www.ifssh.info VOLUME 4 ISSUE 3 AUGUST 2014 ezine Journal highlights Executive news Member society updates ifsshCONNECTING OUR GLOBAL HAND SURGERY FAMILY
Mallet Fingers Around the Globe: Mobilisation
DEGENERATIVE ARTHRITIS: PROPHYLAXIS GUIDELINES FOR VTE DISTAL RADIOULNAR JOINT FOLLOWING UPPER LIMB SURGERY NEW SUBSCRIBERS: Take 20% off
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046 JWS Ad IFSSH.indd 1 23.04.2014 12:43:27 August 2014
Contents
4 Editorial 38 Pioneer profiles By Professor Michael Tonkin, deputy editor of • Jenó Manninger the IFSSH ezine • Kenya Tsuge Obituaries: Nils Carstam, Judy Bell-Kratoski 40 Journal highlights 8 Share section Tables of Content from leading journals such as The Journal of Wrist Surgery, The American Journal of Hand Surgery, Journal of Hand Surgery Asian Volume, 9 VTE survey Journal of Hand Surgery European Volume and the Journal of Hand Therapy. 10 Member society updates • Brazilian Society for Hand Surgery 44 Upcoming events • Asociación Boliviana de Cirugía de la Mano List of global learning events and conferences for • The Australian Hand Surgery Society hand surgeons and therapists 12 Committee reports • IFSSH Scientifi c Committee on Degenerative Arthritis – Distal Radioulnar Joint (part 1) • IFSSH Scientifi c Committee on Musician’s Hand 26 Hand therapy Mallet Fingers Around the Globe: Does One Best About the front cover Method for Immobilisation and Mobilisation Exist? This historical photo was taken at the founding meeting of the Part II: Mobilisation IFSSH in Chicago, USA, 21 January 1966. The original eight founding Societies of the IFSSH were 35 Research roundup represented by the following Delegates (from left to right): A • A review of prophylaxis guidelines for venous Bonola (Italy); T Morotomi (Japan); A Barsky (USA); G Stack (UK); N thromboembolism following upper limb surgery Carstam (Scandinavia-Sweden); D Buck-Gramcko (Germany); A • The application of DASH and the QuickDASH Pernet (Brazil); R Tubiana (France) instruments in Norway Photo courtesy of Dr Sergio Gama (Brazil)
IFSSH ezine AUGUST 2014 3 editorial
IFSSH Pioneers of Hand Surgery
Traditionally during the Congresses of purpose of this presentation. In its early years, the IFSSH recognised the International Federation of Societies The Council of the International “Giants of Hand Surgery”, those who for Surgery of the Hand, a number Federation of Societies for Surgery of have been drawn from past literature. of “Pioneers of Hand Surgery” are the Hand has reviewed and discussed Subsequently, Pioneers have been acknowledged. This is a long standing a list of these important persons, and honoured for their contributions, custom which dates back to the 3rd takes great pleasure in presenting largely from the time of the mid-1940s. Congress in Tokyo held in 1986. them to you at this time. To recognise However, Sterling Bunnell is not an To date, 142 physicians have been a Pioneer for his great contributions is IFSSH Pioneer but is listed as a Giant of granted the honour of becoming a enriching to all of us. Hand Surgery, which he certainly was. “Pioneer of Hand Surgery”. The Federation considers it most Many of our national societies are born The enormous contribution of the appropriate that offi cial praise and of more recent times. A continuation of Pioneers to Hand Surgery will infl uence commendation be extended to our awarding the title of “Pioneer” of Hand many generations of Hand Surgeons Pioneers in grateful recognition of their Surgery has raised some comment. to come. Ultimately of course, their truly exemplary record of contributions Some suggest that the terminology accomplishments will benefi t countless to the fi eld of Hand Surgery and to of our Pioneers award should now patients far into the future. people everywhere. This occasion be changed to a term which refl ects The words of Alfred Swanson, at provides us an opportunity to recognise signifi cant contributions to a fi eld of his acknowledgement of the Pioneers those who have come before us, and surgery which is well-established rather of Hand Surgery announced at the particularly, these gentlemen who than in its pioneering days. However, 5th international congress in Paris in by their wealth of discoveries and after consideration, the IFSSH Executive 1992, elegantly describe the purposes advances in Hand Surgery have so Committee has decided that the of this award: vastly improved the lives of thousands term “Pioneer” remains appropriate, “The knowledge of this specialty of persons the world over.” given both the disparate degree of is relatively new in the world and Alfred Swanson’s words in 1992 the sophistication of hand surgery has reached development and refl ect the timing of development of in diff erent countries throughout dissemination through the work and Hand Surgery as a sub-specialty. The the world and because more recent contributions of many great individuals. American Society for Surgery of the advances in hand surgery may continue Appropriate recognition of these Hand (ASSH) was established in 1946 to be appropriately considered as of a persons is diffi cult. Recognising those following the eff orts of Sterling Bunnell pioneering nature. living persons who have spent their and colleagues to provide services for Another important question is how lives to further our specialty is the those injured in the Second World War. to decide whether the contributions
IFSSH disclaimer: The IFSSH ezine is the offi cial IFSSH ezine editorial team: mouthpiece of the International Federation of Societies Editor: Professor Ulrich Mennen (Immediate Past President of the IFSSH) for Surgery of the Hand. The IFSSH does not endorse Deputy Editor: Professor Michael Tonkin the commercial advertising in this publication, nor the (President of the IFSSH) SUBSCRIBE TO THE content or views of the contributors to the publication. Publication coordinator: Subscription to the IFSSH ezine is free of charge and the Marita Kritzinger (Apex ezines) ezine ezine is distributed on a quarterly basis. To subscribe, Graphic Designer: Andy Garside please click here. Should you wish to support this ifssh publication through advertising, please click here. FOR FREE 4 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 5 editorial
of any particular person are worthy of “The continued recommendation from the national the award of IFSSH Pioneer of Hand recognition of those society (one page maximum); Surgery. I am sure that all would agree - the nominee’s curriculum vitae that if the criteria are too loose and the who have excelled (abbreviated - three pages award given too freely, then the worth in hand surgery is maximum); and of the award is diminished. Currently, to - the nominee’s photograph. be nominated as a Pioneer the person an important role of Nominations must be received must be at least 70 years of age or the IFSSH” by the secretariat at least six months deceased, must be a recognised leader before the Congress date. A nomination in hand surgery and have contributed should be supported by a vote at the signifi cantly to the development 5. Publication of chapters and/or books individual society annual meeting of Hand Surgery nationally and/or which made major contributions. and not be a proposal from an internationally. 6. Involvement in outreach programs individual or an Executive Committee. The nomination must come from of signifi cant importance. It is recommended that each society a society, not from an individual. The 7. Specifi c international contributions give careful consideration to its IFSSH Nominating Committee, chaired to promote hand surgery, such as responsibility when putting forward the by the Immediate Past-President involvement in Federation activities; nomination for consideration. The IFSSH of the Federation, is responsible for and involvement in regional Nominating Committee will assess the assessing the nominations and making activities. recommendations and advise the IFSSH a recommendation as to whether the 8. Specifi c contributions to promote Executive Committee of its decision. nominee is to receive a Pioneer award hand surgery nationally, such as I believe that the continued at the next IFSSH Congress. Society activities. recognition of those who have excelled Perhaps the guidelines provided 9. Visiting Professorships and in hand surgery is an important role of to our constituent societies are lack- invitations to lecture internationally. the IFSSH. In understanding, respecting ing in the detail necessary to assist the 10. Paper and poster presentations at and acknowledging our history, we societies in determining if a particular International Meetings. create the circumstances to establish person has excelled to an exceptional 11. Preparation of video programs for our future. level, beyond that which is normally teaching purposes. expected, and therefore is deserving of 12. Development of equipment Michael Tonkin the award of IFSSH Pioneer of Hand Sur- and processes for clinical use or President, IFSSH gery. As such, the Executive Committee academic programmes. has suggested that the following criteria Of course, this list is not exhaustive, should be assessed when considering a nor must each nominee have excelled possible Pioneer nomination: in all criteria. However, for the Com- 1. Exceptional ability to teach and mittee to recommend the award of train hand surgeons at registrar and “Pioneer of Hand Surgery”, the nominee fellowship level. must have made outstanding contribu- 2. Signifi cant contributions to basic tions in many of the above categories. hand surgery research. The Secretary-General will call for 3. Signifi cant contributions to clinical nominations from member societies at hand surgery research. least nine months before the date of the 4. Publications in peer reviewed triennial Congress. Nominations should journals which substantially add to be received in writing and include: our understanding of hand surgery. - a summary of the reasons for
4 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 5 obituary
Professor Nils Carstam 1913-2014
Professor Nils Carstam, Malmö, Sweden, Nils Carstam was provided a number passed away May 28 2014 at the age of of beds reserved for patients with 100 years. hand injuries at the General Hospital The founder of Department of in Malmö by the inventiveness of the Hand Surgery in Malmö, and one of the head of Department of Surgery, Helge internationally recognised pioneers in Wullf. By 1962 the fi rst independent Hand Surgery, Nils Carstam was a true Department of Hand Surgery in Sweden pioneer in the fi eld of Hand Surgery. He was founded in Malmö with Nils Carstam had the vision to initiate the organisation as the head. He was granted an associate of Hand Surgery in Malmö more than 60 professorship in Hand Surgery in 1954. years ago. A large number of patients in At his retirement 1979 he was given the southern part of Malmö have been a professorship in Hand Surgery and successfully treated by Professor Carstam he was awarded the title ”pioneer of and by the colleagues who were trained hand surgery” at the annual meeting of by him. International Federation of Societies for Nils Carstam was born in Växjö, Surgery of the Hand (IFSSH) in Paris 1992. Sweden September 13 1913 and got his Due to two important initiatives by medical degree and residency in Surgery Nils Carstam the speciality Hand Surgery in Lund, Sweden. During his early career was strengthened – Hand Surgery as a general surgeon, his interest in as its own speciality in 1969 and the in Louisville headed by Professor Harold Hand Surgery was sparked by having founding of the Swedish Society for Kleinert, was also an initiative by Nils to treat a large number of patients with Surgery of the Hand in 1973. In 1973 Carstam. injured hands caused by their work in Nils Carstam was also the president of During his leisure time Nils Carstam the glassware and furniture industries in the Scandinavian Society for Surgery showed, above his great interest and that region. Nils Carstam was aware of of the Hand (initially called The “Nordic knowledge in art, which was clearly the growing and extensive experience Club for Hand Surgery”). Nils Carstam revealed during his lecture at retirement, among the colleagues in USA of Hand had a rich and extended international also a very high skill in playing bridge, Surgery due to the large amount of hand network in Hand Surgery and he was an tennis and golf – activities that he injuries from the Second World War. honourary member of both the British continued in his later years. Colleagues Therefore, in 1950 he visited, together (BSSH) as well as the American Societies and the entire society for Hand Surgery with his mentor Professor Erik Moberg, for Surgery of the Hand (ASSH). In the in Sweden are grateful to Nils Carstam for the American Society for Surgery of the fi eld of Hand Surgery Nils Carstam all the work that he did for development Hand and attended a specifi c course was particularly interested in repair of our speciality. We remember him with in Hand Surgery, which was followed and reconstruction of injured hands, honour! by an extended visit to the “father of but he also put a large eff ort into the Göran Lundborg Hand Surgery”, Sterling Bunnel, in San treatment of Dupuytren´s contracture Professor emeritus Francisco. These events were fruitful and and congenital malformations of the crucial for the development of Hand hand. Exchange programmes with Lars B. Dahlin Surgery in Sweden. several international departments of Professor and President for the Swedish After the return from the USA 1951, Hand Surgery, e.g. with the Hand Center Society for Surgery of the Hand
6 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 7 obituary
Judy Bell-Krotoski 1945 – 2013
It is with sadness that the international working at the US Public Health Service hand rehabilitation community heard of in Carville, Louisiana and I was working the passing away of one of the pioneers at the US Public Health Service Hospital in hand therapy, Judy Bell-Krotoski. in San Francisco, California. Because I Judy was passionate about her job and was working with patients diagnosed made many valuable contributions with Hansen’s disease, I began talking to the body of knowledge of hand with Judy, by phone, about topics such therapy, both in the USA as well as as hand therapy, nerve compression, internationally. She will always be leprosy, and sensory testing using the remembered for her contribution in the Semmes-Weinstein Monofi laments. Judy fi eld of nerve injuries and sensory loss, was very helpful as our talks became especially the validation of Semmes- more frequent. I was sent by USPHS to Everything Judy did was done with Weinstein Monofi laments as objective travel to Carville to visit and learn on site, her total commitment and devotion test instruments to measure sensibility. how to treat and care for my patients to the task. Whether it was her work or She was one of six founder with Hansen’s disease. one of her many hobbies, she gave it members of the American Society of Judy was a champion of people she her full attention and results were near Hand Therapists (ASHT) and served as believed in, and of causes she believed perfection. Judy had so many interests, President of this Society in 1998. She in. She became well known for her work and would easily surprise me and others played an important role in laying the with sensibility testing of hands and with another ability that few would foundations for the publication of the upper extremities using the Semmes- know of her. Judy sang at her own Journal of Hand Therapy and served on Weinstein Monofi laments. She felt that wedding. She loved and grew orchids, the Editorial Board for 11 years. testing sensibility with monofi laments while at the same time maintaining Judy published more than 100 would give the healthcare professional her own horse ‘ranch’ which provided scientifi c articles and chapters in books an accurate sensibility map which would her with some horse race winners, and was one of the co-editors of the fi rst coincide with eff ects of medications especially one who won a race just a edition of Rehabilitation of the Hand and used to allow for improvements to few weeks before she passed away. Judy Upper Extremity. She was the author of individuals’ neuropathies. This would would search for rocks of semi-precious one or more chapters in all six editions of enable a healthcare professional to stones wherever she went with plans this prestigious publication. follow a patient’s progress as he/she to eventually polish them and make However, Judy was so much more than showed either improvement or decline jewellery. Judy was a devoted wife and a good researcher and clinician. She was a in nerve status. mother, in addition to being an excellent true friend and supportive colleague, as is Judy will always be remembered for clinician and researcher. illustrated by the words of one of her life- her steadfast devotion to reach as many It was an honour to know Judy as long hand therapy colleagues and close of the health professionals working well as I did. It was a total pleasure, as friend, Donna Breger-Stanton: with Hansen’s disease as possible. She well as an honour to be among Judy’s endeavoured to make them understand close friends. She was a mentor and My memories of Judy Bell-Krotoski and appreciate how a simple evaluation friend to me and I will never forget her I knew Judy Bell-Krotoski since about tool as the Semmes-Weinstein for all so many reasons. I miss her. 1979, soon after I joined the US Public Monofi laments can give information Corrianne van Velze Health Service (USPHS). Judy was otherwise potentially overlooked. Donna Breger-Stanton
6 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 7 Share
Share Section
The Exco of the IFSSH receives If you have anything which email to the Editor with your request occasional requests by individuals another Surgeon or Therapist may and a contact email address. or Hand Surgery Units for donations use in her/his practice, please off er it NB: The IFSSH ezine acts solely or fi nancial support to purchase by sending a short description of the as contact agent, and does not instruments, books, and various item(s) to the Editor([email protected]), take any responsibility for any equipment needed to practise their as well as a contact email address. exchanged goods. The actual trade as fellow Hand Surgeons and If you are in need of a specifi c item, exchange and arrangements are the Therapists. you are also welcome to send a short full responsibility of the two parties Many of our members have involved. surplus instruments and other such items which could be of use to those in less fortunate circumstances. The IFSSH ezine would like to dedicate a ‘Share Section’ in every issue to facilitate contact between those seeking support and those looking for recipients of their surplus.
8 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 9 survey
Tell us: How do you treat VTE? Venous thromboembolism (VTE) after hand and wrist surgery has only been reported twice in the literature. That might be because the conditions are rare; it might be because it is encountered but the surgeon has not considered it worthy of a case report; it might have been reported but the Editor felt it was not of relevance. Please spend a few moments of your time on this anonymous online survey to see whether the incidence is higher than previously thought. We might also be able to detect regional diff erences through the international hand community. Thank you for taking part in our survey! CLICK HERE
8 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 9 member society updates
Member society updates
Brazilian Society of Hand Surgery
The Brazilian Society of Hand Surgery was founded in Rio de Janeiro on June 17 1959 and in 1985, SBCM moved its headquarters to São Paulo. In 1966, in Chicago, the SBCM, represented by Alipio Pernet, participated in the foundation of the International Federation of Societies for Surgery of the Hand. The fi rst Brazilian Meeting for Hand Surgery was held in 1967, in São Paulo. For several years, world experts It is held until today. The webinar is Asociación Boliviana de in Hand Surgery participated in the presented in Portuguese and access is Cirugía de la Mano Brazilian Meeting, such as Moberg, free for surgeons. Starck, O’Brien, Vainio, Pulvertaft, Boyes, In 2013, the Journal HAND The Asociación Boliviana de Cirugía de Wakefi eld, Tubiana, Kleinert, Bora, becomes a scientifi c publishing la Mano (ABOCIMA) was founded in Swanson, Barton, Omer, Burkhalter, partner of SBCM. In 2014, the SBCM 1997. In 2013, ABOCIMA was admitted Gilbert, Steichen, Taleisnik, McFarlane, completes 55 years of existence. We to membership of the International Manske and Green. are currently just over 500 members, Federation of Societies for Surgery of On November 22, 1992, SBCM distributed throughout Brazil. The 34th the Hand (IFSSH), with the support participated in the founding of Meeting of Brazilian Society for Hand of IFSSH member nations such as the South American Federation for Surgery was realised in March 27-29, in Argentina. The scientifi c activities of Hand Surgery. In 1999, MANUS was the city of Maceio. 570 attendants took ABOCIMA include: launched. This informative newspaper part with intense participation in the ● 1st PRACTICAL COURSE IN is still published today in 2002, the Scientifi c Programme. MICROSURGERY medical residency in Hand Surgery in The following photo shows a 15-20 November, 1993; Santa Cruz Brazil became a 2-year residency. debate by participants during a de la Sierra, Bolivia. From 2004 to 2007, Dr Pardini session in 34th Meeting of Brazilian ● 2nd PRACTICAL COURSE IN chaired IFSSH. In 2005, the ‘Club of Society for Hand Surgery. MICROSURGERY the Hand Online’ programme of Thank You 24-26 March, 1994; Santa Cruz de la continuing education was started. Carlos Henrique Fernandes Sierra, Bolivia. General Secretary of Brazilian ● 1st INTERNATIONAL SYMPOSIUM Society for Hand Surgery OF HAND AND UPPER LIMB Brazilian Society for Hand Surgery SURGERY [email protected] 6-8 March, 1996; Santa Cruz de la www.cirurgiadamao.org.br Sierra, Bolivia.
10 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 11 member society updates
The Australian Hand at Singapore General Hospital was Surgery Society represented by Dr Bien Keen Tan, and the other guest speaker was Dr Filip Every even year, the AHSS contributes Stilleart from Ghent in Belgium, who to the Royal Australasian College of was the visiting Professor in the Plastic surgeons meeting, and every odd year Surgery Section. the AHSS contributes to the Australian There was a key note presentation ● 1st INTERNATIONAL COURSE OF Orthopaedic Association Annual from Professor Michael Tonkin, who SURGERY OF THE HAND AND Scientifi c meeting. This year therefore the is an AHSS member and currently UPPER LIMB AHSS contributed to the RACS meeting. President of the IFSSH. 20-22 March, 1997; Santa Cruz de la The RACS Annual Scientifi c Our guest Professor, Jagdeep Sierra, Bolivia. Congress was held in Singapore at the Nanchahal, gave excellent ● INTERNATIONAL SYMPOSIUM Marina Bay Sands Convention Centre presentations on the science behind AND MEETING OF EXPERTS form Monday May 5th to Friday May fracture healing, and a master class on IN HAND AND UPPER LIMB 9th 2014. The Hand Surgery Section hand trauma reconstruction. He also SURGERY was conducted over the Thursday and presented a fascinating insight in to 23-25 March, 2011; Santa Cruz de la Friday of the congress. his research relating to the aetiology Sierra, Bolivia. The visiting speaker for the Hand of Dupuytren’s Disease. Over all there ● 1st ZANCOLLI COURSE and Surgery Section was Professor Jagdeep were 8 sessions or key note lectures, 1st BOLIVIAN-SPANISH Nanchahal, who was Professor of with over 20 papers presented. INTERNATIONAL SYMPOSIUM Hand, Plastic, and Reconstructive The formal Hand Surgery Sections ON ORTHOPAEDICS AND Surgery, at the Kennedy Institute of dinner was held in combination with TRAUMATOLOGY Rheumatology, at Oxford University in the Plastic Surgery and Burns Surgery 28-30 March, 2012; Santa Cruz de la the United Kingdom. Department at the Fullerton Hotel on Sierra, Bolivia. This year the congress was run the Wednesday evening. The entire concurrently with the Australian and meeting was well attended by AHSS ABOCIMA DIRECTORS: 2012-2014 New Zealand College of Anaesthetists members. Dr. Juan Carlos Suárez López Annual Scientifi c Meeting. This off ered Dr D Stabler PRESIDENT opportunities for numerous combined President Dr. Alfonso Soria Galvarro Bort academic sessions across the various The Australian Hand Surgery Society VICE-PRESIDENT specialty groups. Dr. Julio Cesar Irigoyen Suárez There were combined sessions with SECRETARY GENERAL the Burns Surgery, Trauma Surgery, Dr. Kenyi Nitabara Koga and Military Surgery Sections. There SECRETARY: TREASURER were combined sessions with Pain Dr. Jorge Arredondo Saucedo Medicine of the RACS, and the Chronic SECRETARY: MINUTES Pain Group from the College of Dr. Eduardo Omar Lizarazu Jaldin VOCAL Anaesthetists. Dr. Juan Carlos Mendieta Rojas VOCAL The Burn Surgery Department
10 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 11 committee reports
IFSSH Scientific Committee on Degenerative Arthritis – Distal Radioulnar Joint Chair: Luis R. Scheker (USA), Committee: Chris Milner (United Kingdom), Ilse Degreef (Belgium), Gregory I. Bain (Australia), Eduardo R. Zancolli III (Argentina), Richard A. Berger (USA) Report submitted April 2014 Part 1: Overview of Degenerative Arthritis – Distal Radioulnar Joint
Introduction DRUJ. This is followed by an evaluation of the individual. Therefore, the health Disease of the distal radioulnar joint of how OA impacts the DRUJ. Part 2 and function of the joint is dependent (DRUJ) has challenged the medical includes a history of how DRUJ OA has upon its correct initial formation during profession for centuries and has been surgically addressed and details embryogenesis, maintenance during been approached through a diverse current techniques including how use and repair after injury. The structure spectrum of medical and operative these can help in the salvage situation of articular cartilage refl ects these strategies. Where for decades, the following DRUJ ablation. requirements and consists of highly mainstay of treatment for advanced specialised articular chondrocytes DRUJ pathology has taken the form Articular Cartilage and embedded within a tightly regulated of distal ulna ablation, the modern Degenerative Joint Disease extracellular matrix (ECM) scaff old era of advanced biomaterials has now Structure, Function and the of collagen and ground substance. coupled with new insights into the Pathobiology of Osteoarthritis Through the careful arrangement structure and function of the DRUJ to Articular (hyaline) cartilage is a of structural collagen types II and IX culminate in a complete repertoire 2-4mm thick white layer of highly around the extremely hygroscopic of techniques to eff ectively address specialised tissue that forms the aggrecan-containing ground substance, DRUJ pathology in all its forms, without interfacing surface between bones that articular cartilage is able to maintain a sacrifi cing its essential role in hand articulate within diarthrodial synovial very smooth surface at the joint line in function. joints1. The functional requirement of conjunction with structural resilience This review has been compiled articular cartilage is to withstand and to applied loads. The synovial fl uid by an international panel of hand effi ciently transmit load across the joint contains lubricin and hyaluronan (HA) surgeons, all with extensive expertise in under both static conditions and during that both minimise frictional resistance treating DRUJ pathology even though movement of the joint surfaces during and also deliver oxygen and nutrients collectively they have a broad range of articulation. Successful dynamic load to the isolated but metabolically opinion on the subject. Part 1 begins by transfer requires the articular cartilage active synoviocytes locked within the summarising the latest ideas regarding to maintain a very low frictional cartilage matrix. Finally, the highly osteoarthritic joint degeneration and its coeffi cient even where local pressures vascular synovium controls synovial medical management, before looking reach high levels and this role must be fl uid composition and plays an essential at the structure and function of the maintained throughout the lifespan role in cartilage homeostasis and repair
12 IFSSH ezine AUGUST 2014 committee reports
following injury 2. “The DRUJ forms wear every time the joint is moved Traditional descriptions of OA classify the distal half of that exacerbates the damage and the disease into either primary or potentiates the infl ammatory stimulus. secondary types. Primary OA develops the bicondylar In addition to ineff ective remodelling in previously intact joints with no articulation between of the ECM, articular chondrocytes obvious cause, whilst secondary OA the forearm bones also calcify the remaining cartilage follows a defi ned pre-disposition such in keeping with their hypertrophic as trauma, septic arthritis, joint instability that, in association phenotype, and this thins the overall or other identifi ed syndromes with with the proximal depth of articular surface covering the recognised joint involvement. However, component, provides subchondral bone. The subchondral these distinctions have increasingly bone also alters, undergoing sclerosis, lost their simplicity as evidence for up to 150 degrees of with peri-articular osteophyte formation now demonstrates an inextricable pronosupination of the and reduced overall mineralisation. interdependence between cause forearm” This results in a weakened foundation and eff ect in what is considered to for the overlying articular cartilage be a multifactorial disorder involving with possible direct injury to the that unfortunately occurs right below interplay between genetic and cartilage itself, produces a phenotypic areas of greatest applied joint surface environmental components 3-5. switch in the resident chondrocytes load 4. These osseous changes refl ect Regardless of what initiates from their quiescent state to that of the typical bone oedema seen on MRI the cartilage damage in OA, a hypertrophic calcifying chondrocytes, scanning of subchondral bone in joints pathophysiological vicious circle of normally only seen during aff ected by OA. progressive cartilage damage and embryogenesis of bone 10. These ineff ective repair is triggered that changes are induced in response to Epidemiology and the worldwide ultimately leads to the typical signs circulating cytokines including IL-1β and burden of OA and symptoms of OA. There is now no TNF and are central to the pathological Osteoarthritis (OA) is the most common doubt that infl ammation has a central destruction of the articular matrix form of arthritis and ranks amongst the role in driving this destructive process6. through their expression of bone-related top three causes of disability in the USA This evidence comes from numerous MMPs 3, 9 and especially 13 3. Despite the 12,13. OA is increasingly prevalent in older angles of investigation that demonstrate ECM destruction, articular chondrocytes age, with a female preponderance that a physiological inter-dependence of all attempt repair by synthesising new is typically more severe, with hand and joint tissues including the synovium, ECM components, but these fail to knee involvement seen more frequently subchondral bone, support ligaments, distribute and assemble correctly 11. At a when compared to disease in male muscle and the articular cartilage itself macroscopic level, the accelerated and patients. OA is a heritable condition, 2,4,6-8. Infl ammatory joint synovitis in early- disorganised ECM remodelling process varying by site and with an inherited stage OA demonstrates hyperplasia, results in swelling and microscopic component of between 50 and 65% 14,15. cellular infi ltration, vasculogenesis and surface roughening of the cartilage Familial studies have revealed higher fi brosis 2,7. The associated endothelial surface known as fi brillation that is rates of OA in monozygotic versus activation allows both the loss of associated with a reduction in gliding dizygotic twins and it is more common lubricating HA and lubricin molecules properties 11. Clinically, this is refl ected in fi rst degree relatives and siblings and ingress of infl ammatory cells and in the loss of sheen of healthy articular of aff ected individuals than in the complement in the joint space, bathing cartilage when viewed through an general population 16. Racial patterns the articular surface in hostile factors arthroscope or by the naked eye. of susceptibility also exist with high instead of the nutritive properties of Fibrillation renders the joint susceptible rates of hand and hip OA in Caucasian normal synovial fl uid 9. This, together to further friction-induced surface populations as compared to people
IFSSH ezine AUGUST 2014 13 committee reports
of Asian descent, whereas the reverse “More advanced attempts at arresting the pathological holds true for knee arthritis. disease process. Therefore, whilst At the population level, 12.1% of joint destruction can there are tried and tested techniques the US population were shown to have mirror some features of pain management, the inexorable clinically apparent OA in at least one characteristic of progression of joint damage in OA is joint, giving a fi gure of 26.9 million often addressed through surgical joint from population census fi gures for rheumatoid arthritis reconstruction and the expansion in 2005 12. If this fi gure is extrapolated at the DRUJ, with volar the arthroplasty industry refl ects this. forward to indicate the proportion of subluxation of the radius.” The current paradigm for non-surgical the US population with OA in 2013 management in OA in general is it rises to 28.8 million (data from US therefore to address pain and optimise Census Bureau). Assuming similar For OA specifi c to the hand, the joint function such that the morbidity prevalence rates throughout the world, prevalence was found to be 27.2% of the disease can be reduced to a this gives a worldwide fi gure of 648.8 overall in the Framingham study of 2400 minimum for the longest period of million people with OA, and given participants of age 26 or greater, rising time possible before surgery becomes the high immigrant representation to over 80% in older individuals (with unavoidable. within the US population, this estimate values considerably lower than this In general terms, preservation of of world OA burden may not be an found in another study which identifi ed joint function is achieved through a entirely unreasonable one. Despite symptomatic OA in patients over 60 years combination of physical therapy, patient increasing incidence by age, there of age to be only 8%) 12,20. Extrapolating education, and pain control 22. For is still a signifi cant proportion of these values for hand OA to a national pharmacological pain management individuals aff ected by OA who are of level, Lawrence et al estimated the in mild to moderate OA, there is a working age and several studies have prevalence of symptomatic OA to be in major reliance on simple drugs such as examined the socio-economic impact excess of 13 million people in the USA acetaminophen and NSAIDS. Opioid associated with loss of productivity based on population statistics for 2005. drugs are useful in moderate to severe secondary to symptomatic OA 13,17,18. OA fi gures specifi c to the DRUJ are harder OA pain but again bring their own Using the 2009 National Health and to evaluate, as there are few studies side eff ects including constipation Wellness Survey, DiBonaventura found that provide epidemiological data that and possible dependence. In patients that workers with symptomatic OA includes disease in this joint. Nevertheless, who eventually fail to obtain durable were more likely to be older, female in a cross-sectional study of ulnar sided pain control from these analgesics, and with a higher BMI, and there was wrist pain, Katayama et al found 12.3% of temporary joint splintage and intra- also a signifi cantly higher usage of 1128 patients had radiographic evidence articular or oral steroid therapy can healthcare resources, including medical of primary OA of the DRUJ 21. Due to the bring eff ective symptom control. Such costs 1.5 times higher than those selective nature of subjects included in patients frequently undergo serial associated in workers without OA. OA this study, it is impossible to relate DRUJ steroid administration in an attempt to has also been shown to develop in OA to overall rates of hand or total OA at a stave off surgery for as long as possible. younger age groups who are involved population level. Other attempts to improve joint in heavy manual labour, with other function and pain control have seen studies estimating up to 12% of Current Approaches to Medical some success through the intra-articular symptomatic OA following trauma Treatment of Osteoarthritis injection of HA, especially in its highly when considering disease of the hip, Unlike the revolutionary development cross-linked form. Nevertheless, HA is knee or ankle. This is associated with a of disease modifying drugs available expensive and has not been shown to potential healthcare bill of 0.15% of the for rheumatoid arthritis (RA), OA arrest disease progression or attain a total health care cost per annum 18,19. remains frustratingly elusive to similar clear advantage for symptom control
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over NSAIDS. Likewise, Glucosamine joint administration and secondary this. The ulna is relatively straight in and Chondroitin sulphate have been expression of unwanted phenotypic shape and, through its articulation purported to have a benefi cial eff ect behaviour such as bone formation. with the humerus, provides fl exion and on symptomatic OA but their benefi cial There are also concerns over the extension of the elbow by virtue of the eff ect has yet to be conclusively generation and /or potentiation of insertion of the brachialis distal to the demonstrated in clinical trials. neoplastic cell growth and disease coronoid process of the ulna and the The use of biological disease transmission during the in-vitro cell triceps insertion into the olecranon. In modifying drugs (DMDs) that have processing stages prior to clinical use. contrast to the ulna, the radius has a been so eff ective in RA have so far curved “S” profi le, with a broad funnel- shown mixed results in OA despite Osteoarthritis shaped distal end composed mainly of the core infl ammatory process at the cancellous bone that is responsible for heart of both disease processes 6. The and the Distal accepting axial load and transferring mixed results seen with anti-TNF and it through its shaft towards the radial anti-Il-1 drugs may due to the small Radioulnar Joint head and capitellum. The radius is number of existing human studies, attached to the ulna by the annular compounded by the diverse modes of Basic Anatomy and Function of the ligament proximally and the triangular drug administration used. Ongoing trials DRUJ fi brocartilage complex (TFCC) distally. in this area may hopefully replicate the The DRUJ forms the distal half of the At the DRUJ, the radius and ulna have positive results and defi nitive inhibition bicondylar articulation between the diff erential radii of curvature, making of joint deterioration conclusively seen forearm bones that, in association with this hemi-joint incongruent with only in animal studies. the proximal component, provides for a thin line of direct cartilage contact, Finally, there is increasing interest up to 150 degrees of pronosupination akin to the contact point of a car tyre in the use of mesenchymal stem cells of the forearm 25. This motion makes up to the road surface. This discrepancy (MSC) to treat OA. It is postulated a great proportion of hand functionality permits slight translation of the that the pluripotent nature of MSC and is essential for activities of daily radius in the antero-posterior plane make them well placed to counteract living. The diff erence between the DRUJ during pronation and supination as it the OA phenotype through down- and other bicondylar joints such as the rotates around the head of the ulna. regulation of the infl ammatory knee and the digital interphalangeal If the TFCC were tight enough to process, and restitution of the correct joints is that in the forearm, each bone prevent translation in neutral rotation, articular cartilage framework both has a condyle at one end. The proximal there would be no pronosupination through modulation of the behaviour condyle (radial head) of the radius possible. Indeed, much work has been of resident chondrocytes and direct articulates with the lesser sigmoid notch performed to understand the exact role ECM generation 23. Certainly, there or radial notch of the ulna. Distally, the of the deep and superfi cial fi bres of the is now clear in-vitro evidence for ulnar condyle (ulnar head) articulates distal radioulnar ligaments (DRUL) that chondrocyte behaviour control by MSC, with the radius at the sigmoid notch. regulate the tightly controlled transition and initial reports of its therapeutic use The two areas of contact between the from full pronation to full supination 25- in animals are encouraging. To date, radius and ulna form the radioulnar 27. As the sigmoid notch moves from full the very limited reports of MSC use in joint, with the proximal half known as supination to full pronation, its contact human OA have not demonstrated the proximal radioulnar joint (PRUJ) area with the seat of the ulna reduces successful reconstitution of lost while the distal half is the DRUJ. Both to as little as 10% of the available joint articular cartilage, but have reported halves move together, and pathologies surface in full pronation 28,29. symptomatic improvement 24. Concerns aff ecting one part will aff ect the other. In considering the part played by with MSC therapy include unwanted The radius and ulna have diff erent the interosseous membrane (IOM) in cell migration distant from the site of functions and their anatomy refl ects DRUJ stability, it is erroneously ascribed
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the function of axial load transfer the positions necessary for its work and, previously undergone ulnar head between the radius and ulna. As shown in so doing, has to handle two discreet removal during the Darrach or Sauve- by Skahen et al, the tension in the sets of forces acting upon it. Firstly, the Kapandji procedures 37. In these central band of the IOM during axial forearm must handle axial loads that experiments, painful impingement loading of the forearm is actually very pass principally through the radiocarpal of the ulnar stump against the radius little unless the radial head is excised, interface such as in hand grip or was easily reproduced when the indicating a major load transfer directly pushing against resistance such as in patient was asked to bear weight in the to the humerus via the capitellum of opening a door. Secondly, the hand and ipsilateral hand (Figure 1). Therefore, the radius 30,31. Rather, the two most any associated carried load must be in evaluating any existing or proposed important functions of the IOM are supported against the force of gravity new DRUJ reconstructive procedure, fi rstly to unify the radius and ulna into and this is the function of the ulna 28,33,34. it is essential to evaluate the lifting a single unit during full supination Whilst the biceps and brachioradialis capacity of the forearm before passing for the purposes of lifting; a situation have been described as having roles judgement on its success or otherwise. where the IOM is under tension and in forearm fl exion, biophysical studies Finally, if the supporting role of the thereby converts the radius and ulna have demonstrated that elbow ulna is appreciated, then the manner biomechanically into a single structure fl exion is principally the action of the of current reference to DRUJ instability that the biceps and brachialis can act brachialis muscle where it inserts into can become misleading. For example, in concert upon as pure elbow fl exors. the coronoid process of the ulna. The instability, subluxation and dislocation The other function of the IOM is that biceps is primarily a supinator until full of the DRUJ are typically defi ned on of preventing excessive bowing of supination is reached (see above) whilst the basis of the ulnar head placement the curved radius as seen in boxers brachioradialis cannot voluntarily be relative to the radius and radiocarpal like Frank Bruno, who could generate activated without simultaneous triceps joint. For example, if the ulnar head is 1420lb or 53g of acceleration to the activation and therefore acts principally prominent dorsally, it has traditionally head of their opponent 32. Whilst there as a modulator of elbow movement 35. If been referred to as “dorsal dislocation are additional stabilizing roles ascribed this is appreciated, then the importance of the ulna”. In reality, these positions of to the ECU tendon and subsheath, of the joint reaction force provided joint instability are brought into being ulnocarpal ligaments and pronator by the head of the ulna in supporting through gravitational forces acting on quadratus, the principal stabilising the hand and radius can be realised 36. the unsupported radiocarpal unit and structures at the DRUJ are the dorsal It was with the dynamic radiographic it is in fact, the ulna that is in the correct and volar distal radioulnar ligaments of studies performed by Lees and Scheker position. It is therefore the radius that the TFCC complex. that the loss of the supporting function has subluxed or dislocated. Functionally, the forearm has the of the ulnar head was emphatically In order for the forearm to important task of placing the hand in demonstrated in patients who had perform its functions correctly, all of
Figure 1: Dynamic lateral forearm radiograph demonstrating ulnar impingement upon the radius as it supports the carpus and hand against the force of gravity. Upper X-ray – conventionally acquired A-P view, lower X-ray – dynamic fi lm taken with the patient holding a weight against gravity. Note the wear pattern on the contact surface of the ulna from regular such impingement during activities of daily living.
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Figure 2: Demonstration of the ‘scallop sign’ in the sigmoid notch of the radius as seen in advanced osteoarthritis of the DRUJ. This X-ray was taken of a 16 year old patient with advanced DRUJ arthrosis following previous forearm fracture and multiple corrective surgeries.
its anatomical components must be maintained, and therefore it is essential to address and restore normal anatomy following fracture or ligamentous injury. wear, as seen in congenital DRUJ DRUJ dysfunction include arthrosis abnormalities such as the Madelung following infection and the instability Osteoarthritis at the DRUJ deformity, following direct articular associated with rheumatoid arthritis that Osteoarthritis can aff ect any synovial damage from distal radial fractures, fall outside the remit of this review. joint and the DRUJ is no exception. or after acute or longstanding loss of If early, treatable joint pathologies As in other areas of the body, DRUJ normal joint biomechanics through are not appropriately addressed, DRUJ OA develops from both primary and instability (For the purposes of the rest arthrosis can develop and manifests secondary causes. In addition to of this document, incongruence is clinically with pain on pronosupination the acquired abnormalities of ECM used in reference to pathological joint of the forearm, especially under load. component structure and function mechanics and not the physiological Assessing the functionality of the DRUJ discussed above, primary OA specifi c to incongruence of the curvatures of under such loadbearing conditions is the DRUJ is more common in females, the normal radioulnar interface at the easy and can be achieved by examiner- and is associated with positive ulnar DRUJ). Specifi c causes of instability placed pressure on the patient’s wrist variance 21,38. Secondary causes of DRUJ include direct TFCC component damage whilst the patient is asked to pronosu- OA are extensive but generally result (including Galeazzi fracture dislocations), pinate the forearm. This motion loads from either pathological incongruence distal radial malunion, and instability the DRUJ and will elicit pain if articular or instability at the DRUJ, and follow following radial head excision in the wear has developed 39. More advanced either direct or indirect trauma from Essex Lopresti injury. Other causes of OA of the DRUJ is associated with all fracture or injury to the soft tissue of the radiographic hallmark features stabilising structures, namely the distal of OA including osteophyte formation, radioulnar ligaments. Instability describes “Establishing the nature joint space narrowing and sclerosis the abnormal path of articular contact of DRUJ dysfunction in as well as the so-called scallop sign of that occurs either during or at the end sigmoid notch erosion originally de- of the range of motion and may follow symptomatic patients is an scribed in rheumatoid arthritis (Figure an alteration in joint surface congruence, essential task to perform 2) 40. More advanced joint destruction as well as defi ciencies in the controlling before embarking upon can mirror some features characteristic distal radioulnar ligaments that permit of rheumatoid arthritis at the DRUJ, with excessive movement and shear force treatment and this must in- volar subluxation of the radius. When across the joint. Incongruence at the clude an appreciation of the joint degeneration reaches this stage, DRUJ describes an alteration to the load-bearing role of the ulna, the extensor tendons frequently suff er precise point of contact between attrition-rupture over the prominent the joint surfaces that can produce be it a problem of incongru- ulnar head akin to that seen in Vaughan- unnatural joint loading and accelerated ence, instability or both.” Jackson syndrome 41-44. The functional
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signifi cance of DRUJ loadbearing and both. In our experience, the treatment on abnormalities within the diff erent the development of OA are of relevance plan should be tailored after assessing structures that make up the DRUJ 45. for two reasons. Firstly, as described the presence, direction and degree Group 1 includes ligamentous defects, above, there is a only a small point of of instability, the congruency of the group 2 has loss of ligamentous tension direct bony contact across the DRUJ DRUJ, and the ulnar variance. Pathology due to defi ciencies in intra-articular leading to locally high pressures exerted aff ecting any of these areas can result joint conformation, group 3 comprises on the articular cartilage. In addition, the in pain, decreased strength, limited a combination of ligamentous and movement of this bone contact through range of motion, and loss of forearm articular surface problems whilst group pronosupination generates high shear function. The following discussion 4 demonstrates ligamentous defi ciency forces across the joint as the radius will concentrate on the pathology with extra-articular problems, such as moves progressively into pronation or associated with DRUJ dysfunction that distal radius metaphyseal malunion. supination from neutral at which shear can lead to OA. Although the Bowers classifi cation force is zero. With so little direct contact Clinical DRUJ instability progresses system is useful for identifying DRUJ at an incongruent joint interface, the from dynamic to static in four stages. pathology, appropriate management is health and integrity of the DRUJ articu- In stage 1 (dynamic instability), the usually based on the stage of the disease, lar cartilage is heavily reliant upon the patient complains of a “giving away” not the initial pathology. Scheker, Ozer maintenance of correct joint alignment sensation with no obvious clinical or and Babb 46 have classifi ed the instability aff orded principally by the distal radio- radiographic sign 36. In stage 2 (secondary of the DRUJ as: ulnar ligaments of the TFCC complex, dynamic instability), the symptoms Stage 1: TFC attenuation. and to a lesser extent, the secondary are the same as in stage 1, but the Stage 2: TFC disruption (no DRUJ DRUJ stabilisers including the interosse- joint can be subluxed or dislocated. dislocation or distal radius fracture). ous membrane, ECU and subsheath and In stage 3 (static instability), limited Stage 3: TFC disruption, DRUJ pronator quadratus fi bres 26,29,38. motion and pain become prominent dislocation (no distal radius fracture). features. The joint rests in an unstable Stage 4: TFC disruption, DRUJ Clinical Aspects of DRUJ position, but can be reduced and plain dislocation, fracture (distal radius Degeneration radiographs demonstrate subluxation fracture, malunion) Establishing the nature of DRUJ and malalignment. In stage 4 (advanced Stage 5: Radial instability following dysfunction in symptomatic patients static instability), limited motion is ulnar head resection. is an essential task to perform before the predominant feature, and a fi xed embarking upon treatment and this deformity is established at the DRUJ, with must include an appreciation of the an increased risk of osteoarthritis. From load-bearing role of the ulna, be it a a pathological standpoint, Bowers has problem of incongruence, instability or identifi ed four types of instability based
References 1. Sophia Fox AJ, Bedi A, Rodeo SA. The basic Cartilage. 2007;15(10):1101-1105. proinfl ammatory cytokines in the science of articular cartilage: structure, 4. Lories RJ, Luyten FP. The bone-cartilage pathophysiology of osteoarthritis. Nat Rev composition, and function. Sports Health. unit in osteoarthritis. Nat Rev Rheumatol. Rheumatol. 2011;7(1):33-42. 2009;1(6):461-468. 2011;7(1):43-49. 7. Oehler S, Neureiter D, Meyer-Scholten 2. Scanzello CR, Goldring SR. The role of 5. Pitsillides AA, Beier F. Cartilage C, Aigner T. Subtyping of osteoarthritic synovitis in osteoarthritis pathogenesis. biology in osteoarthritis--lessons synoviopathy. Clin Exp Rheumatol. Bone. 2012;51(2):249-257. from developmental biology. Nat Rev 2002;20(5):633-640. 3. Li Y, Xu L, Olsen BR. Lessons from Rheumatol. 2011;7(11):654-663. 8. So A, Busso N. Osteoarthritis: Crystal- genetic forms of osteoarthritis for the 6. Kapoor M, Martel-Pelletier J, Lajeunesse gazing into the pathogenesis of pathogenesis of the disease. Osteoarthritis D, Pelletier JP, Fahmi H. Role of osteoarthritis. Nat Rev Rheumatol.
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2011;7(12):688-689. correlated with ulnar wrist osteoarthritis: Am. 2008;33(10):1853-1859. 9. Lotz MK, Kraus VB. New developments in a cross-sectional study. Skeletal Radiol. 36. Kleinman WB. Stability of the distal osteoarthritis. Posttraumatic osteoarthritis: 2013;42(9):1253-1258. radioulna joint: biomechanics, pathogenesis and pharmacological 22. Brandt KD. Non-surgical treatment of pathophysiology, physical diagnosis, and treatment options. Arthritis Res Ther. osteoarthritis: a half century of “advances”. restoration of function what we have 2010;12(3):211. Ann Rheum Dis. 2004;63(2):117-122. learned in 25 years. J Hand Surg Am. 10. Drissi H, Zuscik M, Rosier R, O’Keefe R. 23. van der Kraan PM. Stem cell therapy in 2007;32(7):1086-1106. Transcriptional regulation of chondrocyte osteoarthritis: a step too far? BioDrugs. 37. Lees V, Scheker, LR. The Radiological maturation: potential involvement of 2013;27(3):175-180. Demonstration of Dynamic Ulnar transcription factors in OA pathogenesis. 24. Pastides P, Chimutengwende-Gordon M, Impingement Journal of Hand Surgery Mol Aspects Med. 2005;26(3):169-179. Maff ulli N, Khan W. Stem cell therapy for European Volume. 1997;22B:448-450. 11. Heinegard D, Saxne T. The role of the human cartilage defects: a systematic 38. Zimmerman RM, Kim JM, Jupiter JB. cartilage matrix in osteoarthritis. Nat Rev review. Osteoarthritis Cartilage. Arthritis of the distal radioulnar joint: from Rheumatol. 2011;7(1):50-56. 2013;21(5):646-654. Darrach to total joint arthroplasty. J Am 12. Lawrence RC, Felson DT, Helmick CG, et 25. Hagert E, Hagert CG. Understanding Acad Orthop Surg. 2012;20(10):623-632. al. Estimates of the prevalence of arthritis stability of the distal radioulnar joint 39. Scheker LR, Ozer K. A simple method of and other rheumatic conditions in the through an understanding of its anatomy. physical examination for the diagnosis United States. Part II. Arthritis Rheum. Hand Clin. 2010;26(4):459-466. of distal radioulnar joint incongruity. 2008;58(1):26-35. 26. Acosta R, Hnat W, Scheker LR. Distal European Journal of Plastic Surgery. 13. Dibonaventura M, Gupta S, McDonald radio-ulnar ligament motion during 2004;27(1):42-43. M, Sadosky A. Evaluating the health supination and pronation. J Hand Surg Br. 40. Freiberg RA, Weinstein A. The scallop and economic impact of osteoarthritis 1993;18(4):502-505. sign and spontaneous rupture of fi nger pain in the workforce: results from the 27. Schuind F, An KN, Berglund L, et al. extensor tendons in rheumatoid arthritics. National Health and Wellness Survey. BMC The distal radioulnar ligaments: a Clin Orthop Relat Res. 1972;83:128-130. Musculoskelet Disord. 2011;12:83. biomechanical study. J Hand Surg Am. 41. Couturier CA, Alnot JY. [Non-traumatic 14. Michou L. Genetics of digital osteoarthritis. 1991;16(6):1106-1114. osteoarthritis of the distal radio-ulnar Joint Bone Spine. 2011;78(4):347-351. 28. Bell MJ, Hill RJ, McMurtry RY. Ulnar joint: a consecutive series of 11 wrists with 15. Zhang Y, Jordan JM. Epidemiology impingement syndrome. J Bone Joint Surg 42 months follow-up]. Rev Chir Orthop of osteoarthritis. Clin Geriatr Med. Br. 1985;67(1):126-129. Reparatrice Appar Mot. 2002;88(6):573- 2010;26(3):355-369. 29. Huang JI, Hanel DP. Anatomy and 581. 16. Simonet WS. Genetics of primary biomechanics of the distal radioulnar joint. 42. Tanaka T, Kamada H, Ochiai N. Extensor generalised osteoarthritis. Mol Genet Hand Clin. 2012;28(2):157-163. tendon rupture in ring and little fi ngers Metab. 2002;77(1-2):31-34. 30. Skahen JR, 3rd, Palmer AK, Werner FW, with DRUJ osteoarthritis without 17. Maetzel A. The economic burden Fortino MD. Reconstruction of the perforating the DRUJ capsule. J Orthop associated with osteoarthritis, rheumatoid interosseous membrane of the forearm in Sci. 2006;11(2):221-223. arthritis, and hypertension: a comparative cadavers. J Hand Surg Am. 1997;22(6):986- 43. Yamazaki H, Uchiyama S, Hata Y, Murakami study. Annals of the Rheumatic Diseases. 994. N, Kato H. Extensor tendon rupture 2004;63(4):395-401. 31. Skahen JR, 3rd, Palmer AK, Werner FW, associated with osteoarthritis of the distal 18. Rossignol M, Leclerc A, Allaert FA, et al. Fortino MD. The interosseous membrane radioulnar joint. J Hand Surg Eur Vol. Primary osteoarthritis of hip, knee, and of the forearm: anatomy and function. J 2008;33(4):469-474. hand in relation to occupational exposure. Hand Surg Am. 1997;22(6):981-985. 44. Cho CH, Lee SW. Extensor tendon rupture Occup Environ Med. 2005;62(11):772-777. 32. Atha J, Yeadon MR, Sandover J, Parsons KC. caused by instability of the ulnar head 19. Brown TD, Johnston RC, Saltzman CL, The damaging punch. Br Med J (Clin Res with an osteoarthritic distal radioulnar Marsh JL, Buckwalter JA. Posttraumatic Ed). 1985;291(6511):1756-1757. joint: a case report. J Med Case Rep. osteoarthritis: a fi rst estimate of incidence, 33. Hagert CG. The distal radioulnar joint in 2013;7(1):281. prevalence, and burden of disease. J relation to the whole forearm. Clin Orthop 45. Bowers WH. Instability of the distal Orthop Trauma. 2006;20(10):739-744. Relat Res. 1992(275):56-64. radioulnar articulation. Hand Clin. 20. Dillon CF, Hirsch R, Rasch EK, Gu Q. 34. Kleinman WB. Stability of the Distal 1991;7(2):311-327. Symptomatic Hand Osteoarthritis in Radioulnar Joint: Biomechanics, 46. Scheker LR, Ozer K, Babb BA. Distal the United States. American Journal Pathophysiology, Physical Diagnosis and Radioulnar Joint Problems and Solutions. of Physical Medicine & Rehabilitation. Restoration of Function. In: Slutsky D, ed. Surgery of the Injured Hand - Towards 2007;86(1):12-21. Principles and Practice of Wrist Surgery. Functional Restoration. New Delhi: 21. Katayama T, Ono H, Suzuki D, Akahane First ed. Philadelphia: Saunders Elsevier; Jaypee Brothers Medical Publishers � Ltd.; M, Omokawa S, Tanaka Y. Distribution of 2010:41-55. 2009:458-474. primary osteoarthritis in the ulnar aspect 35. Boland MR, Spigelman T, Uhl TL. The of the wrist and the factors that are function of brachioradialis. J Hand Surg
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IFSSH Scientific Committee on Musician’s Hand Chair: Naotaka Sakai (Japan) Committee: Peter C. Amadio (USA), Ian Winspur (UK), Steve Leibovic (USA), Peter Bentivegna (USA) Report submitted September 2013 Report of the IFSSH Musician’s Hand Committee, 2013
As musicians require quite specifi c hand Background of the musician’s hand to be established and these would be movements for performance, hand 1. New criteria for musician’s hand applicable not only to musicians, but for affl ictions are a serious problem for their As the musician’s hand has so any other patients who needs a quick professional career. Some physicians many aspects, it brings many new occupational hand motion such as the noticed the problems in 19th century, concepts to the world of general typist, cook, sculptor, or others. and Poore reported the hand pain of hand surgery. Certainly, there are not 2. Re-evaluation of conservative professional pianists in 18871. so many professional musicians, but treatment However, there have been few understandably the treatment of the Another aspect of management of medical reports concerning the musician’s hand may be a key to open the musician’s hand is a re-evaluation of musician’s health until the 1980s 2-6. the door to alternative methods of non-surgical treatment to avoid surgical In addition, medical conferences assessment and treatment of other complications. Tenosynovial release is focusing on musicians were organised, conditions by hand surgeons. a simple, very easy surgical procedure such as the Performing Arts Medicine For example, most criteria for the and the result is usually good. However, Association (PAMA) symposium, and clinical results include only static some musicians complain of subluxation the European Congress for Musician’s evaluation such as range of motion, i.e. of tendons following this surgery, e.g. Medicine (ECMM). However, as there maximum and minimum fl exion angle, tendon bowing, as it brings a poor eff ect were few hand surgeons participating, grip or pinch strength. Radiological to their music performance. The 1st the discussions on the musician’s parameters also show only static compartment release for de Quervain’s hand could not include causes and positions. DASH tries to evaluate some disease may result in tendon subluxation management in detail. hand activities, but is not detailed when playing on the piano keyboard. As the hand surgeon is a specialist enough to evaluate the musician’s Even small, minor surgery changes of hand clinical matters, the discussion hand activity. Many musicians require the physical structure and some of by the IFSSH members allows more a quick speedy movement of their these could result in poor eff ect for the specifi c and more relevant discussion to fi ngers which cannot be evaluated patient’s hand activity. Similarly, carpal be focused on the musician’s hand. with any criteria so far published. tunnel release may result in bowing of The musician’s hand committee Although the hand surgeon may be fl exor tendons and a similar complaint is composed of fi ve IFSSH members satisfi ed with the clinical result of a may be found among string players. It and three advisers: Dr Kai-Nan An as an good score, some musician patients also aff ects other occupational hand adviser for the biomechanics; Dr. Richard are not satisfi ed because they cannot functions. Corticosteroid injection using C. Lederman and Dr. Eckart Altenmuellar do their performance quickly enough. triamsinolone gives an excellent result as advisers for the focal dystonia. This suggests that new criteria need for any kind of tenosynovitis, and the
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Figure 1 (left): One of the violinists had diffi culty in holding the string with Dupuytren’s contracture. Figure 2 (right): But he was satisfi ed with the result of conservative treatment. Even though the ring fi nger also showed a limited range of motion, he never wanted more improvement.
injection technique has been proposed re-evaluate the after-treatment for an the musician’s hand must adapt itself as providing a better result. However, early return to stage. Minimally invasive to the type of music instrument. The corticosteroid has serious potential side or endoscopic surgery cannot resolve hand surgeon should consider not only eff ects including tendon rupture, and the problem. Discussion of problems the hand condition, but the interface better injection material is expected. of the musician’s hand should be between the hand and the music Amadio and colleagues have studied the more directly related to kinematics of instrument. This is also so for general excursion inside the tenosynovium, and the human hand, and this would be hand patients. clarifi ed its structural mechanism 7. appropriate not only for musicians, 5. Psychosomatic factor of musicians Concerning non-surgical treatment, but for any other patients with hand The fi fth point is the psychosomatic conditions such as carpal and cubital problems. factor of the musician’s hand. Usually, tunnel syndrome, osteoarthritis 4. Interface between the instrument musicians are nervous about their including the Hebereden’s node and and hand hand condition, because even small 1st CMC joint arthrosis, and Dupuytren’s The fourth point is that we hand changes could create a serious contracture should be additionally surgeons should remember that the problem or disability for their specifi c, discussed. hand is always directly related to the music performance. This feature may 3. Practice for music performance object. Therefore, the man-machine often be related to a psychosomatic The third point is that musicians do interface between the hand and factor. Hand surgeons cannot avoid not want to stop their practice for music the object should be more closely or underestimate the importance of performance. They complain that most considered with any hand problems. a psychosomatic factor, because the physicians would fi rstly recommend a Music instruments often require hand is a mirror of brain activity. rest from practice. However, they need musicians to adopt an unreasonable 6. Focal hand dystonia to consume several hours for music hand position or motion. Consider the Focal dystonia should also be instrumental practice to maintain their unnatural hand position of the violinist discussed when assessing the problems performance technique. Otherwise or fl autist. If instruments were tools of confronting the musician’s hand. This they cannot complete the performance daily use, they would have been totally is a most diffi cult musician’s disease to the high, professional level which the changed in design from an ergonomic to treat, and so serious for them audience expects. In order to maintain point of view. However, most music as to cause them to give up their their performance technique level, to instruments cannot be changed professional carrier. Dystonia should be continue to practise, hand surgeons and retain their unique tone. For discussed not only by hand surgeons, should consider what they can and example, string instruments have been but by neurologists. I have asked two what they cannot do. We may have to unchanged for 300 years. Therefore, neurologists who are well known for
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musician’s dystonia to contribute their “As the musician’s hand recommended treatment. In these thoughts. circumstances surgery should be has so many aspects, withheld until playing is compromised. Surgical indications for musicians it brings many new Conversely musicians requiring wide Among the discussion points on the concepts to the world of span – pianists and bassoon players are musician’s hand, surgical indication two examples – are compromised by was thought to be one of the most general hand surgery.” very early disease in the palm without important ones, because musicians digital contracture and surgery or sometimes have a specifi c need, in collagenase injection is indicated at order to improve or maintain their repair or reconstruction when a simpler this early point when not in the general performance activities, rather than compromise may be available. Simple population. simply undertake their daily living examples would be the repair of activities. very distal digital nerve lacerations or Nerve compression syndromes For example, with Dupuytren’s digital or cutaneous nerves on the less The commonest operations performed contracture, some musicians with a important aspects of digits. A further on musicians electively are release of small contracture need surgery, but in example would be the repair of an entrapped nerves particularly release the others, especially some violinists, extensor tendon when the function of of the carpal tunnel. However not all digital fl exion contractures can exist that tendon is reduplicated or of minor musicians suff ering tingling in the with no functional loss even when importance generally; or the secondary fi ngers, even in the median distribution, joints are contracted to a degree where reconstruction of divided tendons have compression of the median surgery is normally indicated. One by tendon grafting when the simpler nerve and this group fare very badly violinist with a Dupuytren’s contracture option of tendon transfer or arthrodesis with inappropriate surgical release. had diffi culty in holding the string may be available and is known to work The indication for surgical release (Figure 1, Dr. Sakai’s patient), but he was well in the general population. The of the carpal tunnel in a musician is satisfi ed with the result of conservative indications therefore for anatomical interference with playing AND positive treatment, even though the ring fi nger repair are much greater in a musician nerve conduction testing and this also showed a limited range of motion than in the general population. applies to all other nerve compression (Figure 2). syndromes amenable to nerve Concerning the surgical indication Non-trauma conduction testing. for musicians, Dr. Winspur off ered a In the simplest terms, if the medical general comment as follows: condition is interfering with a Summary “Surgical indications, the analysis of musician playing at their own high Indications vary from musician the risks of surgery versus the benefi ts, level and all options of conservative to musician, from instrument to diff er in musicians from those in the care, adjustment of technique and instrument and from medical condition general public. In some circumstances adjustment of the instrument have to medical condition and are diff erent the indications are looser and in others been exhausted or are not applicable, from those in the general population. much stricter and they may vary from surgery is indicated. This may be When a musician has injured structures instrument to instrument.” at a later point than in the general from open or closed trauma anatomical population or earlier. An example reconstruction should be the goal even Trauma would be Dupuytren’s contracture when not indicated in a non-musician. In the repair/reconstruction of an which in the left hand in string players When a musician is suff ering a non- injury in a musician one must strive for causes little interference with playing traumatic condition, surgery is only 100% return of function and balance. even with a contracture well past indicated when all other modalities of This may mean a complex anatomical the point one would normally have treatment or adjustment have been
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exhausted and the condition prevents limiting factors for the tendon graft, juncturae tendinum between the index the musician from playing. while the limited function of the index and the middle fi nger mainly caused a fi nger may be a disadvantage of EIP loss of extension of the index fi nger 13. EPL rupture - Transfer or graft? transfer. DeSmet et al. and Noorda et According to von Schroeder et al., As the fi rst topic of detailed committee al. investigated clinical results after the juncturae tendinum between the discussion, we chose the extensor EIP transposition, and they noticed index and the middle fi nger is classifi ed pollicis longs (EPL) rupture, which limited function of the index fi nger into two groups, fascia alone type and usually needs a reconstruction because 9, 10. However, they did not describe fi lamentous bands type, while EIP had of degenerative changes in the end this in detail, because there were no junction with the other extensor of ruptured tendon. Either extensor no complaints on the subjective tendons. Kitano et al. described that indicis proprius (EIP) transposition or a assessment in patients. the index fi nger extension lag after free autologous tendon graft using the On the other hand, Browne et al. EIP transfer would be caused by the palmaris longus tendon may be usually reported that index fi nger extension fi lamentous band type juncturae used. Especially, our question is whether lag after EIP transfer was not caused by tendinum, and they recommended its the EIP transfer would bring poor eff ect removal of the force of tendon, but by excision at the time of EIP transfer to on the index fi nger’s independent factors that caused either disruption of retain the extension of the index fi nger. movement or not. If its extension normal hood function or tethering of its Tubiana stated that the EIP transfer would be limited, it would be a serious normal excursion 11. They recommend might be contraindicated in patients problem for musicians, just as for string a repair of the hood at the EIP transfer whose occupation requires independent players. procedure, to prevent this extension lag. movements of the index fi nger, such as One committee member has a Moore et al. claimed that independent typists and musicians 14. The suggestion case of professional violinist with extension of the index fi nger was was that there was a disadvantage an EPL rupture, who sustained the retained by sectioning immediately for the index fi nger extension after injury 3 years ago but did not have a proximal to the dorsal hood while the harvesting the EIP for transfer. surgical treatment of EIP transfer. She other fi ngers were held fully fl exed 12. One committee member complained that no surgeon could However, 26% of their EIP transfer cases recommended the EIP transfer using explain the residual eff ect of loss of showed an extension lag of the index the “wide awake” approach described the EIP, and that the right index fi nger fi nger. Kitano et al. stated that the by Don Lalonde 15. That method allows is most important for any violinist’s setting of the tension with the patient’s performance. She also did not accept help, and also allows the surgeon to alternative surgery with a free tendon “Discussion of verify independent EDC index function graft, because of the risk of avascular problems of the intraoperatively. Usually, the EDC to necrosis of graft and long time musician’s hand should the index fi nger can independently immobilisation. Fortunately, she could extend the digit, so there is no loss of hold the bow to complete the music be more directly related independent index motion after EIP performance, without full extension to kinematics of the transfer. of the thumb IP joint, but had some human hand, and this Another committee member diffi culty in her daily activities. reported that one violinist who had an Schaller et al. compared the clinical would be appropriate EIP transfer for his EPL rupture had to results between the EIP transposition not only for musicians, give up his professional career as the and the tendon graft, and concluded but for any other extension function was so unbalanced that there were no diff erences in thumb in his left index fi nger. He recommends function 8. They stated that the risk of patients with hand the palmaris tendon graft to reconstruct avascular necrosis of the graft may be problems.” more anatomically.
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In conclusion, both the EIP transfer References and the tendon graft are alternatives 1. Poore, G.V.: Clinical lecture on certain 11. Browne EZ, Teague MA, Snyder CC: conditions of the hands and arm which Prevention of extensor lag after indicis available, even for the musician’s interfere with the performance of tendon transfer. J Hand Surg, 1979;4A:168- hand. However, hand surgeons should professional acts, especially piano-playing. 172. respect the extension function after British Medical Journal, 1887;1:441-444, 12. Moore JR, Weiland AJ, Valdata L: harvesting the EIP tendon for transfer. 1887. Independent index extension after 2. Hochberg F.H., Hand diffi culties among extensor indicis proprius transfer. J Hand A “wide awake” approach would be musicians, JAMA, 1983;249:1869-1872. Surg, 1987;12A:232-236. recommended in order to confi rm 3. Fry, H.J., Overuse syndrome in musicians – 13. Schroeder HPV, Jolla L, Botte MJ: Anatomy independent EDC function of the 100 years ago, Medical Journal of Australia, of the extensor tendons of the fi ngers: index fi nger, and if needed, repair of 1986;145: 620-625. variations and multiplicity. J Hand Surg, 4. Brandfonbrener, A.G.: Myasthenia gravis in 1995;20A:27-34. hood or separation of the juncturae wind players: two cases study. Med Probl 14. Tubiana R: Lesions of the extensors of the tendinum should be considered. A Perform Art, 1988;3:155-157. thumb. In: Tubiana R, ed. The Hand, Vol. III, palmaris tendon graft would make 5. Lederman R. J., Calabrese, L. H., Overuse Philadelphia: WB Saunders, 1988;pp155- possible an anatomical reconstruction, syndromes in instrumentalists, Med Probl 156. Perform Art, 1986;1:17-11. 15. Bezuhli M, Sparkes GL, Higgins A, et al.: but surgeons should consider that 6. Dawson, WJ.: Hand and upper extremity Immediate thumb extension following there would be the risk of avascular problems in musicians. Epidemiology extensor indicis propirus-to-extensor necrosis of the graft, and that a long and diagnosis. Med Probl Perfom Art, pollicis longus tendon transfer using the immobilisation time may bring another 1988;3:19-22. wide-awake approach. Plast Reconstr 7. Zhao C, Sun YL, Jay GD, et al.: Surface Surg, 2007;119:1507-1512. disadvantage for musicians, interrupting modifi cation counteracts adverse eff ects their practice for performance. associated with immobilization after fl exor However, it is questionable whether tendon repair. J Orthop Res, 2012;30:1940- simply the full extension of the index 1944. 8. Schaller P, Baer W, Carl HD: Extensor fi nger is enough for musicians, who indicis-transfer compared with palmaris need an independent quick movement longus transplantation in reconstruction of each fi nger. As stated in the of extensor pollicis longus tendon: A background, we need new criteria for retrospective study. Scand J Plast Reconstr Surg Hand Surg, 2007;41:33-55. the musician’s hand which evaluate 9. DeSmet L, Loon JV, Fabry G: Extensor indicis not only the static position but the proprius to extensor pollicis longus dynamic movement. As such, we need transfer: results and complications. Acta to continue the discussion on optimal Orthop Belg, 1997;63:178-81. 10. Noorda RJP, Hage JJ, deGroot PJM, et al.: management following the trauma to Index fi nger extension and strength after the musician’s hand. extensor indicis proprius transfer. Hand In the future, we will expand Clin, 1995;11:411-412. the discussion to tenosynovitis, hypermobile joints, entrapment neuritis, and focal hand dystonia of musicians.
24 IFSSH ezine AUGUST 2014 ezine ifsshCONNECTING OUR GLOBAL HAND SURGERY FAMILY
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Mallet Fingers Around the Globe: Does One Best Method for Immobilisation and Mobilisation Exist? Part II: Mobilisation
This article is the second in a series of Non-surgical management is the to end immobilisation and commence two articles on the treatment of the fi rst line of intervention to restore mobilisation, immobilisation mallet fi nger. The fi rst article covered tendon continuity or bony union ranges from 4-9 weeks and is often immobilisation of mallet fi ngers (see following type 1 a-b mallet fi nger prolonged another 1-12 weeks by the the May 2014 issue #14 of the IFSSH injury. This is truly a unique situation continuation of night splinting1-15. In ezine). This article was also compiled for the therapist to be able to manage Table 2 each co-author was asked, by Julianne Howell of Oregon, USA a tendon injury without the aid of “How do you decide length of time to and was fi rst published in the February suture or fracture reduction. It is the immobilise”. Their answers suggested 2014 edition of the ASHT Times. therapist’s responsibility to fabricate that immobilisation times served The other contributors were: an orthotic/cast that precisely only as a guideline from which to Melissa Hirth (Melbourne, Australia) positions the tendon/bone for gapless evaluate healing status, all authors Gwendolyn van Strien healing, to impress the patient about used DIPJ extensor lag as the guide, (Den Haag, the Netherlands) the importance of maintaining and defi ned their criteria to begin Lynn Bassini (New York, USA) the immobilised position, and motion. Hirth, van Strien and Devan Dershnee Devan determine when healing is suffi cient start their countdown from the week (Johannesburg, South Africa) for safe transition into the phase of immobilisation began; Bassini and Edited: Corrianne van Velze mobilisation. Howell do not start the 6-8 week The purpose of Part 2 in this series countdown until after active extension is to summarise the literature about of DIPJ is 0 to -5 degrees. Not cited when and how type 1 a-b mallet fi nger in the table, the co-authors also injuries are mobilised and review tools gave consideration to the type of to measure outcomes. The co-authors mallet; bony or tendinous and zone off er tips and tricks which they feel of injury; 1or 2, and unanimously lend to successful transition into the felt tendinous mallets require more phase of mobilisation and defi ne their time to heal, while no consensus was criteria for successful outcomes. achieved regarding the zone of injury Table 1 shows there is no requirements. In stark contrast to the consensus in the literature about when protocol-driven literature, the co-
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Table 1: Week when mobilization is commenced Week when mobilization is commenced Source 4-5 plus 2-4 wks night splint Lester et al, 2000 6 minimum EFSHT Delphi study mallet fi nger, 2008 6 unless >20°lag or patient dissatisfaction; add 4wks Pike et al, 2010 6 plus 2wks night splint Warren et al, 1988; 6 plus 3wks night splint Maitra & Dorani, 1993 6-8 Moss & Steingold, 1983; Hovgaarg & Klareskov, 1988 6-8 plus night splint until wk 12 Tocco et al; 2013 6-9 Shankar & Goring, 1992; 7wks 2d (mean) plus 2 wk night splint Groth & Wilder, 1994 8 plus 2wks night splint Crawford, 1984; Patel, Desai & Bassini-Lipson, 1988 8 review, if no lag, graduated splint withdrawal O’Brien & Bailey; 2011 8-12 Type 1a; 6 Type 1b Katsoulis et al, 2005 8-16 plus 2 wk night splint chronic mallet fi ngers 4-18wks old Patel, Desai, Bassini-Lipson, 1986 authors make decisions based on their clinical observations, and treatment is tailored to each patient’s biological response. Clearly the literature does “there is no consensus in the literature not truly refl ect what is actually being done in clinical practice. about when to end immobilisation and For the most part, in the literature, commence mobilisation, immobilisation should an extensor lag develop or increase during mobilisation there are ranges from 4-9 weeks and is often no stated contingency plans, except prolonged another 1-12 weeks by the in studies by Groth and O’Brien10,13. continuation of night splinting” Groth added 2 weeks of full time immobilisation if at any time DIP lag increased 5° or more10. O’Brien added
Table 3: Literature Details for Mallet Finger Mobilization Mobilization Details Source Week 6: Composite fi st & extension 6x/day 10 reps, return to orthotic Groth & Wilder, 1994 Week 8: Isolated DIP fl exion/extension Week 9: Heavy use Week 8: Loose fi st & full extension 5x/day 10 reps, return to orthotic O’Brien & Bailey, 2011 Week 9-10: Light activity, orthotic off Week 10-11: Wear orthotic for heavy activity Week 6-8: Passive MP fl exion & active IP extension, hold 5seconds, 6-8x/day Tocco et al, 2013 10 reps, orthotic continued Week 7-9: Active fi sting added with above exercises, Week 8: Orthotic only at night Week 2-14: Use hand normally
IFSSH ezine AUGUST 2014 27 hand therapy
Table 2: Therapist’s response to questions regarding mobilization of mallet finger Type 1a-b injuries
Question Bassini (New York, USA) Hirth (Australia) How do you decide length of time to 8 weeks after DIP extension lag has 6 weeks bony, 8 weeks tendinous if no immobilise? been at 0º lag. If lag develops, reapply orthotic for 2 weeks further full time. How long will you wait to achieve your <5º full extension or when patient is Varies with the patient and their criteria before progressing to the phase satisfi ed, needs to understand chance of willingness to continue immobilisation. of mobilisation? recurrence Most will wait until 12 weeks. Beyond this, dependent on current lag, age, work and functional impact. The decision is made with the patient. How do you introduce DIP joint motion? Protected AROM exercises for 2 more AROM exercises and light functional weeks, and a removable cast. use. Orthotic on for heavy activities and overnight.
Please clearly defi ne the terms you Protected AROM exercise: Limited ROM AROM exercises: Actively closing the used above when describing how you based on the limits demonstrated by fi ngers into a comfortable composite introduce DIP joint motion. the therapist. fi st. Light functional use: Use of the hand for activities ≤ 500 grams (1 lb) in weight, e.g. brushing teeth, using cutlery or getting dressed. Heavy use: Avoiding use of the hand for activities >500gm (1lb) such as lifting 2 litre (4.4lb) milk cartons or returning to the gym. When do you commence passive DIP I discourage this until as late as 6 Not prior to 10 weeks post fl exion exercises? months commencement of splinting, and depends on how stiff the DIPJ and the degree of lag/strength of extensor tendon. When do you commence resisted Never resisted extension. Flexion if Not a standard component. Main aims extension and/or fl exion exercises as needed, rarely. of therapy are to maintain extension, part of the standard therapy program? then regain fl exion. Strength comes later with functional hand use. What criteria do you use to continue If no lag develops after 2 weeks or If no lag after 2 weeks of light functional weaning from the device? recovery of motion, and no pain and use and AROM exercises. return to function Defi ne a successful outcome? <5º lag, minimal edema, no pain, <5º lag or neutral (for those with functional fi st (1cm to DPC), no forced pre-injury hyperextension), minimal tight fi st. oedema, no pain, functional fi st, + satisfi ed patient. What type of goniometer do you use? Flat metal fi nger. 15cm plastic. Where do you place the goniometer to Dorsal and lateral Dorsal. measure? What are the 3 most common concerns How long will I have to wear this The existence of a lag. you hear from patients regarding the orthotic? Will it happen again? Presence of a lump on the dorsum of outcome? the fi nger.Finger stiff ness into fl exion and loss of full DIPJ fl exion.
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Howell (Oregon, USA) Van Strien (the Netherlands) Devan (South Africa) 6-8 weeks after DIP extension lag has 8 weeks if no lag. If lag develops, 4 weeks is standard if no lag. If there is been at 0-5º. reapply cast for another 2-4 weeks full a lag, the splint is continued 2 weeks time. further Will go as long as 16 weeks with patient Will wait until 12 weeks. Then, together 6-8 weeks. consent. with the therapist, surgeon and patient decide what to do.
Protected AROM exercises 2 weeks Limited protected AROM for 2 more Discontinue daytime splint, continue elastic tape, further, plus full time orthotic. weeks, plus a removable cast with a protected AROM for 2 weeks. If full extension removable orthotic. is not achieved by then, continue for 2 weeks further and consider splint application, light ADL. Protected AROM exercises: For DIPJ Limited protected AROM: Full DIPJ Protected AROM: Active ROM with mobilisation – fl exion angles of extension. Flexion is limited to 20º OR elastic tape. Light ADL: Self care and MP>PIP>DIP for a soft active fi st around only active DIPJ extension, no fl exion. other activities that do not involve a cone, without cone, and active DIP resistance and heavy lifting. extension. See Tips and Tricks.
Slow recovery is ideal. Can add Not part of standard therapy program. After week 8 where no extensor lag exercises if, after 3 months, no lag is Only when needed for function. Not exists. present and the patient requests. added until 6-12 months or sooner if certain lag won’t increase. Not part of program. Both challenge Strengthening not part of therapy Week 12. tendon’s tensile strength. Goal: no program, recovery by functional use is change in lag for 3 months. preferred. Consider only after healing is stable and no lag. After 2 weeks protected AROM and no After 2 weeks protected motion and no Active DIPJ extension to 0º. lag or increase in lag has occurred. lag or increase in lag.
≤5º lag, minimal edema, no pain, <5º lag, no pain, and functional fi st (full 0º extensor lag. functional fi st + patient satisfi ed. fi st may take a year to achieve).
Flat metal fi nger. Gloria Devore. Jamar metal. Dorsal and lateral. Dorsal. Dorsal.
Persistent lag. Residual lag. Residual swelling. Appearance, i.e. dorsal DIPJ bump and/ Limited DIPJ fl exion after 3 months. Sensitivity of the fi ngertip. or pseudo-swan neck posture. Amount of time and eff ort invested for a How can such a small injury be so relatively minor trauma. fi nicky, take so long to heal and then not be normal?
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the 2 weeks of full time immobilisation introduce motion (Table 3). In Figures comparison among studies quite if DIP lag increased >10°13. Table 2 1-5 each co-author has shared tips and diffi cult. Since DIPJ extension lag is outlines the criteria used by the co- tricks they fi nd useful to begin motion. the gold standard let’s take a look at authors to adjust mobilisation times Each co-author was also asked to this one variable to understand what as well as how long each was willing defi ne the terminology they use in each author considered an excellent to continue immobilisation to achieve their descriptions, such as protected result. Warren and Norris’ criteria was a their benchmark. It is interesting to motion, light functional activity, 0-5° lag; Abouna and Brown a <5°lag, observe that whenever an extended extensor lag, it’s clear to see that even Crawford’s scale is < 10° extension period of immobilisation was required, our terminology is not standardised, an lag; Garberman, Diao, and Peimer’s Hirth, Howell and van Strien brought important requirement for replication. criteria and Tocco et al’s modifi cation in patient-centered care via shared- Table 4 summarises the rating of Garberman’s criteria rated a < 10° decision to guide treatment. criteria used to assess treatment extension lag 4,816,11,17 Notice that The literature is sparse on the outcome. Note that the wide other variables are often combined details of the how’s & when’s to variability by the authors, making with extensor lag, adding further
Table 4: Outcome measurement tools after mallet finger (Type 1a-b) injury Abouna and Brown Categories 1968 Cured Improved Unchanged Lag <5° 5-15° >15° Stiff ness None None Stiff ness or DIPJ motion Normal fl exion/extension Normal fl exion Impaired fl exion
Crawford’s Categories 1984 Excellent Good Fair Poor Lag <10° 10-25° >25° >25° Flexion Full Full Any loss Any loss Pain None None None Persistent
Warren and Norris’ Categories 1988 Success Improved Failure Lag 0-5° 6-15° >15°
Garberman, Diao, and Peimer Categories 1994 Treatment Success Treatment Failure Extensor lag <10° Extensor lag >10° No DIPJ stiff ness or loss of fl exion Associated DIPJ stiff ness or loss of fl exion Cosmetically acceptable to patient Cosmetically unacceptable to patient Patient satisfaction Patient dissatisfaction
Tocco et al’s Modifi cations of Gaberman’s Categories 2013 Treatment Success Treatment Failure Extensor lag <10° Extensor lag >15° No DIPJ stiff ness or loss of fl exion (<25°) No DIPJ stiff ness or loss of fl exion (> 30°)
30 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 31 hand therapy
complexity when attempting to analogue scales to assess diffi culties “For methods that compare each variable directly. with specifi ed functional activities, Table 2 defi nes what each co- residual fi nger pain, satisfaction with could be used to author accepted as a successful fi nger function, and satisfaction with measure these outcome. Interestingly all co- treatment outcome18. This same authors accepted an extension lag as group also classifi ed the size of dorsal common patient successful, even if the contralateral DIPJ prominence as minimal, moderate concerns, Kalainov DIPJ hyperextended. Various authors and large18. Tocco and colleagues et al included included extra variables in some measured residual swelling by using combination in their defi nition of Oval 8 ring sizers™ around the middle visual analogue success such as limited oedema, of the middle phalanx and comparing scales to assess no pain, functional fi st or a satisfi ed to the contralateral digit 8. Kalainov patient. Only one of the authors used defi ned the persistence of a pseudo- difficulties with a formal outcome measurement tool, swan neck deformity in combination specified functional all used diff erent types of goniometers, with DIPJ lag to be signifi cant if PIP joint methods varied in placement (dorsally hyperextension was >10 degrees 18. activities, residual or laterally), and making note of the Perhaps measuring the initial DIPJ finger pain, week measurements were taken may lag and comparing this to the fi nal make a diff erence. These variations DIPJ extension measure would be satisfaction with once again challenge the ability to a method to quantify the degree of finger function, compare studies. change with treatment. This may help Pike et al questioned the validity the patient see improvement, rather and satisfaction of goniometric measure of lag than only comparing the injured digit with treatment and developed a formula called to the non- injured digit and sensing radiologic lag. When radiologic lag lack of success if they are not equal. outcome” was compared to dorsal goniometric While most patients expect treatment measurement between weeks 7-12, to restore normalcy, as we have goniometry overestimated the lag, observed, most authors do not set the whereas by week 24 both measures outcome bar that high. were not signifi cantly diff erent3. They Review of the literature and postulated the early discrepancy was querying the co-authors clearly shows due to acute dorsal digit oedema3. that there is no single best method The most common patient to immobilise and mobilise a mallet concerns after mallet fi nger injury was fi nger. As Merritt states, “We need extensor lag (Table 2). Also making to resist the pressures to make the the list were appearance such as patient fi t the protocol. We must do dorsal lump or swelling, pseudo-swan whatever means are at our disposal”19. neck posture, functional stiff ness or We believe that treatment tailored to sensitivity, and frustration with the the individual’s healing response, and investment of time and energy in tapping the knowledge and clinical treatment without guaranteed success. skills of the hand therapist are the For methods that could be used to means to take us to the best outcomes measure these common patient after mallet fi nger injury. concerns, Kalainov et al included visual
30 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 31 hand therapy
Tips and Tricks for Treatment of Mallet Injury Van Strien
Figure 1: Extend DIPJ with PIPJ held in slight fl exion to (1) make DIPJ extension easier and (2) prevent PIPJ hyperextension. No active fl exion of DIPJ allowed at this time, just let the joint to “drop” into fl exion when fi nger is relaxed after extension. If no lag develops in the 1a 1b fi rst two weeks of mobilization, active fl exion can be started to 20 degrees and slowly increased to more fl exion as long as no extension lag develops. Figure 2: Find a cylinder shape that is easily obtained around the house. Make sure the fl exion around the shape only allows up to 20° of fl exion at the DIPJ for the fi rst two weeks. Use the shape to 2a 2b also actively extend DIPJ away from the cylinder. Figure 3: When there is no increase in DIPJ extension lag, progress to smaller diameters for greater DIPJ fl exion. Figure 4: Eventually use objects to “block” and increase the DIPJ fl exion angle.
3a 3b
4 3b
32 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 33 hand therapy
Tips and Tricks for Treatment of Mallet Injury Hirth Figure 1. At 6 weeks (bony) or 8 weeks (tendinous) AROM is measured with a goniometer pre and post a 5 minute warm water bath whereby the patient actively closes the fi ngers into a comfortable composite fi st. If a lag develops during this period of time, the splint is reapplied full time and the patient reviewed the following week. 1 2 Figure 2. Light functional hand use such as holding a mobile phone is encouraged.
Figure 3. Actively closing the hand into a comfortable composite fi st is given as an exercise for the patient to complete regularly at home. Figure 4. Passive fl exion is generally not commenced prior to 10 weeks post orthosis commencement, and instituted only in patients who have good extension 3 4 but remain very stiff into fl exion.
Tips and Tricks for Treatment of Mallet Injury Howell
Figure 1. The patient wears the tape in the orthotic and for exercise during the fi rst 2 weeks of protective AROM to provide proprioceptive feedback so not to force fl exion. (Note: the tape is not shown in the fi gures that follow) Figure 2a. The patient blocks the MP joint in fl exion and actively extends the PIP & DIP joints for a 3-5 seconds. 1 2a2
32 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 33
hand therapy
Howell (continued)
2b 3a 3b 3b 3c
Figure 2b. (b) Relax active extension. Protected AROM the smaller end of the cone. B) If no change in lag, progress extension exercises are done at twice the repetition rate as to a soft active fi st without the cone. If after 2 weeks of the fl exion exercises. Figure 3. A thermoplastic cone is used mobilization and there is no increase in lag, add C) soft active to guide protected AROM fl exion exercise. A) Week 1: a soft fi st at the larger end of the cone (DIPJ fl exion > PIPJ fl exion). If active fi st (MPJ fl exion > PIPJ fl exion and PIPJ fl exion > DIPJ no increase in lag, add D) soft active hook fi sting commencing fl exion) is desired. In this example, the small fi nger is in the at the larger end progressing to smaller end. Key Point: C and desired position. Week 2: if no change in lag, move toward D place maximum stress on the terminal tendon.
References 8. Tocco S, Boccolari P, Landi A, Leonelli C, mallet fi nger. J Hand Surg 1986; 11A:570-73. 1. Lester B, Jeong G, Perry D, Spero L: A et al: Eff ectiveness of cast immobilization 16. Abouna J, Brown H: The treatment of simple eff ective splinting technique for in comparison to the gold-standard self- mallet fi nger: the results in a series of the mallet fi nger. The American Journal of removal orthotic intervention for closed 148 consecutive cases and review of the Orthopaedics 2002; 29: (3)202-06. mallet fi ngers: a randomized clinical trial. literature. British J Surg; 1968 55: (9)653-67. 2. Cederlund R, Kul F, Rouzaud JC, 2013; 26: (3) 191-201. 17. Garberman S, Diao E, Peimer C: Mallet Wendling U, Aasheim T, Schreuders T; 9. Shankar N, Goring C. Mallet fi nger: a fi nger: results of early versus delayed Results of Delphi round in mallet fi nger long-term review of 100 cases. J of Royal closed treatment. J Hand Surg 1994; 15A: EFHSTconsensus. 2008. College of Surgeons 1992:37:196-98. 850-52. 3. Pike J, Mulpuri K, Metzger M, Gordon Ng, 10. Groth G, Wilder D: The impact of 18. Kalainov DM, Hoepfner PE, Hartigan BJ, Wells N, Goetz T: Blinded, prospective, compliance on the rehabilitation of Carroll C et al: Nonsurgical treatment of randomized clinical trial comparing volar, patients with mallet fi nger injuries. J Hand closed mallet fi nger fractures. J Hand Surg dorsal and custom thermoplastic splinting Ther 1994; 7:21-24. 2005; 30A:580-86. in treatment of acute mallet fi nger. J Hand 11. Crawford G: The moulded polythene splint 19. Merritt WH: Written on behalf of the stiff Surg 2010; 35A:580-88. for mallet fi nger deformities. J Hand Surg fi nger. J Hand Therapy 1998; 11: (2)74-79. 4. Warren RA, Norris SH, Ferguson DG: Mallet 1984; 9A:231-37. fi nger: a trial of two splints. J Hand Surg 12. Patel MR, Desai SS, Bassini-Lipson L: 1988; 13B: (2)151-53. Conservative management of mallet 5. Maitra A, Dorani B: The conservative fi nger. J Hand Surg 1988; 13:329-34. treatment of mallet fi nger with a 13. O’Brien L, Bailey M: Single blind, simple splint: a case report. Archives of prospective, randomized controlled trial Emergency Med 1993; 10:244-48. comparing dorsal aluminum and custom ABOUT THE 6. Moss JG, Steingold RF: The long- thermoplastic splints to stack splint for the term results of mallet fi nger injury: a acute mallet fi nger. Arch Phys Med Rehabil AUTHOR retrospective study of one hundred cases. 2011; 92:191-8. The Hand 1983; 15: (2)151-54. 14. Katsoulis E, Rees K, Warwick D: Hand Julianne W Howell, PT, MS, CHT 7. Hovgaarg C, Klareskov B. Alternative therapist-led management of mallet Samaritan Health Services, conservative treatment of mallet-fi nger fi nger. Br J Hand Ther 2005; 10:17-20. Corvallis, Oregon, USA 15. Patel M, Desai S, Bassini-Lipson L: injuries by elastic double-fi nger bandage. Email: [email protected] J Hand Surg 1988; 13B: (2)154-55. Conservative management of chronic
34 IFSSH ezine AUGUST 2014 research roundup
A review of prophylaxis guidelines for venous thromboembolism following upper limb surgery
United Kingdom
David Warwick from the Hand “There have coagulability rather than immobility of Surgery Unit at the Department of the legs). Death after complex elbow Trauma and Orthopaedics, University been no studies surgery has been reported, so the Hospital Southampton recently examining which problem cannot be denied. co-wrote a review article in the prophylaxis should Journal of Hand Surgery about the What are the most important points prophylaxis guidelines for venous be given after for any hand surgeon to know thromboembolism (VTE) following upper limb surgery about prophylaxis for VTE following elbow, wrist and hand surgery. We upper limb surgery? asked him a few questions about the in those at risk” David Warwick: There is a risk of fatal article: PE after major elbow surgery. Each is being spent routinely giving of these patients should have a risk What sparked your interest to prophylaxis by default to upper limb assessment and prophylaxis is given conduct this literature review on patients who perhaps did not need it. for those at high risk. For patients this particular topic? As s Hand Surgeon who has been undergoing short duration hand and David Warwick: I have been interested researching lower limb VTE for so wrist surgery under regional or local in venous thromboembolism (VTE) long, I thought it was time to review anaesthesia the risk is vanishingly rare in orthopaedics for over 20 years. the literature on upper limb VTE to and so prophylaxis is not required. For My doctoral thesis and much of my see whether there really is a risk and longer duration procedures, when published research has been on this if so who should be considered for there is concomitant pelvic or lower topic. The very great majority of the prophylaxis. limb surgery, or risk factors such a world literature in orthopaedic VTE infection, prior VTE or or a family relates to hip and knee replacement; What were the most interesting history, then prophylaxis should be there has been very little written about results that this review yielded? considered. the risk in upper limb surgery. David Warwick: The occurrence of In the United Kingdom Health VTE after hand or wrist surgery is, at Will you be conducting any further System, there is a stringent mandatory least as far as the published literature research into this area in the future? VTE risk assessment of all hospital is concerned, vanishingly rare. There is David Warwick: There is so much we patients. Whilst this is sensible, it takes a material risk of lower leg thrombosis need to know. Although the literature time for each and every patient to after shoulder surgery (so the aetiology suggests that VTE after hand and be assessed. Health service resource must be due to systemic hyper- wrist surgery is exceedingly unusual,
IFSSH ezine AUGUST 2014 35 research roundup
perhaps that is because events have JOURNAL REFERENCE occurred sporadically but the treating Venous thromboembolism surgeon has never bothered to write following elbow, wrist and hand a case report, or the journals have surgery: a review of the literature never seen fi t to publish submitted and prophylaxis guidelines case reports. We must fi nd out more. J Hand Surg Eur Vol March 2014 39: One option is a survey of surgeons to 306-312 see if they have encountered VTE after upper limb surgery. Another option http://jhs.sagepub.com/ is a registry organised by a national content/39/3/306.abstract society which would either reassure us that the risk is too low to give prophylaxis or that the risk is higher than previously thought. methods in theatre and then an oral As it happens, we have just come chemical agent until the risk has across a case of a man who developed diminished would be a reasonable a signifi cant lower limb DVT after a approach. To prove this would require recurrent thumb infection for which he a randomised trial that would be had three operations and a prolonged exceedingly expensive and which hospital stay. We are writing this up, would still leave most questions highlighting how risk factors (infection, unanswered - which chemical, for repeated surgery) should prompt a how long, which outcome measure? consideration of prophylaxis. So the most sensible thing until we There have been no studies have more knowledge is to avoid examining which prophylaxis should unnecessary prophylaxis (which costs be given after upper limb surgery money and can carry side eff ects) but in those at risk. One would have to make sure that we do a proper risk extrapolate from the vast hip and knee assessment and cover those with risk. arthroplasty literature. Mechanical
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36 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 37 research roundup
The application of DASH and the QuickDASH instruments in Norway Norway
Vilhjalmur Finsen from the Department “If the age consequences of this is that one must of Orthopaedic Surgery at St. Olav’s be very careful when comparing DASH University Hospital in Trondheim, composition among scores from diff erent studies. “If the recently co-wrote a paper in the the patients is age composition among the patients Journal of Hand Surgery about DASH not the same, the is not the same, the scores can not and QuickDash instruments. be compared. We suggest that it may The team collected population- scores can not be be possible to compare scores in based normative data for the DASH compared” diff erent populations when the scores (disabilities of the arm, shoulder and have been corrected for the expected hand ) and QuickDASH questionnaires ‘background DASH’ for the patients’ in order to determine the co-morbidity unlikely. So we collected the DASH sex and age-group. This remains to be to be expected in a group of patients scores in a large sample of the general evaluated. The DASH questionnaire and then studied the correlation population to determine the age- should mainly be used to compare between the two scores. adjusted co-morbidity to be expected, scores before and after intervention in “I translated the DASH questionnaire a kind of ‘background DASH’ in the the same patient,” he said. and later the QuickDASH questionnaire normal population.” The team plans to continue it into Norwegian soon after it started Their main fi nding was that mean doing further research into this area to be reported in the literature. I have DASH scores rise in both sexes with and has recently submitted another used it in a number of studies, but as I age and are surprisingly high in the paper showing that the patients’ gained more experience with it, I began elderly. Mean DASH scores for women socio-economic status, their income to wonder if it was quite as robustly rose with age from 5 among those and number of years at school, is of objective as I had initially taken for aged 20-29 to 22 among those aged importance for the DASH score. granted,” Professor Finsen explained 70-79 and 36 for those over 80. The about the reason for undertaking the corresponding mean values for men JOURNAL REFERENCE study. He continued: “A DASH score in were 5, 13 and 22. The DASH and the QuickDASH an 80 year old patient, is it a measure “We can see no obvious reason why instruments. Normative values in of whatever disease on is studying in this should not be the case, in general the general population in Norway that patient, or also of something else? terms, in all countries where the DASH J Hand Surg Eur Vol February 2014 If one were able to cure the patient questionnaire is used. It also seems likely 39: 140-144 of whatever disease one is studying, to apply to other regional questionnaires http://jhs.sagepub.com/ would the 80 year old patient end up used in orthopaedics,” he added. content/39/2/140.abstract with a DASH score of zero? It seemed According to Finsen, one of the
36 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 37 remembering our pioneers
Pioneers in Hand Surgery Jenó Manninger
Following his graduation from the Medical University of Pèes, Hungary (1942), Professor Manninger specialised in pathology, general surgery and traumatology. He studied hand surgery with Jorg Bohler in Linz, Austria (1959) and with Marc Iselin in Paris (1965). He earned a World Health Organisation Scholarship to further his hand surgery studies in the United Kingdom under the direction of H. Graham Stack, R. Guy Pulvertaft and A.R. Parkes (1967). Professor Manninger dedicated his career to the development of hand surgery in Hungary. He worked at the National Institute of Traumatology in Budapest from 1948 to 1989 where he was appointed Professor of Traumatology Surgery (1972), and later Chairman of the Traumatology Surgery Department and Director of the Institute (1978-1989). He established the fi rst Department for Surgery of the Hand in Hungary (1959) which was one of the fi rst to evolve in the old Eastern Block. In 1962, he organised a series of three-week Hand Surgery courses which he directed yearly at the institute for 25 years. These courses off er simultaneous translation and to this day are heavily attended by surgeons from neighbouring European countries. Professor Manninger was President of the Section for Surgery of the Hand of the Hungarian Society for Traumatology (1978-1986) and President of the Society (1986-1991). He has published 160 articles in scientifi c journals and chapters in four textbooks. He was a member of Hungarian Societies for Surgery, Traumatology Surgery and Hand Surgery, of the German and French Societies for Surgery of the Hand and of the Austrian Society for Traumatology Surgery.
38 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 39 remembering our pioneers
Kenya Tsuge
Born in Okayama, Japan, Professor Tsuge graduated from the Okayama Medical School in 1945, where he became Lecturer (1953) and then Associate Professor (1954). He worked as Dr. Joseph Posch’s Hand Fellow at Wayne State University in Detroit in 1958 and 1959. In 1964, he was elected Professor and Chairman of the Department of Orthopaedic Surgery of the Hiroshima University School of Medicine. Professor Tsuge served as President of the Japanese Society of Surgery of the Hand in 1969. He delivered the Founder Lecture, “Treatment of the Established Volkmann’s Contracture”, at the 28th Meeting of the American Society for Surgery of the Hand held in Las Vegas, Nevada in 1973 and became Honorary Member of the Society. He has been Honourary Member of the South African Society for Surgery of the Hand since 1981. In 1985, Professor Tsuge was nominated Chairman of the Hiroshima Prefectural Rehabilitation Center, Professor Emeritus of the Hiroshima University, Honorary Member of the Japanese Society for Surgery of the Hand and of the Japanese Orthopaedic Association. Professor Tsuge authored a Japanese textbook, “Principles and Practices of Hand Surgery” (1965) which is in its 5th edition and has been read by most Japanese hand surgeons. His “Comprehensive Atlas of Hand Surgery” was fi rst published in 1984. The second edition of this textbook was released in 1986 and was translated in English, Italian, German and Chinese. After his retirement, Emeritus Professor Kenya Tsuge remained Chairman of the Rehabilitation Centre. Professor Tsuge has devoted his career to hand surgery for more than 30 years, treating nearly 10 000 patients and teaching his hand fellows and orthopaedic residents. He has been actively involved in clinical and basic science research covering topics such as congenital malformations, tendon repair and transfers, nerve repair and rheumatoid arthritis.
38 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 39 journal highlights
Journal Highlights Below is a selection of contents pages from the latest issues of the following leading hand surgery journals. Hover your mouse over each article heading and click to go to the original abstract page of the article.
Journal of Wrist Surgery Issue 02 Volume 03 · May 2014 ❚ An Italian Experience Delving Inside to Treat Thumb CMC Arthritis An Alternative Pattern of Osteoarthritis the Wrist ❚ Arthroscopic Resection Arthroplasty of ❚ Spontaneous Flexor Tendon Rupture ❚ Ulnar Shortening Osteotomy for Ulnar the Radial Column for SLAC Wrist Due to Atraumatic Chronic Carpal Impaction Syndrome ❚ The Clinical Outcome after Extra- Instability ❚ The AO Ulnar Shortening Osteotomy Articular Colles Fractures with ❚ Rupture of the Flexor Digitorum System Indications and Surgical Simultaneous Moderate Scapholunate Superfi cialis at the Musculotendinous Technique Dissociation Junction Due to a Forearm Fracture: A ❚ Ulnar Impaction Syndrome: Ulnar ❚ How to Avoid Ulnar Nerve Injury When Case Report Shortening vs. Arthroscopic Wafer Setting the 6U Wrist Arthroscopy Portal ❚ A New Total Wrist Fusion Locking Plate Procedure ❚ The Use of Navigation Forces for for Patients with Small Hands or with ❚ Periprosthetic Osteolysis after Total Assessment of Wrist Arthroscopy Skills Failed Partial Wrist Fusion: Preliminary Wrist Arthroplasty Level Experience ❚ Biomechanical Test of Three Methods ❚ Isolated Lunocapitate Osteoarthritis—
Hand Clinics Latest issue is: Volume 30 • Number 3 August 2014
❚ Evidence-based Medicine in Hand Surgery ❚ Health Services Research: Evolution and Applications ❚ Evidence-Based Medicine in Hand Surgery: Clinical Applications and Future Direction ❚ Measuring and Understanding Treatment Eff ectiveness in Hand Surgery ❚ Patient-Reported Outcomes: State-of-the-Art Hand Surgery and Future Applications ❚ Bench to Bedside: Integrating Advances in Basic Science into Daily Clinical Practice ❚ Comparative Eff ectiveness Research in Hand Surgery ❚ Quality Assessment in Hand Surgery ❚ Collaborative Quality Improvement in Surgery ❚ The Patient Protection and Aff ordable Care Act: A Primer for Hand Surgeons ❚ Patient-Centered Care in Medicine and Surgery: Guidelines for Achieving Patient-Centered Subspecialty Care ❚ Clinical Practice Guidelines: What Are They and How Should They Be Disseminated? ❚ Funding Research in the Twenty-First Century: Current Opinions and Future Directions ❚ Future Education and Practice Initiatives in Hand Surgery: Improving Fulfi llment of Patient Needs
40 IFSSH ezine AUGUST 2014 journal highlights
Hand Volume 9 – Issue 2, June 2014
❚ Overcoming short gaps in peripheral of reconstructing an absent pinch and tendon repair nerve repair: conduits and human hook ❚ The infl uence of mindfulness on upper acellular nerve allograft ❚ An early shoulder repositioning extremity illness ❚ Current concepts: mallet fi nger program in birth-related brachial ❚ Distal radius fractures and the volar ❚ A prospective randomized controlled plexus injury: a pilot study of the Sup- lunate facet fragment: Kirschner wire trial comparing night splinting with ER protocol fi xation in addition to volar-locked no splinting after treatment of mallet ❚ Concomitant upper extremity soft plating fi nger tissue sarcoma limb-sparing resection ❚ A cohort study of one-year functional ❚ Arm ache and functional reconstruction: and radiographic outcomes following ❚ Psychometric properties of health- assessment of outcomes and costs of intra-articular distal radius fractures related quality of life instruments surgery ❚ Digit replantation in children: a in patients undergoing palmar ❚ Arthroscopic dorsal wrist ganglion nationwide analysis of outcomes and fasciectomy for dupuytren’s disease: a excision with color-aided visualization trends of 455 pediatric patients prospective study of the stalk: minimum 1-year follow-up ❚ Targeted muscle reinnervation in ❚ Adherence to therapy after fl exor ❚ MCP arthrodesis using an the initial management of traumatic tendon surgery at a level 1 trauma intramedullary interlocking device upper extremity amputation injury center ❚ Microsurgical principles related to exci- ❚ Cubitus valgus and tardy ulnar nerve ❚ Surgical rehabilitation of a tetraplegic sion of intraneural ganglion at the elbow palsy due to an intracapsular ulnar hand: comparison of various methods ❚ Platelet-rich plasma for zone II fl exor nerve
Journal of Hand Surgery (European Volume) July 2014 J Hand Surg Eur Vol 39, Issue 6
❚ Pyrocarbon metacarpophalangeal trapeziometacarpal joint osteoarthritis: ❚ Variability in local pressures under joint replacement in primary results after minimum 2 years of digital tourniquets osteoarthritis follow-up ❚ The management of viper bites on the ❚ Ten year follow-up of pyrocarbon ❚ The use of a pyrocarbon capitate hand implants for proximal interphalangeal resurfacing implant in chronic wrist ❚ Intercostal and pectoral nerve transfers joint replacement disorders to re-innervate the biceps muscle in ❚ Ten years’ experience with a ❚ Cubital tunnel syndrome: a obstetric brachial plexus lesions pyrocarbon prosthesis replacing the comparison of an endoscopic ❚ Distal radio-ulnar joint instability in proximal interphalangeal joint. A technique with a minimal invasive children and adolescents after wrist prospective clinical and radiographic open technique trauma follow-up ❚ A comparison of the functional ❚ Scaphoid nonunions in skeletally ❚ Morphology of the proximal and diffi culties in staged and simultaneous immature adolescents middle phalanx of fi ngers with regard open carpal tunnel decompression to the Ascension PyroCarbon PIP total ❚ Simultaneous modifi ed Camitz joint opponensplasty using a pulley at the ❚ Partial trapeziectomy and pyrocarbon radial side of the fl exor retinaculum in interpositional arthroplasty for severe carpal tunnel syndrome
IFSSH ezine AUGUST 2014 41 journal highlights
Hand Surgery: Asia Pacific Volume 19, Number 2
❚ Posterolateral Rotatory Instability Of Malunion With Percutaneous Osteoto- Histopathological Findings The Elbow After Corrective Osteotomy my And An Intramedullary Implant ❚ Intraosseous Epidermoid Cyst For Previously Asymptomatic Cubitus ❚ Intraosseous Xanthoma Of The Distal Discovered In The Distal Phalanx Of A Varus Deformity Radius — A Case Report Thumb: A Case Report ❚ Anatomy Of The Extensor Pollicis ❚ Sauvé-Kapandji Procedure In A Patient ❚ A New Building Block: Costo- Brevis Associated With An Extension With Wrist Disarticulation: Case Report Osteochondral Graft For Intra-Articular Mechanism Of The Thumb ❚ Two Cases Of Proximal Pole Scaphoid Incongruity After Distal Radius Fracture Metacarpophalangeal Joint Fracture Accompanied By Lunate ❚ Wrist Arthrodesis In Children — A New ❚ Posterior Interosseous Artery Flap: Fracture Technique: Case Presentation Our Experience And Review Of ❚ A Case Report Of Trigger Wrist ❚ Arthroscopic Assisted Percutaneous Modifi cations Done Associated With Carpal Tunnel Screw Fixation Of Bennett’s Fracture ❚ Flexor Pollicis Longus Reconstruction Syndrome Caused By An ❚ Usefulness Of Braided Polyblend Using The Palmaris Longus In Anterior Intramuscular Lipoma Polyethylene Suture Material For Flexor Interosseus Nerve Syndrome ❚ Spontaneous Rupture Of Epl And Tendon Repair In Zone Ii By The Side- ❚ Structural Changes Of The Carpal Ecrb Tendons In A Washerwoman: An Locking Loop Technique Tunnel, Median Nerve And Flexor Unusual Phenomenon ❚ Surgical Tips To Optimize Digital Flexor Tendons In Mri Before And After ❚ A Case Of Recurring Multifocal Giant Sheath Washout Endoscopic Carpal Tunnel Release Cell Tumour Of The Tendon Sheath In ❚ Management Of Flexor Tendon ❚ Thumb Opposition In Severe Carpal A Child Injuries — Part 1: Australian Tunnel Syndrome With Undetectable ❚ Mycobacterium Kanasii Flexor Contributions Apb-Cmap Tenosynovitis Of The Finger ❚ Management Of Flexor Tendon ❚ Resource Utilisation Associated With ❚ Congenital Defects Of The Flexor Injuries — Part 2: Current Practice In Single Digit Dupuytren’s Contracture Digitorum Profundus Tendon Of The Australia And Guidelines For Training Treated With Either Surgery Or Little Finger Young Surgeons Injection Of Collagenase Clostridium ❚ Atypical Subcutaneous Granuloma ❚ Wrist Arthroplasty: Where Do We Histolyticum Annulare On The Digit: A Case Report Stand Today? A Review Of Historic And ❚ A 20-Year Analysis Of Hand And Wrist ❚ Sea Urchin Spine Arthritis Of The Contemporary Designs Research Productivity In Asia Proximal Interphalangeal Joint Of The ❚ Treatment Of Extra-Articular Distal Radial Hand: Radiological, Intraoperative And
Journal of Hand Therapy Volume 27, Issue 3, July-September 2014
❚ Therapist supervised clinic-based systematic review management of patients with non- therapy versus instruction in a home ❚ Patient-centered care and distal radius radicular peripheral neuropathic pain program following distal radius fracture outcomes: A prospective ❚ Stronger relation between impairment fracture: A systematic review cohort study analysis and manual capacity in the non- ❚ Clinical Commentary: Therapist ❚ The push-off test: Development of a dominant hand than the dominant supervised clinic-based therapy simple, reliable test of upper extremity hand in congenital hand diff erences; versus instruction in a home program weight-bearing capability implications for surgical and following distal radius fracture: A ❚ Outcomes following the conservative therapeutic interventions
42 IFSSH ezine AUGUST 2014 IFSSH ezine AUGUST 2014 43 journal highlights
Journal of Hand Surgery: American volume Volume 39, Issue 8, (August 2014)
❚ Factors Delaying Recovery After Volar Fractures of the Proximal Phalanx Hand Surgeries Plate Fixation of Distal Radius Fractures ❚ Nonunion Without Avascular Necrosis ❚ Discrepancies Between Meeting ❚ Radiographic Scoring System to of Finger Phalangeal Neck Fractures in Abstracts and Subsequent Full Text Evaluate Union of Distal Radius Children: Report of 4 Cases Publications in Hand Surgery Fractures ❚ Radial Collateral Ligament Injury of the ❚ The Infl uence of Patients’ Participation ❚ Malpractice in Distal Radius Fracture Little Finger Proximal Interphalangeal in Research on Their Satisfaction Management: An Analysis of Closed Joint in Young Pianists Claims ❚ Simultaneous Proximal ❚ Headless Bone Screw Fixation for Interphalangeal Joint Arthroplasty and Combined Volar Lunate Facet Distal Extensor Tendon Reconstruction in Radius Fracture and Capitate Fracture: Adjacent Fingers: Case Report Case Report ❚ Estimation of Base of Middle Phalanx ❚ Suture Anchor Fixation for Scaphoid Size Using Anatomical Landmarks Nonunions With Small Proximal ❚ Long-Term Outcomes Following Radial Fragments: Report of 11 Cases Polydactyly Reconstruction ❚ Graft Choice in the Management ❚ Single Osteotomy at the Radial of Unstable Scaphoid Nonunion: A Diaphysis for Congenital Radioulnar Systematic Review Synostosis ❚ Volarly Displaced Transscaphoid, ❚ Comparison of Compression Screw Translunate, Transtriquetrum Fracture and Perpendicular Clamp in Ulnar of the Carpus: Case Report Shortening Osteotomy ❚ Scapholunate Ligament ❚ Radiocapitellar Joint Contact Pressures Reconstruction Using a Flexor Carpi Following Radial Head Arthroplasty Radialis Tendon Graft ❚ Anatomic Findings and Complications ❚ Antegrade Joint-Sparing After Surgical Treatment of Chronic, Intramedullary Wiring for Middle Partial Distal Biceps Tendon Tears: A Phalanx Shaft Fractures Case Cohort Comparison Study ❚ Outcomes of Closed Reduction and ❚ The Impact of Obesity on Periarticular Pinning of Base and Shaft Complications of Elbow, Forearm, and
❚ Manual mobilization of the wrist: A grasps used by adults during ❚ Using smartphone applications as pilot study in rehabilitation of patients performance of activities of daily living hand therapy interventions with a chronic hemiplegic hand post- ❚ A scoping review of the use of elastic ❚ A custom bicycle handlebar stroke therapeutic tape for neck or upper adaptation for children with below ❚ Rehabilitation of a patient following extremity conditions elbow amputations hand replantation after near-complete ❚ A cross-cultural adaptation of the distal forearm amputation Upper Limb Functional Index in ❚ An introductory study of common French Canadian
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Upcoming events
Congress of the European Society 10th Congress of the Asian Pacific for Surgery of the Shoulder and the Federation of Societies for Surgery Elbow of the Hand
17-20 September 2014 2-4 October 2014 Istanbul, Turkey Kuala Lumpur, Malaysia http://secec2014.com www.apfssh2014.org The 25th “SECEC-ESSSE European Society for Surgery of the The Malaysian Society for Surgery of the Hand (MSSH) is Shoulder and Elbow” Congress, which is the biggest Congress pleased to invite you to the 10th Congress of the Asia Paci¬fi c in Europe in the fi eld of Surgery of the Shoulder and Elbow, Federation of Societies for Surgery of the Hand (10th APFSSH) will be held on Sept. 17-20, 2014 at Lütfi Kırdar Convention and and 6th Congress of the Asia Paci¬fi c Federation of Societies Exhibition Center in Istanbul. for Hand Therapists (APFSHT) which will be held from 2nd - 4th October 2014 at Hilton Kuala Lumpur Hotel, Kuala Lumpur, Malaysia. To make it more exciting and well worth your while, ISSPORTH and IBRA are also joining in the academic activities! The conference programme includes: • Cadaveric Pre-Congress Workshops • 18 Industry Forms • Five concurrent sessions with 99 symposia and 12 plenaries • ISSPORTH - International Society for Sport Traumatology of the Hand Meeting • Exhibition booth showcase • Digital interface showcase • International Bone Research Association (IBRA) meeting
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Second International Symposium on Arthrogryposis 17-18 September 2014 St Petersburg, Russia http://amc-2014.org We have pleasure in inviting you to join us to the SECOND INTERNATIONAL SYMPOSIUM ON ARTHROGRYPOSIS «UPDATES FROM AROUND THE WORLD» which will be held in Saint-Petersburg, Russia on 17th and 18th September 2014. The faculty will consist of senior clinicians from all over the world with particular expertise in the management of all aspects of the care of children and adults with Arthrogryposis including, geneticists, neuromuscular paediatricians, surgeons and rehabilitation experts. This is a unique opportunity to discuss the diffi culties of managing this complex condition. One of the world’s most beautiful cities, St Petersburg has all the ingredients for an unforgettable travel experience. The city off ers an extraordinary history One-Day International international expert speakers on the and rich cultural traditions, which have topic of instability in the upper limb. The inspired and nurtured some of the Shoulder and Elbow conference aims to explore both surgical modern world’s greatest literature, music, Symposium and conservative perspectives on how to and visual art. From the mysterious 18 October 2014 manage dysfunction in the shoulder and twilight of the White Nights to world- London, Euston elbow. Clinical cases will be discussed beating opera and ballet productions on www.welbeing-cpd.co.uk/Page. amongst the faculty to generate magical winter evenings, St Petersburg aspx?P_ID=15 debate as well as nuggets of advice. charms and entices in every season The European Society for Shoulder & This conference is targeted to surgeons, Elbow Rehabilitation is the only Europe therapists and physicians. wide society that connects healthcare professionals with an interest in shoulder and elbow dysfunction. The objective of the society is to provide the highest standard of information and education to enhance patient care. This conference is a unique opportunity to hear
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Rome Symposium: Upper limb CUHK-OLC Surgeon Education arthroscopic techniques Program: The 17th Microsurgery 7-8 November 2014 Workshop Rome, Italy 24-28 November 2014 www.studioprogress.it Hong Kong Surgery in general, but especially upper limb surgery, has www.olc-cuhk.org evolved towards a mini-invasive type of surgery. That is aiming Workshop covers advances microvascular techniques, intensive to achieve increasingly precise gestures using increasingly laboratory practice, end-to-side anastomosis. The guest small incisions. During the last 15 years arthroscopy has speaker is Dr Ping tak Chan, the program director is Dr Wing- become a safe and reproducible technique. It has given us the lim Tse and program instructors are Drs Edmund Cheung and opportunity to better understand pathologies, it has changed Clara Wong. indications and it has allowed technical gestures that were unthinkable 10 years ago. During this symposium we have put Surgical techniques in hand surgery: together the best surgeons in the fi eld and we will review the essential technical improvements and the up-to-date surgical Ligaments, tendons, fractures and choices by means of presentations, debates, face-to-face and arthroplasty surgical videos. 11-13 December 2014 Arezzo, Italy Hong Kong International Wrist President, Roberto Adani. Scientifi c Committee: Massimo Ceruso, Pierluigi Tos Arthroscopy Workshop and www.sicm.it Seminar 8-10 November 2014 The 6th Combined Meeting of ASSH Hong Kong www.olc-cuhk.org and JSSH: Unsolved Problems in Program includes symposium on carpal instability, clinical Hand Surgery workshop on wrist examination and wrist pain management, Maui, Hawaii, USA Hands-on wrist arthroscopy workshop on anatomical March 29 - April 1, 2015 specimens. Organised by the Orthopaedic Learning Centre, http://www.assh.org/Courses/ASSH-Courses/2015- Department of Orthopaedics and Traumatology, The Chinese ASSH-and-JSSH-Combined-Meeting university of Hong Kong. Elbow: diseases and clinical experiences: hands-on Cad Lab 13-15 November 2014 Arezzo, Italy www.sicm.it Topics on Anatomical approaches, Arthroscopy, Arthroplasty and Prosthesis, Tendon repair and reconstruction. President, Bruno Battiston. Scientifi c Committee: Andrea Atzei, Riccardo Luchetti.
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The American Society for Surgery of the Hand (ASSH) and the Japanese Society for Surgery of the Hand (JSSH) invite you to submit an abstract for consideration at our 2015 Combined Meeting in! The 6th Combined Meeting will bring hand care professionals from around the world together to share, discuss and learn about breakthrough techniques and procedures advancing the care and treatment of the hand and upper extremity. Mark your calendar for and join us in beautiful Hawaii! 10th World Symposium on Congenital Malformations of the Hand and Upper Limb 7-9 May 2015 Rotterdam, The Netherlands www.worldcongenitalhand2015. com The 10th World Symposium on Congenital Malformations of the Hand and Upper Limb will be held on the 7th-9th May 2015, in Rotterdam, The Netherlands. A broad variation of congenital hand anomalies, genetics, embryology and classifi cation will be presented, discussed and shared. Invited lectures, discussion, free paper sessions and panel sessions will inform you of the latest on congenital hand anomalies. Some of the keynote speakers are Michael Tonkin, Caroline Leclercq and Ann van Heest. The symposium will be preceded by a cerebral palsy pre course on Wednesday the 6th of May. For more information on the program and registration go to: www. worldcongenitalhand2015.com
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NEW DATES 24-28 October 2016
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