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Dr. Stern, we've got a brave 46-year-old rock climber

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3 00:00:05,630 --> 00:00:08,350 who sustained an injury while rock climbing.

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And, um, we're looking at a,

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I think, the ring finger here.

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And, um, here's the long finger next to it.

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And you can see where we are proximal

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to distal by following the lines.

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This is a coronal T1-weighted image.

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So let's go right down to the joint level

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where we'll find the A1 pulley.

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And the A1 pulley looks fine.

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Looks a little attenuated on the T1, but when

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you go to the T2, it shows up very nicely.

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And, uh, go right back to the joint.

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All is well at the joint.

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Now we go distally.

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And all of a sudden, suddenly and without warning,

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on the radial side, there's loss of the pulley.

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You can see the pulley on the other side.

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Then it comes back again.

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It's a little saggy looking.

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There's some fluid pushing it away.

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And then as we keep going, we've got two pulley

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like structures, although attenuated on the T1.

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And the reason that can occur is you can have scar

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tissue there that actually simulates the pulley.

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So that may be occurring, and as

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we keep going, we still have trouble

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seeing the radial side of this pulley.

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But let's keep going to see

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if it shows up on the T2-weighted image.

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And indeed, as we get more distal,

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everything is just blown to smithereens.

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That one's gone.

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That one is no longer attached.

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And the configuration and signal, too

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thick, too irregular, and then nothing.

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Now the flexor tendons are completely bowed

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forward, and there's no pulley seen whatsoever.

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So the A2 pulley is a pretty long structure.

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In my experience, it can get injured,

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you know, anywhere along its length.

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You can injure a hemipulley, you can injure

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half the pulley, both sides of the pulley.

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So how do you deal with a pulley

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injury in somebody that's, you know,

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an active participant in rock climbing?

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So, pulley injuries, uh, are very difficult to

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deal with, and as you said, they can be, uh, really

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bad where, uh, you can visibly see the, uh, flexor

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tendons, the sublimus profundus, uh, anteriorly.

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Here, uh, if, as an orth, with the orthopedic

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eye, the only thing that I would really appreciate

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is that there's a distance from the anterior

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surface of the proximal phalanx, uh, to the

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flexor tendons when I compare adjacent fingers.

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The, uh, flexor tendons should lie, uh, virtually

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adjacent to the volar cortex of the proximal phalanx.

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Like on the long finger here.

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Exactly.

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In the middle finger, uh, that's absolutely,

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um, the correct anatomic location.

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In general, from a clinical standpoint, my experience

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has been that pulley reconstruction can be frustrating

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and patients end up with, uh, stiff fingers.

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So in an injury like this, which is not devastating,

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uh, we would generally treat them with something

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called a pulley ring, which is the same thing

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as, uh, any type of ring that you would put on

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your finger, except it would be a little longer.

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And, uh, they would wear that full time, and

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they generally are not allowed to rock climb

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for anywhere between two and three months.

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Uh, for more devastating injuries, where

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there's a lot of bowstringing, uh, we

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might consider pulley reconstruction, and

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that's a very, very long, long discussion.

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But I'm, I'm quite conservative, uh, with my

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management of, uh, this type of injury.

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I would call it a low to intermediate

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grade, uh, pulley injury.

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Now, if this was, if this was, say, a 21

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year old professional rock climber, would

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that affect how aggressive you are with the

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surgery, or would you go at it the same way?

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I would, well, my daughter's a rock climber.

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She's not a professional, but she probably

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climbs, uh, two or three times every week of

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the year that she, that the weather permits.

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And, uh, they are very

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difficult patients to take care of.

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When, when can I go back, et

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cetera, et cetera, et cetera.

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I would be very conservative

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on a professional rock climber.

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Okay, and then here on the sagittal, you know, we bent

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the finger and you can see the flexor tendons bowing.

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There's no real measurement you can use.

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You just have to look at the other fingers and then

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get a feel for what's an acceptable amount of bowing.

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But you can see the flexor tendons are

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moving drastically away from the MCP,

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which is kind of part of the whole.

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The whole complex, uh, syndrome

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of pulley mechanism injuries.

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And one thing I also try and

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do is compare the sick finger.

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And in this case, I think I

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said it was the index finger.

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That's incorrect.

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It's the ring finger.

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But I compare the ring finger with the adjacent

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normal digit, which in this case is the long

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finger, to help me with the anatomy and

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decide, you know, what's variant, what's

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really torn, and how much bowing I have.

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And here we clearly have distance, even in

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the non-flexed position between the flexors.

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On the ring finger and on the middle finger.

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There are the sublimus tendons wrapping

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around, and there's the profundus for anatomy.

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Any other comments before we get out of this case?

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Uh, I think you've well described things.

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Great.

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Dr. P and Dr. Stern out.