External Compression and Partial Ischemia Decrease Human Finger Flexor Tendon and Subsynovial Connective Tissue Relative Motion

Does endoscopic carpal tunnel release during distal radial fracture fixation improve outcomes? A randomized controlled trial

This study investigated the functional outcome of prophylactic carpal tunnel release during distal radial fracture fixation. A total of 60 patients undergoing anterior locking plate fixation for a distal radial fracture were randomized into two groups: one having prophylactic endoscopic carpal tunnel release and the other serving as a control. Functional outcomes were assessed using the Patient-Reported Wrist Evaluation, Quick Disabilities of the Arm, Shoulder, and Hand, EuroQol 5-Dimension 5-Level questionnaire, Boston Carpal Tunnel Questionnaire, Pain Numerical Rating Scale, grip strength and finger-to-palm distance over a 12-month period. The study found no significant differences in overall functional outcomes or complications between the groups.Level of evidence: I.

Morphological analysis of the median nerve in the carpal tunnel during wrist movements, finger pinching and palm loading

The aim of this study was to analyze the morphology of the median nerve (MN) in the carpal tunnel during hand motion and palmar load in healthy participants using ultrasound. Twenty healthy participants (10 men and 10 women) were enrolled in the study. Wrist flexion angle is negatively correlated with cross-sectional area (CSA) and perimeter, and positively correlated with circularity, whereas wrist extension angle is negatively correlated with MNCSA and circularity. At 15°, 45°, and 60° wrist flexion and extension, both MNCSA and perimeter were significantly smaller than at neutral (all P < 0.05). MN circularity was significantly greater at 30°, 45°, and 60° wrist flexion than at neutral (all P < 0.05). At 30° ulnar deviation of the wrist, MNCSA and perimeter were significantly smaller than the neutral position, while circularity was significantly larger (all P < 0.05). At 15° of wrist radial deviation, MNCSA and perimeter were significantly smaller than at the neutral position (all P < 0.05). Compared to the 40 % maximum voluntary effort (MVE), thumb-ring finger pinch (10 %MVE) resulted in significantly higher MNCSA and perimeter, while circularity was noticeably smaller (all P < 0.05). In the neutral position, no differences were observed in MNCSA, perimeter and circularity unloaded at 100 g, 200 g, 300 g, 400 g and 500 g palmar loads (all P > 0.05). The results indicate that wrist positions involving flexion, extension, and deviations, as well as finger pinch, can significantly impact the morphology of the MN. This is an important step in understanding the biomechanics of MN compression within the carpal tunnel.

Relative motion between the flexor digitorum superficialis tendon and subsynovial connective tissue is time dependent

The subsynovial connective tissue is an integral component of flexor tendon gliding in the carpal tunnel, which is strained during longitudinal tendon displacement. We tested the effects of repetition frequency and finger load on flexor tendon function throughout active finger movement. Eleven participants performed metacarpophalangeal joint flexion/extension of the long finger cyclically at three repetition frequencies (0.75, 1.00, 1.25 Hz) and two finger loads (3.5, 7 N). Relative displacement between the flexor digitorum superficialis tendon and subsynovial connective tissue was assessed as the shear-strain index with color ultrasound throughout the entire time history of finger flexion and extension. In addition, long finger joint angles were measured with electrogoniometry while flexor digitorum superficialis and extensor digitorum muscle activities were measured with fine-wire electromyography to characterize the finger movements. The shear-strain index increased with greater finger flexion (p = 0.001), representing higher relative displacement between tendon and subsynovial connective tissue; however, no changes were observed throughout finger extension. The shear-strain index also increased with higher repetition frequencies (p = 0.013) and finger loads (p = 0.029), further modulating time-dependent effects during finger flexion versus extension. Using ultrasound, we characterized the time-dependent response of the shear-strain index, in vivo, providing valuable data on flexor tendon function during active finger movement. Our results infer greater subsynovial connective tissue strain and shear during repetitive and forceful finger movements. Future research characterizing time-dependent effects in carpal tunnel syndrome patients may further elucidate the relations between subsynovial connective tissue function, damage, and carpal tunnel syndrome.

Carpal tunnel tendon and sub-synovial connective tissue mechanics are affected by reduced venous return

BACKGROUND

The effects of blood flow occlusion and sex-specific differences in tendon-subsynovial connective tissue relative strain are not well understood. Thus, the purpose of this study was to investigate the influence of blood flow, biological sex, and finger movement speed on carpal tunnel tendon mechanics to further develop our understanding of carpal tunnel syndrome.

METHODS

Colour Doppler ultrasound imaging quantified relative motion between flexor digitorum superficialis tendon and subsynovial connective tissue in 20 healthy male and female participants during repetitive finger flexion-extension under brachial occlusion of blood flow and two movement speeds (0.75 & 1.25 Hz).

FINDINGS

Flexor digitorum superficialis and subsynovial connective tissue displacement decreased with occlusion (small effect) and fast speed (large effect). Speed × Condition interactions were found for mean FDS displacement and peak FDS velocity, where slow speed with occlusion reduced both outcomes. Movement speed had a small but significant effect on tendon-subsynovial connective tissue shear outcomes, where MVR decreased with fast finger motion.

INTERPRETATION

These results suggest the influence of localized edema through venous occlusion on tendon-subsynovial connective tissue gliding within the carpal tunnel. This insight further develops our understanding of carpal tunnel syndrome pathophysiology and suggests ramifications on carpal tunnel tissue motion when the local fluid environment of the carpal tunnel is disturbed.

Dynamic Load Model Systems of Tendon Inflammation and Mechanobiology

Dynamic loading is a shared feature of tendon tissue homeostasis and pathology. Tendon cells have the inherent ability to sense mechanical loads that initiate molecular-level mechanotransduction pathways. While mature tendons require physiological mechanical loading in order to maintain and fine tune their extracellular matrix architecture, pathological loading initiates an inflammatory-mediated tissue repair pathway that may ultimately result in extracellular matrix dysregulation and tendon degeneration. The exact loading and inflammatory mechanisms involved in tendon healing and pathology is unclear although a precise understanding is imperative to improving therapeutic outcomes of tendon pathologies. Thus, various model systems have been designed to help elucidate the underlying mechanisms of tendon mechanobiology via mimicry of the in vivo tendon architecture and biomechanics. Recent development of model systems has focused on identifying mechanoresponses to various mechanical loading platforms. Less effort has been placed on identifying inflammatory pathways involved in tendon pathology etiology, though inflammation has been implicated in the onset of such chronic injuries. The focus of this work is to highlight the latest discoveries in tendon mechanobiology platforms and specifically identify the gaps for future work. An interdisciplinary approach is necessary to reveal the complex molecular interplay that leads to tendon pathologies and will ultimately identify potential regenerative therapeutic targets.

Thirty Minutes of Sub-diastolic Blood Flow Occlusion Alters Carpal Tunnel Tissue Function and Mechanics

There is evidence that carpal tunnel syndrome (CTS) development is driven by vascular factors, specifically those resulting from ischemia and edema. The purpose of this study was to investigate the vascular hypothesis of CTS development by quantifying the temporal effects of 30 min of sub-diastolic brachial blood flow occlusion on median nerve edema, intraneural blood flow velocity, nerve function as measured through nerve conduction study (NCS), tendon-connective tissue mechanics and carpal tunnel tissue stiffness. Forty healthy volunteers underwent 30 min of sub-diastolic brachial occlusion while an NCS and ultrasound examination were performed consecutively every 5 min. Motor latency (p < 0.001), sensory conduction velocity (p < 0.001), sensory amplitude (p = 0.04), nerve blood flow (p < 0.001), peak relative flexor digitorum superficialis tendon-sub-synovial connective tissue displacement (p = 0.02) and shear strain (p = 0.04) were significantly affected by partial ischemia. Our results highlight the dependency of carpal tunnel tissue function on adequate blood flow.

Carpal Tunnel Syndrome Treatment and the Subsequent Alterations in Median Nerve Transverse Mobility

OBJECTIVES

The mobility (transverse movement) of the median nerve (MN) is decreased in patients with carpal tunnel syndrome and can be measured noninvasively by ultrasound. To date, there are few prognostic features to help predict the outcome of 2 commonly performed treatments: surgical carpal tunnel release and corticosteroid injection. This study aimed to assess the changes in nerve mobility after the intervention and to correlate this with treatment and the disease severity.

METHODS

A total of 181 patients with carpal tunnel syndrome with different electrophysiologic severities were recruited and assessed by dynamic ultrasound scanning of the MN before and after treatment. The dynamic ultrasound images were collected while the patients performed finger and wrist flexion.

RESULTS

For both injection and carpal tunnel release, the nerve displacement increased with wrist flexion, from a mean ± SD of 7.0 ± 2.4 to 7.9 ± 2.7 mm (P < .005). Patients who underwent surgery showed greater improvement (P < .005) in nerve mobility compared to those who underwent injection. We also observed that the increase in nerve mobility was predominantly in patients with more nerve damage at baseline.

CONCLUSIONS

This study shows that the dynamic behavior of the MN changes in response to treatment and lays a foundation for future studies to assess the prognostic potential of nerve mobility measurement.

Impact of Uniaxial Stretching on Both Gliding and Traction Areas of Tendon Explants in a Novel Bioreactor

The effects of mechanical stress on cells and their extracellular matrix, especially in gliding sections of tendon, are still poorly understood. This study sought to compare the effects of uniaxial stretching on both gliding and traction areas in the same tendon. Flexor digitorum longus muscle tendons explanted from rats were subjected to stretching in a bioreactor for 6, 24, or 48 h, respectively, at 1 Hz and an amplitude of 2.5%. After stimulation, marker expression was quantified by histological and immunohistochemical staining in both gliding and traction areas. We observed a heightened intensity of scleraxis after 6 and 24 h of stimulation in both tendon types, though it had declined again 48 h after stimulation. We observed induced matrix metalloproteinase-1 and -13 protein expression in both tendon types. The bioreactor produced an increase in the mechanical structural strength of the tendon during the first half of the loading time and a decrease during the latter half. Uniaxial stretching of flexor tendon in our set-up can serve as an overloading model. A combination of mechanical and histological data allows us to improve the conditions for cultivating tendon tissues.