To determine the diagnostic accuracy and reproducibility of conventional MR imaging (MRI) of the shoulder in evaluating biceps pulley lesions using arthroscopy as the standard of reference.
In a ...retrospective study, MR examinations of 68 patients with arthroscopically proven torn or intact biceps pulley were assessed for the presence of pulley lesions by three radiologists. The following criteria were evaluated: displacement of the long head of the biceps tendon (LHBT) relative to the subscapularis tendon (displacement sign), subluxation/dislocation of the LHBT, the integrity of the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), lesions of the supraspinatus (SSP) and subscapularis (SSC) tendons adjacent to the rotator interval, presence of biceps tendinopathy and subacromial bursitis.
There were 42 patients with pulley lesions in the study group. Conventional MR imaging showed an overall sensitivity of 95.2%, 88.1% and 92.9%, a specificity of 61.5%, 73.1%, and 80.8% and an accuracy of 82.4%, 82.4% and 88.2% in the diagnosis of pulley lesions. Interobserver agreement was substantial (multirater k = 0.75).
Biceps tendinopathy (97.6%, 95.2%, 97.6%), defects of the SGHL (86.3%, 81.0%, 88.1%) and the displacement sign (88.1%, 81.0%, 85.7%) were the most sensitive diagnostic criteria. Subluxation/dislocation of the LHBT was insensitive (78.6%, 42.9%, 33.3%), but specific (69.2%, 100,0%, 96.2%).
In the diagnosis of pulley lesions, conventional MR imaging is reproducible and shows high sensitivity and accuracy but moderate specificity.
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.
To compare the mechanical characteristics of A2 and combined A2–A4 pulley repair in the intact and damaged flexor pulley system.
After control testing, we recorded tendon excursion and flexion of 11 ...cadaveric fingers after several interventions: (1) complete excision of A2 and A4, (2) repair of the A2 with one ring of tendon graft, (3) repair of the A2 with 2 rings of tendon graft, and (4) repair of the A2 with 2 rings combined with repair the A4 with one ring.
At the proximal interphalangeal (PIP) joint, the maximum rotational angle decreased by an average of 30% after complete excision of the A2 and A4 pulleys. This angle was still decreased compared with the control by an average of 25% after one-ring repair at A2, 23% after 2-ring repair at A2, and 17% after 2-ring repair at A2 combined with one-ring repair at A4. At the metacarpophalangeal joint, the average maximum rotational angle decreased by an average of 17% after complete excision of the A2 and A4 pulleys. This angle was still decreased compared with the control by an average of 11% after one-ring repair at A2, 7% after 2-ring repair at A2, and 4% after 2-ring repair at A2 combined with one-ring repair at A4. Kinematic behavior at the PIP joint with an intact pulley system was most closely approximated by the 3-loop repair. The least similar behavior was with a 2-ring construct at A2.
All repairs increased average flexion at the PIP and metacarpophalangeal joints compared with the unrepaired samples. The 3-ring configuration exhibited a higher recovery of PIP flexion compared with the other repairs.
Although each repair restored flexion, clinical studies are necessary to evaluate the clinical relevance of the mechanical results of this study.
Finger flexor pulley injuries are the most common overuse injuries sustained by climbers. These injuries are caused by forceful gripping techniques specific to climbing, making them uncommon in ...non-climbing activities. With the growing popularity of climbing, there is a rising need for accurate diagnosis and improved treatment methods. This paper explores current diagnostic techniques, including physical examination, ultrasound, and magnetic resonance imaging. It also discusses treatment options, which range from conservative rehabilitation to surgery, depending on the severity of the injury. Finally, it emphasizes the importance of injury prevention through proper warm-up and avoiding excessive strain.
The purpose of the study was to investigate which anatomic structures are affected in a series of patients with pulley lesions and whether all lesions can be classified according to the Habermeyer ...classification.
One hundred consecutive patients with pulley lesions were prospectively studied. During arthroscopy, lesions of the superior glenohumeral ligament (SGHL), medial coracohumeral ligament (MCHL) and/or lateral coracohumeral ligament (LCHL), adjacent rotator cuff, and biceps (long head of the biceps) were recorded. All lesions were then classified according to the Habermeyer classification. The χ2 test was used for statistical analysis.
There were 3 lesions in group 1, 20 in group 2, 6 in group 3, and 35 in group 4 according to the Habermeyer classification. Thirty-six lesions were not classifiable because of an intact SGHL. A lateral pulley sling (LCHL) lesion was found in 95% of the patients, and a medial pulley sling (MCHL-SGHL) lesion was noted 64%. An isolated lesion of the MCHL and/or SGHL was present in 5%, and an isolated lesion of the LCHL was found in 36%. Combined medial-lateral sling lesions were correlated with complete subscapularis tears and biceps fraying.
The lateral pulley sling is more often affected than the medial sling. The SGHL is not always affected, and isolated lesions of the medial sling are rare. Lesions of both slings correlated with complete subscapularis tears and fraying of the long head of the biceps. An updated classification of direct pulley lesions is proposed: type 1, lesion of the medial pulley (MCHL and/or SGHL); type 2, lesion of the lateral pulley (LCHL); and type 3, lesion of the medial and lateral pulley slings. Concomitant lesions of the indirect pulley stabilizers can be mentioned additionally according to the well-known classifications.
Defining the Digit-Specific Confluence of the A1 Pulley Hevesi, Mario; Logli, Anthony L.; Ramazanian, Taghi ...
The Journal of hand surgery (American ed.),
August 2023, 2023-Aug, 2023-08-00, 20230801, Letnik:
48, Številka:
8
Journal Article
Recenzirano
Variations in the description of the flexor pulley system exist, particularly in whether the A1 and A2 pulleys represent discrete or confluent entities. This has potentially important clinical ...relevance at the time of A1 pulley release for symptomatic trigger finger, given the goal of adequate release without overrelease. The purpose of this study was to determine the relative prevalence of confluent A1 pulleys on a digit-by-digit basis employing 2.5× loupes alone, thereby simulating a clinical surgical environment.
Cadaveric anatomic specimens underwent flexor pulley system dissection under 2.5× loupe magnification by 2 hand surgeons. The presence of pulley confluence and length (measured from the proximal aspect to the distal aspect) was recorded and compared on a digit-to-digit basis.
Forty-five digits, comprising 9 adult forearm or hand specimens (5 right and 4 left) obtained from 6 donors (4 men and 2 women, age: 67 ± 8 years), were dissected. A total of 19 confluent A1 pulleys were encountered, with notable digit-by-digit variation in the prevalence of confluent pulleys. There were 0 confluent pulleys observed in the thumb, compared with 6 confluent pulleys observed in the middle finger. The average overall A1 pulley length was 5.0 ± 1.5 mm, with a similar pulley length observed between the digits.
A1 pulley confluence varies on a digit-to-digit basis, with no observed confluence in the thumb and the most common confluence observed in the middle finger.
In the setting of intraoperatively observed pulley confluence, we suggest pulley release under traction in order to develop the plane between the A1 and A2 pulleys and, thus, confirm the complete and isolated release of the A1 pulley.
Pulley injuries are common among rock climbers, which is a growing population. Hand therapists need a therapeutic intervention which promotes healing and enables participation.
The purpose of this ...case series is to detail the functional outcomes of a 12-week protocol using a pulley ring orthosis (PRO) among rock climbers with a grade I, II, or III pulley injury.
A prospective repeated measures case series followed the healing timeline of four participants who rock climbed while wearing the invervention device, the PRO, with weekly measurements to monitor healing
Participants with a grade I, II, or III A2 pulley injury were custom fitted for a PRO, which they wore while rock climbing a minimum of 3 times per week for 12 weeks. Weekly check-ins were scheduled for subjective and objective measurements.
All participants demonstrated indicators of full healing, which, in this study, is defined as progressive improvement in strength, function, and pain, without interruption of their typical rock climbing schedules.
Providers should consider the use of a PRO as a protective orthosis for rock climbing patients with a low-grade A2 pulley injury who want to continue rock climbing while they are healing.
•Adds evidence on how to treat a low-grade pulley injury.•Educates therapists how to fabricate a participation enabling protective orthotic.•Is cost effective for both the practitioner and the client/patient.•Defines two new tests; both target assessment of the strength needed to rock climb.•Introduces a dorsal safety release to reduce the fear of a degloving injury.
Various techniques have been developed to optimize the repair of zone II flexor tendon injuries. The aim of the present study was to compare the biomechanical outcomes of four different methods: ...resection of the single flexor digitorum superficialis (FDS) slip; A2 pulley venting; and two different A2 pulley plasty methods. In total, 36 cadaveric fingers were dissected to determine the gliding coefficients (GC), maximum flexion angles (MFA) and bowstring measurements through digital imaging before and after surgical procedures. The GC increased significantly ( p < 0.05) and MFA decreased significantly ( p < 0.001) in all groups after the surgical interventions. There were no statistically significant differences between the surgical techniques regarding GC ( p = 0.756) and MFA ( p = 0.089). Bowstring distance significantly increased in the pulley venting group ( p < 0.001). The pulley plasty results were comparable to the other techniques. The single FDS slip resection technique should be considered as the method of choice for reducing the GC following flexor tendon repair as it preserves the anatomical structure of the A2 pulley.
Level of evidence
V
To determine the region of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in zone 2 that, when involved by a laceration repair, will reliably catch on the A2 ...pulley after surgery.
Using fresh-frozen cadavers (5 hands, 20 digits), excursions of the FDP and FDS tendons were measured in relation to the A2 pulley. The C1, A3, and C2 pulleys were resected. The digit was maximally flexed by applying traction to the flexor tendon in the forearm. An 8-0 suture tag was placed in the flexor tendons immediately distal to the A2 pulley. The digit was then passively fully extended to measure tendon excursion. Measurements were repeated with 50% venting and 100% release of the A4 pulley. Reference points such as tendon insertions and flexion creases were obtained. This protocol was repeated sequentially for the index, middle, ring, and little fingers.
For all 20 fingers, the suture placed into the FDP just distal to the A2 pulley with the finger fully flexed traveled 1.6 ± 1.9 mm distal to the proximal edge of the A4 pulley with passive extension of the finger. The mean excursion for the FDP was 24.6 ± 3.2 mm, and 16.9 ± 3.1 mm for the FDS. The mean A2 pulley length was 16.2 ± 3.5 mm, and the mean distance between the distal edge of the A2 pulley and the proximal edge of the A4 pulley was 23.0 ± 3.3 mm. Venting the A4 pulley 50% and 100% increased FDP excursion a maximum of 0.9 and 1.9 mm, respectively.
An FDP repair proximal to the A4 pulley will slide under the A2 pulley with full active digital flexion after surgery. If the distal FDP stump lies underneath the A4 pulley with the digit fully extended, the FDP repair will not likely engage the A2 pulley with full flexion after surgery. The FDP excursion can be reliably predicted as a percentage of the A2 (distal) to the A4 (distal) pulley distance. Most importantly, the distance between the repair site and the A4 pulley approximately equals the length of the A2 pulley that requires release to avoid postoperative triggering.
Knowledge of this high-risk region of flexor tendon repair will guide surgeons regarding the potential need for partial release of the A2 pulley.
Introduction Rock climbing has surged in popularity over the past few decades, attracting a diverse range of participants from recreational enthusiasts to professional athletes. While climbing ...offers numerous physical and mental benefits, it also presents significant injury risks. Rock climbing is a sport that imposes extreme stress on the fingers, particularly on the flexor pulley system. Injuries to these structures can severely impact a climber's ability to perform and progress in the sport. Understanding the anatomy, injury mechanisms, and treatment modalities is essential for effective management and prevention. Aim of the study The purpose of this narrative review is to comprehensively describe information on the anatomy, function, mechanism of injury, diagnosis, and treatment modalities of the finger flexor pulley system (FFPS). Materials and methods The methodology for the literature search involved using the keyword "pulley" and adding terms such as "treatment", "mechanism", "function", "anatomy", "diagnosis", and "symptoms". The search terms were entered into the PubMed and Google Scholar databases. The review works and clinical trials were taken into account. Conclusion Finger flexor pulley system (FFPS) strain is a common overuse injury in climbers, often caused by the crimp grip used in rock climbing. Pulleys A2 and A4 are particularly vulnerable. Diagnosis involves physical examination and imaging tests, such as ultrasonography and, if necessary, magnetic resonance imaging. Grade I to III injuries are typically treated conservatively, while surgical treatment may be necessary for grade IVb injuries. Using a splint or H-taping the fingers after an injury can help prevent further damage and provide support for the affected pulleys.
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