This document provides guidance on performing ultrasound examination of the hand and fingers. It describes optimal scanning techniques and positioning for visualizing key anatomical structures like flexor and extensor tendons, pulleys, ligaments and joints. Pathologies that can be identified include tendinosis, tenosynovitis, trigger finger, Dupuytren's contracture and inflammatory arthritis. Ultrasound allows accurate assessment of tendon integrity, fluid collections, synovitis and Doppler flow to evaluate degree of inflammation.

1. Dr/ ABD ALLAH NAZEER. MD.
Ultrasound examination of the hand and finger.

2. SCANNING TECHNIQUE
Either:
Sit the patient on the side of the bed with a pillow on their lap to support
their hand
Sit the patient on a chair on the opposite side of the bed with their hand
resting on the bed.
EQUIPMENT SELECTION AND TECHNIQUE
Use of a high resolution probe (7-15MHZ)with a small footprint is
essential when assessing superficial structures. Careful scanning
technique to avoid anisotropy (and possible misdiagnosis). Beam
steering or compounding can help to overcome anisotropy in linear
structures such as tendons. Good colour / power / Doppler
capabilities when assessing vessels or vascularity of a structure.
Be prepared to change frequency output of probe (or probes) to
adequately assess both superficial and deeper structures.

3. ULTRASOUND OF THE HAND & FINGERS - Normal
PALMAR ASPECT (Flexors)
Finger Flexors
There are 2 flexor tendons of the fingers:
Flexor digitorum superficialis, inserting as 2 separate slips onto the base of the middle
phalanx.
Flexor digitorum profundus, inserting onto the distal phalanx.
Scan plane for the Flexor digitorum
tendons. The Profundus and superficialis.
Normal Flexor digitorum Profundus (FDP) and superficialis
tendons (FDS) at the level of the metacarpal neck.

4. Scan plane for the flexor digitorum tendons
in transverse prior to the separation of
superficialis from profundus.
The Flexor digitorum superficialis tendon
slips (green) can be seen peeling off the
Profundus portion (blue).

5. Scan plane for the flexor digitorum tendon at the A4
pulley, distal to the superficialis insertions.
Flexor digitorum profundus tendon in transverse.
The neurovascular bundles are circled in red.

6. Scan plane for the flexor digitorum
profundus insertion.
The Flexor digitorum profundus
insertion onto the distal phalanx.

7. Pulleys
The flexor tendons are secured in place by a series of pulleys which are fibrous bands
wrapping over the tendons and attaching to the bone.
Annular pulleys: which wrap transversely over the tendons. Numbered A1 – A4.
Cruciate pulleys: which are paired and cross diagonally over the tendons. Numbered C1 - C3.
The annular pulleys are readily visible with high resolution, high quality equipment. The
cruciate pulleys are poorly seen.
Scan plane A2 pulley. A2 pulley at the proximal phalanx.

8. Scan plane for the A2
pulley in transverse.
Transverse view of the A2 pulley (green)
firmly overlying the flexor digitorum
tendon at the mid proximal phalanx.

9. Palmar fascia
Scan plane when assessing
for the palmar fascia Normal palmar fascia (green).

10. DORSAL ASPECT
Extensor digitorum tendons
Unlike the flexors, there is only an extensor digitorum
Scan plane for the extensor digitorum insertion.
Even with high frequency transducer, the very
thin tendon is difficult to visualize without
using a stand-off pad or thick gel.
The extensor digitorum tendon insertion to
the distal phalanx. The tendon is extremely
thin and lies intimately against the bone.

11. Nail-bed
Sac plane for the extensor digitorum insertion.
Note the thick gel. The nail bed is best viewed through a thick gel standoff.

12. Ulnar collateral ligament of the thumb (UCL)
The ulnar collateral ligament of the 1st metacarpophalangeal joint medially.
Rupture is a skiier's or gamekeeper's thumb. If the torn ligament folds under the adductor
pollicis it is referred to as a 'Stenner lesion'.
The ulnar collateral ligament on
the 1st metacarpophalangeal joint.
Rupture is called a skiier's or gamekeeper's thumb. If
the torn ligament folds under the adductor pollicis it is
referred to as a 'Stenner lesion'.

13. ROLE OF ULTRASOUND
To assess for:
muscular, tendinous and ligamentous damage
(chronic and acute).
Foreign bodies.
Joint effusions.
Soft tissue masses such as ganglia, lipomas.
Classification of a mass e.g solid, cystic, mixed.
Post surgical complications e.g abscess, edema.
Guidance of injection, aspiration or biopsy.
Relationship of normal anatomy and pathology to
each other.
Some bony pathology.

14. Joint Effusions
Size
Simple/complex
Any synovial thickening
Any vascularity on power Doppler - Normal is little or no discernable flow. Hyperemia =
acute.
Detection of Effusion in the volar recess of the PIP joint – longitudinal and transverse views.

15. Joint and bursal effusion.

16. Inflammatory Arthritis
Ultrasound(Sonography) aids in the confirmation of synovitis in early
inflammatory arthritis. The sonographic evaluation of inflammatory arthritis has
been aided by consensus definitions of synovitis and erosions by the OMERACT
group. Small amounts of fluid can be detected in joints as well as tendon sheaths.
Ultrasound is also more sensitive in the detection of enthesitis. Increased
vascularization can be demonstrated by power Doppler.
Active synovitis overlying a large metacarpal head erosion.

17. Longitudinal view of the wrist revealing active synovitis.

18. Grey scale ultrasound can be used to demonstrate synovitis. In this image of a
metacarpophalangeal joint of a patient with rheumatoid arthritis, the joint capsule is markedly
distended outwards (arrows) due to underlying synovial effusion and hypertrophy. The presence
of power Doppler demonstrates the increased microvascular flow of the joint, which is
suggestive of active inflammation. M, metacarpal bone; P, proximal phalanx.

19. Colour spots correspond to areas of increased synovial perfusion and/or angiogenesis: (A)
metacarpophalangeal joint (longitudinal dorsal scan), (B) metacarpophalangeal joint
(longitudinal dorsal scan) (detail showing colour spots inside a bone erosion (*) filled by
synovial tissue), (C) finger flexor tendons (T) (longitudinal volar scan), (D) finger flexor
tendons (longitudinal transverse scan).

20. Longitudinal and transverse views of the first MTP revealing
tophaceous dorsal deposit as well as double contour sign.

21. Tendon abnormalities
Look for hyperemia, tendon sheath fluid (simple/complex) and tendon
integrity/homogeneity
Check for tendon thickening (compare with other side)
Fluid in the tendon sheath
Integrity of the tendon- any tear?
does the tendon slide freely when mobilized?
Longitudinal (A) and transverse (B) scans of a flexor tenosynovitis distal palmar region. The thorn
(between calipers, arrow) can be seen as a hyperechoic stripe in a hypoechoic cavity (C). T: tendon.

22. Flexor Tenosynovitis (Fluid around tendon sheath).

23. TB tenosynovitis of the hand flexor tendons. Transverse (top) and longitudinal
(bottom) ultrasound images. The transverse views demonstrate enlarged,
heterogenous appearing tendons with neovascularity within them. There is
thickening and effusion within the tendon sheath on the longitudinal views.

24. Tenosynovitis of the flexor tendons with a large effusion and synovial
thickening in the tendon sheath in a patient with rheumatoid arthritis.

25. Ultrasound appearance of normal flexor tendon sheath and tenosynovitis. a, Normal
appearance, longitudinal view. b, Normal appearance, transverse view. c, Flexor
tenosynovitis, longitudinal view. d, Flexor tenosynovitis, transverse view. Arrows in c and
d indicate tendon sheath thickening. MC: metacarpal; P: phalanx; FT: flexor tendon.

26. Extensor tendinosis in a 34-year-old woman. Sagittal US scan of the dorsal
metacarpophalangeal joint shows a thickened extensor pollicis brevis tendon (ET).
Posttraumatic development of an osseous excrescence (arrow) resulted in chronic repetitive
friction against the adjacent tendon, culminating in tendinosis. MCP = metacarpal.

27. Dupuytren's contracture
What is it?
Fibrosis of the palmer fascia forcing the flexion of the
4th/5th fingers.
Gradual onset
M>F
Often inherited.
Generally affects 4th and 5th fingers.
Scan in longitudinal from the base of the proximal
phalanx down into the palm looking superficial to the
flexor tendon
It will appear as a hypoechoic focal fusiform thickening
of the palmar fascia at the metacarpal head level. Not to
be confused with trigger finger

29. Dupuytren's contracture

30. Dupuytren's contracture of the hand.

31. Trigger finger
What is it?
Tenosynovitis of a flexor digitorum tendon causing
forced flexion of a finger.
Initially in transverse, identify the flexor digitorum
tendons at the metacarpal head level. Follow the
common tendon proximally to the carpal tunnel.
Then follow distally to the insertions: The Flexor
digitorum superficialis divides, with two slips
inserting onto the side of the base of the middle
phalanx. Flexor digitorum profundus inserts onto
the distal phalanx.

32. Short-axis view of the normal A1 pulley in the right middle finger. Open arrow indicates the
A1 pulley and needle trajectory; asterisk, middle of the target triangle and ideal location
for the needle tip for injection; dotted arrows, digital nerves; L, lumbrical muscle; M,
metacarpal; and VP, volar plate. The bifurcation of the common digital artery is shown as 2
small hypoechoic dots below the digital nerve on the left. The common digital artery is
shown as the larger hypoechoic dot below the bifurcating digital nerve on the right.

33. First annular pulley injection for trigger finger before (A) and after (B) injection
with triamcinolone acetonide and lidocaine. Distention of the pulley is noted
(arrows). The images are from a patient not in the study.

34. Trigger thumb with a tenosynovitis and a thickened A1 pulley.

35. Trigger thumb. Left: Axial US scan of the metacarpophalangeal joint of the left thumb
shows focal thickening of the flexor pollicis longus tendon (arrows). Right: Axial US scan of
the metacarpophalangeal joint of the right thumb shows a normal tendon (arrows).

36. Finger Pulleys
What are they? Bands of fibrous tissue holding the flexor
tendon to the finger similar to runners on a fishing rod.
They are named according to their type-Annular
(around) or Cruciform (cross), and numbered from
proximal to distal.
Scan longitudinally over the anterior surface of the
finger. The pulleys may be seen as thin hypoechoic zones
intimately overlying the flexor tendon sheath.
If ruptured, the tendon will no longer follow the bone
and will instead "bowstring".

37. Thickness of A1 pulley and flexor digitorum tendons, but also changes of
quality of these structures contributed to pathogenesis of trigger fingers .

38. Arrows depict A1 pulley hypertrophy on US, with Power Doppler demonstrating hyperemia,
and post-contrast T1 fat-suppressed MRI demonstrating pulley enhancement

39. A, Volar longitudinal
ultrasonographic scan
obtained in a volunteer
shows the A3 annular pulley
(arrows). B, Corresponding
macroscopic section. Also
note the distal end of the A2
pulley (arrowhead). C, Volar
transverse ultrasonographic
scan obtained in another
volunteer shows the fibrillar
pattern of the A3 annular
pulley. Asterisk indicates
volar plate of the proximal
interphalangeal joint.

40. Acute complete tears of A2 pulleys. (A) Schematic drawing and (B) sagittal US
obtained over the palmar aspect of the proximal phalanx (PP) of the fourth digit.
In (A) note the A2 tear and the subsequent palmar dislocation (arrows) of the flexor
digitorum superficialis (FDS) and profundus (FDP) tendons. In (B) the A2 pulley (black
arrow) is thickened and hypoechoic. Note the palmar bowstringing of the tendons
(white arrow). The tendon sheath contains a fluid collection (arrowheads).

41. Game keepers thumb/ skiers thumb
What is it?
Rupture of the ulnar collateral ligament of the
thumb due to a sudden valgus force.
May occur after repeated stretching of the
ligament.
The ligament usually tears at it's distal end from
the base of the proximal phalanx. If there is
marked angulation of the phalanx, the flailing
ligament may impinge under the adductor pollicis
creating a ' Stenner lesion ‘.

42. Game Keeper’s thumb’.

43. Stener lesion in a 28-year-old man. Coronal US scan of the thumb shows a proximally
retracted nodule with an irregular lobulated outline (arrows), an appearance diagnostic
of a Stener lesion. The nodule represents the retracted proximal segment of the UCL
and is consistent with a full-thickness tear. Displacement of this segment superficial
to the aponeurosis results in loss of the smooth contour of the aponeurosis and
surface lobulation. MCP = metacarpal, PP = proximal phalanx.

44. Stener lesion. (a) Coronal US scan of the thumb shows a proximal lobulated nodule (S, arrows), which
represents the retracted displaced proximal segment of the UCL. The smooth contour of the
aponeurosis is distorted by the superficially lying ligament, resulting in bulging of the surface of the
aponeurosis. MCP = metacarpal, PP = proximal phalanx. (b) Axial US scan of the thumb shows a
thickened lobulated UCL (cursors). There is loss of the smooth contour of the aponeurosis with bulging
(arrow). The diagnosis can be made by using the same criteria as on coronal scans. The left side of the
image is radial. ET = extensor tendon, MCP = metacarpal head, TH = thenar eminence. (c) Axial US scan
of the thumb, obtained for comparison with b, shows a normal UCL. The adductor aponeurosis (black
arrowheads) covers the muscle and UCL (white arrowhead). Note the anisotropy of these structures.
There is no nodule, lobulation, or bulging. The right side of the image is radial. ET = extensor tendon,
MCP = metacarpal head, TH = thenar eminence.

45. Foreign bodies
Ensure you approach the proposed site of the foreign
body from different angles. Some materials will be
poorly reflective and almost invisible unless the beam
is perpendicular to them. There will usually be a
surrounding hypoechoic halo representing an
inflammatory reaction
Identify:
The plane of tissue it is in.
How close it is to the entry wound and to any blood
vessels.
It may be helpful to mark the location and orientation
of the foreign body on the skin to guide removal.

46. Foreign body in hand Normal right pulp USG Gray scale.

47. Multiple images for the foreign bodies.

48. Masses
95% of finger tumours are benign.
abscess
granuloma
Ganglia
Neuroma
Fibroma
Glomus tumour (nail bed tumour)
For non-specific palpable or visible
masses see our superficial lumps page.

49. Giant cell tumor – Longitudinal USG-hypoechoic well defined lesion anterior
to the middle finger flexor tendon with increased signal on Doppler.

50. Multiple images for Giant cell tumors:

51. Finger Abscess Without Involvement of Tendon.

52. A ganglion cyst.

53. Multiple images for fibrous tumors.

54. Multiple images for the Epidermoid cysts.

55. Haemangioma with a hypoechoic easy compressible vascularized tumor on the volar side of the flexor tendon

56. Glomus Tumor of the thumb.

57. Joint Abnormalities
Gout: Abnormal uric acid metabolism
resulting in joint inflammation. May see
tophaceous gout as a complex echogenic
mass (tophus) in the soft
Osteoarthritis: Bony irregularities at the bone
ends with joint effusion. When acute the joint
will be hyperemic
Rheumatoid arthritis: Thickened synovium
with a complex 'thick' joint effusion, pannus
& associated bony irregularity

58. Gouty arthritis with increased vascularity.

60. Thank You.