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Sonographic Location of Distal A-1. pulley by means of a bony acoustic landmark on the proximal phalynx: an anatomic study
Brian Jurbala, MD
Highland Center for Orthopaedics, Lakeland, FL

Purpose: The objective of this study was to identify the anatomic relationship (if any) between the distal extent of the A-1 Pulley and the insertion of the palmar plate into the base of the proximal phalanx at the so called P-1 peak, a bony acoustic landmark easily identifiable on sonography of the finger corresponding to the distal palmar plate.
Methods: We studied 48 fingers from 12 fresh frozen human cadaver hands. 12 index, 12 long, 12 ring and 12 small fingers were studied. A high resolution sonogram of each finger was performed. The insertion of the palmar plate at the MP joint was located at the P-1 peak area and marked with a needle sonographically with each finger in neutral flexion/extension. Dissection of fingers proceeded and measurement of the actual distance between the needle and the distal edge of the A1 pulley was performed this was followed by further dissection and location of the distal palmar plate at the P-1 peak with comparison to the actual location of the distal A-1 pulley.
Results: We found location of the P-1 peak sonographically with a needle reliably predicted the distal edge of the A-1 pulley within an average distance of 0.5 mm distal to the distal A-1 pulley in all fingers (range 0 to 1.0mm). In all dissections the distal edge of the A-1 pulley was reliably found correspond to the distal palmar plate insertion at the P-1 peak area within 0.5 mm (range 0 to 0.5 mm).
Conclusions: The so called P-1 peak may be used as a reliable, clearly identifiable sonographic landmark on the palmar surface of the finger to identify the distal extent of the A-1 pulley within 1 mm in cases where a clear distinction between the A-1 and A-2 pulley is not evident sonographically. Using this bony acoustic reference will help to ensure greater safety, accuracy, completeness of release in sonographically assisted percutaneous trigger finger release techniques.

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