Dorsal web injection technique in the treatment of trigger finger and trigger thumb. Anatomical study | Revista Española de Cirugía Ortopédica y Traumatología (English Edition)

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There is meniscal intrasubstance deterioration but no rupture." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Chico-Carpizo, S. Arauz de Robles, J. Alonso-Hernández" "autores" => array:3 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Chico-Carpizo" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Arauz de Robles" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Alonso-Hernández" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1988885620300638?idApp=UINPBA00004N" "url" => "/19888856/0000006400000005/v1_202009220644/S1988885620300638/v1_202009220644/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "Dorsal web injection technique in the treatment of trigger finger and trigger thumb. 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Estudio anatómico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 861 "Ancho" => 855 "Tamanyo" => 155738 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Injection through the dorsal web performed in each finger keeping the metacarpophalangeal joint slightly flexed and directing the needle towards the metacarpal head at a 45° angle to the finger axis." ] ] ] "textoCompleto" => "IntroductionDigital flexor tendon stenosing tenosynovitis, spring finger or trigger finger, is one of the most common causes of pain and disability in the hand, affecting 2.6% of non-diabetic adults and up to 10% of patients with insulin-dependent diabetes mellitus.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>The goal of treatment is to restore smooth and painless sliding of the tendons by achieving full range of motion of the affected finger.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Most trigger fingers can be treated non-surgically by corticosteroid infiltration, with a success rate varying from 45% to 92% according to the number of injections,<a class="elsevierStyleCrossRefs" href="#bib0020">4–7</a> and a low complication rate.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>Different techniques have been described for infiltration, but palmar injection over the metacarpal head is the most commonly used.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> As an alternative to the palmar technique, a mid-axial injection technique has been published at the level of the proximal phalanx, obtaining similar clinical results.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> The main side effect of these techniques is the pain perceived by the patient since palmar skin has a high density of sensory receptors.<a class="elsevierStyleCrossRefs" href="#bib0030">6,11</a> On the other hand, a paper has previously been published describing an injection technique into the synovial sheath and through the dorsal skin with similar effectiveness to that described for other techniques.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Some studies have shown that infiltration deposited outside the synovial sheath, at a subcutaneous level, is as effective as intra-sheath injection and also reduces the risk of tendon damage, and therefore it would not be necessary to locate the infiltration inside the tendon sheath.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a>This is an anatomical cadaver study to assess whether extra-synovial or subcutaneous injection through the dorsal web is safe in the treatment of trigger thumb and finger. The purpose of the paper was to quantify the risk of injury to a major anatomical structure (nerve or artery) during dorsal infiltration and to establish the safest route (radial or ulnar) for the middle and ring fingers.Material and methodSixteen cadaverous upper extremities were used, 10 female and 6 male, all white Caucasians. The mean age was 81 years (range, 70–96). The specimens had no history of trauma, surgery, or regional pathology that would affect the results obtained in the study.One of the investigators performed an infiltration through the dorsal web in each finger using a 2 ml syringe (BD Discardit™ II, Becton Dickinson S.A., Spain) and a 25 G needle (SurGuard2, Terumo®, Terumo Medical Corporation, U.S.A.) as they would in their usual clinical practice. The needle path was fixed using an instantaneous adhesive (La Gotita® 2 ml, Fenedur S.A., Montevideo, Uruguay) to prevent a change in its tract during manipulation of the limb.A dorsal ulnar injection was performed in each thumb at the level of the metacarpophalangeal joint keeping the thumb in maximum abduction and directing the needle towards the subcutaneous cellular tissue at the level of the first metacarpal head at a 90° angle to the thumb axis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). For each middle finger, the puncture was performed by keeping the metacarpophalangeal joint slightly flexed (approximately 30°) and directing the needle towards the subcutaneous cell tissue at the head of the metacarpal at a 45° angle to the finger axis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). One ulnar dorsal injection was performed in each index finger, one ulnar dorsal and one radial dorsal injection in each middle and ring finger, and one radial dorsal injection in each little finger.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The technique was not performed from the radial side of the thumb or from the ulnar side of the little finger because it is not a digital commissure. In the case of the index finger, the puncture was not made from the radial side (first commissure) because being a wider and deeper commissure, we considered it would be more difficult for the investigator to orientate the needle during infiltration.In order to evaluate the exact location of the needle, the palmar skin was carefully resected using 4.5× optical magnifying glasses. In the thumb, a rectangle of skin was resected exposing the entire A1 pulley and the radial and ulnar digital neurovascular bundle. In the middle fingers, a skin area between the mid-palmar crease and the digital palmar crease was resected exposing the A1 pulley and the commissural and digital neurovascular bundle. The resected skin area was arbitrarily selected as it was considered sufficient to expose the anatomical structures at risk but without noticeably modifying the original anatomy.A major injury was defined as one which, if it occurred in vivo, could have clinical impact such as a nerve or arterial injury. We also recorded other injuries that would have little or no clinical impact if they occurred in vivo, such as puncture of the flexor tendon, pulley or the intrinsic musculature.To estimate the risk of injury, the distance between the closest point of the needle to the adjacent anatomical structure was measured in millimetres using a digital calibrator (Tacklife DC02® Mitutoyo, resolution of .01 mm and accuracy of ±.03 mm, Kanagawa, Japan). Two of the investigators measured each infiltration on 3 occasions (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The Kolmogorov-Smirnov test was used to check the normality of the data. The degree of agreement of the measurements made by each investigator was checked by calculating the intraclass correlation coefficient. The result for the first investigator was .9984 (95% confidence interval [CI95%] .9978–.9989) and for the second investigator .9992 (95% CI .9989–.9995), concluding that intra-observer agreement was excellent.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> The mean of the measurements of each investigator was taken and the degree of inter-observer agreement was assessed using the Lin concordance correlation coefficient, obtaining an excellent degree of agreement (.9991 with 95% CI .9987–.9994), and therefore the mean of the measurements was taken as the final measure in each puncture.The risk of neurovascular injury was considered high when the mean distance between the needle and any of the neurovascular bundles was less than 1 mm.All data were analysed using Microsoft Excel 2011 (for Mac, version 14.6.0 2010 © Microsoft Corporation, U.S.A.), StatPlus (for Mac, version V6 2016©, AnalystSoft Inc., U.S.A.) and R Core Team 2019 (version 3.6.2; Bell Laboratories, U.S.A.).ResultsThe mean distance between the needle and the nearest point of one of the neurovascular bundles was 1.77 mm (95% CI 1.56–1.98). Two injuries were observed in 112 infiltrations (1.78%). In addition, 16 minor injuries were seen (14.28%) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The results obtained in each finger are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Thumb: the mean distance between the needle and the neurovascular bundle was 3.13 mm (95% CI 2.44–3.83). No neurovascular injuries were identified. The flexor pollicis longus sheath was punctured in 11 out of 16 infiltrations (68.7%).</li><li class="elsevierStyleListItem" id="lsti0010">•Index: the mean distance between the needle and neurovascular bundle was 1.61 mm (95% CI 1.09–2.13). A neurovascular injury, a digital nerve, occurred (6.25% of the injections). No other injuries were identified.</li><li class="elsevierStyleListItem" id="lsti0015">•Middle finger: the mean distance between the needle and neurovascular bundle was 1.68 mm (95%CI 1.43–1.94). The distance from dorsal-ulnar was 1.83 mm (95%CI 1.51–2.15) and from dorsal-radial was 1.54 mm (95% CI 1.16–1.92). No neurovascular injuries were identified. Puncture to the interosseous musculature was identified in 2 cases and to the A1 pulley in one case (9.37% of the infiltrations), all from dorsal-radial.</li><li class="elsevierStyleListItem" id="lsti0020">•Ring finger: the mean distance between the needle and neurovascular bundle was 1.28 mm (95% CI 1.05–1.51). The distance from dorsal-ulnar was 1.13 mm (95% CI .83–1.41) and from dorsal-radial was 1.43 mm (95% CI 1.08–1.79). A neurovascular injury was identified, a digital artery from dorsal-ulnar (3.12% of injections). The A1 pulley was also punctured in one case (3.12%).</li><li class="elsevierStyleListItem" id="lsti0025">•Little finger: mean distance was 1.72 mm (95% CI 1.08–2.37). No neurovascular injuries were identified. The flexor tendon sheath was injured in one case (6.25% of infiltrations).</li></ul><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DiscussionAccording to the results obtained, the average distance between the closest neurovascular bundle and the needle was more than 1 mm in all the fingers. The digit where the infiltration was most safe was the thumb with a mean distance of more than 3 mm, while the injection was less safe in the ring finger with a mean distance between the needle and neurovascular bundle of 1.28 mm.Two injuries were observed in 112 injections, one in the index finger (digital nerve) and one in the ring finger (digital artery), both in the same hand of the same specimen. We believe that feedback with the patient during infiltration in clinical practice could help to prevent these injuries, as the patient may feel discomfort when the needle is near the neurovascular bundle and this would allow us to slightly modify the needle tract. This should be evaluated in a clinical research study.In the middle finger, the 3 minor injuries occurred when infiltration was performed from dorsal-radial, and therefore we could recommend the dorsal-ulnar injection technique for this finger. In the ring finger, an artery was injured during an infiltration from dorsal-ulnar, and therefore we could recommend the dorsal-radial injection technique for this finger.Corticosteroid infiltration is an effective and efficient treatment for flexor tendon stenosing tenosynovitis,<a class="elsevierStyleCrossRefs" href="#bib0020">4,8,16</a> but pain during injection is an ever-present side effect.Ten percent of patients are very afraid of infiltration, and needle phobia, characterised by an intense and persistent fear of injections, affects approximately 2% of the general population.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Anaesthetic creams, cooling sprays, lidocaine spray, or verbal distraction have been used to reduce the pain and anxiety associated with infiltrations. Vibratory stimulation concomitant with the puncture has also recently proved ineffective in reducing the pain associated with trigger finger infiltrations.<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a>According to several authors, palmar skin has a greater density of sensory receptors than dorsal skin, making it more sensitive to infiltration through it.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9,11,20</a>,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> The visual analogue pain score (0–100) during infiltration of a trigger finger through volar skin is 53 points, although there are few studies published in the literature.<a class="elsevierStyleCrossRefs" href="#bib0045">9,17,18,22</a>This statement has recently been questioned in some studies publishing that the pain perceived when performing a digital anaesthetic block through palmar skin is no greater than through dorsal skin. There is no consensus on the optimal technique.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a>Some studies have shown that corticoid infiltration into the synovial sheath of the flexor tendons is not necessary, with similar results obtained with subcutaneous injection performed using the palmar technique.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> We believe that an infiltration deposited outside the tendon sheath and performed through the dorsal web could be an equally effective but less painful alternative to classic palmar infiltration in the treatment of flexor tendon stenosing tenosynovitis, although this should be evaluated in a clinical study.This study has some limitations. The number of specimens was relatively low and, being an anatomical study, it has the usual limitations of this type of study. The sample has low variability (all the specimens were elderly and all were white) and, depending on the preservation and age of the specimen, the extremities could have had some anatomical abnormality such as atrophy of the intrinsic musculature.A single investigator carried out all the infiltrations while two different investigators, belonging to the same team, carried out the measurements. Despite checking the adequate intra- and interobserver agreement of the different measurements, this aspect could be perceived as a bias.It would be advisable to replicate the study in different populations (countries, continents, ethnic groups) in order to check whether or not similar results are obtained in terms of measurements and thus assess their external validity.Based on the results obtained, we consider that subcutaneous corticoid infiltration near the flexor tendon sheath using a technique through the dorsal skin can be performed with a low but present risk of neurovascular injury. This technique could be used in the treatment of trigger thumb and finger, although this must be corroborated in a clinical study.Level of evidenceLevel of evidence V.FundingThis research study was funded by the Foundation of the Medical Association of Las Palmas (Grant: XXIV Edition R+E Grants - 2019).Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1388599" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1274078" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1388600" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1274079" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:2 [ "identificador" => "xack482873" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-12-05" "fechaAceptado" => "2020-02-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1274078" "palabras" => array:5 [ 0 => "Anatomy" 1 => "Injection" 2 => "Trigger finger" 3 => "Trigger thumb" 4 => "Flexor tendon" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1274079" "palabras" => array:5 [ 0 => "Anatomía" 1 => "Infiltración" 2 => "Dedo en resorte" 3 => "Pulgar en resorte" 4 => "Tendón flexor" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundCorticosteroid injection is an effective treatment for trigger digits but the pain during the injection is an ever-present side effect. Since the palmar skin has a high density of sensitive receptors, injecting through dorsal skin could be less painful. Our aim was to assess whether a dorsal technique through the dorsal web is safe for extra-sheath injection of trigger fingers and thumb. Material and methodThis is an anatomical study in sixteen cadaveric hands. An injection through the dorsal web was performed on each digit. After careful resection of the palmar skin, the distance between the needle and the main anatomical structures was measured. The risk of major injury was considered high when the mean distance from the needle to the neurovascular bundle was below one millimeter. ResultsThe mean distance from the needle to the neurovascular bundle was 1.77 mm. Two neurovascular injuries in 112 injections were observed, one nerve and one artery. The safest digit was the thumb while the most dangerous was the index finger. At the ring finger, the technique was safer when it was carried out from the dorso-radial. ConclusionsA subcutaneous injection near the flexor tendon sheath can be carried out through the dorsal web with a low, but present, risk of neurovascular injury. It could be useful for injection in the treatment of trigger finger and trigger thumb but it should be assessed in a clinical study." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes y objetivoLa infiltración corticoidea es efectiva en el tratamiento de los dedos en resorte aunque el dolor percibido por el paciente durante la inyección es un efecto secundario siempre presente. La piel dorsal tiene una menor densidad de receptores nociceptivos por lo que la infiltración desde el dorso podría ser menos dolorosa. El objetivo de este trabajo fue evaluar si una técnica de infiltración a través de la piel dorsal es segura en el tratamiento de esta patología. Material y métodoEstudio anatómico en 16 manos de cadáver. Se realizó una infiltración a través de la piel dorsal de la comisura digital en cada dedo. Se resecó la piel palmar y se midió la distancia entre la aguja y las principales estructuras anatómicas. El riesgo de lesión iatrogénica se consideró alto cuando la distancia media entre la aguja y alguna estructura neurovascular fue inferior a un milímetro. ResultadosLa distancia media desde la aguja hasta la estructura neurovascular más cercana fue 1,77 milímetros. Se observaron dos lesiones iatrogénicas en 112 inyecciones, un nervio y una arteria. El dedo más seguro fue el pulgar y el menos seguro fue el índice. En el dedo anular, la técnica fue más segura cuando se realizó desde el lado dorso-radial. ConclusionesLa técnica de infiltración a través de la piel dorsal de la comisura digital puede realizarse con un riesgo de lesión iatrogénica bajo aunque presente. Esta técnica podría utilizarse en el tratamiento del pulgar y de los dedos en resorte aunque esto debe corroborarse en un estudio clínico." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Jiménez I, Garcés GL, Caballero-Martel J, Medina J. Infiltración comisural dorsal en el tratamiento del pulgar y los dedos en resorte. Estudio anatómico. Rev Esp Cir Ortop Traumatol. 2020. https://doi.org/10.1016/j.recot.2020.02.002" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 743 "Ancho" => 855 "Tamanyo" => 120265 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Dorsal ulnar injection performed in each thumb at the metacarpophalangeal joint keeping the thumb in maximum abduction, directing the needle towards the subcutaneous cellular tissue at the level of the first metacarpal head at a 90° angle to the thumb axis." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 861 "Ancho" => 855 "Tamanyo" => 155738 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Injection through the dorsal web performed in each finger keeping the metacarpophalangeal joint slightly flexed and directing the needle towards the metacarpal head at a 45° angle to the finger axis." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 785 "Ancho" => 855 "Tamanyo" => 114601 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Distance between the needle and the radial digital nerve of the middle finger measured in millimetres using a digital gauge." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 541 "Ancho" => 855 "Tamanyo" => 114318 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Specimen number 5. Two lesions were identified: ulnar digital nerve of the index finger and radial digital artery of the ring finger." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SD: standard deviation; FPL: flexor pollicis longus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Finger \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Injections \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Technique \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean distance to nerve or artery (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Minimum distance to nerve or artery (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Maximum distance to nerve or artery (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Injured structures \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thumb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dorsal-ulnar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.13 (SD = 1.41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FPL sheath in 11 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dorsal-ulnar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.61 (SD = 1.07) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 nerve \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Middle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.68 (SD = .72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dorsal-ulnar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.83 (SD = .65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dorsal-radial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.54 (SD = .78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 interosseous cases and 1 A1 pulley \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ring \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.28 (SD = .67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dorsal-ulnar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.13 (SD = .58) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 artery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dorsal-radial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.24 (SD = .71) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 A1 pulley \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Little \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dorsal-radial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.72 (SD = 1.31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 tendon sheath \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">112 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,77 (SD = 1.13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 neurovascular injuries (1.75%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2383918.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results observed in each finger." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trigger digits: principles, management, and complications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. 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Original Article

Dorsal web injection technique in the treatment of trigger finger and trigger thumb. Anatomical study

Infiltración comisural dorsal en el tratamiento del pulgar y los dedos en resorte. Estudio anatómico

I. Jiméneza,b,

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isidro_jimenez@hotmail.com

Corresponding author.

, G.L. Garcésb,c, J. Caballero-Martela, J. Medinaa,b

a Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain

b Departamento de Ciencias Médicas y Quirúrgicas, Facultad de Medicina, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain

c Departamento de Cirugía Ortopédica y Traumatología, Hospital Perpetuo Socorro, Las Palmas de Gran Canaria, Spain

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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Injection through the dorsal web performed in each finger keeping the metacarpophalangeal joint slightly flexed and directing the needle towards the metacarpal head at a 45&#176; angle to the finger axis&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Digital flexor tendon stenosing tenosynovitis&#44; spring finger or trigger finger&#44; is one of the most common causes of pain and disability in the hand&#44; affecting 2&#46;6&#37; of non-diabetic adults and up to 10&#37; of patients with insulin-dependent diabetes mellitus&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The goal of treatment is to restore smooth and painless sliding of the tendons by achieving full range of motion of the affected finger&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Most trigger fingers can be treated non-surgically by corticosteroid infiltration&#44; with a success rate varying from 45&#37; to 92&#37; according to the number of injections&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> and a low complication rate&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Different techniques have been described for infiltration&#44; but palmar injection over the metacarpal head is the most commonly used&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> As an alternative to the palmar technique&#44; a mid-axial injection technique has been published at the level of the proximal phalanx&#44; obtaining similar clinical results&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> The main side effect of these techniques is the pain perceived by the patient since palmar skin has a high density of sensory receptors&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;11</span></a> On the other hand&#44; a paper has previously been published describing an injection technique into the synovial sheath and through the dorsal skin with similar effectiveness to that described for other techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Some studies have shown that infiltration deposited outside the synovial sheath&#44; at a subcutaneous level&#44; is as effective as intra-sheath injection and also reduces the risk of tendon damage&#44; and therefore it would not be necessary to locate the infiltration inside the tendon sheath&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This is an anatomical cadaver study to assess whether extra-synovial or subcutaneous injection through the dorsal web is safe in the treatment of trigger thumb and finger&#46; The purpose of the paper was to quantify the risk of injury to a major anatomical structure &#40;nerve or artery&#41; during dorsal infiltration and to establish the safest route &#40;radial or ulnar&#41; for the middle and ring fingers&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0030" class="elsevierStylePara elsevierViewall">Sixteen cadaverous upper extremities were used&#44; 10 female and 6 male&#44; all white Caucasians&#46; The mean age was 81 years &#40;range&#44; 70&#8211;96&#41;&#46; The specimens had no history of trauma&#44; surgery&#44; or regional pathology that would affect the results obtained in the study&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">One of the investigators performed an infiltration through the dorsal web in each finger using a 2&#8239;ml syringe &#40;BD Discardit&#8482; II&#44; Becton Dickinson S&#46;A&#46;&#44; Spain&#41; and a 25&#8239;G needle &#40;SurGuard2&#44; Terumo&#174;&#44; Terumo Medical Corporation&#44; U&#46;S&#46;A&#46;&#41; as they would in their usual clinical practice&#46; The needle path was fixed using an instantaneous adhesive &#40;La Gotita&#174; 2&#8239;ml&#44; Fenedur S&#46;A&#46;&#44; Montevideo&#44; Uruguay&#41; to prevent a change in its tract during manipulation of the limb&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A dorsal ulnar injection was performed in each thumb at the level of the metacarpophalangeal joint keeping the thumb in maximum abduction and directing the needle towards the subcutaneous cellular tissue at the level of the first metacarpal head at a 90&#176; angle to the thumb axis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; For each middle finger&#44; the puncture was performed by keeping the metacarpophalangeal joint slightly flexed &#40;approximately 30&#176;&#41; and directing the needle towards the subcutaneous cell tissue at the head of the metacarpal at a 45&#176; angle to the finger axis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; One ulnar dorsal injection was performed in each index finger&#44; one ulnar dorsal and one radial dorsal injection in each middle and ring finger&#44; and one radial dorsal injection in each little finger&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The technique was not performed from the radial side of the thumb or from the ulnar side of the little finger because it is not a digital commissure&#46; In the case of the index finger&#44; the puncture was not made from the radial side &#40;first commissure&#41; because being a wider and deeper commissure&#44; we considered it would be more difficult for the investigator to orientate the needle during infiltration&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In order to evaluate the exact location of the needle&#44; the palmar skin was carefully resected using 4&#46;5&#215; optical magnifying glasses&#46; In the thumb&#44; a rectangle of skin was resected exposing the entire A1 pulley and the radial and ulnar digital neurovascular bundle&#46; In the middle fingers&#44; a skin area between the mid-palmar crease and the digital palmar crease was resected exposing the A1 pulley and the commissural and digital neurovascular bundle&#46; The resected skin area was arbitrarily selected as it was considered sufficient to expose the anatomical structures at risk but without noticeably modifying the original anatomy&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A major injury was defined as one which&#44; if it occurred in vivo&#44; could have clinical impact such as a nerve or arterial injury&#46; We also recorded other injuries that would have little or no clinical impact if they occurred in vivo&#44; such as puncture of the flexor tendon&#44; pulley or the intrinsic musculature&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To estimate the risk of injury&#44; the distance between the closest point of the needle to the adjacent anatomical structure was measured in millimetres using a digital calibrator &#40;Tacklife DC02&#174; Mitutoyo&#44; resolution of &#46;01&#8239;mm and accuracy of &#177;&#46;03&#8239;mm&#44; Kanagawa&#44; Japan&#41;&#46; Two of the investigators measured each infiltration on 3 occasions &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The Kolmogorov-Smirnov test was used to check the normality of the data&#46; The degree of agreement of the measurements made by each investigator was checked by calculating the intraclass correlation coefficient&#46; The result for the first investigator was &#46;9984 &#40;95&#37; confidence interval &#91;CI95&#37;&#93; &#46;9978&#8211;&#46;9989&#41; and for the second investigator &#46;9992 &#40;95&#37; CI &#46;9989&#8211;&#46;9995&#41;&#44; concluding that intra-observer agreement was excellent&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The mean of the measurements of each investigator was taken and the degree of inter-observer agreement was assessed using the Lin concordance correlation coefficient&#44; obtaining an excellent degree of agreement &#40;&#46;9991 with 95&#37; CI &#46;9987&#8211;&#46;9994&#41;&#44; and therefore the mean of the measurements was taken as the final measure in each puncture&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The risk of neurovascular injury was considered high when the mean distance between the needle and any of the neurovascular bundles was less than 1&#8239;mm&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All data were analysed using Microsoft Excel 2011 &#40;for Mac&#44; version 14&#46;6&#46;0 2010 &#169; Microsoft Corporation&#44; U&#46;S&#46;A&#46;&#41;&#44; StatPlus &#40;for Mac&#44; version V6 2016&#169;&#44; AnalystSoft Inc&#46;&#44; U&#46;S&#46;A&#46;&#41; and R Core Team 2019 &#40;version 3&#46;6&#46;2&#59; Bell Laboratories&#44; U&#46;S&#46;A&#46;&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">The mean distance between the needle and the nearest point of one of the neurovascular bundles was 1&#46;77&#8239;mm &#40;95&#37; CI 1&#46;56&#8211;1&#46;98&#41;&#46; Two injuries were observed in 112 infiltrations &#40;1&#46;78&#37;&#41;&#46; In addition&#44; 16 minor injuries were seen &#40;14&#46;28&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The results obtained in each finger are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Thumb&#58; the mean distance between the needle and the neurovascular bundle was 3&#46;13&#8239;mm &#40;95&#37; CI 2&#46;44&#8211;3&#46;83&#41;&#46; No neurovascular injuries were identified&#46; The flexor pollicis longus sheath was punctured in 11 out of 16 infiltrations &#40;68&#46;7&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Index&#58; the mean distance between the needle and neurovascular bundle was 1&#46;61&#8239;mm &#40;95&#37; CI 1&#46;09&#8211;2&#46;13&#41;&#46; A neurovascular injury&#44; a digital nerve&#44; occurred &#40;6&#46;25&#37; of the injections&#41;&#46; No other injuries were identified&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Middle finger&#58; the mean distance between the needle and neurovascular bundle was 1&#46;68&#8239;mm &#40;95&#37;CI 1&#46;43&#8211;1&#46;94&#41;&#46; The distance from dorsal-ulnar was 1&#46;83&#8239;mm &#40;95&#37;CI 1&#46;51&#8211;2&#46;15&#41; and from dorsal-radial was 1&#46;54&#8239;mm &#40;95&#37; CI 1&#46;16&#8211;1&#46;92&#41;&#46; No neurovascular injuries were identified&#46; Puncture to the interosseous musculature was identified in 2 cases and to the A1 pulley in one case &#40;9&#46;37&#37; of the infiltrations&#41;&#44; all from dorsal-radial&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Ring finger&#58; the mean distance between the needle and neurovascular bundle was 1&#46;28&#8239;mm &#40;95&#37; CI 1&#46;05&#8211;1&#46;51&#41;&#46; The distance from dorsal-ulnar was 1&#46;13&#8239;mm &#40;95&#37; CI &#46;83&#8211;1&#46;41&#41; and from dorsal-radial was 1&#46;43&#8239;mm &#40;95&#37; CI 1&#46;08&#8211;1&#46;79&#41;&#46; A neurovascular injury was identified&#44; a digital artery from dorsal-ulnar &#40;3&#46;12&#37; of injections&#41;&#46; The A1 pulley was also punctured in one case &#40;3&#46;12&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Little finger&#58; mean distance was 1&#46;72&#8239;mm &#40;95&#37; CI 1&#46;08&#8211;2&#46;37&#41;&#46; No neurovascular injuries were identified&#46; The flexor tendon sheath was injured in one case &#40;6&#46;25&#37; of infiltrations&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">According to the results obtained&#44; the average distance between the closest neurovascular bundle and the needle was more than 1&#8239;mm in all the fingers&#46; The digit where the infiltration was most safe was the thumb with a mean distance of more than 3&#8239;mm&#44; while the injection was less safe in the ring finger with a mean distance between the needle and neurovascular bundle of 1&#46;28&#8239;mm&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Two injuries were observed in 112 injections&#44; one in the index finger &#40;digital nerve&#41; and one in the ring finger &#40;digital artery&#41;&#44; both in the same hand of the same specimen&#46; We believe that feedback with the patient during infiltration in clinical practice could help to prevent these injuries&#44; as the patient may feel discomfort when the needle is near the neurovascular bundle and this would allow us to slightly modify the needle tract&#46; This should be evaluated in a clinical research study&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the middle finger&#44; the 3 minor injuries occurred when infiltration was performed from dorsal-radial&#44; and therefore we could recommend the dorsal-ulnar injection technique for this finger&#46; In the ring finger&#44; an artery was injured during an infiltration from dorsal-ulnar&#44; and therefore we could recommend the dorsal-radial injection technique for this finger&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Corticosteroid infiltration is an effective and efficient treatment for flexor tendon stenosing tenosynovitis&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8&#44;16</span></a> but pain during injection is an ever-present side effect&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Ten percent of patients are very afraid of infiltration&#44; and needle phobia&#44; characterised by an intense and persistent fear of injections&#44; affects approximately 2&#37; of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Anaesthetic creams&#44; cooling sprays&#44; lidocaine spray&#44; or verbal distraction have been used to reduce the pain and anxiety associated with infiltrations&#46; Vibratory stimulation concomitant with the puncture has also recently proved ineffective in reducing the pain associated with trigger finger infiltrations&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">According to several authors&#44; palmar skin has a greater density of sensory receptors than dorsal skin&#44; making it more sensitive to infiltration through it&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;11&#44;20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The visual analogue pain score &#40;0&#8211;100&#41; during infiltration of a trigger finger through volar skin is 53 points&#44; although there are few studies published in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;17&#44;18&#44;22</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">This statement has recently been questioned in some studies publishing that the pain perceived when performing a digital anaesthetic block through palmar skin is no greater than through dorsal skin&#46; There is no consensus on the optimal technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Some studies have shown that corticoid infiltration into the synovial sheath of the flexor tendons is not necessary&#44; with similar results obtained with subcutaneous injection performed using the palmar technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> We believe that an infiltration deposited outside the tendon sheath and performed through the dorsal web could be an equally effective but less painful alternative to classic palmar infiltration in the treatment of flexor tendon stenosing tenosynovitis&#44; although this should be evaluated in a clinical study&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; The number of specimens was relatively low and&#44; being an anatomical study&#44; it has the usual limitations of this type of study&#46; The sample has low variability &#40;all the specimens were elderly and all were white&#41; and&#44; depending on the preservation and age of the specimen&#44; the extremities could have had some anatomical abnormality such as atrophy of the intrinsic musculature&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">A single investigator carried out all the infiltrations while two different investigators&#44; belonging to the same team&#44; carried out the measurements&#46; Despite checking the adequate intra- and interobserver agreement of the different measurements&#44; this aspect could be perceived as a bias&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">It would be advisable to replicate the study in different populations &#40;countries&#44; continents&#44; ethnic groups&#41; in order to check whether or not similar results are obtained in terms of measurements and thus assess their external validity&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Based on the results obtained&#44; we consider that subcutaneous corticoid infiltration near the flexor tendon sheath using a technique through the dorsal skin can be performed with a low but present risk of neurovascular injury&#46; This technique could be used in the treatment of trigger thumb and finger&#44; although this must be corroborated in a clinical study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0170" class="elsevierStylePara elsevierViewall">Level of evidence V&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">This research study was funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Foundation of the Medical Association of Las Palmas</span> &#40;Grant&#58; XXIV Edition R&#43;E Grants - 2019&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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              "titulo" => "Antecedentes y objetivo"
            ]
            1 => array:2 [
              "identificador" => "abst0030"
              "titulo" => "Material y m&#233;todo"
            ]
            2 => array:2 [
              "identificador" => "abst0035"
              "titulo" => "Resultados"
            ]
            3 => array:2 [
              "identificador" => "abst0040"
              "titulo" => "Conclusiones"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1274079"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Material and method"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Level of evidence"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Funding"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conflict of interests"
        ]
        11 => array:2 [
          "identificador" => "xack482873"
          "titulo" => "Acknowledgements"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2019-12-05"
    "fechaAceptado" => "2020-02-07"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1274078"
          "palabras" => array:5 [
            0 => "Anatomy"
            1 => "Injection"
            2 => "Trigger finger"
            3 => "Trigger thumb"
            4 => "Flexor tendon"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1274079"
          "palabras" => array:5 [
            0 => "Anatom&#237;a"
            1 => "Infiltraci&#243;n"
            2 => "Dedo en resorte"
            3 => "Pulgar en resorte"
            4 => "Tend&#243;n flexor"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Corticosteroid injection is an effective treatment for trigger digits but the pain during the injection is an ever-present side effect&#46; Since the palmar skin has a high density of sensitive receptors&#44; injecting through dorsal skin could be less painful&#46; Our aim was to assess whether a dorsal technique through the dorsal web is safe for extra-sheath injection of trigger fingers and thumb&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This is an anatomical study in sixteen cadaveric hands&#46; An injection through the dorsal web was performed on each digit&#46; After careful resection of the palmar skin&#44; the distance between the needle and the main anatomical structures was measured&#46; The risk of major injury was considered high when the mean distance from the needle to the neurovascular bundle was below one millimeter&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The mean distance from the needle to the neurovascular bundle was 1&#46;77&#8239;mm&#46; Two neurovascular injuries in 112 injections were observed&#44; one nerve and one artery&#46; The safest digit was the thumb while the most dangerous was the index finger&#46; At the ring finger&#44; the technique was safer when it was carried out from the dorso-radial&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A subcutaneous injection near the flexor tendon sheath can be carried out through the dorsal web with a low&#44; but present&#44; risk of neurovascular injury&#46; It could be useful for injection in the treatment of trigger finger and trigger thumb but it should be assessed in a clinical study&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and method"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La infiltraci&#243;n corticoidea es efectiva en el tratamiento de los dedos en resorte aunque el dolor percibido por el paciente durante la inyecci&#243;n es un efecto secundario siempre presente&#46; La piel dorsal tiene una menor densidad de receptores nociceptivos por lo que la infiltraci&#243;n desde el dorso podr&#237;a ser menos dolorosa&#46; El objetivo de este trabajo fue evaluar si una t&#233;cnica de infiltraci&#243;n a trav&#233;s de la piel dorsal es segura en el tratamiento de esta patolog&#237;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Estudio anat&#243;mico en 16 manos de cad&#225;ver&#46; Se realiz&#243; una infiltraci&#243;n a trav&#233;s de la piel dorsal de la comisura digital en cada dedo&#46; Se resec&#243; la piel palmar y se midi&#243; la distancia entre la aguja y las principales estructuras anat&#243;micas&#46; El riesgo de lesi&#243;n iatrog&#233;nica se consider&#243; alto cuando la distancia media entre la aguja y alguna estructura neurovascular fue inferior a un mil&#237;metro&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La distancia media desde la aguja hasta la estructura neurovascular m&#225;s cercana fue 1&#44;77 mil&#237;metros&#46; Se observaron dos lesiones iatrog&#233;nicas en 112 inyecciones&#44; un nervio y una arteria&#46; El dedo m&#225;s seguro fue el pulgar y el menos seguro fue el &#237;ndice&#46; En el dedo anular&#44; la t&#233;cnica fue m&#225;s segura cuando se realiz&#243; desde el lado dorso-radial&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La t&#233;cnica de infiltraci&#243;n a trav&#233;s de la piel dorsal de la comisura digital puede realizarse con un riesgo de lesi&#243;n iatrog&#233;nica bajo aunque presente&#46; Esta t&#233;cnica podr&#237;a utilizarse en el tratamiento del pulgar y de los dedos en resorte aunque esto debe corroborarse en un estudio cl&#237;nico&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Jim&#233;nez I&#44; Garc&#233;s GL&#44; Caballero-Martel J&#44; Medina J&#46; Infiltraci&#243;n comisural dorsal en el tratamiento del pulgar y los dedos en resorte&#46; Estudio anat&#243;mico&#46; Rev Esp Cir Ortop Traumatol&#46; 2020&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.recot.2020.02.002">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;recot&#46;2020&#46;02&#46;002</span></p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 743
            "Ancho" => 855
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dorsal ulnar injection performed in each thumb at the metacarpophalangeal joint keeping the thumb in maximum abduction&#44; directing the needle towards the subcutaneous cellular tissue at the level of the first metacarpal head at a 90&#176; angle to the thumb axis&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 861
            "Ancho" => 855
            "Tamanyo" => 155738
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Injection through the dorsal web performed in each finger keeping the metacarpophalangeal joint slightly flexed and directing the needle towards the metacarpal head at a 45&#176; angle to the finger axis&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 785
            "Ancho" => 855
            "Tamanyo" => 114601
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Distance between the needle and the radial digital nerve of the middle finger measured in millimetres using a digital gauge&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 541
            "Ancho" => 855
            "Tamanyo" => 114318
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Specimen number 5&#46; Two lesions were identified&#58; ulnar digital nerve of the index finger and radial digital artery of the ring finger&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; FPL&#58; <span class="elsevierStyleItalic">flexor pollicis longus</span>&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Finger&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Injections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean distance to nerve or artery &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Minimum distance to nerve or artery &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Maximum distance to nerve or artery &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Injured structures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thumb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dorsal-ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;13 &#40;SD&#8239;&#61;&#8239;1&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FPL sheath in 11 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dorsal-ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;61 &#40;SD&#8239;&#61;&#8239;1&#46;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 nerve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Middle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;68 &#40;SD&#8239;&#61;&#8239;&#46;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dorsal-ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;83 &#40;SD&#8239;&#61;&#8239;&#46;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Dorsal-radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;54 &#40;SD&#8239;&#61;&#8239;&#46;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 interosseous cases and 1 A1 pulley&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;28 &#40;SD&#8239;&#61;&#8239;&#46;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dorsal-ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;13 &#40;SD&#8239;&#61;&#8239;&#46;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 artery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dorsal-radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;24 &#40;SD&#8239;&#61;&#8239;&#46;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 A1 pulley&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Little&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dorsal-radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;72 &#40;SD&#8239;&#61;&#8239;1&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 tendon sheath&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;77 &#40;SD&#8239;&#61;&#8239;1&#46;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 neurovascular injuries &#40;1&#46;75&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Results observed in each finger&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "Trigger digits&#58; principles&#44; management&#44; and complications"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Ryzewicz"
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                    0 => array:2 [
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                    0 => array:2 [
                      "doi" => "10.2106/JBJS.N.00004"
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                      "titulo" => "Recherches sur une affection particuli&#232;re des gaines tendineuses de la main&#44; caract&#233;ris&#233; par le d&#233;veloppement d&#8217;une nodosit&#233; sur le trajet des tendons fl&#233;chisseurs des doigts et par l&#8217;emp&#234;chement de leurs mouvements"
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                          "etal" => false
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Article information

ISSN: 19888856
Original language: English

DOI:10.1016/j.recote.2020.07.002

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2023 November	176	8	184
2023 October	165	9	174
2023 September	91	7	98
2023 August	68	5	73
2023 July	90	22	112
2023 June	85	20	105
2023 May	152	41	193
2023 April	141	19	160
2023 March	126	18	144
2023 February	103	10	113
2023 January	102	20	122
2022 December	86	17	103
2022 November	93	31	124
2022 October	88	30	118
2022 September	82	29	111
2022 August	85	20	105
2022 July	54	14	68
2022 June	55	18	73
2022 May	53	11	64
2022 April	68	14	82
2022 March	79	13	92
2022 February	83	9	92
2022 January	94	8	102
2021 December	86	12	98
2021 November	73	10	83
2021 October	91	8	99
2021 September	86	11	97
2021 August	83	2	85
2021 July	73	8	81
2021 June	47	6	53
2021 May	58	5	63
2021 April	53	9	62
2021 March	25	8	33
2021 February	18	8	26
2021 January	9	4	13
2020 December	2	0	2
2020 November	1	2	3

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