The gross and functional anatomy of the suspensory ligament (SL) and its ultrasonographic variability are described. Injuries of the suspensory apparatus are divided into lesions confined to the proximal one third of the metacarpus or metatarsus (proximal suspensory desmitis and avulsion fractures), lesions of the body, and branch lesions. Complete breakdown injuries are also discussed. In view of the close association of the SL, the second, third, and fourth metacarpal or metatarsal bones, and the proximal sesamoid bones, associated bony lesions are also considered.