TECHNIQUE

Anatomic Considerations and Reconstruction

of the Thumb Flexor Pulley System
Andrew D. Schneider, MD, Mukund Srinivas, BS, Fady Y. Hijji, MD,
David Jerkins, MD, and Sunishka M. Wimalawansa, MD, MBA

ANATOMY
Abstract: Disruption to the flexor pulley system of the thumb is an
infrequent but devastating injury that can lead to significant compromise in
The thumb pulley system consists of 1 oblique and 2 annular
both strength and function. Acute rupture leads to pain, weakness, reduced
pulleys (Fig. 1). The A1 and A2 pulleys arise from the volar plate
range of motion (ROM), and potential bowstringing of the flexor tendons.
at the level of the metacarpophalangeal (MCP) joint and inter-
Conservative treatment with a pulley ring should be considered in all patients.
phalangeal (IP) joint of the thumb, respectively. The oblique pulley
However, failure of conservative treatment and bowstringing of the thumb are
runs along with the proximal phalanx on the ulnar side proximally
indications for operative intervention. Reconstruction of the oblique pulley
to the radial side distally and can be subdivided into an Av segment
system can be performed either in situ or using a free palmaris longus graft.
proximally.13 It has been demonstrated that the presence of either
Care should be taken to identify the neurovascular bundles to avoid com-
the A1 or oblique pulley is sufficient to maintain acceptable thumb
pression during the reconstruction. Conscious sedation protocols augmented
function.12 However, this concept has been challenged with con-
by ultrasound-guided sheath blocks allow the patient to actively and strongly
flicting data showing that an intact oblique pulley is not sufficient
contract the flexor pollicis longus tendon intraoperatively to appropriately
to prevent bowstringing of the flexor pollicis longus (FPL) tendon
tension the construct for optimal results. Rehabilitation should be performed
in the absence of the A1 and Av pulleys.14 In either case, bow-
in a stepwise manner beginning with early passive ROM, active ROM, and
stringing of the FPL should alert the clinician that damage to the
finally strengthening at around 8 weeks postoperative.
A1, Av, or oblique pulleys has occurred.
During the operative reconstruction of a pulley rupture,
Key Words: thumb, bowstringing, pulley, annular, oblique, the neurovascular bundle must be carefully identified and dis-
reconstruction, Av sected to prevent compression from the graft. The princeps
(Tech Hand Surg 2019;23: 191–195) pollicis artery, arising from the radial artery, courses along the
ulnar side of the first metacarpal bone to the base of the
proximal phalanx, where it lies beneath the tendon of the FPL
muscle and divides into 2 branches. The 2 branches run along
he flexor pulley system’s detailed anatomy is essential for
T the complex functions of the hand. The pulleys maintain
the mechanical advantage for the flexor tendons, allowing
the radial and ulnar aspects of the thumb. In addition to the
branches of the artery, the proper palmar digital nerves off the
median nerve run along the sides of the thumb (Fig. 2).
maximal angular motion with limited tendon excursion.1 Injury
to this system is relatively uncommon, with an annual incidence
ranging from 0.18 to 0.35 per 100,000 persons.2 Injury INDICATIONS/CONTRAINDICATIONS
requiring reconstruction to the pulley system has been descri- Diagnosing a flexor pulley rupture requires a complete history
bed primarily in case reports, with these injuries occurring and physical examination during the initial visit. Previous
mainly in rock climbers or secondary to corticosteroid
injections. These injuries can also be a result of iatrogenic
pulley injury during trigger finger release.3–7 Several techniques
for the reconstruction of the flexor pulley system have
been described in the literature. These techniques fall into
2 broad categories of reconstruction, circumferential and
noncircumferential.3–5,8–11 In general, the principles to restore
proper pulley function consist of replicating the length of
the native pulley, appropriate tensioning of the construct, and
use of a synovial graft.8 Similar reconstructive techniques of the
thumb have been described in previous literature. However,
these descriptions have either utilized other grafting techniques
or have been limited in their description of the operative
technique. This article will discuss our preferred method for
reconstructing the A1, Av, and oblique pulley system of the
thumb using a palmaris longus tendon autograft.

From the Department of Orthopaedic and Plastic Surgery, Boonshoft School

of Medicine, Wright State University, Dayton, OH.
Conflicts of Interest and Source of Funding: The authors report no conflicts of
interest and no source of funding.
Address correspondence and reprint requests to Sunishka M. Wimalawansa,
MD, MBA, 30 E. Apple Street, Suite 2200, Dayton, OH 45409.
E-mail: [email protected]. FIGURE 1. Anatomy of the flexor pulley system of the thumb.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Reproduced with permission from Zissimos et al.12

Techniques in Hand & Upper Extremity Surgery  Volume 23, Number 4, December 2019 www.techhandsurg.com | 191
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
Schneider et al Techniques in Hand & Upper Extremity Surgery  Volume 23, Number 4, December 2019

Conservative treatment should be attempted initially even

after the diagnosis of a flexor pulley rupture is confirmed with
imaging. Patients should be given a pulley ring splint to place
over the injured pulley and advised on activity modification.
The pulley splint has been shown to be an effective con-
servative treatment that helps with reducing pain, restoring
motion, and improving function in pulley ruptures.16 Although
using the splint, patients should be advised to avoid strong
flexion or gripping with the injured finger.7,16 If pain and
function do not improve with the pulley splint and activity
modification, operative reconstruction should be considered. In
the setting of operative reconstruction, obtaining full passive
ROM of the thumb preoperatively is recommended. In cases
with chronic joint laxity, patients with thumb pulley lesions
frequently lose motion at the IP joint and often compensate with
hyperflexion of the MCP joint of the thumb. In these patients, a
preoperative course of hand therapy with a focus on MCP
FIGURE 2. Neurovascular anatomy of the thumb. Reproduced
with permission from Shubinets et al.15 blocking techniques during IP motion exercises is recom-
mended to restore supple joints.
When pursuing operative intervention for flexor pulley
studies in the literature have shown increased prevalence of rupture, the timing of diagnosis relative to the injury may
pulley ruptures in patients with a history of rock climbing, influence the operative technique. In an acute setting, a primary
recent corticosteroid injections in the hand, or operations for repair may be performed depending on the quality of the local
trigger finger release.3–7 Patients with a pulley rupture might tissue encountered intraoperatively. Should the tissue be robust
also recount a specific moment where they would have felt a enough to tolerate primary repair, this may be attempted. This
“snap” in their hand while gripping something corresponding technique is often paired with a step-cut lengthening technique
with the rupture.7 to avoid secondary pulley contracture or stenosis. With chronic
Patients with an acute injury to the flexor pulley system or attritional pulley ruptures, poor local tissue quality frequently
will present with pain at the site of injury, both to palpation and inhibits direct primary repair. The following technique utilizes a
during active range of motion (ROM). Later, patients will free autograft to provide healthy tissue to reconstruct the pulley
present with painless loss of motion and strength of the affected system and resist the strong counter-forces produced by
digit. Consequently, during the physical examination, patients the FPL.
should be evaluated in regard to the ROM of all fingers in
addition to tenderness with movement, ability to pinch, and
power gripping. Tenderness to palpation and crepitance might OPERATIVE TECHNIQUE
also be present within the vicinity of the suspected rupture. The Under ultrasound guidance, the palmaris longus sheath should
presence of bowstringing is a clear sign that disruption to the be accessed and anesthetized with local anesthetic (Fig. 4). Care
pulley system has occurred (Fig. 3). To observe bowstringing, should be taken to avoid extravasation into the FPL muscle
patients should be instructed to flex the injured finger in a belly so that active ROM may be assessed at the appropriate
strong crimp grip against resistance.7 time to establish proper tension of the construct; maintaining
A rupture should be suspected whether the previous the injection within the palmaris longus sheath will produce
clinical findings are present and further imaging should be effective anesthesia at the tendon graft donor site, whereas
initiated. Magnetic resonance imaging can confirm pulley preventing FPL chemical paralysis. This is essential to our
rupture. In addition, dynamic ultrasound can also confirm the technique, as active power pinch is required to identify the
presence of bowstringing. If bowstringing is not present or the correct tension of the pulley reconstruction. In addition, wrist
pulley is partially ruptured, conservative treatment should be blocks of the median and radial nerves should be performed to
sufficient.7 adequately anesthetize the thumb recipient site.

FIGURE 4. Preoperative local anesthetic plan. The palmaris

longus sheath is accessed using ultrasound guidance taking care
to avoid extravasation onto the flexor pollicis longus muscle belly.
FIGURE 3. Clinical bowstring in a patient with a ruptured A1 and Note the blanching of the skin along the injection path in the
Av pulley. forearm because of epinephrine.

192 | www.techhandsurg.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.

Techniques in Hand & Upper Extremity Surgery  Volume 23, Number 4, December 2019 Thumb Flexor Pulley Reconstruction

The dissection can then be performed under tourniquet Both digital neurovascular bundles should be dissected
control for optimal visualization. Of note, the tourniquet is from the skin flap and circumferentially released from the
applied initially for hemostasis and pristine visualization during proximal phalanx to allow tunneling of the tendon graft
dissection and exposure. The tourniquet is later taken down between the nerve and phalanx. Dissection of a tunnel between
following graft application and before patient participation in the proximal phalanx and the deep surface of the extensor
active FPL flexion to allow for appropriate construct tensioning. mechanism, and between the FPL and the bilateral digital
Adequate time must be given following tourniquet discontin- neurovascular bundles should be performed. A Penrose drain or
uation to reverse tourniquet paralysis and prevent any alteration pediatric feeding tube can be used to mark the plane for tendon
of FPL excursion. This technique can be modified to an entirely graft passage (Fig. 5B).
Wide Awake Local Anesthetic No Tourniquet (WALANT) The palmaris longus tendon is harvested using a single
protocol if desired. wrist incision and a tendon stripper. The tendon graft is then
An ulnarly based skin flap is developed to expose the passed volarly superficial to the FPL tendon, laterally beneath
thumb flexor system. A transverse incision should be made in the radial and ulnar neurovascular bundles, and dorsally
the thumb IP flexion crease; this should be carried in the radial between the proximal phalanx and the extensor mechanism.
mid-lateral line over the proximal phalanx, and then extended Before passing the graft volarly, a 0.035” K-wire should be
obliquely into the thenar eminence, sparing the weight-bearing used as a spacer under the reconstruction to establish adequate
palm area (Fig. 5A). This incision design provides optimal space between the FPL and graft to prevent overtightening of
surgical exposure and visualization of the key structures, the pulley reconstruction that could otherwise produce trig-
maximizes perfusion to the skin flap through the dominant ulnar gering symptoms. Before passing the graft dorsally, a penrose
digital arterial system, minimizes scar placement on weight- drain or pediatric feeding tube should be placed into the dis-
bearing structures, and preferentially loads the dissection on the sected space in between the proximal phalanx and the extensor
radial side of the thumb (sparing the more functionally tendon to allow for adequate visualization and to avoid inad-
important ulnar digital artery and nerve as much as possible). vertent tethering or trapping of the extensor mechanism. In
Superficial dissection should consist of a full-thickness skin flap addition, the thumb IP joint should be flexed and extended
and identification of the neurovascular bundles on both the passively with each pass of the encircling tendon wrap to ensure
radial and ulnar sides. Deep dissection should allow for the that no undue tethering extrinsic forces were accidentally
identification of the A1, oblique, and Av pulleys to confirm applied on the extensor/flexor mechanisms. At least 3 circum-
rupture. Clinical bowstringing can be confirmed at this time ferential wraps should be secured with provisional sutures to
as well. allow for clinical assessment of the construct (Fig. 5C).

FIGURE 5. A, Ulnarly based thumb flap used to maximize perfusion because of the dominant ulnar artery, whereas minimizing scar
placement overweight-bearing structures. B, Complete dissection demonstrating the radial neurovascular bundle identified by vessel
loops and tunneled graft space demonstrated by the Penrose drain. C, Preliminary graft in placement with graft ends secured with
small hemostats. D, Final construct before closure.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. www.techhandsurg.com | 193
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
Schneider et al Techniques in Hand & Upper Extremity Surgery  Volume 23, Number 4, December 2019

The patient should be awoken from anesthesia and the for future surgery, etc.) should be discussed with all patients before
tourniquet should be subsequently taken down to reverse undergoing a thumb pulley reconstruction.9,16–19 Patients should be
tourniquet ischemia/paralysis. Meticulous surgical site hemo- advised on strict adherence to rehabilitation protocols in order to
stasis should be achieved during this time. Tacking sutures are decrease the risk of these complications. Stiffness is a common
placed in the pulley reconstruction at this stage to help gauge cause of failure of complete recovery of function postoperatively.
the ideal graft tension. Once sufficient FPL strength has Literature has shown postoperative stiffness can be avoided if
returned (~10 min later), active ROM should be assessed and patient is compliant with rehabilitation.17 If stiffness persists with
the graft appropriately tensioned, including power pinch. If rehabilitation, revision should be considered. Scarring because of
residual bowstringing persists along with the proximal phalanx, surgery can lead to adhesions; these adhesions from scar tissue can
the pulley reconstruction should be further tightened; if bow- bind the tendons to surrounding tissue, leading to a failure of the
stringing occurs across the MP joint, a fourth wrap should be graft. Patients should be counseled on the necessity of tenolysis if
performed proximally and obliquely toward the radial pulley scar tissue leads to incomplete recovery of function.18
remnant to reconstruct the oblique pulley. Again, clinical Infection is not a common complication in flexor pulley
assessment for bowstringing resolution should be performed reconstruction procedures. It is usually preceded by synovitis,
with the patient’s active thumb flexion against resistance. With which can be caused by excessive activity or poor graft placement.
appropriate tension established, the construct should be locked When synovitis is suspected, the patient should be managed
into place with several figure-of-eight 3-0 supramid sutures quickly with immobilization in order to prevent subsequent infec-
placed proximally and distally into the surrounding local tissue tion. The tendon graft needs to be removed in the setting of
to minimize the risk of pulley displacement or migration. infection, and the patient will require antibiotics and debridement.1
Next, weave the proximal-most tail of the tendon graft into In addition to the standard operative complications, pro-
the radial remnant of the Av pulley overlying the MP joint. cedure-specific complications that require discussion are as
Additional 3-0 polydioxanone figure-of-eight sutures should be follows: appropriate graft tensioning, graft failure or rerupture,
placed to link the loops together and strengthen the construct. and phalanx erosion or fracture. When reconstructing, a flexor
Sutures should be placed with knots buried, and after each pulley correct graft tension is the key to restoring full ROM.
suture is placed, active thumb ROM is performed to ensure no Inappropriate graft tensioning, particularly overtensioning of
suture was passed through the FPL tendon. The excess graft the graft, can lead to finger stiffness or triggering. However, a
should be excised (Fig. 5D). Finally, the patient should actively conscious sedation protocol allows for assessment of graft
perform full thumb flexion and extension freely and against tension intraoperatively to ensure this is done appropriately.
resistance to ensure the integrity of the pulley reconstruction As with any grafting procedure, patients should be advised
and to confirm complete flexor and extensor tendon excursion. on the failure or the rupture of the graft itself. Strict adherence
The patient should be placed in a thumb spica splint with to rehabilitation protocols and following up regularly have been
the thumb in the intrinsic plus position and the wrist in slight shown to help prevent graft failure.16,17 Patients should be
flexion and ulnar deviation. This position relaxes the FPL to counseled on their total likelihood of requiring reoperation; a
protect the reconstruction. Digits 2-5 should be left free to allow 10-year epidemiologic study on this procedure showed a
for immediate postoperative active and passive motion. reoperation rate of 6%.2
In addition, resorption of the proximal phalanx underneath
POSTOPERATIVE COURSE AND REHABILITATION the reconstruction has been described in case report literature.
One week postoperatively, the wounds are examined and the splint is This was hypothesized to be because of increased pressure at
exchanged for a custom modified orthoplast thumb spica brace. the graft bone interface. However, the authors note that circu-
Barring wound healing complications, occupational therapy is begun latory deprivation might have played a role as well.19 Care
with gentle passive FPL tendon gliding through the IP exclusively, should be taken to avoid an intraoperative phalanx fracture.
protecting the pulley reconstruction by passively holding the thumb However, should this occur it should be managed in accordance
MP in extension with the thumb carpometacarpal and wrist joints in with standard practices.9
mild flexion. Once the reconstruction is adequately healed (around
4 wk postoperatively), a removable thumb pulley ring is added to CONCLUSION
allow for light active ROM exercises out of the brace. At 6 weeks Disruption to the flexor pulley system of the thumb is an
postoperatively, we initiate progressive thumb place-and-hold infrequent but devastating injury that can lead to significant
exercises. No gripping or pinching activities are allowed for the compromise in both strength and function. Reconstruction of
first 8 weeks; following this, progressive strengthening exercises the A1 and oblique pulleys can be performed using a free
are initiated. palmaris longus graft. Care should be taken to identify the
neurovascular bundle to avoid compression during the
EXPECTED OUTCOMES reconstruction. A conscious sedation protocol should be used
With proper tensioning of the autograft, patients can expect to allow the surgeon to assess the correct tension of the
90% to 100% recovery of strength relative to the contralateral construct intraoperatively for optimal results. Rehabilitation
side by 6 months postoperatively. Postoperative stiffness and should be performed in a stepwise manner beginning with
pain can be expected in all patients and must be appropriately passive range of motion early with progression to place-and-hold,
treated with therapy to ensure an optimal outcome. Our active range of motion and finally strengthening.
rehabilitation protocol maximizes tendon gliding and early
mobilization, whereas delaying strengthening to minimize the
risk of both stiffness and graft rupture. REFERENCES
1. Mehta V, Phillips CS. Flexor tendon pulley reconstruction. Hand Clin.
COMPLICATIONS 2005;21:245–251.
Standard surgical complications (eg, stiffness, neurovascular injury, 2. Dy CJ, Lyman S, Schreiber JJ, et al. The epidemiology of reoperation
scarring, infection, failure of complete recovery of function, need after flexor pulley reconstruction. J Hand Surg Am. 2013;38:1705–1711.

194 | www.techhandsurg.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.

Techniques in Hand & Upper Extremity Surgery  Volume 23, Number 4, December 2019 Thumb Flexor Pulley Reconstruction

3. Arora R, Fritz D, Zimmermann R, et al. Reconstruction of the digital technique and biomechanical analysis. Tech Hand Up Extrem Surg.
flexor pulley system: a retrospective comparison of two methods of 2006;10:114–117.
treatment. J Hand Surg Eur Vol. 2007;32:60–66. 12. Zissimos AG, Szabo RM, Yinger KE, et al. Biomechanics of the thumb
4. Fazilleau F, Cheval D, Richou J, et al. Reconstruction of closed rupture of flexor pulley system. J Hand Surg Am. 1994;19:475–479.
thumb flexor tendon pulleys with a single free palmaris longus tendon 13. Wilson SM, Roulot E, Le Viet D. Closed rupture of the thumb flexor
graft: a case report and review of literature. Chir Main. 2014;33:51–54. tendon pulleys. J Hand Surg Br. 2005;30:621–623.
5. Kimura M, Kuroshima N, Matsushita T. Flexor pulley reconstruction 14. Bayat A, Shaaban H, Giakas G, et al. The pulley system of the thumb:
after rupture following corticosteroid injections for trigger thumb: a case anatomic and biomechanical study. J Hand Surg Am. 2002;27:628–635.
report. Hand Surg. 2013;18:425–428.
15. Shubinets V, Elliott RM. Ulnar thumb pulp reconstruction using the
6. Leeflang S, Coert JH. The role of proximal pulleys in preventing tendon anterograde homodigital neurovascular island flap. J Hand Surg Am.
bowstringing: pulley rupture and tendon bowstringing. J Plast Reconstr 2018;43:89.e81–89.e87.
Aesthet Surg. 2014;67:822–827.
16. Schneeberger M, Schweizer A. Pulley ruptures in rock climbers:
7. Moutet F, Forli A, Voulliaume D. Pulley rupture and reconstruction in outcome of conservative treatment with the pulley-protection splint-a
rock climbers. Tech Hand Up Extrem Surg. 2004;8:149–155. series of 47 cases. Wilderness Environ Med. 2016;27:211–218.
8. Dy CJ, Daluiski A. Flexor pulley reconstruction. Hand Clin. 17. Bommier A, McGuire D, Boyer P, et al. Results of heterodigital flexor
2013;29:235–242. digitorum profundus hemi-tendon transfer for 23 flexor tendon injuries
9. Clark TA, Skeete K, Amadio PC. Flexor tendon pulley reconstruction. in zones 1 or 2. J Hand Surg Eur Vol. 2018;43:487–493.
J Hand Surg Am. 2010;35:1685–1689. 18. Zafonte B, Rendulic D, Szabo RM. Flexor pulley system: anatomy,
10. Kaufmann RA, Pacek CA. Pulley reconstruction using palmaris longus injury, and management. J Hand Surg Am. 2014;39:2525–2532; quiz
autograft after repeat trigger release. J Hand Surg Br. 2006;31:285–287. 2533.
11. Slesarenko YA, Baruch A, Mallo GC, et al. Thumb flexor pulley 19. Lin GT. Bone resorption of the proximal phalanx after tendon pulley
reconstruction with distally based extensor pollicis brevis tendon: reconstruction. J Hand Surg Am. 1999;24:1323–1326.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. www.techhandsurg.com | 195
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.