Flexor Pulley Ruptures

Anatomy

 

5 Annular pulleys

3 Cruciate pulleys

 

Pathology

 

A1 and A5 expendable

 

Loss of other annular pulleys can lead to bowstringing

- A2 & A4 +/- A3

 

Aetiology

 

Rock climbers

- usually when slipping

 

May hear or feel a pop

 

Develop swelling / tenderness / pain

 

Bowstringing

- usually only with multiple pulley rupture

 

Investigations

 

Xray

- exclude fracture

 

Ultrasound

- very good

 

MRI

- if US inconclusive

 

Grading

 

Grade 1

- strain

- A4 tear (has good prognosis)

 

Grade 2

- partial tear A2 or A3

 

Grade 3

- complete A2 or A3 rupture

 

Grade 4

- multiple pulley rupture

- +/- lumbrical avulsion or collateral ligament damage

 

Management

 

Non operative

 

Single complete pulley ruptures

- no climbing for 6 weeks

- gradual return to climbing with pulley taping

- full return to sport at 3 months

 

Operative

 

Multiple pulley ruptures

- repair techniques poor

- reconstruction required

- A2 with palmaris longus graft

- A3 with extensor retinaculum graft