DIAGNOSTIC AND SURGICAL

IMAGING ANATOMY
MUSCULOSKELETAL
II
 DIAGNOSTIC AND SURGICAL
IMAGING ANATOMY
MUSCULOSKELETAL
B.j. Manaster, MD, PhD, FACR
Professor and Vice Ch airman
Department of Radiology
Uni versity of Colorado Den ver & Health Sciences Center

Caroll. Andrews, MD Cheryl A. Petersilge, MD

Muscu loskeletal Radiology Ch air, Department of Rad io logy
Min k Rad io logic Imaging Ma rymount Hospital, Cleveland Clinic Health System
Assistant C linical Professor o f Radiology and
Orth opedic Su rgery
julia Crim, MD Case Western Reserve University
Chie f of M usculoskeleta l Rad iology
Professor of Radiology and Orthopedics
Un ive rs it y of Ut ah Sch ool of Medicine Catherine C. Roberts, MD
Associate Dean, Mayo School of Health Sciences
Assista nt Professor of Radiology
Jeffrey W. Grossman, MD Con sultant Radio logis t
Department of Radi o logy Mayo Cl inic College o f Medi cine
Uni ve rsity of Colo rado Denver & Hea lth
Sc iences Center
Zehava Sadka Rosenberg, MD
Professor of Radiology
Theodore T. Miller, MD New York Un ive rsity School of Medicin e
Atte ndi n g Radiologist NYU- Hospita l for j o in t Diseases
Department of Radio logy and Imaging
Hospital for Special Surgery
Ass istant Professor
We.ill Medical Co llege o f Cornell Universit y

Managing Editor
R. Kent Sanders, MD
Assistant Pro fessor of Radiology
Un iversity of Utah Sch ool of Medicine

AM IR SYS"
ames you know, con tent you t rust
Ill
 AM IRSYS
you "now, <.:on tent vou trust

First Edition
Tex t - Copyright B.j. Manaster MD, Ph D, FACR 2006

Drawi ngs- Copyright Ami rsys Inc 2006

Compilati o n- Copyright Amirsys Inc 2006

All rights reserved. No part of this publ ication may be reproduced, stored i n a retrieval system, o r transmitted, in an y form o r media
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ISB - 13 : 978- 1-931884-31 -0

ISB -I 0: l-93 1884-31-5
lSB -13: 978-1-93 1884-32-7 (International Engl ish Edition)
ISBN- 10: l -93 1884-32-3 (International Engli sh Ed ition)

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Libra ry of Congress Cata loging-in- Publicati o n Da ta

Diagnostic and surgica l imaging anatomy. Musculoskeleta l I B.j.

Manaster ... [et al. l ; managing editor, R. Ke n t Sanclers. - 1st eel.
p. ; em.
Includes index.
15BN-13: 9 78- 1-93 1884-31-0
ISBN- I 0: 1-93 1884-31-5
ISBN-13: 978- 1-93 1884-32-7 (internationa l English eel .)
l SBN- 10: 1-93 1884-32-3 (internat io nal Engl ish ed.)
I. Muscul os keletal system-Anatomy-Atlases. 2. Muscul os ke letal
system- Imaging- Atlases. I. Manaster, B. j. II. Title: Musculo-
skeletal.
[D LM : I . Musculoskeletal System-anatomy & histology-Atlases.
2. Magnetic Resonance Spectroscopy-At lases. 3. Tomography,
X-Ray Computecl-Atlases . WE 17 05365 20061
QMIOO.D53 2006
6 1 l '. 700222-clc22
2006030832

IV
 Dedicated with love to o ur families:

Steve, Tracy Joy, and Katy Rose

John, Sara, and Jenn a
Lester, Philip, and Eleanor
Mandy, Aidan, and Kara-Elise
Terry, jack, Elissa, Benjamin, and Landon
Will, Melissa, and Steph en
j ohn, Emma Patricia, and Austin Ju stice
Ron and Leora
Micki

v
VI
 DIAGNOSTIC AND SURGICAL IMAGING ANATOMY: MUSCU LOSKELETAL

We at Ami rsys, toge t her with ou r distri buti on co lleagu e at LWW, arc p roud to presen t Diagnostic and Surgical
Anato111v: Musml oskeletal, the secon d in our bra n d-n ew seri es of anatom y refe rence ti tl es . A l l books i n th e series are design ed
speci fically to serve cli nicians i n med ica l i m agi n g and each area's related surgical subspec ia l ties. We focus on ana tomy th at is
gen erall y visible on i m aging studies, crossin g m oda l ities and prese n ti ng bul leted brief i n t rodu ctory text descri pt ions along w ith a
glo rious, rich offer i ng of colo r n or m al ana tom y graphics toget h er w i th i n-dep t h mu l ti moda l ity, m ulti plana r hi gh-resol ution
i m aging .

Each im aging ana tom y tex t book con tai ns over 2,500 labeled colo r graphi cs an d high reso l u tion radio logic i m ages, wi t h
heavy emphasis on 3 Tesla M R and state-of-the-ar t mul ti-detector CT. I t is designed to gi ve th e busy m edical professional rap id
answers to imaging ana tomy question s. Each n ormal ana tom y seq uence provi des detai led views o f ana tomic structures never
b efore seen and discussed i n an ana tom y reference tex tbook. Fo r easy reference, Muswloskeletol is subd i vided in to separate
sect io n s tha t cover detai led norma l an atomy of eacl1 m ajor joint w i th adjacen t long bon es (such as sh o ulder, h i p and pelvis,
knee, etc .) .

I n su m m ary, Di(II!IIOStic and Anatolllv: M uswloskeletal is a product designed wi th you, th e reader, in m i nd.
Today's typ ical rad io logic, surgica l, and spo rts m ed ici ne practice settings de m an d both accu racy and efficie n cy i n i mage
interpretatio n fo r cl i n ical decision-maki ng. We think you 'll fi nd this n ew app roac h to an atomy a high ly efficien t and
won der fully rich reso urce tha t wil l b e the core of your referen ce co l lection in mu sculoskeleta l an atomy. T he n ew Diagnostic and
Anato111v: Chest. Abdomm . and Pelvis is al so now avail able. Com i ng in 2007 are vol umes o n Ultrasound as well as
a subsp eci alty - and podi at ry -orien ted tex t o n Knee, A nkl e, an d Foot.

We hope that you wi l l sit back, d ig i n, and enj o y seei ng ana tom y and im agi n g wit h a w ho le differen t eye.

Anne G. Osborn, M D
Execut ive V ice President and Editor-in-Ch ief, Am i rsys I n c.

II. Ric llarnsberge r, MD

CEO & C h airman, Am irsys Inc.

Paula j . Woodwa rd, MD

Se nior Vice Presid ent & Medical Director, Am irsys Inc.

B.j. Manastcr, MD
Vice President & Associate Medi cal Di rector, Am irsys Inc.

V II
V III
 FOREWORD

Depict io n of the musculoskeletal system is a dynami c process which utili zes the latest innovations of imaging technology to
elucidate anatomy, both structu ral and functional. A lthough there h as b ee n n o cha n ge i n th e bo nes, li gaments, mu scles, and
tendons, t here h as been a revolution i n the way t hey arc eval uated. Even the most accomp lished clini cia n will ben efit from an all-
in clusi ve resource providing th e deta ils of th e muscu loskeletal system . Com pilation o f a compreh ensive mu scu loskeletal imaging
atl as, covering th e different imaging modalities-from radiogra phs to MR arth rograph y, as well as havin g three dimen siona l
mu sculoskeletal anatomy o f th e whole bod y-was, until now, lacking.

Th is new atl as is a tim ely add iti on whi ch so lves all o f the problems of prev ious atlases with its n o vel, multifun cti ona l layo ut.
The hi ghly regarded edito r, B..J. Manaster, her m an agi n g ed itor, Kent Sanders, as wel l as the authors, Zc hava Rosenberg, Julia
C rim, Chery l Pc tc rsil gc, Ca rol And rews, Catherine Rober ts, Jeff G rossma n and Ted Mill er are all we ll kn own au t hori ties in the fi eld
o f muscu loskeletal im aging.

Beau tiful black and whi te as wel l as co lor images and i ll ustrati on s arc presen t t hrough out this. wor k along w ith an outl i ned
text that covers those detai ls whi ch both radiologists and clinicians want to kn ow in an easy -to-read format. The multimodality
approach is a breath of fresh air that pu ts i mmensel y valuab le i n formation into a si ngl e text.

A natomy is sh own w i t h th e u sc of rad iographs, arthrography, C r, CT arth rography, MRI and MR arth rograph y. T h e
mdiographs u tilize the standard imaging positio n s, al lowi n g the reader to understan d th e osseous an atomy tha t is b est depicted
in each positio n. A very valuabl e featu re is th e in clusion o f left and right minor im ages for MRI, which ma kes i t easier to identi fy
t ructures with i n the ex t rem i ties wi t hout havi ng to transp ose. Most atlases prov ide imilges for onl y one si de, forcin g the reader to
m en tall y create th e contra lateral side. Su ch exercises can lcilcl to erro rs i n structure ident ificat ion. Three d imensional graphics that
depict muscles, nerves and vessels arc rendered in detail that is invaluabl e to th e practicing clinician. Intrica te an atomy defi n ed by
multiple sma ll structu res, such as th e ligaments see n in th e posterolateral cornE'r of the knee, is nice ly clemon stratccl in diagramatic
for m as well as on MRI.

book shall prove to be ex trem el y usefu l for radio logists, ort hopedic surgeo ns, rheumatologists, ph ysiat rists, ph ys ical
therapists and clinicians, w hether in training o r in practice. I t is the atlas to purchase for those who seek an swers rela ted to
muscu loskeletal anatom y an d its imagin g. Th ese au thors are to be congratulal"ecl fo r compi l ing such a com preh ensive work.

Ly nn e Steinbach, MD
Professor of Clinica l R<Jdiology and Ort hopaedic Surgery
Ch ief, Musculoskeletal Imaging
U ni ve rsi ty of C<Jiifor n ia San Francisco

IX
X
 PREFACE

\Vt' are to present to ou r col leagues a comprehensive atlas of musculoskeleta l imaging. rhc user w ill find the
information in this book to be easi ly accessible on man y levels. First, for the traditional qui ck " iden tit y or loca te the structure"
ques tion, all musculmkelctal body parts are presented in the traditi o nal three planes with extensive labeling. A unique feature is
that , l or th e coronal and axial planes, the right and left side of the bod y are sh own on facing pages. Additionally, n ot onl y the
join t \ but also the long bones and associated structures are sh own in detai l in all planes. For those joints w h ere special
poo;itionmg or planes are utilized, these arc demonstrated and labeled as wel l.

The \econd unique feature of the atlas i s the addition of tex t and over 300 full color graphics which w i ll assist th e reader in
furthering their un derstanding of anatomical structures and pathways in the musculoskeletal system. T h ese graph ics are matched
w ith images to more fully illustrate an atom ical relationships.

Finall y, th e au thors have ch ose n several uniquel y difficult anatomic or functional regions of the mu sculoskeletal system for
amplification. Some exa mples of these in clude th e posterola tera l corner o f the knee, rotator interva l o f the shou lder, pulley and
ligam ent/ tendon system of th e finger, and l igament s of t he w rist. Each of th ese is presen ted as a sub m od ule, w i th its own set o f
text , graphin, images, and i s often supplem ent ed with MR arthrographi c or CT images. We t ru st tha t t hh additional materia l
can be to gain an in-dep th understanding of the muscu loskc lct"al system.

We ho pe and expect our readers will find our " labo r of love" useful i n their work.

B.J. Manastcr, MD, PhD, FACR

Professor and V ice C hairman
Dt•partment of Radio logy
Universi ty of Colo rado Denver & Health Sciences Center

XI
X II
ACKNOWLEDGMENTS

Illustrations
Richa rd Coombs, MS

Image/Text Editing
Kaerli Main
Douglas Grant jac kson
Amanda Hurtado
Me la n ie Hall

Medical Text Editing

R. Ke nt Sa nde rs, MD

Case Management
Ro th LaF le ur
hri stopher Odekirk

Production Lead
Melissa A. Hoopes

X III
XIV
 SECTIONS

Shoulder 00
Elbow [TI]
Wrist []]]
Hand [Y]
Hip and Pelvis [Y]
Knee M
Ankle lVIII
Foot !VIlli

XV
 TABLE OF CONTENTS
Osseous Structures Ill-56
Section I Carol L. Andrews, MD
Shoulder Ligaments 111-76
Carol L. Andrews, MD
Shoulder Overview 1-2
Catherine C. Roberts, Ml) Tendons 111-96
Carol L. Andrews, MD
Rotator Cuff and Biceps Tendon 1-76
Catl1erine C. Roberts, MJ) Neurovascular Structures 111-118
Carol L. Andrews, MD
Rotator Interval 1-90
Catherine C. Roberts, MV

Ligaments 1-102 Section IV

Catherine C. Roberts, MD Hand
Labrum 1-118
Catherine C. Robern, MJ) Hand Overview IV-2
j effrey W Grossman, MV
Clinically Relevant Regions 1-132
Catherine C. Roberts, MO Flexor Mechanism and Palmar Hand IV-30
je((rey W Grossman, MD
ABER Positioning 1-140
Catherine C. Roberts, MD Extensor Mechanism and joints IV-38
j effrey W Grossman, MD
Arm Overview 1-1 52
Catherine C. Roberts, MD
Section V
Section II I I and Pelvis
Elbow
'------------------_j Hip and Pelvis Overview V-2
_ Cheryl A. Pelersilge, MD
Elbow Overview 11 2
Theodore T Mil ler, M IJ Measurements and Lines V-64
Cheryl A . fJetersilge, MD
Muscles and Tendons 11-56
Tl1eodore T M i ller, MU Anterior Pelvis and Thigh V-70
Che1y l A. Pet ersilge, MD
Ligaments 11-82
Theodore T. Miller, MD Lateral Hip V-94
Cheryl A. MIJ
Forearm Overview 11-92
Theodore T M illet; MlJ Posterior Pelvis V-126
Cheryl A. Petersilge, MD

Hip joint V-166

Section Ill Cheryl A. Petersilge, MD
Wrist Th igh Overview V-190
Cheryl A. Petersilge, MD
Wrist Overview 111 -2
Carol L. r1 ndrew>, M lJ

xv i
 Se<:tion VI
Knee
Knee Overview Vl-2
B./. Mnnnster, MD, PhD, FA CH

Extensor Mechanism and Retinacula Vl-64

8./. Mnnnster, MD, PhD, FA CH

Menisci Vl-72
B./. Mnnnster, MD, PhD, FA CH

Cruciate Ligaments/ Posterior Vl-98

Capsule
B./. Mnnnst er, MD, PhD, FACH

Medial Support System Vl-116

B./. Mnnnster, MD, PliO, FACH

Lateral Supporting Structures Vl-126

B./. Mannster, MD, PhD, FACH

Leg Overview Vl-142

B.j. Mnnaster, MD, PhD, FACH

Se<:tion VII
Ankle
Ankle and Hindfoot Overview Vll-2
Zeilnvn Sndkn Hosenberg, MD

Tendons Overview Vll-68

Zelwvn Sndkn Hosenberg, MD

Ligaments Overview Vll - 102

Zehnvn Sndkn Hosenberg, MD

Se<:tion VIII
Foot
Foot Overview Vlll-2
julia Crim, MD

Intrinsic Muscles of the Foot Vlll-64

Julin Critn, MD

Tarsometatarsal joint Vlll-68

Julin Crim, MD

Metatarsophalangeal joints Vlll-74

Julin Crim, MD

Normal Variants Vlll-80

Julin Critn, MD

XV II
XV III
 DIAGNOSTIC AND SURGICAL
IMAGING ANATOMY
MUSCULOSKELETAL

X IX
 SECTION 1: Shoulder

Shoulder
Shoulder Overview 2-75
Text 2-4
G raphics: Muscle-te n dons 5-7
G rap hics: Vessels 8
G rap hics: Ne rves 9
Radiographs 10-15
Grap hics: Muscle o ri gins & in serti o ns 1.6-1 7
Axial MR seque nce 18-45
Co rona l M R sequ e nce 46-63
Sagittal MR seq ue nce 64-75
Rotator Cuff and Biceps Tendon 76-89
Tex t 76
G raphics 77
Images 78-89
Rotator Interval 90-101
Text 90
Graphics 9 1-92
Images 93- 101
Ligaments I 02-1 1 7
Tex t 102
G raph ics 103-104
MR: Gle nohume ral 105-110
MR: Coraco hume ra l 11 1-113
MR: Coracoclav icular 11 4
MR: Coracoac ro mial 115
MR: Ac ro mi oclav ic ula r 116
Labrum 1 I 8-131
Tex t 118
G raphi cs 11 9-120; 124
Images 121 -123; 125-13 1
Clinically Relevant Regions 132-139
Tex t 132
G ra phics: Notch es 133
G raphics: Quadrilateral space 134
Images 135-13 7
Os acromiale 138- 139
ABER Positioning 140- 15 I
Tex t 140
G raphi cs 141
Images 142-151
Arm
Arm Overview 152-1 89
Tex t 15 2
Radiograp hs 153
G ra phics 154- 15 7
Ax ial MR seque n ce 158-177
Co ro n al MR seque nce 178-185
Sagittal MR seque n ce 186-189
 SHOULDER OVERVIEW
o I ntertubercu lar or bicipital groove
IGross Anatomy • Bet ween greater and lesser t uberosities
Overview • Tran sverse ligament, an extension of subscapularis
• Multiax ial ball-and-socke t joint tendon , forms roof o f groove
• Hem isph eric humeral hea d arti cu lates with sha ll ow • Contains long h ead of biceps tendo n &
anterola teral branch o f anterior circumflex
pear-shaped glenoid fossa
humeral artery and vein
o joint su rrounded by a synov ial-lined fibrous capsu le
o Glenoid deepened by labrum, a fibrocartilage rim o f • Sca pul a
ti ssue o Ac ro mion
o Ca rtilage thin s in ce ntral glenoid and in periph ery • Acromion orien tati o n ran ges fro m fla t to sloping,
med io laterall y
of hum era l head
• Range of motion: Fl ex io n , ex ten sion, abduction, • Ro ugh ly classified in to 4 types based on posterio r
adduction , circu mduction , medial rotation & lateral to anteri or sh ape
rotatio n • Type 1: Flat
o Flex io n : Pectora lis m ajor, delto id, co ra cobra chial is • Type II: Curved, paralleli ng humera l head
& biceps m uscles • Type Ill: A nteri or hooked
o Extension: Delto id & te res ma jo r muscles • Type IV: Co nvex undersurface
• Low-lyin g, an terior downslopi ng o r in ferolatera l
• If against resistance, also l atissimus dorsi &
pectora lis major tilt d ecreases vo lume of coracoacro mial outlet
o Abdu ctio n : Del toid & supraspinat us muscles o Os acromial c
• Un-u n i tcd acro mial ossification ce nter
• Subscapu lari s, i nfraspinatus & teres m i nor exert
• Sho uld fuse by 25 years of age
downward tracti o n
• Supraspinatus contribution co ntrove rsial • Incidence: 2-1 0%
o Medial rota t ion: Pectora lis m ajor, deltoid, • 60% bi lateral
latissimus dorsi & teres ma jo r muscles • Four types: Mesoacromion, metaacromion,
• Subscapularis when arm at side preacromion , basiacromion
o Latera l rotation: Infraspinatu s, deltoid & teres o Glenoid
min o r muscles • Shallo w, oval recess
• join t stabilizers • Fibrocartilage labrum increase depth
o Skeletally unstabl e joint o Coracoid process
o Superior suppo rt by coracoacromial arch • M ay ex tend lateral to plane of glenoid
• o rrnal distance between coracoid and lesser
o An terior suppo rt by subscapulari s te ndo n , anterio r
tuberosity> 11 mm w ith arm in internal rotation
capsule, synovial membrane, anterior labrum and
superio r, middle & inferior glen o humeral ligamen ts • C lavi cl e
o Posterior suppo rt by infraspinatus and teres mino r o Ac ro mioclavicu lar joint between d istal clavicle &
tendons, posterior capsule, synovial m embrane, acrom ion
posterior labrum & inferio r gleno humera l ligament • 20 degree range of motion
• Vascu l ar supply o Synovial-l ined joi nt capsule
o Fi brocart ilage-covered ends of bone & cen tra l
o Articular branch es o f anterio r and pos terior hu mera l
circumflex arteri es and tran sverse scapular artery fibroca rtilage d isk
• Inner vatio n • Bone marrow
o Axilla ry and suprascapu lar nerves o Predominantl y yellow marrow in adults with
residual hematopoieti c red ma rrow in glenoid and
prox imal humeral metaphysis
• Glenohumeral joint space
I Imaging Anatomy o 1-2 ml syn ovial fluid
Overview o Normal commun ication with biceps tendon sheath
• Humerus o o rmal comm u n ication with subsca pular rece s
o Eight ossification centers: Shaft, head, greater o Posterior jo in t capsule typically in erts on base of
tuberosity, lesser tuberosity, capitulum , trochlea, labrum
medial & latera l epico ndy les o Anterior joint capsule has variable in sertion
o A nato mic neck loca ted alon g base o f the articu la r • Anterior joint capsu l e inserti o n
surface, region of fused epiphyseal plate and o Type 1: Inserts at tip or base o f labru m
attachment o f joi n t caps ule o Type 2: In serts scapu lar neck< I em from labrum
o Surgi cal neck located 2 em distal to ana tom ic neck o Type 3: In serts scapu lar neck> I em from labrum
below greater and lesser tuberosities, ex tracapsular: • Subscapular recess
m ost co mmon site of fracture o Between scapula & subscapularis muscle anct tend on
o Greater tuberos i ty anterolateral on humeral head o j o int co m mun ication v ia foramen of Weitbrecht:
• Attachment of supraspinatus, in f raspinatus & teres Between su perior and midctle glenohumera l
min or tendons ligaments
o Lesser tuberosity located along proxima l anterior o Joint co mmunica tion v ia foramen of Rouvie re:
humeral head, med ial to grea ter tuberosity Between midctle and inferior glen ohumeral
• Attach m ent o f subscapularis ten d o n l igaments
 SHOULDER OVERVIEW
o Normally opacified d uri ng arthrograph y • Nor mally co nta ins a mi nim al amou n t o f fl uid
• Ro tato r cuff • Ad h erent to undersu rface o f ac ro mion
o Su pra spinatus, infrasp inatus, su bscapu laris & te res • Li es su perficia l to t h e ro ta to r cuff
m in o r o Subcoracoid bursa
o Ten dons inte rd igitate fo rmin g a co n tinu ous ba nd at • Sepa rate fro m the norm al su bscapu lar recess of
attachme nt to h u m erus jo in t
o Origins • Be tween subscapu laris te nd o n and
• Supraspinatus: Supraspina tus fossa of scapula coracobrach ialis/s ho rt head of biceps te ndo n
• In fraspi na tus: Infras pi na tu s fossa of sea pula • Ca n comm u nicate w ith subacromia l-su bdeltoid
• Teres minor: Lateral scapular bo rder, m iddle bursa
• Subsca pul aris: Anterio r sca pu lar s urfa ce • Does not norma ll y comm un icate wi th joint
o Inserti o n s o Infraspina tus bursa
• Supraspinatus, infraspinatus & te res mino r inse rt • Be tween infraspina t us tend o n a n d join t capsule
o n the g reater t u beros ity • Can rare ly commun icate with joint
• Supraspinatus h as a d irect co m po ne nt wh ic h o Oth e r less com mon bu rsae
inserts on anterio r po rtion of tu beros ity & • Deep to co racobrach ia lis muscle
posterio r o bli que co mpo n ent which un de rcuts the • Be twee n teres ma jo r & long head of tri ce ps
infraspin atu s at th e poste ri o r portion of tu be rosity • An terior & posterior to la tissim us do rsi te n do n
• Subscapu laris inse rts o n t he lesser tu be ro sity • Sup e rio r to acromion
• Liga m ents • Ad di t iona l m usc les o f u pper arm
o Co ra coacromi a l liga m ent o Deltoi d, biceps, coracobrachia lis, t rice ps
• Anterio r 2 / 3 of coraco id to tip o f acro m io n • Extr insic s h o ulder m uscles
o Co racocla vicular ligamen t o Trapezius, latissim us dorsi, levator scapulae, m ajo r &
• Base of co racoid process to c lavicle min or rh omboids, serra tus an teri or, subclaviu s,
• Stabi lizes acromioc lavicular joint omoh yoid, pecto ralis ma jor, pectora li s minor
• Co no id & t rapezoid po rtio ns me rge to form a V
o Co racohumeral ligament Inte rnal Struct ure s-Critical Co nte nts
• Latera l base of coracoid to lesser & greater • Q ua d rilateral or q u ad ra ng u lar space
tuberosities o Teres minor, su pe rior border
• Blends w ith subscapula ris tendo n , su p rasp in atus o Teres ma jor, in fe rior bord er
tendon, jo int ca psu le & s uperior g le n o hu mera l o Hu merus, la te ra l borde r
li ga m ent o Lo ng head triceps, med ial border
o Superior & inferior a cromioclavicu lar ligamen ts o Con ta in s ax illa ry nerve and posterio r circu mflex
o Supe ri o r, m iddle & infe rio r glenoh um e ral liga m ents h um eral a rtery
• Su perior and midd le g lenohum eral ligaments • Coracoacro mial arch
exte nd from supe ri or glenoid regio n to lesser o Acrom ion, superior border
tuberos ity o Humera l head, poste rio r border
• Con ge nitall y absent or dim inutive m iddle o Co racoid p rocess and coracoacrom ial liga m e nt,
glenohu meral ligamen t in 30% of popula tio n an te rior border
• Inferi o r glen o h u mera l liga me n t (a nterio r ba n d, o Co nt ains su bacromial-subdelto id bursa,
posteri or band & ax illa ry po uch ) extends from sup rasp inatus m uscle/ tendon, long head o f biceps
inferio r labrum to h um e ral a na tomi c n eck • Ro ta tor inte rval
• Caps ul o labra l com p lex o Tria ngula r space between the inferi o r border of
o Lab ru m s up raspin atus m uscle/ te n don a nd superior border of
• Oval fibrocarti lage t issue a long g le n o id rim subscapularis muscle/ tendon
• Hyaline ca rtil age may lie be twee n labrum & bone o Media ll y bo rde red by coracoid process
• Va ri es in shape, size a nd ap peara nce o La tera ll y bo rd ered by tra n sve rse hu me ral liga m ent
• Ana to mi c variants, most commo n in o Ante ri or bord e r fo rm ed by coracohum era l ligame nt,
ante rosupe ri or regio n, in clude sublabral fo ra m e n supe rior g le n o h umeral liga m ent & joint capsu le
& Bufo rd complex
o Biceps tendon
• Long h ea d arises from supragle noid tu berc le o r !Anatomy-Based Imaging Issues
s upe ri o r labrum
• Lo ng head may be co nge n ita ll y abse nt
Im aging Approa ches
• Long h ead may arise from intertubercular groove • Radiograp h s
or jo int ca ps ule o Sta nd ard views include AP inte rn al rotati o n , AP
• Sh ort h ead origin ates a t co raco id process as ex te rn al rotatio n and axillary views
conjoin ed tendon w ith coracobrach ia lis o Scapula r Y-view to eva lu ate supraspinatus o u tlet and
• Additio na l heads are rarely present and arise fr o m assess fo r di sloca ti on 'J)
o Rockwood view, 30 degrees caudal ti lt AP, to :::r
brachia lis muscle, inte rtuberc ular g ro ove o r 0
greate r t ubercle eva luate a cromion c:
• Bursae o Zanca view, 10-20 degrees ce pha li c ti lt AP, to
0..
o Subac rom ial-subdeltoid bursa eva lua te acromioclavicular jo int ("!)
"""

3
 SHOULDER OVERVIEW
o Intertubercula r o r bic ipital g roove
IGross Anatomy • Between greater and lesser tuberosities
Overview • Tran sverse liga m ent, an exte n sion of subscapu laris
• Multiaxia l ball-and-soc ket joint tendon , forms roof of groove
• Hemispheric humeral head articulates with shallow • Conta ins lo n g head o f biceps te nd on &
pear-shaped gleno id fossa a nte rola tera l branch of anterior circumflex
o Joint surrou nded b y a synovia l- lined fibro us capsu le hume ral artery and vein
o Glenoid d eepe n ed by lab rum , a fibro carti lage ri m of • Scapu la
tissue o Acrom ion
o Carti lage thins in ce ntral gle noid an d in periphe ry • Acromion o rientation ranges fro m flat to slo ping,
of hume ral h ead mediolate rally
• Range of motion: Flexion, ext en s ion, abd uc tion , • Rough ly class ified into 4 t y p es based o n poste rior
adduction, ci rcu m d uct ion, med.ial rota tio n & lateral to ante ri o r shape
rota tion • Type 1: Flat
o flex ion: Pectoralis rna jo r, deltoid , coracobrach ialis • Ty pe II: Cu rved, parall eling hume ral h ead
& biceps muscles • Type Il l: Anterior h ooked
o Extension: De ltoi d & te res major muscles • Type fV: Co nvex undersurface
• If against resistance, a lso latissimus dors.i & • Low-l ying, a nte rio r dow n slopin g o r inferolateral
pecto ra Iis rna jo r t ilt decreases volu me o f coracoacro mial ou t let
o Abduction: Deltoid & suprasp ina tus muscles o Os acrom ia lc
• Subscapul aris, infraspinatus & te res m in or exert • Un-united a cromial ossifi ca tio n center
downward traction • Should fuse by 25 yea rs of age
• In cidence: 2-1 O(Y<)
• Supraspinatus co ntribution co ntroversial
o Medial rotation: Pecto ra li s major, deltoid, • 60% bilate ral
latissimus d o rsi & teres major muscl es • Four t y pes: Mesoacromion, m etaacromi on,
• Subscapularis wh en arm at side p reacromion, basiacromion
o Lateral rotation: In fraspi natus, d e ltoid & t e res o Glenoid
minor muscles • Shallow, oval recess
• joint stabi lizers • Fibroca rtilage labrum in creases depth
o Skeletally unstable jo int o Coracoid p ro cess
o Superio r suppo r t by cora coacromial arch • May ex tend lateral to plan e of g lenoid
o Anterio r su ppo rt by subscapularis t e ndon, ante rio r • Norma l d is tance between co racoid and Jesser
capsule, syn ovial membrane, anter ior labru m and t uberosity> 11 mm with arm in inte rnal rota ti o n
superior, midd le & inferior glenohumeral ligaments • C lavicle
o Poste rior s uppo rt by infraspinatus and teres minor o Acromioclavicula r joint betwee n dis ta l c la v icle &
te ndo ns, poste ri o r capsu le, syn ovia l m e mbran e, acrom io n
posterior labrum & inferior g lenoh umeral ligament • 20 degree range of m o tion
• Vascu lar supply o Synovial-lined joint capsul e
o Arti cular bran ch es o f anterio r a n d posterior h umeral o Fibroca rtilage-covered end s of bone & ce ntral
circumfl ex arteries and tran sve rse sca pular artery fi b ro ca rti Iage dis k
• Innervation • Bon e marrow
o Axil lary and sup rascapu la r nerves o Predo min ant ly yellow m arrow in ad ults with
res idual hemato p o ietic red ma rrow in glenoid and
p roximal humeral m etaph ysis
11maging An atomy • Glenohumeral joint space
o 1-2 ml synovial fluid
Overview o N o rm a l co mmunication with biceps tend o n sheath
• Hum erus o Normal co mmuni cati o n with su bscapula r recess
o Eight o ssification centers: Shaft, h ead, grea te r o Posterio r joint ca psu le t y pi ca ll y in serts on base o f
tuberos ity, lesser t uberos ity, ca pitu lum, trochl ea, labrum
m edia l & latera l e pi condy les o Anterior jo int capsule has variable in sertion
o Anatomic n eck loca ted a long base of the articula r • Ant e r ior joint capsule insertion
s urfa ce, region o f fused e piphyseal plate and o Type 1: Inserts a t tip or base of labrum
attachment of joint ca psule o Typ e 2: In se rts sca pula r neck < l em fr o m labrum
o Surgical n eck located 2 em distal to anatomic neck o Type 3 : Inserts scapul a r n eck > 1 em from labru m
below g reater a n d lesse r tube ros iti es, ex tra capsu lar: • Subscapular recess
most common s ite of fracture o Between sca pula & su bsca p u laris muscle and tendon
o Greater tube rosity ante rolatera l o n humeral h ead o j oint communication v ia foramen of Weitb recht:
• Attachm ent of supraspinatus, infraspina t us & teres Betwee n superio r and midd le glenohum e ral
min or tendo n s ligaments
o Lesser tuberosity located along p rox im al anterior o joint comm u n ica ti on v ia fo ramen of Ro u v iere:
humeral head , m edial to grea ter tuberosity Between middle and inferi or g le n o hum era l
• Attach m e nt o f su bscapularis tendo n ligame nts

?
 SHOULDER OVERVIEW
o o rmall y opacified during arthrograph y • Normally con ta ins a minimal am ount of fluid
• Rota t o r cuff • Adherent to undersurface of acromion
o Supraspinatus, infraspi n atus, subscapularis & teres • Li es superficial to th e ro tator cu ff
rn i nor o Subcoracoid bursa
o Tendons interdigi tate forming a co ntinuo us ban d at • Separate from the norma l sub capular recess of
att ach m ent to humerus joint
o O ri gins • Between subscapu laris tendon and
• Supraspin atus: Supraspinatu s fossa of scapu la coracobrachialis/sho rt h ead o f b iceps tendon
• I nfraspinatus: In fraspinatus fossa o f scapu la • Can commu ni cate with subacro m ial-subdelto id
• Teres min or: Latera l scapular bo rd er, middle bursa
• Subsca pularis: Anteri o r scapul ar surface • Does no t no rmally co mmunica te w ith jo int
o Insertio ns o In fra splna tus bu rsa
• Supraspinatus, in fraspin atus & teres min or in sert • Bet wee n infraspi natu s tendo n and joint ca psule
o n th e greater tuberosity • Can rarel y co mmuni cate with jo int
• Supraspin atus has a direct compo nent wh ich o O ther less common bursae
inserts on anterior portion o f tuberosity & • Deep to coracobrach ia Iis muscle
posterior oblique component w h ich undercuts th e • Bet ween teres m ajor & lo ng head of t riceps
in f raspinatus at th e posterior porti o n o f tubero ity • Anterior & posterio r to la ti ssimus dorsi tendon
• ' ubsca pularis i n serts o n the le ser tubero ity • Superio r to acromion
• Ligaments • Additional muscles o f u pper arm
o o racoacromial ligament o Deltoid, b iceps, co racobrachia lis, triceps
• Ante rio r 2/ 3 of coracoid to ti p o f acromion • Ex trinsic sh ou lder muscl es
o Coracoclavicular liga m ent o Tra pezius, latissi mus dorsi, levator scapulae, m ajor &
• Ba se of coracoid process to clav icle minor rhombo ids, serratus an terio r, subclav ius,
• tabili zes acromioclavicu lar joint o mohyoid, pecto ralis major, pectora l is minor
• Conoid & trapezoid portio n s merge to fo rm a V
o Coracohumeral ligament Internal Structures-C ritical Contents
• Lateral base of coracoid to lesser & g rea ter • Quadrilateral or quadrangular space
tuberosi t ies o Teres minor, superio r borde r
• Blends with subscapu lari s tendon, su praspinatus o Teres major, inferior border
te ndon , joi nt ca psu le & superi or glenohum eral o Humerus, latera l border
I iga men t o Lo n g head triceps, medial border
o uperior & inferior acromioclavicular ligaments o Contains axillary n erve and posterior circumflex
o Superior, middle & inferio r g leno humera l ligaments humeral artery
• uperior and middle glenohumeral ligaments • Coracoacromial a rch
exten d fro m superior glen o id region to lesser o Acromion, su perior border
tuberosity o Humeral h ead, posterior border
• Congenitally absen t or dim inuti ve midd le o Coracoid process and coracoacrorn ial l igament,
gle nohumera l ligamen t in 30% of popul ati o n anterior border
• In ferior glenohumera l ligam ent (a nterior band, o Contains subacromia l-subdelto id bursa,
posterior band & axillary po uch ) extends from supraspinatus muscle/ten d o n , long head of biceps
inferior labrum to humeral an atomic neck • Rotator interval
• Ca psulo lab ra l complex o Triangular spa ce between t he i n feri o r border o f
o Labrum supraspin atus muscle/ tendon and superi o r bo rder o f
• Ova l fi brocart ilage ti ssue along glenoid rim subscapularis m uscle/tendo n
• Hya line ca rtilage may lie bet ween labrum & bo ne o Mediall y bo rd ered by co racoid process
• Varies in sh ape, size an d appearance o Laterally bo rdered by transverse h um eral ligam ent
• An atomic varia n ts, m ost co mmo n in o A nterior border fo rmed by co raco humeral l igament,
anterosuperio r regio n, include sublabral fo ramen superio r glenohum era l ligamen t & joi nt ca psule
& Bufo rd complex
o Bice ps tendon
• Long head arises from supraglen oid tubercle o r !Anatomy-Based Imaging Issues
superior labrum
• Long head may be co ngenitally absent
Imaging Approach es
• Radiographs
• Lo ng head may arise from intertubercular groove
o Standard views include AP in tern al ro tatio n , AP
or jo i nt ca psule
extern al rotatio n and axil lary views
• Short head o riginates at coracoid process as
co njoined tendon with coracobra ch ialis o Sca pularY-view to eva luate upraspi natus ou tlet and
• Add i tion al h eads are rarely present and arise from assess for dislocation V'l
o Rockwood view, 30 degrees caud al tilt AP, to ::r
brach ialis muscle, intertubercula r groove or 0
greater tubercle evaluate acromi o n c:
o Za nca view, 10-20 d egree!> cepha li c til t A P, to
• Bursae a..
o Subacromia l-subdel toid bursa eva luate acrom ioclavicular joi nt ro
'"'I

3
 SHOULDER OVERVIEW
o Ga rth apica l oblique or West Poi nt ax illary v iew to • Indirect method uti lizes IV gadopen tetate
assess antero i nferior glenoid rim d i meglum ine
• Garth : Pati ent sea ted, arm at side, cassette • T 1 FS seq uen ces i n ax ial, coronal oblique &
posterior ly i ng pa rall el to the spi ne o f the scapula, sagittal ob liq ue planes
beam centered at g leno humeral joint angled 45 • Optio n al abduction -ex ternal rotatio n (ABER)
degrees to t he plane of the t h o rax and 45 degrees • Inject ion o f ai r ca n simulate loose bodies
ca udal
• West Poin t axillary: Patient pro n e, head tu rn ed
Imaging Pitfalls
away from in vo lved side, cassette h eld against • Magic angl e phenomenon o n M R
superi o r aspect of shoulder, beam ce ntered at o 55° to m ain m agnetic fi eld when ima-ge TE < 30 ms
axilla an gled 25 degrees d own ward from o In creases signal inten sity i n o ther wi se n o rm al
ho rizonta l and 25 degrees medial structu res
o Stry ker n otch view to assess humeral head and base o Most o ften seen in· supraspinatus tendon,
o f coracoid process commonly in "criti ca l zone," l em from grea ter
• Patient supine, cassette under invo lved sh o ulder, tuberosity
palm of hand on top of head w i th fin gers toward o Can be seen in gleno id labru m and b iceps tendon
back of head prox imal to bicipital groove
• Computed tomograph y (CT) o Avoid pitfall by co mparing wi th images acquired
o Best evaluates bon e contou r wi th lo nger TE
• M agnetic resona nce (M R) imaging • Interdigitation of muscle o r fibrous tissue bet ween
o High field MR scan ner supraspinatus and in f raspinatus tendons
o Low-field d edica ted ex tremity MR sca nners o Simulates increased T2 MR signal within
improvi ng in q ua lity supraspinatus tendo n
o Ded icated sh o ulder coi l cen tered on regio n o f o Exaggerated if imaged in interna l ro tation
interest • Volume averaging of ro tator interval contents on
o Pa t ien t posi tio ning co ro nal oblique images
• Supine, arm neutral to slight externa l rotation, o Si mulates increased T2 MR sig nal within
avoid i ntern al ro tati o n supraspinatu s tendo n
• A rm at sid e and sli gh t ly away from side o f body • Normal flattening or sl ight co n cavity of
o Scou t im ages in coronal plan e posterolateral hum eral head
o Ax ial g rad ient ech o o r T2 FS from acromion thro ugh o Proximal to teres mino r tendon insert ion
inferio r g len o id fossa o Can be con fused w i th II ill -Sach s lesion , whic h is
o Coro nal ob liq ue T2 FS o r proto n d en sity & Tl located more prox imall y, above th e level of th e
sequences oriented parall el to su praspinatus tend o n coracoid process
• f-ro m subscapularis muscle an teriorl y thro ugh • Ac romial pseudospurs mimi ck i n g os teoph y tes
infrasp inatus m uscle posteriorl y o f-i brocartilaginous h ypertroph y at in sertion of
o Sagitta l obl ique T2 FS oriented perpend icu lar to coracoacrom ialligam ent o n in ferior acrom ion
su praspi na tus ten don o Superi o r and inferio r tendon slips ot deltoid m uscle
• Scapular n eck th rough lateral border of grea ter • ormal r esidual red bone m arrow in g len o id a nd
tuberosity proxim al humeral m et aph ys is ca n mimic
• T l sagittal o blique seq uen ce hel pf ul fo r assessing n eoplasti c process
m uscle atrophy o Red m arrow h as higher T 1 signal th an adjacent
• Arthrograp h y muscle
o Conve ntio nal ar th rograp hy o Red m arrow typ icall y decreases in signa l on ou t o f
• Needle placed into glenohum eral jo int under p hase images, compared with in pha se i mages
flu o roscopic guida nce • Anterolateral branch of a nteri o r circumflex
• Adm in ister 10 to l 2 rn l con t rast humeral artery & vein in l ateral bici p ita l g roove
• Contrast should remain within jo int, w i thout o Ca n be m istaken for bi ceps tendon lo ng itudinal tear
ex tension into rotator cuff o r • Hya line carti lage undercutting of superio r labrum
su bacromial-subdeltoid bursa simulating labral tea r
• Opacificatio n o f subscapular recess & bi ceps • Vacuum effect simulating l oose b odies o r
tendon sh eath i s norm al c hondrocalcinosis
o CT arthrograph y hel pful in p atients wi th o Exaggerated o n grad ient echo MR sequences & with
contraindica ti o n to MR ex ternal rotation positioning
o MR arthrograph y • General imaging artifacts
• Best eva luates capsu lolabral com p lex o Motio n artifact ca n be decreased by position ing the
• lntraarticular 12 rn l dil ute gadopentetate arm awa y from patient's body
d imegl umin e (2 mrnoi/L) mixed w ith iodinated o Avo id su perior to in ferior phase encod ing to
con tras t, Marca ine & epi nephri ne acco rding to decrease artifact fro m axill ary vessels
i nsti tul'iona I preferen ce o Metal susceptibil i ty art ifact
• Avoid sho ulder exerci se pri or to i magi ng to • I ncrease band w idth on all seq uen ces
minimize con t rast lea kage • Usc fast spin echo rath er th an co n ven tional spin
ech o sequences

4
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6
7
8
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ro

9
 SHOULDER OVERVIEW
EXTERNAL & INTERNAL ROTATION RADIOGRAPHS

Acromion of scap ul a

=:=====---+-Coracoid p rocess of
scapula

Grea ter tuberosity o f

humerus

Lesser tuberosity of
humerus -----------+- Gl enoid fossa o f
scapula
I n tertu bercular groove

Anatom ic neck of
hum erus
Su rgi cal n eck of
hum erus

Cla vicle

Acromi oclavicular joint

Acrom io n of scapu la

-----'==----+-- Coracoid of
scap ula

Head of hum erus

Greater tuberosity o f >1---- - - - - - - - -+--- Glenoid fossa o f

humerus scapula
Lesser tu berosity o f
humerus

(Top) Standard anteroposte rior (A P) externa l ro ta tion radi og raph of sh ou lde r. A sta ndard AP radiograph produces an
oblique view of the glenohum eral joint, w h ich h as a n ormal anterior a ngle o f approxi m ately 40 degrees. The
standard AP view can be obtained in neutra l positio n , in te rn a l rotation o r ex ternal rotation. With th e arm in external
rotatio n , the greater tuberosity projects a t th e lateral aspect of the humeral h ead. (Bottom ) Sta ndard AP internal
rotation rad iograph of shoulder. T h e lesser tube rosity projec ts at the med ial aspect of th e humeral head . Th e greate r
tube rosity has rotated anterior a nd is partial ly o bscured. Th e posterolatera l aspect of the hume ra l head pro jects
la terally.

10
 SHOULDER OVERVIEW
GRASHEY & GARTH RADIOGRAPHS

Clavicle
Acromion of sea pula

- - -- - - -- - - - ; - - Coracoid process of
Grea ter tuberosi ty of
h um erus scapu la

of - - - - - - - - - - - - - - . - G l e n o i d fossa of
humerus scapu la, posterior rim
Intertubercu lar groove
- - -- -- - - - - ----,-- Gl enoid of
Anatomic nee!.. of
anterior rim
humerus
Surgical neck of
humerus

Acromio n of

a====:!/L--;,----- ----,-- Cla\'icle

Superolatcral h umeral
head , pmterior margi n
- - - -- -- - - - - - - + - Glenoid fossa of
scapula
Anatomic neck of - . : . - - - - - - - - - - -- - + - Coracoid process of
humerus scapula over lappi ng
med ial hum eral head

-------------+- Glenoid fossa of

Surgical neck of scapula, in ferior rim
humerus

(J)
(Top) Grash ey or t rue AP view of sh ou lder. A tru e AP view o f th e shoulder is obtained by tilti ng t he X-ray beam ::T'
approxima tely 45 degrees latera lly from t he st anda rd AP v iew. Thi s produces a true AP view of th e anteriorly angled 0
glenohumeral joi n t. T he anteri or and posteri or rim s o f the glenoid should n earl y overlap on thi s view. The Grashey c
view is h elpful for eva luating joint congrui ty, jo int space narrowin g an d humeral h ead sublu xa ti on. (Bo ttom) Garth c..
view o f sh ou lder. Th e Garth view is obtained by angling th e X- ray beam 45 degrees ca udally from a stan dard A P ..,
(t)

view. T he inferi or glenohumeral rim and posterior m argin o f th e supero lateral h um eral head are well dem onst ra ted .
In patien ts with acute or chro nic anterior humeral head dislocations, th is view may assist in detec ti on of Ba nkart
fractures of the inferior glenoid and Hi ll-Sach s deform ities of th e humeral h ead .
11
 SHOULDER OVERVIEW
AXILLARY & WEST POINT RADIOGRAPHS

Lesser tuberosi ty of
Coracoid process of humerus
Greater tuberosity of
scapula humerus

Glenoid fossa of --1----------

scapul a Acromi oclavicular joint
Distal clavicle

Acromion of scapula

Spine of scapula

Spine of scapula
- - - - - - - + - - Coracoid process of
scapula
- - - - - - - - - + - - Anterior inferior
Glenoid fossa of glenoid rim
scapu la

Acromioclavicu lar joint - - - - - + - Lesser tuberosity of

humerus
--------=;-Greater tu berosi ty of
humerus
Acromion of scapula

(Top) Standard axillary view of shoulder. This v iew is obtained with the patie nt supine, the arm abducted to 90
degrees and the X- ray beam a ngled 15 to 30 d egrees mediall y to com pensate fo r rotation of the scapula. The res ultant
image is tangen tial to the glenohumeral joint. This view is helpful for identifi catio n of hume ral h ead disl ocation and
anterior o r posterior glenoid ri m fractu res. (Bottom) West Po in t axillary v iew of shoulder. This varia tion o n t h e
standard axilla ry view is acq uired with th e patie n t prone and th e abd ucted forea rm ha n gin g o ff the edge of the table.
The X-ray beam is a n gled 25 degrees m edi ally a nd an teri orly. The West Point view better de monstrates the anterior
inferior glenoid, making it usefu l for de tection of Bankart fract ures.

12
 SHOULDER OVERVIEW
STRYKER NOTCH & SUPRASPI NATUS OUTLET RADIOGRAPHS

Acromi on of scapula

----------+- Coracoid process of

Posterolateral aspect of
humeral head

Scapui<J

Acromion of scapula

-=====--====-------4- Supraspi na tus o utlet

region

- - - - - - - - i - - Coracoid process of

llumcral h ea d

- - - - - - -- - - ------"--"-1- C lenoicl fossa of

scapula

- - - - - - - - - -- - - - - - - - ;- Lateral border of

Vl
(Top) Stryker n o tch view of sh oulder. T his view is ob tained w ith the pati ent supine and the arm in an abducted and ::r
extern ally rotated (ABER) position. Th e X- ray beam is angled 10 degrees cephalic. The posterolateral aspect of th e 0
h umeral head, w here a Hill-Sachs deformi ty co uld be loca ted, is well demonstrated. (Bottom) Supraspinatus outlet c:
view of the shoulder. T his view is obtai n ed by placi ng the an terio r aspect of th e affected sh oulder against the X-ray c..
('0
plate, ro tating th e opposite sh oulder approx i mately 40 degrees away from th e plate then til ting the X-ray beamS to
10 degrees ca udally. T he acromi on and subacromia l space arc imaged in profile. T he su prasp inatus outl et view is ""''
helpful for assessing acrom ial morpho logy and hum eral hea d subluxat ion.

13
 SHOULDER OVERVIEW
SCAPULARY VIEW & AP SCAPULA RADIOGRAPHS

Acrom ion of scap ula

Coracoid process o f
Humeral h ead SC!Jpula

Glenoid fossa of
Glen oid fossa o f scapu la, ant erior rim
scapula, posterior ri m

Humeral shaft

Acromion of scapula

Coracoid process o f
scapula
Humeral h ead

Glen oid fossa o f

scapula

Latera l (ax illary) border

of scapu la
Medial (vert ebral)
border of sea pula

;::::::==-t- I nferior angle of

scapula

(Top) Scapular Y v iew of shoulder. The anterior aspect of t he affected sh oulder is placed aga i nst the X-ray p late and
the opposi te sh oul der rotated approxi mately 45 to 60 degrees away fro m the pla te. The x-ray beam is directed along
t he scapular spi n e producing a t rue lateral view of the shoulder. T he scapula is shaped like th e letter Y in thi s
pro jection. The hu meral head shou ld be located at th e cen ter of the Y. An teriorly dislocated houlders w i ll show the
humeral head l yi ng bel ow th e coracoid process. Posterio rl y dislocated shoulders wi ll show t h e humeral head l ying
posterio r to th e glenoid. (Bottom) AP view of scapula. Thi s is obtained sta nding or supi ne w i th th e arm abducted
an d hand supinated. The m ed ial (vertebral) bord er o f t he scapula is sh own through t he upper lung.

14
 SHOULDER OVERVIEW
CONVENTIONAL ARTHROGRAPHY

Acromion o f
Clavicle

Greater tuberosity o f
humerus
Bicep s tendon, lo ng
h ead
Superio r glen oid
labrum
Intertubercula r or
bicipi tal groove -------'=-=;-- Coracoid process of
scapula

Lesser tuberosi ty of

Anato mic neck of

------------+- Gleno id fossa of
scapula
hum erus

Acrom ion of

C lavicle
Contra st i n
subacrom i a1-su bdc I to id
bursa

eed le & con trast-filled

exten sion tubing

- --+- Coracoid process of

scapula
Anatomic neck of
humerus
- --------+- Glenoid fossa of
Lesser tubcrosit y of scapul a

Surgical neck of -+-------

humeru s

Vl
(Top) Conventional shoulder arthrogram. lntraarticular con trast ou tlin es th e confines o f the jo int. Contrast ex tends ::::r
to the anatomic n eck of the humerus, w h ere th e jo int ca psule inserts. Contrast ca n normally extend into th e biceps 0
tendon sh eath and subscapular recess. (Bottom) Subacromia l-subdeltoid bursa inject io n. A 2Sg need le is placed just c:::
below th e acromio n process. Administered con tra st wil l have a curvil in ea r configurati on as it tracks wi thin th e 0.
("t)
subacrom ia l-subdelto id bursa . The shoulder is intern ally rotated on th is image. '"'I

15
....
l)
0
::I
0
c/)

16
{J)
:J""
0
c
c..
ro
...,

17
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Subcu taneo us fa t
mu c le

Skin surface

Subcutaneous fa t

Skin surface

(Top) First i n series of Tl MR images o f the righ t shoulder displayed superi or to inferior. I mages we re acquired using
a shoulder coil on a 3T MR scanner. (Bottom) Th e t rapezius muscle covers th e superior and posterior aspect o f the
upper shou ld er. I t originates from occipi tal bon e, ligamen tum nuch ae an d the spi n ous p rocesses of C7 toT 12. It
inserts on the posterio r border of t h e lateral cl avicle, the medial border o f the acromi on and the spi ne o f the scapula.

18
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Subcu taneous fat

Trapezius musc le

Skin surface

Subcutaneous fat
Trapezius

Skin surface

CJl
(Top) First in series ofT! MR images o f the left sh oulder displayed su peri or to i n ferior. Images were acquired using a :::r
boulder coil on a 3T MR scanner. (Bottom) Th e trapezius muscle covers th e superior and posterior aspect of the 0
upper sh oulder. It ori ginates from occipital bone, ligamentum nuchae and th e spinous processes of C7 to T 12. I t c::
inserts on t h e posterior border of the lateral clavicle, th e m edi al border o f the acromi on and the spine of th e sca pula. 0..
('t)

""''

19
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Acromioclavicular join t

"!;::::=-===-__;;=,._- Trapezius 111 mcle,

an terior fibers

Trape7iu5 rnmcle

Deltoid muscle,
anteri or belly

Acromiocla vicular join t

Clavicle
Acromion process o f
sca pula

Suprascapular vessels muscle

Trape;ius

(Top) The distal clavicle is visi bl e at this level. The trapezius muscl e is p resen t posteriorl y and a few o f th e anterior
trapezius fibers are inserting along the posterior border of the distal clavicle. (Bottom) Th e acromion and distal
clavicle form t h e bo n y roof of t he superio r shou lder. T he supraspi n atus muscle becomes v isible beneath bra nch es of
the suprascapul ar vessels.

20
 SHOULDER OVERVIEW
AXIAL T1 MR, tEFT SHOULDER

Clavicle
Ac romi oclavicular joint

Trapezius muscle,
anterior fibers

Trapezius muscle

Deltoid muscle,
an terior bell y

i\cro mioclavicular joi n t

C lavicle
Acrom ion process of
scapula

Supraspi n atus muscle

Suprascapular vessels

Trapezius muscle

(Top) The d ista l clavicle is visible at this level. The trapezi us muscle is present poste riorly and a few o f the anteri o r
trapezius fibe rs are inserting alo ng th e posteri or border o f the d ista l c lavicle. (Bottom ) The acromion and distal
clavicle fo rm the bon y roof o f the superior shou ld er. The supraspinat us muscle becomes visible benea th branches of
the suprascapu lar vessels.

21
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Con oid tubercle,

clavicle
Deltoid muscle

la vicle

Coracoacromial
ligament attachment to
acromion

Acromi on process of
scapul a

Supraspinatus mmcle

Trapezi us muscle

Deltoid m uscle,
an teri or & middl e
bell ies
Clavicle

Su praspi na tus, an tcrior

direct ten don

Thoracoacromial artery
branch es

Supraspin atus, oblique

ten don Supraspinatus muscle
and tendon
Scapul ar spine

Trapezius muscle

I) (Top) Th e majority o f the acrom ion process o f t he scapula is v isible on this axial image. This is the level to assess for
J the presence of an os acro m iale, an unfused acrom ial apophysis that ca n be sym ptomatic. (Bottom ) Im age is just
J below th e acrom ion process. T he supraspin atus tendon arcs over the humera l head toward the attachment on th e
::>
grea ter tuberosity. The deltoid m uscle cove rs t h e an terior, lateral and posterior aspect of th e should er. It originates
") from t he latera l third of t he clavicle, lateral margi n of the acrom ion an d posterior border o f the scapula r spin e.

2
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Conoid tube rcle,

clavicle
Del toid muscle

C lavicle

Coracoacrom ia l
ligamen t at tach m en t to
acromion

Acromion process o f
scapula

Su pra spinatus muscle

Trapeziu s muscle

Del toid muscle,

anterior & mi ddle
belli es
Clavicle

Supraspinatus, an terio r
direct tendon

Thoracoac romi al artery

branches
Supraspinatus, oblique
tendon
Supraspinatus muscl e
and tendon Scapular spine

Trapezi us muscle

(Top) The ma jority of the acromion process of t he sca pula is visible on this ax ial image. This is t he level to assess for
the presence o f an os acromia le, an unfused acro mial apophys is that can be sympto ma tic. (Bottom) Image is just
below th e acromion p rocess. Th e supraspinatus tendon arcs over t h e hum e ra l head toward the attachme nt on the
grea ter tuberosi ty. The de lto id muscle cove rs the a n te rio r, late ral and posterior aspect of the sh oulde r. It o ri gina tes
from the lateral t h ird o f th e clavic le, late ral margin of th e acromio n and posteri o r border o f t he scapular spine.

23
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Deltoid muscle

Coracoacro mi al &
coracoc lavicular
li ga m en ts

Suprasp inatus muscle

Suprascapu lar vessels
and tendon

Scapular spine

Deltoid muscle

Coraco h umeral I.

Coracoid process

Humera l hea d
Subscapularis muscle

In fraspina tu s tendon
Supraspinatus muscle
Suprascapul ar vessels

Scapu lar sp in e

(Top) Image is through the superi o r as pect of the cora coid process of th e sca pula. The coracoclavicular a nd
coracoacromialligaments extend from the inferior bo rder o f the clav icle and acromion respectively to a ttach to th e
su perior aspect of the co raco id process. (Bottom) The infraspinatus muscle begins to a ppear at th e posterior aspect o f
th e sh oulder, below t h e level of the scapular spine. The co racohum eral liga men t exte nds from th e lateral border of
th e co racoid process to the anterior aspect of th e greater tuberosity of th e humeru s. The coracoh u mera l ligament
blends wi th the supraspi natus tendon at th e attachmen t.

24
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Deltoid m uscle

Coracoacromi al &
coracoclavicu lar
ligam e nt s

Supra\pinatus muscle
and tendon

Scapula r spi ne

Deltoid muscle

Coracohumeral I.
Coracoid process

llumeral h ead

Infraspin a tus ten d o n

Supra\ pin atu s muscle
vessels

Scapular spine

V'l
(Top) Image is through th e superior aspect of the coracoid process o f the scapula. Th e coracoclavicu lar and :r
coracoacromial liga ments extend from th e inferior border of th e clavicle and acromion respec tively to atta ch to the 0
superior aspect of the coracoid process. (Bottom) The infraspi natus muscle begins to appear at: th e posterior aspect of c
the shoulder, below th e level of the sca pula r spi ne. T he coracohum eral ligament exten ds from the lateral border of 0..
the coracoid process to the an terior aspect of th e greater tuberosity of t he hu merus. The co racohumeral l iga ment ro
blends wi th I he su praspinatus tendon at th e atta chm en t . ""''

25
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Deltoid muscle
Short head biceps and
coracobrachi alis
tendom

Supraspinatus tendon, Coraco id process

direct compon ent
Supraspinatus tendon, Bi ceps t., long head
oblique component
Supraglen oid tubercle
llumera I head
Suprascapular artery
Infraspina tus muscle and branches
and tendon
muscle
Deltoid muscle
capular spine

I Deltoid muscle,
an teri or belly
Short head biceps and
coracobrach ia Iis
tendons

Supraspinatus tendon Pectoralis m i nor t.

Greater Anterior labrum

Subscapu laris m. and t.

Hum era l head

Posteri or labrum Suprascapular artery

and nerve
Deltoid mu scle,
Subscapularis muscle
posterio r bel ly
capu lar spine
Infra pinatus mu scle

(Top) T h e long head o f the biceps ten don origi nates from the superio r glenoid labrum and supraglenoid tuberosity o f
the scapu la. The short head of the biceps and coracobrachialis muscles originate from th e tip o f the coracoid process.
(Bottom ) The suprascapular artery and nerve branches co urse along th e posterior glen oid fossa. The point labeled
"su praspi na t us tendon " represents th e most Iatera I ex tent o f ro tator cu ff in terva I, whe re the t ransverse I igamen t
compon ent o f subscapulari s meets the anteri or edge o f supraspinatus (d irect tendon ).

26
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Deltoid muscle
Short h ead biceps a nd
coracobrach ia Iis
te ndons

Coracoid process Su praspi natus tendo n,

d irec t com po ne n t
Su praspin atus tendon,
Biceps t., lo ng h ead
o blique componen t
Supraglenoid tube rcle Hume ral h ead

Suprascapular arte ry
a n d branc hes
musc le
Sup raspi na tu s muscle a nd te ndon

Scapular sp ine Deltoid muscle

Deltoid muscle,
Short h ead bi cep a nd
coracobrach ia Iis a nte rior bell y
te ndom

Pccto ralb mi nor t. Supraspinatus te n don

An terio r labrum Greater tu berosity

Subscapu laris muscle
and tendon Hume ral h ead

Gle noid
Posterior labrum
Suprascapula r arte ry
and n e rve
Del toid m u scle,
Su bscapularis m u scle posterior bell y

Scapular spine
Infraspinatus muscle

Vl
(Top) Th e long h ead of the biceps tendon o riginates from the superior glen oid labrum and supraglenoid tuberosi ty o f :r
the scapula. The short head of th e biceps and coracobrachialis muscles originate fro m th e tip of the coracoid process. 0
(Botto m ) The su prascapular artery and n erve bran ches co urse along t he posterior glenoid fossa. Th e point labeled c:
"supraspinatus ten don" represents th e most lateral ex tent o f ro tator cuff interval , where the tra nsverse ligament 0..
("0
component of subscapula ris meets th e anteri o r edge of supraspinatus (direct tendon).
""'

27
 SHOULDER OVERVIEW
AXIAL T1 MR, RI GHT SHOULDER

Deltoid muscle

Transverse ligament

Sh ort head and

tendon, long
coracobrachialis t.
h ead
Grea ter tuberosity Miclcl le glenohumeral I.

llumera l h ead Anteri or labrum

In fraspina tus tendon

Posterior labru m Suprascapular a. and n.

in notch

ub capularis muscle

In f raspi nat muscle

Deltoid muscle

Del to id mmcl e Bi ceps l. , sh ort head

Coracobrach ia I b
Subscapulari s tendon muscle

Bicep t., long h ead PectoraI minor

muscle
Greater tu berosity

tu berosity An terior labrum

Subscapularis muscle

G len oid

Posteri or labrum Suprascapular a. and n.

in n o tch

muscle
Del to id muscle

lo...
Q) (Top) The middle gleno humeral jo in t is seen as a d ark ba nd near the anterior labrum. This ex tends fro m t h e an terior
""0 gleno id to th e lower part o f t h e lesser t uberosity. (Bo ttom ) T he glenoid labrum is seen as low signal tria ng les at th e
::I anterio r and posteri o r rim o f the glenoid.
0
..c
tJ)

28
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Delto id m u scle,
anterior belly
Cephalic vei n
Transverse ligament
Sh ort head biceps &
coracobrachial is t. Biceps tendo n, lon g
head
Midd le glenohumeral I. Greater tuberosit y

An terior labrum
ll um era l head

Glen oid I n fraspinatus tendon

a. & n. Posterior labrum

i n spinoglenoid notch

Subscapularis
muscle
Deltoid muscle,
posterior belly

Biceps t., hort h ead De ltoid muscle,

an teri or bell y
Coracobrac hial is Subscapul aris tendon
muscle
Pectoralis minor Biceps t., lon g head
muscl e
Greater tuberosity

Anterior labrum Lesser tuberosity

Sub\cap ularis muscle

Glenoid

Posterior labrum
a. & n .
in spinoglenoid notch

mu5cle

Del toid muscle,

posterior bell y

(Top) The midd le glenohumeral joint is seen as a dark band near the anterior labrum . T his ex tends from th e anterior
glen oid to th e lower pa rt o f th e lesser tuberosity. (Bottom) The glenoid labrum is seen as low signa l triangles at th e
anterior and posterior rim of the glenoid.

29
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Del toid muscle,

anterior belly
Subscapularis tendon
Coracobrachial is m.

Biceps t., long head, in Pectorali s min or

bicipital groove muscle and tendon

Bi ceps t. , short head

Lesser tuberosi ty
M iddl e glenohumeral
Greater tuberosity
ligament
Humeral h ead A nterior labru m

Glenoid

Posterior labrum Scapula bod y

Teres minor muscle Subscapu laris muscle

I nfra spin atus mu scle

Del toid muscle,

posteri or belly

Delto id muscle,
anterior belly
Subscapulari s tendon
Coracobrachial is m .

Pectoralis m i no r
Bicep s tendon, lon g muscle and tendon
h ead
A n teri or labrum
Lesser tuberosity
eurovascular bun dle

Humeral head

Subscapulari s muscle

Posterior labrum Scapula body

Subscapul aris mu scle

Infraspinatus muscle

Del toid muscle,

posterior belly

(Top) The lesser tuberosity is located at th e ante rior aspect of t h e hum e ral h ead in this position. The su bsca p ular is
tendon is seen inserting o n the lesser tuberosit y. The long head o f th e bi ceps te ndon is wi thi n th e bicipital groo ve.
(Bottom) The neurovascular bundle lies deep to the pecto ra lis minor muscle. The subclavian arte ry becomes th e
axilla ry artery whe n it extends beyond t he fi rst r.ib below th e clavicle.
 SHOULDER OVERVIEW
AXIAL T1 M R, LEFT SHOULDER

Delto id m uscle,
ant eri or belly Sub sca pu laris tendo n
Co racobrachialis m .
Pecto ralis min or Biceps t., lon g head, i n
m uscle & tendo n bicipital groove

Bi ceps t. , sh ort head Lesser tuberosi ty

M iddle glen ohumera l Grea ter tuberosi ty
ligamen t
Ant eri or labrum Humeral head

Gleno id

Sca pula body Posterior labrum

m uscle
Teres minor muscl e

muscle

Del toid muscle,

poster io r belly

Deltoid mu cle,
ant erio r bel ly
m.
Subscapularis tendo n I
Pectoralis minor Biceps tendon, lon g
muK ie & tendon head

An terior labrum
Lesser tuberosity
, eurovascular bu ndle

l l umeral head
Glenoid

Subscapularh muscle

Sca pul a body Posteri or labrum

muscle

muscle Delto id muscle,

posterior bell y

Vl
(Top) Th e lesser t uberosit y is located at th e an terior aspect o f the humeral head i n this posi ti on. Th e subscapularis ::r
tendon is seen i nsert i ng on the lesser tuberosi ty. Th e long h ead of the biceps tendon is with in Lhe bici pita l groove. 0
(Bo tt om ) The neurovascular bundle lies deep to t he pectorali s mi nor m uscle. The subclavian artery becomes the c:
ax illary artery w hen i t ex tends beyond t he first ri b below the clavicl e. 0.
ro
""'

31
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Deltoid muscle,
anterior bell y
Subscapularis tendon
Coracobrachial is m.

Bice ps ten don, long m i nor

h ead muscle an d ten don

An terior labrum

Ax illary neurovascular
bundle
Hum erus
G lenoid

Posterio r labrum Scapu la body

Teres minor tendon

Subscapularis muscle

Teres mino r muscle Infraspinatus muscle

Cepha lic vein in

Delt oid del topectora l groove
anterior bel ly
Pecto ralis maj or muscle
Bi ceps tendon, lon g
h ead
Pectoralis minor
muscle and tendon

Axi llary neurovascular

bund le
Humerus

Posteri or labrum capula body

Teres minor mu scle Subscapularis muscle

and tendon

muscle

Del toid m uscle,

posterior belly

(Top) Th e te res mino r a n d infrasp ina tus m uscles are d iffi cul t to sepa ra te at t his level. The teres minor muscle is lyi ng
more late ral t h an w hat remain s of th e infraspinatus mu scle, lying mo re m ed ial. (Bottom ) The cephal ic vein
a nte rio rly, lies w ith in the de ltopectoral g roove.

32
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Deltoid mu scle,
anterior bell y

Pecto ral is m i n or
an d ten don
Subscapul aris tendon

Coracobrachialis m.
Bi cep s te ndo n, lon g
head
Axil lary neurovascular
bundl e
l l urnerus
An terior labru rn

Glen oid

Scapula body Posterio r labrum

reres m inor tendon

muscle

Teres m inor muscle

Cephalic vein in
dcltopectora l groove

major
Deltoid muscle,
Pectoral is minor anterior belly
muscle&. tendon
ten don, long
Ax iII a r}' neurovascular head
bundle
ll umerus

G lenoid

Scapula bod y labrum

Teres m in or muscle&.
muscle
tendon

Infraspinatus muscle

Del toid m u scle,

posterior belly

(To p) The teres mi nor and infraspina tus muscles are d i fficul t to separate at thi s level. The teres mi nor muscle is lying
mo re latera l tha n w h at remains of the in fraspin atu s muscle, lying mo re medial. ( Botto m) T he ceph alic vei n
an teriorly, lies wi t h i n the de ltopect ora l groove.

33
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Pectoralis major muscle

Cephalic vein

1., lon g head

minor m.

Co racobrach ialis m.
Biceps m ., sho rt head
Neu rovascu lar bun d le
llum erus, surgica l neck

Subsca pularis muscle

Infraglenoid tu bercle
Labrum, posterio r
inferior portion
capul a

Teres min or muscle

Infraspinatus muscle

Delto id musc le,

pos teri or belly

I Cephalic vei n
Del topectora l groove

Pectora lis major muscle

Pectora lis m i nor m.

Delto id muscle Coracobrach ial is m .

Biceps tendon, lon g Biceps m., short head

head

Neurovascular bundle
llumerus, prox imal
di ap hysis

Subscapularis muscle
Tri ceps tendon, lo ng
head
Scapu la

Del toid muscle, muscle

bell y

(Top) Last image through the inferior gleno id. T h e i n fragleno id tuberosity i s the origin o f the long head of the
tri ceps muscle. (Bottom) Image is just below the level of the glenoid. The long head of th e tri ceps tendon is now
visible below the infragl en oid tubercle.

34
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Pectora lis maj o r musc le

Cepha l ic vein

Pectoralis minor m.
Biceps t., lon g h ead
Co racobrachial is m.
Biceps m., sh or t head
Neurovascular bundle

Humerus, surgical neck

Subscapularis muscle

Infraglenoid tubercle
Labrum, poster ior
inferior portion
Scapul a
Teres minor m uscle

Infraspi natus muscle

Deltoid muscle,
posterior belly

Del topectoral groove

Pectoral is major muscle

Cephalic vei n
Pecto ral is minor m .
Deltoid muscle

Co racobrach ialis m.
Biceps tendon, long
Bi ceps m uscle, short
h ead
h ead
Neurovascular bundle
H um erus, proximal
diaphysis

Sub scapulari s muscl e

5!!!!=="'--"o=;:==:..,;;.,,..;___,! - - Tricep s ten don, long
h ead
Scapula

Deltoid muscle,
Infraspinatus muscle
poste rior bell y

(J'J
(Top) Last image through th e inferior glenoid. T h e in fraglen oid tuberosity is the origi n of the long head of the :::::r
triceps muscle. (Bottom) Image is just below the level of the glen oid. The long head o f th e tri ceps tendon is now 0
visible below the infraglen oid tubercle. c:
0..
('[)
-:

35
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

ephalic vein Pectoralis major muscle

Pectoral is minor m.
Delt oid mu scle

Coracobrachialis &
Biceps tendon, long short head biceps
head muK ies
eurovascular bundle
llumeru , prox imal
Anterior ci rcum flex
humeral vessels

Subscapularis muscle

Trice ps muscle &

tendon, lo ng head
muscle

Deltoid muscle

I Cephali c vein
major muscle

Deltoid muscle
Pectora lis m i nor
mu cle
Bi ceps muscle, sh ort
head

Biceps tendon, lon g oracobrachia lis m.

h ead

Humerus, proximal
diaphysis

Posterior circumfl ex ubscapul aris m uscle

hum eral vessels &
ax ill ary nerve

Triceps m., lon g head

In fra pin atus muscle

Deltoid muscle

(Top) Th e posterio r circumflex humeral vessels and axillary nerve tra verse the quadrilateral space. This space is
form ed by the subscapu laris and teres m i nor muscles superiorly, the teres major inferio rl y, the long head of the
triceps m edially and the surgical n eck of th e hum erus laterally. (Bottom) The short h ead of th e bi ceps muscle and
the coracob rachiali s muscle can be difficult to distinguish as separate structu res in the anterio r shou lder. T h e
co racob rachiali s muscle originates from th e co racoi d process m ore latera lly t han the short head of t h e biceps muscle.
Th e coracobrach ialis muscle th en swings posterior to the sh ort head of th e biceps muscle as it enters th e upper arm.

:6
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Pectoralis ma jor muscle

Ceph al ic vein

Pcctoralb minor m .
Del toid muscle
&
sh ort head biceps Biceps ten don, long
m u cles head
Neu rovascu lar bun dle
Humerus, proxi mal
Anterior circum flex diaph ysis
hum eral vessels

Subsca pularis muscle

Triceps muscle &

ten don, long head

I nfraspinatus mu scle
Deltoid muscle

Pectoralis ma jo r musc le
Cep hal ic vei n
Del to id muscle
Pectorulis minor m.

Coracob rochial is & Bi cep s 111., short head

short head biceps
muscles Bi ce ps t., long head

Neurovascular bundle
Humerus, proximal
An terior ci rcum flex diaphysis
humeral vessels
Posterior circu m flex
Subscapu laris m uscle hum eral vessels &
axi IIa ry nerve

Tri cep s muscle &

ten don, long h ead

lnfrospi n atu s muscle

Deltoid muscle

V"l
(Top) Th e posterior circ umflex humeral vesse ls and ax illa ry ne rve t raverse t h e q uadrila teral spa ce . T his space is ::T"
for m ed by th e subsca pula ris and teres m in or m u scles supe riorly, t h e teres majo r inferiorly, t he lon g head of the 0
trice ps mediall y and the surgical n ec k o f th e hum erus late ra ll y. (Bottom) The short head of t he biceps muscle and c:
the co racobrachia lis muscle ca n be di fficult to distingu ish as separa te struct ures in th e anterio r shoulder. Th e 0..
coracobrac hia lis muscle o rigina tes from th e coracoid p rocess more la te ral ly th an th e short head of th e biceps muscle. ro
The co ra cobrachia lis muscle th e n swings pos terior to the sh ort h ead of th e biceps muscle as it en ters the upper arm. ""''

37
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Cepha lic vein

Pectoralis maj or muscle

Del toid muscle Pectoralis m ino r

muscle
Bi ceps m., short head

Coracobrac h ialis m .
Bi cep s t., lo n g h ead

Hum erus, prox imal Axi lla ry artery

diaph ysis
Radia l n erve

Triceps m. , la teral h ead Subscapula ris muscle

Posterio r circu m flex

humeral vessels &
radial n erve Scapu la

Triceps m ., lo ng h ead
Infrasp inatu s m u scle
Delto id mu scle

Ceph a lic ve in
Pectoralis m ajor muscle

Deltoid muscle Pecto ralis minor

muscle
Biceps m. , short head

Biceps t., long head

Coracobrach ialis m .
Humerus, pro xim al
d iaphysis Neurovascula r bundle

Axillary artery, d istal

Triceps m., la teral head
Sub scapularis m u scle

Teres m ajo r muscle

Scapu la
Triceps muscle, lo n g
h ead
Infraspinatus muscle
Deltoid muscle

(Top) The lateral h ead of the triceps muscle arises directly from th e posterior surface of the humeral shaft. (Bottom)
The teres major muscle arises from the inferior angle of the scapula and inserts below t he lesse r tuberosity o n the
anteromedial hu mera l shaft.

38
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

Pectoralis major muscle Cephalic vein

Pectoralis min or Deltoid muscle

mu scle
Biceps m., short head

Coracob rachial is m. Biceps t., lo ng head

Ax illary artery
Humerus, proxima l
Rad ial nerve diaphysis

muscle

Posterior circumflex
humeral vessels &
Scapula radial nerve
Triceps muscle, long
muscle head

Del toid muscle

Pectora lis ma jor muscle Ceph ali c vein

Pectoralis minor Deltoid muscle

muscle
Biceps m., short head

Corarobrachialis m . Biceps t., long h ead

Neurovascular bundle Humerus, prox imal

diaphysis
Ax illitry art ery, distal nerve
Tri ceps muscle, la teral
muscl e
head

Teres major muscle

capula
Triceps muscle, lon g
head
Infraspinat us riiuscle
Delto id muscle

V'l
(Top) The lateral head o f t h e triceps muscle arises di rectly from t he posterior surface of the humeral shaft. (Bottom) ::r
The tere major muscl e arises from the in ferior angle o f t he scapula and inserts below the lesser tuberosity on th e 0
anteromedial hum eral shaft . c:
a..
..,
('t)

39
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Ceph alic vein

Pectora li'> major

Del toid muscle Pectorali s minor

Bice ps m ., shor t h ead

Pectoralis major t.

13iceps t., long head Coracobrachia l is 111.

eurovascu lar bu ndle

Deep brac hial artery

and radia l nerve

Triceps m., la teral h ead

.'>ubscapul aris muscle

Triceps m ., long h ead

Teres major muscle

Del toid muscle

Latissi m us dorsi muscle

Cepha l ic vein Pectoralis ma jor muscle

Pectoral is minor
Deltoid muscle muscle
Biceps m uscle, short
head Pectoralis major t.

Biceps & Coracobrach ialis m.

tendon, long head
Brachia l artery
Deep brach ia l artery
and radial n erve
Serratus an terior
Triceps m., lateral h ead

Subsca pularis musc le

Triceps m., lo ng head

Teres major muscle Scapula

dorsi muscle
Deltoid m uscle
muscle

(Top) T he axillary artery becomes th e brachi al artery at t he lower m argi n of the teres major mu cle. The brachia l
artery has pai red brach ia l veins, ly ing on each side o f the artery. Th e pectorali s ma jor m uscle h as a long inserti on
along th e latera l aspect of the b ici pi tal groove. I n some places it fuses with the joi n t ca psule, d eltoid tendon and
fascia o f th e u pper arm. (Bo ttom) Th e deep brach ia l artery is th e first branch of th e bra ch ia l artery. The deep brach ial
artery t ravels with th e radi al n erve between t he lateral and lon g h eads of th e t riceps in t h e upper arm.

40
 SHOULDER OVERVIEW
AXIAL T1 MR, tEFT SHOULDER

Pectoralis ma jor muscle Cepha lic vei n

I
Pectoralis m i nor Del toid m usc le
musc le

Pecto ralis maj or t . Biceps m ., sh ort h ead

Co racobrachiali s m. Biceps tendon, long

head
Neurovascul ar bund le

brach ia l ar tery &

Brach ial ar tery
radial n erve

Tri ceps m u scle, lateral

musc le head

Tri ceps m., lon g h ead

Scap ula Teres m ajor mu scle

De ltoid m uscle

Infraspi natus muscle Latissi m u s dorsi m uscle

Pectoralis m ajor musc le

Ceph ali c vein

Pectora I is m in or
muscle De ltoid muscle

Pecto ralis m ajor t. Biceps m., sh or t h ead

Coracobrach ia I is
Biceps t., lo ng h ead
muscle

Deep brach ial artery &

Brach ial artery radial n erve

Serratus an terior m.

Subscapularis muscle

Triceps m ., long h ead

Teres major muscle

Scapula
Deltoid muscles
Latissimus dorsi muscle
In fraspi n at us muscle

Vl
(Top) Th e ax illa ry a rte ry beco mes the brachia l a rtery at t he lower m argin o f t h e te res m a jo r muscle. The brachial ::T
a rtery has paired brachi a l vein s, lyin g o n eac h side o f t h e art ery. T he pecto ra li s ma jor m uscl e h as a lon g inse rt ion 0
a lo ng t he la te ra l aspect o f t he bicipit a l groove. In some places it fu ses with th e jo int capsule, de ltoid t e n don a n d c
fasc ia of the upper arm . (Bottom) T he dee p brach ial artery is the first branch of t h e brachi al arte ry. The deep brachi a l Q.
('!)
artery travels wit h the rad ia l nerve betwee n th e late ra l a nd long heads o f t h e t ri ce ps in t h e up per a rm.
""'

41
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Cephalic vein Pecto ralis ma jo r muscle

Pecto ralis min o r

muscle
Deltoid m uscle
Bi ceps m., short h ead

Biceps m uscle & Coracobrach ial is m .

ten d o n , lo n g h ead
Brach ial a rtery
Deep brachial artery
an d radia l n erve
Serra tus an terior m.
Triceps m., la teral head

Subsca pulari s muscle

Triceps m., lo n g head

Teres ma jo r muscle Scapula

Lati ssimu s d o rsi m uscle
Delto id muscle
Infraspinatus muscle

Pectoral is maj o r muscle

Cep halic vein

Pectoral is mino r
muscle
Deltoid muscle
Biceps m. , s hort h ead

Biceps mu scle &

tendon, long h ead Coracobrachialis m.

Brachial artery
Deep brachial artery - -='--....:;.:.=::::
and radial nerve
Serratus anterio r
Triceps m ., lateral head m uscle

Su bscapularis mu scle
Triceps m., long head

Teres ma jor muscle

Scap ula
Delto id muscle Lati ss imus dors i muscle

Infraspi natus muscle

(Top) The latissimus dorsi muscle courses superio rly from t he lower back, around the inferior border of the teres
major muscle, to insert alo ng th e inferio r aspect of the bicipital groo ve. (Bottom) The su bsca pularis muscle covers
t he entire ventral su rface o f the scapula.

42
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOU LDER

Pec to ralis major muscle

Cephalic vein

Pectoral is minor
muscle Deltoid muscle

Biceps m., s ho rt head

Coracobrachialis m.
Biceps muscle &
tendon, long h ead
Brachial artery
Deep brachial artery
and radial nerve
Serra tus a nterior
muscle
Subscapulari s muscle

Triceps muscle, lo ng
head
Sca pula Teres ma jor muscle

Deltoid muscle
Infra spin atus muscle

Pecto ralis ma jo r muscle

Cephalic vein
Pecto rali s minor
muscle
Deltoid muscle
Bi ceps m., short head

Coracobrachi al is m. Biceps m uscle &

te ndon, lo n g head
Brachia l artery
brachial artery
an d rad ial nerve
Se rratu anterior m .
Triceps musc le, lateral
Su bscapularis muscle head

Triceps m ., lo n g head

Teres major muscle

Scapu la
Latissimus d o rsi muscle Deltoid muscle

Infraspinatus muscle

(Top) T h e latissim us dorsi muscle courses su pe riorly fro m t he lowe r back, around th e inferior border of the teres
ma jor muscl e, to insert alon g the inferior aspect of the bic ipita l groove. (Bottom) The subscap ularis muscle covers
th e entire ventral surface o f th e scapu la.

43
 SHOULDER OVERVIEW
AXIAL T1 MR, RIGHT SHOULDER

Pecto ralis maj or musc le

Cephal ic vei n
Pectoralis mino r
mu scle
Deltoid muscle
Bi ceps m., shor t h ead Axi ll ary fat

Biceps muscle &

tendo n, long h ead Co racobrachial is m.

Brachial arter}'
Deep brachial artery
and rad ia I nerve
Serratus an teri or rn.
Tri ceps m., lateral head
Subscapul ari muscle
Triceps m., lon g h ead

Teres major muscle Latissi m us do rsi muscle

Deltoid muscle

I n fraspin atus muscle

Pectoral is m ajor mu scle

Pectoral is min or
muscle
Cephalic vei n

Biceps m., sh ort h ead

Biceps muscl e &

tendon, long h ead Coracobrach ia Iis rn.

Serratus an terior m.

Deep brachial artery Teres major muscle

and radial n erve

Triceps m ., lateral h ead Subscapul aris musc le

Lat issi mus do rsi mu scle

Triceps m., long head

Scapula

{Top) The pectora lis m ajo r and min or form the a nte rior wa ll o f t he ax ill a. (Bottom) Th e se rratu s anterior muscle is a
thin band o f muscle tha t lies be twee n the ri bs and scapula at the posterolateral as pect of th e upper ch est.

44
 SHOULDER OVERVIEW
AXIAL T1 MR, LEFT SHOULDER

major

Cephalic ve in
Pecto ral is min o r

Del toid muscle

Axi llary fat
Biceps m., sho rt head

Coracobrachialis m . Bi ceps muscle &

tendon, long head
Brachi al artery
;;;;;:<--w-- Deep brach ial artery
and radial nerve
Serra tu s anterior m.
1 riceps m., lateral head
muscle
Triceps m., long head

dorsi muscle Teres major muscle

Del toid muscle

lnlraspina tus muscle

maj or

Pectora lis minor

muscle
Cephalic vein

Biceps m ., sh ort h ead

oracobrachiali s m. Biceps muscle &

tendon, lon g head
Serratus anterior m.
ir----'iiiii-- Deep brachial artery
and radia l nerve
Teres maj or muscle

Subscapularis muscle
Triceps m ., lateral head

Latissi mus do rsi muscle

Scapul a Triceps m., lon g head

Vl
(Top) The pectoralis majo r and minor form the anterior wa ll of the axilla. (Bottom ) The se rra tus a nte rior muscle is a ::J"'
thin band o f muscle that li es be tween th e ribs and scapu la at the posterola tera l aspect o f the upper ch est. 0
c:
0..
ro
""'!

45
 SHOULDER OVERVIEW
CORONAL OBLIQU E T1 MR, RIG HT SHOU LDER

Trapezius muscle
Deltoid muscle,
posterior belly

muscle
Posteri or circumflex
humeral vessels and
ax illary nerve

Triceps musc le, lon g

Triceps muscle, lateral head
head

De lt oid mu cle

Infraspinatus muscle

Posterior circum flex

humera l vessels and
ax illary nerve

...._--::-==-_,;;;-- Deep brachia I

neurovascular bundle

Triceps muscle, lateral

Latissimu 5 dorsi
h ead
Triceps muscle, long
head

(Top) First in series of co ronal oblique T l MR images o f right sh ou lder displayed posterio r to anterior. Images were
obtained w ith a sh oulder coil on a 3T MR sca nner. At th e m ost posterior aspect of the shou lder, th e deltoid mu cle
covers the majority of th e sh oulder joint. T he trapezius m uscle covers the su peromedi al aspec t or the shou lder gi rdle.
(Bottom ) The radia l nerve suppl ies t he triceps muscle. It is part o f t he deep brach ial neu rovascular bundle.

46
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Trapezius mu scle Deltoid mu scle,

p osterior belly

muscle
Posterior circumflex
hum eral vessels and
axi llary nerve

lo ng
head muscle, lateral
head

frape;iu\ m uscle
Deltoicl muscle

muscle

Posterior ci rcumflex
hum eral vessels and
axi llary nerve

Deep brachi al --;;::=.,;::.

neurovascu lar bundle

I atissi mus dor\ i moscle Triceps 111 ., lateral head

111., lo ng head

fJl
(Top) First in series of corona l oblique Tl MR images of left shoulder displayed posterior to anterior. Images were :::::r
obtain ed with a shoulder coil on a 3T MR sca nn er. At the most posterior aspect of th e shoulder, t he deltoid muscle 0
covers th e m ajori ty of the shou lder joi n t . T he trapezius m uscle cove rs t he superomedial aspec t of t he shoulder girdle. c:
(Bottom) T he radial n erve supplies the triceps muscle. It is part o f th e deep brach ial neurovascular bundle. 0..
(0
""'

47
 SHOULDER OVERVIEW
CORONAL OBLIQ UE T1 MR, RIGHT SHOULDER

Acromion
Trapezi us musc le
Deltoid muscle

In fraspinatus muscle

Posterior circumflex
humera l vessels and
axi llary nerve
Teres major muscle

Triceps muscle, long

head Latissimus dorsi muscle

Tri ceps muscle, latera l

head

In fraspi na tus tendon

muscle

Teres m in or muscle

Posterior circumflex
humera l vesse ls and Teres ma jor muscle
ax iII ary nerve

Lal issi rn us dorsi muscle

Deltoid muscle

Tri ceps muscle, long

Triceps m uscle, lateral head
head

(Top) T he lo ng h ead of the trice ps muscle is the most medial m uscle o f the poste rior upper a rm. Ax illary nerve
bra nc h es supply th e skin a nd sh ou lde r join t. (Bottom) The infraspinatus tendo n arc h es over the posterosu perior
aspect of t h e hum era l head to inse rt o n t he g reate r tuberosity.

48
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Acromion
Trapezius mu scle
De lt oid muscle

In fraspi natus muscle

Posterior ci rcum flex

hum eral vessels and
axi llary nerve
Teres major muscle

Triceps muscle, long

Lat issi mus dorsi muscle head

Triceps m uscle, lateral

head

Scapular spine

Infraspi natus tendon

muscle

Teres m i nor m uscle

Pos terior ci rcum flex

Teres major m uscle
hu meral vessels and
ax illary nerve

Latissimu s dorsi muscle

Del toid muscle

Triteps muscle, h:Jng

head Triceps muscle, lateral
head

V'l
(Top) Th e long head of the triceps m uscle is the most med ial muscle o f th e posteri or upper arm. Axil lary nerve ::r
branches suppl y th e skin and shoulder joint. (Bo ttom) Th e i n fraspi natu s tendon arches over th e posterosuperior 0
aspect o f the humeral head to insert on the greater tuberosi ty. c
c..
(t)
'"'I

49
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, RIGHT SHOULDER

Scapu lar spine

Infraspinatus tendon

mu\cle
Deltoid muscle

Teres minor musrle

Posterior circumflex Teres major

h umera I vessels and
axilla ry nerve

Delto id muscle
Latissimus dorsi muscle

Triceps muscle, long

head

Acromion process
capular spine

tendon

llumeral h ead
l n fraspinatm muscle

Teres minor

Posterio r circumflex Teres major

humeral vessels and
axilla ry nerve

Latissi mus dorsi muscle

Del to id muscle
Triceps muscle, long
head

lo..
Q) (Top) Th e teres major muscle originates fro m t he infero lateral border o f the scapula to insert o n the medial aspect of
"'0 the bi cipi tal groove of the anteri o r humerus. (Bottom) Th e posteri o r circumflex humeral artery is a bran ch of the
:I axillary artery an d anastomoses wi th the anteri or circumflex h u meral artery.
0
..c:
rJl

so
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Scapular spi ne

Infraspi natus tendon

muscle l)e l toid muscle

min or

!'ere\ major mu scle Poste rior circumflex

humeral vessels and
axi l la ry nerve

l.ati\\i rnu\ dor\i muscle Del toid m u scle

I riceps mu scle, long

head

.'>capular spine Acromion process

lnfra\pinatus tendon

Infraspinatus muscle
l l urneral h ead

T1.•res minor muscle

m ajor mu scle Posterior ci rcumflex

humeral vesse ls and
axi lla ry n erve

I ati\\illlll\ dor\i

Deltoi d muscle

I riceps mmcle, long

head

(Top) T he teres major muscle originates from th e infero lateral border o f the scapula to insert on t he m ed ial aspect o f
t he bici pital groove o f th e anterior humeru s. (Bottom) Th e posteri o r circumflex humeral artery is a branch o f t he
axillary artery and anastomoses with the anterior circumflex humeral artery.

51
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, RIGHT SHOULDER

Acrom io n process
Sca pul a

Infraspinatus tendo n

Infraspinatus muscle

Teres m inor muscle

Teres ma jo r muscle
Posterio r circumflex
humeral vessels and
ax illary nerve

Deltoid muscle Latissim us dorsi muscle

Trapez ius mu scle

Acromio n process

T horacoacromia l
artery, acromi al
In fraspinatu s tendo n bran ches

Anato mic n eck of

humerus Infraspina tus muscle

G lenoid

Surgical n eck o f
humerus
Te res major muscle

Deltoid muscle

La tissimus do rsi muscle

(Top) The supraspinatus, infraspinatus, teres minor and subscap ula ri s muscles consti tute the rotator cuff. The jo int
ca psul e fu ses distall y with th e rotato r cuff te ndons. (Bottom) The acrom ion process is th e the la te ral continu atio n o f
th e scapu lar spine. Th e surgical n eck of the hum erus is ex traca psular and loca ted distal to the a na tomic neck, whi ch
is located a t th e attachment of the capsule, along th e epiph yseal line.

52
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Acrom io n process
Scapula

In fraspin atu s te ndon

In frasp inatu s muscle

Teres m i nor muscle

Teres m ajor muscle

Posteri or circumflex
h umeral vessels and
ax illa ry nerve

Latissi mus dorsi m uscl e

Deltoid mu scle

Trapezius m usc le
Acromion process

Thoracoacromi al
artery, acrom ia l
branches I n fraspinatus tendo n

Ana tom ic n eck of

I n fraspinatus m u scle humerus

Glenoid

Surgica l neck o f
hu m eru s
Teres m ajor muscle

Del toid m u scle

Latissi m u s dorsi

Vl
(Top) Th e supraspinatus, in fra spin a tus, teres min o r a nd subscapu laris m u scles con stitute t h e rotator cuff. The jo int ::::r
ca psule fuses d ist a ll y wi th th e rota to r cu ff ten don s. (Bo ttom ) Th e acromion process is t he the late ral co nti n uatio n of 0
the sca pu lar spine. Th e surgica l n ec k o f the h umerus is e xtracapsul a r and loca ted d ista l t o t h e ana to mic nec k, wh ic h t:
is located at t he a ttach m ent of the ca psule, al o ng th e e piph yseal li n e. c..
ro
""'l

53
 SHOULDER OVERVIEW
CORONAL OBLIQ UE T1 MR, RIGHT SHOULDER

muKie

Acromion

Infraspinatus tendon,
Poster ior
ilnterio r fibers
labrum
Posterio r oblique fibers Scapu la r
t.

G reater tuberosity
muscle

Scapula

Posterior circumflex
humeral and
ax ill ary nerve Teres major muscle

Del to id muscle
Latissimus dorsi muscle

muscle

Superior labrum with

Acrom ion p rocess biceps anchor
fibers
Subacromial- ubdel toid
bursa Supraspinatus muscle
Suprascapular a. and n.
Supraspinatus tendon
in spinoglenoid n o tch

Grea ter tuberosity capu lar spine

Delto id muscle

Inferio r labrum Subscapu laris rnmcle

I n ferior glenohumeral
I. posteri o r band
major muscle

tendon, long muscle

head

lo...
Q) (Top) Th e scapul ar spine div ides the posterio r border of th e scapu la into the supraspina tus fossa and infraspinatus
""C fossa. Th e su praspi natus outlet refers to the area o f th e lateral third o f the supraspi natus muscle and tendo n.
:::::s ( Bottom ) The superi or and inferio r glenoid labrum are shown h ere. The labrum varies in sha pe and size bu t typi ca l ly
0 has a tri angular shape o f uniform ly low signal.
..c::
(J)

54
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

muscle

Acromion

I n fraspinatus tendon,
an terior fibers
Labrum Posterior ob li qu e fibe rs
suprasp inatu s tendon
' capular spi ne
Greater tuberosi ty

mmcle

Scapula

Posterior circumflex
humeral vessels and
ax illary nerve
major

I dor\i muscle De l toid m uscle

Superior labrum with

pmterior anchor
Acromi o n process
fibers
Subacromial-subdel toid
muscle bursa
a. and n.
in notch Supraspinatus tendon

Scapular spi n e Gre<J ter

Glenoid
Deltoid m uscle

I nferior labrum
muscle

I n ferior glenohumeral
1., posterior ban d
111<1jor

Biceps tendo n, long

I muscle head

(Top) The scapula r spine div ides t he posterior border of t he scapu la into the supraspi natus fossa and infraspina tus
fossa. Th e supraspinatus ou tlet refers to th e area o f th e lateral th i rd of th e suprasp i natus muscle and tendon.
(BoUo m ) T he su peri or an d inferior glen oid labrum arc sh own h ere. The labrum varies i n sh ape and size b ut typ ical ly
has a t riangula r shape of uniform l y low sign al.

55
 SHOULDER OVERVIEW
CORONAL O BLIQU E T 1 MR, RIGHT SHO ULDER

Trapezius muscle
Acromioclavicular joint

Pseudospur: Acrom i al Supraspi natus muscle

attachment
coracoacro m ial I. Lon g head biceps
origin at supraglen oid
Supraspinatus tendon tubercle
Suprascapul ar a. & n.
G reater tuberosity in spinoglen oid notch

Glenoid

Circumflex sca pul ar

Deltoid muscl e vessel s
Inferio r lab rum
Anterio r circumflex
h umeral vessel s
Teres maj or muscle

Biceps tendon, long Lat issimus dorsi mu scle

head

Trap ezius musc le

Acromioclavicular joint Clavicle

Co racoacromi al
ligamen t Supraspinatus muscle

Suprascapul ar a. & n.
Supraspina tus tendon i n suprascapul ar no tch

Humeral head
Glenoid

Subsca pularis musc le

Labrum
Biceps tendon , l ong
h ead Anterior circu m flex
hum eral vessels

Deltoid muscle

Latissi mus do rsi muscle

Biceps muscle, long Coracobrachiali s m .

head an d biceps m., sh ort
head

(Top) Ante rio r c ircumflex a rte ry is a branch of the axilla ry artery. (Bottom) The spin oglenoid n otch contains fat and
the su p ra scapula r a rte ry a nd nerve. A mass in t his region ca n impinge the n erve and produce foca l atrop hy o f th e
infra spinatus muscle.

56
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Trapezim
lr
Acrom ioclavicula r joint
Pseuclospur: Acrom ia l
m uscle
attachm ent
Lon g head coracoacrom ial I.
origi n at supraglenoid
Sup raspinatus tendo n
tubercle
Suprascapular a. & n .
in spinoglc no id notch G rea ter tu be rosi ty

G lenoid

Circumflex scapular
vessels Del toid mu scle
I nferior labrum
An terio r circum flex
humeral vessels
Teres m ajor m uscle

dorsi muscle Biceps te ndon, long

head

Trapezius m u scle

Clavicle
Acro mioclavicular joi nt
Co racoacrom ia I
Supraspin atus m uscle ligamen t

Suprascapular a. 1:;:: n .
in suprascapular notch Supraspina tu te ndon

Humeral h ead
Glenoid

Subscapu laris

Labrum

Biceps tendon, lo ng
Anterior circum flex head
humeral vessels
Deltoid muscle

La tissim us dorsi muscle

Coracobrachiali s Bi ce ps m uscle, lo ng
muscle and bi ceps head
muscle, short head

(Jl
(Top) An teri o r circum flex artery is a b ra nch o f t h e ax illary artery. (Bottom ) T h e spin oglen o id n otch con tains fa t and ::::r
t he su prasca pular artery and n erve. A mass in thi s regio n can impinge t he n erve and p roduce foca l atro phy of the 0
infraspina tus muscle. c
a.
ro

57
 SHOULDER OVERVIEW
CORONAL OBLIQ UE T1 M R, RIGHT SHOULDER

muscle
C lavicle

Coracoacrom ia l I.
Supraspina tus
Del toid m ., middle
bell y
Suprascapu lar a. & n.
Supraspinatus tendon in suprascapu lar n o tch

Bi cipital groove
Subscapularis

In ferior glen oh umeral

li ga m ent, ant erior ba n d

An terior circum fl ex
humeral
Coracob rach
muscle and bi ceps
muscle, sh ort h ead

Bi ceps muscle, lon g

h ead dorsi

aJ C lavic le

Coracoacromi al
Trapezius

muscle
liga m en t

Su prascapu lar a. & n.

i n suprascapu lar notch
Lesser tuberosity

Subscapularis tendon Glenoid

Subscapul ari muscle

Deltoid muscle

Coracobrachia I
muscle and biceps
muscle, head
Biceps muscle, lo ng
head

(Top) Th e long head o f the bi ce ps tendo n is located in the bicipital groove. It o riginates fro m the sup raglenoi d
tubercle and labrum. The long head o f the bi ceps helps prevent humeral head im pingement o n the acro m ion during
delto id contrac ti o n. (Botto m) The subsca pula ris tendon inserts on the lesser tu be rosi ty. The teres major and
lati ssimu s dorsi tendo n s in sert just inferi or to the subscapularis tendo n.

58
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Trapezim muscle
C lavicle
Coracoacromial I.
Su praspinatus muscle

Del toid muscle, miclcl le

bell y
Suprascapu lar a. & n.
in no tch Su praspina tu s tendo n

Bi cipital groove
muscle

In ferior glenohumeral
ligament, anterior band
An terior circum! lex
h umera I vessels

Coracobrach ia Iis
mu\cle and biceps
sh ort h ead

Bi ce ps muscle, long
head
do rsi muscle

Trapezi u s

Clav icle
[M;
Coracoacromia l
ligament

a. & n.
in n o tch tuberosity

Glenoid Subsca pularis tendon

m u scle

Del toid m uscle

Coracobrachialis
muscle and biCeps
mu'>lie, short head
Biceps muscle, lo ng
h ead

Vl
(Top) Th e long h ead of the biceps tendon is located in the bici pi tal groove. It o riginates from the supraglenoid ::T'
tubercle and labrum. The long h ead of the biceps helps prevent humeral h ead im pin gem en t o n the acromion during 0
del toid contract ion . (Bottom) T h e subscapularis tendon inserts on the lesser tuberosity. Th e teres m ajo r an d c:
lati ssim us dorsi ten dons insert just i nfe rio r to the subscapularis tendon. 0..
ro
""''

59
 SHOULDER OVERVIEW
CORONAL OBLIQUE T 1 MR, RIG HT SHO ULDER

Trapezius muscle

0 C lavicle

Supraspinatus muscle
Coracoacrom ial
l iga m ent

Superior glen oid

Subscapularis tendon

Subscapulari s muscle
an d ten don

Deltoid muscle

Coracobrach ial is
muscle and biceps
Biceps m., long head muscle, short head

Cephalic vein

Trapezi us muscle
Coracocla vicu lar 1.,
C lavicle t rapezoid com pon en t

Co racoacromia l I.
Supraspi natu s muscle

Coracohumeral I. Coracoid p rocess

Subscapulari s tendon

Subscapu laris mu scle

Del toid muscle

Ax i ll ary vessels and

nerve

Coracobrach ia I is
mu scle and biceps
muscle, short h ead

Cephal ic vei n

(Top) The deltoid a nd trapezius muscles attach to th e scapu la r spine, latera l th ird o f clavicle a n d acromion. An terio r
compartment muscles are inne rvated by the musculocutaneous nerve. (Bottom) The axillary arte ry beco mes th e
brachial artery below the level of th e te res ma jo r muscle. On th is image the bundle stil l con sists of th e ax illa ry
neurovascu lar structu res. The b rac h ia l artery (not shown on this image) will course along the m edia l borde r of t he
coracobrach ialis muscle.

60
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Trapezius mu scle

Clavicle
Supraspinatus muscle
Coracoacromial
l igam ent

Superior glenoid

Subscapu laris tendon

Subscapularis muscle
and tendon

Deltoid muscle

(Top) The deltoid and tra pezius muscles attach to t h e scap ular spine, lateral third o f clav icle an d acromion . Ante rior
compart men t m uscles are innerva ted by the musculocutaneous nerve. (Bottom) Th e ax illary artery becomes th e
brachial artery below the level of th e teres major m uscle. On t h is i mage th e bun dle still co nsi sts of th e ax illary
neurovascula r st ructures. The brachial artery (no t sh own on t his image) wi ll cou rse along th e m edi al border o f th e
co racobrachialis muscle.

61
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, RIGHT SHOULDER

Trapeziw. m uscle

Clavicle

Coracoclavicul ar 1.,
trapezoid component
Cora,coid process
Coracoacromial l.
Subsca pul ari s tendon
Subscapul aris muscle

Deltoid muscle
Ax illary vessels and
ner ve

Bi cep s m ., long h ead Coracobrachi alis

muscle and biceps
Cep halic vei n muscle, short head

Trapezius muscle

C lavicle Co racoclavicular 1.,

con o id compon en t

Coracoacromia l I.
Coraco id process
Del toid m uscle

Subsca pularis mu scle

Biceps tendon, short

head

Ax illary vessels and

nerve

Cephal ic vein

Biceps muscle, long

h ead

(Top) The coracoclavicu la r ligam ent h elps main tain clavicul ar alignm e nt with th e acromi o n. The ligamen t has
t rapezoid and conoid po rtio ns. Th e tra pezoid portion has an oblique lateral cou rse from the medial ho ri zo n tal
coracoid process to the lateral end of t h e clavicle. The conoid portion has a nea r vertical course. (Bottom) The tip of
t he co raco id process is the site of origin for the coracobrachialis muscle, m ediall y, and t he short head o f bice ps
muscle, late ral ly.

62
 SHOULDER OVERVIEW
CORONAL OBLIQUE T1 MR, LEFT SHOULDER

Trapeziu s musc le

C lavicle

Coracoclavicul ar 1.,
trapezoid componen t
Coraco id process
Coracoacromia l I.
Subscap ulari s tendon
Subscapul aris muscle

Del toid muscle

Ax illary ve5sels and
n erve

Biceps mw,cl e, long

Coracobrachialis h ead
m u scle and biceps
muscle, sh ort head Cephali c vei n

Trapezius mu scle

C lavicle
Co racoclavicu lar 1.,
con oid componen t
Coracoclavicula r I.
Coracoid process
Deltoid muscl e

Su bscapu laris muscle

Bice ps tendon, sho rt

head

Axillary vessels and

nerve

Ce pha lic vei n

Bi cep s muscle, lon g

head

(Top) T he coracoclavicular liga m en t h elps ma in tain clavicu lar a lignment with the a cromion. The liga m ent h as
trapezoid and conoid po rtions. The tra pezoid portion has an oblique late ra l cou rse fro m th e med ial h orizontal
coraco id process to th e lateral e nd of t h e clav icle. Th e con o id portion has a n ear vertica l cou rse. (Bottom) The tip of
th e cora coid p rocess is the site o f orig in for th e coracobrachia lis muscle, media lly, and th e short head of biceps
muscle, Ia te ra ll y.

63
 SHOULDER OVERVIEW
SAGITTAL OBLIQU E T1 MR, RIGHT SHOULDER

Tra pezius muscle

Scap u la r spi n e
Supraspina tus muscle

Serratus ante rior

Delto id muscle m uscle

In fraspin atus muscle

Su bscapularis muscle

Te res m in o r muscle
Lung

Teres ma jo r mu scle

Latissim us dorsi mu scle

Tra p ezius muscle

Sca pul ar spine

Suprasp inatus muscle

Se rra tus a n terior

Deltoid muscle mu scle

Infraspinatu s musc le
Su bsca p ularis muscle

Te res m inor muscl e

Lun g

Teres m a jor muscle

Latissimus dorsi muscle

(Top) Fi rst o f 24 sequential sagitta l oblique Tl MR images o f the righ t sh oulde r di splayed media l to lateral. Images
we re obtai ned with a sh o ulder coi l on a 3T M R sca nne r. Image is far m edial, including a portio n o f th e lateral lung
and ch est wa ll. (Bottom ) The la tissimus dorsi muscle wraps around the inferi or aspect of th e teres m ajor muscle.
These two muscles ca n be difficult to differentia te as sepa ra te stru ctures. Each cou rses superiorl y a n d latera ll y to
insert o n the c rest of t he lesse r tuberosity.

64
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RIGHT SHOULDER

Trapezius muscle

Su p raspi natus muscle

Scapu la r sp ine
Su prasca pular vessels

Serratus a n terio r
Deltoid muscle
muscle

Infraspina tus muscle

Subscapularis muscle

Lung

Triceps muscle, long

head
Latissi mus dorsi muscle

Tra pezi us muscle

Supraspi n a tus muscle

Scap ular spine
O m ohyoid musc le

De ltoid muscle Serratus a nte rior

muscle

Infraspina tu s muscle
Subscapularis muscle

Te res m inor muscle

Lu ng

Triceps mu scle, long

La tissim us dors i muscle
head

(Top) The rota to r cuff muscles consist of th e su praspinatus, infraspi natus, te res min or a nd subscapu laris. All o f th e
rotator c uff muscles o riginate from th e scapul a. (Bottom) Th e omo h yo id muscle o rigi nates from the superior border
o f the scapu la. It has an in fe rior bell y and a supe rior bell y. The superior portion inserts on the lower border of the
hyoid bone.

65
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RIGHT SHOULDER

rrapezi ll\

capular
Supraspinatus

Suprascapular bran ch fossa

vessels

m uscle
Su bscapularis muscle

Teres m i n or muscle Scapula

long
head

Teres ma jor
Rib

Latissimu dorsi muscle

Lung

Trapezius muscle

capu lar spi ne

upraspi natus muscle

In fraspi n atus muscle Brachial plexus

Deltoid Axillary artery and vein

pos terior belly
Te res rn i n or muscle
Subscapu laris

m ajor muscle
Lymph node

l.atis\imus dorsi muscle

'I riceps muscle, long
h ead

(Top) Th e scapul a h as a Y-sha ped co nfiguration due to th e posteri or exten t of the sca pul ar spi ne. The supraspin atus
muscle is contai ned en t irely within t he crux o f th e "Y" and shou ld roughly fi ll t hi s area u n less the m uscle is
atrophi ed. (Bottom) A portion o f the trapeziu s muscle is seen at t he su perior aspect of t he shou lder. Th e trapezius
inserts on th e su perio r border o f th e lateral clav icle, the media l border of the acrom ion and t he superior border of th e
scapular spin e. Th e delto id originates at th e same osseous sites, adjace n t to the t rapezius, bu t on t he opposi te border
o f each o f the bo nes (i nferior border o f lateral clavicle, lateral border of acrom ion , i nferior border of cap u la r spi n e).

66
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RIGHT SHOULDER

Tra pezius m uscle

C lavicle

Sca p ula r spin e

Su prasp ina t us muscle

Suprascapular a n d te n don
n e urovascu la r bu ndl e
in sp inogleno id notc h

Infras pina tus muscle Bra c h ia l p lexus

Su bsca p u la ri s m uscle

Teres m in o r muscle

Axillary a rtery an d vein

Trice ps musc le, long
head

Te res ma jo r m u scle
Latissim us clorsi m uscle

Trapezius m uscle

C lav icle
Sca p ul a r sp ine
C o racoc la vicul a r 1. ,
Supraspina tus m . a nd t.
con o id co mpone n t

Subc lav iu s m usc le

Su prascapula r
neurovascular bund le
in spinog le n o id no tc h
In fras pinatus m usc le

Ax illa ry a rte ry and vein

Teres mino r muscle

Subscap u laris muscle

Triceps muscle, lo ng
h ead La tissimus dors i & te res
m ajor m uscles

Vl
(Top) T he subsca pu la ris m uscle fills t he subsca pu lar fossa o f t he sca pu la. (Bottom) The in fras p inat us a nd te res m in o r ::::r
muscles are loca ted be low t he sca pula r s p ine. Th e infraspinatus muscle is the la rger a nd is loca ted more s u pe rio rly 0
t ha n te res min o r. c::
0..
ro
"""t

67
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RIGHT SHOULDER

Trapezius muscle
lavicle

Scapu lar sp ine muscle

and tendon

capula body
muscle

Deltoid muscle

Teres mino r muscle

Subsca pularis muscle
Triceps tendon, lon g
head

Triceps muscle, long Latissimus dorsi & teres

head major

Trapezius muscle
Di tal clavicle
Coracoclavicu lar 1.,
Acromion process trapezoid component .

Supraspinatus muscle .. Thoracoacromial artery

branch

Infra pinatus muscle Coracoid process

Teres minor muscle Subscapularis muscle

Triceps, lo ng head, at
infragleno id tubercle

Deltoid muscle

Latissi mus dorsi & teres

major muscles
Triceps muscle, long --+--...,.;;;;
head

(Top) The supraspinatus, subsca pu laris, teres m i n or and i nfrasp inatus (clockwise) contin ue to course laterally. The
tendon s o f these muscles wi ll co njoin as th ey reach th e lateral aspect o f the humeral head. (Bottom ) The scapular
spine ends as th e acro mion process. The acromioclavicul ar joint is becoming visi b le. T h e neurovascular bundle lies
alo ng t he anterior surface o f th e subscapularis muscle.

68
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RIGHT SHOULDER

,\cromioclavicular joint

Acrom ion process Coracoclavicular

ligament, trapezoid
muscle compo nen t
and tendon
:====;--- Coracoid process
Infra pin atus muscle
Co njoined tendon

Glenoid fossa of

Teres minor muscle ubscapularis muscle

Coracobrachia lis

1 riceps muscle, long Latissi mus dorsi & teres

head major muscles

Acromioclavicular joint
Acromion process Deltoid muscle

Supraspina tus muscle

and tendon
Coracoid process

Cephalic vein
Subscapularis muscle

Teres minor mu scle

Labrum &
glenoh umeral
ligamen ts

Posterior circumflex
humeral vessels & In ferior glenohumeral
axillary nerve 1., axil lary po uch

Triceps m., long head Latissi mus dorsi & teres

major muscles
Deltoid muscle

Vl
(Top) Im age is at the level of the glen oid fossa o f th e scapula. The dark surround ing rim of th e glenoid labrum is ::::r
becoming vis ible. Th e coracoid process is the origin of the co racobrachi alis and short head of th e biceps tendon. 0
(Bottom) Th e glen ohumeral ligaments are seen as low signal bands of ti ssue surroun di ng the an terior, inferior and c:::
posteroi n fcrior aspects of the shou lder joint. The glenohumeral ligam ents stren gth en the join t ca psule. a.
ro
...,

69
 SHOULDER OVERVIEW
SAGITTAL O BLIQ UE T1 M R, RI GHT SHOULDER

Acrom ioclavicular joi n I Deltoid muKie

Acromion process Coracohumeral

l iga m en t
Supraspin atus m . and 1.

In fraspi n atus m . an d I. Ro tat or in terval

Biceps, short h ead
Subscapularis
Delt oid muscle

Teres mi nor muscle Hum era l head

and tendon

Posterio r circumflex Coracobrach iali' and

art ery & ax ill ary nerve biceps m ., l1 ead

Triceps m uscle, lateral Latissimus dorsi & teres

ll ead maj or

Triceps muscle, long

h ead

Acromioclavicu lar jo in t Deltoid

Coracoacromia l I.
Acro mion process
Cora cohumeral I.
Supraspinatus m . ancl t.

Biceps 1. , long h ead

I nfraspi na tus m . an d I.
muscle

Deltoid muscl e Humeral head

Teres mi nor
and te ndon
Coracobrachi alis an d
biceps 111., short head
Posterior circumflex
artery & ax illary nerve
Latissimus & teres
maj or

Triceps m uscle, latera l

head

(Top) Im age is at t he media l border o f t he h u meral head. T he posterio r ci rcum flex h umeral artery winds around t he
neck o f th e h u m erus to anastomose w ith th e anterior circumflex h u meral artery. (Botto m ) The rotator interval is a
triangular space bo rdered superi o rly by th e supraspi natus tendo n anteri o r ma rgi n, inferiorl y by t h e subscapularis
tendo n superior bo rder, media lly by t h e co racoid base and latera lly by th e long h ead o f the biceps tendon bicipi tal
groove.

70
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RIGHT SHOULDER

\ crom io n Coracoacrorn ial I.

Sup rilspi n atus ten don

Biceps t., lon g h ead

In fras pin atu s tendo n

tendon
De lto id muscle

minor tendo n
cphal ic vei n

Pectoral is m ajor muscle

Pmterior ci rcumflex An terio r circum flex
humeral artery and hum eral ar ter y
ax iII a ry nerve

I latera l Cora obrachial is and

h ead biceps musc le, sho rt
head
llumcral

Supraspi natus ten don

Coracoacro rnial I.

i\crom ion proce s

Supraspi natus an terior
direct ten don
upraspi n atus posterior
ten don obli que tendon

Bi ceps t., lo ng head

Delt oid muscle
ubscil pulari s tendo n

mino r tendo n
Deltoid m w.c le

:=="T- An ter io r circumflex

Po terio r ci rcum llex hu m eral vessels
humeral art ery and
axi l lary n erve
Pecto ralis m ajo r m usc le

·1 lateral
h ead

Vl
(Top) Th e lo ng head o f th e b ice ps tendon arises from the supraglenoid tu berosity at th e up per margin of th e glenoid ::::r
cav ity. On this image i t is seen coursi ng distally over th e humeral head, surrounded by a sy nov ial mem b rane sh eath . 0
The ten don traverses th e capsule through an opening nea r th e intertubercular groove. (Bo tto m ) A t the level o f th e c
m id hum era l head, th e del toid muscl e cove rs th e superfi cial aspect of th e shou ld er. 0..
ro
""'I:

71
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RIGHT SHOULDER

Coracoacromial
ligament
Acrom ion process

Supraspinatus tendon,
direct .componen t
Infraspinatus tendon
Supraspin atus tendon,
poste rio r obliqu e
D eltoid muscle compone nt

Teres min or tendon Subscapularis tendon

Deltoid muscle

Posterior ci rcumflex An terior circum fie"

humeral arter y and humeral artery
ax illar y n er ve

Pecto rali s m ajor muscle

Triceps muscle, lateral

head

Coracoacromial
ligament
Acrom ion process

Supraspinatus ten don

I nfraspinat us tendon Supraspin atus ten don,

posterior oblique
componen t

Teres minor tendon Subscapularis tendon

Deltoid m u scle

Posterior circumflex Anterior ci rcumflex

humeral ar tery and humeral artery
axi llary nerve

Pectoralis major muscle

Cephalic vein i n
del topectoral groove

(Top) Eva lua ting the m o rph o logic type of acro mi o n is best assessed o n th e first image la te ral to th e acromioclavicula r
joint. (Bottom) The rotato r cuff is predom inantly te ndin o us as it passes toward the late ra l aspect o f the hu meral
head. Th e tendons are beginning to fuse with each ot her a nd th e jo int cap sule.

72
 SHOULDER OVERVIEW
SAGITTAL OBLIQ UE T1 MR, RIG HT SHOULDER

Supraspin atus tendon

and join t capsule

In fraspinatus te ndon

Subscapul aris tendon

Teres minor tendon

Posterior circum flex

ar tery and axillary An terior ci rcumflex
nerve h umeral ar tery

Deltoid muscle

Supraspina tu s tendon
and joi nt capsu le

Infraspinatus ten don

Subscapularis tendon

Teres m i nor tendon

Posterior circu mflex

arter y and axi llary
n erve Lesser tuberosi ty

Deltoid muscle

V'l
(Top) Image is nea ring t he latera l aspect of the humeral head. Th e rotator cu ff t e ndons a re form ing a solid arc of :::::r-
ti ssue over the humeral head as they co n t in ue to cou rse late rally. O n t his T l-weigh ted seq uence, t he rot a to r c uff 0
tendons have hi gh er signal th an th e norm ally very low tendon signal due to m agic angle artifact. o rrna l tendon s::::
sign al can be confir med wi t h seque n ces acqui red using in te rmed ia te o r lon g TE. (Bottom) The rotato r cu ff tendons a.
are approaching th eir in se rtions on th e greater and lesse r tube rosities. ro
'""'

73
 SHOULDER OVERVIEW
SAGITTAL OBLIQUE T1 MR, RI G HT SHOULDER

upraspi nalu tendon

Infra5pinatus tendon

Teres minor tendon Subscapularis tendon

Biceps tendon, long

h ead

Supraspinatus tendon
Infrasp inatus tendon

Teres minor tendon

Deltoid muscle

(Top) The subscapularis tend on inserts on the lesser tuberosity and fo rms the roo f o f t h e bi ci pi tal groove. (Bottom)
The supraspinatu s, i nfraspinatus and teres mino r tendons insert o n th e greater tuberosity superior facet, midd le facet
and inferior facet respectively.

74
 SHOULDER OVERVIEW
SAG ITTAL OBLIQ UE T1 MR, RIGHT SHOULDER

Supras pinatus ten don

Infraspina tus tendon

Hume ra l head

Subc utaneous fa t
Deltoid muscle, latera l

Humeral head

De ltoid muscle, late ra l

Subc utaneous fat

(Top) Small portions of t h e su praspin atus and i nfraspinatu s t endons are sti ll visible i nsert i n g o n th e grea ter
tuberosity. (Bo tto m ) T h e fa r lateral, superficial aspect of th e should er is entirely covered by t h e m i dd le belly of
deltoid muscle .

75
 ROTATO R CUFF AND BICEPS TENDON
o An a to mic va ria nts
IImaging Anatomy • An om alo us intra-articular and ex t ra-articu lar
O verview o rigins from rota tor cuff and jo in t capsu le
• Ro tator c uff • May be bifid o r abse nt
o Consists of sup rasp in atus, infraspin atus, teres min o r o Ten d o n sh eath co mmu n ica tes with joint and
a n d subscap ul a ris m uscles an d tendo ns n o rmal ly contain s a small a mou nt of flu id
o Uni for m, h ypointense te n don s o n all seque nces
o C u ff te n do n s blend with sh o ulder joint ca psule
• Supraspin atus m uscle !Anatomy- Based Imaging Issues
o Orig in : Sup rasp ina t us fo ssa o f sca pula Imaging Recommend ations
o Inse rtio n: Su perio r facet (horizontal o rientation) a n d
• Radio gra phs: AP a nd supraspin atus o utle t views to
portion of mid dle facet of greater t uberosit y assess hum eral head position and t h us ind irectly assess
o Ne rve supp ly: Sup rascap ul ar ne rve
supraspin atus tendon
o Blood sup p ly: Suprascapular artery a n d circumflex
• MR: Best st ud y for eval uation o f rotator cuff
sca pula r bran ch es of subsca pula r a rte ry
o Tl sequen ces with o ut fa t sup pression h elpful for
o Actio n: Abductio n o f hume rus
eval uating muscle mass
o Ante rio r a nd posterio r muscle bellies • MR arthrograph y: Im proves eval uation of rota tor cuff
• Ante rio r bell y is large r, has ce n tral te n don an d is
a n d ca psulo labra l com plex
mo re li kely to tear
o Im proved visua li zatio n of c uff artic ul ar surface
• Poste rio r bell y is st rap- like & h as te rm ina l te ndon
o Most comm o n ly injured ro tato r cuff muscle Imaging Pitfalls
• Infraspinatus muscle • Increased signa l in su p rasp ina tus te n d o n
o O rigin : infraspinatus fossa o f scap ula a p p roxima tely 1 em from inse rtio n
o Insertio n: Middle facet greate r tuberosity o Presen t in asym ptomatic patients
o Ne rve su p ply: Sup rascapu la r nerve, distal fibers o Attri bu ted to m agic a ngle a rtifac t, te ndo n
o Blood supply: Suprascap ul ar arte ry a nd circu mflex degen e ra t io n, pa rtial vo lu me effect a n d posi tion ing
scapula r b ra nc hes of subscapu lar a rte ry a rt ifa cts
o Actio n : External rota tio n of h u merus a nd resists • Magic a n g le a rt ifact
poste rio r subluxatio n o In creased signal in collagen fi bers o rie nted 55° to
• Teres m inor muscle ma in magnetic field on short TE images
o Orig in: Late ral sca pula r bo rde r, m idd le half o Ca n occur in rota tor c uff a nd biceps te ndo n
o Inse rti o n: Infe rio r facet (vertical o rie n tation) o f o Recognize by co mpa ring with lon g TE images
h u merus greater • Pa rtial vo lu m e a veragin g
o Nerve supply: Ax illary ne rve o An te rio r su praspinatus m ay vo lume average with
o Blood supply: Poste rior circ um flex hu meral artery & flu id in subscapula ris bursa o r bice ps tendo n sheath
circ umflex sca pular bran ch es o f subscapular a rte ry simulating tea r
o Actio n: Externa l rotatio n of h um e rus • Avoid excessive ex ternal ar m rotat io n
o Least com mon ly in jured rota to r cuff m uscle o Po sterio r oblique fibe rs o f su pras p ina t us attac h deep
• Su bscapula ris muscle to ove rlapp ing an terior fibers of in fraspin atus; cuff
o Ori gin : Subsca pu lar fossa of scap ula may a pp ear th in in th is zon e, so meti mes with
o In sertio n: Lesse r tuberosity and up to 40% may increased li n ea r signal
inse rt at surgical neck • Most pronounced w it h in ternal arm rotatio n
o Nerve suppl y: Subscapular n erve, upp er a nd !.o wer o Mid supraspina t us m ay average with thi cke ned
o Blood su pp ly: Subscapu laris artery regio n o f humeral h ead cartilage
o Actio n : Inte rnal rotatio n of hum erus, also o Ten do ns m ay average with norm al va rian t muscle
adductio n, ex te nsion, depression and flexion sli ps extending abo ve o r belo w te ndo n
o 4-6 te n don slips converge in to main ten do n; • Fo llow m uscle sli ps back to the m uscle belly
multipe n n ate mo rph o logy increases st rengt h • Mo tio n a rtifact
• Rotator c uff tendon blood sup p ly o Recognize by propagation across image in phase
o Derived fro m ad jacen t muscle, bo n e and bursae e n coding direction
o Nor ma l h ypovascula r region s in tendons • Dila ted vei ns in su praspinatus muscle
• Termed "critical zo ne" o Usuall y in t h e pe riphe ry o f m uscle
• Vu ln erable to degenerat io n o May si mulate intramusc ular ganglion cysts
• Howeve r, not the most commo n region of tearin g • Interruptio n of su bacro mial-subd elto id fa t pla n e
• Bice ps tendon, long h ead o Fat p lane is su perficial to bursa
o Low sign al intensity on all seq uences o Can be in te rrupted or abse nt in n o rm al patients
o Origin: Supe rior g le n oid labrum o Not a relia ble sign of rota to r cuff a bno rmality
• Po rtion s may attach to sup ragle noid t u be rcle, • Inc reased sig n a l in la tera l b icipita l g roove
a nte ro supe rior la bru m, posterosuperior labrum o Due to ante rol ateral bra n ch of an terior circu mflex
and coracoid base hum eral a rte ry a nd vein
o Co urses thro ugh supe rior shoulder join t to o Do n o t con fuse wit h fluid from te n osyn ovitis or
inte rtuberc u la r o r bicip ita l groove ten don tea r
o Ac ti o n: Stab ilizes a n d d epresses h umeral head

76
Vl
::r
0
c
c..
ro
"""

77
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS M R, RIG HT S HOULDER

Trape7ius muscle

Clavicle

Scapu lar
Su praspina tus muscle
and te n don

Sup ra'>pina tus fossa

Suprascapul a r branch
vessels

Infraspinatus muscle
Subscapularb muscle
Deltoid muscle

Te res m ino r muscle

Scapulil

Rib
Teres major
Lung

Trapezius muscle
Clavicle

"V" of coracoclilvicu la r
Scapular spine ligamt•n t a tt achmen t to
coracoid

muscle
and tendon in
supraspina tm fmsa
Infraspinous muscle

Subscapu larb muscle

Deltoid

Teres min o r muscl e

Triceps muscle, long

h ead
muscle

Teres major musc le Lung

(Top) First of eigh teen sequential sagittal oblique T2 FS MR images of the right shou lder displayed med ia l to lateral.
Images were acquired at 1.5 T w ith a shoulder coil. (Bottom ) T h e su p raspinatus muscle fills the supraspinatus fossa
o f the scapula. Th e normal muscle shou ld fi ll or extend slightl y above a lin e drawn along the top border of th e Y of
the scapula. W h en the muscle atrophies, th e muscle w i ll be replaced by fat. With atrophy, the supraspinatus tendon
may become eccen tric in location, approaching the superi or border o f the muscle.

78
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, R IGHT SHOULDER

Trapezi u s musc le

Clav icle

Scapular spin e
muscle
and tendon

Suprascapula r
neurovascular b undl e

lnfraspinatm in
fmsa Subscapularb muscle

Teres minor

Triceps mu scle, long

h ead

dorsi muscle
Teres major muscle Lung

Clav icle
muscle
Coracoclavicular 1.,
Scapular \pin e trapezo id com ponent

Su praspi natus m uscle

and tendon

n eurovascular bundle

In fraspin atus muscle Subscapularb muscle

Axi llary vei n

Teres m i nor mu scle
Axi llary ar tery

·1riceps muscle, long

h ead

Lati ssimu s do rsi muscle

Teres majo r muscle
Lung

(Jl
(Top) Th e infraspinatus muscle fi lls th e in fraspinatus fossa of th e scapula. A n ormal infraspinatus muscle should fill :::r
the fossa and ex tend posterior to a line drawn from from th e posterior aspect o f the scapular spine to the inferior 0
border of th e scapula. Infraspina tus muscle atroph y m ay occur in the absence o f tendon abnormality. (llottom) Th e c:
normal subscapulari s muscle should fill th e subscapular fossa. Th e muscle sh ould have a convex anterior bo rder. 0..
('t)
""''

79
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

Trapezius muscle

Acrom io n process
u praspi na tus muscle
and tendon

Sca pu la body
Infraspinatus muscle

muscle
Deltoid muscle

Teres min or muscl e Axi llary artery

Triceps muscle, long

head

Teres majo r muscle

Latissim us dorsi muscle

Trapezius muscle C la vicle

Acromion process Thoracoacrom ial

vessels
Supraspinatus muscle
and tendon
Infraspi natus muscle
Coracoid process

Subscapularis muscle
Deltoid muscle
Labrum
Teres minor muscle
Glen oid fossa of
scapula
Triceps mu scle, long
h ead

Infraglenoid tubercle

Latissimus dorsi & teres

major muscles

(Top) The teres muscle lies infe rio r to th e infraspinatus mu scle. It assists in exte rna l rota t ion o f hume rus. The te res
m inor also resists poste rio r subluxation of th e hume ra l head. (Bottom) All o f the ro ta to r cu ff muscles o rigin ate from
the sca pula a n d inse rt o n t he humera l head.

80
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

C lavic le
Acromi oc lavicular joi nt
Th oracoacro mial artery
Acromion process bran ch

Biceps an chor
Supraspina t us muscle
an d ten don
I n fraspinatus m uscle
Coracoid process
Subscapulari s mu scle
Deltoid m usc le
Labrum
Teres m i no r m uscle

G lenoh umeral joint

Trice ps muscle, long Neurovascular bu ndle

head

Latissimus dorsi & teres

m ajor muscles

Del to id muscle
Acrom ioclavicu lar join t Thoracoacromi al artery
branc h
Acro mion process
Bicep s t., long head
Supraspinatu s m. and t.

Coracoid process
Infraspina tus muscle

Subscapularis m uscle
Del toid m. and t.

Teres m i nor muscle M iclclle ancl i nferior

glenoh umeral
ligamen ts

Coracob rachi alis

m u scle
Triceps mu scle, long
h ead
I n ferior gl enohumeral
liga m ent, axi llar y
Latissimu s dorsi & teres pouch
majo r

fJl
(Top) Image is through the level of th e glenohumera l jo int. Th e long h ead of the triceps muscle originat es from th e :::::r
inferior border of the gle noid . ( Bottom) The g le no id la brum and glenohumeral ligaments provide su ppo rt fo r the 0
humeral head in the somew hat shallow bony glenoid fossa . c
0..
I'D
""'

81
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

Trapezi u s muscle C lavicle

Acrom ion p rocess

Suprasp inatus muscle
and ten don

Scapula body
In fraspinatus musc le

Subscapul aris muscle

Delto id m u sc le
Axilla ry vein

Teres minor muscle Axi lla ry artery

Triceps musc le, lo ng

h ead

Teres m ajor muscle

Latissim u s do rsi muscle

Trapezius muscle Clav icle

Acro m ion process Thoracoacrom ia I

vessels
Supraspinatus mu scle
and tendon
In fraspin atus muscle
Coraco id process
Subscapul a ris m uscle
Deltoid muscle
Labrum
Te res minor mu scle
Glenoid fos sa o f
scap ula
Triceps muscle, long
head

In fraglenoid tu bercle

Latissimus do rsi & te res

m ajor muscles

(Top) The teres m uscle lies inferior to t he infraspinatus muscle. lt assists in external rotati o n of hum eru s. Th e teres
minor also resists posterior subl uxa tion of the humeral head. (Bottom) All o f th e rotator cuff m uscles origina te fro m
the sca pula and insert on th e hum e ral h ead.

80
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

C lavicle
Acromi oclavicular joint
Tho racoacromial artery
Acromion process branch

Biceps ancho r Supraspin atus mu scle

and tendon
In fraspi natus mu scle
Co raco id process
Subscapu laris muscle
Delt oid muscle
La brum
m in or muscle

G leno humeral joint

Triceps long Neurovascular bundle

head

La tissimus dorsi & teres

major muscles

Del to id muscle
Acromioclavi cular joint T h oracoacrorn ial artery
Acromion process bra nch
Biceps t., long head
Su praspinatus m. and t.

Coracoid process
Infraspinatus muscle

Subsca pularis muscle

Deltoid m. and t.

Teres m i nor m u sclc M iddle and inferio r

glen ohumeral
ligaments

Coracobrachiali s
muscle
Tri ce ps muscle, lon g
head
In ferior glen oh um eral
l igamen t, axillary
Latissimus dorsi & teres pouch
major muscles

fJ)
(Top) Image is through th e leve l of th e glen ohumeral joi nt. T he long head of th e t riceps muscle originates from the ::J""
in ferior bord er o f th e glen oid. (Bottom) Th e glen oid labrum and glen ohumera l ligaments provide suppo rt for the 0
humeral h ead in th e so mewhat sh allow bon y gleno id fossa. c::
0..
ro
""''

81
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

Acromioclavicular joint Deltoid muscle

Acromion process Supraspi n atu s muscle
and tendon
Biceps t ., long head
Rotato r interval
I n fraspinatus m uscle
and tendon Superior glenohumeral
ligamen t
Subscapularis muscle
Del toid m . and t.

Teres minor muscle Hum eral head

and tendo n
I nferior glen ohumeral
1., ax illary pouch

Posterior circum flex a. Coracobrachiali s an d

and axillary n. biceps muscle, short
head

Triceps m., long head

Latissi mus dorsi & teres
m ajor muscles

Del toid m uscle

Acromion process
Supraspinatus muscle
and tendon

In fraspi natus muscle

Bice ps tendon, long
and tendo n
h ead

Subscapu lari s musc le

Delto idm. and t. and tendon

Teres minor muscle

H um eral head
and tendon
Pectoral is major muscle

Posterior ci rcumflex I n ferior gleno hum eral

humera l artery and 1., axi llary pouch
axill ary nerve

Tri ceps muscle, l on g Latiss imus dorsi & teres

head ma jo r m u scles

(Top) The rotator in terva l is a triangu lar space betwee n the supraspinatus a nd subsca pularis te ndon s. The lo ng head
o f the biceps traverses t h e rotator inte rva l. The coracohume ral liga me nt a nd superior gleno hume ra l li game nt provide
support for the lo n g h ead of the biceps tendon in the rotator interval. (Bottom) The lo ng h ead of the b iceps in thi s
region is intra-articular but ex trasy novial.

82
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

Su nat us tendon

Coracoacro m ial I.
Acromion process
De lto id muscle
Join t capsul e
t., lon g head
Infraspi natus tendon
Superior glenohumeral
ligament
Subscapularis ten don
Deltoid muscle

reres minor tendon

Pectoral is major muscle

Posterior ci rcum flex

Anterio r ci rcumflex
humeral artery and
h um eral vessels
axi ll ar> ner\'e

Triceps m., lateral head

Coracobrachialis and
biceps m ., sh ort head

llumeral shaft

Coracoacrom ial I.

Acrom ion process ten don

De ltoid
Infraspinatus tendon
Con vergen ce of
co racohumeral
ligam ent & biceps
Delt oid muscle
Subscapul aris te ndon
Teres minor tendon

Pectoralis major muscle

ci rcumfl ex
Anterior circumflex
humera l artery and h u m era I vessels
axillary nerve

Coracobrachial b and
Triceps muscl e, lateral
biceps muscle, short
h ead
head

llu nwral sh aft

V'l
(Top ) As the images m ove laterall y, the superior glenohumeral ligament will form an anterior sli ng around the long ::::r
head o f the biceps t endon, along with th e coracohumeral liga ment. (Bottom) The rotator cuff is becoming 0
progressively tendinou s. c
0..
t'tl
"""t

83
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

Acromion process
tendon
and joint capsule

Infraspin atus tendon

'
Deltoid musc le

Teres minor tendon

Subscapu laris tendo n

Deltoid muscle

Posterior circumflex Latissimus dorsi

artery an d axi llary tendon
nerve

Coracobrachi al is and
biceps muscle, short
Triceps muscle, la tera l head
head
llumeral shaft

Supraspinatus tendon
Del toid muscle and joint capsu le

tendo n

Del to id
Teres mino r tendon

Sub ca pul aris tendon

Posterior ci rcumflex Ceph ali c vein

artery and ax i llary
nerve
=:=;--- An terior ci rcumfl ex
humeral vessels

Coracobrach ia lis and

Triceps muscle, lateral biceps muscle, short
head head

(Top ) The ro ta to r cuff tendons fuse w ith th e jo int capsu le. The co racoh um era l ligament fuses with th e su praspi n a tus
a nd subscapularis ten dons, span n ing th e ga p be tween th e two te ndons . (Botto m) Anterior and posterior circumflex
humeral vessels an as tomose at t he la teral aspect o f th e h u me ral neck.

84
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIG HT SHOULDER

Supraspinatus tendon,
posterior obl ique
compon en t
Deltoid muscle
Supraspi n atus tendon,
I nfraspinatus tendon anterior direct
componen t
Del toid muscle

Teres minor tendon

Subscapularis tendon

Poste rior circumflex

artery and axi llary An terior ci rcumflex
nerve humera l vessels

Pectora I is ma jor muscle

Triceps lateral
head

Supraspi n atus tendon

Deltoid muscle
In fraspi natus tendon Biceps tendon, entering
bicipital groove

Deltoid musc le
Teres minor tendon
Subscapul aris ten don

Posterior circumflex
artery branches

Biceps tendon, long

head (ex lraart icular)

rriceps muscle, lateral

head

(Top) Th e rotator cuff is entirely te ndin o us at this level. Indi vidual tendo ns have fused together. The supraspi natus,
infraspina tus, te res min or and subscap ula ris tendons can be in fer red by their loca tion and insertion o n the humeral
head. (Bottom ) The deltoid muscle cove rs th e superficia l as pect o f t he sh oul der a nterio rly, laterally a nd posteri orly.

85
 ROTATOR CUFF AND BICEPS TENDON
SAGITTAL T2 FS MR, RIGHT SHOULDER

Supraspina tus tendon

In fraspi na tus tendon

Teres minor tendon Subscapulari s ten don

circumnex Biceps tendon, lon g

artery branches head (extraart icu lar)

Deltoid

Supraspinatus tendon

Infraspinatus tendon

Subscapularis tendon

Biceps tendon, long

h ead (extraa rticular)

Deltoid muscle
Deltoid

(Top) The re are t h ree fa cets of th e grea te r tuberosity. The superio r facet is ho rizon tall y oriented. The midd le face t is
oblique ly o riented . T h e inferior facet is verti ca lly orie nted . The supra spinatus, infraspinatus and te res mi nor tendons
insert o n the superior, middle and inferior facets of t h e greate r tuberosity respectivel y. The su praspinatus partially
inserts on the middle face t, as as we ll as o n the superio r face t. (13otto m ) The subscapu laris te ndon inserts o n th e
lesse r tuberosity.

86
 ROTATOR CUFF AND BICEPS TENDON
MR IMAGING PITFALL, INCREASED SIGNAL IN SUPRASPINATUS TENDON

Distal clavicle

Supraspinatus te ndo n
with foca l a rea of Supraspina tu s muscle
increased s ig n al

G le noid

Biceps ten don, long -+-------'-':,..._..:........:

h ead Subscapu laris muscle
and te ndon

Dis ta I clavicle

Sup rasp ina tus tendon

witho ut co rresp onding Suprasp inatu s muscle
ab normal ity o n T2 MR

G leno id

Biceps tendo n , long

h ead Subsca pularis muscle
a n d tendon

(Top) First of two coronal oblique images throug h th e sa me level in the same pa tient. Image is p rot o n den sity
weighted w ith a TE o f 11. A focal area o f increa sed signal in the supraspinatus t e ndon is located approximate ly 1 em
from th e inse rti o n o n the grea ter t u berosity. (Bottom) lmage is T2 weighted with a TE of 93. Th ere is n o
correspo nding abn o rma l signa l on thi s seque n ce. Abno rma l signal in this a rea of the supraspi natus tendon h as been
attributed to ma ny diffe rent entities incl uding magic angle artifact, t e ndon degen e ration and partial volume effect.
The resolu tio n of the abnormal signal wh en th e TE of th e seq ue n ce was in creased favors mag ic a ngle artifact.

87
 ROTATOR CUFF AND BICEPS TENDON
MR IMAGING PITFALL, OBSCURED SUBACROMIAL-SUBDELTOID FAT PLANE

Subacromial-subdeltoid Acromion
fat plane

Supraspina tus muscle

Obscured portio n o f
subacromial -subdel toid
fat plane

Glenoid

Subacromia l-subdel toid Acromion

fat plane

Supraspinatus muscle

Obscured portio n of
subacrom ial -subdelto id
fat plane

Glenoid

Deltoid muscle

(Top) First of two coronal o bliq ue images in the sam e patie nt de monstrati ng a part ia ll y obscured
su bacro mia l-su bdeltoid fat plane. T1 MR image shows the h ig h signa l fat plane to be pa rtia lly abse nt adjacent to t he
sup raspina tus tendon insertion on the grea te r tu be rosity. This fa t p la ne is norma ll y located superficiall y a long the
course of the bursa. Absen ce of this fat pla ne h as been described as an in d icator of in jury or infla mmat io n in the
surro undin g soft ti ss ues. This sign is incon siste ntly seen. The fat pla ne m ay be co mpl etely or partia ll y abse nt in
norm a l patie n ts. (Botto m ) Corona l oblique T2 FS MR image is obta ined at the same loca tion as t he prev iou T l MR
image. The area whe re t he fat p lane is absen t shows no increased sign a l to indi ca t·e injury or in flammation.

88
 ROTATOR CUFF AND BICEPS TENDON
MR IMAGING PITFALL, VESSELS IN BICIPITAL GROOVE

An terola tcra I bran ch,

anterio r ci rcumflex
humeral a. & v.
Biceps ten don, long
head

Gleno id

min or muscle

Deltoid muscle
Anterolaterul branch,
anterio r circumflex
humeral a. & v.

Bi ceps tendon, long

head

Subscapul aris muscle

Glenoid
minor muscle

Vl
(Top) In creased signal w ithin latera l aspect of bicipital groove o n axial T2 FS MR image. The anterolateral bra nch of :r
the an teri or circumflex humeral artery and vein lie withi n th e groove. Th ese vessels should n ot be co nfused with 0
fluid fro m ten osyn ovitis or a tear of the biceps tendon. (Bottom) Co mpanion case sh o wing the an tero lateral branch c
of the anteri or circumflex humeral artery and ve in within lateral aspect o f bici pital groove on axial T2 FS MR image. c..
ro
-:

89
 ROTATOR INTERVAL
• Medial: Tubula r, anterior to LBT
!Terminology • Mid port ion: Fla ttened anterior band with
Abbreviations T-s haped connection to C IIL
• Coracohumera l ligament (CHL) • Lateral: Fuses wit h C HL to form sli ng around LBT
• Superio r g le no h umeral ligament (SG HL) o On axia l images, may be see n as band anterior to
• Lo ng head, biceps ten do n (LBT) biceps ten don
o Optimal imaging plane: Sagittal oblique MR
arthrogram or MR with jo int effusion
11maging Anatomy • Biceps te ndo n, long head
o Origin : Superior g lenoid labrum
Overview • May also have origin from supraglenoid tubercle,
• Triangular space be twee n supraspin atus a nd rota to r cuff, joint capsu le and coracoid base
subscapu laris te n dons o Co urses through· su pe rior shoulder joint to
o Base of triangle a t coracoid process intertubercular o r bicipital groove
o Tip of triangle at transve rse ligament • Traction zone: Intra-articular, extra-syn ovial,
• Borde rs o f rotator interval tendon h istology
o Med ial extent: Coracoid base • Sliding zone: Con tacts hu merus, fibrocart ilage
o Lateral extent: Entrance to bicipital groove, histology
transverse ligament o Action: Stabi lizes and depresses humera l head
o Floor: Hu meral head ca rtilage o Uni fo rm low signa l intensity on all sequences
o Roof: Jo int capsu le Other
• Co raco humeral liga ment on bursal su rface
• Lower rota tor in terva l
• Fasciculus obliq uus o n articular surface o Separate e n tity from the classic rotato r interval
• Synovia l lining
described above
• Co ntents of rotator interval
o Located between teres min or and subscapularis
o Coracohumeral ligament
te n dons
o Superio r g le n o h um e ral ligament
o Instabi lity may d isrup t this region
o Biceps tendon, lo ng head
o Encompasses the ax illary sling
• Coracohum e ral liga ment a nd superior gle n o hum e ral
ligament stab ilize long head of biceps te ndo n as it
e nte rs b icip ita I groove
!Anatomy-Based Imaging Issues
Internal Structures-Critical Contents
• Coraco humeral ligament
Imaging Recommendations .
o O rigin: Base o f co racoid process • MR: Sagittal obliq ue T2 FS images to accentuate flllld
o Insertion: Lesse r an d greate r tuberosi ti es, hum erus in rotator interva l
• Fo rms two bands laterally • MR a rthrography (d irect)
• Large r inserts o n greater tuberosity a nd o Best im agi ng study for rotator interva l
supraspinatus anterio r border o Sagittal o blique T1 arthrogram
• Smaller ba nd inserts on lesse r tuberosity, • CT arthrography: May be useful for patients wit h
transverse ligament a nd su pe rior subscap ul a ris co ntraindication to MR
te ndon Imagin g Pitfall s
o Histologica lly more similar to a ca psule t h a n a • Syn ovium a nd ca psule m ay h e rn iate in to inte rva l
true ligam e nt o Present in asymptoma tic sh oulders
o Blends wi t h su perficia l and deep layers of ro tator o Ca uses foca l fl uid signal in tens ity
c uff te n dons and join t capsule o Ma y simulate tear
o Forms a solid layer o f tiss ue between supraspina tus • Ia t rogen ic d is ruption of rota tor in terval
and subscap ularis tendons o Arthrosco pic surgery with p robe placed thro ugh
o Cove rs the intra-articula r portion of LBT rotator interva l
o Opti mal imaging plane: Sagittal o blique but should o Arthrogra p h y using a rotator in terval approach
be visible in all p lanes
o l lomogeneous low signal on all sequences
o Can not be differentiated from sup rasp inatus a nd
subscapu laris tendons where it is fused
IClin ical Implicat ions
• Supe rior g le nohume ral ligamen t Clinica l Importance
o Origin: Superior tubercle of gle n o id, anterior to • Provides passive should er stability
biceps • Injury to one structure associated with injuries to
o Insertion: Superolatera l lesser tuberos ity, deep to othe r structures w ithin rota to r interval
su perio r bo rde r of subscapularis tend o n • Rotator interval in jury predisposes to add itional
o May not be possible to differe nt iate from inj u ries due to hume ral head in tab ility
coracohu mera l liga ment in absence
intra-artic ula r contrast or joint effusion
o Changes co n figu ratio n through course of interval

90
(J)
:::r
0
c:
a..
(0
'""I

91
92
 ROTATOR INTERVAL
SAGITTAL T1 FS ARTH ROG RAM, RIG HT S HOULDER

Acromion
Lon g head biceps tendon

Supraspin atus ten don

ten don Coracoh um era l l igam en t

Superior glenohumeral I.

Subscapular recess

Su bscapularis tendon

m in or tendon

Coracobrach ial is & biceps

ten don, sh o rt h ead

Acrom ion
Lo ng head biceps ten don

Coracohumeral ligament

Superior glen o humeral

l igamen t

Subscapul aris tendon

Teres m i no r tendon

Co racobrachial is & biceps

tendon, sho r t h ead

Acro m io n
Lo ng h ead biceps te ndon

Superior gleno humeral

ligam en t

Subscapulari s tendon
Teres minor tendon

Coracobrachialis & bicep'

ten don, sh ort h ead

V'l
(Top) First of three sagitta l oblique T l FS M R arthrogram images o f the righ t shou lder. Images are d isp layed m edial to ::T
lateral. The sagitta l oblique pla ne is th e optimal plan e for eval uati ng th e rota tor in terval. These i m ages were ch osen 0
to match th e cross section grap h ics on t h e prior page. T he co racohumeral ligamen t form s th e roof of t h e rotator c:
interval on all three images. (Midd le) The su perior glen ohumeral l igament has aT-shaped junction w i t h the 0..
co racohu meral l igament at th e mid porti on o f th e ro tator interva l. (Bottom) At t he lateral aspec t o f th e rotator
ro
'"'I
interva l, th e su peri or glenohum era l ligam ent form s the i n fe ri or po rtion of the sl ing arou n d th e long h ead of the
biceps tendon.

93
 ROTATOR INTERVAL
AXIAL T2 MR ARTHROGRAM, ROTATOR INTERVAL

Biceps tendon, lon g head

Coracohumeral ligament

Supraspi natus muscle

Biceps tendon, lon g head

tendon
..--=::::;;--- Coracoacromial ligament
Coracohumeral ligamen t
Superior glenoh um eral I.

Superior gleno id labrum

Infraspin atus muscle & tendon

Supraspinatus muscle

Biceps tendon, long head

Coracoacrom ia l ligamen t
Supraspinatus tendon

;;=:;;:;;;.- Coracohumeral ligamen t

==:;- Superior gle no hu mera l I.

Sublabra l foramen

G lenoid
Infraspinatus muscle & tendon --ii--':;';

(Top) First of t hree co nsecu tive axial T2 M R arthrogram images through the rotato r interval. Axial im aging is no t the
optimal plan e for eva luating the rotator interval, b ut ca n be useful. The long head of t he biceps tendo n is een
traversing th e supero medial h umeral head. (Midd le) Th e superi or glen ohumeral liga ment has a roughl y pa rallel
course to the lo ng h ead of t he b iceps tendon o n axial images. (Bottom ) The superio r glenohumeral ligament fuses
w i t h the coracoh umeral ligam ent. These i n turn w ill fuse with the joi nt ca psule and rotato r cuff tendo ns. These
images are T2W I and have i ntra-art icula r contrast. Th e fat and bon e ma rrow are near the in ten sity of a Tl WI study
due to a relati ve ly short TE.

94
 ROTATOR INTERVAL

Coracoacromial ligament Coracoclavicul ar ligamen t,

cono id componen t
Co raco humeral ligament &
joi n t capsule
Su praspi nat us tendon
Superior labrum & superior
Biceps tendon, lon g head glen oh umeral ligamen t

Subscapu laris musc le

Delto id muscle

Coracoclavicu lar ligament

Coracohumeral ligamen t &
joi nt capsule

Superio r glenoh umeral I.

Bicep \ tendon , lo ng head

Ant"erio r glenoid labrum

Subscapul aris muscle

Del toid muscle --+--==

Coracoclav icular ligamen t

Coracoh um eral ligamen t

Superior glenohum era l I.

Supraspinatus tendon

Anteri o r gleno id labrum

Del toid muscle Subscapulari\ muscle

(Top) First o f three con secutive co ronal o blique T2 MR images through the rotator inte rva l. Im ages are di splayed
poste rior to ante ri o r. The ro tator inte rva l is bes t eva lu ated in the sagittal obliq ue plane. (M iddle) Th e lo ng head o f
th e biceps te nd on is exiting the rotator inte rva l as it enters the bicipital g roove. (Bottom) In a n y pla n e, it may be
di ffi cult to se pa rate the superi or g le n o hum e ra l ligament, co ra co hume ra l ligament , joint ca ps ule a n d rota tor cuff
tend o ns, es pecially at th e anterolateral aspect of the ro tato r inte rval.

95
 ROTATOR INTERVAL
SAGITTAL T1 FS MR ARTHROGRAM, RIGHT SHOULDER

Distal clavicle

Sca pul ar sp ine Deltoid

Supraspi na tus muscle Coracohum era l I.

& tendo n
Coracoid process
Rotator int er val
In fraspinatus muscle
Subscapular recess

Subscapularis m uscle
Deltoid m uscle

Labrum &
Teres m i nor muscle & gleno humeral
tendo n l igam ents
In ferior glenohumeral
ligam ent compl ex,
axillary pouch
=;:;:;:;-- Latissi mus dorsi & teres
ma jor muscles
Triceps muscle, long
head

Del toid mu scle

Supraspinatus mu scle
& ten do n Coracoh u m er aI
ligament

Rotator interval
Infraspi n atu s muscle &
tendon
Subscapularis muscle

M iddle glenoh um eral

Deltoid muscle l igament

Teres m in o r muscle & In ferio r glen oh um eral

tendon ligamen t, anterior band

Latissimm dors i &: teres

maj or
Triceps muscle, long
h ead

(Top) First o f twe lve sagittal oblique Tl FS MR arthrogram images o f the ri gh t sh o ulder d isplayed m ed ial to la te ral.
Im ages we re acq ui red a t 1.5 T wit h a sh o uld er co il. This image is thro ugh t h e leve l o f the gle no hum eral join t. The
gle no id labrum fo rm s a n oval low signal band aro und t h e m edial aspect of th e hume ral h ead. (Bottom) The ro tato r
inte rva l is the space be twee n the sup raspinatus a nd subscapularis te ndo n s. The medial exte nt is th e coracoid process.

96
 ROTATOR INTERVAL
SAGITTAL T1 FS MR ARTHROGRAM, RIGHT SHOULDER

Del toid muscle

Acromioclavicular join t
Acromion process Biceps t., lo ng head
Supraspinatus m. & t.
Co racohu meral I.

Su perior glenohumeral
Infraspina tus m. & t. ligamen t
Subsca pulari s m . & t .

Deltoid mu scle

Middl e glen oh umeral

liga ment
Teres min or m . & t.

Coracobrachialis &
biceps m ., sh ort head

La tissimus dorsi & teres

majo r muscles
rriceps m ., lateral head

Acromi on process Bi ceps t., long head

Su pra pi natus tendon

Coracohumeral I.

Superior glenohumeral
Infraspinatus tendon ligament

Subscapula ris tendon

Deltoid muscle

Middl e glen oh um eral

Teres mi n or tend on
ligam en t

Coracobrachialis &
l"riceps muscle, lateral biceps m., sho rt head
head

Pmterior humeral
cortex

fJ)
{Top) The superior glenohumera l ligament has aT-shaped connecti on with the coracoh umeral l igament at this level. :::J""
(Bottom) Th e coracohum era l ligament form s the roof of t he rota tor i nterval. Port ions of th e coracohumeral ligamen t 0
fuse with th e joint capsule, supraspi n atus tendon and subsca pularis ten dons. Note t hat at th i s level th e c:
coracohumeral l iga m en t ex ten ds to t he articu lar surface o f supraspina t us and is med ial to t he origi n of t h e m ore c..
superficial co ra coac romia l ligamen t (sh own on t h e n ext lateral image). ro
'""'

97
 ROTATOR INTERVAL
SAGITTAL T1 FS MR ARTHROGRAM, RIGHT SHOULDER

tendon
Acro mi o n p rocess
Coracoacromial I.
attach ment to distal
coracoid
Coracohumeral I.

Biceps t., long head

In fraspinatus tendon

Superior glenoh umera l

I. fused to capsul e
Del toid m uscle
Subscapu laris tendon
Teres m in or tendon
Del toid muscle

Cephalic vein

Triceps muscle, latera l

h ead

Acro mion process Coracoacrom ia I

ligamen t

Supraspina tu tendon

Coracohumeral I.
In fra spin atu s tendon
Biceps t., long head

Delto id m uscle Subscapularis tendon

Teres mino r tendo n Delto id muscle

Triceps m uscle, la tera l

head

(Top) The lo ng head o f th e biceps tendon co u rses over th e to p o f th e hum eral head. (Bottom) The fl oor of the
ro tato r interva l is the humeral head ca rtilage.

98
 ROTATOR INTERVAL
SAGITTAL T1 FS MR ARTHROGRAM, RIG HT SHOULDER

Coracoacromial I.
Acrom ion process
Supraspinatus tendon

Biceps t. , long h ead

Coracohum eral I.

Su peri or gleno hum eral

tendo n I. fused w i th capsule

Subscapulari s tendon

Deltoid muscle
min or tendon

l'm terior circumflex

humeral artery &
ax illary n erve
Cephalic vein in
deltopectoral groove

Pectoralis ma jo r muscle

Supraspi natus te ndon

Co racoacromia l I.

Coracohumeral I.

Biceps tendon, lon g

tendon h ead

Subscapularis tendon

rninor tendon

Poste rio r c i rcu rn flex

artery & ax i l lary n erve

Cephalic vein in
del topectoral groove
Delto id muscle

(Top) The rotator cuff becomes progressive ly tendinous as it ex tends latera lly. (Bottom) The cuff tendons w ill fuse
with t he joi nt· capsule, as wi ll the coracohumeral liga ment. T he coracohumeral liga m ent w il l span the ro tator
interva l roof to fill the space between the supraspin atus and subscapulari s tendons. Th e cora co humeral ligam ent w ill
not be di stin guishable from th e rotator cuff ten don or joi nt capsule w hen it fu ses.

99
 ROTATOR INTERVAL
SAGITTAL T1 FS MR ARTHROGRAM, RIGHT SHOULDER

Supraspinatus tendon

I
ligament

Biceps t., long head

Infraspinatus tendon

Con vergen ce of
coracohumera l
ligament & SG HL

Teres minor tendon Subscapularis tendon

Posterio r circumflex
artery & axillary nerve

Ceph alic vei n in

Del toid muscle
del topectoral groove

Supra pi natus tendon

Coracoacrorniul
ligament

Biceps tendon, lo ng
Infraspinatus tendon head

Subscapularis tendon

Teres minor tendon

ci rcumflex
arter y & axillary nerve

Del toid muscle Cephalic vein i n

deltopectoral groove

(Top) The long h ea d of the b iceps tendon is nearing the entrance into th e bicipital groove. The coraco humeral
liga ment and superior gleno humeral ligamen t ca n be difficu l t to appreciate but are with in the g lobular soft tissue
anteri o r to the bi ceps tendon. (Bottom ) T h e coraco humeral ligament and superi o r glenohumeral ligament provide
suppo rt to t he lo ng head of th e bi ce ps t endon.

100
 ROTATOR INTERVAL
SAGITTAL T1 FS MR ARTHROGRAM, R IGHT SHOULDER

Supraspina tu s tendon

Bicep s tendon, lon g

Infraspinatus tendon h ead

Sub scapu laris tendon

Teres minor tendon

Posterior ci rcumflex
artery & axi llary ner ve

Deltoid mu scle

Cephal ic vei n

Supraspinatu s tendon

Infraspi n atus tendon

Subscapularis tendo n

Teres m i no r tendon

Posterio r circumflex
artery & ax illary n erve Bi ceps tendo n, long
h ead

Delt o id m nscle

fJl
(Top) The lo ng head of th e biceps tendon is entering th e bicipital groove. The rotator interval ends at thi s level. ::J""
(Bottom) This is one image beyond th e latera l extent of the rotato r interval. The lo ng head of the biceps tendo n has 0
ex ited t he joint and is now traversing the bicipital groove. c::
0..
ro
""'!

1 01
 LIGAMENTS
• Sta bilizes long h ead of biceps tendon from
!Terminology s ub luxi ng med ia ll y into subscap ularis
Abbreviati ons o Stre n gth e ns transve rse li game nt coverin g bicipita l
• Acrom ioclavicular (A groove
• Coracoh um era l (CH) o fu ses with s u praspina tu s tendon, s u bscapularis
• Super ior g le n o h u m e ra l liga m e n t (SG HL) te n do n , jo int ca psule a nd SGH L
• Midd le g len o hum e ra l liga m ent (MGH L) • Co racoac ro mia l liga m e nt
• Inferio r gle nohum e ra l ligam e n t (IG HL) o Form s the coracoacro mi a l arch a lo ng w ith acromion
a nd co racoid process
o Re info rces infe rior aspect of acromioclavicula r join t
11maging Anatomy o Exte nds from d ista l two-th irds o f coraco id to
ac ro mio n tip
Anatomy Relationships o Two co n jo ined o r closely associated ba nds
• G le n o hu m e ra l liga m e nts o May h ave a bro ad acro mial insertion
o Stre ngthe n an d fuse wit h jo in t ca psu le • Co racocla vic ula r liga m e nt
o Presence of tru e liga m e n t s d e ba ted o Maj o r stabil ize r of ac ro mioclavicul a r join t
• May represent fo lds in jo int ca psul e o Ex tends fro m base of coracoid process to
• Termed g lenola b ra l periarticular fi be r co mpl ex unde rsurface o f clavicle
o Vary in n u mber a nd size o Fa n-s haped compl ex wi th two fascicu li
• Type 1: C lassic t h ree liga m e nts (SG HL, MG HL, • Cono id liga m e n t: Po ste romedia l, verti cal
IG HL) • Tra pezoid liga m ent: Anterol atera l, obliq ue
• Type II : MG HL co rd, pseudo- Buford • Acro mioclavic ular liga m e n ts
• Type Ill : Com bined MGH L/ IG HL co rd , o Su perio r and inferio r AC ligaments
pseud o- Buford o Re in fo rce acro mioc lav icular jo in t ca psule
• Ty pe IV: No liga m e nts • T ra n sverse humeral liga m e n t
o Su p e rior g len oh u mera l liga m ent o Ex ten ds betwee n grea te r a nd lesser tuberosities
• Sta b ilizes sho u lde r in adduc ti o n o Contains fibe rs from t he subscapula ris tendon
• May o ri gin at e fro m biceps te ndon, a nte rio r o Covers bic ipital g roove
la bru m , o r in commo n wi t h MG HL • Supe rio r tra n sverse sca pula r liga m e nt
• Exte nd s to lesser tube rosity o Co nverts suprascapular n otch into a foramen
• Fu ses w it h coraco hu m era l liga m e n t o Su prascapu la r nerve passes be low t he ligamen t
• Tra n sve rse orie ntat ion • Pot entia l fo r su prasca pu la r nerve entrapm ent
• Gen t le cu rving s hape o n ax ia l images at leve l o f o Su prasca p ul a r vesse ls pass above t he liga me n t
su per io r coracoid process • Infe ri o r tra n sve rse sca pula r li ga m e nt
• Alm ost a lways ana to mica lly present o Extends fro m scapu la r s pine to glenoid rim
• Vis ible o n 30°/t, co nven tio na l MR, 85% MR o La teral to spinoglen o id n o tch
a rthrograms o Su bsca pular n e rve passes beneath th e ligame nt
o M iddle g le no hume ra l liga m e n t o Incon siste ntly prese nt
• Stabilizes s houlde r in abducti o n
• Origi na tes from a nte rio r la b rum or sca pu la r n eck
• Ex tends alo n g d eep sur face o f subsca pu laris to !Anatomy-Based Imaging Issues
lesse r tuberosi ty
• Obliq ue orienta tio n
Imaging Recomm endations
• Blends wi th joi nt capsule a nd labru m a n teriorly • M R: Liga me n ts have low sign a l intensity on all
• Abse nt o r sm a ll MG HL in 30% im agin g seq ue nces
• May be e n larged a nd cord-like • MR a rthrog ra ph y
• Buford comp lex: Th ick or co rd -like MG HL and o Best imaging s tudy fo r g le n o hum e ra l liga m e nts
absent a n terosu perio r labrum • Sag itta l o b lique for MG HL a n d IG HL
• Ca n fuse with th e a n te rio r band of IG HL • Axial fo r SG HL a n d MG HL
o Infe rio r glenohu m e ra l liga m e n t Imaging Pitfalls
• Resists a nte rior d isloca t io n and stabi li zes in • Suba c ro mia l pseudospur
a bd uct ion o Coracoacrom ia lliga m e n t h y pe rtro p h y
• Mo re accurately ter med IG H L com plex • Lo cat ed a t insertion o n acrom io n
• Ante ri o r ba n e!, fascicles o f ax illa ry po uc h a nd o Hyp e rtrophi ed d e lto id mu scle in fe rior te ndo n
poste rior ba nd slip
• Extends fro m inferior g len o id lab ru m to inferio r o Ca n sim ul ate a su bacromial enthesoph yte
h umera l ana to m ic neck o On T l MR, m ature osteoph ytes shou ld demonst rate
• Vertica l orien tatio n o f a n terior & poste rio r bands fa tty bo ne ma rrow
• Ante ri o r ba n d is u sua ll y larger t ha n posterior ba nd o Scle ro t ic o r im m at u re osteoph ytes m ay not have
• Coraco hu m eral liga ment m a rrow fa t, so compa re wi th rad iograph s
o Co racoid process base to g reater & lesser tuberos ities • MGH L o rig in fro m scapul a r n eck (un common )
o Ho rizo n tal o rien tatio n o May simu late str ippi ng o f a nterior capsule
o Forms roof o f ro t a to r in t e rva l

102
103
104
 LIGAMENTS
SAGITTAL T1 FS MR· ARTH ROGRAM

Coracohumeral I.
Supraspi nal us ten don

Superior glen o humera l

Biceps labra l compl ex ligam en t

M iddle gleno humera l

ligament
Infraspinatus ten don
Subscapu laris tendon

Inferior glenohumeral
Teres minor tendon
ligament complex,
an terior band

Superior glenohumera l
Supraspinatus tendon l igamen t
Coracoh umeral I.

Biceps tendon, long

head M iddl e glenohumeral
ligam ent

In fraspi na tus tendon

Subscapulari s tendon

Teres m i nor tendon Inferior glenohu m eral

ligament complex,
an terior b ane!

Vl
(Top) First o f two seque ntial sagittal oblique Tl FS MR arthrogram images o f th e right shoulder. !m age is through t h e :::::r
medial aspect of the hume ral h ead. The middle a nd inferi or glen o hu meral liga ments have an oblique to vertica l 0
course. (Bottom) This image is located just lateral to the previous image. The superior glen ohumeral liga ment is the c:
rounded soft tiss ue de n si ty located ante ri o r to th e long h ead o f the biceps tendon. a.
ro
""''

105
 LIGAMENTS
AXIAL T1 FS MR ARTHROGRAM, SUPERIOR GLENOHUMERAL LIGAMENT

Deltoid muscle
oracoid process

13iceps tendon, long

head
llumeral head upcr ior glenohumeral
l igament

Biceps labral complex

muscle

Scapular spine

Coracoh umera I
De ltoi d muscle
ligament

Coracoid process
Biceps te ndon, long
head

llumeral head Superior glenohumeral

l igamen t

Superior labrum

In fras pinatus tendo n

muscle
capu lar spine

(Top) First of two axial T1 FS M R arth rogram images o f the ri ght sh oulder. T h e long head o f t he biceps ten don has an
oblique course across th e top of the humeral head. T h e su perior glenohumera l ligamen t is located media l to the long
head o f th e biceps and has a roughly pa rallel cou rse o n ax ial images. (Bottom) This image is located below th e
previous image. T he biceps tendo n is cu rv i ng alo ng the anteri or h umera l h ead towa rd the bici p ital groove. The
superi or glenoh umeral liga m ent fu ses with the cora coh u mera l ligament anteriorly. These structures in turn fuse w ith
the joi nt capsule, su praspinatu s t endon and subsca pu lari s t endon to fo rm th e ro tator interval.

106
 LIGAMENTS
AXIAL T1 FS MR & CT ARTHROGRAM, MIDDLE GLENOHUMERAL LIGAMENT

Biceps tendo n, lo ng
h ead
Subscapularis tendon

Deltoid muscle Midd le glen ohumeral

ligam en t
1\nterior labrum

labrum Subsca pu la ris muscle

Glenoid

tendon

Biceps tendo n, long

head

Middle glenoh umeral

l igament

An terior labrum

muscle
l'm teri or labrum
Glen oid

muscle

Vl
(Top) Axia l T l FS M R ar throgram image. T h e m iddle glen ohumeral ligamen t lies anterior to the an terior labru m. ::::r
(Bo tto m ) Ax ial CT arth rogram image. The m idd le glenoh u meral liga men t is disp laced furt her from th e an terior 0
labru m due to better disten sion of t he joi nt. c
c..
ro
""'

107
 LIGAMENTS
AXIAL T1 FS MR ARTHROGRAM, BUFORD COMPLEX

Bicep s tendon , long head

Subsca pul aris te ndon

Absent anter io r labrum

Deltoid muscle

T hi ck middl e glenohumeral
l igament

Glen oid
Posterior labrum
Subscapularis muscle

In fraspi na tus muscle

Biceps tendon , long head Super ficial fibers subscapulari s

tendon
Absent anterio r labrum
Deltoid muscle
T h ick middl e glenohu m eral
l iga m en t

Posterior labrum
Glen oid

l n fraspina ll:JS mu scle Subscapul aris muscle

Biceps tendon, long h ead Super ficial fibers subscapularis

tendon
Absen t an ter ior labrum

Teres m i no r tendon T hi ck middl e glen ohu m eral

l igam en t

Posterior labrum Gleno id

Deltoid muscle
Subscapul aris muscle

I n fraspi natus muscle

(Top) Ax ial Tl FS MR a rthrogram image o f a Buford complex. The middle gleno hu me ra l ligament is thi ck and
cord-like. The a nterior gle noid labrum is absent. (Middle) First of two seq uential axia l T1 FS MR a rthrogram images
of a Buford complex . (Bottom) Image is located dista l to the previo us image. A thick mi ddl e glen o h u me ra l ligament
is a re lative ly common norm al variant.

108
 LIGAMENTS
SAGITTAL T1 FS MR ARTHROGRAM, VARIANT GHL CONFIGURATION

Superior glenoid labrum

Supraspinatu\ & tendon
Coracohumeral l igamen t
Superior glenohu m era l liga m ent muscle & tendon

muscle & tendon

Small middle glenohumeral I. Teres minor muscle & tendon

Su perior glenoid labrum

Supraspin atu s musc le & tendon
Coracohumeral ligam ent
muscle & tendon
Superior glenohumt'ral ligam ent

Sub\capularis & tendon Teres mino r muscle & tendo n

Biceps te ndon, long h ead

Supraspi natu\ muscl e & tendon
Coracohumeral ligamen t
I n fraspinatus muscle & tendon
Superior glenoh umeral ligament

& tendon Teres m inor muscle & ten don

Axillary po uch

Vl
(Top) First of t hree T l FS MR art h rogram i m ages o f the left shoulder d isp layed media l to latera l. Glenohumera l :::J""
ligamen ts can norm all y vary i n size and presence. The uperi o r and mid dle g lenoh umeral ligamen ts are outlined by 0
con t rast in t h is image. T h e middle glen o humeral l igament is sm aller th an is typically seen . (M id d l e) The superior c::
glenohumeral ligament is larger t han usual an d bl ends w i t h th e coracoh u meral l igament and joint capsule i n this 0..
image. These structures w ill al so fuse wit h th e supraspinatus and subscapularis tendons as th ey ex tend latera l ly.
ro
(Botto m ) An terio r and posterio r bands o f t he i nferio r gl enoh u meral liga ment complex are absen t. Fascicles o f th e """'
axi l lary pou ch are p resent.

109
 LIGAMENTS
SAGITTA L T1 FS MR & CT ARTHROGRAM, INFERIOR GLENOHUMERAL LIGAMENT COMPLEX

Supraspina tus tendo n

Coraco humeral
ligamen t
Infraspinatus tendo n

Subscapularis tendo n

Teres m i no r tendon
In ferior glenohumeral
ligament complex,
an terior ba n d
Inferior glen ohumeral
ligament complex, Inferior gleno humeral
ligament complex,
posterior band
ax illary po uch

Commo n o rigin
superfi cial & middle
Supraspinatus tendon glenohumeral I.
& muscle Coracohu mera l
ligamen t

Infraspinatus tendo n &

Middle glenohumeral
muscle
ligamen t

Subscapu laris tendon

Inferior gleno humeral
li gam ent co mpl ex,
posterior band Inferior glenoh umeral
ligament complex,
Teres minor tendon anterio r band

Inferior glen ohumeral

ligament compl ex,
axi llary pouch

(fop) Sagittal oblique T l FS MR arthrogram i mage o f t he righ t sh oulder sh ows the inferi or gleno humeral liga ment
complex. (Bottom) Sagittal obl ique CT art hrogram i m age o f th e right sh oulder shows the inferior glen ohumeral
ligament comp lex and middle glen ohumeral l igamen t.

11 0
 LIGAMENTS
SAGITTAL PO MR, CORACOHUMERAL LIGAMENT

n at tendo n
Coracoh um eral
ligam ent

labral comp lex

Subsca pu laris tendon

Jeres minor tendon

Inferi or labrum

'lupraspi natus te ndon Coracohum eral I.

Superficial
glen o humeral ligament
Bicep'> tendon, lon g
h ead Coracoid process

tendo n

Teres m i nor tendo n

Proximal humeral

Vl
(Top) First o f two sagi ttal oblique PO MR images of th e right should er. The coraco h umeral ligam ent ex tends from the ::r
base o f the co racoid process to th e greater and lesser tuberosi ties. (Bottom) I mage of th e right shoulder located lateral 0
to the previous image. Th e coracoh umeral ligament form s t he roof o f the rotator i nterv al. It fuses with several c
structures incl uding the supraspi n atus tendon , subscapulari s te nd on, joi nt capsule and su peri or glen oh um eral 0..
(t)
ligament.
""''

11 1
 LIGAMENTS
AXIAL PO MR, CORACOHUMERAL LIGAMENT

oracohumeral
ligamen t
Delt oid muscle

1. , long head
Coracoid process

l lu meral h ead

Supraspinatus muscle

Sca pu la r spine

Coracohumera l I.

Coracoid
Delt oid muscle

1. , lo ng head
Superior glenohumeral
ligamen t
llum eral head
Superior labrum

In fraspi nat u s ten don

muscle

Scapular

(Top) First of two seq uen t ial axial PO MR images o f th e right sh oul der. Th e cora co humeral ligamen t arcs between the
co racoid process an d an terior humeral h ea d. (Bottom) T h i s image is located below th e previous image. Th e
co racohum eral ligam ent i s fusi n g wi th th e superi or glenohumeral ligamen t an d join t ca psule.

11 2
 LIGAMENTS
CORONAL OBLIQUE PO & T2 MR, CORACOHUMERAL LIGAMENT

D istal clavicle

Coracoclavicul ar
Coracohu m eral l iga men t, trapezo id
li ga m en t co mpo nen t

Coracoacromial I.

Co racoid

Lesse r

Subscapularis ten don &

m uscle

De lt oi d muscle

Distal clavicle

Coracohumeral Coracoclavicular 1.,

ligamen t trapezoid co m ponent

Coracoacromia l I.

Coracoid process

Lesser tube rosity

Subscapulari s tendon &

muscle

Deltoi d muscl e

Vl
(Top) First of two corona l obliq ue images t h roug h th e same level. Th e coraco h ume ra l liga me n t has a roughly :::r
tra nsverse course o n co ronal obliq ue images. (Bottom) Coron al T2 MR is th rough t he same level as the prev io us 0
image. Su rroun di ng fa t o utlin es th e coraco h um e ra l liga me n t. When this ligament fuses with th e supraspi n atus c:
te nd o n , subsca pula ris tend o n and jo in t ca psule, th e st ructures ca n not be d ifferentiated fro m ea ch ot her. 0..
ro
""''

113
 LIGAMENTS
CORONAL OBLIQUE T1 MR, CORACOCLAVICULAR LIGAMENT

Coracoclavicu lar
Disla I clavicle ligamen t, conoid

--... Co racoclavicu lar

liga m en t, t rapezoid
Coracohumeral
l igamen t

Subscapu laris tendon &

llurnera l h ead

Delto id muscle

Coracoclavicu lar
Distal clavicle l igament, conoid

Coracoclavicu lar
l igament, trapezoid
Coracohumera l
liga m ent

ll um eral h ead )1======1-- Subscapu laris tendon &

muscle

Deltoid muscle

(Top) First of two co ro nal o blique T 1 MR images. T h e coracoclavicular ligam en t h as two fasc icu li, the co noi d
ligament and th e tra pezoid ligament. The con oid l igament is loca ted m ed iall y and is more ve rtica l in orientatio n.
Th e trapezoid ligamen t is m o re laterally loca ted and h as an ob li que course. (Bottom ) The coracoc lavicu lar l igament
ex tends f ro m th e base o f the co racoid p rocess to t he und ersurface of t h e clavi cle. It acts to stabilize the
acro mioclavicular join t.

114
 LIGAMENTS

De ltoid muscle
Coracoacromia l ligament

Coracoid process
Acromion
Top of coraco humeral ligament

Supraspi n at-us muscle & tendon

Sca pular spi ne

Coracoacrom ia l ligamen t

De l toid muscle Coracohumeral l iga m en t

Coracoid process

Acrom ion
Supraspi n atus muscle & tendon

Scapular spine

Coracoacrom ial ligamen t

Bice ps tendon , long h ead
Coracoh umeral l iga m en t

Coracoid process
H umera I h ead

Acromion

Sup raspin atus muscle

Sca pular spi ne Subscapularis m u scle

CJ)
(Top) First of three ax ial PD MR i mages of t h e rig ht should er. Image is through t h e level o f t h e acromi o n. Th e :::r
coracoacrom ial li ga m ent ex tends from t h e coracoid p ro cess to t h e a nte ri o r aspect o f t h e acro mion . (Middl e) Stra n ds 0
of the coracoacromia l ligame nt a re visible in t his obliquely orien ted structure. (Bottom ) Image is be low th e level of c:
the coracoacromial ligament. The coracohum eral li gam ent is beco m ing v isible. a.
('!)

""''

115
 LIGAMENTS
CORONAL OBLIQUE T1 MR, ACROMIOCLAVICULAR LIGAMENTS

Superior
acrom ioclav icu Jar
ligam en t

In ferior
acromioclav icular
liga m en t
Suprasp in atus tendon
& muscle
Deltoid muscle

Superior labrum

Biceps tendon, lo ng
head

G lenoicl

Supe rio r Distal clavi cle

acrom ioclavicu Ia r
ligament
Supraspinatus tendo n
& muscle
In ferio r
acrom ioclavicu Jar Superior labrum
ligament

Subscapulari s muscle

Deltoid muscle

(Top) Coron al oblique T1 MR image t h rough the anterio r right sho ulder. Superior and in ferior liga ments reinfo rce
the acromiocla v icular jo int. (Bottom) Coronal oblique Tl MR image in a d ifferent pa tient from p revious im age
shows th e superio r and in ferior acrom ioclavicula r ligam ents.

116
 LIGAMENTS

Acrom ion

Pseudospur, likel y the in ferior

tendon slip o f delt oid muscle

In fraspinatus tendon

llumcral head
G lenoid

Deltoid muscle

l'scuclospur

I nfra spin atu s tendo n

llumcral h ead

G len oid

Delto id muscle

Acro mion

llumera l head

Deltoid mu scle

(Top) First o f t h ree co ronal oblique Tl M R images of the right sh oulder in three different patien ts wit h subacromial
pseudospurs. one of the patients h ad a bon y spur on rad iograph s. T he low signal subacromia l pseudospur in t his
pati ent is ori ented laterally and l ikely represents a th e i nferi or tendon slip of the delt oid muscle. (Middle) In thi s
pa t ient, th e low signal subacromial pseudospur is globul ar. It cou ld be due to hy pertroph y o f th e inferio r tendon sli p
o f th e del toid m uscle or the coracoacro mial liga ment. (Bo ttom ) I n thi s pa ti ent, t he low signal suba cromia l
pseucl ospu r is ori ented m ediall y. It is likely due to coracoacrom ial ligament h y pertro ph y.

11 7
 LABRUM
• Laterally angulated, irregular fluid cleft d istal to
\Term inology glenolabral attachment suggests tear
Abbreviations o May be contin uo us with sublabral foram en
• Sublabral foramen (hole)
• Biceps labral complex (BLC)
o Present in 8-18% populatio n
o Anterosuperi or quadra nt of labrum onl y
o Can mi mic tear if filled with flu id or con trast
\Imaging Anato my o Foramen is smooth and tapered
Overview o Tea rs a re irregu lar and displace labrum awa y from
• Glenoid labrum consists o f hyaline cart ilage, glenoid when fi lled with flu id
fibrocartilage a n d fibrous tissue • Su b labral fora m e n with sulcus between biceps
o Inc reases joint circumference and depth tendon a nd su perio r labrum
o Increases surface a rea and surface contact o "Double o reo cookie" sig n o n coro nal o bliq ue M R
o App rox ima tely 4 mm wide o Gle n oid cortex (black) + sublabral recess (wh ite) +
o Provides increased rotatio nal stability labrum (black)+ biceps/superior labrum sulcus
• Variable size, shape and signal intensity (wh ite) + biceps tendon (b lack)
o C lassic tr ia n gle o r wedge shape on ax ial imaging is o Simi lar appea ra nce ca n be seen with superior labral
present in less t han 50% of no rmal anterior lab ra tear instead of biceps/superi or labrum sulcus
and less than 80% of posterior labra
o Normal sh apes include ro und, blunted, crescen tic,
flat, notched and cleaved \Anatomy-Based Imaging Issues
o May be sma ll or absent an te riorly Imaging Recom m endations
o Not always sy m metric a nterior to posterior
• MR arthrograph y (di rect)
o Ca n va ry in signal intensity d ue to muci n ous and
o Coronal oblique p lane best demonstrates biceps
m yxoid contents
labral complex
• Portions of labrum d esc ri bed as positio ns o n face of
o Fibrocarti laginous lab rum o utlined by contrast
clock (eithe r sh oulder)
• CT a rthrography ca n be useful in patie nts with
o 12:00: Superior
cont raindica tion to MR
o 3:00: Ante ri o r
o 6:00: Inferior Imaging Pitfalls
o 9:00: Posterior • Variant a n atomy
• Blood suppl y via periostea l a n d capsula r vessels o Many norma l va riants of labra l ana tom y can be
Anatomy Relationships confused with pathology
o Most n ormal va riants occur a t l l :00-3:00 position
• Labral attachment types
• Magic angle artifact
o Type A: Detach ed free edge overlying glenoid
o An teroinfe rio r a nd posterosu perior labru m
a rticular ca rti Iage (me n iscoid)
• In tra-artic ular b iceps tendon dislocation
o Type B: Adherent to the glenoid a rticular cartilage
o Disloca ted tendon lies adjacent to labrum
• Biceps labra l complex
o Bice ps tendon attachment to labrum o Ma y simulate tear
• Hyal ine cartilage underc utting
o Type 1 BLC: Firm ly ad he re nt to glenoid and superior
o Cartilage lying beneath labrum may simulate tear
labrum, slab type
o Ca rtilage signal intensity is hi gh er than fibro us
o Type 2 BLC: Small sulcus between biceps/labrum
and glenoid, may be con tinuo us with sublab ral labrum
o Differe nti ate by smoot h, even c h aracte r of cartilage
fo ramen, inte rm ed iate type
• Tears tend to be irregular
o Type 3 BLC: Large sulcus between biceps/labrum
o Cartilage does not extend through to opposite labral
and glenoid, la b rum often co ntin ues as su blabra l
surface
foramen, meniscoid type
• Confusion with middle g lenohu meral ligament
• Buford complex
o On axia l images, midd le glenohumeral ligame nt lies
o Diminutive or absen t anterosuperior labrum
ad jacent to anterior labrum
o Thi ck o r co rd-li ke m idd le glenohumeral ligament
• May appea r to be frag me n t of a nterior labrum
o Present in 1-6.5% popu lation
o Cresce nt o f flu id between labrum a nd midd le
o Pseudo-Bufo rd appearance ca n occur whe n middle
gle nohumera l ligament can simulate tear
and inferior glenohumeral liga ments are combin ed
o A "pseudo-sublabral foramen" appearance ma y occur
• Superior sublabral recess (sulcus)
when oblique sagittal images are impro perly
o Located along superio r labrum
• 1-2 mm in t hi ck ness along th e ful l anterior to oriented
o Follow oblique cou rse of middle glenohum e ral
posterior extent
li gamen t on con secuti ve images to confirm that it is
• Does not exten d posteri or to biceps te ndon
a sepa rate stru ctu re fro m labrum
o Fluid ma y extend into recess simula ting tear
o Co nfi rm norm al signal in t he underlying labrum
• Med ial or ve rtica l o rientation of fluid between
• Volume ave raging wit h contrast in su b labral
base of la bru m & carti laginous margin of gle noid
foramen on MR arthrogram may sim ul ate tear
rim suggests recess

11 8
11 9
120
 LABRUM
AXIAL & SAGITTAL T1 MR ARTHROGRAM, BUfORD COMPLEX

Deltoid muscle, m iddl e bell y Biceps tendon, lon g h ead

Co racoh umeral l igam en t

Superior glenohumeral I.

Th ick m iddl e glen ohumeral I.

Absent anterior superio r labrum

Su perior glenoid

In fraspinatus ten don Su prascapular n o tch

Spin oglenoi d n o tch

Scapular spi ne

Transverse I iga m en t

Subscapu laris tendo n

Biceps tendo n, lo ng h ead

Deltoid muscle Th ick m iddle glenohumeral I.

A nterior labrum, 4:00 posi tio n

Mid glen o id
Teres minor tendon

Abnorm al posterior labrum due to

prio r tear

Scapula

Acrom ion Di sta l clavicle

Supraspi natus tendon Coracoacromial ligam ent

Coracohumeral li ga m en t
Infraspi natus ten don
Superior glenohum eral
ligam en t

Thick m iddle gl enohumeral

ligam en t
Teres minor muscle

I n ferior glenohumera I I igamen t

complex, anterior band

Vl
(Top) First of two n o n-sequential ax ial Tl MR arth rogram images of the right sh o ulder w it h Bufo rd co mplex norm al ::r
va riant. T he an teri or su perior glenoid labrum is absen t. Th e middle glen ohumera l ligam ent is thicken ed . The 0
posteri o r labrum has abn o rma l size and shape due to a tear. This is u nrel ated to t he Buford complex . (Middle) I mage c
at the mid-glen o id level. The middle glenohumeral ligament is still thick and cord-l i ke. Labral tissue has reappea red 0..
anteriorly. (Bottom) Sagittal oblique TI M R arthrogram image of th e same patien t i n p revio us i mages. The midd le
ro
glen o hu meral ligament is en larged .
""''

12 1
 LABRUM
SAGITTAL OBLIQU E T1 FS MR A RTHROGRAM, NORMAL LABRUM

oracohumeral
Supraspina tus ten don

upt.' rior labrum

I nfraspi n at us tendon

Posterior labrum

In ferior glenohumeral
Teres m i no r tendo n l iga m ent complex,
an terior band

Coracohu m era l
ligament
Supraspinatus tendon Superior glen ohumeral
ligament
Biceps labral complex

M idd le glenohumeral
ligamen t
Infraspinatus ten don

In ferior glenohumeral
minor ten don l igamen t complex,
anterior band

(To p) First of two sagittal obli que Tl FS MR arth rogram images of the righ t shoulder. T his image through th e
glenoh umeral join t. The labrum is a low signal , pear-shaped structure l in i n g the ed ge of the glenoid fossa . (Bottom )
Im age located ju st lateral to th e p revi ous i mage. T h e m edial aspect o f the humeral head is com ing i n to vi ew. The
lo ng h ead of th e b iceps te ndon fu ses with the superio r labru m to form the biceps labra l complex.

122
 LABRUM
AXIAL & CORONAL MR, LABRAL VARIANTS

Bice ps tendon, lo ng head Subscapu la ris tendon

Infraspinatus tendon
An terior labrum, type B
attach m ent

Posterior labrum , type B

attachment

Subscapularis tendon

Anterior labru m, type A

attach men t

Posterior labrum, type A

attach m en t

"Dou ble o reo cookie" sign

Biceps tendon, long h ead

Glenoid
Biceps/superior labrum sulcus
Labrum
Sublabra I recess

(Top) First of three images of glen oid labral varia nts in t hree d ifferent patien ts. Axia l Tl MR arthrogra m without
fat suppression. The a nterior and poste ri o r labrum a re firml y ad he re nt t o the a rticu lar ca rt il age. Th is is referred to as a
type B attachme nt. (Middl e) Ax ia l PD MR in a diffe rent patient from previo u s image. Th e ante ri o r and posterior
labrum ove rlie th e articul ar cartilage. This is referred to as a type A a ttac hment. (Bottom) The "double o reo cookie"
sign in a different pa tie n t from previous image o n co ro nal T2 FS arthrogram. From med ia l to lateral, the layers of the
cookie corres pond to th e glenoid cor tex (black)+ sublabral recess (w hite)+ labrum (black)+ b iceps/ superior lab rum
sulcus (whi te)+ biceps te n do n (b lack). This sign ca n a lso be see n when a su pe ri or labra l tea r is present in place of t he
biceps/s uperior labrum sulcus.
123
124
 LABRUM

Type 1 bi ceps labral complex

Supraspinatus tendo n Biceps ten don & superior

labrum adh erent to glenoid

Biceps tendon, long head, i n

bicipital groove

Shallow between
biceps/ labrum & glenoid

Biccr tendon, long head, in

bici pital groove

Type 3 bi ceps labral complex

Deep sulcus between meniscoid

labrum &: glenoid

tendo n, lo ng head, in
bici.pital groove

V'l
::r
CJl 0
c
(Top) o f three corona l MR images of the righ t shoulder in three di fferen t patien ts shows biceps labra l complex
normal vMia nts. Coro nal oblique Tl FS MR arth rogram. Th e biceps tendon is fi rml y adherent to the labru m and
::r
0
c
-0.ro
uperior glenoid. This is a type 1 o r slab type BLC. (M iddle) Coronal oblique T1 MR. A relative ly sh allow sulcus lies "'"'I
betwee n th e biceps/ labrum and glenoid. Thi s is a type 2 or i n termed iate type BLC. (Bottom) Coro nal oblique T1 FS 0.
MR arthrogram. A deep sulcus lies between t he biceps/labrum and glen oid. Th is is a type 3 or meniscoid type BLC. ro
"'"'I
I
127
I
 LABRUM
AXIAL PD FS MR

Biceps tendon, long

head
De l toid muscle Co racoacrom ial I.

Cor-acoi d proce5s

Supraspi natus muscle

& tendon

Scapular spine

Infraspi n atus mu\cle

Deltoid muscle

Biceps tendo n, long Coracohumeral

h ead ligament

Hum eral h ead Coracoid process

Superior labrum

Suprasca pular artery mu scle

Scapular spi ne
Infraspinatus muscle &
tendon

(Top) First of twelve axial PD FS MR i mages of th e righ t shoulder presen ted from proximal to d istal. Image is above
th e level of the glenoid labru m. The fi b rous lab ru m increases the stabil ity o f the glenoh um eral joint and is an
impo r tant at ta ch ment site for th e g lenohumeral liga ments and lo ng head o f t he bice ps tendon . (Bottom ) Th e
superior glenoid labrum com es into v iew on th is image. It has n o rmal low sig nal. The long head of th e bi ceps tendon
attaches to t h e superi or labrum, forming the biceps labral complex. Note tha t t h e co racohum era l ligament is
unusua l ly t aut aFl d well demonstrated in this hy per-extern ally rotated shou lder.

126
 LABRUM
AXIAL PO FS MR

Deltoid mmcle,
anterior & m iddle
bellies Coracollumeral
ligamen t

ten don, Coracoid process

obl iq ue
corn pon ent Superior glenohumeral
l l umcra l ll eacl liga men t

artery &
branclles
In fraspinatus m u scle & Subscapularis
tendon
Scapular spine
Deltoid muscle,
posterior belly

Delto id
anterior bell y
Conjoined tendon of
sll ort head biceps &
Supraspi n atus tendon coracobrachialis t.

(lrcater Coracoid process

lnfra\pina tus tendon Middle glenoll umeral I.

Subscapularis m. & t.
l'o\tcrior labrum
Glenoid

l)cl toid m uscl e Suprascapu lar ar tery &

nerve
Infraspina tus muscle Scapula

(Top) The su perior glenohumeral ligam en t attachmen t to the anterio r superior labrum i shown on th is image. The
glenoh umeral ligam ents m ay actually represen t folds o f th e join t capsul e, as opposed to true liga m ents. T he superior
glenohumeral l iga ment will fuse w i th the coracoh um eral liga m ent form a su pport ive sl i ng aroun d the lon g head o f
the biceps ten do n. (Bottom ) Th e middle gleno hum eral ligam ent also arises an teriorly. It is larger than t h e superior
glenohumeral l iga m en t and ca n be con fused for a torn fragm ent o f l abrum if i t is not fo l lowed alon g it s oblique
course.

12/
 LABRUM
AXIAL PD FS MR

Deltoid muscle,
anterio r belly Conjoined tendon of
sh ort head bi ceps &
co racobrachial is

Cephali c vein
Grea ter tu berosi t-y

m. & t.

Middle glenohumeral I.

An terior labrum

Posterior labrum Su blabral sulcu s

Suprascapular artery &
nerve

Scapula

Deltoid muscle,
posterior belly l n lraspinatus muscle

fl Del to id muscle

Bi ceps tendon, long

h ead
Bi ceps t., h ead

Coracobrachialis t.

Pectoral is minor
& tendo n
Subscapularis tendon
Middl e glen ohumeral I.
Teres minor tendo n An terior labrum
Inferior margin
sublabra I sulcus

Po\teri or labrum Glen oid

Subscapu laris muscle

Scapu la body

Deltoid muscle I n fraspi natus muscle

(Top) Th e glen o id labrum h as a w ide ran ge of normal appearances. The typica l appea rance o f th e labrum on ax ial
images is a low signal t rian gle o r wedge ad jacen t to t h e anteri o r and posterior rim of the glenoid. (Botto m ) The
labrum in asympto matic patients ca n be ro und, b lun ted, notch ed, crescen ti c, cleaved, fl at and absent.

128
 LABRUM
AXIAL PO FS MR

tendon

tendon, long
h ead
Lesser tuberosit y
De lt oid mmcle

Coracobrach ialis m.

Pectoral is minor
m uscle & tendon
a
M iddle glenohum eral
l igament

Teres m in or tendon
A nt erior labrum

Posterior labrum
Glenoid

Scapu la body
Deltoid muscle,
posterio r bell y In fras pi nat u s m

Biceps m., short head

Lesser tuberosity
m.

Pectoralis min or
Biceps tendo n, long
m u \cle
head
Ax ill ary n eurovascular
Bici pital groove bund le

A nlt' rior labrum

Subscapularis tendon
Inferi o r glen ohu m eral
Posterior labrum ligam en t, anter ior band

Glen o id
Serratu s an terior m .
Del toid muscle,
pos terio r belly Subscapularis muscle
I nfraspin atus muscle
Sca pula, bod y

fJl
(Top) Th e in ferior glenohum eral li ga m ent co mpl ex con sists of an anterior ban d, axillary pouch and pos teri or band . ::T
Th is co mplex represents th e thickest portion o f th e join t capsule. A distin ct site of origin of this t ri angu lar sh aped 0
complex is more difficult to identify than th e superi or and middle glen ohu meral ligam ent origins. (Bottom) The s::::
anterior and pos teri or labrum can no rmall y have asymm etric shapes. Hyaline cart ilage undercutting o f th e labru m, 0...
seen anteriorly i n this case, can sim ulate a tea r due the relatively increased sign al of ca rtil age compared with the ro
fibrous labrum . ""''
 LABRUM
AXIAL PO FS MR

Lesser 1uberosi ty

Biceps tendon, long Coracobrach ialis &

h ead biceps sh ort head
muscles

Inferior glen oh umera I

ligament, anterior band

Inferio r glen ohumera l Sub5capu laris tendon

ligam ent, posteri or
A nterio r labrum
band
Ax ill ary pouch
Poste ri or labrum

Teres minor muscle

Delt oid muscle Subscapulari5 muscle

Scapula, body

In fraspinatus muscle

Subscapularis ten don

Cephalic vei n

Biceps tendon, lo ng
h ead
Bicipita l groove

Anterior labral/ i nferior

glenohumeral I. eurovascular bundle
com plex

Inferior glenohumeral
1., posteri or band

Posterior labrum
musc le
Deltoid mu scle

Teres minor and capula, bod y

infraspinatus m uscles

Q) (Top) Nea r th e in ferior aspect of t he glen ohu meral joi n t, the ax il lary pouch n orma lly con tains a mall amoun t of
""0 joint flu id. The joint ca psule m ay become redundant in th is area, simulating loose bodies. (Bottom ) Magic angl e
::s artifact can ca use i ncreased signal i n the labrum. Th is is most commonly seen in th e superior and inferior aspects o f
0 bo th th e anterior and posterior labrum on sho rt TE i m ages. Any abnormal labral signal should be co nfirmed on TZ
..c:
IJl sequences.

130
 LABRUM
AXIAL PO FS MR

Cephal ic vein

Pecto ralis maj or muscle

Bicep s tendon, lo ng
Coracobrachial is
head
m uscle

Humerus, surgica l n eck

Neurovascular bundle

Reflection of ax illary
pouch
Infraglenoid tuberosity

Teres m i nor muscle Subscapularis muscle

Scapula
Triceps t., lo ng h ead, at
i nfraglenoid tubercle

Infraspinatus muscle
Deltoid m u scle

Cepha lic vein

Deltoid muscle
Pectora l is maj o r muscle

Biceps t., lo n g head Pectorali s minor m.

Coracobrachialis
Biceps m. , short head m uscle

Neurovascular bundle

Triceps ten don, long

head Subscapulari s muscle

Scapula

Infraspi n atus muscle

Deltoid muscle

(Top) Image through th e labrum, re presentin g the 6:00 positio n . (Bottom) Just below t h e level of th e gle n oid, there
is no labral tiss ue visi ble. The long h ead of the tri ceps m uscle has its o rig in fro m the infrag lenoi d tubercle.

13 1
 CLI NICALLY RELEVANT REGIONS
• Poste rio r bo rd er: Hum era l head
!Terminology o Contents
Abbreviat ions • Subac ro mia l-su bdeltoid bursa
• Coracoacromi al arch (CCA) • Supras pina tus m uscle and tend o n
• Su perior tra n sverse scap ular ligam ent (STSL) • Biceps te ndon, long head
• In fe rior t ran sve rse sca pula r liga m e nt (ITSL) o Os acrom iale
• No rm al vari a nt anatomy 5%
• Unfused acromi al a pophysis
• No rm a ll y fused by age 25
IImaging Anat omy • Mobile and decreases coracoacrom ial space d u ring
Overview motion
• Several regio n s of the sh o u ld e r are o f pa rt icu la r cl inical • Different ia te from acrom ioclavicu lar joint by
importa n ce lo cat ion wit hin th e ac ro m ion process
• Predisposes to impin gem ent & rotator cuff tear
An atomy Relationships • Best imaged by radiogra ph s, CT o r axia l plane MR
• Q uadri latera l sp ace
o Su pe rior bo rder: Teres m ino r muscle
o Infe ri o r bord er: Teres ma jo r muscle !Anatomy-Based Imaging Issues
o Late ral bord e r: Surg ical neck o f h umeru s
o Medial borde r: Lon g h ead of triceps muscle Key Concepts o r Qu est ions
o Co nte nts: Ax illa ry n erve a nd posterior circ um flex • Suprasca pula r neuropa t hi es
hu me ral a rtery o Due t o lesion s in or n ea r su p rasca pu lar o r
• Ax illary n e rve supp lies te res mino r muscle, d eltoid spin ogle noid notc h
m u scle, posterola te ral cu taneo us region of o Ca uses atrop h y o f supraspina t us, in f raspina tus o r
sho ulde r a nd up per arm b oth muscles
o Can have compli catio n s t h at a re purely n eu ro logic, o Pa ralabral cysts
p urely vascul a r o r both • Most co mm o n ca u se o f mass in this region
• Triangu lar s pace • High associa t ion with labral tears
o Loca ted m edia l to qu ad rilate ral space • May ca use bo ne erosio n
o Supe rio r bo rder: Teres mino r muscle o Distal clav icle osteolysis
o in fe rior border: Teres ma jo r m uscle • Course of n erve closely associated with poste rior
o Late ral bo rde r: Lo n g head of tricep s muscle asp ect o f d istal cla vicle & acromioc lavicu lar joint
o Conte nts: C ircumflex sca pula r a rte ry o Ano m alo us o r calcified li gaments
• Bra n ch of subscapula r a rtery sup plying o Sca pula r fracture
infrasp ina tus fossa o Blunt o r p ene trating t ra u ma
• Suprascapu lar n o t ch o Gle n o hum era l join t d isloca tio n
o Roof of n otc h covered by superior transve rse o Rad ical n eck dissection
sca pula r liga m en t o Supraclavicula r lym ph n od e b iopsy
o Con tents: Suprascapula r nerve o Stre tc hi ng o r m ec ha nica l irritation
• Arises from brach ial p lexus superio r t ru n k, 4th -6th o Tumo r
cervica l ne rve roots o Va rices
• Motor a nd sensory fibers • Axillary n e u ropathi es
• Suppli es supras pin at u s a nd infraspinat us muscles o Due to abn orma lities in q uadri latera l space
o Anterio r com press io n causes supraspinatu s a n d • Paralabral cysts
infras pinatus atrop hy • Fibro us bands
o Posterio r co m pressio n causes in fraspin a tu s atroph y • G le no h um eral joi nt d isloca t ion
o Sup ra sca pula r arte ry a n d vein pass above superior • Hum eral frac ture
transverse sca pular liga m ent • Extre me o r p ro lo nged abduc ti o n of arm durin g
• Spinogle no id n otc h sleep
o Locat ed infe rior t o su prascapular no tch, be tween o Atroph y of teres mino r muscle
scapu lar spine a nd post e rio r sur face o f gle noid body o May affect delto id muscle
o Co ntains infraspina tus bra n ch of supra scapu la r • Sh o ulder impingem e nt
ne rve o An y lesion o r a na to mi c varian t th at n arrows t he
• Su pplies in fraspina tus m uscle coracoacro m ial arch predisposes to imp ingeme nt
o Also contains sup rasca pular vesse ls
o eurovascu lar bun d le passes beneath infe rio r
Imaging Recommendati on s
t ra n sverse scap ula r liga ment • MR: Best de m onstra tes the an ato mic spaces a nd
• Liga m e nt present in 50% pop ulation assesses fo r th e p resence o f lesio n s
• Coracoacromia l a rc h • Arteriograph y: To assess fo r occlus ion of posterior
o Borde rs circ um flex hu me ral a rte ry w he n in abd u cted,
• Su pe rior borde r: Acro mi o n ex terna lly rota ted positio n
• Anteri or border: Coracoacromial ligamen t • Radi ogra p h s and CT : To assess for fractu re o r bone
• An te rior bo rde r: Coracoid process t um or

132
133
114
 CLINICALLY RELEVANT REGIONS
AXIAL PD FS MR, QUADRILATERAL SPACE

Ceph ali c vei n

Delto id muscle,
Pectoral is major muscle
anterior belly

m., short h ead

Pectora l is m in or m.
Bi ceps t. , long h ead
Coracobrach ial is m .

proximal
diaph ysis
Axi llary n eurovascular
l'm teri o r circumflex bundl e
humeral vessels &
a>.i ll ary nerve
Subscapularis muscle

Tricep s t., long head

Scapul a
Delto id muscle,
posterior be ll y I nfraspinatus muscle

Cephalic vein
l)eltoid muscle,
an terior bell y Pecto ralis majo r muscle

Pectoralb mino r m.
Hiccp\ m ., sh o rt head

Bicep\ t. , lo ng h ead
Coracobrachialis m .

ll um erus, pro>. imal

diaphysis Ax illar y n eurovascular
bu ndl e
Tri cep'> muscle, lateral
h ead
Pos terio r ci rcumfl ex Sub sca pularis mu scle
hum era l &
ax illary ner ve
Triceps m ., long h ead
Sca pul a

muscle
Del toid muscle,
posterior bell}'

'J)
(Top) First o f t wo ax ia l PO FS MR i mages thro ugh th e quadri latera l space. (Bottom) Th e quadril ateral space co ntains :::r
th e axil lary n erve and posterior circum fl ex humeral vessels. 0
t:
0..
('0

""''

135
 CLINICALLY RELEVANT REGIONS
CORONAL T1 MR, SCAPULA

] Acromion Trapezius

Infraspinatus tendon
Scapular spine

Infraspinatus muscle
Teres min or mu scle

Quadrilateral space

Triceps m., long head

Deltoid muscle

:.=---;.: ;- Teres major N

latissimus
mu scles

Triceps muscle, lateral

head
Triceps musclt', medial
head

Acromioclavicular join t Trapeziu5

In fraspinatus tendon
Su praspinatus

Infraspinatus muscle
Teres minor muscle

Quadrilatera l space

Deltoid mu5cle

Teres major N
latissimus
muscles

Triceps m., lateral h cacl

Triceps m., medial

head

{Top) Fi rst of four coro nal Tl MR images of the right scapula, p resented from posterio r to anterior. The quadrilateral
space contains the axil la ry nerve an d posterio r ci rcum flex humeral artery. (Botto m ) Th e q uad rilateral space l ies
between the teres minor and teres major m uscles, superiorl y and inferiorly, and between the long head of t he triceps
muscle and humerus su rgi ca l neck, med ially and laterally.
 CLINICALLY RELEVANT REGIONS
CORONAL T1 MR, SCAPULA

Trapezius muscle
Acro mi oclav icu la r jo int

tendo n Supraspi n at us muscle

Spi n oglen o id notch Scapul ar spi n e

Suprascapular artery
bran ch

Tricep s muscle, lon g

h ead

De lto id muscle
Teres m a jo r &
lati ssim us dorsi
muscles

Triceps muscle

Trapezius muscle
Distal clavicle

Sup ra spin atus te ndo n Supraspinatus musc le

Sp in oglen o id no tch

Subscapul aris muscle

Te res ma jo r &
Deltoid muscle lati ssimus do rs i
muscles

Trice ps musc le, m ed ia l

bead

VI
(Top) Th e spi noglenoid notch lies between the sca p ula r spine an d glenoid . (Bottom) The infraspina t us branch of the :::r
suprasca pu la r nerve a nd branches of th e su pra sca pul ar vessels t rave rse t h e spinoglen oid n otch . 0
c
c..
('0

""''

13 7
 CLINICALLY RELEVANT REGIONS
AXILLARY RADIOGRAPH & AXIAL CT, OS ACROMIALE

Coracoid process

H_umeral head
Distal clavicle

Os acromiale

Unfused growth plate

Acromion

Acromioclavicular joi nt

Os acromiale
Distal clav icle

Unfused growth plate

Acromion

Scapular spi ne

(Top) Os acromiale, t he most commo n no rmal an atomic va ri an t o f the sh oulder. An axil lary rad iograph
demonstrates an accessory articulation w ithin the acromion p rocess, represen ting an unfu ed ossificatio n center.
(Bottom) An ax ial unenhanced CT in the sa me pati ent better demonstrates the os acromiale.

138
 CLINICALLY RELEVANT REGIONS
30 CT & AXIAL T1 MR, OS ACROMIALE

Coracoid process Humeral h ead

Clavicle Humeral sh aft

Acrom ioclavicular join t

Os acromiale
Glen oid

Un fused growth plate

Acromi on process

Scapular spin e

Acro m ioclavi cu lar joi n t Os acro m iale

Distal clavic le Unfused growth plate

Acro mion process

Suprascapular vesse ls

Deltoid muscl e

Sca p ular

(Top) 30 CT vol ume re nde red im age of a n os acromi ale in th e sam e patie nt as on th e p revious im age. The image is
oriented as if it were being viewed from below. (Bottom) Axial Tl MR of an arthritic os acromiale in a different
pati ent.

139
 ABER POSITIONING
o Unfam iliar position for tech no logists
\Terminology • Requires extra ti me positio ning patient and co il
Abbreviati o ns • Improper a lig nment of axial images
• Abducti o n ex terna l ro tatio n (ABER) o Images need to be prescribed a long s haft of
humerus from orthogonal coronal plane sco ut
o This non standard alignm ent may be d ifficu lt to
achieve w hen no t part of routine study
\Imaging Anatomy • Wrap artifact
Overview o Saturation band ca n be placed over media l ches t
• An o ptional patient position fo r MR arthrography wa ll '
• Inadequate s ignal
Anatomy Rel ationships o Clamshell coil vs. multi element ar ray
• Bicipital g roove rotated to lie at superior aspect of o Malpositio n ·of array elements
humera l head • Me niscoid (type 3) labr um
o Exte rnall y ro tated and elevated o Co ntrast ex tends into a normal ga p betwee n
o Above spinoglenoid notch meniscoid labrum and cartilage
• Inferior glenohumeral ligament is pulled taut
o Exerts tracti o n o n anterior labra l liga men to us
complex \Clinical Implications
o Allows intra-a rticular contrast to flow into tears
• Coracoid process tip indica tes approxima tely Clinical Importance
2:00-3:00 posi t ion of anterior labrum • ABER position for MR imaging improves
• Inferior images show the 5:00-7:00 position of labrum, visualization of severa l regio ns
depending on alignmen t o Anterior a nd posterior la brum
• Es pecially no n-detached tears of anteri or labru m
Internal Structures-Criti cal Contents o Anterior ca psular attachment
• Art icula r surface of rotator cuff and rotator cuff o Inferior g lenohumeral ligament
"footprint" o Undersurface of rota tor cuff
o Relieved o f tension, kinks • When differentiatio n between tend inosis and
o Undersurface tears and fraying fi ll with contrast pa rti al thi ck ness tear is clini ca ll y important
• Labrum • Throwing athletes
o Anterior labrum under tension o lntrasubsta nce or horizontal component tears o f
o Posterio r labru m in contact with arti cular surface of rotator cuff
rotator cuff o Coracohumera l liga men t

\Anatomy-Based Imaging Issues \Selected References

Imaging Reco mmendations 1. Herold T et al: I ndirect MR Art h rograph y of th e Shoulder:
Use o f Abduction and External Ro tation to Detect Full - and
• High fi eld strengt h MR scanner Partial-Thick ness Tears o f the Supraspi natus Tendon .
• Flexible sho ul der coil o r phased array coil Rad iology. 2006
2. Lee SY et al: Horizontal com pon en t of pa r tial -thic kness
Imaging Approaches tears of rotator cuff: i magi ng characteristi cs and
• Standard MR arthrogram in jection performed co mpa rison of AB ER v iew w ith obl ique co ronal view at MR
o 12 ml dilu te gadopentetate d im eglumine (2 arthrography ini tial resul ts. Radiol ogy. 224(2):470-6, 2002
mm oi/L) mixed with iodinated co nt rast, Ma rcaine & 3. C h oi JA et al: Com pa rison b et ween convention al MR
epinep hrine according to institutio nal p reference arth rography and abduction and ex tern al rotation M R
• Ind irect MR art h rogra m IV in jection also useful when arthrograph y in reveal ing tears of t he an tero- in ferior
direct injecti o n not perform ed glenoid labrum. Koreanj Radio!. 2(4):2 16-21, 2001
4. Kw ak SM et al: Gl enohumera l joint : comparison o f
• Arm abducted greater than 90°, unless imaging with sh oulder posi tions at MR arthrography. Rad iology.
an open MR system 208(2):375-80, 19 98
• Hand placed on top of head, over head or behind 5. W in tzell Get al: Indirect M R arth rography of an terior
neck sh oulder i nstability in the ABER and th e app reh en sion test
o Elbow fl exed pos ition s: a prospect ive co mparati ve study of two di ffere nt
• Scout view o btained in coronal plane sh oulder posi tions duri ng MRI u sing in t ravenou5
• Images aligned w ith sha ft o f humerus gadodi amide con trast for enhan ce men t of the join t flui d .
o Hum erus lo ng axis images Skeletal Radio !. 2 7(9):488-94, 1998
6. Cvitan ic 0 et al: Usin g abduction and ex tern al rotation of
o Ob lique axial images through joint the sh ou lder to i ncrease t he se n siti vi ty o f MR arthrograph y
o Oblique sagittal images wi th respect to bod y i n revealing tears o f the anterior glenoid lab rum . AJ R Am J
Roen tgenol. 169(3):837-44 , 1997
Imaging Pitfalls 7. Ti rm an PF et al: MR arth rographic depi cti o n of tea rs o f the
• Improper po sition ing ro tato r cu ff: ben efi t o f abdu ction and ex terna l rotatio n of
o Patients un willing or unable to ho ld this position the arm. Radio logy. 192(3):85 L-6, 1994
due to pain o r appre hension

140
V'l
:::::r
0
c
Q..
('!)
-:
 ABER POSITIONING
ABER T1 FS M R ARTHRO GRAM

Deltoid muscle, middle

head

Acromion

Deltoid m
anterior head

Posterosuperior
sh ou lder

A nterosu perior
shoulder

groove
Lesse r tuberos ity

Co racoid process

(Top) First of twenty T1 FS MR arthrogra m im ages o f the shoulder in th e ABER position pre en ted superior to
i nferior. (Bottom) The patient is positioned with the arm held behind the neck or head. An ort h ogona l corona l scout
image is obtained and ax ia l obl ique im ages are prescri bed along t he long axis of the h u meral sha ft.

142
 ABER POSITIONING
ABER T1 FS MR· ARTHROGRAM

Acrom io n

Contras t i n bi ceps
Lesser tuberosity tendon shea th

Subscapu lari s tendo n

i nserti on

Acromion

Biceps tendon, long

h ead
G reater tub erosity
Lesse r tuberos ity Biceps anchor

tendon
i n se rtion
A n terosuperior labrum,
1:00 posi tion
An terosuperior labrum,
2:00 posi tion

Superio r glenoid

V'l
(Top) Th e subscapulari s tendon insertion on th e lesser t u berosi ty is sh own on th is image. Intra-articular co ntrast ca n ::::r
normally ext end into th e biceps tendon sh ea t h . (Bott om) The long head of th e biceps tendon is sh own alo ng t he 0
length of th e proximal bicipital groove. c:::
c..
(t)
""''

143
 ABER POSITIONING
ABER T1 FS MR ARTHROGRAM

Acromion
Biceps tendon, long
head
Biceps anch or

Lesser tubero si ty
Supraspinatus tendon

Anterosuperior labrum ,
Subscapularis tendon 1:00 positio n

Superior glen oid

Biceps tendon, lo ng
head Acro mion

Supraspinatus tendo n

Superior labrum, 12:00

posi tion & biceps
anch or
Middle glen oh umera l
ligamen t

Subscapu lar recess

Subscapularis tendon

(Top) The m ost superior images through the sh ou lder jo i n t show the long head of th e biceps tendon . Th e biceps
an ch or to the labrum is also demonstrated. Th i s posit ion is relatively insen sitive for the detecti o n o f su perior labral
anterior to posterior (SLAP) tears. (Bottom) The biceps t endon, just proximal to t h e labral attach ment, can be kinked
due to positi oning. Kinking of the biceps tendon ca n sometim es indicate a SLAP tea r.
 ABER POSITIONING
ABER T1 FS MR 'ARTHROGRAM

Scapula r spi n e

Jl um e ral head
Supraspinatus ten do n

Poste rior su pe rio r

la brum , 11:00 po siti o n

Middle gle n o humeral

liga ment

Su bsca pula r recess

Subscapularis te ndo n

Sca pu lar s pine

Hum e ral head Supraspinatus tendo n

Poste rior superi o r

la brum, 11:00 positio n

Middle gle no humeral

ligame nt

Subscapular

Su bsc apularis te ndo n

Vl
(Top) The posterosuperior labrum. is partially visuali zed . The ABER position best sh ows the 2:00- 10 :00 position of the :::::r
labrum. (Bottom) T he midd le glenohume ra l ligament is demonstrated at the attach m en t to the subscapul ar is 0
tendon. T he prese n ce of true gle no humera l ligame nts is deba ted. The gleno hum eral ligaments ma y represent folds of c
the jo int capsule. 0..
ro
'"'I

145
 ABER POSITIONING
ABER T1 FS MR A RTHRO G RAM

Se<tplll ar

tendo n
ll umeral head

Posterior
labrum , I 0:00- 11 :00
posi tion

Inferio r glenohumeral
ligament, an terio r band
Anterio r
labrum , 2:00-3:00
pos ition
Subscapula ris tendon

Sca pular spin e

Sup raspi natus tendo n

in se rti on
l lllmeral head
Posterior superior
labrum , I 0:00 position

Anter io r labrum, 3:00

{Top) Th e anterior ba nd of the inferio r glenohu mera l ligam ent is under traction and is seen curvin g around the
anterior border o f the humeral head. Th e tracti on fo rce i s tran sm i tted to the anterior labrum, increasing the
li keli hood of contrast to enter a small tea r. (Bottom) If posterosuperi or subglenoid impingement of th e humeral
head we re presen t, it may be seen at this level. Contact between th e rotator cu ff undersurfa ce and labrum can be seen
in asymptom ati c patients.

146
 ABER POSITIONING
A BER T1 FS MR' ARTHROGRAM

Scapular sp ine

Transi tion between

su p raspi na tus &
infraspi natus tendons
H um eral head
Posterior labrum,
9:00-10:00 position

Inferior glenoh umera I

ligamen t, anterior band A n terior labrum, 3:00
positio n

Scapul ar spine

Transition between
supraspinatus &
in fraspinatus tendons
Humeral head
Posterio r labrum, 9:00
position

A nterio r labru m,
3:00-4:00 position
Axillary vei n

CJl
(Top) T he traction of th e anterior band of the inferio r gle n ohume ra l ligament also inc reases v isualization of labra l ::::r
tears tha t have part iall y heal ed or h ave been resynovia lized. (Bottom) T h e ABER positio n allows the a n te ro inferior 0
labru m to be imaged wi th out magic a ngle artifact th at can be p resent with st andard, add uc ted postio n ing. c
0..
ro
""t

147
 ABER POSITIONING
ABER T1 FS MR A RTHROGRAM

Scap ula r spi ne

H umeral h ead

Posterior lab rum , 9:00

posi t ion

Axill ary recess

An terior labrum , 4:00
posit ion

Scapular spi ne

I nfraspi natus ten don

Humera l h ead

Spi nogl eno id notch

Axillary recess

An te rior i nferior
lab ru m, 5:00 po>i tion

(Top) Osteochondral i n juries of th e posterosuperio r h umeral hea d, n o t present in thi s case, are acce ntuated i n th e
ABER positio n . (Bottom) Detect ion o f antero in feri or lab ral tea rs i s improved i n the A BER posi t ion.

148
 ABER POSITIONING
ABER T1 FS MR·ARTHROGRAM

Scapu lar spi ne

In frasp i natus tendon

Humeral head

====-- Pos terior labrum,

8:00-9:00 posit ion

Axi llary recess

I nferior labrum, 6:00
pos itio n

Scapu lar spi ne

Humeral head

Poster ior inferior

l ab rum, 8:00 positio n

Anterior labru m,
6:00- 7:00 positi on

V'l
(Top) Th e sm ooth undersurface of th e infraspinatus tendo n is shown. (Bottom) The ABER positio n al lows th e :::r
supraspinat us, infraspinatus and teres m i n o r tendons t o kink. This would p otential ly allow contrast to fill sma ll 0
undersurface tears. T he A BJ::.R position is very helpful for detection o f delaminated rotator cuff tea rs. c
0....
('0
-,:

149
 ABER POSITIONING
ABER T1 FS MR ARTH ROGRAM

Teres minor tendon

Scapular spi ne

Humeral head

Posterior labrum,
7:00-8:00 pmition

Inferior labrum,
6:00-7:00 position

minor tendon

llumeral h ead

Posterior inferior
labrum, 7:00 position

(Top) Undersurface tears of the tere mi n o r ca n be accen tuated in this positi o n, when compared with standa rd
adducted MR i mages. (Bottom) The most inferior image th rough the glenoid labrum ranges from the 5:00- 7:00
position. Th e exact location depends on patient positioning and i mage alignment.

150
 ABER POSITIONING
ABER T1 FS MR·ARTHROGRAM

Teres minor tendon

1-l urneral h ead

Posteri or inferior
labrum, 7:00 posi t ion

Vl
(Top) Alt houg h ABER positio nin g m ay im prove v isualiza tion of some anatomi c stru ctu res a n d ab no rm a liti es in the ::::r
shoulde r, the re are li mitation s. The m ost significant limitat io n is th a t man y patie nts with shou lder pai n will n ot be 0
able to tolera te this positio n. Add itio n a lly, pro per placem e nt of the shou ld e r coil a nd a lig nme nt of t h e im ages ca n be c::
challen gin g fo r tech nologist un fa miliar with th is techn ique. (Bottom) Th e ABER positi o n sh oul d be a n o p tional c..
additi o n to routin e sh o uld er imagin g, ba la nc ing the increased imaging time and pa tient d iscom fo rt wit h the ro
potential for improved visualiza tio n of o th erwi se subtle ab no rmaliti es. ""'

15 1
 ARM OVERVIEW
• erve supply: Radia l nerve
Jlmaging Anatomy • Blood supply: Dee p brachial arte ry branch es
Overview • Action: Elbow exte n sion, ad ducts h um e rus w he n
• Muscles of the upper arm are d ivided in to anterior and arm is e xtend ed
posterior compa rtments o Trice ps m uscle, la teral head
• Origin: Posterior and late ral h um e ra l sha ft, lateral
Anat o m y Relatio nshi ps in termuscula r septu m
• Anterior compartm ent of arm • Insertion: Pro x imal o lecrano n and deep fascia of
o Coracob rach ial is muscle arm after jo ini ng with long and media l heads
• O rigin : Co racoid process t ip, in commo n w ith a n d • Ne rve suppl y: Radia l ne rve
m ed ial to s h ort h ead biceps tendon • Blood su ppl y: Deep brachial artery b ranch es
• Insertio n: Medial s urface of humeral m id shaft, • Act ion: Elbow extensio n
between brachialis a nd triceps muscle o rigins o Triceps muscle; m ed ia l head
• Nerve supply: Musculocutaneous nerve, perforates • Orig in: Poste rior hume ra l s haft fr o m te res majo r
m uscle in sertion to n ea r t roc h lea, medi a l in te rmu scula r
• Blood supply: Brachi al artery, m uscular bran ch es septum
• Act io n: Fl exes and addu cts s h o ulde r, s upports • Insertio n : Proximal olecra n o n a n d deep fascia of
humera l head in glenoid arm after jo ining w ith la te ra l and lon g h eads
• Va riants: Bo n y h ea d extending to m edia l • Nerve supply: Radial & branc hes of ul na r ne rve
epicon dyle, short head ex te n di ng to lesser • Blood s uppl y: Deep brac hia l a rte ry bra nc hes
tuberosity • Action: Elbow exte nsion
o Bice ps muscle, s h o rt head • Variants, triceps muscle: Fou rth head fro m m ed ia l
• Origin: Coraco id process tip, in co mmon with a n d h um erus, sli p term ed t he dorso-epitrochl ear is
latera l to co racobrachialis te n don extending between triceps and latissimus dorsi
• In se rtio n: Rad ial tube rosity after joining lo n g h ead o Anconeus muscle
• Nerve suppl y: Mu scu locutaneous nerve • Orig in: Late ra l ep icondy le o f hum erus
• Blood suppl y: Brachi al arte ry, muscular branch es • Inserti o n : Latera l o lecra n on and poste rio r
• Ac tion: Flexe s e lbo w & sho ulde r, supin at es one-fou rth of ulna
forea rm • Nerve sup ply: Radial nerve
o Biceps muscle, lo n g head • Blood s upply: Deep brac hial a rte ry, m iddl e
• Origin: Predomina n t ly supragl en o id tuberc le; a lso coll at e ra l bra n ch
supe ri or g len oid la brum and coracoid base • Action: Assists elbow exte n sion, abducts uln a
• Insertio n: Rad ial tube rosity after jo ining with • Fascia
s h ort head o Brachial fascia
• Nerve su pply: Musculocutaneo us n erve • Continuous w ith fascia covering del to id and
• Blood s upp ly : Brac h ia l artery, m uscular branc hes pectoralis m a jor
• Actio n : Flexes e lbow & shoulder, s upina tes • Va ries in t h ickness being thin over b ice ps and
forea rm th ick o ve r t rice ps muscles
• Lace rtu s fib rosus (dista l bic ipita l • Lat era I i nterm uscu la r septum fro m lower aspect of
fascia/apone urosis) provides t ract ion o n deep g reate r tu berosity to lateral epico nd yle
fascia of forearm • Med ial inte rmuscular septu m fro m lowe r aspect of
• Variants, biceps muscle : Third head i n 10% a ri sing lesse r tube rosity to m edial epico nd y le
at uppe r m ed ial aspect of brachialis m u scle, fo urth • Perforated by ulnar ne rve, superio r ulnar coll ateral
head can arise from latera l hu meru s, bicipita l arte ry and poste rior b ranch of infe rior ulna r
g roove or greate r tu be rosity collatera l a rte ry
o Brachialis mu scle o Bicipital fasc ia
• Orig in: Distal h alf of anterior humera l shaft and • Also known as lace rtus fib rosus
two intermuscu la r septae • Arises from media l side of distal bi ce ps te ndon at
• Insert ion : Tuberosity of ulna and anterior surface level of e lbow join t
of coronoid process • Passes su pe rficial to brac hial a rtery
• Ne rve supp ly: Muscu locutaneo us n erve plus • Con t in uous with deep fascia of fo rearm
bra n ch o f radia l nerve
• Blood su pply: Brac hia l artery, muscula r branches
and recurren t radial artery !Anatomy-Based Imaging Issues
• Actio n : r:Jexes fo rea rm
• Cove rs a n te rior aspect of e lbow joi nt Imaging Recom mendations
• Varia n ts: Doubled; sli ps to supina tor, pron ator • Radiographs a nd CT: Eval uation of bon e co rtex and
te res, bice ps, lacert us fib rosus o r radiu s m atrix of an y identified bon e lesio n
• Poste rior c ompar tme nt o f a rm • MR: Ax ia l plane m ost helpful to d e li neate bo rd ers of
o Triceps muscle, long head ante rior a nd pos terio r co mpa rtme nts and relatio n s h ip
• Orig in : Tn fraglen oid t u bercle of sea pula to n euro vascular s tw ct u res
• Inserti o n: Proxima l o lecranon a nd deep fa scia of
arm after joi nin g w it h lateral and m edia l heads

152
 ARM OVERVIEW
AP & ROTATIONAL LATERAL RADIOGRAPHS

Acrom io n

Greater tu berosi ty
- ------r- Coracoid process
- - - - - + - G lenoid

Rib
Deltoid tu beros ity

Hum erus, shaft

- - - - -- -+- U l na, o lecran o n

Lateral epicon dyle process

Radius, he<1d

Acro mion

---+- Coracoid process

Lesser tuberosity - - - - - + - G len oid

U lna,
process

Radius, head

Vl
(Top) ormal AP radiograp h o f right hum eru s, ex tern ally rotated. Th e patient is positi on ed with th e shoulder mi ldly ::r
abducted, the elbow extended and th e h and supinated. Both th e sh oulder and elbow join ts should be v isible on the 0
radiograph . (Bottom) Normal internally rotated lateral radiograph o f ri ght humerus. T he pa tient is positioned with c:
the shoulder intern ally rotated and mi ldl y abducted. lf obtained lateromedia l, as in this case, th e elbow i s partia lly 0..
('[)
flexed. If obtained medio latera l, t hen th e elbow wou ld be flexed 90°. ""'!

153
154
V'l
::r
0
c
0..
ro
""'t

155
156
V'l
::::r
0
c
Q..
('D

""''

157
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

Cep halic vein

J3iceps muscle

Del toid tuberosity Cora cobrach ialis

muscle
Humerus Ul nar & m edian n erve,
brachia l vessels
Radial nerve & deep
brachia l artery

Triceps muscle, lateral

head

Triceps long
head

[,l]ld
I .
I
_,

Cephalic vein
Biceps mw.cle

Deltoid tuberosity Coracobrachialis

Del to id muscle
Ulnar & median nerve,
brachial vessels
Radial nerve & deep
brachi al ar te ry

Triceps lateral
head Triceps muscle, long
h ead

(Top) First in seri es of axia l T l MR images of th e rig ht arm displayed p roximal to d i stal. Images were acqui red at 3T.
This image is located just dista l to th e axilla . (Bottom) T h e del to id muscle inserts o n th e delto id t uberosity.

158
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

mF
M
Cepha lic vein

Bi ceps m usclc:

Deltoid tuberosity
Co racobrac h ia lis m.

Ulna r & med ian n erve, Humcrus

brachial vessels
Radial n erve & deep
b rach ial artery

:.-----'iii-- Triceps m uscle, late ral

h ead

Trice ps muscle, lo n g
head

Cephalic vein
Biceps m usc le

Coracob rach ial is m. Deltoid tube rosity

Ulnar & median n erve, De lto id mu scle

brachial vessels
Radial n erve & clee p
brachial artery

Triceps muscle, la te ral

head
Triceps musc le, long
·h ead

CJ)
(Top) Firs t in series of ax ia l T l MR im ages of the le ft a r m dis played p roxima l to di stal. Im ages were acquired at 3T. ::::r
Thi s image is l ocated just d i stal to th e axilla. (Bottom) Th e del to id muscle in serts on t h e del toid tu berosity. 0
c
a..
ro
...,

159
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

Cephali c vein
BicelJs m uscle

Delto id tuberosity

llum erus
w::;::;;-- Uln ar & med ian nerve,
brachia l vessels
Delto id muscle

Rad ia l nerve & deep Triceps muscle, medial

brachi al artery head

Triceps muscle, lateral

head muscle, long
head

Biceps
Cephalic vein

Brach ialis muscle

Ul nar & med ian nerve,

Humerus
brachia l vessels

Radial nerve & deep

Triceps m uscle, media l
brachial artery
head

Triceps tendon
Triceps muscle, lateral
h ead

Triceps muscle, lon g

head

(Top) Th e medial head o f t he triceps is arising from th e posterom edial humera l cortex . (Botto m ) T he brach ia l is
muscle is arising f rom th e anteri or humera l co rtex.

160
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

Cephalic vei n
Biceps m uscle

Deltoid tuberosity

Humerus
Ulnar & median nerve,
brachi al vessels
Deltoid muscle

mu>clc, media l n erve & d eep

h ead brachia l art ery

Triceps muscle, lateral

Triceps muscle, long head
head

Bi ceps mu scle Cephali c vei n

Brachial is muscle

Humeru s
Ulnar & m edi an nerve,
brachial vessels

mu>cle, med ial Radia l n er ve & deep

head brach ial artery

Triceps te ndon
Tr iceps m uscle, lateral
head

Tri cep s -long

head

Vl
(Top) The medial h ea d o f the triceps is arising from the posteromedial humeral co rtex . (Bottom) The b rachi al is :::r
muscle is arising from the anterior humera l cortex.
0
c
0..
('0
"""!

161
 ARM OVERVIEW
AXIAL T1 MR, RI G HT ARM

Cephalic ve in
Biceps mu etc

Brachiali s muscle
Ul nar & media n nerve,
brach ial
H

Brachialis muscle
Triceps medial
Radial nerve & deep head
brachia l artery
Triceps tendon
Triceps muscle, lateral
head
;:.._--==:r-- Triceps muscle, long
head

Ceph alic vein

Bi ceps muscle

Ul nar & median nerve,

Brachiali s muscle brach ial vessels

H umerus

Brachialis muscle
Triceps muscle, medial
Radial nerve & deep head
brachia I art cry
Triceps tendon
Triceps muscle, lateral
head
Triceps muscle, long
head

(Top) The posterior compartment of the a rm consists o f th e three h eads of the tri ce p muscle. (Bottom) The deep
brac hial arte ry a nd radia l nerve course a lo ng the poste ro la te ral h u merus.

162
 ARM OVERVIEW
AXIAL H MR, LEFT ARM

Cephalic vei n
Bi ceps muscle

Ulna r & media n n e rve, Brac h ial is muscle

b rachia I vessels
Hume ru s

Brac h ia lis muscle

Triceps muscle, media l
h ead Radial nerve and deep
brac hial artery
Triceps tendo n
Triceps muscle, la teral
head
Triceps muscle, lo n g
h ead

IE:
M
Cep hali c vei n
Bi cep s muscle

Ulnar & median nerve,

brachial vessels Brac hialis m uscle

Hu merus

Brac hial is musc le

Triceps muscle, m edia l
h ead Radia l nerve and d eep
b rac h ial a rte ry
Tricep s tendon
Trice p s muscle, la te ral
head
Triceps muscle, lo n g
h ead

CJl
(Top) Th e poste rior com partme nt of th e arm co nsists o f t he th ree heads of the triceps m uscle. (Bottom ) The dee p :r
brachi al artery and radia l ne rve co urse along the poste ro latera l hum eru s. 0
c::
a.
ro
""'

163
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

=m
E
Biceps muscle
Ceph al ic vein

M edian n erve, brachial

vessc.Js
Brachialis muscle Ulnar n., superio r ulnar
co ll ateral vessels

Basilic ve in & medial

I lumerus brachi al cutaneou s n.
Latera l intermuscul ar
septum
Triceps muscle, m edi al
Radia l nerve and deep head
brachial artery
Triceps tendon
Triceps m uscle, lateral
h ead Tri cep s muscle, lon g
head

Ceph al ic vein
Bice ps m uscle

M edian nerve, brach ial

vessels
Brachiali s m uscle
.,._......;=-- Basili c vein &
m edi al
brachi al cutan eou s n.
Humerus

Lateral intermuscu lar Ulnar join t, superi or

septum ul nar col latera l vesse ls

Radial nerve and deep

Tri ceps m., lon g head
brachial artery

Triceps m., la teral h ead

Tri ceps m., m edi al
h ead

Triceps ten don

(Top) Branches o f th e rad ial nerve in nervate t he lateral , lo ng and m ed ial heads of t he triceps m uscle. (Bottom ) The
n eurovascula r b u ndle con ta i ning th e m edian n erve and b rach ial vessels d enotes the locatio n o f the media l
i ntermuscu lar sep tum .

164
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

Cephalic vein

Median nerve, brach ial Brachial is musc le

Bas i lic vei n & medial

brach ial n.
Humerus

La teral i n termuscular
I riceps muscle, medial
head Rad ial ner ve & deep
brachial artery
te ndon
lateral
Triceps mu'>Cie, long head
head

Cepha lic vein

Ul nar & m edia n ner ve,

brach ial
Brachial b
vein & medial
brachi al n.

Lateral intermuscular
Triceps m., long head se ptum

Triceps m., m edial Radial n erve & deep

h ead brachia l artery

Triceps muscle, lateral

tendon
head

(Top) Branch es o f the rad ia l ne rve innerva te the latera l, lo ng and m ed ial heads o f the triceps muscle. (Bottom) The
neurovascular bundle co ntaining th e ulnar nerve, median ne rve and brachial vessels denotes the loca tion of the
medial inte rmu scula r septu m .

165
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

Cephalic vein

' - - 4 - M edian n erve, brach ial

vessels
Brachialis muscle
13asilic vein & medial
brachial cutaneous n.

Uln ar nerve

Triceps m., lo ng head

Radial nerve & deep
brachial artery Triceps m., medial
h ead
Lateral supracondylar
ridge
Tri ceps tendon
M ed ial
ridge Triceps muscle, lateral
h ead

Cephalic vein

M ed ian n erve, brachial

ves els
13rachi alis muscle
13asilic vein & media l
brach ial cutaneous n.

1-1 u merus
Ulnar n erve

Rad ial nerve & deep Tri ceps m., lon g head
brachia l artery
Triceps m., m edia l
h ead
Lateral supracondylar
ridge Triceps tendon

Medial supracondyl ar Triceps mu scle, lateral

ridge h ead

(Top) The thi ck t ri ceps te ndon lies between th e triceps late ral and lo ng h eads. (Bottom ) The biceps muscle is
th inning anteriorly.

lF.F.
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

Biceps muscle Cephali c vei n

Median n erve, brac hi al

vesse ls
Brach ial is muscle
Basi l ic ve in & medial
brac h ial cutan eou s n.

Uln ar nerve

Radial nerve & deep

Triceps m ., long head
brachia I arter y
Triceps m., m ed ial
h ead Lateral supracondylar
ridge

Tr iceps tendon M ed ial supracond y lar

ridge
Triceps mmcle, lateral
h ead

Ceph alic vein

Medi an nerve, brachial

vesse ls
Brach ial is mu scle
Basi li c vei n & m edi al
brach ial cu taneous n.

Uln ar nerve Humerus

Triceps m., long head Radi al n erve & deep
brachial ar tery
Tr iceps m., medial
h ead Lateral supracondylar
ridge
Triceps tendon
Medial supracond ylar
Tri cep s lateral ridge
11ead

fJl
(Top) The thick triceps tend o n lies between th e triceps lateral and lo ng heads. (Bottom) Th e b icep s musde is ::T
thinning anterior ly. 0
c::
c..
t'O
""'

167
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

Biceps muscle

Cep halic vein

M ed ian nerve, brach ia l
Brach iali s muscle vessels

Basili c ve in
Radia l nerve C. deep
brachia l artery
Ul na r nerve
l lum erus
l:x tensor n arpi rad ial is Triceps m ed ial
head

Lateral supraco ndylar Triceps m., long h ead

ridge
rriceps tendo n
Medial supracondylar
ridge

Cephal ic vein
M edian n erve, brachial
13rach ial b m u scle

Brach iorad ia I muscle Basi l ic vein

Radia l n erve C. deep Uln ar nerve

brachia l artery
Triceps muscle, m edia l
h ead
Ex tensor carpi radi al is
lo ngus muscle
Triceps lon g
head
La tera l supraco nd ylar
tendon
ri dge
M edial supracon d ylar
ridge

(Top) The exten sor carp i radial is lo ngu s muscl e o rigi na tes fro m the dista l lateral su pracond ylar ridge. (Bottom ) Th e
brachio racl ialis has become the largest m uscle i n th e anterior co mpartment.

168
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

Biceps mu sc le

Ce phal ic vein
t\1l'dinn nerve, brachial
Brach ialis muscle

Iic vci n Brach io rad ialis muscle

Radi al nerve & deep
brach ial ar tery
Ulnar n erve

mmclc, m edial llumerus

head Exte nsor carpi rad ialis
longus muscle

Ill ., lo ng h ead La teral supracondylar

ridge
tendon
M ed ial supracondylar
ridge

muscle
Ceph ali c vein
M edi an nerve, brachial
vessels Brachialis muscle

Basilic vein Brach iorad ial is muscle

U lnar n erve Rad ial nerve & deep

brac hia l artery
I m ., m edi al
h ead
E.xtem or ca rpi radiali s
longus mu scle

rricep'> 111 ., lon g h ead Lateral supr<Jco ncly lar

ridge
Tri ceps tendon
Medial supracond yla r
ri dge

(Top) Th e extensor carpi radialis longus m uscle ori gi n ates from the distal lateral supracondy lar ridge. (Bottom ) T he
brachioradia l is ha becom e the largest muscle in th e anteri or compartm ent.

169
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

ledian n erve
Cephal ic vei n

Brachi orad ial is muscle

Radial n erve
Brach ia lis mu\cle
Brachialis tendon

Ex tensor carpi rad iali s

lo ngus m uscle M ed ia l supracondy lar
ridge

Lateral
r idge
O lecran on fossa & Triceps m uscle, long
posterio r fa t pad h ead
Triceps ten don
Triceps muscle

Cephalic vein
1ed ian cubi tal vein
Brachioradialis m usc le

Radia l n erve
Brachial h mu\cle
Brachial is tendo n

Extensor carpi radia lis

lo ngus mu scle Medial supracondylar
ridge
Lateral sup racon d ylar
ridge
Olecran on fossa &
posterio r fat pad Triceps m., long h ead

Triceps m uscle Triceps tendon

(Top) This image is located at the su perior aspect o f th e elbow. Th e o lecra no n fossa contains t he poste rio r fa t pad .
(Bottom ) The b iceps is n ow almost entirely ten d ino us.

170
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

Biceps muscle

l\led ian nerve

Cephalic vei n
Median cubita l vein
Brach ioraclia l is muscle

Hasi l ic vein
Radia l nerve
Brachialis muscle
Brach ial is tendon
Ex tensor ca rpi radia lis
l\ leclial supracondylar
longus muscle
ridge
Ulna r nerve

Latera l su pracondy lar

Triceps muscle, long ridge
head Olecra n on fossa &
Triceps tendon posterior fat pad
·1riceps

Bicep\ tendon

Biceps muscle

Median n erve
Ceph al ic vei n
Median cub it al vein
Brachioradia lis muscle

Basil ic vein
Radial nerve
Brachialis muscle
Brach ialis tendon

l\ledial supracondylar Ex tensor carpi radi al is

ri dge longus muscle
Ulnar nerve
Latera l su pracondyla r
ridge
rriceps muscle, long
head O lecranon fossa &
posterior fat pad
Triceps ten don
Triceps muscle

Vl
(Top) This image is located at the superior aspect of the elbow. Th e olecranon fossa con tains the posterior fat pad. ::::r
(Bottom) The biceps is now almost entirel y tend inou s. 0
c:
a.
..,
(t)

I
1 71
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

M edian n erve

Biceps ten don

Median cubital vein
Cephal i c vei n
Brachial is muscle
Brach ial is tendon
Basilic vei n
Brachiorad ial is muscle
Trochlea
Radial n erve branch es

Extensor carpi radiali s Medial epicond yle

longus muscle O lecranon process
Ulnar n erve & pos terior
Common exten sor t .
ulna r recurrent artery
Lateral epicondy le
Extensor retinaculum
Capitulum

A nconeus muscle
Triceps tendon

Median nerve Brachialis tendon

Median cubi tal vei n

Ceph alic vein Brachialis musc le

Biceps tendon
Basi l ic vein
Brachioradialis m u scle

Radial n erve bran ches Trochlea

Capitulum Commo n flexor t .

Common ex tensor t.
Medial epi cond y le

Exten sor ca rpi radialis Uln ar nerve & posterior

lon gus muscle ulnar recu rren t artery

Lateral epicondyle
Exten sor retinaculu m

An coneus muscle
O lecrano n proce''

Trici pital aponeurosis

(Top) The ulnar nerve ha s passed be h ind the m edial epicondyle. (Bottom) T he anconeus m uscle a rises from the
late ra l epicondyle.

172
 ARM OVERVI EW
AXIAL T1 MR, LEFT ARM

Median nerve lb:

Biceps tendon
Median cubital vein
Cep h alic vei n
muscle

Basilic vein Brachia l is tendon

I rochlea Brachiorad iali s muscle

Radi al nerve branches
Medial epicondy le carpi rad iati>
longu\ m u scle
Olecranon process
Ulnar ne1ve & posterior Common ex tensor t.
ulnar recurrent artery
Lateral epicond yle

Extensor retinaculum Capi tu lum

An coneus muscle

·1 tendo n

Median nerve
Brachiali s tendon

tendon
Median cubital vein
Cepha li c vei n
muscle
Basilic vein Brach iorad ialis muscle

Radial n erve branch e>

Troch lea
Common flexor t. Capi tulum

t-.lettial epicond y le Commo n extensor L

Extensor ca rpi radialis

Ulnar nerve & pmterior
lon gus muscle
ulnar recurren t artery

Lateral epico nd yle

Lxtensor retin acu lum

Olecranon process Anconeu s muscle

rricipital

(J')
(Top) The ulnar ne rve ha s passed behind th e media l epico n dyle. (Botto m) The a n co n eus muscle arises from the :::r
lateral epico nd yle. 0
c:
0..
("0
""''

1 73
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

Brachialis tendon l edian cubital vein

Cephalic vein
muscle
Bi ceps tendon

Brachioradialis muscle

Radial n erve branch es

Common flexor t.
Common exten sor
tendon

Ex ten sor carpi radialis Ul nar nerve & posterior

longus mu cle ulnar recurrent ilrtery

Capitulum O lecranon process

muscle

Median nerve

Medial cubi tal vein

Bicipital aponeu rosis

Ceph alic vein Brachi alis muscle

Biceps tendon Basilic vein

Radial nerve branch es

tendon
Extensor carpi radialis
longus muscle Troch lea

Medial epicondyle
Common ex tensor t.
U ln ar nerve & posterior
ulnar recu rrent artery
Capitulum

muscle Flexor carpi uln aris

muscle

(Top) The bi cip ital aponeu rosis o r lacertus fibrosis h as o riginated f ro m the medial side o f th e biceps tendon .
(Bo ttom ) The brachialis tendon is nearing the insertion o n th e u l nar tuberosity.

174
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

Median n erve

Brachialis tendon

Median cubital vei n

Cephalic vei n

Brach iali s muscle Biceps tendon

Ha,ili c ve in Brachioradialis mu scle

Rad ial n erve bran ches

Trochlea
Common fl exo r t.
Common extensor
Medial epi condyle tendon
Extensor carpi radial is
Ulnar ner ve & posterior
longus muscle
ulnar recurrent artery

Capi tu lum
O lecra n on

muscle

Median n erve

Bicipi tal aponeurosis

Median cubital vein
Cepha li c ve in
Brachialis muscle Biceps tendo n

Ba'>ilic vein Brachiorad ial is muscle

tendon Radial nerve branches

rrochlea Extensor carpi radialis

lon gus muscle
Medial epi con d yle
Ulnar nerve & Common extensor
ten don
ulnar recurrent artery
Capitulum

Flexor carpi ulnaris Anco n eus muscle

muscle

(Top) The bicipital aponeurosis or lacertus f ibrosis h as originated from the medial side of the biceps tendon.
(Botto m) The brachi al is ten don is nearing t he insertion o n th e ul n ar t uberosity.

175
 ARM OVERVIEW
AXIAL T1 MR, RIGHT ARM

Median nerve

Medial cubital vein

Biceps tendo n
tendon
Ceph Jiic vein
Brach ial is muscle

Radial n erve bran ch es Prona tor teres muscle

Brachi oradi ali s muscle

Basi lic vei n

Radial head Flexor carpi radia l is

muscle
f.x ten or ca rpi radialis
longus muscle U l nar n erve

a mmon ex tensor Palmaris longus muscle

tendon
Ul na
muscle

Median nerve

Medial cubita l vei n

Biceps tendon
Brachialis tendon
Cephalic vein
Brachialis muscle

Radial nerve branc hes Prona to r teres muscle

Brachioradialis muscle

Extensor carpi rad ialis

longus muscle
Flexor carpi rad ialis
Radial h ead m u scle

U ln ar nerve
Co mmo n ex tensor
tendon
Palm aris longus muscle
muscle

Uln a

'-
Q) (Top) T h e radial h ead is com ing into v iew. The bice ps tendon is coursing deep in the antecu bi tal fossa. ( Bottom) T he
"'C majority of J·h e muscle mass at the latera l aspect o f th e elbow co nsists of the b rach ioradiali s and extensor carpi
:::s radialis longus muscles.
0
..c::
rJl

176
 ARM OVERVIEW
AXIAL T1 MR, LEFT ARM

Median nerve

Medial cubital vei n

Biceps ten don
Brach ial is tendon
Cephali c vein
Brach ial is muscle

Pronator teres muscle Radial nerve bran ch es

Brachi oradi alis muscle
Basi lie vei n
Rad ial head
Flexor carpi radialis
muscle Extenso r carpi radialis
Ulnar nerve lon gus musc le

Palmaris longus m u scle Common exte nsor

tendon
Ul n a
Anco neus muscle

Medi an nerve

Medial cubital vein Biceps tendon

Brachialis lendon
Cep hali c ve in
Brachia l is muscle

Radial nerve branches

Pronator teres muscle
Brachioradialis muscle

Extensor carpi radialis

lon gus muscle
Flexor ca rpi radia l is m.

Ulnar nerve Radial h ead

Palmaris longu s muscle Com mon extensor t.

Ancon eus muscle

Ul na

(Top) The radial head is coming into view. The biceps t e ndo n is coursi n g deep in the a n tecubital fossa. (Bottom) Th e
majori ty o f th e muscle mass at th e lateral aspect of the elbow con sists of the brac hiorad ialis and exte n so r carpi
radialis lo n gus m uscles.

1 77
 ARM OVERVIEW
CORONAL T1 M R, RIGHT ARM

muscle
Deltoid tendon
In fraspi na tus tendon
muscle

Teres min or mu scle In fraglenoid tubercle

Deltoid Triceps 1., lon g head

posterior bell y
Teres major muscle
Posterior ci rcum flex
humeral vessels &
ax ill ary nerve
Serra tus anterior m.

dorsi muscle

Triceps m uscle, lateral

h ead
Triceps muscle, long
h ead

Triceps tendon

Superior labrum
Infraspin atus tendon

Teres minor tendon Subsca pul aris muscle

, len oid
Deltoid m uscle;
posterior be lly
Teres major muscle
Posterio r circumflex
humeral &
axilla ry n erve

Rad ial n., deep brachia l

artery Serra tus anterior

Triceps muscle, lateral

h ead
Lati ss i mus dors i muscle

Triceps muscle, m edi al

head Triceps muscle, lon g
head

(Top) First in seri es of sequential coro nal T l MR images o f th e right arm displayed posterio r to anterior. Images were
acquired at 3T. Th e long h ead of the tri ceps originates from th e i nfraglenoid tubercle o f the scapula. (Bottom) T he
muscle mass o f th e pos terior arm con si sts of th e three heads o f th e t riceps muscle.

178
 ARM OVERVIEW
CORONAL T1 MR, LEFT ARM

Supraspina tus muscle

Del toid tendon
Subscapularis muscle In fraspi nat us tendon

I nfraglenoid tubercle Te res minor musde

Triceps t., lon g h ead Deltoid muscle,

posterior belly
Teres major muscle
Posterior circumflex
humeral vessels &
axi llary nerve
Serratus an terio r m .

Latissimus dorsi muscle

Triceps muscle, lateral

head
Triceps muscle, lon g
head

Triceps tend on

Superior labrum
Infraspi natus tend on

Sub capularis muscle Teres minor tendon

Glenoid Del to id muscle

Teres major m uscle

Posterior ci rcum flex
hu m eral vessels &
ax ill ary nerve

Serratus anterior Radia l n., deep brachial

muscle artery

Triceps muscle, la teral

head
Latiss imus dorsi muscle

Triceps musc le, m ed ia l

Triceps muscle, long h ead
h ead

Vl
(Top) First in se ries o f sequ ent ial coronal Tl MR images of the left arm displayed poster.ior to a n te ri or. Images were :::i'
acqu ired at 3T. The long h ead of the tri cep s o riginates from the infragl enoid t u bercle of the sca pu la. (Bottom) The 0
muscle mass o f th e posteri o r arm con sists o f th e three h eads of the triceps m uscle. c:
a.
('[)

179
 ARM OVERVIEW
CORONAL T1 M R, RI GHT ARM

Coracoid p rocess, base

In frasp ina tu s ten don

Su bsca pu la ri s muscle

Del toid muscle

Teres m ajor &
dorsi
Posterior ci rc umflex muscles
humeral vessels &
axillary nerve Brac h ial vessels;
m edian / ulnar nerves
Posterior d eltoid
attac hment
Triceps muscle, la tera l Serratus an te rio r
head m uscle

Radial ne rve & deep Lat iss imus d o rsi musc le

brachi al a rtery

Triceps muscle, lo ng
head
Triceps muscle, m edial
h ead
Triceps ten don

Ulna, olec rano n

process

Coracoid process
Infrasp inatus tend o n
Axil la ry vessels &
brachia l p lex us
Posterior c ircumfle x Subscapul aris musc le
hume ral vessels &
ax ill ary n erve Teres major &
Ia t issi mus d o rsi
muscles
Deltoid m uscle, m iddle
belly Brachial vesse ls;
m ed ia n/ ul na r n e rves
Delto id tuberosity
Serratus a n te ri or
Triceps muscle, la teral muscle
head
Lat issim u s do rsi muscle

Rad ial nerve & radia l

collate ral artery Triceps muscle, long
head

Triceps muscle, med ial

head
Ulna, olecranon
process

(Top) Th e teres major a nd lat iss im us dors i m uscle cou rse anteri orly to insert on the an teri o r hum eral co rtex.
(Bottom) The d eltoid muscle tape rs distally at the a ttachme nt to the de ltoid tuberosity.

180
 ARM OVERVIEW
CORONAL T1 MR, LEFT ARM

Coracoid base
In fraspinatus tendon
Subscap ularis muscle

Deltoid rn u scle
Teres ma jor &
latiss imus dorsi Posterior circumflex
muscles humeral vesse ls &
axillary n erve
Brachi al vessel<;;
m edi an/u ln ar nerves Posterior del toicl
attachm en t

Serra tu an ter io r m. Triceps muscle, la teral

h ead

Lat issimus dorsi muscle

Radial nerve & deep
brachial artery

Tricep s muscle, long

head

Triceps muscle, medial

h ead
Triceps tendon

Ulna, olecranon
process

Coracoid process
In fraspina tu s tendon
Ax illary vesse ls &
brachial pl exu s
Posterior circum fl ex
Subscap ularis muscle humeral vessels &
axi ll ary n erve
Teres majo r &
latissimus do rsi
muscles Deltoid muscle

Brac hial vesse ls;

median/ ul nar n erves Deltoid tuberosi ty

Ser rat us an terior

Triceps muscle, lateral
muscle
head
Latissi mus dorsi muscle

Triceps muscle, lon g Rad ial n erve & radi al

head collateral artery

Triceps muscle, med ial

head
Ulna, olecran on
process

(Top) The teres ma jor and latissim us dorsi muscle co urse anteriorly to in sert on the anteri or hu me ral cortex.
(Bottom) Th e delto id muscle tape rs distall y at the a ttachm ent to the deltoid tuberosity.

181
 ARM OVERVIEW
CORONAL T1 MR, RIGHT ARM

Coracoid process
Supraspinatus ten don

Axillary vessel;&:
brach ial plexus

Posterior ci rcumflex
Subscapul aris m uscle
h umeral vessels &
ax illary nerve Teres major &
lafissimus dorsi
muscles
D eltoid mu sc le, midd le
belly

Serratus anterior m.

Brachial vessel\

Basi lic vei n

Brachialis muscle Latissi mus dor\i muscle

Triceps muscle, lo ng
h ead

Exten sor ca rpi rad ia li s

lon gu s muscle

iiii::::-::::-----"=:::::::::;-- Ulna, olecranon

process

Supraspi natus tendon Coracoid proce;s

Coracobrachialis &
short h ead bicep\
Anterior ci rcumflex tendon
hum eral vessels &
ax il lary n erve Pectoral is m ajor
tendon

Del toid muscle,

anterior belly
Anterior hum eral
cortex Serratus an ter ior
muscle

Lat issimus dorsi muscle

Brachialis m uscle Basilic vei n

Ex ten sor carpi rad ial is

longus m uscle

Common extensor Ulna, olecra n on

tendon proce s

(Top) The brachial is muscle originates from the distal h alf o f the anterior humeral co rtex. (Bo ttom ) T he
coracob rachialis and b iceps short heacl originate fro m the coracoid process.

1 Q')
 ARM OVERVIEW
CORONAL T1 MR, LEFT ARM

Coracoid process Supraspina tus tendo n

Ax illary vessels &
brach ial plex us

Poste ri or circ u m flex

Subsca pu laris m u scle
hume ra l vessels &
Te res m ajor & ax ill ary ne rve
latiss imus dorsi
muscles Deltoid musc le, mi ddl e
bell y
Serratus a n terior
m u scle

Brachial vessels

Bas ilic vein

Brach ia lis muscle
Latissimus d o rsi m u scle

Triceps muscle, lo n g
h ead

Latissim us dors i muscle

Basilic vei n Brac hia lis mu scle

Exten sor carpi radi a lis

longu s muscle

Ulna, olecranon Common exte nsor

process tend o n

Vl
(Top) The brachial is muscl e o ri gin ates fro m the d istal half o f the anteri o r humeral cortex. (Bottom ) The :::r
coracobrac h ialis an d b iceps sh ort h ead o riginat e from the coracoid p rocess. 0
c:
a..
(t)
""'!

183
 ARM OVERVIEW
CORONAL T1 MR, RIGHT ARM

Coracoid process
Biceps ten don, lo ng Coracobrachialis &
h ead i n bici pit al groove short head biceps
tendon
Pectora li s ma jor
Delto id muscle, tendon
anterior bell y

Serratus anterior
muscle

Latissimus dorsi muscle

Brachialis muscle Li ver

vein

Brachiora diali s muscle

l lumerus, med ial
Commo n ex tensor epicondyle
tendon

Clavicle
Del topecto ral groove

ma jor muscle

Delto id muscle,
an terior belly minor
muscle

an terior
m uscle

Hi ceps m uscle

Liver

13rachial is muscle

13rachiorad ialis muscle

ll um erus, capi tulum

I..
Q) (Top) T h e long head of t h e bice ps tendo n t rave rses th e bi cip ital groove. Th e b iceps lon g head and sh ort h ead fuse at
"0 th e u pper h umera l level. (Bottom ) T h e m ost anteri or i m age sh ows t h e del toid muscle at t he shou lder level an d the
::s b iceps mu scle alon g the length o f t he upper arm .
0
..c:
rJ)

184
 ARM OVERVIEW
CORONAL T1 MR, LEFT ARM

Co racoid process
Biceps tendo n, lon g
Coracobrac h ia lis &
head i n bi ci pital groove
short head bi ceps
tendon

Pectoralis major t.
Del toid mu scle,
anterior belly

Serratus an terio r
muscle

Latissi mus dorsi muscle

Liver Brachial is muscle

Basi l ic vei n

Brach ioradia I is muscle

Hum erus, m edial
epicondyle Co mmon exten sor
ten don

C la vicle

Pectoralis ma jor mu scle Deltoid mu scle,

anterior belly

Pectora l is minor
muscle Del topectoral groove

Serratus anterior
mu scle
Biceps muscle

Li ver

Brachial is muscl e

Brachiorad ial is muscle

l lumerus, trochlea
Humerus, cap itulum

Vl
(Top) The long head o f th e bice ps te ndo n traverses the bicipital groove. Th e biceps long head and short head fuse a t :::r
the upper h u me ra l level. (Bottom) Th e most anterior image shows t he de lto id muscle at the shoulder level and the 0
biceps m uscle along the lengt h of the upper arm. c:
c..
(0
""t

185
 ARM OVERVIEW
SAGITTAL T1 MR, RIGHT ARM

Breast ti ssue

Triceps mu scle, lo ng
h ead

Basi l ic vein
Ulnar nerve

Triceps tendo n

Humerus, troch lea

Brachial is muscle

Brachia I ar tery, u I nar &

m edian n erves

Triceps muscle, long

head

M edial interm u scu lar

septum

Triceps tendon

Basilic vein

Brach ialis m uscle Hum erus, troc h lea

(Top) First of e ight sequentia l sagi tta l T l MR images of th e righ t ar m displayed medial to la teral. Images were
acquired at 3T. The basilic vein cou rses distally down th e media l arm. (Bottom) The m edia l in ter muscula r sep tum
separates the a n terio r co mpartment from the triceps m uscle in th e posterior co mpartment.

lRf)
 ARM OVERVIEW
SAG ITTAL T1 MR, RIGHT ARM

Bi cep mu scle, sh o rt
head & Triceps muscle, long
head
muscle

Triceps muscle, m edial

head
artery, m edian
ner ve

Brachial is Trice ps tendo n

O lecran o n fossa and

llumeru '>, t rochlea
posterior fat pad

Delto id
ant erior

Radial nerve
[]
Triceps muscle, lo ng
head

muscle

llumcrus

Triceps musc le, m edial

h ead

Brach ialis muscle

O lecran on fossa and

coronoid posterior fat pad
& an terior faLp ad
U lna, o lecranon

llumeru\ , trochlea

V'l
(Top) The tri ce ps media l head lies d eep to th e lon g and lateral heads. (Bottom) The brachiali s muscle originates from ::r
th e anterior humera l cortex and inserts on th e u l nar tuberosity. 0
c::
0..
I'D
""'I

187
 ARM OVERVIEW
SAGITTAL T1 MR, RIGHT ARM

Triceps muscle, lo ng
head

Hum erus

l'riEeps muscle, m ed ial

h ead

Radial nerve in spiral

Biceps groove humerus

Triceps muscle, lateral

head
Brachi al is muscle

llumerus, capi tulu m

Brachialis ten don Rad ius

[M Cephalic vein Deltoid muscle

Triceps muscle, long

h ead
Middle belly deltoid
attach ment
Radial collateral artery

Tri ce ps muscle, lateral

head
Biceps muscle, long
head
Rad ial nerve

Brachiali s muscle

llum erus, capitulum

Bi cep s tendo n
Radi us, head

(Top) Th e lateral head o f th e tri ceps becomes visible posterio rly. (Bottom ) Th e bi ceps tendon crosses th e el bow joint
and i n serts on t he radi al t uberosity.

10 0
 ARM OVERVIEW
SAGITTAL T1 MR, RIGHT ARM

Deltoid muscle, middl e

belly

Triceps muscle, lateral

head

Cephalic vein
Lateral i ntermuscular
septum

Brachial is muscle

Humerus, lateral
epicondyle

Radius, head

Deltoid muscle

Triceps muscle, la teral

head

Cep hali c vein

Median cepha lic vein

Brachialis

Brachio radialis muscle

Ex tensor carpi rad iaJis

longus

(Top) The cephal ic vein is located in th e subcuta neous fat o f the antero late ral a rm. The lateral intermuscular septum
separates the anterior from pos terior co mpartment. (Botto m ) The exte nsor carpi radialis longus originates from the
la teral epico ndy le o f the humerus.

189
 SECTION II: Elbow

Elbow
Elbow Overview 2-55
Text 2-4
Radiographs 5-7
G ra phi cs : j o int capsul e 8-10
G ra phi cs: Axial 11 -13
G ra phics: Vesse ls 14
G ra phics: Ne rves 15
G ra phics: Cubital fossa & ne rve e nt ra pme n ts 16-19
Ax ia l MR seque n ce 20-33
Co ro nal MR seque n ce 34-49
Sagitta l MR sequ e nce 50-55
Muscles and Tendons 56-8 1
Text 56-5 7
G ra phics 58-60
Ax ia l MR seque n ce 6 1-67
Co ro nal MR seque n ce 68-73
Sagitta l MR seq ue nce 74- 79
FABS sequen ce 80
Bi c ipitorad ia l bursa 81
Ligaments 8 2-91
Tex t 8 2
G ra phi cs 83-85
Axial MR seque n ce 86-88
Co ro na l MR seque n ce 89-91
Forearm
Forearm Overview 92-123
Text 92-94
Graphics: Muscle o rigin s & inse rtio ns 95-96
Radiog raphs 9 7
Axia l MR seque n ce 98-109
Co ron a l MR seque nce 110-11 7
Sagit tal MR seque n ce 11 8-1 23
 ELBOW OVERVIEW
• Pronato r quad ratus muscle: Located in d ista l
!Gross Anatomy forearm, originates on distal ulna a n d inserts o n
joint distal radius
• Compl ex jo int com posed of humerus, ulna, & radi us ligaments
• Has three a rticulation s • Lateral
o Humero-ulnar a rticulation o Radial collateral liga m e nt
• Composed of trochlea of humerus and trochlea r • Restrains against varus stress
no tc h of ulna • O rigina tes o n la teral e picondyle and distally
• Hinge jo in t, a llowing flexio n a nd exte nsio n blends w ith t he anula r ligament-
• Osseo us confi guratio n provides med ia l-late ral o Lateral ulnar collate ra l ligament
stabil it y be tween oo and 30° flexio n • Res trains against posterolatera l instab ility
o Humero-radial articulation • O riginates on late ral epicondyle, just posterior to
• Co mposed of capitellum & rad ial head radial collatera l liga me n t
• Allows both h inge and pivot motion • Courses postero med ia ll y beh in d the radial neck to
• No inheren t osseous stability insert on the supinato r crest on radial side o f
o Proximal radio-ulnar joint prox imal ulna
• Co mposed of th e radial head a nd th e sig mo id • Medial
no tch of the proximal u lna o Medial (a lso called uln ar) collate ral ligame nt
• Pivot joi nt, allowing th e radial head to rota te as • Restrains against valgus stress
fo rea rm supi na tes a nd pronates • Fa n-shaped, ex te nding from medial epicondyle to
• Stabili ty is p rovided by the anu lar ligament, ulna
ho lding the head within the notch • Has three componen ts: Ante rior band
o Congruity of articulating surfaces va ries with (fun ctionall y most im portant), posterior ba nd,
positio n of both e lbow and forea rm: G reatest tra nsverse band
congruity when elbow flexed 90° a nd fo rea rm • Ligaments of the prox ima l rad io-ulna r join t
midway between su pination and pro n ati o n o Anular ligament: Attac hed to a nterio r and posterior
• joint ca psule aspects of rad ial notc h of uln a, forming a coll ar
o Encloses all t hree art iculati o ns around the radial head
o Posterio r attachments: Hume rus prox imal to o Quadrate ligament: Thin fibro us band ex tend ing
o lecranon fossa a nd ca pitellu m, o lecranon p rocess from radi al n ec k to uln a, dista l to anu lar liga men t
anterio r to triceps te ndon
o Ante rio r attach ments: Hume rus proximal to Tendons
coro noid an d radi al fossae, coronoid p rocess, anular • Several flexo r and extensor muscles of forearm arise
ligament from the medial a nd latera l epico ndyles o f hume rus
o Anterior a nd posterio r fat pads are in traca psular but o Common fle xo r tendon
ex tra-synovia l • Arises from medial epico ndyle
• Motion of th e elbow joint • Superficial to medial colla te ra l ligamen t
o Flexion • Co m posed of the flexor-pronato r group: Flexor
• Brac h ial is muscle: Ori ginates a t a nterio r surface of carpi radia lis, flexor carpi uln aris, flexor d igitorum
hum e rus a nd inserts on a nte rio r tube rosity of ulna su perficialis, pronator teres, palmaris longus
• Bice ps brachii muscle: Origina tes a t sh oul der a nd o Common ex tensor te ndon
inserts on radial tuberosity • Arises from la teral e picondyle
• Brac hi o rad ial is muscle: O riginates from late ra l • Supe rficial to radia l collatera l ligament
su pracondylar ridge of humerus a nd inse rts o n • Com posed o f th e extensor-supinator g ro up:
lateral side of the d istal rad ius Extensor carpi rad ialis brevis, extensor carpi
• Pronator te res muscle: Orig ina tes fro m med ia l radia lis longus, ext e nso r d igiti minimi, extensor
epico ndyle and coro n oid process o f ulna and d igitorum comm uni s
inserts o n late ral side of mid-sha ft o f the rad ius
o Extension Bursae
• Triceps muscle: Originates from shoulder and • Poste rior
proximal humerus a nd inserts o n o lec ra no n o Subcutaneous o lecranon bursa: Located
• Anconeus muscle: O riginates from posteri o r aspect subcuta neously, su perficial to olecra non process
of lateral epicondyle & inserts on latera l aspect of o Subtendinous olecranon b u rsa: Located between
ulna and olecranon (also abducts ulna d u ri ng the triceps tendon and the olecra n on
pronation) • An terio r
• Motion of the prox imal radio-u lnar jo int o Bic ipitoradia l bursa: Loca ted between the biceps
o Supination te ndo n and the rad ial tuberosity
• Biceps brach ii muscle (see a bove) • Lateral
• Supinato r muscle: O riginates from latera l o Radio ulna r bursa: Located between th e extensor
epico nd yle and supinator crest of ulna and inse rts digito rum a nd radiohumeral jo in t
0 o n la te ral side of proximal sh aft o f rad ius Nerves
.0. o Pro nation
• Radial n erve
L.U • Pro nator teres muscle (see above)

II
2
 ELBOW OVERVIEW
o Arises fro m posterior co rd of th e brachi al plex us • C ubita l tunnel: l;·i bro-osseous tunn e l formed by
(CS-8, Tl) m edial ep icondyl e and cubita l retin acu lu m
o Spirals poste rola terally a rou nd the hum e ru s w ith t he ("a rc uate ligame nt of Osborn ")
deep brac h ial a rte ry • Cubital tunnel syndrome: Pain and weak ness of
• Gives off posterior cuta neous n e rve o f fo rearm, 4t h a nd Sth finge rs due to co mpression of ulnar
which passes posterio r to latera l cond yle a nd ne rve in c ubi ta l tu nnel
su pplies pos te ri or forea rm o May sublux anteri or to m ed ia l epicond yle in about
o Located ante ro lateral, be tween th e brachialis and 15°;(, of people, usually during flexion
brach ioradialis o Gives articula r branches t o t he e lbow joint
o Su pplies triceps, ancon eus, b rachiora dia lis, a nd o Continues into fo rea rm by dividing into superfi cial
la tera l portion of the brachia lis & d eep h eads of flexor carpi uln a ris
o Gives articu lar bra nch es to th e elbow jo int o Suppli es flexor carpi u lna ris an d media l half of the
o Divides into deep a nd su pe rfi cial bran ch es a t lateral flexor digitorum profundu s
ep icondyle • Musculocutaneo us n erve
o Deep bra n c h o Arises from the latera l co rd of the brachia l plexus
• Purely m otor (C5,6,7)
• Supplies extensor car pi radia lis brevis and o Lies between th e b rachi alis an d biceps brachi i
su pina tor muscles muscles and supplies bo th
• Pierces supin at·o r m uscle a nd winds aro und late ra l o Gives articular branch es to th e elbow joint
aspect of radial neck o Becom es su perficial at e lbow joi nt, con tinu ing
• Exits su pinator muscle in posterio r co m pa rtm e nt latera lly as latera l cutaneous n erve o f fo rearm which
of forea rm as the pos terio r interosseous ne rve inne rvates skin of latera l side of fo rearm
• Poste rior interosseou s n e rve suppli es exten sor • Medial cutaneous n erve o f the fo rearm
m u scles of poste rior compa rtm e nt o f forearm o Accompa nies basllic vein in the arm
• Posterior interosseou s ne rve synd rome: o Located superficia ll y a t elbow, anterior to m ed ia l
Com pressio n of d eep bran ch by arcade of Fro h se epicondyle
(superficia l proxima l ma rg in of the supinato r) o Supplies sensation to posterom edial fo rea rm
o Superficial branc h
• Pu rely se nsory Vessels
• Located in th e a nte rol atera l aspect of the fo rea rm • Brac hial artery
supe rfi cial to the supinato r and p rona tor teres o Continua ti on o f the ax illary artery
muscles (see "Forea rm Overview" section) o Located in the cubital fossa, me dia l to the bleeps
• Median nerve te nd on and deep to the biceps a poneurosis
o Ari ses from both the medial a nd latera l cords of the o Accompanies median n e rve
brach ial plexus (C6-8, Tl) o Has several bra nch es in the arm
o Located in t he cubita l fossa, deep to the biceps • Deep brac h ia l: Desce nds postero latera lly with
aponeurosis radia l nerve, has bra n ches ante ri o r and posterior
o G ives articula r branches to th e e lbow joint to latera l condyle fo rming an anastom os is
o Enters forearm by pass ing be tween h eads o f • Supe ri o r u lnar collate ral: Arises m ed ia ll y and
pronator teres, and located in forearm between descends w it h uln ar ne rve posterio r to medial
flexor d igi to ru m su perficia I is a nd profundu s muscles condyle, form s an a n astom osis w it h branch es of
o May get co mpressed by t he biceps apo neu rosis or by ulna r a rtery
eith e r h ead of pronator teres • Infe rior ulna r coll atera l: Ari ses d istal to superio r
o Suppl ies th e pronator teres, pron ator quadra tus, and u ln a r collateral artery, d escends a nterior to m ed ial
flexors of th e an te rior compartm en t of th e fo rearm condyle, forming a n a n astomos is with branch es o f
(except flexor carpi uln a ris a nd media l half of flexor ulnar arte ry
digitorum profundus, supplied by u ln ar n erve) o Divides into rad ia l artery a nd uln ar artery at level of
o Anterio r inte rosseous nerve rad ia l neck
• Arises fro m media n ne rve at level of pronator teres • Cepha lic vein
• Located in forear m , an te rior to in terosseous o Li es late ral to biceps
membrane, between flexor pollicis lon gus and • Basilic vein
flexor digitoru m profundus o Lies medial to b iceps
• Supplies flexor pollicis longus, pron a to r
q uadra t us, and la te ra l h a lf o f flexor digitorum
profundus I Imaging Anatomy
• Kiloh-Nevin sy ndro m e: Compressio n of anterior
Overview
interosseo us nerve by ulnar head of prona to r teres
• Ulnar nerve • Rad iog raphs
o Arises from medial cord of brachi al plexus (C8, Tl) o AP view
o Located posteromedi ally, d eep to th e t riceps muscles • Pull extensio n and supination
in the distal arm • Media l co ndy le is la rger than late ral
o Passes posterior to m ed ia l epico ndy le in cubital • Luce ncy in distal hum eru s due to th e o lecra n on
tunnel and co ro n o id fossae

II
3
 ELBOW OVERVIEW
• Carrying angle: Intersect i on of longitudinal axes • Fl exed ("u l nar sulcus") : Elbow flexed with hand on
of h umerus and ulna, 154-178° sh ou lder, shoulder an d elbow in sam e plane,
• Humeral angl e: I ntersectio n o f longitudinal ax is X- ray beam straight down, demonstrates
of humerus and a line tangential to articu lar o lecranon process en face, med ial and latera l
surfaces of trochlea and capi tellum, 72-95° epicon dyles, an d ulnar sulcus
• Ulnar angle: Intersection of longitudinal axis of • MR imaging
ulna and a line tangen tial to articular surfaces of o Elbow may be sca nn ed at patient's side o r
trochlea and capitellum, 72-99° "super man " posi tion (pa t ient prone, arm straight
o La teral v iew out over head)
• 90° flexion o Ax ial, sagittal, coronal planes
• Lucent anteri or fa t pad is vis ib le, posterior is not o Tl-wei ghted an d proton density with or without fat
unless there is a join t effusion suppression
• Supinator li ne: Thin lucency of fat superfi cial to o Supplem ental imaging
supina tor m uscle, parallels p roxi m al radial sha ft, • Coronal p lane with 20° postero-inferior tilt: Better
displaced by radia l head fracture or joint effusion demonstrates medial collateral and lateral ulnar
• Anterior humera l line: Drawn along anterior collateral ligaments
cortex of humerus, intersects m idd le thi rd of • FABS : Flexed (elbow), ABducted (a rm ), Supinated
capitell um (forearm), the superman position w ith elbow
o Rad i ocapitellar lin e: Radial head i ntersects fl exed, excellent demonstration of dista l biceps
cap itellum on every v iew tendon and in sertion
o Normal va riants • MR arthrograph y: Useful for evaluation of stabili ty
• Supracon dylar (avian) spur: Bon y spur 5 em of capitellar osteocho ndral fracture and integrity
proxi m al to media l epicondyle, present in 1-3% of of m ed ial co llateral ligament
popu lat ion, usually asym ptomatic
• Ligament o f Struthers: Accessory origin of Imaging Pitfa lls
pronator teres arising f rom supracondy lar spur, • Radiographs
may co mpress med ian nerve o Lucen cy of radia l tuberosity: M i mics lytic lesion
• Os supratrochleare: Accessory ossicle in o I rregular ossification of ca pitellar and trochlear
ol ecran on fossa, m ay mimic loose body epi ph yses: M i mics os teochondra l fracture
• Patella cubiti: Sesam oid in distal triceps tendon o Lucent n otch i n radi al metaphys is: Mimics fracture
• M R imaging or lesion
o Troch lea and capitellu m are rotated 30° anteriorly o Incomplete union of ossification centers: Mimics
relative to humerus fracture
o Synovial recesses: Best appreciated when joint is • M R imaging
distended by effusion or contrast o Pseudod efect of the ca p i tellum
• O lecran on recess: Largest , has superi or, medial , • Normal groove between the capi tellum and latera l
and lateral portions arou nd th e olecranon process condyle
• Anterior humera l recess: Proxim al to co ronoid • Locat ed on posterolatera l aspect of cap i tell um
fossa • Mimics an osteochondra l fracture on coronal and
• Anu lar recess: Surrounds radial n eck sagittal images
• U lnar co llateral ligament recess: Deep to the o Pseudodefect of th e trochlear groove
ligament • orrna l notch on both the medial an d lateral sides
• Radial colla tera l liga ment recess: Deep to the o f the troch lea r notch of u lna, at junction o f
l igament olecran on and coronoid
o Synovial fo lds: Also ca lled synovial fringe • Mimics f racture on sagi ttal images through medial
• Project into t h e joint or latera l side of ulna
• Best appreci ated wi th joint effu sion o r contrast • Not present on mid line sagittal images
• Com mon locations: Radiocapitellar joint o Transverse troc hlear ridge
(meniscus-like), olecranon recess • Norma l bony ridge runn i ng transverse across
troch lear notch o f ulna, at junction o f olecranon
an d coronoid
/Anatomy-Based Imaging Issues • May be incomplete across
• Has no overlyi ng articu lar cartilage
Imaging Recommen dations • Mimics i ntra-articu lar osteophyte or
• Rad iographs post-traumatic deformi ty on sagittal images
o Standard p rojection s: AP, oblique, lateral
o Supplemen tal vi ews
• Rad ial h ead: Elbow flexed 90°, X-ray beam angled ISelected References
45°, demonstrates radial head and neck 1. Rosenberg ZS et al: MR fea tures of nerve d i sorders at the
elbow. Magn Reson Imaging Clin Am. 5(3):545-65, 1997
2. Rosenberg ZS et al: MR imaging of normal and
0 interpretation pi tfalls of the elbow. Magn Reson Imaging
.0 C lin N Am. 5(3):481 -99, 1997
L.L.J

II
4
 ELBOW OVERVIEW
AP & OBLIQUE RADIOGRAPHS

Olecranon

Olecranon foramen
Medial epicondy le

Trochlea Lateral epi co ndy le

Capitell um
llumero-ulnar joint
Radiocapi tellar joint

Coronoid Rad ial head

Proximal radio-ulnar
joint Radial neck

Ulnar shaft Rad ial tuberosity

fedial epicondyle

Troch lea

Capi tellum

Radiocapitellar joint
Co ron o id

Rad ia l head
Proxi mal rad io-ulnar
joint Radia l neck
Ulnar tuberosi ty

Ulnar Radial tuberosity

(Top) AP view o f lhe el bow. This person has an olecranon fora men, a normal variation in which t here is a ho le in
the co rtex between th e olecranon fossa and coronoid fossa. (Bottom) External oblique view. The radius and ul n a are m
no longer overl apped, and bo t h the radial and ul n ar tuberosities are well seen. cr-
0

II
5
 ELBOW OVERVIEW
LATERAL & RADIAL HEAD RADIOGRAPHS

Coronoid fossa

Radial head

Rad ial neck

Radial tuberosity Olecranon fossa

Capi tellum

Trochlea
Coronoid process

Olecranon process

Capitellum
Radial head
Coronoid

Radial neck
Olecranon fmsa

Radial tuberosity

Trocl1lea

Olecranon process
Coronoid process

(Top) Latera l radiograph. The capi tellum and trochl ea are superi mposed on each oth er. The head of t h e rad i us
;s: sh ould always intersect the capitellum (radi ocapit ella r li ne) and a line drawn along th e anterior cortex o f the
0 humerus should always in tersect th e middle o f the ca pitellum (anterior hu meral line). (Bottom ) Radia l head view. A
..0. lateral v iew wi th th e X-ray beam angled transversely. The rad ial h ead is better seen than o n a co nventional lateral
w because the head is not overl appi ng t he coro noi d . Th is v iew i s useful for the evaluation of a suspected radial h ead
fra cture.
II
6
 ELBOW OVERVIEW
RADIOGRAPHS, NORMAL VARIANTS

H u meral shaft

Supraco ndylar spur

Medial epicond yle

O lecranon

Ca pite/Jar epiphysis

Radi al head epiph ysis

Metaphysea l no tch

(Top) The supraco ndylar (avi an) spu r is a normal va riati on that ma y become sym ptoma tic if the ligamen t of
Struth ers, wh ich co nnects it to th e m edial epicondy le, co mpresses th e m edia n nerve. (Botto m ) The meta ph yseal m
notch is a n orma l variant i n children w hich fills in as th e bone m atu res and the physis closes (co urtesy o f Richard 0"
Shore, MD). 0

II
7
 0
..0
Uol

II
8
m
0"
0

II
g
0
..0
w

II
10
0
.0
w

II
12
m
cr
0

II
13
 0
.0
LJ.J

II
14
m
0"'
0

II
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 0
..0
u.J

II
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m
o-
0

II
17
 0
..0
u.J

II
18
m
0"
0

II
19
 ELBOW OVERVIEW
AXIAL T1 MR, RIGHT ELBOW

Biceps brachii muscle

Brachioradialis muscle

B'rach ial is musc le

Radial n er ve
Brachial artery
Exten sor carpi radia l is
longu s muscle

Triceps muscl e, lateral

head
Ulnar nerve

Trice ps muscle, lon g

head
Triceps muscle, medial
head & tendo n

Bicep s brachii muscle

Brach ioradialis m uscle

Brach ialis mu scle

Radial ner ve

Ex ten sor carpi rad ialis

lon gus muscle

Triceps muscle, lateral

head

Ulnar n erve

Triceps m u scle, lo ng
Triceps m uscle, medial head
h ead & tendon

(Top) Ax ia l Tl MR se ries thro ugh t he e lbow, prox imal to di stal. ln this proxima l im age, th e rad ia l, u ln ar, and media n
3: n erves are visibile. The three heads o f the triceps occupy the e ntire poste rio r co mpartm ent. (Bottom) The brac hia lis
0 muscle accou nts fo r most o f th e bu lk in th e anteri o r co mpartm ent .
..0
1.1..1

II
20
 ELBOW OVERVIEW
AXIAL T1 MR, LEFT ELBOW

Biceps brachii
Brachioradialis muscle

m u scle
Radia l nerve
Brachial artery

E.xtensor carpi radialis

longus muscle

Triceps muscle, la teral

head

Ulnar n erve

Triceps muscle, long

head
Triceps muscle, m edial
head an d tendon

Biceps brachii mu scle

muscle

Brachialis muscle
Radial nerve

E.xtensor carpi radial is

longus muscle

vei n

Triceps muscle, latera l

head

Ulnar nerve

Triceps long
head
Triceps m ed ia l
h ead and tendo n

(Top) Ax ial T l MR series through the elbow, p roxim al to d istal. In this proximal image, the radial, u lna r, a nd median
n erves are vis ibile. The three h eads o f the triceps occu py the e ntire posterior compartme nt. (Bottom ) Th e brachialis m
muscle accoun ts fo r most of the bulk in the a nterior co mpartm ent. r:;:r
0

II
21
 ELBOW OVERVIEW
AXIAL T1 MR, RIGHT ELBOW

Cephal ic vei n

Biceps brachi i muscle

muscle

Brachialis
Radial n erve

Brachial art ery

Exte nsor ca rpi rad ia li s

lo ngu s muscle

Triceps l ateral
h ead

Posterior fat pact

Uln ar nerve

Triceps musc le, m edial

rrice ps, long h ead
h ead an d ten don

Cep halic vei n

Biceps brachii muscle

Brach iorad ial is muscle

Rad ia l nerve muscle

Exten sor carpi radia l is Brachial artery

lon gus

Anterior fat pad

Latera l epicond yle

Pronator teres m uscle

Triceps muscle, lateral
h ead
Medial epicond yle
U lnar nerve

Triceps muscle, medial

head an d tendon

(Top) The tri ceps muscl e is starting to taper as it approaches th e o lecrano n . The humeral head of th e pro n ator teres
muscle is coming in to view. This is t he most prox i mal ten don to ari se from the m edia l epicond yle. (Bo tto m ) Th e
0 medial and lateral epi co n dyles are n ow in v iew. Th e ulnar nerve is entering the cubi ta l tunn el.
..0.
w

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22
 ELBOW OVERVIEW
AXIAL T1 MR, LEFT ELBOW

( ephal ic vein

brach i i m
Brachioradiali s muscle

Brilch ill lis 111 uscle

Rad iill nerve

1\rach i<JI mtery

Ex tem or carpi rad ial is

longm muscle

I riceps muscle, lateral

head
Pronator
Posterior fat pad

Ulnar nerve

lon g head
Triceps mmcle, medial
head and tendo n

Cephalic vein

bmth ii
Brachioradialis muscle

Brachialis muscle Radia l n erve

Exten sor carpi radialis

Brachiill artery
longus muscle

A nt erior fat pad

vein

Basili c vei n Lateral epi condy le

Proniltor muscle
Triceps muscle, lateral
lvfl>dial epico ndyle head

Ulnar nerve

Triceps muscle, medial

head and tendon

(Top) The triceps muscle is startin g to taper as i t approaches th e olecranon. Th e humera l head of t he pronator teres
muscle is com ing into view. This is th e most prox imal tend o n to arise from th e medial epi co ndyle. (Bottom) The m
medial and lateral epico ndy les arc now in v iew. T he ul nar n erve is entering th e cu bital tu nnel. 0"'
0

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23
 ELBOW OVERVIEW
AXIAL T1 MR, RIGHT ELBOW

Cephalic vein

Biceps brach ii muscle

Brachioradialis muscle
and tendon
Brachialis muscle
Radi al nerve
Brachial artery

Extensor carpi radialis Median nerve

longus muscle
Anterior fat pad

La teral epicondyle Basili c vei n

M edia l epi co ndy le

Anconeus muscle
Ulnar n erve
Olecranon process
U lnar recurren t artery
Triceps tendon

Cephalic vein

Brachioradial is muscle Biceps tendon

Brachialis muscle
Radial n erve Brachia l artery

Extensor carpi radialis Median n erve

longus muscle

Lateral epicondy le

Olecra non fossa

U lnar coll ateral
l iga m ent
Anconeus muscle Common flexor
tendon
Olecranon process Medial epicon dyle

Ulnar n erve
Arcuate ligament of
Osborn Ulnar recurrent artery

(Top) The triceps tendon is inserting on the olecra non p rocess. Th e biceps brachii muscle is tapering to its distal
3:: te ndon. (Bottom) The ulnar nerve is in the cubital tu nnel, accompanied by the posterior ulnar recurrent artery.
0
..0
L.L.I

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24
 ELBOW OVERVIEW
AXIAL T1 MR, LEFT ELBOW

Cephalic vein

Biceps m. & L Brach ioradial is muscle

Brachia li s muscle
Radial n erve
Brach ial artery

Median nerve Extensor carpi radialis

longus muscle

A nterior fat pad

Basil ic v ein La teral epi condy le

M ed ial epicond yle

Ancon eus m u scle

Ul nar nerve
O lecranon process
Ul nar recurre n t artery
Triceps ten don

Cephalic vein

Biceps ten don Brachioraclia lis muscle

Brachia l is m usc le
Brach ial artery Radi al nerve

Med ian ner ve _,___ Ex tensor carpi radi alis

longus m uscle

La teral epicondyle
Ba si l ic vein
O lecranon fossa
Uln ar collateral I.
Anconeus m uscle
Common flexor t.

Medial epicond yle Olecranon process

Ul nar

Ul nar recurrent artery Arcuate li gament of

Osborn

(Top) Th e t riceps tendon is inserting on the olecranon process. The biceps brach.ii muscle is tape ring to its distal
tendon. (Bottom) The ulnar nerve is in th e cu bital t un nel, accompan ied by th e posterio r uln ar recu rrent artery. m
0"'
0

II
25
 ELBOW OVERVIEW
AXIAL T1 MR, RIGHT ELBOW

Ce phal ic vei n

Biceps ten don

Biceps aponeurosis
Brachi o radial is muscle
Brach ia l artery
Radial nerve

Radial collateral I. Brachialis m. & t.

Ex ten so r carp i rad iali s Med ian nerve

lo n gu s m .

Comm o n ex ten sor t.

Trochl ea
Ul nar co llateral I.

An coneus muscle Co m mon flexor t.

O lecrano n process Fl exor carpi u l naris m.

Uln ar nerve
Fl exor d igitorum
pro fund us m.

Cephal ic vei n

Bi ce ps tendo n
Brach io rad ialis muscle
Bice ps apon eurosis
Radi al nerve

Rad ial co llateral I. Brach ial arle ry

Exten so r car pi rad ial is

M ed ian nerve
lo n gu s 111.

Ex ten sor d ig ito ru111 m . Brachialis 111. & t.

Commo n ex tensor t.

Coro n o id p rocess Ulna r coll ate ral I.

An coneu s m uscle Comm o n flexor t.

Flexor digitoru m
su perficial is 111.
Fl exor d igi to rum
p ro fundus 111. Ul nar n erve

Flexo r car pi ul n aris

(Top) Th e uln a r n erve has passed th roug h th e cu bital tunnel and is n ow entering the fl exor ca rpi u lnar is m uscle.
(Bottom) The flexor digitoru m profundus muscle is now visible, aris in g fro m th e m ed ial side o f th e o lecran on . The
0 bice ps a po neuro sis ex te nds fro m t he biceps te nd o n to th e su pe rficia l surfa ce o f the comm o n flexor m ass .
..t::J
L.U

II
26
 ELBOW OVERVIEW
AXIAL T1 MR, LEFT ELBOW

Cephalic vein

Bi cep s te ndon

Biceps
Brachioradi ali s muscle
Brachial ar te ry
Radial n erve
Brach iali\ m . N t.
Rad ial col lateral I.
M ed ian nerve
r;;.r---.,;;;-- Exten sor carpi radial is
longus muscle

Common ex tensor t.

Troch lea
Ulnar col lateral I.

Commo n fl exor t. A nconeus mu scle

Flexor carpi ulnaris 111 . Olecran o n process

Ulnar nerve
f'lexor digitorum
profundus

Cephalic vein

Biceps tendon

Brach ioradialis muscle

Biceps aponeurosis

Brachi al artery Radial n erve

Radial collateral I.

led ian nerve E'.xtemor ca rpi radiali s

longus muscle
Brach iali s m. & t.

Commo n ex ten sor t.

Pro nator 111.

Coronoid process
Ulnar collateral I.
Commo n flexor t.
A n con eu s muscle
Flexor digitorum
superticialis m .
Fl exor cligitorum
U lnar i'lerve profundus 111 .
Flexor ca rpi ul nari s m.

(Top) The ulnar nerve has passed through th e cubi tal tunnel an d is n ow enteri ng the flexor carpi ul n aris muscle.
(Bott om) Th e fl exor digitorum profundus m uscle i s no w visible, arisi ng from the media l side of the olecranon . Th e m
biceps aponeurosis extends from th e biceps tendon to th e superficial surface o f t he common fl exor mass. 0"
0
:E
II
27
 ELBOW OVERVIEW
AXIAL T1 MR, RIGHT ELBOW

Radial n., superficial

and deep bran ch es Bi ceps tendon

Bi ceps aponeurosis
Brachio rad ialis muscle

Extensor ca rpi radialis Brach ia l artery

longus m.

Median nerve
Radial collatera l I.
Brach ialis m. &: t.
Extemor cligitorum m.
An ular ligament
Common extensor t. -,-----w-- Pronator teres m.

Radial head
Common flexor t.
Latera l ulnar collate ral
ligamen t Flexor digitorum
superficia l is
An con eus muscle
Ulnar nerve
o ro noid p rocess
Flexor carpi ulnaris
Flexor digitorum muscle
profundus 111 .

Supinator
Radial n ., superficial
and deep branch es Brach ial art ery

Brachioradialis muscle Biceps aponeurosis

Biceps tendon
Extensor carpi radialis
longus 111. Medi an n erve

Pronator teres m.
Ex tensor cligitorum m.

Common extensor t.

Radial n eck Common fl exor t.

Palmaris longw, m.
Anconeus muscle
Flexor digi toru m
superficial is
Ulna
Ul nar n erve

Flexor cligitorum Hexor carpi ulnaris m.

profundus m .

(Top) T he annula r ligament wraps around t he radia l head. Th e radial collateral ligament is seen inserting on I h e
lateral aspect of t h e anular ligament. The rad ial nerve has bran ch ed in to superficial and d eep co mponents. (Bottom )
0 The supi nator muscle wraps around the neck of t h e rad i us.
.0
L.U

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28
 ELBOW OVERVIEW
AXIAL T1 MR, LEFT ELBOW

Rad ial n., super ficial &

deep branch es
Biceps tendo n

Brach iorad ialis muscle

Biceps aponeurosis

Radi al collate ral I.

Brachial artery
Ex tensor carpi rad iali s
lon gu s muscle
Median ne rve
Brach ial is m. & t.
Ex tensor digitorum m .
Anul ar liga m en t Common exten sor t.
Pron ator teres m . Radi al h ead

Lateral ul nar co llateral

Common flexor t. l igament

Flexor digitorum Coronoid process

superficia li s m.
An co neus muscle

Ulnar nerve Flexo r digitorum

pro fundu s m.
Flexor ca rpi ulnaris m.

Biceps tendon Supi n ator muscle

Brach ial ar te ry Brachioradialis muscle

Radial n., superficia l &

Biceps apon eurosis deep bran ches

Median nerve Ex tensor ca rpi radial is

lon gus muscle

Pron ator te res m.

Exten sor digito ru m m .
Brach ial is m. & t.
Flexor carpi rad ial is m .
Common ex ten sor t.
Co mmon flexo r t.
Radial neck
Palmaris longus m.
An coneus muscle
Fl exor digito rum
superficia lis m . Uln a

Ul na r nerve
Flexo r digitorum
Flexo r carpi ulnaris m . profundus m .

(Top) The annula r ligame nt wraps around th e radia l head. The radial collateral liga m e nt is see n inserting on the
lateral aspect of th e a nular li game nt. The radia l nerve has branched into supe rfi c ial and d eep compo n en ts. (Bottom) m
The supinator muscle wraps around th e n eck of the radius. 0""
0

II
29
 ELBOW OVERVIEW
AXIAL T1 MR, RIGHT ELBOW

Supi nator muscle

Radia l a. & v.
Radial n., superficia l
and deep Biceps tendon
Biceps aponeurosis
Brachioradialis muscle Ulnar artery
Median nerve
Ex tensor carpi radialis
lon gus m . Pronator teres m.

Ex ten sor digil'orum m .

Common ex tensor t.
Extensor carpi ulnaris
mu 5cle
Rad ial neck
Palmarh longm m.
Anconeus muscle
Fl exor digitorum
Ul n a
superficial is
Ulnar nerve
Flexor cligito rum
Fl exor carpi uln<Hb m.
m.

Supi nator muscle

Brachiorad iali s muscle Radial a. & v.

Biceps tendon
Radial n., superfi cial
and deep branches Uln ar artery

Extensor carpi rad ialis Pronator m.

longus 111.
Median n erve
Ex tensor digit o rum 111.

Radial tu beros it y

Palm <1ris lo ngus m.

Extensor ca rpi ulnari s
muscle

Flexor digitoru m
Anconeus muscle
su perficia I is
Uln a Ulnar nerve

Fl exo r digit o rum Flexor carpi ulnaris

profundus muscle m uscle

(Top) The brachial is tendo n is seen in ertin g on the ulnar tubero ity. The brachial artery has divided into radia l and
3: ulnar branches. (Bottom) The biceps tendo n is seen inserting o n the radial tuberosity. The deep branch of t he radial
0 nerve is sta rting to enter th e supinator muscle o n its way to th e posterior compart men t of the forea rm .
..0
L.I.J

II
30
 ELBOW OVERVIEW
AXIAL T1 MR, LEFT ELBOW

\upinator 111.
Radial n., superficial &
deep branch es
Radial a. er ''·
apo neurosis
Brachiorad ialis muscle
Biceps tendo n
Extensor ca rpi rad ial is
Uln ar ar tery longus m uscle
Median nerve
Extensor digi torum m.
Pronator te res 111.

Com m o n exte nsor t.

Flexor carpi 111.
Extemor ca rpi ulnaris
Com m o n flexor t. muscle

m. Radia l neck

Flc.\or digitoru111 An coneus muscle

m.
Uln a
Rrach ialb 1.
Flexor d igitorum
Ul nar nerve prolundu s m .

Fle.\or t:a rpi ulnaris 111 .

m.

Brachioradial is muscle
Radia l a. & v.

Radial n ., superficial Cl:

Hicep\ tendon
deep bran ch es

Ulnar ar tery
Extensor ca rpi radialis
Pro nator m.
muscle
Median nerve
Ex temor d igitoru m m .
FleM>r carpi rad ial is m.
Radial tuberosity
m.
Ex tensor carpi uln aris
Fl exor digi toru m muscle
111. Anconeus muscle

Ul na
Ul nar n erve

llexor carpi m. Flexor digitorum

profundus rn.

(Top) Th e brachia lis tendon is seen inserting on the ulnar tuberosity. (Bottom) Th e biceps tendon is seen inserting
on th e radial tuberosity. The deep branch of th e rad ial n erve is start ing to enter the supinato r m uscle on its way to
the posteri or compartm ent of th e forearm.

II
31
 ELBOW OVERVIEW
AXIAL T1 MR, RIGHT ELBOW

Brachiorad ialis m. Supinator muscle

Ex ten sor carpi radialis
Radial a. & v.
longus m.
Radial nerve, deep Sleeps ten don
branch
Pron ator teres m .
Extensor carpi radiali s
brevis m . Ul nar artery

Flexor carpi radialis m.

Extensor digitorum m .
Extensor carpi ulnaris
muscle

Radial tuberosity
Flexor d igi to rum
superfi cia lis
Anconeus muscle
Ulnar nerve
Uln a
Flexor carpi ulnaris m.
Flexor digi torum
profundus m.

Brach ioradialis muscle

Supin ator muscle

Extensor carpi rad iali s Radi al a. & v.

longus m.

Extensor carpi radialis Biceps tendon

brevis m.
Uln ar artery

Radia l n., deep branch Pro nator teres m.

Extensor digito rum m . !!IO=i-..-;.- Flexor carpi rad ialis m.

Radial tuberosi ty M cd ian n erve

:19'---:iii-- Palmaris longus m.
Extemor carpi ulnaris Flexor digitorum
muscle superficia l i
Ul nar n erve
An coneus muscle

Flexor ca rpi ulnari ; m.

Uln a

Flexor digito rum

profundus m .

(Top) The deep bran ch of the radial nerve has entered th e supinator muscle. The biceps ten don is attach ing to th e
3: radial tuberosity. (Bottom ) The muscles of th e flexor-p ronator group are becom ing well d efin ed. o te how far
0 distally one must image in order to see th e full ex ten t o f the biceps tendon insertion on the radial t uberosity.
..0
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II
32
 ELBOW OVERVIEW
AXIAL T1 MR, LEFT ELBOW

Su pi nator m.
Brach io radial is muscle
Radial a. & v. Ex tensor car pi rad ial is
longus muscle

Biceps tendon Radia l n., deep

Pronator teres m. bran ch es
Ex ten sor carpi rad iali s
Ul n ar artery
brevis muscle
Flexor carpi radiali m.
Exten sor digitorum m.

Ex ten sor carpi ulnaris

m u scle

Radial tuberosi ty

Flexo r d igitoru m A ncon eus mu scle

super fic ialis rn .
U ln a
Ulnar nerve

Flexor carpi ul naris rn. Flexor di gi torum

profundus m.

Supinator m . Brachiorad iali s m u scle

Radial a. & v. Ex tensor carpi radi alis

longus muscle

Biceps tendon Ext ensor carpi radi alis

brevis muscle
Uln ar artery

Pronator teres rn . Radial n., deep

bran ches
Flexor carpi radial is m .
Ex tensor di gi torum m .

Rad ia l tuberosity
Palmaris lon gus m.
Ex tensor carpi ulnaris
musc le
Flexo r d igi torum
super ficial is m . Anco neu s muscle

Uln ar nerve Ulna

Flexor carp i ul naris m. Flexor di gitorum

profundus m.

(Top) The deep bra n c h o f the radial ne rve h as ente red t h e supinator muscle. The bice ps tend o n is attaching t o the
radia l tube ro sity. (Bottom) The m uscles o f the fl exor-pronato r gro up a re becomi ng we ll defi ned . Note how far m
dista lly o ne must image in orde r to see th e fu ll exte nt o f th e bice ps te ndo n insertio n o n the radial tube rosity. 0""
0

II
33
 ELBOW OVERVIEW
CORONAL T1 M R, RIGHT ELBO W

Triceps muscle, lateral

h ead

Triceps tendon

Olecranon

Trice ps m uscle, lateral

h ead

Triceps ten don

O lecra n on
A nco neus muscle

Flexor digitorum
profundus m uscle

(Top) Series of coronal images, from posterior to anterior. At the ex treme posterior aspect of the arm, t he olecranon
process is just co m ing into v iew. (Bottom) Th e triceps tendon is inserting on th e o lecranon.
0
.D
w

II
34
 ELBOW OVERVIEW
CORONAL T1 MR, LEFT ELBOW

Triceps muscle, lateral

head

Tricep s tendon

O lecran on

Tricep s m uscle, lateral

h ead

Triceps tendon

Olecran o n

An co neus mu scle
Flexo r di gitorum
pro fun dus muscle

(Top) Se ri es o f coro nal images, from poste rior t o a nteri or. At th e ext rem e poste rior aspect of the arm , the olecranon
process is just co ming in to view. (Bottom) The triceps tend on is in serting on th e olecranon. m
0""
0

II
35
 ELBOW OVERVIEW
CORONAL T1 MR, RIGHT ELBOW

Triceps, medial head

Triceps muscle, la tera l

head

tendon

Olecranon

Anconeus muscle

Flexor digitorum
profundus mu5cle

Tri ceps, m edia l h ead

Triceps, long head
Tri ceps muscle, latera l
head

Olecranon

Anconeus m u5cle
Flexor ca rpi ulnaris
muscle

Flexor d igi torum

p ro fundus muscle

Extemor carpi ulnaris

(Top) Th e anconeus and flexor digito rum profundus muscles are now better seen . (Bottom) The flexor carpi ulnaris
3: and ex ten sor carpi ulnaris tendons are now comi ng into v iew.
0
_a
w

II
36
 ELBOW OVERVIEW
CORONAL T1 MR, LEFT ELBOW

Triceps, m ed ial head

Triceps muscle, lateral

head

Triceps tendon

Olecrano n

An co neus

Flexor d igi l oru 111

profundus muscle

Triceps, m ed ial head

rri ceps, lon g head
Tricep s muscle, lateral
head

Olecran on

An co neus
Flexor carpi uln ari s

Flexor digilorum
profundus mu cle

Exten sor carp i ul na ris

m uscle

(Top) Th e anconeus and flexor digi to rum profundus muscles are n ow better seen. (Bottom ) T h e f lexor carpi ul nari s
and ex tensor carpi ulna ris tend ons are n ow com i ng into view. m
0"
0
:E
II
37
 ELBOW OVERVIEW
CORONAL T1 M R, RIGHT ELBOW

Triceps, m edial head

long head
Trice ps muscle, lateral
h ead

Olecranon

Rad ial head U lnar n erve

Flexor carpi ulnaris m.

Anconeus muscle

Flexor digitorum
m.
Exten sor carpi ulnaris
muscle

Extensor cligitorum m .

Brachi orad iali s mu scle

Brac h ialis mu cle

Triceps, lon g head

O lecran on fmsa
Extensor carpi rad ialis

Common flexor l.
Radial head Uln ar co ll ateral I.
Common ex tensor
tendon Coronoid process

Latera l ul nar collateral

m.
ligament

Flexor digitorum
su perficial is m.
Exten sor ca rpi ulna ris
muscle
Fl exor digilorum
Extensor d igi to rum m. profundm 111.

(Top) The ulna r nerve is seen pa ssi ng behind t he m ed ial epicondy le (epicond yle n o t in t h is image). (Bo tto m ) The
lateral u lnar co llatera l ligamen t ru ns li ke a sli n g behind the rad ial neck to p revent posterola teral instability.
0
.0
u.J

II
38
 ELBOW OVERVIEW
CORONAL T1 MR, LEFT ELBOW

'I riceps, m e(li al h ead

lo ng head
1 riceps muscle, lateral
heacl

Olecranon

Ulnar n erve
Radial h ead

llexor carpi

A nconeus

Flexo r d igitorum
profundus muscle
Extensor carpi ulnaris
muscle
Ext ensor d igitorum
111 uscle

flrach iorad ialis muscle

Brach iali s
Triccp'>, lo ng h ead

Ol ecran on fossa Ex tensor carpi radia lis

longus

Co1111110 11 flexor t.
Radial h ead
Ul nar col la teral I.
Commo n ex temo r
Coronoid tendo n

Lateral ulnar collateral

Palmarh longus m uscle
liga ment

Flexor di gi to rum
muscle
Ex tensor carpi ul naris
muscle
Flexor d igitoru m
prolundus muscle Exten sor digitorum
muscle

(Top) T h e ulnar n erve is seen passi ng behind t he medial epicon dy le (epico ndy le not in t h is i m age). (Bottom) The
lateral ulnar collateral ligamen t run s l ike a sl ing behind the rad ial neck to prevent posterolatera l i nstabi li ty.

II
39
 ELBOW OVERVIEW
CORONAL T1 MR, RIGHT ELBOW

Brachio radial is muscle

Brachialis mu scle
Triceps, lo ng h ead

O lecrano n fossa
Ex tensor ca rpi radi alis
longus
Commo n flexor t.

Radial h ead Ul nar collatera l I.

Common exten sor

ten don Coronoid process

Radial collatera l I.
Palmaris Jongu m .

Supi n ator muscle

Flexo r digito ru m
su perficia I is m .
Extensor d igi torum m.
Flexor d igitoru m
pro fund us m.

Brach io radi alis mu scle

Tri cep s, lon g head

Rad ial nerve

Brac h ialis mu scle

Olecranon fossa

Ex ten sor ca rpi radi alis

lo ngus
Common flexor t .
Commo n ex tensor t.
Ul nar collateral I.
Rad ia l collatera l I. Coro noid process

Radia l n eck
Palmaris longu s m.
Supinator m u sc le
Flexor digi torum
Biceps ten don
super ficialis m.
Exten so r d igi torum m.
Flexor digitorum
profundus m.

(Top) Th e common ex tensor tendon is long and thin, while th e common flexor tendo n is short and broad. (Botto m )
3: Th e radial nerve courses between th e brachial is and brach ioradialis m uscles. The d istal biceps tendo n is approaching
0 its insertion on th e radial tuberosity.
..0
L.U

II
40
 ELBOW OVERVIEW
CORO NAL T1 M R, LE FT ELBOW

Brachioradialis

Brachial is muscle
l'ri ceps, long head

Olecranon fossa
Ex ten so r ca rpi radial is
lo ngus
Common flexor t.

Uln ar collatera l I.
om111on ex ten sor t.
Coronoid process
Radial co llateral I.
lo ngus m.

Su pi nato r m.
Hexor digitoru111
superfi cialis m.
Ex ten sor digitorum m.
Flexor digito rum
profundus m .

Brachioradialis mu scle
l'ricep>, lo ng head

Brachial i s muscle

Olecmnon

Co mmo n fl exor t.
om111o n extenso r l'.
Ulnar collate ral I.
Radial coll ateral I.
Coron oid process

Palmari s longus m.
upinator muscle

Flexor digi to rum Biceps tendon

superfi cial is- m. ex ten sor digitorum Ill.

Flexo r digitorum
m.

(Top) The common ex ten sor tendon is long and thin, w hile th e common fl exor tendon is short and broad. (Bottom)
The radial nerve co urses between the brachialis and brachio rad ialis muscl es. The distal biceps Len don is approach ing m
its inserti on on the radia l tuberosi ty. c::r
0
:;;
II
41
 ELBOW OVERVIEW
CORONAL T1 MR, RIG HT ELBOW

Tricep\, lo ng head

Brachiali s

Radial nerve

Coronoid fossa

Basi l ic vei n
Extensor carpi radiali s
longus
Common llexor I.

Ulnar colla teral I.

Com m on ex tensor 1.

Radial col latera l I. Coronoid

Palmaris longu\ m.
Supinator muscle
Flexor cligitorum
Radial superficiali s 111 .

Flexor digitorum
Extensor digitorum m. profundus m.

Brachioradia lis muscle Brachia li\ muscle

vein

Ca pitellum Trochlea

Coronoid process

Ex ten so r carpi radialis Brachiali'> muscle

longus & brevis m.

Supina tor m u scle Pronat or m.

Palmaris m.

Flexor ca rpi radialis m.

Flexor digi torum

superficiali'> m.

(Top) Th e profile of the rad ial tuberosity is well seen . (Bo ttom ) The bra chialis m uscle i draping over the anterior
aspect o f the humeral shaft.
0
..0
u.J

II
42
 ELBOW OVERVIEW
CO RONAL T1 M R, LEFT ELBOW

13rach ioradialis
Trice ps m., long h ead

13rach ialis muscle

Radia l n erve

Co ron oid fossa

13asilic vei n Extensor ca rpi radial is

lon gus muscle

Common flexor t.

Uln ar coll ateral I. Comm on exte nsor t.

Radial collateral l.
Coronoid process

Palm aris longus m.

Supi n ator mu scle

Flexor d igitoru m
Rad ial tuberosi ty
superficial is m .

Flexor digitorum Extenso r digitorum

profu ndus muscle muscle

13rachi al is musc le
Brachioradial is muscle

13asili c vei n

Troch lea
Capitellum

Coron oid process

Exten sor ca rpi radialis

13rach ialis muscle
lo ngus and brevis m.

Pron ator teres m.

Supinator muscle
Pal maris longus m.

Flexor carpi radia li s rn.

Flexor cl igi torum

superficia l is m.

(Top) The profile o f t he radia l tuberosity is well seen. (Bottom ) The brach ialis muscle is drapi ng o ve r t he anterior
aspect of the humera l sh aft . m
0"
0
:E
II
43
 ELBOW OVERVIEW
CORONAL T1 M R, RIGHT ELBOW

Brachioradial is muscle Brachiali s muscle

Basilic vei n

Radial nerve
Trochlea

Cap i tellum Coronoid process

Extensor carpi radia l is Hrachialis muscle

lo ngus m.

Radial head Pronator teres m.

Supinator muscle Pal m aris longus m.

Flexor carpi rad ialis 111 .

Brachioradial is muscle

Basilic vein

Trochlea
Capi tellum

Radial n., super ficial &

deep bra n ch es Brach ialis ten don

Extensor carpi rad ial is

longus 111. Pronator m.

Biceps tendon U lnar artery

Supi n ator m uscle Palmarb longus m .

Flexor ca rpi radialis m.

(Top) The prona to r teres muscle wraps a ro und the a nte rior aspect o f th e fo rea rm . (Bottom ) The biceps a nd brachia lis
3: te ndons are v isualized as they d ive toward their insertion s. The radial ne rve has spli t into its superfic ial a nd deep
0 branc h es .
..c
L.L..I

II
44
 ELBOW OVERVIEW
CORONAL T1 M R, LEFT ELBOW

mu scle
Brachioradialis muscle

Basilic vein

Radial nerve
Troc hl ea

Corono id process Capitellum

Brachialis mu scle
Ex ten sor carpi radial is
lon gus m.
Pronator teres 111.
Radial head
Pal m aris lo ngus mu scle
Supinato r muscle
Flexor ca rpi radialis
muscle

Brachialis muK ie
Brach ioradi ;lii s musc le

\ Basili c vein

Capitellum

Troch lea Radial n erve,

super fic ial an cl deep

I
Brach ialis tendon bran ch es
Ex ten sor ca rpi radi alis
Pro nator teres muscle longu s muscle

U lnar artery Bicep s tendon

Palm ari s lon gu s muscle
Supinato r mu scle
Flexor carpi radi ali s

(Top) The pronato r te res m uscle wraps aro und the a n terior aspect of th e fo rearm. (Botto m) The biceps and brachial is
tendo ns are visualized as th ey dive toward th eir inse rtio ns. Th e rad ial n e rve has split into its superficial and dee p m
bra n ches. 0""
0

II
45
 ELBOW OVERVIEW
CORONAL T1 MR, RIGHT ELBOW

Brachia l is m uscle

Brachioradia lis m uscle

Pron ator teres muscle

tendon

Median nerve

Ex ten sor ca rpi radiali s

lo n gu s and brevis
m u scles
Flexor carpi radia l is
muscle

Brach ia lis muscle

Bice ps brachii mu scle

and ten don

13rach ioradiali s muscle

(Top) T h e m edian nerve courses m edial to th e pro nator teres muscle. (Bottom ) The brachioradia lis m uscle is the
3: only muscle in th e forearm st ill visualized.
0
..D
L.U

II
46
 ELBOW OVERVIEW
CO RO NAL T1 M R, LEFT ELBOW

Brach ialb muscle

13iceps tendon

Brach ioraclia l i'> mu>cle

nerve

Extensor carpi
lon gus and brevis
llexor carpi radialis muscles
musc le

Brachia/is muscle

Biceps brachii muscle

and tendon

Brachioraclia l is muscl e

(Top) The m edian nerve courses medial to the pron ator teres muscle. (Bo tto m ) The b rachioradiali s m uscle is t he
only muscle in the forearm sti ll v isual ized . m
0"'
0

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 ELBOW OVERVIEW
CORONAL T1 MR, RIGHT ELBOW

Biceps brach ii muscle

Cephal ic v ei n

Bice ps brachii muscle

Ceph ali c vei n

(Top) Th e biceps brachii muscle is t he o nl y m u scle still visua lized . (Bottom) j ust below th e subcutaneous fat, th e
ceph alic vein and b iceps m uscle a re stil l seen .
0
L.I.J

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 ELBOW OVERVIEW
CORONAL T1 MR, LEFT ELBOW

Biceps brach i i muscle

Cephalic vei n

Biceps brach ii

Ceph alic vei n

(Top) The biceps b rac hii muscle is th e o nl y muscle still v isua lized. (Bo tto m ) Just below the subcu taneous fat, the
cep halic ve in a nd biceps muscle a re still see n . m
0"
0

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 ELBOW OVERVIEW
SAGITTAL T1 MR, LEFT ELBOW

ve in

Medial epicondyle
Pronator teres muscle

Common llexor
tendon

Flexor digilorurn
muscle

Triceps muscle, long

head
Basi lic vein

Uln ar nerve

Medial epicondyle

Pronator teres m u scle Common fle xor

tendon

Pal ma ris longu s musc le

Flexor digitorurn
muscle Flcl\or carpi ul naris
lllli\Cie

(Top) Sagittal series starting far m edially in the elbow, where the basili c vei n is seen in th e subcutan eous fat. Th e tip
3: of the medial epicondyle is v isual ized, as are t he most m edial muscles. (Botto m) The co mmon flexor tendon and the
0 muscles of th e flexor-pronator group are seen .
..0
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 ELBOW OVERVIEW
SAGITTAL T1 MR, LEFT ELBOW

Bicep\ llrachil mmck

Median nerve

Brachial artery Triceps musc le, long

h ead

Uln ar nerve

·1roch lea
Pronator teres mu'>cle

Commo n flexor
mmcle tendon

Flexo r digitorum
Flexor ca rpi ulnarb
muscle

Flexor digitorum
profundus m usclc

Biceps llrachii mu)cle

Brachii.ll artery Triceps muscle, long

h ead

muscle
Troch lea

Coro n oid proces\

Pronator teres muscle
U ln ar nerve

lle\or carpi radialis Common fle,or

muscle tendon

Flt'xor digitorum

Flexor digitorum
profundus mu \clc

(Top) The structures o f the anterior compartmen t of the arm are n ow coming i nto v iew. (Bottom) The coron o id
process of th e ulna is com ing into view. T h e biceps bra chii muscle is seen anteri o rl y in the arm. m
0"
0

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 ELBOW OVERVIEW
SAGITTAL T1 MR, LEFT ELBOW

Biceps brachii mu scle

Triceps mu scle and

tendon, medial h ead
Brachia l is muscle

Posterior fat pad

An terior fat pad

Trochlea

Troch lear notch o f

Bicep s aponeurosis ul na

Pron ator teres muscle

Flexor digitoru m
superficial is muscle
Flexor digi torum
Flexor carpi radialis m . profun dus muscle

lJ Biceps brachii muscle

Triceps muscle &

tendo n, m edial head

Brach ial is muscle

Poste ri o r fat pact

An terior fat pad

Troc hlea

Troch lea r no tch of

Biceps apo neurosis ulna

Ulnar tuberosi ty
Pronato r teres muscle

Flexor digitoru m
supe rficialis muscle
Flexo r digitoru m
pro fundus mu scle
Flexor ca rpi rad iali s
muscle

(Top) The triceps te nd o n is seen inserting o n the o lecranon process of the ulna. Notice th at the tri ceps m uscle itself
3: also inserts on the olecranon. (Bottom) The dista l aspect of the brachia l is muscle is seen d ivin g towa rd its insertion
0 on th e ulnar tube rosity. The biceps a poneurosis is see n in cross section, ante ri or to the brachia lis .
...!:J
L.L.I

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 ELBOW OVERVIEW
SAGITTAL T1 MR, LEFT ELBOW

Biceps brachii muscle

Triceps muscle and

ten don, medial head
Brachialis muscle

Posterior tat pad

Anterior fa t pad

Capi tellum
Biceps tendon
Proxi mal rad io-u ln ar
joint

Radial heacl

Prona tor muscle

Supinator muscle
U lna

Biceps brachii
Triceps muscle and
tendon, med ial head

mmcle

Capitellum
Biceps ten don
A nco neus
Biceps aponeurosis
Radi al heacl

Bicep<> tendon

Pronator mu scle

Supinator mu scle
Ulna

(Top) The biceps tendon is now seen, diving toward the insertion on t h e radial t uberosity. (Bottom ) T he an coneus
muscle is now visible as the image passes lateral to the o lecranon. m
0"
0

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 ELBOW OVERVIEW
SAGITTAL T1 MR, LEFT ELBOW

Bi ceps brach ii mu scle

and
lateral head
Brach iali s mu etc

Capitellum

Biceps apon eu rosis Synovial fri nge

Radial head

Supinator

Brach ioradialb muscle

E.x temor ca rpi ulnaris

Biceps brachii muscle

Tricep s musc le an d
tendon, lateral h ead

Brachi al is mu etc

Pseudodcfcct of the
capitell um
Biceps apon eurosis
Rad ial h ead

Supi n ator

Brachioradial is mu scle

Exten sor carpi ulnaris

m u scle

(Top) Th e brach ioradia lis muscle i s seen anteriorl y. A fold o f syn oviu m , called t h e synovial frin ge o r plica, projects
3: in to the radio -ca p i tellar joint. (Botto m) Th e pseudodefect of th e ca pitell um, loca ted in the posteri or aspect o f the
0 capitellum , i s a groove between th e capitellum and lateral epicondyle, mim ickin g an osteoch ondral d efect.
..r:J
U-1

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 ELBOW OVERVIEW
SAGITTAL T1 MR, LEFT ELBOW

Tr iceps muscle, lateral

h ead
Brachial is muscle

Biceps brachii muscle

Brachioradialis muscle
Ex tensor carpi rad ialis
lo ngus muscl e

Radial collate ral I.

Radial nerve
Common extensor t.

Radial head

Supinator muscle

Brachioradialis muscle

Extensor ca rpi ulnari s

Triceps mu scle, lateral

Brachial is muscle head

Exte nsor carpi radialis

longus m u scle

Brachioradialis muscle Radial nerve

Common extensor
ten don

Su pi nator muscle

Extensor digitorum
m uscle

(Top) The common ex tensor tendon is comi ng into view, a long wi th the radial collateral ligament. (Bottom ) The
com mon extensor tendon is n ow well see n. Th e brach ioradia lis muscle sweeps forward and becomes the most lateral m
muscle of the forearm. o-
0

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 MUSCLES AND TENDONS
• Insertion: La te ral si de of dista l radiu s
IGross Anatomy • Innervation: Radial ne rve (usua ll y only su pplies
Overview exte n sors)
• Elbow is d ivided into 4 co mpa rtment s: Anterior, • Actio n: Elbow flexion
poste rior, media l, la teral • O nl y elbow flexor in la te ra l com pa rtment
o Ext e n sor carpi radia lis longus
Compartments • Origin: Infe rio r aspect o f lateral su p racondylar
• Anterior ridge (may blend with origin of brac hiorad ia li s)
o Co ntains elbow fle xo rs • Inse rtion: Dorsum o f base of second metaca rpa l
o Biceps brachii • Innervation : Radia l ne rve '
• Origin : Suprag le n oid tubercle (long h ead), • Actio n : Ex tends a nd abd ucts wrist
coracoid process (sh o rt h ead) o Common ex tensor tendon
• Insertion: Radia l t uberosity • Conjoined t endon of exten so r ca rpi radialis brevis,
• Inne rvati o n: Muscu locutaneous n erve ext ensor digi to ru m, exte nso r d igiti minimi,
• Act ion: Elbow flex io n , forea rm supin ation ext e n so r ca rpi ulna ris
• Lacertus fibros u s (biceps aponeurosis): Co nn ect s • Origin: Anterior aspect of latera l e picond yle a nd
d istal biceps tendon to fascia overlying common latera l supra co ndy la r ridge
flexor mass • In serti on: See following individual muscles listed
• Lacertu s fibrosus may com press underl ying o Ext ensor carpi radialis brevis
med ian nerve • O ri gi n: Co mmon ex te n sor te ndon and rad ia l
• Lacertu s fib rosus can prevent ret racti on of collateral liga ment
ruptu red biceps t e ndon • Insertion: Dorsum o f base o f third metaca rpal
o Brachia lis • Innerva tion: Deep branch of ra dia l ne rve
• O rigin: Ante rior surface of humerus • Action: Extends and a bd ucts w ri st
• Inse rti o n: Uln a r t uberosity o Exte nsor digitorum
• Inne rvation : Muscu loc utaneous n erve • O rigin : Co mmon exten sor tendon, in termuscula r
• Action: Elbow flexion septu m
• Lies deep to b iceps brachii • Insertio n: Dorsu m o f 2nd-5th fingers
• Posterior • Inne rva tion: Poste rior interosseo us bra nc h of
o Contai ns e lbow exten sors radial n erve
o Triceps • Action: Extend s fingers at metacarpo pha la ngea l
• O rigin: Infragle noid tu bercle (long h ead), and interph alangeal. join ts, exte nds wrist
poste ri or hume rus proximal t o radial groove o Exte nsor d igiti minimi
(latera l head), poste.rior hume rus d istal t o radial • Origi n: Commo n extensor tendon
groove (media l head ) • Insertion: Dorsum o f Sth finge r
• Insertio n: O lecranon process • Innervation: Poste ri o r inte rosseo us bran ch of
• In n e rvatio n: Radi al ne rve radi a l nerve
• Action: Elbow ext e nsion • Act ion : Extends Sth finger
o An coneus o Exte n sor carpi ulnaris
• Origin : La te ral epicondyl e • O rigin: Common extensor tendon and poste rio r
• Inse rtio n: Lateral portion of o lecranon, posterior aspect o f ulna
aspect of ulna • Inse rtio n: Dorsum of Sth m etaca rpal
• Innerva tion: Radial nerve • In nervation: Posterio r interosseo us branch of
• Act io n : Elbow ext e n sio n, abdu ct io n o f ulna radia l ne rve
d u ring pro n ation • Actio n : Extend s and adducts wrist
o Anconeus epitroc hlearis o Supina tor
• Accessory musc le • Has two h eads of origin
• Anato micall y inconsta n t, presen t in up to 1/3 of • O rigi n of hume ra l head: Lateral epico nd yle, radial
population collateral li ga m ent, a nu lar ligament
• O ri gin: Medial epicond yle • O rigi n o f ulnar head: Supin ator fossa of ulna
• Insert ion: Med ia l portion of olecranon (anterior) and supinat o r c rest o f ulna (poste rio r)
• Actio n : Elbow exte n sion • In se rti o n: La te ra l side of prox imal radial. shaft
• Cou rses th rough c ub ita l tu nn el, p ost e ro med ia l to • Inne rvation: Deep branch of rad ial n erve
ulnar n erve • Act io n : Supinates fo rearm
• Ma y protect ulnar nerve from direct t ra uma, but • Med ia l.
may a lso com p ress it ca usin g cubital tunn el o Conta ins the flexo r-prona tor g ro up
sy ndro m e o Common flexor tendon
• Latera l • Con joined te ndon of flexor ca rpi rad ia li s, flexor
o Conta ins th e extensor-su pina to r gro u p and one carpi uln aris, flexor d igito rum su pe rficia l is (a lso
e lbow flexor called subli mis), palmaris lo ngus, p ro n ator teres
3: o Brachioradialis • O rig in: Med ial e pico ndyle a nd m edia l
0
..0 • Origin: Su peri o r aspect o f lateral supracond yla r supracondylar ridge
w ridge • Inse rti o n: See individ ua l muscles listed below

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 MUSCLES AND TENDONS
o Fl exor ca rp i radiali s o Hard to visualize longitudinally i n sta nda rd sagitta l
• Origin: Com m on flexor tendon plane .)
• Insertion: Volar aspect of base of 2nd metacarpal o FABS v i ew
• Innervation: Median nerve • Fl exed (elbow), ABducted (arm ), Supinated
• Act ion: rlexes and abd ucts wrist , weak flexor of (forearm)
elbow • Patient in superm an position with arm flexed
o Flexor ca rpi u lnaris • Allows fu ll longitudina l v isualization of b iceps
• lias two heads tendon and insertion on radial tuberosity
• Origin of humeral head: Common flexor tendon • Obtain scout images i n plan e coro nal to pati en t's
• Origin o f u lnar head: Medial aspect of olecranon body (wi ll be sagitta l to flexed elbow)
and posterior aspect of ulna • Plot images perpendicu lar to radius (coron al to
• In se rtio n: Pisiform, h ook o f ll ama te, ba se of 5th humeru s)
metaca rpal • Also sh ows longitudinal extent of brachialis
• Innervation: Ulnar nerve tendon
• Action: Flexes and adducts wrist • Sn apping triceps tendon
o Fl exor d igito rum superfici alis o Medial h ead snaps over media l epi condy le du ri ng
• Has two heads elbow fl exion
• Origin of hum ero-uln ar head: Common fl exor o May ca use ul nar nerve to disloca te anteriorl y during
tendon, u l nar collateral ligament, co ron oid f lex io n
process o Must image in axial plane i n both ex tension and
• Origin of radial head: Anterior aspect of p roximal flexio n
rae! ius o Dyna mic scanning can be performed
• Insertion: Vo lar aspect o f midd le phalanges of sonogra phica lly as el bow flexes and extends
2nd-5 th fingers
• In nervation: Median nerve
• Action: r lexes the proximal interphala ngeal joints, ISelected References
weak flexor of metaca rpophalangeal and wrist 1. Giuffre 13M et al: Optimal posi tioning for MRI of the distal
joints biceps brachii tendon: flexed abducted supinated v iew. AJR
o Palmari s longus Am J Roentgenol. 182(4):944-6, 2004
• Origin : Common flexor tendon 2. Skaf AY et al: 13icipi toradial bursitis: MR imaging
• Insertion: Palmer aponeurosis of hand in eight patients and anatomic data from contrast material
• Innervation: Median nerve opacilica li on of bursae followed by routine radiography
• Action: Fl exes wrist and MR im aging in cadavers. Radio logy. 212(1 ):111-6,
1999
o Pronator teres
3. Cot ten Act al: Normal Anatomy or th e El bow on
• Has two heads Conventional MR Imaging and MR Arthrograph y. Scm in
• Origin of humeral hea d: Common flexo r tendon Racliol. 2(2): 133- 140, 1998
• Origin of ulnar head: Coronoid process 4. Spi nner RJ et al: Snapping of the med ial head of the triceps
• Insertion: Lateral aspect of mid shaft of radius and rt'current dislocation of the uln ar nerve. Anatom ical
• In nervation : Median nerve and dynam ic factor\. J Bone j oint Surg Am. 80(2):239-47,
• Acti on: Pronates forearm, fl exes elbow 1998

jlmaging Anatomy
Overview
• Common extensor tendon
o Longer and thinner than com mon flexor tendon
o May be hard to distinguish from underl ying radial
collateral ligament
• Triceps tendon
o May look wavy on sagitta l images w ith full elbow
ex tension
• Bicipitorad ial bursa
o Loca ted between distal biceps tendo n a'nd radial
tuberosity
o friction on biceps tendo n during pronation
o Has inverted tear-drop sh ape

!Anatomy-Based Imaging Issues m

Imaging Recommendations 0"
• Dista l bice ps tendon 0
:;
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m
o-
0

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 MUSCLES AND TENDONS
AXIAL T1 MR, RIGHT ELBOW

Cephalic vei n

Biceps brachii muscle

Brachioradialis muscle

Brach ialis mu scle

Extemor carpi radial is

longus 111 usclc

Distal aspect o f
Basil ic vein

muscle and
tendon

Cephalic vei n

Biceps brach i i muscle

1 rachioraclialis

Brachialis muscle

Extensor carpi
longus muscle

Distal aspect of
humerus

friceps muscle and

ten don

(Top) First of fou rteen axial images in th e d istal aspect of the arm, t he tri ceps muscle accounts for the entire posterior
compartm ent, and the brachial is muscle accounts for most of th e anterior compartment. (Bottom) M the m
supraco ndylar leve l of the humerus, the triceps muscle is startin g to thi n out. o-
0

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 MUSCLES AND TENDONS
AXIAL T1 MR, RIGHT ELBOW

Cephali c vein

Biceps brach i i muscle

Brachioradialis muscle

Brachi ali s muscle

Radial nerve
Brachial arterr

Ex tenso r carpi radialis

longu s muscl e

Lateral epicondyle o f
hum eru s

Pronator teres mu scle

Trice ps and
tendon
Med ial epico nd y le of

Ceph al ic vei n

Brachio radialis muscle

Biceps brachii muscle
and tendon
Brachialis muscle

Radial nerve Brach ial artery

Ex tensor carpi rad ial is M edi an nerve

longus muscle

Common exten sor

tendon
Lateral epicondyle Pronator

Tri cep s and

tendon Medial epicondyle of
humerus
Arcuate ligam en t o f
Osborn U ln ar nerve

(Top) At t h e level of th e superi o r aspect o f t he epicond y les, the pro nator teres muscle o rig i n is n ow v isualized.
(Bo tto m ) The lateral head of th e t riceps is st i ll p rese nt, adjacent to the o lecrano n process. The small ulnar nerve is
0 wel l seen in th e cu bital tunnel, surrounded by h igh signa l intensity fat and enclosed by th e arcuate ligament.
.D
LU

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 MUSCLES AND TENDONS
AXIAL T1 MR, RIGHT ELBOW

Superficial and deep

of rad ial
nerve

Biceps brachii tendon

Brachioradialis muscle

Brachial is musc le and

tendo n Brach ia l artery

Median nerve
l.xtensor c<Jrpi radialis - --;;;F--;:;:;;;;n
longus mu\cle

Co mmon
tendon

Lateral epico nd yle of Co mmon fl exor

ten don

Medial epicondyle of
Ancon eus muscle
h um erus
Ul nar n erve

Superficia l an d deep Biceps brach ii tendon

branches of radi al
nerve
Brachioradiali \ muscle
Biceps apon eurosis

Brachi al is musck• and

tendon Brachial artery

Extensor carpi rad ialis

Median nerve
longus muscle

Common ex ten sor

tendo n

Capi tellum of humeru s Common flexor

tendon
An coneus mu\clc

Troch lea of humerus

Olecranon proi."ess
Ulnar n erve

(Top) The anconeu muscle is now visible between the olecranon and lateral epicondyle. The biceps brachii muscle
has tapered to its d ista l tendon, ancl t he common extensor ancl flexor tendons are visible at their attachments to the

I
m
condyles. The radial n erve has split into its superficial and d eep bran ch es. (Bottom) Th e th in biceps aponeurosis 0"'
("lacertus fibrosus") can be seen arising from the d ista l biceps tendon and heading media lly towa rd t he pronator teres 0
of th e common flex o r muscle group.

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 MUSCLES AND TENDONS
AXIAL T1 MR, RIGHT ELBOW

Superfi cial and deep

branch es o f radial
n er ve
13iceps brach ii tendon

Brachi orad ial is muscle Biceps

Brachi alis muscle and Brachi al art ery

tendon
Ex ten sor ca rpi radiali s
lo ngus muscle Median nerve

Common ex tensor
tendon

Capitellum o f humerus

Com m on flexor
Anconeu s muscle
tendon

Flexor ca rpi ulnaris

muscle
Olecranon process
Ul nar nerve

Superfi cial and dee p

branch es o r the rad ial Biceps brachii tendon
nerve

Brachioradial is muscle Biceps aponeuro is

Brachi al is muscle and

ten don
Brach ial artery
Ex ten sor carpi radiali s
longus muscle Median nerve

Exten sor digitorum

muscle !!!.;:ir ,;; -- Common flexor
tendon
Radial h ead

Anconeus muscle Flexor carpi

muscle

O lecranon process
U l nar nerve

(Top) Th e ulnar n erve has pa ssed thro ugh the cub ital tunnel and is no w enteri ng th e fo rearm between the t wo heads
of the flexor carpi ulnaris muscle. T h e common ex tensor tendon is starti n g to di vide into its indiv idual compo nents.
0 (Bottom) The b rachialis muscle is taperi ng as its tendon heads toward its insertion o n t h e u l n ar t uberosity.
.0
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 MUSCLES AND TENDONS
AXIAL T1 MR, RIGHT ELBOW

tendo n Brachial artery

Brachioradialb Biceps aponeurosis

Supin ato r m uscle

l:x tem or carpi radia l is Pronator teres mu scle

longus muscle
M ed ian n erve

Flexor ca rpi radial is

Ex tem or digitorum m uscle
muscle
Palm aris lo ngus muscle
'-W'--w-- Flexor digitorum
llrachial h tendon superficial is

U lnar n erve
A ncon eus muscle

Flexor ca rpi ulnaris

( orono id process o f
m uscle
uln a

Flexor digi torum

pro fundus

tend on
Brach ial artery
Brachio radi alis muscle
Superficial and deep
o f the radia l Biceps apo neurosis
n erve

Supinat or muscle Pronator teres m u scle

htemor ca rpi radialis

longus muscle Median nerve

Radi al ned. Flexor carpi radialis

m u scle
F.x tem or digi torum
Palm aris longu s musc le
m uscle

Brac hial b tendo n

-=----- Flexor cligi to rum
superficial is
Ul n ar n erve
mu scle

Ul na r tuberosi ty Flexor ca rpi ul na ris

muscle

Flexor d igi to ru m
profundu s

(Top) Th e componen ts o f t he common fl exor mass are beco ming visible, as th e biceps apon eurosis blends with the
anterio r surface. Th e pro xi mal aspect o f th e supinator muscle is also becomi n g visi ble aro und the rad ia l head and
neck. (Bo ttom) Th e brach ia lis tendon inserts on the ulnar tuberosit y. The supinato r mu cle is no w well seen
ex tending aroun d th e radial neck, wi t h th e superficial an d deep branch es of th e rad ial n erve on i ts an terior aspect.
The ulnar nerve l ies be tween th e superfi cial and dee p h eads of the flexor ca rpi ulnaris m uscle.

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 MUSCLES AND TENDONS
AXIAL T1 MR, RIGHT ELBOW

muscle

Superficial branch of Median nerve

radial nerve

Brachia l artery
Extensor carpi radia lis
longus and brev is
muscles Biceps brach ii tendon

Deep branch o f rad ial Pronator muscle

n erve
Radiu\
Exten sor digitorum Flexor carpi radialis

Supinator muscle
Flexor digitorum
muscle
Extemor carpi ulnaris

Uln ar ner\'e
Anconeus muscle
Flexor carpi ulnarb
lllU\Cie
Ul na
Flexor digitorum
muscle

Brachioradialis muscle Median nerve

Brach ial artery

Extensor carpi radialis
longus and
muscles

Biceps brachii tendon

Superficial bran ch of Pronator teres muscle

th e radial nerve
Radius
Extensor digitorum Flexor ca rpi
muscle

Su!Jinator muscl e Palmarb longus muscle

Flexor digitorum
\uperficialis muscle

Extensor ca rpi ulnaris

muscle Ulndl' nerve

Anconeus muscle Flexor carpi ulnaris

muscle
Flexor digi torum
Ulna muscle

(To p) Th e deep branch of the radia l nerve sta rts to enter th e an ter io r aspect of the supinator muscle, where it w ill
ex it posteriorl y as th e posterior in terosseous nerve. The dista l biceps tendon nea rs its i nserti o n o n the rad ial
0 tuberosity. (Bo tto m ) The biceps tendon inserts on t he rad ial tuberosity. Th e deep bra nch of the rad i al nerve is not
...!::J we ll appreciated o n this image.
L.LJ

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 MUSCLES AND TENDONS
AXIAL T1 MR, RIGHT ELBOW

muscle

ca rpi radiali s
Radi al artery
lon gus muscle

t·arpi radial is M ed ian n erve

brt'vb
U l nar art ery
Deep bra nch of th e
rad ial nerve
Pro nator teres muscle

digi torum
muscle

Flexor digitorum
muscle
Extensor ca rpi ulnaris
muscle Ulnm n erve
,\rKont'us
Hexor ca rpi ulnaris
muscle
Ulna
Flexor digit o rum
pro fundus mu scle

1\rach iorad ia I is muscle

Rad ius

htemor cc1rpi r<1dialis

Radial artery
longm mu cle

Uln ar artery
htemor carpi radiali\
brevis muscle Median nerve

Deep branch o f the Pronator teres mmcle

radial nerve

Extem or digitorum
muscle

Supinator muscle
Fl exor di gitorum
ca rpi uln aris
superficial b muscle
m uscle

U ln ar n erve
Anco neus muscle
llexor ca rpi ul naris
mu \cle

llexor cli git orum

pro fundus mu,cle

(Top) Th e deep bra nch o f th e radia l nerve is v isual ized w ithin th e supinator muscle, bu t the su perficial branch is not
well seen o n this image. T he individ ual components o f th e fl exor-pronator group are n ow w el l de lineated. (Bottom) m
Th e co mpo nen ts of th e ex tensor group are now starting to be delinea ted. 0"'
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 MUSCLES AND TENDONS
CORONAL T1 MR, LEFT ELBOW

Triceps

O lecra n on process

Triceps muscle and

tendon

Olecra non process

Anconeus
Fl exor digi torum
profundus mu cle

(Top) First of twe lve coronal images at the posteri o r aspect of th e elbow, t he tri ce ps muscle and olecrano n process are
3: seen. The triceps tend o n is not ye t visuali zed. (Bottom) The triceps tendon is now seen attaching to the o lecranon.
0 The posterior aspects o f the an coneus o n the lateral side and flexo r digitoru m profundus o n t he med ial side are also
..C now com ing in to view.
L.U

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 MUSCLES AND TENDONS
CORONAL T1 MR, LEFT ELBOW

Triceps muscle an d
tendo n

O lecranon process

Flexor ca rpi u l na ris

An con eus muscle

Flexor digit orum Ex tensor ca rpi uln aris

profundus muscle

Triceps tendon an d
medi al head

muscle, long
Trice ps muscle, lateral
head
h ead

r roch lear notch of

ul n a

Ul nar n erve

Radi al h ead
Flexor ca rpi ul naris
mu scle
Supinator muscle

Flexo r digitorum
profundus llliJ SCie
Extensor carpi ulnaris
muscle

(Top) Th e fl exor carpi ul naris and ex tensor ca rpi ulnaris muscles are now becoming visi bl e. (Rottom) Just beh ind the
medial epicondyle (epico ndy le not seen o n thi s image), th e ulnar nerve passes t hrough t he cubital tunnel and passes m
between the two head s of th e fl exor carpi u.lnaris muscle. Th e posterior aspect of th e radial h ead is just coming into r::r
view, w ith th e surrounding supinator m uscle. 0

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 MUSCLES AND TENDONS
CORONAL T1 MR, LEFT ELBOW

Tricep\ muscle, lateral

head
Triceps m uscle, lon g
head Brachioradialis muscle

O lecran on fossa Ex tensor carpi radial is

lon gus muscle

Common fl exor
ten don Rad ial head

Ul nar coll ateral

ligamen t
Common ex tensor
tendon
fl ex or carpi ul n aris
muscle
Lateral ulnar coll atera l
Flexor digilorum ligament
pro fund us muscle
Supi nator muscle

Ex tensor <ligitorum
m uscle

lateral
head

Trice ps muscle, lo ng
h ead

O lecran o n fossa

Comm on flexor Extensor carpi radialis

tendon longus m u\cle

Palm aris lo ngus te ndon Rad ial head

Comm o n extcn,or
Ul n ar co llateral tendon
l igament
Rad ial coll ateral
Flexor digi to ru m ligament
superficialis muscle
Supinator mu\cle
Flexor carpi ulnaris
muscle

l'lexo r cl igit orum Ex temor digitorurn

profundus mu,cle m uscle

(Top) Th e posterior aspect of the comm o n ex tenso r ten don is een superfi cial to t he lateral ulnar collatera l ligamen t.
3:: T h e lateral u l n ar co llateral l igament is seen w i nd i ng posterio r to the radius towards its attachment o n the ul na. Th e
0 co mmo n flexor ten don i s sh o rter and b roader than t he comm o n extensor ten don, and is seen attaching to t he
..0 med ial epico ndy le. (13ottom) Th e com m o n ex tensor tendo n is now better v isualized, su perficial to the rad i al
w co llateral ligamen t. T he pa lmaris lon gus co mpo n ent o f th e co m mon flexor tendo n i also seen , wi t h the u l na r
collateral ligament deep to th e commo n fl exo r muscle gro u p.
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 MUSCLES AND TENDONS
CORONAL T1 MR, LEFT ELBOW

muscle

Brachialb Brach ialis

Radia l nerve

Ex tem or carpi radialis

Pronator longus muscle

vein
Com m on extemor
Common flexor te ndon
tendon
Radia l coll ateral
ligament
lo ngus mu'>cle
Supi n ator

Flexor digitorum
superficialh tendon

Flexor digi torum

Radial

Brachioradialis muscle

Brachi alis muscle

Troch lea of humerus

Radial nerve

Capi tellum

Pronator tere' mmde

Extensor ca rpi radialis
lon gus mu scle

Palmaris longu) rnu)cie Rad ial head

Flexor carpi radialb Supi nator mu5cle

nni\clc

Flexor di gi torum Biceps te ndon

superficia li s

(Top) Th e radial nerve ca n be seen runn i ng between t h e brach ioradia l is and brach ialis muscles. T h e brachialis
tendon approaches its insertion on th e ul nar t uberosit y. (Bottom) Th e dista l biceps tendon is visualized, proximal to
its inserti on on the rad ial tuberosity The course of the pronator teres m uscle is well een, extend i ng from th e med ial
side of th e humerus to tl1e proximal s11Mt of th e radius.

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 MUSCLES AND TENDONS
CORONAL T1 MR, LEFT ELBOW

Brachio radialis muscle

Brachial is muscle

Troch lea o f hu m erus

Capite llum

Pronator teres muscle Exten sor carpi radialis

longus muscle
Median n erve

Palmaris longus muscle Supinator muscle

Flexor carpi radial is

Biceps ten don
muscle

Flexor digitorum
Uln ar artery
superficial is muscle

muKie
Brachial is muscle

Pronator teres m uscle

Med ian n erve Ext en sor carpi radialis

longu\ and
mu cles
Palmaris lon gus muscle
Biceps tendon

Ul nar artery
Flexor carp i radial is
m uscle

(Top) Th e m ed ian nerve and u l na r artery are com ing into v iew, adjacent to th e biceps tendon. ( 13o ttom ) The
$: longitud ina l exten t o f th e m edian n erve is we ll seen.
0
..0
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 MUSCLES AND TENDONS
CORONAL T1 MR, LEFT ELBOW

Brach ialis musc le

Biceps muscle and

tendon

Exten sor carpi radialis

brevis and lo ngus

Biceps muscle and

tendon

Cephal ic vei n

(Top) The biceps muscle is n ow coming into view. (Bottom ) The only m uscle seen at the m ost ex treme anterior of
the elbow i the biceps.

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 MUSCLES AND TENDONS
SAGITTAL T1 MR, LEFT ELBOW

Hasilic vein

Medial epicondyle
Pronator teres muscl e

Pa l ma ris longu s muscle

l'riceps musclt•, long

h ead

U lnar collate ral

l iga m en t M edia l epicondyle

Pro nato r teres muscle Com m on fle xor

tendon

Palm aris longus muscle

Flexor cligi toru m

superficial is

Flexor ca rpi ul narb

(Top) Fi rst o f t welve sagittal images. On ly th e ex trem e t ip o f th e media l epi condy le is v isible in this medi(l l sect ion.
3: The p ro nator teres and palmari s longus muscles are th e most medially located and are just comi n g into v iew.
0 (Bottom) Th e m edial epico ndyle is now better seen, wi th the attachm en ts o f the ulnar collateral ligam ent and
..D. com m on flex o r te ndo n.
L.I.J

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 MUSCLES AND TENDONS
SAGITTAL T1 MR, LEFT ELBOW

Triceps muscle, long

h ead
Brachiali; muscle
M edial epicondyle
Ulnar collateral
ligament

Pron ator teres muscle Comm o n fle xor

tendon
Pal m aris lo ngus muscle

Flexor digi torum

superficia l is muscle

I'Jexor carpi uln aris

muscle

Bice ps brachi i mu cle

Brach ial arte ry Triceps muscle, lon g

h eacl

Brachi al is muscle
Trochlea

Trochlear n o tch o f
ulna

Pronator teres muscl e

Flexor cl igi toru m

Flexor carpi radialis
superficial is muscle

Flexor cligi torum

p ro fundus muscle

(Top) The bra chia l is muscle is n ow com i n g int o view. (Bottom) The brachiali s muscle is now better seen an d the
mo re super fi cial biceps brachii m uscle is co m ing in to v iew, with t he brach ial ar tery i.n between them. m
r::r
0

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 MUSCLES AND TENDONS
SAGITTAL T1 MR, LEFT ELBOW

Biceps brach i i muscle

Posterior fat pad

Mel:lial head of triceps

m uscle and tendon
Anterio r fat pad in
coro n oid fossa

O lecranon

Brachial is muscle
O lecranon

Biceps apon eu rosis

Coron oid

Troch lea

Pro nator teres muscle

Flexor digi torum
mu\cle

Flexor digit orum

superficia l is

Bi ceps brachii m u cle

Posterior la t pad

Medial head oft riceps

An te ri or fat pad i n muscle and tendon
coron oid fossa

Olecranon f<hsa

Brachi alis
O lecranon process

Biceps apo neurosis

Troch lea
Coro n oid p rocess

Pronator teres m u scle

Flexor digi torum
profundus
M edian n erve
Flexor digit orum

(Top) Part of th e triceps muscle itself is seen inserting o n th e o lecran o n process. The bice ps a po ne urosis is now
3: v isible. (Bo ttom) Th e brachialis muscle is neari ng its insertio n o n th e u lna r tube rosi t y. The media n nerve is now
0 v isible between the pronator te res a nd fl exo r digitorum supcrfi cialis muscles .
..0
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 MUSCLES AND TENDONS
SAGITTAL T1 MR, LEFT ELBOW

La tera l hc<td of triceps

muscle

Capite llum

Biceps brachii tendon

Anconeus muscle
Radial head

Proximal radio-u ln ar
joint

Pronator muscle
Supinator muscle

Lateral head of triceps

muscle

Brachictlh

Synovial fri nge

Anconeus musc le

Biceps brachii tendon

Supinator muscle
Radial artery

Superficial branch of
radial ner\'e

(Top) The radial head and prox i mal radio-ul nar joint are coming into vi ew. The distal biceps te ndon is diving toward
its insertion on the radial tuberosity. (Bottom) The biceps tendon is seen attaching to th e radial tuberosi ty. A m
synovia l fringe, also ca lled a synovial plica, is a meniscus-shaped in-folding of the joint capsule. o-
0
:E
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 MUSCLES AND TENDONS
SAGITTAL T1 MR, LEFT ELBOW

Bi ceps brach ii muscle

La teral h ead of the

triceps
Brach ia l is muscle

Capi tel lum

Rad ia l nerve Pseudodefect of the

capitell um

A ncon eus rn uscle

Brachio radialis m uscl e Supinator muscle

Extensor carpi ul naris

musc le

Latera l head of triceps

muscle
Bi cep s brach i i muscle

BL"ach ioradi al is muscle

Rad ial nerve Ex tensor carpi rad ialis

lo ngus muscle

Com mon exte nsor

tendon

Brachio radial is m uscle Supi n ator muscle

Exten so r digitorum
Sh aft of t he rad ius m uscle

(Top) The pse ud odefect o f th e capi tellum is seen at the posterior aspect o f the cap.i tellum, re prese nt ing a norm al
3: groove be twee n the ro und capitellum a n d lateral cond yle. (Bottom) The co mm o n extensor tendo n is inserting at the
0 tip o f t he late ral epico ndyle .
..!::J
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 MUSCLES AND TENDONS
SAGITTAL T1 MR, LEFT ELBOW

Latera l head of triceps

brachii muscle m uscle

Brachioradialis Extemor ca rpi radiali s

lo ngu s

Extensor ca rpi radial is

brevis m

Extensor carpi radiali\

mu\cle

Extensor digilorum
muscle

Veins

Brachioradia lh mu1.cle
Exten sor carp i radiali5
11lU5CIC

(Top) Along the far lateral aspect of the el bow, th e muscles o f th e ex tensor group arc vis ualized, fo rming the fles hy
lateral aspect o f the forearm. (Bottom ) Com i ng out of t he latera l m uscles into the subcutaneous fat, vein s m
are een. 0"'
0

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 MUSCLES AND TENDONS
FABS VIEW: T1 MR, LEFT ELBOW

Biceps b rachi i muscle

an d te ndon
Ul n a

Radia l tuberosity

Brac h ial is muscle a nd

te ndo n
Ulnar t uberosity

Radius

(Top) Im aging transverse to the forearm in the FABS positio n shows th e ful l longit ud in a l exte nt of the distal biceps
3: tendon insertin g on the radial tuberosi ty. (Bottom) Imaging t ran sverse to t h e fo rearm in th e FABS position a lso
0 sh ows t h e full longitudinal extent of the brachialis te ndon inserting on the uln ar tuberosity.
.0
u.J

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 MUSCLES AND TENDONS
AXIAL T2 FS MR, BICIPITORADIAL BURSA

Bici pitoradia l bursa

Biceps tendon
Radial tuberosity

U lna

Bicipitoradial bursa

Biceps tendon
Radial tuberosity

Ulna

(Top) The bicipitoradial bursa is tear-drop sh aped and located between the biceps tendon and radial tuberosity to
protect the tendon during pronatio n. (Bottom) In a different patien t, the bicipitoradia l bursa is more distended but m
stil l tear-drop shaped. The biceps tendon is mildly tend inotic, ma nifest by swel ling and signal altera t ion . o-
0

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 LIGAMENTS
• Transve rse: Fun ctiona ll y unimportant, for ms base
!Terminology of triangle between anterior and posterior bands
Abbreviat ion s o Lies deep to common flexor tendon
• Ulna r coll ateral ligament (UCL) Proximal Radio -Uln ar joint
• Radia l collatera l li game nt (RCL) • Anular liga m e nt: See prior
D efinitions • Q u ad rate ligament
• Elbow ligaments a re intrin sic ligaments: Thi cken in gs o Thin fibrous band
o f the jo int capsule o Origin: Lateral side of u lna, di stal to radial notc h
o Insertion: Med ial side o f rad ial neck, di stal to anu lar
ligame nt
Jlmaging Anatomy o St abil izes proximal rad io-ul na r joint in full
supination
Lateral Side of Elbow joint • Oblique cord
• Lateral collate ra l Ligament complex o Anatomicall y inco n stant
o Radial collateral liga m e nt o Origin: Lateral side o f uln a, distal to tube ro sity
• Triangular sh aped o Insertion: Medial side o f radi us, distal to t uberosity
• Apex is on the latera l epicond yle
• Base blends wi th anular ligament a ro und radial
h ead JAnatomy-Based Imaging Issues
• Lies deep to overlying common exte n sor t endon
• Provides origin for the superfi cial head of
Radia l Collateral Ligament
supinator m uscle • Seen best o n coron al images
o Lat eral UCL • Low signal intensity structure, may be difficult to
• Thin liga m ent distinguish from overlying common exte nsor tendon
• Provides restraint to posterolatera l instability o f • Men isc us-like sy novial fo ld may proj ect from its deep
rad ia l h ead surface into th e rad iocapitellar jo int
• O rigin: Lateral epico ndyle, blending with Lateral UCL
posteri or aspect of o rig in o f RC L • Di ffi cult to visua lize beca use of thi n size and oblique
• Inse rt io n: Supina tor c rest of lateral side o f co urse
proximal uln a o Im proved visuali zatio n w ith
• Courses posterior to radia l head, partia ll y • Thin secti on coron a l plane
ble ndi ng with a n ular ligament • Oblique coronal plane
o Anular ligament • MR-arthrograph y
• Attach ed to an te rio r and poste rior aspects of rad ial
n o tc h of ulna Ulnar Collateral Ligament
• Form s a ring o r collar around radia l h ead • Anterior band is routinely visuali zed on coro nal
• Ante rior atta c h m e nt becomes taut in supination images, othe r bands a re not
• Posterior att ach ment becomes taut in extreme • Coronal images: In verted triangle appea rance
pronation o Broad proxim a l aspect attach ing to u ndersurface of
• Provides origin for superficial head of supin a to r m edial condyle
muscle • May h ave in te rmedia te signa l intensi ty
o Accessory lateral colla tera l liga m ent o Thin dista l aspect attaching to sublime tubercle of
• An atomica lly inconsta n t coronoid process, flush with edge of coro noid
• Origin : An terior inferior aspect of anula r li gament • Un ifo rmly low signa l inte nsity
• Insertion: Sup inato r c rest o f ulna, blendin g with • Usually sepa rated fro m ove rlyin g commo n flexor
insertion o f lateral UCL t e ndo n by deep fascia l fat
• Stabil izes a nul ar liga m ent during varus stress • Improved visua liza t ion wit h oblique co rona l p lane
• May requ ire MR-arth rogra ph y to v isualize partial tea r
Medial Side of Elbow joint of deep distal aspect ("T" sign)
• Ulnar (medial) collateral ligament
o Restrai nt against va lgus stress Anular Ligament
o Tria ngu lar shaped • Best visualized on axial images a t level of radia l head
o O rigin: Inferior su rface o f m ed ial epicondyle
o Insertion: Coronoid a nd olecranon portions of u lna
o Composed of t h ree ba nds ISelected References
• An te ri or: Functi ona ll y most impo rtant, ex te nds
1. Cotten A et al: Collateral l igaments of t he elbow:
fro m medial epicondyle o f hum erus to sublim e con vention al MR imaging and MR arth rography with
tube rcl e of coro noid process coron al oblique plane and el bow flexion. Radiology.
• Poste rior: Fu nct iona Ji y less important bu t 204(3):806- 12, 1997
mainta in s reciprocal tautn ess with an te rior band, 2. Murrey BF ct al: Fu nctional an atom y of th e ligamen ts of
exte nds from media l epicond yle to o lecranon the el bow. C li n Orthop Relat Res. (20 1):84-90, 19!\S

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m
o-
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 LIGAMENTS
AXIAL T1 MR, RIGHT ELBOW

Radial co llatera l
ligam ent

Lateral epicondyle
Ul nar colla tera l
ligament

Common fl exor t.

M edial epi condy le

O lecrano n
Uln ar nerve

A rcuate li ga m en t of
0 born

Radial col latera l

l igament

Com mon ex tensor

tendon

.rr:o=:;,....-:-- Sli ps o f comm on flexor

tendon

M edi al co llatera l
l iga m ent

Ulnar n erve

(Top) First o f six ax ial images a t the leve l of t he epi co ndy les, th e attachm ents of the radia l a n d ulna r collateral
3: liga m ents a re seen. Th e a rcuate ligament hold s the uln ar nerve in th e cu bital tunn e l. (Bo ttom) Distal to th e ir
0 attachm ents to the epicondyl es, the coll atera l liga m ents and ove rl ying common tendons are mo re vis ib ly separated .
.D.
u..i

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 LIGAMENTS
AXIAL T1 MR, RIGHT ELBOW

co lla teral
ligamen t

Slips of common
ex ten sor ten don

Co mmon f lexor
tendon

Ulnar co ll ateral
l iga m ent

1\nular ligament,
anterior asprct

Slip> o f co mmon
exte nsor tendon
Rad ial collateral
l igamen t

Anul ar l igament,
posterior aspect
Uln a

Supi nator cres t

(Top) The a nterior band o f th e ulnar coll atera l ligam e nt is seen attachin g to the olecra n on. (Bottom ) At th e level o f
the radial l1 ea d, th e radial collatera l ligamen t blends with the anuJar ligament. m
cr
o

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 LIGAMENTS
AXIAL T1 MR, RIGHT ELBOW

Common extensor
tendon Radial colla tera l
ligam ent

Lateral ulnar collateral

ligament

Anular ligament
u pi na tor crest

Comm on ex ten sor

ten do n

Lateral uln ar col latera l

ligam ent

Supin ator crest

(Top) At a level just beyond the rad ia l head, th e la te ral uln a r collateral ligame nt ble nds with t he posterior fibers o f
3: the an ular liga m e nt o n its way to attach to the supinator crest of th e ulna . (Bottom) At th e level of the radial neck,
0 the lateral ulna r collate ra l ligament can be see n a ttac h ing to th e supinator c rest o f th e ulna. T he rad ia l co lla te ral
.C liga me n t is no lo n ger visib le .
I.U

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 LIGAMENTS
CORON AL T1 MR, LEFT ELBOW

Medial epicondy le

Co m m o n fl exor
ten don Radi al head

Ulnar (medi al)

coll ate ral ligamen t
Latera l ulnar collateral
l igament
Coronoid process

Medial epicondyle

Co mmon flexor
te ndon Lateral epicon dyle

Uln ar collateral
l iga m en t Common extensor
tendon

Coron oid process

Radial co llateral
ligament

Radia l head

(Top) First of fo ur corona l images. This section is located post eriorly withi n t h e elbow joi nt. The late ra l ulna r
colla te ral liga me n t is a th in band, seen at th e level o f th e poste rior aspect of th e rad ial h ead. It extends fro m its origin m
posterior to the origin o f t h e rad ial collat era l ligame nt, pos teri or t o th e rad ia l head & neck, to inse rt on th e su pinator 0"'
crest of the u lna . (Bo ttom) At a co ronal image midway t h rough th e radial head (a n teri o r to t he prior image), the 0
radial collateral liga me nt is seen , dee p to the com m on ex te n sor te n don . Th e uln ar colla teral ligament extends fro m :E
t he u nde rsu rface o f the media l epicon dyle to the coronoid process of th e ulna, also well seen at this level.
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 LIGAMENTS
CORONAL T1 M R, LEFT ELBOW

Com m o n extensor
tendon

Common flexor
tendon
Rad ial collateral
Iigam en t

Com mon exten sor

tendon

(Top) At a level through th e extre m e anterior aspect o f the coronoid, tile ulna r collateral ligament is no longer see n.
Th e rad ial collatera l ligamen t is seen d eep to the comm o n ex ten sor te n don. (Bottom) Fu rthe r a nte ri orly, the
0 collate ra l liga me nts a re n o longe r see n .
..0
L.U

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 LIGAMENTS
CORONAL T1 FS MR-ARTHROGRAM

Ul n ar co llateral
ligament

Co ronoid
Lateral ulnar collate ral
ligamen t

Radial h ead

Comm o n ex tensor
tendon

Radial collateral
ligament

Lateral ulnar collateral

l igament

Supi n ato r crest

(Top) Fat-suppressed Tl weighted coronal MR-arthrogra m located poste riorl y within the joint sh ows the late ral ulnar
collateral ligament sweeping around th e rad ia l head and neck (neck n ot seen). The contrast also o utli n es th e articula r m
surface of the ulnar collateral liga m ent, w hic h is frayed in this case. (Bottom) Fat-suppressed T l weighted coronal cr-
MR-a rthrogram at the same location in a differen t patient. The d istal aspect of th e latera l ulnar collateral li gament is 0
seen inserting on the supinator crest of the ulna. The proxima l aspect is partia lly volumed with the posterior aspect :E
of the radia l col lateral ligame nt.
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 FOREARM OVERVIEW
• O ri gin o f ulnar head of supin ator m uscle
IGross Anatomy o Supinator crest
Osseous Anatomy • Posterior aspect of supin ator fossa
• Radius • O rigin of ulnar head of supinator m uscle
• Inserti on o f lateral ulnar co llateral liga ment
o Laterally located
o Sh o rter than u l na o Shaft: Has three surfaces
o Wider distally • Lateral : Fl at and sharp, att achment si te o f
in terosseous membrane
o !lead
• Posterio r: Rounded ridge, diviqing line between
• Disc shaped
extensors (lateral) an d flexors (media l )
• Covered w ith articular ca rti lage alo ng su perior
surface and circum feren ce • Anterior: Rou n ded, covered by flexor digitorum
• A rticu lates w ith ca pitellum of elbow jo in t and profu ndus o ri gin
o Distal
ulnar notch o f proximal radioulnar jo int
o eck • Small sty lo id process med ially
• Small ro und head: Art iculates with ulnar notch of
• Attachment o f jo int capsule
• Angled I so w ith shaft of radius distal rad i us
o Radial tuberosity • Does not art iculate wi th carpus
• At juncti o n o f neck and shaft Articulations
• Insert ion of biceps brachii ten don • Proxi m a l radi o ulna r jo int
o Sha ft o Pi vot joint
• Media l surface: Sharp and st ra ight , attachment site o D isc-shaped rad ial head and rad ial no tch o f ulna
o f in terosseous membra n e o Held i n pl ace by an nular liga men t
• La teral su r face: Rounded and co nvex lateral, w ith o Enclosed w i thi n elbow joint capsu le
pro nato r tubercle at apex o Communica tes with elbow joint
• A nteri or oblique line: Ridge o n anterior surface • Distal radio ulna r jo int
ex ten d i ng fro m radial tuberosity (p rox imal o Pi vo t joint
medial) to pronator tubercle (distal la tera l) o Ulnar head and ulnar no tch o f rad ius
• Pro ximal 759·6 o f sh aft i s concave anteri or o L-lel d i n p lace by t h e t rian gula r fibrocart ilage
• Dis tal 25% o f shaft is flat and w ide (a rticu lar disc)
• Stylo id process: Most distal ex tent of rad i us o Syn ovial joint w ith i ts o wn capsule
• Dorsal (" Li ster") tubercle: O n dorsum o f distal o Does not normally communi cate with radiocarpal
aspect, separa tes second and t h ird ex tensor joi nt
com partments, i s o rigin o f som e extrinsic • M oti ons
ligaments of wrist o Supi n ati o n
• Ulnar n ot c h : Med ial distal aspect, articulates w ith • Princi pa l muscles: Biceps brachii, supinator
distal ulna o Pronation
• Distal articula r surface arti cula tes with carp us via • Princi pa l muscles: Pronator teres, pronator
scaph oid fossa and lun ate fossa q uadratus
• Ulna
o Located m edi ally Interosseous Fibrous Attac hments
o Longer than rad i us • A nular ligament: L-l o lds radial head in radial notch o f
o W ider proxima lly proxima l radi o ulnar joint
o O lecrano n process: Most proximal exten t • Qu adrate ligam ent: Thin f ib rous ba nd co nnecting
o Coronoid process rad ial n eck to ulna, distal to anular liga ment
• Anteri or p ro jectio n of p rox imal shaft • Oblique cord
• U lnar tuberosity: A nterio r inferi o r aspect, o A natomica lly inconsta nt
insertion of brachial is tendon o Unknown fun ct ional sign ifica nce, if any
o Trochlear notc h o Extends from inferior aspect o f u lnar tuberosity to
• Fo rm ed by coro noid an d olecranon processes infer ior aspect o f radial tuberosity
• Articulates wi th troch lea of h umerus • Interosseous m embrane
• Transverse trochlear ridge: Dema rca tes junction of o T hin, broad sheet of fibro us tissu e
o lecran o n and co ronoid (see "Elbow Overview" o Connects med ia l si de of rad ius to lateral ide of ulna
section ) o Begins 2-3 em distal to radial tube rosity
• Trochlear grooves: normal grooves o n eith er side o Provides attachmen t for deep muscles of forearm
o f t rochlear n otch (see "Elbow overview" sectio n) (see below)
o Radial notch o Fibers course inferomedially
• Lateral aspect o f co ronoid process • Transfers load from d ista l radi us to u l n a, and from
• A rticulates w ith rad ial head there up to humerus and boulder
o Supinator fossa • Fibers are taut in mid-p ro ne position (th e usua l
• Depression o n lateral si de of sh aft, just below position of fu ncti on)
radial notch • Triangular f i brocartilage (articular d isc): l lo lds ulna r
• Gives cl earan ce to radial tuberosity duri ng head in ulna notch of d istal rad ioulna r jo int
pronati o n /supination • Ex tensor retinaculum

II
 FOREARM OVERVIEW
o Dorsum of distal fo rea rm and wrist • Posteri or compartment: Superfi cia l g roup
o Origin: Distal radius o Extensor carpi rad ialis brevis, extensor ca rpi ul naris,
In sertion : U ln ar styloid, triquetrum, pisiform ex ten sor digito rum , ex tensor digiti minimi
o l ias deep slips that form the 6 ex ten sor ten don • Originate from common ex tensor tendon of
co mpartments o f dista l forearm and w ri st el bow (sec "Muscles and Ten dons" cctio n)
• I st extensor compartment: Abd uctor pollicis o Extensor carpi radia l is lo n gus
longus, extensor pollicis brevis • Arises from lateral supracondyl ar ridge humerus
• 2nd extensor compa rtm ent: Extensor ca rpi radialis (see "Muscles and Tendo n s" sect ion)
lo ngus and brevis • Posterior compartment: Deep group
• 3rd ex ten sor compart men t : Ex tensor poll icis o Abd uctor pollicis longus
lo ng u • Origi n: Posterior surfaces o f rad i us, ulna, and
• 4th extenso r co mpartmen t: Ex tensor digitorum , i nterosseou s membrane
ex ten so r indicis • Inserti o n : Posteri or surface of base of l st
• 5th extensor compa rtment: Ex ten sor dig iti minimi metacarpal
• 6th extensor compa rtment: Ex tensor ca rpi ulnaris • I nnervation: Posterio r n erve
o Prevents bowst ringing of ex ten sor tendons • Acti o n: Abducts and extends thumb at
metacarpophala ngea I joint
Muscles • Dista l tendon fo rm s an terio r (volar) aspect of
• An teri o r compartment ana tom ic snuff box o f wrist
l ias 8 flexor m uscles, in three gro ups o Ex tensor po llicis brev is
• Anterior compart ment: Su perfi cial group • Origin : Posterior su rfa ce of radius and interosseous
Fl exor ca rpi rad iali s, flexor carpi u l nari s, prona tor membrane
teres, pa l maris longus • Insertion: Posteri or surface o f ba se of 1st proximal
Origina te fro m commo n flexor tend o n o f elbow (sec pha lanx
"Muscles and Tendon s" secti o n ) • Innervation: Posterior interosseous nerve
• Anterior compart ment: Intermediate g roup • Action: Ex ten ds thu m b at ca rpometaca rpa l and
o Flexor d igi to rum su perficiaI is metacarpopha langea l joints
o Originates from common tl exor tendon of elbow • Dista l tendon forms anterior (vola r) aspect of
(sec "M uscles and Tendons" secti on) anatomic sn uff box of Wrist
• Anterio r compa rtmen t : Deep g roup o Extensor poll icis lo ngus
o Flexor d igi to rum profundus • O rig in: Post erio r surfa ce o f ulna and interosseous
• Origi n : Proximal o f anterior and medial membrane
surfaces o f ulna and ad jacent interosseous • Inserti o n: Posterior su rface o f base of 1st distal
m embrane phalanx
• In crtio n : Base of the 2nd-5th d istal phalanges • Inner vation: Posterior i nterosseou s n erve
• Innervation: Ulnar nerve for 4th and Sth fingers, • Actio n : Extends interph alan gea l jo int o f thumb
anterior interosseous nerve of median nerve for and 1st metacarpoph alan gea l jo int
2nd an d 3rd fingers • Distal tendon form s posteri or (d orsal ) aspect o f
• Actions: Flexion of distal and prox imal an atomic sn uff box o f wrist
in terph alangca I joints, metacarpopha langeal o Ex ten sor indicis
joints, wrist joint • O rigin: Posterio r surface of ulna and interosseous
o Flexor poll icis longus membrane
• Li es latera l to fl exor digi to rum pro fundu s • Insertion: Extensor h ood ex pan sion of 2 nd finger
• Origi n : Anterior surface of radius (di stal to • Innervatio n: Posterio r interosseou nerve
ante ri or oblique line), lateral aspect o f • Action: Extends 2nd metacarpophal an gea l jo int
interosseous mem bran e
• I nserti o n: Pa lmer aspect of ba se of d i stal phalanx Nerves
of th um b • A nterior com par tm ent
• I nner vatio n: Anterior interosseous nerve of o Median n erve
median nerve • Principal n erve of an terior compartment
• Action: Flexio n of interphalangeal jo int of thum b, • Supplies: Pronator teres, fl exor ca rpi radia lis,
I st m etaca rpoph alan geal joint, ca rpometacarpal palmaris longus, flexor digitorum superficiali s
jo int, and wri st joi nt • Enters fo rearm from cubital fossa by passi ng
Pronator quadratus between the humeral and u lna r heads of pronator
• Deepest muscle of anteri or fo rearm teres
• Origin: Distal 25 1M, of an te ri or surface o f ulna • Courses d istally, attached to deep surface of fl exor
• I nsertion: Distal 25% o f anterio r su rfa ce of radi us d igito ru m superfi cia l is m uscle by a fasc ial sh eath
• Innervatio n: A nterior interosseous nerve o f • Pronato r synd ro m e: Com pression of median nerve
median nerve as it passes between pronator heads and under
• Action: Pro na tion of forearm, holds d istal radius f lexo r: digitorum superficial is
and ulna toge ther • At wrist, emerges from lateral side of flexor
m
• Posterio r compartment digito rum super fi cia lis and is deep to palm aris 0"
0
o l i as 9 extenso r muscles, in t wo gro u ps lon gus tendon and fl exo r retin acu lum

II
93
 FOREARM OVERVIEW
o A n terio r i nterosseous n er ve • Supp l ies: Ex tensor d igitorum, extensor d igit i
• Arises from median nerve at level o f pronato r teres minimi, extensor indicis, extensor carpi ul naris,
• Cou rses distally alo n g anteri o r urface of abductor poll ici s longus, extensor pollici brevis,
interosseous me mb rane ex ten sor pollicis longus
• Acco mpan ied by interosseous branch of ul n ar • Termi na tes in articular bra nches to wrist join t
artery • l)osterior osseous n erve sy ndrome: Compression of
• Li es bet ween f lexor d ig ito rum p ro fundus an d deep bra nch of radia l nerve as it en ters supinator
flexor po llicis longus muscle
• Ends at p ron ator quadratus muscle, g iv i ng
articu lar branches to w ri st jo i nt and the palmar Arteries
cutaneou s branch (su perficiaI to flex or • Brach ia l a r te ry d iv ides i nto radial artery and u l nar
retinacul um) art ery in cu b ita l fossa
• Supplies: Flexor pollicis lo ng us, pro nato r • Radial artery
q uad ratus, latera l h al f o f flexor d ig itorum o M ed ial to distal biceps ten don
pro fundu s o Covered by brach io rad iaI is muscle
• Kilo h -Nevin syndro m e: Compressio n o f anteri o r o D istally, leaves fo rearm an d moves laterally, crossing
in te rosseus n erve, most o ften d ue to fi b rous ba nds fl oor of anatom ica l snuff box
o U l na r nerve o Termi nates in deep pa lma r arch o f h and
• After passi ng behi nd med ial epicondy le, enters o Radial recu rren t artery
forea rm by passing bet ween h u meral and ulnar • Runs prox ima lly along lateral side of elbow to
heads of flexor ca rpi ulnaris fo rm anastomosis with branches of deep b rachial
• o ur es d ist ally betwee n flexor carpi ulnaris and artery
flexor d ig ito rum pro fundu s o Muscu lar branches to lateral si de o f fo rearm
• Distally, becom es su perfi cial and passes in to w rist o Distal an astomotic bra nches: Pa l ma r ca rpal arch,
superficial to flexo r retinaculu m su perficial pal m ar arch, dorsal carpal arch
• Supp lies: Flexor ca rp i u l n aris, medial half o f flexor • Ulnar a rter y
d igitorum profundus o Proxi mally, deep to pronator teres
• Pal m er cut an eous branch: Arises i n midd le of o Distally, lies o n flexor d ig itorum p ro fun dus and is
fo rearm and suppl ies skin over m ed ial sid e o f Ia teral to u l nar nerve
pa lm o A nterio r an d posterio r u l nar recurren t arteries: Form
• Dorsa l cu tan eous branch : Arises distally between anasto m osis around media l ide of elbow w it h
ul na an d flexor carpi ul n aris to supply d o rsal branch es o f brach ial artery
su rface o f m edial side o f h and o Com mo n interosseous artery: Arises in dista l aspect
o Su perfi cial b ra n c h o f radia l nerve of cubit al fossa
• D irect continuatio n of rad ial nerve after deep • Anter ior i nterosseous arte ry: Runs d istally on
branch h as split o ff at level o f la teral epicon d yle in terosseous mem bra ne and ends i n dorsal carpal
• Courses dista ll y, deep to brach ioradial is arch
• In distal forea rm passes in to posterio r • Pos terior interosseous artery: Enters posterio r
co mpartm ent co mpartment proximal to in terosseous
• Gives ter mi nal branches to su pp ly ski n o f latera l mem b ra ne, between su p i nator and abductor
2/3 o f dorsum of w ri st, hand , an d lateral 2 I /2 po llicis longus, su p plies pmteri or m uscles
fingers o M uscular bra nch es to med ial side o f fo rea rm
o Lateral cutaneous n er ve o Di stal anasto m oti c branches: palmar carpal arch,
• Continuatio n of m usculocuta neous nerve of dorsal carpal arch
elbow
• Supplies skin o f lateral aspect o f fo rearm
o M edial cuta n eous n erve jAnatomy-Based Imaging Issues
• Ari ses from med ial co rd o f brachial p lexus (C8,
Tl)
Anomalous Muscl es
• Duplica te muscles, accessory muscles, anomalous
• Acco mpanies basi lic vein i n arm
o rig ins an d insertions
• Anterio r to medial epi co ndy le
o Common ly i nvolve pal m aris longus, flexor ca rpi
• Supplies skin of posterom ed ial fo rearm
uln aris, abductor digiti m inim i, flexor d igiti min im i
• Posteri o r compart ment
• M ay p resent cl inically as mass: !las signal
o Posterio r interosseo us n erve
characterist ics an d ap pearance of muscle
• Pu rely mo tor
• May present clini ca lly due to com pression of
• Con tinuatio n o f deep b ran ch o f rad ial ner ve afte r
adjace n t ner ve
deep bran ch passes through su p inator muscle to
reach posteri o r compartm ent
• Li es o n posterior surface o f i nterosseous
mem b ran e, deep to exten sor poll icis lo n gus ISelected References
• Accom pani ed by posterior interosseous artery I. ll odler J ct al : Magnetic resonance imaging or the rorcarm:
0 an atomy i n a cndavcric model. l nvc\t
..0
Radio!. 33( I ):6- 1 I , 1998
L.U

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m
0"
0
:E
II
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 0
..0
L.U

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 FOREARM OVERVIEW
AP AND LATERAL RADIOGRAPHS

Olecranon

Coronoid

Radial h ead

Radial neck

Rad ial tuberosity

Sh aft o f ul na
Shaft of radiu s

Radial styloid Uln ar styloid

O lecranon

Coronoid
Rad ial head

Radial n eck

Radial tube rosity

Shaft of uln a
Shaft of radi us

(Top) AP radiog raph shows normal mild bowi ng of the radius a nd ulna. (Bottom) Latera l radiograph shows no
bowi ng of the ra diu s and ulna. The d istal aspects of th e rad ius and ulna shou ld overlap at the d istal rad ioulnar joint. m
r::::r
0

II
97
 FOREARM OVERVIEW
AXIAL T1 MR, RIGHT FOREARM

IJ Biceps brac hii tendon

Brachia I artery

Medi an ne rve
Brachial is m . & 1".

Prona to r teres mu scle

Brachioradialis mu scle

Trochlea
Exte nsor ca rpi rad ia lis
longus muscle
Palmari s longus muscle
Common exten sor and tendon
tendon

Lateral epico ndyle Ulnar n erve

An coneus muscle
O lecranon process

Brach ia l artery
Cepha lic vei n
Median nerve
Biceps brachii tendon
Pro nato r teres muscle
Brach ial is m. & t.
Brach io radial is mu scle Flexor ca rpi radiali s m.

Extensor carpi radialis

longus mu scle Pal maris longu s mu scle

Co mmo n exten sor t. Coronoid process

Flexor digitorum
Ex tenso r cligito ru m m . superficial is
Ulna r nerve
Anular ligament
Flexor carpi ulnaris
Radia l head
muscle
An coneus muscle Flexor d igitorum 111 .

O lecranon

(Top) Ax ial seri es thro ugh th e forea rm , p roximal to distal. T he proxi mal aspects of th e flexo r-pro nator group and the
$: extensor group are seen. (Bottom) At th e leve l of the prox im al radi oulnar jo int, there is a com bi nation of muscles
0 that act o n th e el bow, wrist and hand .
.!:J
I.LJ

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98
 FOREARM OVERVIEW
AXIAL T1 MR, LEFT FOREARM

Brachial arte ry Biceps brachii tendon

M ed ia n nerve Brachial is muscle an d

ten don
Pronator teres
Brachiorad ial is muscle

Troch lea Exten so r carpi rad ia l is

longu'>
longus
and tendon Common extensor t.

Ul n ar nerve Liiteriil epicondyle

Anconeus muscle
Olecranon

Brachial artery

Brachialh m. & t. Cepha l ic vein

l ed ian ner ve brach ii tendon

Pronator teres muscle

Urachioradialis m uscle
1-lexor carpi radialis m .
Ex tensor ca rpi radialis
l'almiirh lon gus muscle
lon gus muscle

Com m on extensor t.
Flexor digit oru m
'> uperfi cial is Ex tensor di gitorum m.

Ul nar n erve i\nular l igament

1-lexnr Ciirpi ul naris m . Radial head

llexor digitorum m.
Anconeus

Olecranon

(Top) Ax ial seri es th ro ug h the forea rm, p rox imal to di stal. The p rox imal aspects of th e fl exor-p ro nator gro u p and th e
ex tensor group are seen . ( Bottom) At the level o f th e prox i m al radio ulnar jo in t, th ere is a com b inati on of muscles m
that ac t o n tile elbow, w ri st and han d. r:;r
0

II
qq
 FOREARM OVERVIEW
AXIAL T1 MR, RIGHT FOREARM

Brachial artery & vei n s

Cephalic vein

Radia l nerve, brachii tendon

superficia l branch
M edian n erve
Radial n erve, deep
branch Prol'lator teres muscle
l:lrachioratlialb muscle
Flexor ca rpi radial is m .

Ex tensor carpi radial is Pal mari s longu s m. & t.

longus and brevis
muscles Flexor digitorum
Exten sor digitorum m.
Ul nar n erve
Supina to r muscle
Brach ial is tendon

Extensor carpi ulnaris

muscle Flexor ca rpi uln aris m .
Anconeu s muscle
Flexor digitorum
pro fun dus mu,cle

Ul na

Brach ial artery and

veins
Radial n erve, M edian n erve
superfi cial branch

Pronator teres muscle

Flexor carpi radialis m.

Brachioradiali s muscle

Radius
Palmaris longus rnu cle
and tendon
Extensor carpi rad ial is
lo ngus and brevis
muscl es
t::=o=;;;;;r--- = - Flexor digi to rum
superficial is
Extenso r digitorum 111.
Ul n ar nerve

Supinator muscle
Flexor carpi ulnaris m.

Extensor ca rpi ulnaris

muscle Fl exor digitorurn
profundus mmcle
Anco neus muscle
Ulna

(Top) The fl exo r m uscles a re grou ped an teri o rl y, and th e ex tenso rs posteriorly. (Bottom) Th e deep branc h o f t he
$: radial ne rve h as e ntered the supina to r muscle o n its way toward th e posterior com partment of th e forearm a nd is not
o di sce rnibl e .
..!:J
t..L.I

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 FOREARM OVERVIEW
AXIAL T1 MR, LEFT FOREARM

Brachial artery and

Ceph alic vein
vei n s

Biceps brachii tendo n Radial ner ve,

superfi cial branch
M ed ian nerve

Rad ia l ner ve, dee p

Pronato r teres muscle branch

Brachio rad ial is muscle

Flexor carpi radial is
muscle
Pa lm aris lo ngus muscl e Exten so r carpi radialis
and te ndon lo n gus and brevis
mu scles
Flexor digitoru m Ex ten sor digi torum 111.
su per ficia I is
Supi na tor m uscle
Ulnar n erve

Flexor carpi ul n aris m .

Exten sor carpi ul naris
Brachialis ten don m u scle
A ncon eus mu scle
Flexor d igi to rum
pro fun dus mu scle Uln a

13rachia l ar tery an d
vein s Radi al nerve,
M edian n erve superficia l branch

Pro nator teres muscle Brach iorad ia lis m uscle

Flexor ca rpi radial is m.

Palmaris lo ngus m u scle Rad ius

and tend on
Ex tenso r carpi radi al is
lon gus an d brevis
Flexor digi torum musc les
super fi cialis
Ex tensor digi torum
Ul nar nerve muscle

Flexor carpi uln aris m . Supinator m u scl e

Flexor di gi torum Extenso r carpi ul naris

profun du s m u scle muscl e

An coneus m uscle
Uln a

(Top) Th e fl exo r m uscles are grouped a n te ri o rl y, a nd the ex te nsors p oste riorly. (Bottom) The d eep bra n ch of the
radial nerve has entered the supin a to r m uscle on its way towa rd th e posterior compa rtmen t o f t he fo rea rm a n d is n ot m
discernible. c;r
0

II
1 01
 FOREARM OVERVIEW
AXIAL T1 MR, RIGHT FOREARM

Radial nerv e, Radial and ulnar

superfi cial branch arte ries
Medi an nerve

Brachioradialis muscle
Pron ator teres mu scle

Flexor carpi radialis m.

Radius
Palmaris lon gu s muscle
Exten sor carpi radialis and ten don
longus & brevis
muscles
Flexor di gitorum
Ex ten so r digi torum m. superficial is

Supi n ator m u scle Ulnar n erve

Flexor carpi ulnaris m .

Ex ten sor carpi ul nari s Flexor digito rum

muscle profundus mu scle

Anconeus mu scle Ul na

Radia I artery
Flexor ca rpi radialis m.
Rad ial n erve,
superficial b ran ch
Pal m aris longus muscle
Brachioradialis muscle

Flexor pollicis lo ngus

muscle M edian nerve
Extensor carpi radialis Ulnar artery
brevis & lo ngus
muscles Fl exor digito rum
superfici alis muscle
Radius

Abductor pollicis Fl exo r ca rpi ulnaris m .

longus
Extensor digitoru m m.
Flexo r digitorum
Posterior i n terosseous
profundu s muscle
artery
Exte nsor digiti rninimi
muscle Interosseous m em brane

Ex ten sor pol li cis lon gus

Ul na

Ex ten sor carpi ulna ris

muscle

(Top) Just distal to t he rad ial t uberosity, the supinato r muscle is still visible w rappin g aro und the proxima l sh aft of
3: the radi us. (Bottom) The interosseous mem bran e is now visib le, helping to separate th e anterior a nd posterior
0 co mpartments .
.0
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102
 FOREARM OVERVIEW
AXIAL T1 MR, LEFT FOREARM

Radial nerve,
Ra d ial nerve,
branch
superficial branch
Median nerve
Brachioradialis muscle
Pronator teres muscle
Radiw.
Fle,\or Cill'pi
musc le J:x ten>or carpi radial is
lo ngus and brevis
l'almarh longus muscle
and tendon
l: xtcmor digitorum
Ulnar nerve muscle

llexor d igi toru rn Supind tor muscle

pcrficia I is
carpi uln aris
rlexor carpi ulnaris
m uscle
muscle
Anco neus muscle
i'lcxor digitorum
profundm rnmclc

Ul na

Raliia l ar tery
Radial nerve,
su perficial branch
Flc\Or carpi radialb
muscle Brachioradialis muscle

Median nerve I n terosseou s membran e

H exor pollicis longus

Palmaris longus muscle m uscle

Hcxo r digitorum carpi radial is

\uperlil"ialis muscle br lon gus

Radi us

Abductor pol licis

Hexor carpi ulnaris 111 . longus

Flexor digi torum Ex temor di gitorum m.

profundus muscle
F.x temor digi ti minimi
Ul na

interosseous
Lxtemor carpi ulnaris artery
muscle
Exten,or pol licis longus

(Top) Ju st distal to th e rad ial tube rosity, the su pinator muscle is still visible w rappin g arou nd the proximal s haft of
the radi u s. (Bottom) Th e inte rosseou s mem brane is now visib le, he lp ing to separate the ante rior a nd posterior
compa rtm e nts.

II
103
 FOREARM OVERVIEW
AXIAL T1 MR, RIGHT FOREARM

Flexor ca rpi radia li s

muscle
M edi an nerve Palmaris muscle

Rad ial n erve & vesse ls Flexor digitorum

superticia lis muscle
Brachi oradialis ten don
Flexor digitoru m
Flexor pollicis lo ngu s profundu s mu scle
muscle
Supinator muscle

Extensor ca rpi radi alis

lo ngu s & brevis
An terior in terosseous
muscles & ten don
n erve
Radius
Uln a
Abd uctor pollicis
lon gus muscle pollicis
muscle
Ex tensor digito rum m. Extemor carpi ulnaris
mu scle
Ex tensor digiti min i mi
muscle

Flexor carpi rad ialis

M edian n erve muscle

Radial n erve Palm aris longus tendon

(superficial bran ch)
and
Flexor digi to rum
Brachioradia l is ten don supe rfi cia li s muscle
Ulnar nerve
Flexor pollicis longus
mu scle Flexor carpi ul naris
Extensor carpi radial is muscle
longus & b revis
Flexor digit orum
tendon s
profundus musc le
Radius
Abductor po llicis U lna
longus muscle
Anterior
Extensor pollicis brevis n erve
muscle
Extemor carpi ulnaris
Extensor cligitorum muscle
Ex temor poll icis longus
Ex tensor digiti minim i muscle
musc le

(Top) The i n terosseous membran e is not as prominen t in th is image as the p reviou s o ne. T h e ulnar n erve and
$: med ian n erve are located in the intermuscu lar septu m between the deep flexors (flexor digitorum and flexor pol licis
0 lo ngus) and th e more su per fi cia l flexors o f the an terior co mpa rtm ent. (Bottom) Th e an teri o r i nterosseou nerve and
..0 accom panyi ng vessel s are wel l seen anterio r to th e inte rosseous mem brane.
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 FOREARM OVERVIEW
AXIAL T1 MR, LEFT FOREARM

Flexor ca rpi radiali s

muscle
Pal marh
Median n erve

Flexo r digito rum Radia l nerve and

muscle vessels
Flexor polli cis lon gus
Flexo r digito rum mu scle

Brachio rad ialis tendon

Supinator muscle
Flexor carpi ulnaris
Ex ten sor carpi radial is
& brevis
Anterior interosseou s
muscles & tendon
nerve
Ul na Radius

l.xtemor pollicb longus Abductor pollicis

muscle longus m u scle

Extemor carpi ulnaris Ex temor digitorum

muscle muscle
Ex ten sor digiti mi nimi
muscle

Flexor ca rpi radialis Median n erve

mu5cle
Radial nerve
Palmaris longus tendon
(superficial bran ch) &
vessels
Flexor digitorum
Flexor polli cis longus
muscle
muscle

Ul nar nerve Brachioradialis tendo n

Radius
Flexo r ca rpi ulnaris - -iiiiii>'=="
muscle Exten so r ca rpi radial is
lon gus and brevis
Flexor digi torum
ten dons
pro fundus m uscle
Ex tensor po ll ici s brevis
Uln a muscle

Anterior intermseous Abdu ctor po llicis

n erve lo ngus m u scle
Lxtemor carpi ul naris
mldscle Ex tensor cligitorum

Extemor pollicis longus

muscle Extensor digiti minimi
muscle

(Top) The in terosseou s membrane is not as prominent in this image as the previo us one. Th e u l nar nerve and
median n erve arc located in the interm uscular septum between th e deep flexors (fl exor digitorum an d fl exor poll icis
longus) and th e more su perfici al fl exors of th e anterior co mpartment. (Bottom) Th e anteri or interosseous nerve and
accom panyin g vessels are well seen anteri or to the interosseous membrane.

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 FOREARM OVERVIEW
AXIAL T1 MR, RIGHT FOREARM

Palmaris tendon

Flexor digitorum
Flexor carpi rad iali s superficialis muscle
tendon
Flexor carpi uln<Hi
Median n erve muscle
Flexor po lli ci s lon gus Ulnar nerve
muscle
r""'-liiiii-- Flex or digitorum
Radi us profundus
Exten sor Pronator quadratus
tendon muscle
Abductor poll icis
longus tendon Ulna

Exten so r ca rpi rad ialis Extensor digiti minimi

longus & brevis muscle
muscles & tendon
Extensor indicb muscle
Extensor pollicis longus
tendon E.\ tensor digitorum

Palmari\ longus tendon

Flexor digitorum
Flexor car pi radialis
superficialb muscle
tendon

M ed ian n er ve Flexor carpi uln ari

muscle
Flexor pollicis longus
Ulnar nerve
tendon
Radius
_ Flexor cligitorum
profundm muscle
Exten so r po llicis brevis
tendon Pronator quadra tu s
Abducto r po lli cis muscle
lo ngus tendon
Ul na
Extenso r carpi rad iali s
brevis & longus E" tensor d igiti minimi
tendons tendon
l:.xten sor po ll icis longus E" tensor iml ich
tendon tendon
Extensor digitorum
muscle

(Top) Th e tendons of the abd uctor pollicis lo ngus an d exten sor po llici s brevis cross superficia l and anterior to the
ten dons of th e ex tensor ca rpi rad ial is b revis and longus. A t this level o f the dista l forearm, the pronator quadratus is
0 now v isible. ( Bo tto m ) The extensor ten do ns are startin g to align th emselves into the six ex tenso r compart men ts of
..0 the wrist .
w

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 FOREARM OVERVIEW
AXIAL, T1 MR LEFT FOREARM

Palmaris lon gu \ tt•ndon

Flexor ca rpi radial is
ten don
Hexor cligi torum
\u pcrficia I is muscle Median nerve

Flexor digitorum Flexo r po llicis longus

profundus muscle m u scle

Flexor ca rpi ul na ri m . Radi us

Uln ar nerve
Ex temor pollicis brevis
tendon
Pronator quadratus
muscle
Abductor pollicis
Ulna lon gus ten don

l'x te nsor digi ti minim i

lllUSC IC extensor carpi radialis
brevis and lon gus
htensor i n dich muscle
m uscle and ten don

E:\tensor digitorum
muscle
Ex temo r pollicis longus
tendo n

Pal maris longu\ tendon

flexor digitorum
profund us muscle
Median nerve
Flexor d igi torum
superficia Ii\ muscle
Flexor ca rpi radialis
Flexor carpi ul na ri tendo n
muscle
Flexor poll icis lo ngus
Ulnar nerve
tendon
Extensor pollici s brevis
Pronator qu ad ratu s te ndon
muscle
Ulna Abductor poll icis
lon gus ten don

Extensor digiti min i mi

tendon Ex ten sor carpi radial is
brevis & longu s
tendons
Extemor i ndicis Rad iu s
tendon

Exten sor cligi torum

Exten so r po lli c is lon gu s
muscle
ten don

(Top) The tendo n s of the abducto r po lli cis lo ngu s and ex te nso r po ll icis brevis c ross su perficial a nd an te rior to th e
tendons of th e exte n o r ca rpi radia lis brevis and lo ngus. At th is level of t h e d istal fo rea rm , th e p ro na to r quadratus is
now v isible. (Botto m ) Th e ex te n so r te n do ns a re sta rting to align t he mselves in to the six ex te n sor compa rt me nts of
the wrist.

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 FOREARM OVERVIEW
AXIAL T1 MR, RIGHT FOREARM

lJ Median nerve

Fl exor carpi radiali s

tendon
Palmaris

Flexor digit orum

ten don

superficia lis tcndom

Flexor pollicis longus
tendon Flexor carpi ulnari
muscle
Radius
Uln ar nerve
Abductor po llicis
longus tendon
Flexor digitorum
Exten sor po lli cis brev is profundus tendons
tendon
Ulna
Extensor carpi radialis
lo ngus tendon Pron ator
muscle
Extensor ca rpi radiali s
Exte nsor carpi ulnaris t.
brevis tendon
Extensor digiti m ini mi
Lister tu bercle tendon

Extensor polli cis longus Extensor digit orum and

tendon indicis tendom

IJ Ex ternal m arker

Med ian nerve

Palmaris

Fl exor digitorurn
tendon

tendon s

Fl exo r ca rpi radialis

tendon Flexor carpi ulnari
tendon
Flexor po llicis longus
tendon
Ulnar nerve
Abductor pol li cis
longus tendon
Flexor digitorum
profundus tendom
Extensor polli cis brevis
tendon
Prox i mal carpa l row

Extensor carpi radialis

longus tendon l:.xtensor carpi ulnaris
tendon

Ex tenso r carpi radialis Extensor digiti rn in i 111 i

brevis tendo n tendo n

Extensor pollicis longus Extensor digitorum and

tendo n indicis tendom

(Top) The wrist is supinated. The six ex te nsor compartm ents are visua li zed. (Bottom) The te ndo n o f the fo rearm
3:: muscles have n ow passed into the wrist.
0
..0
L.L.I

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 FOREARM OVERVIEW
AXIAL T1 MR, LEFT FOREARM

Pal ma ris lo ngu s tendon

llexor d igi torurn

Median nerve
tendo ns
Flexor carpi radialis t .

Flexor cn rpi ul nari Flexor polli cis longus t .

l' ro nil tor quadratu s m.

Uln ar nerve
Rad iu s
Fil•xo r d igitorum
tendons Abductor pollicis
lon gus ten don

Ulna pollicis brevis

tendo n

btensor carpi ulnaris Ex tensor carpi radial is

ten don lon gu; tendon
Ex ten;or carpi radiali s
Ex tensor digi t i minimi
brevis tendon
tendon
Li ster tubercle
btensor tligitoru m and
Ex tensor pollicis longus
i ndicis tendons
tendon

I:.x ternal m arker

Palmari; longu\ tendon

J'J exor d igi toru m Median n erve

\u perficial h tendons
Flexor carpi radialis t.

Hexor ca rpi ulnari

tendon
Flexor polli cis longus t.
Ulnar nerve

Fle\or d igitorum Abductor pollicis

prolundu\ ten dons longus tendon

Ex tenso r pollici s brevis

tendon
Proxima l carpa l row
carp i
tendon Ex temor car pi rad ial is
lon gus t.
digit i rninimi
tendon ca rpi rad ial is
brevis tendon

tligitorum & l:.x temor po llicis longus

intlicb tendons tendon

(Top) Th e wrist is supinated . The six ex te n so r compartme nts a re visua lized. (Botto m ) Th e tendon s o f the forearm
muscles have now passed into the wrist.

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 FOREARM OVERVIEW
CORONAL T1 MR, RIGHT FOREARM

Brachi alis muscle

Bi cep s brachii tendo n

P.ro nator teres muscle

Cephal ic vein

Brachialis muscle

Bi cep s brachi i ten don

Pro nato r teres mu scle

Brachial artery
Bra chioraclialis muscle

Radi al artery

(Top) Coronal series of the forearm, anterior to posterior. The muscles about the e lbow are seen at this ex t re mely
3: anteri or location . (Bottom) The brachial artery h as d ivid ed into the radia l artery (seen) ancl the ulna r a rtery (no t seen
0 in this image) .
..0
UJ

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 FOREARM OVERVIEW
CORONAL T1 MR, LEFT FOREARM

Bralhialis muscle
Biceps brach ii tendon

Pronator teres muscle

Cep hali c vein

Bralhialb muscle

brachii tendon

Pronator teres

Brachioradialh muscle
Brachi al artery

Radial artery

(Top) Coro nal seri es o f the forearm, anterior to posterio r. T he m uscles about the el bow are seen at this extremely
anterior loca tio n . (Bo tto m ) The brachial artery has d iv ided into t he rad ia l artery {seen) and th e ulnar artery (n o t seen m
in this image). o-
0

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 FOREARM OVERVIEW
CORONAL T1 MR, RIGHT FOREARM

Trochlea
Brach ial is tendon
Medial epi condy le
Biceps tendon

Pronator teres mu scle

Brachioradial is m uscle

Flexor ca rpi radi alis

mu scle
Radial artery

Flexor digitorum
superficial is

Palmaris lon gus muscle

and tendon

Supi n ator muscle Com mon flexor

tendon
Brach ioradialis muscle
and tendon Fl exor carpi rad ia l is
muscle

Flexor digi torum

superfi cia lis muscle

U ln ar artery

Pal m aris lo ngus mu scle

(Top) Th e pronator te res sweeps from th e med ia l epicond yle to th e p rox im al rad ius. Note th e brach ialis ten don
3: located med ia l to the b iceps ten don. (Bottom) Th e b rach ioradia lis muscle is the most la teral of all th e fo rear m
0 m u scles .
..0
w

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 FOREARM OVERVIEW
CORONAL T1 MR, LEFT FOREARM

Brachialis tendo n

Medial epiconclylc
Biceps tendon
Trochlea

Pronator teres muscle Brac h ioraclialis muscle

Fl exo r carpi radia l is

musc le Radial artery

Flexor digitorum
superficial is

Palmaris lo ngus muscle

and tendon

Co mm on flexor Supinator muscle

tendon
Brach ioraclial is muscle
& tendon
Flexor ca rpi radialis
muscle
Flexor digi to rum
superficia lis muscle

U lnar artery

Palmaris longus mu scle

(Top) The pronator te res sweeps from th e m ed ial epico ndyle to the proxima l radius. Note th e brac h ial is te n don
located media l to the biceps tendon . (Bottom) Th e brac h io rad iali s muscle is th e most latera l o f a ll the fo rearm
muscles.

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 FOREARM OVERVIEW
CORONAL T1 MR, RI GHT FOREARM

.
.
EJ Brachioradia l is muscle
Coronoid process

Supinator
Ob li que cord

Flexor carpi uln aris

Radius muscle

Flexor pollicis longu s Flexor d igi torum

muscle pro fundus

Pronator quad ratus

muscle

Ul nar h ead

Supin ator muscle

Flexor digitorum
profundus muscle
Ex ten sor carpi radia li s
lon gus & brevis Ulna
m uscles

Abductor pollicis
longu s m uscle

Extensor poll icis brevis

m uscle

(Top) j u st anterior to the ul na and interosseous m embran e, the three deep muscles of t h e anterio r compartmen t are
$: seen: Flexor carpi ulnaris, fl exor d igitorum profun d us, and p ron ator quad ra t us. (Bottom ) Th e flexor digitorum
0 p rofundus muscl e drapes over the medi al aspect of th e ulna, and is separa ted fro m th e exten sor muscles o f the
..0 post erior co mpartmen t by the posterior ridge o f the ul na .
L.U

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 FOREARM OVERVIEW
CORONAL T1 MR, LEFT FOREARM

13rach ioradia l is muscle

Coronoid process

Supinator
Oblique co rd

Flexor carpi ulnari s

muscle Radi u s

Flex or digi torum

profundu s Flexor po l licis
muscle

Pro nator q uadratu s

muscle
Ul nar head

Supina tor muscle

Flexor digitorum
profundus muscle
Extensor carpi radia lis
U ln a longus and brevis
muscles

Abductor po l licis
lon gus muscle

Ex ten so r pollici s brev is

m uscle

(Top) Just anterior to the ulna a nd interosseous me mbrane, the three d eep m u scles of the anterio r compartm ent a re
seen: Flexor carpi u lnaris, flexor digitor um profund us, a n d pro nator qu ad ratu s. (Bottom) The flexor digitorum
profund us muscle drapes over th e m edi.a l aspect o f th e ulna, a nd is se parated from the exte nsor muscles of th e
posterior compa rtm e nt by th e poste rior rid ge of t h e uln a.

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 FOREARM OVERVIEW
CORONAL T1 MR, RIGHT FOREARM

Ul na

Flexor d igi torum

Ex ten sor ca rpi ul n aris
profu n dus muscle
muscle

Ex ten sor digitorum

m uscle

Exten sor digiti mi ni m i

m uscle

7:l
LJ
Ex ten sor carpi ulnaris
m uscle cortex of ulna

Exten sor di gi to rum &

d igi ti min.i mi m uscles

(Top) T he ex tensor carp i uln aris m uscle is th e m os t m edial muscl e of the posterior com part men t. (Bottom) The
3: ex ten sor carpi ulnaris and extensor d igito rum and digiti minimi m uscles are th e most su perficia l m uscles o f th e
0 posterior (exten sor) co m part ment.
..0
UJ

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 FOREARM OVERVIEW
CORON AL T1 M R, LEFT FOREARM

Extensor carpi ulnaris

Ulna

Flexor digito rum

profundus muscle Extensor digitorum
muscle

Exten sor digiti minimi

muscle

Extensor ca rpi ulnaris

Po\terior cortex of ulna muscle

Extensor digitorum and

digiti minimi muscles

(Top) Th e extensor carpi ulna ris muscle is t he most m edial m uscle of t he posterior compa rtment. (Bo tto m ) T he
ex tensor carpi ulnaris and extensor digito ru m and d igi ti mini m i m uscles are the most superficia l muscles of the
posteri o r (ex ten sor) co mpartmen t.

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 FOREARM OVERVIEW
SAGITTA L T1 M R, LEFT FO REA RM

IJ
Brachioradialis muscle
Exten sor carpi radial is
brevis muscle

IJ
Brachioradiali5 mu scle

Extensor carp i radialis

longus muscle

Extensor carpi radialis

b revis mu scle

Radi us

(Top) Sagittal se ries of th e fo rea rm, latera l to med ia l. At th e extreme late ral aspect of the forearm, only th e
bra chio rad ia lis musc le ante ri o rl y a nd th e extensor ca rpi radia li s brevis m uscle posterio rly are visua lized. (Bottom )
0 The ex tensor ca rpi radia lis longus muscle is now visible, anterior to t he brevis m uscle .
.0
u.J

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 FOREARM OVERVIEW
SAGITTAL T1 MR, LEFT FOREARM

Brachioracliali s muscle
carpi radia l is
longu s muscle

Ex temor ca rpi radia l is

brevis muscle

Rad ius

bt emor c<Hpi radial is

longus muscle Brachioradialis muscle

l:.xtcn\or carpi radialis

brevis muscle
Pron ator teres m uscle

digitorum

Flexor po llicis longus

m uscle

(Top) Th e brach ioradialis te ndo n will inse rt o n th e dista l aspect o f t he rad ius, while t he t e ndo n s o f t he exte n sor ca rpi
rad ialis lo ngus a nd b revis wil l pass in to the w rist via th e 2 nd ex ten sor co mpa rt ment. (Bottom) 'I he b rachi o ra dia lis m
muscle is a fl exor o f th e e lbow, th e pro nato r te res is a ro ta to r of th e rad io ulnar jo ints, a nd th e othe r m u scles see n in 0"'
this image act on th e wrist or fingers. 0
:E
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 FOREARM OVERVIEW
SAGITTAL T1 MR, LEFT FOREARM

IJ Ca pitell um

Radial head

Supina tor muscle

Brach iorad iali s mu scle

Radius Pronator teres muscle

Abductor pollic is
longus muscle
Flexor pollicis longus
Ex temor digi torum
muscle
Flexor carpi radialis
muscle

lon gus tendon

Distal radius

]] Ca pitellum

Radial h ead
Brachialis muscle

brachii tendon

Ancon eus Cephalic vein

upinator muscle

Abdu ctor pollicis

longu s muscle

rlexor polli cis lon gus

Ex tenso r digitorum and
musc le
digiti minimi muscles
Flexor ca rpi radialis
musc le
Palma ri s longus tendon
Interosseous membrane

(Top) The pa lm aris longus m uscle has a long tendon i n the ex trem e anterior aspect of the fo rearm. This tendon is
3: often harves ted for surg ica l grafts. (Bo tto m) The t h in cross secti on of the i nterosseous mem brane is seen, d iv iding
0 the forearm into an terio r (fl exor) and posteri or (ex ten sor) compart men ts .
.D.
L.L.J

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 FOREARM OVERVIEW
SAGITTAL T1 MR, LEFT FOREARM

Brachial is muscle
Capitellum

Radia l head
Biceps brachii tendon
Anconeus

Supi nator muscle

Flexor digi to rum

profundus muscle

Flexor cligitorum
muscle
E:\temor longus
muscle

!:\tensor digiti m i nimi Interosseous membrane

muscle

Flexor carpi ulnaris

muscle

Dis tal ul na

·lroch lea
Olecranon
Brachia lis muscle

Pronator teres muscle

Flexor digitorum
profu n dus Flexor digi torum
superficia l is muscle

Ul na

(Top) The flexo r digito rum profundu s is the deepest a nd la rgest m uscle of the a n terior compa rtment. (Bottom) The
pronato r te res m u scle is see n in cross section as it courses o bliq ue ly ac ross t h e proxima l aspect of the fo rearm from its m
h u mero-u Ina r o ri gin s to its rad ia I inse rtio n . r::;r
0

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 FOREARM OVERVIEW
SAGITTAL T1 MR, LEFT FOREARM

[] ] Triceps tendon

Olecranon
Troc hlea
Bra ciliali s muscle

Pronator teres muscle

Flexor digitorum Flexor digilorum

profundu s muscle superficialis muscle

[]]
O lecranon

Pron ator teres

Flexor carpi ulnaris

muscle
Flexor digitorum
profundu s muscle

(Top) Med ial to the posterior ridge o f the u lna, all the muscles are flexors. (Bottom) The flexor digitorum profundus
3: muscle d rapes over the m edial side o f the ulna, and is therefore both anterior and m ed ial to the ulnar shaft.
0
...!:J
u..r

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 FOREARM OVERVIEW
SAGITTAL T1 MR, LEFT FOREARM

Olec ranon

Pronator teres muscle

Flexor carpi ul naris

muscle

r:Jexo r di gito rurn

pro fun dus muscle

Medial epico nd yle

[]
Prona tor teres muscle
Co mmon flexor
tendo n

Fl exor carpi ulnaris

muscle

(Top) The pronator te res muscle, seen here in cross sectio n, originates on t he media l side o f the e lbow a t th e medial
epi condyle and prox ima l ulna, and sweeps anterior and distal across the forea rm to insert on the mid-shaft of th e
radius. (Bottom) The flexor carpi ulnaris muscle is the most m ed ial of the forearm muscles.

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123
 SECTION Ill: Wrist

Wrist
Wrist Overview 2-55
Text 2-4
Graphics: 3D reconstructi on car pals S
Radiographs 6- 7
Graph ics: Liga men ts 8
Graph ics: Tendons 9
Graph ics: Vessels 10
Graph ics: Nerves 11
Axial MR sequ ence 12-29
Coronal MR sequence 30-45
Sagittal MR sequence 46-55
Osseous Structures 56-75
Text 56-58
Radiographs 59-64
Graph ics: Measurem ents 65-69
CT: DRUJ 70 -71
Accesso ry ossicles 72
Wrist compartmen ts 74
Vascula r chan nels & trabeculae 75
Ligaments 76-9 5
Text 76-78
Gra phi cs : Ligam ents 79
Axial MR arthrogram 80-8 5
Gra phi cs: Intrinsic ligaments 86
G rap hi cs: Ulnocarpa l ligamen ts 87
MR: TFCC 88
Corona.! MR: Ligaments 89-92
Arth rogram 93-95
Tendons 96- 11 7
Text 96-98
G rap h ics: Tendon s 99-10 3
Ax ial MR seq uence 104-106
Grap h ics: Anato mic snuffbox 107
G raph ics: Intersection anatomy 108
G rap hi cs: Anoma lous muscle origins 109
Sagittal MR 110-113
Coronal MR 114-11 7
Neurovascular Structures 118-133
Text 118-120
G raph ics: Neu rovascular 121-125
MR: Carpa l t unn el 126
MR: Guyon canal 127
Gra ph ics: Vascular structu res 128
MR angi ogram 129
Ax ia l MR 130-133
 WRIST OVERVIEW
o First CMC (thumb base): Saddle joi nt, h igh ly
\Terminology m obile; ROM : Flexion, extension, abduction,
Abbreviat ions ad duction, circu mduction, rotation, opposit io n
o l nterm etaca rpal s 2nd-5 th : Gliding jo ints; ROM:
• Carpom etaca rpal (CM C)
• Distal radi o ulnar jo i nt (DRUJ) Limited mobi lity o f 2nd & 3 rd CMC, increasing
• Metacarpal (M C) mobi l ity of 4th & 5th CMC
• Triangular fibrocart i lage (TFC) • See "Osseous Structures" section
• Triangu lar fibrocartilage complex (TFCC) Wrist Motion
• Abductor po ll icis longus (APL) • Tendon contri b utio n to m otion
• Abductor po ll icis brevis (APB) o Flexi on: FCU, FCR, PL, APL (FDS & FOP may assist
• Extensor carpi rad i al is b revis (ECRB) wh en fi ngers are i n full extension )
• Extensor ca rpi radialis longus (ECRL) o Ex tension: ECRL, ERCB, ECU (ED & EPL may assist
• Extensor ca rpi ul nar is (ECU) wh en fingers in clenched fi st)
• Ex tensor digi to rum (ED) o Radia l deviatio n (wrist abduction): APL, EPB w ith
• Extenso r po ll icis b revis (EPB) contribu t ion by FC R, ECRL, ERCB, EPL
• Exten sor po ll icis lo ngus (EPL) o Ulnar deviatio n (wrist adduction ): FCU, ECU
• Extensor indicis (El) o Pronatio n: PQ, PT
• Extenso r digiti m i n imi (EDM) o Supina tio n : Su pina to r, b iceps brach ii
• Fl exor carpi radi alis (FC R)
• Flexor ca rpi u lnaris (FCU) Nerves of Wrist Jo int
• Flexor digito rum profundus (FOP) • T h ree majo r nerves serve wrist region
• Flexor digito rum superficiali s (FDS) • Median
• Flexor polli cis longu s (FPL) o Origi n : Brachial p lexus lateral & med ial cords
• Palmaris brevis (PB) o Course in w rist: Deep to f lexo r retinaculum,
• Palmaris longus (PL) superficia l to FDS/ FDP, lateral in ca rpal tun nel
• Pronator quadratus (PQ) o Su pplies: PT, FC R, PL, FDS
• Pronator teres (PT) o Branch: A nterio r interosseou s
• Gadoli n iu m (Gd) • Course i n w rist: Di stal interosseous m em bran e
• Normal sa lin e (NS) betw een FPL & FDP to terminate in PQ &
• Range of mo ti on (ROM) rad iocarpa l jo in t
• Suppl ies: Radial 1/2 o f FOP, FPL, PQ
D efinitions • U lnar
• Vola r = palmar o Origin: Brach ial plexus medial cord
• Ulnar = m edia l o Cou rse in wrist: M ed ial to ulnar artery, superficial to
• Radial = l ateral flexor retinaculu m, d eep to PB; bi furca tes in Guyon
ca nal

IGross Anatomy o Supplies: FCU, u lnar 1/2 of FOP

• Radial
o Origin: Brachial plexus posterio r co rd ; mul ti ple
Overview
branches; termin ates i n superficial & deep bran ches
• Wrist joint refers to complex articulatio n s i ncluding
o Superficial branch course i n the wrist : Passes under
d istal rad io ulnar joint, radiocarpa l, pisot riquetral,
brach io radialis tendo n into d o rsal wr ist & divides
midcarpal, 1st C M C, 2nd-5th CMC jo in ts & attend an t
• Lateral b ranch: Sup pli es radial wrist & thu mb skin
ligamento us & tend inous attachmen ts
• Media l branch: Supplies dor al wrist kin; divides
j o ints to dorsa l d igi ta l nerves
• Distal (in ferio r) rad ioulnar: Pivot jo int; ROM: D ist al o Deep bran ch co urse i n the wrist: Enters supinato r
radius rot ates aro und dista l u l na; rad ius & ul na are m uscle ventrally; exi ts d istally & posteriorly as
parallel in full supi nati o n pos terio r i nterosseous nerve
• Rad iocarpa l: Ell ipsoid joint created by proximal carpal • Supplies ECRB, supinato r, ED, EDM, ECU, EPL,
row articu lating w ith d ist al rad ius & ulna; ROM: APL, El
Flexion, extensio n , abduction, adductio n, • See "Neu rovascular Structures" section
circumd uct io n , no ro tation
Vessels of Wrist Joint
• Pi sotriquet ral: Gliding joint created by pisifo rm &
• Su pplied by three ma jor arteries
triq uet rum; discretely separate fro m radiocarpal joi n t
o Uadial: Term in al bran ch of brachial artery
in 10-25%; ROM: Min i ma l
o Ulnar: Term i n al branch of brach ial artery
• Midcarpal: G liding joint created by arti cu lati on of
o Com mon interosseous: Branch o f ulnar artery
proximal & distal ca rpal rows; ROM: Some exten sion,
• Branches into a n terior & posterior interosseous
abducti o n, minima l ro ta tion
arteri es
• Interca rpal : Glid i ng jo in ts crea ted by interface o f
• Vessel s create three major vo lar arches & one ma jor
indiv idual carpal bones; ROM: Complex
dorsal arch
• Carpometacarpal
• See "Neurovascular Structures" sec tion

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 WRIST OVERVIEW

ltmaging Anatomy Muscles & Tendons

• Muscles acting on t h e wrist joint o r te ndon s cross ing
Osseous Structures th e wrist join ts (listed by action o n t he w rist)
• Distal radius: Articula tes wi th scap hoid, lunate & • Fl exors, deep
ulna; structure: Scaphoid & lunate fossae; radial o Flexor digitorum profundus: Origin ulna, insertion
stylo id; Lister tubercle - dorsa l promin ence; sigmoid index, middle, rin g & littl e fi nger d i stal ph alan gea l
notch - medial con cavity for ulna base
• Dista l ulna: Articu lates wi th radius, arti cular disc o Flexor pollicis l o n g us: Origi n radius, interosseous
(TFC); tructure: I lead- di stal & lateral ulna, arti culates m em brane & co ro no id process ul na, insertio n
with radiu s; ulnar stylo id ; ulnar fossa- base o f st ylo id thumb distal p hala ngea l base
o Ulnar va rian ce refers to len gth of distal ulna relative o Pronator quadratus: O ri gin ulna & aponeurosis,
to distal rad i us; ulnar minus: U lna > 2 mm shorter insertion distal radius
than rad ius; ulnar p lus: ulna lo nger than radiu s • Fl exors, superfici a l
• Proximal ca rpal row: Scaphoid, lunate, triquet rum, o Flexor carpi rad ialis: Origin medial epicondyle,
pisiform insertion 2nd MC base with sl ip to 3rd MC
o Scaphoid: Articul ates with radius, lunate, capitate, o Palmaris l ongus: Orig in media l epicondy le,
trapezium, trapezoid; stru cture: Waist- mid po rtion insertion superficial flexor ret i naculum & pal ma r
of ca rpal; tuberosity- distal volar pro minence aponeurosis
o Lunate: A rt iculates w ith ca ph o id, radi us, articular o Flex or carpi ulnaris: O ri gin (h umeral head) m edial
di c (TFC), triquetrum, cap itate; structure: Lu nar o r epicondy le & (ulna r head) medial
half-moon shape; con cavity d irected dista lly o lecranon / p roxima l ulna, inserti o n pi siform &
o Triquetrum: Articu lates with articu lar disc (TFC ), flexor retin acu lum
lunate, pisiform, hamate; structure: Triangular shape o Flex or digitorum superficial is: Origi n
o Pisiform: Arti culates wi th trique trum; structure: (hum erou lnar h ead) medi al epi co ndy le & coro noi d
Sesamoid- like; FCU attaches & continues distally as process of ulna & (radial h ea d) anterio r radi us,
pisohama te & pisom etacarpal ligamen ts insertion index through little fi nger middle
• Distal ca rpal row: Trapezium, trapezoid, capitate, ph alangeal
hamate • Extensors, deep
o T rapezium (grea ter multangular): Articu lates w ith o Abductor pollicis longus: Origin ulna, insert io n
1st, 2 nd MCs, scap ho id, trapezoid; structure: Saddle radial 1st M C base with sli ps to trapezi um & APB
sh ape: Link between carpals & thumb o Extensor pollicis brevis: O rigin radius, in erti o n
o Trapezoid (lesser multangular): Articulates w ith t h u mb proximal ph alangeal base
tra pezi um , sca ph o id , capitate, 2nd M C ; structure: o Extensor pollicis longus: Origi n mid u ln a, insertio n
Wedge sh ape thumb distal pha langeal base
o Capitate: A rt iculates w ith sca ph o id, lun ate, hamate, o Extensor indicis (pro priu s) : Origi n mid ulna,
trapezoid, 2nd, 3rd M Cs; structure: Head - proximal inserti o n joins w ith u lnar side of ED tendo n
rou nded portion; neck (or wa ist) - narrowed mid inserting into 2nd digit ex ten sor hood
portion; body - bu lky distal portion • Extensors, superf ic ial
o Hamate: Articulates w ith triquetrum, capi tate, 4th, o Brachioradialis: Ori gin proxim al humerus,
Sth M Cs; stru ct ure: Wedge sh ape; hook (hamulu s) - insertion radi al sty lo id base
promin ent vo lar pro ject ion o Extensor ca rpi radialis l ongus: Origin lateral
• See "Osseous Strucl u res" section supracondy lar ri dge of humerus, insertio n d o rsal
radial 2nd MC base
Ligaments o Extensor carpi radia lis brevis: Origin lateral
• Extrin sic (connect radius, ulna to ca rpals or ca rpals to humeral epicondyle, insertion dorsal radial 3rd MC
M C) o r intrinsic (interconnect carpals)
base
• Majo r wri st stabilizers: Volar liga ments o Extensor digito rum (communis): Origin lateral
• Sum ma r y by loca ti o n humeral epicon dy le, insertion i n to middle & distal
o Volar radiocarpal : Radi oscaph ocapitate, lo ng
phalan ges
radiolunate, radi o ca pholunate, sho rt radi o lunate o Extensor digiti minimi [Ex digiti quinti (V)
o U lnocarpal : U ln o lunate, ulnotriquetral; pro prius!: O rigin co m mon ex tensor tend o n of lateral
ulnocapitate humera l epicond y le, insertio n extensor hood little
o Dorsa l radiocarpa l : Dorsal radiocarpal, dorsal
finger
interca rpal , dorsal ca photriq uel ra I o Exten sor carpi ulna ris: Origin commo n ex ten sor
o Volar midcarpal : Scaphotrapeziotrapezoid, tendon of latera l humeral epicondy le, insertion Sth
sea p h ocapi tate, tri q uetrocapi tate, triq uetroha mate
M C base
o Prox imal interosseous: Sca pho lun ate,
• Thenar
lu no t riq uetral o Abductor pollicis brevis: O ri gin flexo r ret in aculum,
o Distal interosseous: Trapezio trapezoid, sca pho id tuberosity & tra pezium ridge, insertion
t rapeziocapi tate, capitohamate thumb proxima l pha lanx
o Distal radioulnar: Dorsal radio ulnar, volar (palm ar) o Opponens pollicis: Origin trapezium & flexor
radioulna r, arti cular d isc (TFC) retinaculum, i nse rtion 1st MC
• See "Li gaments" secti o n

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 WRIST OVERVIEW
o Flex o r poll i cis brevis: Superficial o ri gi n flexor
retinaculum & trapezi um, deep origin trapezoid &
!Anatomy-Based Imaging Issues
capitate, i nsertion thum b prox i mal p halanx Imaging Recommendations
o A ddu cto r po llicis: Ori gin ca pi tate, 2n d & 3rd M C • Radiography : For al ignment, join t space width,
bases, insert ion u l nar thumb proximal p halan x mineralizat io n, range of motion
• H y pothen ar • Arth rograph y: For i ntri nsic liga ments & TFC integrity
o Pal mari s brevis: O rigin fl exor retinaculum & o ln jectate: Undi l uted iodi nated contrast
pa lmar aponeu rosis, i nsertion skin of palm o Volumes: Midcarpal: 4-5 cc; radiocarpa l : 2-3 cc;
o Ad d u cto r d i git i m ini m i: Origin p isi fo rm & FCU, D RUJ: 1 cc
i nsert io n little fi nger proxi mal phalanx • CT: Acquire thin section (0.5-lmm) 20 and 3 0
o Flexor digi t i min i m i brevis: Origin ham at e hook & reform ati on; for align men t, cortica l i ntegri ty
fl exor ret inacu l um, insertion u l nar li ttl e finger • CT arthrogra phy: Used if unable to undergo MR
proximal ph alan x o lnjectate: Iod i nated contrast: NS (1:2-3)
o Opponen s d igi t i m i nimi: Origi n h am ate hook & • M R: Dedi ca ted co ils, 8-10 em fie ld of view, thin
flexor retinacul um, i n sertion 5th MC secti on s essen tial for imagi ng sm all, complex wrist
• See "Tendon s" section anatomy
Retinacula o T l: Single p lane; for anatomy, m arrow, spaces
• Fl exor reti nacu lu m o Inversion recovery: Coronal plane; for marrow
o Superfi cial (volar carpal ligam ent o r l igam en tum contusion , so ft t issue m asses, flu id col lections
carpi pa l mare): Attach ed to styloid p rocesses of ul na • Limitat ion s: Poor spatial resolution
& radius; merges w i th deep co mponent distally o GRE (T2*): Coronal pla ne; for liga m ents, art icular
o Deep (tran sverse ca rpal ligamen t or ligamen tum cartilage
flexorum): Attached to pisiform & hook o f h ama te • Limitations: Magic angle effect, suscepti bil ity
medially, scapho id & tra peziu m laterally arti fact
• Ex te n sor retinaculu m o PD/T2 (w/ or w/o fat suppression): Axia l plane;
o Attaches to u l nar sty loid p rocess, t riquetrum & m arrow, cartilage, ligamen ts, fluid co llect ions
pisiform m ed ially, crosses obliquely to attach Lister o In t raven ous Gd/Tl w/fa t suppression: For uspected
t ubercle & rad ial sty loid process laterally m asses, i n flammation, i n fections
• Sends septae to rad i us crea ting compar tm ents fo r o St ructu res best v isualized (by plan e)
extensor te ndons • Coron al : Osseous structures, alignment, intrinsic
o Compartm ent con ten ts: 1) APL, EPB; 2) ECRL, ECRB; & extrinsic ligamen ts, T FCC
3) EPL; 4) ED, El; 5) EDM; 6) ECU • Ax ial: Ten dons, neurovascular struct ures, DRUJ,
• See "Tendon s" section pi sotriquetra l join t
• Sagi ttal: Alignme nt, cross section ligaments,
Anatomic Sp aces pi sot riquetra l joi nt
• An atomic snuffb ox • MR art hrogra phy
o M argins: D ist al radius (prox imal ma rgin), EPL o ln jecta te: Gd : Fl uid mix (1:100-200); flu id :
(d orsa l margin), APL & EPB (vo lar m argi n) NS/iodinated contrast (50:50); allows for
convergen ce o f APL/EPB just distal to 1st CM C diagnostic/CT arth rography
(distal m argin); snuffbox b ase formed by radial • Ultrasound: Dy namic evaluation of tendons,
styloid, scaph oid, t rapezi u m & 1st CMC ligam ents, n eurovascu lar structu res
o Conten ts: Cephal ic vei n, radial nerve, (superf icial
b ran ch), radial artery
Imaging Pitfalls
• Carpal tunn el • M an y tendon varia tion s incl ude spli t or duplicated
o Margi ns: Carpals (dorsal margin), flexor tendon s
ret inaculum (vola r margin ); p isi fo rm & ho ok of th e • Small amount extensor tendo n sh ea th flu id is
ham ate (m ed ia l margin), scaph oid & tra pezium common (part icularly ECRB & ECRL); shou ld not be
(l ateral m argin), rad iocarpal join t (proximal margin) mistaken for ten osyn ovi tis
& MC base (distal margi n ) • TFCC attachmen ts may mimic tears: Radia l
o Contents: FDS, FOP, FP L, median n erve attachments to hyaline cartilage rather than cortex;
• Guyon can al ulnar attachment to ulna fossa often intermediate
o Margins: Superfic ial f lexor ret i naculum (volar carpal signal due to magic angle or vol u me averaging
liga ment o r ligam entum ca rpi palm are) tventra l o Arti cu lar disc may develop asymptomatic attritional
m argi n], p isi form & rcu lmedial m arginl, deep tears
flexor retinacu lu m (transverse carpa l ligamen t or • Scaphol un ate & lunotriq uetral liga men ts may attac h
ligamentu m flexorum) l lateral & do rsa l margi n] to arti cu lar cartilage rather than co rtex
o Con ten ts: Ulnar artery & vein, ul nar nerve • M alposition ing: U lnar or radial devia tion may create
• See "Ten dons" and " eurovascular St ructu res" sectio ns apparent instability patterns
• M agic an gle effect: Orga nized fibers (t. or 1.) crossing at
55° to mai n m agnetic field m ay have in termediate
signal on sh ort T E i magi ng (Tl, PO, GRE)
o Exa mples: ECU crossi n g dorsu m of u l na; EPL
crossi ng dorsa l w rist obliquely

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Ill
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 WRIST OVERVIEW
RADIOGRAPHS, PA & LATERAL

3rd, 2nd & 1st

Sth & 4th m e taca rpal m etacarpal bases
bases

Ho ok of h amate Trapezoid

Hamate

Triq u etrum Capitate nec k

Scaphoid wa ist
Pisi form
Radia l styloid
Lunate
Scaphoid fossa

Ulnar styloid
Liste r tu be rcle

Ulna r fossa
Lun ate fossa
Ulna r h ead

Sig m o id notch

[
3rd me tacarpa l base,
dorsal
Trapezoid
Capitate
Tra pezium
Ha ma te
Sca p hoid

Pisi fo rm Triqu e trum

Lu n a te

Uln a r styloid
Radiu s

Ulnar fossa

(Top) PA radiogra ph o f th e wrist. Image is obtained a t ze ro-rotation by position ing patient at 90 d egrees abd uctio n o f
sho ul de r & 90 degree fl ex ion of e lbow. (Bottom) Lateral rad iograph obtain ed in zero- rotatio n positio n . Note th e
position o f t he pisiform overlyi ng th e mid waist of th e sca phoid indi cates a p roperly positioned la tera l. !mage is
o btained wi th the wrist resting on the film cassette with the shoulder at 90 degrees abd uc tio n & th e e lbow at 90
degree flexion.

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 WRIST OVERVIEW
RADIOGRAPHS, PA & LATERAL

3rd, 2nd & I st

5th & 4th metacarpal m etacarpal bases
bases

Hook of hamate

llamate Trapezium

Triquet rum Cap itate n eck

Scap hoid wahl

Radial styloid
Lunate
Scap ho id fossa

Ulnar stylo id
Lister tubercle

Ulnar
Lunate fossa
Ulnar head

Sigmoid notch

Trapezoid
3rd m etacarpal base,
dorsal
Trape.dum

Capitate
Scap hoid

Pisiform Triquetrum

Lunate

Ulnar styloid
Radius

U l nar fmsa

(Top) PA radiograph o f th e wrist. Colo r-cod ed to facil itate key structure identifica tio n. Third m etacarpal : Magenta;
ca pi tate: Blue; lunate: Yellow; rad ius: Red. (Bottom) Lateral radi ograph ob tained in zero-rotatio n position .
Color-coded to faci litate key st ructure identifica ti o n . Third metaca rpal: Magenta; capitate: Blue; l unate: Yellow;
rad i us: Red.

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I

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Ill
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 WRIST OVERVIEW
AXIAL T1 MR, RIGHT WRIST

Extensor po llicis longus

Extensor digitorum tendon
tendon sl ips
Lister tu bercle

Extensor ca rpi rad ialis

Exten sor d igiti min i mi brevis t.
tendon
Extensor indicis t. Extensor ca rpi rad ialis
t.
Ex ten sor carpi ulnaris t
Extensor pollicis brevis
Flexor digito rum tendon
profundus t.
Abductor pollicis
longus l.

Flexor carpi ulnaris Flexor carpi rndinlis t.

muscle & tendon

Flexor longus t.

Flexor digi torum

superficia l is m . & t.

Extensor retinaculum

Compa rtment J: EPL

Co mpartm ent S: EDM

Compartment 2: ECR L,
ECRI3

Radial n., superfi cial

Compart ment 4: El, ED bran ch
Compa rtment 6: ECU Compart m ent I : APL,
EPJ3
v. Lateral an tebrach ial
cutaneous n.
Uln ar n .
Radial a. & cephal ic v.
U lnar a.
M edian n.
Ulnar v.

Antebrachial fascia

(Top) First of eigh teen sequential Tl ax ial images o f right w rist, from proximal to distal, displays tendons &
musculature at Lister tubercle. (Botto m) Slightl y distal, at level of ulnar h ead & distal radius, neurovascular structures
& fascia are anno tated. T h e extensor retinacu lum crea tes six sepa rate tunnels or compartments as it attaches to
underlyi ng bon e. Each compartment con tains o ne or mo re tendo ns as foll ows: 1) Abd uctor pollicis lo ngus, extensor
pollicis brevis; 2) Exte nsor ca rpi radia li s lo ngus & brevis; 3) Extensor pollicis longus; 4) Extensor indicis, ext·ensor
digitorum; 5) Extensor d igiti minimi; 6) Exte nsor carpi uln ari s.
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 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

Extensor pol licis longus

tendon Ex tensor digito rum t.
'>l i ps
tubercle
Ex ten sor digi t i minimi
carpi rad ia lis
te ndon
brevis t.

Ex tensor ca rpi radialis Ex tensor i ncl icis t.

longus t.
carpi ulnaris t .
Exten sor pol licis brevis
ten don
Abduc tor pollicis Flexor cl igi toru m
longus t. profundu s t.

Flexor carpi ulnaris

Hexor ca rpi rad ial is t.
muscle & tendon
Flexor pollkis longus t.
Flexor cl igito rum
superficia lis m. & t.

l:.xten sor retinaculum

Com par t men t 3: CPL

ompa r tm en t 5: EDM
Compart ment 2: ECRL,

Rad ial n., superficia l

branch Com partmen t 4: El, ED

I : A PL, Com partment 6: ECU

EPB
Latera l an tebrach ia l
cu taneous n.

Rad ial a. N. ce phal ic v.

Medi an n.

An tebrachi al fascia

(Top) f-irst o f 18 sequential Tl ax ial images o f left w rist, fro m proxima l to d istal, displays tendons & musculature at
Lister tubercle. (Bo ttom) Slightly distal, at level o f ulnar h ead & distal radiu s, neurovascular stru ctures & fascia are
an notated . Th e extensor retinacul um creates six sepa rate tunnel s or compartm ents as it attach es to underl ying bone.
Each com part ment contain s one or more tendons as fo llows: 1) Abd ucto r pollicis longus, exten sor po llicis brevis; 2)
Ex ten sor carpi radia lis longus & brevis; 3) Extensor pollicis longus; 4) Extensor inclicis, ex ten sor d igitorum; 5)
Ex ten sor digit i minimi; 6) Ex tensor carpi ulna ris.

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 WRIST OVERVIEW
AXIAL T1 MR, RIGHT WRIST

Exten sor digi torum t.

Extenwr longus
ten don
Extemor digit i mini m i
tendon Lister tubercle
Extemor carpi radia l is
t.
Ex ten sor indicis t.
Extensor carpi rad ialis
Sigm oid notch lo ngus t.
Ex ten so r carpi uln aris t. Extemor pollicis brevis
Ul n ar styloid tendon
Abductor
Vola r radiou l n ar I. longus t.

Flexor digitoru m
Flexor carpi radialis t.
pro fund us t.
Flexor pollicis longus t.
Flexor carpi uln aris
muscle & ten don Flexor digitorum
m. & I.

Extensor ret i naculum

Lunate Radial nerve,

uperl icia l branch

rad ioulnar I.
Radial styloid

Ulnitr styloid process

Vo lar rad iouln ar I.

U l nar n.

U lnar a.

Ul na r v.

(Top) Ex ten sor tendons are tet hered by ex ten sor reti n acu lum. Ex tensor pol licis longus tendon l ie w i th in a dorsa l
osseous groove ulnar to Lister t ubercl e. Fl exor muscu lo tendino us jun ct io ns are v isualized prox i ma l to carpal tunnel.
Palm aris lo ngus ten don i s absen t as i t i s in approximatel y 10% o f the general po pu lat io n . (Bo tto m) Extensor
ret i nacul um i ident ifiab le at u ln ar stylo id t ip & radial st y lo id base. Median & u l nar nerves arc read i ly v isual ized as is
superfi cial bran ch o f radial n erve.

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 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

Extensor pollicis lo ngus Ex temor digi torum t.

tendon sli ps

Lht er tubercle Extemor digiti minimi

tendon
Extenso r carpi rad ialis
brevis t.
inclicis t.
Ex ten>o r carpi rad i<liis igmoicl notch
longus t.
Ex tenso r carpi ulnaris t.
Extensor poll icis brevis
tendon
Abductor po llicis Volar radioulnar I.
longus t.
1-lexor digitorum
Fil'xor ca rpi rad iali s t. profundus t .

llcxor longus t. Flexor ca rpi ulnaris

muscle & tendon

1-lexor digitorum
superficialis m . & t.

ret inacu lum

Lunate
Radial nerve,
branch
Dorsa/ radiouln a r I.
Hadial base
Ulnar styloid process
Radia l v.
Volar radiou l nar I.
Radial a.

Radial v. Ulnar n .
Ulnar a.
Median n.
Ul nar v.

(Top) Extensor ten dons are teth ered by ex t en sor ret in aculum . Exten sor p o llicis longus te n don l i es w i t hin a dor sa l
osseous groove ulnar to Lister t u bercle. Flexor muscul o ten di nous j u n cti o n s are v i su al i zed p roximal to ca rpal tunnel.
Palmaris longu s ten don i s absen t as i t i s i n ap proximat el y 10% o f t he gen eral po p ula tion . (Botto m) Ext ensor
retinacu lum is identifiable at u lnar st y l o i d ti p & rad i al sty lo i d base. Med i an & ulna r n erves ar e readi ly visua li zed as is
superfi cial bran ch o f ra dial nerve.

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 WRIST OVERVIEW
AXIAL T1 MR, RI G HT WRIST

Extemor indicis t.

Extemor digitorum t. pollicis longus

sli ps tendon
Extensor carpi radia l is
Ex ten sor digiti minimi brevis t .
tendon
carpi radia l is
t.
Dorsa l radioulnar I.
Radial styloid process
Extensor ca rpi ulnaris t. Extensor pollicis brevis
tendon
Vola r radioulnar I. Abductor pollicb
Lunate longus t.
Scaphoid
Flexor digitorum
t. Flexor carpi radialis t .
Hcxor pollicis longus t.
Flexor carpi ulnaris t.
Flexor digitorum
su perficia I is t.

scaphot riquetral
ligament

Scapholunate 1., dorsal

band
Extensor retinacu lum
Radial n.,
branch

Dorsal radiocarpal I.
Cepha lic v.

Triquetrum Scaphoid
Uln o triquetral I.
Radial a., v.
Uln ocapitate I.
Lu n ate Radiosca ph oca pita te I.

Lo ng radio lunate I.
Uln o lunate I.
Scapholunate 1., volar
Uln ar n. band

Uln ar a., v. Median n.

(Top) At proximal lunate, ex tensor pollicis longus tend on begins to cross radially. Abdu ctor pol licis longus&.
ex ten sor poll icis brevis tendons are d iv iding in to m ul t i ple sl i ps. Extensor carpi ulna ris tendon has some intermediate
intrasubstan ce signal inten sity no rma lly. This does not represent a tear. Dorsal &. vo la r rad ioulnar l iga men ts,
com pon ents of triangular f ib roca rti lage comp lex, are ev ident. (Bottom) Volar &. d orsal extrinsic ligamen ts&.
u ln ocarpa l l iga men ts are evident at level of mid lu nate. Media n nerve is rou n ded prior to en teri n g carpal tu nnel with
signa l inten sity equal to muscle.
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 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

Extensor inclicis t.

Extensor pollicis longus

tendo n Extensor dig itorum t.
slips
Extensor carpi radialis
brevis t.
Extensor digiti minimi
Extemor carpi radialis tendon
lo ng us l.
Dorsa l radio ulnar I.
Radial styloi d process
Extensor pollicis brevi s Exte nsor carpi ulnaris t.
tendon
Abductor pollicis Vola r radioulnar I.
longus t.
Lunate
Scaphoid Fl exor d igi to rum
profu ndus t.
Flexor ca rpi radialis t.
Flexor carpi ul naris t.
Flexor pollicis longus t. Fl exor d igi to rum
su perfi cialis t.

tlj!
Dorsa l scaphotriquet ra l
ligamen t
Scaphol un ate 1., do rsal Extensor retinacul um
band
Radial n., superfi cial
Dorsa l radiocarpal I.
branch
Cephali c v.
Triq uetru rn
Scapho id Ulnotriquetral I.

Radial a., v. Lunate

Ulnocapitate I.
Radioscaphocapitate I.
Ulnoluna te I.
Long radiolunate I.
Ulnar n.
Scapholunate 1. , vo lar
Ulnar a., v.
band

Median n.

(Top) At p roxima l lunate, extensor pollic is lo n g us tendon b egin s to cross radiall y. Abductor p o ll ic is lo ngus &
extensor po llic is brevis te ndons are div iding into multiple slips. Extensor carpi ulna ris te ndo n h as so m e in term ed ia te
intrasubstan ce signal inte n s ity normall y. T hi s d o es n o t rep resent a tea r. Do rsal & volar rad ioulnar ligaments,
components of trian gu la r fib roca rtilage complex, are ev ide nt. (Bottom) Volar & dorsa l extrins ic liga ments &
ul noca rpal ligame nts a rc evide nt a t level o f mid lunate. Median n e rve is rounde d pr ior t o e ntering carpal tunn el w ith
sign al intensi ty eg ua l to muscle.

Ill
17
 WRIST OVERVIEW
AXIAL T1 MR, RIGHT WRIST

Extensor i ndicis t.

Ex tensor poll icis longus

tendon
Extenso r digi torum t.
Extensor carpi radialis
slips
brevis t.

Extensor digiti min imi Extensor ca rpi radialis

tendon t.

Extensor carpi ulnaris t.

Extensor poll icis b revis
tendon
Triquetrum
Lunate Abd uctor pollicis
longus t.
Pi siform

Flexor carpi ulnaris t. Scaphoid

Flexor digitorum Flexor carpi radi al is t.

profu ndus t. Flexor pollicis longus t.
Flexor digi torum
superficial is t.

Extensor reti naculum

Dorsa I i n terca rp aI I.
Dorsal scaphotriq uetral
l iga m en t
Radial n., superficial
Dorsal radiocarpal!. bran ch

Triquetrum
Cep hal ic v.
Lun ate Radial a. & v.
Pisohamate I. Scaph oid

Ca pi tate
Pisiform
Radioscaphocapi tate I.
Ul nar n.
Ul nar a., v. M edi an n.

Volar carpa l I. Flexor retinaculum

(Top) Slig htl y more di stal, a t level of di stal lunate & proximal pisifo rm, ext en sor poll ic is lon gus tendon is not eas ily
identified as a sepa rate structure as it crosses d orsa l to ex te nsor carpi radial.is brevis te ndo n . (Bottom ) Exten sor
re tinaculu m dista l fibers are vis ual ized at level o f lunocapitate artic ula tio n . Extrinsic dorsa l & vo l.ar liga m e nts are
a ppa re nt as components of ca psule. Median n erve rema ins rounded as it e nters prox im a l carpal tu nne l. Guyon ca n al
is borde red by pi siform , deep & supe rfi cial bands of flexo r retina cu lu m, tran sverse carpa l ligame nt prox imall y &
volar ca rpal liga m ent.
Ill
18
 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

Extensor indi ci s t.
Extensor polli cis lo ngus
tend on Exten sor digitorum t.
slips
Extensor ca rpi radial is
brevis t.
Extemor digiti m i nimi
Extenso r carpi radi al is ten don
longus t.

Extemor poll icis brevis Exten so r ca rpi ulnari s t.

tendon Trig uetru rn
Lunate
Abd uctor pollicis
lon gu s t. Pi siform
Scaphoid Flexor d igitorum
pro fu ndus t.
Flexor carpi rad iali s t.
Flexo r ca rpi ul naris t.
Flexor pol l icis lon gus t.
Flexor d igi to rurn
super ficialis t.

Ex tenso r retinacu lum

LJo rsal intercarpa l l. Dorsal sca pho tri quetral

liga ment
Radial n., su perficia l
branch
Dorsal radiocarpal I.
Ceph alic v.
Triquetrum
Scaphoid
Lun ate
Radia l a. & v.
Ca pi tate Pi so hamatc I.
Radioscaphocapitate I.
Pi siform
Median n.
Ul nar n.

U lnar a. , v.
Flexor retinacu lum
Volar carpal I.

(Top) Slightly more distal, at level of distal luna te & proxima l pisiform, extensor polli cis longus ten do n is n ot easil y
idcnt"ificd as a separate structure as it crosses dorsa l to extensor ca rpi rad ialis brevis tendon. (Bottom) Ex te n so r
reti n acu lum d istal fibers are visua lized at level of lun ocapit ate a rti cu latio n . Extrinsic dorsa l & vo lar liga m ents are
ap parent as co mpo ne nts of capsule. Med ian ne rve re m ains ro unded as it ent e rs prox imal carpal tun n e l. G uyo n canal
is bo rdered by pisiform , deep & superfic ia l bands of flexor retin acul um, tran sve rse ca rpal ligament proximall y &
volar carpal liga ment.
Ill
19
 WRI ST OVERVIEW
AXIAL T1 MR, RIGHT WRIST

Ex ten sor i nd icis t.

Ex ten sor carpi rad ialis
brev i t.
Exten sor digitoru m t. Ex ten so r po ll icis longus
sl ip s tendon

Ex ten sor digi ti m i n i mi Exten so r ca rpi radial is

te ndon lo ngus t.
Ex tenso r ca rpi ulnaris t.
Capi tate

Triq uetru m Ex ten sor po ll icis brevis

ten don
Ham ate

Pisi fo rm Abd ucto r pollicis

lo ngus l.
Abductor digiti m i n i mi
m uscle Scaph oid

Flexor ca rp i rad ia li s t .
Flexor di gi torum
profund us t. Flexor pollicis lon gus t.

Flexor di gi toru m
su perficial is t.

Do rsa l in terca rpal I. Ca p i tate

Rad ia l n., supe rfici al

H am ate brilnch
Ceph alic v.
Tri quetrum
Rad ia l a., su perficial
pillmilr b ranch
Uln ocapitate I.
Abductor d igi ti mi n i m i Scap ho id
m u scle
Rad iosca ph ol u nate I.
Ulnar n. Median n.

Uln ar a., v. Flexor ret i nacu l u rn

Palmar apon eurosis

(Top) At d istal pisotri quetral articu lation, Guyon canal is loca ted radial to pisiform & contai n s u lnar nerve, artery &
vei n . Ex ten sor pollici s longus tendo n crosses do rsa l to ex ten so r carpi radial i.s brevi s ten do n & its o bliq u ity m akes it
di fficul t to distingu ish as a sepa rate tendo n . (Bo ttom) At the l evel o f d is tal t riq uetrum & distal pol e o f sca pho id,
ulnar ner ve bra n ches int o d eep & su perficial branch es. Note beginning o f t hen ar & hy po then ar m uscl es wh ich
originate fro m flexor ret i n aculum .

Ill
20
 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

Lxtcnsor indicis t.

bten sor ca rpi radialis

t.

1-.xtensor poll icis longus Extemor digitoru m t.

ten don sl i ps
Ex tensor ca rpi radialis digiti m i nimi
longus t. ten don
Extensor ca rpi ul naris t .
Capi tate
Triquetrum
Extcmor b revis
tendon !Iam ate
Abductor pollicis Pisiform
longus t.
Abdu ctor digi ti minimi
Scaph oid muscle
Hcxor carpi radialis t.
Flexor digitoru m
Flexor pollicis longus t. pro fundu s t.

Hexor d igi torum

super ficial is t.

Capitate

Dorsa l intercarpal I.
Radial n., \uperficial
branch
Cephalic v. !Ia mate

Radia l a., superficial 'I riquetrum

palmar branch
Uln ocapitate I.

1\bcluctor digit i minim i

I. muscle
Median n. Ulnar n.

Uln ar a., v.
ril:.\Or retinaculum
Palma r aponeurosis

(Top) At distal pisotriquetra l art iculation, Guyon can al is loca ted radial t o p isiform & contains ul nar nerve, artery &
vei n. Extensor pol licis longus tendon crosses dorsa l to ex ten sor ca rpi radialis brevis tendon & its obliquity m akes i t
difficult to distinguish as a sepa rate t endon. (Bottom) At th e level of di stal tri quetrum & distal pole o f scaphoid,
ulnar nerve branches in to deep & superfi cia l bran ches. Note beginn i ng o f then ar & h ypothen ar m u scles which
originate from flexor retina culum.

Ill
21
 WRIST OVERVIEW
AXIAL T1 MR, RIGHT WRIST

Extemor indicis t.

Extemor carpi radialis

brevb t.
Capi tate
l::xtensor digitorum t.
sl ips carpi radialis
t.
Ex ten sor di gi ti mini mi Extensor pol l ici s longus
tendon liga men t

ll ama te Scaphoid
Ex ten sor carpi uln aris t. Extensor pol l icis brevis
tendon
Flexor digi toru m
pro fundus t. Opponem pollicb m.

Abd uctor digiti minim i Trapezium

Flexor carpi radia l is t.
Fl exor digitorum
superficialis t. Abductor pollicis brevis
muscle
Flexor pollicis lo ngus t.

TrapeLiocapitate I.
dorsal band

Capi tate Trapezoid

Radial n ., super ficial

Ca pit oh amate 1., dorsa l branch
band Cephal ic v.
Ham ate
Extemor polli cis brevi5
Capit oh am ate 1., volar tendon
band
Uln ar n., deep bran ch

Abductor digiti minimi Trapezium

m uscle
Opponens m.
U lnar a., deep bra nch
Abductor poll icis brevis
I look of hamate mu 5cle
U lnar n. & a.,
fed ian n.
branches

Flexor reti naculum

(Top) l lamate bod y (proximal to hook) & scaph o trapezio t rapezoid articula t io n co rrespond to mid-level carpa l
tunn el. EPL tend on intersect s dorsa lly with EC RL tendo n . T he median nerve is sligh t ly flat tened . (Botto m) At hook
o f hamate & trapezium tubercle, ulna r ner ve branch es into deep & superfi ci al bran ches w ith deep bra nch passing
do rsal & u l n ar to hamate hoo k. Po rti on s o f vo lar & do rsa l in terosseous ligaments are visua lized.

Ill
22
 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

Extem or carpi radialis

brevis t.

Capitate Ex temor in dicis t.

ca rpi radialis Ex tensor cligi toru m t.

longus t . slips

Extensor pollicis lo ngus Ex tensor digi t i minimi

ligament ten don

Hamate
Scaph oid
Extensor po l licis b revis Extensor carpi ul naris t.
tendo n

Abd uctor digiti minimi

Oppon en s po l licis m . m u sc le
Trapezium Flexo r digitorum
p rofundus t.
Fl exor carpi radia l is t.
Abducto r po llicis brevis Flexor digitorum
m u scle superfi cia l is t.

Flexor poll ici s lon gu s t.

Trapeziocapitate I.
do rsa l ba nd

Trapezoid Capi tate

Radial n erve,
superfi cial branch
Capi toham ate 1., dorsa l
Cep hali c v. band
Hamate
Extenso r po lli cis brevis
ten don Capitoha m ate 1., volar
Abd uctor polli cis band
longus t. U l nar n ., deep bran ch

Trapezium Abductor digiti minimi

muscle
Oppon ens po llicis m.
Ul nar a., deep branch
Abducto r po ll icis brev is Hook of hamate
m uscle
U l na r n . & a.,
M ed ian n. superficial branches
Flexo r retinaculum

(Top) Hamate body (proxim al to hook) & scaphotrapezio trapezoid articul ation correspond to mid-level carpal
tu n nel. EPL tendon intersects dorsall y w ith ECRL t endon. The median nerve is sl ightly fl attened . (Bottom) At h ook
of hamate & trapezium tubercle, u lnar n erve bran ches into d eep & su perficial bran ch es wit h deep bran ch passi ng
dorsal & ulnar to hamate hook. Portion s of vo lar & dorsa l in terosseo us liga men ts are vi suali zed.

Ill
23
 WRIST OVERVI EW
AXIAL T1 MR, RIGHT WRIST

Extensor digitorum t.
sli ps Extensor indi cis t.

Cap i ta te Extensor carpi radial is

b revis t.
Flexor d igi torum
p ro fundu s t. Ex tensor carpi radi alis
lo ngus t.
Ham ate
Ex tensor pollicis lo ngus
tendon
Exte nsor digiti minimi
tendon Trapezoid
St h m etaca rpa l base I st metacarpa l base
Extenso r ca rpi ul nari s t. Fl exor carpi radial is t.

Abductor digiti minimi Oppo nen s po l l icis m.

muscle
Tra pezium
Hook of h amate
Abductor pollicis brevis
Palmar aponeurosis m u scle

flex or digitorum
Fl exor poll icis longu s t.
super ficial is t .

Trapezoid
Ca pi tate

Radi al a., deep bra nch

Hamate
Sth metaca rpal base
Cephalic v.
Oppon ens digiti
m i nimi m.
1st m etacarpa l base
Abductor digi ti minim i
muscle Oppon em m.

Ul nar n ., deep b ranch Abductor pollicis brevis

m usc le
Ulnar n . sup erficial
bra nch es Trapezium
Ulnar a., v.
Median n.
Palmar aponeurosis Flexo r reti naculum

(Top) At distal hook of hamate, fl exo r digitorum te nd o n s pass through ca rpa l tu n n el with two m ost su perfic ial
tendons ex te ndin g to long & rin g fingers, t wo in ter m ed iate te ndo n s to index & small fin gers & pro fundus ten dons
comp rising deep laye r. (Bottom) Distal carpal tu n ne l co ntent s are passing through n arrowest portion o f carpa l
tunnel a t level of carpometacarpal a rticula tio n s. Ulna r ne rve deep bra n ches pass dorsa l & d ista l to hook o f hamate.
Uln ar n erve superfic ial branc hes continue distally into palm. A porti on o f deep palmar arch (radia l artery, deep
bra nch ) is visual ized. However, maj o r dorsal & vola r vascu lar arches a re typ ica lly not readily visua lized .
Ill
24
 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

Ex ten so r indicis t. Ex tensor digi torum t.

Extensor ca rpi radialis slips
brevis t.
Capitate
Exten sor carpi radialis
Flexor digi torum
longus t.
pro fundus t.
Extensor pollici lon gus
ten don Hamate

Exten sor digiti mini m i

Trapezoid te ndon

1st m etacarpal base 5 th metacarpal base

Flexor carpi ra di al is t. Ex ten sor car pi ul naris t.

Opponens pollici s m. Abductor digiti minimi

mu scle
Trapezium
Hook of hamate
Abductor pollicis b revis
muscle Pa l mar aponeuros is

Flexor po l licis longus t. Flexor d igitorum

superfi cialis t.

Trapezoid
Capitate

Radia l a., deep bran ch

llamate

Ce phal ic v. 5th metacarpal b ase

Opponens digiti
1 metacarpal base m i nimi m .

Abd uctor digiti m i ni m i

Opponens pollicis m . muscle

Abductor po llicis brevis Ulnar n., deep branch

mu scle
U ln ar n., super ficial
bran ches
Trapezium
Ulnar a., v.

Median n. Palmar aponeurosis

flexor reti naculum

(Top) At di stal h ook of ha m ate, fl exor d ig itorum te ndons pass through ca rpa l t unnel with two most superficial
tend o ns ex tend in g to long & ring fi ngers, two intermed ia te t e ndon s to index & s m all fingers & profundus te n dons
compris ing deep layer. ( Bo ttom ) Dista l carpal tunn el con tent s are pass ing th ro ug h na rrowes t po rt ion of carpal
tunn el at leve l of ca rpom etaca rpa l a rt icu lations. Uln a r nerve d eep bra n ches pass dorsal & di sta l to h ook of hamate.
Ulna r nerve superficial b ra n ches co n tinue dista lly in to pa lm . A portio n o f d eep palmar arch (rad ia l artery, deep
bran ch) is v is ua li zed. However, m a jor dorsa l & volar vascu la r a rc hes a re ty pica lly not readi ly v isua lized .

Ill
25
 WRIST OVERVIEW
AXIAL T1 MR, RIGHT WRIST

Jrd metaca rpal base

Ex temor digitorum t.
slips Ex tensor carpi radial is
brevis t.
Flexor digito rum 2nd metaca rpal base
profundu s t. Ex tensor carpi radialis
lor;j,gus t.
4t h m etacarpal base Fx tensor poll icis longus
Ex temor digi ti mi n im i tendon
ten don
Flexor lon gus t.
Sth m etacarpal base Adductor pollicis rn .

Flex or polli cis brevis m.

Opponem digi ti
minimi m .
I st m etacarpal base
Abductor digi ti minimi
Abductor pollicis bre\'iS
muscle
Hexo r digit minimi
brevis m. O ppo nens pollicis m.

Ulnar n., superficia l Flexor digi torum

b ranch t.

Ulnar a.

l'alrnar apon eurmis

3rd m etacarpal
4th m etaca rpa I base
2nd m etacarpal base

lntc rmctacarpall., Deep palmar arch

volar bands
I m etacarpal
Sth metaca rpal base

Median n.
Ulnar n., superfi cia l
Fl exor retinaculum
branch
U lnar v.

Ulnar a.

Palmar aponeurosis

(Top) T h e na r & h ypothena r musculature is we ll -d eve lo pecl at carpo metaca rpa l a rt iculatio n. Exte nsor poll ici longus
te ndo n now beco mes ev ident aga in as its co urse becomes mo re p e rpendicu lar to ax ial plane. Ex te nso r di g ito rum
te nd o ns a re becom ing flattened nea r inse rti o n si tes. (Bo ttom) At d ista l flexo r retinac u lum & metacarpal bases, the
carpal tunnel e nds with median ne rve bran ching into m usc ular bra n ches & digita l nerves. Ulnar ne rve, s upe rfic ia l
branch, re mains eviden t. A small po rtio n o f radial co ntributi o n to deep palma r a rch is see n between 1s t & 2 nd
m etaca rpa l bases.
Ill
26
 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

3rd metacarpal base

Exten sor carpi

brevis t.
Ex ten sor digito rum t.
2nd metacarpal base slips

Extensor ca rpi radial is 1-lexor digi torum

longu t. profun dus t.

Extensor pollicis lo ngus 4th m etacarpal base

ten don
Extensor digiti rnin i m i
Flexor polli cis longu s t. tendon

Adductor po lli cis 111. Sth metacarpal base

Flexor pollicis brevis 111 . O ppo nens di giti

mi nim i 111 .
I st metaca rpa I base
Abductor digiti min i mi
Abductor po l licis brevis mu scle
muscle
Flexor digiti minimi
Oppone ns po l licis m. brevis m .
Flexo r digitorum Ul na r n., superfi cial
supe rficialis t. branch
Ulnar a.
Palmar apon eu rosi s

3rd m etacarpal base

2nd m etacarpal base

4t h m etaca rpal base

Deep palmar arch

ln te rmetaca rp al 1.,
volar ban ds
1st metacarpa l
5th m etaca rpal b ase

Media n n .
U lnar n., superfi cial
Flexo r reti naculum branch

Uln ar v.

U l nar a.

Palmar apo neurosis

(Top) Thenar & h yp othenar musculature is well -developed at ca rpom etaca rpa l articulati o n . Extensor pollicis l ongus
tendo n n ow becomes evident aga in as its course becom es m o re perpendicular to axial plane. Exte nso r digito rum
tendon s a re becomi ng fla t te ned nea r inse rt io n sites . (Bo ttom) At d is tal flexor ret in aculum & meta ca rpa l bases, the
carpal tu nn e l ends wi th med ian ne rve branchi ng in to muscul ar branches & d ig ita l nerves. Ulnar n erve, su perficial
branch, rema in s evident. A small porti o n of radial contribution to deep palmar arch is seen between I st & 2 nd
metacarpa l bases.
Ill
27
 WRIST OVERVIEW
AXIAL T1 MR, RIGHT WRIST

3rd metacarpal base

2n d m etacarpal base

Flexor digitorum
Extenso r digi torum t. profun du s t.
sl ips
lnt.::rosseous rn.
4th m etaca rpal base Exten sor pol l icis longus
tendo n
Extensor digiti minimi I st m etacarpal sh aft
tendon
St h metacarpal base Adductor pollicis m.
Flexor pollicis brevis m.
Opponens digiti
minimi m. pollici s lo ngus t.

Abdu ctor digiti min imi Opponens pol li cis rn.

mu scle
Abductor polli cis brevis
Flexor digi t m in im i muscle
brevis m . Flexor cligitorum
superficial is t.
Ul na r n ., superficial
branch
Pal mar ap oneurosis

3rd m etacarpal

2n d metacarpal

Interosseous rn .
4th metacarpa l Exte nsor pollicis longus
tendo n
Sth m etaca rpa l I st metacarpal

In terosseus m.
====r-.:-- Flexor po ll icis brevis 111 .

Abductor digi ti minimi Oppo nen s pol l ic is 111 .

muscle
Abductor polli cis brevis
muscle
Flexor digi ti minim m.
Opponens digiti Fl exor pollicb longus t.
minimi m.

Palmar aponeurosis Median n.

(Top) Metacarpal bases m ar k transi t ion from wrist int o ha n d. Extensor d igitoru m tendo n s fl atte n & spread across
dorsum of m etaca rpal bases. (Bottom) Interosseous m uscula ture is evident at metacarpal bases. Thenar & hypothenar
muscul ature is we ll-developed . Dista l branch es of radial & ulna r nerves are not disce rnible, but median ne rve
branches are visible.

Ill
28
 WRIST OVERVIEW
AXIAL T1 MR, LEFT WRIST

.lrd metacarpal base

2nd metacarpal base

He>.or digi torum Ex tensor digitorum t.
t.
m. 4th metacarpal base
Ex temor poll ic is
tendon Extemor di gi ti m i nim i
ten don
I ;t mc tacarp;tl shaft
Sth m etacarpal base
Adductor pollicis m.
Oppon ens digi ti
Fle>.or minimi m.
Opponens pollicis m . - -;;......,::=='--' Abductor digiti mini m i
Flexor longus t. muscle

t\lxtuctor brevis Flexor digi ti m i nimi

muscle brevis m .
llexor digitorum
superfi cial is t. Ul nar n., superficial
branch
Palmar apo neurosi s

2nd metacarpal
3rd metacarpal
Interosseous m .
4th m etacarpal
Extcmor lon gus
ten don
lntermseus m.

St h m etaca rpa l

Fk>.or pollicis brevis 111 . - -;p;.-:..=?---

Op poncm poll icis m . - -=--==-- Abd uctor digiti m ini m i

m u sc le
Abdu ctor pollicis brevis
muscle Flexor digi ti m in i mi m .

O pponens digiti
1-il'>.or longus t.
minimi m .
:-.redian n.
Pa l mar aponeurosis

(Top) M etacarpal bases ma rk t ransition from wrist into h and. Extensor digitorum tendons flatten & spread across
dorsum of mctaca rpa I bases. (Bottom) Interosseou s m uscula tu re is evident at metacarpa I bases. T hena r & hypot hen ar
musculature is well-developed. Distal branch es of rad ial & uln ar nerves are n ot discern ibl e, but median nerve :E
bra nch es arc v isible. """'
'Jl
...-+-

Ill
29
 WRIST OVERVIEW
CORONAL T1 MR, RIGHT WRIST

Dorsal vein

Dorsal vein
Dorsal vein

Jrd metacarpal base

Exten sor pollicis longus

tendon

Ulnar Lister tubercle

Exte nsor cligitorum t.

(Top) Fi rst in seri es of co rona l Tl MR i mages of righ t w ri st, displa yed from dorsa l to volar. A network of veins over
do rsa l wrist drains i n to cephalic vei n radially & basi lie vein ulnarly. (Bottom) Ex ten sor digitorum tendons are most
dorsa l wrist stru ct ures. Do rsa l po rti ons of ulnar sty loid, do rsal radius (Lister tubercle) & 3 rd metaca rpa l base are seen.

Ill
30
 WRIST OVERVIEW
CORONAL T1 MR, LEFT WRIST

Dorsal vein

Dorsal vein
Dorsal vein

3rd metacarpal base

Ex tensor po llicis lo ngus

ten don

List er tubercle Ul nar sty loid

Ex tensor digitorum t.

(Top) First in series of co ron al T l MR images of right w ri st, d isplayed from dorsal to volar. A n etwork o f veins over
dorsal w rist d rains in to ce ph alic vein rad ia lly & ba sil ic ve in ulna rly. (Bottom) Ex tensor digitorum tendons are m ost
dorsal wrist st ructures. Dorsal po rtions of ul n ar sty loid, do rsa l radi us (Lister tubercle) & 3rd m etacarpal base are seen.

c.r>
,....,.

Ill
31
 WRI ST OVERVI EW
CORONAL T1 MR, RIGHT WRIST

3rd m etaca rpal base

4th metacarpa I base

2 nd m etacarpal base

Ex te n sor pollic is lo ng us
te n don Exten sor carpi radiali s
brevis t.

Ulnar h ead l.iste r tubercle

3 rei m e taca rpa I base

2nd m e tacarpal base

4th metacarpal base

Tra pezoid
Hama te
Capitate
Do rsal inte rca rpa l I.

Dorsal rad ioca rpa l I. Dorsal scaphotriquetral

ligame nt
Dorsal radiouln a r I.
Ex te nsor ca rpi radi al is
lo ng us t .
Ulnar head

Radiw.

(Top) Liste r tu bercle & ulna r h ea d are dorsally positio ned with ex te n sor po ll icis longus tend on passi ng u ln a r to
tubercle in a sha ll o w g ro o ve & co u rs in g radially over exten sor carpi radialis (EC R) te ndo n. EC R passes ra dia l to
tuberc le . (Bottom) Do rsa l extrinsic & intrin sic liga me nts a re vis ua lized as thin low signal inten sit y bands cou rsing
h o rizo nta ll y across w ri st. Th o ugh man y o f th ese small, thin ligaments may be di fficult t o identify as disc rete
s tru ctures, dorsa l intercar pa l & dorsa l radioca rpa l li gaments are ro ut in ely seen .

Ill
32
 WRI ST OVERVI EW
CORONAL T1 MR, LEFT WRIST

]rd m etaca rpa l

2nd m etacarpa l base 4th metacarpal

Capitate

Extensor po llicis longus

l·.xtensor ca rpi radial i\ ten don
L

Lbter tubercle Ul nar head

3rd metacarpal

2nd m etacarpal base 4th m etaca rpa l base

Tra pezoid

Hama te
Capi tate
i nterca rpal I.

Dorsa l scapho t riq uc tral Dorsa l radiocarpal I.

ligam ent

radi o ulnar I.
carpi
t. Ulnar head

Radius

(Top) Li ster tu bercle & ulnar h ead are dorsally positio ned w ith ex ten sor po llicis longus tendo n passing ulnar to
tu bercle in a shallow groove & coursi ng radially over exten sor carpi radialis (EC R) ten don . ECR passes radial to
tubercle. ( Bottom) Dorsa l extri nsic & intrinsic ligam ents are visuali zed as thin low sig nal intensity band s coursing
ho rizontall y across w ri st. Th o ugh m an y o f th ese small, thin ligaments ma y be d iffi cult to identify as discrete
structures, do rsa l interca rpal & do rsal rad iocarpal ligaments Cl re ro utinely seen .

Ill
33
 WRIST OVERVIEW
CORONAL T1 MR, R IGHT WR IST

3rd m etacarpal base 2nd metacarpal base

4th metacarpal base

Trapezoid
Ham ate
Capitat e

Triquetrum Scaphoid

Lun ate Radial styloid proce's

radiou ln ar I.

Extensor carpi radial is

longus t.
Ulna

Radi u'

4th metacarpal ba\c

2n d m etacarpal base
5 th metacarpal base
Trapezoid

llamate Extensor carpi radial is

lo ngus t.

Triq uc t rum Capi tate

Lunate Scaphoid

Extensor ca rpi uln ari s t. Scapholunatc I.

Triangular
Radius
fi brocartilage

U ln a
Extensor brevis
tendon

(Top) Slightly volar to th e do rsa l l iga ments, th e d o rsa l radioulnar liga ment, a co mpo n ent of tria ngula r fib rocarti lage
complex is evident as are dorsal proximal & dista l row carpi. Extensor carpi radia lis tendon cou rses distally to attach
to 2nd m et acarpal base. ( Bottom ) U lnar h ead is sea ted in sigmoid notch of distal radius. Triangu lar fibrocartilage
articula r disc is readily visual ized. Ex tensor carpi u lnaris (ECU) tendon passes dorsally in E.CU u ln ar groove. Small
intrinsic carpal row liga men ts, scapholunate & luno triquetral, are presen t but poorly seen o n Tl imaging.

Il l
34
 WRIST OVEKVII:W
CORONAL T1 MR, LEFT WRIST

3rd metacarpal base

4th m etacarpa l base

Trape70id

Cil pitate llamate

Scaphoid Triq uetrum

Radial process Lunate

Dorsal radioulnar I.
F.xtemor carpi
longus tendon

Ulna
Radius

.{rd metacarpal bdse

4th m etacarpal base
2nd rnct"acarpal
Sth m etacarpal base

Trapezoid
Hamate
L.\temor carpi rad ial is
t.

Capitat e Triquetrum

Scaphoid Lunate

Scapholunate I. Exten sor carpi ulnaris t .

Triangular
Radi us fibrocart ilage

btemor
tendon Uln a

(Top) Sl ightly vo lar to th e dorsal liga m en ts, th e dorsa l radi oulnar ligament, a component of triangula r fibrocart ilage
complex is evident as are dorsal proxima l & distal row ca rpi. Ex tensor ca rp i radialis tendon courses distally to attach
to 2nd m etacarpal base. (Bottom) Ulna r head is sea ted in sigmoid notch of distal radiu s. Triangular fibrocarti lage
articular disc is readily visualized . Extensor ca rpi ulnari s (ECU) tendon passes dorsally in ECU ulnar groove. Sma ll
intrinsic ca rpal row ligam ents, scapholunate & lunotriquetral, are present but poorly seen on Tl imaging.

Ill
35
 WRIST OVERVIEW
CORONAL T1 MR, RIGHT WRIST

3rd m e tacarpal base

4th m e tacarpa l base
2 nd m e tacarpal base
5 th m e taca rpal base
Tra pezium

Hamate
Tra pezoid

Trique trum Capitate

Scaph o id
Extenso r carpi ulnaris t.
Abdu ctor po llicis
Lunotriq uetral I. longus t.

Scapholun a te I.
Tri angular
fibrocart ilage Radius

Ulna
Ex tenso r po llic is brevis
tendon
Pro nator q u adratus m .

5th metacarpal base

Extensor ca rpi ulnaris t.

Trapezium

Hamate Trapezoid
Capitate
Triq uetrum

Luna te Scaphoid

Lunotrique tra l I.
Radial styloid

Ulnar sty loid

Scapholuna tc I.
Volar radiou lnar I.
Ex te n sor pollicis b revis
& abd uctor pol licis
Ulna brevis t.

Pro nato r quad ra tus m . Radi u s

(Top) Triangul a r fibroca rtilage covers ulnar head & fossa, a ttach ing t o ulnar stylo id base. Exte nsor pollicis brevis
tendo n co mbines with (&is o ft en indistinguishable from) abductor pollicis longus tendon in ex te n sor com pa rtm ent
#1. Inflammatio n of this co mpartment is De Que rva in te n osynovitis. (Botto m ) Pronator qu adratu s muscle arises
fro m ulna at th is level. The volar tria n gula r fib roca rtilage complex compo n ent seen h ere is the vo lar rad io uln ar
li game nt. Small in terosseous li gaments such as scapholunate & lunotriqu etra l ligaments are prese n t bu t n o t well
visual ized.
Ill
36
 WRI ST OVERVIEW
CORONAL T1 MR, LEFT WRIST

3rd metacarpa l base

2nd metacarpal base 4th m e tacarpa l base

S tl1 m e tacarpal base

Trapezium

Hamate
Tra pezoid

Capita te Triq ue trum

Exten so r c arpi uln aris t.

Sc aphoid

Luno t riq u etra l I.

Abductor po llic is
lo ng us t.
Tria ngular
Sca ph o lunate I. fib rocarti Iage

Racl ius Uln a

Extensor po llicis brevis

tendo n
Pro n ator q uadratus m.

S th metacarpal base
I st me tacarpal base

Exte nsor carpi ulnaris l.

Trapezi um
Ha mate

Tr iquet rum

Lu nate

Radia l sty lo id Lunotrique tra l l.

Ulna r sty loid

Sca phol u nate I.

Exten sor po llicis b revis Volar radioulna r I.

& abdu ctor pollicis
b revis t. Ulna

Pronator qua dratus m.

(Top) Tri a ng ular fib roca rti lage covers ulnar head & fossa, a ttach in g t o u lna r styloid base. Extensor pollicis b revis
ten do n com b ines w ith (& is o ften ind istin guisha ble from) abd ucto r po ll icis longu s te ndon in exten sor com pa rtmen t
#1. Inflam ma ti o n of th is compartment is De Que rva in te n osyn ovitis. (Bo ttom) Pro n ato r quad ratus muscle a rises
from ulna a t th is level. The vo lar t riangula r fibroca rt ilage com plex co m pone nt seen here is the volar rad ioulnar
ligament. Sm a ll in terosseo us liga m ents such as sca pholu nate & lunotriqu etral ligament s are presen t but no t well
visual ized.
Ill
37
 WRIST OVERVIEW
CORONAL T1 MR, RIGHT WRIST

I st metacarpal base
St h metacarpa l base

I look of hamate

Trapezoid
Triquet rocapi tate I.

Triquetrum Scaph oid

Ul nocapi tate I. Scaph ol unate I.

Exten sor pollicis brevis
Lunate & abductor pollicis
longus t.

Radius

Ulna Pron ator qu adratus m.

Flexor digitorum
profundus t.

Abducto r digi ti mini m i

I st m etacarpa l base
mu scle

Hook of hamate
Trapezi um

Fl exor carpi radialis t.

Pisi fo rm Scapho id

Lunate Abduct or pollicis brevis

tendon
Uln ol unate l.
Lon g radioluna te I.

Radius

Pronator quadratus m.

(Top) At level of do rsa l pisot riquetral joint & base o f scaphoid tubercle, portions of vola r ligaments are noted
including ulnocapltate & triquetrocapitate ligamen ts. Extensor pollicis brevis & abd uctor pollicis longus tendons pass
through sn uffbox regio n of wrist. The hook of the hamate is evid e nt. (Bottom ) At level o f volar side of pisotriqu et ral
joint & scaphoid tubercle, pronator quadratus muscle bell y is visua li zed . Flexor d igitorum profundus tendo n s pass
through dorsal ca rpal tun ne l.

Ill
38
 WRIST OVERVI EW
CORONAL T1 MR, LEFT WRIST

Capi tate

I st m etacarra l base
5 th m etacarpal base
Tra pcz.i u m Hook of hamate

Trapezoi d
Triquetrocapitate I.

Sca phoid Triq uetrum

Ul n oca pi tate I.
Scapholunate I.

Ex tenso r pol l icis brevis Lunate

& abductor poll icis
longus t .

Rad ius Ul na

Pron ator quadratus m .

Flexor digitorum
profundu s t.

Abductor digi t i minimi

muscle

Trapezium I look of hamate

Fl exor carpi radialis t.

Scaphoid

Abductor po ll ici s brevis

tendon

Long radiolunate I.
U lno lu nate I.
Radius

!'rona tor 111.

(Top) At level of dorsal pi sotri quetral joi nt & base of scaph oid t u bercle, portion s of volar ligaments are noted
including ulnocap ita te & t riq uetrocapitate ligam ents. Ex ten sor polli cis brevis & abductor polli cis lo ngus tendon s pass
th rough snu ftbox region o f w rist . The hook o f t he hamate is evident. (Bottom) At level of volar side o f piso triquetral
join t & scaph o id tubercle, pronato r q uadratus muscle belly i s visualized. Flexor digitorurn profundus tendons pass
through dorsal ca rpal tunnel.

Ill
39
 WRIST OVERVIEW
CORONAL T1 MR, RIGHT WRIST

Adductor m.

Flexor digi torum t.

I st metacarpal base

Abducto r d igi ti minimi

muscl e
Trapezi um
I l oo k o f h am ate

Scapho id

Pisi form
Abducto r pollicis
longus t.
U lnar n., a. & v.

Radial a.
Radi us

Pronator quadratus m .

Flexor digito rum Flexor longus t.

pro fundus m.

Adductor pollicis m.
Fl exo r digit o rum
profundus t.

Abducto r d igiti mini m i

m uscle
;;;;;:::::;,;.-- Carpa l tun n el region
I l ook of hamate
Trapezium
Guyon cana l region

Pbohamate I.
Scaphoid

Pisiform

Ul nar n .
Flexor pollicis longus t.

Fl exo r d igi torum

superficia li s t . Rad ial a.

(Top) Volar to radius & ul na, flexor digi torum pro fu nd us & superficia l is tendon s pass d orsal (deep) to fl exor
ret i naculum . Radial & ulnar arteries are visualized in prox i mal w rist but rapid ly branch in to smal ler vessels whi ch
may n o t be ev iden t on routi ne M R imaging. (Bottom ) Guyon canal region is defi ned by pi siform & deep &
superficial co mponents of med ial f lexor retin acul um. It con tain s uln ar n erve, artery & vei ns a we l l as ra t . Ca rpa l
tunn el region is dorsa l (deep ) to Guyo n canal & co n ta ins flexor digi torum profundus & supcrficiali s tendons, fl exor
po llicis lon gus tendon & median n erve.
Ill
40
 WRIST OVERVIEW
CORONAL T1 MR, LEFT WRIST

Adductor poll icis m .

Flexor digi torum t.
Flexor poll icis longus t.

I st metacarpal base

Abd uctor digi ti m i ni mi

Trapezi um m uscle
Hook of h am ate
Scaph oid

Abd uctor poll ici s Pisi form

lon gus t.
U ln ar n ., a. & v.

Radia l a. Rad iu s

Pronator quad ratu s m.

Flexor poll icis lon gus t.

Flexor digi toru m
p rofund us m.

Flexor digitoru m
p rofu ncl us t.
Add ucto r po ll ici s rn.

Abductor digiti minimi

Ca rpal tu n nel regio n muscle
Hook of h amate

Trapezi um Guyo n canal region

Piso hamate I.
Scap ho id

Pisi form
Flexor pollicis lo ngus t. Ul nar n.

Flexor cl igi torum

Rad ial a.
superficialis l.

(Top) Vo la r to rad ius & u ln a, flexor digitorum p rofun d us & supe rficialis ten do ns pass do rsal (deep) to fl exor
retinacu lum. Radia l & uln a r arte ri es a re visua li zed in proximal w rist but ra pid ly bra n ch in to smaller vessels wh ich
may not be evident o n ro utine MR imaging . (Bottom) Guyo n ca n al regio n is defined by p isifo rm & dee p &
superficial com pon e nts of med ial flexor re tin aculu m . lt contain s ulnar n erve, a rtery & vein s as well as fa t. Carpal
tun nel region is dorsal (deep) to Gu yon ca n al & co n tains flexo r cligito ru m profundu s & su perficialis tendons, flexor
poll icis lo ngus ten don & med ian ne rve.
Ill
41
 WRIST OVERVIEW
CORONAL T1 MR, RIGHT WRIST

brevis

Abd uctor digiti minimi

muscle Trape.dum

l'iso hamat e I.
Median n.

Flexor ca rpi radia lis t.

Ulnar a., v.
Radial a.

Flexo r digito rum

perficia I is t.

Flexor cligi torum

111.

Abductor pollicis bre,·is

muscle

I rapcziu m

Pisi form

Med ian n .
Flexor ca rpi t.

Ulnar a., v.
Fl exor carp i radia l is t.

H exor digitorum
perficia I b t.

(Top) Sma ll slips of flexor retinaculum pass ho rizontal ly from sca p hoid towa rd ha ma te & pisi form . T h e flexor
digito rum superficial is tendons are just dorsa l to flexo r reti nacul um. Ul nar nerve is ulna r to u l nar artery & vein as i t
pa ses through Guyo n canal. (Bottom) M edia n n erve i s su perficial & rad ial in ca rpal tunn el & is typically isointense
to muscle, w hich may make it di ffi cult to disti nguish on T l i magi ng.

Ill
42
 WRIST OVERVIEW
CORONAL T1 MR, LEFT WRIST

i\hdullor pollich brevi;

Abductor d igiti m in im i
Trapezi um mu;cle
I.
l cd ian n.

I ltxor CMpi t. Pisi form

Radial a.
Ulnar a., v.

Flexor d igi to rum

supcr ficiali> t.

Hcxor digilorum
\upcrficia l b m.

Abductor pollicb brevis

m u;cle

Trapezi um

Pisi form

tvl ed ian n.
Flexor carp i ulnaris t.
Flexor po llich lo ngus t.
Ul n ar a., v.

Flexor digitorum
\Upcrficiali; t.

(Top) Sma ll slips o f fl exor ret inacul um pa ss h orizontall y from scaphoid towa rd hamate & pisiform. The f lexor
digitorum superfi cial is tendons are just dorsal to fl exor retinaculum . Ulnar nerve is ul na r to ul n ar artery & vein as it
passes through Guyo n ca nal. (Botto m ) Median nerve is superfi cial & radi al in carpal tunnel & is typically isoi ntense
to muscle, whi ch m ay make it d ifficult to di stin guish on Tl imaging.

Ill
43
 WRIST OVERVIEW
CORONAL T1 MR, RIGHT WRIST

Abductor pollicis brevis

Flexor carpi ulnaris t. Flexor digitorum

superficia lis m .

Flexor carpi radialis t .

Superfi cia l vei ns

(Top) Volar musculature of d i stal fo rearm & thenar eminen ce i s read ily seen . (Bottom) A n etwork of vein s over volar
wris t drains into ce phalic vein radial ly & basilic vein ulnarl y.

Ill
44
 WRIST OVERVIEW
CORONAL T1 MR, LEFT WRIST

Abductor pollicis b revis

m u scle

Flexor d igi torum

superficialis 111 . Flexor ca rpi u l naris t.

Flexor carpi radialis t.

Superficial veins

(Top) Vola r m u scul a ture of dis tal fo rearm & the na r e m ine n ce is read il y seen . (Bo t t om) A network of vei ns ove r volar
wrist drain s into cephalic vein radia lly & basilic ve in ulnar ly.

Ill
45
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Extenso r digi toru m l.

Abduct o r digiti mi n i mi
m uscle
Oppon en s d igit i
min i mi m. 5th Jn etaca rpa I base

Ex ten sor car pi ul naris l.

Basili c v.

Ulna

Oppon en s d igiti
minim i m.

Abducto r di gi ti minimi 5th metaca rpa l

muscle
Extenso r di gito rum t.

Piso hama te li ga m en t

Triquetrum

Pisifo rm
Extensor carpi ulnari' l.

Uln ar sty loid process

(Top) First of 20 sequential Tl coronal images o f t he wri st, d ispla yed from ulnar (medial) to radia l (lateral ). Extensor
ca rpi ulnaris (ECU) t e ndo n passes over distal ulna in ECU ulnar groove. Hypothe nar m uscula ture is vo la r & exte nsor
digito ru m tendons are dorsa l to Sth metacarpal base. (Bottom) Pisoh am ate ligament ex te nds d ista l t o pisifo rm &
ulnarwa rd. The pisot riquet ra l joint is no ted.

Ill
46
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Extensor digitorum t.

Opponens digiti
m i nimi 111.
4th metacarpa l base

Abdm:tor digiti minimi

ITIU5Cie 5th metacarpal ba5e

l'i5ohamate ligament
I Ia mate

l'isi form
Triquetru m

Flexor carpi ulnaris t. ex tensor ca rpi ulna ri5 t.

U lna

Ex tensor cligi torum t.

Oppone n s digiti
minimi 111.
4t h metacarpal

5th m etacarpa l base

I Ia mate

Pisiform

Triquetrum
tlcxor carpi t.

U lnotriquetral I.
Triangular
fibrocarti lage

l·lc.\or cligi to rum Ul nar head

p rofundu5 m. &: t.

(Top) Pi so triquetral joint is read i l y evident as is pisohamate liga m ent. H ypothenar musculatu re is less robust near it s
origi n fro m flexo r retinaculum. (Botto m ) Flexor ca rpi ulnaris tendon inserts o n pisiform. Ulnotriquetral l iga ment
arises fro m volar radiou lnar ligam ent, insert i ng on volar tr iq uetrum. :f
""'I
IJ')
r"+

Ill
47
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Oppo nens digi ti Extensor ctigitorum t.

minimi 111 .

4th t::netacarpal base

I l ook of h amate

Hamate body

Triq uct rum

Pisi form

Ulnar a. Luna te

Ul nar n .
Dorsal radiou l nar I.
Volar radioul nar I.
Triangul ar
Flexor digitoru m
fibrocarti lage
profundus t.

Ulna

Fl exor digi torum

super fici alis t.

4th metacarp al ba e

Ex ten so r digitorum t.

H ook of hama te J-lamatc

Exten sor digitorum t.

Dorsal in terca rpal I.

Ulnar n .
Triq u ctru m

Dorsal radioca rpal I.

Lunate

Fl exor digitorum Radiw.

superficia lis t.
Extensor digitorum t.
Flexor ctigitorum
profundu s t.
Ulna

(Top) Ul nar n erve & artery pass lateral & d i stal t o pi sifo rm with in Guyon ca nal. Hook of hama te is p rominent.
Tri an gular fi brocartil age (TFC) is visualized as a low signal i ntensity disc interposed bet ween uln ar h ead &
triquetrum. Vo lar & dorsa l radiou lnar ligaments com bine with TFC & ad jacent structures to f orm triangular
fibrocartilage com plex. (Bottom) I ntrinsic & ex trinsi c ligaments ma y be difficul t to identify as ind ividual st ructures,
pa rti cularly in the absen ce o f jo int disten sion. Ligam ents are labeled where v isibl e or in the region of an expected
ligamen t. Dorsal in tercarpal ligament is a key dorsal wri st stabilizer but is v isual ized in o nly l imi ted fashi o n.
Ill
48
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Flexor retina culum

4th m etaca rpal
rlc>.or digitorum
t.

Ex ten sor digi torum t.

I' IC\Or digitorum
profundus t.
ll arnatc

Radioscaphocapitate I. Dorsal intercarpal I.

Dorsal radioca rpal I.

Lunate
Sh ort radiolunate I.

Radius

Pronator m.

3rd m etacarpal

Flc;-.or retinacu lum

Capitate

l'lc>.or digitorum
t. Dorsa l intercarpal I.

Radim aphocapi tate I. Hamate

Flexor digi toru m Do rsal radi ocarpa l I.

profundus t.
Lun ate

Short radio lu nate I.

Radi m

Pronator quadratu s m.

(Top) digitoru m superficialis & p rofundus tendons pass deep to the ho ri zo ntally oriented flexor retinaculum.
Ext en sor digi torum tendons cou rse t hrough 4th ex tensor compart ment & are stabi lized by ex ten sor retinacul um.
( Bottom) Portions of rad ioscaph olunate & short radiolun ate ligaments are visualized vo larl y. Th e dorsal radi oca rpa l
ligament is seen dorsally & region o f dor al intercarpal ligament is m arked.

Ill
49
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Flexor digi torum 3rd m etacarpa l base

superfi cia li s t.

Extemor cligitorum t.
Fl exor retinaculum

Flexor digitorum Capitate

profundus t.

Dor\al intercarpal!.
Rad ioscaphoca pitate I.

rad iocarpal I.

Lu11<1te

Short radio lu n ate I. Extemor in dicis m. & t.

Pronator quadratus m.

Oppon en s polli cis m.

Jrd metacarpal base

Flexor digitorum
superficia lis t. Extemor digitorum t.

Flexo r retinacul um Capi tate

I. Dorsa l in tercarpal I.

Flexor digito rum radi ocarpal I.

pro fundu s t.

Lunate
Sh o rt radiolu na te I.

Radiu\

Pronator quadratus m.

(Top) T h ird metaca rpa l base, cap ita te, lu na te & lu n ate fossa of radius align, c reating a stab le ce ntral ax is of wrist.
(Botto m ) Exte n sor indicis te ndon is radia l-most ten do n in 4th ex tensor compartment. Oppo nens pollicis te ndon
originates fro m flexo r re ti nacul um at this level.

Ill
50
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Opponens m.

Abducto r pollicis brevis 3rd metacarpal base

m u scle
Extensor indicis t.
Flexor digitorum
profundus t.
Capi tate

Median n .
Dorsa l in tercarpal I.

Rad ioscaph ocapitatc I.

Lunate

Flexor pollicis lo ngus t. Dorsa l rad iocarpa l I.

Long radiol unate I. Extensor pollicis longus

tendon

Radi us

Pronator quadra tus m.

Oppon ens pollicis m .

3rd metacarpal base

Abductor po l licis brevis
muscle
2nd metacarpal base

Flexor digitorum
profundus t.
Capitate

M edian n. Dorsa l intercarpal I.

Dorsal scaphotriquetra l
Radioscaphocapitate I. l igament

Scaphoid
Flexor pollicis lo ngus t.
Extensor longus
tendon
Lo ng radiolunate I.
Lister tu bercle

Rad ius

Pronator quadratus m.

(Top) Median ne rve lies s u perficia l to flexo r po ll ic is lo n gus tendon & deep to fl exor ret inacu lum . Lo ng radi o lunate
ligament ari ses fro m rad ius just radia l to rad ioscaph o id & sh o rt rad iolun ate ligam e nts. (Bottom ) Ext e nsor po lli cis
long us tendo n li es ulnar to Liste r tu be rcl e crossing dis ta lly & rad ia ll y over extensor carpi radia lis b revis & long us
tendo ns as it extends to thumb .

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51
 WRIST OVERVIEW
SAGITTA L T1 M R, WRIST

Op po n en s pol licis 111 .

Flexo r po ll icis brevis m.

2n d m etaca rpal base

Abductor polli cis brevis
muscle
Capitate

Trapezoid

Exte nsor ca rpi radialis

b revis t .

Do rsal sca p hotriq uetral

ligament

Scapho id
Flexor pollicis long us t.
Exten so r po lli cis lo ngus
te ndo n
Lo ng radiol unate I.
Lister tubercle

Radius

Pronato r q u ad ra tus m .

Opponens poll icis 111 . Flexor pollicis brevis m.

Abducto r pollicis brevis 2 n d m etacarpal base

muscle

Trapezoid

Ex ten sor carpi radialis

brevis t .

Sca ph o id
Flexor carpi radialis t.

Radioscaphocapitate l.
Do rsa l scapho triq uetral
ligament

Lister tubercle

Radius

(Top) This secti o n demonstrates articular inte rsectio n o f t rapezo id, capitate & scap hoid. Flexor pollicis lo ngus tendon
is deep to uln ar n erve & just ulna r to flexo r carpi rad ialis tendon. (Bottom) Flexor carpi radialis tendo n passes
superficial to scaphoid tubercle to insert o n 2 nd metaca rpal base. Radioscaphocapitate ligament originates fro m volar
rad ial lip.

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52
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Opponens pollicis m. Flexor p oll ici s brevis m.

Abducto r pollicis brevis 2nd m etacarpal base

muscle

Flexor carpi radi alis t.

Trapezoid

Trapezium
Exten sor ca rpi radial i s
brevis t.

Scaph oid

Radioscaphocapitate I.

Flexor poll icis brevis m.

Abductor pollicis brevi s 2nd metacarpal base

muscle

Trapezoid
Trapezi um

Scaphoid

Radioscaphocapitate I. Extensor carpi radialis

longus t.

Radial collateral I. Rad ial stylo id

(Top) Flexor ca rpi radialis tendon passes superficial to scap hoid t ubercle to in sert on 2nd m etacarpa l base. Extensor
carpi radi alis brevis tendon crosses dorsum of wrist to insert on dorsal 3rd metacarpal base. (Bottom) Radia.l -most
component o f rad ioscaphocapitate ligament is someti m es called radia l collateral liga m en t. Extensor carpi radialis
longus tendon crosses dorsum of wrist to insert o n 2nd metacarpal base.

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53
 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Flexo r po llicis b revis m.

Oppo nens pol licis m .

Abductor polli cis brevis

m uscle 2 nd me taca rpal base

1st m etacarpa l base

Tra pezium Ex ten sor carp i radi alis

lo ng us t.

Scap h oid

Rad ial a . An atomic s nu ffbox

Cepha lic v.
Rad ia l stylo id

Opponens pollicis m . Flexo r po ll icis b revis m .

Abducto r po llicis b revis

muscle

1st metaca rpal base

Extenso r carpi rad ialis
lo ngus t.
Trapezium

Ce ph alic v.
Radi al a.

Abductor po llicis
lo n gus t.

Exten sor pollicis brevis

tend o n

(Top) Rad ial artery, superficial rad ial nerve & cep halic vein pass th rough anato mic snuff box whi ch is bounded by
tra pezium, scap ho id, & rad ial styloid . Abductor pollicis longus & extensor pollicis brevis tendo ns fo rm vo lar margin
o f snuffbox & extensor pollicis lo ngus tendon fo rms do rsal margin. (Bottom) Abducto r po llicis lo ngus & extensor
pollicis brevis tendon s fo rm distal margin of snuffbo x as th ey convergen ce just distal to 1st ca rpo metacarpa l join t.

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 WRIST OVERVIEW
SAGITTAL T1 MR, WRIST

Opponen s poll icis m . Flexor po llicis brevis m.

Abductor pollicis brevis

muscle

l st rnetacarpa I base
Radial a.

Trapezium

Ex ten sor p ollicis brevi s

tendon

Abductor pollicis
longus t .

Opponen s pollicis rn. Flexor polli cis brevi s m.

Abductor po llicis brevis

muscle

Radia l a.

l st m etaca rpal base

Ex tensor pollicis brevis

ten don

Abducto r polli cis

t.

(Top) Radial artery branches & continues distally to form deep palmar arch. (Bottom ) Abductor polli cis longus &
ex ten or po llicis brevis tendon converge to insert on 1st metacarpal base.

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55
 OSSEOUS STRUCTURES
o Pis iform: Onl y ca rpal with tendo n attachm e nt
!Terminology (FCU)
Abbreviations • Articu lates with triqu etrum
• Abdu ctor pollicis longus (APL) • Key con to u rs: Ovoid articular facet
• Carpom etaca rpa l (CMC) • Sesamoid-li ke with FCU insert ing & co ntinuing on
• Distal radi ou ln ar jo int (DRUJ) as pisohamate & pisom e tacarpal liga m ents
• Ex ten so r po lli cis brevis (E PB) • Distal ca rpal row
• Fie ld o f v iew (FOV) o Tra p ezium (greater multangula r): Saddle-s haped
• Flexor ca rpi uln a ris (FCU) • Articula tes with sca ph oid, 1st & 2 nd MCs,
trapezoid
• Flexor re tinacul um (FR)
• Meta carpa l (M C) • Key contours: Groove for FC R; volar tubercle
• Opponens d ig it i mini mi (ODM) (ridge) - a ttach m ent fo r FR, intrin sic & extrin sic
• Radioscap h o lunate li gament (RSC) liga m ents
• Tria n gu la r fib rocarti lage (TFC) • Key link between ca rpals & l st MC
• Triangula r fibrocarti lage complex (TFCC) o Trapezoid (Jesser mu lta n g ul ar)
• Vo lar interca lated segment instabil ity (V IS!) • Articula tes w ith sca ph o id, 2 nd MC, trapez ium,
capita te
Definitions • Key contours: Articu lar facets
• Interca la ted= in terposed • Varia nts: Small facet articul ates w ith 3 rd MC
• Palmar = volar (33%)
• Radial = lateral o Capitate: La rgest carpa l bone
• Ulnar= media l • Articulates with sca ph o id, lunate, 2 n d , 3 rd & -Hh
• Wri st abd u ctio n = rad ial flexio n MCs, trapezoid , h ama te
• Wrist adduction =u ln ar flex ion • Key con tours: Head- proximal p ortion; n eck-
co nstricted region just dis ta l to hea d; body- di stal
portion; volar su rface nea r n ec k a ttac hment o f
!Imaging Anatomy de lto id vo la r ca rpa l li game nt s
• Va riants: Small facet fo r 4th MC (85°;b); m ultipl e
Osseous Anatomy ossificat io n cente rs
• Eigh t ca rpal s w ith 6 mai n s urfaces (exce pt pis ifo rm ) o Hamate: Wedge-sh aped
o Do rsal & vol a r: Non-artic ula r; rough e ned surfaces • Arti cu lates w ith lunate, 4th & Sth MCs,
for li ga m ent a tta chme nts; dorsal surface broader triquetrum, ca pitate
than vo la r (except sca phoid & lunate) • Key con tou rs: Arti cula r fa ce t wi nds arou n d waist,
o Proxima l & d ista l: Proximal su rface con vex, dis tal fac ilita tes triq u etra ! m o ti o n o n vo lar ham ate;
s urface con cave; covered with articu la r cartilage hook (h a mulus) of hamate- volar di sta l project ion
o Med ial & late ral: Covered with articular cart ilage attach m e nt fo r FR, pisoh ama te liga m e nt & OD I
• Proxi mal ca rpa l row • Va riants: Hypop las t ic hamate h ook; h oo k as
o Sca phoid (carp a l nav ic ular): Largest proxim a l separa te ossicl e
ca rpa l bo n e • Distal radius
• Articu la tes with rad ius, tra p ezium, trapezo id, o Artic ulates wit h scaphoid, lunate, & u ln a
luna te, capitate o Key co nto u rs: Lister tubercle- dorsa l ri dge; sca phoid
• Key co ntours: Tuberosity- dista l vola r & lunate fossa - con caviti es a rticulate with proxima l
prom in e n ce; wa ist (ridge) - mid latera l porti o n , scaph oid & lunate; radial styloid - latera l d ista l
lo ca tio n for vascula r ch anne ls & liga m e nt pro min en ce; sigmoid notch (fo ssa, uln a r n otch ) -
attach m e n ts; proximal pole- prox im a l to wa ist; m edia l con cavity articula tes with u ln ar head; latera l
d ista l po le - di sta l to waist para llel grooves fo r EPB & APL; dorsa l grooves for
• Va ria nts: Bipartite scap h oid with ossicles sepa ra ted exte nsor compa rtme nts
at waist • Distal ulna
o Luna te o Articulates with radius, scap hoid & T FC
• Articu lates w ith radi us, capitate, hamate, o Key co nto urs: Head - sm ooth , ro und ed distal
t riqu etrum , sca pho id, TFC articula r surface; fovea (fossa)- con cavi ty at base o f
• Key contours: Vola r > dorsal h eight s tyloid for a ttachm en t of TF ; s ty lo id- m edial
• Va riants: Type l (34.5%) - no art icu lation with distal prominen ce; dorsa l groove fo r ECU
hama te; type II (65.5%) - facet a rticu lates with • Wrist varia nts
h ama te o Osseou s coa liti o n s: Ma y be fibr ous, ca rtilagin o u o r
o Triquetrum osseous; lun o trique tra f m ost commo n
• Arti cula tes w ith pis ifo rm, lunate, h amate, TFC o Ossicles: Common about wrist; rounded &
• Key contours: Ovo id facet articu lates w it h we ll -corticated; ca n be mi sta ken fo r loose bodies o r
p isifo rm fract ures
• Do rsa l & vo lar li gament attachments equa ll y • Lunu la : Be twee n TFC & tri qu etrum , may fu se to
stro ng (unlike o ther ca rpals); dorsa I li gamen ts ulnar st y loid; ma y be diffi cul t to di stin guis h from
co nve rge o n t riq u etrum, may av ulse bo ne pri o r uln a r s ty loid avu lsio n
frag m ent wi th forceful wrist flexion

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 OSSEOUS STRUCTURES
• Os stylo id eum : Dorsal between 2nd & 3 rd MC o Columnar concept: Carpa ls fun ctio n in three
bases; kn own as ca rpal boss if fused w ith 3rd MC column s
• Os hamuli: Oss ic le a t tip o f h amate h oo k • Radial: Mobi le colu mn co m prised of rad ius,
• Epil u natc: Dorsal to lunate scap h o id , tra pezium, t rapezo id; ce ntral :
• Vascu lar c hann e ls Flex/ extend colu mn comprised of rad ius, lunate,
o Small, disc rete ly d e fin ed c h ann els are e ntry poi nts capitate; ulnar: Rotatio na l col u m n com prised of
of nutri e nt ve sels; m ay mimi c erosio n s tri quetrum & hamate
o Vessels enter a lo ng ligament & ca psule attachm ents, o Ring con cept: Ca rpa ls fun ction as ring wi th m obi le
at non-arti cul ar bone surfaces w itho u t cartilage proximal ca rpa l row & rigid di sta l ca rpal row; ring
cover disruption = i nstabi Iity
• Ca rtilage s urfaces • Alig nme nt var ies with w r is t pos ition
o Hyali n e ca rtilage (1.0-1.5 m m ) lines a ll g li ding • Neutra l alignme nt
s urfa ces; v is ib le on distal radius, ulnar h ead & ca rpal o Defi ned as long axes of radius, luna te, & ca pitate
urfaces • Dorsiflexion
o Ma y b e diffi cult to disting uish fro m adjacent joint o Occurs primaril y across midcarpa l row
fluid o n routine imagin g o Lunate & capi tate dorsi fl exed ; pisiform pulled
• Sy nov ial s urfaces proximally by FCU
o Covers all wrist jo int surfaces o Muscle p ul l is asymm etric resu lting in d o rs iflexion
o Ty pically n ot vis u a li zed o n routin e im aging; m ay be ing slightly radia lly d eviated
e nhan ce with intrave n o us gado linium • Vo la rflexion
o Occurs primar ily at radio ca rpal joi nt
Compartm ents o Lunate & capitate vola rflexed
• Wrist is mu ltipl e articulatio n s o rgani zed into o Mu scle pull is asym metric resulting in volarflexion
co mpartm e nts by ligam ento us attachme n ts be in g slightly ulna r d evia ted
o Dista l (inferior) radioulnar margins: Distal • Wris t abdu ction (radial flexion o r d eviati o n )
rad io ulna r a rticulation, capsul e, TFCC o Sca ph o id flexes vola rly a round RSC (s ling) li ga men t,
o Radioca rpal m a rg in s: Distal radius, TFCC, p rox imal becoming fo resh o rten ed; tra pez io t ra pezoi d complex
ma rgin o f proxi m a l carpal row, radia l collatera l rides dorsa l to sca phoid d istal pol e; luna te flexes
li gament; co mmunica tes wit h p iso tr.iqu etral jo int in vo larly, becom in g tr ia n g ula r; triquetrum vo la rflexes,
- 80% moving proxi ma l to h amate; p isifo rm pulled distall y
o Mid carpal marg ins: Dis tal m a rgin of proxima l carpa l by p iso h amate & pisot riquet ra l li gaments; capitate
row, inte rca rpal artic ula tion s of di stal carpal row, bo dy slightl y do rsi flexed
communica tes wit h common carpo m etaca rpal join t • Wrist a dduction (u ln a r flexion o r deviation )
o Pisotriquetral m a rg ins: Pisiform , triquet rum o Triquet rum g lides d is tally & volarly alo ng hamate
o Co mm o n carpometaca rpa l marg ins: Space be tween in to dorsifl ex io n , s lig htly over la p ping h ama te;
2 nd-5th MC bases; space betwee n hamate, 4 th & 5 th lunate dors iflexes, becoming t rapezoida l; scaphoid
MCs is occasiona lly sepa ra te com partme n t p u ll ed into lo ngit udinal attitude; capitate is s lig htl y
o First ca rpomet aca rpa l m argin s: Trapezium, 1st MC volarflexed
base • Rotati.on
• Indi vidual compa rtments can be inj ected to evaluate o Radius rota tes around u lna; p ro natio n: Ulna slig htly
integrity (see: "Liga m ents" section) d o rsa l to radius; s u p ination : Ulna s lightly volar
Ca rpal Alignment Radiographic Analys is
• onnal forces across wris t : Ax ia l co mpress io n b y • Measureme nts may be u sed to evaluate & descri be
fo rearm mu scles wr ist alignme nt or m alalignment due to a rthropathies,
o Axial. co m p ress io n o f forearm muscles is bo rne trauma, conge n ita l d eformities
a lo n g long axi s o f ra dius, lunate & cap ita te • Posteroanterior r a diograph m easurements
• Distal radial volar tilt: Displaces lun ate vola rl y o Radial tilt (rad ia l inc lination, radia l d evia tion , u lnar
• Lunate : Shorter dorsally; tends to ro tate dorsa lly inclination, radia l a ngle)
• Scapho id: Tends to volarflex • Ta n gent to radia l sty lo id & ul n ar rad ius intersects
• Triquetrum: G lides along vo lar hamate; tends to li n e draw n perpe ndicular t o ulnar long axis (nl:
d o rs ifl ex 21 ° ± 3.6°)
• Sca pho lur:_ate & lun o triquetral ligamen ts stab ilize o Carpal arcs
carpal te nde n cy to flex volarly o r d o rsall y • Arcs of Gilula : Arcs outlining 1 ) p roximal margin,
o Di.stal ra dius a n g ulation ten ds to di rect ca rpa ls proxima l car pa l row; 2) distal ma rgi n, prox im al
volarl y & u lna rl y ca rpal row; 3) prox im al margin , d ista l ca rpal row;
• Ex trin sic vo la r & dorsa l radi oca rpa l ligaments sh o ul d b e smooth & para llel
stabili ze ca rpal tende ncy to tilt o r translate • Greater & lesser a rcs: Lesser arc- circumscribe
• Func tional o rga nization theo ries joints around lun ate; greater a rc- crosses mid or
o Row con cept: Ca rpa ls fu nction as proximal & dista l p roxim al p o rtions of scaphoid , capita te, hamate &
row; scaphoid b rid ges two rows triquet rum
• Proximal ca rpa ls inte rcalated bet wee n radiu s &
distal ca rpals with no te ndon attachm en ts

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 OSSEOUS STRUCTURES
• Vulnerable zon e: Region enco mpassed between o Carpal angl es
greater & lesser arcs as well as scaphoid & • Rad iolun ate: < 15°
trapezium; majority of wrist fractures & • Scapholunate: 30-60°
l igamento us in ju ries occur in v ulnerable zon e • Capitolunate: 0 -30°
o Carpometa carpal joint alignment • Lunotriquetral: 14- J 6°
• CMC join ts 2-5 are parallel & create a contour • D i stal rad ioulnar align m ent
rem iniscen t o f an "M"; clenched fist vi ews disrupt o Assessment w ith radiography lim i ted to gross
this smoo t h l i ne on radiograph ma lalignment; more sub tl e subluxa t ion best defined
o Ulnar variance (rad ioul n ar index) by ax ial imagi n g (CT/ MR)
• Compariso n o f distal radiu s co rtex (ulnar aspec t) o All methods have some l im i tatiori's; co mparison
to d ista l u ln a cortex (radial aspect) w ith u naffected side may be u efu l
• U lnar neutral: Ulna, no more t h an 2 mm sh orter o Radioulnar ratio: Identi fy center o f ulnar head (C);
th an radiu s; ulnar minus: Ulna > 2 mm sho rter draw line fro m vo lar (A) to dorsa l (8) m argins of
than radius, associated w i t h Kienbock di sease; sigmoid n o tch (line AB); drop perpendicula r f rom
u lnar p lus: Ulna longer t han radi us, associated ulna r head center (C) to margin line (D); ratio=
w ith ulnolunate impaction syn drome & TFC tears AD/A B (nl pro nation : 0.6 ± 0.05; neu tral : 0.5 ± 0.04;
o Carpa l angle supination: 0.37 ± 0.09)
• Angle for med by lines draw n ta ngent to prox imal
sca phoid/ lu nate & proxi m al t riquetru m / lunate
(n l : 130°) !Anatomy- Based Imaging Issues
o Carpa l height r atio
• Carpal heigh t : Distance from 3rd MC base to Imaging Recommendations
distal radial articular surface • Radiographic eva luatio n
• Ca rpal height ratio: Ratio o f ca rpal h eight/ 3rd M C o Basic survey
shaft len gth (nl : 0.5 4) • PA, lateral, semipronated oblique
• Can also be measured as a ratio o f carpa l o Ran ge of motion & alignmen t
h eight/capitate length (n l : 1.57 ±.OS) • Ul n ar & rad ial d eviation, d orsinexion,
o Carpa l height i ndex vo larfl ex ion, clen ched fist
• Rati o o f ca rpal h eight ratio do minant hand /carpa l o Other v iews for fractures, arthriti s, foreign bodi es
height vs. ratio n on-dom ina n t hand (nl: 1.0 ± • Scaph oid v iew, se misu pi nated ob lique, carpal
0.1 5) tunn el, carpal bridge
o Ulnar head incl i nation • CT evaluation
• In tersecti on o f lines drawn parallel to ulna lo ng o Thi n section imaging (0.5 mm), sma ll FOV,
axis & along ulnar head articu lar surface facing multiplanar reformations
sigmoid notch; compare inju red to non-injured o Posi tioning
w rist (nl: l l -2r) • Routine: Palm on tab le, forearm al ign ed
o Radiouln ar an gl e perpend icular to gantry
• Intersecti on of lines draw n alon g u lnar head • Scaphoid imaging: Pa lm o n table wit h lo ng axis of
art icular surface facing sigmoid no tch & along scaphoid pa rallel to gantry
radial & uln ar distal radius joint; compare injured o Add ition o f art h rography may i mprove ca rtilage &
to no n-injured wrist (n: 90-111°) ligamen t evaluation
o Lunate overhang • MR evaluation
• W idth o f lunate compared to radial lunate fossa o M eticu lous positioning with wrist in neutral
(nl: <50%>of lunate "overh angs" u l nar edge o f align ment as n ea r center o f magn etic fi el d as
rad ius) possible; 8-12 em FO V; ded icated coils
• Lateral radiograph m easurem en t s o Ideal positioning wi th patient p rone, w rist pronated
o Vo lar ti lt (volar angle, d orsal ti l t, pal mar till, palmar above h ead ("Superm an" posi t ion)
slope) o Cortices un iforml y low signa l i ntensi ty; marrow
• Line drawn ta ngent to anterior & posteri or rad ial spaces interm ed iate signal inten sity, in terspersed
margins i n tersects line drawn perpendi cular to w ith trabeculae
radi us lon g axis (n l : 10-12°) o Marrow edema may be readily apparent on flu id
o Carpal axes sen sitive seq uen ces
• Radius: Li ne t hrough long axis o f radi us, fro m o GRE (T2) i m aging co mm only used for ligament
midpoint o f bone at 2 & 5 em prox imal to evaluation b ut susceptible to field i n homogeneity
rad iocarpal joint caused by trabeculae; underestimates ed ema
• Lun ate: Line perpendicular to line drawn betwee n
Imaging Pitfalls
two distal poles
• Alignmen t analys is on MR may be problematic
• Capi ta te: Lin e verti ca l through head & body or
o Patient i n "Superma n" position may have w rist in
tangent to d orsa l 3rd M C
slight ulnar deviat ion; resul ts in l unate vola r
• Sca pho id : Line d rawn between pa lmar p roxi mal &
angulation wh ich ma y mim ic VIS!
dista l margi ns
o Pronated wrist: Uln a appea rs dorsa lly subl uxa ted
• Tri qu etrum: Li n e drawn t hrough prox i mal &
• Vascular chan nels arc not erosions
dista l poles

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 OSSEOUS STRUCTURES
RADIOGRAPHS, PA & LATERAL

Capitate wabt
Capitate body
Capitate head
·1rape7oid

·1rape7ium volar I loo k of hamate

tubercle
Tra pczi u m llamate

Scaphoid distal pole Triquetrum distal pole

waist
Pisi form
Scaphoid proximal pole Luna te volar li p
Luna te li p

fmsa
Ulnar st yloid process
tubercle

Ulnar fovea
lunate fossa

Ulnar head
Sigmoid notch

3rd metacarpal

Capitate do rsal body

1 rapczium & 1st
Trapezoid
metacarpal base
llamate

Triquetrum
Scaphoid tli\tal pole

Radi<ll qyJoid process Lunate

Radi u s, li p o f
Radiu\, volar lip of
notch
notch
Ulnar styloid process

Ulnar fo vea

Ulnar head

(Top) Zero-rota tio n I)A radiograph. Image obtai ned by posi tioning pa tien t at 90° abduction o f shoulder & 90° flexion
of elbow. I land prone on cassette. Beam perpendicular to casse tte & cen tered on ca pi tate head. (Bottom )
Zero-rotation lateral radiograph. Image obtained with similar should er & el bow positioni ng. I la nd lateral w ith ulna r
side on cassette. Beam p erpendicu lar to casse tte & ce n tered on capitate head. Note that i n th is ideal lateral, there is
slight dor at placem ent of the ul na relative to th e rad i us. T his position ing allows eva l uation o f th e coax ial
arrangement of tile radius, lunate, capitate, and 3rd metacarpa l.
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 OSSEOUS STRUCTURES
RADIOGRAPHS, DORSIFLEXION & VOLARFLEXION

Scaphoid tubercle

Pisiform
3rd metacarpal

Capi tate

Lunate

Ulna fovea

3rcl m etacarpa l

Capitate n eck

Proximal pole
Scaph oid tubercle
Lunate

Pi si fo rm Ulnar styloid

(Top) Lateral do rsiflexion. Wrist placed in n eutra l late ra l o n cassette & max ima ll y do rs iflexed. Cen ter beam
perpe nd icular to cassette & centered on scap ho id wa ist. (Bo ttom) Latera l volarflexion. Wrist placed in n eutral la te ral
on cassette & m axima ll y vo larflexed. Ce n te r beam pe rpendicul ar to cassette & centered on scaphoid wa ist.

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 OSSEOUS STRUCTURES
RADIOGRAPHS, SEMIPRONATED & SEMISUPINATED

3rd m etacarpal

Trapezoid Capi tate body

Trapezium Triqu etru m

Pisi form
Scaph oid waist

Lunate
Radia l styloid
Ul na r head

I look of hamate

Pisot riquetral joint

Cap itate h ead

Pisi form

Radial styloid

Lu nate

U lnar head

(Top) PA sem i pronated oblique. Radia l hand ra ised 4 5° fro m cassette without fl exio n o r ext ensio n. Bea m
perpe ndicular to cassette & ce ntered on ca pi ta te head . (Bottom ) Sem isu pinated oblique. Uln ar w rist placed with
30-45° su pination from neutra l la te ral position . Ce nter bea m perpend icula r to cassette & cente red o n cap itate head.
T he sup ina ted oblique is ideal for eva luati o n of th e h ook of ha m ate, pisiform, or t riquetra ! fractu res.

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 OSSEOUS STRUCTURES
RADIOGRAPHS, RADIAL & ULNAR DEVIATION

ll ooh. of hama te
3rtl m etaca rpal

Triqu etrum

Pisi form
Trapezoid
Lumtte

Ulnar styloid
Trapezium

Sigmoid notch

Sca phoid

3rd metacarpal

Trapezium

Trapezoid Capitate body

Scaph oid distal pole

I look ol hamate

Scaphoid prox imal pole Pi iform

Lunate

Ulnar fovea

(Top) PA radia l deviatio n. Positioned pa lm flat on cassette, wrist in maximum abduction wi th o ut flexion or
ex tensio n . Beam perpendicu lar to cassette & ce n tered on cap i tate h ead. Note the "target sig n" of the volarflexed
scaphoid, m aking evaluati o n of th e wa ist fo r fra ctu re qu i te d i ffi cul t. (Bo ttom ) PA ulnar deviation . Positio ned palm
flat o n casse tte, w rist in maximum abd uct ion without fl exion o r ex tension. Bea m perpendi cu lar to cassette &
cen tered o n capitate hea d. Note that u lnar d eviation elo nga tes the scaphoid, and is ideal fo r eva lua ti o n fo r scaphoid
waist fracture.
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 OSSEOUS STRUCTURES
RADIOGRAPHS, SCAPHOI D & CLENCHED FIST VIEWS

J rcl m etacarpa l

Trapezoid
Capit<J tc wa ist
Trapezium

Scaphoid distal pole

llamate body

Scaphoid waist rriquct rum

Scaphoid proximal pole

Lunate

Radius

I look of hamate
Trape7ium
llamate body

Capitate waist Pisi form

Scaphoid body
Triq uctrum

tuberc le
Lunate

Radius

(Top) Scaph o id view. Radia l wrist raised 30° o ff casse tte w ith sligh t u lnar deviation . Beam angula ted 35° toward
e lbow & ce ntered on scap h o id wa ist. ( Bottom) Clenched fist. Wrist placed p rone (or su pine) o n cassette & hand is
clenched t ightly. Cen ter bea m perpe ndi cu la r to cassette & centered on capitate head.

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 OSSEOUS STRUCTURES
RADIOGRAPHS, CARPAL TUNNEL & BRIDGE

Trapezium ridge
Pisiform
Scaphoid
Hook of hamate

Triquetrum
Trapezi um
Capi tate

Scaphoid L una te

Triq uctrum
Capitate

(Top) Carpa l tunnel view. Hand placed o n cassette pa lm down & ma ximall y dorsiflexed . Cente r beam directly
tan gent to pa lma r wrist & centered o n center of carpal tunnel. (Bottom) Carpal bridge view. Dorsal fo rea rm o n
cassette wit h wrist maxima ll y flexed. Beam angled 45° tange nt to & ce nte red o n do rsa l wri st center.

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 OSSEOUS STRUCTURES
PRONATED & NEUTRAL AXIAL CT, DISTAL RADIOULNAR JOINT ALIGNMENT

Sl igh t dorsa I
displacement

Extensor ca rpi uln aris t.

Sigmoid not ch

Sigmoid notc h
Ex tensor ca rpi ulnari s t.

(Top) Full pro nation . Placing wrist in full pronation results in slight dorsal displacement of ulna in sigmoid notch.
ECU is sea ted with in ulnar groove. Radi us ro tates aro u n d ulna . (Bo tto m ) eutral. Placi ng w rist in n eutral rota tio n
allows distal ulna to be fully seat ed in radial sigmoid n otch. ECU is seated within ulna r groove.

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 OSSEOUS STRUCTURES
SUPINATED & PRONATED AXIAL CT, DISTAL RADIOULNAR JOINT ALIGNMENT

Sigmoid notch

Ex tensor carpi uln aris t.

(Top) Full supination . Placi n g w rist in fu ll supination results in slight volar displacemen t o f u lna in sigmoid notch.
ECU is draped over medial rim of ul nar groove. Radiu s rot ates aro und ulna. (Bottom) Radi oulnar ra ti o is used for
evaluation o f subtle sublu xa tion . Identify ulnar h ead center & dra w perpendicu lar to line d rawn across margins o f
sigmoid notch . AD/ AB: Radioulnar rati o. Normal ra tio d epends on patien t position .

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 OSSEOUS STRUCTURES
CORONAL T1 & GRE MR, BONE & CARTILAGE STRUCTURE

ll amale vascular Cap itate vascula r

cha n nel c hannels

Ca pitate, scaphoid &

lunate cartilage
Lunate, type II surfaces
Norm al cortex

Physeal sca r

Norm al trabecula

utrient vessel chan n e l

Hya lin e carti lage

Lu nate, type I

Trian gular
fibrocar ti lage
Ulnar minus variance Ph yseal. scar

(Top) Co ro na l T1 reveals vascular channels at capitate waist & dorsa l ha mate. Co rtica l ma rgi ns a re t hin, low signal
intensity but trabecu lar pa ttern is clea rl y evident as fine mesh wo rk. Thi s m esh work creat es field inhom ogen eit y in
GRE imaging. Cart ilage surfaces are prese nt but visua.lized in li mited fash ion in non-con trast imaging. Note type II
lunate wi th face t articu latin g w ith h a mate. (Bottom) Coron a l G RE (1.5 tesla) revea ls norma l t rabecu lar pa ttern with
low signa l intensity cortices. Ca rtilage is well seen in gradien t sequ ences as a high signal struc ture. Note uln ar minus
va riance wi th compensa tory thi ckeni ng of triangu lar fibrocartilage. Type I lunate is present. Field in h o m ogene ity in
th is seque n ce may obscu re in traosseous edem a.
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 LIGAMENTS
o Acti on: Const ra i ns radioca rpa l p ronation,
!Terminology ul nocarpal transloca t ion; stabi lizes distal scaphoid
Abbreviations pole; creates sling for scaphoid
• Ca rpometa carpal ( MC) • Long radiolunate (volar rad io lunotriquet ral , volar
• Dorsal radioca rpal (D RC) radiotriquetral ligamen t)
• Dorsa l radioulnar (DRU) o Origin: Radius ulnar to RSC; course: Passes volar to
• Ex tensor ca rpi radialis longus (ECRL) sca phoid & SL l igament; insertion: Volar l unate rim;
• Ex tensor ca rpi u lnaris (ECU) co ntinues to t riquetrum
• Field o f v iew (FOV) o Action : Constrain s ulnar transloca tion & distal
• Flexor carp i ulnari s (FCU) translat ion of lunate; creates sling for lunate
• Gadolinium (Gel) o M ay appea r as two sepa rate ligaments: Rad io lu nate
• Long radiolunate liga ment (LRL) & l uno triquetral
• Lunotriqu etral (LT) • Radioscapholuna te (l igament of Tesl ut; intra-articular
• Metacarpal (MC) fat pad)
• Normal saline (NS) o Origin: Volar radius ulnar to LRL; insertion:
• Radioscaphoca pitate ligament (RSC) Proximal scaph o id, lunate & SL ligamen t
• Range of motion (ROM) o Action: Mechanoreceptor of SL rel ationship
• Scaph olunate (SL) o Not true l igament: Contains fat, arterioles, vcnules
• Scaphotrapezium-trapezoid (STT) & sm all n erves
• Sho rt radiolunate liga ment (SRL) • Short radiolunate
• Triangular fibroca rti lage (TFC) o Origin: Volar radius ulna r to LRL; insertion: Volar
• Triangular fibroca rtilage complex (TFCC) lunate (rad ial 2/3)
• Triquetroca pitate (TC) o Acti o n : Stabilizes lunate; facilitates m otion in
• U lnocapitate (UC) fl exion /extension
• Ulnolunate (U L) • Arc uate ("V" ligament): Confluence of ligaments on
• U lno triquetral (UT) volar capi tate includ ing RSC, UC & TC
• Vola r radioulnar (VRU) Dorsal Radiocarpal ligament
Definitions • Dorsal radiocarpa l {dorsa l rad io tri quctra l; dorsa l
• Intrinsic l igamen ts: Conn ect ca rpals to ca rpal s rad io l u notriq uetral)
• Extrinsic ligaments: Con nect radiu s/ulna to carpals; o Origin: Broad at tac hment to dorsa l radius from
carpals to metaca rpals Li ster tube rcle to sigmo id notch; insertion: Dorsal
lunate & triquetrum
o Ac ti on: Reinfo rces dorsal LT ligament; constra i ns
I Imaging Anatomy ulnar tran sl ocat ion of carpal s; crea tes dor al sli ng for
triquetru m
Overview Volar Midcarpal ligaments
• Terminol ogy
• Scaphotrapezium-trapezoid
o Ligament terminology va ri able in literature
o Origin: Scaphoid tubercle; insertion : Volar
o Ligament names, where controvers ial, are based o n
trapezium; few fibers to t rapezoid
an at om ic dissecti on studies (Berger, 1997) w ith
o Action : Maintains scaph oid in volarflcxion;
alternate terms i n parentheses
stabilizes scaph o id, trapezium & t rapezoid
• Generalizatio ns
• Scaphoca pitate
o Ligaments run obliquely; fro m periphery to mid l ine;
o Origin: Vola r sca ph oid distal po le; insertion: Volar
from proximal to di stal
capitate body
o Volar ligam ents are key stabi lizers; dorsal ligaments,
o Action: Stabil izer of scaph oid; balances vo lar flex io n
less crucial
tendency of sn- ligament
o Capitate & lunate have most ligament attachments
• Triquetrocapitate
o Triquetrum is u l na r anchor for capsular ligaments
o O rigin: Vola r triquetrum; inserti o n : Vola r capitate
o A ll adjacent car pals have interosseous liga m ents:
body
Media l/ lateral, distal/ proximal (except lunate &
o Action: M idcarpa l stabilization
capitate- n o p roximal/distal ligament)
• Triq uetroh amate
Volar Rad iocarpal ligaments o O ri gin: Vola r triquetrum; insertion : Vo lar hamate
• Radioscaphocapitate (sli ng, radiocapi tate) body at hook base
o Origin: Dista l radius, radial styloid; course: Passes o Action : Midcarpal stabi lization
across scapho id w ai st wi th minimal attachment; • Pi soh amat e
insertion : Capitate body (10% of fibers); arcs arou nd o Origin : Vo lar pisiform; insertion : Hook of hamate
di stal lunate, in terdigitates w ith UC & TC to form o Acti on: Transmits pull of FCU on pisiform to
a rcuate ligament ca rpals; considered a prolongation of FCU
• Radial colla teral : Rad ial-mos t fibe rs of RSC; • Deltoid: Confluence ot scaphocapitate &
existence as separate liga ment debated triquetrocapitate liga men ts; para llels arcua te ligament

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 LIGAMENTS
Dorsa l Midcarpal Ligaments Carpo metaca rpal Ligaments
• Do rsa l inte rca rpa l • Pisom e t acarpa l
o O ri gin : Do rsa l tri q ue tru m , in te rdig itatin g with DRC o O rigin : Vo lar p isifo rm ; inse rt io n: Vola r 5t h MC
liga m ent; inse rt ion : Scaph o id & dorsal trapezo id o Act ion: Transmi ts pul l of FC U o n pisifo rm to
o Ac ti o n : En ve lo ps rad ial artery in a n ato mic snuffbox; m et aca rpa ls; co n sidered a pro lo n gation of r:cu
con st ra in s mid ca rpa l ro ta tion ; acts as labrum to • Carpometaca r pa l liga m e nts of th um b
capitate head & proxima l h ama te o O rigin: Dorsa l, lateral & rad ial trapeziu m ; insertion:
• Do rsal scap hotrique tra l Do rsa l, volar & late ra l th umb MC base
o O ri g in : Scaph o id , ex te n d ing d o rsa l & dista l to SL/ LT o Actio n : Stabilizes high ly mob ile thu mb base
li gam e nts; inse rtion : Dorsa l triq uetru m • Dorsal c arpo m et a carpal
o Acti o n : Sta b ilizes SL/ LT ligaments; labrum fo r o Origin : Ad jacent carpa ls give 2-3 liga m en t slips
capitate h ead & h ama te proximal po le each; insertio n : 2 nd-5th d o rsa l M C bases
o Ac tio n : Stabilizes CMC joints slid ing mo tion
Proxima l Inte rosseous Liga ments • Vola r c arpo m et acarp a l
• Scapho luna tc o O rigin: Ad jace nt ca rpa ls give 1-2 li ga m ent slips
o O ri g in / inse rti o n : Ulna r scaph o id to radi al lun ate; eac h ; insertio n : 2 nd-5 th d o rsa l MC bases
hya li n e ca rtilage atta chme nt o Actio n : Stabilize s CMC jo in ts slid in g m otion
o Action : Dorsa l portion res ists vo la r-d o rsa l
transla t io n ; vola r po rt io n lim its fl ex ion/ext ension Distal Radiouln ar ligaments
ro tati o n; prox imal acco mm oda tes co mpressio n & • Do rsa l rad ioulna r
shea r fo rces ac ross rad ioca rpa l jo int o O r igin : Do rsa l sig mo id notch , bo ne a ttachm e nt;
o U-shaped liga men t with d o rsa l, p rox ima l & vo la r insertion : Dorsa l fibers fo rm ECU sheat h & attach
co m pone nts to st yloid p rocess; vo la r fibers a ttach to u ln a r fovea
• Do rsal com po n en t th icker (5 mm ) th a n vola r (1-2 o Acti o n : Stab ilizes d ista l ulna, preven tin g vo lar
m m ); fu nctio na ll y m o re impo rta nt th an proxima l sublu xa tion during supination
portion • Vo la r radioulna r
• Prox ima l co m po ne n t is m enisc us-like avascular o O rigin: Vo la r sigm o id no tch, bo n e attac hme n t;
fib ro carti lage; t riangula r sha pe in sertio n: Uln a r fo vea; joins wit h vo la r fib ers of
o Att ritiona l tea rs w ith age DRU & crea tes a "rin g" (appa rent on MR)
• Luno triqu etra l o Action: Se rves as base for UL & UT ligame n t o rig ins;
o Origin / inse rti on : Ulnar luna te to rad ia l t rique trum; stabilizes dista l ulna, preve nti ng do rsa l subl uxa tion
hyalin e ca rtil age attachment d u ring pro n ati o n
o Actio n : Volar portio n limits t ra n slati o n of lun ate &
t rique trum; dorsa l po rtion stabilizes join t Ulnocarpal Structu res
o U-sh a ped ligame nt with dorsa l, proxim a l & vo lar • Ulno lu n a te
co m po nen ts o O rigin: Arises from VRU; ulnar t o SRL; insertion:
• Vol ar co mpo ne nt th ic ke r (2.3 mm) tha n dorsal (1 Lu na te (uln a r 1/3) ad jacen t to SRL
mm ); fun ctio na lly more impo rtan t th an proxima l o Action: Stabil izes lu nat e thro ugh wrist RO M
po rtio n o Arises from li ga m e nt rathe r t h an bo ne, redu cing
• Proxim al com p o ne nt is me n iscus-like avascula r e ffect of fo rea rm rot at io n to carpal s
fibroca rti lage; t ria ngula r shape • Ulno triquctra l
o Attriti o na l tea rs with age o Lateral ban d
• O rigin : Ari ses fro m VI"W u lna r t o UL; insertio n :
Distal Inte rosseous Ligaments Triqu etru m , m ed ia l to LT li gam en t
• Trapeziotra pezoid • Acti o n : Rest ricts & sta bil izes t riq ue trum
o Do rsa l & vo la r com pon e nts: Thickn ess 2 m m ; fo rm s o Me dia l ba nd (ulnar collatera l ligament)
fl oo r o f EC RL te ndo n sh eath • O rigin: Ari ses from DRU a t it s in sertion on ulna r
o Acti o n : Stabilizes dista l ca rpals; m a intains carpa l styloid ; insertion: Lat era l triq ue trum
arch • Acti o n: Forms floo r o f ECU te n don sheath;
• Tra peziocapitate co n st rains d ista l tra nslatio n o f triq uetrum
o Do rsa l, vo la r & dee p co mpone nts: Thic kn ess 1-2 • Actua l ex ist en ce of u ln ar co ll at e ra l li game n t is
mm ; deep po rtio n con nects do rsa l t rapezoid t o vo la r debat ed
capi ta te o Arises fro m liga men t rat he r t han bon e, re d ucing
o Actio n : Stabilizes d ista l ca rpa ls; ma intain s ca rpa l e ffects o f forea rm rota t io n o n ca rpa ls
a rch o La te ra l & m ed ial ban ds se pa rat e just di sta l to
• Ca pi toh a m a t e p restylo id recess; lead t o pisotr iquetral jo in t (in
o Do rsa l, vo la r & deep co mpone nts: Thi ckness 1-2 90%)
mm ; vo la r aspect co ntiguo us with vo lar li ga m en ts, • Ulnoca pitate
co ntribu tin g to li ga me nto us ring of ca rpa l tu n nel o Origin: Ulnar fovea, bone attach m ent; insertio n :
o Ac t io n : Stab ili zes dista l car pals; m a intains carpal Fi be rs inte rd igita te w it h vo la r LT liga m e nt; continue
arch di st all y to capit a te; b le n d with RSC t o fo rm arcuate
ligam e nt

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 LIGAMENTS
o Ac tion : Rein forces ulnoca rpal join t ca ps ule & LT • annal sign a l varies from uniform low to striated
joint; anchors carpa ls to uln a; c reates vo la r sling fo r in termedia te signal; may be a m orph ous in
triquet rum proximal portio n
• Ulnoca rpal m e niscal homo log u e • Attach to cartilage rath er th an bone; should not
o Caps ul ar t h ic ke nin g, trian gula r s ha pe; variably be mistaken for a tear
present • Visu a lized o n coronal & axial; impo rtant to
o Li es dista l to uln a r TFC & ulnar sty lo id ti p; be tween scru tinize ax ial imaging as disruption of dorsa l,
DRU & radi a l volar E U tendon sh eath ; sepa rated vola r co m ponents co rrela tes with instabi lity
fr o m TFC b y p resty lo id recess o pening o TFCC: Low s ig n a l intensity articular disc a ttaches to
• T ri a ngula r fibrocartilage (articular disc) ca rtil age a long s igmoid notch-
o Origin: Ari ses from rad ial s ig m o id n ot ch, attaching • Arthrography
to hyaline cartilage; inse rtion: Ulnar fovea & s tyloid o Good eval uation for integrity of SL, LT & TFC;
tip limited fo r ex trins ic ligamen ts
o Va riab le thi c kness p ropo rtiona l to ulnar le n gth o Inj ections spaced to allow contra st resorptio n one
(t hi cke r with uln a r minus, th inne r with ulnar plus); compa rtme nt before 2nd injected
ulnar portion 2-3x thic ker tha n radia l • Rad ioca rpa l joint injected first (most li kely to
o Ulnar porti o n is vascula rized; radia l & centra l document w ith sing le in ject io n ); if no tear, wait
portions a re not 30-60 minutes & proceed seq uentiall y with DRU
o Attritiona l tea rs wit h age & midca r pa l in jections
• Triangu la r fi broca rtilage comp le x o Dig ita l subtraction allows dynamic eva lua t ion of
o Complex in cludes a rticul a r d isc, DRU, VRU, UL, UT ligament statu s & seque ntia l co mpa rt me nt in jection
& ECU tendon shea th without delay
o Action : Transm its portion of axia l loa d from ulnar o lnj ecta te: Iodinated con trast (180-300 mg l/ ml );
carpals to distal ulna; stabili ze r o f DRU jo int; volumes: Midcarpal, 4-5 cc; radiocarpal, 2-3 cc; DRU,
stabili ze r of ulnar carpa ls 1-2 cc; p isotriquetral, 1-2 cc
• MR imaging
Recesses o GRE (T2) imagin g maxim izes visua li zation of
• May be see n a rth rograph ica ll y &/ or arthrosco p icall y ligame n ts in absence of intra-articular fluid
• ln terli gamentous sulcus: Arth roscopic landma rk; o Coron a l: SL, LT, TFCC, extrinsic ligaments
sepa ra tes RSC fro m LR L a llowing m o tio n be tween o Axial : TFCC, dorsal & vo lar SL/LT, extrinsic
the e ligaments on radia l & u lnar d ev ia ti on ligaments
• Space of Poirie r: Area of weakn ess in volar ca psule o Sagitta l: Extrin sic ligaments
accessed via in ter liga m entous sulcus; located just o MR arthrography: lnjectate: 1/ 200 NS:Gd; vo lumes
prox imal to de lto id ligam e nt; vola r lunate dislocation as n o ted a bove
ca n occur here. • CT imaging
• RSC ligament region: Space between vola r sca phoid o Ligaments n ot see n in absence of contrast; CT
proximal pole & RSC d eep su rface a rthrograph y allows evalua tion of ligam e nt
• Prestyloid recess: Loca ted at ap ex of DRU & VRU in tegri ty; diagnostic efficacy equa l to MR
ligaments just d istal to ulnar fovea; lined with o Injectate: 1:1 S: iodinated cont rast; a llows standard
syn ovi um ; variably commu n ica tes w ith ulnar sty lo id arth rography & CT arthrography
tip • Ultrasound
• Dorsa l transverse recess: Arises between dorsa l o Described fo r eva luat ion of ext rin sic ligamen t tears;
ca pitate h ead/ n eck, h amate & d o rsal midcarp al jo int performed w ith stand-off pad; 10-12 MHz
caps ule, dorsa l di stal scaphoid transducer; h igh ly operat or-de pe nde n t
• Ulnar recess: Arises m ed ial to t riquetrohamate
a rticulati o n Imaging Pitfalls
• Radi a l recess: Arises latera l to STr & palmar recess • Attritiona l tears/ fenestrations: TFC, SL, LT
anterior to ca pitate • Liga ment attach me nts to cartilage rath er th an bon e
mimi cs tears (e.g., TFC, SL, LT)
• Sa tisfaction of search : If intrin sic liga m e nt tear see n,
!Anatomy-Based Imaging Issues exa mine ex trins ic ligamen ts carefully for
accompan ying a bn o rmalities
Imaging Recommendations
• MR appea ra n ce
o Extri n sic liga ments: Low sign a l or striated ba nds o n ISelected References
a ll sequences 1. Theumann NH et al: Ex trinsic carpal ligaments: n orma l MR
o In terosseous ligaments: Low sign a l bands; variab ly ar thrographic appearance in cadavers. Radiology.
visu a lized , espec ia ll y in midca rpal & di sta l rows; 226(1): 171-9, 2003
d ee p co m po n e nts tend to be th ick, sh ort li game nts 2. Berger RA: The ligam en ts of the wrist. A cu rrent overview
• Scapholu n ate/ lunotr ique tra l ligam ents: Dorsa l & of an atomy w i th considerations of thei r potential
vo lar contours band-like with proxima l (ce n tral) fu nctions. Hand Clin. 13( I ):63-82, 1997
portio n tr ia n g ular in s ha pe

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 LIGAMENTS
AXIAL GRE MR ARTHROGRAM, INTRINSIC & EXTRINSIC LIGAMENTS

Dorsa I radiocarpal I.

Dorsal radiou l nar I.

Lunate

Prox i m al po le sca phoid

Exten sor ca rpi ulnaris
tendon & sh ea th Radial sty loid

Radioscaph ocapitate I.
Volar radioulnar \.

U\no\unate \.

Do rsa l radiocarpal I.
Lun ate
Dorsal radiou l nar I.
Scaphol unate liga m en t,
Exten sor carpi u \na ris dorsal portion
tendon & sheath
Scaph oid

Prestyloid recess Scaph ol unate ligament,

volar p ortion

Vo lar rad iou lnar\. RSC ligam en t recess

Radioscaphocapitate I.
Ul nolunate I. l n tcrl igamentous recess

Long radio lun ate I.

Racli oscapholunate I.

Short racl iol unate I.

(Top) First o f twelve ax ia l GRE images from MR arth rogram (prox ima l to distal). Joint diste nt io n accen t uates volar &
dorsa l ligame nts & a ssociated recesses. Radiocarpal com partmen t may co mmun icate with ECU ten don shea th , as
with this n ormal individual. (Bottom) Key liga me n ts appea r as low sig nal intensity o n all MR seque n ces.
lnterliga m e nto us recess is a key art hroscopic recess as it leads to space of Poirie r. Prestyloid recess is interposed
between TFCC & m eniscal h omologue.

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 LIGAMENTS
AXIAL GRE MR ARTHROGRAM, INTRINSIC & EXTRINSIC LIGAMENTS

Dorsal radioca rpa l I.

Lunate

Triquetrum Scaph oid

Extensor ca rpi ulnaris
5heath Radial collatera l I.

Rad iosca phocapitate I.

Volar radioulnar I.
lnt erligam entous recess
Uln ocapitate I.
Long radiolunate I.
Uln olunate I.
Radiosca pholunate I.
Short radiolunate I.

Lunate
Dor5al radiocarpal I. Scapho lunate ligament,
dorsal portion
Lunotriqu etral
ligament, dorsal Scaphoid
portion
Radial coll ateral I.
Triquetrum
Radioscaphocapitate I.
Ul nocapitate I.
Long rad io lunate I.
Ulnolunate I.
Sca pholunate ligament,
Lunot riquetral volar portion
ligament volar portion
Space of Poi rier

(Top) Dorsal radiocarpa l ligam en t is prima ry proximal do rsa l stabilizer, spanning medial dorsal radia l cortex &
sweeping di sta ll y to dorsal triq uetr um . Vola r stab ili zers incl ud e radioscap hocapitate, long & short radio lunate &
ulnoca rpal liga me nts. (Bo ttom) Rad ioscap h ocapitate & u ln ocapitate ligam en ts inse rt on volar capitate, creatin g the
arcuate o r "V" liga m e nts, leaving vola r lunat e vuln e ra b le in s pace o f Poirier.

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 LIGAMENTS
AXIAL GRE MR ARTHROGRAM, INTRINSIC & EXTRINSIC LIGAMENTS

Dorsal radiocarpal I.
LLm ate
Lunotrigue tral 1., dorsal Scaphol una tc ligame nt,
portio n dorsa I portio n
Tr ique trum
Dorsa l tra n sverse recess
Ulnotrigue trall.
Scaphoid
Prestyloid recess
Ulnocapitate I. Radiosca ph ocapitate I.
Scapholuna te ligament,
Ul n o lunate I. volar portion
Rad ioscaph o lunate I.
Luno triquetra l
liga m e n t, vola r portion Short radio lunate I.

Dorsa l lip lunate

Scaph o lu nate ligam ent,

Dorsal radiocarpal!. d o rsal p ortio n
Lun otriguetra l 1., d o rsa l
portion Dorsal tran sverse recess
Scaph o id
Ulnotriqu etrall.
Head of capitate
Prestyloid recess
Long radiolunate I.
Uln ocapitate l.
Scapho lunate ligament,
Lu notrig uetral volar portion
ligame nt, vola r portion
Radioscapholuna te I.
Volar li p lunate
Sh o rt rad io luna te I.

(Top) Proxima l row carpal ligamen ts are U-shaped with do rsal, volar & proximal portions. Prestyloid & dorsal
t ra nsverse recesses are evident. (Botto m) Extrinsic liga ments serve as ca psular reinfo rce ments.

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 LIGAMENTS
AXIAL GRE MR ARTHROGRAM, INTRINSIC & EXTRINSIC LIGAMENTS

Dorsal scaphotriquetral
Dorsal radiocarpal I.
ligam en t

Trique trum Dorsal transverse recess

Distal pole scaph oid
Prest yloid recess Cap itate

Pisotriquetral joint Raclioscaphocapitate I.

Vo lar lip lun ate
Pisiform

Ulnoca pi tate I.

Dorsal sca photriqu etra l

ligament
Dorsal radiocarpal I. Dorsal t ransverse recess
Ulno triqu etral I.
Capitate
Triquetrum
Radioscaph ocapitate I.
Pisi form

Ul nocapitate I.

(Top) At the level of th e ju n ctio n o f proximal and distal ca rpal rows, the dorsa l & volar liga m en ts become less
numerous. Radioscap hocapitate & ulnoca pitate ligaments create arcuate or "V" ligament volarly. Dorsal
scaphotriquetral liga ment fibe rs spa n dorsa l proxi ma l ca rpa l row. (Bottom) Ulnotriq uetral liga m ent may be see n as
two bands. Medial band form s ECU tendon sheath floor & is sometimes referred to as ulnar collateral ligament.

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 LIGAMENTS
AXIAL GRE MR ARTHROG RAM, INTRINSIC & EXTRINSIC LIGAMENTS

!Ia mate Dorsal sca ph o triquctral

ligam ent
Dorsal radioca rpal I. Dorsal transverse recess

Cap it ate
Triquetrum
Scaphoid

Pisiform Radioscaph ocapitate I.

Uln ocapi tate I.

..

Dorsa l scaph o triquetral

Capitoh amate ligamen t
l iga m ent, deep portion
Capita te
llamate
Dorsa l intercarpal I.
Triquetroh am ate Scaphocapitate
liga m ent, deep po rtion ligament, deep portion

D istal pole scaphoid

Triquetrum
Rad ioscaphocapitate I.
Pi siform

Uln oca pi tate I.

(Top) Vo lar extrinsic ligam ents form th e ca rpa l tunn el floo r. Small interosseous li gaments are present between all
ca rpa ls, p roxi m ally, distally, medially & lateral ly (except lunate-capi tate relat ion, w here th ere are no prox imal-distal
ligaments). ( Bottom) Dorsal interca rpa l ligament arises distal to sca ph otriquetral l igarn ent, spannin g scaphoid &
trapezoid (radi ally) to triquetrum (ulnarly).

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 LIGAMENTS
AXIAL GRE MR ARTHROGRAM, INTRINSIC & EXTRINSIC LIGAMENTS

Dorsa l scap ho tri quetral

ligament
Capi tate
Capi toh am ate
ligamen t, dee p por ti on
Dorsal in terca rpa l I.
Hama te
Scaph ocapitate
Triquet roham ate liga m ent, deep por tion
ligamen t, deep por tion
Sca phoid
Ul nocapitate I.
Radi osca phocap i tate I.
Pisi form

Capitoham ate Dorsa l interca rpa l I.

ligam ent, deep por tion

ll am ate
Triq uetroh am ate 1., Sca phocapitate
deep portion l igamen t, deep p ortion

Triquetrum Scaph oid

Ulnar recess

(Top) Inte rosseous ligaments are present but poorly visua lized without join t distention. (Bottom) Dorsa l interca rpa l
ligamen t se rves as dorsa l d ista l stabili zin g liga me nt, ble nding with d o rsa l scap hot riquetra l ligament at triquetrum.
Ulna r recess is m edia l to triqu et ro ham ate a rti cul ation.
'Jl
I"'+

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 LIGAMENTS
CORONAL GRE & T1 FS MR ARTHROGRAM, TFCC

len iscal h om o logue

Prestyloid
Exten sor carpi ulnaris t.

Tria n gu lar Scapholunate 1.,

fi brocarti lage proximal po rtion

Hyal ine GHt ilagc

Meniscal h om o logue

Prestyloid recess Lunot riquetral 1.,

proxima l portion

Triangu lar
fi brocarti Iage Scapholunate 1.,
proxi mal portion

(Top) Coronal v iew o f triangular fibroca rtilage dem o nstrates no rmal fib rocartilage attach m ent to h yaline cartilage o f
radial sigmoid notch. Linear sig nal in ex ten sor carpi u lnari s tendo n is n ormal. Meniscal homologue represents a
capsular thi ckeni ng that is variab ly v isualized & i s separated from tria ngular fibroca rtilage by th e presty loid recess.
( Bottom ) Coro nal Tl fat suppressed rad iocarpal arth rogram image accentuates meniscal h o mologue. Tria ngular
fi brocarti lage, scaph o luna te & lun o tri quetra!liga m ents are i n tact.

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 LIGAMENTS
CORONAL GRE MR, EXTRINSIC LIGAMENTS

Radioscaphocapi tatc I.

Triquctrocapitatc I. Scaphocap itatc I.

U lnocapitate I.

Radi al colla teral I.

Radioscap h ocapi tatc I.

Tria ngular
fibrocar tUage
Dorsa l rad iouln ar I.

(Top) First o f e ig ht selected coronal G RE images (from vola r to dorsal). Radi oscap hocapitate & ulnoca pitate li gaments
blend with trique trocapitate li ga m ents to create a rcuate (inverted "V") ligam ent. Lun ate is immediate ly prox ima l to
this co nfluence o f li ga m e nts whic h crea tes a vulnerable place in vola r capsule, th e space of Poir ier. (Botto m)
Liga ments are ofte n wispy, th in , t ri ated st ructures as demonstrated by th e rad ioscap h oca pitate & ulnocap ita te
ligaments in this ima ge. Ligam e nts may blend togeth er, m a kin g ide nt ification of indiv idual ligaments more
chall enging.
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 LIGAMENTS
CORONAL GRE M R, INTRINSIC LIGAMENTS

Trape.dot rapezoid I.

Capi toharnate I.

Scaphocapitate I.

Radial collateral I.
Lunotriquet ral
l igament, volar portion
cap holunate ligament,
vola r portion
Triangu lar
fibrocarti lage

Carpometacarpal
ligament o f thumb

api toharnate
ligam en t, deep portion Scaphotrapezium-trapezoid
1., deep portion

Luno triquetra l 1.,

proximal portio n Scaphol unat e 1.,
proxima I portion

(Top) Trian gu lar fi b rocartilage shows intermediate signal intensity. Proximal ca rpa l row interosseous ligam ents are
low signal dorsa lly & volarly wi th low to interm ed iate signal i n proxima l portion. (Botto m) Proximal portions of
luno triquetral & scaph olunate ligaments arc triangular i n shape & may be h eterogen eous. Interosseous ligamen ts in
dista l ca rpa l row h ave not o nly vo lar & dorsa l po rti on s but dee p thick bands which contribute to stabi l i ty.

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 LIGAMENTS
CORONAL GRE MR, INTRINSIC LIGAMENTS

Ca rpom etacarpa l
liga ments

Sea pho trapczium-trapezoid

Ca pi to hamate - -==== 1., deep portion
ligam ent, deep por tio n

Trapeziocapi tate 1.,

dorsa l portion
Extensor carpi ulnaris t.

Mcnisca l ho mo logue
Sca pho lun atc 1.,
Triangular proximal portio n
fi broca rti Iage

Carpometaca rpa l
liga ments

Trapezioca pitate 1.,

Ca pito hamatc dorsal po rtio n
liga me n t, do rsa l
portion

Dorsa l rad iou lnar I.

(Top) Tri a ng u la r fibrocartil a ge, sca p h o lu na te & lun o t riquetra l ligame n t s attac h to h ya lin e ca rtilage covering sigmoid
notch , sca ph o id , lu n a te & tr iq ue trum respectively & crea te a regio n o f in te rm ediate sig n a l betwee n liga m ents &
adjacent bon e. Th is sh o u ld n o t be mistaken for a tea r. (Bo ttom) Car p o m etaca rpa l & in te rosseou s liga m e nts a re
visua lized dorsa ll y.

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 LIGAMENTS
CORONAL GRE M R, EXTRINSIC LIGAMENTS

Dorsa l intercarpa l
ligam en t

Dorsal sca pho triquetral

Dorsa l radiocarpa l
ligament ligam en t

Dorsa l intercarpal
ligamen t

Dorsa l
l igament
Do rsal radioca rpal
liga m ent

(Top) Dorsa l stabil izing ligam ents i n clude do rsal radi oca rpa l, scapho t riquetral & intercarpa l ligam ents. (Bottom) The
triq uetrum ser ves as an anchor poin t for the m ajo r dorsa l midcarpal ligamen ts.

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 LIGAMENTS
PA RADIOGRAPH ARTHROGRAM, RADIOCARPAL CO MPARTMENT

Pisotriquct ral joint

I ntact lunotriquetral
Prestrlo id recess
ligament

Intact Tr: C Intact scapholunate

ligamen t

(Top) Radiocarpal arthrogra m . In jection performed from dorsal approach with 2-3 ccs contrast i ntrod uced. (Bottom )
Intact radiocarpal co mpartment w i th con trast fi ll ing piso triquetral joi nt via prcstyloid recess. Triangular
fibrocartilage distal surface is outlined. Scapholu n ate & l unot riquetra ll iga ments are intact, with no evidence of spill
into midca rpal compa rt m ent.

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 LIGAMENTS
PA RADIOGRAPH ARTHROGRAM, DISTAL RADIOULNAR COMPARTMENT

Intact TFCC

(To p) D istal radiouln ar join t i nject io n, perfo rm ed 60 min utes after radiocarpal compart ment i nject ion. 1 cc of
contrast was inst il led. ( Bo ttom) Norm al distal radi ou l nar join t w ith cap-li ke fil l ing o f capsu le, outli nes TFCC
u ndersu rfa ce.

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 LIGAMENTS
PA RADIOGRAPH ARTHROGRAM, MID CARPAL COMPARTMENT

Common
carpometacarpal
compartment

Fi rst ca rpo m etacarpal

compartm en t
Intact lu notriquetral
l iga m ent

In tact sca pholunate

ligament

(Top) Midcarpal compartm ent i njection, performed immed iately after distal rad ioulnar compartment injection . Th e
needle is pla ced at t h e "4 corners", the juncti on o f l unate, triqu etru m, h amate, and capi tate. 4 ccs of contrast are
instilled. (Bottom) Contrast fill s the m idca rpal & co mmo n ca rpo metaca rpal compartments. T he fi rst
carpometa car pal com partm ent rem ains separate. Note contrast ex tending into scapholunate & luno triquetra l joints
without passi ng into radi oca rpal compartmen t, i ndi ca ti ng intact scapholunate & luno tri quctral ligaments.

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 TENDONS
o Pro n ator quadratu s
!Terminology • Origin: Medial distal volar ulna; course: Passes
Abbreviati on s medial to lateral; insertio n: Lateral distal dorsal
• Abd uctor pol licis b revis (APB) radius
• Abd ucto r poll icis longus (APL) • Action: Pronates hand
• Adductor digiti minimi (A DM) • Innervation : Median nerve, anterior interosseous
• Adducto r pollici s (A P) • Variants: May split into 2 or 3 layers; additional
• Carpal tunn el (CT) p roximal or distal attachments
• Carpa l t unnel syn drome (CTS) • Superficial
• Carpom etaca rpal (CM C) o Flexor carpi radialis
• Extensor carpi radia l is brevis (ECRB) • Origin: Media l epicondy le/common flexor
• Extensor ca rp i rad ia lis lon gu s (ECRL) tendon; course: Th i n tendon passes t h rough cana l
• Extensor ca rp i ul na ris (ECU) in lateral FR across volar t rapezi um groove;
• Extensor digito rum (ED) insertion : 2nd M C base; sli p to 3rd MC base
• Extensor digiti min i mi (EDM) • Action: Flexes hand at wrist; abducts wrist
• Extensor indicis (EI) • Inner va ti o n: Median nerve
• Extensor pol licis brevis (EPB) • Variants: May attach to trapezium & / or -Hh MC
• Extensor pol licis longus (EPL) o Palmaris l on gus
• Flexor carpi radialis (FCR) • Origin: Medial epicondyle/ common flexor
• Flexor ca rpi ulnaris (FCU) tendon; course: Thin tendon passes superficial to
• Flexor d igitoru m (FD) FR; insertion : Volar distal FR & aponeurosis
• Flexor digitorum profundus (FDP) • Act ion: Flexes hand at wrist
• Flexor digitorum superficia lis (FDS) • Innervati o n: Median nerve
• Flexor pollicis brevis (FPB) • Variants: Abse n t i n 10o/o; duplicated; comp lete or
• Flexor pollici s longus (FPL) part ial insert ion on antebrachial fascia, FCU
• Flexor retinaculum (FR) tendon, pisiform , or scaphoid; short tendo n with
• I n terphala ngeal (IP) low ly ing muscle bel ly may com press median n.
• M etaca rpal (MC) o Flexor carpi ulnaris
• M etaca rpoph alangeal (MCP) • Ori gin: Media l epico ndy le/common flexo r tendon

!
• Pal ma ris longus (PL) (humeral head) & med ial proxima l ulna (u l nar
• Pron ator quadratus (PQ) head); course: Run s m ed ial to the ulnar
• Proximal i nterphalangeal (PIP) n eurovascular bund le; insertion : Pisiform
(continui ng distally as p isohamate &
D efinitions p isometacarpa l ligaments)
• Palmar= volar • Action : Flexes hand; adducts wrist
• Ulnar= medial • Innerva ti on : Ul nar nerve
• Radial = lateral o Flexor digitorum superf i cia l is
• W rist abduction = radia l flexio n • Origin: Medial epicondy le/ common flexor tendo n
• Wrist adduction = ulnar flexion & ulnar coro noid process (humeroulnar head);
vo lar proximal radius (radial head); course:
Di vides into superficial (tendons to middle & ring
!Imaging Anatomy f ingers) & d eep (tendon s to index & li tt le fingers);
passes deep to FR with superficial tendo ns volar to
Flexo rs deep tendons; inserti on : Middle ph alanges of
• Deep flexor group index, midd le, ring & l ittle fingers
o Flexor digi torum p ro fun d us • Acti on : Flexes PTP & MCP joints of i ndex, midd le,
• O rigin : Proxi mal u l na; cou rse: Spli ts i nto 4 ri ng & l ittle fi ngers
tendons proxima l to PQ, passing through CT, • Innerva ti on: M ed ian nerve
deep to FR & FDS tendons; i nserti on : Index, • Varian ts: Absent litt le fi nger sl ip; accessory sl ips
midd le, ring & little finger di sta l ph-a langeal bases to index & middle fin gers; di tal muscle belly
• Acti o n: Flexes dista l phalanges; flexes other alon g proxi m al phalanges may mimic mass
pha langes & hand wi t h continued action
• In nervation: Median, anterior interosseous, ul nar Extensors
n erve • Deep
• Vari ants: Duplica ted slips o A bductor p ollicis l o ngus
o Fl exor pollicis l ongus • Origi n : Dorsa l lateral ulna, dorsal mid rad ius;
• Origi n: Radius, interosseous membrane, co ronoid course: Passes obliquely distal & latera l; crossi ng
process; cou rse: Passes deep to FR between FPB & over ECRB & ECRL, passing (wi th EPB) into
AP; inser tion: Thum b distal phalangea l base ex tensor co mpa rtment # I ; i nsert i o n : I st MC
• Ac tio n: Flexes thumb I P; flexes th umb M CP w i th radial base wi th sl i ps to trapezium & AP B
co n ti nued action • Action: Abducts & extends thumb; abducts wrist;
• Innervation: Median n erve, anterior i n terosseous flexes wrist minimal ly
• Varian t: Add i tional sli p to i ndex finger

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 TENDONS
• Innervation : Deep radia l ne rve, posterior • Action: Exte nds index, middl e, rin g, lit tle fingers;
interosseous branc h abclucts index, ring & little fin gers away fro m
• Variants: Multiple slips; insert o n trapezium or FR middle fin ger; extends hand at wrist with
• APL & EPB intersect ECRB & EC RL jus t proximal con tinued action
to ext·e nso r retinacu lum; m ay impinge at • Innervation: Deep rad ia l ne rve
muscul o te ndinous inte rsection • Variants: Mu ltiple sl ips; in sertion o n thumb
o Ex tensor pollicis brevis o Exten sor digiti minimi (extensor digiti quinti (V)
• Origin : Dorsa l mid radi us; co urse: Medial & proprius)
contiguous with APL; crossing over EC RB & EC I(L • Origin: Lateral epico nd yle/com mon exte n sor
to enter ex te nso r compartm e nt # 1 w ith APL; tendon; cou rse: Passes medi a l to ED & late ra l to
insertion: Thum b prox imal p h alangea l base ECU; passes deep to ex te n so r retin ac ulum in
• Action : Extends thumb MC P; extends 1st MC a t co mpartm ent #S; inse rtion : Exte nso r hood of
CMC wi th co ntinued ·actio n; abducts wrist li ttle n·n ger proximal phala n x with slip to rin g
• In n e r vation: Deep radial nerve, pos te ri o r finger
interosseous bran ch • Action: Ext ends lit tl e fin ger; ex tends ha n d a t wrist
• Va ri a n ts : Ma y be absent; fused with EPL w ith continued action
o Ex tensor pollicis lo ngus • Innervation: Deep radial n erve
• Orig in : Dorsal mid ulna; course: Passes into wri st • Variants : Fused wi th ED; abse nt ring finge r slip
under ex te n so r re tinaculum in compartme nt #3; o Extensor carpi ulnaris
crosse la te ral & s uperfic ia l to ECRL & ECRB a t • Origin: Common exte nsor te ndo n & dorsa l ulna;
45°; inse rtion : Thumb d is ta l phalanx base course: Passes in to w ri st deep to ex tenso r
• Action : Ex te nds thu mb t ip; extend s thumb retinaculum in compartm e nt #6; insertion: Dorsal
prox ima l phalanx & l st M C by conti n ued action ulnar Sth MC base
• Innervation: Deep radial n erve, posterior • Action: Extends & adducts ha nd
inte rosseous branch • Innervation: Deep radia l ne rve
• Variant : Fused with EPB • Variants: In sertio n on 4th MC
o Ex tensor indic is (p ro prius)
• Origin : Do rsa l mid ulna & inte rosseous Muscles Originating at Wrist
mem brane; co urse: Passes und e r ex te n sor • Thenar
ret ina culum in compartment #4, runnin g deep & o Abductor pollicis brevis
media l to ED; jo ins tendon slip near ulnar inclex • Origin: FR, scaph o id tube rosity, trapezium ridge;
finger; inse rtion: Ex tensor hood of ind ex finge r course: Extends laterally; insertio n : Radial thumb
• Action : Extends & adducts index finger p rox imal pha langea l base
• Innerva tion : Deep rad ial nerve, posterior • Action: Abducts thumb a t CMC & MC join ts;
inte rosseous branch d raws thu mb away from palm at rig ht a ngle
• Variants: Duplica ted muscle; slip to middl e finge r • Innerva tion : Median n erve
• Superficial • Variants : Absent o r dupl ica ted te nd on slips
o Exte nsor ca rpi radialis longus o Opponens pollicis
• Orig in : Latera l e picondyle/com mon exten sor • Origin: FR, trapezium ri dge; course: Deep to APB;
tendon; cou rse: Proximal to carpus, crosses i nsertion: Radial th um b MC
be nea th AP L & EPB; passes deep to ex te n sor • Action: Abducts, flexes & rotates 1st MC; d raws
retinaculum in compa rtment #2; inse r t ion: Do rsal t hu mbs across palm
radial 2 nd MC • Innervation: Median n e rve
• Actio n : Exte nds & abducts hand at wrist o Flexor pollicis brevis
• Innervatio n: Rad ial n erve • Consists of su perficial (la rge r & latera l) & deep
• Variants: Multiple tendons, inse rt o n 2 nd, 3 rd , o r (sma lle r & m edial) co mponents
4 th MC • Origin: Superfic ia l-dista l FR & tra pez ium tubercle;
o Extenso r ca rpi radia lis brevis deep-trapezoid & ca pitate; cou rse: Located medial
• O ri gin: La te ral epico ndyle/common ex tenso r & di stal to APB; inse rti on : Comm o n tendo n
tendon; course: Passes beneath APL & EPB; passes inserts on rad ial thumb proxim a l pha la n gea l base
deep to ex te n sor retin aculum in compa rtme nt #2; • Action: Flexes thumb proxim a l ph a lanx; med ia ll y
insertion : Dorsal radia l 3 rd MC rotates thumb MC
• Action : Extend s & abducts hand at w ri st • I nnervation: Superfic ia l-media n n .; dee p-ulnar n.
• Inn e rvation : Raclia l nerve o Adductor pollicis
• Variants: Multiple tendons, insert o n 2 nd, 3 rd, or • O rigin: Obliq ue h ead-capi tate, 2 nd & 3rd MC
4th IC bases, FCR te ndon shea th; tra n sverse head-3rd
Ex te nsor digitorum (communis) MC; cou rse: Obli que-passes ob li q ue ly di stall y &
• Origin : La teral epico ndyl e/comm on ex tensor converges to tendo n (w hic h co ntains sesa m oid);
tendon; course: Passes di stall y, dividing into 4 tra nsverse-fibers con ve rge latera ll y; insertion :
sl ips; passes dee p to ex te n sor retin aculum in Oblique & tra nsve rse-ulna r thumb prox ima l
com partme nt # 4; ex te nds into index, middle, phalangeal base
rin g, little finge rs; insertio n : Middl e & distal • Action: Abducts thu m b proximal pha lanx toward
phal a nges o f in dex, midd le, ring, little finge rs pa lm

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 TENDONS
• Inne r va tio n : Uln ar nerve • Attach es at pis iform, hoo k o f h a m a te, scaphoid
• Hy po the na r tubero sity, tra peziu m pa lma r s urface & ridge; deep
o Pa lmar brevis surface o f pa lma r apo n eu ros is
• Orig in : FR & pa lm a r apo n eu ros is; insertion: Skin • C reates ca rpa l t unn e l co nta inin g m edian nerve,
o f uln a r pa lm FDS, FDP & FPL; crea tes tun ne l for FCR across
• Actio n : Draws s ki n of u ln arward pa lm towa rd t rapeziu m
midd le • Hypot hena r & t h enar m usculatu re arise from FR
• Inn e rva ti on : Ulnar n erve, s upe rfic ia l branc h • C arpal tu nnel re lease typica lly divi d es FR ulnarly
o Abduc to r di g iti minimi nea r h ook of hamate attac h ment
• O rig in: Pis ifo rm & r:cu t endon; insertio n : Ulna r • Ext e n so r re tin aculum (d o rsal carp<tl li ga m e nt)
li ttle fi nge r prox ima l pha langea l base o T h icken ed d ista l a n tebrach ial fascia co m b ined with
• Acti o n : Abducts littl e fi n ge r a way fro m ri n g t ransverse fib rous b u nd les
fin ger; flexes proximal pha la n x o Attach es to u lnar styloid process, m edia l ma rgin of
• Inne r vatio n : Ulnar ne rve, d eep bra n ch pis ifo rm & triq ue tru m, la te ra l rad ius m a rgin
o Flexor dig iti m inim i brevis o Attac hes to d o rsa l rad ia l ridges, creating
• O rig in : Hook o f hama te & FR; i n se rtio n : Uln ar fib ro-osseo us com pa rtme nts (re ferred to by n umber)
little finger p rox im a l p h a la ngea l ba se • # 1- APL, EP B; #2- EC RL, ECRB; #3- EPL; #4- ED,
• Actio n : Flexes little fi n ger at M C P El; # 5 - EDM; #6 - ECU
• Inne r vation: Ulnar n erve, d eep b ran ch
• Va r ia n t: Ano m a lo us o rig in m ay co mpress ulna r Tendon She aths
ne rve • Wrist & ha n d sy nov ia l ten do n s hea ths a rc specialized
o Opponens di g it i mi nimi b ursae; tubul ar w ith viscera l & pa rie ta l layers;
• O ri g in : Hoo k o f h a mate & FR; in se rti o n : Le ng t h in te rvening p o te n t ia l s pace co nta in s mi ni m a l fl uid &
of 5 t h MC s m a ll b lood vessels normall y; fills with flu id whe n
• Action : Abd ucts, flexes & la tera lly ro ta tes 5 th MC in flamed
• Inn e rva ti o n : Uln a r ne rve, d eep b ra n ch • Flexor s h eaths
o Co mmo n flexor te ndo n sh eath (u lna r bursa)
Anomalou s Muscles e ncases FDS, FDP; a rises 2 .5 em p roxima l to fR;
• Ma y p resen t as a soft tissue mass; m ay create ne ura l index, mid d le & ring shea t h s te rminate in pa lm,
co mpress ion li ttle fi nge r sheath at d istal p hala n x
• Accessor y p a lmaris longus: Supe rfic ia l to FD ten d o ns, o Flexor po llic is lo n g us ten don s h ea th (radia l bu rsa)
m edial to FC R en cases FPL; arises 2.5 e rn p rox ima l to FR; te rminates
• Ex ten so r dig ito rum m anus b revis: Ari ses fro m dis ta l a t th umb di stal pha la nx
rad ius o r d o rsa l rad ioca rpal liga m e nt; inserts o n 2 nd • Exte n so r s h eaths
MC o Si x di screte te ndo n sheaths encase tendons of six
o May be te nd e r o r p rese nt a s mass ex te nsor co m partmen ts; a rise proximal to extenso r
• Ext e n sor ca rp i rad ialis inte rm ed ius: Arises fro m reti nac ul u m ; te rm in ate ad jacent to dorsa l MC
hu m eru s o r as accesso ry sli p fro m EC RB o r ECRL; base/ s haft
inserts o n 2 n d &/o r 3 rd MC
• Exte n sor ca rp i rad ia lis accessory: Ari ses fro m Anatomic Snuffbox
h um erus o r ECR L; in serts 1st MC, AP B, o r 1st d o rsal • Marg ins: Distal radi us (prox imal m arg in ), EPL (do rsa l
in terosseous m arg in), APL & EPB (vola r m argin ), APL & EPB
• Accessor y ex te nsor polli c is lo n gus: Located in #3 co n verge just dista l to 1st CMC (d is ta l ma rgin),
ex te n sor co m pa rtme n t may be te nde r & mi m ic mass sca p h o id , t ra peziu m, I st CMC & radial styloid (deep
• Accessory a bducto r digi ti m inim i: Ari ses from FR o r m a rg in)
PL; inserts o n ADM. May compress ulna r o r m ed ia n n . • Conte nts: Cepha lic vein , rad ia l nerve, rad ia l artery
• Lumbrica l mu sc les: Arise fro m FD te nd o n s dista l to
ca rpal tunne l bu t may a rise p rox ima ll y w ithi n carpa l
tunnel causin g CTS !Anatomy-Based Imaging Issues
Fascia & Retinacula Imaging Issues
• Flex o r ret in aculum • Ma n y va ria t ions o f flexo r & ex te nso r m uscles &
o Superficia l (vo la r ca rpa l liga m e n t o r ligame ntum te n do n s
car p i palrnare) p o rtio n • Mul tiple t e ndon sli ps ca n mimic lo n gi tud ina l te ndon
• Th icke n ed d ista l a ntebrac h ia l fascia co mbined tea rs (e. g., APL)
w it h transverse fibro us bund les • Magic a n g le effect : Co ll agen b und le o rie n tatio n so
• Attac hes a t u lna r sty lo id p rocess & rad ial sty lo id t hat images o bta ined 55° to m ain magneti c fie ld m ay
process; ble n ds di sta ll y w ith FR yie ld in t er med iate sign a l rathe r t ha n expected low
• C reates roof o f Guyon canal; uln a r n erve, a rte ry & sig n a l in tens ity (es pecia ll y in s hort TE imaging - Tl,
veins ru n deep to fa scial layer but supe rfi cia l to FR p ro to n density o r G RE) (e.g., ECU, EPL)
o Flexo r re tin a cu lum (tra n sverse ligam e nt o r • Sma ll amo u nt o f fluid common in te ndon sheath (e.g.,
liga m e n tu m fl exorurn) EC RB, EC RL, ECU)

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 TENDONS
AXIAL T1 MR, PROXIMAL WR IST

Ex tenso r digito rum Exten sor po llicis longus

tendon sl ips ten don

Extensor carpi radialis

Ex ten or d igiti minimi brevis tendon
tendon

Ex ten sor carpi rad iali s

Extensor carpi ulnari s t. lo ngus tendon

Extenso r indicis t. Extensor pol li cis brevis

tendon
Flexo r digi torum
profundus ten don Abductor po llicis
longus tendon
Flexor pollicis longus t.
Ulnar nerve

Flexor ca rpi radi al is t.

Flexor carpi ulnaris
Median nerve

Flexor cligitoru m Palmaris lon gus tendon

t.

Extensor r ollicis longus

Extenso r digito rum
tendon
tendon sli ps

Extemor carpi radialis

Ex ten sor digi ti minimi brevis tendon
ten don

Extensor carpi radialis

Ex ten sor carpi t.
longus te ndon

Exten sor i nd icis t. Extem or polli cis bre\'is

tendon
Flexor digito rum Abd uctor pol licis
profundus tendon
lon gus tendon

Flexor pollicis lon gu s t.

U lnar n erve

Flexor ca rpi radialis t.

Fl exo r ca rpi ulnaris
Median n erve

Flexor digitoru m
superficia l is t. Palmaris longus tendon

(Top) First o f six selected axial M R i mages (fro m proxi mal to d istal) demonstrate tendon course & relatio n ship to
surrounding osseous structures. (Bo ttom) Extensor retina cu lum secures various extensor tendo n into six discrete
co m pa rtments.

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 TENDONS
AXIAL T1 MR, MID WRIST

Ex ten sor digitorum

tendon sl ip s Extensor po llicis longus
tendon

Extensor digi ti m i nirni Extensor carpi radialis

tendon brevis tendon

Exten sor carpi ul naris t. Exten sor carpi radial is

lo ngus ten don

Extensor indicis l. Ex ten sor pollicis brevis

tendon
Fl exor digi torum
Abductor pollicis
profund us t.
lo ngus ten don

U lnar nerve Flexor pol licis longus t.

Flexor carpi radi alis t.

Flexor carpi ul naris
M edian n erve

Flexor digitorum Palmaris longus tendon

superficial is tendon

Ex tensor digi toru m

tendo n slip s
Ex ten sor carpi radialis
brev is tend on
Extensor digiti mini m i
tendon
Exten sor po llicis longu s
tendo n
Ex tensor inclicis t.
Exten so r carpi radialis
lo ngus tendon
Extensor carpi ul na ris t.
Ex tenso r pol licis brevis
Flexor digi torum ten don
profundus tendo n

Abducto r p o lli ci s
lo ngus te ndon
Ulnar nerve
Flexor carpi radial i s t.
Flexor cmpi uln aris
f lexo r poll icis longu s t.
Flexor retina culum,
superficial Median nerve

Flexor digitorum Flexo r retinaculum

superficia I is ten don

(Top) Media n n e rve is rou nded & lies superfi cial & lateral to flexor d ig ito rum t e ndo ns. (Bottom) Note magic a n g le
effect on EPL as it c rosses over th e EC RB.

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 TENDONS
AXIAL T1 MR, M ID W RIST

Ex ten sor di gito rum

Ex ten o r ca rpi radialis
ten don sl ips
brevis tendon

Extensor po llici s longus

Extensor t. ten don

Exten so r digiti mi nimi

Exten sor carpi radialis
ten do n
lo ngus tendon
Ex ten sor carpi uln ari s 1.

Flexor digitorum
Exten sor poll icis brevis
profundus ten do n
ten don

Abductor pollicis
lo ngus tendon
U l na r n erve
Flexor carpi rad ialis t.

Flexor reti nacul um, Flexor po l licis longus 1.

superficia l portion
M ed ian ne rve
Flexor cl igito rum
superficialis ten don Flexor reti naculum

Exten sor d igi torum

ten don slips Ex tem or carpi
brevis tendon

Ex tensor polli ci s longus

Ex ten sor indicis t.
tendon
Ex tenso r digi ti m inimi
tendon Extensor carpi rad ial is
Exten sor carpi ul naris t. lon gu s tendo n

Flex o r digitorum
Extensor po llicis
profundus tendon
tendon

Abducto r digiti mi ni mi
m uscle Abductor poll icis
lon gu s tendon
Ul nar nerve, superficial
& deep Flexor carpi rad ial is t.

Fl exo r d igitorum Flexor pollicis longus t.

superficialis tendon
M edian nerve

Flexor retin acul um

(Top) The carpal tun nel is span ned by th e flexor retin aculu m f rom scap hoid tu berc le to h ook o f ha mate. Its
superficial fi bers form the roo f of G uyon can al. (Botto m ) Th e flexor ret i naculum attaches to the tra pezial rid ge
radially & th e ham ate h ook ulnarly.

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 TENDONS
SAGITTAL T1 MR

Ex tensor polli cb lon gus

tendon

Radial styloid Ex tensor carpi rad ialis

longus tendon

Flexor ca rpi radialis

ten don Exten sor po lli cis lo ngus
tendon

Extensor carpi rad ial is

brevis tendon

(Top) Fir t of eigh t selected sagittal images (from radi al to u lnar). Exten sor ca rp i radiali s longus exten ds distal to 2 nd
metaca rpa l base. Ex tensor pol licis lo ngu s is a thin ten don passi ng superficial & distal to extensor carpi radialis lo ngus
& b revis tendons. (Bottom) Fl exor ca rpi rad ialis med ial to sca phoid & al o ng trapezi um vo lar groove. Ex ten sor ca rpi
radia lis brevis is m edi al to extensor carp i radia lis lo ngus & ex ten ds to 3rd metacarpa l base.

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 TENDONS
SAGITTAL T1 MR

Abd uctor polli cis brevis

muscle

Ex tensor digitorum
M edian nerve tendon slip

Flexor digitorum
profundus ten do n

Flexor digitorum
superficialb tendon

Abductor poll icis b revis

Exten sor d igitorum

ten don sli p
Flexor digitorum
tendo n
Ex tensor indi cis
tendon
Flexor digitorum
superficiali s tendo n

(Top) Flexo r digitoru m supe rfi cia l is & profund us tendon s are apparen t in la te ral carpal tunnel. Abductor po ll ic is
brevis mu scle arises fro m tlexor retin acul um. ( Bottom ) Slig htly med ia ll y, ext e n so r indicis tendon is deep to ex tensor
digito rum tend o n slips. :E
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 TENDONS
SAGITTAL T1 MR

Oppon en s digiti
min i mi mu clc

Extensor digitorum
tendon sl i p
Flexor digi toru m
profundu s tendon

Flexor cligito ru m
superficiali s tendon

Flexor digitorum t .

Abdu cto r digi ti mi ni m i

mu clc

Flexor cligitorum
tendon
Extensor digi t i mini m i
tendon

(Top) Flexor tendons o f ring & little finger pass deep to flexor ret i n aculum in m edial ca rpal tunnel. Hypothenar
muscles take ri se from flexor retinaculum. (Bottom) Abductor digiti minimi ari ses from flexor retinacu l um. Exten sor
digiti minimi pa sses through 5th ex tensor compartment.

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 TENDONS
SAGITTAL T1 M R

Flexor carpi ulnarh t.

Ulnar nerve

Extensor carpi uln aris t.

Ulnar stylo id

(Top) Flexor carpi ulna ris inserts o n pisifo rm with fi bers co ntinuing d is tally as pisohamatc & pisom etacarpa l
ligaments. (Bo tto m ) Ex te nso r carpi ulnaris te ndon passes over dorsa l groove of distal u lna to insert o n Sth
metacarpa l base.

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 TENDONS
CORONAL GRE MR

Flexor ca rpi ulnaris

Flexor digitorum Flexor digitorum

superficialis tendon tendon

Opponens pollicis m.

Flexor digi ti minimi .

Abductor pollicis brevis
brevis muscle
muscle

Flexor pollicis longus t.

Abducto r d igiti m i nimi
muscle

Median n erve

Uln ar nerve

Flexor d igitorum
superficial is tendo n

(Top) Seri es of eight selected coronal images (fro m vo lar to d orsal). Fl exor ca rpi ulnari s i n serts on pisifo rm whil e
flexo r digito rum superficial is t endon s run d eep to flexor ret i naculum. (Bottom) Deep to flexor ret i naculum, fl exor
d igitorum p rofund us & super fi cial is tendo ns ex tend into hand. Hy pothenar musculature ari ses from pisiform, h ook
o f h arna tc & flexor reti naculum. T hen ar museu Ia ture a ri ses fro m flexor retin acu lum, sea phoicl, tra pezium &
trapezoid.

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 TENDONS
CORONAL GRE MR

Flexor digiti minimi m.

Abductor digiti minimi

tendon Flexor pollici5 longus t.

r-lcxor tligito rum

profun dus tendon

Ul nar nerve

Flexo r digit orum

superfi cia l is t.

Lxtensor carpi t.

Abductor pollicis
lo ngus ten don

(To p) Carpal tun nel contains flexor digitorum tendons (profundus & superfi cial is) as well as flexor pollicis longus.
(Bottom) Extensor carpi ulnaris passes over FCU groove in distal ul na wh il e abductor pollicis lo ngus passes over
radial styloid.

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 TENDONS
CORONAL GRE M R

Exten sor pollicis longus

ten don

Ex tensor carpi radi alis

Extenso r carpi ul naris t. lo ngus tendon

Extensor digiti minimi

tendon

Exten sor ca rpi radial is

lo ngus tendon

Exte n sor ca rpi ul n aris

tendon

(Top) Do rsall y, p o rtions of extensor tendons become visible. (Bottom) Exte nso r digiti minimi swee ps dista lly &
medially to in se rt on little finger exte nsor h ood. Extensor ca rpi rad ial is lo n gus inserts o n 2nd metaca rpal.

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 TENDONS
CORONAL GRE MR

Extemor digitorum
tendon slip
Extensor carpi radialis
l.xtcnsor digiti minimi tendon
tendon carpi radial is
lo ngus tendon

Li ster tubercle

Extensor lon gus

muscle t:< tendon

Extensor carpi radialis

brev is tendon

Extensor lon gus

tendon

Lister tubercle
Extensor digito rum
tendon-sli ps

{Top) Ex tensor poll icis longus tend on is located med ial to Li ster tubercle, which separates it from ex tensor carpi
radialis brevis at thi level. Distal to th e tubercle, ex tensor pollicis lon gus crosses superfi cia l to exten sor ca rpi radialis
brevis, and courses latera lly towards i ts insertion on th e thumb. (Botto m) Ex ten sor digitorum tendon sl ips pass
through 4th compart men t . Extensor ca rpi radialis brevis inserts on 2nd & 3rd metacarpa ls.

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 NEUROVASCULAR STRUCTURES
• Pa lma r c u ta n eo us bra n ch a ri ses p rox imal to
!Terminology carpa l tunn e l & re m a ins supe rficia l to FR; supplies
Abbreviatio ns pal m a r skin o f th en ar e min ence; may be in jured
• Abduct o r dig iti m in imi (ADM) d ur in g carpal t unnel release as it is sma ll &
• Abd ucto r p o llicis b rev is (APB) difficu lt to iden tify; impin ge m e nt m ay m imic CTS
• Abducto r p o ll icis lo n g us (APL) • M uscular b ra n ch es a ri se di st a l to CT; sup p lies
• Adduc to r pollicis (AP) APB, OP, FPB
• Avascula r n ecrosis (AVN) • Ter mina l bran ch es to l st-3 rd co m mon pa lma r
• Ca rpa l tu nne l (CT) d ig ita l & proper digita l n erves; supply lumbrica ls
• Ca rpa l t un n e l syn drom e (CTS) & v olar skin o f fin gers
• Distal ra dioul n a r joint (DR UJ) o Va ri a nts: Bifid m ed ian n e rve, high bifu rca tion o f
• Ext enso r carpi rad ia lis brevis (ERC B) median n e rve in fo rearm, resul tin g in med ia l &
• Ext e nso r d ig ito rum (ED) late ral branch es at w rist
• Ext e n so r digiti min imi (EDM) • Rad ia l n e rve
• Exten so r po lli cis b revis (EPB) o O rigin : Bra ch ial p lex us-p oste rio r cord
• Ext e n so r p o llicis lo n gus (EPL) o C ourse in w rist : Bra n ch es into su p erfic ia l & d ee p
• Fie ld o f v iew (FOV) b ra nc h es in dista l fo rea rm
• Flexor ca rpi rad ialis (FCR) o Bra n ch es
• Flexor ca rpi u lnaris (FC U) • Supe rficia l b ranc h passes unde r b rach ioradi a li s
• Flexor d igiti mi nimi b revis (FDMB) tendon in to d orsal wrist; d iv id es into late ra l
• Fl exor d ig ito rum su pe rficial (FDS) bra nch (sup p lies radial w ri st & thu m b skin ) &
• Flexor p ollicis brev is (FPB) m edi a l bra nch (su p p lies m id & u ln ar wris t skin );
• Flexor p ollicis lon g us (FPL) d iv id es to do rsal d ig ita l n e rves supply ing u ln ar
• Fl exo r retinaculu m (FR) thum b, in d ex , middle & rad ia l ring finge rs
• Me tacarpa l (M C) • De ep b ranch ente rs s upina tor vola rly; exits
• O p po n e ns d ig iti m ini mi (O DM) distally & post e rio rl y as p oste r ior in terosseou s
• O ppo n en s po ll ic is (O P) ne rve; suppl ies EC RB, su pin ato r, ED, EDM, EC U,
• Palm aris brevis (PB) EPL, APL & EI
• Palm a ris lon g us (PL) • U lnar nerve
• Pro na tor q u ad ratu s (PQ) o O rig in : Brachial plexus-med ial cord
• Pro n a to r t e res (PT) o Course in wrist : Rad ia l t o FCU, c lose to ul na r a rtery
• At p rox ima l pis ifo rm: Nerve prox im al to
Definitions b ifurcatio n ; n e rve deep to FCU, u ln ar to ulna r
• Pa lma r = vo la r a rter y & veins
• Uln ar = m edia l • At dis t a l pisiform: Nerve bifu rca tes into d eep
• Radial = la te ral (m o tor) & superficial (sensory) b ran c h es
• At hook of hama te: Supe rfi c ia l b ra n c h es vo lar to
h o ok o f h ama te & ADM ; n e rve u ln a r t o u ln ar
!Imaging Anatomy a rte ry & veins; d eep bra n ch es a re d o rsa l & u ln ar
t o h o o k of h amate, dee p to ADM, su perficia l to
Nerves of Wrist j o int p iso m e ta carpal liga m en t
• Med ia n n e r ve o Bra n c h es
o O rigin: Brach ia l pl ex us-late ra l & m ed ia l co rds • Muscular branch es (n ear e lbow); su pply FCU,
o Course in w rist ulna r Yz FDP
• At DR UJ : Ne rve is ro und ed; d eep t o PL, m ed ia l & • Dorsa l bra n c h p asse s betwee n FCU & ulna,
s upe rficia l to FC R & FPL, late ra l & sup e rficia l t o d iv id es into dorsal dig ita l n e rves; su pplies dorsal
FDS ulnar h and sensory in n ervatio n
• At leve l of p is ifo rm (p rox ima l CT): Ner ve • Palmar c uta n eou s bran ch p a ra lle ls ulna r artery,
slig htly fl atte ned; deep t o FR, su p erficia l to FPL & pe rfo rates FR; supp li es pa lm ar uln a r h a nd sensory
FDS inn ervation
• At level of h oo k of h a m a te (d istal CT): Ne rve • Ter m in a l u lnar n er ve crosses u lnar w ri st w ith
flatte n ed; d ee p t o FR, superficial to FPL & FDS ulnar a rtery, deep t o PB; di vides in to s uperfic ia l &
o Bra n ch es d eep bra n ches
• M u scular b ran ch es nea r e lb ow; supply PT, FCR, • Superficia l branch locat ed superficia l to fascia of
PL, FDS AD M; divides into co mmo n & pa lmar d ig ita l
• An t e rior inte rosseous branch travels alo n g d ista l bra n ch es; suppli es PB, h y p o the n a r em in e n ce skin
vo lar in tero sseo us m embra n e between FPL & FOP & rin g/ little fin gers
to terminate in PQ & radi ocarpa l jo in t; supplies • Deep bran ch co urses sh arp ly u ln a rwa rd over h ook
radia l 1/z FOP, FPL & PQ o f h amate t hro ug h p iso h amate h ia tus (risk fo r
compression in this regi on ); s upplies m o to r
inne rvati o n to ADM, FDMB, O DM, AP, 3 rd & 4th
lu mbricals, a ll inte rossei
• j o int inne rvatio n

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 NEUROVASCULAR STRUCTURES
o DRUJ: Median n e rve, a nte rior interosseous branch; • Superficial palmar bra n ch con t inues d ista ll y,
radial nerve, posterior interosseo us branch su perficial to FR; passes th ro ug h the nar eminence
o Radiocarpal: Media n ne rve, ante ri o r inte ro sseo us muscle to a na stom ose (variably) w ith ulnar a rte ry
bra nch; rad ial n erve, posteri o r inte rosseou s branch ; to fo rm supe rfici a l palma r a rch at m e taca rpa l
ul na r nerve, do rsa l & dee p bra nc h es base leve l; ma y gi ve a sm all branch tha t joins
o Mid carpal: Ulnar n erve, carpal bran ch es; m edian ulnar artery bran ch to fo rm volar interca rpal
nerve; radial ne rve, post erio r interosseous bran ch a rch
• Volar dermatomes: C6- thumb, thenar eminen ce; C7 • Ma in radial a rte ry contin ues d orsa l at ra dia l
- palm, index & mid dle fingers; C8- hypot he nar styloid, deep to EPB & APL, crossing an atomic
em inence, ring & little fingers s nuffbox
• Dorsal derm atom es: C6 - th umb; C7- dorsal w rist, • Do rsal carpa l b ra n ch a t level of do rsal scaphoid
index & middle fingers; dorsal wrist, ring & little wa ist joins u ln a r a rte ry, dorsal carpa l branch, to
fingers · crea te "dorsa l carpal (interca rpa l) arch
• Ma in rad ia l a rte ry continues di stal, pa sses between
Anatomic Spaces heads of 1st dorsal interosseous muscle to enter
• Carpal tunnel palm, jo ini ng ulna r ar tery, dee p palmar branc h, t o
o Fibro-osseou s tunne l borde red by ca rpa ls (do rsal), form deep palma r arch
scapho id & trapezium tubercles (late ra l), hook o f • Uln ar artery
hamate & pisifo rm (m edial ) & FR (vo la r) o O rigin: Te rmin al bran ch of brachial arte ry
o Contents: 4 FDS, 4 FOP, FPL, m edian ne rve o Course in w rist: Su pe rfic ial to PQ (volar & ulna r);
o Ana tomic va riants see n in 41 % : In clude bifid continui ng between FCU & FDS te ndo n s
media n n erve; persis tent m edian artery; ano ma lo us o Bran ches
muscles inclu din g reversed palm a ri s lo ngus, • Common interosseous arte ry bra nches in forea rm
palmaris profundus, accessory FDS, aberrant th enar to a nterior & poste rior interosseous a rte ries
or lumbrica l origins • Ante rior interosseous a rtery trave ls vo lar to
o Anatomic va ria nts may result in compress io n in interosseous membrane deep to FOP & FPL; at
(rela ti ve ly) rigid tu nnel prox imal PQ gives small branch which pi erces PQ
• Guyon ca nal & jo ins volar radioca rpa l arc h ; pierces
o Fibro-osseou s t ria ngu lar canal bordered by pisiform membrane, e ntering do rsal fo rearm wh ere it
bone & pisohamate ligam ent (m ed ial ), hook of anastomoses with posterior interosseo us a rte ry
ham ate (d ista l), FR (do rsa l) & vo lar carpa l liga m ent jo inin g dorsal radiocarpa l & inte rcarpal arches;
(vo lar) m edian artery (bra nc h of ante rior interosseous
o Contents: Ulnar a rte ry, ulnar n erve, ulnar vein, fat artery) a rise s in forea rm & m ay persis t
o Zones (a rea con tai nin g uln a r ner ve, based o n (acco mpanyin g median n erve) into ca rpal tunnel,
bifu rca t ion ): 1) nerve proxima l t o bifurcat ion ; 2) co ntri buting to superficial palmar arch
ulnar nerve, deep branch (m oto r); 3) ulnar ne rve, • Posterior interosseous artery t rave ls di stal
su perficial branch (sen sory) be twee n deep & su perficia l ext ensors, s u pe rfi cial
o Ana to mic varia n ts seen in 25%; include reversed to EP B & APL to a nasto mose with anterior
palmaris lo ngus, accessory ADM, accesso ry FCU interosseous artery
Vessels of Wrist joint • Palmar ca rpa l branch arises at proximal carpa ls,
anastomoses with ra dia l a rt ery, palmar ca rpal
• Ex traosseous vascular s uppl y
• Radial artery branch , & an t erior interosseous branch es to fo rm
pa lmar (vo la r or transverse) radiocarpal arch
o Origi n: Te rmina l bra nc h o f brachial artery
o Superfi cial to PQ (vola r & ra dia l); con tinu es dorsally • Dorsal carpal bra n ch ari ses at pisifo rm, passes
do rsa lly benea th FCU into dorsum of w ris t, d eep
around radia l styloid p rocess; passes deep to APL &
EPB, across a n ato mic snu ffbo x & deep to EPL to ex te nso r tendons, t o anasto mose w ith radial
o Branch es artery, dorsal ca rpal branc h, to crea te dorsal
carpal (intercarpal) arch
• Palmar carpa l bra nch a ri ses nea r distal edge of
• Deep palmar bra n c h arises at FR; passes med iall y
PQ; runs across pa lm ar wrist at radiocarpal level to
through h ypo thenar muscles (AP & FDMB); turns
anastomose (variabl y) wi th ulnar a rte ry, pa lm ar
late ral into palm to anas tom ose w ith radial artery,
carpal bra nch , & a nte rio r inte rosseous branches to
form palmar (volar or transverse) radiocarpal deep palmar branch, to fo rm d ee p palmar arch
arch • Superficial palmar branc h co ntinues di sta l
supe rfi cial to FR t o join radi al artery, supe rficia l
• Small do rsal bra nch jus t prox im al to anatom ic
branch, creatin g superficial palmar arch
snuffbox passes d o rsa ll y, & remains d eep to
• Vasc ular variations: Many variations are described,
extensor compa rt me n ts jo ining ulnar a rte ry to
for m dorsal ra diocarpal arc h pa rticularl y re lated to vessel co nt ributions to vascu lar
arches
o Do rsal arches

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11 9
 NEUROVASCULAR STRUCTURES
• Radiocarpa l a rch: Prese nt in 80°;b, m ost • Ca pitate: Dorsa l (2-4) & vo la r (1-3); no significa nt
important fo r ca rpa l vascul a r supply; a nasto moses anastomoses in 70%
va riab le: Ra dia l & a n terior interosseo us (o ccurs • Hamate: Dorsa l (3-5) suppl y 30% of ca rpus; volar
80%); ra dia l, u ln a r & in terosseous (occurs less (1 in hook of hamate) supplies 70°;h; anasto moses
co mmonly) with dorsa I in 50%
• Dorsal carpal (intercarpal) arch: Presen t in 99%; o lntraosseou s vascular supply correlated with
a nastomoses va riab le: Rad ial , ulnar, & clinical incide n ce of avascula r necrosis
interosseous (occurs 53%); rad ia l & uln a r (20%); • G rou p 1: Vessels enterin g from on ly o ne su rface or
rad ial & interosseous (20 1Jih); ulnar & in terosseo us large areas d e pe nde nt on o n e vessel; includes
(7%) sca phoid , capitate & 8% of lunafes; high risk fo r
• Basal metacarpa l a rc h: Co mpl ete in 27%, absent AVN
in 27%; partial (rad ia l on ly) in 46% • G rou p 2: Bones w ith absence o f intern al
o Volar arches a nastomoses; h a ma te & t rapezoid; less risk for
• Radiocarpal arch: Present in 100%; anastomoses: AVN
Ulna r, radia l & in te rosseous anastomoses (87%); • Group 3 : Bones wit h rich inte rnal a nastomoses;
radia l & ulnar (13%) t rapeziu m, t ri quetru m , pisiform & 92% o f lunates;
• I ntercarpal arch : Sma llest & most var iable; seen least risk for AVN
in o nl y 539·\J; a na stomoses: Radia l, ul na r &
interosseous (75%); rad ia l & ulnar (25%)
• Deep palmar a rch: Presen t in 100%; !Anatomy-Based Imaging Issues
a n astomoses: Radial & ulnar (97%); n o
anastomoses between radial & ulnar (13%): Imaging Re commendations
Proximal, deep & d ista l syst ems a rise from t his • Ne ura l structure eva lua t ion
a rch ; volar a rches are con nected lo ngitudina ll y by o Appea rance: lsointe nse to muscle on a ll sequences;
radia l, ulnar & interosseous a rte ries & d eep pa lm ar la rger ne rves may h ave a stippled appearance (in
recurrent arter ies (w hich arise from dee p pa lmar ax ia l sectio n) as longitudi nally-orien ted fascicles
arch) have sli g h t inc reased signal in tensity compa red to
• Vesse l visua liza tio n o n standard m ultiplanar imaging lower signal intensity o f surro u nding
at mid-carpal level epi/pe rin euriu m
o Radial & uln a r a.: 3-4 mm; ty pica lly visuali zed o Best pla n e for n eu ra l eval uation: Axial pla ne; 8-12
o Vascular arches: 1 mm; in con siste nt ly visua lized e m FOV
o Multip le branches & anastomoses: < 1 mm; rarely o Sequences for n e ura l evaluation: T1 for anatomi c
visua li zed d et ail; PO o r T2 fa t suppression or STIR to evalua te
• Intraosseous vascu lar supply abnorm a l in creased signa l
o Overview o Patie nt positi o n ing needs to max imize patient
• Exte n sive vola r & dorsal anasto m oses typica ll y comfort; best w ith wr ist in cente r o f m agn etic field;
exist patient in prone position w ith h a nd pronated above
• Vessels enter in a reas w ithout ca rti laginous cover, head ("Supe rma n ") position
nonarticula r, at liga m e nt or caps ule attachments • Vascu lar eva lu at io n
• Pitfa ll: Entry poin ts o f nutri ent vessels should not o Gado linium-en hanced MR angiography provides
be mi stake n for erosion s on MR or CT sca nnin g detail of vessels in cluding small digital arteries;
o Carpal vessel entry poin ts (nu mber of vessels) & compa rable to co nve ntion al angiography
anastomoses • 12-14 em FO V to visu alize multiple branc hes
• Scaph o id: D.istal (at volar distal pole), laterovolar • Fast 3D spoiled gradie n t -ec ho sequence in
(at scap ho id wa ist), & dorsa l (at d orsal ridge) at combination with h ig h q ua lity receiver coi l a llows
ligamentous attachm en ts with ric h anastomoses; sh ort acquisitio n t im e with adequ ate
1 inconsequ en ti al proxima l pole vessel e nte rs at signal-to-noise ratio; acq u ire pre-in ject ion 3D
radiosca pho lunate ligam e n t a ttachment (13-14% images & post-inj ectio n begi n ning approx im ately
h ave no vessel ente ring p rox imal to scaph oid 15 second s a fte r in jectio n ; acq uire 3-4 sequences
wa ist); proximal pole is at h igh risk H trauma to maximize da ta acg.Llisition in arterial, capilla ry
occu rs a t sca p hoid wa ist proximal to vessel e ntries & ve no us phases
• Lunate: Dorsa l & volar (1-2) at liga me ntous • Limi ted in pa tie n ts wit h flex ion contractu res,
attach ments; extensive anastom oses in abi lity to re m a in still, ph ysical restri cti o n s to
• Triquetr um: Dorsa l (2-4 a lo ng dorsa l ridge) u nde rgoin g MR (i.e., pacem aker)
supply 60% of carpus; volar (2-3 proximal to o Gadolinium-enhanced MR facilitates evalua tion of
pisiform) supply 40%; extensive anastomoses in bone via bility; resul ts in se nsiti vity 66%, speci fi city
86% 88% & accura cy 830f<,
• Pisiform: Prox imal & di stal po les (1-3); ex te n sive
anastomoses
Imaging Pitfall s
• Trapezium: Dorsa l (1-3), vo lar (1-3) & la te ra l • eural sign al in tens ity is typically in te rmedia te in spin
(5-6); anastomoses but do rsal su pply domin ates ec ho imagin g; with fast spin ech o technique, n erves
dem o nst ra te increased s.ig n al th at sh ou ld not be
• Trapezoid: Dorsal (3-4) su pply 70% of ca rpus;
vola r (1-2) supply 30°/c,; no anastomoses mistake n as abnorm al

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120
Ill
12 1
Ill
122
', '

Ill
124
Ill
.125
 NEU ROVASCULAR STRUCTURES
CORONAL GRE & AXIAL T1 MR, CARPAL TUNN EL

Med ian nerve

Flexor digitorum
&
1.
Flexor digi to rum
superficial is t.

Flexor pollicis lo ngus t .

f.lexor digito rum Flexor digito rum

profundus t. superficia lis t.

Flexor polli cis longus t.

ledian nerve

Proximal flexor
retinaculum

l'lcxor digitorum
profundus l.

Flexor digitorum
superficiali s tendon
(little & index ) 1\ ledian nerve

Flexor digit orum

supcrficialis tendon
(middle & ring)
Median n erve

(Top) Selected coron al images (superficial to deep). Median nerve h as a striated appearance as it t rave ls fro m
prox i mal to distal, acco m pani ed by flexor digitorum & flexo r pollicis l o ngus te ndo n s. (Bott o m ) Selec ted ax ial images
(p roximal to dista l). Upper left: Proxi m al carpa l tu nn el w ith rou nded median nerve, fl exor digito rum & fl exor pollicis
lo ngus tendons deep to nerve. Upper ri ght: M id carpal tu nnel w ith median nerve vo lar & rad ial to tendons. Lower
left: Mid ca rpal tunnel with tendo ns deep to med ian nerve & organ ized i n layers w ith middle & ri ng superficia l is
tendons lyi n g vo lar to l ittle & index tendo n s. Pro fund us tendo n s lie across carpa l t unn el ba se w ith little finger
tendo n most m ed ial & index fi nger tendo n most radia l. Lower ri ght: M edian nerve is di m i n i heel in size & flattened
Il l as it bran ches to term i nal branch es.
126
 NEUROVASCULAR STRUCTURES
CORONAL GRE & AX IAL T1 M R, GUYON CANAL

Ulnar n erve, deep

bran ch
H ook o f hamate

U l na r nerve, super ficial

Pisiform bran ch

Ulnar n erve Ul nar ner ve

Fl exor ret i nacul um Deep ulnar n.

Su perficial ulnar n.

U lnar artery

Vo lar carpa l I.

Deep ulnar n.
Ul nar a. & v.
Superficial ulnar n.
Deep ul na r n.

U lnar artery
Superfi cial ul nar n.
U lnar vei n

(Top) Se lected co ro na l images (supe rfi cial to deep). Ulna r nerve p asses distal, lying medial to u ln ar artery & vei ns,
passing latera l to pisifo rm where it divides into s upe rficial & d ee p bra nch es w ith deep branc h curving medially
thro ug h p iso hamate hia tus. (Bottom) Selected ax ia l images (proxim a l to di sta l). Up per le ft: Proxim a l Guyon can a l
with volar ca rpa l ligame nt fo rm in g roof & fl exo r retina cu lum formin g floor of ca na l. Uppe r rig h t: Ulna r ne rve
divid es, a t m id pisifo rm , into su perfi c ia l & deep b ranch es . Lowe r left: Superficial ulnar ne rve pa sses vola r to ti p o f
hamate ho o k & d eep uln ar n erve co u rses medi a ll y t hro ug h pisohamate hiatus. Lowe r righ t: Ulna r nerve branc h es
contin ue d is ta ll y su p pl ying sen sory (supe rficial) & m o to r (deep ) t o u ln a r wrist & ha n d.
Ill
127
Ill
128
 NEUROVASCULAR STRUCTURES
MR ANGIOGRAM, VES SEL VARIATIONS

Ulnar a., inco mplete

superficial palma r arch
Deep pa l mar arch

Ulnar a., medial branch

Radial artery, deep
palmar arch

Ulnar artery

Radi al artery

Anterio r int erosseous a.

Superficial palmar arch

Deep palmar arch

Ulnar artery

Dorsal in tercarpal arch

Radial artery

Palmar ca rpal arch

(Top) Cont rast-enhan ced angiography revea ls major vessels but many smaller b ra n ches w ill no t be seen . While deep
palmar arch is identified, superfi cial palmar arch is inco mplete. Note promin ent ulnar arterial contribution to wrist &
hand in this patien t. (Bottom) Con trast-en hanced angiography (i n different patient) shows rad ial artery to be
dominant. Image was obtain ed la ter in scanning sequence. Superfi ci al & deep palm ar arches h ave con tri buti on s from
both radial & ulnar arterie .

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 NEUROVASCULAR STRUCTURES
AXIAL T1 & T2 FS MR, ARTERIES & VEINS

Accessory cephalic v.

v.

Ceph al ic vei n

Palma r carpal arch,

ulnar artery
Rad ial a. & v.

M edian artery
Ul na r a. & v.

Median nerve

Accessory cephalic v.

Subcuta neous v.

Ceph al ic vein

Palma r carpa l arch,

ul na r artery
Radial a. & v.

artery
Uln ar a. & v.

Median nerve

(Top) Ser ies o f fo ur selected axial T l M R, paired wi th T2 FS MR at same level (proximal to distal). At dista l radi o ulnar
jo int, rad ial & ul nar arteries are read ily apparent w ith acco m pany ing ve in s para l lel i ng t h ei r co urse. (Bo tto m ) Axial
T2 MR at sa me level w i t h fat-sup pression shows m ul tiple small vein s su rrounding radial & u lnar arterie .

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 NEUROVASCULAR STRUCTURES
AXIAL T1 & T2 FS MR, ARTERIES & VEINS

Subcutaneous v.

Cephalic vein

Radia l artery

Radi al artery,
Ulnar a. & v. superficia l branch

Medi an nerve

Subcutaneous v.

Cep hal ic vein

Radial artery

Ulnar nerve
Radial artery,
supe rficia l bra nch
Ulnar artery

Median nerve

( ro p) Ax ia l Tl MR, a t ra di o ca rpa l join t, de m o n s tra tes bra n c hin g rad ia l a rte ry w ith m a in po rtio n di rec ted latera ll y &
dorsally into a n a to mi c s nuffbox whi le supe rfic ia l bra n c h c o n t inues d istally in vola r pa lm . Sig nal of vessels & ne rves
is intermediate. (Bo tto m ) Axia l T 2 M R with fa t-su ppressio n d e mo n stra tes hi g h s ig n al vesse ls. T h o se w ith h ig h e r fl ow
volume a p pear as a low sig n al ce n te r w ith hig h s ig nal inte n sity ri m a s seen w it h radial & uln a r a rt e ry whi le s low-flow
are m o re u niform in appeora n ce. M cd ion nerve stippled .

Ill
n1
 NEUROVASCULAR STRUCTURES
AXIAL T1 & T2 FS MR, ARTERIES & VEINS

Cep ha lic vei n

Ulnar a., deep b ra n c h

Med ia n nerve

Ulna r a rtery, supe rficial

b ranc h

Basa l m e tacarp a l arch

Basa l m e taca rpa l a rc h

Ce ph a lic vei n

Uln a r a., d ee p bra n c h

Med ian ne rve

Ulna r arte ry, supe rfic ial

b ranch Radial a., supe rficial
pa lmar branch

(Top) Axia l T l MR, at mid ca rpal tunnel (hook o f h ama te/ trapezi al ridge), dem o nstrates u lnar artery & veins withi n
Guyon ca nal. M edian n erve is deep to flexor retinacul um. (Bo ttom) Axia l T2 MR wi th fat- uppre ion reveals ulnar
arter y has bran ched with deep branch travel i ng dista lly to form deep palm ar arch while super fi cial bran ch wi ll form
superfi cial pa l mar arch.

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132
 NEUROVASCULAR STRUCTURES
AXIAL T1 & T2 FS MR, ARTERIES & VEINS

Rad ia l artery
Deep pal mar a rch
Deep pal mar arch
Ulnar a., deep branch

Med ian nerve

Ulna r art ery, superficial

branch

Basal metaca rpal arch Basa l me taca rpal arch

Deep pal mar arch Radial artery

Deep pa lma r arch

Ulnar artery, dee p

branch Medi an nerve

Ulna r a rte ry, supe rfi cial

branch
Radia l a. superficial
pal mar bra nch

{Top) Ax ial T l M R, at d istal carpal tunnel level, reveals o nl y majo r arterial structures as finer m esh work o f
interco nnected arterial arches & ven o us structures are d i minutive in distal wrist. (Bottom) Axial T2 w ith
fa t-su ppression revea l s small vessels along d o rsa l basal metaca rpal arch wi th bridging bran ches tha t con t ribute to
deep palmar arch as we ll as co n t ri bu tio n s from rad ia l & ulnar b ranches. Sup erficial pa lmar branch of rad ial artery is
noted su perficial to th enar emi nence.

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 SECTION IV: Hand

Hand
Hand Overview 2-29
Text 2-4
Gra phics: Ten don injury zones 5
Graphics: Muscle o ri gi n s & insertion s 6-7
Rad iographs 8-9
Graph ics: In terossei 10-11
Gra phics: Th en ar & h ypo thenar 12-13
Gra ph ics: Lum brica l s & nerves 14
Graph ics: Vesse ls 15
Ax ial M R sequen ce 16-23
Coronal M R sequence 24-27
Sagittal MR sequence 28-29
Flexor Mechanism and Palmar Hand 30-3 7
Text 30-3 1
Graphi cs: Flexor m echanism 32-33
Axial M R seq uence 34-36
Sagittal M R sequen ce 37
Extensor Mechanism and Joints 38-45
Text 38-39
Graphics: Ex tensor m echanism 40-42
Ax ial M R sequence 43-44
Coronal MR 45
 HAND OVERVIEW
• Vola r groove o f head t ra n smi ts flexor tendons in
!Terminology exte nsio n and accommod ates VP (especially in
Abbreviations flexion)
• Abducto r d ig iti m in im i (A DM) • La teral and medial no tc hes are origin of colla te ral
• Abductor pollicis brevis (APB) liga m ent com p lex
• Ca rpom etaca rpal (CMC) Ph alanges
• Dista l inte rphala ngea l (joint) (D IP) • 3 each (proximal, midd le, a nd dista l) for digits 2-S
• Dorsal palmar arch (DPA) • 2 (proxima l and d ista l) for 1st d igit
• Ext en sor d ig itorum com munis (EDC) • Com prised of base, dia phys is, a nd h ead
• Exten sor pollicis longus (EP L) • Ossificati on cen te r (epiphysis) is proximal (base)
• Ext e n sion, ext ensor (ext.) • Heads a re b.icondylar volarly with condyles separated
• Flexor digiti m in imi (FDM) by sha llow groove
• Flexor digitorum profundus (FO P) • Groove tra n smits flexor te nd on s in exten sion and
• Fl exor di gi to rum superficia lis (FDS) accommoda tes VP (especially in flexion)
• Flexion, fl exo r (flex.) • Pro xim al a rticula r su rfaces of proxima l phalanges are
• Flexor pollicis brevis (FPB) uniforml y con cave
• Flexor pollicis longus (FPL) • Proximal articula r surfaces of middle and dista l
• Interosseus membrane (10 M) pha langes are biconcave with a median ridge running
• Interphala n gea l (jo int) (IP) anteropos teriorl y
• Metaca rpa l (MC) • Median ridge tracks in groove between con dyles: Hel ps
• Metacarpophalangeal (joint) (MCP) preve nt late ral translation
• Oppon e ns d igiti m inimi (ODM)
• O ppo n ens pollic is (OP)
• Pha lanx (phal.) IMuscles of Hand
• Proxima l interphalangeal (joint) (PIP)
• Retin ac ulum, ret in acula r (ret inae) See "Flexor M echan ism and Palmar Hand"
• Signal-to-noise ra tio (SNR)
Section for
• Superfi cia l pa lm a r arch (SPA)
• Volar plate (V P) • Flexor d igitorum superficia l is, flexo r digi torum
profundus, flexor po ll icis longus, th ena rs,
Definitions hypoth e nars, add uctor pollicis, and palmar in terossei
• For this text, the h a nd will be defined as beginning a t
th e carpometaca rpal jo int
See "Extensor Mechanism and join ts"
• In anatomic positio n , th e hand is in supination Section for
• Radial: Toward radius and synon ymo us with lat eral(ly) • Exten sor d igitorum comm un is, ex te n so r indicis,
• Ulnar: Toward ulna and syn on ymous with medial(ly) extensor digiti m inimi, lumbricals, dorsa l interossei,
• Mesia l: Toward midl in e of struc ture exte nsor pollicis lo ngus, and ex te n sor pollicis brevis
o In th e hand, fo r exa mple, 3rd digit is m ore m esial
than 2 nd and 4th digits, which are mo re mesial
t h a n l st and Sth digits IVessels of Hand
• Bo th supe rficia l palmar a rch a nd deep palmar arch run
IOsseus Anatomy fro m rad ial artery to ulnar artery
o Ulna r arte ry prim arily supplies the superficia l
M etacarpals palmar arch
• Comp rised o f a base, dia physis, neck and h ead (from o Radia l a rte ry primarily supplies t h e deep palmar
proxi m al to d istal) arch
• Normal ossification cen ter (epiph ysis) is d ista l (head) Radial Artery: Proximal to D istal
for digits 2-S and p roxi m al (base) fo r 1st digit • 1) At radi ocarpa l jo int level gives off co ntribution to
• Bases a re tr-apezoidal in shape (broade r de rsa lly) wi th SPA vola rl y whic h pierces f\ PB before joining SPA
con cave a rticul a r su rface • 2) Tra vels superficia lly (superficia l to EPL and ex t.
• 1st m etacarpal a rticul a tes with trapezium re tinae.) arou nd radial aspect of wrist t o travel dorsa lly
• 2nd-5t h metacarpa ls a rt icu lat e with trapezoid, in ana to m ic sn u ffb ox
capi ta te, a n d ha m ate (both 4t h and St h) respect ively, • 3) Distal to snuffbox, gives off branch w hic h splits
as well as wi th o ne a nother into princeps pollicis a nd rad ia li s indicis a rteries
• Dia ph ysis is roughly triangu lar in cross-sect io n with • 4) Di ves deep in inte rspace be tween 1st and 2nd
apex vo la rly: Crea ting med ial a n d la te ra l volar surfaces m etaca rpa ls
and d o rsa l su rface • S) Travels between heads o f 1st d o rsal in te rosseus and
• Dia ph ysis is gen tly concave volarly (co n vex dorsa ll y) adductor polli cis muscles before form ing DPA
through o ut its proxim al to di stal course • 6) DPA run s betwee n flexor tendo ns a nd metacarpals
• Head is relatively sph erical with sh a llow groove
volarly and sh o rt notc hes late rally and me dially Ulnar Artery: Proximal to Distal
• 1) Runs superficial to .flexor retina culum

IV
2
 HAND OVERVIEW
• 2) Passes radial to pisifo rm o High fi eld strength magn et
• 3) Gives off deep branc h t o DPA just proxima l to h ook • At least 1.5 Tesla gen erall y recomme nded
of hamate which runs be tween ADM a nd FDM • Inc reasing magn e t stre ngth = im proved SNR
• 4) Forms SPA which runs be tween palmar a pone urosis o Small field of view
and flexo r t e ndo ns o Minimize m otio n by maxi mizi ng patient comfort
• S) Arteri al supply to late ral aspect 5t h digit usuall y and m inimi zing scan times
en tirely from ulna r artery o Ce nterin g hand with in magnet bo re impro ves SNR
• Pa ti ent prone or sup ine wi th arm over head: T his
Common Palmar Digital Arteries is often less co mfo rtable than arm at side a nd ma y
• Betwee n metacarpa l n ecks a nd heads in 2nd, 3 rd, a nd result in more mo tio n
4th interspaces • Can also be done with pa tien t supine a nd h a nd
.-
• Varia bly su ppl ied by SPA and DPA over a_bdo me n if h a nd is su pported on platfor m
separate fro m patie nt: Prevents respiratory motion
Proper Digital Arteries
• Coils
• Arise at MCP joint level
o Circumferential coils are gen erally preferred
• Ru n in subcu tan eous fat a long latera l aspects of d igits
• Dedica ted co mbined h and and wrist coils
available
INerves of Hand • Dedicated wri st coils gen erall y will not
a ccommodate e ntire hand, but a rea o f interest ca n
Median N erve be p laced in cen te r
• Travels in ca rpa l tu nnel • Knee coil s ca n be used if n othing else available:
• Aft er exiting car pal tunnel, gives o ff recurrent branch Place hand o n fo lded towels to center in coil
(moto r su pply to th e nars) • Dedica ted finger coils exist
• In h and, motor to th enars (O P, APB, a nd FPB) as we ll o Surface coils
as lst a nd 2nd lumbrica ls • Poore r fat-satura tio n than c irc um fe re ntia l coils
• Senso ry • Lose signal as distance from surface coil increases
o Palma r su rface: Radial Yz of pa lm , digits 1-3 a nd • Place area of interest on surface (i.e., do not put
rad ial 1/z 4t h di gi t palm dow n to im age exten sor tendons) ·
o Do rsa l surface: just dista l to PIP t o fingertip digits • Best plane fo r imaging ·
1-3 a nd rad ial Yz o f 4th o Flexor te nd ons: Ax ial and sagitta l
o Ext en sor te nd o ns: Axial and sagitta l
Ulnar Nerve o Tend o n sheaths: Ax ial > sagitta l
• In h and, motor to h ypothe n a rs (ODM, ADM, a nd o Musc ulature: Axial > coronal and sagittal
FDM), a ll interosse i, 3 rd and 4th lumbrica ls, and o Pu ll eys: Axia l > sagittal
adducto r poU icis o Co llatera l ligaments: Coronal a nd ax ia l
• Sensory o Vo la r plate: Sagittal > a xial
o From radiocarpal joint to finge rtips of 5th a nd uln ar
1/z of 4th digits: Both volarl y and d o rsa ll y Ultrasound
• Highly operator dependent
Radial Nerve o For this reason (as we ll as lack o f read er expe rie n ce
ot usu a ll y seen o n rout ine i maging and com fort), n ot ro utine ly used fo r MSK imagi ng
o moto r inn e rvati o n in hand in th e United Stat es
• Sensory • Mos t co m mo n exception wou ld be im aging o f
o Dorsa l surface from radiocarpal joi nt to just dista l to suspec ted ganglion
PIP jo ints fo r digits 1-3 and radia l 1/z of 4th digit • Ca n be usefu l for evaluation of te ndons in t h ose
with contrai ndica tion to MR
• Linea r, high freque ncy (at least 8 MHz) transd ucer
Jlmaging Modalities needed for MSK imaging
o At least 12 MHz transducer sh ould be used as d epth
Radiograph s of penetration n eed ed is usually 1 em
• Genera ll y th e first m odal ity in all instances
• Standard views CT
o PA and la teral often sufficie nt • Not routinely used
o Obli q ues may h elp by d ec reasin g supe ri mposition o f o Can be useful fo r eva lua tin g co m plex fractures,
d igits evalua tin g n eoplasms fo r evidence of subtle osseous
o Ball-catc her's view useful fo r evaluation of erosions or chondro id matri x, or eva luation of susp ected
(a rthr itis) osteoid osteoma

MR Angiography
• Most u seful for eva lua tio n o f soft tissue in juries, • Gen e rally done fo r eva luat io n o f suspect ed
masses, marrow abnormalities (inclu ding eva luation of e m boliza tion, a rteria l in jury, vasc ulitis, and surgica l
occu lt fractures), sy novitis, and infectio us processes p la n n ing
• High SN R req uired whe n eva luating small st ructures
within a smal l stru ct ure (the hand)

IV
3
 HAND OVERVIEW
o Conventional a n giograp h y gives best resolution, o Norma l ossification cent e rs are reverse o f above, i.e.,
ability to tailor exa m rea l-time, a nd possibility of d ista l aspects of MCs 2-5 a nd base o f 1st MC
inte rvention o Occasio na lly mi sta ken for fracture
o MR angiography can be done wh en con ven tional • Especiall y wh en sm all cleft re m ains at lateral
angio is u n ava ilable o r contraindicat ed aspects of physea l lin e 2° to incomplete fusion
• Small round or oval notches at la tera l bases of
Nuclear Medicine proximal ph alanges .
• Rarely used for suspicio n o f osteom yelitis, refl ex o May be m istaken for e rosion s; however, eroswns
sympathetic dystrophy, occult frac tu re, surgical typica ll y involve MC h ead s first
plann in g (e.g., viabi lity eva luatio n in frostbite), a nd • Sesamoids
(very) rare ost eoid os teoma of tubula r bones of th e o Up to 2 sesamoids can be present a t each MCP joint
hand and a t 3 rd DIP jo int
o 1 sesamoid ca n be presen t at each DIP joint
o Sesam o ids a re usua ll y embedd ed in VP
!Imaging Pitfalls o No docume ntatio n o f sesamoids occur ring at PIP
• Magic a ng le phenomenon jo ints
o Seen with sh ort TE seq ue nces (predo minately Tl , • Accessory ossification cen ters of epiphyses a t bases of
proton density, and some grad ie n t ech o sequ ences) pha langes
o Occurs when st ru ctures co mposed of para lle l fibers o May be m istaken for fractures, especiall y when sm al l
(a lm ost exclusively te nd on s) are orie nted at 55o to and lateral
main magnetic vector • Trapezium secun da rium
o Lack of increased signal in same location on long o Accesso ry ossifica ti o n ce nter a t ulnar aspect of 1st
TE (usua ll y T2 or STIR) sequences confirms magic CMC joi nt . .
angle o May be mistake n for an avul sio n fracture, especiall y
o Most likely to be seen in fl exor tendons on sagittal wh en sma ll
v iews (wh en imaged in flexion) and in ten do ns o f • Triphalangeal thumb
1st digit in coro na l plane • Bifid distal phalanx
• When hand is imaged (w ith MR) with finge rs in Muscular
fl ex ion, t he lum bricals ca n be p ulled into the ca rpa l
• May be mistaken for neoplasm or oth e r pa th o logy
tunne l.
• Follow muscle signal o n a ll imaging sequences
o Not to be mistake n for a m ass or proxima l origin o f
• Not u n co mmo n : Preva lence in norma l popu latio n
lumbrica ls (a n o rma l va ri a nt)
given in pa renth eses where kn own
• Inhomoge n eous fat-sa turi;ltion
o Accessory abductor digiti minimi (24%>)
o Can be mist a ke n for path ologic h igh signa l
• Muscle located palmar a nd latera l (rad ia.l) to
o More like ly to be seen when
pisifo rm is diagnostic
• Coil not in center of magnet
o Proximal origin of lumbricals (22%)
• Fie ld of v iew is sm aller
• Lu m brical s in carpa l tunnel when finge rs are
• Coil not circumfe rentia l
extended is diagn os ti c
• A s mall amount o f flu id is normal in tendon
• Lumbrica ls may norma lly migra te proximally into
sheaths
ca rpal tunne l when finge rs a re flexed
o W h en fluid becomes circumfere ntial abou t a
o Exte nso r digit o rum m anus brevis (1-3°ft>)
te ndon, it is usually pathologic
• Muscle bell y associa ted wi th EDC te ndons distal
• Colla teral liga me nt comp lex of MC P join ts are ofte n
to CMC joint is d iagn ostic
intermediate signal a n d h eterogen eous o n MR
o Palmaris lon gus varia nts
o Do not mistake for pa thology: Compa re to othe r
• No rm al muscle be ll y sho uld be o nl y in the
col lateral liga men ts and eval uate continuity
prox imal half of the forearm, and the te ndon
• Ani sotropy
inserts o n / in the palmar a poneurosis
o Ultrasound artifa ct that occurs in stru ctures
• Variants may ha ve a d istal m uscle belly, digastric
composed of parallel fibe rs
muscle be llies, or mu s.Gie along almost e ntirety of
• Tendon s> ligame nts a nd muscles
the ex pected course of the te nd o n
o When a ngl e of incide nce of ultrasound beam is no t
• Muscle tiss ue in the midli n e superficia l to the
at o r near 90° (with respect to pa ralle l fibe rs),
flexo r ret inaculu m a t t h e level of the ca rpus is
ech ogeni city may c hange
di agnost ic
o Hy poechoic defects are path o logic o nl y if th ey
• Not to be con fused with the Palmaris brevis
p e rsist without change regard less o f ch an ging
(no rmal structure) w hic h is ulnar (n ot midl ine)
o rie ntatio n o f transd ucer
a nd more distal (level o f CMC jo int)
o Digastric flexor digitorum superfi cialis of 2 nd digit
• A second muscle belly is presen t in th e
I Normal Variants mid-portio n of the FDS tendon to th e 2 nd d igit at
Osseous mid-met aca rpa l level
• Accesso ry ossification ce nte r at base o f MCs 2-5 o r
distal aspect of 1st MC

IV
4
IV
5
IV
6
IV
7
 HAND OVERVIEW
RADIOGRAPH, POSTEROANTERIOR

Median ridge

Phalanges

M etacarpal h ead
n o tches for collateral
I. com plex

Sesa moid
Capitate .
Carpometaca rpal join t
l ine (red li ne)
Hook of ha m ate
Trapezoid
Ham ate
Trapezium
Triq uetrum
Sca phoid
Pisiform

Rad ial styloid

U ln ar styloid

Radiocarpa l joi n t
Luna te

Distal rad ioul n ar joi nt

The d o rsol ateral grooves of the m etacarpal heads (indicated o n the fo urth d igit here) are th e si tes o f ori gin for th e
co ll atera l li gam ent complexes of th e M C P joints. Th ey are ro utinely seen on radiographs and sho uld no t be mistaken
"'0 for path o logy. On a PA radiograph of t he hand, on e sh o uld be able to trace th e carpom etacarpal jo in t (as ind icated
; by the red li n e) as a continuo us up and down "zig-zag". In abili ty to d o so sh ould raise the suspicion o f a d isloca tion.
I

IV
8
 HAND OVERVIEW
RADIOGRAPH, LATERAL

Condyles of head of
middle phalanx

Phalanges

M etacarpals

Trapezoid (green)

Hook of hamat e
Ca pitate (blue) (purple an terior
projection)

llamate (purple)
Trapezium (yel low)

Triquetrum (yellow) Scaphoid (red)

Pisifor m (orange)

Lunate (green)

Ulna Radiu s

Lateral rad iograph o f th e hand w ith ca rpal bones ou tlin ed. There shou ld alwa ys be a coaxial (th ough not necessaril y
paralle l) relationship between th e radius, lunate, capitate, and 3rd metacarpal.

IV
9
IV
10
IV
11
IV
12
IV
13
IV
14
IV
15
 HAND OVERVIEW
AXIAL T1 MR, LEFT HAND

Ex tensor digitorum
communis tendons

Flexor digitorum
pro fundus tendo ns

Radial arter y
Flexor retinaculum

Abducto r digiti minimi Flexor carpi radialis t.

Flexor poll icis lon gus

Ulnar ner ve
tendon
Flexor digitorum
Ulnar artery
superficiali> tendons
Palmar ca rpal ligament
(roof of G uyon ca nal)

R;tdia l artery

Flexor carpi radial is

insertion

Flexo r digiti minimi

Opponens polli cis
Abductor digiti m i nimi
Abd uctor brevis
Ulnar nerve
Flexor ret inaculum
Ul nar artery

Palmaris brevis

(Top) First in series of axial T1 MR i m ages of th e left h and. o te the ulnar artery and nerve in Guyon ca nal. Also
n o te the gh ost ing (pul sation) artifact fro m th e radial artery at the radia l aspect o f the dorsal w ri st. Th is artifact ca n
"'0 occasio nall y h elp locate t h e n ormal va scular structures . (Bottom) Ax ial MR image o f the left hand at the level o f
c h ook o f hamate. No te the thenar muscles origi nating from th e flexor retin acu lum . A t th e level of th e hook of th e
rd
:::c hamate, th e ul na r artery gen era lly passes anterio r or antero medi al to the h ook , whereas the ulnar nerve and i ts
branch es genera ll y pass lateral to the hook.
IV
16
 HAND OVERVIEW
AXIAL T1 MR, RIGHT HAND

Exten sor d igito rum

tendons

Flexor tligit orum

profun dus ten dom

arter y
Flexor retinaculum

Flexor carpi t.
Abducto r digi ti m i nimi

Flexor poll icis lon gu s U ln ar n erve

tendo n
Flexor digitorum U ln ar artery
superficialis tendo n s

Palmar carpa l l igament

(roof of Gu yo n cana l )

Rad idl artery

Flexor carpi

Flexo r d igiti m in i rn i
Oppo nen s poll ici s
Abductor digi t i mi nimi
Abductor polli cb brevi s
U Inar n erve
Hcxor retinaculum
U l na r artery

Palmari s brevis

(Top) First in se ri es o f axia l T l M R i mages o f th e right hand . a te the u l nar artery and nerve in Guyo n can al. Also
note the ghos ting (pul sa t ion ) artifact from the radial artery at the rad ial aspect of t he d orsal w rist. Th is arti fact can
occasiona lly hel p locat e the norma l vascular structu res. (Bottom) Axial M R image o f the right hand at t he level of
hook of h amate. Note th e thenar m u scles originati ng from th e flexor retinacul um . At the level o f th e hook o f the
hamate, the ul nar artery generall y passes an terior or an tero medial to th e hoo k, wh ereas t he ulnar n erve and i ts
branches gen erally pass lateral to th e h ook.
IV
17
 HAND OVERVIEW
AXIAL T1 MR, LEFT HAND

artery

1st dorsa l in terosseu s

3rd pa lmar interosseus

Add uctor pollici

Flexo r digi ti minimi

Abductor digiti m i nimi Flexor pollicis brevis

Oppon en s digi ti Abducto r po llicis brevis

m i nim i
Flexor poll icis lo ngus
Palmari s brevis
tendon
Palmaris lo ngus
i nsertion

3rd dorsal i nterosseu s

2nd dorsal in terosseus
4th dorsal interosseu s
1st dorsal i n terosseu s
Oppon en s digiti
m i nimi
Adductor pollicis
Abductor di gi ti m i nimi
Flexor poll icis brevis
Flexor digi ti m i ni m i Abdu ctor pollicis brevis

Flexor pol licis lo ngus

3rd pal mar i nterosse us
tendon

2nd palmar in terosseu s 1st pal m ar interosseus

Palm ar aponeurosis

(Top) Axia l T1 M R image of th e left h and through t he level o f t h e meta ca rpal h eads. The pa lm a ris longus inserts
o nto th e palmar apon eurosis (a fa scia l layer superfi cial to the flexor re tinaculu m ) and ca n be identified as a mid line
""0 thi cke ning of t h e palmar aponeurosis. lt is a relatively insignifica nt muscle, and as suc h , its long te ndo n is o ften
c::
1\S sac rifi ced for tendo n repa irs at o the r sites. (Bottom) Ax ia l T1 MR image of the left h and th rough th e
:c mid-m etacarpals. At this level, we a re beyond the carpal tunn el, and as such, the muscle inten sity foci adjacent to the
flexor tendo n s (althoug h not labeled o n thi s image) are t he beginn ings of th e lum brical muscles.
IV
18
 HAND OVERVIEW
AXIAL T1 MR, RIGHT HAND

Rad ia I a rlery

1st dorsa l interosseus

Addu cto r po llicis 3rd palmar interosseu s

Flexor digiti minimi

Flexor pollicis brevis Abductor digiti min imi

Abductor pollicb brevis Oppo nens digiti

minimi

Flexor poll icis Palm aris brevis

te ndon
Pal m aris longus
insert ion

3rcl dorsal interosseus

2nd dorsa I interosseu s
4th dorsa l interosseu s
I st dorsal interosseu s

Oppon ens digi ti

m i nimi
Add uctor polli cis
Abductor di giti minimi
Flexo r poll icis brevis
Flexor di giti rninimi
Abductor pollicis brevis
3rd palmar interosseus
Flexor pollicis longus
tendon
2n d pa l mar in terosseus
1st palmar in terosseus
Pal mar apone urosis

(Top) Axial T1 MR image of the righ t hand t hroug h the level of t he metaca rpal h eads. T h e palm a ris lo ngus in se rts
onto t h e palmar a poneurosis (a fascial layer s uperficia l t o th e flexor retin acul um ) and can be identifi ed as a midline
thicken ing of the pa lmar apon eurosis. lt is a relat ively insignifican t muscle, and as such , its lon g te ndon is o ft e n
sacrificed for tendon repairs at o th er sites. (Bottom) Axia l T l MR image of t h e right hand through th e level of th e
mid-metacarpals. At this leve l, we are beyond th e carpa l t u n nel, a nd as such , the musc le int e nsity foci ad jacent to the
flexor tendon s (a ltho ug h n o t labe led o n t h is image) are th e begin nings o f t he lumbrical m uscles.
IV
19
 HAND OVERVIEW
AXIAL T1 MR, LEFT HAND

2nd palmar i n terosseus

Jun ctura tendi nu m 3rd dorsa l interosseus

Ex tensor digitorum Exten sor indicis l.

commun is tendon
Exten sor digitorum
Ex tenso r digiti minim i commun is tendon
te ndon
4th dorsa l interosseus
Flexor poll icb longus
Abduc tor digiti m inimi te ndon

Flexor digiti min im i I st I i nterosscus

3rd pa lmar in terosse us 2n d dorsa l interosseus

1st palmar in terosseus

Lum brica Is

Jrd dorsal i nterosseus

2n d pa l m ar interosseus

2nd do rsal interosseu

4th dorsa l interosseus
1st palma r interosseus
3rd pa l m ar interosseus
Flexor pollicis longus l.
Abd uctor digi ti minimi
Jst dorsal interosseus

Flexor digi ti min imi

Lumbrica ls

(Top) Axia l Tl MR image o f th e left h and through the d i stal metacarpal diaph yses. The juncturae tendinum are
fibrous bands w hich i ntercon n ect th e ex ten sor ten dons o f digits 2-5 just proximal to theM P jo in ts. These fibro u
bands help p revent lateral t ra n slation o f th e exten sor ten do ns over the metacarpals. Because o f th ese
interconnections, d igital ex tensio n can be relati ve ly preserved in the fa ce of a complete tran ectio n o f a si ngle
exten sor d igi to rum com mun is te ndon proxi mal to th e juncturae, and such an injury may n ot be evid ent clin ica ll y.
(Bottom) Axial T 1 M R image of the left han d thro ugh the m etaca rpa l h eads.
IV
20
 HAND OVERVIEW
AXIAL T1 MR, RIGHT HAND

2nd palmar in terosseus

3rcl dorsal i nterosseu s j un ct ura tend i num

Exten sor i nclicis Ex te n so r di gi torum

tendon communi s tendon
Extensor digi torum
communi s tendon Extensor digi ti mi nimi
tendon
4th dorsal interosseus
Flexor pollicis lon gus
tendon Abdu ctor di gi ti minimi

tst dorsa l in terosseus

Flexo r di giti minimi
2nd dorsal in terosseus
3rd palmar in terosseus
1st pa lm ar in terosseus
Lumbrica ls

3rcl dorsal interosseus

2n d pal m ar interosseus
2nd dorsal in terosseus
4th dorsal interosseus
l t palmar i n terosseus
3rd palmar interosseus

Flexor pol licis longus t.

Abductor d igi ti minimi
1st dorsal int erosseus

Fl exor di giti m i nimi

Lu m br ica ls

(Top) Axia l Tl MR image of the right h and th rough the di stal metacarpa l diaph yses. The juncturae tendinum are
fibrous bands wh ich interconnect the extensor tend on s of digits 2-5 just p roxima l to th e MCP join ts. These fibrous
ba nds help prevent la te ral tran slatio n o f th e ex te nso r t endo n s over th e m eta carpals. Beca use o f th ese
interco nn ections, digital exte nsio n ca n be relatively preserved in th e face of a complete transection of a si ngle
extenso r digitorum co mmunis tendo n proximal to the jun ctura e, and such an in jury m ay not be evide nt cli nica lly.
(Bottom ) Ax ial Tl MR images o f the right hand through the m e tacarpal h eads.
IV
21
 HAND OVERVIEW
AXIAL T1 MR, LEFT HAND

Interosseus tendons
beginning to form
Sagittal band lateral bands
Ul nar collateral
Collateral l igam en t liga ment lst digitlP
complex joint
5 th digit extensor
Flexor pollicis longus
tendon (combo of EDC
imertion
& EDM tendon s)
Rad ial collateral
Abductor & flexor ligament 1st digit IP
digiti minimi tendons joint
inserting
Fl exor digitorum
Deep tran sve rse
profundus tendon
metacarpal l igamen ts
Flexor digitorum
superficial i> tendon

La teral band \
Extensor h ood
Extensor digitorum
communis tendon

A2 pulley
Flexor tendons &

Proper d igi ta I
n eurovascul ar bundl es

(Top) Axia l T l MR image of th e le ft hand slig h tly mo re d istall y th rough t he metacarpa l h eads. The la te ral no tches o f
th e MC heads are the si tes of origin of t he coll at era l ligame n ts wh ic h a re the inte rm ed iate signal structu res deep to
"'C th e sagittal a nd late ral ba nds. The deep t ra n sverse me tacarpa l ligamen ts connect t h e vo la r plates of digits 2-5.
c::
(Bo tto m ) Axia l Tl MR image of the left ha nd t hrough the proxima l pha langes. The la te ral bands can be defined as
:r: th e latera l thi ckeni ngs of th e exte nso r h ood, a nd the EDC te nd o n ca n be defined as th e ce nt ra l thicken in g o f th e
ex ten sor h ood. We know we a re stil l in th e la teral ba nds in stead o f th e con jo ined tendo n as we arc still proxi mal to
the PIP jo in ts.
IV
22
 HAND OVERVIEW
AXIAL T1 MR, RIGHT HAND

Interosseus tendons
beginning to form
lateral bands Sagittal ba nd
Ulnar coll ateral Collateral li gament
liga ment l st digi t II' complex
joint
5 th digit extensor
Flexor pollicis lo ngus
tendon (combo of EDC
insertion
&: EDM tendons)
Radial collateral
ligament 1st digit IP Abducto r &: fl exor
joint digiti minimi tendons
inserting
Flexor digito ru m
Deep transverse
profundus tendon
metacarpal ligaments

Flexor digi toru m

superfi ciali s tendon

Latera l bands
Ex tensor hood

E.\tensor digitoru m
communi s tendon

A2 pulley
Flexor tenclom &:
sheat h

Proper digita l
neurovascula r bundles

(Top) Ax ia l Tl MR image o f the right h a n d slig h t ly m o re dista ll y through t h e m etacarpal heads. T h e latera l n o tches
of the MC h eads a rc the sites of or igin of the collate ra l li ga m e nts wh ic h are the intermediate signa l struc t ures deep to
the sagittal and latera l bands. The deep tra n sve rse m etaca rpa l liga m e nts conn ect the vo la r plates of d igits 2-S.
(Bottom) Ax ial T l MR image of th e righ t h and through th e proximal ph ala n ges. The la te ra l bands can be defined as
\he \ateral th ic ke nin gs o f th e exten so r h ood, a nd th e EDC te nd o n ca n be de fin ed as the ce n t ral thickening o f the
extenso r h ood. We know we a rc s till in the late ral bands in stead o f the co n joined tendo n s a s we are sti ll prox ima l to
the PIP jo ints.
IV
23
 HAND OVERVIEW
CORONAL T1 MR, LEFT HAND

Add uctor pollicis

l st Ium b rica I

Oppo nens digiti

minimi Flexor poll icis lon gus
rlexor d igiti minimi ten don

Opponens poll icis

Abducto r digi li m inimi b revis

Hook of hamate Abd uctor pollicis brevis

Base o f I st metacarpal
Pisiform
Trapezi um

Volar plate
3rd l u m brical
2n d lu mbrica l
4 th lu m brical
h t lu m brica l
Fl exor digi torum
profundus t. (Sth)
I st dorsal i n terosseus
O p po nen s digiti
min i mi
Flexor pollicis longus
Flexo r d igi ti min i mi
tendon
Abd uctor digiti mi n imi
Ad ductor poll icis

(Top) Fi rst in series o f coro nal Tl M R i mages o f t he left hand. T h is is located far vo larly. (Botto m ) Coronal T l M R
image o f th e left hand, t hrough t he deeper pa l mar structures. At this level, we happen to catch a port ion of the MCP
vo lar p lates of digit s 2-5 (on ly labeled on the thi rd digit i n th is image). It ca n be determin ed t hat th ese are vola r
p lates by t heir locatio n an d th ickn ess. N o te h ow much thi cker they are compared to th e flexo r tendons.

IV
24
 HAND OVERVIEW
CORONAL T1 MR, RIGHT HAND

Add uctor po ll icis

I st l umbrical

Op ponen s digi ti
Flexo r pollici lo ngus minimi
tendo n
Flexor digi ti m i nimi
O pponens pollicis
brevis Abductor digiti minimi

Abductor pollicis brevis

Hook of hamate
Base of 1st m etaca rpa I
Pisi forrn
Trapezium

Volar plate
3rd lumbri cal
2nd lumbrical
4t h l umbrica l
1st lumbrica l
Flexor d igitoru m
profundu s t. (5th)
1st dorsa\ interosseus
Oppo nens digiti
mi n imi
Flexor po llicis lo ngus
Flexor d igi ti minimi
tendon
Abdu ctor digiti mini mi
Adductor poU icis

(Top) Fi rst in series of co ro na l Tl MR images of the ri ght hand. This is located fa r volarly. (Bottom) Coron al T1 MR
image of the right hand through the deeper pa lmar stru ct ures. At th is level, we h appen to catch a po rtion of t he MCP
vola r plates of digits 2-5 (o n.ly labeled on th e thi rd digit in thi s im age). It ca n be dete rm in ed that th ese a re volar
plates by t heir locatio n an d thi ck ness. Note how muc h thic ker th ey are compared to the flexor te ndon s.

IV
25
 HAND OVERVIEW
CORONAL T1 MR, LEFT HAND

IJ
Uln ar collateral Radial collateral
ligamen t l igam ent

Lateral ban d
3rd dorsal interosseus
fibers co ntributing to M u scu lo tendinous
latera l ban d jun ction o f 2n d dorsal
interosseus
M uscu lotendinous
3rd dorsal interosseus junction o f I st palmar
in terosseus

1st dorsa l interosseu s

4th dorsa l in terosseus

Extensor pollicis longus

tendon

[lJ
Ulnar collateral Radial collatera l
ligament 2nd PIP joi nt ligament 2nd PI P joint

Exten sor d igi torum digitorum

communi s tendom commu nb tendon

Ex tensor polli cis longu;

Exten sor indicis tendon
tendon

Dorsa l su bcutan eous

ve nous plex us

(Top) Coronal Tl MR image of t he left hand through th e metacarpals. Alth o ugh th e dorsal i nterossei are
predominately imaged in thi s plane, some o f the 1st pa lmar in tero seus is visible in th e 2nd interspa ce. You can tell
that thi s is palmar interosseus since it is co n tributi n g fibers from its musculo tendinous junctio n Io the ulnar lateral
band of th e 2 nd digi t instead of th e radial lateral band of t h e 3rd digit (as the 2nd dorsal i nterosseus docs). (Bottom)
Coronal T l MR image o f the left hand (dorsal) dem o nst ra tes a few of t h e exten sor digitorum comm un is tendo n s as
well as th e ex tensor indicis tendo n. N ote that the co llatera l ligaments of the PI P jo in ts (and DIP jo ints as we ll,
al thoug h n o t seen here) do n ot ari se from th e lateral n otches of th e h eads o f th e phalanges as they do in their
IV counterparts (the lateral no tches o f th e meta carpa l h ea ds) at th e M C P joints.
26
 HAND OVERVIEW
CORONAL T1 MR, RIGHT HAND

Radial collateral Ul nar col lateral

ligam en t li ga m en t

Lateral band
3rd dorsal in terosseus
M usculotend i no us fibers con tributi ng to
junctio n of 2nd do rsal lateral ban d
i nterosseus

M u scu lotendi nou s

junction o f 1st palmar 3rd do rsa l in terosseus
i nterosseu s

4th dorsal interosseu s

1st dorsal interosseu s

Extensor pollicis lo ngus

tendon

Radial co l lateral U lnar co l lateral

ligilment 2nd PIP joint ligamen t 2nd PI P joi nt

Ex tenso r digitorum Exten sor digitorum

co mmuni s tendon co mmunis ten don s

Extensor poll icis longus

Extensor in dici s
te ndon
tendon

Dorsal subcutan eous

venous pl exu s

(Top) Co ronal Tl MR image of th e rig ht h a nd through th e m etaca rpa ls. Al th o ugh th e dorsa l interossei are
predom in ately imaged in thi s pla n e, some of the 1st pa lmar inte rosse us is visible in th e 2nd in te rspace. You ca n t e ll
that th is is palmar inte rosse us si n ce it is contribut ing fibe rs from its m uscu lotendinous junctio n to t h e u ln ar lateral :c
!:lJ
ba nd of the 2 nd digi t instead of th e radial la te ral band of the 3rd digit (as the 2n d dorsal inte rosseus does). (Bo ttom) :::s
Coronal T l MR im age of the righ t hand (do rsa l) d e monst rates a few o f th e extensor di gito rum communis tendons as a..
well as th e ext ensor indic is tendo n . No te th at th e collateral ligaments of the PIP joints (and DIP joints as well,
although not seen here) d o not a rise from th e la te ra l n otc hes of th e h eads of the pha langes as they do in th ei r
cou nterparts (th e late ral n o tc hes of th e metacarpa l heads) a t th e MC P joints. IV
27
 HAND OVERVIEW
SAGITTAL T1 MR, RIGHT HAND

Flexor digitorum profundus

Flexor digitorum supcrficialis
i n sertion

Dorsal structure

Abductor digiti minimi

Flexor digiti minimi

Opponens digiti minimi

1J Flexo r cligitorum profundus tendon

Volar plate
3rcl pal mar

E.DC tendo n

4th dor al

Oppo nens digiti minimi

I look o f h amate

]]

Volar p late
Radial a pect 4th metacarpal
h ead

2nd palma r interosseus

3rd
3rdlu mbrica l
Neurovascular bund le o l deep
Flexor tendons palmar arch

ED tendon/ exten sor h ood

(Top) First of six sagi ttal T1 MR images of th e right hand, at the level of th e Sth digi t. The d o rsal tr iangular structure
is a triangular-shaped vascularized fib rous structure o f unknown significance w hich can be identified o n MR and
ultrasound imaging. (Middle} Sagittal T l MR image of the right hand through the level o f th e 4th digit. (Bottom)
Sagittal Tl MR i mage of the right hand obtained between the 3 rd and 4 th digits.

IV
28
 HAND OVERVIEW
SAG ITTAL T1 M R, RIGHT HAND

Flexor digitorum profundu s tendon

Inserti on site o f flexor
digi torum super ficial is
A3 pu l ley

FDS tendo n to 2nd digit

Opponens pol lici s Adductor poll i.cis

flexor pollicis lon gus tendon

Flexor po llici s brevis

EDC tendon /exten sor hood
Abdu ctor pollicis brevis

Inserti on si te for FDS tendo n

EDC tendon/extensor hood

Volar plate

Flexor pollicis longus tendon 1st dorsa l in terosseus

Adductor pollicis
Flexo r po llicis brevis
Opponens po ll icis
Abdu ctor poll icis b revis

[I

FPL tendon
Proximal ph alan x
Sesamoid
Portion of 1st MCP UCL
Flexo r & abducto r pol licis brevis Adductor aponeurosis
muscles

(Top) Sagi ttal T1 MR im age of t he right hand throug h the 3rd d igit. Alt h ough not routinely seen , the A3 pulley ca n
be identifi ed in t his image as a sligh t, focal thickening of the flexor te ndo ns just superficial t o the PI P joint. (Midd le)
Sagittal T1 MR image of the right hand through the 2 n d d igit. Note t he slight pro min ence of low signal on th e vola r
su rface of th e middle phalanx. This is th e in se rtion site of th e fl exor digitorum su pe rficia lis. (Bottom) Sagitta l Tl MR
image of the right hand o btained obliq ue ly through th e th u mb met acarpa l phala ngeal joint. As this is a tru e sagittal
image with respect to th e h a nd, it is an obliqu e p lane m id-way between sagit tal and corona l wit h respect to the true
axis of the thum b (l st digit). As such , the ul n ar as pect of th e MC P joint o f th e thumb is image right.
IV
29
 FLEXOR MECHANISM AND PALMAR HAND
• Flexor pulleys serve to foca ll y anchor tendon sheaths
Extrinsic Flexor Musculature: Digits 2 to volar surface of their respective digits at
through 5 mech anically stra tegic points

Flexor Digitorum Superficialis (FDS) Anular Pulleys D igits 2 through 5

• Origin: Common flexor tendon (medial humeral • Den oted w i th A fo r anular and a number
epicondyle) of elbow and mid-rad ius o umbered 1 th rough 5 from proxi mal to distal
• Inserti on: Volar plates of the proximal interphalangea l • Odd numbered pulleys are superficial to oval parts of
joints as we ll as th e ba ses of the middle phalanges of digits (i.e., joi n ts)
di gits 2 through 5 o Al pulley is located at level o f metaca rpophalangeal
• I nnervation: Median nerve joint
• Superfi cia l is tendo n s split at level o f t he bases o f o A3 pulley is located at level of p roxima l
p roximal ph alan ges, forming two di stinct tendon slips interph alangea l join t
o Sli ps pass circumferentia lly around th e lateral o AS pulley is loca ted at level of distal i nterphalangeal
aspects of flexor digitorum profundus tendon before joint
inserting deep to th e FDP tendon o Odd numbered pulleys attach to underlying volar
o This forms a "tun nel " through which the Flexor plates
digitorum profundus tendon passes • Even numbered pulleys are superficia l to elega nt
o just proximal to thei r insertion level, some fi bers wa ists (mid diaphyses) of phalanges
from each sli p of FDS tendon decussate to th e o A2 pulley is located at level of m id-diaphysis of
contra lateral insert ion site o f the same digit proximal phalanx
• Flexes both the metacarpoph alangeal joints (aided by o A4 pulley is located at level of mid-diaphysis o f
lumbrica ls and in te rossei) and p rox imal distal phalan x
in terph alan geal joints o f digits 2 through 5 o Even numbered pull eys attach to underly ing
periosteum
Flexor Digitorum Profundus (FOP) • A2 an d A4 pulleys are th e m ost important c lini ca lly
• Origi n: Proximal and m id radius, as well as th e (fo r no rmal finger flexio n), an d are the onl y pulleys
interosseu s membrane usually seen on rout i n e imaging
• In se rtio n: Vo lar p lates o f the distal i nterp halangea l • Eva l uation for p ulley ruptu re (wi th M l"l.) h ou ld be
joints as well as the bases of t he dista l ph alanges o f performed w ith the fingers both in extension (as is
digi ts 2 th rough 5 routi ne) an d flex ion
• Innervatio n: U lnar and m ed ian n erves • Pulley injury ca n be identified if discon t inuity of a
• Flexes th e distal in terpha langeal joints, an d to lesser pulley is directly v isualized (which is rare), but is more
ex tent, the metacarpopl;lalangea l (aided by l umbrica l s commonly i n fe rred by "bow tringin g" of flexor
and interossei) and proximal interphalangeal joi nts of ten dons
digi ts 2 through 5 • "Bowstringin g" of flex or tendons refers to an abnormal
increase i n distance between flexor tendons and
Vinculum Breve and Longum
underlyi ng bones du ring flexion
• Vincu lum breve (short) and vincu lum longum (long)
• "Internal" com parison to th e o th er fingers can give
are focal fib rovascular bands which course between
one an idea of the "norma l " di tan ce between the
the flexor tendons and volar surfaces of t h e ph alanges flexo r ten dons an d the vola r bony surface of the finger
• Each o f the fl exor digitoru m superfici alis and fl exor
digi toru m profundus tendon s has o ne v inculu m breve Cruciform Pull eys D igi ts 2 through 5
(distally) and o ne v incu l um longum (proxim ally) • Not iden t i fi ed on rou tine imaging
• Al though no t usually seen on routine imaging, these o Deno ted wi th C for cruc i form and a number
are importan t stru ctures as they provide n utrients (via • Numbered lthrough 3 from proxima l to dista l
small vasc ular chan nels) to the flexor te ndons
Pulley System 1st Di git
• A 1 pull ey: Level of metacarpoph ala n gea l joint
I Extrin sic Flexor Musculature 1st Digit I • Oblique pulley: Runs from ulnar aspect of p roximal
phalanx to radial aspect of distal pha lanx
Flexor Pollicis Longus (FPL) o Crosses interphalangeal joint, so becomes lax in
• Origin : Mid-radius and interosseus m embran e f lexion
• Insertion: Base of d istal phalanx of 1st d igit • A2 pulley: Level of interpha langeal joint
• Innerva tion: Anterior interosseus nerve (branch o f o Clinically, th e m ost impo rtant p ull ey for flex ion
median n erve) of thumb
• Flexes 1st digit in terphalan geal an d • Av pulley: Variab le in posi tion and may be an ywhere
m etacarpophalangeal joi nts over the proxi mal half of the prox imal phalanx

IFlexor Pulleys IThenars and Hypothenars

• Foca l thickenings of fi brous tissue o f the co mmon • Then ars: Opponens poll icis, abductor pollicis brevis,
digital tend on sheaths and fl exor pollicis brevis

IV
30
 FLEXOR MECHANISM AND PALMAR HAND
o Origi n: Al l o riginate fro m the flexor retinaculum • A lth ough often grouped with the thenar muscles (by
and tubercle o f the t rapezium v irtu e of proxim ity), the adductor poll icis is d istinct
• Abductor pol l icis brevis also o ri gi nates from the from t hem , as it is separated fro m t hen ar muscles by a
tubercle of the ca phoid fascia l plane, and i nnervated by ulnar nerve (as
o Insertio n : Abd ucto r poll icis b revis and flexor pollicis opposed to median nerve)
brevis share a combi ned insertio n at the l.ateral base
of the proximal pha lanx o f th e 1st digit
• T he Abd uctor po llicis brevis also con t ributes fibers IPalmar Interossei
to the ex ten sor hood of th e 1st digi t (thumb)
• Deno ted lthrough 3 from rad ial to ulnar
o Insertion: Oppon ens pollicis inserts o n th e proximal
• O ri gin: Mesial palmar diaphyses o f t he 2 nd, 4 th, and
two-thirds of th e vo lar diaphysis of th e 1st
5th metacarpals
metaca rpal
• Insertion: NJesial lateral bands and mesial aspect of t he
o Innerva tio n: All by recurrent bran ch of median
bases o f proxim al pha langes o f the same digit from
nerve
which th ey origina te
o Actions
• I nnervat ion: Ulna r nerve
• The Abd uctor pollicis brevis aids in extensio n of
• Actions: Adduct digits and assists lumbricals with
the joints of th e 1st digit vi a its co ntributions to
fl ex ion of th e metacarpophalangea l join ts and
the ex ten sor hood
ex tension of the i nterpha langeal jo i nts of digits 2, 4,
• Acti o ns of th e th enars are o therw ise as their na me
and 5
implies
• 1-lypoth enars: Oppon en s digiti min i mi , abducto r digiti
minimi, and fl exor digi ti m in imi
o Origin : Fl exor digit i m i nim i and o ppon ens digiti
!Tendon Sheaths
minimi originate from t h e f lexor retina culum and • Commo n flexor sheath (also kn own as the ulnar
the h ook of th e ll amate bursa)
o Origin: Abductor digiti minimi origi nates fro m the o Co ntains the flexor d ig ito rum superfi cia l is and
pisiform profu ndus t en dons
o Inserti o n : Flexor digiti minimi and abductor digiti o Begins just prox imal to th e carpal tu nnel
minimi share a combined inserti o n o n the ulnar o Ex ten ds to just beyond th e level o f the carpa l tu nnel
base of the prox i ma l phalanx of the Sth digit over digits 2 th rough 4
• Abductor digiti minimi al so contributes fibers to o En co mpasses th e St h digit f lexor tendons over th eir
the ulnar lateral band and extensor hood of th e en t ire course (to level of distal in terphalangeal jo int)
Sth digit • Common digital shea th s (d igits 2 th rough 4)
o Insertio n: Opponens digiti min i rni inserts o n the o Enco mpasses the fl exor tendons fro m the level of
proximal and m id d iaph ys is o f th e Sth metaca rpal the m etacarpal necks to the bases of t h e distal
o Innervati o n : All by ulnar nerve pha langes
o Action s o Co mmon digital sheaths may connect to the ulnar
• T he Abdu cto r d igiti min im i aids flexion of t he bursa (common flexor sh ea th) proxi mall y i n up to
metacarpopha langea l jo i nt and ex tensi o n of th e 101Jio of p o pulation
interphalangeal joi nt of the 5th digit via its • T his possible connection is important as it may
contribu tions to th e 5th d igit ulnar latera l band p rov ide a route for spread o f infection from
and extensor hood digits 2 through 4 to common flexor sh ea th (an d
• Acti ons of the hypothenars are oth erwise as thei r v ice versa)
name implies • Flexor pol licis longus tendon sheath (also kn own as
radia l bu rsa)
o Encompasses fl exor pol licis longus t endo n from just
!Adductor Pollicis proximal to th e begin n i ng of th e carpal tunnel to
th e level o f its insertio n (level of interphalangeal
• Com prised of oblique (proximal) and transverse
joint of thum b)
(distal) heads
o It occasio nally co mmunicates with ulnar b ursa
• Origi n: Capitate, trapezoid, 2nd and 3rd m etacarpals
(commo n flexor sheath) at level of ca rpa l tu nnel as a
• Insertion : U ln ar base of the proximal phala nx of t h e
normal va riant
1st digit, 1st d igit interphalangeal jo int volar pla te,
• Th is possible con nection is important as it can
and it contributes fibers to the ex ten sor hood o f the
allow spread of infection
1st d igit (whi ch forms the adductor apo neurosis)
• Ten don sheath s arc l i n ed by synoviu m
• Innervation : Ulnar nerve
• Synovial fluid produced by t h e f lexor sheath synovium
• Acti ons: Adducts the thumb towa rd th e 3 rd digit and
bathes the flexor tendo ns w ith nutrien ts and decreases
aids in extension of the thumb interphalangeal joint
friction for sm ooth tendon motion during flexion
(via its contribution to extensor hood of l st digit)

IV
31
IV
32
IV
33
 FLEXOR MECHANISM AND PALMAR HAND
AXIAL PO FS MR, RIGHT HAND

flase o f 3rd prox imal

Prox im al phalanges -lth
ph ala n x
& 5t h

Flexor digitorum
profundus ten don

Fl exor digitorum
superficialis tendon

A I pulley & flexor --;=-_,.::;--'

tendon shea th
distended with fluid
Flexor tendon s &
ten don

Beginning of A2 pulley
Proxi m;1l aspect
proximal ph alanx 3rd
digit Proxi mal pha la nges -lth
& 5 th d igits
Flexor digitorum - """i'-"=----,
pro fundus ten don

Tend on sh ea th

Flexor digi torum

superficialis tendon Flexor tendons

(Top) First o f six axial PD FS MR images o f th e fingers. T he flexor tendons an d tendo n sh ea ths are often insepa rable
fro m o ne another o n ro utine imagi ng un less o utlined by path o logic fluid (as in the third d igit in t h is example).
(Bottom) Th e FDS tendon splits at the proxi mal aspect o f the proxima l pha lan x as demo n st rated in t h e thi rd digit.
Th e sam e relation ship exists in the 4th digi t in thi s image, but d elineation o f the tendo n s as sepa rate structures is
diffi cult with ou t the pathologic tendon shea th fluid presen t in th e thi rd digit.

IV
34
 FLEXOR MECHANISM AND PALMAR HAND
AXIAL PD FS MR, RIGHT HAND

of 3rd
proximal ph alanx Flexor digi torum
profundus tendon

A2 pu lley
:;;oiiiii!- Diaphysis proximal
pha lanx 4th digit

Flexor d igito rum

profundus ten don

Flexor digi torum

su pe rficialis tend on

Flexo r digitorum
superficia lis te ndon

Co ndy les o f vo lar

aspect of l1ead of Port ion of 3rd PIP volar
proxi m al pha lan x plate

Base of 4th digit

mi dd le phalanx

Dccussilting fibers o f • ...,....,

4..._ Flexor digito rum
flexor d igi to rum superficia I is ten don
superfic iali s tendon i nserti on

Flexor d igi torum

Flexo r d igitoru m profund us ten don
profundus tendon

Prop er digi tal

A3 n ewovascular bun dle

(Top) After th e FDS ten don sp lits, it travels la te ra ll y aro und the FDP tendon fro m superficial to d eep. In t he 4th digit
here, even with ou t path o logic fluid for co nt rast, th e fl exor te ndon s can be seen as sepa rate stru ctures. The A2 Pulley
can be identifi ed by its loca t ion and thi ckness (compare to t hickn ess of tendon sh eath on th e nex t im age). (Bottom )
Jn the 4th digit, the slips of the FDS tendon are begin ni ng to inse rt on th e vo lar aspect o f t he prox imal portion of th e
middle phalanx . In the 3rd d igit, the dec ussation of fibe rs from one slip of t h e FDS tendon to th e other ca n be seen.
ote the vola r bico nd ylar shape of th e h ead of the 3 rd proximal p hala nx vs. t h e oval sh ape of th e base o f 4th middle
phalanx.
IV
35
 FLEXOR MECHANISM AND PALMAR HAND
AXIAL PO FS MR, RIGHT HA ND

Prox imal po rtion o f

3rd digit m iddl e
phalan x

In sert io n o f flexor
digito rum superficial is Mid d iaphysis of ·Hh
tendon digit middle phalanx

Flexor digit orum

tendon

Flexor cl igi to rum

pro fun dus tendon

Flexor digi torum

profundus ten don

Midsh aft middl e

ph alanx 3rd d igit Volar plate

Distal diaphysis middle

Vo lar pla te
ph alan x 4th digit

Flexor cligitorum
profundus ten don

A4 pulley

(Top) In t h e 3rd digi t, the FDS tendon s i n sert on th e vo lar aspect of th e proxima l portio n of t he midd le ph alan x. In
t he 4th digit, we are already beyond t he inserti on of th e FDS ten don, and accordingly, on ly o ne tendon (th e FDP
tendon ) is seen. (Bo ttom) Understa ndi n g th e normal locati on o f the pulleys al lows identi fica t ion of the A4 pu l ley at
the m id shaft o f th e middl e ph alan x 3rd digit. Addi ti on ally, note th at the pulley is t hicker than t he n orma l tendon
sh ea th : Com pa re to prev ious im age w here th e norm al tendon sh eath i s barely (i f at al l) d iscern i ble.

IV
36
 FLEXOR MECHANISM AND PALMAR HAND
SAGITTAL PO FS MR, RIGHT HAND

PIP volar plate: Decu satin g of

Membranous port io n flexor cligi toru m
superficial is tendon
Interphalangea l joint
''oiar plat es: T hi ck
porti on M C P joint volar plate

Flexor cligitorum
superficialis tendon

A4 pull ey
A2 pu ll ey

Flexor digito rum

profundus

PIP joint volar plate A2 pul ley (bracketed)

A.J pulley (brad.eted)

DI P join t vola r plate

Flexor digitorum Flexor digi torum

profundus tendon super ficialis ten don

(Top) First of two sagittal PD FS M R images of 3 rd d igit. T his is the sa me d igit from the p revi ous ax ial series. As
before, path o logic fluid is presen t within and abo ut the co mm o n digital tendo n sheath prov iding excel lent contrast
for del ineation o f n ormal structures. In thi s image, t h e FDS tendon appears discontinuo us; however, remember that
the FDS tendo n spl its and i ts slips pass lateral to the FDP tend o n from just distal to th e M P joint until its
decussa ti o n. Note th e thin membra n ous portion of the volar plate of the PI P jo in t· (not norma lly seen ). In thi s plane,
only the volar-most po rti o ns o f the A2 and A4 pulleys can be seen. (Bottom) Th is image i s sl ightly m o re lateral than
the previous image. In this plane, we see that th e FDS tendon is intact. We arc also just lateral en o ug h to ca tch some
of the lateral portion s of the A2 and A4 pul leys.
IV
37
 EXTENSOR MECHANISM AND JOINTS
IExtensor Mechanism: Digits 2-5 o T his combin ed ex ten sor tendon inserts on dorsal
ba se o f prox imal phalanx o f Sth d igi t and also
Extensor Digitorum Communis (EDC) blends wi th jo int ca psu le of Sth proxi mal
• O rigin: Common exten sor tendo n (lateral humeral interphalan gea l joint
• Inner va ti o n : Posterio r i nterosseus n erve (bra nch of
epicondy le)
radia l ner ve)
o Di stin ct ex ten sor digitorum communis tendon to
• Extensor digiti min imi tendo n s are gen era ll y loca ted
Sth digit is present in only approxi mately SO% of
population sl ig htly ulnar and d eep to Sth digit ex tensor digitoru m
o W hen distin ct St h digit EDC tendo n i s absent, fiber comm unis tendo n (or i ts equiva lent ) at level o f
metacarpo pha langeal joint -
contributio ns fro m 4th digit EDC tendo n and
junctura tendinu m fo rm a "makeshift" Sth digit EDC Lum bricals
tendon • N umbered 1-4 from radial to ulnar
• I nsertio n : Inserts as central sli p o n dorsa l bases of • Origi n : Flexor digi torum pro fundu s tendo ns begin just
middle pha langes and proximal interphalangeal joint distal to ca rpal tunnel
capsules • Inserti o n: Radial lateral bands of d igits 2-5
o just proximal to p roximal interph alangea l jo ints, • I n nerva tion
ex ten sor digitorum co mmu nis tendons trifurcate o 1st and 2nd lumbrica ls: Median nerve
into a ce ntral slip and t wo lateral slips o 3 rd and 4th lumbricals: Ulnar nerve
o Latera I slips each fuse with th ei r adjace nt Ia tera I • Ex tends interphalangeal jo ints and fl exes
band to fo rm conj o ined tendo n s m etacarpophalangeal joints of d ig its 2-5
o Di sruption o f central slip (via lacera tio n o r avulsion)
ca n allow proximal interphala ngeal jo int to flex and Dorsal Interossei
herniate bet ween EDC tendon lateral slips and • N umbered 1-4 from radi al to ulna r
lateral ba nds d uring extensi o n resu lting in a • Origin: Dorsolatera l m etaca rpa l d iaphyses
Bouto nniere deformity • Insertio n: M esial-m ost (in hand) adjacen t lateral bands
• Easy to diagnose when associated with av u lsion of o f d igits 2-4
osseus insertion • Innerva tion: Ulnar nerve
• If articular po rtio n of avulsed fragm ent i s g reater • Extends 2nd -5 th interphalan gea l join ts and abducts
than one-third o f to tal art icular surface, open dig its 2-5
reductio n wi th intern al fixa tion is usually required
• When boutonniere deformity is present Latera l Bands/Conjoined Tendons
without an associated osseus f ragm ent, and • Lateral bands are fo rmed by lum bri ca l and in tero seus
there is n o history or associated findings to m uscle tendo n s
suggest inflammatory arthritis or connective o Exception: Abdu cto r digiti min i mi fo rms uln ar
tissue disease, central slip disruption shoul d be lateral band of Sth d igit
su spected • At level of the distal aspect o f proxi mal
• Innervatio n : Pos terior interosseus n erve (branch of interph alan gea l jo ints, lateral bands fuse w ith latera l
radial n erve) sli ps o f ext en sor digitorum comm un is tendons to form
con joined tendo ns
Extensor lndicis (EI) • At level of the d istal interphalangeal jo int, con joined
• Orig in : Posterior, distal u lna and in terosseus tendo n s fuse to fo rm terminal tendo n s
membrane • Terminal tendo n s insert o n do rsal ba ses of d istal
• Insertion : Ex tensor ind icis tendo n b lends with 2nd p halan ges and fuse wi th distal in terp halangea l jo i nt
d igit ex tensor digitorum co mm uni s tendo n and ca psules o f digits 2-5
ex tensor hood • just p roximal to the level o f distal interphalan gea l
• Innerva ti o n : Posterio r interosseus nerve (bran ch of joints, conjo ined tendo ns are interconnected by a
radial nerve) sho rt band of t ransverse fibers ca lled triangular
• Ex tensor ind icis ten don is generally located slightly liga ment
u l nar and deep to 2 nd digit exten sor digito rum o Triangu lar ligament helps preve nt lateral
communis tendo n at level of me ta ca rpopl 1alan gea l transla tio n /vo lar sublu xa t io n o f con joined tendo n s
joint · • Sudden fo rced fl ex ion of an extended distal
i nterphal angeal joi nt m ay ca use terminal tendon to
Extensor Digiti Minimi (EDM) avu lse its osseus insert io n (a.k.a. ma llet fi nger o r
• O rig in: Common ex ten sor tendo n (lateral humeral baseball finger)
epicond y le) o If articular surface in vo lve ment is greater than
o In most cases, exists as two d istin ct tendo ns over o ne- thi rd o f to tal articular surface, o pen reduction
w rist and Sth metacarpal and interna l fixatio n is genera lly req uired
• Insertion
o Two tendo n s of ex ten sor dig iti minimi fu se with o ne Extensor Hood
anoth er and w ith Sth digit ex tensor digito rum • Begins just proximal to metaca rpoph alangea l joi nts
"0 co mmunis tendo n (if it exists), or, in its absence, and terminates just prox imal to proximal
c: w i th its "makeshi ft" counterpa rt i nterph alangeal jo ints
::c
IV
1R
 EXTENSOR MECHANISM AND JOINTS
• Dorsal hood of fibers o ri ented nearl y perpendicular to
long axis o f ex tensor tendo n s
!Joints
• Fibers o f extenso r h ood interdigitate w ith ex tensor M et acarpophalangeal joints: Synovial
digitoru m comm unis (a nd extensor indicis and digiti
minimi) tendon to help prevent latera l translation
Condylar j oints
• Sagittal band • Allows flexion , as well as minimal ex tension,
o Prox i mal-most fibers of ex tensor hood abduction, and adduction
• Loca ted at metaca rpophalangeal jo int level Inte rphalangeal joints: Syn ovial Hinge joints
o Atta ched to vo lar plate volarl y
• Allows f lex ion and minimal extensio n
o Prevents lateral tran slation of ex ten sor digitorum
co mmuni s tendo ns at metacarpo phalangeal joint Vo lar Plate
level • Constitutes ma jo rit y o f vo lar aspect of jo i nt capsules
• Fibers o f distal portio n of extensor h ood extend over of all rnet<karpophalangeal and i n terp halangeal jo ints
dorsum o f finger from o ne latera l band to opposite • Di stally, volar pl ate is t hick and firm ly attached to
lateral band of sa me digit volar base of adjacen t phalanx
• In ce ntral aspect of t h e thick po rtion of volar plate
(m id-sagi ttal plane) there is a norma l, focal d efect
IExtensor Mechanism 1st Digit known as central recess
o T his sh ould not· be mistaken fo r pathology
Extensor Pollicis Longus (EPL) • Prox im al ly, vo lar p late is thin (mem bra no us po rt ion)
• Origin : Mid-ulna and interosseus membrane and redund ant in o rder to accommoda te full range o f
• Insertio n : Dorsal base of 1st digit distal phalanx mot ion
o AI o interdigitates with fibers o f ex tensor h ood • W ith forced ex tension o r posteri o r d isloca ti on at a
Innervation: interosseus ner ve (branch of metacarpoph alangea l o r interph alangeal joint, vo lar
radial nerve) plate may avu lse
• Extends bo th metacarpophalangeal and o W hen vola r plate avulses i ts o sseus inser tion, an
interphalangeal joi nts o f 1st digit intra-articu lar f racture results
Extensor Pollicis Brevis (EPB) o If articul ar portion o f avulsed fragm ent is greater
than one-th ird of tota l articu lar surface, open
• Origin: Di stal radius and interosseu s mem bra ne
red uction and interna l fixat io n generall y is required
Inserti o n: Dor al base o f 1st digit proxima l phalanx
• Vola r plates of digits 2-5 are attached to one an ot her
o Also interdigitates w ith fibers of ex tensor hood
at metacarpoph alangea l join ts by d eep transverse
Innervation: Posterior interosseus ner ve (bran ch of
metaca rpal ligaments
rad ial nerve)
• Ex tends I st digit metacarpophalangeal joint Collateral Ligamen t Complex
Extensor H ood • Const itutes majo ri ty of latera l aspects o f jo in t ca psules
o f all metacarpoph alan gea l an d interpha langea l joi nts
• Formed by fibers from adductor po llicis u l narly and
• Comprised of m ai n and accessory compo nen ts
abductor pollicis brevis rad ially
• Fibers of both ma in and accessory co llateral l igaments
• Aids exten sio n o f interphalangea l joint
co urse obliquely from dorsa l (proxi mally) to volar
• Adducto r pollicis contributio n to ex ten sor hood is also
(distally); albeit, at slightly different obliq ui ties
known as adductor aponeurosis
• Mai n co llatera l ligament inserts o n vo lar/ lateral base
o Ulnar collateral ligament o f 1st
of n ex t d istal-most ad jacen t phalanx
meta carpop halangeal joi n t is especially pro ne to
• Accessory collateral l iga ment inser ts o n mid to distal
tearing in forced abduction and ex tension
vo lar plate
• Such an injury is common ly referred to as
• Colla teral l igamen ts o f metacarpophala ngea l jo ints are
ga mekeeper's thumb or skier's tllumb
norma lly heterogen eous in signal
o W h en u lnar collatera l ligam ent is torn, the
o Similar appearance of other collate ral l igaments
position of i ts p roximal free end with respect to
should h elp prevent o ne from m ista king this
adductor aponeu ros is is of utmost i mporta n ce
appearance for pathology
• If prox imal portion i s displaced superficial to
adductor aponeuros is,it is referred to as Stener Bare Areas
lesio n , and surgery is usuall y required as the • Intra-articul ar bone not covered by carti lage
displaceclproximal stump will not spontaneou sly • Location of initia l erosions in infl amma tory arthritis
reduce
• At m eta ca rpophalangeal joint, metaca rpa l head is
• If proximal portion remains deep to adductor usually i nvo lved by erosions before adjacent proxima l
aponeurosis, co nserva tive management ma y pha lanx
suffice as in si tu fibros is can provide adequate
stability

IV
39
IV
40
:r
::::s
0..

IV
41
IV
42
 EXTENSOR MECHANISM AND JOINTS
AXIAL PO MR, LEFT HAND

EDC tendo ns
In terosseus tendon s beginning
to form lateral bands

Collateral ligam en t complex

Volar plate Deep transverse metaca rpal

l igam en t
Deep m etaca rpal
li ga m ent
Lumbri ca l m uscles

EDC: tendons

Distal metacarpal h ead 2n d

digit
Base of proximal ph alanx 4th digit

Sagi tta l band porti on of

extensor hood

Volar plate
CollateraI Iiga men t com pi exes
Radial side of A I pulley

Ex ten sor hood

EDC tendon
Lateral ba nd

Latera l band
Proper digital neurovascular
bund le

(Top) First of six ax ial PO MR images o f the fingers. The deep tran sverse m etaca rpal l iga men ts interconnect the vo lar
plates of digits 2-4. o te that the intcro sci pass dorsal and the lumbrical s pass vola r to th e d eep transverse
metaca rpa l liga m ents. T he co llateral ligam ent complexes are in termediate an d som ewhat heterogeneous in signal:
Thi is normal. (M iddle) A lthough a portion of the Al pull ey was captured o n this image, it is n o t common to see
this pull ey o n ro utine imaging. Thi s was t h e o nly image in thi s series to visua lize any of the A l pull eys, and it only
caught a portion o f thi s stru cture. (llottom) The A2 pul leys arc v isible on all digits in this image . The lateral bands of
the 3rd digit arc th e lateral-most thi ckenings of the ex tenso r hood. The EDC tendo n is the central t hickening o f the
extensor h ood. IV
43
 EXTENSOR MECHANISM AND JOINTS
AXIAL PO MR, LEFT HAND

Interco m m unica tio n o f lateral

Radia l co ll ateral l iga m en t
bands & EDC te ndon
com p lex o f PIP

Ul nar co llil teral ligam en t complex --;...;;;,...,;;•

of PI P

Bico ndylar appea rance o f h ead o f

4th prox i mal ph alan x

Interco mmunication o f la teral

l:x EDC tendon
Con join ed tendo ns o njoin ed ten dons

M iddl e phal an x 2n d d igi t

Coll atera l ligam ent complexes

o f PIP 3rd digit

Conjo in ed tendo n s

Trian gul ar l igam ent Tria n gular l igam en t

Rad ial collateral li ga m en t [) I P

Ulnar col late ral l iga m en t D IP 4th 2nd digit
digit

(Top) At th e level o f the distal d i aph ysis o f the 3 rd prox imal phalan x, as th is digi t is lo nger th an the o th ers. In the
4th digit (ima ge left), no distinct thi ckenings to define th e lateral bands o r EDC tendo n can be disce rn ed as th ese
st ru ctures arc sending fiber band contribu tions to one an other. No te that the PIP co llateral ligam ents are relat ively
h o mogeneous and low si gnal, in contradistin cti o n to th e MCP collatera l ligam ents. (M i ddle) Dislal to th e 2nd and
4th PI P jo ints, th e two distin ct fiber bands over the d o rsum of th ese digi ts are t h e co njo ined tend o ns. (Bo ttom) The
3rd digit still sho w s two distinct conjoi n ed tendo n s. T he 2 nd & 4th digits show a co ntin uo us do rsal fiber band whi ch
is th e tri angular l igam ent. As in the PI P joi nts, th e co llatera l li gam en ts o f the DIP joints are relati ve ly h o mogen eously
IV lo w in signal.
44
 EXTENSOR MECHANISM AND JOINTS
CORONAL PD FS MR, LEFT HAND

Dl P coll ateral
liga m en ts

Proper digital
neurovascular

PIP colla tera l

l igament!>

MCP lateral collateral

ligaments

Close-up co ro nal PD FS image centered on the 3rd digit w h ich shows t h e d i ffe ren ces i n t h e co llatera l liga men ts of t he
MCP joint co mpared to the interpha langeal joi n ts. Th e co llateral l iga ments of t h e MCP join ts are thicker and more
heterogeneous an d intermediate in signal th an the collatera l ligaments of th e in terpha langeal joints. ote the very
small amoun t of no rmal fluid in th e interphalangeal jo in ts. A small amoun t of fl uid ca n also be normally seen in the
MCP ioinls de pite nol being dcn1o nstratcd on this image.

IV
45
 SECTION V: Hip and Pelvis

Hip and Pelvis

Hip and Pelvis Overview 2-63
Text 2-4
Grap hi cs 5-8
Rad iograp hs 9-15
Axial MR seq uence 16-32
Sagittal MR sequ ence 33-51
Coronal MR sequence 52-63
Measurements and Lines 64-69
Text 64-65
Rad iograp hs with measurements 66-69
Anterior Pelvis and Thigh 70-93
Text 70-71
Grap hi cs: Symphysis pubis 72
Ax ial MR sequence 73-80
Co ro na l MR sequence 8 1-87
Sagittal MR seq uence 88-93
Lateral Hip 94-125
Tex t 94
Gra ph ics 95
Ax ial MR: Exte rn al ro tators & cuff 96- 105
Sagittal MR: Externa l rota tors & cuff 106-1 18
Coronal MR: Externa l rotators & cuff 11 9-1 25
Posterior Pelvis 126-165
Text 126-127
Graphics 128-130
Axial oblique MR: Sl jo ints 131-1 40
Coronal obliq ue MR: Sl jo ints 141-153
Sagittal MR: Grea ter sciatic no tch 154-1 58
Axial MR: Sciatic nerve 159-162
Co ronal MR: Scia ti c nerve 163-165
Hip Joint 166-189
Text 166-167
Graphics 168-169
Art hrogram L70
Axial MR arthrogram 171-1 75
Oblique ax ial MR arthrog ram 176-180
Coro nal MR arth rogram 181-184
Sagittal MR arthrogram 185-1 89
Thigh
Thigh Ove rview 190-279
Text 190-192
Grap hics 193-20 1
Rad iographs 202-203
Compartments 204-205
Axial MR sequence 206-257
Coronal MR sequence 258-267
Sagittal MR seq uence 268-278
Grap hics: Dermato m es 279
 HIP AND PELVIS OVERVIEW
o Lesser troch an ter : o nical projectio n ari ing
!Terminology posterio r medial p rox imal diaphysis
Abbreviations • Cl inica l note: En face vi sualiza ti o n o f lesser
• A nterio r superi o r iliac spin e (AS IS) trochanter o n radiograph s i ndica tes femo ral
externa l rotatio n
• Avascular necrosis (AV )
• Posterior superio r il iac spine (PSIS) o Intertrochanteri c line: Anterio r ridge con nect i ng
• Stru ctu re suppl ied by ner ve or artery (S) trochanters
• Slipped capital femoral epiphys is (SCFE.) • W inds under lesser t roch anter & continues
• Sacroiliac jo int (SI) posteri orl y as spi ra l line
o In te r t rochanteri c r idge/ crest : Con nects t rochan ters
posterio rly
o Lin ea aspera: Ri dge along posterio r femo ral
!G ross Anatomy
d iaph ys is
Overview • Divid es prox im al ly i n to m edial & lateral lips
• Pelv ic ring com posed of sacru m, coccyx, hip bon e • Medial lip ble nds with spira l line
o Arti culations: Lu mbosacral , sacrococcygeal, • La teral lip b lends w ith gl utea l tube rosi ty
sacro il iac, sym ph ysis p ub is • D istally d i vides into supracondy lar li nes
• Transmits body weigh t to lower ex t remi t ies & absorbs o Piriformis (tro ch anteri c) fossa: Deepening
fo rces from lower ex tremity posteri o rl y bet ween g rea ter trochanter & femo ral
• Anterio rl y til ted neck
o Pelv ic in let 50° from hori zontal • I nsertio n si te o f hip ex ternal rotato rs
o ASJS & anterosuperi or pubi s al o ng sa me vertical axis o Cond yles (see "Kn ee Overview" sectio n )
• Acetabulum faces in ferom edially • I lium
o Acetabular no tch opens inferi o rly o T h i n ala & 2 large columns
• Pattern o f ossifica t ion o Con cave intern al i l iac fossa
o 3 primary cen ters: Ischium, il iu m , pubis o Con vex ex tern al au r ic ula r surfa ce (glu teal fossa)
• j o ined by t riradiate ca rtilage; m atures 15- 16 y/o o Arcuate line marks inferio r aspect il iac fossa
o 5 secondary centers: Iliac crest , an teri o r inferi o r iliac o Superi o r iliac crest w it h overhangi ng ex tern al lip
spine, ischia l tu berosity, pubis, AS IS ex tends fro m AS IS to pos terio r su peri or iliac sp ine
• Begi n ossi fica tion puberty, ma ture 20-25 y!o • Tubercle o f ili ac crest at an terosuperior m argi n
• Hip bo n e: Isch i um, ili um, pu bi s o Anterio r protu beran ces: An terior super io r i l i ac
o Articulati o n : Bal l and socket hi p joint (sec "!li p spine, anterior inferior iliac spi n e
j oint" sect ion) • Shallow no tch between
• Anatom ic boundaries between pelvis & lower limb: o Posterior protu beran ces: Posteri or superi or iliac
Ex ternal su rfaces pelvic bon es/sacru m/coccyx, iliac spi ne, posterio r infer ior iliac spine
crest , inguinal li gam en t, sym ph ysi s pubi s, ischiopubic o Form s 2/5 acetabul um
rami, isch ial tuberosity, sacrot u berous ligam ent o C l in ica l no te: Usc su perio r aspect il iac crest o n
ph ys ica l examinati o n or rad iograph s to identify t he
Bon es L4/5 level
• Coccy x • Ischium
o Tri angular shape o V-sh aped bo ne w ith bod y & ramus
o 3-5 rud imen tary ve rtebra o Apex is i schia l tuberosi ty
o Coccygeal co rnua ar ti culates w ith sacrum o Isch ial spine: Oriented posteromedial ly
• Femur • Greater sciatic no tch above (see "Poste rior Pelvis"
o Femo ral h ead i s 2/3 sph ere sect io n)
• Central car ti lage vo id at fovea ca piti s • Lesser scia t ic no tch below (sec "Pos terio r Pelvis"
o Neck co nnec ts sh aft, h ead sec tio n)
• Narrowe r n ca r head, wider near t roch an ters o Ram us jo ins in fe rio r pubic ramus fo rming
• Al lows shaft to clear acetabu lum & pelvis du ri ng isch iopubic ramus
mot ion o Bod y fo rm s 2/ 5 acetabulu m
• Subcapital regio n : Head-neck junct ion o C lin ical no te: In seated position i chia l tuberosities
• Basi cerv ical regio n : Base o f neck bear all body weight
o Sha ft: Ci rcular cross secti on w i th t hick ridge • Pubi s
posterio rl y (linea aspera) o Bod y & 2 rami
o Fem o ral n eck/shaft angl e (angle of inclination ), (see o Bodi es m eet midline at sym p h ysi s pubis (sec
IJl
"M easurem en ts and Lin es" secti on) "A nterior Pelv is and T h igh " section)
> • Sm aller i n women secondary to w ider pelv is o lliopubi c (i liopectineal) eminen ce at ju nct ion with
(J,)
c.. o Femo ral an teve rsio n/ to rsio n angle/a ngle of ili um
"'C declin at ion : Anteri or angulati o n neck relati ve to o Inferior ramus par t of ischiopubic ram us
c sh aft (see "Measu rem ents an d Li nes" section ) o Pu bic crest alo n g an terior superior border o f
o Greater troc ha n ter : Lateral fa cin g ex tension from sym ph ysis & pubic bod ies
a. su perio r fem u r o Pubic tubercle: Lateral aspect pubic cres t
:r:: • Attachmen t i nguinal ligam en t

v
2
 HIP AND PELVIS OVERVIEW
o Pec te n : Latera l ridge along su peri or ramus fro m o I n ferio r gluteal v . travels with artery, drains into
pubic tubercle to arcuate li n e internal ili ac v.
o Body is 1/ 5 aceta bulum • Obturator a rtery: Bran ch anterior d iv isio n in terna l
o Clinica l no te: llio pubi c eminence is common site of il iac a.
insufficien cy fracture o Travels latera l pelvic wa ll; lateral to ureter, ductus
o Clinica l no te: Il iopectinea l thi ckening is often first deferens, peri to n eum
si te of Paget d isease o Leaves pelv is via obturator cana l, en ters media l
• Sacrum thigh
o Triangular, co ncave an terior, con vex posteri o r o Acetabular branch via ace tabu lar notch to
o Contains 5-6 fused rud im enta ry verteb ra (va riati o ns liga mentum fovea cap i ti s
of Sl segmentatio n are com mo n ) o 20% incidence aberrant art ery from i nferio r
o 4 ridges & 4 anteri o r (ventral) n eural fo ram i na epigastric a.
• Ridges re mnants interve rtebral d iscs o Obturat or v. w ith a., drai ns i nto i nterna l il iac v.
• C lin ica l note: Sacral a rcs are superior ma rgin • Superio r g lutea l a rtery : Contin uatio n posterior
fo ramina; 2-3 should be v isible, sho uld be di vision internal i liac a.
symmetri c; ab ence indicates destructi ve process o Passes bet ween lumbosacral trunk & Sl n.
o Sacra l al a (wings): Lateral aspect o Exits pelv is superio r to piri fo rm is m.
o Lami na fu sed po teriorly; cove r spin al ca nal o Divides
o Media n sacral crest: Fusion sp ino us processes • Su per ficial: S - g l uteu s ma xim u s m .
except SS +/- S4 • Deep : S- gluteus med i us & min i mus m., tensor
• I ncom p lete fusion crea tes sacra l hiatu s fascia lata
o In termed iate sacra l crest: Fu sio n arti cular processes o Su perior g lu teal v.: Travel s w ith artery, drain s i nto
o Lateral sacral crest : Ti ps fu sed transverse processes inte rnal iliac v.
o Sacra l co rnua: Inferio r arti cula r facets SS
• Articulate with coccyx (may be f ib ro us or fused)
Nerves
o Latera l surface: Art iculate with ilium • Pre-ax ial : Anterior to bone
• Anteri o r auricular surface, syn ovia l arti culation • Pos t-ax ial: Posterior to bone
• Posterio r synde mosis, inserti o n interosseous • Lu mbar plexus: Ve ntral rami Ll , L2, L3, po rtion of L4
ligaments o f-o rms al ong anterio r transverse p ro cesses with in
o Sacra l p romo nto ry: Anterio r superio r projection Sl psoas major m.
o Lumbosacra l a n g le: 130-160° o Branches: Il iohypogastr ic: Ll ± Tl2; ilio ingui na l : Ll ;
genitofem ora l: Ll, L2 (pre-axial ); lateral femo ral
Muscles cutaneo us: L2, L3 (pos t-axial); o bturato r: L2, L3, L4
• Anterior femo ral muscles (see "Anterior Pelv is and (pre-ax ial ); accesso ry obturator: L3, lA (pre-axial );
Th igh " and "Th ig h Over view" section s) fem o ral: L2, L3, lA (post-ax ial)
o Kn ee ex ten sio n & weak hip fl exio n • Obtura to r & fe mo ral n s. (see "T h ig h Overv iew'"
• La teral femora l (glutea l) muscles (see "Lateral I li p" sect io n)
secti o n ) • Sacral plexu s: Lumbosacral trun k (descending L4,
o Hip abductio n & ex tern al ro tati o n anterior ramus LS), Sl , S2, 53
• Medial femora l muscles (see "Thigh Overview" sectio n ) o Fo rms anterio r surface p i ri formis & coccygeus m s.
o Hip adducti o n & wea k internal rotatio n, flexion o Branches
• Posterior fem o ral muscles (see "Thi gh Overv iew" • Scia tic n. divides i nto tibial n.: L4, LS, Sl , S2, S3
secti o n) (p re-axia l); co mmo n peroneal n.: L4, LS, S l , S2
o Hip extensio n & kn ee flex io n (post-axial); (see "Posterio r Pelvis" section)
• M uscular b ranches: Pi riform is: Sl , S2; leva tor ani
Vessels & coccygeus: S3, S4; quadra tus fe mo ris & inferior
• Femoral arter y: Continuatio n ex ternal i li ac a. after gemellus: L4, LS, SI ; obtura to r intern us & superi o r
passing beneath inguina I I iga men t gemeJlus: LS, S I , S2
o Bisects femoral tr ia ngle, enters adducto r ca nal, • Superio r gluteal n. : L4, LS, Sl ; inferio r gluteal n.:
traverses adducto r hiatus, becom es po pliteal a. LS, Sl , 52; posterio r femora l cutaneous n.: Sl, S2,
o Femoral vein : o ntinuation poplitea l v. in adductor S3; perfo rating cutaneous n .: S2, S3; pudendal n .:
hiatus S3, S4; pelvic splanchnic n .: S2, S3, S4; peri neal
• Becomes ex ternal il iac v. at inguinal ligamen t b ran ch 54
• fem o ral v.; part of deep • See "Posterior Pelvis" section
venous sys tem • Coccygea l plexus: S4, SS, coccygea l n s.
o See "Thi gh Overv iew" sect ion o Supplies coccygeus & leva to r ani m s.
• In ferio r g lutea l a rt er y: Larger terminal branch o Branch: Anococcygeal n.
anterior division internal iliac a.
o Passes between l & S2 o r S2 & S3 Other
o Exits pel vis through cia tic notch inferi or to • Fasci a lata: Fascia encasing entire thigh
pi rifor mis m. o Su perio rly attached to ingui nal ligament
o Posteromedial to scia ti c n. o Iliotibia l tract is latera l t h ickeni ng
o S: Pelvic diaph ragm, piriformi s, quad ratus femo ris, • Attach m ents: Tubercle o f iliac crest & lateral
upper ham string & gluteu s maxi mus 111. , scia tic n . cond yle ti bia

v
3
 HIP AND PELVIS OVERVIEW
• Insertion site portions of gluteus maxi m us & o AP
tensor fascia lata m s. o Judet, obturator, or i n ternal oblique: Patient 45°
o Lateral intermuscular septum separat es vastus anteri or oblique
lateralis & biceps femoris ms. • Vi sualizes posterior acetabular ri m, anterior
o Medial intermuscular septu m separates add ucto r acet abular column, obturator forame n, Sl jo int
muscles & vastus medialis m . o Judet, i liac or externa l oblique: Patient 45° posterior
o Saphenous opening for saph enous v. oblique
• G lutea l fasci a (aponeurosis): Between iliac crest & • Visualizes anterior acetabular rim, posterior
gluteus maximus m. acetabular col umn, iliac wing, ischial spine
• G reater (false) and l esser (true) pelvis o Inlet: 40-50° ca udad tube angulation
o Di vided by pelvi c i nl et • Visualizes rotationa l & anterior to posterior pelvi c
o Greater pelvis: Part of abdo min al cavity align ment
• Obtura tor foram en : Covered by o bturator membra ne o Outlet: 35-40° cranial tube an gulation
o Boundaries: Pubis, ischium , superior pubic & • Visualizes superior to in ferior pelvic alignment
ischiopubic rami o Sacrum: AP 35-40° cranial tube angulation
o Redu ces weight of pelv i s • En face v iew sacrum & L5-S I d isc space
o Obturator cana l : Ob turator a., v., n . thru o Coccyx: AP 15° caudad angu lation
membrane o Sacrum and coccyx: Lateral
• Pel vic inlet: Pelv ic brim, sacra l pro monto ry, sacral ala, o Sl joints: AP, 30-35° cran ial tube angula t ion
li n ea termina l is (arcuate line of il ium, pecten p ub is, o Sl joi nts: Oblique; patient 25-30° posterior oblique
pub ic crest) • Radiographs: Hip (unless otherw ise indicated cassette
• Pelvic o utlet: Pubic arch , isch ial tu berositi es, ho ri zon tal to floor, tube perpendicu lar to floor, patient
sacrotubero us liga men t, tip of coccyx supine, legs extended)
• Teard ro p : Osseous margi n s isch ium at anteroinferi o r o AP
fossa o Frog lateral: Supine, kn ees & hips flexed , hip
externally rotated, soles of feet togeth er
• Visualizes femoral head & upper femur
11maging Anatomy • Used in ped iatrics, eva l uation AVN, SCFE
o Ax io lateral, shoot thru lat era l, trauma latera l, gro in
Femur lateral: Supi ne, opposite leg eleva ted/flexed, casse tte
• Compressi ve & tensile t rabecular pa ttern upper femur verti ca l parallel femoral neck, tube parallels table &
o Princi pal compressive: Medial cortex neck to perpendi cular to cassette
su perior femora l head • Keeps in jured leg immobile
o Secondary compressive: Medial co rtex shaft i n feri o r • Eva l uate suspected femora l neck fracture
to princi ple co mpressive trabecula o Lauenstein latera l : Patient teep lateral affected side
o Principal tensile: Latera l cortex below grea ter d own, affected h ip/ kn ee flexed
trochanter to inferior femora l head • Eva l uate non traumatic conditions femoral head,
o Secondary tensile: La tera l cortex below pri nciple proximal fem ur, i .e., arth ritis
ten sile, co urse ad jacent to prin cipal te nsile, o False profile: Affected side 65° posterior oblique
term in ate after mi d neck • Evaluate an te rior fem o ral acetabular coverage (see
o Greater t rochanteric: Lateral cortex to superior "M easurements and Lin es" section)
cortex greater t rochan ter; tensile • CT
• Ward tria n gle : Bounded by prin cipal com pressive, o 5 mm thick reconstructed ax ial images entire pelvis
secondary compressive, tensil e tra becul ae o 2.5 mm th ick reconstructed ax ial images through
• C lini ca l note: Trabecu lar pattern & Wa rd trian gle hip joint
exa mined to assess ex tent of osteoporosi s • Intra-arti cu lar fragments/bod ies especially
post-trauma
Acetabulum
• Contrast: Air for bodies, ai r+ contrast fo r cartilage
• Conceptualize as in verted Y o 1-3 m m thick corona l and sagittal reconstructions
o Stem: Ilium o 30 imagi ng for fractu res especially acetabulum
o Anterior colu mn : Jliopubic column
• MR
• An teri o r iliac crest to pub ic symphysis o Fluid sensi ti ve sequence to screen entire pelvis;
• Radiographs: Ili opecti nea l li ne coronal plan e p referred
o Posterior col umn : Ilio i sc hia l co lumn • FOV: 32-44 em ; THK: 5-8 mm
• Ilium from top scia tic notch to inferior isch ium o Tl & fl uid sen sit ive sequences painful side
• Radiographs: llio ischial lin e
• Use surface coi l
• FOV: 14-26 em, THK: 3-5 mm: Matri x 256 x 256
• Sagi ttal, axia l, coron al, o bliqu e axia l planes
!Anatomy-Based Imaging Issues • Arthrograph y, CT arthrography, MR arthrography,
Imaging Recom m endations iliopsoas bursography (sec "Hi p joint" section)
• Radiograph s: Pelvis (un less otherwi se i n d icated
cassette h orizonta l to floor, tube perpen dicular to
floor, patient supi ne, legs ex tended )

v
4
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5
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6
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7
v
8
 HIP AND PELVIS OVERVI EW
AP P ELVIS & AP HIP RADIOGRAPHS

L4 vertebral body

LS verteb ra l body Il iac crest

Sacral ala Posterior superio r iliac

spine
Sacroi liac joint
Ante rio r supe rio r iliac
sp ine
Sacral arcs
Pelvi c brim
Ischial spine
Medial wa ll
acetabulum llioischial line
An terio r acetabular rim
Posterior acetabular
Superior pubic ramu s rim
Obtura to r fo ra men Iliopectineal line
Inferio r ramu s
Symphysis pubis
Ischial tuberosity

Anterior superio r iliac

sp ine
Sciatic notch
Anterior in fe rio r iliac
Supraacetabula r ilium spi ne
Acetabular roof

Fovea capitis Femo ral head

Femoral head / neck
junction
Tea rdrop

Subcapital region
Greate r trochanter
Basice rvical region
Intertrochanteric
region
Lesser trochanter
Subtrochanteric regio n

Femo ra l di aphysis

(Top) AP radi og raph of t h e pelvi s. Not e contin u ity be tween t he seco n d sacra l a rc and the p e lv ic brim . Disrupti on of
this continuity is a sign of ma lalignment. The symphysis p u b is has a norm a l appea ran ce. Multiple b o n y prominences
are visibl e: Ante ri o r su perior & inferior ilia c spi n es, poster io r superior il ia c spine, isch ia l spine , & pubi c tube rc le. The
iliac crest extends fr o m posteri o r to anterior superior ilia c sp ines. The acetabular rim s are v isib le . (Bottom) AP
radiograph o f the h ip . T he s upra-a cetabu lar iliu m is above t h e acetabu lar roof. The thin m edial acetabul a r wa ll
ove rl aps the ilio ischialline . The teardrop is present a t th e in fe rior aspect of t h e media l wal l. T he regions of the
femora l neck a re the sub capita l region at the head -neck junction and the ba sicerv ical reg ion adjacent to th e
intertroch a nteric re gi o n. v
9
 HIP AND PELVIS OVERVIEW
LATERAL HIP RADIOGRAPHS

Sciatic n o tch

Su p raacetabu lar i li um A n terior inferior iliac

spi ne

Posterior acetab ular

rim
An terio r aceta bu lar ri m
Fem o ral head/ neck
M edial wall junction
acetabulu m
Greater trochan ter
Teardrop

Subca pital region

Lesser t roch an ter

Su btrochan teric region

Fem oral diaphysis

Anterior inferior iliac

Acetabula r roof -+------=:=='--------- pi ne

Posterior acetabu lar -+---="""'=""---------•

r im Hernia tio n pi t

Grea ter t rochan ter

Ant erior acetabular ri m

Isch ial spi ne - +-- Fem oral n eck

'"'----.:...._--------+-- Lesser t ro chanter

Ischi al tubero sity

(Top) Frog late ral radiograph of t he h ip. The greate r troch a nte r and fe mo ral n eck ove rla p. The fe mo ral neck and
sha ft are in a st ra igh t line. As a resu lt of th e exte rnal rotatio n the anterior aspect o f th e femoral h ead is visible a n d
the lesser troch anter is see n in profile. (Bottom) La ue n stein lateral of the hip. Similar to th e frog late ral thi s view is
obtained with poste rior obliquity of t h e pelvis. Slightly diffe re nt pro fi les o f th e greater t roch anter a n d fe m o ral neck
are presented. The ante ri o r aspect o f the fe mo ra l head is well assessed. T he re lationsh ip of the acetab ular rims is
reversed d ue t o th e obliq uity. Note t h e h e rn iat ion pit, located at th e a nte ro latera l aspect of the fem oral n eck. T hese
v ma y be see n normall y, o r be a part of the findings in fe mo ral acetabula r impin gement. This view is freq ue ntl y used
il} th e workup o f t hi s synd ro m e.
10
 HIP AND PELVIS OVERVI EW
LATERAL HIP RADIOGRAPHS

Femora l head

Femoral neck
Pubic ramus

Anterior rim

Su perior rim
Fem oral di aph ysis
Pel vic brim
G reater t rocha nter

Poste rior rim Lesser troch anter

Ischial tuberos i ty

Il iac crest

Iliac wi n g

Sacroi l iac joi n t

Anterior su perior iliac
spi ne

Greater sci ati c notch

Acetabular margin An terior in ferior il iac
spin e
Acetab ul ar roof
Greater troch anter
Acetabul ar fossa

Lesser troc hanter

(Top) Axio late ra l v iew of the hi p most commonl y used fo r suspected fracture o r eva lu atio n o f acetabu lar version after
total hi p replacemen t. The prominence of the ischial tuberosity iden tifies the posterior aspect of the hip. Close
inspectio n wil l reveal th e tria n gula r ma rg ins o f th e anteri o r a nd poste ri o r acet abu lar rim s. Th e superior rim is seen
extending from a nterior to posterior rim. The lesser troc ha nter is a post e rior struct ure and the greate r trocha n ter
overlaps the fe moral n eck. (Bottom) False profile view o f the le ft hi p used to determi n e anter io r acetabu la r coverage
(see "Measu rem ents and Lines" sec tion). Th e anatom y is similar to the iliac oblique view although th e obliq u ity is
greater o n this view (65 vs . 45 d egrees). The a nte rio r-most m argin of the acetabular roof is seen and is a landmark for
measurement. v
11
 HIP AND PELVIS OVERVIEW
RADIOGRAPHS, JUDET VIEWS

I liac crest

Sacroiliac joint
Anterior column

I li o pectineal junction

Superio r pubic ramus

Posterior ri m
Obturator fora m en

Inferior ramus
Isch ial tuberosity

II iac crest

Iliac wing

Sacroi liac joi nt

Posterior co lumn An terior rim

Isch ial tuberosity

til

>
Q)
0..
"'0 (Top) Obturator (left anterior) obl iq ue o f t h e left h i p (iliac oblique ri gh t hi p) . On this v iew the an teri o r o r
c:: il io pectin eal col umn of th e acetabulum is seen in profile. Th e posteri or acetabular rim is well v isualized. (Bottom)
rtl
Iliac (left posterior) obliqu e o f the left hip (obturator oblique right hip). T h e posteri o r (il ioischia l) col umn is p rofiled.
c.. The isch ial spin e pro t rud es from the poster ior column (cen ter limb of label). T he anterio r acetabular ri m is well seen .
:c Each oblique o f the pelv is is an o bturator ob lique for o n e hi p, i liac ob l ique fo r th e o ther hip. For each h i p o ne
anteri o r and o ne posterior structure is p ro fi led.
v
12
 HIP AND PELVIS OVERVIEW
RADIOG RAPHS, INLET/OUTLET VIEWS

II iac crest
LS transverse process

Sacroil iac joi nt

Sacra l ala
Anterior inferior il iac Posterior superior i l iac
spi ne spine
Pelvic brim M edi al wa ll
acetabulum
Superior pubic ramus
llioischial l in e
Posterior ri m
Symphysis pubis
Obturator forame n

In ferior ramus Ischium

Isch ial tuberosi ty Pu bic arch

Posterior superior iliac

spine

Sac ral promon tory Sacra l ala

1st sacral arc

2nd sacra I arc
II iac crest

Pelvic brim
Coccyx

lsch ia I spine A n terior superio r iliac

spine

I nferior pubic ramu s

Superior pubic ramus

Symph ysis pubi s

(Top) Outlet view of th e pelvis used for dete rmini ng superior to inferior d isplacements. On this radiograph n ote the
relationship between th e medial wall of the aceta bulum and the ilioischial line. The pubic arch is well demonstrated
in th is projecti o n . Th e arch is along the inferior m argins of the inferior pubic rami. The pubic angle is th e angle
between the two inferior ra mi. (Bottom ) Inl et view of th e pelvis is u sed to assess an te rior t o posterio r a lignmen t
with in th e pelvis. T he pubic rami are near ly superimposed. The infe ri o r ram us is slightly posterior t o the superior
ramus. The an te rior and posterior iliac spi nes a re well seen and th e iliac c rest between the two spines is laid out. Note
continui ty betwee n the second sacral a rc and the pelvic brim .
v
13
 HIP AND PELVIS OVERVIEW
RADIOGRAPHS, SACRUM AND COCCYX
r---------------------------------,

Disc remnan t
Sacral ala - - - 1 f - - - - - - -

1st sacral arc ---1;=...-------- l st n eural foramen

2n d neural foramen

3rd neural foramen

4th n eural foram en

Sacrococcygea l jun ction

Coccygeal segments

Posterior superior i liac spine

Spinous processes 1st sacral arc

2nd sacral arc

3rd sacra l arc

Ped icle

Sacrococcygea l junctio n 1st coccygeal segment

2nd coccygeal

Iliac crest

f used posterior clem ents

Sacra l promontory

Posteri or inferio r iliac spi n e

Grea ter sciatic n o tch

An terior i nferior iliac spi ne

Isch ium
Sacrococcygeal jun ction
Ill
>
Q)
l:l.
"'0 (Top) AP sac ra l radiograph . Each sac ra l seg me n t is visua li zed with disc remna n ts betwee n eac h segme nt. The nerve
cCo;:! roo t exits be low its respective segm e nt just as in th e lumbar spine. The n e ural fo ramina a re ea ily app reciated . The
sa cra l a rcs a re th e superior m a rgins o f eac h neura l fo ramina. (M iddle) AP radiog rap h of the coccyx . The coccyx is
0.. pro jected above t h e ante rio r pelvic structures. Three coccygeal segme nts are visible. In t hi s pro jection th e pedic les
:r: a n d spino us processes of the sac ra l segm ents a re visible. Looki ng past the sac ru m the pos te rio r su perio r il iac spine is
prese nt. T he posterio r inferio r ili ac spine is n o t easil y ide ntified on radiogra ph s. (Bottom) Late ra l v iew o f the sacru m
a n d coccyx . The e ntire pelv is is visib le. The fused pos terior ele me n ts can be app reciated . T h e greater sciatic notch is
v ni cely d em o n stra ted.
14
 HIP AND PELVIS OVERVIEW
RADIOGRAP HS, SACRO ILIAC JOINTS

join t

Iliac articular synovial joint

iiii==:::-====r- Sacral articular surface, synovial
jo in t

Posterior iliac spine -i=---..:=

Posterior joint -;=---- Syn ovia l joi n t
A nt erior joint - f . - - -

Syndesmotic join t

Sacral articular \urface, syn ovial --1-........:::::::;r:--=---,...:---==

jo int Iliac articular syn ovia l
join t

(Top) In the left posterior obl ique (right anteri o r oblique) the righ t sacro iliac joint i s profil ed and th e articular
surfaces delineated . Th e diagnostic usefulness of th is view is li mited. (M iddle) AP radi ograph o f t he sacro i li ac joi nts.
Two joints are v isible. T h e lateral proj ec ting joint is the an terio r aspect of the joint, whi le the medial projecting jo in t
is the posteri o r aspect of the jo in t. T h e superior 1/3 of th e joint is syn desm otic. It appears as a w ide ned "jo i nt" and
the articular surfaces are n o t con gruent. ote the irregular but reciproca l contours of the articu lar surfaces of the
synovial po rti o n of th e joint. Thi irregularity con t ributes to stability. Th is anatomy is discussed in the "Posteri or
Pelvi "sectio n . (Botto m ) In the right posterior oblique (left an terior obliqu e) position th e art icular surfaces of the left
sacroi liac joint are profil ed. v
15
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, UPPER PELVIS

External ob lique
aponeuros is

I n ternal obl ique/

Rectus abdo m i n is m. tra-n sversus aponeurosis

External oblique m .

I n ternal obl ique m .

Iliac a., v. Tran sverse abdom inis

m uscle
lA ver tebral body

L4 n erve root

Psoa m.
Erector spi nae m.
L4/ LS facet joint

Geni tofemoral n.
Li n ea alba

Psoas minor m.

Rectus abdom i ni s m.
External obl ique m.

Intern al ob liq ue m .

Tran sve rse abdo mi nis

Ilia c a. , v. muscle

Gluteus m edi u s m .

Psoas ma jor m .
Erecto r spi nae m .
L4/ LS facet joint

Thoraco lumbar fascia

CJl
>
Q)
c..
"'0 (Top) First in se ries o f thiry-fou r axia l images of the pe lvis, shown from supe ri or to inferio r. T h e three laye rs of t he
c m uscles o f t h e la te ra l ant eri or abdo min a l wa ll a re clearly visib l.e. The psoas m uscle co u rses in feriorly fro m its
mu ltiface ted spi nal origin . Th e supe rio r most aspect of t he iliac crest corresponds to the L4/ LS in te rvertebra l disc
0.. space. (Bottom) The aorta has just bifurcated . The paired rectus abdorn in is muscles in t he cen ter of t h e abdom en are
::r: visible.

v
16
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, UPPER PELVIS

Rectus abdo 111inis 111 .

Ex ternal obl iq ue m.
In terna l obl ique 111.

Transverse abdominis
m uscle
Iliac a. , v.
m.
Il iacu s 111. LS vertebral bod y

Glu teu medius m. Il ium

Erecto r m.

Rectus abdominis m .
External obli que 111.
Internal obliq ue m.

Tran sverse abdom i nis

mu scle
Iliac a., v. m.

Ilia cus 111 . LS vertebra l bod y

m edius 111 . IIi um

Erector spin ae 111 .

[ lop) The glu teus m ed ius m u scle has the most superi o r o ri gin of t he gluteu s muscles. The e recto r spinae m uscles a re
a paired longitudina l muscle compl ex along th e posteri or aspect of the spine. (Bottom) The iliacus muscle h as a
broad o rigin fro m th e deep surface of the iliu m . Note t h e close association of the neurovascular bundle, coursing
adjacent to th e psoas. This associatio n is m a intai ned thro ugh t h e entire pelvis.
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, UPPER PELVIS

Rectus abdo minis m.

o blique m.
Inte rnal oblique m.
Tra n sverse abdomi n is
muscle
lliac a., v. Psoas m .
lliacus m. LS vertebral body
LS ne rve roo t
LS/ S I face t joint
Glute us medius m .
Iliu m
Erector spi nae m .

fmi Ge nitofemora l n .

Gon adal vessel

Rectu s abdom in is m.
External ob lique m.
In te rna l oblique m .
Left u reter
Transverse abdominis
muscle
Iliac a., v. Psoas m.
Iliacus m . LS verteb ra l bo dy
Gluteus m edius m .

LS/Sl fa cet jo in t Il ium

Gl uteus max imus m.
Erecto r sp inae m.

c.l'l
>
Q)
0...
'"'0 (Top) Th e LS n erve roo t exits the ne u ra l fo rami na. Th e ili ac vessels cou rse a lo ng th e m edia l as pect o f th e psoas
c: muscle. No te th a t t h e iliacus & psoas remain separate through the maj o rity of th ei r pe lvic cou rse. (Bottom ) T he
C'tS
glu teu s maxim u s m uscle originates from th e ex terna l surface of t h e ili um posterio r to the glut eus medi us muscle.
0..
:c
v
18
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, UPPER PELVIS

External obl ique m.

Rectus m. Internal obl ique m.

Transverse abdominis
muscle
Iliac a., v.
Psoas m.
Il iacus m.
Gluteus medius m.

LS nerve root femoral n.

S I nerve root LS vertebral body

Gluteus maximus m .
Sacrum
Erector spinae m.

II ium

I nternal ob l ique m.

Rectus abdominis m. Externa l obl ique m.

Tramverse abdominis
Iliac a., v. 111UKie
Psoas m.
Iliacu s m. G I u teus m edius m.
LS vertebral body
LS nerve root
Sacrum
S 1 nerve root
Ilium
Gluteus maximus 111.
Erector spinae m.

(Top) The Sl ne rve root has separated from the thecal sac. The transve rse abdominis and internal oblique muscles are
intimately related. They share a conjoined tendon/a poneurosis. The external oblique muscle is a more d ist inc t
muscle. (Bo tto m ) 1 o le the course of t he LS n erve root along the anterior aspect of the sacrum. The LS/Sl disc is
partially visualized.

v
19
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, UPPER PELVIS

External oblique

Rectus abdo minis m. ob li que m.

Interna l oblique 111 .

II iacu s 111 . Transversus abdomi nis

muscle
G lut eus minimus m.
II iac vessels
acru111
G l uteus m ed ius m .
Sacroiliac joint S I n erve root

SZ nerve root
Gl ut eus maximus 111.
Erector spin ae m .

Ex terna l oblique
Left ureter apon eurosis

Internal obliq ue 111.

Tran sversus abclominis

Rectus abclominis m. muscle

E.\ternal oblique m.

Anterior superio r iliac

spine
Ili acu s m.
Glut eus min i 111u s m.
Iliac a., v.
G luteu s m ediu s m. acrum

Sacroili ac joint S I nerve root

52 n erve root
Erecto r spi nae 111. Gl uteus maximus m.

Cll
>
Q)
c..
"'0 (Top) Th e S2 ner ve root i s now apparen t . Th e anteri or synov ial and posterior syndesmoti c po rti o n s of the sacroiliac
c:: jo in t ca n be appreciated on this im age. For mo re detai l o n this joi nt see "Posterior Pelvi s". (Bottom) The o rigi n o f th e
g luteus minimus m uscle is th e most anterior o f t he gl utea l muscles. T h e an terio r superio r iliac spine is seen as a
0.. bu l bous en largement from th e an terior aspect o f t he ilium . It serves as the si te o f origi n of th e i nguinal l iga men t. T he
:::c liga men t is th e inferio r edge of t he ex terna l obl ique apo neurosi s.

v
20
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, UPPER PELVIS

Rectus abdomi ni m . Ex ternal oblique m.

In tern al oblique 111.

Iliac a., v. Tra n sversu s abdominis
Iliacus m. muscle

Psoas m .
m edi us m.
LS nerve root Sacrum
Sacroiliac joi n t S1 n erve root
Ili um
Gluteus maximu s 111.
Erector m.

Rectus alx lom ini s m . Ex ternal obliqu e m.

In ternal oblique m .
Iliac a., v. Tra nsversus abdomi n i s
m uscle
Ili acu s m.
Psoas m .
G lu teus mediu s m .
Sacrum
LS ne rve root
Sacro ili ac joi n t Sl n erve roo t

Il ium
G lu teus maxi mus 111.
Erector spi n ae m.

(Top) The glu teus max im us has an i nferior an d la teral course. At i ts superior aspect only a small p ort ion o f the
muscle is v isible. (Bottom) The erector spinae m uscle complex diminishes i n size as th ey n ear th eir inferior ex tent.

v
21
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, MID PELVIS

Externa l oblique
aponeu rosis

Transversus abdom in is
Rect us m.

In ternal ob li que 111.

Femora l n. in iliopsoas
Ili acus m. groove
Iliac vessels P oas m.
, (ulcus mini mus m.

G l uteus m edi us m . Sacru m

S I nerve root
Sacroil iac jo in t
IIi um
S2 nerve root Glu teus maximus m .

!:.rector m.

External oblique
aponeurosis
Rectus abdominis m.
Internal obl ique m.
Tran versus abdominis
Iliacus m.
m. Ext-ernal iliac

Gluteus minirnus m. Internal iliac vessels

,(ul cus m edius m.

S I nerve root
Sacro i liac joi n t
IIi Ulll
G l uteus maximus m.
S2 nerve root
Sacrum
Erector spi n ae 111 .

!J)

>
Q)
c..
""0 (Top) just below t he an terior superio r i liac spi n e th e ex tern al obliq ue muscle belly is no longer v isi ble. (Bottom ) T he
c i li ac vessels have bifurcated . The in tern al il iac vesse ls w i ll course posterior ly as t h ey t raverse t h e pelv is. At this mo re
inferi o r level the sacro i l iac join t .i s com pletely syn ovial.
0..
I

v
22
 HIP AND PELVIS OVERVI EW
AXIAL T1 MR, MID PELVIS

External oblique
apon eurosis

In ternal obl ique m .

m.

abdorninis

Iliacus m. Femora l n . in il io psoas

groove
m.
Extern al iliac a., v.

minimus 111. I n terna l il iac a., v.

Gluteus rn.
S I nerve root
Sacroi liac joint
IIi um

52 n erve roo t G luteus m aximus rn .

Sacrum
Erecto r spinae m.

External oblique

In te rnal oblique m.
Rect us abdo rninis m .

Transve rsus abdomin is

muscle
Iliacu s 111 .

Ex terna l il iac a., v.

1.5 nerve root
Gluteus m.
Internal i l iac a., v.
Glut em m edius 111 .
I n erve roo t
Sacroi liac joi n t

52 n erve root Gluteus maximus m .

Erector spinae 111 .

(Top ) ote ttie relative sizes of th e gluteal muscles. (Uottom ) Th e iliacus and psoas muscles are more di ffi cul t to
iden ti fy as separate muscle bellies. Note how anterior th e LS nerve roo t is now loca ted . The 51 n erve roo t is also
moving anterior.

v
23
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, MID PELVIS

Externill ob liqu e
apon eurosh

I nternal obl ique m .

Rectus ilbdominb m.
Transversu abdominis
muscle
IJi opSOilS m.
Gluteus minimus m.
External iliac a., v.
LS nerve root
Gluteus mediu s m.
Internal iliac a., v.
Supe ri or glu tea l a., v.
SI nerve root
S2 nerve root
Sacroiliac joint
Glu teus maximus m.

External oblique
aponeu rosis

Interna l ob lique m.

Transversus abdominis
Rectus abdominis m. muscle

Ilio psoas m . FemoraI n.

.Ju teu s m ed ius m .

Gluteus minimus m.
External iliac a., v.
Left ureter
Obtura tor n.
LS nerve root
Superior glutea l a., v.
Internal iliac a., v.
Piriformis m .
SI nerve root
S2 nerve roo t Gluteus maximus m.
S3 nerve roo t Sacrum

til
>
Q)
c..
""0 (Top) Branches o f the internal iliac vessels in cl uding t he superior glutea l vessel s are present w i th in the pelvis. The
c ex ternal il iac vesse ls ha ve main tained t heir posi tio n alo ng th e medial aspect of the psoas muscle. (Bottom) The
obturator nerve is v isib le along t·h e medial border of t he psoas muscle posterior to the ex ternal iliac vessels. Its course
a. is presented in greater detail in the "Pos terio r Pelvis" secti o n .
:c
v
?4
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, MID PELVIS

Extern al ob lique
aponeurosis

In ternal obl ique m.

Rectus abdomini s m.
Tra nsversus abdomi nis
I lio psoas m. mu scle

Glu teu s minimu s 111 . External il iac a., v.

Obturator n. Ili um
Gl uteu s m ediu m. I n ternal iliac a., v.
51 n erve root
Superior glutea l a., v.
Gl uteus m ax imus m.
Pi riform is m .
SZ nerve root Sacru m

External oblique
aponeurosis

Interna l ob lique m .
Rectus abdo m i nis m .
Tensor fascia lata m. Transversus abdomini s
muscle
Ili opsoas m .

Gluteus minimus m .
External iliac a., v.

Ob turator n . II i.um

Posterior in ferior i l iac

Gluteus m ed ius m . spine
Pi riform is m . L5 nerve root

SZ n erve root Sl n erve root

Sacrum G luteus maximus m.

(Top) The superio r g lutea l vesse ls a re exiting t he pelvis along the superior border of th e pi rifo rmi s m uscle. The
interna l oblique and transverse abdomin is muscles a re now mo re m edially loca ted th an in m ore superio r images.
This positio n is consisten t wi th their m edial a nd inferior course. (Bottom) Mu scle fi be rs of t h e tensor fascia lata are
now visi ble. The poste ri or inferior iliac spine ma rks the supe rio r post e rior ma rgin of th e greater sciatic n otch .

v
25
 H I P AND PELVIS OVERVIEW
AXIAL T1 MR, MID PELVIS

®1
Gon adal a., v.,
genitofemoral n.
Du ctus deferen s Tramversu s abdomi nh
muscle
Rectus abdom i nis m.
Interna l obl ique m .
Ten sor fascia lata m.

Iliopsoas m. Fem oral n.

Glu teus minimus m. External iliac a., v.

Obturator n. Left ureter

I I ium
Gluteus medius m .
Sacral plexus &
Pi riformis m. bran ches internal ili ac
ar tery, vein
Sacru m Gl uteu s m axi mus m.

External obl ique

Interna l obl iqu e 111.

Rectus abdo minis m.

Ten sor fascia lata 111. abdomi nis
mu\cle
Iliopsoas m .
G luteus 111inimus m.
External iliac a., v.
Obturator n.
Ilium
Gluteus medi us 111 .
Sacral plexm &
uperio r gl uteal a., v. bran ch es internal iliac
artery, vei n
Piriform is m.
Gl uteu s m axi mus m .
Sacrum

t.rl
>
Q)
c..
"'0 (Top) A co mplex re lationshi p exists betwee n the branc hes of th e in ternal iliac ve sels a nd the nerve roo ts of th e
c: sacra l pl ex us. These structures are ide nti fied a lo n g the dee p surfa ce of the p iri formi s muscle a n d a re discussed in
de ta il in th e "Poste rior Pelvis" section. (Botto m ) Once th ey exists the pelvis th e u perior gluteal vesse ls trave l in th e
0. fat pla n e deep to the glute us max im us m uscle.
:r:
v
?f.
 HIP AND PELVIS OVERVI EW
AXIAL T1 MR, MID PELVIS

Spermatic cord
In ternal ob lique 111.
Inferior epigastric a., v.
Femo ral n.
Rectus abdo minis m . Femoral branch
gen itofemoral n .
Sa rtorius m .
Te nsor fascia lata m.
Iliopsoas m .
An te rior inferior iliac
,Juteus m inimus m . spine
Obtu rator n . Externa l il iac vessels
Obt urator in ternus m. Iliu m
Gluteus medius m. Scia tic 11 .

Piriform is m. Gl uteus maximus m.

Sacrum

Rectus abdomi11is m. In ternal oblique m .

Sartorius m. Tensor fasci a lata m.

Ilio psoas 111. Anterio r inferior iliac
Gluteus mini111us 111. spine
Externa l iliac a., v.
Obturator 11.
Il ium
Gluteus medius 111 .
Obtu rator i11ternus m. Sciatic n .

Piriformis m.
Sacrum Gluteus maximus m .

(Top) The origin o f th e obtu rato r inte rnus m uscle is m edi al to t he a ceta bu lum. T he pirifo rmis muscle origina tes fro m
the sacrum and cou rses late rally fillin g the g rea te r scia tic notch . The sa rto ri us m usc le is n ow a pparent, in fe rio r to its
origin from the a nte rior superi or iliac spine. The ext e rn a l ob lique apo ne urosis is no longer d ist in ct from the internal
oblique m uscle. (Bottom) The a n te rio r in fe ri or iliac spine is present just superi or to th e acetab ulu m . The scia ti c n erve
is a distinct struct u re a long th e la tera l deep surfa ce of th e piriform is m uscle.

v
27
 H I P AND PELVIS OVERVIEW
AXIAL T1 MR, LOWER PELVIS

Conjoin ed tendon
Rectus abdom in is m .
Proxi m al inguinal
ligam ent
Left ureter
Rectus fem ori t.

Sa rto ri us 111 . Tenso r la ta 111.

Ex tern al iliac a., v.
Iliopsoas m.
G lut eus m edius m .
Obturator n.
Supra-acetabula r i lium
Gluteus m i nimus m.
Obtura tor in ternus m.

Sciatic n. Pi ri formi s m.

G l u teus max i mus m .

Sacrum

Con joi n ed tendon

Rectus abdom inis m .

Rectus fem oris t.

Sa rt ori us m .
Ten sor fascia la ta m.

Iliopsoas m . Ex ternal iliac a., v.

G lu teus min imus m .
G lut eus med i us m .
Obturator n.
Sup ra-acetabular il ium
Internal pudendal a., v. Ob turat o r i n ternu s m.
Sciat ic n.

Gl u teus m ax i mus 111.

Sacru m

(Top) The rectus fe m o ris te ndo n is present between the iliopsoas m uscle and g lu teus minim us m uscle afte r
origina t ing fro m t h e a nterio r infe rio r iliac spine. (Bottom) Th e infe rior medial most aspect o f t he tra nsverse
abdo min is a nd in ternal o b lique m uscles is evide nt as the con jo ined te ndo n . Below this level t he te n do ns a re not
d isti nct fro m the rectus abdo minis m uscle. The in tern al pude ndal vessels a re lo ca ted posterior to the ob tura tor ne rve.

v
28
 HIP AND PELVIS OVERVIEW
AXIAL T1 M R, LO WE R PELVIS

Sartori us m.
Rectus abdo m i nis m .
Rectus femoris t.
Il iopsoas m.
Tensor fascia lata m. Ex ternal iliac a., v.
G luteus medi us m.
Femoral head
Acetabulum
Gluteus minimus m .
Obtu rator internus m .
Sciatic n .
Sacrospi nous ligament

Coccyx Gluteus m aximus m.

Rectu s abdominis m .

Inguin al ligament
(middle)
Ex terna l i liac a., v.
Sartorius m. Rectus femoris t.
Ili opsoas m. Ten sor fascia lata .

Glu teu s minimus m. G l uteus m ediu s m .

Fem o ral head Acetabul um
Piriformis m . Obturator internus m .
Sciat ic n .

Sacrospinous ligam ent

Coccyx
G luteus max imus m.

(Top) The sacrospin ous ligament is visible. The iliopsoas m uscle is in ti mate ly re lated to the anterior aspect o f th e hip
joint. (Bottom) Th e scia t ic ne rve is prese nt in its typical location just pos te rior to the a cetabulum .

v
29
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, LO WER PELVI S

ffil
Rectu s abdomin is m .

In g uin a l ligame n t

Il iop soas m .
Rectus fe m oris m .

Te n sor fasc ia lata m . Ex te rna l iliac a., v.

G lu teus m in im us m. G luteus m edius m .

Femora l head Acetabulu m

G rea ter trochanter Obtura tor inte rnus m.

Pi rifo rm is m.
Scia ti c n.

Sacrospinous I iga m en t
Coc cyx .Juteus ma xim us 111.

00
tB Rectu s abdo m in is rn.

Ing uin a l liga m en t

Il iopsoas rn . Femoral n .

Rectus fe m o ris m . Sa rto rius m .

Te n sor fasc ia lata m . Ex te rn a l iliac a., v.

Gl u teus m in imus m . G lu te us m ed ius 111 .

Fem o ra l h ead Aceta b ul u m

Grea te r trochanter Ob turator in te rnus m .

Scia tic n .

Sac rotube ro us liga m e nt

C occyx Glute us max im u s m.

rJ'J
>
Q)
c..
""0 (Top) Th e in gui n al ligamen t is p rese nt ju st latera l to th e rectus abdo minis mu scle. Like th e m uscles this struc ture
c:: a lso has an in fer ior m edia l co urse so th at we on ly see segm e nts a nd its most infe ri o r exte n t will be med ia lly loca ted .
rt:S (Bottom) Segm e n ts o f the sacrotu bero us li ga me nt are p rese n t a lo ng th e d ee p surface of th e gluteus maxim u s muscle.
Cl. The vertical o ri en tat io n of t h is liga m e nt means th a t o nly segm en ts will be visib le o n axia l images. Fo r m o re de ta il o n
:::r: th is stru cture see "Posterior Pelvis" sect ion.

v
30
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, LOWER PELVIS

Rectus m.
Fem oral n .
Il iopsoas 111.

Rect us m.
Common fem oral a., v.
Ten so r lata 111.
G lu teu s m ed ius m.
Gluteus mini mu m .
Femora l head
Grea ter trochante r O bturato r intern u s m .

uperior gem ellu t.

Ischia I spin e
Sacrospinou s liga m en t
Coccyx Sacrotu berous ligam ent

m ax imus m .

Rectus abclomi nis 111.

Pectin eus m.

Il iopsoas m . Femoral n.
Rectus fem oris rn. Sartorius m .
Com m o n fem oral a., v.
Ten sor lascia la ta m .
Gluteus m in imus m . Gl uteus m ed ius m.

Fe m oral head Acetabulum

Greater trochant er Obturator intern us m.

Sciatic n . Ob turator i ntern us t.

Sacrotuberous I i game nt
G luteus m ax imus m.
Coccyx

(Top) At this po int the ex te rn al ilia c vessels have crossed be n ea th the ing uin a l ligam ent a nd have becom e the
common fe m ora l vessels. (Bottom) Th e femoral n e rve is visible as a sepa rate structu re la te ral t o the vessels. Note th e
dramatic cha nge in co urse of t he o btura to r in te rnus muscle as it exits th e pelvis. The scia tic ne rve is closely applied
to the pos terior a pect of th e o btu ra to r inte rn us te ndon a n d is d ifficult to identify as a sepa ra te structure. T he rectus
abdominis m uscles a re nearin g the ir o rigin fro m the pu bic cres t. T h e sy mph ys is pubis is now visibl e.

v
31
 HIP AND PELVIS OVERVIEW
AXIAL T1 MR, LOWER PELVIS

Ob tu rato r can al &

vessels

Sym ph ysis pu bis

Fem oral n.
Pecti ne u s m.

Sarto riu s m. Sar-torius m.

Comm on femo ral a. , v.
Rec tus fem o ris m .
Ilio psoas m .
Tensor fasc ia lata m .
Glu te us m ed ius m.
Fem o ral n eck
Obturator in tern u s m.
Greater trochan ter
ii--w-- In ferio r gemellus rn .
Sciat ic n .
Sacrotu bero us ligam e nt

Sym ph ysis p ub is

Pectineus m .

Sarto ri us m .
Common fe m ora l a., v.
Rectu s fe m oris m .
IJiopsoas m.
Ten sor fascia lata m .
G luteus med ius m .
Fe m oral n eck
Obt u rator internus m.
Grea te r troch a n ter
r-----'w-- In ferior gem e llus m.
r -;;;;;-- Sciatic n.
Sacrotuberous ligamen t
G luteus max im u s m.

til

>
Q)
0..
"'0 (Top) Note t h e exte nsio n o f te ndon slips fro m the rectus abdo min is alo n g the a n te rio r as pec t o f the sym physis pubis.
c:: These fibe rs se rve to rein force the jo in t. The add uctor muscles of the thigh a re now vi sible. Th e pectineus muscle is
ro the most superio r o f t h ese muscles. Fo r a mo re tho roug h disc ussion of the ad d ucto r m uscle o rigins see the "Ante rio r
c.. Pelvis a nd Thigh" section . (Bottom ) At th e ope n ing of the o btu ra to r foramen the obtura to r inte rnu s cove rs th e en tire
:::c deep surface. The obtu rato r ex ternu s muscle is n ot yet v isi ble. To follo w th e stru ct u res o f th e thig h more inferiorly
see the "Thigh Overview" sectio n .
v
32
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, MEDIAL PELVIS

Long dorsa I sacroi I iac I.

Rectus abdominis m .

Pubic body

Long dorsal sacroil iac I.

Rectus abdo minis 111.

Pubic body

(Top) First of thirty-eight sagittal images of the pelv is and upper thigh from m edial to lateral. The sacrum and coccyx
and their individual segments and disc remnants are easily apprecia ted . This image is off midline and th e spinal
canal is not present. (Rottorn) Th e rectus abdominis m uscle is a lon gitudinally orien ted midli ne muscle that
originates fro m th e pubic crest and su perior pubic ramus.

v
33
 H I P AND PELVIS OVERVIEW
SAGITTAL T1 MR, MEDIAL PELVIS

Sacrum

Rectus abdominis m.

Pubic body

Pectineus m.

Adducto r brev is m .

Gracilis rn.
Adductor lo ngus m.

Sacrum

Internal iliac a., v.

Rect us abdom ini s m.

Pubic body

Pectineu s m .

Add uctor brevis m .

Addu ctor 111. Gracilis rn .

CJl

>
Q)
0..
"'0 (Top) T he rect us abdominis m uscle is a longi tudinall y orien ted midlin e m uscle tha t originates fro m th e pubi c cres t.
c The complete lon g axis of the long d orsal sacroil iac ligament is easy to appreciate on thi s image. ote that th e origin
of th e adductor muscles from the pubis can be seen . ( Bo ttom ) Adductor brevis muscle is loca ted deep to th e aclcluctor
0.. longus muscle. Note the long tendon o f the adductor lon gus muscle. Its origi n is a small footprint on the anteri or
:c aspect of th e pubic body.

v
34
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, MEDIAL PELVIS

S1 n erve roo t

Division internal i liac

artery, vein

abdominh 111 .

Pubic bod y

Pectin eu\ m .

Adductor 111.

G racilis t.
Adductor brevis m .

nerve root Freet or spi nac m.

Divisio n intern al il iac

arter y, vein

m.

Rect u\ m.

Pubic bod y

l'ectin eu\ m.

Adduct or lo ngm m.

Adductor brev i\ m .

(Top) The gracilis m uscle is th e m os t medial of th e adductor muscles. It h as a thin tendinous origin fro m th e m edial
aspect of th e inferior pubic ramus. (Botto m ) The piriformis muscle takes o rigin from the anterior surface of th e
sacrum. The obturato r i nternu s muscles lines almost the entire deep surface of the pelv is.

v
35
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 M R, ME DIAL P ELVIS

I n ternal iliac a., v.

SI nerve root

Rectus abdomini s m.

Aponeuroses
abdom inal m.

upcrior ramus

Pectineus m.

Obturator ex tern u s m.

Adductor longus m.

Add ucto r brevis 111. Adductor magnus 111.

Internal iliac a., v.

Erector spinae m.

S I nerve root

Division in ternal iliac

artery, vei n

Rectus abdomin is m.

Aponeu roses
abdom i na l 111 .

Su peri or ramus

Pectineus m.

Obtu rator ex tern us m.

Adductor m.

Grea ter saphenous v.

Adductor brevis m. Adductor magnus m.

(Top) The obturato r foramen is between th e su perior and inferior pubic rami. The obturator intern us an d ex ternus
muscles arise from the respective surfaces o f m argins o f the foram en an d the membran e wh ich covers t he foramen .
(Bottom) The adductor magnus muscle occupies the positio n assumed by th e gra cil is muscle on more media l images.
T h e aponeuroses of the ex ternal an d internal obl ique and tran sversus abdominis m uscles arc present just lateral to
the rectus abd o minis muscle.

v
36
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 M R, M EDIAL PELVIS

Erector spi nae m.

Internal iliac a., v.

SI nerve roo t

Division internal iliac

artery, vein

Rectus abdominb m.
=.;.:,.;;===#---!--- Sacrospinous liga ment
Sacrotuberou s ligament
Inferior epigast ric a., v.
Coccygeus m.
Aponeuroses
abdo minal m .
Inguinal
Superior ramus

m.

Obturator ex ternus 111.

Grea ter saphen ous v.

Adductor lon gus m .

Adductor magn u s 111.
Adducto r brevis m .

Erector spinae 111.

SI nerve root

1-.xternal i l iac a., v.

abdominis 111 .
Inferior ep igastric a., v.
Aponeuroses Sacrospinous li gamen t
abdom inal m . Coccygeu; m .
Inguinal li ga m ent
Superi or ramus

Pectineus m .

Obtu rator ex tern us m .

(.realer v.

Adductor longus 111.

Adductor brevis m. Adductor magnus m .

(Top) Th e tran sverse abdomi nis an d internal oblique tendo ns are present just latera l to th e rectu s abdominis muscle.
The somewh at h ori zontal fibers o f th e sacrospin ous l iga men t are deep to th e mo re vertica l fibers of the sacrotuberous
ligament. (Bo ttom) T his image bisects th e long ax is of th e ex ternal iliac vesse ls. The ingu i nal l igamen t is the infer ior
edge of t h e aponeurosis o f th e ex ternal oblique muscle. T h e cross section o f th e pubic ram i arc presented.

v
37
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, MEDIAL PELVIS

abdom ini s rn .
Erector m.

'..,-..:::.'l""r-::;.=:::,o;;..,;:.,------=;:....- Interosseou s ligament

ofSI joi n t
Externa l il iac a., v.

Transverse abdom inis

muscle

Intern al obl iqu e m.

Inferior epigastric a., v.

Apon euroses _.:.,i;i=:;:::=i---+- l igam ent
abdomina l m.
m.
I nguinal l igamen t

Supe rior ramus

Pecti n eus m.
Iliopsoas m.

G reater sa pheno us v.

Adductor longus 111.

Adductor b revis 111 . Adductor magnus m.

Rectus 111. l n tero\\eous ligaments

Sl joi nt

Iliopsoas m.

Tran sverse abdominis

muscle

I n ternal obl ique 111.

Ex ternal iliac a., v. .V!·F-f!Aiif;=;..=-+-- -+- Sacro t u bcrou s I igame n t
Apon euroses Sacrospinou l iga men t
abdomina l m.
-_...._..;li:::;=;::.=r-:-- ----;- Coccygeus m.
I nguinal li gament

Superior ramus

111.

G rea ter saph enous v.

Iliopsoas m .

Adductor lo ngus m.
ell Adductor brevis m. Adductor magnu s m.
>
Q)
c..
""0 (Top) The transition between the rectu s abd o minis muscle and the more lateral muscl es is indistin ct o n sagittal
c images. Th e rectu s abdo minis m uscle is wider superio rl y than it is in ferio rl y; t hus it exten ds o nto m o re lateral
i m ages. The interosseous ligamen ts o f the sacroiliac joint are seen in cross section. (Bottom) Th e ad ductor magnus
0.. muscl e h as two separate o ri gins both of which are visible on thi s image. Th e ischioco ndy lar po rti o n o riginates from
:c t h e ischial tuberosity wh ile the adducto r portio n o riginates fro m th e in ferio r pubi c ramu s. This is th e most lateral
image o n w h ich th e greater saph eno us vei n is present. It drai n s into th e co mm o n femora l vein throug h th e
v sap hen o us hiatus.
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, LATERAL PELVIS

In terosseous ligaments
Sl joi nt
Transverse abdomin is
muscle

Iliopsoas m.

Internal obl ique m.

External iliac a., v.

A pon euroses
abdominal m. Sacrospi nous ligament

Inguinal l igamen t Sacrotuberous ligament

lliopecti neal junctio n

Com mon femoral a., v.

recti neu s m .

Iliopsoas m.

Sartoriu s m.
Adductor brevis m . Adductor m agnus m.

Erector spinae m .
Tra nsverse abdom inis /=--T------'i- - In terosseous ligam ent
muscle o f SI join t
.,..,;;;=>-...;---":i -- ll i u m
Ili opsoas m .

Interna l oblique m .

Aponeuro es
abdo minal 111 .

I nguinal ligament I n ternal puden dal a., v.

Sacrospi nous ligament

Iliopectineal junction Sacrotuberous ligament
Common femora l a., v. Ob tura to r in ternus m .
Pecti ne us 111 .

Il iopsoas 111 .

Sartorius 111.
Adductor brevis 111. Adductor magnus m.

(Top) The ex terna l iliac vesse ls h ave c rossed un de r th e inguin al liga ment to becom e the common femora l vessels.
The sacroiliac jo int is oblique ly o rie nted and thus short segm e nts will be seen on m ultip le images. The cross section
of th e il iopectineal junction is larger than the superio r pubic ramus indicating t rans ition from superior pubic ramus
to acetabu lum. (Bottom) The lo ng ax is of t h e ilio psoas muscle is present al o n g t he late ral aspect of the pelvis. The
intern al pud e nda l vesse ls exit the pelvis to wrap a roun d the sac rospino us ligame nt and en te r the perineum.

v
39
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, LATERAL PELVIS

abdom ini s
muscle
.: r::.,---;;; -- Posterior iliac
spine

Internal obl ique m .

Iliopsoas m.

Aponeuroses
abdominal m.

Inguinal ligamen t

Iliopectineal juncti on ligamen t

Obturator m.
Common femoral a., v.

Iliopsoas m.

Pectineus m.
Sartorius m .
Adductor brevis m. Adductor magnus m.

abdominis
muscle
\:J-::.:------';w-- Posterior iliac
spine

Internal oblique m.
Posterior inferior iliac
spi ne
Ili opsoas m.

Aponeuroses
abdominal m .

Anterior acetabular rim

Common femoral a., v.

m.

Pectineus m.
Sa r torius m.
r.ll Adductor m agnus m.
Adductor brevis m.
>
Q)
0..
"'0 (Top) A long segment o f th e inferio r aspect of the sacrotubero u ligament as i t attaches to the ischial tuberosity is
c:: nicely dem o nstrated . A long segmen t of the sciatic n erve on the deep surface o f the pirifo rmis muscle is also visible.
T he inferior gluteal vessels are located just medial to the sciatic nerve. (Bottom ) T he posterio r superior and inferior
c.. il iac sp ines are apparent. Th e inferior iliac spine ma rks the superior aspect of the grea ter sciatic notch.
J:

v
40
 HIP AND PELVIS OVERVI EW
SAGITTAL T1 MR, LATERAL PELVIS

Tran sverse abdomi ni s

m u scle

In terna l obl ique m .

Iliopsoas m.

Apon euroses
abdom i nal m .

Anteri o r aceta bular ri m

Fem oral head

- - - - - - . ; . . - Sacrotuberous l igam en t
i - - - - - T - - Obturator i nternu s m.
Com mon fem oral a., v.
Iliopsoas m.

Sa rtorius m . Ischial t uberosity

Pectineus rn .

Rectus fem oris m. Addu ctor magnu s m.

Transverse abdo mini s

muscle
::;..---.;;;;-- Posterior superior iliac
spine

Internal oblique m .

Psoas m.
Ili acus m.

Apon euroses
abdominal m.

Anterior acetabular rim

Fem ora l h ead

r----_,;-_ Sacrotuberou s l igament
-------ir-- O bturator i n ternus m.
Common femo ral a., v.

Iliopsoas m .
Sartorius m . Ischial tuberosity

Pecti neus m .
Rectus femoris m. Add uctor magn us m.

(Top) The superior gluteal vessels exit th e pelvis a bove th e su perior bo rder of the piriform is musc le. The sciatic ne rve
and inferi o r gluteal vessels ex it infe ri o rl y. A co mprehen sive discussion of this anatomy is presented in th e "Post erior
Pelvis" secti o n . (Bottom) The psoas and il iacus muscles are distinc t a lo ng th e late ra l aspect of th e pe lvis.

v
41
 H I P AND PELVIS OVERVIEW
SAGITTAL T1 MR, LATERAL PELVIS

Glut<.'U'> medim m.

I nternal oblique m.
Ilium
Transverse abdominis
muscle

Psoas m .
Iliacus m .

Aponeuroses
abdominal m .
Anterior ri m

l'emoral head

Sartori us m.

Iliopsoas m.

La teral circumflex ,;;;;::;r------iiir-- Isch ial tuberosity

femoral a., v. 1\ lrd ia I ci rlllm flex
m. femoral a., v.

Rectus femoris m . Adductor magnus m.

External oblique m. Gluteus m.

Interna l oblique m .

m.

Tra n sverse abdominis

muscle

Iliopsoas m.

Aponeuroses
abdomina l m.

Anterior rim

Femora l head

Iliopsoas m .

m.
Lateral ci rcumflex
femoral a., v.
===ii-----iiii-- Ischial tuberosity
Iliopsoas m. Media l circum flex
Pect i Ileus ri1. femoral a., v.
til
Rectus frmoris m. Adducto r magnus m .
>
Q)
c..
"'0 (Top) T he m edial circumflex fem o ral vessels are fo und between th e pecti neus and iliopsoas muscles wh ile th e lateral
c:
('lj
ci rcumflex femora l vessels are located deep to t h e sarto ri us an d rectus femoris muscles. (Bottom) Th e rectus femoris
m uscle is n ow v isi ble alon g the anterior aspect o f the th igh. Note the inverted Y appeara nce of the ilium and
0.. acetabul um . The stern is th e il ium and the an terio r limb th e an terio r acetabu lum and the posterior limb is the
I posterio r co lum n ex tending f ro m th e il i um thro ug h th e ischium .

v
42
 HIP AND PELVIS OVERVIEW
SAG ITTAL T1 MR, LATERAL PELVIS

External obli que m.

m edius m.
Il iacu s Ill .
Ilium
Transverse abdomini\
muscle

Internal obl ique m .

m.

Acetabul ar roof

Fem oral head

m.

Sarto rius m .

Lateral circumflex
fem oral a., v. ;r=;r-- - ---1;;-- Ischial
Quadra tus fem ori s m.
m.
Sem i m embran osus t.
Rectus femoris m .

Externa l obl ique rn .

Gluteus m ed i us m.

Transverse abdominis Ilium

In terna l obl iq ue 111.

m.

Acetabular roof

Fem ora l h ead

Iliopsoas m.

Sartorius m.
Lateral circumflex
fem oral a., v.

Iliop soas. m.
Pecti neus 111 .
Sem i m em bran osu s t.
Rectus femoris m.

(Top) The th ree layers of th e anteri or latera l abdominal wa ll are now discernibl e. (Bottom ) The external ro tators o f
the hip are presen t alo ng th e posteri or surface o f th e acetabul um . These muscles are well deta iled in "Lateral! li p".
ote also the origin of semimembranosus from th e lateral po rti on of t h e ischial tuberosity.

v
43
 H I P AND PELVIS OVERVIEW
SAGITTAL T1 MR, LATERAL PELVIS

Externa l obliqu e m.
G luteus m edius m.

Transverse abclominis Ilium

muscle

Internal obl ique m.

Iliopsoas m .

Acetabu lar roo f

Femoral head

Iliopsoas m.

Sa rtori us m .
Lateral circumflex
femo ral a., v.

II iopsoas m.
Conjoined origin
r ecti neus m. & long
head biceps m.
Rectus femo ris m.

Ex terna l obl ique m .

med ius m.

Tran sverse abdomini s

muscle

Interna l obl iq ue m .
G luteus maxim u s m.

r - - - ---;;;;- - Gluteus rninimus 111.

Iliopsoas m.

Acetabular roof

Sarto rius m.

Femo ral h ead

II iopsoas m.

Lat eral ci rcumflex

femoral a., v.
Quad ratus rn .
Lesser trochan ter on joined origi n
& lo ng
til head biceps fem ori s 111.
Rectus femoris m.
>
Q)
0..
"0 (Top) Th e sciatic nerve is no t identifiable as a separate stru cture due to it s close approximati o n to th e ex ternal
c ro tato rs of t he hip. T he con joined origin o f the semitendinosus and lo ng head of t he bi ceps femo ri s mu cles takes
o rigin from the ischial tuberosi ty post erior to th e semi m embranosus muscle o ri gin. The q uad ratus fem oris muscle
a. also o ri ginates fro m the ischial tuberosity. Th e q uadratus femo ris muscle is deep to t he h amstr ing tendo ns. (Bottom)
:c The i liopsoas m uscle inserts onto th e lesser t rochanter. Th e origin of the gl uteus minimus muscle is visible o n thi
image.
v
44
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, LATERAL PELVIS

Ex ternal obl ique m .

Transverse abdom in is
muscle Ilium

Internal obliq ue m.
Gluteus max imus m.
Ex ternal oblique
Gl uteus medius m.
aponeurosis

Anterior in ferior i liac

spi ne

Sar torius m .

Femoral h ead

Ili opsoas m . External rota tors

Lateral circumflex Medial ci rcum flex

femoral a. , v. fem oral a., v.
or-----,;;;-- Quad ratus femori s m.
Iliopsoa s m.
Lesser troc hanter

Rectus femori s 111. Semi tendinosus m.

Ex ternal obliqu e m.
Transverse abdomi n is
muscle

I nternal obliqu e m.
Jlium l1DLj
Gluteus maxim us m .
External obliqu e
aponeurosis Gluteus medi us m .

Rectus femoris t.

Sartori u s m.

Femoral head

Iliopsoas m.

Lateral circum flex

femoral a., v. ,.._.,._ _ _____,___ Medial circu mfl ex
femoral a., v.

-
Rectus femoris m .
Lesser trochanter

Quadratus femoris m.
Semi tendi nosus m .

(Top) The an te rior in ferior iliac spine is an osseous protuberance just above th e h ip joint. (Bottom) The rect us
femoris muscle o rigina tes from th e a nte rior infe ri or iliac spine. The infe ri or gluteal vessels are still ap parent along th e
deep surfa ce of the gluteus max im us muscle. Alth o ugh a discrete nerve is still n ot d iscernibl e the wis ps of tissue
adjacent to the inferior glu teal vessels a re the sciatic nerve. The inguin a l li game nt is the most inferio r edge o f the
external obi ique aponeurosis.

v
45
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, LATERA L PELVIS

External oblique m.
Transverse abdominis IIi um
m uscle
Iliacus m.
In ternal obliq ue m.

G luteus ma.\imus m.
A nteri or superior ili ac
spine Gluteus medius m.

Iliopsoas m .

Rectus femoris t.

Sa rtorius m.

Femora l head

m. =*-----:;;...- Ex ternal rotators

::;;:::;:-------i; -- Obturator m.
Latera l ci rcu m flex = r - - - - ---'liii-- M ed ial ci rcumflex
femora l a., v. fem oral a., v.

Sciatic n.
Rectus femoris m. Lesser trochan ter

latera l is m. Quadratus femoris 111.

Externa l obl ique m.

Tra n sverse abdomini s IIi um
muscle
II iacus
Internal oblique rn. 111.

Anterior superio r i l iac Glut eus maximus ITl.

spine G lut eus medius m .

Glut eus minimus m.

Ili opsoas m.

Sartorius m.
Rectus femoris t.

Fem oral h ead

II iopsoas m.

Lateral circumflex
fem ora l a., v.

Rectus femori s 111 . Lesser trochanter

<Jl Vastus lateralis m. Sciatic n.

>
Q)
c..
""'0 (Top) The m edial ci rcumflex femoral vesse ls are now present posterio r to th e femur, having co ursed around the
s:::: m edial aspect o f the femora l neck. Note t he posterior orientatio n o f the le ser trochanter. The t hree layers of the
anterio r abd o mi nal wall are al l present an d th e separa te muscles are easily d iscerni ble. Note al so t h e o rigin of th e
0.. sartorius m uscle from th e an terior su peri or iliac spine. (Bottom) A lo ng segment of th e sciatic nerve is seen closely
:c applied to th e posteri or surface of th e q uadratu s fe m oris ten don . It no longer has the fatty striations which were
present within th e ner ve more superiorl y.
v
46
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, UPPER THIGH

External oblique m.
Iliac crest
Trans\ abclominis
muscle Iliacus m.
Internal oblique m .
Anterior superior ili ac Gluteu\ maxi mu s m .
spine
G luteus medius m.

Gluteus minimu s m.

Reflected h ead rectus

femorh m.

Femora I n eck
m.

Cap\ular ligam ents

Lateral circumfl ex
fem o ral a., v. Sciatic n.
; r - - -- - ....;;;r-- Q uadratus femoris m.

Rectus fem oris rn. Lesser t roch anter

lateral h m.

External obl ique m .

Transverse abdom ini s Iliac crest
muscle Iliacus m.

Internal oblique m .
max imus m .
Anterior superior i li ac G luteu s medius m.
spine
G l uteus minimus m .

Tcmor fascia lata m.

ligam en ts

Basicervica l femoral
neck

l .;lleral ci rcu m flex

fem oral a., v.

Q uadratus femoris m.
Rectus fc m oMs m.

Vast us lateralis m . Sciati c n.

{Top) The reflected head o f th e rectus fem o ri s muscle is very nicely demon strated on th is image. It origin ates from a
groove just above the ace tabulum . The thick an teri or joint ca psule ca n be seen. Its anatom y is discu ssed in the "Hip
joint" secti on. (Bottom) Note th e fibers of the gl uteus m i nimus muscle arising fro m the auricular su rface o f the
ilium.

v
47
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, UPPER THIGH

Exte rna l ob liq ue m.

Iliac crest
Internal obliq ue 111 .

Transverse a bdo mi nb
muscle

m.
Gluteus minimus m .

Tensor fascia lata m .

Capsular ligame nts

Basicervical fem oral

n eck
Lateral circum flex
femoral a., v.

Rect us fe m o ris m . Q uadratus fe m o ris m.

Sciatic n.
Vast us Jaterali s m.

Externa l o bl iq ue 111.
Il iac crest
Internal o bliq ue m.

Transve rse abd o m inis

muscle

C lu teus m ed ius 111.

Gluteus minimus m .

Gluteus m.
Te nsor fascia lata m.

Capsular li ga m e n ts

Late ral circum flex

femoral a., v.

Rectus femo ris m . Quadratus femoris m.

til Vastus Ja tera lis 111.

>
Q)
c..
""0 (Top) The tensor fascia lata an d rectus fem o ris muscles overlap each oth e r, th e rectus fe m o ri s muscle is more med ial
c a nd on th ese latera l sagittal images mo re infe rior. No te how far a nte riorl y the glute us min imus is loca ted. ( 13ottom)
The exte rnal rotator muscles are closely re la ted to th e posterio r and lateral aspect of th e fe moral n eck as they
0.. approac h the ir insert io n site.
:c
v
48
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, UPPER THIGH

External oblique m.
Iliac crest
Internal oblique m .

Tra nsverse abdominis

muscle Glu teus medius m.

Gl uteu s minimus m.

m ax i mus m.
Tensor fascia lata m.

Capsular liga m ents External ro tators

Lateral circumflex
fem ora l il., v.

Rectus m.
Quadra tus femoris m .

Vastus m.

Exte rn al oblique m.
Iliac crest
Intern al oblique m.

Transverse
G luteus medius rn.

Gluteus minimus m.

Gluteus maximus m.

Lateral circumflex
femoral a., v.

Tensor fascia lata 111 .

femoris m.

Vastus m.

(Top) The transve rse abdominis muscle originates from the inner margin of th e iliac c rest. (Bottom) The vastus
latera lis muscle has a re la t ively b road bu t not very long o rigin from the anterior aspect of the superior femo ral
diaphysis as see n o n this image. Even tho ugh it is called th e "lateralis" muscle in the u p per thigh, th is muscle wraps
arou nd th e anterio r aspect o f the upper femur.

v
4'
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, UPPER THIGH

External obl ique m.

Iliac crest

Internal obl ique m.

G l uteus medius m.

G lu teus minimus m .
G luteus maximus m.

Gluteus med i us t.

Lateral circumflex
femoral a., v.

Quadratus femoris m.
Rectus femoris m.

Vastus lateralis m. Vas tus media lis m.

External oblique m.
Iliac crest

Gl uteus medius m.

Gluteus minimus m.
Gl uteus maximus m.

Gluteu s medius t.

Rectus fem o ri s m. Externa l rotators

Lateral circu mflex

femoral a. , v.
Quadratus femoris m.

Vastus latera lis m . medial is m.

(Top) Th e internal o blique muscle ori ginates from th e superior aspect of th e iliac crest. Th e g lu teus medius tendon
extend s fro m the inferior border of that m uscl e. (Bottom) The gluteus medius tendon reaches towa rds the lateral
facet of th e g rea ter trocha nter. T h e obturator externu s tendon is the most i nferior tendon to in sert onto the
pirifo rmi s fossa located o n the medial su r face o f the grea ter t rochanter.

v
50
 HIP AND PELVIS OVERVIEW
SAGITTAL T1 MR, UPPER THIGH

Externa l oblique m .
lliac crest

Gluteus med ius m.

Gl uteus m in im us m .
Gluteus maximus m.

G lute us medius t.

External rotators
Reel us femoris m.
Greater trochanter

Lateral circum flex

fe moral a., v.

Vastus la teralis m . Vastus media lis m.

Externa l oblique m.
Ili ac crest

G Iu teus mecl ius m.

Gl uteus m in imus m.

Glute us m edi us t.

Externa l ro ta tors
Greater trochanter

Rectus fem oris m. Gluteus max im us m .

Vastus lateralis m. Vastus medialis m.

(Top) The rema inin g exte rnal rotato r tend o n s in sert o nto th e pirifo rmis fossa. Th e gluteus medi us tendo n inserts
onto t he grea te r troch an te r. (Bottom) The vastu s m edial is t e ndo n ta kes an o rigi n from the u pper a nterior femo ra l
diaphysis and th e muscle belly lies d eep to th e vastus late ra l is muscle in th e u ppe r thig h . For a discussion of a nato m y
lateral to t his poin t see the "Latera l Hip" section.

v
51
 HIP AND PELVIS OVERVIEW
CORONAL T1 MR, POSTERIOR PELVIS

Erecto r spi n ae m.

Ili um

Sacru m In terosseous l igam en t,

Sl joi nt
Sacroi liac jo int
(synovial)

Piriformis m .

Sciatic n .

Long h ead, biceps Sem itendi nosus m.

fem o ris m.

Erector spi nae m.

II i um
I n terosseous Iiga men t,
Sacru m
Sl joi nt
Sacroi liac jo in t
(syno v ia l)

Pi ri fo rmis m .
Scia tic n.

Isc hial tuberosity

Sem itendinosus t.

Lon g h ead, bice ps Sem itendinosus m.

fem oris m.

(Top) First of twen ty-four coronal images of th e pelvis from posterior to anterior. The broad expanse o f th e g luteus
max imus muscle is easy to a ppreciate on this image. (Bottom) The se mite ndinosus t e ndo n is q uite lo ng, exte ndi ng
fro m th e isc hial tube rosity well into th e thig h . ft is located along t he d eep surface o f th e muscle be ll y in th e m id
thi gh .

v
52
 HIP AND PELVIS OVERVI EW
CORONAL T1 MR, POSTERIOR PELVIS

Erector spinae m.

Ilium
Interosseous ligament,
Sacrum Sl joint
Sacroi I iac joint
(synovia l )
Piriform i m. - -=-----.;===
Inferior gluteal a., v.

,_____,__ Conjoined origi n

semitendinosus & long
h ead biceps femoris m.

Semimembranosus

Long head, Scm i tend i nos us

femoris m.

Erecto r spinae m.
In I iga men t,
Ilium
Sl joint
Sacrum
S1 nerve root
Sacroi li ac joint
(synovial)
111.

Ischial tuberosit y --+-Conjoined origin

Long head biceps semitendi n osus & long
rr1. head IJiccps femoris m .
Add uctor magnus rn.
emimembranosus rn.

111.
Vastus latera l ism.
Long hcacl,
rn.

(fop) The inferior gluteal vessels follow the same course as the sciatic nerve. The vessels are located med ial to the
nerve. (Bottom) Th e proxima l aspect o f the hamstring tendons are visible. In the proximal thigh the
semimembranosus muscle is purely membra n ous and is seen as a thin black sli p. The ischiocondylar portion of the
adductor magnus muscle is th e m ost m edial m uscle, t h e lo ng h ead of the biceps femoris is most lateral and the
semitendinosus is in between. The m embrane o f the sem imembranosus muscle is along th e deep surface of the
semitendinosus muscl e. A long segment o f th e Sl nerve roo t is seen as it exi ts the neu ral fora mi na.
v
53
 HIP AND PELVIS OVERVIEW
CORONAL T1 MR, POSTERIOR PELVIS

I lium Interosseous li gament,

Sl joi nt
Sacrum
Sl joint (synovial )
Internal iliac a., v.

Long head biceps -+-----"-',;;;;;;;;;;;;;;

femoris m.

Adducto r magnus m.

G racilis m.
Vastus lateral is m.

Ilium

Sacrum
Interna l iliac a., v.

Quadratus femo ris 111.

Ischial tuberos i ty

Add uctor 111agnus 111.

Gracili s m.
Vastus lateralis 111.
1./l
>
Q)
c..
"'0 (Top) The sacroil iac join t is composed of two different types o f articulation s, the thin ante rior syn ovia l portio n of
c: th e joint, a nd the wider posterior syndesmotic porti on of the joint. The strong interosseous ligaments conn ect to th e
ro two surfaces o f th e syndesmotic portion o f th e joint. (Bottom) Th e adductor magnus muscle dominates th e poste rior
0.. th igh. Th e gra cilis muscle is the most media l muscle of the thigh. Th e vastus latera lis muscle occupies a large section
:I: of the late ral thigh.

v
54
 HIP AND PELVIS OVERVI EW
CORONAL T1 MR, POSTERIOR PELVIS

Ilium

Sacrum

In ternal ilia c a., v. Sl joint (synovial)

Adducto r magn us m.

Vastus lateralis rn.

Sacrum

Internal il iac a., v.

Sl joint (synovial)
IIi um

Post erio r acetabular - +-----,;::=:=-::D

rim
Quadratus fem oris m.

Adductor rnagn us m.

Gracili s 111.
Vastus latcral is 111 .

(rop) The broad q uad ratus fe m oris muscle is seen cou rsing fro m th e ischi a l tuberos ity to th e posteri or aspect of the
fe mur. (Bottom ) The sac roilia c joi nt is now e ntire ly syn ovia l. The small inferior pubic ramu s exte nds fro m the isch ial
tuberosity.

v
55
 H I P AND PELVIS OVERVI EW
CORONAL T1 M R, POSTERIOR PELVI S

Sacrum

Internal iliac a., v.

Il ium

Isch i um

Posterior aceta bular

rim

Pectineus m . -+---:

Adduc tor m agnu s m.

Gracilis m.

Deep fem o ral a., v.

Vastus la terali s m.

Abdo minal wal l m.

Sacrum
II m.
In ternal iliac a., v.

I lium

Ischium

Obturato r extern us m .

Pectineus m .

Adductor magnus m.
Gracilis m.

Deep femoral a., v.

Vastus m.
tJ'l

>
Q)
c..
""0 (Top) Nea rly th e enti re exten t of the obtura to r ex tern us muscle is v isible from its origi n at the obturator fo ramen to
s:::: i ts inserti o n o nto the pi riformis fossa. The lo n g ax is o f th e posterior co lu m n of the aceta bu lu m is p resent extending
from th e ili um t h rough th e ischiu m , hence the nam e il io isch ial colu mn. (Bottom ) The images are n ow entering t he
0.. adductor musculat u re. T he pectineu s m uscle has the mos t su perio r inser tio n of th e add ucto r mu scl es o n to the
:r: posterior femur. Segmen ts o f the deep fe mo ral vessels are v isible.

v
56
 HIP AND PELVIS OVERVIEW
CORONAL T1 MR, MID PELVIS

Abdominal wall 111.

Sacrum
Iliacus 111 .

Interna l iliac a., v.

rnaximus m.
Glu teus medius 111.
IIi um

Pectineus 111.

111.
Adductor rnagnus rn.

Deep femo ral a., v.

latera lis 111.
m.

Superficia I femora I Greater v.

vein

Abdomin al wall rn. Psoas 111 .

Internal iliac a., v. Iliacus m.

Gl uteus rnaximus m.

Il ium

Gl ut eus medius l.

Pecti neus m.

Graci lh m. Adductor longus m.

Deep femoral a., v. Adductor 111agnus m.

Vastus lateralis 111.

m.
Grea ter v.
Superficial femoral
vein

(Top) The im ages a re now en tering the add uctor m uscul a ture . T h e pect ineus muscle has t h e mos t superior inserti o n
of the add uc to r mu scles o nto the poste rior fe mur. Segm e n ts o f the d eep femo ral vessels a re v isible. (Bottom) ote
the gene ral re lations hip of the major vesse ls o f th e thi g h . The g rea te r sa phe nous vein is med ia l withi n the
subcu ta neous fat, th e supe rf icia l fe mora l vesse ls a rc medial to th e d eep fe mora l ves e ls.

v
57
 HIP AND PELVIS OVERVIEW
CORONAL T1 MR, MID PELV IS

Abdominal wall m.
Psoa\ m.

Internal iliac a., v.

Iliacus m.

medius m.
Ili um

(; Iuteus medius t .

Grea ter trochanter

Ilio psoas m.

Pect ineus m.

Graci l is m.
m:::aiii-i-- Deep femoral "·· v.
Femur
Adductor longw. m.
Vastus m edialis 111 . lateralis m .
Superficia l fem ora l Greater sa phenous v.
artery, vei n

Abdo minal wa ll m.
m.

Internal i liac a., v.

Iliacus m.
G l uteu s medius m.
IIi um

Obturator ex ternus m.
Il iopsoas m .

Pect i neus 111.

Craci lis m.
Deep femora I a., v. Adductor longus m.

Vas tus laterali s m.

fem o ral
Greater v.
artery, vei n
Vastus medialis m.
Ill
>
OJ
0..
"'0 (Top) Th e gl uteus med ius tendon inser ts o nto the lateral facet of t h e grea ter trochanter. (Bottom ) ote how difficult
c:: i t is to identi fy th e i nferi or pubic ra mus. The ex tern al rota tor tendons are seen just m ed ial to t he greater t roch anter
as th ey i n sert o nto the piriformis fossa. T he te ndon s are no t labeled. Th is anato m y is presented in the "La tera l Hip"
0. secti o n .
:c
v
'i/1
 HIP AND PELVIS OVERVIEW
CORONAL T1 MR, MID PELVIS

Abdominal wa ll m .
lliJc a., v.

Psoas m .

Ili acus 111.

G lu teus medi us m.
Ilium
G lu teus minimus m.

Obturator ex tern us m.

II iopsoas m.
Pectineu s 111.
Add uctor brevis m.
;;;;;=:==;--t- Deep fem o ral a., v.
Adductor longus m.

Superficial fem o ral Vastus lateralis m .

artery, vein
G reater saphenous v.

Abdo minal wa ll m.

Ex ternal ilia c a., v.

Psoas m .
Ili acu s m.
G luteus medius 111.
Il ium
G luteus minirn us 111 .
Reflected te ndon,
rectus fem or is

Superio r ram us
Obturato r extern us 111.
Jliotibial band
Iliop soas m .
Pect ineus m. Adductor brevis m.
;:;;;;=;;r-+-- Deep fem o ral a., v.

Adductor longu s m.
Super ficia l fem oral
Vast us lateralis m .
artery, vei n
Greater sa pheno us v.
Sartori us m.

(Top) The ilio psoas muscle tra ve ls a lo n g the medial aspect of the join t as it cou rses pos teriorly to its inse rtio n onto
the lesser troch a nte r. (Bottom) The glu teus minim us te ndon inserts o nto the an terior fa cet of t h e grea ter t roch anter.
The commo n fem ora l vesse ls h ave just bifurcated into deep femoral and supe rficial femora l vesse ls. The vastus
lateralis muscle wra ps th e entire a n te ri o r aspect of th e upper fe mur.

v
59
 HIP AND PELVIS OVERVIEW
CORONAL T1 MR, MID P ELVI S

Abdominal wal l m.

External iliac a., v.

Il iacus m.
medius m.
Ilium
minimu\ m.
Reflected tendon,
reel us femoris m.

Gluteus minim us t.
Obturator extern us m.
Iliotibial band
lliop oas m.
Pectineus m .

Common fem oral a., v.

Greater saphenous v.
lateralis m.
Sartori us m.

Abdom i nal wal l m.

Iliacus m .
m ediu '> m.
I lium
Gluteus minimu s rn .

Both tendons rectus

Common femoral a., v.
fem oris m .
Gluteus minimus t.

Il iopsoas m.

Common femoral a., v.

Greater saphenous v.

Vastus lateralis rn .
Sartori us m.

<Jl
>
Q)
0...
""'C (Top) T he common femoral vessel s co urse along th e anterior surface of t h e adductor longus muscle which forms the
c:: floor o f the femoral tri angle. (Bottom) Th e point of crossing o f th e sartori us muscle and t h e ad ductor longus m uscle
forms the apex of the femora l tria ngle. From t his point i nferior the vesse ls tra verse th e adductor canal. Th e course of
Q.. th e vessels through the cana l is depicted o n th e images posterior to this o ne. T h e ten or fascia lata muscle is located
:c along the anterior border the ili o tibia l band.

v
 HIP AND PELVIS OVERVI EW
CORONAL T1 MR, ANTERIOR PELVIS

Abdomin al wall m.

Iliacus m .

IIi um G luteus minirn us m.

Both tendons rectus

femoris m.

Iliopsoas rn.
Superior ramus
Symphysis pubis

len or fascia lata 111.

Adductor lon gus m.

Greater saphenous v.

Sartorius m.
Vastus latcralis m.

Abdomi nal wa ll m.

II m.

Ilium
Gluteus minimus m.

lliopsoils rn.
Externa l iliac a., v.

Common femoral a., v.

Superior ramus
fascia lata 111 .
Pecti neus m.
Add uctor lon gus rn.

Rectus femoris rn., deep

Grea ter saphenous v.
bell y

111.

Vastus lateral is rn .

{Top) The symphysis pubis i s the art iculation of th e an terior aspect o f the pelvis. (Bottom ) The externa l iliac vessels
are medial l o th e il iopsoas muscle as t hose structures enter t he thigh . As th e vessels pa ss ben ea t h the inguinal
ligament; they becom e the common femora l vesse ls. Th e femoral nerve i s t he most lateral structure enteri ng t he
femora l tri angle. Jt is not identifiab le on thi s examination.

v
61
 HIP AND PELVIS OVERVIEW
CORONAL T1 MR, ANTERI OR PELVIS

Abdo minal wa ll m.

Iliacus m . Gluteus minimus 111 .

An terior inferior iliac

spine Straigh t ten don o f
Iliopsoas m. rectus fem o ris

External i liac a., v.

Comm on fem oral a., v.

Ten so r fascia lata m . Pectineus m .

Greater saph en ous v.

Sa rtori us 111 .

Rectus fem oris m .,

superficia l belly

Vastu s la tera lis m .

Abdomina l wall m.

Iliacus m.

Iliopsoas m. Gluteus m i ni mu s m.

Co mmon fe moral a., v.

Inguinal ligament
Superior ramus
Ten sor fasci a lata m.

Ly m phat ics
Sa rtoriu s m.

Rectus femori s m .,
super ficial belly

(Top) The junct io n of t h e g reater saphen ou s ve in and commo n femoral vei n is ni cely see n on t h is image. The rectus
femori s muscle o riginates from th e an terio r inferi o r iliac spine a nd sup raacetabu lar ili um. The pec tin e us m uscle has
th e m ost latera l o rigin o f the muscles arising from the supe rior pubic ra mus. (Bottom) A sh o rt segm e nt o f th e
ingui nal li gamen t is visible near its a ttachme nt to t he pu bic tube rc le . Th e lym phatics are th e most late ra l structures
at th e entrance to the fe mora l triangl e.

v
62
 HIP AND PELVIS OVERVI EW
CORONAL T1 MR, ANTERIOR PELVIS

Rectus abd o m in is m.
ili acus m .

Il iopsoas m. Gluteu s m ini m u s m .

Tensor fascia lata m.

Ingu inal ligam e nt Su perior ramu s,
parasym physis
Lym p hatics
Sarto rius m .

Rec tus fe m oris m .

Linea alba

ll iac c rest
Rectus abd o m in is m.

Lym p ha t ics Sa rtoriu s rn .

(Top) Th e sartorius a nd rect us fe m oris m uscles are th e mo st a n terior o f the th igh muscles. Note thei r o blique
ori entation fro m supe rior la te ral t o in ferio r m edial. A ric h supply o f lymp ha tics is presen t in th e anterior t hi gh .
(Bottom) The pa ired midline rectus abd ominis muscles are visible. The m uscles originate (not insert) fro m the
superior pubic ra m u s and p ubi c crest. Fo r more detai ls see th e "Anterio r Pelvis a nd Thigh" section.

v
63
 MEASUREMENTS AND LINES
• Measure angle between lin es 1 & 2
!Terminology o R: Anteversio n norma l sta te
Abbreviations • Antevers io n: Ante rio rl y fac in g acetabular o pening
• Purpose (P) • (Line 2 en ds med ia l to line 1)
• Imaging exami n at io n o n w hi ch measureme nt o A: Ret roversio n
performed (E) • Re tro versio n: Posteriorly facing acetabular
• Co n str uct ion of measu rement (C) ope n ing
• No rmal ra nge ( R) • (Line 2 e n ds la te ral to line 1)
• Abnorma l ra n ge (A) • Symptoms n ot likely until > 15°
• Acetabula r versio n : Axiolate ra l h ip rad iograph
o P: Dete rmin atio n o f anterior to po ster io r acetabu la r
!Anatomy-Based Imaging Issues an g ula tio n re la tive t o p e lv is
• Abnormal may ca use femoroacetabular
• Acetabula r prot rusion im p ingem e n t o f n ative or rep laced h ip
o P: Med ia l p ositio n o f acetabulu m re la ti ve to pelv is o E: Axio lateral or g ro in latera l rad iograph
o E: AP rad iograph pelvis or h ip o C: Co n st ruction
o C: Ide n tify medial wall acetabulu m, ilio isch ial li ne • Draw h orizonta l lin e of pe lvis; assu me edge of film
o Measure d ist a n ce between ilio ischia l li ne & medial is rep resentative (lin e 1)
wall acetabu lu m • Draw lin e th rough acetab ula r rim s (li n e 2)
o R: Med ia l wa ll acetabu lum in close prox imi ty to • Measure a ng le between lines l and 2
ilioischial line o R: An teversion (an gle o pe n an teriorly)
o A: Media l wa ll medial to ilioischia l line o A: Retroversio n (a ngle open poste riorl y)
• > 3 mm in m en abnorm al • Alpha (<X) a ngle
• > 6 m m in women abn orma l o P: Det er m inatio n of femoral h ead-neck offset
• Aceta bu la r a ngle/index • Lack of o ffset (o r cutba ck) between femoral h ead
o P: La tera l acetabula r coverage of fe m oral head a n d n eck m ay ca use femoroacetabula r
• Developmental dysp lasia im pingem ent
o E: AP rad iograph pelvis o E: Obli que ax ia l MR, CT, radiograph
o Con struc t ion o C: Con s truction
• Draw J-J ilge n rei n er lin e (li ne H) • Iden t ify center of fem oral head (point C)

I
• Draw lin e center femoral h ead to latera l m a rg in • Creat e bes t fit c ircle of fe mora l head (c ircle H)
aceta bul um (li ne 2) • Draw lo ng ax is fe mora l neck th rough poin t C (l ine
o Measu re angle between line H & line 2 1)
o R: Up t o 30° • identify junction o f fem o ral neck an d circle 1
• Age de pe ndent (po in t J)
o A: Greater than 30° suggests d ysplasia • Draw li ne t h rough po int C and poi nt J (line 2)
• Aceta bular versio n : AP radiogra ph • Measure angle be tween li nes 1 and 2
o P: Anterio r to posterior acet abular an gu lation o R: 50° or less is n or m al
re lative to pelvis o A: G reate r t ha n 50° a bno rmal
• Abnormal m ay ca use impingement by n a tive o r • Ce nter-e dge a ngle (of Wiberg)
replaced h ip o P: Determin e latera l acetabular cove rage of fe m o ra l
o E: AP rad iograph; extrem ely sensitive to positio ning h ead
o Con st ruction • Developme n tal d ysplasia
• Ide n t ify acetabu lar rims • M ust be o lder tha n 5 years fo r measu rem ent to be
• Assess posi t ion of a n terior rim to posterio r rim valid
o R: An teri or a nd po ste rio r rim s fo rm an in verted "V", o E: AP rad iogra ph pelvis
w ith anterior rim med ial to po ste ri o r rim o C: Co nstruct ion
o A: Anterior rim lateral to posterior rim • Ident ify center o f femoral h ead
• May be fo cal especia ll y superio rl y • Draw H ilgenreiner line (l in e H)
o A: Altern ative: Posterio r rim m ed ia l t () center • Draw line perpe ndic ula r to lin e H th ro ugh cen te r
femoral head o f femora l head (lin e ·1)
• Aceta bula r ve rsio n : CT • Draw line cente r o f fe m oral head to la te ra l edge
o P: Anterior to posterior acetabular angula tion aceta bular roof (line 2)
re lative to pelvis • Meas ure a ngle between lin es 1 and 3
• Abno rmal may cause femoroaceta bu lar o R: Grea ter t han 25°
impingement of native or replaced hip o A: Less than zoo
o £: C hoose ax ia l CT image a t w idest point femora l • Cente r edge a ngle: False p rofi le v iew
h ead o Also k nown as VCA (vertical ce n ter a nte rio r
o C: Constr uction ma rg in ) a n g le
• Draw pelvic h orizonta l axis line t h ru ischi a l o P: Determ in e ante rio r ace tabula r coverage o f femoral
tube rosities o r posteri or ischiu m h ead
• D raw line perpendicular to h o rizonta l (lin e 1) • Developme ntal d ysplasia
• Draw line thru rim s of acetabulum (lin e 2) • Performed in adu lts

v
64
 MEASUREMENTS AND LINES
o E: Fat e profile view hip • Rad iograph s with rule r between legs; spo t images
o C: Constru ction hip, knee, ankle
• Identify center of femo ral h ead • CT scout image pelv is to ankle
• Draw long axi s of pelvis (l ine 1); assu me edge of • CT axial images hip, knee, ankle
fi l m is representative o Cl: Iden tify la ndma rks
• Draw line from ce nter of femora l head to anterior • Superior iliac crest (l)
edge of acetabulu m (line 2) • Superior femoral head (F)
• Ieasure angle between lines l and 2 • Cen ter medial fe moral condy le (M )
o R: 20° or greater • Center tibi al p lafond (T)
o A: Less than 20° o C2: Identify landmark positi ons
• Femora l an teve rsion • Rad iograph: Draw hori zontal l ine from anatom ic
o P: Anterior rota ti on femoral n eck relative to shaft point t o rul er
• In toeing/ out toeing • CT scour: O n workstation identify slice position at
• Femoroacetabul ar impingement each point of in terest, record locat io n
o E: Ax ial CT images hip & knee • CT axial images: Identify slice position for each
o C: Con struction point o f interest, record locatio n
• Draw lo ng axis femoral neck (l ine 1) o C3: Measurement: Subtract position s to d etermin e
• Draw intercond y lar line dista l femur (line 2) length
• Measure angle between lines 1 and 2 • Femoral length: F - M
• eed to transpose line from on e image to the • Ti bia l length: M - T
other or superi mpose images • Overall length : F- T
o Alternative measure on workstation • Overall length : I - T (accounts fo r
• M ea ure an gle line 1 relative to horizontal (angl e acetabula r/ pel v ic disease)
I) o R: Post-op correct to 1 em difference
• Mea ure angle line 2 relative to horizontal (an gle o A: Greater than 2 em discrepancy is sign ificant
2) • Mech anica l axis
• Subtract angle 2 from angle 1 o P: Axis of weigh t transmission th rough lower
o R: 30-40° at birth , 8- 15° adult (men< women) ex trem i ty
o A: In creased an gle • Abnormal leads to osteoarth ri tis
• Excessive femo ral anteversi on: M edial fem oral • Abnormal may result from arthriti s
to rsion o E: Mechanical ax is or long cassette v iew,
• Ad ult up to not definitel y abnormal weight-bearing
• Under 3 years old < 45° normal • Entire lower ext remi ty hip to ankle
o See "Knee Overvi ew" section o C: D raw line from ce nter of femoral head to center
• Femoral angl e o f i n cl i n ati on (neck-sh aft angle) ti bial p lafond (l in e M )
o P: Determine angulation fem oral neck relative to o R: Line M passes through center of knee
shaft o A: M edial o r lateral devi ati on of line Mat )<nee
o E: AP radiograph hip, femur or pel v is • Per k i n line
o C: Construction o Vertical l ine lateral acetabular roof perpendicular to
• Lo ng axis femo ral neck (l ine 1) Hi lgenrei n er line
• Lo ng axi s femo ral diaphysis (l ine 2) • Sh en ton li n e
o Measure angle between line 1 & line 2 o P: Relationship fem ur to acetabulum
o R: 1-W-150° birth, 125° adult • Developmental dysplasia
o A: Decreased angle: Coxa vara o E: AP pelvis
o A: Increased angl e: Coxa va l ga o C: Line m edial co rtex femoral neck through superi or
• Hi lgenreiner lin e obturator fo ram en
o P: Estnblish horizon tal axis of pelvis; used as o R: Con tinuous line
landmark line for other measurements o A: Interru pted line
o E: AP pelvis radi ograph
o C: Drawn betwee n inferior margins of tea rdrop or
triradiate cartilage ISelected Referen ces
• Lateral mi gra ti on femoral h ead 1. Notzli H Petal: The con tour o f the femoral head-neck
o P: Relation ship between femoral head & acetabulum jun cti on as a predictor for the ri sk of anterior
• Developm ental d ysplasia impingement. J Bo ne join t Surg. 84:556-560, 2002
o E: AP pelvis 2. Reynolds D et al: Retroversion o f the acetabulu m. J Bone
o C: ll ilgenreiner line & Perkin l ine (see below) j oin t Surg. 81-B:28l-288, 1999
• Divides acetabulum into quadrants 3. Tonn is D et at: Dim ini shed fem o ra l antetorsion syndrome:
o R: ormal h ead / met-aph yseal beak in lower inner a ca use of pai n an d osteoa rthriti s. J Peel Orthop.
11 :419-431, 199 1
corner o f quadrants
o A: Dislocated h ead upper outer quad rant
• Leg l ength
o P: Iden ti fy leg length discrepan cy
o E: Exa mination s

v
65
 MEASUREMENTS AND LINES
RADIOGRAPHS, ACETABULAR PROTRUSION; FEMORAL INCLINATION: MECHANICAL AXIS

Medial wall
acetabu l um

Lon g ax is tem oral ned.

llioisch ial li n e

Long ax is fem oral

diaphysis

Superior poin t line M:

en te r of femoral head

Assess relatiomhip of
line M to J..nce

Inferior poi nt li ne M:
Ce n ter of t ibial pia fond

(Top) Determ i na tion of fem oral angle of incli n ati on o f the left hip. Th e angle o f inclination (an gle a) is m easured
between th e long ax is o f t he fem ora l diaph ysis and the lon g axi s of t h e femora l n eck. To assess for acetabular
p rotrusio th e relat ion shi p of the medial wa ll to t h e ilio isch ial li ne i s determi ned. I n this normal hip the medial wall
of the acetabulum is w ithin 6 m m o f the i lioischi al lin e. Thus n o protrusio deformity is present. (Bo ttom)
Determ i n ati on of th e m echan ica l axis (lin e M ). W ith a n ormal mech anica l axis th e m ain force o f weigh t is t h rough
th e cen ter of t he knee.
v
66
 MEASUREMENTS AND LINES
RADIOGRAPH & MR: ACETABULAR ANGLE, LATERAL MIGRATION HEAD, ALPHA ANGLE

Axis of acetabular roof

Hilgenreiner line

Anterior cortex of
femoral neck

Long axis of femoral

neck drawn th rough
cen ter of femoral head

(Top) The acetabular angle/ index (angle <X ) is measured on the right. Hilgenreiner line is constructed. The axis of the
acetabular roof is drawn (see left hip for an atomic reference). The angle form ed by t hese two lines is measured.
Lateral m igration of the femora l head is determi ned on t he left. Hi lgenreiner and Perkin lines are constructed. In t h is
normal h i p th e h ead & metaph ysea l beak are in the i nferior medial quadran t formed by these lines. A norma l
Shenton line i s present on the right, w ith continuous curvature extending from t h e obturator foramen to fe moral
metaphysis. (13o n o m ) The al pha (a) angle i s co nstructed on ob li que axial i m age. Critica l points include: Circle 1-1 -
best fit to perimeter of femoral h ead, point C - cen ter o f femoral h ead, point J - junction of circle H & anterior
femoral neck, line CJ, long axis of femoral neck through point C. v
67
 MEASUREMENTS AND LINES
AP & FALSE PROFI LE RADIO GRAPHS, CENTER EDGE ANGLE

tl
Perpend icular to
llilgenreiner, thru
cen ter femoral head

Line center of femoral

head to lat eral margin
acetabulum

llilgenreiner line

Line bet ween

acetabular rims

(I)

>
OJ
0...
"'0 (Top) O n an A P radiogra ph the cen ter ed ge angle (a ngle <X) o f the ace tabulum is constructed. Th i an gle measures
c:: latera l ace tabu lar cove rage of th e fem o ra l head. (Bottom) T he verti ca l ce nter edge angle or V A angle (a ngle <X) is
con structed o n the false pro file view of th e h i p. T hi s angle m easures an terior acetabular coverage of the femora l
c.. head. T h e lo ng axi s o f the pel v is is a parallel to the edge o f th e film and is often depicted as goi ng t h rough the cen ter
J: o f th e fe m o ral head, pa rallel to this lin e. Th e angled l i n e ex tends from th e acetabular rim th rough t he center of th e
fem o ral head.
v
68
 MEASUREMENTS AND LINES
RADIOGRAPHS & CT, ACETABU LAR VERSION

Anterior acetabu lar ri m

Posterior acetabular rim

rim

ll orizontal axis of pelvis

Perpen dicu lar to horizontal of

pelvis

Li n e bet ween acetab ul ar rims

Li n e perpen dicular to
An terio r rim
ho rizon tal of pelvis

Posteri o r rim

HoriLon ta l axis o f pelvis

(Top) Acetabu lar versio n as d ete rmined by radiographi c assess m ent. The re la t ions hip of the two acetabula r rim s is
assessed . Th e ante rior rim sh o uld be me dia l to t h e poste rior ri m . The poste rio r ri m sho u ld be la te ra l to th e cente r of
the fe mo ra l head. (Middle) Acetabula r ve rsio n (a ngle a ) measu red o n an ax io latera l v iew o f th e hip. Th e h orizontal
axis of the pelvi s is assumed to be paralle l to the edge of th e film. A perpendicula r line to thi s ax is is draw n . A line is
then drawn thro ug h the two rims o f th e ace tabulum. (Bottom) Acetabular versio n (a n gle a ) as m easured on axia l CT
image. Th e patie nt must be well positioned so th a t the h ip jo ints arc each im aged thro ugh the sa m e po int. The
horizontal axis o f the pe lvis is drawn thro ugh t h e poste rio r aspects o f th e ischiu m . A perpendicul a r line to this line is
constru cted . A lin e is th e n drawn between the acetabula r rim s. v
69
 ANTERIOR PELVIS AND THIGH
• Gracil is m.: Origin fro m anterior symph ysis pubis &
I Terminology
e ntire inferio r pubic ra mus
Abbreviations o O rigin m edial to adductor brevis m ., d eep to
• Anterior superior iliac spine (ASJS) adductor longus m .
• Muscl e insertion (I) Anterior Abdominal Wall
• Muscle functio n (F) • Contributors to groin pain
• Field of view (FOV) o He rnia
• Nerve supply (N) • Sportsman herni.a: Appa rent only with straining,
• Muscle origin (0) preh ernia condition
• Section thickness (THK) o Injuries rectus abdo min is m. inserti on
o Ab norm alities con joi ned te ndon
o Posteri o r inguinal wa ll d eficiency
IImaging Anatomy o Tear exte rnal oblique aponeurosis a t exit

Anterior Pelvis: Osseous Anatomy ili o hypogastric n.

o Ilioinguin al n. irrita tion
• Bodies of pubis articulate midline a t symphysis pubis
• F: Trunk fl exion, side to side bending, rotation;
• Supe rio r & inferior rami extend from p ubis
co mpress abdomin al cavity, elevate diaphragm
• Pecten: Ridge posterior aspect superior pubis
• N: Intercostal 7-11, subcostal, iliohypogast ric,
o Origin pectine us m.
ilio inguinal
o Insertion conjoined te ndon
o Iliohypogastric n.: Tra verses internal oblique m.
• Pu bic crest: Superio r surface anterior aspect pubic
a nterior to AS lS, traverses extern al oblique m. above
bod y
superficia l inguin al ring
o Insertion tran sversus abdo mini s & extern al obliqu e
o Ilioinguinal n.: Traverses internal obliq ue m.
ms.
adj acen t to deep inguinal ring, cou rses through
o Origi n rectus abdo minis m .
inguinal ca n al
• Pubic tubercle: Small protuberance lateral oorder
• Abdominal wall muscles
pubi c c rest
o Rectus abdominis: Paired mid lin e m uscles
o Attachmen t inguinal ligame nt
• 0: Superior pubic ramus, pubic crest
• Pubic a rch: Undersurface of isch iopubic (inferio r)
• 1: Xiphoid process, costal cartiIages S-7
rami
o Externa l oblique: Most su pe rficial
o Major d ifferential fea ture between male & fema le
• 0: Ribs S-12
pelvis
• I: Pubic crest, a nterior iliac crest, linea alba
o Wid e r (near 90°) in wo me n
• Ingu inal liga ment: Lower border of a po n eurosis
• Pubic angle: Between. ischiopubic (infe rio r) ra mi
o Internal oblique: Between external oblique,
Symphysis Pubis transversus abdominis
• Ca rtilaginous joint be twee n pubic bod ies • 0 : La te ra l inguinal ligamen t, iliac crest,
• Hya line cartilage a lon g articular surfaces th oracolu mbar fascia
• Fibroca rt ilaginous intra-a rti cul ar di sc • l: Pecte n (conj o ined tendo n), pubic crest, inferior
o Internal cleft with advancing age aspect ribs 10-12, linea alba
o Thicke r in females • Origin anterior to d eep inguina l ring
• Supe rior pubic ligament: La terall y extends to pubic • Insertio n lateral to rectus abdo min is m., posterior
tubercles & medial to superfi cial inguinal rin g
• Infe ri or pubic ligam e nt (arcuate pubic ligament) • Arch es ove r inguinal ca n al for min g roof
• Reinforced an teriorly by conve rging fibers rectus o Tra nsversus abdom inis: Deepest
femo ris, ex te rnal abdo min al ob lique, adducto r longus • 0: Iliac crest, posteri o r as pect of lateral inguinal
& brevis ms. ligament, thora columbar fascia
• Contributes little to pelvic stabil ity • 1: Pubic crest, pecten (co nj oined te nd on), linea
o Diastasis up to 2.5 em with intact p osterior a lba
ligame nts & maintena n ce pelvic stability • Remains posteri o r to ingu inal cana l
• Abnormal motion: 2 mm su pe rior to inferior • Transversalis fascia -a lon g deep su rfa ce
o Flamingo views, see following o Con joined te ndon (inguina l falx): Con join ed
• Norma l wid th may be up to 7 mm inse rti on inte rnal obliq ue & transversus abdominis
m s. o n to pecte n
Adductor Musculature (see "Thigh • Inconsistently present
rJl o Linea alba: Apo neu rotic junct io n rectus femoris,
Overview" section)
> • Contributors to groin pain tra nsve rse abdominis, in ternal & externa l obli q ue
Q)
0.. o Ten operiosteal injuries adducto r longus m. ms.
o Avulsion gracilis m. • Between rectus abdomin is m uscle bellies
"0 • Rectus sh eath: Anatom y below um bil icus
c: • Add uctor longus m.: Thin tendon arises from med ial
supe rior p ubi c ramus o An te rior: Apon euroses internal oblique, ex te rn al
c.. o Overlies origins gracil is, add uctor brevis & rnagnus oblique, transversus abdomi nis ms.
o Poste rio r: Pe ritoneu m
:c ms.

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70
 ANTERIOR PELVIS AND THIGH
• More commo n overall
Inguinal Ligament • M o re com mo n in men
• Thickening inferi o r border external obliq ue • May enter scro t um / labia
aponeurosis o All hernias ex it superfi cial ingui nal ring
o Lacuna r l i ga m en t : Deep fibers of inguinal 1., arch ed o Inguinal hern ias media l & superior to pubi c tubercl e
& posteriorly directed to insert la tera l to pubic o See "Thigh Overv iew" for femora l hernias
tubercl e
• M edial wall sub inguina l space Clini cal Notes
• Pect i n eal liga m ent: Lateral most fibers lacuna r 1., • Groi n pain
i nsert along pecten o Vague term attributab le to multitude of causes
o Reflec ted i nguinal ligam ent: ribers of ingu i na l I. includ i ng internal d erangements hip, symph ys is
travel beyond pubic tLiberc le to i nterd igitate wit h pu bi s, abdomina l wa ll ms., adductor ms., stress
contralateral ex ternal oblique aponeu rosis fractureS" femu r & pelv is
• Attachments: ASIS & pubic tubercle • Pubalgia
• Separates lower extremity fro m pelvis o Groin pain, indeterm i nate ph ysica l exami natio n
• Fascia lata attach es to inferior bord er
• Subinguina l space: Deep to inguinal l igament
o Passageway fo r femo ral vessels & n erve, i l iopsoas m. !Anatomy- Based Imaging Issues
into femo ral tri angle
o Ex ternal iliac vesse ls become femo ral vessels once Imagin g Recommendations
enter space • Radiographs
• llio pubic trac t o AP pelvis: General assessment
o Thickening inferior bo rder transversa lis fasci a o Pelv ic inlet: Anter ior to posterior displacem ent
o Deep & para llel to inguinal ligament • Usually post-trau ma
o Pelvic out let: Superio r to inferio r d ispl acement
Inguinal Canal • Usually post-trauma
• An terior wa ll : Ex ternal o blique apo neurosis & internal o Flam ingo v iews: Instability
oblique m . • A P pelvis, weightbearing o n each lower ex tremi ty
• Posterior wa ll: Tra nsversa lis fascia & co n jo ined ten don • Used occasion all y fo r ch ronic injury, gro in pain
• Roo f: Lower bo rder interna l oblique m. • CT
• Floor: lliopubic tract Ia teral, i nguina I I iga men t o Assess osseous i n tegrity
midpo rti on, lacu nar ligament m edial o 2.5 mm thick reconstru ction s
• En tran ce: Deep i n&ruinal r ing • MR
o Loca ted midinguinal ligament o Coronal, axia l images preferred
o Opening of cvagi nated transversalis fascia t h ro ugh o Tl -weighted, flui d sensi tive sequences, no con trast
which spermatic cord/ro und l iga ment pass o FOV: 18-30 em, TIIK: 3-5 rn m , Matri x : 256 x 256
• Exit: Superfi cial inguin al rin g o Su tface coil
o Superfi cia l ing uin al ring: Divisio n o f extern al o Prone posit ion ma y el i m i nate motion ar tifacts
oblique aponeurosis latera l to pubic tubercle o Screen en t ire pel vis: Fl uid sensitive co ro nal
• Latera l c r us: In serts pubic tubercl e • j o int puncture
• Med ia l c rus: Inserts pubic crest o Uncommon
• Inte rcrura l fibe rs: Superfi cial to ca nal; ru n medial o Indicati o ns: In fecti o n , an esthetic & steroid injection
crus to lateral crus o Arthrography: Diagnose adductor avulsions
• Oblique orien tatio n m ed ial & inferior • Herniography
o Obliquity protections against herni a formatio n o Con trast inj ecti on abdomi nal cavit y to identify
o Obliqu i ty accounts fo r changi ng bounda ri es f ro m o utpouchings (herni as)
lateral to m edial
• Contents: Ilio ing uinal nerve; male- spermatic cord, Imaging Pitfall s
female- round l iga ment; associated vessels • Ostei tis pubis
o Covered by evagi nated tran sversali s fascia o W iden i ng/ narrow ing, osteopen ia/ sclerosis,
• Clinica l no te: Hernias fragmen tation, erosion s/ cysts, beakin g/osteophytes,
o Direct inguinal hernia from weak posterior inguinal instability, bone marrow edema
wa ll o Common wi t h advancing age
• Medial to inferio r epigastric a. o Likel y resul t of chro nic repetitive stress
• Latera I to sperm ati c co rd o Reserve term fo r imagi ng fi ndi ngs wit h or w ithout
• Tot in d eep i nguinal ring symptoms
• o preformed sac • Correlate with symptom s in at h lete
• Transversalis fa cia cove rs • W hen associa ted symptom s, traum atic os tei tis
o Indirect i nguinal h ernia through patent processus pubi s o r pub ic bone stress injury
vaginalis into deep i nguinal ring • Hernias
• Processus vaginalis: Perito neal d ive rti cu l um that o Li ttl e success fu l i magi ng for early hernias
follows descending testes, usually closes o ff o J-lerniography not in widespread usc
• La teral to in ferior epigastri c a. o U lt rasoun d may be useful for sportsman herni a
• W ithi n spe rmati c co rd

v
71
rJ)

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c
0..
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v
72
 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Rectus abdominis m.
Inguinal ligame nt
Sa rtorius muscle

External iliac a., v. muscle

Femoral head
Acetabulum

Obturator internus m.
Sciat ic nerve

Sacrospi no us ligament

Gluteus maximus m. Sacrotuberous ligament

Aponeurm is abdomin is m.

Inguina l ligament
Sartorius muscle

b.ternal iliac a., v. II muscle

Femora l head

Acetabu lum

Obturator int ernu s m.

Sc iati c nerve

Sacrospin ous ligamen t

Gluteus m. Sacrotuberous ligament

(Top) Ax ial images fro m superior to infe rior. Th e rectus abd omi ni s m uscles are pa ired mid li n e m uscles. At t h is leve l
the ex te rnal and inte rn a l abdominal obliqu e a nd t ra n sversu s muscle belli es are no longer visible. The aponeu roses of
these mu c les have joine d toget h e r. (Botto m ) The in g uin al liga m e nt is th e inferior borde r o f the externa l o b lique
aponeuros is . Its o ri e ntation is from s upe ro late ra l to infe romedial. On axia l ima ges it is see n a long t he lateral edge of
the fused apo ne uroses.

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73
 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS P U BIS & ADDUCTOR MUSCLES

Aponeurosis Rectu abdominis m.

Ingui nal ligament

Sartori us muscle

External i liac a., v. Il iopsoas mu scle

Fem ora l h ead

Acetabul um

Obturato r i n ternus m .
Sciatic n erve

ligament

Glu teus ma xi 111us 111. Sacrotuberou'> ligament

Rectus abdom in is m .
Aponeurosis

Inguina l ligament
Sartori us muscle

Ex ternal iliac a., v. Iliopsoas mu -cle

Femoral head

Acetabu lum

Obturator internus m.
Sciatic nerve

ligam en t

Gluteus m aximus 111. ligament

tJl
>
Q,)
Q..
""0 (Top) T h e i n gu inal liga ment is a la n d mark separating th e pel vis from thigh. In th e axial plane t he struct ures lateral
c:: to th e ligam en t are within the t high . The structures m edial and deep arc with i n the pelvis. (Bo tto m ) T h e ex ternal
C'd
i liac vessels are deep to th e ingu i nal ligamen t.
a..
:c
v
 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Apo ne u roses Re c tus abdomin is m .

Inguinal ligamen t
Sarto rius muscle

Com mo n fe m o ra l a., v.
II iopsoas muscle

Pectine u s musc le
Fe m o ra l head

Acetabulum

Obtu ra tor inte rnus m.

Sciatic ne rve
Superio r gem e ll u s t.

Sacrotub ero us liga m e nt

Glute u s maximus m.

Aponeu roses Rectus abd o minis m .

Ing ui n a l li ga m e nt
Sarto rius m usc le

Com mon fe m ora l a., v.

Iliopsoas muscle

Pec ti n eus m u scle

Femora l h ead
Obturator foramen
Acetabu lum

Obtura tor inte rnus m.

Scia tic nerve

Obturator in te rnus
musc le & te ndon
Sacrotuberous liga ment
Glute us max imus m .

(Top) As th e vesse ls pass by th e ingui nal li game nt th ey beco me the common femoral vesse ls o f the th ig h . (Bottom)
The vesse ls are n ow located within th e fe moral t ria n gle.

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75
 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Aponeurosis Rectus abdomi nis m .

Inguinal ligament Sartori us muscle

Common fem oral a., v.

muscle

Pectineu s muscle
Femora l head
Obturator foram en
Acetabulum

Obtura tor i nternus m.

Obturator i nternus
muscle & tendon

acrot uberous ligament

Gluteus maxi m us m .

Aponeurosis Rectus abdominis m.

Inguinal ligament
Sa rtorius muscle

Com mon fem oral a., v.

IIiopsoas muscle

muscle

Femoral h ead Obt urator foramen

Acetabu lum

Obturator in tern us m.

Sciatic nerve
Obtu rato r i nt ern u s
m u scle & tendo n

Sac ro t u bcrous I iga m en t

max i mus m.

(J')

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Q)
c..
"'0 (Top) The pectineus origin from t he pec te n of the su perio r pub ic ra m u s is the m ost su pe rior o f th e adductor m uscle
t:: o ri gin s. The muscle wraps around t he su pe rior a nd a nte ri o r su rface of t he su pe ri o r pubic ram us. ( Botto m ) The
ro obturato r fo ra m e n is visib le a lo ng th e ante ri or as pect o f t h e pe lvis. Its conte n ts a rc the obtu ra tor vessels and n erve.
0..
J:

v
76
 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Rectus abdomin is m .
Pubic tubercle
Sartori us m uscle

Fe moral n erve
Com mon femo ral a., v.
I liop soas m u scle Pectineus muscle

Femora l h ead

Obturator in tcrnus m .

I nferior gemellus m.
lsch ia I tuberosi ty

Sacrot uberous li ga m en t
Gluteu s m axim us m.

Pubic body Rectus abdom i nis fibers

Pubic tuberc le Symp hysis pubis

Sa r torius musc le
Fe mo ral nerve
Common femora l a., v.
Pecti neus m .
Il iopsoas m uscle

Ad ductor brevis m.

Obturator internu s 111.

Isch ia l tube rosi ty

Sacro tubero us ligam en t

Gl uteus maxi m u s m.

(Top) The femo ral n e rve has been travelin g along the late ra l aspect of th e artery on all im ages superior to this one;
however th is is the first im age o n wh ich it can be ide ntified. It is t h e most latera l structure in th e femora l t ria n gle.
(Bottom) The pro tr usio n of the pubic tubercle fro m the a nte rior su rface of pubic bod y is apparen t. This tubercle is
the site of the med ial a ttachm ent of th e inguinal liga ment. Fibers fro m th e rectus a bdominis m usc le travel beyond
the muscle to se rve as rei nfo rcements to the anterior aspect o f th e sym p hysis pu bis.

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 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Pubic body Symphysis p ubis

Add uc to r lo ngus t.
Sa rtori u s muscle
Common fe m ora l a ., v. Femoral nerve

Pet ti ne u s muscle
Il io psoas m uscle
Add uctor b revis m.

Ob tura to r exte rn us m.

Ob tu rato r inte rnus m.

Ischial t uberosity
Hamstring orig ins

G luteu s m axim us m .

Pubic body Symph ysis pubis

- -+- Ad ductor lo n gu s t.
Sart o rius muscle
Fe m oral nerve
Co mm on femo ral a. , v.
Pectineus muscle
Ili opsoas muscle
Aclcluctor brevis m .

Obtura to r extern us m.

Obtu ra to r inte rnus m .

Isch ial tube rosity

Ham string o rigins

G lute u s maximus m.

(Top) The o rigi n of the obturator ex tern us muscle includ es the obtu ra tor m embran e wh ich is n o t visible o n these
images. Its origin from t he pu bic m a rgin o f th e fora me n is readily app reciated. (Bottom) The addu ctor lon gus muscle
orig inates via a lo ng tend on from a small region of t h e a nterior pubic body infe ri o r to th e pubic crest.

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 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Pubic body Symphysis pubis

...:;;::"--===-+--- Adductor longus

Sartorius mu scle tendon & muscle

Com mon fem ora l a., v. Fem oral nerve

Pecti neus musc le

Iliopsoas

Adductor brevis m.

Obturator externus m.

Obturator internus m .

Ischia l tuberosi ty
Ham str ing origin s

Gluteus maximus m .

Pubic bOd )' Symphysis pubis

,.--:=:i-- Adductor longu s

Sartorius mu scle tendon&. muscle

Common fem oral a., v. Femora l nerve

muscle
Iliopsoas muscle

Adductor brevi s m.

Obtura tor externus rn .

Ischial tuberosity
H am string origim

(Top) The origin o f the adductor brevis muscle is from the anterior surface of the i nferio r pubic ra m us just distal to
the symph ysis pubis. Th e adductor b revis muscle is located d eep and lateral to the adductor longus muscle. (Bottom)
The adductor brevi muscle is loca ted anterio r to the obturator extern us muscle and on axial images may be difficult
to separa te from t hat muscle.

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79
 ANTERIOR PELVIS AND THIGH
AXIAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Sa rtorius muscle ,.:,.....=;:::;--- Adductor longus

tendon &
Common fem ora l a., v.
Pecti neus muscle
Ilio psoas muscle

Adducto r brevis m .

Inferio r p ubic ramus

Obturator CJ\ tcrnus m.

Ischi al tuberosity
lla111slring

Gluteus m aximu s rn.

Sa rtorius m uscle ,=.=.;-- Adductor

ten don &
Common fem oral a., v.

Ili o psoas muscle Pecti nem muscle

Adductor brevis 111.

In ferior pubic ramus

Obt urato r 111.

Ischial tuberosi ty
llamsl ri n g origin s

G luteu s m ax imus 111.

(Top) From anterio r to posterior in th e upper thigh th e add uctor muscl es are pectin eus, adductor longus and
adducto r brevi s respectively. (Bottom ) In the coronal p lan e th e pectineus and adductor lo ngus muscles lie in t he
same plane. T he o rigi n o f th e gracilis muscle is from t h e in ferio r pubi c ram us an d inferior su r face of t he sym ph ysis
pubi s. For im ages o f the o ri gin o f thi s tendon and ana tom y inferi or to this level sec" Thig h Overview" section .

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 ANTERIOR PELVIS AND THIGH
CORONAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Ex ternal ili ac a., v.

Ili opsoas muscle

Ilium

Femoral h ead

Obtura to r extern us m.

Inferior pub ic ramus

Ad d uctor magnus m .

Adductor brevis m.

Pecti n eu s muscle

Graci lis mu scle

External iliac a., v.

Iliopsoas mu scle

Ilium

Femora l h ead

In ferior p ubic ramus

Adductor magnus m.

Pectin eus muscle

Add uctor brevis m.

Graci lis muscle

(fop) Coro nal images of t h e ante rior pe lvis fro m poste rio r t o a nterior. The obturator exte rnus and intern u s muscles
are see n a long th e inne r a nd oute r margin s of th e fo ra m en. The adductor muscles are difficult to distinguish from
one another. The ad duc to r magnus is th e most poste rior of th ese m uscles. Its uppe rmost fibe rs a re horizontally
oriented. (Bottom) In th e anterior to post e ri o r d irec tion th e ad duct o r brevis musc le is located between th e addu ctor
magn us and adducto r longus m uscle. Th e refore th ese three muscles ma y not be see n in th e sa me plane. Th e adductor
brevis fibe rs travel la tera l a nd infe ri o r.
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81
 ANTERIOR PELVIS AND THIGH
CORONAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Ex ternal i liac a., v.

ll iLMll

Fem oral head

Obt urator t'xternus m.

Inferior pu bic ramus

Pecti neus muscle

Adductor bre\'iS m.

Gracilis muscle
Rectus fem o ri s m.

Ex tern al iliac a., v.

Ili opsoas muscle

Fe m oral head

Obturator extern us m.

Inferior p ubic ramus

Pecti neus muscle

Adductor ill.

Gracilis
Rectu s fem oris m.
til

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0..
-o (Top) The gracilis m uscle is the most media l of the addu cto r muscles. (Bottom) The pectineus m uscle is located
c la teral to t he adducto r lo ngus and brevis m uscles. Th e pectineus muscle has the most med ial insertio n of th ese
muscles o nto the pos te rio r aspect of the fem ur.
0..
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v
R2
 ANTERIOR PELVIS AND THIGH
CORONAL T1 MR, SYMPHYSIS PUBI S & ADD UCTO R MUSCLES

Externa l iliac a., v.

Fem ora l head

Obt urato r extern u s m.

Iliopsoas m uscle

Superior p ubic ram u s Pec tineus muscle

Adductor longu s m.

Rectu s femori s m .
Gracilis muscle

Exte rnal iliac a., v .

Ili o psoas muscle

Fe m o ra l head

Obtura to r externu s m.

Supe rio r pubi c ramus

Pec tineu s muscle

Iliopsoas musc le

Rectu s fem oris r11.

G racil is musc le
Commo n fe m o ra l a ., v.

(fop) Recognition of the superi o r pubic ramus is one landmark that will help iden t ify t he adductor lo ngus m uscle
an d differentiate it from th e adductor brevis muscle. (Bottom ) T h e ad ducto r longus muscle fo rms th e medial borde r
of the femora l triangle. Thus, the vessels may be used as landmarks fo r d ifferentia t ion of the addu ctor longus and
brevis muscles in th e coronal pla ne.

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 ANTERIOR PELVIS AND THIGH
CORONAL T1 M R, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Iliopsoas muscle

Ex ternal iliac a., v.

Iliopecti n eal jun ction Pecten

Obturator extern us m.
Superior pubic ramu s

Pubic symphysis muscle

Adductor lo ngus m.
Common femoral a., v.
Arcuate ligam en t
Rectus femori s m .

Ex ternal iliac a., v.

II ium

Ili opsoas muscle

Pecten
Superior pubic ramus

Symph ysis pubi s

Pubic body -...;;;:= Pectineus

Add uctor lo ngus t.

Common fem oral a., v. Adductor lo ngus m .

Rectus femoris m. Arcuate ligamen t

til
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Q)
c..
"0 (Top) T h e arcuate ligament is a relat ively thi ck structure whi ch hel ps to rei n force the inferi or aspect of th e symphysis
r::::: pubis. Th e ridge alon g the superi o r pubic ramus is known as th e pecten. (Bo ttom) o te t he small area of origi n o f
C'\S
the adductor longus tendon.
0..
::r:
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 ANTERIOR PELVIS AND TH IGH
CORONAL T1 MR, SYMPHYSIS PU BIS & ADDUCTOR MUSCLES

rn .
An teri or superior iliac
spi ne
Ex terna l iliac a., v.
Rectus femo ris t.

Pecten

Superio r pubic ramus

Pubic crest Pectineus m .

Pubic body
Adduc tor lo ngus m .
Commo n femoral a., v.
femoris m .
Arcuate ligament

Greater v.

Iliopsoas mu scle
Rectus femo ris t.

Common lemoral a ., v. Superio r pubic

liga ment
Pubi c cres t

Pectin eus m uscle

Pubi c body

Rcctu \ fcmorb t. & m. Adductor longus t.

Arcuate ligament

Greater saphenous ' '·

(Top) Th e addu c to r longu s muscle is in close p roximity t o t h e sy m p h ysis pubis. Dysfuncti o n or injury to the
adductor longu mu c le may con t ribu te to in s tabi lity of t h e symph ysis. (Bottom) Th e re lative ly sm a ll supe rior pubic
ligame nt is v isibl e o n this im age .

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 ANTERIOR PELVIS AND THIGH
CORONAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

l liop oas muscle

In gu i nal l iga m en t

Comm on fem ora l a., v.

onjoi n ed tendon
Pubic crest
Pubic tubercle

Sa rtori us muscle

Symph ysis pubis

Greater sa phenous v.

Transve rsus abdomi nis

m u scle

I n terna l oblique m .

Exte rn al ob lique m.

Il iopsoas m uscle I nguinal l igamen t

Commo n femora l a., v.

Pu bic crest
Pubic tubercle

Sarto rius m uscle Rectus abdom i nis fibers

G reater sap henou s v. Sym ph ys is pubis

til

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c..
""0 (Top) T h e pubic t ubercles are easy to v isua l ize o n t his image. The pubic crest is th e superi o r po rtio n o f the pubic
c bod y m edial to the tu bercl e. T he conjo ined tendo n of th e obturator internu s and transversus abdo minis muscl es
inserts o nto the pubi c crest. (Bottom) The inguinal ligam ent o rientation fro m supero lateral to in fero medial is easy to
c.. appreciate o n this image. Note the vessels as th ey cross benea th th e l igament to enter th e femoral t riang le.
::r:
v
Qt:
 ANTERIOR PELVIS AND THIGH
CORONAL T1 MR, SYMPHYSIS P UBIS & ADD UCTOR MUSCLES

Inferior ep igastr ic a., v.

Transversus abdominis
muscle

Internal obl ique m .

External oblique m .

Conjoined ten don

Sarto riu s m uscle Inguinal ligament

Lymphatics

I nfer ior epigast ric a., v.

Transversu s abdo m i n is
m u scle

Lymphati cs

Sa rtori u s musc le

(Top) The late ra l aspect of t he anterior abdomina l wa ll co n sists o f t h re e laye rs. T he transverse abdominis fibers a re
the deepest and are h o rizontally o ri ented. The middle layer, interna l o blique muscl e, is com prise d of muscle fibe rs
which are orie n ted from th e iliac c res t upward an d medially. The external obliq ue fibe rs are o ri e n ted from
superolateral to infcromcdia l. (Bottom) The anterior abd o m inal wa ll consists o f the paired m idline rectus abdominis
muscle wi th longi tud inally o ri en ted m uscle fibe rs. T h e in fe rior epigas tric vessels are located a lon g the lateral aspec t
of these muscle bellies.
v
87
 ANTERIOR PELVIS AND THIGH
SAGITTAL T1 M R, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Sacrum

Rectu s abdom inis m .

Coccyx

Sym physis p ubis

Arcua te liga m e nt

Sacrum

Rectus abdomi n is m.
Coccyx

Pu bic c rest

Symph ysis pubis

Arcua te ligament

(Top) Sagittal images o f th e anterior pelv is f ro m midlin e to lateral. Th e symph ysi s pubis is present as part ia l vol umed
pu bic bodies. ( Bottom ) The th ick arcuate l igamen t along th e i nferior aspect of th e symphysis pubis is nicely seen.
The rectus abdomi nis m uscles arise fro m pub ic crest . Fi bers from t h ese m uscles travel i nferio rly to rei nfo rce the
an te ri o r aspect of th e sy m physis pubis.

v
 ANTERIOR PELVIS AND THIGH
SAGITTAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Sacrum

m.

Pubic crest

Pubic body

Sacrum

Rectu s abdominis m.

Pubic crest

Pubic body

(Top) The elongated sh ort axis of the pu bi c body is visible. ( Bottom) Note h ow the rectu s abdom i n is muscle thins
from superior to in ferior.

v
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 ANTERIOR PELVIS AND THIGH
SAGITTAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Sacrum

Rectu s m.

Pubic crest

Adductor lon gus t.

Add uctor rn.

Sacrum

abdomini s m.

Pubic tubercle

Add uctor lon gus t. Obturator extern us m.

Add uctor brevis rn.

Add uctor lon gus m .

Ill
>
Q)
c..
""0 (Top) Th e sma l l si te o f o rig in of the adducto r lo ngus muscle is we ll depicted o n t his image. T h e p ub ic body th ins
c:: alo ng its lateral aspect prio r to giv i ng ri se to the pu bic ram i . ( Bottom) The an terior pro t rus io n of t he pu bic tubercle is
apparen t . The adducto r brevis muscle lies deep to th e adducto r lo ngus muscle. T h e obtura to r ex tern us m uscle is deep
0. to the adducto r brev is muscle.
:r:
v
 ANTERIOR PELVIS AND THIGH
SAGITTAL T1 MR, SYMPHYS IS PUBIS & ADDUCTOR MUSCLES

Erector spinae ms.

Reclus abdominb m. complex

Sacrum

Tran sversus abdomin is

muscle

Apo neurosis Glu teus max imus m.

Pubic tu bercle
Obtu rator internus m.
Adductor t.
Obturator extern us m.
Pect in eus mu cle

Adductor brevi\ m.

Gracilis muscle
Adductor longus m.

Erecto r spinae ms.

complex
Reclus abdom in is m .

Sacrum

Tran sversu s abdo minis

muscle

Apo neurosis Gluteus maximus m .

Pubic tubercle
Obturato r internus m.

Obtu rato r ex tern us m.

Pectine us muscle

Adduct or longus t .

Adductor brevis m .

Adductor longus m .
Gracilis muscle
:::J
""C

(Top) The transitio n from th e rectus abdomi nis muscle to th e lateral abdomi nal muscles is n o t a d istin ct tra nsition.
The gracilis muscle takes origin fro m t he inferio r pubic ramus and th at o rigin is n icely seen on this image. (Bottom)
-...
c
i
The thin fused apon euroses o f th e la te ral abdominal muscles is located along t h e inferior and la te ral aspect of the (t
abdom inal wa ll. The ingu inal liga men t is formed by the lower border of the external obl ique aponeurosis. The <
attachment of that structure to the p ubic tubercle is visualized h ere. II'.

'
9
 ANTERIOR PELVIS AND THIGH
SAGITTAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Erector nH.
I nternal oblique m. complex

Sacrum
abdominis
muscle

Aponeurosis
Gluteus maximu s m.

I ngui nal ligament

Superior p ubic ramus Obturator internu s 111.

Obturator extern us 111.

Pectineus muscle
Inferior pubic ramu5
Addu ctor lon gus l.

Adducto r brevi5 rn.

Adductor longus m.
Gracilis mu\cle

Erector \pi nae m s.

Intern al obliqu e m. co mpl ex

Sacrum
Transversus abdominis
mu scle

Gluteus maxi m.

Inguin al ligament

Superior pubic ramus Obturator internus 111.

Obturator m.
Pecti neus mu scle
I nferior pubic ramus

Adductor brevis 111. Adductor magnus m.

Adductor longus m.
rJ'l
Graci lis

>
Q)
0...
"'0 (Top) Th e superi o r p ubic ramus is sligh tly anteri o r to t he inferior pubi c ramu s. This relationship sh ould be
c rem embered w hen review ing o ut let view s o f th e pelv is (see " li i p and Pelvis Overv iew" section). (Bottom ) The
ingu inal l igament is visi ble along th e i nferior aspect of the abdomina l wa ll aponeurosis.
0.
:c
v
Q')
 ANTERIOR PELVIS AND THIGH
SAGITTAL T1 MR, SYMPHYSIS PUBIS & ADDUCTOR MUSCLES

Erector spinae m s.
Internal oblique m . com plex

Sacrum
Tra nsversus abclominis
m u scle
Pi riformi s mu scle

Apon eurosis
Gluteus rn axi m us m .
Inguinal ligam en t

Superior pubic ramus

Obt urator i nternus m .
Pecti neus m u scle
Obt urator ex tern us m .

I n ferior pubic ram us

Adductor brevis m.

Addu ctor m agn us rn.

Adductor longus m .

Erecto r spinae m s.
com plex
00
Internal obl ique m .

Sacrum
Transversus abdom in is
muscle

Piriform is m uscle

Apon eurosis
Gl u teus m axi m u s m .

Ingui nal l igam en t

Superior pubic ramus Obt urator in ternu s m.

Pecti n eus m .
Ob turator ex ternus m.

l n fer ior pubic ram us

Adductor brevis m.
Addu ctor magn us m.
Adductor lo ngu s m.

{Top) Note the tra nsit ion from gracilis m uscle to add uc to r m agnus muscle as the images m ove from m edial to la te ral.
The origin o f t he p ect ineus muscle fro m th e pecte n of the supe rio r pubis ramus and it s w ra pping over the top o f the
ramus is well visua lized o n this image. (Bottom) Note h ow the pectin eu s m uscle and add u ctor longus m uscle lie in
the same co ro n a l pla ne. Fo r a n ato m y la te ra l to th is locat io n re fe r to "Hip a nd Pelvis Overview" an d "Thigh Ove rview"
sections.

v
93
 LATERAL HIP
o N: Superio r glu tea l
!Terminology o F: Hip flexio n, abdu ctio n & wea k inte rnal ro ta t ion
Abbreviat ions • Quadratus femoris
o 0 : Latera l ischia l t u be rosi ty
• Ante rio r superio r il iac sp ine (ASIS)
o 1: Quad rate line, intertrocha nteric cres t fem u r
• Funct io n (F)
• Greater (G r) o N: L4, L5, Sl
• Muscle in sertio n (1) o F: Strong hip external rotatio n
• Nerve supply (N) • *Triceps coxae: Obturato r internus, s uperi or &
• Muscle origin (0) inferio r ge m elli fun ctio n as o n e
Rotator Cuff of Hip
• G luteus medius & minimus tendo n s, troch anteri c
IImaging Anatomy bu rsa, subgluteu s medius & minimus bursa
lateral Femoral (Gluteal) Muscles • Clinical note: Experie nces same pathologic
abn o rmaliti es as rotato r cuff o f shou lder
• Pos t-axial : Glute us max imus, gluteus medius, glute us
o Typ icall y elderly women
minimus, tensor fascia la ta, piriformis
o Athletes un commonly affected
• Pre-axial: Obtu rator inte rnu s & externus, superio r
ge m ellus, in fer ior gem ell us, quadra tus femoris Bursa
• Common func tio n : Hip abduction, external rotatio n • Trochante ri c: G r. troch anter & gluteus maxim us m.
o Va riab le, see indi vidual functions • lsc hi oglutea l: Ischi al tuberosity & g lu teus max im us m.
• Gemellus inferior* • Subgluteus m ed ius: Gr. t rochanter & glute us m ed ius
o 0: Ischial tuberosity • Subgluteus minimus: Gr. troc hante r & g luteu s
o I: Piriformis fossa minimus m .
o N: N. to qua dra t us fem oris m . • Gluteofemoral: Iliotibial tract & vastus latera lis m .;
o F: Hip external rotation & weak abduct io n also te rm ed subcuta n eus o r su perficia l t roch a nteric
• Gem e llus supe ri or* · • Bursa of obturator internus: Muscle & ischi um
o 0 : Ischial spine • Obturator extern us bursa: Syn ovial protru sion be n ea th
o 1: Pirifo rmi s fossa infe rior border
o N: N . to obtura tor internus m.
o F: Hip externa l rotation, weak abductio n Greater Trochanter
• G luteus maxi mus • Ante rior facet : Insertio n glute us minimus m.
o 0: Posteri or gluteal line (iliu m ), posterior sac rum & • Lateral facet: Insertion glute us med ius m.
coccyx, sacrotuberous ligamen t • Superoposterior: Insertio n g luteu s mediu s m.:
o I: Ili o tibia l tract, gl uteal tuberosity Horizontal surfa ce, most cra nial portion tro chanter
o N: Inferior gluteal • Poste rior: No te ndon in sertion, covered by
o F: Hip extensor, hip abduction & externa l rotati o n trochanteric bursa
• G luteus m edi us
o 0: Be tween anterior & posterior gluteal lines (ilium )
Other
o I: Latera l & supero poste rio r fa cets g reater trochanter • Iliotibial trac t: Thi ckening latera l aspect fascia lata
o N: Superio r gluteal o 0: Tubercle il iac crest
o F: Hi p abducti o n & inte rn al rotatio n o 1: Anterolate ra l tibial condyle
• Gluteus minimus Piriformis Fossa
o 0: Ext erna l ilium between ant. & inf. gluteal lin es • Between p osterior fe m o ral neck & poste ri o r m ed ia l
o 1: Ante rior face t greater trochante r surface greater trochanter
o N: Su perior gluteal • Site of insertion fo r pirifor mis, s uperi o r & inferior
o F: Hip abdu ctio n & internal rotation ge m elli, obturator inte rnus
• Obturator externus: Media l fe mo ral muscle
o See "Thigh Ove rview" section
• Obturator int e rnus* !Anatomy-Based Imaging Issues
o 0: Interna l su rface o btu ra tor foramen & membrane
o I: Piriformis fossa (joins with gem elli tendons) Imaging Recommendations
o N: L5, Sl , S2 • MR: Rotato r cuff lesio n s
o F: Hip external rotatio n , weak a bduction o Sagittal & coronal images
• Piriformis o Proton d en sity & T2WI to characterize
o 0: Anterior sacrum, sacrotuberous li ga m ent o FOV, 14-26 mm: THK, 3-5 mm: Mat rix, 256 x 256
o I: Greate r trochanter (may fuse with o bturator
internus & gemellus ms.)
o N: Sl, S2 ISelected References
o F: Hi p external rota tion , assist s abduction
1. Pfi rrma n n CW e t al: Greate r t roch anter of th e hi p:
• Tensor fascia lata
a ttachment of the abductor m ech a n ism a n d a complex of
o 0: External lip anterior iliac crest, external ASJS, th ree bursae--MR im aging a ncl MR bu rsography in cadavers
n o tc h bel ow spine a n d MR imaging in asympto mat ic volunteers. Radi o logy.
o I: Iliotibia l t ract 22 1 (2) :469-77, 2001

v
94
v
95
 LATERAL HIP
AXIAL T1 MR, EXTERNAL ROTATORS & CUFF

Ili opsoas m.

Rectus femoris t.
Fem ora l a., v.

A nterior superior i liac

spine
minimus m.

O bturator n.

Gluteus medius m.
Obturato r int ernus m.
Obturato r a., v.

Sciatic n.

Inferi or glutea l a., v. Gluteus maximus m.

Interna l pudendal a., v.

Superior gluteal a., v.

Sacrospinou s ligament

Iliopsoas m .

,-

Fem oral a., v. Rectus femoris t.

Anterio r superior iliac

spin e

Obtu rator n.

G lut eus medius m.

Obturator internus m.

Obturator a., v.

Sciatic n.

Inferior glutea l a., v. G lut eus maximus m.

Internal pudendal a., v.

Superior gluteal a., v.

Sacrospi n ous ligament

til
> Sacrotuberous ligament
Q)
0..
""0 (Top) First of twen ty axia l images of t h e lateral aspec t of t h e hip from superi or to inferior. At this level of th e
c: buttocks th e glutea l muscles have alread y arisen from th e lateral surface of t he il ium. From deep to superficial they
ro are the gluteus min i mus, medius and maxim us muscles. (Bo ttom ) T he ob turator internu s muscle has th e deepest
a. origi n of the ex ternal rotators. It o rigi nates w i thin the pelvis alo ng t h e obturator foramen. A porti on o f its o rigin
:::c extends su periorl y to t he inner margin of th e i lium al ong t h e m edial wa ll of t he ace ta bul um. At thi s re latively
su peri or level t he obturator n erve an d vessels are separated. T h e nerve has t raveled from the posterior margin of the
v psoas muscle w hi le the vessels are branches of th e anteri or division of th e internal il iac vessels.

96
 LATERAL HIP
AXIAL T1 MR, EXTERNAL ROTATORS & CUFF

ll.i opsoas m .
Te nso r fasc ia lata m .

Femoral a., v. Rect us femoris t.

O bturator n.

Supra-acetab u lar iliu m Glute u s medius m .

Obturator a., v.
Obturator internus m.
Gl u te us mediu s t.
Sciatic n .

In fe rio r glutea l a ., v. G lute us maxi mus m .

Intern a l pu dend a l a., v.

Superior glu tea l a., v.

Sacrosp in o us ligam e nt

Sacrotuberous ligam e n t

Ilio psoas m. Te n sor fascia lata m .

Femora l a., v.
Rectus fe moris t.

O btura tor n .

Glute us m ed ius m .

Obturator a. , v.

Obtura to r intc rnus m.

Glute us medius t.

Sc ia tic n. G lute u s max imus m.

Infe rio r glutea l a ., v.

Sacrospin o us ligamen t
Interna l pu dendal a--:, v.

(Top) The gluteus m ed ius tendon forms with in the subst a n ce of t he m u scle along t he post erior a spect of t h e m uscle
bell y. (Bottom) As it ex its t he pe lv is an d courses towards t h e g reater troch ant er th e p iriformis musc le rapidl y tapers
in size.

v
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 LATERAL HIP
AXIAL T1 MR, EXTERNAL ROTATORS & CUFF

/
, I m. Tensor fascia lata m.
( li
Fem o ral a., v.
Rectus femoris t.

Obturator n .
Fem o ral head Gluteus medius m .
Acetabulum

Obtu rat o r internus m.

Obtura tor a., v.
Gluteus m edius t.

Sciatic n. Glu teus maximus m.

I n ferior glu teal a., v.

Superior gl uteal a., v.
Internal pu dendal a., v.

ligam ent
Sac ro t liga m ent

fasci a lata m.
Fe m o ral a., v.

Rectus femoris t.
Il iopsoas m.

Obturator n.
Fem oral head G lu teus m ed ius m.

AcNabulum

Obtura tor internus m.

G luteus med ius t.

G luteus max i mus m.

Sciatic n.
Inferior gluteal a., v.
Internal pudendal a., v. Pi ri form is t.

Sacrospinous l iga m ent

(Top) Fro m su peri o r to inferi o r alo ng th e posterior rim o f th e acetabulum the deeper externa l rotators arc in close
prox imity to one another and often difficul t to d efin itive ly identify. The pirifo rmis m uscle is th e m ost su perio r of
these muscles as seen here at t he superio r aspect o f the hi p jo i nt. (Bottom) Th e piriformis tendo n is seen o n this
image. Note th e positio n of th e sciatic nerve w here it m ig h t be m istaken for a porti o n of the pirifo rmis muscle belly.

v
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 LATERAL HIP
AXIAL T1 MR, EXTERNA L ROTATORS & CUFF

Il iopsoas m . Ten sor fascia lata m.

Femora l a., v.
Rectus femoris t.
EJJ

Gluteus minimus m .

Femoral h ead Iliotibia l ba nd

Gl uteu s m edius m.
Aceta bu l u rn

Piri formis t.
Obturator internus m.
Gl uteu s m edius t.

Gl uteus maxim us m .
In ferior glutea l a., v.
Sciati c n.
Internal pudendal a., v.

Sacro tuberou s liga m ent

Coccygeus m.

Ten sor fascia lata m .

Femora l a., v.
Rectus femori s m. & t.
Iliopsoas m.

Ilio ti bial band

Fem o ral h ead

Gluteu s medius m .
Acetabul um

Obturator in ternus m . Piriformis t.

G luteus m edius t.

Isch ial spine G luteus m aximus rn .

Inferi or gl uteal a., v. Superior gem el lu s 111.

Sacrotuberous l iga!.n ent

Coccygeus m .

(Top) The gluteus me dius te nd on becomes bette r de fined along th e infe rior aspect of the muscle. On this im age
taken between th e piriformis muscle su periorly and the triceps coxae muscle in fe riorly, th e sciatic nerve is visible as a
distin ct structure. On the more inferior images it wi ll be difficult to identify due to its close proximity to the gemelli
mu scles. (Bottom) The superior gemellus muscle arises from t he supe rior aspect of t he late ra l surface o f th e ischial
spine. The muscle is located just infe rio r to t h e pirifor mis muscle. Note how th e sciatic n erve mi ght be m istake n fo r a
portion of the supe rior gemell us m u scle belly.
v
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 LATERAL HIP
AXIAL T1 MR, EXTERNA L ROTATORS & CUFF

Ten sor fascia lata rn.

Fem ora l a., v.

Il iopsoas m. Rectus femoris m . & t.

Il io t ibial band

Femoral h ead
Glu teus medius m .
Acetabu lum

Pirifo rmis t.
Obtura to r internus m.
Gluteus m edius t.

Gl uteus max imu s m.

Ischia l spi ne
Su perio r gemellus m.

Sacrotuberous ligament

Coccygeu s rn .

t21J Tensor fascia la ta m .

:J1J Fem oral a., v.

Il iopsoas rn .
Rectus fe moris m . & t.

Fem ora l h ead

Gluteus minimus t.

Acetabu lum Gluteus m ed ius m.

Piriform is t.
Obtura to r in te rnus m.
G luteus m ed ius t.

Glu te us maximus m .
Isc hial spi ne
Superior gemell us m.
Obturator inte rnus t .

ell
Coccygeus m .
>
Q)
c..
'"'0 (Top) O n thi s image the o rigin of the supe ri or gemellus muscle is easy to a p preciate. Th e pirifo rmis tendon a nd
c: gluteus medi u s t endon are in close proxi m ity to o ne another. The gluteus medius tendon inserts o nto the su perior
bo rder o f th e greater troch a n te r while t h e piri for mis tendo n is the m ost superior tendo n to insert in to th e piriformis
0.. fossa along the m edial border of the greater trochante r. (Bottom) As the o bturator internus muscle ex its the pelvis it
:c abru ptl y turn s la tera lly, wrapping around th e ischi al sp ine just below the o rigin of the superior gem e llus muscle.

v
100
 LATERAL HIP
AXIAL T1 MR, EXTERNAL ROTATORS & CUFF

rensor fascia lata m.

Femoral a., v.

Pectineus m .
Iliopsoas m .

Obturator fo ram en

Femoral head G luteus m i nimus t.

Aceta bulum
Triceps coxae ts.

Obturato r i n ternus m . Grea ter trochanter

Superior gemellus m.
Ischial spi n e
Sciatic n.
Obturator internus t. &
i nferior gem ellus t. Inferio r glutea l a., v.

Sacro tuberous ligament

Coccygeus m .

Ten sor fascia lata m .

Femoral a., v.
Pecti neus m.
EJj
Iliopsoas m .

Obtura tor foramen

Fem oral h ead G luteus minimus t .

Acetabulum Gl uteus med ius m .

Triceps coxae ts.

Obturator in ternus rn . G reater troch an ter

Superio r gemellus m.
Obt urator internus t. &
Inferior gemellus m .
inferior gem ellu s t.
Sciatic n.

Sacrot uberou s Gluteus m axi mus m.

Coccygeus m.

(Top) Th e obturato r internu s tendo n forms as the muscle wraps around the ischia l spine. In this i ndividual th e
tendon im mediatel y fuses with th e inferi or gemel lus ten don as th e latter arises from t h e lateral border o f the ischial
spine. The enti re co urse o f t his tendon ca n be appreciated o n thi s image. Its insertion on to th e m ed ial border o f th e
grea ter troch anter is well seen. (Bottom) T h e origi n o f t he inferior gemellus ten don is n ice ly demonstrated on thi s
image. The gluteus minimus tendon can now be identified. Like the gluteus medi us tendon, the glut eus minim us
tendon forms along th e posterior aspect o f th e muscle. T h e obturator foramen is visi ble alon g the anteri o r aspect of
the obturato r i n tern us muscle. T he conten ts of the fo ramen are the obturator n erve, artery and vein .
v
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 LATERAL HIP
AX IAL T1 MR, EXTERNAL ROTATORS & CUFF

Femoral a., v. Tenso r fasc ia lata m.

Pectineus m.

fli o p soas m .

Obtu rator fo ram en

Fem oral head
Glu teus rnin imus t.

Acetabulum
Glu teu s medius m.

Obturator internus m. Greater trochanter

In fe rior gemel lus m.

Scia tic n.
Ob tu rator intern us t . & Inferior glutea l a., v.
in fe rio r gemellus t .

Sacrotuberous ligament

Femoral a., v. Tensor fascia lata m .

Pect ine us m.

Iliopsoas m.

G lu teus minimus m.
Obturato r fora m en
Fem ora l h ead
G lu teus m inim us t.
Acetabulum
G luteus m edius m.

Obturato r in ternus m. Greater t rochanter

Inferior gemell us m.

Sciatic n.
Inferior gluteal a., v.
Sacrotubero u s ligam ent
Gluteus maximus m.

til
>
Q)
0..
-o (Top) The muscle belly o f the in ferior gemellus muscle arises fro m the te ndo n several centimeters la te ral to the origin
c: of the tendon . In th is in d ividual the muscle bell y wraps the inferior surface of the fu sed te nd o n o f th e obturator
internus a nd superior gemellus muscles. Because the d ee per layer of t he ex te rna l rota to rs follows a co urse th at is
c. oriented from inferomedial to superomedia l th e muscle bell y o f the in ferior gemellus muscle is seen inferior to its
J: in sertion. (Bottom) The gluteus min imus tend on inserts onto the a nteri o r facet of the greater trocha nter. This
insertion is located infe rio r to the in se rtio n o f the glute us m ed ius m uscle. Note how the sciatic ne rve continues to be
v difficult to separa te from th e adjacent muscles.

102
 LATERAL HIP
AXIAL T1 MR, EXTERNAL ROTATORS & CUFF

Femoral a., v.
Pecti neus m.

Iliopsoas m.

Obturator externus m.

Obturator a., v. & n.

G luteus m inimus t.

Greater troch an ter

Obturator internus m.
Obtura tor ex te rnus t.

Q uadratu s fem o ris m.

Sciatic n.

Femora l a., v.
Pect ine us m.

Iliopsoas m .

Obturato r ex tern us m.

G luteus minimus t.

Obturator internus m. G reater troc hanter

O bturato r ex te rn u s t.

Q uadratus fem o ri s m.
Sciatic n.
In ferio r gluteal a., v.

(Top) T he ob tu rator ex ternus tendo n is the m ost in ferio r tendo n to i nsert into th e piriformi s fossa. This muscl e also
has a complex t h ree dimen sional orien tati o n and on thi s image its o rigin is seen medially w hile its i n serti on is seen
laterally. Th e intervening muscle, however, is only v isible o n more i nferior im ages. (Bottom) Th e m uscle belly of the
gluteus minim us muscle remains v isible as th e te ndon inserts o nto th e anterior facet of the grea ter trochanter. Th e
muscle belly wi ll co ntinue in feriorly for several mo re i mages. The quadratus femo ri s muscle takes origin from the
lateral surface of th e ischial t u berosity uperior to th e ham string m uscles.

v
103
 LATERAL HIP
AXIAL T1 MR, EXTERNAL ROTATORS & CUFF

Fem oral a., v.

Pectine us m.

Ili o psoas m.

Adductor brevis m .

Vastus la tcralis m.
Obtu rato r externus m .
G luteus minimus t.

Obturator internus m.
Greater troch an ter

Quadratus femoris m.

ciatic n.

Fem oral a. , v.
Pectine u s m .

Iliopsoas m.

Adductor lon gus

Adductor brevis m.
Gluteus min imus m .

Obturato r ex tern us m. Gluteus min imus t .

Obturator in tern us m.
Femur

Ischiu m Quadratus femo ris m.

Sciatic n.

(Top) T h e full ex ten t of th e obturat o r ex tern us muscle is easy to appreciate o n th is image extendin g from th e
exte rna l marg in s of the obtura tor foram en to th e piriformis fossa . (Bottom) At its origin the vastus lateral is muscle is
in close re lat io n sh ip to t h e in ferio r m ost ex te nt o f th e glu teus minim us muscle along t he anterio r aspect of the
femur.

v
104
 LATERAL HIP
AXIAL T1 MR, EXTERNAL RO TATORS & CUFF

Femoral a., v.
Pec tineus m .

Ili opsoas m .

Adduc tor lo ngus m .

Adduc to r brevis m.
Gluteus minimus rn .

Obt u ra to r extc rnus m .

Obtu ra to r in te rnus m .
Femur

Q uadratus fe m o ris rn .
Scia tic n.

Fe m oral a., v.

Pectine us 111 .

Ilio psoas m.

Adductor longus m.

Adductor brevis m .

Obturator ex tern u s m .

Ob turator int e rnus m .

Fe m ur

Isch ium Quadratus fe m oris m .

Sciatic n .

(fop) Th e i nsertion of th e quadratus femori s muscle o nto th e posterior aspect of th e femur is well seen h ere. It is
superi or t o th e inserti on of th e pectineus muscle and latera l to the inserti on of the gl uteus m axi m us muscle.
(Bottom) The scia t ic nerve travel s al ong th e posterior aspect of th e quad ratus femoris muscl e. It finall y becomes a
distinct structure. Th e obturator internus muscle is st ill vi sible coveri ng the en t i re inner aspect of th e obturator
foramen. As with many of the o t her ex tern al rotator muscles it h as a com plex three di m ensiona l orientation. Whi le
the muscle bell y is quite large i t funnels t o a very narrow st ru cture t h at courses t hrough th e lesser sciatic n otch and
makes th e abrupt latera l turn towards th e greater troch an ter. For anatomy more inferio r to t his level see "Thigh
Overview" secti on. v
105
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

[] A nterior abdomi nal

wa ll m s.
G luteus m aximus m.

Ilium

Superior gluteal a., v.

Ili opsoas m.
Piri form is m .

Scia tic n.

Inferior gluteal a., v.

Anterio r rim Ischial spin e
Obtura tor in ternus t . &
Femoral head
in ferior gem ellus t.

Obtu rator i nternus m .

Commo n femo ral a., v.
Obturato r ex tern us m. Sacrotuberous ligamen t

Pectin eus m.
Isch ial tu berosity
Sartorius m .
Adductor magnus m .

G luteu s max irnus m .

Anterior abdo minal
wa ll m s.

Superior glu tea l a., v.

Il iopsoas m .
Pirifo rm is m.

Anterio r rim Inferior glu tea l a. , v.

up. gem ellus m. & t.

Femoral h ead O bturat or in ternus t. &
in fe rior gem ellus t.

Obturato r internus m.
Obturato r extern us m.

Commo n fem oral a., v. acro tu berous ligam ent

Pectineu s m. - -+--
Ischial tuberosi ty
Sarto rius m.
Adducto r magn us m.

(Top) First of twen ty six sagittal images o f the lateral hip from medial to la teral. For d etail o f the m ore medial
anatom y see "Posterior Pelvi s" section. The images are immediately lateral to t he ischia l spin e. The gemell i muscles
both originate from th e outer aspect of the ischial spine. I n t his patien t the te ndons o f t he obturato r internus and
inferio r gemell us muscle are fused. Fusio n between the obturator internus tendons and th e gem elli tendon s is
co mmon . The piriform is tendon may also join th e fu sed tendon . (Bottom) The m uscle belly o f the superi or gemellus
is v isib le. It is su perior to th e obtu rator i nternus tendo n. The piriform is muscle is we ll abo ve th e o th er ex tern al
v rotators of the hip at thi s point. A few fibers of th e ischiocond y lar portion of th e adductor m agnus m uscle (n o t
labeled) are seen arising from th e media l aspect o f the ischial tuberosity.
106
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

Glu teu s maximus m .

Anterior abdom inal Ilium
wa ll ms.

Su perior glu teal a., v.

Piri fo rm is m .
Ili opsoas m .

Sciatic n .

Infe rio r g lutea l a., v.

Sup. gem e ll us m . & t.

Femoral head
O bturator in ternu s t . &
inferior gemell us t.

Obtu ra to r exte rn us m . O btura tor inte rnu s m.

Com m o n femoral a., v . Sacro tuberous ligamen t

Pecti ne us m .
Ischial tuberosity
Sartorius m .
Ad du ctor m ag nus m .

Glute us m axim u s m.

An te rio r abdo minal Glu teus m edius m.

wall m s.
IIi um

Su perior glutea l a., v.

Il iopsoas m . Pi ri fo rmis m .

Scia tic n .

In ferio r g luteal a., v.

Sup . ge m e llus m. & t.

Femoral h ead
O bturator internus t. &
in ferior gemellus t.

Obturator extern us m . O bturato r in tern u s m .

Common fe mora l a ., v. Sac ro tube rous ligamen t

Pecti ne us m .
Isch ial tuberosity
Sarto rius m .
Adducto r m agnus m .

(Top) The tendo n of the superior gemellus muscle is loca ted along the inferio r bo rder of t he muscle in close
prox imity to the fused tendo ns o f the obturato r internus and inferior gemellus m uscles. The obtu rato r exte rnus
muscle is anteriorly located relative to the isc hium and the oth er extern al rotator tend o ns. (Bo tto m) The sciatic
nerve is located alo ng th e inferio r border o f the pi rifo rmis muscle as it enters th e lower extremity. The muscle belly
of th e obturator internus tapers as it co urses along th e posterior aspect o f th e hi p joint.

v
107
 LATERAL HIP
SAGITTAL T1 M R, EXTERNAL ROTATORS & CUFF

Gluteus maximus m.

An terio r abdominal Gluteus m edius rn.

wa ll m s.
IIi um

Superior gluteal a., v.

Iliopsoas m.
Piriform is m.
Inferior gluteal a., v.

Scia tic n.

Sup. gemellus m. & t.

Fem ora I h ead
Obturator internus t. &
inferior geme llus t.

Obturator ex tern us m. Obturator internus m .

Sa rtorius m. Sacrotuberous ligament

Pectineus m. Ischial tuberosit y

Rectus femoris m. Adductor magnus m.

G luteus maximus m.
Anterior abdominal
wall ms. G luteus medius m.

Ilium

Su perior gluteal a., v.

Iliopsoas rr1. Pi riformi s m.

Inferior gluteal a., v.

Sciatic n.

Sup. gemellus m. & t.

Fem oral h ead
- -+- Obturator internus t. &
inferior gemellus t.

Obturator extern us m.

Sacrotu berous ligament

Sartori us m.

Pect ineus m. Ischia l tuberosi ty

Rectus femoris m. Adductor magnus m.

(Top) T h e piriformis m uscle is insepa rabl e from th e gl uteus medius muscle over the next several i mages as t hey move
lateral ly. The gluteus maximus muscle covers th e entire superi or to inferior ex ten t o f t he buttocks. T he gluteus
m ed ius is just deep to th e gl uteus maxi mus muscle but has a mo re lateral origin. (Bottom) Th e sacro tuberous
ligament is located alo ng t h e ex terna l surface of th e obturator internu s muscle. Th e liga ment follows a superomedial
to inferolateral co urse. Its inferior mos t extent is v isible on th ese i mages.

v
108
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

G luteus maximus m .
Anterio r abdominal
wall m s. G luteus m edius m.

Ilium

Superior g luteal a., v.

Ilio p so as m. Piri formi s m.

Infe rior glu teal a., v.

Sciatic n .
Fem o ral h ead
Sup. geme llus m. & t.

O btura to r in ternus t. &

Sa rto rius m. inferio r ge me llus t.

Obtu ra tor externus m.

Isc h ial tuberosit·y

Pec t in e us m .

Rectus fe m oris m.
Adductor magnus m .

An te rio r abdominal Glu teus maximus m.

wall m s.
Glu teus medius m.

lli.um

Glute us minimus m .

Iliopsoas m .

Sup. gem e llus m. & t .

Fe moral head

Sa rtoriu s m.
'-:---+- Obtu ra to r in tern u s t. &
infe rio r ge mellus t.
O bturator ex te rn us m.

Isch ial tuberosity

Pectine u s m .

Rec tus fe m o r is m . Ad ductor m agnus m.

(Top) The scia tic nerve drapes alon g the posterior surfaces of th e externa l rotato r muscles and tend on s and is difficu lt
to identify as a separa te st ructure. The inferio r g luteal vessels are not d iscernible as discrete st ru ctures in th e far lateral
aspect of the buttocks. Th e superio r gluteal vessels re mai n visible. (Bottom) Along th e la teral most margin of th e
ischi um th e obt ura to r exte rn us muscle moves p oste rior.l y gaining proximity to the o ther ex te rn al rotator tendons.

v
109
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

Anterior abdom inal Gluteus maximus m.

wa ll ms.
Gluteus medius m.

Ilium
Gluteus m inimus m.

Superio r gluteal a., v.

Il io psoas m.

Pirifo r mis m .

Sup. gemellus m. & t.

Femoral h ead Obturator internus t. &

inferior gemellus t.
Sartorius m.

Obturator externus m .

Iliopsoas m.
Ischial tuberosi ty
Pectineus m.

Rectus femoris m. Adductor magnus m .

Anterio r abdominal
wall ms.
Glu teus medius m.

Ili um
Gluteus min imus m.

Iliopsoas m.

Sart orius m.
'---+- Sup. gem ellus m. & t.

Femoral h ead ---+- Ob turator in ternu s t. &

in ferior gemellus t.

Obturato r externus m . ;....--.;-- Sciatic n.

:tr--+-- Inferior gemellus m.
--+-Conjoined origin lo ng
head biceps femo ris m.
& semite ndi nosus m .
Rectus femoris m.
Lesser troch a n ter
f.l'l
Pecti neus m . Se mim embranosus m.
>
Q)
c..
"'0 (Top) The glu teus minim us muscle origin is the deepest and most latera l o f the gluteal muscles. Th e supe rior gl uteal
c:: vessels are still visible as they travel in the fat plane deep to the gluteus max imus muscle. Lateral to the isc hium the
obturator extern u s muscle courses poste rio rly to join th e oth er externa l rotators of th e hip. (Bottom) The inferio r
a.. gemellus m uscle bell y appears in a relatively lat eral position in thi s individual. It is located inferior to the ob turator
:::c inte rnus te n don . The piriformis tendon is now visible, located at th e inferio r most aspec t of the gluteus m edius
muscle. The tendon of the semimembranosus muscle is loca ted anterior to the conj oin ed tendon of the long h ead of
v the biceps fe m oris muscle a nd the semi te ndinosus musc le.

11 0
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

Anterior superior iliac

spine

Ilium

Rectus femoris t.

Iliopsoas m.
Sartorius m.

Femora I head ..;...._-+- Obturator int ern us t. &

inferi or gemellus t.

Obturator extern us m.

Iliopsoas m . Quadratus femoris m.

Lesser trochanter Semim embranosus t.

Rectus femoris m . Conj oined origin

Anterior superior iliac

spi ne

IIi um

Rectus femo ris t.

Il iopsoas m.
Sartorius m.

Femoral head

r-,=-+-- Inferi or gemel lus m.

--+-- Obturator ex tern us m.
Rectus femoris m.
Ili opsoas m.

Lesser trochan ter Quadratus femoris m .

Conjoin ed o rigin

(Top) The su per io r ge mel lus te ndon h as now fused w ith t h e tendon s o f the obtu rator intern us and inferior gem ell us
muscles. These three musc les act in co n cert and are a lso kn ow n as the triceps coxae. T he quadratus fem o ri s muscle
takes origin from th e latera l aspect of the isc hia l tuberosity deep to th e h amstring tendons. (Bottom) Th e obturator
extern us muscle has now assum ed a more pos ter io r pos itio n a n d wi ll travel with the oth e r externa l rotators a lo ng th e
poste ri o r aspect of th e hi p joint. Th e m ed ia l c ircumflex femo ra l vessels (not labeled ) a rc jus t inferior to th e obturato r
externus muscl e (sec "Hip a n d Pe lv is Ove rv iew" secti o n ) . The sciatic nerve is n o t id ent ifiab le o n these im ages. The
obturator inter n u s muscle a nd the geme lli muscles fun ction togeth er and are kn ow n as the triceps coxae muscl es.
The tendons of the muscles often fu se as in this individua l.
v
111
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

A n terio r superior iliac

spine

Sa rtorius m.

Iliopsoas m.

Rectus fem ori s t.

Fem oral neck

' - - -.,..--- Inferior gem ellus m .
Il iopsoas m. '--+-- Sciatic n .

Rectus fem ori s m .

Lesser t rochan ter Q uadratu s fem oris m .

Vastus laterali s m .

Ilium

Sar tori us m.

Refl ected h ead rectus

fem ori s m .

Rectu s fem ori s L r---+-- Superior gem ellus m .

Triceps co xae ts.
Iliopsoas m .

Femoral n eck

Capsular ligam ents

Rectus fem oris m.

Lesser trochan ter

IJ'J Vastus la teralis m.
>
Q)
c..
"'0 (Top) Th e sciat ic nerve is now v isible as it t ravels below the border o f the inferior gem el lus muscle. Once it assumes
c its position along th e posteri or hip t he obturator ex tern us muscl e rapidly d ecreases in si ze. (Bottom) Th e
ro relation sh i ps of th e external ro tators is apparent. A long th e deep layer o f muscles, t he m os t su perior tend on is the
c.. pirifo rmi s, fo l lowed by superi or gemell us, obturator in ternus, in ferior gemellus th en obturator externus. T hese
:r: muscl es all in sert o nto t h e piriformi s fossa. The quadra tus femoris muscle is d eep to the gluteus ma x i mus m uscl e and
inserts m edial t o that m uscle on the posteri or aspec t of th e femur. Th e gl uteus minim us and medius m uscles bo th
v insert o n to th e greater trochan ter.

11 2
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

Ilium

Gluteus minimus m.

Su perior gluteal a., v.

Iliopsoas m.
Piriformi s t.
Superior gemellus m.
Femoral neck
Triceps coxae ts.

Capsul ar li gamen ts
In ferio r gemel lus m.

Iliopsoas m.
Obturator extern us t.

Rectus femoris m .
femoris m.
Lesser trochanter
Vastus lateralis m.

Ilium

Gl uteus maximus m.
(
Gl uteus medius m.
Glu teus minimus rn.

Iliopsoas m.

'---.-..::.+-- Superior gemellus m.

Capsular
'----+--- Triceps coxae ts.

Rectus femoris m.

Femoral
Vastus latera lis m.

(Top) The broad origin of the gluteus minimus muscle from the an terior aspect of the auricular surface of the ilium
can be easi ly appreciated o n this i mage and the more lateral i mages. (Bottom) T h e glu teus medius muscle begins to
taper inferiorl y. Thi s tapering wi ll lead to formation of its tendon.

v
113
 LATERAL HIP
SAGITTAL T1 M R, EXTERNAL ROTATORS & CUFF

Glute u s min imus m.

Te n sor fas cia lata m.

Ca psu lar liga m en ts

Fe m o ral diaph ysis --;..;=

Vastu s la te ralis m.

[]
G lute u s minimus m.

Te n sor fascia lata m .

Capsular ligam ents

Femoral d iaph ysis - -l==

Cl'l Vastus late rali s m.
>
Q)
c..
""0 (Top) Th e broad expa n se of the gluteus minimus m uscle covers bo th a nteri o r and su perio r surfaces o f th e jo int.
c:: (Bo ttom ) Th e in ferior taper of the glute us medi us muscle is now well-defined . Note t he orientation of t he fibe rs
with in th e m uscle. Their lo ng axis follows the taper o f th e muscle.
c..
:I:

v
11 4
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

Gluteus minimus m.

Tenso r fasci a lata m.

Rectus femo ris m.

Femoral diaph ysis

Vastus latera lis m .

G Iu teus mini mus 111.

Tensor fascia lata Ill.

Vas tus latera lis rn.

(Top) The piriform is tendon is deep to the gluteus medius muscle. It is closely related to the obt urator internus and
gemell i tendons. (Bottom) The gluteus medius tendon is now easily seen.

v
115
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL ROTATORS & CUFF

Glu teus minim us m.

Te nsor fascia lata m.

Vastus latera lis m.

G luteus rn inimus m .

:------:-- Gluteus m ed ius t.

,...--- -;--- Triceps coxae ts.
Tenso r fa sc ia lata rn.

rJl Vastus late ra lis rn.

>
Q)
c..
""0 (Top) The obturator ex tern us tendon inserts alon g the inferi o r-most aspect of t he pirifo rmis fossa. Th e fos a is
c:: located alo ng th e mesial surface of th e grea ter trochanter. (Bottom) The pi rifo rmis tendo n and th e obturator
internus and gemelli muscles insert at th e piriformis fossa, superi o r to th e obtu rator ex tern us tendon. The gl uteus
0.. medius tendon i n serts o nto the lateral facet of th e grea ter trochanter. Th e glu teu s m ed ius ten don has two
:r: co mponents, o ne whi ch is co ronally o riented and th e o ther more sagittally oriented. T h e coron ally oriented
co mponen t is visi b le here.
v
11 6
 LATERAL HIP
SAGITTAL T1 MR, EXTERNAL RO TATORS & CUFF

Gluteus minimus m.

Glu teus m ini mus t.

Tenso r fascia lata m.

Vastus late ra lis m.

Gluteus mi n im us m.

Gluteus min imus t.

Tensor fascia lata m .

Fe moral diaphysis

Vas tus la te ralis m .

{Top) The ten don o f t he gl ute us minimus m uscle is not as well-defin ed as the tendon o f th e glu te us m ed ius m uscle.
(Bottom) Th e glu teus mini m us te ndo n inserts o nto t h e anteri o r fa cet o f th e greater t roch ante r.

v
1 17
 LATERAL HIP
SAGITTAL T1 M R, EXTERNAL ROTATORS & CUFF

Gl uteu s minim us m .

G luteus minimu s t.

Femoral diaphysis

Ten sor fascia lata m .

Vas tus latera lis m.

Gluteus m i nimus m.

Femoral diaph ysis

Ten sor fascia lata m.

rJl Vastus latera lis m.

>
Q)

-o (Top) Th e m o re sagittal portion of t h e gluteus medius tendo n is v isible. (Bottom ) o te the continuatio n of the
C:: gl uteus minimus muscle beyond its insertio n .

0..
:r:
v
118
 LATERAL HIP
CORONAL T1 MR, EXTERNAL ROTATORS & CUFF

Glute us ma ximus m .

Glute us medius m .

Sciatic n.

Superio r gem ellus - - niiiiiiiiii':;=

muscle & tendo n

O bturato r in te rnus t. &

Obtu ra to r internus m. infe rio r ge m ellus t.

In ferio r gem ellu s m .

Obtura tor inte rnus m .

Sciatic n .

Isc hium

Hamstring te n dons

Gluteus max imus m .

Pi riformis m . Glute us m edius 111.

Scia t ic n.

Supe rio r ge m ellus

muscle & te n d o n

Obturator inte rn u s t. &

inferior gem ellu s t.

Inferior g e m ellus m.

Q uad ratus fe m o ris rn .

Ha m string te ndo n s

(Top) First o f fourtee n coronal images of th e lateral aspect of th e left hip from posterio r to anterior. This image is just
anterio r to the ischial sp ine. The supe rior to inferi o r relatio nships of the deeper layer of the exte rna l rotators is easily
appreciated . The piri fo rmis muscle is th e most superior. Of the muscles intima tely rela ted to the ischial spi n e t h e
superio r gemellus muscle is most superior. Its tendon is along the inferior surface of the muscle belly. (Bottom) The
obturator inte rn us te ndon is located between th e superio r a nd infe rior gemell us m uscles. The te ndo ns of the
obturator internus muscle and infe rior gemellus muscles are fused in this indiv idua l.
v
119
 LATERAL HIP
CORONAL T1 MR, EXTERNAL ROTATORS & CUFF

Glute us max imus m .

Piriformis m .
Glute us m edius m .

Sciati c n .

Gl ute us med ius t.

Supe ri or ge mellus m.

Greate r troc hante r

Obtu ra tor inte rnus m. Trice ps coxae ts.

Inferi o r gem ellus m.

Q uadratus fe m o ri s m .

Hamstring tend o ns

Il ium
Glu teu s m axim us m.

Piri form is m.
Glu te u s m ediu s m .

Sciatic n .

Piriformis m.

Superior gemellus m. Glute us m edius t .

Greate r troc ha nte r

Obturator internus m. Tri ce ps coxae ts.

Inferio r ge m e llus m .

Ischium
Quadratus fe m o ris m.

Hams tring tendo ns

(Top) Two portions o f the obtu rator in tern us muscle are visible. The largest portio n of the muscle is located within
the pelvis where it completely covers the o bturato r foramen . Once it has passed through the lesser sciatic forame n &
abruptly turned lateral the m uscle is significa ntly smaller & its tendon is visible along the enti re co urse of thi s
portion of the muscle. The tendo n o f the obturator intern us muscle fuses with the tendo ns of th e gemell i muscl es.
These t hree muscles function as a unit and are known as th e tri ceps coxae muscles. (Bottom ) Th e tend on o f the
gluteus medius muscle fo rms along th e posterior-most portion o f th e muscle. W hile n ot visible on more posterior
v images its full ex tent is appa rent on the two images on th is page. The te ndon has a broad insertion o nto the
superoposterior facet of t he greater trochanter whic h is clea rly seen o n th is image.
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 LATERAL HIP
CORONAL T1 MR, EXTERNAL ROTATORS & CUFF

Jl ium Glute us maximus 111 .

Gl ute us m ed ius 111.

Pirifo rmi s t.

Glute us medius t.
Super io r ge m e llus rn .

G re ate r tro c han te r

Obtura to r in te rnus rn.
Triceps coxae ts.

Obturato r ex tern us rn .
In feri o r ge m e llus 111 .

Isc h ium

IIi um
Gluteus maxirnu s m.
LJ[
Gluteus medius m .

Glute us mi n irnus m .

Piriformis t.
Supe rior gem e llus m .

Greater trochan ter

In fe rior gem ellus m .
Gluteu s m edius t .
Obturato r in tern us m .
Triceps coxae ts .

Obtura to r exte rnus m. O bturator externu s t.

Isch iu m

(Top) As it courses late rall y th e tendon of the piriformis muscle develops. This tendon is the most superio r tendon to
insert into the piriformis fossa. The second portion o f the glu teus m edius tendon inse rts along th e lateral facet of the
grea te r trochanter. The tra n si tio n between the two insertion sites is visible on this image. Th e inse rt ion onto the
lateral facet exte nds more inferiorly than the insertio n onto th e superoposterior facet. (Bottom) Th e piriformi s
tendon inse rts o nto the media l aspect of the greater trochanter, a region known as the piriformis fossa. Note the
oblique superomedial to inferola te ral course of t h e tendon. Compa re this to the ori entat io n o f t ri ceps coxae tend on
on more anterior images. The obturator exte rnu s tendon is the most infe rior tendon inserting into the piriformis
fossa.
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 LATERAL HIP
CORONAL T1 MR, EXTERNAL ROTATORS & CUFF

Gluteus m aximus m.

Ilium Glute us medius m .

Gl ute us minimus m.

Piri fo rmb l.

G reater troch a nte r

Inferior ge m e llus m.
Glute us medius l.
Obtu ra tor internus 111.
Tri ceps coxae ts.

Obt u ra tor extern u s m. Obturator ex tern u s l.

Ischium

Ili um
Glu te us maximus m .

Glu teus medius m .

Glu teu s min im u s m .

Tri cep coxae ts.

Obturato r in te rnus m. Grea te r trochan te r

G lute u s m ed iu s t.

Obtura tor cxtcrnus t.

Obturator externus m.

Ischi u m
Lesser trocha nter

(Top) The gl ute us medius tendon con tinues its insertio n o nto th e la teral facet of the grea ter trochanter. Th is
insert ion will conti n ue a nte rio rly to join with th e insertio n o f the glute us min im us te ndo n . (Bottom) The t riceps
coxae tendo ns also in sert into t he pirifo rmis fossa. Betwee n th e image above a nd this image note the diffe rin g
o ri e nta ti o ns between the piriformis tend o n a nd th e tri ce ps coxae te ndon s. The obtu rato r exte rn us muscle fu ll y
covers the ex terna l surface of th e obtura tor fo ramen. As it co urses superiorly a nd latera lly to its insertion it tapers to a
co mpletely tendin o us structure.
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 LATERAL HIP
CORONAL T1 MR, EXTERNAL ROTATORS & CUFF

II iu m
Gluteus maxi mus m.

Gluteus medius m.

G lute us minimus m.

Triceps coxae ts.

G reate r troch a nte r
Obturator internus 111.

O bturator extern us t.

Obturator e x tern u s m.

Ischium

Lesser trochanter

Il ium

G lute us medius m .

G lu te us mi n im us m.

Obtura to r internus t. &

in ferior gem e llus t.

Greater trochante r
Obtu rator inte rnu s m.

O btura tor extern us t.

Obtu rato r ex te rnus m.

Ischi u m
Lesser troch a n te r

G lu te u s maxi mus m.

{Top) The gluteus minimus muscle originates from the anterior aspect of the auricular surfa ce of t he ilium . (Bottom)
The superior extension of the obturator internus muscle o rigin along the i nner aspect of th e ilium, along the med ial
wa ll of th e acetabul um, is easy to appreciate. The obturator externus muscle wraps aro und th e posterior aspect of the
femoral neck.

v
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 LATERAL HIP
CORONAL T1 MR, EXTERNAL ROTATORS & CUFF

Il ium
G lute us ma>.im us 111.

G lut e us m ed ius m.

G luteus m in imus m .

Triceps coxae ts.

Greater t rochanter
Obtu ra to r inte rnus m.

Obtu ra to r extern us t.

Obtura to r cxtc rnus m.

Ischiu m

trochant e r

IIi u m

G lute us medius m .

Gl ute us minimus m.

Fem o ra l h ead
Capsula r ligamen ts

G lute us minimus t.
Obtura to r in te rnus m.
G rca tcr troc hanter

Obturator ex te rn us m.

Ischium

Ill G lut e us max imu s m .

>
Q)
0..
"0 (Top) The gluteus mi nim us m uscle originates from the anteri or aspect of th e auricular surface o f th e ilium . (Bottom)
c Th e gluteus minimus tendon i s much shorter and th i nner than the gl uteus m edius ten don.
('j

0..
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 LATERAL HIP
CORONAL T1 MR, EXTERNAL ROTATORS & CUFF

Ilium
Ilio tibial ban cl

Glute us mecl ius m .

[1f
Glute us m in imus m.

Fe m ora l head
Cap sula r ligam en ts

Glute u s minimus t.
Obtura tor in te rn us m .

G reater troc ha nte r

Obturato r exte rn us m.
Glute u s m ax im us m .

Isc hium

Il iot ibial ba n d

Glute us m in imus m.

Fe moral h ead
Cap su lar ligam ents

Glu teus mi n imus t.

Obtu rato r in te rn us m .

Gl ute u s max imus m .

Obturator exte rn us m .

Isch ium

(Top) The glute us min im us te nd on inse rts on to the ante rior facet of the greate r troch a nter. Note h ow the gluteus
med ius m uscle co ntinues a nte riorly to wrap aro und the anterior aspect of th e glute us m inimus te ndo n . (Bottom)
The gluteus mediu s and min im us m uscl e bellies continue a nte ri o rly beyond their inse rtions onto th e grea ter
trocha nte r. Fo r more ante ri o r im ages see "Hip and Pelvis Overv iew" section .

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125
 POSTERIOR PELVIS
• > 1 em ve rtica l or posterior displacement o r
!Terminology rotation of ilium relat ive to sacrum
Abbreviations • CT: Posterior Sl w idened
• Sacroi liac (SI) joint o Bilatera l disrupti o n sac ro tuberous & poste ri o r
• Structures (S): Supplied by a nerve o r artery sacroiliac liga me nts
• Complete ly disrupts ring
• Separates spin e from lower extremities
!Imaging Anat omy Greate r Sciatic Forame n
Sacroiliac joint • G rea te r sciatic notch converted to f.orame n by
sacrospi n o us liga m ent
• Anterio r syn ovial joint
• Co ntents: 7 nerves, 3 sets of vessels, pi riform is m.
o Auricular su rfaces sacrum & ilium
• Passageway from pelvis to thig h
o Distal 1/3 h as syn ovial features
o Struc tures identified as exiting pelvis above or below
o Upper 2/3 microscopically symph ysea l, not synovial
piriformis m.
• Posterio r sy ndesmosis: Tuberosi ties sacru m & ilium
• Above: Superior glutea l a., v., n .
• Function: Pri marily weight transfer axial to
• Be low: Pudendal n ., inte rnal pudendal a., v., n. to
appendicu la r skeleton
obturator inte rnu s, sciatic n ., inferior gluteal a., v.,
o Limited gli d ing & rota tion
n., posteri or cuta neous n . of th ig h, n. to quadratus
• Widen ing ante ri o rly ca n occur without in stability
femoris m.
• Posterior w ide ni ng ind icates instabi lity
o Relatio n ship of structu res
• Sacroiliac ligaments
• Most media l: Pudendal n.
o I nterosseo us sacro il iac: Within syndesmotic jo int
• Most lateral: Scia tic n .
• Between tube rosities ilium & sac rum
• N. to quadra tus femor is m . deep to sciatic n.
• O ri ented supe riorly & latera ll y
• Infe rior gluteal a rtery
• Weig ht t ransferred to sacrum, sac rum displaced
o Larger term ina l branch anterior division internal
inferio rl y, force tra n smitted to liga m e nts;
il iac a.
ligaments pull ili i inward, compress sacrum &
o Passes between Sl & 52 or 52 & 53
interlocking surfaces SI joints
o Exits pe lvis inferi or to piriform is m.
• Extremely strong
o Poste rom ed ial to sciatic n .
o Ante rior sacroil iac: Weak ligaments
o Pre natally continuous wi th popli teal a., re mnant is
• Ma inl y anterior joint capsul e
a rtery to scia tic n .
o Posterior sacroiliac: Posterior fibers interosseou s
o S: G luteus ma ximus, obtu rator internus, quad ratus
ligament
fe m oris, superior hamstrings m s.
• Short dorsal sacroil iac: Horizonta l; la te ral sacra l
o I n fe rio r g lutea l v. travels with artery, drain s in to
crest Sl & 52 to posterior iliac crest
internal iliac v.
• Long dorsa l sacroiliac: Vertical obl ique; posterior
• Inferior gl u tea l n erve
supe ri or iliac spine to late ra l sacra l crest 53, 54
o Bra nch of sacra l p lex us
Posterio r Sacroiliac ligaments of Pelvis o Exits pelvis inferior to piriform is m.
• Prim ary stabilizers of pelvis o Poste rior to scia tic n .
o Little con t ribu tio n from an te rior st ruc tures • Su perior g luteal a r tery
• Resist rota ti onal forces & vertical shea r o Continuatio n poste rio r d ivision internal iliac a.
• Sacrotuberous: Superior & inferior posterio r iliac o Passes between lu mbosacral t runk & S1
spines, sacrum & coccyx to ischial tube rosity o Exits pelvis superi o r to piriformis m.
• Sacrospinou s: Latera l sacrum & coccyx to ischial spine o Superficial bra n ch : S - gluteus maxi m us m.
• Iliolumbar: Tip LS transverse process to iliac crest o Deep bra n ch : S- glu te us m ed ius & minimu s, tensor
• Sacroiliac liga m e nts: Interosseous, lo n g & sh ort fascia lata m s.
dorsal o Su perio r g lu tea l v. travels w ith a rte ry, drains into
• Stages of pe lvic disruption inte rnal il iac v.
o Up to 2.5 em disru ptio n sym phys is p ubis with intact • Superi or g luteal n e rve
posterior ligame nts o Branch of sacral p lex us
o Symph ysis > 8 em likely poste ri o r li gament o Exits pelvis superio r to piriformi s m.
disru ption • Sciatic n e rve
o Disrupt sacrospinous, a nte rior sacroiliac li ga ments o Exits pelvis in fe rio r to p iriformis m.
• Pelvis w iden s o Most la teral structure
• Posterio r supe rio r iliac spines impinge on sacrum, o See fo llowing page
limit widen ing • Pudenda l n . & in ter na l p udendal vessels
• Rota tion & shear stability preserved o Exit inferio r to piriformis m.
• CT: Ante rior SI widened, posterior SI in tact o Nerve most med ia l structure
o Unila te ral disruptio n sacrotuberous & posterior • Nerve to o b turat o r i n tern us m.
sacroiliac ligame nts o Exits pelvis infe rio r to piri formis m .
• Crea tes vertical & rotational instabili ty

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126
 POSTERIOR PELVIS
o T ibial n.: Pre-axial
Lesse r Sciatic Fora men o Co mm o n peroneal n.: Post-a xial
• Le ser sciatic n otch con ver ted to foramen by • Largest n erve in bod y
intersect ion (cross in g) sacrotu be rous a nd sacrospin o us • Exits pelvis inferio r to pi rifo rmi s m.
li ga me nts • Relati o nships
Puden da l n . & in tern a l pude nda l vessels o Deep to gluteu s m axi m us m ., biceps femoris m.
o Pass over sacrospinous li ga m e nt o Midwa y betwee n isch ial tuberosi ty & grea ter
o Exit buttock, e nter peri ne u m trochante r
• Obturato r inte rnus m. (see "La te ral Hip" sectio n ) o Poste rio r to obturato r inte rnus, q uad ratus femoris,
add uctor m agnus m s.
Sacral Pl exus • S: Posterior thigh, entire leg, entire foo t
• Ven t ral rami L4, LS, Sl , 52, 53, 54 • With in thigh s upplies
o lA , LS enter as lumbosac ra l trunk o Tibial n. : Lo n g head biceps fe moris, sem ite ndin osus,
• Lumbosacral trunk: Form s at pelvi c bri m ; travels se m imem branosus, isch iocondylar portion adducto r
late ral a nte rior to Sl joi nt, th rough psoas m . m agnus ms.
med ial to obturato r n .; joins sacral plexus o Common pe roneal n .: Short h ead biceps femor is m.
o Su pe rio r gluteal a. passes betwee n lumbosac ral trunk • Anoma lo us re latio nshi p betwee n scia t ic n . &
&S I pirifo rm is m . com m on
o 54 di vided between sacral & coccygeal plex us o Undivided n. en ti rely belo w muscle 90<)1(,
• Forms o n a nterio r s urface pi ri form i m . & coccygeus o Divided n e rve o ne po rt ion t h ru muscle, sin gle one
111.
below 7.1 %
• Bran ches o Divided n e rve abo ve & below m uscle 2.1%
o Infer io r g lutealn : LS, Sl , 52 o Und ivided nerve w ith in muscle 0.8%
• Ex its pe lvis in fe ri or to p iriform is m . supe rfic ia l to • C linical note: Piriformis syndrome
sciatic n. o Sciatic n . comp ressio n in greater scia ti c n otch
• S: Gluteus maximus m . o Ca uses: e rve anoma lies, fibro us ba nd s, abe rrant
o . to levator a ni & coccygeu s: 53, 54 vessels, rare m asses & h emato ma
• Exits plexu s, en te rs musc le o C linicall y: Sciat ica, no bac k pa in
o N. to obturator inte rnus m . & s uperio r gemell us
o Diag nosi s of exclusio n ·
m .: LS, S I, 52
• Exits pelv is infe ri or to piriformis 111 .
• Late ra l to in terna l pudenda l a., v. !Anato my-Based Imaging Issues
o . t o piriformis: Sl , 52
• Exi ts plex us, en ters m uscle Imaging Recommendati ons
o N. to quadratus femoris m . & infe rior ge m e llus • M R: So ft tissue assess me nt
m.: L4, LS, S I o Diag nose m asses, a nato mi c a noma lies, o th er ca uses
• Exits pelvis infe ri o r to piriformi s m ., d eep of ne rve co m pression
(a nter io r) to scia tic n . o Seque nces
• Articu la r branc h to h ip • T 1W I sagittal, axial, coron al provide anatomic
o Pelvic spla n c hn ic: 52, 53, 54 assessme n t
• Trave ls anterior ly to jo in inferi o r h ypogast ric • STIR corona I
plexus o Para me te rs
o Pe rin ea l branch S4 • FOV: 35-40 em
• Exits pelv is via coccygeus m. • T I-I K: 5 mm, n o gap
o Pe rfo ra tin g c uta n eo us n .: 52, 53 • Ma t rix: 384 x 5 12
• o u rses through sacro tuberous liga ment • Limit cove rage to sciati c n o tch
• S: Skin medial buttoc k • MR: preferred modality fo r sacroi liitis
o Poste ri or femoral c uta n eou s n . of t hi g h : Sl , 52, 53 o FOV: 30 e m
• Ex its pelvis inferi or to piriformis m. o THK: 3 mm
• S: Ski n infe rior buttock, poste rior thigh, popliteal o Mat rix 256 x 256
fossa, latera l perin eum, upper m ed ial thig h o Obliqu e co rona l & axia l pla n es
o Pude nda l: 52, 53, 54 • Re lative to sacral long ax is
• S: Peri ne um o Intravenous contrast usefu l
o Sc iatic n .: L4, t s, Sl , 52, 53 • Nor ma l joint has no e nhancem e n t
• See be low
o Supe rio r g lutea l n .: L4, LS, Sl
• Ex its pelvis supe rior to pirifor m is m .
• Betwee n gluteus m edius & minimus ms.
ISelected References
1. Puhakka KB et al: M R imagi n g of the norm al sacroi liac
• S) gl uteus med ius & minimus, tenso r fascia la ta
join t wi th correlation to histology. Skeleta l Racl iol.
Ill S.
33( 1): I S-28, 2004
2. Beaton LE et al : Th e sciatic n erve an cl th e piri fo rmi s
Sciatic Ne rve muscle: thei r i nterrelati on a possible cause o f
• 2 nerves in o n e shea th; typica ll y di vide a t po pliteal coccygodyn ia . J Bone j oi nt Surg. 20:686-8, 1938
fossa

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127
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130
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

External ilia c arte ry & Psoas musc le

ve in
L4 nerve trunk
Inte rnal iliac a rte ry &
vein Fe m o ra l n e rve
O btura to r & accessory
o bturato r n s.
LS n e rve trunk
L4 ne rve trunk Iliac u s m uscle
Sacrum, 1st segm e n t Sl ne rve root
T h ecal sac
Sl jo int, syn d esm o t ic

IIiac c rest
Sho rt dorsa l sacro iliac I.
"-----+- Erec to r s pinae m s.
com plex

Exte rna l il iac a rtery & Psoas muscle

vein
Internal iliac art e ry & L4 n e rve trunk
vein
Fe m o ral n e rve
Obturato r & ac cessory
o bturato r ns. LS n e rve trunk
Iliacus musc le

Sl jo in t, synov ial Sl nerve roo t

Il ium
Sl jo int, syndesm o tic
Sacrum, 1st segme n t

La te ra l sacral c res t
Glute us m edius m .

Erecto r spinae m s. -+--- - -..!/

complex

(Top) This seri es of axial images is o b lique ly oriented along the axial plane of the sacru m. The images cove r fro m
superi o r t o inferior. By thi s level the L4 ne rve t runk is still sepa rate from LS and has n ot yet formed the lumbosacral
trunk. (Bottom) Th e synovial portion of the sacroiliac joint is now visible. Thin layers of a rticular carti lage are
present withi n this po rtion of the joint a n d it is much n arrower t h an the sy ndesmoti c portion of th e joint. The
prom in ent lateral sacra l crest is seen a long th e poste rior sacral border. It is th e site o f origin o f the short, and m o re
infe ri orl y, lo ng do rsal sacro iliac li gam e nts. The 52 n erve roots have separated from the th ecal sac.
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131
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

Internal il iac artery &

External i liac artery & vei n
vein Psoas mu scle

Fem oral n erve

Obturato r & accessor y

L4-n erve tru n k
obturator n erves
LS nerve tru n k
L4 nerve t runk
Ili acus muscle
Sl joint, synovial S I n erve root

Sacrum, I st segm en t
Sl joint, sy n desm otic
Lateral sacral crest

Gluteu s m edi us m. 52 nerve roo t

Iliac crest
Sh or t do rsal sacroi liac I.

Erector sp inae m s.
complex

Ex tern al iliac artery &

vein Psoas muscle

Obturator nerve In tern al i liac artery &

vein
L4 nerve trunk
L4 ner ve trunk
Iliacus m uscle
LS nerve trunk

Sl joint, synovial 51 nerve root

51 join t, syn d es mot ic Sacru m , 1st segm ent

52 ner-ve root

Gluteus m edius m. Iliac crest

Sh or t d orsal sacroiliac I. 53 ner ve roo t

:;;;,;:,.,;=.----+--Th ecal sac
Erector spi nae m s. - + - - - - ---Y
com plex

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""C (Top) Two art icular surfaces of the ili u m are present. The a nte rio r a rticu lar surface is part o f the syn ovia l po rti o n o f
c t h e joi nt, & th e posterio r tuberosity is pa rt of the syndesmosis of the sacroiliac jo int. The fe m oral nerves are located
C\1
posterior to th e psoas muscle & are not se parable o n t h ese images. The L4 n e rve tru nks a re al so posteri o r to t h e
0.. psoas; th eir relat ionships are differen t from side to side in this image. O n th e right th e n erve is separated from th e
:r: muscle whil e o n the left it is more closely approx ima ted to t he muscle. The obturator n erve is loca ted m ore med ia lly
alon g the posterior bo rd er of t h e psoas muscle. (Botto m ) The Sl n erve roots a re seen traveli ng a n te riorly to exit th e
v ve ntral n eura l fo ramina and the 53 nerve roots have n ow se para ted fro m th e t heca l sac.

132
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

Psoas muscle
External iliac a., v.
Internal i liac a., v.

Femoral nerve Obturator & accessory

obturator n erves

L4 nerve trunk lA n erve trunk

Iliacus m. LS n erve trun k

Sl joi n t, synovia l Sl n erve root

Sl join t, syndesm otic Sacru m, 1st segment

Ilium
Gluteus m edius m.
52 n erve roo t

Erector spi nae ms. - + - - - - - - - - - f f

co mplex ---·- _ _ ,. ----""="

Psoas m .
External iliac vesse ls In ternal iliac a., v.
Obturato r & accessory
Femoral n erve obtura tor n s.

L4 n erve trun k L4 nerve trunk

Iliacus rn.
LS nerve trunk

Sl joint, sy novia l Sl nerve root

SI /S2 elise remna n t

Gluteus medi us m. Sac rum, 2nd segment

Sl join t, syndesmotic
52 n erve root
Long dorsal sacroi l iac I.
Posterior il iac crest

Erector spinae m s.
compl ex

------:;- - - = - - -- - -· - - -- __,.-- - .:=; - · ,-

(Top) The obt urator and accessory obturato r nerves are see n traveling m edially a n d posteriorly. They a re loca ted
along t h e la tera l aspect of the interna l iliac vesse ls. The fem o ral nerves a re tucked behind the p soas muscle and exi t
with in the iliopsoas fa t p lane. The posteri.or most aspect o f the ilium a t thi s level is the iliac crest. T he crest co n t inues
an teriorly to the an te ri or supe rio r iliac spine a nd ext e nds inferi o rly to th e posterior superior iliac sp ine. (Bottom) A
remna nt of the Sl /S2 in tervertebra l disc is present and identifies the tra n sition from t he Sl to S2 sacra l segments.
Irregula r but congrue nt articu la r surfaces of the sacro iliac joint are evident especially o n the right. The irregula ri ty
con tri butes to stabil ity.
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 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACRO ILIAC JOINTS

Exte rnal iliac a., v.

Femoral n.

O bturator n .

lA nerve tru nk
L4 nerve trunk
Intern al iliac a., v.

Sl joint, synovial LS nerve trun k

Sl / 52 disc remnant

Gluteus medius m . acrum, 2nd segment

Sl jo in t, syn desmotic 52 n erve root

Short dorsa l sacroil iac I.

Lateral sacral crest iliac crest

Erector spinae ms.

. -.: : :. . :. .____-+- 53 nerve roo t
complex 54 nerve root

External iliac a., v.

Femoral n.
P oas rn .

Obt ura tor n . Iliacus m.

lA nerve tru nk Obturator n.

Internal iliac L4 n erve trunk

Superi or glut eal vessels LS n erve trun k

SJ nerve trunk

Sacrum, 2nd segment

G luteus m edius m.
IIi um
Sl joint , syndesmotic
52 nerve root
Short dorsal I. 53 nerve root
La teral sacral crest Posterior iliac crest
Erecto r spinae m s.
complex
...,
>
Q,)
0..
"'0 (Top) Th e S I n erve roots have ex i ted th e ventral neura l forami na . The syn ovial portion of th e I jo int now occupies
c 1/2 of the anteri o r to posterior dimensio n of th e entire jo int. The synovi al and syndesmotic portions o f the Sl joint
C\1
are in the same o ri entation. Th e synovial porti o n is located more laterally, the syndesm o ti c portio n more m ed ially.
0. T hi s o ri entatio n expl ains the relatio n ship of th ese po rtions of th e join t as seen o n AP radiographs. The iliac vessels
:c have n ow bran ched into internal and ex tern al vessels. (Bottom) Th e sho rt dorsa l il iac ligam ents arc we ll depi cted.
T h eir h o rizontal o rientation is easi ly apprecia ted and their attachments to the lateral crest o f the sacrum and to the
v posteri o r il iac crest are we ll seen.

134
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

l: xtl'rn al iliac a., v.

Psoas m.

Il iacu s m.
Obturator n.

Superi o r gluteal a., v. L4 nerve tru nk

Anterior division, LS n erve trun k

int ern al iliac a.
Sl n erve trunk

Sacru m, 2nd segment

IIi Ulll
Glut eus medius m .
52 n erve root
Sl jo int, S3 n erve root
54 nerve root
Gluteus maximus m. --l=:::il!.._
Short I.
Latewl crest
Erector spinae m s. - + - - -------?
co mrl ex

l:x ternal iliac a., v.

Psoas m.

Obturator n.

Superior glutea l a., v. lliacm m .

l.-1 n erve trunk L-1 nerve trunk

LS n erve trunk LS nerve trunk

Anterio r divi sion,
internal il iac a. SI nerve trun k

Sl joint, sy novial Sacrum, 2nd segmen t

Glut eus m edius m.
52 nerve root
Sl joint,
IIi um

Glut eus maximus m. S3 nerve root

Short I.

l·.recto r spinae ms.

complex _ ,.-- --- --- L ---=---- • -- - - --

(Top) T he L4 & LS n erve tru nks are co nverging to become the lu mbosacral trunk, and t h at is con verging with the 51
nerve trun k as they trave l infer io r and lateral to fo rm the sacral plexus. Th e i n tern al iliac artery has branched into
an terio r and pos terior divisio n s. The fem ora l ner ve is no lo nger v isi ble si nce it is w it h i n t h e groove between t he
iliacus and psoas m uscles. (Bottom) Th e irregul arity of th e articular su r faces of t h e sacroi liac joi nts is even grea ter at
thi s level an d is we ll app reciated o n the left. Wh ile t h e jo in t surfaces are congruent, t hei r u ndulating co urse prohibits
any significant motio n th ro ugh the join t. T h e superio r gluteal art ery i s th e con ti nuatio n of the pos terio r d iv ision of
the internal i l iac artery. It passes bet wee n th e lu mbosacral tru nk (o r in th i s case LS since t he lu mbosacral nerve t run k
has not ye t co nverged) and 51 n erve root.
v
13 5
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

Externa l il iac a., v. Psoas 111.

Iliacu s 111.
Obturator n.
Obtura tor n.
L4 n er ve trunk
L4 ne rve trunk

Superio r gl utea l a., v. LS nerve trun k

An terior div ision,

internal ili ac a. SI nerve trunk

Sl joint, synovial Sacrum, 2nd segment

Gluteus m.
52 nerve root
Sl joi nt, 53 nerve root

54 nerve root

Erector spi nae m s.

complex

Ex ternal i l iac a., v.

Psoas m .

Iliacus m.

Obturator n.

L4 n erve trun k,
con vergi n g
Superior glu tea l a., v. LS n erve trunk

Anterior division,
SJ nerve trunk
internal i l iac a.

Sl join t, synovial Sacrum, 3rd segment

Glu teus m ed ius m .

52 nerve roo t
S2/S3 disc remna n t
53 nerve root
Sl joint, sy ndesmotic
S4 ner ve root

Short dorsa l sacroi l iac I.

Erecto r spinae rns.

compl ex -.=( .. 6 ""-- _.o:o -- -- - - - - -

(Top) A con siste nt relatio nsh ip between the nerve roots o f th e sacra l plex us a nd th e ad jacent vessels exists. T h e
inferior glutea l vessels will pass fro m a n teri o r to poste ri o r be tween t he Sl & S2 n e rve roots o r betwee n the S2 & S3
ne rve roo ts. T he supe ri or g luteal a rte ry previo usly passed between th e lumbosac ral trunk (or LS trunk) a nd S 1. ate
t he "wand ering" co u rse o f th e right L4 ne rve t runk; it kinks a n te rio rl y and the n posteri orly, w hile th e left fo llows a
straight co u rse. Suc h a lte ration s in course ca n be confu sin g. ( Bottom) The S3 ne rve root o n the ri ght h as ex ited the
ve ntra l neura l fora me n . Th e orientation o f the sy ndesmotic portio n o f the sacroiliac jo in t has c ha n ged fro m a more
v di rect posterior o rie n tatio n to an o bliq ue o rie ntatio n angle med ia ll y. A remn a nt of the S2/S3 in tervertebra l disc space
he lps identify th e d iffe ren t sacral segm ents.
136
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

Psoas m.
Ex ternal iliac a., v.

Iliacus m.

Obturato r n.
Obturator n.
Superior gluteal a., v.

lA & LS nerve trunks Lum bosac ral trunk

combin ing to Sl joint, syn ovial
lumbosacral trunk
SJ nerve trunk
Anterior division,
internal iliac a. S2 n erve trunk
Gluteus medius m.
S3 n erve trunk
Sacrum, 4th segm en t
SI joint, sy ic Posterior superior i l iac
spine
l.ong dorsal sacroi liac I.
54 nerve root
Erector spi nae
complex

External a., v.
Psoas m.

IIiacus m.

Ob turat or n.
Obtu rator n.

II ium
uperior gluteal a., v. Lumbosacral trunk

Anterior clivi ion, 51 joint, syn ovial

internal i l iac a. 51 nerve trunk

S2 nerve trunk
Gluteus m edius m.
53 n erve t runk
Gluteus mal\imus m.
54 nerve root
Sacrum, 4th segment

Long dorsa l sacroi li ac I.

Lateral

Erector sp inae ms.

co mpl ex

(Top) The posterior superior iliac spine is evident. It marks t he posterior extent o f the iliac crest. The long dorsal
sacroiliac ligaments attach superiorly at thi s site. Note t h e close proxi m ity of the S2 and S3 nerve roots at this level.
The transiti on from the third to t h e fourt h sacral segmen ts is marked by the S3 n eural foramina. ote that L4 & LS
nerve trunks arc combining to for m th e lumbosacral trun k on both sides. (Bo tto m ) The S2 and S3 n erve trunks
course anterio rly and latera l ly and w il l even tu al ly joi n the lumbosacral t runk and Sl nerve trunk i n formation o f the
sacral plex us. In thi s i maging plane the syn ovia l portion o f the sacroiliac joi n t contin ues more i nferiorly t han t h e
syndesmotic porti on.
v
137
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JO INTS

External iliac a., v. m.

Iliacus m.

Ob turator n.
lliuQ1

Superio r glu teal a., v. Lu m bosacra I trunk

SI nerve trunk
Anterior divi sion, Gluteus m edius m.
internal il iac a.
Piriformi rn .
Sl join t, synovial
S2 & S3 n erve trunks
Superior glutea l vcs cis
Sacrum, 4th segment
G lu teus max i m us m.
S4 ner ve trunk
Long dorsal sacroi liac I.

Erector spinae ms.

complex

Psoas m.
Ex ternal iliac a., v.

m.

Obturato r n .
IIi um

Superior glu teal a., v. Lumbosacral trun k

SI ner ve trunk
In ferior glut eal a. , v.
Pi riform is m.
Gl uteu s m cclius rn.
S2 & S3 nerve trunks
Superior gluteal a., v.
Sl joint, sy novi al

Gluteus m. Sacrum, 4th segm ent

Long dorsa l sacroi l iac I. S4 nerve trunl-.

Erecto r spinae m s.
complex
til

>
Q)
c..
""0 (Top) The sacro iliac join t is now completely synovial. Injections into the joint sho uld be directed at thi s level to
c: avoid injection of th e syndesmosis. The su peri o r most fibers o f the pirifo rmis muscle ca n be seen o rigi nat ing from
the sacrum. (Bo ttom) Th e tran si tio n fro m th e fourth to th e fifth sacral segm ent is marked by th e $4 neural foramina .
0.. The verti ca l fibers of th e long d o rsa l sacro i liac li gaments are vi sibl e as is th eir o ri gin from the lateral sacral crests. The
:r: stru ct ures o f th e sacra l plexus and th e associated vessel s conti nue to move laterall y alo ng t he deep surface of the
pi rifo rmis mu scle.
v
138
 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

Ex ternal iliac a., v.

Psoas m.

Iliacus m.

IIi um

Superior gluteal a., v.

Lumbosacral trunk Lumbosacral & S I

n erve t ru n "-s
S I n erve t runk
Anterior divisio n, Piri formi s m.
i nternal i liac a.
Glu teus med iu s 111.

Superior glutea l a., v. S2 & 53 n erve trunks

Sl joi nt, synovial

Sacrum, 4th segm en t
m axi mu m.
S4 nerve trunk

Erector spinae ms. -+---- - --__;;:=

complex

Exte rn al il iac a., v.

Iliopsoas m.

Obturator n. Ilium

Superior gluteal a., v.

Lumbosacral trun k
Lumbosacra I & S I
Sl nerve trunk n erve trunks
Anterior Piriform is m .
internal iliac a.
G l uteus m ediu s m .

S2, S3 nerve trun k

Gluteus m axi mu s m.
54 ne rve trunk

(Top) At th is more in ferior level the obtu rator nerve i s beginning to course m ore posteri orly to its eventual position
along th e medial aspect o f the obtu rator internus muscle. T he 54 neural foramina marks the t ran sition between th e
fourth and f i fth sacral segments. (Bo ttom ) Th e inferior most aspect of the sacroiliac joi nt is v isible. Below thi s is the
grea ter sci ati c n o tch, which is primarily fill ed with th e piriformis muscle.

v
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 POSTERIOR PELVIS
OBLIQUE AXIAL T1 MR, SACROILIAC JOINTS

Ex ternal iliac a., v. lliop m.

Ilium Ob turator nerve

Lu m bosacral trunk/5 1
con vergence
Lumbosacral trunk/S I
Superi or glut eal a., v. con ve rgence
Anterior division, G l uteu s m ediu s m.
internal i liac a.
Piriform is m.

Superior gluteal a., v.

G lut eus maxi mus m. S4 nerve trun k

Sacrum, St h segment

Exte rna l i l iac a. , v.

Iliopsoas m.

Ili um
Obturator nerve

II ium

Superior gluteal a., v.

Lumbosacral 1 Lumbosacral trun k/ 51
convergence convergence
An terior division,
i n ternal iliac a. G lut eus m edius m .

S3, S4 nerve trunks

Piri formis m.

Sacrotuberous ligamen t G luteus maximus m.

Sacrum, Sth segmen t

(Top) Th e superior glutea l vessels exit th e pelvis above t he piriformis muscle and are seen curvi ng aro und the
posterior aspect o f the il ium on t he right. I laving ex ited the pelvis th e vessels t ravel bet ween the g luteus maxim us
and medius muscles. (Bottom ) Th e upper most sciatic no tch is filled with piriformis muscle. T he sciatic nerve is
v isible alo ng th e deep surface of t he m uscle. In this sect io n, either the anterior division of the int ernal il iac ar tery has
no t yet div ided o r t·he supe ri or gluteal and intern al pudendal vessels are not separable. Th e muscular an d cuta neous
nerves w hich ex it along the inferior border of th e muscle are no t d efin able. The m ost su perio r aspect o f th e
v sacrotuberou s ligament is present and blends with th e inferio r fibers of t h e long dorsal sacroi liac liga m ent. For m o re
i n ferior i mages see "Ax ial Tl MR, Sciatic Nerve".
140
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

L-1 vertebral body L3 n erve root

Psoas m.
1.4 dorsal root ganglion

Thecal sac
Short dorsal sacroi liac I.

L4/LS facet jo in t
L4 spinous

Ilium

i=Yr----+- Erector spi 11 ae ms.

complex

L4 vertebral body L3 n erve root

rn.

Lum bar plexus

Short dorsal sacroiliac

ligament

Long dorsa I sacroi I iac

ligament
Gluteus medius rn.

IIi um

Erector spi n ae ms.

complex

(Top) This seri es o f coronal images is o riented along the long axis of the sacrum and begin s posteriorly. The oblique
coro nal orientation presen ts th e posteri or elements in an unusual fashion, as seen h ere with visibility of the L4/S
facet joi nts and th e L3 nerve root. (Bottom ) The posterior ligaments of the sacroiliac joint are well depicted. The
vertica lly orien ted lo ng dorsa l sacro iliac liga ments and the h orizontally oriented short dorsal sacroiliac l igament are
visible. Porti on s o f the lumbar p lexus arc seen.

v
141
 POSTERIOR PELVIS
OBLIQUE CORON A L T1 M R, Sl JOINTS & GREATER SCIATIC NOTCH

L4 ve rtebral body

L4/ LS di sc Psoas m.

T h eca l sac lliolombar l iga m en t

Short do rsal sacro iliac I.
LS/Sl facet joint

Gl uteus m edius m.

Long dorsal sacroiliac I.

Ilium

Erector spinae m s.
complex

L4 ver tebral bod y

L4/LS elise
Psoas m .

Ob turator n .

Thecal sac L4 nerve trun k

Short dorsa l sacroiliac I.

LS/Sl facet joi n t
Long dorsal sacro iliac I.

G luteus m edius m.

I li u m

Sl joint, syndesm os is

Erector spinae m s. G l uteus maxi m us 111 .

complex

rJl

>
Q)
c..
"'0 (Top) Th e ilio lumbar liga ment exte nds fro m the tip of the LS tra nsverse process to the inner margin of the iliac crest.
c:: (Bottom) The dorsal sacro ili ac liga me n ts a re co nti guo us with the most posterior fibers o f th e in terosseous ligam ents
c..s and the transition is visible on th is and the n ext image. The obturato r nerve is presen t along the media l border of th e
0.. psoas muscle.
I

v
142
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

L4/LS disc
Psoas m .

L4 nerve trunk
Iliacus m.

Thecal sac

Gluteus medius m.

Ilium

Sl join t, syndesmosis

L4/ LS disc

Psoas m.
LS vertebral body -..;====
LS nerve dorsal roo t
ganglio n

Ili acus m .
L4 nerve trunk
S I nerve roo t

$2 n erve root
Glu teus m ed ius m.

Ilium

S-1 nerve root

Sl join t, syndesmosis

(fop) Thi s imaging plane is through a lo ng axi s o f th e term ina l aspect of the th eca l sac. Multi ple i n terosseous
ligaments o f th e syndesmotic portion o f the sacroilia c joint are still v isible. ote their superior and lateral
orientation . ( Bottom) Th e L5, 51, 52, 53, 54 nerve roots arise from th e thecal sac and cou rse laterally and inferio rl y
and are directed anteriorly. Th e L5 n erve roots are w ithin the neural foramina on th is image.

v
143
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

L4/ LS el ise sp ace

Psoas m .
LS vertebral body
LS nerve dorsal root =:::;;:; - - Lum bar plex us
gang lio n branc h es

Iliacus m. L4 n erve tru nk

Sl nerve root

Iliu m Glu te us medius m .

Sacrum , 2 n cl seg ment

52 nerve root

52!53 el ise re mnant

Sacrum, 3rcl segment

L4 / LS eli se space
Psoas m .
LS vertebra l body
Lumbar plexus
LS/S l eli se bra n c hes
Fe m o ra l n e rve
LS nerve t run k

lliacus m. L4 nerve tru n k

5 1 n e rve roo t
Sl jo int, synovial

Sl / 52 elise re mna n t
Gluteus m ed ius m .
Ilium
Sacrum , 2nd segm e nt
52 n erve root
S2/S3 eli se re mna n t
Sacrum, 3 rcl segment

Sacral ala

til

>
Q)
c..
"'0 (Top) Th e sacroiliac joint is t ran sitioning from synd es moti c poste riorly to syn ovia l m o re a nte rio rl y. The sacral n erve
c:: roo ts are seen entering the neura l fora mina. (Bottom) A compa ri son of the intervertebral discs reveals a h ealthy t hick
L4/ LS disc and th e normal sligh tly n arrower LS/Sl di sc. Re mn ants of the Sl /52 a nd S2/S3 intervertebral discs are
0.. visible wi thin th e sacrum. The a nterior syn ovial portion of the sacroiliac joint is seen. This portion of th e joi nt is
J: thinn e r and articu lar cartilage is present within. This image thro ugh the long axis of t h e m id sacra l body di splays the
fu ll ex te nt o f th e sacral a la.
v
144
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

LS vertebral body L4/ LS d isc

LS/S I disc Psoas m.
LS n erve trunk
1.5 nerve trunk
Femoral nerve
Femoral nerve
L4 ne rve trun k
lA n e rve trun k
Il iac u s m.
Sacrum, l st segmen t
S I nerve roo t
Sl joi n t, syn ovia l
S I /52 disc rem n a n t
G luteus m edi us m .
Ilium
Sacru m , 2nd segm ent
S2 nerve root
S2/ S3 disc re mn a nt

Sacrum, 3 rd segm e nt
S3 ne rve root
S2/ S3 tl rem n a n t

LS vertebra I bod y
Psoas m.
LS/ S I elise
Femoral ne rve Obturator n e rve

LS nerve trunk L4 n e rve trunk

Iliacus m .
Sacrum, 1st segment
S I nerve root
Sl joi nt, synovial

Il iu m
G luteu s medi u s m .
52 ne rve roo t Sacrum, 2nd segm e n t

Sacrum , 3 rd segm e n t
S3 nerve root

Sacrum, 4th segment

Sacral ala
G lute us maximus m .

(Top) T he sacral ala contin ue to be well seen, as are th e sacroiliac joi nts. Th e irregular in terlocking arti cular surfaces
of t he sacroi liac joi n ts are easy to appreciate. Th is irregularity signi ficantly l imi ts mobi lity and i mproves stability of
the sacroi l iac join t. (Bottom) T he sacral nerve roots cou rse forward within the n eural foramina.

v
145
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

LS ve rtebral body Psoas m .

LS/S l disc
Femoral nerve

LS n erve trunk L4 n erve t ru n k

Iliacus m . LS rrerve t ru n k

Sacru m , I st segmen t
S1 n erve root
51 joint, syn ovial

Glu teus m ed ius m .

52 n erve root

Ili um

Gl uteu s maxi m us m .

LS ve rtebral body Il iac a.

LS/S l disc Psoas m .

Fem oral n erve

L4 n erve trunk
L4 n erve tru nk
LS n erve tru nk
Sacrum, 1st segmen t
S1 n erve roo t
Sl join t, syn ovia l

G l uteus m edius m.
52 n erve roo t
II i um

Sacral ala
Pi riform is m.

G lu teus maximus 111 .

{Top) At th is ante rior position the sacro iliac jo int is co mple te ly sy no vial. (Bottom ) The lumbosacral trunk co u rses
inferiorl y and late rally to jo in th e sacral plexus. Th e piriformis muscle takes o ri gin fro m th e a nte rio r aspect o f the
sacrum.

v
146
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

LS vertebral body Iliac a.

LS/ Sl di sc Psoas m .
Obtu rato r n erve
Fem oral n erve

L4 n erve t runk Obtu rator n.

LS n erve tru nk
Sacra I prom on tory
Superior gluteal a., v.
Sl joint, synovial
Sl n erve root
Iii um
Inferior glutea l a., v. Glu teus m edi us m.

52 nerve root Rectum

Pi ri form is m .

Glu teus m axi m u s m .

Iliac a. Gen itofem o ral n.

Iliac v. Psoas m.
LS/S I disc
Fem o ral n.
Sacral prom o n tory
Iliacus m. L4 n erve trunk
Supe rior gl utea l a., v. Obturator n .

LS n erve trun k Superio r gluteal a.

S I n erve trun k Sl join t, synovial
Inferior gluteal a., v.
LS n erve t ru nk

52 n erve trun k Ilium

Gl u teus medius m.
Rectum
Piri form is n1.

Gluteu s maximu s m.

(Top) Alo ng th e ante rio r aspect o f th e sacrum the pirifo rmi s m uscle is identified an d its fibers are mie nted latera ll y
and inferiorly. The superior gl uteal artery is seen passing be tween the lumbosacral t ru nk (o r LS) and Sl n erve t runk
as the a rte ry cou rses poste rio rl y. Th e gen itofem ora l ne rve is now a pparent along t h e anterior aspect o f t he psoas
muscle. (Botto m ) The an terio r d ivision o f th e in te rn al iliac arte ry has div ided a n d the inferior gluteal vessels a re now
di st inguis hable. Th e vesse ls a re located betwee n th e Sl and 52 n e rve roo ts. The sacral prom o nto ry, the a nte rosuperior
project ion of Sl, is well seen .
v
14 7
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

Gen ilofcmoral n.
Iliac a., v.
Psoas m.
LS/S I di sc ==;-- Obluralor n.
Iliacus m. Fem oral n.

Femora I n. L4 nerve lrunk

lA n er ve l runk Sacn11n, segment

LS nerve tru n k
Sl jo in t, synovial
Su perior glutea l a., v.
IIi um
Anterior
internal i liac a. Gluteus medius m.

52 nerve lrunk
Superior glulea l a., v.

Piriformi s 111.

Gluteus m.

Sacrotuberous ligament

Femoral n.

II iacus m. Femoral n.

Internal iliac a., v. Obturator n.

Lumbosacral lrunk
II ium
Anlerior divisio n,
internal iliac a.

Superio r gl uteal a., v. Gluteus medius m.

Superior gluleal a., v..

Piriformis m.

Gluteus m ax i mus 111.

Vl
>
Q)
c..
""0 (Top) Th e sacrotuberous ligament converts t he greater scia tic no tch into a foramen which is primaril y fil led with the
c piri formis muscle. The ligament is loca ted i nferio rly to t he muscle. The in ternal iliac vessels have divided and the
superior gl uteal artery is th e co n t inuation of the posterior division. (Botto m ) T h e superior glu teal vessels exit the
0. pelvis above th e superior border of t h e piriformis muscle on th e righ t . The vesse ls arc partial volu m ed with the
:c adjacent piri fo rm i s muscle. On the left th e vesse ls are seen deep t o the gluteus max i mus m uscle after exitin g the
pelvis. Note that asymmetry ca n occur; the lumbosacral n erve trunk has fo rmed o n the right side, but 1.4 and LS
v nerve trunks are st i ll separate structu res o n the left.

148
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

Il iac a., v.

Fem oral n. Femora l n.

L4 n erve t run k
Iliacus m. Obturator n.
I n ternal il iac a., v.
Ilium
Inferior glut eal 11., v.
Supe rior gl utea l a., v.

Sciatic n.
Internal pudendal a., v.
Glu teus m ed ius m .

Piriformis m . Supe rio r gl utea l a., v.

G l u teu s maximus m.
Sacrotuberous ligament

Psoas rn .

Femora l n.
Iliac a., v.
Obt urat or n . Il iacu s m .

Inferior gluteal a., v. Iliu m

Sciat ic n .
Super ior gl utea l a., v.
lntl•rnal puden dal a., v.
Gl u teus m edius m.
Piriform is m .
Superior glu teal a., v.

Gluteus maxi mus m.

Sacro t uberous I iga m en t

(Top) The interna l pudendal an d inferior gl utea l vessels are visi ble; th ey are th e term ina l bran ch es of the anterio r
division o f the in ternal iliac artery. Th e sciatic n erve, th e largest bran ch of t he sa cral plexus is v isible as a discrete
structure. The obturator nerve is seen alon g the latera l aspect o f the internal iliac vessels. It reaches t his location by
pas ing posteri or to the common iliac vessels, a re lat ion ship n ot well depict ed on these images. (Bottom) Th e
superior glutea l vessels on the l eft are exiting th e pel vis. Th e piriform is muscle fills th e grea ter sci atic foram en wh ich
is bounded by t he ilium superiorly and th e sacro tuberous ligament inferi orl y.
v
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 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

Fem o ra l n .
lliac a., v.

O b tu rator n. Iliacus m.

Il ium

Inferior glu teal a., v.

G lute us minimus m .
Sc iatic n .
Gluteus medius m .
Interna l pudendal a., v.

Piri formi s m .

G luteus maximus m.

Sacrotuberous ligamen t

Psoas m .
Il iac a ., v.
Il iacus m .

Obturator n .

Il ium

In ferior g luteal a., v.

G luteus mi n im us m .
Sc ia tic n .
G lu teus m edius 111 .
Inte rnal pudendal a., v.

Pi riform is rn.

G lute u s maximus m.
Sacrospinous liga men t

rJ')

>
Q)
c..
"'0 (Top) Th e obtu rator n erve now resides in the groove betwee n th e psoas and iliacus muscles . The sciatic ne rve
c continues its lateral direction moving to become the most lateral structure to ex it the pelvis alon g the infe ri o r bo rd e r
of t he piri fo rmis m uscle. (Bottom) Th e sciati c ne rve has its more t ypi ca l a ppeara n ce wit h fatty st riati o ns within. The
0.. interna.l pudenda l vessels are among t he more medial struct ures exi ting th e pelvis inferior to the piriformis muscle.
I

v
150
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

Psoas m.
Iliac a., v.
lliacus m .

Obturator n.

Ili u m

Inferior gluteal a., v. G lu teus minimus m .

Sciatic n .
Internal pude ndal a. , v.
Piriformis m .

Gluteus m ed ius m .

Sacrospinous li gament Glu te u s max im us m .

Psoas m .
Iliac a., v.
Iliacus m.

Obturator n .

Ilium
Inferior gluteal a., v.
minimus m.

Sciatic n .
Interna l pude n da l a., v.

Pirifo rmis m.
Gluteus medius m.

Gluteus maximus m.

(Top) The cour e of the piriformis muscle t hrough th e greater scia ti c foramen is v isible. This imagi ng plane
erroneously create the impression that th e piriformis muscle is loca ted between the gluteus minim us and medius
muscles. See "Axia l T l MR, Scia tic erve" to understan d its relationship to these muscl es. Note the inferior glutea l
vessels coursing fro m latera l to m edial, posterio r to th e sciatic n erve. (Bottom) The sciat ic nerve is m ore clea rl y seen
on this im age.

v
15 1
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

Psoas m.
Iliac a., v.

Il iacu s m.
O bturator n .

Ilium
Inferior gluteal a., v.
G lu teu s minimus m .

Sciatic n.

m.
Internal pudendal a., v.

G I u teu s m edi us m.

Coccygeu s m.
Gl uteus maximus m .

Iliac a., v. m.

Il iacus m.

Ilium
Obturator n.

I n ferior glu teal a., v. Gl uteus minimu s m.

Scia tic n.
Pi riformis rn.

Internal pudendal a., v.

Gl uteus medius m.

Coccygeus m.
maxi mus m.

fJl
>
Q)
c..
"'0 (Top) Th e in ferio r g lutea l vessels are seen co ursing to a m o re m edial position. They exit th e pelv is alo ng th e inferi o r
c:: border of t·h e pi riformis m u scle in close proximi ty to the internal pudendal vesse ls. T he pudendal n erve, whi ch i s the
C\l
most media l structure along the inferior p irifo rmis bo rder, is n ot discernible. (Bo ttom) A t th is an terio r position th e
0.. inferi o r-most po rti o n of the pi riformi s muscle is present. Th e sci atic n erve is t he most lateral stru cture to ex it the
:r: pelvi s alon g the inferior border o f th e p irifo rmis m uscl e.

v
152
 POSTERIOR PELVIS
OBLIQUE CORONAL T1 MR, Sl JOINTS & GREATER SCIATIC NOTCH

m.
Iliac a., v.
Iliacus m.

Ilium
Obturator n.

Obturator internus m.
Gluteus m ini mus m.
Inferior gluteal a., v.

Sciatic n. Piriformis m .

Internal pudendal a., v.

Gl uteus medius m.
Coccygeus 111.

Glu teus maxirnus rn .

Il iac a., v.

Il iacus m .

Obturat or intcrnus 111 .

Glut eus rninim us m.
Inferior glutea l a., v.

SciCIIic n .

Internal pudendal a. , v.
Gl u teus medius m.
Coccygeu m.
Gluteus maximus m .

•occyx

(Top) The sciatic nerve has exi ted th e pelvis. Its lo ngi tudinal orientati on is vis ible by t he d irection of the fatty
striati on s w i th in . T h e n erve is qui te wide but relati vel y fl at (see "Axial T1 MR, Sciatic Nerve"). Th e obturator n erve is
ccn coursing inferiorly to its even tual positio n along the inner border o f th e obturator i ntern us m uscl e. (Bottom )
Th e piri formi m uscle is now a lateral struct ure, havin g passed through t he n otch. It is now t raveling latera lly to its
insertio n in to t he pi ri form is fossa o f th e hip. T h e sciatic n erve will continue its course, runn ing i nferiorly through
the po terior th igh (see "Thi gh Overview" sec ti on) .
v
153
 POSTERIOR PELVIS
SAGITTAL T1 MR, GREATER SCIATIC NOTCH

Iliopsoas m. - - r -- -

Tran sverse abdomin is

m uscle uperior glutea l a., v.

Sacral plex us

Pi riformis rn.

Ex ternal ili ac a., v. In ferio r gluteal a., v.

Sacros pin ous l iga m ent

Sacro tu berous li ga m en t

Superio r pubi c ram us In ternal pudendal a., v.

Obturator i n tern us m.
O bt urator ex ternu s m .

Pect ineu s m .
Gluteus m ax imus m.
Aclcluctor m agnus m .
In ferior (ischi opubi c)
Aclclu ctor brev is m.
ramus

Adductor m.

Sacrum
Tra n sverse abclo m i nis
m uscle
Iliopsoas m .
Superior glu teal a., v.

Pi ri formis m .

Sacral plexus

In ferior glu teal a., v.

External i liac a., v. Sacrospi no us liga m ent
In terna l p uden dal a., v.

Superi or pu bic ram us Sacro tuberous li gament

Obturat or intern u s m.
Obtura tor externus m .

Pecti neus m . Gl uteus m ax imus m.

Inferior

Adductor brevis m .
t/)
Addu cto r lon gus m Adductor m agnus m.
>
Q)
c..
""0 (Top) Thi s seri es o f sagi ttal images fro m med ial to lateral begi ns just lateral to m id l ine. Th e sacra l n erve roots are
c seen con ve rgi ng to form th e sacra l plexus on the d eep surface o f the piri fo rmis m uscle. T he i nferi o r g lu teal and
intern al pudendal vessels are v i sible. (Bottom) Th e sacrospino us ligament is n i cel y seen . O n this i mage th e i nternal
a. puden da l vessels are seen co ursing around th e ligamen t to travel fro m th e buttocks to th e peri neu m . T h e fibers o f th e
:c sacro tuberous l igament are vertically o rien ted. They are seen as a thi ck band alo n g the deep surface o f t he gluteus
max im us muscle an d t hey serve as a site o f o ri gi n fo r that muscle.
v
15 4
 POSTERIOR PELVIS
SAGITTAL T1 M R, GREATER SCIATIC NOTCH

Transverse f(lf
muscle

Internal oblique m. Ilium

Iliopsoas m.
Piriformis m .

Sciatic n.
I nferior gl ut ea l a., v.

Common femora l a., v. In ternal pudendal a., v.

Sacrotuberous ligament

=r--+- Sacrospi nous l igament

Obtu rator 111. Obturator internus m.

Pectineus m. G luteus maximus m .

Inferior (ischiopubic)
ramus
Adductor brevis 111 .
Adductor magnus m.
Adductor longus m.

Transverse abdominis
muscle

Piri form is m.

Sciatic n.

Inferior gl utea l a., v.

Interna l pudenda l a., v.

Il iopectineal jun cti o n
Sacrospi n ous ligamen t
Common fem ora l a., v.
Sacrotu berous ligamen t

Obturator internus m.
Obturator extern us 111.

Pectineus 111 .
Gl uteus maximus m.
Inferi or (ischiopu bi c)
ramus
Adductor brevis m.
Adductor magnus m .
Adductor longus m.

(Top) The sacrospinous l igam en t has an obl ique hori zon ta l orien tation wi th a sligh t inferior course as it travels from
the sacrum to the ischial spine. O n t h is image it is seen moving anteriorly and inferi orly and will continue in this
path as t h e i m ages progress from medial to lateral. The fibers of the sacrotuberous ligamen t follow a similar course.
Between these two i mages both ligam ents h ave m oved inferi orl y. ( Bottom) M ore latera lly along t he deep surface of
the piri fo rm i s m uscle th e sciati c nerve ca n be identified as a discrete structure. The other branch es of the sacral
plexus are too small to identify. Th e long ax is of t he intern al pudendal vesse ls is seen, including their ex it from the
pelvis below the piriform is m uscle. They exit medi al to th e sciatic nerve. They then bend around the sacrospi nous
ligamen t to enter the perineum. v
155
 POSTERIOR PELVIS
SAGITTAL T1 MR, GREATER SCIATIC NOTCH

Transverse abdomi n is
muscle

Internal oblique 111. IIi u m

Su perior gluteal a., v.

Sciatic n .
I lio psoas 111.

Piriform is m .

In ferio r glu teal a., v.

Internal pudendal a., v.

Sacrospi n ou s ligament
Obt urato r int ernu s 111.
ligament

Commo n femoral a., v.

Obturator extern u s m.
Pectineu s m.
G luteus m aximus m.
Adductor magnus m.
Adductor brev is m . Inferior (ischiopubic)
ramus
Adductor longu s m .

Transverse abdo m i nis

muscle

In tern al obl iqu e 111 . IIi um

Superior glu teal a., v.

Sciatic n.
Iliopsoas m .
Pi riformis 111 .

In ferior glutea l a., v.

Ob turator internus m .
;::::;::=-+- Isch ial spi ne
ligamen t

Common femoral a., v.

Ob tu rator extern u s m . Gluteus maxi mus m .

Pecti neu s m .

Adductor m agnus m . In ferior (isch iopubic)

ramus
rJl Sartorius m.
>
Q)
0..
"'C (Top) The ex it of t h e inferior glutea l vessels fro m th e pelvis i s seen by fo llowing t he vesse ls from media l to lateral.
c: Here they are just below the piriformis muscle an d are in cl ose proxim ity to the internal pudendal vessels. Th e distal
attachment of t he sacrospinous l iga men t o nto the isch ial spine is seen between t his image as well as th e nex t one.
c.. (Bottom) On this m ore lateral image the sacrotuberou s liga ment is seen onl y o ver a sh ort segment and is more
:c inferi orly positioned th an on th e m ore medial im ages. The sciatic nerve is begi nning its exit from the pelvi s. The
superior gluteal vessel s are well seen as they course alon g the superi o r bord er o f th e piriformi s muscle to enter th e
v buttocks.

156
 POSTERIOR PELVIS
SAGITTAL T1 MR, GREATER SCIATIC NOTCH

Transverse
muscle
Gl uteus maximus m .
Interna l obliq ue m.
Ilium

Superior gl uteal a., v.

Piri fo rmis m.

Sciati c n.

I n ferior glutea l a., v.

Fem o ra l head Obturato r intcrn us t. &

inferior gemellu s t.

Obturato r ex ternus m .
Obtu rator m.
Pectin eus m .
Common femoral a., v.

Sa rto ri us m . Isch ial tuberosi ty

Adducto r magnus rn . ll am stri n g origi n

Tra n sve r e abdo rninis

muscle

I nternal oblique rn .
Iliu m

Pi rifor mis m.
Iliopsoas m .

I n ferior gluteal a., v.

Superior gem el lus m .

Fem oral h ead
Obturato r in ternus t. &
in fe rior gem ellus t.

Obturator ex ternus rn .
O bturator internus m .
Pectineus m.
Sac ro tuberous Iiga ment
Comm o n fem o ral a., v.
Ischia l tuberosi ty
Sartorius m .

Adducto r magnus m . Jla m stri ng origi n

(Top) Along the lateral aspect of the pirifo rmi s muscle th e superior and inferior glu teal vessels are seen above and
below t he pi riformis muscle respectively. The vessels are deep to the gluteal maximus muscle and w ill branch w ithin
this fat plane. (Bo tto m ) The attachmen t of th e sacro tuberous liga men t onto the ischi al t uberosi ty is seen . From
medial to la teral the ligament has followed an i nferior course. T he external rota tors o f t h e hip are just now visible.

v
157
 POSTERIOR PELVIS
SAGITTAL T1 MR, GREATER SCIATIC NOTCH

Transverse abdomin is
muscle
Gluteus maximus m .
Internal obl ique m.
Ilium

Pi riformi m .
Il iopsoas m.

Fem oral head Sup. gem el lus m. & t.

Obturator internus t. &
inferio r gemellus t.

Obturato r externus m.

Pectin eus m.
li ga ment
Co mmon femoral a., v.
Ischial tuberosi ty

Transverse abdominis - -;;;r------'---,

muscle
Glu teus maximus m.

Ilium

Superior glute<ll a., v.

Piriformi s m.

Sciatic n .
I n ferior gluteal a., v.
Femo ral head Sup. gem el lu s m. & t.

--+- O bturato r intcrnus t. &

in ferior gemellus t.

O bturato r internus m.
Pectin eus m. -+--i Sac rotuberous l igament
Commo n femoral a., v.

Sa rtorius m.

Adductor magnus m.

(Top) The sciatic n erve is difficult to sepa rate from the adjace nt m usculature on th is image. There a re seg ments o f
th e n erve like this whe re the nerve is d ifficul t to ide ntify as a separate structure. (Bottom) The sciat ic ne rve is aga in
visible, n ow a t th e inferior bord e r o f th e pirifo rmis m uscle. The co urse of th e ex ternal rota to rs arou nd the posterior
aspect of the hip is beco ming mo re clea rl y defined. For more info rmation on th ese muscles see the "Latera l Hip"
secti o n .

v
158
 POSTERIOR PELVIS
AXIAL T1 MR, SCIATIC NERVE

Co n joi ned ten don

Sarto rius m .

Rectus abdomin is m. Tensor fascia la ta m.

Inferior epigastri c a., v. Il iopsoas m .

-.;...- An terior inferior ili ac

spi ne
Externa l i l iac a., v.
Gluteus 111 inimus m.

Ilio tibial band

Supraacetabular il ium

Obturator in ternus 111. G l u teus m edius 111.

Inferior gl uteal a., v. Sc iatic n.

Internal pudendal a., v. Superior glutea l a., v.

Pi riform is 111 .

Sacrotuberous l iga m en t

=="'iiiiil"'--- - -- - - -- - - - -- + - Glu teus max i mu s m.

Co njoined tendon Sa r tor ius 111 .

Rectus abdomin is 111. Tensor fascia lata m.

Inferior epigastric a., v. Iliop soas m .

=r--=:;-- Anterior in ferior iliac
spi ne
Externa l il iac a., v.
Glu teus m inimu s m.
flio ti bial band
Ob turator n.
Supraacetabu lar ilium

Gl uteus m ed ius m .
Ob tu rator in tern us 111.

Sciatic n.
Inferio r glu teal a., v.
Superio r gl uteal a., v.
Internal pudend al a., v.

Sacrum

(Top) Ax ia l MR se ri es fo ll owi ng t h e sciatic n e rve. The midpo rtion o f the greater sciatic notch is at the level of th e
superio r aspect of th e hip joint. The supe ri or gl utea l vessels have a lread y exited above th e pirifo rmi s muscle (see
"Oblique Ax ial T l MR, Sacroiliac j oi nts"). The vessels a re identified in the plane between the gl uteus max im us and
medi us musc les. The sciatic nerve is assuming its pos ition a long th e lateral aspect of th e notc h. The inferior gluteal
vessels are just m ed ial to the n e rve and th e inte rn al pudendal vessels a re the most medial. of the v isible st ructures.
(Bottom) Like th e piriformis muscle th e sacrotuberous liga ment has a lateral and inferior course. At this m o re
superior position its late ra l fibe rs are visib le. It follows along th e in fe rior a spect o f th e piriform is m usc le, co nve rtin g
the grea ter sciatic n otc h into a foramen. v
159
 POSTERIOR PELVIS
AXIAL T1 MR, SCIATIC NERVE

Conjoined te ndon Sartorius m .

Rectus abdominis m. Ten sor fascia lata m .

I nferior epigastric a., v. Il iopsoas m .

;.-.,__ Rectus femoris t.
External il iac a., v.
Gl uteus mini mus m.

Il iotibial band

Supraacetabular ilium

Obturato r internu s m. Gl uteus medius m.

Sciatic n.
In fe ri o r gl uteal a., v.
Superior glutea l a., v.

Internal p uden dal a. , v.

Sacrum

Conjoined tendon Sarto rius m .

Rectus abdomin is m. Tensor fascia lata m.

Inferior ep igastri c a., v. Il iopsoas m .

Rectus fem oris t.

External iliac vessels
G l uteu s minimu s m.

Il iotibial band
Obturator n.
Supraacetabu lar i lium

Obturator i nternus m. Gl uteus medius m.

Sciatic n.
Inferior gluteal a. , v.
Superior glutea l a., v.

In tern a I pudenda I a. , v.

Sacru m

(Top) The media l margi n o f t he piriformis muscle moves lateral as t h e m uscle extends inferiorly and t h e re is a larger
gap between th e m uscle and the sacrum th an on the more supe rior images. The in te rna l pude n dal vessels are seen
both within th e pe lvis a n d in t h e buttocks. As it exits t he pelvis t he scia t ic ne rve is identified by t h e fatty st riati on s
within . (Botto m) Th e sacral attachment o f the sac rot u berous ligament is well visualized. More laterally it se rves as a
site of o rigi n for the gluteu s max im us muscle.

v
160
 POSTERIOR PELVIS
AXIAL T1 MR, SCIATIC NERVE

Con joi ned tendon

m.

Rect us abdom i n is m . Ten sor fascia lata m .

Inferior a., v. Iliopsoas m .

;;;;;;;;;,.-- + - Rectus fem oris m .

External i l iac a., v.

G lu teus min imus m.

Anterio r col u m n
acetabulum Ilio tibi al bancl
Obt urator n.
Fem oral h eacl

Obturato r i n ternus m. Gl u teus m ed ius m .

column Pi ri form is m .
acetabulum

Inferio r glu teal a., v.

In ternal puden dal a., v.

Sacros pi no us l igamen t

Sa crum

Sartorius m .

Rectu\ abdo111i n is 111. Ten sor lata m.

In feri or epigast ri c a., v. Il io psoas 111 .

l·.x ternal iliac a., v.

:r.---t- fem oris m .

An terio r column <.. l utcu\ min i mus m.

acetabulum
Il ioti bial ban d

Obturator n. Fem oral Il eac!

Obturato r i ntcrnu s m. G l uteu s rnecl ius m .

Posterio r col u mn Pi rifo rmi s m .

acetab ulu m
Supe rio r glu tea l a., v.
In ferior gl utea l a., v.

Internal p udenda l a., v.

l iga nl en t

Sacrum

[lop) As it exits the pelv is th e sciati c nerve is closely applied to th e posterior colu mn of t he acetab ul u m. Th is osseous
landmark can be used on o t h er exa m i natio ns such as CT w here th e soft tissue d iscrim i nation is no t as grea t as MR.
(Bo ttom ) During its ex it from th e pelv is th e sciatic nerve can be di fficult to iden t ify. Kn owledge o f i ts expected
locat ion can aid th e search. Little variab ility in i ts posi ti on ex its. At its most inferi or ex tent t h e p i rifo rm is muscle i s
ident ified as a far lateral structure approaching i ts inserti on in to the piriformis fossa. T he sacrospi nous ligamen t is
now visible. It is relat ively horizontal in its o ri en tation. It lies d eep to the sacrotu berous ligamen t; th e in te rn al
pudenda l vessels upon leaving the pelv is immediately pass aroun d th is str ucture to en ter the peri neum.
v
16 1
 POSTERIOR PELVIS
AXIAL T1 MR, SCIATIC NERVE

Conjoi ned tendon Sartori us m .

Rectus abdominis m. Ten so r fascia lata m.

Inferior epigastric a., v. Iliopsoas m.

Ex ternal i liac vessels Rectus fem oris t.

Glu teu s minimus m.

Anterior co lumn Iliotibial ban d

acetabulum
Obturator n. Fe moral head

Obturator i nternu s 111. Gl u teu s m ediu s m.

Posterior col um n Pi ri formi s 111 .

acetabulum
Sciati c n.
Inferior gl uteal a., v.

Internal pudendal a. , v.

Coccygeus rn.

Sacrum

®1 Sarto rius m.
Conjoined tendon

Rectus abdominis m. Tensor fascia lata 111.

Inferio r epigastri c a., v. '<"'----';-- II i.o psoas m .
External i liac a., v. r<:-+- Rectus femo ris t.

Gl uteu s mini mus m.

An terior column
Il io tibia l band
acetabulum
Obturator n .
Fem oral head

Gl uteu s m ediu s 111 .

Obturator i nternus m.

Posterior column Pi r iformis m.

acetabu lum
Sciati c n.

Internal pudendal a. , v.

Coccygeus m.

r.ll Coccyx
>
Cl)
c..
"'0 (Top) The sciatic n erve continues to be d ifficult to identify as a d iscrete structure. This is a common appearan ce of
!:: the nerve at th is po int. (Bottom) The sciati c n erve is n ow visible as a discrete structure. It h as its ty pical flattened
C'j
ovo id sha pe. Upon exiting the pelvis t he inferior glutea l artery branch es. One of the branches is visible here cou rsing
0. along th e poste ri or asp ect of the sciati c n erve. Thi s vasc ul a r morph ology may contr ibu te to compression of the nerve
J: and the development of piriform is syndro me.

v
162
 POSTERIOR PELVIS
CORONAL T1 MR, SCIATIC NERVE

Piri form is m .

Inferior gl u teal a., v. M usc ul ar b ra nch

i n ferior glu tea l artery
Sacrospinous l igam en t

Internal pu dendal a., v.

Obturator ex tern u s m .

Obturator i n tern us m .

Pi riformis m .

Internal pu clen clal a., v.

Sacrospinous ligam ent

Inferior gl uteal a. , v.

{Top) Th is se ries o f co ronal images d e picts the re la tio n shi p of t h e struct ures exiting the pelvis via th e grea ter sciat ic
notch . T h ose struct ures include t he superi o r glut ea l a rtery, whi ch ex its a lo ng t h e supe rio r bo rder o f the piriform is
muscle. Th e visible struc tures ex itin g a lo ng the infe rio r border o f th e muscle in cl ude t h e sciatic n e rve, th e infe rior
gluteal and inte rna l pude nda l vesse ls. He re, after t h e in ferior gluteal artery exits t h e p elvis it h as man y bra n ches
(such as th e la rge muscula r b ra nc h w h ic h is visib le o n thi s image) . T he intern a l pudendal vessels im mediate ly leave
the butt ocks by passin g a round the sac rosp inous li gam ent to en ter th e lesser sciat ic n ot c h . (Bottom ) T he
horizon tally orie nted fi be rs o f th e sacrosp ino us liga me nt a re iden tified . The course o f t h e intern a l pudenda l vesse ls
before a nd a fte r piercing the ligament is seen .
v
163
 POSTERIOR PELVIS
CORONAL T1 MR, SCIATIC NERVE

Superior gluteal a., v.

I n ferior glu teal a., v.

In te rn al pudendal a., v.

Branch i n ferior gl u teaI

Ischial arte ry, vein
Internal pudendal a., v.

Obturator internus t.

Ischi um Con join ed origi n long

head bi ceps fem o ris m.
& m.

Superior glu teal a., v.

Pi ri form is m .

Inferio r glu teal a., v.

ciatic n.
I nterna l pudendal a., v.

Superior gem ell us 111 . Bran ch i n ferior gl uteal

In tern al pudendal a., v. artery, vein

Obtu rato r t. Sciatic n .

I n ferio r gem ell us m .

Obturator intern us m .

Conjoin ed origin long

head bi ceps femoris 111 .
Isch ium
& semi ten dinosus m.

rJ)

>
Q)
0..
"'C (To p) O nce ex i ting t he pelvi s th e su perio r glutea l artery travels between th e glu te us m ed i u and m ax i m us m uscles.
c Th e i nferio r g lu teal vessel s and scia tic nerve are pa rti al vo lumed togeth er on t his im age. T he i nferio r glu tea l vessels
and sciat ic n erve travel i n close prox im i ty; t he vessels t ravel alo n g the medi al aspect of th e nerve. ( Bo ttom ) T he
c.. sciatic nerve is th e most lat eral structure to ex it alo ng th e inferio r border o f th e p iri fo rmi s musc le. T he lon g axis of
:r: th e sciatic nerve is nicely dem o n strated . Its course pos teri o r to the ex tern al ro ta to rs o f the hip is easi ly appreciated.

v
164
 POSTERIOR PELVIS
CORONAL T1 MR, SCIATIC NERVE

Gluteus maxi mus m.

Pirifo rmb m.

Inferior glu teal a., v.

Internal pudendal a. , v.

Internal pudendal a., v.

Obturato r int crnus I.

branch
Inferior gemellu s m. in ferior gl utea l n.

Obturator m.

origi n long
head biceps femoris m .
&. m.
Ischium
emimembranosus t.

Pi ri formis m.
G l u teus m ax imus m.
Ant eri or div ision
in ternal ili at a., v. G luteus medius m.

Sciati c n.

Superio r gem el lus m.

Obturato r int crnu s t.

Inferior m.

Obturator internus m.

Ulll Semimembran osus t.

(To p) T h e sciatic n erve exiting from t h e pelvi s is n icely seen. Note how o n th ese images the nerve is partial vo l umed
with t he adjacent ex ternal ro tato r muscles. T his close app roxim ati o n m akes iden t ifica ti o n o f th e n erve at t h is level
difficul t i n all imaging planes. (Bottom) Alo ng t he anteri o r bo rder o f the p i ri fo rm is m uscl e t he scia ti c n erve has its
typi cal appearan ce wi th lo ngitudinally o riented fa t stri ati o ns.

v
165
 HIP JOINT
o Labroligamentous sulci: junctio n liga me nt &
IImaging Anatomy labrum
Overview • Thickest posterior & su pe rior
• Most stab le arti cul ation in body • Widest ante ri o r & superior
• Greatest range o f motio n afte r glenoh um eral joint • Vascular sup pl y: Branch es obtura tor, superior &
• Motion inferio r glutea l a rte ries
o Flexion with knee fle xed li mited by abdome n o Ma in ly ca psula r surface
o Flexion wi th knee exten ded limited by hamstrings o Articu lar surface avascular
o Ex tension limited t o 30° past vertica l • Limited ability to repair
o Abd uction w itho ut limitation • Sh ape
o Addu ction li mited by opposite extre mity o Triangular 66-94%
o Ex te rna l rotation > inte rnal • Decreasing incidence wi th increasi n g age
o Internal rotation weakest motion o Va riants: Rounded, blunted, absent
• Muscle/ ligame nt balan ce o Absent labra: Con stellat io n absen t ante ri or la b rum
o Anterior ligaments stronger t han inte rna l rotators & sm all remnant su perio rl y
o Exte rnal rota tors stronge r than p osterior li gam ents • 10- l 49il asymptomatic indi viduals
• Maxi mu m sta bility in ex tensio n • MR signa l
o Fu ncti o n of capsular ligaments o Typicall y low signal all seque nces
o Sign al va riati o ns
Acetab ulum • Me n > wom en
• For med by pubis, ilium, ischi um • Increase incid e nce with increasing age
• Oriented ante ri o r, inferior, la te ral • Most com mon anterior & supe ri or
• Cove rs > 50% fe m o ral head • Inter mediate Tl & proton d en sity: 58%
• Lunate surface along o uter margin • Intermed iate T2 sig nal : 3791>
o Cove red by horseshoe sha ped articul ar cartilage • Bright T2 signal: 15%
• Acet a bular fossa: Central cart ilage devoid region • Glo bular, linea r, curvilinear
o Ma inly ili um • May extend to labra l margins
• Acetabular n otc h : Osseous openi ng infe rior margin • Etio logies: Degene ra t ion , fibroca rt ilaginous
• Pulvinar: Fibrofatty ti ssue fills aceta bular fossa bund les (especiall y a t base), osseous m etaplas ia
o Cove red by synovi um: Extra-art icular (extensio n o f ri m into base)
• Co n sider as inve rted Y: Transfe rs weight ax ial to • Fun ction
appendicular skeleton o Protect cartilage: Distributes fo rces by main taining
o Anteri or iliopubic (iliopectineal) column sy novial fluid layer between articula r surfa ce
o Posterio r ilioischia l cblum n o Preve nts lateral translation femoral h ead
o Stem: Iliu m
• Anterio r & posterior rims: Osseous margins of
joint Capsule
acetabulum • 2 laye rs: Internal syn ovial; ex te rnal fibrous
• Media l wall: Quadri late ral p late ilium o Externa l fo rm s capsular ligaments
o Radiographic acetabula r line • Attachm ents
• Teardrop: Radi ographic co nglomera te sh ad ow o Acetab ulum
o Latera l: Wa ll acetabula r fossa • Base o f labrum anter io rl y & po terior ly
o Medial: Anterior, inferior quadril ateral p la te • Several milli met e rs above labrum superiorly
• Tra n sverse liga me nt in fe rio rly
Femoral Head o Fe m ur
• 2/3 o f sphe re • Anteri o r: Inte rtroch ante ric line
• Covered by articula r ca rtilage • Poste rior: Proximal t o inte rtrochante ric crest
o Excep t cen t ral fovea capitis • Anterior a t tac hm ent m o re latera l th a n posterior
o Ca rtilage thi ckest supe riorly attachme nt
o Cartilage th in s at h ead / neck junction o Perilabral recess: Be twee n labru m & capsul e
• Fovea capitis: Central cartilage devo id d ep ression o n • Smaller anterior & posterio r
head • Larger su perio r
o Attachment site ligamentum teres • Extern al layer: Ligaments of joint ca psule
o Iliofe moral (Bigelow ligament)
Labrum • Anterior, superi or longitudina l spiral
• Fibroca rtilage • Inverted Y-sh ape
• Resides o n acetabular rim • Preve nts h ype rex te nsion
• May overl ie articu lar ca rtilage • Stron gest li ga me n t in body
o Labrocartilaginous cleft • Medial a ttachm ent anterio r infe rio r il iac sp ine
• Be twee n articu lar ca rti lage & labrum o Pubofe moral: Anterior, inferior, longit ud in al spiral
• Anterosuperior, posteroinferi o r • Prevents h yperabdu ct ion
• Likely normal va ria nt • Medial attach m ent obtu rator c res t pubi s
• j oins transve rse ligament at m argin s acetabular notc h o Isc h iofemoral: Poste rior, lo n gitud inal spi ral
• Weakest

v
166
 HIP JOI NT
o Zona orbicularis: Deep, ci rcu lar o In jec t 0.2 mmo l gadopen teta te d imegl umine
• Synovial layer o I mage w ithin 20-30 min u tes
o Longitudin ally o riented folds/ retinacula o Fat su ppressed T l-weighted or gradien t echo images;
o Retinacu lar ar teries with in fo lds o n e seq uen ce w ithout fat suppression
o Screen en ti re pel v is wi th fluid sensi ti ve seq uence;
Bursa co ro nal pl ane best
• Ilio psoas bursa: La teral and /or medial to tendon o Imaging pl anes
o om munica tes with h i p joint between pubo femo ral • M i nimum 3 p lanes to fully visual ize labru m
& il iofem ora l li gaments: 10-14911 • Ax ial, coronal, sagit tal, obli q ue ax ial
• Obtu rator externu s bursa: Outpouching betwee n • Oblique ax ial : M ay replace axial, needed for alpha
zona o rbiculari s & ischi ofemoral l igaments ang le
Ligamentum Teres • Radial imagi ng may be usefu l
• CT art hrograph y
• Attachme nts: Fovea ca pi t is & t ra n sve rse liga m en t
o Altern ati ve if unable to un dergo M R
• Lined by syn oviu m: lntraca psul ar, ex tra-a rticul ar
o Acq uire as thi n as possi ble to maximize mu ltipla nar
• Artery of ligamentum te res within
reconstruction s
o Negligi ble su pply femoral h ead
o Co nsider in terleaved acqui sition
arrow su perior, w ider inferio r
o Do uble contrast best: Sma ll vo lu m e co ntrast 3-5 cc,
• Function unknown
air 5-7 cc
• Tension in flex ion, adduction, external rotat ion
• Iliopsoas bursograph y
• May be pain gen era to r
o Diagn ostic: Snappi ng h ip
Transverse Ligament o Therapeut ic: Bursi t is an y cause
• Spans acetabular n otch o I n ject ion: Target su peromedial femora l
o om pletes socket of acetabulum head /acetabu lar ri m, h it bone, retract needle 3-5
• Blen ds wit h lab ra at margins of no tch mm
o Labrol igarnen tous sulci at junctio n • I f hip replacemen t (l i m at ti p lesser trochan te r
o Diagnostic: Inj ect con trast first & eva lu ate tendo n
Vascular Supply motion
• Branch es o f media l & lateral circumfl ex fem o ral, d eep • Overdi stentio n m ay d im ini sh sensitivi ty
divi ion superio r gl utea l, i nferior gl utea l arteries, a. o f • Vol ume fo r diagnos tic: 3-5 cc
ligame nt u m teres (branch o f ob turato r a.) • Rep uncture fo r t h erapeutic
• Abnormal m otio n : Sudden sn ap from flex ion,
Inn ervation abductio n , ex tern al rotation to ex ten sion,
• Branches from n . to rectus femo ris, n . to quadra t us adduct ion, i n tern al rotation
femoris, anterior division ob turator n ., accessory
obturator n., superior gluteal n. Imagin g Pitfalls
• Anterior labrocartilaginous cleft
o No definit ive li terature
!Anatomy-Based Imaging Issues o Con t roversy norm al variant or pathologic
• Likely normal varian t
Imaging Recommendations o Differen tial d iagnosis: Labral detachment
• MR-a rt hrography preferred to assess intra-arti cular • Di fferential features: Smooth labral marg ins,
struct ures sm ooth ca rtilage ma rgin s, intact attachment
• Art hrography/ joi n t pu ncture labrum & rim, absence o ther pa th o logy
o Conventional arl'hrograph y p ri m arily fo r joint
replacem en t loosening
o Diagnos ti c & therapeutic in jec ti on w ith lidocain e,
bu pivacai ne, stero ids co mm o n
ISelected Refere nces
I. Scldcs RM et al: Anatomy, histologic feat ures, and
o joint aspiration fo r i nfectio n co mm o n
vascu lari ty of the adult acetabular labrum. l in Orth op
o Patien t posi tio n : Flexio n & i nternal ro tation Relat Res. (382):232-40, 200 I
maxi mizes joi n t vo lume 2. Tan Vet al : Contribution of acetabular labrum to
• Bolster under kn ees articulating surface area and femoral head coverage in
• Knee & toes poin t i n ward (tape feet if needed) ad ul t h ip joi nts: an anatom ic in cadavera. Am J
o 'eedle direct ion: St ra ig h t dow n over cen ter o r Or thop. 30( 11):809-12, 200 I
la teral femora l head, or angle t op grea ter trochanter 3. Abc I et al: Acetabular labrum: abnormal at MR
to lateral femoral head imaging in asym ptomatic Rad iology. 2 16(2):576-8 1,
2000
• Avoid m edial femora l head to avoid iliopsoas
4. Cotten A et al : Acetabular labrum: ti.IR I in asymptomatic
bursa volunteers.] Compu t 22( 1): 1-7, 1998
o joint vol ume: 8-20 cc 5. Lccouvet FEet al : MR i magi ng of t he acetabular labrum:
o I lip comm u nicates with i l iopsoas bursa 10- 14% va riations in 200 asymptomatic 1\jR Am J Rocntgcno l.
• MR art h rograph y 167(4) :1 025-8, 1996
o Ind ica ti ons: LabraI tea rs, loose bodies, ca rtil age
defects

v
167
 Vl
>
Q)
c..
"'0
r:::::
C"d
a..
:r:
v
168
v
169
 HIP JOINT
RA DIOGRAPHS, HIP & B U RSA L INJECTIONS

Il iopsoas ten don

CJl

>
a;
c..
"'0 (Top) AP radi ograph du ring injecti o n o f the hi p jo int. An o blique approach to th e jo int was used . Note th at the
c: posterior-m ost ext en sion o f contrast is m edial to the most latera l exte nsion o f contrast anteri o rly. The inferio r
margi n o f th e labrum is o utlined by cont rast. (Bottom) Ilio psoas bursa l inj ectio n. A d irect ap proach is used. The
a. need le is d irected to hit th e ante rio r rim, then withdraw n 5 mm. Th e co ntrast flows al on g the b ursa infe ri o rl y to th e
J: lesser troch a nte r. Va riab le superior exte nsio n of co nt rast may be seen . In th is patient th e superior ex te nt is lim ited.
The tendon is fai n tly o utlined by contrast.
v
1 70
 HIP JOINT
AXIAL GRE MR ARTHROGRAM

Common fem o ral a., v. Ten so r fascia lata m .

Rectus femoris tendon

II iopsoas m. & t.
Anterior i nferio r i li ac
spi ne
Iliofemora l ligament

Superior peril abral

sulcus

Superio r acetabulum
Gluteus minimu s m.

Obturator internu s m.

Glu teus m edius muscle

Pir i formis mu scle

Glu teus m ax imus m .

Sa rtorius muscle

Common femoral a., v.

Ten so r fascia lata m.

Rectu s fem oris t.

Iliop soas m. & t.
Iliofemoral liga ment

Superior peri Iabra I

sulcus

Acetabular rim

Superior acetabulum
Glu teus minimus m .

Obturator internus m.

G luteus m ediu s muscle

Pi rifor m is muscle
Sciatic n erve

(Top) First of ten Tl-weighted gradient echo ax ial images with intra-articula r co n trast from supe rior to inferior. The
two heads o f th e rectu s femo ris m u scle are vis ible. The direct head arises from the an te rior inferior iliac spine, the
indirect head has arise n fro m a g roove above t h e acetabu lum. (Bottom) At t h e supe ri o r aspect of t h e jo int th e
con trast is w ithi n t he superio r perilabra l su lcus between th e joint ca psu le (iliofemoral ligament) a nd the acetabular
rim.

v
17 1
 HIP JOINT
AXIAL GRE MR ARTHROGRAM

Common fe moral a. , v.
Rectu s femori m. & t.

Il iopsoas m. & t.

lli Giemo ral l iga m ent

An terior col u mn

Acetabula r fo ssa
Fem o ra l head
Obtura tor nerve

Medial wal l

Gluteus min i mus m.

Posterior colu m n
Gl uteus m edius m uscle
Ob turato r i n ternus m .
Pi riformis mu scle

Sci a tic nerve

Gl uteu s m ax imus m .

Comm on fem o ral a., v.

Rectus femoris m. & l.

Ili opsoas m. & t. Tensor fascia lata m .

A nteri or labrum
(absent)
Il iofemoral l iga m en t
An te rior col umn
Fovea capi tis Femoral head

Obtu rator nerve

Medi al w all

Pu l vi nar
Gluteus min imus m .

G lu teus m edius muscle

Obturator in tern us m.

Posterior colum n
Piri form is tendon

(Top) The aceta bu lar notch (fossa) is visible as a contra st filled de fect w ith in the acetabulum . T he thin m edia l wa ll is
its osseous boundary. Th e iliofe mora l ligament w raps ove r th e anterio r a nd supe rior aspect o f th e joi nt. (Bo ttom) A
sm a ll de fect is seen in the joint ca psule just la teral t o th e ilio psoas muscle. Thi s defect is th e site of comm unicatio n
between the joint a nd th e bursa. Co ntrast ma te ria l fill s th e space between the joint cap sule a n teri o r ri m in thi s
patie n t wit h a n a bsen t labra. A sm all de pression is seen on the fe m oral h ead. Th is is th e fo vea capitis w hi ch is d evo id
of ca rtilage.
v
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 HIP JOINT
AXIAL GRE MR ARTHROGRAM

Sartorius muscle
Common femoral

Rcct us femoris m.

Tensor fascia lata m.

Anterior labrum Articu lar ca r ti lage
(absent)
II iofernoral Iigament
Anterio r colum n

Ligamentum teres Fem or<JI head

Obturator nerve ligament
Medial wal l
Pulvinar Posterior lab rum
Posterior peri labra l
recess
minimus m.
Posterior rim
muscle
l'o\terior column

Sciati c nerve

Gluteu s maximus m .

Common femoral a., v. Rectus femoris m. & t.

Ten or fascia lata m.

Articular cartil age

Anterior rim
Gluteus minimus m.
Anterior column
Femoral head
Ligamentum teres
Ischiofemoral ligament
Medial wall G luteus minimus t.
Pulvinar Gl uteus m ed ius m uscle
Quadrilat eral plate Posterior labrum
Obturato r m.
Posterior peri labral
Pmterior rim
,reater trocha nter
Posterior co lumn Pi riformis tendon

Scia tic nerve Superior gem ell us m.

Ischia l spine Glu teus max i mus m .

(Top) T he l igamentum teres arises from the fovea ca piti s. T he m edial wall o f t he acetabu lum is ex tremely th in and
the adjacent acetabular fossa is fi lled w ith the pu lv i nar. The posteri o r labru m is seen as a b lack triangu lar stru cture on
th e edge of acetabular rim. The posterior perilabra l sul cus is distended with contras t. (Bottom) A thin smooth g ray
layer of arti cu lar ca rtil age is identified o n th e femora l h ead. The acetabular arti cu lar carti lage is no t as easily seen. T h e
anterio r labrum and peril abral sulcus are no lo nger v isibl e. T he ca psu lar ligamen ts are n o t discrete structures but
rather arc iden tified by position. T h e i lio femo ral ligament is th e most exte nsive and the stro n gest. It encompasses th e
upper an teri o r and the media l superi o r aspect of th e ca psule.
v
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 HIP JOINT
AXIAL GRE MR ARTHROGRAM

Rectus femoris m. & t.

Common femoral a., v.

Te nsor fascia lata m.

Ilio femoral ligament

Anterior rim
Fem-oral h ead
Anterior column
Gl u teus minimus m.
Ligam en tum teres
Isch io femoral ligament
Medial wall
Gl u teus minim us t.
Pulvin ar
Posteri o r labrum
Quadrila teral pla te - --,!=o;;w;;=
Posterio r peri labral
Obturator internus m. - ...;::::;;::..::=: recess
Posterior rim
Gl uteus m edius tendon
Poster ior column
Greater troch an ter

Sciat ic nerve

Ischial spi ne
Gluteus maximu s m.

Sartori u s muscle
Common femoral a., v.

Iliopsoas m. & t .
Tensor fascia lata m.

Pubofem oral l igament

An terior colu mn

Femoral head
Ligamentum teres
Pul vi nar
Gl uteu s minimus m.
Medial wall
Q uadri lateral plate Ischiofem oral l igam en t

Ob turator in ternus rn. G reater troc hanter

G luteu s medius tendon

Gemelli muscles

Gluteus maximus m.
V'J
>
Q)
c..
"'C (Top) Th e isch iofemora l ligament courses from posterior to ante rior over th e lateral aspect of the femoral n eck. Its
c:
(\$
origin from the ischium is weJJ seen on this image. Th e fl attened cross sec tion of t h e liga m entum teres is present
m edial to the femoral h ead. (Bottom) The pu bofem oral ligame nt covers the an te rior inferior aspect of the jo int. The
c.. th in med ial wall of t h e acetabulum a nd th e quadrilate ral pla te of the ilium a re visibl e. These structu res form the
:c bounda ries of the teardro p o n radiographs.

v
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 HIP JOINT
AXIAL GRE MR ARTHROGRAM

Sartorius muscle
Common femoral a., v.
Rectus fem o ris m. & t.

II io psoas m. & t.
Pubofemora l ligament

Zona orbicularis

Femora l ileac!
Ligamentum teres
Femoral neck
M ed ial wall
Glu teus rninirnus rn .
Quadrilat era l plate

Obturator internm rn .

Pm tcrior column m.

Gemelli

Glu teu; max imus m.

Sartorius muscle
Common femoral a., v.

muscle
Pubofemoral ligament
m . & t.
Zona orbicularis

Transvcr,c liga ment Gluteus minimus m .

Acetabular n otch
Grea ter t rochanter

Obturato r i nt ernus 111.

(Top) A focal area of thi ckening is seen i n the lateral joi nt ca psu le at the site of t he fi bers o f the zona orbicularis. The
atta chment of the l iga m entum teres to t he tran sverse liga ment occurs i n the inferio r aspect o f the joint. (Bo ttom ) A
short segmen t of the transverse ligam ent is seen at the posterior ma rgin of the acetabular notch marking th e i nferior
exten l o f the ace tabulu m and hip joint. Along the femora l neck no te the m ore lateral extension of the an terior joi nt
ca psule co mpared to the posterior joi n t capsu le.

v
175
 HIP JOINT
OBLIQUE AXIAL T1 FS MR ARTHROGRAM

An terio r perilabral Il iofemoral l igamen t

recess

Fem oral head

A rticular cartilage
Zona orbicularis
Acetabu lum

Posterior labrum

Posterior perilabral
sulcus
Greater troch an ter

:1lJ
A nteri or peri Iabra I
recess
Il iofemoral l igament

Art icular ca rtilage

l'emoral head

Acetabulum
Zon a orbiculari s
Posterior labrum
Posterior rim

Posteri or perilabral
sulcu s
Greate r trochan ter

V'l

>
Q)
c..
"'0 (Top) First o f te n fat suppressed Tl we ighted ob lique ax ial images alo ng the lo ng ax is o f t he femoral n ec k with
c: intra-artic ular con trast. Images a re fro m superior to infe rio r. At th e su perior as pect of t he join t the a nte ri or perilabral
('j
sulcus is seen . This indi vid ua l has an absent anterosuperior labrum. The iliofemo ral ligame nt is an anterior
0.. longitudina ll y oriented black structure. Th e circula r o rie nta t ion of the fibers of th e zo na o rbicu la ris is a lso well see n .
I (Bottom) The a rticular ca rt ilage is easily appreciated between the acet abulum and femora l h ead, a ltho ug h fe mo ra l
and acetab u lar cartil age are not ea sil y d isce rnible as sepa rate structures. T h e poste ri o r labrum is the triangular
v structure a t th e tip of the poste rio r acetabular rim. Note the con tinuity o f th e fibe rs o f the zo na o rbicu la ris w ith the
focal area o f thi cke ning a nte riorl y d escri bed o n the axial images.
176
 HIP JOINT
OBLIQUE AXIAL T1 FS M R ARTHROGRAM

An terior pcrilabral

Iliofemoral ligamen t
An terior rim

Articular ca rtilage
f em oral h ead

Acetabulum

Posterior labrum Zon a orbicula ris

Posterior rim

Posterior peri Ia bra I

Greater troch anter
sul cus

Anteri or peri labral

Iliofemoral ligament
Anterior rim

Articular cart i Iage

Femoral head
Act'tabulum

Posterior labrum
Zona
Posterio r rim

Posterior perilabral Greater trochan ter

sulcu s

(fop) The posteri or perilabral sulcus is prominent in pa rt due to th e laxity of the posterior joint secondary to slight
ex terna l rotation. Th e anterior capsular structures are tau t. (Bottom ) At this level the articular cart ilage of t he
femoral head is distinctly seen. The acetabu lar cartilage is normally extremely t h i n.

v
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 HIP JOINT
OBLIQUE AXIAL T1 FS MR ARTHROGRAM

An terior labral Ilio fem ora l ligam en t

remnan t
Ar ticu lar ca r tilage

Femora l hea d

Acetabul um

Poste rior labrum

Zona orbicul aris
Posterior rim

Posterior peri labra l G rca tcr t roch an tcr

sulcus
Isch io fem oral li ga m en t

Il iofem oral liga m en t

An terio r labrum
(absen t)
Art icu lar car ti lage

Fovea capi t is Fem oral head

Acetabulu m

Zona o rbi cularis

Labroca rti lagi nous cleft

Posterior pcril abral

sul cus Ischi ofemoral l iga m en t

(Top) At th e ante rior aspect o f t he joi nt a sma ll t ria n gula r anterior la brum is prese nt. Co ntinuity between the fibe rs
of the ischio fe m o ral liga me nt and th e fibe rs of the zo na o rbicularis posteriorl y ca n be apprecia ted on this im age.
(Bottom) A thin collectio n of contrast is identified posterio rl y between th e articu lar cartilage and the poste rior
labrum. T his labroca rtil agino us cleft is a norma l va riant. The cartilage o f th e fe m o ral head thins at th e m argin s of the
fovea ca pi tis.

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 HIP JOINT
OBLIQUE AXIAL T1 FS MR ARTHROGRAM

Pubo fem oral ligam ent

Air bubble
Zon a o rbicularis

Fovea capitis
Femoral h ead

Pulvinar

Acetabulum Zon a orbicul arb

G rcater troch an ter

Labrocarti laginou s cleft

perilabral
sulcus

Pubofem oral ligament

7ona orbicularis

remora I h ead
Li gam entum teres

Pul vi nar
lon a orbicularis

M argin acetabular fossa

peril abral
sulcus

(Top) T he fovea capitis is an im pression on the central portion o f th e femora l head. A sm al l ai r bu bb le col lects in th e
anteri or perilabral recess. Th e pul vinar is difficult to appreciate as a d istin ct stru cture on fa t suppressed images. It
blends w ith th e adj acent acetabulum. (Bottom) Th e attachment o f the ligam entum teres to th e fovea capitis is
visible. At thi s inferi or aspect of the joint t he pubofemoral ligam ent forms th e ex tern al laye r o f the joint capsu le.
o te the abrupt loss of acetabular arti cular cartilage at the posterior margin of th e acetabu lar fossa .

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 HIP JOINT
OBLIQUE AXIAL T1 FS MR ARTHROGRAM

Pubofemoral li gament

Tran sverse ligament

Ligamentum teres Zona orbicularb

Pulv in ar
Femur
Aceta bu lum

Acetabular notch

Pubofemoral l igament

Transverse liga m en t
Ligam en tum
Obtu rator extern us
Pu lv inar

Acetabul um Femur

Acetabular no tch

r.n
>
Q)
0..
"'0 (Top) The posterior m argi n o f th e aceta bu lar no tch is easily apprecia ted. The fi bers of the transverse ligam en t span
s:: t he notch from anterior to posterior. Th e labra have blended with the t ransverse l igament by the level. (Bottom) The
l iga mentum teres attach es to t he tran sverse ligamen t at t h e in feri o r aspect o f the jo i nt. Th e o bturato r externus bursa
a. is an ou t pouch ing of the synovium fro m benea th the inferi or margi n of the obtu rator extern us muscle along th e
I posterior aspect of the joint.

v
180
 HIP JOINT
CORONAL T1 FS M R ARTHROGRAM

Su praacctabular ilium

rim

Zon a orbi cul aris

Obturator
bu rsa

Grea ter troch an ter

t rochanter

Acetabular roof

l·emoral head Posterosuperior labrum

M ed ial wa ll Zona

ligament
Greater trochanter

Pmteroinferior labrum

troc hanter

(Top) First of eight Tl-weighted fat suppressed coro nal images w ith intra-articular contrast from pos terior to anterior.
Images begin at th e posteri o r acetabular rim. The fibers of the zona o rbi cularis are visible as a circu lar band of f ibers.
T he obturator extern us bursa is presen t as a posterior outpo uching of the jo int fro m beneath the i nferio r border of
the obturator cxternu muscle (sec "Lateral Hip" secti o n). (Bo ttom) T he en t ire cou rse of th e posterior labrum is see n.
At the posterior margin of th e ace tabular notch the l.abrum blends w ith t he tran sverse ligament.

v
181
 HIP JOINT
CORONAL T1 FS MR ARTHROGRAM

Acetabular roof
Articular cartilage
Margin acetabular
Supsrior labrum
Fem o ra l head

Medi al wall
Zon a orbicularis

Labroligam entous
su lcus
Transverse l igament

Labrum

Acetabular roof Articular cartilage

Superior labrum
Margi n acetabular
Superior peri labral
recess
M edia l wal l
Zon a orb icularis
Pul vin ar

Transverse ligament

Ill
>
Cl.l
c..
"0 (Top) Th e la bro li gamento us sul cus is crea ted a t the junction o f the poste rior la bru m a nd th e t ransverse ligament.
c Th is sulcus sho uld not be m isinte rpre ted as labra l pa t ho logy. The a rti cula r s urfaces o f the a cetabul um a nd fe mo ra l
h ead are di scern ible as two separa te structures o n this image. (Bottom) An abrupt loss o f acetabu lar a rt icula r ca rtil age
0. occurs a t the med ial ma rgi n o f the aceta bula r fo ssa. The cross sec ti o n o f th e tra n sve rse liga m e nt is seen alo ng the
:c ace ta bula r no tch. It is t ria ng u lar in sha pe simi lar to th e labru m . The su perio r labrum is prese nt as a sma ll black
t ria ng u la r struc ture a lo n g th e latera l ma rg in o f the ace ta bula r roof.
v
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 HIP JOINT
CORONAL T1 FS MR ARTHROGRAM

Articular carti lage

Acetabular roof
Superior labrum
Margin acetabular fossa
Superior peril ab ral
recess
M ed ial wall
Fem o ral h ead
Pul vin ar
Zon a orbicularis

Ligament um teres Ischiofemora l ligam ent

Transverse l igam ent

Superior perila bral

recess
Acetabular roof

Art icular cart ilage

Sup erior labrum

Margi n fovea capiti s Fem oral head

Il iofem oral ligam en t
Liga m en tum teres
Zona orbicularis
Pulvinar

Ischiofemoral liga ment

Transverse ligament

I liofem ora l ligam en t

(Top) The s uperi o r lab rum is ni cely visua lized . In this patien t it overla ps t h e a rti cu lar cartilage. A sma ll air bubble is
noted in th e superior peri labral recess. The long axis of the ligamentu m teres is seen extending fro m th e fovea capitis
to t he t ransve rse liga me n t. Th e ischiofemora l ligamen t is th e most la te ra l of th e capsular ligam e nts. With fa t
suppressi o n it is difficult to vis ualize th e pulvina r an d adjacent medial wa ll of the acetabulum as separat e st ruct ures.
(Bottom) Su pe riorly the jo in t capsule inserts several millimeters above t he acetabu lar rim creating a larger pe rilabral
recess. The fovea capitis is the centra l depressi o n on t h e femoral head. It is devoid o f cart il age and an abrupt d ro p off
of ca rti Iage is seen at its edge.
v
183
 HIP JOINT
CORONAL T1 FS MR ARTHROGRAM

Ili um

Superio r per ilabral

recess
A r ticul ar ca rtil age
Supe.rior labrum

Fovea ca pitis Fem oral head

Iliofem ora l li ga m en t

Tra n sverse ligamen t

Pubofem o ral l igam en t l sch iofem o ral I igamen t

Iliofem o ral li ga m en t

I lio psoas tendo n Superior pe ri labra l

recess
An terior labrum
(absen t)

Iliopecti neal junction

Ili ofem oral li gamen t

Fem oral head

Pubo fem oral ligament

(Top) Visua li za ti on o f th e a rticular cartilage is excellent in th is portion of the join t. The superi o r labrum is a lso nicely
d em o n strated as a triangu lar stru cture al o ng t h e acetabu lar ri m . (Bottom) Th e pubofe m o ral li ga m ent is the m ost
inferi o r of the ante rior external capsula r ligaments. At this transition fro m superior to anterior labru m a co ntrast
filled de fect is seen a t the ex pected locati o n o f th e anterior lab rum . This anato mi c vari a nt is n o t un co mmo n . Th e
iliopsoas tend o n is crossing th e iliopectineal junction and its intimate rela tionship with th e jo in t is easily
ap preciated.
v
184
 HIP JOINT
SAGITTAL T1 FS MR ARTHROGRAM

An terior col umn

Il iop soas tendon

Acetabular fossa

Anterior acetabu lar rim

Posteri or (ilioischial )
Ligam en tum teres column

Tran sve rse li ga m ent

Acetabula r roof M argi n acetabular fossa

A nteri or labrum
(abse n t) Posterior (i li oisch ial)
column
Fovea capi tis

Femora l h ead

Ilio psoas tendo n Tran sverse l iga m ent

(Top) First o f te n fa t suppressed Tl-we ighted sagitta l images from med ial to latera l w ith in tra-art icular contrast. This
medi a l m ost image is t hro ugh t h e ace tabu lar n otch. A segm ent o f t h e lon g axis of th e ligam entu m te res is see n
nea ring its a tta chme nt to the tra n sve rse ligame n t. The h o ri zo nta l fibe rs o f the tra nsverse ligam en t span th e
acetabular not c h from anterior to posterior. The close re la tionsh ip between th e il iopsoas te ndon and th e anterio r
aspect of the jo in t is easil y a ppreciat ed. (Bo ttom) Mo re late ra lly the cross sec tion o f th e "hip socket" is seen
compl eted by t he t ra nsve rse ligam ent in fe riorly. A sma ll a nte rior pe ri labral recess is present a nd t h e anterior labrum
is absen t. Th e depressio n o f th e fovea ca pi tis ca n be app reciated o n the fem o ra l head.
v
185
 HIP JOINT
SAGITTAL T1 FS MR ARTHROGRAM

Acetabular roof
Anterior acetabular rim
Margin acetabul ar fossa

Anterior labrum
(absent) Poster ior (i lioisch ial )
column

Femoral head

Pos terior ri m

Iliopsoas tendon Posterior labrum

Posterior perilabra l
su lcus

An terio r inferi or iliac

spi ne

Anterior acetabu lar rim

Anterior peri Ia b raI

ulcus
Posterior (i l ioisch ial )
An terio r labrum column

Femo ral h ead

I liofem o ral ligam ent

Posterior ri m

Posteri or lab rum

Poster io r peri Ia braI

sulcus

rJ)

>
Q)
0..
""0 (Top) The sharp margin of the articular ca rtilage a t the edge of th e acetabular fossa sh o uld n ot be co nfused with an
c: articular ca rtilage defect. Anteri or to the margin of the fossa the femoral and acetabul ar cartilage bl end togeth er
C\S
imperce ptibly. The posterior perila bra l sulcus is qu ite prominent. (Bottom) On this image a small ante ri or labrum is
c.. see n o n the a nterio r acetabular rim. T h e posterior labrum is well seen on the tip o f the poste rior acetabula r rim a nd a
I prominent posterior pe rilabra l sulcu s is present. The attac hme nt of th e ilio fe moral liga me n t to the anterio r infe rior
iliac spine is well seen.
v
186
 HIP JOINT
SAGITTAL T1 FS MR ARTHROGRAM

Anterior inferior iliac

spine Acetabular roof

An terio r perilabral

An terio r labrum
Posterior acetabu lar
ri m
Femoral h ead

Iliofe m o ral ligament

labroca rt i lagi no us
su lcus

Posterior labrum

Sa rt·oriu\ t.

An terior inferio r iliac Acetabular roof

5pine
Articular cartilage
Anterior peri labral

Anterior labrum
Posterior acetabular
rim
Femoral head

Ilio fem ora l l igamen t

Posteri or labrum

(Top) The anterior labrum is v isible as a small t riangular structure. On th is image it pa rti ally overlies the arti cular
ca rtil age. A small peril abral recess is presen t. T he articu lar ca rt ilage of t he femoral head and ace tabul u m are visible as
separate structures. A small posterior labroca rt ilagin ous su lcus is present. (Bottom ) The anterior inferior iliac spine is
visible. The attach men t of th e iliofem oral ligame nt to the spin e is ni ce ly demonstrated. A sma ll anterior perilabra l
sulcus is presen t.

v
187
 HIP JOINT
SAGITTAL T1 FS MR A RTHROGRAM

tendon
Supra-acetabu lar ilium

An terior/superior Ar ticu lar carti lage

peril abral sulcu s

Posterio r acetabul ar
rim

Ischiofemoral l igamen t
Fem ora l h ead
Posterior labrum

Iliofem oral liga m en t Zona orbicul aris

A n terio r/su perior

peri labra l sulcu s Superior labrum

Sar tori us tendon

Isell iofemoral ligament

Fem oral h ead

Zona orbicu laris

Ilio femoral li ga m en t

rJ)

>
Q)
c..
""0 (Top) 1 o te t h e th ick i liofemoral ligamen t . T his l igam ent must be pierced for success ful joi nt pu nctu re. O n this image
c: slight infiltration of t he li gam ent with contrast is visi ble. (Botto m ) T h e co urse of the superior labr um over the top of
t he femo ral head i s well appreciated on t hi s i mage. Recognition of t h e labrum on sagittal i mages is crucial for
0. determinin g th e fu ll anterior to posterior extent of labral tears. Cross referenci ng betwee n images w ill aid in
:r: iden tification o f t he labrum i n thi s plane. Th e circul ar fibers o f the zona orbiculari s ca n be well seen.

v
188
 HIP JOINT
SAGITTAL T1 FS M R ARTHROGRAM

Sa rtorius tendon

I chiofem oral ligamen t

Femoral neck

tendon

lsch iofemora I I igamen t

Femora l neck Obturator extern us

bu rsa

(Top) The ischio fem o ral ligament is t he most latera l o f t he ex tern al ca psu lar ligaments. It passes from posterior to
anterio r at the latera l margin of the joint. (Bo tto m ) The obtu rator externus bursa is an outpouch i n g of the synovium
beneath the inferi or bo rder of the obtu rator extern u s muscle (see "Lateral H ip" sectio n ). The anterior capsu lar
insertion extends more laterally than th e posterior capsular i n se rti o n.

v
189
 THIGH OVERVIEW
o lschi ocond ylar portio n: See "Posterior Fem o ral
!Terminology Muscles"
Abbreviations o Adductor hiatus be tween 2 divisions of muscle in
• Anterior supe rior iliac spine (AS IS) distal thi gh
• Function (F) • Gracilis
• Muscle insertion (I) o 0: Inferior pubic ramus, sy mphysis pubis
• Nerve supply (N) o 1: Med ial proximal tibia (pes anse rin e)
• Muscle origin (0) o F: Also ass ists knee flexion
• Struct u re suppli ed by a ne rve o r vesse l (S) • Obturator externus
• Sacroiliac jo in t (SI) o 0: Exte rnal margin s obturator foram e n & membra n e
o 1: Piriformis fossa
o F: Hip ext erna l rotation only
IImaging Anatomy • Pectineus
o 0: Superior pubic ram us, pecte n
Compartment Anatomy o 1: Pectin eal line femur
• Compartmenta l a natomy is d iffere nt from o Femoral n . ±accessory obtura tor n .
functional groupi ngs below o Un clea r pre- or post-axia l muscle
• Th igh divided into anterior, med ial, and posterior • See "Anterior Pelvis and Th igh " sectio n
compa rtmen ts
Anterior Femoral Muscles
o Anterior compartment: Ilioti bial t ract, t e nsor fascia
• Commo n inne rvatio n: Femoral n erve
lata m., quadriceps m s., sa rtori us m.
• Common function : Knee ex tension
o Medial compartment: Gra cili s m ., adducto r ms.
o Except sa rtorius m.
o Posterior compartment: Hamstring m s., short h ead
• Post-axia l m uscles
of biceps femoris m., sciati c n.
• Articularis genu
• Muscles at junction pelvi s/thi gh: Each con sidered
o 0: Anterior lower femu r
sepa ra te compartme nt
o .1: Synovial m embrane kn ee
o Pectineus, ilio psoas, obturator ext e rn us, lateral
o N. t o vastus inter m edius
femo ral ms.
• Rectus fe moris
• Extensions from fascia lata divide compartme nts
o 0: Straight head- a nteri o r infe rio r ili ac spine,
o Media l intermuscular sep tum: Anterior/m edial
reflected head -groove above acetabu lum
o Lateral intermuscular septu m: An te ri or/ latera l
o I: Superior patella, tibial t uberosity
o Thi n fascia separates m edial, poste rio r
o F: Also hip flexion
compartme n ts
o C rosses 2 jo ints
• Clinical note: Co m pa rtnrent ana tomy critica l to tum o r
• Sartorius: (Tailor's m.)
staging & bio psy pla nning
o 0 : AS IS, no tch below
o Cross compa rtment ex te n sion o f tumor,
o 1: Prox ima l medial t ibia (pes a n serine)
contami nation by biopsy requ ires chan ge from li mb
o F: Hi p flexio n, abduct ion, externa l rotation; knee
salvage to amputatio n
flexion
Medial Femora l Muscles o C rosses 2 joi nts
• Common n e rve: Obturator n ., except pectin eus m. o Lo ngest muscle in bod y
o Anterior division: Adductor brevis & lo ngus, gracil is o Sepa rate fascia l covering
m uscles • Vastus lateralis
o Poste ri o r division: Adducto r portio n addu ct or o 0 : Superior intertrochanteric line fe mur, anterior &
magnus m. in fe rior great e r trochanter, gluteal tu berosity, lateral
• Co mmo n functi o n: Hip adductio n ; assist hip flexion, li p linea aspe ra, late ral inte rmuscu lar septu m
interna l rotation o 1: Lateral tibial condyle (la te ra l patella r retinaculum)
o Except obturator extern us m . superola teral patella (quadriceps tendo n )
• Pre-axial muscles • See "Ex te n sor Mechanism a nd Retinacu la" sectio n
• Adductor brevis o Largest quadrice ps muscle
o 0 : Inferior pubic ramus • Vastus m ed ia lis
o I: Inferio r 2/3 pectineal line, superio r 1/ 2 m ed ial lip o 0: Entire m edial lip lin ea aspera, in ferior
linea aspera inte rtroc h ante ric line, m edia I in te rm uscu Ia r sept um
• Adductor longus o I: Tendon rect us fem o ris m ., su pe romed ial patell a
o 0: Pubic body in fe rior to crest (quadriceps tendon ), m edial condyle tibia (m edial
trl
o 1: Med ial li p linea aspera pat e lla r retin acu lum )
> • Adductor m agn us: Two separate muscles with • See "Ex te n so r Mechanism and Ret inacula" sectio n
Cl)
c.. different innerva tio n s & functio n s • Vastus intermedius
o Addu ctor portion o 0: Anterior & la te ra l femora l sh aft, inferior latera l
"'0 lip linea aspera , lateral int erm u scu lar septum
c: • 0: Ischiopubic ra mus
l'tl • 1: Glutea l tuberosity, medial lip linea aspera, o I: Ble nds alon g deep aspect rect us femoris, vas tus
0.. med ial supracondyla r li n e medialis, vastu s late ra lis ms.
::c
v
190
 THIGH OVERVIEW
• Quadriceps femor is: Rectus femoris, vastu s lateralis, • 0: Il iac crest, iliac fossa, sacral a la, Sl joint capsule
vast us me dia I is, vastus inte rmedius m s. • Fe m oral n.
o Common tendon of insertion onto superio r, la te ra l, o Psoas m a jor
m edial patella • 0 : lateral ve rtebral bod y & inte rvertebral discs
T1.2-LS, a ll lum ba r transve rse processes
Posterior Femoral M uscles • Ll , L2, L3
• Comm on ne rve: Scia tic n . o Psoas mino r
o Tibia l d ivisio n: Lo ng head bi ceps fem o ris, • 0 : lateral vertebral body Tl2, L1 & Tl2-Ll
sem ite ndin osus, semim embra n osus, ischi ocond ylar in terve rteb ral di sc
portio n add uctor magnu s ms. • Ll, L2
o Common peron eal d ivision: Short head biceps
femoris m. Femoral Triangle
• Common functio ns: Hip ex tensi o n, knee flexio n • Anterior wa ll.: Ingu inal ligament
• Pre-axial muscles except sh or t h ead biceps femoris m. • Posterior wa ll : Adductor longus & pectin eus ms.
• Biceps femoris (medial), iliopsoas m . (lat eral)
o Lo ng head: 0 - isc hi al tu berosity (infe rio r, medial) • Medial border: Add uctor longus m.
• Common tendo n wit h sem ite ndinosus m. • Lateral border: Sartorius m.
o Short h ead: 0 - late ra l lip linea aspera femur, lateral • Apex: Crossing addu cto r longus & sarto ri us ms.
su pracon dylar line, late ra l intermusc ular septum • Contents: Femora l n. & bra n ches, femoral vessels,
• Post-axial muscle lymph no de (Cloquet node), fe mora l sheath
• Not part o f h a mst ring ms. o Structures latera l to med ia l at entrance: NAVeL
o 1: Fibular head, la te ra l condyle t ibia • Nerve, Arte ry, Vei n, Lymphatics
o F: Also ex ternal ro tation flexed knee • Fem ora l artery/ vei n relation ships
• Semimembranosus o En trance: Arte ry latera l
o 0: lsch ia I tube rosi ty (s upe rio r, Ia te ra l) o Apex: Artery anterior
o 1: Posterio r medial co ndy le tibia, popliteal fascia • Fe mo ra l n . branches with in tr iangle
• Some fibers extend to fo rm o blique po pli tea l I. o Sap he n o us n. , & n. to vast us m edia lis only bran ches
(see "Medial Support Syste m s" section) to exit trian gle
o F: Also inte rna l rot a tio n fl exed knee • Femoral sheath: Transversa J.is fascia covers vessels
o Membranous in upper thigh proxima lly
• Semitendinosus o 3 co m partme n ts
o 0: Ischi al tuberosity (inferior, media l) • Lateral: Arte ry
• Com m on tendo n lo n g head biceps femoris m. • Middle: Vei n
o 1: Medial proxima l tibi a (pes anserine) • Med ial: Lymph node (femoral canal)
o F: Also internal rotatio n fl exed kn ee • Fe m o ra l ca n al : Med ial compartm en t femora l sheath
o Entirel y te nd in ous in distal th ig h o Anterior bord er: In gu ina l liga m en t
• lsc hioco ndyl a r portion of adduc tor magnus o Posterior border: Pu bic bone
o 0: Ischia l tuberosity o Medial border: Lacuna r ligame n t
o I: Add uctor tube rc le o La te ra l borde r: Fem o ral v.
o Med ial-most aspect add uct o r m agnus m . o Entran ce: Femoral ring
• Hamstrings: Lo ng head bice ps femoris, • Anterior borde r: Medial in guina l ligament
sc m i mcm bra nous, se mite ndinosus, ischiocondylar • Pos terior border: Su perior pubic ramus
portion add uctor magnus m s. • Med ia l border: La cu na r liga me nt
o Does not inclu de sh ort h ead biceps femor is m . • Late ra l borde r: Septum between femoral ca nal &
fem o ra l v.
Lateral Femoral (Gl uteal) M uscles • O pe n to perito neal cavity
• (See "Lateral Hip" section) o Contents: Lymph a tic vessels & nodes (Cloquet
Other node), fa t, connect ive t issue
o Clin ical no te: Fe m oral h e rnia
• Pes a n se rine (see "Kn ee Overview" sectio n)
• Latera l & infe rio r to pubic t ubercle
o Common aponeurosis fo r insertion gracilis,
• Travels femora l ring to femoral canal to
semi tend i n os us, sa rtor ius te ndo n s
sap hen ous openin g to subcuta n eou s tiss ue
o Pes an serine bursa be tween tendons & tibia
• More common in wom en
• Iliotibia l trac t / T)and: Late ra l thicke n ing fascia lata
• Strangu lation at femora l ri ng
o 0: Tubercle ili ac crest
• Ing uin a l h ern ias: See "Ante rior Pelvis and Th igh"
o 1: Late ra l co ndyle tibia
o Insert ion site tensor fascia lata m., portion of gluteus Add uctor (Subsartorial or Hunter) Canal
max imus m . • Fascia l passagewa y fo r vesse ls rnid t h ig h
Hip Flexors o Boundaries a re fascia l surfaces of adjace nt muscles
• Anteromedial border: Sa rto rius m .
• Sarto ri us: Anterior fe moral muscle
• Anterolatera.l border: Vastus medialis m.
• Pect ineus: Med ia l femo ra l muscle
• Poste ri o r bo rd er: Addu ctor lo ngus & magnus m s.
• Iliopsoas: I - lesse r trocha n ter
• Entrance: Apex femora l tria ngle
o II iacus
• Ex it: Adductor hi atus

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 THIGH OVERVIEW
o Adductor hiatus: Ga p ad duc to r m ag nus m. betwee n o C utaneo us n e rves: Ante rio r fe mo ral cuta neo us,
addu ctor po rt ion & ischi ocond yla r portion distal sa phe nous
t h igh • Saphen o us n . exits tri a ngle, ente rs adductor ca na l
• Vessel passageway from thigh to popliteal fossa o Articular branch es hip & knee
• Vessels travel caudad & posterior within hi at u s
• Co nten ts: Fe m o ral a. & v., saphen ous n. Obturator Nerve
o Ne rve initially an te ri o r to a rtery t he n media l • L2, L3, L4; pre-ax ial
o Artery ante rio r to vein • Branch lu mba r plex us
o Descending geni cula te a. arises in cana l • Re lationships
o Poste rio r t o iliac vessels
Femora l Vessels o Medial to pso as m .
• Enter thigh dee p to in guinal ligament, m id point o La te ra l to inte rna l iliac vesse ls
b etwee n ASIS & symph ysis pu b is • Via o btura to r forame n to thi gh
o Change from externa l ili ac vessels to comm o n • S: Adductor ms., h ip & knee jo ints, skin m edial d ista l
fe m o ral vessels thigh
• Uppe r thigh: Vessels within femo ra l tri angle • Accesso ry o btu rato r n: L3, L4
o Ente r: Artery la teral to ve in o Prese nt in 9o/o
o Ex it: Artery an terio r
• Mid thi gh: Vessels with in add ucto r can a l Sciatic Nerve
o Entran ce: Arte ry a nterio r • L4, L5,S l , 52,53
o Exi t: Arte ry a nterior • Largest branc h sacral plex us
• Distal thi gh: Exit adduc tor canal via adduc to r hiatus, • Two n erves in o ne sh ea th
e n ter p o plitea l fossa o Tibia l n. (medial) & comm o n pero neal n. (late ra l)
• Common femora l artery branches o Separate in lower thigh
o Superficia l epigastric, superficia l circu mflex iliac, • Ex its pelvis infe ri o r to piriformis m.
superficial external p udendal arise anteriorly o Ano ma lo us re la tio n ship in lO<Jiu
o Deep external pudendal a rises media l.ly o See "Posterior Pelvis" secti o n
• May bran ch from medial circu mfl ex fe mora l • C rosses over supe rior geme ll us, obturator internu s,
o Di vides into supe rfic ia l & d eep branch es inferio r gem e ll us, qu adratu s fe m o ris, ad du cto r m agnu s
o Superficia l femo ral a rtery mu scles
• Branch: Descending gen icular • Dee p to long head bice ps fe mo ri s m .
o Deep femoral (profunda femoris) • Branch es a rising in thigh : Arti cula r to h ip, ne rves to
• Arises late ra ll y in fe m o ral t ria ngle ha m st ring ms.
• Dives be twee n pectine us & ad d ucto r lo ngus m s. • Tibial nerve: Large r divisio n o f scia t ic n.
• Med ial to fe mur, deep to adductor longus m . o S: Posterior femora l ms. except sh ort head biceps
• Bran ches in fem ora l triang le: Medial circu mflex fem o ris m.
femoral (ma in supp ly fe m ora l head & nec k), • Common peroneal n e rve
la te ral circ umflex femoral , muscular branch es o O blique latera l course w ith bice ps fe m o ri s m .
• Bran ches in add ucto r cana l: 3 pe rfora ti ng o S: Sho rt h ead bice ps fem o ris m .
branc h es, desce ndi ng ge n icular • See "Kn ee Overv iew" secti o n
• Terminal bra nch: 4th perfora ting a rte ry
• Fe moral vein: Tra vels with arte ry
o Tri bu ta ries: Deep femoral, d escen d in g geni cular, !Anatomy-Based Imaging Issues
lat eral circumfl ex fe mora l, medial circumflex
Imaging Recommendation s
fe mora l, d ee p externa l pude nda l, greate r saphen o us
vs. • Radiographs
o Great er saphe n o us ve in o Fe mur: AP & late ral v iews
• Longest vein in bod y • Use film diagon a l to cover grea test le ngth
• Toes to saphen o us o pening (fascia lata) • Like ly n eed se para te uppe r & lowe r coverage
• Tribu ta ries: Accessory saph enous, superficial • CT
e pigast ric, supe rfic ia l c ircu mfl ex fem o ra l, o Best for eva lua tion of kn own osseous abn ormality
supe rficia l exte rn a l pude nd al vein s o Acq ui re 0.625-1. 25 m m to improve reco n structio ns
• Conside r inte rleaved acquisitio n
Femoral N erve • Recon st ructio n s: 2-3 mm
• L2, L3, L4, L5; post-axia l • MR
\1) • Largest branc h lumbar plex us o Sequen ces
> • Exits plexus lowe r psoas m . • Tl & STIR id eal lon g axis
Q.) • Travels in groove bet wee n psoas & il ia cus ms. • Fat suppressed T2 for axial pla n e
c.. • Ex its pe lv is ben eath in guina l liga me nt, lateral to o Parameters
"'C fem ora l vessels, e nte rs femoral t ria ngle • Lo ng ax is thigh (s) : FOV 35-40 mm; TH K 5 mm
s::: • Multiple b ranch es in femora l triang le • Single extre m ity a xial: FO V 20 mm; TH K 5-8 m m
(\l
o Muscul ar branc hes: To pectineus, sartorius, rectu s • Matrix: 256 x 256
·-IQ.. fe mori s, vastus la tera lis, vastus medi a lis, vastus
interm edius m s.

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199
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200
v
201
 THIGH OVERVIEW
RADIOGRAPHS, UPPER FEMUR

Iliac crest

Sacroi l iac joi nt

Sacra l arc Iliac wing

Fovea capitis
Sacrum
Femoral Ileac!
Subcapi tal region
Teardrop
Bas icervica l region
Superior pubic ramus
Greate r troc han ter
Pubic tubercle
I n tertrochan teric crest
Sym physis pubis
Lesser trochanter
Pubic body

Inferior ramus

Obturator foramen

Isch ia l tuberosi ty
Femoral di aphysis

Iliac crest

Iliac w i ng

Sacroiliac joint

Su praacetabular il ium
Teardrop Femoral h eacl
Superior pu bic ramus
Greater trochanter
Pubic tubercle

Symphysis pu bis
Lesser trochanter
Pubic body

I n ferior ramus

Obturator foram en
Femoral di aphysis
Ischial tuberosity

(Top) AP radiograph of th e proxi mal femur. Note th e regio n s of t he proxima l femu r: The su bcapita l region a t the
jun cti o n of the fem o ral head and neck, t h e basicervical region at the base o f the fe m o ra l neck. For descriptive
purposes fractu res between t he basicervical a nd su bcapital regio n s are referred to as transcervical (not labe led). In a
well positioned AP fe mu r the lesser troch a nte r po ints medial a nd posteri o r. The inte rtrochanteric crest, a posterior
promine n ce connect ing the two trochanters, is v isible. Th e fovea capitis a ppea rs as a cen tral depression on the
femora l head. (Bottom) Lateral view o f t he p roximal femur. With ext erna l rotati o n the lesser trochanter is n ow seen
v in profile, its inferior cortex blending with th e cortex o f the ad jacent fe moral n eck. The femo ral head, nec k and
grea ter trochanter are all overlapping.
202
 THIGH OVERVIEW
RADIOGRAPHS, LOWER FEMUR

Femora l diaphysis

Li nea aspera

Supracondylar femur

Patella Adductor tu bercle

Lateral fem oral co nd yle Medial fem oral condyle

N utrient foramen

Linea aspera
Femora l di aphys is

Supracon dylar femur

Fem oral con d y les

Patella

(Top) AP radi ograph of th e distal fem ur. The anatom y is less co mplex tha n th e proximal fe mur. The lips of t h e linea
aspera are well visuali zed in th is patie nt. The adducto r tubercle is loca ted just above the m edial fe m o ral condyle. Th e
supracondy lar region is a frequen t site of fracture. (Bottom) Lateral radiograph o f the distal fe mu r. Th e thicke ned
cortex of the linea aspe ra is apparent. A nu trie nt fora me n (vascular channel) is also v isible. The blood will e nter the
cortex a nd fl ow proximall y. "To the elbow l go and fro m t h e kn ee r flee" will he lp one to remember th e ori entation
of a vascula r c h ann el. The fe m o ral condy les can be identified if the patell a femoral groove ca n be seen on the la te ra l
fe moral co nd yle. In gen era l th e medial cond yle is more ro unded th a n the lateral. A more d eta iled d escrip tion of t h e
knee ca n be fou nd in th e "Kn ee Overview" secti on . v
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 THIGH OVERVIEW
COMPARTMENTS OF THIGH

An terior compartment

Mcclial compart men t

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-o (Top) Co mpartm ent anatom y of the upper thigh. Th e femoral vessels a nd th e femu r a re extracompa rtme ntal.
C (Bottom) Compa rtment a natomy upper mid thigh. The sciatic n erve is located within the posterior compart men t.
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v
204
 THIGH OVERVIEW
CO MPARTM ENTS OF TH IGH

Anterior com partm ent

Poster ior compartment

An terior compartment

Posterior compart m en t
Medial co mpartmen t

(Top) Compartmental ana tomy lower mid thigh. At this level the med ial compartment is quite small. Th e a nte ri or
and poste ri or co m pa rtme nts remain similar in size. (Bo ttom ) Compartm ental anatomy d ista l thigh . Most of the
muscles of the medial co mpa rtm e nt have already inserted onto t he fe m ur. Sign ifica n t extracompa rtme nta l fat exists
and ex tracompart mental extension of tumor is likely at this level.

v
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 THIGH OVERVIEW
AXIAL T1 MR, UPPER RIG HT THIGH

IJ Sar torius muscle

Ten sor fascia lata m .

Com m on femoral
artery, vei n & n erve

Ingui nal ligam ent

Rectu s abdomi nis m .
Rectus femoris m. Iliopsoas muscle
Vastus lateral is m.
An l'erior colum n
Iliofemoral l igament

Femoral h ead

Il ioti bial band

:r::;::r:'-7--'=--::._:::::;;--- I sc h io femoraI I igame n t
Greater trochanter
Posterior column
Ex tern a I ro ta tors

Gluteus maxi mus m.

IJ Sar to rius m u scle

Ten sor fascia lata m.
Com m on fem ora l
ar tery, vei n & nerve

Rectus abdominis m.

Rectus fem oris m. Iliopsoas muscle

Vastus lateralis m.
An terior col umn
Iliofem oral l iga m en t
Acetabular fossa
Ilioti bial band

Grea ter trochanter -..Jr:;;#-==

Posterio r column
Quadratus femoris m.

Gluteus maximus m.

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'"0 (To p) Ax ia l images of the thi gh from superi or to inferior. The t h igh begins a t t h e inguin al liga m ent and the external
c: surfaces o f the pelvis. Th e superior-most aspect of the lower extre mity is deta iled in the "Hip Overview" sectio n. Th is
series of images begins at t he inferi or m edial aspect of the inguinal liga men t. The external il iac vessels have just
0.. e n te red t he fe m o ral triangle and become th e co mm on fe m o ral vessels. The ilio ti bial band is prese nt between the
I t ensor fascia la ta and gl ute us max imus muscles. The obtura to r inte rnus muscle has traveled th rough th e lesser sciatic
forame n and ch a nged d irection in t he buttocks as it co urses t o t he pi rifo rm is fossa . (Bottom ) The sacrotuberous
liga ment is visible along th e deep surface of th e g luteus m ax im us muscle. Th e vastus lateral is m uscle h as t h e most
v prox ima l o rigin o f the vastus muscles.
206
 THIGH OVERVIEW
AXIAL T1 MR, UPPER LEFT THIGH

Common femoral
artery, vein & n erve
I n gui na l li ga m en t Sartoriu s muscle

Rectus abdom i nis 111. Tensor fascia lata m.

Il iopsoas muscle Rectus fem oris rn.

Anterior column Vastus lateralis m.

Ilio femoral liga m en t

Medial wall

Ischio fem ora l ligam en t

_.,::o...:..=;-- Greater trochant·er
Posterior colum n
External rota to rs

Obturator intern us m .
Gluteus maximus rn .

Sacro tuberous I.

Co mmon femoral
artery, vein & nerve Sartorius muscle
Rectus abdo minis m.
Ten sor fascia lata m.

Iliop soas muscle Rectus fem oris m.

Vastus laterali s m.
An terio r column
Il iofem oral liga m ent
Acetabular fossa
Ilio tibial band
M ed ial wa ll
Femora l n eck
Greater trochanter
Posterior colum n

Obtu rator in tern us 111.

Glu teus rn aximus m.
Sacrotuberous I.

(Top) Ax ial images o f t h e thi gh from supe rior to inferior. Th e thigh begins at the inguinal ligament and the external
su rfaces of t h e pelv is. Th e superior-most aspect of t h e lower ex tremity is detailed in t he "Hip Overv iew" secti o n. Thi s
series of images begins at t he infe rio r m ed ial aspect o f th e inguinal ligament. The ex ternal iliac vesse ls have just
entered th e fe moral trian gle and become the common femoral vesse ls. The iliotibial band is present between the
tensor fascia lata and glute us max im us muscles. The obturator intern us muscle has t raveled thro ugh the lesser sciatic
foram e n and changed directi o n in the buttocks as it courses to the piriformis fossa. (Bottom) Th e sacrotuberous
ligament is v isible al o ng th e dee p surfa ce o f th e glu teus maximus muscle. The vastus la te rali s muscle has th e mos t
proxima l o rigin o f the vastus muscles. v
207
 THIGH OVERVIEW
AXIAL T1 MR, UPPER RIGHT THIGH

Comm on fem oraI

artery, ve in & nerve
Sartorius muscle
Ten sor fasci a lata m. abdominis m.

Rectus fe m o ris m. Iliopsoas muscle

Pect in eus muscle

Ilio tibial ban d

Vastus lateralis m .
Acetabu lar fossa
Fem oral neck

Gl uteus m edius t. O bturato r extern us m.

Gl uteus max imus m .

Comm o n femora l
artery & vein
Sarto rius muscle

Ten sor fascia lata m. Rectus abdomini s m .

Rectus fem oris m. Pecti neus muscle

I lio psoas muscle

Add uctor brev is m.

Vastus lateral is m .

Obtu rator internus m.

---::::==-t-- Con joined origi n lo ng

Gluteus maximus m. h ead biceps fem ori m .
& se mitendinosu s m.

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"'0 (Top) On the mo re p revio us images th e sciatic n e rve was not di stingu ish able fro m the adjacent muscula tu re. On this
c::: image it is now seen as a di screte structure. The te nsor fascia lata and sartorius m uscles a re on a divergent course
('j
head ing late rall y and media ll y respecti ve ly. (Bottom) The obturator inte rnus a nd ex te rn us muscles are seen o n th e
c.. respecti ve surfaces o f th e o btura tor forame n. The o btu ra tor me m brane se parates th e muscles. The ili o psoas muscle is
:I: taperin g towa rd s its inserti on onto th e lesse r t roch an te r. The gluteus maximus muscle co ntinues its significa n t
coverage o f the inferior aspect of the b uttocks.
v
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 THIGH OVERVIEW
AXIAL T1 MR, UPPER LEFT THIGH

Common fem ora l

ar tery, ve i n & nerve Sartori us mu scle
Rectus abdominis m. Tensor fascia lata m.
Ili opsoas muscle Rectus femori s m.
Pecti neus muscle Il io ti bial ban d

Acetabular fossa

Obtura tor ex tern u s m.

Ischium

Ob tu rato r i nternus m.
Gluteus ma xirnus m .

Co mm on fem o ral
artery & vein

Sartorius muscle
Rectus abclo minis m. Ten sor fascia lata m.
Pectin eus muscle Rectus femori s m.

Iliopsoas muscle

Adductor brevis m .

Obtu rator in tern us m .

===:-- Q uadratus femoris m.

Sem im em branosus t.
:===:-- Scia tic n erve

Con joi ned o rigin lo ng .....

h ead bi ceps fem oris & G luteus maximus m.
se mitendi nosus m s.

(Top) On the mo re previous images th e sciatic n erve was not d istinguishable from the adjacent m usculature. On this
image it is n ow seen as a discre te struct ure. The te nsor fascia la ta and sartori us muscles are on a d ive rgent cou rse
heading late ra lly and m ed iall y respecti vely. (Bottom) The obturator internus an d exte rnus m uscles a re seen on t h e
respective surfaces o f th e obturato r fo ra men. The obturator m e m b ra ne sepa rates th e muscles. The iliopsoas m uscle is
tapering towards its insertion onto the lesse r troch ante r. The gluteus maxim us m uscle conti nues its sign ifica n t
coverage o f th e infe ri o r aspect of the bu ttocks.
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 THIGH OVERVIEW
AXIAL T1 MR, UPPER RIGHT THIGH

Sartorius muscle
Rectus fem oris m.
Common fem ora l
Ten sor fascia lata m . ar tery, vei n & nerve
Ilio psoas m u scle Pectineu s m .
I liotibia l band
Vastus lateralis m.

Ob turator in tenlLIS m.
Gl uteus m edius t.
Isch ial tuberosity
Quadratus fem oris m . Semimembran osu s t.
ciatic n erve
Con joined o rigin long
h ead bi ceps femoris m .
G luteus m axi mus m . & semitendinosus m.

Sarto rius muscle

Rectus femoris m.
Grea ter aphenous v.

Tensor fascia lata m. Com m on femoral

artery, vein & n erve
Iliotibial band Adductor brevis m.

Vastu s lateralis m .
'"-'"--=--==--r- Pectineus muscle

Iliopsoas muscle
Femur
G luteus m edius t .
Isch ial tuberosity
Quadratu s femoris m .
Semime m branosu s t.
Sciatic nerve
Con jo in ed o rigin long
h ead biceps femoris m .
Gluteus maxi mus m . & sem i tendinosus m .

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""0 {Top) T h e more superior and lateral origin o f the semimembranosus muscl e from the exte rn al su rface of t he isch ial
c tuberosi ty and t h e more inferior an d medial co njoin ed origin o f the semiten di nous and lon g head of t he b iceps
fe m oris muscles are v i sib le. The ad ductor b rev is m u scl es lies d eep to the pect i neus muscl e. (Bo tto m ) T he greater
0.. saph eno us vein is feed i ng into th e co mm on femoral vein . The gluteus m edius tendon has its i nsert ion along th e
:c lateral facet o f th e greater trochanter. Except for the glu teus max im us muscle the quadratus femo ri s m uscle is th e
most inferi or of t he external. rotators o f the hip and is recogni zed b y its h orizontal orien tatio n d eep to the gluteus
v maxim us m uscle.

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 THIGH OVERVIEW
AXIAL T1 MR, UPPER LEFT THIGH

Sarto r ius muscle

Rectus femoris m .

Co mmo n femora l Ten sor fascia lata m .

artery, vein & nerve
Iliop soas muscle
Pecti n e us m u scle

Adducto r b revis m .

Obturato r externus m .

Obt u rato r in ternus m .

Quad ratus fem o ris m .

Semim em branosu s t.
F--T- Sciatic nerve
Co n jo ined o rig in lo ng
head biceps fem o ris m .
& semitendinosus m . G lute us m aximus m .

Sartorius muscle
Greater sa p h eno us v. Rectus fe m o r is m .
Co m mon fem o ra l Ten sor fascia la ta m .
artery, ve in & n erve
Add uctor brevis m . Ilio tibia l ban d

Isch ia l tu berosity
Q uad ratu s femoris m .
Semim em b ran osu s t.
= =-T- Sciatic n erve
Conjoi ned origin long
h ead bice ps fem oris m.
& semi tend ino sus m. Glute us m ax imus m.

(Top) The mo re su pe ri o r a nd late ral o rigin of the semimembranosus muscle from t h e ex te rna l su rface o f t he isch ial
tuberosity a n d the more in ferio r a nd med ial co n jo ined o rigin of the se m it endino us and lon g h ead of the b.iceps
fe moris m uscles a re vis ible. Th e addu ctor brevis m uscles lies d eep to th e pectineus m uscle. (Bott om) The grea ter
sa phe no us vein is feed ing into t he common femoral vein . The gluteus m edi us tendo n has its insertion al ong th e
lateral facet o f the grea te r t roc hante r. Exce pt fo r t he g.lu teus m ax imus muscle th e q uad ra t us fe m oris muscle is th e
mo t inferi o r of t he ex te rn al rotato rs of the h ip a nd is recogni zed by its ho ri zontal o rie nta tion deep to the glut e us
maxim u s muscle.
v
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 THIGH OVERVIEW
AXIAL T1 MR, UPPER RIGHT THIGH

Fem oral n erve

Common fem oral
vessels
Sa rt o ri us muscle
Greater saph en ous v.
Ten sor fascia lata m.
Adductor lon gus t.
m. r ecti neus m.
Latera l circumflex
Adducto r brevis m.
femoral artery & vei n
Il iopsoas m.
I liotibial band

laterali s m.

Isch ial tube rosity

Q uad ratus fem oris m .
Sem imembran osus t.
Scia tic n erve - +---'-:::::::
Conjoi ned origin lo ng
head biceps fem oris m.
Glu teus maximus m. & semi tendinosus m .

Sartorius muscle Fem oral n erve

Rectus femoris m. Com mon fem oral
artery & vei n
Tensor fascia l ata m .
G reater sa phe nou s v.
Lateral circum flex
fem oral artery & vei n

Vastus la teral ism.

I n ferior (ischiopubic)
ramus
Quad ratus fem o ri s m . ---;.;:;==:;:::

Sciatic n erve
Con jo ined o rigin long
h ead biceps fem o ris m.
Gl uteus m aximus m. & sem i tendi nosu s m .

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"'0 (Top) Th e origin of th e adductor longus muscl e is v ia a sm all tendon from t he pubic bod y. T he add uctor longus an d
c pectin eus muscle l ie i n t he same plane and t hus occupy th e sam e positio n as images move fro m su perior to inferior.
res Thi s transition is demonstrated on t hese two i mages. (Bottom) The i liopsoas m uscl e i nserts on to t he lesser
0. troch an ter. The lateral circumflex femo ral artery courses d eep to the sartori us an d rectus fem oris m uscl es. No te th e
:::c m ovement o f th e semimembranosus tendon from a more la teral to an an terior posi tion relative to the
semi tendinosus an d long head b iceps fem oris tendons.
v
212
 THIGH OVERVIEW
AXIAL T1 MR, UPPER LEFT THIGH

Common fem ora I

Fem ora l nerve
artery & vein
Greater saphenous v. Sa rtori us muscle

Tensor fascia la ta m.
Adductor lon gus t.
Rectus fem o ris m.
Pect ineu s muscle
=.;;r-----i-- Lateral circumflex
Adductor brevis m. fem oral artery & vei n
r - - -"-'-;--- Ilioti bial ban d

Ob turator exte rnus rn.

Inferior ramus

Ischia l tuberosity
Se m i membranosus t.
Conjoi ned origin long
head biceps femoris m.
& semitendinosu m.

Femoral nerve
Sa rtorius muscle
Co mmon fem o ral
artery & vei n
Rectus femoris m.
Greater saphenous v.
Tensor fascia lata m.
Add ucto r lo ngus t.
r-------...::;-- Latera l circumflex
Adductor brevis m .
femoral art ery & vei n

-===;...:r- Ilioti bial band

r-:=;=;-- Il iopsoas muscle
In ferio r (isch iopubic) --->=== Vastu s laterali s m .
ramus
P'---'--=:;-- Lesser trochanter
___;;;==:;--- Quadratus femoris m.
Semim embran osus t .
Con join ed origin lon g
= - ....r- Scia tic nerve
head biceps femori s m.
& semitendinosus m.

(Top) Th e origin of t h e adductor longus muscle is v ia a small tendon from the pubic body. The adductor longu s and
pectineus muscle lie in th e same plane and thu s occupy th e sa me posi t ion as images m ove fro m su peri or to inferior.
This tran ition i s demonstrated on th ese two images. (Bottom) The iliopsoas m uscle inserts o nto t he lesser
trochanter. Th e lateral ci rcumflex femoral artery courses deep to the sartori us and rectu s femoris muscles. Note the
movem ent of th e semi m embra n osus tendon from a more lateral to an anterior positio n relative to th e
sem itendinosus and long head biceps femo ris tendons.
v
213
 THIGH OVERVIEW
AXIAL T1 MR, UPPER RIGHT THIGH

Femoral nerve
Co mmon fe m o ral
Sartorius muscle artery & vein

Rectu s femori s m . Grea ter saphe nous v.

Adductor lo n gus m .
Tenso r fascia lata m .

Adductor brevis m .
Il io tibial band
Pee t i n e u s mu scIe
Vastus media lis m.

Vastus lateralis m .

Quad ra tus femoris m .

Semimembranosus t .
Sciati c n erve -.;==-==
Semitendinosus m .

Gluteus maxim us m . ====-....o;;:'iii''-"-+-- Conj o ined origin long

h ead biceps femoris m.
& sem ite ndinosu s m .

Comm on fe moral
artery & vein
Sartorius m uscle
Greate r saphenous v.
Rectu s femoris m .
Ad ducto r longus m.
Tensor fascia la ta m .
Il iotibial b a nd

Vastus m ed ialis m.

Vastu s la tera lis rn.

Adductor m agmas m.
Quad ratus femor is m .
Sem imembranosus t.
Conjoin ed origin lo n g
h ead b iceps fe m oris m .
Gluteus maximus m . & semiten d ino u s m.

(Top) As images move more inferiorly the greater saph e no us vein assu mes a more superficial positio n. Th e vastus
med iali s origin from the proxi mal fe moral diaphysis is seen and is deep to the vast us late ralis at this level. Th is is t he
most inferior image on whi ch t h e femo ral ne rve ca n be identified. It bra n ch es entirely wit h in the femora l triangle.
The two origin s of t h e adducto r magnus m uscle are visible. The more a nterior adductor portion origina tes from the
in fe rior p ubic ramus, the more posterior portio n of the muscle o rigina tes from the ischial tuberosity. (Bottom) The
c h anging o rie ntatio n between th e semimembranosus and the other h amstring tendons continues. The
v semime mb ranos us tendon is now mo re medially positioned. These a re the first images o n whic h the thin graci lis
tendo n is vis ible. It is pa rtia l volu med with o the r structures above this level.
2 14
 THIGH OVERVIEW
AXIAL T1 MR, UPPER LEFT THIGH

Femoral n erve
Co mmon fem oral
ar tery & vei n Sartori u s m uscle

Greater sa ph enous v. Rect us femo ris m.

Add uctor lon gus m.

Adductor brevis m .

Gracilis tendon

Adductor rnagnus m .

Semimembranosu s t.

Semitendin osus m.

Co njoined origin long

head biceps fem oris m .
& semitendi nosus m .

Common fem ora l

artery & vein
Sartorius muscle
G reater saphen ou s v.
Rectus fem oris m.
Adductor longus 111.

Adductor brevis m.

Adductor magnus m .

Sem i m embran osu s t.

Semitendinosus m.

Co njoi ned or igi n long

head biceps femoris rn
& em itendinosus rn.

(Top) As images move m ore inferiorly the greate r saph e n ous vein assum es a more superficia l positio n. The vastus
medi alis origin fro m th e p roximal fem o ra l diaphys is is seen a n d is deep to th e vast us latera lis a t this level. This is the
most infe rior image o n whi ch th e femoral n erve ca n be identified. It branch es enti re ly within the femoral t riangle.
The two origins of the adductor magnus muscle are visible. The mo re anteri o r adductor portio n originates from th e
inferi or pubic ramus, th e more posterior portion o f the muscle originates fro m the ischial tuberosity. (Bottom) Th e
cha nging orie ntat io n between th e semimembran o sus a nd the ot he r ham string te ndo ns continues. The
se mimemb ranosus te ndo n is n ow m ore m edially position ed . These are the first images on whi ch th e thin gracilis
tendo n is visible. It is partial vo lumed with oth er structures above this level. v
21 5
 THIGH OVERVIEW
AXIAL T1 MR, UPPER RIGHT T HIGH

Rectu s fem o ris m. Sa r tori us muscle

G reater sa phenou s v.
Ten sor fascia lata m.
Adductor longus 111.
Comm o n fem oral
Iliotibial ban d arte ry & vei n
Vastus m ed ialis m . = = =-- Adductor brevis 111 .

Vastus lat eral ism .

====-- Pecti n eus muscle
G raci lis muscle
Adductor magnus m., Adductor m agnus 111.,
(add ucto r) (ischiocon dylar)
Sciatic n erve - -l==== em i m em branosus t .
Lo ng h ead bicep s -{====
femoris m .
G lu teu s 111axi111u s 111.

muscle
Su perficial fem o ral
Rectu s femo ris m . artery & vei n

Great er saph en ous v.

Ten sor fascia lata m .
Adductor lon gus m.

Ilio t ibia l ban d

Vastu s m edial is m . ;::;=:;I-- Adducto r brevis m.
;::::!::::;;:.- Pectineu s muscle
Vastus lateral is m. - -i=:;;=:::;:=
Adducto r magnus m ., --F=== Gracili s muscle
(adductor)
Adductor m ag nus m .,
(ischiocondy lar)
Sciatic nerve - -1==:;==-:.::
Se mimembranosus L
Lo ng h ead, biceps
fem oris m. Sem i tendinosus 111 .

Ill
>
Q)
c..
"'0 (Top) In th e upper thi gh the rect us femo ri s tendon is present alon g the an terio r aspect of t he m uscle. T h e m uscle
c: bellies o f the semiten dinosus and lon g head o f t h e biceps fe moris muscl es are now presen t. ( Bottom) The common
l't1 femo ral vessels have div ided into superfi cia l and deep femoral vessels. The gracilis muscle is now vi sible. Th e tenso r
0.. fascia lata muscle has assumed a more flattened pro fil e. Thin sli ps o f t he pectineus and adductor brevis m uscles are
J: present as th ey insert alo ng th e posterior fem ur.

v
216
 THIGH OVERVIEW
AXIAL T1 MR, UPPER LEFT THIGH

Sar torius mu scle Rectus femoris m .

Greater saph en ous v.

Tensor fascia lata m .
Add ucto r lo ngus m .

Common fem oral a., v. Iliotibial band

Adductor brev is m. Vastus medi alis m.

Pectineu s muscle -..;;;::;=:;; Vastu s la tcral is m.

G raci l is muscle -;;;;:;=;=;;
Adductor magnus m.,
Adductor magnus m.,
(add uctor)
(isch iocondylar)
Sciatic nerve
Semim em branosus t.
Long h ead, biceps
fem oris m.

Sartoriu s muscle

Superfi cial fem oral

Rectus femori s m.
arte ry & vei n

Greater saphenous v. Ten sor fascia lata m .

Adductor longus m.

Deep femoral a., v. rliot ibial ban d

Adducto r brevis m. Vastus m edialis m.

Pectineus muscle Vastu s lateralis m .

Graci l is muscle
Addu ctor m agnus rn.,
Add ucto r magnus m .,
(adductor)
(isch iocondylar)
Sciatic n erve
Semimem branosus t.
Lo ng h ead, biceps
Sem itendi nosus m. fem oris m.

(Top) In the upper t h igh the rectus femoris tendon is prese nt alo n g the a nte rior aspect of th e muscle. The muscle
bellies of t h e sem iten d inosus and lon g head o f th e bice ps femoris m uscles are now present. (Bottom ) Th e co mmon
fem oral vessels have divided into superficial and d eep femoral vessels. The g racil is m uscle is now visible. The tensor
fascia lata muscle has assum ed a more flatten ed profile. Thin s.lips of the pectineus and add uctor brevis muscles are
prese nt as th ey insert along th e posterior femur.

v
2 17
 THIGH OVERVIEW
AXIAL T1 MR, U P P ER RIG HT T HIGH

Rectus femoris m.
Sar torius mu<,cle
Tensor fascia lata m. Greater saphenous v.
Superficia l fem o ral
Vastus lateralis m .
artery & vein

Adductor longus m.

Vastu s m ed ial is m . Deep fe moral a., v.

Adductor brevis m .

G racilis mu cle

Adductor magnus m.
Semimembranosus t.
Long head biceps
fem oris m. m.

Rectus fem o ri s m. Sartorius muscle

Vastus lateral is m . Greater saphenous v.

Superficial fem o ral
art ery & ve in
Vastus medial is m. .--=---...,;.- Adduc tor longus m.
Ilio ti bial ba nd ----;;;-- Deep femo ral a., v.

Per fora ti ng vessels

Sc iat ic n erve
Semimembranosus t.
Lo ng h ead biceps --;o:--..::,....:..o:..___
femoris m. Sem itendino us m.

(Top) T h e two portions of the adducto r magnus m uscle are now in close proxim i ty. T he semimembranosu
co ntinues as a thin m em bra nous slip thro ugh t he p roximal and mid thigh alon g the d eep su rface of th e
sem i tendinosus muscle. (Bottom) A large per forati ng artery is v isible. It is a branch o f t he deep femoral artery. The
te n sor fascia lata m uscle has completely inserted onto th e i lio tibial band. Thro ug ho ut the th igh the sciatic nerve
resid es d eep to th e biceps femoris muscle.

v
218
 THIGH OVERVIEW
AXIAL T1 MR, UPPER LEFT THIGH

Sarto rius muscle Rectus femoris m.

Grea te r v. Tensor fascia lata m .
Superficial fe m o ral
Vastu lateralis m.
artery & vein
Adducto r longus m .

Deep femoral a., v.

Adductor brevis m .

G raci lis muscle

Adductor magnus rn.

Semimembranosus t .
r----=;,..-;-- Long head biceps
Sem itendinosus m . femoris m.

Rectus femoris m.
Sa rt o rius
Grea te r saphenous v.
Vastus late ralis m.
Superficial femoral
artery & vein
Adductor lo ngus m . --=----"-' Vastus m edialis m.
Deep femora l a., v. --:---.., Ilio t ibial band

Adductor magnus m.
Semimembranosu s 1.
• ===;:.............;-- Long head, biceps
Semitendinosus m . femoris m .
Gluteus maximus m .

(Top) The two portions of the adductor magnus muscle are now in close prox i m i ty. T he semimembranosus
continues as a thi n m embran ous slip through the proximal and mid t high al ong the deep surface o f th e
semitendinosus muscle. (Bottom ) A large perforating artery is vis ible. It is a bran ch o f the deep femora l artery. The
tensor fascia lata muscle has comp letely inserted onto the iliotibial band. Throughou t the th igh th e scia tic nerve
resides deep to th e biceps femori s muscle.

v
219
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT TH IGH

femoris m.
Sartorius m .
Vastus lateralis m.
Grea ter saphenous v.
:'------"w-- Superficial femoral
artery & vein
m edial is m .
Add uctor lon gus m .
.:...._-1; -- Deep femoral a., v.

Vastu s i nterm edi us m.

Ilioti bial band
Adductor magn us m.

Long head, biceps Semimembran osus t.

femoris m.
Semitendinosus m.

Rectus femori s m .
Sar to rius muscle
Vastus lateralis m.
Greater saphenous v.

Superficial femoral
,..:...--,----...!W-
Vastus medial is m. artery & vein
:.r--i-- Adductor longus m.
--1;.-- Deep femoral a., v.
Femur
- --;;;.-- Adductor brevis m.
Vastus i n term edi us m.

Semi m em bra nosus t.

Lon g head, biceps
fem ori s m.
Semitend inosus m.
Glu teus maxi m u s m. --+"'====-.=..:..o=-----"=-=:

(Top) D ifferen t iatio n of the vastus muscles is di fficul t in th e midthigh . Inco mplete fat pla n es pa rtiall y separate the
m uscles. T he add uctor m uscles are slightly m o re d isti n ct but often blend togeth er in secti o n s. (Botto m ) Th e sartorius
m uscle co ntinues i ts course across th e thigh fro m anterio r to medial. It i s now loca ted m ed ial to the rectus femor is
muscl e. T he inferior most aspect o f th e gluteus max imus muscl e is v isible. Its inferior most i nsert ion is o n to th e
dista l up per 1/ 3 o f t h e fe mur via t he linea aspera. As t he vessel s course throu gh the fe m ora l tri angle th e arter y
assumes a mo re an ter io r position as seen o n t hese images.
v
220
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

SMto rius muscle

Rectus fem oris m.
Superficial fem o ral
artery & vein Vastus lateca lis m.

Greater saphenous v.
Adducto r lo ngus 111 .

Deep fe m ora l a., v.

Adducto r brevis 111 .

Gracilis muscle

Add u ctor magn us m .

Sem imem branosus t.

Lo n g h ead, biceps
fe moris m.
Semite nd inosus m.

Rectus femo ris m.

Sarto riu s muscle
Superfi cial femoral Vastus latera lis m.
artery & vein

Grea ter saph en o u s v.

Adducto r longus m.
Dee p fem oral a., v.
Adductor b revis m.

Gracilis muscle
Adductor magnus m .

Semimem branosu s t.

Semi tendi nosus m .

- -- - - -- ----"f-- Lo ng h ead, b iceps
fem oris m .

(Top) Diffe ren tiation of the vastus m uscles is d iffic ult in the midthigh. Incomplete fat planes partially separate the
muscles. The add ucto r muscles are slightly more d istin ct but often blend together in sections. (Bottom) The sartorius
muscl e continues its course across the thi gh from anterio r to medial. It is n ow located medial to the rectus femoris
muscle. The inferior most aspect of t he gluteus maximus muscle is visible. lts inferior most insertio n is onto th e
distal upper 1/3 of the fe mur via the linea aspera. As the vessels course th rough the femoral trian gle the artery
assumes a m ore anterior position as seen on th ese images.
v
221
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus fem oris m . Sartori us muscle

Vastus latera lis m . Super ficial fe m oral

ar ter y & vein
Ilio ti bial band
Grea ter v.
Vast us m ed ia lis m.
r-:,-..:_____;;;-_ Adductor lo ngus m .

-':---w-- Deep femora l a., v.

,______.; -- Adducto r brevis m .

Vastus intermedi us m.

Sciati c n erve
Lon g head, biceps
fem o ris m .
Sem i tendi nosus m.
Gluteus m ax i m us m.

Rectus fem o ris m.

Sartori m uscle

Vas tus lateral is m. Super ficial femoral

artery & vein
Ilio tibial ba nd
Grea ter saph en ous v.
Vastu s m edia lis m.
Adducto r lon gus m .

,..:..._-.;-- Deep femoral a., v.

Add uctor brevis m .
Vastu s in term ed iu s m.

Lo ng h ead, biceps
fem oris m.
Gl uteus m axim us m. Sem itendi n osus m .

Cll

>
Q)
0..
-o (Top) The semite n d in osus m uscle be ll y e nlarges through th e mid thig h. Th e muscle be llies o f the sem ime m branosus
c a nd sem itend inosus m uscle sha re a reciprocal relatio nship. As the se mi te n d in os us m uscle becomes sma ller alo ng its
C\l
inferio r exte nt th e se mime mb ra n osus m uscle becomes la rger. (Bottom ) Th e vastu s inte rm edius muscle o ri gin is now
c.. visible. At th is level th e vastus late ralis muscle is a nteri or to t he inter medius m u scle a nd ante rola teral to the vastus
:r: m ed ialis muscle.

v
222
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Sartorius muscle Rectus fem o rb m.

Superficial fem o ral Vastus lateralis m.

ar ter y & vei n

Greater sa ph en ous v.

Addu ctor longus m .

Deep fem o ral a., v.
Adductor brevis m.
G racilis muscle

f\dductor magnus m .

Semimem branosus t. =----.....__ _:____-+- Long h ead, biceps

femoris m.

Semitendin osu s m.

artorius muscle Rectus femoris m.

Superficia l femoral Vastu s lateralis m.

artery & vein
Ilioti bial band
Grea ter sa ph enous v.

Adductor m.
Deep fem o ral a. , v.

Adductor brevis m.

Graci lis muscle

Adductor rn. n erve
Semimembran osus t. r====rT-------+- Long head, biceps
femorb m .
Semiten di nosus m.

(Top) The se mite ndinosus muscle bell y e nlarges through th e mid thigh. The muscle bell ies of the sem imem branosus
and semite ndinosus muscle sh are a reciproca l rela ti o n ship. As the semitendinos us m uscle becom es smaller along its
inferi o r ex tent th e semi m e mbranosus muscle becom es la rger. (Bo ttom) The vastu s intermedius muscle o rigin is now
visible. At thi s level the vas tus late ra lis m uscle is anterio r to th e inte rmedius m uscle and ante ro la teral to the vastu s
medialis m uscle.

v
223
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT TH IGH

Rectus fe m oris m.
Sarto r ius muscle
Vastus lateralis m.
Superficial femo ral
art£ry & vein
Vastus medialis m.
G rea ter saphenou s v.
Vastus intermedius m.
'-----w- Adducto r longus m.
Deep fem o ra l a., v.

Ad d u ctor brevis m .

--=t-- Add uctor magnus m.

Semimembran osus t.
Long head, b iceps
femoris m.
Se m itendi n osus m .

Rectus fe m oris m.

Vastus latera lis m. Sartorius muscle

Superfic ial fe m oral
artery & vein
Vastus medialis m.

Vastus in term edius m.

Add uctor lo n gus m .
Femur
Deep fe m oral a., v.
Adducto r brevis m .

Sciatic nerve Addu ctor m agn us m.

Se mimembranosu s t.
Lo ng head, biceps
fe m o ris m .
Sem iten d in osu s m .

c.ll

>
(J.)
Q..
"'0 (Top) No te th e con tinuatio n of the superio r te ndon of the semitend inosus muscle along its deep la te ral surface. The
s:: gracili s m uscle follows a subtl e post e rior course from superior to inferio r thigh. (Bottom) The vastus inte rmedius
m uscle wraps th e anterior aspect of the femoral d iaphysis. Th e adductor m agnus is the la rgest mid-thigh muscle.
c..
I

v
224
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectu s femo ris m.

Sarto riu s muscle Vastus Jateralis m .

Superficia l fem ora l
artery & vein
Vastus m edial is m.
G reater sap h e n ous v.

Adducto r lo ngus m.
Deep femoral a., v.

Adductor m agnus m .

Sem imembranosus t.
Lo ng h ead , biceps
fe m o ris m.
Se m ite ndinosus m .

Rectus fe moris m.

Sartorius muscle Vastus late ralis m.

Superficial femo ral
artery & vein
Vastus m edialis m.
G reater saphenous v.
Adductor lo ngus m .

Deep fe m o ra l a., v.

Adductor m agm as m.
Scm i m e mbra nos us t.
;r-.-"=7- - - = - - - - + - - Lo ng head, biceps
..! femor is m.
Semiten dinosus m .

(Top) Note the con t inuation of the superior tendon o f t he semitendinosus muscle along its d eep latera l surface. The
gracilis muscle fo llows a subtle posterior course from superior to inferio r th igh. (Bottom) The vastus intermedius
muscle wraps the anterior aspect of the femoral diaphysis. The adducto r magnus is the largest mid-thigh muscle.

v
225
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus fe m oris m .

Vastu s latera lis m .

Sartorius muscle
Superfi cial femoral
Vastus m ed ialis m. artery & ve in
Vastus in termedius m.
Greater saphenous v.

Deep femoral a., v.

Adductor brevis m .

Semimembra nosus t.
Long head, b iceps
fe moris m.

Semitendi n osus m.

Rectus femoris m.
Vastus laterali s m.
Sartori us muscle
Vastus m edialis m . Superficial femoral
a rtery & vein
Vastus interm edius m.
Greater saphe no u s v.

Deep femoral a., v.

Adducto r brevis m.

Adductor magnus m.
Long head, biceps - +------'-----=:-,
fe moris m.
Semimembran osus
Sem iten d ino sus m . mu scle & tendon

rJl
>
Q)
0..
"'0 (Top) The greate r sap he nous vein may have several tributaries as seen here. (Bottom) The semimembranosus muscle
t: belly is see n forming alo ng the media l aspect o f t he semitendinosu s muscle. The sa rtorius muscle c rosses th e
rd
adductor longus muscle, identi fy ing the inferio r exten t of th e femoral triangl e. The superficial fe m oral vessels a re
0.. n ow loca ted within the add uctor ca nal. The a rtery, the smalle r vessel , is anterior to th e ve in.
::r::

v
226
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectus fem oris 111 .

Vastus Jateralis m.
muscle

Vas tus m edia lis m .

Superficia l fe m ora l
artery&. vein

Greater saph e n o u s v. '-"---"-=:;--- Fe mu r

Adductor longus m . --w---..,o;;;;;r'iiiiii '---.:=--;--- Deep fe m o ral a., v.
---=---+- Adductor m.

Semime mbranosu s t.
Lo ng head, bi ce ps
femoris m.
Semit endinosus 111.

Rectus femo ri s m .
Vastus latera li s 111.

Sartorius muscle
Vastus medialis rn .
Superficial femoral
artery &. vci n Vastus intermedius rn .

G reater sapheno u s v.
Adductor lo ngus m . ---.;...-- Deep fem o ral a., v.
----+- Addu ctor brevi s m.

r+--_::.-----+- Long h ead, biceps

rt!!...-.!iiillr; femori s m .
Semi m e mbra nosu\
muscle &. tendon

(Top) Th e grea ter sa phenous vein m ay have severa l tri butaries as seen h ere. (Botto m) The semimembra n osus muscle
belly is seen forming along th e med ial aspect of t h e se m ite nd inosus m uscle. The sa rtorius muscle crosses th e
adductor longus muscle, identifyi ng th e in fe ri or exten t of th e fe mo ra l triangle. The su pe rfi cial femo ral vesse ls are
now located withi n the add uc to r ca n al. The arte ry, t h e sma lle r vessel, is anteri or to th e vein.

v
227
 THIGH OVERV IEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus fe m oris m.

Vastus lateralis m . Vastus med ialis m .

Sar to ri us muscle
Vastus in termed iu s m . Superficial femoral
artery & n e rve

Femur .""'---'-----;i-- Grea ter saph enous v.

'-iiiiii-=-- - - - ; - Adductor lo n gus m.
Deep fe m ora l a. & v.

Ad ductor m agnus m.
Long head, bi cep s
fe m o ris m.

Semite ndinosu s m.
Se mimembranosu s
muscle & te ndo n

Rectus fe m o ris m .
Vastus la tera lis m.

Vastu s medialis m .
Vastus intermedi us m . Sa rtorius musc le
Superficial fe m o ral
Femur a rtery & nerve
Greater saphe no u s v.
Add uc tor longus m.
Deep femo ra l a., v.

Graci lis muscle

Adducto r magn u s m.
Long h ead, b iceps
fem o ris m.

Semitendinosus m. Semimem bra nosus

muscle & tend o n

(Top) The sartorius muscle continues its medial and now p oste rio r cou rse. It will eve ntually reside immediately
a n teri.or to th e gracili s muscle. The add uc to r b revis m uscle is no lo nger visible. It d oes n ot co ntinue into th e lowe r
thigh. (Bottom) The semimembranosus m uscle con tinues to e n large. The lon g head o f th e bice ps femoris muscle is
a t its largest mid th ig h.

v
228
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectu s fe m ori s m .
Vastus m ed ia lis m . Vastus la te ral is m .

Sa rto rius muscle

Su pe rficial fe m ora l Vast us inte rmedi us m .
arte ry & n e rve

Grea te r saph e no us v.
Fe m u r
Ad d uc to r longu s m .

Adductor m agn u s m .
'r;-i=-------- - ; . - Lo n g h ead, bice ps
fe m oris m .

Sem ite n d in osu s m.

Sem imembranosu s
m u scle & tend o n

Rec tus fe m oris m.

Vastus la teralis m.

Vastu s m ed ialis m .
Sa rtor ius m. Vastus in term ed ius m.

Superfi cial femoral

a rte ry & vein Fe m ur
G reater saph e n ous v.
Adductor lo n gus m .

G racilis muscle

Ad ducto r magnu s m .
;--7=---- - --_,;-- Lo n g h ead, b icep s
fe m oris m.

Se m itendinosus m .
Sem im e mbranosu s
m uscle & ten'tlo n

(Top) The sa rto rius muscle co n ti n ues its media.! and now posterio r course. It will even tuall y reside immedia tely
an terior to th e grac ilis m uscle. Th e ad ducto r brevis muscle is no lo nge r visible. lt d oes n ot co ntin ue into th e lower
th igh. (Bottom) The sem im embra n osus muscle co ntinues to e nlarge. Th e lo ng head o f th e biceps femoris muscle is
at its largest mid thig h.

v
229
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus fe moris m.

Vastus latwal is m.

VaS1us m ed ia lis m .
Vas tus inte rm edius m.
Sa rt o ri us muscle
Supe rfi cial fe m ora l
Femur a rtery & vein
'1!'' ----'---iiii-- G reater sap he n o us v.

Deep femo ral a., v. ,;;;;:;r.---;;;. -- Adduc to r lo n g us m .

muscle

Adduc tor m agn us m .

Long h ead, biceps - ....;;;> ' - - - - - - - - ' ' : -
femori s m .

Semite ndin osu s m.

e mim e mbranosus 111 .

Rectus fe m oris m.
Vastu s late ralis m.

Vastus m ed ialis 111.

Vast us intermed ius m . Sa rtorius muscle

Superficial fe m o ra l
a rtery & vein
11'----;;-- Greate r saphen o u s v.
Deep fe m oral a., v. 'iiiiir----ii i - - Add uc to r longus m.

m.

Long h ead, biceps Add uc tor magnus rn .

fe m o ris m.

Semi tendinosus m. Semimem bra n osus m.

rJl
>
Q)
0..
""C (Top) T he gracilis muscle conti n ues its posterior co urse. The sartori us muscle m oves closer to the gracil is muscl e.
c (Bottom) T he semimembranosus muscle belly increases in size as th e semitendinosus muscle bell y decreases in size.
Th e adductor longus muscle lies anterior to the adductor magnus muscle throu ghout the th igh .
c..
:c
v
230
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Reel femoris m.
Vastus lateral is m.

m edial is m.

m. Vas tus i ntermedi us m.

Superficial fem oral
artery & vei n
Femur
Greater saphenous v.

Adductor longus m.

(, racilis m.

Adductor milgn u s m.
I on g head, biceps
fem o ris m .

m. Sem itendin osus m.

m.
Vastus lateralis m.

medialis m.
Vastus in termedius m .
Sa rtorius m .
Superficial fem o ral
art ery & vein

Greater v.
Adductor longu s m .

Graci li s m .

Adductor magnus m.

Long h ead, biceps

femoris m.
Semimembranosus m. Semitendinosus m.

{Top) The gracilis muscle continues its posterior course. Th e sartorius muscle m oves closer to th e gracilis muscle.
(Bottom ) T he sem i m embran osus m uscle bell y i n creases i n size as the semitendinosu s muscle bell y decreases in size.
The adductor longus muscle l ies anterior to th e adductor m agnus muscle throughout the thigh.

v
23 1
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

EE Vastus la teral is m .
Rectus fe moris m .

V.as tus m edialis m.

Vastus inte rmed ius m .
Sarto rius m.
Supe rficia l femo ral
artery & vein
Dee p fem ora l a., v. !1!!'-------ii -- Greater sapheno u s v.

Scia tic n.

Adductor magnus m.
Lo ng h ead, bi ceps
fem o ris m .
Semi ten d in osus m. Semi m e m b ra nosus m .

Rectus fe m oris m.
Vastus la tera lis m .

Vastus medialis m.
Vas tus interm ed ius m .
Sa rtorius m.
Femu r Supe rficial fe m oral
arte ry & vein
Greate r saphenous v.
Deep femora l a., v.

Sciatic n .
Gracili s m .

Long h ead, biceps

Ad d u ctor magnus m .
fem o ris m.

Sem ite n d inosus m. Sem im e mbranosu s m .

til

>
Q)
c..
"'0 (Top) Beca use of its o blique course and its own separate fascial covering, the sa rtorius muscle is often con sidered a
c:: separate compa rtment althoug h it is co mmonl y included with in th e med ial co mpartment (see "Compa rtments of
t\:l Thigh" pages). Su perior to this level the muscle is n o t in direct continuity with th e other muscles of the an terior
c.. compartme nt. (Bottom) The boundaries of th e adductor cana l a re a p parent: The sa rtori us, vastus med iali s, add uctor
:r: lo n gus and addu cto r m agnus muscles. Th e semimembranosus and se mite ndin osus muscle are o f similar size. In th e
mid thigh t he tendon of th e rectus femoris muscle is located within the muscle belly.
v
232
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectus femoris m.

Vast us lateral is m.

medial is m.

Sa rt oriu s m.
Superficial femora l
artery & vein
Greater saphenous v.
Adductor longus 111 .

Gracilis 111.

Adductor 111agnus 111.

: . ; - - - - -......,.;-- Long head, biceps
femoris m.

m. Semitendinosus 111.

Rectus femoris m .

Vastus late ra lis m.

media lis m. Vastus intermedius m.

Sartorius m.
Supe rficial femoral
artery & vein
Grea ter saph eno us v.

Aclcluctor longus m.

Gracilis m.

Lo ng head, biceps
Adductor magnus 111. femo ris m.

m. Se mitendinosus m.

(Top) Because of its oblique co urse and its own separate fascia l covering, the sa rto rius muscl e is o ften co nsidered a
separate co mpartme nt alth ough it is co mmonl y incl ud ed w ithin the med ia l compartment (see" om partme n ts of
Thig h " pages). Su pe rio r to this leve l th e m uscle is not in direc t co ntinuity with the other muscles o f the an terior
co mpartment. (Bottom) The bo undari es o f the add ucto r ca nal a re apparent: T he sarto riu s, vastus medial is, adducto r
longus and addu ctor magnus muscles. T h e se m im embranosus and semitendinosus m uscle a rc of similar size. ln the
mid thig h th e te ndon of the rectus femo ri s muscle is locat ed withi n th e m uscle bell y.
v
233
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectu s femoris m.

Vastus la terali s m.

Vastus intermedius m.
Vastus medialis 111.

Sar torius m.
r---ii-"'w - Superficia l femoral
artery & vein
Deep femoral a., v.
·"'------;i -- Greater saphenous v.
Adductor Ion gus m.

Graci lis m.

Adductor magnus 111.

Long head, biceps
femoris m.

Semite ndinosus rn. Semimembran osus m.

Rectus femoris 111.

Vastu s la teral is 111 .

Vastu s m edia li s 111 .

Sartori us m .
--------"----;;;;-- Supe rficial fem oral
artery & vei n
Deep fem oral a. , v.
F-:--------;r-- G reater saph enous v.

Sciatic n.

Graci l is m.

Lon g head, biceps Add uctor magnus m.

femoris 111.

Sem i tendinosus 111. Semimembranosus m.

(J)

>
Q)
c..
"0 (Top) The deep femo ral vessels have followed an inferio r and late ral course from their point o f branchi ng in the
c: upper thigh . They now cou rse posterior to the fe mur. The infe rior-most aspect of the addu ctor longus m uscle is
C\:1
visible. The adductor m agnus, gracilis and sarto rius m u scles are th e on ly med ial compartment m uscles to contin ue
c.. into the d istal t high . (Bottom ) The rectus fem o ris m u scle is now n estled betwee n t he vastus m edial is and late ral is
l: muscles.

v
234
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectus femoris 111.

Vastus lateralis m.

Vastus rn ediali rn .

m.
Superfi cial femoral
a rte ry & vein
Greater v.
Add ucto r longus m.
Sciatic n .

G raci lis rn.

Adducto r m agnu s 111 . Lo ng h ead, biceps
fe m oris rn .
Semimem branosu s m. Semiten din osus m.

Rectus m.

Vastu s la te ralis m.

Vastus m edi a lis m.

Sartoriu s m.
Superfi cia l femoral
a rte ry & vein
Grea te r sa ph e no us v.
Ad d u ctor lon gus rn.

Graci lis m.

Adductor m.
Lo n g h ead, biceps
femor is rn .
Sem im e m bra nosus m. Sem itendin osus m.

(Top) T h e deep fe m oral vessel s h ave followed an inferior and lateral course from th ei r poin t o f bran ching in th e
upper thigh. Th ey n ow course poster ior to the fem ur. The inferior-most aspect of t he adductor lon gus muscle is
visible. The adductor m agnus, gracilis and sartorius muscles are th e on ly medial com partm en t m uscles to co ntinue
into the distal thigh. (Bottom ) Th e rectus fe mo ris muscle is now nestled between th e vastus med ialis and lateral is
muscl es .

v
235
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus femoris m .
Vastus lateral ism.

Vastus in termedius m. Vastus m ed ialis m .

Sartorius m.

Short head biceps

Su perfi.cial femoral
fe m oris m .
a rtery & vein
'-----;;;--- G reater saphe no u s v.
Scia tic n .
G racilis m .

Lo ng h ead, biceps Adductor magnus m.

fe m oris m.

Sem imem bra nosus m.

Semitendinos us m .

Rectus femoris m.
Vastus lateralis m.

Vastus intermed ius m. Vastus medialis m .

Fe mur

Short head biceps '----=-1r-- Superficia l femoral

femo ris m. artery & vei n

Sciatic n. '---...;..- Greater sa phen o us v.

-----;;w.- Gracili s m.

Long h ead, biceps

Adductor m ag m as m.
femori s m .

Semime mbranosu s m.
Semitendinosus m.

IJl
>
Q)
0..
'"C (Top) The o rigin of the sho rt head of the b iceps femoris muscle is in the midthigh . The te rminal portion of the d ee p
c: femo ral vessels also occurs mid th igh. (Bottom) The vastus muscles are easily separated at this level. The sa rto rius
and gracil is muscles are n ow in close prox imity. The se mimembranosus muscle is located medial to th e
0. semitendinous. At the ischial tuberosity it originated latera l to th e se mite n d in osus, then crossed th e dee p surface of
:r: the semitendinosus tendon; its me m branous portion resides on th e deep surface of th e muscle belly in the upper
thigh.
v
236
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectus fe m o ris m.
Vastus late ralis m .

Vastus in termediu s 111.

Vastu s media lis m .

Sa rto rius m .

Supe rficial fe m oral

Sh o rt head biceps
artery & vein
fe m o ris m .
Greater v.
Scia tic n .

Gracilis m .

Long h ead, b iceps

Adduc tor m. fe m o ris 111.

Sem im e mbranosus m. Semitendi n osus m.

Rectus femoris m.
Vastus la te ral is m .

Vastus inte rmedius m.

Vastus m edia lis m .

Sartorius m .

Superfi cia l fe m ora l Short h ead b iceps

a rte ry & vein fe m o ri s m.
C rca te r saph e n ous v. Sc iatic n.
Graci lis m .

Adduc tor mag nus m. Long head, bi cep s

fe m o ris m .
Semime mbranosu s m .
Semitendin osus m.

(Top) The origin o f the sh ort head of th e biceps fem oris muscle is in the midthigh. Th e termin al portion o f the deep
femora l vessels also occurs mid thigh. (Bottom) Th e vastus m uscles are easily sepa ra ted at th is level. Th e sartorius
and graci li muscles are now in close prox imity. T he sem imem bra nosus muscle is located m edia l to th e
semitendinou . At th e i schial tuberosity it originated l ateral to the semitendinosus, t hen crossed th e deep su rface of
the semitendinosus tendon; i ts m embranous port ion resides on th e deep surface of th e muscle belly in the upper
thigh.
v
237
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus femoris m.
Vastus lateral is m.

Vastus intermed ius m . Vastu s m ediali s m.

Short head biceps

fem oris m. fem o ral
artery & vein
Sciatic n.

Adductor magnus m. '----;;;-- Addu ctor magnus m .

(adductor) (isch ioconclylar)
Long h ead, biceps
femori m. Graci lis m.

Semitendinosus m.
Semimembranosus m.

Rectu 5 femoris m .
Vastus lateral i5 m .

Vast us intermedius m . m.

Short head biceps ;.......o'- ---'i-- Superficia l femoral

fem oris m. artery & vei n
Sciatic n.

Adductor magnu5 m.
(adductor) Adducto r magnus m .
(isch iocond yla r)
Long head, biceps
femoris m .
Gracilis m .
Semiten dinosus m .
Semimembronosus m.

rJl

>
(!)
c..
"'0 (Top) The isch iocondy la r and adductor porti o ns of th e addu ctor magnus muscle are again separabl e as th e adductor
c po rt ion inserts on to the posterior fem u r. (Bottom) T h e ten do n of the rectu s femoris muscle is n ow located alo n g the
deep surface o f th e muscle. Th e muscle bel l y o f t he lo n g head of th e biceps femoris muscle con ti n ues to enlarge. The
0.. isch iocondy lar po rt io n of the adductor magnus muscle is now m edial to the adductor portio n of th e muscle.
:r:
v
238
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT TH IGH

Rectus fe m o ri s m.
Vastus late ralis m.

Vastus m edia lis m.

Sarto rius m.
'-----.-.;;;; -- Short head bi ceps
Su perficial femoral fe moris m .
a rte ry & vein
Greater sa ph e no us v. Scia tic n .

Adduc to r m agnus m . Adduc to r magnus 111 .

(isch iocondylar) (add ucto r)

G racili s m. Long h ead, biceps

fe m o ris m .
Sem im e mbra n os us m .
Sem itendinosus m .

Rectus fe moris m .

Vastus Jateralis m.

Vastus med ia lis m.

Sa rto ri us m .

Superficial fe m ora l Short head bicep s

arte ry & vein fem oris m.

G reater sa phe no u s v. Scia ti c n.

Adducto r magnus m . Adductor magnus m .

(ischiocondylar) (adductor)

Gracilis m . Long h ead, biceps

fe m oris m.

Semime m bra nosus m . Semitendin osu s m .

(Top) Th e isch ioco ndylar and adducto r portions of th e add uctor magn us muscle are aga in separable as the adductor
po rtion in serts o nto the posterio r femur. (Bottom) Th e ten don of the rectus femo ris muscle is n ow located along the
dee p surface of t he mu scle. The muscle bell y of the lon g head of t h e biceps femoris muscle continues to enla rge. The
ischioco ndy lar po rti on of the adductor magn us muscle is n ow m edial to the add uctor portio n of t h e m uscle.

v
239
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus fem o ris m.

Vastus la tera lis m .

Vastu s m ed ialis m.
Fem u r Add uctor mag nus m .,
(adducto r)
Vastus interm edius m .
Short head b ice ps
fem o ris m. Superficial femo ral
artery&< vein
Scia tic n .
::"!1'"-:------;r-- Grea ter sa phen ous v.
o--- -;;;.- Adducto r magn us m.,
(is h ioco nd ylar)
Long h ead , b ice ps
fem o ris m .

Sem ite nd inosus m . em im embra nosu s m .

Reel u s fe m o ris m.
Vastus latera lis m .

Vastus m ed ia lis m .
Fe m u r Adductor m agnus m .,
Vastus inte rm ed ius m . (ad d ucto r)

Short head bicep s

fem o ris m .
-----..---.;-- Su perfi cial fe moral
Sciati c n . a rtery & vein
If:,----;;-- C reate r sa ph enous v.
- '----iiiii -- Ad d u ctor m agn us m .,
(ish iocondylar)
Long h ead, b icep s
femo ris m . Gracilis m.

Semi ten d inosus m .

Semi membra nosus m.

tJ)

>
Q)
c..
""0 (Top) T he m uscl e bell ies o f the rectus fem o ri s and semi tend i nosus m uscle d ecrease in size in the d istal thigh . T he
c::: sho rt head o f the b iceps fem o ris muscle has a lo ng o ri gi n fro m th e posterio r femur. (Bottom) The vast us m ediali s
ro muscle becomes q u ite large i n the distal t h igh . T h e sciati c n erve continues to resid e alo ng the deep su rface of the
c.. lo ng head of th e biceps fem o ris m uscle.
I

v
240
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectus femoris m .
Vastus lateral is m.

Vastus m edial is m.
Femu r
Addu ctor magn us m .,
(adductor)
Vastus intermedius m.
Sa rtori us m .
Short h ead biceps
Super ficial fem oral fem oris m .
artery & vein
Sciatic n .
Grea ter saphenou s v.

Add uctor m agnus m.,

(isch ioco nd yla r) Lon g head, biceps
Graci l is 111 . femoris m .

Sem itendi n osu s m.

Sem im em branosus m.

Rectus fem oris m.

Vastus lateral is 111.

Vastus medial is m .

Add uctor magnus m .,

(addu cto r)
Sartoriu s m . - + - ---"-
'---4 : -- Short head biceps
Superfi cial femoral - +-..---- fem oris m.
artery & vei n
Sciatic n.
Greater sa ph enous v.
Adductor magnus m., - ...;;;;--- -
(isch ioconclylar)
Lon g head, bicep s
Gracil is m.
femor is m.

Semi ten dinosus 111 .

SemimembranosLis m.

(Top) The m uscle bellies of the rectus fem o ri s and se mite nd in os us m uscle d ecrease in size in th e distal thigh. Th e
sho rt h ead of th e biceps fe m oris muscle h as a lon g o rigin fro m t h e posteri or femu r. (Bottom) Th e vastus media lis
m uscle beco mes q uite la rge in th e d istal t h igh . The scia tic ne rve contin ues to resid e alon g the deep surface of th e
long h ead of the biceps fe m oris muscle.

v
24 1
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus fem oris m.

Vastu s lateralis m .

VaS'I us medialis m .

Femu r Adduc tor magnus m.,

(addu ctor)
Vastus i n termedius m. Superfi cial femo ral
artery & vein
Sh or t h ead biceps - - - -w - Adductor m agnu s m.,
femoris m. (isch iocondylar)
Scia ti c n. Sartorius m.

G reater v.
Long h ead, biceps
femoris m.
Gracilis m.
Sem i tendi nos us m.
Semimem branosus m.

Rectus femoris m.
Vastus lateralis m.

Vastus medial is m.

Femur Adductor magnus m.,

(adductor)
Vastus intermedi u s m .
Su perficial fem o ral
Short h ead biceps artery &vein
fem oris m. r---..w-• - Sar to rius m.

magnus m .,
(ishiocondy lar)

G reater saphenous v.
Long head, biceps
femoris m. Gracilis m.
Semitendin osus m. Semimembranosus m.

Vl
>
Q)
c..
""0 (Top) Note th e th ickening of t h e posterior co rtex of t h e femur at this level and through out the thi gh. This
c::: th ickening is t he linea aspera wh ich serves as a site of o rigin and inserti o n for mul tiple muscles. T h e sartorius and
(\$
gracil is muscles are now within the posteri or 1/2 o f th e m ed ial aspect o f t he th ig h. Th e semitendinosus mu scle is
a.. becoming quite sma l l. (Bottom) The sepa ratio n of t h e adductor and ischiocondy lar portions o f the adductor magnus
I m u scle fo rms th e adductor hiatus. Th e su perficial femora l vessel s pass thro ugh t h e ad ductor hiat us to enter the
popli tea l fossa. Upon passing th ro ugh the hiatus th ey become the po pli tea l vessels.
v
242
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectus fem oris m.

Vastu s lateralis m.

Vastus m ed ialis m .

Adducto r magnus 111 ., Fe m ur

(addu cto r)
Superficial femoral
artery & vein
'---"'iiiii-- Short h ead biceps
Sartorius m.
fe m oris m .
Adductor magnus m.,
(isch iocon dylar)
Greater saphenous v.

Lon g head, biceps

Graci l is 111. fe moris m .

Sem itendinosus m.
Semimembranosus m.

Rectus fem oris 111 .

Vastu s lateral is m.

Vastus m ed ial is m.

Adductor m agn u s m.,

(adducto r) Fem ur

Superficia l fe moral Vastus in te rmediu s m.

arter y & vei n
---"!W- Sh ort head bi ceps
femoris m.
Adductor m agn u s m., - --;;;;i=------'"
(ischiocon dylar)
Greater saph enous v.

Lon g h ead, bicep s

fe moris m .
Gracilis m .
Sem i tendi n osus m.
m.

(Top) Note th e thickenin g of th e post erior co rtex o f the fe mur at this level and th rough o ut the th igh . This
thi ckeni ng is the linea aspera wh ich serves as a site of o rigin and inse rtion fo r mu lt iple mu scles. Th e sartorius and
gracil is muscles are now wit h in the posterior 1/ 2 o f the medial aspect of t h e thi gh. The semiten din osus m uscle is
becoming q uite small . (Bottom) The se paration of the adductor and ischioco ndy la r po rti on s of t h e adduct or magnus
m uscle for ms the adductor hiatus. Th e su perficial fe mo ra l vessels pass through t he addu ctor hiatus to ente r th e
po pliteal fossa. Upon passing through the hiatus they becom e the popliteal vessels.
v
243
 THIGH OVERVIEW
AXIAL T1 MR, MID RIGHT THIGH

Rectus femoris m .
Vas tus lateralis m .

Vastu s intermed ius m . Vasfi1s medialis m.

Popliteal a., v.
Sho rt h ead biceps
femoris m. Descendi ng genicular
artery & ve in
Sciatic n.

Greater saphenou s v.
Lo ng h ead, biceps
femoris m.
Gracilis m.
Sem itendi n osus m. Semimembran os us m.

Rectus femoris m.
Vastus lateralis m.

Vastu s m edialis m.
Vastus interm ed ius m .

,_____ _ __ , _ Descending gen icula r

artery & vein
Sciatic n.
Short h ead bicep s
fe m o ris m .
Greate r saph enous v.
Long h ead, bicep s
fe moris m.
Graci lis m.

Sem iten d in osus m . Semimem branosus m.

r.J'l
>
Q)
0..
""C (Top) The supe rficial femora l vessels upo n passing th ro ugh the adductor h iatus have become th e popliteal vessels.
c:: .Just befo re this transitio n the descen ding genicular a rtery bra n ches from the superficia l fe moral artery. The sciatic
nerve begins a slig htly anterior course along the medial aspect of the sh ort h ead of the biceps femoris muscle.
c.. (Bottom) At this inferior level the semimembran osus muscle h as a large muscle bell y. Th e dista l te ndon of th e
:r: semitendinosus muscle is seen alo ng t h e poste rior surface of t he muscle belly.

v
244
 THIGH OVERVIEW
AXIAL T1 MR, MID LEFT THIGH

Rectus femoris m.
Vastus la tera lis m .

Vastus in termedius m .
Vastus medi a lis m.

Popliteal a ., v.
Short h ead biceps
Descending gcnicular fe m o ris m.
artery & vein

Sartorius m . Sciatic n.

Greater aphenous v.
Gracilis m . Lon g head, biceps
fe moris m.

m.
Semi ten dinosu s m.

Rectus femoris m.
lateralis m.

Vastus intermedius m.
Vaslus medialis m.

Po pliteal a ., v.
Descending gcnicu lar - - r'--------'!
a rtery & vein
Sciatic n .
r-'------;--- Short head biceps
fem o ris rn.
Greater saphenous v.
Long head, biceps
Gracili s m.
femor is rn.

Scmimcmbranos\!5 m.
Semitendinosus m.

(Top) The superfi cial femora l vessels upo n passing t hrough the adductor h iatus have become t h e popli teal vessels.
Just before thi s transi t ion the descen di n g gen icular artery b ra n ches from t he superficial femoral artery. T h e sciatic
nerve begins a sligh t ly anterior course along the m ed ial aspect of th e sh ort head of t he biceps femoris muscle.
(Bo tto m ) At this i nferior level the sem imembranosus muscle has a large m uscle bel ly. T he distal tendon of the
semitendinosus muscle is seen alo ng t he posterior su rface of the m uscle belly.

v
245
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL RIGHT THIGH

Rectus femorb m.
Vastus lateralis m.

m edia lis m.

Vastus in termedius m. Popliteal a., v.

"------;;;-- Descending gen icular
artery & vein
Sciatic n.
Short head biceps
femoris m .
Greater sap hen o u s v.
Long head, biceps
femoris m. Graci lis m.

Sem itend inosus m. Semimembranosu m .

Rectus m.

Vas tus la terali s m.

Vas tus m edialis m .

Vastus intermediu s m .
,.__ _...,.....,__ Descendi ng geni cul ar
a rtery & vein

Short head biceps

fem o ris 111.
Greater saphenous v.
Lo ng head, biceps
fem o ris m. Gracilis m.

Semitendinosus m. Semime m branosus m.

til
>
Q)
c..
""0 (Top) The popliteal vesse ls course d eep to the semime mbranosus muscle as th ey t ravel to the poplitea l fossa. The
c: sciatic nerve con tinues to travel anter io rly. (Bottom) The sh ort and long heads of the biceps fem oris muscle jo in . The
sepa ration of th e se mime mbranosus a nd semi te ndin o us m uscles from the biceps femoris muscle is beginning as
c. images approa ch the su perio r aspect of the po pli teal fossa.
J:

v
246
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL LEFT THIGH

fe moris m.
lateral is m.

Vastus m edialis 111.

Popliteal a., v.

Descending gen icu lar

artery & vei n
Scia tic n .

Sarto ri us 111 . Short h ead biceps

fe m o ri s 111.
Grea ter sap hen o us v.
Long h ead , biceps
Gracilis m. fe m o ri s rn.

em im embra nosus rn. m.

Rectus femoris 111.

Vast us lateralis 111.

Vastus m edialis 111.

Popliteal a., v.

genicula r
artery & ve in
Sa rtorius m. Short head
femor is m.
Greater v.
Long h ead, b iceps
Grac ilis 111. fem o ris m .

m. Semit endinosu s m.

(Top) Th e popliteal vesse ls co urse deep to th e sem ime mbran osus muscle as t h ey t ra ve l to the poplitea l fossa. The
scia tic n erve con tinues to travel a n te rio rly. (Bottom ) The short a nd lo ng h eads of the biceps femo ris muscle join . The
separa tio n of th e se mi me mbranosus a nd semi tendinous musc les fro m the biceps femoris muscle is beginning as
images approach the superior aspect of the popli teal fossa.

v
247
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL RIGHT THIGH

Vastus lateral is m. Rectus femo ris t.

Vastus intermedius m.
Vastus m ed ialis m.

Popl iteal a., v.

Descending gen icu lar

Il io t ibial tract - --'iiiiiiF-----"1. a rtery & vein
Sciatic n. --;;;;;"*"=-=:.....-:;..:..;

Sh o rt h ead biceps Sartori us m .

femoris m.
Grea ter sa p hen o us v.
Long head, biceps
femor is m. Gracilis m .

Sem itendinosus m. Semimembran osus m .

Rectus femoris t.
Vastus latera lis m .

Vastus inte rm edius m.

Vastus m edia lis m.
Femur

Popliteal a., v.

Descending gen icular

a rte ry & vein

Sh o rt h ead bice ps Sartorius m.

fem o ris m .
Greater saphen o u s v.
Long head, biceps
fe m o ris m. Gracilis m .

Semitendi nosu s m. Semimembra nosus m.

(Top) The rectus femori s m uscle is now a flat t end ino us band wh ich fo rms th e ce ntra l porti o n of th e quadriceps
te ndon. The te n don of t he vastus inter medius muscle is deep to t he rectus fem o ris te n don. The vastus medialis and
vastus lateralis tendon s are also v isible. (Bottom) The sciatic n erve has assumed a bilobed appearan ce as it begins its
sepa ratio n into common peroneal a nd tibial nerves. On this image th e popliteal vein is lateral to th e po plitea l artery.
The vein s a nd arteries ca n be identified beca use a vei n will always be larger th a n its companion artery. The mo re
typical position of t h e artery is deep to the vein.
v
248
 THIGH OVERVIEW
AXIAL T1 MR, DI STAL LEFT THIGH

Rectu s femoris t.
Vastus late ral is m.

Vastus in termedius m.
Vastus medialis m .

Popl iteal a., v.

Desce ndin g geni cular

artery & vein

Sartorius m. Short h ead biceps

fe m o ris m .
Greater sapheno us v.
Long head, biceps
fe m o ris m.
G racili s m .
Semitendinosu s m.
Se mim embranosus m.

Rectus femoris t .
Vastu s Jateralis m.

Vastus intermedius m .
Vastus medialis m .

Popliteal vessels

Desce ndin g ge ni cu lar

artery & vein

Sartorius m. Sh o rt h ead bi ceps

femo ris m.
Greate r saphenous v.
Long head , biceps
fe m o ris m.
G racili s m.
Se mi tendi n osus m.
Semim embran osu s m .

(Top) The rectus femoris muscle is n ow a flat tendinous band wh ic h form s th e ce ntral portio n of t he quadri ceps
te ndon. The te ndon o f th e vastus intermedius muscle is deep to t he rectus femo ris tendon. The vastus medialis and
vastus lateralis tendons are also visible. (Bottom) The sciatic n erve h as assumed a bilobed appearan ce as it begi n s its
separation into common pero neal and tibial n erves. On this image the popliteal vein is lateral to th e popliteal artery.
The vein s and arte ries can be ide ntified beca use a vein will always be larger than its co mpa ni o n ar tery. The m o re
t y pi cal position of the a rte ry is deep to th e vein.
v
249
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL RIGHT THIGH

IJ Vastus in termediu s l. Rectu s femoris t.

Vastus lateral is rn .

Vastus 111 .

rnediali; rn.

Popl itea l a., v.

Medial superior
gen icular a., v.

Short head biceps Sar to rius m.

fem ori m.
Greater v.
Long h ead, biceps
femoris m. Graci lis rn .

Sem imembranosus rn.

Semi tendi nosu s
& tendon

IJ Vastus intermed iu s l. Rectu s femoris I.

Vastu s lateralis rn .

Vast us m.

Femu r Vastus medial is m.

!f.:..:.......;:;....=::::::::l= -- Pop l iteal a., v.

Ti bial n . - - ;=r-=-...:.=- Med ial superior
gen icular a., v.
Com rnon peron ea l n.
Sartorius m .
Sh ort head biceps
femoris m . Grea ter saph en ous v.

Long head, biceps Gracilb rn.

femo ris m.
Semi m em bra nos us m.
Semi tendi nosus m uscle
& tendon
CJl
>
Q)
c..
"0 (Top) Th e semite nd in os us is tendinous thro ugh the di stal thig h. He re th e te ndon is see n alo n g th e med ial aspect of
c: th e residual muscle bell y. The sa rto rius a nd gracilis m uscle are n ow adj ace n t to o n e a noth er. (Botto m) Th e sartori us
1\1
muscle begins to w ra p around t he gracil is m uscle. The med ial supe ri o r genicul ar vessels a re visible; they a re branc hes
0.. of t he popliteal vessels. The two d iv isio ns o f t he sciati c n e rve a re now distin ct.
J:

v
250
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL LEFT THIGH

Rectus fe m o ris t.
Vastus in term edius t.

Vastu s laterali s m.

Vas t us interm edius rn.

Va tus m ed ialis m.

Poplitea l a., v.

Medial supe rior

gen icula r a., v.
a rto rius m. Short h ead biceps
femori s m .
G rea ter saphen o us v.
Lo n g head, biceps
Gracil is m. fe m o ris m .

Semime mbranosus m .
Sem ite nd inosus muscle
& te ndo n

Rectu s femoris t. Vas tus interm e dius t.

la te ralis m .

Vastus interm edius m.

Vast us m. Fe mur

Poplitea l a., v.

Med ia l su pe rio r _;:__---.:=;- Tibial n .

gen icu la r a., v. pero n eal n.
m.
Short head bi ceps
Greater saphe no u s v. fe moris m .
Gracilis m. Lo ng h ead , biceps
femoris m.
Semime mbra nosus m .
Semitendinosus muscle
&: tend o n

(Top) Th e sem ite nd inosus is tendin o us thro ugh t he di sta l thi gh . He re th e tendon is see n a lo ng t h e m ed ia l aspect of
the residua l muscle bell y. The sarto rius a nd gracilis m uscle are now adjace nt to one anot he r. (Bottom) T he sartorius
mu scle begins to wrap a ro und the gracilis m uscle. The m ed ial su perio r gen icula r vesse ls are visible; they are bra n ches
of the poplitea l vesse ls. T h e two division s of th e scia ti c ne rve a re now distinct.

v
251
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL RIGHT THIGH

Quadri ceps tendon

Vastus latera lis m .

Femur
Vastus m ed ial is m .
Vastus interm ediu s m.

I lio ti bial tract Po plitea l a., v.

Tibial n.
Common peroneal n .
Short h ead biceps
fem oris m. G reater sa phenous v.
Long h ead, biceps
fem oris m.
emimembran osus m .
Semi tendinosus t .

IJ Q uad riceps tendon

Va tus lateral is m .

Femur

Vastus in termedius m . m ed ialis m.

Ili otibial tract
Lateral superior
genicu lar a., v.

Tibial n.

Com mon peron eal n .

Biceps femoris m. G rea ter saph en ous v.

Gracil is m.

Semimembranosus m.
Semiten di nosus m .
1.1)

>
ClJ
c..
"'0 (Top) T hrough th e distal th igh t he semite nd in osus te ndo n resides along the supe rfi c ia l surface of the
c:: semimem branosus muscle. The lo ng and sho rt head s o f t he biceps fem o ris muscle are no lo nge r discerni b le a
ro d isc rete structures. (Bottom) Slips from te ndon s o f th e vastu s m edialis, lateralis, in te rm ed ius, and rectus femoris
a. muscles jo in to fo rm the quadri ceps te ndo n . T he latera l supe rior gen icu la r vesse ls, branc hes of the po pliteal vessels,
:c a rc prese nt.

v
252
 THIGH OVERVIEW
AXIAL T1 MR, DI STAL LEFT THIGH

Q uadriceps tendon

Vastus lateralis m.

Femur
Vas tu s m ed ia lis m.
Vas tus in term edius m.

Popliteal a., v. Iliotibial t ract

Medial su perior
genicular a., v.
- --::===== Tibial n.
Com mon peroneal n.
Sartorius 111 .
Sh o rt h ead biceps
Greater sa ph e nous v. fe m oris m.

Gracilis m . Long head, b icep s

fem oris m.
Semimem bran osus 111. Semitendin osus t.

Quadriceps tendon

Vastus lateralis m .

Femur

Vastus m ed ialis m. Vastus interm edi u s m.

• ''.:,::::-=''-----'--== ;!Oo--"'1:;;;-- La tera l su perior

Popliteal vessels gcn icu lar a ., v.

Sartoriu s 111.

Greater saph enous v. Biceps femoris m.

Graci lis m .

Semime mbranosus m.
Semitend inosus t.

:c
"'C
$:).)

(Top) Through t h e dista l th igh t he semiten d in osus ten don res ides along t h e superfi cial surface of the ::I
semi mem branosus m uscle. The lo ng an d short heads of th e biceps femoris m uscle are no longer d iscernible as
a.
""0
discrete structu res. (Bottom ) Slips from t e ndon s of the vast us m edia li s, lateral is, intermedi us, and rectus femoris ro
muscles joi n to fo rm the q uad riceps tendo n . Th e late ral supe rio r gen ic ula r vessels, bra nch es of t he popliteal vessels,
are present.
<
CJl

v
253
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL RIGHT THIGH

IJ Quadriceps tendon

Vastus lateralis m.

Fem u r

Vastus inte rmed ius m. Vastus m ed ialis m .

Ilio tibial tract

La te ra I s u perio r - -iiiii=""-'=j;,----,,....,.
genic ular a., v. Popliteal a., v.
Tibial n.
Common pero n eal n.

13iceps fe m oris m. Greater saph e no us v.

Se mime mbra n osus m. Graci lis m .

Sem itendinosu s t.

IJ Quadri ceps te ndo n

Vastus latera lis t.

Fe mur
Vastus m edi a lis m .
inte rmed ius m.

Ilio tibial tract

Latera l su perio r
gen ic ular a., v. Po pli teal a., v.

Tibial n.
Sartoriu s m.
Commo n peroneal n.
Greater saphenous v.
Biceps femori s m.
Se m imembra nosus m. Gracili s m.

Semite ndinosu s t.

til
>
Q)
c..
""0 (Top) Th e femu r broaden s distally during the transiti on from diaphysis to m etaph ys is and th e su pracondy lar portion
c: (th at portion just above the fem oral condy les). (Bottom ) The gracilis muscl e is now extrem ely sm all and only th e
tendon extends inferi orly from this point. The origin of the lateral superior geni cular vessels is inferior to th e vessels
0.. consistent w ith t h e lateral and superior course of those vessels.
:r:
v
254
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL LEFT THIGH

Q uadriceps tendon
Vastu s lateralis rn.

m. Vastus intermedius m .

Ili o tibial t ract

;;..,,...---;::;_:_-.:.:;iiir- Lateral superio r

Poplit eal a., v. genicular a., v.

o mmon peron ea l n.

Greater v. Biceps femori s m.

C racilis m . Sem im embranosu s m .

Semitendin osus t.

Quadriceps tendon

Vastus lateralis l.

Vastus m.
Vastus interm edius m .

Ilio tibi al tract

l.ateral superior
Poplitea l a., v. geni cul ar a., v.

Sa rto rius m .
ornm on peroneal n.
Grea ter v.
Bice ps fem oris rn .
m.
Sem i mem branosus m.

Semitendinosus t.

(Top) T he fem ur broadens distal ly during the transition fro m diaphysis to metaphysis and th e supracondylar portion
(th at port ion just above th e femoral condy les). (13otto m ) The gracil is m uscle is now extremely sm al l and only the
tendon extends i nferiorly fro m this point. The origin of the lateral superi or geni.cu lar vessel s is inferi or to the vessels
consistent wi th th e latera l and superi or course of those vessels.

v
255
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL RIGHT THIGH

IJ Quadriceps tendo n

Vastus lateralis t.

fe mu r Vastus medialis m.

Vastus inte rmedius m .

Tibia l n.

Biceps fe m oris m.

Common peroneal n. G rea te r sapheno u s v.

Artic u lar branc h Graci lis L

Sem itendi n o us t. Semimembra n osus m.

IJ Q uadriceps tendon

Vastus latera lis t.

fe mur
Vastus m ed iali s m .
Vastus in te rmedius m .

Il ioti bial tract

Tibial n.

Biceps fe m oris m.
G reater sap he n o us v.
Common pe ronea l n.

Articular branch G racili s t.

Semite ndi n osus L Sem im emb ranosus m .

til

>
Q)
0..
"'0 (Top) Th e distance between th e semime mb ranosus and bice ps femoris muscles in creases in this image t h rough th e
s::: upper poplitea l fossa. An articular branch is seen arising fro m th e tibia l nerve. (Bottom) Th e quadriceps tendon is
ro begin ning its in sertion onto t he supe rio r aspect of the pate lla. The common peronea l n erve is m oving lateral alon g
c.. t he medial borde r of th e biceps femo ris muscle. lt wi ll follow th is m uscle a ro und the fib ular head. Note the presen ce
:c o f a n articu lar branch from the tibial nerve. Th e tibial nerve moves medially and wil l course through t he ce nte r of
the popli tea l fossa. For a discussion o f ana tomy infe rior to t his level see "Knee Ove rview" section .
v
256
 THIGH OVERVIEW
AXIAL T1 MR, DISTAL LEFT THIGH

Quadriceps tendo n

Vastus la teral is t.

Fe mur

Vastus medialis m .
Vastus in termedius m.

Iliotibia l tract

Popliteal a., v.

Greater saphe nous v. Com mon p eronea l n .

Gra c ilis t. Articu lar bra n c h

Semi m e mbranosus 111.
Semitend inosus t.

Quadriceps ten don

Vastus late ra lis t.

Fe mu r
Vast us m edia lis rn.
Vastus inte rmedius m .

Iliotibial trac t

Pop liteal a., v.

Sarto rius 111 .

G reater sap h enous v. Common peron ea l n .

Graci li s t .
Arti c ular b ra nc h
Semim emb ranosLis m . Semitendi nosu s t.

(Top) The d istance betwee n t h e sem imemb ranosu s and biceps femoris muscles increases in t h is image through the
upper popl iteal fossa. An articular branch is seen aris ing from th e tibia l n e rve. (Bottom) The q uad rice ps tendon is
beginning its insert ion o nto the supe rio r aspect of th e patella. Th e com mon pero neal nerve is moving la teral along
the medial border of the b iceps femoris m u scle. It wil l follow t h is muscle arou n d t he fibul ar h ead. Note t he presence
of a n a rticu lar bra nch from th e t ibi al n erve. The t ibial n erve m oves media lly a nd will course through the ce nte r o f
the popliteal fossa. For a discussion o f ana tomy infe ri o r to this level see "Knee Overview" section.
v
257
 THIGH OVERVIEW
CO RONAL T1 MR, POSTERIOR THIG H

Gluteus maximus m .

cm ite ndi n os us t.
Add uctor m agnus m .

Bi ceps fe m o ri s m.

Sem im e mbranosus m.
Greate r saphenou s v.

Gluteus maximus m .

Sem ite ndi n osus t.

Addu ctor mag nus m.

Biceps fe m oris m.

Gracilis m .

Greater sapheno u s v.
Semime mb ranosus m.

trJ
>
Q)
c..
"'0 (Top) First .i n series o f Tl we ighted coro na l images from p ost e rio r to anterior. Supe rio rly in the poste rio r thigh th e
c semitendinosu s m uscle is more promin ent wh ile inferiorly t h e sem im embranosus muscle is larger a nd more
promin ent. (Bottom) A lo ng segment of the gracilis muscle is visible. It is the most medial m uscle in the th igh. The
0.. se mime mbranosus a nd biceps fe moris m uscles fol low d iverging courses in the lower thigh at th e su perior aspect of
:::c th e popl itea l fossa.

v
258
 THIGH OVERVIEW
CORONAL T 1 MR, PO STERIOR THIGH

Glut eus max imus m.

lj ]

Adductor magn us m. Lo n g head biceps

femoris m .

Short h ead biceps

Gracilis m. femoris m.

G reater 5aphenous v.
Semimembranosus m .

Biceps fe m ori$ m .

Gluteus maximus 111.

Long head biceps

femoris m.
Adductor mag nus m.

Graci lis m. Short h ead b iceps

fem o ris rn.

Greater saphenou s v.

Semimembranosus m.
Biceps fem o r is m.
Sartorius m .

Popliteal a., v.

(Top) In this plane the adductor magnus and sem i mem branosu s m uscl es are di fficult to separate. T hey can be
identified by fo llowi ng their cou rses more an teriorly. T he adductor m uscle i s more prom i n en t superio rl y, t h e
semimembranosu s more i nferior ly. Th e grea ter saph enous vein i s th e m ost superficial structure in th e m edial th igh.
(Bo ttom ) In t he d ista l t high t he sarto rius m uscle and. th e gracilis m u scl.e are closel y approxi mated and the sa rtori us
muscle is loca ted more anteriorl y. On thi s image they appear to be continuous. Each m uscle is iden tified by
fo llo wing i t on ad jacen t images.
v
259
 THIGH OVERVIEW
CORONAL T1 MR, POSTERIOR THIGH

Gluteus maxi mu s m .
Obturator i n tern us m.
Ischial tuberos ity
Con joined origin , long
h ead biceps femoris &
semi tendi nos us m s. Sen2irnembranosus t.

Semit endi nosu s m.

Lon g h ead biceps

femoris m.
Adductor rnagnus m.

Short head biceps

femoris m.
Gracilis m.
Greater saph enous v.
Semime m branosus m .

Biceps femoris m.
Sartoriu s m .

Femoral condyles

Pop l iteal vessels

Gluteus maximus 111.

Obtura tor in tern us m. Quadra tu s fem ori s m.

Ischial tuberosity
Con joined origin , long
head bicep s fe moris & Semimemb ranosus t.
sem itendi nosus ms.
Semitendi nosus m.

Long head biceps

femoris m.
Adductor m agnus m.
Graci l is m.
Semitendinosus t .

Greater saphenous v.

Sem imem branosus m.

Lon g h ead biceps

Sartoriu s m. fem oris m .

Popli teal fossa

Pop l iteal vessels

rJ'J Femoral co nd yles

>
(])
0..
'"0 (Top) Alth o ug h t he origi n o f the semimembra n osus tend on is immed iately proximal and late ral to tha t of the
c con jo in ed lo ng head biceps and sem itendinosus te nd o n s, th e se mim embranosus fairly immedi ate ly m oves to a more
C'j
anterior, and then med ial positio n relative to the conj oined tendon. Th e labeled semimem bra nosus in this image is
0.. of th e m e mbra n o us portion, seen just media l to t he co nj o ined o rigin o f the lo n g head of th e biceps fe m o ris and
J: semite ndinosus muscles. (Bottom) The origin o f th e isch iocondylar po rtion of t he add ucto r magm as m uscle fro m th e
ischi al tube rosity is visib le. This muscle is the m ost m edia l ha m st rin g. The distinction between the gracilis and
v sa rtorius muscles is apparen t o n this image. The q uad ratus femoris muscle is a flat m uscle al o ng th e deep surface of
the glute us maxim us muscle.
260
 THIGH OVERVIEW
CORONAL T1 MR, POSTERIOR THIGH

Piriformis m .
Obturator i n ternus m. G luteus maximus 111.
Quadratus femori s m .
Isch ia l tuberosi ty
Scm i mcm bran osu s t.

Add uctor magnus m.

Vastus lateralis m.
G raci lis 111.

G reater saphenou s v.

Sartori us m .
Vastus m edialis m .

Biceps fem o ri s m.
Pop liteal a., v.
Fem o ral condy les
Interco ndy lar notch

Piriformis t.
G lut cm m aximus m.
G rea ter t roch anter
Obtura to r i nternus m .
Obturator ex tern us m.
h chial tu beros ity Lesser trochanter

Adductor m agnus m.

G racili s 111 .

Greater sa ph en ous v.
Adducto r hiatus

Sartorius m .
Vast us laterali s m.

Po plit eal a., v.

Vastu s m ccli alis m .

rem o ra! cond y les

Intercondylar notch
:::c
""'0

:::::1
(Top) Th e course of the piriformis tendon to t he greater t rochan ter is v isible. Th e tendon is superior to the tendon s
o f th e o ther ex ternal ro tators of the hi p. For furth er d etails of this anatomy see th e "Lat eral Hip" section. (Bottom)
c..
""C
Th e separati on o f the adducto r and i schiocond y la r port ions o f t he add uctor m agn us muscle crea tes the adductor ro
hiatu s. Th e superfi ci al femoral vessels transition to popliteal vessels at th is poi nt. <
C.ll

v
261
 THIGH OVERVIEW
CORONAL T1 MR, MID TH IGH

Acetab u l um Gl uteus medius t.

Obturator i n tern us m. I lio tibial band
Obturator ex ternus m .
Lesser trochanter
In ferior ra m us
m agnu s m.
Adductor brevis m .

Adductor longus m.
G raci lis m.
Adducto r magnus m.

Greater saphenous v.
Superficial femora l
artery & vei n

Sartorius m. Vastus in termedius m .

Vastus laleralis m.

Vastus m edia l is m.

Supracon dylar femu r Femoral condyles

Acetabulum Gl uteus m i n i mus m.

Obturator internus m.
Ili otibia l band
Obturator extern u s m.
Ili opsoas m.
Inferio r ram us
Adductor brevis m . Adductor m agnus m.

Graci lis m. Adductor lo ngus m .

Deep fem oral a., v.

Adducto r magnus m.
Superficia l femora l
ar tery & vein Greater saph en ous v.

Sartorius m.
Vaslus intermediu s m.
Vastus media l is m.
Vastus Jateralis m .

Fem oral diaphysis

Supracondylar femur
Femoral condyles
rJl
>
Q)
c..
"'0 (Top) Th e infe rio r (ischiopubi c) ram us is seen in cross section. These ram i a re rather sm all and sh o uld not be
c confu sed with fat deposits. The glute us med ius ten don is seen inserting o nto the grea te r t rochanter. (Bo ttom) The
ro dee p a nd superficial femora l vessels are visua li zed. The obtura tor inte rn us and extern us muscles are vis ible o n either
0.. side of th e o bturato r mem brane. Th e adductor longus muscle is di fficul t to separate from the ad ductor magnus
:::c muscle.

v
262
 THIGH OVERVIEW
CORONAL T1 MR, MID THIGH

Acetabulum

Obtu rator internus 111 .

Inferior ramus
G luteus minimus m .
Femoral h ead

Obturator ex ternus m.
Iliopsoas m .
IT
Add uctor brevis m . Pecti n eus m.

Add ucto r longus m.

Gracilis m . Deep fe m oral a., v.

Adductor magnus m.
Superficial femoral
artery & vein Greater saph en ous v.

Sartorius m .

Vastu s i ntermedius m.
Vastus medi ali s 111 .
Vastus lateralis m.

Femora l diaphysis

Supracondylar fem ur

Gluteus mediu s m .

Obturator internus m .

Inferi or ramus
Obturator
minimus m.
Fem oral h ead

I liop soas m.
111 .
IT
Adductor brevis 111. Pectineus m.

Gracilis m. Add uctor longus m.

Deep femora l a., v.

Add uctor magnus m.
Superficial femoral
artery & vei n Greater saphenous v.

Sartorius m. Vastus i ntermedius m.

Vastus medialis 111. Vastus m.

Femora l diaph ysis

(Top) Within the anterio r thigh the addu cto r longus, brevis and pectineus m uscles are most pronounced. T he
adductor magnus is a more posterior st ructure within th e com pa rtm ent. The o rigi n of th e gracilis muscle from the
inferior pubic ramu s is v isible. The m o re lateral position of the deep femoral vessels relat ive to the superficial fe moral
vesse ls is evident. (Botto m ) The iliopsoas muscle hugs the media l aspect of the join t as it nears its inserti o n onto th e
lesser trochanter. The vastus intermed ius muscle i s seen both media l and lateral to t h e femora l d iaph ysis. The muscle
wraps aro und a significa nt po rtion of th e anterior femur i n the di stal thigh.
v
263
 THIGH OVERVIEW
CORONAL T1 M R, A NTERIOR THIGH

Gluteus medius m.
Femoral head
Gluteus minimus m .
Obturator internus m.
Obtura tor extern us m.
Ilio psoas m.
In fe rior ram u
Pectineus m.
Adductor longus m.
Gracilis m. DeejJ femo ral a. , v.

Add ucto r magnus m.

Supe rfic ia l fe moral
Grea te r sap henous v.
a rtery & ve in

Sarto rius m.
Vastus intermedius m.

Vastu5 lateralis m.
medialis m.

Femoral diaph ysis

Gluteus mediu s m . Gluteus 111inimu s 111.

Iliopectineal junction Fe mora l head
Ilio psoas m. Obtu rator extern us m.

Pectineus m.
Adductor longus m.
Deep fe moral a., v. Graci lis m.
Adductor mag nus m .
Superfic ia l femo ra l
artery & vein Greate r saphenous v.

Sa rto rius m.
Vastus in termedius m.

Vastus la teralis m .

Vastus media lis 111.

Patella
Ill
>
ClJ
c..
""0 {Top) The pectin eus and adductor longus m uscles l ie in th e sa me coronal p lane and the adductor longus is th e m ore
s::: inferi or mu scle. (Bottom) The adductor canal is v isible. Its boundaries are t he sa rtori us, vastus medialis and adductor
('j
magnus muscles. The superficial femoral vesse ls are wi thin the canal.
0..
:::c

v
264
 THIGH OVERVIEW
CORONAL T1 MR, ANTERIOR THIGH

Iliopectinea l emi nen ce

pubis
Gl u teus mini111us m.
Femoral h ead

m.
Pectineus 111.
IT
Adductor longus m.
Deep femoral a., v.
Add uctor magnus m.

Superficia l fem o ral Greater saphen ous v.

artery & vein
Vastus interm edius m .
Sartorius 111.
Vastus lateralis m.

Vastus mediali s m.
Rectus femoris & vastus
interm edius muscles

t.

Patella

mini mus m.
m.
Superior pubic ramus
Pectineus m .
Adductor longus m.
Common femoral a., v.
Superficial femoral
Adductor magnus m. artery & vein

Greater saphenous v.
Sartorius m .
Rectus femoris m .

lateralb m.

(Top) The rectus fe mor is tendo n a nd the te nd on of th e vas tu s intermedius tend o n blend together in th e distal thigh
in the plane be tween the two muscles. More d istally, with t he addition of tendons from t h e vastus m edia lis and
vastus latera l is muscle th e q uad ri ce ps ten don is form ed. ( Bottom ) The sym physis pubis a nd superior pubic ram us a re
seen at the a nte rio r aspect o f t h e pe lvis. T h is ana to m y is prese n ted in great e r detai l in the "An teri o r Pelvis and Thigh"
sect ion. The iliopsoa muscle is seen as it trave ls from th e pelvis to th e lower ext re mi ty ove r th e iliopecti nea l
e minence. ote th e an te ri or ex tent of the glute us minimus muscle.
v
265
 THIGH OVERVIEW
CORONAL T1 MR, ANTERIOR THIGH

Iliopsoas m.

Tensor fascia la ta m.
Supe rior pubic ramus
Symph ysis pubis
Pecti neus m.

Common fe m oral a., v. Aclclucto r longus m .

Greater saphe no u s v.

Sartorius 111 . Rectus femo ris m.

Vastus late ral is m.

Ilio psoas m.
Superior pu bi c ra m us
Te nsor fascia lata m .

Sym physis pubis Pec t ineus m.

Common femoral a., v. Aclcluctor longus m .

Greater sapheno u s v.

Rectus fe moris m .
Sartori us m.

Vastus late ralis m.

Ill
>
Q)
c..
"'0 (Top) The common femoral vessels a re anterior structures e ntering the thi gh just deep to th e ingu inal liga m ent. Th e
c:: medial position o f the vessels relative to the iliopsoas muscle is well visua li zed . (Bottom) In th e upper thigh the
r'd
tendon o f th e rectus femoris muscle is located along the anterior aspect o f th e muscle belly.
c..
::r:
v
266
 THIGH OVERVIEW
CORONAL T1 MR, ANTERIOR THIGH

Inguinal ligament
ll iopsoas rn.
rn:
l1_
Ten sor fascia lata rn .

Common fe m ora l a., v.

G reater sap henou s v.

Sa rtori us m .

Rectus femo ris m.

Vastus latera li s m .

Lymphatics

Tenso r fasc ia lata rn .

Sa rtorius rn .

Vastus lateral is rn.

(Top) The m edia l edge of the inguinal ligament is nicely seen. The passage of the vessels deep t o the ligaments can
be visuali zed. (Bottom ) The lympha tics o f th e inguina l region a re well demonstrated, with a series of lym phatic
channels trave rsing between n orma l sized lym ph nodes. Th e an terio r most muscles of the th ig h a re the sa rtori us,
rec tus femoris and vastus lateralis muscles. Note their oblique orientation.

v
267
 THIGH OVERVIEW
SAGITTAL T1 MR, MEDIAL THIGH

Rectus abdomini s m .
Gluteus maxi mus m.
Pubis

Pectineu s m .
Addttctor brevis m.
Adductor longus m .

G racilis m.

Rectus abdo minis m.

Glu teus maximu s 111.

Pubis
Obtu rator i n ternus m.
Pectineus m .

Adductor brevis m . Obturator exte rnu s 111.

Add uctor longus m.

Graci l is m .

(Top) Sagittal images of the t h igh from media l to lateral. In the mid li n e th e rectus abdom in is m uscles are p resent.
The glute us maxim us muscle is th e only posterior muscle. The gracilis muscle is a thin strip of muscle; th e majority
o f this muscle is o nl y v isible on this most m ed ial image. (Bottom) The obturato r inte rnu s muscle is seen e n face. Th e
long tendinou s o ri gin of the add uctor lo ngus m uscle is we ll d epi cted o n this image. Ma ny muscl es are prese n t in th e
medial co mpartmen t in the uppe r th igh. The adductor brevis muscle is deep t o the pectin eu s and adductor longu s
muscles.
v
268
 THIGH OVERVIEW
SAGITTA L T1 MR, ME D IAL THIG H

Interna l obliq ue m .

Su perior pub ic ramus Gl uteus maximus m .

[[
Pecti neus m . Obturator i n tern us m .

Obturator cxternus 111. Ischi al tuberos ity

Add uctor b revis m.

Adductor magn us m.
(isch iocondy lar)
Add uctor longus m.

Gracil is m.
Greater saphenous v.

Internal oblique
Superior pu bic ramus
111 .
Glu teus m ed ius m .

Gl uteus ma xi mus m .
[[
lliu m
recti n eus m .
Obturator i nternus 111 .
Obturator extern us m .

Adductor b revis m . Isch ial tuberosity

Add uctor longus 111 .

Add uctor m agn us m.

Greate r saphenous v.

(Top) Due to th eir curved cou rse around t h e a n te rior abdo minal wa ll th e inte rn al oblique a n d transve rsu s muscles
are obliq uely profi led . The long axis of t he ischi oco n dylar po rti o n o f th e adductor magnus muscle is well visualized.
(Bottom) A long segme nt o f t he grea te r sa phenous ve in is evident. T he add uctor b revis muscle lies d ee p to the
adductor lo ngu s muscle. The o rigin of th e pectineu s muscle from the superior p ubic ramus is n icely seen o n this
image.

v
269
 THIGH OVERVIEW
SAGITTAL T1 MR, MEDIAL THIGH

IJ
Uiopsoas m . Glu teus m edius Ill .
Il ium
Piriform is m.

Common fem oral a., v.

Gluteus m aximu s Ill .
Pecti neus m.
Obturato r i nternu s m.
Obturator extern us m.
Ischi al tuberosity
Add uctor b revis m .

Ad ductor lo ngu s m .

Addu ctor rnagnus m.

Sartori us rn.

G rea ter saph en ou s v.

IJ Iliop soas rn.

Common fem ora l a., v.

ll ioisc h ial jun cti on
Gl u teu s maximus m .

Ob turator extern us m.

Pecti n eus rn. Ob tura tor in tern us m .

Adductor b revi s m . Add uctor m agn us m.

Adductor longu s m.

Sar to riu s rn.

Grea ter saph en ou s v.

trl
>
Q)
c..
"'0 (Top) The obtura tor internus and externu s m uscles are sepa rated by the obturato r me m brane. Th e pectineus a n d
c:: add uctor lo ngus muscle lie in the same coro nal pla ne. Th e adducto r lo ngus muscle is inferior to the pectine us
muscle. (Bottom) A lo n g segment o f the sarto ri us muscle is seen o n the a nterior aspect of t his med ial image. Its d ista l
c.. cou rse is simila r to t he graci lis m uscle. The iliopsoas muscle trave ls from th e pelv is to the thi gh o ve r t he il iopectineal
r junction .

v
270
 THIGH OVERVIEW
SAGITTAL T1 MR, MEDIAL THIGH

Iliopsoas m .
Femoral h ead

Commo n femoral a., v.

Isch ium

Piri formi s m.
Extern al rotators
[[
Pectineus m. Gl uteus m ax imus m.

SiJ rt ori us m. Ischium

Adductor brev is m. Ob tu rator ex tern us m.

Adductor longus m.

Adductor m.

m edialis m.

Graci l is m.

m.
Fem ora l h ead
Isch ium

Pi riformis m.

Ext ernal rotators

[[
Comm o n femoral a., v.
Isch ial spine
Pectineus m.
Gl uteus max imus m .
Sartori us m.

Adductor m. Obturato r ex tern us m.

Adductor longus m. Adductor magnus m .

Vastu s mediali s m.

Sem i m embranosus m.

Gracilis m.

Greater sa ph en ous v.

(Top) The adductor magnus muscle occupies a large portion of the medial thigh. (Bottom) T h e two origins o f th e
adductor magnus muscle are visible. The ischiocondylar portio n arises fro m the ischial tuberosit y w hile th e adductor
portion of th e muscle origi nates from t h e i chiopubic ramus. The vastus medialis m uscle is also a la rge m uscle along
the medial thigh. Th e externa l rotators of the hip are presen t at th e level of the ischial spi ne. Thei r anatomy is
presented in greater detail in the "Lateral Hip" section.

v
271
 THIGH OVERVIEW
SAGITTAL T1 MR, MEDIAL T HIG H

IJ
Femoral h ead
Sartorius m.
Iliopsoas m. Pi riformis m .

Obturator ex tern us m. External rotators

Pectineus m. Gl ut eus maximus m.

Comm on fem oral a., v.

Adductor brev is m.

Add uctor longu s m. Adductor m agnu s m .

Rectus fem o ri s m.
Superli cial fem oral
artery & vein

em i membran osus m.

Vast us medialis m.

M edia l femo ral condy le

IJ Iliop soas m .

Sar torius m.
Obt urator extern u s m .

Pectin eu s m.
Femoral head
Piri fo rm is m .
Externa l ro tators

Isch ial tu berosi ty

Gl uteus maximus m .
Common femoral a., v.
Semitendi n osus m .

Adductor brevis m .

Adductor longus m. Adductor magnus m .

Rectus fem o ris m .

Semim embranosus m .
Superfi cia I femoral
artery & vei n

Vastus m edialis m .

rJ) Medial femoral condyle

>
Q)
c..
"'0 (Top) Th e inferior cou rse of the graci lis muscle is seen as it nears i t insertion onto th e tibia . The course of th e
c::: su perficial fem o ral vesse ls in th e mid thigh is easily appreciated. (Bottom) The semimembranosus muscle bell y is a
ro large structure occu pying a significant po rtion of the posterior aspect o f the d istal thigh . T he semitendin osus tendon
a.. takes o rig in from th e superior and m ed ial aspect o f th e i nfero media l ex tern al surface o f th e i chial tuberosity.
:r:
v
272
 THIGH OVERVIEW
SAGITTAL T1 MR, MEDIAL THIGH

Femora l head
Iliopsoas m.
Obturator extern us m.
Gluteus medius m.

Piri formis m.

Isch ial tuberosi ty

[[
Superficial femoral
artery & vein Glu teus maximus m .

Deep femoral a., v.

em itendinosus m .

Add uctor magnus m.

Rectus femoris m .

Semimem b ranosus m .

Superficial femoral
artery, vein

Vastus m ed ialis m.

Medial femoral condy le

Glu teus medius m.

Femur

Ili opsoas m.
Gluteus maximus m,
Piriform is m.
Obturator ex tern us m.
[[
Conjoi n ed origin
Pectineus m. semitendinosus, long
h ead biceps femoris
Rectus femoris m.
Semimembranosus t.
Add uctor lo ngus m. Semitend in osus m.

Adductor magnus m.

media lis m. Su perficia l femora l

artery & vei n

Semimembranosus m.

Medial femoral condyle

Patella
Medial head
gastrocnemius m.

(Top) The common femoral vesse ls have div ided into superfi cial and d eep femoral vessels. The superficia l vessels
course med ially whi le the deep femoral vesse ls are seen on thi s image as they head more laterally. (Bottom ) The
rectu s femoris muscle occu pies th e anterior aspect o f th e thigh. The membranous origin of the semimem branosus
muscle from the superi o r and lateral aspect of the external su rface of the i schial tuberosity is n icely demon strated on
this image. The long h ead of the b iceps femoris muscle and the semi tendinosus muscle share a common origi n from
the ischia l tuberosity.
v
273
 THIGH OVERVIEW
SAGITTAL T1 MR, MEDIAL THIGH

IJ Gluteus m in imus m.

Fem oral neck

Il iopsoas m.
Glu teus maximus m.
Piriformis m.
Quadrat us femo ris m .
Lesser trochanter
Pec ti neus m.
Scm i m e m bra nos u s t.
Rectus femor is m.
Se mite n d in osu s m.
Ad du cto r lo n g us m .

Ad d u ctor m agn us m .

Vastus medialis m.
c mimembranosus m.

Po pliteal a., v.

Quadriceps te ndon
Intercon dylar roof
Patella
l'ost e rior crucia te gast rocne m ius 111.
ligament

IJ Gluteu s minimus m .
Tensor fa sc ia lata m .
Femora I neck
Pirifo rm is t .

Quadratus femoris m.
Lesser trochan ter
Pec tineus m .
Gluteus maximus m .

Rectu s femoris m.

Scm i m e m b ranosus t.

Vastus Semi tendi nosus m .

m edia Iis/in tc rm ed i us
muscles Add ucto r m agnu s m.

Vastu s in termedius m .
c mimcm bra nosus m .

Vastus la tc ral is m .

Pop litea l a., v.

Quad riceps tendon

Intercondylar roof
Patella Lateral h ead
Patellar te ndon gastrocnemius m .

(Top) Th e iliopsoas m uscle inserts o nto the lesser trochanter. ear th e i liac w ing th e 3 g luteus muscles are seen . Fro m
anteri o r to posterio r they are gluteus minimus, medius an d maximus. (Bottom) Th e tran sitio n fro m vastus med ialis
to vastus intermedius i s d ifficult to apprecia te and i s mostl y recognized by anato mic position . Th e vastus intermedius
origi nates fro m the an te rio r surface of the mid to d istal fe mur. Th e junction of th e m embrano us portio n o f the
semimem bran o us muscle and its muscle belly i s wel l seen o n thi s image.

v
274
 THIGH OVERVIEW
SAGITTAL T1 MR, MID THIGH

Glute us mi n imu s m . Gluteus m edius m .

Te n sor fascia la ta m .
G lute us m axim us m .
Fe m o ral ne c k
Q ua dratus femoris m.

Vastu s late ra lis m .

Rectu s fe m o ris m.
Se mime m branosu s t.

Semi tend inosus m.

Vastus inte rmedius m. Adduc to r m agn us m .

Sc iat ic n.
Vastus lateral is m .

Popli teal a ., v.

Quadri ce ps te ndo n Semime m bra nosus m .

Pa te lla
La teral head
gastro c ne mius m.
Patella r te nd o n

Gl ute us m in imus 111 . Gl ute us me d ius m.

Greater trocha nte r
Te nsor fascia lata m.
Quad ra tus fe m o ris m.

Gl ute u s max imu s m.

Rec t us fe m oris 111 .

Vastu s la te ra lis m .

Se m ite ndin osus m.

Adduc to r m agn us m .

Long h ead b iceps

Vastus inte rm ed ius m . femo ris m.
Sci a tic n.

Se m ime mbra n o sus m .

Q uad ri ceps te n<:!_o n

Po pliteal a., v.
Pa te lla
La te ra l h ea d
Lat e ra l fe m o ra l con d yle gas trocn e mius 111 .

(Top) At th e anterola te ra l aspect o f th e uppe r thigh th e te nsor fascia lata m u scle is visible. T he qu adra tu s fem oris
mu scle is h orizo nta ll y o rie nted a nd tra vels deep to th e glute us ma ximus muscle. (Bottom) No te t he reciprocal
re la ti on shi p be tween semim embranosus and se mite n di nosus m uscles. As o n e m u scl e belly e nlarges th e oth er
decreases in size. Th e m edial marg in o f the po pliteal fossa, the semi mem branosus muscle, is visible o n this im age.
Th e inse rti o n o f the g luteus mediu s muscle o nto the great e r t ro chante r is seen. For m ore details see th e "Late ral Hip"
sectio n .
v
275
 THIGH OVERVIEW
SAGITTAL T1 MR, MID TH IGH

IJ Gluteus m in imus

Te n sor fascial la ta
111 .

111.
Gluteus m ed ius m.
Greater trochanter

Quadra tu s femoris m.
Rectus fe m oris m . Gluteus maximus m.

Vastus la teralis m.
Adductor m agn u s m.

Long head biceps

fe m oris m .
Vastus in termed ius m .
Short h ead biceps
fe m oris m.

Scia tic n.

Semimem branosus m.
Q uadriceps te n don

Pa tella La te ra l head
gast rocne m ius m .
La tera l femo ral condyle

IJ Gl uteus minimus m.

Te n so r fascial lat"a m .
Gl u te us medi us m.
Grea ter troch a n ter

Quadra tus fe m oris m.

Gluteus maximu s rn.

Vastus in te rmedius m . Lon g head biceps

fe m oris rn.
Vastus lateral ism.

Short head biceps

fe moris m .

Sciatic n.

Lateral head
IJ) Lateral femo ra l condyle gastrocn e mius m.
>
Q)
c..
""0 (Top) The scia tic ne rve is present al ong th e deep surface o f th e long h ead of the biceps fe mo ri s muscle. O n most
c: images it is not d iscernible as separate from the muscle. (Bottom) The exte nsive inferior margin o f the gl u teus
maxim us muscle can be app recia ted on t his image. The sciatic nerve is see n bisecting the popl iteal fossa.
0..
I

v
276
 THIGH OVERVIEW
SAGITTAL T1 MR, LATERAL THIGH

G lut e us minimus m. Glu te us m ed ius m.

Grea te r trochan te r

Tensor fascia lata 111 . Quadratus femoris m.

Gluteus rnax imus m.

Vastus latera lis m.

Long h ead biceps

femoris m .

Vastus intermedius 111 .

Short h ead biceps
fe m o ris m .

Glute us medius m.
G rea ter troc hante r
Tensor fasc ia lata m .
Glu teus rnaximus m .

Vastus latcrali s 111 .

Bi ceps fe m o ris m.

(Top) The origin o f th e vastus lateralis muscle from the superior most aspect of the femora l diaph ysis can be easily
see n o n this image. The biceps fe moris musc le is n ow visible at the lateral border of the popliteal fossa . (Bottom) The
broad insertio n o f th e gluteus medi u s muscle o nto the la te ra l aspect of the superior greater trochanter is easily
appreciated. Fo r detai ls see th e "Lateral Hip" section .

v
277
 THIGH OVERVIEW
SAGITTAL T1 MR, LATERAL THIGH

IJ Glu teus med ius t.

Glute u s maxi mus m .
Tensor fascia lata m.

Va tus late ra li s m.

Biceps femo ris m .

Gluteus m axi mus m .

Temor fascia la ta m.

Vastu s lat e ra lis m.

intermedius

til

>
Q)
c..
""0 (To p) Note the tendon of th e g lu teus med ius as it travels a lo ng the la te ral aspect of th e g reater troc ha nte r. (Bottom)
C: The most latera l m uscles of the thi gh a re th e vastu s la te ra l is and g lu teus maxim us muscles.
0..
::c
v
278
:::c

v
279
 SECTION VI: Knee

Knee
Knee Overview 2-63
Text 2-4
Radi ograph s: Angles & meas urements 5-9
Grap hi cs: Muscle origins & insertion s 10-13
CT a rt hrogram 14-15
G rap hi cs: Vesse ls 16-17
G raphi cs: Nerves 18-19
Ax ial MR seque nce 20-33
Corona l MR sequ en ce 34-53
Sagitta l MR seq ue n ce 54-63
Extensor Mechanism and Retinacula 64-71
Text 64
Gra phics & MR: Patellar stabilizers 65-68
MR sequ en ces: Plica 69-71
Menisd 72-9 7
Tex t 72
Graphics & MR: Men isci 73-91
MR: No rma l menisca l variants 92-97
Cruciate Ligaments/ Posterior Capsule 98-115
Text 98
MR: C ruc ia te liga m en ts 99-101
MR: Assoc ia ted li ga m e n ts & va ri a nts 102-109
Graphics & MR: Posterior capsul e 110-114
CT arthrogram: Cruciates & pos terior capsule 115
Medial Support System 116-1 25
Text 11 6-117
Graphics & MR: Med ial su pport str uctures 1 I 8-125
Lateral Supporting Strudures 126-141
Text 126-12 7
Graphics & MR: Lateral s upporting structures 128-141
Leg
Leg Overview 142-187
Tex t 142-144
Grap hics: Muscle o rig in s & inse rtions 145-149
Radiograph s 150-151
G raphi cs: Muscles 152-157
G raph ics: Vessels & ne rves 158-159
Ax ia l MR sequence 160-175
Co ro nal MR seq ue n ce 176-179
Sagittal MR sequ e nce 180-182
MR & Grap hi cs: Va rian ts 183- 187
 KNEE OVERVIEW
• Sa rtorius: O rigin a n terior superior il iac spine,
!Terminology insertion anteromedial tibia, crosses both hip and
Abbreviations knee joints, flexes both hip and kn ee joints,
• An te rior c rucia te ligament (ACL) rotating thig h latera ll y to bring lim bs into
• Posterior c rucia te ligament (PC L) positio n ado pted by the cross-legged tailor; sartor
• Medial (tibial) collat e ral ligament (MCL) =a tailor
• Lat e ra l (fibular) collateral ligament (LC L) • Gracilis (origin pubi s, insert ion anteromedia l t ibia;
crosses both hip and kn ee jo ints, adducts thigh,
flexes knee, and rotates flexed leg mediall y)
• Sem itendinosus (or igin ischia l tobewsity,
IGross Anatomy insertion anteromedia l tibia; crosses both hip and
Ove rview knee joints, ex tends hip, flexes knee, med ia lly
• La rgest and m ost complex joint ro tates flexed leg)
o Hinge joint throughout its greatest range of motio n • Sem ime mbra nosus (o rigin ischia l tu berosity,
o In a ll positions, fem ur in co ntact with t ibia, with insertion poste rior medial con d yle tibia; crosses
large a reas o f contact both hip and knee jo ints, ex tends hip, flexes kn ee,
o In all positions, patella in conta ct with femur med ially rotates flexed knee)
o Bones do n ot interlock; stabilit y maintained by • Popliteus (arises as te ndon fr o m popliteal groove
ligaments, te ndons, capsul e, and m e nisci at lateral femo ral co ndyle, in serts onto posterio r
• Motion o f knee and re lationsh ip of osseou s s tru ct ures su rface tibia; flexes knee a n d medi ally rotates tibia
o In full flexion at beginning o f fle xion
• Posterio r su rfaces of femora l co nd yles articulate o Internal rotators of leg: Popli teus, gracil is, sartorius,
with posterior t ibial cond yles sem itendin osus, sem imembranosus
• Lateral facet of pa te ll a in co ntact with late ral o External rotator of leg: Biceps femor is
fe mo ral condyle • Nerves of knee joint
• Suppo rting liga m ents are not taut, and rotation of o Femo ra l n e rve supplies
leg is allowed • 3 branches, o ne to eac h o f the vasti, and to
o During moti o n of extension anterosuperior part of joint
• Patell a sl ides upwa rds on femu r, passing first on to • Largest is n e rve to vastus m edia lis w h ich
its middle facet and then its lower facets acco mpanies d escending geni cula r a rtery
• Femoral condyles roll for ward o n tibial condyles o Common peroneal n e rve supplies
and menisci • Superior late ral genicular n erve descends into
• Late ra l fe m o ra l cond yle sho rter anteroposte riorly popliteal fossa and suppli es su perolateral part of
than medi a l a nd reaches ful l exten sion earlier jo int, pass ing deep to biceps, through latera l
• Medial fe mora l condyle co ntinues to slide after intermuscul ar septum above femoral condyle
lateral stops, a nd ro tates slightly media lly o n tibia • In fe rio r latera l gen icula r ne rve: Sma ll & som etimes
a nd m ed ia l me ni scus ("screwing it horn e"), a n d absen t; arises with s upe ri o r late ral gen icular nerve
tighten s ACL, collate ral ligaments, and posterior & curves dow nwa rds & forwards over lateral h ead
cap sula r ligaments, tu rn ing kn ee into a rigid pi ll ar of gastrocnemius, passing betwee n the ca psu le &
o Initia ti ng flexion from full y ex ten ded knee fibular coll ateral ligame nt
• Requires slight medial rotation of tibia, pro du ced • Recurrent geni cular n erve: Small twigs reaching
by popliteus the a n tero infe ri or pa rt of joint
• "Unlocks" joint, allowing remainder of motion to o T ibia l nerve suppli es
take place • Superior m edial geni cular n erve: Runs medially
• M uscles acting on knee join t around fem u r above medial condyle, deep to
o Extensors: Fo u r pa rts of qu ad rice ps femoris adductor magn us, th e n t h rough vastus medialis to
• Rectus femoris (origin anterior in ferio r iliac spine, s upe ro med ia l part o f join t
insertion patella; crosses both h ip and kn ee jo ints, • Midd le gen icular ne rve: Runs forwards through
fle xing h ip and extending knee) fibrous capsul e to c rucia te ligame nts
• Vastu s late ra l is (or igin late ral shaft o f fe mur, • Inferior medial genicular nerve: La rgest, runn ing
insertion patella) al o ng u pper bo rde r o f poplite us, passi ng fo rwa rds
• Vastus med ialis (origi n m edial shaft of fe mur, between sh aft of tibia a nd medial colla tera l
insertion pate lla) ligament, curvin g superiorly to inferom edial part
• Vastus intermediu s (origin anterior shaft of fe mur, of capsu le
in se rti o n pa tella) o Obturator nerve: Sen ds a ge nicular branch th rough
o Flexors adductor rnag nus to join poplitea l a rte ry, running to
• Biceps fe m oris (orig in ischial t uberosity, insert ion posterior aspect of joint
fibu lar h ea d a nd tibia; crosses both hip and kn ee • Vessels of knee joint: 8 arter ies supply a large
joints, exte n ding hi p and flexing knee) a n astom osis
o Popliteal artery su pplies 5 genicul ar branches
o An te rior tibial a rte ry suppli es 2 recurrent branches
o Femoral artery su pp li es desce nding geni cu lar
branch

VI
2
 KNEE OVERVIEW
o Lateral ci rcumflex a rte ry supplies d escen d ing • Triangular sesamoid
gen icular branch • Wider at base su periorly tha n at a pex in feri orly
• Arti cula r surface d iv ided by vertical ridge into
late ral and med ia l facets
IImaging Anatomy • Late ral face t long and shallow a ng le
• Med ial facet short and more strongly angulated
Overview • Several oth er facets desc ri bed but not of imaging
• Multiple speci fic a n atomic relatio n ships must be importance
mai n tained in o rde r to assu re sta bil ity & ful l func ti o n • Lower 25% non -a rticular
• No n-articular o uter su rface may develo p
Osseous Anatomy
promin ent e n thesopathy where quad ri ceps
• Distal femur
te nd on insert io n blends into origin of infe rio r
o Osseous features pa te llar t endon
• Distal femoral metaphysis flares into medial and
• Bipartite (multipartite) patella: Always upper o ute r
late ral e picondyles
quadrant; osseous fragme nts may not appea r to
• Osseous irregularity m ay be seen a t poste ro m ed ial
"match ", but ca rtil age is conti n uo us over defect
femora l m etaphysis: "Tug" a t ad ductor o r med ial o Cartilage
gastrocnemi us in sertion , termed "corti cal
• Thic kest cartilage in body (3-4 mm)
d esmoid" • Uniform thi ckness
• Medial femo ral cond yle large r than la te ra l • May have d o rsa l pa te llar defect as n orma l va riant
• Late ral femoral co ndyle has an indenta ti on in its
anterior we igh t-bea ring surface (la te ra l fe m o ral Articular Capsule
condylar recess); measures< 2 mm • Highly complex, noncontiguous structure
• Intercondylar notc h accom moda tes cruc ia te • o ntributi o ns from multiple muscles, tendons, and
ligaments; seen as Blumensaat line o n radiograph ligaments
• An teriorly, trochlear groove accommodates patella • Som e structures may be intra-articular but
a n d is gen era ll y V- haped extra-synovia I
o Possible s ites of avu lsion • Also see sections: "Ex tenso r Mech an ism ", "Cruc iate
• Poste ro la te ra l inte rcond ylar notch (AC L o rigin) Liga ments and Posterio r Capsule", "Media l Supporting
• Media l epi co ndy le (MCL o rigin) Stru ctures", "Latera l Suppo rtin g Structures"
o Ca rtilage
• Thicker ove r posterior cond yles than norma l Extensor Mechanism
weight-bea ring surface • Quadriceps tendon converges on patella
• Foca ll y thi n a t latera l fe mo ral cond ylar recess • Fi bers of rectus femoris cou rse over patella to form
• Prox imal tibi a infe ri o r patella r tendon
o Osseous features • Fibers of vastus latera l is a n d medialis con t ri bute to
• Poste rio r tilt of ti b ia l surface 10° la te ra l a n d m edial retin acula, respectively
• Tibial tube rc le (apoph ys is) ante ri or and slightly • See a lso sect ion: "Extensor Mechanism"
la teral, severa l em distal to join t
Internal Structu res
• Ge rd y tu bercle a nte rolatera l just dista l to jo int
o Possible sites of av ul sion • Men isci
• Tibial spine (A CL in sertion) o Cushi o n , lubrica te, and stabilize knee
• Posterior mid tibia a t joi nt line (PC L insertion) o Fibrocartil age
• Medial joint line (coro n a ry ligament insertion ) o O nly peri pheral portion vascu larized
• Latera l jo int li ne (ca psular inse rt ion; ma y avulse o Attached by an te rior and posterior roots to tibial
wi th va lgus twist) : Segond su rface
• Ge rd y tuberc le (ili otibi a l band) o Med ia l attached to ca psule through o ut extent
• Tibial a poph ysis (patellar tend o n inse rtion): In o Latera l attac hed to capsul e a t ante ri o r ho rn and far
skeleta ll y im mature patien t posteriorly, b ut by fascicles to popliteus a t body and
o Cartilage: Uniform ly thin posterio r horn
• Prox imal fibu la o La teral h as consta nt size and sh ape
o Osseo us features o Med ial has elo nga ted posterior horn a nd small body
• Posterolatera l relative to tibia o See a lso section: "Men isci"
• Fibular stylo id process • Cru ciate ligaments
o Tibiofibu la r jo int o Intra-articular but extra-synovial
• True synovia l joint; subject to a n y a rthriti c process o Major stabil izin g structures to anteroposterior
• Con nects to knee jo int in 20% motio n
o Possible si tes of avulsion o ACL o rigina tes a t poste rolate ra l inte rcon dylar notch,
• Lateral fib ul ar head (in sertion of co njoint tendo n ) crosses anteromedially, and inserts at med ia l t ibial
• Thin fragme nt medial stylo id (inser tion of arcuate spine/tibia l surface
ligamen t) o PC L o riginates a t mid medial interco ndylar notch,
• Patella crosses posteriorly and slightly laterally, and inse rts
o Osseous fea tures ext ra -articularly at pos terior cen ter of tibi a below
jo int line

VI
3
 KNEE OVERVIEW
o Inju ry generally intrasubs ta n ce, but avulsions m ay o Arcuate liga m ent o rigi na tes from stylo id process
indicate injury (o ri g in a n d in sertion, respecti vely) fib u lar h ead, in te rdigitates wit h popliteus, and
• ACL: Posterolatera l Blu men saat line or medial in se rts into post e rio r ca psule near o blique popliteal
tibi al spin e ligam ent
• PCL: M id medial inte rcondylar notch o r posterio r o Several o the r small and inconsta nt structures loca ted
central tibia poste wlate rally which a re difficul t to d ifferentiate
o Norm al variants could possibly be co nfusin g by imagin g
• ACL: ln fra pate ll a r plica, meniscocrucia te ligament, • See section: "Late ra l Su pportin g Structu res"
m en iscomen is cal I igament
• PCL: Meniscofemoral liga m ents
o See section: "Cruciate Ligaments" [Anatomy-Based Imaging Issues
Medial Supporting Structures Imaging Recomm endations
• Su perficial (laye r 1) • Rad iograph s: AP standing, late ral, ax ial pa tella with
o Pes anserinu s: Anteromedi a l t ibia l insertion zoo flexion
• Sar torius em bedded in crura l fasc ia • MR
• G racilis immediately deep to sartori us o T l in o ne plane to evalua te marrow and ana to m y
• Sem iten di nosus immedia tely deep t o g rac ilis o PD is most accu rate seq ue n ce to eva luate m enisc i
• Midd le (layer 2) o Fluid sen si tive seq ue n ce to eva luate location a nd
o Superfic ial media l coll ateral li gament (lo ng itudi na l tracking of flui d coll ectio ns
and o blique components) • M R a rth rograph y (ind irect)
• Origin medial epicondyle; runs sl ig h t ly o C linical ind ica tions
an terom ed iall y to insert on ti bia 5 em d ista l to • Articula r processes (syn ov itis)
jo int li n e • Post surg ica l (m eniscal re-tear)
• Ante rio rly, lo ngitud inal compo n ent fascia blends • Evaluati o n o f osteochon d ra l defect (fo r intact
w ith layer 1 cartilage or loose body)
• Posterio rl y, oblique component ble nds with layer o Technique
3 as poste rior obli que li ga m ent • Exe rcise fo ll owing IV in jection
• Deep (layer 3) • Image Z0-30 mi n utes fo ll ow in g in ject ion
o Ca ps ula r layers (some times termed deep fibers of • MR art hrog raphy (direct)
MCL) at mid po rtion of knee o Clinical indica ti o n s
• Meniscofemoralligament • Rare ly requi red; indicatio ns si milar as for ind irect
• Meniscotibial (coronary) ligamen t arthrograph y, but w he n no effusio n is p resent
o More poste riorl y, su p.erfi cia l MC L blends wit h o Tech nique
caps ular laye rs MCL • Knee flexed, either m edial or lateral su bpatell ar
o Poste ri o r o blique liga m ent a ri ses fro m supe rfi cial needle placem ent
MCL • Sta y below m id pole o f pa te lla (otherw ise may
• Blends wi th postero media l me ni scus inject into pre-fe m ora l fa t pad)
• Receives fibers from semi membranosus t e ndon • Aspirate a ll fluid in knee so that inj ected fluid is
• Envelops poste rior aspect fe m oral cond yle, te rmed not di luted; inject volum e o f 40 cc
o blique poplitea l ligament • CT arthrography
• See sectio n : "Medial Su ppo rting Str uctures" o Clinica l indication s: Same as above, if MR
Lateral Supporting Structu res cont ra indica ted
o Tech niq ue: Sa m e a s above, dilute contrast of choi ce
• Superficia l (layer 1)
50/SO with bacteriostatic saline
o Il ioti bial band a nteriorl y, inse rting o n Gerdy
o Acq uire sub-mill imeter sec tion s; reformat
tubercle
o Su perfi cial portio n biceps fe m oris postero late ra ll y, Imaging Pitfalls
inse rting on fi bula r s tyloid • Va riants: Listed above a nd in sectio ns
• Middle (layer 2) • Loose bod ies on MR: Easi ly missed
o Quad riceps ret inacul um anteriorly • Partial volu ming over co n vex surfaces: Morp ho logy of
o Poste rio rly, Z li ga m ento us t h ickenings w hic h trochl ea, femoral condyles, a nd patell a m akes th em
o riginate from latera l pate lla particula rl y difficul t to evalua te in 3 standard pla nes
• Prox imal one terminates a t latera l inte rm uscu lar • Malpos ition ing
septum o n fe mur o AP rad iograph : Flexion o bscu res join t space
• Distal o n e t erm in ates at fe moral insertion of o Axia l patell a: Flex ion > zoomay reduce su bluxation
posterolateral capsule and late ral h ead of o r tilt
gast rocn em ius • Imaging cartil age
• Deep (layer 3): Severa l thicken ing in latera l part of o TZ underestima tes ca rtilage thickness since co rtex
capsule function as discrete struct ures and ca rtilage have si m il a r sig nal
Q)
o Lateral (fibul a r) collatera l ligamen t origin ates lateral o PD may h ave simi la r signa l for carti lage and
Q) femoral epicondyle, exte nds poste ro laterally to adja cent jo int fluid , obscuring defects; fat-sa turatio n
c:: insert o n late ral fibu lar head solves this

VI
4
 KNEE OVERVIEW
CT SCANOGRAM

The ye llow line d rawn o n the ri ght lower extremity depicts th e mech an ical axis, drawn from the cente r of t he
fe mo ral h ead to t he center of the tibial p lafo nd. T h e n o rmal m ech anical axi s t ra verses the cen ter of th e knee joint.
The green lines bisecting th e d istal femur and prox imal tibia sho ws the no rmal va lgus angula tion of th e knee
(ave rage 6°).

VI
5
 KNEE O VERVIEW
AP & AXIAL RADIOGRAP HS

Adducl"O r t ube rcle

Lateral ep icondyle
Medial ep icon dyle

Popliteal sulcus
Interco ndy lar notch

Lateral ti bial spi ne M edial ti bial spine

Tibial tubercle

Lateral patellar facet Medial patellar facet

(Top) AP rad iograp h of the knee, shows its osseo us fea tures. The de pt h o f th e in te rco ndy lar n o tc h is not appreciated
o n an AP rad iogra p h. (Bottom) Axia l rad iograph of the knee, o btain ed with the knee flexed 20° (allows max ima l
subluxatio n o f patella). Not e that th e la tera l pate llar face t is elo ngated a n d less sharply angled than t he medial. T he
a ngle fo rmed by the line t hrough the condy la r pea ks (gree n) and la tera l pate ll a r facet (ye llow) is n o rma ll y o pe n
la te rally; reversa l of this a ngle const itutes pa te llar tilt. A li n e d ra wn pe rpe ndi cular (reel) to th e co nd yla r peaks line
(green), 1 mm la teral to th e media l cond yla r pea k sh o u ld in tersect the patella. If th e pate ll a li es lateral to t h is line, it
is latera ll y sub luxecl . The angl e of the su lcus is norm a lly 136 +/- 6°; values> 140° are associated with instab ili ty an d
VI condylar/ latera l troch lea r d ysp lasia.
6
 KNEE OVERVIEW
LATERAL RADIOGRAPH

Quad riceps tend on

Sup ra pa tellar fat pad

Suprapatel lar bursa

(collapsed) Add uctor tubercle

Bl um en saat li ne
(intercondylar no tch)

Latera l fem ora l

M edial femoral con d yle
co ndylar sulcus

Inferior p atellar tendon Lateral fem oral condyle

Hoffa (pret i bial) fat p ad

T ibial tubercle

(Top) La teral rad iograph o f th e knee. No te that the intercondylar n otch is delineated by Blumen saa t line. The medial
fe mora l co nd yle is slightl y larger t h an the lateral; th e lateral fe moral cond yle can also be ide ntified by th e presence of
the latera l fe m oral sulcus at its anterio r weight-bearing portion. (Bottom) Patellar positi on o n late ral rad iograph. t h e
length o f th e patella r tendo n (yellow line) and the grea test length of th e patell a (green line) form a ratio that
averages 1.17 (ra n ge 0.8-1.3) .

VI
7
 KNEE OVERVIEW
AXIAL CT, FEMORAL TORSION

Cent er o f femoral head

on cut through mid
fem o ral neck
Cent er of sh aft on cu t
through base of
fem oral neck

Line depicting axis of

femo ra l neck

Line depicting axis of

fem oral n eck

Epico ndy lar axis

Transcondylar line

(Top) Ax is o f femoral neck, determined by superimposed CT scan s th rough the mid femora l neck an d base of
femoral n eck. T h e line connecting the center o f the head in the su perior cut and t he cente r of shaft in the lower cut
determines t h e femoral neck axis; this line m akes an angle with the tra nsischial line; in this case th ere is 15° femora l
neck an teversion. (Bottom) Femoral to rsio n, measured by CT. Angle formed by the ax is of t he femoral neck (green
lin e from prev ious i mage) & the transcondy lar li ne (yellow) gi ves th e degree of femora l to rsion. In the norma l
situat ion , th e distal femur i s internall y rotated relative to th e femo ral n eck, w h i ch is termed fe mora l anteversion or
femora l antetorsion; different studi es show average anteversi on to be 15-24° in adults (range 3-48). Th e
VI epico ndy lar/posterior co ndylar angl e should be 5.7 +/- 1. r. Epicondylar axis (red li ne) is another useful landmark.
8
 KNEE OVERVIEW
AXIAL CT, TIBIAL TORSION

Transcondylar li ne
(d istal femur)

Transverse ax is o f
proxima l tibia

Transverse axis of
proximal ti bia

Tra n sverse axi s o f distal

tibia

(Top) Occasio na lly o ne may be required to m easure th e rota ti o n o f t he proximal tibia o n th e d ist a l fe m ur. The re is
usua ll y sligh t ly exte rnal rotation of the tibia re la tive to th e fe m ur a nd is measu red by the a n gle fo rmed by the
tran scond yla r line o f th e dista l fe mur (ye llow) a nd th e t ransverse axis o f th e proxim al tibia (red lin e). (Bottom) Ti bia l
torsion is measured by the angle fo rmed by th e proxim a l tibia l t ra n sve rse ax is (red line) and distal tibia l transve rse
ax is (blue line). Th ere is no rmall y externa l rotation (to rsion) of t h e dista l t ibia m easuring 30° in ad u lts (ra nge 20-50°),
as shown by several CT st ud ies. Tibial torsio n g reate r tha n 40° shows a n inc reased incidence o f adverse pa te lla r
mechan ics and ma la lignme n t sy ndrome.
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 KNEE OVERVI EW
CT ARTHROGRAM, AXIAL & SAGITTAL REFO RMATS

Lateral pate ll ar
Patho logic th inning at ca rti lage
patellar apex
Suprapatell ar recess

Posterior lateral
femoral condyle
ca rtilage

Suprapatellar recess

Prefemoral fat pad

Pre-gastrocnem iu s
recess

.,;....-;;;-- Posterio r horn lateral

m eniscus
An terior h orn latera l
m eniscus Supe rior fascicle
(popl i teom eni scal I. )
Inferior patel lar tendon
Popli tea l ten don

l n frapatel lar (Hoffa) fat Poplitea l hi atus

pad

(Top) Ax ia l d irect CT scan through fe mo ra l co nd yles post a rthrogra m . T h e co n t rast di ste n ds the jo in t, fi lli n g recesses
and o utl in ing cartilage and all in tra-art ic u la r st ru ctures. CT arthrogram m ay be substitu ted if t he re is a
co nt raindicatio n to MR in a patie nt. (Bottom) Sagit ta l re fo rma t, CT art h rogra m , t h rough th e la te ral co mpa rt m en t.
Th e su prapatellar bursa is distended , outlining patellar cartilage defects. Th e menisci are o utlined, sh owing th e m to
be in tact . The superio r fascic le of p oste rio r ho rn is we ll see n, as is po pl itea l tendo n in its h iatus.

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 KNEE OVERVIEW
CT ARTHROG RAM, CORONAL REFORMATS

ln tercruciate recess

Posterior cruciate Anterior cruciate

l iga m ent ligament

Bocly, later al m eniscus

Bocly, m ecl ia l meniscus

Meclial fem oral

Latera l femoral conclyle
co nclyle, posterior
port ion

Posterior cruci ate

ligam ent
Popl i teal tenclo n origin

Popl iteal h iatu s

Posterior crucia te recess

Bocl y lateral m en iscus

Poste rior horn mecl ial

m en iscus

(Top) Coro na l refor mat thro ugh the mid joint, CT arthrogra m. This section ou tlines the bodies of the menisci we ll,
as well as th e crucia te ligaments. (Bottom) Coron al reformat, CT a rthrogram, in t h e poste ri or port ion of the knee.
Th e posteri o r cruciate is o utlin ed, with the adja ce nt bu rsa distended. The m enisci aga in are well see n.

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 KNEE OVERVIEW
AXIAL T1 MR, RIGHT KNE E

Qu adriceps tendon

medi al is m.
Prcfemoral fat pad

Ilio t i bial tract

Vastu s lateral is m . Adduc tor m agnus t.

Plan taris muscle Medial superior

geniculate arter y
Latera l superior Poplitea l artery
genicul ate artery

Poplitea l vei n Sa rtori us muscle

Common peron eal

Graci lis ten do n
n erve
Biceps femori s muscle emimem branosus m.
Tibial n erve
Semit endi nosus t.

Quadriceps tendon

Prefem oral fat pad

Vastu s m edialis
obliquus muscle

Ilio ti bial tract

Adducto r magnus t .
M edi al head
ga>t rocnemiu s muscle

Pop l iteal ar tery

Popliteal vei n
Sarto ri us muscle
Common peron ea I n .
G raci l is tendon
T ibial n erve
Se mimembranosus m.
Biceps fem o ris m.
emitendi n osus tendon

(Top) First in seri es o f axia l T l MR i mages of t he ri ght knee. Th e cu t is above th e patella and at the prox imal portion
of th e femoral m etaphys is. At this level, the o rig in o f p lantaris muscle is seen , bu t it is sti ll prox imal to the ad ductor
Q)
Q) tubercle. (Bottom) T hi s cut is immedi ately above the adducto r tubercle. The vastus medialis obliquu s is seen , serv i ng
c as media l support for th e superior por tion of th e pa tel la.
:::t::

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 KNEE OVERVIEW
AXIAL T1 MR, LEFT KNEE

Q uadriceps t.

Vastu s m edial i s m.
Prefemoral fat pad

Ilio tibial tract

Vastus lateralis m .
Adductor m agnus t.

Medial superior
genicula te artery Lateral superio r
Popliteal artery gen iculate arter y

Poplitea l vein
Sa rtori us muscle
Common pero neal n.
Graci lis tendon
Ti bial n er ve
Semimembran osus m.
Bi.ceps fem oris muscle
Semiten di nosu s t.

Q uadr iceps t.

Vastu s medialis Prefem o ral fat pad

obliquus mu scle

Medial superi or
geni culate artery Ilio tibial tract

Add uctor magn u s t. Vastus lateralis t.

M edial head
gastrocn emius mu scle Latera l superior
geniculate artery
Popl i tea l artery

Sa rtori us muscle Popl i teal vei n

Commo n peroneal n.
Gracilis tendo n
Ti bial nerve
Sem i m embran os-u s m .
Bi cep s femoris muscle
Semi tendinosus t.

(Top) First in series of axia l T1 MR images of the left knee. The cu t is above t he patella and at th e prox ima l port io n of
the femora l metaphysis. At t h is level, th e origin of p la n ta ris mu scle is seen, but it is st ill proxima l to the addu ctor
tuberc le. (Bottom ) T his c ut is im m ed iate ly above th e a ddu ctor tubercle. Th e vastu s media lis o bl iquus is see n, serving
as m edia l support for the superior portion of the patella.

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 KN EE OVERVIEW
AXIAL T1 MR, RI GHT KNE E

Vastus m edia li
ob liquus tendon

Vastus m edialis
obliguus mu scle
La te ra l patellar
re tin acu lu m

Sup rapatellar recess

Iliotibial ban d

Origin lateral head Adductor mag n us t .

gastrocnemius
Popliteal artery Medial h ead
Plantari s muscle gastrocn e mius muscle

Bice ps femor is m . & t. Sarto rius m uscle

Graci lis tendo n
Co mmon peroneal n .
C rural fascia
Tibial n e rve Sem iten dinosu s te ndo n
Sem im e mbranosus
muscl e & tend o n

Med ial p atello fem o ral

li ga m e n t

Lateral patell a
re tinacul u m

II iotibial tract
Medial collate ral
Iigamen t

Popl iteal artery Medial h ead

gastrocnemius muscle
Tibial ne rve
Sartori us muscle
Biceps fe moris m. & t.
Gracilis tendon
Pian ta ris muscle Se mimembra n os us l.
Comm o n pe ron eal n .
Se mitendinos us te ndon
Latera I head
gastrocnemius muscle

(Top) This cut is at the level of the adducto r t u bercle, wh ich serves at its superior aspec t as in sertio n si te of adductor
m agnus tendon. T he superior portion of the media l pate lla is stabilized by t h e te n d in ous a ttach ment of vastus
med ialis obliqu u s. Note tha t th e st ructu res comprising th e pes an serinus are aligning th e m selves. ( Botto m ) Slight ly
dista ll y, th e infe rior aspect of the adductor tubercle serves as sit e o f origin o f m ed ial pa tellofemoral liga m ent, which
in serts on th e upper 2/3 o f medial patella a nd is an impo rta nt pa tel lar stabilizer. It also serves as site of origin of
su pe rficial m ed ial collateral ligament fibe rs.
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 KNEE OVERVIEW
AXIAL T1 MR, LEFT KNEE

Vast us m cd ia Iis
obliquus tendon

Vnstus m edi alis

muscle Lateral patell ar
retinacul um

Suprapa tellar recess

Ili o tibial ban d

Popliteal arter y
Adductor magnus t. Origin lateral head
Medial head gast rocnemius
gastrocnemius m .
Biceps femoris m. & t.
Sar torius muscle
Plantaris muscle
tendon
Common peron ea l n.
Crural fascia Tibial n erve

emit cndi nosus t. Scm i mcrn bran o sus

muscle & te ndon

1cdia l patellofcmoral
ligament

Lnteral patellar
retinacu lum

Ilio tibial tract

Medi al col lateral I.

Medial h ead
gastrocnemi u s muscle
Popl i teal arte ry
Sartoriu s muscle
Bi ceps fcmorb rn. & t.
Gracilis tendon
muscle
Scm i mcm b ra t.
Common peroneal n .

Lateral h ead
Semi tendinosus t.
gastrocnemius muscle
Tibia l nerve

(Top) Th is cut is at t he leve l of th e adductor tubercle, w hich serves at i ts superior aspect as insertion site of adductor
magnus tendon . The superior portion o f the medial patella is stabilized by th e ten dinous attach m en t of vastus
media lis obliquus. Note that the structures com prising the pes anserinus are align ing th emselves. (Bo tto m ) Sl ightly
distall y, t he i nferior aspect of t he adductor tubercle serves as site o f origin o f m edia l patcl lo femoral l iga mcnt, which
inserts on t he upper 2/3 of m edi al patella and is an im portant patellar stabi lizer. It also serves as site of origin of
upcrficial med ial collateral liga m ent fi bers.
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 KNEE OVERVIEW
AXIAL T1 MR, RIGHT KNE E

Lateral reti naculum

Anterio r cruc iate Posterior cruciate I.

ligam en t
Posterior capsule

Poplitea l artery
La teral collatera l
liga m ent
Sartorius muscle &

Biceps fem oris m . & t.

Greater saph enous vein
Plantaris muscle
emimembranosus t.
Commo n pe ro neal n.
Semiten dinosu s tendon
Lateral h ead
gast rocnemi us m . gastrocn em i us m.
T ibi al nerve
Lesser saph en ous vei n

Inferior patel lotibia l

ligament
Latera l reti n aculum Medial reti nacu lum

A n terior cruciate I.

Posterio r capsule

Il iotibial band

Popl itea l art ery Medial collatera l I.

Popl iteus tendon Posterior cruciate I.

Lateral co llateral I. Graci l is tendon
Sar torius m uscle &
ten don
Hiceps fem o ri s m . & t.
Greater saph en ous vein
Pl an taris m uscle
Sem imembranosus t.
Common perone<•l n.
Semitendinosus tendon
LateraI head Medial head
gastrocnemi us m . gastrocn emius m.
Lesser saphen ous vei n Ti bial nerve

(Top) T his cut is th ro ugh t h e i n tercon d ylar no tch; origin s o f both anterior and posteri or cruciate l iga men ts are seen.
Th e ham st rings are n earl y com p letely ten di nous, about to cross med ially to th e kn ee join t. Th e origin s of both
col latera l l igam ents are n ow seen. (Botto m) At th e lower end o f patella, the medial support is fro m th e in fe rior
patell oti bia l ligament. The C-sh aped semi membranosus tendo n i s d isti n ctl y differen t fro m t h e elemen ts o f pes
an se ri nus (sartori us, gracil i s, sem it end in osus). T he bice ps femori s and l ateral collatera l l iga men t begi n to approach
on e ano th er as t h ey extend to t hei r in sertio n on th e f ib ular head; t h e popliteus ten don ari ses from i ts su lcus on the
lateral fem o ral con dyle.
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 KNEE OVERVIEW
AXIAL T1 MR, LEFT KNEE

M edial reti naculum

Lateral retinaculum

Anteri or cruciate I.
cruciate I.
Posterior capsul e

M ed ial collateral I.
llio t ibiai iJand

Gracilis tendon
Popl itea l artery

Sartorius m. & t. La teral collateral I.

Ti bia l nerve
Grea ter saphenous v.
Biceps fem o ri s m . & t .

Sem i membran osus t.

Plantari s muscle

t. Common peronea l n.
Latera I h ead
Medi al head gastrocnemius musc le
gastrocn emius mu scle
Lesser saphenous v.

Inferior patello ti iJial l.

M ediil l retinaculum

Ant erior cruciate I.

Posterior capsule
Pm terior crucia te I. I liotibial band

Popliteal artery
collateral I.
Popliteus tendon
Gracili s tendon
Lateral collateral I.
Sa rtoriu s m . & t.
T ibial nerve
Greater saphenou s v.
Biceps temor is m . & t.

Semimembran osus t. Pla n tari s muscle

Semitendin osu s t.
ornmon peroneal n.

M edial h ead
gastrocnemius muscle
gastrocn emiu s muscle
Lesser saphenous v.

(Top) Th is cut is through th e intercondyla r no tch; origins o f bo th an terio r and posterior cruciate ligaments are seen.
Th e hamstrings are nearl y completel y tendi nous, about to cross medial to the knee joint. T he origin s of both
collateral l igaments are n ow seen. (Bottom) At th e lower end of patella, the medial support is from the inferior
patello tibial ligam ent. T he C-shaped semimembranosus tendon is disti n ctl y different from th e elem ents o f pes
an serinu s (sartoriu s, gracilis, semiten di n osus). The bi ceps fem oris and lateral co llat eral ligament begin to approach
one an o ther as they ex tend to their insertion on the fibu lar h ead; the popliteus tendon arises from its sulcus on the
lateral femoral co nd y le.
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 KNEE OVERVIEW
AXIAL T1 MR, RIGHT KNEE

I nferior pa tellotibial
lnfrapatellar (lloffa) fat ligamen t
pad

Longi tud in al fibers

m edi al colla teral I.
An terior cruciate
Iigament
Ob lique fibers m edial
Iliotibial band coll atera l ligament

Obl ique popliteal I.

La teral collateral I. Posterior oblique I.

Poplit eus tendo n Sartori us m. & t.

Bi ceps femoris m. & t.

Gracilis ten don
Poplitea l artery
Greater saphenou s vein
Plantaris muscle Sem imembranosus t.

Common peron ea l n. tendon

Lateral head Medial h ead

gastrocnemi us muscle gast rocnemius muscle
Tibia l nerve

I nferior pa tellot i bial

lnfrapatellar (Hoffa) fa t ligamen t
pad

Anterior crucia te I.
Posterior cruciate
Ilio ti bial band
ligamen t
Lon gi tudinal fibers
MCL
Poplit eus ten don Obl ique fibers MCL

Lateral co ll ateral I.
G racilis tendon
Biceps femoris m. & t. Sartori us m. & t.
Popli teal artery G reater saphe nous vein

Common peronea l n. Scm i mern branosus t.

Plan taris muscle Semi tendinosus tendon

Ti bi al nerve Medial h ead

gast rocnemius muscle
Latera I head
gastrocnem ius muscle

(Top) T his cut is l. S em above the knee jo int. T h e postero latera l structures now include t he popliteu s tendo n,
ex tending posteromedially around the lateral femo ral co ndyl e within the popliteal hia tus. Ad ditio nall y, the posterior
oblique l igamen t, ari sing from fi bers of th e medial collateral ligament, joins fibers f ro m semimem bra nosus to
su pplem ent th e posterio r ca psule as th e obl ique popliteal ligamen t. (Bottom) T h is cut i s im mediately above the knee
jo in t. Th e posterior cruciate is appro aching its i n se rtio n o n posterio r tib ia and anterior crucia te spreads out towards
its inserti o n o n the plateau.
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 KNEE OVERVIEW
AXIAL T1 MR, LEFT KNEE

-
In te rior patell o tibial I.
l nfrapatellar (ll offa ) fat
pad

Lo ngitudin al fi bers Anterior cruciate I.

m ed ial colla teral I.
Ilio tibial band
Ob l ique fibers m edial
coll atera l li gam en t
O bl ique popliteal I.

Posterior oblique I. Lateral collateral I.

111. & t. tendon

Graci lis tendo n fem oris 111. & t .

Popli teal artery
Grea ter v. Comm on peroneal n.
I.
Plant aris muscle
Semitend in osus 1. Lateral head
gastrocnemius musc le
M edial head
gast roc nemius musc le Ti bial ner ve

In ferior patell o tibial I.

l n frapa tcllar (lloffa) fat
pad
[i
Iliotibial band
Lo ngi tud inal fibers
M CL An terior cruciate I.
Posterior cruciate I.
Popliteu s tendo n
Oblique fibers M C L
Lateral co llateral I.
m. & t.

Bi cep s fem ori s 111 . & t.

Gracili s ten don
Popliteal ar tery
Grea ter saph en ou s v.
Commo n pero neal n.
Semimem branosu s 1.
Plantaris muscl e
Semi ten di nosu s I. La teral h ead
gastrocn emius muscle
ledia l head
gast rocn em i us muscle 'I i bia l n erve

(Top) Thi s cut is l.S em above th e kn ee joint. The posterolateral structures now include th e popliteu s tendon,
ex tending posterom edially around th e lateral fem ora l condyle w i thi n the popliteal hiatus. Additio ni! lly, the posterior
oblique I igam en t, aris ing from fibers o f th e media I col latera I I igamen t, joins fibers from semi m embran os us to
suppl em ent th e po steri or capsule as the oblique poplitea l ligament. (Bottom) Thi s cu t is immediate ly above th e knee
joint. Th e po teri or cruci ate is ap proachi ng its insertion o n pos teri or tibia and anteri or cru ciate spreads out towards
its inserti on on th e plateau.
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 KNEE OVERVIEW
AXIAL T1 MR, RIGHT KNEE

In ferior patellar t . Medial reti n aculum

Transverse ligam ent Posterior cruciatc I.

Late ral retinacu lu m Popl i tea l artery

Medi al m eniscus
Ilio tibial band M C L, longitudinal pa rt
an terior & obliq ue part
Lat eral m eniscus pos terior
Sa r tori us tendon

Latera l co llat eral I. Posterior oblique I.

ten don
Biceps fem o ris t.
Sar torius muscle
Po pliteu s muscle
Sem i m embranosus t.
Commo n peroneal n.
Scm i membra nos us
branch/ obli que
Late ral h ead poplit eal I.
gastrocnemius muscle t.
M edial h ead
gastrocn emius muscle

Inferi or patellar t.

Lateral retinaculum
Posterior cruciate
ligamen t

Ilio ti bial band Popliteal art ery

Medial colla teral I.

Lateral collateral I. Sa rt orius tendon

Bi ceps fem o ri s t. Gracilis ten don

Sa rt orius ten don
Popli teus muscle
Common peron ea l Sem imem bran osus t.,
nerve direct & ca psular parts

Lateral h ead Semitendi n osus t.

gastrocn emius muscle
Medial head
gastrocnemius muscle

(Top) Th is cut is through th e kn ee joint. T h e m enisci are seen , alo ng w ith the transverse liga ment extending between
th e an terior ho rns. T h e anterio r cruciate l iga ment has i n serted adjacent to the ti bial spin es and t he posterior cruciate
ligam ent i s h ea ding posterio r to its inserti on o n t he tibia in an ex tra-arti cu lar posi ti o n . (Bottom ) Th is cut is
imm ed iately dista l to the m enisci within the jo int. Th e semi membranosus begi ns to attac h to postero media l ti bi a
and th e popl iteus muscle broaden s to its insert io n o n posterio r tibia as well.

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 KNEE OVERVIEW
AXIAL T1 MR, LEFT KNEE

t-. l edial retin aculum Inferior patellar t.

Transverse I.

La teral retinaculum
Posteri or cru ciate I.

Medial meniscus Iliotibial band

Medial collat eral I.
(longi tudinal & oblique Lateral
compo nen ts)
Posterior obl iq ue I. Lateral collatera l I.

ten don
Biceps fem oris t.
Sartorius tendon Pop I i muscle
Semimembran osus t.
Com mon peroneal n.
Scm i mem bran osus
branch to obl ique Lateral head
popliteal ligamen t gastrocn emius m uscle
Se mitendin osus t.
Popl itea l artery
Medial head
gast rocn emius mu scle

Inferior pa tell ar t.

Lateral retinaculum

Iliotibial ban d

Medial collat eral I. Posterior cruciate I.

Lateral collateral I.
Sartorius tendon
Biceps t.
Graci l is tendo n

Popl iteus mu scle

Sartorius muscle
Com mon peron ea l n.
Semimembran osus t.
direct &
La teral h ead
tendo n gast rocnemius muscle

Medi al head Popli teal artery

gastrocn emius mu\cle

(Top) This cut is through the kn ee joint. Th e menisci are seen, alo ng with the transverse ligament extending between
the anterior horns. Th e anteri or cruciale liga ment has i n serted adjacent to the ti b ial spines and the posteri o r cruciate
ligamen t is h eadi ng posteri or to its inserti o n o n th e tibia in an ex tra-articu lar position. (Bottom) T h is cut i s
i mmedi ate ly distal to th e meni sci with in th e jo i nt. T he semimembran osus begins to attach to postero med ial tibia
and th e popli teus m u scle b roaden s to i ts in serti o n o n post erio r t ibi a as well.

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 KNEE OVERVIEW
AXIAL T1 MR, RIGHT KNEE

Inferior pate llar tendo n

Ili o tibia l tract

Fibul ar coll ateral I.

sem imembran osus t.
Biceps femoris t.
artorius m . & t.

Po pl iteus muscle
Greater saphenous v.
Co mmon peronea l n.
Semitendi n osus t.
Popl itea l artery

Plan tar is muscle Tibial ner ve

La tera l h ead
gastrocnemius muscle
gastrocne mi us m uscle

Inferior patellar t.

Gerdy tubercle

Ili otibial tract

M eclial coll ateral I.

Fibula r coll atera l I.

Sartorius m. & t.
Biceps femoris ten do n Graci lis tendon

o mmon peron ea l n.
Greater sa ph enous vei n
Popliteus m uscle
Se mitendinosu s t .
Popl i teal ar tery Tibial nerve
Plantarb
Medial h ead
gastrocnemius muscle
La teral h ead
gastrocnemi us m uscle

(Top) Thi s cut is th ro ugh t he ti bial p lateau . T h e ten do ns of pes an serin u s (sa rto rius, gracil is, and semi ten d i nosus) are
li n i n g up, ex tending towards t heir in sert io n o n th e antero m ed ial t ibia. T h e popl iteus muscle is sti ll b road, with the
ti bial nerve an d popl iteal vessels interposed between it and the su per fi cial m uscles of the leg. ( Bottom ) T his cut is
t hro ugh the lower portio n of the ti bial p lateau, i mmediat ely pro xi m al to the fib u lar h ead . ote the com mo n
pero neal ner ve, loca ted pos teri o r to t he bi ce ps femo ri s tendo n.

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 KNEE OVERVI EW
AXIAL T1 MR, LEFT KN EE

I n ferior patel lar t.

Il iotibial tract
Medial collateral I.

Direct bran ch
semimembranosus t.
Pop li teus muscle

Sar to rius 111. & t. Fibular collatera l I.

Gracilis te ndon Biceps femori s t.

grea ter saphenous v. Commo n peron eal n.

Po pliteal artery
Se mitendin osus l.
Plan ta ris muscle
Tibia l ner ve

Latera l h ead
M ed ial head
gastrocnem ius m uscle
gast rocnemius muscle

I n ferior patellar t.

Gerdy tubercle

I liotibial tract

Medial col lateral I. Popl iteus muscle

Sartorius m . & t . Fibular co llateral I.

Gracilis tendon
Biceps fem o ri s tendon
Greater saph enous v.
Common peroneal n.
Semitendinosus t. Poplitea I arter y
Tibial nerve Planta ris muscle

Lateral h ead
Medial head
gastrocnemius muscle
gastrocnemius muscle

(Top) Th is cut is t h rough the tibial platea u. The tendo ns of pes anserinus (sartorius, gracilis, a nd semite ndin osus) a re
lining up, extending towa rd s th eir insertion on the an te ro med ial tibia . The popliteus m uscle is st ill broad, with the
t ibial n erve and popli tea l vessels interposed between it and the superficial muscl es of the leg. (Bottom ) This cut is
through the lower por tion o f the tibial p latea u, immediat ely proximal to th e fibular head . Note the common
peroneal n erve, located poste rior to the biceps femoris te ndon.

VI
31
 KNEE OVERVIEW
AXIAL T1 MR, RIGHT KNEE

In ferio r patell ar t.

Iliotibial tract

Gerd y tu bercle

Biceps femoris ten don

expansion
Bi cep s femoris tendon G racilis tendon
Sartorius ten don
Lateral collateral I. Greater saphenou s v.
Common peron ea l n. Semitend in osus t.

Popliteus muscle Tibial n erve

Plan tari s muscle Medial head

gastrocnemi us muscle

Lateral head
Po pliteal artery
gastrocn em ius muscle

Inferior patel lar t.

Ili otibial tract

Gerd y tubercle

Gracilis tendon
Biceps femoris tendon
ex pansion
Biceps femoris tendon Sartorius tendon

Lateral collateral I. G reater sap henous vei n

Co mmon peronea l n.
Sem i tencl i nos us t.
Popliteus muscle
Medial h ead
Plantaris muscle gast rocnemius muscle

Ti bial nerve

Lateral h ead
Poplitea l artery
gastrocn emius muscle

(Top) At the level of the apex of the fibula r head, t h e pes a nserin us is wrapp ing around t he tib ial metaph ysis to its
inserti o n a nteromedially. The biceps femoris tendon ex pands aro und th e la te ral collateral ligamen t as both cou rse
towards their insertion o n the fibula r h ead. (Bottom ) This cu t is a t the level of the fe mo ral head and shows th e
insertio n of t he biceps femoris and lateral colla teral ligame nt a nte ro laterally on the head. Th e short head o f bice ps
femori s h as a thin a nte rior expa n sion that extends to the a n tero lateral tibia.

VI
32
 KNEE OVERVIEW
AXIAL T1 MR, LEFT KNEE

In fer io r patell ar tendon

lliotibial tract
Popliteal artery Gerdy tu bercle

Tibia l n erve
Biceps femo ris tendon
Gracilis ten d o n
expansion
Sarto rius ten d o n Biceps femoris tend on

Greater saphe no u s v. La teral co ll ateral!.

Comm o n peroneal n.
Sem ite ndinosus t.
Po pliteus muscle
Med ial h ead
gast rocne mius muscle Plan taris muscle

La tera I head
gastrocnem ius muscle

/?d)
M
Inferio r patellar tendon

Po pl iteal artery Iliotibial tract

Gerdy tubercl e
Tibial ne rve

Gracili s tendo n Bi ceps femoris tendon

ex pansion
Sa rto rius t·endo n Biceps femoris tendon

G rea ter sa phenous v. Latera l co llateral I.

Co mmon pero n eal n .
Semitendinosus t.
Po pliteus muscle
Medial h ead
gastrocn emius muscle Plantaris m uscle

Lateral head
gast rocnemius mu scle

(Top) At th e level of t h e apex o f the fibu lar h ead, the pes anse rinu s is wrapping a ro u nd the tibia l meta physis to its
inse rtion a n tero medially. The biceps fe mor is tendon ex pands a ro und th e latera l collateral ligamen t as both course
towards th eir insertion on th e fibula r head. (Bottom) This cut is at the level of t he femora l h ead a nd shows the
insertio n of th e bi ce ps femoris and lateral collateral liga me nt anterolaterall y o n t h e h ead. The sh o rt h ead of biceps
femori s has a thin anterior expansion that ex ten ds to t h e an terolateral tibia.

VI
33
 KNEE OVERVIEW
CORONAL T1 MR, RIGHT KNEE

13iceps fe m oris muscle

Semimembranos us m.

Sem itendi nmus m . & t.

Lesser saphenous v.

Lateral gast rocnemius

muscl e
Medial gastrocnemi us
muscle

Semimemb ra nosus m.
13iceps femori s muscle

Greater saphenous v.

Common peronea l n.

Tibia l n erve

Semitendinosus t.

Medial gastroc nemiu s

Lateral gastrocnem ius
mu scle
muscle

(Top) Fi rst in series of posterior coronal Tl MR images of th e rig ht kn ee, displayed fro m poste rio r to anterior, hows
th e se mi ten di nos us m uscle as well as te ndon. We are also poste rio r e n ough to see lesser sap henous vein. Mo re
d istall y in the leg, t he sural nerve accompa nies this structu re. (Bottom) Slightly mo re a nterior, th e courses of
common peronea l an d tibial nerves ca n be seen. Sem itendinosus tendo n is d istin ctl y seen as th e poste rio r portion of
th e pes anserinu s.

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34
 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

Bi ceps femoris muscle

Semimembranosus m .

Semi tendinosus m. & t.

Lesser sa ph enous v.

Lateral gastrocn em ius

muscle
Medial gastrocnemius

Semimembranosus m .
Biceps femoris muscle
Grea ter saphen ous v.

Sa rtorius tendon

G racilis m. & t.
Common peroneal n.

T ibial nerve

Crura l fascia

Semitendinosus t.

M edial gastrocnen1ius Latera l gastrocnem i us

muscle m u scle

{Top) Fi rst in series of posteri or corona l T l MR images o f t he left knee, displayed from posterio r to an terior, shows
the semitend inosus m uscle as we ll as tendo n. We are also posterio r enough to sec lesser saphenous ve in. More
dista lly in t he leg, t he sural nerve accom panies t his structure. (Botto m) Slightly more a nterior, the courses of
com mon peronea l and tib ial nerves ca n be seen . Semitend in osus tendo n is disti nct ly seen as the posterio r portion of
the pes anserinu s.

VI
35
 KNEE OVERVIEW
CORONAL T1 MR, RIGHT KNEE

Biceps femoris muscle

Semimembranosu s m.

G racil is muscle

Commo n pero neal n.

Tibial n erve

Plantaris muscle

M eel ia I gastrocn emius

musc le

Lateral gast rocnemius Graci lis tendon

mmcle
Se mitendinosus t .

Biceps fem oris muscle

Common peroneal n.

Tibial n erve

Plantaris
--7:----+- M ed ial gastrocnemiu
muscle
La tera l gastrocnemius
muscle
Pop litea l vessels Semi m cmbranosus
tendo n

Greater sa ph enous v.

Gracilis tendo n

(Top) In this slightly more ante ri or cut, the course o f commo n peron ea l nerve is seen following posterior biceps
fem o ris tendon . The elements of pes anserinus are d istin ctly seen , with gracilis and sa rto rius muscles in thi s plane
posterior to their tendons (seen in sl ightly more anterio r cu ts). Sem itend inosus tendon, the posterio r of the three
elem ents of the pes, i s seen in t hi s section; its muscle fi bers however are in a more posteri or section (prior im ages).
(Bottom) I n the most anteri or cut of this series, we see the divi si on o f th e tibia l and co mm o n pero nea l nerves, as
well as th e separate co mponents of the pes anserinus.
VI
36
 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

m. Biceps fem oris muscle

muscle

Common peroneal n.

Tibial nerve
Grea ter saphenou s v.
Planta ris muscle

M edia l gastrocn em i us
muscle

Latera l gastrocn em ius

m uscle
Gracilis ten don

Sem iten din osus t.

Biceps fem o ris m uscle

Common peron ea l n.

Tibial n erve

Plantaris
t- tcdia l gastrocnem i us
m uscle
Lateral gastrocn em ius
m uscle
Scm i m c m bran osu s
Popl i tea l vessels
tendon & ex pansio n

Grea ter saphen ous v.

Gracili s tendon

(Top) In t his slightl y mo re anterior cut, t he course of comm o n pe ro nea l nerve is see n fo llowing posterio r biceps
fe mo ris te ndo n . The ele me n ts o f pes a nse rinus a re distinctl y see n, with gracilis and sa rto rius muscles in t his pla n e
posterio r to th eir tendon s (see n in slig ht ly mo re a nte rio r c uts) . Semi tendin osus te nd on, the posteri o r o f the three
ele me nts o f t h e pes, is seen in th is secti o n; its muscle fi bers however a re in a more poste rio r sectio n (prio r images).
(Bo ttom) In thi s mos t a nterior cut o f this se ri es, we see th e div isio n o f th e tibial a nd co m mo n pero neal n erves, as
we ll a th e separa te compo n en ts o f the pes a nserin us.
VI
37
 KNEE OVERVIEW
CORONAL T1 MR, RIGHT KN EE

Biceps femoris muscle Semimem bran osus m .

Co mm o n peroneal n.

Tibial nerve

M edia l gastrocnemius
Latera I gastrocnemius muscle
muscle

Biceps femoris muscle

Semimembran osus m .

Popliteal vei n

Lateral head
gastroc nemi us muscle

M edial gastrocnemius
muscle

Biceps femoris tendon

i n serti on

Latera l gast rocnemius

muscle
Peroneus longus m.

(Top) First in series o f coronal Tl MR images of th e right kn ee. Thi s series is in a slightly different obliquity than th e
prior, allowing slightly differen t combinations of structures to be seen in a single cu t . The series is shown from
posterior to anterior. The tibial nerve and common peroneal nerve are seen in this cut, as they lie m ore posteri or
than th e popliteal vessels. (Bottom) Slightly more anteri or image. The gastrocn emius muscles predominate in th e
posterio r porti on of the lower k nee; t he deeper muscles are sma ller at this poin t. Laterally, th e ori gin of th e peroneus
longus muscle is seen at the fibu la.
VI
38
 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

Biceps femo ris m uscle

111.

Commo n peronea l n.

Tibial nerve

:VIe(lial
Lateral gast roc nem ius
muscle
m uscle

Biceps femoris m uscle

Semimem b ran osus m .
Popli teal ve in

La te ra I head
gastrocnemius muscle

tvled ial gast rocn emiu s

m usc le

Sem itend inosus t.

Biceps fe moris tendo n

in sertion
Lateral
m uscle
Peron eu s longus 111 .

(Top) First i n series of coro nal Tl MR images o f th e left kn ee. This series is in a slightl y di fferent obliqui ty than the
prio r, allowing l igh tly different combinatio n s o f stru ctures to be seen in a single cut. Th e series is shown from
posterior to an te ri or. The t ibial ner ve and co mmo n p eron eal ner ve are seen in thi s cut, as th ey lie more posterior
th an t h e po pli tea l vesse ls. (Bottom) Sl ightly more anteri o r im age. The gastrocnem ius muscl es p redomi n ate in th e
posterio r porti o n o f th e lower kn ee; th e deeper muscles are smaller at t his po int . Laterall y, t h e o ri gi n o f the pero neus
longus m uscle is seen at th e fibu la.

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39
 KNEE OVERVIEW
CORONAL T1 MR, RIGHT KNE E

Biceps fem o ris muscle

Se mim embranosus m.
Popliteal vein

Pla n taris tendon

Medial h ead
Lateral head gastrocn emius muscle
gastrocnemius muscle

Popliteus tendon

Posterio r ho rn latera l
m eniscus
Bi ceps femoris tendon Posterior crucia te I.

La teral colla tera I I. Sem itend inosus t.

Gracis tendon
Popliteus muscle
Medial gastrocnemius
muscle

Pero n e u s lo n gu s m .

Bicep s femor is muscle Semim em branosus m.

Po pliteal vein
G racilis tendon

Plantaris tendon

Lateral head Medial head

gastrocnemius muscle gastrocnemiu s muscle

Lateral col lateral I.

Sartorius ten don
Popli teus tend o n
Roo t posterio r horn
Posterio r crura l fa scia
lateral m en iscus
Posterio r cru cia te I. Posterio r horn m edial
meniscu s
Semi m embra n os us
tendon in sertion

Poplite us m uscle

Peroneus longus m. Meclia l gastrocn emius

muscle

(Top) Sl ightly more anterio rl y, and deep to th e majority of gastrocnem ius muscle m ass, the popliteus tend on is seen
arising from its notch on the lateral femoral condyle, extending posteri orl y and inferiorly to th e poplitea l hiatus. The
individual structures in th e postero latera l corner a re generally better seen on a fluid sensitive sequence because of the
flu id in the popliteal hiatus; for greater detail, see secti o n d etail ing postero latera l structures. (Bottom) The la teral
collatera l ligament can now be seen aris.i ng from lateral fe mora l condyle, coursing toward s its insert ion, along with
biceps femo ris, o n the fibular styloid process.
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40
 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

Biceps fe moris m uscle

Semi m embra nosus m. Popliteal vein

Pl antaris tendon

Medial h ead
gastrocnemi u s muscle Lateral head
gastrocnemi us muscle

Po pli teus ten don

Posterior horn lateral

m e n iscu s

Post erio r c ruciate I. Biceps fe moris ten don

Lateral collateral I.
Se m itendinosus t.
Po p liteus muscle
Gracilis tendo n

Med ial gastrocn em ius Pero n eus longu s m.

muscle

Semim em b ranosus m. Biceps fem o ris muscle

Graci li s tendo n Pop liteal vei n

Pl an taris tendon
Medial head
gastrocnemius muscle Lateral h ead
gast rocnem ius muscle

Sartorius tendon La teral collate ral I.

Poste rio r cru ra l fascia Popliteus tendon

Poste rior ho rn m ed ial

Root posterior horn
meni scu s
lateral m eniscus
Se mimembran osu s
tendo n in sertio n
Posterior cruciate I.
Semitendi n osus t.
Popl iteu s muscle

Perone us longus m.
Media l gastrocn emiu s
muscle

(Top) Slightl y mo re anteriorl y, and deep to the ma jo rity of gastrocnemi us muscle mass, t he popliteus tendon is seen
arising from its n otch o n th e latera l femoral condy le, extending posterio rl y and inferio rly to the popliteal hiatus. The
individua l structures in th e posterola te ral co rn er are generall y better seen o n a flu id sensitive seque n ce because o f th e
fluid in the po pliteal hiatus; for grea ter detail, see section detailing posterolateral structures. (Botto m) Th e lateral
collate ral liga ment can now be seen a ri sing from latera l femoral cond yle, coursing towards its insertion, along with
bice ps femoris, on the fibular sty loid process.
VI
41
 KN EE OVERVIEW
CORONAL T1 MR, RIGHT KNEE

Biceps fe m oris m uscle

Popl itea l a. & v.

Sa rtori u s muscle

Plantaris muscle
Graci l is tendon

Medial h ead
Lateral collateral!.
gastrocnemius muscle
Popli teu s tendon
Posterior horn medial
Body la teral men iscus m en iscus
Sem im embranosus
tendon i nsertion
Root posterior horn
latera l m eniscus
Solealli ne
Posterior crucia te l.
Soleu s m. (tibial origi n)
Peron eu s lon gus m .
Sem itend i nosus t.

Greater saphenous v.
Pop l iteus mu scle
Medial gast rocnemius
m uscle

Pop liteal vei n

Bicep s fem o ris m.

Plan taris :------;;; - - Medial h ead

gast rocnem ius muscle

Lateral co llatera l I.

Popl iteus tendon Gracilis te ndon

Body lateral m eni scus

Posterior cruciate I.

Jun ction
body/posterior horn
m edial m eniscus
Peroneu s lo ngus m .
Semimembranosu s
Exten sor di gi torum ten don i nser tion
longus muscle
Genicu lar bran ches

Tibia l i s posterior m. Medial gastrocnemius

muscle

(Top) More an teriorl y, note th e la rge ex panse of insertion of popliteus muscle o n posteri o r tibia. The medial soleus
o ri gin arises at its dista l ed ge, alo ng the solea ll in e. The fibula r orig in o f soleus occurs m ore proximally. (Bottom)
Image o f the posterio r po rti o n o f the knee joint, which is more complex than the ante rio r. The gastrocnem ius and
posteri o r vessels are still seen, as well as the hamstring muscles. lnferolatera lly, the muscles can be co nfusing o n
coronal imag ing since in a single plane such as this one, muscles from lateral compartment (peroneus), anterio r
compartm ent (extensor d igitorum longus), and poste rio r co mpartment (tibialis posterio r) can be seen. This is because
th e cut extends o bli q uely across th e interosseous membrane between tibia and fib ula.
VI
42
 KNEE OVERVIEW
CORONAL T 1 MR, LEFT KNEE

m. Biceps femoris muscle

Popliteal a. & v.

Plantaris m.

Gracilis tendon

Medial head
Lateral coll atera l I.
gas! rocnem ius muscle
Popliteus tendon
Posterior ho rn m ed ial
meniscu Body latera l meniscus
Semimembranosus
Root posterior h orn
tendo n in se rti on
latera l
Solcal line
Posterior cruciate I.

Soleus mu scle

Scm i tend i nos us t. Peroneus lon gus m .

Greater saph en ous v. Pop I i teus muscle

M edial gastrocnemius
muscle

Semi membra n os us m. Popl iteal vein

Biceps fem oris m uscle

M edial head Plantar is

gastrocn cm ius muscle

Latera l collateral I.

Graci lis tendon

Popliteu s tendon

Posterior crucia l c I. Body lateral m en iscus

juncti on
body/ posterior horn
medial m eniscu s
Peroneus longus m.
Scm i m embra n os us
tendon insertio n Extensor digitorum
lon gu s musc le
Genicular bran ches

Medial gastrocnemius Ti bialis posterior m.

lllllSCIC

(Top) More anteriorly, note the large expanse of i nsertio n of popl iteus muscle on posterior tibia. T he m edia l soleus
o rigin arises at its di tal edge, al o ng the solea l line. Th e fibul ar origi n o f soleus occurs more proxi mally. (Bottom)
Im age of the pos terior po rtio n of the knee jo i n t, w hich is more com plex than the anterior. T h e gastrocnemius and
posterior ve sel are still seen, as well as the ham strin g mu scles. lnferolaterally, the muscles can be confusing on
co ronal imagi ng since in a single p lane such as th is one, muscles fro m lateral compartment (peroneus), an t·erior
co mpartment (extensor cligitorum longus), and posteri o r com partment (tibialis pos terior) can be seen. This is because
the cut extends o bliquely across the in terosseous membrane between tibia and fibu la.
VI
43
 KNEE OVERVIEW
CORONAL T1 MR, RIGHT KNEE

Popl iteal artery

Biceps femoris muscle

--:-.:,---1;-- Med ial h ead

Plan taris m. gas.trocnemius muscle

Lateral gastrocnem ius

tendon

Popl iteus tendon

Body lateral m eniscus Graci l is tendon

IIioti bia I tract Greater saphen ous v.

Anterior crucia te 1.,

posterolateral band

Semimembranosu t.

Medial in ferior
geniculate artery

Peroneus longus m.
Medial gastrocnemius
muscle

Biceps fem ori s m u scle

Plantaris muscle

=--=----,=-- Medial gastrocnemius

muscle

Ilio ti bial tract Posterior cruciate I.

Anterior cruciate I.

Body lateral m eniscus ru ral fascia

Body m edi al m eni scus

Pero neu s longus m.

Medial inferior
Exten sor digitorum geniculate artery
longus muscle

(Top) As t h e images become m ore anterior, one sees th e last of the elements of the pes a nserinu . Sartorius and
graci lis a re see n in this image, located more an terio rl y a t th e joint li ne than the third ele ment of the pes,
Q)
Q) semi tendi nosus. Th e m ost posterior fibers of th e anterior cruciate li ga m ent are see n as well . (Bottom ) More
c: anteri o rl y wit h in th e n otch, th e en ti re a nteri or c rucia te ligament is seen in its oblique route from th e lateral femo ral
condyle to the insertion adjacent to th e med ia l spines. Note th at th e deep and su perficial fibers o f med ial coll ateral
ligame nt are not separable on these Tl images. For m o re de fin ition o f these m edia l st ru ctu res, sec images and
comme nta ry in "Med ial Sup port Syste m" sectio n .
VI
44
 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

Sem imembranosus m Popl iteal artery

femo ris muscle

Medial h ead
gas trocn emiu s muscle Planta ris m.

Lateral gastrocnemius
Posterior cruci ate I.
tendon

Popliteu s tendon
Gracilis tendon
Bod y latera l meniscus

I lioti bia l tract

Greater saphenous v.

An terior cru ciate 1.,

Scm i m ernbranmus t.
posterolatera l band

Medial inferior
genicu late artery

Peroneus longus m.
Medial gastrocnemius
musc le

Biceps fem oris muscle

Plantaris mu5cle

M edial gastrocn emius

Posterior cru ci ate I.

Iliotibial tract
M ed ial collateral I.

An terior cruciate I.
C rural fascia
Body lateral meniscus

Body medial m eniscus

Peroneu s lon gus m.

M edia l inferior
geniculate art ery
Exten so r digitorum
longus muscle

(Top) As the images become more anteri o r, one sees t h e last of the elemen ts of the pes anser inus. Sartorius and
gracilis are see n in th is image, located mo re anteriorly at the joint line tha n the thi rd elemen t o f the pes,
semitendinosus. Th e most posteri o r fibe rs o f t he anteri or cruciate liga me nt a re see n as well. (Bottom) More
a nteriorl y wi thin th e n o tc h, th e entire a nte rio r cruciate liga ment is seen in its oblique route from the lateral femoral
con dyle to th e inse rtion ad jacent to t he medial spines. No te tha t the deep and supe rficial fi be rs of medial collateral
ligam ent a re no t epa rab le o n these Tl images. Fo r more defi ni tio n o f these m ed ial structures, see images a nd
commenta ry in "Media l Support Syste m" section .
VI
45
 KNEE OVERVIEW
CORONAL T1 MR, RIGHT KNEE

Iliotibial tract

Posterio r crucia te I.

Med ial collateral 1.,

longitudi nal
An terior cr uciate I.
Medial co llateral 1.,
ob liq ue
Body medial meniscus

Distal anterior band of

pes

Medial in ferior
geni cu late ar tery Med ia l collatera l
l igamen t

Vastus lateral is m .

Lateral superior
gen iculate ar tery

Il iotib ial tract Medial reti nacu l um

Medial co ll ate ral I.

(lo ngi t udinal fibers)

Anterior ho rn lateral
meni scus Bod y m ed ial meniscus

Medial i nferior
Exten sor digi to rum genicu late artery
longu s rn u scle
Pes anse rin u s t.

(Top) Note th e length of th e media l colla te ral liga me nt. The o ri gin is intim ate ly associated with t he o rigin of t he
m edial patellofemoral ligament, im med iat e ly d istal to th e addu ct or tube rcle. Th e inser ti on is abo u t 5 e m d ista l to t he
knee jo int a nd is usually not entirely in cl uded in st a nda rd knee MR exa ms. The med ial in fe rior ge ni cula te a rteria l
b ra n ches a re seen in c ross secti o n betwee n the superficial m edial colla teral ligam e n t a n d the tibial cortex. (Bottom)
An teri o r cu t is t h rough t he antero-m id porti o n of th e jo int. Beca use t hese are Tl images, t h ere is litt le co n trast
be tween hyaline cartil age a nd me n isci. For m o re detai led images a n d discu ssio n o f m enisci, see th e "Men isci" section.
VI
46
 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

Sartori us 111 uscle

Il iotibial tract

Media l collateral 1., Posterior cruciate I.

lo ngi tudinal
An terior crucia te I.
Medial collateral 1.,
oblique

Bod y m edial
Dis tal an terio r band o f
pes

Medial inferior
geniculate artery
Medial colla teral I.

Vastus lateral is m.

V<tstus m ed iali s m.

Lateral superior
geni culate artery

Il iotibial tract
Medial retinaculum

M edi al co llateral I.
(lo ngitudinal fibers)

An terior h o rn lateral
Body medial m en iscus m en iscu s

Medial in fe rior
geniculate arl'ery
Ex tensor cligitorum
lo ngus mu scle
Pes anserinus t.

(Top) Note th e length of the media l colla te ral ligament. The origin is intimately associated with the origin of the
medial patellofe m oral li gament, immediately dist al to th e adductor tubercle. Th e in sertion is about 5 em distal to th e
knee joint and is usuall y n o t e ntire ly in clud ed in standard knee MR exa m s. Th e medi al inferior geni cu late arteria l
branches are see n in c ross sec tion between th e superficial medial collateral liga me nt and t he tibial cortex. (Bottom)
Ante ri or cut is through the antero-mid portion of th e jo int. Beca use these are Tl lmages, there is lit tle contrast
between h ya li n e ca rtilage and m enisci; for m ore deta iled images and d iscu ssio n o f m enisci, see th e "Menisci" secti on .
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47
 KNEE OVERVIEW
CO RO NAL T1 MR, RIGHT KNEE

Vastus m edialis m.

Vastus la teralis m .

Iliotibia l tra ct
ju nc tion an terior
horn/ body m edial
m en iscus
lnfrapate ll a r fat pad
Transverse ligamen t
Gerdy tubercle
Pes anseri nus

Vastus m ed ialis m.

Vastus la te ralis m.

ln fra p atella r fat pad

An terior horn, m ed ial

Iliotibia l trac t men iscus

(Top) This far an terio rly, the transverse ligament is seen crossing the a n terio r jo int from th e anterior horn medial
meniscus towards th e a nte rior horn lat eral m en isc us. The iliotibia l t ract is see n inserting on Gerd y tubercle. (Bottom)
Far a nterio r cut through the joi nt space. Note tha t because of the slightly oblique a n gle a t w h ic h coron al knee MR
im ages a re obtai n ed, th e anterior horn medial m e niscus is visua li zed in fa r a nterior coronal cuts with out a n y po rti o n
of the late ral meniscus.

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48
 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

Vastus medialis m.

Vastus lateralis m.

ll iotibial tract

Junction anterior
horn/ body medi a l
meniscus lnfrapa tellar fat pact
Transverse ligament

Gerety tubercle
Pes anseri nus

Vastus medialis m.

Vastus lateralis m.

Infrapate llar fat pad

Anterior horn, medi a l

Il iotibial tract
meniscus

(Top) Th is far an terio rl y, th e t ransverse ligament is see n crossing the an te rio r joint from th e ant erior h orn medial
meniscus towards t he anterior horn late ral m eniscus. The iliotibial t ract is seen inse rting on Gerdy t ubercle. (Bottom)
Far a n teri o r cut throug h the join t space. Note t h at because of th e sli ghtl y oblique an gle at w h ic h co ro nal kn ee MR
images a re obtai n ed , th e an terior ho rn med ial m eniscus is visua lized in far anterio r coron al cuts with ou t a ny portion
of the lateral meniscus.

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49
 KNEE OVERVIEW
CORONAL T1 MR, RIGHT KNEE

Vastus med ial is m.

Lateral su perior
gen icula te n ., a., & v. Medial superior
geni culate n., a., & v.
Vast us lateral is m .

llioti bia I t ract

Medial fem oral con dy le

Lateral reti nacu l um

Medial reti naculum

Lateral i nferior
genicu late artery

Inferi o r pate llar t.

Vastus lateral is m.
Vastus m edi alis m.

Prefem oral fat pad

An terio r lateral
troch lear ri dge Anterior m edial
t roch lear ridge

Latera I reti naculum

l nfrapatellar (Hoffa) fat Medial reti naculum
pad
Med ial in ferio r
Inferior pa tell ar t . genicu late artery

(Top) Co rona l c ut t h ro ugh the a nte rio r fe mo ral shaft. Th e jo int is fairly featureless, co nsisting most ly of fat pad s and
a nastom osing vascu lar st ructures. (Bottom) The cut is t hrough th e anterior fe moral condyles. Fa t pads, both
p refem ora l a nd in frapatella r, predom inate in th e ante rio r jo int. The retinacula a re seen as well. Note th e multip le
ge n iculate and colla teral arteries supplying th e kn ee joint.

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 KN EE OVERVI EW
CORONAL T 1 MR, LEFT KNEE

m edialis m.

Latera I superior
Medi al superi or geniculate n ., a., & v.
geniculate n ., a., & v.
Vastu s laterali s m.

I lioti bial tract

Medi al l ern oral cond yle

Latera l retin acul um

La tera I i n ferior
l\l edial retinacul um
genicul ate artery

I n ferior pa tellar t.

lateralis m .
Vas tus m ed ial is 111.

Prcfem ora l fa t pad

Anterior lateral
troclllear ridge
A nterior m edi al
trochl ear ridge
Lateral ret i n aculum

Medi al retin aculum ln frapat c llar (Hoffa) fat

pad

Medial i nferi or
gen icul ate artery
In ferior pa tella r t.

(Top) Coronal cut through the an terior femoral shaft. The joi nt is fairl y featu reless, con sisting m os tl y of fat pa ds and
anasto mosing vascular structures. (Bottom ) T he cut is through the anteri or femo ral con dyles. Fat pads, bo th
prefemoral and infrapatellar, p redominate in th e anterior joint. The reti nacula are seen as we ll. ot e the m ul tip le
geniculate and co llateral arteries supply ing th e kn ee joi n t .

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 KNEE OVERVIEW
CORONAL T1 M R, RIGHT KNEE

Q uad riceps ten don Vastus m ed ial is m.

Lat era l retin acul um

Med ial retin aculum

I nferi or patellar t.

Q uadri ceps tendon

Vastus media lis m.

Vastus media lis

Latera l reti n aculum ten don/ aponeurosis

Med ial retinaculum

In ferior patello tibial I.

I nferior patel lar t.

(Top) Coron al cu t th rough posterior pa tella. Note th e large size o f the vastus media l is. Th is ca n h el p iden t ify the
m edia l side o f the knee on corona l or ax ial planes. (Bottom ) This an terior-m ost i m age of the series shows th e medial
and latera l suppo rti n g struct ures o f t he pa tell a, as well as the quadriceps an d inferi or patellar tendons. Bo t h the
quadriceps an d inferior pa tellar ten do ns are fai rl y broad, as arc th e m edi al and lateral reti n acula, effective ly
surrounding the patella.

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 KNEE OVERVIEW
CORONAL T1 MR, LEFT KNEE

Vastus medial is m . Quad riceps tendon

Lateral retinaculum

Medial reti naculum

In ferio r patellar t.

Quad rice ps tendon

Vastus medialis m .

Vastus medialis
tendon/a poneurosis La teral reti nacu lum

Medial reti naculum

In ferior pat ello tibiall. Inferio r patell ar t.

(Top) Co ro n a l cut th ro ug h post eri o r pa te ll a. o te the large si ze o f the vastus m ed ial is. This ca n h e lp identi fy th e
med ia l side of th e knee on co rona l o r axial plan es. (Bottom) T h is anteri or-most image of th e se ri es sho ws the medi a l
and la te ra l su ppo rt ing stru ctures of th e patella, as well as th e quadri ceps and inferior patella r te ndon s. Bo th th e
q uadri ceps and infe ri o r patellar te nd o ns are fairl y broad, a s are th e med ia l a n d la te ra l re tina cu la, e ffecti vely
sur roun d ing th e pate lla.

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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

Vastus m edia lis m .

M edial superior
genicul ate artery

Sa rto rius mu scle

G racilis tendon

Medial co llateral
liga m e nt

M edial gastrocn e mius

musc le

Sem im em b ranosus Ill.

Vastus med ia lis m .

Sartori us tendon

Grac ilis Ill . & t.

Medial femoral condyl e

Media l co llateral!.
Sem itend inosus t.

Medial gastrocne mius

muscle

(Top) First of t wen ty sagittal Tl MR images of th e left knee. This is a far medial cu t. Note th e sartori us muscle and
tendon, with gracilis m uscle and tendon extending immediate ly poste rior to it. (Bottom) This cu t is barely through
th e medial femoral condyle, so only a thin re mnant of sartorius is seen. Graci lis a nd semitendinosus are seen
extending posteriorly, fo rming with sa rtorius the th ree tendons of the pes anserinus.

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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

Vastus medialis m.
Semiten dinosu s t.

Volume averaging,
adductor magnus t. at
add uctor tubercle Semi membra nos us
muscle & tendon
Posterior edge medial
condyle; medial
gastrocnemius t.

Sartorius tendon
G racilis tendon

Medial gastrocnemius
muscle

Semimembranosu s m.
Vastus medialis m.

Adductor m agnu s m. &

t. at in sert ion Med ia l h ead
gast rocnemius te nd o n
Edge of add ucto r
tubercle

Medial ret inacu lu m

Semimembranosu s t.

An terio r horn, m edial Posterior capsule/

m en iscus p osterior oblique I.

Posterior h o rn m ed ial Capsular expa nsio n

meniscu s semimem branosus t.

Sa rtor iu s tendon

Media l gastrocnem ius

muscle

(Top) This is a m ed ia l cut th ro ug h the fe m o ral co nd yle. Not e th e la rge se mime mbra n osus tendon , with its extensive
in se rt ion along t he posteromed ial ti bia. (Bottom) Th is cut goes th roug h th e medial compartment, near t he central
edge of body of m ed ial men iscus. Th is is still slightly a bow t ie con figuratio n of the men iscus.

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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

Semimembranosus m.
Vastus media lis m .
Adductor magnus m.

Med ial gastrocne mius

tendon & 111 uscle
Posterior cruciate
ligament o rig in

Media l retin aculum

Anterior h o rn medial Po ste rior capsule/

meniscu s o blique popliteal I.
Posterior h o rn medial
meniscu s

Popl iteus muscle

Popliteal vesse ls
Vastus m edia lis m.

Semime m bra nosus m.

Poste rior join t capsu le

& oblique popliteal I.

Tibial nerve

Posterior cruciate J.

Med ial gast rocnemius

muscle
Ante rior horn medial
meniscus
Posterio r h o rn m edial
meniscus

Po pliteus muscle

(Top) This cut is through the medial com partment, approaching the intercondylar notch. The posterio r aspect of the
media l fe mo ral condyle is o nl y partial ly seen . The obl ique popliteal ligament contributes to the posterio r ca psule at
this point. (Bottom) This cut is at the medial-most aspect of the intercondylar notch, w here the origin of the
posterio r cruciate ligament is first seen. Note that by this point the o blique popliteal ligament contributes more ful ly
to the posterior joint capsul e.

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56
 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

Popliteal artery
Vast us medialis m.
Semimembranosus m.

Posterior capsule &

obl ique popl iteal I.

Ligament of Wrisherg

Posterior cruciate I. Medial inferior

gen iculate artery

Anterior h orn medial

Media l gastrocnemius
Root posterior horn muscle
medial meni scus

Popliteus mu scle

Semimembranosus m.
Semitendinosus t.
Poplitea l artery
Vast us mediali s
Medial superior
geniculate artery
Lesser saphenous vei n
& sural nerve

Penetrating vessel of
Posterior capsule,
popliteal artery
obliq ue pop liteal I.

Ligamen t of Wrisberg

Root posterior horn

An terior ilorn medial media l meniscus
meniscus
Medial gastrocnemius
muscle
Posterior cruciate I.
Soleus muscle

Popl iteus muscle

(Top) This cut is through th e m edial aspect o f th e intercond ylar notch. The posteri or cruciate ligamen t is fully seen .
(Botto m) Mid intercon dylar n otch . Note t hat at the posteri or intercondylar notch the posteri or ca psule is pen etrated
by vesse ls from the popli teal artery. The capsu le is th erefore i n complete posteriorly.

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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

iJ
Biceps femoris muscle

.? Vastus m edi alis m. Semimembranosus m .

Popliteal vei n

ar ter y

Medial retinaculum

Root, anterior horn

Ligament of Wrisberg
m edial m en iscus
Transverse ligament
Medial gastrocnemius
l n frapatellar (Hoffa) fat m u scle
p ad

Poste rior cruciate I.

Soleus muscle

Popli teu s muscle

Bi cep s fe mori s muscle

Vastus medialis m.
Tibial nerve

Popli teal ve in

Common peroneal n.

Anteri or cruciate I.

Liga m en t o f Wrisberg
M ed ial reti nacul um

Root posterior horn

latera l m en iscus
Tran sverse l igament

Inferior patellotibial I. Medial gastrocnemius

muscle
::;;;;;;.--;--- Popliteal vei n

Soleus muscle

Po pl iteus muscle

(Top) The cut is at the mid intercondyla r n otch, transitio ning from the posterio r to a nte rior c ru cia te ligament. The
posterior ca psule is still incomplete, due to pe netrating vesse ls. (Bottom) Slightly la terally within t h e inte rco ndyla r
notch, th e a nterior cruciate ligament is m ost fu ll y seen. In the previous four images, n ote th e pathway o f the
ligament of Wrisberg (posteri or m eniscofemoral ligament), arising fro m the medial aspect of th e interco ndyla r notch,
trave rsing posterior and superi or to t he poste rio r cruciate liga ment, an d inserting o n th e superi or aspect o f th e root
of posteri or h orn, lateral me ni scu s.
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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

Biceps femoris muscle

Vastu s m edialis m.

Tibial & com m on

peroneal n erve

Medi al patella Posterior capsul e &

obl ique popl iteal I.

Plan tari s muscle

Medi al retinaculum
Lateral h ead
gastrocnemius m .
Tran sve rse li ga m ent
Po pli teus m uscle
A nterior cru ciate I.

Root, posterior horn

lateral m eni scus
Soleus rn uscle

Rectu s femo ris muscle Biceps fem ori s m u scle

Vastus medialis m . Common peron eal n.

Tibial ner ve

M edial patella Plantaris muscle

Posterio r h orn lateral

I nferi or patellar t. / m en iscus
m edial reti n aculum

Tran sver e ligam ent Lateral gast rocn emius

m uscle
Root an terio r h orn
lateral m en iscu s

So leu s musc le

(Top) Late rall y within th e interco ndy la r notc h , where there is partial voluming o f t he anterior cruciate/lateral
fem oral cond yle a t t h e AC L in sertion. Note th e transverse li gam ent, seen in cross-sect ion, ext ending across in front
of ante ri o r cruciate liga m en t t owards root o f ante rio r horn, late ra l me niscus. Th e a nt erior horn is n o t yet seen .
(Bottom ) Th is cut sh ows t h e begi nn ing of th e lateral com partment, imm ediate ly adj acent to the intercondylar
notch. No te the muscu lote ndino us junctio n o f po pliteus.

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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

Rectus femoris muscle

Biceps femoris muscle

ommon peroneal n.
Q uadrice ps tenclon

Plantaris muscle

Inferi or pa tellar t.
Arcuate popl iteal
ligament & capsule
Tra n sverse ligament
Posterior horn lateral

l nfrapatellar (Hoffa) fat

pad Popliteus m. & t.
Anterio r horn lateral
m en iscus

Soleus muscle

Rectus femoris muscle

Biceps femoris muscle

fem o ris t .

Vastus m ed ia l is &
lateralis tendon ommon peroneal n.

Vastus intermedius t. Plan taris muscle

Arcu ate popliteal

l igament & capsule

l nfrapa tell ar (Hoffa) fat

Latera l head
pad
gastrocn em ius m .
Inferior pa tellar t.

Popliteus tendon
Transverse liga ment
Posterior horn lateral
An terior ho rn , lateral
m eniscus

oleus muscle

(Top) Late ra l co mpa rtmen t. ote the pa t h of th e commo n pero neal ne rve, ante ro med ia l to t h e bulk of the biceps
fe m oris muscle. The plan taris musc le is seen , a ri si n g on the la te ra l femo ra l condyle just m ed ial to the latera l head of
gast rocnem ius. (Botto m) Because of t he o bliq ui ty w ith w hich sagittals a re obtained, the ex te n so r com plex is seen in
th e more late ra l sagi tta l images. The t ril a minate natu re o f the qu adriceps tendon is dem o nst ra ted he re. T he
transverse ligame n t has not yet co n tac ted th e a n te rior ho rn, lateral m e n iscus. Note t h e popli teu tend o n. Altho ugh it
is w it h in the pop litea l hiatus, it is d ifficul t to d ist ing uish fro m fluid in t he h iatus, as well as t he lateral men iscus. Thi s
regio n is be tte r imaged with fluid sensitive seq ue nces. See "Me ni sci" section for mo re det·ail.
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 KNEE OVERVI EW
SAGITTAL T1 MR, KNEE

Biceps femoris muscle

Rect u femoris tendon

Vast us medialis &

latcrali s tendon
Com mon peroneal n.
Vas tus intermedius t.
Pla ntaris muscle

Arcua te popl iteal

l igamen t & capsule
lnfrapat cllar (Hoffa) fa t
pad La tera l h ead
gastrocn emius muscle
Inferior patellar t.

Transverse ligament Popliteus tendon

Anterior horn, lateral Posterior horn lateral

m eniscus men iscus

Soleus muscle

Extensor digi torum

longus muscle

Biceps femoris muscle

femoris tendon

Vastus medialis &

lateralis tendon

Vast us intermedi us t. Pla ntaris muscle

Arcuate popliteal
ligament & capsule
lnfrapatcll ar (Hoffa) fat
Lateral h ead
pad
gastrocnemius
Inferior patellar t .

Transverse ligament Popliteus tendon

Ant erior horn, lateral Posterior horn lateral

meniscus meniscus
So leus muscle

Exten sor digi torum

longus muscle

(Top) In the lateral portion of the knee jo in t, t he popli teus te ndon is seen within the popliteal hiatus. It is
su rro unded by fluid, not easily distinguished on a Tl seq uen ce. Sim ila rly, the fascicles (or popliteomen iscal
ligamen ts) co nnecting the posterio r horn lateral meniscus with popliteus tend on are n ot easily seen as separate
structures. See "Men isci" section for fluid sen sitive seq ue n ces and grea te r deta il. (Bo tto m ) The transverse liga ment
a p proaches its insertion site o n a n terio r ho rn la te ral m e ni scus. The m uscles a risi ng from the anterior fibula and
an te ro la tera l tibia a re see n bu t not casi Iy distingu is h eel from one a n ot her.
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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

Bicep s femoris muscle

Rectus fem oris tendon

Vastus medialis &

lateralis tend on

Vastu s intermedius t.
Plantaris muscle

Arcuate pop li teal

ligament & capsu le
ln frapa tellar (Hoffa) fat
Latera I head
pad gastrocnemi us muscle
Inferior patel lar t.
Transverse ligament
Pop liteus tendon
A n terio r horn, latera l Pos terior horn late ral
men iscus m en iscus
r.:P.!='"':::;;-- Soleus muscle

Vastu s lateral is m .

Vastus interm edius m. Biceps femoris muscle

Qu adri ceps tendon Late ral superior

geniculate artery

Pl antari s m u scle

Lateral h ead
gast rocn emi us tendon

Origi n lateral collateral

l iga m en t
Origi n popliteus t.

Biceps fem oris tendon

Inferior patell ar t .

Soleus muscle

Ti bia li s anterior m.

(Top) Th e tra nsverse ligament inserts on a nte ri o r ho rn lateral m eniscus fairl y far laterally within th is compartment.
Th e poplite us tendon just enters the popliteal hi atus at this poste ro late ral co rn er. (Bottom) At th e late ral aspect of
t h e la tera l fe mora l con dyle, o n e sees t h e origin of th e latera l h ead of gast rocnemius from th e lateral femoral
e pico ndy le, as wel l as late ral collateral ligam ent and po pliteal te nd on.

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 KNEE OVERVIEW
SAGITTAL T1 MR, KNEE

latcral is m . Biceps femoris muscle

Lateral superior
Quadriceps tendon geniculate artery

Latera l head
gastrocnem i us muscl e

Po p litea l tendon

Lateral collateral I.

Bow tie lateral

meniscus

Bicep' femorb tendon

lateralis m.

Quad riccp; tendon

I lioti bial tract

Lateral reti n aculum

Lateral collatera l I.

Biceps femoris t.

Gercly tubercle
(i l io tibia l tract
imertion)
I l ead of fibula
libiali' anterior m.
Peroneus lon gus m.

(Top) Lateral-most port io n of t he joi n t. Th e bow ti e co nfiguration of th e men iscus is seen . T h e latera l col lateral
l igament is seen ex tending posteroin fe ri or towards its inserti on o n th e fibular head, ad jacent to the insert ion of
biceps femo ris ten don . (Botto m ) Far lateral in the kn ee. Th e lateral col lateral ligament and biceps femoris tendon
insert ad jacen t to one ano th er o n t h e h ead o f the fi bu la. O nly porti ons of oth er lateral stabi lizing st ructu res (iliot ibial
tract, latera l retinaculum) are seen o n thi s image.

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 EXTENSOR MECHANISM AND RETINACULA
!Terminology Lateral Retinacu lum
• La tera l stabi lize r o f pa te llofemo ral joint
Abbreviations • Ex tends fro m pa tella to vastus la te ral is
• Vastu s med ialis o b liquus (VMO) • 3 laye rs
• Media l pate llofe moral liga m ent (MPFL) o I (su perficial) : Il iotibia l tract a nd its a nte ri o r
ex pa n sio n , supple mented pos te ri o rly by su pe rficial
po rti o n o f biceps fe moris and its a nterior ex pansio n
!Imaging Anatomy o II (mid): Ret inacul um o f quad riceps (vastu s lateral is)
Overview o III (deep) : Latera l pa rt o f jo in t caps·ul e
• Exte nso r mech a ni sm: Qu a driceps m usc le and t e n do n, Anterior Fat Pads
pa te lla, pa te ll a r tendo n , a nd pate lla r ret in acula • Eac h in te rposed betwee n jo int ca psule exte rn a ll y and
sy novium-lined jo int cavity (in tracapsular but
Quadriceps
extrasy novia l)
• Muscles: Rectus femo ris, vastus la teralis, vastus
• Sup ra pa te llar bursa ou tlined by ante rior su pra pa tel lar
m edia Iis, vast us inte rm ediu s
(q ua driceps) and posterio r su pra pa te llar (pre-fem ora l)
• Qua drice ps te n d on
fat pads
o Trilaminar co nfigura tio n (gene ra lly) : Fascia o f
• lnfrapa tellar (Ho ffa fat pad)
co mpo nent muscles wit h interposed fat
o Bo rd ered by
• Superficial (anterio r on sagitta l): Rectus femoris
• Inferior pole pate ll a (superi o r)
• Midd le: Vast us late ra lis a n d vastus m ed ialis
• j o in t ca psule a nd pate llar ten do n (a nterior)
• Deep (poste rior on sagittal): Vast us inte rmed ius
• Proxim al tibia & d eep in fra pa te llar bu r a (in fe rio r)
o May appea r as 2 o r 4 layers: Media l and late ra l
• Synovia l-lined jo int ca psul e (poste rio r)
co mpo ne nts o f middl e layer me rge in diffe rent
o Ca n be teth e red po steri o rly at a pex by in fra pate llar
co mbinati o ns or rem a in discrete
plica
o Te n don inse rts on non-a rticula r (a nte rio r) po rtio n o f
o Attach ed to ante rior h o rn s of me nisci in fe ri o rly and
pa te lla
to tib ia l p e ri osteum
Patellar Tendon o Tra n sverse li game nt co u rses withi n fat pad
• Ma inl y co m posed of rec tus femoris fibe rs th a t co urse o Interface between poste rior aspect o f fa t pad and
over pa te ll a jo int space co nsists o f seve ra l ynovia l reces es
• Ex te nds fro m in fe rior pole o f pate lla to tibi al o An asto m ot ic vessels course thro ug h fa t pad , seen in
tuberosity cro ss-sect io n o n sagittal im ages
• Le ngth a p proximates 5 em Pli ca
o Length abo u t eq ua l he ight of pate lla
• Synovia l folds; pe rsiste nt embryo nic remna nts
o Va ria tio n by > 2Q<J1, o f cranioca uda l le ngth o f pa te lla
• Superior (su prapa tellar, supe romed ia l): Co mmo n
resul ts in pate lla a lta o r baja
o Medial suprapate lla r pouch , 2 e m su pe rior to patella
• 3 em wid e superiorl y to 2 e m inferio rl y
o Fold o r co m plete sep tum
• 5-6 mm th ick
o Runs o bliq ue ly dow nwa rd from ynovium at
• So lid low sign a l t h ro ugho ut
a nteri or aspect o f fe m o ra l m etaphysis to poste ri or
M edial Retinaculum Complex as pect of quad rice ps te ndo n
• Med ia l stabi lize r o f patello fe m o ral jo int o Inserts above patel la; best see n o n sagitta l
• Ex te n ds fro m pa tella to vastus medi a lis • Me dial (plica sy nov ia lis, pa tella r shelf, med ial
• Med ia l retin acular co mplex d ivided into supe ri o r, mid, intra-articula r ba n d)
and infe rior portions, whi ch ble nd into o n e ano th er o Arises m ed ial wa ll of sy novia l pou ch o r unde r
o Su pe rio r: VMO a nd MPFL m edia l ret in acul um & exte nd s oblique ly d ow n ward
• VMO: Musc u la r slip of vast u s media lis; a ri ses to insert o n syn ovium cove ring in frapa tella r fat pad
e it her fro m add ucto r magnu s ten do n o r from o Inserts on sy nov ium cove ri ng infra patellar fa t pad,
add uctor tu bercle at media l edge o f pate ll a; see n o n sagi tta l o r ax ia l
• VMO inserts at superio r m ed ia l border o f pate ll a o lf la rge, can impinge o n m ed ial facet of troch lea o r
• VMO apon eu rosis is tigh tly ad h eren t to unde r medial face t o f pa te lla
u nde rlyin g MPFL • Infe rio r (infrapa tellar plica/ fo ld /septum, liga me ntum
• M PFL: Arises from ad d uc to r tu bercle ad jacent to m ucosa): Co mmo n
MC L o rigin an d inserts at med ia l border of pate lla o Extend s fro m Ho ffa fa t pad in in terco nd yla r notch,
o M id po rtion: Th in fibers of supe rficia l MCL fascia paralleling and ante ri o r to A L; best see n o n sagitta l
o Infe rio r o May be spli t o r fe n estra ted ; d im ensions va ry
• Pa te llo t ib ia l li gament a ri ses fro m tibia at level o f • La t eral : Rare
in sert io n of gracil is and se mitend inosus o O riginates from la te ra l wa ll superio r to po pli tea l
• Pa te llo tib ia l liga ment inserts on inferio r aspect hiatus a nd exte nds to infrapatella r fa t pad
pa te lla an d patellar te ndon o Oblique coron a l o ri e nta tion; thin, 1-2 e m latera l to
• Media l pa te llom e n iscal ligam en t lies deep to pa te lla
pa te llo tib ia l li ga me n t • Size an d morpho logic features o f a g ive n plica d o no t
• Fo r greate r de ta il , see "Media l Suppo rt System" sectio n relia bly indica te w h eth e r it is clin ica lly signi fica n t

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 EXTENSOR MECHANISM AND RETINACULA
GRAPHIC & P O MR, EXTEN SOR TENDON

An teri or suprapatell ar
Rectus femo ris tendon --;,-----
(quad riceps) fat pad
latcralb & medialis tendon
Va tus interm ed ius tendon bursa
Posterior suprapatell ar
(prcfemora l) fat pad

lnfmpatellar (Ho ffa) fat pad

Inferior patella r tendon

Rectus fem oris tendon Anterior

(q uadri ceps) fat pad
m edialis t.
Suprapatellar
Va\tus intermedius tendon Posterior suprapatellar
(prefemoral) fa t pad

l nfrapa tellar (Hoffa) fat pad

Inferior patellar tendon

medialis muscle Rectus femorh tendon

Vastus lateralis tendon

Medial patcll ofcm o ral li ga m ent Lateral retinaculum

Pate ll o tibial li gament

Inferior patel lar tendon

(Top) G ra phic shows trilaminar configuration of t h e quadri ceps tendon. The superficia l port ion is rectu s femoris,
middle portion is the aponeurosis of vastus med ia l is and latera l is, and deep portion is vas tu s in termed i us tendon.
(Middle) Sagittal PD MR shows the t rilaminate character o f the ex ten sor tendon. T h e suprapatell ar bursa is not
di stended . Th e surrounding fat pads are wel l dem on st rated. The i nfrapatellar fat pad, w i th anastomosi ng joi n t vesse ls
coursing through it, is also seen. (Bottom) Anterio r coro na l T l MR shows com pon ent s o f patellar at tach ments. The
quad ri ceps and inferior patellar tendons attach superi orly and i nferi orl y, respect ive ly. Th e latera l reti naculu m
attache along th e en tire lateral edge of patella. Vastus med ial is obliquus, m ed ial patell ofemora l, and i n ferior
patell o tibia l ligam ents con t ribute to m edial ret inacul um from superior to inferi or. VI
65
VI
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 EXTENSOR MECHANISM AND RETI NACULA
SAGITTAL PD MR, PATELLAR STABILIZERS

medialis
ob liquu s

M ed ial retinaculum
in serti on on pa tell a

Medial pa tell o m cn isca l

liga m ent
Pa tcllotibial liga m en t

Il iotibial tract

lat eralis muscle

Port ions of latera l

reti naculum

Gcrcly tubercle

Bi ceps femoris

(Top) Sagittal PO MR im age t hrough med ial portion o f i ntercondy lar notch shows va rious port ions of medial
retinacu l um, including VM O, m edial pa tellomeniscal ligament, and patellotibial liga ment. These, alo ng wi th medial
patellofemoral ligament, blen d together to form th e m edial ret inacu l um. (Bottom) Sagittal PO MR image, far lateral,
shows po rtions o f lateral retinaculum . Con tri bution s co me from vastus lateral is, anter ior expansion iliotibial tract,
anteri or expansio n superfi cial biceps fem o ri s, and joint capsule.

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 EXTENSOR MECHANISM AND RETINACULA
AXIAL PD MR, PATELLAR STABILIZERS

Superior patella & m ed ial

reti n aculu m /V M O apo neurosis

Vastu s m edial is obl iquus m . Vastus la teral is

Ilio t ibial tract

C rura l fascia (layer 1)

Latera l crural ex tensio n of
reti naculum
Bicep s fem oris

Med ia l pa tello fem oral ligam ent

(superi or m edi al reti n aculum)

Lateral retinaculum
Adductor tuberc le

Superficial (lon gi tudi nal) fibers Ilio ti bial tract

m ed ia l co llateral !.

Biceps fem o ris

Patel lotibial li gament (in ferior

m edial retinaculum )
M erged fibe rs o f super ficial M CL Lateral reti naculum
fascia & crura (layers I & 2)
Il io tibial tract
Superficial m ed ia l collateral
l igamen t (lay er 2)

C rural fascia (layer 1)

M erged fibers o f superficial M C L &
deep M C L (layers 2 & 3) Bice ps fem oris te ndon

Sarto rius

(Top) First of t h ree a xial PO MR im ages, lo cat ed just a bo ve th e adductor t ube rcle, shows vastu s media lis o bliq uu s
co ntrib ut in g to the s uperior po rtion of m ed ia l reti na cu lum . The late ral ret inacu lum receives fibe rs fro m an te rio r
ex pansio ns o f bot h il iotibia l tract and bice ps fem o ris. (Middle) At the level o f ad ducto r t ubercle, t h e su perficia l fibers
o f MCL a nd the med ia l patello fem o ra l liga m ent are seen a t their orig in . The MPr L ext e nds to th e pa te ll a as t he
s u peri o r portion of m ed ial re tin aculum at this level. (Botto m ) At t h e leve l of jo in t line, t h e m edia l re ti na cu lum
receives a co n t ri butio n fr o m t h e m erged fibers o f supe rficia l MC L fa scia a nd its o verl ying cru ra . Th e pa te ll o t ibial
ligame n t is also a m aj o r co n tri bu to r a t t h is le ve l.
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 EXTENSOR MECHANISM AND RETINACULA
SAGITTAL PO & AXIAL T2 MR, PLICA

Inferio r (infrapat ell ar)

plica

Anterior cruciate
ligament

Superior (suprapatellar)
plica
Vastus m edial is

(Top) Sagi t tal PO MR image throug h the inte rcond ylar notch sh ows a t ypical infe rior (infrapate ll a r) plica. This
nor mal va rian t ex tends from the in ferior pole o f the patell a, throug h Hoffa fat pad, paralle ls th e ACL, and a ttaches to
the fe m ora l co nd yle at t h e interco ndyla r notc h . It may simulate a me ni scocruciate liga ment, but the a n terior sites of
o rig in a rc disti nct ly di ffe re nt. (Bottom) Ax ia l T2 MR image at the level of the distal fem ur, shows a syn ovia l fo ld
exten ding across th e m ed ia l sid e o f the suprapate ll ar po uc h . This is a co mmon fo rm of p li ca, seen pa rti cularly well
because o f the large e ffu sio n . It is te rmed th e su perio r, o r sup ra patella r, pli ca.
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 EXTENSOR MECHANISM AND RETINACULA
SAGITTAL PD & PD FS MR THROUGH INTERCONDYLAR NOTCH, PLICA

Superior (suprapatella r)
pl ica

Pa te lla

Ante rio r crucia te

ligam e nt

Su pe rior (suprapate llar)

plica

Poste ri or cruc ia te
ligame nt

(Top) Sagittal PD MR through t h e intercondylar n otch o f the sam e patien t seen in th e previous image, sl1owing a
superior (suprapatellar) plica. The plica extend s fro m just su perior to the patella, medially through the suprapatellar
Q)
Q)
pouch. (Bottom) Sagittal PD FS MR i m age is slightl y medial to th e previous image (note th e posterior cruciate
c:: l igament), sh ows the plica extending furth er supero mediall y. Th is is a common var iant w hich does not h ave clinica l
consequences.

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 EXTENSOR MECHANISM AND RETINACULA
AXIAL T2 MR, THROUGH THE PATELLA

Medial pl ica

Medial facet signa l

abno rmali ty

Medi al pl ica

(Top) First of two ax ial T2 MR images thro ugh the mid pate lla shows a medial plica exte ndin g ove r the medial facet
of the trochlea and under the m ed ial face t of the patella. (Bottom) Slightly distal image, sh ows the med ial plica, with
signal abnormality, a pproaching th e m edial facet of th e patella, wh ich also shows signal abnorm ality. The m edial
plica is more likely to result in sym ptomatic damage (eithe r at the media l patellar facet or m edial t roc hlea) than the
other plicae.

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 MENISCI
• Posterior horn attaches just posterior to ACL, a nd
!Terminology anterior to PCL as PCL ex tends behind tibial
Abbreviations plateau to its insertio n o n posteri or tibia
• An terio r/posterior c ruciate ligament (ACL/PCL) • Root of poste rio r ho rn LM al o is a nterio r to root
• La te ral/medial men iscus (LM/MM) of posterior h orn MM
• Medial collatera l ligame nt (MCL) o MM roots: MM is more semil unar in sha pe th an
semicircular LM, so its roots are located a t center of
tibial plateau, but more anteriorly and posterio rl y
!Imagi ng Anatomy fo r a nteri or h o rn and poste ri or horn, respecti vely
th an those of LM
Overview • Root ante ri o r ho rn MM a nte ri o r to o ri gin of ACL
• Meni sci eva luated by mo rphology, signal and • Root posterior h orn MM imm edia tely anterio r to
a ttac hm e nts PCL but posterio r to root of poste rior ho rn LM
• All portions tape r from height o f 3-5 mm pe rip he ra ll y • Ca psular attachments
to sha rp, thin, cen t ral (free) edge o MM entirely a ttac h ed to joi nt capsu le with
• Norma ll y specific a nd predictable size/sh a pe exception of small inte rruption at MCL
• Morphology va riance indicates tea r o r varia nt whic h is • MM serves as o rigin of men iscofemoral ligame nt
a t increased risk for tear portio n of deep fibe rs of MCL; this ligament eithe r
inserts on the ad jacen t femu r o r su perficial MCL
Morphology • MM also serves as origin o f men iscotibial liga me nt
• La tera l meniscus (coronary liga me nt) porti o n of deep fibers o f th e
o Overall con figurati o n: Semicircular MCL, which inserts on the adjacent tib ia
o Shape: Un ifo rm, minimally and grad ually enla rg ing • Fibrofatty tissue.as we ll as MCL bursa sepa rate MM
fro m a n terio r to posteri o r a nd deep fibe rs o f MC L fro m supe rficia l MCL
o Normal recess: Periphera l, located in fe ri o rl y at o LM entirely attach ed to joi nt capsu le o nl y in
a nte rior horn anterior and far posterior po rtions, wit h
• Medial me niscus attachment being inte rrupted a t bod y and much
o Overall co nfig ura tio n: Semilunar (C-s haped) of posterior horn by popliteal hiatus
o Sha pe non-uni fo rm: Anterior h o rn simila r in size & • After origina tion fro m latera l fe moral co nd yle,
sha pe to LM but midbody is sma ll, approxim at ing popliteus tendon pe ne tra tes capsu le a nd takes
a n equil a tera l t ria ngle; MM poste rior ho rn is largest int ra -articula r course
portion o f MM, nearly 2x as long as anterior h o rn • lntra-a rti cul a rl y, popliteus tendon ex te nds di stall y
o Normal recess: Pe riph eral, loca ted su perio rly at in posteromedial directio n
posterio r horn • Poplite us tendon sepa ra tes LM from its ca psular
• Menisca l "flo unce": Buckling o f a portio n of th e insertion alo ng body & ma jo rity o f poste rior horn
me niscus, pe rha ps related to femoro tibi al su b luxa tion • Superior and inferior fascicles se rve as attachments
between LM and popliteal te ndon a nd, in turn,
Signal capsu le
• Gen erall y unifo rm ly low signal th rough o ut • Infe rior popliteomeniscal fascicle extends fro m
• Exceptions lateral edge of bod y of meniscus to infe rio r
o C hildre n a n d adolescents may h ave inc reased portion of popli teus para teno n, forming fl oor o f
intrameni sca l signal th at does not extend to surface popliteal h iatus
d ue to rich vascu la r supply • Infe rior fascicle co mple te at level of body of LM,
o Adults may develop central degenerative changes but n o t posterior h o rn
see n as linea r o r globular sig nal that does not exte nd • Superior popliteome niscal fascicle ex tends fro m
to su rface body/ posterio r h o rn LM to su pe ri o r portio n
o Various hi gh signal clefts and dots ca n no rma ll y be popliteal parateno n a nd o n to capsul e, fo rming
seen in an terio r horn LM at a nd near its root ceiling of the po plitea l hiatus
a ttac hm ent, d ue to im mediate adjacen cy of o rigin o f • Superior fa scicle incomp le te at body, bu t complete
ACL and di vergen ce o f longitudina l fibers at root a t body/poste rior ho rn LM
o Peripheral portio n o f meniscus is quite vasc ula r
• O uter me niscal margin as seen by MR is usua ll y Meniscal Variants
not true periphery of structure: Meniscus sig nal in • Transverse liga m e nt: Conn ects menisci anteriorly
its perip heral vascular portion (10-30%) blends in o Oblique insertio n o n LM a nterior h o rn may
wi th gray signal of t he capsule simula te a tea r; may be absen t
o "Magic a ngle" may affect poste rior h o rn o f LM in • Meniscofemoral ligam e nts: Ex tend fro m posterior
region of intercondylar notch media l femora l co ndy le to posterior h o rn LM
o At insertion o n LM, may sim ul ate a tear
Meniscal Attachments • Oblique m e nisco-menisca l ligame nts: Cross from
• Osseous attac hme nts: Both menisci a re firm ly a n terio r horn o f o ne to posterio r horn of o the r
a ttached to tibia a t their roots me niscus, passing be tween ACL and PCL
o LM roots: Located near center o f tibial platea u • Va rio us othe r meniscal va riants have been o bserved,
• Ante ri o r h o rn attac hes immediately la te ral to including men isco-ACL Iiga men t
o rigin o f AC L

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 MENISCI
SAGITTAL PO MR, MEDIAL MENISCUS

r:---+- Medial head,

gastroc nemius muscle

Posterior capsule

Posterior h orn, m edial

Anterior horn med ial

meniscus Semimembranosus t.,
direct component
Body media l m eni scus

Slip from
semimemb ranosus to
proximal oblique

Medial head of
gastrocnem ius muscle

Poste rior
Subgastrocn emi us - +--'"-= ca psu le/oblique
bursa pop l iteal l igament

Ante rior h orn m ed ial

m eni scu s por ti on of
m eniscus, blend ing
into capsule

Pos terior ho rn m ed ial

meniscus

(Top) First of eight sagittal PD MR images thro ugh medial meniscus. Far medial (periph eral ) sagittal cut through the
medial men iscus, sh ows th e bowtie configura ti o n , enco mpassing port ions of the anterior h orn, body, and posterior
horn of th e media l meni scus. (Bottom) Mid sagittal cut thro ugh the media l m en iscus, sh ows t he di fferential size and
shape of t·h e anteri or and posterio r ho rns. This image and prev ious image sh ow th e low sign al meniscus blen ding
indisti n ctly into the g ray vascular porti o n o f the meni scu s, whi ch in turn blends into th e ca psu le.

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 MENISCI
SAGITTAL PO MR, MEDIAL MENISCUS

Medial of Posterior capsule

in terco ndy lar no tch

Extracapsular fat stripe

An terior horn med ial Posterior h orn, med ial

menbcus meniscus

Posterior capsule

Men iscofemora I -;;;;;;r-.,.--,-------,-,------:-::::---:i

ligament (ot
I lumphrey) Posterior cruciate
ligamen t
An terior ho rn, medial
meniscus Poster io r horn, media l
men iscus

(Top) Cut through t h e med ial meniscu s, approaching the intercondylar notch. The anteri or and posterior horns
retain t heir differential size and shape. (Bottom) Cut through th e med ial men iscus as it enters the medial porti on of
th e intercondylar n otch. Th e posteri o r cruciate ligamen t is see n, ari sing from t he mid portion o f Blumensaat l i ne
along t he m ed ial femora l co ndy le. The anteroinferior meniscofemoral ligament (o f l l umphrey) is seen in
cross-secti on beneath the pos terior cr uci ate ligament. Th e pos teri o r h om of the med ial meni scus is beginni ng to
change its shape as it approaches its root attachment to th e tibial pla teau . Because of t he obliquity at w h ich t he kn ee
is sca nned for the agi ttal images, the anteri or horn is no t yet approaching its root, but retain s its t riangu lar shape.
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 MENISCI
SAGITTAL PO M R, M EDIAL PORTI ON OF INTERCONDYLAR NOTCH

Gastrocn emius muscle,

m edial h ead

Posterio r capsule

Posterior cruci at e
Tran sverse ligament ligament
origin from m edial '---":;-.,.:?W:;:;:::-.=::..::...;- M eniscofemoral
m eniscus ligament (of
t-lumphrey)
Root o f an terio r h orn
m edial ::::;;::.;-- Root o f posteri or horn,
m edial

Inferior patell ar tendon

Insertion o f posterio r
cruciate ligament o n
ti bia

Posterior capsule

....::=;,..:::;-- Posterior crucia te

ligament

Tran sve rse l igament

M en iscofemoral
Roo t of an terior horn I iga m ent" (of
m edia l m eniscus Hum phrey)

In ferior patellar tendon Insertion o f pos terio r

cruciate ligamen t o n
tibia

Po pl iteus muscle

(Top) This cut shows the roots of both the an terio r and poster ior horns o f th e medial m eniscus. The root of th e
posteri or h orn of medial m en iscus terminates immediate ly in front of th e posterior cruciate in sertion on the tibia.
(Bottom) T he ad jacent image shows the anteri or ho rn of th e medial meniscus terminatin g in its roo t; the transverse
l igament ari ses at th is point. Both the transverse and meniscofemoral ligaments arc seen in cross-sectio n.

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 MENISCI
SAGITTAL P O MR, MID INTERCONDYLAR NOTCH

Tra nsverse ligamen t

,----:-:::;:.:;;;;:::;;;;...,.8 - Men iscofem o ra I

ln frapa tel lar (Hoffa) fat ligamen t (o f
pad ll umph rey)

of posterior
cruciatc liga m en t on
tibia

Anterior cru ciate Intracapsular fatty

ligamen t tissue

Transverse liga ment

Meni scofemoral
ligam en t (o f
H umph rey)

(Top) This cu t shows n o me nisci; th e m e niscofemo ra l liga m ent is beg in nin g to elonga te a n d parallel th e po sterior
c ruciate liga m e nt. o te that th e posteri o r capsule is interrupted , allowing neurovasc ular structures to en ter the joint.
(Bottom) Cut be twee n th e cruciate ligam e n ts shows t h e t ra n sverse ligament in cross-section, contin u ing ac ross the
a nteri o r jo int space. The meniscofe m o ral ligament elo nga tes towards its insertio n on th e posterior horn of the latera l
me niscus; th e la tte r stru cture is not see n unti l t he next cut towards th e lateral side.

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VI
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 MENISCI
AXIAL PO FS MR, THROUGH JOINT LINE

1\ledial collatera l ligam ent

An terior cruciate ligamen t

Posterio r c ruciate ligament Origin o f popli tea l tendon

Latera l coll ateral li ga m ent

An terior cruciate l iga m ent

1\ledial femora l condyle Anterior h orn lateral menbcus

Body la teral meniscus

Root h orn MM Posterior horn lateral men iscus

Posterior cruciate l igament

Popliteal tendon

Transverse ligament
Anterior h orn m edia l meniscus

Root anterior h orn latrral

Body m edial meniscus
men iscus

La tera l tibial platea u

Popl i tea l hiatus

Posterior c-ruciate ligam ent

Poplitea l tend on &

muscle

(Top) First of three axial PD FS MR images thro ugh t h e joint line. Image loca ted i mmed iately above th e kn ee joint
li ne. The cru ciate liga ments as well as th e origins of the medial and lateral collateral ligaments are seen. (Middle)
Image thro ugh the knee joint line, sh ows parts of the menisci as well as th e course of the popliteal ten don thro ugh
the popliteal hiatu s. (Bottom) Image thro ugh the t ibial p latea u at th e join t line, shows parts of the meni sci and their
roots. The popliteal tendo n is also seen ex tending to the po pl iteus muscle. The transverse meniscal ligamen t bridges
between th e two anteri o r horns .

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VI
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 MENISCI
SAGITTAL PO MR, THRO UGH LATERAL PORTION OF INTERCONDYLAR NOTCH

An terior ban d, an te rior H----:-1-- Posteri or capsul e, wi th

cruciate liga m ent i n terruption for
n eurovascular bundl e

M en iscofe mo ral I. (of

H um ph rey)

Root o f posterior horn,

latera l m eniscus

Popli teus m uscle

An teri or band an terior

cruciate liga m en t

I n termediate fibers
Posterior band an terior -+--'.....____.,'::'
an terior cru ciate
cruciate I iga m en t
l igam en t
r===;;-- Men iscofem oral
liga m en t (of
H umphrey)

;;;;::::::;-- Root o f posterior horn,

lateraI me niscus

(Top) First of eigh t sagitta l PD MR images through th e la te ral co mpa rt me n t sh ows the m id por tion o f the
inte rcon dyla r n o tc h. Not e th e me n isco femora l ligament approaching the poste ri o r ho rn la te ral m enisc us. (Botto m )
At th e late ra l aspect of inte rcond ylar n otch, th e me ni scofe m o ra l ligame nt joi n s t he poste rio r horn late ral meniscus
n ear its root. This a ttachme n t m ay be misinterpreted as a torn m eniscus. ote t hat, due to t h e ob liqu ity with wh ich
sagittal seq ue n ces a re ro utin ely o bta ined, it is not u nco mm on to see th e tra n sve rse ligament ante rio rly as well as the
root o f t he p o ste rior h orn fo r several cuts befo re the roo t o f the a n terior h orn o f the la te ral me niscus is see n. The root
o f the late ra l me niscal a n te ri or h orn arises la te ral to th e origin of th e a nte rio r c ru ciate ligam e nt fro m th e tibi a;
VI th erefo re we sho uld n o t ex pect to see it in th ese images.
82
 MENISCI
SAGITTAL PO MR, LATERAL COMPARTMENT: ADJACENT TO INTERCONDYLAR NOTCH

Posterior h orn, lateral

meniscus

Posterior capsule

ligament

Root of anteri or horn -;;;::;-.;::----::-...,;,;r-:------"

lateral meniscus

Popliteus muscle

Posterior capsu le

Posterior horn lateral

men iscus
Transver\C ligamen t Popliteal
m usculotend i no us
junction
Anterior horn lateral
m en i scus

Inferior patellar tendon

(Top) In the lateral co mpartment, adjacent to the intercondylar notch, o ne sees the root of the anterior horn lateral
me ni scus, with the transverse ligament approaching it. (Bottom) In the adjacen t, sli ghtly m ore latera l, image, the
transverse ligament more c losely approaches the an terior horn o f lateral m e niscus. Note that in both of th ese cuts,
the poste rior horn of the latera l meniscus blends in d irectly to the posterior capsule. In t hese cuts the popliteus
muscl e (top) and popl itea l muscu lot"endinous junction (bott om) are ext ra-arti cular. This far posterior region is t h e
o nl y po rtion of th e latera l meniscus whi ch directly attac hes to th e posterior ca psu le and is n ot interrupted by the
popliteal hiatus.
VI
83
 MENISCI
SAGITTAL PO MR, MID PORTION OF LATERAL COMPARTMENT

Plantaris muscle

Capsu lar attachmen t

lateral head
tendon

Superior fascicle
(popl iteomeniscal)

.,.,..,___.;:;r_ Popl i tea l hi atus

Tran sverse ligamen t
Popl i tea l tendon
Anteri o r horn latera l
meniscus Inferior fascicle
lnfrapatellar (Hoffa) fat (pop I i teo men iscal)
pad

In ferior patellar ten don

Biceps fem oris muscle

Pla ntaris muscle

Lateral head o f
muscle

r.;;::::::::;o- Superior fascicle

(popl iteorncniscal)

Popliteal tendon
w i th i n popl iteal hiatus
Anteri or horn lateral
m eniscus
In ferior fascicle
ln frapatellar (Hoffa) fat -+=------,.; (popliteomen iscal)
pad

In ferior patellar tendon

(Top) Image through the lateral compartmen t shows the tran sverse l igament joining the anterior horn latera l
meniscus. Posteriorly, one sees the popliteal tendon wi thin the popliteal hiatus. T his struct ure is intra-a rt icular bu t
Q)
Q) extra-synovial. The superior fascicle extends from th e superior aspect of the posteri or horn lateral m eniscus to the
c: para ten on of popl i teal tendon and on to th e capsule, forming th e roof of t h e popliteal hiatus. Th e i nferior fascicle
ex tends from t he inferior aspect o f t he posterior horn lateral meniscus toward s the popliteal ten don but is
in terrupted by th e tendon's passage into th e extra-articul ar positio n of the musculotendinous juncti on. (Bottom)
The adjacent m o re lateral cut shows a similar relation ship of the fascicles, with th e su perior extend i ng to the
VI po pliteal tendon and capsule, and inferior fascicl e being interrupted.
84
 MENISCI
SAGITTAL PD MR, LATERAL PORTION OF LATERAL COMPARTMENT

Latera l h ead
gastrocnemius muscle

Origin lateral collateral

liga m ent

Superior fascicle
(popli teomeniscal)

Poplitea l te ndon
wi thin popliteal hiatus

Anteri o r horn lateral Inferior fascicle

m en iscus (pop Ii teo men isca l)

In feri or patellar tendon

Origin popli teal tendon

Po pl iteal tendon

Bod y lateral meniscus

A nterior horn lateral lnferior fascicle

meniscus (popliteom en i scal)

(Top) Cut thro ugh the lateral compa rtme nt sh ows the beginn ing o f the bowti e configuration of the meniscus. The
popliteal tend o n is within th e hiatus, outlin ed superiorl y by the superior popliteom en iscal fascicle and inferi o rl y by
th e infe rio r popliteomeniscal fascicle. (Bottom) Fa rther late ra lly, the bowtie co nfiguration of the la teral me niscus is
complete. Th e o rigin o f the po plite us tendon (loca ted just anteriorly and infe riorly t o the o rigin of the la teral
collatera l ligame nt o n the latera l fe m ora l cond yle) is see n. A portion of the popli teal ten don is see n coursing towa rds
its intra-a rticula r position in the popliteal hiatus. The superior popliteomeniscal fasc icle has n ot ye t fo rm ed as th e
popliteal tendon passes the superior portion of the poste rior ho rn but th e infe rior pop liteo menisca l fasc icle clea rl y
forms t h e floor of th e hi atus.
VI
85
VI
86
 MENISCI
CORONAL T2 FS MR, ANTERIOR KNEE JOINT

[I_
Root, anterior h orn m edial
m eni scus, extending into transverse Ilio tibial band
ligament

Anterior ho rn, medial meniscus

Gerdy tubercle

[I_
Il iotibial ba nd

lnfrapa tellar fat pad

Anterior horn, m edia l m eniscus

Transverse ligamen t

Superficial fibers, m edial collateral I

[I_
Ilio tibial band
(layer 2 o f medial co mplex)
M edial patellofemoral
I./ retinaculum (la yer 1 of medial
complex)
Meni scofem oral ligam ent (medial
col lateral liga m en t, deep fibers) An terior h orn lateral m eniscus
Body m edi al m eniscus
Root, anterior horn lateral
Meniscotibial ligamen t (coronary m eniscus
ligament, msdial coll ateral
l igamen t deep fibe rs)

(Top) First of nine coronal T2 FS MR images presented from anteri or to posterio r. Anterior cut shows that anteri or
horn m edial m eniscus is located anteri or to anterior horn lateral meniscus. Tran sverse ligament extends from
anterior horn medial men iscus towards anterior horn lateral m eniscus (Middle) Transverse ligam ent seen ex tending
towards anterior h orn LM . (Bottom ) Root of an terior horn lateral men iscus is severa l mm posterior to that of med ial
meniscus. By this cut, m edial meniscus is tran sform ing from anteri or ho rn to body. One can see that i n the mid
porti on o f th e kn ee th ere is separation between layer 2 and 3 o f the m edial supporting st ructures (superfi cial and
deep fibers o f m edial co ll ateral ligam ent, respective ly). Deep fibers con sist of t h e meniscofem oralligament,
ex tending fro m bod y o f meniscus to superfi cial medial collatera l ligam ent, and meni scotibial (coronary) ligament. VI
87
 MENISCI
CORONAL T2 FS MR, MID KNEE JOINT

IJ Posterior cruciate ligam ent

Medial collatera l l igament,

superfici al fibers An terior cruciate ligament
Meniscofemoral ligament (deep An te rior h orn/ b£>dY lateral
fibers of medial coll ateral) meniscus
Medial collateral l igamen t bursa

Meni scot"ibial ligament (deep fi bers

of m edial co llateral)

Lateral co l lateral l igamen t

Posterior cruciate ligament

Body medial m eniscus, merging to Popliteal ten don

posterior horn

Body la te ral m eni scus

Medial collateral ligament,
superficial fibers & oblique fi bers

Sa rtorius tendon

ID Posterior cruciate ligament

Lateral collatera l ligamen t

Posterior h orn, m edial m eni scus Pop I i teal tendon

Body latera l m en iscus

Medial col la teral ligamen t

(Top) Co ronal cut through the mid joint shows the body of the med ial me niscus to be th e smallest, approaching an
eq uilateral triangle in shape. The ante ri or crucia te ligament is reliably seen in this region, as are both the deep and
superficial laye rs of t h e medial collateral liga men t. (Middle) In a cut that is slightly more posterior on e sees th at th e
deep and superficial la yers of the medial collateral ligament merge together. On the lateral side, the popliteal tendon
is seen at its origin, extending towards the joint line. The body of the late ral men iscus is still firmly attached to the
ca psul e. (Bottom) Even mo re posteriorly, the medial me niscus is transforming to its posterior horn. On the latera l
side, the popli teal tendon is seen enterin g th e joint su periorl y to th e body of the lateral meniscus, at the begin ning of
VI t h e popliteal hiatus.
88
 MENISCI
CORONAL T2 FS MR, POST ERIOR KNEE JOINT

crucia te liga m ent Root, posterior horn lateral

meni scus
Root posterior ho rn medial
meniscus Popliteal tendon
Posterior horn medial meniscus ---;;;:::::;-=;;
Popliteal hiatus

Fused oblique fibe rs MCL & ca psule Inferior popliteomeniscal

fascicle
Semimembranosus tendon, direct -ir:;:;:=; Lateral meniscus
attachmen t

Biceps muscle

Lateral collateral li gamen t

Posterior horn m edia l meniscus Popl i tea l tendon

artorius musc le l:x ten don Popl i tea l h iatus

Posterior cruciate ligament - ;;:::::;::;;;;: In ferior popliteomenisca l

fasci cle
Semimembran o u tendo n
Posterior horn lateral meniscus

Graci lis tendon

Biceps fem oris muscle

Lateral head gastrocnemius m.
Lateral colla teral ligament
cruciate ligament
insertion

Sa rtorius tendon
Popl iteal tendon
Posterior horn m edia l meniscu s Popliteal hiatus

em imembranosu s tendon Posterior horn lateral meni scus

(Top) Pos te ri orl y in the jo int, but ante ri o r to the poste ri o r cruciate liga ments, th e posterior men iscal roots are fo und .
Media ll y, th e medial collatera l ligame nt has merged w ith th e capsule. Laterally, the popl iteal tendo n enters the
articular space by way of the popli tea l hiatus. (M idd le) The popliteal hiatus beco mes more p rominent as th e te ndo n
extends poste riorly and downward. The inferior po pliteo meniscal fascicle forms the fl oor of t h e popliteal hia tus at
this point. (Bottom) At th e poste rio r exte nt of the intra-articu lar portion of th e kn ee joint, the poplitea l ten don
crosses in its downward and posterior co urse to its muscu lo te ndin o us junction. The h iatus is pro minen t here, and
must no t be mistaken fo r a tear in th e posteri o r horn la te ral meniscus. Both posterior ho rn s are see n this far
posterio rly, beyond their roots. VI
89
 MENISCI
SAGITTAL PD MR & CORONAL T2 MR, LATERAL COMPARTMENT

Body, discoid la teral

meniscus

Posterior h orn, discoid

Anterior horn, discoid -+-----___::.....=.___:=i!iiiF latera l meniscus
lateral m en iscus

Popli teus
Inferio r pa tell ar tendon
musculo tendinous
junctio n

IJ
ACL, an teromedi al
ban d

ACL, posterolateral
ban d

Di scoid body lateral

m eniscus

(Top) Sagittal image is fro m th e mid portio n o f th e lateral co mpartm ent, a nd sh ows a d iscoid la te ral meniscus. Note
th at the m en iscus is seen with all three porti o ns, t h e a nterio r horn, bod y, a nd poste ri o r h o rn. Thi s bowtie
appearance sho uld be seen o nly in th e oute r porti on o f the joint. Th e fact th at the fibula is not seen, as wel l as that
th e popliteus musculotendinous ju nction (rat he r t ha n just th e po pliteus te ndo n ) a nd patellar te n don are both in this
image indicates t hat th e loca tion is fa r too inte rio r in the joint fo r a normal bod y o f meniscus to be seen. Thus, the
bod y of the meniscus is too la rge, indicating the discoid va ri ant. (Bottom) Coro na l image t hro ugh th e mid portion
of the joint (as indicated by the mo rph o logy a nd presen ce o f the AC L) sh ows the bod y of th e la te ral me n iscus to be
VI too la rge, con firming that it is di scoid.
90
 MENISCI
SAGITTAL CT ARTHROGRAM, MR ARTHROG RAM: DISTENDED JOINT

Suprapatellar bu rsa

Posterior suprapatella r (prefemoral)

fat pad

Sup erior popliteome n iscal

fascicle
Popliteal hiatus
l nfrapatella r (H o ffa) fat pad
Popliteal tendon

Posterior capsul e

Meniscocap su lar portion

superior fascicle

Obl ique (medial ) arcuate I.

Superior fasci cle
(m en iscopopli teal l igament)
Po pl iteal ten don
Pop l iteofi bular li gam ent

Inferior pop li teomeniscal

fascicle

Superior recess posterior h orn

medial m en iscus

An terior h orn m ed ial meniscus Posterior h orn m edi al m eniscus

(Top) Reformatted sagittal image through th e late ral com partment in aCT arthrogram. Note that with distension o f
the jo int by cont rast, continu um of the joint fl uid wit h th e popliteal hia t us is readil y see n. The supe ri o r
pop liteomenisca l fascicle, exte nding betwee n the post e rio r ho rn lateral me ni scus and popliteal t e ndo n , is ou tl ined by
fluid . (M iddl e) MR a rthrogram sh ows diste n ded popliteal h iatus a n d outlines bot h t he su pe rior an d inferior
menisco po pliteal fascicles (s truts) as well as t he po plitea l ten don . Popliteofibula r a nd arcuate ligamen ts are see n well .
(Bottom) Reforma tted sagittal im age th ro ugh m edial compa rtment in a CT arth rogra m shows the superior recess of
posterior h o rn medial m eniscus. This sh o uld not be m istaken for a pe ri pheral me n iscal tea r or m eniscoca psula r
separa t ion. Note that cartilage wid th va ries over the fe m ora l cond yle (thi cker post e riorly). VI
91
 MENISCI

Men iscofemora LI iga men t

Posterior horn lateral meniscus

Meniscofemoral ligament

Posterior horn lateral meniscus

Meniscofem oral li gament (of

M edial femoral condylar notch
Wrisberg)
origin of meni scofe m o ral li gamen t

Posterior horn lateral meniscus

Popliteus muscle

(Top) First of three images d epi cti ng t he meniscofemoral ligament o f Wrisberg. This agittal image is slightly lateral
to the intercondylar notch and root o f posterior horn lateral m eniscus. Meniscofemoral ligam ent is distinct ly
separate fro m meniscus. (Middle) App roaching intercondy lar n otch and root of posterior horn latera l meniscus,
meniscofemoral ligament more closely approach es lateral men iscus to merge w ith it. It is at this poi nt th at a tear of
posterior h orn cou ld be mistaken l y d iagnosed. (Bottom) Coro nal image loca ted posteriorly in the join t hows
m eniscofemoral ligament of Wri sberg over n early its entire ex tent, originati ng at medial femoral condy le in th e
intertrochanteric notch and m erging w ith posteri or h o rn lateral meniscus.
VI
92
 MENISCI
SAGITTAL PO MR, NEAR INTERCONDYLAR NOTCH: NORMAL VARIANTS

An terior ho rn lateral
men iscu s

;;;:::::=:.,;-- An terior cruciate

l igamen t
Anterior la teral
m en iscocrucia te I.

Anterior root latera l

m eniscus

(Top) First o f two sagittal PD MR images near th e inte rco n d yla r n otch, latera l to m edi a l, shows a la rge tra nsverse
liga me nt. Th is li ga me nt con nec ts t h e two a n terior m e niscal horns a nd is seen in cross-section on sag ittal images. It
cou ld possibly be con fused fo r a m e nisca l tear as it me rge s with th e late ra l men iscus, closer to t h e no tc h. The
li ga me n t is gen era lly sm aller t h a n this, o r ma y be abse nt. ( Bottom ) Image th rou gh t he la t·e ra l po rtio n of
inte rco nd ylar no tch sh ows a discrete st ruct ure w hi ch para ll els t he a nte rio r cruc iate liga m ent a nd exte nd s fro m th e
roo t o f th e anteri or h o rn lateral men iscus to th e lat e ra l fe m o ra l condy le. Th is represents th e n orm a l varia n t, ante rior
la te ra l m e n iscoc ruc ia te li ga m ent. It is distin gui sh ed from infrapa te lla r p lica (w h ich can a lso parallel th e ACL in th e
sa m e manne r) by its site o f o rigin at the me n iscus rathe r tha n th e pa te lla. VI
93
 MENISCI
AXIAL PO FS & SAGITTAL PO MR, THROUGH INTERCONDYLAR NOTCH: NORMAL VARIANT

Anterior h orn m ed ia l m en iscus

Transverse ligam en t (bowed)

An teri or m eni scocruciate I.

An terio r horn late ral m en iscus
An terior cruciate liga m ent
insertion o n tibia

Anterior m en iscocruciate ligam ent

An terior cruciate ligam en t

)]

A pex Ho ffa fat pad

(Top) First o f two ax ia l PD FS MR images at the leve l o f the jo int line, sh ows a slightl y tethe red transverse ligament,
with an ante rior m enisco cruciate ligament arising from it. Note that th e li ga m ent is ante ri or to the a n teri or crucia te
liga m e nt. (Middle) Image sli ghtly highe r th a n the previo us image, in th e in te rcond ylar n otch. Th e a nterio r
me niscocruciate li ga m ent para llels t he an terior crucia te ligame nt th rough out the no tch. (Bo ttom ) Sagittal PD MR
image sh ows t he le n gth of th e anterior m enisco cruciate ligam e nt, pa ralleli ng the anteri or cruciate liga me n t. This
n ormal variant sh o uld n o t be m istaken for an in trasubstance tear of the anterio r cruciate. o te that th e apex of Ho ffa
fat pa d is free of th is ligam ent (not attached as in an infrapate ll ar plica).
VI
94
 MENISCI
CORONAL PO FS MR, THROUGH ANTERIOR MID JOINT: N O RMAL VARIANT

[[
La teral men iscus
fascicle An terio r c ruciate
l igam ent

Roo t an terior horn

lateral m en iscus

[[
Anterio r cruciate
Lateral men iscu s l iga m ent
fascicles

Lateral m en iscus,
ju n ction b ody/an terio r
horn

(Top) First of two co ronal PD FS MR im ages in the anterior portion of the jo int. Th e tra n sverse liga me n t in thi s
patien t was a bsen t (m o re a nte rio r cut no t sh ow n). The fibe rs of t h e ante rior horn lateral m eniscus, whi ch no rma lly
ble nd in to th e t ra n sverse ligame n t, in stead form discre te latera l m en isca l fascicles whi ch asce nd towards the a n teri o r
cruciate ligament. ( Bottom ) Co ro n a l image slig htly posterio r to the previous im age sh ows th e late ra l me n isca l
fascic les ascending t o intersect t h e anterior cruciate ligam e nt. T hese fibers clea rly a re not part o f the a nterio r cru cia te
liga ment sin ce t h ey ascen d a t a diffe re n t a ngle. This n o rma l va rian t shou ld n o t be m ista ke n fo r pa t ho logy suc h as a
d isrupted ACL or a rne n isca l fragme n t from a bucket hand le tear.
VI
95
 MENISCI
AXIAL PO FS MR, 2 DIFFERENT PATIENTS: NORMAL VARIANTS

Medial femoral con dyle

M ed ial oblique
meniscom en isca l
An terior cruciate ligamen t
liga m ent
Posterior cruciate
La teral femoral con dyle ligamen t

Medial femoral con dyle

Medial obl ique

m en iscomen iscal
Anterior cru cia te l igamen t
l igament

Posterio r h orn lateral

Posterior cruciate
l igament

(Top) Si n gle ax ial image, ju st above th e joi nt line, shows the normal variant medi al oblique men isco m eniscal
li ga m e nt. It ar ises from the an terio r ho rn medial me n iscu s a n d inse rts o n the poste rior horn lateral m eniscus,
Q)
Q)
threading its way be tween the ACL a n d PC L. (Bottom) First o f three images in a di ffe re nt pa t ie nt, ax ial PD FS MR
c: thro ugh th e jo in t li ne, shows a n orma l variant, the media l oblique me niscom enisca l liga ment. T h e ligament extends
fro m the a n terior ho rn media l me n iscus ac ross th e inte rco ndylar n o tch to insert on pos te rior horn latera l m en iscus.
At thi s leve l of the me nisci, the variant ligament appea rs to split the ACL a t its insertio n on th e t ibia. It norma lly
exte nd s betwee n t he ACL and PCL. The mirro r image va ria n t, lateral m e niscome ni scal ligament, ex te n ds from
VI an terior h o rn la te ra l m eniscus to poste rio r ho rn m ed ia l me ni scus (n o t shown h ere).
96
 MENISCI
CORONAL PO FS MR, THROUGH MID JOINT: NORMAL VARIANT

M edi al fem ora l condyle Lateral femoral con dyle

Medi al
Anter ior cruciate
meniscom en isca l
ligam ent
ligam ent

[[
M edial fem oral co nd yle

Anterior crucia te
M ed ia l ligamen t
men iscomen i sea I
ligamen t

(Top) First of two corona l MR images, at the a nte rior portion of mid-jo int, shows th e t iny medial meniscomeniscal
ligam ent in c ro ss sectio n ad jacent to the anterior cruciate ligament. This is th e same patient as shown o n the
immedia te previo us ax ial image. (Bottom) Second coro na l image, 3 mm posterior, with the m eniscomeniscal
ligament givi ng t h e a ppearance of a loose bod y o r frag ment ad jacent to the ACL. Th e location and low signal of this
normal variant ligam ent ma y be misdiagnosed as a meniscal fragment or bucket hand le fragment. It is important to
correla te it with th e appeara n ce o n either ax ial or sagittal images, wh ere t h e ligament will be seen as a lo ngitudinal
structu re placed betwee n t h e ACL and PCL, and angl ing ob liq uely across th e notc h between the two men isci.
VI
97
 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
• Meniscofemoral l i ga m ents
!Termino logy o Bo th arise from posterio r horn latera l men iscus and
Abbreviations insert on media l femoral co ndy le; at least one
• Anteri o r cru ciate li gam ent (AC L) p resen t 70% of ti me
• Post erio r cruciate I igam ent (PCL) o Posterio r (Wrisberg) lies posterior to PCL
o Anterior ( Humphrey) lies an terio r to PCL; intact
ligament o f Hum ph rey m ay mim ic an i ntact PCL
o May pl ay a ro le i n secondary re traint to posterior
!Imaging Anatomy
i nstabi li ty; m ay stabil ize latera l men iscus during
Overview flexi on
• C ruciate ligam en ts are in an extrasynovi a l but • MR imaging: Seen wel l in al l th ree planes, solid low
intracap sular loca tio n signal th roug hou t
o Fatty ti ssue lie between th e cruciates • Blood supply : Mi ddle geni culate arte ry proxi m al and
o Synov ial mem brane surro unds anteri o r, medial, and m iddle thirds; geniculate an d popli teal arter y base;
lateral porti o n s o f crucia tes b ut is refl ected ca psu lar vesse ls thro ugh entire length
posterio rl y from PCL to adjoi ning parts o f jo int Posterior Capsule
capsule
• Complex fibrous structure, augmented by extensions
ACL o f adjace nt tendons
• Multiple separate fasc icl es w hich spi ra l latera lly from • Incom p let e, p ierced ce ntrally by neurovascular
femur to tibia (fi bers ro tate externally 90°); fatty tissue structu res
i s seen bet wee n fibers • Prox i m a l attachment: Ve rt ical fibers at tached to
o Con t inuum o f f ibers allows variable tensio n, with pos terior m argins o f femora l con d y les an d
som e taut througho ut kn ee range of m otion intercondy lar fossae
o A nterom ed ia l bund l e: Tight in fl exio n, lax in • Distal attachmen t is to posterior margins of tibial
extensio n condy les and i nterco ndy lar areas
o Posterolatera l bund l e: Tight in ex ten sio n , lax i n • Tendons/ ligaments at tach to posterior capsule to
fl exio n p rovide reinforce ment
• Origin of AC L: Pos teri o rly fro m lateral fem o ral o Proxima lly (medially and laterally): Tend i nous
condy le at intercondy lar notch (seen o n radiograph as heads o f gastrocn emius
juncti o n o f pos terio r fe moral cortex and Blumen saat o Posteromedia l corner: Semimem branosus and
l i ne) posterior o bli q ue ligam ent
• Insertio n of AC L: An terom ed ial ti bial spine and o Posterol ateral co rn er : A rcuate ligament and
adjacen t plateau ; bund1 es fa n o ut at tibi al attachm en t, ilio tibial t ract
fo rmin g "foo t" o Posterior centra l : Oblique popliteal ligamen t
• Function Spaces W ithin Cruciate/ Posterior Capsule
o Primary res train t to anterior ti bi al trans la tion
• Sy novi al m embran e su rrounds anterior, med ial, and
o Majo r secondary restra int t o interna l ro tat ion ,
lateral port io ns o f cruciates, bu t is reflected posteriorl y
mino r secondary restraint to exte rnal rot ation
from PC L to adj oi ni ng parts o f joint capsule
o M inor seco ndary restra int to varus/va lgus at full
• Results in a po tential space (PC L bursa o r recess)
exten sio n
o Seen o nly w hen f lu id-fi lled, best on co ro nal and
• MR imaging: Seen well in all three p lan es, low signal
sagittal p lanes
w ith fat interspersed bet ween bun clles
o Seen posteri o r to PCL and ad jacent to lateral aspect
• Blood supply: Mid dle geniculate arter y (p ierces
o f medial femoral cond y le
post erio r capsu le fro m popliteal); lesser supply from
o No cont act between PC L recess and the proximal
fat pad (inferio r med ial and lateral gen i culates)
third of the PC L (fat is interposed)
• Nerve: Pos terio r articular (branch of posterio r tibial)
o Comm un ica tes w it h m edial (fem oro ti b ial)
PCL co mpart ment of knee
• Appea rs as a sing le round ligament but co nsists o f o Does not co mmu nicate w ith latera l com pa rtmen t
two majo r parts; rotates 90° fro m an antero-posterio r o If ligam ent of W risberg is present, it lies
alignment at fem ora l o rigin to m ed ial -lateral insertio n posterosuperior to PCL recess
at posterio r t ibia • I ntercruciate recess
o A nterolatera l b und l e: Bulk o f ligam ent, taut in o Localized potentia l fluid collection be tween AC L
fl exion , lax in exten sio n and PCL, best seen on sagittal an d axia l pl an es
o Posteromedial (oblique) bundle: Taut in exten sion, o Communicates w ith ei th er lateral o r med ial
lax in flex io n (fem o rotibia I) co rn pa rt men ts
• O r igin of PC L: M id po rti o n o f medial fe mo ral co ndy le
at interco ndylar notch
• Inserti on of PCL: Mid posterio r ti bi a, 1 em below ISelected References
jo int line, w h ere it bl ends in w ith posterior ca psule I. De M aeseneer M et. al: ormal an atomy and pathology of
• Function : Prim ary restraint again t pos terio r th e posterior ca psular area of the knee. AJR. 182:955-62,
t ran slati o n 2004

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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
SAGITTA L T2 FS MR, CRUCIATE LIGAME NTS

Posterior fat

Posterior capsule
Medial femoral co ndyl e

Ligament of H umphrey
Posterior jo in t recess

Posterior cruci ate

l igament

Lateral femoral condyle

Pre-cruciate joint recess
An teri or cruciate
l igamen t Fat which li es bet wee n
cruciate ligaments

"Foot" attachm en t o f
an terio r cruciate
ligam ent

(Top) First of two sagitta l T2 FS MR im ages through the intercondy lar n otch in the mo re m edial po rtion of t h e
no tc h, sh ows the o rigin of the PC L from th e ante rio r portio n of the medial n ot ch , as well as the insertio n post eriorly
to the tibia, 1 e m below th e jo int lin e. The PC L appears as a th ick sing le ba n d, usua ll y in at least two adjacent
images. The re is fat loca ted immediately posterior to th e p roximal portion of th e PCL. More dista lly, t he posterior
joint recess abuts th e PCL. The poste rior capsule lies be hind this fa t and the recess. In this case, th e men iscofemo ral
liga me nt o f Hu mphrey is prese nt; th e ligament of Wr.isberg is absent. (Bottom) This image is loca ted slightl y
lateral ly, with in th e intercond ylar notch. Th e an terior crucia te ligam ent a rises from th e posterio r lateral femoral
condyle within the notch; the broad inserti on on the tibia l plateau is seen . VI
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
CORONAL T2 FS MR, CRUCIATE LIGAMENTS

Posterior cru ciate

l igamen t

Posterio r ho rn lateral
Posterio r h o rn m ed ial
meniscus
m eniscu s

Lateral femoral co nd y le
O rigi n posterio r
cruciate ligament
Anterorneclial bundle Postero lateral bund le
anterior crucia te I. anterio r cruciate
ligam en t

Media l t ibial spin e

(Top) Fi rst of two corona l T2 FS M R images sh ows the cru ciate ligamen ts. This m o re posterio r image sh ows the
poste rior c ruciate ligame nt a pproach in g its in serti on o n the post eri or aspect of the t ibial platea u. No po rti o n of
anterior cruciate is seen . N ote that while we expect to see the ACL as a co mple te band on coronal images, th e PCL is
incomple te ly see n. (Bottom) This mo re an te rio r image also sh ows the cruciate liga m e n ts. The anterom ed ial bund le
a nd poste ro latera l bundle of AC L a re seen arising from th e lateral fe moral co nd yle a nd in serting on t h e t ibial platea u
adja ce nt to the media l tibial spine. Both a re see n o n the sa me cut because of th e obliquity at whi ch coro na l images
a re obtai ned. Because the leg is in exten sio n , th e postero lateral bundle is taut.
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
AXIAL T2 FS MR, CRUCIATE LIGAMENTS

Lateral femoral condyle

Fat wi thin intercond ylar area

O rigin anterior cruciate

Posterior cruciate recess ligament

Sartori us muscle
Sem imem branosus tendon
Posterior capsu le

Pre-cruciate recess
O ri gin posterio r cruciate ligament
Anterior cruciate li game n t
Pos terior cruciate recess

Semimembranosus tendon
Medi al gastrocnemius muscle Posterior capsu le

Lateral gastrocnemius muscle

Lateral femoral condyle/ joint

An terio r cruciate ligamen t

Posterio r cruciate ligamen t

Popliteus ten don
Sa rtorius muscle

Posterior capsu le
Semitendinosus tendon

(Top) First of three ax ial T2 FS MR images sh ows the cruciate ligaments within th e inte rcondy lar notch. l n the upper
portion of the notch, th e ACL is seen arising fro m the posterior aspect of th e lateral femo ral condy le within t h e
notch. The remainde r of the notch is filled with fat and a potential space (posterior cruciate bursa). (Middle) Axial
cut through the mid porti o n of the in terco ndy lar notch. Th e ACL extends obliquely towards its insertion on the
tibial plateau. The origin of PCL is seen at t h e anterior med ial fem o ral condy le within the notch. Fluid-filled recesses
are seen a nte rior to the AC L and posteromedial to the PCL. (Bottom) Inferior portion o f intercondylar notch shows
ACL as it approach es insertion on tibi al plateau. The PCL is still within capsule, but beginning to b lend with it as it
approach es in se rtio n o n posterior tibia. The cruciates are well seen axiall y. VI
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
MR, VARIANTS AROUND CRUCIATE LIGAMENTS

Anterior crucia te ligament

Ob liq ue m en isco m en isca l
liga m en t
Poste rior cruciate ligam en t

An terio r cruciate ligam ent

l n frapa tellar plica

An terior cr uciatc ligament

(Top) Ax ial. PO FS MR image through the femora l co ndyles, shows a n oblique me n iscomen iscal ligame nt. This
uncommon va rian t co nn ects t he anter io r horn of o ne me ni scus with th e posterior h orn o f the contra la te ral
m e ni sc us. It runs between th e a nteri or and posterio r c rucia te ligaments. (Middle) Sagitta l PO MR image through th e
inte rcond ylar notch, shows the va ri a nt infrapate lla r p li ca . This plica arises fro m th e patella, extends across Hoffa fat
pad, and along the a nterior surface o f anteri or cruciate ligament. (Bottom) Sagitta l PO MR through th e in tercond ylar
n otch in a nother patie nt, sh ows an infrap atellar plica. The plica is seen exte n d ing through Hoffa fat pad, paralleling
the curva t ure of t he femoral cond yle, an d then pa ra lle ling the a nterio r cruciate liga m e nt.
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
SAGITTAL PO MR, MENISCOCRUCIATE LIGAMENT

Anterio r

l iga m ent
==-=-=-=--- Anterio r cruciate
l iga m ent

Anterior h o rn lateral --+-- :Piii=o

menbcu s

M eniscocruciate
ligament
An terior cruciate
l igament
Transverse ligam en t

An terior horn lateral

(Top) Sagi ttal PO MR through the intercond y lar notch, shows a m eniscocruciate ligam ent. The ligament arises from
the anterior h orn medial meniscus and ex tends along t h e anterior surface of the anteri o r cruci ate ligam ent to th e
femo ral condyle. I t could possibly be mistaken for a lon gitud inal tear in the anteri or cruciate. (Bottom) Sagi ttal PO
FS image in a different pa ti ent, showi n g ano ther varian t meni scocruciate ligament. This liga m ent is arising from t he
t ransverse ligament; as it extends parallel to an d anterior to the anteri or cruciate ligament, it could si mulat e a
longi tudinal or pa rti al tear in t his cruciate.

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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
CORONAL PO FS MR IMAGES, VARIANT

An terior cruciate
liga m en t
An terior m en isca l
fasci cle

A n terior ho rn lateral
men iscu s and root

An terio r m en isca l An terior crucia te

fascicle l igament

(Top) First of t wo coro nal PD FS MR images sh ow s a va riant anteri o r m enisca l. fascicle ex ten d in g to th e anterio r
cruciate ligamen t . T h e fasci cle ari ses fro m the anterio r horn lateral men i scus and i ts root . It then ex ten ds u pward to
m erge with th e synovi u m over t h e anterio r cruciate ligament. In this anterior slice, th e fasci cl e appea rs as a sepa ra te
fi ber. T he anterio r cr uciate i s in its n ormal po sition, ex tend ing from t he lateral fem o ral cond y le to its i n sert io n
adjacen t t o the med ia l tibia l spi ne. (Bottom) Image is loca ted sligh tly post erio r to th e previo us i mage. T he me nisca l
fasc icle i s seen ex ten ding fro m i nfero latera l to su perom edial , an o pposit e angulatio n relati ve to t he anterio r cruciate.
Thi s is a pot en t iall y con fusing appeara nce and sho u ld no t be co n fused wi th cru cia te pathology.
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
SAGITTAL & CORONAL MR, LIGAMENT OF WRISBERG

Ligament o f Wrisberg

. .=-----+- O rigi n l igam en t o f Wri sberg,

m edial fem oral con d yle

Insertio n ligam ent o f W risberg,

posteri o r h or n lateral m eniscus

Ligament o f W risberg
Posterior horn lateral m eniscus

(Top) First o f three images of the posterior crucia te liga m ent a nd the associa ted posterio r me ni scofem o ral ligament
(Wrisberg). Sagit tal image through the posterior cruciate shows the ligament of Wrisberg in cross-section as it ex tends
fro m the media l fe m ora l co nd yle towa rds the posterior horn la te ra l meniscus. (Middle) Coronal PD MR image
loca ted poste riorl y in th e joint in th e same patien t as previous image, sh ows the ligame nt of Wrisbe rg para lle ling the
poste ri o r c ru ciatc li gam ent in its path fro m th e m edial fe m o ra l cond yle to the poste rior horn late ra l m eniscus.
(Bo ttom) Sagittal PD FS MR image lo cated in the la tera l compartment immediate ly adjacent to th e inte rco ndylar
notc h, a t t h e root o f poste rior horn late ral m e niscus. Th e liga ment of Wrisberg inserts at this poin t; just prio r to the
insert io n, thi s ap pearan ce cou ld give a fa lse impression of rneni sca l tear. VI
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
AXIAL & CORONAL MR, LIGAMENT OF HUMPHREY

Lateral fem o ral condy le

Meniscofemoral --;:=;;;;:=
ligament (llumphrey)

cruci ate
ligament

Medial femoral condyle

Meniscofemoral
ligament ( llumphrey)
Anterior cruciate
ligam ent

(Top) Ax ial PD FS M R, through the fe m ora l con dy les and intercondylar no tch . T he men iscofemoral l iga ment of
Hu mphrey ex tends from the media l femoral co ndyle across in fro nt of th e posterio r cruciate liga ment towards its
inserti on o n the post erior horn lateral meniscus. (Bottom) Coronal PD FS MR image shows t he an teri or cruciate
ligam ent ex tending from the latera l fe m oral cond y le towa rd th e tibial spin e. At the sa me level, th ere i s a liga m entous
structure arising from the media l femo ral co ndy le. This is loca ted sligh t ly anteriorly to the ori gi n of the pos terior
cru ciate l igam ent, and is the m eniscofemora l ligament of Hum phrey.
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
CORONAL MR, LIGAMENT O F HUMPHREY

Posterior crucia te
ligament Lateral femora l condyle

Meni scofc m o ral Anter ior crucia te

liga m ent ( Humphrey) l igamen t

Posterior cruciate
ligamen t Latera l femora l condyle

Meniscofcmoral Root posterior h orn

ligament (Humphrey) lateral meniscus

(Top) Coronal PD FS MR image located slightly posterior to previous i mage. The intercondylar n otch is quite full,
containing the normally positioned anterior cruci ate ligam ent as well as the origin of posterior cruciate ligament.
T h e origin of menisco femo ral ligam ent o f Humph rey is noted imm ediately anterior and inferior to that o f posterior
cruciate. (Bottom) Th is co ron al image is loca ted furt her posteri o rl y. This shows the m en iscofemoral l iga ment of
llumphrey crossin g from th e m ed ial femo ral condyle t o i nsert on the root of posteri or horn lateral meni scus. It
crosses directl y in front of posterior cruciate ligament. It is som ewhat unusua l to see i l in its en t iret y on a single
coronal image . Bone bruise on th e latera l tibial plateau is incid entally seen in th is example.
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
SAGITTAL PO MK, KNEE: LIGAMENT OF HUMPHREY

Posterior cruciate
ligament

Origin , liga m ent of

Hu mphrey
---,---::;:+-- Posterio r horn medial
m en iscus

Posterior cruciate
ligamen t

M id portion , I igamen t
of Hum ph rey

Poste rior ho rn , medial

meniscus

Crop) Fi rst of fo ur sagittal PD MR images shows m eniscofemoral l iga m ent of Hum phrey. Image is medial wi thin the
intercondy lar notch , at th e level of the pos teri o r cru ciate ligam ent. The l igament o f Hum phrey is seen origi nating
from the m edial interco ndy lar not ch , immedia tel y inferio r and anteri or to the posterio r cruciate li ga ment. (Bottom)
This im age, min imally latera l to th e previous im age, sh ows th e ligam ent of Humphrey in cross-sect ion, i mmedia tely
inferior to the post erior cruciate l igament.

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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
SAGITTAL PO MR, KNEE: LIGAMENT OF HUMPHREY

A n tcri o r cruciate
ligam en t

Posterior cruciate
ligament

Insertion li ga m ent of
Humphrey

Root posterio r h o rn
la tera l m en iscus

(Top) This image is furth er lateral wi thin the interco ndy lar n otch co mpared with the p revious two images. ribcrs of
bo th anteri o r and posterior crucia te l iga ment are seen. The ligamen t of Hum p hrey is still loca ted anteroinferior to
th e posteri or cruciate, ex tending towards th e root of posterior horn lat eral meni scus. (Bottom) Further l ateral within
th e intercondylar n otch , th is image sh ows the terminati o n of th e ligament of Humph rey as it inserts o n th e pos terior
ho rn lateral meniscus at its root. This insert ion ma y be mi staken for a loose body, m eniscal fragment, o r oth er
abn o rma lity if i t is n ot correctl y identified .
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
SAGITTAL GRAPHIC & PD MR, MID POSTERIOR CAPSULE

Popl itea l art ery & vei n

ra t i n terposed between capsu le

& PC L
Perforating vesse ls
In t ercruci ate recess
Poste rio r cruciate recess
Pos te rio r c ru cia t e I iga m en t ---if-------:,.,....,..:-:r-.,..,...,-:rli-::-:---:-r-...;:__
Poste rior capsu le/ ob l ique
po pl iteal l igamen t

Popl i teal vesse ls

Perforation i n posterior capsule for

vessels
Posterior cap sule

Posterior cru cia te ligam ent

Perforati o ns in posterior
Post erior ca psule capsu le

(Top) Graphi c at t h e level of cruciate liga ments. Th e ca psule, strength ened by th e ob liq ue popliteal liga men t,
exten ds fro m t he posterior m argin of fem o ral condy les to t h e in terco ndy lar fossa at th e t ibia. It is in comp lete, with
severa l small per forat ion s at its mid port io n fo r vesse ls ex tending fro m th e popl itea ls to t he joi nt. Th e posterior
cruciate recess is found between the capsule and t h e lower 2/ 3 o f th e PCL. Th ere m ay be a small am ount of fl uid in
the i ntercruciate recess. (Middle) Sagi t ta l im age throu gh posterior cru ci ate, sh ows pos terior ca psule with o nly a sma l l
perfo ration for a vessel; t h e ma jo rity of th e ca psul e appears com plete. (Bottom) Imm ediately ad jacent, slightly lateral
sagittal image shows severa l more perforation s in pos teri o r capsule fo r vessel s. T he ca psule is i n co m plete at this
VI poi nt, but i s su rro u nded both anteriorly an d pos teri orly by fat .
112
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
GRAPHIC & CT A RTHROG RAM, SPACES WITHIN POSTERIOR CAPSULE REGION

Patella

Lateral fem o ral con dyle

Posterior crucia te ligamen t

An terior crucia l'e liga m en t
Sy nov i um coverin g posterio r
Synovi um cover ing anterior
cruciate li ga men t
cruciate l igament
Sartorius muscle
Biceps femoris muscle
Med ial gastrocn em iu s
Lateral gastrocnemius m .
Superficial fascia (crura) Po sterior ca psul e
Po plitea l vessel s

M ed ial recess, su p rapatellar bursa

Lateral recess, su prap atellar

b u rsa
In tercrucia te recess
An terior cruciate ligam en t
Posterior cruciate ligament

Posterior cruciate recess

Medial recess, suprapat ellar bursa

l n te rcruciate recess
Anterior c ruciate l igament

Posterio r crucia te recess Posterio r cruciate ligam ent

(Top) Graph ic sh ows t h e re lations h ips of the post e ri o r capsul e. The m ost superfi cial layer is the crural fascia, wh ich
e n ve lo ps the sartorius a nd o th erwise con fines all the structures. The posterior capsule (white) is co n t inuous wi th t he
sy n ovium (pink, n ext to pu rple synovial fl uid ) both poste ro m ed ially and poste rolatera ll y. Howeve r, a t th e
inte rcond ylar area, t he sy novi um sepa ra tes from the capsule a nd· cove rs the cruciate ligame nts. It is thi s fea t u re that
a llows us t o o u t li ne t h e c ruciatcs wi th inj ected fluid; t h ey are in tra-articu lar bu t extrasyn ovial. T hus, at t hi s
inte rcond ylar area, the posterio r capsu le h as no syn ovia l coveri n g. Th e capsule con tinues across th e poste ri o r aspect
of th e joint, anterior to th e po pliteal vessels, a nd is interru pted by perforating vessels. (M iddle) CT arthrogram, with
VI flu id-filled spaces. (Bottom) Spaces seen more dist ally.
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 CRUCIATE LIGAMENTS/POSTERIOR CAPSULE
CT ARTHROGRAM, SPACES WITHIN CRUCIATE/PO STERIOR CAPSULE REGION

Origin posterior cruc iate I.

ln tcrcruciate recess Anterom ed ial ba n d anterior

crucia te ligament

lnt ercruciate recess

crucia te liga m ent Posterola teral ba n d an terior

cruciate ligament

M edial femoral condyle

Posterio r cruciate ligament

Posterior cruciate recess

(Top) First of three coro nal refo rmatted images from CT arthrogram. W ith joint distension, the synovial-li ned
su rfa ces o f th e crucia te ligamen ts are outl ined. In this more an terio r cut, the anteromcdial band of th e AC L is
primari ly seen; o nl y th e o rigin of PC L is seen at th e m edial fe mora l co ndylar portion of the notch. Th ere is an
intercruciate recess th at fill s with jo i nt d isten sion. I ncidental no te is made o f a focal ca rtil age defect in the medial
femo ral weight-bearing surface. (Midd l e) Sl ightly more posterio rl y, bot h the postero latera l band of ACL and a large r
po rtion of PCL arc seen . The men i sci arc we ll o utlined, an d the intercruciate recess is again noted . (Bottom) More
posteriorly, the PC L is seen approaching its posterior tibial inserti o n. Th e posteri o r crucia te recess contacts th e dist al
2/3 of PCL and flows into the media l (n o t lateral) compartment of the knee. VI
11 5
 MEDIAL SUPPORT SYSTEM
o Attaches closely to posteromedia l po rti o n o f
!Terminology m eniscus; th is co nj o ined stru cture is te rm ed the
Abbreviations posterior oblique liga m ent
• Med ial (t ibia l) colla te ra l ligame nt (MCL) Semimembranosus
• Vast us medial is obliq uus (VMO) • Comple x inserti o n, in volving bo th midd le and d eep
• Medial pa te llofemora l ligamen t (MPFL) layers
• Main portio n in se rts o n posteromedia l tibial plateau
• Othe r a ttachment s
l tmaging Anatomy o Tibia be nea th MC L
Overview o Posteromedial ca psu le
o Oblique po pli tea l li game nt
• Medial capsul o liga ment o us co mplex has 3 layers that
o Superficial fibers of MCL
va ry from ant erior to m id to posterior; high ly
com p lex, wi th laye rs m erging at different sites Deep Layer (Layer 3)
• Primary stabilizers of fe m o roti bia l joint in va lgus • Anterior
mot io n ; seco nda ry stabili zers to rotation o Continu ou s with ca psule a lon g supra patella r recess
• Prima ry stabili zer aga inst lateral o Pa te llo m eniscalligamen t ex te nd s a n terio rly from
su blu xa tio n / d isloca tion of pate lla m eniscus to pa te lla m argin
Superficial Layer (Layer 1) • Mid knee: Capsu lar layer, so me t imes te rm ed d eep
fibers o f MCL
• Prima ril y con sists of crura l fascia
o Ca psule thi ckens to fo rm these two li game nts
• Anteriorl y and superiorly, thi s crura l fascia is
o Meniscofemoral
con t inuo us with fascia ove rl yi ng vastus medialis
• 1-2 em long
• Sartorius mu scle/tendo n e n veloped by thi s fascia and
• Exte nds fro m o uter supe ri o r aspect of body o f
is pa rt o f supe rficial layer
media l m eni scus oblique ly a n d proximall y
• Semime m b ranosus, sem ite nd inosus, a nd gracilis are
• Atta ches to e ither su perfi cial MC L o r fe m u r
immed iate ly dee p to sa rto rius a nd supe rficia l fascia
o Meniscotibial (coro n a ry ligame nt)
• Tend on s of semitendinos us and gracilis blend with
• Sh o rt (1 em ) _
fa scia o f layer 1 and fibe rs of MCL as they in se rt
• Exte nds from ou ter inferior aspect of bod y o t
d ista ll y on t ibia
med ia l m e niscus to tibi a ju st d ista l to joint line
o This mea ns sem itendin os us a nd graci li s cross just
• Sligh tly m o re posteri o r th an
su pe rfi cial to MCL (layer 2) and are between layers 1
o Ca psular layers fuse posteriorly with tJ bers
a nd 2
of superfi cial MCL (no fa t in ter posed) to torm
o Sa rto rius, sem ite ndin osus, a nd gra cilis togethe r for m
posteri or o blique liga ment
pes anserinu s at th e ir insertio n on anterom ed ia l
• Posteriorly, primarily capsul e, but receives fibe rs fro m
ti bia, approxi m a tely 5 em below joint line
o Se mim e mbranosus
• Sa rto ri us crosses media l knee jo int a nterior to
o Obliq ue fibe rs o f su pe rficial MCL (in t he fo rm o f
gracil is, which in turn is a nte rio r to
poste rior oblique ligamen t)
se mi ten d inosus
o Oblique popliteal ligament . .
• Sartorius h as t h e broadest and most ante ri o r
• Receives fibers from semimem branosus, su pe rfiCia l
insertion o n tib ia
MC L (poste ri o r obli que ligame nt), a nd synovial
• G ra cili s in serts directly ad jace n t to sarto rius, with
sheath
se mite ndinosus d irectl y posterior a nd slightly
• Envelo ps post eri o r aspect of femora l cond yle to
in fe rio r to gracili s
become a poste rior st ru c ture
Middle Layer (Layer 2) Bursa
• Ante riorly, superficia l (lo ngit udin a l) fibe rs of MCL
• Va ri able a m o unts of fa t between layers 1, 2 and 3
(laye r 2) me rge with c rural fascia (layer 1)
• Ma y see a small bursa (MC L bursa) betwe en su pe rfi cial
• M id knee: Su pe rficial fibers of MCL form layer 2
a nd deep layers of MC L
o Verti ca l fibe rs
o Requires fluid (disten sion ) to be seen on
o 12 em lo ng
o Bursa can extend t o di sta l exte nt of superficia l MCL,
o 1-2 em wide
th o ugh usually is sm aller, lyin g just over body of
o 2-4 mm thick
m eniscus a nd deep fibe rs of MCL
o Origin: Medial e picond yle
o Delineat ed a nte ri o rl y by a nterio r m a rgin of
o Courses slight ly a nteriorly to inser t on tibia
supe rfi cial M C L ..
approximately 5 em below joint line
o Delinea ted posteri o rly by m e rger of supe rfi Cial and
o Layer o f fat co nt a ining m edia l infe rior ge nicular
deep fibers of MCL
a rtery lies betwee n superfi cial MC L a nd t ibia
• An o the r bu rsa separates sem imembra nos us te ndo n
• Posterio rl y, superficial MCL has a po ste rior oblique
from poste rio r ca psule
co mponent
o O blique fibers ext e nd from laye r 2 poste riorly and Medial Stabilizers of Patella
fuse with layer 3 • Loosely te rm ed media l retina cul um

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 MEDIAL SUPPORT SYSTEM
o Extends from vastus medialis superiorl y to t i bia • Deep in relat ion to patellotib ial ligament
inferi orl y (anatomi ca lly i n layer 3)
o Inserts alo ng m ed ial edge o f pa tella
• H ighly complex, wi th 3 layers w hich differ in
Poste romedial Capsule
superi o r, mid, and i nferior portion s • Medial side o f posterior capsule: Fibers from several
o Layer 1 is m ost su perfici al, just deep to structures merge wit h and co ntri bute to capsule
subcutaneo us t issues o Fibers from distal sem i membran osus tendon
• Deep crural fascia fo rming oblique pop.liteal ligament '
• A nterosuperio rl y, continuo us w it h fa scia o fibers from superficial M CL, forming posterior
overl y ing vas tus mediali s obliq ue liga ment, wh ich also co ntribute to oblique
o Layer 2 is just deep to la ye r 1, an d just super fici al to po pl itea l ligament
la yer 3 (joint capsule) o Capsu le attaches to pos teri o r fem oral cortex a few
o Within laye rs 2 and 3, co ndensations o f fibers form em above the level o f th e m os t su perior aspect of
ligaments o f m edial retinacular complex cartilage
o With in laye r 2, media l retin acu lar complex o Ca psu le attaches inferio rly to t ibia l-2 em below
ligaments form an inve rted triangle i n sagittal plane, joint li ne
with a central spli t which defines 3 separate o A bursa separa tes capsule and semi m embra n osus
ligaments ten don
• MPH.: Superior aspect o f tri angle o A little m ore towards center of knee,
• Super fi cial M CL: Posterior aspec t of triangle semim embranosus is repla ced by m ed ial
• Patellotibial ligament: Anteroinferio r aspec t of gastrocnemius
trian gle o Superiorly, capsu le joins gastrocn emi us t endon
o Layer 3: joint ca psule • Mid p o rt ion of posteri o r capsu le
• Superi or porti o n of medial pa tellar sta bilizers o Capsul e i s incomplete posteriorly
o Vas tus m edialis obliquus o Th erefore intraa rticular space is not completely
• Inferior portion of vast us m ed iali s separate from ex t ra articu lar fa t·
• Acts as a dynam ic stabilizer, neutra lizing the o Po pliteal artery and vein course behind capsule
lateralizing fo rces o n patella exe rted b y vastus • Perfo rating vessel s extend fro m th ese thro ugh
lateral is during quadri ceps co ntract ion posterio r capsule
• Arises from addu cto r m agnu s tendon, media l • Perfo rating ner ves accompan y vessel s
intermuscula r septum , or ad ductor tu bercle
• M erges wi th M PFL an d inserts o n superi o r 2/3 of
m ed ial patella jAnatomy-Based Imaging Issues
o Media l patellofemoral ligament
• M ajo r ligamento u s restraint preventing l ateral
Imaging Reco mme ndations
• Superficia l MCL: Co ro nal and axi al
pa tellar subl uxation (50-609{> to tal restrai ning
• Capsular la yers (deep M C L): Coron al
force)
• MPFL and VMO best seen on axials immed iately
• Ori gin is va riable: Ad ducto r tubercl e, medial
inferior to adductor tubercle
epico ndyle, or superficial MCL
o MPFL seen at its o rigi n in 801!1>
• Runs forwa rd and slightly inferiorly, just deep to
o MPFL seen at patellar insertion i n 100%
VMO, fuses with aponeurosis of VMO
• Media l retinaculum seen just inferi or to M PFL/VMO,
• Inserts o n superior 2/3 of medial patella; seen as
also on axial s
distinct st ru cture at insert ion
o M ed ial retinacu lum seen at midsu bsta nce and
• Length 4.5-6 em
patellar in sertion in 100%
• < 0.5 em th ick
• Patelloti bial and m edial patellomeniscal m eniscal
• W idth 1-2 em at femur, 2-3 em at patella
ligaments seen at level of knee joint, o n axial s
• M erges wi th layer 2 (m edial retinaculu m)
• Oblique popli teal ligament en velo ps post erio r aspect
in fe rio rl y
o f femoral condy le, best seen o n ax ials
• M id portion of m ed ial patellar stabi li ze rs
o Seen 100% o n axial MR
o Superfi cia l MCL (layer 2), fuses with crura l fascia
(layer 1) to fo rm m ed ial retin acul u m (pro per)
an teriorl y
o M erges w ith VMO fa sci a anterio rl y
J Selected References
o In serts in to medial margin o f patella t. Elias D et al : Acute latera l pa tell ar dislocation at MR
• In feri or portion of m edial patellar stab ilizers i magi ng: in jury pa ttern s of m ed ial patellar soft-tissu e
o Pa telloti bia I liga m ent restraints and osteoch o nd ral injuries of the inferomedial
patell a. Radi o logy. 225:736-43, 2002
• Originates o n tibia at level o f insertion of gracilis
2. De Maeseneer Met at: T hree layers o f the medial capsula r
and scmiten d i n os us
and supporting stru ctures o f th e kn ee: MR
• j o ins layer I and extends o bliquel y prox i mall y to imaging-ana tomic correlati o n. Radiograph ies. 20:583 -589,
in sert o n i n fe rior aspect o f patella and on patell ar 2000
tendon 3. Spritzer C et at : Medial retinacul ar co mp lex i n jury in acute
o Medial patcllomenisca l l igament patell ar dislocation: MR fi ndings. AJ R. 168: I 17-22, 1997

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 MEDIAL SUPPORT SYSTEM
SAG ITTAL T1 MR, P ES ANSERINUS
Semimembranosus muscle

Sartorius muscle

Graci lis muscle bl: tendon

Medial colla teral ligament

Sem itendinosm t.

Semitendi nosus muscle

Semimembranosus te ndon

Sem imembranosus muscle

Semitendinosus tendon

Semi mem te ndon

im ertion

(Top) lightly more medial cut sh ows a rem nant o f sa rt orius. Gracilis tendon is i mmediately posterior and deep to
sa rtorius. Semi tendinosus tendon fo ll ows even mo re posterio rl y and medially. (M i ddle) Furth er med ially, the
semimembranosus muscle and tendon are seen, wi th semitendinosus muscle and tendon rem ain behind them.
Wh ile the semitendinosus co ntinues its course, following gracilis towards its anteromedia l ti b ial insertion,
semimembranosus inserts at t h e prox im al tibia posteri orl y and medially. (Bottom) Approaching the tibia with a
more m edial sectio n, sem im embranosus is seen to broad en at its tendinous insertion on the poster ior as well as
medial tibia, immediately be low the joint line. Th e slips from semimembranosus to medial collatera l ligament and
posterior capsule via t he posterior oblique ligament are no t seen as sepa rate structures here. VI
 MEDIAL SUPPORT SYSTEM
CORONAL T1 MR, PES ANSERINUS

Sartori us m uscle

Semimembran osu s i nser ti on

Gracili s ten don

Sem imem branosus muscle

Graci l is musc le

Sa rtorius ten don

Se m i tend i nosus te ndon

Sem im em bra nosu s muscle

Semi tendin os us m uscle & tendon

(Top) First o f th ree coro nal Tl M R im ages th rough th e p osterio r p o rt io n o f th e jo int, shows th e med ial-latera l
relatio n shi ps o f t he tendo ns com pri si ng the pes anseri n us. At th e level o f t h e po pli tea l vessels, just posterio r to t he
ti bia, the semimem brano sus spreads o ut into its i n sert io n, w hich i s w ide at the posterior as wel l as posterom ed ial
tibia . The sartorius muscle is seen at th is level, with its tendon curvi n g an teri orly o u t of th e plane. A po ri o n o f
graci li s tendon is seen paral leli ng and d eep to sarto ri us tend o n. (Middle) Slightly more posterio rl y, a rem nan t o f
sart o rius is seen, b ut gracil is muscle & tendon are m ore com pl etely seen . A ve ry sma ll po rtio n o f semiten d inosus
ten d o n is seen dista l ly, b ehi nd & medi al to gracil is. (Bottom ) Even mo re po sterio rly, semi te n dinosus m uscl e &
VI ten do n are shown posterio r to the m uscle belly of semimem brano sus.
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 MEDIAL SUPPORT SYSTEM
AXIAL T1 MR, PES ANSERINUS

Vastus m ed ial is obliquu s m .

Anterio r medial crura l fascia

Or igi n, med ial patell o fem oral

ligament & m ed ia l collateral I.

Sartori us tendon
Sartorius muscl e
Graci lis tendon
Semimem b ranosus m u scle
C rural fascia
Semitendinosus te ndon

Medial patell ofem ora l l igament

Medial coll ateral l igament

Sa r to rius tendon
Sartori u s musc le
Graci l is tendo n Cru ra I fascia
Scm i m em branosus tendon
Sem i tend i nos us tendo n

Medial coll ate ral l iga m ent,

lon gitu clin al po rtio n
M ed ial co l lateral l iga m en t, ob li qu e
p ortio n Posterio r obl ique l igamen tou s
extension of obli que fi bers
Sar to rius tendo n MCL
Graci l i s ten do n Sem i memb ranosu s t.

Scm itcocli nosus tendon

(Top) Fi rst of t h ree axial T l MR im ages sh ows the an ato m y of pes an serin us. Sar torius is th e most superfi ci al. lt i s
invested by crural fascia to fo rm layer 1. G racilis tendon is m edial t o sarto ri us and fo ll ows i ts ten don in a slightly
pos terio r posi ti o n. Sem i tendi nosus is post eri o r to semimembran osus, and dist inctl y pos teri o r and m ed ial to gracilis
tendo n . (Midd le) Superficial MCL ari ses distal to adduct o r t ubercl e and for ms layer 2. (Bottom) At th e level o f the
joint line, th e eleme nts of the pes line up in o rder (sa rto riu s, gracilis, semi ten d i n osus) o f th eir insertion o n the
an teromedial t ibia. An t erio rly, layers 1 (sartori us) and 2 (superfi ci al MCL) m erge to co ntribute to m edi al ret inacul um.
Graci l is & semi tendinosus lie betwee n layers 1 & 2. Poste ri o rl y, layers 2 & 3 (superfi cial & deep M C L, respecti ve ly)
merge to fo rm t h e posterio r oblique ligam en t, contri buti ng to ca psu le. VI
121
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 MEDIAL SUPPORT SYSTEM
CORONAL T2 FS & SAGITTAL PD MR, SEMIMEMBRANOSUS

Sem im e mbra n osus muscle &

te ndo n

Plantaris muscle

Sarto rius m u scle Poste rior t ibi al a t tach m ent

sern i m e mbra nos u s

Sem im emb ra n osus muscle &

te n don
Planta r is m u scle

Slip to 'oblique pop litea l from

Slip to MCL fro m sem imemb ranosus
semi m e m bra n os us
Posterom edial tibial in sertio n
' emim e mbran osus
Sa rto rius m u scle

Sem imemb ranosus tendon

Posterom ed ial t ibial

attac hm en t
Medial colla tera l ligament Media l ti bia l a ttach m ent/slip to
MC L

(Top) First of two posterio r co ro n al T2 FS im ages shows se mi m em bra nosus in se rtio n a t t h e postero m ed ia l tibia.
(Middle) Sligh t ly m o re a nte rior cut sh ows th e m ultiple slips of semimem bra nosus. These inclu de insertio n s at the
poste ro m ed ia l t ibia, a n d a n o t he r more d irectly medi a lly. Ad di t io na ll y, t h e re are slips exte nd ing from
se mi m embran os us to t he o bliq ue popl iteal and med ial coll ateral liga m e nts. (Bottom) Sagi t ta l PD M R image sh ows
semimembra n os us inserti o n on th e postero media l t ibia, a lo ng w it h its sli p exten di ng to th e m edia l coll ateral
Iiga m en t.

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VI
125
 LATERAL SUPPORTING STRUCTURES
• Internally rotates t ibia o n fe m ur (a t initiation of
JTerminology flex ion o f kn ee)
Abbreviations • Protects posterio r horn lateral m enisc us by
• Iliotibia l (IT) t ra ct withdrawi n g it fro m jo int space d uring flex io n
• Lateral (fibular) co llateral ligame n t (LCL) and rotati o n
• Stabili zes posterolatera l corner fro m ro tatory
Synonyms instabil ity
• Popliteofibular = sh o rt ext erna l lateral liga m ent =
fibular o rigin of popliteus= popli teofib u lar fa scicles
Posterolateral Capsule
• Arcuate li ga m ent fibe rs contribu te to t:a ps ul e latera lly
• Popliteal tend on (intraarti cul ar but ex trasynovia l)
Jlmaging Anatomy firml y atta ched to poste rior capsule
• Popliteal recess may extend d ee pl y be hind tibia (in
Overview front of caps u le); m ay ha ve continuity w ith proxima l
• Com b ination of m uscles, te nd on s, a nd ligame nts tibiofibul a r jo int
wh ich contribu te to late ra l stabil ity o f knee • Lateral gastro cnem ius m uscle contributes fibe rs to
capsul e
Muscles Contributing to Lateral Stability
• Iliotibial tract Late ral Support System Co nsists of 3 Layers
o Origin : Stro n g ba nd of deep fascia com posed o f th e • Layer 1 (superficial)
fusio n of apo n eu roti c coverings of o Anteriorly, IT t ract
• Ten so r fa scia lata o Posterolate rally, su pe rficial port io n of bice ps
• G luteus m ax imus • La yer 2 (middl e)
• Gluteus minimu s o Anteriorly, latera I retinacul um
o Above kn ee, IT tract h as insertion arms to o 2 ligam entous thi cke nin gs o rig ina te f rom late ra l
• Supracondy la r tu bercle of late ral fe moral condyle pate ll a
• Ble nds wi th in term uscular se ptum • Prox ima l one te rmin ates at late ra l in termuscular
o Main insertion se pt um
• Ge rety tubercle (anterolatera l t ibia nea r plateau) • Dista l one te rm in ates at fe mo ra l in serti o n of
• Small other a tt achments to pate lla a nd pate llar poste rola te ra l ca psule a n d late ra l head of
li ga m ent gastroc nemius te nd o n
• Biceps femoris • Layer 3 (deep)
o Long h ead jo ined by sh o rt h ead above knee o Forms late ral pa rt o f capsu le
o Main insertion si te is l:l ead a nd styloid process o Co ntains several thi cken in gs th a t functi o n as
fibula di screte structures
o Severa l tendinous a nd fascia l insertiona l • Lateral (fibula r) coll ate ral li game nt
compo ne n ts, including a po rtio n th at inse rts o n • Arcuate com plex, co n sistin g o f m ultiple ligame nts
poste rior edge o f IT tract o Poste ro lateral co rner ligam ent a na tom y is ex tremely
o Anterior oblique fibers of conjoi.ned tendon arise complex
from an te rio r bu nd le o f short hea d biceps and insert Posterolateral Corne r Stru ctu res
o n tibia
• All insert o n fib ula r head and provide poste ro la te ra l
• Popli teus
support
o Tendino us attachment at pop litea l sulcu s of la te ra l
• Not aU are see n with eq ual reliability on imagin g (see
fe mo ral co ndy le
"A nato m y- Based Imaging Issues" below)
• Inferior and d eep to o rigin of LC L
• Postero late ra l corn er structures ma y be divided into
o Extends posteromedia ll y thro ugh popliteal hiatus
superficial a nd dee p
(runs deep t o fabe llofibular and arc uate ligame nts)
o Superfi cial : Lo ng and short heads o f b iceps fe moris,
o Superior popliteorneniscal fascicle exte nd s fro m
and LC L
poste rio r ho rn lateral m en isc us to paratenon tissues
o Deep: Pos terolatera l rein fo rce ments of fibro us
of popliteus tendo n
capsule, includin g fabe llofibu lar, a rcua te, o bli qu e
• Superior pop li teo me ni sca l fasc ic le an d arcuate
popliteal, a nd po pli tcofibula r ligamen ts
ligament fo rm roof of popliteal hiatus
• Long head of biceps femor is
o Inferior popliteo meniscal fasc icle extends fro m
o 2 major tendin o us com pone n ts
posterio r h o rn lateral m eniscus to paratenon tissues
• Direct a rm inse rts o n fib ula r head
o f pop! iteus t endo n
• Ante rior a rm inserts just ante rio r to d irec t a rm o n
• In ferior popliteome n iscal fascicle fo rms floo r of
fibu lar head a nd continu es distal ly as th e a nterio r
popli teal h iatus
apo neurosi s that ex te nd s anterola te rall y a ro und
o Superio r a nd infe rior fascicles join and insert on
leg
fibular styloid as poplit eofibu lar l igament
• Short head of biceps femoris
o Popliteus muscle a ttach es to posterom ed ia l aspec t
o 2 tendin o us co m po n e nts
Q) o f proximal tibial metaph ysis
Q)
• Direct a rm inserts o n fibu la r h ead a nter io r to
o Function o f popli teus muscle
c: st yloid process and media l to lo ng h ead biceps
• Ass ist with flexion of kn ee

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 LATERAL SUPPORTING STRUCTURES
• An te ri o r arm passes m ed ia l to la te ra l coll at eral o Obliqu ity run s a nte rosupe rio r to poste r:oinfe ri o r,
ligament a nd inserts in to superolatera l edge of gen erally para ll e l to popliteal tendon as seen o n
late ra l tibia l con dyle, approac hing Gerd y tube rcl e sagitta ls
• Lateral collate ra l ligame nt
o Proximal a ttach m ent at distal fe mur just proxima l Imaging "Sweet Spots "
a nd po sterior to la te ral epicondyle • Statistics be low based o n 1 .5T MR ima gin g
o Prox im a l a ttachm ent is sligh t ly prox imal and • Bice ps see n well in all 3 planes, 100%
an te rior to su lcu s for o ri gi n of pop lite us tendon o In divid ua l compo nents ma y be seen sepa rately on
o LCL extends poste ro latera ll y to in se rt o n upp e r facet ax ia ls n ea r fibul ar attach m ent
o f fibu lar h ead • Short head bice ps, d irect arm 70 1Yt,
• An te rol ateral to a ttac hment o f fabe ll ofib ula r a nd • Lo ng head biceps, d irect a n d an terior arms 70%
arcuate liga m e n ts • LCL seen we ll in a ll 3 planes, 100°/r,
• Fa be llofibu la r ligame nt • Superior popliteomen iscal fa scicle seen best o n sagitta l
o Origina tes a t fabella (or proximal to it) fluid sensitive sequ ence, at level of posterior horn
o Inse rts at lat e ra l as pect of apex of fibu lar h ead late ra l me ni scus; 100(}1,
(styloid process) • Inferior popli teomeniscal fascicle seen best o n corona l
o Inse rts jus t anterolateral to in sertio n o f fluid sen sitive sequen ce, a t leve l of bod y latera l
popliteofibular liga m en t on fib ular hea d m e niscus; 100(}·(,
o Fabell o fib ula r ligament may be d ominant wh en • Arc uate li gam ent
a rcuate is diminu t ive o In cadaver study, at least 1 limb seen in 70% o n
• Arc u ate ligame nt sagi ttal o r corona l MR
o Y-sh aped • La te ral limb arcuate seen 57% (better wh e n fabe lla
o Ari ses fro m fi bu lar st y loid process, just deep to abse nt)
fabe ll ofibu lar li gam e nt • Med ia l limb arcuate seen 57% (bette r when fabe ll a
o Lateral lim b courses st rai gh t upwa rd a long late ral presen t)
kn ee capsu le t o reach la te ra l fe m ora l co ndy le o Corona l o blique M l\ may in c rease like lih ood
o Medi a l limb c rosses over posterio r surface of • Fabell o fibu la r liga ment rare ly seen as se parate e ntity
popliteal tendon a n d attac h es to posterior kn ee (coron a l or sagitta l)
capsule • Popliteofibular liga m en t
• Media l lim b, a lo ng with s upe rio r po pli teomeniscal o In cadaver s tud y, seen 579f>using coro nal o bl iq ue
fasc ic le, forms bowed roof of po pliteal hia tus (38% w ith s tan da rd planes)
• At- inserti o n on posteri o r kn ee ca ps ul e, media l • Obli que po pl iteal liga me n t 100%, ax ia l
limb arcuate m e rges wit h fibers fro m o bl ique Avulsion Fractu res at Poste rolateral Corner
pop litea l liga m e n t • "Arcu ate sign"
o Arcuate m ay be domina n t wh en fabe ll o fibul a r is
o T h in sli ver avulsio n at posterosuperior portio n of
absent (or m ay co nta in fi bers o f fa bell o fibul ar
fibula r st y lo id
liga ment) o Site o f (n ea r) com m o n in sertio n o f fabe ll ofibular,
o Inferior late ra l geni cul at e a rte ry passes ante rior po p liteofibu lar, a nd a rcua te ligaments
re lative to a rcuate o Marrow e dema may a lso ind icat e in ju ry a t th is site
• Obli q u e popliteal li gament
o Poste ri o r c ruc iate li gament in jury is o fte n associated
o Arises medially from sl ips of semim embranosus and
• Antero late ra l femoral hea d a vulsion (no t fibul ar
m ed ial tibia l condyle, courses su pe ro late ra ll y; see
styloid)
"Media l Suppo rt Syst e m " secti o n o LCL/biceps avulsion
o Joins a rcua te .l igament postero latera ll y at its femo ral
in se rtio n (m argin of interco ndylar fossa and
pos te ri or sur face o f late ral femoral condyle)
• Po pliteo fibular liga m e nt
Iclinical Implications
o Arises from con flu en ce o f su per ior & inferior Clinical Importan ce
fascicles • Poste ro lateral struc tures act primarily as static
o Inse rts o n fibul ar h ea d (see "po pli teu s" above) co n strai nts to va rus ang ulati o n and ex te rna l rotatio n
o Popliteofibular liga m e nt may be dom inan t, with o f kn ee
ne ithe r arcuate o r fabellofib ular liga m ents prese nt • Secondary restraint agai nst poster io r tra n slation o f
tibia

!Anatomy-Based Imaging Issues Biomechanica l Selective Cutting Study

• Ma jor stru ctu res preventi ng posterolateral inst abil ity
Imaging Recommendations a re LCL and popl iteu s te n do n
• C rucia l pos terolate ral struct ures see n o n axial a nd • Po p li teo fi bul ar li ga men t al so im porta nt in providing
rout ine o bliq ue sagitta l imagin g (gene ra ll y prescr ibed stati c stabil ity
on ax ia l, obli qu ed alo ng course o f ant er ior cru ciate 1.) • Surgery primarily focuses o n res toring these ligamen ts
• Co rona l oblique suggested to inc rease proba bili ty o f • Ide nt ifying pop li teo fibu lar o n MR is vari ab le (eve n
vis ua Iizi ng poste ro la te ra I st ructures with coronal o b li que)
o Prescribed off sagittal im age o Limita tion in assess ing po ste ro la tera l co rne r injuri es

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 LATERAL SUPPORTING STRUCTURES
AXIAL T2 MR, POSTEROLATERAL STRUCTURES

Latera l col latera l I.

Arcua te
l iga men t / popl i teofibu lar
l igament

femoris tenclon

capsu le/obli que

pop li tea l li ga m ent

Latera l coll atera l I.

Arcuate l iga ment

Bicep> femoris tenclon

Pos terio r
capsule/oblique
pop liteal liga ment Poplitea l ll iatu s

(Top) Slightly distally, the popliteus tendon enters the poplitea l hiatus as it t ravels posteriorly and inferiorly around
the lateral fem o ra l condy le towa rds th e jo i nt l i ne. ( Bottom ) Approachi ng the joint l ine, th e popliteus tendon curves
posteriorl y within t h e popliteal hiatus. Bo th th e arcuate and popl i teofibular liga ments arc seen extend ing from their
o ri gi n at' the fi bu lar styloid process p rox i ma lly to co n t ribute to the posteri or ca psule and popl i teus para tenon,
respectively. M o re superfi cia ll y, the latera l collateral liga ment approaches biceps femoris as t h ey head towards t h eir
inserti on on the lateral fibu lar head .
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 LATERAL SUPPORTING STRUCTURES
AXIAL T2 MR, POSTE ROLATERAL STRUCTURES

Lateral col lateral I.

Popliteofibular
ligament
Biceps femoris tendon

Arcuate/ fabel l ofi bular

ligam ent
Po pliteus tendon

Po pliteus muscle

Ilio tibial tract insertion

Biceps/ LCL con joi n ed

tendon
Popl iteus mu scle
Arcuate/ po p! i teofi bula r
ligam en t

Popliteus
musculotendinou s
junction

(Top) At th e leve l of th e joint line, the biceps and LCL approach merge r to become a co nj oined tendo n prior to
inse rti o n o n fibular head; thi s occu rs fai rl y ofte n. The tissue lying between the conjoined tendon a nd posterolateral
tibia co nsists o f the popliteofibul ar li ga m ent (deep) and arcuate & fabellofi bula r ligam ents (more superficial). The
popliteus continues in the hia tus towards its muscul otendino us jun ct ion. (Bottom) App roach ing the fib u lar head,
th e same relationships m aintain except that popliteus te ndon now reaches t he musculotendinous junction and
popliteus m uscle is seen posterior to the tibia. An terolatera ll y, iliotibial band has inserted on Gerdy tube rcle.
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 LATERAL SUPPORTING STRUCTU RES
CORONAL & SAGITTAL T1 MR, FA BELLOFIBULAR LIGAM ENT

Sem im em branosu s m .

.------+- Lateral h ead

ga;trocn em ius mu scle
M edial head o f
gastrocne mius mu scle

Latera l head
gastrocn emi us muscle

Biceps femoris muscle

Superior fascicle
(popliteom eniscal I.)
Fabella
horn latera l
m en iscus

Fabellofi bular ligament

ten do n

Poplit eo fi bular
li gament

..,...;;;:;;--+-- Insertion fabellofibul ar

l igamen t o n fibular
h ead

(Top) Thi s far posterior coronal cut shows a fabella w ithi n th e latera l h ead o f th e gastrocnemius. There is a
prominent fabello fibular ligament, ex tending fro m the fabella to the posteri or aspect of the head o f th e fibula ,
Q)
Q)
immediately posteromedial to long h ead biceps tendon inserti on. Thi s l igament is hypertrophied; it is not usually
c: see n this well. (llottom) Sagittal cut loca ted laterall y shows th e h ypertrophied fabellofi bular ligament in th e same
patient as previous image. The fabella is distinctl y seen, wi th the fabellofibular ligament investing it and ex tending
to the apex of fibular sty loid . The popliteu s tendon is w ith in th e poplitea l hiatus; the superior fa scicle extends from
posterio r h orn lateral meniscus to the superi or paratenon of popli teus. The thin popliteofi bu lar ligam en t is seen
VI extendin g from fibular head to popl iteus as well .
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 LATERAL SUPPORTING STRUCTURES
SAGITTAL T1 MR, BICEPS FEMORIS INSERTION, FABELLOFIBULAR, & ARCUATE LIGAMENTS

Lateral collateral ligament

Biceps femoris tendon

Lateral coll atera l l igament

insertio n
Long head biceps tendon
Anterior arm sh or t h ead biceps
insertion

Bi ceps femoris muscle &

tendon

Lateral collateral ligamen t

Anterior arm short h ead biceps

tendon Biceps, short head

Popli teu s tendon

Popl itcofibular l igament

(Top) First of three sagittal T l M R images, far latera l, showing t he complex set o f insertions of long and short heads
of biceps femor is. Alth ough t hey are no t often discerned as separate on MR imagi ng, t he long head of biceps h as two
i nsertions on th e posterolateral portion o f fibul ar h ead. The short head o f biceps has one insertion on th e fibular
head immed iatel y anteri or to t he long h ead & a secon d broad insertion on an terola teral tibia. Th e LCL inserts
immediately medial to long h ead biceps. (Middl e) Slightly m edial, on e sees a remnant o f lateral co llateral ligament.
Short head o f biceps is still see n inserting on an tero lateral ti bia, w ith a branch insert ing on fibu lar h ead. (Hottom)
Image at th e level of bowtie of m eniscus, shows popliteus tendon ex tending t o hiatus, popl iteofibular l igament
extending from paratenon to fibula, and posterio rl y, th e arcuate ligament. VI
135
 LATERAL SUPPORTING STRUCTURES
SAGITTAL PO MR, POPLITEU S TENDON

Lateral head
gastrocnemius m.

Lateral coll ateral

ligament

Long h ead biceps

temoris i m ertion

Oblique popl i teal

ligament/ posterior
capsule

.:::;::::::;-- Superior rascicle

(popliteomeniscal
ligament)
Arcuate liga men t

Posterior ho rn lateral tendon

meniscus
Popliteoribular
li gament

(To p) First o f five sagi t ta l PD M R im ages fo llowi ng t he course o f th e popli teus ten don. I n thi s fa r la teral image, the
bi ce ps fem oris is seen i n serti n g o n fibu lar h ead . A h int o f origin o f popliteus tendo n in its su lcus i n latera l fe moral
co ndyle is seen , alo ng w ith th e origi n o f lateral collateral liga men t. (Bottom) Sl igh t ly m ediall y, the popl i teus tendon
enters the jo i n t and its hiatus. The lateral (obl ique) h ead o f arcuate ligam ent is seen arising along wi t h
popliteofi bular liga m ent from th e fi bu lar sty loid; t h e arcuate l igamen t conti n ues towa rds t he obl iq ue popl iteal
l igamen t an d capsu le of t h e jo int.
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136
 LATERAL SUPPORTING STRUCTU RES

Lateral head ga strocn em iu s m .

Superior fascicle/medi al arcuate

ligament
Meclial bra nch. arcuate ligam en t

Pop litea l hiatus

Popl iteus ten clo n

Popliteofi bular ligam en t

Superior fascicle/m eclial arcuate

li gament: Roof o f popl i teal
hiatus
Meclia l branch arcuate l iga m en t

Popl iteus ten clon

Pop l iteofibu lar l iga m en t

Posterior capsule
rn !
.

Posterior horn l ateral m en iscus

Popliteus ten clon

Popl iteus musculote nclinous

junction

Pop liteu s muscl e

(Top) Slightly m o re m ed iall y, th e popli teus elongates downward; th e popliteofibu la r liga me nt me rges with its
para teno n. By this point, th e m edial branch o f a rcuate ligame nt h as joined th e superio r fascicle to form the roof of
the popliteal hiatus. (Middle) The poplit e us te ndo n approach es its muscu lotendinous juncti o n. Note th e arched roof
of popliteal hia tus fo rm ed by the superior fascicle and the m ed ial bra nch of the a rcuate li gament. (Bottom)
Approaching, bu t not yet in t he inte rcon dyla r no tch, the pop lite us tendo n is at its muscul otendinous jun ct ion. The
muscle ca n be see n ex te nd ing d ista ll y towa rd its insertion on posteri or tibia . By t hi s po in t, th e posterior horn lateral
meni scus has rejoi ned t he poste ri o r capsu le.
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 LATERAL SUPPORTING STRUCTURES
CORONAL T1 MR, POSTEROLATERAL STRUCTURES

Biceps femoris muscle

Mu culotendinous
junction, popliteus

Pop li teus muscle

Arcuate ligament

Pop li teu 5 tendo n

Biceps femoris
in ertion

Popliteus muscle

(Top) First o f two coron al T l M R images, far posterio r, sh ows structures in the posterior-most aspect of posterolateral
corn er. The musculo ten dinous junction o f popliteus is seen, ex tendi ng into popliteus m uscle. (Bo ttom) Sl ightly
more anteri orly, t h e long h ead of biceps fem ori s in serts on the outer aspect of fi bular h ead. A corner o f popli teus
tendon is seen ex ten di ng aroun d th e posterolateral tibia toward s its musculo tendin ous jun ction. Arcuate l iga ment is
seen joining posterior ca psule.

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 LATERAL SUPPORTING STRUCTURES
CORONAL PD MR, POSTEROLATERAL STRUCTURES

[[
Posterior ho rn la teral m en iscus
Fluid in popliteal hiatus

Pop liteus ten d o n

Po pliteofibular liga men t

Bice ps femo ris te ndo n

Popli te us mu scle

Lateral collatera l li ga m ent

Poplite us ten don

Body/posterior horn lateral
meniscus
Popli teofibula r/la tera I arm
arcuate li gaments

Biceps fe moris muscle

O rigin lateral coll atera l

ligam en t

Origi n popliteus tendo n

Body lateral m eni scu s

(Top) First o f t h ree co ro nal PD MR images, fo llowing th e popliteus tendon, out li n ed by fluid wi thin the popliteal
hi atus. Thi s more posteri or of th e th ree shows the po plite us muscle, as well as the popliteus te ndon as it traverses th e
hi atus, with fluid sepa rating the tendon fro m th e posterior h o rn latera l menisc us. Biceps femoris tendon inserts
la te rally on fibular head. (Middl e) Slightly more anteriorly, the m id portion of la teral colla te ral liga me nt is seen
extend ing towa rds its in sertion o n late ra l femora l head. Popliteus te ndon is just enterin g the hiatus at the level o f
junctio n poste rior h orn/body o f lateral meniscus. (Bottom) At a mid-co ronal cut, the o rigin s of both la tera l collateral
ligament a nd poplite us tendon a re see n. At th is point, the body o f lateral meniscus is d irec tly atta ched to ca psule
sin ce popliteus h as not ye t entered t he hiatus. VI
139
 LATERAL SUPPORTING STRUCTURES
CORONAL OBLIQUE T1 MR, POSTEROLATERAL STRUCTURES

]J Biceps femoris muscle

Planta ris m.

M edial arm arcuate

liga m en t, b lending Arcuate l igament origin
into posterior capsu le

Apex fibular styloid

Bi ceps femoris muscle

Popliteu5 tendon o rigin

Popli teu s tendon

wi th in hiatus

Popliteus
Latera l genicul ate -+------'2 m usculo tendi no us
nerve & vein junction

Fibu la r origi n
popl i teofibular
ligamen t

(Top) First of fou r coro nal oblique T l MR images o f posterolateral structures. Th e images arc prescribed off a sagittal,
angli ng fro m anterosuperior to posteroi nferi or, following th e popliteus tendon. Thus, in th is image we sec more of
th e l ateral fem ora l condyle th an fibu la. It allows visualizatio n of oblique posterior structures such as t h e
fabcllo fibular l igament and arcuate l igament. Thi s i m age is too far posterior to incl ude m uch popli teu s tendon.
(Bottom) Slightly anterior to the previous image, thi s lays th e popliteus t endon out such that it is seen from its
ori gin to musculo tendinous junctio n. Th e fibular o ri gi n of th e popliteo fibul ar l igament is seen, w ith fibers stretching
up to m ee t the poplitea l paraten on. Portion s of t he arcuate ligament may be present but are n o t well seen . Since we
VI are at the apex o f the fibula, th e biceps has no t ye t inserted.
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 LATERAL SUPPORTING STRUCTURES
CORONAL OBLIQUE T1 MR, POSTEROLATERAL STRUCTURES

Origin lateral coll atera l

ligament

Popliteus tendon

Tibiofibular l igament &

capsu le

Long head bice ps

femoris i nser ti on

Lateral collatera l
ligamen t
Posterior horn lateral
m eniscus
Popliteus tendon

Bicep s femoris
insert ion

(Top) Sl igh tly anterio r i mage continues to show more of t h e origi n of poplit eus tendon. T h e o rigin of LCL is seen,
and t he long h ead of biceps femoris i nserts o n the m id porti on of t he fibula laterally. (Bottom) More anterio rly,
popl iteus ten don i s seen separated from posterior ho rn lateral m eniscus by f luid i n th e popliteal h iatus. Th e bicep s
m ore fu ll y inserts o n fib ula, w ith latera l co ll ateral ligam ent inserting immedi ately med ia l t o it.

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 LEG OVERVIEW
IGross Anato my o Ends attached to anterior bo rders of ti bia and fib ula
o Long exten sors, pero neus terti us, anterior tibial
Osseous Anatomy vessels, and deep peron eal nerve pas behi nd it
• Tibia o Medial part splits to enclose tendon o f tibial is
o Prox imal tibiofib ular joint anterior, forming a sl ing fo r it
• I lead of fibula and lateral cond y le tibia joined by • Inferior extensor retinacu lum: Distal to ankle jo int
fibrous capsule except for attach ment o f on e band to an terior part of
• May co mmunicate w ith knee jo int medial malleol us
• Poste rolaterall y loca ted • Superior peroneal retin acul um
• Syn ovial; at ri sk for any articular process o T h ickened deep fascia securing pero neal tendons to
o Antero lat-eral ti b ia: Origi n of anterior muscles o f leg back of latera l malleol us, peroneus longus su perficial
o Anteri or border (shin): Sharp ridge runn i ng from to brevis
tibi al tuberosity p roxima lly to ante rior margi n of o Retinaculum attached to back of lateral mal leolu s
m edial m alleolus and to lateral retrot rochlear tubercle of calcaneus
o Med ial tibi al surface • Flexor retina culum: Posteroinferior to med ial
• W ide and flat malleol us
• Proximall y, covered by pes an serinus Mu scles o f Leg
• Remainder is subcu taneous • Compartments separated by deep fasc ia, w h ich give
o Medial bo rder of tibia: Saphen ou s nerve and great partial origin to several m uscles
saphenous vei n run along it • Post eri o r compa rtmen t: Su p erfici al muscl es
o Posterior ti b ia: O rigin of d eep posteri or muscles o f o Gastrocn emius
leg • Origin : Medial from posterior femoral metaph ysis;
o Lateral border of tibia: Ri dge for atta chment o f latera l from posteri o r edge of lateral epico ndy le
interosseous membrane • Heads separated from posterior capsu le by a bursa
o Med ial malleolus: 2 col licu li, anteri or lo nger than • 2 heads un ite to form main bul k o f muscle
pos terior • Join i n a th in apon eurotic tendon nea r mid leg
o D i tal tibi ofibu lar joint • Joins soleus aponeurosis to form Ac hilles tendon;
• Fibu la arti cu lates wit h tibi a at fibu lar n o tch· co ncave in cross section ; muscu lotendinous
joined by interosseous ligament ' junction 5 em above cal can ea l inserti on
• Strength ened by an te ri or and posteri or tib io fibula r • Nerve su ppl y: T i bial n erve
liga ments • Action: Pla n tar flexor o f ankle and flexor of knee
• Posterolatera l ly located o Plan taris
• Fi bula • Origin: Superior and medial to latera l h ead o f
o An terior fibula gastrocnemius o ri gin, as well as from oblique
• O rigi n of lateral muscles o f leg pop litea l liga m ent
o Med ial fi bu la • Continues deep to lateral head gastrocnemius
• Origin o f deep posterio r muscles of leg • M yotendinous juncti on at level of origin of soleus
o Posterolateral fi bula (muscle is 5-10 em lo ng)
• Origin o f posterior muscl es of leg • Tendo n t hen lies between medial head
o Latera l m alleol us: 1 em l on ger than m edial gastrocnemius and soleu
mal leo lus • Follows m ed ial side o f Ac hilles to insert ei th er
Interosseo us Membrane antero medially on Achilles or on calca n eus
• Stretch es across in terva l betw een tibia and fibu la • Planta ris absent 7-101!«>
• Greatly ex tends su rface for origi n of muscles • Nerve su ppl y: Tibial n erve
• Strong, oblique fibers ru n d own ward s and lateral ly • Acti on: Acts w i th gast rocnemius
from ti bia to fibula o Sol eus
• In upper part, below lateral condy le o f tibia, th ere is • O rigin: Exten sive, from back o f fibular h ead and
an opening for passage of anterior tib ial vessels upper 1/ 3 of posterior surface o f shaft o f fi bu la,
• Distall y, an opening allows passage of perforating from solea l l ine and midd le 1/ 3 of medial border
bran ch of peron eal artery of tib ia, and fro m tend in ous arch joining these
• Tibialis posterio r and fl exor h allucis longus take partial across th e popli teal vessels
origin from the back o f memb ra ne • Fl at, thick, powerful muscle en ds in stro ng tendon
• Tib iali s anterior, long ex tensors of toes, and peron eus • joins w ith tendon o f gastrocnemius to form
tertiu s take parti al origin from front of m embrane Ac hilles tendon
• Nerve suppl y: Tibial n erve
Reti nacu la • Act ion : Stabi l ize ankle in tanding, plan tarflexes
• Di scussed i n grea ter detail in "An kl e Overv iew" ankle
sec ti on • Accessory soleus: Rare va riant, arises from anterior
• Superio r exten sor retinaculum surface o f soleu or fro m fibula and solea l line of
o Stron g, broa d band tib ia; inserts into Achi lles o r o nto calca neus
o Stretches across front of leg fro m tibia to fi b ula, an terornedial ly to Achilles; presents as mass
immediately above ankle joint • Posterio r com partmen t: Deep m u scl es

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142
 LEG OVERVIEW
o Popl iteus • Muscle is medial to peroneus longus at o ri gin but
• Origin: Tendon from popliteal groove of lateral overlaps pero neus longus in middle 1/3
fem oral cond yle • Tendon cu rves forwa rd beh ind lateral m alleolus,
• Passes through popliteal hiatus posteriorly and in front of peroneus longus tendon
med ially, pierces posterior capsu le of knee • erve supply: Superficial peroneal
• M. fiber directed medially & downwards to insert • Action: Everts foot and secondarily p lantarflexes
on posterior surface of tibia above soleal l ine foot
• erve sup ply: Tibial n erve o Sy novia l sheath for peroneals begin s 5 em above tip
• Act ion: Fl exes kn ee and medially ro tates leg at o f lateral malleol us and envelops bo t h ten dons;
onset of fl ex ion (unlockjng ex ten si on "screwing divides into 2 sheaths at level of ca lcaneus
h ome" m echanism) o Peron eus tert ius (see anteri or compartment)
o T i b ialis Posterio r o Peroneus quartus: Accessory muscle w ith
• Origin: In terosseous membrane and adjoi ning prevalence of 1O'V.J; originates from dista l leg,
pa rt o f posterior su rfaces of t ibia an d fi bula frequen t ly from peroneal muscles, with variable
• Superior end bifid; an terior tibial vessels pass inserti on sites at foot; at level o f malleolus, located
forward between th e 2 attachments medial or posterior to bo th peroneal tendon s
• Dis tally it incl ines m edially, under flexor o Peron eus digiti minimi: Accessory wi th preva lence
digitorum longus o f 15-36%; extends from pero neus b revis muscle
• Grooves and cu rves around media l malleolus around m edial m alleol us to foot; ti n y tendinous slip
• 1 erve supply: Tibial nerve • Anterior compartment
• Acti on: Plantarfl exes and inverts foot o T i bi alis anterior
o H exor digitorum l ongus • Origin upper hal f of lateral surface o f tibia and
• O rigin : Posterior surface of tibia, below popliteus, interosseous mem bra ne
and medial to th e verti cal ridge • Ten don ori ginates in distal l /3; passes through
• rosse superficial to distal pa rt of t ibia lis retinacula
posterior • Nerve suppl y: Deep peronea l and recu rren t
• Tendon grooves lower en d o f t ibia latera l to tha t genicul ar
o f th e tibialis posterio r, passes around medial • Act i.on : Dors iflex or and inve rto r o f foot
malleo lus to foot o Ex tensor digitorum
• Nerve su pply: Tib ial nerve • Origin f rom upper 3/4 anteri or su rface fi bu la
• Ac ti on : Fl exes interp halangeal and • Descends behind ex tensor retina cula to an kle
metata rsophalangea l join ts o f lateral 4 toes; • Nerve supply: Deep peroneal
planta rflexes an d inverts foot • Act ion: Extends i n terphalan gea l and
o Fl exor h alluc is l on gus metatarsophalangea l joi nts of lateral 4 toes,
• O rigin : Posteri or surface of fibula, below ori gin of dorsiflexes foot
soleus o Peron eus terti us
• Pa sses m edially, d escen ds d own posterior to mid • Small, n ot al ways p resent
tibia • Origin: Con tin uo us w i th ex tensor digitoru m
• Associated w i th os t rigonum posterior to tal us lon gus, arising from di stal 1/4 of anterior surface
• Tendon o ccupies deep groove on posterior su rfa ce o f fibu la and interosseous membra ne
o f talus, passes around medial mall eol us, to grea t • Inserts into dorsal surface base 5th m etatarsa l
toe • erve supply: Deep peronea l
• erve supply: Tibial nerves • Action: Dorsiflexes ankle and everts foot
• Ac tio n: Fl exes the interph alangeal an d o Extensor hallucis
metata rsoph alan geal joints o f great toe; • Thin muscle h idden between tibialis anterior and
pian ta rfl exes foot extensor digitoru m longus
• Lateral compartm ent • O rigin: M idd le 2/4 of an terior surface o f fibula
o Peron eal s separated from ex ten sors by anterio r and in terosseous membrane
i ntermuscular sep tum and from posteri or mu scles by • Ten don passes deep to retinacu la to great toe
posterior cp tu m • Nerve suppl y: Deep peronea l
o Pero neus lo n gu s • Action: Extends phalanges of grea t toe and
• O ri gin upper 2/3 lateral surface of fibul a and dorsiflexes foot
intermuscuiar septa and adjacent muscula r fascia
• Become tendinous a few em above lateral Vessels of Leg
malleo lus • Popliteal artery
• C urves fo rward behind lateral malleolus, posterio r o Ends at distal bord er of popli teus i n two bran ches:
to peroneus brevis Anterior and posterior tibial arteries
• erve upply: Superfi cial peron eal o Paired venae comitantes of anterior and posterior
• Action: Everts foot and secondarily plan tarfl exes tibial arteries join to form popli tea l ve in
foot • Anteri or tibial artery
o Peron eus brevi s o Sma ller of the 2 terminal branches of popl i teal
• Origin lower 2/3 lateral surface of fibula and o Ori gi n in back o f leg, at distal bord er of popl it eus m .
intermu scu lar sep ta an d adjacent muscula r fascia o Passes t h rough upper part of interosseous m em brane

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143
 LEG OVERVIEW
o Straight course dow n front of leg to beco m e dorsalis • La te ral te rminal branc h to late ra l d o rsum of ankle
pedis o Superficial peroneal nerve: 2nd of 2 te rm inal
o Muscula r branches alo n g le ngth branch es
o Ma lleola r branches ramify over mall eoli; latera l on e • Descends in substa n ce o f pe ron e us lo ngus unt il it
anasto m oses with perfo rating branch of pe ro nea l reach es peron eus brevis
a rtery • Passes obliq ue ly over ante rior bo rder of brevis a nd
• Posterior tibial artery desce nds in groove betwee n peroneu s brevis and
o Larger of th e 2 te rmin al branches of popliteal ex te nsor digitorum lo ngus
o Main blood su pply to foot • In distal 1/3 of leg, pi erces deep fascia a nd d ivides
o Passes dow n wards and slightl y med iall y alo ng with into m edial and la teral bran ch es-ro foo t
tibial nerve to end in space between media l • Tib ia l nerve
ma lleol us and calcaneus o Descend s unde r fascial se ptum whi c h sepa rates d eep
o Di vides into latera l and m edial plantar arteries and su pe rficial posterio r muscle com partm e nts
o Branch es o In u ppe r 2/3, lies o n fascia o f tibia lis posterior a nd
• Circumfl ex fibular (may arise from anterior tibial), on flexor digito rum lo ngus
run s laterally around n eck o f fi bula o Jn lower 1/3, loca ted midway between Ach illes
• Nu trien t arte ry to t ibia t e ndon and medi al border o f tibia
• Mu sc ular branch es o C ro sses posterior surfaces of tibia and ankle jo int
• Pero n eal artery: Largest branch o f posterior tibia l o Poste rior tibial vesse ls run w ith it, crossing in fro nt
a rtery; ru ns oblique ly dow nwards and laterally o f it fro m latera l to m ed ial side
ben eath so leu s t o fibula, alo ng whic h it d escend s o At ankle, under flexor retinaculu m, d ivides into
deep to flexo r ha ll ucis lo ngus late ra l a nd m edial pla n ta r n e rves
• Great saphe nous vein • Saphenous nerve
o Begins at m ed ial bo rder of foo t o Lon gest bra nc h of femora l n e rve, ar ising 2 em below
o Asce nds in fro nt of m ed ial malleolus inguin al liga me n t a nd desce nding via adductor
o !)asses obliquely upwards and bac kwa rds across can al
m edial surface of d ista l 1/3 of t ibia o Passes posterior to sarto riu s, descen ds poste romedial
o Passes ve rtica ll y upwa rd along medial borde r o f tibia to kn ee whe re it pierces t h e deep fascia
to poste ri o r part of m edial side of kn ee o In leg, accompa ni es great saph enous vein
• Small saphenous vein • Sura l n e rve
o Ex te nds behind latera l malleolus, asce nds late ral to o Arises in popliteal fossa fro m ti b ial ne rve
Achilles o Desce nds between 2 h eads of gastrocnemius
o At midline of calf in lower popliteal regio n, p ie rces o Pierces deep fascia midwa y bet ween kn ee a nd a nkle
po pliteal fascia a nd te rmin ates in poplitea l vei n o Acco mpanies small sa ph enous vein to lateral border
of foot
Nerves of Leg
• Common peronea l
o Smalle r o f 2 te rmin a l divisions of scia t ic ne rve !Imaging Anatomy
o Arises mid thig h , run s downwards latera lly along
m edial borde r of bice ps femoris A nat omy Re latio nships
o Crosses plan ta ris and late ral head of gastrocn e mi us, • C riti ca l variant: Th ird h ead of gast rocnemi us
passes poste rio r a nd superficial to head of fibula o Muscu la r ano ma lies o f gastrocn e mius are n u me rou s
o Th is loca tio n at fibular h ead/ neck put pero neal o 2% show anomalous third h ead of gastrocnemi us
nerve a t risk in multip le clinica l situations • Originate fro m post e rior di stal femoral me ta ph ysis
• Fi bular n eck fract ure ma y res ul t in foo t drop either med iall y or at mid po rti o n
• Total kn ee replacement in a pati ent wh o had bee n • Cou rses latera ll y to jo in late ral h ead of
in ch ro nic va lgus m ay damage nerve wi th gast rocn emi us
realignment of knee • Poplitea l vessels loca ted between third head and
o Ends betwee n lateral side of n eck o f fibula a nd medial h ead of gastrocnemius
peroneus longus by dividing into 2 te rmin al o These a nom alies have pote n tial fo r causin g poplitea l
b ra n ch es compression, and shou ld be sought (axial images),
o Deep peroneal nerve: O ne of 2 terminal branc h es bu t m ay be asymptoma tic
• Arises on lateral side o f n eck of fibu la, under • C ritical va riant: Hypertroph y of sh ort head biceps
pe ron eus lo ngus o May cause en croach m ent on fa t surro und ing
• Pierces ante rior intermu scu lar septum & ex tensor commo n pe ro neal ne rve
d ig ito rum lo ngus to enter a nterior compartm ent o Abno rmalities whi ch may ca use peron eal
• Exte nds clown to ankle between ti bialis an terior neu ropath y
and lo ng ex tensors • Hypertrophi ed short head bice ps
• Nea r ankl e, c rossed by exte n sor hallucis and • Distal ex ten sion of lo ng head of b iceps
passes to ank le midway be tween ma lleoli • Prominent la teral h ead of gastrocnemius
• Muscu la r branch es to a n terior co mpartment and • Diabe tics ma y accumul ate excess fa t around
a rti cular twig to ankle joint peroneal n erve at fib u lar neck
• Media l termina l branch to d orsum of foot

VI
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VI
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VI
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VI
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VI
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 LEG OVERVIEW
RADI O GRAPH, ANTEROPO STERIOR

Gerdy tubercle

r ibula r h ead Ti bia l apophysis

Fi bular n eck

Latera I surface
Lateral sur face

In terosseo us bo rders

Medial subcu taneous

surface

Crista m edialis

Medial surface

Medial mal leolu s

Latera I m aII eo I us

Ante roposte rio r radiograp h of the le g. Note th at t he fibul a is sligh tly posterolatera l to the tibia, and t h at t here is
exp ected overlap at the proximal an d dista l tibiofibula r jo in ts. Th e inte rosseo us borde rs o f both lo ng bones a re often
a; irregu lar; this re la tes to th e insertion o f the stro ng in terosseous m embra n e a nd is not periosteal reaction. Th e late ral
ma lleol us extends 1 em farther d istal th an the m ed ial.

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 LEG OVERVIEW
RADIOGRAPH, LATERAL

Proximal tibiofibular
Tibial apoph ysis
joint

Flexo r ha l lucis longus

Posterior colli culus
medial m alleolus

An terior coll iculus

medial m alleolus Latera l mall eolus

Lateral radi ograph of the leg. As on the an te roposterior view, there is overlap of the bones at both the proximal and
distal tibiofibu lar join ts. At th e ankle, both the collic uli of the m edial mal leolus can be see n , along w ith the slightl y
lo nger lateral m alleolus.

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JJ

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VI
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]

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[[

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]]

Q)
Q)
c

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VI
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 LEG OVERVIEW
AXIAL T1 MR, RIGHT LEG

Inferior patellar tend on

Medial reti naculum
Lateral retin aculum

Iliotibial band
Medial coll ateral
Lateral co llateral ligament (superficial )
ligam ent

Popliteal tendon

Biceps femoris
em i mem branosus
Oblique po pliteal
ligament & joi nt
capsule Semi tendinosus
Common peroneal n.

Lateral h ead
gastrocnemius

Plantaris

Inferi or patellar ten don

M edial coll ateral

ligament

Sar toriu s
Lat era l co llatera l
l iga m ent
Greater sa ph enous vei n
Biceps fem oris
Semi tendin osus
Comm on peroneal n.
Scm i m embra nos u s
Popliteus muscle

Lateral head Medial h ead

gastrocn emi us

(Top) First in seri es of axial Tl MR images of th e righ t leg; th i s is just above the knee joint, included for co ntinui ty o f
st ructures. (Bottom) Ax ial Tl MR image of rig h t leg, just below the knee joint. Fo r greate r detai l about th e knee joint,
Q)
Q) see "Kn ee Overview" sect io n .
c:

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 LEG OVERVIEW
AXIAL T1 MK, LEFT LEG

Inferior patellar tendon

Medial reti n aculum
Lateral retinaculum

Iliotibial band
fedial col lateral
ligament (superficial ) Lateral collateral
l igam ent
Popliteal tendon
Sarto rius
Biceps fem o ris
G raci l i s
Obl ique po plitea l
liga m ent & joi n t
Se m imem branosu s capsule

Se mitendinosu s Common peroneal n .

M ed ial head Lateral head

gastrocn em ius gastrocn emius
Plan taris

Inferior patellar tendon

Medial collateral
liga m en t
Sem imembranosu s
artoriu s
La teral collateral
Greater sa phenous vein ligam en t
Biceps fem oris
emiten di nosu s
Comm o n peron ea l n.

Medial head Popli teus muscle

gastro nemi us
Lateral head
gast rocnemius

(Top) First in series o f axia l Tl MR i mages o f th e left leg; t hi s is just above t h e knee joint, in cluded for continu ity o f
st ru ctures ( Bottom) Ax ial MR image o f left leg, just below the knee joi nt. For greater deta i l about t he knee joint, see
"Kn ee Overview" section. A
:::3
ro
ro
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 LEG OVERVI EW
AXIAL T1 MR, RIGHT LEG

Sartori us
Tib iali s an teri or

Ex tensor digi torum G racil is

longus
Peron eus longus G rea ter sa ph enous ve i n
Semite ndinosu s
Biceps femoris tendon
expan si on Popl iteus muscle
Co mmon peronea l n.
Tibia l n erve
Posterior ti bial artery

Planta ris Medial h ead

gastrocn em ius
Lateral h ead
gas trocnemi us

TI
Pes anseri nus
Tib ia lis an te ri or
Medial collateral
Ex ten sor di gi torum l igam ent (superficial)
longus
Popli teus muscle
Tib ial is posterior
Anterior tibial a.
Tibia l nerve
Peron eus lo ngus
Posterio r tibial artery Plan taris tendon

So leus Medial head

gastroc nemi us
Lateral h ead Sural nerve
gastrocnemius

Lesser saphenous vein

(Top) Axial T l MR image o f right leg at the prox ima l tib iofib ular joint. No te that th e p lantaris is st ill m uscu la r, lying
in front of the late ra l h ead of the gastrocne mi us. (Bottom) Axial Tl MR image o f right leg at th e pro xi m al
metaph ysis. By t h is point, the sole us ha s a risen from th e fibula; th e section is too p roximal to see th e t ibia l o rigin o f
soleus since th e p opl iteal m uscle is stil l present. The pla nta ris is n ow tendin o us, lying betwee n t h e soleus and m ed ia l
h ead of gast rocn em ius. At th is level, o ne sees the t ib ia lis posterior arising as a bifid structure from bot h tibia and
fibula; the a n terior tibial vessels a re seen coursi ng fo rwa rd to wa rd s th e ante ri o r co mpa rtme n t, bet wee n these two
attach ments.
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 LEG OVERVIEW
AXIAL T1 MR, LEFT LEG

Sartorius Tibiali s anterior

Gracilis E.xtensor digitorum

longus
Greater saphenous ve in Peroneus longus

Se mitendinosus Bi ceps femoris tendon

expansion
Popliteus muscle
Common peroneal n.
Tibial nerve Posterior ti bia l artery
Plantaris
Medial head
gastrocnemius Latera l head
gast rocnemius

rn
Pes anscrinus
Tibial is anterior
Medial collateral
ligament (superficial ) Extensor digitorum
lon gus
Popl iteus muscle
Tibial is p osterior
Anterior tibial artery
Peroneus longus
I ibial nerve
Posterior tibi al artery
Pian ta ris tendon

Medial h ead Soleus

gastrocnemiu s La teral head
Sural nerve gastrocnemius
Lesser saphenous vei n

(Top) Ax ia l Tl MR image of left leg a t the prox imal tibiofemora l joint. Note that the pla ntaris is still muscular, lying
in front o f the la te ral head of the gastrocnemi us. (Bottom) Axia l Tl MR image of left leg a t th e pro ximal metaph ysis.
By this po int, the soleus has arisen from th e fibula; the sectio n is too proximal to see t he tibial origi n o f soleus since
the popliteal muscl e is still present. T h e p lantaris is n ow tend in o us, lyi ng between th e soleus and med ial h ead of
gas trocnem ius. At thi s level, o ne sees the t ibialis poste rio r arisin g as a bifid st ructu re from both tibia and fib ula; the
anterior tibial vesse ls are see n coursin g forward towards the ante ri or compartm ent, between th ese two attachmen ts.
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 LEG OVERVIEW
AXIAL T1 MR, RIGHT LEG

Tibia lis an terior

Tibialis posteri or
Tibia l ne rve, posterio r
Intermuscular septu m ti bial vessels

Extensor di gito ru m Po pli teus

Deep peronea l nerve &

a nte ri o r tibi al vessels Med ial head
gast rocnemi us
Peroneus brevis Sole us

Pero n eus lo n gus Plan taris

Flexor h allucis
Sural nerve
Peroneal vessels

Lateral h ead
gastrocn emi us

Tib ia lis an terio r

Extensor d igi to ru m Ti b ia l n erve, posterior

tibial vessels
Ti bial is posterior

Deep peronea l nerve & Medial head

anterior t ibial vessels gastrocnemius
Soleus
Peroneus brevis
Pla ntaris
Peroneus lo n gus

Flexor ha llucis
Su ra l n erve
Peroneal vessels

(Top) Axial Tl MR image of right leg at the proxim a l dia ph ysis. Note that by this point, p e roneus brevis a nd flexor
hallucis begin to originate from the fibula. There remains a slip of popliteus at th e posterior tibi a. The ma jo r vessels
of the leg h ave trifu rcated. (Bottom) Axial Tl MR image o f right leg, slightly distal. Note that the poplite us inserti o n
on th e t ibia has e nded , and the soleus gains its ti b ia l o rigin. The lateral h ead of gastrocn emius h as beco me e ntire ly
te ndin ous.

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 LEG OVERVIEW
AXIAL T1 MR, LEFT LEG

Tibial is anterior

Ti biali s posterior

Popliteus Extensor cligi torum

Deep peroneal ner ve &

Medial h ead anterior tibial vessels
gastrocn emius

Tibial nerve, posterior Peroneu s brevis

tibial vessels
Peroneus longus
oleus
Flexor ha llucis
Pla n taris
Peroneal vessels
Sural nerve
Latera l head
gastrocnemius

Tibiali s an terior

Tibiali s posterior

In termuscular septum

Tihial nerve, posterio r

t ibial vessels Extensor cligito rum

Deep peroneal nerve &

Med ial head an terior ti bial vessels
gastrocnemius
Peroneus brevis
Soleus

longus
Pl antaris
Flexor hallucis

Sural nerve Peroneal

(Top) Axia l T1 MR image of left leg at th e proxim al diaphysis. Not e that by thi s poi nt, peroneus brevis and flexor
hallucis begin to originate from th e fibu la. Th ere remains a sli p o f popliteus at t he posterior tibia. The ma jor vessels
of th e leg have t rifurcated. (Bottom) Axia l T1 M R image of left leg, sl igh t ly d ista l. Note that the popliteus inserti on
on t he tibia has ended, an d the soleus gai n s its tibial origi n. T h e l atera l head o f gastrocnemius has become en t irely
tendinous.

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 LEG OVERVIEW
AXIAL T1 MR, RIGHT LEG

Tibi alis anteri or

Ex ten sor hallucis

lo ngus
d igi to rurn
Extensor digitorurn longus
lo ngus
Tibia lis posteri or
Tibial n erve & posterior
Deep peroneal n erve & tibial vessels
ant erior tibial vessels
Soleus
Peroneus lo ngus
Peron eus brevis Pl antaris tendon

Pero neal vessels

Medial head
gastrocn em i us
Flexor hall ucis lo ngu s
Sural nerve

Tibialis an terior

Ex ten sor hallucis

longus
Ex ten sor digi torurn Tibial n erve & posterior
lon gus tibial vessels
Dee p peron ea l nerve &
anterio r tibial vessels

Pero neu s lon gus

Peroneus brevis Plan taris tendon

Tibia lis posterior

Peroneal vessels ural ner ve

f-lexor hallucis longus

(Top) Ax ial T1 MR image of the right leg at the junction o f proximal and middle thirds. At th is poin t, t he extensor
hallucis lo ngus m akes its appeara nce, ari sing from t h e anterior fibula an d interosseous m embrane. Flexo r digitorum
longus also is n o w seen, arisin g from the posterior tib ia. Th e lateral head of gastrocn emius h as beco me tendinous,
w it h soleus maki n g up th e bulk o f the posterior m uscles. (Bo ttom) Slightly distal axia l T l MR i mage o f th e ri ght leg.
At th is poin t, the ex ten sor hallucis lon gus is loca ted between tibialis an terior and exten sor digi torum longus and is
no t easily distingui shed from them . Similarl y, th e peronea l muscl e/tendons are not easily distinguished becau se o f
poorl y v isualized fat p lanes in the leg. Note also t hat the plantaris tendon still lies between med ial head o f
VI gastrocnemius and soleus, but is tracking media lly.
166
 LEG OVERVIEW
AXIAL T1 MR, LEFT LEG

Tibialis anterior
Extensor digi to rum
Fl exo r digitorum longus
longus hallucis

Tibial ner ve N: posterior

tibial vessels Deep peroneal nerve &
an terior ti bial vessels
Soleus longus

F-____,w _ Peroneu s brevis

tendon
posterior
Medial h ead
gastrocnemius
Peronea I vessels

nerve
Flexor hallucis lo ngus

Tibial is anterior

Extensor hallucis
H e'Xor digitorum
longus
Extensor digitorum
longus
l ibial nerve & posterior
tibial Deep peron ea l nerve &
anterior tibial vesse ls

Peroneus longus
So leu s
Peron eus brevis
tendon
Medial h ead Tibial is posterior

Pe ro nea l
Sural nerve
Flexor hallucis lon gus

(Top) Axial Tl MR image o f the left leg at the junction o f proximal and middle th irds. At thi s poin t, th e ex tensor
hall ucis longus makes its appearance, arising from the anterior f i bula and i nterosseous membrane. Flexor digitorum
longus also is now seen, arising from the posterior tibia. Th e latera l head of gastro cnemius has becom e tendinous,
with soleus making up th e bul k of the posterior muscles. (Bottom ) Slightly distal axial T1 MR image of t h e left leg. At
this point, th e ex tensor h allucis longus is located between ti biali s anterior and ex tenso r digi toru m lon gus and is not
easil y disti nguished from them . Simi larly, the peroneal m uscle/ tendons are not easi l y dist i n guish ed because of poorl y
visualized fat planes in th e leg. Note al so that th e plantari s tendon still lies between med ia l head of gastrocnemius
and soleus, but is tracking medially. VI
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 LEG OVERVIEW
AXIAL T1 MR, RIGHT LEG

Tibialis anterior
Flexor d igi torum
Ex tensor hallucis longus
longus
Extensor digito rum
Posterior tibial vessels
& n erve
An terio r tibial vesse ls &
deep peronea l n erve

Peroneus brevis Soleus

Peroneus lon gus

Plantaris tendon
Tibial is posteri o r
Medial head
Peronea I vessels gast rocnemius

Flexor hallucis longus

T ibialis anteri or

Flexor digitorum
An terior tibial vessels &
deep peron ea l nerve
Extensor h all ucis Tibial is posterior
longus
Tibial nerve & posterior
Exten sor digitorum tibi al vessels
longus
Pero neu s brev is Soleus

Plan taris tendon

Peron eus longus

Peronea l vessels Gastrocnem i us tendon

Flexor hallucis longus

(Top) Axia l T l MR image of the ri ght leg at th e mi d d iaph ysis. At th is point, in th e mid leg, the gastrocne mi us
muscle has becom e n ea rly com p le te ly te nd in o us. (Bottom) Sli g h t ly d istal axia l T1 MR image of t he right leg. The
gastrocne m ius is now en ti rely t endi nous, and t he plan tar is te n do n lies subcut aneously adjacent to the medial aspect
of th e gast roc n emius tendon.

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 LEG OVERVIEW
AXIAL T1 MR, LEFT LEG

Tibialis anteri or

Extensor hallucis
Fl exor digitorum
longus
longus
Ex tensor digi torum
Posterior t ibial vessels Anterior ti bial vessels &
& nerve deep peroneal n erve

Peron eus brevis

Soleus
Perone us longus
Plan tari s ten do n
Tibial is posterio r
M ed ial head
gastrocnemi us Peroneal vessels

Flex or hallucis longus

Tibialis an terior

Anterior tibial vessels &

Ti bialis posterior deep peroneal nerve

Fl exor digitorum Exten sor ha ll uci s

longus
Extensor d igi torum
Tibi al nerve & posterior lo ngus
ti bial vessels Peron eus brevis
So leu s Peron eal vessels

Planta ri s tendon Peroneus longus

Flexor halluci s lon gus

Gastrocn em iu s tendo n

(Top) Axial Tl M R image of the left leg at the mid d iaphysis. At this point, in th e m id leg, th e gastrocn emi us m uscle
has beco me n ea rl y completely t e ndin ous. (Bottom) Sli ghtly d istal axial Tl MR image o f th e left leg . The
gast rocn emius is now entirely tend inous, and the pla ntaris tendon lies subcutaneo usly adjacent t o the m edial aspect
o f th e gast rocn e mius te ndon.

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 LEG OVERVIEW
AXIAL T1 MR, RIGHT LEG

Tibial is an terior

Anterior ti bial vessels &

deep peron eal n erve

Extensor hallucis Flexor d igitorum

longus lon gus
Ex tensor digitorum
longus Tibialis poste rior
Peronea l vessels Posterior tibial vessels
Peroneus brevis & tibial nerve

So leu s
Peroneus longus

Flexor hallucis longus

Ach ill es tendo n

Tibialis anteri or

Ex ten sor halluci s Tibiali s pos terior

longus
Exte nsor digitorum Flexor digi torum
longus lo ngus
Anteri or ti bial vessels
Posterior tibial vessels
Peron ea l vessels & tibial nerve

Flexor ha ll ucis lon gus

Pero neus longus
Soleus
Peroneus brevis Achill es tendon

Su ral nerve

Lesser saphenous vei n

(Top) Axial Tl MR image of the righ t leg at the jun ctio n of middle a nd d ista l t hi rds. The deep muscles o f the
posterior compartment a re now more prominent t h a n the supe rfi cia l. (Bottom) Sli ghtly distal axia l Tl MR images of
th e right leg, with t h e compartments more distinctly seen .

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 LEG OVERVIEW
AXIAL T1 MR, LEFT LEG

Tibiali s anteri or
EE
Anterior tibi al vessels &
deep peronea l nerve

Flexo r d igito rum Ex tensor hall ucis

longus longus
Extensor digitoru m
longus
posterio r
tibial vessels Peron eal vessels
i'x tibial n erve Peron eus brevis

Soleus Flexor ha llucis lon gus

Peron eus

tendo n

T ibial is an terior

Extensor hall ucis

longus
T ibialis posterior Exten sor digitorum
longus
Flexor tligitoru m An terior tibial ve seb
lon gus
Pm terior tibial Peronea I vessels
& ti bia l n erve

Flexor h allucis lo ngus

Peroneus
Soleus

Achi lles ten don Peron eu s brevis

Sural nerve

Lesser ve in

(Top) Ax ial T1 MR im ages o f the left leg at the junction of th e middle and d istal t hirds. The deep m uscles of the
posteri or co m partm ent are n ow mo re prom inent th an th e superficial. (Bottom) Slig htly d istal axia l T l M R i mages of
th e left leg, with th e compartments m o re distinct ly seen .

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 LEG OVERVIEW
AXIAL T1 MR, RIGHT LEG

An ter io r ti bia l vessels & Ti bialis an terio r

deep peron eal nerve

Exten sor hallucis

lo ngu s Tibi alis posterior

Exten sor digi torum

lo ngus
Peroneal vessels Flexor digi torum

Flexor hal luci s longu s Posteri or t ibial vessels

& ti bial ne rve

Peron eus l ongus Plan taris ten don

tendon
Peroneus brevis Ach illes tendon

Sural ner ve & lesser

saph en ou s vein

Ti bial is anterior
Deep pe ro nea l nerve &
an terior ti bia l vessels

Exten sor hallucis Tibial is posterior

lo ngus
rlexo r di gito rum
Exten so r digi torum longus
lo ngus
Posterior tibi al vessels
Tibial n erve
Flexo r h allucis longus
Peroneus longus
Plantari s tendo n
Peroneus brevis
Achilles tendon
Sural nerve & Jesser
saphenous vein

(Top) Axial T1 MR image of the right leg approach ing the d istal metap h ysis. The anterior and posteri or tibialis
tendons a re n ow d efin ed, as is the Achilles tend o n. (Bottom ) Axial Tl MR image of the right leg at the distal
metap hysis. The m a jor tendons of the leg are becoming more distinct.

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 LEG OVERVIEW
AXIAL T1 MR, LEFT LEG

anterio r Anterior ti bial vessels &

deep peroneal nerve

Extensor hallucis
lon gus

posterior Ex tensor digitorum

longus
Flexor digi to rum Peron ea l vessels
tibial vessels
& tibial nerve
Peroneus longus
Plan taris tendon tendon
Achi lles tendon Peroneus brevis
Flexor hallucis longus

Sural nerve & lesser

vei n

Tibiali\ anterior
Deep peroneal nerve &
anterior tibial vessels

Ex tensor hallucis
Tibialis longus

Flexor digitorum l:.xtensor digi torum

longus longus

Posterior ti bia l vessels

Peroneus lon gus
Tibial nerve

Peroneus brevi s
Plantaris t.
Su raI nerve & lesser
sa phenou s vein
Achi lles tendon

Flexor

(Top) Ax ial T l MR i m age o f t he l eft leg approaching th e d istal metaphysi s. The an terior and posterior t ibialis tendons
are now defi ned, as i s the Achilles tendon. (Bottom ) Ax ial Tl MR image of the left leg at t he distal metaphysis. The
major tendons of th e leg are becomi ng m ore di stinct.

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 LEG OVERVIEW
AXIAL T1 MR, RIGHT LEG

Ti bial is anterior

Anterio r ti bial vessels

Inferior extensor
retinaculum
Extensor hallucis
lon gus
Ti bialis posterior
Extensor digito rum
lon gus
Flexor digitorum
longus
Posterior tibial
& ti bial n erve

Peron eus longus Flexor ha l lucis longus

Peroneus brevis Ach i l les tendo n

Sural nerve & lesser

saph enous vein

T ibialis an terior

Exten sor hal lucis

longus Tibialis posterior
An terior tibia l vessels

Extensor digitorum
Fl exor digitorum
longus
lon gu s
Posterior ti bial vessels
& ti bial n erve
Peroneus longu s

Fl exor ilalluci s lon gu s

Peroneu s brevis
Achi lles tendon
Sural n erve & lesser
saphen ous vein

(Top) Ax ia l Tl MR image of the right leg a t the distal t ibiofibu lar joint. T h e tendons of the a n kl e are m uch more
clearly defined, though flexor ha ll uci s longus is still high ly muscula r. (Bottom) Ax ial Tl MR image o f the right leg at
the ankle joint. Note that the ankle is shown in much greate r deta il in th e "Ankle Ove rview" sectio n.

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 LEG OVERVIEW
AXIAL T1 MR, LEFT LEG

Tibial is anter ior

Anterior tibial vessels

Inferior extensor
reti n acu lu m
Exten sor hallucis
longus
posterior
Exten sor d igitorum
longus

Flexor tligi torum

lo ngus
Posterior tibial vessels
& tibial nerve
Peroneus longu\
Flexor ha l lucis longus

tendon
Peroneu s brevb

Sura l nerve & lesser

vei n

Ti bialis anterior

Extensor hall ucis

longus

An terior tibial
Tibia l is posterior

Exten sor cligi torum

l lexor digitorum longus
longus
Posterior ti bial vessels
& tibial n erve Peroneus

Flexor hallucis

Achilles tendon Peroneus brevis

Sural nerve Is< lesser

vei n

(Top) Ax ial T1 MR i mage o f the left leg at th e distal tibiofibular joint. Th e ten dons of the ankle are m uch more
clea rly defined, th ough flexor h allucis lo ngus is still highly muscular. (Bottom) Ax ial Tl MR image of the left leg at
t h e ank le joi nt. ote that th e an kle is shown in m uch grea ter detail i n th e "A nkle Overview" section .

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 LEG OVERVIEW
CORONAL T1 MR, BILATERAL LEGS

Medial head
gastrocnemi us

Soleus

Peroneus brevis

Ach illes tendon

Plantaris tendon

Ca lcan eus

First of fo ur coron a l images of th e legs. T hi s is the m ost posteri o r image, largely throug h t he posterior su pe rficia l
m u scles. Note the p lantaris ten don which is see n we ll in th e le ft leg, trave lin g and inse rtin g media ll y to the Achi ll es
CLI tendon.
CLI
c

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 LEG OVERVIEW
CORO NAL T1 MR, BILATERAL LEG

IT
Popl i teus

Po plitea l vessel

gilst rocnem iu

Peron ea l vessel
longus

Posterior t i biill

Flexor llallucis longus

Peroneus brevb

lightly more anteri or coron al image of the legs, loca ted posteriorly, through the fibula. Portions o f the deep and
uperfi cial posterior compartm ent are seen, alon g with t he lateral compartment.

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177
 LEG OVERVIEW
CORONAL T1 MR, BILATERAL LEGS

]
Popliteus
Popl i teus

Meclial heacl
gastrocnemiu s

Ex tensor cligitorum
lon gus
Sole us
Extensor ha llucis
longus

Flexo r cl igito rum

lo ngus

Posterio r t ibial cortex Ti bial is posterior

Coro na l image of the legs, through the poste rio r tib ial cortex . The more com plex deep and superficial posterior
compartments are pa rtiall y seen.

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178
 LEG OVERVIEW
CORONAL T1 MR, BILATERAL LEGS

IT
Medial coll ateral
ligament i nsertion

Tibia lis an terior

Exten sor digitorum

longus

Extensor hallucis
longus

Coronal image o f th e legs, loca ted anteri orly. ote the bare anteromedial aspect of th e tibia. Because there is no
overlyi ng muscle, th e blood supply i s easily compromised wh en th e t ibia is fractu red.

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 LEG OVERVIEW
SAGITTAL T1 MR, LEG

IJ Popliteus
Medial head

anteri or

]] Posterio r cruciate
ligament Media l head
gastrocnem ius
Plantaris
Popliteus

Soleus

Flexor cli gitorum

longus

Flexor hallucis longm Achi ll es

(Top) f.irst of six sagittal T1 MR i mages of th e leg, starting medially. The bulk of the muscle h ere i s the med ial
superficial poste ri or muscles, soleus an d gastrocnem ius. (Bottom ) Sagittal T l M R image, med ia l leg. A porti on of the
deep pos terior muscles is now seen , including th e distal tendo n o f fl exor hall ucis longus. Note th e d istal extent of
popliteus muscle, an d th e fa ct that th e tibial origin of soleus is from the soleallin e, along t he dista l site of inserti on
o f popl iteus.

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 LEG OVERVIEW
SAGITTAL T1 MR, LEG

Inferior patellar tendon

Popl iteus
La teral head

anterio r
Soleus
Flexor digitoru m
longus

Flexor hallucis longus

l·.x tensor h allucis

longus

Lateral head
gastrocn em ius

Tibia lis anterior

Tibialis posterior Flexor cl igi to rum

longus

Sol eus

Flexor hallucis lo ngus

(Top) Sagi tt al T J MR image, mid leg. The bulkiness o f f lexor h alluci s longus can be apprecia ted, al on g wi th the
pre-Achilles fat pad separatin g it from Achilles tendon. Note al so th e bare m edial aspect o f the sh aft of t ibia .
(Botto m ) Sagittal T l MR image, slightly lateral in the leg. Tib ial is anterior is seen arising from t h e lateral aspect o f
the shaft of tibi a.

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 LEG OVERVIEW
SAGITTAL T1 MR, LEG

1J Popliteus tendon

Lateral h ead
gastrocnemius

Soleus

Ti bialis anterio r

Extensor hallucis
lon gu s & exten sor
digi torum longus

Peron eus brevis

IJ
Lateral head
gastrocnemius

Ti biali s anterio r

Soleus

Extensor h allucis
lon gu s & exte nsor
digitorum longus

Pero neus lo ngus

(Top) Sagitta l Tl MR im age, leve l of fibula. Th e fibula r o rigin of the sole us, as well as pe roneus and ex te nsor
d igitorum is seen. (Bottom ) Sagittal Tl MR image, level of fibula . Given th e bu lky muscles arising fro m th e fibula , it
is not surprising tha t th e fibular surface is irregul ar. This should n ot be mistaken for periost eal reacti o n.

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 LEG OVERVIEW
AXIAL T2 MR OF KNEE, VARIANT GASTROCNEMIUS

Th ird h ead gast rocnemius

Popliteal vessels

Plan taris
Th ird h ead gastrocne mius

Latera l h ead gast rocn emius m.

lcdia l head gas! rocnemiu s muscle

Third head
Po plit eal vessels

(Top ) First of three ax ial T 2 M R images showing a variant, third h ead o f gas trocn emius. The aberra nt head arises
from the medial fe moral m etaph ys is, adjacen t to the n orma l medial head gastrocnemi us. llowever, it deviat es
laterally, fo rming a muscular sli ng aro und the po pliteal vessels. (M iddle) Image i n series i s slig htly more d istal,
showing t he aberrant third head as we ll as the no rm al m ed ial an d lateral heads of gast roc nemius. (Bottom) Fin al
axial i mage, slightl y more distal towards kn ee jo int , sh ows the popli teal vesse ls surro u nded by the normal med ial
head and the th ird head o f the gastrocnem ius. T his may result in symptoms of claudica ti o n. However, th e variant is
more likely to cause ym pto m s if it splits the poplitea l ar tery and vei n.
VI
183
Q)
Q)
c

VI
184
[[

VI
185
 LEG OVERVIEW
AXIAL T1 MR, VA RIA NT, HYP ERTROPHIED BICEPS FEMORIS

Planta ris

Biceps fem oris,

h yper trop hi ed

Common peroneal
n erve

Lateral gastrocnemiu s
muscle

Bi cep s femoris,
h ypert rophi ed

Common peronea l
nerve

Late ral gastrocn emi us

(Top) First of two im ages, this one at the top o f the interco ndy la r notch . These two axial T1 M R im ages show
co m p ression of th e common p ero neal nerve between a h ype rtro phied b iceps fem o ris m uscle and the la tera l
gastrocnemi us. Normall y the biceps is mo re graci le in this location, with th e common pe ron ea l ne rve loca ted mo re
poste riorly. This va ri ant may cause nerve co mp ression a nd may be symp to mati c. (Bottom) Sligh tly more d istal axia l
Tl MR image shows pe rsistence o f th e relations h ip of th e hypertrophi ed biceps, co mpressing the common pe ronea l
nerve aga in st the gastrocnemius muscle.
VI
186
 LEG OVERVIEW
AXIAL & SAGITTAL MR, VA RIANT: ACCESSORY SOLEUS

[[
Accessory soleus muscle

Achilles te ndon
Flexo r lo ngus m. & t.

o rmal soleus muscle

[[
Ach i l les (xa nthofibroma )

Flexor hal lucb lo ngus

Flexor halluci\

Accessory soleus

Achi lles ten do n

(Top) Sagittal T2 MR image shows a bulky soleus muscle extend i ng more distally than expected. T his is an accessory
so leus and presents clinically as a mass. (Middle) Opposite leg i n same patien t as previous i mage, show i ng th e
n orma l soleus fo r compari son. It h appens th at this patient h as an abnormal Achilles tendon on th is side
(xa nth o fi broma). (Bottom) Axia l T2 M R of th e first i maged leg, showing the accessory soleus. At th is level, o n th e
opposi te leg, th ere was n o sol eus mu scle rem aining (n ot sh own) .

VI
18 7
 SECTION VII: Ankle

Ankle
Ankle and Hindfoot Ove rview 2-6 7
Text 2-4
G raphi cs 5-12
Rad iogra phs & m easure m e nts 13-18
CT: Subtala r joi nt 19 -2 1
Axial MR seque n ce 22-4 1
Co rona l MR sequence 42-59
Sagittal MR seq uence 60-67
Tendons Overview 68-10 1
Tex t 68
G raphics 69-72
MR: Achill es tendo n 73-77
MR: Pos te rio r t ibial tendon 78-83
MR: Flexo r ha ll ucis longus 84-90
MR & Gra phic: Pe ro n eal tendons 9 1-101
Ligaments Overview 102-131
Tex t 102
G raphi cs: Tibiofibular syndesmot ic ligame n ts 103
MR: Tib iofibular syndes motic ligame nts 104-1 09
M R: Late ra l coll a tera l ligaments 110-11 3
G raphics: De lto id liga m ent J 14
M R: De ltoi d liga me n t 11 5-119
Graphics: Tarsa l ca n a l & sinus tarsi ligaments 120
MR: Tarsa l canal & sinus tarsi ligaments 121- 123
G raphi cs: Sprin g liga m e nt 124
MR: Spring liga m e nt 125-1 27
G raphics: Bifurca te ligame n t 128
MR: Bifurcate liga m e nt 129
MR: Long & short p lantar li gaments 130-131
 ANKLE AND HINDFOOT OVERVIEW
IGross Anatomy Ligaments
• 3 sets bind ankl e: Dista l tibi ofibula r syndesm o tic
Osseous An atomy complex, la teral collatera l & deltoid ligame nts
• Ankl e (ta locrural) joint • 4 tibio fib ular sy ndesmotic ligaments
o Tibia, fibula & talu s fo rm sy novial jo int o Anterior & posterior t ibiofibu lar ligame nts
o Su ppo rted by la te ral & m edial collateral ligame nts • Ex te nd obli que ly bet ween anteri or & po sterior
o Mai nly un iax ia l h inge jo int, dorsifl exion, plantar tibial & fibula r tubercles respecti vely
flexion , a lso dyn amic sh ift o f axis o f ro tation during • Distal a nteri o r tibio fibu lar liga me nt: Bassett
d o rsi & plantar flexion ligamen t '
• Distal tib iofibular joint o Infer ior transverse ligament: Distal pa rt of
o Fibrou s joint poste rior t ibiofibular li gament .
o Sup ported by syndesmotic li ga me nts o Interosse ous liga m e nt: Dista l t hi cke nin g o f
o Sy novial recess from a nkle jo int ex tends into joint syn des m oti c me mbran e
o May ha ve articu la r cartilage far d istally • 3 late ral collate ral liga ments
o Minimal stretch ("give") d uring do rsiflexion: Allows o An te rior talofibu lar liga ment
in crease in m a ll eola r ga p & slight fibula r lateral • Originates 1 e m proximal to lateral m a ll eola r t ip,
ro tat io n inse rts o n ta la r neck
• Hindfoot: Talus & calca neus • Stabi li zes ta lus aga in st a n terio r displaceme nt,
o Poste rio r, m idd le & an terio r subta la r jo in ts between inte rnal rota tion & in vers io n
tal us & calca n eus • Wea kest, first to tea r
o Middl e & anteri or subtal a r joi nts ofte n co nflue nt o Calcaneof ibular ligament
o Aids in in ve rsio n, eversio n , adductio n, abducti o n • O rig inates from late ra l m al leolar tip, inserts on
o Talus calcan ea l troc hl ea r e min ence
• Affo rds plan ta rflexio n & d o rsifl ex io n of ankle • Deep to pe roneal te ndo ns .
• Keystone o f me dia l longitud in al arch • Lateral rest rai nt of sub ta la r joint, ofte n tears w1 th
• Proxima l bod y (trochlea ) a rticulates with tibia anterior ta lo fib u lar liga me nt
• Troc hlea broade r ante ri o rly th an poste ri o rly o Posterior ta lofibu lar ligament
• Body a rticulates with m edial & late ra l ma lleo li • Extend s fro m latera l m all eola r fossa to latera l talar
• Poste rio r process: G roove betwee n m ed ial & tube rc le
lateral tubercles fo r flexor h a llucis lon gus tendon • St ronges t, rarely tears
• 3 infe rior facets a rticu late with ca lca neus • Deltoid liga m e n t (m edial collatera l liga m e nt)
• Head arti cul ates with n avi cular bone, spring o Fan sha ped, origi nates fro m anterior, apex &
ligament & ta li post erior m ed ia l malleo lus, inse rts o n talus,
• No m uscle attac hm ents, 2/ 3 co ve red by ca rtila ge, sustentaculum tali, s pring ligament & na vicula r
do m inant blood supply ente rs neck o Deep: Poste ri o r & anterio r tibi ot ala r bands
o Calcaneus o Supe rfi cial: Tibiocalcanea l, tibiospring,
• Ta la r ar ti culation s: Anterior, midd le & posterior tibionavicular & posterior tibio ta lar (variabl e) bands
facet s
• Weig ht-bea ri ng, springboa rd for locomotion • Spring ligame nt {pla nta r ca lca n eonavic ular
• Anteri o r pro cess a rti cu lates w ith c ubo id ligament)
• Sust e ntaculum ta li: Med ial protuberance, middl e o Binds ca lcan eu s to navicular, 3 compo n e nts
face t o Superomedial- origin: Su ste n tacul u m tal i,
• Tube ro sity: Ach ill es te n don inserti on , posterior insertion: Supero media l navicul ar, tibiospring band
s ubta lar facet o f de lto id
• Plantar su rface: Ante rior, media l & latera l o Medioplan ta r oblique- origin: Calca neal co ro n o id
tubercl es fossa, insertion: Plantar n avicu la r
• Critica l a n gle o f G issa n e: jun cti o n of poste rior o In feroplantar longitudinal - o rigin: Coronoid fossa,
facet & ante rior calca neal process insertion: Na vicular beak
• Sinus tarsi Reti nacu la
o Lateral, funn e l shaped s pace betwee n ta lar nec k &
• Focal th ickening of d eep fascia
ca lcaneus
• Preve nts bowstrin gi n g, binds te ndons down
o Base is ta rsa l canal, between posterior subtala r joint
• Superior extensor retinac ulum
& sus te n tacul um ta Ii
o A few em above a nkl e jo int
o Traversed by: Medi al, late ral & intermediate roots of
o Attach es to ante rio r fibu la late ra!Jy, tibia m ed ia ll y
inferior extensor retinacu lum, cervica l &
o Proxima lly con tinues with fa scia cru ris
ta loca lca n eal in terosseous li gament s, fat ,
o Distally atta ch es to infe rio r extenso r retina cul um
neurovascul a r a nastom os is
o Binds down a nte ri o r com pa rtme nt m uscles
o Talocalcaneal interosseo us ligame nt: Most media l,
• Inferior extensor retinacu lum
ext e nds from tal a r sulcus to ca lcaneus between
o At a n kle joint, Y shaped, ste m late ra ll y, proximal &
posterio r & mid d le cal ca neal facets, taut in eversio n
di sta l ba nds medially
o Cervical ligament: Ante rior & lat eral, ex tend s from
o Ste m a ttach es late rall y to upper calca ne us
talar neck to calca n e us, taut in in versio n
• Loops around extensor te ndo n s

VII
2
 ANKLE AND HINDFOOT OVERVIEW
• Root ex tend into sinus tarsi • Proximally has common tendon sh ea th with
o Proximal medial band has deep & superfi cial layers, peron eus brevis
loop around ex ten so r hallus longu s tendon & • Second tendon sheath at sole of foo t
occasi o nally tibi alis anteri or tendon • Descends behind peroneal tubercl e, deep to
o Di stal media l band su perficia l to ex tensor hallucis inferio r pero neal retinaculum
lo ngus & ti biali s anterior ten dons • u rves under cubo id deep to lo ng plantar
• Attaches to plantar aponeurosis liga ment
o Do rsa lis pedis vessels, deep pero neal nerve: Deep to • Inserts o n plan tar base o f l st metatarsal, m ed ial
all layers of inferio r ex tensor retinacul u m cu nei form
• Flexor retinacu lu m • Pla n ta rfl exes ankle, everts foot, supports
o Attach es to medial malleolus lo ngitudina l & tran sverse arch es during walking
o Proximall y continuous with d eep fascia of leg • Os peron eum always present, ossified in abou t
o Distally con tinuous wi th planta r aponeurosis 201J1J of individual s
o Abductor hallucis partl y attached to it o Peron eus brevis ten don
o Binds deep fl exor tendons to tibial & ca lcanea l • Anteromedial to peroneus longus tendon in
grooves retro fib ular groove, deep to superi or peron eal
o La teral bord er of tarsal tunn el retin acu l um
• Superior peroneal retinaculum • Descends anterio r to pero neal tubercle o f
o Origi n : Lateral mal leolus, insertions vary, m os t ca lca n eus, deep to i nferior peroneal ret inaculum
commonly to d eep fascia of leg & calca n eus • Inserts in to base of St h metatarsal
o Binds pero nea l tendon s into retrofi bular groove • Everts foot, limits foot inversion
• Inferi or peroneal retinaculum • Superficial posterior compar tment
o Continuous w ith inferio r extensor retinacu lum o Achilles tendon
o Inserts on lateral ca lcaneu s, peron ea l tubercle • Largest & strongest tendo n in body
(trochl ea) • Conjoined tendon o r media l & lateral
o Binds peroneus brevis, peroneus longus tendons to gas trocnemius & soleus muscles
ca lca neus • Approximately 15 em long
• Lacks tendo n sheath, enclosed by paratenon
Tendons • Inserts o n posterior calcaneal t uberosity
• Muscles di scussed in grea ter detail in leg m odule • J{et roca lca n eal bursa between d istal tendo n &
• A nterior (ex ten sor) compartment ca lcaneal tuberosi ty
o T ibialis anterior tendon • Main p lantarflex or of ankle, foot
• M os t media l & larges t tendon in anteri o r • Planta ri s tendon
compartment o Vestigia l, slender t endon, medi al to Achill es tendon
• Inserts o n medial cuneiform, ba se o f 1st o Inserts o n or m edial to Ac hill es tendon
meta ta rsa I • Deep posterior (flexor) compartment
• Dorsi fl exes ankle, inverts foot, t ightens plantar o Tib ia l.is pos terior tendon
aponeurosi s • Crosses flexor digito rum lo ngus tendo n above
• Supports m edial lo ngitudinal arch during wa lki ng ankle jo int to become m ost pos tero medial tendo n
o Ex tensor h allucis lo n g us te n don • Sha res tibial groove with fl exor digitorum lo ngus
• Inserts o n dorsa l base of 1st d istal phalanx tendon
• Extends I st phalanges, dorsi fl exes foo t • I nserts o n nav icul ar t uberosity, cune i fo rms,
o Extensor digitorum l o n gu s tendon susten tacul um tali , bases o f 2nd-4th metatarsals
• Div ide\ into four o n dorsum of foot • Main invertor o f foot, aids in plantar fl ex ion
• Slips receive tendinous contributions fro m • upports m edial longitudinal arch
extensor digito rum brev is, l urnbrica ls & o flexo r digitorum l ongus tendon
interosseous m uscles • Latera l t o ti bialis posterior tendon in t ibial groove
• Each sli p divides into 3: Central one inserts o n • C rosses flexor h alluci s lo ngus te ndon at master
do rsa l ba se of middle phalan x & 2 co llatera l o nes knot o f Henry
which reunite & on bases of 2nd-5th d i stal • Divides into 4 slips wh ich give origin to
phalanges lu m brica Is
• Dorsiflexes ankle, ex tends toes, t ightens pl antar • Slips pass thro ugh o penings in co rresponding
aponeurosis. tendons of f lexor digi torum brevis
o Peroneu s terti us te ndon • Sl ips i n se rt on bases o f 2 nd-5th dista l pha langes
• Ty pica ll y pa rt of ex ten sor dig itoru m longus • Flexes distal pha langes, a-;si sts in p lantar flex ion of
tendo n ankle
• Inserts o n dorsa l ba e o f Sth m etatarsal • Wh en foo t on groun d: Maintai ns pads of toes o n
• Lateral compartment ground
o Peroneus lo ngus tendon • W h en foot off g rou nd : Plantar flexes 2nd -St·h
• Posterolateral to peron eus brevis tendo n in p halanges, aid s in main taining lo ng itud inal
retrofibular groove, deep to superior pero neal arches
retinaculum o Flexor halluch l o n gus te n don

VII
3
 ANKLE AND HINDFOOT OVERVIEW
• Passes 3 fibro-osseous tu n nels: 1) betwee n m edial o Pu rely se nsory to lateral ankle, foot up to base of 5th
& la tera l tala r t ubercles, 2) und e r suste n tacu lum metatarsal
tali, 3) between 1st medial & lateral sesamoids
• Crosses & se nds slip t o flexor digitorum longus at
maste r knot o f Hen ry IImaging Anatomy
• Inserts on base of 1st distal phalan x
• W hen foot o n ground : Mai ntai ns pad of 1st toe Overview
o n g ro und • Rad iogra p hy of ank le joint
• When foot off ground: Plan ta r flexes 1st • Ro utin e ra d iograp h s: AP, latera l & ankle m o rtise
pha langes, a ids in maintaining m edial (15-20° inte rn al obliqu e) v iews '
longitud in al arc h o AP view: Ta lus overla ps m edi al aspect of lateral
• Weak p la nta r fl exo r of ankl e ma lleolus
• Innervated by ti bia l n e rve o Ankle m o rti se view t a ken in dorsiflexion to avoid
overlap of fib ula on ca lca n eus
Vessels (For D etai l, See Leg & Foot Sectio ns) o Talus should be eq uidistant fro m tibial pla fo nd o n
• Anterior tibia l a rt e ry beco mes dorsalis ped is at ankl e AP & m o rtise views
joint • May appea r asymmet ric in join t wh en AP taken in
• Posterio r ti bial a rtery divides i nto media l & latera l plan tarflexion
plantar arteries in ta rsa l tunn el • Tata r ti lt o f up to soconsidered n orma l by many
o Transverse line across m edial m alleolus: Base o f
N erves
poste rior coll iculus
• Posterio r ti b ial nerve o Co nvex lin e within ti p o f latera l ma lleo lus:
o Traverses tarsal tunn el
Atta chm ent of posterior talofibular ligament
o Ta rsal t unnel: Deep to flexor retinaculum , traversed o Syndesm o tic t ibiofibular clea r space (TFC),
by t ibialis posterio r, flexo r digitorum & flexor tib iofibular overlap (TFO), m edial clear space (MC):
ha ll uc is tend on s & p oste rior tibia l ne u rovascular Assess ligame n to u s in tegri ty, m easu red o n AP &
bundle mo rtise v iews
o Poste rio r tib ia l n erve di vides proxima l o r at ta rsal o TFC: D ist a nce between pero neal groove (or ante ri or
tunn e l into : Medial calca neal nerve, m edial & lateral tib ia l cortex) & m ed ia l fibu lar cortex
plantar nerves o TFO: Overlap between poste rio r tibial cortex and
• 1st branch of latera l plantar ne rve is infe rior fibul a
calcan eal ne rve (Baxter nerve)
o TFC, TFO measured 1 em above t ibial plafo nd, range
o Med ia l calcaneal n erve varies w it h gender
• Sen sory to m edial he.el o Norm al TFC sa me o n AP & m ortise views: 4 mm, (up
o Media l p lantar n erve to 6 mm co nsid ered n or mal by som e), < 44% of
• Sensory to medial 2/3 of plan tar foo t fibu lar width
• Motor to abducto r ha ll ucis, flexor digitorum o Normal TFO: > 6 mm , > 24% of fibula r w id th o n AP,
brevis, fl exor ha llucis brevi s, 1st lu m brical > 1 mm o n m o rt ise
o Lateral p lant a r n erve o No rmal MC: Measured l / 2 em be low t ibia l plafo ncl,
• Senso ry to la tera l mid foot & forefoot 4 mm o r equa l to supe rior tibio ta la r space
• Supplies m ost plantar m uscles o f foot • Poor la te ral view (5 em heel lift), 45° internal and
• Dee p pero n eal nerve ext erna l AP views: Bette r visua liza t io n of posterior,
o Deep to extenso r ret inacula, in anteri or ta rsa l tunnel m edia l, late ra l ma lleoli & a nterio r t ibial tubercle
o Predomi n antly motor
respectively
o Di vides just above ankle into media l (main ly • Brode n view, os ca lcis (tange nt ial calcan eal) views
sen so ry), late ra l (mainly m oto r) branches
dep ic t su bta lar joints
• Medial b ranch contin ues dorsal to ta lonavic ular
• Co m puted tomograph y
joi nt, middle cuneiform & in between 1st & 2nd o Obliq ue axial images opt ima l visua lizat ion of
meta ta rsa Is subta lar jo in ts
• Lateral b ranch ends a t exten sor d igitoru m brevis o Su perio r to MR for de tectin g sma ll avul sion
o ln leg: Motor to a nterior tibial, exte nsor d igit o rum fragm ents
longus, exte n so r hallucis longus, peroneus tertius o 3D volume renderin g of bo nes, tend o ns
o In foot: Moto r to extensor di gitoru m brevis, se nso ry • MR of an k le & hindfoot
(&someti mes motor) to 1st web space o Must image in axia l, coro n al & sagitta l p lanes
• Superficial peroneal nerve o Coronals paralle l to a nte ri o r talar m argi n , based on
o Ex its deep fascia 10-15 em a bove a n kl e jo int tra n sve rse image
o Subc uta n eous 6 em above an kle, d ivides into o Sagitta ls paralle l to lon gitudinal calcaneal ax ial,
subcutaneous bra nch es based o n tran sverse image
o In leg m otor to peroneus brevis & p eron eus longus o Axials opt ima l for ank le te n dons, liga m ents
t endo n s, sen so ry to dista l 2/3 lateral leg o Corona ls useful fo r bones, cartil age, ankle a nd sinus
o In foot se nsory to dorsa I foot ta rsi ligamen ts
• Sural ner ve o Sagitta ls optimal for Achilles tendo n , bo n es,
o Fo rmed by m e rger of bran ch es from tibia l nerve & cartilage, sinus ta rsi ligame nts
comm o n pe ro n eal nerve

VII
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VII
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VII
6
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VII
8
VII
9
VII
10
VII
11
VII
12
 ANKLE AND HIND FOOT OVERVIEW
AP & OBLIQUE RADIOGRAPH S, RIGHT ANKLE

Tibia

Fi bula
Posterior distal tibial
Syndes mo t ic clear border
space
Tibial growth plate scar
An teri or ti bial tubercle

Posterior ti bial tubercle M edi al clear space

Latera I m a II eo Ius Posterior coll iculus

m edial ma lleolus
Fi bula r fossa
An terio r collicul us,
Lateral talar process
m edi al m alleolus

Ta l us
Cal ca neu s
Pos terio r subtalar facet

Cuboid
1st m etatarsal

Ti bia

fi bula Pos terior distal ti bial

border
Syndesm o tic clear
space Tibial gro wth plate scar

Medial clear space

Anterior tibial tuberc le
Posterior coll iculu s
m ed ial mall eolu s
Posterio r tibial tubercle

Lateral m alleolus Anterio r co ll iculus,

m edi al mall eolu s
ribul ar fossa

Posterior subtalar facet

Talar head

CalcanQus Navicular

Late ral cal canea l 1st metatarsa l

tubercle

(Top) Routine no n weight-bea rin g AP view of the a nkle is obtain ed with the patient supine, th e h eel on the casse tte
and th e toes pointed upwa rd. The X-ra y beam is directed at the cent er o f t he ank le joint. The ta lus ove rlaps t h e distal
fibula obsc uring the lateral ank le mortise. Note tha t anterio r margin of the tibia exten ds furthe r la te rall y compared t o
the posteri o r tibial margin. Similarly the anterio r coll icul us o f th e media l malleolus exte nds more d istally th an th e
posterior collicul us. (Bottom ) Non weight-bearing ankle mortise view (obliq ue) is obtained with the pa ti ent supine
and th e foot internaLl y rota ted until th e m ed ial and lateral mall eoli are eq u id istant from the cassette. The lateral
ankle mortise is n ow visualized. The talus sh ould be equidistant from th e tibial plafon d o n bo th th e AP and ankle
mo rti se view. VII
13
 ANKLE AND HINDFOOT OVERVIEW
LATERAL RADIOGRAPHS, RIGHT ANKLE

Tibia l'ibula

Lat e ral talar process An terior col licu lus

Tatar neck med ia l
Posterio r colli cul us,
Tatar head media I ma lleol

Anterio r process of Posterior tibial

ca lca neus ma lleolus
Late ra l malleo lu s
avicul a r
Lateral tu bercle, talus
2 nd
jo int Medial tubercle, ta lus

2nd cuneiform Posterior subla lar fac et

1sl tarsometata rsal Middle subtalar join t
joint
1st cuneiform ta li

3 rd cun eiform Ca lcanea l tuberosity

Cuboid
Lateral ca lcaneal
5th metatarsal stylo id tubercle
An terior calcaneal
eutra l triangle tubercle

Flexor longus
muscle

So leus musc le

Pre-Achilles fa t pad
Tibialis anterio r t.
(Kager fa t pad)

Achi lles tendon

Normal anterio r ankle
fat pad
Retrocalca neal fat pad

Quadratus plantae

Flexor digito rum brevis

muscle

(Top) A non weight-bearing latera l v iew of the ank le . The latera l view depicts bo th the ca lcaneus and talus in profi le .
The pos te rior, m e dia l and la teral m alleoli a re supe rimposed over one another and over the talus, potent ia ll y
obscuring fra ctures a t those loca ti ons. The la te ral view s ho u ld include th e ba se o f the 5th m etata rsa l. The midd le
subta lar jo int is typi ca lly visu alized o n a weig ht-bearing late ral view. ( Bottom) La te ral view, ank le soft tissues. The
Ach ill es tendo n s h o uld be un ifo rm in dia m e te r. A small ret rocalcanea l fat pad, location o f re trocalca n ea l bursa, is
fo und between the te ndon & calcane us. A no rmal pre-Ac hill es fat pad separates th e Achil les te ndon from t h e an kl e
jo int. T h e tibialis anterior tendon is noted on the dorsa l surface of the ankle. Ob li teration of a small fa t pad a n terior
VII t o th e an te rior join t line is con sistent wit h joint e ffusion.
14
 ANKLE AND HINDFOOT OVERVIEW
OS CALCIS & BRODEN RADIO GRAPHS, RIGHT ANKLE

Middle subtalar join t

Sin us tarsi

joint

Calcaneus

Posterior subtal ar joi nt

(Top) The os ca lcis v iew is obtained with th e pa ti ent supin e or standing and the foot i n maximum do rsiflexion. The
view depi cts the midd le and posterior subta lar joints. (Bottom) Broden views are obtained with t he pati en t su pine,
foot i n 45° of internal ro tat ion and 10, 20, 30 and 40° o f tube an gulation. Th e vi ews afford visualizatio n of the
pos teri or subtalar jo int bu t have become somewhat obsol ete as co mputed tomography is used more frequently for
problem solv ing in t he ankle.

VII
15
 ANKLE AND HINDFOOT OVERVIEW
RADIOGRAPHS, CA LCANEAL PITCH & TALAR BASE ANGLES

Calcaneal pitch an gl e

Talar base a ngle

(Top) A weight-bearing lateral v iew of the foot provides information on the heigh t of the longi tudin al arch. The
calcaneal pitch is an angle formed by intersection of a line along th e p lantar aspect of the ca lcan eus with the floor. It
should measure about 20-30°. (Bottom ) T he n ormal ta lar-base angle is formed by the intersecti on of the longitudi nal
axis o f the ta l us w ith a line para llel to the floor. It normally measures 14-36°.

VII
16
 ANKLE AND HINDFOOT OVERVIEW
RADIOGRAP HS, ANGLES OF THE HINDFOOT

Ta localcaneal angle (Kite angle)

Taloca lca neal angle (Kite angle)

Boehler an gle

(Top) Normal lateral ta localcaneal angle, (Kite angle), for med by intersection of ta lar & calcaneal longitudinal axes,
measu res 25-55°. Dec rease in late ra l angle is indicative of equinus hi ndfoot deformity & inc rease is indicative of );>
cal ca neus h indfoo t deformity. (Middle) Normal AP talocalcaneal angle, m easured along lo ngitud in al axes o f tal us & :;j
calca neus is 15-40°. Dec rease in AP angle is indi cative of va rus hind foot defo rmity & increase is ind ica tive of valgus 7'\
hindfoot defor mity. (Bottom) Boehler angle reflects integrity of the posterior calcaneal facet & calcaneal height. The C'tl
ang le is form ed by the intersectio n of a line d rawn alon g the apices o f anterior calcanea l process & posterior
calca neal facet & a line drawn along the apices of superior calcan eal tuberosity & posterior calcaneal facet. The
n o rm a l ra nge is 20-40 °. VII
17
 ANKLE AND HINDFOOT OVERVIEW
RADIOGRAPHIC MEASUREMENTS, ANKLE

Tibia
Fibul a

Lateral clear space

Ta lus

Tibio fi bu lar overl ap

M ed ial clea r space

(Top) T h e lateral sy ndesmotic clear space & t ibi ofi bu lar overlap, indicators o f the integrit y o f th e tib io fibul ar
syndesm o tic joint, are m easured approx i mately I em above t he tibial plafond. T he lateral syndesmo tic clear space is
measured from the posterior tibial margin to t he med ial fibula r margin. o nnal m easurements va ry i n th e li terature
and range from 4-6 mm o n both th e AP an kle and ankle mortise views. (Midd le) T h e t ibiofibu lar overl ap
measurements al so va ry and range from 6-10 mm i n t he litera ture. An overl ap o f 6 mm, however, o n the AP view
and I mm o n the ankle mortise vi ew are co nsid ered norm al by m ost. (Bo ttom ) Th e talus sho u ld be equidistant f ro m
th e tibi al pl afond o n the A P and an kle mort ise v iews. Minima l ti l ts are wi thin normal. T h e n o rmal med ia l clea r
VII space, measured 0.5 em below the talar articular surface, sh ould be 4 mm in size.
18
 ANKLE AND HINDFOOT OVERVIEW
AXIAL CT, RIGHT HINDFOOT

tarsi
Tarsal can a l
Talus
Mi ddl e subta la r joi nt

Posterior subtalar jo in t
Suste nt aculum tali

Calcaneus

Tal us

An terio r subta la r joint

Sin u s tarsi

Ca lca n e us

(Top) Axial CT v iew at the level o f th e midd le and posterior subta lar join t. At th i s leve l th e post erior and midd le
subta lar joints are usuall y parallel to each other. Th e tarsal canal is a medial spa ce, con tinu ous with the sinus tarsi
laterally, w hich separates th e posteri or from th e middle subtalar join ts. (Bottom) A more an terior axial CT. Th e
anterior subta lar joint i usually hori zonta l in orientat ion . The opening of th e i nus tarsi toward t he latera l aspect of
th e ankle is now bet ter vi suali zed.

VII
19
 ANKLE AND HINDFOOT OVERVIEW
SAGITTAL CT RE FORMATS, RIGHT ANKLE

T ibi a

Posterior subtalar join t

Ta lu s

Sinus tarsi

M iddle subta lar jo i nt

Sustentacul um tal i
Navicular

Tal us

Tatar neck
Posterior subtalar joi n t

An terior subtalar joi nt

N av icular
eutral trian gle
2rd cu nei fo rm Cal can eocuboid jo in t

3rd cuneiform

2n d metatarsal
3rd metatarsal

(Top) Medial sagitta l reconst ructio n o f the a nkl e. At this fairly m edial level both th e midd le and poste rio r subta la r
joints are visuali zed . Fa r medially the posterior subtalar joint te nds t o be more h orizo ntal than lateral. An area of
relative rad io luce ncy in th e calca neus betwee n th e compressile trabeculae th at occasio nall y ca n mimic a lytic lesio n
is see n. (Bottom) A more lateral sagitta l reconstruct ion. The a nte rior subtalar jo int is more h orizontal th an the
middle o ne whil e th e posterior su btalar jo int is now more obliq ued th an it was more m ediall y. Th e n e utral triangle is
an area of trabecular rarefact io n n o ted in between the posterior and a nte rio r compressile trabecu lae o f the calca neus
and shou ld not be mist aken for a lytic lesion.
VII
20
 ANKLE AND HINDFOOT OVERVIEW
CORONAL CT R EFORMATS, RIGHT ANKLE

Tib ia

Fibular tip

Tal us

Sin us ta rs i Middle subtala r joint

Susten tacu lum tali

Ca lca n e us

Tibia

Fibular tip

Ta lus

M iddle subtala r jo int

Si nus ta rs i

Susten tac ulum tali

Calca ne us

(Top) oronal CT recon struction s at t he middl e subtalar joint. Note that th e middle subtalar joi nt is oft en
subop timall y seen o n coro nal reconstru ctio ns d ue to partial vo lume averaging. This may also be noted on axial CT
images and should no t be misinterpreted as subtalar coa lition. Performing axial images perpendicular to the su btalar
joints is advisable w hen tarsa l coa litio n is suspected. Also, sagittal reco nstru ctions will usually depict the no rmal
relationship between th e sustentaculum tall and the talus. (Bottom) Coro nal recons tructio n at the middle su btala r
jo int. o te that th e middle sub tala r jo int is mo re clea rly seen o n this image but, d ue to partial vo lume averagi ng, is
still no t optimall y defined as o n th e sagittal reconstru ctions.
VII
21
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT ANKLE

anterior t.
E>. tem or
In ferior exten sor
lon gus rn . & t.
reti n acul um

Ex tensor digi toru m Grea ter saph en ous vei n

lon gus, pero neus
A nter ior t i bial vessels
m . & l.

Dcc1j peron eal n erve

Tibia posterio r t.

Fl exor d igi to rum

Fibula tendon

Posterior tibial art ery,

brev is m . & t. vei n
Posterior tibial n erve
Pero neus longus t.
Fle>.o r reli naculum
Branch es, saphenous
v ei n Fl c>. or hallu cis longus
& tendon
Sura l ner ve
Plantaris tendo n
Ac hill es tendon

Tibi ali s an terio r t.

Exten or h all ucis
longus m . & t.
In ferior ex tensor
retinaculum
Ex tensor cligitorum
Grea ter vei n
longus, pero neus
ter tius 111 . & t. An terior tibial vessels

Deep pe ro neal nerve

Tibi a

Tibial is posterior t.
Anterior ti bi o fi bula r I.
Flexo r cl igi toru m
lo ngus tendon
Posteri or ti bi o fibul ar I.
Posterior ti bial artery,
Peron eu s brevis m. & t. vein

tibial nerve
Peroneus lon gu s t. Flexor reti naculum
lesser
Flexor h al l ucis longus
saph enous vein
m u scle & tendon

Sural n erve
Plantaris tendon
Achi lles tendo n

(Top) First in seri es of axial T1 M R images of th e right ankle. T he cut is just above the tibia l p lafond. At t h is level ,
exclud ing t h e tib ial is an terior, ti biali s posterio r and peroneu s longus, all th e muscles of t he anterior, latera l and deep
pos terior co mpartm ent are still vi sualized. The pos teri or tibi al nerve, found behin d th e posterior t ibial vessels, h as
no t yet div ided into the m edial and lateral plantar n erves. Th e su ral nerve is an te ro lateral to th e Ach i lles tendon.
(Bottom) Th e ante rior and posterior ti bio fibu lar liga ments ex tend from th e dist al tib ia to th e fib u la and along w ith
the in te rosseus ligam ent, support the dista l ti bi o fi bu lar joint. The anteri or surface of t he Achilles tendon is flat. Th e
tend on is pa rti ally surrounded by a pa ratenon . T he pl an ta ris tendo n is found just m edial to the Achilles te ndon .
VII
22
 ANKLE AND HINDFOOT OVERV I EW
AXI AL T1 MR, LEFT ANKLE

anterior t.
Extensor hallucis
longus m. & t.
In ferior exten sor
retinacu lum
Grea ter sa ph enous vei n Extensor digitorum
longus, peroneus
tertius m . & t.
Anterior tibial vessels
Deep peronea l nerve

Tibialis posterior t.

Flexor digitorum Tibia

longus tendon
l'ibula

Posterior tibial artery, Peroneus brevis m. & t.

vein

Posterior tibial n erve

Peron eus longu s t.
Flexor retina culum
Fl exor h allucis lo ngus Branch es, saph en ous
muscle & tendon vei n

Sura l nerve
tendon
Achi ll es tendon

Tibial is anterior t.

I nferi or ex tensor
retinaculum
Ex ten sor h allucis
longus m. & t.

Ex tem or digitorum
Lll
Greater saphenous vei n longus, peroneus
tert ius m. & t.
An terior tibial vessels
Deep peroneal nerve

Tibia

Tibiali\ posterior t.
Anterior tibiofibular I.
rlexor digitorum
lon gus tendon Posterior tibiofibular I.

Posteri or tibial artery, Pero neus brev i s 111. & t.

vei n

Posterior tibial nerve

Pe10n eus lon gus t.

Fl exor retinaculum Branches, lesser

saphenous vei n
Flexor hallucis lo ngus
muscle & tendo n
Sural nerve
Plantaris tendon Ach illes tendon

(Top) First in series of axial T1 MR i mages of t h e left ankle. Th e cut is just above the tibial pla fo nd. At this level,
excluding the tibialis anterior, t ibialis pos terior and peron eus lo ngus, al l the muscles of the anterior, lateral and deep
posterior co mpartment are still v isualized. T he posterior tibia l nerve, fou n d behind t he posterior ti bial vessels, has
no t ye t divided into the media l and la tera l plan ta r nerves. Th e sural n erve is anterolateral to the Ach illes tendon.
(Botto m) The an terior an d posterior ti biofi bu lar liga ments extend fro m the d istal tibia to the fi bu la and alo ng w ith
the in terosseous ligament, support the d istal fibrous ti bio fi bu lar jo i nt. T h e anterior surface of the Ach illes tendon is
flat. The tendo n is partially su rrounded by a pa ratenon. Th e p lan ta ris ten don is found just med ial to t he Ac hilles
tendon. VII
23
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT ANKLE

Extenso r hallucis T ibial is anterior t .

lo ngus m . & t.
Anterior ti bial vessels
Exten sor digitorum
longus, pe ro neus G rea ter sa phenous vein
ter tius m. & t . Anterior ti bio talar,
tibionavicular,
Medial, lateral
superficial del toid
bran ch es, deep
pero nea l nerve
Medial malleo lus

Anterior ti biofibular I. Art icular cart ilage

Tibia l is posterior t.
Posterior ti biofibul ar I. Flexor digitorum
lo ngus tendon
Pero neu s brevis t. & m.

Flexor retin aculum

Peroneus lo ngus t .
Posterior tibial vessels
Bran ches, lesser Posterior tib ial nerve
sapheno us vein
Flexor ha ll ucis lon gus
Sura l nerve muscle & tendon
Achilles tendon
Plan taris tendon

Dorsal is ped is vessels

Ex ten sor hallucis Tibialis an terior t.
lon gu s m. & t.

Exten sor digi torum Greate r saph enous vei n

longus m . & t.

Peroneus terti us t. An terior tibiotalar,

ti bio navi cular,
Medial , lateral superficia l deltoid
branch es, deep
peron ea l nerve
M edial m all eolus
Anterior ti biofibular
A rticular ca rti lage
liga m ent
T ibia lis posterio r t.
Interosseous li gam ent
Posterior ti biofibular Flexor digi torum
ligament lon gus tendon
Peron eus brevis t. & m.
Flexor ret inaculum
Posterior tibia l ves els
Pero neus longus t .
Branches, lesser Posterior tibia l nerve
saphen ous vein
Flexor hallucis lon gus
muscle & tendo n
Sura l nerve
Ach illes tendon Plantaris ten don

(Top) The sh a red groove of th e tibial is posterior a nd flexo r digitorum longus tendons is no ted posterio r to the med ial
malleolus. The deep pe ro nea l n erve a nd its accompanyi ng a nte rio r tibial and t h en do rsalis ped is vesse ls are loca ted
d eep to the infe rior extensor retinaculum but ma y be difficult to distinguish fro m each o ther. The deep pe ro n eal
nerve divides in to a la te ra l, motor b ra n ch, supply in g t he extenso r digitorum brevis m uscle and a medial branc h
which carries sensation a nd o ccasiona ll y suppli es moto r in n ervation to the 1st dorsal web space. (Bottom) The
interosseous ligamen t is v isualized in between th e tibia and fibul a. This ligam en t, a thickening of th e in te rosseo us
membrane, is var ia ble, & may be perforated or abse nt. The cross sectio na l a rea of the tibia lis pos terior tend o n is
VII grea te r t h an the rest of poste rior com pa rtme nt te nd o ns.
24
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, LEFT ANKLE

'J anterior t. Exten sor h allucis

longus m. & t.
Anterior tibial ve sc i\

Greater saphenous vein Extensor digitorum

longus, peroneus
An terior tibiotalar, tertius m. & t.
t i bionavicu Ia r,
superfi cial deltoid Med ial, lateral
b ran ches, deep
Medial mall eo lus peron eal n erve

Articular ca rti lage

Anterior tibiofibular I.

Tibialis posterior t.
Posterior tibiofibu lar I.
Fl exo r digito rum
longus tendon
Peroneus brevis t.
Flexor retinaculum
Posterior tibial vesse ls Peroneus lon gus t.

Posterior tibial n . Branch es, lesser

Flexor h allucis lo ngus saphenous vein
& tendon
Sural nerve
Plantaris tendon Achilles tendon

Tibialis anterior t. Extensor h allucis

Dorsa lis pedis vessels longus m. & t.

Greater saphenous vein Exten sor d igitorum

longus m. & t.
An terior tibiotalar,
tibionavicular, Peroneus tertius t.
superficial deltoid Medi al, lateral
branches, deep
Medial ma l leolus peroneal n erve
Articular ca rtilage
Anterior tibiofibula r
ligament
posterio r t.
Interosseous ligament
Flexor digi to rum Posterior tibiofibula r
longu s ten don ligamen t
Peroneus brev is muscle
Flexor reti naculum & tendon
Posterior tibial vessels Peroneus longus t.
Posterior tibial nerve Bra n ches, lesser
saph en ous vei n
Fl exor hal lucis longus
m uscle & tentlon
Sural n erve
Plan taris tendon Achilles tendon

(Top) T h e sha red groove of the tibialis posterio r and flexor digi to rum longus tendons is noted posterior to the medial
malleol us. T he deep peroneal n erve and its accompanying anterior tibial and then dorsalis pedis vessels are located
deep to the inferior ex ten sor retinaculum but may be difficult to disti nguish from each o th er. Th e deep peroneal
nerve divides into a latera l, motor bran ch, supplying th e ext en sor digitorum brevis muscle and a med ial branch
w hich ca rri es sensa ti on and occasio nally suppli es m otor innervati on to th e 1st dorsal web space. (Bottom) The
interosseous ligament is visualized in be tween th e t ibia and fibu la. T his ligament, a thickening of the interosseous
membrane, is variable, & m ay be perforated or absent. Th e cross sec tional area of t he tibialis posterior tendon is
greater than the rest of posterior compartment tendons. VII
25
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT AN KLE r
Extensor h allucis Tibial is anterior t.
longus tendon

Exten sor digitorum Do rsal is pedis vessels

lo ngus m. & t.
Grea ter saph enous vei n
Anterior tibio talar,
Peron eu s tertiu s t.
t ibiona vicul ar,
Deep pe ronea l n erve superficial del toid

Ta lu s M edial malleolus

Tibial is posterior t .
A n terio r tibio fi bular
l igamen t Flexo r d igitorum
longus ten don
Fibula

Posterior m al leol us, Flexor reti naculum

tibia
Posterior tibial vessels
Posterior tibio fibular I.
Posterio r ti bial n erve

Peron eus lon gus t .

fle xor hallucis longus
Peroneus brevis m . & t. muscle & ten don
Lesser sa ph enous vei n Plan taris tendon

Sural nerve
Paratenon, Achi l les
Achill es tendon te ndon

Extensor h allucis
Tibialis anterior t.
lo ngus ten don

Ex ten sor digitorum

Greater sap henou s vein
longus m . & t.
An terior tibiotalar,
Peron eus terti us t. tibion avicular,
super ficia I del toid
Deep peron ea l nerve
Posteri or ti biotalar,
deep del to icl
An terio r tibio fibular
l iga m en t
Tibial is posterior t.
Inferior t ransverse Flexor digitorum
l iga m ent longus tendon

Peroneu s brevis m. & t . Flexor ret i nacul um

Posterior t ibial artery,

vei n
Peron eus longus t.
M edial plantar nerve
Branch es, lesser Latera l plantar nerve
sa phen ous vein
Flexor hallucis lon gus
Sural nerve tendon

Achilles tendon Plan taris ten don

(Top) On ly the muscles o f the flexor h allucis longu s & peroneu s bre vis are seen w hile the other muscles ha ve become
te ndinous. Th e a nte rio r t ibiot ala r & tibio navicula r bands of th e superfi cial delto id o rigin a te from the ante rior
colliculus o f m edial m alleolus. Note that t h e fibula is ro und a t the leve l of syndesmotic ligame nts. (Bottom) The
deep poste ri or tibiotalar compone nt of the deltoid ligame nt o riginates from the poste ri o r coll iculus & is typical ly
stria ted. The very ti p of t h e ante rio r tibiofibul ar ligame nt is noted at th e level of the ta la r do me (ta lus is square a t this
level). The infe rior tra n sverse ligam ent, the very inferior aspect o f the posterior tibio fibular liga m ent, ext e nds d istal
to the tibia l poste rio r surface. It ca n in sert into the t ibia quite far m ediall y, as seen h ere.
VII
26
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, LEFT ANKLE

Tibia Iis anterior l. Extensor h all ucis

longus tendo n
Dorsalis ped is vessels Extensor digitorum
longus m. & t.
Greater sa phenous vein
Peroneus tertius L
An terio r tibiotalar,
tibionavicular, Deep peronea I nerve
superficial deltoid
Med ia l Ta lus

Tibialis posterior l. Anterior tibiofibular

ligament
Flexor digi torum
longus tendon Fibula

Posterior
Flexor retinaculum t ibia
Posterior tibiofibular I.
Posterior tibial vessels
Posterior tibial nerve
Peroneus longus t.
Flexor h al lucis lo ngus Peroneus brevis m. & t.
muscle & tend o n
Lesser saphenous vein
Planta ri s tendo n
Su ral nerve
Paraten o n, Achilles t.
Achilles tendo n

Tibialis anterior t. Exten sor hallucis

longus te ndon
Greater sap he no u s vein Extensor dig ito rum
lo ngus rn. & t.
Anterior tibiotalar,
tibio navicula r,
superficial deltoid Pe roneus terti us

Posterior t ib io talar, Deep peronea l nerve

deep deltoid

Tibia Iis posterior t. Anterior tibiofi bular

Flexor d igi to rum ligament
longus tendon
Inferior transverse
Flexor retinaculum ligament
Peron eus brevis m. & t.
Posterior tibial artery,
vein
Pe ro neus longus t.
Medial plantar nerve

Late ra l p lanta r n erve Branch es, lesser

saphenous vein
Flexor hallucis lo n gus
tendon Sura l nerve
Plantaris tendon
Achi lles te ndon

(Top) Only the muscles o f t h e fl exo r ha ll u c is lo n gus & peroneus brevis a re seen wh ile the other mu sc les have becom e
tendinou s. The an te rio r tibio talar & tibio navic ula r bands of the su p e rfi c ial delto id o riginate from t he anterior
coll icul u s of m e dial ma lleol u s. ote that the fibu la is ro u n d a t th e leve l o f sy ndesm otic ligaments. ( Bottom) T h e
deep posterior tibiotala r compon ent of the de lto id li gamen t originates from the p oste rior coll ic ulu s & is typ ica ll y
str iated. T h e very tip o f the ante ri o r tibi ofibu lar li ga m e nt is n oted at the leve l of t he talar d o m e ( talus is squa re at this
level). The in ferio r transve rse liga m e nt, th e very inferior aspect of the posterior t ib iofib ular ligament, extends di sta l
to the tibial posterior surface. It can insert into th e tibia quite fa r m e dia ll y, as seen here.
VII
27
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT ANKLE

Ex tensor hallucis Tibialis anterior t.

longus tendo n
Dorsa l is pedis vessels
Extensor digito rum
longus tendo n G reater sa pheno us vein
A nterior tibio talar,
Pero n eus tertius t.
tibionavicula r,
supe rficial del toid
Ta lus
Ti biocalcaneal,
tibiospring, superficial
deltoid
Inferio r transverse An terior, posterior
l igamen t tibiotalar, deep deltoid
Fibroca rtilaginous ridge Tibia lis posterior t.
Flexor digitorum
uperio r peroneal lon gus tendon
retinaculum
Flexor retinaculum
Pero neus lon gus t.
M edial talar tubercle

Peron eus brevis m . & t . Posteri or t i bia l vessels

Flexor hallucis lon gus
Lesse r saphenou s vein ten don
Posterior t i bial ne rve
Achilles tendon
Plant aris tendon

Ex tensor hall ucis

lon gu s tendo n Tibial b an terior t.

Dorsalis pedis vessels

In ferior ex ten sor
Extensor digitorum reti naculum
longu s tendo n
Greater saphen ous vein
Peron eus tertius
Tibiocalcanea l,
ti biospri ng, super ficial
M edial talar tubercle del toid
Unfused latera l An terior, posterior
tubercle (os trigonum ) t ibiotala r, deep deltoid

Tibiali s posterior t.
Posterior ta lofibular
ligam ent Flexor d igi to rum
lo ngus tendon
Peroneus brevis m. & t.
Flexo r retinaculum
Superior peroneal Posterior tibial artery,
retinaculum vein
Peroneus lon gu s t. Posterior tibial nerve

Lesser saph enous vein Flexor h allucis longus

tendon

Ach i lles tendon Plantari s tendon

(Top) T h e ta lus i s w ider anterio rly than pos teri orly. Its posterior process is subd ivided into medial and lateral
tubercles, thus provi ding a tunnel for th e f lexor ha llucis lo n gus tend on. The deep d elto id l igamen t is subd iv ided into
an an teri o r and posteri o r tib iota lar bands. Th e su per ficial deltoid compon en ts form a trian gular band wh ich is
d iv ided into i ts va rious ligam en ts based o n th eir respecti ve inserti o n sites. T he fibula at the level o f the syndesm oti c
ligam ents i s ro un d and the ta l us is sq uare. (Bo tto m) T h e fl exor hallucis longus tendon d escend s between th e m edial
and lateral tubercl es of t he posterior talar p rocess. In thi s instance th e lat era l t ubercl e is unfused, and is term ed an os
trigonu m . Th e pero neus brevis tendo n often has a mild crescentic shape as it acco mmod ates t o the fibu la anteri o rl y
VII and th e peron eus lo ngus tendo n posteriorl y.
28
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, LEFT ANKLE

Tibial is anterior t .
Extensor hal l ucis
Dorsal is pedis vessels
longus tendon
Greater sa phenous vein
Extensor digitorum
Anterior tibiotalar,
longus tendon
t ibionavicul ar,
superficial deltoid
Peroneus ter ti us t.
Tibiocalcaneal ,
tibiosp rin g, superfi cia l
del toid Talu s
An teri or, posterior
tibiotalar, deep deltoid
In ferior tran sverse
Ti bial is posterior t.
l igam ent
Flexor digitorum
Fi brocartilagin ous ridge
lon gus tendon
Superior peroneal
flexor reti n aculum retinaculum
M edial talar tubercle Peroneus lon gus t.
Posterior ti bial vessels
Flexor halluci longus Peroneus brevis muscle
tendon & tendon
Posterior tibia I nerve Lesser saph enous vei n
Plan taris tendon Ach illes tendon

Exten sor hallucis

Ti bialis an terior t. longu s tendon
Dorsal is pedi s vessels
In ferior exten sor
reti n aculum Exten sor digitorum
longus tendon
Greater saph en ous vein
Peroneu s terti us
Ti bi oca lcaneal ,
tibiosp ring, superficia l
del toicl Medial talar tu bercle
An terior, posterior
tibiotalar, deep del toid Unfused lateral
tubercle (os trigonum )
Tibialis posterio r t.
Posterior talofibular
Flexor digitorum ligament
longus ten don Peron eus brevis muscle
Flexor reti na cul urn & tendon

Posterio r tibial artery,

vein Superior peron ea l
retin aculum
Flexor hallucis longus
tendon Peroneus longus t.

Posterior tibial ner ve Lesser saph en ou s vein

Plan taris tendon Achi lles tendon

(Top) Th e tal us is wi de r a nteriorly than posteriorly. Its posterio r process is subdivided in to med ial a nd la teral
t ubercles, thus p roviding a tunn el fo r th e flexo r h all ucis lo ngus te ndon . The deep delto id liga me n t is subdivid ed into
a n a n terior and poste rior tibiota lar bands. Th e superficia l deltoid components form a tr iangular band wh ich is
d ivided into its var io us liga ments based o n th eir res pec tive inse rti on sites. The fibula at the level of th e syn desmotic
ligaments is round and t h e talus is sq uare. (Bottom) The fle xor ha ll ucis lo ngus tend on d escen ds bet wee n th e medial
and latera l tubercles of th e posterior ta la r process. In this instance t h e lateral tubercle is unfused, and is termed an os
trigonum . The peroneus brevis tendon often has a mild crescentic shape as it accommo dates to the fibula anteriorl y
and th e pe roneus longus tendon posteriorly. VII
29
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT ANKLE

Exten sor halluci s Tibialis anterior t.

longus tendon Talar h ead
Ex ten sor digitoru m
longus tendon Grea ter saphenous vein
Talocal can eal
Peroneu s tertius t.
interosseous ligament
Posterior subtala r joint Tibiocalcaneal,
ti biospring, superficial
Ante ri or talofibular del toid
ligament Tibialis posterior t.
Pmterior talofibular
liga m ent Flexor digitorum
longus ten don
Pero neus brevis t.
Flexor retinacu lum
Fibula
tibial
Superior peroneal
retinaculum Flexor hallucis lon gus
tendon
Peroneus longus t.
Medial pla ntar nerve

Lesser sa phenous vein Lateral plan tar nerve

Plantaris tendon
Ach illes tendon

Exten sor halluci s Tibialis anterior t.

lo ngus tendon
Tarsal canal
Extensor digitoru m Ta localcaneal
longus tendon I.
Extensor hallucis brevi s Middle subtalar joint
muscle
Superomedia l spring
Posterior subtalar jo int l iga m ent

An teri or talofibular Tibia l is po tcr ior t.

ligament Flexor digitoru m
longus tendon
Posterior talofibular
ligament Flexor retinaculum
Peroneus brevis t. Medial pl antar nerve
Fi bu lar ti p

Peroneus longus t. Posterior tibial vessels

Superior pero neal
reti nacu lum Latera l plantar nerve

Lesser sa phenous vein

Planta ris ten don
Flexor hallucis longus
tendon
Bone isla n d, calcan eus
Ach illes tendon

(Top) T he ext ensor halluci s longus tendon is barel y v isualized due to magic angle effect. Th e anterior and posterior
talofibul ar ligaments are visualized distal to the talar dome. Note that the fibula has a medial inden tation, the
malleolar fossa , an d that the talus has lost its square shape at thi s level. (Botto m ) The superomedia l component of
the spring ligam en t extends from t he sustenta culum ta l i of the ca lcaneus to t he plan tar navicular, forming a sl ing
around th e tal ar head. It also i nserts on t he t ibiospring component of the d el toid liga ment". T h e su pero m edia l
compon ent of the spring ligam ent is seen on coro nal images as we ll as on axial images, as it hugs the talar head,
d eep to the ti bialis posterior tendon. The posteri o r tibial nerve has now split into its two major branches, the media l
VII an d lateral pl antar nerves.
30
 ANKLE AND HINDFOOT OVERVI EW
AXIAL T1 MR, LEFT ANKLE

Exten sor hallucis

Tibialis an terior t. longus tendon
Greater saph enous vein Extensor digitorum
longus tendon
Talar head
Tibioca lcanea l, Pero neu s te rti us t.
tibiospri ng, superficia I Talocalcan eal
deltoid in te rosseou s I.

Tibiali s posterior t. Anterior talo fibul ar

l i.ga m ent
Flexor digi torum
longus tendon Posterior talofi bular
l igamen t
Flexor hallucis longus
Fi bula
ten don
Pe ron eu s brevis t.
Medial plan tar nerve
Super i.or peronea l
reti nacul um
Posterior ti bia l vesse ls
Pero neus longu s t.
La teral plantar n erve
Posterior subta lar join t

sap henous vei n

Plantaris tendon
Ac h illes ten don

Extensor h all ucis

longus ten don
Tibia li s anterior t.
[xtenso r digitorum
M iddle sub talar joint longus tendon

Supero m edial spring Exte n sor ha ll ucis brevis

ligament m uscle

Tibialis posterior t. Tarsa l cana l

Flexor hallucis lon gus
Posterior sub talar joint
tendon
Flexor digi torum Anterior ta lofi bular
longu s tendon ligam ent
Posterior talo fibular
Flexor retinaculum l igament
Medial plantar nerve Perone us brevis t.

Poster ior tibial vessels Fibular tip

Peron eus lon gus t .

Lateral plan tar nerve Supe rior peroneal

ret i n acu lum
Planta ris tendon Lesser saphen ous ve in

Bo ne island, calcaneus

Ach i lles tendon

(Top) The exten so r h allucis longus te ndo n is barely visualized due to magic angle effect. The anteri01: and posterior
talofibular liga m en ts are visuali zed d istal to the talar dom e. Note th at the fibula has a media l inden tat ion, th e
malleol ar fossa, a n d tha t t h e ta lus has los t its squa re sh ape at this level. (Bottom) Th e superom edi al compo ne nt o f
the spring ligament exte nds from th e su stentaculum tali of t h e ca lcaneus to t h e plantar navi cu lar, forming a sling
a ro un d th e talar h ead . It also in se rts on th e tibiospring com ponent of the de ltoid ligame n t. The superornedial
component of th e spring ligamen t is see n o n coro nal images as wel l as on ax ial images, as it hugs the talar h ead,
deep to the t ibialis posteri or te ndon. The poste rior t ibial nerve has n ow split into its two ma jor branches, the media l
a nd lateral pla n tar n erves. VII
31
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT ANKLE

Extensor ha ll ucis
avicu la r
longus tendon
Ex tensor digito rum
longus tendon Tibia lis an terior t.
Ex tensor hallucis brevis Tala r head
muscle Superomed ial spring
Tarsa l vessels, te rminal liga men t
bran ches, deep Midctle subta lar join t
pero nea l nerve
Tibia lis posterior t.
Cervi ca l ligament Flexor digito rum
Sinus tarsi longus tendon
Tal ocal canea l
Susten tacu lum tali
interosseous ligament
Posterior subtalar joint Flexor ha llu cis longus
tendon
Ca lcan eofi bular Med ial pla nta r nerve
liga ment
Pe ro ne us brevis t.
Posterior tibial vessels
Peroneus longus t.
Ta rsal canal
Plan taris tendon
Lateral pla ntar ne rve

Achill es te ndon

Extensor ha llucis anterio r t.

lo ngus tendon
Greater sap henous vein
Extenso r digito rum
lo ngus tendon
Navicula r tuberosity
Ex tensor digitorum
brevis muscle Superomedia l spri ng
ligament
Extensor halluc is brevis Tibia lis posterior t.
muscle
Midd le subta lar join t
Cervica l ligamen t Flexor digi torum
Posterio r subtala r jo int longus tendon

Calcan eofibular Abd uctor ha ll ucis m .

liga ment
Suste ntaculum tali
Peroneus brevis t.
Medial plan tar nerve
Peroneus lo ngus t.
Lesser saphenous vein Posterior tibial vessels
Flexor ha llucis longus
tendon
Late ra l plantar nerve
Ach ill es tendon

(Top) T h e poste rio r a n d m idd le subta la r joi nt a re now seen . Th e ante ri or subtalar jo in t is ofte n con flu e nt with the
midd le subtal a r jo int and may n ot be see n a s a di sti n ct jo in t . The posterior tibial nerve h as sp lit in to the m ed ia l and
la te ra l p lanta r n e rves. The flexo r h a ll uc is lo n gus te nd on is n ow trave lin g w it h in its secon d fibre -osseous t u nne l
unde r th e sus tentaculum ta li. The tarsa l ca n a l is a n ar row space in bet ween t h e midd le a n d pos te rio r subta la r jo in ts,
traversed by th e interosseo us ta lo ca lca n eal li ga m e nt a nd contiguo u s lat e rall y with t h e sin u s ta rs i space. (Bottom ) The
s inu s ta rs i is a fat-fil le d spa ce traversed by t h e c e rv ica l li ga m e nt and b y the m edi a l, in term ed ia te a n d la te ral roots of
the infe rior e xte n sor re tinac ulum. Th e ca lcan eo fi bu lar liga m e nt is seen ad ja ce nt to the late ra l ca lca n ea l w all a nd d eep
VII to the pe ro ne u s brevis and p e ro n e us long u s te nd o n s .
32
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, LEFT ANKLE

Extensor hallucis
longus tendon

Tibialis anterior t.
Tala r head Extensor hallucis brevis

Middle subtalar joi n t

Tarsal vessels, terminal
branch es, deep
Superomedial spring peron eal nerve
ligament
ervical ligament
Tibia lis posterior t .

Flexor digitorum
Posterior subtalar joi nt
lon gus tendon

Susten taculum tali Calcaneofi bu lar I.

Medial plantar nerve Peroneus brevis t.

Posterior tibial vessels

Peroneus longus t.
Lateral plantar nerve Talocalcaneal
in terosseous ligament
Plantaris tendon
Tarsal canal

Fl exor hallucis lon gus

Ach illes tendon
ten don

Ti bialis anterior t. Exten sor hallucis

lon gus tendon
Grea ter sa ph enous vei n
Ex ten sor digi torum
Navicul ar tuberosi ty lo ngus ten don
Ex tensor digitorum
uperomedial spring brevis muscl e
ligament
Exten sor hallucis brevis
Tibial is posterior t . muscle

M iddle subtalar joi nt Cervical l igamen t

Flexor digi torum
lo ngus tendon Posterior subtalar joi nt
Ca lcaneofibular
Abducto r hallucis m. l igamen t

Susten taculum tal i Pero neus brevis t.

Medial plantar nerve Peroneus lon gus t .

Lesser vei n
Posterior tibial vessels
Flexor halluci s lon gus
tendon
Lateral plantar nerve
Achilles tendon

(Top) Th e posterior and midd le subta lar joint are n ow see n. Th e a nte rior subtalar jo int is ofte n confluent with the
middl e su btala r jo int a nd may not be seen as a distinct join t. Th e poste rio r tibial n e rve has split into the m edial and
lateral p lan ta r n erves. Th e fl exor ha ll ucis longus te ndo n is n ow t rave li ng w ithi n its seco nd fib ro-osseous tunnel
under the sustentaculu m tali. The tarsa l ca na l is a n ar row sp ace i n between th e midd le a nd posterio r subta lar joints,
trave rsed by the inte rosseous ta loca lca n ea l liga me nt a nd co n tiguous la te ra lly with th e sinus ta rsi space. (Bottom ) Th e
sinus ta rsi is a fat-fi lled space traversed by th e ce rv ical ligame nt a nd by t he m ed ial, inte rmed iate and la te ral roots of
the inferio r ext e n so r re tin aculum . Th e ca lca n eofibular ligam ent is seen adj acent to th e latera l ca lca n eal wa ll and deep
to th e peron eus brevis a nd pe rone us lo ngus te n dons.
VII
33
 ANKLE AN D HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT ANKLE

2nd cunei fo rm l st cu n eiform

Tibial is anterior t.
Exten sor digi torum
tendon
avicular
Ex ten sor digitoru m Medioplantar oblique,
brevis m uscle sprin.g ligament

vesse ls, termin al Sesamoid bone, tibialis

branch es, deep posterior tendon
pero neal nerve
Flexor digitorum
Ta lar head longus tendon
Medial root, i nferior
extensor reti naculum Flexor hallucis longus
tendon
Peron eus brevis t.
Medial plantar nerve
Peroneus longus t.
Calcaneofibu lar Abductor hallucis m.
ligament
Lateral plantar
Lateral plantar n erve

Ca lcanea l tubero i ty

Ach il les tendon

Exten so r d igi torum I st cune iform

longus tendon

Tibialis anterior t.
2nd & 3rd cunei form s

tert ius t. lnferoplantar

longitudinal, spri ng I.
Extemor digi torum
brevis muscle 1avicular beak

An terior process,
ca lcaneus Tibialis posterior t.
i nsertion
Calcaneofibul ar
ligamen t
Flexor cligitorum
longus tendo n
Peroneus brevis t.
Flexor ha llucis longus
Peron eus lon gus t.
tendo n
I nferio r peroneal Media l plantar
retinaculum neurovascular bundle

Ca lcaneus Abductor hallucis m.

Lateral plantar
neurovascular bundle

(Top) T he med ioplantar obliq ue ban d of the sp ring l iga ment originates from coron oid fossa of ca lca neus, between
th e midd le an d anterior cal ca nea l facets and inserts o n th e nav icu lar, lateral to the t ibialis posterior tendon. It is
often st riated and is best seen on ax ial im ages. A sm all sesa moid bon e in the ti bialis posterior te ndon sh ould not be
mi si nterp reted as a t endon tear. Th e i n serti on o f t he ca lcaneo fibular liga ment to th e calca n eus is seen deep to t he
pero neal ten don s. (Bottom ) T he i nferop lan tar longitudina l co m ponent o f the spri ng liga m ent is short an d straight
an d inserts i nto t h e navicu lar beak. T he t ib ialis posteri or ten do n, distal to its navicu la r i nsertion , con t i nues toward
its various insertion sites i n to the rem aind er o f th e tarsa l bones and the 2nd-4th metatarsa l bases. The abductor
VII hall ucis m u scle forms the medial border of the tarsa l tunn el.
34
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, LEFT ANKLE

1st cuneiform 2nd cuneiform

l:.xtensor digitorum
Tibialb an terior t.
longus tendon
avicu lar
Talar heaci
Exten sor digitorum
Sesamoid bone, tibialis brcvb muscle
pmterior tendon
Ta rsa I vessels, term ina I
branch es, deep
Medioplantar obli que, peroneal nerve
spring ligamen t
Medial root, i nferior
Flexor digitorum extensor reti naculum
longus tendon
brevb t.
Flexor hallucis longus
Peroneus longus t.
tendon
Ca lcaneofibular I.
Abductor hallucis m.
Medial plan tar nerve
Lateral plantar vessels Lateral plantar nerve

Calca neal tuberosity

tendon

1st cuneiform Extensor d igi torum

longus tendon
an terior t.
2nd & 3rd cuneiforms
lnferoplan tar
longi tudinal, spring Peroneus tertius t.
ligament Extensor digitorum
avicular beak brevis muscle

Tibialis posterior t. Anterior process,

insertion slips calcan eus

Flexor cligitorum
tendon Pero neus brevis t.

Flexor hallucis lon gus Peroneus longus t.

tendo n
Calcaneofi bu lar I.
Medial plantar
neurovascular bundle Inferior peronea l
retinacu lum
Abductor hallucis m.
Lateral planar vessels alcaneus
Lat eral plantar nerve

(To p) The medioplantar obl ique band o f th e sprin g ligam ent ori ginates from corono id fossa of calcaneus, between
the middle and an terior ca lcanea l facets and inserts on the navicular, lateral to the tibia lis posterior tendon . It is
often striated an d is best seen on axial i mages. A sma ll sesa m oid bone in the tibia l is posterior tendo n shou ld not be
misin terpreted as a tendon tear. The insertion of th e ca lcan eofibu lar ligamen t to the calca neus is seen deep to the
peron ea l tendo n s. (Bo ttom) The in feropl an tar lo ngi tudi n al co m ponent o f th e spring l igament is short and straight
and inserts into the navicular beak. The tibial is posteri or tendon, dist al to i ts navi cular i nsertion, co nt-inues toward
i ts various insertion si tes into t h e rem ainder of th e tarsa l bo nes and th e 2nd-4th metatarsa l bases. T h e abd uctor
hallucis muscle forms the m edia! border of the tarsal tunne l. VII
35
 AN KLE AND HINDFOOT OVERVI EW
AXIAL T1 MR, RIGHT ANKLE

2nd cuneiform lst cunei form

Extensor digitorum
Tibialis anterior t.
longus tendon
Peroneus tertius t.

3rd cun ei form Distal slip tibialis

posterior tendon
Extensor digitoru m
brevis m uscle Flexor digitorum
lo ngus tendon
Tarsal vessels, termin al
branches, deep
peroneal nerve Flexor hall ucis longus
tendon
An terior process,
ca lcaneus Medial plantar
Peroneus brevis t. neurovascular bundle
Abductor hallucis
Pero neus longus t . muscle & tendon

Inferior peroneal Lateral plantar

retinacul um neurovascular bundle

Flexor d igi torum brevis

muscle

l ed ial calcan ea l
tubercle

2nd cunei form I st cunei form

Extensor digi to rum I ntercu neiform

longus tendon ligament
Tibialis anterior t .
Pero neus tertius t.
Distal slip tibialis
3rd cunei form posterior tendo n
Ex tensor digitorum Flexor digitorum
brevis muscle longu tendon

Cuboid Abductor hallucis m.

Flexor hallucis longus

Peroneus brevi s t. tendon
Peroneus longus t. M ed ial plantar
neurovascular bundle
Short plan tar ligament
Lateral plantar
neurovascular bundle

Flexor digitorum brevis

muscle

M edial ca lcanea l
tu bercle

(Top) T h e flexor d igito rum lo n gus and flexor h all ucis lo ngu s tendo n s are just abo ut to cross each o ther at t h e kn o t of
Henry, p lantar to th e navicular (not seen). A d istal insertio n sli p o f the ti bialis posterio r tendon, approaching the
cunei fo rm s, is seen . Th e t ib ialis an terior tendo n i nserts to th e m ed io p lantar aspec t of the I st cu neiform and to t he
base o f th e 1st m etata rsal. The m edial plan tar nerve co nti nues i n the plantar aspect of t he foot in close proxi mi ty to
t h e fl exor hallucis lo ngus ten d on . Th e pla ntar nerves and thei r associated vessels may be difficu l t to disti ngu ish from
o ne ano th er. (Bottom) Th e sh ort an d lo ng plan tar l iga ments bi nd th e cubo id to the ca lcaneus. The short planta r
liga m en t is a t hicker ban d th at is d eeper and mo re med ial t han the lo ng plantar l igament. T he intercunei fo rm
VII ligamen ts b ind t he cu n eifo rm s to o ne anoth er.
36
 ANKLE AND HINDFOOT OVERVI EW
AXIAL T1 MR, LEFT ANKLE

2nd cun ei form

J st cuneiform Ex tensor digitoru m
lon gu s tendon
Ul_,
Tibialis anterior t.
Peroneus terti us t.
Cuboid
Distal slip tibialis 3rd cuneiform
posterior tendon
Extensor digitorum
brevis m u scle
Flexor digitorum
longus tendo n
Tarsal vesse ls, terminal
Flexor hallucis lon gu s branches, deep
tendon peron ea l ner ve

Medial p lantar Anterior process,

neurovascular bundle calcaneus
Peroneus brevis t.
Abductor hallucis
muscle & tend o n Peron eus lo ngus t.
Lateral plantar Inferior peron ea l
neurovascul ar bundle
retinaculum
Flexor digitorum brevis
muscle

M edial calca n ea l
tu bercle

1st cuneiform

lntercuneiform I.
Tibialis anterior t.
2n d cuneiform
Exten sor digitorum
longus tendon

Peroneus terti us t.
til
Distal slip t ibi ali
post eri or tendon 3rd cuneiform
Exten sor digitorum
Flexor digitorum
brevis muscle
longus tendo n
Cuboid
Abductor hallucis m . Sh ort plantar ligam ent
Flexor hallucis longus
tendon
Peroneus brevis t.
M edial plantar n erve

Medial plantar vessels Pero n eus lo n gus t.

Lateral pl antar
neurovascular bundle

Flexor digitorum brevis

M edial cal ca n ea l
tubercle

{Top) T he flexor digitorum longus and fl exor hallucis longus tendons are just about to cross each other at the kn ot of
ll enry, plantar to the navicular (n o t seen). A distal insertion slip of t h e tibialis posterior ten don, approach ing th e
cunei forms, is seen . The tibiali s anteri or tendon inserts to th e medioplantar aspect of t h e 1st cun eiform and to the
base of the 1st metatarsal. The m edial p lantar n erve continues i n the plantar aspect o f the foot in close proximi ty to
the flexor hallucis lon gus tendon. Th e plantar nerves and their associated vessels may be difficult to distinguish from
one another. (Bottom) The short and long plan tar ligaments bind the cuboid to t he calca neus. T h e short plan tar
ligamen t is a thicker ba n d t hat i s d eeper and more m edial than th e long plantar ligam ent. T he intercuneiform
liga ments bind the cunei forms to o ne an o th er. VII
37
 ANKLE AN D HINDFOOT OVERV I EW
AXIAL T1 MR, RIGHT ANKLE

I st metatarsal
2nd metatarsa l
Lisfranc ligam ent
Ex ten sor digi toru m I st cuneiform
longu s ten don 2nd cunei fo rm

Pero neu s tertius t. Tibi al is anterior t.

3 rd cuneiform ln teFCu neiform I.

Ex tensor digitorum Abducto r h allucis m.
b revis musc le
Distal tibial is posterior
Cu bo id sli ps
Crossin g flexor
Pero neus brevis t. digitorum & flexor
h allucis longus tendon
Pero neu s lon gus t.
Flexor digi toru m brevis
Short p lantar l igament muscle

Quadratus plan tae m.

Lateral p lantar
Lateral calca neal neurovascular bu ndle
tu bercle
Medial calcaneal
tubercle

2nd metatarsal Lisfran c li ga m en t

Ex ten so r digi toru m l st m etatarsal
lo ngus tendon
Ti bialis an terio r t.
Peron eus ter tius t.
I st cu n ei form
3 rd cunei for m
Abd uctor hallucis m .
Extensor digi tor um
brevis mu scle Tibialis posterior t. sli ps
Flexor hallucis longus
Cu boid
tendon
Shor t p lan tar ligam en t Medi al plantar
neu rovascular bundle
Peron eus b revis t. Flexo r cli gito rum
lo ngus ten don
Peroneus longus t .

Abd uctor digi ti minim i Flexor di gito rum brevis

m uscle

Qu adratus p lan tae m.

Lateral ca lcaneal
t ubercl e Lateral plan tar
n eu rovascu lar bun d le

M edia l ca lcaneal
tu be rcle

(Top) The m edial pla nta r n erve and its accompan ying vesse ls occupy a fa t plane in between the abd uctor ha ll ucis
a nd flexor digitorum brevis muscles. The latera l plantar nerve and its acco m pa n yin g vessels occu py the fat plane in
between the flexor d igito ru m brevis and quadratus p lantae muscles. Lisfra n c ligame nt o rigina tes from th e 1st
c uneiform a nd ex tends towa rd its 2 n d metatarsa l inserti o n. (Bottom) The calca ne us has two p oste rio r p la nta r
tubercles: The larger medial tube rcl e a nd slightly m ore anterior lateral tubercle. T h ese provide th e origin for th e 3
muscles o f the 1st la ye r of the foo t. The med ia l tubercl e gives o rig in to all th ree muscles: Abductor d igiti min im i,
flexor digitoru m brevis a nd abductor hallucis while th e la te ra l tubercle gives origi n on ly to the abd ucto r d igiti
VII minimi m uscle.
38
 ANKLE AND HINDFOOT OVERV I EW
AXIAL T1 MR, LEFT ANKLE

1st metatarsal
2nd m etatarsa l
1st cuneiform
Exten so r di gitorum
Lisfranc li ga m ent"
longus tendon
Ti bialis an terio r t.
2nd cunei fo rm Peroneus tertius t.
lntercuneiform I. 3rd cun eiform
Exten sor digitorum
Abductor h allucis m.
brevis muscle
Di stal ti bialis posterior
te ndon sl ips Cuboid
Sho rt plantar ligament
Cross ing flexor
digitorum & flexor Peron eus brevis t.
hallucis longu s tendon

Flexor digi torum brevis Pero neus lo ngus t.

muscle
Quad ratus plantae m.
Lateral p lantar
neu rovascular bundl e

Late ral cal can eal

Medial calcaneal tubercle
tu be rcle

Lisfranc ligament 2nd m etatarsa l

Exten so r digi torum
I st m etatarsal
longus tendon

Ti bialis anterior t.
Peroneus tertius t .
Abd uctor h allucis m .
3rd cuneifo rm
I st cuneiform
Extensor digi toru m
brevi s muscle
Tibial is posterior t. sl ips

Flexor hallu cis longus Cuboid

tendon
Short pl an tar ligam ent
Medi al plan tar
n eu rovascular bundle
Peroneus brevis t .
Flexor digi torum
longus tendon Pero neus longus t.
Abductor digiti m i ni m i
Flexor d igitorum brevis
muscle Lateral plantar
neu rovascu lar bun dle
Quad ratus plan tae m .
Late ral calcanea l
Medial ca lcaneal tuberc le
tu beccle

(Top) The m ed ia l plan tar nerve a nd its accompany ing vessels o cc upy a fa t plane in between th e abd ucto r h allucis
and flexor digi torum brevis muscles. The la te ral pla ntar nerve and its acco m pa nyi ng vessels occu py th e fa t p la n e in
between th e fl exor d igito rum brevis and q uadratus pla n ta e muscles. Lisfranc ligame nt originat es fro m the l st
cuneiform and ex tends toward its 2n d meta ta rsal in sertion . (Bottom ) Th e calca n eus has two posterior plantar
t u bercles which p rovide origin to t h e 3 m uscles of t he 1st layer o f th e foot: Th e larger medial tubercle and slight ly
more a nterior la te ral tube rcle. The medial tu bercle gives o rigi n to all three m uscles: Abd uctor d igiti m inimi, flexor
digitorum brevis a nd abductor h allucis wh ile t he la te ral tubercle gives origin only to t he abducto r d igiti mi ni mi
muscle.
VII
39
 ANKLE AND HINDFOOT OVERVIEW
AXIAL T1 MR, RIGHT ANKLE

2nd m etatarsal lst m etatarsal

Ex tensor digi torum
Tibiali s an terior t.
lo ngus tendon
Abductor ha llucis m .
Peron eus tertius t.
Li sfranc ligament
3rd cunei form
1st <;;u nci form
Cuneocuboid ligament
Ex tensor digitorum Tibia l is poste rior t. sl ips
brevis muscle
Flexor hallucis lon gus
Cuboid tendon
Flexor d igi torum
Peroneus brevis t.
lon gus tendon
Peron eu s longus t. Medial plantar
Short plan tar ligament n eurovascular bundl e
Flexor digitorum brevi s
Abductor digi t i min i mi muscle
muscle
Lateral pl antar Quadra t us plantae m.
neurovascular bu ndle

2n d m etata rsal lst m etatarsal

Ex ten sor digitorum Tibia l is an teri or t.
lo ngus tendon
Abductor hallucis m .
Peron eu s tertius t.
Li sfra nc ligamen t
3rd m etatarsal
l st cuneiform
Exten sor digi torum
brev is muscl e Tibia l is poster io r t. sl ips
Flexor hallucis lon gus
Cuboid
tendon
Base 5 th m etata rsal
Medial plantar
Peroneus brevis t. n euro vascul ar bundle

Peroneus lon gus t. Flexor digitorum

lon gus tendon

Abductor digiti m i ni mi Flexor digi torum brevi s

muscl e muscle

Quad ratus plan tae m .

(Top) The quadratus plantae muscle o rigina tes fro m the lateral and medial surfaces of th e calca neus. The bases of the
cuneiform s and the bases of the metatarsals are wedged, thus forming th e tran sverse arch of the foo t. The lateral 3
extensor digitorum brevis tendo ns joi n the exten so r digitorum lo ngus tendon s passing to 2nd-4th toes. ( Bottom)
The peron eus longus tendon is just about to curve under the cuboid tunn el toward its insertion into th e plantar base
of the 1st metatarsal. The roof of th e cuboid tunnel is fo rm ed by the lon g plantar ligamen t. The pero neus brevis
tendo n becomes more linear .in shape as it approaches its insertion into the base of th e 5th metatarsal.
VII
40
 ANKLE AND HINDFOOT OVERVI EW
AXIAL T1 MR, LEFT ANKLE

2nd m etatarsal
I metatarsal Extensor digito rum
Tibialis anterior t. longus tendon

Abd uctor hallucis m . Peron eus tertius l.

I st cuneiform 3rd cuneiform
Li sfranc ligament Cuneocuboid I.
Extensor d igitorum
Tibialis posterio r t. slips brevis muscle

Flexor hallucis lon gus

Cuboid
tendon
Short plan tar ligament
Flexor digitorum
longus tendo n Peron eus brevis t.
Medial plantar Peron eus longu s t.
neurovascular bundle Quadratus plan tae m .
Flexor digitorum brevis Lateral plantar
muscle neurovascular bundle

Abductor digiti minimi

muscle

2nd metatarsal
lst m etatarsal
Extensor digito rum
Tibialis anterio r t. longus tendon

Abductor hallucis m.
Peroneus terti us t.
I st cuneiform
3rd metatarsal
Li franc ligament
Extensor digitorum
Tibialis posterior t. slips brevis muscl e

Flexor hallu cis longus Cu boid

tendon
Medial p lan tar Base 5th metatarsal
n eurovascular bundle
Peroneus brevis t.
Flexor digitorum
longus tendon Peroneus longus t.
Flexor digitorum brevi s Quadratus plantae m.
muscle
Abductor digiti m i nimi
m uscle

(To p) The quadratus plan tae muscle orig inates from t he lateral and medial surfaces of the ca lca neus. The bases of the
cuneiforms and the bases of the metata rsals are wedged, th us for mi ng the transverse arch of the foot. The lateral 3
extensor digitorum brevis tendons join t he extensor digitorum longus tendons passi ng to 2nd-4th toes. (Bo tto m )
The peroneus longus tendon is just about to curve under the cu boid tunnel toward its insertion in to the plantar base
of th e lst me tatarsa l. The roof of the cuboid tu n nel is fo rmed by the lo ng plantar ligament. The peroneus brevis
tendon beco mes more linea r in sh ape as it approaches its insertio n into the base o f t he Sth meta tarsal.
VII
41
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Peroneus brevis m. Flexor halluci' lon gus

musc le
Soleus muscle
Tibialis posterio r m.
Lesser saphenous vei n

Su ral nerve

Ach il les tendo n

Ca lcaneal t uberosity

rat pad of h eel

Peroneus brevis 111.

Flexor hallucis longus
tendon
Flexor hallucis lo ngus
muscle Tibialis posterior t.
mu scle

Lesser sa phenous vein

Sural nerve

Pre-Achilles fat pad Plan taris tendon

Ca lcaneal tuberosity

Medial ca lcaneal
tubercle

Fat pad of heel

(Top) First in series of coro nal T1 MR images o r right a nkl e. T he Ach illes te ndon is the la rgest tendon in t h e body. It
inserts into th e ca lca nea l tuberosity slightly below its supe ri o r a pex. Th e Achilles te ndo n is se parated fro m th e
calca neus by a sm a ll fat pad and the retrocalcanea l bursa. Th e Achilles te ndon does not h ave a te ndo n sh ea th but
ra th er a pa rate non . (Botto m) The pre-Ach illes fa t pad, a lso ca lled Kage r fat pad, is fo und an terior to th e ca lca neus
and is trave rsed by small vessels. The long and thi n plantaris 1·e ndo n d escends to insert o n the posterior surface of
the ca l.caneu s media l and slightl y ante ri o r to the Achilles te nd o n . T he sura l ne rve a ncl lesser saphe nou s vein clescencl
togethe r ante rior ancl late ra l to t h e Achi lles te ndo n.
VII
42
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, LEFT ANKLE

Flt•xor hallucis longus Peroneus brevis m .

muscle
Tibialis posterior m.

Lesser sa phenous vei n

Sural nerve

So leus muscle

/\chi li es tend on

Calcaneal tuberosity

Fat pad of heel

Peroneus brevis 111.

Tibialis posterior t.
Flexor hallucis longus
muscle & tendon

Soleus muscle

Lesser saphenous vein

Sural nerve

Plan taris tendon Pre-Ach i l ies fat pad

Calcan ea l tuberosity

M edial ca lcaneal
tubercle

Fat pad of heel

(Top) First in se ries of co ronal T 1 MR images o f left a nkl e . T he Ach illes te ndo n is the largest te ndon in the bod y a n d
is the stro ngest p lanta r fl exor of th e ankle. It inse rts into the calcaneal tuberosity slig htl y below its s u per io r apex. The
Ach illes tendo n is sepa ra ted from the ca lcaneus by a sma ll fat pad a nd the retrocalca nea l bursa. T he Ach illes tendon
docs not have a te ndo n sh ea th but rath er a pa ra ten o n w hi ch partia lly e ncircles the tendo n . (Bottom) Th e
pre-Ac hilles fat pad, also call ed Kager fat pad, i anterio r to th e ca lcan eu s and is t rave rsed by ma ll vessels and sep ta.
The lo ng a nd th in plantaris te nd on d escen ds to insert o n th e poste rior surface of t he calca n eus med ial and sli g htly
a nte rio r to th e Ac hill es tendon . The sural n e rve and lesser sa phe no us vei n desce nd togethe r a nte rior and lateral to
th e Achill es te nd o n .
VII
43
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 M R, RIGHT ANKLE

Peronea l tendons T ibial is posterior t.

Peron eus brevis m. Tibial is posterior m.

Fi bular cor tex
Flexo r hallucis longu s
muscle
Posterior tibial
Flexor hallucis longus neLl[ovascular bund le
tendon

Lesser saphen ou s vein

Calcanea l tuberosi ty Medi al ca lca neal

tubercle
Latera l ca lca n eal
tu bercle
Central band, plantar
aponeurosis

Fib rous sep tae

Peronea l tendons Tibial is posterior t.

Fibula Tibial is posterior m .

Flexor hallucis longus

muscle
Posterio r t ibial ner ve
Peron eus brevis m.

Flexor h allucis longus

tendon

Lesser saphen ou s vei n

Pre-Ac h illes fat pad

Calcaneal tuberosity

Lateral calca nea l

tubercle Medial calcanea l
tubercle
Lateral band, plantar
aponeurosis
Ce ntra l b and, plan tar
apo neurosis

(Top) Th e flexor h allucis lon gus m uscle is broad and remains muscular m ore dista ll y th a n the o th er muscles o f the
posterior compart ment o f th e leg; it may be seen dow n to th e ankle joint. The peron eus brevis muscle also desce nds
down to the ankle joint whil e the peroneus lon gus muscle is no longe r visuali zed at that leveL (Bottom) In th e distal
leg a n d a n kle t h e posterior tibi al nerve a nd its accompa n ying vessels descend wit h in a fat plane antero medial to th e
flexo r h allucis longus muscle and po sterio r to the tibiali s poste rio r and flexor digitoru m lo n gus muscles. The
pero neal t e ndons ca n be d ifficu lt to sepa rate from one a noth er on coronal images but the peron eus lo ngus is
typica ll y more lateral t hat the perone us brevis tendon. Th e t ibialis posterio r t e ndon is lateral to the flexor digito rum
VII lo ngus te ndon above the a nk le joint.
44
 ANKLE AND HINDFOOT O VERVIEW
CORONAL T1 MR, LEFT ANKLE

t.
Peronea l tendo ns
Tibial is posterior m.
Fibular cortex
Flexor hallucis lo ngus
muscle

Pero neus brevis m .

tibial
neurovascul ar bun d le Flexor hal lucis longus
tendon

Lesser sap hen ous vein

M edial calca neal

tubercle alcaneal tuberosity

Cent ral band, plantar Lateral ca lcanea l

aponeurosis tubercle
Fibrous se ptae

Tibia lis posterior t.

Pero neal tendons

Tibialis posterior m . Fi bula

Flexor hallucis lo ngus

muscle
Posterior tibial nerve
Peroneus brevis m.

Fl exor hallucis longus

tendon

Pre-Achi lles fa t pad Lesser saphen ous vei n

Calca neal tu berosity

Lateral calcaneal
Medial calcan ea l tubercle
tubercle
Lateral band, plan tar
aponeurosis
Cen tral ban d, plan tar
aponeurosis

(Top) Th e f lex or h allucis lo ngus m uscle is broad and remains muscu la r m ore distally t han th e o th er muscles o f t he
posteri or co m partm ent of t h e l eg; it may be see n down to th e ankle joint. Th e peron eus b revis m uscle also descends
down to t he an kl e joint w hi le the peroneus longus muscle is no lo nger v isualized at th at level. (Bott om ) In t he distal
leg and an kle th e posterio r tib ial nerve and its accom pany ing vessels d escen d within a fa t p lane ante rornedial to the
flexor h alluci s longus muscle an d posterior to th e t ibiali s posterior and flexor digito rum lo ngu s muscles. T he
peroneal te ndon s can be d iffi cul t to separate from on e ano th er on coro nal i m ages bu t th e peron eus lo ngus tendon is
ty p ical ly more lateral th at th e p ero neus b rev is tend on. T h e t ibialis po sterior tendo n is lateral to flexor digitorum
longus ten don at d istal leg but i s mo re medial to it at th e an kle joint . VII
45
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Fibula Tibia

Flexor hallucb lon gus Flexor digitorum t.

muscle
Tibialis posterior t.
Peroneus longus t.
Tibial is posterior rn.
Peroneus brevis t.

Peroneus brevis m. r.Jexor h allucis longus

tendon

Lesser saphenous vein Posterior tibial vessel

Ca lcan ea l tuberosity

Lateral calcaneal
tubercle
Abductor hallucis m.

Abd uctor digi ti m ini mi

Central ba nd, plantar
muscle
aponeurosis

Latera l band, pla ntar

aponeurosis

Tibia
Fibula

Flexor hallucis longus Tibia l is posterior t.

muscle

Peroneus brevis m. & t. Flexor digitorum

longus m. & t.

Flexor h al lucis longus

tendon
Lesser saph eno us vein

Posterior tibia l vessels

Ca lcanea l tuberosity
Abductor h allucis m.
Lateral calcaneal
tubercle
Quad ratus plan tae m.
Abductor digi ti mini m i Flexor d igi toru rn brevis
muscle

La teral ba n d, plan tar Centra l band, plantar

aponeurosis aponeurosis

(Top) T h e med ial & lateral tubercles o f the calca neus give origin to the fi rst layer of intrinsic m uscles of the foot & to
th e plan tar aponeurosis. The abductor digiti minimi muscle origi nates from the lateral tubercle & th e flexor
digitorum b revis, abductor hallucis & abductor digiti minimi muscles origi nate from the media l tubercle. (Bottom)
Th e tibialis posterior tendon crosses t he flexor digitorum longus tendon j ust above the ankle joint to become the
m ost med ial tendon of the posterior compartment. The pos teri or tib ial neurovascular bundle descends medial to the
fl exor hallucis lon gus ten don . The plantar apon eurosis has 3 proximal parts: A stro ng, broad and th ick central band,
a latera l band covering the abductor digiti mi ni mi and a thin ba nd coverin g the abductor hallucis muscle, and
VII contin uous w it h the flexor reti naculu m .
46
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, LEFT ANKLE

Tibia
Fibula
Flexor digitoru m
longus tendon Fl exor h allucis longu s
m uscle
Ti bia lis posterior t.
Peroneus longu s t.
Tibiali s posterior m .
Peroneus brevis t .
Flexor hallucis longus
tendon Peron eus brev is m.

Poste rior ti bial vessel

Lesser saphenous vei n

Calcan ea l tu berosity

Lateral ca lcanea l
tu bercle
Abductor hallucis m.

Ce n tral band, plan tar Abductor digiti minim i

aponeurosis muscle

Lateral band, plan tar

apon eu rosis

Ti bia Fibul a

Tibialis p osterior t. Flexor hallucis longus

muscle
Fl exo r digitorum
longus m. & t. Peroneus brevis m. & t.

Flexor hallucis longus

tendon

Lesser saphenou s vei n

Posterio r tibial vessels
Ca lcaneal tuberosity

Abductor h allucis 111.

Lateral calcan eal
Quadratus plantae m. tubercle
Flexor d igi torum brevis Abductor digiti m inimi
mussle m uscle

Central ba n d, plantar
Lateral band, plantar
aponeurosis
apo n eurosis

(Top) The media l a nd la tera l tubercles of the calcan e us give origin to the 1st layer of in trinsic muscles of the foot and
to the pla n ta r apon eu rosis. The abd uctor di giti minimi muscle o riginates from the latera l tube rcle a nd the flexor
digitorum brevis, abd uctor h al lucis a nd abductor digiti minimi muscles originate from the media l t ube rcle. (Bottom)
The t ibialis pos terio r te nd o n crosses th e flexo r d igitorum long us tendon above th e ankle joint to become t h e m ost
media l tendon o f th e poste rior com partment. The posterior tibial neurovascula r bu nd le desce nds med ial to the flexor
hallucis longus te ndo n. The plantar apon eurosis has 3 p roximal parts: A strong, broad and thick centra l band, a
lateral band covering the abducto r digiti minimi a nd a thin , medi al band which covers the abductor hallucis muscle,
a nd continuo us with the flexo r retin aculum. VII
47
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Fibula

Interosseous membrane
Tibialis pos terior t.
Tibi a

Interosseus li gam ent

Fl exor digitorum
Pero neus longus t.
longus tendo n

Peroneus brevis m.
Flexor h al lucis longus
Peron eu s brevis t. tendon

I n ferio r tran sverse Posterio r ti bial

ligament neuro vascular bu n dle

Abductor h al luci s 111 .

Calca nea l tuberosity
Q uadra tus plan tae 111 .
Lateral calcaneal f-lexor digi torum brevis
tubercle muscle
Abductor digiti mini mi
Centra l band, plan tar
muscle
aponeurosis
Lateral ban d, plantar
aponeurosis

Deep peronea l vessels

Grea ter saphenous vei n
Posterio r mal leolu s
Fi bula Ti bi al is posterior t.

Posterior ti biofi bular Flexor digi torurn

ligament lon gus tendon
Os trigonum, talu s
In ferio r transverse
Peroneus lo ngus t. l igamen t
Fl exor hallucis lon gus
Pero neus brevis t. tendon

Medial plantar
n eu rovascul ar bundl e
Calcan eal tu berosi ty
Abductor hallucis m.

Abductor d igi ti mini m i Lateral plantar

muscle n eurovascular b undle
rl exor digitorum brevis
Quadratus plantae m.
muscle

(Top) The p osterior tibial a nd flexor digitorum tendon sha re a retrotibial groove and descend in close proximity to
o ne anoth er. The fl exo r hallucis longus te n don descends posterio r to t he talus in betwee n th e m edial and lateral
tubercles (best seen o n ax ial images). The interosseus membrane and interosseus ligamen t are noted in between the
t ibi a and fibul a. (Bottom) Th e posterior tibia l nerve has split into the med ial a nd la tera l p lantar ne rves. These
bran ches may be di fficu lt to distinguish from t h ei r accompanying vessels o n coronal images. Typica ll y th e ne rves are
found m o re lateral than the vessels. The medial plantar n erve trave ls superior to t h e latera l planta r nerve and close to
the flexo r hallu cis longus te ndon. The posterior tibiofib ul ar ligament a nd inferi o r t ransverse liga ment are now seen.
VII Th e in ferio r transverse li gament extends distal to th e tibia.
48
 ANKLE AND HINDFOOT O V ERVI EW
CO RONAL T1 MR, LEFT ANKLE

Ti bia Fibul a

Tibial is posterior t. In terosseous membrane

Interosseus ligamen t

Flexo r digitorum
longus ten don Peroneu s longus t.

Peroneus brevi s m.
Flexor h allucis longus
ten don Peroneu s brevis t.

Posterior tibi al
neurovascular bun dle In ferior t ransverse
li gam ent
Abductor hallucis m.

Calcaneal tuberosity
Quadratu plantae m.

Fl exor digitorum brev is Lateral ca lcan eal

muscle tubercle
Abd uctor digiti minimi
Central, lateral ba nds, muscle
plan tar aponeurosis

Ti bia

Deep peroneal vessels

Greater sa ph en ous vei n

Posterio r malleol us

Fi bu la
Tibialis pos terior t.
Posterio r tibiofibu lar
ligament
Flexor digitorum
longus tendon Pero neus lo ngus t.
Peron eus brev is t.
Flexor hallucis longus
tendon Os trigonum, talus

Medial plan tar I n ferior transve rse

n eu rovascular bundl e ligament

Abductor hallucis m. Calcanea l tuberosi ty

Lateral plan tar

n eu rovascular bund le Abdu ctor digi ti minimi
m uscle
Flexor digitorum brevi s
muscle Qu adratus plan tae m.

(Top) The posterior t ibi al and flexo r digi toru m tendo n share a re trotibial groove a nd descend in close proximity to
one another. The flexor ha ll uc is lo ngus tendon d esce nds poste rior to the talus in between th e medial and lateral
tubercl es (best see n o n axial im ages). Th e in terosseus membrane a nd interosseus ligament are n ot ed in between t h e
tibia a nd fibula. (Bottom ) The poste rior tibia l nerve h as split into t h e m edia l and la te ral plantar n erves. These
b ranch es may be difficult to d istinguish fro m t h e ir accompa n ying vessels on coronal images. Typically th e nerves are
fo und more la te ral than th e vesse ls. The medial plantar nerve travels superio r to the late ral pla ntar ne rve a nd close to
the flexor hallu cis longus tendon . The poste rior tibiofi bular liga m ent and inferior transverse liga me nt are now seen.
The inferio r transve r e ligame nt ex te nds distal t o th e t ibia. VII
49
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Ex tensor di gitorum
longus m uscle
Latera l tal ar tubercle &
os trigon um

Inferio r transverse Tib ia lis posteri or t.

liga men t
Fl exor digitoru m
Mall eolar fossa lo ngus tendon

Lateral mall eolus Medial ta lar tubercle

Peroneus b revis t.
Flexor llall ucis longu s
Pero neus lo ngus t. ten do n
Medial plan tar nerve
Origin , ca lcaneofibular
ligam ent Medial plan tar vessels
Late ral pla n tar
Calcaneus neurovascular bundle

Abductor llallucis m.
Abducto r digiti minimi
muscle Flexor digitorum brevis
muscle
Quadratus plantae m.
Cen tral band, plantar
apon eurosis

Extensor digitorum
lo ngus muscle

Talus

Posterior talofibul ar Posterior collicul us,

ligament media l ma lleolu s

Lateral mall eo lus Tib ial is posterio r t.

Flexor digitorum
Ma ll eolar fos sa lo ngus tendo n
Posterior subta lar joint Fl exor lla ll uci longus
Pero neus lo ngus t. tendon

Peroneus brevis t. Media l plantar

neuro vascu lar bundle
Ca lcaneofibul ar
ligam en t
Abd uctor llall ucis m.
Lateral plantar
neurovascular bundle
Abducto r digi ti mini mi
muscle Flexor digitorum brevis
muscle
Quadratus plantae m.
Ce ntral bancl, pla ntar
apon eu rosis

(Top) The calca n eofibular ligame nt is cons ist e ntly see n on co ronal im ages o f t h e hind fo ot d eep to th e pe ron ea l
Q) tendons and can be foll owed, in c ross sectio n, f rom its fibular o rigin to its in se rti o n to th e ca lcaneus. The posterio r
tibiofibular liga m e n t originates fro m t h e infe rior t ibia a nd in serts into the fibu la above th e m al leo lar fossa . Th e
c: in fe rior tran sve rse ligament extends d is ta l to th e t ibial posterior su rfa c e and in se rts q u ite far medially close to th e
<( m e dia l ma ll eolus. (Bottom) T he poste rior talofibular ligamen t originates be low t h e t a lar d o m e a n d in se rts into t h e
fibul a at th e mall eolar fossa. T h e subc uta n eou s fa t betwee n the abduc to r ha ll uc is a nd fl exor digito rum b revis muscl e
is ty p ica ll y n ot t rave rsed by septa and therefore ca n be mis taken for a lipoma.
VII
50
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, LEFT ANKLE

Extensor digitorum
longus muscle
Tibia

La teral talar tubercle & I nferior Ira nsverse

os trigonum ligament
Flexo r digitorum Posterior tibiofibula r
longus tendon

Tibiali s l.

Medial talar tubercle Lateral ma lleolu s

llexor halluci5 longus Peron eus lo ngus t.
tendon
Peron eus brevis t.
plantar n erve
M edial plantar vessels alcaneofibu lar I.
Lateral plantar
neurovascular bund le
Quadratus plantae m .
Abducto r h allucis m.
Abductor digiti minimi
M edial, cen t ral bands, muscle
plantar aponeurosis
Flexor cligitorum brevis
m uscle

Exten sor di gitorum

longus tendon

Talus
Posteri or coli iculus,
med ial malleolus Posterior talofibu la r
ligam ent
l'ibialis posterior t.
Lateral m alleolus

Flexor di gitorum
longus tendon Mall eolar fossa
Sy nch ondrosis, os
Flexor h<JIIucis longus trigonum
tend on
M ed ial plan tar lo ngu s t.
neurovascular bundle Peron eus brevi s t.
Calcan eofibu lar I.
Abductor hallucb m.
Latera l plan tar Posterior subtalar joint
neurovascular bu ndle
Flexor digilorum brevis Abd ucto r digiti minimi
muKie mu5cle

Cen tral band, plan tar Quadratus plan tae rn .

aponeurosis

(Top) T h e calca n eofibular ligament is seen o n sequential co rona l images deep to t h e pero neal tendons fro m its
fibula r origin to its insertion to t h e ca lca n eus. Th e posterio r tibiofi bular l igamen t o rig ina tes fro m t h e i n ferior ti bia
and i n serts into th e fibu la above t he malleolar fossa. T h e lateral tu bercle of the talus may rema in unfused to the talus
fo rming an os tri gonum . (Bottom) Th e posterio r ta lo fibular ligam ent o ri gin ates below th e ta lar d o me an d inserts
in to th e fib ula at the ma lleo lar fossa, a m edial inden tation i n the d i sta l fibul a. The ca lca neus is i n m i nimal va lgus
orientatio n relati ve to th e t ibial sha ft. Th e medial neurovascular bun d le remains plantar to th e fl exor hall ucis longus
tendo n thro ugho ut most o f its co urse i n the foo t.
VII
51
 AN KLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Notch o f Harty

Extensor di gitorum Posterior ti biotalar,

longus mu scle deep deltoid

Ti bialis posterior t.

Posterior talofibular Su st"'ntaculum tali

ligam ent
Flexor digitorum
Lateral mall eol us longu s tendon

Flexor h allucis lo ngus

Calcan eofibul ar I. tendon
Medial plantar nerve
Peroneus longu s t.
Medial plantar vessels
Peroneus brevis t.
Abductor hallucis m.
Posterior subtalar joi n t
Lateral p lan tar
Quadratus plantae m . neurovascular bundle
Abductor digiti minimi Norm al subcu ta neous
mu scle fat

Ce n tral band, plantar Flexo r digi torum brevis

aponeurosb muscle

Extensor digito ru m
longus mu scle

Notch of Harty

Talus Posterior ti biotalar,

deltoid
Posterior subtalar join t Tarsa l canal

Tibia l is poste rior t.

Lateral malleol us
Flexor d igitorum
Calcaneofibul ar I. longus muscle

Peroneus brev is t. Sustentacul um tali

Peron eus lo ngus t. Flexo r ha llucis lo ngus

tend on
Inferior peroneal Abdu ctor hallucis m.
retin aculu m
Lateral plan tar
Calcaneus neurovascu lar bundle

Abductor digiti minim i Norm al subcutan eous

muscle fat
Flexor digitorum brevis
Quadratus plan tae m. musc le

Centra l band, pl an tar

apo neu rosi s

(Top) Th e su stentaculu m t a li is a m ed ial protuberan ce of the ca lca neus wh ich acco mmodates the middle subtala r
joint & gives o ri g in to the spring ligament. The flexor hallucis longus tendon h as trave rsed its first tu n ne l betwee n
the latera l a n d m edial ta la r tuberc les a nd is now traversing its seco nd tunn e l under th e suste n taculum tali. (Bottom)
The dee p posterior ti biota lar band of t h e deltoid ligament is an o rd erly stria ted structure o rigi nating from the
poste ri o r coll ic ulus o f th e med ia l malleolus. The superficial band of th e delto id is a broad, fan s haped st ru cture
w hose compone nts (tibi otala r, t ibiocalcaneal, tibiospring and tibionavicu la r) are va riab le and best ide ntifi ed based
o n th eir insertio n sites. The s ubc uta neo us fat in betwee n the abductor h a llu cis and fl exo r digitoru m b revis muscles
VII lacks septa and should not be m is inte rpreted for a li poma.
52
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, LEFT ANKLE

Ti bia
Notch o f llarty
Exte nsor digitorum
Posterio r tibiota lar, lon gu s muscl e
deep del toid

Tibial is posterior l. Tal us

Flexor cligi torum Posterio r ta lo fibu lar I.

longu s tendon
Lateral malleol us
Su stentacu lum tal i

Flexor hallucis longus Calcaneofi bular I.

ten don
Peroneus brevis t.
Medi al p lan tar nerve
Peroneu s lon gu s t.
Medial planta r vessels
Posterio r su btalar joint
Abd uctor h allucis m.
Lateral plan tar Calcan eus
neurovascular bundle
Abductor digi ti minimi
Norm al subcutan eous muscle
fat Quadratus plantae m.
Flexor digitoru m brevis
muscle Cen tral band, plantar
apo neurosis

Notch of H arty Exten sor digitorurn

longus m u scle

Posterior tibiotalar,
deep del toid
Ta rsal cana l
Tibial is posterior t.
Ta lus
Flexor digi toru m
longus muscle Lateral ma lleolus
Su sten taculu m tal i
Calcaneofibular I.
Flexor hallu cis longus
tendon Peron eus brevi s t.
Abd uctor hallucis m. Peron eus lon gus t.

Medial plan tar In ferior peron ea I

neurovascular bundle retinacu lum

Norm al subcutaneous Posterior subta lar joint

fat Calca n eus
Lateral plantar
neurovascular bundle Abd uctor digi ti rnin i mi
m u scle
Flexor digi torum brevis
muscle Q uad ratus plan tae m.

(Top) Th e su ste ntacul um tali is a media l protube ra nce of t h e calcane us which accommodates the middl e subt a la r
jo int & gives origin to th e spring ligament. The flexor hall ucis lo ngus te nd on has traversed its first tunne l between
the lateral a nd m edial talar t u bercles a nd is n ow trave rsing its second tunnel und er t he sust entaculum ta li. (Bottom)
The deep poste rior tibio ta lar band of the de ltoid li gament is a n o rderly st ri ated st ructure o riginating fro m th e
po teri o r colliculus o f t h e m edial ma lleol us. The supe rficial ba n d o f the d eltoid is a broad, fan sh aped structure
wh ose compo n ents (t ibio ta lar, tibioca lca nea l, ti biosprin g a nd tibionavicular) a re va ri able a nd best ide nti fied based
o n th eir insert io n sites. The subcutaneo us fat in between t h e abducto r h allucis a nd fl exor d igito rum brevis muscles
lacks septa an d shou ld n o t be mis inter preted fo r a lipoma .
VII
53
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Extensor halluci s
lon gus muscle

Extenso r digitorum Notch of Harty

longus muscle
M ed ial malleolus
Tarsal ca nal
Posterior tibi ota lar,
I n terosseou s deep delto id
talocalca n eal ligamen t
Tibiocalca nea l,
An terior tibiofi bular super ficial deltoid
l igament
Posterior subtal ar joint Tibia l is posterior t.
Flexo r di gi torum
Lateral process o f ta l us longus ten don

Calcaneofibular I. Flexo r hallucis lo ngus

tendon
Peroneus brevis t. M ed ial plan tar
neurovascu lar bundle
Peroneus longus t.
Abdu ctor hallucis 111 .
Cal caneu s
Lateral plan tar
Abductor digiti mini m i neurovascular bundle
muscle
Flexo r d igitorum brevis
Q uad ratu s plantae m. muscle
Central band, plantar
aponeurosis

Extensor hallucis
lo ngus muscl e Tibia

Extensor d igi torum Anter ior ti bio talar

lo ngu s muscle band, deltoid

Middl e subtalar joint Tibiocalca n ea l ba nd,

deltoid
An te ri o r ti biofibu lar
ligament Tibial is posterior t.
Tal us
Flexor ha llucis lo ngus
Ta loca lcanea l tendon
i nterosseous ligament Flexor digitorum
lo ngus tendon
Ca lcaneofibular I.
Medial plan tar
neurovascular bundle
Pero neus brevis t.

Peroneu longus t. Abdu ctor hallucis m .

Ca lcaneus Lateral plan tar

neurovascu lar bundle
Abdu ctor digiti minimi
muscle Flexo r d igitorum brevis
muscle

Quadratus plantae m. Cen tra l, lateral ba nds

plantar apon eurosis

(Top) The posterio r subtalar jo int is q uite b road and wide and is seen o n mu ltipl e images. The posterio r subtalar jo int
is separated from th e middle subtalar joint by the tarsa l ca n al. The tibiocal ca neal li gament is the strongest of the
su perficial delt o id components. It is in co ntinuity a nte riorly with the tibiospring ligament. The t i.bialis poste ri o r
te ndon crosses th e tibiocalcaneal and tibiospring ligamen ts and its ten osynovia l floor is diffi cul t to se parate from the
ligaments. (Bottom) The interosseous taloca lca neal ligame nt traverses t he tarsal can al m ed ially. T h e middle su btalar
joint is o ften su bopti m a ll y seen o n coronal MR images & requ ires correlat ion with sagitta l images to avo id
overcalling a subtalar coa lition. Th e fi bular inse rtio n o f calca neofibular ligament is visual ized. ot e atrop hy of
VII quadratus plantae muscle in this patient.
54
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, LEFT ANKLE

Extensor hallucis
Notch o f Harty lon gus muscle
Extensor digitorum
M edial malleolus
longus muscle
Posterior t ibiotalar,
An terio r tibiofib ul ar
deep deltoid
ligam ent
Tibiocalcaneal, Tarsal canal
superficial deltoid
Interosseous
Tibialis posterio r t. tal ocal caneal l igam ent
ustentaculum tali
Posterio r subtalar joint
Flexor digitorum Lateral process o f talus
longus tendon
Calca n eofib ul ar I.
Flexor hallucis longus
tendo n Peroneus brevis t.
Abductor hal lucis m . Pero neus longus t.
Medial plantar
Calca n eus
neurovascular bundle

Lateral plantar Abdu ctor digiti minimi

neurovascular bundle muscle

Cen tral band, plantar Quadratus plan tae m.

aponeurosis Flexor digitorum brevis
muscle

Extensor halluc is
Anterior colliculus, longus muscle
medial mall eo lus Exten sor digi torum
longus muscle
Anteri or t ibiotalar,
deep deltoid Middle subtalar joint

Ti biocalcaneal band, Anterior tibiofibular

del toid l igam en t

l"ibialis posterior t. Fibula

Flexor di gito rum Talus
lon gus ten don Taloca lcaneal
in terosseous ligament
Flexor hallucis lon gus
tendon
Calcaneofibular I.
Medi al plantar
neurovascular bund le Peroneus brevi s t.

Abductor hallucis m. Peroneus longus t.

Lateral plantar
Calca neus
neurovascu lar bundle

Fle.\ or digitorum Abdu ctor digiti minimi

muscle muscle
Central , lateral bands, Quadra tu s plan tae m.
plantar aponeurosis

(Top) The posterior subta lar joint is quite wide and is seen o n mul ti ple images. It is sepa rated from the middle
subtalar joint by the ta rsal canal. T h e tibiocalcanea l l iga ment is the strongest of the superficial del toid components.
It inserts into the sustentaculum tali and is in continuity anteri orly with the tib iospring ligament. The tibiali s
posterior tendon is superficial to th e t ibioca lcaneal and tibiospring ligam ents and its teno synovial floor is difficu l t to
separate from th e ligaments . (Botto m ) T h e i nterosseous taloca lcaneal l igament traverses the tarsa l ca nal med ially.
Th e middle subtalar joint is often subopti mall y seen on coronal MR images & req uires correlation with sagittal
images to avoid overca lling a subtalar coalition. The fibular insertion of ca lcaneofibular ligament is v isualized. Note
atroph y of quadratus plantae muscle in this patient. VII
55
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Tibialis anteri or m. & t.

Extensor h allucis
lon gus ten don Anterio r tibial vessels

Extensor digitorum otch of Har ty

lo ngus m. & t.
Anterio r colliculus,
Tarsal canal medial m alleol us
Talocalcaneal Tibiospring band,
i nterosseous I. deltoid
T ibialis posterior t.
Supero medial, sp ring I.
Flexor digi to rum
Posterior subtalar joint lo ngus ten don
recess, ex tendi n g into
si nus tarsi
Flexor hallucis lo ngus
Peroneus brevis t. tendon

Pero neu s longus t. Abdu ctor hallucis m.

Calcan eu s M edial plan tar
neurovascular bundle
Abdu cto r digi ti mi nimi
muscle Lateral plan tar
neurovascular bundle
Lateral band plantar
apo neuros is Flexor di gitorum brevis
muscle
Q uadratu s plan tae 111 .

Tibial is an terior m. & t.

Exte nsor hall ucis
longu s tendon
An terio r ti bial vessel s
Extensor digitorum
longus m . & t.

Tibio tala r I.
Talar head
Superomedial
Medial root, inferior compon ent of sprin g I.
exten sor reti naculum
Tibiali s posterior t.
Med ioplantar obl ique,
sp ring ligament Flexor digi to rum
longus te ndon
Peroneus brevis t.
Medi al p lantar
Peroneus longus t. neu rovascular bundle

Calcaneus Flexor hallucis longus

tendon
Abductor digiti m i nimi
Flexor digi torum brevis
muscle
muscle

Qu adratus plantae 111 . Lateral plan tar

neurovascu lar bun dle

(Top) The n otch o f Harty is a sma ll elevation in th e tibial medial surface, often associated with low signal sclerosis
above it, that sh ould not be mista ke n fo r tibia l osteochond ral lesio n. The tibiospring com ponent of the de ltoid
descends to join the superomedial component of th e spring. fluid-filled recess ma y exte nd fro m the posterior
subtalar joint into the sin us tarsi and sh ou ld not be inte rpreted as d isease. Note atroph y o f the quadratus p la ntae
mu scle. (Bottom) The tibialis anterior tendon is th e largest ex tensor te nd on. Tt can be foll owed on sequ ential co ronal
images of the hin dfoot but its attachm e nt to th e 1st cu neifo rm and base of 1st me ta tarsal may o n ly be visua li zed o n
midfoot images. Th e sinus tars i is a latera l, funnel shaped space be tween the talus a nd calcaneus whic h is co ntinuo us
VII with the medially located tarsa l ca na l (see previous image).
56
 ANKlE AND HINDFOOT OVERVIEW
CORONAL T1 M R, LEFT ANKLE

Tibial is anteri or m . & t.

Anterior tibial ve sels Ex tensor hallucis
longus tendon
Notch of Harty
Exten sor di gitorum
Anterior co lliculus, longus m. & t.
medial ma l leo lus
Tarsa l canal
Tibiospri ng band,
del toid Talocalcanea l
in terosseous I.
Tibial is posterior t.
Superomedial spring I.
Flexor digitorum
lon gus tend on Posterior subtalar join t
recess, exten ding i nto
r-Iexor ha ll ucis lo ngus si n us tarsi
tendon
Peron eus brevis t.
Abductor hal l ucis m.
Pero neus longus t.
M edial plan tar
neurovascu lar bund le Ca lca n eus
Lateral plan tar Abd ucto r digiti m i n i m i
neu rovascu lar bundle mu scle
Flexor digitorum IJrevis Lateral ba nd, plantar
muscle apo neurosis
Cen tral ba nd, plan tar Q uad ratus plantae m.
aponeurosis

Tibialis anterior m. & t.

An terior ti bia l vessels

Extensor hallucis
lon gu s tendon
Cl:
Extensor digi torum
longu s 111. & t.

Tibiota lar ligamen t

Superomedial,spri n g I. Talar h ead

Tibialis p osterior t.
Medial root, i nferior
Fl exor digitorum exten sor retinaculum
longus tendon Medioplantar oblique,
spri ng li ga m en t
Abductor hallu ci s m.

Peron eu s brevi s t.
Medial plan tar
neurovascular b undle Peroneus longus t.
Fl exor hallu cis longus
tendon Abductor digiti minimi
Flexor digitorum bre.,.is muscle
muscle
Quadratus plan tae rn.
Latera l plan tar
n eurovascular bundle

(Top) The notch of Hart y is a sm all e levation in the tibial m ed ial surface, often associated with low signal sclerosis
above it, that shou ld not be mistaken for t ibial osteoch o ndra l lesion . Th e t ib iospring component of the deltoid
desce nds to join the superomeclia l com pone nt of the spring. Fluid-fill ed recess may extend from th e posterior
sub talar joint into t he sinus tarsi a nd should n ot be inte rpreted as disease. Note atro ph y of the q ua d ratus p.la n tae
muscle. (Bottom) The tibia lis a n terior te ndon is the largest extensor tendon. lt ca n be fo llowed on seque n t ial co rona l
im ages of the hindfoot bu t its a ttachment to the 1st cu n eifo rm and base o f 1st metata rsal m ay only be v isua lized o n
m idfoot im ages. The si nus tarsi is a la te ra l, funnel shaped space between the talus and calcaneus which is co ntinuous
with the m edially located ta rsal cana l (see previous image).
VII
57
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, RIGHT ANKLE

Exten sor hallucis

longu s tendon
Ti bialis an terior t.

Exte nsor dig.i torum

lon gus m . & t .

Talarl'lead

M edial roo t, infer ior

Medioplantar oblique,
extensor reti naculum
spring ligam en t
Si nus tarsi Navicular tu berosi ty
Cervica l l. Ti bial is p osterior t.
An terior process,
calcaneus Abd uctor hallu cis m.
Extensor d igi torum Fl exor digitorum
brev is muscle longu s tendo n

Peron eus brevis t.

Flexor halluci s longu s
Peroneus longus t. tendo n
Lateral plan ta r Flexor digi toru m brevis
neurovascu lar bund le muscle

Abd uctor digiti minimi

muscle

bJ Exten sor h al luci s

longus te ndon
Extensor d igitorum
longu s muscle
Tibial is an te rior t.

Lateral root, inferior

extensor reti nacu lum Greater saphenous vein

Ce rvical li ga m en t
Talar head

Navicul ar
Anterior process,
calca neu s lnferoplantar
lon gi tudi nal, spri ng l.
Ex ten sor digitorum
brevis muscle Tibia lis poste ri or t .

Cuboid Abductor ha llucis m.

Flexor hal l ucis lon gus
Peroneus brevis t.
tendo n

Peroneus longus t. M edial plantar

n eurovascul ar bu ndle
Qu ad ratus plantae m .
Lateral plan tar Flexor d igitorum
neurovascular bundle lon gus tendon

Flexor d igitorum brevis

Abduct·or d igiti minimi
muscle
muscle

(Top) The fl exor digitorum longus a nd flexo r hal lucis lo n gus tendo n approxima te & the n cross eac h othe r under th e
na vic ular, at th e kn ot o f Henry. The ce rv ica l ligame nt is the most anterior ligament of the sinus ta rsi. The
m ediopla ntar o blique compo n ent, as t he inferoplantar longitudina l component, of the sprin g li ga me nt o rigina te
from th e co ro n o id fossa be twee n th e a nte ri o r and midd le subta lar joints. (Bottom) The extensor digito rum brevis
and extensor hallu cis brevis muscles originate in the sinus tarsi fro m th e su peri o r aspect of the ante rior process of t h e
ca lcaneus. The lateral root of th e inferior ex te n sor retin ac ulum o rigina tes la te ral to th e exte n sor cligito rum b revis
muscle. The pe roneus lo ngus tendon is beginning t o curve unde r th e cuboid toward its in se rtio n int o th e base o f the
VII 1st me tatarsal and 1st c uneifo rm .
58
 ANKLE AND HINDFOOT OVERVIEW
CORONAL T1 MR, LEFT ANKLE

Ex tensor hall ucis

Tibia l is anterior t.
lo ngus tendon

Talar head
Ex ten sor digitorum
longus m. &: t.

Medioplan ta r obl ique,

spri n g ligam en t Medial root, inferior
extensor retinaculum
Navicula r tuberosi ty
Si nus tarsi

Cerv ical I.
Tibia l is posterior t.
An terior process,
calcaneus
Abductor m. Ex tenso r di gito rum
brevb muscle
Flexor d igi to rum
longu s tendo n Peron eus brevis t.
Medi al plantar Peroneus lo ngus t.
n eurovascular bundl e
Lateral plant ar
n eurovascular bundle
Hexor halluc is longu s
tendon
Abductor digiti minimi
Fle>.or digitorum brevis muscle
m uscle

Ex tensor hal l ucis

longus tendon
Tibial is anterior t.
Ex tensor digitorum
longus muscle

Grea ter saphenou s vei n Lateral roo t, inferior

ex ten sor retinaculum
Talar heacl
avicular Cervical ligam en t

ln feroplantar Anterior process,

longi tudi nal, spring I. calcaneus
Extenso r digi toru m
Ti bial i s posterior t. brevis muscle

Abducto r ha llucis m . Cu boid

Flexor hall ucis Peroneu s brev is t.
tendon
Peron eu s lo ngus t.
Medial plan tar
neurovascular bundle Quadratus pla n tae m .

Flexor d igitoru rn Lateral plan tar

longus teni1on neurovascul ar bundle

Fl exor digi torum brevis

Abductor digi ti m in imi
m u scle
mu scle

(Top) T h e fl exor digi to rum lo ngus and fl exor hallucis lo n gus tendon approx imate & then cross each o th er under the
navicular, at th e kn o t of Henry. The cerv ica l liga ment is the most an terior ligamen t of th e sinus tarsi. The
medioplantar o blique co mponent, as the inferoplanta r lo ng itudinal co mponent, o f the sprin g ligamen t o ri gin ates
from th e co ron o id fossa i n betw een the anterior an d middle subta lar jo ints. (Botto m) T he extensor d igi torum brevis
and ex tensor h alluci b revis m uscles o riginate i n the si nus tarsi from th e sup erio r aspect of the an terior process o f t h e
calcaneus. The latera l root of t he i nferio r ex ten sor retin acu lum o riginates lateral t o the ex ten sor d igi toru m brevis
muscle. T h e peroneus lo ng us ten don is beginn i ng to curve u nder th e cu bo id toward its insertio n in to the base o f the
1st metatarsal and 1st cunei form . VII
59
 ANKLE AND HINDFOOT OVERVIEW
SAGITTAL T1 M R

G rea ter vein

bran ches

Navicular t uberosity

Ti biali s anterior t .

I st cunei form
Tibia l is posterior t.

I st m etatarsa l

Abductor hallucis m.
Ex tensor h all ucis
ten don

Plantar aponeurosis
Flexor h allucis brevis
muscle

iJ Superficia l anterior
tibiotalar,
tibionavicular deltoid

Superficia l
ti biocalcaneal , deltoid
Superomedia l, spring I.
ligamen t Posterior
med ial ma ll eolus
Greater ve in
Flexor digitorum
longus tendon
Navicular
T ibial is poster ior t.
T ibiali s ant erior t.
Tibia l is poster ior t. sl ip
I st cunei form to Jst cune iform

I metatarsa l Abductor hallucis m.

Exten or h allucis
longus tendon
Flexor ha l lucis longus
Flexor hallucis brevis tendon
muscle

(Top) The most m edial sagi ttal image depicts bran ches o f th e grea ter saphenous vein . T h ree tendo n attachments are
present alo ng t h e 1st meta tarsal axis: Ti bialis pos teri o r tendo n to t he navicular tuberosi ty and 1st cune iform, anterior
tibial tendon to the 1st cuneiform and 1st metat·arsal base and the peron eus lo ngus tendon to the lateral pla ntar base
of th e 1st m etatarsa l. Not infrequen t ly small ten dinous sl i ps of the tibialis posterior tendo n may be v isual ized as t h ey
go under th e nav icul ar to th eir respective inserti on sites. (Bottom ) Th e superficia l componen ts of th e del toid
liga ment including t he t ib io talar, tibio navicular, tibi osprin g & tibioca lcan ea l ligaments origina te from the anterior &
post erior col liculi o f the medial malleolus. Th e superomedial compon ent of t he spring l iga men t an d ti bialis posterior
VII tendon insertio n to t he cun ei form are also v isuali zed.
60
 ANKLE AND HINDFOOT O VERVIEW
SAGITTAL T1 M R

Posterio r coil icu Ius,

medial m alleolus

An terior col li culus,

m edial malleolus
Anterior tibiota lar, Tibialis posterior l.
deep del toid
Posterior tibi o talar,
Talar h ead deep deltoid

Tibialis ant eri or l. Flexor digit orum

longus ten don

Tibialis posterior t. slip

Sustentaculum tali

Navicular Medial ca lca n eal nerve

I st cuneiform
M ediop lan tar oblique,
Ex temo r hallucis spri ng l iga m en t
tendon
Flexor digitorum
Flexor hallucis lo ngus longus tendon
ten don
Abd uctor h al lucis
l st metatarsal muscle & tendon
Add uctor hallucis, Peroneu s longus t.
oblique h ead

Greater saph en ous vein

[_[
A nterio r colliculus,
media l mal leol us
T ibialis posterior t.
Talar h ead
Flexor d igi toru m
Tibialis an teri or l. longus ten don
Posterior ti bio talar,
avicu lar deep delt oid

libialis posterior l. slip Posterior tibial nerve

Medial plantar nerve

Ex tensor ha llu cis
longus tendon Lateral pl an tar n erve

l st cu neiform Flexor h all ucis longus

tendon
2nd cun eifo rm
Medioplantar oblique,
l st metatarsal spring ligamen t
Flexor digitorum
lo ngus Lateral plan tar artery
Abductor hallucis m.
2nd m etatarsa l
Medial pl an tar artery
Adductor hallucis,
oblique h ead Medial pl antar nerve

(Top) T he deep tibiotalar compo nent of the d elto id ligamen t o riginates fro m the posterior co lliculus o f the medi al
malleo l us. T he i nsert io n of the peroneus longus te ndo n o n the plantar lateral base of t h e 1st metata rsa l & on the 1st
cun eiform is now v isualized. The supero medial compo n ent o f th e spring ligament o riginates from t he sustentaculum
ta li and ca n some tim es be seen slightly m edia l to the tibialis posteri o r tend o n inserti on o n the na v icular. (Bottom )
T h e talar insertio n of t he d eep t ibiotalar delt oid ligament fo rms a l ow si gnal shadow o n the medial talar bod y. Th e
pos terior tibial n erve divides int o t h e med ial and lateral pl antar nerves deep o r prox imal to th e flexor retin aculum.
T h e fl exor digito rum lo ngus ten don overli es th e sustentacu lu m ta li (see previo us image) w hile th e fl exor hallucis
lo ngus tendo n traverses under it. VII
61
 ANKLE AND HINDFOOT OVERVIEW
SAGITTAL T1 MR

iJ Greater sa phenous vei n

Tibial i s posterior t.

Flexor digitoru m
lo ngus tendon

Tibiali s anterior t. Talar troch lea

Talar h ead Deep..ti biota lar, deltoid

l iga m ent
Exten sor hallucis
lo ngus ten don Tibial is posterior vei n

N avicu lar M edial talar tubercle

Dor salis pedis a. Sustentaculum tali
2nd cuneiform Flexo r ha llucis lo ngus
1st m etatarsal tendon

Quadratus plantae m.
Pero neu s lon gus t .
Lateral plan tar vein
Flexor digitorum
longus tendon Medial cal ca n ea l
Exten sor h alluci s brevis tubercle
mu scle & tendon Tibial is posterior t. slip
2nd m etatarsal Flexor digi to ru m brevis
muscle
Adductor h allu ci s,
oblique head Medi al plantar n erve

IJ Ti bial is posterior
muscle & tendon
Soleus muscle
Flexor digi torum
longus tendon

Talar h ead
Tibialis an teri or t.
Middle subtalar joi nt
Deep peronea l n erve In terosseous
tal ocal ca nea l ligam en t
Exten sor hallucis
lo ngus t . & m . Flexor h all ucis longus
te ndon
Dorsal ta lo nav icu lar I.

M ediop lantar ob lique,

Nav icu lar
spri ng li ga m ent
Dorsalis ped is artery
Ach illes tendo n
2n d cunei fo rm
Medial ca lcanea l
Peron eus lon gus t. tubercle
Quadratus plantae m.
2n d metatarsa l Ce ntra l band, plantar
Addu cto r hallu cis, aponeurosis
oblique head
Fl exor digitorum brevis
muscle

(Top) The flexo r d igitorum longus tend o n travels o bliquely and cha n ges positions relative to the rest o f the posterior
compartme nt te ndons. Prox imal to the a nkle joint it is first medial a n d then posterio r to the tibialis posterio r
tend o n. More dista lly it is la teral to the tibialis poste rio r te n don a nd medial to th e flexo r h all ucis lo ngus te ndon.
Under t h e navicular t uberosity the tendon crosses and becomes late ral to th e fl exor hall ucis longus te ndo n . (Bottom )
Th e pla ntar apon eurosis is subd ivided into three bands: A thin medial band ove rly ing th e abductor ha ll ucis m uscle, a
strong central band, overlying the flexor digitorum brevis muscle (see n here), a nd a lateral band overlying th e
abductor digiti min imi. Th e med ioplantar oblique ba nd o f t he spring ligame nt origina tes from the coro noid fossa,
VII sligh tly late ra l to the suste ntaculum tali.
62
 ANKLE AND HINDFOOT O VERVI EW
SAGITTAL T1 MR

[I
"I i biali s posterior
m u scle & tendon
Tibia m uscle

Flexor hallucis longus

Tibial is anterior t. m. & L
neck Talar troch lea

Tibiota lar capsule

Ext ensor ha llucis
lon gus m . & t. ervica l ligam ent

Dor\a l ta lo navicular Lateral talar tu bercle

ligam en t
Posteri o r subtalar joint
pedis artery
Achilles tendon &
pre-Achilles fat pad
1 avicular
Medioplantar oblique,
2nd cuneifo rm
spring ligament
digi torum
Lateral plantar vei n
brevis muscle
Ca lcanea l tu berosity
2nd metatarsal Central band, plan tar
aponeurosis
Peroneus longus L
Flexor di gi torum brevis
Adductor hallucis, rn uscle
ob liqu e h ead
Q uad ratu s plan tae m.

Tibial is posterior
muscle & ten don

Tibia muscle &

tendon

ribial is anterior t. Flexor hallucis longus

m. & L
l·.x temor hallucis
longus tendon Cervical ligament

Interm ediate root,

Dorsalh ped is artery i nferior extenso r
reti naculum
Navicul ar Achilles t. &
pre-Ach i lies fat pad

Extcmor digitorum Med ia l root, i n ferior

brevis muscle ex ten sor retin aculum
l nferoplan tar
3rd cu n ei form longitudin al, spring
ligam en t
2nd metatarsa l Long plan tar ligament

Peroneus longus t. Cen t ral band plan tar

apon eurosis
3rd metatarsal
Quadratus plan tae m.
Adductor hallucis, Flexor digi torum brevis
oblique h ead muscle

(Top) The peroneus lo n gus tendon can be followed o n seq uen ti al an kle sagittal images from its plantar attachment
to ba se of 1st metatarsa l up to its descent posterio r to the fi bula. The sinus tarsi is traversed by t·h e latera l,
intermediate and m ed ial roots of t h e extensor retina culum and by th e cervi ca l liga m ent. The ta rsal ca n al, medial to
the sinus tarsi is traversed by th e interosseous talocalcan ea l ligament. (Bottom) T h e soleus tendon, toget h er wi th
tendo ns of th e gastrocnemi us, fo rm th e Ac hilles tendo n . T h e in feropl antar lon gi tudinal ba nd of the sprin g ligam ent
inserts to th e n avicu lar beak & d ue to its st ra ight co urse, is o ften seen o n a lateral sagittal image. The ce rv ica l
ligament is the most anterior l igament traversing th e sinus tarsi. T he intermediate root o f th e in ferio r ex ten sor
retinaculum is typi ca lly fo und posterio r to it. VII
63
 ANKLE AND H INDFOOT O V ERVIEW
SAGITTAL T1 MR

IJ Tibialis an terior m. & t.

T ibia
Soleu s m . & t.

Ti bialis posterior m.
Flexor halluci s longu s
& t.
Ill.

Ex ten sor ha l lucis Gastrocnem i us t.

longus tendon
l nfertor t ransverse I.
Dorsal is ped is artery
Ach illes t . &
pre-Ach ill es fat pad
Ex tensor digi torum
longus m. & t.
I nterm ediate root,
inferio r extensor
3rd cunei form reti naculum
Lateral talar tubercle
Extensor digitorum Posterior sub talar joi nt
brev is m . & t.
Cervica l ligam en t
In terosseou s Anterior process,
cuneocuboid I. ca lcan eus

Intermetatarsa l I. Lo ng plantar ligam en t

3rd metilt'arsal Cen tral band, plantar

Adductor h all u cis, aponeurosis
obl ique head Flexor digitoru m brev is
muscle

iJ Ti bialis an terio r m . & t.

Extensor hallucis
lon gus tendon
T ibiali s posterior m.

Soleus m . & t.

Flexo r h all ucis longus

Ill. & t.

Talar body
Gastrocn emius t.
Ex tensor di gi toru m
lon gus m . & t.
In ferio r transverse I.

Cervica l li ga m ent
Posterio r tal ofibular I.

Latera l
ca lcan eonav icu!ar, Achilles tendon
bifurca te ligament
Exten sor digitorum Pre-Ach i lles fat pad
brevi s muscle
In te rmediate root,
3rd cuneiform in ferior extensor
In terosseous retin aculum
cuneocuboi d I. Abd uctor digiti mini m i
muscle
3rd m etatarsal Lateral band, plantar
4th m etata rsal apon eurosis

Peroneus longus t .

(Top) The p re-Ach il les fat pad, also ca lled Kage r fat pad, se parates t h e Ach illes ten do n fro m th e poste rio r
compartme nt m uscles. It is typi ca ll y traversed by fine septa a nd vascula r ch a nne ls. Th e pe roneus lo ngus tendo n
c u rves under th e cu boid to travel t owa rd its insert io n to t h e 1st me tata rsa l base. The long pla ntar liga m ent binds th e
ca lcaneocu boid jo in t, exte n ds t o th e bases o f the m etatarsals and thus fo rm s th e roof o f th e cubital tun nel. The
poste rior t ib io fib ular ligamen t origina tes from the poste rio r tibia. It ext ends d istal t o th e a n kle join t as the inferio r
t ran sve rse li ga m e nt. (Bottom) The bifurcat e ligame nt o rigin at es from t h e calca n eus just late ral to th e sp ring
ligamen t. Its n avicula r lim b (sh ow n here) inserts in to the nav icul a r, dorsa l a n d la te ra l to th e sprin g liga me nt
VII in sertion . A second limb (n ot seen) inserts into t he cuboid .
64
 ANKLE AND HINDFOOT OVERVIEW
SAGITTAL T1 MR

Tibialis posterior m.
anterior rn . & t.
Soleus muscle
l·.xtemor
lon gus m . & t.
Gast rocnemius t.
digi torum
lon gus m . & t. Flexor hallucis longus
muscle & tendon
Tibia

Extensor digitoru m Talar body

lon gus tendon

Lateral root, inferior I n ferior tran sverse I.

exten sor retinaculum
Posterior talo fibular I.
Latera l
calcaneonav icular, Lateral process, talus
bifurcate ligament
Sinu s tarsi
Extemor digitorum
brevi muscle Ca lcaneal tuberosity

Cuboid Latera l band, plantar

apo n eurosis
4th meta ta I
Abducto r digiti rninim i
51h metatarsal
muscle
Flexor digit i minimi
brevi s m uscle Pero neus longu s t.

Tibia l is po terior m.
Tibialis anteriorly m.
Soleus muscle
Extemor hallucis
longus m. & t.

Anterior tibia vein Flexor hallucis longus

muscle & tendon

Ti bia Lesser saph en ous vein

Extemor digi torum I nferior transverse I.

Iongu m. & t.
Lateral root, inferior Posterior talofibular I.
exten\or retinaculum
Sural nerve
Extensor digi torum
brevis musc le Lateral process, talu s

Exten sor digitorum

te ndon Sinus tarsi

C uboid Abductor digiti min imi

muscle
4th metatarsal
Lateral band , plantar
5 th m etatarsa l aponeurosis

Fle:-or digiti minimi

muscle Peroneus lo ngus t.

(Top) Th e extenso r digitoru m brevis muscle origi nates from the superi or anterior ca lcaneus within th e lateral sinu s
tarsi space. The lateral root o f th e in ferior ex ten sor retinaculum enter th e sinus tarsi lateral and slightly posteri or to
the m u cl e. Th e talofi bular liga m ent o rigin fro m the ta lus is v isualized. The inferior tran sverse ligamen t extends
beyond the tib ial posterior surface. (Bottom) Th e deep pero nea l n erve and anterio r tibial vessels are optimall y
visuali zed on axia l images but occasionall y may be n o ted (as seen h ere) on a sagittal image in a p lane between the
tibia and fibula. T he lateral ba nd o f the p lantar fascia is superficial to the abductor digiti minimi muscle. T he
exten sor digi torum longus tendon an d ex ten sor hall ucis longus tendo n travel close to each other in th e distal leg and
may be difficult to distinguish from on e anoth er. VII
65
 AN KLE AND HINDFOOT OVERVI EW
SAGITTAL T1 MR

IJ Exten sor hallucis

longu s tendon
Soleus muscle

Sural nerve

Flexor hallucis longus

muscle
Extensor digito rum
longus m . & t. Peroneus brevis m.

Fibula Posterior tal ofibular I.

Lateral process, tal us

Anteri or talofibular
ligam en t
Lesser sa ph enous vei n
Latera! root, i n ferior
extensor rel'inacu lu m Calca neofibu lar I.
Extensor digitorum
brevis muscle
Sin u s tarsi
Exten sor digi torum
longus ten don
Peroneus lo ngus t.

Sth metatarsal Abducto r digiti mini mi

m u scle
Flexor digiti minimi
brevis muscle
Cuboid

jJ Extensor cligitorum
Soleus mu scle
Fl exor h alluci s longus
muscle
lo ngus 111 . & t.

Peroneus brevis m .

Fi b ul a

Calcaneo fibular
ligamen t
An terior talofibular
liga m en t
Peron eus brevis t.

In ferio r peroneal
Ex tensor digitoru m
retin aculum
brevis muscle
Peron eus longus t.
Sth m eta tarsal
Lateral band, plantar
aponeurosis
Abductor digi ti mini mi
muscle

(Top) The fibula r origin s of t he syndesm otic and co lla teral liga me nts a re someti m e e ncounte red on a far lateral
sagitta l image. Due to pa rti al volume averaging the calca neofibula r liga me n t ma y be seen as an o bl iquely o rie nted
ba nd overl ying the pe ronea l te ndo n s (see next im age also). Th e pero ne us longus tend o n is desce nding along the
lateral wall of the calcan eu s toward its cuboid tunnel. (Bo ttom) The peroneal tendo n s d escend posterior to th e fibula
with th e pe ro ne us lo ngus tendon posterior t o the peroneus brevis tendo n. They diverge from each othe r along the
late ral wall of th e calcane us, sometimes sepa ra ted by a pe roneal tu bercle. The inferior pe roneal re t inac ulum, difficult
to visua lize o n sagittal images, separates the t e ndo n s from one a n other.
VII
66
 ANKLE AND HINDFOOT O VERV IEW
SAGITTAL T1 MR

Soleus muscle
f<..x ten;or digitorum
lo ngus, peroneus
tertius mu scle

Peroneus brevis m .

Anterior ti bial vein

Peroneus brevis t.

Fibula Peroneus longus t.

Posteri or talo fi bular

l igam en t

Lesser vei n

Peron eus t.

Peroneus longus t.
Abductor digi ti minimi
muscle Base Sth

extensor digitoru m
long w, muscle Peroneus m.

Peroneus longus t.

Fibul a

(Top) T he peron eus longus tendon is typica lly po tero lateral to t he peron eus brevis ten don and is appreciated better
posterior to th e fibula on fa r l ateral images. T he peron eu s brevis i n serts ont o the base o f t h e Sth metatarsa l. The
an teri or tibial vein pierces the interm uscular septum and may be seen anterior t o th e fibula on far lateral sagi ttal
im ages. (Bott om ) The extensor digi torum longus muscle and peroneus brevis muscle arc respecti ve ly th e most
ant erolateral and postero lateral m uscl es o f the distal leg.

VII
67
 T ENDONS OVERVIEW
• Pero n eus brevis typicall y fla t to mildly c resce nt ic
I Imaging Anatomy i.n retro fibul ar groove
Overview • Peron eus brevis tendo n ma y be g lo bular when
• Radiograph s m edial t o pe ro n eus longu s, may simulate medial
o Achilles te ndo n visualized on lateral view of a nkle subluxati o n as it descend s unde r the fibula r tip
• Muscle of peroneus brevis n oted at ankle jo int
• In serts approximat ely 1 em distal to superior
ca lca neal tuberosity • Perone us brevis, pe ron e us lo ngus share a com m on
• Small fat pad separa tes tendon from ca lcaneal tendon sheath proxim ally
tube rosity, location of retrocalcan eal bursa • Retrofibular groove co ncave/fl at in 82% of
indi viduals
• Kager fat pad anterior to Ach i lies te ndo n
• Superior p ero neal retinacu lum h olds tendo n s
• Co mputed tomograph y
o Te nd o n s subopti ma ll y vis ual ized on routine images wit hin retrofibular groove
o 30 vo lume rende ring recon struction s can be • Superior peroneal retinac ulum : Low signal
pe rformed but presently not ro utinely utili zed for curvilinear structure, best see n o n axial images
assessing te ndons except as associa ted with fractu re origina ting fro m la te ral mal leolus app roxi m ate ly 1
• MR em above d istal fibular tip
o Tend ons are opt im all y visua lized o n axial MR • Fibrous ridge, small low sig nal triangle, origi nates
from lateral fibular ti p, d eepen s retrofibular
im ages
o Sagittal images optimal for Achilles tendon groove
o Tendo n s typ ica lly low in signa l o n all pulse
• Calca n eofibular liga me nt deep to peroneal
sequ en ces t endons
• Inferior peronea l retina culum: Low signal,
o Exceptions to low signal of n o rmal tendons:
Magic a n gle effect, ossicles, fibrocar tilage in tend on s curvilinea r st ructure inserts o n peron eal tubercle,
• Magic angle effec t sepa rates peroneal tendons late ral to ca lcanea l
• All tendon s, except for Achilles, are susceptible to wall
magic angle effect as they cu rve arou nd ankle o Normal MR of the posterior tibial te ndon
jo int • Most postero m edi al te n don
• Shares groove be hi nd tibia wi th flexor cligito rum
• Magic angle effec t results in increased te ndo n
lo ngus te ndon
signa l o n low TE seque n ces
• Magic ang le effect can be avo ided by 1: Pla ntar • Held in groove by flexo r retinaculum
• Except Achilles la rgest posterior te nd o n,
flexing foot, patie nt su p ine 2: Imaging patient
approximately 2-3 times size of ad jacent flex o r
prone 3: Co rrelating tendon's sign al alte ration s on
digito rum o n axia l images
high TE sequences .
o Tendon sheath • May have n o rmal m inima l fluid in tendon sheath
• Often increased signal at n avicu lar at tachme nt
• Prese nt in al l te ndons except Achilles
• M inim al fluid norm al in flexor tendons clue to m agic angle effect, fibroca rt ilage, os
• No t endo n sheath d istall y; distal pe rite ndin o us
• Low in sign al, see n only if di st ended by fluid
• Fluid in ex te nso r shea th s us uall y pathologic signa l is abn o rmal
• Distal insertio n slips can be see n on ax ial images
• Large amoun t o f fluid in fl exo r hallucis lo ngu s
• Inho mogeneo us sig nal distall y m ay be related to
sh eath can be normal clue to n o rma l
m agic angle effect, fat between the d istal tendon
comm unication of sh ea th w ith a nkle jo int
slips, prese nce of type I os n av iculare
o Ac hilles te nd o n has a pa ratenon, loose connective
• W h en a t ype JI accesso ry navicular is prese nt:
tissue around tendon, but n o t e ndon sh eath
Typically tendo n inserts d irectl y into it a nd is
o Normal MR of Achilles tendon
di scontinuo us from d istal tend o n slips
• Tendo n best seen o n sagittal images
o Normal MR of the flexor hallucis longus te ndon
• Un iform in d iamete r o n sagittal images
• Co ncave o r flat anteri o r surface on axial images • Ofte n surro unded by fluid d ue to norm al
comm uni ca ti on o f sh ea th with a nkle joint
• Occasional shi fting bulge on anterio r surface
• Ca n sometimes have a seagull appeara n ce in di stal
reflects spiraling sole us and gastrocnemius tendo n
leg as tendinous slips join eac h oth er to form a
fibers
single t endon
• Punctate increased sign al o n Tl , PO, due to
infolding parate n on vesse ls, con n ective tissue • Muscle ex te nds more distally t h a n a ll o ther
• Parateno n: Rin g o f inte rmediate signa l muscles in ankl e
• Ide ntified o n sagittal images as tendon cu rving
surro undin g m edia l, posterior, lateral tendo n
posterior to sustentaculum ta li
ma rgins
• Susce ptible to magic angle effect a t level of
• Kager fat pad anterior to tendon, typically
suste n tacu lu m tali
traversed by vessels
• Mini ma l a m oun t of flu id in retrocalcaneal bursa is o Normal MR of exten sor tendons
• Largest m os t m ed ial dorsa l te ndon is anterior
norma l
• Sm all tend on media l to Achi lles is plantaris tibial tendon
• Tendo n sh ea th fluid is rare a nd u sua lly pathologic
o Normal MR of peronea l tendons
• Peron e us brevis typically a nterior or anteromeclia l • Very susceptible to m agic angl e effect
to peroneus longus

VII
68
VII
69
VII
70
VII
71
 Q)

c::
<(

VII
72
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: ACHILLES TENDON

Tibi a

Fibu la

Soleus muscle

Soleu s tendo n

Medial & lateral

gastrocnemius tendon s

Soleus muscle

Plan taris tendon

Soleus tendon
Achilles tendon

(Top) The Achilles tendon originates at th e musculo tendinous junctio n of the soleus and gastrocnemius tendons
(apo neurosis) in th e midd le of the ca lf. Prior to the merger, t he gastrocnemius tendons form a C-shaped aponeu rosis
along th e posterior aspect o f th e distal leg. T h e soleus tendo n is found anterior to the apon eurosis embedded in i ts
muscle. (Bo ttom) As th e sol eus join th e gastrocnem i us aponeurosis it forms a lateral bu mp on the an terior surface of
the tendon. Th e Achil les tendon spirals as it descends down th e ca l f so that t h e gastrocnemius con tribution is main ly
on the lateral & pos teri or surface o f th e tendon. Thi s spira l ing, w hich occurs a few em above the tendon 's i n sertion
to the ca lca n eus, produce a focal area w hich is vulnerabl e to tea ring.
VII
73
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: ACHILLES TENDON

Tibia

Fibula

Soleus muscle

Plan taris tendon

Achill es tendon

Tibia

Fibula

Plan tarb tendon

Pre-Achil les fat pad

Ach i l les ten don

Para te non

(Top) Close to th e merger of the tendons th e anterior surface of t h e Achi lles tendon m ay be irregular or con vex.
More distall y (see nex t image) the norm al Achilles tendon has a fl at o r concave anterior surface. Convexi ty o f the
dista l tendon is consistent with disease o f th e tendon . ( Bo ttom ) Th e an teri or surface o f th e Achi lles tendon is now
flat to slightly con cave. Note th e subtle normal h eterogeneity o f the tendon reflec ti ng intrasubstance vascular
ch an n els. A large pre-/\ch i lles (Kager) fat pad separates t he Achil les ten don from th e deep posterior com part men t
tendons. This fat pad i s typ ically t ra ve rsed by fine, low signa l vesse ls and septa. Note th e plantaris tendon descending
along t h e m edial aspect o f the Achilles tendon.
VII
74
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: ACHILLES TENDON

Achill es tendon

Ca lcaneus

Ach illes tendon

Calcaneus

Acl1i l les tendon

(Top) The Achi lles tendon inserts in to a large rough area on the posterior ca lcaneus, a few millimeters below the
apex of t h e calcanea l tuberosity. The tendon flattens approx i mately 4 ern above its insertion as seen in this image.
ote normal heterogeneity of t he tendon. The tendon may be carti laginous at its very distal aspect. (Mi dd le) Note
broad inserti on of the Ac hilles tendon to ca lcaneus. (Bottom ) o te interdigitation of bone and tendon at the
insertion of Ach ill es tendon to ca lcaneus.

VII
75
 TENDONS OVERVIEW
SAGITTAL T1 MR, RIGHT ANKLE: ACHILLES TENDON

IJ Fl exor hallucis longus

muscle & tendon
Soleu s muscle

T ibia Achill es tendon

Pre-Ach ill es fa t pad

Retroca lcaneal bursa

Talus

IJ o leus muscle &

tendon

Flexor halluci s longus Gastrocnem ius tendon

muscle & tendo n

Pre-Achilles fat pad

Tibia

Achilles tendon

Ta lus Retrocalcanea l bursa

(Top) The Ach illes tendo n m eas ures approximate ly 15 em in len gth . Unli ke most tendons th at are best assessed o n
ax ial images the Ach illes tendon is o ptima ll y v isuali zed o n sagittal images. T h e tend o n is typica lly low in sign a l o n
a ll pu lse seq ue nces. Its a nte rior & posteri o r margi n s are parall el to one a nothe r o n sagit tal images. (Bottom) ote t h e
me rger o f the soleus tendon wit h th e gastrocn e m ius tendon / apon eu rosis. Tears of th e Ac h illes te ndon typically occur
2-6 em a bove t h e insertion of the tendo n, an a rea th a t is well seen o n routin e sagittal ank le images. Tea rs of th e
Ac hilles m uscul o te nd inous junction, howeve r, m ay req uire more proximal imaging of the d istal leg.
VII
76
 TENDONS OVERVIEW
SAGITTAL & AXIAL T2 FS MR, RIG HT ANKLE: ACH ILLES TENDON

Tibia

Fibul a

Plan taris tendon

tendon Para tenon

[[
Ta lus
Retrocalcaneal bursa

tendo n

Calcaneus

(Top) The Achill es paratenon. The Achilles ten don lacks a tendon sheath but is enclosed by a parate non, a thin
gl id ing m e m bra ne of loose areolar tissue wh ich is seen as a ring o f bright signal a round the ten don on fat suppressed
ax ial images. (Bottom) Re trocalca n eal bursa. A sma ll fat pad separa tes th e Ach illes tendon from th e apex of the
calcanea l tu berosity; t he ret rocalca n eal bursa is fo und within t h is fat pad. Minimal am o unt o f flui d within t he
rctrocalcanca l bursa is a normal find ing w h ich sho uld n o t be m isinterpret ed as disease.

VII
77
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: TIBIALIS POSTERIOR TENDON

iJ T ibia
Tibialis posterior
tendon

Flexor digitorum
lon gus muscle &
tendon

Tibia lis pos terior

Fi b ula musc le

Flexor hallucis longu s

muscle & tendon

Tibia
Tibial is posterior
tendon

Flexor di gitorum
longus muscle &
tendon

Fibul a

Flexor hallucis longus

muscle & tendon

(Top) In the distal leg the tibialis poste ri o r muscle li es bet ween the flexor ha ll ucis lo ngus and flexor digi torum
lo ngus muscles. Oft e n, the muscle has two te ndin o us slips (as see n here) which t yp ically fu se into one slip by the
time th e te ndo n reaches the ankle joint. Occasional ly the two tendo n sli ps are still see n a t the ankle joint a n d should
n ot be m istaken for a torn tend on. (Bottom) A few em above ankl e joint the tibia lis posterior tendon crosses deep to
th e fl exor digito rum longus tendon to become the m ost media l tendo n o f the d eep posterio r compartm ent. Note th at
th e muscle o f th e ti bialis posterior h as d isappea red w hile the rest of the deep post erio r compa rtm e nt muscles are still
visua li zed.
VII
78
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: TI BIALI S POSTERIOR TENDON

Tibialis an terior tendon

Ti bia

Ret ro ti bial groove

Fibula

Tibialis posterior
ten don

Flexor retinacu lum

Flexor digi torum

Flexor hallucis lo ngus lo ngus te ndon
muscle & te ndon

Superom eclial spri ng

li game n t
Talus
Tibial is posterior
ten don

Middl e subtalar facet

Flexor digitorum
longus tendon

rlexor ha llucis longu s

tendon
Ca lcan eus

(Top) just above th e a n kle jo int the tibia lis posteri o r & the mo re lat e ra ll y loca ted flexor digit o rum lo ngus te ndon
d escend together, deep to th e flexo r re tin acu lu m, within a comm on retroti bial groove poste rior to the ti bia & med ial
ma lleol us. Each te ndon, h owever, is e ncl osed within its own separat e te ndon sh eath. The fl exo r re tinaculu m h olds
the tendo ns in place withi n t he re t roti bial groove. The tibialis pos terio r tendo n at this level is uni fo rml y low in
signal. Its size sh ould be approxima tely 2-3 times the size of the adjacent fl exor d igitorum longus te ndo n. (Bottom)
As the ti b ia lis pos te ri o r te nd o n d escends media l to th e t alar head, it lies superficial to the delto id liga me nt a n d then
superficial to th e superomed ia l compon ent o f t he sp ring ligament.
VII
79
 TENDONS OVERVIEW
AXIAL T1 MR, RI GHT ANKLE: TIBIALIS POSTERIOR TENDON

Medioplantar obl ique,

spri n g ligament

Fat bet ween tibialis

posterior tendon slips

Talar head articular avicula r tuberosity

surface
2 tibia l i s
posterior tendon slips
lnferop lant ar
longitudinal, spri ng
ligament Flexor digitorum
longus tendon

Ca lcan eus
Flexor longus
tendon

Navicular tuberosity

l nferoplan tar
Multiple tibialis
longitudinal, spri ng
posterior tendon slips
ligament

Flexor digitorum
Cu boid longus tendon

Calca n eus Flexor h allucis longus

tendon

(Top) I n th e foot t he tibialis pos terio r tendon d ivi des i nto two major co mponents a seen in thi s image: 1) larger,
more medial division inserts di rectly into the navicular tuberosity, 2) latera l, sma ller div ision inserts to all o th er
tarsal bon es, (excluding talus), & 2nd-4th metatarsal bases. The t ibialis posterior tendon may appear heterogeneous
at i ts navicular in serti on for the foll owing reasons: 1) magic angle effect , can be mi n im ized by imaging in mild
plan tar fl exio n (su p i ne) or i n pron e position (uncomfortab le to patient), 2) fa t in betwee n the vari ous tendon sli ps
(seen here), 3) presen ce o f an fib rocartilage/type I os naviculare, 4) heterogen eity related to ad jacen t deltoid & spring
ligaments. (Bottom ) An image sligh t ly more distal d epicts furth er splitting of th e tib ialis posterior tendon .
VII
80
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: TIBIALIS POSTERIOR TENDON

l st-3rd cuneiforms

Ti bialis posterior distal

Cuboid tendon slip

Calcaneus

l st-3 rd cu neifo rm s

Cuboid Ti bialis posterior d istal

tendo n slips

Calcaneus

(To p) A single, prominent dista l ti bialis posterio r te ndon slip is see n approaching th e bases of the cuneiform s.
(Bottom) Mo re distal axial image depicts a number of tibialis poster.io r t e ndon sli ps. Th e m ost lateral & most
pro minent o ne in sert s o n th e p lantar base o f the 3 rd cun eiform. Two othe r slips a re seen approachi ng th e plantar
surfaces of 1st & 2 n d cune i fo rms. Th e numero u s plan ta r inserti o n sit es of th e tibial is poste rior tendon make it th e
most powerful in vertor of th e foot. T h e tendon is also a maj o r co nt ributo r t o ma intaining th e m ed ial lon gitud in al
arch .
VII
81
 TENDONS OVERVIEW
AXIAL T1 & T2 FS MR, RIGHT ANKLE: TIBIALIS POSTERIOR TENDON

Type I os navicu lare

Tibialis posterior
tendo n

Medio planta r obl ique,

spri ng ligamen t

Superom ed ial spring

l igament
Tal us

T ibia l is posterior
tend on
Flexor d igi to ru m
lo ngus ten don

Middle subtalar facet

f-lexor ha llucis lo ngus

Ca lca neus ten don

(Top) Hete rogen e ity at t he inse rtion o f the tibia lis posterior te ndon may be re la ted to the presen ce of type I os
n aviculare. Three types o f ossificatio ns ca n occ ur a t th e navicu lar tu be rosit y. Type 1 os nav iculare is a sm all sesamoid
bone embedd ed in t he tibialis posterior tendon. Type Il os is a large triangular ossification rep rese nti ng a no n fused
accessory ossifica tio n o f the na vicula r. A sync h o nd ros is is present between th e ossifica ti o n & the navicul ar. Most o f
th e fibers of t he t ibialis posterior insert into the accessory ossifica ti on center rather than t o t he na vicula r; this
weakens the tendons action s and causes stress o n t h e sy nc hond rosis. Type lll nav icul are is a fused accessory
ossification producing a co rnuate navic ular. (Bottom) Minimal amount o f fluid within t he tibia lis poste ri o r te nd o n,
VII is normal & shou ld n ot be misinterpre ted as d isease.
82
 TENDONS OVERVIEW
SAGITTAL T1 MR, RIGHT ANKLE: TI BIALIS POSTERIOR TENDON

[j_

M edia l ma lleolus

Tibialis an terior tendon Tibial is posterior

tendo n

Navicular tuberosi t y

Distal sl i p of tibia lis

posterior ten don
1st cuneiform

Medial malleolus
Ta lar h ead

Tibi alis an terior tendon

Tibiali s posterior
tendon

Navicular tuberosi t y

Distal sl ip of ti b ialis
Lst cu n eiform posterior ten don

(Top) The tibialis posterior tendon is optima ll y assessed o n axial images. The d istal in se rt io n o f t he tendon, h owever,
is o ften better assessed on sagittal images. The synovial sheath of the tendon terminates 1-2 em above th e navic ular
in se rtion. The refore, fl uid at t he n avicular insertion o f th e t endo n is pat ho logic. Sagittal im ages often depict t h e
mo re di stal sli ps o f the tibia lis pos terior tend o n. Incidenta ll y no ted is th e ti b ia li s an terior tendon cou rsing toward its
1st cune iform, 1st m etatarsal insertion. (Bottom) A d ista l slip of th e tibia lis poste rior te ndon to the c uneiform is
noted.
VII
83
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: FLEXOR HALLUCIS LONGUS TENDON

Tibia

Fibula

Flexor hallucis longus

muscle
Two flexor h al lucis
longus tendon sli ps

Tibia

Fibula

Flexor hallucis longus

muscle
Two flexor ha llucis
longus tendon sl ips

(Top) The flexo r hallucis longus tendon descends down th e dista l leg with in the posterior aspect of its muscle. ot
infrequen tl y the tendon is for med by two major tendon slips wh ich usua ll y merge in to a single tendon above the
a nkl e joint but sometimes remain separate quite fa r d ista ll y. Th e secondary irregu la rity & he te rogeneity of the
tendon sh ould no t be misinterpreted for d isease. (Bottom) Note h e terogeneity of the flexor hallucis longus te ndon as
the two tendon slips m erge to form one tendon. Note also the poste ri or posi tion of the tendo n relative to the m uscle.

VII
84
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: FLEXOR HALLUCIS LONGUS TENDON

Ti bia

Fibul a

Flexor ret-in acu lum

Posterior tibial nerve

Flexor hallucis longus

tendon

Talar body

Groove for flexor Medial ma lleolus

hallucis longus tendon

Fibula Flexor ret inaculum

Talar med ial tubercle

Flexor hall ucis longus

Ta lar lateral tubercle tendon

(Top) T h e flexor h alluci s lo ngus tendo n descends with i n the ta rsa l t unnel, deep to t he fl exor reti nacu lu m . The
posterior t ibial n erve is typica ll y m edi al t o the tendon. o te that the fl exor hallucis longus m uscle is the on ly muscle
o f the deep fl exor com pa rtment that extends quite fa r distall y into the ankle area. (Bottom) The flexor ha llucis
longus tendon traverses two majo r tunnels i n th e ankle and hi ndfoot. The t unnel is betwee n t h e medial and la teral
tubercles of t he talus. A fibrous band con ve rts t he groove i nto a tunne l.

VII
85
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: FLEXOR HALLUCIS LONGUS TENDON

Ta lu s

Tibi al is poster ior

ten don

Fi bul a Flexor retinacu l um

Fl exor digitorum
lon gus ten don
Calcaneu s
Flexor hal l ucis lon gu s
ten don

Ta lar articular surface avicul ar tuberosi ty

Tibi al is pos teri or

tendo n

Flexor cl igi torum

lon gus ten don

Cuboid
Flexor hal l ucis lon gus
ten don

(Top) Th e t u nn e l t h e flexor hall ucis lon gus tra verses in th e a n kle a nd hin d foot is u nde rn ea t h the sustenta culum ta li
o f th e calcaneus. A fib ro us ba n d converts th is groove int o a tu nnel. The flexor h allucis lon gus te n do n is predi sposed
to tea ring at t h e tal a r and sustentacular tali tunnels. (Bottom ) As t he flexo r h all uc is lo ngus te n don t ra ve ls in to th e
p la ntar foot it takes an oblique cou rse toward its m ed ial insert ion in to t he p lanta r base o f the l st d istal toe (it
tra verses a t hi rd t un ne l in be tween the sesam o id bo nes of t h e digit). Plantar to the navicular tube rosity the tend o n
first approach es a n d the n c ro sses the flexo r digito ru m lo ngus te n don as th e latte r takes a n obliq ue la te ral co urse
toward its dista l inse rtio n sit es.
VII
86
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: FLEXOR HALLUCIS LONG US TENDON

Navicular

posterior
Cuboid tendon sl i ps

Flexor digitorum
longus tendon

Flexor ha llucis lo ngus

tendo n

Flexor hallucis lon gus

tendon
Cuboid
f'l exor digitoru m
tendon

(Top) As th e fl exor hal lucis longus tendon crosses th e flexor digi torum longus tendon, (under the navicular
tuberosity, at the knot o f llen ry}, i t sends a fibrous sli p to the latter tendon. This slip prevents the flexo r h allucis
longus tend on from significa nt proxima l retraction if it tea rs distal to th e kn ot of Henry. (Bottom) Followi ng the
cross over, the flexor hal lucis longus tend on is noted superior and medial to th e flexor digi torum longus tendon.

VII
87
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: FLEXOR HALLUCIS LONGUS TENDON

ledia l mall eolus

Flexor longus
tendon

Ankle join t

Fluid in flexo r hallucis

longu s tendon shea th

Knot of l len ry

Fluid in flexor hallucis

longus tendon shea th

(Top) Communica ti o n between t he flexor h allucis lo ngus tendo n & ankle joint is present in 20-30(}(, of indi viduals.
Thu s, fluid in th e flexo r hallucis lo ngus tendon sheath, in th e settin g o f ankle joint flu id, is a freq uent finding not to
be misinterpreted as tenosynovitis. However, iso lated flu id i n the tend on sh ea t h without ankle join t fluid is usually
patho logi c. Foca l fluid column proximal to the flexor ha ll uci s lon gus te n don's tu n nels is also su p icio us for disease .
(Bottom) Fluid w i t h in the flexor ha llucis lo ngus tendon sh eat h m ay ext end q u ite far distally in to the knot of llenry.
This is ty p icall y a ben ig n fi nding and of no cl inica l sig n i fi ca nce. Isolated fluid in th is area, however, witho ut fluid
proxima l to it, may indicat e tenosynoviti s. The med ial plan tar n erve follows t h e flexor h allu cis longus ten don and
VII ma y be impinged u pon by the fluid.
88
 TENDONS OVERVIEW
SAGITTAL T1 MR, ANKLE: FLEXOR HALLUCIS LONGU S TENDON

[I1
Ti bia

Flexor ha llucis lo ngus

tendo n

Sustentaculum tali,
calcaneus

[[
Tibia

Flexor hal lucis lon gus

tendon

Ta lus Tibialis posteri or

neu rovascular bund le

tali,
calca neus
Medial plantar nerve

Flexor d igi torum

lon gus tendon

(Top) The flexor hallucis longus tendo n is frequentl y seen on sagittal images o f th e ankle as i t descends under th e
sustentaculum tali. Detecting pathology o f t h e tendon, however, is m ore optim ally perfo rm ed on ax ial images.
(Bo ttom) ote that the di tal flexor digitoru m longus te ndon is typicall y seen on the sam e sagi ttal image in whi ch
the flexor h al lucis lo ngus tendon i s n oted to descend under the sustentacul um tal i. This is due to t h e crossing over of
the tendons in th e knot o f Henry, under th e n avicular t uberosity. ot e also t he medial plantar nerve's prox imity to
th e flexor h allucis longus tendon .
VII
89
 T ENDONS OVERVIEW
SAGITTAL & AXIAL T1 MR, RIGHT ANKLE: FLEXOR HALLUCIS LONGUS TENDON

IJ
Tibi<l

Flexor halluci s longus

muscle & tendon

Talus

M edial tala r tubercle

Flexor hallucis longus

Latera l talar tubercle tendon

Low lying flexor

hallu cis longus muscle

(Top) Note th e distal extent o f the flexor h al lucis m uscle to below th e level of ankle joint. Occasi o nally, further
extension of the m uscle into the talar tunnel may be seen and ca n prod uce sym ptoma t ic en trapment of the muscle.
Care sho uld be taken no t to overca ll t h is, however, si n ce wi th ankle dorsifl ex ion the posterior m uscles ex ten d furth er
d istally th an in plantarflexi o n . (Bottom) Typica lly the muscle o f the flexor hallucis longus extends to the ankle joint
and is not seen at th e level o f t h e talar groove. In a low lying flexor h alluci s lo ngus m uscle, as in this patient, m uscle
t issue ex tends i nto the groove an d may produce sym pto ms.
VII
90
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: PERO NEAL TENDONS

Tibia

Fibu la

Peroneus tendon

Peroneus longus
tendon

Peroneus brevis muscle

Tibia

Fibula

Peroneus brevis tendon

Peroneus longus
tendon

Superior pe roneal
ret i nacu Iu m

Peroneus brevis muscle

Deep fascia of leg

(Top) The peron ea l tendons descend together i n t h e lateral compartment of the leg. In the dista l leg the peroneus
longus mu cle has becom e entirely tendinous wh i le both mu cle & tendon of t he peroneus brevis are v isualized.
o te that in the dista l leg th e peron eal tendon s are lateral rath er than posterior to the fibu la; this should n ot be
m isin terpreted as subluxation of t he tendon s. (Botto m ) As th e tendo ns approach t h e ankle they lie directly posterior
to the distal fibula. The pos terior su rface o f th e fibula becomes fl at or concave to fo rm a retromalleol ar groove
accom m od ating both ten dons. Th e pero neus brev is tendon is typi ca l ly crescentic in shape & is located an teromedia l
to the peroneus longus tendon. Th e superio r peronea l retinacu lum extends from t he d ista l fibula to ca lca neus & deep
leg fascia & maintains th e peronea l tendons w i thin t he retromalleolar groove. VII
91
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: PERONEAL TENDONS

Talus

Fibul a
Medial mal leolus

Flat retromal leolar

groove

Fibrocartilaginous ridge

Peroneus longus Peroneus brevis tendon

tendon

Superior peroneal
ret inaculum

Peroneus brevis muscle

Talus

Peroneus brevis tendon

Calca neu s
Peroneus lo ngus
ten don

Inferior peron eal

reli nacu lurn

(Top) Th e superi or peroneal retinaculum is a reinforcement of the leg aponeurosis. It i s seen as a low sig nal band
originatin g fro m the lateral distal f ibula, at the ret romalleolar groove, approxima tely 1 em above the fibula r tip. It
ca n be followed to its insert io n to th e deep fa scia of t he leg. Freq uently, a sm all , low signal, tri angular
fibroca rti lagino us or fi brous ridge is n o ted at or close to th e fibular origin of the reti naculum. This ridge deepens th e
retro m alleolar groove. (Bottom ) T he pero n eal tendons share a com mo n sh eath at th e retromalleolar groove. Along
the lateral calca n ea l wa ll the tendons & thei r sheath becom e separated by the inferior peroneal retina cu l um &
peronea l tubercl e (when present). The inferior pero neal retin aculum is visualized as a thin , low signa l structure,
VII enve lo ping & in between t h e peroneal tendons.
92
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: PERONEAL TENDONS

Talus

Ca lea n eofi bu Ia r

Ca lcaneus
tendo n

Superi or peroneal
retin acu lum

Ta l us Ei
Peron eus brevis tendon

Ca lcaneofibular
ligament
tendon

Superio r peroneal Calcaneus

retinacu lum

Cf op) The ca lca n eofibular ligament in serts o n the ca lca n eus deep to the peron eal tendons. The liga men t m ay be
visualized as a low signal stru cture in between th e calcan eus & the peroneal ten do ns. (Bottom) T he proximity of the
peroneal tendons to the ca lcan eo fibula r ligam ent ca n result in co nco mitant tearing of the com mon peroneal tendo n
sheath & calcaneofi bular liga men t du ring inversion inj uries. Thi s ca n produce reacti ve fluid wi thi n the peronea l
tendon sheath whi ch sh ould not be mi sinterpreted as tenosyn ovitis.

V II
93
 TENDONS OVERVIEW
AXIAL T1 MR, RI GHT ANKLE: PERONEAL TENDONS

Navicu lar

Cuboid

Peroneu s brevis tendo n

Peron eus longu s

tendon

Tibial is anterior tendo n

I st cunei form

C ubo id

Peroneus brevi tendon

Pero neus lon gus

tendon

(Top) T he perone us brevis tendon con tinu es toward its in se rtion o n the 5 th m eta tarsal base. The peron eus longus
tendon e nters th e cu boid tunn el, plantar to the cuboid and continues along th e sole of the foot toward its insertio n
o n 1st c une iform & 1st metatarsal base. (Bottom ) T h e dista l co urse of the p eron eu s lo ngus tendo n al o ng th e plantar
su rface of th e foot is best seen on short axis mi d foot images but may also be seen o n di stal axia l images of th e an kl e.
The tendo n is o fte n suboptim a lly seen on T1 WI d ue to m agic a n gle e ffect. Not e th e in sertion o f the tibia lis a nterior
tendon on th e 1st cuneiform.
VII
94
 TENDONS OVERVIEW
AXIAL T2 FS MR, RIGHT ANKLE: PERONEAL TENDONS

lst cunei for m

Cuboid

Pero neus lo ngus

tendon

Peroneus brevis tendon

!st cunei fo rm

Cubo id
Peroneus longus
tendon

5th metatarsa l

Peroneus brevis tendo n

Plan tar fasc ia

(Top) The course o f the peroneus lo ngu tendon along t he plantar surface of the foo t freq uently bette r see n o n
ax ial FS T2 we ight ed images due to the relative lack of th e magic a ngle effect. (Bottom) On a more distal ax ial image
th e pe ro n eus longu s te ndon continues deep to the 3rd compartme n t muscles. ate th e insertio n o f the peroneus
brevis tendon on the base of t he Sth metatarsal. The peroneus brevis a n d plantar fascia insert o nto the plantar base
of the 5th m etata rsa l while the peroneus te rtius tendo n inserts o n the dorsa l base o f the 5th metata rsal.

VII
95
 TENDONS OVERVIEW
AXIAL T2 FS MR, R IGHT A N KLE: PERONEAL TENDONS

1st meta tarsa l

Peroneus longus
tendon

5th me ta tarsal

lst metatarsal

Peroneus longus
tendo n

5th metatarsal

(Top) Note the stria tion of t he very d istal peron eus lo ngus tendo n. (Bottom) The peroneus lo ngus tendo n fa ns ou t at
its insertion to t he plan ta r base of t he 1st m eta tarsal. It is o ften heterogeneo us and stri ated at the inserti o n site.

VII
96
 TENDONS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: PERONEAL TENDONS

Talus

Fibula

Fibrocarl i lagi no us ridge

Peroneus brevis tendon
Peroneus brevis muscle
Superior peroneal
retinaculum

Peroneus longus
tendon

Talus

Fibula

Peroneus brevis tendon

Peroneus longus
tendon

Superior peroneal
retinaculum

(Top) Usua lly the peroneus brevis tendon is anteromcdial to th e peroneus longus ten don with in t he retromalleolar
groove. Occasionally, however, the peroneus brevis tendon is located medial to the peroneus longus tendon. In those
in tances, as the tendon d e cend dista lly, the peron eus brevis tendon may appear medially subl uxed relative to the
distal fibular tip (sec n ext i mage). Thi s is a normal finding wh ich should not be m isinterpreted for disease. (Bottom )
Note the pscudosubluxation of the peroneus brevi s tendon relati ve t o the dista l fibular tip. This is a n orma l fin ding.

VII
97
VII
98
 TENDONS OVERVIEW
SAGITTAL T1 MR, ANKLE: PERONEAL TENDONS

[I"

Fibula
Peroneus longus
tendon

brevb tendon

5th metatarsal

[[

Ca lcaneus

tendon
C uboid

(Top) The peroneal tendons are opti m ally assessed o n axial images but m ay be followed o n sagittal images as they
proceed toward their insertion si tes. T h e peroneus brevis tendon is predisposed to fri ction and tearing as it descends
within t h e fibular retro m alleolar groove. (Bottom) The peroneus lon gus ten don traverses with in th ree fi bro-osseous
tunn els. It fi rst shares the retromalleo lar groove w ith the pero neus brevis tendon. It the n descends along t h e latera l
wa ll o f the ca lcaneus, w here it ca n undergo fri ct ion posterior to the peroneal tubercle. Its fi nal tunnel i s plan tar to
the cuboid with in the cubo id tunnel. In th is image the peron eus lo ngus t endon descends along the latera l wall of the
ca lcaneus approaching its cuboid tunn el.
VII
99
 TENDONS OVERVIEW
SAGITTAL T1 MR, ANKLE: P ERONEA L TENDO NS

IJ

Calcaneus

Cuboid

Peroneu s lon gus

te ndon

IJ

C uboi d Long plan ta r ligament

Peroneus lon gus

ten don

(Top) In t his im age, t he peron eus longus is seen starting to curve under the p lan tar su rface o f the cubo id to en ter the
cu boid tunnel. (Botto m) Th e pero neus longus tendo n has now en tered the tunnel u nder the cubo id . The tendo n is
held in place by a stro ng fib rous ba nd derived from the lo ng plantar liga ment. Seq uen tia l sagittal im ages allow
visualizatio n of t he peroneus longus tendo n as it obliquely crosses the so le o f the fo ot. The tendon is typically seen
in cross sectio n as a sm all linea r, low sign al structure d eep to the plan ta r m uscles.

VII
100
 TENDONS OVERVIEW
SAGITTAL T1 MR, ANKLE: PERONEAL TENDONS,

[[

Peroneus longus
tendon

Calcaneus

Peroneus longus
tendon

(To p) The perone us lo ngus tendon is seen o blique ly trave rsing the plantar surface o f the sole towa rd its inse rtion.
(Bottom) The pe roneus longus tendon is n ow und er the 2 nd m etatarsa l base. The inserti on to the metatarsal is n ot
always well see n o n T LWI due to striatio n and magi c angle effect.

VII
101
 LIGAMENTS OVERVIEW
o Su perficial subd iv id ed i nto anterio r t ibiota lar
Jlmaging Anatomy
posterio r ti biotalar, tibi o na vicular,
Overview tibiocalcaneal
• Imaging recom m enda ti o n s o Deep subdivided into anterior tibio talar, posterior
o Foot mildly pl an ta r flexed: Decreases magic an gle tibiotalar
effect, v isualizes calcaneo fi bu lar ligament o Deep tibi otalar often striated
o Ro utine Tl or PO, T2 FS axials o Superficia l com ponents o rigi nate from medial
o T2WI FS o r GE coronals ma lleolu s as co ntinuo us band, d i fferen tiation based
o T I W I & STIR sagittaIs on insertion sites
o Ax ials o ptimal for detecting syndesm o tic, lateral o Ti biospring ba nd co n t inuo us with Stlpero med ial
collateral, deltoid, spri ng ligamen ts, suboptim al for com ponent of spring l iga men t
si nus tarsi liga m en ts o Compo nents hig h l igh ted by fat
o Sagittals op timal fo r sinus tarsi ligaments, • Tarsal ca na l & si n u s ta rsi ligaments
i nferoplantar component of spring, plantar, o Limit talocalcanea l mo ti o n
bifurcate; subo ptimal for syndesmoti c ligaments, o Cervica l ligam ent: Most an ter io r l igament, obli que
lateral co llatera l ligaments, d eltoid co urse, cal can ea l o rigi n med ial to exten sor
o Corona l images useful fo r all ligam ents, o ptimal fo r digito rum b revis, ascends u pward, medially &
ca lca neo fibular l igament & supero media l anteriorly to in ferolatera l talar n eck; w h o le ligament
component of spri n g ligament o ptimally visualized o n coro na l images; porti o n s
• Syndesmotic tib iofibular compl ex seen o n consecutive sagittal, axial images;
o Bind th e fibro us d i stal tibiofibu lar joint i ntermediate signa l
o Com posed o f 1) anterior tibiofibu lar, 2) posterio r o Tal ocalcan ea l interosseous l igament : Most med ial
t ibio fibula r, 3) in fe rio r transverse, 4) i nterosseous & posterio r ligament, o bliqu e co urse, calca neal
t ibiofibular origi n an terior to posterior subtalar join t; ascen ds
o Optim ally vi sua lized o n axial , coro nal MR im ages; superiorly, medi ally to medial talar su lcus,
i n termedia te to low in signal in termedi ate to low signal
o Anteri o r, posterior tibi o fib u lar: May be o Roots, i nferi or ex ten sor retinac u l um : Med ial: M os t
heterogeneous d ue to fa t between fascicl es; o blique posterior, calcaneal insertion anteri or to
course, ex ten d to level of ta lar dome tal ocalcan eal i nterosseous ligamen t; interm ed iate:
o Inferio r tran sverse: Thick, h eterogen eous signal; Ca lca neal insertion pos teri o r to ce rvica l l igamen t;
band- like, ex tends distal to ti bial posteri o r surface; latera l : Calcanea l insertio n latera l to extensor
ti bial inserti o n alm ost at med ial malleolus digitorum brevis muscle
o Posteri o r tibi ofibu lar l iga ment ma y simu late an • Spring ligamen t
intra-a rticular body on 'sagi ttal images o Binds ca lcaneus to navicular, su pports tala r head &
• Lateral colla tera l ligaments medial longi tud inal arch
o Bind talus & ca lca n eus to fibula o Superomedial , m edioplantar obl iq ue, inferoplantar
o Composed of 1) anterior ta lofibular ligament, 2) lo ngitud inal com pon ents
posteri o r talofi bular ligam ent 3) ca lcaneofibular o Su perom edi a l : St rongest, hammock sha ped; o rigin :
ligamen t Susten tacul um tali & t ibia p ring band of del to id;
o An terio r talofibular & posterio r tal o fibul ar l igaments i nsert io n: Su pero m ed ial navicular; o pti mally seen
o ptimally v isualized o n axial i mages o n coron als, ax ials, latera l to ti bial is posterior
o Posterio r talo fibu lar, ca lcaneo fibular well seen o n tendo n , h ugs talar h ead
co ro n al images o Medioplan tar obl i q u e: Origin : oronoid fossa;
o Ligamen ts refl ect thi ckenin g o f the capsule; insertion : Plantar to navicu lar t uberos ity, latera l to
th ere fo re d elineated by jo i nt fl uid o n flu id sen si t ive ti bia l is posterio r tendon; bes t seen on ax ials;
images stria ted, obl ique course
o Highlighted by fat, o bliteration o f fa t indica ti ve o f o ln feropl antar lo n gitudinal : Orig in: Coronoid fossa;
di sease i nserti o n: Navicula r beak; op ti ma lly seen on ax ia ls,
o Insert o n fibula at m alleolar fossa sagitta Is; short, straight course
o Talus is oblong shaped .at level o f latera l co llateral • Bifurca te ligament origin : Calca nea l anterior process;
I iga men ts insertion v ia two li mbs to navicular & cubo id· thin
o Posteri o r talo fi bu lar ligament ma y simulate an best seen o n sagittal images lateral to
i ntra-articular body on sagittal images lon gitudinal component of spring ligamen t
o Posterio r talo fibular ligament is fan sh aped & • Sh o r t & lo n g p l antar l igaments
striated at its insertion to fibul a: Heterogenei ty o Bind calcan eus & cuboid, support longitudinal arch;
should n o t be mi sinterpreted fo r a tear best seen o n sagitt aIs & axials
o An terior talofibular ligamen t shoul d be straigh t, o Sh ort p lantar ligament (plantar calca neocuboid):
w ith a m ooth undersurface Origi n : Ca lcaneal anteri or tubercle; inser tion:
o Ca lcaneo fibular ligamen t is usuall y seen on axial Cubo id; very striated, med ial, short
images per fo rm ed in mil d plantar flex io n o Long p l an tar ligamen t: Superfi cial to short plantar
• Deltoid l iga m en t liga men t : Ori gin: At & anterior to medial, lateral,
o Subdivided into superficia l & deep band s, man y an teri or tubercles; insert ion: uboid, bases 2nd-5th
va ri al io n s metata rsals; striated

VII
102
VII
103
 LIGAMENTS OVERVIEW
AXIAL T1 AND T2 FS MR, RIGHT ANKLE: TIBIOFIBULAR SYNDESMOTIC LIGAMENTS

IJ
T ibia
Tib io fibular i nterosseous
m embrane

Fibula

Tibia
T ibio fibular i n terosseou s ligam ent

Fibula

A n kl e joi n t recess extendi ng i n to

t i biofibu la r jo int
Ti bia
Fi bula

Tibio fibular i nt erosseou s ligamen t

(Top) The tibio fibular interosseous me m b rane. Th e m e m bran e is typicall y visua lized as a we ll de fined , low signa l
structure, b inding the tibia & fibula. just above t he a nkl e jo in t, the m emb ra n e becom es less defi ned and may even be
discontinuous. (M iddle) T h e tibiofibular interosseo us liga m ent. Th e ligament is a di sta l thi cke ning of the tibiofibular
m em bra n e. Occasional ly, it ma y be vis ua lized as a d istinct st ructure as in th is image, bu t ofte n it may be poo rl y
defined, d iscon tinu ous, a n d even absen t. (Bottom) A fluid fill ed recess, measuri ng between 0.5-1.0 em extends fro m
th e a nkl e join t in to the tibiofibular fibrous jo int. The tibiofi bu lar liga m ent is frequentl y present at the superior
m argin of th e recess. In this partic ular case it extends posterior to the recess.
VII
104
 LIGAMENTS OVERVIEW
AXIAL T1 MR, RIGHT ANKLE: TIBIOFIBULAR SYNDESMOTIC LIGAMENTS

Anterior tibiofibula r l igament Tibia

Fibula

Posterior tibiofibular ligament

T ibiotalar articu lar su rface

An terior tibiofibulm ligament M edial malleolus

Fibula In ferior transverse I igamen t

Posterior ma lleol us

Posterior tibiofibular ligament

Talar dome (body)

Ante ri or tibiofibular l igament Media l malleolus

Fibula
Inferior tramverse ligament

(Top ) The an terior and posterior t ib iofibular ligamen ts above th e ankle join t. T h e ligaments are optimal ly seen on
axial images. The anterior t ibiofibular l iga ment i s often heterogeneous and may appear discontinuous due to fat i n )>
between its fascicles. (Middl e) An terior and posterior tibiofibu lar l igaments at the ankle join t. The ligaments are ::;,
visualized at, or sligh t ly below, the ankle joint. Note that at t h is level, th e fibula is round w i thou t t he more d istal '7\
medial indentation of the m all eola r fossa. (Bottom) Th e an teri or and posterior t ibiofibu lar l igaments at t h e tala r I'D
dome (talus is squa re at th is level). Th e ve ry infer ior aspect of the anterior t i b iofibu lar ligament has been coined
Bassett ligament. T he in fe rior transve rse l igamen t is co n t inuous wi th th e posterior tibiofibular ligament but extends
distal to the posterior tibial articular surface. VII
1OS
 LI GAMENTS OVERVIEW
AX IAL T2 FS M R & CORONAL T1 MR: TIBIOFIBULAR SYNDESMOTIC LIGAMENTS

Tatar body
M edi al m alleolus
Anterior tibiofibular ligament

In fe rior transverse ligam ent

Fibu la

Tibiofibular interosseous
m embra ne
Tibia
Posterior tibiofibular ligament

Fibula
Ma lleolar fossa

Calca neus

T ibi ofibular in terosseous

m em brane

Tibia Posterior t i biofibular l igamen t

Fibul a

Ta tar os trigonum

Calcaneofibular ligament
Malleolar fossa

Ca lcan eus

(Top) Axia l T2 FS image of t he right ante rior t ibiofibula r li game nts at t he ta lar d o me. Not e th e sq ua re sh ape of the
talus and t he round sh ape of the fibula. Because of the oblique descent of the anterior tibiofibular ligam e nt it ma y
appear d isco ntin uous at its fibula r insertion as is seen in thi s image. T h is sh o uld no t be misinterpreted as a tea r.
(Midd le) Coronal Tl of the left ankl e shows the poste rio r t ibiofibu lar ligament. Th e down wa rd ob lique course o f th e
ligament is best a ppreciated on corona l im ages. The ligame nt descends from its superio r positio n o n t he tibia towa rd
its more inferio r fibular inse rti on. Note that the ligament inserts on th e fibula above the malleolar fossa . (Bottom)
Co rona l Tl of the left ankle shows the poste rior tibiofibular ligame n t. Th e striation of the li gament is du e to fat
VII interposed betwee n its fascicles and sho u ld n ot be misinte rpre ted as a tear o n axial images .
106
 LIGAMENTS OVERVIEW
CORONAL T2 FS MR, LEFT ANKLE: TIBIOFIBULAR SYNDESMOTIC LIGAMENTS

Posterior tibiofibular
ligament
Tibi a
Fibula

Inferio r transverse
ligam ent

Malleolar fos a

Talus
Posterior talofibular
l igament

Ca lca neus

Posterior tibiofibular
Tihia l igament

Fibula

In termalleola r I iga men t

Talus Mall eolar fossa

Posterio r talo fi bu lar

ligam en t

Calcan eus

(Top) Posterior tibio fibu lar ligam ent on coronal flu id weighted fat su ppressed image. ote t hat the inferior tran sverse
ligament extends dista l to t he posterior ti b ia, formin g a posterior l ab ru m & deepening the posterior ankle joint. Its
ti bial i n ser tion is quite far m ed ial, almost to th e level of t he m edial m alleolus. The tibiofib u lar ligaments insert o n to
the fibula above t h e m alleolar fossa wh il e th e talo fibu lar l igam ents i nsert below it. (Bottom ) Th e intermalleolar
ligamen t on coronal fluid weighted fat su ppressed i mage. T he i nterma lleolar liga ment, also called t he tibia l slip, is a
norma l variant wh ich extend s from th e posterior talofibular liga men t almost to th e ti bia l medial ma lleolus. This
ligament is fou nd between th e i nferior tra nsverse and po steri or talofibular ligamen ts. It m ay be difficult to
distinguish it from th e in ferior transverse ligament. VII
107
 LIGAMENTS OVERVIEW
SAGITTAL T1 & STIR MR, ANKLE: TIBIOFIBULAR SYNDESMOTIC LIGAMENTS

IJ Tib ia Posteri or ti biofi bu lar l igamen t

Ta l us

Ca lcaneus
Bi furcate l iga m en t
Long plantar ligam en t
Cuboid

)] Ti bi a
I nferior transverse l igament

Tal us
Latera l tubercle of the ta l us

Short plan tar l igamen t

Cuboid Long p lan tar liga m en t

IJ Tibi a

I nferior t ra n sverse li gamen t

Tal us

Ca lcaneus

(Top) Tl weighted sagit ta l image de m o nst rates the inferior extent of t he tibiofibula r ligame nt d istal to th e tibia l
poste rio r surface. The sagittal images are suboptimal fo r visualizing t he tib io fibular and t alo fibula r ligaments.
(Middle) On sagittal images the tibi o fibular and ta lofibular li gaments are typically seen in cross section as sm all low
signal in te n sity ova l stru ctures, poste rio r to the talus, a nd sho uld not be misinte rpreted as intra-artic ula r bodies.
Fo llowing t he ligam e nts o n seq uential images will obviate this proble m . Note tha t the posteri o r talofibu lar ligame nt
is ba re ly visuali zed as it origina tes from th e lateral tube rcle o f the talus. (Bottom) Sagittal STIR image de picts the
infe ri o r tra n sverse liga m ent sur rounded by fl uid, simulating an intra-ar ticular body.
VII
108
 LIGAMENTS OVERVIEW
SAGITTAL & AXIAL T1 MR, RIGHT ANKLE: TIBIOFIBULAR SYNDESMOTIC LIGAMENTS

T ibia

An terior tibiofibular
ligam en t

Fibula Posterior talo fibu lar

l igam en t

Calcaneofibu lar
l iga men t

Calcaneus

Pero neus lo ngus t.

M edial m all eo lus

Ti bia

Anterio r ti bio fi bu lar

l iga m en t

Posterio r tib iofi bu lar

l igam en t

(Top) A far la te ra l sagittal T1 WI a llo ws a glimpse o f t he ante rio r t ibio fibul a r li gam ent t rave rsing betwee n th e tibia
a nd fib ula . No t e th e striati o n o f th e liga m e nt. The calcaneofibul a r liga m e nt is a lso visualized . (Bottom ) Norm a l
stri at ion o f t he a nte rio r tib iofibul a r li ga m ent o n axia l TlWI. Beca use of th e ob liq ue desce nt o f th e a nte rior
tibiofibula r ligam e nt a nd th e fa t inte rposed between its fascicles it m ay appear di scontin uous. This sh o uld n ot be
mi sin te rpreted as a tea r.

VII
109
 LIGAMENTS OVERVIEW
CORONAL T2 FS MR LEFT ANKLE & AXIAL T2 RIGHT ANKLE: LATERAL COLLATERAL LIGAMENTS

An kl e joint ex tending to
tibio fibular joint Posterior tibiofibular ligam ent

Tibia I n ferior tran sver5e ligamen t

Fibula

Fibu lar malleolar fossa

Tal us
Posterior talofib,ular l iga m en t

Calcan eofibular ligament

Calcan eu5

An kle joint recess extending to

Tibia dista l tibio fibular join t

Fi bula

Fibular mall eolar fossa

Ta l us
Posterior talofi bu lar l igamen t

Cal ca n eo fibu lar ligament

Calcaneus

Ant eri or ta lofi bular l igamen t

Talus

Fibula

Posterior talofibul ar ligam en t

(Top) Coron a l fat su ppressed image o f the la te ra l colla teral liga ments. T h e posterior tal o fi bu la r, ca lcaneofibular &,
less freque n tl y, an teri or talofi bu la r ligamen ts a re we ll seen on coro na l images. T h e fib ula r o rigin o f the poste ri o r
talofib ular li ga me n t is at th e level of th e ma lleola r fossa. No te a n ormal an kle joi nt recess extending in to th e distal
tibi o fibul a r jo in t . (Middle} Slightly m o re a n terio r co ron a l fat s u p pressed image. The posteri o r tal o fi bu lar liga me n t is
v is ualized as a d ist in ct st ructure fro m the poste ri o r t ibio fi b ula r liga m ent. (Bottom) La te ral collatera l ligaments on T2
ax ia l image. T he liga m ents are o pti ma ll y seen o n ax ia l images. Since these liga me n ts are thic kening of the capsule,
they a re highlighted by fl uid. N ote th e fa n s haped & stria ted inserti o n o f th e posterior ta lofibular liga men t wh ich
VII s h o ul d no t to be mistake n fo r a tear.
110
 LIGAMENTS OVERVIEW
SEQUENTIAL CORONAL T1 MR, LEFT ANKLE: LATERAL COLLATERAL LIGAMENT

Tibia Fibula

Posterior tibiofibular ligam ent

Posterior ani-le joint recess

Os trigonu m, talus
Peroneus brevis tendon
Peroneus longus tendon
Ca lcaneofibular ligament
Calcaneus

In terosseous ligament

Fibula
Tibia

Posterior tibiofi bular Iiga men t

In ferior transve rse ligamen t Fibular malleolar fossa

Ta lus Peroneus brev is tendon

Peroneus longus tendon
Calcaneofibular ligamen t

Tibia
Fi bul a

Tibial insertion , inferior transverse Inferior transverse ligam en t

ligam ent
Ta l us Posterior tal ofibular ligament

Calcaneofibular ligament
Peroneus brevis tendon
Calcaneus Peroneus longus tendon

(Top) A posterior coronal T1 W I of th e calcaneal insertion o f th e calca n eofibula r ligament. The liga ment can be
followed on sequential coron al images from its fibular o rigi n to its calcanea l insert ion. Whil e the ligament is
occasio n ally seen on axia l images, its cross sectio n is co nsisten t ly vi sualized on corona l images. Note the fat
su rrounding the liga m ent; obliteratio n of thi s fa t is con sistent w i th d isease of t he ligament. (Middle) Ca lcaneofibular
ligam ent on a mo re anteri o r co ro nal T l W I. Note p roxi mi ty o f the l igamen t to pero neal t endons, w hich ca n be used
to loca te the ligame nt. A tear o f th e l igament may produ ce reacti ve flu id within th e common peroneal tendo n
sheath; this should n ot to be mistaken for peroneal tenosynoviti s. (Bottom ) I n a mo re anterior i mage, the o rigin o f
the ca lca n eofibular liga ment from th e fibula is visuali zed. VII
11 1
 LIGAMENTS OVERVIEW
AXIAL & SAGITTAL T1 MR, RIGHT ANKLE: LATERAL COLLATERAL LIGAMENTS

Supero medial, spri ng

ligament
Ta l us

Fi bular tip

Peron eu s brevis t .

Peroneus lo ngu s t. Calcaneu s

Calcan eol'ibul ar
ligament

jJ
Fibula

Calcaneofibu lar
ligamen t

Peron eu s brevis t.
Peroneu s lon gu s
tendon

(Top) Ca lcaneofibula r ligament on axial Tl W I. The calca neofibu lar liga me nt c hanges o rien tation with ankle
m oveme nts. In m ild plantar fl exion t he ligament beco mes c lose to ho rizontal in orientatio n and may be visua lized
on ax ial images as it hugs the calca n eus, deep to th e pe ro nea l te ndo n s. Its locatio n deep to th e pero neal te ndons is a
clue in locating this li gament. (Bottom) On far sagittal image the calcaneofibular ligament ma y be visua lized, due to
pa rti a l volume averaging, as a low sig nal sh aclow supe ri mposed o n the peron ea l te n dons. Note th at in this pa tie nt,
scan n ed in planta rfl exion, the ca lcaneofib ula r liga me nt is re latively h ori zo ntal. Mild plantar fl exion of the ankle a ids
in detecting th e ca lcan eofibula r ligament on ax ial images beca use of th is relatively horizon tal orientation.
VII
11 2
 LIGAMENTS OVERVIEW
SAGITTAL T1 MR: LATERAL COLLATERAL LIGAMENTS

[[
Fibula

Anterior ta lofibular li gament brevis tendon

Ca lcaneofibu lar li gam ent Peroneus longus tendon

Tibia Fibula
An terior ti biofibu lar ligament
Peroneus brevis muscle

Posterior talofi bular ligament

Calcancofibular ligam ent

Ca lca neus

Peroneus longus tendon

Tibia
Fibu la

Medial ca lcaneocuboid, bifu rca te Calcaneofibular ligamen t

l igam ent

Ca lca neus

(Top) Sequential sagittal T l weighted i m ages o f the calca neo fibular ligament, lateral to med ia l. Occasio nal ly the
ligam en t may be v isual ized on sequential sagittal images f rom i ts fibu lar or igi n to its posterio r ca lcanea l insertion.
(M iddle) T h e ca lcaneofibu lar liga m ent is now visualized as it is trave rsin g the regio n ben ea t h the peroneal tendo ns
(pero n ea ls not well seen i n this im age). Note also the triated posterio r talo fi bu lar ligament beh i nd t he fi bula.
(Bo tto m ) Sagi ttal T l W I of th e ca lca n eo fi bul ar l iga men t. The calcan eofibular ligame nt is now seen in cross seclion as
it inserts o n to the ca lca neus.

VII
113
VII
114
 LIGAMENTS OVERVIEW
AXIAL T1 MR, LEFT ANKLE: DELTOID LIGAMENT

Anterior tibio talar,

libionavicu lar,
superficial del toi d

Medi al m all eolus

Anterior tibio fibul ar

ligament
Posterior m all eolus

Fibu la

Posteri or ti bio fibul ar

liga m en t

An terior tibio talar,

tibiona vicu lar,
superficial delto id

I ibiospring, Tala r dom e (body)

tibiocalca nea l
superficia l deltoid

Medial m all eolus

Anterior tibiofibul ar
li gam ent

Posterior malleo lus Inferior tra nsverse

l iga m ent

Fihula

Pm terior ti bio fi bular

liga ment

(Top) Origin of the superfi cial delto id ligament o n axia l T1 W I. The superficia l deltoid l igament o riginates from
anterior & posterio r coll iculi o f medial malleol us as a si ngle contiguo us ban d. Th e band 's va rio us compo n ents
in cluding the ti bio navicu lar, anterio r & posteri o r tibi o talar, ti biospring & ti biocalcan eal have no fat plan es bet ween
th em & are differen tiated from each other main ly based o n t h eir relative origin & insert ion si tes. T he su perficia l
ti bionavicu lar and anteri o r ti biotalar liga men ts origi nate toge the r from the anterio r co lli cu l us. Thei r relative
posi tio ns to each o ther is va ri able, t herefore distin cti o n bet wee n t hem on ax ial i mages is difficult. (Bottom) An axia l
T l W I located slig htly more distally depicting the very orig in o f the tibiocalcan eal an d tib iosp ring ligaments of the
deltoid. VII
115
 LIGAMENTS OVERVIEW
AXIAL T2 MR, LEFT ANKLE: DELTOID LIGAMENT

Ante rior tibiota lar,

tibionavicu lar, An terior tibi o talar,
superficia l d el toid deep de l toid

Tibiospri n g,
ti biocalcaneal,
superficia l deltoi d Talar dome (body)

Ti bial is posterior t.

Posterior tibiotala r, Poster ior talo fibular

deep del toid ligamen t

Pl exor retin aculum

Fibula

Superior peroneal
ret i naculum

Anterior tibiota lar,

tibionavi cular,
superfici al d eltoid
Talus
Ti biospring,
ti biocalcan eal
superficial cleltoicl
Posterior tal o fibular
Tibial is posterior t . ligame n t

Anteri or talo fibul ar

Flexor ret inacul u m li ga m en t

Fi bula

Superior pero neal

reti nacu I u m

(Top) An axia l T2Wl at level o f talar dome depicts the origin o f th e tibiocalcaneal and tibiospring ligam ents of the
delto id. Note th e striation of th e deep tibiota la r delto id . Note a lso the proxi mity of the tibia lis posterior tendon to
th e deltoid. Fluid in t h e te ndon sheath o f the tibia lis pos te rior te nd on may be seen fo llowi n g d eltoid inju ry a nd
sh ould n ot be mi sinterpreted as tenosy novitis. (Bottom) An ax ial T2WI Iocat ed slightl y more d istal ly d e picts the
origi n of the tibiocalca n ea l and t ibiospring ligame nts o f the deltoid. Both the tibiospri ng & tibi ocalcaneal in se rt on
the suste ntacul um t a li; the tibiospring (which a lso inserts o n the superomedial sprin g li gament) is an te rior to the
tibiocalca n ea l but n o fat plane is present between the m & th e division is almost a rbitrary.
VII
116
 LIGAMENTS OVERVIEW
SEQUENTIAL CORONAL T1 MR, RIGHT ANKLE: DELTOID LIGAMENT

Posterior collicu lus,

medial malleol us

Ta lar body Poste ri o r tibiotalar,

deep deltoid

Tibioca lca neal,

superficial deltoid

Sustentaculum tali,
calcaneus
Calcaneus

Posterior colliculus,
medial malleolus

Talus Posterior tibiotalar,

deep deltoid

Flexor retinaculum

Ti biocal canea l,
superfi cial delto id

Anteri or process,
calcaneus

Cuboid

(Top) A posterior T l W I of th e deltoid l igament depi cts the deep tibiotalar band and superficia l tibioca lca neal ba nd of
th e del toid. The deep tibio talar band of th e deltoid is typ ica lly identified o n corona l i mages as i t o riginates from th e
posterior colliculus of the med ial malleo lus. Its fascicles tend to be more horizo nta l and more striated than those of
the superfi ci al ba nd. Th e tibi ocalcaneal band is often seen superficial to th e deep ti biota lar deltoid on coron al
image . (Botto m) A more anterior coronal T l i mage still depicts the deep tibiotalar deltoid and tibiocalca neal ba nd
of th e superfi cia l deltoid ligament. T he di stincti on between th e sl ightly m ore anterior tibiospring and th e
tibi oca lcan ea l liga ments, however, is often arbi t rary.
VII
11 7
 LIGAMENTS OVERVIEW
SEQUENTIAL CORONAL T1 MR, RIGHT ANKLE: DELTOID LIGAMENT

Anterior tibiofibular Anterior col liculus,

li gament media l malleolu s

Anterior tibiota lar,

deep deltoid
Talar head
Tibiospri ng, superficial
Cervi cal ligament deltoid

Anterior process, Superom edia l spring

calca neus ligament
l:.x temor digitorum
brevis m.

C uboid

Tibia

Anterior
medial malleolus

Anterior tibiota lar,

deep deltoid

Lateral root, inferior Anterior tibiotalar,

extensor retinaculum superficial deltoid

Cervica l li gamen t Ta lar h ead

Extensor cligitorurn Navicular tuberosity

brevis muscle

Spri ng I iga men t

Anterior process,
ca lcaneus
Cuboid

(Top) Sl ightly mo re an teri o r i mage of the d elto id depicting th e tibiospring band. The bands of the superfi cia l deltoid
ligament arc often only arbitrarily distingui shed from each o th er on the co ron al images. While thi s image is ma rked
as ti biospring deltoid, it may reflect partial vol u me averaging with t he adjacent ban ds of t·hc su per ficial deltoid. Note
a glimpse o f th e stri ated anterior tibiofib ular ligament o rigina ti ng from the tibia. (Bottom ) Anterio r corona l image.
Because of th e obl iquity of the superficial tibi ota lar and tibionavicu lar ba n ds, th ey arc rare ly seen on corona l i mages .
The tibiota lar can occasion ally be identified as a far anterior low sign al band d escending from the anterior coll iculus
o f the medial malleolus.
VII
118
 LIGAMENTS OVERVIEW
SAGITTAL T1 M R: DELTOID LIGAMENT

posterior
ten don

Media l malleolus Pmterior tibio talar,

deep del toid

Anterior tibi o talar,

deep deltoid

avicular

Superomcclial \[)ring

Medial tubercle,

[[
1 ibia

Talar im ertion ,
posterior t ibiotala r,
Talus deep del toid

M ed ial tubercle,
Navicu lar
tali

(Top) An terior & posteri or tibi o tala r bands, d eep deltoid, on far medial sagi ttal image. T he anteri or & posterior
tibiota lar co mponents o ri ginate from th e anteri or & poste ri or collicu li of th e medial malleo lus & i n tercoll icular area
respecti ve ly. Bo th co mponents are striated. The an terio r ti biota lar may be sm all or absent. It is best seen on sagittal &
axia l im ages of the ankle. The posterior deep tibi o tal ar co mpo nent is con sistently seen on bo th ax ial & sagi ttal
images. (Bo ttom ) A m o re m edial sagittal im age depicts t h e talar i nserti on of the post erior tibi o talar band o f d eep
deltoid. Th e low signa l band sh oul d no t be co nfused w i th an osteochondral ta lar lesion.
V II
11 9
VII
120
 LIGAMENTS OVERVIEW
CO RONAL T1 , SAGITTAL T1 & SAGITTAL T2 FS M R: S IN US TARSI LIGAM ENTS
Posterior colliculus, m ed ial
ma ll eolus
Posterior tibio ta lar, deep
deltoid
Fibula
Flexor reti naculum

Tarsa l canal
Talus
Tib ioca lcaneal, superfi cia l
del toid

Talocalcaneal interosseous ligament

Su sten tacu lum tal i, calcaneus

Calca n eus

[[
Tibia

Talus

Tarsa l cana l I n ferior transverse ligament

PosteriOr subta lar joint
Medioplantar oblique, spring

Ta localcanea l in terosseous
C uboid ligament

Short plantar ligament Calcaneus

Tibia
Fibula

Lateral talus
Inferior ex tc ruor retinaculum

Posterior sub tala r joint recess Posterior subta lar joi n t

Bifurcate ligam ent

Calcaneus

Cubo id

(Top) Talocalcaneal interosseous l igament. The ligament t raverses t he tarsal ca nal an d ascends obliq uely & medially
to in ser t on the talar sulcus. The ligamen t i s best iden tified on coronal & sagi ttal i m ages as the m ost posterior &
medial of sinus tarsi ligaments. Its calca n eal i nsertion is just an terior to the posterior subtalar joi nt. (M iddl e) A
sagi ttal image depicts th e interosseous ligamen t a a ba n d ex ten d i ng from the talus to the calca neus, found anterior
to the posterior sub talar joi n t. T hi s l igamen t is ty p ically found on the most m edia l sagitta l images of the sin us ta rsi.
(Botto m ) Sinus tarsi fl uid often impli es acute or chronic disease. However, a fl u id filled recess m ay extend fro m the
posterior subtalar jo int into t he si n us tarsi. Th is should not be m isi nterpreted as pathology of the sinus tarsi.
VII
12 1
 LIGAMENTS OVERVIEW
CORONAL & SAGITTAL T1 MR, LEFT ANKLE: SINUS TARSI LIGAMENTS

Tibia

Ta lus

Posterior tibio talar,

deep deltoid

Superom ed ia l, spri ng

Cerv ical liga men t Calcaneu s

Extensor digi torum

m.

IJ Tibia

;..:--'"""""'=i-- I n term edi ate root,

inferior ex tensor
ret inaculu m

Cerv ica l liga m ent

M ed ioplantar obliq ue,

spri n g l igamen t

Cuboid

Short p lan tar ligamen t

(Top) Cerv ica l ligament o n coro na l T l W I. Til e ce rv ical ligament is the st rongest ligame nt co nnecti ng the talus to t he
calca n eus. It is also t h e most anteri o r ligament of the sinus tarsi. Its ca lcaneal o rigin is med ial to the origin o f the
extensor digito rum brevis m uscle. Th e l igament ascend s upwa rd, an terio rly and media lly to insert o n t h e i n ferior
aspect o f th e ta lar neck. The li gam ent becom es m o re horizon ta l in valgus and m ore ve rtica l i n varus positio n of t he
ca lca n eus. (Bottom) The cer vica l l igament on sagitta l T l W I. Th e l iga men t's anterior course fro m th e ca lcaneus to the
talus is better appreciated o n sagittal images. Note th e intermediate root o f the i nferior ex ten sor retinacu lu m located
immediately pos terior to th e cervica l l iga ment.
VII
122
 LIGAMENTS OVERVIEW
SAGITTAL T1 MR: SINUS TARSI LIGAMENTS

Ti bia

Inferio r extemor
retina culum
In termediate roo t,
inferior ex tensor
ret i n acul um
Extensor digitorum
brevis

Medial calca neocuboid,

Bifurcate ligam ent

Cuboid

Talus

Lateral root, inferior

extensor retinaculum

Ex tensor digitorum
brevis mu,cle

Cuboid

(Top) Roots o f ex tensor retinaculum. T h e interm ed iate root in serts into the calcaneus slightly posterior to the
ce rvi cnl ligame n t. The medial root has media l and lateral ca lcanea l i nsert ion s and o ne ta lar in sertion. The
interm ed iate and lateral componen t o f th e media l root may insert ve ry cl ose to each o th er o n the ca lcaneus bu t th e
latter is fo und closer to th e posterior subtalar joint. (Bo tto m ) Th e lateral root of the in ferior ex tensor reti naculum o n
sagit tal T l W I. The root inserts into th e ca lca neus lateral to the o rigin o f the extensor digi torum brevis muscle. It is
continuous with t he inferi o r peronea l retin aculu m and deep fascia. T h e ligament is fo und on very peri pheral sagi t ta l
images of the sinus tarsi.
VII
123
VII
124
 LIGAMENTS OVERVIEW
AXIAL T1 MR, RIGHT AN KLE: SPRING LIGAMENT

Talus

Supero m eclial spring liga m ent

Ca lca neofibular ligam ent
Tibialis posterior tendon
Peroneus b revis & longus t.
Flexor digi toru m lo ngus tendon
Pero neu 5 quartus muscle Sustentaculum tali
Calcaneu s
Flexor h allucis lo ngus tendon

Talus
Su peromedial spri n g ligamen t

Sin us tarsi
l'ibialis posterior tendon
Flexo r digi torum ten don

Sustentaculum tali
quart us m uscle
Flexor h allucis longus tendon
Ca lcaneus

avicu l;H beak

Navicular tuberosity
Ei
l nferopla n tar longi tudinal spring Tibialis posterior tendon
l igament
Flexo r cl igitorum tendon
M eclioplantar ob lique, spring
ligament
Flexor hallucis lon gus tendon

Calcaneus

(Top) Sequentia l ax ial T l W I of the superom edial spring ligament. Th e superomedial spring is seen on ax ial images as
it origi nates from th e sustentacul um tali and curves around the talar head toward its navicular insertion (latter n o t
seen). oti ce th e proximity of th e tibi al is pos terior ten don. (M iddle) A more distal axial Tl WI of th e superomed ial
spring ligamen t . (Botto m) A mo re d istal axial Tl WI. Th e m eclioplantar obl ique and infero pl antar longitudinal
components o f the spring ligamen t originate from the cal caneus at the coron oid fossa (between the sustentaculum
tali and ant eri or calcan eal process). The med iop lanta r oblique is co nsisten t ly seen as it inserts into th e plantar
navi cular, just lateral to navi cular tuberosity & t i bialis posteri or t endo n. The inferoplantar longitu dinal inserts on t h e
beak of the navicular. VII
125
 LIGAMENTS OVERVIEW
AXIAL T1 MR, LEFT ANKLE: SPRING LIGAMENT

avicular

Tibia lis
ten don

Mediopl an tar obl ique,

spring l igamen t

avicular bcah.
Navicul ar tuberos it y

l nferoplantar
Ti bia lis posterior longitudi na l,
ten don ligament
Medioplan tar obliq ue,
spring ligam en t

(Top) T h e m edio pl antar o bl iq ue com ponent o f th e spring ligam ent o n axial i mage. The l igament is freq uently
striated & is often rela ti vely thick. (Bottom) A mo re distal ax ial T I W I. o te th e n avicula r beak at the insert ion of t he
i nferoplantar com ponen t o f the spring ligament. Because o f the strai ght cou rse of t h e inferoplantar lo ngitudinal
co m ponent of the spring liga m en t, it is o ften seen o n ax ial and sagittal images.

VII
126
 LIGAMENTS OVERVIEW
SAGITTAL T1 MR: SPRING LIGAMENT

posterior l.
Posterior tibi otal ar, deep deltoid

An terior tibiolalar, deep deltoid

Navicula r tuberm ity Flexor cligitorurn longus t.

Tibia

Talus

avicular bea k Sustcn tilculum tal i

l nfcropl<tntar lon gitudinal, spring

ligament
Mcclial ca lcane<tl tubercle

T ibi a

Ta lus

Navicular beak

lnfcroplantar longitudinal, spring

ligament

(Top) rhe supero mcd ial component o f th e sprin g ligament is someti mes seen on a far medial image as a low signal
band supero m cdial to th e navicular tuberosity & lateral to the tibialis posterior tendon. (Middle) Th e i nfero plantar )>
lo ngitudin al band o f t he spring ligament. Because of i ts oblique cou rse th e medioplan ta r o blique compo nent of the ::J
spring l igament is diffi cult to identi fy o n routi ne sagitta l im ages and may been seen on cross seclion as an oval low ;:;-
signa l stru cture. Th e inferopla n tar lo ngi tudin al co mpo nent, however, becau se of i ts straig h t and short co urse is r'C
frequently seen o n sagittal images. Vi suali zation of the beak of th e navicu lar aids in iden tify i ng the ligamen t.
(Bott om) lnfero plantar lo n gitu di n al ligament. Th e ligament is a low signal band exten d i ng fro m t h e navicu lar bea k
to the co ron o id fossa o f the cal ca neus. VII
12 7
VII
128
 LIGAMENTS OVERVIEW
SAGITTAL & AXIAL T1 MR, LEFT ANKLE: BIFURCATE LIGAMENT

Talus

Lateral calcaneo navicu la r, bi furcate

Long plantar ligament

C uboid

Talus

Latera l root, i nferior ex tensor

reti naculum

Medial ca lca neocuboid, bifurcate

Cuboid

[I
C uboid
Late ra l calcaneonavicular
componen t, bifurca te ligament

Medial ca lcaneocuboid
com pon en t, bifurcate ligament
Tibionavicu lar, superficia l del toid
Anterior process, ca lcan eus

Tal u s Cerv ical ligament

(Top) The lateral calcaneona vicula r ligament o f the b ifurca te li game nt is best seen o n a sagittal image just lateral to
the origin of the inferop lantar longitudinal component o f the spring ligament. It is see n as a fi ne, curved, low signal
structure o riginating from th e anteri o r process o f the calca ne us. (Middle) The medial calcaneocuboid compo nent of
th e bifurcate ligament origin ates latera l to th e lateral calca neon avicu la r compo ne n t. It is often quite a delica te, low
signal intensit y structu re whi ch may be abse nt in so m e in d iv iduals. (Bottom) The bifurcate ligament is occasionally
seen on oblique axia l images of the h indfoot.

VII
129
 LIGAMENTS OVERVIEW
AXIAL T1 MR, LEFT ANKLE: LONG & SHORT PLANTAR LIGAMENTS

Cuboid

Sh ort plantar ligament

Peroneu s brevis t.
Anterio r calcaneal
tubercle
Peroneu s lon gus t.

Calcaneus

uboid

Peroneus brevis t.

Peroneus longus t.
Anterior ca lcaneal
tubercle

(Top) T he plantar ca lcaneocuboid liga men t i s subdiv ided i nto sho rt, deep, and lo ng superficial plantar liga ments.
The sho rt pla n tar ligam ent, also cal led the short p lantar calcaneocuboi d ligament is m ore m ed ial than th e lo ng
plantar liga ment. I t originates from the anterior tubercle o f th e calcaneus and i n se rts on th e en tire posterior plantar
surfa ce o f and o n bea k of cuboid. (Botto m) A more di sta l (p lan tar) axial i mage in the sa me pa tie nt. The lon g plan tar
l iga ment origi nates from the an terior tu bercle and mo re posteriorly fro m the an terior aspect and in tertubercular
segmen t of th e pos teri or ca lcanea l tuberosities. Its deeper fibers, representi ng the bul k o f l iga ment, insert to the
cubo id crest and its superficial fibers form a thinn er layer wh ich form s th e roof of t he cuboid tu nnel o f the pe roneus
VII longus tendon & in serts on th e 2nd-5th m etatarsa l ba ses.
130
 LIGAMENTS OVERVIEW
SAGITTAL T1 MR: LONG & SHORT PLANTAR LIGAMENTS

[[
lnferoplantar longitudinal, spri ng
li gament

""'-""'"·___:.= =-'---+- Calca n eus

avicular plan tar ligament

Lo ng plantar ligament

Cuboid

[[

C uboid

Lon g plan tar l igament

Tal us

Cuboid

Peroneus lo ngus t .

(Top) ote the proximity o f the p lantar componen t o f t h e spring ligam en t to the hort plantar ligament. The
inferoplantar longitudi nal ligam ent inserts i nto the beak o f the navicu lar. The short planta r ligamen t is found more
plantarly and i deeper than the lon g plantar ligament. I t inserts on the cuboid. (M iddle) A more la teral sagittal
image in the sa me patient. Note the marked striation of both t he sh ort and long plantar l igamen ts. (Bottom) A more
lateral sagittal im age in a different patient. The superficial fibers of the long plan tar l igament con ti n ue di tal to the
cuboid to insert o nto the bases o f 2n d-5th m eta ta rsa ls and th u s form the roof of the peron eus longus tunn el, under
the cubo id.
VII
131
 SECTION VIII: Foot

Foot
Foot Overview 2-63
Text 2-4
Graphics: Planta r muscles 5-8
Graph ics: Neurovascul ar 9-10
Graph ics: Liga me nts 11-1 5
Rad iogra ph s 16-1 7
Axial MR sequen ce 18-31
Coronal MR seq uence 32-55
Sagittal MR sequen ce 56-63
Intrinsic Muscles of the Foot 64-67
Text 64
Graphics: M uscle orig ins & insertions 65-66
MR: Muscles 67
Tarsometatarsal Joint 68-73
Text 68
Radiographs: Li sfranc joi nt 69
CT: Lisfra n c joint 70
Grap h ics: Lisfranc jo int 71
M R: Lisfra nc jo int 72-73
Metatarsophalangeal Joints 74-79
Text 74
Gra phics: Metatarsophalan geal jo in ts 75
Radiograph & MR: Metatarsophalangeal joints 76-79
Normal Variants 80-95
Tex t 80
Gra phics: Accesso ry ossificatio n ce nte rs 81
Grap hi cs & imaging accessory n avicul a r 82-8 7
M R: Cu boi des seconda rium 88
Images: Os peroneale 89
Images: Os vesalia num 90
Images: Os intermetata rseum 91
Images: Sesam oid va ri a nts 92-93
Oth er varia nts 94-95
 FOOT OVERVIEW
• Axis of tal us contin ues a lo n g axis o f 1st
ITerminology m eta tarsa l, or between 1st a n d 2 nd m etatarsa ls
Definitions • Midfoot a lign m e nt
• Three m a jor d iv isio ns o Lateral rad iograph
o Hindfoot: Calcaneus and talus • Inferio r margins of calcaneus, cuboid aligned if
• Hindfoot is discussed in An kle section weight-bearing
o Midfoot: Navicula r, cu ne iforms, and cuboid • Pitfall: Ca lcaneocu bo id joint usua ll y appears
o Forefoot: Metatarsa ls and pha langes subluxated on nonweight-bearing late ral
• Two colum ns radiograph
o Medial column: Ta lus, navicu la r, cune iforms 1-3, • C uneiforms overlap with eac h oth er
digits 1-3 • Latera l cu ne ifo rm overl aps with cu boid
o Lateral colum n: Calcaneus, cuboid, digits 4 and 5 o Anteroposteri or radiograph
• Som e a uth ors usc 2 columns in hind and midfoot as • Media l portion of navicu la r pro trudes medially
above, but divide forefoo t into 3 columns beyo nd m a rgins of tala r head and 1st cun e iform
o Med ial column: 1st toe • lst cun e ifo rm , talar head are aligned a t m edia l
o Middle colu m n: 2nd-4th toes ma rg in
o Late ra l col umn: Sth toe • lntercuneifo rm joints and cuneocuboid joints
ove rlap
• Forefoot alignment
o Late ral radi ograph
jlmaging Anatomy • 1st a nd 2nd m etatarsa l bases at dorsum of foot
Overview • Metatarsals 3-S prog ressively m o re plant"igrade
• Al ignme nt of foo t ca n on ly be assessed o n • All MTP joints at sa me pl a nta r positi on
weigh t-bea rin g radiograp h s • MTP joi nts slightl y dors i flexed; thi s is most
pro mine n t a t 1st MTP due to its hi gh e r in clination
Arches of Foot angle
• foot is arched from poste ri o r to ante ri o r, and from o Anteroposterior radiograph
med ia l t o late ral • 1st metata rsa l cente red on 1st cu neiform
• Transverse a rc h of foot • 2nd metatarsal medial ma rgin aligned to media l
o Cun eiform bo nes form keyst on e of arch d ue to m argin 2n d cu ne iform
triangular sh ape • 3rd metatarsal centered o n 3rd cun eifo rm
o Majo r supporting st ructures of transverse arch • 4th me ta ta rsal aligned to medial m argin cubo id
• Spring liga m ent • 5th meta tarsal styloid process exte nd s beyond
• Lisfranc ligame nt a nd intermetatarsa l ligaments lateral border of cuboid
• lntertarsalligaments • lnte rmetatarsa l angle between 1st and 2 nd
• Longitu di n al arch of foot m etatarsa ls norm ally less tha n 10°
o From posterior process ca lcane us to metatarsal h ead s • Sligh t l st MTP abdu ction (hall ux va lgus) is
o Med ial side is higher t h an latera l normal, up to about 1so
o Apex of arch is at navicular and cu neiforms
o Metatarsals slant downwa rd fro m apex of arch to Distribution of Weight-Bearing
m etatarsop h a la ngeal (MTP) jo int from arch apex • 5Q!}h o f weight bo rne on subta lar joint and calcaneus
• This is called inclination angle • Remainder tra n sm itted via a rch anterio rl y to
• Incli nation an gle decreases from zooat 1st to soat m etatarsopha langea l joints, greatest we ight on 1st toe
5th metatarsa l Bony Anatomy
o Major su pporti n g stru ctures o f longitudina l a rc h
• Cuboid bone
• Plan ta r fascia o Rough ly cuboida l sh a pe
• Lon g a nd short pl a nta r liga me nts
o 1 ossifica tion center: Ossifies between 9t h fe tal
• Spring ligament
month and 6 months age
• Posterior tibial tendon, pe roneu s longus t endo n o Articula tes with ca lcaneus, n avi c ular, 3rd cuneiform ,
• Rad iographic assess m ent o f normal lo ngitudinal 4th and Sth meta tarsals, rarely head o f tal us
arch
• Do rsal liga m e nts (ca lcaneocu bo id, cubonavicula r,
o Eval uate talo metatarsal a li gnment
cuneocuboid, cubome tatarsal) st rength e n each of
• Norma l: Axis of talus continues along ax is of 1st
these art iculations
m e tatarsa l • Sh ort and long plan tar ligaments a ttach to plantar
• Pes pla nus: Axis of tal us falls below ax is of 1st
surface
metatarsa l o Su lcu s at latera l margin, under which passes
• Pes cavus: Ax is o f talus exte nds above ax is of 1st
pero neus lo ngus tendon
m etatarsa l
o Sth m etatarsa l base extends beyond la teral ma rgin
Alignment • Navicu lar bone
....0 • Hindfoot relati ve to forefoot a lignment
o Defined by ax is of talus o n ant e roposteri or
o Curved sh ape, co nca ve proximally and co nvex
d istal ly
0 radiograph o 1 ossificati on cente r: Ossi fi es in 3rd yea r o f life
LL o Art ic ulates with ta lus, c ubo id, cu n eifo rm s

VIII
2
 FOOT OVERVIEW
• Dorsa l ligaments streng then each of these o 1st la yer: Abduc to r hallu cis, flexor digitorum brevis,
arti culatio ns abductor digiti m inimi, pe roneus brev is
• Si ngle facet proximall y for a rti cula tion with head o 2nd la yer: Q uad ratus plantae (flexor accessori us),
o f ta lus fl exor d igito ru m a nd hallu cis longus, lumbrica ls
• 3 fa cets di sta ll y fo r cuneiform articulatio n s o 3rd layer: Flexor hall ucis brevis, adducto r h a llu c is,
• I facet la te rall y for artic ulation with cuboid fl exo r d igiti mi n imi b revis, tibialis poste rio r
• Con nected to ante rior process of ca lcan eus by o 4th layer: Pla nta r inte rossei (3), dorsal interossei (4)
bifurca te ligame nt o Peron eus lo ngus courses across a ll layers, from
• Co nnec ted to sustentaculum tali by spring supe rfic ial planta r late ra ll y to deep plantar media lly
ligament • Dorsa l muscles: 2 muscle layers
o La rge m ed ian em inence for a ttachm e nt of poste ri o r o Supe rfi cial layer: Tibia lis anteri or, ex te nsor h a ll ucis
tibia l te nd on is located m o re pla ntar than main lo n gus, ex tensor digito rum lo n g us, peron eus tertius
bod y of n avicu la r o Deep laye r: Ex te n so r ha ll ucis brevis, extensor
• Cuneiform bones d igito rum brevis
o Wedge-s h a ped, with base o f wedge a t dorsa l surface o In forefoo t, .long an d sh ort extensors run side by
o f 2 nd a nd 3 rd cun eiforms, dorso medial surface 1st side in sin gle la ye r
cuneiform
o In co mbination, fo rm arch
Compartments
o 1st cun eiform (m edia l c uneifo rm) • 4 plantar compartments d ivid ed by fascial layers
• Arti cul ates with na vicu lar, 2nd cune iform , 1st o La teral and media l int ermu scular septa e determine
meta ta rsa I ma jor com partmen t divisi o ns
• I or 2 ossifications ce nters: Ossify in 2nd year of • Medial plantar compartmen t
li fe o Conta ins abductor hall ucis, flexo r hallucis lo ngus,
o 2nd cun e ifo rm (middle o r interm ed ia te cuneiform) and flexor ha llucis brevis
• Arti cu lates with nav icular, 1st and 3rd c uneifo rms, • Central plantar co mpartment
2nd m etatarsa l o Su perfic ia l subco mpa rtmcnt: Contains flexo r
• Sma llest o f cuneifo rm s d igitoru m brevis, dista l portion of fle xor dig ito rum
• 1 ossifi ca tio n cente r: Ossifies in 3 rd year of life longus
o 3rd cun eiform (la teral cun eiform ) o Interm ed iary subcompa rtment: Co nta in s proximal
• Art iculates with n avicular, 2nd c uneifo rm, cu boid, pla n tar po rti o n of flexor digito rum longus,
3 rd meta ta rsal quadratus plantae, lumbricals
• Metatarsal bones o Deep subcompa rtm e nt: Limited to fo refoot, co ntai ns
o 2 ossifica tion s ce nte rs: Shaft o ss ifies in 9 th prenatal adductor h a llu cis
week, epiphys is in 3rd-4th yea rs of life • Lateral p lantar compartment
• 1st m etata rsa l ha s ep iphys is a t proximal end, o Contains abductor and fl exor digi ti min imi
o th e rs at d istal e nd • Interosseous compartment
o 2nd-5th me tatarsa ls have articulations at bases w ith o Contains planta r a nd dorsal inte rosseo us muscle
ad jace n t m etatarsa ls • Dorsal compart ment
o 1st metatarsal o Superficial layer: Ex trin sic extensor tendon
• La rgest o f m etatarsa ls o Deep layer: Intrinsic exten sor musc le
• Art iculates with 1st cu neifo rm, 1st proximal Major Ligaments
pha lanx, sesa m o ids of m etatarsal head • Pla nta r fascia (apo n euros is): 3 port ions ex tend from
• Va riable articulatio n wit h 2 nd m etatarsa l base tuberosity of calcan eus to transve rse metatarsal
o 2nd-3rd meta ta rsals 1iga me n ts of to es
• Articula te w ith respective c une iforms and o Med ial band: Thin structure superfi cial to abductor
proximal pha langes hallucis muscle
• 2nd metatarsal base recessed relative to 1st and o Central ba nd: Thick, stro ng struc ture supe rficial to
usually 3rd flexo r d igito rum brevis
o 4th-5t h metatarsals • Divid es in to se parate bands t o each toe; these are
• Articu late with cu bo id and respec tive proxima l linked by t ra nsverse bands
phalanges • Distall y sends septae superficially into
• St yloid process o f 5th metata rsal extends lateral to subcuta neous fat a nd deep t o MTP joints
cuboid o Lateral band: Thin structure supe rficial to abductor
• Phala n ges digiti minimi
o 1st t oe is bipha langea l, other toes are triphala ngea l
o Medi al and la te ral bands sometim es te rminate at
o 5 th toe sometim es has fail ure o f seg m en ta ti on o f
level of mid metat a rsals
mi dd le and distal phalanges
• Long plantar ligamen t: Originates calca neal tuberosity,
o 2 ossificatio n centers: Shaft o ssifies 9 th-1 5th
inserts cuboid a n d bases 2nd-4th metat arsals
pre n atal weeks, epiphysis 2nd-8 th yea rs o Forms retinaculum for peron eus longus tendon as it
Musculature courses medially on plan tar aspect of foot
'T1

-
• Plantar muscles: 4 muscl e layers, numbered from • Short plantar (p lanta r ca lcaneocuboid) liga me n t: Deep
t o lo n g ligamen t, inserts m ore p roximally on c uboid
0
su perficial to deep 0

VIII
3
 FOOT OVERVIEW
• Plantar calca neocuboid (sp ring) ligament: Originates
sustentaculum tali, inserts plantar aspect navicular
!Anatomy-Based Imaging Issues
• Bifurca te liga ment: Ori gi nates anterior process of Imaging Recomm endation s
ca lca n eus do rsally, inserts na v icular and cuboid • Radi ograp hs: Weight-bearing when possible
• Li sfranc ligam ent: O rigin ates 1st cu neiform, in serts o Standa rd v iews: An teroposteri o r (dorsoplantar),
ba se 2nd metatarsal lateral, oblique
• lnterm etatarsa l ligam ents: Dorsal and p lantar • MR: Better images obtained when field o f v iew limited
ligaments between 2nd-5th metatarsal bases to area o f co ncern, not entire foot
• Transverse m etata rsal ligaments: Superfi cial and deep • CT: Mult id etecto r 1 mm images w i th ag ittal and
liga ments between meta tarsal head s co rona l reformatio ns
Ne rves Imaging Pitfalls
• Tibia l n erve divides into medial an d lateral p lanta r • Alignmen t can on ly be reliab ly assessed o n
branches at level of tarsal tunn el we igh t-bearin g rad iograph s
o Medial pl a n tar ner ve
• Between I stand 2nd muscle layers, accompan ies
medial plantar artery
• Moto r b ran ches: Abductor hall ucis, flexo r
IClinical Implications
digito rum and hallucis brevis, 1st lumbrical Foot Motion
• Pla n tar digita l nerves to l st-3rd toes, m edial • Supination : Eleva tion of medial arch of foot
aspect 4th toe o Combi n atio n of in ve rsio n and adductio n
o Lateral plantar nerve: Has deep and superficial • Pronation: Depressio n o f media l arch o f foot
d iv isio ns o Combi n ati o n of eversion and abduction
• M o to r b ran ches: Flexor digiti min i mi b revis, • Com plex mo tion s at m ultiple jo i nts; following is a
lumb rica l s, interossei, adductor h allucis simplified description of ma jor motions
• Superficial latera l plantar n erve: Bet ween 1st and • C ho part (ca lcaneocu boid and talonavi cular) joint
2nd muscle la yers o Th ese 2 jo ints move togethe r o n an ob lique axis to
• Plantar cligita l nerves to Sth toe, latera l aspect 4th produce com po und moti o ns
toe o Pro natio n-abduction-exten sion to
• Deep lateral plantar n erve: Bet ween 3rd and 4th su pi nation-adductio n-fl ex io n
muscl e layers; accompanies latera l plantar artery • Tarsometatarsa l joints
• Deep p eron eal nerve: Ex tend s alo n g d o rsum o f foot, o Do rsiflexion and planta r flex ion
between tibi al is anterior and exten sor h allucis lo ngus o 2nd and 3rd tarso metatarsal joi nts relative ly
o M o to r branch : Ex tensor digitorum brevis immobile
• Su per f i cial pero n eal n er ve: Divides into medial and o Slight abduction of 1st tarsome tatar al joint
lateral bran ch es at dorsum of foot • Metatarsoph alan gea l jo i n ts
o Sen sor y branch es to dorsal foot o Do rsi flexion and pl an tar flexion
• Su ra l n er ve: La teral, superficial bran ch of tibia l ner ve o Abduction an d adduct io n at I st
o Ex tends alo ng lateral margin of foot metatarsop halangeal joi nt
o Sen sor y bra nch es to lateral foot
Alignment
Arte ries • Norm al weight-bea ring and ga it depend o n normal
• Posteri or tibial artery d iv ides into medial and lateral foot alignment
plan tar arteries at level o f tarsa l tunnel • Evaluated i niti ally with an teropos terio r an d latera l
o Plantar arteri es acco mpan y m edi al and deep latera l weight-bea ri ng radiographs
plantar nerves
• Pero neal artery acco mpanies superficial peron ea l nerve Malalignm ent
do wn antero lateral aspect ankle • Fo refoot aclductus: Medial angulati on of metatarsals
o May jo in o r repl ace posteri or tibi al artery from axis o f hindfoot
• Anterior tibial artery co n tinues into foo t as do rsa lis • Forefoot va rus: I nve rsio n of me tatarsa ls resulting in
pedis artery, deep to ex tensor retin aculum shift of weight-bea rin g to Sth m etatarsal from 1st
o Divid es into multiple bran ch es i n midfoot, forming metatarsal
arcad e • M etatarsus primu s varus: M ed ial d eviation of 1st
metatarsal ax is rela ti ve to 2nd
Bursae • Hallux valgus (hallux abductus): La teral deviation of
• Extenso r digito ru m b revi s: Between muscl e and 2 nd 1st prox imal pha lanx relative to ax is of 1st m etatarsa l
cuneiform and meta tarsa l bases o Valgus refers to an angular deformity in t h e vertical
• Ex ten sor hallucis longus: Bet wee n ten don and 1st pla ne, where the apex points m ediall y
cuneifo rm an d metatarsal bases o Abductus refe rs to an an gular deformi ty in th e
• Abductor digiti mini mi : Bet ween muscle and ho ri zontal plane, where th e apex points med ially
tuberosity o f Sth metatarsal o Therefo re, ha llux va lgus is a m is nomer, bu t it
...... • M etatarsophalangeal joints: Dorsally; between remai n s t he term co mmo n ly used for hall ux
0
0 metatarsal h eads; and m ed ial to 1st metatarsa l head abductu s
u.
VIII
4
-
"T1
0
0

VIII
5
 -
0
0
LL.

VIII
6
.,0
-0

VIII
7
-0
0
u.
VIII
8
-
"T1
0
0

VIII
9
 ...
0
0
LL

VIII
10
 .,
-0
0

VIII
11
 ....0
0
u..

VIII
12
-
"T1
0
0

VIII
13
 ...
0
0
u.

VIII
14
,
-0
0

VIII
15
 FOOT OVERVIEW
AP, OBLIQUE WEIGHT-BEARING RADIOGRAPHS

I st interphalangeal
joint
Sth distal
interpha langeal jo int

St h proximal
interpha langeal jo in t
csamoids of I st toe

Cuboid
avicu lar
Sulcus for peroneus
longus tendon
I lead of talus

onnal notch at dorsal

Scsamoids of I st toe
medial metatarsal head

Sth m etata rsa l styloid

process

Sul cus for peroneus avicular

longus tendon

-
(Top) An teroposterior weigh t-bea ri ng radiograph o f foo t shows no rmal am o unt of overlap of bones o f midfoot.
Articulati ons between cu boid and na vicular, between cu n eifo rm s, and between cu boid and lateral cuneiform are not
seen in p rofil e. Tarsomet atarsal jo ints are som etimes i n profile, but jo in ts may not be v isi ble clue to obl iquity of join t;
0
0 thi s sh o uld n ot be mistaken for join t fusio n. (Bottom) O n obliq ue vi ew, intercuneifo rm joints, ta rsometata rsa l joi nts
LL and stylo id p rocess (also ca lled tuberosity) at base o f Sth metata rsal are usually better seen than on an teroposteri or
v iew. Norm al notch at media l margin of m etatarsal heads is o ften th row n into p rofile o n thi s v iew and should n ot be
mi staken fo r erosion.
VIII
16
 FOOT OVERVIEW
LATERAL RADIOGRAPHS, WEIGHT-BEARING & NONWEIGHT-BEARING

2 nd tarsometatarsal
joint

lst tarsometatarsal
joint
Navicu lar
I st m etatarsa l

Median eminence,
I st
n avicular
meta ta rsophal angeal
joi nt Cuboid
Sesa m oids of 1st
m etata rsa l Styloid p rocess 5 th
m etatarsal

1st tarsometatarsa l C h opart join t

join t

1st --;:=:;=;;o..-:--='-::-- Stylo id process 5th

metatarsal
metata rsop ha lan geal
join t
Bipart i.te sesa m o id of
1st toe

{Top) Latera l we ight-bearing radiograph shows lo n gitud in a l a rch of foot, from posterior process of calcaneus t o 1st
MTP joint. ote relative ly pla ntar posi tion of median eminence of n avicular. Line drawn alon g center of talar axis
wi ll continue a long ax is o f 1st meta ta rsal in n ormally a ligned foot. 1st and 2nd metatarsal bases are both at do rsal -n

-
aspect of foot; they ca n be disti nguish ed by m ore proximal position of 2nd m etata rsa l. (Bottom) On 0
no nweight-bearin g la te ra l radiograp h, lo ngitudina l arch of foot usuaUy appears higher than on we ight-bea ring view. 0
Calcaneocu boid and ta lonavicula r joints appear subluxa ted infe rio rl y on this view but that is a normal finding which
resolves on weight-bea rin g radi ograph s.
VIII
17
 FOOT OVERVIEW
AXIAL T1 MR, PLA NTAR ASPECT OF RIGHT FOOT

'
Plan tar fascia, d igital

Fl exor d igi toru m brevis

muscle

Abductor digiti minim i

muscle

Plan tar fascia, digital

ba nds

Flexor digito rum brevis

Flexor d igi ti minimi muscle
muscle

Abd uctor digi ti minimi 1st & 2n d plantar

muscle digital

Lat era l plantar a. & n.,

superficial branches

(Top } f-irst in seri es of axial T l MR i mages thro ugh t he ri ght foot, fro m plan tar to dorsa l. Flexor digito rum brevis and
abducto r digiti m i nimi are most p lantar in posit io n of foot m uscles. (Bottom ) Pla ntar fasc ia, uperficial to fl exor
0 digi torum brevis m uscle, is seen dividing i nto digi tal bands in fo refoot.
0
LL

VIII
18
 FOOT OVERVIEW
AXIAL T1 MR, PLANTAR ASPECT OF LEFT FOOT

Pla ntar fascia, d igi tal

ban ds

Flexor digitorum brevis

m u scle
Abducto r digiti minimi
muscle

Pla n tar fascia, digital

ba nds

Flexo r digit orum

mu scle Flexor di giti m i ni mi
muscle

1st & 2nd plantar Abductor digit i rni n imi

digi tal vessels muscle

Lateral plantar a. & n.

superficial branch es

(Top) First i n series o f axial Tl MR i m ages t h rough th e left foo t, from p lantar to dorsal. Flexor digitorum brevis and
abductor digi li minimi are most plan tar i n posi tion of foot m uscles. (Bo ttom ) Plantar fascia, superficial to fl exor
digitorum brevis muscle, is seen di viding in to d igital ba nds in forefoot . "TT

-
0
0

VIII
19
 FOOT OVERVIEW
AXIAL T1 MR, PLANTAR AS PECT OF RIGHT FOOT

Flexor longm
tendon

Plantar digital vessel s

Flexor digitorum
longus t. to Sth toe

Flexor ha ll ucis brevis

Flexor digiti minimi muscle, medial head
brevis muscle

Abductor digiti minimi

muscle Latera l plant ar nerve
Sth metatarsa l styloid
process Medial plantar nerve
Peroneus longus Abductor
tendon muscle

lst interphalangeal
joi nt

Sesam oids o t I st toe

Flexor hallucis longus Abductor hallucis

tendon tendon

Flexo r digitorum Flexor hallucis brevis

longus tendon muscle, medial &
latera l heads

Flexor digiti minimi

Adductor hallucis
muscle
muscle, oblique head
Abductor digi ti minimi
muscle
Peroneus lon gus Abductor muscle
tendon
Quadratus plantae
muscle

(Top) Med ia l plantar ne rve courses lateral to medial plan tar arte ry, between abductor hallu cis a nd flexor digitorum
brevis. Lateral plantar nerve courses between fl exor digitorum brevis muscle and quadratus plantae muscle, and
00 con tinues la terally, divid in g into dee p a nd superficial branch es at level of Sth metata rsal base, between fl exor
digitoru m b revis and abd uctor digiti minimi. (Bottom) Med ial a nd la te ral head s of flexor digito rum brevis muscle are
LL seen a ttac hing to sesamoids of 1st toe. T h eir di sta l insertion, onto base of l st proxima l phalanx, is not seen o n this
image.
VIII
20
 FOOT OVERVIEW
AXIAL T1 MR, PLANTAR ASPECT OF LEFT FOOT

Flexo r h allucis lo ngus

tendon

Plan tar digi tal vessels

Flexor digi torum

longus t . to 5th toe

Flexor hallucis brevis

muscle, m ed ial h ead Flexor digi ti minim i
brevis muscle

Abd uctor digiti minimi

Lateral plantar n erve muscle

5th m etatarsal sty loid

Medi al plantar n erve
process
Abducto r ha llucis
muscle Peron eus longu s t .

l.st in terphalangeal
joi n t

Sesa moids o f 1st toe

Abducto r hallu cis Flexor h allucis longus

tendon tendon

Flexor h al lucis brevis

muscle, medial & Flexor digi torum
lateral h eads longus tendon

Adductor h allucis Flexor digiti minimi

muscle, ob lique head m uscle

Abd uctor digi ti m inimi

m uscle
Abdu ctor h allus muscle
Peroneus longus
Quadratus plan tae tendon
muscle

(Top) Media l planta r nerve courses lateral to m edial plan ta r a rtery, between abd uctor haUucis and flexor d igitorum
brevis. Late ral plantar nerve cou rses be tween flexor digitorum brevis muscle and quadratus plantae muscle, and
continues late rall y, dividing into deep and superficial branc hes at level of 5th m etatarsa l base, betwee n flexor

-
"T1
digitorum brevis muscle and abductor digiti m ini mi. (Bottom ) Medial and late ral heads of fle xor d igitorum brevis 0
muscle are seen attaching to sesamoids o f 1st toe. Their d istal insertion, o nto base of 1st proximal p ha lanx, is not 0
see n on th is image.
V III
21
 FOOT OVERVIEW
AXIAL T1 MR, PLANTAR ASP ECT OF RIGHT FOOT

Flexor cligitorurn
tendon Flexor digitorurn
4th toe longo s tendons

Lum br ical tendon

imertion, 2nd toe

of I toe
Lumbrical
Flexor hallucis longus
muscle, lateral head

Flexor hallucis brevis

Abductor digiti minim i medial head
muscle

Quadratus plantae Flexor digit orum

muscle longus tendon

Peroneus brevis tendon

Abd uctor hal l ucis
musc le

Adductor hall ucis

tendon insertion
Medial and la teral
colla tera l Abductor hallucis
4t h toe tendon insertion

Flexor hallucis brevis

Add uctor hallucis muscle, lateral head
muscle, tran sverse hea d
Flexor brevis
muscle, medial h ead
3rd plantar
in terosseous muscle
Adductor hallucis
Abductor digiti min imi obl ique head
muscle

Peroneus longus Quadratus plan tae 111.

tendon
Abductor hallucis m.
Peroneus brevis tendon
Medial plantar n. & a.

(Top) Note insertion o f q uadratus p lantae muscle i nto fl exor digito ru m lo ngus tendon just p roximal to i ts division
into sli ps to 4 lateral toes. Lumbrica l muscles ari se fro m individua l slips o f fl exor d igi to rum lo ngus tendon, and insert
00 on medial aspect of p roximal phalan x . A flexor digito rum lo ngus ten don sli p to Sth d ig it is va riably present.
(Botto m ) Termin o logy for addu ctor and abducto r hall ucis muscles becomes clear once it i s rem embered that
LL. abd uctor pull s 1st toe away from 2nd t oe, and adductor pull s it toward 2 n d toe. i.e., ax is of reference here is foo t, not
en tire body.
VIII
22
 FOOT OVERVIEW
AXIAL T1 MR, PLANTAR ASPECT OF LEFT FOOT

Fl exor digitorum
Flexor digitorum lon gus tendon
lon gu s tendon insertio n, 4th toe
Lumbri cal tendon
insertion, 2nd toe

Sesamoids o f I st toe
Lumbrical muscle
Flexor ha ll ucis lon gus
muscle, lateral head

Flexo r brevis
musc le medi al head Abductor digi ti minimi
muscle

Flexo r digitorum Quadratus plantae

lon gus tendon m uscle

Peron eus brevis ten don

Abductor hall ucis
mu scle

Adducto r h allucis
tendon i nser tio n
Medial & latera l
Abductor hallucis
collateral ligaments,
tendo n i nser ti on
4th toe

Flexor hallucis brevis

muscle, lateral head Add ucto r h allucis
m uscle, tran sverse head
Flexor hallus brevis
muscle, m edial head 3rd plan tar
in terosseous muscle
Adductor hallucis
Abductor digiti m i nimi
muscle, obl ique head
m uscle

Quadrat us plantae m . Peron eus lo ngus

tendon
Abductor
Peroneus brevis tendon
Medial plan tar n. & a.

(Top) Note inserti on o f quadratus plan ta e muscle into f lexor digitoru m lon gus tendon just p roxima l to its div ision
into sl i ps to 4 lateral to es. Lumbrica l m uscles arise fro m individual sl ips of flexor digitorum longus tendon, an d i n sert
on medi al aspect o f proxima l ph alan x. A fl exor d igitorum lo ngus tendon slip to Sth digit is variably present.

-
"T1
(Bottom) Terminology for add uctor and abductor h al luci s muscles becomes clea r once it is remembered that 0
abducto r pulls 1st toe away from 2nd toe, and adductor pu lls it toward 2nd to e. i.e., axi s of reference here is foot, n o t 0
entire body.
VIII
23
 FOOT OVERVIEW
AXIAL T1 MR, PLA NTA R AS P ECT OF RIGHT FOOT

Add ucto r ha ll u cis

In terosseo us muscles muscle, transve rse h ead

Adductor h all ucis Flexor hallucis brevis

m uscle, o bliq u e h ead muscle

Abducto r h all ucis

St h metatarsal muscle

Peroneus longus
ten d o n
Tibia lis poste rio r
Q uadra tus plantae ten d o n, a n terio r sli p
muscle

Digi tal vessels, 2nd toe

Adductor h a llucis
muscle, tra n sverse h ead

Interosseous mu scles

Adducto r h all ucis

Abducto r d igiti min im i m uscle, o blique head
muscle

Abdu cto r h all ucis

Peroneus longu s m uscle
tendo n l st cun eifo rm
Tibial is posterio r
tendo n, an terio r slip
Cuboid

(Top) Obliq ue h ead o f adductor ha llucis muscle is t hic k and broa d, wh ile tra n sverse head is th inner, a n d so metimes
con ge n itally absen t. (Bottom) Insertio n of peron eus longu s tendo n on 1st me ta tarsal is well seen . Note t h read-like
00 d igita l vessel s at m ed ial and latera l margins of 2nd toe.

LL

/Ill
24
 FOOT OVERVIEW
AXIAL T1 MR, PLA NTAR ASPECT O F LEFT FOOT

Adductor hallucis
Interosseous musc les
muscle, transverse head

Flexor hallucis Adductor h allucis

muscle muscle, obl ique head

Abductor h allucis
mu scle Sth metatarsa l

Peroneus longus
tendon
Tibia lis posterior
tendon, anteri or sli p
Quad ratus plan tae
muscle

Digital vessels, 2nd toe

Adductor h all ucis m.,

transverse head

Interosseous muscles

Adducto r h all ucis

muscle, oblique h ead Abducto r digit i m i nimi
muscle

Abductor h allucis
mu cle Peroneus longus
I st cuneiform ten don
Tibialis posterio r
tendon, anterior slip
C uboid

(Top) Oblique head of adductor hallucis muscle is thick a nd broad, while tra nsve rse head is thinner, and so me times
conge nitally absen t. (Bottom) Insertio n of peroneus longus tendon o n 1st metatarsa l is well seen . Note thread-like
digita l vesse ls at medial and lateral margins of 2nd toe. 'T1

-
0
0

VIII
25
 FOOT OVERVIEW
AXIAL T1 MR, P LANTAR ASPECT OF RIGHT FOOT

lsl dorsal interosseous

2nd do rsa l interosseous
muscle

Adductor hallucis
muscle, oblique h ead
3rd plan tar
interosseou s muscle

Abductor digiti minimi Abductor hallu cis

muscle

Ti bialis anterior tendon

avicular

Sth middle & di stal

ph alanges (fused)

Dorsa I in terosseous
In term eta tars a I muscles
ligam ents

1st cunei fo rm
C uboidocunei form
l igament

Exten sor digitoru m

brevis muscle

(Top) Plantar interossei arise from med ial margin o f 3 lateral toes, a nd insert on med ial aspect of base o f th eir
respective proximal p halanges. (Bottom) There a re fo ur dorsal inte rosseous muscles, each with 2 h eads ("bipe n nate")
00 a rising from bases of adjace nt metatarsals. 1st dorsal interosseo us inserts on med ial aspect of base of 2nd proximal
phalanx, and 2nd-4th to the latera l aspect of base of 2 nd-4th metata rsals.
u.

VII I
26
 FOOT OVERVIEW
AXIAL T1 MR, PLANTAR ASPECT OF LEFT FOOT

I st dorsa I interosseous 2nd d o rsa l interosseou s

muscle m uscle

Adducto r hal lucis

muscle, oblique head
3rcl plan tar
i nterosseous muscle

Abductor digi ti m i nimi

Abdu ctor hallucis
muscle
m uscle

Tibialis an terio r tendon

Navicular

Sth m iddle & distal

p halanges (fused)

Dorsa l interosseou s
muscles In lerm etat a rsa I
l iga men ts

I st cune ifo rm Cuboid ocu neiforrn

liga m en t

Exte n sor cli gi torum

brevis muscle

(Top) Planta r in terossei a rise fro m media l ma rgin o f 3 late ra l toes, and insert on med ial aspec t of base o f the ir
respective proximal ph ala n ges. (Bottom ) Th ere a re fo u r do rsal interosseous m uscles, eac h with 2 heads ("bipen n ate")
a rising from bases o f ad jace nt me tata rsa ls. l st do rsal inte rosseo us in se rts o n m edi a l aspect o f base o f 2 nd proxima l

-
"T1
pha la nx, and 2n d -4 th to t he la tera l aspec t of base of 2 nd-4th m etatarsals. 0
0

VIII
27
 FOOT OVERVIEW
AXIAL T1 MR, DORSAL ASPECT OF RIGHT FOOT

·1s t-4th d o rsal

interosseou s muscles

lntermetata rsa l
ligamen ts
4th metata rsal

Plan tar Lisfranc

ligamen t

Ex tensor d igi toru m Navicu lar

brev is muscle

Exten sor te ndo ns

Dorsa l in terosseous
muscles

4th metata rsa l

Cuneiform-cubo id
ligamen t
Tibia lis anterior tendon
Ex ten sor d igito rum
brevis m uscle

Cubo id

(Top) 2 nd-5th m etata rsal bases are jo ined by do rsa l, interosseo us and p lan ta r inte rm e ta ta rsa l liga ments. Stabil ity
between 1st and 2nd rays is ach ieved by 3 liga me nts fro m 1st cune iform to base o f 2nd me tatarsa l: Dorsa l,
00 inte rosseous, a nd pla nta r. Interosseous 1st c une ifo rm to 2nd m e tatarsal liga me n t is b roadest a nd stro ngest, a nd is a
t rue Lisfra nc liga me nt. How ever, "planta r" and "dorsal Lisfranc li gament" are t er ms w hic h a re commo nl y a n d
LL app ro priate ly used. (Bottom) Note articu latio n s between m etatarsa l bases. T h ese a re consta nt a t th e la te ral toes, but
va ria bility is seen in a rtic ulations between 1st a nd 2 nd m eta tarsals whe re a n artic ula t ion is variabl y present.
VIII
28
 FOOT OVERVIEW
AXIAL T1 MR, DORSAL ASPECT OF LEFT FOOT

1st-4th d o rsal
in terosseo us muscles

lntermetata rsal
ligame n ts
4 th metatarsal

Pl an tar Lisfran c
ligamen t

avicula r Exten so r d igitorum

brevis m uscle

Exten sor tendo ns

Do rsal in terosseo us
m u scles

4th m etata rsa l

Cu n eifo rm -cuboid
ligamen t
Tibi al is an terio r te ndo n
Ex ten so r d igito rum
brevis m uscle

Cu bo id

(Top) 2nd-5th metatarsal bases are joined by d o rsa l, in terosseous and plantar intermetatarsalliga me n ts. Stability
bet ween 1st and 2nd rays is achieved by 3 liga m en ts from 1st cuneiform to base o f 2nd m eta tarsal: Do rsal,

-
interosseous, and plantar. In terosseo us 1st cun eiform to 2nd m etatarsal ligamen t is broad est and st rongest, and is a "'T1
t ru e Li sfra nc ligamen t. However, "plantar" and "do rsal Lisfranc liga ment" are terms w hich are commonly and 0
appro priately used. (Bottom ) Note art iculati ons betwee n metatarsal bases. These are co nstan t at t he latera l toes, b ut 0
va ri ability is seen in articula tio ns between 1st and 2nd m etata rsals where an articulatio n is variably presen t.
VIII
29
 FOOT OVERVIEW
AXIAL MR, DORSAL ASPECT O F RIGHT FOOT

Extensor digito rum

longu s tendon, 3rd toe

Exten sor digi toru m

1st & 2n d do rsa l
brevis tendon, 3rd toe
interosseous m uscles

Lisfranc liga m en t
I n tercunei form
liga m en ts

Tibialis anterior tendon

Ex ten so r di gi torum
brevis muscle

Extenso r hallucis
lon gus tendon

1st dorsal i nterosseous

muscle

Li sfranc ligament

Extenso r digitoru m
brev is muscle
Tibial is anterior ten don

l n tercuneiform
li gaments

(Top) Dorsa l soft tissues a re m uc h th inne r than plan ta r, es peciall y in forefoot. Indi vidual extensor tendon sli ps are
seen ex te nding t o toes, with ex te nsor digitorum brevis t e n don slips lateral to correspo ndin g exte n so r d igitoru m
(5 lo ngus te ndon sli ps. Digital vessels and n e rves a re well outlined by subc uta neous fat. (Bottom) Ex tensor digitoru m
0 brevis m u scle originates a t lateral margin of calcane us a nd fa n s out to toes. Tibialis a nte ri o r te ndon wraps around 1st
U. cu n eifor m to insert o n its p lantar surface as well as o n plan ta r surface of 1st m etatarsal.

VIII
30
 FOOT OVERVI EW
AXIAL MR, DORSAL ASPECT OF LEFT FOOT

Extensor digitorum
longus tendon, 3rd toe

Extensor digitorum
I st & 2nd do rsal brevis ten don, 3rd toe
interosseou s muscles

Lisfranc l igament
In tercu nei form
l iga m ents

Tibialis an te rio r tendo n

Extensor digi torum

brevis muscle

E,xte nsor hal l ucis

lo ngus tendon

1st dorsal interosseous

mu scle

Li sfranc ligam ent

Extensor digi torum

brevis muscle

Tibial is an te rior tendon

Jntercunci form
ligam en ts

(Top) Dorsal soft tissues are m uch thinner than plantar, especia ll y in forefoot. In dividual extensor tendon slips are
seen extending to toes, wi th ex te n sor d igito rum brevis te nd o n slips latera l to correspond ing extensor digit orum
lo ngus ten don slips. Digita l vesse ls and n erves a re well o utlin ed by subcutan eous fat. (Bottom) Extensor d igitorum ,
brevis muscle o ri ginates at lateral margin of calca neus a nd fa n s out to toes. Tibialis anteri o r te ndon wraps around 1st
cuneifo rm to insert on its p la n tar surface as we ll as o n planta r su rface of 1st m etatarsal.
-
0
0

VIII
31
 FOOT OVERVIEW
CO RO NAL M R, CH O PART JOINT RIGHT FOOT

Tibialis an terior tendon

Ex tensor hallucis
lo ngus tendon

Ex ten sor d igito rum

Ta lus
lon gus tendon
Na"icular

Exten so r di gitorum Spri ng ligament

brevi s muscle insertions
T ibi alis po terior
tendon
Ca lcaneocuboid joi nt Abductor hallucis m .

Flexor ha llucis lon gus

Pero neus brevis tendon tendon
Flexor digitorum brevis
Sho rt plantar l igament muscle

Long plantar liga men t Quadratus plantae

muscle
Abd uctor digiti m inim i Flexor digi to rum brevis
muscle mu cle

Ex ten sor hallucis Tibia lis anterior tendon

longus tendon

Ex tensor di gito rum

longus tendon

Ex ten sor di gi torum

brevis mu scle Master knot of Henry

Tibial is posterior
tendon insertion
C uboid
Abductor hallucis m .
Long planta r liga ment
Quad ratus pl an tae m.
Peroneus brevis tendon
Planta r fascia, media l
band
Pero neus lo ngus
tendon Flexor digi torum brevis
muscle
Abductor digiti minimi
muscle
Latera l plantar nerve
Plan tar fascia, lateral
Plan tar fascia, cen tral
band
ban d

-
(Top) First o f twen ty-fo ur sequential T1 w eighted coronal MR images through th e right foot from C ho part joint to
phalanges. At level o f talona vicular and calca neocubo id joi n t (together known as C h o part joint), flexor d igitorum
lo ngus and f lex o r h allucis longus tendo ns co n verge, exchanging fibers at master knot of Henry. (Bottom) Plan ta r
0
0 fasci a (apon euro si s) has 3 d ivi sio n s: M ed ial overlies abd ucto r hall ucis, central overl ies flexor d igi to ru m brevis, and
LL lateral overlies abdu ctor digiti minimi. Central port io n is stro ngest and functi o nall y most important. M ai n portion of
t ibialis posteri or tendo n is seen attaching to navicu lar; additional sli p continu e anterio rly and insert o n 1st
cuneiform, cubo id, and 2nd-4th metatarsa l bases.
VIII
32
 FOOT OVERVIEW
CORONAL MR, CHOPART JOINT LEFT FOOT

Tibialis an terio r tendo n

Extensor hallucis
longus ten don

Ex tensor digi torum

Head o f tal us lo ngus tendon

Navicular

Ex ten sor digi torum

Spri ng I. i nsertions brevis ten don
Tibialis posterior
ten don
Abductor hallucis m.
Ca lca n eocuboid join t
f-lexor hallucis longus
ten don
Peroneu s brevis tendon
Flexor digitorum brevis
m u scle Short plantar ligament

Long pla n tar ligamen t

Quadratus plantae
m u scle
Abductor d igi ti m i nim i
Flexor digitorum brevis
muscle
m u scle

Tibialis an terior tendon Extensor h al lucis

longus te ndon

Extensor digitorurn
longus te ndon

Ex tensor d igi torum

brevis muscle
Tibial is posterior
tendo n i nser tion

Master knot of Henry Cuboid

Abductor hallucis m .
Long plan tar l igam en t
Quadratus p lantae m .
Peroneus brevis tendo n
Plantar fascia, m ed ial
band
Peron eu s lon gus
Flexor digi to rum brevis
tendon
muscle
Abdu ctor digiti rninimi
Lateral planta r nerve muscle
Plan tar fascia, lateral
Plantar fascia, cen tral
band
band

(Top) Fi rst of twe nty-fo ur sequen tial coronal Tl weig hted MR im ages through the left foo t fro m Chopart join t to
phalanges. At level of ta lonavicular a nd calcaneocubo id jo in t (togeth er kn own as Chopa rt joint}, flexor digitoru m
longus and flexor hall ucis longus tend ons con verge, exc hanging fibers at m aster k not of Henry. (Bottom) Plantar 'TI

-
fascia (aponeurosis) has 3 divisio ns: Medial overlies abducto r hall ucis, central overlies flexor d igito rum brevis, and 0
lateral overlies abducto r d igiti minimi. Central portion is strongest and functio nall y mos t i m po rtant. Ma in port ion of 0
tibialis posterior tendon is seen attaching to navicular; ad d itio nal sli p con tinu e anteriorly an d insert on 1st
cuneiform, cuboid, and 2nd-4t h metatarsal bases.
VIII
33
 FOOT OVERVIEW
CORONAL MR, CU BO ID & NAVICULAR RIGHT FOOT

anterior tendon
Dorsa l is pedis ar tery &
deep fibular nerve
I nferior extensor
retinaculum
Extensor cligitorum
lo ngus tendom G rea_! vein

Navicu lar
Ex tensor digitorum
brev is muscle
Tibialis posterior
tendon
C uboid
Short pla ntar ligament
Master knot of ll enry
Long plantar l igament
M ed ial plantar
Peroneus brevis tendon n eurovascu lar bund le

Lateral plan tar

Peroneus
n eu rovascu lar bundle
tendon
Abductor digiti minimi
mu cle

Exten sor hallucis

Tibia l is an terior tendon
lo ngus tendon

Ex ten sor digi torum

longus tendons
Navicu lar

Tibialis posterior
Extensor digit orum ten don anterior sl ip
brevis muscl e
Flexor hallucis tendon
& flexor digitorum
Cuboid longus tendon

Long plan tar ligament Abductor h allucis m.

Peroneus brevis tendon Quadra tus plantae m.

Peroneus longus
tendon
Flexor digitorum brevis
Abd uctor digiti minimi muscle
muscle

(Top} Posteri o r t ibial neurovascular b und le bifurca tes into medial and lateral pl an tar d iv isions at origin o f abductor
hallucis muscle. M edi al plantar neurovascular bundle courses between abductor hallucis and quadratus plantae.
00 Lateral plantar neurovascu lar bundle diverges laterally betwee n quadratus plantae and flexor digi torum brevis.
(Bottom ) Peroneus longus tendon begins to curve med ial ly ben eath p lantar aspect of cu boid. Long plan tar l igament
LL superficial fibers form roof and deep fibers form floor of tunn el th rough which it passes.

VIII
34
 FOOT OVERVIEW
CORONAL MR, CUBO ID & NAVICULA R LEFT FOOT

Tibialis il nt erior tendon

Dorsalis pedis art ery &
Inferio r extemor deep fibular n erve
retinacu lum
Extensor digitorum
Great sa phenous vein longus

Navicular
Extensor digi torum
brevis muscle
Tibiali s posterior
tendon
C uboid
Master k not of Henry Short plantar ligament

Medial plantar Lo ng plantar liga m en t

n eu rovascular bundle
Peroneus brevis tendon

Lat eral pl an ta r Peroneus longus

n eurova cular bundle tendon

Abd uctor d igi ti minimi

muscle

Extensor hallucis
Tibiali s anterior tendon
longus tendo n

Ex tensor digito rum

longus tcndom

avicular

Tibialis posterior
tendon ante ri o r slip
Ex tensor digitorum
Flexor hallucis tendon brevis muscle
& flexor digito rum
longus tendon
Abducto r hallucis m. Cuboid

plan tae m. Long plant ar liga m en t

Peroneus brevis l.

Peron eus longus l.

Fl exor digitorum brevis
muscle

Abductor digi ti minimi

muscle

(Top) Pos terior tibial neurovascular bund le bifurca tes into m edia l and lateral plantar divisions at o ri gin of abducto r
hallucis muscl e. M ed ial plantar neurovascular bundl e courses between abductor hallucis and quadratus plantae.

-
Lateral plantar neurovascular bundle diverges laterally between quadratus plantae an d flexor digi to rum brevi s. 'T1
(Bottom ) Peron eus lo n gus tendo n begins to curve med ial ly benea th p lantar aspect of cuboid. Lo ng plan tar ligamen t 0
superfi cial fibers fo rm roof and d eep fibers form floor of tunnel t hrough w h ich it passes. 0

VIII
35
 FOOT OVERVIEW
CORONAL MR, CU NEIFORMS RIGHT FOOT

Extensor
longus tendon

Extenso r hallucis Tibial is anterior t.

mu cle
L avicul ocunei form
joi nt
Planl ar cun eonav icula r
3rd cuneiform l igamen t
Tibia l is t.

Flex or h allucis lon gus

Cuboid tendon
Abductor m.
Quadratus plantae m.
Plan tar m edi al
Peroneus brevis t. band
Flexor digitorum
lo ngus tendo n
Peroneus longus t.

Flex or digitorum brevis

Abductor digiti min imi
muscle
muscle

Pla n tar fascia, central

band

Extensor hallucis brevis Tibi al is an terior t .

muscle

Exten sor cli gitorum

brevis m uscle
Plan tar cun eonavicular
l igament
C un ei forms
Tibia lis po terio r
tendo n, anterio r slip
Cuneiform-cuboid I.
Abductor hallucis m .
Flexor digitorum
longus tendon Flex or hallucis longus
tendo n
Quadratus plantae 111.
M edial plan tar
n eurovascular bundl e

Peroneus lon gus t.

Flex or digitorum brevis

Lateral p lan tar
muscle
neurovascular bundle

Abductor digi ti minimi

muscle

(Top) The navicular and cuneiforms are bridged by pla n tar cu neonavicular ligaments which lie deep to anterior sli ps
of tibialis posterior tendon . (Bottom) Quadratus plantae muscle has a broad inse rtion on fl exor digitorum lo ngus
00 tendon . Tibia lis anterior tendon is turnin g mediall y towa rds its in se rtio n o n plan tar aspect of 1st cuneifo rm and 1st
metatarsal.
LL

VIII
36
 FOOT OVERVIEW
CORONAL MR, CUNEIFORMS LEFT FOOT

Extensor ha llucis
longus tendon
Tibia lis an terio r t.
Extensor hallucis brevis
aviculocu neiform muscle
jo int
Plan tar cuneonavicul ar 3rd Cuneiform
ligament
Extensor d igitorum
Tibialis posterio r t. brevis muscle

Flexor hall ucis longus

tendo n
Cuboid
Abductor hall ucis m. Quadra tus plan tae m.

Plan tar fasc ia, medial Peroneus brevis t.

band
Flexor digitorum
longu s t.
Peroneus lo ngus t.
Flexor digitoru m brevis
muscle Abductor digiti minirni
muscle
Plan tar fascia, central
ba nd

Cuneiforms
Extensor ha llucis brevis
Tibia lis a n terior t. muscle

Extensor d igitorum
brevis muscle
Plan tar cuneo navicular
ligamen t
Tibial is pos terior t.,
anterior sli p

Abd uctor ha llucis m.

Cuneiforrn-cubo.id
Flexor d igi torum liga men t
longus tend o n
Quad ratus plantae m.
Flexor hallucis longus
tendo n Cuboid
Media l plantar
neu rovascular bu ndl e Peroneus lo ngus t.

Flexor digitorum b revis Lateral plantar

muscle neu rovascular bund le

Abductor d ig iti m in imi

m uscle

(Top) Th e navicular and cuneifo rms are bridged by plantar cuneon av icular ligam ents which lie deep to anterior sli ps
of tibialis posterio r tendo n. (Bottom ) Quadratus plantae muscle has a broad insertio n o n flexor digito rum lo ngus
tendon . Tibialis anterior tendo n is turning medially towards its insertion on planta r aspect of 1st cun eifo rm and 1st .,
meta tarsal.

-
0
0

VIII
37
 FOOT OVERVIEW
CORONAL MR, CUNEIFORMS RIGHT FOOT

Extenso r hallucis
Dorsal intercu n ei form lo ngus tendon
I.
ln tercuneiform
T ibialis an terior t.
ligam en t
Extensor digitoru m
longus tendon l st -t:un eiform
Plantar in tercu nei form
l iga m en t
T ibial is posteri or
tendon, an terior slip
Cuneiform -cuboid
I igamen t
Abductor hallucis m.

Peroneus l ongus t. Flexor h allucis longus

tendo n
M ed ial plan tar
La teral p lantar
neurovascular bund le
neurovascul ar bun dle
Q uadratus plan tae m.
5 th metatarsal

Peron eu s brevi s tendon Flexor digi torum brevis

mu scle
insert ion

Exten sor h al lucis

2n d cunei form longus ten don

Tibial is anterior t .

I nterosseous
intercu neiform
1st cu neiform
l iga m ent

Exten sor digitorum

brevis muscle Abdu ctor hallucis 111.

Tibia li s posterior
Long plan tar ligament,
i n sertion on ·1st
deep fib ers
cun ei fo rm

Medial pl an ta r
Peroneu s lon gus t.
n eu rovascular bundl e

Flexor digitorum
Flexor digi ti mini m i m. lon gus tendon

Flexor digi torurn brevis

Abd uctor di gi ti m ini m i muscle
muscle
Plantar fascia

(Top) Cuneifo rm bon es form tra n sverse arch by virtue of their wedge sh ap e. They are he ld in position by dorsa l,
planta r and in terosseous liga me nts. (Bottom) At this level, th e 3 maj or com partme nta l di visions o f pla ntar muscles
00 are we ll seen: Medial compartment, benea th 1st ray, lateral co mpartm ent benea th Sth ray, a nd inte rmediate
compa rtm ent be n ea th 2nd-4th ra ys. The compartments are separa ted by vertically o ri en ted fascia l la yers.
LL

VIII
38
 FOOT OVERVIEW
CORONAL MR, CUNEIFORMS LEFT FOOT

!· >.tensor hallucis Dorsal intercuneiform

longus tendon ligament

In tercunei form
ligament
an terior L
Exten sor digi torum
longus te ndon
I cunei fo rm

Pl antar interr uneitorm

l igament
Tibial is posterior Cuneiform -cuboid
tendon, anterior sl i p ligament
Abductor hallucis m.
Cuboid
Flexor hallucis longus
tendon
Peroneus 1.
led ial plantar
neurovascular bundle
Late ral plan tar
bun dle
Fl exor digitorum brevis
muscle
brevis t.
Quadratm plan tae m. i nsertion

Extensor hallucis
longus t.
2nd cuneiform

Tibialis anterior 1.

In terosseous
I cu neiform i n tcrcu nci form
ligamen t

Abductor hallucis m . Extensor cl igitorurn

brevis muscle

Tibial is posterior
insertion on l st Long plantar li gament,
cuneiform deep fibers

Medial plantar
neurovascu lar bundl e Peroneus longus L

Flexor digi torurn

longus tendon
Flexor digi ti minimi m.
rtexor digitorum brevis
muscle Abd uctor digiti minimi
muscle
Plantar

(Top) Cu neifo rm bones fo rm t ransverse arc h by virtue of their wedge shape. They a re held in position by dorsal,
plantar and interosseou s ligaments. (Bottom ) At t his level, the 3 major compartmental division s of plantar muscles
are we ll see n : Medial compa rtment, ben ea th 1st ray, la te ral co mpartme nt benea th Sth ray, and inte rm ediate "T1

-
com partment beneath 2nd-4th rays. The co mpartme nts are separated by vertica lly o ri e nted fascia l layers. 0
0

VIII
39
 FOOT OVERVIEW
CORONAL MR, LISFRANC JOI NT RIGHT FOOT

Ex tensor hallucis t.
2nd tarsometatarsal
joint
I st cu n eiform
Ex tensor digi torum
tendons
In Lisfra nc I.

3rd cuneifo rm
Abductor hallucis m .

4th metatarsal
Peroneus lo ngus t.
La teral plantar nerve, Flexor hallucis lon gus
deep & superfici al tendon
branches
Flexor digitorum
Sth m etatarsal lon gus tendon
Quadratus plantae m .
Abductor digiti min imi
muscle Flexor digitorum brevis
muscle

Ex tensor hallucis
lon gus tendon

2nd m etatarsa l
Lisfranc ligament
Ex ten sor digitoru m
brevi s muscle

Peron eus longus t.

3 rei cunei form
Flexor hallu cis brevis
4th m etata rsa l
muscle
1\clclu ctor h allucis
muscle, obliqu e h eacl Flexor hallucis lon gu s
tendon

Sth m etatarsa l Flexor digitorum

lon gus ten don

Abductor digi ti mini m i

Quad ratus p lantae m .
muscle
Flexor digi ti minimi
brevis muscle Flexor digitorum brevis
tendon

-
(Top) Interosseous Lisfra nc ligament is seen at its o rigi n from 1st cunei form. (Bottom) Lisfranc ligam ent courses
distal ly between 1st cuneiform and 2nd cuneiform, attach ing to m edial m argi n of 2nd m etatarsa l ba se.
0
0
LL

VIII
40
 FOOT OVERVIEW
CORONAL MR, LISFRANC JOINT LEFT FOOT

2nd m etatarsal join t

Exte nsor hall ucis t.
Extensor di gi torum
longus ten don s
I st cunei fo rm

Interosseou s Li sfranc I.

3rd cun ei form

Abductor hall ucis m .

4th m etatarsal

Flexor hallucis longus Peron eus lon gu s t.

tendon
Fl exor cligi torum Sth m etatarsal
lon gu s tendon
Lateral plan tar nerve,
Qu ad ratus plantae 111.
deep & super ficial
branches
Flexor digi torum brevis
muscle Abductor digi t i m in imi
muscle

Ex ten sor h al lucis

longus te ndon
Zncl m etatarsal

Lisfranc ligam en t
Ex tensor digi torum
brev is muscle

Peroneus lon gus t.

3rd cuneiform
Fl exor h allu cis brevis
muscle 4th m etatarsa l
Adducto r h allu ci s
Flexor halluci longus m uscle, oblique h ead
tendon
Flexor digi torum
Sth m etatarsal
longus ten don
Q uadratus plan tae m .
Abd uctor digiti minimi
muscle
Flexor digi torum b re.vis
tendon Flexor digiti minim i
brevi s muscle

(Top) Interosseo us Lisfranc li gam e nt is seen at its o rigin from 1st cuneifo rm. (Bottom) Lisfranc liga ment courses
distall y between 1st cuneiform and 2nd cuneifo rm, attaching t o media l margin of 2nd meta tarsal base.

-
"T1
0
0

VIII
41
 FOOT OVERVIEW
CORONAL MR, PROXIMAL METATARSALS RIGHT FOOT

Extensor ha llucis
Lisfran c ligam en t, lon gus tendon
insert ion on 2nd
metatarsal
1st \.(1rsom etatarsa l
joi n t
ln term etatarsal Peron eus lo ngus t .
l igamen ts
Abductor hall ucis m .

Flexor hallucis brev is

Adductor hallucis m uscle
muscle, obl ique head
Flexor hallucis lon gu s
5th metatarsal tendon

Flexor digitorum
Flexor digiti m inim ! lon gus tendons
brevis

Flexor digi torum brevis

Abductor digiti m inimi
muscle
muscle

Dorsa l interosseous
muscles 1st metatarsal

Abductor hall ucis m .

Flexor hallucis brevi s,

m ed ial & lateral heads

Flexor hallucis longus

tendon
Plan tar i nterosseou s
muscles Flexor digi torum brevis
Abductor digiti mini mi muscle
muscle

Flexo r digiti m ini m i

brevis muscle
Flexor digitorum
longus tendons

(Top) Perone us lo ngus te ndon ends in slips attach ing to base of 1st metata rsal, 1st cun eifo rm and sometimes base o f
2 nd metata rsal. Obliq ue head o f ad ducto r h allucis muscle o riginates from bases of 3rd and 4th metata rsa ls and from
00 tendo n sh eath of pero ne us longus. (Bottom) Flexor h allucis brevis muscle h as two heads, a nd th e flexor hall ucis
lo ngus tend on is centered be tween them. Abd ucto r hallucis muscle is closely apposed to medial head of fl exo r
LL hallucis b revis muscle.

VIII
42
 FOOT OVERVIEW
CORONAL MR, PROXIMAL METATARSALS LEFT FOOT

F.xt em o r hallucis
lo ngus ten don Lisfranc ligam en t,
in sertion on 2nd
meta tarsaI
I st tarsom etatarsal
joint lnterm eta tarsaI
ligamen ts
Pcro ncm lon gus t.
Abductor hallucis m.

Adducto r hal lucis

rl exor halluci brevis m uscle, obi ique head
muscle
Flexor halluci' lo ngus
tendo n
5th metatarsa l
Flexor d igitorum
lo ngus tendons
Abductor digiti minimi
m uscle
Flexor d igi to rum brevis
muscle Flexor digiti minimi
brevi s

I \1 rnetatar, al
Do rsal interosseous
muscles
Abd uctor hallucis m .

Fl exor halluci s brevi s,

medial & latera l heads

Fl exor hallucis lon gus

tendo n Plan tar i n terosseous
muscles
Flexor digitorum brevis
muscle Abduc tor digiti mini mi
musc le
Flexor digit i m i nirni
brevis muscle
llcxor digitorilm
tendon s

(Top) Pero neus longus tendon e nds in sl ips attaching to base of 1st met atarsal, 1st cun e iform and sometimes base of
2nd me tata rsal. Oblique head o f add ucto r h a llucis muscle o rig ina tes from bases o f 3rd and 4th meta ta rsals a nd from
te ndon sheath o f pe roneus lo ngus. (Bottom) Flexo r ha ll uc is brevis muscle h as two heads, and t h e flexor h a lluc is "TT

-
longu s tendo n is ce nte red be tween th em. Abd ucto r ha llucis muscle is closely apposed to m edial head of flexo r 0
h a llucis brevis musc le. 0

VIII
43
 FOOT OVERVIEW
CORONAL MR, MID M ETATARSALS RIG HT FOOT

l:.xtensor hallucis brevis

tendon

Dor al interosseous Ex tensor hallucis

muscles lor!.gus tendon

Flexor ha llucis brevis

muscle

Abductor hallucis t.

Flexor hallucis longus

Flexor digiti minimi m . tendon

Adductor hallucis
Abductor digiti mi nimi
muscle, oblique head
tendon

Plan tar in terosseous Lumbrical muscles

muscles
Flexor digitorum
Fl exor d igito rum brevis longus tendon to 4th
tendon to 4th toe toe

Extensor hall ucis

longus & brevis
Extensor digitorum tendons
tendons
Flexor ha II ucis brevis,
medial and lateral
heads

Abductor hall ucis t.

Adductor hallucis
muscle, tran sverse head Flexor hallucis longus
tendon
Flexor digi torum
longus & brevis tendo n Adductor hallucis
& lumbrica l m uscle muscle, oblique head

Plantar fascia

(Top) Flexor digitorum brev is and lon gus tendons have div id ed into individual sl i ps to toes. Brevis tendo ns slips are
superficia l to lo ngus. Lumbrica l muscles are seen ad jacent to fl exor digitoru m longus tendon slips. (Bottom)
Tran sverse head of add uctor hallucis m . su ppo rts metatarsa l heads. It may be congenitally absen t . Tran ve rse and
00 oblique heads are sh own co nverging t owards th ei r attachment on tbe lateral sesamoid of the grea t toe.
u..

VIII
44
 FOOT OVERVIEW
CORONAL MR, MID METATARSALS LEFT FOOT

brevis
tendon

Ex tensor hallucis
lon gus t. Dorsa l interosseous
muscles
Adductor hal lucis
mu:,cle, ob lique h ead

Fl exor hal lucis brevis

muscle

Abductor hallucis l.

l·lexor longus
tendon Flexor digi ti mi nimi m.

Abductor digiti minimi

Lumbrica l mu scles tendon
Plantar interosseous
muscles

Flexor cligitorum brevis

Flexor digilorum tendo n to 4th toe
lo ngus tendon to 4th
toe

Ex ten sor hallucis

longus & brevis
tendons Exten o r digitorum
tendons

Flexor hallucis brevis,

medial & lilteral heilds

Abducto r hal lucis t.

Adductor hallucis
Flexor hallucis lo ngus tran sverse head
tendo n
Adductor hallucis
muscle, ob lique head Fl exor digi torum
longus & brevis tendon
& lumbrical muscle
Plantar fascia

(Top) Flexor digitorum brevis a n d lon gus tendons have d ivided into individual slips to toes. Brevis tendons slips are
supe rfi cial to longus. Lumbrical m u scles are seen ad jace nt to fl exor d igito rum longus te nd on slips. (Bottom)
Transve rse h ead of adductor hallucis m. supports m etatarsa l h eads. It ma y be congenitally absent. Transverse and "TT

-
oblique heads a re sh ow n converging towa rds th eir attachm ent on th e la te ral sesamoid of th e great toe. 0
0

VIII
45
 FOOT OVERVIEW
CORONAL MR, DISTAL METATARSALS RIGHT FOOT

I st dorsa l interosseous Dorsal digital

muscle neurovascu lar bundle

Extensor cligit orum Fl exor ll allucis brevis t.

lon gu s and brevis
tendo ns, 3rcl toe Abductor hallucis l.

Addu cto r hallucis Flexor hallucis longus

muscle, transverse head tendon

Adductor hallucis
Plant ar plate, 4th muscl e, obl ique head
metatarsophalangeal
join t
Plan tar fascia
Flexor digitorum
longus tendon, 3rd toe Flexor digitorum brevis
tendon, 3rd toe

Extensor digitorum Extensor hallucis l.

longus tendon, 2nd toe

Extensor digitorum Medial collatera l

brevis tendon, 2nd toe ligament

Abductor hallucis t.
Adductor hallucis t.

Fl exor hallucis brevis

Lumbri cal l., 4t h toe tendon, m ed ial h ead

Flexor digito rum

lo ngus tendon Flexor hallucis lon gus
ten don
Flexor digi torum brevis Flexor hal l ucis brevis
tendon tenclon, lateral h ead

(Top) Plantar fasci a sends fibers dorsally and su perficiall y in an arborizi ng pattern. ( Bottom) Flexor digi torum longus
and brevis tendon s are centered beneath metatarsal h eads, w i th b revis superficia l to lo ngus, in close p roximity to
00 plan tar plate o f m etatarsoph ala ngeal joints. Lumbri ca l muscles cou rse m edial to metatarsals heads and wil l in sert on
medial ma rgin o f proximal phalanges.
LL

VIII
46
 FOOT OVERVIEW
CORONAL MR, DISTAL M ETATA RSALS LEFT FOOT

1st dorsal interosseous

Dorsal digi tal m uscle
neurovascu lar bundle
Extensor di gi torum
Flexor Hallu cis brevis t. longus & brevis
tendons, 3rd toe
Abductor hallu cis t.
Adductor h allucis
m uscle, transverse head
Flexor hall ucis lo ngus
ten don Pla ntar p la te, 4th
Adductor h allucis metatarsop hal angea I
mu scle, obl iqu e head joint
Flexo r cli gi torum
Plan tar fascia longus tendon, 3rd toe

Flexo r cli gitorurn brevis

tendon, 3rd toe

Extensor hallucis t. Extensor hallucis brevis

tendo n

M ed ial collateral Extensor h allucis

ligam en t longus tendon

Abd uctor hallucis t.

Add uctor hallucis t.

Flexor h allucis brevis Lumbrica l t., 4th toe

tendon, m ed ia l head

Flexor digi torum

Flexo r hal l ucis lo ngus
longus ten don
ten don
Flexor hallucis brevis
tendon, lateral head Flexor digi toru m brevis
tendon

(Top) Plantar fascia sends fibe rs d orsa ll y a n d superficia lly in an arborizin g pattern. (Bottom) Flexor digito ru m lon gus
a nd brevis tendon s a re cent ered beneath m etatarsal heads, with brevis su perficial to longus, in close proxim ity to
,
-
p la nta r plate of metatarsophalangeal jo ints. Lumbrical m uscles co urse media l to m etata rsa ls heads and w ill inse rt o n
medi al margin of prox imal ph alanges. 0
0

VIII
47
 FOOT OVERVIEW
CORONAL MR, METATARSAL HEADS RIGHT FOOT

Exte n so r di gitorum
longus tendon , 2nd toe
Exte nso r reti n acul um,
2nd_!:oe
Extensor digitoru m
brevis tendo n , 2nd toe
Sesam o ids o f 1st toe

Dorsal di gital vesse ls,

5 th toe
Flexor hallucis longu s
tendo n

Deep fibers of plantar Plantar fascia

fascia

Dorsa l d igi tal

neurovascul a r bundles Late ral collateral
ligament

Med ial collateral

ligam e n t
Fl exor hallucis brevis,
m edial head &
Pl antar p late, 2n d a bduc to r ha llucis
metatarsophalangeal
jo in t Fl exor hallu cis longu s
tendo n
Flexor digitoru m Flexor h allucis b revis,
longus ten don , 2nd toe late ral head & adductor
hal lucis
Flexor digitorum brevis
tend o n , 2nd toe

(Top) Medial sesam o id of 1st toe is in the te ndon of m edial h ead flexor h all ucis brevis te nd on, and is also attached to
adductor hallucis tendo n. Late ra l sesamoid is in lateral h ead flexor h all ucis brevis te nd on, and also a ttach ed to
00 abductor hallucis tendo n. Flexor hallucis longus tendon courses between sesamoid s. Fibro us se ptae exte nding from
main portio n of plantar fascia to MTP joints are well seen o n this image. (Bottom) Plantar plate exten ds from
LL. metata rsal neck to base of proximal phala n x, and is an important stabilizer o f th e MTP joints.

VIII
48
 FOOT OVERVIEW
CORONAL MR, METATARSAL HEADS LEFT FOOT

Extemor digitorum
longus tendon , 2nd toe
E.xten sor digi toru m
brevis ten don, 2nd toe

Ex ten or retina cu lum,

2nd toe

Sesamoids of I st toe

Dorsal digital vessels,

5th toe
Flexor longus
tendon

Pla ntar fascia Deep fi bcrs of pian ta r

fascia

Dorsa l digital
neurovascular bundles
Latera l collatera l
ligament

Media l collateral
ligam ent

Flexor hallucis brevis,

medial head and
abducto r hallucis Plantar plate, 2nd
metata rsop ha Ia n gea I
jo in t
Flexo r hallucis lo ngus
tendon
Flexor digi to rum
Flexor brevis, longus tendo n, 2nd toe
latera l head and
adductor hallucis Flexor digitorurn brevis
te ndon, 2nd toe

(Top) Medial sesamoid of 1st toe is in th e tendon of medial head flexor hallucis brev is tendon, and is al so attach ed to
adductor ha llucis tendon. Lateral sesam oid is in latera l head flexor hall ucis brev is tendon, and also attached to
abductor hallucis tendon . Flexor halluci s longus tendon co urses between sesamoicls. Fibrous sep tae extending from .,0
main portion o f plantar fascia to MTP joints are well seen on this image. (Bottom) Plan tar plate ex ten ds fro m
meta tarsal neck to base of proxima l pha lanx, and is an important stabilizer of the MTP joints.
-0

VIII
49
 FOOT OVERVIEW
CORONAL MR, PROXIMAL PHALANGES RIGHT FOOT

Medial & lateral f.x temor hallucis

collaleral liga m en ts, lo ngus tendon
2nd loe
Ex tensor ten don s, 3rd
& 4th toes

Flexor ha ll uci brevis,

Plantar digi tal m ed ial head &
neurovascular bundles adductor hallucis

Flexor digitorum Flexor halluci lon gus

longus & brevis, 4th tendon
toe
Flexor hallucis brevis,
latera l head & add ucto r
h allucis

Extensor ret inaculum, Extensor hallucis

2nd toe lon gus tendon

Dorsal digi tal

n eurovascular bu ndles

Flexor hallucis lon gus

tendon

Fl exor digitoru m
tendo n s

(Top) Plantar vessels and nerves lie between metata rsal h ead s wh ere nerves are susceptible to com pression. (Bottom)
Ex ten sor retinacula are seen superficial to exten sor tendon s and attaching to d orsolatera l margi ns o f phalanges.
00 Fl exor re tinacu la are not well seen on this im age because of th eir obliquity to imagi ng plane. At level of prox imal
ph alanges, fl exor digitorum brevis tendon s split into media l and latera l slips wh ich attach to the midd le pha langes.
LL Fl exor digito ru m longus tendo n courses betwee n th em. Th e tiny sli ps are difficult to dist inguish on Mit Dorsa l
digita l neurovascu lar bu n dles are present at m edial and latera l aspects o f digits.
VII I
50
 FOOT OVERVIEW
CORONAL MR, PROXIMAL PHALANGES LEFT FOOT

Medial & lateral

collateral l igaments,
hallucis 2nd toe
longus tendon
Ex tensor tendons, 3rd
& 4th toes

Flexor hallucis brevis,

medial head & Plan tar d igital
adductor hallucis neurovascular bun dles

Flexor digitorum
Flexor longus lo ngus & brevis, 4th
tendon toe
Flexor brevis,
lateral head & adductor
hal lucis

Extensor retinaculum,
2nd toe
F.xten sor hallucis
longus tendon

Dorsal digital
neurovascular bundles

Flexor longus
te ndon

Flexor digitorum
tendons

(Top) Plan tar vessels and n erves lie between m etatarsa l heads wh ere nerves are susceptible to com pres ion. ( Bottom)
Extensor retinacu la are seen superficial to exten sor tendons and attaching to dorsolateral m argins of ph alan ges.

-
Flexor ret inacu la are not well seen o n thi s image beca use o f their obliquity t o imaging plane. At level of proximal "11
ph alanges, flexor digito ru m brevis tendons split into m edial an d latera l slips which attach to th e m idd le ph alanges. 0
Flexor digitorum longus tendon courses between t hem . Th e t i ny slips are difficul t to d istingu ish on MR. Dorsa l 0
digita l n eurovascular bundles are present at m ed ial and lateral aspects of digits.
VIII
51
 FOOT OVERVIEW
CORONAL MR, PHALANGES RIGHT FOOT

Ex tensor digitorum
longu s tendon, 3rd toe

Extensor digitorum Plan tar di gi tal

brevis tendon, 3rd toe neur.ovascu lar bundles

Flexor reti naculum , 4th

toe
Flexo r hallucis longus

Flexor digi torum Flexo r retin aculum, l st

lo n gus & brevis toe

Extenso r hallucis
Ex ten sor digito rum lon gus tendon
lon gus tendons

Dorsal di gi tal
neurovascul ar
structures

Fl exor digitorum Plan tar digi tal

longus tendon, 4th toe n eu rovascular bundle

Flexor digitorum
lo ngus tendons

(Top) Flexor digitorum brevis div ides into 2 te nd o n slips to each toe, inserting on middle pha lanx. Flexor digi to rum
lo ngus has a single slip which passes between them to insert on distal p h alanx. (Bottom) Flexo r digito rum brevis
00 d ivides into 2 te ndon sli ps to each toe, inserting on middl e phala n x. Flexo r d igitorum longus has a single slip whi c h
passes betwee n the m to insert o n d istal phalanx. Extensor digito ru m brevis te ndo n slips a ttach to la teral side o f
LL exte nsor dlgitorum lo ngus ten don slips.

VIII
52
 FOOT OVERVIEW
CORONAL MR, PHALANGES LEFT FOOT

Exten sor digi torum

longus tendon , 2nd toe

Plan tar digital Extensor digi torum

neurovascular bundles brevis tendon, 2nd toe

Flexor reti naculum, 4th

Flexor hal l ucis lon gus toe

Flexor retina culum, 1st

toe Flexor digitorum
longus & brevis

Exten sor ha l lucis

longus ten don Exten sor digi torum
longu s tendons

Dorsal digital
neurovascular
structures

Flexor digi torum

Plantar digital
longus tendon, 4th toe
n eurovascu lar bund les

Flexo r d igitoru m
longus tendons

(Top) Flexor digitorum brevis d ivid es into 2 tendo n slips to each toe, inse rting o n midd le phalan x. Flexo r d igitorum
longus has a single sli p which passes between them to in sert o n di sta l phalanx. (Bottom ) Flexor d igitorum brevis
divides into 2 tendo n slips to eac h toe, inse rting on m iddle phalanx. Flexor d igitorum longus h as a single slip whi ch

-
"T1
passes betwee n them to insert on d ista l phalan x. Extensor digit o ru m brevis tendon slips atta ch to late ral side o f 0
exte n so r d igitorum longus te ndon slips. 0

VIII
53
 FOOT OVERVIEW
CORONAL MR, PHALANGES RIGHT FOOT

Extensor di gi torum
tendon s
Extensor hallucis
longus ten don

Prox i ma l Flexo r ha llucis lo ngus

interpha langeal joint, ten don
3rcl toe Flexor cligitorum
lo ngus tendo n, 3rd toe
Flexor digi torum brev is
ten don, 3rcl toe

Exten sor digil"o rum

longu s tendon s
Flexor te ndon sh ea th
2nd toe

Flexor hal l ucis longus

tendo n
Flexor cligitorum
longus tendons

(Top) Flexo r d igitorum longus tendo ns run between flexo r digito rum b revis a nd a ttach to di stal phalanges. (Bottom)
Distal phalanx o f 4t h toe and middle p h ala nges of 2n d-4th toes a re included on th is image. Flexo r tendo n sheaths to
00 2nd a nd 3rd toes form sling around flexo r tendo ns.

u..

VIII
54
 FOOT OVERVIEW
CORONAL MR, PHALANGES LEFT FOOT

Exte nsor digit orum

tendons
Exten sor hallucis
longus tendon

Flexor hallucis longus

tendon Proximal
interphalangea l joint,
Flexor digitorum
3rd toe
lon gus tendon, 3rd toe
Flexor digitorum brevis
tendon, 3rd toe

Ex tensor cli gitorum

longus tendons
Flexor tendon shea th
2nd toe

Hexor
tendon
Flexor cligi to rum
longus tendon s

(Top) Flexor d igito ru m lo ngus te n do ns run between fl exor d ig ito rum b revis and attach to d istal phala nges. (Botto m)
Distal pha lanx of 4th toe a n d m iddle ph alanges of 2 nd -4th toes arc includ ed o n t his image. Flexor tendo n sh eath s to
2nd and 3rd toes fo rm ling around fl exor te ndo ns.

-
"T1
0
0

VIII
55
 FOOT OVERVIEW
SAGITTAL MR, 1ST RAY

iJ
1st prox imal phalanx
1st cuneiform

Navicular

Medial sesamoid of 1st

toe
Abductor hal lucis m.
Flexor hallucis brevis
muscle, m ed ial h ead

iJ
Plan tar plate

Exten sor h alluci s

lon gus tendon

Flexor h al lucis longus

tendon

Medial sesa moid o f l st

toe

Flexor hallucis brevis

muscle, med ial h ead

(Top) First of sixteen sagit tal MR images from m edial to latera l, aligned alo ng axis o f 1st meta ta rsal. Abductor
hallu cis muscle lies medial to 1st metatarsal, while flexor h allucis brevis lies beneath it. (Bottom) Plantar pla te is a
00 strong fibrocar tilagin o us thicken ing o f plantar joint capsu le. It is attached to both sesa m o ids, to metatarsal neck, to
medial a nd late ral collateral ligaments, and to base of proxima l p halanx .
LL

VIII
56
 FOOT OVERVIEW
SAGITTAL MR, 1ST RAY

[[

Ex ten sor h all ucis b revis

ten d on
Dista l p ha la nx, l st toe

Flexo r ha llucis lo ng us fl exo r ha ll ucis brevis

te nd o n muscle

Flexo r digitorum brevis

muscl e

Plan ta r fa scia

2 nd m etatarsal

Ist dorsa l interosseous 2nd cuneifo rm

muscle

Lateral sesa m o id o f I st 1st m etatarsal

toe

Flexor h allucis b revis

m uscle, lateral h ead
Flexor digitorum brevis
muscle
Plantar fasc ia

(Top) Flexo r hallucis longus tendon co urses between sesamo ids of 1st toe, and inserts o n dista l phalanx of 1st toe.
Ex tensor hallucis brevis tendon lies lateral to longus tendon, and inserts on proximal p ha lan x of 1st toe. (Bottom )
Distal portion of peron eus lo ngus tendo n is seen attachin g to 1st metatarsal base. "T1

-
0
0

VIII
57
 FOOT OVERVIEW
SAGITTAL MR, 2ND RAY

IJ
2nd tarsometatarsal
joint
1st dorsal interosseous
Extensor hallucis brevis
muscle
musc le

Lateral sesamoid, 1st

toe

Adductor hallucis
muscle, oblique head
Flexor digitorum brevis
muscle
Flexor digito rum
longus tendon

IJ
2nd m etatarsal base

1st dat·sal interosseou s Extensor hallucis brevis

muscle muscle

Adductor h allucis
3rd cuneifo rm
muscle, obl ique head

Quadratus plan tae m.

Flexor digi torum
longus tendon Flexor digi torum brevis
muscle

(Top) Thi ck, broad adductor hallucis musde is seen a ttachi ng to late ral sesamoid of 1st toe. Quad ratus plantae
m uscle is seen a ttachin g to flexor d igito rum lon gus tendon. (Bottom) Inte rspace between 1st and 2nd metatarsals
00 contains on ly a dorsal inte rosseous muscle, attaching to medial aspect of 2nd proxima l ph ala n x. Remaining
inte rmeta tarsa l interspaces contain d o rsal and plan tar interosseo us muscles. Dorsal m uscles attach to la te ral aspect o f
LL proximal phalangeal bases 2-4, a nd plantar attach to media l aspect of proximal phalangea l bases 3-5.

VIII
58
 FOOT OVERVIEW
SAGITTAL MR, 2ND RAY

2nd m eta tarsa l

Adducto r h al lucis Ex ten sor d igi toru m

muscle, ob lique h ead brevis muscle

3rd cuneiform
Adductor h allucis
muscle, transverse h ead

Flexor digitorum
lo ngus te ndon

Flexor digi torum brevis C uboid

tendon

Fl exor d igitorum brevis

muscle

b . tensor digitorum
ten don

Adductor h allucis
oblique head

Addu ctor hallucis Exte nsor digitorum

transverse h ead brevis muscle

Plan tar plate

:----+- Flexor digil orum brevis

mu scle

(Top) Flexor digitorum b revis muscle di vides into sli ps to toes 2-4 and somet im es 5 at level of metata rsal shafts.
Tendons are su perficial to flexor digitorum longus tendo ns. ( Bottom) Exten sor digi torum longus and b revis tendons
run side by side in forefoot , w ith brev is lateral to co rrespon ding longus te ndon . Brevis tend on attaches to lateral

-
"T1
margin of longus tendon. 0
0

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 FOOT OVERVIEW
SAGITTAL MR, 2 ND -4TH RAYS

Int erosseous m.

digitoru m Exten sor cl igitorum

lo ngus tendon m.

Add ucto r hallucis

muscle, transverse head Jrd metatarsal

;:::=:::::;:;.- Adductor h allucis

Flexor digitorum muscle, oblique head
longus tendon

Cuboid
Plantar fascia
longus t.

jJ

Extensor digitorum
lon gu s tendo n
Extensor digi torum
brevis
Fl exor digitorum
lon gus tendo n

Adductor hallucis
muscle, transverse head
Flexor d igi torum brevis
tendon

(Top) In fo refoot, plantar fascia divides into digi ta l bands. At level of metatarsal h eads, it arborizes i nto superficia l
and deep co mponents. (Bottom) Peroneus longus tendon li es in groove benea th cubo id, held in place by long
0 plantar ligament.
0
LL.

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 FOOT OVERVIEW
SAG ITTAL MR, 3 R0-4TH RAY

Interosseous 111.

Add uctor h allucis

muscle, transverse h ead
Exten sor digi torum
brevis muscle
Digi tal neurovascular
bund le
4th metata rsa I

Flexor digitorum
lo ngus tendon
Peroneus lo ngus t.
Flexor digi torum brevis
tendon
Q uadratus pl antae m.

Lumbrical m.
Add uctor halluci s
muscle, oblique h ead

Ex ten sor digi torum

Interosseous muscles brevis

Flexor digi ti minimi 111 .

Abducto r digi ti minimi

muscle

(Top) Thin lumbrical muscles lie adjace nt to fl exor di gitorum te ndon slips in 2 nd layer o f planta r muscles. (Bottom)
Because of normal fanni n g of toes, sagitta l images a ngled to 1st metata rsal will beco me oblique a t lateral aspect of
foot, as shown on this image. 3rd meta ta rsophala n geal jo in t, 4th me ta ta rsa l and Sth m etata rsal base a re seen h ere o n

-
"T1
a single 3 rnm thic k slice. In clinical pract ice, sagi tta l axis for imaging fo refoot will be c h osen fo r metatarsal o f 0
concern , or as defau lt alo ng 1st m e ta ta rsal ax is. 0

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 FOOT OVERVIEW
SAGITTAL MR, 4TH-5TH RAY

iJ
Interosseous muscles

Flexor digitorum
longus tendon 4th

( tyloid
process), 5 th metatarsal

Flexor digiti mi nimi Peron eus brevis tendon

muscle
Abductor digiti minimi
muscle

IJ
Ex tensor digitorum
longus ten don, 4th toe
in serti on
4th dorsal
muscle
Flexo r cligito ru m
lo ngus tendon, 4th toe
Tuberosity o f Sth
Plantar fascia metatarsal
Abductor digiti minimi
muscle

Plantar fascia, lateral

band

(Top) Flexor d igit i m in imi muscle lies at plantar aspect o f Sth m etatarsa l, an d abductor digiti m inim i muscle lies at
its lateral aspect. Pero ne us b revis tendo n attaches to tuberosity (sty loid process) a t latera l ma rgin of metatarsal base.
0 (Bottom) Fine digi ta l fascial n etwork whic h is dista l te rminati o n of pla ntar fascia is we ll seen.
0
u.

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 FOOT OVERVIEW
SAGITTA L MR, 5TH RAY

Flexor digitorum 4th & J rd

tendon pla ntar interosseous
muscles

Abductor digi ti minimi

muscle

Flexor digitorurn
lon gus tendon, 4th toe
Sth m etatarsal head

Abductor d igiti minimi

muscle

(Top) Note that a in rest ing, nonweight-bearing beari ng position proximal interpha langeal joi nt is minimally flexed,
and distal interphalangeal joint is straight. (Bottom ) Abd uctor digi t i minimi is most lateral musc le of forefoot.
.,0
-0

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 INTRINSIC MUSCLES OF THE FOOT
o Add ucto r ha ll ucis
IGross Anatomy • O rigin: Obl iq ue head o riginates from bases of 2nd,
Plantar Musculat ure 3rd, and 4th m etatarsa ls, t ransverse head
• 4 laye rs of muscles deep to p lantar aponeu ros is o rigina tes from 3rd, 4th a nd som etimes Sth
• Peron eus longus tendon cou rses across a ll 4 layers planta r MTP liga m en ts
from late ral to medi a l • Insertion: Lateral sesamoid of 1st toe and base of
• Arte rial supp ly by n etwork of med ial and la te ra l 1st proxim al p h ala n x
plantar arte ries and p lantar a rterial arch • Innerva tion : Deep bra n ch latera l plantar nerve
• Superficial (1st) m uscle layer • Functio n: St abi li zes metatarsal heads, flexes
o Abd uctor hallucis proxima l ph alan x of 1st toe
• Origin: Medial aspect posterio r process calcaneus, • Va riant: Tra n sve rse hea d ma y be absent
flexo r retinaculum, plantar fascia, inte rmuscula r o Flexor d igiti mi n im i b revis
se ptum • Origin: Base of Sth m eta tarsal and sheath of
• Inse rtio n: Med ial sesa m o id o f 1st toe and media l peroneus longus tendon
aspect 1st proximal ph alangea l base • Insertio n: Lateral m argin, base o f Sth proxima l
• Innervatio n: Med ial pla ntar nerve ph ala n x
• Fu nctio n : Moves 1st to e m ed ia ll y • Innerva tion : Superficial branch of lateral plan tar
o Flexo r digitoru m brevis n erve
• O rigin: Posterior process calca neus, planta r fascia, • Function : Flexes MTP joint of Sth toe
in te rmu scular septum • In terosseous (4th) layer
• Divisio n s: 4 ten don sli ps split into medial a n d o Pla ntar in terossei: 3 muscles, to 3rd, 4th and Sth
lateral tendons at meta ta rsopha langea ls (MTPs) toes
• In se rtion: Medi al and latera l m argin s of bases o f • Origin : Medial bases of 3 rd, 4th and Sth
midd le p ha la nges m etatarsa ls
• Innerva t ion: Media l pla ntar nerve • Insertion : Medial base of prox imal phalanges of
• Functio n: Flexes proximal in te rpha la ngeals (PIPs) same toes
o Abd uctor digiti m in imi • Innerva tion : Deep bran ch lateral plantar n erve
• Origin: Posterior process calca neus • Fu nct io n: Add uct 3rd-St h toes, flex
• Insert ion: Base St h proxim al p ha lanx m etatarsopha langeal joints, exte nd proximal
• Inn ervation: Lateral p la n tar n erve inte rpha lan geal joints
• Function: Moves Sth toe latera lly o Do rsal interossei: 4 muscles, to 2nd , 3rd, 4th, Sth
• Va riant: Abd ucto r ossis m etatarsi quinti a rises toes
t uberosity Sth meta ta_rsa l, merges with abductor • O rigi n: Each h as 2 heads, fro m late ra l and med ial
digiti minimi margin s of 2 ad jacent metata rsals
• M iddle (2nd) m uscle layer • Insertion : 1st to media l margin 2n d proximal
o Tendons of 2 ext rinsic muscles: Flexor digito ru m p ha lanx, 2n d-4 th to latera l margin of 2nd-4t h
lo ngus and flexor hallucis longus proxima l p hala nges
• Fibers fro m th ese 2 tendon s join at m aster knot of • In n erva tion: Deep branch la te ral plan tar ne rve
Henry, and exchange fi bers • Function: Deviate to es laterally, flex MTP joints,
o Quadratu s pla n tae (a lso called flexo r accessorius) exten d PIP join ts
• Origin: 2 heads a ri se from posterior process Dorsa l Muscles
calca n eus and lo ng plantar ligament • Ex t rins.ic m uscles: Te n dons o f t ibiali s anterior
• Insertio n : Te ndo n of fl exo r d igitorum brevis exte n sor ha ll ucis lo ngus, extensor digito rum brevis,
• Innervation: Lateral pla ntar n erve pero neus t ertius
• Function: Flexes lateral 4 toes • In t rin sic muscles
o 4 lumbricals o Exten so r h allucis brevis: Pa rtiall y joined to extensor
• Origin : Tendo n s of flexor digitoru m lo n gus digitorum brevis
• Inse rtion: Proximal ph alanges of 4 late ra l toes • O rigi n: Ante rio r aspect calcaneus
• Innerva tio n: 1st lumbrical from m ed ial pla ntar • In sertio n: Base prox ima l phalanx of 1st toe
nerve, ot he rs by deep bran ch lateral plantar nerve • In nervation: Deep peron ea l nerve
• Function: Ma in ta in extensio n of inte rpha langeal • Fu nction : Extend s proximal ph alanx
joi nts o Ext ensor d igito ru m brevis
• Deep (3rd) muscle layer • O r.igin: Ante ro latera l aspect ca lca n e us
o Flexor ha llucis brevis • In se rti o n: La te ral ma rgi n s of extensor digitorum
• Origin: Latera l head o rigin a tes fro m plan ta r lo n gu s tendons to 2n d-4th digits and bases middle
surfa ce cuboid; medial h ead arises latera l division phalanges
t ibialis post e rior and medial intermuscular septum • In nervatio n : Deep peron ea l ne rve
• Inse rtion: Med ial a nd la te ra l head s insert

-
• Fu nction : Extend p hala nges of toes
respectively o n media l a nd late ral aspects base 1st • In h ind foot, extrinsic tendons superficial to int ri nsi c
proxim al p h ala nx tendo n s
0 • Cont ains: Medi al a nd lateral sesa moids of lst toe • In forefoot, in t ri nsic (brevis) tendons lateral to
0 • Inne rvat io n: Medial plan tar nerve extrinsic (longus) tend o ns
LL • Fu n ctio n: Flexes proxima l p ha lanx of 1st toe

viii
64
-
'"T1
0
0

VIII
65
 ...
0
0
LL.

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 INTRINSIC MUSCLES OF THE FOOT
CORONAL T2 M R, M USCLE LAYERS

Pero neu s longus t. Abd uctor h allu ci s m.

Quadratus plantae m. rlexor h al lucis brevis

mu scle

Flexor halluci longus

Flexor digitorum tendon
longus ten don
In term uscular fascia
Flexor digiti m i n imi
brevis mu scle Flexor digi torum brevis
muscle

Abductor digit i minimi

muscle

2nd dorsa l in terosseou s

muscle
3rd &. 4t h do rsal
i nterosseou s muscle
1st dorsal interosseous
musc le

Plantar vascula r arch 1st plan tar i nterosseous

muscle
Flexo r digi ti minimi
muscle
abductor digiti minimi - -n;;;;;;;iiir
muscle Adductor hallucis,
oblique h ead
Fl exor di gi torum
longus ten don

Flexo r digitorum brevis Abducto r ha llucis m.

muscle

Flexor ha ll ucis brevis

Flexor hallucis longus
muscle
ten don

(Top) First o f two non -adjacent coro n al T2 MR images, at t he level of c un eifo rms. Divi sio n o f p lantar m uscles into
d istinct m edial, interm ediate, and late ral compartments is we ll seen. Fascia d ividing the com pa rtments are o fte n
mo re read ily appa rent on T2WI than on Tl WI. The four layers o f plan ta r m u scles show co nsiderable overlap; for

-
"TT
example abductor hall uc is musc le, in 1st layer, is dorsal t o flexor hall ucis brevis, in 3rd layer. (Bottom) More dista l 0
image from pre vio us image. Ma in plantar compartme n ts of fo refoot are read il y apparen t o n corona l images. 0
Abducto r a nd flexo r h allucis m uscles a re in media l compa rtme nt; abd uctor a nd flexor d igiti mi ni m i musc les a re in
lateral compa rtment; addu ctor h allucis and fl exor d igitorum m uscles are in central com part m ent.
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 TARSOMETATARSAL JOINT
• Intermetatarsal ligaments
ITerminology o Dorsal, interosseous and plantar ligaments between
Synonyms 2nd-5th metatarsal bases
• Lisfranc jo int o o dorsa l o r p la ntar ligam ents between 1st a nd 2 nd
m etatarsa l bases
• Wea k interosseous liga ments are prese nt in this
I Imaging An at o my region
• The lack of inte rm etatarsa l li game nts between 1st
Overview and 2nd me ta tarsals increases impo rtance of
• 1st-5 t h tarsometatarsal articul ations u sua ll y Lisfran c liga ment '
considered functionally as 1 join t Bursae
• Follows tran sve rse a rc h co nfi guration estab lished by
• Bursa between 1st and 2nd m etata rsa l bases
wedge shape of cune ifo rms
• Lateral a nd p la nta r bu rsae at base Sth meta tarsal,
o Bases of 2nd and 3rd metatarsals also h ave wedge
under abduc tor and fl exor m. origin s
shape
• Bursa at pla ntar 1st tarsometatarsa l join t, under origin
• In corona l plan e, jo int extends obli quely fro m
flexor hall uci s brevis
anterom edial to p osterolateral
• Bursae at p lantar tarsome ta ta rsa l joints, under
o 2n d me tatarsal recessed relative to 1st and 3rd
extensor tendons
• This provides added bo n y stability ("mortise and
t en o n " co nfigurati on) Motion
• Some individ uals lack recessed position of 2nd • lst tarsome tatarsa l join t allows abd uction, slight
metata rsa l: T h ey ha ve hi gh er in cidence of flexion and extension
d islocation • 2nd and 3 rd tarso m etatarsa l joints relatively immobile
o Cuboid slightly recessed relative t o 3rd cuneiform • 4th and Sth tarsometatarsa l joi nts have abou t JOo of
• Creates mortise and te no n configuration in fl exion and e xtension
op posite o ri e nta tion to 2nd tarsometatarsal joint
Synovial Divisions
• 3 separate synovial joint cavities
!Anatomy-Based Imaging Issues
o 1st tarsome tatarsa l jo int Imaging Recommendations
o 2nd and 3rd ta rsometatarsal joint • Radiograph s must be we ight-bearing to evaluate
• Usually continuous with joint between 2nd and a li gnm e nt
3rd cuneiforms, and naviculocun e iform jo int o Abd uc t ion stress views may e lic it instability
o 4th a nd Sth ta rso m etatarsa l joint • Axia l and co ronal MR provide best visuali za t ion of
o Tnte rm etata rsa l jo ints have continuous cavity with Li sfra n c ligament
ta rso m etata rsa l jo in ts o Optim ize w ith small surface coi l placed o n dorsu m
Ligaments o f foot, centered at Li sfran c joint
• Dorsal tarsometata rsal ligame nts Imaging Pitfalls
o 1st cune iform to 1st metatarsal • Interosseo us Lisfra n c ligament structura lly most
o 1st cuneifo rm to 2n d m etatarsa l (do rsa l Lisfranc important sta bil izer of Li sfran c joint
liga me nt) o Since obliquely o riented, see on seq ue ntia l co ro nal
o 2nd and 3rd cun e ifor m s to 2nd metatarsal MR images
o 3rd cuneiform t o 3rd meta tarsa l o See o n ax ia l MR images through midporti o n of
o Cu bo id to 4th and Sth m etatarsals c une ifo rm s and m etatarsa l bases
• Interosseou s ta rsometata rsal ligame nts
o Lisfranc ligament: O riginates late ral sm face 1st
cuneiform, courses anterolaterally and slightly IClinical Implications
inferi orly, inse rts lower ha lf of m edial surface o f 2nd
m eta tarsal base Clinical Impo rtance
• Th ick, broad li ga m ent, and key stabiliz ing • Injuries of Lisfranc joi nt comm o nly missed in
stru cture e m ergen cy depa rtment setting
• Nea rly 1 em fro m top to bottom, 0 .5 em • Isolated tears of Lisfranc ligame n t occur with plantar
m ediolateral flexion , axial load
• Ligament co m posed of 2 sepa rate bands in up to • Eve n slight late ral di splace ment o f 2nd me tata rsa l
1/ 4 of population med ial ma rgin relative to m ed ial ma rgi n o f 2nd
o Variable ligamen ts between 2nd and 3 rd cun eifo rm s cuneifo rm indi cates disruptio n o f Lisfran c li gament
and respective metatarsa ls • rlatte ning of tran sve rse and lo ngitudinal arch es of
• Planta r tarsometat arsal ligaments foot a nd osteoa rthriti s of Lisfranc jo int develop rapidly

-
0
0
LL
o 1st cuneifo rm t o 1st metatarsa l
o 1st cuneiform to 2nd and 3rd m e tata rsals
• Act with Lisfranc ligame nt, also important
sta bi Iizers
if ligamentous disrupti o n untrea ted

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 TARSOMETATARSAL JOINT
RADIOGRAPHS, LISFRANC JO INT
ll'"ll'".............

l st tarsom etatarsal joi n t

2nd tarsometatarsal joi n t

3rd tarsom etatarsal join t
1st cun eiform

4th tarsom etatarsa I jo int 2nd cuneiform

5 th tarsom etatarsal jo int

Tuherosity (stylo id process) o f 5th

m eta tarsal

1st tarsometa tarsal join t

2nd ta r5ometatarsa l joi nt
3rd tarsom etatarsa l jo int
1st cunei form
4th tarsom etatarsa l jo int
2n d cun eiform
5th tarsom etatarsal joint

3rd cunei form

Tubermi ty (stylo id process) of 5th
me tatarsal

I st tarsom eta tarsa l jo int

:;.==....;;-==r- Sty loid process (tuberosity) 5th

metatarsal

(Top) Anteroposte ri o r ra diogra ph sh ows zigzag configurati on o f tarsometata rsal joi n t, from an te ro medial to
poste ro la tera l. 2n d me tatarsal is recessed re lati ve to 1st and 3rd, and cuboid is recessed re lative to 3rd cu n eiform.
Ta rsome tata rsa l jo ints are in profile in t his subject, bu t in other norma l subje ct s may not be clea rly seen du e to th eir .,
-
obliquity. Metatarsal bases a re overlapping, and inte rme tatarsal joints a re not v isu alized. (M iddle) Antero posterio r 0
rad iograph sh ows 2 nd m etatarsa l base is not recessed relati ve to 3rd, a norm al va riant w h ich predisposes t o 0
disloca ti o n. (Bottom) O n la te ra l rad iograp h , 1st and 2nd ta rso m etatarsa l jo ints are at do rsum of foot, a nd 2nd
ta rsom e ta tarsal jo int is located more prox imally.
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69
 TARSOMETATARSAL JOINT
SAGITTAL CT, LISFRANC JOINT

1 avicular

I st tarsometatarsa l joint
bt cuneifor m

I st proximal phalanx

[jJ 2nd cuneiform

2nd tarsometatarsal joint

3rd ta rsometa tarsa l joint

lntwmetatarsal join t
Cuboid

3rd metatarsa l

[j]
Cuboid
Sth joint
4th metatarsal joint

lnterme tatarsal joint Styloid process (t uberosity), Sth

m eta tarsal

4th m etatarsal

-
(Top) First o f three sagitta l CT scan s t hrough Lisfran c joint shows bony anatomy. The 1st cuneiform , metatarsal base
and tarsom etatarsal joint a re muc h larger than co rres po ndi ng bones of the late ra l digits. The re sh o uld be n o plantar
0 or dorsal o ffset o f the 1st proximal phala n x re lati ve to the 1st cun eifor m, even on no n -weight-bearing studies.
0 (Middle) Sagitta l CT t hrough 2nd and 3rd tarso metatarsa l jo ints showing recessed position of 2nd metata rsa l base
L1. relative to 3rd. lnte rmetatarsal joint betwee n bases of 2nd a nd 3rd meta tarsals is also well seen . (Bo ttom ) Sagitta l CT
th rough 4th and 5th t a rsometata rsal bases showi ng a rticu la tio n of cuboid with 4th and 5th metatarsa ls. The
tuberosity (styloid process) of 5th metata rsa l exte nds beyo nd la te ra l margin o f cu boid.
VII I
70
 "T1

-0
0

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 TARSOMETATARSAL JOINT
AXIAL T1 MR, LISFRANC LIGAMENT

Dorsa l Lisfranc liga m en t

1st cune iform -

In terosseous Lisfranc ligam en t

Tibial is an terio r tendo n

Pl antar Lisfranc l iga m en t

Tibialis anterior tendon

1st cunei form

3rd cuneiform

-
(Top) First o f three ax ia l T l MR images, fro m do rsa l to m ore plantar positions through th e Li sfran c joi nt. At t he
dorsal aspec t o f tarsomet a ta rsa l joint, a t hi n liga m en t extends fro m 1st c un eifo rm to 2nd me ta tarsa l. Isolated injury
0 to Lisfra n c ligame nt occurs with planta rflex io n of midfoot, so thi s li gament is 1st to be inj ured . (Midd le)
0 Interosseous Lisfra n c liga me nt is primary st abilizer between 1st and 2nd ra ys. It is thic k a nd broad wh en com pa red to
LL other inte rosseous ligame nts o f foot. (Bottom) Pla ntar Li sfra n c liga m e nt is a thin structu re pa rall eling dorsal and
in terosseous Lisfra nc Iiga me nts.

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 TARSOMETATARSAL JOI NT
CORONAL T2 MR, LISFRA NC LIGAMENT

Dorsa l Lisfranc
l igamen t

Interosseou s Li sfranc
l igament

Plan tar Li sfran c

ligam en t

Dorsa l Li sfranc
l iga m ent

Interosseous Lisfra n c - .;;:;::::=

l iga m ent

Pl an tar Lisfran c
ligament

(Top) First of two corona l T2 MR images of Lisfranc ligamen ts. Since ligaments are o bliquely o rie nted, t he ir entire
cou rse will n ot be see n on a single co ron al image. This image shows o ri gin from l st cuneiform. (Bottom ) Adja cent to
previous image sh ows insert ion of interosseous Lisfra nc ligam en t on 2 nd m etata rsa l base. .,
-
0
0

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 METATARSOPHALANGEAL JOINTS
• Medial and latera l collatera l ligaments: Well-defined at
!Imaging Anato my each digit
Overview Bursae
• In normal weight-beari n g stance, all o f t he m et atarsa l • l st metatarsophalangeal
h ead s a re at same level, and all a re weight-bea ring o Dorsal: Va riably presen t sepa rate from tendon
o Metatarsopha langeal (MTP) joints are slightly sheat h o f extensor hallu cis lo n gu s
ex tended in standing positio n o Pla n tar: Subcuta n eous, at pla n tar and medi al aspect
• Eac h metata rsop ha langeal join t is a separate synovial of metatarsal head
cavity • Inte rmetata rso ph a langea I
1st Me tata rsopha langeal joint o Loca ted bet ween me tatarsal heads
• Dorsiflexio n o f toe important in push-off phase of gait o Do rsal to tra n sve rse m etatarsa l li game nt
• Meta tarsa l h ead h as 2 co ncave facets at p lantar o Ad jacent to plantar digital n e urovascu lar bundle
su rface, 1 for each sesamoid, sepa rated by ridge (cri sta) • Bursitis m ay irrit ate nerve, mim ic Morton
• Distal a rticula r surface of metata rsal h ead m ay be fla t, neu ro ma
rounded, o r have a central prominence o Usually absent bet wee n 4th a n d Sth toes
• Base o f p roxim al pha lanx h as con cave cont o ur • Sth me tatarsopha langea l
• Sesamoids o Plantar: Subcutaneous, at p la n tar aspect o f
o Either sesa m oid may be unipa rt ite or bipa rtite me ta tarsal h ead
o Med ial sesa moid in medial head flexo r h allucis Nerves
brevis a nd abducto r hallucis • Plantar a nd do rsal ne rves course with arte rioles alo ng
o Latera l sesa moid in la teral h ead fl exor hallucis brevis m edial a nd la teral aspects of dig its
and addu cto r h allucis a nd deep meta ta rsal ligam e nt • Plantar ne rves vuln e rable to impin geme nt betwee n
o Medial a nd la te ral sesa m o ids jo in ed by m etata rsal heads
in te rsesamoid liga ment
• lnte rsesa mo id ligament is floor of ca n al in whi ch
run s fl exor h allucis lo ngus tendon !Anatomy-Based Imaging Issues
o Both a re e m bed ded in p lanta r plate of jo int
o Sesam oph a la ngeal appa ratus Imaging Recomm e ndation s
• Sesamoids fixed in positi on rela tive to 1st • Sesamoid eval uatio n
prox imal pha lanx, move relative to 1st me ta tarsal o Due to sm all size, fractures may be m issed o n
• The refo re disp laced la terally in hallux valgus rout ine exa minatio n
• Plantar plate o Wrist coil provides superior resolu ti o n to extremity
o Fibrocarti laginous pla nta r ca psula r t hi ckenin g coil
extending from m etatarsal n eck to base prox imal o Toes advanced into wri st co il past m e tatarsa l hea ds
p hal a nx o 2 mm Tl WI an d T2W I th rough sesamoids in
o Incorporates sesa moids sagittal, axial planes
lateral Metata rsophala ngea l joints
• Convex metata rsal h ead articular surface a rt icul ates
with concave arti cu lar surface of proximal phala ngeal
IClinical Implications
base Clinical Importance
• Plantar aspect of m etata rsa l head h as rounded contour • Instability of MTP jo ints results in pain and d eform ity
• Dorsal aspec t o f m etatarsal head is sma lle r t han of forefoot
plan tar aspect
o Has co ncave or notched conto ur alo n g medial a nd Stability of 1st MTP joint
late ral m argins • Colla te ral ligam en ts
• Sesamoids va riab ly present, most co mmonl y at 5th toe • Flexor a nd exte nsor h all ucis brevis mm
• Pha la ngeal apparatus is com bina t ion of pl a nta r plate • Flexor a nd extensor h allucis longu s have a sma lle r
and proximal phala nx co ntributi o n to sta bility
• Pla n tar p late
o Fibrocartilaginous pla nta r ca psula r t hickenin g Stability of lateral MTP joints
exte nding fro m m etatarsa l neck to base prox ima l • Colla te ral liga ments
phala n x • Pla ntar p lat e
o Attached to deep transve rse m etata rsa l l igame nt, o Rupture of planta r p late results in do rsa l sub lu xation
planta r fascia and flexo r ten don shea th , m edial and of MTP joint and h am m er toe defo rmity
latera l collateral liga m ents
Short 1st Metatarsal (Morton Foot)
o Instability m ay m imic Morton neuroma
• No rmal va riant but increases stress on 2nd m etata rsa l

-
0
0
LL
ligaments
• ln te rmeta tarsa l ligaments: Betwee n m etatarsa l heads
• Pla ntar fascia: Dist al a ttachm ents t o jo int ca psules
• Predisposes to osteo necro sis of 2 n d metatarsal head
(Freiberg in fraction)

VIII
74
-
"T1
0
0

VIII
75
 METATARSOPHALANGEAL JOINTS
RADIOGRAPH & MR, 1 ST METATARSOPHALANGEAL JOINT

1st distal phalanx

Articular faceb of I st
metatarsa l head

Lateral sesamoid Medial sesa m oid

Medial collateral
Lateral collateral l igament
ligament

1st dorsal interosseous

muscle

(Top) Sesamoid radiog raph obtained tangen t to sesamoids, w ith toe dorsiflexed. Se am oids are ce ntered o n articular
facets of m etatarsa l head. (Bottom) Ax ial Tl MR in patien t with co nical shape of 1st metatarsal head; shape of
(5 articular surfa ce varies fro m flat to ro und to co nica l i n di fferent patients.
0
LL

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76
 METATARSOPHALANGEAL JOINTS
M R CORONAL, 1 ST M ETATARSOPHALANGEAL JOINT

Extensor re tinaculu m

Lateral coll atera l I.

Medi al co llateral I.
l nterm etatarsa l bursa

Ar ticula r carti lage

Latera l sesamoid
l n tersesa rnoid l igam en t

Flexor hal lucis brevis

tendon

Ex tensor retinaculum

M ed ial collateral
l iga m en t
Lateral co llatera l I.

Articular cartilage

Abd uctor ha ll ucis

tendon

Adductor hallucis t.
Flexor hall ucis brevis
tendon, m ed ial head
Fl exo r h allucis bre.v is l ntersesa m oid ligament
tendon, lateral head
Flexor ha l lucis brevis
tendon

(Top) Co ro na l T2 MR shows no rma l amoun t o f fluid ou tlin in g a rticula r structu res. Also note flu id in inte rm etata rsa l
bursa. Bursae lie between each of the metata rsa l heads, an d sho uld not be m istaken for Morton neu roma.
Gadolinium-e n ha n ced MR is u seful in dist inguish ing t h ese t wo e ntities. (Bottom ) Corona l Tl MR sh ows norma l "'T1

-
positio n o f 1st toe sesa rnoids, and their stabilizin g struct u res. 0
0

V III
77
 METATARSOPHALANGEAL JOINTS
AXIAL MR, LATERAL METATARSOPHALANGEAL JOINTS

Plantar
muscles

5 th metatarsal head Dorsal

muscles

2nd metatarsal

Medial collatera l
liga ment

Lateral colla teral

l igamen t

Normal con cavity o f

dorsal portion o f
metatarsal head

(Top) Axia l Tl M R through plan tar aspects o f 3 rd t hro ugh 5th metata rsal h eads. At this level, heads have an ovoi d
shape. Tendo n s o f interosseous muscles lie between metatarsa l heads, with plantar interossei in erti ng on medial side
00 of proximal ph alan geal bases, and do rsal interos ei on lateral side. (Bo ttom) Axia l Tl MR through do rsa l aspects of
2nd and 3rd metatarsal heads. At thi s level , heads ha ve concave conto ur at both med ia l and lateral margin. T hese
U.. shou ld no t be mistaken fo r erosions. Distal arti cu lar surface is flat in con to ur o n 2 nd metata rsa l compared to 3 rd.
Thi s sho u ld not be mistaken for Freiberg infract ion .
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78
 METATARSOPHALANGEAL JO INTS
CORONAL & SAGITTAL MR, LATERAL METATARSOPHALANGEAL JOINTS

Extensor digitorum
Extensor digi torum lon gus t., 3rd toe
brevis t., 3rcl toe

Dorsal d igi tal vesse ls &

nerve 2n d dorsa l in terosseous
tendon

I n term etatarsa l 2n d m etatarsal h ead

liga m ent

Pla ntar plate 2nd

m eta larsoph a Ia ngea l
Flexor digi lorum jo in t
longus ten don Lu mbrica l ten don

Digital ban ds o f pla n tar

fascia

Exte nsor cligitoru m --+--------::::

longus tendon Proxi mal margin o f
dorsa l joi n t capsu le

Art icular cart i lage

Flexor digitorum --l=;::==;,;="

tendons

(Top) Co ron al Tl MR image th ro ug h metata rsophala ngea l jo ints sh ow m etat a rsa l head s are con cave a t th eir medi a l
and la te ral aspects, and la rger at the ir plantar th an th e ir dorsa l sur face . Inte rosseous t e nd o n s lie between m eta ta rsa l
h eads, flexor a nd lu m bri cal ten dons o n pla n tar s urfa ce, and exte nsor tendo n s a re dorsa l. Th ic k pla n ta r plat e is dee p "T1

-
to fl exor ten dons. Medi a l and late ral collat e ra l li gam ents a re we ll seen as thi ckeni ngs o f joi nt ca ps ule . (Bottom) 0
Sagitta l T2 M R t hro ug h 2 nd me ta tarsophalangea l jo int sh ows plan t ar plate deep to flexo r t endo n s. Articular ca rtilage 0
ends slightly proxima l to jo int capsule ma rg ins, leavi ng a n unco ve red "ba re a rea" w he re ea rliest bo n y e rosio n s w ill be
visible in cases o f in fla mmat o ry ar th rit is.
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 NORMAL VARIANTS
• 35% n o a rticu lar facet
!Terminology • 38% sm a ll articular face t
Definitions • 27% well-deve lo ped a rticula r face t
• Accessory cente r of ossifica tion: Va ria nt cente r of o Recessed positio n o f 2nd m e tatarsal relative to 3 rd
ossification associa ted with a bo ne n ot unive rsa ll y p resent
• Sesamoid: Ossicle arising withi n a tendo n • Position o f 2nd tarsometata rsa l jo int
o Always proximal to 1st tarsometatarsal joint
o May be proxima l to o r in sa m e plane a J rd
IImaging Anatomy metata rsal joi nt
• Morton foo t: 1st me ta tarsal short relafive to 2n d
Overview o Resu lts in increased stress o n 2nd (MT)
• Norma l va riants a re comm o nly fo u nd in foot • Failure of seg me ntati o n: Middle and di stal pha langes
• See Ankle section fo r descriptio n of norma l varian ts o f of 5th toe common ly fail to segment
hindfo ot Muscle Variants
Accessory Centers of Ossification • Q uadratus plantae: May be absent; may send slip to
• Os supranavi c ul are (a lso ca lled os ta lo nav iculare 5th toe, to 2nd-4th toes, o r to 2nd-3rd toes
do rsale or Pirie bo ne): Dorsal, proxima l margin o f • O ppo nens di gi ti minimi: Va riab ly present muscle slip
navicular of flexo r d ig iti minimi, sha ring its origin a nd insert ing
• Accessor y nav ic ular (a lso call ed os tibia le ex ternum): on d ista l 5th meta tarsal sha ft
Ossicle at m ed ian em ine nce of navicu lar • Pe ro neus tertius: Absent in 10% of popu lat ion
o Type 1: Sesamo id in tibia lis posterio r tendon Childhood Variants
o Type 2: Accessory ce nter o f ossificatio n jo ined to
• av icul ar: May be scle ro ti c, flat, multipartite
navicul ar by sy nchondrosis
o Sa me appea ran ce seen in symptoma ti c avascu lar
o Type 3 (a lso called cornua te o r gori llo id navicular):
necrosis of n avicular
En larged median e mine n ce of navicul a r
• Media l cuneiform : May have 2 ossification ce nte rs
• Os intercuneiform : Do rsal aspect foo t, be tween l st
• Meta tarsals
and 2 nd cun e ifo rm s
o May ha ve accessory epiphysis a t o ppos ite end of
• Cuboides secondarium (seco ndary cubo id): Proximal
bone from t rue epiph ysis
m edial aspect o f cuboid, between cuboid a nd navicular
• 1st metatarsa l: Ep iphysis prox imal, accesso ry
• Pa rs peronea m c tata rsalis primi: Pla ntar aspect foo t,
e piphysis di sta l
between base 1st me tatarsal and 1st cun eifo rm
• 2 nd-5th metatarsals: Epiphysis d ista l, accesso ry
• Os vesalianum: Base 5th me ta ta rsa l (MT)
e piph ysis proximal
• Os intermetatarscum : Do rsa l, between 1st a nd 2 nd
o Epiphyses ma y be bipartite
m etatarsal s
• Os c a lcaneus secondar ius: Dorsal , ad jacent to
anterior process calca n e us
!Anatomy-Based Imaging Issues
Sesamoids
• Os pe ron eal c (a lso ca lled os peron eu m): Sesa moid
Imaging Recommendations
within perone us longus muscle, seen adja cent to • Use radiographi c, C r or MR c rite ria to d istinguish
late ral margin of cuboid n o rmal va riants fro m frac tu re
• Sesamoids of g reat toe o Fracture c harac te risti cs
o Med ia l (tibi al) sesa mo id: Benea th metata rsal head , • j agged frac ture pla n e
within flexor digi to rum brevis and abducto r h a ll ucis • Acute angle a t frac ture margin
o La te ra l (fibul ar) sesa mo id: Beneath metatarsal head • No n sclero tic margi n (if acute)
with fl exor d ig itorum brevis a nd adduc tor hallucis' • Bo ne ma rrow ede m a o n M R
o 30% bipartite o r multipa rtite (ma y not be sy mm et ric o Accesso ry ossicle/bipart ite ossicle cha racteristi cs
o n co ntral atera l foo t) • Smooth, rounded margins
o Medial sesa mo id mo re freq ue ntly b ipartite than • Obtuse angle a t margi n be tween ossic les
latera l • Surro unded by cortex
o In terphalangeal sesa moid: At inte rpha langeal join t, • Bon e ma rrow ede m a sometimes p resen t o n MR if
within flexo r ha lluc is longus tendo n inju red
• Sesamoids of 2nd-5 th toes • Accessory centers ma y be sym pto matic, due to inju ry
o Variabl y prese nt of synchondrosis betwee n ossicle a nd parent bo ne
o May be at metatarsophalan geal o r inte rp ha la ngeal o If symptoma t ic, edema will be see n o n MR, ce nte red
jo ints o n syn chondrosis
o May h ave bo th medial and la te ral sesa m o ids at 5th Imaging Pitfalls
metata rsophalangea l jo int

-
• o te: onn al va ria nts may no t be bi laterally
Miscellaneous N ormal Bony Variants sym me t ric
0 • ln te rmeta tarsa l joint o f 1st and 2 nd digits
0 o Arti cular facet between bases of 1st and 2nd
u. me ta ta rsa ls va ri ab ly prese n t

VIII
80
 -
"T1
0
0

VII I
81
 -
0
0
LL.

VIII
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 NORMAL VARIANTS
NAVICULAR VARIANTS

Type 1 accessory
navicular

Os supranaviculare

(Top) Anteroposterior radiograph shows la rge type 1 accesso ry navicu la r. Despit e its un usually large size it is
di st ingui shed fro m ty pe 2 by the lack o f an a rtic ular face t with th e ma in n avicular body. (Bottom) Lat e ra l radi ograp h
shows tria n gular ossicle at p roxima l, do rsa l ma rgin of nav icu la r. Os sup ranaviculare i s also known as os .,
0
talo naviculare do rsa le, o r Piri e bone. Many so called cases of os supranavicula re probably rep rese n t o ld, nonunited
fractures. 0....
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 NORMAL VARIANTS
ACCESSORY NAVI CULAR TYPE 2

Navicular

Type 2 accessory
navicular

Head of talus

Type 2
navicular

Cuboid

(Top) Antero posterio r view shows rounded type 2 accessory nav icular overl yi ng med ial emi n ence of navicular.
Syncho nd rosis w ith navicular may or may no t be seen i n profi le o n anteroposterior v iew. (Bottom) Latera l view of
0 same pa ti ent as p revious im age sh ows re latively plantar positio n o f accessory navicular.
0
LL

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 NORMAL VARIANTS
CT, ACCESSORY NAVICULAR TYPE 2

Medi al m alleol us

Type 2 accessory
navicular Tibial is posterior
ten cion

Navicula r Posterior process

calcaneus
Synch on drosis

Medi al ma lleolus

Type 2 accessory
navicul ar Tibial is posterior
tendon

Navicular Posterior process

calcaneus

(Top) Sagittal CT sh ows t ype 2 accessory na vicular and synch o ndrosis. Apposing bo n y margins of accessory n avicular
and main navicu la r arc irregula r and sclerotic. This appea rance is co mmon, a nd sugges ts abnormal m o ti o n at
syn cho nd rosi s. (Bottom) Soft tiss ue CT window a t sa me level bette r shows the n or mal appea ring ti bial is posterio r

-
"T1
tendon attachi ng to accessory ossicle. 0
0

VIII
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 NORMAL VARIANTS
MR, ACCESSORY NAVICULAR TYPE 2

I st cuneiform

Synchondrosis

I lead of ta lu s Ty pe 2 accessory
navicular

iJ
Type 2 accessor y
navicular

Navicular Tibialis posterior

tend o n

(Top) Ax ial PD M R w ith FS sh ows type 2 accessory n avicular having a flat facet joi ned by a synchondrosis to parent
navicu lar. (Bottom) Sagi tta l STIR MR of sa me patient as previo us image shows attach ment of t ibialis posterio r
00 tendon to accessory ossicle.

L1.

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 NORMAL VARIANTS
ACCESSORY NAVICULAR TYPE 3

Medial cun cilorm

Type 3 navicular

Type 3 navicu lar

Sprin g l igam ent

(Top) An teroposterior radiograph shows ty pe 3 navicular, also ca lled corn uate or gori ll oid. Th is is an assimilated
accessory nav icular ossicle which forms a pro jecti on at m edial eminence of navicu lar. Th is con figuration m ay ca use
impingement o n shoes and especially on ski boots. (Bottom) Axial PO FS MR shows type 3 accessory navicular. ,
-
Spring ligament is attaching both to t he bon y prominen ce and mo re med iall y to the ma i n porti on of t h e navicu lar. 0
0

VIII
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 NORMAL VARIANTS
CUBOIDES SECONDARIUM

Cuboid es secondariu m
Ca lcaneocuboid joi nt

Cuboid

Cubo id

-
(Top) Coronal T 1 MR shows ossicle at proxima l, m edial, superior marg in of cuboid, between cuboid and navicular.
(Bottom) Ax ial PO wi th FS MR shows rel atio nsh ip o f ossicle to bo th cubo id and navicu lar. This ossicle is very
uncommon.
0
0
LL.

viii
88
 NORMAL VARIANTS
O S PERONEALE

Bipa rti te os peroneale

Os pcro nealc

(Top) Lateral rad iograph shows bipa rt ite os peroneale. This ossicle may be u nipartite or bipartite. It lies in pe roneus
longus tendon, adjacent to ca lca neocuboid joint or cuboid . Proximal d isplacement of os peroneale can be seen as

-
plain radiographic finding of peroneus longus tendon ru pture. (Middle) Obliq ue radiograph ln another patient "TT
sh ows unlpartite os peronea le. Ossicle is just p roxima l to po in t w he re peron eus lo ngus courses under cuboid groove. 0
(Bottom) Ax ial CT, soft tissue window, shows bipartite os peron eale with in perone us lo n gus tendon.
0

VIII
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 NORMAL VARIANTS
OS VESALIANUM

Synchondrosis betwee n os
vesalianum & Sth metatarsal

Os vesalianum

- - - +- Cu boid

Os vesa lianum

Synchondrosis

Os vesa lianu m

-
(Top) On anteroposterior rad iograph, os vesa lianum overl ies styloid process o f 5th metatarsa l, and synch o ndrosis
may be mistaken for fractu re. (Middle) O n latera l radi ograph, rounded conto u r of o ssicle, co nsiste nt wit h accessory
0 center of ossifi cation rather than fractu re, is evid ent. (Bottom) Ante ro poste rio r radiograph sh ows la rge os vesalia num
0 and multiple cysts at synchondrosis.
u.

VIII
90
 NORMAL VARIANTS
OS INTERMETATARSEUM

1st metatarsal

Os intcrrn cta tarseum

1st cuneiform

Os in term etatarseum

lst metatarsal

"""'------...=;.:=:::;-- 1st ta rsometatarsal jo int

Os in termetatarseum

1st metata rsal

(Top) Anteroposterior radiogra ph shows teardrop-shaped os inter m etatarseum, arising between 1st and 2nd
metata rsal bases. Sometimes this ossicle will be pa rtially assimilated to 1st metatarsa l base. (Middle) O n lateral
radiograph, ossicle is dorsal in position, ad jacent to base of 1st metatarsal. (Bottom) On coronal os "T1

-
inte rmetata rseum is rou nd ed in appearance, and n o donor site from ad jacent bones is visi ble. Th ese signs h elp 0
di stinguish it from a fracture fragment . 0

VIII
91
 NORMAL VARIANTS
BIPARTITE MEDIA L SESAMOID 1ST METATARSOPHALANGEAL JOINT

Lateral sesa m o id Bi parti te media l

sesa m oid

13ipa rti te medial

(To p) A ntero p osterio r rad iograp h shows bi parti te m ed ial sesamoi d of 1st toe, and un i pa rti te lateral sesa mo id.
(Bo t to m ) Lateral radiograph sh ows ro unded co n to ur characterist ic o f b ipartite sesam o ids. Fractu re fragm en ts, i n
00 co n trast, w ill sho w angular margi n s.

LL

VIII
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 NORMAL VARIANTS
SESAMOIDS OF METATARSOPHALANGEAL JOINTS

Bi parti te lateral Un ipart ite m edi al

sesamo id sesam o id

Sesam oi d of 2n d
m etata rsal h ead

Sesamoid of Sth
metatarsa l head

(Top) An te roposteri or rad iog ra ph shows bipa rtite la te ral sesa moid o f 1st toe, and unipart it e m ed ial sesamoid .
Bipa rtite scsamoids a re usually m ore roun ded in con tour t ha n fract u red sesamoid s. Bi parti te sesa m o ids a re usua lly
larger t han un ipa rti te sesa m oids. Bipa rt ite sesa mo ids ma y o r may no t be prese nt o n cont ra la te ra l foot . (Bottom) "T1

-
Anteroposterior rad iog raph shows sesamoids of 2nd an d Sth m etatarsal h ead s. Sesa mo ids of lat e ral toes a re vari ab ly 0
present. They a re a lways sm all, and may be roun d o r ova l. 0

VIII
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 NORMAL VARIANTS
MISCELLANEOUS VARIANTS

Accessory & 2nd

metatarsal articulation

Exosto'>b

(Top) A rticu lation between bases o f 1st and 2nd metatarsals may be absent, small, or a fa irly large joint a in this
case. (Botto m ) An exostosis is co mmo nly seen f rom m edial margin, base of 1st dista l pha lan x . Occasionally,
00 exos tosis is qu i te large.

LL

VIII
94
 NORMAL VARIANTS
CHILDHOOD VARIANTS

Accessory epiphysis

Accessory epiphyses

Bi par tite 1st cun eiform

ossi fica tion cen ter

Navicul ar

Apo ph)(sis

(Top) Ossifica tion ce nter for 1st metata rsa l is at prox im al end of bone. Ossification cente rs o f re m a ining m etatarsal s
are d istal. Acce sory e piph yses may fo rm a t o p posite e nd of metatarsal. T h is pa tien t has furth er variants: Bipartite 1st
cuneifo rm ossifica tion center, sclerotic, fragm ented appearin g n av icu lar, a n d bipartite metatarsa l head o s ificatio n -n
centers. (Bottom) Apoph ys is at base of 5 th me ta tarsa l. Fractures in th is location te n d to be horizontall y o rien ted,
while apo physis is lo ngitudina lly o rie nted .
-0
0

VIII
95
 INDEX
A Acetabu lar notch , V:S, 175, 180
Acetabu lar protrusion, V:64, 66
A I pulley, IV:32-34, 42,43 Acetabular rim, V:171
A2 pulley, IV:22, 23, 32- 35, 37, 43 anterior, V:9-12,40-42,69, 106,169, 174, 177,
A3 pulley, IV:29, 32, 33, 35 185,186
A4 pulley, IV:32, 33, 36, 37 line between, V:68, 69
AS pu lley, IV:32, 33 posterior, V:9- 13, 44, 55, 56, 69, 169, 173, 174,
Abdom in al muscle, V:S6- 62 176-78, 181, 186-88
anterior, V:70, 106-10 superior, V:11
aponeurosis, V:36-42, 73-76, 91-93 Acetabular roof, V:9-ll , 43-46, 67, J 81-83, 185-87
Abductor digiti m ini m i, III :20-29, 38-43, 46, 47, Acetabular version, V:64, 69
100,103, 106, 112, 114, 115,124, 12, Acetabulum , V:29-31, 73-76,98- 102, 166,176-80,
13, 16-25, 28, 30, 32, 40, VII:38-41, 46-59, 64- 262, 263
67, Vlll: S, 18-23, 25-27, 32-45, 61-63, 66, 67 anterior column, V:12, 161, 162, 169, 172-74,
accessory, Ill :109 185, 206,20 7
Abductor ha llucis, VII: 32-41, 46-61, Vlll:20-23, 25- articu lar surface, V:S
27,32-45,48,49,56,66,67,77 med ial wall, V:9, 10, 13, 66, 169, 172- 75, 181-83,
insertion, Vlll:5 206,207
transver e head, VIII :?, 22, 23 posterior column, V:12, 161, 162, 169, 172-75,
Abductor po llic is brevis, II:105, lll:22-29, 36-39, 185, 186,206,207
42-45,51-SS, 100, 111, 114, 1V:6, 13,16-19,24, Ach illes tendon, VI :14S, 146, 148, 149, 152, 153,
25,29,30,32 157, 158, 170-76, 180, 187, Vl l:9, 10, 12, 14,
Abductor poll icus longus, 11:96, 102-9, 114, 11 5, 22-35,62-64,69,71,72,73-77
120, 111:9,12-15, 18-23,36-41,55,99,100, axia l T1 MR, Vli:73-7S
102-8, 11 S, 123-25, IV:6, 40 sagitta l and axial T2 FS MR, VII:77
multiple sli ps, 11 1:109 sagitta l Tl MR, Vll: 76
ABER (abd uction ex ternal rotation) positi o ning, Acromia l plexus, 1:8
shou lder, 1:140-51 Acromioclavicul ar joint, 1:10, 12, 20, 21, 56, 57, 69,
Accessory abduc to r digiti minimi, IL1:109 70,81,82, 97, 117,136-39
Accesso ry cepha lic vein, 111: 130 Acro mi oclavicula r ligament, 1:103, 104, 116
Accessory collateral liga ment, IV:42 Acromion , 1:6, 7, 10-15, 20-23,48-55,68-72, 77,
Accessory epiphysis, Vlll:95 80-84,88,91,93,97-99,103,104,115,117,
Accessory extenso r pollicis lon gus, 111:109 121, 133,134,136,138,139,141- 44, 153-SS
Accessory lateral co ll ateral ligament, II:83 Adductor aponeurosis, IV:29
Accessory metatarsal articulation, Vll1:94 Addu cto r brevis, V:7, 34-40, 57-59, 72, 77- 82, 90-
Accessory naviculilr, Vlll :81, 82- 87 93, 104, 105,154-56, 194,197,208-27,262,
Accessory obtu rator nerve, V:131-33 263,268-72
Accessory ossicles Add uctor can al, V:191-92
foot, Vll l:81-91 Add uctor h allucis, Vlll :22, 23,46-5 1,66, 75, 77
wrist, 111:72 oblique h ead, V11:61-64, VIJ I:7, 20-23, 25-27,
Accessory palmaris longus, Ill:109 40-47,57,58,60,61,66,67, 75
Accessory soleus, Vl:187 t ransverse h ead , Vlli:2S, 26, 44- 47, 58, 60, 61, 75
Accessory vein, 11:22, 23 Add ucto r hi atus, V:198, 261
Acetabu la r angle/ index, V:64, 67, 68 Add ucto r lon gus, V:7, 34-38,57-61, 72,78-80,83-
Acetabula r fossa, V:5, 11, 172, 185, 206- 9 85,90-93, 104, 105, 154-56, 194, 197, 199-201,
margin, V:ll, 179, 182, 183, 185, 186 212-35,262-66,268- 72,274 •
I
 INDEX

Adducto r m agnus, V:S, 7, 8, 36-42, 53-57, 92, 93, Anococcygeal n erve, V:129
106-10,129, 154-58,194,198,199,214- 43, Anomalo us muscles, wrist, !1 1:98, 109
258-65,269-76, VI:10-13, 16, 17,20-23,66 Antebrach ial cutaneous nerve
a t adducto r t ubercle, Vl: SS lateral, 1:154, III:12, 13
at inse rtio n, VI :SS, 56 media l, 1:9, 156, 157
ischi oco nd ylar portio n, V:198 posterior, J:15 5, 157
Addu cto r po lli cis, !!1:26- 29, 38-41 , IV:6, 13, 18, 19, Antebrach ial fa scia, !!1:12, 13
24-25,29,30 Anterio r abdomi n a l wa ll muscle, V:70, 106- 10
obli que head , IV:12, 13 An terior a nul ar liga m en t, !!:87
osseous inse rti o n, IV:1 2, 13 Anterior calcanea l facet, Vll: 6, 8, 120, 124, 128, 130
transverse head, IV:J 2, 13 Anterio r calcan ea l tu bercle, VII: 14
Add uctor tube rcle, V: 193, 203, VI: 6, 7, 55, 66, 68 Ante rior capsule, !!:9, V: 170
Alph a a ngle, V:64, 67, 68 Anterior circumflex humeral a rtery, 1:6, 8, 71-73,
An atom ic sn uffbox, !11:5 4, 98, 107 89, 154
An coneus, !:155, 172-77, ll:12, 13,24-29,32-39, Anterio r circu mflex hu mera l vessels, 1:56- 59, 83-85,
53,59,63- 69,77,78,96,98-103, 120, 121 182, 183
Anco ne us epitroc h learis, Il:1 9 Anterior colliculus, VI:14S, 151 , Vll: 13, 14, 56, 57,
Ankle, Vll:2- 131 61,118
ax ia l T1 MR, Vll :22- 41 An terior co mpartmen t, th igh , V:204, 205
co ro na l CT reformats, Vll :21 Anterio r cruciate ligame nt, VI: 10, 11, 13, 15, 24- 27,
co ro na l T1 MR, Vll:42-59 46,4 7,58,59,69, 70,77-80, 82,86, 88, 93-94,
graphi cs, VU: S-12 96-99, 101-4, 106, 107, 109, 112, 114, 125
liga ments, Vll :2, 7, 8, 103-31 a nte rior band , Vl:82
ne rves, Vll: 4, 11, 12 a nte rom ed ia l ba nd, VT:90, 11 S
osseo us a nato m y, VII:2 anteromed ia l bu ndle, Vl: l OO
ove rview, VJI :2-67 "foot" attachmen t, Vl:99
radiography, Vll :13-18 insertion on tib ia, Vl:94
AP, Vll :13 intermed iate fibers, VI:82
Boeh le r angle, VII: 17 o rigin, VI:101
Brode n view, Vll :15 posterior band, Vl:82
calca neal pitch , Vll :16 posterolateral ba nd, Vl:44, 45, 90, L15
la te ra l, Vll :14 postero lateral bundle, Vl:l OO
measurements, VII:18 synovium covering, Vl:11 4
ob liq ue, Vll:13 Anterior fat pad, !:18 7, 1!:9, 11 , 22, 23, 52, 53 , 76,
os ca lcis view, Vll :1S Vl:64, VII:1 4, 72
tala r base an gle, VII:1 6 Anterio r femoral muscles, V:190-91
taloca lcan ea l an gle, VII :17 Anterior glutea l line, V:5
retinacu la, Vll :2-3, 9 Ante rio r inferio r gle no id rim, 1:12
sagitta l CT reformats, VII :20 Ante rio r inferior il iac sp ine, V:S, 9-11, 13, 14, 27,
sagittal T1 MR, VTI:60-67 45,62, 159, 171, 186, 187,193
te ndo n shea ths, Vll :71 Ante rio r interosseo us artery, 11 :14, 111:1 0, 128, 129
tendo ns, Vll: 3- 4, 10, 11, 68-101 Ante rio r interosseous ne rve, II: LS, 16, 18, 104, lOS
30 CT volum e rendering, Vll:72 Anterio r joi nt recess, !1 :9
ax ia l T1 MR, Vli :73-7S, 78- 82, 84-88, 90- 94, Anterior lab ral remnant, V:l 78
96,98 Ante rio r labrum, 1:26-33, 95, 10 7, 128- 30 , 133, 142-
ax ial T2 FS MR, VII:77, 82, 95 44, 146-49,156, V:1 69, 186, 187
graph ics, Vll :69-71, 98 absent, 1:108, V:172, 173, 178, 184-86
late ra l rad iography, VII :72 type A attach m en t, 1: 123
sagitta l T1 MR, Vll :83, 89, 90, 99- 101 type B attach m en t, 1:123
sagitta l T2 FS MR, VIl:77 Anterior lateral m eniscocrucia te ligame n t, Vl:93
vessels, Vll :4 Ant erio r lateral troch lea r ridge, Vl:SO, S1
Ankl e jo int recess, Vll :88 Anterio r lo ngitud ina l ligament , V:130
extending to d ista l t ibiofibular jo in t, VII :11 0 An terior m ed ial crural fascia, Vl:l21
extend ing to t ibiofibul ar joint, Vll :104 Anterior medial t roc hlea r ridge, VI:SO, 51
pos terior, Vll:111 Anterio r men isca l fascicle, VI : 104

ii
 INDEX
Anterior meniscocruciate ligament, Vf:94, 103 Av p ulley, IV:32
Anterior perilabra l recess, V:176, 177 Axillary artery, 1:8, 38, 39, 66-67, 79, 80
An terior perilabral sulcus, V:186-88 Axillary fat, 1:44, 45
Anterior recurren t tibia l artery, VJ:1 59 Axillary nerve, 1: 7, 9, 36, 37, 46-55, 60-63, 69-73,
Anterior recurrent tibia l nerve, Vl:1 59 77,82-85,99-101,134,135,155,178,179,
Anterior sacro.iliac ligament, V:130 182,183
Anterior subtalar joint, VTI:19, 20 Axillary neurovascu lar bundle, 1:32, 33, 129, 133,
Anterior superior iliac spine, V:5, 9, 11 , 13, 20, 46, 135, 156
47,85,96, 111,112,168,193, 197, 199 Axillary pouch, 1:5, 69, 81, 82, 96, 104, 109, 110,
Anterior suprapate llar fat pad, Vl:65 119, 120, 130, 131
Anterior talar fa cet, VU:5 Axillary recess, 1:147-49
Anterior talofibular li ga ment , VII:7, 30, 31, 66, 103, Axillary vein, 1:67, 79, 80, 147
110, 113, 116, 128 Axill ary vessels, [:60-63, 66, 67, 180-83
Anterior t ibial artery, VJ :1 7, 158, 159, 162,163,
VIJ:22-25, 56, 57, VIII:9
Anterior tib ial tubercle, VII:13 B
Anterior tibial vein, VU :22-25, 56, 57, 65, 67 Ba ker cyst, Vl:lll
Anterior tibial vessels, VI: 164-7 5 Basal metacarpal arch, lfl :128, 132, 133
Anterior tibio fibular ligam ent, VII :7, 22-27, 54, 55, Basicervicalfemoral n eck, V:47, 48
103, 105, 106, 109, 113- 15, 118, 128 Basicervical region, V:9, 202
Anterior t ibiotalar ba nd , VJ1:54, 55 Basilic vein, 1:156, 157, 164-77, 182-86, II:ll, 12,
Anterior tibiotala r ligament, Vll :8, 24-29, 60, 61, 20-25, 42-45, 50, 61-63, 71, 74, lll:10, 12, 13,
115, 116,118,119,127 46, 128
Anterior tubercle, V!T:6 Biceps, 1:157-59, 162-77, 184, 185, 188, 11:11-13, 16,
Anterio r u lnar recurrent artery, 11:1 4 24-33,40,41,44-47, 53,58,59,60, 65,71-73,
Anu lar ligament, 11 :12,28,29,83, 85, 87, 88, 98,99 81, 95, 112, 113
Anu lar pull eys, IV:30 ad h erent to glenoid, 1:125
Apophysis, Vlll: 95 entering bicipital groove, 1:85
Arcade of Frohse, ll: 17 long h ead, 1:5, 6, 15-17,26-45,54-63, 70, 71,
Arches, foot, VIII :2, 14-15 74,77,81-83,85-87,89,91-95,97-101,
Arcs of Gilula, III:65 103-9, 111,112,1 15,119-21,123, 124,126,
Arcuate artery, VJ!l:9 128-31, 133, 135, 141, 143, 144, 154,
Arcuate ligament, V:84, 85, Vl:ll, 12, 113, 128-31, 156, 188
135, 136, 138 in bicipital groove, 1:1 25, 184, 185
fibular o rigin, Vl:133 short head,l:6, 16, 17, 26-31, 34-45,56-63,70,
lateral, VT:122, 132, 133, 139 71, 82-84, 93,97, 103, 128- 31, 133, 135, 141,
med ial, VI:91, 122, 132, 133, 137, 140 154, 156, 182-85, 187, VI: 12
origin, Vl:140 con joined tendon with coracobrac hialis,
of Osborn, 11 :24, 25, 62, 86, V:88 1:127, 128
Arcuate line, V:5 Biceps ancho r, 1:5, 8 1, 143, 144, 154, 187
Arcuate poplitea l l igament and capsule, Vl: 60-62 Bicep s brachii, Il:20-25 , 46- 49, 51-55, 58, 61-64,
Arm, 1:152-89. See also Elbow; Forearm; Wrist 66,75-80,98-101,110,111,120,121
AP and ro tational latera l rad iograph y, 1:153 Biceps femoris, V:198, 200, 252-61, 277, 278, Vl:11,
ax ial T1 MR, 1:158-77 12,17-45,58-63,67-68,84,85,89, 113,1 14,
coronal T1 MR, 1:178-85 129, 134-35, 138-40, 147-49, 152, 154, 15 7,
graphics 158, 160, 161, 185
ante rio r, 1: 154 expansion, VI:32, 33, 130, 131, 134, 162, 163
axia l, 1:156, 15 7 fibrous extension, Vl:l29
posterior, 1:155 hypertrophi ed, Vl:186
sagittal T1 MR, 1:186-89 inserting on fibu lar head, Vl:157
Articular ca rtilage, 1:123, 124, JV:42, V:168, 169, insertion, Vl:38, 39, 135, 138
173, 176-78, 182-84, 187, 188, VII:24, 25, lo ng head, V:7, 8, 52-54, 129, 194, 216-53,259,
VTII :77, 79 260,275-77, VJ:136
Articul ar facet, V:6, VIII:15, 76 anterior arm, Vl: 128
Articu laris genu, V:194
•
I
iii
 INDEX
con joined origin with semitendinosus, V:44, anterior, VJ1:6, 8, 120, 124, 128, 130
53, 164, 165,208- 15, 260, 273 middle, VII: 6, 8, 120, 124, 128
direct arm, VI:128 posterior, VII: 5, 6, 124, 128
insertion, Vl:135, 141 Calcaneal n erve
short head, V:194, 198, 236-53, 259, 260, 276, infe rior, VII :12
277, VI:135, 148, 149 m edial, VI1: 12, 61
anterior arm, Vl:1 28, 135 Calcanea l p itch a ngle, Vll: 16
d irect arm , Vl:128 Calcaneal sulcus, VII :6
insertion, VI:128 Calcaneal tubercle
Biceps groove, 1:142 anterior, Vll:l 4
Biceps lab ral com plex, 1:104-6, 111, 122, 141 lateral, VII:6, 13, 14, 38, 39, 44-49
norma l variants, 1:124, 125 medial, Vl1:36- 39, 44, 45, 62, 119, 127
Biceps tendon sheat h , contrast in, 1: 143 Calcan eal tuberosity, Vll:6, 14, 34, 35, 44-49, 63, 65
Biceps/superior lab rum sulcus, 1: 123 Calcaneocuboid bifurcate ligam en t, Vll:8, 120, 124,
Bicipital apone urosis, 1:174, 175, II :l2, 16, 18, 26- 128,129
3 1, 52, 54,58,60,63-65,76 Ca lcaneocubo id jo int, Vll:20, VIII: 32, 33, 88
Bicipital groove, 1:58, 59, 89, 104, 129, 130 Calcaneocuboid ligament
Bicipitoradial bursa, li:81 do rsal, VII:?, 103
Bifurcate ligament, VII: ? , 8, 102, 103, 108, 113, 120, dorsolatera l, VII:1 20, 128
121, 123, 128-29, Vlll:11 medi al, VII:l1 3, 120, 123
calcaneocuboid, VII:8, 120, 124, 128, 129 Ca lca neofibular ligam ent, VII: ? , 32-35, 50-55, 66,
calcaneonavicular, Vll :8, 64, 65, 124, 128, 129 93, 103, 106, 109-13, 125, 128
Blumen saa t line, Vl:7, 75 in sertion, VII:6
Boehler angle, VTT:l 7 origin, Vll:50, 51
Brachial artery, 1:6, 8, 40-45 , 154, 156, 157, 186, Ca lcan eo navicul ar bifurcat e ligament, Vll :8, 64, 65,
187, II:ll-13, 14, 16, 20-29, 51, 61-65, 75, 98- 124, 128, 129
101, 110, 111 Calcaneus, VI:1 76, VII:6, 7-9, 11, 13, 15, 19-21, 30,
d eep , 1:7, 8, 40-45, 77,_134, 156, 158-69, 178-81, 31,34,35,50,51, 54-57, 70,75-77,79-82,86,
IT:1 4 89,92,93,98- 101,103,106-14, 11 7, 120-3 1,
Brachial cutaneous nerve, medial, 1:9, 156, 157, VIII:1 3
164-67 anterior process, VII :6, 14,34-37,58,59, 64, 11 7,
Brachial neurovascul a r b undl e, d eep, 1: 46, 4 7 118,129
Brach ia l plexus, 1:9, 66, 67, 180-83 body, VII:6
Brachial vein, 1:156, 157, II:lOO, 101 posterior process, VIII: 85
Brachial vessels, 1:158-69, 180-83 Ca pitate, 1!1:5- 7, 18-25, 32- 39, 49- 52, 60, 64, 83-
Brachialis, 1:16, 17, 154, 157, 160- 77, 182- 89, II:ll- 85, IV:8, 9
13, 16,20-31,38-47,51-55,59- 64,71-73,75- body, III:59, 61, 62
78, 80,95,98-101, 110-13, 120-22 ca rtilage surface, Ill:75
Brachioradialis, 1:154, 155, 157, 168-77, 184, 185, d orsal body, III:59
189, Il:11-1 3, 16, 20-33, 38-47, 54, 55, 6 1-67, h ead, 111:59, 73 , 82
70- 72, 78,79,95,96,98-100, 102-5, 110-1 5, neck, III:5-7, 60
118--20 secondary, III: 72
Breast tiss ue, I: 186 vascular channel, III: 75
Buford complex, 1:108, 120, 121 wa ist, lll:59, 63
Capite Uar epiphysis, ll: 7
Capitell um, II:5, 6, 42-45, 53, 54, 63, 64, 71, 72, 77,
c 78, 120, 121
Cl pulley, IV:32, 33 pseudodefect, 11:54, 78
C2 pulley, IV:32, 33 Ca pito ham ate liga m ent, III: 79, 90
C3 pulley, IV:32, 33 deep,III:84,85, 90,91
C5 spinal nerve, I:9 dorsal, III:22, 23, 91
C6 spinal nerve, 1:9 volar, III:22, 23
C7 sp in a l ne rve, 1:9 Ca pito lunate angle, III:69
C8 spinal nerve, 1:9 Capitulum, 1:1 72- 75, 184, 185, 188
Calcanea l fa cet Capsula r junction, VI:110

IV
 INDEX
Capsular ligaments, V:47-49, 113, 114, 124, 125, Circumflex iliac artery
Vll:l20 deep, V:195
Capsulo ligamen tous compl ex, medial, V1:125 superficial, V: 195
Carpa l al ignmen t, Ill:57-58, 68, 69 Circu mflex iliac vein
Carpa l angle, 111 :65 deep, V:1 96
lateral, 111 :69 medial, V: 196
Ca rpal a rch Circumfl ex scap ula r artery, 1:6, 8, 9, 56, 57, 154
d orsa l, 111 :10 Clavicle, 1:10, 11, 13, 14, 20-23, 56-63, 67-69, 78-
pa lma r, 111 :10, 121, 128-30 81, 104, 139, 153, 184, 185
Carpa l axes, lateral, III:68 con oid tubercle, 1:22, 23
Ca rpal bridge view, IJI :64 distal, 1:12,68,87, 96, 103, 113, 114, 116,121,
Carpal he ight ratio, 111 :67 137-39
Ca rpal li ga m ent Cloq uet n ode, V:201
pa lma r, IV:1 6, 17 Coccygeal nerves, V:1 29
volar, 111:1 8, 19, 121,124, 125, 127 Coccygeal plexus, V:3
Carpal row, proxima l, II:1 08, 109 Coccygeal segm ent, V:14
Carpal tunne l l st,V:14
co rona l GRE a n d axia l Tl MR, lll :126 2nd, V:14
mid, 111 :125 3rd, V:1 4
proxi m al, 111 :124 Coccygeus, V:7,3 7,38,99- 102, 152, 153, 162
Ca rpal tunnel regio n , lll:40, 41 Coccyx, V:2, 6, 13, 14,29-31, 33, 88,148-53,193
Ca rpa I tun nel view, Ill :64 Co lla te ral artery
Ca rpo ham ate liga ment, IIJ:8 inferior ulna r, 11:1 4
Ca rpometaca rpa l a li gnment, III: 65 midd le, 1:155, 157
Carpometaca rpal compartm ent, comm on , radial, 1:155, 157, 180, 181, 188
111 :74, 95 supe rior ulnar, 1:157, II:14
Carpometaca rpa l joi nt, IV:8 Collateral bursa, medial, Vl:l24
Carpometaca rpal liga me nt, JI1 :8, 77, 79, 90, 9 1 Col late ral ligament
Ca rpome tacarpa l portal, com mon, II1: 74 accessory, IV:42
Cen ter edge angle, V:64- 65, 67, 68 fibular, Vl:30, 3 1
Cep ha li c vein, 1:28,29, 34- 45, 60- 63, 69, 71, 84, 86, inte rphalangeal joint, JV:45
98,101,1 28,130,131, 133, 135,156-77,188, la teral, VI:ll-13, 24- 29, 32, 33, 40-43, 63, 79,
189, 11:11 , 12, 22- 27, 48, 49, 61, 62, 73, 98-101, 88,89,128-32, 135, 136,139, 141 , 160, 161,
110,111 , 120, 111 :10, 12,13,16-25, 54, 124, Vl1:102, 110-13, Vlll :22, 23, 48, 49, 76- 78
125, 128, 130-32 2nd toe, Vll l:50, 5 1
accessory, Ill :130 accessory, !I:83
in d eltopectora l groove, 1:32, 33, 72, 99, 100 bursa deep to, Vl:133
median, I: 189 insertion, VI:128, 135
Cervica l a rte ry, transverse, I:8 m etacarpop ha langea l jo int, lV:45
Cervica l liga ment, VII: ?, 32, 33, 58, 59, 63, 64, 103, o rigin, Vl: 62, 85, 139, 141
118,120, 122, 128, 129 main, !V:42
C ho part joint, Vlll :17, 32-33 m ediaC 11:86, Vl:10, 11, 13, 16, 22-25, 30, 31,
Circumfl ex fem oral artery 44-47,54,66, 79,88, 119, 121,123, 124,
lateral, V:42-5 1, 195,212,213 133, 145, 160-63, Vlll:22, 23, 46-49, 76-78
m ed ial , V:42, 45, 46, 195 2nd toe, VIJ! :50, 5 1
Circumflex vein bursa, Vl:88
lateral, V:42-51 , 196, 212,213 deep, Vl:124, 125
medial, V:42, 45, 46 fat between superficial and dee p fibers,
Circumflex hu mera l artery Vl:124
anterio r, 1:6, 8, 71- 73, 89, 154 insertion, VI: 179
poste rior, 1:7-9, 70-73, 77, 82-86, 99-101, 134, lon gitudinal, Vl:26-29, 46, 47
135, 155 oblique, VT: 26-29, 46, 47, 88, 89, 121
Circumflex humera l vessels o rigin, Vl:121
a n terio r, 1:56-59, 83-85, 182, 183 superficia l, Vl:68, 86-88, 124-25
posterio r, 1: 36-39, 46- 55, 69, 178-83 t wo arm s, VJ:1 22
•
I
v
 INDEX
rad ial, II:l2, 26-29, 40-43, 55, 71, 83, 85-91, con jo ined tendon w ith short head biceps,
111 :8, 53, 79, 81, 89, 90, IV:22, 23, 26, 27, 44 1:127, 128
ulnar, 11:12, 24-27, 38-43, 70, 74, 75, 83, 85-87, Coracoclavicu la r liga ment, 1:24, 25, 62, 63, 78, 114
89,91, IV:22,23,26,27,44 conoid co mpo nent, 1:67, 95, 103, 114
a nterior band, 11:84 t rapezoid component, 1:60, 61, 68, 69, 79, 103,
first metaca rpopha langea l jo int, !V:29 113, 114
gra ph ic, II: 84 Coracoh um era l liga m ent, 1:5, 24, ?-5, 60, 61 , 70, 83,
la tera l, 11:12, 28, 29, 38, 39, 70, 83, 88, 89, 91 91-100,103- 6,109,110, 111 - 13,114,115,119,
posteri o r band, II:60, 84 121, 122, 126, 127
tra nsve rse ba n d, II:60, 84 Coracoid process, 1:6, 10-15, 24-27, 60-63, 68, 69,
Co llatera l ligament comp lex, IV:8, 22, 23, 39, 42-44 77, 80, 8 1, 92, 96, 103, 106, ] 1 J- 15, 126, 127,
Co llatera l vesse ls, superio r u lnar, 1:164, 165 138, 139, 141, 142, 153, 154, 180- 85
Coli icul us Coronoid, Il: 5, 85, 91, 97
anterior, Vl:145, 15 1, Vll:l3, 14, 56, 57, 61, 118 Coronoid fossa, 1:187, 11:6, 42, 43, 76, Vll:6
posterio r, VI:1 45, 15 1, Vll:l3, 14, SO, 51, 60, 6 1, Coronoid process, 11:26-29,38-45,5 1,65,89,98,
114, 117, 121 99, 114, 115
Co m mon carpometacarpa l compa rt ment, 11 1:74, 95 C rista medialis, Vf:150
Com mon carpometacarpal porta l, III:74 C ruciate ligam ents, VI:99-115. See also Anterior
Commo n d igital ten do n sheath , IV:32, 33 cruciate ligament; Posterior cru ci ate ligament
Com mo n exten sor te ndo n , 1: 172-77, 182- 85, Il:12, C rucifo rm pulleys, lV:30
26-31, 38-43, 55, 59, 62-64, 70, 7l, 78, 85-91, C ru ral fascia, Vl:22, 23, 34, 35, 44, 45, 68, 121, 125
95,98,99 C ubita l fossa, II:16
Commo n fe mo ral artery, V:31, 32,39-41,60-62, C ubital retinacu lu m, 11:11, 19
75-80,83-86,106, 107,155-58, 171-75,1 95, C ubital vein, medial, 1: 170-77
201,206-17,265-67,270-72 C uboid, VII: ?-9, 11, 13, 14, 20, 36-41., 58, 59, 65,
Co mmo n femoral ne rve, V:206-1 1 66, 70,80,81,86,87,94,95,98-100, 103, 108,
Commo n femo ral vein, V:31, 32, 39- 41, 60- 62, 75- 11 7, 118, 121- 23,128-31, Vl ll :13, 15-17,25,
80,83-86, 106,107, 155-58, 171-75, 196,20 1, 26,28,29,32,33,34-35,36,37,58,60, 70,84,
206-17,265-67,270- 72 88,90
Common flexor muscle m ass, II: l 6, 58, 84 Cuboid tu n nel, Vll :ll, 70
Com mon fl exor tendon , 1:172-75, 11:11, 12, 16, 19, Cuboides secon darium, Vlll :88
24-3 1,38-43,50,51,60,63,64, 70, 7 1, 74, 75, Cubo idocuneiform ligament, Vll l:26, 27
84-87,89,90,95, 112, 113,123 Cuneiform, V[IJ:13, 15, 16, 36-39
Com mon fl exor ten do n s heath , III:101, IV:32 1st, VII:ll, 34-41, 60, 61, 70, 83, 94, 95, Vlll:25-
Com mo n iliac arte ry, V:195 27,38-41,56,69, 70,72,86,91
Com mo n iliac vein, V: 196 bipartite ossification cen te r, VIII:9S
Com mon interosseo us a rte ry, II: 14 1st-3 rd, Vll:81
Commo n palma r digital arteries, IV:3, 15 2nd, VII:14, 20,34-39,61-63, Vl ll:38, 39, 57,
Common peron eal n erve, V:l29, 200, 250- 57, 69, 70
Vl:18-39, 58-61, 128, 129, 158-63, 184, 3rd, VII:14, 20,34-41,63,64, Vlll :36, 37, 40, 41,
185, 186 57,58,69, 70,72
Con joined origin, sem iten d inosus a nd lo ng head m edial, VIII :87
b iceps fe mo ris, V:44, 53, 164, 165, 208-15, C uneiform-cuboid ligamen t, Vll l:ll, 28, 29, 36- 39
260,273 Cun eocuboid ligament, Vll :40, 41
Conjo ined tendon, 1:69, IV:40-42, 44, V:28, 86, 87, interosseous, VII:64
159-62 Cun eonavicu lar liga m ent, plantar, VU! :36, 37
coracobrac h ia lis and sh ort h ead biceps, Cutaneous nerve
1:127, 128 in te rmediate do rsa l, Vll:11
Coracoacromia l a rc h, 1:132 la teral, 11:15
Coracoacro m ia l ligament, 1:22-25, 56-63, 70-72, latera l antebrach ia l, 1:154, 111: 12, 13
77,83,94,95,98-100,103,104, 113, 115, 121, m ed ia l, 11:15
126, 141, 154 m edia l a nteb rachia l, 1: 9, 156, 15 7
Coracob rac hi a li s, 1:6, 16,26- 45,56-63,69-71,81, medial brachi a l, 1:9,156, 15 7, 164-67
82,84,93,97,128-31,133,135, 154, 156, 158, medial dorsa l, VII:] 1
159, 182-85, 187 perforating, V: 129
posterio r, Hl :ll, V:8, 129, VI: 18
posterior antebrach ia l, 1:155, 157
VI
 INDEX
D Derma tomes
hand an d w rist, lll:121
Deep brachial a rtery, 1:7, 8, 40-45, 77, 134, 156, th igh, V:279
158- 69,178-81, 11:14 Descend ing gen iculate artery, V:195, 244-49, Vl:16
Deep brachial n eurovascula r bundle, 1:46, 47 Descending geniculate vein, V:244-49
Deep circumflex iliac artery, V:195 Digital arteries
Deep circumflex iliac vein, V:196 common palmar, 1V:3, 15
Deep deltoid ligament, VII :S, 26-29, 52-SS, 61, 62, pla n ta r, VIII: 10
103,1 14, 11 6-22,127 proper, IV:3, 15
Deep femora l artery, V:S6-59, 195, 216-35 Digital ne rves
262-65, 273 '
do rsa l, VIIJ:9, 79
Deep femoral vein, V:S6-59, 196, 216-35, p lantar, VIII:10
262-65,273 Digital ne urovascula r bu n dl e, Vll l:6 1
Deep medial collatera l ligament, Vl:l24, 125 dorsal, VIII:46, 4 7, S0-53
Deep palmar arch, 111 :26, 27, 129, 133, JV: 15 St h toe, VIII:48, 49
neurovascu la r bundle, IV:28 plan tar, Vlll: S0-53
radial bran ch, Ill: 10, 128 proper, IV:22, 23, 35, 43, 45
ulnar branch, Ill : 10 Digita l tendon sheath, common, IV:32, 33
Deep peroneal nerve, VI:159, 164- 73, 184, 185, Digital vessels
Vll:12, 22-27, 32-37, 62, VII I:9 2nd toe, VII 1:25, 26
lateral branch , VII:12 Sth toe, VIII:48, 49
medial and late ral terminal branches, Vl: l 59 do rsal, VIII: 79
med ial branch, Vll:ll, 12 pla ntar, Vlll:18-21
Deep peronea l vessels, Vll:48, 49 Disc re mnant, V:6, 14, 33
Deep radia l artery, 11 1:24,25 Distal anterio r band of pes, V£:46, 47
Deep radial ne rve, 11 :13, 15-1 7, 28-33, 44, 45, 63- Dista l flexor retinaculum, lll:126
67, 100, 101 Distal in terosseous ligament, lll:77
Deep scaphocapitate ligament, III:84, 85 Dista l interphalangea l joint
Deep semimembranosus bursa, VI:110 Sth, VIII :16
Deep tibiotalar ligament, Vll :62 capsule, IV:41
Deep transverse metacarpal ligament IV:22 23 co ll atera l ligament, 1V:45
32,43 I I I

vo la r plate, IV:37
Deep triquetrohamate li gamen t, 111 :84,85 Dista l radio ulnar compartment, JI[:74, 94
Deep ulnar artery, Jll :22,23, 128, 132, 133 Distal radio ulnar in jection portal, III:74
Deep ulnar nerve, 111:22-25, 121, 127 radioulnar joint, 111:67, 70, 71, 123, TV:8
Delto id, I:S, 7, 16, 17,22-31 36-66 68-73 77 78 D1stal rad io u lnar ligamen t, Ill:77
80-86,88,89,94-101, 106-8, 1l1-16, :i Do rsal ca lcaneocuboid liga me nt, VII:7, 103
126-31, 133, 134, 136, 137, 139, 155, 156,158- Dorsa l ca rpal arch, l!l:10
61, 178-81, 188, 189, VII :S4-57, 124 Dorsa l carpal radial artery, 111:128
anterior belly, 1:7, 20-23, 26, 27, 30-33, 127, 128, Dorsa l cutaneous nerve
133, 135, 156,182- 85,187 intermediate, Vll:ll
anterior head, I:142 medial, Vll:11
inferior tendon slip, I: 117 Dorsal digital nerves, Vl ll:9, 79
Ia teral, I: 75 Dorsa l d igital neurovascula r bundle, Vlll:46-53
middle belly, 1:22, 23, 58, 59, 121, 127, 133, 156 Dorsa l digital vessels, Vll1:48, 49, 79
180-83, 188, 189 I
Dorsal interca rpal arch, 111: 128, 129
middle head, l:l42 Do rsal intercarpal ligament, III:8, 18-21 , 32, 33, 48-
posterior belly, 1:6, 26, 27, 30-35, 46, 47, 66, 51,79,84,85,92
127-29, 133, 135, 156, 178, 179 Dorsa l intercuneiform liga me nt, Vlll: 38, 39
Deltoid ligament, VII :S, 102, 114-19 Dorsal intermetatarsal ligament, Vlll:11 , 71
deep, VIJ:S, 26-29, 52-SS, 61, 62, 103, 114 116- Dorsa l interosse i, IV:33, 38, 41, 42, VIIJ:8 26-29
22, 127 ' 42-45, 65, 78 I I

superficia l, VII:?, 8, 24-31, 54, 55, 60, 103, 114- 1st, IV:7, 10, 18-21, 24-27, 29, VIIT:26, 27, 30
18,120, 121,129 31,46,47,57,67, 76 I
De ltoid tuberosity, I :153, 158-61, 180, 181 1st-4th, Vlll :28, 29
Deltopectora l groove, 1:34, 35, 184, 185
• •
I I
vii x
 INDEX
2nd, IV:?, 10, 18-21, 26, 27, VIII: 26, 27, 30, 31, jo int, 11: 2
67, 79 jo int cap su le, 11:8-10
3rd, IV:?, 10, 18-21, 26-28, Vlll :67 ligaments, !1:2, 82-91
4th, IV: ?, 10, 18-21, 26-28, 40, VIII: 62, 63, 67 median n erve entrapme nt, 11:18
gra phics, 1V:10 muscles and t endo ns, 11: 2, 56-81
Dorsal jo int capsule, VII1:79 nerves, 11:2-3, 15
Dorsal Lisfranc ligament, Vlll:11, 71-73 radial nerve entrapment, 11:1 7
Dorsallun otriquetralligament, lll :81, 82, 86 radiography
Dorsa l m etacarpa l a rtery, III:10 AP oblique, ll:5
Dorsal m etatarsa l artery, VIII:9 latera l rad ia l h ead, 11 :6
Dorsal midca rpal ligament, 111:76 normal variants, 11 :7
Dorsal radiocarpal a rch, lii: 128 sagittal T1 MR, !1:50-55
Dorsa l radioca rpal ligament, 111:8, 16-19, 32, 33, uln ar nerve entrapm ent, ll:1 9
48-5 1,79-84,92 vessels, 11 :3
Dorsal rad iou lnar ligament, lll:8, 14-17,32-35,48, Epi condylar ax is, VI:8
79,80,87,89,91 Epigastric artery
Dorsal root ganglion inferio r, V:27, 37, 38, 87, 159-62, 195
L4, V:141 superficial, V:195
L5, V:143, 144 Epigastric vei n, inferior, V:27, 37, 38, 87,
Dorsal sacra l foramen, V:6 159-62, 196
Dorsa l sacro iliac liga m ent Epilunate, Ill:72
long, V:33-35, 130, 133, 137-42 Epi physis
short, V:130-36, 141, 142 accessory, Vll1 :95
Dorsal sca phol unate li ga ment, IU:8, 16, 17, capitellar, II:?
80-82,86 Epipyram is, 111 :72
Dorsal scaphotriq uetral ligament, IIT:8, 32, 33, 5 1, Erector spinae, V: 7, 16-23, 33-39, 52, 53, 91- 93,
52,79,83-85,92 131- 39, 141,142
Dorsa l sca pula r a rte ry, 1:8, 9 Exostosis, foot, Vlll:94
Dorsal scapu lar n erve, 1:9 Exte nsor carpi rad ialis b revis, ll:l2, 13, 32, 33, 42,
Dorsa l subcutaneous venous plexus, IV:26, 27 43,46,47,59,65-67, 72, 73, 79,100-109, 114,
Dorsal ta lofib ula r ligament, Vll :114 115, 118, 119, IIJ:9, 12-27,32,33,52, 53, 99,
Dorsal talo navicular ligament, Vll :7, 8, 62, 63, 103, 100,102-6, 108, 110, l1 7, 123-25, IV: ?
128, VllT:ll Extensor ca rpi radialis longus, 1:1 57, 168-77, 182,
Dorsal ta rsom etatarsa l ligament, Vlll:ll 183, 189, 11 :11-13,20-33,38- 47, 55, 59, 61-67,
Dorsal transverse recess, lll: 82- 84 70-73,78,79,95, 98- 109,114, 115,118,119,
Dorsal triangu lar stru cture, 1V:28 111 :9, 12-27, 32-35, 54, 99, 100, 102-8, 110, 116,
Dorsa l vein, 111:30, 31 117, 123-25, JV:7
Dorsal ven o us plexus tributa ry, lll: 10 Extensor carpi u lna ris, 1!:13, 30-33, 36-39, 54, 55,
Dorsa lis ped is artery, Vl:159, VH:24-29, 62-64, 59,66, 67,69, 78,100,102-5,108, 109, 11 6,
VIII:9, 34, 35 11 7, III:5, 9, 12-25, 34- 37,46,47, 70, 71, 80,
Dorsalis pedis vein, Vll :24- 29 81,87,88,91,99, 100, 102-6, 11 3, 115, 11 6,
Dorsolateral calcaneocuboid ligament, Vll:120, 128 123-25, IV: ?, 40
"Double oreo cookie" sign, 1:123 Extensor digiti minimi, 11 :59, 102- 9, 116, 11 7, 120,
Ductus deferen s, V:26 121, III :9, 12-29, 99, 100, 102-6, 112, 116, 11 7,
123-25, IV:20,21,38, 40
Extensor digitorum, !1:12, 13, 28-33, 38-43, 55, 59,
E 64-67, 78,79,98-100, 103-9, 117, 119,
Elbow, II:2-SS. See also Forear m 120, III: 9, 12, 13, 30, 3 1, 46-50, 99, 100, 102-6,
arteries, ll :14 111,112,117,123-25, Vl:148, l 56-57, 164-65,
axial graphics, 11 :11- 13 168, 169, Vlll :40, 41, 44, 45, 54,55
axial T1 MR, II :20-33 s lips, Ill :12- 29
bu rsae, 11 :2 Extensord igitorum brevis, 11 :70,101, 102, Vll :12,
compartments, JJ: 56-57 34-41,58,59,63-66,72, 118,120, 122,123,
corona l Tl MR, II:34-49 Vlll :26-41, 46, 4 7, 58, 60, 61, 65
cubita l fossa, ll :16 2 nd toe, Vlll :46-49
graphics, l1:8-19 3rd toe, Vlll :30, 3 1, 46, 47, 52, 53, 79

vi i i
 INDEX
Extensor digitorum communis, IV:1 6, 17, 20- 23, Externa l o blique, V:7, 16-2 1,42-51, 72, 86, 87
26-29,38,40-44 aponeurosis, V:16, 20, 22-26,45
Extensor d igitorum lo ngus, Vl:11, 12, 42- 47, 60, 61, External pudenda l artery, V: 19 5
147, 162, 163, 166, 167,170-75,178, 179, 182, External rotators, V:43-51, 206, 20 7, 271, 272
VH:9, 10,22-41,50-59,64-6 7,69-72, VIIl: 32- axial T1 MR, V:96-1 05
35,38,39, 46,47,52-55,60,65, 79 coron al T1 MR, V:ll9-25
2nd toe, Vll 1: 46-49 sagittal Tl MR, V:l06-18
3 rd toe, VIT1 :30, 3 1, 46, 4 7, 52, 53, 79 Extracapsular fat stri pe, VI:75
4th toe, VIII: 62
Extensor digitorum m anu s brevis, 111:109
Extensor d igito rum profundus, central tendon slip, F
rv: 7 Fabella, Vl:l32, 134
Extensor h allucis, Vl: 147, Vlfl:40, 41, 46, 4 7 Fabellofibular ligam ent, VI:12, 128, 129, 131, 132,
Ex tensor hallucis brevis, VII:12, 30-33, 62, Vlll: 36, 134, 135
37,44,45,57, 65 Femoral angle of inclination, V:65, 66
Exten sor hallucis lon gus, Vl: 156, 15 7, 166-75, 178, Femoral anteversion, V:65
179, 181-82, Vll :9, 10, 12,22-33, 54-66,69-72, Fem o ral artery, V:3, 96-105, 169, 192
Vlll :30-45, S0-57, 65 common, V:31, 32, 39-41, 60-62, 75-80, 83-86,
Extensor h ood, IV:22, 23, 38-43 106,107,155-58,171-75, 195,201,206-17,
Extensor indicis, H:96, 106-9, 1II:9, 12- 25, SO, 51, 265-67,270-72
99, 100, 102-6,111, 123-2S,IV:20,21 ,26,27, deep , V:56- 59, 195,216-35,262-65,273
38,40 lateral circumflex, V:42-Sl, 195, 212,213
Ex tensor mechanism m edial circumfl ex, V:42, 45, 46, 195
hand , JV:38-45 superfi cial, V:5 7-59, 195, 216- 43, 262-65,
knee, VI:3, 64-71 272,273
te rm in a l te ndo n, IV:7 Fem o ra l canal, V:201
Extensor muscles Fe moral cond ylar n otch , medial, Vl :92
elbow, II:16 Femoral cond ylar sulcus, lateral , Vl:7
wrist, III:96-97 Fem oral condyle, V:203, 260-62
Ext ensor po llicis brevis, 11 :96, 104-9, 114, 115, IIJ:9, late ra l, V:203, 275 , 276, VI:7, 14, 15, 96, 97, 99-
12-15, 20-23, 34-39, 54, 55, 99, 100, 102-8, 101, 106, 107, 114
125, IV:7, 39, 40 medial, V:203, 272, 2 73, VI: 7, 15, SO, 51, 54, 79,
Extenso r poll icis lo ngus, lf:96, 102-5, 107-9, 121, 96,97,99, 105, 106, 110, 115, 124
lll:9, 12-19, 24, 25, 28- 33, 51, 52, 99, 100, 102- Fem o ral cutaneous nerve, poster ior, V: 129
8,1 10, 11 6, 11 7, 123-25, IV: 7,26,27,39,40 Femora l diaphysis, V:9-ll , 66, 113-18, 202, 203,
accessory, 111:109 262-64
groove, lll :S Femo ral head, V:9-11, 29-31, 41-46, 56-60, 67, 73-
Extensor retin aculum, 1:1 72, 173, III:9, 12-19, 100, 77,81- 83,98-102, 106-1.1,124,125, 157,1 58,
108, IV:40, VI:159, VII:9, VIII :48-51, 77 161, 162, 166, 169, 172-79, 181- 88,193,202,
in fer.ior, VI:1 74, 175, VU:9- 12, 22, 23, 28, 29, 34, 206,207,263-65,271-73
35, 69, 71, 12 1, 123, Vfll: 34, 35 cente r, V:66
intermedi ate root , VII :63, 64, 120, 122, 123 lateral migration, V:65, 67
latera l root, VII:S8, 59, 65, 66, 118, 120, Femoral muscles
123, 129 anterior, V:190-91
medial root, Vti: S6-59, 63, 120 lateral, V:94
stem, Vt1 :.70 posterio r, V: 19 1
superior, Vll :9-12, 69-71 Fem o ral n eck, V:9- 11 , 19,20, 22-24,26,27,30-32,
Extensor te ndo n, Vlll :28,29 47,77- 79, 112, 113, 131-34, 175, 189, 193,206-
3rd and 4th toes, VIII: 50, 5 1 9,274,275
5th finger, IV:22, 23 an terior cortex, V:67
common, 1:172-77, 182-85, Il: l2, 26-3 1,38-43, basicervical, V:47, 48
55, 59,62-64,70, 71,78,85-91,95,98,99 long axis, V:66, 67
External il iac a rtery, V:8, 22-30, 37-39, 59-62, 73, Femoral nerve, V:l44-50, 169, 192, 200, 201, 212-15
74,81-85, 128, 131- 40, 154,1 59,160, 199 common, V:206-ll
External iliac vein, V:8, 22-30, 37-39, 59-62, 73, 74, superficial, V:228, 229
81-85, 128, 131-40, 154, 159, 160, 199 Femoral sh aft, V: 193 •
I
IX
 INDEX
Femoral sheath, V:201 3rd toe, Vlll:46, 4 7, 54, 55
Femoral torsion, axial CT, VI:8 4th toe, Vlll:SO, S 1
Femoral triangle, V:191 Flexor digitorum lon gus, Vl:146, 155, 158, 166-75,
apex, V:200 178, 180, 181, VII:9, 10,22- 41, 46-62,69, 78-
contents, V:201 80, 82, 86, 87, 89, 125, 127, VIII: 5, 20-23, 34-
Femoral vein, V:96- 105, 169, 192 47, 52-55,57,58,60-63,66,67,79
common , V:31, 32, 39-41, 60-62, 75-80,83-86, 2nd toe, VITT:48, 49
106,107,155-58,171-75, 196,201,206-17, 3rd toe, VIJI :46, 47, 54, 55
265-67,270-72 4th toe, VIII:S0-53, 62, 63
deep, V:56- 59, 196,216-35,262-65, 2 73 insertion, VIII:6, 22, 23
late ral circumflex, V:42-51, 196,212,213 Flexordigitorum profundus, 11: 12,13,26-43,51,
medial circumflex, V:42, 45, 46 52,65-71,75, 76,95,96, 100- 109,114-17, 121-
superficia l, V:57-59, 196, 216-2 7, 230-43, 262- 23, IIT: 9, 12-29, 38-41, 4 7- 5 1, 99, 100, 102-6,
65,272,273 111,112,115,124, 126,IV:6, 14, 16,1 7,22-25,
Femur, V:2, 57, 58, 104, 105, 180,208-11, 218-57, 28-30,32-37
273 Flexor d igito rum superficial is, II:1 2, 13, 26-33, 38-
anterior, V:194 43,50- 52,60,65- 67,70- 72, 74- 76,95,98-109,
distal, V:203 112, 113, 121, 122, III:9, 12-29, 40-45,48-50,
proximal, V:202 99, 100,102-6, 111, 112,114,1 15, 126, IV:6, 16,
supraco ndylar, V:203, 262, 263 17, 22,23, 29, 30,32- 37
Fibrocartilaginous ridge, VII: 28, 29, 92, 97 in sertion, IV:28, 29
Fibrous septae, VII:44, 45 Flexo r hallucis, Vl:1 64, 165, Vlll:34, 35
Fibula, VII: ?, 9, 13, 14, 18, 22, 23, 26, 27, 30, 31, Flexor hallucis brevis, VII:60, VIII:25, 26, 40-47, 57,
44-49,66,67,73, 74,77-79,84-86,88,91,92, 66,67, 77
97- 99, 103- 7,109-13, 115, 116, 120, 121, lateral head, VIII :6, 7, 20, 21 ,42-5 1,5 7, 75, 77
123, 128 medial h ead, VIII:6, 7, 20-23, 42-51, 56, 57,
Fibular collateral liga ment, VI: 30, 31 75, 77
Fibular cortex, Vll :44, 45 Flexor hallucis longus, VI:146, 151, ISS, 158, 168-
Fibular fossa, Vll:13 75, 177, 180, 18 1, 187, VII:9, 10, 12, 14,22-41,
Fibular head, V:193, VI:63, 129, 134, 150, 154, 159 44-66,69,71, 72, 76,78-80,82,84-90,125,
Fibular neck, VI: 150 VTII: 6, 7, 20, 21, 32, 33, 36-57, 66, 67, 75
Fibular styloid, VI:140 axial Tl MR, VII:84-88, 90
Fibular tip, VII:21 , 30, 3 1, 112 groove, VII:5, 6, 85
First carpom etacarpal compartment, III: 95 lateral head, VIII:22, 23
First carpo metacarpal injection portal, III: 74 low lyi n g, VII: 90
Flexor carpi radialis, 1:154,176, 177, IT:13, 28-33, sagitta l Tl MR, Vll: 89, 90
42-47,51, 52,60,65- 67,71,72,75,98-108, slips, VII:84
112, 113, 120, III:9, 12- 25, 38, 39, 42- 45, 52, tendon sh eath, flui d in, Vll :88
53,99, 100,102-6,1 10, 123-25, 1V:6, 16,1 7 Flexor mechanism , h and, IV:30-37
groove, lll :73 Flexor muscle mass, common, II:16, 58, 84
insertion, IV:16, 17 Flexor muscles, wrist , III:96
Flexor carpi uln aris, 1:155, 174, 175, ll:12, 13, 19, Flexor pollicis brevis, III:26-29, 38, 39, 52-55, 100,
26- 33,36- 39,50,51,60,64-6 7,69,70,74,75, lV:6,13, 18,19,29,30
96,98-109, 114, 115, 121-23, Ill:9, 12-19, 42- Flexor pollicis lo ngus, II :95, 102- 9, 114, 115, 119,
45,47,99,100,102-6,1 13, 114, 123, 124,IV:6 120, 1II:9, 12-29, 40, 41, 51, 52, 99-106, 114,
Flexor digiti minimi, ll:98, III:ll5, IV:6, 16-25, 28, 115, 123-26, IV:6, 16-21,24,25,29,30
30, 32, VIII:6, 7, 18-21, 62 insertion, IV:22, 23
aberrant origin, III:109 Flexor p ulleys, JV:30
Flexor digiti minimi brevis, III:26-29, 100, 114, Flexor retinaculum, III:18-27, 49, 50, 89, 100, 103,
VII:65, 66, VIII: 20, 21, 38-45, 61, 66, 67 105,106,121,124-27, IV:12-14, 16, 17,32,
Flexor digito rum, ll:99, Ill:40, 41, 112, 123-25, VII:9, 10, 22-31, 69, 71, 79, 85, 86, 114, 116,
VII:46, 4 7, VIII:50, 51, 79 117, 121
Flexor digitorum brevis, VII:14, 36-41, 46- 59, 62- 1st toe, VIII: 52, 53
64, 72, VIII:5, 18, 19, 32-41, 44- 4 7, 52, 53, 57, 4th toe, Vlll:52, 53
58,60,61,66,67, 75 distal, III:126
2nd toe, VUJ :48, 49 p roximal, lll:1 26

X
 INDEX
supe rficial, 111:103, 105, 106 AP and lateral rad iographs, ll :97
Flexor sh ea th, IV:22, 23 a rteri es, 11:93
Flexo r tendon , IV:22, 23, 28, 32, 34, 42 articulations, II:92
common, 1:172- 75, 11:11, 12, 16, 19,24-31,38- axial T1 MR, Il:98-109
43,50,5 1,60, 63,64, 70, 71, 74,75,84-87, bo nes, 11:92
89,90,95, 112,113,123 coronal T1 MR, II:110-17
Flexor tendon shea th, VJJl:S, 6 interosseous fibrou s attachments, ll :92-93
2nd toe, VIII: S4, 55 muscles, 11:93
comm on, 111:101, IV:32 nerves, II:93
roo t, Vlll: 2-94 origi n s and insertio n s, 11:95,96
l st ray, Vlii :S6-57 sagi ttal Tl MR, li :llS-23
2nd ray, Vlf l:S8-59 Fovea capitis, V:9, 172, 178, 179, 184, 185, 202,
3rd-4th ra y, VIIJ:60-61 206,207
Sth ra y, Vll1 :62-63
alignment, VIII: 2
arches, Vlll :2, 14- 15 G
axia l T1 MR Gastrocnemius, VI:10, 75, 110, 111, 168, 169, VII:64,
dorsal aspect, Vlll :28- 31 65, 76
pla ntar aspect, Vlll:1 8-27 lateral, VI:19, 34-39, 44, 45, 59, 60, 101, 113,
bony a natom y, VJIT:2-3 114, 152, 153, 157, 185, 186
Chopart join t, VTJ1:32-33 lateral head, V:194, 274-76, Vl: 11-13, 18, 22-33,
column s, Vlll :13 38-41, 59, 6 1-63, 84, 85, 89, 134, 136, 137,
compartments, VJU :3 154, 160- 65, 181- 83, Vll: 73
coron a l T1 MR, VIII :32-SS m ed ia l, Vl:1 8, 19, 34-45, 54-58, 66, 101, 110,
cuboid, VII 1:34-35 111,
cu neiforms, V Ill :36-39 m edia l head, V:194, 273,274, Vf:12, 13, 18, 20-
gra phics, VII I:S-15 33,40-45,55,74,76,134, 154, 160-69, 176-
ligame nts, Vlll :3-4 78, 180, 183, Vll :73
dorsal, VIII :1 1 third h ead, VI:183
planta r, V!H: 12 va ria nt, Vl:183
Lisfranc joint, VIII:40-41 Gemellus, V:174, 175,200
lo ng itudinal a rch, VIJI:1 4 inferior, V:7, 8, 32, 77, 95, 101, 102, 106- 12, 119-
metata r al heads, VIII:48-49
metatarsa ls superior, V:7, 8, 31, 75, 95, 106- 13, 119-21, 129,
d istal, Vll1: 46-47 157,158,1 65, 194,198
mid, Vlll :44-45 Geniculate artery
prox ima l, Vlll:42-43 descending, V:195, 244-49, Vl: 16
m etata rsophala ngea l joints, VIJI :74-79 inferior lateral, V:195, Vl :l7, SO, 5 1
muscles, Vl!1:3, 64-66 inferior med ia l, V:195, VJ: 16, 17, 44-47, SO,
dorsa l, VI1I: 64, 65 51,57
pla ntar, VIII :S-8, 64, 66 superior lateral , V:l 95, 252-55, Vl:l7, 20, 21, 46,
navicula r, VITI:34-35 47,50,51,62, 63
neurova scula r structures, Vll 1:4 superior medial, V:195, 250-53, Vl:l 6, 17, 20, 21,
dorsal, Vlll: 9 50,51,54,57
pla ntar, Vlll :lO Geniculate nerve, Vl: SO, 51, 140
n orma l variaRts, VIII:S0- 95 Geniculate vein
overview, Vlll :2-63 descending, V:244-49
pha langes, Vlll: S0-55 latera l, Vl:140
rad iography superior lateral, V:252-SS, VI:SO, 5 1
a nte roposterio r, Vlll:1 6 superior m edial, V:250-53, Vl:SO, 5 1
la tera l, VIII :17 Ge nitofem oral nerve, V: 16, 18, 20, 26, 27, 147
oblique, Vlll :16 Gerdy tubercle, VJ:30-33, 48, 49, 63, 67, 87, 128, 150
sagittal MR, VIII:S6-63 Glen oh umeral joint, 1:8 1
tarsom etatarsal joint, Vlll :68-73 G leno humeral ligam ent, 1:69,96, 104
transverse arc h, VIll:1 5 inferio r, I:S, 69, 81, 82, 96, 104, 110, 119,
Forea rm , II :92-123 120, 129 •
I
xi
 INDEX
anterio r band, 1:5, 58, 59, 96, 104, 105, 110, Greater sciatic forame n, V:1 26, 128
119-22, 129, 130, 146, 147 Greater sciati c n otc h, V:5, 11, 14, 130, 193
posterio r ba n d, 1:5, 54, 55, 104, 110, 119, g ra phics, V:128
120, 130 oblique coronal T1 MR, V:141-53
middle, 1:5, 28-31, 81, 96, 97, 104, 105, 107, llO, sagittal T1 MR, V:l 54-58
119-22,127-29, 144,145 G rea tertrochanter, V:9-1 1,30-32,50,5 1,57-59,94,
sma ll , 1:109 101- 4, 116-18, 120- 25, 168, 169,173-79, 181,
thick, 1:108 193,202,206,207,261,275-77 '
supe rfi cial, I:111 G reater tuberosity, 1:10- 12,15,26-3 1, 54-57, 104,
superio r, 1:5, 82, 83, 91- 95, 97-99, 104, 105, 106, 141, 143, 153-55
109, 110,112, 119-22,127 G rowth plate, unfused, 1:138, 139
va ri ant configurations, 1: 109 G uyon ca na l, Jll:40, 41 , 127
Glen o id, 1: 5, 13, 26-33, 52-59, 87-89, 94, 107, 116,
123, 130, 133, 138, 139, 153, 156, 178, 179
superior, 1:60, 6 1, 121, 143, 144 H
Glenoid fossa, 1:10- 15, 69, 80, 104, 108, 11 7, ll9, Hamate, III:20-25, 32-37, 47-49, 59, 84, IV:8, 9
120, 127-29 body, 111:48, 63
Glenoid rim, anterio r inferior, 1:12 hook, 111:5- 7, 22, 23, 38-41, 48, 59, 61-64, 73,
Gluteal artery 127, IV:8, 9, 24, 25 , 28
in fer ior, V:3, 8, 40-42, 45, 53, 96-99, 10 1-3, 106- vascu la r chann el, Ill :75
9, 128,129,138,147-65,195 wa ist, III: 73
superio r, V:3, 8, 24-26, 41, 42, 96-98, 106-13, Hamstring, V:119, 120
128, 129, 134-40, 147-49, 154, 156-61, 163, origins, V: 78-80, 157, 158
164, 195 Hand, 1V: 2-45
Glutea l line, V:5 3 D CT reconst ructio n
Glutea l n erve dorsal origins and in se rtio ns, IV:7
inferior, V:8, 129, 165 tendon injury zones, IV:5
superior, V:8, 128, 129 volar origins and insertions, IV:6
G lutea l tuberosity, V:1 93 axia l Tl MR, IV:16-23
G lutea l vein bon es, IV:3
inferio r, V:8, 40-42, 45, 53, 96- 99, 101-3, 106-9, coro nal Tl MR, IV:24-27
128, 129, 138, 147-65, 196 dermatomes, III:12 1
supe rior, V:8, 24-26, 41, 42, 96-98, 106-13, 128, extensor mechanis m, IV:38-45
129, 134-40, 147-49, 154, 156-61, 163, flexor mechanism, IV:30-37
164, 196 graphics
Gluteofemora l bursa, V:95 arteries, IV:1 5
Gluteus maximus, V:7, 8, 18-22, 24- 32, 34-57, 73- dorsal interossei, lV: l O
80,91-93,95-125,128, 129, 135-49,151-65, lumbrical muscles a nd nerves, IV: 14
171-75, 194, 198, 199,206-23,258-61,268- 78 palma r interossei, !V:l 1
Gluteus medius, V:7, 8, 16- 32,42-5 1,55-60,95- t hen ars and h ypoth ena rs, IV:l2-13
102, 109-25, 128, 129, 131-53, 159-65, 171-75, imaging m odalities a nd p itfal ls, IV:4-5
189, 194, 198,208-11,262-64,269,270,273, joints, IV:38-45
275-78 muscles, IV:30- 45
G lute us minimus, V:7, 8, 20,22-31 , 44-51,56-63, nerves, 1V:4
95-105, 109-18, 121-25, 129, 150-53, 159-62, norma l variants, !V:5
171-75, 194, 198,263-65,274-77 overview, IV:2-29
Gonada l vessel, V:18, 20, 26 palm ar, IV:30-37
Gracilis, V:5, 7, 8, 34, 35, 53-59, 81-83, 91, 92, 129, radiograp h y
194, 197- 99,201, 214-64,268,269,271,272, lateral, IV:9
Vl:10, 11, 18-37, 40- 45,54, 55, 89, 118-21, 125, p osteroa nterior, IV:8
145, 147, 152, 160-63 sagittal Tl MR, LV:28- 29
Grea ter a rc, 111:65 ten don inju ry zones, !V:5
Grea ter saph enous vein, V:36-38, 57-62, 85, 86, vessels, IV:3-4
196, 201, 210- 58, 260- 67, 269-71, VI:18, 24-27, He rniation p it, V:10
30- 37, 42- 45, 160- 63, VII:22-33, 48, 49, 58-62, Hilgenreiner li ne, V:65, 67, 68
Vlll :34, 35 H indfoot, Vll:2- 67

x ii
 INDEX
angles, VII:1 7 Humeral ligament, transverse, 1:6, 103
ax ial Vl1:19 Humeral vessels
grap hics, VII:S-12 anterior circumflex, 1:56-59, 83-85, 182, 183
ligamen ts, VII :Z, 7, 8, 103-31 posterior circumflex, I:36-39, 46-SS, 69, 178-83
nerves, Vll :4, 11, 12 Humeroulnar joint, Il:S
osseous anatomy, VII:Z Humerus, 1:32, 33, 154, 156-69, 184-89
radi ograp h y, Vll :13-18 anatomic n eck, 1:10,1 1, 15, 52, 53, 124
AP, VI1:1 3 anterior cortex, 1: 182, 183
Boe hle r an gle, Vll: 17 d ista l, ll:1 1, 61
Broden view, VII :1S head, I:I0-14, 24-31, SO, 51, 56, 57, 70, 75, 82,
ca lcaneal pitch, Vll :16 106, 112,114,1 15, 11 7, 127, 133, 138,
latera l, Vll :14 139, 141, 145-51, 156, 11:18, 95
measurements, VII: 18 posterior cortex, 1:97
oblique, Vll:1 3 proximal, 1:104
o ca lcis v iew, Vli:1 S proximal dia physis, 1: 34-39, 111, 135
ta lar base angle, VII:16 shaft, 1:13, 14, 71, 83, 84, 139, 153, 11:7
ta loca lcaneal angle, VII:17 surgical neck, 1:10, 11, 15, 34, 35, 52, 53, 131
re tinacula, VII:Z-3, 9 Humphrey, men iscofemoral ligament of, VJ:?S-77,
vessels, Vll :4 82,99,106-8,125, 129
Hip. See also Pelvi s; Thigh Hunter canal, V:191-92
acetabular versio n, V:69 Hya line cartilage, III: 7S, 88
latera l, V:94-12S Hypolu nate, lll: 72
external rota tors and cuff Hypothenar eminence, HI: 9
ax ial T1 MR, V:96-10S Hypothena rs, IV:12-13
co ro na l T1 MR, V:119-2S
sagittal T1 MR, V:1 06- 18
muscle insertions and b ursa, V:95 I
measurements a nd lines, V:64-69 Ili ac artery, V:16-30, 59, 128, 146-53
overview, V:Z-63 common, V:19S
radiography deep circumflex, V: 195
acetab ular protrusion , V:66 external, V:8, 22-30, 37-39, 59-62, 73, 74, 81-85,
acetabular versio n, V:69 128,131-40,154, 159, 160, 199
alpha a ngle, V:67, 68 internal, V:22- 27, 34-37,54-58, 128, 131-34,
AP, V:9, 68 148, 149, 195
center edge angle, V:67, 68 anterior d ivision, V:135-40, 148, 165
false profile view, V:68 superficial circum flex, V: 195
femo ra l a ngle of inclination, V:66 Iliac crest, V:S,9, 11-14,47-5 1, 63,131,132,193,
Judet views, V:12 199,202
latera l, V:10, 11 p osterior, V:133, 134
latera l migration h ead, V:67 tu bercle, V:S
mechan ical axis, V:66 Iliac fossa, V:S, 193
Hip joint, V: l 66-89 Il iac spine
axia l G RE MR a rthrogram , V:1 71-75 anterior in ferior, V:S, 9- 11, 13, 14, 27, 45, 62,
corona l T1 FS M R arth rogram, V:181-8S 159, 171, 186, 187, 193
graphics anterior superior, V:S, 9, 11, 13, 20, 46, 47, 85,
anatomy-overview, V:169
joi nt capsule an d liga ments, V:168 posterio r inferior, V:S, 14, 25, 130, 193
obli queaxia i Tl FSMRarthrogram, V: 176-80 posterior superior, V:S, 9, 13- 15, 40, 41, 130,
radiograph y, V:170 137, 193
sagitta l T1 FS MR arth rogram, V: 185-89 Iliac vein, V:1 6-30, 59, 146-53
Hoffa fat pad, VJ: 7, 14, 26, 27, 48-S 1, 58, 60-62, 65, commo n, V: 196
69, 77,84,87,91,94, 102 deep circumflex, V: 196
Hume ral artery external, V:8, 22-30, 37-39, 59-62, 73, 74, 81-85,
anterio r circumflex, 1:6,8, 71- 73,89, 154 128, 131-40,1 54,159, 160, 199
posterio r c ircumflex, 1: 7-9, 70-73, 77, 82-86, 99- intern al, V:22-27, 34-37,54-58, 131-34, 148,
10 1 134, 135, I SS
I 149, 165, 196 •
I
xiii
 INDEX
medial circumflex, V:196 Inferi or glutea l vein, V:8, 40- 42, 45, 53, 96- 99, 101-
Iliac wing, V:11, 12, 128, 202 3, 106-9, 128, 129, 138, 147-65, 196
Iliacus, V:7, 17- 23,41-43,46,47,56-63, 131-39, Inferio r iliac spin e
143-53,194, 197,199,201 anterior, V:S, 9-11, 13, 14, 27, 45, 62, 159, 171 ,
Iliofem ora l ligam ent, V:7, 168, 169, 171-74, 176-78, 186, 187, 193
183, 184, 186-88,206,207 posterior, V:S, 14, 25, 130, 193
ll ioischial jun ctio n , V:270 Inferior labrum, 1:54-57, 11 1, 148-51, V:181
llio ischia lllne, V:9, 13, 66, 72 Inferior patellar tend on, Vl: 7, 10-12: 14, 28-33, 50-
Uiolumba r liga m en t, V:7, 130, 142 53,59-62,65,66,76,77,83- 85,90,1 18, 145,
Iliopectin eal e minence, V:265 147-49, 156, 157, 159- 6 1, 181
Ili opect inea l junction, V:S, 12, 39, 40, 84, 155, Inferior pat ellotibiaJ ligamen t, Vl:24-27, 52, 53
184,264 Inferio r pate llotibial te n don , VI:l O
Iliopectinea l line, V:9, 72 Inferi or peroneal reti naculum, Vll:9, 34-37, 52, 53,
Iliopsoas, V:24- 32, 38-47, 58-63, 73-86, 96-113, 66, 92, 98
139, 140, 154-62,170-75,184-86, 194,206-1 3, Infe rior popliteome nisca l fascicle, Vl:80, 81 , 89, 91
262-67,270-74 In fe rior pubic ra m us, V:S, 9, 12, 13, 36-39, SS-59,
bursa, V: 169, 170 72,80-82,92,93, 154-56,168, 193,202,212,
Iliotibial ban d, V:SS- 60, 96-105, 125, 159-62, 175, 213,262-64
197, 198, 206-23,262, VI:11, 12,22- 29, 8 7, Inferio r t h yro id artery, 1:8
160, 16 1 InferiOl·tra n sverse ligam e nt, VII:S, 7, 26-29,48- 51,
Iliotibia l t ract, V:194, 248-57, VI:20-23, 30-33, 44- 64,65, 103, 105-8, 110, 11 1, 115,121
51,63,67,68,1 29,13 1, 157,159 Inferior uln ar co llateral a rtery, II:14
Ilium, V:2, 16-23, 25-27, 38, 39, 42-46, 52-61, 81- lnfero p lanta r lo ngitudin a l spring liga m ent, Vll :8,
84, 106-13, 120- 25, 128, 131, 132, 135, 139-44, 34,35,58,59,63,80, 124-28,131
147-53,155-58,169,184,269,270 Infragleno id tubercle, 1:34,35,80,131, 178, 179
Inferior acromioclavicular li gamen t, 1:103, 104, 116 Infrapat ellar (Hoffa) fat pad, Vl :7, 14, 26, 27, 48-
In ferior calca nea l nerve, Vll :12 5 1,58,60-62,65,69, 77,84,87,91,94, 102
Inferior epigastric a rtery, V:27, 37, 38, 87, Infrapa tellar p lica, Vl:69, 102
159-62, 195 Infras pin atus, 1:5, 7, 17,24-33,36- 55, 64- 75, 77-
Inferior epigast ri c vein, V:27, 37, 38, 87, 86,9 1, 93,94,96-101, 105- 12, 11 7,119-23,
159-62, 196 126-31, 133-36, 148-51,155,156, 178- 81
In ferior extensor reti nac ulum, VI: 17 4, 175, VII :9- ante rior bran ch, I:S4, 55
12,22,23,28,29,34, 35, 69, 71, 121,123, tra n sit io n between supras pinatu s and , 1:147
VIII :34, 35 Ingui na l cana l, V:7l
interm ediate root, VLI: 63, 64, 120, 122, 123 Inguina l liga ment , V:S, 7, 28-30, 37-40, 62, 63, 71,
lateral root, Vli :S8, 59, 65, 66, 118, 120, 123, 129 73-76,86,87, 92,93,200,201,206,207,267
m edia l root, Vll :S6-59, 63, 120 Interca rpal arch , do rsal, IIT :128, 129
stem , VII: 70 In te rcarp a l ligam ent, do rsa l, 11 1:8, 18-21, 32, 33,
Inferior fasc icle, VI:84, 85, 113, 132 48-5 1,79, 84,85,92
Inferior gem ellus, V:7, 8, 32, 77, 95, 101, 102, 106- Interco nd yla r a rea, fat with in, Vl:101
12, 119- 23,1 29, 157,158, 164, 165, 194,1 98 Inte rcondylar n otch , V:261, VI: 6, 7, 75, 76- 77
Inferio r gen iculate artery Inte rcondyla r roo f, V:1 93, 274
lateral, V:195, Vl :17, SO, 51 Intercostobrac h ial ne rve, I:9
medial, V:195, Vl: 16, 17, 44-47, SO, 51,57 In tercruciate recess, VI: 15, 112, 114, 115
In ferior glen o h u mera l liga ment, 1:5, 69, 81, 82, 96, Intercuneiform ligam ent, Vll:36-39, Vll l:30, 31, 38,
104, 110, 119, 120, 129 39, 72
an terio r band, 1:5, 58, 59, 96, 104, 105, llO, l1 9- do rsa l, VIII :38, 39
22, 129, 130, 146, 147 interosseous, VIII: 38, 39
posterio r band, 1:5, 54, 55 , 104, 110, l1 9, p lanta r, Vlll :1 2, 38, 39
120, 130 Jn te rligam entous recess, III:80, 81
Inferior glen o id rim, anterior, 1:12 Interligame nto us sulcus, Ill: 79
Inferior gluteal artery, V:3, 8, 40- 42, 45, 53, 96-99, Inte rm all eola r liga men t, Vll :1 07
101-3, 106-9, 128, 129, 138, 14 7-65, 195 Interm ediate d orsal cutaneous nerve, Vll:11
Inferior glutea l lin e, V:S lntermetaca rpal ligam en t, vola r ban ds, lll :26, 27
Inferior glutea l nerve, V:8, 129, 165 Interm etata rsa l bu rsa, VIII:77
Intermetata rsa l jo int, Vlll:70

xiv
 INDEX
lnte rmetatarsal ligam ent, Vll:64, Vlll :26-29, 42, 43, Interosseo us membrane, 11:95, 96, 102, 103, VIJ: 7,
72, 79 48,49, 103, 120,128
dorsal, VIIJ:ll , 71 leg, VT:l59
pla nta r, VIIl:12 ti biofibular, Vll:104, 106
Intermuscular fascia, VIII:67 Interosseous n e rve
Intermuscular septum, Vl:1 64, 165 an te rior, IJ:l5, 16, 18, 104, lOS
Internal il iac a rtery, V:ZZ-27, 34-37, 54-58, 128, posterior, 11:13, 111:11
149,195 Inte rp h ala n geal joint, IV:39, Vlll:16
anterior division, V: 135-40, 148, 165 1st, VIII :16, 20, 21
Internal il iac vein, V:ZZ-27, 34-37,54-58, 131-34, 5th, v m: 16
148, 149, 165, 196 dista l
Interna l oblique, V:S, 7, 16- 27, 38-50, 86, 87, 92, 5 th , Vlll :16
93,154-58,269 capsu le, IV:41
Internal o blique/t ransve rsus aponeurosis, V:16 collatera l ligament , IV:45
In t e rna l pudenda l artery, V:8, 28, 39, 96-99, 128, vola r plate, IV:37
129, 149-56, 159-65, 169 prox imal
Internal pudendal nerve, V:8, 129 3 rd, Vl11:54, 55
Interna l pudenda l vein, V:8, 28, 39, 96-99, 128, Sth , Vlll: 16
129, 149-56,159-65 , 169 capsu le, lV:40
Inte rn a l thoracic a rte ry, 1:8 collateral liga m e nt, IV:45
Interossei, 11:120, 12 1, 111:28, 29, IV:43, Vl11 :25, 26, volar plate, IV:35, 37
60--62 l nte rsesa moid ligament, Vlll:75, 77
dorsal, 1V:33, 38, 41, 42, Vlll:8, 26-29,42-45, Inte rtrochante ric crest, V:168, 193,202
65, 78 Inte rtrocha nteric line, V:168, 193
1st, IV:?, 10, 18-21,24- 27, 29, VIII:30, 3 1, 46, Inte rtrochant eric region, V:9
47,57,67, 76 In tertuberc ula r groove, 1:10, 15
1st-4th, Vlll:28, 29 ln t racapsular fatty tissue, Vl: 77
2 nd, IV:?, 10, 18-21, 26, 27, Vlll:30, 31, Ischia l ramus, V:S
67, 79 Isch ia l spine, V:5 , 8-11 , 13, 31, 99-101, 106, 128,
3 rd, IV:?, 10, 18-21, 26-28, VliJ:67 156, 164,169,173, 174, 193, 199,271
4th, IV: ?, 10, 18-2 1, 26-28, 40, Vlii: 62, 63, 67 Isch ia l tuberos ity, V:5 , 8-13, 40-43, 52-55, 72, 77-
graphics, IV:10 80,106-10,128,157, 158, 169, 175, 193, 199,
form ing late ral bands, IV:22, 23 202,212,213,260,261,269,270, 272,273
palma r, IV:6, 7, 30, 33, 42 lsch iocavernosus, V: 7
1st, IV: ll, 18-21,26,27 Ischiofem o ral liga m ent, V: l 68, 174, 178, 183, 184,
2 nd, IV: ll , 18-21,28 188, 189,206,207
3 rd, IV:11, 18-21, 28 lschiogluteal bursa, V:9S
graph ics, IV:ll Ischium , V:2, 13, 14,41-43,55,56, 103-S, 119-25,
p lan tar, VIII:8, 42-45, 66, 78 164, 165,208,209,261,271,272
1st , Vlll:67
3rd, Vll1: 26, 27, 63
1nte rosseous artery J
an terior, !1:14, 111:10, 128, 129 Joint capsu le, 1: 7, 73, 83, 84, 91, 95, 104, 133, 134,
common, li:14 II :8-10, V: 166-68, VI:129. See also Anterior
posterio r, ll:14, 102, 103, IIJ:lO capsule; Posterior capsule
recurrent, 11:14 Junctura tendinum, JV:20, 21, 40
Interosseous borde rs, leg, VI:l SO
Interosseous ligament, V:7, VIJ:24,25,48,49, 111
cu neocubo id, Vll:64 K
distal, 111: 77 Knee. See also Leg
inte rcuneiform, Vlll :38, 39 a rticu lar capsu le, VI:3
proxima l, 111: 77 axial CT
sacroiliac joint, V:38, 39, 52-54 femo ral to rsion , VI :8
talocalcanea l, VII :?, 30-33, 54-57, 62, 103, 114, tibial torsion, VI:9
120, 12 1, 128 axial TVl:l MR, VI:20-33
Interosseous Lisfra nc li gament, VITT:40, 41, 7 1- 73 ax ial TVI:2 MR, Vl:l83 •
I
XV
 INDEX
bones, Vl: 3 anterior, 1:26-33, 95, 107, 128-30, 133, 142-44,
coronal TV1:1 MR, Vl:34-53 146-49, 156, V:169, 186, 187
cruciate ligamen ts/posterior capsu le, VI:99-115 absent, 1:108, V:1 72, 173, 178, 184-86
CT arth rog ram type A a ttachment, 1:123
axia l and sagittal, Vl:14 type B attachment, 1:123
corona l, Vl:15 axial and coronal MR, 1:123
CT sca nogram, Vl:5 axial and sagittal T1 MR arthrogram, 1:121
exten sor mechanism, Vl:3, 64-71 axial PD FS MR, 1:126-31 ,
graphics, Vl:16-19 corona l graphics, 1:124
internal stru ctures, Vl:3- 4 coron al MR, I: 125
lateral support system, Vl:4, 126-41 inferior, 1:54-57, 111, 148-51, V:181
m edial support system, VI:4, 116- 25 posterior, 1:26-35, 54, 55, 104, 107, 108, 122,
m enisci, VI:72-97 127- 30, 133, 141, 142, 145-51, 156, V:169,
motion, Vl:2 173, 174, 176- 78, 181, 186- 88
muscles, Vl:2, 18-19 abnormal, 1:121
nerves, VI:2, 18-19 type A a ttachment, 1:123
overview, VI:2-63 type B attachment, 1:123
radiograph y sagittal gra phi cs, J:119, 120
AP and axia l, Vl:6 sagittal T1 FS MR arth rogram, !:122
lateral, VI:7 superior, 1:15, 94, 95, 106, 109, 112, 116, 122,
retinacu la, Vl: 3, 64-71 124, 126, 141-46, 178, 179, V:169,
sagitta l TVI:1 MR, Vl:54-63 18 1- 84, 188
vessels, VI:2-3, 16-17 absent, !:120, 121
Vl:3D CT recon struction, Vl:10-13 adherent to glenoid, I: 125
Knot of He nry, Vll:88 meniscoid, 1:124
wit h poste rio r biceps anchor fibers, !:54, 55
variants, 1:120, 123- 25
L Lacertus fibrosus. See Bici pital aponeurosis
L3 nerve root, V:141 Lateral antebrachial c utan eous nerve, I: 154,
LA III:1 2, 13
dorsal root ganglion, V:14 1 Lateral arc uate liga ment, VI:1 22, 132, 133, 139
nerve root, V:16, 129, 141, 142 Lateral bands, IV:10, 22, 23, 26, 27, 38, 40-44
nerve trunk, V:131-36, 142, 145-49 Late ral ca lcaneal t ubercle, Vll: 6, 13, 14, 38, 39,
spinous process, V:141 44-49
vertebra l body, V:9, 16, 141, 142 Latera l ca lcaneocuboid, bifurcate ligament, Vll:1 20
L4/L5 Latera l ca lca neon avicula r, bifurcate ligament,
disc, V:1 42-44 VII:64, 65, 128, 129
facet joint, V:16, 141 Lateral circumflex femoral artery, V:42-51, 195,
LS 212,213
dorsa l root ganglion, V:143, 144 Latera l circum flex fem oral vein, V:42-51, 196,
129 212,213
nerve trun k, V:131-36, 144-48 Lateral collateral liga m ent, Vl:ll-13, 24-29, 32, 33,
posterior elements, V: 130 40- 43,63, 79,88,89,128-32,135, 136, 139,
transverse process, V:13 141, 160, 161, Vll:102, 110-13, Vlll:22, 23, 48,
vertebral body, V:9, 17-19, 142-47 49, 76-78
L5/S1 2nd toe, VIII:50, 51
disc, V: 144-48 accessory, II :83
facet joint, V:18, 142 bursa deep to, Vl :l33
intervertebra l di sc space, V:8, 199 insertion , Vl:128, 135
Lab ra l remnant, an terior, V:1 78 metacarpoph ala ngea l jo int, IV:45
Labrocartilagin ous cleft, V: 178, 179 origin, VI:62, 85, 139, 141
Labrocartilaginous sulcus, posterior, V:187 Latera l condyle, V:193
Labrol igamentous sulcus, V:182 Lateral cord, 1:9
Labrum, 1:5,56, 57, 69, 80, 81, 96, 118-31, V:1 66, Lateral crura l extens io n o f retinaculum, VI:68
168, 170, 182 Lateral cutan eous nerve, 11:1 5

xv i
 INDEX
Late ral epicond yle, 1:153, 172, 173, 189, 11 :5, 10, 11, Late ra l t ibial plateau, VJ :79
22-25, 62, 63, 85, 86, 89, 98, 99, V: 193, Vl:6 Late ra l t ibia l spine, Vl:6
La te ra l femora l condyla r sulcus, Vl:7 Lateral trochlear ridge, anterior, VJ:SO, 5 1
La teral femoral condyle, V:203, 275, 276, Vl:7, 14, Late ra l uln ar collateral ligament, 11:12, 28, 29, 38,
15,96,97,99-101,106, 107, 114 39, 70,83,88, 89,91
Latera l femoral muscles, V:94 La tissi mus d o rsi, 1:6, 7, 16, 17, 40-59, 64-70, 77-82,
Lateral gastrocnem ius, VI: 19, 34-39, 44, 45, 59, 60, 84,96,97, 103, 133, 134,136, 137, 141, 154-56,
101,113,114,152,153,157,185,186 178- 85, V:7
Latera l geniculate ne rve, Vl:140 Leg, Vl:l42-87
Lateral gen iculate vein, V1:140 a nterior, Vl:147, 156, 159
Lateral inferior gen iculate artery, V:195, VI: 17, axial TVI: 1 MR, VI: 160-75, 186
50,51 ax ial TVI:2 MR, Vl:183, 187
Latera l intermuscular septum, 1:164, 165, 189 bones, Vl:142
Lateral m all eola r artery, VIII:9 coronal TVI:1 MR, Vl:176-79
Lateral malleolus, Vl:150, 15 1, 153, VII:S, 13, 14, d eep fascia, Vll:91
50-53 graphics, VI: 152-59, 184, 185
Lateral meniscocruciate ligam ent, a nterio r, VI:93 lateral, VI:149, 157
Latera l meniscus, Vl:28, 29, 89 media l, Vl: 145
a nterior horn, Vl:14, 46, 47,60-62, 78-81, 83- muscles, Vl:142-43
86,88,90,93-95, 102-4 n erves, Vl: 144
body, VI:15, 42-45, 78-81, 85, 88, 90, 139 obliq ue, VI:148
bow tie, Vl:63 posterior, Vl:146, 152, 153, 155, 158
discoid, Vl:90 radiography
fascicle, Vl:95 anteroposterio r, V£:1 50
junction of body/a nterior h orn , Vl:95 latera l, Vl: 151
posterior ho rn , Vl:14, 40-43, 58-62, 78-83, 86, sagittal TVI:1 MR, Vl :180-82
89,90,92,96, 100, 105,107, 109,113, 132, sagittal TVI:2 MR, Vl:187
134, 136, 137, 139, 141 vessels, Vl:143-44
root , Vl: S9, 89, 93, 104, 107, 109 Vl:3D CT reconstruction, VI: 145-49
Lateral metatarsophalangeal joint, Vlll :78-79 Leg lengt h, V:65
Lateral patellar facet, Vl: 6 Lesser arc, Ill :65
Latera l patellar retinaculum, V:19 7, Vl:22, 23 Lesser saphenous vein, Vl:24, 25, 34, 35, 57, 162,
Late ral pectoral nerve, 1:9 163,170- 75 , Vll:22-33, 44-47,65-67
Lateral p lanta r a rtery, Vll:34, 35, 61, Vlll:lO, 18, 19 Lesser sciatic foramen, V:127, 128
Lateral plantar nerve, Vll:12, 26, 27, 30-35, 6 1-63, Lesser sciatic notch, V:S, 128, 130
VIII: lO, 20, 21, 32, 33 Lesser trochan te r, V:9-ll, 44-47, 56, 111-13, 122-
deep branch, Vlll :lO 24,168,1 70, 181,193,197,202,212,213,
supe rficia l b ranch, V!Il:lO, 18, 19 262,274
Lateral plantar neurovascu lar bundl e, Vll: 34-41, Lesser tuberosit y, 1:10- 12, 15, 28-31, 58, 59, 73, 104,
50-59, Vl11:36-39 113, 129,1 30,141-44, 153,V: 193
Lateral plantar vein, VII:34, 35 Leva tor ani, V: 7
Lateral process, VII:S Leva to r scapu lae, 1:17
Latera l retinacu lu m, VJ:ll, 24, 25, 28, 29, S0-53, Ligamentum teres, V:167-69, 173-75, 179, 180,
63- 65,67,68,156, 157, 160, 161 183, 185
Lateral sacra l crest, V:6, 131-35, 137, 140 Linea alba, V:16, 63,87
La teral sesamoitl, VIII: ?, 57, 75-77, 92, 93 Linea as pera, V:193, 203
Lateral superior gen iculate artery, V:252-SS, VI:20, Lis franc joint. See Tarsom etatarsal joint
Lisfran c ligament, Vll: 38-41, VII I: 30, 31, 40, 41,
Lateral superior genicu late n erve, VI:SO, 51 71-73
Lateral superio r gen icul ate vein, V:252-SS, Vl:SO, 51 dorsal, VIII:ll, 71-73
Lateral su pport system , knee, Vl:4, 126-41 insertio n o n 2 nd metatarsal, VIJI:42, 43
Lateral supracondylar line, V:193 pla ntar, VIIl: l S, 28, 29, 72, 73
Latera l supraco ndylar ridge, 1:1 66-7 1 Lister tu bercle, 11:108, 109, III:5-7, 12-15, 30-33, 5 1,
Lateral syndesmotic clear space, VII:18 52, 59, 63, 117
Latera l tarsa l a rte ry, Vl:1 59, Vl11 :9 Liver, 1:184, 185
Lateral thoracic arte ry, 1:8 •
I
XVII
 INDEX
Long dorsal sacroi liac ligam ent, V:33-35, 130, 133, media l, Vl:145, 150, 15 1, Vll:5, 13, 14, 24-27, 50,
137-42 51,54-5 7,61,83,85,88,92, 105, 106,109,
Long planta r liga me n t, VII:? , 8, 63 , 64, 100, 103, 114, 115, 11 7-19,121, Vl ll:85
108, 114, 128, 129, 130,131, VIII: ?, 8, 12, 14, p osterior, VII: 14, 26, 27, 48, 49, 105, 115
32-35,38,39 Ma ster knot of Henry, Vlll: 32-35
Lo ng radio lunate ligament, lll :8, 16, 17, 38, 39, 51, Mechanical axis, V:65, 66
52, 79-82 Medial antebra chia l cutan eous 1: 9, 156, 157
Lo ng racl io u ln a r ligament, III :8 Medial arc uate li ga m ent, Vl:9 1, 122, 132, 133,
Lon g tho rac ic nerve, 1: 9 137, 140
Lo ngitudinal arc h, foot, VIII:14 Medial brach ial cuta n eo us nerve, 1:9, 156, 157,
Longitud ina l capsula r ligament, V:169 164--67
Longitud in al liga ment, anterior, V:130 Medial ca lcaneal nerve, Vl l:1 2, 61
Longitudina l m edial collateral ligament, Vl:26- 29 Medial ca lcanea l tube rcle, Vll :36-39, 44, 45 , 62,
Longitud inal spri ng ligament, inferoplantar, VII:8, 119, 127
34,35,58,59,63,80, 124-28, 131 Medial calcaneocuboid, bifurca te ligament,
Lower trunk, 1:9 Vll:128, 129
Lumbar pl exus, V:3, 141, 144 Medial ca lcaneocuboid ligamen t, Vll:1 13, 120, 123
Lumbosacral trunk, V:1 28, 129, 137-40, 148 Med ial capsulo ligamentous complex, Vl :125
Lumbrica l, 111:109, IV:14, 20, 21, 33, 38, 42, 43, Medial circumflex femo ral a rtery, V:42, 45, 46, 195
Vll l:6, 22, 23, 44, 45, 6 1, 79 Medial circum flex femora l vein, V:42, 45, 46
1st, lV:14, 24, 25 Medial ci rcumflex il iac vein, V:196
2nd, IV:14, 24, 25 Media l clea r space, Vll:l 3, 18
3rd, IV:14, 24, 25, 28, 40 Med ia l collateral bursa, Vl:124
4th, IV:1 4, 24, 25, VTII:46, 47 Medial collatera l ligame nt, 11:86, Vl :lO, 11, 13, 16,
insertion, Vl ll :22, 23 22-25,30, 31,44-47,54,66, 79,88, 119, 121,
Lunate, lll: 5-7, 14-19,34-39,48-51,59-64, 73, 80- 123, 124, 133, 145, 160-63, Vlll: 22, 23, 46-49,
82, IV:8, 9 76-78
ca rtilage, 111 :75,86 2 nd toe, Vl ll :50, 51
dorsa l li p, 111:59, 82 bursa, VI: 88
fossa, 111:5-7, 59, 87 dee p, Vl:1 24, 125
overha ng, 111 :66 fat between superfi cia l a nd deep fibers, Vl:124
type 1, lll :75 insertion, VI:179
type II, lll:75 lo ngitud inal, VI:26-29, 46, 47
volar lip, 111:59, 82, 83 o blique, VI:26-29, 46, 47, 88, 89, 121
Lung, T:64-66, 78, 79 o rigin, VI: l21
Lunotri quetra l angle, 111:69 superficial, Vl:68, 86- 88, 124-25
Luno t riquetra lligament, III:8, 36, 37, 86, 93, 95 two arms, VI:122
d o rsa l, 111:81,82,86 Medial compartme nt, th igh, V:204, 205
p roximal, lll :86, 88, 90 Med ia l condyle, V:193, Vl: 55
volar, 111: 79,8 1,82,86,90 Medial cord, 1:9
Lu nu la, 111:72 Medial cubital vein, !:170-77
Lym p h node, 1: 66 Medial cuneiform, VITT: 8 7
Lymphatics Med ia l cutan eous n erve, 11:15
anterior pe lv is, V:62, 63, 86, 87 Medial do rsa l cutaneo us nerve, Vll:11
thigh, V:201, 267 Medial epicondyle, 1:153, 172-75, 11 :5, 7, 10, 11 , 15,
22-25,50,62,63, 74, 75,85,86,89,95, 112,
113, 123, V:193, Vl:6
M Medial facet signa l abno rma lity, Vl: 71
Magic a ng le phen omen on, IV:4 Med ia l fem o ral cond yla r notch, Vl:92
Mai n collatera l ligame nt, IV:42 Medial femoral condyle, V:203, 272, 273, Vl:7, 15,
Ma lleola r a rte ry, late ral, Vlll:9 50,51, 54, 79,96,97,99, 105,106,110, 115,
Ma lleolar fossa, Vll:50, 5 1, 106, 107, 110, 111 124
Ma lleo lus Medialfe mora l muscl es, V:1 90
latera l, Vl:l 50, 15 1, 153, Vll:5, 13, 14,50-53 Medial gastrocnem ius, Vl:1 8, 19, 34-45, 54-58, 66,
101, 110,1 11,

xv iii
 INDEX
Medial inferior gen iculate artery, V: l 9S, VI:l6, 17, entrapment, U:18
44-47, SO, 51,57 muscular branches, Ill :1 21
Medial intermuscular septum, l:l SS, 186 pa lma r cutaneous branch, III: 121, 122
Media l ma lleol us, VI:14S, 150, 151, VII :S, 13, 14, proper digital branches, Ill:11, 122
24-27,50,51,54-57,61,83,85,88,92, lOS, recurrent branch, IV:14
106, 109,114, 115,117-19,121, VIII :8S Median ridge, IV:8
Medial m eniscome niscal ligam ent, Vl:96, 97 Mediop lan tar oblique spring ligament, Vll :8, 34,
Medial meni scus, Vl:28, 29, 73-75 35,56- 59,61-63,80,82,121,122,124-26,128
anterior horn, Vl:48, 49, SS-58, 73-76, 78, 79, Menisca l fascicl e, ante rior, Vl:l04
87, 91, 94 Menisca l homologue, 111:88, 91
body, VJ:15, 44-47, 73, 74, 78-80, 86-88, 124 Menisci, knee, Vl: 72-97 . See also Latera l men iscus;
junction of body/anterior horn, Vl:48, 49 Med ial meniscus
junction of body/ posterior h o rn , Vl:42, 43 Meniscocapsular junction, Vl:125
posterior horn, Vl:15, 40-43, 55-57, 73-76, 78, Men iscocruciate ligament, Vl:93, 94, 103
79,86,88,89,91, 100,108, 110, 111 Meniscofemoral ligament, Vl:86-88, 124
superio r recess, Vl:91 of Humphrey, Vl:75-77, 82, 99, 106-8, 125, 129
root, Vl:58, 86, 87 of Wrisberg, Vl: S7, 58, 92, 105, 125, 129
Medial patella, VI:59 Meniscom eniscal ligame nt, VI:96, 97, 102
Medial patellar facet, Vl:6 Meniscopoplitealligament. See Superio r fasc icle
Medial patellar retinaculum, V:197, 199, Vl: l O, 11 Men iscotibial ligame nt, Vl:lO, 11, 13, 16, 86-88,
Medial patellofemoralligament, V1:10, 13, 22, 23, 124,145
65,66,68,87, 11 8,121 Metacarpal, IV:2, 9
Media l patellomeniscalligament, Vl:67 3rd, lll: 59-63
Medial pectoral nerve, 1:9 Metacarpa l arch , basa l, lll:128, 132, 133
Medial plan tar artery, VII:50- 53, 6 1, Vlll:10, 22,23 Metacarpa l artery, 5 th do rsal, lll:lO
Medial p la nta r ne rve, VU:1 2, 26, 27, 30-35, 50-53, Metacarpal base, 111 :5-7 ,26-29, 36,37
61, 62, 89, Vl11:10, 20-23 lst, 111:24, 25,38-41, 54, 55, 59, IV:24, 25
Medial p la ntar neurovascula r bundle, V!I:34- 41, 2nd, III:32-35, 51- 54
48-51, 5-l-59, Vlll :34-39 3rd, III:30-35, 49-5 1
Medial plantar vein, Vll :50-53 4th, III:32-35, 47-49
Medial plica, Vl: 71 5th, II1: 24, 25, 34, 35, 38, 39, 46, 47
Media l ret inacu lum , Vl:24, 25, 28, 29, 46, 47, 50-53, Metaca rpal head, lV:8
55,56,58,59,64,66-68, 125,156, 160,161 4th, radial aspect, !V:28
Media l sesamoid, VIH :5, 7, 56, 75, 76, 92, 93 articular ca rtilage, IV:42
Media l superio r genicu late artery, V:250-53, VI:20, di stal, IV:43
21,50,51,54,57 Metaca rpal ligament, deep transverse, IV:22, 23,
Medial superior genicu late nerve, Vl:50, 51 32,43
Media l superio r gen icu la te vei n , V:250-53, VI:50, 5 1 Metaca rpophalangea l jo int, TV: 39
Med ial suppo rt system, knee, Vl :4, 116-2 5 Metaphyseal beak, V:67
Media l su praco n dylar line, V: l 93 Metaphyseal notc h, Il:7
Media l supraco ndyla r ridge, 1:1 66-71 Metata rsal, Vll1:13
Med ia l tibia l plateau ca rtilage, Vl: l29 l st, VH:ll, 13,38-41,60-62,70,96, Vlll:17, 42,
Med ia l tibial spin e, Vl:6, 100 43,5 7,91
Med ian artery, 111:10, 130 2nd, VII:20,38-41,61-63, Vlll :40,4 1, 57, 58,78
persisten t, 111 :128 Lisfranc liga ment insertion, Vlll: 42, 43
Med ian cephalic ve in , 1:189 2nd-4th, VII:ll, 70
Med ian crest 3rd, VII:20, 40, 41, 63, 64, VIII:60, 70
metatarsal, Vlll :75, 76 4th, VII :64, 65, Vlll:28, 29, 40, 41, 61, 62, 70
sacra l, V:6 5th , Vll:9, 65, 66, 95, 96, 99, Vlll :25, 26,
Med ian eminence, Vlll:1 7 38-43,61
Median nerve, 1:6, 9, 154, 156-77, 180, 18 1, 186, stylo id, Vll:l4, VI11 :62, 69, 70
187, 1[:1 1-13, 15, 16,20- 33,46,47,51,61-65, d ista l, VIII:46-47
67, 72, 76,98- 109,111:11-29,42,43,5 1, 102-6, median crest, Vl ll :75, 76
111,114, 121-26, 130-33, 1V:3, 14 mid, Vll l:44-45
co mmo n pa lmar digita l b ranches, III : I 1, 122 prox imal, Vlll:42- 43
digita l branches, IV: 14 Metata rsal artery, dorsa l, Vlll:9 •
I
xix
 INDEX
Metatarsal articu la tion, accessory, Vlll:94 Naviculocuneiform joint, Vlll: 36, 37
Metata rsal base Neura l foramen, V: 14
2nd, VIII:57 Neurovascular bund le
5th, VIJ: 40, 41, 67 axi llary, 1:32, 33, 129, 133, 135, 156
Metata rsa l head, VIII:48-49 deep brachial, 1:46, 4 7
1st, Vll l:76 d igital. See Digital neurovascu la r bundl e
2nd, VTTI:79 p la ntar. See Plantar
5th, VIII:63, 78 suprasca pular, 1:67, 79
dorsal, VIIJ :78 tibia lis posterior, VII :44, 45, 48, 49, 89, 119,
dorsal m edial, n otch at, V1JI :16 124, 127
Metata rsa l ligament, transve rse, VIII:11 , 12 Neutral triangle, Vll: l4, 20
Meta tarsop ha langeal join t, VIII:74-79 Notch of Harty, Vll :52-57
1st, VIII:1 6, 17,75-77 Nut rient foramen, V:203
2nd, plantar plate, Vlll:48, 49, 79
4th, plantar plate, Vl ll :46, 47
lat era l, Vll1: 78- 79 0
Midcarpal compartment, Hl: 74, 95 Oblique cord, TJ:83, 114, 11 5
Midcarpa l injectio n porta l, 111 :74 Oblique ligament, posterior, Vl:26-29, 55, 11 0, 122,
Midcarpal liga ment 125, 133
dorsa l, fll :76 O bliqu e med ial collatera l ligament, Vl:26-29, 46,
volar, lii: 76 47,88,89, 121
Midd le calca n ea l facet, VIJ:6, 8, 120, 124, 128 Oblique meniscom eniscall igament, Vl:96, 102
Midd le colla teral artery, 1:155, 157 Oblique muscle
Middle glenoh umera l liga ment, 1:5, 28-3 1, 81, 96, external, V:7, 16- 21, 42-5 1, 72, 86, 87
97, 104,105,10 7, 110, 119-22,127-29, aponeuros is, V: 16, 20, 22-26, 45
144, 145 internal, V:5, 7, 16-27, 38-50, 86, 8 7, 92, 93,
sma ll, I: 109 154-58,269
th ick, 1:108 Ob Li que poplitea l liga men t, Vl:26-29, 56, 57, 59,
Middle phalanx 74, 111, 112, 129, 130, 132,133,136, 160,16 1
2nd, IV:44 Oblique pulley, IV:32
3rd Obl ique s pring ligament, m ediop lan tar, Vll :8, 34,
midshaft, IV:36 35,56-59,61-63,80,82, 121,122, 124-26, 128
prox ima l, IV:36 Obturator artery, V:3, 31, 32, 96-98, 103, 195
4th, IV:44 Obtu rator externus, V:7, 36-47, 49, 50, 56- 60, 72,
base, IV:35 78-84,90-93,95,103-16, 121-25, 154-58, 163,
diaphysis, JV:36 189,194,208-13,261-64,268-73
head, condyles, IV:9 bursa, V:95, 168, 180, 18 1
Midd le subtalar facet, Vll: 79, 82 Obtura to r fora men, V:5, 9, 12, 13, 72, 75, 76, 101,
Middle subta la r joint, Vll :14, 15, 19, 20, 21,30-33, 102, 128,1 93,202
54,55,62 Obturat o r groove, V:5
Midd le t runk, 1:9 Obturator inte rnus, V:7, 8, 27-32, 35-43, 52-59, 73-
Musculocutaneous nerve, 1:6, 9, 154, 156, 157, 79,82,91-93,95-111,119-25,128,129, 153-
11:15, 16 65, 171-75, 198-200,206-9,260-64,268-70
bursa, V:95
tu bercle, V:21 0, 211
N Obturator membrane, V:199
Nav ic ula r, Vll :7, 8, 11, 13, 14, 20, 32-35, 58-63, 70, Obtu rato r nerve, V:24-28, 31, 96-98, 103 , 128, 13 1-
87,94, 103, 114, 119,124,128, 129, 131, 40, 142,143, 147-53,159-62, 171-73, 192
VIII:13, 16, 17, 26-29, 32, 33, 34-35, 56, 70, accessory, V: 131-33
84-86,88,95 Obturator ve in, V:31, 32, 96-98, 103, 196
accessory, Vlll:81, 82-87 Olec ra n o n, II:5, 7, 19, 34-39, 86, 87, 96-99, 121-23
articular su rfa ce, Vll:8 Olecranon bursa, 11 :9
beak, VJI :34, 35, 125-27 O lecra no n foramen, 11:5
facet , VII:5 O lecrano n fossa, 1:1 70, 17 L, 187, 11 :6,38-41,70,76
tu berosity, Vll :32, 33, 58- 60, 80, 83, 86, 118, Olecra n o n process, 1:153, 172- 75, 180-83,11:6, 10-
125-27 12,24- 27,63,64,68,69, 76,98,99

XX
 INDEX
Omohyoid m uscle, 1:65 Pa lmaris lon gus, 1: 176, 177,11:12, 13,28-33,38-45,
Opponen s digit i mi nimi , III:24-29, 46-48, SO, 100, 50,51,60,65-67, 70-72, 74,75,98-109, 112,
112, IV:6, 12, 13, 18, 19,24, 25, 28,30,32 113, 120, Ill:102, 104- 6, 123
Opponens polli cis, lli:22- 29, 50- SS, 114, IV:6, 12, accessory, III :109
13, 16-19,29,30 insertion , IV:18, 19
Opponens polli cis brevis, 1V:24, 25 Pa rastylo ideus, lll:72
Os acromiale, !:138, 139 Paraten on, VII :74, 77
Os calcaneus second arius, Vlll :81 Paratrapezium, III:72
Os calcis view, Vll :l S Pars pero nea metatarsa l is primi, Vlll:81
Os cen tra le, lll :72 Parsymphysis, V:63
Os cuboideum secondarius, Vlll: 8 1 Patella, V:193, 203, 264, 265, 273- 76, Vl:70, 114
Os Gru ber, IH:72 apex, p atho logic thi nni ng, Vl:l4
Os ha muli p roprium, Ill :72 lateral ca rtilage, Vl:1 4
Os intercuneiform, VHI:81 lateral facet, VI: 6
Os intermetat arse um , VTTI :81, 91 media l, Vl: 59
Os navicula re, VII :82 m edial facet, Vl:6
Os pa ranaviculare, lll :72 sta bilizers, Vl:66-68, 116-17
Os peron ea le, Vlll :81, 89 superior, Vl:68
Os peroneu m, VII :l l, 70 Patellar ligament, V:194
Os rad iale ext ernu m, ITI: 72 Pate ll ar retinac ulum, Vl:129
Os stylo ide um, ll l:72 lateral, VI:22, 23
Os supra navicu !are, VIJ 1:8 1, 83 m edia l, V:197, 199, VI:lO, 11
Os sustentaculi , VIU: 81 Patellar tendon, V:274, 275, Vl:64
Os tibiale ex tern um, VHI:8 1, 82-87 in ferior, Vl:7, 10-12, 14,28-33 , S0- 53, 59- 62, 65,
type 1, Vl11 :82, 83 66, 76, 77,83-85,90,118, 145, 147-49,156,
type 2, VIII:82, 84-86 157, 159- 61, 181
type 3, VII!:82, 87 Pate ll ofemo ra lligam ent , medial, Vl:lO, 13, 22, 23,
Os trigonu m , Vll:28, 29, 48-5 1, 106, 111, VliJ:81 65,66,68,8 7, 118, 121
Os vesalian um, JIJ: 72, VlJJ :81, 90 Patellom eniscal ligament , med ial, Vl:67
Ossicles, accessory Patellot ibialligament, Vl:65- 68, 118
foot, Vlll:81-9 1 in ferio r, Vl:24-27, 52, 53
w rist, !Il:72 talofibular, VII:66
Pate ll otibia l ten don, inferior, VI :10
Pecten, V:S, 72, 84, 85
p Pecti neal lin e, V:193
Pa lmar aponeurosis, Tll:20, 21, 24- 29, IV: l 8, 19 Pectineus, V:7, 31, 32, 34-44, 56- 62, 75- 85, 91- 93,
Palmar arch 101-10,154-58,175,194, 197,200,201,208-
deep, 111:26, 27, 129, 133, IV:lS 17,263-66,268-74
neurovascula r bun d le, lV:28 Pectoral n erve
radial bran ch , III:lO, 128 latera l, 1:9
ulnar bran ch , lil:lO m edial, I:9
superficia l, III: 129, IV:15 Pectora li s major, 1:16, 32-45, 71, 72, 82, 83, 85, 98,
rad ia l bra nch , ITI:lO, 128 99, 131, 133, 135, 156, 182- 85
ulnar bran ch, UI: lO Pectoralis m ino r, 1:16, 26-45, 128-31, 133, 135, 156,
Palmar carpal arch , fll:l O, 121, 128-30 184, 185
Pa lmar carpa l ligament, IV: l 6, 17 Pedicle, V:14
Pa lmar digit al arteries, common , 1V:3, 15 Pedis artery, d orsalis, V l:l 59, Vll:24-29, 62-64,
Pa lmar hand, IV:30-37 VIII:9, 34, 35
Palmar interosse i, 1V:6, 7, 30, 33, 42 Pedis vein, dorsalis, VII:24-29
1st, lV:ll , 18-21, 26, 27 Pe lvic brim, V:9, 11, 13
2nd, lV:l1, 18- 21,28 Pe lv is. See also Hip; Th igh
3rd, IV:11, 18-21,28 anterio r, V:70-93
graphics, IV:ll axial T1 MR, V: 73- 80
Palma ris brevis, 1V:16-19 coronal T1 MR, V:61- 63, 81-87
graphics, V:72
muscle attach ments, V:194 •
I
xxi
 INDEX
X
Q.J
"0 osseous anatomy, V:70 Peronea l ne rve, Vl:149
r:::: radiograph y, V:72 common , V:129, 200, 250-57, Vl:1 8-39, 58-61,
sagittal T1 MR, V:88-93 128, 129, 158-63, 184, 185, 186
axial Tl MR, V:16-32 deep, VI:l59, 164-73, 184, 185, Vll :12, 22-27,
corona l Tl MR, V:52-63 32-37, 62, Vlll :9
graphics lateral bran ch, Vl1:12
muscle origin /i nsertion, V:7 medial and late ral ter minal b ra_nches, Vi: 159
muscles o f th ig h at, V:8 medial branch, VJ I:11 , 12
osseous structures, V:5 recurrent branch , Vl:l 84
ho ri zontal axis, V:69 superficial, Vl:1 59, 184, 185, Vll :11
late ral, sagittal Tl MR, V:39- 46 lateral b ranch, Vlll: 9
to ng axis, V:68 medial branch, VII 1: 9
tower, axial Tl MR, V:28-32 Pe roneal retinaculu m, Vll :9
m edial inferio r, Vll :9, 34-37, 52, 53, 66, 92, 98
muscles, V: 199 superior, Vll:9, 10,28-3 1,69,71,91-93,97,
sagittal Tl MR, V:33-38 98, 116
mid Peronea l tendons, Vll:44, 45, 91-101
axia l Tl MR, V:22-27 axial Tl MR, VII:91-94, 97, 98
coronal T1 MR, V:57-60 ax ia l T2 FS MR, VII: 95, 96
osseous structures, V: 193 g raphics, VIJ:98
overv iew, V:2-63 sagittal Tl MR, VIJ:99-10 1
posterior, V:1 26-65 Pe ro neal trochlea, VII :6, 98
axial Tl MR, sciatic nerve, V:1 59-62 Peronea l tunnel, Vl: 184
corona l Tl MR, V:52-56 Pe roneal vessels, V1:164-73, 177
sciatic n e rve, V: 163- 65 deep, VII :48, 49
graphics Pe ro ne us brevis, Vl:146, 148, 149, 157, 164-77, 182,
greater and lesser sciati c no tch, V: 128 Vll :9-11, 22-41, 44-59, 66, 67, 69-72, 91-95,
sacral plexus, V:129 97- 99, 111-13, 125, 130, Vlll:22, 23,32-39,
saet·oil iac ligam ell ts, V: 130 62,65
sciatic ne rve, V:129 Peroneus longus, Vl :11 , 12, 38-45, 63, 147-49, 156-
obl ique axia l Tl M R, sacroili ac jo in ts, 57, 159, 162-77, 182, Vll: 9-11, 22-41, 46-59,
V:l31-40 61-67, 69-72, 91- 101, 109, 111-13, 125, 130,
oblique coro na l T1 M R, sac ro iliac joints and 131, VIII:Z0-23, 25, 26,32-43,57,60, 61, 66,
greater sciatic no tch, V: 14 1-53 67,82
sagittal T1 MR, greater sciati c no tch , g roove, VIJ: 6, Vlll:89
V:154-58 o rigin, Vl:1 84
radiograph y sulcus, Vlll: 13, 16
AP, V:9 Peroneus quartu s, Vll :98, 125
inlet/outlet views, V:13 Pe roneus tertius, VII:1 0, 22-31, 34-41, 67, 69, 71,
sagittal Tl MR, V:33-51 Vlll:65
uppe r, ax ia l Tl MR, V: 16-21 Pero ne us tunnel, Vl:1 59
Perforating cutaneous nerve, V: 129 Pes anserinus, V:197, 199, Vl:46- 49, 118-22,
Perforating peroneal artery, VI: 159 162, 163
Perforating veins, V: 196 Phalanges, IV:2, 8, 9, Vl ll :50-55 . See also Middle
Perforating vessels, V:195,218, 2 19,232,233, Vl: 112 phalanx; Proximal phalanx
Pe rilabral recess 5 th m iddle and dista l (fused), VIII :26, 2 7
anterior, V:176, 177 distal, VIII: l3, 56, 76
posterior, V:173, 174 Physeal scar, LII: 75
superior, V:182-84 Pirifo rmis, V:7, 8, 24-30, 35-43, 52-55, 93, 95-100,
Perilabral sul cus 106-17, 119-22, 128, 129,139, 140, 146-65,
anterio r, V:1 86-88 171-73,198-200,261,270-74
posterior, V: 176-79, 186 Piriformis fossa, V:9 4
supe rio r, V: 171, 188 Pisifo rm, III:5-7, 18-21, 38-43, 46-48, 59-64, 73,
Perkin line, V:65, 67 83-85, 127,IV:8,9,24,25
Pe ronea l artery, pe rforating, Vl:159 secondary, 111:72
Pe roneal communicating nerve, VJ:18 Pisohamate ligament, lll:1 8, 19, 40- 43,46, 47, IV:l 4

xxi i
 INDEX
Pisotriquetral compartment, IIT:74 infrapatellar, Vl:69, 102
Pisotriquetral injection portal, III:74 m ed ial, Vl:71
PisotriquetraJ joint, fll :61, 73, 83, 93 suprapatellar, Vl:69, 70
Plantar aponeurosis, VII: 60 Popliteal artery, V:19S, 244-57,259-61, 274,275,
central band, VlJ:44-S S, 62- 64 Vl:20-33, 36, 37, 42-45, 56-58, 77, 112, 114,
lateral band, VI1:44-49, 54-57,64-66 158,177, 183
Plantar arch, Vlll :lO Popliteal cyst, VI:l11
Plantar artery Popliteal fossa, V:198, 260
lateral, Vl1:34, 35, 61, VIII:lO, 18, 19 Popliteal hiatus, Vl:14, 15, 79-81, 84, 86, 89, 91,
med ial, Vll:S0-53, 61, VUJ:lO, 22, 23 113,122,130,133, 137, 140
Plantar cuneonavicular ligament, VIII:36, 3 7 fluid in, VT:l39
Plantar digital a rteries, VIll:lO Popliteal ligament
Plantar digital nerves, VIJI:lO arcuate, VI:60-62
Plantar digita l neurovascular bundle, VIII: S0-53 oblique, VI: 26-29, 56, 57, 59, 74, 111, 112, 129,
Planta r d igital vessels, VIIJ:l8-21 130, 132, 133, 136, 160, 161
Plantar fa sc ia, VII :9S, Vlll:38, 39, 44-49, 57, 60, 62 Poplitea l sul cus, VI:6
central band, VIII:l4, 32, 33, 36, 37 Popliteal surface, V:193
deep fibers, Vlll:48, 49 Popl itea l vein , V:196, 244-57,259-61,274,275,
digital bands, Vlll :18, 19, 79 VI:20, 21, 36-43, 56,58, 112, 114, 177, 183
lateral band, Vlll:32, 33, 62 Popliteofibular liga ment, VI:91, 113, 128, 130, 131,
m edia l band, VIJI: 32, 33, 36,37 134-37, 139, 140, 154
Plantar intercuneiform ligament, VIIJ:12, 38, 39 Popliteomeniscal fascicle
Plantar intermetata rsa lligament, VIII:1 2 inferior, VI:80, 81, 89, 91
Plantar interossei, VIII: 8, 42-45, 66, 78 superior, Vl :80, 81,91
1st, Vlll: 67 Popliteomeniscalligament, VI: 132
3rd, Vll1:26, 27, 63 Popliteus, V: 194, Vl:11-14, 17, 19,24-33, 40-45,56-
Plantar ligament 63, 76- 86,88,89,91,92,101,113,122,129-35,
long, VII :7, 8, 63, 64, 100, 103, 108, 114, 128, 136, 137, 138-39, 141, 146, 153, 154, 160-65,
129, 130, 131, Vlll:7, 8, 12, 14, 32-35, 177, 178, 180-82
38,39 insertion, VI: 154
short, VII:8, 36-41, 108, 114, 122, 130, 131, muscu lotendinous junction, Vl:83, 90, 131, 132,
Vlll:l2, 14, 32- 35 137, 138, 140, 154
Pla n tar Lisfranc ligament, Vlll:1S, 28, 29, 72, 73 o rigin, Vl:1 S, 62, 79, 85, 129, 136, 139, 140
Plantar mu scl es, foot, Vlll :S-8, 64, 66 Posterior antebrachial cutaneous n erve, 1:155, 15 7
Plantar nerve Posterior anular ligament, l1:87
lateral, VII:l 2, 26, 27,30-35,61-63, VIII:10, 20, Posterior calca n ea l fa cet , VIl:S, 6, 124, 128
21,32,33 Posterior capsule, Il:9, V:170, VI:24, 25, SS-57, 59,
deep branch, Vlll: 10 73-77,82,83,91,98,99, 101,110-15,122,
su perficial branch, VTll:lO, 18, 19 125, 129, 130, 132, 133, 136, 137
medial, VII:12, 26, 27, 30-35, S0- 53, 61, 62, 89, perforations, VI :1 12
Vlll:10, 20- 23 and posterior cru ciate ligament, fat interposed
Plantar neurovascular bundle between, Vl:112
lateral , VTl :34-41, 50-59, Vlll: 36-39 Posterior circumflex humeral artery, I: 7-9, 70-73,
medial, VII:34-41, 48- 51,54-59, Vlll:34-39 77,82-86,99-101,134,135,155
Plantar plate, Vlll:S6, 58, 75, 79 Posterior circum flex humera l vessels, 1:36-39, 46-SS,
2nd metatarsophalangeal joint, VTIJ:48, 49 69, 178-83
4th metat arsophalangeal joint, VIII:46, 47 Posterior colliculus, VJ:14S, 151, VII:13, 14, 50, 51,
Planta r vascular a rch, VTll:67 60,61, 114,117,121
Plantar vein Posterior compartment, thigh , V:204, 205
lateral, Vll :34, 35 Posterior cord, 1:9
medial, VIl:S0-53 Posterior cruciate ligament, V:274, Vl: ll-13, 15, 24-
Plantaris, V:194, Vl:12, 13, 19-27, 30-33, 36, 37, 40- 29,40-47,5 7,58,70,75,76, 78-80,86,88,89,
45,59-62,83,84,113,123,140,152,153,154, 96,98-102,105-9, 112,114,115,124,180
160-69, 172, 173, 176, 180, 183, 186, Vll :22-33, insertio n , VI:89
73, 74, 77 origin, Vl:56, 100, 101, 115
Plica, VI:64 synoviurn covering, Vl:114 •
I
XXI I I
 INDEX
Posterior cruciate recess, VI:15, 101, 114, 115 Pre fe m o ral fat pad, Vl:14, 20, 21, SO, 51, 65, 9 1
Posterior crura l fasc ia, Vl:40, 41 Pre-gastrocnemius recess, Vl:14
Posterior c utaneous ne rve, III:1 1, V:8, 129, Vl:18 Prestylo id recess, lll:80, 82, 83, 88, 93
Posterior deltoid attachment, 1:180, 181 Princeps pollicis artery, 1V:15
Poste rior epicondyle, VI:66 Pronator q uad ratus, ll :95, 106-9, 114, 11 5, 111:9,
Posterior fat, Vl:99 36-41,49-52,100
Posterior fat pad, 1:1 70, 171, 187, IJ :9, 11, 22, 23, Pro n ator teres, l:154, 176,177, Il:ll-13, 16, 18,22-
52,53, 76 33, 42-47, S0-53, 60, 62-67, 71, f2, 74-77, 95,
Posterior fem ora l c uta neous nerve, V:129 96,98-10 3, 110-12, 11 9-23
Posterior fe m o ra l muscles, V: 191 Pro per d igital arteries, 1V:3, 15
Posterior g luteal line, V:S Prope r d igita l neurovasc ular bundles, IV:22, 23, 35,
Posterior iliac c rest, V:133, 134 43, 45
Posterior inferio r ili ac spine, V:S, 14, 25, 130, 193 Proximal carpal row, 11:108,109
Posterior in terosseous a rtery, 11 :14, 102, 103, ll l:10 Proxima l carpa l tunne l, 111 :124
Posterior interosseous nerve, II:13, III:ll Prox imal flexor retinaculum, 11 1: 126
Posterior joi nt recess, 11 :9, VI: 99 Prox imal interosseous liga me n t, 111:77
Posterio r labrocartil agi no us sulcus, V:187 Prox imal interp halangea l join t
Posterior labrum, 1:26- 35, 54, 55, 104, 107, 108, 122, 3 rd, VIII :S4, 55
127-30,133,141,142,145-51,156, V:169, 173, Sth, VIII: 16
174, 176-78, 181, 186-88 capsule, IV:40
abnor m a l, 1:121 collateral ligament, JV:4S
ty pe A atta chm ent, 1:123 volar plate, IV:35, 37
type B a ttachm e n t, 1:123 Proxi m a ll unotriquetral ligament, lll:86, 88, 90
Posterior ma lleolus, VII :14, 26, 27, 48, 49, 105, 115 Proximal m etatarsal, VUI:42-4 3
Posterior o blique ligament, VI:26-29, 55, 110, 122, Proxima l phalanx, IV:29, 42, VHI :13, S0-51
125, 133 1st, VHI:S6, 70
Posteriorperi lab ra l recess, V: 173, 174 3rd
Posterior perilabra l sulcus, V:1 76-79, 186 base, IV:34
Posterior subta lar fa cet, Vll :13, 14 diaphysis, IV:34
Posterior su bta lar joint, Vll:15, 19, 20, 30-33, 50- proxima l aspect, IV:34
57,63,64,121-23 4th, IV:34
Posterio r supe rior iliac spine, V:S, 9, 13-15, 40, 4 1, base, IV:43
130, 137, 193 diaph ysis, IV:35
Posterior suprapatellar fat pad, VI:65, 9 1 head, IV:44
Poste rior ta lofibula r ligam en t, Vll :7, 28-31, S0- 53, 5 th , !V:34
64,65,67, 103,110,111,113,116, 128 articular cartilage, IV:42
Posterio r t ibial arte ry, VI: 17, 158, 162, 163, VII:22- head, volar aspect, cond yles of, IV:35
33,46,47 Prox ima l radioulnar joint, II:S, 53, 77, 85
Posterior tibia I cortex, VI: 178 Proximal scaph olunat e liga m ent, Ill:86, 88, 90, 9 1
Posterio r tibia l ne rve, Vl:168-75, VTT:l 2, 22-29, 44, Prox imal tibiofibu la r joi n t, Vl :1 51
45,61,85 Prox ima l tibiofibu lar ligament, Vl:l32, 133
Posterior tibia l tubercle, VII: 13 Pseudospur, su bacromia l, 1:56,57, 117
Posterior tib ial vei n, Vll :22-33, 46, 47, 62, 64 Psoas, V:7, 16-23,41, 42, 57-59, 131-39, 141-53,
Posterior tibia l vessels, Vl:164-75 197, 199,201
Posterior tibio fib u lar ligament, VII :?, 22-27, 48, 49, Pubi c arch, V:13
103,105-11,1 15, 128 Pubic body, V:S, 33-35, 72, 77-79, 84, 85, 89, 202
Posterior tib.iota la r ligament, VII:8, 26-29, 52- SS, Pubic c rest, V:72, 85, 86, 88-90
6 1, 103,114,1 16, 117,119-22, 127 Pubic ra mus, V:ll
Posterior ulnar recu rrent artery, 1:1 72-75, 11:1 2, inferior, V:S, 9, 12, 13, 36-39, 55-59, 72, 80-82,
14, 19 92,93, 154-56,168, 193,202,212,213,
Posterolate ral structures, knee, Vl:128-31, 138-41 262-64
Posteromedia l capsule, Vl:117 superior, V:S, 8, 9, 12, 13, 36-38, 59-63, 72, 83-
Posteromedial structures, knee, Vl:122 85,92,93,154,155,168,193,199,202,265,
Pre-Achilles fat pad, Vl: l 57, Vll:1 4, 44, 45, 63, 64, 266,269
72, 74, 76 Pubi c tube rcl e, V:S, 77, 86, 90, 91, J 68, 201, 202
Pre-cruciate jo int recess, VI:99, 101 Pubis, V:2-3, 8, 128, 168, 199, 268

xxiv
 INDEX
Pu bococcygeu s, V:8, 199 Radial no t ch of u lna, 11:1 2
Pubofemora l ligamen t, V:1 68, 174, 175, 179, 180, Radial st yloid, II :96, 97, III :5-7, 14-17, 34-37, 53,
184 54,59,61,62, 73,80, 110, IV:8
Pudend al a rtery Radial tilt, LII:66
ext erna l, V:195 Radia l t u berosity, II:5-7, 30-33, 42, 43, 58, 71 , 80,
internal, V:8, 28, 39, 96- 99, 128, 129, 149-56, 81,97
159-65, 169 Radial vein, II:30-33, III:14-19, 123, 125, 130
Pudenda l ne rve, V:128, 129 Rad ial vessels, II:1 04, 105
in te rna l, V:8, 129 Radiali s indicis art ery, LV:1 5
Pudendal vein , internal, V:8, 28, 39, 96- 99, 128, Radiocapitell a r jo int, ll:5
129, 149-56, 159-65, 169 Radiocarpal arch, dorsa l, III: 128
Pu lvin ar, V: 168, 169, 172-74, 179, 180, 182, 183 Radiocarpal compartment, III:74, 93
Rad iocar pal inject ion po rtal, Tll:74
Radiocarpal joint, IV:8
Q Radioca rpal ligament
Q uadratus femo ris, V:7, 8, 43-50, 54, 5 5, 103-5, do rsa l, IIJ:8, 1.6-19, 32, 33, 48-51., 79-84,92
111-20, 129,1 94, 198,200,206-15,260,261, vola r, lll:8, 76
274-77 Rad iolunate a ngle, 111:69
Q uadrat us lumbo rum , V:7 Radio.lu nat e li.ga me nt
Q uadratus p lant ae, Vll :14, 38-41,46-59,62,63, 72, long, III: 8, 16, 17, 38, 39, 51, 52, 79-82
Vlll:6, 20-23, 25, 26, 32-41 , 57 , 6 1, 66, 67 sh ort, III:49, 50, 79-82
Q uad riceps, V:252-57, 265, 2 74-76, Vl:7, 12, 16, 20, Rad ioscaphocapit ate liga me nt, ITT: 8, 16- 1.9, 49-53,
2 1,52,53,60,62-64,66, 156, 157 79- 85,89
aponeurosis, Vl:10 Radioscapho lunate ligam ent, III:8, 20, 21, 79- 82
fat pad , Vl:65 Radio uln ar a n gle, III:67
inse rtio n, VI:10 Radio u lna r com partment, d ista l, III: 74, 94
Q uad rilatera l plate, V:173- 75 Rad io u lna r in jectio n port al, d ista l, lll :74
Q uadrilat era l space, 1: 36, 37, 132, 134, 135, 136 Radio uln ar join t, Ill :5
dist al, III:67, 70, 71, 123, IV:8
prox imal, 11:5, 53, 77, 85
R Radio ul na r ligament
Radia l arte ry, II:13, 14, 16, 30-33, 67, 77, 10 2, 103, d istal, III: 77
110-13, 111:10, 12-19, 40-43, 54, 55, 123, 125, d orsa l, lll: 8, 14-1. 7, 32-35, 48 , 79, 80, 87, 89, 91
128-3 1, 133, lV:2, 15-19 long, III :8
contribution to s u perfi c ial pa lma r a rch , IV:1 5 sho rt, JII: 8
deep, rTT:24, 25 vo lar, Ill: 8, 1. 4- 17, 79, 81,87
do rsa I carp al, Ill:128 Radius, 1:188, 11: 13, 66, 67, 80, 96, 101-7, 109, 114,
superficia l b ranc h , TII:13 1 11.5, 119, 120, III:6, 32-41, 48-52, 59, 63,
superfi cial pa lma r bra nc h, Ill:l O, 20, 2 1, 132 87, JV:9
Rad ial bursa, III:10 1, IV:32 distal, 11:1. 20, Ill: 5
Rad ia l collat e ral arte ry, 1:155, 157, 180, 181, 188 head, 1:153, 176, 177, 188, 189, II: 5-7, 12, 28, 29,
Rad ia l collatera l ligament, U:12, 26-29, 40- 43 , 55, 38-41, 44, 45,53-55,64,69-71,7 7,85,89,
71, 83, 85- 91, lll:8, 53, 79, 81, 89, 90, JV:22, 23, 91,95,97-99,120,121.
26,27, 44 n eck, Il: 5, 6, 10, 30, 3 1. , 40, 41, 97
Rad ia l n erve, 1:7, 9, 38-45, 77, 134, 155-71, 178- 81, shaft, 1!:78, 97
187, 188, Ir:11 , 12, 15, 16, 20-27, 40-45, 55, 62, Rectum, V:147
65, 71, 78, 104, 105, IV:3 Rectus abdomin is, V:16-31, 33-38, 63, 72-77,86-91,
b ranch es, I: 172-77 159-62,206-9,268
deep, ll :13, 15-17,28-33,44,45,63- 67, 100, 101 Rectus fem o ri s, V:7, 28- 32, 41- 51, 59- 63,83- 85, 96-
dorsal digita l bra nch es, III :11, 122 105 ,108- 15, 160, 171-75, 194, 197,199, 201,
e n t ra p ment, II:17 206- 51, 265-67, 272-76, Vl:59-62, 65, 156, 157
posterio r cut aneou s bran ch , III: 122 Retrocalcan eal bursa, Vll:76, 77
posterior int e rosseous bran ch, III: 122 Retrocalca neal fa t pad, VII:l 4, 72
in spiral groove hume rus, 1:188 Ret rocondylar bursa, V\:110, 11 1
superficial branch , Jl: 13, 15-17, 28-3 1, 44, 45, Retro m all eola r groove, Vll :92
63- 66, 77, 100-105, III:11-23, 122-24 Retrot ibial groove, VII:79 •
I
XXV
 INDEX
Rhomboideus, 1:17 Sacro ilia c ligament, V:1 30
Rib, 1:14, 66, 78, 153 anterio r, V:130
Rotator cuff, 1:76-89, V:94 graphics, V:130
axia l T1 MR, V:96-105 long d orsal, V:33-35, 130, 133, 137-42
coron al T1 MR, V:119-25 of pelvis, V:126
graphics, 1:77 short dorsal, V: 130-36, 141, 142
imaging pitfa lls, 1:87-89 Sacrospino us liga m ent, V:7, 8, 29, 30, 37-39, 73, 74,
sagittal T1 MR, V:106-18 96-98, 128, 130, 150, 151, 154-56, 161, 163,199
sagittal T2 FS MR, 1: 78- 86 Sacrotuberous .ligament, V:7, 8, 29-32, 37-42, 73-
Rotator inte rva l, 1:70, 82, 90-1 01 77,96-108, 128-30,140, 148-50, 154-62, 198,
axial T2 MR arth rogra m , 1:94 199,206, 207
coronal T2 MR arthrogram, 1:95 Sacrum, V:3, 8, 19-28, 33, 34, 36-39, 52-57,88-93,
gra phics, 1:91, 92 128, 154, 159-62,193,199,202
sagittal oblique T1 MR, 1:91 1st segment, V:131-33, 145, 146, 148
sagittal T1 FS arthrogram, 1:93, 96-101 2nd segment, V:133-36, 144, 145
Rotato rs, externa l, V:43-5 1, 206,207,27 1,272 3rd segment, V:144, 145
4th segment, V:137-39, 144- 46
5th segment, V:139, 140, 147
s a rticular surface, V:15
Sl ba se, V:6
n erve root, V:18,20-25,35- 37,53, 128,129, graphics, V:6
131- 34, 143-47 rad iography, V:14
nerve t runk, V:135-39, 147 Sagittal band, TV:22, 23, 40, 42, 43
S1/S2 disc remna nt, V:145 Saphe no us nerve, V:200, V1:18
S1-S5 segm en ts, V:6 Saphenous open ing, V:201
S2 Saphe no us vei n
nerve root, V:20, 22-25, 36, 37, 128, 129, 131-36, greater, V:36-38, 57-62,85,86, 196,201, 2L0- 58,
143-47 260-67, 269-71, Vl:18, 24-27, 30-37, 42-45,
nerve trunk, V:137-39, 147, 148 160-63, Vll :22-33, 48, 49, 58-62, Vlll: 34, 35
S2/S3 disc remnant, V:136, 144- 46 lesser, VI:24, 25, 34, 35, 57, 162, 163, 170-75,
S3 Vll:22-33, 44-47, 65- 67
nerve root, V:24, 128, 129, 132-36, 143-45 s mall, V1:18
nerve trunk, V:137-40 Sartorius, V:7, 2 7-32, 39-46, 59-63, 73-80, 86, 87,
S4 106-12,157-62,171-75,187-89,194, 197, 199-
nerve root, V:129, 133-37, 143 201, 206- 57, 259-67, 270- 72, VI:10, 11, 16-37,
nerve tru n k, V: 139, 140 40-47,54,55,88,89, 101,114,118-21,123,
Sacral ala, V:6, 9, 13, 14, 145, 146 125, 145, 147,152, 156, 160-63, 177
Sacral arc, V:6, 9, 202 Scaphocapitate li gamen t, lll: 84, 85, 89, 90
1st, V:13, 14 Scaphoid, 1:128, lii:5-7, 16-23, 34-41, 51-54, 64,
2nd, V:13, 14 8 1, 82, 84, 85, IV:8, 9
3rd, V:14 body, fii:63
Sacral crest, V:6, 13 1-35, 137, 140 ca rtilage, III: 75, 86
Sacral forame n, V:6 d istal pole, lll: 59, 62, 63, 83, 84
Sacral hiatus, V:6 fossa, 111:5-7, 59, 80, 87
Sacral plexus, V:3, 26, 127, 129, 154 proximal po le, lll :59, 60, 62, 63, 73, 80
Sacral promontory, V:6, 13, 14, 147 tubercle, III: 60, 73
Sacral tuberos ity, V:6 wa ist, 111:5, 6, 59, 6 1, 62, 73
Sacrococcygeal junctio n, V:6, 14 Scaph o lunate a ngle, 111 :69
Sacroi li ac jo int, V:9, 11-13, 20-24, 52-55, 126, 193, Scapholunate ligame nt, 11 1:34-39, 86, 93, 95
202 dorsal, III:8, 16, 17, 80-82, 86
interosseous ligament, V:38, 39, 52-54 proximal, IJI:86, 88, 90, 91
oblique axial T1 MR, V:131-40 volar, 111:16, 17, 8 1, 82, 86,90
oblique coro na l T1 M R, V:1 41-53 vola r band, lll: 80
radiography, V:l 5 Sca photrapezium-trapezoid ligam ent, ll1 :8, 79,
syndesmotic, V:131-38, 142, 143 90,91
synov ia l, V:131-39, 144-48

xxvi
 INDEX
Scaphotriq uetralligament, do rsa l, lll:8, 16-19,32, co nj oined o rigin with long head biceps femoris,
33,5 1,52, 79,83-85,92 V:44,53, 164,165,208-15,260,273
Scapu la, l:10, 11 ,13-15,34-43,52-55,66, 78, 104, Serrat us anteri o r, !:16, 40-45, 64, 65, 129, 130,
12 1, 127,131,135,136,13 7,153 178--85
body, 1: 30-33, 68, 80, 128-30 Sesamoid, IV:8, 29, VI1:34, 35, Vlll:16, 20, 21, 92- 93
inferior angle, 1:14 1st toe, Vlll: 16, 17, 22, 23, 48, 49, 56, 57, 81, 92
lateral border, 1:13, 14 2nd toe, Vlll:93
med ial border, 1:14 5th toe, Vll l:81, 93
spine, 1:7, 12, 22-27, 48-51, 54, 55, 64-68, 78, of d igits, Vlll :81
79,94,96, 106, 112, 115, 121,126, 127, 134, fa cets, VIII:l3
136-39, 145-50 in fl exor hallucis longus, Vlll:81
Scapu lar artery latera l, VIII:?, 57, 75-77, 92, 93
ci rcumflex, 1:6, 8, 9, 56, 57, 154 med ial, VIII :5, 7, 56, 75, 76, 92,93
dorsa I, I :8, 9 She nto n line, V:65, 67
Scapular ligament, superio r transverse, 1: 77, 104, Sho rt dorsal sacroiliac ligament, V:130-36, 141, 142
133,134 Short plantar ligament, VIJ:8, 36-41, 108, 114, 122,
Scapular nerve, dorsal, !:9 130 , 131, VIII:12, 14, 32-35
Sciatic foramen Sho rt radi o luna te ligament, 111:49, 50, 79-82
greater, V:126, 128 Sho rt radio ulnar ligament, 111:8
lesser, V:127, 128 Sho ulder, !:2-76. See also Arm
Sciatic nerve, V:8, 27-32, 39-43, 46-48, 52, 73-76, 3D CT recon struction , I: 16-17
96-110, 112,119,120,127,129,149-53, 155- ABER (abduction external rotatio n) position ing,
62,164, 165,171-75,192,200,208-5 1, 1:140-51
275,276 anterior and superior graphics, 1:141
axial T1 MR, V:159-62 T1 FS MR arthrogram, 1:142-51
coro nal T1 MR, V: l 63-65 a rthrography, 1:15
graphics, V:129 axial Tl MR, 1:19-45
Sci a ti c notch, V:9, 10 clinically releva nt regio ns, 1:132-39
grea ter, V:5, 11, 14, 130, 193 coron al ob li que T1 MR, 1:46-63
grap hics, V: l 28 graphics
oblique coronal T1 MR, V:141-53 a nterior, I :6
sagi ttal T1 MR, V: l 54-58 brachial plexus, I:9
lesser, V:5, 128, 130 posterior, 1:7
Sem imembranosus, V:7, 8, 43, 44, 52-54, 111, 129, sagitta l, 1:5
165, 194, 198, 199, 208-61,271-76, Vl:10-13, vascular, 1:8
16-29, 34-45, 54-58, 66, 74, 89, 101, 110, 111, labrum , 1:118-31
116,119,120, ligaments, [:1 02-17
152, 154, 160, 161 rad iograp hy
anterior branch, Vl:l22, 133 axillary and West Point view, 1:12
bursa, Vl:110 exte rna l and internal rota tion, 1:10
capsu lar expansion, Vl:55 Garth v iew, 1:11
direct attachment, VJ:89 Grashey view, 1:11
direct branch, Vl:30, 31 scapula r Y and AP scapula views, 1:14
expa nsion, VJ:36, 37 Stryker notch view, I : 13
insertion, Vl:40-43, 119, 120 supraspinatus outlet view, 1:13
po teromed'ial tibia l insertion , VJ:122, 123 rota tor cuff and b iceps tendon, 1:76-89
slip to medial collateral ligament, Vl:122, rotator interval, 1:90-101
123, 133 sagittal ob lique T1 MR, 1:64-75
slip to oblique popliteal, Vl:122 Sigmoid notch, lll :5, 6, 14, 15, 59, 62, 70, 71, 73, 87
sli p to posterior capsule, Vl :125 Sinus tarsi, Vll:15, 19- 21, 32, 33, 58, 59, 65, 66,
tibia l attachment, Vl:122, 123, 133 120, 122
Semitendinosus, V:7, 8, 45, 52, 53, 129, 194, 198, Sinus tarsi ligaments, VII:102, 120-23, 125
199, 214-58,260, 272-75, Vl:lO, 11, 17-37,40- Small sap he n ous vein, Vl:18
43,54,55,57, 101,118-21, 125,145, 147,152, Snuffbox, anatomic, lii:54, 98, 107
160-63 So lea lline, VI:42, 43, 154
•
I
XXV
 INDEX
Soleus, V: 194, Vl:12, 17, 19, 42, 43,58-62, 146, 152, posterior, Vll :l S, 19, 20, 30-33, 50-57, 63, 64,
153, 157, 158, 162, 163, 168- 71, 176-78, 180- 121-23
82, VII: 9, 10, 14, 62-67, 69, 71-74, 76 Subtroch a nte ric regio n, V:9, lO
accessory, Vl:187 Superfi cial circum flex iliac a rtery, V: l 95
n ormal, VI:187 Superfic ia l d elto id ligam ent, VII :?, 8, 24-31, 54, 55,
tibi al h ead, VI:IS4 60, 103, 114-18, 120, 121,129
Space o f Poirie r, 11!:81, 89 Superficial epigastric artery, V:l 95
Spermati c cord , V:27 Superficia l fascia, VI:114
Sph in cte r urethra, V:7 Superficial fem o ral artery, V:S?-59, 195, 216-43,
Spinogle no id no tch , 1:7, 121, 132, 133, 134, 262-65,272,273
137, 148 Superficial fem o ra l n e rve, V:228, 229
Spinous process, V:l 4 Superficial fem o ral vein, V:S?-59, 196, 2 16-27, 230-
Sp ira l line, V: 193 43, 262- 65,272,273
Spring ligament, Vll :8, 102, 118, 124- 27, VIII: ?, 8, Superficia l fl exor retinaculum, IJI :l 03, 105, 106
12, 14,87 Supe rficial glen o hume ra lliga me nt, 1:111
infe ropla ntar lon gitud inal, Vll:8, 34, 35, 58, 59, Supe rficial m edial colla teral ligament, Vl:68, 86-88,
63,80, 124-28,131 124-25
inse rtio n , Vl11: 32, 33 Supe rfic ia l p alma r arch , 111 :10, 128, 129, IV: l S
medi opla nta r o bliq ue, VII :8, 34, 35, 56- 59, 61- Superficial pero neal ne rve, Vl:l 59, 184, 185, Vll:11,
63,80,82, 121, 122, 124-26,128 Vlll :9
supe ro medi a l, VII:8, 30-33, 56, 57, 60, 79, 82, Superficial semimembra nosus bursa, VI:IIO
112, 114, 118, 119,122, 124, 125, 127, 128 Supe rficia l veins, w rist, 111:44, 45
Styloid process, Vlll :13, 16, 17, 20, 21 Superio r acromioclavicu lar liga men t, 1:103, 104, 116
Subacro mial pseudospur, 1:56,57, 117 Superio r articular facet, V:6
Subacro m ial-su bdeltoid bursa, I:S, 54, SS, 119, 120 Supe rior articula r process, V:6
contrast in, 1:1 5 Superio r exten sor retin aculum, Vll :9-1 2, 69- 71
Subac ro mial-subdeltoid fat plane, obscured , 1:88 Superio r fascicle, Vl:14, 84, 85, 9 1, 11 3, 132, 134,
Subcapita l region, V:9, 10, 202 136,137
Subclavia n a rtery, 1:8 Superio r gemellus, V:7, 8, 3 1, 75, 95, 106-13, 119-
Subclaviu s, 1:67 21, 129, 157, 158, 165, 173, 174, 194, 198
Subcuta neous fat, 1:75 Superior genicu la te artery
Subcutaneous vei n , ITI:130, 131 lateral, V: l 9S, 252-55, Vl:17, 20, 21, 46, 47, 50,
Subcuta neous venous plexus, do rsa l, IV:26, 2 7 51,62,63
Subgastrocnemius bursa, Vl:74, 110- 11 m edia l, V:1 95, 250-53, VI:l 6, 17, 20, 21, 50, 51,
Subgluteus m ed ius bursa, V:9S, 169 54,57
Subgluteus minimus bursa, V:9S Su perio r genicul ate n erve, VI:SO, 51
Sublabral fo ram en, 1:94, 120 Superior geniculate vein
Sublab ra l recess, 1:1 23 lateral, V:252-SS, Vl:SO, 51
Sublabral su.lcus, I: 128 media l, V:250-S3, VI:SO, 51
Subsarto rial ca nal, V: 19 1-92 Su perior gle no humera l li ga ment, 1:5, 82, 83, 91-95,
Subscapular nerve, 1:9 97-99, 104, l OS, 106,1 09, 110,112,
Subscapular recess, 1:93, 96, 144, 145 119- 22, 127
Subscapularis, l:S, 6, 16, 17, 24-45,54-74,77-87, Superior glen o id, 1:60, 6 1, 121, 143, 144
89,91,93,95-101,103, l OS, 107-11, 113- 16, Superior gluteal artery, V:3, 8, 24-26, 41, 42, 96-98,
119-23, 127-31, 133, 135,137,141 ,144- 48, 106-13, 128, 129, 134-40, 147-49, 154, 156-61,
154, 156, 178-83 163, 164, 195
insertio n , 1:143 Superio r glutea l n erve, V:8, 128, 129
insertion at lesser tu berosit y, 1: 141 Superio r glutea l vein, V:8, 24-26, 41, 42, 96-98,
superficial fi bers, 1:108 106-13, 128, 129, 134-40, 147-49, 154, 156-61,
Subta lar facet 163, 164, 196
middle, VII: 79, 82 Superio r iliac spine
posterior, VII :13, 14 anterio r, V:S, 9, 11, 13, 20, 46, 4 7, 85, 96, 111 ,
Subtalar jo int 112,1 68, 193, 197, 199
anterio r, Vll:l9, 20 posterio r, V:S, 9, 13-15, 40, 41, 130, 137, 193
middle, Vll :l 4, I S, 19, 20, 21, 30- 33, 54, SS, 62 Superio r la bru m , l:l S, 94, 95, 1.06, 109, 112, 116,
122, 124, 126, 141-46, 178, 179, V:l69, 181-84,
188
:xvii i
 INDEX
absent, I:120, 121 transition between infraspinatus and, 1:147
ad herent to glenoid, 1:125 Supraspinatus fossa, 1:66, 78
men isco id , 1:124 Sural nerve, Vl: 18-19, 57, 162-67, 170-75, VII:ll,
with posterior biceps anchor fibers, 1:54, 55 22-25, 65, 66, VIII:9
Superior patella, Vl:68 Sust entaculum ta li, Vll :6, 14, 19-21, 32, 33, 52, 53,
Superior perilabral sulcus, V:171, 188 61, 62, 89, 114, 117, 119, 121, 125, 127, VIIJ:13
Superior pero neal retinac ul um, Vli:9, 10, 28- 31, 69, Sympath etic t ru nk, V:128
71,9 1-93,97,98, 116 Symph yseal surface, V:5
Superior popliteomeniscal fasc icle, VI:80, 81, 91 Symphysis pubis, V:9, 13, 32, 61, 70, 77-79, 84-86,
Superior pubic ramus, V:5, 8, 9, 12, 13, 36-38, 59- 88,193,201,202,265,266
63,72,83-85,92,93,154,155,168, 193, 199, axial T1 MR, V:73-80
202,265,266,269 coron al Tl MR, V:81-87
Superior tho racic artery, 1:8 graphics, V:72
Superior transverse scapul ar ligament, 1: 77, 104, radiography, V:72
133,134 sagittal T1 MR, V:88-93
Superior ulnar collateral artery, 1:15 7, Il:14 Synchondrosis, VIU:85, 86, 90
Superior ulnar collateral vessels, 1:164, 165 Syndesmotic clear space, VII:13, 18
Superomedial spring ligament, VII:8, 30-33, 56, 57, Syndesm otic joint, V:15
60, 79,82, 112,114,118, 119,122, 124,125, Synovial condyla r joints, IV:39
127, 128 Synovial fringe, II:8, 54, 77
Supi n ator, ll: 13, 17,28-33,40-45,53- 55,65- 67, Synovial hinge joints, IV:39
69-72,77, 78,95,96,100-105,112-15,120,121 Synovium, 1:91
crest, Il:87, 88, 9 1
Supra-acetabular ilium, V:9, 10, 28, 97, 159, 160,
181,188,202 T
Supracondylar femur, V:203, 262, 263 Tl sp in al nerve, 1:9
Supracondylar line, V:193 Talar base angle, VII:16
Supracondyla r ridge, 1:166-71 Talocalcaneal angle, Vll:17
Supracondylar spur, 11 :7 Talocalcaneal interosseous ligament, VII:?, 30-33,
Supraglen oid tubercle, 1:5, 26, 27 54- 57, 62,103,114,120,121,128
Suprapatellar bursa, Vl:7, 65, 91, 114 Talofibular ligament
Suprapatellar fat pad, Vl:7, 65, 91 anterio r, VTT: 7, 30, 3 1, 66, 103, 110, 113, 116, 128
Su prapatellar plica, VI:69, 70 dorsal, VII: 114
Suprapatella r recess, Vl:14, 22, 23 posterior, VII:?, 28-31, 50-53, 64, 65, 67, 103,
Suprascap ular artery, 1: 7, 8, 26-29, 54-59, 126-28, 110,111,113, 116, 128
134, 137 Talofibular patellotibiall igamen t, VII :66
Suprascap ular branch vessels, 1:66, 78 Talonavicular ligament, dorsal, VII:?, 8, 62, 63, 103,
Suprascapular n erve, 1:7, 9, 26-29, 54-59, 128, 128, VIII:11
132, 134 Talus, VII:5, 7, 8, 11, 13, 15, 18-21, 26-29, 48- 55,
infraspinatus branch, 1:133, 156 70, 76, 77, 79,82,86,88-90,92,93,97,98, 103,
in suprascapul ar notch , 1:133 107, 108,1 10-12, 114, 116, 117,119-25, 127,
Suprascapular neurovascular bu ndle, 1:67, 79 129, 131, VIII:13, 32, 33, 84
Suprascapular notch , 1:121, 132, 133, 134 anterio r facet, VII:5
Suprascapular vessels, 1:20, 21, 24, 25, 65, 139 articul ar surface, VII:86
Su praspi n atus, 1: 5-7, 16, 17, 20, 21,24-27,54-61, body, VII:5, 64, 65, 85, 106, 117
64-75, 103,105,106, dome, Vll:105, 115, 116
109-12, 115,116, 119- 22, 125-27, 133, 134, h ead , VTT: 5, 13, 14, 30-35, 56-59, 61, 62, 80, 83,
136, 137, 141, 144, 145, 155,1 78, 179, 182, 183 118, Vlll:84, 86
anterior, 1:22, 23 lateral process, VII:13, 14, 54, 55, 65, 66, 121
anterior direct, 1:85 lateral tubercle, VII:5, 14, 50, 51, 63, 64, 85,
direct, 1:26, 27 90, 108
increased signa l in, 1:87 m edial tubercle, VIJ :5, 14, 28, 29, 50, 51 , 62,
insertio n, I: 146 85,90
oblique, !:22, 23, 26, 27 neck, VII: 5, 14, 20, 63
o utlet region, I: 13 posterior process, Vll: 5
posterior oblique, 1:54, 55, 85, 127 sulcus, VII:5 •
I
xxi>
 IN DEX
trochlea, Vll :5, 62, 63 muscle attachments, V:l94
Ta rsa l artery, late ra l, Vl:159, Vll l:9 muscles
Tarsal cana l, VTI:1 9, 30-33,52-57, 120, 121 adductor, Y: 72-93
Ta rsa l tunnel , Yll :12 anterio r, V:197
Tarsal vessels, Vll: 32-37 medial, Y:199
Tarsometata rsa l join t, Ylll: 15, 16, 4 0-41, 68-73 a t pelvis, Y:8, 199
1st, Ylll:17, 42, 43, 69, 70,91 posterior, Y: 198
2nd, Yll:14, Vlll:1 7, 40, 41, 57, 69, 70 nerves, Y:200
3rd, Ylll:69, 70 osseous structu res, Y:193
4th, YIII :69 pos terior, Y:198, 258-61
5th, YIII: 69, 70 radiography, V:202-3
axial Tl MR, Vlll :72 upper
coronal T2 MR, Vl ll :73 axial Tl MR, V:206-1 9
gra phics, Vlll :71 sagittal Tl MR, Y:47-51
radiography, Yll1 :69 veins, V: 196
sagittal CT, YIIJ:70 Tho racic artery, I :8
Ta rsom etatarsa l ligament, dorsa l, Vlll:11 Tho racic nerve, long, I:9
Teardrop, V:9, 10, 202 Tho racoacromial a rte ry, 1:8, 22, 23, 68, 81
Tendo n injury zones, hand, IV:5 acromial branc h, I:8, 52, 53
Tendon sheaths, IY: 34 clavicular branch, 1:8
ankle, YII: 71 deltoid branch, 1:8
hand, 1V:30 pectoral bra nc h , 1:8
wri st, 111:98 Tho racoacromial vessels, 1:80
Tensor fascia lata, V: 7, 25-32, 47-49, 60-63, 97-105, Thoracodorsal artery, I:8
114- 18,159-62,171-75,197, 20 1,206-19,266, Tho racodorsal nerve, 1:9
267,275-78 Th o raco lumbar fascia , V:16
Teres m a jo r, 1: 6, 7, 16, 17,38- 45,48-57,64-68, 70, Thyrocervical trunk, 1:8
77-82,96,103,133,134,136,137, 141, 154-56, Thyro id artery, inferior, 1:8
178--83 Tibia, Y:193, VII:7-l 0, 13, 14, 18,20- 23,26,27,46-
Teres minor, 1:5, 7, 17,30-35,48-53,64-74,77-86, 49,54,55,63-65,69,71,73, 74,76-79,84,85,
89, 9 1, 93, 96-101, 105, 108-11, 119-22, 128- 89-91,103-11,11 3,114, 118-24,127, 128
179 an terom edial bare area, VI:156
Te rmina l tendo n, 1Y:40-42 d ista I, transve rse axis, VI :9
Theca l sac, V:l31, 132, 141-43 insertion o f p osterior cruci ate ligam en t o n,
Thenar em inence, 111:9 VI:76, 77
The nars, IY:12-13, 30 posterior cortex, VI:178
Thigh, Y: 190-279 proximal, transverse axis, Vl:9
adductor mu scles Tibial apoph ysis, YI:150, 151
axial T1 MR, Y:73-80 Tibia l artery
coronal T1 MR, Y:81-87 anterio r, Vl:1 7, 158, 159, 162, 163, YIJ :22-25, 56,
graphics, Y:72 57, VIII: 9
radiograph y, Y:72 posterior, YI:1 7, 158, 162, 163, Yll:22-33, 46,47
sagittal T1 MR, Y:88- 93 Tibial g rowth p late sca r, Vll: l3
an te rio r, Y: 197, 264-67 Tibial nerve, V:129, 200, 250-57, VI:19-27, 30-39,
arteries, Y:195 56,58,59, 154, 158,1 62-67
compartments, Y:190, 204-5 a nterior recurrent, Yl:159
dermatom es, V:279 articula r branch, Y:256, 257
distal, Y:246-5 7 posterior, VJ:168-75, VI I:12, 22- 29, 44,45,61,85
femoral triangle, V:201 Tibial p la fon d, cente r, Y:66
graphics, V:8, 193-201, 279 Tibial plateau, latera l, Vl:79
lateral, V:277-78 Tibia l sesamoid, 1st toe, Vlll:81
medial, V: 199, 268-74 Tibial spine, Yl:6, 100
mid Tibial torsio n , axial CT, Vl:9
axial Tl MR, Y:220-45 Tib ial tubercle, Vl: 6, 7, VII:13
coronal Tl MR, Y:262-63 Tibial tuberosity, Y: 193
sagittal Tl MR, Y:275- 76 Tibia l vei n

XXX
 INDEX
a nterior, Vll:22-25, 56, 57, 65,67 2 nd , VIU:58-59
posterior, Vll :22-33, 46, 4 7, 62,64 2 nd-4th, VII1:60
Tibial vessels 3rd-4th , Vlll: 61
anterior, Vl:164-75 4th-5th, Vlll:62
posterior, Vl:164-75 5th, VIII:62-63
Tibi alis anterior, Vl:11, 12, 62, 63, 145, 147-49, Trabecula, normal, lll :75
156-57, 162-75, 179-82, Vll:9-12, 14,22-41, Transcondylar li ne, Vl:8, 9
56-65, 69-72, 79, 83, 94, VIII:26-39, 66, 72 Tran sverse arch , foot, Vlll:15
Tibialis posterior, Vl:l2, 13, 17, 42, 43, 146, 155, Transverse cervica l artery, 1:8
158, 162-75, 178, 181, Vll:9, 10,22-35,44-63, Transverse humera l liga me nt, 1:6, 103
65, 69-71, 78-83, 86, 114, 11 6, 125, 126, VIII:?, Transverse ligame nt, 1:7, 28, 29, 77, 121, 154, V:167-
12,32-37,66,82,85,86 69, 175, 180-85, VI: 28, 29, 48, 49, 58-62, 76-80,
anterior s li p, Vlll :25, 26,34-39 82-84,87,93,94,103
axial Tl MR, VIJ :78-82 infe rio r, VII:S, 7, 26-29,48-51,64,65, 103, 105-
ax ial T2 FS MR, VTl: 82 8,110,111,11 5, 121
distal slip, Vll :36-39, 83 Transverse m eni sca lliga ment, Vl:78
fibular o rigin, Vl:1 3, 155 Tra nsverse metacarpal liga ment, deep, IV:22, 23,
insertion , Vll :10, VTIJ: 32, 33, 38,39 32,43
latera l slip, Vll :ll Tra n sverse metatarsal ligament, Vl11:11, 12
medial sli p, Vll: ll Transverse recess, dorsa l, ITI :82-84
sagitta l Tl MR, Vll :83 Tra nsverse scapula r ligam ent, superior, 1:77, 104,
slips, VIJ :40, 41 , 80, 81, 8 7 133,134
fat between , Vll :80 Transversus abdominis, V: 7, 16- 26, 38-49, 72, 86,
tibial origin, VI: 13, 155 87,91- 93,154-58
Tibia lis posterior neu rovascular bundle, VII :44, 45, Trapeziocapitate ligament, III:8, 79
48, 49, 89, ll 9, 124, 127 dorsa l band, ITI:22, 23, 91
Tibioca lcanea l band, Vll :8, 54, 55, 114 Trapeziotrapezo id ligame nt, III:8, 79, 90
Tibiocalcanea lliga ment, VII:28-31, 54, 55, 60, 103, Trapeziu m, TTI:5-7, 22- 25, 36-43, 53-55, 59, 61-64,
115- 17, 120, 121 73, JV:8, 9, 24, 25
Tibiofibular band, Vll:ll 4 ridge, Ill:64, 73
Tibiofibular interosseous membrane, VII : 104, 106 secondary, Jll:72
Tibiofibul ar jo int, prox ima l, Vl:151 volar tu bercle, lll :59
Tibiofibul ar ligament, Vl: 141 Trapezius, 1:16-23, 46-49,52-68, 78-80, 136, 137
anterio r, Vll :7, 22-27, 54, 55, 103, 105, 106, 109, Trapezoid, Ill:S-7, 24, 25, 32-39, 52, 53, 59, 61-63,
113-15, 118, 128 IV:8,9
posterior, VII :?, 22- 27, 48, 49, 103, 105-11, secondary, Ill:72
115, 128 Triangular fibroca rtilage, 111:34-37, 47, 48, 75, 87,
proxima l, Vl:132, 133 88,89-91,93,94
Tibiofibular overlap, Vll:1 8 Triangular liga ment, IV:40, 44
Tibio fibular syndesmotic ligam e nts, Vll:102, 103-9 Triangu lar space, 1:132, 134
Tibion avicu la r band, Vll :8 Triceps, 1:137, 155, 157, 160-73, 178-81, 186, 187,
Tibionavicular ligament, VII:24-29, 60, 115, II :9, 11, 12, 19, 24, 25, 34-37, 61, 62, 68, 69,
116, 129 96,122
Tibiospring ba nd, VII :S6, 57 latera l head, 1:7, 17,38-49, 70-72,77,83-85,97,
Tibiospring ligament, VIJ :S, 28-31, 114- 16, 118, 124 98,133-36, 155-67, 178-81, 188, 189,11:20-
Ti biotalar articLt!a r surface, VII:1OS 23,34-39,54, 55,69,70, 77-79
Tibiota la r band, anterior, VII :S4, 55 long head, I:?, 17,34-5 1,65- 70, 77-82, 96, 131,
Tibiota lar capsule, Vll :63 133-37, 155-71, 178- 83, 186-88, 11:20-23,
Tibiotalar ligamen t, VII :S6, 57 36-43,50,51,69, 70, 74,75
anterior, VII :8, 24-29, 60, 61, 115, 116, 118, med ia l h ead, 1:17, 136, 137, 157, 160, 16 1, 164-
119, 127 69, 178-81, 187, 188, II:20-23, 36-39,52,53,
deep, Vll :62 76,96
posterior, V!l:8, 26-29, 52-SS, 6 1, 103, 114, 116, Tri ceps coxae, V:101, 111- 16, 120- 24
11 7, 119-22, 127 Tricipita l a poneurosis, 1:172, 173
Toe Triquetrocapitate ligame nt, lll:3 8, 39, 79, 89
1st, Vfll :56-57 Tr iquetroh am ate ligamen t, 111 :8, 79 •
deep, lll:84, 85 I
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 INDEX
Triquetrum, lli:S-7, 16-21, 34-39, 46-48, 61-64, 73, III :ll-21, 40, 41, 48, 102-6, 113-15, 121- 25,
81-85, 1V:8, 9 127, 131, IV:3, 14, 16, 17
distal po le, 111 :59 d eep, III:22-25, 121, 127
secondary, lll:72 do rsal bran ch, 111:1 22
Trochanter d o rsa l digita l branches, 111 :11, 122
greate r, V:9-11, 30-32, SO, 51, 57-59,94, 101-4, entrapment , 11: 19
116-18, 120-25, 168, 169, 173-79, 181,193, pa lmar cutaneous branc h, III:11 , J2 1, 122
202,206,20 7,261,275-77 pa lm ar d igital branches, lll:ll , 122
lesser, V:9-11, 44- 4 7,56, 111-13, 122-24, 168, supe rficial bra nch , lll :ll , 22-29, 121, 122, 127
170, 181,193,197,202,212,213, 262, 2 74 Ulnar neutral, 111:66
Trochanteric bursa, V:95, 169 Ulnar p lus, 111:66
Trochlea, 1:1 72-7 5, 184-87, !J:S, 6, 9, 26, 27,42-45, Ulnar recess, Jll :85
5 1,52, 63,64, 71, 72, 75, 76,98, 99, 112, 113, Uln a r recurrent arte ry, II:11 , 24, 25
121, 122 ante rior, Il: 14
Trochlear cle ft, II:9 p osterior, 1:1 72-75, II:l 2, 14, 19
Trochlear notch of u ln a, 11:52, 69, 75 Ulnar st yloid, Il: 96, 97, lll :S, 6, 14, 15, 30 , 31, 36,
Trochlear ridge, VI: SO, 51 37,46,59,60,62, 73,87, 113, 1V:8
Uln ar tuberos ity, II:5, 6, 52, 65, 80
Ulnar variance, lll:130
u Ulna r vein, TII:12-21, 24- 27, 40-43, 124, 127, 131
Uln a, 1:153, 176, 177, 180- 83, 187, ll:12, 13, 28-33, Ulnocapitate ligam ent, lll:8, 16, 17, 20, 21, 38, 39,
53, 66,6 7, 80,81,87, 100- 109,114-17, 121, 79,81-85,87,89
III: 34-39, 46- 48, IV:9 Ulno lunate ligam ent, 111:8, 16, 17, 38, 39, 79-82,87
distal, II: 121, III:S Ulnotr iquetral ligam ent, 111:8, 16, 17, 47, 79, 82,
head, 11:95, 114, 115, III: S, 6, 32, 33, 47, 59, 6 1, 83,87
67, 73 Uppe r trunk, 1:9
posterior cortex, 11:116, 11 7 Urete r, V:18, 20, 24, 26, 28
radial n otch , II:1 2 Urogen ital diap hragm , V:8, 199
shaft, II :S, 97
troch lear n otch , II :S2, 69, 75
Ulnar arte ry, 11:13, 14, 16, 30-33, 44, 45, 67, 72, v
102, 103, 11 2, 113, lll:lO, 12- 21, 24-27,40-43, Vastus intermedius, V: 194, 197, 220-57, 262- 65,
48, 121, 124, 127-31, IV:2- 3, 15-17 274-78, Vl:60-62, 65
a nterior interosseous branc h, III: 128 Vastus la teral is, V:46-S 1, 53- 62, 104, 105, 112-18,
deep, lll :22, 23, 128, 132, 133 194, 197, 198, 206-57, 261-67, 274- 78, Vl:20,
medial branch, Ill:128, 129 21,46- 51,60-63,65,67,68, 156,157
superficia l branch, lll: 22, 23, 132, 133 Vastus m edia lis, V:SO, 51, 57, 58, 194, 197, 199, 214-
superficia l palma r b ran ch , Ill :128 57,262-65, 271-74, Vl: l6, 20, 21, 46-62, 65, 66,
Ulnar bursa, Jll:lOl , JV:32 69, 118, 119, 156
Ulnar collatera l artery, 1:157, 11:14 aponeurosis, VI: S2, 53
Ulnar collate ra l ligame nt, JI:12, 24-27, 38-43, 70, Vastus medialis obliquus, Vl:Z0-23, 66-68, 118, 121
74, 75,83,85-87,89,9 l , IV:22,23,26,27, 44 Vertebral artery, 1:8
anterio r band, !1:84 Vincul um breve, 1V:30, 33
first m etacarpophalangeal joint, IV:29 Vin culum lon gum, 1V:30, 33
graphic, 11 :84 Vola r carpal liga ment, II I:1 8, 19, 121, 124, 125, 12 7
lateral, II :l2, 28, 29, 38, 39, 70, 83, 88, 89, 91 Volar lunotriquetralligame nt, 111 :79, 8 1, 82, 86, 90
posterior band, 11:60, 84 Volar midcarpal ligam en t, 111 :76
transverse band, 11:60, 84 Volar o rigins and in serti o ns, h an d, IV:6
Ulnar collateral vessels, superior, 1:164, 165 Volar p late, JV:24, 25, 28, 29, 36, 39, 43
Ulna r fossa, 111:5, 6 dista.l interp ha langea l jo int, IV:37
Ulnar fovea, IJI :59, 60, 62, 73, 87 m e mb ra no us portion, IV:42
Ulnar joint, 1:164, 165 metacarpophala ngeal jo int, IV:37
Ulnar minus, III:66 proxima l inte rphalangea l jo int, IV:35, 3 7
Ulnar minus variance, 111: 75 th ick portio n, IV:42
Ulna r nerve, 1:9, 156- 77, 180, 181, 186, Il:11-13, 15, Volar radiocarpa l li gam ent, 11I :8, 76
20-33,38,39, 50, 51,62- 6 7,69,86, 98- 109, Volar radioulnar ligament, 111 :36, 3 7, 48, 80

xxx ii
 INDEX
Volar scapholunate ligament, lll:16, 17, 81, 82, coronal T1 and GRE MR, 111:75
86, 90 g rap h ics, 111 :65-69, 74
Volar tilt, 111 :67 rad iography, III:59-64, 74
overview, Ill:2-55
pronated
w 3D reconstruction CT, 111 :5
Wrisberg, me niscofemoralligam e nt of, Vl:5 7, 58, axial 11 1: 70, 71
92, 105, 125, 129 radiography, III:S 9-64
Wrist, 111:2- 133 carpal bridge view, Ill :64
ana to mi c spaces, 111:4, 119 carpal tunne l v iew, I11:64
a rte ries, 111:121, 128-33 clenched fist view, 111: 63
ax ial Tl MR, I fl:12- 29 dorsiflex ion and volarflex io n , lll :60
ca rpal alignment, III: 57-58 lateral, II1:6, 7, 59
compartments, 111: 57, 101 measureme nts, 111:66, 67
ax ial T1 MR, 111:12, 13 PA, III:6, 7, 59
graph ics, Ill :74 compartme nts, 111: 74, 93-95
PA radiograph y, IU:74, 93-95 radial and ulna r deviatio n, 111:62
coronal Tl a nd GRE MR, 111:30-45, 75 scaphoid v iew, Ill :63
dermatom es, III:121 semi pro nated and semisu pinated, III: 61
graph ics, 111 :8-11 recesses, Ill: 78
arcs and al ignment, TH:65 retinacula, III:4, 9, 98
arte ries, 111 :128 sagittal T1 MR, IIJ:46-55
compartme nts, 111: 74 supinated, axial CT, 111:71
late ra l ca rpal angles, III:69 veins, Ill:128- 33
late ra l carpa l axes, III:68 vessels, Ill:2, 119-20
ligaments, 111:8, 79, 86,87 variation, Ill:1 29
n e rves, I!I:ll
n eu rovascu lar structures, 111:121-25, 128
osseous s tructures, Ill:65-69, 74 z
rad iogra phic m easurements, 111:66, 67 Zona orbicu la ris, V:1 69, 175-83, 188, 189
te ndo n s, 111:9, 100-103 Zon es of vulnerability, w ri st, III:65
ve ins, 111 :10, 128
joi nts, 111 :2
ligaments, lll:3, 76- 95
axial GRE MR, 111:80-85, 8 7
coro nal GRE MR, TIT:86, 88- 92
corona l T1 FS MR, Ill:88
graphics, 111:8, 79, 86, 87
motion, Ill :2
MR angiog ram, lll:1 29
m usc lcs and te ndons, lll :3-4, 96-117
3 D reconstruction CT, rii :99, 107, 108
axial T1 MR, 111:104- 9
co rona l GRE MR, IIT:114-17
grap hi cs, Ill:9, 100-103
agittal T-1 MR, III:ll0-13
ne rves, 111: 2,11,118-19,121,122
ne urovascular structures, III:118- 33
axial T1 a nd T2 FS MR, 111:130-33
ax ial T1 MR, 111:123- 2 7
coronal GRE, III:126, 127
graphics, Ill:121-25, 128
MR a ngiography, 111:129
osseous s tructures, Hl:3, 56-75
3D reco nstruction 111: 72, 73
ax ia l 111: 70,71 •
I
xxxii