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Fig. 4.16 Anatomical scheme of the third extensor tendon compartment; EPL, extensor
pollicis longus tendon; R, radius
4.2.1.3 Third Compartment
The third compartment (Fig. 4.16) contains
the extensor pollicis longus tendon.
The Lister’s tubercle separates the second from
the third compartment (Figs. 4.17a, b).
Moving the probe distally, the extensor
pollicis longus tendon crosses the tendons of
the second compartment to reach its distal
insertion (Fig. 4.18). This crossing point can
represent another site of friction that can be
rarely encountered in clinical practice.
4 Wrist
56
Dorsal Side
57
Fig. 4.17b Axial scan of the third compartment. EPL, extensor pollicis longus tendon; ECRB, extensor carpi radialis
brevis tendon; ECRL, extensor carpi radialis longus tendon; L, Lister’s tubercle
Fig. 4.18 Axial scans at the distal third of the forearm show intersection between the third (arrowheads) and second
(II) extensor tendon compartment; LT, Lister’s tubercle
Fig. 4.17a Probe position to evaluate the third
extensor compartment
continue with one tendon each. The fourth ex-
tensor compartment also contains a part of the
myotendinous junctions of these tendons. They
insert on the dorsal aspect of the proximal
phalanx of the I, II, III, and IV finger where
each splits into three branches: the lateral and
the medial insert on the distal phalanx of each
finger, while the median branch inserts on the
intermediate phalanx.
The extensor indici muscle arises from the
posterior aspect of the ulna and interosseous
membrane. Its distal tendon enters the fourth
extensor compartment, then joins the extensor
digitorum tendon of the second ray over the
corresponding metacarpophalangeal joint.
The extensor digiti minimi is a superficial
muscle lying in the posterior compartment of
the forearm, medial to the extensor digitorum
muscle. It arises together with the extensor
digitorum from the posterior aspect of the
lateral epicondyle and the antebrachial fas-
cia. It enters the fifth extensor compartment,
then joins the extensor digitorum tendon of
the fifth ray over the corresponding metacar-
pophalangeal joint. Note that the floor of the
fifth compartment is made by a fibrous band
and the tendon does not lie on the bone, like
the other five compartments.
4 Wrist
58
Fig. 4.19 Anatomical scheme of the
fourth and fifth extensor compart-
ments. EIP, extensor indici pro-
prius tendon; EDC, extensor digito-
rum communis tendon; R, radius;
U, ulna
4.2.1.4 Fourth and Fifth Compartments
The fourth compartment (Fig. 4.19) contains
the extensor indici tendon (radial) and the
extensor digitorum tendons (ulnar).
The fifth compartment (Fig. 4.19) contains
the extensor digiti minimi (or extensor digiti
quinti).
The probe must be moved slightly towards
the ulnar side of the wrist (Fig. 4.20a). The
extensor indici tendon is the most radial within
the fourth compartment. Dynamic scans are
useful to differentiate it from the extensor dig-
itorum tendons.
In order to differentiate the two tendons of
the fourth compartment (Fig. 4.20b) and the
extensor of the little finger tendon (Fig. 4.20c),
make dynamic scans while patient flexes and
extends fingers.
The extensor of the little finger tendon runs
in a space between the radium and ulna and
does not have a bony plane below it.
The extensor digitorum is a superficial mus-
cle lying in the posterior-lateral compartment
of the forearm. It arises from the posterior
side of the lateral epicondyle, the radial collat-
eral ligament, the annular ligament and the
antebrachial fascia. At the middle third of the
forearm, it splits into three bundles: the later-
al separates into two tendons, while the others
Dorsal Side
59
Fig. 4.20a Probe position to evaluate the fourth
and fifth compartments
Fig. 4.20b Axial scan on the dorsal wrist. Arrowheads, extensor digitorum tendons; *, extensor indici proprius ten-
don; R, radius; EPL, extensor pollicis longus (third compartment); LT, Lister’s tubercle; ECRB, extensor carpi radi-
alis brevis; ECRL, extensor carpi radialis longus
Fig. 4.20c Axial scan of the fifth compartment. U, ulna; void arrowhead, extensor of the little finger tendon; R, radi-
um; IV, tendons of fourth compartment
The triangular fibrocartilage complex is
located in the ulnar-carpal space and con-
curs to wrist stability on the ulnar side, also
acting as a shock absorber for axial loads.
The complex includes the triangular fibro-
cartilage itself, the homologous meniscus,
the ulnar collateral ligament, the dorsal and
ventral radio-ulnar ligaments and the exten-
sor carpi ulnaris deep sheath.
4.2.2 Distal Radio-Ulnar Joint
The probe must be moved proximally over the
distal aspect of the radius and ulna (Figs. 4.24,
4.25a, b).
4 Wrist
60
Fig. 4.21 Anatomical scheme of the sixth
extensor tendon compartment. ECU,
extensor carpi ulnaris tendon; U, ulna
4.2.1.5 Sixth Compartment
The sixth compartment (Fig. 4.21) contains
the extensor carpi ulnaris tendon.
The probe must be moved slightly towards
the ulnar side and the wrist must be slightly
bent on the radial side (Figs. 4.22a, b).
Moving the probe on a coronal plane, the
triangular fibrocartilage complex can be seen
between the ulnar styloid process and the tri-
quetrum (Fig. 4.23).
The extensor carpi ulnaris is a superficial
muscle lying in the posterior compartment of
the forearm, arising medially to the extensor
digiti minimi muscle, with branches also
inserting on the posterior aspect of the ulna.
Its bundles are directed medially and its distal
tendon enters the sixth compartment, then
inserts on the fifth metacarpal bone.
Dorsal Side
61
Fig. 4.22a Probe position to evaluate the sixth extensor com-
partment
Fig. 4.22b Axial scan of the sixth compartment. Arrowheads indicate the extensor carpi ulnaris
tendon on the short axis; U, ulna
Fig. 4.23 TFC, triangular fibrocartilage; ECU, extensor carpi ulnaris (long axis);
U, ulnar styloid process; P, pyramidal
4 Wrist
62
Fig. 4.24 Anatomical
scheme of distal radio-
ulnar joint. R, distal
radial epiphysis; U,
distal ulnar epiphysis;
*, joint space and
articular recesses
Fig. 4.25a Probe position to evaluate the distal radio-
ulnar joint
Fig. 4.25b Axial scan of
the distal radio-ulnar joint.
R, radius; U, ulna; *, joint
space
The exam can be commenced either from the
dorsal or the palmar side of the hand.
5.1 Ventral Side
The hand lies on the table with the ventral side
facing up (Fig. 5.1).
5.1.1 Palmar Aponeurosis
The palmar aponeurosis is barely detectable
on US when normal. However, this anatomical
structure is important, as it can be thickened
in a number of common pathologic condi-
tions.
Hand
5
Content s
5.1 Ventral Side
• Palmar Aponeurosis
• Flexor Digitorum Tendons
• Metacarpophalangeal and Interphalangeal Joints
5.2 Dorsal Side
63
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
Fig. 5.1 Hand position to evaluate the palmar side
of the hand
The palmar aponeurosis covers muscles
and tendons of the palm and consists of
central, lateral, and medial bundles. The
central bundle has a triangular shape, with
the apex located over the transverse carpal
ligament, and is the strongest and the thick-
est of the palmar aponeurosis bundles. Its
base divides into four slips, one for each
finger, with expansions for proximal pha-
lanx bones, flexor tendon sheaths, and skin.
The lateral and medial bundles of the pal-
mar aponeurosis are thin, fibrous layers,
which cover the thumb and little finger
muscles, on the radial and the ulnar side,
respectively.
5.1.2 Flexor Digitorum Tendons
Evaluation of flexor tendons should be com-
menced at the carpal tunnel level (see above).
The changing relationship between superficial
and deep flexor tendons (Figs. 5.2a, b) can be
appreciated moving the transducer distally
with axial scans (Figs. 5.3a, b).
Longitudinal scans are useful for passive
dynamic evaluation.
Reflection pulleys can be seen on both
axial and longitudinal scans (Figs 5.4a, b).
The flexor digitorum profundus tendon
originates from the anterior and medial
aspects of the ulna. The flexor digitorum
superficialis has two heads, the humero-
ulnar and the radial. Both muscles originate
from long tendons that enter the carpal tun-
nel and then insert on the fingers. In partic-
ular, deep tendons run straight up to the dis-
tal phalanges, where they insert on the
bases. Conversely, superficial tendons run
up to the middle of the proximal phalanges,
where they split into two branches that sur-
round the deep tendons and insert on the
head of the middle phalanges. The superfi-
cial and deep tendons have common tendon
sheaths. Note that the flexor digitorum
superficialis tendon of the little finger can
frequently be absent.
5 Hand
64
Ventral Side
65
Fig. 5.2a Anatomical scheme of flexor digitorum tendons. *, flexor digitorum profundus tendon; circles, flexor digi-
torum superficialis tendons; M, metacarpal bone; P1, P2, P3, proximal, middle and distal phalanges, respectively
Fig. 5.2b Anatomical scheme of axial section over the metacarpal heads. M, metacarpal bones; FDS, flexor digito-
rum superficialis tendon; FDP, flexor digitorum profundis tendon; L, lumbrical muscles; IO, interosseous muscles;
N, common digital nerve; A, common digital artery