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40 Chapter 2
1. Patient position: Sitting with wrist in full pronation and hand resting on the table
2. Probe/transducer position:
a. LX view/longitudinal view: The transducer is aligned along the extensor tendon, which is
then followed proximal to distal. The most distal structure seen is the nail bed and nail
(Figure 2-32).
Figure 2-32. Ultrasound image of the dorsal aspect of the digit. The extensor tendon (white arrows) is much thinner
than the flexor tendons on the volar aspect of the digit. (DIP = distal interphalangeal joint)
b. SX view/transverse view: The SX view is used only after the extensor tendons are visualized
in the LX view to confirm the findings.
3. Relevant anatomy: The extensor tendons are much thinner than the flexor tendons of the
digits. Dynamic examination is important when the integrity of the extensor tendon is in
question. The nail appears hyperechoic on ultrasound with a hypoechoic nail bed.
4. Points to remember: The skin crease over the MCP and interphalangeal joints causes refraction and attenuation of the ultrasound beam, which results in poor visibility of the tendons
or other structures of interest in this region. Flexing the digits adds a stretch to the loose skin
and is a useful technique to avoid the artifacts created by the skin crease.
Wrist and Hand 41
Collateral Ligaments of Proximal Interphalangeal Joint
1. Probe position:
a. LX view: The transducer is placed on the ulnar/radial aspect of the proximal interphalan-
geal (PIP) joint of the digit (Figure 2-33).
A
B
C
Figure 2-33. Collateral ligament of the PIP joint of digits. (A) Relevant anatomy of the collateral ligament of the PIP
joint. The collateral ligament is divided into 2 parts: proper ligament (green) and accessory ligament (blue). The
proper collateral ligament arises from the head of proximal phalanx (PP) and attaches to the middle phalanx (MP). The
accessory ligament is the smaller part of the collateral ligament and attaches to the volar plate. (B) Probe placement.
The transducer is placed on the ulnar/radial aspect of the PIP joint of the digit. (C) Ultrasound image of the collateral
ligament (white arrows) as a hyperechoic fibrillar structure.
2. Relevant anatomy: The collateral ligament of the PIP joint is divided into 2 parts: proper
ligament and accessory ligament. The proper collateral ligament arises from the head of the
proximal phalanx and attaches to the middle phalanx. The accessory ligament is the smaller
part of the collateral ligament and attaches to the volar plate.
17
3. Points to remember: A thickened collateral ligament may be observed in cases of finger sprain.
42 Chapter 2
Ulnar and Radial Collateral Ligaments of
First Metacarpophalangeal Joint
1. Patient and probe/transducer position:
a. For the UCL: Wrist in mid-supination/pronation with thumb abduction. The transducer is
placed in the LX along the ulnar aspect of the first MCP joint in a slight oblique orientation
(Figure 2-34).
AB
Figure 2-34. UCL of the first MCP joint.
(A) Probe placement. Wrist in midsupination/pronation with thumb in
abduction. The transducer is placed in
the LX along the ulnar aspect of first
MCP joint in slight oblique orientation.
(B) Ultrasound image of the UCL (white
arrows), which appears as a hyperechoic
fibrillar structure between the first
metacarpal and proximal phalanx. (C)
Relevant anatomy: The adductor pollicis
aponeurosis overlies the UCL and has an oblique orientation relative to the UCL. UCL orientation is dorsal to palmar, and
adductor pollicis orientation is palmar to dorsal. (EPL = extensor pollicis longus tendon.)
C
Wrist and Hand 43
b. For the radial collateral ligament (RCL): Wrist supinated and resting on the table. The
transducer is placed in the LX along the radial aspect of the first MCP joint in a slight
oblique orientation (Figure 2-35).
AB
Figure 2-35. RCL of the first MCP joint. (A) Probe placement: wrist supinated
and resting on the table. The transducer is placed in LX along the radial
aspect of the first MCP joint in slight oblique orientation. (B) Ultrasound
image of the RCL (white arrows), which appears as a hyperechoic fibrillar
structure between the first metacarpal and proximal phalanx.
2. Relevant anatomy: Both UCL and RCL are the primary stabilizers of the first MCP joint. The
RCL and UCL ligaments are divided into the larger proper ligament and smaller accessory
ligament. The proper ligament of the RCL and UCL originates from the dorsal aspect of the
first metacarpal head and inserts on the volar aspect of the base of the proximal phalanx.
The accessory ligament of the RCL and UCL attaches to the volar plate and sesamoid bones.
Proper collateral ligaments are taut during flexion, and accessory ligaments are taut during
extension.
18
3. Points to remember: The adductor pollicis muscle overlies the UCL and has an oblique orienta-
tion relative to the UCL. UCL orientation is dorsal to palmar, and adductor pollicis orientation
is palmar to dorsal. In a Stener lesion, the adductor pollicis aponeurosis may be interposed
between the proximal phalanx and the proximally retracted UCL and thus interfere with ligament healing.
18,19
44 Chapter 2
Hand Muscles and Associated Tendons
1. Patient position: Sitting or in supine with wrist in full supination and resting on the table
2. Probe/transducer position:
a. SX view/transverse view: The transducer is placed transversely across the palm to evaluate
the flexor tendons and lumbrical muscles in the hand (Figures 2-36 and 2-37).
A
B
C
Figure 2-36. SX view of the palm at the
level of the metacarpal shaft. (A) Probe
placement. (B) Ultrasound image of
the palm at the level of the metacarpal
shaft. (C) Labelled image showing
flexor tendons (FT), lumbrical muscles
(L), palmar interossei muscles (PI), and
metacarpal (MC).
AB
C
Figure 2-37. SX view of the palm at the level of the metacarpal head-neck junction. (A) Probe placement. (B)
Ultrasound image of the palm at the level of the metacarpal head-neck junction. (C) Labelled image showing FDS,
FDP, and metacarpal (MC).
b. LX view/longitudinal view: The transducer can be rotated 90 degrees to visualize the struc-
ture of interest in the LX view.
Wrist and Hand 45
3. Relevant anatomy: In the hand, the flexor tendons are arranged with the FDP deeper to
the FDS, and the lumbrical muscles are on either side of the tendons, except the first digit,
which has a single flexor tendon (FPL) attaching to the distal phalanx. The FPL runs laterally
through the thenar muscles to the first digit (Figure 2-38).
AB
Figure 2-38 . Thenar eminence. (A) Probe
placement. (B) SX view of the thenar
eminence showing the FPL (white
arrow) surrounded by thenar muscles.
(MC = metacarpal.) (C) LX view of the
thenar eminence showing the FPL (white
arrow) with thenar muscles above and
below it. (MCPJ = metacarpophalangeal
joint.)
C
4. Points to remember: Tenosynovitis of the flexor tendons at the level of the palm and wrist
can be missed due to the presence of hypoechoic muscles in the near vicinity. Color ultrasound should be used to check for signs of vascularity, as can be seen in cases of synovitis or
tenosynovitis.
46 Chapter 2
Carpometacarpal Joints
1. Patient position: Sitting or in supine with wrist in mid-supination/pronation for the first carpometacarpal (CMC) joint and wrist in full pronation with palm side down for other CMC joints
2. Probe/transducer position:
a. LX view/longitudinal view: The transducer is placed in the LX along the carpal and meta-
carpal bones of the CMC joint of interest (Figures 2-39 and 2-40).
A
C
B
Figure 2-39. First CMC joint. (A) Probe placement. (B) Ultrasound image of the
first CMC joint. (CMCJ = carpometacarpal joint; MC = metacarpal.) (C) Relevant
anatomy.
Wrist and Hand 47
A
B
Figure 2-40. Third CMC joint. (A) Probe placement. (B) Ultrasound image of the
third CMC joint. (CMCJ = carpometacarpal joint; MC = metacarpal.) (C) Relevant
anatomy.
C
b. SX view/transverse view: The transducer is placed transversely across the CMC joint if
needed.
3. Relevant anatomy: For the imaging of the first CMC joint, it is important to visualize 4 bony
structures—the distal end of the radius, the scaphoid, the trapezium, and the proximal end
of the first metacarpal—and then focus on the area of interest, which is first CMC joint. This
approach ensures that other pathologies of the region are not missed. For the second through
third CMC joints, the transducer is aligned with the proximal end of the metacarpal.
4. Points to remember: First CMC joint arthritis is common. Ultrasound is a great tool to detect
early bony changes or synovitis, which is often missed in early radiographs.
Carpal boss, which is a bony protuberance of the second or third CMC joint, may presents
as a bump on the dorsum of the hand. Sometimes it is associated with the bursa or cystic mass
that covers the bony protuberance.
48 Chapter 2
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Elbow
Mohini Rawat, DPT, MS, ECS, OCS, RMSK
Contents
• Anterior Elbow
Joint Anatomy
º
Distal Biceps Tendon
º
Brachialis
º
Pronator Teres
º
• Medial Elbow
Common Flexor Tendon
º
Ulnar Nerve
º
Ulnar Collateral Ligament
º
• Lateral Elbow
Common Extensor Tendon
º
Lateral Collateral Ligament Complex
º
Radial Nerve
º
• Posterior Elbow
Joint Anatomy
º
Triceps Tendon
º
Olecranon Bursa
º
3
- 49 -
Atlas of Musculoskeletal Ultrasound of the E xtremities (pp 49-79).
Rawat M.
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