Acute Hand Research Articles

Occupational Therapy for Adults With Acute Hand Conditions: A Mixed-Methods Feasibility Study.

Hand injuries account for up to one third of acute hospital presentations. Current guidelines and standards of care recommend patients with hand trauma are seen by hand therapists, typically occupational therapists. This study explored the feasibility of implementing an occupational therapy-led hand therapy service for adults presenting acutely with a hand condition, using the RE-AIM framework. Purposeful sampling was used to recruit adult participants (n = 13). Outcome measures assessing function, health-related quality of life, pain, and occupational value and competence were completed. Focus groups were completed with patients and health care professionals. Data analysis revealed improvements in outcome measures post intervention and at 6-month follow-up. Participants were receptive of therapy-led services, and barriers and facilitators to service integration were identified using the RE-AIM framework. Occupational therapy-led hand therapy clinics show potential in treating people with acute hand conditions at emergency department settings, based on RE-AIM evaluation.

Management of Acute Hand Burns: A Survey of American Burn Association-Verified Burn Centers.

Hand burns have a significant impact on the long-term function of burn patients. Recently, new protocols and technologies, such as dermal substitutes, have been introduced for the treatment of hand burns. This cross-sectional study investigates the preferred current management of acute hand burns and the role of dermal substitutes in treatment. A 10-question survey related to acute hand burns management was sent to 64 directors of American Burn Association (ABA)-verified burn centers. A total of 51.6% (n=33) directors of ABA-verified burn centers responded to the survey. For the treatment of superficial partial-thickness hand burns, 90.9% preferred a non-operative approach. Conversely, most respondents chose a single-stage excision and skin graft for deep partial-thickness hand burns (75.8%) and full-thickness hand burns (51.5%). However, for full-thickness hand burns, some surgeons prefer a two-stage reconstruction involving excision and placement of a skin substitute (27.3%) or allograft (9.1%), followed by a skin graft. Only 6.1% would utilize a three-stage reconstruction involving excision and allograft, excision and skin substitute, followed by skin grafting. Among surgeons who used skin substitutes (n=26), Integra (42.3%) and Novosorb Biodegradable Temporising Matrix (BTM) (23.1%) were preferred. The top reasons for choosing one specific dermal substitute were surgeon's preference (n=20; 76.9%) and cost (n=9; 34.6%). While a conservative non-operative approach is preferred for superficial partial-thickness hand burns, excision and skin grafting as a one-stage procedure remains the most common strategy for deep partial-thickness and full-thickness hand burns.

Timing in the Treatment of Acute Hand Injuries

Timing in the Treatment of Acute Hand Injuries

764 Acute Ischaemic Hand Following Intra-Arterial Injection into Ulnar Artery

764 Acute Ischaemic Hand Following Intra-Arterial Injection into Ulnar Artery

Genetic variation and evolutionary characteristics of Echovirus 11: new variant within genotype D5 associated with neonatal death found in China

ABSTRACT Echovirus 11 (E11) has gained attention owing to its association with severe neonatal infections. From 2018 to 2023, a surge in severe neonatal cases and fatalities linked to a novel variant of genotype D5 was documented in China, France, and Italy. However, the prevention and control of E11 variants have been hampered by limited background data on the virus circulation and genetic variance. Therefore, the present study investigated the circulating dynamics of E11 and the genetic variation and molecular evolution of genotype D5 through the collection of strains from the national acute flaccid paralysis (AFP) and hand, foot, and mouth disease (HFMD) surveillance system in China during 2000–2022 and genetic sequences published in the GenBank database. The results of this study revealed a prevalent dynamic of E11 circulation, with D5 being the predominant genotype worldwide. Further phylogenetic analysis of genotype D5 indicated that it could be subdivided into three important geographic clusters (D5-CHN1: 2014–2019, D5-CHN2: 2016–2022, and D5-EUR: 2022–2023). Additionally, variant-specific (144) amino acid mutation sites and positive-selection pressure sites (132, 262) were identified in the VP1 region. Cluster-specific recombination patterns were also identified, with CVB5, E6, and CVB4 as the major recombinant viruses. These findings provide a preliminary landscape of E11 circulation worldwide and basic scientific data for further study of the pathogenicity of E11 variants.

CT-like images based on T1-weighted gradient echo MRI sequences for the assessment of fractures of the hand and wrist compared to CT

ObjectiveTo evaluate the performance of a 3D T1-weighted gradient-echo (3D T1GRE) computed tomography (CT)-like magnetic resonance imaging (MRI) sequence for detecting and assessing wrist and hand fractures compared to conventional CT.MethodsSubjects with acute wrist or hand fracture in CT underwent additional 3 T MRI including a CT-like 3D T1GRE sequence and were compared to patients without fractures. Two radiologists assessed fracture morphology on both modalities according to the Arbeitsgemeinschaft Osteosynthese (AO) and graded image quality and diagnostic confidence on a 5-point Likert scale.Besides diagnostic test evaluation, differences in image quality and diagnostic confidence between CT-like MRI and CT were calculated using the Wilcoxon test. Agreement of AO classification between modalities and readers was assessed using Cohen’s Kappa.ResultsTwenty-eight patients with 43 fractures and 43 controls were included. Image quality (3D T1GRE 1.19 ± 0.37 vs. CT 1.22 ± 0.42; p = 0.65) and diagnostic confidence (3D T1GRE 1.28 ± 0.53 vs. CT 1.28 ± 0.55; p = 1.00) were rated excellent for both modalities. Regarding the AO classification, intra- (rater 1 and rater 2, κ = 0.89; 95% CI 0.80–0.97) and interrater agreement were excellent (3D T1GRE, κ = 0.82; 95% CI, 0.70–0.93; CT, κ = 0.85; 95% CI, 0.75–0.94). CT-like MRI showed excellent sensitivity, specificity and accuracy for fracture detection (reader 1: 1.00, 0.92, 0.96; reader 2: 0.98, 0.94, 0.96).ConclusionCT-like MRI is a comparable alternative to CT for assessing hand and wrist fractures, offering the advantage of avoiding radiation exposure.

787 A 13-year Experience with a 3-stage Dermal Regeneration Matrix Approach to Acute Hand Burns

787 A 13-year Experience with a 3-stage Dermal Regeneration Matrix Approach to Acute Hand Burns

A Geospatial Analysis of Hand Trauma Care: A Statewide Cross-Sectional Study.

Traumatic hand injuries often present with high acuity, but little is known about the influence of geospatial and socioeconomic factors on the timely delivery of care. This cross-sectional study used the Michigan Trauma Quality Improvement Program database, a state-wide registry with 35 level I or II trauma centers. Adult patients sustained hand trauma requiring urgent operative treatment between 2016 and 2021. Zip codes of injury location were linked with the corresponding percentile score on the Area Deprivation Index (ADI), a comprehensive measure of neighborhood disadvantage. Multiple regression analyses were used to determine associations of patient, injury and geospatial characteristics with the odds of sustaining acute hand trauma and time to operative treatment. Among 1,826 patients, the odds of sustaining acute hand trauma based on the ADI followed a bimodal distribution. Female sex, smoking, obesity, work-related injury and residence in a minor city were associated with increased odds, while younger age, comorbidities, and rural residence were associated with decreased odds. For 388 patients who underwent surgery within 48 hours, time to treatment was significantly increased in the highest ADI quintile, for patients who underwent fracture fixation, and for those with severe global injury severity. Multi-system injuries, moderate global injury severity and direct admission to an orthopaedic service were associated with shorter times to treatment. Patients in areas with greater neighborhood disadvantage may experience delayed operative care after acute hand trauma. This study highlights the importance of considering underserved populations and geospatial factors when determining the allocation of hand surgery resources. Prognostic Level III.

Usage of Dermal Regeneration Templates (Pelnac) for Coverage of Exposed Hand Tendons in Acute Setting.

The loss of soft tissue coverage of tendons is a challenging reconstructive problem after acute hand trauma. Subsequent tendon adhesions and the loss of range of movement in addition to the poor aesthetic outcome and donor site scarring should be avoided when deciding the plan of management. Pelnac is one of the commonly used skin substitutes in reconstructive surgery that can be used for coverage of exposed tendons, but the postoperative functional outcome needs to be addressed in detail. Twenty-six patients with acute isolated tendon injuries distal to the wrist joint were included. Two-stage reconstructive procedures were performed; the first one was the application of Pelnac. The second stage was carried out after the complete integration of Pelnac via the application of a split-thickness graft. The function outcome assesses the return of the normal range of motion to the affected hand and the QuickDASH score questionnaire. The aesthetic outcome was assessed using the Vancouver scar scale. The Pelnac was integrated in 100% of cases, with complete grafts taken in 22 of 26 patients. The mean QuickDASH score was 20.5 ± 15.7, and mean Vancouver scar scale was 3.53 ± 3.2. The full range of motion returned in 22 of 26 patients. Using Pelnac to cover the exposed hand tendons in an acute setting is a convenient and efficient procedure with minimal morbidity. It can offer a good option for their coverage with preservation of hand function and acceptable aesthetic outcome.

Clinical evaluation of post-surgical scar hyperaesthesia: a longitudinal observational pilot study.

The mechanisms underlying persistent scar pain are not fully elucidated and evidence for the clinical evaluation of scar pain is limited. This pilot observational study investigated participation data and sought to identify objective clinical scar evaluation measures for future trials. With ethical approval and consent, adults undergoing planned hand surgery were enrolled from one NHS hospital. At 1- and 4-months post-surgery scar thermal and mechanical pain thresholds were evaluated with quantitative sensory testing; peri-scar inflammation with infrared thermometry and pliability with durometry. Participation data were analysed with descriptive statistics; the association of clinical measures with patient reported scar pain was analysed. Twenty-one participants (22% eligible patients) enrolled before study closure due to the COVID-19 pandemic; 13 completed follow up. No adverse events or dropouts resulted from clinical scar evaluation. Seventy percent of participants reported undertaking topical, nonprescription scar treatment independently. Neuropathic Pain Symptom Inventory (NPSI) scores were dispersed across the score range, capturing variability in participant-reported scar symptoms. Scar morphology, pliability and inflammation were not associated with scar pain. Differences between scar and contralateral skin in thermal and mechanical pain sensitivity were identified. People with acute hand scars participate in clinical research and independently initiate scar treatment. Clinical testing of acute post-surgical hand scars is well tolerated. The NPSI demonstrates utility for exploring scar pain symptoms and may support the elucidation of mechanisms of persistent scar pain. Clinical tests of thermal and mechanical and sensitivity are promising candidate clinical measures of scar pain for future trials. Background: it is unknown why some scars remain painful long-term. We do not know if scar flexibility, inflammation or sensitivity to temperature or pressure relate to scar pain. We investigated if patients would enrol in scar research, if scar testing was tolerated and if clinical tests are useful for future scar studies. Study conduct: with ethical approval and consent, adult hand surgery patients were enrolled from one NHS hospital. Scar pain, inflammation and response to thermal, sharp and pressure tests were assessed at 1- and 4-months after surgery. Statistically, we analysed study participation, tolerance for clinical scar tests and if the scar tests related to scar pain. Findings: 21 participants (22% eligible patients) enrolled before study closure due to the COVID-19 pandemic; 13 completed follow up. No participants were injured due to scar testing. 70% of participants reported treating their scar independently. Neuropathic Pain Symptom Inventory (NPSI) allows participants to give a broad range of answers about their scar symptoms. Scores for clinical tests of scar flexibility and inflammation did not relate to participant-reported scar pain. Scars were more sensitive to tests of pin prick and cold than unaffected skin. What we learned: people with new hand scars participate in research and independently initiate scar treatment. Clinical testing of post-surgical hand scars is well tolerated. The NPSI is useful for exploring scar pain symptoms and may help us to learn about persistent scar pain. Pinprick and cold clinical tests may be useful objective pain tests for future scar research.

Frequency of patients presenting with Hand Infection and treatment modalities

Introduction: Infections of the hand are one of the most common infections reported by the caring physicians and surgeons. Common types of hand infections include: bite wounds, felon, necrotizing fasciitis, paronychia, flexor tenosynovitis, subcutaneous/cellulitis, osteomyelitis and septic arthritis. Aims: The aim of this study to identify the main etiological factors, possible complications due to acute hand infection and treatment modalities performed in our selected group of patients. Materials and Method: This was a prospective Cross Sectional Observational Study based on 58 patients conducted at King Abdullah Hospital, Bisha, Saudi Arabia. Period of study was one year from May 2022 to April 2023. Patients of all age group were included. Male patients were 16 (27.5%) while females were 42 (72.4%). Result: Most of the patients were gardener / farmer 15 (25.9%), minor children 12 (20.7%), and housewife / maid 9 (15.5%). Major mechanism of injury was penetrating trauma 41 (70.7%). Majority of the patients were between 20 years to 50 years of age group. The risk factors associated with hand infection includes diabetes mellitus 13 (22.4%) and hypertension 5 (8.6%). The smokers were 13 (22.4%) patients. Most of the patients were Saudi national 30 (51.7%) followed by Egyptian12 (20.7%), Pakistani and Sudanese 4 (6.9% each). Surgical intervention includes, incision and drainage in 40 (68.9%) cases while amputation was performed in 3 (5.2%) cases. There were 15 (25.9%) patients treated with conservative treatment protocol. Major organisms causing infection was staphylococcus aureus 28 (48.30%) including methicillin resistant staphylococcus aureus (MRSA). There was no growth in 5 (8.6%) patients and for 19 (32.8%) patients no drainage collection was available and therefore their samples were not analyzed for bacteriology. We have categorized the diagnosis into 6 groups as subcutaneous infection 27 (41.5%), acute Paronychia 11 (16.9%), web space infection 10 (15.4%), pulp space infection7 (10.8%), flexor tenosynovitis 6 (9.2%) and midpalmer/thenar 4 (6.2%). Conclusion: Early clinical diagnosis based on occupational history and control of co-morbid disease such as diabetes mellites, smoking etc is effective in the treatment and prevention of hand infection to avoid devastating surgical intervention of partial or total diabetic hand amputation.

Characterizing enterovirus C96 genome and phylodynamics analysis.

Enterovirus C96 (EV-C96) is a recently discovered serotype belonging to enterovirus C species. It had been isolated from patients with acute flaccid paralysis, hand, foot, and mouth disease, diarrhea, healthy people, or environmental specimens. Despite increasing reports of the virus, the small number of full-length genomes available for EV-C96 has limited molecular epidemiological studies. In this study, newly collected rare EV-C96 strains in China from 1997 to 2020 were combined with sequences available in GenBank for comprehensive analyses. Sequence analysis revealed that the nucleotide sequence similarity of EV-C96 and the prototype strain (BAN00-10488) was 75%-81.8% and the amino acid sequence similarity was 85%-94.9%. EV-C96 had a high degree of genetic variation and could be divided into 15 genogroups. The mean evolutionary rate was 5.16 × 10-3 substitution/site/year, and the most recent common ancestor was dated to 1925. A recombination analysis revealed that EV-C96 may be a recombinant derived from other serotypes in the EV-C group in the nonstructural protein coding region. This comprehensive and integrated analysis of the whole genome sequence of EV-C96 provides valuable data for further studies on the molecular epidemiology of EV-C96 worldwide.

Reduced Access to Acute Hand Care and Potential Role of Telemedicine in Tennessee During the COVID Pandemic.

Previous studies have identified that there is limited, although expanding, access to acute hand care in Tennessee. Because of the rapid changes that occurred in health delivery and access during the coronavirus disease pandemic, we reassessed access to acute hand care, with particular interest in the utilization of telemedicine to assess if this increased access. We surveyed Tennessee hospitals listed by the Tennessee Hospital Association on their management of hand trauma and availability of telemedicine programs. Census data including population demographics such as race, age, income, and county size were merged with the survey data. Descriptive analysis was performed comparing the 2021 cohort with the historic 2018 cohort and between counties that had hand care versus counties that had no hand care. Survey response rate was 71.4% (n = 80 of 112). Telemedicine was used in 80% of the hospitals for other specialties but was not used for hand care. Overall, counties that offered hand trauma care reduced from 60% to 26% from 2018 to 2021 ( P < 0.001). This change was associated with a significant reduction of acute hand care among counties that were classified micropolitan (from 56.3% to 6.7%, P < 0.01). Percentage of hand specialists on staff and 24/7 specialists availability remained low and were similar to the availability in 2018. There was a decrease of acute hand care access in Tennessee during the coronavirus disease pandemic despite widespread utilization of telemedicine for other specialty consults. Expansion of telemedicine in acute hand care, targeted to micropolitan areas, may help to reduce variability in access to care.

Research progress on pathogenic and therapeutic mechanisms of Enterovirus A71.

In recent years, enterovirus A71 (EV-A71) infection has become a major global public health problem, especially for infants and young children. The results of epidemiological research show that EV-A71 infection can cause acute hand, foot, and mouth disease (HFMD) and complications of the nervous system in severe cases, including aseptic pediatric meningoencephalitis, acute flaccid paralysis, and even death. Many studies have demonstrated that EV-A71 infection may trigger a variety of intercellular and intracellular signaling pathways, which are interconnected to form a network that leads to the innate immune response, immune escape, inflammation, and apoptosis in the host. This article aims to provide an overview of the possible mechanisms underlying infection, signaling pathway activation, the immune response, immune evasion, apoptosis, and the inflammatory response caused by EV-A71 infection and an overview of potential therapeutic strategies against EV-A71 infection to better understand the pathogenesis of EV-A71 and to aid in the development of antiviral drugs and vaccines.

Microbiologic Analysis of Hand Infections: A Prospective Study.

Background: Hand infections are a common problem in emergency departments. Staphylococcus aureus is the main pathogen of both hand and blood stream infections. Therefore, the aim of the present study was to evaluate the frequency and impact of bacteremia in patients with hand infections to improve the microbiologic diagnostics. Patients and Methods: A prospective study of 90 patients with acute hand infections without antimicrobial pre-treatment was performed. Blood cultures were taken pre-operatively. If positive, transesophageal echocardiography was performed to rule out infectious endocarditis. Tissue samples were microbiologically processed using standardized culture media. If negative, a broad-spectrum bacterial 16S ribosomal RNA (rRNA) gene polymerase chain reaction (PCR) was applied. The etiology and location of the infection, the length of hospital stay, the number of surgical interventions, and the inflammatory parameters were obtained. Results: Six patients with bacteremia (6.6%) were diagnosed, after animal bites (n = 3) and intra-articular empyema (n = 3). Pathogens included Staphylococcus pettenkoferi, Pasteurella multocida, Staphylococcus epidermidis, Staphylococcus aureus, and Bacteroides pyogenes. No case of infective endocarditis was detected. Patients with bacteremia required more surgical interventions (p = 0.002), had a longer hospital stay (p < 0.001), higher plasma C-reactive protein (CRP; p = 0.016), and a higher age (p = 0.002) compared with those without bacteremia. In 14 cases (15.6%) no pathogen was detected by culture, whereas the subsequent broad-spectrum PCR diagnosed three cases (21.4%). Conclusions: Pre-operative blood cultures in patients with hand infections are important to detect bacteremia as an essential marker of clinical severity. Those blood cultures are indicated after deep animal bites and joint empyema. A precise identification of pathogens is fundamental for an effective treatment of hand infections, for which a 16S rRNA gene PCR can contribute in culture-negative tissue samples.

Reliability and clinical utility of a novel telehealth-based goniometry approach to measure range of motion of the digits of the hand

BackgroundRange of motion (ROM) is an outcome measure commonly used when treating acute and chronic hand injuries and conditions. Increased adoption of telehealth service provision in hand therapy practice, influenced by the advent of COVID-19, has led to the need for a valid and reliable approach to measure the range of motion of the digits of the hand when providing hand therapy services using telehealth. PurposeTo determine if performing manual goniometry during a livestream teleconsultation is reliable and clinically useful to measure the range of motion of the fifth digit when providing hand therapy services using telehealth. Study DesignClinical measurement, repeated-measures study. MethodsAccording to a measurement protocol, 12 independent raters (who currently provide hand therapy services) each obtained several screen-based goniometric range of motion measurements of the fifth digit at 2-time points. Raters were surveyed on the clinical utility of the telehealth-based goniometry approach. Measures of relative and absolute reliability were calculated to evaluate test-retest and inter-rater reliability. Free-text responses were analyzed using content analysis. ResultsInter-rater reliability was excellent for all flexion and extension measures (intraclass correlation coefficient [ICC] ≥ 0.89) but poor for the arc of motion (ICC ≤ 0.67). Test-retest reliability was poor (ICC ≤ 0.43). No statistically significant differences between test and retest measurements were observed (P ≥ 0.24). The overall coefficient of variation indicated good precision (14.69%). Measurement error (≤6.07º) and limits of agreement (≤6.33) had acceptable levels to support clinical use. Content analysis revealed several practical considerations. ConclusionsThis study suggests that performing manual goniometry during a livestream teleconsultation is unreliable for measuring the range of motion of the fifth digit. However, when combined with patient-reported and functional outcomes, this approach may be suitable to facilitate a range of motion assessment for certain functions of telehealth service provision in hand therapy practice.

Beta Changes Induced by Acute Hand Loss Model during NMES.

Neuromuscular electrical stimulation (NMES) has been demonstrated to effectively modulate cortical activities by evoking muscle contraction in upper limb and generating joint movements, which showed an excellent performance in motor rehabilitation. However, due to hand loss and cortical function reorganization induced by hand amputation, how neural activities in sensorimotor cortex response to NMES-evoked muscle contraction in the end of an amputation stump is not clear. In this paper, Ischemic nerve block (INB) technique was used to build an acute hand loss model, and 64-channel EEG signals were recorded from 11 healthy subjects to perform a 2×2 factorial design protocol, with the INB state and the current intensity as factors. The changes of NMES-evoked sensorimotor cortical activities were quantified by computing Beta-band event-related desynchronization (Beta ERD) patterns and the time-varying functional connectivity using adaptive directed transfer function (ADTF) before and during INB. The acute hand "loss" resulted in ipsilateral dominance of Beta ERD induced by NMES with two current intensities in the topographic maps, that is, ipsilateral Beta ERD was significantly higher than that the contralateral one (p<0.05). However, before INB, Beta ERD in the contralateral sensorimotor cortex induced by NMES above motor threshold was significantly higher than that in the ipsilateral area (p< 0.01). Meanwhile, whatever before or during INB, clustering coefficients of the ADTF network in sensorimotor cortex showed temporal dynamics during two NMES tasks. During INB, NMES above motor threshold-evoked lower clustering coefficients of the time-varying network in sensorimotor cortex than that before INB (p<0.05). The present results suggest that the loss of the hand proprioception will degrade cortical activities in the contralateral area, and increase cortical activities in the ipsilateral area compensatively responding to NMES. This finding may be particularly important to improve the reconstruction of the proprioception function of hand prosthesis.

A Case of Traumatic Hand Ischemia – Managed Successfully with Neurovascular and Soft-tissue Reconstruction

Upper limb has rich vascular supply due to sufficient collaterals around the shoulder, elbow, and wrist joints which prevents ischemia and maintains viability of the upper limb in case of vascular injury or occlusion. There are numerous literature available, regarding the management of isolated single arterial injury in the forearm, which suggest that ligation of single artery (radial or ulnar) is safer if the companion arterial supply is intact. Hand salvage becomes more challenging when patient presents with acute hand ischemia following injury to both forearm arteries and has associated musculoskeletal injuries. We hereby report the case of a 24-year-old male who sustained glass-cut injuries to his right distal forearm resulting in both forearm arterial, nerves, flexor tendon injuries, and presented as acute hand ischemia. The patient was managed by reconstruction of radial and ulnar arteries using reverse saphenous vein graft (RSVG) along-with primary repair of median and ulnar nerves and flexor tendons. Skin and soft tissue defect was subsequently covered using antero-lateral thigh flap. The prompt and timely management of patient resulted in hand salvage with good functional outcome.

Teaching NeuroImages: Spinal cord infarct due to fibrocartilaginous embolism in an adolescent

A 15-year-old healthy, active girl presented with acute bilateral upper extremity tingling and hand weakness while playing golf; within several hours, she developed numbness and weakness in all limbs. She denied preceding trauma and bowel/bladder incontinence. Examination showed global weakness, normal tone and reflexes, a C5 sensory level, and decreased light touch/temperature/pinprick in all limbs. Neuroimaging revealed an anterior spinal artery cervical cord infarct (figure), along with a degenerative disk, attributed to fibrocartilaginous embolism.

A commentary from the pioneers on the innovation of the relative motion concept: History, biologic considerations, and anatomic rationale

The relative motion concept is simply recognition of the normal functional anatomic relationships that allow powerful extrinsic muscles, the extensor digitorum communis (EDC) and flexor digitorum profundus (FDP), to vary forces on individual finger joints and function in response to the relative position of adjacent metacarpophalangeal joints (MCPJs) in the hand, one to another. First identified as a cause of complications after surgery, a better understanding now allows us to harness these forces by way of differential metacarpophalangeal joint (MCPJ) positioning using an orthosis. This can reduce undesirable tension and allow immediate controlled active motion while permitting functional use of the hand. Tissue gliding with active motion prevents restrictive scarring, maintains joint mobility and avoids unnecessary limitations and stiffness on normal neighboring structures. The historical development of this concept is shared with explanation of the anatomic and biologic rationale for this approach. Acute and chronic hand conditions that may benefit from better understanding of relative motion are numerous and growing.