Finger injuries in extreme rock climbers. Assessment of high-resolution ultrasonography

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Diagnostic Imaging of A2 Pulley Injuries: A Review of the Literature

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.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Sonography of tendon pathology in the hand and wrist

Traumatic and non-traumatic tendon lesions are common at the wrist and hand. For the diagnosis, therapy management, and long-term prognosis of tendon lesions, a detailed understanding of the complex anatomy and knowledge of typical injury patterns is crucial for both radiologists and clinicians. Improvements in high-resolution ultrasound are producing high-quality images of the superficial tendinous and peritendinous structures. Thus, ultrasound is a valuable first-choice tool for visualizing traumatic, inflammatory, and degenerative conditions of the extensor and flexor tendons, particularly with the advantage of possible dynamic examination. The additional use of duplex-Doppler and power Doppler ultrasound imaging is recommended for detection of tenosynovitis in overuse injury, inflammatory disease, infection, and after traumatic conditions. In traumatic tendon injuries, knowing the precise injury zone is important for treatment decision-making. In cases of tendon rupture, the radiologist should report the tear type (i.e., complete or partial-thickness) and assess the degree of tendon retraction and associated avulsion injury, including the degree of fragment displacement. The function of intact flexor tendons may be impaired by thickening, strain, or rupture of corresponding annular pulleys. This review describes in detail the typical ultrasound imaging features of common pathologies of hand and wrist tendons, including annular pulley lesions.

Pulley, Flexor, and Extensor Tendon Injuries of the Hand

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.

Viscoelastic properties of the human A2 finger pulley

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.

Ultrasonographic Diagnosis of A2 or A4 Flexor Tendon Pulley Injury: A Systematic Review

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.

Olympic competition climbing: the beginning of a new era-a narrative review

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.

Grip Force Measurement as a Complement to High-Resolution Ultrasound in the Diagnosis and Follow-Up of A2 and A4 Finger Pulley Injuries

The ability of finger flexors to generate force has been studied in relation to climbing performance. However, not much attention has been paid to the decrease in finger grip force in relation to annular pulley injuries. The purpose of the present study was to determine if an injured annular pulley implies a finger flexor force decrease, as well as its relation to clinical and sonographic changes. We performed an observational study in 39 rock climbers with A2 or A4 pulley injuries to the 3rd or 4th fingers. The variables considered were pain upon palpation, ultrasound tendon–bone distance, and finger grip strength decrease. Three rock climbing grip types were considered: the one finger crimp, open crimp, and close crimp. Injured rock climbers presented a decrease in finger grip strength compared to non-injured controls when performing a one finger crimp (p < 0.001). There exists a significant correlation between a tendon–bone distance at the level of the injured pulley and a decreased finger grip strength measured by performing a one finger crimp (p = 0.006). A decrease in finger grip strength could be considered in the diagnostic and follow-up process of A2 and A4 pulley injuries to the 3rd and 4th fingers.

Differential sonographic features of the extensor pollicis longus tendon rupture and other finger tendons rupture in the setting of hand and wrist trauma

PURPOSE

To investigate the difference between sonographic findings in extensor pollicis longus tendons rupture and other finger tendons rupture in patients sustaining hand and wrist trauma.

METHODS

Twenty-four patients who presented with signs and symptoms clinically suspicious for tendon injury and surgically confirmed tendon rupture were included in this study. We analyzed 6 sonographic features: discontinuity of the tendon, pseudomass formation, decreased echogenicity of the tendon, retraction of the ruptured tendon, fluid collection within the tendon sheath, and the motion of the tendon. We compared the sonographic features of ruptured extensor pollicis longus tendons with the other ruptured finger tendons.

RESULTS

Discontinuity of the tendon was the most common sonographic findings and retraction of the ruptured tendon was the second most common findings. Fourteen of 16 cases with a dynamic study on sonography showed loss of normal motion of the tendon. Pseudomass formation was the second most common feature in ruptured extensor pollicis longus tendons, in contrast to the other ruptured finger tendons (p < 0.05).

CONCLUSION

Using ultrasonography, detection of discontinuity of the tendon, retraction of the ruptured tendon, and limitation of tendon motion could be very helpful for diagnosing a tendon rupture in hand and wrist trauma. Pseudomass formation could be more specific for diagnosing extensor pollicis longus tendon ruptures compared with other finger tendons.

MRI sport-specific pulley imaging

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.

Diagnosis of Complex Pulley Ruptures Using Ultrasound in Cadaver Models

Pulley ruptures are common in climbing athletes. The purposes of this study were to determine the specific positioning of each pulley with regards to the joint, and to evaluate the ultrasound diagnostics of various pulley rupture combinations. For this, 34 cadaver fingers were analyzed via ultrasound, the results of which were compared to anatomic measurements. Different pulley ruptures were then simulated and evaluated using ultrasound in standardized dynamic forced flexion. Visualization of the A2 and A4 pulleys was achieved 100% of the time, while the A3 pulley was visible in 74% of cases. Similarly, injuries to the A2 and A4 pulleys were readily observable, while A3 pulley injuries were more challenging to identify (sensitivity of 0.2 for singular A3 pulley, 0.5 for A2/A4 pulley and 0.33 for A3/A4 pulley ruptures). Receiver operating characteristic analysis was used to evaluate the optimal tendon-bone distance for pulley rupture diagnosis, a threshold which was determined to be 1.9 mm for A2 pulley ruptures and 1.85 for A4 pulley ruptures. This study was the first to carry out a cadaver ultrasound examination of a wide variety of pulley ruptures. Ultrasound is a highly accurate tool for visualizing the A2 and A4 pulleys in a cadaver model. This method of pathology diagnosis was determined to be suitable for injuries to the A2 and A4 pulleys, but inadequate for A3 pulley injuries.

A Novel Adhesion Index for Verifying the Extent of Adhesion for the Extensor Digitorum Communis in Patients with Metacarpal Fractures

This study aims to determine if the relative displacement between the extensor digitorum communis (EDC) tendon and its surrounding tissues can be used as an adhesion index (AI) for assessing adhesion in metacarpal fractures by comparing two clinical measures, namely single-digit-force and extensor lag (i.e., the difference between passive extension and full active extension). The Fisher–Tippett block-matching method and a Kalman-filter algorithm were used to determine the relative displacements in 39 healthy subjects and 8 patients with metacarpal fractures. A goniometer was used to measure the extensor lag, and a force sensor was used to measure the single-digit-force. Measurements were obtained twice for each patient to evaluate the performance of the AI in assessing the progress of rehabilitation. The Pearson correlation coefficient was calculated to quantify the various correlations between the AI, extensor lag, and single-digit-force. The results showed strong correlations between the AI and the extensor lag, the AI and the single-digit-force, and the extensor lag and the single-digit-force (r = 0.718, −0.849, and −0.741; P = 0.002, P < 0.001, and P = 0.001, respectively). The AI in the patients gradually decreased after continuous rehabilitation, but remained higher than that of healthy participants.

Application of a novel Kalman filter based block matching method to ultrasound images for hand tendon displacement estimation

PURPOSE

Information about tendon displacement is important for allowing clinicians to not only quantify preoperative tendon injuries but also to identify any adhesive scaring between tendon and adjacent tissue. The Fisher-Tippett (FT) similarity measure has recently been shown to be more accurate than the Laplacian sum of absolute differences (SAD) and Gaussian sum of squared differences (SSD) similarity measures for tracking tendon displacement in ultrasound B-mode images. However, all of these similarity measures can easily be influenced by the quality of the ultrasound image, particularly its signal-to-noise ratio. Ultrasound images of injured hands are unfortunately often of poor quality due to the presence of adhesive scars. The present study investigated a novel Kalman-filter scheme for overcoming this problem.

METHODS

Three state-of-the-art tracking methods (FT, SAD, and SSD) were used to track the displacements of phantom and cadaver tendons, while FT was used to track human tendons. These three tracking methods were combined individually with the proposed Kalman-filter (K1) scheme and another Kalman-filter scheme used in a previous study to optimize the displacement trajectories of the phantom and cadaver tendons. The motion of the human extensor digitorum communis tendon was measured in the present study using the FT-K1 scheme.

RESULTS

The experimental results indicated that SSD exhibited better accuracy in the phantom experiments, whereas FT exhibited better performance for tracking real tendon motion in the cadaver experiments. All three tracking methods were influenced by the signal-to-noise ratio of the images. On the other hand, the K1 scheme was able to optimize the tracking trajectory of displacement in all experiments, even from a location with a poor image quality. The human experimental data indicated that the normal tendons were displaced more than the injured tendons, and that the motion ability of the injured tendon was restored after appropriate rehabilitation sessions.

CONCLUSIONS

The obtained results show the potential for applying the proposed FT-K1 method in clinical applications for evaluating the tendon injury level after metacarpal fractures and assessing the recovery of an injured tendon during rehabilitation.

Sonographical parameters of the finger pulley system in healthy adults

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.

Rock Climbing Injuries: Acute and Chronic Repetitive Trauma

Rock climbing has increased in popularity as a sport, and specific injuries related to its practice are becoming more common. Chronic repetitive injuries are more common than acute injuries, although acute injuries tend to be more severe. We review both acute and chronic upper and lower extremity injuries. Understanding the injury pattern in rock climbers is important for accurate diagnosis.

MRI of the hand and fingers

Injuries of the hand and fingers occur commonly in professional athletes as well as weekend warriors. Magnetic resonance imaging plays a vital role in the evaluation of these injuries for accurate diagnosis, preoperative planning, potential complication, and follow-up during rehabilitation. A detailed analysis of these smaller structures necessitates optimal imaging quality coupled with comprehensive knowledge of the imaging anatomy. In this article, we discuss technical aspects and normal anatomy of hand and fingers imaging on magnetic resonance imaging. This section is followed by discussion of soft tissue and osseous injuries including mechanism of injury, clinical presentation, and imaging findings.

Flexor digitorum superficialis repair outside the A2 pulley after zone II laceration: gliding and bowstringing

PURPOSE

To evaluate the changes in maximum flexion angle, gliding coefficient, and bowstringing after a combined repair of both flexor tendons with the flexor digitorum superficialis (FDS) rerouted outside the A2 pulley in cadaveric hands.

METHODS

We performed 4 different repairs on cadaveric hands, with each repair tested on 9 unique digits. In total, 12 cadaveric hands and 36 digits were used. The thumb and little finger were removed from each hand and excluded from testing. Group 1 was sham surgery. Group 2 combined flexor digitorum profundus (FDP) and FDS laceration and repair with both slips of the FDS repaired inside the A2 pulley. Group 3 was FDP repair with one slip of the FDS repaired inside A2 and the other slip left unrepaired. Group 4 was FDP repair with both slips of the FDS rerouted and repaired outside the A2 pulley. Maximum flexion angle, gliding coefficient, and bowstringing were measured in simulated active digital motion for each group.

RESULTS

Rerouting and repairing the FDS outside the A2 pulley (group 4) significantly lowered gliding coefficient compared with repairs with both slips inside A2, with values similar to sham surgery. We observed no significant differences in maximum flexion angle among the 4 groups. Increased bowstringing was observed with both slips of the FDS repaired and rerouted outside the A2 pulley.

CONCLUSIONS

In this cadaveric model, repair of both slips of the FDS outside the A2 pulley improved the gliding coefficient relative to repair within the A2 pulley, which suggests decreased resistance to finger flexion. Repair of the FDS outside the A2 pulley led to a slight increase in bowstringing of the FDS tendon.

CLINICAL RELEVANCE

We describe a technique for managing combined laceration of the FDP and FDS tendons that improves gliding function and merits consideration.

Diagnosis of finger flexor pulley injury in rock climbers: A systematic review

BACKGROUND

Closed injury to the finger flexor pulley system is found frequently in rock climbers. There are no evidence-based published guidelines on the diagnosis and treatment of these injuries.

OBJECTIVES

THE PRESENT SYSTEMATIC REVIEW WAS UNDERTAKEN TO ANSWER THE FOLLOWING QUESTIONS: what are the most commonly recommended diagnostic criteria for finger flexor pulley injury in rock climbers; and, based on the available evidence, what is the best diagnostic test for these injuries?

METHODS

Four electronic databases were searched using specific key terms, with limits set for language and date. Two reviewers independently identified potentially relevant titles based on inclusion criteria. Inter-reviewer variability was assessed using the Kappa statistic. The scientific quality of articles was assessed using validated scales.

RESULTS

Of the 93 articles identified, 29 were included in the present analysis. The inter-rater agreement for selection of potentially relevant titles was 88% (kappa=0.74). The most commonly cited diagnostic criterion for closed finger pulley injury was clinical bow-stringing of the flexor tendons over the volar aspect of the proximal interphalangeal joint. However, the best study of diagnostic accuracy for these injuries supports the use of dynamic ultrasound.

CONCLUSIONS

Dynamic ultrasound is recommended for the diagnosis of closed finger pulley injuries in rock climbers. The prevailing notion that these injuries can be diagnosed by testing for clinical bowstringing is not supported by evidence.

Finger A2 Pulley Lesions in Rock Climbers

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.

Ultrasound of the digital flexor system: Normal and pathological findings()

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.

Factors influencing osteological changes in the hands and fingers of rock climbers

This study examines the osteological changes in the hands and fingers of rock climbers that result from intense, long-term mechanical stress placed on these bones. Specifically, it examines whether rock climbing leads to metacarpal and phalange modelling in the form of increased cortical thickness as well as joint changes associated with osteoarthritis. This study also attempts to identify specific climbing-related factors that may influence these changes, including climbing intensity and frequency of different styles of climbing. Radiographs of both hands were taken for each participant and were scored for radiographic signs of osteoarthritis using an atlas method. Total width and medullary width were measured directly on radiographs using digital calipers and used to calculate cross-sectional area and second moment of area based on a ring model. We compared 27 recreational rock climbers and 35 non-climbers for four measures of bone strength and dimensions (cross-sectional area, second moment of area, total width and medullary width) and osteoarthritis. A chi-squared test for independence was used to compare climber and non-climber osteoarthritis scores. For each measure of bone strength climbers and non-climbers were compared using a manova test. Significant manova tests were followed by principal components analysis (PCA) and individual anova tests performed on principal components with eigenvalues greater than one. A second PCA was performed on the climber subsample and the first principal component was then used as the dependent variable in linear regression variable selection procedures to determine which climbing-related variables affect bone thickness. The results suggest that climbers are not at an increased risk of developing osteoarthritis compared with non-climbers. Climbers, however, do have greater cross-sectional area as well as second moment of area. Greater total width, but not meduallary width, indicates that additional bone is deposited subperiosteally. The strength of the finger and hand bones are correlated with styles of climbing that emphasize athletic difficulty. Significant predictors include the highest levels achieved in bouldering and sport climbing.

Sonographic differentiation of digital tendon rupture from adhesive scarring after primary surgical repair

PURPOSE

After the surgical repair of finger tendons finger range of motion may be limited by tendon rupture or adhesive scarring. Differentiating tendon rupture from adhesive scarring may be difficult clinically. Digital tendon sonography allows the evaluation of tendon integrity in a dynamic setting. Our objective was to determine if sonography could differentiate tendon rupture from adhesive scarring in patients who have had primary tendon repair.

METHODS

A retrospective review was performed of the radiographic, clinical, and surgical records of patients referred for finger sonography over a 2-year period. Twenty-eight digits in 21 patients were evaluated for finger tendon disruption after primary surgical repair. The diagnosis of complete tendon rupture was made when 1 or more of the following was identified: a gap separating the proximal and distal tendon margins, visualization of only the proximal tendon margin, or visualization of only the distal tendon margin. Adhesive scarring was diagnosed if the tendon appeared intact with abnormal peritendinous soft tissue abutting or partially encasing the tendon, with synovial sheath thickening, or with restricted tendon motion during dynamic evaluation.

RESULTS

Sonography correctly identified tendon rupture or adhesive scarring in 27 of 28 digits with 1 false-positive case (sensitivity, 100%; specificity, 93%; positive-predictive value, 93%; negative-predictive value, 100%; accuracy, 96%).

CONCLUSIONS

Sonography is an accurate modality for differentiating tendon rupture from adhesive scarring in patients with prior surgical tendon repair.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic, Level I.

[High frequency sonography in the detection of finger injuries in sport climbing]

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.

Remitting seronegative symmetrical synovitis with pitting edema of the hands: Ultrasound, color doppler ultrasound, and magnetic resonance imaging findings

OBJECTIVE

To assess the value of gray-scale ultrasound (US), color Doppler ultrasound (CDUS), contrast-enhanced CDUS, and magnetic resonance imaging (MRI) in the diagnostic evaluation of the hands in patients with remitting seronegative symmetrical synovitis with pitting edema (RS3PE).

METHODS

Eight patients (5 men, 3 women; mean +/- SD age 69.3 +/- 7.2 years) with clinical diagnosis of RS3PE syndrome underwent US, CDUS, contrast-enhanced CDUS, and MRI. US was performed with a linear array transducer operating at 12 MHz. The US contrast agent (SHU 508; Levovist, Schering, Germany) was intravenously infused in a concentration of 300 mg/ml at a rate of 1 ml/minute.

RESULTS

All patients showed symmetric subcutaneous edema and synovitis of tendons and finger joints on both US and MRI. Vascularity was detected subcutaneously in tendon sheaths and in the joint synovia on CDUS and MRI. Detection of increased vascularity was improved after contrast administration compared with unenhanced CDUS (P < 0.01).

CONCLUSION

Ultrasound, CDUS, contrast-enhanced CDUS, and MRI are valuable tools in the diagnostic evaluation of involved anatomic structures in patients with RS3PE. Contrast-enhanced CDUS is superior to CDUS in assessment of inflammatory edema, effusion, and synovitis.

Value of transducer positions in the measurement of finger flexor tendon thickness by sonography

OBJECTIVE

To assess the value of 2 transducer positions for measurement of finger flexor tendon thickness by sonography.

METHODS

Flexor tendon thickness of the third finger was measured sonographically by 2 independent investigators in 20 healthy volunteers (n = 40 fingers) and in 4 cadaveric specimens (n = 4 fingers). Flexor tendon thickness was measured at histologic examination in the cadaveric specimens. We defined the area of the A1 annular pulley as position I and the area of the A2 annular pulley as position II. Sonographic measurements were performed in transverse (dorsovolar and radioulnar) and longitudinal planes. Interobserver and intraobserver variabilities were evaluated by each investigator performing 3 measurements at each position.

RESULTS

In position I, volunteers had flexor tendon thickness of 2.7 to 4.0 mm (mean +/- SD, 3.28 +/- 0.26 mm) longitudinally; transversally the thickness was 2.5 to 4.0 mm (mean, 3.34 +/- 0.29 mm) dorsovolar and 5.5 to 8.9 mm (mean, 7.34 +/- 0.71) radioulnar in position I. Position II revealed thickness of 3.2 to 4.2 mm (mean, 3.6 +/- 0.23 mm) longitudinally; transversally the thickness was 2.7 to 4.1 mm (mean, 3.4 +/- 0.27) dorsovolar and 4.3 to 6.8 mm (mean, 5.27 +/- 0.65) radioulnar. Interobserver and intraobserver variability for position I was better than for position II (P < .01 versus P < .05). Sonographic findings correlated excellently with histologic findings (r2 = 0.94).

CONCLUSIONS

Standardized transducer positions for sonographic measurements of finger flexor tendon thickness showed good interobserver and intraobserver variability. Position I was found to be more reliable than position II.

[Flexor tendon pulley system: anatomy, pathology, treatment]

Flexor tendon pulley has been very early noticed and described. Terminology usually accepted recognizes 6 arcifom pulleys (A0 to A5) and 3 cruciform pulleys (C1 to C3). Anatomy and physiology of this flexor tendon gliding and reflection system at the level of the digital sheet are exposed. The integrity necessity of this system became obvious regarding the flexor tendons repair. Four main pathologies may be concerned: the trigger finger congenital or progressive, due to a chondroid metaplasia of the A1 pulley; tenosynovial ganglions arising at the weak point between A1 and A2 pulley; lesions of the flexor tendon sheet during traumatic lacerations or surgical repairs; quite experimental lesions creating isolated ruptures of one or several pulleys which occur during sport practice, especially high level rock climbing. The repair techniques are exposed to allow to graduate and hierarchy the reparation technique regarding the pathology. A2 and A4 repair is always indicated. The best reconstruction material is an extensor retinaculum graft. But its poor surface available often draws to use conventional palmaris longus free graft.

Finger pulley injuries in extreme rock climbers: depiction with dynamic US

PURPOSE

To determine the ability of dynamic ultrasonography (US) to depict finger pulley injuries in extreme rock climbers.

MATERIALS AND METHODS

Sixty-four extreme rock climbers (climbing levels 8-11 on a scale ranging from 1 to 11; Union Internationale des Associations d'Alpinisme) with finger injuries (75 symptomatic and 181 asymptomatic fingers) were examined by using US, with the transducer operating at 12 MHz. The distance between the flexor tendon and phalanx was evaluated in extension and forced flexion at the level of the A2 and A4 annular pulleys as an indicator of tendon bowstringing. A distance between the flexor tendon and phalanx greater than 1.0 mm was interpreted as positive for a pulley injury. US findings were compared with those of magnetic resonance imaging. Surgical correlation was available in seven cases. Statistical analysis was performed by using analysis of variance, the Student t test, and the Bonferroni method.

RESULTS

US depicted 16 (100%) of 16 complete A2 pulley ruptures, nine (100%) of nine complete A4 pulley ruptures, six (86%) of seven surgically proved complete combined A2 and A3 pulley ruptures, and 15 (100%) of 15 incomplete A2 pulley ruptures. Measurement of distance between the flexor tendon and phalanx was significantly different among patient subsets without pulley ruptures and those with incomplete, complete, or complete combined pulley ruptures (P <.001). The sensitivity of US for depiction of finger pulley injuries was 98%, and specificity was 100%.

CONCLUSION

Dynamic US allows excellent depiction of finger pulley injuries in extreme rock climbers.

Magnetic resonance imaging of the upper extremity: advances in technique and application

Vast advances in technology have taken place in the field of radiology led by the introduction of magnetic resonance imaging. The added advantages of exquisite soft tissue contrast and multiplanar imaging capabilities have revolutionized the understanding of complex anatomic relationships and diagnoses. The current authors will focus on the introduction of new advances in magnetic resonance imaging of the upper extremity that may prove helpful in the diagnosis and treatment of upper extremity abnormalities.

The effect of circumferential taping on flexor tendon pulley failure in rock climbers

The purpose of this study was to determine whether circumferential taping of the base of the finger increases the A2 pulley's load to failure in a model simulating a rock climber's grip. Nine pairs of fresh-frozen cadaveric hands, 20 to 47 years of age, were rigidly mounted in a specialized jig that maintained the finger in the climber's "crimp" position. Two of the four fingers of each hand were reinforced over the A2 pulley with three wraps of cloth adhesive tape. The flexor digitorum profundus and superficialis tendons were distracted until pulley or tendon failure. Overall, A2 pulley strength was greater in male specimens than in female specimens, and the A2 pulley of the small finger was the weakest tested. The A2 pulley failed simultaneously with the A3 and A4 pulleys in 55% of the tests. In the remaining trials, a single pulley failed initially followed by the remainder of the sheath. Of the 72 fingers studied, complete data were available for comparison of 22 pairs of fingers. No statistically significant difference in load to A2 pulley failure was noted between the taped and untaped finger pairs. Based on our findings we do not support taping the base of the fingers as a prophylactic measure against flexor tendon sheath injury in the climbing athlete.