Temporary threshold shift after noise exposure in hypobaric hypoxia at high altitude: results of the ADEMED expedition 2011.

OBJECTIVES: To evaluate whether there is an increased risk for noise-induced hearing loss at high altitude rsp. in hypobaric hypoxia. METHODS: Thirteen volunteers got standard audiometry at 125, 250, 500, 750, 1000, 1500, 2000, 3000, 4000, 6000, and 8000 Hz before and after 10 min of white noise at 90 dB. The system was calibrated for the respective altitude. Measurements were performed at Kathmandu (1400 m) and at Gorak Shep (5300 m) (Solo Khumbu/Nepal) after 10 days of acclimatization while on trek. Temporary threshold shift (TTS) was analyzed by descriptive statistics and by factor analysis. RESULTS: TTS is significantly more pronounced at high altitudes. Acclimatization does not provide any protection of the inner ear, although it increases arterial oxygen saturation. CONCLUSION: The thresholds beyond which noise protection is recommended (> 80 dB) or necessary (> 85 dB) are not sufficient at high altitudes. We suggest providing protective devices above an altitude of 1500 m ("ear threshold altitude") when noise level is higher than 75 dB and using them definitively above 80 dB. This takes the individual reaction on hypobaric hypoxia at high altitude into account.

Efficacy of corticosteroid injection in rock climber's tenosynovitis.

While many finger conditions in climbers have been studied extensively, no data exist on the treatment of rock climber's finger flexor tenosynovitis. The purpose of this study was to evaluate the outcomes after corticosteroid injection. The study included rock climbing athletes suffering from chronic (longer than 6 weeks) finger flexor tenosynovitis who were seen at our clinic in 2017. All 42 patients received two corticosteroid injections within a 7-10 day period. Thirty-one climbers (73.8%) were pain free after the second injection and a mean of 20.9±23.1 days. The climbers reported an 84.2% decrease in pain level and no complications. The positive outcome after corticosteroid injection therapy and the absence of complications justifies this invasive approach in rock climbing athletes.

[Osteosynthesis of displaced fractures of the greater tuberosity with the Bamberg plate]. / Osteosynthese dislozierter Tuberculum-majus-Frakturen mit der Bamberger Platte.

OBJECTIVE: Internal fixation of displaced fractures of the greater tuberosity allowing functional aftercare. INDICATIONS: Displaced fractures of the greater tuberosity >5 mm. Displaced fractures of the greater tuberosity >3 mm in athletes or overhead workers. Multiply fragmented fractures of the greater tuberosity. CONTRAINDICATIONS: Displaced 3­ or 4­part fractures of the proximal humerus. Nondisplaced fractures of the greater tuberosity. SURGICAL TECHNIQUE: Exposure of the fracture of the greater tuberosity by an anterolateral approach. Open reduction and temporary retention with a Kirschner wire or a "Kugelspieß" or reinforcement of the supraspinatus tendon and distal retention. Bending and positioning of the Bamberg plate and fixation by conventional or locking screws. Optional fixation of the rotator cuff to the plate. Exact monitoring of the implant position using the image intensifier to avoid inadequate distalization of the greater tuberosity. POSTOPERATIVE MANAGEMENT: Arm sling (e. g. Gilchrist) for 2 weeks. Start passive assisted exercise on postoperative day 1. Movement allowed up to the pain threshold. Physiotherapeutic treatment to prevent adhesions and capsular shrinking. RESULTS: In all, 10 patients with displaced fractures of the greater tuberosity underwent osteosynthesis using the Bamberg plate. After a follow-up of at least 6 months, a Constant-Murley score of 94.2  points (range 91-98 points) was achieved. The patients' average age was 45.6 years (range 29-68 years).

Workload during cardiopulmonary resuscitation.

OBJECTIVES: Lay resuscitation is crucial for the survival of the patients with out-of-hospital cardiac arrest. Therefore, lay CPR should be a basic skill for everyone. With the growing proportion of retired people in the Western societies, CPR performed by people with preexisting diseases and at risk of cardiac events is expected to grow. There is little knowledge about the workload during CPR and the minimum workload capacity of the rescuer. METHODS: Pulse frequency, oxygen uptake, and CO2 elimination were measured by telemetry, while CPR was performed using a manikin with digital equipment for the standardization of the procedure. The same parameters were measured during a standard exercise testing protocol (spiroergometry) on a bicycle to analyze the aerobic endurance range of the participants. Data from the resuscitation protocols were correlated with those from spiroergometry to establish a simple standard investigation procedure to check people at risk and to give minimum requirements to perform CPR in Watts/kg. The study consisted of two parts: 1 (n = 16) explored minimal workload cutoffs for the rescuer using the 1995 recommendations and 2 (n = 14) tested the latest 2010 guidelines to compare both recommendations. RESULTS: When tested according to the 1995 guidelines, heart frequency of rescuers increased from 83.0 bpm (±11.3) at rest to 109.9 bpm (±12.6; P = 0.0004). The newer 2010 guidelines increased the workload marginally more (n.s.). CONCLUSION: CPR can be performed by healthy people within the range of aerobic endurance. The minimal requirements for trainings are 1.6-1.8 W/kg body weight in standard cycling ergometry. People at risk should be trained very careful. Since there is no significant lower workload when following the 1995 recommendations, people at risk should be trained according to the latest recommendations. In the case of a real resuscitation, such trained individuals must additionally take into account any symptoms.

Work-relief ratios and imbalances of load application in sport climbing: another link to overuse-induced injuries?

An imbalanced load application of the upper extremity may contribute to overuse-induced injuries of the fingers. Thus, the present study evaluated load-application symmetry between the right and the left hand and its work-relief ratios (WRR) depending on climbing ability and pre-exhaustion level. Twenty-eight sport climbers (age: 29 ± 8 years; body mass index: 22 ± 2 kg/m(2); years of climbing: 10 ± 6; climbing level: 6+ UIAA to 9 UIAA) were assigned to a group of recreational (≤8-UIAA, n = 14) or a group of ambitious (≥8 UIAA, n = 14) climbers. Blood lactate and perceived exertion level were recorded at the end of the climbing attempt. Load application and WRR were derived from video analysis separately for the left and the right hand. Differences in load-application time between the left (47 ± 4%) and the right (53 ± 4%) hand (P < 0.001) were observed. Irrespective of side differences, the overall WRR was 5:1. Increasing climbing level leads to a more symmetric load application (r = -0.42, P < 0.03). Differences of lactate concentration and exertion level were found between the pre- and the non-pre-exhausted group. Depending on climbing ability and exhaustion level, load application for the dominant hand (right) prevails. Further longitudinal studies should focus on imbalanced load application and overuse-induced climbing injuries.

Surgical repair of multiple pulley injuries--evaluation of a new combined pulley repair.

PURPOSE: We report on a combined repair of multiple annular pulley tears using 1 continuous palmaris longus tendon graft to restore strength and function. METHODS: We treated 6 rock climbers with grade 4 pulley injuries (multiple pulley injuries) using the combined repair technique and re-evaluated them after a mean of 28 months. RESULTS: All patients had excellent Buck-Gramcko scores; the functional outcome was good in 4, satisfactory in 1, and fair in 1. The sport-specific outcome was excellent in 5 and satisfactory in 1. Proximal interphalangeal joint flexion deficit slightly increased in 1 patient and remained the same in the other 5. Climbing level after the injury was the same as before in 4 and decreased slightly in 2 climbers. CONCLUSIONS: The technique is effective with good results and has since become our standard treatment. Nevertheless, it is limited in patients with flexion contracture of the proximal interphalangeal joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Injury risk evaluation in sport climbing.

The aim of this study was to quantify and rate acute sport climbing injuries. Acute sport climbing injuries occurring from 2002 to 2006 were retrospectively assessed with a standardized web based questionnaire. A total number of 1962 climbers reported 699 injuries, which is equivalent to 0.2 injuries per 1 000 h of sport participation. Most (74.4%) of the injuries were of minor severity rated NACA I or NACA II. Injury distribution between the upper (42.6%) and lower extremities (41.3%) was similar, with ligament injuries, contusions and fractures being the most common injury types. Years of climbing experience (p<0.01), difficulty level (p<0.01), climbing time per week during summer (p<0.01) and winter (p<0.01) months were correlated with the injury rate. Age (p<0.05 (p=0.034)), years of climbing experience (p<0.01) and average climbing level (p<0.01) were correlated to the injury severity rated through NACA scores. The risk of acute injuries per 1 000 h of sport participation in sport climbing was lower than in previous studies on general rock climbing and higher than in studies on indoor climbing. In order to perform inter-study comparisons of future studies on climbing injuries, the use of a systematic and standardized scoring system (UIAA score) is essential.

Pacemaker failure caused by traveller's diarrhoea.

A female patient with a VVI pacemaker suffered from traveller's diarrhoea which she treated with tea and water. After the onset of arrhythmia a pacemaker failure and a sodium concentration of 117 mmol/l was found. After substitution of sodium chloride, there was a remission of symptoms, the pacemaker ECG was normal.

Risk of transmission of blood borne infections in climbing--consensus statement of UIAA Medcom.

Blood borne infections such as hepatitis B, C (HBV, HBC) and human immunodeficiency disease (HIV) are major health problems globally. As the number of blood borne infections is postulated to increase among athletes, the question to the UIAA Medical Commission arises as to whether there is a risk of transmission in climbing. Using a nominal group consensus model approach a working group was formed during the UIAA Medical Commission's meeting in Adrspach-Zdoóov, in the Czech Republic, 2008. A working document was prepared and circulated via email. After several revisions the following final form was approved by written consent in lieu of a live meeting of the UIAA MedCom on 31st May, 2010: The main pathways of transmission of blood borne infections in athletes are similar to those experienced in the general population. The greatest risk to the athlete for contracting any blood borne pathogen infection is through sexual activity and parenteral drug use, and not in the sporting arena. The transmission risk in climbing is even smaller compared to contact sports. Mandatory HIV, HBV or HCV testing or widespread screening is not recommended, voluntary testing is recommended for all high risk athletes in the same way as for non-athletes. HIV and HBV positive climbers should not be banned from climbing or climbing competitions. The risk of transmission from infected athletes to other athletes is very low, the focus should be on preventive activities and education.

[Traumatic and degenerative tendon lesions of the hand]. / Traumatische und degenerative Läsionen der Sehnen an der Hand.

Tendon lesions are the second most common injury in the hand and therefore an important factor in orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons; nevertheless, also less frequent injuries such as damage to the functional system of tendon sheath and pulley or dull avulsions need to be considered. Besides the clinical examination, ultrasound and MRI have proven to be important diagnostic tools. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger "intrinsic" tendon healing to guarantee a good outcome.

[PACS: acceptance by orthopedic surgeons]. / PACS: Akzeptanz bei Orthopäden und Unfallchirurgen.

PURPOSE: The goal of the study was to evaluate the acceptance of a web-based picture archiving and communication system (PACS) by orthopedic surgeons 1 year after implementation. MATERIALS AND METHODS: One year after the implementation of a web-based PACS all physicians were surveyed with a standardized questionnaire. Questions included: speed of PACS, quality of clinicoradiological meetings, quality of monitors, PACS training, and performance. Data were evaluated separately for the Department of Orthopedic Surgery and the reference group of all other physicians. RESULTS: Among the respondents, 92% of the orthopedic surgeons stated there was a reduction of time required to receive images, and 64% concluded that patient care was faster. Archived images were received in less than 5 min in 82% after PACS and in 8% before PACS. The clinicoradiological meetings improved with PACS in 100% due to beamer presentation. All would recommend a PACS. The equipment to view images in the operating theater was assessed as being good or very good by 83%; monitor quality was judged better for the outpatient clinics (100% good or very good). Conventional radiograms were missed at the ward rounds by 56%. Training for PACS was considered sufficient by 67%, and 15% asked for refresher courses. In the reference group 60% asked for refresher courses. In the comparison of orthopedic surgeons with the reference group PACS was judged better especially concerning the viewing software and quality of monitors. CONCLUSION: There is an over all acceptance of PACS by physicians outside the radiology department. The availability of images was not only facilitated it was faster as well. However, the quality of monitors in the operating theater should be improved. To achieve sustained success of PACS consistent training on PACS and its features is necessary. Conventional radiograms were often missed at the ward rounds.

The influence of concentric and eccentric loading on the finger pulley system.

In this study we investigated the influence of the loading condition (concentric vs. eccentric loading) on the pulley system of the finger. For this purpose 39 cadaver finger (14 hands, 10 donors) were fixed into an isokinetic loading device. The forces in the flexor tendons and at the fingertip were recorded. In the concentric loading condition A2 and A4 ruptures as well as alternative events such as fracture of a phalanx or avulsion of the flexor tendons were almost equally distributed, whereas the A2 pulley rupture was the most common event (59%) in the eccentric loading condition and alternative events were rare (23.5%). The forces in the deep flexor tendon, the fingertip and in the pulleys were significantly lower in the eccentric loading condition. As the ruptures occurred at lower loads in the eccentric than in the concentric loading condition it can be concluded that friction may be an advantage for climbers, supporting the holding force of their flexor muscles but may also increase the susceptibility to injury.

The influence of the crimp and slope grip position on the finger pulley system.

In this study the influence of the grip position (crimp grip vs. slope grip position) on the pulley system of the finger was investigated. For this purpose 21 cadaver finger (11 hands, 10 donors) were fixed into an isokinetic loading device. Nine fingers were loaded in the slope grip position and 12 fingers in the crimp grip position. The forces in the flexor tendons and at the fingertip were recorded. A rupture of the A4 pulley occurred most often in the crimp grip position (50%) but did not occur in the slope grip position, in which alternative events were the most common (67%). The forces in the deep flexor tendon (FDP) (slope grip: 371 N, crimp grip: 348 N) and at the fingertip (slope grip: 105 N, crimp grip: 161 N) were not significantly different between the 2 finger positions, but the forces acting on the pulleys were higher in the crimp grip position (A2 pulley: 287 N, A4 pulley: 226 N) than in the slope grip position (A2 pulley: 121 N, A4 pulley: 103 N). The crimp grip position may be the main cause for A4 pulley ruptures but the slope grip position may be hazardous for other injuries as the forces recorded in the flexor tendons and at the fingertip were comparable at the occurrence of a terminal event.

[Sports ability after patella dislocation]. / Sportfähigkeit nach Patellaluxation.

A dislocation of the patella is a serious injury which can far affect the career of every athlete or even finish it. In a retrospective study we examined 24 athletes (mean age 19.3 years, post surgical observation period 39 (13 to 79) months) which suffered from a patellar dislocation and received arthroscopic surgical treatment. The diagnostics contained clinical investigation and X-rays of the knee joint in 2 plains as well as patella tangential, in pathological axial deformations of the leg completed with whole-leg-images and optional a torsion computed tomography. All 24 patients received an arthroscopical assisted suturing of the medial retinaculum, in 12 patients additional a lateral release was carried out. The postoperative course followed a standard pattern. In 24 operated patients the reoccurrence rate was 12.5 % (3 patients), which is within the range of the latest published figures (average 12.0 %). The Lysholm score was in 15 (62.4 %) of all patients higher than 80 demonstrating the good to very good results, the average Lysholm score was 83.4. Out of 24 patients with patellar dislocation 11 patients (45.8 %) were able to continue their sport career after surgical therapy at the pre-trauma level, 4 patients (16.6 %) had to continue at lower level, 9 patients (37.5 %) had to finish their sport career. The Tegner activity score decreased from 7.2 to 6.0 at about 1.2 points what means a clear decrease of the activity level. On average a full sportive level was reached 9.7 months after surgery. Especially sport athletes needs to be informed about the seriousness of the injury and the long process of rehabilitation.

Climber's back--form and mobility of the thoracolumbar spine leading to postural adaptations in male high ability rock climbers.

In elite climbers, the development of "climber's back" has often been subjectively referred to. However no scientific proof is present. In a cross-sectional cohort study, the spines of 80 healthy asymptomatic male sport climbers were examined. The performance-oriented sport climbers (SC) trained regularly (9.8 +/- 4.3 hr/wk) and had a mean climbing ability of 9.7 +/- 0.6; the 34 recreational climbers (control group) (RC) climbed less frequently (3.4 +/- 2.0 hr/wk) and had a mean climbing ability of 6.0 +/- 0.9. Measurement of the sagittal thoracolumbar spine was performed using the "SpinalMouse". The kyphosis angle in the erect posture was significantly greater in SC verses the RC. The lordosis angle was also greater in SC versus RC but did not reach significance. No significant differences were found in flexion and extension. Further evaluation of the SC group was carried out by subdividing them to a moderate group (SC-moderate) (n = 17) and top-level group SC-top level) (n = 29). Here the kyphosis angle was significantly greater in SC-top-level than in SC-moderate. The results demonstrated that "climber's back" was characterized by an increased thoracic kyphosis, increased lumbar lordosis, and was probably influenced by shortened pectoralis muscles. The climbing ability level was strongly correlated to the postural adaptations.

Cheyne stokes breathing at high altitude: a helpful response or a troublemaker?

Sleep disorders at high altitude are common and well-known for centuries. One symptom of the complex is periodic breathing (PB). PB occurs from a disbalance of the negative feedback loop of ventilation control, and at high altitude, it is increased by a phase shift of 180 degrees between hyperventilation and hypoxia. This paper explains the mechanisms that trigger the problem and discusses whether PB may be of advantage or disadvantage for the person going to high altitude. Up to about 3,000-3,500 m, PB may be of advantage because it stabilizes oxygen saturation at a relatively high level. At higher altitudes, disadvantages predominate because frequent arousals cause total sleep deprivation and mental and physical impairment of the victim. Correct acclimatization and "defensive" altitude profiles are gold standard, which minimize PB and optimizes recreative sleep, although they cannot mask PB completely, especially at extreme altitude.

Finger pain in rock climbers: reaching the right differential diagnosis and therapy.

Injuries and overuse syndromes of the fingers are the most common problems in rock climbers. While injuries to the finger flexor pulley system and tenosynovitis are well known to be frequent problems, other syndromes like the lumbrical shift syndrome or flexor tendon ganglions are rather unknown. The differential diagnosis of finger pain in rock climbers involves many differential diagnoses and can be quite difficult. The diagnostic and therapeutic procedures for the evaluation of finger pain in rock climbers are demonstrated. More than 20 different diagnoses need to be considered. After taking a thorough history, clinical examination and radiography the ultrasound is the most helpful diagnostic aid. Being a cheap and harmless examination it provides plenty of information for further differential diagnosis. A linear array transducer with 10-12 MHz in a prone position performing longitudinal and transversal planes is mostly used. Only occasionally an additional MRI is necessary. The physiologic adaptations due to the high impact of rock climbing onto the fingers need to be strictly separated from pathologic change. The rising number of epiphyseal fractures in young climbers must be observed critically and information needs to be given out to parents, trainers and the athletes themselves. The question of the influence of high intensive climbing and training in young age and a possible higher risk for osteoarthrosis of the finger joints needs to be further explored.

Effect of exercise, body composition, and nutritional intake on bone parameters in male elite rock climbers.

A low body mass index is considered essential for high performance in rock climbing; however its effect on bone may be negative. In this study we compared the BMD of competitive male rock climbers (n = 20) and age- and BMI-matched non-training controls (n = 11). Subjects with any medication or illness affecting bone metabolism or a family history of osteoporosis were not included in the analysis. Total body BMD was measured by dual-energy X-ray absorptiometry. Quantitative computed tomographic scans were made from the femoral neck and the lumbar spine. Dietary intake was assessed by a 5-day protocol. BMD of the TB-scan was significantly higher in the climbers group for all sub-regions except the skull (p = 0.191) and the lower extremities (p = 0.079). Trabecular and cortical BMD of the LS were significantly higher (p = 0.036 and p = 0.004) in the climbers. The same was true for total (p = 0.005) and cortical (p = 0.002) BMD of the FN. Trabecular BMD (p = 0.054), CSA (p < 0.343) and cortical thickness (p = 0.065) of the FN was non-significantly higher for the climbers. Our study indicates that the effect of climbing on bone parameters PER SE is not detrimental in elite male athletes. Contrarily climbers demonstrated significantly higher BMD values at all loaded regions without "steal effects" at skeletal sites with low mechanical impact. Although we determined a moderately negative effect of low BMI on BMD we could not decide whether a low BMI value should be used as an exclusion criterion in high level climbing competitions as practized by the Austrian Sportclimbing Organization.