Pathomechanics of Closed Rupture of the Flexor Tendon Pulleys in Rock Climbers*

We performed a study on twenty-one cadaveric fingers (seven non-paired forearms) to determine the pathomechanics of closed traumatic rupture of the flexor tendon pulleys in rock climbers. The ages of the individuals at the time of death ranged from sixty-one to eighty-four years (mean, seventy-four years). The forearm was placed in a custom-made loading apparatus, and individual fingers were tested separately under simulated in vivo loading conditions. The flexor digitorum superficialis and profundus tendons of each digit were attached to computer-controlled linear stepper motors that were equipped with force transducers, and the force in the tendons was simultaneously increased until avulsion of the tendons or osseous failure occurred. The force in the tendons, the excursion of the tendons, and the force at the fingertip were measured. Damage to the pulleys and bowstringing of the tendons were visualized with a fiberoptic camera. Two fingers fractured before complete rupture of the pulleys. Seventeen of the remaining nineteen fingers sustained an isolated rupture of either the A2 or the A4 pulley as the initial failure event; the A4 pulley ruptured first in fourteen digits (p < 0.001). The A3 and A4 pulleys ruptured simultaneously in one finger, and the A2, A3, and A4 pulleys ruptured simultaneously in another. Subtle bowstringing of the flexor digitorum profundus tendon occurred only after two consecutive pulleys had ruptured (either the A2 and A3 pulleys or the A3 and A4 pulleys). Rupture of all three pulleys was required to produce obvious bowstringing. Isolated rupture of the A2 or A4 pulley did not result in detectable bowstringing of the flexor digitorum profundus tendon. The A1 pulley always remained intact. CLINICAL RELEVANCE: Bowstringing of the flexor digitorum profundus tendon across the proximal interphalangeal joint with resisted flexion of the fingertips has been considered diagnostic for isolated closed rupture of the A2 pulley. The results of the present study, however, suggest that isolated injury of the A2 pulley rarely occurs. On the basis of our findings, we believe that reliance on bowstringing of the tendon at the proximal interphalangeal joint as an indicator of an isolated rupture of the A2 or A4 pulley may be misleading.