Primarily conservative treatment for triple (A2-A3-A4) finger flexor tendon pulley disruption

Triple finger flexor tendon pulley injuries (A2-A3-A4) are generally reconstructed due to the considerable extent of bowstringing and resulting loss of range of motion (ROM). We present a series of 11 patients (12 cases) with triple pulley lesions. Six cases were diagnosed acutely (<2 weeks after injury), one subacutely (4 weeks), 3 late (>2 months) and 2 incidentally (asymptomatic). All patients but one were climbers. All acute and subacute patients were initially treated with two-pulley protection splint at the centre of the middle and proximal phalanx, proximal interphalangeal (PIP) joint extension splints for 2 months and had occupational therapy to prevent extension deficit. At 6 months' follow-up, the 6 patients with acutely and the 1 subacutely diagnosed injuries were back climbing at the same level. Almost no pain or restriction in daily activities remained; they had full flexion but a slight extension deficit (0-25°). Two of the three patients who were seen and diagnosed late had secondary pulley reconstruction because of persistent pain and increased extension deficit in the PIP joint. Both patients gained almost full range of motion without remaining pain. The third patient was asymptomatic with an extension deficit of 30°. Our case series suggests that early conservative treatment in acute and subacute triple pulley ruptures holds promise to decrease bowstringing, regain full flexion and return to pre-injury climbing level. Delayed diagnosis with delayed treatment is associated with less favorable results. Secondary pulley reconstruction of these chronic injuries yields good results even when performed months after the injury occurred.