Impact of taping after finger flexor tendon pulley ruptures in rock climbers

Flexor tendon pulley ruptures are the most common injury in rock climbers. Therapeutic standards usually include a prolonged use of taping applied as a replacement for the lost pulley in a circular fashion at the base of the proximal phalanx. Our biomechanical considerations, however, suggest a new taping method, the H-tape. The purpose of the study is to evaluate whether this new taping method can effectively change the course of the flexor tendon and therefore reduce the tendon-bone distance. In order to compare the effects of different taping methods described in the literature with the newly developed taping method, we performed standardized ultrasound examinations of 8 subjects with singular A2 pulley rupture and multiple pulley ruptures of A2 and A3 pulleys and determined the respective tendon-bone distance for the different taping methods, versus without tape at a preset position on the proximal phalanx. In a second approach, we evaluated the effect of the new taping method on the strength of the injured finger using a force platform on 12 subjects with different pulley ruptures with injuries older than 1 year. The new taping method decreased the tendon-bone distance in the injured finger significantly by 16%, whereas the other taping methods did not. The strength development was significantly better with the new tape for the crimp grip position (+13%), but there was no significant improvement for the hanging position. We recommend taping with the newly presented taping technique after pulley rupture.     

Radial half of extensor carpi radialis longus tendon as graft to elongate muscle tendon unit for correction of finger clawing

In 12 patients, the extensor carpi radialis longus muscle tendon unit was elongated using the radial half of the parent tendon so that it could reach the site of new insertion, the A1-A2 pulley of flexor sheath or lateral bands, after routing the transfer through the carpal tunnel. The tendon was of appropriate thickness and could be split into two halves to be used as a graft. Further splitting of the tendon into four tails was possible. The transferred slips retained adequate strength to activate the fingers after the operation. It is suggested that splitting of the extensor carpi radialis longus tendon to use one half as a tendon graft be considered in patients in whom extensor carpi radialis longus transfer is planned to correct finger clawing. This technique is simple, needs minor modification in the sequence of operative steps, reduces operating time, and saves the patient from postoperative discomfort, muscle herniation, and scarring at the donor site (usually the thigh).     

Comparison of ultrasonographic and intraoperative findings in Achilles tendon rupture

The purpose of the study was to assess the value of ultrasonography in the diagnosis of Achilles tendon rupture, by comparing initial ultrasonographic scans and direct intraoperative findings, as well as to follow up the healing process in operatively and conservatively treated patients. Ultrasound examination was performed in 100 patients (91 males and 9 females, with mean age of 46 years) with clinically suspicious Achilles tendon ruptures. Ultrasonographic findings were compared with intraoperative findings. Eighty-eight patients underwent surgery and twelve patients were treated conservatively. Complete ruptures were diagnosed by ultrasound in 88 patients, and partial ruptures in 12 patients. The length of the tendon (Pearson r = 0.973, p < 0.001, Spearman p = 0.972, p < 0.001) and the size of the rupture (Pearson r = 0.940, p < 0.001, Spearman p = 0.905, p < 0.001) measured before surgery by ultrasound and directly during surgery showed a high correlation. Out of 88 operatively treated patients, 86 had a complete rupture and two had a partial rupture. All patients were examined 3, 5, 8, and 12 weeks after injury or after surgery. In the first five weeks, there were statistically significant differences noted between these two groups. Operatively treated tendons healed more quickly, but after eight and twelve weeks this difference had disappeared. Our study showed that ultrasound is an excellent imaging method for confirming the clinical diagnosis of Achilles tendon rupture as well as for following up the process of tendon healing.     

超声在诊断卵巢黄体破裂中的应用

目的探讨超声对卵巢黄体破裂的诊断价值。方法回顾性分析35例经超声诊断卵巢黄体破裂的声像特点及临床表现。结果35例均有不同程度的腹盆腔积液。24例手术治疗并病理证实,11例保守治疗,超声表现为盆腔积液,卵巢囊肿,附件区包块。结论超声对卵巢黄体破裂的早期快速诊断和制定治疗方案及愈后,有及其重要价值和意义。     

低强度脉冲超声波对肌腱愈合的促进作用

目的:分析低强度脉冲超声波(low intensity pulsed ultrasound,LIPU)对Ⅱ区屈指肌腱愈合的促进作用,并探讨其减少肌腱粘连的临床效果。方法:选取2010年8月至2013年4月在我院接受II区屈指肌腱损伤修复术治疗的患者80例并随机分为两组。LIPU组(33例,共39指),该组患者均接受系统的低强度脉冲超声波进行治疗;对照组(34例,共41指),所有患者在治疗时放置超声探头,但不接通电源。在术后12周,采用视觉模拟评分法(visual analogue scale,VAS)评估患手疼痛程度;采用肌腱总主动活动度(total active motion,TAM)评定标准评价肌腱的功能状况;采用Lovett分级法评价患指屈指肌力。结果:两组术后无肌腱再断裂病例出现。术后12周时,LIPU组与对照组的VAS疼痛评分分别为(1.9±1.8)和(2.3±1.9)(t=0.996,P=0.337)。根据TAM系统评定标准,LIPU组与对照组的优良率分别为94.9%和70.7%,组间差异有统计学意义(X2=12.798,P=0.000),LIPU组显著高于对照组,两组患指屈指肌力恢复正常的发生率分别为100%和95.1%,组间差异无统计学意义(X2=1.951,P=0.162)。结论:LIPU具有促进II区屈指肌腱愈合,改善患指主动活动功能的效果,且不增加肌腱断裂的风险,但其促进肌腱愈合的机制尚需进一步实验研究证实。     

Comprehensive simulation on morphological and mechanical properties of trigger finger – A cadaveric model

Trigger finger has long been a common disorder in hand orthopedics. To clarify the unknown causative factors regarding the disease, numerous experiments were done on human cadavers, including tendon forces, tendon moment arm, mechanical properties of the pulley, gliding resistance, etc. However, most of these studies were conducted on normal fingers. As the etiology of trigger finger is still controversial on whether it is an outcome of tendon nodule or pulley scarring, in this study, a trigger finger model was built combining both the nodule created by silicone gel injection and pulley constriction by external compression. Indentation and gliding resistance tests were performed on cadaveric specimens to verify the model. Results showed that after silicone gel injection into the tendon, a significant increase in thickness was found. In addition, no significant difference was found in the toe region compressive modulus of the tendon after injection. Moreover, maximum, drop of gliding resistance and work of extension were all found to be significantly larger as the severity of triggering increased. Our results indicated we have developed a feasible cadaver model simulating trigger finger nodule which could be utilized for further experiments to elucidate other causative factors and biomechanical features of trigger finger in the future.     

The influence of the crimp and slope grip position on the finger pulley system

In this study the influence of the grip position (crimp grip vs. slope grip position) on the pulley system of the finger was investigated. For this purpose 21 cadaver finger (11 hands, 10 donors) were fixed into an isokinetic loading device. Nine fingers were loaded in the slope grip position and 12 fingers in the crimp grip position. The forces in the flexor tendons and at the fingertip were recorded. A rupture of the A4 pulley occurred most often in the crimp grip position (50%) but did not occur in the slope grip position, in which alternative events were the most common (67%). The forces in the deep flexor tendon (FDP) (slope grip: 371 N, crimp grip: 348 N) and at the fingertip (slope grip: 105 N, crimp grip: 161 N) were not significantly different between the 2 finger positions, but the forces acting on the pulleys were higher in the crimp grip position (A2 pulley: 287 N, A4 pulley: 226 N) than in the slope grip position (A2 pulley: 121 N, A4 pulley: 103 N). The crimp grip position may be the main cause for A4 pulley ruptures but the slope grip position may be hazardous for other injuries as the forces recorded in the flexor tendons and at the fingertip were comparable at the occurrence of a terminal event.     

Tendon displacements during voluntary and involuntary finger movements

In the human hand, independent movement control of individual fingers is limited. One potential cause for this is mechanical connections between the tendons and muscle bellies corresponding to the different fingers. The aim of this study was to determine the tendon displacement of the flexor digitorum superficialis (FDS) of both the instructed and the neighboring, non-instructed fingers during single finger flexion movements. In nine healthy subjects (age 22–29 years), instructed and non-instructed FDS finger tendon displacement of the index, middle and ring finger was measured using 2D ultrasound analyzed with speckle tracking software in two conditions: active flexion of all finger joints with all fingers free to move and active flexion while the non-instructed fingers were restricted. Our results of the free movement protocol showed an average tendon displacement of 27 mm for index finger flexion, 21 mm for middle finger flexion and 17 mm for ring finger flexion. Displacements of the non-instructed finger tendons (≈12 mm) were higher than expected based of the amount of non-instructed finger movement. In the restricted protocol, we found that, despite minimal joint movements, substantial non-instructed finger tendon displacement (≈9 mm) was still observed, which was interpreted as a result of tendon strain. When this strain component was subtracted from the tendon displacement of the non-instructed fingers during the free movement condition, the relationship between finger movement and tendon displacement of the instructed and non-instructed finger became comparable. Thus, when studying non-instructed finger tendon displacement it is important to take tendon strain into consideration.     

Connective tissue reinforcing structures of the digital tendon sheaths of the human hand

At a greater number of humid preparated human hands, all the ligamentous supports of the digital tendon sheath were exposed and their dimensions were determined. The osteofibrous channels, which contain the long flexor tendons of the digits, were bounded on the one hand by transversely concave shaft areas of the phalanges and the palmar ligaments and on the other side by the fibrous parts of the tendon sheath. From the second to the 5th finger, it has a regular extension of length, which begins proximal at the heads of the metacarpal bones and runs distal to the base of the nail phalanx. In some cases, there is a continuous communication between the digital tendon sheath of the little finger and the carpal synovial sheath. The tendon sheath of the flexor pollicis longus muscle in comparison with it is always in an open communication with the radial synovial sac of the wrist. At the fibrous supports of the digital tendon sheath, one can find constant and inconstant ligamentous structures. Regular shaped ligaments consist of annular fibers (A1 to A5). The proximal complex of fiber supports is a formation of the A1 and A2 ligaments. The band A1 can be divided into 2 ligaments both of roughly equal length, which lay between the head of the metacarpal bone and the base of the proximal phalanx. The strongest fibrous support of the whole digital tendon sheath represents the band A2. It is attached to the midth of the proximal phalanx and increases in strength from proximal to distal. The middle length varies between 6.7 mm at the thumb and 18.7 mm at the middle finger. The distal margin is strengthened by fibrocartilage tissue to be in accordance with the important function as a pulley. The annular band A4 forms the distal supporting complex height above the shaft of the middle phalanx. At the 2nd to the 5th finger it is, with a middle length of 6 to 7 mm, very much shorter than A2 and restrains first of all the tendon of the flexor digitorum profundus muscle. In the area of the interphalangeal joints, we can find the annular bands A3 and A5, which fiber texture is formed variable. Both ligaments are attached on either both sides with the joint capsule and the palmar plate. The other inconstant supports of the digital sheaths are systematically recorded indeed (C1 to C3), but only in exceptional cases they exist of cruciform fibers (Lig. cruciatum).(ABSTRACT TRUNCATED AT 400 WORDS)     

Biomechanical model for the determination of the forces acting on the finger pulley system

A mathematical model proposed by Hume et al., 1991. Journal of Hand Surgery-American Volume 16, 722-730 for the determination of the forces acting on the A2 and A4 pulley was used. The parameters necessary for this determination include the angle of flexion, the positioning of the pulley with respect to the centre of rotation in the proximal interphalangeal joint (PIP), the relative mismatch between bone and tendon width at the location of the respective pulleys as well as the tendon height at this position. This model was further developed to include the stiffness of the respective pulley, as well as the fact, that there are two flexor tendons of which only one passes through both pulleys. Each parameter was then evaluated using a sensitivity analysis proposed by Fasham et al., 1990. Journal of Marine Research 48, 591-639 in order to determine their relative importance for the outcome of the model. The most important parameter proofed to be the positioning of the pulley with respect to the centre of rotation in the PIP joint. This observation enabled us to give the best possible placement for a pulley graft after pulley rupture.     

Hyaluronic acid diminishes the resistance to excursion after flexor tendon repair: an in vitro biomechanical study

Adhesion between the tendon and tendon sheath after primary flexor tendon repair is seen frequently, and postoperative finger function is occasionally unsatisfactory. A reduction of the friction may facilitate tendon mobilization, which in turn may reduce the risk of the adhesion and restriction of range of motion. We considered the possibility of utilizing the hyaluronic acid (HA) as a lubricant. To evaluate the effect of HA, the gliding resistance between the canine flexor digitorum profundus tendon repaired by a modified Kessler suture technique with running epitendinous suture and the annular pulley located on the proximal phalanx (corresponding to the A2 pulley in humans) was evaluated and compared before and after administration of HA. The HA solution measurement groups were identified as follows; intact tendon as a control; repaired tendon; tendon soaked in 0.1, 1, and 10 mg/ml HA. The resistance increased after repairing, then it decreased after soaking in 10 mg/ml HA solution. The results of this study revealed that HA diminishes the excursion resistance after flexor tendon repair. We believe that some style of administration of the HA might reduce the excursion resistance and prevent adhesion until the synovial surface is fully developed.     

屏障材料预防肌腱粘连的研究进展

肌腱与腱周组织粘连是肌腱损伤修复术后最主要的并发症,使用屏障材料预防肌腱粘连是一种最直接有效的方法。传统使用的不可吸收材料常常会导致严重免疫反应或阻隔肌腱营养而导致肌腱愈合不良,且常需二次手术取出,已基本淘汰。可吸收膜和水凝胶等具有良好通透性及组织相容性的可吸收大分子材料是目前研究的重点。使用自体或异体组织材料重建腱鞘也可预防肌腱粘连,但自体组织重建腱鞘损伤较大且手术复杂,异体组织常常受到安全性、伦理学等诸多限制,而组织工程化腱鞘可能是未来预防肌腱粘连的一个重要研究方向。     

Studies on the tendinous compartments of the extensor muscles on the back of the human hand and their tendon sheaths. I

In 47 dissected right and left hands of adults of both sexes, kept in a moist condition, significant practical-clinical investigations of the transitional zone between forearm and hand were undertaken. In particular it was sought to determine the characteristic sizes of the extensor retinaculum, the osteofibrous tunnels, the insertion tendons of the hand and finger extensor muscles, and their tendon sheaths. Together with the palmar carpal ligament, the 2 to 3 cm wide extensor retinaculum annularly surrounds the whole circumference of the carpus. It extends obliquely from radial-proximal to ulnar-distal and conducts the extensor tendons over the carpal articulations. According to recent studies, it is divided into a superficial and a deep fibrous layer. From the undermost surface, vertical and oblique septa run to the plane of the forearm and carpal bones. They separate the fibrous portion of the 6 tendinous compartments of the dorsum manus. In 8.5% of cases, an accessory and completely independent tunnel of the extensor pollicis brevis muscle exists in the material investigated, and in 2.2% of cases, there is an additional tunnel for the extensor carpi radialis muscle. Hence, one occasionally finds 8 separate osteofibrous gliding compartments for the extensor muscles in the dorsal hand region. The longest tunnel belongs, as a rule, to the extensor digiti minimi muscle, whilst the widest pertains to the extensor digitorum muscle. Within the tunnel and also proximal and distal to it, the extensor tendons are surrounded by synovial sheaths. Because of its wide encroachment on the dorsum of the hand, the insertion tendon of the extensor digiti minimi muscle possesses the longest tendon sheath, measuring 68.8 mm. The next longest sheath, that of the extensor pollicis longus muscle, which measures 56.2 mm, begins further proximal to the gap of the radiocarpal articulation. In 12.8% of cases, there are divided sheaths of the abductor pollicis longus and of the extensor pollicis brevis muscle. The tendon sheath of both extensor carpi radiales muscles is frequently divided into 2 compartments which, in 2/3 of cases, communicate. The compartment of the extensor carpi radialis brevis muscle, in 91.5% of cases, shares a window-like opening with the roof of the synovial vagina of the extensor pollicis longus muscle. The tendon sheath of the long extensor muscles of the fingers originates 5 mm proximal to the forearm border of the extensor retinaculum and has a communal recess. The IVth tendon sheath opens distally and splays out in a glove-like manner to some distal recesses.(ABSTRACT TRUNCATED AT 400 WORDS)     

腱鞘巨细胞瘤的影像学诊断

目的:分析腱鞘巨细胞瘤的影像学表现以提高对该病的认识。方法:回顾性分析10例经手术病理证实的腱鞘巨细胞瘤的X线平片及MRI表现,其中10例行X线平片检查,8例行MRI平扫及增强扫描。结果:X线平片显示局部稍高密度软组织肿块影,邻近骨质未见明显异常或轻度侵蚀破坏。MRI表现为相应部位软组织肿块影,T1WI多呈较低信号,内可见条片状更低信号影,增强后强化明显;T2WI呈高低混杂信号影;病灶与邻近肌腱关系密切,其中一例包绕指屈肌腱蔓状生长;局部骨皮质可受侵。结论:腱鞘巨细胞瘤的影像学表现具有一定的特征性。     

B超在肝囊型包虫病诊断中的临床价值与意义

目的：评价B超在肝囊型包虫病诊断中的价值与临床意义。方法：回顾性分析我院2000年12月至2011年12月收治的接受B超检查和手术治疗的332肝囊型包虫病例的临床资料。结果：332例肝囊型包虫病患者中,303例经过手术证实;肝囊型包虫病的B超分型可分为单发单囊型、多发单囊型、多子囊型、破裂感染型和坏死钙化型。单发单囊型患者以低年龄组多发,而高年龄组较少;破裂感染型以高年龄组多发;坏死钙化型病人共3例年龄均在60岁以上;破裂感染型占各型中病例数最多。结论：B型超声检查是肝囊型包虫病的主要检查方法,可确定包虫病的分型,了解包虫囊肿的部位、数目、大小和结构,为术前诊断、手术定位、观察治疗效果提供参考依据。     

Correlation between semitendinosus and gracilis tendon cross-sectional area determined using ultrasound,magnetic resonance imaging and intraoperative tendon measurements

The purpose of this study was to examine the correlation in semitendinosus (ST) and gracilis (GT) tendon cross-sectional area (CSA) evaluated directly during anterior cruciate ligament (ACL) surgery and pre-operatively using ultrasound (US) and magnetic resonance imaging (MRI). A total of 14 patients undergoing ACL reconstruction with a quadruple ST–GT graft by the same orthopaedic surgeon participated in this study. Pre-operative evaluation included determination of ST and GT CSA area using US and MRI. Intraoperative measurement of the diameters of the ST, GT and the final ACL graft using a closed-hole sizing block with 0.5-mm increments was made and this diameter was used to estimate tendon CSA. The correlation between graft diameter and CSA were 0.563 (GT) and 0.807 (ST) for MRI and 0.498 (GT) and 0.612 (ST) for US. The final ACL graft diameter displayed a correlation coefficient of 0.813 with MRI CSA and 0.518 with US CSA. No differences in CSA were observed between intraoperative, MRI and US methods (p > 0.05). The intraclass correlation coefficients between the US, MRI and intraoperative graft methods for the ST and GT data ranged from 0.502 to 0.903 with an estimation error ranging from 1.41% to 2.26%. These results indicate that in clinical situations where MRI is contra-indicated or not accessible, US can provide measurable values which could predict sufficient diameter of the ACL graft. In addition, determination of tendon CSA using US displays errors less than 2% which is similar to that observed using MRI. This suggests that the application of US can be applied to in vivo examination of the ST and GT CSA.     

Biomechanical properties of the crimp grip position in rock climbers

Rock climbers are often using the unique crimp grip position to hold small ledges. Thereby the proximal interphalangeal (PIP) joints are flexed about 90 degrees and the distal interphalangeal joints are hyperextended maximally. During this position of the finger joints bowstringing of the flexor tendon is applying very high load to the flexor tendon pulleys and can cause injuries and overuse syndromes. The objective of this study was to investigate bowstringing and forces during crimp grip position. Two devices were built to measure the force and the distance of bowstringing and one device to measure forces at the fingertip. All measurements of 16 fingers of four subjects were made in vivo. The largest amount of bowstringing was caused by the flexor digitorum profundus tendon in the crimp grip position being less using slope grip position (PIP joint extended). During a warm-up, the distance of bowstringing over the distal edge of the A2 pulley increased by 0.6mm (30%) and was loaded about 3 times the force applied at the fingertip during crimp grip position. Load up to 116N was measured over the A2 pulley. Increase of force in one finger holds by the quadriga effect was shown using crimp and slope grip position.     

Further experience in rehabilitation of zone II flexor tendon repair with dynamic traction splinting

A review of all flexor tendon repairs in the "no man's land" performed from January of 1985 to June of 1987 was done to evaluate the efficacy of our method of rehabilitation. There were 60 fingers (57 patients) with complete laceration of the flexor digitorum profundus and flexor digitorum superficialis tendons in zone II. Fingers with phalangeal fractures, joint injuries, or significant skin loss were excluded. Follow-up ranged from 12 to 48 months. Rehabilitation consisted of a 12-week protocol using the U.S. military combined regimen of controlled motion. Features from the technique of controlled active extension against rubber band passive flexion as well as those of controlled passive extension and passive flexion were incorporated. The palmar pulley modification of Kleinert's dynamic traction splint was utilized. Strickland's total active motion formula was employed to determine results. The results were classified into the four categories of excellent, good, fair, and poor. Fifty-two fingers (86 percent) were rated excellent, 4 fingers (7 percent) were rated good, 1 finger (2 percent) was rated fair, and 3 fingers (5 percent) were rated poor.