Pulley System in The Fingers: Normal Anatomy and Simulated Lesions in Cadavers at MR Imaging, CT, and US With and Without Contrast Material Distention of The Tendon Sheath1

Pulley System in the Fingers: Normal Anatomy and Simulated Lesions with and without Contrast Material Distention
of the Tendon Sheath1
2/27/12 9:18 AM
Radiology
radiology.rsna.org October 2000 Radiology, 217, 201-212.
Pulley System in the Fingers: Normal Anatomy and Simulated Lesions in Cadavers at MR Imaging, CT, and US with and without Contrast Material Distention of the Tendon Sheath
Olivier Hauger, MD, Christine B. Chung, MD, Nittaya Lektrakul, MD, Michael J. Botte, MD, Debra Trudell, RA, Robert D. Boutin, MD and Donald Resnick, MD
+ Author Affiliations
Abstract
PURPOSE: To describe the normal anatomy of the finger flexor tendon pulley system, with anatomic correlation, and to define criteria to diagnose pulley abnormalities with different imaging modalities. MATERIALS AND METHODS: Three groups of cadaveric fingers underwent computed tomography (CT), magnetic resonance (MR) imaging, and ultrasonography (US). The normal anatomy of the pulley system was studied at extension and flexion without and with MR tenography. Pulley lengths were measured, and anatomic correlation was performed. Pulley lesions were created and studied at flexion, extension, and forced flexion. Two radiologists reviewed the studies in blinded fashion. RESULTS: MR imaging demonstrated A2 (proximal phalanx) and A4 (middle phalanx) pulleys in 12 (100%) of 12 cases, without and with tenography. MR tenography showed the A3 (proximal interphalangeal) and A5 (distal interphalangeal) pulleys in 10 (83%) and nine (75%) cases, respectively. US showed the A2 pulley in all cases and the A4 pulley in eight (67%). CT did not allow direct pulley visualization. No significant differences in pulley lengths were measured at MR, US, or pathologic examination (P = .512). Direct lesion diagnosis was possible with MR imaging and US in 79%100% of cases, depending on lesion type. Indirect diagnosis was successful with all methods with forced flexion. CONCLUSION: MR imaging and US provide means of direct finger pulley system evaluation. Normal finger flexion is a complex fine motor action that requires the integrity and orchestration of a number of delicate structures that are centered around the flexor tendon system. One of the most important, the pulley system, composed of focal thickened areas of the flexor tendon sheaths (13), is of paramount biomechanical importance in flexion, not only for accurate tracking of the tendon but also to maintain the apposition of tendon and bone across the joint and provide a fulcrum to elicit flexion and extension (2,4). Loss of all or part of the flexor tendon pulley system has a substantial effect on digital motor performance because of the systems role in maintaining the angle of approach of the flexor tendon to its insertion and its role as a retinacular restraint (5). Lesions of the pulley system are recognized with increasing frequency because of the growing popularity of activities such as rock climbing that impose extensive stress on the supporting structures of the hands and fingers. The diagnosis, location, and extent of pulley system lesions are of great importance in managing and predicting functional sequelae (610). Although several investigators (1122) have studied ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging in the evaluation of flexor tendon abnormalities, diagnosis of lesions of the pulley system has been made only indirectly with the detection of a gap between the flexor tendon and the bone on sagittal CT scans and MR images, a
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Pulley System in the Fingers: Normal Anatomy and Simulated Lesions with and without Contrast Material Distention of the Tendon Sheath1
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finding referred to as the bowstring sign. This sign usually reflects an extensive abnormality of the pulley system that leaves limited or partial lesions of the system virtually undetected by means of indirect methods of visualization. In addition, these images must be obtained with the finger in flexion or forced flexion, which can prove challenging with regard to patient positioning and motion artifact. The purpose of this study was twofold: to describe the normal anatomy of the pulley system with MR imaging, CT, and US by using gross anatomic correlation as a standard of reference and to define the diagnostic criteria used to identify abnormalities of the pulley system by using these imaging modalities.
MATERIALS AND METHODS Anatomic and Biomechanical Considerations

The flexor synovial sheath is composed of visceral and parietal elements that extend from the neck of the metacarpal bone to the distal interphalangeal joint and are overlaid by a series of retinacular structures at five specific points along the tendon sheath (Fig 1). At anatomic inspection, Expand these retinacular structures result in focal, well-defined areas of thickening of the tendon sheath that are referred to as the annular pulley system. Additional crisscrossing fibers between the components of the annular pulley system are referred to as the cruciate pulley system. The ensuing discussion will focus on the annular component of the pulley system. Figure 1. Sagittal (left) and coronal (right) depictions of the pulley system of a typical flexor tendon (black areas) of the finger: fibroosseous annular pulleys (A2, A4), palmar plate annular pulleys (A1, A3, and A5), and cruciate pulleys (C1, C2, and C3). Dotted lines represent the division of the flexor digitorum superficialis tendon into two bands at
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this level.
In general, the length of each pulley varies in direct proportion to the length of the digit, and the thickness, in turn, is directly proportional to the length of the pulley (2). The first annular pulley (A1) begins in the region of the palmar plate of the metacarpophalangeal joint and extends to the level of the base of the proximal phalanx. The second annular pulley (A2) arises from the volar aspect of the proximal part of the proximal phalanx and extends to the junction of the proximal two thirds and the distal third of the proximal phalanx. The third pulley (A3) is small and extends over the region of the proximal interphalangeal joint. The fourth pulley (A4) is in the midportion of the middle phalanx, and the fifth pulley (A5) is in the region of the distal interphalangeal joint. The annular pulleys are of biomechanical importance in preventing tendon excursion during digital flexion, whereas the cruciate pulleys provide the necessary flexibility for approximation of the annular pulleys at flexion while maintaining the integrity of the flexor sheath. The primary function of the flexor pulley system in the fingers is to convert the available linear translation and force in the muscle-tendon unit into rotation and torque at the finger joints. Loss of all or part of the flexor tendon pulley system may have a significant effect on digital performance. Study results have shown that the A2 pulley is the strongest, followed by
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the A1 and A4 pulleys (2325). The pattern of injury follows a progressive and predictable pattern: Disruption begins at the distal part of the A2 pulley and progresses from partial to complete rupture, which is followed by involvement of the A3, A4, and, in rare situations, A1 pulleys. Three groups of cadaveric hands were studied. The first and second groups had no known finger abnormalities and were used to depict the normal anatomy of the flexor tendon pulley system; the third group was composed of specimens with surgically created lesions of the pulley system. In all three groups, MR imaging, CT, and US were performed with the hands in a pronated position. Images were acquired with the fingers in extension and as close as possible to the following flexed position: metacarpophalangeal joint in full extension, with the proximal interphalangeal joint in 60 of flexion and with the distal interphalangeal joint in 10 of flexion. Only the second through fourth digits were investigated, since they were the most common sites of injury (6,10,25).
Anatomic Study
Eight hands were harvested from four fresh frozen cadavers (three men and one woman, 6878 years of age at death [mean age at death, 73.5 years]). The specimens were divided into two groups of four hands each (12 fingers per group), which subsequently were evaluated with MR imaging, CT, and US without (group I) and with (group II) opacification of the tendon sheaths with contrast material (MR tenography).
MR Tenography
With fluoroscopic guidance, a 25-gauge needle was inserted into the volar surface of the finger and was advanced, 1 cm distal to the level of the metacarpophalangeal joint, into the flexor tendon sheath of the finger (group II). Subsequently, 0.8 mL of a solution of 1 mL gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany) diluted with 250 mL of normal saline and 1 mL of iodinated contrast material (iohexol, Omnipaque; Nycomed Amersham, Princeton, NJ) was injected into the tendon sheath to verify accurate needle positioning and distend the tendon sheath.
Imaging
MR imaging was performed with a 1.5-T clinical system (Signa; GE Medical Systems, Milwaukee, Wis) with a dedicated phased-array wrist coil. T1weighted spin-echo (repetition time, 400 msec; echo time, 22 msec [400/22]) and fast spoiled gradient-recalled echo (400/12; flip angle, 20) imaging in the transverse and sagittal planes were performed in group I (n = 12). Fat-suppressed T1-weighted spin-echo (400/12) imaging in the transverse and sagittal planes was performed in group II (n = 12) after opacification of the tendon sheaths (section thickness, 3 mm; field of view, 8 8 cm; matrix, 512 256; with two signals acquired). Helical CT (PQ 5000; Picker International, Cleveland, Ohio) was performed in both groups (120 mAs; 150 kVp; section thickness, 2 mm; incremental table movement, 1 mm). Images were displayed by using soft-tissue windows. Gray-scale US was performed by using a 12-MHz transducer (HDI 5000; Advanced Technical Laboratories, Bothell, Wash) in all specimens in both groups by an investigator (O.H.) who was experienced in performing musculoskeletal US. All specimens were studied in sagittal and transverse planes. The study of flexed fingers was limited to the transverse plane because the transducer was too wide for accurate analysis in the sagittal plane.
Imaging-Anatomic Correlation and Analysis

After imaging, all cadaveric specimens were frozen for 24 hours at 60 C, and 3-mm-thick sections were obtained with a band saw in the transverse (four hands, two in each group) and sagittal (four hands, two in each group) planes.
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Two musculoskeletal radiologists (O.H., C.B.C.) randomly analyzed all specimen images, in accordance with imaging technique. First, all MR images in all fingers were evaluated in a random order and were followed by randomly selected CT and US images and anatomic sections of the fingers. Images and anatomic sections were reviewed with consensus. The Pearson correlation test was performed to evaluate any significant differences between the measurements obtained with each imaging technique, as compared with the gross anatomic sections. A P value of less than .05 was considered to indicate a significant difference.
Simulated Pulley Lesions

To evaluate the imaging of abnormalities in the pulley system, an additional 11 hands (group III) were harvested from six fresh frozen cadavers (four men and two women, 5781 years of age at death [mean age at death, 71 years]). As before, only the second through fourth fingers (n = 33) in each hand were analyzed. Partial and complete lesions were created in various combinations to simulate well-documented mechanisms of injury with regard to technique and progression (6,25) (Table 1). Complete lesions constituted total longitudinal pulley transection, whereas partial lesions involved the transection of approximately 10 mm of the distal portion of the pulley. The latter were imposed on the A2 pulley alone. All lesions were created by an orthopedic surgeon (M.J.B.) who specialized in procedures in the hand.
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TABLE 1. Types of Lesions Created in 33 Fingers
A longitudinal midline incision was made in the volar aspect of each digit by using a standard number 15 scalpel. Each incision was of a minimal length and extended proximally and distally only far enough to allow access to the pulley(s) of interest. Dissection was performed through the subcutaneous tissues and along the midline to the level of the flexor pulleys, with maximal preservation of the soft tissues. To simulate a complete pulley rupture, a longitudinal incision was made in the midline of the specified annular pulleys. To simulate a partial pulley rupture, the distal half of the A2 pulley was incised, and the proximal half of the pulley was left intact. The digital incisions then were closed with 3-0 vicryl sutures to approximate the subcutaneous tissue and with 4-0 nylon interrupted sutures to approximate the skin. The incisions were irrigated and filled with normal saline during closure to remove air within the subcutaneous tissues. To simulate active tendon digital flexion, preparation was made to load each of the digital flexor tendons. At the proximal portion of each specimen, a volar incision was made at the level of the distal forearm and wrist to allow identification of the flexor digitorum profundus (FDP) and flexor digitorum superficialis tendons of each digit. The flexor tendons were sutured together with 3-0 vicryl suture in the distal forearm to produce a single common tendon to each digit, which could be loaded to produce digital flexion. A 2-mm nylon cord then was attached to the flexor tendon complex in each digit; this provided a means of loading the tendon with weight (to parallel active muscle contraction), which resulted in finger flexion. The volar forearm incision was closed with 4-0 nylon suture by using a running, locking suture pattern.
Imaging
In all cases, imaging was performed before and within 5 days after lesion creation. US, CT, and MR imaging of the fingers were performed with the same nonenhanced technique described previously. To simulate forced flexion of the fingers at CT and MR imaging, the fingers were taped in flexion, and traction was applied to the flexor tendons, with a 500-g weight attached to the common flexor tendon complex of each finger. No opacification of the tendon sheath was performed because lesion creation led to disruption of the sheath. Because of the potentially interactive nature of US, an attempt was made to
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maximize forced flexion, which closely approximates the clinical situation. Pressure was applied to the common flexor tendon complex as described previously, with simultaneous counterpressure at the fingertip to extend the finger. During this time, the operator performed US with the transducer in the concavity of the finger, at the level of the distal third of the proximal phalanx.
Analysis
Images obtained before lesion creation with each of the three modalities were reviewed, with consensus of the two musculoskeletal radiologists to determine whether or not the pulleys could be visualized. Then the images in those fingers with lesions were reviewed separately by the same musculoskeletal radiologists, who knew that lesions had been created but did not know their number or location. The following parameters were chosen for evaluation on the basis of the results of the initial anatomic study: direct signs related to the appearance of the A2 and A4 pulley system (visualized and normal in appearance vs visualized and disrupted or nonvisualized), and evaluation of the pulley system by using indirect quantitative methods (measurements of the distance between the dorsal edge of the FDP tendon and the bone in the sagittal plane at the level of the distal two thirds of the proximal phalanx, with the fingers in extension, flexion, and forced flexion, ie, the bowstring sign). Measurements were obtained electronically (Fig 2) by using calipers provided with the Windows Advantage version 2.0 software (GE Medical Systems) at the workstation. First, the Pearson correlation test was performed to evaluate any significant differences among the measurements obtained with the different modalities (MR imaging, CT, and US). Subsequently, the measurements obtained with each modality were assessed separately by performing analysis of variance and post-hoc Tukey tests to detect any significant differences among the positions (extension, flexion, and forced flexion) with regard to different lesions (A2 + A3 + A4, A2 + A3, total A2, and partial A2). Again, a P value of less than .05 was considered to indicate a significant difference. Figure 2. Sagittal T1-weighted spin-echo (400/22) MR image in a cadaveric finger shows the electronic caliper measurement of the distance (1 in image) between the dorsal edge of the FDP tendon and the bone at the junction of the proximal two thirds and distal third of the proximal phalanx, from the outer aspect of the
cortex to the FDP tendon.
RESULTS Anatomic Study

Imaging without tenography (group I).Results are shown in Tables 2 and 3. MR imaging demonstrated the A2 and A4 pulleys in the sagittal plane in 10 (83%) and eight (67%) of 12 cases, respectively, by using spin echo and in 10 (83%) and 10 (83%) cases, respectively, by using fast spoiled gradientrecalled echo (Fig 3). The pulleys appeared as focal thickenings of low signal intensity at the level of the proximal third of the proximal phalanx (A2) and at the midportion of the middle phalanx (A4). The distal end of the A2 pulley was readily visible because of the abrupt transition between the pulley and the normal sheath. In the transverse plane, the A2 and A4
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pulleys were depicted in 12 (100%) of 12 cases because of their direct insertion into bone (Fig 4). The A2 pulleys were 1620 mm long (mean length, 17.4 mm), and the A4 pulleys were 58 mm long (mean length, 6.4 mm). The A3 and A5 pulleys were not routinely identifiable at conventional MR imaging. Figure 3a. Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled gradientrecalled echo (400/12, 20 flip angles) MR images. The pulleys appear as focal thickenings of low signal intensity (arrows in a , b , and c ) that are located at the level of the View larger version: proximal third of the In this page In a new window proximal phalanx (A2) Download as PowerPoint Slide and at the midportion (arrowheads in a , b, and d ) of the middle phalanx (A4). (c, d) Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys.
Figure 3b. Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled gradientrecalled echo (400/12, 20 flip angles) MR images. The pulleys appear as focal thickenings of low signal intensity (arrows in a , b , and c ) that are located at the level of the View larger version: proximal third of the In this page In a new window proximal phalanx (A2) Download as PowerPoint Slide and at the midportion (arrowheads in a , b, and d ) of the middle phalanx (A4). (c, d) Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys.
Figure 3c. Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled gradientrecalled echo (400/12, 20 flip angles) MR images. The pulleys appear as focal thickenings of low signal intensity (arrows in a , b , and c ) that are located at the level of the View larger version: proximal third of the In this page In a new window proximal phalanx (A2) Download as PowerPoint Slide and at the midportion (arrowheads in a , b, and d ) of the middle phalanx (A4). (c, d) Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys.
Figure 3d. Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled
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gradient-recalled echo (400/12, 20 flip angles) MR images. The pulleys appear as focal thickenings of low signal intensity (arrows in a , b , and c ) that are located at the level of the proximal third of the proximal phalanx (A2) and at the midportion (arrowheads in a , b, and d of the middle d) View larger version: In this page In a new window phalanx (A4). (c, d) Download as PowerPoint Slide Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys.
Figure 4a. (a) Transverse T1-weighted spin-echo (400/22) MR image. The A2 pulley (arrows) is visualized easily in the transverse plane because View larger version: of its osseous insertions. In this page In a new window (b) Transverse cadaveric Download as PowerPoint Slide section shows the anatomic correlation of the A2 pulley (arrows).
Figure 4b. (a) Transverse T1weighted spin-echo (400/22) MR image. The A2 pulley (arrows) is visualized easily in the transverse plane because of its osseous insertions. (b) Transverse cadaveric section shows the anatomic correlation of
the A2 pulley (arrows).
TABLE 2. Pulley Depiction by Using MR Imaging and US with and without Opacification of the Tendon Sheath
TABLE 3. Location and Mean Longitudinal Dimensions of Finger Pulleys
CT did not depict the pulleys in either the sagittal or transverse plane. US depicted the A2 pulleys in the sagittal plane in 12 (100%) of 12 cases. The pulleys appeared as focal hyperechoic thickenings of the sheath that were in the proximal third of the proximal phalanx. Again, the distal end of the pulley was easily recognizable because of its abrupt transition in thickness compared with the normal sheath (Fig 5). The mean length of the A2 pulley at US was 16.3 mm. US depicted the A4 pulley, which appeared as
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subtle focal hyperechoic thickening of the sheath at the level of the midportion of the middle phalanx, in eight (67%) of 12 cases. The A4 pulley had a mean length of 5.8 mm. Transverse imaging did not allow further detection or characterization of the A4 pulleys. As with MR imaging, the A3 and A5 pulleys were not seen routinely. Figure 5. Sagittal US image depicts the A2 pulley (arrows) as a focal hyperechoic thickening of the tendon sheath at the level of the proximal phalanx.
Imaging with tenography (group II).MR imaging demonstrated the A2 and A4 pulleys in all 12 cases in the transverse and sagittal planes. Such tenography allowed further visualization in the sagittal planes of the A3 and A5 pulleys in 10 (83%) and nine (75%) of the 12 cases, respectively (Fig 6). These pulleys were at the level of the proximal interphalangeal (A3) and distal interphalangeal (A5) joints; the A3 pulley was 23 mm long (mean length, 2.6 mm), and the A5 pulley was 35 mm long (mean length, 3.7 mm). When combined with CT and US, tenography did not allow further visualization of the pulleys. Measurements of the A2 and A4 pulley lengths were unchanged when compared with those obtained with conventional MR imaging.
Figure 6. Sagittal fat-suppressed T1-weighted spin-echo (400/12) MR image obtained after filling of the tendon sheath. Tenography allowed visualization of the A2 (black arrowheads), A3 (open arrow), A4 (solid arrow), and A5 (white arrowhead) pulleys.
Imaging-Anatomic Correlation
Results are summarized in Table 3. At gross anatomic inspection, the five annular pulleys always were visualized. The locations of these pulleys were consistent from one finger to another and were identical to those of the focal thickenings of the tendon sheaths that were observed with the different imaging modalities. There was no significant difference between the lengths of the different pulleys at MR imaging and US and the measurements obtained in the gross anatomic sections (P = .512).
Simulated Pulley Lesions (group III): Imaging

Complete lesions.Results are summarized in Tables 47. On MR images, the A2 and A4 pulleys were visualized in 33 (100%) and 30 (91%) of the 33 fingers, respectively, in the sagittal and/or the transverse plane with T1weighted spin-echo imaging and gradient-recalled echo imaging. The A3 and A5 pulleys were never visualized. After the creation of complete lesions with total medial transection, diagnosis was possible with direct
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visualization of the disrupted sheath on the transverse images (Fig 7) and/or with nonvisualization of the involved pulleys on the sagittal images. Diagnosis with direct imaging signs was possible in all cases in which the A2 and/or A4 pulley was visualized before lesion creation. Figure 7a. Transverse T1-weighted spin-echo (400/22) MR images obtained (a) before and (b) after the View larger version: creation of complete In this page In a new window lesions of the A2 pulleys. Download as PowerPoint Slide In a , the A2 pulleys (arrows) are visualized at their insertion into the cortex of the proximal phalanx. In b , the disruption of the A2 pulleys (arrows) is visualized directly, with retraction between the tendon and bone and discontinuous fibers.
Figure 7b. Transverse T1-weighted spin-echo (400/22) MR images obtained (a) before and (b) after the creation of complete lesions of the A2 pulleys. In a , the A2 pulleys (arrows) are visualized at their insertion into the cortex of the proximal phalanx. In b , the disruption of the A2 pulleys (arrows) is visualized directly, with retraction between the tendon and bone and discontinuous fibers.
TABLE 4. Direct Visualization of the A2 and A4 Pulleys by Using MR Imaging and US
TABLE 5. Distance between the Bone and the FDP Tendon on MR Images
TABLE 6. Distance Between Bone and FDP Tendon at CT
TABLE 7. Distance Between Bone and FDP Tendon at US
With regard to the distance between the bone and the FDP tendon at the level of the distal third of the middle phalanx, which allowed evaluation of the indirect signs of pulley system lesions, no significant tendinous gap was observed before lesion creation at either extension or flexion. After lesion creation, a tendinous gap was observed that was maximum at forced flexion (Fig 8) and increased in proportion to the number of disrupted pulleys (ie, maximum for A2 + A3 + A4 lesions, minimum for A2 lesions alone).
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Figure 8a. Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension, (b) flexion, and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. In a , obtained at full extension, no obvious gap between View larger version: the tendon (arrow in all) In this page In a new window and the bone (arrowhead Download as PowerPoint Slide in all) is shown. A small gap is noted in b and is maximized in c . (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c .
Figure 8b. Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension, (b) flexion, and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. In a , obtained at full extension, no obvious gap between View larger version: the tendon (arrow in all) In this page In a new window and the bone (arrowhead Download as PowerPoint Slide in all) is shown. A small gap is noted in b and is maximized in c . (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c .
Figure 8c. Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension, (b) flexion, and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. In a , obtained at full extension, no obvious gap between the tendon (arrow in all) and the bone (arrowhead in all) is shown. A small gap is noted in b and is maximized in c . (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c .
Figure 8d. Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension, (b) flexion, and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. In a , obtained at full extension, no obvious gap between
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the tendon (arrow in all) and the bone (arrowhead in all) is shown. A small gap is noted in b and is maximized in c . (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c .
CT did not allow direct visualization of the pulleys and did not show any tendinous gap between the bone and the FDP tendon before lesion creation. After lesion creation, a tendinous gap was observed that was maximum at forced flexion (Fig 9) and increased in proportion to the number of disrupted pulleys (ie, maximum for A2 + A3 + A4 lesions, minimum for A2 lesions alone). Figure 9a. Sagittal CT images (2-mm thick, soft-tissue window) obtained at (a) extension and (b) forced flexion after the creation of complete A2 lesions. In a , no gap is seen between the bone (arrowhead) and the tendon (arrow). In b , a moderate gap is observed.
Figure 9b. Sagittal CT images (2-mm thick, soft-tissue window) obtained at (a) extension and (b) forced flexion after the creation of complete A2 lesions. In a , no gap is seen between the bone (arrowhead) and the tendon (arrow). In b , a moderate gap is observed.
US allowed direct visualization of the A2 and A4 pulleys in 33 (100%) and 26 (79%) of the 33 cases, respectively. The A3 and A5 pulleys were never seen. After lesion creation, pulley rupture was suspected because of the disappearance of the A2 and/or A4 pulleys (depending on lesion type) in the sagittal plane (Fig 10). At MR imaging, the diagnosis of pulley rupture with direct imaging signs was possible in all cases in which the A2 and/or A4 pulleys were visualized before lesion creation. Measurements of the tendinous gap at the level of the distal third of the middle phalanx revealed an increase in the distance between the bone and the FDP tendon after lesion creation, which again was maximum at forced flexion (Fig 11) and increased in size in proportion to the number of disrupted pulleys. Figure 10a. Sagittal US image obtained with the finger in extension (a) before and (b) after the creation of a complete lesion of the A2 pulley. The A2 pulley (arrows) is visualized directly in a and is not seen in b . Arrowheads represent the setting level of attenuation.
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Figure 10b. Sagittal US image obtained with the finger in extension (a) before and (b) after the creation of a complete lesion of the A2 pulley. The A2 pulley (arrows) is visualized directly in a and is not seen in b . Arrowheads represent the setting level of attenuation.
Figure 11a. (a,b) Transverse US images obtained after the creation of a complete A2 lesion at (a) full extension and (b) forced flexion demonstrate the View larger version: development of a gap In this page In a new window between the tendon (solid Download as PowerPoint Slide arrow) and bone (open arrow) in b . (c) Corresponding transverse cadaveric section depicts the gap (arrows) at forced flexion.
Figure 11b. (a,b) Transverse US images obtained after the creation of a complete A2 lesion at (a) full extension and (b) forced flexion demonstrate the View larger version: development of a gap In this page In a new window between the tendon (solid Download as PowerPoint Slide arrow) and bone (open arrow) in b . (c) Corresponding transverse cadaveric section depicts the gap (arrows) at forced flexion.
Figure 11c. (a,b) Transverse US images obtained after the creation of a complete A2 lesion at (a) full extension and (b) forced flexion demonstrate the development of a gap between the tendon (solid
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arrow) and bone (open arrow) in b . (c) Corresponding transverse cadaveric section depicts the gap (arrows) at forced flexion.
Partial lesions.The results of analysis of the partial lesions are summarized in Tables 47. On MR images, the A2 pulleys were visualized before lesion creation in all cases. After lesion creation, the distal end of the A2 pulley was not observed in the sagittal plane, whereas, in the transverse plane, direct visualization of the disruption site was possible. A minimal tendinous gap between the FDP tendon and the bone was observed at only forced flexion (Fig 12), but measurements of this tendinous gap proved to have no significance.
Figure 12a. (a) Transverse and (b) sagittal T1-weighted spin-echo (400/22) MR images obtained after the creation of a partial lesion View larger version: In this page In a new window of the A2 pulley. In a , the Download as PowerPoint Slide partially disrupted A2 pulley of the fourth finger (solid arrow) is seen directly, while in b , no significant gap between the tendon (open arrow) and bone (arrowhead) is appreciated at forced flexion.
Figure 12b. (a) Transverse and (b) sagittal T1-weighted spin-echo (400/22) MR images obtained after the creation of a partial lesion of the A2 pulley. In a , the partially disrupted A2 pulley of the fourth finger (solid arrow) is seen directly, while in b , no significant gap between the tendon (open arrow) and bone (arrowhead) is appreciated at forced
flexion.
On CT images, none of the pulleys was visualized before lesion creation. After lesion creation, the measurements of the tendinous gap between the FDP tendon and the bone were similar to those observed on MR images. US initially allowed direct visualization of the A2 pulleys in all cases. After lesion creation, images obtained in the sagittal plane demonstrated the absence of the distal part of the A2 pulleys. Again, the measurements of the distance between the FDP tendon and the bone showed a minimal tendinous gap at forced flexion alone; such measurements had no significance.
Statistical Analysis
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MR imaging and US proved equally matched for the detection of direct signs of partial and complete lesions of the finger pulley system. With regard to the detection of indirect signs of pulley lesions, each imaging modality offered accurate gap measurements between the FDP tendon and the bone in all finger positions, with no significant difference between measurements derived with the various techniques. For the detection of indirect signs of partial A2 lesions, no significant gap was present in any position. For the detection of indirect signs of all complete lesions, all provocative finger positions yielded a significant change in the gap between the FDP tendon and the bone; this suggested the diagnosis of a complete pulley lesion (the gap present with the finger in forced flexion (P < .05) was significantly greater than the gap with the finger in flexion (P < .05), which was significantly greater than the gap with the finger in extension). Among lesion types, a comparison of the gap measurements in extension did not show any significant differences, except that the partial A2 lesion gap was significantly smaller than the complete A2 + A3 + A4 lesion gap (P < .05). In flexion, the gap observed in the partial A2 lesions was significantly smaller than that observed in the other three lesion types. At forced flexion, all differences between lesion types became significant (the A2 lesion gap in partial pulley lesions was smaller than that in the complete A2 lesions, and the gap in the complete A2 lesions was smaller than that in either a complete A2 + A3 or a complete A2 + A3 + A4 lesion). There were no significant differences between the measured gaps in the complete A2 + A3 lesions and those in the complete A2 + A3 + A4 lesions.
DISCUSSION
In the finger, a pronounced disparity between the size and substance of supporting anatomy with respect to structure and function has been emphasized. Finger flexion relies heavily on the delicate focal thickened areas of the flexor tendon sheath, referred to as the pulley system, and the flexor tendons proper to successfully elicit fine motor tasks. Such flexion requires proximal excursion of the flexor tendon and tight apposition of the tendon to adjacent osseous structures during this excursion, both of which are afforded with the pulley system. Of the five annular pulleys (A1A5) identified in the finger flexor complex, the A2 and A4 pulleys appear to be fundamental for accurate and precise flexor tendon function (2,23,26,27). The current study was designed to gain an understanding of the normal and abnormal anatomy and of the optimal means of imaging of the flexor pulley system.
Anatomic Study
Our results indicate that normal A2 and A4 pulleys can be identified and localized accurately by using conventional MR imaging. T1-weighted spinecho imaging and fast spoiled gradient-recalled echo imaging were equally successful in depicting the normal pulleys. The transverse plane proved more reliable than the sagittal plane for pulley depiction and offered optimal visualization of the insertion of the pulley system into adjacent bone, thereby increasing the ease of identification of the pulleys. Identification of the A3 and A5 pulleys also was possible but required a more elaborate technique such as MR imaging with contrast material distention of the tendon sheath (ie, MR tenography). Although MR tenography proved to be an elegant method of analysis of the pulley system, knowledge of both the pattern and clinical importance of injury to the pulley system suggests that information regarding the A2 and A4 pulleys, as opposed to the A3 and A5 pulleys, is critical. With US, the A2 and A4 pulleys were identified readily in both imaging planes and appeared as focal hyperechoic thickenings of the tendon sheath. The distal end of the A2 pulley, the thicker part of the pulley (1), always was identified easily. The difficulty in the identification of the A4 pulley (compared with the A2 pulley) with US but also with MR imaging can be explained by the fact that the A4 pulley constantly is much smaller (6.4-mm length in our study) and thinner than the A2 pulley. Moreover, as specified previously, the length of the pulley is directly proportional to the length of
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the finger (1,2). This explains why the A4 pulley generally is difficult to identify in the index finger or a small hand. This also explains the impossibility of detection of the A3 and A5 pulleys with both US and conventional MR imaging, as these pulleys are thin (thinner than the A4 pulley) and do not have an osseous insertion site. At CT, only the gross morphology of the flexor tendons was depicted. These findings have significant implications with regard to the evaluation of abnormalities of the flexor tendon, which indicates that conventional imaging techniques allow accurate and reliable direct evaluation of the pulley system of the flexor tendons. In addition, such evaluation obviates secondary diagnostic maneuvers, which can prove difficult to perform, owing to patient motion and inconsistencies in patient positioning.
Simulated Pulley Lesion Study

The second purpose of this study was to define the diagnostic criteria related to the identification of abnormalities of the pulley system by using different imaging modalities. With conventional MR imaging, the direct diagnosis of abnormalities of the A2 pulley was possible in all cases (100%), with either direct visualization of the disrupted pulley in the transverse plane or nonvisualization of the pulley in the sagittal plane. In the A4 pulley, direct diagnosis of an abnormality was possible in 30 (91%) of the 33 cases. If the A4 pulley was not identified on initial MR images, lesion detection also was not possible. At the time of surgical inspection, these pulleys appeared to be thin and delicate. With US, our results showed that direct diagnosis of abnormalities of the A2 and A4 pulleys was possible in 33 (100%) and 26 (79%) of the 33 cases, respectively, which corresponded again to the number of A4 pulleys identified before lesion creation. Thus, MR imaging appeared to be the most accurate in the detection of A4 lesions. In contrast, all imaging proved successful in the evaluation of indirect signs of pulley system lesions, with no significant differences among modalities. With the three modalities used in our study, the resultant tendinous gap from total pulley lesions always was maximum and significantly greater at forced flexion than at flexion or extension. It was not unexpected that the tendinous gap at forced flexion increased significantly in proportion to the number of disrupted pulleys. This gap was 58 mm for complete combination lesions of multiple pulleys (A2 + A3 or A2 + A3 + A4), 25 mm for isolated complete lesions of the A2 pulley, and 03 mm for partial A2 lesions. These findings have definite implications for the evaluation of not only the presence but also the extent of the lesions. Moreover, by considering the data regarding the evaluation of direct and indirect findings, a distinction between partial and total A2 lesions is possible. With nonvisualization of the A2 pulley in the evaluation of direct signs of pulley lesions, a tendinous gap at forced flexion indicates a total lesion, whereas a minimal tendinous gap indicates a partial lesion. Given our findings, MR imaging and US appear promising with regard to the detection of direct signs of complete or partial pulley lesions without provocative finger positioning. This might be helpful in current practice because it would reduce motion artifacts caused by forced flexion, which currently are one of the major limitations of MR imaging for the detection of pulley lesions. The diagnosis of pulley lesions at an early stage (partial A2 lesion) also is of clinical importance because treatment options for partial versus total lesions are different (ie, conservative therapy for partial lesions vs open surgery for total lesions). In addition, diagnosis and treatment at an early stage will prevent the progression of lesions and decrease the risk of long-term complications that are associated with fixed finger contracture. This study had several limitations. First, it appears that the ideal method for complete identification of the A2, A3, A4, and A5 pulleys is MR imaging with tenography. This technique is not available routinely and would not appear to be valuable in cases of pulley disruption, owing to the inevitable associated disruption of the tendon sheath. This limitation, however, has little consequence because the functionally important A2 and A4 pulleys are seen well with routine MR imaging or US. Second, although we made every possible effort to re-create a physiologically and clinically accurate model
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of abnormalities of the tendons and tendon sheaths of the finger, the lesions were created surgically in cadaveric specimens. The choice of a cadaveric model allowed us to create a large number of lesions encountered in clinical practice and compare imaging findings in the various patterns of injury. The imaging appearance of long-term pulley disruption may differ between patients because of the development of scar or fibrous tissue. However, such fibrous tissue has already been described in the literature and has not been thought to create any diagnostic difficulty (21). In addition, the cadaveric specimens used in the study were harvested uniformly from an elderly population; this was necessitated by availability. Finally, the quality of the MR images obtained in this study may be difficult to reproduce routinely because, even at extension, some motion artifacts may occur. In these cases, transverse images are of particular interest because they allow visualization of the sites of bone insertion. In summary, our results indicate that the A2 and A4 pulleys can be identified directly with conventional MR imaging and US, while depiction of the A3 and A5 pulleys requires additional techniques such as MR tenography for direct visualization. These findings represent means for the evaluation and direct diagnosis of complete and partial lesions of the pulley system of the flexor tendon system, which may have an effect on the clinical treatment of patients with these injuries.
Acknowledgments
The authors thank Paul L. Clopton, MS, for help with the statistical analysis.
Footnotes
Abbreviation: FDP = flexor digitorum profundus
Author contributions: Guarantors of integrity of entire study, O.H., C.B.C., N.L., D.R.; study concepts, D.R.; study design, O.H., D.R.; definition of intellectual content, O.H., D.R.; literature research, O.H., R.D.B.; experimental studies, O.H., N.L., C.B.C., D.T.; data acquisition, O.H., N.L., M.J.B., C.B.C., D.T.; data analysis, O.H., C.B.C., D.R.; manuscript preparation, O.H., C.B.C.; manuscript editing and review, O.H., C.B.C., D.R.
Index terms:
Computed tomography (CT), comparative studies, 43.12111, 43.12112, 43.12115 Fingers and toes, injuries, 43.489 Hand, CT, 43.1211 Hand, MR, 43.121411, 43.121412, 43.121413, 43.121415 Hand, US, 43.1298 Ultrasound (US), tissue characterization, 43.1298, 43.12988
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Pulley System in The Fingers: Normal Anatomy and Simulated Lesions in Cadavers at MR Imaging, CT, and US With and Without Contrast Material Distention of The Tendon Sheath1

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radiology.rsna.org October 2000 Radiology, 217, 201-212.

MATERIALS AND METHODS Anatomic and Biomechanical Considerations

Imaging-Anatomic Correlation and Analysis

Simulated Pulley Lesions

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TABLE 1. Types of Lesions Created in 33 Fingers

cortex to the FDP tendon.

RESULTS Anatomic Study

the A2 pulley (arrows).

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TABLE 3. Location and Mean Longitudinal Dimensions of Finger Pulleys

Simulated Pulley Lesions (group III): Imaging

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TABLE 4. Direct Visualization of the A2 and A4 Pulleys by Using MR Imaging and US

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TABLE 6. Distance Between Bone and FDP Tendon at CT

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TABLE 7. Distance Between Bone and FDP Tendon at US

Simulated Pulley Lesion Study

Abbreviation: FDP = flexor digitorum profundus

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