Dedos y Mano

15 Disorders of the Fingers
and Hand
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION EXTENSOR TENDONS

FLEXOR TENDONS Central Slip Rupture
Anatomy and Clinical Aspects Mallet Finger
Tenosynovitis Dorsal Hood Injury
Tendon Rupture SMALL JOINTS OF THE HAND
FLEXOR PULLEYS What to Look For
Anatomy Synovitis Versus Effusion
Pulley Injury Grading
Ganglion, Fibroma and Trigger Finger
COLLATERAL LIGAMENTS AND VOLAR PLATE
Ulnar Collateral Ligament of the Thumb
Collateral Ligament and Volar Plate Injuries
INTRODUCTION Key Point
This section will be divided into abnormalities that occur on The superficialis tendon is the superior of the two finger
tendons but it inserts first at the base of the middle phalanx.
the flexor side and those that occur on the extensor side of
In order to achieve this, the tendon splits and sends a
the fingers. Each section will deal separately with disorders medial and lateral slip one each side of the profundus
of tendons and ligaments and retinacula. The flexor and tendon to their respective insertions in the proximal part of
extensor tendons of the hand are divided into zones to help the middle phalanx.
describe and plan the treatment of injuries. The extensor
zones are numbered 1 to 7, with the odd numbers overlying
joints, beginning distally. Zone 1 is therefore the area overly-
ing the distal interphalangeal joint (DIPJ) and zone 7 is
overlying the wrist. The even-numbered zones lie between The profundus tendon continues distally to insert on the
the joints. On the flexor side, there are 5 zones, also num- volar aspect of the distal phalanx. The two tendons
bered from distal to proximal. are contained within a common sheath. Vascular supply
is from the adjacent digital arteries, with the vascular
pedicle, or vincula, invaginating the tenosynovium as the
tendovaginum.
FLEXOR TENDONS
Disorders of the tendon and tendon sheath, as with
tendons elsewhere, include tenosynovitis, tendinosis and
ANATOMY AND CLINICAL ASPECTS
tendon rupture. Tenosynovitis refers to inflammation on
There are two flexor tendons to each finger: one superficial the tendon sheath. The term tendinosis is sometimes used
and one deep. Each arises from the corresponding flexor for intratendinous mucinous degeneration, which is not
digitorum superficialis and flexor digitorum profundus associated with symptoms. Tendinopathy is a similar term,
muscle belly. but in the same context indicates that symptoms are present.
150
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CHAPTER 15 — Disorders of the Fingers and Hand 151
Others use the term tendinosis regardless of whether symp-

toms are present or not.
TENOSYNOVITIS
Key Point
A synovial sheath surrounds the two flexor tendons in the

finger. These are separate from the tendon sheath
surrounding the flexor tendons within the carpal tunnel.
a
Flexor tenosynovitis may occur as a misuse injury in sport.
Increased fluid and synovial thickening within the tendon
sheath can give rise to the classical ‘sausage digit’ appear-
ance. This pattern is particularly associated with seronega- FDS
tive arthropathy, most typically psoriatic arthropathy. The
soft tissue manifestations of psoriatic arthropathy may FDP
precede the appearance of the typical psoriatic rash, so the
absence of a rash does not exclude the diagnosis. The dif-
ferential diagnosis of sausage digit includes infective teno-
synovitis, although this is uncommon. The history of trauma, A MC
LM
particularly a biting injury and a human bite, is often the P
worst, should be sought. Infection can be acute or chronic. b
Chronic infection in the tendon sheath is less often accom-
panied by heat and redness. In these cases tuberculous dac- Figure 15.1 Transverse section of flexor tenosynovitis of third
tylitis should be suspected. Yaws and syphilis are other finger. Note a thickened low-reflective halo around the otherwise
normal tendon. Compare with the adjacent flexor tendon.
uncommon causes.
Practice Tip
Patients with tenosynovitis may initially complain of stiffness

and inability to form a fist and not infrequently arthritis is
suspected.
Inflammatory changes within the tendon manifest as

increased fluid and, with progress of the disease, thickening
of the synovial lining and increased Doppler signal.
Practice Tip
The earliest ultrasound finding is the appearance of the dark

halo around the tendon.
a
This is due to a thin rim of fluid that comes between the
tendon and tendon sheath (Fig. 15.1). This sign is best
appreciated on axial images, especially by comparing the
affected finger with those that are not involved.
As the amount of fluid increases, the tendon sheath
becomes increasingly distended (Fig. 15.2). In long axis
fluid and synovial thickening will not be evenly distributed
along the length of the tendon (Fig. 15.3), but will be ini-
tially constrained in the areas of the flexor pulleys, creating
a lobulated appearance. This should not be misinterpreted
as multiple ganglia. As the disease progresses, the degree of
synovial thickening (Fig. 15.4) and Doppler activity increases
(Fig. 15.5). At this stage associated tendinopathy is common b
and vascular ingrowth is identified within the substance of Figure 15.2 Flexor tenosynovitis. Fluid surrounds the tendon apart
the tendon itself, alongside accompanying intratendinous from where the tenovaginum attaches. Note the slight thickening of
matrix changes. the synovial lining of the tendon sheath.
152 PART 4 — FINGER
Figure 15.5 Transverse section of wrist extensor tenosynovitis.

Increased Doppler activity indicates the areas of active
FDS
inflammation.
Mid P
A
Prox P TENDON RUPTURE
S I
b P Rupture of the flexor tendon may affect either the superficial
or profundus tendon, although the latter is more common.
Figure 15.3 Long axis of flexor tenosynovitis. Note the rind of low-
signal material around the tendon. It has an undulating appearance
where the sheath is constrained by the flexor pulleys.
Key Point
The commonest site of flexor profundus tear is just proximal

to its insertion into the base of the distal phalanx.
This injury is referred to as a jersey finger or rugby finger,

reflecting a common cause of injury. The profundus tendon
of the ring finger is the most commonly affected by the
jersey pull injury. The injured player attempts to grab his
opponent by the jersey but only manages to gain purchase
with the tip of the finger, which is then forcibly extended.
The insertion of the profundus tendon is avulsed from the
underlying bone with a small bony fragment attached, or a
small stump of tendon remains attached to the distal
phalanx (zone 1 injury) and the remainder of the tendon
retracts proximally (Fig. 15.6). The index finger is involved
in 75%.
Clinically there is localized tenderness, pain and swelling
a and inability to flex the DIPJ. The latter can be assessed
during the ultrasound by fixing the proximal interphalan-
geal joint (PIPJ). Additionally, during finger flexion there
will be dysynchronous movement between the proximal and
distal portions of the ruptured profundus tendon. Gentle
finger movements are also helpful to distinguish between
FDS partial and complete tears. Synchronous movement between
Volar plate FDP proximal and distal components of a suspected tear excludes
a complete rupture in the acute phase.
A Practice Tip
Prox P
I S
P The flexor tendons are less strongly attached to the
b
surrounding structures and thus the degree of retraction is
Figure 15.4 Flexor tenosynovitis. Note the sharp reflective margin often quite large.
of the flexor tendon.
A5
A4
A3
A2
FDS
Tear
FDP
A1
Figure 15.7 Schematic diagram of the annular pulleys. Five sets are
Prox P MC present. A1, A3 and A5 are at the level of the articulations on the
A convexity of the tendon. A2 and A4 are on the tendon concavities
I S and are the most prone to injury.
b P
Figure 15.6 Flexor tendons at the level of the palm. The superficial
tendon may itself be avulsed from the avulsed bony frag-
flexor tendon is intact. There is a tear of the profundus tendon that
is retracted.
ment. Retraction of the tendon into the palm is designated
a type 1 and retraction to the level of the PIPJ a type 2,
completing the spectrum of lesions.
Ultrasound is useful not only to confirm the presence of As it is required to cross fewer joints than its deeper
tendon rupture, but also to identify the precise location of counterpart, closed rupture of the superficialis tendon is
the tendon ends. This can be useful for surgical planning uncommon but can occur due to forced extension against
as more precise identification of the tendon ends reduces a contracted muscle. It is also less prone to abrasion against
the need for extensive exploratory surgery. Two small inci- the carpal bones. Open tendon lacerations are a more
sions can be made at the locations identified by ultrasound, common cause of superficial flexor tendon rupture and
thus minimizing the risk of postoperative adhesions. most frequently involve the midsubstance of the tendon.
The location of flexor tendon rupture can also be
reported using the zones method. Zone 1 covers the
segment between the superficialis and the profundus
FLEXOR PULLEYS
insertions. Zone 2 is the area between the superficialis
insertion and the distal palmar crease. In this segment the
ANATOMY
profundus and superficialis tendon lie in close proximity.
Zone 3 is between the level of the A1 pulley and the flexor The flexor tendons of the hand are held in place by a series
retinaculum. Zone 4 covers the section of flexor tendon of connective tissue retinacula that are formed by condensa-
within the flexor retinaculum and zone 5 that portion tions of the fibrous sheath. They are arranged into annular
proximal to it. Jersey finger has its own classification as and cruciate configuration, referred to as the A and C
there is often a small bony avulsion fragment attached to pulleys (Fig. 15.7). The pulley system is important for
the tendon which influences the degree of retraction keeping the flexor tendons close to the phalanges to maxi-
encountered. If a large bony injury is involved, retraction mize their ability to flex the fingers. Clinically, the annular
proximal to the A4 pulley is uncommon. This is designated A pulleys are by far the most important and these are num-
a type 3 lesion. In the rare type 4 lesion the profundus bered A1–5. The A1, A3 and A5 are at the level of the
P
A4 Pulley FD
Dist P
A
S I Mid P
P
b
Figure 15.8 The normal A4 pulley is a low-signal, thin structure

surrounded by a rim of more reflective connective tissue. The A2 and
A4 pulleys overlie the tendon at its most concave portion.
Figure 15.9 With increasing strain, the A2 pulley ruptures. The flexor
tendon separates from the proximal phalanx with bowstringing.
metacarpalphalangeal, PIP and DIP joints respectively. They
are on the convexities of the flexor tendons and are thus
less prone to injury. The A2 pulley is at the level of the
midportion of the proximal phalanx and the A4 pulley at
the midportion of the middle phalanx (Fig. 15.8). These are A small gap (<3 mm) suggests isolated A2 injury and gaps
on the concavity of the flexor tendon and are more prone more than 5 mm suggest multiple pulley involvement. The
to injury. A1 pulley is rarely involved in this injury. Injuries to the
The A2 is the largest of the pulleys. It can be visualized cribriform or C pulleys are reported, but not common.
directly on ultrasound and note is made of any associated
injury. Functionally, it is tested by noting the distance ULTRASOUND IMAGING OF PULLEY RUPTURE
between the profundus tendon and the underlying bone Injury to the pulley itself may be visualized by both ultra-
when the finger is flexed against resistance. With a function- sound and MRI (Fig. 15.10). Ultrasound offers an advantage
ing pulley, the flexor tendon should show minimal separa- over MRI in that the pulley can be stressed dynamically. The
tion from the underlying bone. patient places the back of their hand on the examination
couch and the probe is placed in long axis overlying the A2
pulley. A free finger of the examiner’s hand is placed on the
PULLEY INJURY
distal phalanx of the finger being examined, restraining it
The classic injury leading to pulley rupture is typified by the as the patient flexes (Fig. 15.11). Under normal circum-
crimp grip of rock climbers. Hyperextension occurs at stances, the tendon is constrained by an intact pulley system
the metacarpalphalangeal joint and flexion at the IPJ. If the and there is a minimal gap between the profundus tendon
weight supported by the fingers in this position is suddenly and the underlying bone.
increased beyond the restraining ability of the pulley
system, rupture occurs. The flexor tendons are pulled away
from the phalanges and shorten. This is called bowstring-
ing. The middle and ring fingers are the most vulnerable. Practice Tip
There is some disagreement as to which pulley ruptures
If the A2 pulley has ruptured, the tendons will lift from the
first, although most commonly the injury is said to begin at proximal pahalanx, creating a gap.
the distal portion of the A2 pulley. It then progresses
through A4 with progressive bowstringing of the flexor
tendon (Fig. 15.9).
FIBROMA, GANGLION AND TRIGGER FINGER
Like the A2–A5 pulleys, the A1 pulley is a fibrous retinacu-
Key Point lum that arches over the flexor tendons of the finger.
The normal A1 pulley is easily identified on ultrasound and
The degree of bowstringing measured by the separation of is seen as a very thin, hypointense line surrounded circum-
the flexor tendon from the underlying bone gives a clue on ferentially by an equally thin reflective envelope (Fig. 15.12).
which pulleys are involved. It is best appreciated in the sagittal plane where it normally
measures approximately 1 cm proximal to distal.
Prox P
A1 Pulley
FDS
FDP Volar plate
Figure 15.10 On stressing, the flexor tendon overlying the proximal

phalanx is imaged under tension. Note the separation of the tendon Prox P
from the underlying bone (*) which indicates bowstringing.
MC
A
S I
P
b
Figure 15.12 The normal A1 pulley overlies the MCPJ. It is a shorter

structure than A2. There is also a low signal surrounded by a rim of
more reflective tissue. Note that the A1 pulley overlies the tendon at
its convexity, making it less prone to injury.
Figure 15.11 Injuries to the A2 and A4 pulleys can be assessed by

flexing the finger against resistance. The probe is placed in a sagittal
position over the A2 pulley. The tip of the examiner’s finger is used
to provide resistance to finger flexion.
Practice Tip Figure 15.13 Sagittal image of the flexor tendon overlying the
MCPJ. The A1 pulley is replaced by an ill-defined, low-signal mass
The A1 pulley is rarely torn due to its relationship over the indicative of a pulley fibroma.
convexity of the tendon at the level of the metacarpophalangeal
joint (MCPJ). It is however one of the commonest locations for
symptomatic fibroma, leading to the clinical syndrome known
as trigger finger. Trigger finger is as a combination of a tendon injury
coupled with fibrous enlargement of the A1 pulley (Fig.
15.13). In the early stages, thickening of the pulley causes
little more than a palpable swelling. The underlying flexor
The aetiology of pulley fibroma is incompletely understood tendon is free to move normally beneath it (Fig. 15.14).
but may relate to chronic friction. Some occur as part of the With progression, the flexor tendon becomes chronically
spectrum of palmar fibromatosis. irritated by friction against the thickened pulley and
A1 Pulley
FDS
FDP
Figure 15.15 Trigger finger. A nodule develops in the flexor tendon

secondary to irritation from the pulley fibroma. Initially, it clicks in and
MC out from under the fibroma. In time, on flexion the nodule passes
proximal to the fibroma and will not pass distally without assistance
Prox P A from the patient. This is the classic triggering symptom.
I S
P
b
Figure 15.14 Small pulley fibroma overlying the A1 pulley.
dysfunctional movement is evident. The tendon continues

to pass normally under the pulley, but starts to push against
it, causing the pulley to elevate. In time an intratendinous
nodule develops, causing a sensation of clicking and loss of
the normal smooth flexor tendon movement. The clicking
stage is followed by the triggering stage. In this, the tendon
passes proximally beneath the fibroma on flexion, but the
nodule within it engages at the proximal end of the pulley
a
and cannot pass distally on attempted extension. The
patient must add some additional manual force to push the
nodule back beneath the fibroma and allow the finger to
straighten (Fig. 15.15). This is the classic trigger finger A1 Pulley
symptom. In some patients, the earliest manifestations may FDS
be within the tendon rather than the pulley. FDP
Pulley fibromata have a variable appearance but the
majority are moderately well, though not sharply, demar-
cated and of mixed but predominantly low reflectivity (Fig.
15.14). Occasionally calcification is evident (Fig. 15.16). A
Prox P
I S
Fibromas can occur on any of the other pulleys and Dupuy- P MC
tren’s contracture can itself extend into the finger to the
level of the A1 pulley (Fig. 15.17). Occasionally they can b
occur in children and the thumb is the most commonly
encountered location. Figure 15.16 Small calcified pulley fibroma.
A1 Pulley
A1 Pulley
Volar plate
FDS
FDP
Prox P
MC A
I S
b P
MC Prox P
Figure 15.17 Ill-defined fibrous tissue extends from the palm into A
the level of the A1 pulley. The appearance represents a combination S I
P
of pulley fibroma and Dupuytren’s tissue.
b
The underlying pulley is usually, but not invariably,
obscured by the fibroma. The diagnosis is based on the Figure 15.18 Sagittal image during percutaneous division of pulley
classic location and reflectivity of the lesion. Gentle flexion fibroma. The needle has traversed the fibroma without injuring the
and extension of the finger will identify whether or not tendon.
there is an associated tendon nodule. The movement of the
flexor tendon can also be examined as it passes underneath
the involved pulley. Dysfunctional movement of the pulley
or tendon may be a precursor of the tendon nodule. employed, a digital nerve ‘ring’ anaesthetic block can be
used. Some specialized needles have been described;
TREATMENT OF PULLEY FIBROMA however, an 18 G standard green needle is often sufficient
to cut through the pulley fibroma and disrupt the pulley
itself, thus releasing the flexor tendon. Firm resistance is felt
Key Point
as the needle is passed through the pulley, followed by a
Once detected, pulley fibromas can be treated
sudden reduction when the lesion is fully traversed. A
percutaneously either by direct corticosteroid injection number of passes are recommended to fully divide the
or a combination of corticosteroid injection and needling pulley.
(Fig. 15.18). Depending on the shape of the patient’s fingers, it may
be helpful to create a small angle in the needle. This is
generally placed where the hub meets the needle itself and
The purpose of the needling is to attempt to perform a can be induced using the needle cover as a lever. Additional
pulley release. The fibroma is approached in the sagittal bends can be placed further along the shaft of the needle
plane from either the proximal or distal end, depending on to create a greater cutting angle if there is resistance to
the shape of the patient’s hand. If a distal approach is to be needle passage.
a b c
Figure 15.20 Aetiology of Stener lesion. (A) Before injury. (B) At time
of maximal displacement. (C) Proximal phalanx reduces but ligament
remains displaced external to the aponeurosis.
A2 Pulley
FDS
FDP
recognized for many years under the traditional name of

gamekeeper’s thumb. This reflects the twisting manoeuvre
Prox P used by gamekeepers to dispatch game. Nowadays, the
A injury is more often seen in skiers when the strap of the ski
I S pole acts as a lever to impart an excessive radial or valgus
P
b force at the MCPJ during a fall. This results in a sprain or
tear of the UCLt.
Figure 15.19 Multiple pulley ganglia. The appearances can occa-
sionally mimic tenosynovitis. INJURY
The injury is an avulsion of the distal attachment of the liga-
PULLEY GANGLION ment at its insertion into the base of the proximal phalanx.
Key Point
Key Point
Pulley ganglia are commonly encountered on routine
examination of the fingers and are most often The goal of imaging in tears of the UCLt is to determine
asymptomatic. whether the torn ligament remains reduced or has displaced
proximally.
Ganglia are most frequently observed arising from the A2

pulley, although any of the flexor pulleys may be involved. The commonest circumstance is for the ligament to remain
They are not infrequently multiple (Fig. 15.19). They gener- in place and usually management is conservative. With more
ally arise from one or other end of the pulley; therefore, excessive valgus force at the time of injury (Fig. 15.20), at
when multiple they can simulate tenosynovitis. In most cases the point of maximal displacement, the torn ligament may
the fluid of tenosynovitis surrounding the tendon is com- slip out from underneath the adductor aponeurosis that
pressible and increased Doppler activity is often associated. normally covers it. As the joint reduces, the ligament is
Neither of these phenomena will be present with pulley unable to return to its normal location due to interposition
ganglia. If the lesion is felt to be the cause of the patient’s of the aponeurosis. Displacement of the torn ligament is
symptoms, aspiration can be carried out, although the size referred to as Stener lesion and stable healing will not occur
of the lesion means that very little fluid is actually retrieved without surgical reduction.
and a fenestration procedure is more usually performed. In many cases, the avulsion includes a small fragment of
bone. As this is visible on plain radiographs, the extent of
the injury can be easily determined (Fig. 15.21). If there is
COLLATERAL LIGAMENTS AND no bony fragment, ultrasound or MRI is needed for com-
VOLAR PLATE plete diagnosis.
ULTRASOUND TECHNIQUE
ULNAR COLLATERAL LIGAMENT OF THE THUMB
Careful technique is necessary to identify both the adductor
CLINICAL ASPECTS aponeurosis and the UCL itself. The preferred method of
Injuries to the ulnar collateral ligament of the meta examination is for the patient to sit opposite the examiner,
carpophalangeal joint of the thumb (UCLt) have been palm partially pronated and the probe placed in a long-axis
tightly and a gentle valgus stress can be used using the

examiner’s thumb as a fulcrum. Under normal circum-
stances some widening of the ulnar aspect of the joint is
appreciated but this is increased when the UCLt is torn.
Most ligament tears are reduced and will heal with rea-
sonable stability. The ligament will be swollen, with reduced
reflectivity, but still present ‘within the joint’ under the
adductor aponeurosis. Stress testing may reveal some addi-
tional joint widening compared with the normal side. The
joint should only be stressed if there is uncertainty about
the nature of the stable injury. In these cases, stress testing
is used to differentiate the torn ligament from an old scarred
reattached ligament. The torn end of the ligament may be
easier to see if separation between it and its phalangeal
a b c d
attachment is increased during the stress manoeuvre. Gentle
stress only is needed to make this differentiation, which has
Figure 15.21 (A) Normal anatomy: the UCLt lies deep to the adduc-
tor aponeurosis. (B) Avulsion fracture. A diagnosis can be made on
little impact on management. Vigorous stress should be
plain radiography. (C) In situ ligament avulsion. Ultrasound is required avoided, although the risk of converting a stable to an unsta-
to distinguish this stable injury from (D) Stener lesion, where the ble injury is low.
ligament is displaced proximally and lies outside the adductor
aponeurosis. Key Point
A displaced UCLt injury is called a Stener lesion.
Practice Tip
The tip of the UCLt can be identified, curled up and

associated with a mixed but predominantly hyporeflective
mass, at or proximal to the level of the metacarpal head.
The appearance of the mass and attached ligament has

sometimes been likened to a yoyo (Fig. 15.23). There will
be little substantial tissue in the normal location of the liga-
ment within the joint. Gentle movement of the thumb will
show fluid filling the space deep to the aponeurosis where
the ligament should be. Stener lesions are relatively uncom-
mon compared with injuries where the ligament does not
displace.
Figure 15.22 Slight flexion of the IPJ of the thumb will move the COLLATERAL LIGAMENT AND VOLAR
aponeurosis, helping to visually separate it from the underlying UCLt. PLATE INJURIES
The UCLt itself can be stressed by gentle valgus on the MCPJ.
ANATOMY
Imaging is rarely requested to evaluate the collateral liga-
coronal plane between the thumb and index finger, ments of the small joints of the finger. The anatomy of these
approaching from the extensor side. The injured thumb is ligaments is complex. There is a collateral ligament proper,
then held in the examiner’s free hand with the tip of the one each on the radial and ulnar side of the metacarpalpha-
patient’s thumb held between the middle finger and the langeal joint. These are orientated in the off-coronal plane
thumb, and the index finger placed along the radial aspect with the distal attachment of the ligaments lying slightly
of the injured joint (Fig. 15.22). more volar than the proximal attachment. In addition,
there is an accessory collateral ligament that lies volar to the
proper collateral ligament and is attached, in part, with a
Practice Tip
proper collateral ligament and the volar plate. The volar
In this position, gentle flexion of the IPJ can be used to plate represents a fibrocartilaginous reinforcement of the
identify movement in the adductor aponeurosis. volar aspect of the joint. It is approximately quadrilateral in
shape with its base attached to the base of the proximal
phalanx in the case of the PIPJ volar plate, and the corre-
This manoeuvre does not move the underlying UCLt that sponding proximal bone in the case of the MCPJ and DIPJ.
can thus be appreciated separately. Following this, the index Proximally it attaches by two slips, referred to as the suspen-
finger can be used to secure the patient’s thumb more sory ligaments, on the volar aspect of the distal shaft of the
FDS
FDP
p late
Aponeurosis Volar
Tear
Capsule
UCL
Tear Prox P
MC
b
A MC
Prox P Figure 15.24 Sagittal image overlying the MCPJ. There is separa-
S I
P tion of the volar plate from its attachment of the base of the proximal
phalanx. Degenerative changes are also present in this joint.
Figure 15.23 The UCL has become displaced and forms a mass
just proximal to the level of the metacarpal head. Displaced into this of important respects. They also share a certain similarity.
location, the ligament will not heal without surgical reduction. This is The extensor tendons do not have a tendon sheath and
referred to as a Stener lesion. thus tenosynovitis strictly does not occur; inflammatory
reaction may be present in and around the paratenon
(Fig. 15.25).
metacarpal. The flexor tendon passes volar to the volar plate
outside the capsule of the joint and is constrained by the A1
pulley. Practice Tip
Injuries to the collateral ligament system are common but
are rarely imaged. The most common pathology is inflam- If extensor tendinopathy or paratenonopathy is localized, a
matory and degenerative arthropathies. history of penetrating injury and foreign body material should
be sought (Fig. 15.26).
Key Point
The volar plate, however, can be injured by forced The distal portion of the extensor tendons are most often
hyperextension of the MCPJ either with or without a bony single, as opposed to having a paired superficialis/profundus
fracture on the volar aspect of the base of the middle combination like the flexor tendon. Some are paired in a
phalanx (Fig. 15.24). sense that there are two separate extensor tendons running
side by side. As they approach the PIPJ, they attempt to
simulate the arrangement of the flexor tendons. In this
Static imaging reveals the separation between the plate and location, the tendon divides into a central and two lateral
the underlying bone, with or without an attached bony frag- slips. The central portion, called the central slip, inserts into
ment. Like UCLt injuries outlined above, the presence of a the base of the middle phalanx. The two lateral slips recom-
bony fragment facilitates plain film diagnosis. In its absence, bine and insert as a single extensor tendon into the base of
ultrasound is the primary method for making the correct the distal phalanx.
diagnosis. Gentle flexion and extension show loss of syn- The extensor tendons do not have a true pulley system
chronicity between the plate and the adjacent bone. but are held in place by a ligamentous expansion called
the extensor or dorsal hood. The common injuries to the
extensor system are, therefore, tears of the dorsal hood/
EXTENSOR TENDONS sagittal band, central slip avulsion and avulsions of the
distal insertion. In turn, these are each more commonly
As has already been outlined in the techniques section, the referred to as boxer’s knuckle, boutonniere deformity and
extensor tendons differ from the flexor side in a number mallet finger.
a Ext T
Prox P
P
I S
b A
Ext T
Figure 15.26 Extensor tenosynovitis. In this case, the granuloma-
tous reaction is being stimulated by a small foreign body just visible
between the underlying phalanx and the extensor tendon.
P
I S
A is most commonly due to impact of the fingertip on a ball,
b leading to forced flexion. Clinically, the patient will be
unable to extend the DIPJ with the PIPJ fixed. The diagnosis
Figure 15.25 Extensor tenosynovitis with increased Doppler signal
around the extensor tendon. Fluid is less likely to gather around the
can be made on the plain radiographs if there is an associ-
extensor tendon as there is no loose synovial sheath. ated avulsion fracture. The ultrasound examination demon-
strates interruption of the distal portion of the tendon
either at its attachment or, more likely, just proximal to it,
with a small stump of tendon remaining attached to bone.
CENTRAL SLIP RUPTURE
Some retraction is evident, but the tip of the tendon gener-
The extensor tendon at the IPJ comprises a central slip and ally remains in close proximity to zone 1.
two lateral slips. The central slip inserts into the base of the
middle phalanx. Rupture may be due to hyperflexion injury
DORSAL HOOD INJURY
or penetrating injury. The most common clinical clue is
tenderness centrally over the dorsal aspect of the joint. On The dorsal hood is attached to the underlying metacarpal
occasion, a defect in the tendon may be palpated. Rupture head by medial and lateral sagittal bands (Fig. 15.27). Tears
leads to volar migration of the lateral slips and dorsal dis- of the sagittal bands are most associated with boxing and
placement of the PIPJ, resulting in the classic boutonniere are torn during fist impaction. Tears allow the extensor
deformity. tendon to sublux on flexion. This is usually palpable and
If a bone fragment is included in the avulsion, the diag- imaging is generally not needed.
nosis may be made on plain radiographs.
Key Point
Practice Tip
In cases where there is clinical difficulty or difficulty in
examining large or chubby hands, ultrasound can readily
If a bone fragment is not present, the ultrasound of a central
demonstrate the abnormal tendon movement in dorsal hood
slip tear shows loss of the normal reflective tendon fibrils that
lesions.
are replaced by an ill-defined, low-reflective mass.
The probe is positioned in short axis across the involved

Subluxation of the joint may be evident and gentle flexion metacarpal head. It is sometimes helpful to slightly extend
movements will help to confirm tendon disruption. the wrist to allow the patient to more tightly flex the fingers
when needed (Fig. 15.28). The extensor tendon is usually
located centrally or slightly to one side on the central groove
MALLET FINGER
in the metacarpal head (Fig. 15.29). As the patient flexes
Mallet finger is due to an avulsion of the insertion of the tightly, the extensor tendon moves over the metacarpal
extensor tendon into the distal phalanx. It is also sometimes head (Fig. 15.30). The tear of the sagittal band may also be
referred to as baseball finger or dropped finger. The injury visualized directly.
Ext hood
Ext T
Tear
MC
P
ML
b
A
Figure 15.29 Normal position of the extensor tendon lying central

or just mildly deviated from the centre of the underlying metacarpal
head. Relaxed position; there is a tear of the dorsal hood.
Figure 15.27 Schematic diagram of the extensor expansion. The
dorsal hood is formed in multiple contributions, including interossei.
The dorsal sling preserves the extensor tendon in the current location
on flexion. A tear of one of the components of the hood predisposes
the tendon subluxation.
Ext hood
tT
Ex
Tear
MC
Figure 15.28 The dorsal hood can be stressed by active flexion.

The probe is held in the axial plane over the extensor tendon while
the patient forms a fist with repetitive relaxation.
P
ML
b A
Figure 15.30 Stressed position. The extensor tendon has displaced

around the margin of the metacarpal head.
SMALL JOINTS OF THE HAND
High resolution ultrasound probes with excellent spatial

resolution, particularly for structures near the skin surface,
have led to increasing use of ultrasound in the assessment
of small joint disease. Although a complete examination
which includes both hands and both feet is rather time
consuming, it is considerably less time consuming for the
patient than an MRI examination of these areas. Ultra-
sound can also be targeted to involved joints and cope with
evolving symptoms between clinical referral and imaging.
For the hands, the examination should include at least the
dorsal aspects of the finger and the wrist joints, the radial
aspects of the second MCP, PIP and DIPJs and an assess-
ment of the flexor and extensor tendons. The volar aspects a
of the joints can also be examined during the assessment of
the flexor tendons, although some authors point out that
this is not always additional. The examination of the feet
concentrates on the metatarsophalangeal joints (MTPJs)
but is easily extended to include the interphalangeal and
tarsal joints.
WHAT TO LOOK FOR

The earliest ultrasound finding in joint pathology is MC
effusion.
Trapezium
Key Point L
S I
M
A small quantity of fluid may be detected in the normal joint b
but an increase in quantity is suggestive of underlying joint
disease if there is no history of trauma. Figure 15.31 Long axis coronal view with effusion and synovial
thickening in the first carpometacarpal joint. Low-signal component
represents fluid. Increased reflectivity represents a synovial thicken-
ing with Doppler activity.
In some joints, effusion is common and there is a poor cor-
relation between increasing fluid and symptoms. The first
metatarsophalageal joint is the best example of this. As
the disease progresses, synovial thickening appears with
increased Doppler activity (Fig. 15.31) and, if this remains The use of Doppler colour flow assessment also helps to dif-
uncontrolled, bony erosions can occur (Fig. 15.32). The ferentiate synovial thickening from effusion as well as provid-
role of imaging is to detect clinically occult effusion, syno- ing some measure of synovial blood flow and consequently
vitis and erosion and to help confirm the diagnosis of an inflammatory activity. Without a sensitive assessment of
inflammatory arthropathy, grade it, help determine treat- blood flow, it is difficult to differentiate active synovial thick-
ment and follow improvement during treatment. ening from inactive pannus, fibrosis or complex effusion.
The examiner should take care not to exert undue probe
pressure as blood flow within the smaller vessels may be
SYNOVITIS VERSUS EFFUSION
compressed and obscured. Commercial gel pads are difficult
Synovial thickening has a different appearance on ultra- to secure in position when examining multiple small joints.
sound to joint effusion. Effusion is echo-poor (black), as Liberal use of coupling gel is preferred. The probe can be
opposed to synovial thickening that contains increased floated in the jelly without actually touching the skin and
echoes, reflecting its more complex structure. supported by the operator’s hand, resting on the couch or
the patient.
Practice Tip GRADING

Fluid can also be displaced from one part of the joint to Various grading systems of synovial thickening have been
another either by compression with the ultrasound probe or proposed. Usually a four-point scale (normal, mild, moder-
using joint movement or gravity. Synovial thickening is more ate, severe) is used. Various objective measurements have
difficult to either displace or compress. been proposed; however, these can be difficult to apply to
the normal population.
significant blood flow involving 50% or less of the abnormal

synovium is grade 2. Other authors suggest counting the
abnormal vessels and, if there are between 7 and 10 present,
the Doppler signal is graded 2. Active blood flow involving
more than 50% of the involved synovium, or more than 10
visible vessels is grade 3.
Key Point
The ultrasound report of the involved joint should include

three points: one representing the severity of synovial
thickening, the second referring to the degree of Doppler
activity and the third whether erosions are present.
If necessary, erosions can be further quantified by number

or size or involvement or percentage involvement of the
Ext T
joint surface.
A role for ultrasound contrast medium has also been
proposed. Ultrasound contrast works by releasing micro-
Syno
vium bubbles of gas in the circulation that are easily detectable
by ultrasound. The earliest compounds used microbubbles
of air, whereas later materials use other gases that are more
Radius readily and specifically detected using particular ultrasound
frequencies called harmonics. The combination of tissue
harmonics with contrast injection allows the introduction of
Lunate P subtraction techniques that provide additional information
Capitate
I S on blood flow to the involved joint. Ultrasound contrast can
A be administered either as a single bolus or as continuous
b infusion. Continuous infusion provides a more stable blood
Figure 15.32 Sagittal view of the dorsal aspect of the radiocarpal and level and, consequently, a more accurate assessment of
midcarpal joint. Reflective synovial thickening enlarges the space. The blood flow in the synovium of one joint when compared
underlying bony margin is not smooth, indicative of erosion. with another. Although it has been clearly shown that the
use of ultrasound contrast agents can improve the detection
of blood flow in diseased synovium, the precise clinical role
has yet to be firmly established.
Practice Tip
It should also be appreciated that there is considerable

FURTHER READING
intracapsular but extrasynovial fat in the small joints of the Aronowitz ER, Leddy JP. Closed tendon injuries of the hand and wrist
hand. Consequently, displacement of the capsule or in athletes. Clin Sports Med 1998;17(3):449–67.
periarticular ligaments by increases in periarticular fat should Barton N. Sports injuries of the hand and wrist. Br J Sports Med
1997;31(3):191–6.
not be misinterpreted as joint pathology.
Bollen SR. Injury to the A2 pulley in rock climbers. J Hand Surg
1990;15(2):268–70.
Doyle JR. Anatomy of the finger flexor tendon sheath and pulley
system. J Hand Surg 1988;13(4):473–84.
Fat tends to be reflective or bright on ultrasound, as opposed Hame SL, Melone CP Jr. Boxer’s knuckle. Traumatic disruption of the
to synovial thickening, which is usually darker. extensor hood. Hand Clin 2000;16(3):375.
Ishizuki M, Sugihara T, Wakabayashi Y, et al. Stener-like lesions of col-
Minimal thickening of the synovium when compared with
lateral ligament ruptures of the metacarpophalangeal joint of the
uninvolved joints is graded as mild or 1. Obvious and major finger. J Orthop Sci 2009;14(2):150–4.
synovial thickening is graded 3, with grade 2 between these McNally EG. Ultrasound of the small joints of the hands and feet:
two extremes. The degree of blood flow is also graded. Care current status. Skel Radiol 2008;37(2):99–113.
should be taken to use a sensitive algorithm; a pulse repeti- Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the
athlete. Clin Sports Med 2006;25(3):527–42.
tion frequency (PRF) of 400–500 is suggested. Grade 1 Rajeswaran G, Lee JC, Eckersley R, et al. Ultrasound-guided percutane-
increased Doppler signal is present when a few additional ous release of the annular pulley in trigger digit. Eur Radiol
vessels are identified within the thickened synovium. More 2009;19(9):2232–7.

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15 Disorders of the Fingers

INTRODUCTION EXTENSOR TENDONS

INTRODUCTION Key Point

Others use the term tendinosis regardless of whether symp-

A synovial sheath surrounds the two flexor tendons in the

Patients with tenosynovitis may initially complain of stiffness

Inflammatory changes within the tendon manifest as

The earliest ultrasound finding is the appearance of the dark

Figure 15.5 Transverse section of wrist extensor tenosynovitis.

The commonest site of flexor profundus tear is just proximal

This injury is referred to as a jersey finger or rugby finger,

Figure 15.8 The normal A4 pulley is a low-signal, thin structure

FDP Volar plate

Figure 15.10 On stressing, the flexor tendon overlying the proximal

Figure 15.12 The normal A1 pulley overlies the MCPJ. It is a shorter

Figure 15.11 Injuries to the A2 and A4 pulleys can be assessed by

Figure 15.15 Trigger finger. A nodule develops in the flexor tendon

Figure 15.14 Small pulley fibroma overlying the A1 pulley.

dysfunctional movement is evident. The tendon continues

recognized for many years under the traditional name of

Ganglia are most frequently observed arising from the A2

tightly and a gentle valgus stress can be used using the

A displaced UCLt injury is called a Stener lesion.

The tip of the UCLt can be identified, curled up and

The appearance of the mass and attached ligament has

The probe is positioned in short axis across the involved

Figure 15.29 Normal position of the extensor tendon lying central

Figure 15.28 The dorsal hood can be stressed by active flexion.

Figure 15.30 Stressed position. The extensor tendon has displaced

SMALL JOINTS OF THE HAND

High resolution ultrasound probes with excellent spatial

WHAT TO LOOK FOR

Practice Tip GRADING

significant blood flow involving 50% or less of the abnormal

The ultrasound report of the involved joint should include

If necessary, erosions can be further quantified by number

It should also be appreciated that there is considerable

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