FLEXOR TENDON PULLEYS

    - A1 pulley:         

 - arises from volar plate of MP joint, beginning 5 mm proximal to the MP joint and ending at the base

of the proximal phalanx;

           - average length of A1 pulley is 1 cm;

           - proximal edge of the 1st annular pulley lies about 2 cm from the proximal finger crease;

           - distal edge of A1 pulley lies about 1 cm from the proximal finger crease;

           - note that the proximal phalangeal crease which lies over the mid portion of the proximal

phalanx, and that the A2 pulley begins and  ends in the proximal half of the proximal phalanx;

                  - hence, a tendon sheath incision which extends past the level of proximal phalangeal

crease will probably incise most the A2 pulley; 

           - note that at the level of the A1 pulley, the FDS flattens out and

bifurcates, allowing the FDP tendon to pass superficial;

    - A2 pulley

           - arises from periosteum of proximal half of the proximal phalanx;

           - total length is 20 mm, along the mid portion of the proximal phalanx;

           - of all of the flexor tendon sheaths, this is probably the most important;

           - vascular considerations:

                 - their is a avascular zone within the intrasynovial portion of the FDS and FDP tendons

under the A2 pulley;

                 - distal to the A2 pulley, a digital arterial ladder branch provides arterial inflow to the

vinculum to FDS and long vinculum FDP;

           - in study by G. Mitsionis MD et al (JHS 1999), it was found that 25% of A2 or A4 pulleys may

be excised either separately or in combination;

          - these authors noted that even excision of upto 75% of the pulley resulted in only minimal

decreases in PIP angular ROM;

           - references:

                 - The second annular pulley: a histologic examination  

                 - The effect of partial A2 pulley excision on gliding resistance and pulley strength in vitro.

                 - "Venting" or partial lateral release of the A2 and A4 pulleys after repair of zone 2 flexor

tendon injuries. 
    - C1 pulley;

    - A3 pulley:

           - arises from volar plate of PIP joint;

           - in the report by Jin Bo Tang, MD et al, the authors studied the effects of the A3 pulley and

adjacent sheath integrity on tendon function

                 at the proximal interphalangeal (PIP) joint was investigated in 21 fingers in 7 fresh-frozen

cadaver hands;

                 - 11 fingers were tested after incision of the A3 pulley, of the A3 pulley and its distal

sheath up to the A4 pulley, and of the sheath from the A3 to A4 pulleys;

                 - tendon bowstringing was 0.3 mm after incision of A3 pulley, 0.6 mm after incision of A3

pulley with its distal sheath, 0.8 mm after incision

                            of pulley with its proximal sheath, 1.4 mm after incision of sheath from A3 to A4

pulleys, and 1.6 mm after incision of sheath

                            between the A2 and A4 pulleys;

                 - results suggest that the sheath adjacent to the A3 pulley plays an important role in

restraining tendon bowstringing at the PIP joint, whereas

                            A3 pulley alone is of little importance;

                 - references:

                            - Effect of A3 pulley and adjacent sheath integrity on tendon excursion and

bowstringing. Tang, MD.  J Hand Surg 2001;26A:855-861. 

                            - The A3 pulley

    - C2 pulley;

    - A4 pulley

           - arises from periosteum of mid-portion of middle phalanx;

           - this is the second most important flexor tendon sheath pulley (after the A2);

           - when the FDS tendon is lost, the A4 pulley becomes most essential;

           - there is an avascular zone of the FDP underneath the A4 pulley;

           - in study by G. Mitsionis MD et al (JHS 1999), it was found that 25% of A2 or A4 pulleys may

be excised either separately or in combination;

           - these authors noted that even excision of upto 75% of the pulley resulted in only minimal

decreases in PIP angular ROM;

           - ref: "Venting" or partial lateral release of the A2 and A4 pulleys after repair of zone 2 flexor

tendon injuries. 

    - C3 pulley;

    - A5 pulley arises from volar plate of the DIP joint;

           - Anatomy and histology of the A5 pulley

Zone I extends from just distal to the insertion of the sublimis tendon to the site of

insertion of the profundus tendon. Zone II is in the critical area of pulleys

(Bunnell's “no man's land”) between the distal palmar crease and the insertion of

the sublimis tendon. Zone III comprises the area of the lumbrical origin between

the distal margin of the transverse carpal ligament and the beginning of the critical

area of pulleys or first anulus. Zone IV is the zone covered by the transverse carpal

ligament. Zone V is the zone proximal to the transverse carpal ligament and

includes the forearm.