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Salas C, McIver ND, Telis A, Tufaro R, Qeadan F, Gross J, Mercer D. A Biomechanical Analysis of the H-Taping Method Used by Rock Climbers as Prophylactic or Stabilizing Fixation of Partial A2 Pulley Tears. J Hand Surg Am 2023; 48:1272.e1-1272.e8. [PMID: 35870957 DOI: 10.1016/j.jhsa.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 03/26/2022] [Accepted: 05/11/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Rock climbing can lead to upper-extremity injuries, such as A2 pulley ruptures, leading to the bowstringing of the flexor tendons. Climbing finger positions are specific and can put undue stress on the pulley systems. This causes severe hand dysfunction and is a difficult problem to treat, and prevention is important. Using a cadaveric, experimental model, we evaluated the effectiveness of the H-taping method, commonly used by rock climbers, to prevent and treat A2 pulley tears. METHODS Using fourteen matched pairs of fresh-frozen cadaveric hands with forearms, four experiments were conducted with 56 paired comparisons evaluating the failure force, fingertip force, and mode of failure (112 total tests). Comparisons were as follows: index fingers- intact versus 50% distal A2 pulley tears without H-taping (control); ring fingers- intact versus H-taping as a prophylactic for A2 pulley tears; little fingers- 50% distal A2 pulley tears with H-tape versus without tape; and middle fingers- H-taping as a prophylactic versus H-taping as a stabilizing treatment of torn pulleys. RESULTS The mean index finger failure force was significantly higher in intact vs torn A2 pulleys (control). Failure force for intact H-taped fingers was significantly higher than torn H-taped fingers, but no other finger comparisons for failure force were significant. There were no significant findings in comparison of mean fingertip force values in any of the experiments. CONCLUSIONS We found that H-taping is not effective as prophylaxis against A2 pulley ruptures or as a stabilizing treatment method for partially ruptured pulleys. CLINICAL RELEVANCE While H-taping has not been recommended as prophylaxis for preventing A2 pulley ruptures, the climbing community has embraced this technique as a preventative measure. The present study provides biomechanical evidence against H-taping for this purpose. Furthermore, it does not appear to aid in increasing fingertip force after injury.
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Affiliation(s)
- Christina Salas
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM; Department of Chemical & Biological Engineering, The University of New Mexico School of Engineering, Albuquerque, NM.
| | - Natalia D McIver
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM; Department of Chemical & Biological Engineering, The University of New Mexico School of Engineering, Albuquerque, NM
| | - Alexander Telis
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Rachel Tufaro
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM; Department of Chemical & Biological Engineering, The University of New Mexico School of Engineering, Albuquerque, NM
| | - Fares Qeadan
- Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, IL
| | - Jessica Gross
- Biostatistics, Epidemiology, and Research Design, Clinical & Translational Science Center, The University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Deana Mercer
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM
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Held S, Rappelt L, Rein R, Wiedenmann T, Donath L. Low-intensity climbing with blood flow restriction over 5 weeks increases grip and elbow flexor endurance in advanced climbers: A randomized controlled trial. Eur J Sport Sci 2023; 23:2031-2037. [PMID: 37167343 DOI: 10.1080/17461391.2023.2207079] [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] [Indexed: 05/13/2023]
Abstract
Grip and elbow flexor strength and endurance are crucial performance surrogates in competitive climbing. Thus, we examined the effects of blood flow restricted (BFR) climbing on grip and elbow flexor performance. Fifteen trained climbers (8 females; 20.8 ± 7.0 yrs; 1.72 ± 0.08 m; 63.0 ± 9.7 kg; 21.7 ± 2.7 IRCRCA grade) were either assigned to the intervention (BFR) or control (noBFR) group, using the minimization method (Strata: age, height, body mass, gender, and IRCRA grade). While BFR was used during low-intensity climbing training (2-times 10 min/session; 3-times/week), noBFR followed identical training protocols without BFR over 5 weeks. BFR of the upper limb was applied via customized pneumatic cuffs (occlusion pressure: 120 ± 23 mmHg, 75%; occlusion pressure). Endurance and strength performances were assessed via one-handed rung pulling (GripSTRENGTH), one-handed bent arm lock off at 90° (ArmSTRENGTH), static-intermitted finger hang (GripENDURANCE), and bent arm hang (ArmENDURANCE). Bayesian credible intervals revealed increased GripENDURANCE (+21 s (95% credible interval: -2 to 43 s)) and ArmENDURANCE +11 s (-5 to 27 s); adaptations via BFR. In contrast, GripSTRENGTH +4 N (-40 to 48 N) and ArmSTRENGTH +4 N (-68 to 75 N) were not affected by the BFR intervention. Fifteen cumulative sessions of BFR application with a cumulative total BFR load of 5 h over a 5 weeks macrocycle remarkably increased grip and elbow flexor endurance. Thus, BFR might serve as a promising means to improve relevant performance surrogates in trained climbers.
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Affiliation(s)
- Steffen Held
- Department of Intervention Research in Exercise Training, German Sport University Cologne, Cologne, Germany
- Department of Sport and Management, IST University of Applied Sciences, Duesseldorf, Germany
| | - Ludwig Rappelt
- Department of Intervention Research in Exercise Training, German Sport University Cologne, Cologne, Germany
- Department of Movement and Training Science, University of Wuppertal, Wuppertal, Germany
| | - Robert Rein
- Institute of Exercise Training and Sport Informatics, German Sport University, Cologne, Germany
| | - Tim Wiedenmann
- Department of Intervention Research in Exercise Training, German Sport University Cologne, Cologne, Germany
| | - Lars Donath
- Department of Intervention Research in Exercise Training, German Sport University Cologne, Cologne, Germany
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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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Langer K, Simon C, Wiemeyer J. Physical performance testing in climbing-A systematic review. Front Sports Act Living 2023; 5:1130812. [PMID: 37229362 PMCID: PMC10203485 DOI: 10.3389/fspor.2023.1130812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
Due to the increasing popularity of climbing, the corresponding diagnostics are gaining in importance for both science and practice. This review aims to give an overview of the quality of different diagnostic testing- and measurement methods for performance, strength, endurance, and flexibility in climbing. A systematic literature search for studies including quantitative methods and tests for measuring different forms of strength, endurance, flexibility, or performance in climbing and bouldering was conducted on PubMed and SPORT Discus. Studies and abstracts were included if they a) worked with a representative sample of human boulderers and/or climbers, b) included detailed information on at least one test, and c) were randomized-controlled-, cohort-, cross-over-, intervention-, or case studies. 156 studies were included into the review. Data regarding subject characteristics, as well as the implementation and quality of all relevant tests were extracted from the studies. Tests with similar exercises were grouped and the information on a) measured value, b) unit, c) subject characteristics (sex and ability level), and d) quality criteria (objectivity, reliability, validity) were bundled and displayed in standardized tables. In total, 63 different tests were identified, of which some comprised different ways of implementation. This clearly shows that there are no uniform or standard procedures in climbing diagnostics, for tests on strength, endurance or flexibility. Furthermore, only few studies report data on test quality and detailed information on sample characteristics. This not only makes it difficult to compare test results, but at the same time makes it impossible to give precise test recommendations. Nevertheless, this overview of the current state of research contributes to the creation of more uniform test batteries in the future.
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Kwon BY, Kim D, Kim YJ, Jun D, Lee JH. Isolated A1 Pulley Rupture of Left Middle Finger in Baseball Player: Case Report. Curr Sports Med Rep 2022; 21:358-361. [DOI: 10.1249/jsr.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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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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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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Kadar A, Haddara MM, Fan S, Chinchalkar S, Ferreira LM, Suh N. Use of Thermoplastic Rings Following Venting of Flexor Tendon Pulleys: A Biomechanical Analysis. J Hand Surg Am 2021; 46:485-492. [PMID: 33357985 DOI: 10.1016/j.jhsa.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 09/08/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Normal digital flexion relies on flexor tendon pulleys to convert linear muscular force to angular digital motion. However, there is a growing trend to vent them partially during flexor tendon repair. The objective of this study was to examine the effects of a thermoplastic ring, acting as an external pulley, on flexor tendon biomechanics and finger range of motion (ROM) after pulley venting. METHODS We tested 15 cadaveric digits using an in vitro active finger motion simulator. We measured loads induced by flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) as well as joint ROM with sequential sectioning of the A2, A3, and A4 pulleys compared with an intact pulley condition. At each stage, external thermoplastic pulley rings were applied snugly over the proximal and middle phalanges to recreate A2 and A4 function, respectively. RESULTS After complete venting of the A2, A3, and A4 pulleys, proximal interphalangeal joint ROM significantly decreased by 13.4° ± 2.7° and distal interphalangeal joint ROM decreased by 15.8° ± 2.1°. Application of external rings over the proximal and middle phalanx resulted in a residual ROM decrease of 8.3° ± 1.9° at the proximal interphalangeal joint and 7.9° ± 2.1° at the distal interphalangeal joint, nearly restoring ROM. Similarly, complete pulley venting resulted in reduced FDS load by 37% and FDP load by 50% compared with intact pulleys. After application of external rings, loads were restored almost to normal, with a 9% reduction for FDS load and 9% reduction for FDP load compared with intact pulleys. CONCLUSIONS The application of thermoplastic rings acting as external pulleys is an effective, noninvasive, and reproducible approach to restore flexor tendon biomechanics and digit ROM after pulley venting. CLINICAL RELEVANCE Thermoplastic rings may be a useful therapeutic adjunct in restoring joint ROM and flexor tendon loads after surgical venting of the pulleys.
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Affiliation(s)
- Assaf Kadar
- Division of Orthopedic Surgery, University of Western Ontario, Roth-McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, Ontario, Canada; Department of Orthopedics, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohammad M Haddara
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, Roth-McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, Ontario, Canada
| | - Stacy Fan
- Department of Biomedical Engineering, University of Western Ontario, Roth-McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, Ontario, Canada
| | - Shrikant Chinchalkar
- Division of Orthopedic Surgery, University of Western Ontario, Roth-McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, Ontario, Canada
| | - Louis M Ferreira
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, Roth-McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, Ontario, Canada
| | - Nina Suh
- Division of Orthopedic Surgery, University of Western Ontario, Roth-McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, Ontario, Canada.
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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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Primarily conservative treatment for triple (A2-A3-A4) finger flexor tendon pulley disruption. HAND SURGERY & REHABILITATION 2021; 40:314-318. [DOI: 10.1016/j.hansur.2020.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 01/03/2023]
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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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Closed Traumatic A2 Through A4 Pulley Rupture and Flexor Digitorum Superficialis Avulsion Treated With Reconstruction. Ochsner J 2020; 21:99-103. [PMID: 33828433 PMCID: PMC7993427 DOI: 10.31486/toj.19.0109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Multiple closed spontaneous pulley ruptures are rare injuries and require surgical reconstruction to prevent functional deficits. Pulley rupture combined with avulsion of the flexor digitorum superficialis (FDS) tendon is an even more uncommon occurrence. Case Report: We describe a closed traumatic annular 2 (A2) through annular 4 (A4) pulley rupture with avulsion of the FDS tendon. This uniquely associated pathology was treated with a complex surgical reconstruction that corrected flexion contracture and tendon bowstringing in the left long finger. The desired outcome was achieved through A2 and A4 pulley reconstruction using an autologous palmaris longus tendon graft with FDS tendon excision and proximal interphalangeal joint capsulotomy. Conclusion: Multiple pulley rupture is not commonly combined with FDS avulsion, and treatment of this injury requires careful surgical planning based on pulley biomechanics to maximize postoperative function.
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Iruretagoiena-Urbieta X, De la Fuente-Ortiz de Zarate J, Blasi M, Obradó-Carriedo F, Ormazabal-Aristegi A, Rodríguez-López ES. Grip Force Measurement as a Complement to High-Resolution Ultrasound in the Diagnosis and Follow-Up of A2 and A4 Finger Pulley Injuries. Diagnostics (Basel) 2020; 10:diagnostics10040206. [PMID: 32276341 PMCID: PMC7235872 DOI: 10.3390/diagnostics10040206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Xeber Iruretagoiena-Urbieta
- Department of Physical Therapy, Universidad Camilo José Cela, 28692 Madrid, Spain;
- Eskura Osasun Zentroa, 20200 Beasain, Spain
| | | | - Marc Blasi
- Plastic Surgery Department, Hospital Universitari Germans Trias i Pujol, 08916 Badalona (Barcelona), Spain;
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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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16
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Joint Mobility Protection during the Developmental Age among Free Climbing Practitioners: A Pilot Study. J Funct Morphol Kinesiol 2020; 5:jfmk5010014. [PMID: 33467230 PMCID: PMC7739414 DOI: 10.3390/jfmk5010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/03/2020] [Accepted: 02/10/2020] [Indexed: 11/17/2022] Open
Abstract
Sport-climbing popularity increased intensely over the past years. Particularly, children's and adolescents' interest therein is constantly growing. Despite a large effort in preventing injuries and muscle overloads, a fine-tuned training for each sensitive phase of child development is still needed. The objective of the study was to evaluate an innovative training program aimed at the preservation of joint mobility during the developmental age. This article relies on the results of a steady training program allowing to retain joints integrity among the practice of sport climbing in children. Joint mobility changes have been monitored before and after a one-year training program in fifteen subjects aged between 8 and 18 years. Subjects were divided into three groups depending on age (Turgor Secundus, Proceritas Secunda and Turgor Tertius). The motor tests administered were the sit-and-reach test, coxo-femoral mobility test and scapula-humeral mobility test. Our results showed that one-year training improved joint mobility at each analyzed phase, suggesting that this training program could improve mobility and flexibility. Given the importance of joint mobility preservation for discipline-related injuries prevention and eventually recovering, it is essential to provide a specific training program as a route to approach sport climbing, and even more importantly, at an early age. This work represents a preliminary study in order to demonstrate both efficacy on the joint mobility and the requirement of our playful work to support the global sport-climbing workout.
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Bärtschi N, Scheibler A, Schweizer A. Symptomatic epiphyseal sprains and stress fractures of the finger phalanges in adolescent sport climbers. HAND SURGERY & REHABILITATION 2019; 38:251-256. [DOI: 10.1016/j.hansur.2019.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/28/2019] [Accepted: 05/12/2019] [Indexed: 01/03/2023]
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Lum ZC, Park L. Rock climbing injuries and time to return to sport in the recreational climber. J Orthop 2019; 16:361-363. [PMID: 31024194 DOI: 10.1016/j.jor.2019.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 04/03/2019] [Indexed: 01/03/2023] Open
Abstract
We investigated the injury pattern in rock climbers and their return to sport for operative and nonoperative management. 432 injuries in 237 climbers recorded: 41.9% hand/elbow, 19.9% foot/ankle, 17.3% shoulder. 66% patients required no treatment, 49 (21%) underwent physical therapy, 27 (11%) underwent surgery with 93% satisfaction. Nonoperative patients recovered at 3.9 months; surgical patients took 9.1 months to return to sport (p = 0.01). Return to same level: 79% nonsurgical patients and 70% surgical patients (p = 0.30). Most injuries underwent nonoperative treatment. Operative treatment allowed a similar amount to return to sport at pre-injury level with a longer time course.
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Affiliation(s)
- Zachary C Lum
- University of California: Davis Medical Center, Department of Orthopaedic Surgery, Adult Hip & Knee Reconstruction, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA
| | - Lily Park
- Memorial Medical Center, Department of Internal Medicine, Modesto, CA, 95350, USA
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Abstract
Flexor pulley ruptures with severe proximal interphalangeal (PIP) joint contracture present a complex challenge for the hand surgeon. Four patients were treated with a delayed presentation of pulley rupture and fixed PIP flexion contracture with a technique of external extension torque application followed by splinting without pulley reconstruction. Using this technique, the PIP joint contractures improved from an average of 66° to an average of 19°, patient satisfaction was high, and the pulley injuries were managed with splinting alone without open pulley reconstruction.
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Acute A4 Pulley Reconstruction with a First Extensor Compartment Onlay Graft. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1361. [PMID: 28740775 PMCID: PMC5505836 DOI: 10.1097/gox.0000000000001361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/17/2017] [Indexed: 11/26/2022]
Abstract
Background: The integrity of the flexor tendon pulley apparatus is crucial for unimpaired function of the digits. Although secondary reconstruction is an established procedure in multi-pulley injuries, acute reconstruction of isolated, closed pulley ruptures is a rare occurrence. There are 3 factors influencing the functional outcome of a reconstruction: gapping distance between tendon and bone (E-space), bulkiness of the reconstruction, and stability. As direct repair is rarely done, grafts are used to reinforce the pulley. An advantage of the first extensor retinaculum graft is the synovial coating providing the possibility to be used both as a direct graft with synovial coating or as an onlay graft after removal of the synovia when the native synovial layer is present. Methods: A graft from the first dorsal extensor compartment is used as an onlay graft to reinforce the sutured A4 pulley. This technique allows reconstruction of the original dimensions of the pulley system while stability is ensured by anchoring the onlay graft to the bony insertions of the pulley. Results: Anatomical reconstruction can be achieved with this method. The measured E-space remained 0 mm throughout the recovery, while the graft incorporated as a slim reinforcement of the pulley, displaying no bulkiness. Conclusions: The ideal reconstruction should provide synovial coating and sufficient strength with minimal bulk. Early reconstruction using an onlay graft offers these options. The native synovial lining is preserved and the graft is used to reinforce the pulley.
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Abstract
Closed pulley ruptures are rare in the general population but occur more frequently in rock climbers due to biomechanical demands on the hand. Injuries present with pain and swelling over the affected pulley, and patients may feel or hear a pop at the time of injury. Sequential pulley ruptures are required for clinical bowstringing of the flexor tendons. Ultrasound confirms diagnosis of pulley rupture and evaluates degree of displacement of the flexor tendons. Isolated pulley ruptures frequently are treated conservatively with early functional rehabilitation. Sequential pulley ruptures require surgical reconstruction. Most climbers are able to return to their previous activity level.
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Affiliation(s)
- Elizabeth A King
- Department of Orthopaedic Surgery, University of Cincinnati, TriHealth Hospital System, 538 Oak Street, Suite 200, Cincinnati, OH 45219, USA
| | - John R Lien
- Section of Plastic Surgery, Department of Orthopaedic Surgery, University of Michigan, 2098 South Main Street, Ann Arbor, MI 48103, USA.
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22
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Piper KF, Gold JR, Bodkin RP, Rueckmann EA, Rizzone K, Martina CA. Rock climbers’ management of hand injuries and perceptions on seeking healthcare: A mixed methods analysis. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1395724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Keaton F. Piper
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jillian R. Gold
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Ryan P. Bodkin
- University of Rochester Medical Center Department of Emergency Medicine, Rochester, NY, USA
| | - Erik A. Rueckmann
- University of Rochester Medical Center Department of Emergency Medicine, Rochester, NY, USA
| | - Katherine Rizzone
- University of Rochester Medical Center Department of Orthopedics, Rochester, NY, USA
| | - Camille A. Martina
- University of Rochester Medical Center Department of Public Health Sciences, Rochester, NY, USA
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Ozimek M, Staszkiewicz R, Rokowski R, Stanula A. Analysis of Tests Evaluating Sport Climbers' Strength and Isometric Endurance. J Hum Kinet 2016; 53:249-260. [PMID: 28149428 PMCID: PMC5260593 DOI: 10.1515/hukin-2016-0027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The present study was designed to determine which types of specific tests provide an effective evaluation of strength and endurance in highly trained competitive sport climbers. The research process consisted of three basic components: the measurement of selected somatic characteristics of the climbers, the assessment of their physical conditioning, and a search for correlations between the anthropometric and “conditioning” variables on the one hand, and climber’s performance on the other. The sample of subjects consisted of 14 experienced volunteer climbers capable of handling 7a- 8a+/b on-sight rock climbing grades. The strongest correlations (Spearman’s rank) were found between climber’s competence and the relative results of the finger strength test (r = 0.7); much lower, but still statistically significant coefficients were found between the level of competence and the results of the muscle endurance tests (r = 0.53 – 0.57). Climbers aspiring to attain an elite level must have strong finger and forearm muscles, but most of all, they must be capable of releasing their potential during specific motor capability tests engaging these parts of the body. The forearm muscles of elite climbers must also be very resistant to fatigue. Since highly trained athletes vary only slightly in body mass, this variable does not have a major effect on their performance during strength and endurance tests.
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Affiliation(s)
- Mariusz Ozimek
- Department of Track end Fields Sports, University School of Physical Education, Cracow, Poland
| | - Robert Staszkiewicz
- Department of Biomechanics, University School of Physical Education, Cracow, Poland
| | - Robert Rokowski
- Department of Qualified Tourism and Mountaineering, University School of Physical Education, Cracow, Poland
| | - Arkadiusz Stanula
- Department of Sports Training, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
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24
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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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Bouyer M, Forli A, Semere A, Chedal Bornu BJ, Corcella D, Moutet F. Recovery of rock climbing performance after surgical reconstruction of finger pulleys. J Hand Surg Eur Vol 2016; 41:406-12. [PMID: 26763272 DOI: 10.1177/1753193415623914] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 11/27/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study evaluated recovery of sport performance and correction of bowstringing after surgical reconstruction of closed finger pulley rupture in high-level rock climbers. A total of 38 patients treated with an extensor retinaculum graft were assessed. The mean follow-up time was 85 months, and 30 patients returned to their previous climbing level. The mean total active motion score was 96% of the opposite side. All patients had an excellent Buck-Gramcko score. There was no significant difference in grip strength and tip pinch strength in the crimp position between the injured side and the opposite side. A total of 31 patients were examined with ultrasonography. In 18, flexor bowstringing effects had returned to near-normal values. There was an association between rock climbing level recovery and the flexor bowstringing correction (odds ratio, 6.9; 95% confidence interval, 1.1-42.8). If flexor bowstringing was corrected, patients were more likely to regain their preinjury sport performance. The ultrasonography measurement was a useful tool for predicting functional recovery. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- M Bouyer
- Service de Chirurgie de la Main et des Brûlés, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - A Forli
- Service de Chirurgie de la Main et des Brûlés, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - A Semere
- Service de Chirurgie de la Main et des Brûlés, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - B J Chedal Bornu
- Service de Chirurgie de la Main et des Brûlés, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - D Corcella
- Service de Chirurgie de la Main et des Brûlés, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - F Moutet
- Service de Chirurgie de la Main et des Brûlés, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
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26
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Lutter C, Schoeffl V. Intermittent unspecific osteitis and cortex atrophy of the proximal phalanx after surgical pulley repair. BMJ Case Rep 2015; 2015:bcr-2015-213109. [PMID: 26628314 DOI: 10.1136/bcr-2015-213109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Climbing athletes frequently suffer from pulley ruptures, as the shear stress on the finger flexor tendon pulley system is extremely high, especially in the 'crimping position'. Studies showed that surgery only has to be performed in a multiple pulley rupture situation (grade IV injuries). This case describes a complication that appeared after performing a 'bone-encircling' technique recommended for climbers (modified 'one-and-a-half-loop' technique). Simultaneously with resumption of full-strength training after surgery and rehabilitation, the dorsolateral cortex of the proximal phalanx, to which the tendon transplant (palmaris longus tendon surrounding bone and flexor tendon of the finger) is entangled, developed an osteitis and atrophy. We investigated two athletes with the same complaints and symptoms.
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Affiliation(s)
- Christoph Lutter
- CvPath Institute, Gaithersburg, Maryland, USA Department of Sports Orthopedics, Sports Medicine, Sports Traumatology, Department for Orthopedics and Traumatology, Klinikum Bamberg, Bamberg, Germany
| | - Volker Schoeffl
- Department of Sports Orthopedics, Sports Medicine, Sports Traumatology, Department for Orthopedics and Traumatology, Klinikum Bamberg, Bamberg, Germany
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27
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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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28
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Bayer T, Adler W, Schweizer A, Schöffl I, Uder M, Janka R. Evaluation of finger A3 pulley rupture in the crimp grip position-a magnetic resonance imaging cadaver study. Skeletal Radiol 2015; 44:1279-85. [PMID: 25930946 DOI: 10.1007/s00256-015-2160-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 04/10/2015] [Accepted: 04/21/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE The correct diagnosis of an A3 pulley rupture is challenging for musculoskeletal radiologists. An A3 pulley rupture should in theory influence the shape of the proximal interphalangeal joint volar plate (VP) and the amount of bowstringing at level of the VP during finger flexion. The purpose of this study was to perform MRI with metric analysis of the VP configuration and VP bowstringing in cadaver fingers in the crimp grip position and to determine cut points for A3 pulley rupture. MATERIALS AND METHODS MRI in the crimp grip position was performed in 21 cadaver fingers with artificially created flexor tendon pulley tears (fingers with A3 pulley rupture n = 16, fingers without A3 pulley rupture n = 5). The distances of the translation of the VP relative to the middle phalanx base, the distances between the flexor tendons and the VP body, and the distances between the flexor tendon and bone (TB) were measured. RESULTS Statistical analysis showed significantly lower VP translation distances and significantly higher VP tendon distances if the A3 pulley was ruptured. A2 TB and A4 TB distances did not differ significantly in specimens with and without A3 pulley rupture. The optimal cut points for A3 pulley rupture were a VP translation distance <2.8 mm and a VP tendon distance >1.4 mm. CONCLUSION Reduction of the VP translation distance and augmentation of the VP tendon distance are suitable indirect signs of A3 pulley rupture.
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Affiliation(s)
- Thomas Bayer
- Department of Radiology, University of Erlangen-Nuremberg, Maximiliansplatz 1, 91054, Erlangen, Germany,
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29
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Bayer T, Fries S, Schweizer A, Schöffl I, Janka R, Bongartz G. Stress examination of flexor tendon pulley rupture in the crimp grip position: a 1.5-Tesla MRI cadaver study. Skeletal Radiol 2015; 44:77-84. [PMID: 25253170 DOI: 10.1007/s00256-014-2002-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 08/07/2014] [Accepted: 08/31/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objectives of this study were the evaluation of flexor tendon pulley rupture of the fingers in the crimp grip position using magnetic resonance imaging (MRI) and the comparison of the results with MRI in the neutral position in a cadaver study. MATERIALS AND METHODS MRI in the crimp grip position and in the neutral position was performed in 21 cadaver fingers with artificially created flexor tendon pulley tears (combined pulley rupture, n = 14; single pulley rupture, n = 7). Measurement of the distance between the tendon and bone was performed. Images were evaluated by two readers, first independently and in cases of discrepancy in consensus. Sensitivity and specificity for detecting combined pulley ruptures were calculated. RESULTS Tendon bone distances were significantly higher in the crimp grip position than in the neutral position. Sensitivity and specificity for detecting combined pulley rupture were 92.86 % and 100 % respectively in the crimp grip position and 78.57 % and 85.71 % respectively in the neutral position. Kappa values for interobserver reliability were 0.87 in the crimp grip position and 0.59 in the neutral position. CONCLUSION MRI examination in the crimp grip position results in higher tendon bone distances by subjecting the pulleys to a higher strain, which facilitates image evaluation with higher interobserver reliability, higher sensitivity, and higher specificity for combined pulley rupture compared with examination in the neutral position.
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Affiliation(s)
- Thomas Bayer
- Department of Radiology, University of Erlangen-Nuremberg, Maximiliansplatz 1, 91054, Erlangen, Germany,
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30
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Flexor pulley system: anatomy, injury, and management. J Hand Surg Am 2014; 39:2525-32; quiz 2533. [PMID: 25459958 DOI: 10.1016/j.jhsa.2014.06.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 05/31/2014] [Accepted: 06/03/2014] [Indexed: 02/02/2023]
Abstract
Flexor pulley injuries are most commonly seen in avid rock climbers; however, reports of pulley ruptures in nonclimbers are increasing. In addition to traumatic disruption, corticosteroid-induced pulley rupture has been reported as a complication of treating stenosing tenosynovitis. Over the last decade, there have been 2 new developments in the way hand surgeons think about the flexor pulley system. First, the thumb pulley system has been shown to have 4 component constituents, in contrast to the classic teaching of 3 pulleys. Second, in cases of zone II flexor tendon injury, the intentional partial A2 and/or A4 pulley excision or venting is emerging as a component for successful treatment. This is challenging the once-held dogma that preserving the integrity of the entire A2 and A4 pulleys is indispensable for normal digit function.
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31
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Schöffl V, Küpper T. Feet injuries in rock climbers. World J Orthop 2013; 4:218-28. [PMID: 24147257 PMCID: PMC3801241 DOI: 10.5312/wjo.v4.i4.218] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 07/17/2013] [Accepted: 07/23/2013] [Indexed: 02/06/2023] Open
Abstract
While injuries of the upper extremity are widely discussed in rock climbers, reports about the lower extremity are rare. Nevertheless almost 50 percent of acute injuries involve the leg and feet. Acute injuries are either caused by ground falls or rock hit trauma during a fall. Most frequently strains, contusions and fractures of the calcaneus and talus. More rare injuries, as e.g., osteochondral lesions of the talus demand a highly specialized care and case presentations with combined iliac crest graft and matrix associated autologous chondrocyte transplantation are given in this review. The chronic use of tight climbing shoes leads to overstrain injuries also. As the tight fit of the shoes changes the biomechanics of the foot an increased stress load is applied to the fore-foot. Thus chronic conditions as subungual hematoma, callosity and pain resolve. Also a high incidence of hallux valgus and hallux rigidus is described.
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32
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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, Küpper T, Hartmann J, Schöffl I. Surgical repair of multiple pulley injuries--evaluation of a new combined pulley repair. J Hand Surg Am 2012; 37:224-30. [PMID: 22209212 DOI: 10.1016/j.jhsa.2011.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 10/07/2011] [Accepted: 10/11/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE We report on a combined repair of multiple annular pulley tears using 1 continuous palmaris longus tendon graft to restore strength and function. METHODS We treated 6 rock climbers with grade 4 pulley injuries (multiple pulley injuries) using the combined repair technique and re-evaluated them after a mean of 28 months. RESULTS All patients had excellent Buck-Gramcko scores; the functional outcome was good in 4, satisfactory in 1, and fair in 1. The sport-specific outcome was excellent in 5 and satisfactory in 1. Proximal interphalangeal joint flexion deficit slightly increased in 1 patient and remained the same in the other 5. Climbing level after the injury was the same as before in 4 and decreased slightly in 2 climbers. CONCLUSIONS The technique is effective with good results and has since become our standard treatment. Nevertheless, it is limited in patients with flexion contracture of the proximal interphalangeal joint. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- V Schöffl
- Department of Orthopedic and Trauma Surgery, Klinikum Bamberg, Friedrich Alexander University Erlangen-Nuremberg, Germany.
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34
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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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35
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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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36
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Draper N, Dickson T, Blackwell G, Fryer S, Priestley S, Winter D, Ellis G. Self-reported ability assessment in rock climbing. J Sports Sci 2011; 29:851-8. [PMID: 21491325 DOI: 10.1080/02640414.2011.565362] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Level of ability within rock climbing is generally expressed in terms of a "best ascent", rated using various grading systems within the sport. The most common method of obtaining this information is via self-report. The aim of this study was to examine the validity of self-reported climbing grades. Twenty-nine competitive rock climbers (17 males, 12 females) were first asked to report their current (defined as within the last 12 months) best on-sight lead ascent grade (Aus/NZ). The participants then climbed a specifically designed indoor route, under on-sight conditions (one attempt, no route practice or preview), to obtain an assessed grade. The route increased in difficulty, and was such that the distance achieved by the climber corresponded to a particular grade. The mean (±standard deviation) self-reported and assessed grade was 22.6 ± 3.4 and 22.0 ± 3.0 (Aus/NZ) respectively. Despite slight over- and underestimations in males and females respectively, there was no statistically significant difference between self-reported and assessed on-sight climbing grades. The results of this study suggest that self-reported climbing grades provide a valid and accurate reflection of climbing ability.
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Affiliation(s)
- Nick Draper
- School of Sciences and Physical Education, University of Canterbury, Christchurch, New Zealand.
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Flap irritation phenomenon (FLIP): etiology of chronic tenosynovitis after finger pulley rupture. J Appl Biomech 2011; 27:291-6. [PMID: 21896956 DOI: 10.1123/jab.27.4.291] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
After a pulley rupture, most climbers regain the full function of their previously uninjured fingers. However, in some cases of pulley rupture, a persistent inflammation of the tendon sheath is observed. In this study, 16 cadaver fingers were loaded until pulley rupture and then studied for the rupturing mechanism. In addition, two patients with this pathology were investigated using ultrasound and MRI, and received surgery. In 13 fingers, a rupture of one or several pulleys occurred and almost always at the medial or lateral insertion. In one finger, a capsizing of the pulley underneath the intact tendon sheath was observed, leading to an avulsion between tendon and tendon sheath. A similar pathology was observed in the ultrasound imaging, in MRI, and during surgery in two patients with prolonged recovery after minor pulley rupture. In cases of prolonged tenosynovitis after minor pulley rupture, a capsizing of the pulley stump is probably the cause for constant friction leading to inflammation. In those cases, a surgical removal of the remaining pulley stump and sometimes a pulley repair may be necessary.
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Schöffl I, Oppelt K, Jüngert J, Schweizer A, Bayer T, Neuhuber W, Schöffl V. The influence of concentric and eccentric loading on the finger pulley system. J Biomech 2009; 42:2183-7. [PMID: 19646704 DOI: 10.1016/j.jbiomech.2009.04.049] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 04/03/2009] [Accepted: 04/04/2009] [Indexed: 02/07/2023]
Abstract
In this study we investigated the influence of the loading condition (concentric vs. eccentric loading) on the pulley system of the finger. For this purpose 39 cadaver finger (14 hands, 10 donors) were fixed into an isokinetic loading device. The forces in the flexor tendons and at the fingertip were recorded. In the concentric loading condition A2 and A4 ruptures as well as alternative events such as fracture of a phalanx or avulsion of the flexor tendons were almost equally distributed, whereas the A2 pulley rupture was the most common event (59%) in the eccentric loading condition and alternative events were rare (23.5%). The forces in the deep flexor tendon, the fingertip and in the pulleys were significantly lower in the eccentric loading condition. As the ruptures occurred at lower loads in the eccentric than in the concentric loading condition it can be concluded that friction may be an advantage for climbers, supporting the holding force of their flexor muscles but may also increase the susceptibility to injury.
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Affiliation(s)
- I Schöffl
- Institute of Anatomy 1, Friedrich-Alexander University Erlangen-Nuremberg, FRG.
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Schöffl I, Oppelt K, Jüngert J, Schweizer A, Bayer T, Neuhuber W, Schöffl V. The influence of concentric and eccentric loading on the finger pulley system. J Biomech 2009; 42:2124-8. [PMID: 19646704 DOI: 10.1016/j.jbiomech.2009.05.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 05/22/2009] [Accepted: 05/23/2009] [Indexed: 11/29/2022]
Abstract
In this study we investigated the influence of the loading condition (concentric vs. eccentric loading) on the pulley system of the finger. For this purpose 39 cadaver finger (14 hands, 10 donors) were fixed into an isokinetic loading device. The forces in the flexor tendons and at the fingertip were recorded. In the concentric loading condition A2 and A4 ruptures as well as alternative events such as fracture of a phalanx or avulsion of the flexor tendons were almost equally distributed, whereas the A2 pulley rupture was the most common event (59%) in the eccentric loading condition and alternative events were rare (23.5%). The forces in the deep flexor tendon, the fingertip and in the pulleys were significantly lower in the eccentric loading condition. As the ruptures occurred at lower loads in the eccentric than in the concentric loading condition it can be concluded that friction may be an advantage for climbers, supporting the holding force of their flexor muscles but may also increase the susceptibility to injury.
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Affiliation(s)
- I Schöffl
- Institute of Anatomy 1, Friedrich-Alexander University Erlangen-Nuremberg, FRG.
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Vigouroux L, Quaine F, Paclet F, Colloud F, Moutet F. Middle and ring fingers are more exposed to pulley rupture than index and little during sport-climbing: a biomechanical explanation. Clin Biomech (Bristol, Avon) 2008; 23:562-70. [PMID: 18267349 DOI: 10.1016/j.clinbiomech.2007.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Revised: 12/17/2007] [Accepted: 12/19/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Finger pulley injury is a common incident observed during sport-climbing. The total rupture of one or several pulleys is highly debilitating and requires surgical reconstruction and/or rehabilitation programs. Literature reports show that fingers are not equally exposed to this injury. The ring and middle fingers are usually injured while the index and little fingers are less exposed. The objective of this study was to determine the biomechanical factors leading to the enhanced exposure of ring and middle finger pulleys. METHOD Eight subjects were required to exert maximal four-finger force in a specific sport-climbing finger posture. External fingertip forces and finger joint postures were used as input data of a specifically developed biomechanical model of the four fingers (i.e., index, middle, ring and little). This model was based on classical Newton static laws and used an optimization process to quantify the flexor tendon tensions and the pulley forces in each finger. Passive participation of ligaments was also considered into mechanical equations. FINDINGS Results showed that two main factors could explain the enhanced exposure of ring and middle fingers. Firstly, the fingertip force intensities applied by these two fingers were higher than those observed for the index and little fingers. Secondly, results show that the pulley forces of the ring and middle fingers were close to their rupture thresholds, while it was not the case for the two other fingers. This could be explained by a specific localisation of the finger pulleys of the ring and middle fingers leading to enhanced pulley forces. INTERPRETATION These results are relevant and could help clinicians to understand finger pulley pathologies and adapt the surgical interventions to reconstruct the fingers pulleys.
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Affiliation(s)
- Laurent Vigouroux
- Movement and Perception Laboratory, CNRS UMR 6152, University of the Mediterranean, Faculte des Sciences du Sport, Case postale 910, 163, avenue de Luminy, 13288 Marseille, France.
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Schoffl I, Einwag F, Strecker W, Hennig F, Schoffl V. Impact of Taping after Finger Flexor Tendon Pulley Ruptures in Rock Climbers. J Appl Biomech 2007; 23:52-62. [PMID: 17585178 DOI: 10.1123/jab.23.1.52] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Isabelle Schoffl
- Institute of Medical Physics, University of Erlangen, Nuremberg, Germany
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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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