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Soft Tissue Anatomy

Hand soft tissue anatomy: extrinsic/intrinsic muscle balance, fascial planes, neurovascular relationships & common anatomical variations.

Overview

A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management of acetabular fractures [1]. Comprehensive hand surgery principles emphasize balancing the restoration of function with the maintenance of aesthetic appearance [4]. For distal soft tissue defects at the proximal segment of the index, middle, ring, and little fingers, the dorsal nerve fascial island flap technique restores sensory function without damaging main nerves or blood vessels [3]. This flap is also an optimal option for finger soft tissue defects at the distal segments [3].

Surgical management of specific soft tissue pathologies requires precise indication selection. Dermofasciectomy is a highly effective surgical intervention for advanced Dupuytren disease, offering substantial long-term benefits in terms of function and disease control [6]. Surgical treatment for Keratoderma Hereditarium Mutilans (Vohwinkel Syndrome) should be limited to cases of neurovascular compromise rather than asymptomatic constriction bands [18]. The lateral pectoral flap is a versatile and reliable option for resurfacing soft tissue defects of the hand, offering good functional results, primary donor site closure, and patient comfort due to the elevated cross-chest position [62].

Nerve repair and reconstruction principles include minimizing tension and careful soft-tissue handling [25]. Treatment options for nerve defects include autograft, nerve conduit, and decellular allograft [25]. Latest research on nerve injury treatment includes polyethylene glycol therapy, electrical stimulation, nerve transfers, and neuroma management [25]. Published clinical results for contralateral C7 transfer demonstrate significant improvements in upper limb function for stroke or brain-injured patients [15], with donor site morbidity typically mild and transient [15]. Outcomes of total clavicle reconstruction with free peroneal graft met patient satisfaction, but advantages and complications should be carefully discussed due to limited evidence of superior clinical outcome [16]. Understanding current evidence and appropriate indications is of critical importance for the utilization of emerging technologies in orthopaedic trauma [28]. Safe limits for application time and surface pressures under digital tourniquets are difficult to define [26], questioning the 'one size fits all' philosophy regarding digital tourniquet application [26].

Anatomy & Pathophysiology

Hand surgery prioritizes balancing functional restoration with the maintenance of aesthetic appearance [4]. Accurate diagnosis and management of hand and carpal fractures and dislocations necessitate a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [20]. Biomechanical concepts such as stress, strain, and moments form the foundation for understanding the basic science underlying hand therapy treatment techniques [32].

Osseous and Joint Kinematics: During thumb oppositional motion, internal rotation of the first metacarpal occurs, with the palmar base rotating primarily with respect to the dorsal base [35]. The estimated lengths of principal ligaments stabilizing the thumb carpometacarpal joint change substantially during thumb motions in vivo [33]. Dimensional discrepancies and functional outcomes in obstetric brachial plexus paralysis patients are improved by scapula stabilization procedures [38].

Ligamentous and Pulley Systems: The thumb trapeziometacarpal joint ligaments possess an abundance of nerve endings in the dorsal ligaments but little to no innervation in the anterior oblique ligament [43]. Proprioceptive function is inferred for the thumb trapeziometacarpal joint ligaments in addition to their biomechanical importance [43]. The pulley system of the thumb is composed of 4 components, contrary to the traditional view of only 3 [40]. Individual flexor digitorum superficialis muscle contractions, particularly of the index and middle fingers, contribute most to stabilization against valgus stress [41].

Neuromuscular and Intrinsic Function: In-depth knowledge of extensor mechanism zone III and IV anatomy and biomechanics informs the use of relative motion flexion orthoses for managing non-surgical and surgical extensor mechanism injuries [21]. A force of 0.980 N applied to the lumbrical muscle is ideal for maximum finger trajectory and metacarpophalangeal joint balancing [36]. The investigation of intrinsic thumb muscles defined the action of each thenar muscle and correlated their individual actions with the group as a whole [37]. Dynamic flexion deformity of the distal thumb joint in ulnar-nerve paralysis is explained as a failure of ulnar-innervated muscles to extend the distal phalanx during pinch [37]. The first two lumbrical muscles may be functionally more important than the ulnar two, specifically for precision pinch movements [39]. Extending the ulnar fingers during pinching enhances the activity of key muscles involved in the movement and allows for more rapid force exertion [44].

Soft Tissue Properties: The extensibility of the dorsal skin of the hand generally increases from distal to proximal and from ulnar to radial [34]. Findings on upper limb tendon properties provide novel data to inform graft selection and tailor alternative engineered or regenerative strategies [42].

Classification

Acetabular and Coxa Vara Evaluation: A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management [1]. Evaluation of coxa vara should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5].

Muscle Injury Nomenclature: A nomenclature for skeletal muscle injuries integrates topographic location with histoarchitectonic features of the damage to connective tissue structures [2].

Hand Tumor-like Conditions: Tumor-like conditions of the hand and upper extremity typically present as masses and can be confused with more serious conditions [7]. Diagnosis often relies on clinical examination and imaging [7], but definitive diagnosis requires excisional biopsy to guide treatment [7].

Flexor Digitorum Superficialis Anomalies: Anomalies of the flexor digitorum superficialis are rare and can present a diagnostic dilemma [19]. A new classification for these anomalies has been proposed [19].

Dupuytren Disease Pathophysiology: Identification of extracellular matrix-cytoskeletal connections at the surface of the specialized contractile fibroblast (myofibroblast) is essential to understanding the pathophysiology of Dupuytren disease [23].

Vascular and Tendon Variants: Anatomic variations in the origin and disposition of the arteries to the second and fourth web spaces are associated with an atypical course posterior to the flexor tendons of the index and little fingers, respectively [27]. The cutaneous branch of the deep palmar artery presents several anatomical variants but has a constant existence [13]. This constant existence makes it suitable for use as a pedicle for proximal hypothenar flaps [13].

Extensor Tendon Classification: An additional category (Type 3) has been proposed to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual [50].

Joint Innervation and Sensory Systems: Findings on the innervation of the proximal interphalangeal joint provide an anatomical basis for procedures to denervate the PIP joint [30]. Examination of the distribution of type I and type II nerve endings provides information on the sensory systems of the PIP joints and surrounding structures [52]. Examination of the distribution of type I and type II nerve endings provides new information on the sensory systems of the DIP joints and surrounding structures [54].

Hand Nomenclature: A unified nomenclature for the volar retinacular elements of the hand has been proposed to facilitate clear communication across languages [55]. This unified nomenclature provides a practical anatomical guide for learners and surgeons [55].

Other Considerations: - Vascular Anatomy: The cutaneous branch of the deep palmar artery presents several anatomical variants but has a constant existence [13]. - Diagnostic Dilemmas: Anomalies of the flexor digitorum superficialis are rare and can present a diagnostic dilemma [19]. - Pathophysiology: Identification of extracellular matrix-cytoskeletal connections at the surface of the specialized contractile fibroblast (myofibroblast) is essential to understanding the pathophysiology of Dupuytren disease [23].

Clinical Presentation

A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management [1]. Evaluation of coxa vara requires a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5]. Skeletal muscle injury nomenclature must integrate topographic location with histoarchitectonic features of the damage to connective tissue structures to ensure accurate prognosis and understanding of recurrence [2].

Inspection and palpation of the hand and upper extremity must distinguish between tumor-like conditions, which typically present as masses and can be confused with more serious conditions [7], and classic Dupuytren disease, which is distinct from atypical non-Dupuytren disease in presentation, etiology, treatment, and prognosis [8]. While Dupuytren's disease presenting as a soft tissue mass mimicking a nerve sheath tumour in a Caucasian is a rare occurrence [9], dorsal cutaneous pads are not pathognomonic of the disease and their prevalence is similar in the normal population and Dupuytren's disease patients [46]. Anomalies of the flexor digitorum superficialis are rare and can present a diagnostic dilemma [19], whereas the accessory flexor pollicis longus tendon is a common anatomical variant that challenges existing anatomical knowledge and presents potential clinical implications for surgeons [45].

Palpation of the forearm may reveal muscle swellings; modern imaging and awareness of muscle anomalies can allow surgery to be avoided for clinically benign and asymptomatic cases [12]. In the hand, the cutaneous branch of the deep palmar artery presents several anatomical variants but has a constant existence, making it suitable for use as a pedicle for proximal hypothenar flaps [13]. Dorsal nerve fascial island flaps restore sensory function without damaging main nerves or blood vessels for distal soft tissue defects at the proximal segment of the index, middle, ring, and little fingers [3].

Diagnosis of tumor-like conditions often relies on clinical examination and imaging, with excisional biopsy needed for definitive diagnosis to guide treatment [7]. Histopathological examination of any suspicious lesion in the hand and digits is important when there is a known history of malignancy [47]. Infection of the deep soft tissues of the hand and wrist due to Prevotella bivia highlights the importance of microbiological identification and thorough surgical debridement [48]. Early surgical management may be considered for hand lesions of myositis ossificans with prominent symptoms [11].

Range-of-motion and functional assessment in Dupuytren disease requires identification of extracellular matrix-cytoskeletal connections at the surface of the specialized contractile fibroblast (myofibroblast) to understand the pathophysiology [23]. Early recurrence of Dupuytren's disease is most common in individuals with Dupuytren's diathesis [14]. Hand surgery principles emphasize balancing the restoration of function with the maintenance of aesthetic appearance [4].

Stability and special tests for deltoid contracture reveal pain, skin dimpling, palpable fibrous bands, and winging of the scapula, all of which are resolved by the procedure [22].

Investigations

Plain radiography: Clinical assessment combined with plain radiography demonstrates high accuracy for diagnosing intraosseous xanthoma of the hand in the absence of underlying lipid disorders [53]. Radiographic imaging is also fundamental for evaluating coxa vara, necessitating a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5]. Furthermore, accurate diagnosis and management of hand and carpal fractures and dislocations rely on appropriate imaging to limit joint stiffness while preserving mobility and function [20].

MRI: Magnetic resonance imaging is recommended for any osteolytic, expanding lesion, particularly when clinical and radiological findings do not clearly indicate an intraosseous epidermoid cyst [57]. MRI confirms that the donor site following autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [56]. Anatomical findings regarding the innervation of the proximal interphalangeal joint, confirmed via MRI, provide a basis for procedures to denervate the PIP joint [30]. MRI and histology have confirmed a distinct collagen septum exists between the extensor tendon and skin at the distal interphalangeal joint [61]. Additionally, modern imaging and awareness of muscle anomalies can allow surgery to be avoided for clinically benign and asymptomatic forearm muscle swellings [12]. Radiographic imaging has shown fascicular damage extending beyond the surgeon's visual assessment of epineural damage in simulated peripheral nerve lacerations, indicating that internal damage to nerves from traumatic lacerations was underappreciated by surgeons [67].

Other Considerations: A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management [1]. Skeletal muscle injury nomenclature should integrate topographic location with histoarchitectonic features of damage to connective tissue structures to ensure accurate prognosis and understanding of recurrence [2]. Diagnosis of tumor-like conditions of the hand and upper extremity often relies on clinical examination and imaging, with excisional biopsy needed for definitive diagnosis to guide treatment [7]. Dupuytren's disease presenting as a soft tissue mass mimicking a nerve sheath tumour in a Caucasian is a rare occurrence [9]. Recent studies confirm Littler's previously depicted anatomic consistency regarding the A1 pulley, which is reassuring for surgical procedures based on this consistency [66]. Anatomical findings regarding the flexor digitorum profundus insertion may aid in the anatomical attachment of the FDP tendon in the treatment of zone I injuries [71].

Treatment

A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management [1]. Evaluation of coxa vara should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5]. Treatment principles for hand disorders emphasize the balance between restoring function and maintaining aesthetic appearance [4]. Therapists can tailor therapies to allow optimal recovery based around progressive biophysical stimuli by movement through understanding the temporal and spatial biology of tissue repair [49].

Operative

Indications: Early surgical management may be considered for hand lesions of myositis ossificans with prominent symptoms [11]. Surgery can be avoided for clinically benign and asymptomatic forearm muscle swellings with the benefit of modern imaging and awareness of muscle anomalies [12]. Surgical treatment for Keratoderma Hereditarium Mutilans (Vohwinkel Syndrome) should be limited to cases with neurovascular compromise rather than asymptomatic constriction bands [18]. Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors [51].

Surgical Approach / Technique: A nomenclature for skeletal muscle injuries that integrates topographic location with histoarchitectonic features of the damage to connective tissue structures is proposed as essential for accurate prognosis and understanding recurrence [2]. The dorsal nerve fascial island flap technique restores sensory function without damaging main nerves or blood vessels for finger soft tissue defects at the distal segments [3]. Dermofasciectomy is a highly effective surgical intervention for advanced Dupuytren disease, offering substantial long-term benefits in terms of function and disease control [6]. Classic Dupuytren disease and atypical non-Dupuytren disease are distinct clinical entities that differ in presentation, etiology, treatment, and prognosis [8]. Bridging reconstruction of irreparable rotator cuff tears using acellular dermal matrix is a safe procedure with promising midterm clinical outcomes, showing significant improvement in clinical outcome scores at an average of 5-year follow-up [17]. Contralateral C7 transfer demonstrates significant improvements in upper limb function with donor site morbidity that is typically mild and transient [15]. Outcomes for total clavicle reconstruction with free peroneal graft met patient satisfaction, but advantages and complications should be carefully discussed due to limited evidence of superior clinical outcome [16].

Implant Selection: Principles of nerve repair and reconstruction include minimizing tension, careful soft-tissue handling, and treatment options for nerve defects such as autograft, nerve conduit, and decellular allograft [25]. Hand surgery and hand therapy practice interventions, including the use of relative motion flexion orthoses for management of non-surgical and surgical extensor mechanism injuries, may benefit from an in-depth look at extensor mechanism zone III and IV anatomy and biomechanics [21].

Adjuncts: Safe limits for application time and surface pressures under digital tourniquets are difficult to define, questioning the 'one size fits all' philosophy [26]. Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [28].

Complications

Nerve palsy: While the dorsal nerve fascial island flap technique can restore sensory function without damaging main nerves or blood vessels [3], nerve injuries remain a consideration in complex reconstructions. Published clinical results for contralateral C7 transfer demonstrate significant improvements in upper limb function, though donor site morbidity is typically mild and transient [15]. Anatomical variations in the origin and disposition of the arteries to the second and fourth web spaces are associated with an atypical course posterior to the flexor tendons of the index and little fingers, respectively, which may complicate surgical approaches [27].

Wound complications: Dupuytren's disease presents specific wound challenges, including early recurrence most common in individuals with Dupuytren's diathesis [14]. Full-thickness skin grafts may be helpful in this setting to manage early recurrence [14]. Osteophyte formation associated with Dupuytren's disease may be under-reported and requires minor surgical modifications such as the use of bone nibblers [59]. Additionally, burn scar contractures and Dupuytren's contractures share significant similarities as the body's response to an untoward event, warranting combined data sharing to alter long-term effects [60].

Soft tissue mass mimics: Rare presentations include Dupuytren's disease presenting as a soft tissue mass mimicking a nerve sheath tumour in a Caucasian [9]. Atypical lipomas of the hand and forearm may have a more benign behavior than atypical lipomas of other anatomical sites [63].

Other Considerations: A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management [1]. The proposed nomenclature for skeletal muscle injuries integrates topographic location with histoarchitectonic features of the damage to connective tissue structures to aid in accurate prognosis and understanding recurrence [2]. Treatment principles for hand disorders emphasize the balance between restoring function and maintaining aesthetic appearance [4]. Evaluation of coxa vara should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [5]. Dermofasciectomy is a highly effective surgical intervention for advanced Dupuytren disease, offering substantial long-term benefits in terms of function and disease control [6]. Limited surgical procedures improved finger, thumb, and wrist positions at 2-year follow-up in cases of upper limb congenital muscular hypertrophy and aberrant muscle syndrome in children [10]. The cutaneous branch of the deep palmar artery presents several anatomical variants but has a constant existence, making it suitable for use as a pedicle for proximal hypothenar flaps [13]. Outcomes for total clavicle reconstruction with free peroneal graft met patient satisfaction, but advantages and complications should be carefully discussed due to limited evidence of superior clinical outcome [16]. Bridging reconstruction of irreparable rotator cuff tears using acellular dermal matrix resulted in significantly improved clinical outcome scores with an average of 5-year follow-up [17]. Long-term outcomes of pelvic ring injury are dependent on the injury itself as well as associated injuries, and are complicated by posterior pelvic pain but also largely multifactorial [29]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [24].

Recovery

Light activity (weeks): Specific timelines for light activity, desk work, or driving are not explicitly defined in the provided evidence base. However, early surgical management may be considered for hand lesions with prominent symptoms in myositis ossificans to facilitate recovery [11]. For children with upper limb congenital muscular hypertrophy and aberrant muscle syndrome, limited surgical procedures improved finger, thumb, and wrist positions at the 2-year follow-up [10].

Full activity (months): Patients with pelvic fractures achieved full, independent weight-bearing at a median of 12 months following distraction osteogenesis reconstruction after resection of bone sarcomas [31]. In cases of acetabular fractures, management should be tailored to each patient's dynamic clinical course because these decisions affect patients' overall survival and outcome [68]. Long-term outcomes for pelvic fractures are dependent on the pelvic ring injury as well as the associated injuries [29].

Complete recovery / outcome plateau (months): Patients' clinical outcome scores significantly improved with an average of 5-year follow-up after interposition graft bridging reconstruction of irreparable rotator cuff tears using acellular dermal matrix [17]. Bridging reconstruction of irreparable rotator cuff tears using acellular dermal matrix is a safe procedure with promising midterm clinical outcomes [17]. Long-term outcomes for pelvic fractures are complicated by posterior pelvic pain but are also largely multifactorial [29]. Further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time for autologous matrix-induced chondrogenesis treatment of focal cartilage defects in the knee [24].

Rehabilitation protocol: A multi-disciplinary approach with long-term follow-up is recommended to monitor for local recurrence in intraosseous myoepithelioma of the hand [58]. Surgical treatment for Keratoderma Hereditarium Mutilans (Vohwinkel Syndrome) should be limited to neurovascular compromise rather than asymptomatic constriction bands [18]. Early changes in peri-articular bone density and microstructure seen in rheumatoid arthritis are slow or resistant to recover despite well controlled inflammatory joint symptoms with early DMARD therapy [69].

Functional milestones: A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management [1]. A nomenclature for skeletal muscle injuries that integrates topographic location with histoarchitectonic features of the damage to connective tissue structures is essential for accurate prognosis and understanding recurrence [2]. The dorsal nerve fascial island flap technique restores sensory function without damaging main nerves or blood vessels for finger soft tissue defects at the distal segments [3]. Dermofasciectomy offers substantial long-term benefits in terms of function and disease control for advanced Dupuytren disease [6]. Classic Dupuytren disease and atypical non-Dupuytren disease are distinct clinical entities that differ in presentation, etiology, treatment, and prognosis [8]. Early recurrence of Dupuytren's disease is most common in individuals with Dupuytren's diathesis [14]. The use of full-thickness skin grafts may be helpful in the setting of Dupuytren's diathesis [14]. The procedure for contracture of the deltoid muscle resolved pain, skin dimpling, palpable fibrous bands, and winging of the scapula, with no infections or neuromuscular complications [22]. Osteochondrolipoma of the hand treated with excision showed no sign of recurrence at the 1-year postoperative examination [70].

Other Considerations: Recovery trajectories are heavily influenced by specific pathologies; for instance, early changes in peri-articular bone density and microstructure seen in rheumatoid arthritis are consistent with changes more commonly seen in aging bone [69].

Key Evidence

  • [L5] The authors propose a nomenclature for skeletal muscle injuries that integrates topographic location with histoarchitectonic features of the damage to connective tissue structures, arguing that this combined approach is essential for accurate prognosis and understanding recurrence. (10.1177/2325967120909090)
  • [L4] The technique restores sensory function without damaging main nerves or blood vessels, making it an optimal option for finger soft tissue defects at the distal segments. (10.1186/s13018-022-03309-9)
  • [L5] Evaluation should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify coxa vara and select optimal treatment. (10.5435/00124635-199803000-00003)
  • [L3] Dermofasciectomy appears to be a highly effective surgical intervention for advanced Dupuytren disease, offering substantial long-term benefits in terms of function and disease control. (10.1016/j.jhsa.2025.02.007)
  • [L5] Tumor-like conditions of the hand and upper extremity typically present as masses and can be confused with more serious conditions; diagnosis often relies on clinical examination and imaging, with excisional biopsy needed for definitive diagnosis to guide treatment. (10.1016/j.jhsa.2017.09.012)
  • [L4] Dupuytren's disease presenting as a soft tissue mass mimicking a nerve sheath tumour in a Caucasian is a rare occurrence and to our knowledge not previously described. (10.1177/1753193409341892)
  • [L4] Limited surgical procedures improved finger, thumb, and wrist positions at 2-year follow-up. (10.1177/1753193418774459)
  • [Case_report] Their review of the literature supports the idea that early surgical management may be considered for hand lesions with prominent symptoms. (10.1016/j.jhsa.2017.03.007)
  • [L4] With the benefit of modern imaging and awareness of muscle anomalies, surgery can be avoided for clinically benign and asymptomatic forearm muscle swellings. (10.1054/jhsb.2001.0705)
  • [L5] Although it presents several anatomical variants, its constant existence makes it suitable for use as a pedicle for proximal hypothenar flaps. (10.1177/1558944719895785)
  • [L5] Early recurrence of disease is most common in individuals with Dupuytren's diathesis, and the use of full-thickness skin grafts may be helpful in this setting. (10.5435/00124635-199801000-00003)
  • [L5] Published clinical results have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient. (10.1177/17531934251314640)
  • [Case_report] While outcomes met the patient's satisfaction, advantages and complications of clavicle reconstruction should be carefully discussed with patients due to limited evidence of superior clinical outcome. (10.1186/s12891-019-2588-y)
  • [L4] Our results showed that patients' clinical outcome scores significantly improved with an average of 5-year follow-up, which demonstrates that bridging reconstruction is a safe procedure with promising midterm clinical outcomes. (10.1016/j.arthro.2021.08.001)
  • [L4] The indication for surgical treatment should be limited to neurovascular compromise rather than asymptomatic constriction bands. (10.1177/1753193408098901)
  • [L4] Anomalies of the flexor digitorum superficialis are rare and can present a diagnostic dilemma; this article summarizes previously reported anomalies, reports a further case, and proposes a new classification. (10.1177/1753193413478349)
  • [L5] Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics. (10.1016/j.jht.2023.01.002)
  • [L3] The procedure resolved pain, skin dimpling, palpable fibrous bands, and winging of the scapula, with no infections or neuromuscular complications. (10.2106/00004623-199802000-00010)
  • [L5] Identification of this connection is essential to understanding the pathophysiology of Dupuytren disease. (10.2106/00004623-198769090-00013)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L5] Safe limits for application time and surface pressures are difficult to define, and the 'one size fits all' philosophy is questioned. (10.1177/1753193413492059)
  • [L4] Anatomic variations in the origin and disposition of the arteries to the second and fourth web spaces are associated with an atypical course posterior to the flexor tendons of the index and little fingers, respectively. (10.1177/1753193418764289)
  • [L5] These findings provide an anatomical basis for procedures to denervate the PIP joint. (10.1016/j.jhsa.2018.07.014)
  • [L2] All patients achieved full, independent weight-bearing at a median of 12 months. (10.2106/jbjs.23.00707)
  • [Paper] This introductory article lays the foundation of biomechanical concepts such as stress, strain, and moments, which are necessary for understanding the basic science underlying hand therapy treatment techniques. (10.1016/j.jht.2011.12.006)
  • [L4] The estimated lengths of principal ligaments stabilizing the CMC joint change substantially during thumb motions in vivo. (10.1016/j.jhsa.2010.11.007)
  • [L4] Generally, the extensibility increased from distal to proximal and from ulnar to radial. (10.1177/1753193419864881)
  • [L5] During thumb oppositional motion, internal rotation of the first metacarpal occurred, with the palmar base rotating primarily with respect to the dorsal base. (10.1016/j.jhsa.2017.07.028)
  • [L5] A force of 0.980 N applied to the lumbrical muscle is ideal for maximum finger trajectory and MP joint balancing. (10.1177/1753193415597113)
  • [L5] The investigation defined the action of each thenar muscle and correlated their individual actions with the group as a whole, explaining the dynamic flexion deformity of the distal thumb joint in ulnar-nerve paralysis as a failure of ulnar-innervated muscles to extend the distal phalanx during pinch. (10.2106/00004623-196244060-00004)
  • [L4] Dimensional discrepancies and functional outcomes are improved by scapula stabilization procedures. (10.1007/s11552-014-9640-z)
  • [L5] The first two lumbricals may be functionally more important than the ulnar two, specifically for precision pinch movements. (10.1016/j.jhsa.2013.06.029)
  • [L4] The pulley system of the thumb is composed of 4 components, as opposed to the traditional view of only 3. (10.1016/j.jhsa.2012.08.005)
  • [L4] Individual FDS contractions, particularly of the index and middle fingers, contribute most to stabilization against valgus stress. (10.1186/s13018-020-01640-7)
  • [L5] These findings enhance understanding of upper limb tendon properties, providing novel data to inform graft selection and tailor alternative engineered or regenerative strategies. (10.1177/23259671261425673)
  • [L5] The thumb trapeziometacarpal joint ligaments had an abundance of nerve endings in the dorsal ligaments but little to no innervation in the anterior oblique ligament, inferring a proprioceptive function of these ligaments in addition to their biomechanical importance. (10.1016/j.jhsa.2011.12.038)
  • [L4] Extending the ulnar fingers during pinching enhances the activity of key muscles involved in the movement and allows for more rapid force exertion. (10.1177/17531934231211254)
  • [L4] The accessory FPL tendon is a common anatomical variant that challenges existing anatomical knowledge and presents potential clinical implications for surgeons. (10.1177/17531934251347077)
  • [L3] Dorsal cutaneous pads are not pathognomonic of Dupuytren's disease and their prevalence is similar in the normal population and Dupuytren's disease patients. (10.1016/j.jhsa.2010.06.001)
  • [L4] This case demonstrates the importance of histopathological examination of any suspicious lesion in the hand and digits when there is a known history of malignancy. (10.1177/1753193409103924)
  • [L4] This report describes the first case of infection of the deep soft tissues of the hand and wrist due to Prevotella bivia, highlighting that the importance of microbiological identification and thorough surgical debridement must not be underestimated. (10.1177/1753193414534382)
  • [L5] Understanding the temporal and spatial biology of tissue repair allows therapists to tailor therapies that allow optimal recovery based around progressive biophysical stimuli by movement. (10.1016/j.jht.2022.12.003)
  • [L4] The authors propose an additional category (Type 3) to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual, which were not previously represented in existing classifications. (10.1016/j.jhsg.2023.10.005)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L5] Our examination of the distribution of type I and type II nerve endings provides information on the sensory systems of the PIP joints and surrounding structures. (10.1016/j.jhsa.2010.04.026)
  • [L4] Clinical assessment and plain radiography were very accurate in our series. (10.1177/1753193411409316)
  • [L5] Our examination of the distribution of type I and type II nerve endings provides new information on the sensory systems of the DIP joints and surrounding structures. (10.1016/j.jhsa.2010.11.050)
  • [L5] The authors propose a unified nomenclature for the volar retinacular elements of the hand to facilitate clear communication across languages and provide a practical anatomical guide for learners and surgeons. (10.1016/j.jhsa.2017.12.015)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L4] Magnetic resonance imaging is recommended in any case of an osteolytic, expanding lesion, particularly in cases that are clinically and radiologically not obviously an intraosseous epidermoid cyst. (10.1177/1753193411401987)
  • [L4] A multi-disciplinary approach with long-term follow-up is recommended to monitor for local recurrence. (10.1177/1753193416676229)
  • [L4] This phenomenon may be under-reported and requires minor surgical modifications such as the use of bone nibblers. (10.1054/jhsb.1998.0214)
  • [L5] We confirmed the existence of a distinct collagen septum between the extensor tendon and skin at the DIP joint using MRI and histology. (10.1016/j.jhsa.2008.11.030)
  • [L4] The lateral pectoral flap is a versatile and reliable option for resurfacing soft tissue defects of the hand, offering good functional results, primary donor site closure, and patient comfort due to the elevated cross-chest position. (10.1054/jhsb.1999.0259)
  • [L4] The results of the current series and a review of the literature suggest that atypical lipomas of the hand and forearm may have a more benign behavior than atypical lipomas of other anatomical sites. (10.1016/j.jhsa.2015.12.032)
  • [L5] Recent studies confirm Littler's previously depicted anatomic consistency regarding the A1 pulley, which is reassuring for surgical procedures based on this consistency. (10.1016/j.jhsa.2011.03.047)
  • [L5] Radiographic imaging showed fascicular damage extending beyond the surgeon's visual assessment of epineural damage, indicating that the internal damage to nerves from traumatic lacerations was underappreciated by surgeons. (10.1016/j.jhsg.2025.100833)
  • [L2] Early changes in peri-articular bone density and microstructure seen in RA are consistent with changes more commonly seen in aging bone and are slow or resistant to recover despite well controlled inflammatory joint symptoms with early DMARD therapy. (10.1186/s12891-017-1888-3)
  • [L4] The tumor was treated with excision and showed no sign of recurrence at the 1-year postoperative examination. (10.1016/j.jhsa.2021.05.024)
  • [L5] These findings may aid anatomical attachment of the FDP tendon in the treatment of zone I injuries. (10.1016/j.jhsa.2014.11.004)

See Also

References

[1] Chapter 33 Evaluation and Management of Acetabular Fractures. 2021.

[2] A Histoarchitectural Approach to Skeletal Muscle Injury: Searching for a Common Nomenclature. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120909090

[3] Effect of dorsal nerve fascial island flap on repairing distal soft tissue defects at the proximal segment of the index, middle, ring, and little fingers. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03309-9

[4] 9. Hand Surgery. 2013.

[5] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[6] A Longitudinal Analysis of 281 Cases of Dermofasciectomy Efficacy in Advanced Dupuytren Disease Cases: A 20-Year Perspective. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.02.007

[7] Tumor-Like Conditions of the Hand and Upper Extremity. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.09.012

[8] 1. Dupuytren’s Disease: Anatomy, Pathology, and Presentation. n.d..

[9] The extensor digitorum brevis manus muscle. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409341892

[10] Upper limb congenital muscular hypertrophy and aberrant muscle syndrome in children. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418774459

[11] Management of Myositis Ossificans of the Hand: A Case Report and a Review of the Literature. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.03.007

[12] An Anomalous Flexor Carpi Ulnaris. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2001.0705

[13] The Cutaneous Branch of the Deep Palmar Artery and Blood Supply to the Proximal Hypothenar Skin: An Anatomic Research Oriented to Flap Design. HAND. 2020. DOI: 10.1177/1558944719895785

[14] Dupuytren’s Contracture. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199801000-00003

[15] Harnessing the uninjured hemisphere for treatment of the stroke or brain-injured patient – evolution of the contralateral C7 transfer. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251314640

[16] Total clavicle reconstruction with free peroneal graft for the surgical management of chronic nonbacterial osteomyelitis of the clavicle: a case report. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2588-y

[17] Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium‐Term Results. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.08.001

[18] Keratoderma Hereditarium Mutilans (Vohwinkel Syndrome). Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408098901

[19] Painful, palpable and pathological: anomalous flexor digitorum superficialis brevis in the palm, comparative anatomical context, and an updated classification of anomalies of the flexor digitorum superficialis. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413478349

[20] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[21] An in-depth look at zone III and IV anatomy of the finger extensor mechanism and some clinical implications for use of the relative motion flexion orthosis. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.01.002

[22] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010

[23] Extracellular matrix-cytoskeletal connections at the surface of the specialized contractile fibroblast (myofibroblast) in Dupuytren disease. The Journal of Bone & Joint Surgery. 1987. DOI: 10.2106/00004623-198769090-00013

[24] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[25] Chapter 30 Management of Traumatic Nerve Injuries in the Upper Extremity. 2021.

[26] Variability in local pressures under digital tourniquets. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413492059

[27] Variations in the origins and absence of the common digital arteries of the hand: a cadaveric study. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418764289

[28] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[29] Chapter 32 Pelvic Fractures: Definitive Treatment and Outcomes. 2021.

[30] Innervation of the Proximal Interphalangeal Joint: An Anatomical Study. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.07.014

[31] Distraction Osteogenesis Reconstruction Following Resection of Bone Sarcomas. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00707

[32] Understanding the Biomechanical Nature of Musculoskeletal Tissue. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2011.12.006

[33] In Vivo Length and Changes of Ligaments Stabilizing the Thumb Carpometacarpal Joint. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.007

[34] Longitudinal extensibility of the dorsal skin of the hand. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419864881

[35] In Vivo 3-Dimensional Kinematics of Thumb Carpometacarpal Joint During Thumb Opposition. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.07.028

[36] How the lumbrical muscle contributes to placing the fingertip in space: a three dimensional cadaveric study to assess fingertip trajectory and metacarpophalangeal joint balancing. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415597113

[37] Observations on the Functional Anatomy of the Intrinsic Muscles of the Thumb. The Journal of Bone & Joint Surgery. 1962. DOI: 10.2106/00004623-196244060-00004

[38] Morphometric Analysis of the Effect of Scapula Stabilization on Obstetric Brachial Plexus Paralysis Patients. HAND. 2014. DOI: 10.1007/s11552-014-9640-z

[39] A Biomechanical and Evolutionary Perspective on the Function of the Lumbrical Muscle. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.06.029

[40] Varied Anatomy of the Thumb Pulley System: Implications for Successful Trigger Thumb Release. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.08.005

[41] Valgus stability is enhanced by flexor digitorum superficialis muscle contraction of the index and middle fingers. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01640-7

[42] The Biomechanical, Biochemical, and Morphological Properties of 31 Human Cadaveric Upper Limb Tendons: An Open Access Data Set. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261425673

[43] Innervation Patterns of Thumb Trapeziometacarpal Joint Ligaments. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.12.038

[44] Effect of extension of the ulnar fingers on force control and muscle activity of the hand during a precision pinch. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231211254

[45] Accessory flexor pollicis longus tendon – a clinical and cadaveric study. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251347077

[46] Dorsal Pads Versus Nodules in Normal Population and Dupuytren's Disease Patients. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.001

[47] Leukaemia cutis of the distal phalanx of the right thumb. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409103924

[48] An anatomical study of the neurovascular anatomy of the web spaces between the fingers. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414534382

[49] How controlled motion alters the biophysical properties of musculoskeletal tissue architecture. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2022.12.003

[50] Accessory Extensor Pollicis Longus Tendon Classification Modification. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.10.005

[51] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[52] Distribution of Nerve Endings in the Human Proximal Interphalangeal Joint and Surrounding Structures. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.04.026

[53] Intraosseous xanthoma of the hand without an underlying lipid disorder. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411409316

[54] Distribution of Nerve Endings in Human Distal Interphalangeal Joint and Surrounding Structures. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.050

[55] Anatomy of the Volar Retinacular Elements of the Hand: A Unified Nomenclature. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.12.015

[56] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[57] Intraosseous epidermoid cysts of the hand skeleton: a series of eight patients. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411401987

[58] Intraosseous myoepithelioma: a rare tumour in the hand. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416676229

[59] Osteophyte Formation in Association with Dupuytren’s Disease. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1998.0214

[60] 10. Dupuytren’s Contracture Versus Burn Scar Contracture. n.d..

[61] Dorsal Digital Septum of the Distal Interphalangeal Joint. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.11.030

[62] The Lateral Pectoral Flap. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0259

[63] Conventional and Cellular Atypical Lipomas of the Hand and Forearm: A Report of 9 Cases. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2015.12.032

[66] Anatomical Study of the A1 Pulley: Length and Location by Means of Cutaneous Landmarks on the Palmar Surface. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.03.047

[67] More Than Epineurium Deep: Characterizing Peripheral Nerve Damage Using High-Resolution Micro-Computed Tomography for Simulated Peripheral Nerve Lacerations. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100833

[68] Chapter 31 Pelvic and Acetabular Fractures: Evaluation and Acute Management. 2021.

[69] Micro-structural bone changes in early rheumatoid arthritis persist over 1-year despite use of disease modifying anti-rheumatic drug therapy. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1888-3

[70] Osteochondrolipoma of the Hand. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.05.024

[71] Anatomy of the Flexor Digitorum Profundus Insertion. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.11.004

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