Clinical: 30 y/o male status post finger injury with pain and weakness.
Dx: Complete disruption of the A4 pulley of the 4th/ring finger. There is interposition of portions of the pulley tissue between the flexor tendons and the middle phalanx which would likely preclude healing without surgical intervention. There is associated tendon bowstringing.
Note: While most of these pulley tears can and are managed conservatively, I have seen more than a few pulley lesions with interposition of pulley tissue between the tendon and the bone. These “interposition” cases come to us most commonly as failures of conservative therapy and based on surgical feedback are more difficult to repair and have worse clinical outcomes because of scarring and fibrosis. Because of this, I strongly recommend finger MRI on cases of suspected pulley tears so you can accurately triage those patients who should heal with conservative management and those patients (like this one) who likely need surgical intervention to preserve functionality. For our referring clinicians, the Diversified MSK section has designed a specific finger protocol that is applicable to most 1.5 Tesla or greater MRI systems with high resolution thin slices with no gaps allowing for excellent visualization of the finger pulley mechanism.
1. Schöffl V, Hochholzer T, Winkelmann HP, Strecker W. Wilderness and Environmental Medicine: 2003 – vol. 14, pp. 94-100.
2. Goncalves-Matoso V, Guntern D, Gray A, Schnyder P, Picht C, Theumann N. Skeletal Radiology: 2008 – vol. 37, pp. 307-312.
3. Schöffl V, Schöffl I. The Journal of Hand Surgery: 2006 – vol. 31A no. 4, pp. 647-654.