Lesions of the Flexor Tendons at the Hand

Abstract

Flexor tendon pathologies of the hand are frequently encountered in musculoskeletal radiology and require a precise diagnosis and treatment due to the complexity of the anatomy. Typical conditions are acute traumatic injuries such as tendon and/or pulley rupture as well as open lacerations. In addition, there is a wide range of infectious diseases, chronic overuse conditions, as well as degenerative, neoplastic, and systemic/rheumatic tendon disorders. Accurate characterization of these lesions with ultrasound for basic diagnostics and magnetic resonance imaging for further clarification is crucial for optimal therapy management and prognosis. Following a patient presentation, this article reviews the anatomy and diagnostic imaging features of the most common flexor tendon pathologies.

Keywords

finger - flexor tendon disorders - magnetic resonance imaging - ultrasound - functional examination

Publication History

Article published online:
03 December 2025

• References

• 1 Hentz VR. Functional anatomy of the hand and arm. Emerg Med Clin North Am 1985; 3 (02) 197-220
• 2 Schmidt H-M, Lanz U. Chirurgische Anatomie der Hand. Vol 2. Stuttgart, Germany: Thieme; 1992
• 3 Schmitt R, Hesse N, Grunz JP. Tendons and tendon sheaths of the hand - an update on MRI. Rofo 2022; 194 (12) 1307-1321
• 4 Clavero JA, Alomar X, Monill JM. et al. MR imaging of ligament and tendon injuries of the fingers. Radiographics 2002; 22 (02) 237-256
• 5 Bayer T, Lutter C, Janka R, Uder M, Roemer F. MRI diagnostics of the fingers: current developments and clinical relevance [in English and German]. Rofo 2025; May 26 (Epub ahead of print)
• 6 Schweizer A, Bayer T. Closed disruption of a single flexor digitorum superficialis tendon slip: 3 cases. Hand Surg Rehabil 2019; 38 (02) 121-124
• 7 Hauger O, Chung CB, Lektrakul N. et al. 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. Radiology 2000; 217 (01) 201-212
• 8 Schöffl I, Oppelt K, Jüngert J, Schweizer A, Neuhuber W, Schöffl V. The influence of the crimp and slope grip position on the finger pulley system. J Biomech 2009; 42 (13) 2183-2187
• 9 Schweizer A. Biomechanical properties of the crimp grip position in rock climbers. J Biomech 2001; 34 (02) 217-223
• 10 Bayer T, Bächter L, Lutter C. et al. Comparison of 3T and 7T magnetic resonance imaging for direct visualization of finger flexor pulley rupture: an ex-vivo study. Skeletal Radiol 2024; 53 (11) 2469-2476
• 11 Goncalves-Matoso V, Guntern D, Gray A, Schnyder P, Picht C, Theumann N. Optimal 3-T MRI for depiction of the finger A2 pulley: comparison between T1-weighted, fat-saturated T2-weighted and gadolinium-enhanced fat-saturated T1-weighted sequences. Skeletal Radiol 2008; 37 (04) 307-312
• 12 Guntern D, Goncalves-Matoso V, Gray A, Picht C, Schnyder P, Theumann N. Finger A2 pulley lesions in rock climbers: detection and characterization with magnetic resonance imaging at 3 Tesla—initial results. Invest Radiol 2007; 42 (06) 435-441
• 13 Artiaco S, Bosco F, Lusso A, Cioffi LL, Battiston B, Massè A. Flexor tendon pulley injuries: a systematic review of the literature and current treatment options. J Hand Microsurg 2022; 15 (04) 247-252
• 14 King EA, Lien JR. Flexor tendon pulley injuries in rock climbers. Hand Clin 2017; 33 (01) 141-148
• 15 Martinoli C, Bianchi S, Cotten A. Imaging of rock climbing injuries. Semin Musculoskelet Radiol 2005; 9 (04) 334-345
• 16 Bayer T, Adler W, Janka R, Uder M, Roemer F. Magnetic resonance cinematography of the fingers: a 3.0.  Tesla feasibility study with comparison of incremental and continuous dynamic protocols. Skeletal Radiol 2017; 46 (12) 1721-1728
• 17 Bayer T, Fries S, Schweizer A, Schöffl I, Janka R, Bongartz G. Stress examination of flexor tendon pulley rupture in the crimp grip position: a 1.5-Tesla MRI cadaver study. Skeletal Radiol 2015; 44 (01) 77-84
• 18 Klauser A, Frauscher F, Bodner G. et al. Finger pulley injuries in extreme rock climbers: depiction with dynamic US. Radiology 2002; 222 (03) 755-761
• 19 Miro PH, vanSonnenberg E, Sabb DM, Schöffl V. Finger flexor pulley injuries in rock climbers. Wilderness Environ Med 2021; 32 (02) 247-258
• 20 Schöffl I, Meisel J, Lutter C, Schöffl V. Feasibility of a new pulley repair: a cadaver study. J Hand Surg Am 2018; 43 (04) 380.e1-380.e7
• 21 Schöffl V, Küpper T, Hartmann J, Schöffl I. Surgical repair of multiple pulley injuries—evaluation of a new combined pulley repair. J Hand Surg Am 2012; 37 (02) 224-230
• 22 Heiss R, Librimir A, Lutter C. et al. MRI of finger pulleys at 7T-direct characterization of pulley ruptures in an ex vivo model. Diagnostics (Basel) 2021; 11 (07) 1206
• 23 Bayer T, Adler W, Schweizer A, Schöffl I, Uder M, Janka R. Evaluation of finger A3 pulley rupture in the crimp grip position-a magnetic resonance imaging cadaver study. Skeletal Radiol 2015; 44 (09) 1279-1285
• 24 Schöffl I, Deeg J, Lutter C, Bayer T, Schöffl V. Diagnosis of A3 pulley injuries using ultrasound. Sportverletz Sportschaden 2018; 32 (04) 251-259
• 25 Schweizer A. Lumbrical tears in rock climbers. J Hand Surg [Br] 2003; 28 (02) 187-189
• 26 Lutter C, Schweizer A, Schöffl V, Römer F, Bayer T. Lumbrical muscle tear: clinical presentation, imaging findings and outcome. J Hand Surg Eur Vol 2018; 43 (07) 767-775
• 27 Tani C, D'Aniello D, Possemato N. et al. MRI pattern of arthritis in systemic lupus erythematosus: a comparative study with rheumatoid arthritis and healthy subjects. Skeletal Radiol 2015; 44 (02) 261-266
• 28 Mundada P, Becker M, Lenoir V. et al. High resolution MRI of nail tumors and tumor-like conditions. Eur J Radiol 2019; 112: 93-105
• 29 Thammaroj P, Chowchuen P, Sumananont C, Nasang T. MRI findings of giant cell tumor of tendon sheath and other benign soft tissue tumors in hand. J Med Assoc Thai 2016; 99 (07) 816-822