Login
Register
Reset Password
Publish & Distribute
Publishing Solutions
Distribution Solutions
Subjects
Architecture and Design
Arts
Business and Economics
Chemistry
Classical and Ancient Near Eastern Studies
Computer Sciences
Cultural Studies
Engineering
General Interest
Geosciences
History
Industrial Chemistry
Jewish Studies
Law
Library and Information Science, Book Studies
Life Sciences
Linguistics and Semiotics
Literary Studies
Materials Sciences
Mathematics
Medicine
Music
Pharmacy
Philosophy
Physics
Social Sciences
Sports and Recreation
Theology and Religion
Publications
Journals
Books
Proceedings
Publishers
Blog
Contact
Search
EUR
USD
GBP
English
English
Deutsch
Polski
Español
Français
Italiano
Cart
Home
Journals
Journal of Ultrasonography
Volume 21 (2021): Issue 87 (November 2021)
Open Access
Sonography of tendon pathology in the hand and wrist
Andrea B. Rosskopf
Andrea B. Rosskopf
,
Carlo Martinoli
Carlo Martinoli
,
Luca M. Sconfienza
Luca M. Sconfienza
,
Salvatore Gitto
Salvatore Gitto
,
Mihra S. Taljanovic
Mihra S. Taljanovic
,
Riccardo Picasso
Riccardo Picasso
and
Andrea Klauser
Andrea Klauser
| Dec 15, 2021
Journal of Ultrasonography
Volume 21 (2021): Issue 87 (November 2021)
About this article
Previous Article
Next Article
Abstract
Article
Figures & Tables
References
Authors
Articles in this Issue
Preview
PDF
Cite
Share
Article Category:
research-article
Published Online:
Dec 15, 2021
Page range:
306 - 317
Received:
Apr 26, 2021
Accepted:
May 15, 2021
DOI:
https://doi.org/10.15557/jou.2021.0052
Keywords
tendon injury
,
hand
,
pulley injury
,
tenosynovitis
,
ultrasound
© 2021 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
Fig. 1.
Zonal classification of extensor tendon injuries: from distal to proximal, odd numbers conventionally refer to specific joint levels. In the fingers: zone I indicates the DIP joint level, zone III the PIP joint, zone V the MCP joint; in the thumb: the IP joint level is zone I, the MCP joint is zone III
Fig. 2.
Extensor pollicis longus full-thickness tear. A. Photograph showing a sutured wound over the dorsal thumb due to a penetrating injury by a glass fragment. B. After repair, long-axis 22–8 MHz US image shows signs of extensor pollicis longus retear. Note the subtotal discontinuity of the proximal tendon end (arrowheads) which appears retracted away from the sutures (thin arrow). Mild fluid (asterisk) fills the gap
Fig. 3.
Schematic drawing of the extensor mechanism of the fingers with corresponding transverse slices: (1) terminal tendon, (2) lateral conjoined tendon, (3) medial conjoined tendon, (4) lateral slip, (5) central slip, (6) medial slip (7) sagittal bands
Fig. 4.
Mallet finger. A. On a longitudinal sonogram, the extensor tendon of the fourth finger (arrows) is completely torn from the distal phalanx (Distal Ph) base. The tendon stump is thickened and hypoechoic at the level of the distal third of the middle phalanx (Middle Ph). Tendon retraction (caliper) measured 4–5 mm. B. On a longitudinal T2-weighted MRI image, the extensor tendon retraction (arrows) is shown in the same patient
Fig. 5.
Boutonniere deformity. A. Lateral radiograph and B. corresponding long-axis 17–5 MHz US image of the middle finger demonstrate a small piece of bone (arrow) avulsed from the base of the middle phalanx. In B, the donor site of avulsion (thin arrow) is shown as a small concavity at the base of the middle phalanx. The retracted fragment (large arrow) is in continuity with the central slip (arrowheads) of the extensor hood
Fig. 6.
Sagittal band injury. A, B. Transverse 17–5 MHz US images over the dorsal aspect of the metacarpal head (MetH) of the right third finger acquired in extension (A) and in clenched-fist (B) position show transient ulnar dislocation of the common extensor tendon (arrowheads) during flexion. Mild local effusion (asterisks) is observed along the tendon path. C. Correlative photograph showing tendon dislocation (arrow) on the ulnar side of the third metacarpal head
Fig. 7.
Schematic drawing of the six extensor tendon compartments of the wrist, labeled from I-VI, adapted from(34). APL – abductor pollicis longus; EPB – extensor pollicis brevis; ECRL – extensor carpi radialis longus; ECRB – extensor carpi radialis brevis; EPL – extensor pollicis longus; EIP – extensor indicis proprius; EDC – extensor digitorum communis; EDM – extensor digiti minimi; ECU – extensor carpi ulnaris; Asterisk – subsheath; LT – Lister’s tubercle; Note the retinacula for each compartment are removed for better visibility
Fig. 8.
De Quervain’s syndrome. Short- (A) and long-axis (B) 24–8 MHz US images over the radial styloid reveal a thickened, hypoechoic retinaculum (arrowheads) and the swollen abductor longus and extensor pollicis brevis tendons. Note that the two tendons form a rounded complex and cannot be separated from each other, being constricted by the abnormal retinaculum
Fig. 9.
De Quervain’s syndrome in a 20-year-old patient, related to selective entrapment of the extensor pollicis brevis by a thickened retinaculum. A. Transverse US image shows a vertical septum (thin white arrow) dividing the two tendons in the first compartment. Fluid (thick white arrow) is seen surrounding the extensor pollicis brevis tendon (EPB; yellow asterisk) due to tenosynovitis. Note the thickening of the surrounding retinaculum (yellow arrow heads). The abductor pollicis longus (white asterisk) and the ventral part of the retinaculum (white arrowhead) are unaffected. The transverse color Doppler image (B) and transverse power Doppler image (C) show increased vascularization (arrow heads) surrounding the EPB tendon due to tenosynovitis
Fig. 10.
Distal intersection syndrome. A. Proximal to the criss-crossing point, transverse 17–5 MHz US image shows a distended sheath (asterisk) of the extensor pollicis longus (EPL) as it runs alongside the ulnar aspect of the extensor carpi radialis brevis (ERCB) and extensor carpi radialis longus (ECRL). B. More distally, transverse 17–5 MHz color Doppler US image demonstrates the extensor pollicis longus (EPL) as it crosses over the extensor carpi radialis brevis (ECRB) and longus (ECRL) tendons. The sheath of the second and third compartments appears mildly distended by tenosynovitis with effusion (asterisk). Note diffuse local hyperemia and the swollen appearance of the ECRB
Fig. 11.
Tenosynovitis of the fourth extensor compartment in a patient with psoriatic arthritis. A. Longitudinal US image with fluid, thickened synovium, and thickened retinaculum (white arrows) around the tendons in the fourth extensor compartment and increased vascularity on longitudinal (B) and transverse color Doppler (C) images, both in the synovium and the tendons
Fig. 12.
Screw tip impingement and tear of the extensor indicis proprius tendon in a 45-year-old woman after volar plating for distal radial fracture. A. Transverse 17–5 MHz US image obtained at the level of Lister’s tubercle (LT) reveals the thread and tip of a screw (thin arrow) impinging the extensor indicis proprius tendon. Note the intact extensor pollicis longus (EPL) and the displaced slips of the extensor digitorum communis (EDC). B. Transverse 17–5 MHz US image obtained proximal to A demonstrates the retracted extensor indicis proprius (arrowheads) surrounded by effusion and debris (asterisk). C. Longitudinal 17–5 MHz US image demonstrates the screw (thin arrow) and the empty sheath (asterisks) of the extensor indicis proprius filled with debris and hypoechoic effusion. Note the normal-appearing tendons of the extensor digitorum communis (EDC) as they run more superficially
Fig. 13.
DExtensor carpi ulnaris (ECU) instability. ECU instability in a patient with long-standing rheumatoid arthritis. US image demonstrates the ECU tendon (white asterisk) dislocated out of the groove (white arrows). The subsheath (void arrowheads) appears lax, wavy, and displaced out of the groove
Fig. 14.
Drawing of the flexor tendons of the finger, superimposed on US image. Superficial – flexor digitorum superficialis tendon (yellow), Deep – flexor digitorum profundus tendon (green), DIP – distal interphalangeal joint, PIP – proximal interphalangeal joint, MCP – metacarpophalangeal joint, VP – volar plate
Fig. 15.
Schematic drawing of superficial (red) and deep (orange) finger flexor tendons with corresponding transverse slices. Palmar plate (blue), bone (grey)
Fig. 16.
Zonal classification of flexor tendon injuries: Zone I distal to the flexor digitorum superficialis (FDS) insertions, Zone II between the FDS insertions and the level of A1 pulleys, Zone III between the proximal aspect of A1 pulleys and the lumbricals origin from the flexor digitorum profundus (FDP) tendons, Zone IV at the carpal tunnel region, Zone V from the distal myotendinous junction to the carpal tunnel, TI distal thumb to the IP joint, TII between thumb IP joint and A1 pulley, and TIII at the thenar eminence
Fig. 17.
Jersey finger. Long-axis 12–5 MHz US image of the middle finger reveals fracture of the volar aspect of the base of the distal phalanx with fragmentation (thin arrow) and proximal migration of a small piece of bone (void arrow) up to the distal edge of the A3-pulley. Note the flexor digitorum profundus tendon (white arrowheads) attached to the avulsed fragment and the empty sheath (void arrowheads) distal to it. DPh – distal phalanx; MPh – middle phalanx; PPh – proximal phalanx
Fig. 18.
Trigger finger. A. On an axial sonogram at the level of the fourth metacarpal head (Met IV), the A1-pulley (straight arrows) is thickened (1.5 mm). Its collateral ligaments appear artifactually hypoechoic due to anisotropy. Note the healthy A1-pulley (curved arrow) at the level of the third metacarpal head (Met III). B. On a longitudinal sonogram, A1-pulley thickening is shown. The flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons show fibrillar echotexture and synovial sheath effusion (asterisks) is seen proximally. Hash marks indicate articular cartilage; Met – metacarpal; Prox Ph – proximal phalanx; VP – volar plate
Fig. 19.
Schematic drawing of annular pulleys (A) and longitudinal US image (B) at the level of the proximal phalanx (PP) with normal thin appearance of the A2-pulley ligament (white arrows). Note the normal tendon-to-bone distance (TBD) of <2 mm (yellow double arrow). Flexor tendons (asterisks)
Fig. 20.
Transverse (A) and sagittal (C) US with normal thin appearance of A2-pulley (white arrowheads) with normal tendon-to-bone distance (TBD) in a non-climber. Transverse (B) and sagittal (D) US shows thickened A2 ligament (white arrowheads) due to chronic overuse in a climber. Images courtesy of Prof. A. Schweizer, Handsurgery, Balgrist University Hospital
Fig. 21.
Annular pulley injury. A. Longitudinal 17–5 MHz US image obtained over the injured right long finger of a 15-year-old boy during resisted flexion of the distal interphalangeal joint demonstrates bowstringing and volar displacement of the flexor tendons (arrows) secondary to acute rupture of the A2-pulley. In this particular case, there was also a combined injury of the A3- and A4-pulleys (not shown). An increased tendon-to-bone distance (>2 mm, double arrow), is seen over the proximal phalanx. Note an abundant effusion (asterisks) distending the tenosynovial sheath. B. Corresponding photograph shows volar soft-tissue swelling over the proximal (thin arrow) and middle (arrowhead) phalanges due to bowstringing of the flexor tendons. C. Longitudinal 17–5 MHz US image over the left long finger illustrates the normal A2-pulley as a thin hypoechoic band (white arrowheads) retaining the flexor tendons (arrow) against the shaft of the proximal phalanx
Preview