A1 Pulley Research Articles

Management of stenosing flexor tenosynovitis in primary care.

Management of stenosing flexor tenosynovitis in primary care.

Ultrasound-guided A1 pulley release using fenestration technique

Ultrasound-guided A1 pulley release using fenestration technique

Surgical Treatment for Trigger Thumb Using a Radial Approach

The anatomy of the thumb flexor pulley system and surrounding structures differs from the fingers. The hand's positioning during trigger thumb release is troublesome. Iatrogenic radial digital nerve injuries of the thumb following opened or percutaneous A1 pulley release have been reported. We present the radial approach using a transverse incision for surgical release of the trigger thumb. This surgical approach aimed to restore a familiar surgical hand position, prevent radial digital nerve injury and bowstringing of the flexor pollicis longus, and decrease postoperative pain to facilitate recovery of hand function.

방아쇠 무지 환자를 A1 활차 박리없이 근골격계에 기반하여 침과 전침으로 호전시킨 1례

Objectives Most of the acupuncture or dry needling points for trigger finger were limited around the metacarpophalangeal joint, A1 pulley, and flexor muscle tendon. Thus, this study aimed to report a case of a patient with trigger thumb which improved using dry needling on additional muscle points. Methods The author has investigated why additional points are needed including what its accompanying effects are. Dry needling and electro-dry needling have been conducted based on anatomical structure. Moreover, a follow-up observation was performed twice to evaluate if the effects of this treatment have been maintained. Treatment progress was evaluated using a numeric rating scale (NRS) and Quinnell’s classification of trigger finger. Results After 28 days of treatment, NRS and Quinnell’s trigger grade decreased significantly without adverse effects. The treatment effect has been maintained until follow-up observation. Conclusions Additional points are recommended for the radical treatment of trigger finger.

Common Hand Injuries in the Baseball Player.

The list of potential hand and wrist injuries among baseball players is numerous and includes fractures, dislocations, strains, and sprains. The purpose of this review, however, is to highlight injuries to the hand and wrist which are either particularly common or unique to professional baseball players with an emphasis on diagnostic pearls and treatment principles. For many baseball-related hand and wrist injuries, descriptions of the pathophysiology, diagnosis, and treatment options are based on single institution case series. With the implementation of Major League Baseball's Health and Injury Tracking System, our understanding of the epidemiology of these injuries in professional baseball players has greatly improved. The most common injury requiring operative treatment is a hook of hamate fracture, and recent evidence increasingly supports fracture fragment excision for early pain-free return to sport. Fractures of the proximal phalanges of fingers, thumb phalangeal fractures, and UCL injuries are the most common indication for surgery of the digits. A4 pulley ruptures in pitchers and repetitive trauma to the vasculature of the palm and digits are relatively unique to professional baseball players and are frequently able to be managed non-operatively. While injuries to the hand and wrist are common, the median number of days missed due to such an injury was only 4 days among professional baseball players. Statements and Declarations" for inclusion in the published paper. Please note that submissions that do not include relevant declarations will be returned as incomplete.

Isolated A1 pulley release surgery for trigger finger leads to significant increase in tip-to-tip pinch strength

BackgroundEven in the first application of patients with early complaints of trigger finger, pinch strength of the hand may be affected. Therefore, it is difficult to assess the change of strength as a result of treatment in this problem. In this study, we aimed to evaluate the change of strength taking into account both measured and expected pinch strengths before and after A1 pulley release surgery. MethodsThirty fingers (9 thumbs, 12 middle, 8 ring and 1 index fingers) of 26 patients (17 women, 9 men) who underwent A1 pulley release were included into this study. The mean age of the patients was 53 (16–71). Tip-to-tip finger pinch strengths were measured pre-operatively and at 3 months postoperatively. The expected strengths were calculated using the values obtained from the healthy side and taking into account the dominance effect. In the analysis, pre-operative and postoperative measured strength/expected strength ratios were compared. ResultsThe mean of measured pinch strength/expected pinch strength ratio was 0.91 ± 0.3 pre-operatively and 1.14 ± 0.3 postoperatively (p < 0.05). ConclusionWith the calculation method used in this study, it was found that there was a significant increase in the tip-to-tip pinch strength after surgical A1 pulley release for the trigger finger. Level of EvidenceIII (Retrospective cohort study).

Morphometric study of percutaneous A1 pulley of thumb release

Through anatomy, microscope, histopathology, and simulating needle knife operation on specimens, to accumulate the relevant parameters of the A1 pulley of thumb, and to provide an anatomical evidence for the needle knife therapy of stenosing flexor tenosynovitis. A total of 20 fingers were selected from 20 intact adult upper limb specimens, a small amount of emerald green waterproof dye was injected from the needle insertion point, dissected layer by layer, and the A1 pulley and neurovascular bundle were observed. Observe the loosening of the thumb A1 pulley after 5 and 10 times of simulated needle knife cutting on the specimen; observe the relationship between the needle knife entry point and the A1 pulley under the thumb extension and abduction, and the thumb extension neutral position respectively; further observe the histological characteristics, and the relationship between needle entry point and A1 pulley by microscope. ① In general observation, the A1 pulleys of each finger were transverse fibers perpendicular to the flexor tendon, tough in texture, connected with synovial fibers at the proximal end. It is difficult to distinguish, and connected with oblique fibers at the distal end. ② The release rate of the thumb A1 pulley after 5 and 10 times of simulated needle knife cutting on the specimen were (40.46 ± 2.22)% and (63.52 ± 4.49)%, respectively. ③ In the neutral position of the thumb straightening, the needle entry point is 3.06 ± 0.14 mm from the proximal side of the proximal edge of the A1 pulley, which overlaps with the needle entry point where the thumb is straight and abducted. ④ Observed under a microscope, the A1 pulley is a dense transverse fiber with a pale yellow dense connective tissue, both ends are continuous with the synovial fibers. It is thin and translucent, and loose connective tissue. The A1 pulley is a dense transverse fiber with a pale yellow dense connective tissue. The anatomical key points of the needle knife therapy lie in the extended and abducted position of the thumb. Currently, it is believed that cutting the proximal edge of the A1 pulley is sufficient, and there is no need to cut the entire A1 pulley.

Multiple Flexor Tendon Pulleys Injury in Korean Rock Climber

Multiple Flexor Tendon Pulleys Injury in Korean Rock Climber

Multiple Flexor Tendon Pulleys Injury in Korean Rock Climber

Multiple Flexor Tendon Pulleys Injury in Korean Rock Climber

Wrist &amp; Hand

The December 2022 Wrist &amp; Hand Roundup360 looks at: Anti-tumour necrosis factor therapy for early-stage Dupuytren’s disease; Patient experiences of scaphoid waist fractures and their treatment; Postoperative complications following open a1 pulley release for a trigger finger or thumb; How certain are findings in distal radius fractures: a systematic review of randomized controlled trials; Partial wrist denervation in wrist osteoarthritis: patient-reported outcomes and objective function; Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures; How is reduction lost in distal radius fractures in females aged 50 years and older; The HAND-Q: psychometrics of a new patient-reported outcome measure for clinical and research applications.

Treatment of Trigger finger by ultrasound-guided needle release of a1 pulley: A series of 105 cases.

We aimed to evaluate the efficacy and tolerance of A1 pulley release using the needle technique, under ultrasound guidance, in patients with symptomatic trigger finger. All patients with symptomatic trigger finger underwent A1 pulley release using an intramuscular 21 gauge (G) needle. Quinnell grade (I-IV), Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score (0-100) and pain score on a visual analog scale (VAS: 0-10mm) were recorded at inclusion. The primary endpoint was complete resolution of the trigger finger at 6 months. Eighty-four patients totaling 105 treated digits were included. Mean age was 63.3±10.7 years. Prior to treatment, mean VAS pain score was 5.8±2.6mm, and mean QuickDASH score was 44.3±19.1. At 6 months, disappearance of symptoms was achieved in 85 of 91 digits with follow-up (93.4%), and in 85.7% at 12 months. The absolute reduction in VAS pain and QuickDASH scores at 6 months was respectively 4.1±3.1 (P<0.001) and 36.1±20.7 (P<0.001), and 90% of patients reported being satisfied or very satisfied at 6 months. Long duration of symptoms was significantly associated with persistent trigger finger at 6 months after intervention. Complications were rare and minor. Tenosynovitis occurred in 5.7% of cases, for which a corticosteroid injection into the tendon sheath rapidly led to favorable resolution. Treatment of trigger finger by release of the A1 pulley under ultrasound guidance using the needle technique is a mildly invasive technique that yields rapid and effective symptom resolution with good tolerance up to 12 months.

Clinical Characteristics and Treatment of Adult Idiopathic Carpal Tunnel Syndrome Accompanied with Trigger Digit.

Purpose To investigate the clinical characteristics and treatment of adult idiopathic carpal tunnel syndrome (CTS) accompanied with trigger digit. Materials and Methods A retrospective analysis was performed on a total of 74 patients with adult idiopathic CTS accompanied with trigger digit admitted to and treated at the Hand Surgery Department of Ningbo No. 6 Hospital from January 1, 2017 to December 31, 2019. Data on patients' gender, age, occupation, course of the disease, menstruation, surgeries, examination-related information, complications, treatment methods, and prognoses during follow-up were recorded and subsequently used to analyze the pathogeneses, clinical characteristics, and treatment. Results A total of 74 patients (72 females and 2 males) were included. Among female patients, 51 were postmenopausal and 18 were non-postmenopausal. There were 101 fingers with trigger digit, including 14 patients with trigger digit in both hands, and 115 wrists affected by the CTS. The average course of CTS was 34.5 ± 49.3 months, and that of trigger digit was 10.5 ± 22.4 months. Seventy had both trigger digit and CTS in one hand, while among patients with both hands involved, only 4 had trigger digit or CTS in one hand. Eighty-nine fingers underwent A1 pulley release, and 104 hands underwent carpal tunnel surgery, with steroids being injected under the adventitia of the median nerve during the surgery. All patients who underwent surgeries had I/A-healed incisions, and 14 of them had obvious synovial hyperplasia observed in the carpal tunnel and flexor tendon sheath during surgeries. Follow-up visits, which lasted 3 to 35 months, had an average duration of 1.34 years and included 72 patients. In 63 patients (63/72), the syndrome of tenosynovitis and numbness disappeared and normal hand functions were restored; in 6 patients, the numbness in hands greatly improved and normal hand functions were almost completely restored, while no improvement in numbness of hands and limited hand functions were still observed in 3 patients. Conclusion CTS accompanied with trigger digit was more common in postmenopausal females, and the course of CTS was longer than that of trigger digit. CTS and trigger digit were more likely to simultaneously occur in the same hand, while some patients might not have obvious synovial hyperplasia in the carpal tunnel. Surgeries were effective in severe cases.

Nonpalmar Endoscopic versus Open Trigger Finger Release: Results from a Prospective Trial.

Background:The most common complaint after open surgical release for trigger finger is of pain and scarring at the surgical site. We hypothesized that use of a new nonpalmar endoscopic approach for release of the A1 pulley through an incision at the proximal digital crease would result in decreased scarring and faster recovery compared to those treated with standard open release.Methods:Patients with trigger finger were prospectively enrolled and treated with a nonpalmar endoscopic versus open surgical technique. Outcome measures included scar assessment based on the Patient and Observer Scar Assessment Scale (POSAS) administered 1 week, 1 month, and 6 months postoperatively, time before return to work, occupational therapy visits, and overall satisfaction. Additional outcomes included pain medication use, operative time, and complication and recurrence rates.Results:POSAS scores were better in the endoscopic treatment group than in the open group at all time points with a statistically significant difference seen at 1 week and 1 month postoperatively. The endoscopic group returned to work sooner, required fewer occupational therapy visits, and had better overall satisfaction compared to the open group, but the differences were not statistically significant. Complication and recurrence rates did not differ significantly between groups.Conclusions:Patients treated for trigger finger with a nonpalmar endoscopic release through an incision at the proximal digital crease demonstrate significantly better scarring in the early postoperative period compared to patients treated with the open surgical approach. Treatment for trigger finger with this technique is as effective as the standard open technique.

Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery.

Background:The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program.Methods:Data on operative repair of flexor tendon lacerations from 2006 to 2014 were reviewed and compared with those from 2015 to 2020. National practice trends observed in these data were evaluated and reviewed alongside published literature and evidence-based medicine.Results:In total, 780 patients with flexor tendon laceration injuries were included. Mean patient age was 38 years; mean time between tendon injury and first evaluation was 4 days, and the mean time from injury to operative repair was 12 days. Four-strand sutures remain the most common technique of tendon repair (57%). In the recent cohort, there were significant decreases in tourniquet use (94% versus 89%), general anesthesia (88% versus 74%), and monofilament sutures (44% versus 35%), with a significant increase reported in preserving the A1 pulley (20% versus 29%). Postoperative movement was described as “almost full range of motion” or “good” in 70% of cases, and 74% of patients were satisfied with their results. Postoperative adverse events were reported in 26% of cases, with the most common complications being tendon adhesions (14%) and rupture (3%).Conclusions:Review of The American Board of Plastic Surgery tracer data for operative repair of flexor tendon lacerations establishes a framework by which surgeons can evaluate how their current practice aligns with that of their peers, and whether their practice patterns remain current relative to recommendations from evidence-based medicine.

Safety and efficacy of ultrasound-guided percutaneous A1 pulley release using a needle knife: An anatomical study.

ObjectiveThe present study aimed to assess the efficacy and safety of ultrasound-guided percutaneous A1 pulley release using a needle knife.MethodsThe author performed percutaneous A1 pulley release in 84 cadaveric hands fixed with 10% formalin. The cadaveric hands were divided into three groups: 28 hands in each group (group U: ultrasound-guided needle knife pushing group, group N: non-ultrasound-guided needle knife pushing group, group T: classical needle knife operation puncture group). Percutaneous A1 pulley release was performed, the soft tissue was dissected layer by layer, and the relevant anatomical data were measured.ResultsThe injured cases were as follows: group U, 29 (20.7%); group N, 36 (25.7%); and group T, 28 (20.0%). There is no significant difference between different tissue injury types in different intervention methods. The missed release cases were as follows: group U, 8 (5.7%); group N, 4 (2.9%); and group T, 13 (9.3%). The percentage of released A1 pulley were as follows: group U, 71.4% ± 30.7%; group N, 66.0% ± 20.3%; and group T, 61.0% ± 30.4%. The percentage of released A1 pulley of the three groups were compared: group U > group N > group T, and there was statistical difference between the three groups. The full release rates of the three groups were compared: group U(31.4%) > group N(15.7%) > group T(13.6%), and there were significant difference in the full release of A1 pulley between group U and group T, group N.ConclusionBased on the cadaver specimen, the length and percentage of released A1 pulley is longer by ultrasound-guided percutaneous A1 pulley release using a needle-knife. and there was no statistical difference in the injury rate between the three techniques.Type of Study and Clinical RelevanceClinical anatomic study. To test the efficacy and safety of ultrasound-guided percutaneous A1 pulley release using a needle knife in cadaveric hands, and provide an anatomically based support in clinic.

Efficacy analysis of three kinds of surgery for trigger thumb.

To study the efficacy of three kinds of surgery for trigger thumb. A total of 60 cases of trigger thumb (Quinnell Grade IV) were randomly divided into three groups. The A1 pulley was disconnected at the middle in Group A, at the extreme radial side in Group B, excised in Group C. The following indicators were recorded pre-operatively (D0), and at one (D1), three (D3), seven (D7), 14 (D14), and 28 (D28) days post-operatively: 1. the pain visual analogue score (VAS) when flexing the affected thumb; 2. range of motion (ROM) of the interphalangeal joint with pain tolerance; 3. the time of pain disappearance when flexing the affected thumb. The differences of VAS and ROM between D1 and D0, D3 and D1, D7 and D3, D14 and D7, D28 and D14 were statistically significant (P < 0.05). There was no significant difference in changes of VAS (or ROM) at D1 or D28 in contrast to D0 among the three groups. The differences of VAS (or ROM) changes at D3, D7, and D14 in contrast to D0 among the three groups were statistically significant (P < 0.05). The difference of the time when the pain disappearing in the normal range of motion among the three groups were statistically significant (P < 0.05). Disconnecting the A1-pulley at the extreme radial side is better than another two methods for treating the trigger thumb (Quinnell Grade IV). It has been shown to effectively accelerate postoperative pain relief and functional recovery. Clinical trial registry number: ChiCTR2100051193.

240 Flexor Digitorum Profundus Tendon Segment Length Estimation via Measurement of Adjacent Landmarks in the Secondary Repair of Jersey Finger

Abstract Aim Jersey finger describes injury involving the rupture of a Flexor Digitorum Profundus (FDP) tendon. The rupture occurs at its point of insertion, at the base of the distal phalanx. Cause of injury is forced hyperextension of FDP. Correct tendon tensioning correlates with tendon length during repair and is vital to optimise restoration of function. No evidence-based approach to tendon tensioning exists hitherto. We used cadaveric dissection to measure anatomical landmarks associated with the FDP tendon and assess whether these can be used to estimate the length of the adjacent tendon segments. Method Eight cadaveric hands were dissected (four fresh-frozen and four formalin-fixed). Lumbrical muscles, A1 pulley and distal FDP insertion for digits II-IV were identified. Lengths between the most distal point of the lumbrical origin; proximal and distal ends of the A1 pulley and FDP insertion were recorded. Results Measurements involving the A1 pulley showed a great degree of variation and no clear trend across the digits studied. Conversely, lumbrical origin to FDP insertion lengths were consistent relative to the adjacent digit measurements across all cadavers for digits II, II and IV. This was confirmed by a linear regression analysis (R2 &amp;gt;0.97). Conclusions This study demonstrates how distal lumbrical origin to FDP tendon insertion measurements in digit III can be used to estimate the length of the tendon graft required in digit II or IV, during repair. This injury manifests most commonly in digit IV. Therefore, our finding furthers surgical knowledge and is likely to improve patient outcomes.

A Biomechanical Analysis of the H-Taping Method Used by Rock Climbers as Prophylactic or Stabilizing Fixation of Partial A2 Pulley Tears

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. 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 middlefingers- H-taping as a prophylactic versus H-taping as a stabilizing treatment of torn pulleys. 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. We found that H-taping is not effective as prophylaxis against A2 pulley ruptures or as a stabilizing treatment method for partially ruptured pulleys. 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.

Comparative Study of A1 Pulley Release and Ulnar Superficialis Slip Resection in Trigger Finger With Flexion Contracture of the Proximal Interphalangeal Joint

The purpose of this study was to compare the clinical outcomes of A1 pulley release with ulnar superficialis slip resection (group A) and simple A1 pulley release (group B) in trigger finger with flexion contracture of the proximal interphalangeal (PIP) joint. From January 2016 to December 2019, the 2 surgical procedures were performed alternately every year for trigger fingers with preoperative PIP joint flexion contractures of ≥10°. Twenty-six fingers in group A and 29 fingers in group B that were followed up for >1 year were reviewed in this retrospective study. The visual analog scale (VAS) score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; degree of PIP joint flexion contracture; grip strength; and pinch strength were measured after surgery and compared. The differences in postoperative PIP joint flexion contracture between groups were <4° at 2 and 6 weeks, and there were no clinically relevant differences at 6 weeks and 12 months. At the final follow-up, PIP joint flexion contractures of 5° were observed in 2 fingers in each group. The difference in VAS scores between groups was less than half of a point until 3 months, and there were no clinically relevant differences at 6 weeks and 12 months. The DASH score did not show any difference between groups at the final follow-up. There were clinically relevant differences in the grip and pinch strengths between groups at 6 weeks. However, there were no clinically relevant differences at the final follow-up. Proximal interphalangeal joint flexion contracture measurements and clinical scores did not differ between groups at the final follow-up. Therefore, we recommend use of a simple A1 pulley release, which is simpler than an A1 pulley release with ulnar superficialis slip resection, in cases of trigger finger with PIP joint flexion contracture. Therapeutic IV.

WALANT: A Discussion of Indications, Impact, and Educational Requirements.

Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.