A4 Pulley Rupture

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A4 Pulley Rupture

Authors, Editors, Case Information Author: Rajit Banerjee, MD Affiliation: University of Pittsburgh Medical Center (UPMC) Co Author(s): Dr Ryan Nussbaum Editor: Raul Rosario-Concepcion, MD Clinical Vignette: 18 YO male presented for left 4th digit finger pain when coming off the wall from rock climbing using crimp grip position. Swelling and tenderness to palpation noted in the distal aspect of the middle phalanx of the left hand Type of Probe Used: 22 MHz Ultra-High Frequency Hockey Stick Labelled Left 4th and left 3rd middle phalanx Long axis view of Left 4th middle phalanx (injured) and Left 3rd middle phalanx (non-injured) with labeled phalanx and flexor muscle regions (FDS and FDP). Dotted blue line on Left 4th phalanx designates hypoechoic gap of 0.28cm or 2.8mm and 0.05cm or 0.5mm on the Left 3rd middle phalanx. Unlabelled Left 4th and left 3rd middle phalanx Long axis view of Left 4th middle phalanx (injured) and Left 3rd middle phalanx (non-injured). Left side for both images is proximal. Interpretation Image Interpretation: In non-diseased states, the A4 pulley is normally quite difficult to distinguish in long axis, however it is intact if there is minimal distance between the flexor tendons and phalanx as seen in the non-injured left 3rd middle phalanx. Literature has stated tendon-to-bone distances at least 2mm is usually a sensitive threshold to diagnose A2 and A4 pulley ruptures. This is clearly observed for the injured Left 4th middle phalanx with the hypoechoic gap of 2.8mm. Teaching Pearl: In rock climbing, finger flexor pulley system injuries are the most common overuse injuries and almost rarely occur outside of this activity given unique biomechanical demands. The mechanism for such injuries is usually from crimp grip, a technique utilizing PIP flexion and DIP hyperextension, which is used commonly by rock climbers to maximize contact of the fingertips on rock climbing holds with small surface areas. Specifically, it is the sudden opening of the hand described as the eccentric portion where injury is the most prone given that the pulleys are not muscular in nature. Although the flexor pulleys, particularly A2 and A4, can withstand large amounts of forces relative to other pulleys, repetitive loading can lead to overuse injuries. Ultrasound is highly sensitive and specific for diagnosis and is the initial imaging of choice.
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Authors, Editors, Case Information

Labelled Left 4th and left 3rd middle phalanx

Unlabelled Left 4th and left 3rd middle phalanx

Interpretation

UPCOMING EVENTS

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