Finger Flexor Pulley Injuries in Rock Climbers

Finger flexor pulley system injuries are the most common overuse injury in rock climbers. These occur rarely outside of climbing, owing to sport’s unique biomechanical demands on finger. As climbing continues grow and earn recognition as a mainstream sport, an understanding how diagnose treat these also has become important. Our purpose is describe current concepts anatomy, biomechanics, clinical evaluation, imaging, prevention, treatment strategies relating finger injuries. literature search was performed PubMed with MeSH terms keywords subject headings meet objectives this review. The “crimp grip” used mechanism for A2, A3, A4 pulleys at highest risk injury, especially when loaded eccentrically. Physical examination may reveal “bowstringing,” defined volar displacement tendons from phalanges; however, imaging required characterization underlying injury. Ultrasound highly sensitive specific diagnosis recommended initial technique choice. Magnetic resonance additional study if ultrasound inconclusive. Properly warming up increases amount physiologic bowstringing thought prevent occurring. Pulley be classified grade I through IV. Conservative treatment, including immobilization, H-tape method, use protective splint, III Surgical repair reserved IV that not amenable conservative treatment. IntroductionThe popularity increased remarkably, both recreationally competitively, over past 30 y. Indoor primarily, seen exponential growth globally, within United States. proposed debut competition now postponed 2020 Tokyo Summer Olympics speaks its ever-growing sport.1Lutter C. El-Sheikh Y. Schöffl I. V. Sport climbing: medical considerations new Olympic discipline.Br J Sports Med. 2017; 51: 2-3Crossref Scopus (52) Google Scholar “Free Solo,” rock-climbing film, won best documentary 2019 Oscars ceremony, further emphasizing broad appeal. According annual report by International Federation Climbing, 44,500,000 people worldwide climb regularly, 9,000,000 those States.2International ClimbingAnnual reports.https://www.ifsc-climbing.org/index.php/about-us/key-figures/2-uncategorised/282-annual-reportsDate accessed: July 3, 2020Google Scholar,3USA Climbing OrganizationClimber report.http://www.usaclimbing.org/home.htmlDate 23, ScholarAs consequence growth, climbing-related have concomitantly. An average 2237 injury-related emergency department visits States occurred annually between 1990 2007.4Nelson N.G. McKenzie L.B. Rock treated departments US, 1990–2007.Am Prev 2009; 37: 195-200Abstract Full Text PDF (64) Lower extremity were common, frequent upper extremities.4Nelson More recently, 2 large retrospective national database studies estimated 3419 2008 2014, representing 50% increase 2007 2014.5Buzzacott P. Chimiak J. US departments, 2008–2016.Wilderness Environ 2019; 30: 121-128Abstract (28) Scholar,6Forrester J.D. Tran K. Tennakoon L. Staudenmayer Climbing-related among adults States: 5-year analysis sample.Wilderness 2018; 29: 425-430Abstract (18) patterns remained consistent, lower extremities being vulnerable, likely falls cause injuries.4Nelson Scholar,5Buzzacott ScholarFingers sustain climbers.7Lutter Tischer T. Hotfiel Enz A. Frank et al.Current trends sport after inclusion into olympic program. Analysis 633 years 2017/18.Muscles Ligaments Tendons 2020; 10: 201-210Crossref (9) Scholar, 8Schöffl Popp D. Küpper Injury climbers: evaluation case series 911 2009 2012.Wilderness 2015; 26: 62-67Abstract (87) 9Rohrbough J.T. Mudge M.K. Schilling R.C. Overuse elite climber.Med Sci Exerc. 2000; 32: 1369-1372Crossref (76) Specifically, isolated closed (FFPS) FFPS first described 1990, community been uniquely susceptible training hands sport.10Bollen S.R. Gunson C.K. Hand climbers.Br 1990; 24: 16-18Crossref (88) Scholar,11Tropet Menez Balmat Pem R. Vichard Closed traumatic rupture ring tendon pulley.J Surg Am. 15: 745-747Abstract (51) Subsequently, numerous reports document climbers.8Schöffl 10Bollen Scholar,12Nelson C.E. Rayan G.M. Judd D.I. Ding Stoner J.A. Survey hand climbers.Hand (NY). 12: 389-394Crossref (14) 13Shea K.G. Shea O.F. Meals R.A. Manual consequences climbing.J 1992; 17: 200-205Abstract (57) 14Maitland M. Injuries associated Orthop Phys Ther. 16: 68-73Crossref (29) 15Bannister Foster Upper limb climbing.Br 1986; 20: 55Crossref (42) 16Schöffl Hochholzer Winkelmann H.P. Strecker W. climbers.Wilderness 2003; 14: 94-100Abstract (127) 17van Middelkoop Bruens M.L. Coert J.H. Selles R.W. Verhagen E. Bierma-Zeinstra S. al.Incidence factors indoor climbers.Int 36: 837-842Crossref (12) recent statistics show accounting 41% all injuries.7Lutter fingers diagnoses, 30% 12% shoulder second site 20% sports rarity, small documented baseball pitchers.18Lourie Hamby Z. Raasch W.G. Chandler J.B. Porter J.L. Annular professional pitchers: series.Am 2011; 39: 421-424Crossref (26) ScholarOur goal summarize available injuries.AnatomyThe consists fibro-osseous sheaths which digitorum profundus (FDP) superficialis (FDS) course.19Zafonte B. Rendulic Szabo R.M. Flexor system: management.J 2014; 2525-2532Abstract (41) sheath composed distinct tissue components, synovial retinacular (pulley), serve functions. component acts “packing” allows movement adjacent nondeformable tissues, while lubricating surrounding cartilage. or localized thickenings serves maintain phalanges promote efficiency flexion. sheath, whole, prevents anteroposterior lateral axis finger.20Bianchi Martinoli de Gautard Gaignot digital normal pathological findings.J Ultrasound. 2007; 85-92Crossref (35) Scholar,21Rispler Greenwald Shumway Allan Mass Efficiency human cadaver hands.J 1996; 21: 444-450Abstract fifth digits contain 5 annular (A1–A5) 3 cruciate (C1–C3) interposed segmentally throughout digit, beginning distal palm ending interphalangeal joints (Figure 1).22Doyle J.R. Palmar pulleys.Clin Relat Res. 2001; 383: 84-96Crossref (47) ring-shaped configuration, whereas eponymous cruciform shape.Annular can subdivided true insert directly bone onto plate. plate, found palmar aspect metacarpophalangeal joints, ligamentous structure functions primarily hyperextension digits. A2 broader, stronger, bone. Traditionally, they considered important away phalanges, phenomenon termed “bowstringing.”22Doyle Scholar,23Peterson W.W. Manske P.R. Bollinger B.A. Lesker P.A. McCarthy Effect excision biomechanics.J 4: 96-101Crossref (107) Importantly, intact exhibit bowstringing, “physiologic bowstringing.” proximal middle respectively. others (A1, A5) less rigid pulleys.24Crowley Microsurg. 2012; 25-29Crossref A1, A5 located metacarpophalangeal, (PIP), (DIP) respectively.The A3 attaches phalanx. A4, PIP joint. third A5, DIP joint.25Gupta Lenchik Wuertzer S.D. Pacholke D.A. High-resolution 3-T MRI fingers: review anatomy ligament injuries.AJR Roentgenol. 204: 314-323Crossref (21) No present phalanx.The lumbrical muscles intrinsic originate FDP extensor fingers.26Wang McGlinn E.P. Chung K.C. A evolutionary perspective function muscle.J 149-155Abstract (27) They extend flex joints.26Wang Although relatively muscle, proximity lumbricals renders them grading injuries.BiomechanicsThe high frequency explained demands. often support much climber’s weight few time. maximize contact fingertips holds little surface area. Accordingly, crimp grip injuries.27Schweizer Biomechanical properties position climbers.J Biomech. 34: 217-223Crossref (103) Scholar,28Bayer Adler Schweizer Uder Janka Evaluation position—a magnetic study.Skeletal Radiol. 44: 1279-1285Crossref characterized flexed about 90 degrees, maximally hyperextended 2).Figure 2The position.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Anatomically, puts levels stress FDS contract conformation against body.29Schöffl Oppelt Jüngert Neuhuber influence slope system.J 42: 2183-2187Crossref (46) Scholar,30Roloff V.R. Vigouroux Quaine F. model determination forces acting 2006; 915-923Crossref (55) FDS, paired flexion PIP, counterbalanced bend resistance. tension pulley, 4 times greater than phalanges.24Crowley result, higher incidence distance compared other positions (“slope grip,” “pinch grip”) climbers.27Schweizer Scholar,31Schweizer Hudek Kinetics Appl 27: 116-121Crossref (34) ScholarThe least deformable breaking strength pulleys.32Chow J.C. Sensinger McNeal Chow Amirouche Gonzalez Importance maintaining kinematics hand: study.Hand 9 (105–11)Crossref (16) Scholar,33Mallo G.C. Sless Hurst L.C. Wilson analysis: comparison gender digit.Hand 2008; 3: 13-16Crossref (13) typically withstand approximately 431 N, equivalent nearly 45 kg (100 lbs) force.34Lin G.T. Cooney W.P. Amadio P.C. K.N. Mechanical pulleys.J Br. 429-434Crossref (67) Recreational climbers load 380 N 700 equates 54 (120 force.27Schweizer Scholar,35Harzmann H.C. Burkart Imhoff A.B. Most climbing.Sport Traumatol. 2002; 18: 93-96Crossref (2) magnitudes force well excess limit pulleys; therefore, repetitive supraphysiologic loading pulleys, disruption pulleys.InjuriesThe list differential diagnoses injured climber broad, tendons, bones, FFPS.36Schöffl Simon Lutter Tendon epidemiology, biomechanics treatment-an update.Muscle : 233-234Crossref (7) We will focus FFPS. 1990.10Bollen Since then, extensively.9Rohrbough Scholar,14Maitland Scholar,19Zafonte fourth digit (ring finger) commonly affected, followed (middle finger).37Bollen Soft extreme 1988; 22: 145-147Crossref 38Bollen R Coll Edinb. 35: 18-20PubMed 39Bowers W.H. Kuzma G.R. Bynum D.K. 1994; 19: 782-787Abstract (61) Isolated ruptures frequently reported significant injuries.40Rooks M.D. Johnston 3rd, R.B. Ensor C.D. McLntosh James recreational climbers.Am 1995; 23: 683-685Crossref Scholar,41Bovard 2004; 70Abstract pattern progressive predictable, due known limits pulleys. often, part becomes disrupted, progress partial complete rupture, even before A1 involved.42Hauger O. C.B. Lektrakul N. Botte M.J. Trudell Boutin R.D. al.Pulley simulated lesions cadavers MR CT, without contrast material distention sheath.Radiology. 217: 201-212Crossref (122) ScholarBiomechanical analyses suggested eccentrically.31Schweizer Scholar,43Schöffl Bayer al.The concentric eccentric 2124-2128Crossref (32) Scholar,44Moor B.K. Nagy Snedeker J.G. Friction position.Clin Biomech (Bristol, Avon). 20-25Abstract Given muscular tissue, context denotes direction (eg, extension occurs sudden opening hand). This suggests different capacities under versus loads.31Schweizer weakest, consistently stronger (index finger).33Mallo rare, literature.45Schöffl Eur Vol. 2010; 245-246Crossref injury.16Schöffl Grade include strains 3). II 4). 5). Lastly, involve multiple ruptures, single involvement muscle collateral ligaments.Figure 3Grade manifested strain (triangle).View (PPT)Figure 4Grade pulley.View 5Grade pulley. result seen, illustrated resulting tendon-to-bone (∗) (compare 1).View (PPT)In summary, injured. affected. position, particularly loading, position.Evaluation InjuryClimbers who sustained hearing “pop” grasping hold. commonly, there onset pain swelling affected possible numbness local hematoma formation. Many disregard discomfort continue weeks, chronic digits.9Rohrbough ScholarIn 2006 systematic review, diagnostic criterion 29 papers “bowstringing” joint physical examination.46El-Sheikh Wong Farrokhyar Thoma Diagnosis review.Can Plast Surg. 227-231Crossref diagnostic, does characterize extent If it only finding, allow prognostic determination. Furthermore, infallible sign; some severe demonstrate clinically detectable bo