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Understanding the physical basis of hand function and deformity requires a
fundamental knowledge of the biomechanics of the human digits. Learning the
anatomy of the digits as well as the anatomy, function, and physiology of the
muscles that control digital motion are essential in understanding the biome-
chanical principles that govern hand function. Applying these principles in
treating hand disorders will optimize hand function and recreate hand mechanics.
Copyright © 2005 by the American Society for Surgery of the Hand

he human digit is a complex mechanism that tion of the digit. The biomechanical principles are
has an amazing array of functions. Mechani- applied to pathologic conditions that cause digital
cally, 3 bodies articulating in series inherently dysfunction and deformity.
are unstable. Bony and ligamentous architecture in
concert with force couples of several tendon systems BASIC CONCEPTS OF MECHANICS
impart stability to the digit while permitting fine
control. The joint flexion-excursion is introduced
through the basic principle of forces and joint kine-
matics. The decoupling of the force is expressed as
I saac Newton mathematically described the concept
of inertia force as body mass multiplied by the
center mass acceleration with the resulting units be-
function of the moment arm, its direction and mag-
ing 1 N or 1 kg · m/s2. The inertia force is balanced
nitude in the presence of a constraining element called
by the resultant external force applied to the mass
the pulley.
center and is represented by a vector quantity de-
To understand the function of the digit, an under-
scribed with respect to a fixed inertia frame. Thus,
standing of basic Newtonian mechanics, bone liga-
force must be represented by a point of application, a
ment and tendon anatomy, and physiology of tendon
magnitude, and a direction. The application of a force,
and cartilage is necessary. To this end, these topics are
if it causes movement, results in acceleration of the
reviewed and then synthesized so that the reader may
body mass in a particular direction. When there are
develop a more complete understanding of the func-
several external forces acting on a body mass, their
resultant force must be computed, taking into con-
sideration the resulting magnitude and direction of
From the Department of Orthopedics, Department of Mechanical the force. It should be noted that only the components
Engineering, University of Illinois, Chicago, IL; and the Department of the force along the direction of motion are used
of Orthopedic Surgery, Stroger Hospital of Cook County, Chicago, IL.
Address reprint requests to Mark H. Gonzalez, MD, Chairman of when applying Newton’s Law (F ! ma). When a body
Orthopedic Surgery, Stroger Hospital of Cook County, 835 South is at rest, the summation of all external forces acting
Wolcott, Chicago, IL 60612. E-mail: at any point on the body must be 0. This is the law of
Copyright © 2005 by the American Society for Surgery of the Hand
equilibrium, also known as the first law of mechanics.
1531-0914/05/0501-0009$30.00/0 Newton’s law led to a number of discoveries and
doi:10.1016/j.jassh.2004.11.009 mathematic tools that become standard procedures in


understanding motion. Energy is one of these dynamic Torque is the product of force and moment arm. It
tools that measures half of the product of mass and is a scalar quantity as opposed to the moment, which
velocity squared and is a scalar quantity that is not is a vector.
associated with a direction as in vectors. The efficiency of a lever can be measured through
Stress is described mathematically as force per unit the ratio of the moment arm of the force to the
area. When a force is applied perpendicular to a moment arm of the load, called mechanical advantage.
surface, it represents normal stress. When a force is The larger the lever arm, the proportionately smaller
applied parallel to a surface, it is called shear stress. force that is necessary to achieve the same torque. The
Tensile stress exists when the force applied pulls the disadvantage of increasing a lever arm is a requisite
object, such as a tendon, in opposing directions. For increase in path of excursion necessary to affect an
example, in the hand, when a force is applied to a equivalent degree of rotation. The pulley system
muscle causing it to contract, the tensile force is maintains the flexor tendons close to the center of
transmitted to the tendon. rotation at the distal interphalangeal (DIP) joint,
The tendon bears this force along its segment and proximal interphalangeal (PIP) joint, and the meta-
it will be pulled with an equal tensile force by both carpophalangeal joint (MCP). This minimizes the ten-
the contracting muscle and the bone to which it don excursion required to produce joint flexion.1 The
inserts. geometry of tendon function can be described using
The shear stresses are mostly the result of resistance simple trigonometric functions. For small angles a
to friction. A frictional force occurs between any 2 relationship between the angle, the radius, and the arc
surfaces that are in contact and glide past each other. length it forms are related by the following equation:
It either could be static, when the 2 communicating s (arc length) ! # (angle) · r (radius). (2)
surfaces are stationary, or dynamic, when the surfaces Which can be expressed further as:
are in motion. The friction between 2 bodies is de- # (angle) ! s (tendon excursion) ⁄ r (moment arm).
pendent on the nature of the surfaces (rough v (3)
smooth), and the normal force acting on the surfaces. In this equation, the angle of finger motion at a
When a thin layer of fluid separates 2 moving surfaces particular joint is a ratio of the tendon’s excursion over
the resulting force is not termed friction, but rather moment arm. A flexor tendon is maintained close to
drag, which results from the effect of the surface fluid the axis of rotation of the digit joints by the pul-
shear. In a human joint, this layer of fluid creates a low leys.1-3
frictional interface between the cartilaginous surfaces.1 The amount of energy expended when a force acts
Muscles extrinsic to the hand (long flexors and on a body causing the body to move is termed work. In
extensors) and muscles intrinsic to the hand act on the fact, the work is related directly to the changes to the
joints of the digit through tendons. The moment arm, kinetic energy and similar to the energy function, it is
or lever arm, is the measurement of the perpendicular a scalar quantity. If the force remains constant during
distance from the joint axis to the force that acts on a displacement, it is calculated by the product of force
the joint. The cross-product of a force and its moment and excursion distance associated with the force from
arm about an axis is termed the moment about the axis one location to another.
and is defined as follows:
M (moment) ! F (force) " L (moment arm). MUSCLE PHYSIOLOGY
The moment is a vector quantity with a direction as
defined by the right hand rule. When a body is at rest
the summation of all the moments about any point on
M uscles are composed of individual microscopic
units called sarcomeres that are aligned macro-
scopically in parallel and in series. The length tension
the body must be 0. The tendons in the digit traverse curves of a sarcomere have been investigated in passive
each joint very close to the center of rotation, thereby stretch and in active contraction. Each can be shown
producing a short lever arm for the force to act on the by a graph of muscle tension versus muscle length
joint.1 (Figure 1). An important detail of Figure 1 is the

FIGURE 3. Graph showing the Blix curve.
FIGURE 1. Graph showing passive stretch.
can produce is achieved at its resting length (Figure 2,
definition of muscle resting length, which is the A). Second, the fiber’s resting length is approximately
length of the muscle when the entire limb is at rest. equal to the change in the fiber’s length from com-
In the case of the hand and wrist, in a resting position plete muscle contraction to complete muscle stretch
the wrist is in mild extension and the joints of the (Figure 2, B). This distance (Figure 2, B) from max-
digit are in midflexion. If the muscle tendon were to imum stretch to maximum contraction is called the
be severed, the muscle length would shorten by elastic potential excursion of a muscle.
recoil below its normal resting length. As shown in When Figures 1 and 2 are placed together, they
Figure 1, during passive stretch, the tension is mini- form what is known as the Blix curve (Figure 3), which
mal below and near the resting length of the muscle.1 correctly summarizes muscle physiology. Two as-
As the muscle is stretched beyond the resting length, sumptions are fundamental in the Blix curve: the
the tension increases sharply (Figure 2). Figure 2, first motor nerves are intact and each muscle has its an-
developed by Elftman, shows a different view of mus- tagonist muscle functioning normally to facilitate pas-
cle performance that shows 2 important features of sive stretch.
muscle fibers.1 First, the highest tension that a muscle Each muscle in the hand has an antagonist muscle
opposing its actions. Brand1 modified the Blix curve
to include the elastic recoil effect of the antagonist
muscle, assuming it was of equal strength and ampli-
tude. The opposing muscle’s curve would lie below
the x-axis and its tension would reach 0 as its length
increased, approaching the original muscle’s resting
length. This added effect would cause the Blix curve
of the original muscle to show a sharper increase in
tension with minimal expansion at short lengths,
displaying a squarer curve. This muscle now has a
slightly diminished potential excursion but has a
wider range in which to achieve peak tension. This
system of opposing muscles is very important in joint
stabilization in which there is no overall movement
owing to a careful balance of tension.
Because a muscle’s fiber length, the number of
FIGURE 2. Graph showing active contraction. sarcomeres placed in series from end to end, is pro-

portional to its potential excursion, it is critical that langeal joints of the digits. Pivot joints are created
the fiber length is measured accurately. The most when a central bony pivot is placed into a bony ring,
accurate method is to measure the most distal and allowing for a longitudinal rotational axis. The supe-
most proximal fibers from their respective origins to rior and inferior radioulnar joints of the wrist are pivot
their insertions. This will allow the fibers to remain in joints. Ellipsoidal joints have reciprocal elliptic con-
parallel, which is their natural physiologic alignment. vex and concave articular surfaces that allow move-
The maximum strength, or tension, that a muscle ment in 2 axes, flexion and extension and abduction
can generate is proportional to the number of sarco- and adduction, and occur in the radiocarpal joint of
meres in parallel, which is its physiologic cross-sec- the wrist and metacarpophalangeal joints in the hand.
tional area. Many different methods have been con- A saddle joint, which occurs only in the carpometa-
ceived in the past to estimate a muscle’s strength. carpal joint of the thumb, allows for movement in
Unfortunately, it is difficult to accurately measure 3 different axes: flexion and extension, abduction
physiologic cross-sectional area once the muscle has and adduction, and circumduction. Axial rotation is
been detached from the cadaver. Brand1 was able to not possible in ellipsoidal or saddle joints. Ball-
describe a more accurate way of estimating muscle and-socket joints, which are present in the shoulder
strength by measuring the mass of the muscle. From and hip joints, are formed by a sphere-shaped head
the muscle’s mass, its volume can be calculated and, inserted into a cup-shaped cavity that allows for
along with its known fiber length, the physiologic movement in flexion and extension, abduction and
cross-sectional area can be determined. Thus, using adduction, medial and lateral (axial) rotation, and
these 3 measurable variables, the strength of a partic- circumduction. In the digit, the interphalangeal
ular muscle can be estimated. Because work is pro- joints are hinge joints and the metacarpophalangeal
portional to the bulk, or volume, of the muscle, work joints are ellipsoidal.
can be calculated by multiplying tension by excursion. The instantaneous center of rotation of a rigid body
Brand1 went on to develop the concepts of mass is the point about which the body rotates at a given
fraction, the ratio of muscle volume to the volume of instant. This can be calculated by selecting 2 points
the hand, and tension fraction, the ratio of individual on the rotating body and drawing a line for each point
muscle force potential to the combined muscle force that follows its progression in space. A perpendicular
potential within the hand. line is drawn to each of the lines and the point where
The force generated by a muscle is proportional to the 2 lines intersect is the center of rotation. When
the cross-section and the work of a muscle is propor- the rotation of a 3-dimensional body is limited to 1
tional to its volume. For example, the adductor of the plane with a fixed center of rotation the body rotates
thumb generates a significant force in pinch but does through an axis. A joint with this type of prescribed
much less work than a long flexor because of limited motion is termed a revolute joint or a hinge.
excursion and a much smaller volume. The PIP and DIP joints can be modeled as hinge
joints. The axis of the joint lies in the center of the
JOINT ANATOMY convex head of the more proximal bone. The MCP
joint has 2 main axes of movement: flexion-extension

T here are essentially 6 types of synovial joints
within the human body: plane, hinge, pivot,
ellipsoidal, saddle, and ball-and-socket joints.2 An
and abduction-adduction. A third relatively minor
rotational axis is functional when the finger is in
extension. A key feature to MCP joint mechanics is
example of each joint type appears within the hand the CAM-shaped head at the proximal portion of the
and wrist. Plane joints have flat articular surfaces, joint. In extension, the collateral ligaments around the
allow simple sliding movement, and are limited in MCP joint are mildly lax, allowing for some abduc-
movement by the articular capsule. Plane joints occur tion and adduction at the MCP joint. Because the
in the intercarpal, intermetacarpal, and carpometacar- proximal head of the MCP is CAM-shaped, the liga-
pal joints within the hand. Hinge joints allow move- ments around it become taut when the MCP joint is
ment around 1 axis at right angles to the bones for flexed, limiting further abduction or adduction. Thus,
flexion and extension only, and occur in the interpha- a deviating force cannot be easily dispelled during

MCP flexion and can damage the ligaments and bone instantaneously. Deformation of loaded cartilage
at the MCP joint. tends to trap synovial fluid.
As opposed to the more complex MCP joint, the Loaded cartilage may release synovial fluid in a
DIP and PIP joints can be modeled as simple hinges process termed weeping lubrication. Boosted lubrica-
with only 1 axis for flexion and extension. In each tion occurs during squeeze film conditions when
joint the proximal surface has an intercondylar groove water partially is forced back into the cartilage,
that articulates with a projection, or trochlea, from the leaving a more concentrated (and more viscous)
distal joint surface. The trochlea is perpendicular to pool of hyalouronic acid and protein complex
the rotational axis, providing the joint with stability within the joint.
in medial, lateral, and rotational directions when the When a joint is loaded statically or at rest, a thin
joint is flexed or extended. film of lubricating fluid lines the joint surfaces. This
Friction or drag in normal joints is close to 0 is termed boundary lubrication, and prevents excessive
because the coefficients of friction are so low. The bearing friction and wear.
reason for this low coefficient of friction of human Finally, a majority of cartilage by weight is water.
joints is the use of a system of lubrication. Cartilage is relatively impermeable to fluid and load-
The characteristics of the synovial fluid make it an ing of cartilage increases interstitial pressure while
ideal fluid for hydrodynamic lubrication during joint unloading the collagen proteoglycan matrix.1
motion. The synovial fluid is a viscous, slow-moving
fluid. Joint fluid is thixotropic, which means the fluid TENDON LUBRICATION
resists a change in shape, giving it a tendency to
remain between the joint surfaces. Synovial fluid is a
non-Newtonian fluid: compressive loading will in-
crease the viscosity. This property is vital to the
F lexor tendons lie in synovial sheaths that secrete
fluid to provide simple boundary lubrication. The
synovial sheaths have a double mesothelial layer of
hydrodynamic lubrication of joint surfaces, allowing cells. The visceral layer envelopes the tendon and the
the joint to move over the fluid instead of pushing the parietal layer in contact with the surrounding tissues.
fluid away.1 The secreted fluid minimizes the drag of the flexor
Lubrication of the human diarthrodial joint is tendons.
thought to occur through 2 primary mechanisms:
hydrodynamic and boundary lubrication. Hydrody- THE FLEXOR TENDONS
namic lubrication occurs between 2 moving bodies.
Hydrodynamic lubrication requires 2 slightly noncon-
gruent joint surfaces with different radii of curvature:
a convex articular head and a concave socket with a
T he primary flexors of the digit are the flexor
digitorum profundus (FDP) and the flexor digi-
torum superficialis (FDS) tendons. These muscles
larger radius. This incongruity creates a wedge-shaped originate in the forearm and their tendons insert in
cavity. Synovial fluid fills this wedge-shaped cavity. the middle and distal phalanges, respectively.
As the joint glides, the bone and cartilage move faster The FDS tendon enters the hand beneath the flexor
than the viscous fluid within the joint cavity, which retinaculum and passes through the carpal tunnel
results in the separation of the 2 surfaces by the palmar to the FDP. The tendons then diverge to their
trapped fluid.1 The fluid film, which is thicker than individual fingers. At the level of the MCP joint, the
the average surface roughness of the surfaces, separates FDS tendon enters the digital flexor sheath along with
the 2 surfaces. In this scenario there is no actual the FDP tendon. Once within the sheath, the FDS
contact between the surfaces, making frictional wear tendon starts to flatten and at the proximal third of
virtually 0. There are different mechanisms that are the proximal phalanx it splits and passes around the
thought to act to produce hydrodynamic lubrication. FDP tendon to reunite deep to the FDP tendon. Half
When 2 joint surfaces are forced toward one another of the FDS tendon fibers decussate at the chiasma of
during loading, joint fluid between the surfaces is Camper and the remaining fibers continue distally on
compressed. This compressed film of fluid is termed a the same side. The FDS tendon distal to the chiasma
squeeze film, and actually can support the joint surfaces attaches to the volar crest of the base of the middle

phalanx and extends distally along the metaphysic and pulleys, although not at the joint itself, are important
diaphysis of the middle phalanx.3 because of their rigid attachment to bone. Loss of the
After traversing the flexor retinaculum, the FDP A-2 or A-4 pulleys will cause significant loss of digital
tendons pass through the carpal tunnel at the deepest flexion. In the absence of an A-2 pulley an intact
level and go to their respective digits. The FDP palmar aponeurosis pulley will limit the degree of
tendons enter the flexor sheath at the level of the MCP bowstringing.
joints deep to the FDS tendon. The FDP tendons shift The pulleys maintain the flexor tendons close to the
to a palmar position with respect to the FDS tendon as center of rotation of the DIP, PIP, and MCP joints.
the FDS splits to pass deep and encircle the FDP When a pulley is ruptured, the tendons fall away from
tendon. This split is termed the decussation. The FDS the joints, a phenomenon termed bowstringing. The
continues dorsally to its insertion at the volar base of mechanical result is that the torque across the joint is
the middle phalanx. At the level of the PIP joint, the increased as the beam or lever arm is increased. With
FDP is palmar to the FDS tendon and continues an increased lever arm, likewise the radius is in-
distally to the level of the DIP joint to insert broadly creased, as shown in the previous equation:
onto the base of the proximal volar third of the distal s (arc length) ! # (angle) · r (radius). (2)
phalanx. It can be seen that this will increase the arc length
The FDP tendon passes approximately 5 mm from s for the tendon. This implies that an increased ex-
the center of rotation of the DIP joint, 7.5 mm from cursion is necessary to attain an equivalent degree of
the center of the PIP joint, and 10 mm from the MCP flexion. Because the excursion is limited by muscle
joint. The FDS tendon passes 7 mm from the center of physiology (Blix curve), pulley rupture will cause a
rotation of the PIP joint and 13 mm from the center loss of flexion. Weakness results because the tendon
of rotation of the MCP joint. will be near terminal excursion in midflexion where
In explaining the moments of the tendons acting on grasp is normally the strongest.9
the digital joints, Landsmeer termed the moment arm
a beam. To compare the relative moments of the ten-
dons at the joints, Landsmeer calculated a ratio of THE EXTENSOR TENDON INTEROSSEI
extensor to flexor moments. An increased extensor AND LUMBRICALS
flexor moment ratio at 1 joint as compared with
another meant that there is an increased propensity for
extension at that joint.4 T he extensor muscles of the fingers have small
physiologic cross-sectional areas, and relatively
long fibers. These properties make the extensor mus-
THE PULLEY SYSTEM cles optimally created for excursion and velocity but
not for force generation, having only a third of the

T he flexor sheath arises at the volar plate of the
MCP joint and ends at the proximal volar base of
the distal phalanx. The flexor sheath is comprised of 5
work capacity of the flexors.1 Yet they are the only
extensors for the digits. The extensor digitorum com-
munis (EDC) tendons of the index, middle, and ring
annular pulleys, thickened areas of arcing fibers, and 3 fingers insert into the extensor expansion on the dor-
cruciate pulleys, thin flexible criss-crossing pulleys sum of the 4 fingers.10,11 This attachment forms a
interspaced between the annular pulleys. The palmar complex extensor mechanism. Inside the extensor ex-
aponeurosis pulley also has been shown to have pulley pansion, the EDC tendon splits into a central slip and
function.5 The annular pulleys have been shown to be 2 lateral slips. The central slip attaches to the base of
biomechanically important in preventing tendon the middle phalanx and the 2 lateral slips join with
bowstringing during digital flexion. The cruciate pul- the tendons of the intrinsic muscles to form the lateral
leys are significant because they supply the essential bands. The lateral bands continue distally and attach
flexibility to allow approximation of the annular pul- to the base of the dorsum of the distal phalanx form-
leys while maintaining the reliability of the flexor ing the distal end of EDC tendon.12
sheath during flexion.6,7 The A-2 and A-4 pulleys are Many studies have been performed to find the
critical to the function of the pulley system.8 These numerous variants in the anatomy of extensor ten-

dons.10,11 The most common arrangement of the ex- ulnar nerve. Each DI muscle originates from adja-
tensor system is a single extensor indices proprius cent metacarpals by 2 heads. Each DI muscle con-
tendon to the index finger, a single EDC to the index sists of 2 bellies: a superficial and a deep belly. The
finger, a single EDC to the middle finger, a double superficial belly originates from the midshaft of
EDC to the ring finger, and a double extensor digi- adjoining metacarpals and inserts onto the base of
torum minimi (EDM) to the small finger. The exten- the proximal phalanx. The superficial belly’s major
sor indices proprius integrates with the extensor hood function is to abduct the proximal phalanx and has
and inserts ulnar to the EDC index tendon on the no capability of directly extending the IP joints.
dorsum of the middle and distal phalanges of the The deep belly has the same origin as the superficial
index finger. The EDM inserts onto the dorsal base of belly, but it continues distally to create the lateral
the distal phalanx of the small finger. In a few cadaver band of the dorsal aponeurosis in the 3 radial
dissections, the EDM was defective when the EDC fingers. The function of the deep belly is to abduct
had a tendon inserting into the small finger as well.10 and flex the proximal phalanges (at the MCP joint)
On the other hand, the EDM was well developed and to extend the 2 distal phalanges (at the DIP and
when the EDC had no tendons attached to the small PIP joints) of each finger. The first dorsal interosse-
finger. Interestingly, the EDC usually is considered as ous inserts directly onto the bone of the proximal
1 muscle with 4 tendons because the extensor muscles phalanx and the MCP joint capsule. The signifi-
have an incomplete separation between their muscle cance of the first DI is primarily in its usefulness in
bellies within the forearm and even have tendinous pinch, which is described later. The second and
and fascial connections between their tendons on the third DI insert onto radial and ulnar sides of the
dorsal surface of the hand. These connections within middle finger, respectively. There is no superficial
the extensor system are called the juncturae tendinum belly to the third dorsal interosseous muscle and
and the intertendinous fascia. therefore it has no insertion to the proximal pha-
The juncturae tendinum are slender connective tis- lanx. The deep belly of the third dorsal interosseous
sue strips extending between each EDC muscle and muscle inserts into the lateral band, allowing for
the EDM, but rarely to the extensor indices proprius, flexion at the MCP joint and extension of the DIP
conferring greater independence to the index finger.12 and PIP joints in the middle finger. The fourth DI
Similar to the extensor tendon anatomy, the juncturae to the ring finger inserts on the ulnar side of the
tendinum have several anatomic configurations. These finger. The small finger does not have a DI, but is
bands also have multiple biomechanical functions in- able to abduct with the use of the abductor digiti
cluding dynamic MCP joint stabilizers. During digi- minimi, which originates from the pisiform bone
tal flexion, the juncturae tendinum redistribute the and inserts into the lateral band of the small finger
tensile forces imparted on the extensor system, and base of the proximal phalanx.
thereby dynamically stabilizing the digits against any There are 3 palmar interossei muscles that arise
radial or ulnar deviating forces. The intertendinous from the medial side of the second metacarpal and
fascia arises between the tendon sheaths and is present the lateral sides of the fourth and fifth metacarpals
between all the extensor tendons. As a minor partic- and insert onto the ulnar side of the index finger
ipant along with the juncturae tendinum, the inter- and the radial sides of the ring and small fingers at
tendinous fascia works to prevent independent exten- the base of the proximal phalanges and the extensor
sion of the digits. The juncturae and intertendinous expansion. Hence, their primary function is MCP
fascia prevent extensor subluxation during MCP joint joint flexion and IP joint extension and secondary
flexion. finger adduction. The palmar interossei muscles are
The interossei muscles have short fibers and long more effective as DIP and PIP joint extensors than
tendons of insertion.13-15 These muscles are rela- the lumbricals, given their muscle fiber character-
tively strong based on their cross-section, but have istics.
a relatively meager excursion because of a short fiber There are 4 lumbrical muscles, all of which orig-
length. There are 4 dorsal interossei (DI) muscles inate at the FDP tendons. The muscle fibers run up
and 3 palmar interossei muscles innervated by the to 90% of the total muscle’s length. This relatively

long fiber length implies that the lumbricals were The excursion of the extensor tendon from full
created for excursion and velocity. Because these flexion to full extension according to Zancolli19 is 24
muscles have small pennation angles and small mm, assuming that the tendons followed the convex-
cross-sectional areas, they also are well designed for ities of the joints (14 mm MCP, 6 mm PIP, 4 mm
an even contractile force. The lumbrical muscles DIP). However, the measured excursion is only 20
originate from the radial side of the FDP tendons mm. Zancolli explains that the descent of the lateral
and insert on the radial lateral bands of the digits at bands at the PIP joint saves approximately 4 mm of
the MCP joint. The 2 radial lumbricals are inner- excursion.19
vated by the median nerve, whereas the 2 ulnar
lumbricals are innervated by the ulnar nerve. The ELECTROMYOGRAPHY
movement of the lumbrical muscles is restricted by
the fibrous attachments the muscles make with the
intermetacarpal ligaments and volar plates in the
palmar side on their way to the lateral bands.
T he studies of Long et al13,14 and Brown examined
muscle activity during finger flexion. The FDP is
active in finger flexion when the DIP joint is flexed.
Because they insert onto the lateral bands, their
The FDS is active when the wrist is flexed and during
contraction will result in extension of the IP joints.
firm grasp. The EDC is active during all finger flexion.
Because the lumbricals will contract when the FDP
The interossei is active during simultaneous MCP
muscle contracts, the contraction of the lumbricals
flexion and PIP extension. The lumbrical muscle is
will cause laxity in the FDP tendon distally, pre-
active during IP extension.
venting flexion of the IP joints. Because their in-
sertion is on the lateral bands, their contraction will
result in extension of the PIP and DIP joints and THE BIOMECHANICS OF DIGITAL MOTION
flexion of the MCP joint. Therefore, when the hand
is reaching to grasp an object, the action of the
lumbricals will cause MCP flexion and IP joint
extension, allowing the fingers to surround the
I n single-digit unloaded flexion the FDP tendon is
active whereas the FDS shows little or no activ-
ity.13,14 The long extensor tendon maintains a con-
object before the FDP fully contracts, causing flex- stant activity. Although the FDP tendon does not
ion of the DIP and PIP joints as well. As a minor have an insertion on the middle or proximal phalan-
function, the lumbricals are radial deviators of the ges, the FDP tendon is able to flex these joints.
MCP joints as well.1,12-14 Flexion is initiated at the DIP joint by virtue of the
The extensor hood consists of a central tendon anatomic insertion of the flexor tendon volar to the
that splits over the proximal phalanx into 1 middle center of rotation of the DIP joint. As the DIP flexes,
and 2 lateral bands. The extensor hood is stabilized the FDP now creates an angled path as it exits the A-4
over the MCP joint by the sagittal band. The pulley. This creates a normal force on the A-4 pulley
middle extensor band inserts onto the base of the that is transmitted to the middle phalanx, creating a
middle phalanx. The lateral extensor bands proceed flexion moment on the PIP joint. Similarly, the ten-
distally to join the lateral interosseous bands and don creates a normal force on the A-2 pulley, creating
form the lateral bundles distal to the PIP joint. The a flexion moment at the MCP joint.
lateral bundles then unite distally as the terminal There is coupling of the DIP and PIP joints as a
tendon. The lateral tendons are connected by the result of the 2 systems. The spiral oblique ligament
triangular ligament over the middle phalanx. The arises from the flexor sheath proximal to the PIP joint
wing tendon is composed of lateral and medial and attaches to the terminal extensor tendon. Tension
interosseous components. The medial interosseous is increased in the ligament by DIP flexion and PIP
component divides into dorsal and palmar compo- extension. When the DIP joint flexes through the
nents that envelope the lateral and medial band of action of the FDP tendon, increased tension in the
the extensor tendon. The fibers of the lateral in- spiral oblique ligament is offset by coupled flexion of
terosseous component join the lateral extensor band the PIP joint. The second system that couples DIP
to form the lateral bundle.11 and PIP flexion is the extensor mechanism. The lateral

FIGURE 4. The moment arm of the flexor tendon at any specific joint assists resisting pinch forces but may require an additional
flexor tendon contribution to maintain finger balance.

bands and the central slip are cross-connected dorsally. DIP joint is large enough to counteract the externally
FDP flexion of the DIP joint creates increased tension applied force on the tip of the finger, but not enough
in the lateral bands with an instantaneous relative for the larger moment on the PIP joint (Figure 4).
laxity of the central slip. The increased tension in the Here, the contracting FDS comes into play, which
lateral bands resists further DIP flexion whereas the adds a moment to the FDP moment across the PIP
laxity of the central slip permits PIP flexion. Once the joint and both together counteract the externally ap-
PIP flexes, tension in the central slip is restored. This plied force to the tip of the finger. Without the FDS,
unloads the lateral bands further, permitting incre- the PIP joint would tend to go into extension and the
mental flexion at the DIP joint. As the PIP flexes the DIP joint would tend to go into flexion. It is clear that
lateral bands slip volarward. This further decreases the most of the unopposed flexion is provided by the FDP,
extensor moment at the PIP joint. This couple creates but is supported by the FDS when added force is
coordinated flexion between the 2 joints. required. It has been pointed out by Landsmeer4 that
The FDS tendon is not recruited in simple digital because the FDS passes closer to the center of rotation
flexion but is active in power pinch. The difference in of the PIP than the MCP, it has a larger moment
moment arms of the FDP tendon at the PIP and DIP acting on the MCP joint. Thus, isolated FDS contrac-
joints is 5 mm, 10 mm PIP minus 5 mm DIP. During ture leads to preferential MCP flexion relative to the
pinch the moment arm of an external force is up to 20 PIP joint. When the fingers are in equilibrium before
mm greater at the PIP than at the DIP joint (by virtue grasp the MCP is extended and the PIP joint is in
of the length of the middle phalanx, which acts as a slight flexion. The FDP tendon is tensioned but the
lever arm). The moment created by the FDP on the FDS is not firing because the FDS would cause the

FIGURE 5. Swan-neck deformity of the finger.

MCP joint to go into relative flexion in relation to the taining the PIP joint in relative extension. The defor-
PIP. A contribution of the FDS generally is seen only mity of MCP extension and PIP flexion is termed a
in firm grasp or when the wrist is in flexion.13,15,16 claw hand deformity and is associated with interosseous
The difference in excursion between the FDS and paralysis. It is discussed in the Claw Hand Deformity
FDP tendons is less than 1 cm. Even though the section of the Clinical Application portion of this pa-
overall excursion difference is minimal, the FDP ten- per.14,18,19
don crosses 3 joints in the digit, whereas the FDS joint
only crosses 2. At both the PIP and MCP joints the CLINICAL APPLICATION
FDP tendon lies closer to the center of rotation of the
joint. The earlier equation (s [excursion] ! " Swan-Neck Deformity
[angle] · r [radius]) shows that the necessary excursion Swan-neck deformity is an abnormal posture of the
for a given angle is diminished for the FDP relative to finger in which the DIP joint is in flexion and the PIP
the FDS because r is decreased. In actuality, contrac- joint is in hyperextension (Figure 5). The deformity
ture of the FDS may have a pulley function as the most often is encountered in patients with rheumatoid
decussating bands of the FDS contract and draw the arthritis. In rheumatoid arthritis, synovitis of the PIP
FDP in close contact with the PIP joint.1 joint damages the periarticular tissues including the
When the hand opens before grasp, the proximal volar plate, which is the primary stabilizer against
phalanges extend relative to the metacarpals and distal hyperextension of the joint. Frequently, this is asso-
phalanges. The extensor/flexor moment ratio of the ciated with rupture of the FDS tendon, which dynam-
MCP joint is greater than the PIP joint. Thus, acti- ically resists PIP hyperextension. Any deformity that
vation of the long extensor and flexors before grasp increases the extensor moment across the PIP joint
will cause MCP extension and PIP flexion. Interosse- then can cause hyperextension. EDC tightness second-
ous activity is necessary to flex the MCP while main- ary to tendon subluxation at the MCP joint and MCP

FIGURE 6. Boutonniere deformity of the finger.

subluxation both cab lead to extrinsic EDC tightness. Boutonniere Deformity
As the PIP joint hyperextends, the lateral bands slip Boutonniere deformity is a tendon imbalance
dorsally. This is compounded by synovitis-induced caused by attenuation or rupture of the central exten-
attenuation of the lateral retinaculum that normally sor tendon of the PIP joint. This is seen commonly
prevents dorsal subluxation of the lateral bands. As with rheumatoid arthritis and as a result of trauma. In
the lateral bands slip dorsally, their distance from the rheumatoid arthritis the initial pathology is thought
center of the PIP joint increases effectively, increasing to be attenuation and eventual rupture of the central
the extensor moment at the PIP joint. When flexion is slip by synovial proliferation at the PIP joint. Atten-
attempted the lateral bands no longer can slide over uation and relative lengthening of the central slip
the condyles. This further limits PIP joint flexion. leads to decreased tension and a decreased extension
The dorsally and centrally displaced lateral bands moment of the PIP joint. The extensor mechanism
become slack and with increased PIP hyperextension migrates proximally, increasing tension in the lateral
become ineffective in extending the DIP joint. This bands and the terminal tendon. This leads to the
leads to a flexion deformity at the DIP joint. It should characteristic flexion deformity at the PIP joint and
be noted that intrinsic tightness also could produce an hyperextension at the DIP joint (Figure 6).1,20
increased extension moment at the PIP joint.20 With rupture of the central tendon there is rupture
Swan-neck deformity also may begin with a disrup- or attenuation of the triangular ligament that main-
tion of the extensor tendon at the DIP joint. Terminal tains the dorsal position of the lateral bands. The
extensor tendon rupture may be associated with syno- lateral bands slip volarly. Both the rupture of the
vitis of the DIP joint, leading to a DIP joint flexion central tendon and the volar position of the lateral
deformity. When there is concomitant laxity of the bands decrease the extensor moment of the PIP joint.
volar plate the ensuing proximal migration of the As the lateral bands slip volar to the center of rotation
lateral bands can increase PIP joint hyperextension as of the PIP joint, they impart a flexion moment to the
tension in the central slip is increased.1,20 joint. In this subluxed position tension of the lateral

bands increases, producing an increased extension mo- out gapping. To this end, a number of 4- and 6-strand
ment of the DIP joint. This leads to flexion of the PIP repairs have been introduced. The surgeon must real-
joint and hyperextension of the DIP joint.20 ize that a stronger repair provides little benefit if the
repair is bulky or stiff. A bulky or stiff repair will
Claw Hand Deformity increase the drag on the tendon. The work of flexion
After division of the ulnar nerve the fourth and is increased duly. Thus, the stiffer and bulkier repair
fifth digits assume a posture of MCP hyperexten- may have a greater tensile strength but greater force is
sion and PIP flexion. When the ulnar nerve is required for the tendon to glide. Thus, any improve-
divided, innervation to the interossei and to the ment in tensile strength of a tendon repair must be
lumbricals to the fourth and fifth digits is lost. The evaluated also in terms of work of flexion to decide if
ratio of extensor to flexor moment at the MCP joint the repair actually has a beneficial effect.
is greater than at the PIP joint. As a result of the If a critical pulley A-2 or A-4 is damaged or
unbalanced pull of the extrinsic tendons the fourth lacerated, pulley reconstruction is necessary to prevent
and fifth MCP joints posture in extension and the bowstringing and restore normal tendon mechanics.
PIP joints fall into flexion. Attempts to extend the Pulley reconstruction should be broad to minimize
PIP joints simply create further hyperextension of bowstringing and distribute force through a wide
the proximal phalanx. As the MCP joint goes into contact surface. A narrow pulley reconstruction dis-
hyperextension the PIP joint further flexes as the tributes force over a small area, causing significant
tension on the flexor tendons increases and the long deformation of the tendon. This in turn increases drag
extensor has come to the limit of excursion. It and the work of flexion.
should be noted that the second and third digits do To improve tendon exposure and gliding, some
not exhibit this profound deformity as a result of investigators have advocated pulley venting. Venting
the median innervated lumbricals. However, in is the partial release of a pulley on its proximal or
power pinch, collapse of the MCP joint into hyper- distal aspect. Recent research has shown experimen-
extension occurs as the force applied to the fingertip tally that 50% release of the proximal A-2 or A-4
creates a large extension moment at the MCP joint pulley causes significant flexion loss as a result of
by virtue of the lever arm of the phalanges.1,20 bowstringing.8
Flexor Tendon Repair
A detailed discussion of flexor tendon repair is CONCLUSION
beyond the scope of this article but several points
related to biomechanics are discussed. Newer proto-
cols for rehabilitation after flexor tendon repair em-
phasize active motion to decrease tendon adherence
K nowledge of biomechanical principles allows the
surgeon to understand the physical basis of hand
function and deformity. The application of sound
and ultimately improve range of active motion. Me- biomechanical principles will allow the surgeon to
chanically, a tendon repair initially must have a embark on a treatment plan that will optimize func-
greater tensile strength to permit early motion with- tion while re-creating normal hand mechanics.


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