DOI: 10.1148/rg.264055117
US Diagnosis of UCL Tears of the Thumb and Stener Lesions: Technique, Pattern-based Approach, and Differential Diagnosis1
Farhad S. Ebrahim, MD,
Michel De Maeseneer, MD, PhD,
Tjeerd Jager, MD,
Stefaan Marcelis, MD,
David A. Jamadar, MB, BS, FRCS, DMRD and
Jon A. Jacobson, MD
1 From the Department of Radiology, University of Michigan Health System, Taubman/B-1/Room 132, Box 0302, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0302 (F.S.E., M.D.M., D.A.J., J.A.J.); the Department of Radiology, Aalsters Stedelijk Ziekenhuis, Aalst, Belgium (T.J.); and the Department of Radiology, University of Lie`ge, Lie`ge, Belgium (S.M.). Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received May 12, 2005; revision requested June 13 and received September 15; accepted September 16. All authors have no financial relationships to disclose.
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Figure 1. Results of stress testing in a 35-year-old man. Radiographs of the metacarpophalangeal joints of the thumbs show asymmetric widening (arrows), which is greater on the left side (the normal joint) than on the right (the injured joint).
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Figure 2. Axial anatomic section of the first metacarpophalangeal joint shows the extensor tendons (ET), flexor tendons (F), radial collateral ligament (R), and UCL (U). A white aponeurosis (black arrows) covers the UCL. White arrow = adductor pollicis.
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Figure 3. Axial drawing of the first metacarpophalangeal joint shows the radial collateral ligament (R), extensor tendons (T), and UCL (U). Note the normal superficial relationship of the adductor aponeurosis (arrows) to the UCL.
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Figure 4. Sagittal anatomic section of the first metacarpophalangeal joint shows the fibrous volar plate (V) in its intraarticular location (arrow).
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Figure 5. Photograph of the dorsal first-to-second web space shows the first dorsal interosseous muscle (DI). The extensor pollicis brevis (EPB) is located more radially than the extensor pollicis longus (EPL). The adductor pollicis is intimately attached to the ulnar side of the first metacarpophalangeal joint (arrow).
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Figure 6. Axial US scan of the metacarpophalangeal joint of the thumb in a 35-year-old volunteer shows the flexor pollicis longus tendon (F) between the sesamoids (arrows).
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Figure 7. An-teroposterior radiograph of a cadaveric hand shows the synovial sheath of the flexor pollicis longus (arrows), which was injected with iodinated contrast material. The synovial sheath extends from the wrist toward the tip of the thumb.
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Figure 8. Photograph of the dorsal aspect of the first web space in a 38-year-old volunteer shows the technique for scanning the UCL. A high-frequency US probe can be directed from the second digit (2) onto the ulnar side of the thumb in the longitudinal plane (L). In addition, a transverse section (T) can be obtained at the first metacarpophalangeal joint. 3 = third digit.
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Figure 9. Axial US scan of the thumb shows the normal extensor tendons (E) and UCL (U), which demonstrates anisotropy. Arrow = adductor aponeurosis covering the UCL.
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Figure 10. Coronal US scan of the thumb of a 30-year-old volunteer shows a normal UCL (arrows). The deeper fibers of the UCL appear anisotropic. MCP = metacarpal, PP = proximal phalanx.
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Figure 11. Spectrum of UCL injuries of the thumb. 1 = normal appearance, 2 = strain, 3 = partial-thickness tear, 4 = full-thickness tear, 5 = Stener lesion.
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Figure 12. UCL strain in a 32-year-old man. Coronal US scan of the thumb shows diffuse thickening of the UCL (arrows) without a tear. MCP = metacarpal, PP = proximal phalanx.
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Figure 13. Partial-thickness UCL tear. Coronal US scan of the thumb shows thickening (T) of the proximal UCL. There is a hypoechoic incomplete tear (thin arrow) in the ligament with intact overlying superficial fibers (SF). MCP = metacarpal, PP = proximal phalanx, thick arrow = aponeurosis.
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Figure 14. Full-thickness UCL tear. Coronal US scan of the thumb shows a hypoechoic cleft (white arrow) that extends through the UCL. The proximal ligament (cursor) is still covered by the smooth aponeurosis (black arrows). MCP = metacarpal, PP = proximal phalanx.
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Figure 15. 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.
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Figure 16a. 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.
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Figure 16b. 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.
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Figure 16c. 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.
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Figure 17a. Dorsal hood injury of the thumb in a 16-year-old girl. The left side of the images is ulnar, and the right side is radial. (a) Axial US scan of the normal thumb, obtained for comparison, shows the extensor pollicis longus (L) and brevis (B) tendons centered over the metacarpal head. Arrow = cortical edge of metacarpal head. (b) Axial US scan of the injured thumb shows the extensor pollicis longus tendon (L) displaced over the cortical edge (arrow) of the metacarpal head.
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Figure 17b. Dorsal hood injury of the thumb in a 16-year-old girl. The left side of the images is ulnar, and the right side is radial. (a) Axial US scan of the normal thumb, obtained for comparison, shows the extensor pollicis longus (L) and brevis (B) tendons centered over the metacarpal head. Arrow = cortical edge of metacarpal head. (b) Axial US scan of the injured thumb shows the extensor pollicis longus tendon (L) displaced over the cortical edge (arrow) of the metacarpal head.
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Figure 18. Thenar muscle injury. Transverse US scan of the thenar eminence (TH) shows a hypoechoic area (arrow), which represents a muscle rupture.
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Figure 19a. Strain of the radial collateral ligament. The left side of the images is distal. (a) Coronal US scan of the thumb shows a thickened elongated radial collateral ligament (R). (b) Coronal US scan of the contralateral thumb, obtained for comparison, shows a normal radial collateral ligament (arrows).
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Figure 19b. Strain of the radial collateral ligament. The left side of the images is distal. (a) Coronal US scan of the thumb shows a thickened elongated radial collateral ligament (R). (b) Coronal US scan of the contralateral thumb, obtained for comparison, shows a normal radial collateral ligament (arrows).
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Figure 20. de Quervain disease. Axial US scan of the base of the thumb shows both the abductor pollicis longus and extensor pollicis brevis tendons (arrow), which are situated within a distended synovial sheath with low levels of internal echoes (arrowheads). This appearance is consistent with tenosynovitis. (Courtesy of Cynthia Fan, MD, University of Michigan, Ann Arbor.)
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Figure 21. Degenerative disease of the carpometa-carpal joint in a 60-year-old woman. Sagittal US scan of the carpometacarpal joint shows joint effusion (black arrows) and intraarticular bodies (white arrow). The left side of the image is distal.
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Figure 22a. Vascular injury in an active young woman with pain at the base of the thumb. (a) Coronal US scan of the base of the contralateral thumb, obtained for comparison, shows the superficial branch of the radial artery (RA), which has a normal appearance. (b) Coronal US scan of the base of the symptomatic thumb shows a faint echogenic line (T) parallel to the wall of the radial artery, an appearance consistent with intraluminal thrombosis.
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Figure 22b. Vascular injury in an active young woman with pain at the base of the thumb. (a) Coronal US scan of the base of the contralateral thumb, obtained for comparison, shows the superficial branch of the radial artery (RA), which has a normal appearance. (b) Coronal US scan of the base of the symptomatic thumb shows a faint echogenic line (T) parallel to the wall of the radial artery, an appearance consistent with intraluminal thrombosis.
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Figure 23. Proximal rupture of the extensor pollicis longus tendon. Sagittal US scan of the carpal region shows a fusiform hypoechoic synovial sheath (arrows). This finding is due to proximal retraction of a torn extensor pollicis longus tendon, leaving the sheath empty. The proximal tendon stump is not seen in the image but may manifest as a mass at clinical examination, thus prompting imaging.
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Figure 24. Distal rupture of the extensor pollicis longus tendon (mallet finger). Sagittal US scan shows a cleft (arrow) in the extensor pollicis longus tendon. Note that the distal interphalangeal joint is held in slight flexion. DP = distal phalanx, PP = proximal phalanx. (Courtesy of Freddy Machiels, MD, Free University, Brussels, Belgium.)
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Figure 25. Synovitis in a patient with psoriasis. Sagittal US scan of the dorsal metacarpophalangeal joint of the thumb shows that the extensor tendon (short arrows) is displaced by synovial hypertrophy and effusion (long arrows). The tendon demonstrates mild anisotropy due to mass effect from the joint inflammation. The left side of the image is distal.
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Figure 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.
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Figure 27a. Normal and abnormal volar plate. MCP = metacarpal. (a) Sagittal US scan of the ventral metacarpophalangeal joint in the neutral position shows a normal volar plate (cursors). Note the normal displacement of the flexor pollicis longus tendon (arrowheads) from the osseous landmarks. The left side of the image is proximal. (b) Sagittal US scan of the ventral metacarpophalangeal joint of the thumb shows a hypoechoic swollen volar plate (black arrows) with a central cleft (white arrows). The cleft represents a tear through the substance of the volar plate. The apparent malalignment of the proximal phalanx (PP) is an artifact created by the scanning plane.
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Figure 27b. Normal and abnormal volar plate. MCP = metacarpal. (a) Sagittal US scan of the ventral metacarpophalangeal joint in the neutral position shows a normal volar plate (cursors). Note the normal displacement of the flexor pollicis longus tendon (arrowheads) from the osseous landmarks. The left side of the image is proximal. (b) Sagittal US scan of the ventral metacarpophalangeal joint of the thumb shows a hypoechoic swollen volar plate (black arrows) with a central cleft (white arrows). The cleft represents a tear through the substance of the volar plate. The apparent malalignment of the proximal phalanx (PP) is an artifact created by the scanning plane.
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Figure 28. Infectious tenosynovitis. Sagittal US scan of the flexor pollicis tendon (T) shows hypoechoic synovial reaction (white arrows) adjacent to the tendon. Incidentally noted is a normal volar plate (black arrow).
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Figure 29a. Normal and abnormal pulleys. Arrow = flexor pollicis longus tendon. (a) Axial US scan shows a normal pulley (NP). (b) Axial US scan of a patient with trigger thumb shows a thickened pulley (P).
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Figure 29b. Normal and abnormal pulleys. Arrow = flexor pollicis longus tendon. (a) Axial US scan shows a normal pulley (NP). (b) Axial US scan of a patient with trigger thumb shows a thickened pulley (P).
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Figure 30. 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).
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Copyright © 2006 by the Radiological Society of North America.
