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