BIOMECHANICS OF THE DIGIT

BY MARK H. GONZALEZ, MD, MEng, VIVEK MOHAN, BS, BASSEM ELHASSAN, MD, AND
FARID AMIROUCHE, PHD

Understanding the physical basis of hand function and deformity requires a

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

T
he human digit is a complex mechanism that
has an amazing array of functions. Mechani-
cally, 3 bodies articulating in series inherently
are unstable. Bony and ligamentous architecture in
concert with force couples of several tendon systems
impart stability to the digit while permitting fine
control. The joint flexion-excursion is introduced
through the basic principle of forces and joint kine-
matics. The decoupling of the force is expressed as
function of the moment arm, its direction and mag-
nitude in the presence of a constraining element called
the pulley.
To understand the function of the digit, an under-
standing of basic Newtonian mechanics, bone liga-
ment and tendon anatomy, and physiology of tendon
and cartilage is necessary. To this end, these topics are
reviewed and then synthesized so that the reader may
develop a more complete understanding of the func-
From the Department of Orthopedics, Department of Mechanical
Engineering, University of Illinois, Chicago, IL; and the Department
of Orthopedic Surgery, Stroger Hospital of Cook County, Chicago, IL.
Address reprint requests to Mark H. Gonzalez, MD, Chairman of
Orthopedic Surgery, Stroger Hospital of Cook County, 835 South
Wolcott, Chicago, IL 60612. E-mail: hand15@aol.com
Copyright 2005 by the American Society for Surgery of the Hand
1531-0914/05/0501-0009$30.00/0
doi:10.1016/j.jassh.2004.11.009
tion of the digit. The biomechanical principles are
applied to pathologic conditions that cause digital
dysfunction and deformity.
BASIC CONCEPTS OF MECHANICS
I saac Newton mathematically described the concept
of inertia force as body mass multiplied by the
center mass acceleration with the resulting units be-
ing 1 N or 1 kg m/s2. The inertia force is balanced
by the resultant external force applied to the mass
center and is represented by a vector quantity de-
scribed with respect to a fixed inertia frame. Thus,
force must be represented by a point of application, a
magnitude, and a direction. The application of a force,
if it causes movement, results in acceleration of the
body mass in a particular direction. When there are
several external forces acting on a body mass, their
resultant force must be computed, taking into con-
sideration the resulting magnitude and direction of
the force. It should be noted that only the components
of the force along the direction of motion are used
when applying Newtons Law (F ! ma). When a body
is at rest, the summation of all external forces acting
at any point on the body must be 0. This is the law of
equilibrium, also known as the first law of mechanics.
Newtons law led to a number of discoveries and
mathematic tools that become standard procedures in

48 JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND ! VOL. 5, NO. 1, FEBRUARY 2005

understanding motion. Energy is one of these dynamic
tools that measures half of the product of mass and
velocity squared and is a scalar quantity that is not
associated with a direction as in vectors.
Stress is described mathematically as force per unit
area. When a force is applied perpendicular to a
surface, it represents normal stress. When a force is
applied parallel to a surface, it is called shear stress.
Tensile stress exists when the force applied pulls the
object, such as a tendon, in opposing directions. For
example, in the hand, when a force is applied to a
muscle causing it to contract, the tensile force is
transmitted to the tendon.
The tendon bears this force along its segment and
it will be pulled with an equal tensile force by both
the contracting muscle and the bone to which it
inserts.
The shear stresses are mostly the result of resistance
to friction. A frictional force occurs between any 2
surfaces that are in contact and glide past each other.
It either could be static, when the 2 communicating
surfaces are stationary, or dynamic, when the surfaces
are in motion. The friction between 2 bodies is de-
pendent on the nature of the surfaces (rough v
smooth), and the normal force acting on the surfaces.
When a thin layer of fluid separates 2 moving surfaces
the resulting force is not termed friction, but rather
drag, which results from the effect of the surface fluid
shear. In a human joint, this layer of fluid creates a low
frictional interface between the cartilaginous surfaces.1
Muscles extrinsic to the hand (long flexors and
extensors) and muscles intrinsic to the hand act on the
joints of the digit through tendons. The moment arm,
or lever arm, is the measurement of the perpendicular
distance from the joint axis to the force that acts on
the joint. The cross-product of a force and its moment
arm about an axis is termed the moment about the axis
and is defined as follows:
M (moment) ! F (force) " L (moment arm).
(1)
The moment is a vector quantity with a direction as
defined by the right hand rule. When a body is at rest
the summation of all the moments about any point on
the body must be 0. The tendons in the digit traverse
each joint very close to the center of rotation, thereby
producing a short lever arm for the force to act on the
joint.1
DIGIT BIOMECHANICS ! GONZALEZ ET AL 49
Torque is the product of force and moment arm. It
is a scalar quantity as opposed to the moment, which
is a vector.
The efficiency of a lever can be measured through
the ratio of the moment arm of the force to the
moment arm of the load, called mechanical advantage.
The larger the lever arm, the proportionately smaller
force that is necessary to achieve the same torque. The
disadvantage of increasing a lever arm is a requisite
increase in path of excursion necessary to affect an
equivalent degree of rotation. The pulley system
maintains the flexor tendons close to the center of
rotation at the distal interphalangeal (DIP) joint,
proximal interphalangeal (PIP) joint, and the meta-
carpophalangeal joint (MCP). This minimizes the ten-
don excursion required to produce joint flexion.1 The
geometry of tendon function can be described using
simple trigonometric functions. For small angles a
relationship between the angle, the radius, and the arc
length it forms are related by the following equation:
s (arc length) ! # (angle) r (radius). (2)
Which can be expressed further as:
# (angle) ! s (tendon excursion) r (moment arm).
(3)
In this equation, the angle of finger motion at a
particular joint is a ratio of the tendons excursion over
moment arm. A flexor tendon is maintained close to
the axis of rotation of the digit joints by the pul-
leys.1-3
The amount of energy expended when a force acts
on a body causing the body to move is termed work. In
fact, the work is related directly to the changes to the
kinetic energy and similar to the energy function, it is
a scalar quantity. If the force remains constant during
a displacement, it is calculated by the product of force
and excursion distance associated with the force from
one location to another.
MUSCLE PHYSIOLOGY
M uscles are composed of individual microscopic
units called sarcomeres that are aligned macro-
scopically in parallel and in series. The length tension
curves of a sarcomere have been investigated in passive
stretch and in active contraction. Each can be shown
by a graph of muscle tension versus muscle length
(Figure 1). An important detail of Figure 1 is the
50 DIGIT BIOMECHANICS ! GONZALEZ ET AL
FIGURE 1. Graph showing passive stretch.
definition of muscle resting length, which is the
length of the muscle when the entire limb is at rest.
In the case of the hand and wrist, in a resting position
the wrist is in mild extension and the joints of the
digit are in midflexion. If the muscle tendon were to
be severed, the muscle length would shorten by elastic
recoil below its normal resting length. As shown in
Figure 1, during passive stretch, the tension is mini-
mal below and near the resting length of the muscle.1
As the muscle is stretched beyond the resting length,
the tension increases sharply (Figure 2). Figure 2, first
developed by Elftman, shows a different view of mus-
cle performance that shows 2 important features of
muscle fibers.1 First, the highest tension that a muscle
FIGURE 2. Graph showing active contraction.
FIGURE 3. Graph showing the Blix curve.
can produce is achieved at its resting length (Figure 2,
A). Second, the fibers resting length is approximately
equal to the change in the fibers length from com-
plete muscle contraction to complete muscle stretch
(Figure 2, B). This distance (Figure 2, B) from max-
imum stretch to maximum contraction is called the
potential excursion of a muscle.
When Figures 1 and 2 are placed together, they
form what is known as the Blix curve (Figure 3), which
correctly summarizes muscle physiology. Two as-
sumptions are fundamental in the Blix curve: the
motor nerves are intact and each muscle has its an-
tagonist muscle functioning normally to facilitate pas-
sive stretch.
Each muscle in the hand has an antagonist muscle
opposing its actions. Brand1 modified the Blix curve
to include the elastic recoil effect of the antagonist
muscle, assuming it was of equal strength and ampli-
tude. The opposing muscles curve would lie below
the x-axis and its tension would reach 0 as its length
increased, approaching the original muscles resting
length. This added effect would cause the Blix curve
of the original muscle to show a sharper increase in
tension with minimal expansion at short lengths,
displaying a squarer curve. This muscle now has a
slightly diminished potential excursion but has a
wider range in which to achieve peak tension. This
system of opposing muscles is very important in joint
stabilization in which there is no overall movement
owing to a careful balance of tension.
Because a muscles fiber length, the number of
sarcomeres placed in series from end to end, is pro-

portional to its potential excursion, it is critical that
the fiber length is measured accurately. The most
accurate method is to measure the most distal and
most proximal fibers from their respective origins to
their insertions. This will allow the fibers to remain in
parallel, which is their natural physiologic alignment.
The maximum strength, or tension, that a muscle
can generate is proportional to the number of sarco-
meres in parallel, which is its physiologic cross-sec-
tional area. Many different methods have been con-
ceived in the past to estimate a muscles strength.
Unfortunately, it is difficult to accurately measure
physiologic cross-sectional area once the muscle has
been detached from the cadaver. Brand1 was able to
describe a more accurate way of estimating muscle
strength by measuring the mass of the muscle. From
the muscles mass, its volume can be calculated and,
along with its known fiber length, the physiologic
cross-sectional area can be determined. Thus, using
these 3 measurable variables, the strength of a partic-
ular muscle can be estimated. Because work is pro-
portional to the bulk, or volume, of the muscle, work
can be calculated by multiplying tension by excursion.
Brand1 went on to develop the concepts of mass
fraction, the ratio of muscle volume to the volume of
the hand, and tension fraction, the ratio of individual
muscle force potential to the combined muscle force
potential within the hand.
The force generated by a muscle is proportional to
the cross-section and the work of a muscle is propor-
tional to its volume. For example, the adductor of the
thumb generates a significant force in pinch but does
much less work than a long flexor because of limited
excursion and a much smaller volume.
JOINT ANATOMY
T here are essentially 6 types of synovial joints
within the human body: plane, hinge, pivot,
ellipsoidal, saddle, and ball-and-socket joints.2 An
example of each joint type appears within the hand
and wrist. Plane joints have flat articular surfaces,
allow simple sliding movement, and are limited in
movement by the articular capsule. Plane joints occur
in the intercarpal, intermetacarpal, and carpometacar-
pal joints within the hand. Hinge joints allow move-
ment around 1 axis at right angles to the bones for
flexion and extension only, and occur in the interpha-
DIGIT BIOMECHANICS ! GONZALEZ ET AL 51
langeal joints of the digits. Pivot joints are created
when a central bony pivot is placed into a bony ring,
allowing for a longitudinal rotational axis. The supe-
rior and inferior radioulnar joints of the wrist are pivot
joints. Ellipsoidal joints have reciprocal elliptic con-
vex and concave articular surfaces that allow move-
ment in 2 axes, flexion and extension and abduction
and adduction, and occur in the radiocarpal joint of
the wrist and metacarpophalangeal joints in the hand.
A saddle joint, which occurs only in the carpometa-
carpal joint of the thumb, allows for movement in
3 different axes: flexion and extension, abduction
and adduction, and circumduction. Axial rotation is
not possible in ellipsoidal or saddle joints. Ball-
and-socket joints, which are present in the shoulder
and hip joints, are formed by a sphere-shaped head
inserted into a cup-shaped cavity that allows for
movement in flexion and extension, abduction and
adduction, medial and lateral (axial) rotation, and
circumduction. In the digit, the interphalangeal
joints are hinge joints and the metacarpophalangeal
joints are ellipsoidal.
The instantaneous center of rotation of a rigid body
is the point about which the body rotates at a given
instant. This can be calculated by selecting 2 points
on the rotating body and drawing a line for each point
that follows its progression in space. A perpendicular
line is drawn to each of the lines and the point where
the 2 lines intersect is the center of rotation. When
the rotation of a 3-dimensional body is limited to 1
plane with a fixed center of rotation the body rotates
through an axis. A joint with this type of prescribed
motion is termed a revolute joint or a hinge.
The PIP and DIP joints can be modeled as hinge
joints. The axis of the joint lies in the center of the
convex head of the more proximal bone. The MCP
joint has 2 main axes of movement: flexion-extension
and abduction-adduction. A third relatively minor
rotational axis is functional when the finger is in
extension. A key feature to MCP joint mechanics is
the CAM-shaped head at the proximal portion of the
joint. In extension, the collateral ligaments around the
MCP joint are mildly lax, allowing for some abduc-
tion and adduction at the MCP joint. Because the
proximal head of the MCP is CAM-shaped, the liga-
ments around it become taut when the MCP joint is
flexed, limiting further abduction or adduction. Thus,
a deviating force cannot be easily dispelled during
52 DIGIT BIOMECHANICS ! GONZALEZ ET AL
MCP flexion and can damage the ligaments and bone
at the MCP joint.
As opposed to the more complex MCP joint, the
DIP and PIP joints can be modeled as simple hinges
with only 1 axis for flexion and extension. In each
joint the proximal surface has an intercondylar groove
that articulates with a projection, or trochlea, from the
distal joint surface. The trochlea is perpendicular to
the rotational axis, providing the joint with stability
in medial, lateral, and rotational directions when the
joint is flexed or extended.
Friction or drag in normal joints is close to 0
because the coefficients of friction are so low. The
reason for this low coefficient of friction of human
joints is the use of a system of lubrication.
The characteristics of the synovial fluid make it an
ideal fluid for hydrodynamic lubrication during joint
motion. The synovial fluid is a viscous, slow-moving
fluid. Joint fluid is thixotropic, which means the fluid
resists a change in shape, giving it a tendency to
remain between the joint surfaces. Synovial fluid is a
non-Newtonian fluid: compressive loading will in-
crease the viscosity. This property is vital to the
hydrodynamic lubrication of joint surfaces, allowing
the joint to move over the fluid instead of pushing the
fluid away.1
Lubrication of the human diarthrodial joint is
thought to occur through 2 primary mechanisms:
hydrodynamic and boundary lubrication. Hydrody-
namic lubrication occurs between 2 moving bodies.
Hydrodynamic lubrication requires 2 slightly noncon-
gruent joint surfaces with different radii of curvature:
a convex articular head and a concave socket with a
larger radius. This incongruity creates a wedge-shaped
cavity. Synovial fluid fills this wedge-shaped cavity.
As the joint glides, the bone and cartilage move faster
than the viscous fluid within the joint cavity, which
results in the separation of the 2 surfaces by the
trapped fluid.1 The fluid film, which is thicker than
the average surface roughness of the surfaces, separates
the 2 surfaces. In this scenario there is no actual
contact between the surfaces, making frictional wear
virtually 0. There are different mechanisms that are
thought to act to produce hydrodynamic lubrication.
When 2 joint surfaces are forced toward one another
during loading, joint fluid between the surfaces is
compressed. This compressed film of fluid is termed a
squeeze film, and actually can support the joint surfaces
instantaneously. Deformation of loaded cartilage
tends to trap synovial fluid.
Loaded cartilage may release synovial fluid in a
process termed weeping lubrication. Boosted lubrica-
tion occurs during squeeze film conditions when
water partially is forced back into the cartilage,
leaving a more concentrated (and more viscous)
pool of hyalouronic acid and protein complex
within the joint.
When a joint is loaded statically or at rest, a thin
film of lubricating fluid lines the joint surfaces. This
is termed boundary lubrication, and prevents excessive
bearing friction and wear.
Finally, a majority of cartilage by weight is water.
Cartilage is relatively impermeable to fluid and load-
ing of cartilage increases interstitial pressure while
unloading the collagen proteoglycan matrix.1
TENDON LUBRICATION
F lexor tendons lie in synovial sheaths that secrete
fluid to provide simple boundary lubrication. The
synovial sheaths have a double mesothelial layer of
cells. The visceral layer envelopes the tendon and the
parietal layer in contact with the surrounding tissues.
The secreted fluid minimizes the drag of the flexor
tendons.
THE FLEXOR TENDONS
T he primary flexors of the digit are the flexor
digitorum profundus (FDP) and the flexor digi-
torum superficialis (FDS) tendons. These muscles
originate in the forearm and their tendons insert in
the middle and distal phalanges, respectively.
The FDS tendon enters the hand beneath the flexor
retinaculum and passes through the carpal tunnel
palmar to the FDP. The tendons then diverge to their
individual fingers. At the level of the MCP joint, the
FDS tendon enters the digital flexor sheath along with
the FDP tendon. Once within the sheath, the FDS
tendon starts to flatten and at the proximal third of
the proximal phalanx it splits and passes around the
FDP tendon to reunite deep to the FDP tendon. Half
of the FDS tendon fibers decussate at the chiasma of
Camper and the remaining fibers continue distally on
the same side. The FDS tendon distal to the chiasma
attaches to the volar crest of the base of the middle

phalanx and extends distally along the metaphysic and
diaphysis of the middle phalanx.3
After traversing the flexor retinaculum, the FDP
tendons pass through the carpal tunnel at the deepest
level and go to their respective digits. The FDP
tendons enter the flexor sheath at the level of the MCP
joints deep to the FDS tendon. The FDP tendons shift
to a palmar position with respect to the FDS tendon as
the FDS splits to pass deep and encircle the FDP
tendon. This split is termed the decussation. The FDS
continues dorsally to its insertion at the volar base of
the middle phalanx. At the level of the PIP joint, the
FDP is palmar to the FDS tendon and continues
distally to the level of the DIP joint to insert broadly
onto the base of the proximal volar third of the distal
phalanx.
The FDP tendon passes approximately 5 mm from
the center of rotation of the DIP joint, 7.5 mm from
the center of the PIP joint, and 10 mm from the MCP
joint. The FDS tendon passes 7 mm from the center of
rotation of the PIP joint and 13 mm from the center
of rotation of the MCP joint.
In explaining the moments of the tendons acting on
the digital joints, Landsmeer termed the moment arm
a beam. To compare the relative moments of the ten-
dons at the joints, Landsmeer calculated a ratio of
extensor to flexor moments. An increased extensor
flexor moment ratio at 1 joint as compared with
another meant that there is an increased propensity for
extension at that joint.4
THE PULLEY SYSTEM
T he flexor sheath arises at the volar plate of the
MCP joint and ends at the proximal volar base of
the distal phalanx. The flexor sheath is comprised of 5
annular pulleys, thickened areas of arcing fibers, and 3
cruciate pulleys, thin flexible criss-crossing pulleys
interspaced between the annular pulleys. The palmar
aponeurosis pulley also has been shown to have pulley
function.5 The annular pulleys have been shown to be
biomechanically important in preventing tendon
bowstringing during digital flexion. The cruciate pul-
leys are significant because they supply the essential
flexibility to allow approximation of the annular pul-
leys while maintaining the reliability of the flexor
sheath during flexion.6,7 The A-2 and A-4 pulleys are
critical to the function of the pulley system.8 These
DIGIT BIOMECHANICS ! GONZALEZ ET AL 53
pulleys, although not at the joint itself, are important
because of their rigid attachment to bone. Loss of the
A-2 or A-4 pulleys will cause significant loss of digital
flexion. In the absence of an A-2 pulley an intact
palmar aponeurosis pulley will limit the degree of
bowstringing.
The pulleys maintain the flexor tendons close to the
center of rotation of the DIP, PIP, and MCP joints.
When a pulley is ruptured, the tendons fall away from
the joints, a phenomenon termed bowstringing. The
mechanical result is that the torque across the joint is
increased as the beam or lever arm is increased. With
an increased lever arm, likewise the radius is in-
creased, as shown in the previous equation:
s (arc length) ! # (angle) r (radius). (2)
It can be seen that this will increase the arc length
s for the tendon. This implies that an increased ex-
cursion is necessary to attain an equivalent degree of
flexion. Because the excursion is limited by muscle
physiology (Blix curve), pulley rupture will cause a
loss of flexion. Weakness results because the tendon
will be near terminal excursion in midflexion where
grasp is normally the strongest.9
THE EXTENSOR TENDON INTEROSSEI
AND LUMBRICALS
T he extensor muscles of the fingers have small
physiologic cross-sectional areas, and relatively
long fibers. These properties make the extensor mus-
cles optimally created for excursion and velocity but
not for force generation, having only a third of the
work capacity of the flexors.1 Yet they are the only
extensors for the digits. The extensor digitorum com-
munis (EDC) tendons of the index, middle, and ring
fingers insert into the extensor expansion on the dor-
sum of the 4 fingers.10,11 This attachment forms a
complex extensor mechanism. Inside the extensor ex-
pansion, the EDC tendon splits into a central slip and
2 lateral slips. The central slip attaches to the base of
the middle phalanx and the 2 lateral slips join with
the tendons of the intrinsic muscles to form the lateral
bands. The lateral bands continue distally and attach
to the base of the dorsum of the distal phalanx form-
ing the distal end of EDC tendon.12
Many studies have been performed to find the
numerous variants in the anatomy of extensor ten-
54 DIGIT BIOMECHANICS ! GONZALEZ ET AL
dons.10,11 The most common arrangement of the ex-
tensor system is a single extensor indices proprius
tendon to the index finger, a single EDC to the index
finger, a single EDC to the middle finger, a double
EDC to the ring finger, and a double extensor digi-
torum minimi (EDM) to the small finger. The exten-
sor indices proprius integrates with the extensor hood
and inserts ulnar to the EDC index tendon on the
dorsum of the middle and distal phalanges of the
index finger. The EDM inserts onto the dorsal base of
the distal phalanx of the small finger. In a few cadaver
dissections, the EDM was defective when the EDC
had a tendon inserting into the small finger as well.10
On the other hand, the EDM was well developed
when the EDC had no tendons attached to the small
finger. Interestingly, the EDC usually is considered as
1 muscle with 4 tendons because the extensor muscles
have an incomplete separation between their muscle
bellies within the forearm and even have tendinous
and fascial connections between their tendons on the
dorsal surface of the hand. These connections within
the extensor system are called the juncturae tendinum
and the intertendinous fascia.
The juncturae tendinum are slender connective tis-
sue strips extending between each EDC muscle and
the EDM, but rarely to the extensor indices proprius,
conferring greater independence to the index finger.12
Similar to the extensor tendon anatomy, the juncturae
tendinum have several anatomic configurations. These
bands also have multiple biomechanical functions in-
cluding dynamic MCP joint stabilizers. During digi-
tal flexion, the juncturae tendinum redistribute the
tensile forces imparted on the extensor system,
thereby dynamically stabilizing the digits against any
radial or ulnar deviating forces. The intertendinous
fascia arises between the tendon sheaths and is present
between all the extensor tendons. As a minor partic-
ipant along with the juncturae tendinum, the inter-
tendinous fascia works to prevent independent exten-
sion of the digits. The juncturae and intertendinous
fascia prevent extensor subluxation during MCP joint
flexion.
The interossei muscles have short fibers and long
tendons of insertion.13-15 These muscles are rela-
tively strong based on their cross-section, but have
a relatively meager excursion because of a short fiber
length. There are 4 dorsal interossei (DI) muscles
and 3 palmar interossei muscles innervated by the
ulnar nerve. Each DI muscle originates from adja-
cent metacarpals by 2 heads. Each DI muscle con-
sists of 2 bellies: a superficial and a deep belly. The
superficial belly originates from the midshaft of
adjoining metacarpals and inserts onto the base of
the proximal phalanx. The superficial bellys major
function is to abduct the proximal phalanx and has
no capability of directly extending the IP joints.
The deep belly has the same origin as the superficial
belly, but it continues distally to create the lateral
band of the dorsal aponeurosis in the 3 radial
fingers. The function of the deep belly is to abduct
and flex the proximal phalanges (at the MCP joint)
and to extend the 2 distal phalanges (at the DIP and
PIP joints) of each finger. The first dorsal interosse-
ous inserts directly onto the bone of the proximal
phalanx and the MCP joint capsule. The signifi-
cance of the first DI is primarily in its usefulness in
pinch, which is described later. The second and
third DI insert onto radial and ulnar sides of the
middle finger, respectively. There is no superficial
belly to the third dorsal interosseous muscle and
therefore it has no insertion to the proximal pha-
lanx. The deep belly of the third dorsal interosseous
muscle inserts into the lateral band, allowing for
flexion at the MCP joint and extension of the DIP
and PIP joints in the middle finger. The fourth DI
to the ring finger inserts on the ulnar side of the
finger. The small finger does not have a DI, but is
able to abduct with the use of the abductor digiti
minimi, which originates from the pisiform bone
and inserts into the lateral band of the small finger
and base of the proximal phalanx.
There are 3 palmar interossei muscles that arise
from the medial side of the second metacarpal and
the lateral sides of the fourth and fifth metacarpals
and insert onto the ulnar side of the index finger
and the radial sides of the ring and small fingers at
the base of the proximal phalanges and the extensor
expansion. Hence, their primary function is MCP
joint flexion and IP joint extension and secondary
finger adduction. The palmar interossei muscles are
more effective as DIP and PIP joint extensors than
the lumbricals, given their muscle fiber character-
istics.
There are 4 lumbrical muscles, all of which orig-
inate at the FDP tendons. The muscle fibers run up
to 90% of the total muscles length. This relatively

long fiber length implies that the lumbricals were
created for excursion and velocity. Because these
muscles have small pennation angles and small
cross-sectional areas, they also are well designed for
an even contractile force. The lumbrical muscles
originate from the radial side of the FDP tendons
and insert on the radial lateral bands of the digits at
the MCP joint. The 2 radial lumbricals are inner-
vated by the median nerve, whereas the 2 ulnar
lumbricals are innervated by the ulnar nerve. The
movement of the lumbrical muscles is restricted by
the fibrous attachments the muscles make with the
intermetacarpal ligaments and volar plates in the
palmar side on their way to the lateral bands.
Because they insert onto the lateral bands, their
contraction will result in extension of the IP joints.
Because the lumbricals will contract when the FDP
muscle contracts, the contraction of the lumbricals
will cause laxity in the FDP tendon distally, pre-
venting flexion of the IP joints. Because their in-
sertion is on the lateral bands, their contraction will
result in extension of the PIP and DIP joints and
flexion of the MCP joint. Therefore, when the hand
is reaching to grasp an object, the action of the
lumbricals will cause MCP flexion and IP joint
extension, allowing the fingers to surround the
object before the FDP fully contracts, causing flex-
ion of the DIP and PIP joints as well. As a minor
function, the lumbricals are radial deviators of the
MCP joints as well.1,12-14
The extensor hood consists of a central tendon
that splits over the proximal phalanx into 1 middle
and 2 lateral bands. The extensor hood is stabilized
over the MCP joint by the sagittal band. The
middle extensor band inserts onto the base of the
middle phalanx. The lateral extensor bands proceed
distally to join the lateral interosseous bands and
form the lateral bundles distal to the PIP joint. The
lateral bundles then unite distally as the terminal
tendon. The lateral tendons are connected by the
triangular ligament over the middle phalanx. The
wing tendon is composed of lateral and medial
interosseous components. The medial interosseous
component divides into dorsal and palmar compo-
nents that envelope the lateral and medial band of
the extensor tendon. The fibers of the lateral in-
terosseous component join the lateral extensor band
to form the lateral bundle.11
DIGIT BIOMECHANICS ! GONZALEZ ET AL 55
The excursion of the extensor tendon from full
flexion to full extension according to Zancolli19 is 24
mm, assuming that the tendons followed the convex-
ities of the joints (14 mm MCP, 6 mm PIP, 4 mm
DIP). However, the measured excursion is only 20
mm. Zancolli explains that the descent of the lateral
bands at the PIP joint saves approximately 4 mm of
excursion.19
ELECTROMYOGRAPHY
T he studies of Long et al13,14 and Brown examined
muscle activity during finger flexion. The FDP is
active in finger flexion when the DIP joint is flexed.
The FDS is active when the wrist is flexed and during
firm grasp. The EDC is active during all finger flexion.
The interossei is active during simultaneous MCP
flexion and PIP extension. The lumbrical muscle is
active during IP extension.
THE BIOMECHANICS OF DIGITAL MOTION
I n single-digit unloaded flexion the FDP tendon is
active whereas the FDS shows little or no activ-
ity.13,14 The long extensor tendon maintains a con-
stant activity. Although the FDP tendon does not
have an insertion on the middle or proximal phalan-
ges, the FDP tendon is able to flex these joints.
Flexion is initiated at the DIP joint by virtue of the
anatomic insertion of the flexor tendon volar to the
center of rotation of the DIP joint. As the DIP flexes,
the FDP now creates an angled path as it exits the A-4
pulley. This creates a normal force on the A-4 pulley
that is transmitted to the middle phalanx, creating a
flexion moment on the PIP joint. Similarly, the ten-
don creates a normal force on the A-2 pulley, creating
a flexion moment at the MCP joint.
There is coupling of the DIP and PIP joints as a
result of the 2 systems. The spiral oblique ligament
arises from the flexor sheath proximal to the PIP joint
and attaches to the terminal extensor tendon. Tension
is increased in the ligament by DIP flexion and PIP
extension. When the DIP joint flexes through the
action of the FDP tendon, increased tension in the
spiral oblique ligament is offset by coupled flexion of
the PIP joint. The second system that couples DIP
and PIP flexion is the extensor mechanism. The lateral
56 DIGIT BIOMECHANICS ! GONZALEZ ET AL
FIGURE 4. The moment arm of the flexor tendon at any specific joint assists resisting pinch forces but may require an additional
flexor tendon contribution to maintain finger balance.
bands and the central slip are cross-connected dorsally.
FDP flexion of the DIP joint creates increased tension
in the lateral bands with an instantaneous relative
laxity of the central slip. The increased tension in the
lateral bands resists further DIP flexion whereas the
laxity of the central slip permits PIP flexion. Once the
PIP flexes, tension in the central slip is restored. This
unloads the lateral bands further, permitting incre-
mental flexion at the DIP joint. As the PIP flexes the
lateral bands slip volarward. This further decreases the
extensor moment at the PIP joint. This couple creates
coordinated flexion between the 2 joints.
The FDS tendon is not recruited in simple digital
flexion but is active in power pinch. The difference in
moment arms of the FDP tendon at the PIP and DIP
joints is 5 mm, 10 mm PIP minus 5 mm DIP. During
pinch the moment arm of an external force is up to 20
mm greater at the PIP than at the DIP joint (by virtue
of the length of the middle phalanx, which acts as a
lever arm). The moment created by the FDP on the
DIP joint is large enough to counteract the externally
applied force on the tip of the finger, but not enough
for the larger moment on the PIP joint (Figure 4).
Here, the contracting FDS comes into play, which
adds a moment to the FDP moment across the PIP
joint and both together counteract the externally ap-
plied force to the tip of the finger. Without the FDS,
the PIP joint would tend to go into extension and the
DIP joint would tend to go into flexion. It is clear that
most of the unopposed flexion is provided by the FDP,
but is supported by the FDS when added force is
required. It has been pointed out by Landsmeer4 that
because the FDS passes closer to the center of rotation
of the PIP than the MCP, it has a larger moment
acting on the MCP joint. Thus, isolated FDS contrac-
ture leads to preferential MCP flexion relative to the
PIP joint. When the fingers are in equilibrium before
grasp the MCP is extended and the PIP joint is in
slight flexion. The FDP tendon is tensioned but the
FDS is not firing because the FDS would cause the

FIGURE 5. Swan-neck deformity of the finger.
MCP joint to go into relative flexion in relation to the
PIP. A contribution of the FDS generally is seen only
in firm grasp or when the wrist is in flexion.13,15,16
The difference in excursion between the FDS and
FDP tendons is less than 1 cm. Even though the
overall excursion difference is minimal, the FDP ten-
don crosses 3 joints in the digit, whereas the FDS joint
only crosses 2. At both the PIP and MCP joints the
FDP tendon lies closer to the center of rotation of the
joint. The earlier equation (s [excursion] ! "
[angle] r [radius]) shows that the necessary excursion
for a given angle is diminished for the FDP relative to
the FDS because r is decreased. In actuality, contrac-
ture of the FDS may have a pulley function as the
decussating bands of the FDS contract and draw the
FDP in close contact with the PIP joint.1
When the hand opens before grasp, the proximal
phalanges extend relative to the metacarpals and distal
phalanges. The extensor/flexor moment ratio of the
MCP joint is greater than the PIP joint. Thus, acti-
vation of the long extensor and flexors before grasp
will cause MCP extension and PIP flexion. Interosse-
ous activity is necessary to flex the MCP while main-
DIGIT BIOMECHANICS ! GONZALEZ ET AL 57
taining the PIP joint in relative extension. The defor-
mity of MCP extension and PIP flexion is termed a
claw hand deformity and is associated with interosseous
paralysis. It is discussed in the Claw Hand Deformity
section of the Clinical Application portion of this pa-
per.14,18,19
CLINICAL APPLICATION
Swan-Neck Deformity
Swan-neck deformity is an abnormal posture of the
finger in which the DIP joint is in flexion and the PIP
joint is in hyperextension (Figure 5). The deformity
most often is encountered in patients with rheumatoid
arthritis. In rheumatoid arthritis, synovitis of the PIP
joint damages the periarticular tissues including the
volar plate, which is the primary stabilizer against
hyperextension of the joint. Frequently, this is asso-
ciated with rupture of the FDS tendon, which dynam-
ically resists PIP hyperextension. Any deformity that
increases the extensor moment across the PIP joint
then can cause hyperextension. EDC tightness second-
ary to tendon subluxation at the MCP joint and MCP
58 DIGIT BIOMECHANICS ! GONZALEZ ET AL
FIGURE 6. Boutonniere deformity of the finger.
subluxation both cab lead to extrinsic EDC tightness.
As the PIP joint hyperextends, the lateral bands slip
dorsally. This is compounded by synovitis-induced
attenuation of the lateral retinaculum that normally
prevents dorsal subluxation of the lateral bands. As
the lateral bands slip dorsally, their distance from the
center of the PIP joint increases effectively, increasing
the extensor moment at the PIP joint. When flexion is
attempted the lateral bands no longer can slide over
the condyles. This further limits PIP joint flexion.
The dorsally and centrally displaced lateral bands
become slack and with increased PIP hyperextension
become ineffective in extending the DIP joint. This
leads to a flexion deformity at the DIP joint. It should
be noted that intrinsic tightness also could produce an
increased extension moment at the PIP joint.20
Swan-neck deformity also may begin with a disrup-
tion of the extensor tendon at the DIP joint. Terminal
extensor tendon rupture may be associated with syno-
vitis of the DIP joint, leading to a DIP joint flexion
deformity. When there is concomitant laxity of the
volar plate the ensuing proximal migration of the
lateral bands can increase PIP joint hyperextension as
tension in the central slip is increased.1,20
Boutonniere Deformity
Boutonniere deformity is a tendon imbalance
caused by attenuation or rupture of the central exten-
sor tendon of the PIP joint. This is seen commonly
with rheumatoid arthritis and as a result of trauma. In
rheumatoid arthritis the initial pathology is thought
to be attenuation and eventual rupture of the central
slip by synovial proliferation at the PIP joint. Atten-
uation and relative lengthening of the central slip
leads to decreased tension and a decreased extension
moment of the PIP joint. The extensor mechanism
migrates proximally, increasing tension in the lateral
bands and the terminal tendon. This leads to the
characteristic flexion deformity at the PIP joint and
hyperextension at the DIP joint (Figure 6).1,20
With rupture of the central tendon there is rupture
or attenuation of the triangular ligament that main-
tains the dorsal position of the lateral bands. The
lateral bands slip volarly. Both the rupture of the
central tendon and the volar position of the lateral
bands decrease the extensor moment of the PIP joint.
As the lateral bands slip volar to the center of rotation
of the PIP joint, they impart a flexion moment to the
joint. In this subluxed position tension of the lateral

bands increases, producing an increased extension mo-
ment of the DIP joint. This leads to flexion of the PIP
joint and hyperextension of the DIP joint.20
Claw Hand Deformity
After division of the ulnar nerve the fourth and
fifth digits assume a posture of MCP hyperexten-
sion and PIP flexion. When the ulnar nerve is
divided, innervation to the interossei and to the
lumbricals to the fourth and fifth digits is lost. The
ratio of extensor to flexor moment at the MCP joint
is greater than at the PIP joint. As a result of the
unbalanced pull of the extrinsic tendons the fourth
and fifth MCP joints posture in extension and the
PIP joints fall into flexion. Attempts to extend the
PIP joints simply create further hyperextension of
the proximal phalanx. As the MCP joint goes into
hyperextension the PIP joint further flexes as the
tension on the flexor tendons increases and the long
extensor has come to the limit of excursion. It
should be noted that the second and third digits do
not exhibit this profound deformity as a result of
the median innervated lumbricals. However, in
power pinch, collapse of the MCP joint into hyper-
extension occurs as the force applied to the fingertip
creates a large extension moment at the MCP joint
by virtue of the lever arm of the phalanges.1,20
Flexor Tendon Repair
A detailed discussion of flexor tendon repair is
beyond the scope of this article but several points
related to biomechanics are discussed. Newer proto-
cols for rehabilitation after flexor tendon repair em-
phasize active motion to decrease tendon adherence
and ultimately improve range of active motion. Me-
chanically, a tendon repair initially must have a
greater tensile strength to permit early motion with-
REFERENCES
1. Brand PW, Hollister A. Clinical mechanics of the hand. 2nd
ed. St. Louis: Mosby Year Book, 1993.
2. Chung KW. Gross anatomy. 3rd ed. Media, PA: Williams &
Wilkins, 1995.
3. Idler RS. Anatomy and biomechanics of the digital flexor
tendons. Hand Clin 1985;1:3-11.
4. Landsmeer JM. Functional morphology, functional mecha-
nism, and biomechanics related to surgery of the hand.
J Hand Surg 1989;14A:347-348.
DIGIT BIOMECHANICS ! GONZALEZ ET AL 59
out gapping. To this end, a number of 4- and 6-strand
repairs have been introduced. The surgeon must real-
ize that a stronger repair provides little benefit if the
repair is bulky or stiff. A bulky or stiff repair will
increase the drag on the tendon. The work of flexion
is increased duly. Thus, the stiffer and bulkier repair
may have a greater tensile strength but greater force is
required for the tendon to glide. Thus, any improve-
ment in tensile strength of a tendon repair must be
evaluated also in terms of work of flexion to decide if
the repair actually has a beneficial effect.
If a critical pulley A-2 or A-4 is damaged or
lacerated, pulley reconstruction is necessary to prevent
bowstringing and restore normal tendon mechanics.
Pulley reconstruction should be broad to minimize
bowstringing and distribute force through a wide
contact surface. A narrow pulley reconstruction dis-
tributes force over a small area, causing significant
deformation of the tendon. This in turn increases drag
and the work of flexion.
To improve tendon exposure and gliding, some
investigators have advocated pulley venting. Venting
is the partial release of a pulley on its proximal or
distal aspect. Recent research has shown experimen-
tally that 50% release of the proximal A-2 or A-4
pulley causes significant flexion loss as a result of
bowstringing.8
CONCLUSION
K nowledge of biomechanical principles allows the
surgeon to understand the physical basis of hand
function and deformity. The application of sound
biomechanical principles will allow the surgeon to
embark on a treatment plan that will optimize func-
tion while re-creating normal hand mechanics.
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retinacular system at the metacarpophalangeal joint. Anatom-
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extrinsic muscle control of the hand in power grip and
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15. Long C 2nd. Intrinsic-extrinsic muscle control of the fingers.
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ed. Philadelphia: Lippincot, 1979.
17. Brown TI, Rack PM, Ross HF. Electromyographic responses
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18. Forrest WJ, Basmajian JV. Functions of human thenar and
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