoming events

upcoming events

Upcoming events
International
Dissection Course
On Peripheral Nerve
Surgery & Tendon
Transfers
8-10 June 2015
Alicante, Spain
http://www.studioprogress.it/
en/convegni/6th-internationaldissection-course-reconstructivemicrosurgery
This course is aimed at Plastic Surgeons,
Neurosurgeons, Orthopaedic Surgeonsand Hand Surgeons who want
to improve their technical skills inperipheral nerve surgery and palliative
tendon transfers on the upper and lower
limb. The course consists in discussion
time on clinical anatomy, dissection
techniques and lectures delivered byexperts in the ﬁeld, followed by practicalsessions with cadaver dissection
performed directly by the participants.

Hand and Wrist
Biomechanics
International (HWBI)
Symposium
16-17 June 2015
Milan, Italywww.hwbi.org/2015.html
In conjunction with 20th Congressof Federation of European Societies
for Surgery of the Hand (FESSH 2015)
and the 2nd International Thumb
Osteoarthritis Workshop (ITOW 2015),
the Symposium Chairs are Marc GarciaElias, MD, Insitut Kaplan, Spain andFrederick W. Werner, MME, SUNY Upstate
Medical University, USA.
The main topics are wrist, carpal
tunnel, thumb, ﬁnger mechanics, DRUJ,
distal radius, ligaments, tendons andbiomaterials.

July 6-10, 2015

XX FESSH Congress
17-20 June 2015
Milan, Italy
fessh2015.org
In 2015, Federation of European
Societies for Surgery of the Hand
(FESSH) is organising the Annual
FESSH Congress in the beautiful cityof Milan in Italy. The congress will
explore all aspects of hand surgery
and its impacts. Surgical technology
development, biomechanical tools,
ethical, legal, social and ﬁnancial
topics, individualised medical aspects,
diagnostic and therapeutic issues,
advanced technologies, and manyother related topics will be presented
and discussed by professionals in theirﬁelds. We encourage delegates to use
this congress as a meeting place toassemble their clinical and academic

Advanced microvascular techniques , Intensive laboratory practiceInstructor guidance , End
End-to-sideside anastomosis, Kidney transplantation

Course Outline

•
•
•
•
•

End-to-end anastomosis: femoral artery (posterior-wall-first anastomotic technique)End-to-side anastomosis: femoral artery to the side of the carotid artery
End-to-side anastomosis: jugular vein to side of carotid artery
End-to-end anastomosis: femoral vein (continuous anastomotic technique)
Kidney transplantation
Accreditations (TBC)
Guest Speaker:
HKCOS: 15 CME Points, 10 Training Points
Dr. Ping-tak Chan
CSHK: 18 CME Points
HKCORL: 12 CME Points

Program Director:
Dr. Wing-lim Tse

Program Instructors:
Dr. Edmund Cheung
Dr. Clara Wong
Organized by:

52

IFSSH ezine MAY 2015

IFSSH ezine MAY 2015

Venue:
Orthopaedic Learning Centre,

Prince of Wales Hospital, Hong Kong

Registration Fee: HKD 9,000
Registration Deadline:
April 30, 2015
Supported by:

Course Secretariat:
Ms. Charis Lau
Tel: (852) 2632 1654
E-mail: olc@ort.cuhk.edu.hk
Website: www.olc-cuhk.org

53

upcoming events

upcoming events

interest-groups. FESSH 2015 will be an
intellectually broad and exciting event at
which ideas and researchers from Europe
and around the world interact.

XV South American
Congress on Hand
Surgery
6-8 August 2015
Chilewww.schot.cl

IX International
Symposium On Spinal
Cord Injuries

3-5 December 2015
Brescia, Italy
www.midollospinale.com
Symposium Main Topics and Events
include:• Honorary Lecture by Nobel Laureate
A. Yonath• Basic and applied research inexperimental Spinal Cord repair andregeneration• Experimental studies and clinical useof stem cells and neurotrophic factors• Robotics and Telemedicine• Young Neuroscientist supported byDompè Investigator Award• The 4th “Brunelli Club Meeting”
dedicated to the most advanced
surgical and neuro- rehabilitation
techniques in the treatment of the
ﬂaccid and spastic palsies of upper
limbs, including case reports.

54

IFSSH ezine MAY 2015

World Congress ofBrachial Plexus andPeripheral Nerve
Surgery

New Delhi, India
4-7 February 2016
www.wcns2016.com
The ISPNS is a 100 member strong
young Indian Society of Brachial Plexus
and Peripheral Nerve Surgeons, which iscommitted to the spread of education
regarding the brachial plexus andperipheral nerves to young surgeons
from the country and abroad.
The event will be the 5th Annual
meeting of Indian Society of Peripheral
Nerve Surgery (ISPNS) and will featurea one-day Pre-conference cadaveric
Hands-On workshop on 4th February
2016, at Cadaveric Training and Research
Facility, All India Institute of Medical
Sciences, New Delhi; followed by 3
day long CME (5-7th February 2016)
by expert faculty from all around theglobe. The meeting is expected to
be attended by numerous delegatesfrom across the country, and abroad,including neurosurgeons, handsurgeons, orthopaedic surgeons andplastic surgeons. A number of national
and international faculty are expected toattend this event.

IFSSH ezine MAY 201555

upcoming events

upcoming events

Australian Hand Surgery Society &American Society for Surgery of the Hand
2016 Combined Meeting
Wednesday 30 March - Saturday 02 April 2016

AHSS Welcomes all
Members of the ASSH
We look foward to an exciting
academic & social program

D O LTO N E H O U S E , S Y D N E Y, N S W AU S T R A L I A
Conference Secretariat
2016ahss@tayloredimages.com.au+ 61 7 3366 2205 /+61 7 3366 5170
PO Box 247, ASHGROVE, QLD 4060
332 Waterworks Road, ASHGROVE, QLD 4060

56

IFSSH ezine MAY 2015

IFSSH ezine MAY 2015

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