Hand Clin 19 (2003) 1731

Biomechanics and hand trauma: what you need

Steven L. Moran, MDa,*, Richard A. Berger, MD, PhDa,b
a

Division of Plastic Surgery, Division of Hand and Microsurgery, Mayo Clinic,

200 First Street SW, Rochester, MN 55905, USA
b
Department of Orthopaedic Surgery, Mayo Medical School, Rochester, MN 55905, USA

Mutilating hand injuries pose many challenges

to the hand surgeon. The variety and severity of
these injuries has led to the development of several
grading scales, ow charts, and algorithms to help
the surgeon organize his or her treatment plan [1
4,112]. These tools help the surgeon in preparation
for surgery, but fail to predict hand function following reconstruction accurately. It can be agonizing for the hand surgeon, especially the young
hand surgeon, intraoperatively to contemplate
accurately the functional loss imposed by immediate joint fusion or digital amputation. Heroic
attempts are often made to salvage joints and digits, whose loss results in little functional decit. In
addition, these severely injured ngers and joints
often become sti and insensate, requiring delayed
amputations. This not only prolongs patient recovery but also prolongs the surgeons anxiety.
Many articles dealing with the mutilated hand
contain experience-based protocols and reference
previous anecdotal reports [58]. Are there any
biomechanical principles of hand dynamics that
could help in deciding what must be preserved
and what can be discarded? Unfortunately, biomechanical studies involving mutilating hand injuries
are scarce. This article establishes a biomechanical
foundation for determining what anatomic components are needed for hand function.
The essentials
In its most elemental form, the hand is composed of a stable wrist and at least two digits that

* Corresponding author.
E-mail address: moran.steven@mayo.edu
(S.L. Moran).

can oppose with some power. One digit should be

capable of motion so it can grasp objects. The
other digit need only act as a stable post against
which the movable digit can pinch. To allow for
prehensile movements the digits require some form
of cleft to divide them, which allows for the accommodation of objects. The digits need to be sensate
and pain free or they provide little benet over
prosthesis [6,7,9]. Requirements for functional
sensation have been dened as two-point discrimination of less than 10 to 12 mm [10].
The hand allows for prehension, which is the
ability to grasp and manipulate objects. As dened
by Tubiana et al [11], prehension may be dened
as all the functions that are put into play when an
object is grasped by the handsintent, permanent
sensory control, and a mechanism of grip. Prehension requires that the hand be able to approach, grasp, and release an object [11,12]. If
only two sensate digits remain to oppose each
other, some prehension is possible.
In terms of biomechanical motion the hand
performs approximately seven basic maneuvers,
which make up most hand function:
1. Precision pinch (terminal pinch). This involves exion at the distal interphalangeal
(DIP) joint of the index and at the interphalangeal joint (IP) joint of the thumb. The ends
of the ngernails are brought together as in
lifting a paper clip from a tabletop (Fig. 1).
2. Oppositional pinch (subterminal pinch). The
pulp of the index and thumb are brought
together with the DIP joints extended. This
allows for force to be generated through thumb
opposition, rst dorsal interosseous contraction, and index profundus exion. This is often
measured with a dynamometer (Fig. 2).

0749-0712/03/$ - see front matter 2003, Elsevier Science (USA). All rights reserved.
doi:10.1016/S0749-0712(02)00130-0

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S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

Fig. 1. Precision pinch (terminal pinch).

3. Key pinch. The thumb is adducted to the radial side of the middle phalanx of the index
nger. Key pinch requires a stable post (usually the index nger), which has adequate
length and a metacarpal phalangeal (MP)
joint, which can resist the thumb adduction
force (Fig. 3).
4. Directional grip (chuck grip). The thumb, index, and long nger come together to surround a cylindrical object. When using this
grip, a rotational and axial force is usually
applied to the held object (ie, using a screwdriver) (Fig. 4).
5. Hook grip. This requires nger exion at the
IP joints and extension at the MP joints. It is
the only type of functional grasp that does
not require thumb function. This grip is used
when one lifts a suitcase (Fig. 5).
6. Power grasp. The ngers are fully exed while
the thumb is exed and opposed over the
other digits, as in holding a baseball bat.
Force if applied through the ngers into the
palm (Fig. 6).

Fig. 2. Oppositional pinch (subterminal pinch).

Fig. 3. Key pinch.

7. Span grasp. The DIP and proximal interphalangeal (PIP) joints ex to approximately 30
degrees and the thumb is abducted. Force is
generated between the thumb and ngers, distinct to power grasp where force is generated
between the ngers and the palm. Stability is
required at the thumb MP and IP. This grip
is used to lift cylindrical objects (Fig. 7)
[11,13,14].
Postoperatively, the hands ability to adopt
these positions and exert force through them
impacts how well the patient rehabilitates. These
maneuvers are predicated on good sensation in
the ngers and thumb. Through the preoperative
history, the hand surgeon can determine which
hand functions benet the patient most in

Fig. 4. Directional grip (chuck grip).

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

19

Fig. 5. Hook grip.

Fig. 7. Span grasp.

returning to their previous employment or activities, and direct the reconstruction appropriately.
Many classication schemes divide hand
trauma into dorsal, volar, radial, and ulnar injuries [1,3]. When assessing the eects of mutilating
trauma on hand mechanics, however, it may be
easier to think of the hand as containing four functional units: (1) the opposable thumb; (2) the index
and long nger, whose stable basal joints serve as
xed posts for pinch and power functions; (3) the
ring and small nger, which represent the mobile
unit of the hand; and (4) the wrist. It may also help
to think of only two major forms of hand motion,
as opposed to seven: thumb-nger pinch and digitopalmar grip. Pinch requires preservation of the
thumb unit and a stable post. If the patient is able
to add a third digit to pinch, they can achieve more
precision. Pinch function tends to be preserved
when the median nerve is intact and the thumb

and index-long units of the hand are salvageable.

Without median nerve function, thumb sensation
and thenar function are lost, making ne motor
movements negligible. In comparison, ulnar nerve
function and the ring-small nger unit are more
important for digitopalmar grip, where exion and
sensation in the ulnar digits are essential. Thumb
preservation is also important in power grasp to
provide stability and control of directional forces.
With these principles in mind this article now
examines how digital loss aects hand function.
The biomechanical impact of amputation
Partial or complete amputations are present in
most mutilating hand injuries. It has been recommended that immediate amputation be performed
when four of the six basic digital parts (bone, joint,
skin, tendon, nerve, and vessel) are injured [8,15
20]. It is important to consider amputation in these
situations because long-term stiness and pain in a
salvaged digit can severely hamper the rehabilitation of the remaining hand. When performing an
amputation, however, one should understand how
digital loss impacts overall hand function.
The thumb

Fig. 6. Power grasp.

The functional importance of each digit has

been debated. If one were to prioritize the digits
to be saved following mutilating injury, the thumb,
with its importance in prehension and in all forms
of grasp, takes top priority [109]. It provides 40%
of overall hand function in the uninjured setting
[2123]. Following mutilating trauma, when digits
are missing or sti, the thumb can account for
greater than 50% of hand function [24]. Its uniqueness and versatility in humans is caused by the

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S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

position of the thumb axis. The thumb axis is

based at the trapeziometacarpal (TMC) joint and
is pronated and exed approximately 80 degrees
with respect to the other metacarpals in the hand
[25]. This positioning allows for circumduction,
which permits opposition [2629].
Opposition of the thumb is necessary for all
useful prehension and its preservation provides
the basis for successful salvage procedures. Opposition of the thumb is the result of angulatory
motion, which is produced through abduction at
the TMC joint, and exion and rotation of the
TMC and MP joints [30]. Multiple muscles are
required for functional opposition. These include
the abductor pollicis brevis, the opponens pollicis,
and the supercial head of the exor pollicis brevis. These muscles act simultaneously on the
TMC joint and the MP joint. The abductor pollicis
brevis provides the major component of opposition, with the opponens pollicis and exor pollicis
brevis providing secondary motors for opposition.
All measures should be directed toward preserving
or reconstructing the abductor pollicis brevis if
possible [25,2832]. The extensor pollicis longus
(EPL) and adductor pollicis (ADD) are antagonists to thumb opposition providing a supinating
extension and adduction force.

The priorities of thumb reconstruction vary

with the level of amputation, but at all levels reconstruction should attempt to restore opposition and
pinch (Fig. 8). Injuries distal to the IP joint (zone 1
injuries) may produce little functional decit,
because oppositional length tends to be maintained
[33,34]. Residual insensibility and dysesthesia from
trauma produce more functional problems at this
level than the mechanical loss of length [35,36].
Subterminal pinch and precision pinch are compromised if an unstable or painful scar is present
at the thumb remnant. Loss of the distal phalanx
and IP joint (zone 2 injuries) may also not require
reconstruction. Function may be preserved if TMC
and MP motion is maintained [37].
Level three injuries, through the level of the
MP, are the most common and do represent a signicant loss of function. Unreconstructed injuries
result in a decrease in pinch dexterity and grip
strength [38]. The MP joint of the thumb has no
other mechanical equivalent in the hand. It has
three degrees of freedom; it represents a ball and
socket joint in extension, but when the joint is
exed, the tightening of the collateral ligaments
causes the MP joint to function more like a hinge.
The intrinsic muscles provide motion but also provide dynamic stability to the joint.

Fig. 8. Diagram depicting levels of thumb injury, as originally described by Hentz [31]. Zone 1 injuries result in tissue
loss distal to the IP joint. Zone 2 injuries result in thumb loss distal to MP joint. Zone 3 injuries result in loss of the MP
joint but preservation of thenar musculature. Zone 4 injuries occur distal to TMC joint with loss of thenar musculature.
Zone 5 injuries result in loss of the TMC joint. The zone of injury determines reconstructive priorities.

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

In injuries proximal to the MP joint one may

proceed with a free toe transfer, which is the gold
standard. The great toe metatarsal phalangeal
joint can reproduce the exion and extension arc
of the MP joint, but fails to reproduce the MP
joints 15 to 20 degrees of supination [35]. Functional opposition is also possible with a toe wraparound ap. This reconstruction only allows for
TMC motion. Excellent results have been obtained
when the fusion angles with bone graft were 30
degrees of exion and 45 degrees of internal
rotation. These fusion angles allowed for pinch
between all ngers and produced pinch and grip
strengths of 60% and 97%, respectively [39]. Nonmicrosurgical methods for reconstruction of level
three defects can include deepening of the rst
web space, but any injury to the adductor or thenar musculature should be signicantly discouraged in an already traumatized thumb.
Level four injuries result in damage to the thenar
muscles, with resultant instability to the TMC joint.
This produces a major stumbling block in thumb
reconstruction, because TMC stability is required
for any successful thumb reconstruction. Injuries
at this level often require some form of soft tissue
reconstruction for restoration of opposition and
pinch [38,40]. In its most primitive form pinch can
be recreated, as in the tetraplegic patient, with
fusion of the IP and MP and reconstruction of the
adductor musculature. For reconstruction of oppositional pinch, however, tendon transfers may be
necessary. In a study by Cooney et al [27], muscle
cross-sectional area and moment arm analysis were
used to determine the best donor muscle for oppositional transfer. The exor digitorum supercialis
(FDS) of the long nger and the extensor carpi
ulnaris (ECU) muscles closely approximated
thenar muscle strength and potential excursion.
Abduction from the palm was greatest after transfer of the FDS from the long and ring ngers
and after ECU and extensor carpi radialis longus
(ECRL) transfers. Pulley location was found to
inuence the motion and strength of transfers in
both the exion and abduction planes. Both
Bunnell [41] and Cooney et al [27] stress the importance of directing the force of the transfer
toward the pisiform. Transfers that are distal to
the pisiform, such as those using the extensor digiti
minimi (EDQ) or abductor digiti minimi (ADQ),
produce more exion than abduction. Transfers
proximal to the pisiform, such as the FDS using
the exor carpi ulnaris (FCU) loop as a pulley, produce more abduction and less metacarpal exion
(Fig. 9).

21

Level ve injuries represent a loss of the TMC

joint. In these cases restoration of TMC mobility
is probably best achieved by index ray pollicization, if available. The TMC joint is mechanically
equivalent to a universal joint [28,30,42]. The
TMC joint allows for thumb circumduction and
thumb extension with associated supination, and
pronation with thumb exion. The TMC joint is
very complex because of its inherent instability at
the radial aspect of the wrist with no bony stabilizers proximal (mobile scaphoid). This inherent
instability accounts for the large number of ligamentous supports that surround the joint (Fig.
10.). There are ve major internal ligamentous
stabilizers of the TMC joint: (1) dorsal radial
ligament, (2) posterior oblique ligament, (3) rst
intermetacarpal ligament, (4) ulnar collateral ligament, and (5) the anterior oblique ligament. The
dorsal radial ligament prevents lateral subluxation. The posterior oblique ligament provides
stability in exion, opposition, and pronation.
The rst intermetacarpal ligament is taut in abduction, opposition, and supination; it holds the rst
metacarpal tightly against the second metacarpal.
The intermetacarpal ligament is joined by the
ulnar collateral ligament, which prevents lateral
subluxation of the rst metacarpal on the trapezium and controls for rotational stress. The base
of the index metacarpal should be spared during
any type of ray resection to preserve the intermetacarpal ligament [43,44]. The fth and most important ligament is the volar anterior oblique ligament

Fig. 9. Diagram depicting the use of the supercialis

tendon from the long nger for restoration of thumb
opposition. Tendon transfers directed proximal to the
pisiform tend to produce greater metacarpal abduction
and less metacarpal exion as compared with transfers
directed distal to the pisiform. The supercialis tendons
from the long and ring ngers closely approximate the
excursion and strength of the original thenar musculature, and provide for an ideal tendon for transfer.
FDS exor digitorum supercialis; FCU exor
carpi ulnaris; P pisiform.

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S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

Fig. 10. Diagram of the trapezio-metacarpal joint

showing the outlay of the dorsal and volar ligaments.
Special attention must be given to preservation of this
joint for adequate thumb stability. The most important
ligaments for reconstruction and preservation are the
dorsal radial ligament (DRL), posterior oblique ligament
(POL), ulnar collateral ligament (not depicted), rst
intermetacarpal ligament (IML), and the anterior oblique
ligament, deep and supercial heads (DAOL and SAOL).
APL abductor pollicis longus; DIML dorsal intermetacarpal ligament; DT-II MC dorsal trapezio-II
metacarpal; DTT dorsal trapeziotrapezoid.

with its deep and supercial components. The ligament arises from the volar tubercle of the trapezium and inserts on the volar aspect of the
thumb. The anterior oblique ligament is taut in
extension, abduction, and pronation; it controls
pronation stress and prevents radial translation.
The deep anterior oblique ligament serves as a
pivot point for the TMC joint and guides the metacarpal into pronation while the thenar muscles
work in concert to produce abduction and exion.
These bers limit ulnar translocation of the metacarpal during palmer abduction while working
with the supercial anterior oblique ligament to
constrain volar subluxation of the metacarpal.
The anterior oblique, intermetacarpal, and dorsoradial ligaments are the most critical for preservation and reconstruction [4244].
The index nger
The index nger may be of next highest importance because of its exion and extension inde-

pendence, its ability to abduct, and its closeness

to the thumb. It has a major role in precision pinch
and directional grip [11,13,45,46]. A good range of
motion for the index nger is more important than
length. Amputation through the PIP leaves all
remaining stump exion to the control of the
intrinsics. This allows for exion to approximately
45 degrees. It may be shortened to the end of the
proximal phalanx and still participate in directional grip, span grasp, and lateral pinch [13].
The body, however, is quick to bypass the digit
for the long nger if it becomes insensate or sti.
The long nger replaces the index for terminal
and subterminal pinch if amputation exists below
the DIP level.
Elective loss of the index ray has been well
studied. Murray et al [47] studied patients who
underwent elective ray amputation. The study
found that power grip, key pinch, and supination
strength were diminished by approximately 20%
following surgery. Patients with persistent dysesthesia following ray amputation experienced larger
losses in grip strength. In addition, pronation
strength was diminished by 50% following ray
resection. Pronation strength is used for directional grip. This large decrease in pronation
strength is caused by a shortening of the palms
lever arm. In the intact hand, the width of the grip
extends from the hypothenar region to the index
nger. The ulnar aspect of the palm represents
the internal fulcrum and the radial aspect of the
palm represents the external fulcrum of movement. With the loss of the index nger ray the fulcrum is decreased by approximately 25% (Fig. 11).
This results in a loss of stability and a decrease
in mechanical advantage. Despite the loss of
strength, all patients in this study, without postoperative dysesthesia, believed that their overall hand
function had been improved, especially in regard
to prehension with the thumb [47]. This suggests
that the ability to perform precise activities is more
important for postoperative patient satisfaction
than the preservation of grip strength. In comparison, a recent study of patients with traumatic
proximal phalanx amputations of the index nger
and patients with elective index ray resections
found that patients with amputation through the
proximal phalanx demonstrated a better functional outcome when assessed with the DASH
questionnaire. A 30% decrease in pinch and grip
strength was seen in both groups. Cosmesis was
believed to be better with ray amputation [48].
Overall, it seems that a remaining proximal phalanx stump does provide a benet in terms of grip

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

Fig. 11. Diagram showing the resultant eects of ray

excision on pronation and supination strength. Resection of the metacarpal narrows the palms. This shortens
the palms lever arm and decreases the hands mechanical advantage during pronation and supination.

strength and overall hand function. In light of the

high rate of postoperative dysesthesia associated
with ray resection, it seems that immediate index
ray resection should be reserved for very proximal
injuries where there is little chance of postoperative MP motion.
The long and ring ngers
The long nger does provide the most nger
exion force when tested individually [49,50]. Its
central position allows it to participate in power
grip and precision grip. Patients are easily able to
substitute this digit for terminal and subterminal
pinch following the loss of the index nger. The
middle ray does lack the specialization of the rst
dorsal interosseous muscle when performing pinch
functions. Transfer of the rst dorsal interosseous
to the insertion of the second dorsal interosseous
has been suggested following rst ray resection;
however, studies have shown that this does not signicantly increase pinch strength [47,51]. In addition, this transfer can lead to the development of
an intrinsic plus deformity in the long nger
[47,52]. The ring nger has less strength than either
the index or long. It is also rarely used for precision
pinch or grip. As an individual digit, Tubiana et al
[11] believe the ring ngers loss leaves the least
functional decit in the hand. When this nger is

23

combined with the small as a functional unit, however, it can provide for adequate power grip and
replace the index and long for pinch maneuvers
should both digits be lost.
Central ray deletion, or loss of both ring and
long ngers, may produce scissoring of the remaining digits because of instability of the transverse
metacarpal ligament and compromised interosseous function. Three-point chuck pinch is compromised, as is hand competence, because small
objects may fall through the central defect [53
55]. Acute central ray resection with repair of the
transverse metacarpal ligament may still result in
scissoring of the neighboring digits, inadequate
closure of the gap, and loss of abduction of the
small ray [54,56,57]. In cases of central digital loss,
a ray transposition may alleviate hand incompetence and reduce scissoring of the digits. Results
of strength testing following ray transposition for
central digital loss have found an average decrease
in grip and pinch strength of 20%, with larger
decreases in function being seen for index to long
transfer when compared with small to ring transfers. Loss of motion was only 9% following
transfer [56]. Although ray amputation may be
indicated in cases of central digital loss, it seems
most prudent to perform this procedure in a
delayed fashion, after a discussion has been carried
out with the patient regarding his or her needs with
regard to hand strength and motion.
The small nger
The small nger has the least strength in exion; however, its loss can have broader implications on hand function. In digitopalmar grip the
fth ray presses objects and tools into the palm.
This is caused by the additional motion provided
by its carpal-metacarpal (CMC) joint, which can
move forward 25 degrees. Stabilization is also
added by the hypothenar muscles, which augment
the exion of the rst phalanx of the small nger.
In addition, the small ngers abduction capabilities signicantly enhance span grasp. Tubiana
et al [11] believe the fth nger, with its metacarpal,
has the greatest functional value after the thumb.
Digital loss
For the most part single digit amputation, with
the exception of the thumb, does not result in the
loss of essential hand function. Brown [18] studied
183 surgeons who suered partial or total digital
amputations. Only four surgeons were unable to
continue operating following their injuries. Most

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S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

surprising was the nding that 15 surgeons who

had experienced thumb amputations through the
metacarpal or MP joint level were able to continue
operating with only minimal adaptation in their
surgical practice. Brown [18] concluded that the
motivation of the patient is more important than
the actual number of retained digits when attempting to predict functional outcome for digital
amputation. Of note, none of these surgeons had
to perform repetitive strenuous activity with the
hand and grip strength presumably was not a
major issue.
Unlike single-digit amputation, the amputation
of several digits still remains a challenging problem. Unfortunately, in the mutilated hand, multiple digital losses are the norm, because severely
crushed and avulsed digits preclude replantation.
Preservation of the thumb and a single digit allows
for some prehensile grasp, but for optimal function the reconstruction of an additional digit is
recommended [24,5860]. The preservation or
reconstruction of the thumb and two digits allows
for the possibility of chuck pinch, which is stronger
than subterminal pinch. The use of a third digit
confers lateral stability in power pinch. A third
digit also allows the patient to perform hook grip
and power grasp. Span grasp is now possible
because functional palmar space is increased
allowing for grasp of larger objects [24,5860].
Wei and Colony [24] have found it preferable to
place toes next to remaining mobile ngers or in
the interval between them. They believe the adjacent digits contribute to cosmesis, help coordinate
movement, and smooth oppositional contact.
In injuries where there is loss of all ngers but
sparing of the thumb, reconstructive goals should
attempt to maintain useful thumb web space and
an opposable ulnar post of adequate length. Additional digits may be created with microvascular toe
transfer [24,5962]. Other options include the
transfer of remaining functional digits to more
useful positions. Transferring salvageable digits
to the ulnar side of the hand maintains the width
of the palm, and allows for power grasp and
the incorporation of pinch [21,22,24]. The radial
placement of reconstructed digits is more cosmetically pleasing but fails to take advantage of the
added power provided by intact hypothenar musculature and the motion provided by the fth
CMC joint. In cases where there has been loss of
all digits including the thumb, microvascular
reconstruction of the thumb is required with the
additional creation of a stable ulnar post. The previous practice of constructing a cleft hand has been

shown to provide little benet for hand function. It

often has no eective prehension or grasp and does
not adequately compare with the results obtainable with microsurgical reconstruction [24,5962].

The biomechanical impact of fusion

There are several instances where the severity of
the trauma precludes any anatomic restoration of
the joint surface. These situations may require
fusion. Unfortunately, change in a single joint has
implications on the balance of the entire digit, and
the biomechanics of the hand. How do fusions
impact overall hand function?
Finger fusion
Of all fusions, DIP fusions are well tolerated
and probably impart the least detriment to hand
function. Fifteen percent of intrinsic digital exion
occurs at the DIP joint but the DIP joint contributes only 3% to the overall exion arc of the nger
[63]. Recent mechanical testing has shown that
after simulated DIP fusion of the index and middle
nger, there is a 20% to 25% reduction in grip
strength when compared with prefusion values.
The decrease in grip strength may be secondary
to the limited excursion of the profundus tendon
following fusion; this can create a quadriga eect.
It has been suggested that fusion in a more exed
position creates additional slack in the profundus
tendon, decreasing the loss of grip strength; however, this has not been shown clinically [64]. For
most individuals, with the exception of musicians,
arthrodesis is preferred over arthroplasty at the
DIP level.
The PIP joint produces 85% of intrinsic digital
exion and contributes 20% to the overall arc of
nger motion. Littler and Thompson [65] described this joint as the functional locus of nger function. PIP joint impairment can adversely
aect the entire hand; however, a full range of PIP
joint motion is not essential for hand function. An
arc extending from 45 to 90 degrees can provide
relatively normal function [66,108]. In addition,
mild exor contractures at the PIP level can be
compensated for through hyperextension of the
MP joint. This allows the nger to move out of
the plane of the palm when attempting to lay the
hand at or when placing objects into the palm.
A PIP fusion is often well tolerated in the index
nger because the indexs relatively independent
profundus function does not impose a signicant
quadriga eect on the other ngers during power

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

grasp. PIP fusion of the long nger, however, has

been shown to decrease the excursion of all profundus tendons, reducing grip strength. PIP fusion
restricts profundus excursion to a greater extent
than DIP or MP fusion [47,67,68]. In a study by
Lista et al [67], a signicant decrease in grip
strength occurred when the PIP joints of the index
and small nger were xed at less than 45 degrees
and when the long and the ring were fused in a
position of less than 60 degrees of exion. If both
MP and PIP joints are injured, salvage of the
MP joint through arthroplasty or other measures
is preferred over PIP joint arthroplasty. Grip
strength is decreased because of a quadriga eect,
but prehension can be maintained as long as the
thumb or border digit is capable of opposition. It
is important to remember that two consecutive
fusions increase stress at the next proximal joint,
because of an increase in the lever arm working
across the joint. This accelerates the degeneration
of adjacent joints if they are also injured.
Delayed arthroplasty of the PIP joints in cases
of trauma maintains motion and improves grip
strength [69]. Classic teaching has suggested that
index PIP joint arthrodesis be performed instead
of silicone arthroplasty, to provide stability for
key pinch. Surface replacement arthroplasty, however, may provide adequate stability for index
nger PIP arthroplasty. PIP stability has been preserved following surface replacement arthroplasty
with loads up to 22 N in experimental cases where
there was preservation of 50% of the index collateral ligaments [70].
The MP joints probably represent the most
important joint for hand function. They contribute 77% of the total arc of nger exion [63,
65,66,71,72]. Unlike the giglymoid IP joint, which
functions like a sloppy hinge joint, the condyloid
MCP joint is diarthrodial, allowing for exionextension, abduction-adduction, and some rotation [71,7375]. Most prehension grips require
that the digits extend and abduct at the MP joint
[74,76]. Precision pinch requires exion, rotation,
and ulnar deviation at the MP joint [73,74]. During
pinch the radial intrinsics and the collateral ligament to the index must resist the stress applied
by the thumb. According to the American Medical
Associations Guide to the Evaluation of Permanent Impairment, fusion of the MP joint results
in a 45% impairment of the involved nger [77].
Some have suggested that a single sti MP joint
can impair the entire hands function [78]. A full
range of motion, however, is not required for hand
function. Most activities of daily living require

25

only 50% of normal joint motion [73,79,80]. Studies have shown that obtaining 35 degrees of
motion at the MP is satisfactory if the arc of
motion is within the functional range and the
joint is stable [73]. Many rheumatoid patients
who have had PIP and DIP fusions maintain a
useful hand through the preservation of MP
motion. Previously, MCP arthrodesis was recommended for border digits in heavy laborers; however, these indications may be reconsidered with
the availability of new surface replacement arthroplasty [70,80].
Wrist fusion
Although less common than nger fusion,
immediate limited wrist fusion or total wrist fusion
may be necessary following penetrating ballistic
trauma, punch presstype injuries, or in cases of
gross carpal instability. A stable wrist is necessary
for power grasp. In addition, a stable wrist prevents the dissipation of nger exion and extension forces as tendons pass over the carpus.
What are the requirements for a functional wrist
and what eect does fusion have on wrist and hand
function?
The requirements for functional wrist motion
have been debated. Palmer et al [81] found that
the normal wrist had an average exion-extension
arc of 133 degrees, but only 5 degrees of exion
and 30 degrees of extension were needed for most
activity. Brumeld and Champoux [82] found that
10 degrees of exion and 35 degrees of extension
allowed one to complete the activities of daily living. Ryu et al [83], however, found in 40 normal
patients that most activities of daily living could
be accomplished with 40 degrees of exion, 40
degrees of extension, 10 degrees of radial deviation, and 30 degrees of ulnar deviation.
Limited carpal fusions consist of intercarpal
fusions and radiocarpal fusions (Fig. 12). Mechanical studies by Meyerdierks et al [84] show that
fusions that cross the radiocarpal joint produce
the greatest loss of motion. On average radiolunate, radioscapholunate, and radioscaphoid fusions decrease the exion extension arc by 55%.
Recent studies have suggested that removal of
the distal pole of the scaphoid in radiocarpal
fusions unlocks the capitate, allowing unhindered
midcarpal motion. In the laboratory setting this
has produced exion extension arcs that are equivalent to normal wrist motion [85]. Fusions that
cross the midcarpal joint result in the next largest
loss of wrist motion. Scaphocapitolunate and

26

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

Fig. 12. Diagram depicts the multiple sites for limited wrist fusions. (1) Four corner fusion or midcarpal fusion.
(2) Scaphotrapezialtrapezoid (STT) fusion. (3) Radioscapholunate fusion (radiocarpal fusion). (4) Scaphocapitate (SC)
fusion. (5) Lunotriquetral (LT) fusion. Fusions involving the radiocarpal joint result in the greatest loss of motion.
Fusions involving the same carpal row result in a 12% to 15% loss of motion.

capitolunate fusion can produce a 35% loss of the

exion and extension arc and up to a 31% loss
of radial and ulnar deviation. Scaphotrapezialtrapezoid fusion produces a 23% decrease in the
exion extension arc and 31% decrease in radial
and ulnar deviation, whereas scaphocapitate
fusion results in a 19% loss in the exion extension
arc and a 19% loss in radial and ulnar deviation.
Inclusion of the lunate within partial wrist fusions
was found to nearly double the resultant loss of
wrist motion when compared with fusions that
did not include the lunate [84]. Fusion within the
same carpal row tends to have a minimal eect
on overall wrist motion, with average loss of only
12% of the exion and extension arc.
The choice for total wrist fusion must be carefully contemplated. Removal of all wrist motion
results in the loss of the benecial eect of tenodesis for any subsequent tendon transfer. In addition, wrist dorsiexion is important for pushing
o, rising from a chair, and power grasp. In those
cases where there is substantial carpal loss, however, fusion may be the only option.
Wrist fusion can have a negative impact on MP
motion and thumb motion presumably because of
extensor adhesion [86]. A 25% decrease in grip
strength may be seen [86,87]. Strength with key
pinch, subterminal pinch, and directional grip are
better maintained at approximately 85% of the
normal side. Maximum preservation of power grip
is found to occur in 15 degrees of extension and
15% of ulnar deviation [88]. Weiss et al [89] found
that patients believed they were able to accomplish

85% of the activities of daily living following total

wrist fusion. Patients were least able to use a
screwdriver and perform perineal care. Overall,
skills that presented the most diculty were those
that required signicant wrist exion in a small
space, where compensatory movements by the
shoulder and elbow are eliminated.
In severely mutilating trauma, the preservation
of wrist mobility imparts some function to a forearm stump with the addition of prosthesis. Modern prosthetic techniques allow the incorporation
of the prosthesis to the wrist so that proximal
straps and attachment to the elbow are unnecessary. Preservation of wrist motion also eliminates
the need to incorporate a wrist articulation into
the prosthetic unit [6,17,90]. In addition, preservation of the distal radio-ulnar joint (DRUJ) further
improves function, because 50% of forearm rotation can be transferred into the prosthesis [91].

Tendon requirements
Tendon injuries are present, in some aspect, in
all cases of mutilating hand trauma. Tendons
may be divided, avulsed, or have large segmental
gaps that prohibit immediate repair. It is important to understand how tendon loss aects hand
function.
Extensor tendons
Multiple authors have pointed to the diculties
in obtaining excellent results with extensor tendon

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

injuries [9294]. The supercial position of the

extensor tendons, their complex architecture, and
paucity of surrounding subcutaneous tissue often
result in postoperative adhesions, which limit exion and produce extensor lags [94,111]. It has been
shown that injuries in the distal zones (1 through 5)
result in poorer outcomes and greater postoperative extension decits. Extensor tendon injuries
also carry a signicantly worse prognosis when
associated with underlying fractures [19,94].
The extensor mechanism has less excursion
than the exor system [95]. In addition, it has less
ability to compensate for signicant shortening
because of the interconnections between the intrinsic and extrinsic mechanisms. Extensor tendon
excursion in the region of the PIP joint is only
between 2 and 5 mm. There is little margin for
adherence or shortening if a reasonable result is
expected [95,96]. If signicant shortening takes
place following repair and the lateral bands and
oblique retinacular ligament are intact, one can
opt to leave the central extensor mechanism unrepaired. This may avoid exion loss, without producing a PIP or DIP extension lag. Loss of long
extensor function can destabilize the MP joint,
however, resulting in a loss of active nger abduction-adduction [97]. Further biomechanical
studies are required to determine the absolute
requirements for functional nger extension.
Maximizing intrinsic function helps in the preservation of full nger extension. Intrinsic function
can be compromised after metacarpal fractures.
Metacarpal shortening or fracture angulation
beyond 30 degrees can result in a shortening of
intrinsic muscle ber length [98]. Muscle ber
length determines the potential excursion of the
intrinsic tendon [31]. With metacarpal malreduction or shortening, potential excursion force
is wasted as slack in the muscle. Starting muscle
tension is also decreased. Both of these factors
decrease intrinsic tendon excursion and joint
motion [98,99]. This loss of intrinsic function
emphases the need for preservation of metacarpal
length and the anatomic reductions of fractures in
cases of signicant hand trauma.
Extensor tendon injuries proximal to the junctura produce less postoperative decits. Quaba
et al [100] examined long-term function in patients
who had lost nger extensors in zones 6 and 7.
In the nine patients studied, no attempt was made
to reconstruct the extensor tendons. Soft tissue
coverage alone was provided to the dorsum of
the hand. In long-term follow-up, there was a
26% decrease in total active nger motion, most

27

evident at the MP joint. DIP and PIP extension

were preserved because of intact intrinsic function.
Active motion at the MP joint was only 60% of
normal. Surprisingly, patients reported a 90% satisfaction rate with hand function. Diculty was
noted with tying knots and unscrewing lids. All
patients did maintain the extension of their thumb
and wrist extensors. This emphasizes the importance of thumb abduction and extension for prehensile function when MP motion is limited. The
ability to move the thumb out of the palm allows
for the accommodation and prehension of objects
even with a moderate digital exion stance. The
loss of the central extensors decreases power grip
by approximately 30%, whereas severance of wrist
extensors results in a 50% reduction in grip
strength [97,100].
Flexor tendons
Loss of profundus function prevents subterminal and terminal pinch, unless the DIP joint is
fused. If the profundus tendon becomes adherent
to the remaining sublimis tendon or fracture callus
it may tether the profundus tendons of adjacent
uninjured ngers, preventing full digitopalmar
grip [14,101]. Classically this quadriga eect
applies only to the long through small ngers,
because of their common muscle belly. The quadriga eect can also extend to the index nger, however, because heavy synovium at the level of the
carpal tunnel, termed the bromembranous retinaculum, can link the index profundus tendon to the
other three [102].
Power grip and forceful pinch are still possible
with supercialis loss. Loss of the supercialis with
preservation of the profundus tendon may result
in hyperextension of the PIP joint in supple individuals. This phenomenon is called recurvatum. In
exaggerated cases, this may produce delayed nger
exion. Patients may have to help the involved nger initiate PIP exion with the adjacent digits
before active exion can ensue. Recurvatum can
be avoided by leaving the portion of the supercialis distal to the chiasm [14]. With loss of both profundus and supercialis tendons, exion of the MP
joint to 45 degrees may be possible if intrinsic function is intact.
Retraction of the profundus tendon, following
more proximal amputations, may result in shortening and contracture of the corresponding lumbrical. During exion, contraction of the profundus
muscle belly places stretch on the shortened lumbrical, which results in paradoxical extension of

28

S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

the PIP joint. This is termed the lumbrical plus

deformity. This deformity can be oset by dividing the lumbrical or suturing the profundus tendon to the exor sheath in a relaxed position
[14,110].
With multiple digital amputations, retraction
of the exor mechanism can lead to lumbrical
migration into the carpal tunnel. Proximal lumbrical migration may then lead to compression of the
median nerve and development of carpal tunnel
syndrome [6,103]. These patients may not present
with classic digital paresthesias if there has been
signicant digital soft tissue loss. Patients may
instead complain of generalized pain within the
wrist and palm, which may be exacerbated by the
standard provocative maneuvers. Carpal tunnel
release should be pursued in such instances.
During any exor tendon surgery it is important to preserve the A2 and A4 pulleys [104107].
If either is divided the exor tendon moves away
from the phalanx, leading to bowstringing. The
A2 and A4 pulleys are located over the bony shafts
of the proximal and middle phalanx. This anatomic conguration prevents the bowstringing
that occurs with joint exion and the bowstringing
that can occur over the phalanx shaft. Palmer plate
pulleys (A1, A3, and A5) have a variable relationship to the joint axis depending on joint position,
and restrain only the joint-type of bow stringing.
They also shorten up to 50% with nger exion,
which reduces their eciency. Cruciate pulleys
vary the most in their anatomic position and have
little eect on restraining bowstringing [105,107].
Bowstringing increases the exion moment arm
at the PIP and MP joints. A longer moment arm
allows the exor mechanism to overcome the
extension forces, resulting in a exion deformity.
A longer moment arm also means the tendon must
move through a longer distance to obtain the
same motion at the joint, decreasing mechanical
eciency. As in the quadriga eect, grip strength
is decreased because full excursion is now
limited [107].
Summary
Mutilating hand trauma presents the surgeon
with many reconstructive challenges. This article
establishes some biomechanical guidelines to help
the surgeon evaluate the hand trauma patient.
Through a basic understanding of hand biomechanics, the surgeon may access more accurately
what motion and function can best be salvaged.
By understanding how amputation, fusion, and

tendon loss impact on postoperative hand motion,

the surgeon can better focus his or her reconstructive eorts to achieve the highest functional outcome for the patient.
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