Ultra-Minimally Invasive Sonographically Guided Trigger Digit Release: An External Pilot Study

Objective: The most common surgical option for releasing the first annular pulley in trigger digit is classic open surgery followed by blind percutaneous release. However, they have been related to major complications and incomplete releases, respectively. Classic. The intrasheath sonographically guided first annular pulley release has recently shown to be safe and effective in every digit. The objectives of this pilot study were to preliminary compare clinically an intrasheath sonographically-guided first annular pulley release versus a classic open technique and to evaluate the feasibility of a future clinical trial in patients with trigger digits. Methods: Thirty patients were 1:1 randomized in an external pilot study comparing the two surgical techniques: a percutaneous sonographically-guided release performed through a 1 mm incision using a hook knife versus a classic open surgery with a 1 cm incision. Inclusion criteria were primary trigger digit grade III (Froimson). We defined success if primary (safety and efficacy) and secondary objectives (recruitment rates, compliance, completion, treatment blinding, personnel resources and sample size calculation for the clinical trial) could be matched. We registered the grip strength, the Quick-DASH score and a set of clinical postoperative variables at 1, 3 and 6 weeks and at 3 months. We calculated the sample size for the clinical trial using the Quick-DASH at the end of the follow-up. Outcomes assessors were blinded. Results: All patients in both groups showed resolution of their symptoms with no associated complications or relapses. Secondary feasibility objectives were matched: 76.9% of eligible patients were included in the study, 3.3% refused randomization, 20 patients per month were recruited, 100% received blinded treatment, 98.5% showed compliance and 100% completed the study. The sample size for a future clinical trial was of 84 patients. There were no differences in grip strength. The intrasheath sonographically-guided first annular pulley release showed significantly better scores for the Quick-DASH, until the 6th postoperative week. Conclusions: The intrasheath sonographically-guided first annular pulley release is safe and efficacious and it shows a trend towards clinical superiority versus the classic open procedure, which should be confirmed with a clinical trial. Our study shows that a randomized clinical trial is feasible.

Grip Force Measurement as a Complement to High-Resolution Ultrasound in the Diagnosis and Follow-Up of A2 and A4 Finger Pulley Injuries

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.

Ultrasound of the Wrist and Hand

Chapter 122 covers US of the wrist and hand. US is gaining popularity as a useful modality for imaging wrist and hand pain, providing soft tissue resolution superior to MRI, with the additional benefits of real-time imaging, ease of comparison to the contralateral side, and dynamic imaging. US provides excellent visualization of tendons and the small joints of the hand. Peripheral nerves are easily identified and assessed with US with resolution surpassing MRI. Median nerve entrapment can be quickly and easily evaluated when carpal tunnel disease is suspected. Dynamic evaluation allows further assessment for the presence of Stener lesion, sagittal band and annular pulley injuries, and for tendon subluxation. US easily shows joint effusions, osteophytes, erosions, and synovial hypertrophy when arthritis is suspected. Soft tissue masses, such as ganglion cysts or giant cell tumor of the tendon sheath, are accurately imaged with US.

Tendons

The tendon chapter is written by surgeons together with hand therapists to describe tendon pathology and its treatment (including hand therapy). The anatomy of flexor and extensor tendons is detailed, along with zones of injury, surgical principles of tendon repair, and their rehabilitation. Late tendon reconstruction is also described including the principles of tenolysis and also tendon grafting. There is also a section on annular pulley injury and reconstruction. Inflammatory tendon pathology including trigger digits and tenosynovitis and tendonitis is described, along with a section on work-related upper limb disorder.

A Cadaveric Study of the Thread Trigger Finger Release: The First Annular Pulley Transection Through Thread Transecting Technique

Background: After the thread transecting technique was successfully applied for the thread carpal tunnel release, we researched using the same technique in the thread trigger finger release (TTFR). This study was designed to test the operational feasibility of the TTFR on cadavers and verify the limits of division on the first annular (A1) pulley to ensure a complete trigger finger release with minimal iatrogenic injuries. Methods: The procedure of TTFR was performed on 14 fingers and 4 thumbs of 4 unembalmed cadaveric hands. After the procedures, all fingers and thumbs were dissected and visually assessed. Results: All of the digits and thumbs demonstrated a complete A1 pulley release. There was no injury to the neurovascular bundle (radial digital nerve in case of thumb), flexor tendon, or A2 pulley for each case. Conclusions: The cadaveric study showed that the technique of TTFR was safe and effective, and the future clinical study is necessary to verify the findings of this study.