The boomerang flap in managing injuries of the dorsum of the distal phalanx

Finding an appropriate soft-tissue grafting material to close a wound located over the dorsum of a finger, especially the distal phalanx, can be a difficult task. The boomerang flap mobilized from the dorsum of the proximal phalanx of an adjacent digit can be useful when applied as an island pedicle skin flap. The vascular supply to the skin flap is derived from the retrograde perfusion of the dorsal digital artery. Mobilization and lengthening of the vascular pedicle are achieved by dividing the distal end of the dorsal metacarpal artery at the bifurcation and incorporating two adjacent dorsal digital arteries into one. The boomerang flap was used in seven individuals with injuries involving the dorsal aspect of the distal phalanx over the past year. Skin defects in all patients were combined with bone,joint, or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-step procedure preserves the proper palmar digital artery to the fingertip and has proven valuable for the coverage of wide and distal defects because it has the advantages of an extended skin paddle and a lengthened vascular pedicle. When conventional local flaps are inadequate, the boomerang flap should be considered for its reliability and low associated morbidity.     

The Obłazowa 1 early modern human pollical phalanx and Late Pleistocene distal thumb proportions

The human distal thumb phalanx from the earlier Upper Paleolithic of Ob?azowa Cave, southern Poland, exhibits features of its palmar surface that align it morphologically principally with early modern humans. These aspects include the configurations of the proximal palmar fossa, the flexor pollicis longus tendon insertion, the proximal margin of the palmar apical tuft, and especially its low ulnar deviation angle. If it is assumed that it possessed the pollical phalangeal length proportions of an early modern human, it would exhibit modest base and tuft breadths. However, given Late Pleistocene archaic-modern contrasts in relative pollical phalanx lengths, the isolated nature of the phalanx prevents secure assessment of its radioulnar interphalangeal articular and apical tuft hypertrophy. Similar constraints apply to the assessment of other Pleistocene Homo pollical phalanges.     

Functional anatomy of the hand of Australopithecus africanus

The Sterkfontein hand bones, attributed to Australopithecus africanus, were analysed to determine potential hand function of the power grip type of this species. The metacarpus is as stable as that of modern humans, as indicated by the depth of the groove on the base of metacarpal 2, the styloid process of metacarpal 3, the base articular surface areas, and the ligament markings on the bases of the metacarpals. The flexion and rotation of metacarpal 5 might have been less than that of modern humans, due to a more marked ventral articular lip on the base. The metacarpus acts as a lever, acting in various planes. The extensor carpi ulnaris and extensor carpi radialis longus muscles were probably better developed than in modern humans. The extensor carpi radialis brevis and flexor carpi radialis muscles would probably have been as well developed as in modern humans. None of the long tendons have a mechanical disadvantage as compared to modern humans. The metacarpals have a high robusticity index. The proximal phalanges show some midshaft swelling, slightly greater curvature than in modern humans, and some side to side bowing: pongid features. The fibrous flexor sheath markings are well developed, but resemble those of modern humans rather than those of the pongids. A single middle phalanx resembles that of modern humans, and has well developed ridges for insertion of the flexor digitorum superficialis muscle. The distal phalanx of the thumb has a well developed region for insertion of the flexor pollicis longus muscle, and has a mechanical advantage over modern humans for action of this muscle at the interphalangeal joint. The features indicate that the hand of A. africanus was well adapted to powerful hand use, as in hammering, striking, chopping, scraping, and gouging actions, as well as for throwing and climbing activities.     

The ligaments of the fingers. Anatomical study of the Cleland ligaments

The aim of this study was to establish a precise architecture of the retinacular ligaments of human digits. Sixty selected digits from human cadavers aged 40-70 years were used in this study. We were able to identify, under the dissecting microscope, two distinct ligamentous complexes: one proximal of greater importance and the other distal of lesser importance. Both structures extend from the periosteum as well as from the fibrous part of the digital sheath to the skin. There are many variations in size and in shape of these structures but they are not related to a particular digit. The role of these ligaments is to prevent the 'effet de doigt de gant', to stabilize and to maintain the neurovascular bundle of the digit at the moment of the digital flexion.     

Clinical anatomy of the m. flexor carpi radialis tendon sheath

At the transitional zone from the forearm to the hand the insertion tendon of the m.flexor carpi radialis (FCR) glides on a fibrous and fatty cushion, which is connected dorsally with the joint capsule of the radiocarpal articulation. The tendon distally crosses the palmar side of the scaphoid tubercle and enters the dorsally curved rim of the trapezoid tubercle. At the level of the wrist joint the narrow tendon sheath begins, which extends to the insertion at the metacarpus. Immediately after entering the gliding tunnel the tendon branches off radially as a rule with an accessory fibre strand 8 mm in width to the scaphoid, trapezium and the joint capsule between these two bones. The insertion tendon regularly is attached to the palmar and radial surfaces of the second and third metacarpal bones. The wall of the osteofibrous gliding tunnel can be prominent following trauma, inflammation or arthrosis deformans in the trapezio-scaphoideal joint and may irritate the tendon (tendovaginosis stenosans). Against resistance forces pain will occur in the wrist joint during palmar flexion. The typical point of tenderness is situated at the entering of the tendon in the thenar region. Operative decompression will be effective by opening the radial wall of the tendon sheath from the carpal tunnel.     

Collateral ligaments of the distal sesamoid bone in the digit of Equus: re-evaluating midstance function

The distal forelimb of the horse has a complex array of ligaments that play a critical role in determining function of the digit and are often associated with the initiation of foot pathologies. The collateral ligaments of the distal sesamoid bone (CLDS) play an important role in digit stabilization near the end of foot contact and there is also limited evidence to suggest that the CLDS stabilize the proximal interphalangeal joint (PIPJ) during weight bearing. By virtue of their anatomical attachments where the ligaments pass dorsal to the axis of rotation of the PIPJ, it is reasonable to assume that the CLDS prevent flexion of the PIPJ during weight bearing or midstance in a moving horse. To test this functional hypothesis, forelimb specimens from three mixed-breed horses were loaded in compression in a materials testing frame. Limb loading was applied with the CLDS intact and following transection. Average PIPJ angle and metacarpophalangeal joint (MCPJ) angle at maximum load (approximately 3000 N) were calculated from angular changes of proximal and middle phalanges and the third metacarpal, which were compared between intact and transected trials. PIPJ angles were found to be the same (175 degrees) at maximum load for intact and transected trials. The proximal and middle phalanges rotated together remaining aligned, regardless of the CLDS condition. Contrary to expectation, however, the combined proximal and middle phalanges unit rotates less relative to the third metacarpal under load after transection, indicating less digit extension at the metacarpophalangeal (fetlock) joint without the influence of CLDS. Since the mechanical properties of the fetlock joint are unchanged by CLDS transection, observed proximal and middle phalanx motion is dependent on increased rotation of the distal phalanx after transection. The original hypothesis was not supported and the results suggest that at midstance the CLDS function primarily to stabilize the articulation of the middle phalanx about the distal phalanx to limit distal interphalangeal joint extension during weight bearing. Establishing the functional role of the CLDS may help to better understand the biomechanical consequences of ligament injuries and diseases of the pastern.     

Comparative morphology of the pollical distal phalanx

Functional analysis of human pollical distal phalangeal (PDP) morphology is undertaken to establish a basis for the assessment of fossil hominid PDP morphology. Features that contribute to the effectiveness of grips involving the distal thumb and finger pulp areas include: 1) distal thumb interphalangeal joint morphology, facilitating PDP conjunct pronation with flexion; 2) differentiation of a proximal, mobile pulp region from a distal, stable pulp region, providing for firm precision pinch grips and precision handling of objects; and 3) asymmetric attachment of the flexor pollicis longus (FPL) tendon fibers, favoring PDP conjunct pronation. A proportionately larger size of the ulnar vs. radial ungual spine suggests differential loading intensity of the ulnar side of the proximal ungual pulp and supporting nail bed. Stresses at the distal interphalangeal joint are indicated by the presence of a sesamoid bone within the volar (palmar) plate, which also increases the length of the flexor pollicis longus tendon moment arm. Dissections of specimens from six nonhuman primate genera indicate that these human features are shared variably with individuals in other species, although the full pattern of features appears to be distinctively human. Humans share variably with these other species all metric relationships examined here. The new data identify a need to systematically review long-standing assumptions regarding the range of precision and power manipulative capabilities that might reasonably be inferred from morphology of the distal phalangeal tuberosity and from the FPL tendon insertion site on the PDP.     

Hyaluronic acid diminishes the resistance to excursion after flexor tendon repair: an in vitro biomechanical study

Adhesion between the tendon and tendon sheath after primary flexor tendon repair is seen frequently, and postoperative finger function is occasionally unsatisfactory. A reduction of the friction may facilitate tendon mobilization, which in turn may reduce the risk of the adhesion and restriction of range of motion. We considered the possibility of utilizing the hyaluronic acid (HA) as a lubricant. To evaluate the effect of HA, the gliding resistance between the canine flexor digitorum profundus tendon repaired by a modified Kessler suture technique with running epitendinous suture and the annular pulley located on the proximal phalanx (corresponding to the A2 pulley in humans) was evaluated and compared before and after administration of HA. The HA solution measurement groups were identified as follows; intact tendon as a control; repaired tendon; tendon soaked in 0.1, 1, and 10 mg/ml HA. The resistance increased after repairing, then it decreased after soaking in 10 mg/ml HA solution. The results of this study revealed that HA diminishes the excursion resistance after flexor tendon repair. We believe that some style of administration of the HA might reduce the excursion resistance and prevent adhesion until the synovial surface is fully developed.     

Mechanical advantages of the Neanderthal thumb in flexion: a test of an hypothesis

It has been proposed that the pollical phalangeal length proportions of the Neanderthals provided them with a greater mechanical advantage relative to recent humans for their pollical flexor muscles in power grips across the interphalangeal (IP) joint at the expense of the mechanical advantage of those pollical flexor muscles in precision grips at the finger tip. To test these related hypotheses, we compared the pollical load arm dimensions (phalanx lengths) to power arm dimensions (dorsopalmar articular heights) for the European and Near Eastern Neanderthals and for European and Amerindian samples of recent humans. It was found, initially, that the proximal articular height of the pollical distal phalanx is a poor predictor of the power arm at the IP articulation, even though the proximal articular height of the pollical proximal phalanx was an adequate indicator of the power arm size at the metacarpophalangeal (MCP) joint. In addition, differences in distal pollical ulnar deviation at the IP joint appeared to make little difference in the mechanical advantage comparisons. More importantly, the relative shortness of Neanderthal proximal pollical phalanges and the relative lengthening of their distal pollical phalanges was confirmed, and it was determined that, despite some minor differences in articular dimensions between Neanderthals and recent humans, these pollical phalangeal length contrasts translated into significant differences in mechanical advantages for the flexor muscles across the MCP and IP articulations.     

Middle phalanx skeletal morphology in the hand: Can it predict flexor tendon size and attachments?

Specific sites on the palmar diaphysis of the manual middle phalanges provide attachment for the flexor digitorum superficialis (FDS) tendon. It has been assumed in the literature that lateral palmar fossae on these bones reflect locations for these attachments and offer evidence for relative size of the flexor tendon. This assumption has led to predictions about relative FDS muscle force potential from sizes of fossae on fossil hominin middle phalanges. Inferences about locomotor capabilities of fossil hominins in turn have been drawn from the predicted force potential of the flexor muscle. The study reported here provides a critical first step in evaluating hypotheses about behavioral implications of middle phalangeal morphology in fossil hominins, by testing the hypothesis that the lateral fossae reflect the size of the FDS tendon and the location of the terminal FDS tendon attachments on the middle phalanx. The middle phalangeal region was dissected in 43 individuals from 16 primate genera, including humans. Qualitative observations were made of tendon attachment locations relative to the lateral fossae. Length measurements of the fossae were tested as predictors of FDS tendon cross-sectional area and of FDS attachment tendon lengths. Our results lead to the conclusion that the hypothesis must be rejected, and that future attention should focus on functional implications of the palmar median bar associated with the lateral fossae.     

Paraterminal ligaments of the distal phalanx.

The paraterminal ligaments of the distal phalanges have been studied by dissection. They are a normal feature of all distal phalanges in both the hand and foot, and connect the paraterminal spines and paraterminal tubercles of the distal phalanx on both sides. Branches of the proper palmar digital artery and nerve pass under the ligament to reach the matrix of the nail, which they supply.     

Studies on the tendinous compartments of the extensor muscles on the back of the human hand and their tendon sheaths. I

In 47 dissected right and left hands of adults of both sexes, kept in a moist condition, significant practical-clinical investigations of the transitional zone between forearm and hand were undertaken. In particular it was sought to determine the characteristic sizes of the extensor retinaculum, the osteofibrous tunnels, the insertion tendons of the hand and finger extensor muscles, and their tendon sheaths. Together with the palmar carpal ligament, the 2 to 3 cm wide extensor retinaculum annularly surrounds the whole circumference of the carpus. It extends obliquely from radial-proximal to ulnar-distal and conducts the extensor tendons over the carpal articulations. According to recent studies, it is divided into a superficial and a deep fibrous layer. From the undermost surface, vertical and oblique septa run to the plane of the forearm and carpal bones. They separate the fibrous portion of the 6 tendinous compartments of the dorsum manus. In 8.5% of cases, an accessory and completely independent tunnel of the extensor pollicis brevis muscle exists in the material investigated, and in 2.2% of cases, there is an additional tunnel for the extensor carpi radialis muscle. Hence, one occasionally finds 8 separate osteofibrous gliding compartments for the extensor muscles in the dorsal hand region. The longest tunnel belongs, as a rule, to the extensor digiti minimi muscle, whilst the widest pertains to the extensor digitorum muscle. Within the tunnel and also proximal and distal to it, the extensor tendons are surrounded by synovial sheaths. Because of its wide encroachment on the dorsum of the hand, the insertion tendon of the extensor digiti minimi muscle possesses the longest tendon sheath, measuring 68.8 mm. The next longest sheath, that of the extensor pollicis longus muscle, which measures 56.2 mm, begins further proximal to the gap of the radiocarpal articulation. In 12.8% of cases, there are divided sheaths of the abductor pollicis longus and of the extensor pollicis brevis muscle. The tendon sheath of both extensor carpi radiales muscles is frequently divided into 2 compartments which, in 2/3 of cases, communicate. The compartment of the extensor carpi radialis brevis muscle, in 91.5% of cases, shares a window-like opening with the roof of the synovial vagina of the extensor pollicis longus muscle. The tendon sheath of the long extensor muscles of the fingers originates 5 mm proximal to the forearm border of the extensor retinaculum and has a communal recess. The IVth tendon sheath opens distally and splays out in a glove-like manner to some distal recesses.(ABSTRACT TRUNCATED AT 400 WORDS)     

Structural modifications involved in the fore- and hind limb grip of some flying foxes (Chiroptera: Pteropodidae)

A mechanism which enables flying foxes to lock their hind limb digits and thumbs in flexion is described. The deep digital tendons of the hind limbs have roughened fibrocartilage surfaces. The adjacent flexor tendon sheath supports ridges which interact with the rough tendon surface, temporarily 'locking' the two structures together. This tendon locking mechanism is of importance as it enables bats to reduce the energetic cost of hanging from branches. It does this by reducing, or eliminating, the need for digital flexor muscle activity.     

Insertions and functions of certain flexor muscles in the hind leg of rodents

This survey includes 58 genera of rodents from 26 families. The medial tarsal bone is probably unique to the order. Its presence, nature, and constant relationship with M. tibialis posterior are discussed. This muscle inverts and supinates the pes at the astragulo-navicular joint and moves the ankle. The M. flexor tibialis inserts on the medial sesamoid, on this sesamoid and the integument, on the sesamoid and the tendon of M. flexor fibularis, on the latter tendon only, or on the integument only. The occurrence, nature, and cam-like action of the sesamoid are described. A distal segment of the tendon of M. flexor tibialis usually extends from the sesamoid to either the first phalanx of the first digit or to fascia of an adjacent muscle. Functions of the medial sesamoid include (1) stabilization of the tendon of M. flexor tibialis, (2) deflection of this tendon to benefit flexion of the first phalanx, (3) winching of the medial tarsal ligament to flex the first metatarsal, (4) control of the angle of insertion of the tendon to provide flexion or abduction of the first digit as appropriate during swimming, (5) mechanical multiplication of the tension in the tendon between the segments proximal and distal to the sesamoid, and (6) longitudinal folding of the sole of the pes to grip the substrate, as in climbing.     

Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers

The distal portion of the flexor aspect of the forearm has been used as the donor site of full-thickness skin grafts, venous skin grafts, and Chinese forearm flaps. This article describes the use of a free flap harvested from the flexor aspect of the wrist and based on the superficial palmar branch of the radial artery to repair skin defects of the hand and fingers. The advantages of this flap are as follows: (1) the operative field is the same; (2) the radial artery is preserved; (3) it is thin, pliable, and hairless and thus can supply a gliding surface for tendons beneath it; (4) when it involves a palmaris longus tendon and/or the palmar cutaneous branch of the median nerve, it can be used as a vascularized tendon or nerve graft; and (5) in view of the flow-through type of the pedicle of the flap, the digital artery can be reconstructed simultaneously. However, it should be noted that a hypesthesia in the proximal central carpal area remains when the palmar cutaneous branch of the median nerve is harvested as a vascularized nerve graft. The scar of the donor site should be left in the distal wrist crease. If it is not lying in the distal wrist crease, it may suggest that the patient has tried to commit suicide.     

Four Anchor Repair of Jersey Finger

BackgroundVarious surgical techniques for treating avulsions of the flexor digitorum profundus tendon at the distal phalanx have been published but no ideal technique has emerged. We introduce a new all-internal 4-anchor flexor tendon repair technique and evaluate outcomes in three clinical cases.MethodsIn this retrospective case series, we reviewed three patients that sustained an avulsion of the flexor digitorum profundus tendon at the distal phalanx. All patients were surgically treated with the four-anchor repair technique. Two titanium anchors were inserted into the distal phalanx and two all-suture anchors were inserted distal to the first set of anchors. The tendon was then attached to these four anchors using a Krackow stitch pattern and the anchors were sown to each other. Active flexion and extension of the proximal and distal interphalangeal joint were measured at 3-month, 12-month, and 5-year follow-up. Postoperative complications were documented.ResultsAll patients achieved excellent clinical outcomes according to assessment criteria. At 3-month follow-up, all patients regained full flexion; two patients had full extension, while one patient was 3 degrees short of full extension. At 12-month follow-up, all patients had full flexion and extension. Five-year follow-up demonstrated the same results with no loss of function, sensation or grip strength. The repairs healed without rupture, and no complications were reported.ConclusionThe 4-anchor flexor tendon repair is a viable surgical technique for zone 1 flexor digitorum profundus tendon repair or reconstruction. Further studies are needed to replicate these promising results and biomechanically validate this technique.Level of Evidence: IV     

Quantification of fingertip force reduction in the forefinger following simulated paralysis of extensor and intrinsic muscles

Objective estimates of fingertip force reduction following peripheral nerve injuries would assist clinicians in setting realistic expectations for rehabilitating strength of grasp. We quantified the reduction in fingertip force that can be biomechanically attributed to paralysis of the groups of muscles associated with low radial and ulnar palsies. We mounted 11 fresh cadaveric hands (5 right, 6 left) on a frame, placed their forefingers in a functional posture (neutral abduction, 45° of flexion at the metacarpophalangeal and proximal interphalangeal joints, and 10° at the distal interphalangeal joint) and pinned the distal phalanx to a six-axis dynamometer. We pulled on individual tendons with tensions up to 25% of maximal isometric force of their associated muscle and measured fingertip force and torque output. Based on these measurements, we predicted the optimal combination of tendon tensions that maximized palmar force (analogous to tip pinch force, directed perpendicularly from the midpoint of the distal phalanx, in the plane of finger flexion–extension) for three cases: non-paretic (all muscles of forefinger available), low radial palsy (extrinsic extensor muscles unavailable) and low ulnar palsy (intrinsic muscles unavailable). We then applied these combinations of tension to the cadaveric tendons and measured fingertip output. Measured palmar forces were within 2% and 5° of the predicted magnitude and direction, respectively, suggesting tendon tensions superimpose linearly in spite of the complexity of the extensor mechanism. Maximal palmar forces for ulnar and radial palsies were 43 and 85% of non-paretic magnitude, respectively (p<0.05). Thus, the reduction in tip pinch strength seen clinically in low radial palsy may be partly due to loss of the biomechanical contribution of forefinger extrinsic extensor muscles to palmar force. Fingertip forces in low ulnar palsy were 9° further from the desired palmar direction than the non-paretic or low radial palsy cases (p<0.05).     

A new friction tester of the flexor tendon.

We have developed a new device to measure the friction force and calculate the friction coefficient between a rabbit flexor tendon, a pulley and a proximal phalanx. The flexor digitorum fibularis tendon of a rabbit was taken intact with the proximal phalanx, and tendon pulleys were attached to both ends of the bone. Both ends of the tendon were clamped to acrylic plates and connected to stainless-steel plates equipped with strain gauges. A pretension of 1.96 N was applied so as not to loosen the tendon. The proximal phalanx was fixed to an acrylic plate on the actuator, which gave 8 mm of transfer to the acrylic plate at a speed of 2 mm/s. The interface between the tendon and the surrounded tissue created the friction force, when the load was applied on the distal pulley. The friction force could be obtained from the difference between the tension of both ends of the tendon, which was measured with strain gauges and sampled with a personal computer. The friction force and the friction coefficient were calculated from the measured force and the applied load. The load and the pre-loading time, which was defined as loading duration before gliding, were varied in order to observe the change of the friction coefficient. The friction coefficient was not affected by the load and increased with the pre-loading time. The value of mu(s) ranged from 0.027 to 0.111 (0.072 +/- 0.023), and that of (mu)d ranged from 0.010 to 0.069 (0.039 +/- 0.014) (pre-loading time was 5 s). Our method will allow for the examination of various surgical treatments and lubricants. Moreover, it can be applied to other tissues of any animals with similar structures to the rabbit's digitorum.