scholarly journals Transverse Carpal Ligament and Forearm Fascia Release for the Treatment of Carpal Tunnel Syndrome Change the Entrance Angle of Flexor Tendons to the A1 Pulley: The Relationship between Carpal Tunnel Surgery and Trigger Finger Occurence

2013 ◽  
Vol 2013 ◽  
pp. 1-4 ◽  
Author(s):  
Nazım Karalezli ◽  
Harun Kütahya ◽  
Ali Güleç ◽  
Serdar Toker ◽  
Hakan Karabörk ◽  
...  
Keyword(s):  
Carpal Tunnel ◽  
Trigger Finger ◽  
Distal Forearm ◽  
Transverse Carpal Ligament ◽  
Predisposing Factor ◽  
Maximal Increase ◽  
Entrance Angle ◽  
Flexor Tendons ◽  
Carpal Tunnel Surgery ◽  
A1 Pulley

Purpose. The appearance of trigger finger after decompression of the carpal tunnel without a preexisting symptom has been reported in a few articles. Although, the cause is not clear yet, the loss of pulley action of the transverse carpal ligament has been accused mostly. In this study, we planned a biomechanical approach to fresh cadavers.Methods. The study was performed on 10 fresh amputees of the arm. The angles were measured with (1) the transverse carpal ligament and the distal forearm fascia intact, (2) only the transverse carpal ligament incised, (3) the distal forearm fascia incised to the point 3 cm proximal from the most proximal part of the transverse carpal ligament in addition to the transverse carpal ligament. The changes between the angles produced at all three conditions were compared to each other.Results. We saw that the entrance angle increased in all of five fingers in an increasing manner from procedure 1 to 3, and it was seen that the maximal increase is detected in the middle finger from procedure 1 to procedure 2 and the minimal increase is detected in little finger.Discussion. Our results support that transverse carpal ligament and forearm fascia release may be a predisposing factor for the development of trigger finger by the effect of changing the enterance angle to the A1 pulley and consequently increase the friction in this anatomic area.Clinical Relevance. This study is a cadaveric study which is directly investigating the effect of a transverse carpal ligament release on the enterance angle of flexor tendons to A1 pulleys in the hand.

scholarly journals Aberrant Positioning of the Ulnar Nerve Found During Carpal Tunnel Release: A Case Report

2019 ◽  
Author(s):  
David R. Veltre ◽  
Kelvin Naito ◽  
Xinning Li ◽  
Andrew B. Stein
Keyword(s):  
Case Report ◽  
Median Nerve ◽  
Ulnar Nerve ◽  
Carpal Tunnel ◽  
Carpal Tunnel Release ◽  
Distal Forearm ◽  
Anatomic Variations ◽  
Transverse Carpal Ligament ◽  
Iatrogenic Injuries ◽  
Flexor Retinaculum

Introduction: Aberrant positioning of the ulnar nerve volar to the transverse carpal ligament is a rare anatomic variation.Case Presentation: We present the case of a 55-year-old female with unique ulnar nerve anatomy that was discovered introperatively during carpal tunnel release.  The ulnar nerve was running directly adjacent to the median nerve in the distal forearm and as the median nerve traversed dorsal to the transverse carpal ligament (flexor retinaculum) to enter the carpal tunnel the ulnar nerve continued directly volar to this structure before angling towards Guyon’s Canal.  The unique ulnar nerve anatomy was successfully identified, carefully dissected and managed with a successful patient outcome.Conclusion: Variations of the anatomy at the level of the carpal tunnel are rare but do exist.  Awareness of these anatomic variations and adequate visualization of the ulnar nerve along with the surrounding structures is crucial to avoid iatrogenic injuries during carpal tunnel release. 

Value of anatomic landmarks in carpal tunnel surgery

2013 ◽  
Vol 38 (6) ◽  
pp. 641-645 ◽  
Author(s):  
O. Y. Yavuz ◽  
I. Uras ◽  
B. Tasbas ◽  
M. Kaya ◽  
R. Ozay ◽  
...  
Keyword(s):  
Carpal Tunnel ◽  
Transverse Carpal Ligament ◽  
Safe Distance ◽  
Kirschner Wires ◽  
Anatomic Landmarks ◽  
Motor Branch ◽  
The Third ◽  
Carpal Tunnel Surgery ◽  
Web Space ◽  
The Relationship

This study investigated which anatomic landmarks were most useful for correct and safe incision placement in carpal tunnel surgery. Kirschner wires were attached to the hands to mark previously defined landmarks. The bony attachments of the transverse carpal ligament, which were identified previously, were drawn on an anteroposterior digital x-ray of the hand, with the thumb in full abduction. The relationship between anatomic landmarks and these bony attachments were examined. In all hands, either the line along the third web space or the crease between the thenar and the hypothenar regions, or both, were on the ulnar half of the transverse carpal ligament. During incision placement, we recommend selecting the most ulnar choice between the line drawn along the third web space and the crease between the thenar and hypothenar regions in order to be at safe distance from the recurrent motor branch of the median nerve.

PEDICLED HYPOTHENAR FAT FLAP FOR MEDIAN NERVE COVERAGE IN RECALCITRANT CARPAL TUNNEL SYNDROME

Hand Surgery ◽  
2000 ◽  
Vol 05 (01) ◽  
pp. 33-40 ◽  
Author(s):  
Ch. Mathoulin ◽  
J. Bahm ◽  
S. Roukoz
Keyword(s):  
Carpal Tunnel Syndrome ◽  
Median Nerve ◽  
Carpal Tunnel ◽  
Anatomical Study ◽  
Ulnar Artery ◽  
Transverse Carpal Ligament ◽  
Carpal Tunnel Surgery ◽  
Tunnel Syndrome ◽  
Normal Nerve Conduction

We report the use of a hypothenar pedicled fat flap to cover the median nerve in recalcitrant carpal tunnel syndrome. Forty-five patients with recurrent symptoms after previous carpal tunnel surgery were included in this study. Patients with incomplete release of the transverse carpal ligament were not included. We performed an anatomical study on 30 cadavers. The original technique with the section of the deep branch of ulnar artery was modified. The flap could be transferred onto the median nerve without stretching. The median follow-up was 45 months (range, 12–80 months). Pain completely disappeared in 41 patients with normal nerve conduction. Based on clinical and electromyographic signs, the global results showed excellent results (49%), 19 good results (45%), two average results (4.5%) and two failures (2%). The use of a hypothenar pedicled fat flap to cover the median nerve in recalcitrant carpal tunnel syndrome is a simple and efficient technique which improves the trophic environment of the median nerve and relieves pain.

The relationship of trigger finger and flexor tendon volar migration after carpal tunnel release

2013 ◽  
Vol 39 (7) ◽  
pp. 694-698 ◽  
Author(s):  
S. K. Lee ◽  
K. W. Bae ◽  
W. S. Choy
Keyword(s):  
Carpal Tunnel ◽  
Carpal Tunnel Release ◽  
Trigger Finger ◽  
Neutral Position ◽  
Wrist Flexion ◽  
Flexor Tendons ◽  
Tendon Biomechanics ◽  
The Mean ◽  
Relationship Of ◽  
The Relationship

It has been suggested that the increased frequency of trigger finger (TF) after carpal tunnel release (CTR) may be caused by the volar migration of the flexor tendons at the wrist altering the tendon biomechanics at the A1 pulley. This hypothesis has not been validated. We performed pre- and post-operative ultrasonography (USG) on the affected wrists of 92 patients who underwent CTR. Pre-operative USG was performed in neutral with no tendon loading; post-operative USG was performed in neutral unloaded and in various positions of wrist flexion whilst loading the flexor tendons with gripping. The mean volar migration of the flexor tendons after CTR was 2.2 (SD 0.4) mm in the unloaded neutral position. It was 1.8 (SD 0.4) mm in patients who did not develop TF and 2.5 (SD 0.5) mm in those who did ( p = 0.0067). In loaded wrist flexion, the mean volar migration of flexor tendons after CTR in patients who did not develop TF and those who did was 2.1 and 3.0 mm in 0° flexion; 3.2 and 3.9 mm in 15° flexion; 4.3 and 5.1 mm in 30° flexion; and 4.9 and 5.8 mm in 45° flexion, respectively. There were significant differences between patients with and without TF at each flexion angle. Our data indicate that patients with greater volar migration of the flexor tendons after CTR are more likely to develop TF. This conclusion supports the hypothesis that the occurrence of TF after CTR may be caused by the bowstringing effects of the flexor tendons.

scholarly journals Comparison of the Thickness of Pulley and Flexor Tendon Between in Neutral and in Flexed Positions of Trigger Finger

2016 ◽  
Vol 10 (1) ◽  
pp. 36-40 ◽  
Author(s):  
Junko Sato ◽  
Yoshinori Ishii ◽  
Hideo Noguchi
Keyword(s):  
Flexor Tendon ◽  
Tendon Sheath ◽  
Trigger Finger ◽  
Neutral Position ◽  
Flexor Tendons ◽  
Flexor Tendon Sheath ◽  
Posterior Direction ◽  
Flexor Digitorum ◽  
A1 Pulley ◽  
Anterior Posterior

Objective: This study aims to compare the morphology of the A1 pulley and flexor tendons in idiopathic trigger finger of digits other than the thumb between in neutral position and in the position with the interphalangeal joints full flexed and with the metacarpophalangeal (MP) joint 0° extended (hook grip position). Method: A total of 48 affected digits and 48 contralateral normal digits from 48 patients who initially diagnosed with idiopathic trigger finger were studied sonographically. Sonographic analysis was focused on the A1 pulley and flexor tendons at the level of the MP joint in the transverse plane. We measured the anterior-posterior thickness of A1 pulley and the sum of the flexor digitorum superficialis and profundus tendons, and also measured the maximum radialulnar width of the flexor tendon in neutral and hook grip positions, respectively. Each measurement was compared between in neutral and in hook grip positions, and also between the affected and contralateral normal digits in each position. Results: In all the digits, the anterior-posterior thickness of flexor tendons significantly increased in hook grip position as compared with in neutral position, whereas radial-ulnar width significantly decreased. Both the A1 pulley and flexor tendons were thicker in the affected digits as compared with contralateral normal digits. Conclusion: The thickness of flexor tendons was significantly increased anteroposteriorly in hook grip position as compared with in neutral position. In trigger finger, A1 pulley and flexor tendon were thickened, and mismatch between the volume of the flexor tendon sheath and the tendons, especially in anterior-posterior direction, might be a cause of repetitive triggering.

scholarly journals A cadaveric assessment of percutaneous trigger finger release with 15° stab knife: its effectiveness and complications

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Abbas Abdoli ◽  
Majid Asadian ◽  
Seyed Houssein Saeed Banadaky ◽  
Rabeah Sarram
Keyword(s):  
Success Rate ◽  
Tendon Injury ◽  
Trigger Finger ◽  
Safe Alternative ◽  
Flexor Tendons ◽  
Flexor Tendon Injury ◽  
Percutaneous Release ◽  
Significant Difference ◽  
A2 Pulley ◽  
A1 Pulley

Abstract Percutaneous release of the A1 pulley has been introduced as a therapeutic approach for trigger fingers and is suggested as an effective and safe alternative, where conservative treatments fail. The aim of the current study was to determine if percutaneous release with a 15° stab knife can effectively result in acceptable efficacy and lower complication rate. Methods In the present study, the percutaneous release of the A1 pulley was evaluated by percutaneous release using a 15° stab knife in 20 fresh-frozen cadaver hands (10 cadavers). One hundred fingers were finally included in the present study. The success rate of A1 pulley release as well as the complications of this method including digital vascular injury, A2 pulley injury, and superficial flexor tendon injury was evaluated, and finally, the data were analyzed by the SPSS software. Results The results showed a success rate of 75% for A1 pulley release in four fingers, followed by eleven fingers (90%) and eighty-five fingers (100%). Therefore, the A1 pulley was found to be completely released in eighty-five fingers (100%). Overall, the mean of A1 pulley release for these fingers was determined as 97.9%, indicating that percutaneous trigger finger release can be an effective technique using a 15° stab knife. Furthermore, our findings revealed no significant difference in the amount of A1 pulley release in each of the fingers in the right and left hands. Additionally, 17 fingers developed superficial scrape in flexor tendons, while 83 fingers showed no flexor tendons injuries and no other injuries (i.e., vascular, digital nerve, and A2 pulley injuries). Conclusions Percutaneous release of the A1 pulley using a 15° stab knife was contributed to acceptable efficacy and a relatively good safety in the cadaveric model.

scholarly journals Location and Extent of A1, A2 Release and Its Impact on Tendon Subluxation and Bowstringing—A Cadaveric Study

2019 ◽  
Vol 52 (03) ◽  
pp. 349-354
Author(s):  
Laxminarayan Bhandari ◽  
Alireza Hamidian Jahromi ◽  
Aden Gunnar Miller ◽  
Huey Tien
Keyword(s):  
Surgical Treatment ◽  
Upper Extremity ◽  
Traction Force ◽  
Cadaveric Study ◽  
Trigger Finger ◽  
Flexor Tendons ◽  
Safe Limit ◽  
A2 Pulley ◽  
A1 Pulley

AbstractSurgical treatment of trigger finger involves release of A1 pulley. Some authors have theorized that the loss of A1 pulley can lead to ulnar subluxation of flexor tendons, which can be prevented by release of A1 pulley radially, even in a nonrheumatoid hand. However, there is no evidence in literature to either support or oppose this hypothesis. Occasionally, difficulty is encountered to precisely identify where A1 ends and A2 begins. While incomplete release of A1 can cause relapse of triggering, release of substantial A2 can cause bowstringing. Knowledge of the safe limit of concomitant A2 release is beneficial. The study was conducted in 12 cadaver upper extremity specimens. A1 pulleys of 48 fingers were divided at the radial (24 fingers) or ulnar (24 fingers) attachment. A 20lb traction force was applied on the flexor tendons. Any subluxation or bowstringing was noted. The experiment was repeated following serial release of the A2—initially 25%, followed by 50% and 100%. No bowstringing or subluxation was noted when A1 pulley was opened, either by radial or ulnar incision. The same was true for A1 + 25% A2 release. When A1 + 50% A2 pulley were released, bowstringing was observed in 3/48 fingers. When A1 + 100% of the A2 pulley were released, bowstringing occurred in all cases. The location of incision for release of the A1 pulley has no effect on bowstringing or tendon subluxation. Release of additional 25% of the A2 pulley can be performed safely, which corresponds to the level of palmar digital crease.

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