Rehabilitation of the Hand and Upper

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 CONTRIBUTORS

Joshua Abzug, MD Pat L. Aulicino, MD

Fellow, Hand Surgery Sentara Hand Surgery Specialists
Thomas Jefferson University Hospital Chesapeake, Virginia
The Philadelphia and South Jersey Hand Centers, P.C.
Philadelphia, Pennsylvania Alejandro Badia, MD, FACS
Badia Hand to Shoulder Center
Julie E. Adams, MD Doral, Florida
Assistant Professor
Orthopaedic Surgery Mark E. Baratz, MD
University of Minnesota Professor and Executive Vice Chairman
Minneapolis, Minnesota Director, Division of Upper Extremity Surgery
Program Director, Orthopedic Residency and Upper
Steven Alter, MD Extremity Fellowship
Orthopedic Hand Surgeon Department of Orthopedics
Orthopedic Surgical Associates Drexel University for the Health Sciences
Lowell, Massachusetts Allegheny General Hospital
Pittsburgh, Pennsylvania
Emily Altman, PT, DPT, CHT
Senior Physical Therapist Mary Barbe, PhD
Hand Therapy Center Professor of Anatomy and Cell Biology
Hospital for Special Surgery Temple University School of Medicine
New York, New York Philadelphia, Pennsylvania

Ann E. Barr, DPT, PhD

Peter C. Amadio, MD Vice Provost and Executive Dean
Lloyd A. and Barbara A. Amundson Professor of Orthopedic College of Health Professionals
Surgery Pacific University
Mayo Clinic Hillsboro, Oregon
Rochester, Minnesota
Mary Bathen, BS
Thomas J. Armstrong, BSE, MPH, PhD Medical Student
Professor, Industrial and Operations Engineering and University of California, San Diego, School of Medicine
Biomedical Engineering La Jolla, California
The University of Michigan
Ann Arbor, Michigan Jeanine Beasley, EdD, OTR, CHT
Assistant Professor
Sandra M. Artzberger, MS, OTR, CHT Grand Valley State University;
Certified Hand Therapist Hand Therapist
Rocky Mountain Physical Therapy and Sports Injury Center Cherry Street Hand Therapy
Pagosa Springs, Colorado Advent Health;
Hand Therapist
Sarah Ashworth, OTR/L East Paris Hand Therapy
Shriners Hospital for Children Mary Free Bed Rehabilitation Hospital
Philadelphia, Pennsylvania Grand Rapids, Michigan
ix
x CONTRIBUTORS

John M. Bednar, MD Salvador L. Bondoc, OTD, OTR/L, CHT

Clinical Associate Professor of Orthopaedic Surgery Senior Occupational Therapist
Thomas Jefferson Medical College William Randolph Hurst Burn Center at New York–
The Philadelphia and South Jersey Hand Centers, P.C. Presbyterian Hospital
Philadelphia, Pennsylvania Weill-Cornell Medical Center
New York, New York
Judith A. Bell Krotoski, MA, OTR/L, CHT, FAOTA
CAPTAIN, United States Public Health Service (retired); Michael J. Botte, MD
Guest Lecturer/Instructor Clinical Professor
Texas Women’s University University of California, San Diego;
Houston, Texas; Attending Surgeon
Private Research, Teaching, and Consulting VA San Diego Healthcare System
Hand Therapy Research San Diego, California;
Baton Rouge, Louisiana Co-Director, Hand and Microvascular Surgery
Scripps Clinic
Mark R. Belsky, MD La Jolla, California
Clinical Professor
Tufts University School of Medicine
David J. Bozentka, MD
Boston, Massachusetts;
Chief of Orthopedic Surgery
Chief, Orthopaedic Surgery
Penn Presbyterian Medical Center
Newton-Wellesley Hospital
University of Pennsylvania School of Medicine
Newton, Massachusetts
Philadelphia, Pennsylvania
Pedro K. Beredjiklian, MD
Associate Professor of Orthopaedic Surgery Zach Broyer, MD
Thomas Jefferson School of Medicine; Thomas Jefferson University Medical School
Chief, Hand Surgery Division Philadelphia, Pennsylvania
The Rothman Institute
Philadelphia, Pennsylvania Donna Breger-Stanton, MA, OTR/L, CHT, FAOTA
Associate Professor
Richard A. Berger, MD, PhD Academic Fieldwork Coordinator
Professor of Orthopaedic Surgery and Anatomy Samuel Merritt University
Dean, Mayo School of Continuous Professional Development Oakland, California
College of Medicine
Mayo Clinic; Anne M. Bryden, OTR/L
Consultant, Orthopedic Surgery; The Cleveland FES Center
Chair, Division of Hand Surgery Cleveland, Ohio
Mayo Clinic
Rochester, Minnesota
Katherine Butler, B Ap Sc (OT) AHT (BAHT)
A Mus A (flute)
Thomas H. Bertini, Jr., DPT, ATC
Clinical Specialist in Hand Therapy
Department of Physical Therapy & Rehabilitation Sciences
London Hand Therapy
Drexel University
London, Great Britain
Philadelphia, Pennsylvania

Sam J. Biafora, MD Nancy N. Byl, MPH, PhD, PT, FAPTA

Fellow Professor Emeritus
Thomas Jefferson University University of California, San Francisco, School of Medicine
The Philadelphia Hand Center Department of Physical Therapy and Rehabilitation Science;
Philadelphia, Pennsylvania Clinical Professor
San Francisco State University
Teri M. Bielefeld, PT, CHT Physical Therapy Program;
PT Clinical Specialist Physical Therapist
Outpatient Clinic Physical Therapy Health and Wellness Program
Zablocki Veterans Affairs Medical Center University of California, San Francisco, Faculty Practice
Milwaukee, Wisconsin San Francisco, California

Susan M. Blackmore, MS, OTR/L, CHT Nancy Cannon, OTR, CHT

Assistant Director of Hand Therapy Director
The Philadelphia Hand Center Indiana Hand to Shoulder Center
King of Prussia, Pennsylvania Indianapolis, Indiana
 CONTRIBUTORS xi

Roy Cardoso, MD Phani K. Dantuluri, MD

Assistant Professor of Clinical Orthopaedics Assistant Clinical Professor
University of Miami Leonard Miller School Medicine; Department of Orthopaedics
Orthopaedic Surgeon Emory University Midtown Hospital
Bascom Palmer Eye Hospital Atlanta Medical Center
Miami, Florida Resurgens Orthopaedics
Atlanta, Georgia
James Chang, MD
Professor and Chief of Plastic and Reconstructive Surgery
Stanford University Sylvia A. Dávila, PT, CHT
Stanford, California Hand Rehabilitation Associates of San Antonio, Inc.
San Antonio, Texas
Nancy Chee, OTR/L, CHT
Adjunct Assistant Professor
Samuel Merritt University Paul C. Dell, MD
Oakland, California; Chief of the Hand Surgery Division
Hand Therapist Department of Orthopaedics
California Pacific Medical Center University of Florida Orthopaedics and Sports Medicine
San Francisco, California Gainesville, Florida

Jill Clemente, MS
Research Coordinator Ruth B. Dell, MHS, OTR, CHT
Department of Orthopaedics Chief of the Hand Therapy Division
Allegheny General Hospital Department of Orthopaedics
Pittsburgh, Pennsylvania University of Florida Orthopaedics and Sports Medicine
Gainesville, Florida
Mark S. Cohen, MD
Professor and Director, Hand and Elbow Section;
Director, Orthopaedic Education Lauren M. DeTullio, MS, OTR/L, CHT
Department of Orthopaedic Surgery Assistant Director
Rush University Medical Center The Philadelphia and South Jersey Hand Centers, P.C.
Chicago, Illinois Philadelphia, Pennsylvania

Judy C. Colditz, OTR/L, CHT, FAOTA Cecelia A. Devine, OTR, CHT

HandLab Adjunct Instructor
Raleigh, North Carolina Department of Occupational Therapy
Mount Mary College;
Ruth A. Coopee, MOT, OTR/L, CHT, MLD, CDT, CMT Clinical Coordinator, Hand Therapy
Hand Therapist Froedtert Hospital
Lymphedema Therapist Milwaukee, Wisconsin
Largo Medical Center
Largo, Florida
Madhuri Dholakia, MD
Cynthia Cooper, MFA, MA, OTR/L, CHT Thomas Jefferson University Medical School
Clinical Specialist in Hand Therapy The Rothman Institute
Faculty, Physical Therapy Orthopedic Residency Program Philadelphia, Pennsylvania
Scottsdale Healthcare
Scottsdale, Arizona
Edward Diao, MD
Randall W. Culp, MD, FACS Professor Emeritus
Professor of Orthopaedic, Hand and Microsurgery Departments of Orthopaedic Surgery and Neurosurgery;
Thomas Jefferson University Hospital Former Chief
Philadelphia, Pennsylvania; Division of Hand, Upper Extremity, and Microvascular
Physician Surgery
The Philadelphia and South Jersey Hand Centers, P.C. University of California, San Francisco
King of Prussia, Pennsylvania San Francisco, California

Leonard L. D’Addesi, MD
The Reading Hospital and Medical Center Annie Didierjean-Pillet, Psychoanalyst
Reading, Pennsylvania Strasbourg, France
xii CONTRIBUTORS

Susan V. Duff, EdD, PT, OTR/L, CHT Paul Feldon, MD

Associate Professor Associate Professor of Orthopaedic Surgery
Department of Physical and Occupational Therapy Tufts University School of Medicine
Thomas Jefferson University; Boston, Massachusetts
Clinical Specialist, Occupational Therapy
Children’s Hospital of Philadelphia Sheri B. Feldscher, OTR/L, CHT
Philadelphia, Pennsylvania Senior Hand Therapist
The Philadelphia and South Jersey Hand Centers, P.C.
Matthew D. Eichenbaum, MD Philadelphia, Pennsylvania
Chief Resident in Orthopaedic Surgery
Thomas Jefferson University Hospital Elaine Ewing Fess, MS, OTR, FAOTA, CHT
Philadelphia, Pennsylvania Adjunct Assistant Professor
School of Allied Health and Rehabilitation
Bassem T. Elhassan, MD Indiana University
Assistant Professor of Orthopedics Indianapolis, Indiana
Mayo Clinic
Rochester, Minnesota Lynn Festa, OTR, CHT
Certified Hand Therapist
Melanie Elliott, PhD Crouse Hospital
Instructor of Neurosurgery Syracuse, New York
Thomas Jefferson University
Philadelphia, Pennsylvania Mitchell K. Freedman, DO
Clinical Assistant Professor
Timothy Estilow, OTR/L Thomas Jefferson University Medical School;
Occupational Therapist Director of Physical Medicine and Rehabilitation
Children’s Hospital of Philadelphia The Rothman Institute
Philadelphia, Pennsylvania Philadelphia, Pennsylvania

Roslyn B. Evans, OTR/L, CHT Alan E. Freeland, MD

Director/Owner Professor Emeritus
Indian River Hand and Upper Extremity Rehabilitation University of Mississippi Medical Center
Vero Beach, Florida Jackson, Mississippi

Marybeth Ezaki, MD Mary Lou Galantino, PT, PhD, MSCE

Professor of Orthopaedic Surgery Professor
University of Texas Southwestern Medical School; Richard Stockton College of New Jersey
Director of Hand Surgery Pomona, New Jersey;
Texas Scottish Rite Hospital for Children Adjunct Research Scholar
Dallas, Texas University of Pennsylvania
Philadelphia, Pennsylvania;
Frank Fedorczyk, PT, DPT, OCS Clinician
Physical Therapist PT Plus Christiana Care
Yardley, Pennsylvania Wilmington, Delaware

Jane M. Fedorczyk, PT, PhD, CHT, ATC Kara Gaffney Gallagher, MS, OTR/L, CHT
Associate Clinical Professor Occupational Therapist/Hand Therapist
Director, Post-Professional Clinical Programs King of Prussia Physical Therapy and Sports Injury Center
Department of Physical Therapy & Rehabilitation Sciences King of Prussia, Pennsylvania
College of Nursing and Health Professions
Drexel University Marc Garcia-Elias, MD, PhD
Philadelphia, Pennsylvania Consultant, Hand Surgery
Institut Kaplan
Lynne M. Feehan, BScPT, MSc(PT), PhD, CHT Barcelona, Spain
Postdoctoral Fellow
Michael Smith Foundation for Health Research Bryce W. Gaunt, PT, SCS, CSCS
Department of Physical Therapy Director of Physical Therapy
University of British Columbia HPRC at St. Francis Rehabilitation Center
Vancouver, British Columbia, Canada Columbus, Georgia
 CONTRIBUTORS xiii

Charles L. Getz, MD Eduardo Hernandez-Gonzalez, MD

Assistant Professor Private Practice
Department of Orthopaedic Surgery Miami, Florida
Thomas Jefferson Medical School;
The Rothman Institute Heather Hettrick, PhD, PT, CWS, FACCWS, MLT
Philadelphia, Pennsylvania Assistant Clinical Professor
Drexel University
Philadelphia, Pennsylvania
Jason Gould, MD Vice President, Academic Affairs and Education
New York, New York American Medical Technologies
Irvine, California
Thomas J. Graham, MD
Chief, Cleveland Clinic Innovations Alan S. Hilibrand, MD
Vice Chair, Orthopaedic Surgery Professor of Orthopaedic Surgery
Cleveland Clinic Professor of Neurology
Cleveland, Ohio Thomas Jefferson University Medical School;
The Rothman Institute
Philadelphia, Pennsylvania
Rhett Griggs, MD
Alpine Orthopaedics, Sports Performance & Regional Hand Leslie K. Holcombe, MScOT, CHT
Center Consultant
Gunnison, Colorado Pillet Hand Prostheses, Ltd.
New York, New York
Brad K. Grunert, PhD
Harry Hoyen, MD
Professor, Plastic Surgery;
Assistant Professor
Professor, Psychiatry and Behavioral Medicine
Department of Orthopaedic Surgery
Medical College of Wisconsin
Case Western Reserve University Medical School
Milwaukee, Wisconsin
Cleveland, Ohio

Ranjan Gupta, MD Deborah Humpl, OTR/L

Professor and Chair Children’s Hospital of Philadelphia
Orthopaedic Surgery Philadelphia, Pennsylvania
University of California, Irvine;
Principal Investigator Larry Hurst, MD
University of California, Irvine; Professor and Chairman
Peripheral Nerve Research Laboratory Department of Orthopaedics
Irvine, California SUNY Stony Brook
Stony Brook, New York
Maureen A. Hardy, PT, MS, CHT Asif M. Ilyas, MD
Director Assistant Professor of Orthopaedic Surgery
Rehabilitation Services and Hand Management Center Thomas Jefferson University;
St. Dominic Hospital The Rothman Institute
Jackson, Mississippi Philadelphia, Pennsylvania

Michael Hausman, MD Dennis W. Ivill, MD

Robert K. Lippmann Professor of Orthopedic Surgery Clinical Assistant Professor
Mount Sinai School of Medicine; Thomas Jefferson University Medical School;
Vice Chairman Staff Psychiatrist
Department of Orthopedic Surgery; The Rothman Institute
Chief, Hand and Elbow Surgery Philadelphia, Pennsylvania
Mount Sinai Medical Center
New York, New York Sidney M. Jacoby, MD
Assistant Professor
Department of Orthopaedic Surgery
David Hay, MD Jefferson Medical College
Chief Resident Thomas Jefferson University;
Stanford University Hospital and Clinics The Philadelphia and South Jersey Hand Centers, P.C.
Standford, California Philadelphia, Pennsylvania
xiv CONTRIBUTORS

Neil F. Jones, MD, FRCS Zinon T. Kokkalis, MD

Professor of Orthopedic Surgery Consultant
Professor of Plastic and Reconstructive Surgery First Department of Orthopaedic Surgery “Attikon” University
Chief of Hand Surgery General Hospital
University of California, Irvine University of Athens School of Medicine
Irvine, California; Athens, Greece
Consulting Hand Surgeon
Shriners Hospital L. Andrew Koman, MD
Los Angeles, California; Professor and Chair
Consulting Hand Surgeon Department of Orthopaedic Surgery
Children’s Hospital of Orange County Wake Forest University School of Medicine
Orange, California Winston-Salem, North Carolina

Lana Kang, MD Scott H. Kozin, MD

Assistant Professor Professor
Weil Cornell Medical College of Cornell University; Department of Orthopeadic Surgery
Attending Orthopaedic Surgeon Temple University;
Hospital for Special Surgery; Hand Surgeon
Attending Orthopaedic Surgeon Shriners Hospital for Children
New York–Presbyterian Hospital of Cornell University Philadelphia, Pennsylvania
New York, New York
Leo Kroonen, MD
Parivash Kashani, OTR/L Assistant Director of Hand Surgery
Hand Therapist Naval Medical Center
University of California, Los Angeles San Diego, California
Los Angeles, California
Tessa J. Laidig, DPT
Leonid Katolik, MD Department of Physical Therapy & Rehabilitation Sciences
Attending Surgeon Drexel University
The Philadelphia and South Jersey Hand Centers, P.C. Philadelphia, Pennsylvania
Assistant Professor
Thomas Jefferson University School of Medicine Amy Lake, OTR, CHT
Philadelphia, Pennsylvania Texas Scottish Rite Hospital for Children
Dallas, Texas
Michael W. Keith, MD
Professor Paul LaStayo, PhD, PT, CHT
Case Western Reserve University; Department of Physical Therapy
Orthopedic Surgeon Department of Orthopaedics
MetroHealth Medical Center; Department of Exercise and Sport Science
Principle Investigator University of Utah
Case Western Reserve University Salt Lake City, Utah
Cleveland, Ohio
Mark Lazarus, MD
Rothman Institute
Martin J. Kelley, PT, DPT, OCS
Philadelphia, PA
Good Shepherd Penn Partners
Penn Presbyterian Medical Center
Philadelphia, Pennsylvania Marilyn P. Lee, MS, OTR/L, CHT
Supervisor, Hand and Upper Extremity Rehabilitation
Crozer Keystone Health System, Springfield Division
David M. Kietrys, PT, PhD, OCS Springfield, Pennsylvania
Associate Professor
University of Medicine and Dentistry of New Jersey
Michael Lee, PT, DPT, CHT
Stratford, New Jersey
Clinical Director
Maximum Impact Physical Therapy
Yasuko O. Kinoshita, ORT/L, CHT Tucson, Arizona
La Jolla, California
Brian G. Leggin, PT, DPT, OCS
Diana L. Kivirahk, OTR/L, CHT Team Leader
Scripps Clinic Division of Orthopaedic Surgery Penn Presbyterian Medical Center
La Jolla, California Philadelphia, Pennsylvania
 CONTRIBUTORS xv

Matthew Leibman, MD Glenn A. Mackin, MD, FRAN, FACP

Assistant Clinical Professor Associate Professor of Clinical Neurology
Orthopaedic Surgery Pennsylvania State University/Milton S. Hershey Medical
Tufts University School of Medicine Center
Boston, Massachusetts; Hershey, Pennsylvania;
Newton-Wellesley Hospital Director and Staff Neurologist
Newton, Massachusetts Neuromuscular Diseases Center and ALS Clinic
Lehigh Valley Health Network
L. Scott Levin, MD, FACS Allentown, Pennsylvania
Professor and Chairman
Department of Orthopaedic Surgery Leonard C. Macrina, MSPT, SCS, CSCS
Professor, Plastic Surgery Sports Certified Physical Therapist
Hospital of the University of Pennsylvania Certified Strength and Conditioning Specialist
Philadelphia, Pennsylvania Champion Sports Medicine
Birmingham, Alabama
Zhongyu Li, MD, PhD Kevin J. Malone, MD
Assistant Professor Assistant Professor
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Wake Forest University School of Medicine Case Western Reserve University
Winston-Salem, North Carolina MetroHealth Medical Center
Cleveland, Ohio
Chris Lincoski, MD
Hand Surgery Fellow Gregg G. Martyak, MD
Thomas Jefferson University Hospital Orthopedic Surgery, Hand and Upper Extremity
Philadelphia, Pennsylvania San Antonio Military Medical Center
Fort Sam Houston, Texas
Kevin J. Little, MD
Assistant Professor John A. McAuliffe, MD
Department of Orthopaedic Surgery Hand Surgeon
University of Cincinnati School of Medicine; Broward Health Orthopaedics
Cincinnati Children’s Hospital Medical Center Fort Lauderdale, Florida
Cincinnati, Ohio Philip McClure, PT, PhD, FAPTA
Professor
Frank Lopez, MD, MPH Arcadia University
Assistant Professor Glenside, Pennsylvania
University of Pennsylvania
Philadelphia, Pennsylvania Pat McKee, MSc, OT Reg (Ont), OT(C)
Associate Professor
John Lubahn, MD Department of Occupational Science and Occupational
Orthopaedic Residency Program Director Therapy
Hamot Medical Center Faculty of Medicine
Erie, Pennsylvania University of Toronto
Toronto, Ontario, Canada
Göran Lundborg, MD, PhD
Kenneth R. Means, Jr., MD
Professor
Attending Hand Surgeon
Lund University;
The Curtis National Hand Center
Senior Consultant
Union Memorial Hospital
Department of Hand Surgery
Baltimore, Maryland
Skåne University Hospital
Malmö, Sweden Robert J. Medoff, MD
Assistant Clinical Professor
Joy C. MacDermid, BScPT, PhD University of Hawaii John A Burns School of Medicine
Assistant Dean, Rehabilitation Science Honolulu, Hawaii
Professor, Rehabilitation Science
McMaster University School of Rehabilitation Science Jeanne L. Melvin, MS, OTR, FAOTA
Hamilton, Ontario, Canada; Owner
Co-Director of Clinical Research Solutions for Wellness
Hand and Upper Limb Center Private Practice
London, Ontario, Canada Santa Monica, California
xvi CONTRIBUTORS

R. Scott Meyer, MD Scott N. Oishi, MD

Section Chief, Orthopaedic Surgery Texas Scottish Rite Hospital for Children
VA San Diego Healthcare System; Dallas, Texas
Associate Clinical Professor
Department of Orthopaedic Surgery A. Lee Osterman, MD
University of California at San Diego Professor, Orthopaedic and Hand Surgery
San Diego, California Chairman, Division of Hand Surgery
Department of Orthopaedic Surgery
Susan Michlovitz, PT, PhD, CHT Jefferson Medical College
Adjunct Associate Professor Thomas Jefferson University;
Rehabilitation Medicine President, The Philadelphia and South Jersey Hand Centers, P.C.
Columbia University and Hand Surgery Fellowship Program
New York, New York; Philadelphia, Pennsylvania
Physical Therapist Lorenzo L. Pacelli, MD
Cayuga Hand Therapy Consultant
Ithaca, New York Ascension Orthopedics
Austin, Texas
Steven L. Moran, MD
Professor of Plastic Surgery Allen E. Peljovich, MD, MPH
Associate Professor of Orthopedic Surgery Attending Surgeon
Chair of Plastic Surgery The Hand and Upper Extremity Center of Georgia;
The Mayo Clinic Clinical Instructor
Rochester, Minnesota; Department of Orthopaedic Surgery
Staff Surgeon Atlanta Medical Center;
Shriners Hospital for Children Attending Surgeon
Twin Cities Shepherd Center;
Minneapolis, Minnesota Medical Director
Hand and Upper Extremity Program
William B. Morrison, MD Children’s Healthcare of Atlanta
Professor of Radiology Atlanta, Georgia
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania Karen Pettengill, MS, OTR/L, CHT
Clinical Coordinator
Edward A. Nalebuff, MD NovaCare Hand and Upper Extremity Rehabilitation
Clinical Professor Springfield, Massachusetts
Orthopaedic Surgery
Nicole M. Pettit, DPT
Tufts University School of Medicine;
Department of Physical Therapy & Rehabilitation Sciences
Hand Surgeon
Drexel University
New England Baptist Hospital
Philadelphia, Pennsylvania
Boston, Massachusetts
Cynthia A. Philips, MA, OTR/L, CHT
Donald A. Neumann, PT, PhD, FAPTA Hand Therapist
Professor, Physical Therapy Farmingham, Massachusetts
Marquette University
Milwaukee, Wisconsin Jason Phillips, MD
Orthopaedic Resident
Richard Norris, MD Albert Einstein Medical Center
Director Philadelphia, Pennsylvania
Northampton Spine Medicine
Northampton, Massachusetts; Jean Pillet, MD
Board Certified, Physical Medicine and Rehabilitation Strasbourg, France
Fellowship, Orthopedics; Marisa Pontillo, PT, DPT, SCS
Founder and Former Director Senior Physical Therapist
The National Arts Medicine Center GSPP Penn Therapy and Fitness at Penn Sports Medicine
Washington, District of Columbia Center
Philadelphia, Pennsylvania
Michael J. O’Brien, MD
Assistant Professor Ann Porretto-Loehrke, PT, DPT, CHT, COMT
Department of Orthopaedics Therapy Manager
Tulane Institute for Sports Medicine Hand and Upper Extremity Center of Northeast Wisconsin
New Orleans, Louisiana Appleton, Wisconsin
 CONTRIBUTORS xvii

Neal E. Pratt, PhD, PT Erik A. Rosenthal, MD

Emeritus Professor Retired Clinical Professor of Orthopaedic Surgery
Department of Physical Therapy and Rehabilitation Sciences Tufts University School of Medicine
Drexel University Boston, Massachusetts;
Philadelphia, Pennsylvania Honorary Staff
Baystate Medical Center
Victoria W. Priganc, PhD, OTR, CHT, CLT Springfield, Massachusetts
Owner, Hand Therapy Consultation Services
Richmond, Vermont Ralph Rynning, MD
Fellow
Thomas Jefferson University Hospital
Joshua A. Ratner, MD Philadelphia, Pennsylvania
The Hand Treatment Center
Atlanta, Georgia Douglas M. Sammer, MD
Assistant Professor of Surgery
Christina M. Read, DPT Washington University School of Medicine
Department of Physical Therapy & Rehabilitation Sciences St. Louis, Missouri
Drexel University
Philadelphia, Pennsylvania Rebecca J. Saunders, PT, CHT
Clinical Specials
Mark S. Rekant, MD Curtis National Hand Center
Assistant Professor Union Memorial Hospital
Department of Orthopaedic Surgery Baltimore, Maryland
Thomas Jefferson University
Philadelphia, Pennsylvania Michael Scarneo, DPT
Department of Physical Therapy and Rehabilitation Sciences
Drexel University
David Ring, MD, PhD Philadelphia, Pennsylvania
Associate Professor of Orthopaedic Surgery
Harvard Medical School; Christopher C. Schmidt, MD
Director of Research Shoulder, Elbow, and Hand Surgery
MGH Orthopaedic Hand and Upper Extremity Service Department of Orthopaedic Surgery
Massachusetts General Hospital Allegheny General Hospital
Boston, Massachusetts Pittsburgh, Pennsylvania

Annette Rivard, MScOT, PhD(Can) Lawrence H. Schneider, MD

Assistant Professor Retired Clinical Professor
Department of Occupational Therapy Department of Orthopaedic Surgery
University of Alberta Jefferson Medical College
Edmonton, Alberta, Canada Thomas Jefferson University
Philadelphia, Pennsylvania
Marco Rizzo, MD
Associate Professor Karen Schultz-Johnson, MS, OTR, CHT, FAOTA
Department of Orthopedic Surgery Director
Mayo Graduate School of Medicine; Rocky Mountain Hand Therapy
Associate Professor Edwards, Colorado
Department of Orthopedic Surgery
Mayo Clinic Jodi L. Seftchick, MOT, OTR/L, CHT
Rochester, Minnesota Senior Occupational Therapist
Human Motion Rehabilitation
Allegheny General Hospital
Sergio Rodriguez, MD Pittsburgh, Pennsylvania
McAllen Hand Center
Edinburg, Texas Michael A. Shaffer, PT, ATC, OCS
Coordinator for Sports Rehabilitation
Birgitta Rosén, OT, PhD UI Sports Medicine;
Associate Professor Clinical Supervisor
Lund University; University of Iowa Hospitals and Clinics;
Occupational Therapist Department of Rehabilitation Therapies
Department of Hand Surgery Institute for Orthopaedics, Sports Medicine and
Skåne University Hospital Rehabilitation
Malmö, Sweden Iowa City, Iowa
xviii CONTRIBUTORS

Aaron Shaw, OTR/L, CHT Elizabeth Soika, PT, DPT, CHT

Clinical Specialist Physical Therapist, Certified Hand Therapist
Harborview Medical Center Results Physiotherapy
Seattle, Washington Clarksville, Tennessee

Eon K. Shin, MD Dean G. Sotereanos, MD

Assistant Professor in Orthopaedic Surgery Professor
Department of Orthopaedic Surgery Drexel University
Jefferson Medical College Philadelphia, Pennsylvania
Thomas Jefferson University; Vice Chairman
The Philadelphia and South Jersey Hand Centers, P.C. Department of Orthopaedic Surgery
Philadelphia, Pennsylvania Hand and Upper Extremity Surgery
Allegheny General Hospital
Conor P. Shortt, MB, BCh, BAO, MSc, MRCPI, FRCR, Pittsburgh, Pennsylvania
FFR RCSI
Assistant Professor of Radiology
Thomas Jefferson University Hospital Alexander M. Spiess, MD
Philadelphia, Pennsylvania Clinical Instructor
Allegheny General Hospital
Roger L. Simpson, MD, FACS Pittsburgh, Pennsylvania
Assistant Professor of Surgery
State University of New York, Stony Brook, New York; David Stanley, MBBS, BSc(Hons), FRCS
Director of Plastic and Reconstructive Surgery and the Burn Honorary Senior Lecturer
Center University of Sheffield;
Nassau University Medical Center Consultant Elbow and Shoulder Surgeon
Long Island Plastic Surgical Group Northern General Hospital
Garden City, New York Sheffield, South Yorkshire, United Kingdom
Terri M. Skirven, OTR/L, CHT
Director of Hand Therapy Pamela J. Steelman, CRNP, PT, CHT
The Philadelphia and South Jersey Hand Centers, P.C. Nurse Practitioner, Certified Hand Therapist
Director The Philadelphia and South Jersey Hand Centers, P.C.
Hand Rehabilitation Foundation Philadelphia, Pennsylvania
Philadelphia, Pennsylvania
Scott P. Steinmann, MD
David J. Slutsky, MD, FRCS(C) Professor of Orthopedic Surgery
Assistant Clinical Professor of Orthopedics Mayo Clinic
Chief of Reconstructive Hand Surgery Rochester, Minnesota
Harbor-UCLA Medical Center
David Geffen UCLA School of Medicine
Los Angeles, California Stephanie Sweet, MD
Clinical Assistant Professor
Beth Paterson Smith, PhD Department of Orthopaedic Surgery
Associate Professor Thomas Jefferson University;
Department of Orthopaedic Surgery Attending Hand Surgeon
Wake Forest University School of Medicine The Philadelphia and South Jersey Hand Centers, P.C.
Winston-Salem, North Carolina Philadelphia, Pennsylvania

Kevin L. Smith, MD, MS Varik Tan, MD

Private Practice Professor
Charlotte Plastic Surgery Department of Orthopaedics
Charlotte, North Carolina; University of Medicine and Dentistry of New Jersey
Associate Clinical Professor of Plastic Surgery The New Jersey Medical School;
University of North Carolina, Chapel Hill Director
Chapel Hill, North Carolina Hand and Upper Extremity Fellowship
University of Medicine and Dentistry of New Jersey
Thomas L. Smith, PhD The New Jersey Medical School
Professor Newark, New Jersey;
Department of Orthopaedic Surgery Attending Surgeon
Wake Forest University School of Medicine Overlook Hospital
Winston-Salem, North Carolina Summit, New Jersey
 CONTRIBUTORS xix

John S. Taras, MD Chris Tuohy, MD

Associate Professor Assistant Professor
Department of Orthopaedic Surgery Orthopaedic Surgery
Drexel University and Thomas Jefferson University; Wake Forest University School of Medicine;
Chief Orthopaedic Surgeon
Division of Hand Surgery North Carolina Baptist Hospital
Drexel University; Wake Forest University Health Sciences
The Philadelphia Hand Center, PC Winston-Salem, North Carolina
Philadelphia, Pennsylvania

Angela Tate, PT, PhD Sheryl S. Ulin, MS, PhD

Adjunct Faculty Research Program Officer
Arcadia University University of Michigan
Glenside, Pennsylvania; Ann Arbor, Michigan
Clinical Director
H/S Therapy, Inc
Lower Gwynedd, Pennsylvania
Gwendolyn van Strien, LPT, MSc
Director/Owner
Matthew J. Taylor, PT, PhD, RYT Hand Rehabilitation Consultancy
Founder and Director Den Haag, the Netherlands;
Dynamic Systems Rehabilitation Clinic Director
Scottsdale, Arizona Hand Therapy Unit
Lange Land Hospital
Andrew L. Terrono, MD Zoetermeer; the Netherlands;
Clinical Professor Clinical Instructor
Orthopaedic Surgery Department of Rehabilitation
Tufts University School of Medicine; Erasmus University Rotterdam
Chief Rotterdam, the Netherlands;
Hand Surgery Course Director and Instructor
New England Baptist Hospital Post Graduate Allied Health Education
Boston, Massachusetts National Institute for Allied Health
Amersfoort, the Netherlands
Allen Tham, MD
Resident
Department of Orthopaedic Surgery June P. Villeco, MBA, OTR/L, MLDC, CHT
Temple University Hospital Montgomery Hospital
Philadelphia, Pennsylvania Norristown, Pennsylvania

Michael A. Thompson, MD
Scripps Clinic Medical Group Rebecca L. von der Heyde, PhD, OTR/L, CHT
La Jolla, California Associate Professor of Occupational Therapy
Maryville University;
Wendy Tomhave, OTR/L Certified Hand Therapist
Shriners Hospital for Children Milliken Hand Rehabilitation Center
Twin Cities Shriner’s Hospital for Children
Minneapolis, Minnesota St. Louis, Missouri

Patricia A. Tufaro, OTR/L

Senior Occupational Therapist Ana-Maria Vranceanu, PhD
William Randolph Hearst Burn Center at New York– Clinical Staff Psychologist
Presbyterian Hospital Weill-Cornell Medical Center Massachusetts General Hospital
New York, New York Boston, Massachusetts

Thomas H. Tung, MD
Associate Professor of Surgery Heather Walkowich, DPT
Division of Plastic and Reconstructive Surgery Physical Therapist
Washington University School of Medicine The New Jersey Center of Physical Therapy
St. Louis, Missouri Riverdale, New Jersey
xx CONTRIBUTORS

Mark T. Walsh, PT, DPT, MS, CHT, ATC Terri L. Wolfe, OTR/L, CHT
Assistant Clinical Professor Director
Department of Physical Therapy and Rehabilitation Sciences Hand and Upper Body Rehabilitation Center
College of Nursing and Health Professions Erie, Pennsylvania
Drexel University
Philadelphia, Pennsylvania; Raymond K. Wurapa, MD
President, Co-Founder/Owner The Cardinal Orthopaedic Institute
Hand and Orthopedic Physical Therapist Associates, PC Columbus, Ohio
Levittown, Pennsylvania;
Consultant Michael J. Wylykanowitz, Jr., DPT
Hand Therapy and Upper Extremity Rehabilitation Department of Physical Therapy & Rehabilitation Sciences
Department of Physical Therapy and Rehabilitation Drexel University
Lower Bucks Hospital Philadelphia, Pennsylvania
Bristol, Pennsylvania
Theresa Wyrick, MD
Jo M. Weis, PhD Assistant Professor
Associate Professor, Psychiatry and Behavioral Medicine Department of Orthopaedic Surgery
Medical College of Wisconsin Arkansas Children’s Hospital
Milwaukee, Wisconsin University of Arkansas for Medical Sciences
Little Rock, Arkansas
Lawrence Weiss, MD
Assistant Professor of Orthopaedic Surgery Kathleen E. Yancosek, PhD, OTR/L, CHT
Pennsylvania State University School of Medicine; MAJOR
Chief United States Army
Division of Hand Surgery
Lehigh Valley Hospital Jeffrey Yao, MD
Allentown, Pennsylvania Assistant Professor of Orthopaedic Surgery
Robert A. Chase Hand and Upper Limb Center
Kevin E. Wilk, PT, DPT Stanford University Medical Center
Associate Clinical Director Stanford, California
Champion Sports Medicine;
Director of Rehabilitative Research David S. Zelouf, MD
American Sports Medicine Clinical Instructor
Birmingham, Alabama Department of Orthopaedic Surgery
Jefferson Medical College
Gerald R. Williams, Jr., MD Thomas Jefferson University;
Professor, Orthopaedic Surgery; Assistant Chief of Trauma Surgery
Chief, Shoulder and Elbow Service Thomas Jefferson University Hospital;
The Rothman Institute The Philadelphia and South Jersey Hand Centers, P.C.
Thomas Jefferson University Philadelphia, Pennsylvania
Philadelphia, Pennsylvania

Scott Wolfe, MD
Chief, Hand and Upper Extremity Surgery
Attending Orthopedic Surgeon
Hospital for Special Surgery;
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
New York, New York

As was true in previous editions of Rehabilitation of the Hand
and Upper Extremity, the editors’ purpose in this sixth edition
is to bring updated contributions from recognized experts in
the field.
When I think of the sixth edition, for me it’s not just a
new volume with new authors and new information. I rec-
ognize in each chapter a fulfillment and tribute to what came
before. The depth and quality of experience lived by pioneer-
ing hand surgeons and therapists, readily available to us in
the literature, influences every facet of hand rehabilitation as
we know it today. Those who had the vision to create our
unique medical specialty put us in a position to see old prob-
lems with fresh eyes and invite us to use our creativity to
find new ways to help our patients. We honor our predeces-
sors through our passion for continuous improvement. We
stand, truly, on the shoulders of giants. They would be proud,
as am I, of this new edition.
It was not always so. In the War between the States (1861–
1865), no special consideration was given to treatment of the
injured hand and little was recorded. Despite the number of
wrist and hand fractures due to gunshot and other injuries,
only a few pages of the Medical and Surgical History of the
War of the Rebellion dealt with hand wounds and surgery.
In World War I, somewhat less than three hundred lines
covered hand injuries in the Medical Department of the
United States Army’s World War, Volume XI, Surgery, Part I.
Prior to World War II, surgery for hand injuries sustained
by military personnel consisted essentially of drainage of
infections, amputations, and wound closure, with only iso-
lated efforts at repair. Physical and occupational therapy were
used inadequately or ignored.
World War II stimulated significant interest in reparative
hand surgery. Much of the early success in managing severe
hand injuries was due to the wise leadership of the Surgeon
General, Major General Norman T. Kirk. Rather than giving
hand wounds routine treatment, he considered them a sepa-
rate category worthy of specialized treatment. Nine “hand
centers” in selected military hospitals were established across
the country where officers trained in plastic, orthopedic,
and neurological surgery were entrusted with the repair of
wounded hands.
Under the guidance of Sterling Bunnell, MD, civilian con-
sultant to the Surgeon General, a two-phase plan for manag-
ing hand injuries was implemented. Instructional courses
and technical manuals outlined primary care for field sur-
geons. Soldiers receiving emergency wound closure in the
FOREWORD
Mediterranean and European Theaters of Operations were
returned to the United States via advanced transport for
definitive repair of tendons, nerves, and fractures.
Dr. Bunnell realized that postoperative therapy was as
critical to recovery and socioeconomic well-being as the
surgery itself. Patients with hand injuries who reached the
desired stage of healing were placed in a single ward close to
physical and occupational therapy departments. His seminal
idea of therapists participating as part of a fully coordinated
team to deliver optimal care gained momentum with hand
injuries that occurred during the Vietnam War.
Dr. Bunnell’s pioneering efforts attracted the interest of
younger hand surgeons who recognized the advantages of a
total care approach in civilian practice. One of these sur-
geons, James M. Hunter, MD, as civilian consultant in ortho-
pedic surgery to the department of the Army at Valley Forge
General Hospital (1964–1973), envisioned the team approach
in his private hand practice. Along with his partner, Lawrence
H. Schneider, MD, the Philadelphia Hand Center was founded
in 1972 in a former Horn and Hardart bakery.
The remarkable progress in total care of the injured hand
and upper extremity over the past half century is reflected in
the founding of the American Society for Surgery of the Hand
(ASSH) in 1946, the International Federation of Societies for
Surgery of the Hand (IFSSH) in 1968, the American Society
of Hand Therapists (ASHT) in 1978, and the International
Federation of Societies of Hand Therapy (IFSHT) in 1986.
Just as important, however, it is reflected in the rapid growth
and high quality of peer-reviewed scientific literature on hand
rehabilitation, most notably in the Journal of Hand Surgery
and the Journal of Hand Therapy.
Although there were textbooks on the surgical manage-
ment of hand injuries, in the 1960s there were few references
for therapists who were eager to learn more about postopera-
tive management. When I began working with Dr. Hunter in
the 1960s, the only reference available was a text on hand
rehabilitation by Wing Commander Wynn Parry, MD, who
was Consultant in Physical Medicine to the Royal Air Force
of England.
Six soft-covered manuals by Maude Malick, OTR (1967–
1972) describing hand splinting, management of the quad-
riplegic upper extremity, and management of the burn patient
took their place beside Wynn Parry’s text in the early litera-
ture on postoperative management.
During this time, another book was published abroad—
The Hand: Principles and Techniques of Simple Splintmaking
xxi
xxii FOREWORD
in Rehabilitation by Nathalic Barr, MBE, FBAOT of Great
Britain. It was intended to serve as a splinting guide in the
management of hand conditions. Nathalie was a major con-
tributor to hand rehabilitation in Europe, especially in the
early years after World War II.
Four years after the founding of the Philadelphia Hand
Center, an educational symposium was launched, chaired by
Drs. Hunter and Schneider and Evelyn Mackin, PT. The
meeting, “Rehabilitation of the Hand,” set a pattern and high
standard for future meetings. Together at the podium, sur-
geons and therapists discussed mutual problems before
a rapt audience of 450 of their peers. The success of the
1976 meeting set the stage for increasingly sophisticated
“Philadelphia Meetings” sponsored by the Philadelphia Hand
Rehabilitation Foundation and held every year since the origi-
nal meeting. Under the leadership of Terri Skirven, OTR/L,
CHT, and Lee Osterman, MD, the symposium has continued
to evolve, with a concurrent symposium directed to surgeons
introduced in 1999. Both meetings are considered must-
attend events by new and returning participants alike.
The papers presented at the first Philadelphia meeting
were incorporated into the first edition of Rehabilitation of
the Hand, edited by James Hunter, Lawrence Schneider,
Evelyn Mackin, and Judith Bell, OTR, FAOTA, CHT, which
brought surgeons and therapists together again as authors.
Chapters addressed functional anatomy, processes of wound
healing, surgical and postoperative care of hand injuries, and
the development of hand centers, among other topics.
With each succeeding edition (1984, 1990, 1995) edited
by James Hunter, Lawrence Schneider, Evelyn Mackin, and
Anne Callahan, MS, OTR/L, CHT, the text has been recog-
nized as the “bible” of an eager band of dedicated and enthu-
siastic therapists (JBJS) and as a “living classic” (JAMA).
It is impossible to reminisce without remembering the
hundreds of surgeons and therapists, leaders in their respec-
tive fields, who have made the editions and the meetings
possible, and to have known personally some of the giants
of in our field: Dr. William Littler, who in 1945 as Maj. J.
William Littler, MC, established a ward at the Cushing
General Hospital designated specifically for the care of hand
injuries, in accordance with Dr. Bunnell’s plan. Dr. Paul
Brand pioneered the surgical treatment of the hands of
leprosy patients in India, and established centers where
patients with reconstructed hands, under the care of physical
and occupational therapists, could learn a trade that would
make them self-reliant. Dr. Earl Peacock, having visited Dr.
Brand in India, was influenced by Dr. Brand’s advocating the
team approach in the care of the hand patient. He brought
this model of practice back to Chapel Hill, North Carolina,
and formed the “Hand House,” which was the first civilian
hand center in the United States. Joining him in the effort
were Irene Hollis, OTR; John Madden, MD; and Gloria
DeVore, OTR. I was inspired by these people. I still am.
If anyone should be mentioned especially as having influ-
enced my career, it is Dr. Hunter, my mentor and friend. His
forward vision, enthusiasm, and unwavering support of the
hand therapist in the early years was so important to the
development of hand therapy and the recognition it now
enjoys. He had the rare ability to lift those around him, hand
surgery fellows and hand therapists alike, to the level of
excellence that he always expected of them.
Almost a decade has passed since publication of the fifth
edition of Rehabilitation of the Hand and Upper Extremity
edited by Evelyn Mackin, Anne Callahan, Terri Skirven,
Lawrence Schneider, and Lee Osterman. It remains an indis-
pensible reference. However, with the continuing advances
in hand surgery and hand therapy, it becomes more important
than ever that new editions deliver the latest information to
our growing professional community worldwide.
It is an honor and a very much appreciated privilege, for
several reasons, to have been invited to write the foreword
to the sixth edition edited by Terri Skirven, Lee Osterman,
Jane Fedorczyk, PT, PhD, CHT, ATC, and Peter Amadio, MD.
Foremost is the respect I have for the editors. Then there is
the list of participating authors, who are recognized experts
on their subjects. Perhaps most of all, I have no doubt that
the hard work and dedicated efforts of the editors will ensure
that this groundbreaking and ever-evolving book will remain
for many years the most authoritative work on rehabilitation
of the hand and the upper extremity.
The Chinese say, “May you live in interesting times.”
I have.
Evelyn J. Mackin

Synergy, in general, may be defined as two or more agents
working together to produce a result not obtainable by any
of the agents independently. Synergy is the ability of a group
to outperform even its best individual member. The sixth
edition of Rehabilitation of the Hand and Upper Extremity is
the product of the synergy of editors, authors, publishers and
many others involved in its publication.
The impetus for the first edition of Rehabilitation of the
Hand grew out of a unique symposium that featured hand
surgery correlated with hand therapy, sponsored by the Hand
Rehabilitation Foundation in Philadelphia in 1976. The
original editors of the book were also the chairpersons and
faculty for the symposium: James M. Hunter, MD; Lawrence
Schneider; Evelyn Mackin, PT; and Judith A. Bell Krotoski,
OTR, FAOTA, CHT. Joining the effort with the second
through fifth editions was Anne D. Callahan, MS, OTR/L,
CHT. These extraordinary individuals introduced a working
partnership of hand surgeons and hand therapists for the care
of the hand patient that has endured and flourished over the
years and is evidenced by the publication of the sixth edition
of this book.
The expansion of this text and its readership is in keeping
with the growth of the specialty of hand rehabilitation. This
current two-volume edition features a total of 143 chapters,
37 of which are new, and more than 75 new authors. The
authors of the text include physical and occupational thera-
pists, certified hand therapists, orthopedic and plastic sur-
geons, physiatrists, neurologists, psychologists, psychiatrists,
clinicians, researchers, and educators—all having expertise
in the care of the hand and upper extremity patient.
Since the first edition, the table of contents has expanded
with each edition to include separate sections on the shoul-
der, elbow, and wrist, as well as the hand. Many returning
sections have been modified and expanded to reflect current
practice. For example, the term orthosis is used to refer to
the custom fabricated devices typically referred to as splints.
Far from just a technical skill, the design and fabrication of
hand and upper extremity orthoses require an in-depth
knowledge of anatomy and pathology, as well as the healing
and positioning requirements for the range of conditions and
surgeries encountered. Hand, occupational, and physical
therapists are uniquely qualified to design, apply, monitor,
and modify orthotic devices as part of the rehabilitation treat-
ment plan.
PREFACE
Taking advantage of the advances in information technol-
ogy, this edition is complemented by a companion web site
allowing supplemental information and video clips of therapy
and surgery procedures to be included.
Given the emphasis on evidence-based practice in the
current healthcare environment, special focus has been
placed on providing peer-reviewed literature support for the
information given in this text. However, published research
in hand and upper extremity rehabilitation is limited in many
areas. In some cases the best evidence is the clinical experi-
ence of the individual authors. Where it is stated that no
evidence exists to support a particular approach or tech-
nique, the intention is not to suggest that it be abandoned;
rather the goal is to stimulate the reader to adopt a critical
attitude and to pursue clinical research, whether as a single
case study or a multicenter randomized controlled trial.
We have dedicated this edition to Evelyn Mackin, who has
been the driving force behind the book, as well as so many
other groundbreaking achievements. Her leadership, dedica-
tion, determination, and inspiration have been instrumental
in advancing the specialty of hand rehabilitation, as well as
inspiring countless others (including the current editors) to
follow her lead and further her initiatives. Available on the
book’s web site is a fascinating interview with Evelyn,
recounting the early days of hand therapy, the formation of
the American Society of Hand Therapists, the development
of the Journal of Hand Therapy, and many other aspects of
her extraordinary career.
The publication of the sixth edition of Rehabilitation of the
Hand and Upper Extremity is the result of the efforts of many
people over more than 3 years and acknowledgments are due.
First and foremost, we would like to thank all of the authors
who have contributed their clinical expertise and insights to
this text.
Our special thanks is extended to Evelyn Mackin, who
has written the foreword for this edition and who has pro-
vided guidance, support, and encouragement to the current
editors.
We would like to acknowledge our editors at Elsevier for
their ongoing support and persistence to see the text through
to publication. In particular, Lucia Gunzel has been the
perfect combination of coach, cheerleader, and disciplinar-
ian. With Dan Pepper’s diplomacy and wise counsel, rough
patches were navigated and resolved. Ellen Sklar deserves
xxiii
xxiv PREFACE

recognition for her professional management of the final We are proud to present this sixth edition of Rehabilitation
stages of the editing process, a daunting task. of the Hand and Upper Extremity.
Thanks to Leslie Ristine, Administrator of the Philadelphia
Hand Rehabilitation Foundation, for providing administra- Terri M. Skirven
tive support, and to Andrew Cooney, Executive Director of A. Lee Osterman
the Philadelphia and South Jersey Hand Centers, who has
provided encouragement and support during the work on the Jane M. Fedorczyk
sixth edition, as well as for prior editions. Peter C. Amadio
Finally, we thank our families, friends, and colleagues
who have provided encouragement and patience during the
3 years that it has taken to complete the book.
 ONLINE SUPPLEMENTAL ELEMENTS

Forms: Chapter
Number Title
Figure 10-1 Upper Quarter Exam Form (8 1 × 11) (Chapter 16 Documentation: essential elements of an
2
10) upper extremity assessment battery
Kinesiotape Manual (Chapter 119) Elaine Ewing Fess
29 Staged flexor tendon reconstruction
Part I: staged flexor tendon reconstruction
James M. Hunter
Archive Chapter from the Part II: staged flexor reconstruction:
Third Edition: postoperative therapy
Evelyn J. Mackin
Chapter 56: Desensitization of the traumatized hand, Lois M. 34 Splinting the hand with a peripheral nerve
Barber injury
Judy C. Colditz
46 Mechanics of tendon transfers
Paul W. Brand
Archive Chapters from the 47 Tendon transfers: an overview
Fifth Edition: 83
Lawrence H. Schneider
A functionally based neuromechanical
Chapter approach to shoulder rehabilitation
Number Title Sandy L. Burkart, William R. Post
1 Atlas on regional anatomy of the neck, 109 The use of biofeedback in hand
axilla, and upper extremity rehabilitation
J. E. Healey, J. Hodge Susan M. Blackmore, Diana A. Williams,
13 Sensibility testing with the Semmes- Steven L. Wolf
Weinstein monofilaments 116 Anatomic considerations for splinting the
Judith A. Bell-Krotoski thumb
14 Sensibility assessment for nerve lesions-in- Judy C. Colditz
continuity and nerve lacerations 120 Splinting the hand of a child
Anne D. Callahan Patricia M. Byron

xxxi

Dedication video: An interview with Evelyn Mackin (2010)
Video 2-1: Wrist anatomy and surgical exposure (Berger
2009)
Video 2-2: Diagnostic wrist arthroscopy—(Nagle 2009)
Video 3-1: Anatomy of the elbow and proximal radioulnar
joints (Pratt 2010)
Video 4-1 Essental anatomy of the glemohumeral joint (Pratt
2010)
Video 7-1: Clinical exam of the wrist—(Skirven / Culp 2009)
Video 10-1: Upper quarter screen—AROM screening for
neural tension (McClure 2010)
Video 10-2: Upper quarter screen—cervical special tests
(McClure 2010)
Video 10-3: Upper quarter screen—cervical spine AROM and
passive overpressure (McClure 2010)
Video 10-4: Upper quarter screen—deep tendon reflexes
(McClure 2010)
Video 10-5: Upper quarter screen—joint scan (McClure
2010)
Video 10-6: Upper quarter screen—median ULTT (McClure
2010)
Video 10-7: Upper quarter screen—myotome scan (McClure
2010)
Video 10-8: Upper quarter screen—palpation neural com-
pression (McClure 2010)
Video 10-9: Upper quarter screen—radial ULTT (McClure
2010)
Video 10-10: Upper quarter screen—sensory scan (McClure
2010)
Video 10-11: Upper quarter screen—ulnar ULTT (McClure
2010)
Video 20-1: Compartment release of the hand and forearm—
(McCabe 2010)
Video 20-2: Flap coverage: cross finger, reverse cross finger,
thenar (Levin 2007)
Video 20-3: Radial forearm flap (Levin 2007)
Video 22-1: Dupuytren’s disease: percutaneous release (Eaton
2007)
Video 30-1: Pinning of metacarpal fractures and PIP joint
fractures (Belsky 2007)
Video 30-2: Dynamic external fixation—(Badia 2007)
Video 30-3: The mini compass hinge—(Sweet 2007)
Video 30-4: Volar plate arthroplasty (Belsky 2007)
Video 30-5: Hemi-hamate arthroplasty (Stern 2007)
Video 32-1: ORIF Bennett’s fracture (M. Hayton 2010)
Video 32-2: Gamekeeper’s thumb (Leslie 2007)
ONLINE VIDEO LIST
Video 35-1: Zone II repair (S. Wolfe 2010)
Video 35-2: Pulley reconstruction (T. Trumble 2010)
Video 35-3: Tendon exposure and retrieval (Strickland
2004)
Video 35-4: Popular core sutures (Sandow 2004)
Video 35-5: Zone 1 repair techniques (Sweet 2004)
Video 37-1: Techniques of grafting staged reconstruction
(Taras 2004)
Video 38-1: Repair boutonniere deformity (G. Germann
2010)
Video 38-2: Techniques of ORIF for bony mallet finger (A.
Shin 2010)
Video 38-3: Extensor tendon anatomy and approaches
(Zelouf 2004)
Video 38-4: Extensor tendon repair in fingers (Newport
2004)
Video 40-1: Tenolysis (Meals 2004)
Video 43-1: Primary nerve repair: median and ulnar nerves
at the wrist (Hentz 2004)
Video 44-1: Nerve graft harvest (Rekant 2004)
Video 44-2: Nerve conduits (Taras 2004)
Video 45-1: Grip formation: note wide aperture (width
between thumb and fingers) during reach-to-grasp of
blocks (Duff 2010)
Video 45-2: Demonstration of two of three components of
in-hand manipulation: translation (palm to fingers) and
shift (movement along fingertips) (Duff 2010)
Video 45-3: Use of a splint with ring and small finger
loops attached to a palmar bar to minimize “intrinsic
minus” or claw posturing after ulnar nerve injury (Duff
2010)
Video 45-4: CASE: subtest from the Jebsen test of hand func-
tion, turning cards (Duff 2010)
Video 48-1: Fat flap for failed CTR (Zelouf 2009)
Video 48-2: Carpal tunnel release: endoscope (Beckenbaugh
2004)
Video 48-3: Carpal tunnel release: mini (Zelouf 2004)
Video 50-1: Ulnar nerve release techniques: in situ/medial
epicondylectomy (Meals 2004)
Video 50-2: Ulnar nerve release techniques: SQ/Sub (Mackin-
non 2004)
Video 51-1: Radial nerve decompression (Sweet 2008)
Video 51-2: Ulnar nerve release at the wrist: sensory and
motor (Baratz 2004)
Video 51-3: Pronator and anterior interosseous nerve syn-
dromes (Stern 2004)
xxxiii
xxxiv ONLINE VIDEO LIST
Video 52-1: Therapist’s management of other nerve compres-
sions about the elbow and wrist (Porretto-Loehrke/Soika
2010)
Video 57-1: Surgical approaches to quadrilateral and sub-
scapular spaces (Brushart 2004)
Video 58-1: Radial nerve tendon transfer (Trumble 2004)
Video 59-1: 3 months post-op Jebsen—small items (Duff
2010)
Video 59-2: 3 months post-op Jebsen—cards (Duff 2010)
Video 59-3: 3 months post-op 9-hole peg test (Duff 2010)
Video 59-4: 6 months post-op Jebsen—small items (Duff
2010)
Video 59-5: 6 months post-op Jebsen—cards (Duff 2010)
Video 59-6: 6 months post-op 9-hole peg test (Duff 2010)
Video 60-1: BP tendon transfer (Kozin 2010)
Video 61-1: The Oberlin transfer for biceps reinnervation
(Levin 2008)
Video 63-1: Simple lymphatic drainage (Villeco 2010)
Video 63-2: Finger wraps (Villeco 2010)
Video 65-1: Demonstration of MEM home program (Artz-
berger 2010)
Video 69-1: Dorsal BP (Medoff 2010)
Video 69-2: Dorsal exposure (Medoff 2010)
Video 69-3: Radial column approach (Medoff 2010)
Video 69-4: Radial pin plate (Medoff 2010)
Video 69-5: Ulnar pin plate (Medoff 2010)
Video 69-6: Volar buttress pin (Medoff 2010)
Video 69-7: Volar plate fixation (Medoff 2010)
Video 69-8: Volar plate pitfalls (Medoff 2010)
Video 69-9: Volar rim exposures (Medoff 2010)
Video 69-10: Trimed fracture specific fixation (Medoff 2006)
Video 69-11: Synthes plate fixation (Jupiter 2006)
Video 69-12: Volar fixed angle correction of radius malalign-
ment (Orbay 2006)
Video 71-1: Ulnar extrinsic ligament repair (Osterman 2009)
Video 71-2: Ulnar shortening osteotomy (Rekant 2009)
Video 71-3: Suave Kapandji (Szabo 2009)
Video 71-4: Total distal radial ulnar joint replacement (Berger
2009)
Video 71-5: Anatomy of the DRUJ (Bowers 2006)
Video 71-6: Arthroscopic repair of the peripheral TFCC
(Ruch 2006)
Video 71-7: Reconstruction of DRUJ instability (Adams 2006)
Video 71-8: DRUJ replacement (Bowers 2006)
Video 72-1: Articular disc shear (Lee 2010)
Video 72-2: CIND 2 (Lee 2010)
Video 72-3: DRUJ grind and rotate 2 (Lee 2010)
Video 72-4: DRUJ instability 2 (Lee 2010)
Video 72-5: ECU instability 2 (Lee 2010)
Video 72-6: GRIT2 (Lee 2010)
Video 72-7: LT Ballotement test (Lee 2010)
Video 72-8: PT grind test 2 (Lee 2010)
Video 73-1: Percutaneous scaphoid fixation (Slade 2009)
Video 73-2: Surgical exposure and reconstruction for scaph-
oid nonunion (Garcia-Elias 2009)
Video 73-3: Vascularized bone grafting (Bishop 2006)
Video 73-4: Radial shortening wedge osteotomy (Glickel
2006)
Video 74-1: Scaphoid shift test (Garcias-Elias 2010)
Video 74-2: Increased laxity of palmar midcarpal ligaments
(Garcias-Elias 2010)
Video 74-3: Spiral tenodesis (Garcia-Elias 2009)
Video 74-4: Acute SL injury: mitek? augment? (Cohen
2006)
Video 74-5: Lunatotriquetral repair AO capsulodesis (A. Shin
2006)
Video 74-6: Scapholunate dissociation: clinical forms and
treatment (Garcia-Elias 2009)
Video 74-7: Pathomechanics and treatment of the nondis-
sociative clunking wrist (Garcia-Elias 2009)
Video 76-1: Wrist fusion (Bednar 2009)
Video 76-2: Proximal row carpectomy (Lubahn 2006)
Video 76-3: Four-quadrant fusion techniques—memodyne
staple (Osterman 2006)
Video 78-1: ORIF radial head fractures (Geissler 2008)
Video 78-2: Monteggia fracture dislocation (Hanel 2008)
Video 78-3: Radial head replacement (Baratz 2008)
Video 78-4: ORIF intracondylar distal humerus (Geissler
2008)
Video 81-1: Elbow arthroscopy (Savoie 2008)
Video 81-2: Open contracture release (Hausman 2008)
Video 83-1: Open lateral release (Hastings 2008)
Video 83-2: Arthroscopic release (Savoie 2008)
Video 83-3: Anconeus flap for failed lateral release (Culp
2008)
Video 84-1: Dual incision (Steinmann 2008)
Video 84-2: Endobutton repair (Wolf 2008)
Video 103-1: CMC splint (Biese 2010)
Video 103-2: Resting pan (Biese 2010)
Video 105-1: Eaton procedure (Belsky 2007)
Video 105-2: Wilson osteotomy (Tomaino 2007)
Video 105-3: CMC arthroplasty (Badia 2007)
Video 105-4: Artelon interposition (Osterman 2007)
Video 107-1: Total wrist replacement (Adams 2009)
Video 107-2: PIP joint implant: volar silastic (Greenberg
2007)
Video 110-1: Convertible total elbow prosthesis (King
2008)
Video 116-1: Movement dystonia associated with CRPS
(Walsh 2010)
Video 116-2: Mirror visual feedback (Walsh 2010)
Video 118-1: Base component motions of the ULNTT for the
three major nerves in the upper extremity—median nerve
(Walsh 2010)
Video 118-2: Base component motions of the ULNTT for the
three major nerves in the upper extremity—ulnar nerve
(Walsh 2010)
Video 118-3: Base component motions of the ULNTT for the
three major nerves in the upper extremity—radial nerve
(Walsh 2010)
Video 118-4 Courses of the nerve in the upper limb (Pratt
2010)
Video 120-1A: Midrange mobilization (MRM) technique of
the glenohumeral joint described in Yang et al. (Fedorczyk
2010)
Video 120-1B: End-range mobilization technique (ERM) of
the glenohumeral joint described in Yang et al.20 (Fedorc-
zyk 2010)
Video 120-2A: Anterior glide of the glenohumeral as described
in Johnson et al.21 (Fedorczyk 2010)
Video 120-2B: Posterior glide of the glenohumeral as
described in Johnson et al.21 (Fedorczyk 2010)

Video 120-3A: Glenohumeral joint flexion as a high-grade
(IV) technique as described in Vermeulen et al.22 (Fedorc-
zyk 2010)
Video 120-3B: Glenohumeral joint flexion as a low-grade (II)
technique as described in Vermeulen et al.22 (Fedorczyk
2010)
Video 120-4: Application of a posterolateral glide MWM
technique for pain limiting shoulder motion as described
by Teys et al.23 (Fedorczyk 2010)
Video 120-5A: MWM technique for tennis elbow: sustained
lateral glide with pain free grip as described by Bisset
et al.24 (Fedorczyk 2010)
Video 120-5B: MWM technique for tennis elbow: sustained
lateral glide with movements of the elbow as described by
Bisset et al.24 (Fedorczyk 2010)
Video 121-1: 3 Part breath (Taylor 2010)
Video 121-2: Assisted breathing (Taylor 2010)
Video 121-3: Breath awareness (Taylor 2010)
Video 121-4: Corpse (Taylor 2010)
Video 121-5: Dandasana (Taylor 2010)
Video 121-6: Directed breathing (Taylor 2010)
Video 121-7: Fish (Taylor 2010)
Video 121-8: Half forward bend (Taylor 2010)
Video 121-9: Mountain (Taylor 2010)
Video 121-10: Sitting awareness (Taylor 2010)
Video 121-11: Standing awareness (Taylor 2010)
Video 121-12: Treatment cycle (Taylor 2010)
Video 122-1: Rashid’s hand motion at 3 months post injury
(McKee 2010)
Video 122-2: Rashid’s hand motion with wrist orthosis
(McKee 2010)
ONLINE VIDEO LIST xxxv
Video 122-3: Rashid using walker with wrist orthosis (McKee
2010)
Video 122-4: Rashid propelling wheelchair with wrist ortho-
sis (McKee 2010)
Video 122-5: Rashid writing with pen with wrist orthosis
(McKee 2010)
Video 122-6: Peggy’s hand motion with orthosis, ulnar view
(McKee 2010)
Video 122-7: Peggy’s hand motion without orthoses, radial
view showing limited active (McKee 2010)
Video 122-8: Peggy tying shoes with orthosis (McKee 2010)
Video 126-1: CMC strap (Biese 2010)
Video 126-2: Soft CMC splint (Biese 2010)
Video 126-3: Distal ulna support (Biese 2010)
Video 140-1: Bennett hand tool dexterity test (Schultz-
Johnson 2010)
Video 140-2: Crawford small parts dexterity test—screws
(Schultz-Johnson 2010)
Video 140-3: Crawford small parts dexterity test—pins and
collars (Schultz-Johnson 2010)
Video 140-4: Minnesota rate of manipulation test (Schultz-
Johnson 2010)
Video 140-5: Purdue pegboard–assembly test (Schultz-
Johnson 2010)
Video 140-6: Lifting evaluation (Schultz-Johnson 2010)
Video 140-7: Minnesota rate of manipulation test (Schultz-
Johnson 2010)
Video 140-8: Rosenbusch test of finger dexterity (Schultz-
Johnson 2010)

Anatomy and Kinesiology
of the Hand
NEAL E. PRATT, PhD, PT
OSTEOLOGY OF THE HAND
ARTICULATIONS OF THE HAND
SKIN, RETINACULAR SYSTEM, AND
COMPARTMENTATION OF THE HAND
INTRINSIC MUSCLES OF THE HAND
CRITICAL POINTS
 The hand can assume almost countless positions and
postures that allow it to perform numerous functions
and manipulations.
 The muscles of the hand permit it to perform tasks that
require both great strength and delicate precision.
 The skin of the hand, particularly that of the palm, is
richly supplied with a large variety of sensory receptors
that allow it to detect minute differences in texture and
shape.
 The joints and muscles of the hand contain large
numbers of proprioceptive receptors that enable it to
detect miniscule differences in position and thus
perform precise manipulations extremely smoothly.
Osteology of the Hand
The bones of the hand form its framework and are important
in maintaining its shape and providing a stable base on which
to anchor its various soft tissue structures. The bones are
arranged to maximize the functional efficiency of the intrin-
sic muscles and the tendons of the extrinsic muscles of the
hand. The 19 major bones are of only two types: the meta-
carpals and the phalanges (Fig. 1-1). All of these bones are
classified as long bones and have central shafts and expanded
proximal and distal ends (epiphyses). Additional small bones,
sesamoids, are usually found in the tendons of certain intrin-
sic thumb muscles.
CHAPTER
1
TENDONS OF THE EXTRINSIC MUSCLES OF
THE HAND
DIGITAL BALANCE
NERVE SUPPLY OF THE HAND
BLOOD SUPPLY OF THE HAND
One metacarpal is associated with each digit, that of the
thumb being considerably shorter than the others. These
bones form the bony base of the hand, and their integrity is
essential for both its natural form and function. Each bone
has a dorsally bowed shaft with an expanded base (proximally)
and head (distally) (Fig. 1-2). From closely positioned bases,
the bones diverge distally to their heads. This arrangement
determines the shape of the hand and separates the digits so
they can function independently as well as manipulate large
objects. The metacarpal of the thumb is anterior to the others
and rotated approximately 90 degrees so it is ideally posi-
tioned to oppose (see Fig. 1-1).
The shaft of each metacarpal is triangular in cross section,
with the apex of this triangle directed volarly and composed
of more dense bone than the dorsal aspect of the shaft.1 This
concentration of dense bone reflects the significant compres-
sile force on the flexor side of the bone. The overall shape of
each metacarpal (along with that of the phalanges) contrib-
utes to the longitudinal arch of the hand. The dorsal convexi-
ties of the metacarpals along with their triangular cross
sections provide significant room for the soft tissue of the
palm, the bulk of which consists of the intrinsic interossei
muscles and the more volarly positioned long digital flexor
tendons and accompanying intrinsic lumbrical muscles. The
mechanical advantage of these muscles is also enhanced by
the metacarpal shape; their lines of pull are located volar to
the flexion–extension axes of the metacarpophalangeal
(MCP) joints.
The bases of the four medial metacarpals are irregular in
shape and less wide volarly than dorsally, thus contributing
to the proximal transverse arch (Fig. 1-3). Articular surface is
found on the sides as well as the proximal aspect of the base.
The base of the thumb metacarpal is significantly different. The
somewhat flattened proximal surface is in the shape of a
3
4 PART 1 — ANATOMY AND KINESIOLOGY

Distal Middle
phalanx phalanx
Distal
phalanges Head
Middle
phalanges Proximal phalanx
Tuberosity
Proximal Distal
Base interphalangeal Base
phalanges
Head Metacarpals joint
Proximal Head
Base Carpals interphalangeal
joint Posterior
Head tubercle
Base Metacarpophalangeal
joint
3rd Metacarpal

Head
Base 4 3
5 2
Sesamoids
1 Base
Hamate and Third
hook Trapezoid carpometacarpal
Facets
joint
Pisiform for 3rd
Trapezium
metacarpal
Triquetrum Scaphoid Capitate
Lunate Capitate
Figure 1-2 Lateral view of the middle finger and the capitate. Note the
dorsal convexities of the metacarpal and proximal and middle
Bones of right wrist and hand (palmar view) phalanges.
Figure 1-1 Volar view of the bones of the hand and wrist. Note that
the thumb is rotated approximately 90 degrees relative to the rest of the
digits.

The hand contains 14 phalanges; the thumb has only 2,

shallow saddle, all of which is articular surface. The concave
surface is oriented from medial to lateral; the convex from
anterior to posterior. (Keep in mind that this bone is rotated
about 90 degrees relative to the other metacarpals and this
description is based on the anatomic position.) The most
medial aspect of the base protrudes more proximally than the
rest of the base and thus presents a triangular beak.
The heads of all the metacarpals are similar. The articular
surface is rounded, both from side to side as well as dorsal
to palmar. The side-to-side dimension is considerably shorter
than the length from dorsal to palmar, but it is wider on the
palmar aspect than it is dorsally. And importantly, the surface
extends farther onto the volar aspect of the bone than dor-
sally. Prominent dorsal tubercles are found dorsally on each
side of the head, just proximal to the articular surface.
The shapes of the metacarpals also contribute to the proxi-
mal and distal transverse arches of the hand (see Fig. 1-3).
The proximal arch is at the level of the distal row of carpal
bones and the bases of the metacarpals. The bases of the
metacarpals as well as the distal row of carpals are wedge-
shaped in cross section, and the apex of each wedge is
directed volarly. Since the metacarpal bases and distal carpals
are positioned very close to one another and are held tightly
together, they collectively form a dorsal convexity and thus
a side-to-side arch. The distal transverse arch is at the level
of the metacarpal heads and is also a dorsal convexity. This
arch is larger than the proximal arch and merely reflects the
orientation of the metacarpals and the fact that the metacar-
pal heads are farther apart than their bases.
whereas each of the other digits has 3. The proximal and
middle phalanges, like the metacarpals, are bowed dorsally
along their long axis and thus contribute to the longitudinal
arch of the hand. The shafts of the phalanges serve as anchors
for the long digital flexor tendons. The volar aspect of the
shaft is flat from side to side and rounded dorsally. The junc-
tions of the rounded and flat surfaces are marked by longi-
tudinal ridges that serve as the attachments for the fibrous
part of the digital tendon sheath (see Fig. 1-1). Each bone
has an expanded epiphysis on each end, with the base (proxi-
mally) being larger than the head (distally).
Longitudinal
arch
Distal
transverse
arch
Proximal
transverse
arch
Capitate
Figure 1-3 The transverse and longitudinal arches of the hand.
 CHAPTER 1 — Anatomy and Kinesiology of the Hand 5

The surface of the base of the proximal phalanx is biconcave

and consists entirely of articular surface. The bases of both the
middle and distal phalanges are concave from dorsal to ventral,
with a central ridge oriented in the same direction. This
surface is entirely articular surface. The heads of the proximal
and middle phalanges are cylindrical from side to side with a
central groove oriented perpendicular to the cylinder. This
surface is also articular surface. The distal phalanx is shorter
than the others. It has no head but rather ends in an expanded
and roughened palmar elevation, which supports the pulp of
the fingertip as well as the fingernail.
Articulations of the Hand
The carpometacarpal (CMC) joints are the most proximal
joints in the hand and connect it to the wrist. Even though
they are all synovial joints, the thumb CMC joint is signifi-
cantly different from those of the four medial digits. The
CMC joint of the thumb allows significant and complex
motion; those of the other digits allow a small amount to
virtually none.
The four medial joints are between the bases of the four
medial metacarpals and the distal row of carpal bones: the
trapezium, trapezoid, capitate, and hamate. The articular sur-
faces of both sets of bones are irregular, continue on the
medial and lateral aspects of the metacarpal bases and the
carpals, but are quite congruent so the bones fit closely
together. Each metacarpal base articulates with one, two, or
even three carpal bones. Strong ligaments hold all of the
bones tightly together, both side to side and across the CMC
joint space. A single joint capsule encloses all of these joints
so there is a single synovial cavity. This cavity extends not
only across the span of the collective joints but also some-
what distally between the metacarpal bases and proximally
between the distal carpal bones.
The motion available at these joints is variable and minimal.
There is essentially no motion permitted at the CMC joints
of the index and middle fingers. These two metacarpals along
with the distal carpal row form the rigid and stable central
base of the hand. A small amount of motion is permitted at
the CMC joints of the ring and small fingers. This motion,
primarily a bit of flexion, permits slight cupping of the medial
side of the hand and is important in both manipulation and
grip (Fig. 1-4).
The first CMC (trapeziometacarpal) joint is between the
base of the first metacarpal and the trapezium. Since the thumb
articulates with only the trapezium, its location and orienta-
3rd 2nd
4th
5th
Metacarpal
1st
Fourth and fifth Thumb (first)
carpometacarpal carpometacarpal
joints joint
Figure 1-4 Volar view of the metacarpal and carpal bones of the right
hand, showing the relative motion of the five carpometacarpal joints.
Note that there is more motion at the thumb, ring, and little finger joints
than at the index and middle fingers.
metacarpal base moves on the convex surface of the trape-
zium. Motion in the sagittal plane, where the thumb moves
toward and away from the index finger, is adduction (toward)
and abduction (away). This occurs as the convex surface of
the metacarpal base moves on the concave surface of the
trapezium. Since both saddles are shallow and the soft tissue
restraints are somewhat lax, axial rotation is also permitted.
This rotation, opposition (pronation), occurs primarily at this
first CMC joint and represents an essential ingredient for the
usefulness of the thumb. Retroposition (supination) is the
opposite of opposition. In reality, certain motions are coupled.
Abduction is accompanied by a bit of medial rotation (oppo-
sition). This is due to the slightly curved concave surface of
the trapezium. Retroposition, then, is a combination of lateral
rotation and adduction. Flexion and extension also involve
some rotation, albeit less. Flexion is accompanied by a bit
of opposition and extension by a bit of retroposition.2
This is caused by the slightly curved convex surface of the
Intermetacarpal
ligament
e

C
1st Metacarpal
v c av

tion is the basis for the position of the thumb. The trapezium C o
Flexor carpi o Co
n

is obliquely oriented, almost in the sagittal plane, and proj- C o n ve x

e
x

radialis c Capsule with radial

ects more volarly than the trapezoid or scaphoid with which a
v collateral ligament
it articulates. Capitate e
The articular surfaces (Fig. 1-5) of both the base of the Anterior oblique
first metacarpal and the distal aspect of the trapezium are ligament
Scaphoid
shaped like shallow saddles. As a result, each surface has a Palmar tubercle
convex and a concave component, and these elements are on trapezium
perpendicular to one another. The shapes dictate that the Palmar view
major amount of motion occurs in two planes, which also
Figure 1-5 Palmar view of the carpometacarpal joint of the right thumb.
are perpendicular to one another. Motion in the coronal plane, The joint is open and the metacarpal reflected radially. Note the saddle-
where the thumb moves across the palm, is flexion and shaped articular surfaces of both bones and the concave and convex
extension. These motions occur as the concave surface of the aspects of each.
6 PART 1 — ANATOMY AND KINESIOLOGY

Proximal
MII phalanx

IML
MI
FCR Collateral
UCL Volar plate ligaments
FR Head
AOL
Collateral Cord
ligaments Accessory Posterior
APL
tubercle

Metacarpal

Key
AOL, Anterior oblique ligament
UCL, Ulnar collateral ligament Dorsal view
IML, First intermetacarpal ligament Figure 1-8 Dorsal view of the metacarpophalangeal joint that is opened
APL, Abductor pollicis longus tendon dorsally to show the articular surfaces. Note the biconvex metacarpal head
FCR, Flexor carpi radialis and the biconcave proximal phalangeal base.
FR, Flexor retinaculum
MI, First metacarpal
MII, Second metacarpal
ment that interconnects the palmar tubercle (beak) of the
Figure 1-6 Palmar view of the ligaments of the carpometacarpal joint metacarpal base and the distal part of a ridge on the tubercle
of the left thumb. of the trapezium. This ligament is generally considered a
major stabilizing ligament of the joint and is taut in abduc-
tion, extension, and opposition.5 Bettinger and coworkers6
trapezium. Hanes3 suggested the coupling was due to the described a superficial anterior oblique ligament and a deep
tautness of certain of the ligaments of the joint; Zancolli and anterior oblique ligament, which they considered the beak
colleagues4 considered the coupling was due both to the ligament. The ulnar collateral ligament is on the volar and
articular surfaces and the ligaments. medial aspects of the joint and extends from the transverse
The ligaments (Figs. 1-6 and 1-7) of this joint are found carpal ligament to the palmar-medial aspect of the first meta-
on all sides of the joint. Their nomenclature can be confusing carpal base. The posterior oblique ligament is on the dorsal
because several systems are used to name them and there are aspect of the joint and interconnects the dorsal aspect of the
differences of opinion relative to how many ligaments there trapezium and the ulnar (medial) base of the metacarpal. An
are. The anterior oblique, or beak, ligament is a strong liga- intermetacarpal ligament (or pair of intermetacarpal [anterior
and posterior] ligaments) interconnects the bases of the first
and second metacarpals. The dorsoradial ligament extends
from the dorsolateral aspect of the trapezium to the dorsal
IML base of the first metacarpal. The joint capsule is complete and
POL
somewhat loose, which is necessary for axial rotation.
MII The metacarpophalangeal (MCP) joints (Fig. 1-8) of the
MIII MI
four medial digits are formed by the bases of the proximal
phalanges and the heads of the metacarpals. The articular
DRL surface of the metacarpal head is biconvex, cam-shaped so it
ECRL
extends farther volarly than dorsally, and it is wider volarly
APL than dorsally. The articular surface of the phalangeal base is
ECRB biconcave, shallow and smaller in area than the articular
surface of the metacarpal head. These shapes would appear
FCR
to permit the phalanx to move in virtually any plane on the
metacarpal head. However, due to soft tissue restraints, active
Key motion is limited to flexion and extension and adduction and
IML, First intermetacarpal ligament abduction. Adduction is movement of the digits toward the
POL, Posterior oblique ligament middle finger; abduction is movement away from the middle
DRL, Dorsoradial ligament finger. The middle finger can be deviated either radially (lat-
APL, Abductor pollicis longus tendon erally) or ulnarly (medially). Axial rotation is available only
ECRL, Extensor carpi radialis longus tendon passively.
ECRB, Exensor carpi radialis brevis tendon
The joint capsule of the MCP (Fig. 1-9) joint is highly spe-
MIII, Third metacarpal
cialized. Like any capsule it encloses the joint space and
Figure 1-7 Dorsal view of the ligaments of the carpometacarpal joint attaches to the edges of both articular surfaces. It is different
of the left thumb. in that its volar aspect is formed by a strong plate of

Interphalangeal joint’s
collateral ligaments
Proximal phalange
Volar plates
Metacarpo- Dorsal capsule
True
phalangeal joint’s
Accessory
collateral ligament
Fibrous digital sheath
Metacarpal
Volar plate
Figure 1-9 Lateral view of the joint capsules of the metacarpophalan-
geal and interphalangeal joints of a finger.
fibrocartilage—palmar ligament, or volar plate. The medial
and lateral edges of the plate serve as attachments for the
fibrous part of the digital tendon sheath, specifically the first
annular ligament (A1 pulley). Thus, the plate is important in
the stability and positioning of the long digital flexor tendons.
The plate is thick and rigid distally and its volar aspect has
a thin side-to-side attachment to the volar base of the proxi-
mal phalanx. This hingelike attachment allows the plate to
move as a unit relative to the proximal phalanx. Proximally
the plate thins, is a bit loose and flexible, and attaches to
volar base of the metacarpal head. With flexion the volar plate
slides proximally (Fig. 1-10); this is possible because the
proximal part of the plate can fold.
The collateral ligament (see Fig. 1-10) is triangular in
shape and consists of two distinct parts, both of which attach
proximally to the dorsal tubercle of the metacarpal. From
that attachment, the fibers of the ligament diverge as they
pass distally. The true, or band, part of the ligament extends
more distally and is the strongest part of the ligament. From
the dorsal tubercle it passes obliquely volarly and attaches to
the volar aspect of the side of the proximal phalangeal base.
This true ligament is somewhat loose in extension and thus
permits abduction and adduction. As the proximal phalanx
is flexed, this part tightens because of the cam shape of the
metacarpal head and because the metacarpal head is wider
volarly. As a result of the tightness, abduction and adduction
are very limited in flexion. The accessory, or fan, part of the
ligament is more obliquely oriented and attaches to the volar
plate. Since the fibrous tendon sheath also attaches to the
volar plate, the accessory collateral ligament plays an impor-
tant role in stabilizing the long digital flexor tendons. The
accessory ligament loosens slightly as flexion occurs.
The MCP joints are reinforced dorsally and laterally by
the extensor hood (see Fig. 1-20, online). This hood consists
of a flat layer of fibers that is oriented perpendicular and
oblique to the long axis of the digit and sweep around the
joint from one edge of the volar plate to the other. The fibers
on either side of the joint are in the sagittal plane and called
the sagittal bands. The hood blends with the long digital
extensor tendon, slides proximally and distally, respectively,
with extension and flexion, and is the mechanism through
which the proximal phalanx is extended. The hood is also
important in centralizing the extensor tendons at the MCP
joint.
CHAPTER 1 — Anatomy and Kinesiology of the Hand 7
True part of
collateral ligament
(loose in extension)
Volar plate
Membranous
portion of volar plate
(folds in flexion)
True part of
collateral ligament
(tight in flexion)
Figure 1-10 Lateral view of the metacarpophalangeal joint of a finger.
The band part of the collateral ligament and the volar plate are depicted
in full extension, partial flexion, and flexion. Note how the tension of the
band part of the ligament changes as the proximal phalanx is flexed. Note
also how the proximal part of the volar plate folds as flexion occurs.
The MCP joint of the thumb is both similar to and different
from the other MCP joints. The articular surfaces and col-
lateral ligaments are quite similar. In general, the joint
capsule is similar but part of it, the volar plate, varies. The
volar plate contains two sesamoids bones, which form a
trough for the tendon of the flexor pollicis longus muscle.
The sesamoids are also partial insertions for the adductor
pollicis muscle on the ulnar side and the flexor pollicis brevis
muscle on the radial side. The more superficial layer of
fibrous support is a somewhat modified extensor hood. The
ulnar side of the hood is stronger and heavier than the radial
side and formed by the tendon and aponeurosis of the adduc-
tor pollicis muscle. It extends dorsally to blend with the
tendons of the extensor pollicis brevis and extensor pollicis
longus muscles. The radial side of the hood is formed by the
tendons of the abductor pollicis brevis and flexor pollicis
brevis, which also blend with the extensor pollicis brevis and
extensor pollicis longus tendons dorsally. The aponeurosis
on the ulnar side forms a strong restraint against abduction
forces. However, since the thumb is in a different plane than
the other digits it is more vulnerable to adduction and abduc-
tion forces.
8 PART 1 — ANATOMY AND KINESIOLOGY
Distal phalanx
Volar plate Distal
interphalangeal joint
Collateral True
ligament Accessory
Middle phalanx
Base
Proximal
interphalangeal
Volar plate
joint
Check-rein ligament
Head
Collateral True
ligament Accessory
Proximal
phalanx
Dorsal view
Figure 1-11 Dorsal view of the interphalangeal joints of a finger. The
joints are opened dorsally to view the articular surfaces. Note the sagittal
groove of the phalangeal heads and the sagittal ridge of the phalangeal
bases.
The motion available at the thumb MCP is similar in direc-
tion to the other MCP joints but more limited because of the
stability of the joint. Flexion and extension are less free, and
adduction and abduction are significantly more limited.
However, motion varies considerably from person to person
so possible limitation should be compared with motion on
the opposite side.
The proximal interphalangeal (PIP) joint (Fig. 1-11) is
formed by the head of the proximal phalanx, which is shaped
like a short transverse cylinder, and the base of the middle
phalanx, which is concave from dorsal to ventral and thus
conforms to the cylindrical head. In addition, the phalangeal
head has a sagittally oriented groove and the phalangeal base
has a sagittally oriented ridge. These surfaces enhance the
stability of the joint and ensure that the motion is limited to
one degree of freedom, which is in the sagittal plane (flexion
and extension).
The joint capsule is similar to that of the MCP joint. It is
reinforced by the volar plate palmarly, the collateral and reti-
nacular ligaments and the lateral bands on both sides, and
the triangular membrane and central band dorsally. These
structures blend with the capsule to different degrees and
thus move (glide) differently relative to the capsule and to
each other.
The volar plate (Fig. 1-12) is similar to that of the MCP
joint and moves in the same way during flexion and exten-
sion. The sides of the proximal attachment are longer than
the central part and are referred to as the “check-rein liga-
ments.”7 These ligaments tighten as the middle phalanx is
extended and thus limit hyperextension at the PIP joint. The
volar plate is also the attachment for the third annular liga-
True part of
collateral ligament
Central band
Accessory
part of
collateral
ligament
Check-rein
ligament
Middle phalangeal
Recess attachment of central
80% of volar plate
Figure 1-12 Sagittal view of the proximal aspect of the middle phalanx
and volar plate of the proximal interphalangeal joint. Note that only one
half of the volar plate is depicted.
ment (A3 pulley) of the fibrous flexor digital tendon sheath.
This pulley attaches along the sides of the plate and ensures
the flexor tendons stay in place as they cross the joint. The
stability of this plate is therefore essential for proper flexor
tendon position and function.
The collateral ligaments (see Figs. 1-11 and Fig. 1-12) are
similar to those of the MCP joints, are triangular in shape,
and consist of true (band) and accessory (fan) parts. From
their attachment to the dorsal tubercle of the proximal
phalanx, the two parts diverge as they cross the joint—the
true part attaching to the side of the base of the middle
phalanx and the accessory part attaching to the volar plate.
The true part is taut throughout the range of motion and thus
stabilizes the joint in all positions; the accessory part stabi-
lizes the volar plate.
Like the MCP joints, the PIP joints are reinforced to some
degree by components of the extensor mechanism. The
central band and triangular membrane are positioned dor-
sally, and the lateral band and retinacular ligament located
on the sides. The tendons of both the flexor digitorum pro-
fundus and flexor digitorum superficialis pass volar to the
joint.
The distal interphalangeal (DIP) joint is quite similar to the
PIP joint. The architecture of the articular surfaces is similar,
so the motion is limited to only the sagittal plane and that is
flexion and extension. The joint capsule, volar plate, and
collateral ligaments are also similar, so the motion of each
and the support they provide are very much the same as the
PIP joints. The volar plate provides an attachment for the
fibrous part of the flexor digital tendon sheath; in this case
it is the fifth annular ligament (A5 pulley).
The extra-articular structures that cross the joint are quite
different. Only the tendon of the flexor digitorum profundus
crosses its volar aspect. Dorsally, only the central band blends
with the joint capsule as it crosses the joint.
Skin, Retinacular System, and
Compartmentation of the Hand
The skin on the dorsum of the hand is different from that on
the palmar aspect. The dorsal skin is thin, loose, and quite
mobile. This mobility is due to a very thin subcutaneous

Septa forming canals
Midpalmar space
Palmar aponeurosis
Common palmar digital
artery and nerve
Lumbrical muscle
in its fascial sheath
Flexor tendons to 5th
digit in common flexor
sheath (ulnar bursa)
Hypothenar muscles
Dorsal interosseous fascia
Dorsal subaponeurotic space
Dorsal fascia of hand
Dorsal subcutaneous space
Figure 1-13 Transverse section through the palm of the hand. (Netter illustration from www.netterimages.com. © Elsevier Inc. All rights reserved.)
tissue (superficial fascia) that is loosely attached to the deep
fascia. The palmar skin is thicker and less mobile. The sub-
cutaneous tissue of the thenar and hypothenar eminences is
thick and fatty and thus forms considerable pads. Centrally
the palmar skin is firmly attached to the palmar aponeurosis
by multiple septa and is thus almost immobile. This arrange-
ment greatly enhances grasp.
The entire upper limb is enclosed in a sleeve of connective
tissue called the investing fascia. In the arm and forearm this
layer is connected medially and laterally to the bones by
intermuscular septa with resulting anterior and posterior
compartments. This same layer continues into the hand,
where it becomes a complex system of fibrous layers and
septa that form multiple compartments. Structures of similar
function are isolated and confined to individual compart-
ments. Since a retinaculum is a structure (usually composed
of connective tissue) that retains other anatomic structures,
this is called the retinacular system.
At the wrist the investing fascia is reinforced by circum-
ferential bands of fibers both dorsally (extensor retinaculum)
and volarly (flexor retinaculum). Both of these retinacula
stabilize tendons that enter the hand from the forearm. The
flexor retinaculum has a more proximal superficial part, the
superficial part of the flexor retinaculum or the volar carpal
ligament, and a deeper distal part called the deep part of the
flexor retinaculum or the transverse carpal ligament. The
deep part forms the volar boundary of the carpal tunnel and
is significantly thicker and stronger.
In the hand the investing fascia attaches to both the
first and fifth metacarpals (Fig. 1-13). Dorsally it is thin,
attaches to the other metacarpals, and is called the dorsal
interosseous fascia. In the palm it is thin over the thenar
(thenar fascia) and hypothenar (hypothenar fascia) emi-
nences. Centrally it is greatly thickened to form the palmar
aponeurosis.
This palmar aponeurosis (palmar fascia) is a strong fibrous
structure composed of fibers that are oriented from proximal
to distal. It is narrow proximally where it is continuous with
the tendon of the palmaris longus muscle and blends with
the transverse carpal ligament. It widens as it is followed
CHAPTER 1 — Anatomy and Kinesiology of the Hand 9
Profundus and superficialis flexor tendons to 3rd digit
Septum between midpalmar and thenar spaces
Thenar space
Flexor pollicis longus
tendon in tendon
sheath (radial bursa)
Extensor pollicis
longus tendon
Adductor pollicis muscle
Palmar interosseous fascia
Palmar interosseous muscles
Dorsal interosseous muscles
Extensor tendons
distally, and just proximal to the MCP joints it separates into
four digital slips, which contribute to the formation of the
fibrous digital tendon sheaths. The digital slips are intercon-
nected by transverse fasciculi proximally and the transversely
oriented superficial transverse metacarpal ligament at the level
of the MCP joints. The palmar aponeurosis is firmly attached
to the skin by multiple septa and to the metacarpals by
several septa.
Additional fibrous layers separate various structures in the
palm and define four definitive compartments. The thenar
septum extends from the junction of the thenar fascia and
the palmar aponeurosis to the first metacarpal and with the
thenar fascia forms the thenar compartment. Similarly, on the
ulnar side of the hand, the hypothenar septum extends from
the junction of the hypothenar fascia and the palmar aponeu-
rosis to the fifth metacarpal and with the hypothenar fascia
forms the hypothenar compartment. A deep layer crosses the
palm, attaching to the first, third, fourth, and fifth metacar-
pals. This adductor–interosseous fascia, together with a dorsal
interosseous fascia that interconnects all of the metacarpals
dorsally, forms the adductor–interosseous compartment,
which more or less is between the metacarpals. The central
area of the palm, the central compartment, is deep to the
palmar aponeurosis, bounded medially and laterally by the
hypothenar and thenar septa, respectively, and limited deeply
by the adductor–interosseous fascia. Like the compartments
in the arm and forearm, these compartments contain muscles
that have similar function and are innervated by one or two
nerves. The contents of the compartments are listed in Table
1-1 (online).
In addition to these literal compartments that contain
muscles and other structures, some potential spaces are
fascial planes, bursae, or synovial tendon sheaths. These
structures normally enhance movement between adjacent
structures. However, these potential spaces can become
actual spaces when they accumulate blood or inflammatory
material, which would, in each case, produce a characteristic
swelling.
The thenar and midpalmar clefts (Figs. 1-13 and 1-14), or
spaces, are in a fascial plane between the long digital flexor
10 PART 1 — ANATOMY AND KINESIOLOGY

Digital synovial The radial bursa is associated with the flexor pollicis longus
tendon sheath muscle and extends from just proximal to the carpal tunnel
Digital fibrous
to the distal phalanx of the thumb. The ulnar bursa is associ-
tendon sheaths:
Crossed portion
ated with all eight tendons of the flexor digitorum superficia-
lis and profundus muscles in the palm but continues distally
Annular portion Flexor digitorum
into the digit with only those to the little finger. This bursa
profundus
extends from proximal to the carpal tunnel into the palm and
distally to the distal phalanx of the little finger. Digits two,
Flexor digitorum three, and four have individual synovial digital tendon sheaths
superficialis that extend from just proximal to the MCP joints to the distal
phalanges. Each of these can also become enlarged.
Midpalmar space
On the dorsum of the hand there are two potential planes
(see Fig. 1-13) where fluid can collect: one in the subcutane-
ous tissue and the other associated with the long extensor
tendons. The subcutaneous tissue is dorsal to the metacarpals
Deep part and contains the long digital extensor tendons, cutaneous
of flexor Thenar space
nerves, dorsal venous network, and most of the afferent lym-
retinaculum
Radial bursa phatics from the hand. Since these lymphatics drain most of
Ulnar bursa
the hand, inflammation in virtually any part of the hand can
lead to a general swelling on the dorsum of the hand. The
long extensor tendons, aside from those to the thumb, are
Figure 1-14 Volar view of the hand and wrist depicting the radial and enclosed by supratendinous and infratendinous layers of fascia.
ulnar bursae, digital tendon sheaths, and the thenar and midpalmar
spaces. These two layers unite on both sides of the group of tendons,
thus forming a type of compartment around the tendons.
Since the tendons do not occupy the entire side-to-side
dimension of the dorsum of the hand, the subcutaneous
tendons and the adductor–interosseous fascia. This plane is plane is wider than the tendon plane.
separated into ulnar midpalmar and radial thenar space by
the midpalmar septum that extends between the palmar apo-
neurosis and the third metacarpal. The thenar space is located Intrinsic Muscles of the Hand
on the volar aspect of the adductor pollicis muscle; the mid-
palmar space on the volar aspects of the medial interossei The intrinsic muscles (Figs. 1-15 and 1-16) are those small
muscles. muscles that both arise and insert within the hand and gener-
The radial and ulnar bursae (see Fig. 1-14) are parts of the ally are involved in the finer movements of the digits. With
synovial tendon sheaths of the long digital flexor muscles. the exception of the palmaris brevis, these muscles are found

Flexor digitorum
profundus tendons

Flexor digitorum
superficialis tendons
Camper’s
chiasm

Flexor pollicis
Flexor digitorum longus tendon
profundus tendons
Adductor pollicis
Lumbricals
Flexor pollicis
brevis
Abductor digiti minimi
Abductor pollicis
Flexor digiti minimi brevis

Opponens Opponens pollicis

digiti minimi
Superficial part of
Deep part of flexor retinaculum Figure 1-15 Volar view of the superficial
flexor retinaculum muscles of the hand.
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN