Multiple-pulley ruptures are the surgical ones and they are time-critical: double-pulley injuries need surgery if therapy starts later than 10 days after the injury, and full load returns only after 6–9 months
Key Findings
Surgery is indicated for all triple-pulley injuries (A2, A3 and A4) and for double-pulley injuries (A2/A3 or A3/A4) when the injury is older than 10 days at the start of therapy or the bowstringing cannot be reduced on ultrasound.
Grading used: strain (grade 1), partial tear (grade 2), complete single tear (grade 3), double-pulley injury (grade 4a) and triple-pulley injury (grade 4b).
Single-pulley injuries (grades 1–3) are treated conservatively with early functional therapy and a thermoplastic pulley support ring.
After surgery: immobilisation for at most 2 weeks; free movement without the ring from 6 weeks; easy climbing after 4 months with protective taping, continued for another 6 months; full sport-specific load after 6 to 9 months.
Practical Application
Red flags that mean a hand specialist this week, not "rest and see": a pop with immediate pain on a crimp, a tendon that visibly lifts off the finger when it is flexed against resistance (bowstringing), swelling over more than one finger segment, or loss of full flexion.
The 10-day window is the reason for urgency: waiting can turn an injury that could be splinted into one that needs reconstruction.
This grading puts a complete single rupture at grade 3; the table in REF-1037 is worded differently — do not mix the two, and do not assign a grade at all.
Limitations
A technique description from one centre: expert opinion, no patient series. Full text was read.