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Hand Surgery, Vol. 14, Nos.

2 & 3 (2009) 139142 World Scientic Publishing Company

Arkaphat Kosiyatrakul, Surasak Jitprapaikulsarn, Sebastien Durand and Christophe Oberlin Department of Orthopedic Surgery Upper Limb, Hand, and Nerve Surgery Unit, Bichat Hospital 46, Rue Henri Huchard 75877 Paris, Cedex 18, France Received 6 January 2009; Revised 15 June 2009; Accepted 15 September 2009
ABSTRACT Closed exor pulley rupture of the thumb is extremely rare. We report a case with this condition. The anatomic and biomechanical studies, clinical and operative nding as well as the management of the closed exor pulley rupture of the thumb are discussed. Keywords: Thumb; Flexor; Pulley; Rupture.

Flexor tendon pulley of the digit is a reinforcing structure of the tendon sheath. The functions of the pulleys of the digit are to maintain the tendon close to the bones and joints, to facilitate accurate tracking of the tendon, and to provide mechanical efciency for the motion of the digit. Pulley system of the ngers has ve annular and three cruciate pulleys1 whereas pulley system of the thumb has one oblique and two annular pulleys (A1 and A2).2 Loss of both oblique and proximal pulleys leads to bowstringing of the exor pollicis longus tendon.3,4 Bayat et al.5 described the variable annular pulley or Av pulley and found that when A1 and Av pulleys have been sectioned, the oblique pulley cannot prevent bowstringing of the exor pollicis longus. Closed exor pulley ruptures of the nger are relatively uncommon injuries. These conditions are usually found in rock climbers.6,7 Closed exor pulley rupture of the thumb

is extremely rare. To our knowledge, there have been only two cases reported.8 We reported a case of closed exor pulley rupture of the thumb.

A 53-year-old woman presented with lack of full motion of her right thumb. The patient had a sudden onset of severe pain with clicking sensation in her right thumb while opening a lid of jar one year ago. The patient complained of gradually progressing cord-like structure at the volar aspect of her thumb altogether with decreasing range of motion. The physical examination showed obvious bowstringing of the exor tendon from the metacarpophalangeal joint to the interphalangeal joint (Fig. 1). A magnetic resonance imaging showed bowstring of the exor pollicis longus (Fig. 2). Surgical exploration showed

Correspondence to: Dr. Arkaphat Kosiyatrakul, Department of Orthopaedics, Pharamongkutklao Hospital and College of Medicine, 315 Rachawithi Rd., Bangkok 10400, Thailand. Tel: (+66) 2-246-0066 (ext. 93459), Fax (+66) 2-664-4940, E-mail:


A. Kosiyatrakul et al.

Fig. 1 Physical examination shows the bowstringing of the exor pollicis longus tendon.

Fig. 3 Intra-operative nding shows volar subluxation of the exor pollicis longus tendon.


a volar subluxation of the exor pollicis longus (Fig. 3). The A1, oblique, and A2 pulleys were ruptured. Large amount of brosis was found around the tendon especially in the bone-tendon interval. After the brosis was removed, a full passive range of motion of the metacarpophalangeal and the interphalangeal joints were gained. The reconstruction of the exor pulley was performed by a triple-loop plantaris tendon graft technique proposed by Okutsu et al.9 for the A2 pulley reconstruction of the nger (Fig. 4). Bowstringing disappeared after the oblique pulley was reconstructed (Fig. 5). An active range of motion started at one week after the surgery. The patient gained full active range of motion at two months after the surgery.

(B) Fig. 2 Pre-operative coronal (A) and sagittal (B) magnetic resonance images show the bowstring of the exor pollicis longus. (S = Sesamoid bone, FPL = exor pollicis longus tendon.) Fig. 4 Triple-loop plantaris tendon graft is used to reconstruct the oblique pulley.

Closed Flexor Pulley Rupture of the Thumb


Fig. 5 Bowstringing has disappeared.

Closed traumatic ruptures of the nger exor tendon pulleys are relatively rare injuries. Most of the cases have been identied clinically in rock climbers.7 Closed exor pulley rupture of the thumb is a rare condition. Only two cases have been reported in the literature by Wilson et al.8 The rst case had spontaneous rupture a short period after a steroid injection for a chronic tenosynovitis of the exor pollicis longus tendon. In another case, the rupture occurred while the patient exed the thumb against resistance. This patient also had a history of steroid injection for carpal tunnel syndrome. The mechanism of exor pulley rupture of the nger in climbers is thought to be secondary to the transfer of high forces to the pulleys during crimping position.6,7 However, the mechanism of exor pulley rupture of the thumb is unknown. In the anatomic point of view, Doyle and Blythe2 described the similarity between thumb and nger pulley systems. Bayat et al.5 supported this concept and proposed that the A1- Av-oblique-A2 pulleys of the thumb are comparable to the A1-A2-C1-A3 pulleys of the ngers. However, this comparison cannot fully apply to the clinical nding. Biomechanical studies of Marco et al.6 indicated that the A4 pulley of the nger was predisposed to rupture rst when the hand was in the crimp position and the A1 pulley was almost always intact. In two cases of closed exor pulley rupture of the thumb that reported by Wilson et al.8 and our case, all of the pulleys (A1, oblique, and A2) were ruptured. There are guidelines for a conservative or surgical treatment in the closed pulley rupture of the nger but not for the thumb.7,10 In biomechanical study of Zissimos et al.,3 the bowstring was signicantly observed only when both A1 and oblique pulleys were sectioned. They indicated that repair or reconstruction of

either A1 or oblique pulley will obtain normal thumb kinematics. Esplin et al.4 found that tendon excursion was signicantly increased after sectioning of the exor retinaculum, A1 and, oblique pulleys or after sectioning of the A2, oblique and A1 pulleys. They concluded that an intact oblique or A1 pulley could maintain normal excursion of the exor pollicis longus tendon. In contrast, the anatomic and biomechanical study of Bayet et al.5 showed that the oblique pulley is inserted between two articular bones (proximal and distal phalanx). This pulley was lax during exion and tense during extension of the thumb. They proposed that the oblique pulley may act to restrain hyperextension of the interphalangeal joint of the thumb and has no role in preventing bowstringing. Repair or reconstruction of either the A1 or the Av pulley would be sufcient to obtain the normal thumb motion. However, Le Viet and Samson10 concluded that when both A1 and oblique pulley are absent, the A1 pulley reconstruction with tendinous plasty from the adductor pollicis tendon should be done if a radial stump of the A1 pulley exists. If there is no radial stump of the A1 pulley, the reconstruction should be done with a loop method by passing the tendon graft between the proximal phalanx and the extensor tendon. We reconstructed the exor pulley of the thumb with a triple-loop plantaris tendon graft.9 According to the anatomic study of Doyle and Blythe,2 the reconstructed pulley was placed in the region of the oblique pulley. It may not an anatomic pulley reconstruction as described by Bayat et al.5 However, the position of the thumb interphalangeal joint, exion or extension, has no effect on the reconstructed pulley since the reconstruction conned only in the proximal phalanx. The reconstructed pulley is strong enough to prevent the bowstringing. Closed pulley rupture of the thumb is a rare condition. Surgical treatment seems to be appropriate for this injury. However, the procedure of choice is still controversial.

1. Doyle JR, Anatomy of the nger exor tendon sheath and pulley system, J Hand Surg 13A:473484, 1988. 2. Doyle JR, Blythe WF, Anatomy of the exor tendon sheath and pulleys of the thumb, J Hand Surg 2:149151, 1977. 3. Zissimos AG, Szabo RM, Yinger KE, Sharkey NA, Biomechanics of the thumb exor pulley system, J Hand Surg 19A:475479, 1994. 4. Esplin VS, Tencer AF, Hanel DP, Cosio MQ, Restoration of function of the thumb exor apparatus requires repair of the oblique and one adjacent exor tendon pulley, J Orthop Res 14:152156, 1996. 5. Bayat A, Shaaban H, Giakas G, Lees VC, The pulley system of the thumb: anatomic and biomechanical study, J Hand Surg 27A:628635, 2002.


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6. Marco RA, Sharkey NA, Smith TS, Zissimos AG, Pathomechanics of closed rupture of the tendon pulleys in rock climbers, J Bone Joint Surg 80A:10121019, 1998. 7. Schf VR, Schf I, Injuries to the nger exor pulley system in rock climber: current concepts, J Hand Surg 31A:647654, 2006. 8. Wilson SM, Roulot E, Le Viet D, Closed rupture of the thumb exor tendon pulleys, J Hand Surg 30B:621623, 2005.

9. Okutsu I, Ninomiya S, Hiraki S, Inanami H, Kuroshima N, Three loop technique for A2 pulley reconstruction, J Hand Surg 12A:790794, 1987. 10. Le Viet D, Samson P, Repair of nger exor pulleys 2, in Dunitz M (ed.), Current Practice in Hand Surgery, London, pp. 2527, 1997.

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