You are on page 1of 15

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 can oppose with some power. One digit should be
to the hand surgeon. The variety and severity of capable of motion so it can grasp objects. The
these injuries has led to the development of several other digit need only act as a stable post against
grading scales, ow charts, and algorithms to help which the movable digit can pinch. To allow for
the surgeon organize his or her treatment plan [1 prehensile movements the digits require some form
4,112]. These tools help the surgeon in preparation of cleft to divide them, which allows for the accom-
for surgery, but fail to predict hand function fol- modation of objects. The digits need to be sensate
lowing reconstruction accurately. It can be agoniz- and pain free or they provide little benet over
ing for the hand surgeon, especially the young prosthesis [6,7,9]. Requirements for functional
hand surgeon, intraoperatively to contemplate sensation have been dened as two-point discrim-
accurately the functional loss imposed by imme- ination of less than 10 to 12 mm [10].
diate joint fusion or digital amputation. Heroic The hand allows for prehension, which is the
attempts are often made to salvage joints and dig- ability to grasp and manipulate objects. As dened
its, whose loss results in little functional decit. In by Tubiana et al [11], prehension may be dened
addition, these severely injured ngers and joints as all the functions that are put into play when an
often become sti and insensate, requiring delayed object is grasped by the handsintent, permanent
amputations. This not only prolongs patient re- sensory control, and a mechanism of grip. Pre-
covery but also prolongs the surgeons anxiety. hension requires that the hand be able to ap-
Many articles dealing with the mutilated hand proach, grasp, and release an object [11,12]. If
contain experience-based protocols and reference only two sensate digits remain to oppose each
previous anecdotal reports [58]. Are there any other, some prehension is possible.
biomechanical principles of hand dynamics that In terms of biomechanical motion the hand
could help in deciding what must be preserved performs approximately seven basic maneuvers,
and what can be discarded? Unfortunately, biome- which make up most hand function:
chanical studies involving mutilating hand injuries
are scarce. This article establishes a biomechanical 1. Precision pinch (terminal pinch). This in-
foundation for determining what anatomic com- volves exion at the distal interphalangeal
ponents are needed for hand function. (DIP) joint of the index and at the interpha-
langeal joint (IP) joint of the thumb. The ends
of the ngernails are brought together as in
The essentials lifting a paper clip from a tabletop (Fig. 1).
In its most elemental form, the hand is com- 2. Oppositional pinch (subterminal pinch). The
posed of a stable wrist and at least two digits that pulp of the index and thumb are brought
together with the DIP joints extended. This
allows for force to be generated through thumb
* Corresponding author. opposition, rst dorsal interosseous contrac-
E-mail address: moran.steven@mayo.edu tion, and index profundus exion. This is often
(S.L. Moran). 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
18 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 ra-


dial side of the middle phalanx of the index
nger. Key pinch requires a stable post (usu-
Fig. 3. Key pinch.
ally the index nger), which has adequate
length and a metacarpal phalangeal (MP)
joint, which can resist the thumb adduction 7. Span grasp. The DIP and proximal interpha-
force (Fig. 3). langeal (PIP) joints ex to approximately 30
4. Directional grip (chuck grip). The thumb, in- degrees and the thumb is abducted. Force is
dex, and long nger come together to sur- generated between the thumb and ngers, dis-
round a cylindrical object. When using this tinct to power grasp where force is generated
grip, a rotational and axial force is usually between the ngers and the palm. Stability is
applied to the held object (ie, using a screw- required at the thumb MP and IP. This grip
driver) (Fig. 4). is used to lift cylindrical objects (Fig. 7)
5. Hook grip. This requires nger exion at the [11,13,14].
IP joints and extension at the MP joints. It is
the only type of functional grasp that does Postoperatively, the hands ability to adopt
not require thumb function. This grip is used these positions and exert force through them
when one lifts a suitcase (Fig. 5). impacts how well the patient rehabilitates. These
6. Power grasp. The ngers are fully exed while maneuvers are predicated on good sensation in
the thumb is exed and opposed over the the ngers and thumb. Through the preoperative
other digits, as in holding a baseball bat. history, the hand surgeon can determine which
Force if applied through the ngers into the hand functions benet the patient most in
palm (Fig. 6).

Fig. 2. Oppositional pinch (subterminal pinch). 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 activ- and index-long units of the hand are salvageable.
ities, and direct the reconstruction appropriately. Without median nerve function, thumb sensation
Many classication schemes divide hand and thenar function are lost, making ne motor
trauma into dorsal, volar, radial, and ulnar inju- movements negligible. In comparison, ulnar nerve
ries [1,3]. When assessing the eects of mutilating function and the ring-small nger unit are more
trauma on hand mechanics, however, it may be important for digitopalmar grip, where exion and
easier to think of the hand as containing four func- sensation in the ulnar digits are essential. Thumb
tional units: (1) the opposable thumb; (2) the index preservation is also important in power grasp to
and long nger, whose stable basal joints serve as provide stability and control of directional forces.
xed posts for pinch and power functions; (3) the With these principles in mind this article now
ring and small nger, which represent the mobile examines how digital loss aects hand function.
unit of the hand; and (4) the wrist. It may also help
to think of only two major forms of hand motion, The biomechanical impact of amputation
as opposed to seven: thumb-nger pinch and digi-
topalmar grip. Pinch requires preservation of the Partial or complete amputations are present in
thumb unit and a stable post. If the patient is able most mutilating hand injuries. It has been recom-
to add a third digit to pinch, they can achieve more mended that immediate amputation be performed
precision. Pinch function tends to be preserved when four of the six basic digital parts (bone, joint,
when the median nerve is intact and the thumb 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 rehabilita-
tion of the remaining hand. When performing an
amputation, however, one should understand how
digital loss impacts overall hand function.
The thumb
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 unique-
Fig. 6. Power grasp. ness and versatility in humans is caused by the
20 S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

position of the thumb axis. The thumb axis is The priorities of thumb reconstruction vary
based at the trapeziometacarpal (TMC) joint and with the level of amputation, but at all levels recon-
is pronated and exed approximately 80 degrees struction should attempt to restore opposition and
with respect to the other metacarpals in the hand pinch (Fig. 8). Injuries distal to the IP joint (zone 1
[25]. This positioning allows for circumduction, injuries) may produce little functional decit,
which permits opposition [2629]. because oppositional length tends to be maintained
Opposition of the thumb is necessary for all [33,34]. Residual insensibility and dysesthesia from
useful prehension and its preservation provides trauma produce more functional problems at this
the basis for successful salvage procedures. Oppo- level than the mechanical loss of length [35,36].
sition of the thumb is the result of angulatory Subterminal pinch and precision pinch are com-
motion, which is produced through abduction at promised if an unstable or painful scar is present
the TMC joint, and exion and rotation of the at the thumb remnant. Loss of the distal phalanx
TMC and MP joints [30]. Multiple muscles are and IP joint (zone 2 injuries) may also not require
required for functional opposition. These include reconstruction. Function may be preserved if TMC
the abductor pollicis brevis, the opponens pollicis, and MP motion is maintained [37].
and the supercial head of the exor pollicis bre- Level three injuries, through the level of the
vis. These muscles act simultaneously on the MP, are the most common and do represent a sig-
TMC joint and the MP joint. The abductor pollicis nicant loss of function. Unreconstructed injuries
brevis provides the major component of opposi- result in a decrease in pinch dexterity and grip
tion, with the opponens pollicis and exor pollicis strength [38]. The MP joint of the thumb has no
brevis providing secondary motors for opposition. other mechanical equivalent in the hand. It has
All measures should be directed toward preserving three degrees of freedom; it represents a ball and
or reconstructing the abductor pollicis brevis if socket joint in extension, but when the joint is
possible [25,2832]. The extensor pollicis longus exed, the tightening of the collateral ligaments
(EPL) and adductor pollicis (ADD) are antago- causes the MP joint to function more like a hinge.
nists to thumb opposition providing a supinating The intrinsic muscles provide motion but also pro-
extension and adduction force. vide 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 21

In injuries proximal to the MP joint one may Level ve injuries represent a loss of the TMC
proceed with a free toe transfer, which is the gold joint. In these cases restoration of TMC mobility
standard. The great toe metatarsal phalangeal is probably best achieved by index ray polliciza-
joint can reproduce the exion and extension arc tion, if available. The TMC joint is mechanically
of the MP joint, but fails to reproduce the MP equivalent to a universal joint [28,30,42]. The
joints 15 to 20 degrees of supination [35]. Func- TMC joint allows for thumb circumduction and
tional opposition is also possible with a toe wrap- thumb extension with associated supination, and
around ap. This reconstruction only allows for pronation with thumb exion. The TMC joint is
TMC motion. Excellent results have been obtained very complex because of its inherent instability at
when the fusion angles with bone graft were 30 the radial aspect of the wrist with no bony stabil-
degrees of exion and 45 degrees of internal izers proximal (mobile scaphoid). This inherent
rotation. These fusion angles allowed for pinch instability accounts for the large number of liga-
between all ngers and produced pinch and grip mentous supports that surround the joint (Fig.
strengths of 60% and 97%, respectively [39]. Non- 10.). There are ve major internal ligamentous
microsurgical methods for reconstruction of level stabilizers of the TMC joint: (1) dorsal radial
three defects can include deepening of the rst ligament, (2) posterior oblique ligament, (3) rst
web space, but any injury to the adductor or the- intermetacarpal ligament, (4) ulnar collateral liga-
nar musculature should be signicantly discour- ment, and (5) the anterior oblique ligament. The
aged in an already traumatized thumb. dorsal radial ligament prevents lateral subluxa-
Level four injuries result in damage to the thenar tion. The posterior oblique ligament provides
muscles, with resultant instability to the TMC joint. stability in exion, opposition, and pronation.
This produces a major stumbling block in thumb The rst intermetacarpal ligament is taut in abduc-
reconstruction, because TMC stability is required tion, opposition, and supination; it holds the rst
for any successful thumb reconstruction. Injuries metacarpal tightly against the second metacarpal.
at this level often require some form of soft tissue The intermetacarpal ligament is joined by the
reconstruction for restoration of opposition and ulnar collateral ligament, which prevents lateral
pinch [38,40]. In its most primitive form pinch can subluxation of the rst metacarpal on the tra-
be recreated, as in the tetraplegic patient, with pezium and controls for rotational stress. The base
fusion of the IP and MP and reconstruction of the of the index metacarpal should be spared during
adductor musculature. For reconstruction of oppo- any type of ray resection to preserve the intermeta-
sitional pinch, however, tendon transfers may be carpal ligament [43,44]. The fth and most impor-
necessary. In a study by Cooney et al [27], muscle tant ligament is the volar anterior oblique ligament
cross-sectional area and moment arm analysis were
used to determine the best donor muscle for oppo-
sitional 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 trans-
fer 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 im- Fig. 9. Diagram depicting the use of the supercialis
portance of directing the force of the transfer tendon from the long nger for restoration of thumb
toward the pisiform. Transfers that are distal to opposition. Tendon transfers directed proximal to the
pisiform tend to produce greater metacarpal abduction
the pisiform, such as those using the extensor digiti
and less metacarpal exion as compared with transfers
minimi (EDQ) or abductor digiti minimi (ADQ),
directed distal to the pisiform. The supercialis tendons
produce more exion than abduction. Transfers from the long and ring ngers closely approximate the
proximal to the pisiform, such as the FDS using excursion and strength of the original thenar mus-
the exor carpi ulnaris (FCU) loop as a pulley, pro- culature, and provide for an ideal tendon for transfer.
duce more abduction and less metacarpal exion FDS exor digitorum supercialis; FCU exor
(Fig. 9). carpi ulnaris; P pisiform.
22 S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

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 direc-
tional 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 dyses-
Fig. 10. Diagram of the trapezio-metacarpal joint
thesia following ray amputation experienced larger
showing the outlay of the dorsal and volar ligaments.
losses in grip strength. In addition, pronation
Special attention must be given to preservation of this
joint for adequate thumb stability. The most important strength was diminished by 50% following ray
ligaments for reconstruction and preservation are the resection. Pronation strength is used for direc-
dorsal radial ligament (DRL), posterior oblique ligament tional grip. This large decrease in pronation
(POL), ulnar collateral ligament (not depicted), rst strength is caused by a shortening of the palms
intermetacarpal ligament (IML), and the anterior oblique lever arm. In the intact hand, the width of the grip
ligament, deep and supercial heads (DAOL and SAOL). extends from the hypothenar region to the index
APL abductor pollicis longus; DIML dorsal inter- nger. The ulnar aspect of the palm represents
metacarpal ligament; DT-II MC dorsal trapezio-II the internal fulcrum and the radial aspect of the
metacarpal; DTT dorsal trapeziotrapezoid.
palm represents the external fulcrum of move-
ment. With the loss of the index nger ray the ful-
with its deep and supercial components. The lig- crum is decreased by approximately 25% (Fig. 11).
ament arises from the volar tubercle of the tra- This results in a loss of stability and a decrease
pezium and inserts on the volar aspect of the in mechanical advantage. Despite the loss of
thumb. The anterior oblique ligament is taut in strength, all patients in this study, without postop-
extension, abduction, and pronation; it controls erative dysesthesia, believed that their overall hand
pronation stress and prevents radial translation. function had been improved, especially in regard
The deep anterior oblique ligament serves as a to prehension with the thumb [47]. This suggests
pivot point for the TMC joint and guides the meta- that the ability to perform precise activities is more
carpal into pronation while the thenar muscles important for postoperative patient satisfaction
work in concert to produce abduction and exion. than the preservation of grip strength. In compar-
These bers limit ulnar translocation of the meta- ison, a recent study of patients with traumatic
carpal during palmer abduction while working proximal phalanx amputations of the index nger
with the supercial anterior oblique ligament to and patients with elective index ray resections
constrain volar subluxation of the metacarpal. found that patients with amputation through the
The anterior oblique, intermetacarpal, and dorsor- proximal phalanx demonstrated a better func-
adial ligaments are the most critical for preserva- tional outcome when assessed with the DASH
tion and reconstruction [4244]. questionnaire. A 30% decrease in pinch and grip
strength was seen in both groups. Cosmesis was
The index nger
believed to be better with ray amputation [48].
The index nger may be of next highest impor- Overall, it seems that a remaining proximal pha-
tance because of its exion and extension inde- lanx stump does provide a benet in terms of grip
S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731 23

combined with the small as a functional unit, how-


ever, 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 remain-
ing digits because of instability of the transverse
metacarpal ligament and compromised inteross-
eous function. Three-point chuck pinch is com-
promised, 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 incompe-
tence and reduce scissoring of the digits. Results
of strength testing following ray transposition for
Fig. 11. Diagram showing the resultant eects of ray central digital loss have found an average decrease
excision on pronation and supination strength. Resec- in grip and pinch strength of 20%, with larger
tion of the metacarpal narrows the palms. This shortens decreases in function being seen for index to long
the palms lever arm and decreases the hands mechan- transfer when compared with small to ring trans-
ical advantage during pronation and supination.
fers. Loss of motion was only 9% following
transfer [56]. Although ray amputation may be
strength and overall hand function. In light of the indicated in cases of central digital loss, it seems
high rate of postoperative dysesthesia associated most prudent to perform this procedure in a
with ray resection, it seems that immediate index delayed fashion, after a discussion has been carried
ray resection should be reserved for very proximal out with the patient regarding his or her needs with
injuries where there is little chance of postopera- regard to hand strength and motion.
tive MP motion.
The small nger
The long and ring ngers The small nger has the least strength in ex-
ion; however, its loss can have broader implica-
The long nger does provide the most nger
tions on hand function. In digitopalmar grip the
exion force when tested individually [49,50]. Its
fth ray presses objects and tools into the palm.
central position allows it to participate in power
This is caused by the additional motion provided
grip and precision grip. Patients are easily able to
by its carpal-metacarpal (CMC) joint, which can
substitute this digit for terminal and subterminal
move forward 25 degrees. Stabilization is also
pinch following the loss of the index nger. The
added by the hypothenar muscles, which augment
middle ray does lack the specialization of the rst
the exion of the rst phalanx of the small nger.
dorsal interosseous muscle when performing pinch
In addition, the small ngers abduction capabil-
functions. Transfer of the rst dorsal interosseous
ities signicantly enhance span grasp. Tubiana
to the insertion of the second dorsal interosseous
et al [11] believe the fth nger, with its metacarpal,
has been suggested following rst ray resection;
has the greatest functional value after the thumb.
however, studies have shown that this does not sig-
nicantly increase pinch strength [47,51]. In addi-
Digital loss
tion, this transfer can lead to the development of
an intrinsic plus deformity in the long nger For the most part single digit amputation, with
[47,52]. The ring nger has less strength than either the exception of the thumb, does not result in the
the index or long. It is also rarely used for precision loss of essential hand function. Brown [18] studied
pinch or grip. As an individual digit, Tubiana et al 183 surgeons who suered partial or total digital
[11] believe the ring ngers loss leaves the least amputations. Only four surgeons were unable to
functional decit in the hand. When this nger is continue operating following their injuries. Most
24 S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

surprising was the nding that 15 surgeons who shown to provide little benet for hand function. It
had experienced thumb amputations through the often has no eective prehension or grasp and does
metacarpal or MP joint level were able to continue not adequately compare with the results obtain-
operating with only minimal adaptation in their able with microsurgical reconstruction [24,5962].
surgical practice. Brown [18] concluded that the
motivation of the patient is more important than
the actual number of retained digits when attempt- The biomechanical impact of fusion
ing to predict functional outcome for digital
amputation. Of note, none of these surgeons had There are several instances where the severity of
to perform repetitive strenuous activity with the the trauma precludes any anatomic restoration of
hand and grip strength presumably was not a the joint surface. These situations may require
major issue. fusion. Unfortunately, change in a single joint has
Unlike single-digit amputation, the amputation implications on the balance of the entire digit, and
of several digits still remains a challenging prob- the biomechanics of the hand. How do fusions
lem. Unfortunately, in the mutilated hand, multi- impact overall hand function?
ple digital losses are the norm, because severely
Finger fusion
crushed and avulsed digits preclude replantation.
Preservation of the thumb and a single digit allows Of all fusions, DIP fusions are well tolerated
for some prehensile grasp, but for optimal func- and probably impart the least detriment to hand
tion the reconstruction of an additional digit is function. Fifteen percent of intrinsic digital exion
recommended [24,5860]. The preservation or occurs at the DIP joint but the DIP joint contrib-
reconstruction of the thumb and two digits allows utes only 3% to the overall exion arc of the nger
for the possibility of chuck pinch, which is stronger [63]. Recent mechanical testing has shown that
than subterminal pinch. The use of a third digit after simulated DIP fusion of the index and middle
confers lateral stability in power pinch. A third nger, there is a 20% to 25% reduction in grip
digit also allows the patient to perform hook grip strength when compared with prefusion values.
and power grasp. Span grasp is now possible The decrease in grip strength may be secondary
because functional palmar space is increased to the limited excursion of the profundus tendon
allowing for grasp of larger objects [24,5860]. following fusion; this can create a quadriga eect.
Wei and Colony [24] have found it preferable to It has been suggested that fusion in a more exed
place toes next to remaining mobile ngers or in position creates additional slack in the profundus
the interval between them. They believe the adja- tendon, decreasing the loss of grip strength; how-
cent digits contribute to cosmesis, help coordinate ever, this has not been shown clinically [64]. For
movement, and smooth oppositional contact. most individuals, with the exception of musicians,
In injuries where there is loss of all ngers but arthrodesis is preferred over arthroplasty at the
sparing of the thumb, reconstructive goals should DIP level.
attempt to maintain useful thumb web space and The PIP joint produces 85% of intrinsic digital
an opposable ulnar post of adequate length. Addi- exion and contributes 20% to the overall arc of
tional digits may be created with microvascular toe nger motion. Littler and Thompson [65] de-
transfer [24,5962]. Other options include the scribed this joint as the functional locus of n-
transfer of remaining functional digits to more ger function. PIP joint impairment can adversely
useful positions. Transferring salvageable digits aect the entire hand; however, a full range of PIP
to the ulnar side of the hand maintains the width joint motion is not essential for hand function. An
of the palm, and allows for power grasp and arc extending from 45 to 90 degrees can provide
the incorporation of pinch [21,22,24]. The radial relatively normal function [66,108]. In addition,
placement of reconstructed digits is more cosmeti- mild exor contractures at the PIP level can be
cally pleasing but fails to take advantage of the compensated for through hyperextension of the
added power provided by intact hypothenar mus- MP joint. This allows the nger to move out of
culature and the motion provided by the fth the plane of the palm when attempting to lay the
CMC joint. In cases where there has been loss of hand at or when placing objects into the palm.
all digits including the thumb, microvascular A PIP fusion is often well tolerated in the index
reconstruction of the thumb is required with the nger because the indexs relatively independent
additional creation of a stable ulnar post. The pre- profundus function does not impose a signicant
vious practice of constructing a cleft hand has been quadriga eect on the other ngers during power
S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731 25

grasp. PIP fusion of the long nger, however, has only 50% of normal joint motion [73,79,80]. Stud-
been shown to decrease the excursion of all pro- ies have shown that obtaining 35 degrees of
fundus tendons, reducing grip strength. PIP fusion motion at the MP is satisfactory if the arc of
restricts profundus excursion to a greater extent motion is within the functional range and the
than DIP or MP fusion [47,67,68]. In a study by joint is stable [73]. Many rheumatoid patients
Lista et al [67], a signicant decrease in grip who have had PIP and DIP fusions maintain a
strength occurred when the PIP joints of the index useful hand through the preservation of MP
and small nger were xed at less than 45 degrees motion. Previously, MCP arthrodesis was recom-
and when the long and the ring were fused in a mended for border digits in heavy laborers; how-
position of less than 60 degrees of exion. If both ever, these indications may be reconsidered with
MP and PIP joints are injured, salvage of the the availability of new surface replacement arthro-
MP joint through arthroplasty or other measures plasty [70,80].
is preferred over PIP joint arthroplasty. Grip
strength is decreased because of a quadriga eect,
Wrist fusion
but prehension can be maintained as long as the
thumb or border digit is capable of opposition. It Although less common than nger fusion,
is important to remember that two consecutive immediate limited wrist fusion or total wrist fusion
fusions increase stress at the next proximal joint, may be necessary following penetrating ballistic
because of an increase in the lever arm working trauma, punch presstype injuries, or in cases of
across the joint. This accelerates the degeneration gross carpal instability. A stable wrist is necessary
of adjacent joints if they are also injured. for power grasp. In addition, a stable wrist pre-
Delayed arthroplasty of the PIP joints in cases vents the dissipation of nger exion and exten-
of trauma maintains motion and improves grip sion forces as tendons pass over the carpus.
strength [69]. Classic teaching has suggested that What are the requirements for a functional wrist
index PIP joint arthrodesis be performed instead and what eect does fusion have on wrist and hand
of silicone arthroplasty, to provide stability for function?
key pinch. Surface replacement arthroplasty, how- The requirements for functional wrist motion
ever, may provide adequate stability for index have been debated. Palmer et al [81] found that
nger PIP arthroplasty. PIP stability has been pre- the normal wrist had an average exion-extension
served following surface replacement arthroplasty arc of 133 degrees, but only 5 degrees of exion
with loads up to 22 N in experimental cases where and 30 degrees of extension were needed for most
there was preservation of 50% of the index collat- activity. Brumeld and Champoux [82] found that
eral ligaments [70]. 10 degrees of exion and 35 degrees of extension
The MP joints probably represent the most allowed one to complete the activities of daily liv-
important joint for hand function. They contrib- ing. Ryu et al [83], however, found in 40 normal
ute 77% of the total arc of nger exion [63, patients that most activities of daily living could
65,66,71,72]. Unlike the giglymoid IP joint, which be accomplished with 40 degrees of exion, 40
functions like a sloppy hinge joint, the condyloid degrees of extension, 10 degrees of radial devia-
MCP joint is diarthrodial, allowing for exion- tion, and 30 degrees of ulnar deviation.
extension, abduction-adduction, and some rota- Limited carpal fusions consist of intercarpal
tion [71,7375]. Most prehension grips require fusions and radiocarpal fusions (Fig. 12). Mechan-
that the digits extend and abduct at the MP joint ical studies by Meyerdierks et al [84] show that
[74,76]. Precision pinch requires exion, rotation, fusions that cross the radiocarpal joint produce
and ulnar deviation at the MP joint [73,74]. During the greatest loss of motion. On average radiolu-
pinch the radial intrinsics and the collateral liga- nate, radioscapholunate, and radioscaphoid fu-
ment to the index must resist the stress applied sions decrease the exion extension arc by 55%.
by the thumb. According to the American Medical Recent studies have suggested that removal of
Associations Guide to the Evaluation of Perma- the distal pole of the scaphoid in radiocarpal
nent Impairment, fusion of the MP joint results fusions unlocks the capitate, allowing unhindered
in a 45% impairment of the involved nger [77]. midcarpal motion. In the laboratory setting this
Some have suggested that a single sti MP joint has produced exion extension arcs that are equiv-
can impair the entire hands function [78]. A full alent to normal wrist motion [85]. Fusions that
range of motion, however, is not required for hand cross the midcarpal joint result in the next largest
function. Most activities of daily living require 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 85% of the activities of daily living following total
exion and extension arc and up to a 31% loss wrist fusion. Patients were least able to use a
of radial and ulnar deviation. Scaphotrapezial- screwdriver and perform perineal care. Overall,
trapezoid fusion produces a 23% decrease in the skills that presented the most diculty were those
exion extension arc and 31% decrease in radial that required signicant wrist exion in a small
and ulnar deviation, whereas scaphocapitate space, where compensatory movements by the
fusion results in a 19% loss in the exion extension shoulder and elbow are eliminated.
arc and a 19% loss in radial and ulnar deviation. In severely mutilating trauma, the preservation
Inclusion of the lunate within partial wrist fusions of wrist mobility imparts some function to a fore-
was found to nearly double the resultant loss of arm stump with the addition of prosthesis. Mod-
wrist motion when compared with fusions that ern prosthetic techniques allow the incorporation
did not include the lunate [84]. Fusion within the of the prosthesis to the wrist so that proximal
same carpal row tends to have a minimal eect straps and attachment to the elbow are unneces-
on overall wrist motion, with average loss of only sary. Preservation of wrist motion also eliminates
12% of the exion and extension arc. the need to incorporate a wrist articulation into
The choice for total wrist fusion must be care- the prosthetic unit [6,17,90]. In addition, preserva-
fully contemplated. Removal of all wrist motion tion of the distal radio-ulnar joint (DRUJ) further
results in the loss of the benecial eect of tenode- improves function, because 50% of forearm rota-
sis for any subsequent tendon transfer. In addi- tion can be transferred into the prosthesis [91].
tion, wrist dorsiexion is important for pushing
o, rising from a chair, and power grasp. In those
cases where there is substantial carpal loss, how- Tendon requirements
ever, fusion may be the only option.
Wrist fusion can have a negative impact on MP Tendon injuries are present, in some aspect, in
motion and thumb motion presumably because of all cases of mutilating hand trauma. Tendons
extensor adhesion [86]. A 25% decrease in grip may be divided, avulsed, or have large segmental
strength may be seen [86,87]. Strength with key gaps that prohibit immediate repair. It is impor-
pinch, subterminal pinch, and directional grip are tant to understand how tendon loss aects hand
better maintained at approximately 85% of the function.
normal side. Maximum preservation of power grip
Extensor tendons
is found to occur in 15 degrees of extension and
15% of ulnar deviation [88]. Weiss et al [89] found Multiple authors have pointed to the diculties
that patients believed they were able to accomplish in obtaining excellent results with extensor tendon
S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731 27

injuries [9294]. The supercial position of the evident at the MP joint. DIP and PIP extension
extensor tendons, their complex architecture, and were preserved because of intact intrinsic function.
paucity of surrounding subcutaneous tissue often Active motion at the MP joint was only 60% of
result in postoperative adhesions, which limit ex- normal. Surprisingly, patients reported a 90% sat-
ion and produce extensor lags [94,111]. It has been isfaction rate with hand function. Diculty was
shown that injuries in the distal zones (1 through 5) noted with tying knots and unscrewing lids. All
result in poorer outcomes and greater postopera- patients did maintain the extension of their thumb
tive extension decits. Extensor tendon injuries and wrist extensors. This emphasizes the impor-
also carry a signicantly worse prognosis when tance of thumb abduction and extension for pre-
associated with underlying fractures [19,94]. hensile function when MP motion is limited. The
The extensor mechanism has less excursion ability to move the thumb out of the palm allows
than the exor system [95]. In addition, it has less for the accommodation and prehension of objects
ability to compensate for signicant shortening even with a moderate digital exion stance. The
because of the interconnections between the intrin- loss of the central extensors decreases power grip
sic and extrinsic mechanisms. Extensor tendon by approximately 30%, whereas severance of wrist
excursion in the region of the PIP joint is only extensors results in a 50% reduction in grip
between 2 and 5 mm. There is little margin for strength [97,100].
adherence or shortening if a reasonable result is
expected [95,96]. If signicant shortening takes
Flexor tendons
place following repair and the lateral bands and
oblique retinacular ligament are intact, one can Loss of profundus function prevents subtermi-
opt to leave the central extensor mechanism unre- nal and terminal pinch, unless the DIP joint is
paired. This may avoid exion loss, without pro- fused. If the profundus tendon becomes adherent
ducing a PIP or DIP extension lag. Loss of long to the remaining sublimis tendon or fracture callus
extensor function can destabilize the MP joint, it may tether the profundus tendons of adjacent
however, resulting in a loss of active nger ab- uninjured ngers, preventing full digitopalmar
duction-adduction [97]. Further biomechanical grip [14,101]. Classically this quadriga eect
studies are required to determine the absolute applies only to the long through small ngers,
requirements for functional nger extension. because of their common muscle belly. The quad-
Maximizing intrinsic function helps in the pres- riga eect can also extend to the index nger, how-
ervation of full nger extension. Intrinsic function ever, because heavy synovium at the level of the
can be compromised after metacarpal fractures. carpal tunnel, termed the bromembranous retinac-
Metacarpal shortening or fracture angulation ulum, can link the index profundus tendon to the
beyond 30 degrees can result in a shortening of other three [102].
intrinsic muscle ber length [98]. Muscle ber Power grip and forceful pinch are still possible
length determines the potential excursion of the with supercialis loss. Loss of the supercialis with
intrinsic tendon [31]. With metacarpal malre- preservation of the profundus tendon may result
duction or shortening, potential excursion force in hyperextension of the PIP joint in supple indi-
is wasted as slack in the muscle. Starting muscle viduals. This phenomenon is called recurvatum. In
tension is also decreased. Both of these factors exaggerated cases, this may produce delayed nger
decrease intrinsic tendon excursion and joint exion. Patients may have to help the involved n-
motion [98,99]. This loss of intrinsic function ger initiate PIP exion with the adjacent digits
emphases the need for preservation of metacarpal before active exion can ensue. Recurvatum can
length and the anatomic reductions of fractures in be avoided by leaving the portion of the supercia-
cases of signicant hand trauma. lis distal to the chiasm [14]. With loss of both pro-
Extensor tendon injuries proximal to the junc- fundus and supercialis tendons, exion of the MP
tura produce less postoperative decits. Quaba joint to 45 degrees may be possible if intrinsic func-
et al [100] examined long-term function in patients tion is intact.
who had lost nger extensors in zones 6 and 7. Retraction of the profundus tendon, following
In the nine patients studied, no attempt was made more proximal amputations, may result in short-
to reconstruct the extensor tendons. Soft tissue ening and contracture of the corresponding lumbr-
coverage alone was provided to the dorsum of ical. During exion, contraction of the profundus
the hand. In long-term follow-up, there was a muscle belly places stretch on the shortened lum-
26% decrease in total active nger motion, most brical, 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 tendon loss impact on postoperative hand motion,
deformity. This deformity can be oset by divid- the surgeon can better focus his or her reconstruc-
ing the lumbrical or suturing the profundus ten- tive eorts to achieve the highest functional out-
don to the exor sheath in a relaxed position come for the patient.
[14,110].
With multiple digital amputations, retraction References
of the exor mechanism can lead to lumbrical
migration into the carpal tunnel. Proximal lumbr- [1] Campbell DA, Kay SP. The hand injury severity
scoring system. J Hand Surg [Br] 1996;21:2958.
ical migration may then lead to compression of the
[2] German G, Sherman R, Levin LS. Decision-
median nerve and development of carpal tunnel making in reconstructive surgery (upper extrem-
syndrome [6,103]. These patients may not present ity). Berlin: Springer; 2000.
with classic digital paresthesias if there has been [3] Tomaino MM. Treatment of composite tissue loss
signicant digital soft tissue loss. Patients may following hand and forearm trauma. Hand Clin
instead complain of generalized pain within the 1999;15:31933.
wrist and palm, which may be exacerbated by the [4] Weinzweig J, Weinzweig N. The tic-tac-toe
standard provocative maneuvers. Carpal tunnel classication system for mutilating injuries of the
release should be pursued in such instances. hand. Plast Reconstr Surg 1997;100:120011.
During any exor tendon surgery it is impor- [5] Brown HC, Williams HB, Woolhouse FM.
Principles of salvage in mutilating hand injuries.
tant to preserve the A2 and A4 pulleys [104107].
J Trauma 1968;8:31932.
If either is divided the exor tendon moves away [6] Burkhalter W. Mutilating injuries of the hand.
from the phalanx, leading to bowstringing. The Hand Clin 1986;2:4568.
A2 and A4 pulleys are located over the bony shafts [7] Hentz VR, Chase RA. The philosophy of salvage
of the proximal and middle phalanx. This ana- and repair for acute hand injuries. In: Wolfort FG,
tomic conguration prevents the bowstringing editor. Acute hand injuries: a multispecialty
that occurs with joint exion and the bowstringing approach. St. Louis: Mosby; 1979.
that can occur over the phalanx shaft. Palmer plate [8] Michon J. Complex hand injuries: surgical plan-
pulleys (A1, A3, and A5) have a variable relation- ning. In: Tubiana R, editor. The hand, vol. 2.
ship to the joint axis depending on joint position, Philadelphia: WB Saunders; 1985. p. 196213.
[9] Entin MA. Salvaging the basic hand. Surg Clin
and restrain only the joint-type of bow stringing.
North Am 1968;48:106281.
They also shorten up to 50% with nger exion, [10] Moberg E. Reconstructive hand surgery in tetra-
which reduces their eciency. Cruciate pulleys plegia, stroke, and cerebral palsy: basic concepts in
vary the most in their anatomic position and have physiology and neurology. J Hand Surg [Am]
little eect on restraining bowstringing [105,107]. 1976;1:2934.
Bowstringing increases the exion moment arm [11] Tubiana R, Thomine J, Mackin E. Movements of
at the PIP and MP joints. A longer moment arm the hand and wrist. In: Tubiana R, Thomine J,
allows the exor mechanism to overcome the Mackin E. Examination of the hand and wrist. St
extension forces, resulting in a exion deformity. Louis: Mosby; 1996. p. 40125.
A longer moment arm also means the tendon must [12] Radischong P. Les problemes fondamentaux du
retablissement de la prehension. Ann Chir 1971;
move through a longer distance to obtain the
25:927.
same motion at the joint, decreasing mechanical [13] Duparc J, Alnot J-Y, May P. Single digit
eciency. As in the quadriga eect, grip strength amputations. In: Campbell DA, Gosset J, editors.
is decreased because full excursion is now Mutilating injuries of the hand. Edinburgh:
limited [107]. Churchill Livingstone; 1979. p. 3744.
[14] Smith P. Listers the hand. London: Churchill
Livingstone; 2002.
Summary [15] Arellano AO, Wegener EE, Freeland AE. Mutilat-
Mutilating hand trauma presents the surgeon ing injuries to the hand: early amputation or repair
and reconstruction. Orthopedics 1999;22:6834.
with many reconstructive challenges. This article
[16] Beasley RW, DeBeze G. Upper limb amputations
establishes some biomechanical guidelines to help
and prostheses. In: Aston SJ, Beasley RW, Thorne
the surgeon evaluate the hand trauma patient. CHM, editors. Grabb and Smith: plastic surgery.
Through a basic understanding of hand biome- 5th edition. Philadelphia: Lippincott-Raven; 1997.
chanics, the surgeon may access more accurately p. 100920.
what motion and function can best be salvaged. [17] Brown P. Sacrice of the unsatisfactory hand.
By understanding how amputation, fusion, and J Hand Surg 1979;4:41723.
S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731 29

[18] Brown PW. Less that ten: surgeons with ampu- [37] Matev IB. Reconstructive surgery of the thumb.
tated ngers. J Hand Surg 1982;7:317. Essex, England: Pilgrims Press; 1983.
[19] Duncan RW, Freeland AE, Jabaley ME, Mey- [38] Shin AY, Bishop AT, Berger RA. Microvascular
drech EF. Open hand fractures: an analysis of the reconstruction of the traumatized thumb. Hand
recovery of active motion and of complications. Clin 1999;15:34771.
J Hand Surg [Am] 1993;18:38794. [39] Lee KS, Park JW, Chung WK. Thumb recon-
[20] McCormack RM. Primary reconstruction in acute struction with a wraparound free ap according to
hand injuries. Surg Clin North Am 1960;40: the level of amputation. J Hand Surg [Am] 2000;
33743. 25:64450.
[21] Soucacos PN, Beris AE, Malizos KN, et al. [40] Leung PC. Thumb reconstruction using second-toe
Transposition microsurgery in multiple digital transfer. Hand 1983;15:1521.
amputations. Microsurgery 1994;15:46973. [41] Bunnell S. Opposition of the thumb. J Bone Joint
[22] Soucacos PN. Indications and selection for digital Surg 1938;20:26984.
amputation and replantation. J Hand Surg [Br] [42] Katarincic JA. Thumb kinematics and relevance to
2001;26:57281. function. Hand Clin 2001;17:16974.
[23] Strickland JW. Thumb reconstruction. In: Green [43] Bettinger P, Linscheid R, Berger R, Cooney WP,
DP, editor. Operative hand surgery. 2nd edi- An K. An anatomic study of the stabilizing liga-
tion. New York: Churchill Livingston; 1988. ments of the trapezium and trapeziometacarpal
pp. 2175262. joint. J Hand Surg [Am] 1999;24:78698.
[24] Wei FC, Colony LH. Microsurgical reconstruction [44] Bettinger PC, Berger RA. Functional anatomy of
of opposable digits in mutilating hand injuries. the trapezium and trapeziometacarpal joint. Hand
Clin Plast Surg 1989;16:491504. Clin 2001;17:15168.
[25] Napier JR. The form and function of the carpo- [45] Buck-Gramcko D, Homann R, Neumann R. In:
metocarpal joint of the thumb. J Anat 1955; Hand trauma: a practical guide. New York:
89:362. Theime; 1986. p. 6073.
[26] Cooney WP, Chao EYS. Biomechanical analysis [46] Campbell DA, Gosset J. In: Mutilating injuries of
of static forces in the thumb during hand function. the hand. Edinburgh: Churchill Livingstone; 1979.
J Bone Joint Surg Am 1977;59:2736. p. 3744.
[27] Cooney WP, Linscheid RL, An KN. Opposition of [47] Murray JF, Carman W, MacKenzie JK. Trans-
the thumb: an anatomic and biomechanical study of metacarpal amputation of the index nger: actual
tendon transfers. J Hand Surg [Am] 1984;9:77786. assessment of hand strength and complications.
[28] Imaeda T, An KA, Cooney WP. Functional J Hand Surg 1977;2:47181.
anatomy and biomechanics of the thumb. Hand [48] Karle B, Wittemann M, Germann G. Functional
Clin 1992;8:915. outcome and quality of life after ray amputation
[29] Napier JR. The attachments and function of the versus amputation through the proximal phalanx
abductor pollicis brevis. J Anat 1952;86:33541. of the index nger. Handchir Mikrochir Plast Chir
[30] Cooney WP, Lucca MJ, Chao EYS, Linscheid RL. 2002;34:305.
The kinesiology of the thumb trapeziometacarpal [49] Ejeskar A, Ortengren R. Isolated nger exion force:
joint. J Bone Joint Surg 1981;63:137181. a methodological study. Hand 1981;13:22330.
[31] Brand PW, Beach RB, Thompson DE. Relative [50] Hazelton FT, Smidt GL, Flatt AE, Stephens RI.
tension potential excursion of muscles in the fore- The inuence of wrist position on the force pro-
arm and hand. J Hand Surg [Am] 1981;6: duced by the nger exors. J Biomech 1975;
20919. 8:3016.
[32] Kaplan EB. Function and surgical anatomy of the [51] Chase RA. The damaged index digit: a source of
hand. 2nd edition. Philadelphia: JB Lippincott; components to restore the crippled hand. J Bone
1965. p. 15862. Joint Surg Am 1968;50:115260.
[33] Delloca RL, Hentz VR. Thumb reconstruction. [52] Linscheid RL. Historical perspective of nger joint
In: Goldwyn RM, Cohen MN, editors. The motion: the hand-me-downs of our predecessors.
unfavorable result in plastic surgery. Philadelphia: J Hand Surg [Am] 2002;27:125.
JB Lippincott; 2001. p. 80529. [53] Carroll RE. Transposition of the index nger to
[34] Urbaniak JR. Thumb reconstruction by micro- replace the middle nger. Clin Orthop 1959;15:24.
surgery. Instr Course Lect 1984;33:42546. [54] de Boer A, Robinson PH. Ray transposition by
[35] Morrison WA, OBrien BM, MacLeod AM. intercarpal osteotomy after loss of the fourth digit.
Thumb reconstruction with a free neurovascular J Hand Surg [Am] 1989;14:37981.
wrap-around ap from the big toe. J Hand Surg [55] Posner MA. Ray transposition for central digital
1980;5:57583. loss. J Hand Surg 1979;4:24257.
[36] Morrison WA. Thumb reconstruction: a review [56] Colen L, Bunkis J, Gordon L, Walton R. Func-
and philosophy of management. J Hand Surg 1992; tional assessment of ray transfer for central digital
17:38390. loss. J Hand Surg [Am] 1985;10:2327.
30 S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731

[57] Steichen JB, Idler RS. Results of central ray carpalphalangeal implants. J Bone Joint Surg Am
resection without bony transposition. J Hand Surg. 1976;58:4837.
[Am] 1986;11:46674. [74] Flatt AE. Care of the rheumatoid hand. 4th
[58] Tsai TM, Jupiter JB, Wol TW, Atasoy E. edition. St. Louis: Mosby; 1983.
Reconstruction of severe transmetacarpal mutilat- [75] Krishnan J, Chipchase L. Passive and axial
ing hand injuries by combined second and third toe rotation of the metacarpophalangeal joint. J Hand
transfer. J Hand Surg 1981;6:31928. Surg [Br] 1997;22:2703.
[59] Wei FC, Chen HC, Chuang CC, et al. Recon- [76] Zancolli E. Structural and dynamic bases of hand
struction of a hand amputated at the metacarpo- surgery. 2nd edition. Philadelphia: JB Lippincott;
phalangeal level by means of combined second and 1983.
third toes from each foot: a case report. J Hand [77] American Medical Association. Guides to the
Surg [Am] 1986;11:340. evaluation of permanent impairment. 2nd edition.
[60] Wei FC, Chen HC, Chuang CC, Noordho MS. Chicago: American Medical Association; 1984.
Simultaneous multiple toe transfers in hand [78] Hagert CG, Branemark PI, Albrektsson T, et al.
reconstruction. Plast Reconstr Surg 1988;81: Metacarpalphalangeal joint replacement with
36677. osseointegrated endoprostheses. Scand J Plast
[61] Gorsche TS, Wood MB. Mutilating corn-picker Reconstr Surg 1986;20:20718.
injuries of the hand. J Hand Surg [Am] 1988; [79] Doi K, Kuwata N, Kawai S. Alumina ceramic nger
13:4237. implants: a preliminary biomaterial and clinical
[62] Wei FC, Colony LH, Chen HC, Chuang CC, evaluation. J Hand Surg [Am] 1984;9:7409.
Noordho MS. Combined second and third toe [80] Linscheid RL, Beckenbaugh RD. Arthroplasty of
transfer. Plast Reconstr Surg 1989;84:65161. the metacarpal phalangeal joint. In: Morrey BF,
[63] Littler JW, Herndon JH, Thompson JS. Examina- An K-N, editors. Reconstructive surgery of the
tion of the hand. In: Converse JM, Littler JW, joints. 2nd edition. New York: Churchill Living-
editors. Reconstructive plastic surgery, vol 6. stone; 1996. p. 287.
Philadelphia: WB Saunders; 1977. p. 2973. [81] Palmer AK, Werner FW, Murphy D, Glisson R.
[64] Morgan WJ, Schulz LA, Chang JL. The impact of Functional wrist motion-a biomechanical study.
simulated distal interphalangeal joint fusion on J Hand Surg [Am] 1985;10:3946.
grip strength. Orthopedics 2000;23:23941. [82] Brumeld RH, Champoux JA. A biomechanical
[65] Littler JW, Thompson JS. Surgical and functional study of normal functional wrist motion. Clin
anatomy. In: Bowers WH, editor. The interpha- Orthop 1984;187:235.
langeal joints. New York: Churchill Livingstone; [83] Ryu J, Cooney III WP, Askew LJ, et al. Func-
1987. p. 142. tional ranges of motion of the wrist joint. J Hand
[66] Foucher G, Hoang P, Citron N, et al. Joint Surg [Am] 1991;16:40919.
reconstruction following trauma: comparison of [84] Meyerdierks EM, Mosher JF, Werner FW. Lim-
microsurgical transfer and conventional methods: ited wrist arthrodesis; a laboratory study. J Hand
a report of 61 cases. J Hand Surg [Br] 1986;11: Surg [Am] 1987;12:5269.
38893. [85] McCombe D, Ireland DCR, Mcnab I. Distal
[67] Lista FR, Neu BR, Murray JF, et al. Profundus scaphoid excision after radioscaphoid arthrodesis.
tendon blockage (the quadrigia syndrome) in the J Hand Surg [Am] 2001;26:87782.
hand with a sti nger. Presented at the 43rd [86] Field J, Herbert TJ, Prosser R. Total wrist fusion.
annual meeting of the American Society for J Hand Surg [Br] 1996;21:42933.
Surgery of the Hand. Baltimore, September, 1988. [87] Labosky DA, Waggy CA. Apparent weakness of
[68] Neu BR, Murray JF, MacKenzie JK. Profundus the median and ulnar motors in radial nerve palsy.
tendon blockage: quadriga in nger amputations. J Hand Surg 1986;11:52833.
J Hand Surg [Am] 1985;10:87883. [88] Pryce JC. The wrist position between neutral and
[69] Kleinert JM, Lister GD. Silicone implants. Hand ulnar deviation that facilitates the maximum
Clin 1986;2:27190. power grip strength. J Biomech 1980;13:50511.
[70] Linscheid RL, Murray PM, Vidal MA, Becken- [89] Weiss AP, Wiedeman G, Quenzer D, et al. Upper
baugh RD. Development of a surface replacement extremity function after wrist arthrodesis. J Hand
arthroplasty for proximal interphalangeal joints. Surg [Am] 1995;20:8137.
J Hand Surg [Am] 1997;22:28698. [90] Childress DS, Hampton FL, Lambert CN,
[71] Ellis PR, Tsai T. Management of the traumatized Thompson RG, Schrodt MJ. Myoelectric immedi-
joint of the nger. Clin Plast Surg 1989;16:45773. ate postsurgical procedure: a concept for the tting
[72] Swanson AB. Flexible implant arthroplasty for the upper extremity amputee. Artif Limbs 1969;
arthritic nger joints. J Bone Joint Surg Am 1972; 13:5560.
54:43555. [91] Wright TW, Hagen AD, Wood MB. Prosthetic
[73] Beckenbaugh RD, Dobyns JH, Linscheid RL, et al. usage in major upper extremity amputations. J Hand
Review and analysis of silicone-rubber meta- Surg [Am] 1995;20:61922.
S.L. Moran, R.A. Berger / Hand Clin 19 (2003) 1731 31

[92] Hauge MF. The results of tendon suture of the during nger exion. J Hand Surg [Br] 1994;19:
hands: a review of 500 patients. Acta Orthop Scand 4348.
1954;24:25870. [104] Doyle JR, Blythe W. The nger exor tendon
[93] Kelly AP. Primary tendon repairs: a study of 789 sheath and pulleys: anatomy and reconstruction.
consecutive tendon severances. J Bone Joint Surg In: Hunter JM, Schneider LH, editors. Symposium
Am 1959;41:58198. on tendon surgery in the hand. St Louis: Mosby;
[94] Newport ML, Blair WF, Steyers CM. Long-term 1975. p. 817.
results of extensor tendon repair. J Hand Surg [Am] [105] Hume EL. Panel discussion: exor tendon re-
1990;15:9616. construction. In: Hunter JM, Schneider LH,
[95] Verdan CE. Primary and secondary repair of exor Mackin EJ, editors. Tendon surgery in the hand.
and extensor tendon injuries. In: Flynn JE, editor. St Louis: Mosby; 1987. p. 65862.
Hand surgery. Baltimore: Williams & Wilkins; 1966. [106] Idler RS. Anatomy and biomechanics of the digital
p. 22075. exor tendons. Hand Clin 1985;1:311.
[96] De Voll JR, Saldana MJ. Excursion of nger [107] Lin A, Amadio PC, An K, Cooney WP.
extensor elements in zone III. Presented at the Functional anatomy of the human digital exor
American Association for Hand Surgery. Toronto, pulley system. J Hand Surg [Am] 1989;14:
Canada, 1988. 94956.
[97] Boyes JH. Bunnells surgery of the hand. 5th [108] An KN, Chao EY, Cooney WP, Linscheid RL.
edition. Philadelphia: JB Lippincott; 1967. Forces in the normal and abnormal hand. J Orthop
[98] Ali A, Hamman J, Mass DP. The biomechanical Res 1985;3:20211.
eects of angulated boxers fractures. J Hand Surg [109] Curtis RM. Opposition of the thumb. Orthop Clin
[Am] 1999;24:83544. North Am 1974;5:30521.
[99] Elftman H. Biomechanics of muscle with partic- [110] Louis DS, Jebson PJL, Graham TJ. Amputations.
ular application to studies of gait. J Bone Joint In: Green DP, Hotchkiss RN, Pederson WC,
Surg Am 1966;48:3707. editors. Greens operative hand surgery. 4th
[100] Quaba AA, Elliot D, Sommerlad BC. Long term edition. New York: Churchill Livingstone; 1999.
hand function without long nger extensors: a p. 4875.
clinical study. J Hand Surg [Br] 1988;13:6671. [111] Scheker LR, Langley SJ, Martin DL, Julliard KN.
[101] Verdan CE. Syndrome of the quadriga. Surg Clin Primary extensor tendon reconstruction in dorsal
North Am 1960;40:4256. hand defects requiring free aps. J Hand Surg [Br]
[102] Fahrer M. In: Verdan C, editor. Tendon surgery of 1993;18:56875.
the hand. Edinburgh: Churchill Livingstone; 1979. [112] Slauterbeck JR, Britton C, Moneim MS, et al.
p. 1724. Mangled extremity severity score: an accurate
[103] Cobb TK, An KN, Cooney WP, Berger RA. guide to treatment of the severely injured upper
Lumbrical muscle incursion into the carpal tunnel extremity. J Orthop Trauma 1994;8:2825.