MAY, 1975

ROENTGENOGRAPHIC ANATOMY OF THE TENDON

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SHEATHS OF THE HAND AND WRIST:

TENOGRAPHY*
By DONALD RESNICK, M.D.
SAN DIEGO, CALIFORNIA

T HE radiographic evaluation of the METHOD OF TENOGRAPHY

normal and abnormal tendon sheaths In all 10 instances evaluation of the
of the hand and wrist has received little
flexor tendon sheaths in each finger was
attention.’2 These synovial-lined structures accomplished by the introduction of .5-3
are altered in various disease states, becom-
ml. of Renografin 6o (meglumine diatrizo-
ing local avenues for the spread of infection
ate, Squibb); the exact amount depended
from one site to another5 or partaking in a
upon whether or not the individual tendon
more widespread synovial affliction such
sheath communicated with the radial or
as rheumatoid arthritis.2
ulnar bursa in the wrist (Table I). A 22
It is the purpose
of this report to outline gauge, i inch needle is introduced through
the anatomy of the tendon sheaths of the
the palmar skin overlying the distal one-
hand and wrist emphasizing relationships
third of the proximal phalanx of the second
which are of importance in the pathogenesis
through fifth fingers. As one advances the
of certain disorders, and to describe tenog-
needle in a proximal direction, palpating
raphv, the technique of contrast evaluation
the tendon, one notes the increased resis-
to these structures.
tance as the needle enters the tendon. One
can withdraw the needle slightly, noting
MATERIAL
the sudden drop in resistance, and further
Hands and wrists in io cadavers were advance it in a shallow attitude within the
utilized. They were first injected at various sheath.
sites, as described below. Subsequent eval- The injection of the sheath of the flexor
uation included either careful dissection of pollicis longus may be accomplished by
the tendons on the volar and dorsal sur- flexing the terminal phalanx of the thumb,
faces of the hand and wrist or freezing for palpating the tendon, and inserting the
48 hours at -20#{176} C., followed by sectioning needle directly into it.
in various planes. In 3 instances contrast evaluation of the

TABLE I
DIGITAL FLEXOR TENDON SHEATH INJECTIONS

Communications
Site of Injection Number of
Injections
Ulnar Bursa Radial Bursa

Thumb I0
I#{176}
Index Finger 10 i

Middle Finger JO
Ring Finger io
Little Finger 10 5 -

*From the Departments of Radiology, University Hospital, University of California at San Diego and the Veterans Administration
Hospital, San Diego, California.

44
 VOL. 124, No. i Roentgenographic Anatomy of Tendon Sheaths of Hand and Wrist 5
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extensor tendon sheaths on the dorsum of of the second, third and fourth fingers.57
the wrist was accomplished. The tendons The relationship of the digital flexor
can be easily palpated and a needle in- tendon sheaths and the joints of the second,
serted through the dorsal carpal ligament. third, fourth and fifth fingers is of clinical
importance. There is a considerable amount
THE DIGITAL FLEXOR TENDON SHEATHS
of fibrous tissue between the metacarpo-
(Fig. I) phalangeal joint of each of these fingers and
The flexor tendons of the fingers, the the sheath.5 Slightly more distally near the
sublimus digitorum and profundus digi- base of the proximal phalanx, the sheath
torum, are enveloped by digital sheaths and bone are more intimate; at the prox-
from a line of insertion of the flexor pro- imal interphalangeal joint more fibrous
fundus to a line i cm. proximal to the tissue separates the sheath and synovial
proximal border of the deep transverse cavity as at the metacarpophalangeal
ligament.6 This arrangement, which is not joint.’ Sections reveal that the axial portion
constant, is most frequent in the index, of the joint capsule at the proximal inter-
middle and ring fingers.6’7 Any of these phalangeal joint is indistinguishable from
three sheaths may extend to the wrist.’0 the fibrous tendon sheath.4
The flexor sheath of the thumb extends The digital sheath of the thumb lies dis-
from the terminal phalanx to a point 2-3 tally near the proximal phalanx, but as it
cm. proximal to the proximal volar crease ascends toward the palm it separates from
of the wrist,7 although on occasion a septum the metacarpal head. Thus the sheath is
separates proximal and distal halves of the separated from the first metacarpophalan-
sheath.7 The synovial sheath of the little geal joint by considerable fibrous tissue.5
finger also commences at its terminal
SYNOVIAL SACS OF THE PALM
phalanx. It may end near the deep trans-
verse ligament or continue into the palm, (Fig. 2 and 3)

expanding to envelop the adjacent tendons Communication between the individual

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46

0
4injud
t
SAeas’,f
or
Donald
Resnick

Z/Ina,”
I,yam
Catpat
.7J,,a n,

s’st
s1er4e
MAY,
1975
 VOL. 124, No. i Roentgenographic Anatomy of Tendon Sheaths of Hand and Wrist 7

digital tendon sheaths and synovial sacs

or bursae in the palm is not constant;’#{176}
most frequently such continuation is noted
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involving the first digit. Not uncommonly

the digital sheath of the fifth finger also
continues into the palm.1’5’7 Such com-
munication is uncommon in the second,
third and fourth fingers.
The ulnar bursa on the medial aspect of
the palm is composed of three communicat-
ing invaginations;6’7 a superficial extension
lies in front of the flexor sublimis, a middle
one between the tendons of the sublimis
and the profundus and a deep extension is
found behind the flexor profundus.”6 The
bursa, beginning at the proximal end of the
finger sheaths, spreads out proximally over-
lying the third, fourth and fifth meta-
carpals.5 A statistical analysis of the tendon
sheath patterns in the hand using air in-
sufflation techniques’0 in 367 cases demon-
strated that the ulnar bursa communicated
with the sheaths of the little finger in 8i
per cent, index finger in 5.1 per cent, mid-
dle finger in 4.0 per cent and ring finger in
3.5 per cent of cases.
The radial bursa is the expanded prox-
imal continuation of the digital sheath of
the flexor pollicis longus. It is found on the FIG. 3. Pa/mar sac communications. (A) The radial
radial aspect of the palm overlying the and ulnar bursae may be separate distinct cavities
or communicate via intermediate bursae. (B) The
second metacarpal. It continues proximally
digital flexor sheaths of the first and fifth fingers
along the volar radial aspect of the wrist, (T) extend into the wrist. A large palmar sac
terminating about one inch above the (closed arrows) consists of communicating radial
transverse carpal ligament.5 and ulnar bursae. An intermediate bursa (open
Intercommunications between the ulnar arrows) is recognizable.
and radial bursae are frequent’ and may be
noted in 50 per cent of cases.5 Such con- tenor between the carpal canal and flexor
nection is made via intermediate bursae. profundus of the index finger or less con-
These accessory synovial sacs may be pos- stantly anterior between the superficial

FIG. 2. Synovial sacs of the palm.

(A) The digital flexor tendon sheaths of the second through fourth fingers terminate proximal to the
metacarpophalangeal joint. That of the fifth finger communicates with the ulnar bursa. The sheath of the
flexor pollicis longus is continuous with the radial bursa. Note the 3 invaginations of the ulnar bursa and,
in this drawing, absence of communication between radial and ulnar bursae. (B) Injection of the digital
sheath of the fifth finger (curved arrow) reveals communication with the ulnar bursa (straight arrows).
(C) The synovial sheath of the flexor pollicis longus (T) is continuous with the radial bursa (arrows).
(Fig. 2A adapted from an original painting by Frank H. Netter, M.D., from Clinical Symposia. Copyright
by CIBA Pharmaceutical Company, Division of Ciba-Geigy Corporation. All rights reserved.)
 48 Donald Resnick MAY, 1975
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‘.‘;/

A transverse
/ cross sect.....s through the c. .. the flexor tendons and sheaths wi
the carpal canal (large straight arrows). The transverse carpal ligament (curved arrow) is apparent.
(B) Contrast medium within the communicating radial and ulnar bursae delineates many flexor tendons
within the carpal tunnel (arrows). (C) An injection of the sheath of the flexor pollicis longus (T) outlines
a noncommunicating radial bursa (arrows) within the carpal tunnel.

and deep tendons of the index finger.5 A verse a canal on the volar surface of the
separate carpal sheath, without communi- wrist formed between a deep excavation on
cation with either radial or ulnar bursa, the undersurface of the carpal bones and
may be found enveloping the index flexor the transverse volar carpal ligament. The
tendons.6 Additionally, a small synovial sac latter extends in the wrist from the radial
may enclose the tendon of the flexor carpi (inserting on the trapezium, navicular, and
radialis as it passes under the crest of the occasionally the radial styloid) to the ulnar
trapezium.6 side (inserting into the pisiform and hook of
the hamate.)6 On its radial aspect a small
CARPAL TUNNEL
opening in the volar carpal ligament as it
(Fig. 4)
bridges the trapezium produces a tunnel
Tendons, vessels and nerves passing for the flexor carpi radialis tendon. Through
from the forearm to the hand must tra- the canal proper, which is triangular in
 VOL. 124, No. i Roentgenographic Anatomy of Tendon Sheaths of Hand and Wrist 9
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p.- 4;.
/

Fic. g. Extensor tendon sheaths.

(A) The synovial sheaths passing beneath the dorsal carpal ligament are separated into 6 distinct com-
partments; the numbers correspond to those used in the text. (B) A transverse cross section through the
distal radius (RAD), ulna, ulnar styloid (5) and inferior radio-ulnar joint (arrow) reveals the 6 compart-
ments of the extensor tendons and sheaths. (C) An injection has been made into the sheath (open arrows)
enclosing the tendons (T) of the extensor digitorum communis and extensor indicis proprius. A previous
injection in the flexor digital sheath of the fifth finger (curved arrow) introduced contrast material which
continued into the ulnar bursa (closed straight arrow).

transverse section, pass the digital flexor the dorsum of the wrist beneath the dorsal
tendons and sheaths, and the median carpal ligament; they extend for a short
nerve. Compression of the latter may result distance above and below that ligament.6
in the carpal tunnel syndrome; this may be By insular attachments of the dorsal carpal
associated with local or systemic dis- ligament on the posterior and lateral sur-
eases.3’8’9 faces of the radius and ulna, 6 distinct
avenues are created for transport of liga-
EXTENSOR TENDON SHEATHS
mentous structures.5’7 The most medial
(Fig. ) compartment contains the extensor carpi
Several synovial sheaths are located in ulnaris tendon and sheath (.-5 cm. in
 50 Donald Resnick MAY, 1975

length) lying at the dorsomedial aspect of septic arthritis accompanying hand infec-
the distal ulna. In the second compartment, tion are apparent. A future report will dis-
a long sheath (6-7 cm. in length) covers cuss in detail these particular aspects.
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the extensor digiti quinti proprius which Tenography in the rheumatoid hand2
lies in close proximity to and may corn- allows accurate appraisal of the extent of
rnunicate with the inferior radio-ulnar synovial involvement, thereby assisting the
joint.6 The third compartment on the surgeon. It may also allow further under-
posteromedial aspect of the radius con- standing of the pathogenesis of hand de-
tains a large sheath (-6 cm. in length) en- formities in that disease.
closing the tendons of the extensor digi- Outlining the synovial sheath within the
torum cornmunis and the extensor indicis carpal tunnel may demonstrate local me-
proprius. In the fourth compartment are chanical factors producing the carpal tun-
the sheath (6-7 cm. in length) and tendon nel syndrome.
of the extensor pollicis longus. The sheath
SUMMARY
may extend as far distally as the trapezium
or first metacarpal bone.6 Lateral to this in The radiographic anatomy of the tendon
the fifth compartment are sheaths (-6 cm. sheaths of the hand and wrist is described.
in length) covering the extensor carpi Contrast evaluation, tenography, of these
radialis longus and brevis which may com- synovial-lined channels utilizing 10 cada-
municate with the sheath of the extensor ver limbs was accomplished outlining their
pollicis longus. Finally, a compartment relationship to adjacent osseous and artic-
along the lateral aspect of the radius con- ular structures.
tains a common synovial sheath (-6 cm. The technique is simple and provides the
in length) enclosing the abductor pollicis radiologist with further understanding of
longus and extensor pollicis brevis. the pattern and distribution of roentgeno-
logic alterations accompanying septic and
DISCUSSION
granulomatous processes of the hand and
Tenography is a relatively simple radio- wrist including “horseshoe abscesses” of
graphic technique, particularly in indi- the palm, osteomyelitis, pyarthrosis, and
viduals in which exuberant synovial pro- rheumatoid tenosynovitis.
liferation has resulted in distention of the Tenography should be added to the
synovial sheaths. This is frequent in radiologist’s ever-increasing arm amen tar-
rheumatoid arthritis.2 Although this study ium.
was confined to cadavers, our own expe-
Department of Radiology
rience and previous reports”2 have indi-
Veterans Administration Hospital
cated the practicality of similar techniques San Diego, California 92161
in patients. A ring block at the base of the
injected finger” or local skin anesthesia is I wish to thank Ruth Valleau for her
ample. Roentgenograms which may include drawings, Donald Litzenberg, R.T., for
anteroposterior, oblique and lateral pro- technical assistance and Willa Johnson for
jections must be taken within 5-b min- her secretarial aid.
utes as contrast material diffusion will pro-
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