ifssh
ezine

www.ifssh.info VOLUME 4 ISSUE 2 MAY 2014

Journal highlights
Executive news
Member society updates

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

Genetics of upper limb development
NEW CLASSIFICATIONFOR CONGENITALANOMALIESDART THROWINGMOTION OF THE
WRISTHAND THERAPY:MALLET FINGER
SPLINTING

NEW SUBSCRIBERS: Take 20% oﬀ
A quarterly peer-reviewed periodical covering all aspectsof wrist surgery and small bone surgery of the hand
Journal of Wrist Surgery
Editor-in-Chief: D. Slutsky
2014/Volume 3/4 issues p.a./ISSN 2163-3916
USA and Canada
Individuals: $182 $146
Institutions: $492
Please contact customerservice@thieme.com
For institutional licenses, please contact esales@thieme.com
Mexico, Central and South America
Individuals: $198 $158
Institutions: $510
Please contact customerservice@thieme.com
For institutional licenses, please contact esales@thieme.com
Europe, Africa, Asia, Australia, and New Zealand
Individuals: €139 €111
Institutions: €371
(Please add handling charges: €36)
Please contact customerservice@thieme.de
For institutional licenses, please contact eproducts@thieme.de
Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka
For subscription rates in INR, please contact
customerservice@thieme.in

SUBSCRIBE NOW AND STAY UP-TO-DATE IN 2014
Visit www.thieme.com/jws in order to subscribe or renew your subscription.
Take full advantage of your individual subscription by registering online athttps://www.thieme-connect.de/products• Individual subscribers get free online access to current and back issues of their journal(s)• Advanced online access for select journals via the eFirst service• Compatibility with smartphones and mobile devices• Advanced search across our entire library of journals

ORDER TODAY

http://www.thieme.com

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

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

Follow us @ThiemeNY

May 2014

Contents
4 Editorial

By Professor Ulrich Mennen, editor of the IFSSH ezine
Photo Gallery

5 Executive news

Newsletter from the Secretary-General:
Marc Garcia-Elias

6 Member society updates• American Association for Hand Surgery• American Society for Surgery of the Hand
• British Society for Surgery of the Hand
• Federation of South American Societies for Surgeryof the Hand
• Singapore Society for Hand Surgery• Slovak Hand Surgery Society• Spanish Society for Hand Surgery• Swiss Society of Surgery of the Hand
• Turkish Society of Hand and Upper Extremity
Surgery

14 Committee reports• IFSSH Scientiﬁc Committee on Congenital
Conditions: Classiﬁcation of Congenital Hand andUpper Limb Abnormalities• IFSSH Scientiﬁc Committee on Genetics in
Hand Surgery: New Insights on Upper Limb
Development: Digitising the Hand

IFSSH ezine MAY 2014

• IFSSH Scientiﬁc Committee on Anatomy andBiomechanics: Wrist biomechanics and Instability Wrist dart-throwing motion updated

30 Hand therapy

Mallet ﬁngers around the globe: Does one best
method for immobilisation and mobilisation exist?
Julianne Howell

37 Research roundup
Basic science of bone healing

38 Special feature
40 Pioneer profiles
Douglas Lamb
Luis Gómez Correa

42 Journal highlights

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

46 Upcoming events

List of global learning events and conferences forhand surgeons and therapists

3editorial

Important information for Delegates
The IFSSH Charter states that
“Each constituent society will be
represented by one Delegate”.
Many delegates are not awareof their important functions andresponsibilities. The IFSSH cannot
function without the active involvement
and participation of each Delegate.
Please be reminded that the duties ofdelegates include the following:❚ Delegates represent the members of
their societies❚ Delegates form the IFSSH Council,
which is the governing body of thefederation❚ Delegates are therefore obliged toattend the IFSSH Annual Council
Meetings❚ Delegates are responsible to informthe members of their societies
about the federation activities, e.g.
Congresses, the IFSSH website❚ Delegates are required to share/
forward relevant correspondence
to their society members e.g. theIFSSH ezine, the official electronicmagazine❚ Delegates are expected to help
identify able and willing members of
their societies to serve as Scientiﬁc
Committee Members whenrequested by the IFSSH President❚ Delegates need to ensure that theirsociety annual dues are paid-up❚ Delegates are encouraged toacquaint themselves with thebylaws of the IFSSH in order tobe able to make a meaningful
contribution as member of the
IFSSH Council❚ Delegates will be requested
to recommend Pioneers fromtheir societies to be submitted
to the Nominating Committee(NB: Pioneers are only members
who have made a signiﬁcant
contribution)
From the above it should beclear that the role and function of a
Delegate is not only an honourable
one, but carries with it active
participation and accountability.
The 2014 IFSSH Delegates’ Council
Meeting will be held at 12h00,
Thursday 19th June at the FESSH
Congress venue in Paris, France.

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

See you there!
Ulrich Mennen
Editor: IFSSHezine
Past-President: IFSSH
www.ulrichmennen.co.za

IFSSH CONTRIBUTORPHOTO GALLERY
Dear colleague,
You are invited to sendinteresting photos from yourpractice which you would like toshare with the other membersof our profession.
Please add one short
sentence to describe the photo
which should be of goodquality. Your name and country
will be added to acknowledge
your contribution. Send yourcontributions to:editor@ifssh.info‘Sweet’ result of an index finger
pollicisation - Ulrich Mennen,
South Africa

IFSSH ezine editorial team:

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

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

O THE
SUBSCRIBE T

ifssFRhEE
ezine

FOR

IFSSH ezine MAY 2014

executive news

Message from the Secretary-General:

Marc Garcia-Elias
Dear friends
It seems as if it was yesterday, butmore than one year has passed since
we last met in India. One full year, andyet, the warm colors of Delhi keep
haunting us. If you had the wonderfulprivilege of being there, you willprobably understand what I mean.
India was deﬁnitively fabulous…
period!
...but it’s time to move ahead: theannual meeting of the Federation ofEuropean Societies for Surgery of theHand (FESSH) is around the corner(*), and believe me, if Paris alone isalways worth the trip, this time it will
be more than worth, it will be a unique
opportunity,…and I mean it.
In most travel agencies it iscustomary to say that a trip to Paris isalways a good idea. I agree. It was an
excellent idea to bring the 2014 FESSH
meeting back to Paris. Last time wasin 1996. Eighteen years! That is toomuch time for a city like Paris not to bevisited by an International Federationof hand surgeons. Let’s thank FESSH
for giving us such a long awaited
opportunity.
They say that June is a great time
to visit Paris. Warm weather andcozy gardens to enjoy the summer
sunshine, however, should not be theonly reasons for you to book your ﬂight
tickets. I don’t know why, but I suspectthat our French colleagues, with thesupport of the Council of FESSH, are
IFSSH ezine MAY 2014

about to give us more than that. I
suspect that we all will be oﬀered themost amazing gift one may get in suchoccasions: the best scientiﬁc program
wrapped by delightful social activities…a gift that will be kept in our minds
for a long time. Paris, indeed, knows
how to treat visitors.
I know that the French event is
not our meeting, and that perhaps I
am trespassing a red line here. I knowthat it is not up to the SecretaryGeneral of the IFSSH to advertise
another federation’s meeting, but I
do not care. The Société Française deChirurgie de la Main, organisers of theFESSH meeting, are also membersof our Federation and, as a rule, any
initiative by an IFSSH member aimed
at improving the quality of handcare delivery will always meet our
sympathy. So, let’s give a big hand to
our French friends.
There is a second reason for me
to bring this meeting up to yourattention; a practical reason, if you
will. We have scheduled our annual
Delegate’s Council meeting during
the FESSH congress. It will start atroom 242B of the Palais des Congrès
de la Porte Maillot, sharp at noonon Thursday, 19th of June, 2014. All
National Delegates are expected toattend that meeting. As in the past,
doors will be open to all of those whowant to hear about what is going on
in our Federation. Among other things,

we will discuss, and hopefully approve,
our new bylaws, the ones that willallow us a new legal status. We will
also analyse what has been done so
far and what needs to be done. Several
educational projects are going on,
how can we enhance their success?
What about our next 2016 congressin Buenos Aires? What about beyond
that? Yes, if our Federation was a sailingship, Paris would be our lighthouse.
Let’s trust what Paris has to teach us,
and beyond that…full-speed ahead!
Yours truly,
Marc Garcia-Elias
Secretary-General of the IFSSH(*) see http://www.fessh2014.com/en/welcome5member society updates

Member society updates
American Association forHand Surgery
Highlights of AAHS 2014 Annual
Meeting in Hawaii
Under the direction of program
chairs, Dr Steve Moran and Dr Joy
MacDermid, the AAHS Annual Meeting
held January 2014 was as spectacular
academically as it was in its beautyin the setting of the island of Kauai,
Hawaii. The morning only sessions
had spectacular courses in all areas ofwhat is new in hand therapy and handsurgery. Highlights included several
sessions on wide awake hand surgery.
The improvement in outcomes
obtained by seeing active movementin ﬂexor tendon repair before theskin is closed is now evident withdecreased rupture rates, decreased
tenolysis rates, and more conﬁdence
in doing true active movement
postoperatively. Substituting
epinephrine vasoconstriction for the
tourniquet has removed the needfor sedation and permitted moving
carpal tunnel surgery out of the main
operating room into the clinic oroﬃce for much greater convenienceof the surgeon and the patient.
Relative motion extension splints forfunctional early return to work after
extensor tendon repair should now
be considered by all. Relative motion
ﬂexion splints are revolutionizing
boutonniere management. Gentian
violet for chronic paronychia is a
simple solution that works.
The AAHS Annual Meeting is

6

attractive in that it happens every year
in a warm beautiful place in January.
It also always happens at the sametime as the American Society for
Microsurgery and American Society
for Peripheral Nerve meetings forenhanced educational opportunity.
Serious contributions by therapists
in panels and courses in the AAHS
meeting is rewarding. The relaxedatmosphere with nightly social events
permits plenty of time for informationexchange between expert and novice.
The 2015 AAHS Annual Meeting
being organized by Drs Mark Baratz,
Tom Hughes, and Christine Novak, ajoint meeting with the British Society
for Surgery of the Hand, will be held
January 21-24, 2015 at the Atlantis on
Paradise Island in the Bahamas. Visit
http://meeting.handsurgery.org for
more information.
Dr Donald Lalonde
AAHS Past President

American Society for
Surgery of the Hand (ASSH)
The 69th Annual Meeting of theAmerican Society for Surgery of
the Hand will be held in Boston,
Massachusetts from September
18-20th. For the past several years,
ASSH has invited the members of ahand society from another country
to participate in the meeting as ourInternational Guest Society. This
year, we are honored to host theBrazilian Hand Surgery Society as
our International Guest Society.
We look forward to meeting withour colleagues from Brazil andfrom around the globe. For travel
information, visit our website.
As always, the ASSH meeting willfeature the highest quality medical
education and research ﬁndings forattendees, and this year, we are also
focusing on medical outreach. The
meeting’s theme, “Hands Helping
Hands” celebrates our most basic goals
as physicians – to serve.
Additionally, ASSH is co-hosting
two international meetings in 2015.
The ﬁrst will be with SSHS in Singapore
in February 25 - 28, 2015. The second
will be a combined meeting with ASSH

IFSSH ezine MAY 2014

member society updates

and JSSH in Maui, Hawaii, March 29 –April 1, 2015.
We hope that you will join us,
either in Boston or at our meetings
with SSHS and JSSH, but we also
realize that, between the challengesof travel and the need for high quality
education, it is imperative that webuild tools beyond face-to-facemeetings to facilitate education. ASSH
recently launched an online learning
community called Hand-e (hande.assh.
org), ﬁlled with peer-reviewed videos,
articles and more. This community
is free for ASSH members and ASSH
international members, and it willsoon be available to international
non-member surgeons at an adjusted
subscription rate designed to makethe tool aﬀordable for physicians of all
countries.
Visit www.assh.org to learn about
many other opportunities, like the
ASSH Textbook of Hand and Upper
Extremity Surgery and our outreachprograms.

IFSSH ezine MAY 2014

British Society for
Surgery of the Hand
Although an informal dining club had
existed since 1952 (The Hand Club),the British Society for Surgery of theHand (BSSH) owes its true origins
to a more serious group founded in1956 and rather facetiously named“The Second Hand Club”. This group,
led by Guy Pulvertaft and Graham
Stack, organized regular meetings
to discuss hand surgery, arranged
instructional courses, and at a very
early stage looked outside the United
Kingdom to forge wider friendships
and collaboration in the emerging
specialty.
The Club ﬂourished for 12 years,
then developed a more formal
constitution, adopting the title it has
today. An important stimulus for theformation of these successive groups
was the spread of hand surgery across
two major specialties. It embodied
a desire in orthopaedic and plastic
surgeons, at that time, to join forces

and cooperate in the creation of amerged specialty based on friendshipand shared expertise. The fruitfulcooperation between surgeons fromorthopaedic and plastic surgery
backgrounds is a strong theme of
the Society. BSSH maintains an evenhanded balance between the parent
specialties in its Oﬃcers and Council
members.
The objectives of BSSH are “topromote and direct the developmentof hand surgery and to foster andcoordinate education, study andresearch in hand surgery”. Althoughhand surgery is not a separate
specialty in the UK, many surgeonsdevote all, or most, of their time tohand surgery. Current membership of
BSSH is 725.
In 1992, BSSH instituted a national
system of fellowships in handsurgery, after training in one of thetwo parent specialties. Each of these“Interface” posts provides training inboth orthopaedic and plastic surgery

7member society updates

elements of hand surgery. Educational
approval is given by the BSSH throughthe “Training Interface Group for Hand
Surgery” which regulates the training,in conjunction with the national
training committees in orthopaedic
surgery and plastic surgery. Between
1992 and 2014, over 200 surgeons
completed this programme.
BSSH holds a two or three day
scientiﬁc meeting each Autumn andin most years also holds a Springscientiﬁc meeting. Some meetings
are held jointly with the British
Association of Hand Therapists andwith other National Hand Societies.
For many years regular instructionalcourses were run alongside meetingsand in 1999 a regular cycle of formal
advanced courses was set up, covering
the whole ﬁeld of hand surgery every
3 years. This has been very successful
and has considerable international
appeal. These biannual two-day
courses run in Manchester over athree-year cycle and cover the entire
spectrum of surgery of the hand.
Typically each course has 120-150
participants, 40% of whom are fromother countries, mainly in Europe.
Following on from this, BSSH incollaboration with the Universityof Manchester has since 2007,
established a Diploma in Hand Surgery,using the content of the courses as
the basis for a syllabus. Surgeons in
the fellowship programme take amodular course of face-to-face tuition
with tutorials and projects. There areinternal assessments at the workplace
and a ﬁnal external examination.
The Journal of Hand Surgery is theoﬃcial journal of the Society, evolvingfrom the “Proceedings of the Second

8Hand Club”, through “The Hand”, edited
by its founder Graham Stack, to its
present form. It was initially linked
to the American Journal of the same
name and more recently adopted as
the oﬃcial European journal. It haslong been established as one of theforemost publications on the subject.
The Journal is run through a committeewith European and wider international
representation. It is the oﬃcial journal of
the FESSH, the Belgian Hand Group, theNetherlands Society for Surgery of theHand, the Société Français de Chirurgie
de la Main, the Swedish Society for
Surgery of the Hand and the Swiss
Society for Surgery of the Hand. An
annual donation of £35,000 (€42,000) is
made to FESSH from the income of the
Journal.
From its earliest days the Society
has recognized the vital roles playedby physiotherapists and occupational
therapists in the treatment of patients,
and close, highly supportive links
with those disciplines have been
established and maintained throughprofessional collaboration, joint
meetings and educational activities,
and sponsorship in both directions.
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.
In collaboration with the Healing
Foundation, an Academic Post in Hand
Surgery has been funded by the BSSH.
The sum of £500K will be spent tosupport a University Chair, which will
set up a national network to research

the treatment and outcomes of many
conditions.
BSSH has played an active rolein the development of internationalorganizations promoting hand surgery;from the outset, the BSSH included
representatives from the whole of
Ireland.
Formation of the International
Federation of Societies for Surgeryof the Hand was ﬁrst proposed at a
meeting of The Hand Club in 1965.
Graham Stack was the second Secretary
General and Douglas Lamb the third
President. The Society has also played
an active role in the formation andgrowth of the Federation of European
Societies for Surgery of the Hand
(FESSH), successfully hosting the 2006
Congress in the UK.
To support research education andtraining BSSH awards several prizes,
bursaries and grants, totalling £85,000
each year.
BSSH is involved in overseas
work; since 2010 groups of surgeonsanaesthetists hand therapists andnurses, funded by BSSH, have been
visiting the Holy Spirit Hospital in Sierra
Leone to treat the local population andtrain local staﬀ. The ultimate goal isself-sustainability.
For the future, BSSH continues topromote hand surgery nationally andinternationally, and seeks to match therapid growth in the number of trained
surgeons dedicated to the specialty withincreased opportunities for purposedesigned training programmes crossing
speciality boundaries.
David Shewring
BSSH Delegate to IFSSH/FESSH
davidshewring@me.com
www.bssh.ac.uk
IFSSH ezine MAY 2014

member society updates

Federation of SouthAmerican Societies forSurgery of the Hand
The Federation of South American
Societies for Surgery of the Hand has
produced an open access book on
Hand Surgery in Portuguese.
You are welcome to follow thelink here http://fedscm.com/book_chapters

Singapore Society for
Hand Surgery
Hand surgery in Singapore has been an
independent specialty, with a training
track separate from orthopaedics andplastic surgery training, since 1998. In
the last few years, with the introductionof the American residency system
for specialty training locally, Hand
Surgery Residency Programs have been
established in Singapore with three
institutions currently accredited to run
the program.
Even prior to hand surgery
becoming an independent specialty,
the Singapore Society for Hand
Surgery (SSHS) was established in1982 as a forum for hand surgeons in
Singapore to share their knowledge
and experience, particularly in the
management of hand conditions
arising from leprosy, rheumatoid
arthritis and a high incidence ofindustrial accidents. Over the years, themembership of our society has risen
greatly, owing to an increase in thenumber of hand surgeons in Singapore,occupational therapists with an interestin hand therapy, as well as our overseas
associate members, many of whom had
spent some time working with various
hand surgical units in Singapore.
Apart from the annual scientiﬁc
IFSSH ezine MAY 2014

Friends of Singapore Hand Surgery at the Post 2013 IFSSH Congress Tour in Rajasthan, India.
Seated (L to R): Andrew Chin (President Singapore Society for Hand Surgery); Tan Ter Chyan(Singapore); Lim Beng Hai (Singapore). Standing (L to R): Kalvis Pastars (Latvia); Sandeep Sebastin(Vice President Singapore Society for Hand Surgery); Peng Yeong Pin (Singapore); Aivars Tihonovs(Latvia); Pasi Paavilainen (Finland); Aymeric Lim (Singapore); Shalimar Abdullah (Malaysia); Yrjana
Nietosvaara (Finland); Janis Krustins (Latvia).

meeting and comprehensive hand
review course, SSHS organizes various
courses and lectures by invited speakers
throughout the year, some of which
are attended by regional participants.
Additionally, SSHS also contributes to thecontinuing medical education of handsurgeons and hand surgical trainees byorganizing regular teaching seminars.
In 2013, our annual scientiﬁcmeeting was a combined meeting withvarious overseas hand surgical societies– the Joint Singapore-MalaysiaFinland-Estonia-Latvia Hand Surgery
Societies Meeting (incorporating the22nd Comprehensive Review Course
in Hand Surgery and Annual Scientiﬁc
Meeting) was held from 28th February
2013 to 2nd March 2013. The event
allowed generous exchange of ideas

Singapore’s first Pioneer in Hand Surgery, Prof
Pesi B Chacha receiving the Pioneer Award from
Prof Ulrich Mennen (Immediate Past presidentof IFSSH) at the 12th Triennial Meeting of the
IFSSH at New Delhi, March 2013.

9member society updates

among hand surgeons from diﬀerent
regions. Apart from lectures oncongenital hand surgery by our invitedinternational speaker, Professor Simo
Villki, all participants were treated to awhole range of lectures touching on
all aspects of hand surgery deliveredby surgeons from all the participating
societies. And in true Singaporean
style, all participants were also treatedto a variety of delectable local andinternational cuisine during theconference period.
Apart from the combined meeting,
SSHS also hosted distinguishedsurgeons from overseas in 2013.
Professor Fuminori Kanaya presented adinner lecture on ‘Motor and Sensory
Nerve Diﬀerentiation’ in March 2013
while Professor Scott Kozin discussed‘The Surgeon’s Role in Providing Pinchand Grip’ in July 2013.
Our annual scientiﬁc meeting
this year was held in January 2014
with Professor Alexander Shin andProfessor Tu Yuan-Kun as our invitedinternational speakers. Apart fromthe hand review course, sessions
dedicated to brachial plexus surgery
were conducted by local andinternational faculty.
Meanwhile, the society has started
preparation for our 2015 annual scientiﬁc meeting – the Inaugural Combined
Scientiﬁc Meeting of Singapore Societyfor Hand Surgery (SSHS) and American
Society for Surgery of the Hand (ASSH).
The dates for this meeting have beententatively set from 26th February to 1st
March. The society would like to use thisopportunity to invite surgeons to thisevent which is expected to be a truly
enriching experience.

10

Teodor Kluka, M.D., PhD.
Email: tkluka@unlp.sk

Drahomír Palenčár,
SHSS Vice President

Slovak Hand Surgery Society
This history of hand surgery in Slovakia
reﬂects the historical developments
in Slovakia itself: the Slovak Republic
was founded on 1st January 1993 andbecame a successor state following
the dissolution of Czechoslovakia.
Similarly, the hand surgery group wasestablished as a combined “Czech andSlovak Hand Surgery Society”, entering
the IFSSH in 1993, followed by thefoundation of the Slovak Hand Surgery
Society (SHSS) on 1st January 1998.
Most of the credit for creating the
Slovak Hand Surgery Society has to begiven to the founding members andmembers of the Steering Committee:
Jozef Janovic, Teodor Kluka and Jaroslav
Ciganak. These three doctors also
served on the ﬁrst Slovak Hand Surgery
Society Committee, whose members
were Jozef Janovic (Chairman), Teodor
Kluka (Secretary), Jaroslav Ciganak,
Ladislav Kostal and Drahomir Palencar,
along with Peter Kovar as the Auditor.
Inﬂuential surgeons in thedevelopment of hand surgery in Slovakia
include A/Prof Jozef Janovic, A/Prof Jozef
Fedeles and A/Prof Stefan Guzanin.
The ﬁrst Hand Surgery Congressin Slovakia took place in 1996 at theHigh Tatra Mountains. The SHSS has

Silvia Vajcziková,
SHSS President

since organised numerous handsurgery congresses, presenting
successes in microsurgery (Kluka,
Palencar), distraction and external
ﬁxation (Guzanin, Ciganak, Kluka) andreconstructive plastic surgery (Palencar,
Kluka). Technical literature includes thehistorical Hand Surgery Atlas (Simun,
1980) and more recent titles such as
External Miniﬁxation in Hand Injuries(Ciganak, 1998) and Flexor Apparatus
Surgery (Bansky, 2006).
Hand surgery training is organisedby the Slovak Medical University in
pre-attestation preparation for plastic
surgery, during which participants takecourses in hand surgery. There is no
current certiﬁcation for hand surgery
as a speciality.
In 2013, the SHSS oﬃcers elected
were Silvia Vajcziková (President),
Drahomír Palenčár (Vice-President) andTeodor Kluka (Secretary).
The 10th Slovak Congress of Hand
Surgery will be held in Tále from 2-3
October, 2014. For further information,email: ozhippokrates@gmail.com.
Teodor Kluka, M.D., PhD.
Email: tkluka@unlp.sk
Drahomír Palenčár, SHSS Vice President
Silvia Vajcziková, SHSS President

IFSSH ezine MAY 2014

member society updates

Spanish Society for Hand
Surgery
In February 1969, the ﬁrst assemblyof surgeons with a special interest in
hand surgery was held in Zaragoza.
This was so, thanks to the organisationof Dr Alfredo Quintana and with thecollaboration of Dr Pulvertaft, Dr Vainio,
Dr Tubiana and Dr Souquet as invited
guest professors. A few months later,on 11th May 1969, the Spanish Societyfor Hand Surgery (SECMA) was foundedin Zaragoza with only 29 members
and under the leadership of the newpresident Dr Enriquez de Salamanca.
At present, SECMA has a total numberof 380 members (310 full members, 19
associated members, 25 international
members, 26 honour members).
New Board of the SECMA. The
new board of the Spanish Society wasconstituted during the last national
meeting, held in Mallorca in May 2013
and its members are: Dr Miguel delCerro (President), Dr Angel Ferreres(Vice-President), Dr Pilar Pradilla(General Secretary), Dr Luis Aguilella(Vice-Secretary), Dr Gabriel Celester(Treasurer), Dr Roberto S. Rosales(International Delegate), Dr Fernando
Corella and Dr Pedro J. Delgado(Editors of the Ibero-American Journalof Hand Surgery), Dr Marta Guillen and
Dr Joaquim Casañas (Council of the
web side and communications).
SECMA Foundation. In 2014, the
SECMA Foundation was establishedwith the purpose of sponsoring the
SECMA instructional courses, thebest scientiﬁc paper and posters
at our national meeting, the ASSH
travelling fellowship award and all
those activities related to research andteaching in the hand surgery ﬁeld. This
IFSSH ezine MAY 2014

VI Congress of the
Moroccan Society for
Surgery of the Hand,
Marrakech March, 22nd
2014. SECMA was the guest
society. From the left tothe right: Dr Ferreres (VicePresident of the SECMA),Dr Rosales (International
Delegate of SECMA), Dr
Fnini (President of the
Moroccan Society), Dr
Pradilla (General Secretaryof the SECMA), and Dr
Cuadros (Past President of
the SECMA).

project was started in 2011 by Dr D.
Fernando García de Lucas, who was
the previous President of the SECMA,
and ﬁnished by Dr Miguel del Cerro,
the present President.
SECMA & RICMA (The IberoAmerican Journal of Hand Surgery).
The new online version of the“Revista Iberoamericana de Cirugíade la Mano (RICMA)”, the IberoAmerican Journal of Hand Surgery,has been presented recently. The new
editors, Dr Fernando Corella and Dr
Pedro J. Delgado, have carried out atremendous task in designing a newelectronic journal with an application
for smart phones and tablets. We
hope that in a short period of time, we
may get our journal indexed. http://
revistaiberoamericanamano.org/
SECMA & IFSSH. All the membersof the SECMA are proud of the electionof Dr Marc García Elías, outstanding
member of our society, as General
Secretary of the IFSSH.
SECMA & FESSH. The Spanish
Society has always been working

Magazine cover of the “Revista Iberoamericanade Cirugía de la Mano”, the Ibero-American
Journal of Hand Surgery with the support of
the Hand Societies of Spain (SECMA), Argentina(AACM), Brazil (SBCM), Portugal (SPOCMA),
Uruguay (SCPRE-Hand Section) and Venezuela(SVCM).

11member society updates

closely with all the councils of theFESSH. A special mention must be
made of Dr Angel Ferreres (VicePresident) and of Dr Enrique McKenney(Previous International Delegate),
as examiners in the European Board
Diploma for the last years. Besides,
following the recommendations of
Dr Bruno Battiston, we have selected
the required delegates in the Hand
Trauma Committee. Finally, the city of
Santander won the bid for the FESSH
congress, which is to be held in 2016,
with Dr Piñal as president.
SECMA & The JHSE. Recently, twomembers of our society have been
added to the Journal of Hand Surgery(European volume) editorial committee:
Dr D. Francisco Piñal, as one of theeditors, and Dr D. Roberto S. Rosales as
member of the editorial board.
SECMA INSTITUTIONALCOURSES. SECMA offers a two-day
institutional instructional course every
year, with lectures and lab cadaver
sessions. This year, the course will take

Swiss Society of Surgeryof the Hand
A brief history of Hand Surgery in
Switzerland
In fact, whatever manual, intellectual,cultural or spiritual activity each of us has
devoted his life to, at the time of death,the individual is nothing; what he hasachieved, however is everything.
This is one of the last sayings ofClaude E. Verdan, a genious pioneer
in Hand Surgery, who influenced not
only the national but also international
scene in Hand Surgery. This mostremarkable surgeon founded together
with 50 General Surgeons the Swiss

12

place in Madrid under the directionof Dr D. Pedro J. Delgado on 24-25th
April. Last year, the Spanish Societysponsored a new instructional course
on Clinical Research Methodology in
Hand Surgery. That one-day course,
directed by Dr RS Rosales approached
the clinical design , level of evidence,
the use of patient reported outcome
instruments and data analysis using
the IBM SPSS Statistics.
SECMA AND OTHER HAND
SURGERY SOCIETIES. The Spanish
Society will collaborate as guest
society in the Moroccan Hand Society
Meeting in Marrakech on 22-23rd
March 2014, and in the Portuguese
Hand Society Meeting in Lisbon, in
April 2014. Finally, the SECMA will be
the guest society at the ASSH Meetingin Seattle, in 2015.
On behalf of the SECMA, I thank the
IFSSH for the opportunity to present
this updated news report of our society.
R S Rosales, MD, Ph(International Delegate of the SECMA)

Society of Surgery of the Hand on
November 12th, 1966 in Lausanne.
During the following years thissociety grew to over 214 ordinary andextraordinary members (2014) and also

RICMA website, the electronic version of the“Ibero-American Journal of Hand Surgery”. Freeand open-full access at the following link: www.
revistaiberoamericanamano.org

became part of the FESSH (1990, firstdelegate, Daniel V. Egloff, Lausanne) andIFSSH (1983, first delegate, Henry Nigst,
Basel). A council of 9 members including
an administration office is in charge totake care of the daily business of thesociety as well as to take positions in
the political processes concerning the
medical care in Switzerland. An annual
congress is organised by the president.
In 1988, Hand Surgery was
acknowledged as sub-speciality by
the Swiss Medical Association (FMH). A
recognition as a speciality on its own
was given by the Federal Council in
2007. Another 6 years of certification
IFSSH ezine MAY 2014

member society updates

process and political struggle passed
until the accreditation as a fully
acknowledged speciality by the
Swiss Medical Association (FMH) wascompleted. Trainees who completed astructured und veriﬁed postgraduate
training may then use the title“Handchirurgie FMH” - a title which isrecognized in most European countries.
The oﬃcial postgraduate training withthis new accreditation will start in
October 2014.
Training of a Hand Surgeon in
Switzerland
The new oﬃcial training starts witha common trunk of two years ofGeneral Surgery completed by an
examination of surgical basics. After
passing this exam the trainee canenter the specialized training in Hand
Surgery and in Surgery of peripheral
Nerves. This training takes 4 years in
at least 2 diﬀerent institutions andﬁnishes with an oral and written
examination. Passing this exam andfulﬁlling a deﬁned logbook, the trainee
receives the Swiss Hand Diploma (FMH
certiﬁcate).
Another way to become a Hand
Surgeon is by entering the specialist
training after completing the training
as a General, Plastic, Pediatric or
Orthopedic Surgeon. The achievementof this rather long education resultsin two diplomas acknowledged inEurope.
Politics
Being a specialist in Switzerland
you are allowed to perform certain
surgeries restricted to the specialist
category and you are rewarded with
better payment rates compared
IFSSH ezine MAY 2014

Turkish Society of Hand andUpper Extremity Surgery

to surgeons without a certiﬁcate.
Ongoing political discussions now try
to cut these rates down in order to use
the money for the general medical
practitioners who slowly become arare species. Therefore, there will be a
lot of political work for the society andits council to keep a fair remuneration
for a long education.
Furthermore, the society’s main
responsibility is to maintain a highstandard in medical education and
Hand Surgery training – a task we
fulﬁll with great enthusiasm andjoy. Multifactorial reasons such as
more intellectual information andmore technical skill requirements(microsurgery, arthroscopy and soon
to be robotic surgery) to learn withshortening the time spent in training(resident work restrictions) andgenerational diﬀerences (balanced
lifestyle) challenge all but Hand
Surgery training too.
Mario Bonaccio,
Frauenfeld and Esther Vögelin,Bern, Switzerland

The Turkish Society of Hand and Upper
Extremity Surgery was founded in 1977
by the Honorary President, Professor
Rıdvan Ege. The society has 247
members, and it is a member of IFFSH
and FESSH. The IFFSH meeting in 2001,
and the FESSH meeting in 2013 wereorganised in Turkey by the society.
The society organises national handsurgery congresses every two years,
and the 14th national congress will beheld between May 15-18, 2014, in Bursa.
These congresses are held regularly since1992. During the last three meetings
hand physiotherapists organised theirown congress along with the national
congress of the hand surgery society.
The society also publishes the ‘’Hand
and Microsurgery’’ Journal since 2012,
and accepts manuscripts in both English
and Turkish. Every year the society
organises courses about emergency andelective hand surgery directed to theresidents in hand surgery, orthopaedics
and plastic surgery, as well as emergency
department physicians.
The society has its own hand surgery
education curriculum since 2011. TurkishSociety of Hand and Upper Extremity
Surgery Educational Committee is responsible for coordination of the education. The members of this committee are
selected from the hand centers giving
education. Hand Surgery diplomas were
given by the Ministry of Health to 130
hand surgeons between 2011 and 2012,and hand surgery became a certiﬁed
subspecialty in Turkey. Since 2012, there
are currently in eight university and state
education hospitals having hand surgery
departments with residents.
www.turkhandsociety.org

13

committee reports

IFSSH Scientific Committee on
Congenital Conditions
Chair: M Ezaki (USA). Committee: GH Baek (Korea), E Horii (Japan), S Hovius (Netherlands).
Report submitted February 2014

Classification of Congenital Hand and Upper Limb Anomalies
Our committee recommends adoptionof a revised classification system forCongenital Anomalies of the Hand
and Upper Limb. The Swanson
Classification was proposed in the
1960s and was subsequently adopted
by the IFSSH Congenital Conditions
Committee. This classification has beenof significant benefit, but remains
based on a morphological rather thanetiological system which is unable toadapt to increasing knowledge.
Dr. Paul Manske, along with Drs.
Michael Tonkin and Kerby Oberg,
began working on a classification
system that would incorporate newer
knowledge of the etiology, molecular
genetics, and developmental biology
into our thinking about these
conditions. After Dr. Manske’s death,the work has been refined by Drs.

Tonkin and Oberg, and vetted by
the members of the committee andan international study group. The
current document has been discussed
extensively. While no classification
system is perfect, this OMT system has
the ability to be flexible and respondto new developments and additional
conditions. The classification of someconditions remains controversial and,for these, the principle of “best fit”
has been utilized. It is designed to bea working classification that can berevised and/or modified.
It should be noted that theclassification system, as proposed below,
describes main groups and sub-groups,
but allows for addition of surgical subclassifications (such as those for thumb
duplication, thumb hypoplasia, cleft
hand, etc) within an expanded version.

The IFSSH Scientific Committee on
Congenital Conditions recommends
adoption of the OMT classification
with reviews at 3-year intervals
according to responses from the handsurgery community. The Committee
invites comments and advice basedon improvements in knowledge at
the time of these reviews when theclassification may be modified.

“While no classification
system is perfect, thisOMT system has theability to be flexible
and respond to new
developments andadditional conditions.”

OMT CLASSIFICATION OF CONGENITAL HAND AND UPPER LIMB ANOMALIES
I. MALFORMATIONS
A. ABNORMAL AXIS FORMATION/
DIFFERENTIATIONENTIRE
UPPER LIMB
1. Proximal-distal axis
i. Brachymelia with brachydactyly
ii. Symbrachydactyly14a) Poland syndromeb) Whole limb excluding Poland
syndromeiii. Transverse deficiencya) Ameliab) Clavicular/scapularc) Humeral (above elbow)d) Forearm (below elbow)e) Wrist (carpals absent/at levelof proximal carpals/at level of
distal carpals ) (with forearm/arm
involvement)f ) Metacarpal (with forearm/arm
involvement)
IFSSH ezine MAY 2014

committee reportsg) Phalangeal (proximal/middle/
distal) (with forearm/arm
involvement)
iv. Intersegmental deﬁciencya) Proximal (humeral – rhizomelic)b) Distal (forearm – mesomelic)c) Total (Phocomelia)
v. Whole limb duplication/triplication
2. Radial-ulnar (anterior-posterior)
axis
i. Radial longitudinal deﬁciency Thumb hypoplasia (with proximal
limb involvement)
ii. Ulnar longitudinal deﬁciency
iii. Ulnar dimelia
iv. Radioulnar synostosis
v. Congenital dislocation of the radialheadvi. Humeroradial synostosis - Elbow
ankyloses
3. Dorsal-ventral axis
i. Ventral dimeliaa) Furhmann/Al-Awadi/RaasRothschild syndromesb) Nail Patella syndromeii. Absent/hypoplastic extensor/ﬂexor
muscles
4. Unspecified axis
i. Shouldera) Undescended (Sprengel)b) Abnormal shoulder musclesc) Not otherwise speciﬁed
ii. Arthrogryposis
B. ABNORMAL AXIS FORMATION/
DIFFERENTIATION HAND
PLATE
1. Proximal-distal axis
i. Brachydactyly (no forearm/arm
involvement)ii. Symbrachydactyly (no forearm/arm
involvement)
iii. Transverse deﬁciency (no forearm/arm involvement)a) Wrist (carpals absent/at level of
IFSSH ezine MAY 2014

proximal carpals/at level of distal
carpals)b) Metacarpalc) Phalangeal (proximal/middle/
distal)2. Radial-ulnar (anterior-posterior)
axis
i. Radial deﬁciency (thumb - noforearm/arm involvement)
ii. Ulnar deﬁciency (no forearm/arm
involvement)
iii. Radial polydactyly
iv. Triphalangeal thumbv. Ulnar dimelia (mirror hand – noforearm/arm involvement)
vi. Ulnar polydactyly
3. Dorsal-ventral axis
i. Dorsal dimelia (palmar nail)ii. Ventral (palmar) dimelia (including
hypoplastic/aplastic nail)4. Unspecified axis
i. Soft tissuea) Syndactylyb) Camptodactylyc) Thumb in palm deformityd) Distal arthrogryposis
ii. Skeletal deﬁciencya) Clinodactylyb) Kirner’s deformityc) Synostosis/symphalangism(carpal/metacarpal/phalangeal)iii. Complexa) Complex syndactylyb) Synpolydactyly— centralc) Cleft handd) Apert hande) Not otherwise speciﬁed
II. DEFORMATIONS
A. Constriction ring sequence
B. Trigger digits
C. Not otherwise speciﬁedIII. DYSPLASIAS
A. Hypertrophy
1. Whole limb
i. Hemihypertrophy
ii. Aberrant ﬂexor/extensor/
intrinsic muscle
2. Partial limb
i. Macrodactyly
ii. Aberrant intrinsic muscles ofhand
B. Tumorous conditions
1. Vasculari. Hemangioma
ii. Malformationiii. Others
2. Neurologicali. Neuroﬁbromatosis
ii. Others
3. Connective tissue
i. Juvenile aponeurotic ﬁbroma
ii. Infantile digital ﬁbromaiii. Others
4. Skeletal
i. Osteochondromatosis
ii. Enchondromatosisiii. Fibrous dysplasia
iv. Epiphyseal abnormalities
v. Others
IV. SYNDROMES*
A. Specified
1. Acrofacial Dysostosis 1 (Nager type)
2. Apert
3. Al-Awadi/Raas-Rothschild/Schinzel
phocomelia
4. Baller-Gerold
5. Bardet-Biedl Carpenter
6. Catel-Manzke
7. Constriction band (Amniotic Band
Sequence)
8. Cornelia de Lange (types 1-5)
9. Crouzon
10. Down
11. Ectrodactyly-Ectodermal DysplasiaClefting

15

committee reports

12. Fanconi Pancytopenia
13. Fuhrmann
14. Goltz
15. Gorlin
16. Greig Cephalopolysyndactyly
17. Hajdu-Cheney
18. Hemifacial Microsomia (Goldenhar
syndrome)
19. Holt-Oram
20. Lacrimoauriculodentodigital (LevyHollister)
21. Larsen
22. Leri-Weill Dyschondrosteosis
23. Moebius sequence

24. Multiple Synostoses
25. Nail-Patella
26. Noonan
27. Oculodentodigital dysplasia
28. Orofacialdigital
29. Otopalataldigital
30. Pallister-Hall
31. Pfeiffer
32. Poland
33. Proteus
34. Roberts-SC Phocomelia
35. Rothmund-Thomson
36. Rubinstein-Taybi
37. Saethre-Chotzen

38. Thrombocytopenia Absent Radius
39. Townes-Brock
40. Trichorhinophalangeal (types 1-3)
41. Ulnar-Mammary
42. VACTERLS association
B. Others*The specified syndromes are thoseconsidered most relevant; however,many other syndromes have a limb
component categorized under “B.
Others”.
OMT Classification 3rd February, 2014

IFSSH Scientific Committee on
Genetics in Hand Surgery
Chair: Kerby C. Oberg (USA).
Committee: Maria A. Ros (Spain), Charles A. Goldfarb (USA)
Report submitted May 2013

New Insights on Upper Limb Development:
Digitising the Hand
During the 5th week of humandevelopment, the distal end of theupper limb bud begins to flatten
and expand forming the autopod or
handplate. Over the next few days
the handplate will transform intoa predictable series of segmented
digits. The molecular mechanisms
underlying digit formation are notfully understood, however, recent
investigations in animal models

16

and clinical genetics provide someinteresting insights into the process.

Limb initialisation, outgrowth anddevelopmental axes
The position of the upper limb along
the cranial-caudal axis is established by
Hox transcription factors (Fig. 1a and1b)3;42. Within the presumptive upper
limb field, Hox transcription factors
up-regulate the T-box containing

transcription factor 5 (TBX5) which,in turn, up-regulates fibroblast
growth factor 10 (FGF10) secretion topromote upper limb bud initiation andoutgrowth1;15;20;24;31. The subsequentmorphogenesis of the emerging limb
bud can be described in terms of threecoordinate axes – the proximal-distal
axis, the anterior-posterior (or radialulnar) axis and the dorsal-ventral (ordorsal-volar) axis as depicted in Figure
IFSSH ezine MAY 2014

committee reports

Figure 1. Limb Induction and Signaling Center
Formation. A) Depiction of an emerging upper
limb bud in Carnegie stage 12 embryo. B)
Hox genes establish upper limb position andpolarity. C) Cascade of events that initiate limb
bud formation and proximal distal polarity
with formation of the apical ectodermal ridge(AER) and induction of Fgf8. D) Cascade ofevents that induce the expression of Shh andformation of the zone of polarising activity
establishing radial-ulnar (anterior –posterior)polarity. E) Unknown factors in somites and/or intermediate mesoderm initiate Wnt7a
expression in what will become the dorsal
ectoderm. Bmps induce the expression of En1
in what will become the ventral ectoderm andthereby establishes the dorsal ventral boundary
where the AER will form (orange).

1. Each of these axes is controlled by asignaling center that initiates a cascadeof axis-related pathways. Although all
three axis-related pathways contributeto digit formation, the anteriorposterior axis establishes the numberof digits and digit-speciﬁc morphology(phalange size and number) and willbe the primary focus of this report.
Prior to handplate formation,
expression of the ﬁrst phase of distal
HOXD transcription factors (HOXD1013) occurs in a nested collinear fashion
along the anterior-posterior axis, with
HOXD10 exhibiting the largest initialexpression domain. Each successively
more distal HOXD transcription factor
is nested within the previous gene’s
expression domain (See Figure 2).
HOXD13, the terminal transcription
IFSSH ezine MAY 2014

factor in the HOXD cluster, has thesmallest expression domain andoverlaps the zone of polarising activity(ZPA), within the distal posterior or
ulnar aspect of the limb bud. Thisﬁrst phase of distal HOXD expression
corresponds to the forearm or
zeugopod speciﬁcation.
Sonic hedgehog (SHH) is secreted
from the ZPA and establishes aposterior to anterior gradient along theanterior-posterior (radial-ulnar) axis.
SHH manifests its action via the familyof GLI-Krupple zinc ﬁnger transcription
factors (GLI1, GLI2 and GLI3). Of these
GLI3 is the most important during
limb development. In the absence ofSHH, Gli3 is processed into a truncatedform that is a strong transcriptional
repressor (GLI3R) 27;38. SHH inhibits

this processing, thus the posterioranterior SHH gradient is translated into
a complementary anterior-posterior
intracellular gradient of GLI3R (SeeFigure 2)38. SHH/GLI3 regulationis critical for posterior (ulnar) limb
proliferation and distal patterning(forearm and hand) 33;44.

Digitising the handplate
The handplate is the last segmentof the limb bud to form, appearing
about 37 days post ovulation (Carnegie
stage 16, Figure 2). As the handplateforms, several molecular pathways
converge. HOXA13, the terminal
Hox transcription factor of the HOXA
cluster, is induced in the distal limb
bud demarcating the handplateboundary41;43. Concurrently, a second

17committee reports“late”, SHH-regulated phase of distal
HOXD expression (that correspondswith digit formation) is generated
that partially reverses their expression
domains, i.e., reversed colinearity19. In
addition, there is a graded expression
intensity with HOXD13 exhibiting themost robust expression within thedigits, and HOXD10 exhibiting the least
intense expression, what has beentermed quantitative colinearity11.
Experimental evidence suggested
that the ZPA produced a diﬀusible
morphogen that established a spatialconcentration gradient across theanterior-posterior limb bud axis29.

Figure 2. Molecular Pathways Regulating Digit Formation . TBX5 expression (yellow) persists as
the autopod forms (Carnegie stage 16, post fertilisation day 37; comparable to mouse embryonicday 12 or e12) and begins to differentiate (Carnegie stage 18, post fertilisation day 44; comparable
to mouse e13). However, expression of TBX5 in the autopod is limited to the anterior-proximal
aspect (illustrated as a yellow-dashed line). HOXA13 is expressed within autopod cells (illustrated
as magenta) and delineates the proximal autopod boundary. Interestingly, digit 1 or the thumb, isthe only digit to have the combined expression both TBX5 and HOXA13. The distal HOXD complex(HOXD10-13) is expressed in a nested collinear pattern in early limb development (early phase, Stg
15 or mouse e11). This nested pattern is also thought to participate in the induction or maintenanceof SHH expression. GLI3 processing by SHH (purple) sets up an anterior-posterior gradient of GLI3
repressor(GLI3R)(orange). SHH also regulates the expression of the distal HOXD transcription factors(HOXD10-13) (Carnegie Stg 18 or mouse e13) within increasing intensity (quatitative collinearity).
These transcription factors appear to physically interact with GLI3 to refine digit identity (theSHH dependent boundary is highlighted by a purple dashed line). HOXD 10-12 have overlapping
expression domains in presumptive digits 2-5, but are restricted from the thumb domain. HOXD13
in contrast is expressed in all of the digit domains including the presumptive thumb, though its lateextension into the thumb domain is SHH independent.

18

This provided cells with a positional
value according to their position
within the gradient ﬁeld. SHH wassubsequently identiﬁed and validated
as the morphogen secreted by the ZPA
critical for limb patterning and digit
identity9;23. More recently, SHH has
been shown to have dual, separable
functions in both patterning andgrowth33;44.
The accumulated evidence suggeststhat these molecules work collectively
to establish the ﬁve digit patterncommon to most tetrapods (animals
with four limbs). Although a molecular
gradient has been a popular hypothesis,
a gradient model does not fully explain
the repeating digital-interdigital pattern.
Recent analysis of compound deletionsof distal Hox (Hoxa13, Hoxd11-13)
and Gli3 genes in mice, exposed an
intrinsic self-organising mechanism
involved in patterning the digits28.
With the progressive reduction of
HOX gene dose in the absence of Gli3,
there is a progressive increase in digit
numbers (up to 14 digits) that is notaccompanied by a corresponding
increase in handplate size, thus thedigits are increasingly thinner andshorter.
Alan Turing ﬁrst proposed amathematical diﬀusion-reaction
model to account for repetitive selforganising patterns, such as stripesor spots in animal skin and fur34. Thismodel proposes two molecules, anactivator and inhibitor, which diﬀuse
into a ﬁeld of cells. The activator autoupregulates itself and upregulates its
own inhibitor. In contrast, the model’s
inhibitor suppresses the activator andauto-inhibits its own expression (seeFigure 3).
IFSSH ezine MAY 2014

committee reports

Small random molecular
ﬂuctuations of the activator and theinhibitor eventually lead to steadypatterns, usually spots or stripes.
The pattern is dependent upon therobustness of activator and inhibitor
expression as well as their diﬀusion
rates. This intrinsic self-organising or
Turing mechanism controls the initialalternating digit/non digit pattern inthe handplate. Although the molecular
identity of the activator and inhibitor
are not yet known, these investigations
indicate that the terminal HOXA/Dtranscription factors, in concert with
SHH/Gli3 regulation, modulate theintrinsic self-organising mechanism
and are critical in resolving thecommon digit-interdigit pattern ofpentydactyly.
Once the number of digits has
been established, digit speciﬁcmorphologies are determined. The
mechanisms that regulate digit
morphology are not full characterised,
but at the distal end of each digit
there is a thin cap of cells called thephalanx forming region (PFR) or digital
crescent (Figure 4)16;30. Signals fromthe adjacent posterior interdigitaltissue regulate digit morphology
and function relatively late as thephalanges are progressively being
formed 6. Our current understanding
suggests that SHH – GLI3R/GLI3FL
counter gradients and SHH-regulated
HOXD10-13 transcription factors(particularly for digits 2-5), likely
through BMPs (predominantly BMP2,
4 &7) and from AER-related FGFs
and WNTs instruct the PFR to form
the appropriate number and size ofphalanges16;25;26;30;39;40.
The thumb domain is somewhat
IFSSH ezine MAY 2014

Figure 3. Turing-Like Patterning in Limbs. In the upper left-hand boxed region is a diagram of the
diffusion-driven instability model with an activator and inhibitor. Modulation of this intrinsic
self-organising mechanism (ISOM) by FGF and HOX/GLI is also depicted. In the model describedby Sheth et al. (2012), FGF from the apical ectodermal ridge (AER) promotes a radial stripe patternfrom the ISOM and ultimately regulates digit length (blue), while FGF in concert with distal HOX andGLI transcription factors limit the number of digits (green). On the bottom of the figure, a series ofhandplates show the rapid progression from fluctuating activator-inhibitor interaction (noise) to astabilised 5-digit pattern. On the right, progressive loss of digit suppressing HOX/GLI transcription
factors (green bar) causes an increase in the number of digits patterned by the ISOM.

diﬀerent, expressing factors that arethought to inﬂuence the specialised
morphology of the thumb 21. TBX5
expression extends into the proximal
handplate, associated with thepresumptive carpals and thumb, butdoes not extend into the ulnar digits(digits 2-5)(Figure 2)12. Moreover, thethumb domain is accentuated by

the lack of HOXD10-12 expression
and only the most terminal HOX
transcription factors, i.e., HOXA13 and
HOXD13, are expressed.
When the digit morphology has
been established, the AER regresses
and the terminal phalanges begin
to form5;26. Formation of terminal
phalanges is morphologically and19committee reports

mechanistically diﬀerent from otherphalanges. Although a cartilage model
forms similar to other phalanges,
ossiﬁcation begins at the distal tapered
tip rather than as a collar around the
mid-shaft4. A keratinised nail also forms
on the dorsal aspect of the terminal or
ungual phalanx. In mice, the terminal
phalanges are demarcated molecularly
by the expression of Bambi, a Bmp
inhibitor, and Sp8, a member ofthe speciﬁcity protein family oftranscription factors that mediates Wnt
signaling (Figure 4, last panel)4;10. In
addition, the terminal phalanx retains
the expression of MSX1, a transcription
factor that is thought to convey thecapacity for ﬁngertip regeneration2;7.

Clinical Genetics
While animal models are important incharacterising many of the pathways
that regulate digit formation, genetic
analysis of patients with congenital
upper limb anomalies are instrumental
in providing relevant molecules
to investigate and in conﬁrming“The molecularmechanisms
underlying digit
formation are not fully
understood, however,recent investigationsin animal models
and clinical genetics
provide someinteresting insights
into the process.”
conservation of suspected pathways.
For example, disruption of GLI3 was
ﬁrst recognised in patients with
Greig cephalopolysyndactyly37.
GLI3 was subsequently conﬁrmed
as the molecule disrupted in themouse mutant extra-toes (Xt), that
had some features akin to Greig
cephalopolysyndactyly36. However,it was several years later before GLI3

was recognised as the transcription
factor mediating SHH function14.
Limb features in patients with thisautosomal dominant mutation
include broad thumbs with a central
phalangeal defect/hole and distal
phalangeal duplication, features
similar to those seen in heterozygote
mouse knockouts indicating functional
conservation of GLI3 in vertebrate limb
patterning32{personal observation, RosMA).
Similarly, functional conservationof SHH in limb patterning and its limb
speciﬁc regulation have also been
demonstrated in humans. In fact,
it was point mutations in patientswith preaxial polydactyly type II or
triphalangeal thumbs that unveiled thevertebrate ZPA regulatory sequence(ZRS){Lettice, 2002 1362 /id;Lettice,2003 1360 /id}.
Based on animal models, lossof SHH function would limit ulnar
expansion and aﬀect the developmentof the ulna and ulnar digits, features
known clinically as ulnar longitudinal

Figure 4. Digit Morphogenesis. After establishing digit number and the SHH dependent/independent domains, digit morphologies are specified. Digit
morphologies are determined by the adjacent posterior interdigital mesoderm as illustrated (ID1–ID5). The inderdigital tissue conveys specified digit
morphology to the phalanx forming region (PFR—magenta) capping the distal tip of each digital anlagen. The PFR, in concert with the AER (orange),
determines phalanx size, length and positioning of joints. The interdigital tissue subsequently undergoes Bmp mediated programmed cell death(speckled regions). As the AER regresses the distal or ungual phalanx begins to form and is demarcated by expression of mesodermal Msx1 (blue) andectodermal Sp8 (green). (Image adapted from Oberg et al., 2010)20

IFSSH ezine MAY 2014

committee reports

deﬁciency. However, in humans, no
syndromic or genetic basis of ulnar
longitudinal deﬁciency has yet been
identiﬁed.
Disruptions of distal HOXD and
HOXA genes also have known
mutations that demonstrate theirinvolvement in hand development.
Synpolydactyly has been linked to
HOXD13 mutation and has central
polydactyly supporting a role for
HOXD13 in deﬁning the numberof digits formed18. While Handfoot-uterus syndrome is causedby disruption in HOXA13 and ischaracterised by shortened thumbs
and little ﬁngers, occasionally withhypoplastic middle phalanges
reducing the digital lengths of all of
the ﬁngers 17;35. These ﬁndings support
a role for HOXA13 in establishingdigital lengths.
The thumb is an unusual digit
and from a developmental biology
standpoint, is diﬀerentiated from otherdigits by being the last to form, being
independent of SHH, and lacking
the expression of the distal HOXD
genes. These features also appear to
put the thumb at signiﬁcant risk of
disruption as over 1100 syndromes
have hypoplastic thumbs as afeature21. Thus, it appears that thumbdevelopment (radial longitudinaldeﬁciency) is most frequently
impaired following any disruptionthat compromises the width of the
handplate, particularly with persistent
SHH function preserving the posterior
or ulnar aspect of the limb bud13;22.
Molecular contributions to theterminal phalanx proposed by animalmodels have also been demonstrated
in humans2 and implicated in the
IFSSH ezine MAY 2014

conserved regenerative capacity ofdigit tips8. These past recent successes
in delineating the molecular basisof hand development encouragecontinued genetic evaluation of limb
malformations to further characterise
the involved pathways. Further
discoveries are likely to occur fromthis synergistic relationship between
clinical genetics and developmental
biology.

References
1 Agarwal P, Wylie JN, Galceran J et al.
Tbx5 is essential for forelimb bud
initiation following patterning of
the limb ﬁeld in the mouse embryo.
Development 2003;130:623-633.
2 Allan CH, Fleckman P, Fernandes
RJ et al. Tissue response and Msx1
expression after human fetal digit tip
amputation in vitro. Wound Repair
Regen 2006;14:398-404.
3 Burke AC, Nelson CE, Morgan BA,
Tabin C. Hox genes and the evolutionof vertebrate axial moprhology.
Development 1995;121:333-346.
4 Casanova JC, Badia-Careaga C, Uribe
V, Sanz-Ezquerro JJ. Bambi and Sp8expression mark digit tips and theirabsence shows that chick wing digits
2 and 3 are truncated. PLoS One
2012;7:e52781.
5 Casanova JC, Sanz-Ezquerro JJ. Digit
morphogenesis: is the tip diﬀerent?
Dev Growth Diﬀer 2007;49:479-491.
6 Dahn RD, Fallon JF. Interdigital
regulation of digit identity andhomeotic transformation bymodulated BMP signaling. Science
2000;289:438-441.
7 Han M, Yang X, Farrington JE, Muneoka
K. Digit regeneration is regulatedby Msx1 and BMP4 in fetal mice.
Development 2003;130:5123-5132.
8 Han M, Yang X, Lee J, Allan CH,
Muneoka K. Development andregeneration of the neonatal digit tip inmice. Dev Biol 2008;315:125-135.

9 Harfe BD, Scherz PJ, Nissim S, Tian H,
McMahon AP, Tabin CJ. Evidence foran expansion-based temporal Shh
gradient in specifying vertebrate digit
identities. Cell 2004;%20;118:517-528.
10 Kawakami Y, Esteban CR, Matsui T,
Rodriguez-Leon J, Kato S, Izpisua
Belmonte JC. Sp8 and Sp9, two closely
related buttonhead-like transcription
factors, regulate Fgf8 expression andlimb outgrowth in vertebrate embryos.
Development 2004;131:4763-4774.
11 Kmita M, Fraudeau N, Herault Y,
Duboule D. Serial deletions andduplications suggest a mechanism forthe collinearity of Hoxd genes in limbs.
Nature 2002;420:145-150.
(12) Koshiba-Takeuchi K, Takeuchi
JK, Arruda EP et al. Cooperative andantagonistic interactions between Sall4
and Tbx5 pattern the mouse limb andheart. Nat Genet 2006;38:175-183.
13 Lee J, Tickle C. Retinoic acid and patternformation in the developing chickwing: SEM and quantitative studies of
early eﬀects on the apical ectodermal
ridge and bud outgrowth. J Embryol
Exp Morphol 1985;90:139-69.:139-169.
14 Marigo V, Johnson RL, Vortkamp A,
Tabin CJ. Sonic hedgehog diﬀerentiallyregulates expression of GLI and GLI3
during limb development. Dev Biol
1996;180:273-283.
15 Minguillon C, Nishimoto S, Wood S,
Vendrell E, Gibson-Brown JJ, Logan
MP. Hox genes regulate the onset
of Tbx5 expression in the forelimb.
Development 2012;139:3180-3188.
16 Montero JA, Lorda-Diez CI, Ganan Y,
Macias D, Hurle JM. Activin/TGFbeta
and BMP crosstalk determines
digit chondrogenesis. Dev Biol
2008;321:343-356.
17 Mortlock DP, Innis JW. Mutationof HOXA13 in hand-foot-genital
syndrome. Nat Genet 1997;15:179-180.
18 Muragaki Y, Mundlos S, Upton J, Olsen
BR. Altered growth and branchingpatterns in synpolydactyly caused
by mutations in HOXD13. Science
1996;272:548-551.

21

committee reports

19 Nelson CE, Morgan BA, Burke AC etal. Analysis of Hox gene expression
in the chick limb bud. Development
1996;122:1449-1466.
20 Ng JK, Kawakami Y, Buscher D et al.
The limb identity gene Tbx5 promotes
limb initiation by interacting with
Wnt2b and Fgf10. Development
2002;129:5161-5170.
21 Oberg KC. Review of the Molecular
Development of the Thumb: Digit
Primera. Clin Orthop Relat Res 2013.
22 Raynaud A, Clergue-Gazeau M.
[Chemically induced ectropodia in theLacerta viridis embryo and formation ofstyliform limbs in reptiles]. C R Acad Sci
III 1984;298:457-460.
23 Riddle RD, Johnson RL, Laufer E, Tabin
C. Sonic hedgehog mediates thepolarizing activity of the ZPA. Cell
1993;75:1401-1416.
24 Rodriguez-Esteban C, Tsukui T, Yonei S,
Magallon J, Tamura K, Izpisua Belmonte
JC. The T-box genes Tbx4 and Tbx5
regulate limb outgrowth and identity.
Nature 1999;398:814-818.
25 Rowe DA, Cairns JM, Fallon JF. Spatial
and temporal patterns of cell deathin limb bud mesoderm after apicalectodermal ridge removal. Dev Biol
1982;93:83-91.
26 Sanz-Ezquerro JJ, Tickle C. Fgf signaling
controls the number of phalanges andtip formation in developing digits. Curr
Biol 2003;13:1830-1836.
27 Schweitzer R, Vogan KJ, Tabin CJ. Similar
expression and regulation of Gli2 andGli3 in the chick limb bud. Mech Dev
2000;98:171-174.
28 Sheth R, Marcon L, Bastida MF et al.
Hox genes regulate digit patterningby controlling the wavelength of aTuring-type mechanism. Science
2012;338:1476-1480.
29 Summerbell D. The control of growth
and the development of pattern acrossthe anteroposterior axis of the chicklimb bud. J Embryol Exp Morphol
1981;63:161-80.:161-180.
30 Suzuki T, Hasso SM, Fallon JF. Unique
SMAD1/5/8 activity at the phalanx-

22

forming region determines digit
identity. Proc Natl Acad Sci U S A
2008;105:4185-4190.
31 Takeuchi JK, Koshiba-Takeuchi K, Suzuki
T, Kamimura M, Ogura K, Ogura T. Tbx5
and Tbx4 trigger limb initiation throughactivation of the Wnt/Fgf signalingcascade. Development 2003;130:27292739.
32 te Welscher P, Zuniga A, Kuijper S
et al. Progression of vertebrate limb
development through SHH-mediatedcounteraction of GLI3. Science
2002;298:827-830.
33 Towers M, Mahood R, Yin Y, Tickle C.
Integration of growth and speciﬁcationin chick wing digit-patterning. Nature
2008;452:882-886.
34 Turing AM. The chemical basis ofmorphogenesis. 1953. Bull Math Biol
1990;52:153-197.
35 Verp MS, Simpson JL, Elias S, Carson SA,
Sarto GE, Feingold M. Heritable aspects
of uterine anomalies. I. Three familial
aggregates with Mullerian fusion
anomalies. Fertil Steril 1983;40:80-85.
36 Vortkamp A, Franz T, Gessler M,
Grzeschik KH. Deletion of GLI3 supports
the homology of the human Greig
cephalopolysyndactyly syndrome(GCPS) and the mouse mutant extra
toes (Xt). Mamm Genome 1992;3:461463.
37 Vortkamp A, Gessler M, Grzeschik KH.
GLI3 zinc-ﬁnger gene interrupted
by translocations in Greig syndrome
families. Nature 1991;352:539-540.
38 Wang B, Fallon JF, Beachy PA.
Hedgehog-regulated processing of
Gli3 produces an anterior/posterior
repressor gradient in the developing
vertebrate limb. Cell 2000;100:423-434.
39 Winkel A, Stricker S, Tylzanowski P etal. Wnt-ligand-dependent interactionof TAK1 (TGF-beta-activated kinase-1)
with the receptor tyrosine kinase Ror2
modulates canonical Wnt-signalling.
Cell Signal 2008;20:2134-2144.
40 Witte F, Chan D, Economides AN,
Mundlos S, Stricker S. Receptor tyrosine
kinase-like orphan receptor 2 (ROR2)

and Indian hedgehog regulate digit
outgrowth mediated by the phalanxforming region. Proc Natl Acad Sci U S
A 2010;107:14211-14216.
41 Woltering JM, Duboule D. The originof digits: expression patterns versus
regulatory mechanisms. Dev Cell
2010;18:526-532.
42 Xu B, Wellik DM. Axial Hox9 activity
establishes the posterior ﬁeld in thedeveloping forelimb. Proc Natl Acad Sci
U S A 2011;108:4888-4891.
43 Yokouchi Y, Sasaki H, Kuroiwa A.
Homeobox gene expression correlatedwith the bifurcation process of limb
cartilage development. Nature
1991;353:443-445.
44 Zhu J, Nakamura E, Nguyen MT, Bao
X, Akiyama H, Mackem S. Uncoupling
Sonic hedgehog control of pattern andexpansion of the developing limb bud.
Dev Cell 2008;14:624-632.

*A general summary of upper limb
development can be reviewed at:
http://digitalav.llu.edu/llu/sm/oberg/
assh/index.htm (Courtesy of theAmerican Society for Surgery of the
Hand)

IFSSH ezine MAY 2014

committee reports

IFSSH Scientific Committee on
Anatomy and Biomechanics
Chair: Hisao Moritomo (Japan)
Committee: Emmanuel P. Apergis (Greece), Marc Garcia-Elias (Spain), Frederick Werner (USA), Scott Wolfe (USA)
Report submitted September 2013

Wrist biomechanics and Instability: Wrist dart-throwing motion updated
Introduction
The term “dart-throwing” (DT) motion,
or dart-thrower’s motion, is used todesignate one of the most frequently
utilised planes of wrist motion, the onethat brings the wrist from a radiallydeviated-extended position (radialextension) to an ulnarly deviatedﬂexed position (ulnar ﬂexion).1 DTmotion is particularly prevalent inmost occupational, recreational
and avocational activities, such as
hammering, clubbing or ﬂy ﬁshing.2-6 In
2007, the IFSSH (International Federationof Societies for Surgery of the Hand)
Committee on Wrist Biomechanics
published a historical perspective anda summary of the basic principles ofDT biomechanics.1 The purpose of thisarticle is to update that report basedon the most recent research publishedon the kinematics, kinetics, and clinicalapplications of DT motion.
Carpal kinematics
The wrist is a composite joint. Whenit moves, a complex interaction andaccumulation of motions occur at
its diﬀerent levels. For the wrist toreach its maximal range, all of its joints[radiocarpal (RC), midcarpal (MC) andIFSSH ezine MAY 2014

intercarpal] must collaborate in thatrotation. That rule has two exceptions:1) when the wrist rotates along theDT plane of motion, only the MC joint
moves about a proximal row thatremains still, and 2) when the wrist
rotates along the so-called reversed DT
plane of motion (from ulnar extension
to radial ﬂexion), motion occurs almost
exclusively at the RC joint. From akinematic point of view, therefore, thewrist can be compared to a universal
joint with two axes of motion, one for
the RC joint, another for the MC joint,
separated by an intercalated segment(the proximal row) aimed at coordinating
the two levels of rotation. What follows
is a review of the studies that haveprovided new data in these regards.
Crisco et al.7 predicted near-zero
scaphoid rotation when the wrist
rotates along an oblique planeoriented at an angle of 33° to thesagittal plane, while for the lunate
to remain still, the wrist needs tomove along an oblique plane 20° to
the sagittal plane. These values areslightly inferior to the ones reported by
Werner et al. who found that, to obtain
minimal scaphoid and lunate rotations,
the wrist needs to move along motion

paths oriented at an angle of 45° and
37° respectively to the sagittal plane.8
It is important to note, that in bothinvestigations the wrist was mobilised
taking the neutral wrist position asa reference (zero degrees on both
ﬂexion-extension and radio-ulnar
deviation). Indeed, one may bring thehand from radial extension to neutral
and continue from neutral to ulnar
ﬂexion, following an oblique planethat intercepts both the coronal andsagittal planes at the same time. This,
however, is not the most common.
More often on actual activities, DT
rotation is done along an obliqueplane that is parallel to the previous
one, but that has an oﬀset toward thedorsal side and does not intercept thecoronal and sagittal planes at the zero
position5,9. When this happens, thatDT plane is said to be a “functional”
DT plane. By contrast, when the wrist
takes an oblique path across theneutral wrist position, the DT planeis said to be a “pure” DT plane. The
kinematic diﬀerences of mobilising thewrist along a “pure” or a “functional” DTplanes are not fully understood, but
certainly the subject deserves speciﬁc
attention. There are circumstances23

committee reports

in which it may be advisable torehabilitate a wrist by performing
repeated rotations along a pure DT
plane of motion; in other cases it may
be advisable to avoid such commonlyused paths. In general, it is admitted
that, after certain types of radiocarpal
and/or proximal row reconstructions,motion along a pure DT plane can beallowed without concern for disruption
or attenuation of the reconstruction,
because the proximal row remains
relatively still during that particular
type of rotation.10
There are still many unknowns inregards the kinematics of DT motion.
For instance, it is still unclear whether
the functional DT plane of motion
which is used most commonly inactivities of daily living (such as inhammering) is the same as the pureDT plane where scaphoid and lunate
motion is minimal. The recent ﬁndings
regarding the relative contributionof the radiocarpal joint to the overall
wrist motion during DT rotation havevary substantially from one author
to another 7,8,11-13. Scaphoid rotation
during DT motion has been reported
to be as little as 26% and as much as
50% of overall wrist motion, while therange of reported lunate rotations
has varied from 22% to 40% of overall
wrist motion. While it is convenient
to imagine a single plane of motionthat enables complex wrist functions,most researchers agree that several
DT motion paths of composite radioulnar and ﬂexion-extension are likely
to contribute to a wide variety offunctional activities.
Leventhal et al.14 examined
healthy volunteers with computed
tomography (CT) scans, performing

24

a simulated hammering task, usinga path of wrist motion from radialextension to ulnar ﬂexion, and foundthat during a simulated hammeringtask the rotations of the scaphoidand lunate were not minimal but
averaged 40% and 41% respectivelyof total wrist motion. According tothat, radiocarpal motion accounted
for 40% of the overall wrist motion,with the remaining 60% occurringat the midcarpal joint. These greater
percentages of scaphoid and lunate
motion during hammering, ascompared to the ones found for pureDT motion with near zero scaphoidand lunate motion, appear to indicate
that, indeed, pure DT and functional
DT are diﬀerent wrist motion paths.
Furthermore, in that study, the averageplane of motion while hammering wasoriented 41° from the sagittal plane,
and was parallel to the pure DT planewith a substantial oﬀset between the
two. From that study we learned that,
motions which require a greater rangeof gripping force, such as hammering,are likely to exhibit greater ranges ofscaphoid and lunate motion. In otherwords, there exist a wide range of DT
planes, parallel to the “pure” DT plane,
each with its own advantages whenit comes to move while grasping or
gripping an object.
Crisco et al.15 demonstrated in the
cadaver that mechanical axis of thewrist, and found this not to be alignedwith the anatomical sagittal or coronalaxes of the hand. The envelope of all
possible wrist positions was ellipsoidal
in shape and oriented obliquely ata mean angle of 26.6° ± 4.4° to thesagittal plane of motion.15 It was also
noted that the greatest total rangeof motion, in the direction of radialextension to ulnar ﬂexion, was 142°
which was greater than their total
range of ﬂexion-extension motion of
129°. This supports the concept that afunctional DT facilitates those activities
which require greater wrist motion.
Because several DT paths ofcomposite radio-ulnar and ﬂexionextension are likely to contributein a variety of functional activities,
the term “coupled” wrist motion is
emerging as a more inclusive term fordescribing out-of-plane motion froma kinematic, clinical and rehabilitative
perspective16. Measuring coupledwrist motion clinically has presented
unique challenges. While goniometricmeasurement of the conventional
orthogonal planes of ﬂexion-extension
and radio-ulnar deviation has been
demonstrated to be accurate andrepeatable within 10 degrees,17 nosimilar reliability study has been
performed for manual measurementof coupled motions or postures.
The technique and challenges ofmeasuring coupled motion along theDT plane in a rehabilitation practicewere recently outlined by Bugden 18.
The emergence of in vivo
three-dimensional motion analysis
techniques [markerless boneregistration technique using sequential
CT or magnetic resonance imaging(MRI)] enabled precise analysis ofcomplex motions of the individual
carpal bones in live subjects 7,10,13,14,1922. However, we need to be careful
in interpreting these results because
the technique is limited to a quasistatic analysis of wrist motion andthe inability to recreate physiologic
rheology conditions of the joint in the
IFSSH ezine MAY 2014

committee reports

3-dimensional gantry. Additionally,
the levels of ionizing radiation
limit the use of this technique ingeneral practice. The use of so-called
4-dimensional advanced imaging,whether ﬂuoroscopy, ultra-fast CT
scans or MRI, is evolving 23-25 and has
already been found useful to study
what happens within the carpus
when a wrist with a scapholunate
dissociation rotates along a DT plane.25
Garcia-Elias et al reported that, when
the scapholunate ligaments were
torn, the scaphoid shifted towards theradial styloid considerably more thanthe lunate, inducing a scapholunate
gap.25 Based on these ﬁndings, they
did not recommend dart-throwing
exercises after scapholunate ligament
repair.25 Video recording of motion canqualitatively demonstrate diﬀerencesin circumduction arcs between normal
and injured wrists or between patients,
but cannot yet be utilized currently toprovide objective kinematic data.
Recently, unique algorithms forkinematic analysis using applied skin
optimal marker sets and measured bymultiple simultaneous video cameras
have been eﬀectively utilized toaccurately quantify normal motion
during functional activities.9,26,27 It is
likely that these techniques will further
evolve to facilitate accurate upper
extremity analysis and reporting in vivo.
Brigstock et al 9 using passive reﬂective
markers and 3-dimensional motion
analysis in 10 subjects, conﬁrmed invivo the use of DT motion during daily
activities in both seated (forehand haircombing, backhand hair combing anddrinking from a glass) and standing
positions (hammering a nail, throwing
a ball, pouring from a jug, undoing
IFSSH ezine MAY 2014

“It is also a common
belief that early
mobilisationand prompt
physiotherapy
prevent thedevelopment of CRPS
after fractures.”a button, doing-up a button, andtwisting oﬀ and on the lid of a jar). They
found the mean plane of a measured
simulated DT motion to be 44° to thesagittal plane of the forearm, inclined
from a position of radial extension
to ulnar ﬂexion. They demonstrated
that wrist motion approximated the
DT motion when hammering a nail,throwing a ball, drinking from a glass,pouring from a jug and twisting oﬀ andon the lid of a jar since their planes of
motion ranged from 38 to 48 degrees
from the sagittal plane and were
not signiﬁcantly diﬀerent from thesimulated dart throw motion plane.
Two activities were found to not have aplane of motion similar to a dart throw
motion; combing hair or buttoning or
undoing a button.

Impact of carpal bone fusions on DT
motionDisorders that aﬀect DT motion include
anything that disrupts the coordinatedgliding of the radiocarpal or midcarpal
joints, including ligament disruption,
post-traumatic or degenerative arthritis,inﬂammatory arthritis, Kienböck’s
disease, or Preisser’s disease. Garg
et al 28 examined the relationshipbetween wrist coupling (the amountof ﬂexion-extension per degree ofradial-ulnar deviation) and functional
performance in patients after midcarpal
arthrodesis. They found that altered
wrist coupling will result in diminishedperformance in selected occupationaland sporting activities (dart throwing,
hammering, pouring, and basketballtasks). Compensations aﬀorded by theelbow and shoulder may inﬂuence theperformance of certain functional tasks.
Several authors have recently
recommended radiocarpal rather
than midcarpal fusions (if the
cartilage in the midcarpal joint is
intact), in order to preserve midcarpal
function. Arimitsu et al reported thatthe midcarpal motions were wellpreserved after both radio-lunate andradio-scapho-lunate arthrodesis 20.
The postoperative direction of wrist
motion in their study was oblique
from radiodorsal to ulnopalmar along
a DT plane. Additionally, it has been
demonstrated that midcarpal andlunotriquetral motion are increased
after simulated radio-scapho-lunate
fusion 29, 30. Moritomo et al revealed
that capitate motion relative to thescaphoid was essentially uniaxial andthat the motion plane was oblique
from radiodorsal to ulnopalmar,
whereas the direction of capitatemotion relative to the lunate had more
ﬂexibility and could range between
the pure ﬂexion-extension plane
and the DT plane 13. Therefore, theresidual motion plane of the capitate
after radio-lunate arthrodesis is more
ﬂexible than after radio-scapho-lunate
arthrodesis.20 If the scaphoid is ﬁxed
to the lunate, the direction of capitatemotion relative to the lunate is25committee reports

dominated by the direction of capitatemotion relative to the scaphoid andlimited to the DT plane.
Distal scaphoidectomy has beendeveloped in order to improve therange of motion after radio-scapholunate arthrodesis. 31 There are reportsthat distal scaphoidectomy also
improves fusion rates and lowers
the incidence of midcarpal arthritis
31. However, distal scaphoidectomy
could alter the kinematic behavior of
the remaining joints with unknown
consequences. Since it was suggested
that the scaphotrapezium-trapezoid
joint is a key anatomical factor thatstabilises and controls DT motion32,
distal scaphoidectomy could abolishes
the plane of DT motion and how thewrist moves through an oblique DT
motion -like plane of motion. We needlong-term surgical outcomes to better
elucidate these concerns.
Kamal et al 22 measured the in vivo
articulation of the triquetrum-hamate
joint as the wrist moves along the DT
path. The study suggested that wrist
ulnar ﬂexion is constrained by thetriquetrum-hamate joint. The concave
distal ridge of the hamate guides thetriquetrum toward the hook of thehamate until it is fully engaged, whichblocks further ulnar ﬂexion of thewrist. This may provide carpal stability
while also serving as a rationale
for triquetrum excision to increase
the range of wrist motion. Pervais33
postulated that removal of boththe triquetrum and distal scaphoidconverts the complex midcarpal
joint into a simple ball and socket
joint, though the kinematics of thatcondition have not been fully studied.
It is possible that the beneﬁt from an

26increase in midcarpal motion may beoﬀset by the well-established belief
that altered kinematics may changeload distribution and accelerate
degenerative osteoarthritis 34.

Coupling of wrist and forearm
rotations
Anderton and Charles 35 tried toquantify the coordination and couplingof wrist and forearm rotations in healthy
subjects performing activities of dailyliving. They reported that ﬂexion of
the wrist is often accompanied byulnar deviation and supination, andextension is often accompanied byradial deviation and pronation. On thecontrary, Leventhal et al 14 stated thathammering is performed with limited
forearm pronation/supination motion.
More study will be needed regarding
the coupling of wrist and forearm
rotations.
Carpal Ligaments
Tang et al 21 investigated lengthchanges in radiocarpal and midcarpal
ligaments of the wrist, in diﬀerent
positions of the DT motion in vivo.
They found that from radial extension
to ulnar ﬂexion the lengths of volar
ligaments (radioscapohocapitate(RSC), long radiolunate (LRL), ulno
capitate (UC) and ulnotriquetral (UT))
signiﬁcantly decreased, whereas thelengths of the dorsal ligaments (dorsal
radiocarpal; portion of the dorsalintercarpal ligament inserting on the
trapezoid) increased progressively.
The ulnolunate ligament and the
portion of the dorsal intercarpal
ligament inserting on the scaphoidwere shortest in the neutral position.
They noted that the four ligaments(RSC, LRL, UC and UT) that were tighterin radial extension and more lax inulnar ﬂexion represented both radial
and ulnar stabilising structures. It may
be that more stability is provided
in radial extension at the start of a
dynamic motion such as hammeringand throwing and less is needed ordesirable as the wrist moves into ulnar
ﬂexion. In addition, biomechanicalstudies on the UT ligament haveshown that its length is maximum
during wrist radial extension, thus thisligament is at risk at the extension
phase of DT motion, especially withthe forearm in supination 21, 36, 37. Upalet al 10 have shown that scapholunate(SL) interosseous ligament elongation
is minimal as the wrist is positioned
along the DT path. It is known that the
STT and scaphocapitate ligaments are
considered as collateral ligaments of
the STT joint that stabilise and control
DT motion.38 However, recent studies
demonstrate that these ligaments
have very few proprioceptivefunctions—implying that theirprincipal function is mechanical—incontrast to the dorsal intercarpal
ligaments and triquetral-hamatecapitate ligaments, which are thought
to constrain the end points of DT
motion (i.e. “stops”) via their substantial
proprioceptive properties 39.

Role of the Muscles
We know that the two wrist motor
tendons directly involved in generating
swing motion along the DT plane
are the ﬂexor carpi ulnaris (FCU) andthe extensor carpi radialis brevis andlongus (ECRB-L). According to the paper
presented by Salva-Coll et al 40, these
two muscles together with the
IFSSH ezine MAY 2014

committee reports

abductor pollicis longus (APL) areconsidered as muscles that supinate the
midcarpal joint (midcarpal supinators).
Since the ligaments crossing the
midcarpal joint (ulnar arm of thearquate ligament, SC ligament and STT
ligament) are intact, the supination
moment will also be transmitted tothe proximal row bones. The authors
argued that if all carpal supinatormuscles contract while the pronators(extensor carpi ulnaris (ECU), ﬂexor
carpi radialis (FCR)) relax, the scaphoidis likely to rotate further into supination,a position in which the dorsal SL
ligament is better protected. It istherefore reasonable to assume that,by performing a task along the planeof DT motion under the contraction of
the supinator muscles of the midcarpal
joint, the SL joint is more stable.
In a cadaver study, according toWerner et al 41 during a DT motion, themean and peak tendon forces of ECRLand FCU were the greatest compared tothe corresponding values of ECU, ECRB,APL and FCR tendon forces. Both thepeak and mean FCR forces were shown
to be signiﬁcantly less during the DT
motion than during wrist ﬂexionextension, radioulnar deviation or
circumduction motions. On average thepeak FCR forces were 24% less while themean FCR forces were 49% less thanduring the other motions. Conversely
the mean and peak FCU forces weresigniﬁcantly greater during a DT motion
compared to the other 3 motions (peakforces 86% greater, mean forces 79%
greater). These results indicate that toachieve diﬀerent desired wrist motions
diﬀerent tendon forces are required.
Weak musculature may alter theoblique plane of motion necessary to
IFSSH ezine MAY 2014

minimize the tendon forces to achievea given activity.

Evolutionary significanceTang 42 analysed the skeletal
specimens of a variety of vertebral
animals, ranging from prehistoric andextinct animals to modern primates.
The author highlighted ﬁve distinct
evolutionary changes: ﬁrst, the singlebone intercalated segment became
multiple bony structures between
the forearm and the metacarpus;
second, a lengthy and a prominentequivalent of the pisiform, which wasa dominant feature of the ulnar side of
the carpus in animals requiring palmar
ﬂexion or weight bearing, evolved tothe smallest carpal bone, much lessprominent in comparison to those ofancient and giant animals; third, theratio of the metacarpus to carpus;
fourth, the changing roles of the carpal
bones from alignment to stability andthen to mobility and ﬁfth, the presenceof a broad distal part of the radiusthat causes the overlying tendons to
protrude outwards and increases the
distance from the tendons to theircenters of motion, thereby creating
greater moments to maintain or
generate the dominant wrist motion
pattern which is from radial extension
to ulnar ﬂexion, that is DT motion.
Evolutionary signiﬁcance has been
ascribed to the DT plane, as it appears
that the motion path may be uniqueto Homo Sapiens, and adaptations
in carpal bone development may
have abetted tool making, hunting
and defensive abilities of early prohominids.43

References
1. Moritomo H, Apergis EP, Herzberg G, et al.
2007 IFSSH Committee Report of Wrist
Biomechanics Committee: Biomechanics of
the So-Called Dart-Throwing Motion of theWrist. J Hand Surg (Am). 2007;32A(9):14471453.
2. Bunnell S. Surgery of the Hand. J.B.Lippincott;1944.
3. Capener NJ. The hand in surgery. J Bone Joint
Surg 1956; 38B:128–151.
4. Fisk G. Biomechanics of the wrist joint. In:
Tubiana R, ed. The Hand. Philadelphia: W. B.
Saunders, 1981:136 –141.
5. Palmer AK, Werner FW, Murphy D, Glisson R.
Functional wrist motion: a biomechanicalstudy. J Hand Surg [Am] 1985 Jan;10(1):3946.
6. Saﬀar P, Seumaan I. The study of thebiomechanics of wrist movements inan oblique plane. In: Schvind FA, An KN,
Cooney WP, Garcia-Elias M, eds. Advancesin the Biomechanics of the Hand and Wrist.
New York: Plenum Pres, 1994:305–311.
7. Crisco JJ, Coburn JC, Moore DC, et al. In
vivo radiocarpal kinematics and the dart
thrower’s motion. J Bone Joint Surg Am.
2005;87(12):2729-2740.
8. Werner FW, Green JK, Short WH, Masaoka
S. Scaphoid and lunate motion during awrist dart throw motion. J Hand Surg (Am).
2004;29(3):418-422.
9. Brigstocke GH, Hearnden A, Holt C, Whatling
G. In-vivo conﬁrmation of the use of thedart thrower’s motion during activities ofdaily living. J Hand Surg Eur Vol 2012 Oct 11
10. Upal MA, Crisco JJ, Moore DC, Sonenblum
SE, Wolfe SW. In vivo elongation of
the palmar and dorsal scapholunate
interosseous ligament. Journal ofHand Surgery - American Volume.
2006;31(8):1326-1332.
11. Werner FW, Short WH, Fortino MD, Palmer
AK. The relative contribution of selectedcarpal bones to global wrist motion during
simulated planar and out-of-plane wrist
motion. J Hand Surg (Am). 1997;22(4):708713.
12. Ishikawa J, Cooney WP, 3rd, Niebur G,
et al. The eﬀects of wrist distraction on
carpal kinematics. J Hand Surg (Am).
1999;24(1):113-120.
13. Moritomo H, Murase T, Goto A, Oka K,

27

committee reports

Sugamoto K, Yoshikawa H. In vivo threedimensional kinematics of the midcarpal
joint of the wrist. J Bone Joint Surg Am 2006
Mar;88(3):611-21.
14. Leventhal EL, Moore DC, Akelman E, Wolfe
SW, Crisco JJ. Carpal and forearm kinematics
during a simulated hammering task. J Hand
Surg (Am). 2010;35(7):1097-1104.
15. Crisco JJ, Heard WM, Rich RR, Paller DJ, Wolfe
SW. The mechanical axes of the wrist areoriented obliquely to the anatomical axes. J
Bone Joint Surg Am. 2011;93(2):169-177.
16. Li ZM, Kuxhaus L, Fisk JA, Christophel TH.
Coupling between wrist ﬂexion-extension
and radial-ulnar deviation. Clin Biomech(Bristol, Avon ) 2005 Feb;20(2):177-83.
17. Carter TI, Pansy BE, Wolﬀ AL, Hillstrom HJ,
Backus S, Lenhoﬀ M, et al. Accuracy andReliability of Three DIﬀerent Techniquesfor Manual Goniometry for Wrist Motion. J
Hand Surg [Am] 2009 Jan 2;34(1422):1428.
18. Bugden B. A proposed method ofgoniometric measurement of the dartthrowers motion. J Hand Ther 2013
Jan;26(1):77-80.
19. Moritomo H, Murase T, Arimitsu S,
et al. Change in the length of theulnocarpal ligaments during radiocarpal
motion: possible impact on triangularﬁbrocartilage complex foveal tears. Journalof Hand Surgery - American Volume.
2008;33(8):1278-1286.
20. Arimitsu S, Murase T, Hashimoto J, et al.
Three-dimensional kinematics of therheumatoid wrist after partial arthrodesis. J
Bone Joint Surg Am. 2009;91(9):2180-2187.
21. Tang JB, Gu XK, Xu J, Gu JH. In vivo lengthchanges of carpal ligaments of the wrist
during dart-throwing motion. J Hand Surg
(Am). 2011;36(2):284-290.
22. Kamal RN, Rainbow MJ, Akelman E, Crisco
JJ. In vivo triquetrum-hamate kinematics
through a simulated hammering task
wrist motion. J Bone Joint Surg Am.
2012;94(12):e85.
23. Carelsen B, Bakker NH, Strackee SD, Boon SN,
Mass M, Sabczynski J, et al. 4-D rotational
xray imaging of wrist joint dynamic motion.
Med Phys 2005;32(9):2771-6.
24. Kober C, Gallo L, Zeilhofer HF, Sader RA.
Computer-assisted analysis of human upperarm ﬂexion by 4D-visualization based on

28

MRI. Int J Comput Assist Radiol Surg 2011
Sep;6(5):675-84.
25. Garcia-Elias M, Alomar Serrallach X, Monill
Serra J. Dart-throwing motion in patientswith scapholunate instability: a dynamic
four-dimensional computed tomography
study. J Hand Surg Eur Vol. 2013 Apr 8.
[Epub ahead of print]
26. Wolfe SW, Syrkin G, Stoecklein HH, Backus S,
Wolﬀ AL, Kraszewski A, et al. Altered wrist
coupling results in diminished performanceof functional tasks. Proc.Am.Orthop.Assoc.
2009. 2009.
27. Wolfe SW, Garg R, Kraszewski A, ackus S,
ogekwu N, enhoﬀ M, et al. Comparisonof Wrist Kinematics and Functional
Performance between Surgical Treatments
for SLAC Wrist. Proc.Am.Soc.Surgery Hand
2011, 142. 9-9-2011.
28. Garg R, Kraszewski A, Stoecklein H, etal. Eﬀects of midcarpal arthrodesis on
wrist coupling and performance. Paper
presented at:2010 Annual Meeting of theAmerican Society of Biomechanics; August
2010; Providence, RI.
29. Calfee RP, Leventhal EL, Wilkerson J, etal. Simulated radioscapholunate fusion
alters carpal kinematics while preserving
dart-thrower’s motion. J Hand Surg (Am).
2008;33(4):503-510.
30. Berkhout MJ, Shaw MN, Berglund LJ, et al.
The eﬀect of radioscapholunate fusion
on wrist movement and the subsequenteﬀects of distal scaphoidectomy andtriquetrectomy. Journal of Hand Surgery:
European Volume. 2010;35(9):740-745.
31. .Garcia-Elias M, Lluch A, Ferreres A, PapiniZorli I, Rahimtoola ZO. Treatment ofradiocarpal degenerative osteoarthritis byradioscapholunate arthrodesis and distal
scaphoidectomy. Journal of Hand Surgery American Volume. 2005;30(1):8-15.
32. Moritomo H. The Kinematics and ClinicalImplications of the Dart-Throwing motion.
In: Slutsky DJ, ed. Principles and practiceof wrist surgery. Philadelphia, PA: Saunders
Elsevier; 2010.
33. Pervaiz K, Bowers WH, Isaacs JE, Owen
JR, Wayne JS. Range of motion eﬀects of
distal pole scaphoid excision and triquetral
excision after radioscapholunate fusion: acadaver study. Journal of Hand Surgery -American Volume. 2009;34(5):832-837.
34. Hug U, Guggenheim M, Kilgus M, Giovanoli
P. Treatment of radiocarpal degenerative
osteoarthritis by radioscapholunate
arthrodesis: long-term follow-up. Chirurgie
de la Main. 2012;31(2):71-75.
35. Anderton W, Charles SK. Kinematic couplingof wrist and forearm movements. Paper
presented at:2012 Annual Meeting of theAmerican Society of Biomechanics; August
16-18 2012; Gainsville, FL.
36. Tay SC, Berger RA, Parker WL. Longitudinal
split tears of the ulnotriquetral ligament.
Hand Clinics. 2010;26(4):495-501.
37. DiTano O, Trumble TE, Tencer AF.
Biomechanical function of the distal
radioulnar and ulnocarpal wrist ligaments.
Journal of Hand Surgery - American
Volume. 2003;28(4):622-627.
38. Moritomo, H., Viegas, S.F., Nakamura,K., DaSilva, M.F., Patterson, R.M. The
scaphotrapezio-trapezoidal joint. Part 1: An
anatomic and radiographic study. J Hand
Surg , 25A:899-910, 2000.
39. Hagert E, Forsgren S, Ljung BO. Diﬀerencesin the presence of mechanoreceptors
and nerve structures between wrist
ligaments may imply diﬀerential roles inwrist stabilization. Journal of Orthopaedic
Research. 2005;23(4):757-763.
40. Salva-Coll G, Garcia-Elias M, Leon-Lopez MT,
Llusa-Perez M, Rodriguez-Baeza A. Eﬀects
of forearm muscles on carpal stability.
Journal of Hand Surgery: European Volume.
2011;36(7):553-559.
41. Werner FW, Short WH, Palmer AK, Sutton
LG. Wrist tendon forces during various
dynamic wrist motions. J Hand Surg (Am).
2010;35(4):628-632.
42. Tang JB. General concepts of wrist
biomechanics and a view from otherspecies. Journal of Hand Surgery: European
Volume. 2008;33(4):519-525.
43. Rohde RS, Crisco JJ, Wolfe SW. The
advantage of throwing the ﬁrst stone:
how understanding the evolutionary
demands of Homo Sapiens is helping us
to understand carpal motion. J Am Acad
Ortho Surg 2010;18(1):51-8.

IFSSH ezine MAY 2014

ifsshezine

CONNECTING OUR GLOBAL HAND SURGERY FAMILY

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

Mallet fingers aroundthe globe: Does one best
method for immobilisationand mobilisation exist?
Part I: Immobilisation
Compiled by Julienne Howell, thisarticle was ﬁrst published in theJanuary 2014 issue of the American
Society of Hand Therapy Times(ASHT Times). Howell asked various
therapists from diﬀerent part of theworld to explain their methods oftreating patients with a Mallet ﬁnger.
Contributors: Melissa Hirth, Melbourne,
Australia; Gwendolyn van Strien, Den
Haag, the Netherlands, Lyn Basini,
New York, USA, Dershnee Devan,
Johannesburg, South Africa.
According to Doyle’s classiﬁcationof mallet injuries Type 1a-b are closed
injuries with or without a fracture1.
Non-surgical treatment is favoured
over surgery following Type 1a-b
mallet ﬁnger injury 2, 3. Consensus has
been reached that immobilisation isneeded to primarily heal these closed
bony or tendinous injuries4. However,some of the ﬁner details regarding
immobilisation are inconclusive as
highlighted in Table 1. Hageman etal. indicated that when consensus is30

lacking, health care providers fall backto their personal preferences to maketreatment recommendations5. We
suspect, given the inconclusiveness ofthe evidence for treatment of malletﬁnger injuries, hand therapists will
similarly fall back to personal preference
when recommending a cast or orthotic
for immobilisation of these injuries.
Hageman et al. noted in addition topersonal preference, when our handsurgery colleagues are confronted
with inconclusive evidence they fallback to the best available outcome
evidence base and involve patientcentered care via shared decision to
guide treatment5. Unfortunately,much of the literature regarding
management of mallet injuries consistsof retrospective studies, lacking detailand control of methodology. Given
the poor quality of the evidence,
hand therapists no doubt may ﬁnd
it diﬃcult to feel conﬁdent when
making treatment recommendations
to patients. Table 2 summarises

some of the evidence issues aswell as anatomical/biomechanicalobservations.
Many reports, including the mostrecent and well-designed study
by Tocco and associates, found nostatistically signiﬁcant diﬀerence
between a cast and an orthotic in
recovery of DIPJ extension6. Perhaps
in our quest to improve outcome
evidence by looking for a single best
method to immobilise all malletﬁngers, could we be overlooking
the possibility that it does not exist?
Instead of an approach driven byprotocol, a better method may bethat both the immobilisation andmobilisation methods be tailored tothe patient. To test this hypothesis,
hand therapists would need to beskilled in multiple immobilisation
techniques, and would be required
to merge their examination andassessment ﬁndings to decide what isbest for each patient. Periodically ashealing proceeds, re-assessment of the
IFSSH ezine MAY 2014

hand therapy

patient may require the orthotic or cast
to be swapped for another method,
immobilisation time lengthened
and/or mobilisation exercises
slowdown. Additionally a consensus
among therapists for the purpose ofdefining key terms and standardisingmeasurement, would improve thequality of the evidence-base.
Part one of this article is intended
to share a variety of immobilisation
techniques and tips from handtherapists who work in different
corners of the globe and in diverse
healthcare settings. Their clinicalinsights for treatment progression arebriefly outlined in Table 3. Part twoof this article will elaborate on thetechniques and tips these therapists
use during the mobilisation phase.
The techniques and tips are offered
as food for thought to encourage
hand therapists and surgeons tore-think their approach in the overallmanagement of Type 1a-b malletfinger injuries.

“Given the poor
quality of theevidence, handtherapists no
doubt may find
it difficult to feel
confident when
making treatment
recommendations
to patients”
IFSSH ezine MAY 2014

Table 1
Areas of consensus and no consensus in the management of mallet finger
injuries (Type 1 a-b)
CONSENSUS● Immobilisation
NO CONSENSUS● Joints to be immobilised – DIPJ only or PIPJ + DIPJ
● Position of joint(s) – DIP neutral or hyperextension; slight blanching; PIP
flexion angle● Type of device- Orthotic or cast or commercial dorsal, volar, circumferential● Definition of acute and chronic● Duration of full time immobilisation – bony and tendinous the same ordifferent● Patient removal or not● Effectiveness of night immobilisation● How long after injury can immobilisation be used and be effective● Best method(s) to measure outcome – ROM, pain, edema, appearance, etc.
● Effect on outcome - % of articular surface, chronicity, edema, age, PIPJ
hyperextension, compliance, etc.
● At what time should the final outcome be measured● Definition of successful outcome

Table 2
Summary of best available outcome/evidence based and anatomical/
biomechanical observation from which to make treatment
recommendations for mallet finger (Type 1 a-b)
●
●
●
●
●

●

immobilisation is at least 6 - 12 weeks (sometimes longer)5-7
0.5mm Terminal Tendon (TT) gap = 10° DIPJ lag; 1mm TT gap =25 ° DIPJ lag8
20% of all patient outcomes have at least a 10 ° or greater DIP extension lag9
Despite the best compliance return to normal is a challenge10
Skin breakdown, satisfaction with appearance and joint pain/stiffness may be
issues 2,4,5
Later surgical intervention may be an option431

hand therapy

Table 3
Questions presented to Hand Therapists from different corners of the globe who work in diverse healthcare
settings concerning their decision making for the acute mallet finger (Type 1a-b).
Questions
What is your ideal time to start
immobilisation?
In reality when does
immobilisation typically start?

Lynn Bassini
ASAP

Melissa Hirth0-5d

Varies from same day to weeks later

2-10d

Orthotic or cast?
DIP only?
If yes, DIP neutral or (+)
hyperextension?
When do you immobilise boththe DIP + PIP joints?

Cast
Yes
DIPJ 0° to slight hyperextension no
blanching
If PIPJ hyper- extends; add PIPJ to cast in
20-30° flexion

Orthotic + tape
Yes
Bony 0° to +10°
Tendon +5° to +15°
Only if PIPJ hyperextends

Frequency of visits?

1x/wk or as necessary

1x/wk or 1x/2wks

Are tendon/bony mallets
immobilised the same?

6wks bony
8wks tendinous
If lag 8+wks bothNoNo, at minimum:
6wks bony
8wks tendinous
Prefer not until 4wks

8 wks after DIP extension lag is 0°

6/8wks if no lag
If lag develops reapply orthotic forfurther 2wks FTAROM exercises & Light functionaluse. Orthotic on for heavy activities &overnight

Do patients remove device toclean?
How do you decide length ofimmobilisation?
How do you introduce DIPJ
motion?

Protected AROM exercises for 2 more
wks + removable cast

What criteria do you use tocontinue weaning from thedevice?
Do you ever only night splint?
When?

If no lag develops on recovery of
motion, and no pain and return tofunction
No
Night and protected splinting go
together
8wks after DIPJ is at 0° extension

When do you stop full time
immobilisation?
Define a successful outcome?

How long post injury would
you initiate immobilisation for achronic mallet finger?

32<5° lag, minimal edema, no pain
+functional fist (1cm to DPC); no forced
tight fist
As needed even if it is many years

If no lag after 2wks of light functionaluse & AROM exercises
Yes
2wks further after wean from day use
If lag persists after 12wks FT orthotic.
Negotiate with patient to continue<5° lag or neutral (for those with priorhyper-extension) minimal oedema, nopain, functional fist + satisfied patient
Preferably no > 6m. Have had a successafter 18 years!

IFSSH ezine MAY 2014

hand therapy

Gwen van Strien
Week 1

Dershnee Devan
Week 1

Week 1 or, Week 6 when referred toour clinic, after first treatment failed
elsewhere
CastYes+5° to+10°

Week 1-2

If PIPJ is hypermobile

Only if there is pathology/hyperextension of the PIPJ
1x/wk

Yes

Week 1-2 twice/wkly
Thereafter, 1x/wk or 1x/2wk
Yes

Prefer not until 4wks

No

6-8 wks after DIP extension lag is 0-5°.
PIP motion of -30° to 90° flexion is
initiated at 4wks
Protected AROM exercises 2 wks
further + orthotic

8wks if no lag
If lag develops between wk 8 to 12
return to FT cast for 2-4 more wks
Limited protected AROM for 2more
wks + replace cast with a removableorthotic

Yes
Elastic tape remains in situ
4 wks is standard if no lag.
If lag- orthotic continued 2 weeks
further
Discontinue daytime orthotic continue
elastic tape, exercises and light ADL

After 2wks protected motion and nolag or lag

After 2wks protected motion and nolag or lag

Active DIPJ extension to 0°

RarelyDIPJ painful or fails to keep full passive
extension
No increase in lag. Will go as long as
16wks w patient consent<5° lag, minimal edema, no pain,
functional fist + patient satisfiedYes
As many weeks as needed after
weaned of daytime splint
No increase in lag

Yes
At wk 4 when day splinting is
discontinued, for an additional 2 wks
At 4wks if no lag<5° lag, minimal edema, no pain,
functional fist (full fist may take a year
to achieve.
Up to 6months

0° extensor lag

Julianne Howell1-5d
No later than 10d
7-14d;
weeks later
Orthotic +tape
NoStandardly
PIPJ 20-30° flexion
DIPJ +0° to +15°
1x/wk; PRN

IFSSH ezine MAY 2014

Yes
Unless post-surgical

–
<

–
<

Anytime, what is there to lose if thepatient is willing?

Orthotic + elastic tapeYes
neutralRecommend it as a first option.
Chronicity will prolong treatment
progression

33

hand therapy

Hand therapist:

Melissa Hirth

Hand therapist:

Lynn
Bassini
1

1

2a

2

2b

3

Figure 1: Tip 1: To avoid excessive stretching of the plastic wait until it has
started to become opaque again before pinching above the fingertip &pulling the plastic up to achieve DIPJ hyperextension.
Figure 2a: Tip 2a: To enable full PIP joint motion and to avoid distal splint
migration cut a small arc in the proximal volar surface of the splint, and flare
ever so slightly by dipping the proximal end 2-3 mm in the hot water and use
your fingers to smooth.
Figure 2b: Tip 2b: To stop the seam from splitting dip the plastic into hot
water at the proximal seam and gently stretch these small tabs to place one
on top of the other & squeeze together.
Figure 3: Tip 3: To maintain hyperextension, avoid rubbing or slippage, & assist
oedema management via effectively creating a circumferential orthotic placea strip of tape in the ‘no-stretch’ direction firmly adjacent to the seam & press
the finger down into the splint.

34

Figure 1: Tip 1: Do this at a sink, use
about one-third of a roll of narrowplaster. Wet the roll and squeeze excesswater out of roll, cool water lengthens
the time you have to work the plaster.
Wrap securely but not too tight aroundthe finger leaving the distal tip exposed
to check for color and feeling. While
doing this ask the patient to relax the
PIP joint while the therapist pushes the
DIPJ into (hyper) extension. If the PIPJ
hyper-extends, include the PIPJ in the
cast and flex it to 20/30°.
Figure 2: Tip 2: once the cast is hard,
ask the patient to flex the PIPJ to assure
motion is comfortable and the castdoes not slip off. Wrap the cast andextend the wrap more proximal with aself-adherent wrap to keep it clean andanchor it.
IFSSH ezine MAY 2014

hand therapy

Hand therapist:

Gwen van Strien

1

2

3

Figure 1: Tip 1: Place a length of clothlike tape along the volar middle anddistal phalanx to pull the DIPJ into theprecise position of hyperextension.
The patient holds the tape, so thetherapist can mold with both hands.
Use 4 strips of plaster (2” wide; 5” long);
fold each strip in half lengthwise. Dip
strips in water, lay out on a paper
towel, and lightly stroke each strip toremove excess water making it morepaste-like. Carefully wrap in a circular–
manner and smooth. Start with the 1st
strip proximally, the 2nd strip distally,
and the 3rd to make it “neat” (at times
another circular strip may be needed).
Save the 4th strip for ﬁnishing/reinforcing.

Figure 2: Tip 2: There is no need topush the DIPJ into extension whenmolding (pressure points), because
the patient is holding the tape. Placethe 4th strip at an angle, crisscrossing
over the dorsal side of the cast; to add
reinforcement; make certain the distal
nail is visible. The cast sticks to thetape, so it will not slip oﬀ.

Figure 3: Tip 3: For this picture, thecrisscrossed strip was not smoothed
for identiﬁcation. Cut the ends of the
exposed tape. Smooth the plasteraway from the PIPJ ﬂexion crease. A
coat of clear ﬁngernail polish makes
it more water resistant. Round tipped
scissors work well for removal; start at
proximal-volar aspect, nip away along
the line of the tape distally, and peelaway the cast and tape.

IFSSH ezine MAY 201435

hand therapy

Hand therapist:

Julianne Howell

1

2a

2b

3

Figure 1: Tip 1: Attach a strip of cloth-like tape to the volar PIPJ then up & overthe end of the fingertip; have the patient hold the tape to keep DIPJ (hyper)
extension. The therapist now has two working hands to mold the plastic; ask
the patient to lower the angle of the tape as the plastic is molded over the
dorsum of the finger. The PIPJ remains in neutral extension.
Figure 2 a&b: Tip 2a: While the plastic is still warm, carefully and quickly trim
off the excess plastic on both sides of the orthotic to make seams.
Tip 2b: As the plastic cools press up lightly on the volar fingertip for DIPJ
position and flex the PIPJ to the desired position.
Figure 3: Tip 3: Remove the orthotic for finishing, the tape will remain on thefinger- have the patient hold the tape to maintain DIPJ position. Trim seams toallow adjustability and secured with cloth-like tape; encourage the patient to
add tape as needed to snug the seams together between visits.

About the author
Julianne W Howell, PT, MS, CHT, Samaritan Health Services, Corvallis,
Oregon, USA. Email Julianne at julianneh@earthlink.net

36

References

1. Doyle JR. Extensor tendons: Acuteinjuries in Green DP, editor, Operative
hand surgery 4ed, New York, NY,
Churchill Livingstone 1999.
2. Geyman JP, Fink K, Sullivan SD.
Conservative versus surgical treatmentof mallet finger: a pooled quantitative
literature evaluation. J Amer B FamPract 1998:11:382-390.
3. Kalainov DM, Hoepfner PE, Harigan BJ,
et al. Non-surgical treatment of closed
mallet finger fractures. J Hand Surg
2005: 30A:580-586.
4. Handoll HH, Vaghela MV. Interventions
for treating mallet finger injuries.
Cochrane Database Syst Rev 2004: (3);CD004574 (updated 2008).
5. Hageman M, Guitton TG, Ring D. How
surgeons make decisions when theevidence is inconclusive. J Hand Surg2013:38A:1202-1208.
6. Tocco S, Boccolari P, Landi A, et al.
Effectiveness of cast immobilisationin comparison to the gold-standard
self-removal orthotic intervention for
closed mallet fingers: A randomised
clinical trial. J Hand Ther 2013: (26)3;
191-201.
7. Pratt AL. Is eight weeks’ immobilisationof the distal interphalangeal joint
adequate treatment for acute closed
mallet finger injuries of the hand? A
critical review of the literature. Br J
Hand Ther 2004:9;4-10.P
8. Patel MR, Sheklar SD, Bassini-Lipson
L. Conservative management ofchronic mallet finger. J Hand Surg
1986:11A:570-573.
9. Schweitzer TP, Rayan GM. The terminal
tendon of the digital extensor
mechanism: Part 1 anatomic study. J
Hand Surg 2004: 29A: 898-902.
10. Strauch RJ. Extensor tendon injuries.
In: Green D, Hotchkiss R, Pederson W,
editors. Green’s operative hand surgery.
6th ed. New York: Elsevier, Churchill
Livingstone; 2001. p 159-188.
11. Groth GN, Wilder DM, Young VL.
The impact of compliance on the
rehabilitation of patients with malletfinger injuries. J Hand Ther 1994: 7; 2124.

IFSSH ezine MAY 2014

research roundup

Basic science of bone healing
USA
In a recent article published in Hand
Clinics Dr Michael Darowish led a
review of the biology involved in
the regeneration of new bone after
fracture, and factors inﬂuencing bonehealing, including diabetes, smoking,
NSAID use, and bisphosphonates. He
talked to the IFSSH ezine about his
investigation: “I was lucky enough tospend a year during my residency
working in the orthopaedic researchlab at the University of Rochester under
the direction of Dr Regis O’Keefe. Dr
Sathyendra (my co-author) spent a year
working in the Penn State orthopaedic
research lab with Dr Henry Donahue. So
we both were lucky to be exposed tothe basic science side of orthopaedics
during our training. Thus, when Dr
Lawton approached me to provide
an article for Hand Clinics, the fracture
healing article was a natural ﬁt. I have
tried to incorporate my understandingof basic science into my clinical practice,
applying easy and practical steps into
patient management,” he commented.
For Darowish, some of the mostinteresting points that the review
highlighted about bone healing
was that understanding the factorsthat are within the control of thephysician and the patient is essential
in optimising bone healing. “NSAID
use, smoking, utilisation of bonestimulators; these are all things we
as surgeons frequently overlook but
can signiﬁcantly impact our patients’outcomes,” he explained.
IFSSH ezine MAY 2014

“Being mindfulof metabolic,endocrine, or
external influenceson healing canonly benefit thepatient”
He further believes that
understanding the eﬀects ofbisphosphonates on fracture healing is
not well understood. “We are all awareof the subtrochanteric femur fractures
which were caused by ‘frozen bonedisease’ from taking bisphosphonates for
too long, but understanding that they
may impact the speed of healing in yourpatients may change your management– longer immobilisation, more cautious
rehabilitation, etc,” he added.
“I think that many of us
underappreciate the inﬂuence of
these outside factors. I also thinkthat metabolic inﬂuences on bonehealing – vitamin D deﬁciency, poor
nutrition, etc, are frequently ignored,”he continued, adding that Brinker et al
showed that in patients with fracture
nonunion in the setting of a well done
surgery, nearly 84% of their patientswere found to have either a metabolicor endocrine abnormality. According
to him, that being mindful of theseissues earlier in the course of treatment
can potentially beneﬁt patients greatly.

The fundamental principles that
hand surgeons and therapists should
understand about bone healing
include that diﬀerent methods offracture treatment will yield diﬀerent
forms of healing – casting or pinningwill heal by endochondral ossiﬁcation,
where a rigid plate and screw
construct will heal by primary bonehealing – and understanding how tointerpret radiographs accordingly.
“Being mindful of metabolic, endocrine, or external inﬂuences on healing
can only beneﬁt the patient, and being
proactive in checking for these factors
rather than waiting for a complication to
occur before evaluation or discussion ofthese issues can prevent some of these
problems. Some of these factors are outof our control (age, renal disease), butsome can be easily changed or treated.
It really doesn’t add much time to yourinteractions to discuss these issues. And
while many of us are not comfortable
managing these issues, we can obtainsome basic screening laboratories andthen appropriately refer the patients forfurther care if it is indicated,” he concluded.

JOURNAL REFERENCE
Hand Clinics, Volume 29, Issue 4 ,Pages 473-481, November 2013
http://www.hand.theclinics.com/
article/S0749-0712(13)00057-7/
abstract37special feature

Thoughts on patient
contact: the doctor nevereven touched me!
Increasing age and inﬁrmity inevitably
introduces you to more clinicalcolleagues than your previous social
circle could ever provide. In recent
years I have developed a varietyof complaints which ensure myintermittent attendance at a disturbingly
large number of hospital clinics. I feel I
am now on ﬁrst name terms with mostof the staﬀ within the large hospital inwhich I work. Those wishing to audit
the hospital’s performance should savethemselves time and money, put away
their clip boards and simply take meout for a decent lunch. I can tell themeverything they need to know.
Against that introductory
background herewith some thoughtson the potentially explosive matterof health care professionals touching
their patients, and whether that formof patient contact has added value
over contact arising from simple
clinical necessity. Is patient contact
therapeutically beneﬁcial and, within
careful limits, to be encouraged - or has
respect for a patient’s ‘space’ reachedsuch a level that touching patientsshould be, where possible, avoided?
Who touches patients? In many
departments it is the nurses and38

technicians who touch patients.
The physicians (particularly) touch
their patients relatively infrequently,
particularly if they work in a
sophisticated health care system which
provides them with so much detailed
internal information through the wide
variety of scans which are now available
and so frequently requested. When I wasa cardiology trainee, many years ago, I
remember the duties to be a ’hands-on’
experience; it was the only way to gather
the limited clinical evidence that was at
the time available. Touching the patient
is now for physicians less necessary and,in my experience, more rarely employed.
Hand surgeons touch patients.
I’ve never found it possible to do thejob without touching and testing thepatients hand function. There areof course cultural sensitivities to berespected in this area. However I cannot
recall any patient exhibiting reluctanceto a hand examination during my career.
I believe I have suﬃcient sensitivity to
be aware of any possible reluctance oroﬀence in such circumstances.
Do patients like being touchedby their doctors? I suspect, within
carefully chosen parameters, they do. It
can represent solidarity, rapport withthe patient and empathy with theirsituation. I have certainly taken comfort
from doctor contact over the last few
years. It has a long history to commend
it, stretching back to the physicians of
Greece and Arabia. The laying on ofhands was part of a physician’s practice.
I accept this may be an area whereattitudes could well be changing. Overthe last 20 years patients have become
more concerned about preserving thespace around them and may be lesstolerant to that space being invaded.
Medical students are now taught to
ask permission to touch their patients,
a practice that was never felt necessary
in the past. It will be interesting to see
how these attitudes continue to evolve.
Perhaps society now prefers moredetachment from their doctors - a drier,distant, more technical response.
PS. I know what you’re thinking –there goes another medical dinosaur –trotting oﬀ into the sunset!
Frank Burke
Archivist IFSSH

IFSSH ezine MAY 2014

special feature

IFSSH ezine MAY 201439

remembering our pioneers

Pioneers in Hand Surgery
Douglas W. Lamb, M.B., F.R.C.S.Ed.
Douglas Lamb, a native of Edinburgh,
Scotland, received his M.B. and
Ch.B. degree from the Universityof Edinburgh. He was a Surgeon
Lieutenant in the Royal Navy from1945 to 1947 and became a fellowof the Royal College of Surgeons of
Edinburgh in 1948. Following two
years of general surgery training at theWestern General Hospital, Edinburgh,
he completed his orthopaedic surgery
training at the University of Edinburgh,
Royal Inﬁrmary and Princess Margaret
Rose Orthopaedic Hospital (1950-1960)
where he later served as a Consultant
Orthopaedic Surgeon (1960-1988). In
1959, he did an orthopaedic surgery
fellowship at the Rancho Los Amigos
Orthopaedic Hospital and a handsurgery fellowship with Dr Joseph
Boyes in Los Angeles, California.
Lamb’s appointments with the
British Society for Surgery of the Hand
have included Founder Member(1969), Honorary Secretary (1969to 1976), President (1976 to 1977),
Member of Council (1978 to 1992),
Chairman of the Education andTraining Committee (1986 to 1991),
and Delegate to the International
Federation of Societies for Surgery of
the Hand. He has chaired the IFSSH
Committees on Rehabilitation –Prosthetics/Orthotics (1979 to 1989)
and on Congenital Abnormalities(1979 to 1992), and has been the
President of this prestigious Federation

40

from 1989 to 1992. Mr. Lamb has
been a member of the Overseas
Examination Teams to Malaysia, Burma,Hong Kong and Saudi Arabia. He hasserved the Royal College of Surgeonsof Edinburgh as Member of Council(1978 to 1988), Director of Overseas
Doctors Training Scheme (1988 to
1990), and examiner in anatomy,
surgery and orthopaedic surgery.
Lamb is a fellow of the British
Orthopaedic Association and Honorary
Member of the American, French,
South African, and Scandinavian
Societies for Surgery of the Hand. His
impressive career as a hand surgeon,organiser, educator and author has
included appointments as Chairman of
the Editorial Board of the Upper Limb
and Hand Series (Churchill Livingston),member of the Editorial Committeesof the Journal of Hand Surgery (British
Volume) and of the International
Medical Society of Paraplegia.
He has organised the Annual
Instructional Course in Surgery of theHand at the Princess Margaret Rose
Orthopaedic Hospital for the past 15
years. He gave the Founder Lectureof the American Society for Surgeryof the Hand (1975), the Charles Belllecture (1981), and the Mason Brown
Memorial Lecture (1983) at the Royal
College of Surgeons, Edinburgh, andthe Hugh Owen Thomas Lecture at
the University of Liverpool (1984). He
received the Farquharson Award for

Teaching Anatomy from the Royal
College of Surgeons (1984) and theLawrence Poole Prize for Rehabilitationfrom the University of Edinburgh(1983).
Lamb has published a numberof books on the practice of handsurgery, including paralysis, trauma,
ﬂexor tendon injuries and upper limb
deﬁciencies in children.

IFSSH ezine MAY 2014

remembering our pioneers

Luis Gómez Correa, M.D.
Dr Gómez graduated from the
University of Mexico Medical School
in 1943. He trained in general surgery
and traumatology and later studied
plastic surgery. While appointed
surgeon to the slaughter houses of
Mexico, he was exposed to a greatvolume of hand trauma cases anddeveloped a keen interest in this ﬁeld.
Starting in 1953 he studied handsurgery under the direction of Mario
Gonzalez Ulloa and many visiting
professors including J. William Littler,
Michael L. Mason, W.L. White, Bob
Chase, Sylvester Carter, Earle Peacock,
Eugene Kilgore and others. Dr Gómez
was appointed general surgeon andplastic surgeon at the La Raza General
Hospital (1958) where he took care ofsevere trauma cases and performed
his ﬁrst successful hand replantation in
1967.
Gómez, a dedicated surgeon andteacher, played a crucial role in thedissemination of knowledge of handsurgery through Mexico, Central
America and the Caribbean. In
association with the Department ofLabor Medicine of the Mexican Social
Security, he has organised a seriesof hand trauma courses that havebeen held since 1961 in most major
cities of Mexico. He also conducted
hand surgery courses throughout
most Latin American countries, theﬁrst having been held in Caracas,
Venezuela in 1963. Dr Gómez was
IFSSH ezine MAY 2014

appointed Professor of Plastic Surgery
at the La Raza Hospital in 1968 andat the University of Mexico in 1971.
He served as Consultant in plastic
and hand surgery for the emergency
hospitals of Mexico City (1974 to 1976)
and has been working as full-time
hand surgeon at the Hospital 20 deNoviembre since 1977.
In 1980, the University of Mexico
oﬃcially recognized a one-year handsurgery training program for surgeons
having completed their plastic, generalor orthopaedic surgery residencies. Dr
Gómez, as director of the only handsurgery program available in Mexico,
has trained 52 hand surgeons. In
co-operation with Dr Luis Badell from
Caracas, Venezuela, he founded the
Caribbean Society for Surgery of theHand in 1968. In 1976, he organized
the ﬁrst Panamerican Congress forHand Surgery in Mexico City. Dr
Gómez is the author of a number ofpublications on hand trauma and has
translated into Spanish a series of handsurgery videotapes made available by
the American Society for Surgery of
the Hand.
Gómez was President of the
Mexican Society of Plastic Surgeons(1959-1962) and became Honorary
Member of the American Society
for Surgery of the Hand in 1975. Hereceived the Gold Medal from the
Mexican Social Security (1969), wasnominated emeritus Member of the

Mexican Academy of Surgeons (1991)
and honoured as Pioneer Professor by
the International Federation of Ibero
Latin American Societies of Plastic
Surgery.

41

journal highlights

Journal Highlights
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 online journal

Journal of Wrist Surgery Issue 01 Volume 03 · February 2014
❚ Radiographic Predictors of DRUJ

Instability with Distal Radius Fractures❚ Distal Radius Malunion and Forearm
Rotation: A Cadaveric Study❚ Radiographic and Arthroscopic
Assessment of DRUJ Instability Due
to Foveal Avulsion of the Radioulnar
Ligament in Distal Radius Fractures❚ Inﬂuence of Ulnar Translation of the
Radial Shaft in Distal Radius Fracture
on Distal Radioulnar Joint Instability❚ Deﬁning Residual Radial Translationof Distal Radius Fractures: A Potential

Cause of Distal Radioulnar Joint
Instability❚ Revision Wrist Arthroscopy after Failed
Primary Arthroscopic Treatment❚ RSL Fusion with Excision of Distal
Scaphoid and Triquetrum: A Cadaveric
Study❚ One Size Does Not Fit All: Distal
Radioulnar Joint Dysfunction after
Volar Locking Plate Fixation❚ Ectopic Bone Formation after Medial
Femoral Condyle Graft to Scaphoid
Nonunion❚ Osteotomy for Sigmoid Notch

Obliquity and Ulnar Positive Variance❚ Fixation of Distal Ulna Fractures
Associated with Distal Radius Fractures
Using Intrafocal Pin Plate❚ Important Anatomical Relationships of
the Posterior Interosseous Nerve in the
Distal Forearm for Surgical Planning: A
Cadaveric Study

Hand Clinics Latest issue is: Volume 30 • Issue 2 May 2014
❚ An Evolutionary Perspective on the History of Flap Reconstruction in the Upper Extremity❚ Anatomy and Physiology of Perforator Flaps of the Upper Limb
❚ Local Flaps of the Hand
❚ Flap Reconstruction of the Elbow and Forearm: A Case-Based Approach❚ Free Muscle Flaps for Reconstruction of Upper Limb Defects❚ Indications, Selection, and Use of Distant Pedicled Flap for Upper Limb Reconstruction❚ Free Skin Flap Coverage of the Upper Extremity❚ Reﬁnements and Secondary Surgery After Flap Reconstruction of the Traumatized Hand
❚ Optimizing Functional and Aesthetic Outcomes of Upper Limb Soft Tissue Reconstruction❚ Dermal Skin Substitutes for Upper Limb Reconstruction: Current Status, Indications, and Contraindications

42

IFSSH ezine MAY 2014

journal highlights

Hand Volume 9 – Issue 1, March 2014
❚ Rehabilitation following handtransplantation❚ Metacarpal fractures: treatment andcomplications❚ A hand surgeon’s guide to common
onychodystrophies❚ Surgeon perspectives on alternative
nerve repair techniques❚ Prospective randomized comparison of
single-incision and two-incision carpal
tunnel release outcomes❚ Concomitant endoscopic carpal andcubital tunnel release: safety andefficacy❚ Carpal tunnel release using the Paine
retinaculotome inserted through apalmar incision❚ Eﬀects of multiple injections ofhypertonic dextrose in the rabbit carpal
tunnel: a potential model of carpal

tunnel syndrome development❚ A role delineation study of handsurgery in the USA: assessing variations
in fellowship training and clinicalpractice❚ The correlation of phrases and feelings
with disability❚ The association of education level onoutcome after distal radius fracture❚ The impact of demographic factors andcomorbidities on distal radius fracture
outcomes❚ MRI Detection of Forearm Soft Tissue
Injuries with Radial Head Fractures❚ Reconstruction of swan neckdeformities after proximal
interphalangeal joint arthroplasty❚ The Eﬀect of Pulley Reconstruction
on Maximum Flexion, Bowstringing,and Gliding Coeﬃcient in the Settingof Zone II Repair of FDS and FDP: a
Cadaveric Investigation❚ Importance of proximal A2 and A4
pulleys to maintaining kinematics in
the hand: a biomechanical study❚ Utility of MRI for diagnosing completetears of the collateral ligaments of themetacarpophalangeal joints of thelesser digits❚ Computed tomography for suspectedscaphoid fractures: comparison ofreformations in the plane of the wrist
versus the long axis of the scaphoid❚ Idiopathic avulsion of the ﬂexor pollicis
longus: Case report and review of theliterature❚ Oral smoothened inhibitor foradvanced basal cell carcinoma of thehand: a case report

Journal of Hand Surgery (European Volume) May 2014 J Hand Surg Eur Vol 39, Issue 4❚ Dart-throwing motion in patientswith scapholunate instability: adynamic four-dimensional computed
tomography study❚ Unifying model of carpal mechanics
based on computationally derived
isometric constraints and rules-based
motion – the stable central column
theory❚ Dynamic motion analysis of dart
throwers motion visualized throughcomputerized tomography andcalculation of the axis of rotation❚ In-vivo conﬁrmation of the use of thedart thrower’s motion during activities
of daily living❚ Contact areas of the scaphoid andIFSSH ezine MAY 2014

lunate with the distal radius in neutral
and extension: correlation of falling
strategies and distal radial anatomy❚ In vivo length changes of wrist
ligaments at full wrist extension❚ Three-dimensional analysis of thepalmar plate and collateral ligaments
at the proximal interphalangeal joint❚ The connective tissue and ligamentsof the distal interphalangeal joint:
a review and investigation using
ultra-high ﬁeld 16.4 Tesla magnetic
resonance imaging❚ Long-term outcome (22–36 years)of silicone lunate arthroplasty for
Kienböck’s disease❚ Scaphocapitate arthrodesis fortreatment of late stage Kienböck
disease❚ Secondary displacement of distal
radius fractures treated by bridging
external ﬁxation❚ Corrective distal radius osteotomy
following fracture malunion using aﬁxed-angle volar locking plate❚ Acute calcium deposits in the hand
and wrist; comparison of acutecalcium peritendinitis and acutecalcium periarthritis

43journal highlights

Hand Surgery: Asia Pacific Volume 19, Number 1, 2014
❚ Reliability of the hand20❚ The eﬀect of ultrasound guided

tumor in a childquestionnaire: comparison with the
36-item short-form health survey❚ Brachial plexus injuries: diagnosis
performance and reliability of
everyday tools❚ Risk factors for dislocation of the ulnar
nerve after simple decompression for
cubital tunnel syndrome❚ Comparison between castimmobilization versus volar locking
plate ﬁxation of distal radius fracturesin active elderly patients, the Asian
perspective❚ Proximal ulnar stump stability after using
the pronator quadratus muscle transfer
combined with the Sauvé-Kapandji
procedure in rheumatoid wrist❚ Early results of combined palmardorsal scapholunate ligament
reconstruction❚ The modiﬁed Brunelli procedure forscapholunate instability: a single
centre study❚ Clinical characteristics of neuropathic
pain in patients with carpal tunnel
syndrome

steroid injection on progression tosurgery in thumb cmc arthritis❚ A prospective randomized controlled
trial of controlled passive mobilization
vs. Place and active hold exercises afterzone 2 ﬂexor tendon repair❚ The McCash technique for Dupuytren’s
disease: our experience❚ Simultaneous four ﬁnger
metacarpophalangeal joint fusions –indications and results❚ Outcome of pyrocarbon proximal
interphalengeal joint replacement❚ External ﬁxation of the hand: a simple
approach to comminuted proximal
interphalangeal joint fractures❚ The radial nerve palsy caused byembedding in the humeral shaft
fracture — a case report❚ Malignant schwannoma of the radial
nerve with unusual presentation: acase report❚ Acute bilateral spontaneous forearmcompartment syndrome❚ Intraneural malignant granular celltumor — report of an extremely rare

❚ A case report of a giant forearm lipoma

causing anterior interosseous nerve
palsy after fracture of the distal radius❚ Compressive neuropathies related toganglions of the wrist and hand
❚ Osteolysis with secondary arthritis of
the scaphotrapeziotrapezoid joint in
Hajdu-Cheney syndrome: a case report❚ Extensor tendon dislocation after endto-side transfer in a rheumatoid patient❚ Simple surgery to improve ﬂexion
deﬁcit resulting from mal-union of
fracture neck of the proximal phalanx— a case report❚ Synovial chondromatosis aﬀecting a
digital proximal interphalangeal joint❚ Trichilemmal cyst of the third ﬁngertip:a case report❚ Vascularized nail transfer from nonreplantable digit: a case report❚ Fixation of an ulnodorsal fragment
when treating an intra-articular
fracture in the distal radius❚ The path of screw insertion forstabilization of the scapholunate joint:a cadaveric study

Journal of Hand Therapy Volume 27, Issue 2, April-June 2014
❚ Surgical and therapy update on the❚ The use of the Artelon CMC Spacer for

management of Dupuytren’s disease❚ Current uses of botulinum toxin
A as an adjunct to hand therapy
interventions of hand conditions❚ Advances in nerve transfer surgery❚ Upper extremity limb loss: Functional
restoration from prosthesis and targeted
reinnervation to transplantation❚ Evolution of basal joint arthroplasty
and technology in hand surgery

osteoarthritis of the basal joint of thethumb❚ Thumb basal joint: Utilizing newtechnology for the treatment of acommon problem❚ Update on the surgical treatment forrheumatoid arthritis of the wrist andhand❚ SSc management – In person
appointments and remote44

therapy (SMART): A framework
for management of chronic handconditions❚ A Physician’s perspective on
volunteering overseas… It’s not allabout sharing the latest technology❚ Clinical Commentary in Response
to “A physician’s perspective on
volunteering overseas… It’s not allabout sharing the latest technology”

IFSSH ezine MAY 2014

journal highlights

Journal of Hand Surgery: American volume

Volume 39, Issue 5, (May 2014)❚ Arthroscopic Reduction of❚ Early Results of Anterior Elbow Release

Comminuted Intra-Articular Distal
Radius Fractures With DiaphysealMetaphyseal Comminution❚ The Inﬂuence of Surgeon Age on
Distal Radius Fracture Treatment in
the United States: A Population-BasedStudy❚ Distal Radius Volar Locking Plate
Design and Associated Vulnerability of
the Flexor Pollicis Longus❚ Relationship of Bone Mineral Densityof Spine and Femoral Neck to Distal
Radius Fracture Stability in Patients
Over 65❚ Volar Percutaneous Screw Fixation of
the Scaphoid: A Cadaveric Study❚ Vascularized Bone Grafting and Distal
Radius Osteotomy for Scaphoid
Nonunion Advanced Collapse❚ Rotational Stability for Intercarpal
Fixation Is Enhanced by a 4-Tine Staple❚ Bicolumnar Intercarpal Arthrodesis:
Minimum 2-Year Follow-Up❚ The Eﬀect of Soft Tissue Distraction
on Deformity Recurrence After
Centralization for Radial LongitudinalDeﬁciency

With and Without Biceps Lengthening
in Patients With Cerebral Palsy❚ The Eﬀect of Asymmetric Core Suture
Purchase on Gap Resistance of Tendon
Repair in Linear Cyclic Loading❚ Attrition or Rupture of Digital Extensor
Tendons Due to Carpal Boss: Report of2 Cases❚ Metastases to the Hand and Wrist: An
Analysis of 221 Cases❚ Chondroblastoma-Like Chondroma of
the Hand: Case Report❚ Superﬁcial Angiomyxoma of theThumb Mimicking a Malignant Bone
Tumor: Case Report❚ Nerve Transfer From Triceps Medial
Head and Anconeus to Deltoid for
Axillary Nerve Palsy❚ Patient Satisfaction and Self-Reported
Outcomes After Complete Brachial
Plexus Avulsion Injury❚ Factors Inﬂuencing Infection Rates
After Open Fractures of the Radius
and/or Ulna
❚ Povidone-Iodine Soaks for Hand
Abscesses: A Prospective Randomized
Trial

IFSSH ezine MAY 201445

upcoming events

Upcoming events
European Voice of Plastic Surgery (ESPRAS)
6-11 July 2014
Edinburgh, Scotland
www.espras2014.org
ESPRAS 2014 will oﬀer delegates the opportunity to experience a truly
multi-disciplinary, multi-national and multi-cultural programme with world
leading experts across the entire spectrum of disciplines associated with
Plastic, Reconstructive and Aesthetic surgery.
28, al 30 de Agosto de 2014 | Hotel Pozos Colorados | Santa Marta - Colombia

XXX Congreso Nacional de laAsociación Colombiana de
Cirugía de la mano

INVITADOS
Dr. Michel Merle.
FranciaDr. David Slutsky.
Estados Unidos
Dr. Juan Gonzalez del Pino.
EspañaValor inscripciones
Miembros al día
ASOCIMANO y ASCOTEMA$ 550.000

No miembros$ 700.000

Residente, estudiante y médico $ 400.000
GeneralCirujano plástico,
ortopedista, medico
General y FT o TO internacional $ 300 USD

6th European Plastic
Surgery Research Council(EPSRC) 2014
21 – 24 August 2014
Hamburg, Germany
www.epsrc.eu
The EPSRC is a non-proﬁt organisation
managed by and for the beneﬁt of theyoung plastic, reconstructive and aesthetic
surgery research community. We are kindly
requesting that all European national societies
announce our next meeting aimed atyoung plastic surgery researchers. It will oﬀer
an exciting opportunity for young plastic
surgery researchers to discuss their latest
work and future challenges in a uniquely
informal, interactive format for basic scienceand clinical outcome research. The EPSRC
meeting will provide a valuable means ofdisseminating information and ideas in a waythat cannot be achieved through the usual
channels of communication - publications andpresentations at large scientiﬁc meetings. The
conference oﬃcial language is English.

Inscripción de trabajos libres, de ingreso y deposter,hasta: 30 de Mayo de 2014
Entrega de trabajos libres, de ingreso y poster,
hasta: 30 de Junio de 2014

Informes:
E-mail: secretaria@asocimano.org
www.asocimano.org
Celular: 316 6164988

46

IFSSH ezine MAY 2014

upcoming events

Second International Symposium
on Arthrogryposis
17-18 September 2014, St Petersburg, Russia
http://amc-2014.org/
We have pleasure in inviting you to join us to the SECOND
INTERNATIONAL SYMPOSIUM ON ARTHROGRYPOSIS«UPDATES FROM AROUND THE WORLD» which will be held inSaint-Petersburg, Russia on 17th and 18th September 2014.
The faculty will consist of senior clinicians from all over theworld with particular expertise in the management of all
aspects of the care of children and adults with Arthrogryposis
including geneticists, neuromuscular paediatricians, surgeons
and rehabilitation experts. This is a unique opportunity to
discuss the diﬃculties of managing this complex condition.
One of the world’s most beautiful cities, St Petersburg has all
the ingredients for an unforgettable travel experience. The
city oﬀers an extraordinary history and rich cultural traditions,which have inspired and nurtured some of the modern world’s
greatest literature, music, and visual art. From the mysterious
twilight of the White Nights to world-beating opera and balletproductions on magical winter evenings, St Petersburg charms
and entices in every season

IFSSH ezine MAY 2014

10th Congress of the Asian PacificFederation of Societies for Surgeryof the Hand
2-4 October 2014, Kuala Lumpur, Malaysia
www.apfssh2014.org
The Malaysian Society for Surgery of the Hand (MSSH) is
pleased to invite you to the 10th Congress of the Asian Paciﬁc
Federation of Societies for Surgery of the Hand (10th APFSSH)
and 6th Congress of the Asian Paciﬁc Federation of Societies
for Hand Therapists (APFSHT) which will be held from 2nd - 4th
October 2014 at Hilton Kuala Lumpur Hotel, Kuala Lumpur,
Malaysia. To make it more exciting and well worth your while,
ISSPORTH and IBRA are also joining in the academic activities!
The conference programme includes:• Cadaveric Pre-Congress Workshops• 18 Industry Forms• Five concurrent sessions with 99 symposia and 12 plenaries• ISSPORTH - International Society for Sport Traumatology of
the Hand Meeting• Exhibition booth showcase• Digital interface showcase• International Bone Research Association (IBRA) meeting47

upcoming events

Elbow: diseases and clinical experiences:hands-on Cad Lab
13-15 November 2014
Arezzo, Italywww.sicm.it
Topics on Anatomical approaches, Arthroscopy, Arthroplasty and Prosthesis, Tendon
repair and reconstruction. President, Bruno Battiston. Scientiﬁc Committee: Andrea
Atzei, Riccardo Luchetti.

Under the auspices of

PRELIMINARY PROGRAM

Hands-on Cad Lab
November 13th - 15th 2014

Elbow: diseases andclinical experiences
Topics on Anatomical approaches,
Arthroscopy, Arthroplasty and Prosthesis,
Tendon repair and reconstruction
President
Bruno Battiston
Scientific Commettee
Andrea Atzei, Riccardo Luchetti
Provisional Faculty
Renzo Angeloni
Paolo Angelo Arrigoni
Andrea Atzei
Mark E. Baratz
Bruno Battiston
Prospero Bigazzi
Filippo Castoldi
Andrea Celli
Massimo Ceruso

Maurizio Fontana
Enrico Guerra
Michael Hausman
Riccardo Luchetti
Italo Pontini
Roberto Rotini
Luigi Tarallo
Pierluigi Tos
Adolfo Vigasio

CME CREDITS Requested

SPECIAL SESSION FOR THERAPISTS
48

One-DayInternational
Shoulder and Elbow
Symposium
18 October 2014
London, Euston
www.welbeing-cpd.co.uk/Page.
aspx?P_ID=15
The European Society for Shoulder &Elbow Rehabilitation is the only Europe
wide society that connects healthcare
professionals with an interest inshoulder and elbow dysfunction. The
objective of the society is to provide
the highest standard of informationand education to enhance patientcare. This conference is a unique
opportunity to hear international
expert speakers on the topic ofinstability in the upper limb. The
conference aims to explore both
surgical and conservative perspectives
on how to manage dysfunction in theshoulder and elbow. Clinical cases will
be discussed amongst the faculty togenerate debate as well as nuggets ofadvice. This conference is targeted tosurgeons, therapists and physicians.

10th World
Symposiumon Congenital
Malformations of theHand and Upper Limb
7-9 May 2015
Rotterdam, The Netherlands
worldcongenitalhand2015.com
The 10th World Symposium on
Congenital Malformations of theHand and Upper Limb will be held on
the 7th-9th May 2015, in Rotterdam,
IFSSH ezine MAY 2014

upcoming events

10th World Symposium on

Congenital Malformations of theHand and Upper Limb
7-9 May 2015 Rotterdam, The Netherlands
www.worldcongenitalhand2015.com
The Netherlands. A broad variation ofcongenital hand anomalies, genetics,
embryology and classiﬁcation will bepresented, discussed and shared. Invitedlectures, discussion, free paper sessions
and panel sessions will inform you of thelatest on congenital hand anomalies.
Some of the keynote speakers are
Michael Tonkin, Caroline Leclercq
and Ann van Heest. The symposium
will be preceded by a cerebral palsy
pre course on Wednesday the 6thof May. For more information on the
program and registration go to: www.
worldcongenitalhand2015.com

Surgical techniques in
hand surgery:
Ligaments, tendons,
fractures andarthoplasty
11-13 December 2014
Arezzo, Italy
President, Roberto Adani. ScientificCommittee:
Massimo Ceruso, Pierluigi Tos
www.sicm.it

IFSSH ezine MAY 2014

Under the auspices ofSpecial Session for Therapists

December

11th - 13th

2 0 1 4

Preliminary Program

SURGICAL TECHNIQUESIN HAND SURGERY:
Ligaments, Tendons,
Fractures and Arthroplasty
Hands-on Cad Lab
President
Roberto Adani
Scientific Commettee
Massimo Ceruso
Pierluigi Tos

Provisional Faculty
Roberto Adani
Massimo Ceruso
Tyson Cobb
David Elliot
David Espen
Nicola Felici
Thomas Giesen
Riccardo Giunta

Giulio Lauri
Alberto Lluch
Gianfranco MerendiFrank Nienstedt
Michele Riccio
Marco Rizzo
Pierluigi Tos
Adolfo Vigasio

49

upcoming events

ATES
NEW D

24-26er
Octob6201

50

IFSSH ezine MAY 2014

ifsshezine