Hand Association News
Winter 2019




Message from the AAHS President: W. P. Andrew Lee, MD

W.P. Andrew Lee, MD
W. P. Andrew Lee, MD
AAHS President

Happy holidays to the members of the AAHS! This time of the year is often filled with festive events of the season and time spent with family and friends. It is also a time for last minute preparations for our annual meeting on January 8-11 at Fort Lauderdale, and our Program Chairs and Central Office staff are hard at work arranging for a wonderful conference.

This month we launched the AAHS/ASHT International Reverse Therapy Fellowship with a request to our members to utilize their broad international networks to share this wonderful opportunity with therapists around the world. Modelled after our successful International Reverse Surgery Fellowship for hand surgeons, the Therapy Fellowship will begin in 2020, although applications are now being accepted. More information can be found online on Therapy Fellowship webpage.

With the year coming to an end, many of you may be looking to donate to charitable causes near and dear to your heart. Throughout 2019 I have shared with you the aspirations of the Hand Surgery Endowment's fundraising campaign. The Endowment leadership set a campaign goal to achieve a 50% giving rate among our membership over 2019 and 2020 to support our missions in honor of AAHS's 50th anniversary milestone. While the generosity of our membership has been clear as we have received substantial contributions to date, we have not reached the 50% participation goal. Please consider a contribution to the Hand Surgery Endowment to support its important work in research and international education and outreach before the end of 2019. You can direct your contribution to the Endowment activities of most interest to you.

Finally, I hope you are planning to attend our meeting next month. The 2020 Annual Meeting scientific program, organized by Drs. Jaimie Shores and Sami Tuffaha, along with Jane Fedorczyk, PT, PhD, CHT and Gary Solomon, MSOT, MBA, CHT, will feature an outstanding roster of speakers including Past President Dr. Jesse Jupiter ("Innovation in Hand Surgery and the Challenge of Scott's Parabola"), Dr. Anthony Chang ("Medical Application of Artificial Intelligence"), and Dr. James Chang ("Inside Rodin's Hands: Teaching Surgery Through Art and Anatomy"). The Saturday combined meeting keynote speaker, Dr. Eric Olson from University of Texas Southwestern Medical Center, will speak on his pioneering work on gene-editing for treatment of Duchenne muscular dystrophy. The social program includes a Friday afternoon Beach Party open to all our meeting attendees and their families, attesting to the welcoming and relaxed tenor of our Annual Meeting. Our guest societies for the Ft. Lauderdale meeting are the Delegation of Chinese Hand Surgeons and the Hong Kong Society for Surgery of the Hand.

Thank you for entrusting me with leading our Hand Association. It has been a privilege to serve as your President. I wish all of our Hand Association members a joyous and healthy holiday season and a prosperous new year.

With warm wishes,
W. P. Andrew Lee, MD
W. P. Andrew Lee, MD
President, American Association for Hand Surgery




Therapist Corner by Lisa Michael, OTD, OTR/L, CHT:
Ulnar Collateral Ligament Injuries to the Metacarpal Phalangeal Joint (MCPJ) of the Thumb

Lisa Michael, OTD, OTR/L, CHT
Lisa Michael, OTD, OTR/L, CHT

Winter is upon us in the Northeast, and many hand surgeons and therapists are seeing a fair number of patients with Skier's Thumb, a common injury to the ulnar collateral ligament (UCL) of the thumb. This occurs when acute excessive valgus stress is applied to the thumb MCPJ causing a partial or complete rupture of the UCL, or an avulsion fracture of the ulnar–volar base of the proximal phalanx (1,2,3), both which result in instability of this joint. This instability significantly impacts a person's functional ability to complete many mundane daily tasks. These include turning a key, texting, writing, and opening bottles, jars and doors to name a few. Therefore, restoring this stability must be addressed as soon as possible after injury to optimize the outcome.

A thorough assessment of the integrity of the UCL must be performed to determine the optimal intervention. Once X-rays rule out a fracture of the proximal phalanx or metacarpal, stress testing to the UCL is completed. The first metacarpal is stabilized by the examiner who then fully flexes the MCPJ and applies a valgus stress to the joint. Rupture has occurred if there's a 35° angle or comparison to the contralateral side reveals ≥ 15° discrepancy in valgus mobility. When complete rupture is suspected, a Stener lesion; incarceration of the distally avulsed ligament superficial to the adductor aponeurosis (2), must also be ruled out. This valgus test should also be assessed in extension: A positive finding indicates the accessory UCL is also torn. This lesion represents a Grade III tear, which also encompasses a displaced avulsion fracture, or complete UCL tear without Stener lesion. Grade III injuries will require surgical intervention and are not amenable to conservative intervention the majority of time. (1,3)

Surgical interventions vary depending on the mechanism of injury and the acuity of the lesion and are beyond the scope of this article. The post-op course of treatment starts with cast immobilization, most often in a forearm-based thumb spica. It is critical for the surgeon to educate the patient to attain and maintain full AROM of all joints in the extremity not immobilized by the cast. This is particularly important for the IP joint which is often restricted when the patients arrive to their first hand therapy session. The patients' fear of "ruining the surgery" precludes them from flexing this joint which can quickly stiffen from adherence of the extensor mechanism along the dorsum of the thumb. Fingers are also at risk for stiffness from the same fear of using the hand and/or a cast which has been molded a little too distal to the proximal MCP crease of the palm, thus restricting MCP flexion.

Hand therapy consists of converting the patient from a cast to a custom forearm or hand based removable thermoplastic orthosis. Therapists and surgeons should collaborate to determine the least restrictive type that offers optimal protection of the repair, if early controlled AROM of the MCP can be initiated, and any other pertinent surgical findings. As with Grade I or II injuries (incomplete tear or non-displaced fractures), the orthosis is typically worn full time other than for bathing, and controlled AROM of the thumb for 4-6 weeks, at which time it is weaned to progress ROM and initiate light strengthening. Unrestricted use of the thumb is delayed until 10-16 weeks post injury or surgery (3). Throughout the rehabilitation process, therapists work closely with the patient to help regain full ROM in the uninvolved joints of the thumb, and gradually help restore ~full mobility of the MCPJ. It must be stressed to the patient repeatedly that stability of this joint is much more important than mobility for optimal function of the thumb. Therapists should also continually educate the patient in activity modification, adaptive equipment and techniques to maximize functional independence during this entire process. As each phase of healing progresses, so should the education to permit more integrated function of the thumb into each patient's daily routines.

With prompt medical attention by the patient, accurate diagnosis and surgery or early referral to therapy by the hand surgeon, and skilled hand therapy, patients with this injury typically have excellent outcomes.

Article written by Lisa Michael, OTD, OTR/L, CHT

  1. Tsiouri C, Hayton MJ, Baratz M. Injury to the ulnar collateral ligament of the thumb. Hand (N Y). 2008;4(1):12-8.
  2. Koczan BJ, Moore S. Ligament Injuries of the Hand. In: Saunders R, Astifidis R, Burke SL, Higgins J, McClinton MA,
    Eds. Hand and Upper Extremity Rehabilitation - 4th Edition St Louis, Missouri: Churchill Livingstone; 2016:403-412.
  3. Patel S, Potty A, Taylor EJ, Sorene ED. Collateral ligament injuries of the metacarpophalangeal joint of the thumb: a treatment algorithm.
    Strategies Trauma Limb Reconstr. 2010;5(1):1-10.






Announcing the NEW International Reverse Therapy Fellowship

The American Association for Hand Surgery in partnership with the American Society of Hand Therapists have established an International Reverse Therapy Fellowship. The program sponsors an international hand therapist's visits with AAHS and ASHT member therapists at their institutions with the aim to provide expert education so that the Fellow may return home to improve therapy education and patient care in his or her home country.

The application for the 2020 Reverse Therapy Fellowship is now available! Hand Association members have such broad, international networks. Please be sure to forward this opportunity to those who may be eligible and interested.

The selected International Reverse Therapy Fellow will receive $10,000 from AAHS to be used towards a 4-week visit to North America to travel to the ASHT Annual Meeting and the institutions of two AAHS and ASHT member therapists in October 2020. Fellowship funding will also cover attendance at the AAHS Annual Meeting in January 2021 so that the Fellow can provide a summary of his or her experience, and how that experience has changed education and care in their practice.

Applications for the 2020 International Reverse Therapy Fellowship are due March 15, 2020.




Support the Hand Surgery Endowment and Celebrate the AAHS!

Endowment

AAHS will celebrate its 50th Anniversary in 2020! In celebration, Hand Surgery Endowment is fundraising and look to you to help continue the legacy of these organizations. With your participation and donation, AAHS and the HSE can continue to ensure under-resourced areas around the world gain knowledge and skills to care for their communities, continue to award funding for research to optimize treatment for hand and upper extremity related conditions, and promote education at the highest level.

Help the Endowment achieve a donation participation rate of 50% of the Hand Association membership! Direct your donation or pledge to one or more of following HSE funds. Donate Now | Pledge Now

  • Jaiyoung Ryu Lectureship Fund. Dr. Jaiyoung Ryu, a longtime member of AAHS and a friend to many within the hand care community, was severely injured in January 2017 while at the Hand Association Annual Meeting in Hawaii. Dr. Ryu passed away in January 2019 after two years of C4 quadriplegia as a result of his accident. AAHS has established the Jaiyoung Ryu Lectureship in honor of Dr. Ryu, which supports an innovative, cutting-edge lecture at the Annual Meeting. The innovation theme reflects Dr. Ryu's career interests in research and teaching.

  • International Reverse Surgery Fellowship and International Reverse Therapy Fellowship (New!). The International Surgery and Therapy Fellowships offer educational opportunities at U.S. centers for surgeons and therapists from developing countries. The International Surgery Fellowship is now in its third year, while the International Therapy Fellowship is a new program that will launch in 2020 in collaboration with ASHT.

  • Research funding. Support hand care research! Research funding is awarded annually to clinicians or therapists in private or academic practice for small clinical studies focused in hand care, or for pilot studies leading to more major hand care studies.

  • International Volunteer Scholarships. Since 2015 AAHS and HSE have been providing international volunteer scholarships to members to educate local medical teams and provide care to patients in developing-world countries. Donate to help expand this outreach program!

  • General AAHS 50th anniversary campaign. The Endowment will distribute funding to its education and outreach programs based on greatest need.
Thank you for celebrating 50 years of inclusion and outreach, and ensuring 50 more with AAHS! Visit the Hand Association website to learn more about Endowment funded program.




The 2020 Annual Meeting is Just Weeks Away!

Be sure to check out the following program highlights:

  • Last Person Standing Competition: Wednesday, January 8, 9:00 AM
  • Knowledge from AAHS Past Presidents (Panel): Things We Thought Were TRUE, But Are No Longer; Wednesday, January 8, 10:30 AM
  • Guest Speaker Jesse Jupiter, MD: Innovation in Hand Surgery and the Challenge of Scott's Parabola; Wednesday, January 8, 11:30 AM
  • Guest Speaker Anthony Chang, MD, MBA, MPH, MS: Artificial Intelligence; Thursday, January 9, 9:45 AM
  • New! Best Hercules Case vs. Best Holmes Case Session: Thursday, January 9, 11:00 AM
  • Danyo Lecture by James Chang, MD: Inside Rodin's Hands, Teaching Surgery through Art and Anatomy; Friday, January 10, 9:15 AM
  • Oral Boards Prep Course: Friday, January 10, 3:00 PM
  • AAHS Beach Party: Friday, January 10, 3:00 PM
  • Dinner Dance: Friday, January 10, 7:00 PM
  • Yoga as Spinal Health for Surgeons, on the beach with Dr. Susan Mackinnon: Saturday, January 11, 7:00 AM
  • Joint Presidential Keynote Lecture by Eric Olson, MD: Editing the Genome, New Hope for Genetic Disorders; Saturday, January 11, 10:00 AM
See the full program online including instructional courses, abstracts, panels and guest speakers.

There is still time to register for the meeting! Register online before arrival on-site in Ft. Lauderdale.




2020 Guest Societies

Guest societies of the 2020 AAHS Annual Meeting are The Delegation of Chinese Hand Surgeons and the Hong Kong Society for Surgery of the Hand (HKSSH). Please welcome them to the Annual Meeting in Ft. Lauderdale!




Message from the Editor

Message from the Editor
John Fowler, MD
Editor, Hand Association News

As the AAHS celebrates its 50th Anniversary, it is interesting to look back on the field of hand surgery and think about how it has evolved. For a specialty that was born out of necessity to care for injuries sustained in World War II, it is impressive to see the breadth that "hand surgery" now encompasses. It is my opinion that hand surgeons are some of the most "complete" musculoskeletal surgeons. We feel comfortable treating both adult and congenital conditions. We routinely treat bone, tendon, nerve, and blood vessel. Many are proficient both under the microscope and with joint arthroplasty. There are few specialties that are as "feared" by those who are not adept at treating conditions of the hand. I am always intrigued when I get referrals from my trauma colleagues who will spend hours piecing a tibial plateau fracture back together and then refer a transverse metacarpal shaft fracture in the same patient.

For a specialty that began exclusively with white men, it is also encouraging to see that our field has started to increase its diversity. Surgeons and AAHS members with different backgrounds and experiences will serve to strengthen the practice of hand surgery and result in better care for our patients. There is clearly a long way to go, but I am thankful for the diversity trailblazers in our field.

There has also been an evolution in hand surgery research and its implementation into clinical practice. I always find it interesting to review papers from the 1980's. The outcome measurements seem so crude and non-specific compared to the measures used today. There has been a shift from using surgeon derived outcomes (based on radiographic findings, range of motion, etc) to patient reported outcomes. It remains unclear, to me, if the patient reported outcomes are any "better" than older outcome scores that were based on objective clinical findings, but this is clearly the way our field is trending. I have a passion for research and feel the responsibility to continue to develop more "accurate" outcome measures so that we can continue to advance our field.

As I reflect back on the year during this holiday season, I am immensely thankful for my family and friends. I am incredibly thankful for the opportunity to be a hand surgeon and for the chance to positively impact the lives of others.

May your holiday season be filled with joy.

John Fowler, MD
Editor




HSE International Volunteer Scholarship Recipient Mission Reports
Adam Crelling, MS, OTR/L, CHT: Lima, Peru


Adam Crelling, MS, OTR/L, CHT

In January 2018, I learned that I was awarded one of the HSE/AAHS Volunteer Therapist Scholarships. Initially the plan was to join a team of medical volunteers on a trip to Nicaragua that was being organized by The Touching Hands Project. Due to Nicaragua's political instability at the time the team was planning to travel (June 2018), it was determined that it would not be safe to send volunteers and the trip was cancelled. With other organized volunteer trips already having a dedicated hand therapist, I requested to delay my experience until 2019. The HSE board membership agreed to my request, thus allowing me to seek out other potential hand therapy volunteer opportunities.

After doing some investigating, I was able to connect with Dr. Grant Thomson, founder and team lead, of Hand Help, Inc. Hand Help (handhelp.org) is a non-profit foundation set up by Dr. Thomson over 20 years ago. Through the foundation, he has organized over 20 volunteer medical trips where hand surgery and hand therapy are provided to both children and adults in developing nations around the world. I explained to Dr. Thomson the goal/mission of the HSA Volunteer Therapist Scholarship and also shared my personal interests in volunteering as a hand therapist with a multidisciplinary team of medical professionals. Fortunately, he agreed to have me join the Hand Help team on their 2019 volunteer trip to one of the children's hospital in Lima Peru (April 27 – May 4). The HSE scholarship funds helped to offset the cost of travel to Peru for the week as well as the cost of purchasing some clinic/hand therapy supplies. Additionally, it allowed me to make a small donation towards Hand Help's fundraising efforts for the current trip.

Overall the experience was incredibly positive. I met and got to work alongside some truly wonderful individuals. We were able to provide care to some complex pediatric cases with a variety of diagnoses. The hand therapist's role focused primarily on post-operative orthotic fabrication to protect repairs of complex surgeries, patient and family education and co-treating with local Occupational and Physical Therapy hospital staff on post-operative and non-operative upper extremity case. Some diagnoses seen included: thumb hypoplasia (thumb pollicization surgery), polydactyly, burn contractures, fractures, CP and arthrogryposis (elbow contracture release). The Hand Help team will be returning to the same children's hospital in Lima in 2020 to continue to provide care to this community. Happily, I will be joining them all once again for the week. I am honored to have been awarded one of the AAHS/HSE volunteer therapist scholarships. It is a true pleasure to be part of an association that looks to promote hand therapy knowledge and skills through volunteerism.

Kind regards,

Adam Crelling, MS, OTR/L, CHT
2018 HSE Volunteer Scholarship Recipient




Alexandra MacKenzie, BSOT: Fiji/Solomon Islands

The Loloma Foundation has been doing medical missions since 2001, when an anesthesiologist and a resort owner in Fiji met and decided they wanted to do something to help improve the health of people in the South Pacific. They now do dental, eye, general medical/surgical, ENT, OBGYN, and hand surgery missions every year.

Our team for the week consisted of two hand surgeons (Lorenzo Pacelli and Julie Woodside), a nurse (JJ), Lance Hendricks and Linda Kwasny from the Loloma Foundation and myself. There was also a surgeon visiting from the Solomon Islands and a general surgery resident from North Dakota. The anesthesiologist and the surgical scrub tech were from larger hospitals on the mainland. Terri, a former scrub tech from Michigan who now lives in Fiji most of the year, managed many of the day-to-day logistics and communications between patients and staff.

The hospital we worked out of was on the island of Taveuni, in the north. Lushly tropical, it is known as the ‘Garden Island.' The International Date Line passes through a field adjacent to the hospital, one of the very few places in the world where it crosses land. On the day I arrived, I was greeted not only by ukulele music in the airport, but also by a beautiful misty double rainbow, a far cry from the scene I had left at JFK in NYC. Patients came to Taveuni by ferryboat from all over the country, and some people had never left their home island before or been on a boat. The surgical diagnoses seen that week included syndactyly, polydactyly, and burn contractures to hands and elbows. Working out of the garden courtyard, I treated patients and made splints (non-surgical diagnoses were widely varied and included ulnar nerve palsy, spina bifida and osteoarthritis). I also consulted with a local physiotherapist, Sylvia, who is working a two-year government posting in the local village healthcare center. She sees a range of diagnoses, anything from arthrogryposis to CVAs and is also working on developing a fitness and wellness program to combat the prevalence of obesity and diabetes seen in the area. The biggest issue she faces is a lack of basic equipment, such as canes, walkers and wheelchairs.

The population of Fiji is under 1 million people, spread out over 300 islands. Poverty is one issue that Fijians face, but there is also a lack of access to basic healthcare and skilled providers. Trained healthcare professionals may move out of the region for better opportunities and pay. Rehabilitation is part of the mission of the World Health Organization in Fiji, however, this is an area that is still growing. There are fewer than 40 physiotherapists working in Fiji.

I had a great week of working at Taveuni Hospital with my colleagues there as part of Loloma. The people of Fiji are warm, easy to laugh, incredibly social and will say your name any chance they get. I am so thankful to AAHS/HSE for this opportunity and look forward to someday returning!




Julie Woodside, MD: Taveuni, Fiji

Our mission trip to Taveuni, Fiji was almost indescribable. We traveled with an experienced group that has served the island many times throughout the years. Our trip started with one big clinic where myself and the other hand surgeon evaluated all the potential patients, examined x-rays, and discussed surgical options. We stayed as a group at a resort on the ocean, getting to eat all of our meals together; we shared fun, music, and stories with the locals who worked alongside us. The owners of the resort made it feel like staying with family.

On our trip we had 2 hand surgeons, one nurse, one hand therapist, one anesthesiologist, an orthopedic surgeon from the Solomon Islands, one Fijian anesthesia resident and nurse scrub technician. We also had a general surgery resident from the US that joined us for part of the week as well. There was also year round staff at the small hospital and clinic that were amazing at organization, family management, and patient screening to help us spend the most time we could helping as many people as possible.

We spent each day operating together, sometimes both hands or feet at the same time, performing syndactyly releases, duplicated thumb corrections, burn contracture releases, and in between these we would meet on the wards with the patients and families who all stayed at the hospital together.

Most of the patients were children, but we did have a few adults and then some needing repeat surgeries almost yearly for complex syndactyly or severe burns.

We had one patient whose children were killed in a house fire where she was severely burned over most of her body. Both hands and arms were involved and she could not use either hand almost at all. While we could not help her in all the ways we wanted at that time, we did release the scar contracture of her elbow and performed a partial digital amputation for a chronic wound on her hand. While she needs many more complex procedures, even a small step in the right direction meant the world to her.

Our team became instant friends and shared a week immersed in the Fijian culture, sharing laughs and tears with the families and patients that traveled a long way for our help.

My favorite memory was the last evening there, we walked up to the hospital to say goodbye to the patients and families and to deliver care packages of bandages and soap for their journeys back to the islands they traveled from as well. After saying our goodbyes, one father stood up and spoke for the group, saying how thankful they were for all our service, the entire group then sang us a beautiful Fijian thank-you and farewell song with tears in their eyes. It was such a special moment and something I will always remember.




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