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J Neurosurg 101:541–544, 2004

A quiet hand for microneurosurgery: twiddle your thumb

Technical note

R. LAWRENCE FERGUSON, M.D., AND KIRK JOBE, M.D.

Department of Neurosurgery, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois

√ Fatigue is both the most tremor-producing factor and the constant companion of a busy neurosurgeon. Because of
the difficulty in controlling tremor-generating factors, the authors sought to develop a means of manipulating surgical
instruments with minimal muscle movement while allowing accurate and repeatable movements in all conditions. The
“quiet hand technique” is an isolation technique that creates a stable platform by forming the four fingers into a salute
that thenceforth moves as one. Fine movements are supplied by the thumb. For instruments that open and close, the
thumb abducts and adducts. For suture placement using a round needle holder, the thumb flexes and extends.
Because only the thumb moves, the extent of movement is decreased and therefore momentum and inertia are lim-
ited as well. Previously, microsurgeons favored ballistic movements. With the quiet hand technique, however, tension
movements are easy. The greater control makes tying 10-0 and 11-0 sutures more predictable. Although the quiet hand
technique was developed for use in small-vessel anastomosis, the neurophysiological principles on which it is based
apply to movement at all levels and are applicable to working a bipolar coagulator, pickups, a vascular clip holder, or
other soft-tissue manipulators.

KEY WORDS • ballistic movement • tension movement • fatigue •

quiet hand technique • tremor

E report on a simple surgical technique applicable
W to soft-tissue surgery in general and small-vessel
anastomosis in particular. The neurophysiologi-
cal principles behind its development, the technology sur-
rounding its use, and the patients for whom it was devised
involve complex issues.
The quiet hand technique for microneurosurgery is an
isolation movement in which a stable platform is created
when the four fingers form a salute that moves as one unit.
Fine movements are supplied by the thumb. When using
a flat-handled instrument that opens and closes, the thumb
abducts and adducts. When using a round needle holder, the
thumb flexes and extends. Although a microsuturing tech-
nique with 10-0 and 11-0 sutures is the focus of this pa-
per, the neurophysiological principles behind the movement
in the quiet hand technique are as relevant in manipulating
pickups, a bipolar coagulator, or vascular clips.
An unintended consequence of single-digit movement is
the decreased mass of the moving portion. This translates to
decreased inertia and momentum and an increased facility
with tension movements.
Physiological tremor is an important component of nor-
mal smooth movement and, in fact, without it our move-
ments would be course and rough. This normal physio-
logical component usually becomes a problem only if its
pathological variant, essential tremor, is present. Nonethe-
less, normal physiological tremor can become an issue for
some microsurgeons while they work at magnifications of
10 or 16. When we began teaching microsurgical small-
vessel anastomosis 25 years ago, we used jeweler’s forceps
and 10-0 nylon sutures. Our first students were either young
neurosurgical residents from neighboring countries or old-
er general/vascular surgeons from neighboring towns in Illi-
nois. The anxiety of the former group stood in stark contrast
to the relaxed attitude of the more experienced surgeons.
We began a study of the many factors that affect tremor and
incorporated our findings into a syllabus to enhance train-
ing. In addition, we developed a biofeedback machine that
both measured the error of motion and allowed for self cor-
rection.1
Experience has revealed the limitations of our concept.
The major tremor-enhancing factor, fatigue, is the con-
stant companion of the clinical neurosurgeon. Furthermore,
many neurosurgeons in the past few years have not learned
the techniques of microanastomosis. Also, access to small-
animal surgical laboratories is increasingly difficult.
Our own experience with external carotid artery–internal
carotid artery bypass has decreased as well, but over time
we began using an isolation technique when manipulating
flat-faced surgical instruments such as the bipolar coagu-
lator and aneurysm clip holders. Only the thumb abducted
or adducted after the four fingers were closed in the four-
finger salute. One of us (R.L.F.) first used the technique of
flexion and extension of the thumb in a high internal caro-

J. Neurosurg. / Volume 101 / September, 2004 541

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FIG. 1. Drawing depicting linear extension and flexion of the
thumb rotating a round needle holder.
tid artery suture driven by necessity rather than by plan. The
round needle holder used in this case demonstrated the pos-
sibility of performing an isolation technique for suturing.
When we went to the laboratory to learn small-vessel
anastomosis, we incorporated the lessons of the past and
twisted a round needle holder with good success by using
10-0 nylon sutures and a variety of dry props. The next ses-
sion was directed toward the femoral artery and vein in the
rat. One of us (K.J.) had been operating all night and tremor
became an issue. By forming his four fingers into a four-
finger salute and rolling the needle holder through flexion
and extension of the thumb, he was able to suture the fem-
oral artery. When he combined inhalation with flexion and
exhalation with extension of the thumb, smoothness was
achieved and the quiet hand technique for microneurosur-
gery was born (Fig. 1).
Quiet Hand Technique for Microneurosurgery
1) Assume the best microsurgical posture.
542
R. L. Ferguson and K. Jobe
2) Form the four fingers into a salute that moves as a
whole.
3) Flex the thumb so that its tip holds the needle holder to
the first finger.
4) Inhale with thumb flexion.
5) Position the needle.
6) Extend the thumb (extensor pollicis longus muscle).
7) Exhale with thumb extension to ensure smooth ro-
tation.
8) Pick up the needle with a flexed thumb and repeat.
9) When tying the suture, form a loop on inhalation and
lay down the knot on exhalation. It is important to maintain
the four-finger salute during this step.
10) The sharpshooter variation includes extending the
thumb; stabilizing the thumb with the third, fourth, and fifth
fingers; and moving only the index finger.
Discussion
Neurosurgeons have recognized the importance of limb
and hand stabilization to enhance accurate movement since
the specialty began. Most microsurgeons operate in two-
dimensional structures on which hand stabilization is pos-
sible. This is not the case in many microneurosurgical pro-
cedures in which the hands must remain clear of the brain.
When the four fingers are formed into a salute that moves
as a single unit, the ability to rotate the wrist is limited. Fur-
thermore, the natural tremor frequency of 12 per second in
a single finger converts to three per second in the forearm.
When we began our study of small movements, we ap-
proached it from the perspective of tremor. We tried to con-
trol tremor by reducing the factors that enhanced it. Factors
that aggravate tremor can be categorized as long term, in-
termediate, or short term. Long-term factors include health
and age. Intermediate factors are skill, alcohol, nicotine, and
caffeine. Short-term factors, which occur during surgery,
include limb support, direction of movement, physical fa-
tigue, and anxiety.5 We also became familiar with the size
principle of motor unit recruitment; that is, the smallest mo-
tor units are recruited first.2 This combination of obser-
vations indicated that a microsurgeon should learn proper
posture and positioning of the hands to minimize fatigue of
the smaller motor units before surgery is complete. Further-
more, one should recruit the least number of motor units to
perform a task because each contracting muscle fiber adds
to the tremor.
A biofeedback machine was developed to reduce unnec-
essary muscle contraction. This machine measured the error
of motion and helped define the accuracy of each motion.1
Voluntary movements are classified as either ballistic or
tension. In ballistic movements, the extremity is propelled
toward the target without conscious guidance. Only the end
point is under voluntary control. Hence, the end point is
set before the movement is triggered. In tension move-
ments, the extremity is guided visually and proprioceptive-
ly throughout the course of the movement. The end point is
not predetermined. The intermediate position can be cor-
rected voluntarily or stopped anywhere along its intend-
ed path.
In the past, microneurosurgeons required extensive prac-
tice to learn accurate skilled ballistic movements using flat
J. Neurosurg. / Volume 101 / September, 2004
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A quiet hand for microneurosurgery: twiddle your thumb
jeweler’s forceps. Recognizing that the most tremor-pro-
ducing factor, fatigue, is difficult to control in a busy gener-
al neurosurgical practice led us to search for a simpler tech-
nique based on minimal muscle movement while allowing
microneurosurgeons to perform to the best of their ability in
any given situation. This led to the development of the quiet
hand technique. In contrast to the process of learning to op-
erate with jeweler’s forceps, the quiet hand technique can be
learned in a few hours by using a round needle holder. Ten-
sion movements can be performed with ease. Because on-
ly the thumb moves in the quiet hand technique, momen-
tum and inertia are experienced less than with techniques in
which other fingers are moving. The tensile strength of 10-
0 nylon is 50 g or 1.61 oz (troy); that of 11-0 is somewhat
less (Ethicon, personal communication, 2003). With sutures
of this size, tension movements will serve most microsur-
geons better than ballistic movements. Failure to keep the
four-finger salute intact increases the inertia and momentum
of the motion through increased wrist motion and compro-
mises one’s ability to perform tension movements.
The first two students to study the quiet hand technique
came to the laboratory in a fatigued state. Each of them ini-
tially performed complicated microsurgical exercises with
difficulty and frustration. Shortly after learning the quiet
hand technique, these same exercises were performed with
accuracy.
Our work at the Department of Mechanical and Industrial
Engineering, University of Illinois, Chicago, is directed to
the experimental validation of the quiet hand technique in
terms of tremor control and fatigue resistance.
We have tested the maximal tensile strength of 2-0, 8-0,
and 10-0 sutures. The suture length tested was 1 in. The test-
ing machine was an Instron 8500 UTM (Canton, MA).
Black monofilament nylon BV130-S endured a maximum
load of 0.465 N or 0.1045 lb. The maximal extension was
5.565 mm.
We can now estimate the pressure on the suture line by
measuring the clamping pressure applied to the needle hold-
er. Three pressure sensors—two on the index finger and one
on the thumb—are affixed to the digit with scotch tape and
worn under the glove.
We can also measure the angle of extension and flexion
being used. Two fabricated angle sensors are placed be-
tween the joints; one is placed between the thumb and the
index finger, whereas the other is placed on the thumb joint.
The angle sensors are rotary potentiometers fixed to the out-
side of the glove by using Velcro.
Accurately measuring the tremor was crucial to the suc-
cessful completion of this project. Our previous tremor ma-
chine measured the error of motion, which we correlated to
tremor. Currently, we are researching the use of high-speed
Panasonic charge-coupled device cameras to capture the
hand at millisecond intervals. Once we have refined our
method, we will study the effects of fatigue on tremor first
with the quiet hand technique and then with other tech-
niques (L Ferguson, F Amirouche, and J Martin; personal
communication, 2004).
It is not necessary for microsurgeons to understand
the microanatomical and physiological principles of small
movements to learn the quiet hand technique, but doing so
will help them plan their schedules so that the finest move-
ments are available when the need arises.
The building block of movement is the motor unit. A mo-
J. Neurosurg. / Volume 101 / September, 2004
tor unit is defined as a motor neuron and the muscle fibers
it innervates. Muscles are movers of joints and can be clas-
sified as Type I (slow, oxidative), Type IIA (fast, oxidative),
and Type IIB (fast, glycolytic). Type I muscles are the red
slow-twitch fibers, and Type IIB are the white quick-twitch
fibers of an earlier classification. Regardless of their fiber
type, their nature is determined by the size of the motor unit
that innervates them. Small motor units induce Type I mus-
cle fibers, and large motor units induce Type IIB muscle fi-
bers. Motor units consist of as few as two muscle fibers (the
larynx) or as many as 1000 muscle fibers per unit (the ham-
string). Note that the eye has 10 muscle fibers, whereas the
hand has 100. Most muscles are heterogeneous with a com-
bination of Type I and Type II fibers.
Three principles of neurophysiology help to explain the
order of muscle recruitment and the coordination of mus-
cle fiber discharge that results in smooth controlled move-
ments: 1) the size principle; 2) rate coding; and 3) transmis-
sion failure.
The Size Principle. There is a functionally related sig-
nificant relationship between the size of individual motor
neurons and their susceptibility to discharge by physiolog-
ical stimuli. The smaller the cell, the more readily it is
discharged by normal stimuli. The size principle has been
demonstrated in a variety of experiments in which the dis-
charge of motor neurons has been induced by stimulation of
the motor cortex, basal ganglion, cerebellum, or brainstem
or by evoking stretch, flexor, or crossed reflexes.2
Rate Coding. Small motor units operate at a lower fre-
quency than larger units. When these larger units are re-
cruited, the smaller units increase their frequency to the
upper limits of their range. The force of muscle contraction
increases with the number of fibers recruited and the fre-
quency of these contractions.2
Transmission Failure. Large sensory afferents may not
discharge all of the motor neurons they innervate if the stim-
ulus is too weak. The closer a motor unit is to the entry point
of the sensory nerve root, the more likely it is to discharge.
When smaller units are unavailable for use, minimal senso-
ry input may lead to transmission failure and smaller move-
ments.3
Differences in anatomy explain why small motor unit
discharge has an all or nothing quality and larger units have
an incomplete discharge. Small motor units are innervated
by a single branch, whereas large units are innervated by a
large sensory branch that bifurcates after entering the spinal
cord. The branches taper as they progress cephalad and cau-
dad. Terminally placed neurons are served last or not at all
if the stimuli are too weak.4
Exercise for microsurgeons should be a personal choice
based on their own muscle patterns. Most of us are 50%
Type I and 50% Type II fibers. A world-class sprinter will
have 80% Type II muscle fibers, whereas a world-class
marathoner will have 80% Type I muscle fibers. It will take
1 or 2 days for small motor units to recover once lost. In
the event that you are not a world-class marathoner, use the
quiet hand technique and just twiddle your thumbs when the
small units are challenged.
An exercise specific to the quiet hand technique involves
taping the four fingers together or placing them together on
a tabletop and stretching the thumb in all directions.
543
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Conclusions
The quiet hand technique for microneurosurgery is an
innovative method developed to overcome fatigue. Consis-
tency and durability of movement is improved by using
extrinsic rather than intrinsic hand muscles, and tension
movements give the microsurgeon more control. Moreover,
the minimal muscle recruitment involved in this technique
diminishes the effect of environmental challenges. Forming
four fingers into a unit quiets the hand, and proper breath
control will further smooth the movement. The quiet hand
technique is simple and easy to learn.
References
1. Hartwell RC, Ferguson RL: Physiologic tremor and microsurgery.
Microsurgery 4:187–192, 1983
2. Henneman E: Recruitment of motoneurons: the size principle in
544
R. L. Ferguson and K. Jobe
motor unit type, recruitment and plasticity in health and disease.
Prog Clin Neurophysiol 9:26–60, 1981
3. Luscher HR, Ruenzel P, Henneman E: Composite EPSPs in mo-
torneurons of different sizes before and during PTP: implications
for transmission failure and its relief in Ia projections. J Neuro-
physiol 49:269–289, 1983
4. Luscher HR, Ruenzel P, Henneman E: How the size of moto-
neurons determines their susceptibility to discharge. Nature 282:
859-861, 1979
5. Patkin M: Ergonomics and the operating microscope. Adv Opthal
37:53–63, 1978
Manuscript received December 5, 2003.
Accepted in final form May 14, 2004.
Address reprint requests to: R. Lawrence Ferguson, M.D., 4501
North Winchester, Chicago, Illinois 60640. email: lferguson78@
aol.com.
J. Neurosurg. / Volume 101 / September, 2004