Anatomy, Pathophysiology, and Biomechanics of Fingers

Disusun Oleh:

dr. Ihsanil Fahmi

S932302007

Pembimbing:

dr. Sp.OT

DEPARTEMEN ORTHOPAEDI DAN TRAUMATOLOGI

UNIVERSITAS SEBELAS MARET / RSUD DR. MOEWARDI
SURAKARTA
2023
 TABLE OF CONTENTS

TABLE OF CONTENTS i

I. ANATOMY 1
A. BONE ANATOMY 2
B. NEUROVASCULAR 2
C. MUSCLE AND TENDON ATTACHMENT 8
D. JOINTS 9
II. PATHOPHYSIOLOGY 10
A. CAPSULAR PATTERN 10
B. NON-CAPSULAR PATTERN 15
C. DISORDERS OF CONTRACTILE STRUCTURE 16
III. BIOMECHANICS 20
REFERENCES 27
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I. ANATOMY
A. Bone Anatomy
In the human body, there are 14 phalanges. Each digit has three
phalanges except for the first (the thumb), which has only two; however,
the phalanges of the first digit are stouter than those in the other fingers. 1
The first metacarpal bone corresponds to the thumb, the second to
the index finger, the third to the long finger, the fourth to the ring finger,
and the fifth to the small finger. The thumb has two phalanges, named
proximal and distal phalanges. The proximal phalanx base forms the
metacarpophalangeal (MCP) joint with the first metacarpal head. The head
of the proximal phalanx articulates with the base of the distal phalanx to
form the interphalangeal (IP) joint. The index, long, ring, and small fingers
each have proximal, middle, and distal phalanges. The proximal phalanges
form MCP joints with their respective metacarpal bones. The head of each
proximal phalanx articulates with the base of each middle phalanx to form
proximal interphalangeal (PIP) joints. The head of each middle phalanx
articulates with the base of each distal phalanx to form distal
interphalangeal (DIP) joints. 2
 2

Figure 1. Palmar view of the bones of hand 3

Figure 2. Dorsal view of the bones of hand 3

Each phalang has a head, shaft and proximal base. The proximal
phalanges are the largest, the middle ones are intermediate in size, and the
distal ones are the smallest. The shaft tapers distally, its dorsal surface
transversely convex. The palmar surface is transversely flat but gently
concave anteriorly in its long axis. The bases of the proximal phalanges
carry concave, oval facets adapted to the metacarpal heads. Their own
heads are smoothly grooved like pulleys and encroach more on to the
palmar surfaces. The bases of the middle phalanges carry two concave
facets separated by a smooth ridge, conforming to the heads of the proximal
phalanges. The bases of the distal phalanges are adapted to the pulley-like
heads of the middle phalanges. The heads of the distal phalanges are non-
articular and carry a rough, crescentic palmar tuberosity, to which the pulps
of the fingertips are attached. 1,4

B. Neurovascular
 3

Arterial Supplies
Because its function requires it to be placed and held in many
different positions, often while grasping or applying pressure, the hand,
especially the fingers is supplied with an abundance of highly branched and
anastomosing arteries so that oxygenated blood is generally available to all
parts in all positions. Furthermore, the arteries or their derivatives are
relatively superficial, underlying skin that is capable of sweating so that
excess heat can be released. To prevent undesirable heat loss in a cold
environment, the arterioles of the hands are capable of reducing blood flow
to the surface and to the ends of the fingers. 4

Figure 3. Arteriogram of the wrist and hand 4

Arterial supply to the hand comes from the ulnar and radial arteries,
which are branches of the brachial artery. Dorsal hand vascular supply
comes from the dorsal carpal arch. This arch forms from anastomosis of the
 4

dorsal carpal branches of radial and ulnar arteries. Metacarpal branches

subsequently arise from the dorsal carpal arch. The first metacarpal branch
courses along the radial border of the second metacarpal, supplying the first
web space and second metacarpal. The second through fifth branches
course along the ulnar borders of the second through fifth metacarpals and
provide branches to the interosseous muscles as well as the periosteum.
Metacarpal branches generally arise from the deep arch, while digital
arteries arise from the superficial arch. Metacarpal branches form
anastomosis with digital arteries. 2
The palmar hand vascular supply comes from the superficial and
deep palmar arch. The superficial palmar arterial arch is primarily formed
by the ulnar artery, while the radial artery mainly supplies the deep palmar
arterial arch. The superficial palmar arch, the main termination of the ulnar
artery, gives rise to three common palmar digital arteries that anastomose
with the palmar metacarpal arteries from the deep palmar arch. Each
common palmar digital artery divides into a pair of proper palmar digital
arteries, which run along the adjacent sides of the 2nd–4th digits. 2,4
 5

Figure 4. Terminal vascular arcades over the distal phalanx 1

Venous Drainage
Digital veins drain into the superficial and deep venous palmar
arches, associated with the superficial and deep palmar (arterial) arches,
then they will drain into the deep veins of the forearm. Dorsal digital veins
pass along the sides of the fingers, joined by oblique branches. They unite
from the adjacent sides of the digits into three dorsal metacarpal veins that
form a dorsal venous network over the metacarpus. This is joined laterally
by a dorsal digital vein from the radial side of the index finger and both
dorsal digital veins of the thumb, and is prolonged proximally as the
cephalic vein. Medially, a dorsal digital vein from the ulnar side of the little
finger joins the network, which ultimately drains proximally into the basilic
vein. A vein often connects the central parts of the network to the cephalic
vein near the mid-forearm. Palmar digital veins connect to their dorsal
counterparts by oblique veins that pass between metacarpal heads. They
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also drain to a plexus superficial to the palmar aponeurosis, extending over

both thenar and hypothenar regions. 1,4

Figure 5. Venous drainage of the fingers 1

Innervation
The median, ulnar, and radial nerves supply the hand to the fingers.
In addition, branches or communications from the lateral and posterior
cutaneous nerves may contribute some fibers that supply the skin of the
dorsum of the hand. In the hand, these nerves convey sensory fibers from
spinal nerves C6–C8 to the skin, so that the C6–C8 dermatomes include the
hand. The median and ulnar nerves convey motor fibers from spinal nerve
T1 to the hand. 4
The median nerve usually divides into four or five digital branches.
It often divides first into a lateral ramus, providing digital branches to the
thumb and the radial side of the index finger, and a medial ramus,
supplying digital branches to adjacent sides of the index, middle and ring
fingers. These digital branches supply the fibrous sheaths of the long flexor
 7

tendons, blood vessels (vasomotor) and sweat glands (sudomotor). Distal to

the base of the distal phalanx, each digital nerve gives off a branch that
passes dorsally to the nail bed. 1
The ulnar nerve divides into superficial and deep terminal branches.
The superficial terminal branches divide into two palmar digital nerves.
One supplies the medial side of the little finger; the other (a common
palmar digital nerve) sends a branch to the median nerve and divides into
two proper digital nerves to supply the adjoining sides of little and ring
fingers. The deep terminal branch accompanies the deep branch of the ulnar
artery as it passes between abductor digiti minimi and flexor digiti minimi,
and then perforates opponens digiti minimi to follow the deep palmar arch
dorsal to the flexor tendons. 1
The radial nerve supplies no hand muscles. The superficial branch
of the radial nerve is entirely sensory. It pierces the deep fascia near the
dorsum of the wrist to supply the skin and fascia over the lateral two thirds
of the dorsum of the hand, the dorsum of the thumb, and proximal parts of
the lateral one and a half digits. 4

Figure 6. Dorsal aspect of innervation of the hand and fingers 4

 8

Figure 7. Palmar aspect of innervation of the hand and fingers 4

C. Muscle and Tendons Attachment

Articular ligaments and numerous muscles are attached to the
phalanges. The tendon of flexor digitorum profundus is attached to the
palmar aspect of the base of the phalanx and the tendon of extensor
digitorum to its dorsal surface. The tendon of flexor digitorum superficialis
and its fibrous sheath are attached to the sides of the middle phalanx, and a
part of extensor digitorum is attached to the base dorsally. The fibrous
flexor sheath is attached to the sides of a proximal phalanx, part of the
corresponding dorsal interosseous is attached to its base laterally, and
another dorsal interosseous is attached medially. The phalanges of the little
finger and the thumb differ. Abductor and flexor digiti minimi are attached
to the medial side of the base of the proximal phalanx of the little finger.
The tendon of extensor pollicis brevis and the oblique head of adductor
pollicis (dorsally), and the oblique and transverse heads of adductor
pollicis, sometimes conjoined with the first palmar interosseous (medially),
are attached to the base of the proximal phalanx of the thumb. 1
 9

Figure 8. Muscles and tendons attachment of the hand and fingers 1

D. Joints
The metacarpophalangeal (MCP) joint and interphalangeal (IP) joint
are the joints that make up the articulations of the fingers. The
metacarpophalangeal joints are the condyloid type of synovial joint that
permit movement in two planes: flexion–extension and adduction–
abduction. The interphalangeal joints are the hinge type of synovial joint
that permit flexion– extension only. The heads of the metacarpals articulate
with the bases of the proximal phalanges in the MCP joints, and the heads
of the phalanges articulate with the bases of more distally located phalanges
in the IP joints. A joint capsule encloses each MCP and IP joint with a
synovial membrane lining a fibrous layer that is attached to the margins of
each joint. 1,4
The fibrous layer of each MCP and IP joint capsule is strengthened
by two (medial and lateral) collateral ligaments. These ligaments have two
parts: Denser “cord-like” parts that pass distally from the head of the
 10

metacarpals and phalanges to the bases of the phalanges; and thinner “fan-
like” parts that pass anteriorly to attach to thick, densely fibrous or
fibrocartilaginous plates, the palmar ligaments (plates), which form the
palmar aspect of the joint capsule. 4

Figure 9. MCP and IP joints 4

II. PATHOPHYSIOLOGY
Pain and paraesthesia are two symptoms that are common in the hand and
fingers. Pain is very often the result of either local trauma or overuse. Precise
localization is possible in pain that is not referred from a lesion higher up in the
limb. Paraesthesia may reflect a proximal lesion and the patient has difficulty in
identifying the source of his symptoms. 5

A. Capsular Pattern
Any of the joints of the fingers may become affected by one or
other form of arthritis, which results in limitation of movement with a
capsular pattern. The capsular pattern at a finger joint is an equal loss of
movement at the beginning and end of the normal range in either direction.
The presence of a capsular pattern indicates that an arthritis has developed,
the type of which can be defined from the history. 5
 11

Rheumatoid Arthritis
Rheumatoid arthritis (RA) is an autoimmune systemic disease that
results in synovial inflammation affecting joints, tendons and bursae. It has
a particular predilection for the hands, which can result in pain, deformity
and functional limitation, often in a symmetrical pattern. 6 Rheumatoid
synovium destroys articular cartilage by a poorly understood enzymatic
reaction, invades subchondral bone, and stretches the soft tissues that
support the involved joint. It also surrounds and invades the flexor and
extensor tendons. 7

Figure 10. Progression of rheumatoid hand deformities 7

Early in the course, a capsular pattern develops and one or more

metacarpophalangeal joints or proximal interphalangeal joints of one or
both hands show the familiar spindle-shaped swelling. Later, when bone
 12

destruction takes place, a palmar luxation of the fingers occurs and they
deviate towards the ulnar side as the result of subluxation in the
metacarpophalangeal joints. The fingers may develop the typical buttonhole
and swan neck deformities: the former results in hyperextension of the
metacarpophalangeal joint, flexion at the proximal interphalangeal joint and
extension at the distal interphalangeal joint; the latter results in flexion at
the metacarpophalangeal joint, hyperextension at the proximal and flexion
at the distal interphalangeal joints. The thumb becomes Z-shaped (‘ninety-
ninety’ deformity): the metacarpophalangeal joint is fixed in 90° flexion,
the interphalangeal joint in 90° extension. The joints are also warm to the
touch. 5

Figure 11. Plain radiograph showing ulnar deviation deformity and

extensive joint destruction of interphalangeal joint 8

Traumatic Arthritis
The typical history of direct contusion, indirect sprain or reduced
dislocation of a finger joint indicates the presence of a traumatic arthritis.
On inspection, a spindle-shaped swelling is often seen, which resembles the
swelling of rheumatoid arthritis. Examination further reveals a capsular
pattern, and on palpation warmth may be felt, especially after a severe
injury. As the arthritis may be combined with a tendinous lesion, resisted
movements of the fingers can be examined. Although a single trauma may
 13

sometimes be sufficient to induce arthropathy, repeated injuries and excess

body weight are known to increase the risk for traumatic arthritis. 5,9
After the immediate consequences of injury, mechanobiological,
molecular and cellular changes in cartilage and other joint structures slowly
progress into an acute post-traumatic phase. This inflammatory phase can
spontaneously resolve after a couple of months or persist through a long
clinically asymptomatic latency period. The chronic phase lasting years
after the initial injury may lead to chronic OA or inflammatory arthritis. 9

Figure 12. Traumatic arthritis deformity and contracture of DIP 10

Arthrosis
Occasionally arthrosis in one joint develops as the result of severe
injury but more often the condition has a spontaneous onset and affects
several joints. Arthrosis begins at the distal interphalangeal joints, and its
knobbly appearance is quite different from rheumatoid arthritis. Both hands
are usually affected more or less symmetrically. The index, middle and ring
fingers are most usually affected. At the base of the distal phalanx,
Heberden’s nodes can be seen. A varus deformity may develop at a distal
joint, usually at the index. 11
 14

Some years later, the arthrosis may spread to the proximal

interphalangeal joints (with the formation of nodes at index and middle
fingers, Bouchard’s nodes); it seldom reaches the metacarpophalangeal
joints. From time to time, a new node forms at an affected joint and the
patient will mention some aching or slight pain over 1 or 2 months, during
which time the fingertip may occasionally become pink. The colour is
mottled and different from the shiny red of gout. After a month or two the
discolouration passes off and the node ceases to be painful. 5,11

Figure 13. Bouchard’s and Heberden’s nodes at PIP and DIP joints,
respectively 11

Gout Arthritis
Gout arthritis is a precipitation of crystalline material within the
confines of an enclosed space (joint or tenosynovial space) incites an acute,
fulminant inflammatory reaction marked by intense swelling, erythema,
and pain. Gout is a disorder of urate metabolism in which the
overproduction of uric acid causes hyperuricemia and hyperuricosuria. 7
The low solubility of monosodium urate is responsible for its
crystallization and deposition in peripheral sites, including subcutaneous,
intraarticular, and tenosynovial locations. Attempted phagocytosis by
peripheral leukocytes releases lysosomal enzymes that produce an intense
 15

inflammatory synovitis. If left unchecked, the disease results in the

formation of gouty tophi, which are large, lobulated subcutaneous deposits
of monosodium urate crystals commonly seen in the pinna of the ear and
the great toe. 7,12
Deposition in the hand occurs relatively late in the disease and is
uncommon with good medical management. Gout arthritis is manifested by
acute and rapidly escalating joint pain over the first 24 hours, followed by
spontaneous resolution over the next week to 10 days. 5,7

Figure 14. Gouty tophus of the DIP joint 7

B. Non-capsular Pattern
Non-capsular pattern is restriction of the joint that can be because of
loose bodies and/or extra articular adhesions which does not affect the
capsule. The restriction could be in just one movement or direction with
pain where other directions or movements remain pain free with full range
of motion. 5

Unreduced Dislocation
Dislocation is sometimes mistaken for traumatic arthritis at the
interphalangeal joint of the thumb. The joint is so swollen that it is not
 16

obvious that it is fixed in full extension (a clear noncapsular type of

limitation). In late cases, reduction is impossible and surgery is required. It
is important to note that a dislocation is only unstable in the early stages of
the injury, particularly if it has not been reduced. With time, the unreduced
dislocation becomes stiff, and stiffness is the opposite of instability. 7
Chronic dislocation is uncommon and defined as persistent dislocation
or subluxation of the joint due to late presentation or missed finger injury
for 4 weeks or more. Different combinations of structures are injured, based
on mechanism, including collateral ligaments, volar plate, and the central
slip of the extensor mechanism. 13

Figure 15. Plain radiograph showing neglected dislocation of the PIP

joint 13

C. Disorders of Contractile Structure

Strains of muscles and tendons in the hand are not infrequent. They
have no tendency to spontaneous cure. All the intrinsic muscles of the hand
 17

and their short tendons respond immediately to adequate deep transverse

friction but not to infiltrations with steroids. 7

Dorsal Interosseus Muscle

A lesion in an interosseous muscle is usually traumatic, either the
result of a direct injury or of a fracture of a metacarpal bone. Less
commonly it follows overuse. There are three possible localizations for the
lesion: in the muscle belly; in the tendon where it crosses the
metacarpophalangeal joint; and at the insertion into the base of the phalanx.
If the lesion is in the tendon or at the insertion, the pain is accurately felt at
one side of one knuckle. The joint may be slightly swollen at the site of the
lesion. Passive deviation of the finger away from the painful side is painful,
as well as resisted abduction towards the painful side. Again, palpation
must be performed very carefully to determine the exact painful spot. 5

Figure 16. Sites of lesions of dorsal interosseus muscle 5

Weakness and wasting of one interosseous muscle only occurs in cases

of localized pressure (usually occupational) on the deep palmar branch of
the ulnar nerve in the palm of the hand (cyclist’s palsy). 5

Thenar Muscle
A lesion of a thenar muscle may follow an abduction sprain of the
thumb. The origin of the oblique portion of the adductor pollicis muscle at
the palmar aspect of the base of the (second or) third metacarpal bone is
 18

most commonly affected. Resisted adduction of the thumb is painful, as is

passive abduction. 5

Trigger Finger
Trigger finger is a common condition causing pain and disability in the
hand. It can arise spontaneously or can be the result of repetitive minor
trauma or a complication of rheumatoid arthritis. The third or fourth finger
is most commonly involved. The disorder is caused by swelling of one of
the digital flexor tendons just proximal to the metacarpophalangeal joint, in
combination with narrowing of its tendon sheath. The condition presents
with discomfort in the palm during movement of the involved digits.
Gradually the flexor tendon causes painful popping or snapping as the
patient flexes and extends the digit. 5

Figure 17. Trigger finger 5

As the condition progresses, the digit may begin to lock in a particular

position, more often flexion, which may require gentle passive
manipulation into full extension. Trigger finger arises through a
discrepancy in the diameter of the flexor tendon and its sheath at the level
 19

of the metacarpal head known as the A1 pulley. This thickening of the

sheath can result in a narrowed tunnel for tendon excursion and ultimately
result in a block to tendon excursion. However, the flexors are usually
powerful enough to overcome this obstruction, whereas the weaker
extensors are less able to counteract the block, resulting in the finger being
locked in flexion. A painful nodule, the result of intratendinous swelling, is
easily palpated in the palm, just proximal to the head of the metacarpal
bone. 5,14

Figure 18. Locking of right middle finger in flexion position 15

Mallet Finger
Mallet, which means hammer, was the term used to describe the
hammer-like deformity that occurred in sports-related injuries. As the result
of an injury that flexes the distal interphalangeal joint while it is actively
held in extension, the long extensor tendon may rupture or may become
detached (avulsion fracture) from the distal phalanx. Distinction between
the two can be made by radiography. On examination, the distal joint is
 20

held in flexion and the patient is not able to extend it actively. Passive
testing is normal. 5,16
Mallet injuries with and without a bony fragment may be effectively
treated by splinting the distal interphalangeal joint in extension for 8 weeks,
followed by 1 month of night splinting. 5

Figure 19. Mallet finger on DIP and the use of splinting as treatment 5

III. BIOMECHANICS
Effective function of the finger requires precise coordination of multiple
muscles and the resulting finger motion is constrained by the forces exerted by
the joint capsules, ligaments and joint articular surfaces. In manual activities,
the highly complex musculoskeletal system of the hand and forearm is well
coordinated to generate appropriate fingertip forces and finger postures. 17
Coordination between various structures is necessary for converting a
muscle contraction into a movement and then into a function. Signals from the
brain are transmitted through the nerves to the muscles; the tendons move
through pulleys across fulcrums, and the joints ultimately move to perform. Not
to forget the opposing groups resisting it so that the movement becomes
controlled and the hand does not collapse. Even the skin plays a vital role in the
grip. 18
The complexity of the hand is evident, its anatomy efficiently organized to
carry out a variety of complex tasks. These tasks require a combination of
 21

intricate movements and finely controlled force production. The close

relationship between different soft tissue structures contributes to the complex
kinesiology of the hand. Injury to any of these even very small structures can
alter the overall function of the hand and thereby complicate the therapeutic
management. 19

Position of Hand
When the hands are observed wherein the opposing groups of muscles are
in a state of relaxation while a person is sleeping, it is noticed that the forearm is
slightly pronated and the wrist is kept in neutral or minimal flexion and minimal
ulnar deviation. The MCP joints are kept flexed as a cascade from the index
through the little fingers (45–70 degrees) and the IP joints in flexion of varying
levels. The thumb is abducted and is away from the plane of the palm. This
position is commonly called the resting position. 18
While attempting a function, the position changes into an extension of
approximately 30 degrees at wrist opening up of the MCP joints with the
proximal phalanx of the index parallel to the thumb and the IP joints flexed as if
to oppose the thumb pulp. This is called the functional position, and commonly
the hand is dressed in this position. 18
The intrinsic position is the one in which the wrist is extended more, the
MCP joints are kept flexed approximately 60 to 75 degrees, and the IP joints are
kept straight. In this position, the MCP capsule, long extensors, and the extensor
expansion over finger including the lateral bands are kept relaxed. This is the
ideal position for splinting in tendon transfers or in repair of extensors. 18
If this is visualized in a clinical situation, wherein there is infection of the
hand or there is trauma, the hand goes into position of ease to relax the flexors.
The wrist goes into flexion, the MCP joint goes into compensatory extension,
and the IP joints into more flexion. This leads to the MCP joint capsular
 22

contracture, and if left uncorrected, the IP joints also go into flexion

contracture. 18

Figure 20. Positions of hand. a, resting position. b, functional position. c,

intrinsic position. d, flexion contracture 18

Arches of Hand
There are two transverse arches, proximal and distal. The proximal arch is
formed by the proximal and distal rows of carpal bones forming the carpal
tunnel. The distal arch is formed by the heads of metacarpals, varies in shape,
depending on the positions of the fingers, and alters dynamically in various
positions of grasp. 18
Every ray of the finger and thumb forms the longitudinal arches. They are
formed by the phalanges and their corresponding metacarpals The thumb ray is
the most mobile and then the little and ring fingers; the index and middle fingers
are more or less stable. An oblique arch formed by the thumb ray and the fingers
can also be described. This is again dynamically altered by the movements of
thenar and hypothenar muscles. The oblique arch of the thumb with the index
finger is important for precision grip, whereas that with the little finger tightens
the grip. 18
 23

Figure 21. Arches of hand 18

In grasping, the arches provide a postural base to the hand and have a role
in the production of finger joint movements and the assurance of a stable grasp.
The arches form a hollow cavity that changes its shape during hand pre-shaping
and grasping according to the object to be grasped. The contraction of thenar
and hypothenar muscles plays a role during hand shape modulation. 19

Joints and Ligaments

The MCP joints are ellipsoidal or condylar joints with two degrees of
freedom, but it also allows for conjoint rotation, e.g., in a pinch grip, the index
finger can rotate to a certain degree. The place of the collateral ligament of the
MCP joint and the prominent condylar shoulders that the collateral ligaments
must cross causes the ligaments to be tight in the flexed position, making it
almost impossible to abduct and adduct in MCP-flexed position and abduct the
fingers when in flexion. In the extended position, the ligaments are at their
maximum relaxed position which can be observed in a swollen hand where the
hand tends to adapt the position of injury: MCP extension and IP flexion. 19
 24

Figure 22. MCP joint extension (top), the proper collateral ligament (PCL) is
somewhat relaxed allowing for abduction and adduction. In flexion (bottom),
both the PCL and the accessory collateral ligaments (ACL) are tight 19

The PIP joint differs from the MCP in that an intact volar plate and its
check rein ligaments effectively restrict hyperextension. The volar plate is
attached to the accessory collateral ligament (ACL) which is tight in extension,
thus pulling the volar plate against the phalanges and together with the proper
collateral ligaments (PCL) completely stabilizes the PIP joint. No ulnar or radial
deviation is passively possible. In some flexion, the PCL is still tight and helps
in stability of the PIP joint. The volar plate is a fibro-cartilaginous structure
attached to the check rein ligament, a swallowtail-like structure. The volar plate
serves as a volar articulating surface and is an additional confining structure for
synovial fluid. Lesion or laxity can result in swan neck deformity. 20
 25

Figure 23. The volar plate of the PIP joint 20

In the extended finger, it is impossible to flex the DIP without also flexing
the PIP joint unless the PIP joint is blocked in extension. The main reason is the
oblique retinacular ligament (ORL) or Landsmeer’s ligament which passes volar
to the axis of the PIP joint and attachment at the distal joint on the dorsal side
and allows transfer of tension between the dorsal aspect of the DIP joint and the
palmar aspect of the PIP joint. This couples the movement of the two joints
because increased tension in the terminal tendon simultaneously increases
tension in the ORL, thereby adding a flexion moment at the PIP joint. The ORL
acts as a passive tenodesis assisting in DIP extension as the PIP joint is extended
and relaxing with PIP flexion to allow full DIP flexion. It has been calculated
that on average, every 1° of PIP joint flexion results in 0.76° of DIP joint
flexion. 19,20

Muscles and Tendons

Usually the muscles are divided into extrinsic, where muscles have their
origin proximal to the hand, and intrinsic muscles, which have their origin and
insertion within the hand. In general, each finger has six muscles controlling its
movements: three extrinsic muscles (two long flexors and one long extensor)
 26

and three intrinsic muscles (dorsal and palmar interosseous and lumbrical
muscles). The index and small fingers have an additional extrinsic extensor. 19

Figure 24. Musculotendonal structure of the finger 3

In the carpal tunnel, anatomical interconnections between the tendons of

the flexor digitorum profundus (FDP) are consistently present. These
interconnections limit the mutual tendon displacements, which decrease finger
independence; this is sometimes called the Quadriga phenomena or Verdan’s
quadriga syndrome. Another reason why the FDP cannot move independently is
the common muscle belly. The flexor digitorum superficialis (FDS) is not
normally activated until firm grasp is required or the wrist is in flexion. 19
The extensor tendons do not have a synovial sheath system, but at the wrist
level, the extensors are restricted by the extensor retinaculum that forms six
fibro-osseous compartments within which 12 extensor tendons pass. The
extensor retinaculum at the dorsum of the wrist functions as a pulley, keeping
the wrist and finger extensor tendons near the axis of the wrist during motion. 19
 27

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