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J Hand Surg Am. 2014 Dec;39(12):2525-32; quiz 2533. doi: 10.1016/j.jhsa.2014.06.005. Epub 2014 Nov 21.

Flexor pulley system: anatomy, injury, and management.

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  • 1Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA.
  • 2Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA. Electronic address:


Flexor pulley injuries are most commonly seen in avid rock climbers; however, reports of pulley ruptures in nonclimbers are increasing. In addition to traumatic disruption, corticosteroid-induced pulley rupture has been reported as a complication of treating stenosing tenosynovitis. Over the last decade, there have been 2 new developments in the way hand surgeons think about the flexor pulley system. First, the thumb pulley system has been shown to have 4 component constituents, in contrast to the classic teaching of 3 pulleys. Second, in cases of zone II flexor tendon injury, the intentional partial A2 and/or A4 pulley excision or venting is emerging as a component for successful treatment. This is challenging the once-held dogma that preserving the integrity of the entire A2 and A4 pulleys is indispensable for normal digit function.


Flexor pulley; annular pulley; pulley reconstruction; pulley rupture; rock climbing

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