Flexor tendon pulley system: anatomy, pathology, treatment

F. Moutet

Chirurgie de la main 22 (2003) 1–12
DOI: 1 0 . 1 0 1 6 / S 1 2 9 7 - 3 2 0 3 ( 0 2 ) 0 0 0 1 0 - 0

Abstract:
Flexor tendon pulley system has been very early noticed and described. Terminology usually accepted recognizes 6 arcifom pulleys (A0 to
A5) and 3 cruciform pulleys (C1 to C3). Anatomy and physiology of this flexor tendon gliding and reflection system at the level of the digital
sheet are exposed. The integrity necessity of this system became obvious regarding the flexor tendons repair.

Four main pathologies may be concerned:
• the trigger finger congenital or progressive, due to a chondroid metaplasia of the A1 pulley;
• tenosynovial ganglions arising at the weak point between A1 and A2 pulley;
• lesions of the flexor tendon sheet during traumatic lacerations or surgical repairs;
• quite experimental lesions creating isolated ruptures of one or several pulleys which occur during sport practice, especially high level rock
climbing.

The repair techniques are exposed to allow to graduate and hierarchy the reparation technique regarding the pathology. A2 and A4 repair is
always indicated. The best reconstruction material is a an extensor retinaculum graft. But its poor surface available often draws to use
conventional palmaris longus free graft.