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Vigny S, Rubinstenn E, Michelin P, Sabatier T, Dhellemmes O, Duparc F, Auquit-Aukbur I, Lalevee M. Ultrasound identification of hand and wrist anatomical structures by hand surgeons new to ultrasonographic techniques. Surg Radiol Anat 2024:10.1007/s00276-024-03355-4. [PMID: 38597950 DOI: 10.1007/s00276-024-03355-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/21/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Ultrasound is becoming an essential tool for hand surgeons, but most of them are trained on the job, without any diploma or dedicated training. The aim of this study was to assess the ability of hand surgeons new to ultrasound to identify hand and wrist anatomical structures. METHODS A monocentric study was conducted from January 2022 to April 2022. Ten residents and five attending hand surgeons, ultrasound novices, were involved in this study. The participants underwent two tests, wherein they were required to identify 17 anatomical structures using ultrasound, on the same subject. The second test was similar and carried out 2 to 6 weeks later by all participants. The number of structures successfully identified and if it was the case, the detection time per structure, were recorded. The correlations between participants age, years of surgical experience, surgical background (orthopedic or plastic) and the ability to perform immediately during the first test or to progress between the two tests were also assessed. RESULTS The average number of structures identified during the first test (T1) was 14.1+/-2.1 (82.9%), versus 16.2+/-0.8 (95.3%) structures during the second test (T2) (p = 0.001). The mean detection time per structure was 53.4 +/- 18.9 s during T1 versus 27.7 +/- 7.2 s during T2 (p < 0.0001). A moderate negative correlation between the progression in the number of anatomical structures identified between the two tests and the years of surgical experience (ρ=-0.56; p = 0.029) was found. The other parameters were neither correlated with the ability to perform at the first test nor with the progression between the two tests. CONCLUSION Hand surgeons new to ultrasound are most of the time able to identify hand and wrist anatomical structures. Comparison of their first and second tests showed significant potential for improvement in anatomical structure identification and detection time of those, especially in surgeons with limited surgical experience.
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Affiliation(s)
- Solène Vigny
- Department of Orthopedic Surgery, Rouen University Hospital, Rouen, 76000, France
- Laboratory of Anatomy, Faculty of Medicine, Rouen Normandy University, Rouen, 76000, France
| | - Eva Rubinstenn
- Department of Orthopedic Surgery, Rouen University Hospital, Rouen, 76000, France
| | - Paul Michelin
- Department of Radiology, Rouen University Hospital, Rouen, 76000, France
- Rouen Normandy University, CETAPS, Mont Saint Aignan, UR 3832, 79821, France
| | - Thibaut Sabatier
- Department of Epidemiology and Health Promotion, Rouen University Hospital, Rouen, 1073, F 76000, France
| | - Octave Dhellemmes
- Department of Plastic and Hand Surgery, Rouen University Hospital, Rouen, 76000, France
| | - Fabrice Duparc
- Department of Orthopedic Surgery, Rouen University Hospital, Rouen, 76000, France
- Laboratory of Anatomy, Faculty of Medicine, Rouen Normandy University, Rouen, 76000, France
- Rouen Normandy University, CETAPS, Mont Saint Aignan, UR 3832, 79821, France
| | | | - Matthieu Lalevee
- Department of Orthopedic Surgery, Rouen University Hospital, Rouen, 76000, France.
- Rouen Normandy University, CETAPS, Mont Saint Aignan, UR 3832, 79821, France.
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Iruretagoiena X, Schöffl V, Balius R, Blasi M, Dávila F, Sala X, Sancho I, De La Fuente J. High-resolution ultrasound tendon-to-bone distances in partial and complete finger flexor A2 pulley ruptures simulated in human cadaver dissection: toward understanding imaging of partial pulley ruptures. Front Bioeng Biotechnol 2023; 11:1123857. [PMID: 37351474 PMCID: PMC10282126 DOI: 10.3389/fbioe.2023.1123857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
Introduction: The A2 pulley tear is the most common injury in rock climbing. Whereas complete A2 pulley ruptures have been extensively researched, studies focused on partial A2 pulley ruptures are lacking. A2 pulleys rupture distally to proximally. High-resolution ultrasound imaging is considered the gold-standard tool for diagnosis and the most relevant ultrasound measurement is the tendon-to-bone distance (TBD), which increases when the pulley ruptures. The purpose of this study was to establish tendon-to-bone distance values for different sizes of partial A2 pulley ruptures and compare these values with those of complete ruptures. Material and methods: The sample consisted of 30 in vitro fingers randomly assigned to 5 groups: G1, no simulated tear (control); G2, simulated 5 mm tear (low-grade partial rupture); G3, simulated 10 mm tear (medium-grade partial rupture); G4, simulated 15 mm tear (high-grade partial rupture); and G5, simulated 20 mm or equivalent tear (complete rupture). A highly experienced sonographer blinded to the randomization process and dissections examined all fingers. Results: The tendon-to-bone distance measurements (medians and interquartile ranges) were as follows: G1, 0.95 mm (0.77-1.33); G2, 2.11 mm (1.78-2.33); G3, 2.28 mm (1.95-2.42); G4, 3.06 mm (2.79-3.28); and G5, 3.66 mm (3.55-4.76). Significant differences were found between non-torn pulleys and simulated partial and complete pulley ruptures. Discussion: In contrast, and inconsistent with other findings, no significant differences were found among the different partial rupture groups. In conclusion, the longer the partial pulley rupture, the higher the tendon-to-bone distance value. The literature is inconsistent regarding the tendon-to-bone distance threshold to diagnose a partial A2 pulley rupture. The minimum tendon-to-bone distance value for a partial rupture was 1.6 mm, and tendon-to-bone distance values above 3 mm suggest a high-grade partial pulley rupture (15 mm incision) or a complete pulley rupture.
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Affiliation(s)
- Xeber Iruretagoiena
- Deusto Physical TherapIker, Physical Therapy Department, Faculty of Health Sciences, University of Deusto, San Sebastián, Spain
- Eskura Osasun Zentroa, Beasain, Spain
- Sputnik Investigación, Madrid, Spain
| | - Volker Schöffl
- Section Sportsorthopedics and Sportsmedicine, Department of Orthopedic and Trauma Surgery, Klinikum Bamberg, Bamberg, Germany
- Department of Trauma Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
- Section of Wilderness Medicine, Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO, United States
- School of Clinical and Applied Sciences, Leeds Becket University, Leeds, United Kingdom
| | - Ramón Balius
- Consell Catala de l´Esport, Generalitat de Catalunya, Barcelona, Spain
- Sport Medicine and Imaging Department, Clínica Diagonal, Barcelona, Spain
| | - Marc Blasi
- Department of Plastic Surgery, Hospital Germans Trias I Pujol, Barcelona, Spain
| | | | - Xavier Sala
- Anatomy and Embryology Department, School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Anesthesiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Igor Sancho
- Deusto Physical TherapIker, Physical Therapy Department, Faculty of Health Sciences, University of Deusto, San Sebastián, Spain
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Hoffman DF, Honsvall Hoefler A, Bianchi S, Hoxie S, Smith J. Ultrasound visualization of the thumb annular pulleys: A cadaveric validation study. PM R 2023; 15:203-211. [PMID: 35077024 DOI: 10.1002/pmrj.12769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 01/07/2022] [Accepted: 01/17/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The thumb annular pulley system is unique from the other digits and is integral to normal thumb function. Injuries to this pulley system can present a diagnostic challenge. No prior study has evaluated the ability of ultrasound (US) to evaluate all four thumb pulleys. OBJECTIVE To validate the sonographic visualization of all four thumb pulleys. DESIGN Prospective cadaveric laboratory investigation. SETTING Academic center procedural skills laboratory. PARTICIPANTS Twelve unembalmed cadaveric hands from seven adult male donors ages 78-89 years with body mass index 21.9-26.6 kg/m2 . INTERVENTIONS Based on anatomic descriptions, a single examiner used a standardized protocol and high-frequency linear transducers to identify the A1, variable (Av), oblique (Ao), and A2 pulleys of the thumb in 10 cadaveric hands. As part of the validation process, the presumed Ao pulley was injected with diluted colored latex using US guidance. Two additional cadaveric specimens were dissected for detailed study of the thumb pulley system. MAIN OUTCOME MEASURES Correlation between the four anatomic pulleys as revealed by dissection and the US findings, including identification of latex location with respect to the Ao pulley. RESULTS US correctly identified all four thumb pulleys as distinct anatomic structures and the sonographic appearance of the pulleys correlated with the dissection in all 10 specimens. Latex was observed in the Ao pulley in 100% of the cadavers. CONCLUSIONS Ultrasound can be used to accurately identify all four thumb pulleys, including distinct Ao and Av pulleys, and should be considered in the evaluation of thumb pulley injuries. This is the first study to validate the US visualization of the annular pulley system of the thumb.
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Affiliation(s)
- Douglas F Hoffman
- Departments of Orthopedics and Radiology, Essentia Health, Duluth, Minnesota, USA
| | | | | | - Samuel Hoxie
- Department of Orthopedics, Wrist and Hand Service, Essentia Health, Duluth, Minnesota, USA
| | - Jay Smith
- Departments of Physical Medicine and Rehabilitation, Radiology, and Clinical Anatomy, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Common Hand Injuries in the Baseball Player. Curr Rev Musculoskelet Med 2022; 16:19-23. [PMID: 36508080 PMCID: PMC9839919 DOI: 10.1007/s12178-022-09812-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE OF THE REVIEW The list of potential hand and wrist injuries among baseball players is numerous and includes fractures, dislocations, strains, and sprains. The purpose of this review, however, is to highlight injuries to the hand and wrist which are either particularly common or unique to professional baseball players with an emphasis on diagnostic pearls and treatment principles. RECENT FINDINGS For many baseball-related hand and wrist injuries, descriptions of the pathophysiology, diagnosis, and treatment options are based on single institution case series. With the implementation of Major League Baseball's Health and Injury Tracking System, our understanding of the epidemiology of these injuries in professional baseball players has greatly improved. The most common injury requiring operative treatment is a hook of hamate fracture, and recent evidence increasingly supports fracture fragment excision for early pain-free return to sport. Fractures of the proximal phalanges of fingers, thumb phalangeal fractures, and UCL injuries are the most common indication for surgery of the digits. A4 pulley ruptures in pitchers and repetitive trauma to the vasculature of the palm and digits are relatively unique to professional baseball players and are frequently able to be managed non-operatively. While injuries to the hand and wrist are common, the median number of days missed due to such an injury was only 4 days among professional baseball players. Statements and Declarations" for inclusion in the published paper. Please note that submissions that do not include relevant declarations will be returned as incomplete.
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Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery. Plast Reconstr Surg Glob Open 2022; 10:e4558. [PMID: 36225846 PMCID: PMC9542854 DOI: 10.1097/gox.0000000000004558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
Abstract
The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program.
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Sims LA. Upper Extremity Injuries in Rock Climbers: Diagnosis and Management. J Hand Surg Am 2022; 47:662-672. [PMID: 35256226 DOI: 10.1016/j.jhsa.2022.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 02/02/2023]
Abstract
Rock climbing places substantial stress on the upper extremities and can lead to unique injuries not common to other sports. With increasing popularity of the sport, hand surgeons are expected to see more patients with these pathologies. An understanding of the sport, accurate diagnoses, and appropriate treatment protocols are critical to maintain climbers' competitive abilities.
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Affiliation(s)
- Laura A Sims
- University of Saskatchewan, Saskatoon Orthopedic and Sports Medicine Centre, Saskatoon Saskatchewan, Canada.
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Berrigan W, White W, Cipriano K, Wickstrom J, Smith J, Hager N. Diagnostic Imaging of A2 Pulley Injuries: A Review of the Literature. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1047-1059. [PMID: 34342037 PMCID: PMC9292555 DOI: 10.1002/jum.15796] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/30/2021] [Indexed: 05/29/2023]
Abstract
Injury to the A2 pulley is caused by high eccentric forces on the flexor-tendon-pulley system. Accurate diagnosis is necessary to identify the most appropriate treatment options. This review summarizes the literature with respect to using ultrasound (US) to diagnose A2 pulley injuries, compares ultrasound to magnetic resonance imaging and computed tomography, and identifies current knowledge gaps. The results suggest that US should be used as the primary imaging modality given high accuracy, relatively low cost, ease of access, and dynamic imaging capabilities. Manual resistance is beneficial to accentuate bowstringing, but further research is needed to determine best positioning for evaluation.
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Affiliation(s)
- William Berrigan
- Department of OrthopaedicsEmory University School of MedicineAtlantaGeorgiaUSA
| | - William White
- Department of Rehabilitation MedicineMedstar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
| | - Kevin Cipriano
- Department of Rehabilitation MedicineMedstar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
| | - Jordan Wickstrom
- Department of BiomechanicsUniversity of Nebraska at OmahaOmahaNebraskaUSA
| | - Jay Smith
- Department of Physical Medicine and Rehabilitation, Radiology, and Clinical AnatomyMayo ClinicRochesterMinnesotaUSA
| | - Nelson Hager
- Department of Physical Medicine and RehabilitationUniformed Services University of the Health SciencesBethesdaMarylandUSA
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Schöffl V, Schöffl I, Flohé S, El-Sheikh Y, Lutter C. Evaluation of a Diagnostic-Therapeutic Algorithm for Finger Epiphyseal Growth Plate Stress Injuries in Adolescent Climbers. Am J Sports Med 2022; 50:229-237. [PMID: 34817275 DOI: 10.1177/03635465211056956] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Finger epiphyseal growth plate stress injuries are the most frequent sport-specific injuries in adolescent climbers. Definitive diagnostic and therapeutic guidelines are pending. PURPOSE To evaluate a diagnostic-therapeutic algorithm for finger epiphyseal growth plate stress injuries in adolescent climbers. STUDY DESIGN Case series; Level of evidence, 4. METHODS On the basis of previous work on diagnostics and treatment of finger epiphyseal growth plate stress injuries (EGPIs) in adolescent climbers, we developed a new algorithm for management of these injuries, which was implemented into our clinical work. During a 4-year period, we performed a prospective multicentered analysis of our patients treated according to the algorithm. Climbing-specific background was evaluated (training years, climbing level, training methods, etc); injuries were analyzed (Salter-Harris classification and UIAA MedCom score [Union Internationale des Associations d'Alpinisme]); and treatments and outcomes were recorded: union, time to return to climbing, VAS (visual analog scale), QuickDASH (shortened version of the Disabilities of the Arm, Shoulder, and Hand), and a climbing-specific outcome score. RESULTS Within the observation period, 27 patients with 37 independent EGPIs of the fingers were recorded (mean ± SD age, 14.7 ± 1.5 years; 19 male, 8 female; 66.7% competitive athletes). Regarding maturity at time of injury, the mean age at injury did not differ by sex. Average UIAA climbing level was 9.5 ± 0.8, with 6 ± 4.6 years of climbing or bouldering and 14 ± 9.1 hours of weekly climbing-specific training volume. Among the 37 injuries there were 7 epiphyseal strains, 2 Salter-Harris I fractures, and 28 Salter-Harris III fractures (UIAA 1, n = 7; UIAA 2, n = 30). Thirty-six injuries developed through repetitive stress, while 1 had an acute onset. Twenty-eight injuries were treated nonoperatively and 9 surgically. Osseous union was achieved in all cases, and there were no recurrences. The time between the start of treatment and the return to sport was 40.1 ± 65.2 days. The climbing-specific outcome score was excellent in 34 patients and good in 3. VAS decreased from 2.3 ± 0.6 to 0.1 ± 0.4 after treatment and QuickDASH from 48.1 ± 7.9 to 28.5 ± 3.3. CONCLUSION The proposed management algorithm led to osseous union in all cases. Effective treatment of EGPIs of the fingers may include nonsurgical or surgical intervention, depending on the time course and severity of the injury. Further awareness of EGPI is important to help prevent these injuries in the future.
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Affiliation(s)
- Volker Schöffl
- Department of Orthopedic and Trauma Surgery, Klinikum Bamberg, Bamberg, Germany
- School of Clinical and Applied Sciences, Leeds Becket University, Leeds, UK
- Section of Wilderness Medicine, Department of Emergency Medicine, School of Medicine, University of Colorado, Denver, Colorado, USA
- Department of Orthopedic and Trauma Surgery, University Erlangen-Nuremberg, Erlangen, Germany
| | - Isabelle Schöffl
- School of Clinical and Applied Sciences, Leeds Becket University, Leeds, UK
- Department of Pediatric Cardiology, University Hospital Erlangen, Erlangen, Germany
| | - Sascha Flohé
- Department of Orthopedic and Trauma Surgery, Klinikum Solingen, Solingen, Germany
| | - Yasser El-Sheikh
- Department of Surgery, North York General Hospital, Toronto, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Christoph Lutter
- School of Clinical and Applied Sciences, Leeds Becket University, Leeds, UK
- Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany
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Iruretagoiena X, De la Fuente J, Rodríguez-López ES, Davila F, Dorronsoro A, Goenaga L, Blasi M. Longer Tendon-Bone Distances of the A2 and A4 Annular Pulleys in Experienced High-Level Sport Climbers: Injury or Adaptation? Wilderness Environ Med 2021; 32:450-456. [PMID: 34538713 DOI: 10.1016/j.wem.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 07/02/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Experienced high-level climbers are subject to a number of bone and soft tissue changes over the years and are also among the most exposed to pulley injuries. One of the main consequences of pulley rupture is the separation of the flexor tendons from the subjacent phalanges, also known as bowstringing. The purpose of this study was to determine whether this population has asymptomatic bowstringing of the A2 and/or A4 pulleys as determined by tendon-bone distance (TBD) values when compared to nonclimbers. METHODS High-resolution ultrasound TBD measurements in active forced flexion were made for the A2 and A4 pulley of the ring finger bilaterally. Participants were 21 asymptomatic sport climbers who had 21 consecutive years of climbing at a level above 9.66 in the International Mountaineering and Climbing Federation difficulty metric scale. Control subjects were 21 age-matched nonclimbers. RESULTS A significantly longer TBD-25% (0.3 mm) and 35% (0.4 mm) for the A2 and A4 pulleys, respectively-was found in the experienced climbers group (experienced climbers group: A2 1.6±0.5 mm and A4 1.6±0.4 mm; nonclimbers group: A2 1.2±0.1 mm and A4 1.2±0.2 mm). CONCLUSIONS Our results suggest that bowstringing of A2 and A4 pulleys occurs in asymptomatic experienced high-level climbers, which could be interpreted as either an adaptive mechanism to workloads endured over years of climbing or a consequence of underdiagnosed pulley ruptures.
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Affiliation(s)
- Xeber Iruretagoiena
- Department of Physical Therapy, Universidad Camilo José Cela, Madrid, Spain; Eskura Osasun Zentroa, Beasain, Spain; Department of Physical Therapy, Universidad of Deusto, San Sebastian, Spain
| | | | | | - Fernando Davila
- Orthopedics Department, Clínica Pakea-Mutualia, San Sebastián, Spain
| | | | | | - Marc Blasi
- Plastic Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona), Spain
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Abstract
Injuries of the hand and wrist are common in baseball. Because of the unique motions and loads encountered in this sport, physicians treating baseball players may encounter hand and wrist injuries ranging from common to rare. An understanding of these baseball-related injuries must include their pathoanatomy, diagnosis, and treatment options. This knowledge is critical for the general orthopaedic surgeon treating baseball players to allow for timely and appropriate treatment. This article reviews the pathophysiology, diagnosis, and treatment of baseball-related hand and wrist injuries, with a target audience of general orthopeadic surgeons.
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Rosskopf AB, Taljanovic MS, Sconfienza LM, Gitto S, Martinoli C, Picasso R, Klauser A. Pulley, Flexor, and Extensor Tendon Injuries of the Hand. Semin Musculoskelet Radiol 2021; 25:203-215. [PMID: 34082447 DOI: 10.1055/s-0041-1727196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tendon injuries represent the second most common injury of the hand (after fractures) and are a common scanning indication in radiology. Pulley injuries are very frequent in rock climbers with the A2 pulley the most commonly affected. Tendon and pulley injuries can be reliably evaluated using ultrasound (US) and magnetic resonance imaging (MRI). US can be postulated as a first-line imaging modality, allowing dynamic examination. MRI is essential for cases with ongoing diagnostic doubt post-US and also for preoperative pulley reconstruction assessment.
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Affiliation(s)
- Andrea B Rosskopf
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Department of Radiology, ARISTRA, Zurich, Switzerland
| | - Mihra S Taljanovic
- Department of Medical Imaging, University of Arizona, Business, SimonMed Imaging, Scottsdale, Arizona
| | - Luca M Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milano, Italy.,Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Salvatore Gitto
- Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Carlo Martinoli
- Cattedra di Radiologia-DISC, Università di Genova, Genova, Italy
| | - Riccardo Picasso
- Cattedra di Radiologia-DISC, Università di Genova, Genova, Italy
| | - Andrea Klauser
- Department of Radiology, Division of Rheumatology and Sports Imaging, Medical University Innsbruck, Innsbruck, Austria
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12
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Viscoelastic properties of the human A2 finger pulley. Arch Orthop Trauma Surg 2021; 141:1073-1080. [PMID: 33550452 DOI: 10.1007/s00402-021-03781-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Biomechanical evaluation of the viscoelastic properties tissue deformation, stiffness, and maximum breaking load of the human A2 pulley. We hypothesized that the A2 pulleys of index, middle, and ring fingers exhibit no difference regarding the aforementioned biomechanical parameters. METHODS Forty-one A2 pulleys of 14 upper extremities (8 body donors) were assessed. Cyclic and load-to-failure testing were performed. The biomechanical parameters tissue deformation during cyclic and load-to-failure testing, stiffness, and maximum breaking load were determined. RESULTS No significant differences between the fingers could be detected regarding the biomechanical parameters. A significant negative correlation could be detected between stiffness and deformation of the pulley. Significant positive correlations could be identified between stiffness and maximum breaking load and between maximum breaking load and deformation of the pulleys. CONCLUSIONS Assessment of the viscoelastic properties of the A2 finger pulley promotes precise diagnosis of pulley lesions and will help to optimize treatment.
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13
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Miro PH, vanSonnenberg E, Sabb DM, Schöffl V. Finger Flexor Pulley Injuries in Rock Climbers. Wilderness Environ Med 2021; 32:247-258. [PMID: 33966972 DOI: 10.1016/j.wem.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/06/2021] [Accepted: 01/21/2021] [Indexed: 01/03/2023]
Abstract
Finger flexor pulley system injuries are the most common overuse injury in rock climbers. These injuries occur rarely outside of rock climbing, owing to the sport's unique biomechanical demands on the finger. As rock climbing continues to grow and earn recognition as a mainstream sport, an understanding of how to diagnose and treat these injuries also has become important. Our purpose is to describe current concepts in anatomy, biomechanics, clinical evaluation, imaging, prevention, and treatment strategies relating to finger flexor pulley system injuries. Our literature search was performed on PubMed with MeSH terms and keywords as subject headings to meet the objectives of this review. The "crimp grip" used in rock climbing is the mechanism for these injuries. The A2, A3, and A4 pulleys are at the highest risk of injury, especially when loaded eccentrically. Physical examination may reveal clinical "bowstringing," defined as the volar displacement of the flexor tendons from the phalanges; however, imaging is required for characterization of the underlying injury. Ultrasound is highly sensitive and specific for diagnosis and is recommended as the initial imaging technique of choice. Magnetic resonance imaging is recommended as an additional imaging study if ultrasound is inconclusive. Properly warming up increases the amount of physiologic bowstringing and is thought to prevent injury from occurring. Pulley injuries may be classified as grade I through IV. Conservative treatment, including immobilization, the H-tape method, and the use of a protective pulley splint, is recommended for grade I to III injuries. Surgical repair is reserved for grade IV injuries that are not amenable to conservative treatment.
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Affiliation(s)
- Paulo H Miro
- University of Arizona College of Medicine, Phoenix, AZ.
| | | | - Dylan M Sabb
- University of Arizona College of Medicine, Phoenix, AZ; University of California, Davis, Department of Family & Community Medicine, Sacramento, CA
| | - Volker Schöffl
- Section Sportsorthopedics and Sportsmedicine, Department of Orthopedic and Trauma Surgery, Klinikum Bamberg, Bamberg, FRG, Germany; Department of Trauma Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, FRG, Germany; Section of Wilderness Medicine, Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO; School of Clinical and Applied Sciences, Leeds Becket University, Leeds, UK
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14
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Iruretagoiena-Urbieta X, De la Fuente-Ortiz de Zarate J, Rodríguez-López ES, Barceló-Galíndez P, Oliva-Pascual-Vaca Á, Otero-Campos Á, Blasi M. Ultrasonographic Diagnosis of A2 or A4 Flexor Tendon Pulley Injury: A Systematic Review. Wilderness Environ Med 2020; 31:498-505. [PMID: 33132034 DOI: 10.1016/j.wem.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 06/17/2020] [Accepted: 07/21/2020] [Indexed: 01/02/2023]
Abstract
A2 or A4 annular finger pulley tears are common injuries in rock climbers. This study reviews the measurement procedures used and tendon-to-bone distance data obtained on high-resolution ultrasound images when diagnosing isolated rupture of the A2 or A4 pulleys. Out of 3447 records extracted, only 7 remained after applying the exclusion criteria. In diagnosing a complete rupture, tendon-to-bone distance used varied widely from 1.9 to 5.1 mm for A2 and from 1.8 to 3.1 mm for A4. Our findings point to a lack of consensus diagnostic criteria for pulley injuries and identify technical details needing further research.
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Affiliation(s)
- Xeber Iruretagoiena-Urbieta
- Department of Physiotherapy, Universidad Camilo José Cela, Madrid, Spain; Eskura Osasun Zentroa, Beasain, Spain
| | | | | | | | | | | | - Marc Blasi
- Department of Plastic Surgery, Hospital Germans Trias i Pujol, Badalona (Barcelona), Spain
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15
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Lutter C, Tischer T, Schöffl VR. Olympic competition climbing: the beginning of a new era-a narrative review. Br J Sports Med 2020; 55:857-864. [PMID: 33036996 DOI: 10.1136/bjsports-2020-102035] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 12/19/2022]
Abstract
Climbing as a competition sport has become increasingly popular in recent years, particularly the sub-discipline of bouldering. The sport will debut in the Tokyo Summer Olympic Games. National and international competitions have three disciplines: lead (climbing with rope protection), bouldering (climbing at lower heights with mattress floor protection) and speed (maximum speed climbing on a standardised route in 1-on-1 mode). There is also a 'combined mode' of all three disciplines (combined) which forms the Olympic competition format; all competition formats are held on artificial walls. Existing literature describes a predominantly low injury frequency and severity in elite climbing. In comparison to climbing on real rock, artificial climbing walls have recently been associated with higher injury rates. Finger injuries such as tenosynovitis, pulley lesions and growth plate injuries are the most common injuries. As finger injuries are sport-specific, medical supervision of climbing athletes requires specific medical knowledge for diagnosis and treatment. There is so far little evidence on effective injury prevention measures in top athletes, and antidoping measures, in general, requiring further work in this field. An improved data situation regarding high-performance climbing athletes is crucial to ensure that the sport continues to be largely safe and injury-free and to prevent doping cases as extensively as possible.
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Affiliation(s)
- Christoph Lutter
- Department of Orthopedics, Rostock University Medical Center, Rostock, Germany
| | - Thomas Tischer
- Department of Orthopedics, Rostock University Medical Center, Rostock, Germany
| | - Volker Rainer Schöffl
- Section of Sports Medicine, Department of Trauma and Orthopedic Surgery, Klinikum Bamberg, Bamberg, Germany.,Department of Trauma Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen-Nuremberg, Germany.,Section of Wilderness Medicine, Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado, USA.,School of Clinical and Applied Sciences, Leeds Becket University, Leeds, UK
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16
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Perone MV, Yablon CM. Musculoskeletal Ultrasound in the Emergency Department: Is There a Role? Semin Roentgenol 2020; 56:115-123. [PMID: 33422179 DOI: 10.1053/j.ro.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Corrie M Yablon
- Department of Radiology, University of Michigan, Ann Arbor, MI.
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17
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Shapiro LM, Kamal RN. Evaluation and Treatment of Flexor Tendon and Pulley Injuries in Athletes. Clin Sports Med 2020; 39:279-297. [DOI: 10.1016/j.csm.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Efficacy of corticosteroid injection in rock climber's tenosynovitis. HAND SURGERY & REHABILITATION 2019; 38:317-322. [DOI: 10.1016/j.hansur.2019.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/19/2019] [Accepted: 07/24/2019] [Indexed: 01/03/2023]
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19
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Bhatt F, Batul A, Schwartz-Fernandes F. A Potentially Inexpensive Diagnostic Method for A2 Pulley Ruptures. Cureus 2019; 11:e5751. [PMID: 31700762 PMCID: PMC6822555 DOI: 10.7759/cureus.5751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Injuries to the flexor pulley system of the hand, while uncommon, can be problematic and debilitating for patients. Current standards of diagnosis for A2 pulley disruptions often include costly imaging studies and inaccurate clinical testing. We present the case of a patient with an isolated complete A2 pulley avulsion that was diagnosed by employing a simple technique using a silicone wedding ring. A silicone wedding band was applied over the region of a suspected A2 pulley rupture, resulting in the immediate restoration of full range of motion as well as complete resolution of the injury after three months, without any need for surgical intervention. The usage of this ring confirmed an A2 pulley avulsion that was visualized on magnetic resonance imaging (MRI). The proposed “Wedding Band Test” is potentially an accurate and inexpensive diagnostic tool for clinical evaluation of A2 pulley ruptures.
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Affiliation(s)
- Fenil Bhatt
- Miscellaneous, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Arij Batul
- Miscellaneous, University of South Florida Morsani College of Medicine, Tampa, USA
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20
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21
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Sonographic imaging of hand and wrist injuries: applications in the ER setting. Emerg Radiol 2018; 26:227-240. [DOI: 10.1007/s10140-018-1649-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023]
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22
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Hoff MN, Greenberg TD. MRI sport-specific pulley imaging. Skeletal Radiol 2018; 47:989-992. [PMID: 29018907 DOI: 10.1007/s00256-017-2786-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We aim to create a novel MRI methodology that employs sport-specific stress views for imaging finger pulley injuries in the evaluation of post-operative healing effectiveness. The goal is to measure the bone to tendon distance (BTD), which is the current standard for determining pulley injuries. MATERIALS AND METHODS The athlete was imaged in a crimp-grip stressed position to emulate sport-specific biomechanics. A Gradient Echo technique was modified to maximize the signal to noise ratio and minimize distortion near the bone and tendon, simplifying the determination of the BTD. RESULTS A stress-crimped hand position is imaged in less than one half-minute to enable diagnostic visualization of a normal proximal phalanx' bone and tendon via measurement of their BTD. CONCLUSION This novel stress methodology allows for sport-specific imaging, which is ideal for determining functional compromise of the hand's pulley mechanism. Surgical outcomes may be more sensitively compared when using stress views, and these comparisons may then direct optimal repair technique. Future studies will utilize this technique to attempt early-stage detection of pulley injuries prior to complete rupture.
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Affiliation(s)
- Michael N Hoff
- Diagnostic Physics, Department of Radiology, University of Washington Medicine, 222F Portage Bay Building, Box 357987, Seattle, WA, 98195-7987, USA
| | - Todd D Greenberg
- Department of Radiology, University of Washington Medicine Eastside Specialty Center, 3100 Northup Way, Bellevue, WA, 98004, USA.
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23
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Avery DM, Rodner CM, Edgar CM. Sports-related wrist and hand injuries: a review. J Orthop Surg Res 2016; 11:99. [PMID: 27633260 PMCID: PMC5025579 DOI: 10.1186/s13018-016-0432-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/28/2016] [Indexed: 12/15/2022] Open
Abstract
Background Hand and wrist injuries are common during athletics and can have a significant impact especially if initially disregarded. Due to their high level of physical demand, athletes represent a unique subset of the population. Main body The following is an overview of hand and wrist injuries commonly seen in athletics. Information regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided. Conclusion Knowledge of these entities and special consideration for the athlete can help the team physician effectively treat these players and help them achieve their goals.
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Affiliation(s)
- Daniel M Avery
- University of Connecticut Musculoskeletal Institute, 263 Farmington Avenue, Farmington, CT, 06030-4037, USA.
| | - Craig M Rodner
- University of Connecticut Musculoskeletal Institute, 263 Farmington Avenue, Farmington, CT, 06030-4037, USA
| | - Cory M Edgar
- University of Connecticut Musculoskeletal Institute, 263 Farmington Avenue, Farmington, CT, 06030-4037, USA
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24
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Abstract
Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions. Ultrasonography can depict masses and fluid collections, help locate radiolucent foreign bodies, characterize traumatic or overuse tendon or ligament pathology, and help evaluate compressive peripheral neuropathy and microvascular blood flow. Additionally, this modality improves the accuracy of therapeutic intra-articular or peritendinous injections and facilitates aspiration of fluid collections, such as ganglia.
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25
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Schneeberger M, Schweizer A. Pulley Ruptures in Rock Climbers: Outcome of Conservative Treatment With the Pulley-Protection Splint—A Series of 47 Cases. Wilderness Environ Med 2016; 27:211-8. [DOI: 10.1016/j.wem.2015.12.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/22/2015] [Accepted: 12/30/2015] [Indexed: 01/20/2023]
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26
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Bassemir D, Unglaub F, Hahn P, Müller LP, Bruckner T, Spies CK. Sonographical parameters of the finger pulley system in healthy adults. Arch Orthop Trauma Surg 2015; 135:1615-22. [PMID: 26282734 DOI: 10.1007/s00402-015-2304-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Indexed: 02/09/2023]
Abstract
INTRODUCTION To establish normative values of tendon to bone distances (TBDs) to evaluate the A2 and A4 annular pulley integrity, we hypothesized that these values correlate with gender, athletic exercise, occupation, individual's age and body height. METHODS Ultrasonography of 200 healthy individuals was performed prospectively. TBDs for the A2 and A4 pulley sections were measured for all fingers. Evaluation was performed in resting position and active forced flexion. Examination parameters included gender, age, body height, occupation, athletic exercise level, and hand dominance. Assessment of resting position and active forced flexion was done. RESULTS No clinically relevant differences of TBDs with respect to the aforementioned parameters were observed. But TBDs were significantly greater in active forced flexion than in resting position for all measured pulley sections. Intraobserver reliability was very satisfactory. CONCLUSIONS Establishing normative values will help to detect injured pulleys more precisely and examination should be performed both in resting position and active forced flexion.
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Affiliation(s)
- Dominik Bassemir
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
| | - Frank Unglaub
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany.,Medical Faculty Mannheim of the Ruprecht-Karls University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Peter Hahn
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
| | - Lars Peter Müller
- Department of Orthopaedics and Traumatology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Thomas Bruckner
- The Department of Medical Biometry and Informatics, Ruprecht-Karls University, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Christian K Spies
- Department of Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany.
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27
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Kamineni S, Butterfield T, Sinai A. Percutaneous ultrasonic debridement of tendinopathy-a pilot Achilles rabbit model. J Orthop Surg Res 2015; 10:70. [PMID: 25986341 PMCID: PMC4490679 DOI: 10.1186/s13018-015-0207-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 04/22/2015] [Indexed: 11/10/2022] Open
Abstract
Background Tendinopathy is a common clinical pathology, with mixed treatment results, especially when chronic. In this study, we examine the effects of an ultrasonic debridement modality in a rabbit tendinopathy model. We asked four questions: 1) Was it possible to create and visualize with ultrasound a tendinopathy lesion in a rabbit Achilles tendon? 2) Was it possible to guide a 19-gauge ultrasonic probe into the tendinopathy lesion? 3) Following ultrasonic treatment, was tendinopathy debris histologically present? and 4) Was the collagen profile qualitatively and quantitatively normalized following treatment? Methods Skeletally mature female New Zealand white rabbits (n = 12) were injected with, ultrasonography localization, 0.150 ml of collagenase into the Achilles tendon. The collagenase-induced Achilles tendinopathy (3 weeks) was treated with percutaneous ultrasonic debridement. The tendons were harvested, at 3 weeks after treatment, and were subjected to histological assessment (modified Movin score) and biochemical analysis (collagen isoform content). Results Histopathological examination revealed that all tendons injected with collagenase showed areas of hypercellularity and focal areas of tendon disorganization and degeneration. The treated tendons had lower (improved) histopathological scores than injured tendons (P < 0.001). Western blot analysis showed that ultrasonic therapy restored, within statistical limits, collagen type I, III, and X expressions in a treated tendon, to qualitative and semi-quantitative levels of a normal tendon. Conclusions We were successfully able to create a collagenase-injected tendinopathy lesion in a rabbit Achilles tendon and visualize the lesion with an ultrasound probe. A 19-gauge ultrasonic probe was inserted into the tendinopathic lesion under direct ultrasound guidance, and minimal tendinopathic debris remained after treatment. The treated tendon demonstrated a normalized qualitative and semi-quantitative collagen profile and improved histological appearance in the short term. This technique demonstrates scientific merit with respect to the minimally invasive treatment of tendinopathy and warrants further studies. Clinical relevance Recalcitrant tendinopathy has evaded consistent non-operative treatment since the tendinopathic debris remains in situ, to some extent, with non-operative approaches. This percutaneous emulsification/evacuation approach, under direct ultrasound visualization, has the potential to cure recalcitrant tendinopathies without open surgery, which would benefit the patient and result in significant healthcare cost reductions.
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Affiliation(s)
- Srinath Kamineni
- Elbow Shoulder Research Centre, Department of Orthopaedics and Sports Medicine, University of Kentucky, Lexington, KY, 40536, USA.
| | - Timothy Butterfield
- Department of Athletic Training, University of Kentucky, Lexington, KY, 40536, USA.
| | - Anthony Sinai
- Department of Microbiology, University of Kentucky, Lexington, KY, 40536, USA.
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28
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Abstract
The goal of flexor tendon repair is to achieve normal range of motion of the finger or thumb. The surgical approach depends on the level of injury. Multistrand core suture repairs are recommended for primary flexor tendon repair. It is evident that at least 4 strands are required to an initiate and active range of motion protocol. The epitendinous suture can also increase the strength of the repair. Careful attention to the post-operative therapy regiment is critical to a successful repair.
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Affiliation(s)
- Isabella M Mehling
- Department of Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG Trauma Center Frankfurt am Main, Friedberger Landstrasse 430, Frankfurt am Main 60389, Germany
| | - Annika Arsalan-Werner
- Department of Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG Trauma Center Frankfurt am Main, Friedberger Landstrasse 430, Frankfurt am Main 60389, Germany
| | - Michael Sauerbier
- Department of Plastic, Hand and Reconstructive Surgery, Hand Trauma Center, BG Trauma Center Frankfurt am Main, Friedberger Landstrasse 430, Frankfurt am Main 60389, Germany.
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29
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Starr HM, Sedgley MD, Murphy MS. Ultrasound in hand surgery. J Hand Surg Am 2014; 39:2522-4. [PMID: 25240435 DOI: 10.1016/j.jhsa.2014.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/04/2014] [Accepted: 08/08/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Harlan M Starr
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Orthopaedics and Sports Medicine, Ellicott City, MD
| | - Matthew D Sedgley
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Orthopaedics and Sports Medicine, Ellicott City, MD
| | - Michael S Murphy
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Orthopaedics and Sports Medicine, Ellicott City, MD.
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30
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[Secondary reconstruction of the digital A2-flexor pulley]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2013; 25:499-504. [PMID: 23475135 DOI: 10.1007/s00064-011-0053-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Secondary reconstruction of A2 flexor pulley for after closed rupture. INDICATIONS Persisting impairment of finger function and strength after combined injury of A2 and C1 pulley. Passive free movement of all finger joints. CONTRAINDICATIONS Fixed flexion contractures of interphalangeal joints after complex finger injuries. Degenerative arthrosis of interphalangeal joints. SURGICAL TECHNIQUE A strip of extensor retinaculum approximately 10 mm in width together with the periosteum from the second floor of the extensor tunnel was used for reconstruction of the A2 pulley. After drilling bilateral burr holes in the palmar aspect of the phalanx at the distal and proximal ends of the A2 pulley, the graft was fixed by the periosteum to the bone of the phalanx, placing the synovial layer innermost. POSTOPERATIVE MANAGEMENT Postoperatively, patients in both treatment groups wore a palmar splint which extended from the distal interphalangeal joint to the proximal palmar crease for 4 weeks. The metacarpophalangeal joint and the proximal interphalangeal joint were held in full extension. After removing the splint, physiotherapy was started. Full load-bearing, hard manual work and sport activities were not permitted for 3 months. RESULTS Fifteen patients were treated using the extensor retinaculum for reconstruction of the A2 flexor pulley. The mean follow-up time was 48 months. The average range of motion of the PIP joint was 97 %, the average power grip strength 96 %, the finger pinch strength 100 %, and the average circumference 95 % of the uninjured contralateral side. The Buck-Gramcko score showed the following results: 10 excellent, 2 good, and 1 fair.
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31
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Wiater BP, Hentzen ER, Meunier MJ, Abrams RA. A2 pulley insufficiency. J Hand Surg Am 2013; 38:158-63. [PMID: 22995700 DOI: 10.1016/j.jhsa.2012.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 07/21/2012] [Indexed: 02/02/2023]
Affiliation(s)
- Brett P Wiater
- Department of Orthopedic Surgery, Division of Hand and Microvascular Surgery, University of California San Diego, San Diego, CA, USA.
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Schöffl V, Heid A, Küpper T. Tendon injuries of the hand. World J Orthop 2012; 3:62-9. [PMID: 22720265 PMCID: PMC3377907 DOI: 10.5312/wjo.v3.i6.62] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 05/11/2012] [Accepted: 06/05/2012] [Indexed: 02/06/2023] Open
Abstract
Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an “intrinsic” tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing.
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33
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Crowley TP. The flexor tendon pulley system and rock climbing. J Hand Microsurg 2012; 4:25-9. [PMID: 23730085 DOI: 10.1007/s12593-012-0061-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 01/03/2012] [Indexed: 01/24/2023] Open
Abstract
Rock climbing has increased in popularity over the past two decades. Closed traumatic rupture of the finger flexor tendon pulleys is rare among the general population but is seen much more commonly in rock climbers. This article reviews the anatomy and biomechanics of the finger flexor tendon pulleys, how they may be injured in rock climbing and how these injuries are best diagnosed and managed.
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Affiliation(s)
- Timothy P Crowley
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, NE1 4LP UK
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34
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Merritt AL, Huang JI. Hand injuries in rock climbing. J Hand Surg Am 2011; 36:1859-61. [PMID: 22036284 DOI: 10.1016/j.jhsa.2011.08.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 08/02/2011] [Accepted: 08/20/2011] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew L Merritt
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
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35
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McNally EG. The development and clinical applications of musculoskeletal ultrasound. Skeletal Radiol 2011; 40:1223-31. [PMID: 21847751 DOI: 10.1007/s00256-011-1220-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 05/27/2011] [Accepted: 05/29/2011] [Indexed: 02/02/2023]
Abstract
Musculoskeletal ultrasound has come a long way in 40 years. Reflecting changes in computer technology, ultrasound equipment has developed from machines that have filled examination rooms with mechanical probes linked by hinged arms for spatial localisation, to high-resolution machines that are the size of laptops using compact hand-held probes designed for both external and internal imaging.
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36
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Abstract
The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.
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37
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Sivaloganathan SS, Kenward C, Sarraf KM, Jain A. Acute tendon injuries in the hand and their management. Br J Hosp Med (Lond) 2011; 72:M34-8. [DOI: 10.12968/hmed.2011.72.sup3.m34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Charlie Kenward
- Department of General Surgery, Bristol Royal Infirmary, Bristol
| | | | - Abhilash Jain
- Kennedy Institute of Rheumatology and Department of Plastic and Reconstructive Surgery, Imperial College London/Imperial College NHS Trust, Charing Cross Hospital, London W6 8RF
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38
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39
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Abstract
Management of flexor tendon injuries is one of the most demanding tasks in hand surgery. Despite substantial improvements in surgical technique and postoperative rehabilitation protocols, functional outcomes may still be somewhat unreliable. In the present article, the authors present complications encountered after flexor tendon repair and provide their preferred methods of prevention and treatment.
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Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA
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40
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Abstract
The quality of ultrasound imaging to examine anatomical structures in the wrist and hand has improved highly over the last years. The value of ultrasonography (US) performed by hand surgeons on treatment decisions was investigated in this study. One hundred and ninety-five patients with an unclear clinical hand problem were evaluated by high-definition ultrasonography from January 2005 until June 2007. In 21% of cases, the procedure and therapy were influenced by the ultrasonographic findings. In 26 patients examined by ultrasound, surgery was avoided, while 14 patients had unexpected ultrasound results that led to surgery. In 22 of the 84 performed operations, ultrasound had a direct impact on the surgical procedure itself. The agreement of the ultrasonographic diagnosis and the post-operative diagnosis (n = 80) was better, though not statistically significant compared to the agreement between clinical diagnosis and diagnosis after operation (n = 84). Ultrasound imaging performed by the hand surgeon improves quality in the evaluation of hand problems. Ultrasonography is a cost-effective high-resolution investigation with the possibility of dynamic imaging.
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41
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Yeh CK, Chen JJ, Li ML, Luh JJ, Chen JJJ. In vivo imaging of blood flow in the mouse Achilles tendon using high-frequency ultrasound. ULTRASONICS 2009; 49:226-30. [PMID: 18835004 DOI: 10.1016/j.ultras.2008.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 08/20/2008] [Accepted: 08/23/2008] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Achilles tendinitis is a common clinical problem with many treatment modalities, including physical therapy, exercise and therapeutic ultrasound. However, evaluating the effects of current therapeutic modalities and studying the therapeutic mechanism(s) in vivo remains problematic. In this study, we attempted to observe the morphology and microcirculation changes in mouse Achilles tendons between pre- and post-treatment using high-frequency (25 MHz) ultrasound imaging. A secondary aim was to assess the potential of high-frequency ultrasound in exploring therapeutic mechanisms in small-animal models in vivo. METHODS A collagenase-induced mouse model of Achilles tendinitis was adopted, and 5 min treatment of continuous-mode low-frequency (45 kHz) ultrasound with 47 mW/cm(2) maximum intensity and 16.3 cm(2) effective beam radiating area was applied. The B-mode images showed no focal hypoechoic regions in normal Achilles tendons either pre- or post-treatment. The Doppler power energy and blood flow rate were measured within the peritendinous space of the Achilles tendon. CONCLUSION An increase in the microcirculation was observed soon after the low-frequency ultrasound treatment, which was due to immediate induction of vascular dilatation. The results suggest that applying high-frequency Doppler imaging to small-animal models will be an invaluable aid in explorations of the therapeutic mechanism(s). Our future work includes using imaging to assess microcirculation changes in tendinitis between before and after treatment over a long time period, which is expected to yield useful physiological data for future human studies.
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Affiliation(s)
- Chih-Kuang Yeh
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu 30013, Taiwan, ROC.
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Guntern D, Goncalves-Matoso V, Gray A, Picht C, Schnyder P, Theumann N. Finger A2 Pulley Lesions in Rock Climbers. Invest Radiol 2007; 42:435-41. [PMID: 17507816 DOI: 10.1097/01.rli.0000262756.65849.12] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate magnetic resonance imaging (MRI) at 3 T in the diagnosis and characterization of lesions of the finger flexor A2 pulley in patients with clinically suspected A2 pulley lesions. MATERIALS AND METHODS Eight consecutive patients with clinically suspected lesions of the A2 pulley were included in this retrospective study. 3 T MRI was performed with T1-weighted, T2-weighted fat suppressed, and T1-weighted fat suppressed contrast enhanced sequences. The A2 pulley of all the fingers visible on the images were analyzed and pulley lesions characterized. RESULTS All asymptomatic pulleys were normal at MRI. In the 8 symptomatic fingers 7 pulleys were abnormal at MRI. With the clinical examination as gold standard, sensitivity, specificity, positive predictive value, and negative predictive value of MRI were 87.5%, 100%, 100%, and 95.2% respectively. Characterization of the different pulley lesion was possible. CONCLUSION MRI at 3 T allows reliable direct visualization and characterization of traumatic A2 pulley lesions.
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Bianchi S, Martinoli C, de Gautard R, Gaignot C. Ultrasound of the digital flexor system: Normal and pathological findings(). J Ultrasound 2007; 10:85-92. [PMID: 23396583 DOI: 10.1016/j.jus.2007.03.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Recent improvements in ultrasound (US) software and hardware have markedly increased the role of this imaging modality in the evaluation of the musculoskeletal system. US is currently one of the main imaging tools used to diagnose and assess most tendon, muscle, and ligament disorders. Compared with magnetic resonance imaging, US is much less expensive; it has no contraindications and is also widely available. Diseases affecting the digital flexor system (DFS) require early diagnosis if treatment is expected to limit functional impairment of the hand. US scans performed with high-resolution, broad-band transducers allows superb visualization of the flexor tendons of the hand and the annular digital pulleys. In addition, dynamic US can be used to assess movement of the tendon within the pulleys during passive or active joint movements. This article examines the anatomy and US appearance of the normal DFS and reviews the US findings associated with the most common disorders affecting it.
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Affiliation(s)
- S Bianchi
- Clinique et Fondation des Grangettes, Genève, Switzerland
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Arora R, Fritz D, Zimmermann R, Lutz M, Kamelger F, Klauser AS, Gabl M. Reconstruction of the digital flexor pulley system: a retrospective comparison of two methods of treatment. J Hand Surg Eur Vol 2007; 32:60-6. [PMID: 17126460 DOI: 10.1016/j.jhsb.2006.09.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Revised: 09/18/2006] [Accepted: 09/25/2006] [Indexed: 02/03/2023]
Abstract
The rare injury of closed rupture of the A2 and A3 flexor pulleys was treated using two non-encircling techniques of pulley reconstruction. Thirteen patients were treated with an extensor retinaculum graft (Group A). At a mean follow-up time of 48 months, the average PIP flexion was 97%, the power grip strength 96%, the pinch grip strength 100% and the thickening 94% of the uninjured side. Ten patients were treated with a free palmaris longus tendon grafts (Group B). At a mean follow-up time of 57 months, the average PIP flexion was 94%, the power grip strength 98%, the pinch grip strength 100% and the thickening 95% of the uninjured side. In both groups, finger extension was unrestricted. The Buck Gramcko score included 10 excellent, two good and one fair result in Group A and seven excellent, two good and one fair result in Group B. Both techniques proved beneficial. All climbers returned to their previous standard and all non-climbers regained full finger dexterity in their previous job.
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Affiliation(s)
- R Arora
- Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck (MUI), Innsbruck, Austria.
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Schöffl VR, Einwag F, Strecker W, Schöffl I. Strength measurement and clinical outcome after pulley ruptures in climbers. Med Sci Sports Exerc 2006; 38:637-43. [PMID: 16679977 DOI: 10.1249/01.mss.0000210199.87328.6a] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Ruptures of the finger flexor pulleys are the most frequent injuries in rock climbers. Whereas multiple pulley injuries demand a surgical reconstruction, single ruptures are mainly treated conservatively. Nevertheless, the question of the clinical outcome or a persisting finger strength deficit after conservative therapy arises. METHODS Twenty-one rock climbers (age 34 +/- 9 yr) with a grade 2-4 pulley injury were reevaluated 3.46 (range: 0.25-18) yr after injury. The clinical evaluation followed a standard questionnaire in combination with an ultrasound examination in extension and forced flexion. In order to determine the finger strengths, the subjects hung with the respective finger in various postures on a ledge attached above a door frame, while standing on a force platform, which measured the relative release. RESULTS The 21 subjects had old (3.46 yr, range: 0.25-18) pulley injuries in 27 fingers (10 A2, 1 A3, 11 A4, 3 A2/3, 2 A3/4). The clinical outcome was excellent (Buck-Gramcko score of 3) in all cases; the subjects regained their climbing level within a year. There was no difference between the initial ultrasound examination and the follow-up during the study. For 17 finger pairs, data for the relative strength of the injured and the respective healthy finger could be gathered. The finger strength was not significantly different for the injured and the healthy finger in either the hanging or the crimping finger position. CONCLUSIONS Nonsurgical treatment of single pulley ruptures is recommended. The clinical outcome was good to excellent, and no long-term strength deficit for the injured finger could be observed.
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Schöffl VR, Jüngert J. Closed flexor pulley injuries in nonclimbing activities. J Hand Surg Am 2006; 31:806-10. [PMID: 16713847 DOI: 10.1016/j.jhsa.2006.02.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2005] [Revised: 01/29/2006] [Accepted: 02/01/2006] [Indexed: 02/02/2023]
Abstract
Closed flexor pulley injuries have been reported in rock climbers. We report 6 digital flexor pulley injuries in 6 patients aged 5 to 73 years that were not associated with a climbing injury. Excellent outcomes were achieved through conservative therapy in 5 patients and surgical therapy in 1 patient.
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Schöffl VR, Schöffl I. Injuries to the finger flexor pulley system in rock climbers: current concepts. J Hand Surg Am 2006; 31:647-54. [PMID: 16632061 DOI: 10.1016/j.jhsa.2006.02.011] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2003] [Accepted: 01/06/2004] [Indexed: 02/02/2023]
Abstract
Closed traumatic ruptures of finger flexor tendon pulleys began to be recognized specifically over the past several decades. This injury, although rare in the general population, is seen more commonly in rock climbers. This article analyzes this type of injury and the current diagnostic and therapeutic criteria. Ultrasound and magnetic resonance imaging are used to differentiate between a pulley strain, partial rupture, complete rupture, or multiple ruptures. Grade I to III injuries (strains, partial rupture, single ruptures) are treated conservatively with initial immobilization and early functional therapy under pulley protection. Grade IV injuries (multiple ruptures) require surgical repair.
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Klauser A, Gabl M, Smekal V, Nedden DZ. [High frequency sonography in the detection of finger injuries in sport climbing]. ACTA ACUST UNITED AC 2005; 56:13-9. [PMID: 16218523 DOI: 10.1016/j.rontge.2005.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sport climbing shows an increasing popularity, including even school sport activity on high climbing levels. Climbing related injuries are predominantly located in fingers/ hands ("climber's finger"), and can present as annular pulley rupture or more common as overuse injury. Beside clinical examination imaging modalities such as MRI and high frequency sonography have shown to allow for detection of climbing related injuries. High frequency sonography enables for exact differential diagnosis of climbing related finger/hand injuries and therefore plays a central role in adequate therapeutic management.
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Affiliation(s)
- Andrea Klauser
- Universitätsklinik für Radiodiagnostik, Radiologie II, Anichstrasse 35, A-6020 Innsbruck.
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