Ultrasound-guided first annular pulley injection for trigger finger

OBJECTIVE

The purpose of this study was to develop an ultrasound-guided first annular (A1) pulley injection technique for trigger finger with documentation of outcomes at 1 year.

METHODS

We performed a short-axis injection into a triangle bordered by the A1 pulley, the flexor digitorum superficialis and profundus tendons and volar plate, and the distal metacarpal bone with a 10-mg median dose of triamcinolone acetonide and 2% lidocaine. This was a prospective study of 50 of 52 consecutive trigger fingers from 24 patients recruited from a physical medicine and rehabilitation private practice.

RESULTS

All patients were available for follow-up, with 94% (47 of 50) of fingers having complete resolution of symptoms at 6 months, 90% (37 of 41) at 1 year, 65% (17 of 26) at 18 months, and 71% (12 of 17) at 3 years after a single injection.

CONCLUSIONS

Our ultrasound-guided A1 pulley injection technique is a highly effective and minimally invasive treatment option for trigger finger with a 90% success rate at 1 year for complete resolution of symptoms after a single injection. Assuming similar patient populations, our results were statistically significant (P < .01) compared with the 56% to 57% success rates recently reported for blind injections.

Sonographic appearance of the flexor tendon, volar plate, and A1 pulley with respect to the severity of trigger finger

PURPOSE

To evaluate trigger digits with sonography to determine morphological changes in the A1 pulley, flexor tendon, and volar plate in relation to the severity of triggering.

METHODS

We evaluated 67 trigger digits and graded them into 1 of 4 groups. We compared the groups according to severity and to contralateral fingers, which served as controls.

RESULTS

The thickness of the flexor tendons under the A1 pulley was proportional to the severity of triggering. The anteroposterior thickness of the flexor tendon increased significantly among the grades exhibiting triggering regardless of the affected digit. However, in digits other than the thumb, tendon thickness increased even in the absence of active triggering. Thickening tended to be greater with finger flexion. The A1 pulley exhibited the greatest thickness and the volar plate exhibited significant thickening in the group that exhibited continuous triggering that was easily reduced with active extension (grade III).

CONCLUSIONS

The flexor tendon thickened significantly before patients experienced triggering except in the thumb. In the thumb, the flexor tendon and A1 pulley thickened significantly only after patients exhibited triggering. Thickening of the volar plate appears to have an important role in continuous triggering. Although most clinicians can easily determine the severity of a trigger digit by clinical examination, ultrasound might be helpful for objectively understanding the severity and response to treatment, by examining the thickness of the flexor tendon and A1 pulley. In particular, sonographic measurement of the A1 pulley might be useful in judging the progression of trigger finger severity. In cases where a Doppler signal is detected inside the A1 pulley, more conservative therapies might be worth considering before surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic ΙΙΙ.

Volar locking plate versus external fixation for the treatment of unstable distal radial fractures: a meta-analysis of randomized controlled trials

BACKGROUND

The choice between volar locking plates (VLP) and external fixation (EF) for unstable distal radius fractures have not reached a consensus. The meta-analysis of randomized controlled trials was performed to compare VLP with EF to determine the dominant strategy.

MATERIALS AND METHODS

Meta-analysis was performed with a systematic search of studies conducted by using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. The randomized controlled trials that compared VLP with EF was identified. Characteristics, functional outcomes, radiological results, and complications were manually extracted from all the selected studies.

RESULTS

Six studies encompassing 445 patients met the inclusion criteria. There was significant difference between two procedures in disabilities of the arm shoulder and hand scores at 3,6, and 12 mo, visual analogue scale at 6 mo, grip strength at 3 mo, supination at 3 and 6 mo, extension at 3 mo, ulnar variance at 12 mo, and reoperation rate at 12 mo, postoperatively. However, there was no significant difference between flexion, pronation, radial deviation, and ulnar deviation at all follow-up points postoperatively and overall complications at 12 mo, postoperatively.

CONCLUSIONS

EF had less reoperative rate due to complications, however, VLP had advantages in functional recovery in the early period after surgery, but two methods had similar functional recovery at 12 mo, postoperatively. Clinician should make the treatment decision with great caution for the patients who sustained unstable distal radial fractures.

Sex-related differences in carpal arch morphology

The purpose of this study was to investigate the sex-based differences in the carpal arch morphology. Carpal arch morphology was quantified using palmar bowing and area of the arch formed by the transverse carpal ligament. The carpal arch was imaged at the distal and proximal tunnel levels using ultrasonography in 20 healthy young adults (10 women and 10 men). It was found that females had a smaller carpal arch height compared to men at both distal and proximal levels (p<0.05) and smaller carpal arch width only at the proximal level (p<0.05) but not distally. Palmar bowing index, the carpal arch height to width ratio, was significantly smaller in females at the distal level (p<0.05) but not at the proximal level. Carpal arch cross-sectional area normalized to the wrist cross-sectional area was found to be significantly smaller in females at both tunnel levels compared to men (p<0.05). This study demonstrates that females have a smaller carpal arch compared to men with a reduced palmar bowing distally and a smaller arch area at both tunnel levels. The findings help explain the higher incidence of carpal tunnel syndrome in women as a smaller carpal arch makes the median nerve more vulnerable to compression neuropathy.

Imaging finger joint instability with ultrasound

Closed injuries affecting the metacarpophalangeal and interphalangeal joints and their stabilizers in the thumb and fingers occur very commonly in athletes, possibly leading to finger joint instability and long-standing or permanent disability. This article reviews the spectrum of joint injuries of the thumb and fingers that are common in the athletic population with a main focus on the ultrasound features of collateral ligament tears, palmar plate injuries, and thumb sesamoid fractures. A thorough understanding of the complex anatomy, mechanism of injury, soft tissue abnormalities, and imaging findings is critical in the diagnostic work-up of closed finger joint trauma and may help improve outcomes.

Swan neck deformity due to chronic radial collateral ligament injury of the little finger proximal interphalangeal joint

We present seven cases of a relatively rare swan neck deformity resulting from chronic radial collateral ligament (RCL) injury of the proximal interphalangeal (PIP) joint in the little finger. All patients were middle-aged women (mean 51 years old, range 42-55), and the duration between the initial injury and surgery was 20 years (range 5-40). The chief complaint was painful snapping of the PIP joint. All patients had hyperextension and ulnar deviation of the PIP joint with mobile swan neck deformities that had not improved with conservative treatment. Radiographs revealed osteoarthritis and ulnar deviation of the PIP joints in all cases. We describe a method for reconstruction of both the palmar plate and the RCL of the affected PIP joint using a distally-based ulnar slip of flexor superficialis tendon. The prevention of PIP joint hyperextension was critical for successful resolution of symptoms; the aim of RCL augmentation was to prevent the recurrence of the deformity.

LEVEL OF EVIDENCE

IV.

Carpal tunnel syndrome caused by volar dislocation of the lunate in a patient with rheumatoid arthritis

We report a case of carpal tunnel syndrome caused by volar dislocation of the lunate in a patient with rheumatoid arthritis. A 74-year-old woman complained of numbness in her fingers. Carpal tunnel syndrome was diagnosed, and carpal tunnel release was performed. However, the symptoms recurred. Three-dimensional computed tomography and magnetic resonance imaging revealed volar dislocation of the lunate and synovitis around the distal radioulnar joint, respectively. Resection of the lunate and the Sauvé-Kapandji procedure were effective.

Skyline view versus intraoperative 3D fluoroscopy for dorsal screw protrusion identification following volar plating in the treatment of distal radial fracture

BACKGROUND

Dorsal screw protrusion can lead to complications such as extensor pollicis longus (EPL) tear or rupture after volar locking plate (VLP) fixation. Previous studies displayed that intraoperative 3D fluoroscopy and skyline view had similar diagnostic accuracy. This study investigated the efficacy of intraoperative 3D fluoroscopy compared to skyline view for detecting dorsal cortex screw protrusion in VLP procedures for unstable intra-articular distal radius fractures (DRF). We used postoperative computed tomography (CT) to assess the efficacy and addressed the limitations of previous methods in evaluating screw penetration accurately.

METHODS

We utilized the ICUC database, a prospective cohort of patients with surgically treated DRF, to collect cases with available images, including skyline views, intraoperative 3D fluoroscopy, and postoperative CT scans. The postoperative CT confirmed whether the screw protruded through the dorsal cortex. The interrater reliability was assessed using Cohen's Kappa, and a diagnostic test was utilized to compare the two intraoperative imaging modalities.

RESULTS

Twenty-one unstable DRFs were included in the study. The agreement between skyline view and postoperative CT was moderate agreement, with a kappa value of 0.481 (95% CI: 0.297-0.652, N = 84), identifying 10 uncertain, 56 shorter screws, and 18 screw penetrations. Intraoperative 3D fluoroscopy demonstrated almost perfect agreement with postoperative CT, with a kappa of 0.839 (95% CI: 0.703-0.975, N = 84), identifying 62 shorter screws and 22 screw penetrations. The sensitivity and specificity of intraoperative 3D fluoroscopy in detecting dorsal screw protrusion were 81.8% and 98.4%, respectively, while the skyline view's sensitivity and specificity were 72.2% and 90.9%.

CONCLUSION

3D fluoroscopy offers an almost perfect evaluation, whereas the skyline views provide only moderate agreement. 3D fluoroscopy could reduce cumulative radiation exposure of surgeon and patient compared to skyline view. Clinically, 3D fluoroscopy would be beneficial for surgeons to evaluate dorsal screw protrusion precisely and safely.

Soong Classification Using Radiographs Only Moderately Correlates With Distal Radius Plate Position on Computed Tomography

BACKGROUND

The Soong classification grades the prominence of volar locking plates used to treat distal radius fractures in relation to the volar rim. The basis of the classification scheme is that increasing plate prominence over the volar rim and distal radius watershed zone is associated with increased likelihood of flexor tendon irritation and need for plate removal. However, recent studies report mixed results on the predictive value of the Soong classification for these outcomes. We hypothesized that the decreased predictive accuracy of Soong classification is due to misclassification between Soong grades secondary to a suboptimal correlation between the Soong classification on radiographs (XRs) and computed tomography (CT).

METHODS

Fifty volarly displaced distal radius fractures treated with a volar locking plate in the international and publicly available ICUC database were reviewed. All cases with a postoperative XR and CT were included. Soong classification of the volar locking plate in relation to the volar ulnar rim was determined on both XR and CT by 2 independent, fellowship-trained hand surgeons using CT imaging as the gold standard. The distribution of Soong grades on XR and CT was compared using Pearson's χ2 test, and correlation was calculated using the Matthews correlation coefficient (MCC). A multi-class confusion matrix was used to calculate each grade's positive predictive value (PPV).

RESULTS

We found an MCC of 0.65, indicating only moderate correlation between the 2 modalities. Per individual Soong grade, the PPV was the highest for grade 2 (0.96), with lower PPVs for grade 0 (0.63) and grade 1 (0.60).

CONCLUSIONS

The distribution of Soong grades was significantly different when using XR versus CT (P < .001).

LEVEL OF EVIDENCE

Oxford Centre for Evidence-Based Medicine, diagnostic, level 2b.

Results of volar locking plating for unstable distal radius fractures

OBJECTIVE

The aim of this study was to analyze the complications and functional and radiographic results of volar locking plating in the treatment of unstable distal radius fractures.

METHODS

Forty-six patients (mean age: 48.7 years) with Type C distal radius fractures were treated with volar locking plates and evaluated over a mean follow-up period of 19 months. Range of motion, strength, DASH questionnaire and MAYO wrist score were assessed. Shortening, inclination and palmar tilt were recorded on standard radiographs and tenosynovitis and tendon ruptures were assessed using ultrasound. The uninjured wrists were examined as controls. Statistical analysis was made using t-tests.

RESULTS

All fractures achieved union. Postoperative MAYO scores revealed 14 excellent results, 11 good, 20 satisfactory and one poor result. The mean postoperative DASH score was 15.9 (range: 0 to 72). Active wrist motion averaged 52.3 degrees of flexion, 57.7 degrees of extension, 79.2 degrees of supination and 79.3 degrees of pronation. Mean grip strength was 82% of the uninjured side and mean loss of radial inclination was 0.6 degrees and palmar tilt was 6.6 degrees as compared to normal side. Carpal tunnel syndrome was observed in one patient, flexor tenosynovitis in one patient, extensor tendon rupture in one patient and extensor tenosynovitis in eleven patients. Functional and clinical limitations were most evident in the patients with tendon tear or tenosynovitis.

CONCLUSION

Fixation of unstable distal radius fractures with volar locking plates provides sufficient stability, and satisfactory clinical outcomes. However, these systems have complication potential that may limit better outcomes.

Influence of palmar plate injury on outcomes of zone 2 flexor tendon repair

This study investigates the impact of proximal interphalangeal joint palmar plate injury on outcomes of flexor tendon repair in zone 2, excluding cases with fractures or dislocations. A retrospective review of 47 digits in 45 patients treated between 2014 and 2022 was conducted, analysing surgical notes, ultrasound images and patient photographs. The palmar plate was injured in 17 digits and intact in 30. Outcomes were assessed using the Strickland criteria for active range of movement 6 months postoperatively. Our analysis revealed that palmar plate injuries significantly affect flexor tendon repair outcomes, with a normal palmar plate increasing the likelihood of excellent recovery by 18 times. Although previous studies indicate no consensus on the impact of flexor digitorum superficialis repair, our findings emphasize the importance of palmar plate integrity. Nerve injury and flexor digitorum superficialis repair did not show significant effects on recovery in this cohort. Our study provides valuable insights into the importance of the injury to the palmar plate.Level of evidence: III.

The Interobserver Reliability of Grading of Distal Radius Volar Plate Prominence

PURPOSE

The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments.

METHODS

In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface.

RESULTS

The interobserver agreement of the classification was "fair" (κ = 0.32; 95% confidence interval [CI] = 0.27-0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013-0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42-0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35-0.48).

CONCLUSIONS

Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair.

CLINICAL RELEVANCE

The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.