FINGER INJURIES IN ROCK CLIMBING

4. Grade 1-3 injuries (strains, single or par- tial ruptures) can be treated conservative- ly, while grade 4 injuries (multiple rup- tures) require surgical repair.

Grade 1 injury Grade 1 injuries are pulley strains with less than 2mm dehiscence of tendon from bone as shown on an ultrasound or MRI scan. With a Grade 1 injury symptomatic treat- ment can be given. Mobility needs to be maintained but if immobilisation is required it should be applied only to the involved joint allowing free movement at the joint above and below. This will main- tain mobility of the long tendons in their sheaths that cross the involved joint (8). Transverse friction massage to the site of the lesion may help to prevent the devel- oping scar tissue adhering and restricting movement. Gentle isometric and mobility exercise within the pain free range can begin one or two days after injury. As hand function returns the exercises can be pro- gressed appropriately. As pain may inter- fere with the functional use of the hand for some weeks after the injury, taping can be used to minimise stress through the joint.

Grade 2 injury Grade 2 injuries consist of either a com- plete rupture of the A4 pulley or a partial rupture of the more essential A2 or A3 pul- ley. Full recovery can normally be achieved in 4-6 weeks post injury. Depending on local swelling and the time post injury, immobilisation should be considered for the first 10 days. This is best achieved by a palmar splint and elevation in a sling. Splinting should be in a protective position to prevent capsular and ligamentous con- tracture while also protecting the joint from further injury. Icing and non-steroidal anti-inflammatory drugs may be used to reduce the inflammation. Taping should be applied when climbing for pulley protec- tion for the following three months.

Grade 3 injury Grade 3 injuries have a prolonged recovery and consist of complete ruptures to either the A2 or A3 pulley. Immobilisation is again necessary usually for 10-14 days post injury and then intensive functional reha- bilitation must begin as soon as possible after this. A thermoplastic/soft-cast ring should be used for pulley protection during the following four weeks. Exercises to work on the pinch and power grip actions can be used initially. Small objects can be used to

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Figure 1: Diagnostic and therapeutic algorithm (Schoffl et al, 2003)

Suspected pulley rupture X-ray Fracture Yes No Ultrasound Dehiscence of tendon from bone < 2mm Strain

Symptomatic therapy

> 2mm Single rupture

Conservative treatment

Questionable MRI

Multiple ruptures

Surgical repair

improve the pinch grip and larger items to affect the power grip, in activities such as lifting, holding and releasing. Mobility may be performed by isolating the movement to the affected joint and then this can be taught to the climber as a self-help exer- cise performed with their uninjured hand. Isometric exercises could include the use of therapeutic putty, elastic tubing, Theraband hand exerciser and small weights. It is important to include functional exercises such as pushing, pulling, locking, rapid grip changes and releases. Easy sport-spe- cific activities are allowed after 6-8 weeks. Return to full climbing can be achieved after three months, with the use of addi- tional taping for pulley protection, up to six months post-injury.

Grade 4 injury Grade 4 injuries require surgical interven- tion to prevent any functional deficit. Postoperatively, immobilisation will be necessary for two weeks, followed by early functional rehabilitation with the protec- tion of a thermoplastic/soft-cast ring for four weeks. Early controlled motion should be allowed to prevent contractures and to

maintain differential tendon gliding in the sheath but protect the sutured tendon. This can be in the form of passive flexion and extension of the finger and also joint mobilisation. Transverse friction massage needs to be started to reduce any scar adhesions. Four weeks postoperatively active range of movement can gradually be increased. Light resistance work can be introduced with therapeutic putty and the hand can be used in light functional activ- ities. By 8-10 weeks the emphasis should be on progressive grip-strengthening exer- cises and endurance work with sustained grasp activities. If contractures exist dynamic splinting may be required and a vigorous stretching regime introduced with joint mobilisation techniques. Easy sport- specific activities can be resumed at four months but the use of taping for pulley protection during climbing should be continued for at least 12 months.

PREVENTION Many climbers will use circumferential tap- ing of the proximal phalanges as a method of preventing flexor tendon pulley injury. Given the anatomy of the annular tendon

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