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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 (1–3), 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 system’s 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 (6–10). Although several investigators (11–22) 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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is directly proportional to the length of the pulley (2). and the fifth pulley (A5) is in the region of the distal interphalangeal joint. The third pulley (A3) is small and extends over the region of the proximal interphalangeal joint. palmar plate annular pulleys (A1. which can prove challenging with regard to patient positioning and motion artifact. and the thickness. 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. Dotted lines represent the division of the flexor digitorum superficialis tendon into two bands at View larger version: In this page In a new window Download as PowerPoint Slide this level. the length of each pulley varies in direct proportion to the length of the digit. In addition. 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. Study results have shown that the A2 pulley is the strongest. The ensuing discussion will focus on the annular component of the pulley system. The purpose of this study was twofold: to describe the normal anatomy of the pulley system with MR imaging. 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. 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 fourth pulley (A4) is in the midportion of the middle phalanx. well-defined areas of thickening of the tendon sheath that are referred to as the annular pulley system. Sagittal (left) and coronal (right) depictions of the pulley system of a typical flexor tendon (black areas) of the finger: fibroosseous annular pulleys (A2. 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.full Page 2 of 18 . Loss of all or part of the flexor tendon pulley system may have a significant effect on digital performance. CT. in turn.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 finding referred to as the bowstring sign. At anatomic inspection. A4). these images must be obtained with the finger in flexion or forced flexion. and C3). and A5). Additional crisscrossing fibers between the components of the annular pulley system are referred to as the cruciate pulley system. C2. A3.org/content/217/1/201. 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). The annular pulleys are of biomechanical importance in preventing tendon excursion during digital flexion. Expand these retinacular structures result in focal. and cruciate pulleys (C1. Figure 1. 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.rsna. In general. followed by http://radiology.

73.full Page 3 of 18 . 3 mm. Anatomic Study Eight hands were harvested from four fresh frozen cadavers (three men and one woman. 1 mm). Schering. Wis) with a dedicated phased-array wrist coil. The first and second groups had no known finger abnormalities and were used to depict the normal anatomy of the flexor tendon pulley system. and 3-mm-thick sections were obtained with a band saw in the transverse (four hands. all cadaveric specimens were frozen for 24 hours at −60° C. Bothell. Helical CT (PQ 5000. two in each group) planes. since they were the most common sites of injury (6. Imaging MR imaging was performed with a 1. GE Medical Systems. Advanced Technical Laboratories. 1 cm distal to the level of the metacarpophalangeal joint. The study of flexed fingers was limited to the transverse plane because the transducer was too wide for accurate analysis in the sagittal plane. into the flexor tendon sheath of the finger (group II). which subsequently were evaluated with MR imaging. Images were displayed by using soft-tissue windows. section thickness.5 years]). Berlin. echo time. 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. The specimens were divided into two groups of four hands each (12 fingers per group). Picker International.10. which is followed by involvement of the A3. a 25-gauge needle was inserted into the volar surface of the finger and was advanced.8 mL of a solution of 1 mL gadopentetate dimeglumine (Magnevist. field of view. two in each group) and sagittal (four hands. All specimens were studied in sagittal and transverse planes. 22 msec [400/22]) and fast spoiled gradient-recalled echo (400/12.) who was experienced in performing musculoskeletal US. and US without (group I) and with (group II) opacification of the tendon sheaths with contrast material (MR tenography). http://radiology. Subsequently. matrix.5-T clinical system (Signa. MR Tenography With fluoroscopic guidance.H. 68–78 years of age at death [mean age at death. Only the second through fourth digits were investigated. 512 × 256. 8 × 8 cm. 2 mm. Imaging-Anatomic Correlation and Analysis After imaging. CT. CT. Cleveland. Ohio) was performed in both groups (120 mAs. and. Images were acquired with the fingers in extension and as close as possible to the following flexed position: metacarpophalangeal joint in full extension.25). Wash) in all specimens in both groups by an investigator (O. the third group was composed of specimens with surgically created lesions of the pulley system. 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. Omnipaque. Milwaukee. 400 msec. 20°) imaging in the transverse and sagittal planes were performed in group I (n = 12). NJ) was injected into the tendon sheath to verify accurate needle positioning and distend the tendon sheath. Princeton.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 the A1 and A4 pulleys (23–25). and US were performed with the hands in a pronated position. Nycomed Amersham. T1weighted spin-echo (repetition time. A1 pulleys. MR imaging. with the proximal interphalangeal joint in 60° of flexion and with the distal interphalangeal joint in 10° of flexion.rsna. Gray-scale US was performed by using a 12-MHz transducer (HDI 5000. A4. 0. 150 kVp. flip angle. in rare situations. incremental table movement. In all three groups.org/content/217/1/201. Three groups of cadaveric hands were studied. with two signals acquired). Germany) diluted with 250 mL of normal saline and 1 mL of iodinated contrast material (iohexol.

CT. which resulted in finger flexion. Dissection was performed through the subcutaneous tissues and along the midline to the level of the flexor pulleys. a longitudinal incision was made in the midline of the specified annular pulleys. The flexor tendons were sutured together with 3-0 vicryl suture in the distal forearm to produce a single common tendon to each digit. 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.rsna. and the proximal half of the pulley was left intact. with maximal preservation of the soft tissues. Because of the potentially interactive nature of US. preparation was made to load each of the digital flexor tendons.) randomly analyzed all specimen images. 57–81 years of age at death [mean age at death. as compared with the gross anatomic sections. Simulated Pulley Lesions To evaluate the imaging of abnormalities in the pulley system..C. A P value of less than . The volar forearm incision was closed with 4-0 nylon suture by using a running. Complete lesions constituted total longitudinal pulley transection. which could be loaded to produce digital flexion.B. View this table: In this window In a new window TABLE 1. All lesions were created by an orthopedic surgeon (M. Partial and complete lesions were created in various combinations to simulate well-documented mechanisms of injury with regard to technique and progression (6. Imaging In all cases. an additional 11 hands (group III) were harvested from six fresh frozen cadavers (four men and two women.full Page 4 of 18 . The incisions were irrigated and filled with normal saline during closure to remove air within the subcutaneous tissues. and MR imaging of the fingers were performed with the same nonenhanced technique described previously. As before. First. US. Each incision was of a minimal length and extended proximally and distally only far enough to allow access to the pulley(s) of interest.25) (Table 1). and traction was applied to the flexor tendons. To simulate a complete pulley rupture.H.org/content/217/1/201. The latter were imposed on the A2 pulley alone. 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.B. The Pearson correlation test was performed to evaluate any significant differences between the measurements obtained with each imaging technique. only the second through fourth fingers (n = 33) in each hand were analyzed. Images and anatomic sections were reviewed with consensus. whereas partial lesions involved the transection of approximately 10 mm of the distal portion of the pulley. this provided a means of loading the tendon with weight (to parallel active muscle contraction). At the proximal portion of each specimen. No opacification of the tendon sheath was performed because lesion creation led to disruption of the sheath. 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. the fingers were taped in flexion. with a 500-g weight attached to the common flexor tendon complex of each finger.) who specialized in procedures in the hand. C. in accordance with imaging technique. To simulate forced flexion of the fingers at CT and MR imaging. A 2-mm nylon cord then was attached to the flexor tendon complex in each digit. imaging was performed before and within 5 days after lesion creation. 71 years]).05 was considered to indicate a significant difference. 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. To simulate active tendon digital flexion.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 Two musculoskeletal radiologists (O. locking suture pattern. To simulate a partial pulley rupture. the distal half of the A2 pulley was incised. an attempt was made to http://radiology.J.

0 software (GE Medical Systems) at the workstation. with simultaneous counterpressure at the fingertip to extend the finger. by using spin echo and in 10 (83%) and 10 (83%) cases. who knew that lesions had been created but did not know their number or location. Subsequently. 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. RESULTS Anatomic Study Imaging without tenography (group I). from the outer aspect of the View larger version: In this page In a new window Download as PowerPoint Slide cortex to the FDP tendon. Then the images in those fingers with lesions were reviewed separately by the same musculoskeletal radiologists. and partial A2). flexion. which closely approximates the clinical situation. A2 + A3. The distal end of the A2 pulley was readily visible because of the abrupt transition between the pulley and the normal sheath. 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). at the level of the distal third of the proximal phalanx. Figure 2. and US).rsna. the bowstring sign). ie. Pressure was applied to the common flexor tendon complex as described previously. and forced flexion. CT. Again. 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. a P value of less than . First. with the fingers in extension. MR imaging demonstrated the A2 and A4 pulleys in the sagittal plane in 10 (83%) and eight (67%) of 12 cases.—Results are shown in Tables 2 and 3. 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. respectively.full Page 5 of 18 . the A2 and A4 http://radiology.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 maximize forced flexion. In the transverse plane. Measurements were obtained electronically (Fig 2) by using calipers provided with the Windows Advantage version 2. the Pearson correlation test was performed to evaluate any significant differences among the measurements obtained with the different modalities (MR imaging. the operator performed US with the transducer in the concavity of the finger. flexion. During this time. 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).org/content/217/1/201. total A2. and forced flexion) with regard to different lesions (A2 + A3 + A4. respectively. 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. by using fast spoiled gradientrecalled echo (Fig 3).05 was considered to indicate a significant difference.

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 . Figure 3a. The pulleys appear as focal thickenings of low signal intensity (arrows in a . d) Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys. 20° flip angles) MR images.org/content/217/1/201. Figure 3c.full Page 6 of 18 . and d ) of the middle phalanx (A4). The A3 and A5 pulleys were not routinely identifiable at conventional MR imaging. The pulleys appear as focal thickenings of low signal intensity (arrows in a . b . Figure 3d. 6. 20° flip angles) MR images.rsna. d) Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys. b. b. d) Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys. 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 . (c. (c.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 pulleys were depicted in 12 (100%) of 12 cases because of their direct insertion into bone (Fig 4). 20° flip angles) MR images. 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 . 17. and the A4 pulleys were 5–8 mm long (mean length. (c. and d ) of the middle phalanx (A4). b .4 mm). Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled gradientrecalled echo (400/12.4 mm). Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled gradientrecalled echo (400/12. Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled gradientrecalled echo (400/12. Sagittal T1-weighted (a) spin-echo (400/22) and (b) fast spoiled http://radiology. b . The A2 pulleys were 16–20 mm long (mean length. The pulleys appear as focal thickenings of low signal intensity (arrows in a . and d ) of the middle phalanx (A4). Figure 3b.

and d of the middle d) View larger version: In this page In a new window phalanx (A4). Again.full Page 7 of 18 .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 gradient-recalled echo (400/12. which appeared as http://radiology. b . The A2 pulley (arrows) is visualized easily in the transverse plane because View larger version: of its osseous insertions. (a) Transverse T1weighted spin-echo (400/22) MR image. US depicted the A2 pulleys in the sagittal plane in 12 (100%) of 12 cases. Figure 4b. (c. Pulley Depiction by Using MR Imaging and US with and without Opacification of the Tendon Sheath View this table: In this window In a new window TABLE 3. The A2 pulley (arrows) is visualized easily in the transverse plane because of its osseous insertions. and c ) that are located at the level of the proximal third of the proximal phalanx (A2) and at the midportion (arrowheads in a . the distal end of the pulley was easily recognizable because of its abrupt transition in thickness compared with the normal sheath (Fig 5). Location and Mean Longitudinal Dimensions of Finger Pulleys CT did not depict the pulleys in either the sagittal or transverse plane. 20° flip angles) MR images.3 mm. In this page In a new window (b) Transverse cadaveric Download as PowerPoint Slide section shows the anatomic correlation of the A2 pulley (arrows). US depicted the A4 pulley. b.org/content/217/1/201.rsna. The pulleys appeared as focal hyperechoic thickenings of the sheath that were in the proximal third of the proximal phalanx. Figure 4a. The mean length of the A2 pulley at US was 16. d) Download as PowerPoint Slide Sagittal cadaveric sections show the anatomic correlation of the (c) A2 and (d) A4 pulleys. (b) Transverse cadaveric section shows the anatomic correlation of View larger version: In this page In a new window Download as PowerPoint Slide the A2 pulley (arrows). (a) Transverse T1-weighted spin-echo (400/22) MR image. View this table: In this window In a new window TABLE 2. The pulleys appear as focal thickenings of low signal intensity (arrows in a .

View larger version: In this page In a new window Download as PowerPoint Slide Imaging-Anatomic Correlation Results are summarized in Table 3. the A3 pulley was 2–3 mm long (mean length. 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. Simulated Pulley Lesions (group III): Imaging Complete lesions. 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 = . At gross anatomic inspection. 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. in the sagittal and/or the transverse plane with T1weighted spin-echo imaging and gradient-recalled echo imaging. Tenography allowed visualization of the A2 (black arrowheads). and the A5 pulley was 3–5 mm long (mean length. the five annular pulleys always were visualized. Sagittal fat-suppressed T1-weighted spin-echo (400/12) MR image obtained after filling of the tendon sheath.rsna.org/content/217/1/201. respectively (Fig 6). 2.8 mm. Figure 5.7 mm). respectively. Figure 6. A4 (solid arrow).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 subtle focal hyperechoic thickening of the sheath at the level of the midportion of the middle phalanx. diagnosis was possible with direct http://radiology. 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. the A2 and A4 pulleys were visualized in 33 (100%) and 30 (91%) of the 33 fingers. View larger version: In this page In a new window Download as PowerPoint Slide Imaging with tenography (group II). The A4 pulley had a mean length of 5. After the creation of complete lesions with total medial transection. A3 (open arrow). Transverse imaging did not allow further detection or characterization of the A4 pulleys.—Results are summarized in Tables 4–7.512).—MR imaging demonstrated the A2 and A4 pulleys in all 12 cases in the transverse and sagittal planes.6 mm). Sagittal US image depicts the A2 pulley (arrows) as a focal hyperechoic thickening of the tendon sheath at the level of the proximal phalanx. in eight (67%) of 12 cases. the A3 and A5 pulleys were not seen routinely. When combined with CT and US. On MR images.full Page 8 of 18 . These pulleys were at the level of the proximal interphalangeal (A3) and distal interphalangeal (A5) joints. The A3 and A5 pulleys were never visualized. and A5 (white arrowhead) pulleys. As with MR imaging. 3.

with retraction between the tendon and bone and discontinuous fibers. a tendinous gap was observed that was maximum at forced flexion (Fig 8) and increased in proportion to the number of disrupted pulleys (ie. In b . Direct Visualization of the A2 and A4 Pulleys by Using MR Imaging and US View this table: In this window In a new window TABLE 5. Distance Between Bone and FDP Tendon at CT View this table: In this window In a new window TABLE 7. Transverse T1-weighted spin-echo (400/22) MR images obtained (a) before and (b) after the creation of complete lesions of the A2 pulleys. maximum for A2 + A3 + A4 lesions. In b . View larger version: In this page In a new window Download as PowerPoint Slide View this table: In this window In a new window TABLE 4. which allowed evaluation of the indirect signs of pulley system lesions. the A2 pulleys (arrows) are visualized at their insertion into the cortex of the proximal phalanx. Diagnosis with direct imaging signs was possible in all cases in which the A2 and/or A4 pulley was visualized before lesion creation. 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. minimum for A2 lesions alone). Download as PowerPoint Slide In a . the A2 pulleys (arrows) are visualized at their insertion into the cortex of the proximal phalanx.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 visualization of the disrupted sheath on the transverse images (Fig 7) and/or with nonvisualization of the involved pulleys on the sagittal images.org/content/217/1/201. Figure 7a. After lesion creation. no significant tendinous gap was observed before lesion creation at either extension or flexion. the disruption of the A2 pulleys (arrows) is visualized directly. with retraction between the tendon and bone and discontinuous fibers. In a .full Page 9 of 18 .rsna. 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. the disruption of the A2 pulleys (arrows) is visualized directly. Figure 7b. Distance between the Bone and the FDP Tendon on MR Images View this table: In this window In a new window TABLE 6. http://radiology.

(d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c . and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. In a . Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension. no obvious gap between the tendon (arrow in all) and the bone (arrowhead in all) is shown.rsna. A small gap is noted in b and is maximized in c . A small gap is noted in b and is maximized in c . Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension. View larger version: In this page In a new window Download as PowerPoint Slide Figure 8d.org/content/217/1/201. In a . (b) flexion. obtained at full extension. A small gap is noted in b and is maximized in c . (b) flexion. Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension. Figure 8b. obtained at full extension. and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys.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 Figure 8a. 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. Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension. In a . In a . (b) flexion. and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c . (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c . obtained at full extension. (b) flexion. Figure 8c.full Page 10 of 18 . and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. 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. no obvious gap between http://radiology.

Figure 9a. At MR imaging. Sagittal CT images (2-mm thick. no gap is seen between the bone (arrowhead) and the tendon (arrow). (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c . respectively. 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). Sagittal CT images (2-mm thick. View larger version: In this page In a new window Download as PowerPoint Slide Figure 9b. maximum for A2 + A3 + A4 lesions. no gap is seen between the bone (arrowhead) and the tendon (arrow). 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. http://radiology. After lesion creation. a moderate gap is observed.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 the tendon (arrow in all) and the bone (arrowhead in all) is shown.full Page 11 of 18 . The A3 and A5 pulleys were never seen.rsna. The A2 pulley (arrows) is visualized directly in a and is not seen in b . View larger version: In this page In a new window Download as PowerPoint Slide US allowed direct visualization of the A2 and A4 pulleys in 33 (100%) and 26 (79%) of the 33 cases. Figure 10a.org/content/217/1/201. which again was maximum at forced flexion (Fig 11) and increased in size in proportion to the number of disrupted pulleys. In a . After lesion creation. A small gap is noted in b and is maximized in c . In b . a moderate gap is observed. Arrowheads represent the setting level of attenuation. soft-tissue window) obtained at (a) extension and (b) forced flexion after the creation of complete A2 lesions. 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. a tendinous gap was observed that was maximum at forced flexion (Fig 9) and increased in proportion to the number of disrupted pulleys (ie. Sagittal US image obtained with the finger in extension (a) before and (b) after the creation of a complete lesion of the A2 pulley. minimum for A2 lesions alone). soft-tissue window) obtained at (a) extension and (b) forced flexion after the creation of complete A2 lesions. In b . View larger version: In this page In a new window Download as PowerPoint Slide 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. In a .

The A2 pulley (arrows) is visualized directly in a and is not seen in b .full Page 12 of 18 . (c) Corresponding transverse cadaveric section depicts the gap (arrows) at forced flexion.org/content/217/1/201.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 http://radiology.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 .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 View larger version: In this page In a new window Download as PowerPoint Slide Figure 10b. Figure 11c.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 . (a. (a. Arrowheads represent the setting level of attenuation. (c) Corresponding transverse cadaveric section depicts the gap (arrows) at forced flexion. View larger version: In this page In a new window Download as PowerPoint Slide Figure 11a.rsna. Figure 11b. (a. Sagittal US image obtained with the finger in extension (a) before and (b) after the creation of a complete lesion of the A2 pulley.

no significant gap between the tendon (open arrow) and bone (arrowhead) is appreciated at forced View larger version: In this page In a new window Download as PowerPoint Slide flexion. while in b . such measurements had no significance. none of the pulleys was visualized before lesion creation. no significant gap between the tendon (open arrow) and bone (arrowhead) is appreciated at forced flexion. direct visualization of the disruption site was possible. Figure 12a.rsna.org/content/217/1/201. in the transverse plane. the Download as PowerPoint Slide partially disrupted A2 pulley of the fourth finger (solid arrow) is seen directly. whereas. On MR images.full Page 13 of 18 . the A2 pulleys were visualized before lesion creation in all cases.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 arrow) and bone (open arrow) in b .—The results of analysis of the partial lesions are summarized in Tables 4–7. images obtained in the sagittal plane demonstrated the absence of the distal part of the A2 pulleys. the distal end of the A2 pulley was not observed in the sagittal plane. the measurements of the tendinous gap between the FDP tendon and the bone were similar to those observed on MR images. On CT images. In a . Figure 12b. the measurements of the distance between the FDP tendon and the bone showed a minimal tendinous gap at forced flexion alone. After lesion creation. In a . while in b . (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. View larger version: In this page In a new window Download as PowerPoint Slide Partial lesions. US initially allowed direct visualization of the A2 pulleys in all cases. the partially disrupted A2 pulley of the fourth finger (solid arrow) is seen directly. (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. After lesion creation. Statistical Analysis http://radiology. but measurements of this tendinous gap proved to have no significance. (c) Corresponding transverse cadaveric section depicts the gap (arrows) at forced flexion. After lesion creation. Again. A minimal tendinous gap between the FDP tendon and the bone was observed at only forced flexion (Fig 12).

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. as specified previously. which was significantly greater than the gap with the finger in extension). Finger flexion relies heavily on the delicate focal thickened areas of the flexor tendon sheath. each imaging modality offered accurate gap measurements between the FDP tendon and the bone in all finger positions. always was identified easily. MR tenography). For the detection of indirect signs of all complete lesions. except that the partial A2 lesion gap was significantly smaller than the complete A2 + A3 + A4 lesion gap (P < . is critical. all differences between lesion types became significant (the A2 lesion gap in partial pulley lesions was smaller than that in the complete A2 lesions. T1-weighted spinecho imaging and fast spoiled gradient-recalled echo imaging were equally successful in depicting the normal pulleys.05). thereby increasing the ease of identification of the pulleys. the thicker part of the pulley (1). For the detection of indirect signs of partial A2 lesions. Anatomic Study Our results indicate that normal A2 and A4 pulleys can be identified and localized accurately by using conventional MR imaging. 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. all provocative finger positions yielded a significant change in the gap between the FDP tendon and the bone. 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.05) was significantly greater than the gap with the finger in flexion (P < . With regard to the detection of indirect signs of pulley lesions. with no significant difference between measurements derived with the various techniques. In flexion. Of the five annular pulleys (A1–A5) identified in the finger flexor complex.23. the A2 and A4 pulleys were identified readily in both imaging planes and appeared as focal hyperechoic thickenings of the tendon sheath. the length of the pulley is directly proportional to the length of http://radiology.rsna.4-mm length in our study) and thinner than the A2 pulley. the A2 and A4 pulleys appear to be fundamental for accurate and precise flexor tendon function (2. 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. There were no significant differences between the measured gaps in the complete A2 + A3 lesions and those in the complete A2 + A3 + A4 lesions.27). both of which are afforded with the pulley system. this suggested the diagnosis of a complete pulley lesion (the gap present with the finger in forced flexion (P < .full Page 14 of 18 . no significant gap was present in any position. and the flexor tendons proper to successfully elicit fine motor tasks.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 MR imaging and US proved equally matched for the detection of direct signs of partial and complete lesions of the finger pulley system.org/content/217/1/201.05). With US. Although MR tenography proved to be an elegant method of analysis of the pulley system. 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. DISCUSSION In the finger. Such flexion requires proximal excursion of the flexor tendon and tight apposition of the tendon to adjacent osseous structures during this excursion. Among lesion types. At forced flexion.26. a pronounced disparity between the size and substance of supporting anatomy with respect to structure and function has been emphasized. the gap observed in the partial A2 lesions was significantly smaller than that observed in the other three lesion types. Moreover. The distal end of the A2 pulley. referred to as the pulley system. a comparison of the gap measurements in extension did not show any significant differences. 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).

Given our findings. In contrast. 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. 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. all imaging proved successful in the evaluation of indirect signs of pulley system lesions. by considering the data regarding the evaluation of direct and indirect findings. a distinction between partial and total A2 lesions is possible. lesion detection also was not possible. This also explains the impossibility of detection of the A3 and A5 pulleys with both US and conventional MR imaging. These findings have definite implications for the evaluation of not only the presence but also the extent of the lesions. which corresponded again to the number of A4 pulleys identified before lesion creation. owing to patient motion and inconsistencies in patient positioning. At the time of surgical inspection. it appears that the ideal method for complete identification of the A2. has little consequence because the functionally important A2 and A4 pulleys are seen well with routine MR imaging or US. First. 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. This gap was 5–8 mm for complete combination lesions of multiple pulleys (A2 + A3 or A2 + A3 + A4). direct diagnosis of an abnormality was possible in 30 (91%) of the 33 cases. With US.org/content/217/1/201. At CT. and 0–3 mm for partial A2 lesions. such evaluation obviates secondary diagnostic maneuvers. and A5 pulleys is MR imaging with tenography.rsna. It was not unexpected that the tendinous gap at forced flexion increased significantly in proportion to the number of disrupted pulleys. as these pulleys are thin (thinner than the A4 pulley) and do not have an osseous insertion site. respectively. Thus. This study had several limitations. these pulleys appeared to be thin and delicate.full Page 15 of 18 . MR imaging appeared to be the most accurate in the detection of A4 lesions. Second. with either direct visualization of the disrupted pulley in the transverse plane or nonvisualization of the pulley in the sagittal plane. If the A4 pulley was not identified on initial MR images. a tendinous gap at forced flexion indicates a total lesion. which can prove difficult to perform. In addition.2). This explains why the A4 pulley generally is difficult to identify in the index finger or a small hand. 2–5 mm for isolated complete lesions of the A2 pulley. MR imaging and US appear promising with regard to the detection of direct signs of complete or partial pulley lesions without provocative finger positioning. the direct diagnosis of abnormalities of the A2 pulley was possible in all cases (100%). only the gross morphology of the flexor tendons was depicted. conservative therapy for partial lesions vs open surgery for total lesions). A3. This might be helpful in current practice because it would reduce motion artifacts caused by forced flexion. In addition. although we made every possible effort to re-create a physiologically and clinically accurate model http://radiology. With conventional MR imaging. Moreover. A4. In the A4 pulley. 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. This technique is not available routinely and would not appear to be valuable in cases of pulley disruption. These findings have significant implications with regard to the evaluation of abnormalities of the flexor tendon. with no significant differences among modalities. which indicates that conventional imaging techniques allow accurate and reliable direct evaluation of the pulley system of the flexor tendons.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 the finger (1. This limitation. however. 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. whereas a minimal tendinous gap indicates a partial lesion. owing to the inevitable associated disruption of the tendon sheath. With nonvisualization of the A2 pulley in the evaluation of direct signs of pulley lesions. which currently are one of the major limitations of MR imaging for the detection of pulley lesions.

In summary. 14:949-956. J Hand Surg Am 1990. 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. Medline 3. 43.C. J Hand Surg Br 1990. eds. injuries. O. 43. 43.12112. Medline 2. Wright .D.121415 Hand. tissue characterization.H. 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.H.489 Hand. study concepts. for help with the statistical analysis. Medline 5.H.. Anatomy of the finger flexor tendon sheath and pulley system. Cooney WP..L. Lin GT. 1:3-11. Functional anatomy of the human digital flexor pulley system.12988 References 1. Vichard P.L. St Louis. D. Anatomy and function of the palmar aponeurosis pulley. O. study design.rsna. data analysis.. These findings represent means for the evaluation and direct diagnosis of complete and partial lesions of the pulley system of the flexor tendon system.H. Flexor and extensor tendon injuries.H. IIIPE.org/content/217/1/201.C. Acknowledgments The authors thank Paul L. R. J Hand Surg [Am] 1988. 15:268-270. MS. Balmat P. O. transverse images are of particular interest because they allow visualization of the sites of bone insertion.B..J.H. comparative studies. 13:473-484.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 of abnormalities of the tendons and tendon sheaths of the finger. Amadio PC.12111. O.B. Campbell’s operative orthopaedics. M. J Hand Surg Am 1989.. O. 1998. literature research. O. Finally. C.. D... Tropet Y.. D. Bollen SR.H. 43. In these cases.C.. 15:72-82.. C.R. Idler RS... In addition... 43. D. 43. 6.H. 43. such fibrous tissue has already been described in the literature and has not been thought to create any diagnostic difficulty (21). some motion artifacts may occur. data acquisition. D. 33183376. even at extension.121413.121412.12115 Fingers and toes. which may have an effect on the clinical treatment of patients with these injuries..H.full Page 16 of 18 .B.R. The imaging appearance of long-term pulley disruption may differ between patients because of the development of scar or fibrous tissue... C. 43. 43.C. Hand Clin 1985.1298 Ultrasound (US)..1211 Hand. the cadaveric specimens used in the study were harvested uniformly from an elderly population. 43. However. O. the lesions were created surgically in cadaveric specimens..T. Clopton.. Doyle JR. 4. manuscript preparation. N. Pem R. D. D. 43. Mo: Mosby. CT.B. Anatomy and biomechanics of the digital flexor tendons. Menez D. 9th ed.R. O. US. C.1298.B. N.B.R.C.C. Footnotes Abbreviation: FDP = flexor digitorum profundus Author contributions: Guarantors of integrity of entire study. Injury to the A2 pulley in rock climbers.. O. C. Closed traumatic rupture of http://radiology. this was necessitated by availability.121411. An KN.. experimental studies. In: Canal ST.R. the quality of the MR images obtained in this study may be difficult to reproduce routinely because.B.. N. CrossRef Medline 7.L. D. definition of intellectual content.R... Doyle JR.B. Index terms: Computed tomography (CT).T. 43. manuscript editing and review. MR. C.

Derchi LE. eds. Jr. Bonavita JA. Radiology 1996. Tomaino MM. Abstract 16. Tonkin LJ. Medline 10. 19:782-787. 198:219-224. 21:469-473. AJR Am J Roentgenol 1996. Colour Doppler ultrasound examination of hand tendon pathologies: a preliminary report. Roulot E. Le Viet D. Giordano P. AJR Am J Roentgenol 1996. Snijders CJ.rsna. CrossRef Medline 24. The role of ultrasound in the management of zone 1 flexor tendon injuries. Amadio PC. Jr. Moutet F. Ann Plast Surg 1999. CrossRef Medline Articles citing this article Sonographically Guided Percutaneous First Annular Pulley Release: Cadaveric Safety Study of Needle and Knife Techniques J Ultrasound Med November 1. Zissimos AG. Paris. et al. Godefroy D. Khaleghian R. Skeletal Radiol 1998. 15:429-434. Balkissoon AR. Ultrasound examination of the hand. La main du sportif: monographie du groupe d’étude de la main. 166:615-620. Abstract/FREE Full Text 11. 42:403-407. Conway WF. Grewal R. 19:76-80. Pechlaner . Gabl M. 15:213-219. CrossRef Medline 15. Silbermann-Hoffmann O. Medline 12. J Clin Ultrasound 1984. Marco RA. Radiology 1986. DeLone FX. Ball J. Smith TS. Ultrasonic examination of the flexor tendons of the fingers. La main du grimpeur. Medline 25. Rousselin B. France: Expansion Scientifique Française. Lee JP. Hayes CW. Gerard P. J Ultrasound Med 1996. CrossRef Medline 21.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 the ring finger flexor tendon pulley. J Bone Joint Surg Am 1998. Abstract/FREE Full Text 23. Rubin DA. Feasibility of partial A2 and A4 pulley excision: effect on finger flexor tendon biomechanics. Lutz M. 80:1012-1019. Jones R. Duval MA. et al. 21:245-248. Silbermann-Hoffmann O. et al. Bynum DK. Ann Chir Main Memb Super 1993. Cooney WP. De Geus JJ. Pequignot JP. Approche expérimentale et clinique. Abstract/FREE Full Text 19. 26:651-655. McClellan RM. 12:547-551. 167:347349. Kuzma GR. 160:853-854. Naranja RJ. Rifkin MD. Am J Sports Med 1998. 2010 29:11 1531-1542 Abstract Full Text Full Text (PDF) Sonographic Depiction of Trigger Fingers in Acromegaly J Ultrasound Med November 1. Pfaeffle HJ. Bastidas JA. Rangger C. Quadri P. Fornage BD. Mechanical properties of human pulleys. Wang PT. Stam HJ. High resolution sonography of the flexor tendons in trigger fingers. Subcutaneous rupture of long finger flexor pulleys in rock climbers: 12 case reports. J Hand Surg Br 1990. Schut HA. J Hand Surg Br 1996. McGeorge S. Diagnostic medical ultrasound in the management of hand injuries. CrossRef Medline 27. 24:310-314. Sharkey NA. Mitsionis G. The mechanical effect of partial resection of the digital fibrous flexor sheath. Parellada JA. 161-167. J Hand Surg Am 1990. Houvet P.org/content/217/1/201. Fink C. Medline 22. J Hand Surg Br 1990. J Hand Surg Am 1999. J Hand Surg Br 1994. Medline 9. Complications of flexor tendon repair in the hand: MR imaging assessment. Bowers WH. CrossRef Medline 17. Rudisch A. Kneeland JB. Tardif-Chastanet de Gery S. CrossRef Medline 18. Guinard D. Flexor tendon tears in the hand: use of MR imaging to diagnose degree of injury in a cadaver model. 26. Bowstring injury of the tendon pulley system: MR Imaging. 15:745-747. Serafini G. Closed traumatic rupture of finger flexor pulleys. Savage R. J Hand Surg Am 1996. Lin GT. 15:256-261. 15:435-442. Buyruk HM. 2009 28:11 1441-1446 http://radiology. In: Allieu Y. Fischer KJ. Closed ruptures of the flexor digitorum tendons: MRI evaluation. Drape JL. 12:182-188[French]. J Hand Surg Am 1994. Pathomechanics of closed rupture of the flexor tendon pulleys in rock climbers. Corduff N. J Hand Surg Br 1990. 1995. CrossRef Medline 14. et al. Lantieri L. Kitay GS. Abstract/FREE Full Text 20. An KN. Medline 13. McGeorge DD. Ultrasonic assistance in the diagnosis of hand flexor tendon injuries. Drape JL. Disruption of the finger flexor pulley system in elite rock climbers. Lameris JS. Diagnosis of digital pulley rupture by computed tomography. Witham RS. Medline 8.full Page 17 of 18 . 27:617-624.

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