The A2 pulley is the proximal pulley overlying the proximal phalanx, the longest and most clinically important annular pulley. Its preservation is essential in flexor tendon repair — sacrifice causes bowstringing that severely limits grip. In trigger finger surgery, the A1 pulley is released but the A2 must be preserved. Partial A2 tears in rock climbers cause the most functionally disabling pulley injuries.
Primary restraint to flexor tendon bowstringing at the proximal phalanx; the most important pulley for finger flexion efficiency; cannot be sacrificed without causing bowstringing.
The A2 pulley is the primary pulley for all digital flexor tendon reconstructions. Zone 2 flexor tendon repair (within the flexor sheath between A1 and A2) requires careful preservation of the A2 pulley edge. Bowstringing from A2 sacrifice is corrected by pulley reconstruction using a tendon graft looped around the proximal phalanx.
Forced passive MP extension during active crimp grip tears the A2 pulley producing an audible snap and bowstringing of the flexor tendons, the most common pulley injury in rock climbers, managed by 6-8 weeks of thermoplastic ring splinting.
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