doi: 10.1055/s-0042-1743114.
eCollection 2022 Mar.
Two Sides of the Same Coin: Tendoligamentous Similarities and Dissimilarities of Great Toe and Thumb Anatomy on MRI
Affiliations
- PMID: 35722646
- PMCID: PMC9200492
- DOI: 10.1055/s-0042-1743114
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Two Sides of the Same Coin: Tendoligamentous Similarities and Dissimilarities of Great Toe and Thumb Anatomy on MRI
Indian J Radiol Imaging.
.
Abstract
Evolution and functional necessities have compelled the great toe of the foot and its embryological kin, thumb, to have some tendoligamentous differences with a similar basic anatomical structure. This provides biomechanical advantage to these joints: the thumb is apposable and more mobile, ensuring hand dexterity and tool-handling, whereas the great toe is less mobile and more stable, ensuring weight bearing, strength, and stability for bipedal locomotion. This pictorial review will methodically illustrate the similarities and dissimilarities of the joint morphology and its tendoligamentous attachments at the level of carpometacarpal joint, metacarpophalangeal joint, and interphalangeal joints of thumb compared with tarsometatarsal joint, metatarsophalangeal joint, and interphalangeal joints of great toe. It intends to provide a comprehensive understanding of the normal anatomy of great toe and thumb to the radiologists, enabling better interpretation of the pathologies.
Keywords: MRI; great toe; hallucis; pollicis; thumb.
Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).
Conflict of interest statement
Conflicts of Interest None declared.
Figures
Overview of the joints of great toe and thumb. (
A
) Axial T1-weighted (T1W) magnetic resonance (MR) image shows that the great toe lies in the same plane as the rest of the toe. The tarsometatarsal (TM) joint, metatarsophalangeal (MTP) joint, and interphalangeal (IP) joint are marked. (
B
and
C
). Serial sagittal T1W MR image of the thumb shows that the thumb lies at almost ninety degrees to the plane of the rest of the fingers and is rotated medially. The first carpometacarpal (CM) joint, metacarpophalangeal (MCP) joint, and IP joint are marked.
Planning of magnetic resonance imaging great toe. (
A
) First, the localizer was used to plan axial images perpendicular to the long axis of the metatarsal and proximal phalanx. (
B
) The coronal slices were planned on the sagittal plane, parallel to the to the long axis of the metatarsal and proximal phalanx. (
C
) Using axial images, sagittal scan was planned perpendicular to the line joining the two sesamoids.
Planning of magnetic resonance imaging thumb. (
A
) First, localizer was used to plan axial images perpendicular to the long axis of the proximal phalanx. (
B
) Using axial images, coronal scan was planned parallel to the line joining the two sesamoids (outlined with yellow circle). (
C
) Using axial images, sagittal scan was planned perpendicular to the line joining the two sesamoids.
Ligaments around first tarsometatatarsal joint. (
A
) Diagrammatic representation of the three dorsal ligaments: dorsomedial ligament (dC1-M1) that is between dorsal surface of medial cuneiform (C1) and the dorsal surface of the base of first metatarsal (M1), proper Lisfranc's ligament (dC1-M2) between the dorsal surface of medial cuneiform (C1) and base of second metatarsal (M2) and the intercuneiform ligament (dC1-C2) between the dorsal surfaces of the medial (C1) and intermediate cuneiform (C2). (
B
) Diagrammatic representation of the three plantar ligaments: plantar tarsometatarsal ligament (pC1-M1) between plantar surface of medial cuneiform (C1) to base of first metatarsal (M1) and the proper plantar Lisfranc's ligament's complex (pC1-M2/M3) extending between medial cuneiform and plantar surface of base of second (M2) and third metatarsal (M3). (
C
) Sagittal fat suppressed proton density (PDFS) weighted magnetic resonance image shows dorsomedial ligament (thin green arrow) and plantar tarsometatarsal ligament (thin yellow arrow). (
D–G
) Serial axial PDFS image from dorsal to plantar aspect shows proper dorsal ligament (thick green arrows, (D) and intercuneiform ligament (green arrow heads,
D
). pC1-M2 (thick yellow arrow,
E
) and pC1-M3 (yellow arrow heads,
F
) components of proper plantar Lisfranc ligament. The tendon of tibialis anterior (white arrows,
F
) can be seen attaching to the base of distal phalanx and the adjacent proximal aspect of medial cuneiform. The tendon of the peroneus longus (black arrows,
G
) can be seen attaching to the lateral aspect of base of the first metatarsal.
Ligaments and tendons around the trapeziometacarpal joint. (
A
) Diagrammatic representation of thumb in coronal plane shows the components of dorsal first carpometacarpal ligaments. The dorsoradial ligament (DRL) is a capsular thickening between the dorsal surface of the trapezium (T) to the dorsoradial surface of the base of the first metacarpal (m1) deep to the abductor pollicis longus (APL) tendon. The posterior oblique ligament (POL) is also a capsular ligament between the trapezium and base of first metacarpal, positioned more ulnar to the attachment of the DRL. The intermetacarpal ligament (IML) extends from the ulnar side of the base of first metacarpal (m1) to the radial side of the base of the second metacarpal (m2). (
B
) Diagrammatic representation of thumb in coronal plane shows components of volar first carpometacarpal ligaments. The thicker anterior oblique ligament (AOL) has superficial and deep components, extending from the volar tubercule of trapezium (T) to the volar tubercle of the first metacarpal (m1). The ulnar collateral ligament (UCL) is a thinner ligament between the volar surface of the trapezium, near the attachment of the flexor retinaculum to the base of the first metacarpal and is often not well delineated on conventional magnetic resonance imaging (MRI). (
C
and
D
) Serial sagittal fat suppressed proton density (PDFS) MR image shows DRL (thick green arrow,
C
) deep to the APL (white arrow heads,
C
) and the AOL (yellow arrows,
C
and
D
). The POL (thin arrow) is seen, ulnar to DRL and is seen on the sagittal section where APL is no longer visible, but extensor polices tendon (white arrow) is seen. (
E
) The oblique coronal reformatted PDFS MR image of a different patient demonstrates the IML (green arrowheads).
Ligamentous attachments around the first metatarsophalangeal (MTP) joint representing the plantar plate complex. (
A
) Diagrammatic representation of the first MTP joint shows the medial (M) and lateral (L) sesamoids and their paired attachments to the plantar surface of the base of proximal phalanx—the sesamoidophalangeal ligaments (SPL), paired metatarsosesamoid ligaments (MSL) between the respective sesamoid and neck of first metatarsal. Medial (M) and lateral (L) collateral ligaments are obliquely oriented, from the head of metatarsal on each side to the plantar surface of the base of proximal phalanx. The intersesamoid ligament (ISL) is between the two sesamoids. (
B
) Axial fat suppressed proton density weighted (PDFS) magnetic resonance (MR) image and (
D
) sagittal T2-weighted imaging (T2WI) shows the lateral SPL (yellow arrow heads) as thick ligament extending from the lateral (L)sesamoid to the base of proximal phalanx, deep to the conjoint tendon of the adductor hallucis (yellow arrow). Similarly, (
B
) axial PDFS and (
E
) sagittal T2WI show the medial SPL (green arrow heads) as thick ligament extending from the medial (M) sesamoid to the base of proximal phalanx. (
C
) The subsequent T1W axial image shows the abductor hallucis (green arrow), which is superficial to the medial SPL. (
F
and
G
) Sequential PDFS axial MR image shows the medial collateral ligament (MCL) (bent green arrow) and lateral collateral ligament (LCL) (bent yellow arrow) extending from the base of proximal phalanx to the head of first metatarsal on each side. Note the discontinuity and preligamentous edema at the metatarsal attachment of MCL suggestive of a tear.
Ligamentous attachments around the first metatarsophalangeal (MTP) joint. (
A,
C
) Axial diagrammatic representation and (
B, D
) corresponding fat suppressed proton density (PDFS) axial magnetic resonance image at the level of first metatarsal head and base of proximal phalanx shows the medial collateral ligament (bent green arrows) and lateral collateral ligaments (yellow bent arrows). The lateral sesamoidophalangeal ligament (MTS, curved arrow in a, straight arrows in B) is seen extending between the lateral sesamoid and metatarsal head, merging with the collateral ligaments. The medial MTS ligament (curved green arrow in
A
) is seen between medial sesamoid and adjacent metatarsal head; the corresponding axial PDFS image (
B
) shows fluid signal (green arrow) and absence of T2 hypointense signal at the location of the ligament suggesting tear of the medial MTS ligament. The sesamoidophalangeal ligaments are seen at the level of base of proximal phalanx (C, D; medial—green arrowhead, lateral—yellow arrowhead). The adductor hallucis tendon (yellow arrow) and abductor halluces tendon (green arrow) are seen superficial to the ligaments, ultimately merging with it.
Musculotendinous attachments around the first metacarpophalangeal (MCP) joint. (
A
) Diagrammatic representation and (
B
) corresponding axial T1-weighted magnetic resonance (MR) image show the adductor hallucis muscle attaching to the lateral sesamoid (L) and to the base of proximal phalanx and adjoining capsule-ligamentous complex (not shown here), the medial and lateral heads of the flexor hallucis brevis (FHB) attaching to the respective sesamoids, and the tendon of abductor hallucis (green arrow) is seen attaching to the medial sesamoid (M). (
C
) Coronal fat suppressed proton density MR image shows transverse head of adductor hallucis and its tendon (yellow arrow), lateral and medial FHB and its tendons (white arrows) and in the medial most aspect, tendon of abductor hallucis (green arrow).
Plantar plate complex. The serial sagittal T2-weighted magnetic resonance images show the components of the plantar plate complex of the first metatarsal joint with corresponding level of section (shown in the inset). (
A
) The medial most section shows attachment of the abductor halluces (green arrow) to the medial sesamoid and capsuloligamentous structures attaching to the medial side of the base of the first metatarsal. (
B
) The next section shows medial sesamoidophalangeal ligament (SPL; bent green arrow) between the medial sesamoid (M) and plantar surface of the base of the base of the first proximal phalanx and the medial head of flexor halluces brevis (FHB) attaching to the medial sesamoid (M). (
C
) The section through the midline of the metatarsophalangeal (MTP) joint, shows the flexor halluces longus (FHL) tendon (blue arrows) passing over the fibrocartilage part of the plantar plate (white asterisk) and inseparable from the intersesamoid ligament (thin white arrow). (
D
) The sagittal section at the level of the lateral sesamoid (L) shows the lateral SPL (bent yellow arrow) between the lateral sesamoid(L) and plantar surface of the base of the base of the first proximal phalanx and the lateral head of FHB attaching to lateral sesamoid (L). (
E
) The lateral most section through the first MTP joint shows the conjoint tendon of adductor halluces (yellow arrow) attaching to the lateral sesamoid, adjacent capsuloligamentous complex, and lateral surface of the base of proximal phalanx.
Extensor and flexor compartment muscles of the great toe. (
A
) Sagittal schematic diagram and (
B
) sagittal fat suppressed proton density (PDFS) shows that the flexor halluces longus (FHL) (blue arrows) attaches to the base of the distal phalanx on the plantar aspect, passing over the plantar plate of distal interphalangeal (DIP) and plantar plate complex of metatarsophalangeal (MTP) (white asterisks). The extensor hallucis brevis (EHB) (short green arrow) attaches to the dorsal aspect of the base of the proximal phalanx and the extensor hallucis longus (EHL) (long green arrow) goes on to attach on the dorsal aspect of the base of the distal phalanx, passing over the dorsal plates (yellow asterisks) at the level of intervening joints. (
C
) Axial schematic diagram and (
D
) corresponding axial PDFS magnetic resonance image at the level of proximal phalanx shows the EHL (green arrow) is secured to the underlying bone through thin sagittal bands (white arrows).
Ligamentous and tendinous attachments around the first metacarpophalangeal joint (MCP). (
A
) Schematic diagram shows the ligamentous and tendonous attachments around the first MCP. The radial (RCL) and ulnar collateral ligaments (UCL) are seen extending obliquely from the palmer aspect of head of metacarpal to the base of proximal phalanx on the radial and ulnar aspect respectively. The adductor pollicis (AdP) attaches to the ulnar sesamoid (U), with aponeurotic extension to the base of proximal phalanx. While the tendon of flexor polices longus (FPL) passes across the MCP joint in between the two sesamoid bones, the flexor polices brevis (FPB) attaches on the radial sesamoid (R). The abductor pollicis brevis (AbPB) attaches directly to the base of radial aspect of proximal phalanx. (
B–E
) Serial coronal fat suppressed proton density magnetic resonance imaging showing the radial (R) and ulnar (U) sesamoid bones and FPL tendon (long green arrow) in (
B
). FHB tendon (short green arrows;
c
) is seen attaching on the radial sesamoid and base of proximal phalanx. The RCL (blue arrow heads;
D
–
E
) lies deep to the AbPB(blue arrows;
D
), whereas the UCL(yellow arrow heads;
D
–
E
) lies deep to the AdP aponeurosis(yellow arrows;
D
–
E
), attaching distally to the base of proximal phalanx on its radial and ulnar aspect, respectively.
Ligamentous and tendinous attachments around the first metacarpophalangeal (MCP) joint
.
(
A
) Schematic diagram and (
B
) axial T1-weighted imaging at the level of the head of the first metacarpal joint showing the ligamentous attachments around the first MCP joint. The proper radial (p-RCL,
A
; dark blue arrow heads,
B
) and proper ulnar (p-UCL,
A
; dark blue arrow heads,
B
) collateral ligament proximally attach to the metacarpal head, whereas the accessory radial (p-RCL,
A
; light blue arrow heads,
B
) and accessory ulnar (a-UCL,
A
; light blue arrow heads,
B
) collateral ligaments attach to the radial (R) and ulnar (U) sesamoid bones, respectively. The volar plate (asterisk) is between the two sesamoid bones, with the flexor pollicis longus (FPL) tendon running along its volar aspect. The abductor pollicis brevis tendon (AbPb, blue arrow) and the adductor pollicis aponeurosis (AdP, yellow arrows) lie superficial to the respective collateral ligaments, attaching distally to the base of the proximal phalanx (not shown).
Muscles of the flexor and extensor compartment of the great toe. (
A
) Sagittal schematic diagram and (
B, C
) serial sagittal fat suppressed proton density (PDFS) shows that the flexor pollicis longus (FPL; green arrows) attaches to the base of the distal phalanx on the volar aspect, passing over the volar plates (white asterisks) at the level of metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints. The extensor pollicis brevis (EPB; short white arrow) attaches to the dorsal aspect of the base of the proximal phalanx and the extensor pollicis longus (EPL) (long white arrow) goes on to attach on the dorsal aspect of the base of the distal phalanx, passing over the dorsal plates (yellow asterisks) at the level of intervening joints. Note that there is a synovial recess (yellow arrow,
B
) at the proximal attachment of the volar plate, which should not be misinterpreted as a tear. (
D
) Sagittal schematic diagram and (
E
) serial sagittal PDFS shows the attachment of the flexor pollicis brevis (FPB; short green arrows) on the radial sesamoid (R) and volar aspect of the base of proximal phalanx.
Pulley system around the flexor pollicis longus (FPL) tendon. (
A
) Coronal schematic diagram showing the positions of annular pulleys (shaded in green): A1 and A2 are along the metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints, respectively. The oblique pulley (Ao) is along the diaphysis of proximal phalanx and oriented obliquely. The variable pulley (Av) is between the A1 and A2. (
B
) Axial schematic diagram showing the position of annular pulleys in relation to the FPL tendon. The pulleys (green line) surround the FPL tendon, attaching to the palmer aspect of the phalanges, preventing bowstringing of FPL. (
C–F
) Corresponding axial magnetic resonance T1-weighted images are shown in the panel on the right with the pulleys marked with green arrows. To merge either A1 and A2 pulleys are seen to merge with the underlying volar plates.
Extensor muscles of the thumb. (
A
) Coronal and (
C
) axial schematic diagram, (
B
) coronal fat suppressed proton density magnetic resonance (MR) images and (
D
) axial T1-weighted MR images at the level of first metacarpal bone show that the extensor shows that the extensor pollicis brevis (EPB, short white arrow) lies radial to the extensor pollicis longus (EPL, long white arrow). Note that even at the level of distal forearm and wrist, the EPB is more on the radial aspect as it belongs to the first compartment and EPL belongs to the third compartment of the extensor group of muscle. The tendons are held in central position by the sagittal bands (shaded in gray in a, black arrows in
C
–
D
), in and around the metacarpophalangeal (MCP) joint, whereas more distally, it is supported by a faint triangular expansion (shaded in purple), which is not well appreciated on imaging.
Ligamentous and tendinous attachments near the distal interphalangeal (DIP) joint of the great toe. (
A
) Coronal schematic diagram and (
B
) coronal fat suppressed proton density (PDFS) magnetic resonance (MR) image at the level of DIP joint show the lateral (LCL) and medial (MCL) collateral ligaments (blue arrows) extending from the lateral and medial aspects of distal end of proximal phalanx to the proximal end of distal phalanx, respectively. (
C
) Coronal schematic diagram and (
D
) axial PDFS MR image at the level of base of distal phalanx show LCL and MCL (blue arrows), extensor hallucis longus (EHL; long white arrow) and flexor hallucis longus (FHL; long green arrow) attached to the dorsal aspect and volar aspect respectively. The prominent volar plate is deep to the FHL tendon and is marked with white asterisk. The dorsal plate (yellow asterisk) is small.
Ligamentous and tendinous attachments near the distal interphalangeal (DIP) joint of the thumb. (
A
) Coronal schematic diagram and (
B
) coronal fat suppressed proton density (PDFS) MR image at the level of DIP joint show the radial (RCL) and ulnar (UCL) collateral ligaments (blue arrows) extending from the radial and ulnar aspects of distal end of proximal phalanx to the proximal end of distal phalanx, respectively. (
C
) Axial schematic diagram and the (
D
) axial PDFS MR image at the level of base of distal phalanx show the radial and ulnar collateral ligaments (blue arrow) attached laterally, extensor pollicis longus (EPL; long white arrow) and flexor pollicis longus (FPL; long green arrow) attached to the dorsal aspect and volar aspect, respectively. The prominent volar plate is deep to the FPL tendon and is marked with white asterisk, while the A2(small green arrows) pulley covers the FPL on its superficial aspect. The sagittal bands (small white arrow) are thin linear bands that secure the EPL tendon.
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