Flexor Tendon Pulley Injuries: A Systematic Review of the Literature and Current Treatment Options

Abstract

Closed injuries of the finger flexor pulley system are rare among the general population, and most of them occur during rock climbing. During the last few decades, scientific interest on this topic has increased. We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The research was limited from January 2000 to March 2022. PubMed and Scopus databases were investigated for full-text articles published in English, French, and Italian using the following MeSH terms: ([pulley rupture] OR [finger pulley lesion]) AND ([injur*] OR [ruptur*] OR [damage] OR [trauma*]). Initial screening results identified 461 studies, among which 172 were included after including additional records identified through other sources and excluding repeated studies. Finally, four clinical studies were included in the analysis. The methodological quality of the articles was evaluated through the methodological index for nonrandomized studies (MINORS) score. Our search identified four studies that enrolled a total of 189 patients, of whom 164 were male and 25 were female. We finally examined 154 patients with a total of 208 pulleys damaged. Except for the thumb, all fingers were involved. Depending on the type of flexor pulley injury, graded with Schöffl classification, 69 patients underwent a surgical procedure, whereas 85 patients were treated conservatively. Closed finger pulleys injury occurred in rock climbers and non ̶ rock climbers. All patients had excellent results on the Buck-Gramcko score regardless of the return to sports activity. Considering the overall outcomes of the reviewed articles, functional results were satisfactory in both conservative and surgical treatment. Moreover, in grade 3 and 4, surgical results were positive regardless of the specific technique used for finger pulley reconstruction. Only minor complications were reported. Closed flexor tendon pulley injuries require a careful clinical and imaging examination to confirm the diagnosis. In most cases, positive clinical results can be achieved with either conservative or surgical therapy.

Keywords

bowstringing - flexor tendon - pulley reconstruction - pulley rupture - rock climbing

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Publication History

Article published online:
28 June 2022

• References

• 1 Dy CJ, Daluiski A. Flexor pulley reconstruction. Hand Clin 2013; 29 (02) 235-242
• 2 Crowley TP. The flexor tendon pulley system and rock climbing. J Hand Microsurg 2012; 4 (01) 25-29
• 3 Schöffl V, Hochholzer T, Winkelmann HP, Strecker W. Pulley injuries in rock climbers. Wilderness Environ Med 2003; 14 (02) 94-100
• 4 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6 (07) e1000100
• 5 Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg 2011; 128 (01) 305-310
• 6 Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003; 73 (09) 712-716
• 7 Schöffl VR, Jüngert J. Closed flexor pulley injuries in nonclimbing activities. J Hand Surg Am 2006; 31 (05) 806-810
• 8 Buck-Gramcko D, Dietrich FE, Gogge S. Bewertungskriterien bei Nachuntersuchungen von Beugesehnenwiederherstellungen. [Evaluation criteria in follow-up studies of flexor tendon therapy] Handchirurgie 1976; 8 (02) 65-69
• 9 Nielsen AB, Jensen PO. Methods of evaluation of the functional results of flexor tendon repair of the fingers. J Hand Surg [Br] 1985; 10 (01) 60-61
• 10 Arora R, Fritz D, Zimmermann R. et al. Reconstruction of the digital flexor pulley system: a retrospective comparison of two methods of treatment. J Hand Surg Eur Vol 2007; 32 (01) 60-66
• 11 Bouyer M, Forli A, Semere A, Chedal Bornu BJ, Corcella D, Moutet F. Recovery of rock climbing performance after surgical reconstruction of finger pulleys. J Hand Surg Eur Vol 2016; 41 (04) 406-412
• 12 Cole KP, Uhl RL, Rosenbaum AJ. Comprehensive review of rock climbing injuries. J Am Acad Orthop Surg 2020; 28 (12) e501-e509
• 13 Jones G, Johnson MI. A critical review of the incidence and risk factors for finger injuries in rock climbing. Curr Sports Med Rep 2016; 15 (06) 400-409
• 14 King EA, Lien JR. Flexor tendon pulley injuries in rock climbers. Hand Clin 2017; 33 (01) 141-148
• 15 Cockenpot E, Lefebvre G, Demondion X, Chantelot C, Cotten A. Imaging of sports-related hand and wrist injuries: sports imaging series. Radiology 2016; 279 (03) 674-692
• 16 Freilich AM. Evaluation and treatment of jersey finger and pulley injuries in athletes. Clin Sports Med 2015; 34 (01) 151-166
• 17 Bianchi S, Martinoli C, de Gautard R, Gaignot C. Ultrasound of the digital flexor system: normal and pathological findings(). J Ultrasound 2007; 10 (02) 85-92
• 18 Desai B, Sumarriva G, Dunbar R. Closed traumatic A2 through A4 pulley rupture and flexor digitorum superficialis avulsion treated with reconstruction. Ochsner J 2021; 21 (01) 99-103
• 19 Soulii L, Amirouche F, Solitro G. et al. Evaluation of A2 and A4 hand pulley repair using tendon graft rings. J Hand Surg Am 2021; 46 (07) 626.e1-626.e6
• 20 Jakubietz MG, Meffert RH, Schmidt K, Gruenert JG, Jakubietz RG. Acute A4 pulley Reconstruction with a first extensor compartment onlay graft. Plast Reconstr Surg Glob Open 2017; 5 (06) e1361