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: An 18-year-old 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 were noted in the distal aspect of the middle phalanx of the left hand. Type of Probe Used: 22 MHz Ultra-High Frequency Hockey Stick Unlabeled long axis view of the injured left 4th middle phalanx Unlabeled long axis view of the injured left 4th middle phalanx Labeled long axis view of the injured left 4th middle phalanx Labeled long axis view of injured left 4th middle phalanx. The dotted blue line on left 4th phalanx designates hypoechoic gap of 2.8mm representing an increased distance between the phalanx and FDP/FDS tendons. Unlabeled long axis view of the uninjured left 3rd middle phalanx Unlabeled long axis view of the uninjured left 3rd middle phalanx Labeled long axis view of the uninjured left 3rd middle phalanx Labeled long axis view of the normal uninjured left 3rd middle phalanx Interpretation Image Interpretation: There is increased distance between the FDP/FDS tendons and left 4th middle phalanx at 2.8mm compared to negligible distance in the uninjured left 3rd middle phalanx. This is consistent with a left 4th A4 pulley rupture. Teaching Pearl: Finger flexor pulley injuries are common in rock climbers because crimp grip places high loads on the pulley system. A4 pulley rupture is evaluated dynamically by measuring the tendon-to-bone distance at the middle phalanx during resisted finger flexion and comparing it with an adjacent uninjured digit. Bowstringing may be subtle at rest, so dynamic testing is necessary. The scan should identify which pulley is injured and whether the tear is isolated or combined with A2/A3 injury, because treatment and return-to-climbing decisions can depend on severity. References: 1. Klauser A, Frauscher F, Bodner G, et al. Finger pulley injuries in extreme rock climbers: depiction with dynamic US. Radiology. 2002;222(3):755-761. doi:10.1148/radiol.2223010396 2. Iruretagoiena-Urbieta X, De la Fuente-Ortiz de Zarate J, Rodríguez-López ES, et al. Ultrasonographic diagnosis of A2 or A4 flexor tendon pulley injury: a systematic review. Wilderness Environ Med. 2020;31(4):498-505. doi:10.1016/j.wem.2020.07.007 3. Miro PH, vanSonnenberg E, Sabb DM, Schöffl V. Finger flexor pulley injuries in rock climbers. Wilderness Environ Med. 2021;32(2):247-258. doi:10.1016/j.wem.2021.01.011
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Authors, Editors, Case Information

Unlabeled long axis view of the injured left 4th middle phalanx

Labeled long axis view of the injured left 4th middle phalanx

Unlabeled long axis view of the uninjured left 3rd middle phalanx

Labeled long axis view of the uninjured left 3rd middle phalanx

Interpretation

UPCOMING EVENTS

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