The climber's finger: imaging of non-pulley finger injuries

Climbing is a rapidly growing sport that subjects the fingers to intense mechanical stress, predisposing athletes to a wide spectrum of injuries beyond the well-recognized flexor pulley lesions. Non-pulley-related finger injuries, although often underrecognized, can impair performance, cause chronic pain, and lead to long-term complications such as osteoarthritis, cyst formation, or tendon rupture. These injuries involve flexor tendons, collateral ligaments, volar plates, joint capsules, extensor mechanisms, lumbrical muscles, epiphyseal growth plates in adolescents, digital nerves, and palmar fascia. Multimodal imaging plays a central role in diagnosis, characterization, and follow-up of finger injuries. Conventional radiography is first-line for fractures, avulsions, osteophytes, and epiphyseal injuries. High-frequency ultrasound offers dynamic assessment of tendons, ligaments, muscles, nerves, and fascial structures, detecting edema, tears, or hypervascularity. MRI provides superior soft tissue contrast, delineating occult fractures, tendon pathology, capsular inflammation, and chronic degenerative changes, while CT or CBCT is reserved for complex osseous injuries. Imaging not only identifies acute lesions but also evaluates chronic adaptations such as cortical hypertrophy, subchondral sclerosis, joint widening, and dorsal osteophytes. This narrative review synthesizes current knowledge on the anatomy, biomechanics, and imaging features of non-pulley-related digital injuries in climbers, emphasizing sport-specific mechanisms, including considerations for epiphyseal fractures in adolescent athletes. Recognition of these injuries allows early intervention, targeted conservative or surgical management, and safe return to climbing. Radiologists and clinicians should integrate detailed anatomical knowledge, biomechanical understanding, and sport-specific stress patterns to optimize functional outcomes, prevent long-term complications, and guide follow-up in both elite and recreational climbers.