longest and the most consistent pulley, has the highest injury rate, followed by A4.6 These injuries must be care-fully identiﬁed and managed; otherwise, they can lead to deﬁnitive loss of interphalangeal joint ﬂexion and osteoarthritis.7 High-resolution ultrasound imaging (US) is considered Moreover, it is widely recognized that the middle and ring fingers are most commonly associated with traumatic A2 rupture. Pulley Injuries. The VP became significantly thicker and shorter during finger flexion as well as after A3 pulley rupture. The pulleys are appropriately named, as they have a pulley-like function that allows the flexor muscle and tendon units to efficiently exert their force upon their respective fingers. If the pain becomes much worse during or after crimping, this indicates a pulley injury. Questions (5) QUESTIONS. Flexor pulley injuries have also been reported in bowling, baseball and other sports. Injury of the pulley system begins at the distal part of the A2 pulley, the most important component in flexor tendon function, and progresses from partial to complete rupture, which is followed by involvement of the A3, A4, and rarely A1 pulleys (, 48). A direct visualisation of the A3 pulley was achieved in 61 % of the fingers. Background: Multiple closed spontaneous pulley ruptures are rare injuries and require surgical reconstruction to prevent functional deficits. These are overwhelmingly the result of a discrete trauma occurring with the hand in a finger grip position. The annular and cruciate pulleys are areas of focal thickening of the flexor tendon sheath that are of critical importance to the normal biomechanical function of the finger. The annular pulleys are designated A1 through A5, with cruciate pulleys C1, C2, and C3. The presence of neurovascular injuries should also be assessed for open lacerations at any level. Second, in cases of zone II flexor tendon injury, the intentional partial A2 and/or A4 pulley excision or venting is emerging as a component for successful treatment. The A2 and A4 pulleys among differing digits and genders have similar biomechanical properties in regards to maximum breaking load, displacement, and stiffness. One of the most common and unique lesions occurring in the rock climbing population is the closed rupture of the flexor pulley system of the fingers due to Closed-hand crimping.An A2 pulley strain is the most common finger injury for climbers and most frequently occur in the ring or middle finger. Finally, 29 rock climbers (22 A2 injuries/7 A4 injuries) entered the study. They are most frequently seen in competitive climbing athletes, up to a quarter of whom report finger pulley injuries. All A2 and most A4 pulley ruptures require surgical repair in order to regain function. Flexor tendon/pulley ruptures are rare, and require immediate medical attention. A1 or A5 tears almost never occur. Use Tape. The A2 and A4 pulleys arise from the periosteum on the proximal half of the proximal phalanx and the mid portion of the middle phalanx, respectively. On the other hand, Bouyer et al. Usually only one finger flexor tendon pulley disrupts, the A2-pulley being one-and-a-half to two times more likely to be involved than the A4-pulley of either the ring or the middle finger. Pulley Injuries. Case Report: We describe a closed traumatic annular 2 (A2) through annular 4 (A4) pulley rupture with avulsion of the FDS tendon. of the A2 pulley, 1 underwent surgery due to Dupuytren disease, 1 was diagnosed with a multiple pulley rupture (A2/A3/A4 without bowstringing), and 16 presented with bilateral A2 or A4 pulley injuries of the 3rd or 4th ﬁngers. In this particular setting, usually under the guidance of a health care provider, the climber will follow the Management of an Acute Pulley Injury Protocol. To keep it simple, the most common finger injuries among climbers are strains to either tendons or ligaments. This post will revisit the anatomy, and look at the causes and symptoms, and then discuss treatment methods. RESULTS: Injuries to the A2 and A4 pulleys were diagnosed via ultrasound with sensitivities of 90 % and 94 % and specificities of 100 % and 97 %, respectively. Rock climbing commonly involves flexion of the metacarpophalangeal and PIP joints and extension of the DIP joints, which places high stress on the pulleys and can result in complete or partial tears. Fingers: Torn A3 and A4 Pulleys I was pulling on a small side pull in an open-handed grip with marginal feet and heard a loud pop. FIGURE 15-2 Flexor tendon pulley system. However, the SPOrt also works well for partial injuries of the A2 or the A4 pulley which we identify commonly in climbers with ultrasound or MRI. One study reported a 58% incidence of flexor pulley injury as a result of rock climbing in a sample size of 623 patients, and of those patients, 52% involved the middle finger and 50% involved the A2 pulley . In so doing, the pulleys assure proper movement and apposition of the flexor tendons relativ… Complete rupture of A4 or a partial rupture of A2 or A3 comprise the grade II injury, and grade III injury encompasses complete A2 or A3 pulley rupture. I got injured exactly one year ago while bouldering. This injury was first described by Bollen and Tropet in 1990 [1, 2] in rock climbers and had not been described in … Flexor tendon pulley injuries occur most commonly in rock climbers, accounting for 27% of all finger injuries (Schoffl et al 2003). The Local Solution: The anatomy of the hand is complex. 27 Grade I injuries represent pulley strains where imaging demonstrates no flexor tendon subluxation. If you’ve had pulley injuries before, research has been showing H Taping is the preferred method to support A2, A3, and A4 pulleys. If you have a pulley injury, and the acute inflammation is not too bad, it should still be possible to pull on holds with a fully open-handed grip without pain. Average 4.4 of 46 Ratings. If one of your pulley ligaments is injured, your flexor tendon is likely injured too. According to an algorithm presented by Schöffl et al., 4, 5 singular A4 pulley injuries rarely justify surgical intervention. After that my left ring finger felt unsupported and I couldn't weight it. This specimen has a relatively thin A4. Pulley rupture combined with avulsion of the flexor digitorum superficialis (FDS) tendon is an even more uncommon occurrence. The annular pulleys (A1, A2, A3, A4, A5) hold your flexor tendons close to the bone and act as pulleys. A biomechanical comparison of A2 and A4 pulleys among gender and digit was carried out to identify any gender specific susceptibility to A2 pulley rupture. Your finger pulleys hold the tendon close to the bone and are basically a ligament that rejoins to the same bone rather than cross a joint to neighboring bone.