Closed traumatic rupture of the ring finger flexor tendon pulley We report an unusual case of closed traumatic rupture of the ring hnger flexor tendon pulley not previously reported in the literature. This hrjury occurred in a 21.year-old athlete during rockclhnbing. Lack of flexion of the distal interphahmgeal joint was accompanied by a palpable subcutaneous cord on the palmar side of the proximal phalanx. A simple repair of the pulley was done. The postoperative functional result was satisfactory. (J HAND SURC 1!990;15A:745-7.)
Y. Tropet, MD, D. Menez, MD, P. Balmat, MD, R. Pem, MD, and Ph. Vichard, MD, Besancon, France
T
o our knowledge closed traumatic rupture of the flexor tendon pulley has not previously been reported. Such lesions present a distinct clinical picture. Case report This report concerns a 21-year-old rock climber, who necessarily grips the cliff with his finger tips for short periods only. During a climb, he suffered an acute pain in his right ring finger forcing him to loosen his grip. Luckily, his ensuing fall was harmless, thanks to security belts. He was first examined 5 days after this episode. Active Aexion of the distal phalanx was possible, reaching only 20 degrees, but this range was enough to eliminate an avulsion or rupture of the flexor digitorum profundus tendon. Moreover, during pulp-to-pulp grip of the thumb against the ring finger, active flexion of the distal phalanx was impossible in the ring finger, whereas it reached 80 degrees on the left. During this pulp-to-pulp position, the examiner felt a subcutaneous cord corresponding to the flexor tendons on the palmar side of the proximal phalanx of the ring finger (Fig. 1, A and B). This finding confirmed closed rupture of the pulley at this level. The force generated by the thumb against the ring finger was consequently diminished, partly explaining
From the Department of Orthopedic and Plastic Surgery, J. Minjoz Hospital, Besancon, France. Received for publication May 15, 1989; accepted in revised form Sept. 1, 1989. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Y. Tropet, MD, Hospital J. Minjoz, 25030 Besancon Cedex, France. 3/l/17419
why the climber loosened his grip. The patient, hampered by his weak grip, immediately consented to our proposed surgical treatment. With the patient under regional anesthesia and tourniquet control, a palmar approach was used. An oblique rupture of the A2 pulley was observed starting from the radial side of the ring finger at its metacarpophalangeal fold to reach the ulnar side of the proximal phalanx at its distal part (Fig. 2). The edges of the ruptured pulley were sharp enough to allow an end-to-end repair by sutures made of a No. 4 resorbable thread (Fig. 3). After operation, the finger was maintained in a splint for 21 days after which progressive active mobilization was performed for 1 month. At the six-month follow-up, the functional result was good. He had recovered 70” of active flexion of the distal joint. The preoperative palpable subcutaneous cord had disappeared. Discussion The role of the flexor tendon
pulley is well docu-
mented. In a sagittal plane, the pulleys press the flexor tendon against the phalangeal skeleton. This function is accomplished by the A2 and A4 pulleys.’ When these pulleys are missing or when one is ruptured as in this patient, the tendon is bowstrung and active flexion of the distal phalanx is limited. During clinical examination, a pulp-to-pulp grip between the injured finger and the thumb increases the deficit in flexion of the distal joint and makes the subcutaneous cord appear prominant. Moreover, if the proximal phalanx of the injured finger is gripped anteroposteriorly by the examiner, active flexion of the distal phalanx becomes possible. These different maneuvers confirm diagnosis of flexor tendon pulley ntpture, thus excluding tendinous rupture. A rock climber, needing complete and strong flexion
THE JOURNAL
OF HAND
SURGERY
745
746
Tropet et al.
The Journal of HAND SURGERY
Fig. 1. A, Obvious subcutaneous tendon cord (arrow) during pulp-to-pulp grip between the thumb and the rilng finger. B, Same grip as compared with the other hand. Note the loss of DIP active I
flex ion.
Fig. 2. Oblique rupture (arrow) of the A2 pulley on the proximal phalanx of the ring finger.
Vol. 15A, No. 5 September 1990
Closed traumatic
Fig. 3. End-to-end
rupture
of ring jnger
tendon pulley
i ‘47
plasty of the pulley according
to Ka-
suture of the free ends of the pulley with resorbable
of his fingers, will not be able to resume his sport with the weak grip resulting from such an injury. From a therapeutic point of view, surgical repair of the pulley is undoubtedly justified. A palmar approach through the proximal phalanx widely exposes the lesion. The sharp edges encountered on the ruptured pulley in this particular case allowed a simple edge-to-edge suture. Otherwise, an enlargement plasty of the pulley according to Kapandji’s technique might have been indicated (Fig. 4).* He proposes joining the edges of the pulley after making short incisions at its insertion points as shown in Fig. 4. It seems improbable that such an injury could totally destroy the pulley. If such an eventuality is encountered, other currently well-known procedures such as the use of a portion of the extensor retinaculum or free tendon graft encircling, or not, the phalanx3-6 may be used. REFERENCES 1. Doyle JR, Blythe W. Anatomy of the flexor tendon sheath and pulleys of the thumb. J HAND SURG 1977;2: 149-5 1. des poulies meta2. Kapandji IA. Plastic d’agrandissement carpiennes. Ann Chir Main 1983;2:281-2. 3. Doyle JR, Blythe W. The finger flexor tendon sheath and pulleys anatomy and reconstruction. In: A.A.O.S. Ed., Symposium on Tendon Surgery. St. Louis: The CV Mosby Co.. 197581-7.
Fig. 4. Enlargement pandji’s technique.
flexor
nylon.
Karev A. The belt loop technique for the reconstruction of pulleys in the first stage of flexor tendons grafting. J HAND SURG 1984;9A:923-4. Kleinert HE, Bennett JB. Digital pulley reconstruction employing the always present rim of the previous pulley. J HAND SURG 1978;3:297-8. Lister GD. Reconstruction of pulleys employing extensor retinaculum. J HAND SURG 1979;4:461-4.
Y. Tropet, MD, D. Menez, MD, P. Balmat, MD, R. Pem, MD, and Ph. Vichard, MD, Besancon, France
T
o our knowledge closed traumatic rupture of the flexor tendon pulley has not previously been reported. Such lesions present a distinct clinical picture. Case report This report concerns a 21-year-old rock climber, who necessarily grips the cliff with his finger tips for short periods only. During a climb, he suffered an acute pain in his right ring finger forcing him to loosen his grip. Luckily, his ensuing fall was harmless, thanks to security belts. He was first examined 5 days after this episode. Active Aexion of the distal phalanx was possible, reaching only 20 degrees, but this range was enough to eliminate an avulsion or rupture of the flexor digitorum profundus tendon. Moreover, during pulp-to-pulp grip of the thumb against the ring finger, active flexion of the distal phalanx was impossible in the ring finger, whereas it reached 80 degrees on the left. During this pulp-to-pulp position, the examiner felt a subcutaneous cord corresponding to the flexor tendons on the palmar side of the proximal phalanx of the ring finger (Fig. 1, A and B). This finding confirmed closed rupture of the pulley at this level. The force generated by the thumb against the ring finger was consequently diminished, partly explaining
From the Department of Orthopedic and Plastic Surgery, J. Minjoz Hospital, Besancon, France. Received for publication May 15, 1989; accepted in revised form Sept. 1, 1989. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Y. Tropet, MD, Hospital J. Minjoz, 25030 Besancon Cedex, France. 3/l/17419
why the climber loosened his grip. The patient, hampered by his weak grip, immediately consented to our proposed surgical treatment. With the patient under regional anesthesia and tourniquet control, a palmar approach was used. An oblique rupture of the A2 pulley was observed starting from the radial side of the ring finger at its metacarpophalangeal fold to reach the ulnar side of the proximal phalanx at its distal part (Fig. 2). The edges of the ruptured pulley were sharp enough to allow an end-to-end repair by sutures made of a No. 4 resorbable thread (Fig. 3). After operation, the finger was maintained in a splint for 21 days after which progressive active mobilization was performed for 1 month. At the six-month follow-up, the functional result was good. He had recovered 70” of active flexion of the distal joint. The preoperative palpable subcutaneous cord had disappeared. Discussion The role of the flexor tendon
pulley is well docu-
mented. In a sagittal plane, the pulleys press the flexor tendon against the phalangeal skeleton. This function is accomplished by the A2 and A4 pulleys.’ When these pulleys are missing or when one is ruptured as in this patient, the tendon is bowstrung and active flexion of the distal phalanx is limited. During clinical examination, a pulp-to-pulp grip between the injured finger and the thumb increases the deficit in flexion of the distal joint and makes the subcutaneous cord appear prominant. Moreover, if the proximal phalanx of the injured finger is gripped anteroposteriorly by the examiner, active flexion of the distal phalanx becomes possible. These different maneuvers confirm diagnosis of flexor tendon pulley ntpture, thus excluding tendinous rupture. A rock climber, needing complete and strong flexion
THE JOURNAL
OF HAND
SURGERY
745
746
Tropet et al.
The Journal of HAND SURGERY
Fig. 1. A, Obvious subcutaneous tendon cord (arrow) during pulp-to-pulp grip between the thumb and the rilng finger. B, Same grip as compared with the other hand. Note the loss of DIP active I
flex ion.
Fig. 2. Oblique rupture (arrow) of the A2 pulley on the proximal phalanx of the ring finger.
Vol. 15A, No. 5 September 1990
Closed traumatic
Fig. 3. End-to-end
rupture
of ring jnger
tendon pulley
i ‘47
plasty of the pulley according
to Ka-
suture of the free ends of the pulley with resorbable
of his fingers, will not be able to resume his sport with the weak grip resulting from such an injury. From a therapeutic point of view, surgical repair of the pulley is undoubtedly justified. A palmar approach through the proximal phalanx widely exposes the lesion. The sharp edges encountered on the ruptured pulley in this particular case allowed a simple edge-to-edge suture. Otherwise, an enlargement plasty of the pulley according to Kapandji’s technique might have been indicated (Fig. 4).* He proposes joining the edges of the pulley after making short incisions at its insertion points as shown in Fig. 4. It seems improbable that such an injury could totally destroy the pulley. If such an eventuality is encountered, other currently well-known procedures such as the use of a portion of the extensor retinaculum or free tendon graft encircling, or not, the phalanx3-6 may be used. REFERENCES 1. Doyle JR, Blythe W. Anatomy of the flexor tendon sheath and pulleys of the thumb. J HAND SURG 1977;2: 149-5 1. des poulies meta2. Kapandji IA. Plastic d’agrandissement carpiennes. Ann Chir Main 1983;2:281-2. 3. Doyle JR, Blythe W. The finger flexor tendon sheath and pulleys anatomy and reconstruction. In: A.A.O.S. Ed., Symposium on Tendon Surgery. St. Louis: The CV Mosby Co.. 197581-7.
Fig. 4. Enlargement pandji’s technique.
flexor
nylon.
Karev A. The belt loop technique for the reconstruction of pulleys in the first stage of flexor tendons grafting. J HAND SURG 1984;9A:923-4. Kleinert HE, Bennett JB. Digital pulley reconstruction employing the always present rim of the previous pulley. J HAND SURG 1978;3:297-8. Lister GD. Reconstruction of pulleys employing extensor retinaculum. J HAND SURG 1979;4:461-4.
