## 5 Articles with Instrumental Evaluation  
In the study by [PERSON] et al. (2002), a sample of 64 climbers with A2 and A4 pulley injuries was examined using a 12 MHz ultrasound. The aim was to determine if ultrasounds could detect pulley injuries compared to magnetic resonance imaging (MRI). The tendon  
Figure 2: PRISMA Flow Diagram.  
to-bone distance (TBD) was used as an indicator, measured at rest and during active flexion with resistance. A TBD greater than 1.0 mm was interpreted as a lesion. Ultrasound detected 100% of complete A2 pulley lesions, 100% of A4 pulley lesions, and 100% of incomplete A2 pulley lesions. The study concluded that dynamic ultrasounds excellently illustrate pulley injuries in climbers with a sensitivity of 98% and a specificity of 100% [21]. [PERSON] et al. (2003) conducted a prospective study on 604 climbers with hand injuries, classifying pulley injuries based on severity (scored from 1 to 4) by measuring TBD with ultrasound. Pulley injuries were the most frequent in this sample, with 39% Grade 1, 25% Grade 2, 30% Grade 3, and 6% Grade 4. Grades 1 to 3 responded well to conservative treatment, while Grade 4 required surgical repair [19]. [PERSON] et al. (1999) aimed to assess the accuracy of ultrasounds and MRI in diagnosing complete finger flexor pulley injuries. In a prospective study, 32 patients with suspected pulley injuries were evaluated using ultrasound and MRI, with a control group of 10 volunteers. Complete annular pulley injuries were diagnosed by ultrasound and MRI in 14 cases, confirmed by surgery. A TBD of 3 mm at rest and 5 mm with actively flexed fingers indicated complete pulley injury [22]. [PERSON] et al. (1999) dynamically examined 34 climbers with finger injuries using ultrasounds, comparing them with 20 healthy volunteers. Climbers' finger tendons were thicker than those of volunteers, demonstrating significant tendon stiffness. TBD was measured, confirming the validity of ultrasounds in diagnosing pulley injuries [27]. [PERSON] et al. (2017) analyzed 34 cadaver fingers via ultrasound with constant forced flexion to assess A2 and A4 pulley injuries. A 100% detection rate was reported for A2 and A4 pulley injuries, while A3 pulley injuries were more challenging to evaluate. This study was one of the first to use cadaver ultrasound examinations for various pulley injuries, highlighting its efficacy for A2 and A4 pulleys but inadequacy for A3 pulley injuries [23]. [PERSON] et al. (2023) aimed to establish tendon-to-bone distance values for various sizes of partial A2 pulley injuries and compare these values with complete tears. They used 30 in vitro fingers randomly assigned to five groups simulating different degrees of injury. The results showed significant differences between intact pulleys and those with partial or complete injuries, suggesting that a TBD above 3 mm indicates a high or complete A2 pulley tear [24]. [PERSON] et al. (2014) investigated the factors contributing to tendon bowstringing on the proximal phalanx. They used fresh cadaver arms and mechanically loaded flexor tendons and simulated A2 and A3 pulley injuries. Ultrasound revealed significant bowstringing with a 30% A2 pulley removal, while partially removing the A3 pulley did not produce significant bowstringing [17].