A Publication of the American Association for Hand Surgery

Spring 2004

ANNUAL MEETING 2004 IN REVIEW

Report of the Program Chair Vargas Award for 2004. Based on Scientific for the AAHS 34th Annual the groundwork laid at our Palm Program Chair Meeting, Palm Springs, CA, Springs meeting, Lynn Bassini Warren January 14-17, 2004 MA, OTR, CHT and Dr. Miguel Schubert MD Pirela-Cruz are presently orga- (left) receives nizing this year’s Vargas trip to well-deserved he Annual Meeting of Guatemala. The program will recognition from the American Association include a two-day Central out-going president for Hand Surgery American hand conference at Allen Van Beek MD. (AAHS) was held at the Hotel Santo Domingo in T beautiful Westin Mission Antigua, Guatemala, August 5-6, Hills in Palm Springs, California. and a surgical/therapy team We had perfect weather, a great operating August 9-13 in program, great camaraderie, and Guatemala City. wonderful opportunities with Concurrent Panels included our families and friends for fun the Management of Radial and relaxation. The program had Nerve Palsy, Thumb 233 registrants, with 70 scientific Carpometacarpal Joint Disease, paper presentations, 8 poster Computers in Your Practice, presentations, and 20 instruc- Failed Nerve Repair, Nerve tional courses. In addition, for Decompression, and a stimulat- the first time we offered 12 excel- ing debate on Clinical lent computerized instructional Challenges for the Past courses. Our 46 exhibitors repre- Presidents of the AASH. sented the largest number we Dr. Susan Mackinnon have had at any meeting. addressed the landmark Hand Therapy Specialty Day advances of her career in her Nash Naam, MD (left) receives the 2004 was coordinated by Paul Brach presentation “Merging Science Clinician/Teacher of the Year award from MS, PT, CHT. It was an out- and Multidisciplinary Expertise: Richard Berger MD and Allen Van Beek MD. standing day with an excellent Nerve Allograft to Nerve overview of key challenges fac- Transfer.” Dr. Elvin Zook gave a ing therapists and hand sur- stimulating and thought-provok- geons. Dr. Sue Michlovitz and ing presentation entitled Paul Brach reviewed their expe- “Generation-X. Out of Hand?” riences in Chinle, Arizona, on Our combined AAHS, the Navajo reservation this last American Society for Peripheral year as part of the Vargas Nerve (ASPN), and American International Hand Therapist Society for Reconstructive Teaching Award. It was a very Microsurgery (ASRM) day on moving presentation that out- Saturday, January 17, included lined the expanded role that the Presidents’ invited lecturer, therapists play in the Indian Dr. John McDonald, who has Health Service. Sharon Dest PT, pioneered many advances in the CHT and Paula Galaviz OT, management of spine-injured AAHS luminaries at the gala reception. CHT were recipients of the continued on page 6 FROM THE EDITOR’S DESK

fectly acceptable to the former top “You DO?” said Gary, clearly flab- “I Have All specialists no longer was. Their bergasted. “I didn’t know you were income had not gone down; it doing so well!” The conversation The Money bought the same amount as it had quickly turned to other topics. the year before. But it was no Of course, Steven was not any longer the biggest pay, so somehow better off financially than Gary. In I Need” that meant in the eyes of those spe- fact, it is quite probable that cialists that the value of their spe- Steven’s income was considerably ow much money is cialty, and therefore themselves, smaller than Gary’s. But, unlike enough? To gauge from had dropped. Gary, Steven knew what he needed, television and popular Of course, while most people and knew that he had it, and that magazines, no amount is gauge their own worth by looking was enough for him. Mostly, what H really enough. People want around them, and seeing what oth- Steven needed was a muskie on his to be as rich as “the Donald” so ers have, some are guided by an fishing line, good friends, good badly that they will do or say inner compass. Which brings me health, and a loving family. He had almost anything, in living (finally!) to the title of this article. a warm, comfortable home. He did- color and in prime time, just A few years ago, I was at a dinner n’t need a mansion, or a second to have a chance to be his party with friends. I was not the place in Vail, or New York, or apprentice. I remember an host, so some of the guests were London. He had a perfectly service- article once, in New York mag- able minivan, and felt no need to azine (Thy Neighbor’s Budget, trade up, or to own multiple vehi- by David Kirkpatrick, New WHILE MOST PEOPLE cles when he could only drive one York, 8/7/2000), which dis- at a time anyway. Steven spent his cussed the personal finances GAUGE THEIR OWN WORTH BY time mostly with his family, or fish- PETER C. AMADIO MD of people whose incomes ing, while Gary seemed to be ranged from $25,000 per year up to LOOKING AROUND THEM, AND spending all his time looking for a $10,000,000 per year. A common competitive edge. thread ran through all the inter- SEEING WHAT OTHERS HAVE, I was reminded of all this recent- views: ‘I can get by OK on what I’m ly when Steven told me that his making, but if I only had a little SOME ARE GUIDED BY AN friend Gary had passed away. I did- more, THEN I would be living on INNER COMPASS. n’t ask, but I wondered whether Easy Street!’ Of course, the $25,000 Gary had still been looking for earner thought that her life would another score, and whether he was be complete if only she could afford any more content with himself than a few meals in restaurants, while new to me. One of them, I’ll call he had been at that dinner party. I the $10,000,000 man longed for his him Gary, was a real go-getter. He don’t know the answer to that, but I own private jet, but at every level in had at least a half dozen business do know this: my friend Steven between it was the same: I am OK, ventures in process. He was always was, and is, on to something. but.... looking for new opportunities to Contentment and money have little The article goes on to quote an turn a profit. He spent much of the in common. The French call it being economist, whose research has evening talking about his business- comfortable in your own skin. If shown that it is not absolute es, how much he made, and the you are, what more do you really income, but relative income, that opportunities there were for the need? If you’re not, it’s unlikely matters most, when people are other dinner guests to invest with that any amount of money will ever asked if they are satisfied with their him, and share the wealth. As he buy you a skin that feels right. I’m Hand Surgery income. At one medical institution went around the table with his glad Steven’s my friend. You might Quarterly with which I am familiar, everyone pitch, he got to a person I’ll call say I’m comfortable with that. H ..... draws a salary, which is specialty Steven. “C’mon Steven”, he said. Spring specific. There had been a pecking “Everyone can use a little more 2004 order to the specialties that was sta- money!” The URL for the NY article is ble for years. Recently, a new spe- I still remember what happened http://www.newyorkmetro.com/nymetro/news/ cialty moved from the middle of next as clearly as if it had been yes- bizfinance/finance/features/3620/index.html. the pack to the top. Suddenly, the terday. “Nope”, Steven said. “Not 2 compensation that had been per- me. I have all the money I need.” FROM THE PRESIDENT

from all of our previous leaders and reaching these mission goals and it Challenge in continue to do so. In particular, I is our charge to continue these would like to acknowledge the per- efforts. Having just completed an 2004: Core spectives that close proximity and ACGME accreditation renewal site friendship can bring, my partners at visit, I have become acutely aware the Mayo Clinic, Past Presidents of the concept of “core competen- Competencies Drs. Robert Beckenbaugh and Peter cies” as they relate to Hand Surgery Amadio. Our previous leadership Fellowship training. I believe we for AAHS has been exemplary, and the men- can apply the “core competency” torship offered by those individuals concept to organizations, as well, has been invaluable, and still is to and derive those competencies from ince my introduction to the this day. In particular, the close the principles defining the Mission American Association for partnership I have developed with Statement. Hand Surgery, I have devel- our immediate Past President, Dr. The first group of competencies oped a deep respect for its Allen Van Beek, will always be with could be under the heading of Smission and its unique and me. Dr. Van Beek did an outstand- “Service to our Members” and positive traditions. This organiza- ing job as President and adhered to would include Education, tion is composed of good, good the Mission Statement while intro- Communication and Fiscal people from a variety of training ducing numerous innovative initia- Responsibility. Our education- backgrounds. The very constitution tives. The annual meeting in Palm al commitments are strong, of this organization celebrates those Springs that Dr. Van Beek and Dr. and include the annual meet- differences to foster a rich environ- Warren Schubert assembled was ing and associated educational ment for exchange of ideas, tech- one of the best ever, and they and venues, and our commitment niques and friendships. I have their program committee are to be to an annual free-standing gained so much insight and advice soundly congratulated. Critical to CME course. This year, the RICHARD BERGER MD, PhD the success of the annual meeting AAHS and the American and the daily work of managing Society for Surgery of the Hand this organization is our Central (ASSH) are once again co-sponsor- Office staff. I have known Laura ing the Work Related Upper Downes Leeper since I was first Extremity Disorders Course, May

President introduced to the AAHS, and I can- 21-23, 2004, in Chicago. The AAHS Richard Berger, MD, PhD not think of anyone who could is also co-sponsoring, with the Editor have been more helpful and sup- Romanian Society for Surgery of Peter C. Amadio, MD portive through Central Office the Hand, the Post-IFSSH Congress Executive Director activities. Through my years on the to be held in Bucharest, Romania, Laura Downes Leeper, CAE Board of Directors, I have had the June 19-21, 2004. Beginning in 2005, Managing Editor pleasure of working with so many the AAHS will assume a role in co- Anne B. Behrens gifted, friendly and dedicated sponsoring, with the ASSH, the Hand Surgery Quarterly is a publication of friends and colleagues, which as Specialty Day program on upper The American Association for Hand you might expect with this organi- extremity problems at the annual Surgery and is published strictly for the zation, is a direct reflection of the meeting of the American Academy members of AAHS. This publication is membership. of Orthopaedic Surgeons. designed as a forum for open discussion and debate among the AAHS member- Article II of our Bylaws states A number of surgeon members ship. Opinions discussed are those of the “The purpose of the American have asked for assistance in prepar- authors or speakers and are not necessarily Association for Hand Surgery shall be ing for board recertification exami- the position, posture or stance of the to foster and promote the highest nations, and we have responded by Hand Surgery Association. quality of hand care through the devel- committing to develop a series of Quarterly ..... Copyright ©2004, The American opment and sponsorship of educational instructional courses at our annual Association for Hand Surgery. All rights programs related to the hand and upper meetings that will integrate review Spring reserved. No portion of this newsletter extremity, through communications topics on a cyclic basis over multi- 2004 may be printed without express written with health care professionals and the ple annual meetings. We will con- permission from the publisher, 20 N. public, and through the endowment of tinue to communicate through a Michigan Avenue, Suite 700, Chicago, IL research.” That just about says it all. variety of means, including the 60602, 312-236-3307. That is what we are all about. That very well-respected Hand Surgery 3 is our mission. We have gone far in continued on page 4 FROM THE PRESIDENT Hand Surgery Care for the Navajo continued from page 3 Nation in Chinle, Arizona Quarterly publication as well as our website. We are looking for new ant to apply your knowledge and skills in hand surgery over a means of communication, such as a long weekend to help patients who don’t have easy access to development of a peer review jour- Whand care without traveling to a third world country? Interested nal as an Association organ. in exploring some of the most beautiful canyons in America without All of these efforts must be car- planning an entire vacation? ried out in a responsible manner in The Hand Clinic and Rehabilitation Unit at the Chinle order to insure the fiscal soundness Comprehensive Health Care Facility (http://www.lapahie.com/Chinle.cfm) that is necessary for our mission to is part of the Indian Health Service that serves the Navajo Nation. The be carried forth through future gen- facility is located in Chinle, Arizona, which is adjacent to beautiful and erations of hand care professionals. unmatched Canyon de Chelly that offers incredible vistas and hikes. We are in great shape financially The hand clinic is staffed by an outstanding group of therapists, nurses, and growing, thanks to the watch- and support staff. It is a new facility that offers most of the comforts, ful eye of our Treasurer, Dr. N. services and technologies of your own hospital. You are treated with the Bradly Meland, and adherence to utmost respect and receive enormous gratitude for your help in provid- an investment policy adopted by ing care. My time spent last year was enjoyable in everyway, including the Board of Directors three years the outpatient care, operative experience, and off-time exploring the ago. We will strive to bring new local canyons. I plan to return this year and again for years in the members into our organization at future. You won’t find a more rewarding way to spend a long weekend. all levels of membership in order to If you’re interested in volunteering, please contact the AAHS Central insure vitality in the AAHS for Office as soon as possible as your help is greatly needed in the near future generations. We will contin- future. ue to actively promote and support —Brian Adams MD the Hand Surgery Endowment, for its mission for supporting educa- tional opportunities, research pro- website has matured to a truly Arizona. Dr. Brian Adams is coordi- jects and awards truly enriches the effective, efficient and aesthetic sta- nating these efforts, and explains existence of the AAHS. We will also tus, thanks to the tireless efforts of the structure of this program in strive to make this a record-setting Dr. Keith Brandt. Not only are we more detail in the article above. year for new member recruitment witnessing an increase in usage Our “to do” list seems full at all levels. from our members, but the public is enough as it is, but we cannot for- Taking the core competency con- hitting the site at an ever increasing get about the culmination of the cept one step further, the second pace. We will continue to encourage year at the annual meeting of the level could concentrate on service to this by developing resources help- American Association for Hand our community. “Our community” ful to the public and to connect the Surgery at the Sanibel Harbor can be defined as the community of inquiring public with clinical ques- Resort and Spa on the beautiful hand care professionals, both with- tions to interested members. central gulf coast of the Florida in our organization and without, as The ultimate level of service to peninsula, January 12-15, 2005. It well as the public community that community may be considered to will be again held in conjunction we serve. We will continue to work be volunteer efforts to provide with the annual meetings of the with our health care partners in a hand and upper extremity care to American Society for cooperative fashion, particularly the underserved populations in need. Reconstructive Microsurgery and ASHT, ASRM, ASPN and the ASSH. The AAHS and Hand Surgery the American Society for Peripheral The challenges we face in health Endowment have been doing this Nerve. Dr. Scott Kozin is our care are bigger than any of us can through the Vargas Award program Program Chair. The preliminary Hand Surgery imagine, and we cannot face them for years. It is a proud tradition that program looks exciting already and Quarterly successfully alone. It behooves all of celebrates the professional relation- we look forward to seeing all of ..... us to link arms with our partners ships of therapists and surgeons, you there. In the meantime, I chal- Spring and work on these issues together, and we pledge to continue this lenge each and every member of 2004 while still maintaining the dignity effort. Additionally, we are going to the AAHS to get involved at some and identity that our great organi- begin to actively encourage our level. This is our organization and zation deserves. We are preparing a members to serve our community only we can make it work. series of public service announce- through volunteerism by short Together, we truly can make a dif- 4 ments for the public related to sea- tenures at the Chinle Comprehen- ference. H son upper extremity injuries. Our sive Health Care Facility serving the Navajo Nation in Chinle, LEADERSHIP PROFILE

and microsurgery practice at the and the resident/fellows awards Treasurer N. Bradly Mayo Clinic in Rochester, MN, from contest. He served as program chair Meland MD 1987–1993. During that time, he was on the hand section at the ASPS the Program Director of the Plastic annual meeting for the association. Surgery Residency and their associ- He has been a director at large and . Bradly Meland, MD has been ated fellowships. In 1993 he trans- is currently entering his last of three an active member of the ferred to the Mayo Clinic Scottsdale years serving as treasurer for the NAmerican Association of Hand to replace Dr. Irons in his retirement. AAHS. Surgery since his first meeting and From 1993-1998, he was the Chief of His greatest blessing has been acceptance into member- the Division of Hand the friends he has made throughout ship in Toronto in 1989. Surgery at Mayo Clinic his involvement in the association. He was led to the orga- Scottsdale. He was fortunate He is specifically pleased with our nization by his partners during his years at the Mayo affiliation with the therapists in this at the Mayo Clinic in Clinic to be active in clinical group. H Rochester, MN. Dr. and basic science research, Meland feels very fortu- publishing over 70 scientific nate to be a participating articles primarily related to AAHS 2004 member in this great plastic surgery, microsurgical organization and is reconstruction and hand Officers exceedingly grateful to the leaders surgery. He has also written 15 book and Board he has worked with and learned chapters and numerous abstracts from over the past 15 years. and reviews. He has been guest pro- Officers Brad was born in 1953 in fessor in both microsurgery and Northwood, North Dakota, a town hand surgery at several institutions President of 1200 people. He attended the in the United States, Europe and Richard Berger, MD, PhD University of North Dakota where Canada. President-Elect he graduated in 1975 with a degree In 1998 he left the Mayo Clinic to Susan Mackinnon, MD in natural sciences and Latin. He pursue private practice. Since 1998 Vice President was then accepted to the University he has been sole proprietor in his Ronald Palmer, MD of North Dakota School of hand and plastic surgery private Medicine, graduating in 1979 with practice in Scottsdale, AZ, doing all Treasurer his MD degree. aspects of plastic surgery and upper N. Bradly Meland, MD He matched in a general surgery extremity hand surgery. Treasurer-Elect program at Saginaw Cooperative At the time of leaving Mayo Richard Brown, MD Hospitals in Saginaw, MI, an affili- Clinic, he was an Associate Secretary ate of Michigan State University. He Professor of Plastic Surgery and A. Lee Osterman, MD then went to the Mayo Clinic in Orthopedic Hand Surgery. Rochester, MN, and completed two Despite his busy clinical practice, Historian years of plastic surgery training he maintains a busy family life. He Jaiyoung Ryu, MD under the direction of Ian Jackson, has been married to his wife, Sue, Parliamentarian Jack Fisher, John Woods, P. G. for 25 years. She is a physical thera- Richard Brown, MD Arnold and George Irons. It was pist working in sports medicine/ Senior Director At Large during that time that he developed physical therapy for Nova Care. He Allen Bishop, MD his interest in upper extremity and has four daughters, Angela, Shaina, microsurgery, rotating on the ortho- Jessica and Tessa. Junior Director At Large pedic service. He spent six months Dr. Meland has been very active Mary Lynn Brown, MD Hand Surgery Quarterly doing orthopedic microsurgery in the AAHS since becoming a Junior Affiliate Director training with Mike Wood and Bill member. He started his service in Aviva Wolff, MA, OTR, CHT ..... Cooney in Rochester, and then fin- 1993 where he was the ASPS repre- Spring ished his hand surgery training at sentative of socioeconomic commit- Elected Committee Positions 2004 the University of South Florida in tee for two years. He was chairman Nominating Committee Tampa under the guidance of Bob for two years on each of several Brian Adams, MD Belsole, Tom Green, John Rayhack committees: commercial exhibits, Miguel Pirela-Cruz, MD and Ellen Beatty. He then returned program, time and place, member- 5 to Rochester Mayo Clinic on staff in ship (streamlining the application 1987. He maintained an active hand procedures and moving it online) 2004 ANNUAL MEETING IN REVIEW

Golf tournament winning foursome: (l to r) Jeffrey Freidman MD, William Swartz MD, Lawrence Colen MD and David Drake MD.

continued from page 1 Office. Thanks also to George Balfour, patients such as Christopher Exhibits Chair; Craig Reeves. Johnson, Chair of the Dr. Miguel Saldana reported Resident and Fellow on the progress being made by Awards Committee; the AAHS Endowment, and and for help and advice many individuals made contri- from William Geissler, butions at our meeting. previous AAHS Contributions are still welcome! Program Chair. Special (The Hand Surgery thanks to the 56 mem- Endowment, 6222 South Major bers who worked to put Avenue, Chicago, IL 60638, together excellent www.handsurgery.org) Attendees enjoying the joint association reception. instructional courses, We were honored to have Dr. our 32 panelists, and Roy Meals, president of the Hungary and Rumania is planned our eleven members who put American Society for Surgery of the in between these two meetings. together 12 computerized courses. Hand (ASSH) who was able to Our new project of computer- Finally, I would like to thank my address our group, and welcome ized courses was coordinated by ASPN and ASRM program chairs, our members to attend the ASSH our Technology Chair, Dr. George Dr. Thomas Tung and Dr. Michael meeting in New York, September 8- Landis. This is likely to be the ‘kick Neumeister, who were the best col- 11, 2004 (www.hand-surg.org). off’ of a whole new part of our leagues and co-chairs I could have Dr. Zsolt Szabo represented the AASH educational program. In worked with. International Federation of Societies addition, George was able to coor- I look forward to seeing you all for Surgery of the Hand (IFSSH) dinate a presentation on digitizing next year at the Sanibel Harbor meeting planned in Budapest, home movies for families. Resort, Sanibel Island, Florida Hungary, June 13-17, 2004, and wel- Special thanks to our president January 12-15, 2005. Richard Berger comed the participation of our Dr. Allen Van Beek for allowing me and Scott Kozin promise to have an Hand Surgery membership (www.ifssh2004.com). to serve as Program Chair, to the 19 exemplary program (www.hand- Quarterly Dr. Alexandru Georgescu, repre- members of the Program surgery.org)! ..... senting the Romanian Society for Committee and to Paul Brach and For those of you have not Spring Surgery of the Hand and the George Landis. I would like to attended ASPN or ASRM meetings 2004 Romanian Society for thank our international guests, Dr. (www.asrm.org), 2005 will be a Reconstructive Microsurgery, also Szabo and Dr. Georgescu, for mak- great year and a great venue to welcomed our members to attend ing the long trip to recruit us to par- attend those meetings as well! their post-IFSSH congress in ticipate at the Budapest and 6 Bucharest, Romania, June 19-21 Bucharest meetings. Special thanks Warren Schubert, MD, FACS (www.postifssh2004.ro). A special to Laura Downes Leeper and 2004 AAHS Scientific Program Chair journey through the countryside of Celeste Martinez from our Central H lessons make sure you keep on Surgery Endowment because of the Did You See practicing! Bring your harmonica generosity and challenge to the next year and perhaps Hand Harp foursomes enjoying the course on a That? Surgeons Band of Mark. Dr. Mark beautiful desert afternoon. Baratz, thanks for the fun moment Congratulations to the foursome: and do you think if everyone prac- Dr. William Swartz (AAHS 1999 he annual AAHS meeting is tices we will be ready for a record- president), Dr. Lawrence Colon, Dr. inclusive and the coordinated ing session next year? Jeffrey Friedman and Dr. David Teducational and leadership The first ever designated Joseph Drake for accumulating the best activities of ASHT, ASRM and Danyo Keynote speakers Dr. Elvin score (-6). Next year that foursome ASPN have established a powerful Zook and Dr. Susan MacKinnon will have to be reassigned! educational coalition. Each year this brought the topics of manpower, Visits by Dr Jim Wells, president combination becomes increasingly practice philosophy and the process of the American Society of Plastic important to professionals interest- of peripheral nerve advancement Surgeons and Dr. Roy Meals, presi- ed in hand and reconstructive into perfect harmony. Another dent of the ASSH, along with surgery. Over and over the “did annual meeting Educational updates from those organizations you see that?” comment was heard; Highlight was the establishment of kept members abreast of coopera- the meetings have become the computerized instructional courses. home of innovation, creativity, pro- Nine courses were available for fessional satisfaction, excitement attendees to review. Each comput- and essential information. erized IC station had extensive use This year’s faculty of panelists, by individual viewers. instructional course chairs, and sci- If education is important, so is entific session presenters brought maintenance of our professional new horizons to the meeting. The esprit de corp. The Pete Dye variety of topics was daunt- ing. And it is especially exciting to see residents pre- senting their papers and hearing genuine sponta- neous floor discussion dur- ing the scientific program sessions! Truly exciting, and where else does this occur? ...and even while donating to the Hand It is nearly a lost venue Surgery Endowment (we hope!). except at our annual meet- ing! tive efforts for member advocacy For those of you partici- and educational efforts between pating in the blues harp organizations. ...while on the golf course.... Everyone enjoyed the Gala event sponsored by ASRM celebrating designed golf course their 25th birthday. Dr. Berish was a beautiful setting Strauch’s review of their organiza- for the annual meet- tion’s birth made many realize that ing. The 16th hole of time does change things personally the golf course became and professionally. Dr. Scott Levin’s Hand Surgery a special challenge to historical review was a multimedia Quarterly those enjoying the day masterpiece. Thanks to Scott and ..... at the links golf venue. Berish. Spring Dr. Miguel Saldana The cooperation in the meeting 2004 and Dr. Van Beek were format of AAHS, ASHT, ASRM and able to raise over ASPN continues to mature and the $1,000 on that benefit symbiosis created at the meeting is hole for the Hand palpable. The meeting format is not Attendees had fun while at the reception... 7 continued on page 8 2004 AWARD 2004 MEETING REVIEW exciting potentials are on the hori- zon: AAHS organized international WINNERS continued from page 7 service opportunities; support of humanitarian efforts of other orga- Research Grant Awards only the cutting edge of hand and nizations on mission trips; our own reconstructive surgery but also the journal with information content Kevin Chung, MD cutting edge of the future formats patterned like the annual meeting Sandra V. Kotsis, MPH of meeting. Cooperative informa- as a new member benefit; and University of Michigan tional sessions, conjoined scientific improvement of handsugery.org Ann Arbor, MI program, conjoined social venues, through the use of the web site as Factoring Influencing Residents’ excellence in education combined an E-learning vehicle. Decisions to Pursue a Career in with rejuvenation of our enthusi- What about next year? Dr. Hand Surgery: A National Survey asm and esprit de corps for our pro- Richard Berger will again lift the fession. Special thanks to Terence Myckatyn, MD ASRM President Ronald Susan E. Mackinnon, MD Zuker, MD, ASHT Washington University President Mr. Paul Brach, St. Louis, MO and ASPN President Dr. Application of a Novel Auto- Keith Brandt for their Fluorescing Mouse Model to leadership, cooperation Stermine Where the Axons in the and help in making the Terminal End of an End to Side annual meeting success- Neurorrhaphy Come From ful. Special thanks to pro- gram Chairperson Clinician/Teacher of the Year Warren Schubert, and the Nash Naam, MD program committee for advancing the AAHS Incoming President Richard Berger MD, PhD (left) thanks annual meeting to a new out-going President Allen Van Beek MD for his service. 2004 Vargas International level sophistication. Hand Therapy Teaching Award Their ability to work with program covers off perplexing problems and Sharon Durst OTR/L committees of ASRM and ASPN challenge each of us with an Paula Galaviz OTR/L, CHT assured that the emerging tech- increase in amplitude of teaching nologies and techniques were pre- and fun at our annual meeting. sented and that the annual gather- Save the dates January 12-18, 2005 ing continued to be the for the combined AAHS, ASHT, AAHS 2004 NEW MEMBERS meeting to attend if you ASRM, and ASPN and be part of wanted to educate your the best of the best in hand surgery. mind and rejuvenate Active Members Candidate your professional spirit. Allen Van Beek MD Budoff, Jeffrey Members The AAHS board of AAHS Immediate Past President Houston, TX Avena, Ricardo directors met during the H Kalliainen, Loree Louisville, KY annual meeting and Columbus, OH Beck, Joel Ladd, Amy San Mateo, CA Palo Alto, CA Bueno, Reuben Malerich, Matthew New York, NY The American Association for Bakersfield, CA Lionelli, Gerald Hand Surgery Matiko, James St. Peters, MO Hand Surgery would like to thank Quarterly San Bernardino, CA McAdams, Timothy ..... Stafford, James Palo Alto, CA the following sponsors: Houston, TX Spring Nasser-Sharif, Susan 2004 Wilmington, DE Avanta Affiliate Member Spinner, Robert Blake, Christine Rochester, MN Micrins Mt. Pleasant, SC Wolf, Jennifer 8 Rochester, MN HARD THERAPY AND AFFILIATES’ CORNER

tune with this diminutive instru- Music Theme ment. Words simply can not describe the enjoyment that was Perfectly had by all in the ballroom that morning. The afternoon session, which Pitched at was moderated by Keith Bengtson MD, continued the musical theme Hand Therapy started at the end of the morning session by discussing the Specialty Day Performing Artist: Then vs Now. Many thanks go to Peter Amadio MD and Lauren Valdata-Eddington he beautiful city of Palm PT, CHT for putting together an Springs, California, home to afternoon session that stimulated 2004 Vargas International Teaching Award Winners Sharon such celebrities and everyone’s interest in the area of the Durst OTR/L (left) and Paula Galaviz OTR/L, CHT. Presidents as Bing Crosby, performing artist and how to man- T Dinah Shore, Bob Hope, age what can be a very difficult Henry Truman, and Dwight population. Eisenhower, was home, if only for a The day ended with 2003 Vargas short time, to this year’s AAHS Award winners Sue Michlovitz PT, annual winter meeting. PhD, CHT and I giving our presen- The theme of this year’s opening tation on the experiences we both day was Hand Therapy Through had at Chinle Hospital on the the Ages, co-chaired by myself and Navajo Indian Reservation in Warren Schubert MD. The morning Chinle, Arizona, along with Brian session, which was moderated by Adams MD and Lee Osterman MD. Sue Michlovitz PT, PhD, CHT Paul LaStayo PT, PhD, CHT must included interactive discussions be praised again on organizing an between surgeons and therapists on experience that Sue and I will not topics dealing with fracture, soft tis- soon forget. Andra Battocchio PT HT Specialty Day panel moderator Sue sue and nerve injury on a continu- needs to be recognized as well for Michlovitz PT, PhD, CHT and Daniel Nagle MD. um from the early years to the later her tireless efforts in scheduling the years. patients for clinic, coordinating Last of all, best wishes to incom- The early session ended on a education sessions for the local ing Senior Affiliate Director Gail “blues note” when Mark Baratz therapists and surgeons, and lastly, Groth OTR/L, CHT and Junior MD ascended to the podium and for being such a wonderful travel Affiliate Director Aviva Wolff gave an unbelievable harp solo to guide for Sue, Lee, Brian and OTR/L, CHT. I know that the next start his presentation on the history myself. few years will go smoothly and effi- of the harmonica in blues music. Cheers go out to Sharon Durst ciently with these two in the After passing out more than 60 har- OTR/L and Paula Galaviz OTR/L, Affiliates’ Corner. monica’s (unfortunately there were CHT, who were named the 2004 not enough to go around), or Vargas Traveling Fellows. They will Paul Brach PT, CHT “harps” to the people in the biz, the be traveling to Guatemala for two Hand Therapy Specialty Day Co-Chair audience was on the edge of their weeks this summer. H seats to learn the intricacies of this The Board of Directors, outgoing Hand Surgery soulful instrument. Dr. Baratz was AAHS President Allen Van Beek, Quarterly the leader of the band. Believe me, MD and Program Chair Warren ..... there were no American Idol har- Schubert MD should be commend- Spring monica players in the room on this ed for creating such a wonderful 2004 day. However, in the end, after Dr. scientific program this year. As the Baratz’s simplified demonstration outgoing Senior Affiliate Director, it and teaching tips, everyone (well, at was a privilege to have served least everyone) was able to carry a alongside these fine individuals. 9 THE HAND SURGERY ENDOWMENT

Dr. Robert Schenck, HSE’s first payment of the yearly dues. Hand Surgery president and founder, managed to Obvious on that form is an HSE increase the assets to $226,760.00. donation box for $150.00 dollars Endowment His goal was to eventually increase that can be checked. If every one of the assets of HSE to $1,000,000.00. the AAHS members donated Once that lofty goal is Status 2004 reached, the HSE would be able to support twenty times thought that I would update all the educational goals that of you on the status of our Hand the HSE supports now. Surgery Endowment (HSE). The In 1996, at the inception Board of Directors hired Smith of the HSE, 35 AAHS mem- IBarney in March 2002. Prior to bers supported the embry- that time the HSE assets were vest- onic HSE. During the early ed in several mutual funds. phase there was a vigorous When these funds were ana- growth phase with tremen- lyzed by experts at Smith dous support from our Barney, it was noted that on members (see chart below). Risk/Return Analysis these Over the last two years, mutual funds were on a high our members seem less Drs. Miguel Saldana and Allen Van Beek raising funds for risk tract. Some of them were inclined to continue the early the Endowment at the 16th hole. high risk and low return also. stellar support to the HSE. Invesco-National Asset What ever the reasons for this $150.00 for four years in a row, we Management was hired to decline, it is important for you to would achieve the $1,000,000.00 MIGUEL SALDANA MD manage the account at Smith know that the HSE assets have mark! grown from $226,760.00 in June Setting an example with substan- AAHS MEMBERS DONATING 2002 to $282,000.00 by December tial donations from the AAHS 31st of 2003. Board of Directors were Drs. Allen This year at the 34th Annual Van Beek, Susan McKinnon and AAHS meeting your HSE support- Alan Freeland. Their leadership by ed two Vargas Award Recipients, example is kindly appreciated. Paula Galaviz, MS, ORT, CHT and AAHS members who moved Sharon Dest, PT, CHT with into the Topaz Lever ($1,000.00) $1,500.00 for their trip to Venezuela during 2003 were the following: later on this year. The HSE was Mark Baratz ready to support a $500.00 “Best Lawrence Cervino Therapist Paper” and a $250.00 James Clayton “Best Poster Award,” but unfortu- Robert Gardere nately these winners were not iden- Frederick Heckler tified to the HSE. That money was David Hildreth returned to the HSE. Ronald Joseph At the Palm Spring meeting Dr. John Lang Mark Baratz’s “harmonica session” W. R. McArthur to the general meeting promulgated Hiriam B. Morgan a sale of his CD that generated Somprasong Songcharoen Hand Surgery Barney. The style of the account is $205.00 for the HSE. My sincere Eric Wyble Quarterly Large Cap Core Treasury Balanced. thanks for his generosity...... The Board of Directors dictated to During the golf outing, your The Board of Governors for the Spring the Invesco-National Asset attempts at a “hole in one”at the HSE, Drs. Joseph J. Danyo, N. 2004 Management for the style of the 16th par 3 added $1,200.00 to the Bradly Meland, William Swartz, HSE account to be conservative HSE. My hardy thanks to all of you Robert Walton and myself, kindly with the primary goal being who generously supported that par- thank all of you who have gener- Principal Preservation followed by ticular effort. ously supported the Endowment 10 Capital Appreciation. Remember that the best time to efforts this past year. H donate to the HSE is during the AROUND THE HAND TABLE

Hand Problems of the Performing Artist

At the recently concluded 2004 Annual Meeting, the Hand Therapy Specialty Day included a panel to discuss the hand prob- lems encountered by musicians. We have asked the same experts to once again share their insights and treatment approaches in this Around the Hand Table. Moderator Keith Bengtson MD, Director of Hand Rehabilitation, Mayo Clinic, Rochester, MN, is joined by surgeons Peter Amadio MD, Professor of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, and Mark Baratz MD, Allegheny General Hospital, Pittsburgh, PA, and hand therapist Lauren Valdata-Eddington PT, CHT, Baltimore, MD.

Dr. Bengtson: The record of hand how often they’re performing. a nerve problem, problems in musicians dates back Also, whether they changed from you’ve got to do a to the time of Robert Shuman. solo to ensemble or the kind of complete exam start- However, it wasn’t until the last 20 ensemble, or even the room in ing from plexus down years or so that problems have which they’re playing, whether the to the fingertips. I received more attention. In fact, the temperature changed or the seating think that one of the first medical problems of musi- changed. There are a variety of things that I have cian’s conference were held as things you really have to take into found helpful that’s recently as 1983. First of all, Dr. consideration, really the entire been talked about for I THINK THAT A LOT Amadio, perhaps you could dis- environment of the musician, if a long time in care of OF THE MUSICIANS cuss how you approach the history you’re going to try to sort out what the musician is to taking of a musician that comes exactly is the source of the prob- have them bring their LOOK A LOT LIKE MY into your office? lem. Today in the office, I saw two instrument to the FIBROMYALGIA musicians where these issues office. Sometimes Dr. Amadio: If I have a musician weren’t as relevant. One came in that’s easy to do, PATIENTS. who’s coming in, particularly if it’s with carpal tunnel syndrome that sometimes it isn’t. But a performance related problem, as was performance related but it was for someone like a opposed to, for example, a colles a very straight forward diagnosis flautist who has trou- fracture or something like that, I and evaluation: it was an older ble with the small fin- think it’s important to spend a fair person, who had rheumatoid ger you can get a amount of time taking a history. arthritis in addition to being a sense for how far they Specifically, everyone has a life that musician. Another was a pianist have to reach. I had a is varied and includes a lot of com- who had a locked trigger thumb young girl who was a KEITH BENGTSON MD ponents—their family, their work, that actually came from a new cellist who was hav- and so forth. Particularly in musi- hobby of throwing clay pots. So ing symptoms consistent with tho- cians, the relationship between a sometimes it’s not as important racic outlet syndrome and it was person and the music that they do and it’s much more straightforward clear after moving from a 3/4 size for either a job or a significant to make a diagnosis and evaluate. cello to a full size cello that she was hobby is really exaggerated. I think But often you’re going to have a putting her arm into the provoca- it’s very, very important to try to musician that comes in with a less tive position for thoracic outlet syn- piece that relationship together and specific complaint, and then I think drome. The use of the instrument is try to find out exactly how impor- it’s very, very important to dissect probably the one thing that is dif- tant the musical performance is to out the history, as I’ve described. ferent in my examination from the the person as well as what the non-musicians. Hand Surgery symptoms are that bring the musi- Dr. Bengtson: Dr. Baratz, perhaps Quarterly cian to you. It’s very, very impor- you’d like to mention how you Dr. Bengtson: Ms. Valdata- tant to sort those issues and to go exam a patient who is a musician Eddington, perhaps you can say ..... back as far as you can in the histo- that comes in to see you. something about the therapist Spring ry to when they weren’t sympto- approach to evaluating musicians? Dr. Baratz: I think that it’s not much 2004 matic and then come forward to different from dealing with any Ms. Valdata-Eddington: Initially, I the present, with particular atten- other person who has a specific wouldn’t typically look at the tion to the details of any changes in complaint or problem. You want to involved area. I would probably technique, practice habits, reper- be thorough and if it is for exam- start with a full body evaluation of 11 toire, how often they’re practicing, ple, something that is suggestive of continued on page 12 AROUND THE TABLE

continued from page 11

various postural checkouts. I ask what they do outside of playing their musical instruments, since a majority of my patients are in high- school or college. These students are dealing with their school work and not doing any physical activities to keep up their strength and endurance. Typically, they are very weak yet they are playing their instruments many hours using small muscles. I usu- ally do a quick pos- CUBITAL TUNNEL tural evaluation including axial SYNDROME IS extension, pelvic tilt, COMMONLY SEEN IN lumbar and hip flex- flexibility and see the muscles that their instrument when they have ors, and flexibility. HARMONICA PLAYERS. are either elongated or weak or the an injury? Usually they have muscles that are shortened and in Ms. Valdata-Eddington: Again, most THEY HOLD THEIR weak abdominal and spasm. From there I would proba- of the people I am treating have gluteal muscles. I bly check the different muscles for ELBOWS BENT FOR music as their life. Since most of then look at their pain and spasm, such as is found my patients are anywhere from col- EXTENDED PERIODS injured part to see in flexor tendonitis and extensor lege freshman to Master students, how that would lateral epicondylitis. I would delay without their instrument they don’t OF TIME WHILE relate or assimilate a muscle test at that point because have school. One of the main with their instru- they’re usually in acute pain and it THEY PLAY. things that I have tried is to utilize ment. I don’t typical- would not be indicated. Dr. Richard Norris’ book, Return to ly evaluate them Finally, since we have the Play, Chapter 14. Many of his theo- with their instru- advantage of a full time social ries are similar to mine. I will try to ment on their first worker who is a hand and upper MARK BARATZ MD get the musician playing as soon as exam. Since I’m extremity specialist, she can help they can shadow play and hold going to be seeing them deal with relaxation, whether their instrument without pain. them more frequently than their it is from stage fright to pure relax- If they’re presenting with Dr. physician and for a longer period ation for the patient and their mus- HJH Frye’s category five (having of time, I like to initially concen- cles. Most people don’t relax pain everywhere with all activities trate on their full body. because they are constantly on the causing pain), it takes a good while I’m usually given a specific go, dealing with their schoolwork for them to reduce their symptoms. diagnosis. For example, in a cellist as well as with the tension caused That person would not return to with impingement, I want to look by not being able to play their play at that moment; instead I have at his range of motion, check his instrument for their classes or them delegate their time mentally grip and pinch and see if there are recitals. So she’s usually consulted Hand Surgery any thoracic outlet problems. Next, so they’re actually mentally play- Quarterly during the time frame of my initial ing. Since that’s not going to help check for particular areas of pain history and beginning of treatment...... whether it be trigger points, their situation, I get them to men- Spring acupuncture points, or just total Dr. Bengtson: You mentioned return tally play their pieces. They actual- 2004 muscle spasm. In addition, when to play. ly need to delegate anywhere from I’m doing that evaluation, I want to a half hour to an hour looking at Ms. Valdata-Eddington: Yes. look at their standing and sitting their piece, thinking about their posture. Since the person is usually Dr. Bengtson: When is it appropriate instrument, doing visualization, 12 playing in an asymmetrical posi- to have a patient actually play their and play the different piece that tion, I want to see their muscle instrument or return to playing they may have been working on, and/or other pieces that are more ing anything. I would have him the palm. Often I will cross into the simple. This is done prior to “shad- doing some types of active activi- distal forearm a little bit, all under ow playing”. As their pain is ties that would improve finger local anesthesia. After I release the reduced and they’re able to rate motion to simulate chord position flexor retinaculum, I ask the patient their pain, on the pain scale, from a or to just continue playing and to make a tight fist with the wrist zero to a three, I then start them building up his time in the shadow in neutral position. If in that posi- playing again. I had a cellist who zone without the instrument. Then tion the flexor tendons hop up over had an impingement syndrome I have him move over to holding the hook of the hamate, which due to changing his instrument an instrument and not do scales, sometimes they do, I reconstruct from the two that he had played but just move his fingers along the the flexor retinaculum. Again, I do for many, many years to one that chord hand (left), and then the bow this in everybody, not just in musi- was a little larger, but with a differ- hand (right). He may be able to cians. The reason I do ent bridge angle. Due to his body hold the bow anywhere from one that is because I think type and posture, he had signifi- to three minutes. If he can do that that that subluxation cant impingement problems. He with no problem as time goes on, of the flexor tendons actually started to return to play then have him actually put it onto over the hook of the three weeks into hand and upper the instrument. hamate can be a extremity treatment because we source of pain. If I Dr. Bengtson: What if there’s a sur- wanted to get him doing the men- need to reconstruct gical problem? Perhaps if you see a tal play immediately. After three the retinaculum, I use patient that has something straight weeks he was able to play twice a a radially based rota- forward surgical, like carpal tunnel day for three minutes with a twen- tion flap of the flexor syndrome, do either the surgeons THAT'S THE ty-minute break, then another three retinaculum, so you in the group here treat the patient minutes. To have this patient lengthen the flexor PROGRESSION OF any differently because they’re a progress from the mental play to retinaculum as you musician? RETURNING TO shadow play without the instru- close it. I begin finger ment, to shadow play holding the Dr. Amadio: I treat them basically motion the day of PLAY—MENTAL, instrument in the proper position the same. I do an open carpal tun- surgery, wrist motion SHADOW WITHOUT, (because of cell memory he would nel release. I think the big thing is the next day with a just revert back into the bad posi- to make the right diagnosis and to splint to protect the SHADOW WITH THE tions), then to the three minutes, provide a treatment that you’re wrist in between exer- was an excellent accomplishment. confident will address the particu- cise, and I encourage INSTRUMENT, HOLDING That’s the progression—mental, lar problem, and then move on the patients not to WITHOUT PLAYING. shadow without, shadow with the with an aggressive rehabilitation. I posture the wrist in instrument: holding it but not play- make a small incision at the base of flexion, especially if the flexion retinacu- lum has not been “East Meets West” repaired. I usually also close the palmar LAUREN VALDATA-EDDINGTON, Post-IFSSH Congress fascia before I close PT, CHT the skin. Usually June 19-21, 2004 within about two Bucharest, Romania weeks they can start getting back to following the IFSSH meeting in some activities, including musical Budapest, Hungary activities if it’s a musician. Dr. Baratz: I think that the most This meeting is organized by the Romanian Society for important point today is the need Surgery of the Hand and the American Association for Hand to make the correct diagnosis. Surgery, and is endorsed by the RSRM, ASRM and IFSSH. There’s nothing worse than dealing Hand Surgery The post-congress will be held in an area of Europe well with any patient, musician or oth- Quarterly erwise, who has had a failed carpal known for its natural beauty, history, art, and architecture ..... and will offer an academic program of benefit to both hand tunnel surgery because they had surgery for hand pain rather than Spring surgeons and microsurgeons. Please contact the AAHS numbness in a median nerve distri- 2004 representative for the congress, Jaiyoung Ryu at bution. [email protected] for further information, or visit the For everyone, including a pro- website at: http://www.postifssh2004.ro/ fessional musician, professional athlete or my next-door neighbor, I 13 continued on page 14 Dr. Amadio: AROUND THE TABLE range of motion. If I started work- Ms. Valdata- ing on the person within the first Eddington’s already mentioned continued from page 13 couple of days, I would definitely some of them, like thoracic outlet use a treatment to decrease pain with cello. And there’s this whole do a limited open carpal tunnel and swelling, such as a (TENS) issue about keyboarding and release and I encourage them to use unit. Even more effectively, I’ve carpal tunnel syndrome, but I don’t their hand right away. I don’t splint been using the JACE unit which is think there’s any question that par- them; I have them wear an ACE a high frequency galvanic electrical ticularly for a piano that can be an bandage for one week. stimulation and/or interferential issue. And unlike typing, for exam- I like the concept of graded treatment. It’s a little more comfort- ple, where typically you just have return to activities for musicians able than the TENS unit. to put very light pressure on a key- and for the pianist in Depending upon the person and board to activate the key, in piano particular. I’ve had their wound, I would not initially the whole point of it is sometimes good luck having do ultrasound even though it’s you’re pressing hard and some- them work initially good for reducing scars. I would times you’re pressing softly, and so on a keyboard do ultrasound if there was a lot of the amount of loading can be quite instead of a piano. scarring over the wrist. I would considerable. Carpal tunnel syn- The action on the start gentle friction massage, and a drome in the right hand of pianists keyboard is a little deeper massage for the scar tissue is certainly a common association. bit lighter and a little to try to mobilize it. In addition, I Most piano pieces are written for bit easier on the would do and also teach the the right hand and I don’t think (UNLESS HE HAS HIS hand. The one per- patient to do a light fluid flushing that there’s any coincidence about son that I slow down massage, not the retrograde mas- that, that people who play the OWN PREFERENCE) is the right-handed sage which is too heavy. I also use piano can have trouble with the CLARINET PLAYERS string player who manual edema mobilization tech- carpal tunnel on the right side. For has carpal tunnel niques to help reduce swelling. string players, it depends. For the SUPPORT THE WEIGHT surgery done on their Using an edema reducing glove violin or the viola, sometimes the that has a very gentle amount of OF THE INSTRUMENT left hand, or the gui- left wrist can be postured in a fair tarist who has to pressure would be appropriate for amount of flexion as it’s holding WITH THEIR THUMB, play with a lot of night and day wear. Home mas- the strings out towards the end of sage by the patient should also be the instrument and so carpal tun- STRETCHING OUT THE wrist flexion. I usual- ly ask them to wait done in addition to light, protected nel syndrome there can sometimes UCL OF THE THUMB. two weeks before active range of motion exercises be be a problem, but more often they play using the three to five times per day. cubital tunnel syndrome, and we left hand. If it’s In addition to that, there is haven’t talked about that, maybe someone who is a something called kinesiotape that we should talk a little bit about the classical guitarist, I’ll we’ve been working with for the treatment for that. The cubital tun- PETER AMADIO, MD have them use a gui- past ten or so years. It is a tape that nel syndrome in the left arm of tar that has lighter can be utilized for retraining, scar string players, especially violin and action, like an electric guitar, where mobilization, muscle support, and viola, can be an issue. They also they don’t have to put as much swelling reduction. It came out of can have neck problems depending flexion into their wrist and don’t Japan in ’78, but I don’t think we on how they hunch up their shoul- have to put as much pressure on got it until the ‘90’s. It also helps to der and neck to hold the instru- their fingers. increase blood flow. It mimics the ment, as they typically do. massage over the skin because it One of the other things that Dr. Bengtson: Ms. Valdata- actually fits to the skin and it can commonly also happens in the Eddington, you must have some stay on the person from anywhere hand of clarinet players is they experience with postoperative reha- from one day to five or more days. support the weight of the instru- bilitation. Because you wash it, it just acts ment with their thumb as they get Hand Surgery Ms. Valdata-Eddington: Yes. like skin. Because it’s protecting the more or less classical gamekeepers Quarterly Unfortunately most of the people skin, as in the case of carpal tunnel, type thumb, where they stretch out ..... that do well we don’t see. I’m typi- decrease the sensitivity of the skin the ulnar collateral ligament and scar if that is a problem. against the weight of the instru- Spring cally seeing people that are having ment. You often see people who are 2004 pain problems. But on an average Dr. Bengtson: You’re mentioning a playing wind instruments who I’d say we see 3% of carpal tunnel bit about certain instruments with actually use a neck strap to take patients. If someone walks in with certain problems. Perhaps, Dr. some of the load off of their thumb, pain, my goal is to immediately Amadio, you could state some- because otherwise typically they’re decrease the pain, decrease the thing about how certain diagnoses 14 bearing most of the weight of the swelling, and increase pain-free are seen with certain instruments? instrument along that one side of music and don’t take care of them- tions. One that is often helpful in the thumb and the get an attritional selves in terms of general condi- musicians is Inderal, because stretching out of the ulnar collateral tioning. I’m a big believer in aero- there’s a lot of performance anxiety ligament of the thumb metacarpal bic exercise. It doesn’t have to be that can be associated with play. A phalangeal joint. So those are some more than just getting out and tak- beta blocker can sometimes work of the common associations that ing a walk. I also believe in the wonders as far as their perfor- you have with some commonly benefits of stretching, particularly mance anxiety is concerned, but I played instruments. using the techniques taught in haven’t found anti-inflammatory yoga. medications to be particularly help- Dr. Bengtson: Dr. Baratz, certainly ful, because usually the problems you have a particular interest in Dr. Bengtson: Well from a physia- are in the overuse or mal-use or Blues musicians, do they have any trist’s standpoint certainly I’m a big inappropriate use family. The treat- specific injuries that they suffer? believer in conditioning as well. I ments really have to do with look- think that a lot of the musicians Dr. Baratz: Cubital tunnel syndrome ing at their practice regimen and look a lot like my fibromyalgia is commonly seen in harmonica modifying that, and looking at their patients. In fact, people that are players. They hold their elbows fitness status and working on that, poorly conditioned many times bent for extended periods of time rather than using drugs. have chronic painful conditions while they play. and are focusing on the wrong Dr. Baratz: I’ve become very wary Dr. Bengtson: How about alternative thing. They tend to focus on their about using anti-inflammatory medicine? Has anybody had any playing technique rather than what agents in folks in general, particu- experience with musicians coming they’re doing with the rest of their larly people who may not have a in to use any particular type of body. And yes, I agree, certainly regular diet, such as young women alternative medicine that is either a I’m a big believer in conditioning and older people as they may ..... hindrance or help? and posture and postural princi- develop gastritis. Spring ples. Dr. Baratz: I’ve got to tell you, I’m a Dr. Bengtson: You mentioned perfor- 2004 How about medication? Does big believer in two things with mance anxiety; I think there are cer- anybody have any feelings about some of these repetitive type disor- tainly a lot of other psychological medications for musicians? ders. One of them is aerobic exer- aspects as well in dealing with cise, I find that a lot of musicians Dr. Amadio: I don’t see many musi- 15 continued on page 16 tend to put a lot of effort into their cians asking for a lot of medica- AROUND THE TABLE 2005 Application for continued from page 15 musicians. A lot of the musicians I see have a certain amount of Research Grants depression if they can’t get back to playing their instrument either professionally or as an avocation. I The AAHS Research Grant Awards were established to further the think a lot of times it’s then impor- purpose of the Association as stated in its Bylaws and to foster tant to send them to psychological creativity and innovation in basic and/or clinical research in all counseling particularly in those that might be a career ending type areas pertinent to hand surgery. of injury that they have. Does any- body have any ideas in regards to the psychological aspects? Awards and Eligibility Ms. Valdata-Eddington: I mentioned earlier that I have people see our social worker. She deals typically Grants will be made for a one year period to up to three investiga- with traumatic hands but over the tors. Grants are available to all AAHS members. One of the investi- years has become a performing gators must be an active or affiliate member of the association. artist specialist. The social worker will get them to listen to various Grant Application relaxation tapes and then coaches them to make relaxation part of their daily routine. If you just tell Applications may be obtained from the AAHS website at them to do it it’s always put to the www.handsurgery.org, or, you can call 312-236-3307 to request a side because they have so many copy. other responsibilities. At the hand Applications (an original plus seven copies) must be received by the center again, I’m looking at the full committee chair no later than Monday, November 1, 2004, in order body. So a lot of times I’m seeing for the judging to be completed in time and the recipients to be scapula tightness and/or weak- announced at the Annual Meeting. ness depending on their muscles The AAHS and the Research Committee are required by the IRS to that are used. I have the patient lie document disbursement of grant funds. Award recipients will be down where it’s a restful area and required to sign a letter of acceptance and submit a progress report treat them with moist heat as well once each year. The AAHS must be acknowledged as the source of as the pain reducing modality of funding in any presentation or publication. A final report must be JACE and/or interferential. The submitted at the completion of the study. It is expected that the social worker will go in with the results of the funded research be submitted for presentation at an patient and speak with them while Annual Meeting within two years of the receipt of the award. they’re in a more pain free state. Funds must be returned to the AAHS if the study is not undertaken They would practice that treat- within twelve months of the receipt of the award. ment at home as well. Failure to follow these guidelines will disqualify the recipient from One of the things you talked any further grant opportunities and from presenting any papers at about is complimentary treat- the AAHS Annual Meeting for a period of three years following such ments. Many of the musicians default. have already gone previously to different alternative types of treat- Hand Surgery Mail Grant Proposals to ment. I think as adjuncts to thera- Quarterly py they can be great. One activity that I have found ..... W. P. Andrew Lee, MD to be best for the mind, body and University of Pittsburgh Spring spirit is Tai Chi. You’re utilizing 3550 Terrace Street 2004 your full body in very slow and Scaife Hall 690 controlled positions. I’ve found Pittsburgh, PA 15261 that for the musicians, Tai Chi will also have a calming effect over 16 their body. These are some of the different techniques that I utilize. An example is a patient of mine with a little fascial flap can be who was a six-foot, four-inch something that can be done expedi- pianist who had not played with tiously. It doesn’t affect really very his left hand for four months. His much the muscle function, so they initial diagnosis was a focal dysto- can get back into musical activities nia. He was also a basketball play- within a week or two, and the reha- er, and he could not finish one bas- bilitation can often be fairly rapid. ketball game without moderate So I think that that’s a reasonable fatigue. We did all the various treat- operation, again, assuming that you ments mentioned in addition to have a clear and accurate diagnosis. conditioning. When treatment was This isn’t the operation for every- almost finished, we knew that it one with elbow pain, or who says was a combination of different that their hand gets numb from things causing his problem includ- time to time. But if you’re quite ing overuse, technique change, a confident that they have cubital new school and recital practice and tunnel syndrome, then I think that use of new muscles as well. He was that can be a pretty effective treat- not only able to return to play but ment with good results and getting he was also able to play two games people back to play within a rela- of basketball and not even be tired. tively short period of time. He was able to progress his piano Dr. Baratz, how do you manage play to complete his school year this? and senior recital. His case was an Dr. Baratz: I either do Susan example of how we utilized some- Mackinnon’s version of the intra- thing the patient enjoyed to muscular/submuscular transposi- improve the strength and tion or a subcutaneous transposi- endurance of his injured upper tion. I tend to base it on body habi- extremity as well as full body. tus. People that are thin, I put the Dr. Bengtson: Dr. Amadio, you’ve nerve beneath the muscle, and mentioned that cubital tunnel syn- someone that’s got a little bit of drome on the left hand in stringed padding, I’ll consider the subcuta- instruments, so how do you neous transfer. approach cubital tunnel syndrome Dr. Amadio: Yes, well, unfortunately in people that have to keep their in the United States we rarely have elbow bent like that? that former category. But yes, I Dr. Amadio: Well it can be a problem, think that is true. It’s been my expe- because you can’t really modify the rience also that in someone who is instrument allowing them to extend thinner and doesn’t have very the elbow, so often if it’s a problem much subcutaneous fat, that the you need to consider an ulnar ulnar nerve can be tender in the nerve transposition. I think that’s a subcutaneous position. I am a little pretty reasonable operation to do, hesitant in such cases, and normally and I typically have done a subcu- I would do the exact same thing as taneous transposition in those peo- Mark on that. Maybe that is some- ple, using a technique that Richard thing with a little bit of a difference Eaton described. You have to with a musician as opposed to a release all the major structures, of non-musician, since I get a little course, the medial intermuscular worried about doing an operation septum, the arcade of Struthers, the that might affect the strength or use Hand Surgery cubital tunnel retinaculum, and the of the flexor pronator muscles. But Quarterly superficial and deep fascia over the usually a submuscular transposi- ..... two heads of the flexor carpi tion works very well also, and it Spring ulnaris, and you have to be careful certainly does put the nerve in a 2004 not to injure the motor nerves to good intermuscular plane. So that the flexor carpi ulnaris, or the cuta- would be another option. Dr. neous nerves that go over to the Baratz, how quickly do you rehabil- olecranon. But I’ve found that itate somebody after you’ve done doing a subcutaneous transposition 17 continued on page 18 AROUND THE TABLE The AAHS Board of Directors and continued from page 17 the 2004 Annual Meeting Program Committee that kind of a submuscular trans- would like to thank the following companies position? for their support and participation: Dr. Baratz: I put patients in a padded dressing and a sling. After two days they remove the sling A.M. Surgical Lippincott Williams & Wilkins and start moving their arm. I was always protecting the repairs of Acumed Instruments Micrins Surgical Incorporated the flexor-pronator fascia. Patients Corporation don’t seem to have a lot of weak- MicroAire Surgical Instruments ness after the submuscular trans- American Development Group, Microsurgery Instruments, Inc. position because the origin is very LLC broad and you don’t slide the Mitek Products muscle very much. I have not seen Arthrex, Inc. much weakness of either the finger NeuroRegen, LLC flexors of the wrist flexors. Ascension Orthopedics, Incorporated Dr. Bengtson: Well, how do you all New Medical feel about operating on basilar ASPS thumb DJD in more elderly musi- Ortheon Medical cians, particularly pianists? ASSI, Accurate Surgical and Orthofix, Inc. Dr. Baratz: I think that’s a hard Scientific Instruments problem, and I have a patient in Corporation PMT Corporation my practice right now in that situ- ation. The biggest issue with the Avanta Orthopaedics Prime Clinical Systems Inc. thumb CMC arthroplasty is that any major hand procedure on a Carl Zeiss, Inc. Smith Barney musician is going to affect their finger velocity. They may end up Cook Surgical Southwood Pharmaceuticals with a pain free thumb, but getting that thumb to move with the same Cook Vascular Incorporated Stryker Leibinger speed that it did is going to be hard. That, to me, is the issue in DePuy, a Johnson & Johnson Co. Synovis Micro Companies any major joint reconstruction. I Alliance saw a pianist a couple of weeks EBI ago who has terrible PIP joints and Surgical Specialties Corp. would like PIP arthroplasties. He’s Hand Innovations, Incorporated younger and is a bad candidate TriMed, Inc. because of the stress that’s going HealthSouth Corporation Wright Medical Technology, Inc. to be placed on the implants. In Hemedex, Inc. addition, we would have difficulty restoring velocity to his fingers. Instratek, Inc. Dr. Amadio: Now that’s a good point that Dr. Baratz brings up. Integra NeuroSciences Because of the velocity seen espe- Hand Surgery cially in a high level musician, the KMI, Kinetikos Medical, Inc. Quarterly differences are so subtle between ..... the top level, full-time professional LifeCell Corporation Spring musicians and the next rank down, 2004 which is a pretty much a club level. They’re so subtle that just the tiniest thing can knock some- body out of whack. Now I guess if 18 someone has really bad symptoms and can’t play at all, playing some is better than not playing at all. But if you’re talking about getting back AMPAC Educational Opportunity to the very top rung, you have to be very, very careful. And for me With the increasing need for political involvement on the part of the the indication for doing something like thumb CMC arthroplasty is medical community, it is important for all of us to fine-tune campaign that the current symptoms are so skills and learn the latest techniques. Please consider attending the bad that they cannot perform and AMPAC Campaign School scheduled for April 14-18, in Arlington, that they would be willing to per- form at a diminished level com- Virginia. This general five-day program is designed for those physi- pared to their original level before cians interested in playing a role in political campaigns. This popular they had the arthritis. If that’s program is taught by a bipartisan team of top professionals. Topics where they’re at, then I think that you can help them. But you cer- include everything you’ve always wanted to know about the political, tainly shouldn’t try to promote an communications and fundraising aspects of campaigns. operation with the idea that they’re going to get back to their pristine, The $1,000 tuition is waived and hotel rooms provided for AMA mem- pre-arthritic state of musical perfor- mance. I think Dr. Baratz is exactly bers and their spouses provided they are not currently candidates for right, these philosophy issues are federal office. Space is limited so please apply as soon as possible. so important, and just the slightest Applications can be obtained by contacting Lisa Friel, thing setting things off by a mil- lisecond can make the difference Manager of Political Education (phone: 202-789-7465 and email: between whether or not they can [email protected]), or downloaded from the web site at play the piece properly or not. That www.ama-assn.org/go/politicaleducation. is just too much to ask of an arthro- plasty, and particularly something as gross as a resection arthroplasty which is typically what we end up Dr. Amadio: Well the only thing I’d a lot of the problems have to do doing for the thumb CMC joint. like to say is that this is a really with posture and so forth, areas challenging area, but it also can be where physical therapists may Ms. Valdata-Eddington: I agree with very rewarding. When I was a resi- have additional experience. The both doctors. In my experience our dent in Boston, Richard Smith was team also has to include the musi- doctors definitely would not opt the hand surgeon at the time, and if cian and, finally but not least, the for surgery unless it was mandato- a musician came in one door he musician’s teacher. Every high level ry and especially if it was the high walked out the other. He didn’t musician has at least one teacher performing person. Some of the want to have anything to do with and you have to get the teacher on people that I have treated that are them because they were so compli- board because if you’re telling the younger that are just totally abus- cated and difficult to manage. And patient to do one thing and the ing their thumbs, we typically I think they can be, but I think that teacher’s telling the patient to do would have them splinted doing as long as you keep a more holistic something else you’re not going to other activities of daily living, as approach to these patients and get anywhere. So everybody’s got well as have them in therapy for think of them in a more global con- to be on the same page and I think various pain reducing treatments text, that it’s not just anatomy and if you do that, if you take the time and on home programs. We would physiology but that there’s a lot to do it, I think it can be quite try to either use silver ring splints, more involved, and that you have rewarding. CMC protective splints, or whatev- to develop a good team relation- er appropriate splint will try to Dr. Bengtson: Thank you all for par- ship, you can do OK. I know Ms. protect the individual joint when ticipating in this discussion. Valdata-Eddington mentioned this H they’re not playing. Then when and I just want to emphasize it Hand Surgery they do play, they can use their maybe as the bottom line: a team Quarterly thumbs more effectively! relationship, so that you have not ..... Dr. Bengtson: In interest of time per- only a surgeon on the team, but Spring haps we should wrap things up also a non-surgical physician, 2004 this evening. I want to thank every- because most of the problems don’t body for participating tonight, require surgery. A therapist is great, thanks so much for lending your and particularly someone with a expertise. Any other closing physical therapy background. As remarks? Ms. Valdata-Eddington mentioned, 19 CODING CORNER

annular ligament resection, and procedures generally have 60000 Common Hand codes 24354 and 24356 are when series codes because the procedures bony stripping or a partial ostecto- involve nerve manipulation. Problems of my is performed, respectively. Carpal tunnel release performed Wrist tendonitis conditions that via an open incision corresponds to occur in musicians include 64721. If an endoscopic approach is Musicians deQuervain’s disease and flexor undertaken, the code 29848 is carpi radialis inflammation. appropriate. Cubital tunnel release his issue of the Coding Incision and release of the first and transposition of the ulnar Corner focuses on the musi- extensor compartment corresponds nerve, by any means, corresponds cian’s hand. For the purpose to 25000. Release of the FCR sheath to 64718. Note that if the of our coding discussion, we at the wrist is coded with 25001. flexor/pronator muscle mass is Twill look at the problems of Incision of the tendon sheath in the lengthened (such as a Z-lengthen- tendonitis, ganglions, and nerve hand to treat a trigger finger is ing), an additional code of 24305 compression syndromes. coded with 26055. If the pulley may be considered. Decompression Common tendonitis condi- release is performed percutaneous- of the ulnar nerve at the wrist cor- tions include problems at the ly, the code 26060 is appropriate responds to 64719. Release of the elbow, wrist and fingers. (the exact description for this code radial sensory nerve in the distal Lateral or medial epicondylitis uses the word “tenotomy” although forearm would qualify as “neuro- surgery has several codes the work involved is essentially the plasty, major peripheral nerve, arm associated with it. The code same as for a percutaneous tendon or leg” and consequently the code 24350 is for a simple fascioto- sheath release). 64708 would be correct. my at the distal humeral epi- Note that ganglions of the wrist condyle. If an extensor origin and digital flexor sheath can also be You Code It LEON S. BENSON, MD detachment is performed, use problematic in the musician’s hand. code 24351. Code 24352 refers to Excision of a primary wrist gan- A musician with chronic wrist ten- glion (dorsal or donitis decides to pursue surgical Tendonitis Procedures volar) is coded options after conservative measures with 25111. If have failed to treat deQuervain’s 24350 Fasciotomy, lateral or medial the surgery is tendonitis. Release of the first 24351 As above, with extensor origin detachment performed for extensor compartment is completed 24352 As above, with annular ligament resection a recurrent as a single procedure. 24355 As above, with stripping lesion, use the 24356 As above, with partial ostectomy code 25112. Solution: 25000 Incision, extensor tendon sheath, wrist Removal of a 25000 Incision, extensor tendon 25001 Incision, flexor tendon sheath, wrist digital flexor sheath, wrist 26055 Tendon sheath incision cyst is coded 26060 Tenotomy, percutaneous, single, each digit with 26160. Nerve com- Ganglion Excision pression syn- Coding Corner 25111 Excision of ganglion, wrist, dorsal or volar, primary dromes that Addendum 25111 Excision of ganglion, recurrent can be associat- 26160 Excision of lesion of tendon sheath or joint capsule, ed with instru- A previous column in this newslet- hand or finger mental musi- ter addressed coding for thumb cians include carpometacarpal arthritis proce- Hand Surgery Nerve Entrapments cubital tunnel dures. A clarification of coding Quarterly 64721 Neuroplasty and/or transposition, median nerve at syndrome, options for CMC resection arthro- ..... carpal tunnel carpal tunnel plasty is warranted since the codes Spring 29848 Endoscopy, wrist, surgical, with release of transverse syndrome, for this procedure are not complete- carpal ligament 2004 Guyon’s canal ly straightforward. 64718 Neuroplasty and/or transposition, ulnar nerve at elbow pathology, and The primary code to be used is 24305 Tendon lengthening, upper arm or elbow, each tendon radial sensory obviously 25447. The real question 64719 Neuroplasty and/or transposition, ulnar nerve at wrist nerve compres- is what additional codes are appro- 64708 Neuroplasty and/or transposition, major peripheral sion. These priate. Part of the problem is that 20 nerve, arm or leg, other than specified HAND THERAPY PROFILE

there are a variety of ways to per- Ann C. Kammien PT, CHT form this operation and some of the available codes are vague. While Personal: I was born and raised in St. Louis, Missouri and still call it adding code 20924 (tendon graft, home. After Physical Therapy school at University of Missouri, from a distance) might initially Columbia, I returned to St. Louis not far from my parents and five sib- sound more technically “accurate,” lings. My early career was spent in the hospital acute care and rehabili- there are few problems using code tation setting. I continue to find that in- 20924 as an add-on to 25447: patient experience helpful in the global a) The graft can sometimes be assessment and treatment of upper extrem- obtained through the same inci- ity patients. In my first years out of school, I found that the topics I grew to know the sion. best were the ones I had the opportunity to b) The graft for this procedure does teach. With three PT schools and an active not actually qualify as being therapy community, there have been many “from a distance” (it’s not like opportunities to learn and share over the the plantaris or toe extensor). last 25 years. I currently work full time in a c) The RVU assigned to 20924 is too private practice. My husband and 2 small considering the work teenage children are great supporters of the involved for the procedure. profession I love. Education: BS (cum laude) in Physical With this in mind, the other Therapy in 1979: Certified Hand Therapist codes that fit better are 25310 (ten- in 1991 don transplantation or transfer, flexor or extensor, forearm and/or Employer: Co-owner of private practice, wrist, single; each tendon) or 26480 Hand Therapy Inc., St. Louis, MO (11 years), with partner Christine or 26485 (transfer or transplant of Burridge PT, CHT. We are part of a larger network with 7 hand clinics in tendon, CMC area of hand; without all. Earlier employment at a private practice, County Physical Therapy, free graft, each tendon). Note that Washington University at Barnes Hospital (Milliken Hand Center), and 26480 is for a dorsal graft and 26485 St. Mary’s Hospital affiliated with St. Louis University. is for a palmar graft. AAHS Involvement: Became an affiliate member in 1995. Co-authored It should be noted additionally Lateral Epicondylitis overview for Hand Therapist’s Corner in Hand that the Global Services book does Therapy Quarterly Autumn 1995. Attended Kona, Hawaii and Cancun, not bundle 25447 with tendon Mexico meetings. We find the quarterly newsletter to be a great learning transfers or tenodeses, so additional tool and topic for discussion at our clinics. codes for this operation are certain- Best Part of My Job: The best part of my job is the variety it provides. ly appropriate. Also note that edits I enjoy moving from clinic patient care to covering doctor’s hours to of the Correct Coding Initiative link preparing a lecture to negotiating a new lease all in one day. code 25447 with code 25310, so one Major Accomplishments: Developing and sustaining a private practice, would need to use a -59 modifier teaching as a guest lecturer at the Program in Physical Therapy at when using 25310 with 25447. Washington University for 21 years, providing annual community edu- In summary: when performing a cation programs at Practical Anatomy Lab of St. Louis University for 11 CMC resection arthroplasty proce- years, Comprehensive Review of Hand Therapy lectures (ASHT) in 1995 dure that uses a tendon to function and 2000. Lecture “Regaining ROM s/p Partial Wrist Fusion” ASHT as an interpositional graft, it is 1993, Lecture “Treatment of RSD” for MO PT Assoc. and MO Academy probably your best option to code of Family Physicians 1992, Lectures “Rehabilitation of Hand Injuries” 25447 with 25310 (and the -59 mod- NC PT Assoc. 1983. ifier), although 26480 (or 26485 if Hand Surgery Clinical Specialties: Trauma, arthritis, brachial plexus injuries. Quarterly you use a palmarly based tendon Greatest Challenge: graft) can also be used with 25447. Being flexible on a daily basis. To continue to pro- ..... I hope this helps clarify coding for vide care in therapist owned settings, we continually have to change the way we see and do things. Billing, marketing, scheduling, and patient Spring this procedure. H care are frequently being modified to reflect to latest in reimbursements 2004 issues and treatment options. We must think in small detail and in a global sense in the same thought. Three Words That Describe Me: Lucky, grateful, welcome a challenge. H 21 THE DIGITAL HAND SURGEON

Benefits of drawing hands on Build a library of reusable images. Draw Your Own your computer This is a huge benefit. Once you’ve assembled a few templates of anato- Really understand what you are Conclusions: my, you can dip back into the col- doing. If you can’t draw the anato- lection to create new images with my, it may be because you don’t Creating Hand very little effort. Vector graphic file really know the anatomy. That was format is perfect for this (Figure 3). Images On Your the point of drawing the brachial plexus. It’s an interesting and often Computer humbling experience to compare what you’ve drawn to pictures of the real thing—you learn some- t some point on the thing every time. road to becoming hand surgeons, It’s fault tolerant. Drawing pro- we’ve all been grams let you choose and tweak the appearance of what you draw, Agiven the task of Figure 3. Herbert screw 3D modelled in producing pictures for oth- but more importantly, let you Hamapatch, rendered in Truespace. ers, as a performance. It undo, redo and modify what you’ve already done—like a word starts in residency: lectures, Augment your practice. Once you handouts, and as part of processor. CHARLES EATON MD have images you’re happy with, our studies. I still have this It looks better. Again, like the out- you’ll find many uses for them in nightmare in which I’m about to be put of a word processor, the final your practice. You can use your arrested, but the policeman offers document not only looks better, but handiwork in brochures for paper and pencil, saying, “I might usually is more understandable patients, on your web site, in your be able to let this go if you could than a handwritten note. powerpoint presentations, as logos just... draw the brachial plexus for Gain unique insights. Something for your office, and more. me....” Yikes! No, not just for exams, special happens when you create a drawing of what you’ve done or Where to start? what you plan to do, especially In many ways, it’s all about the soft- when you see the flaws in what ware. Graphics software can be very you initially thought was correct. expensive, but are many free-to- Also, there are certain anatomic under-$200 programs which are relationships which are only appar- powerful enough to serve the pur- ent in when multiple images are poses listed above. But before get- compared by overlay, animation or ting started on software, let’s review a 3D view (Figure 1). the terrain of the computer graphic Plan new operations. Preoperative world. Programs are often task ori- planning can be both simplified ented: like surgical specialists, they and enhanced by either drawing or may perform certain operations, but electronically manipulating digital not others. Here are some of the ter- images. Preoperative planning of minologies and categories of opera- Figure 1. Screenshot of phalangeal skeletal model drawn in flaps and osteotomies are particu- tions that a particular program may Hamapatch. larly suited to this (Figure 2). or may not handle. but in everyday practice, hand Bitmap vs.Vector. This is analogous Hand Surgery surgery is an intensely visual spe- to the difference between digital Quarterly cialty. Most of us have personal and analog. Most graphics pro- ..... image archives of unusual hand grams are either better at, or anatomy or injury—but visual doc- exclusively handle only one of Spring uments have potential applications these formats. Bitmap images are 2004 vastly beyond this. You owe it to a collection of dots. Images yourself to spend a little time draw- obtained by a digital camera, a ing hands on your computer. Here’s scanner, FAX machine, or indi- why: vidual frames of a video are 22 bitmap images. Your web brows- Figure 2. Preop external fixation planning. er shows JPEG and GIF images— Modelled in Poser, annotated in Paint Shop Pro. these are bitmaps. They may be from different angles, and paint- which comes with a library of enhanced or added to in a paint or ed (“rendered”). 3D models are all human figure models and 3D photo editing program, but the vector-based, but can export hand models with individual fundamental content is fixed. scenes to individual bitmaps or controls for Enlarge them and they become animations. Most 3D programs positioning blocky (“pixelated”); shrink them are capable of animating and of every digi- and you permanently lose detail. tweening. tal joint! It The dots remain static dots, dis- Realtime vs. Scripted. The user produces ani- crete, digital. Vector images are friendly image construction pro- mations with not dots, but shapes created the grams are “what you see is what tweening and same way that mathematical you get”. But remember, you’re will render to curves are defined by equations. not painting with a paintbrush, look like a Vector images can be resized you’re giving a computer instruc- Figure 4. Small sample of cartoon, without losing detail, and can be tions. Some older or high end Poser rendering options. wireframe, easily modified. Vector shapes CAD and rendering programs pencil sketch, are drawn by moving the control operate from a set of instructions realistic texture and others with points (“handles”) which define that you provide. These are not great flexibility (Figure 4). the position and angle of lines for the casual user. Paint Shop Pro (http://www.jasc. (called “splines”). Those slick Structural vs. Organic. Structural com) is primarily a 2D bitmap Flash animations on your web programs, such as CAD drawing drawing program with some browser are vector graphics. programs are geared toward pro- vector based tools. Comparable Modeling vs. Rendering. Drawing ducing diagrams and pictures of to the Adobe line but less expen- (modeling) programs create and machinery, buildings, or land- sive, it handles a variety of file modify the content. Rendering scapes—inorganic structures. formats (Figure 5). programs start with a vector for- Organic drawing mat model and flesh it out with a programs are more choice of surface textures, light- suited to drawing ing effects and backgrounds to cartoons—and create a final image. hands. Static vs. Animated. Some pro- grams can be used both to create Programs an image and make an anima- tion. Animations can be made OK, enough about from a series of bitmap images, the lingo, show me starting with one image per the stuff! Here are the frame, which is fairly labor core programs that I intensive. Animating from vector have found useful to formats is much easier, using a make images and ani- process called “tweening”. With mations of hands for tweening, you create a picture, my office, the web, Figure 5. Paint Shop Pro handles a wide variety of file formats. label it as the first frame of an powerpoint, and just animation, then modify it and to help me figure label it as the last frame, and the things out for myself. Most of these Hamapatch (http://www.geoci- computer creates all of the frames are not mainstream—I use them ties.com/hamapatch/pro- in between. Cool! Because of because they do what I want. There gram/#dl) is a free, powerful 3D shortcuts such as this, vector are many, many more out there. static organic modelling pro- image formats are used to create gram with some rendering capa- essentially all commercially pro- Arts and Letters Express (www. bility. It’s a great program to cre- duced animations, including arts-letters.com) is a 2D, vector ate 3D shapes which can then be computer generated movies, car- based, static image, organic fla- imported into other animating or Hand Surgery Quarterly toons, video games, and Flash vored program geared to car- rendering programs (Figure 1)...... animations. tooning. I started using it 10 Moho (http://www.lostmarble. 2D vs. 3D. A 2D program treats the years ago because it came with com) is an inexpensive 2D vector Spring computer screen like a canvas, nice anatomy clip art including cartoon animation program 2004 viewed from one angle—the pic- the hand. Excellent tool to draw which can export to flash anima- ture is the canvas. 3D programs for web or print publication. tions. work with models: three dimen- Poser (http://www.curiouslabs. sional surfaces which can be com) is a 3D organic program continued on page 24 23 independently moved, viewed AAHS Calendar

THE DIGITAL HAND 2004 July 15–17, 2005 September 7–9, 2006 Mid-Year Board of American Society for continued from page 23 May 21–23, 2004 Directors’ Meeting Surgery of the Hand – Work Related Disorders The Lodge & Spa at 61st Annual Meeting of the Upper Extremity Truespace is a powerful 3D Cordillera Washington, DC Wyndham Chicago Edwards, CO rendering and animating Chicago, IL program (Figure 3). September 22-24, 2005 2007 Version two is available July 9–11, 2004 American Society for January 10–13, 2007 free at http://www.jlstsi. Mid-Year Board of Surgery of the Hand – 37th Annual Meeting Directors’ Meeting 60th Annual Meeting com/download/trueSpace The Westin Rio Mar St. Regis Monarch Beach San Antonio, TX 2.zip. Resort Beach Resort Flash (http://www.macro Dana Point, CA Rio Grande, Puerto media.com) is a versatile 2006 Rico 2D vector animation cre- September 9–11, 2004 January 11–14, 2006 ation program which is the American Society for 36th Annual Meeting Surgery of the Hand – 2008 industry standard for web Loews Ventana Canyon 59th Annual Meeting January 9-12, 2008 animations. Two problems: Resort New York, NY Tucson, AZ 38th Annual Meeting a fairly steep learning The Westin Century curve, and a $500 price 2005 July 14–16, 2006 Plaza Hotel & Spa tag. Options: get it or get Mid-Year Board of Beverly Hills, CA programs which export to January 12–15, 2005 Directors’ Meeting 35th Annual Meeting it, such as Moho. The Broadmoor Hotel Sanibel Harbor Resort Colorado Springs, CO Sanibel Island, FL So. There’s no excuse. Start drawing hands! H For information contact: AAHS Central Office at 312-236-3307 or www.handsurgery.org

PRSRT STD U.S. Postage PAID Documation

www.handsurgery.org 20 North Michigan, Suite 700 Chicago, IL 60602 Inside This Issue: 1 2004 Annual Meeting In Review 3 From the President 5 Leadership Profile: N. Bradly Meland, MD 9 Hand Therapy & Affiliates’ Corner 10 Hand Surgery Endowment Update 11 Around the Hand Table: Hand Problems of the Performing Artist 20 Coding Corner 21 Hand Therapy Profile 22 The Digital Hand Surgeon