ANATOMY AND

BIOMECHANICS OF THE
EXTENSOR SYSTEM
Christian Dumontier MD, PhD
Guadeloupe, FWI
 EXTENSOR SYSTEM

• Extrinsic extensor tendons [radial nerve]

• Intrinsics : extensor tendons, lumbricals, interossei,

reticular system [median ulnar and radial]

• The MP joint is the border

 EXTENSOR TENDONS
• Appeared early in
Ophiacodon (- 250 Millions
BC)

• Three groups of extensors

• Evolution to:

• Thumb independence

• Disparition of small hand

muscles
WHEELER-HAINES R. A revision of the extensor muscles of the forearm in tetrapods. J Anat. 1939 Jan; 73(Pt 2): 211–233.
 EXTENSOR TENDONS
• Radial: Brachioradialis, extensor carpi
radialis longus & brevis (& supinator)

• Super cial: extensor digitorum,

extensor carpi ulnaris, extensor digiti
minimi (and anconeus)

• Deep: abductor pollicis longus,

extensor pollicis brevis, extensor pollicis
longus, extensor indicis proprius

• EPL only inserts on thumb,

• No EPB in primates, 94% in humans

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 COMMON FEATURES

• The tendons cross the wrist

under the retinaculum
extensorum

• 6 compartments

• Synovial sheath

• Innervated by the radial

nerve (BR, ECRL, supinator,
ECRB, EDC, ECU, EDM, APL,
EPL, EPB, EIP)

Abrams RA et al. Anatomy of the Radial Nerve Motor Branches in the Forearm. J Hand Surg 1997;22A:232-237.
 COMMON
FEATURES
• Under the plane of nerves
and veins

• Loose aponeurotic
connections that thicken to
form the juncturae

• Round tendons amenable

to core sutures

• Ends at MP level
 FINGER EXTENSORS
• 3 muscles

• Extensor digitorum communis divides in 4

tendons, one for each nger.

• EDC tendons are linked by juncturae

tendinum.

• Extensor indices proprius and extensor

digiti minimi join the EDC on their ulnar
side

• Up to 28% of anatomical variations

(number of tendons, accessory muscles, …)

Hirai Y et al. An Anatomic Study of the Extensor Tendons of the Human Hand. J Hand Surg 2001;26A:1009–1015
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 JUNCTURA(E) TENDINUM

• ONLY between the EDC tendons

• 3 types

• Type 1: thickening of inter-

tendinous fascia

• Type II : Pseudo-ligament

• Type III: Tendinous type

Groves RJ; Dead languages in the living hand. JHS 1993; 18A(4):758-759.
Von Schroeder, H. P., Botte, M. J., and Gellman, H. Anatomy of the juncturae of the hand. J. Hand Surg (Am.) 15: 595, 1990.
Wehbé MA. Junctura anatomy. J Hand Surg 1992;17A: 1124 –1129
 PHYSIOLOGY OF JUNCTURAE 596 May-June 2003

RadioGraphics
• Limit nger independence : NO [may be for
the index]

• Stabilisation of extensor tendon during nger Figure 3. Axial anatomic slice (a) and axial T1-weighted M
forearm show the extensor muscles. 1 ! extensor carpi radial

exion over the metacarpal head : NO sor digiti minimi, 4 ! extensor carpi ulnaris, 5 ! abductor po
pollicis longus, 8 ! extensor indicis, 9 ! brachioradialis.

[sagittal bands] brevis, extensor digitorum, extensor digiti mi-

nimi, and extensor carpi ulnaris. These mus-
cles mainly originate from the posterior side of the
lateral epicondyle and in a portion of the inter-
muscular septum. The extensor carpi radialis lon-

• Participate to the extension of adjacent gus inserts on the dorsum of the base of the sec-
ond metacarpal, the extensor carpi radialis brevis
inserts on the dorsum of the base of the third

ngers metacarpal, and the extensor digitorum chiefly

inserts on the dorsal side of the fingers. The ex-
tensor digiti minimi inserts on the small finger,
and the extensor carpi ulnaris inserts on the dor-
soulnar side of the base of the fifth metacarpal.
From radial to ulnar, the group of deep
muscles consists of the abductor pollicis longus,
extensorJHS
Von Schroeder HP, Botte MJ. Anatomy of the Extensor Tendons of the Fingers:Variations and Multiplicity. pollicis brevis,
1995; extensor pollicis
20A:27-34. Vonlongus,
Schroeder
and extensor indicis. These muscles mainly origi-
HP, Botte MJ. The functional signi cance of the long extensors and juncturae tendinum in nger nate extension. J Hand Surg
in the midforearm in the 1993;18A:641-7.)
interosseous mem-
Kitano K et al. Independent index extension after indicis proprius transfer: excision of juncturae tendinum. J Hand Surg Am.
brane and cross the forearm in an 1996;21(6):992-6.
oblique fashion,
toward the radial aspect of the wrist. The abduc-
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 EXTENSOR DIGITI MINIMI
• Osteo- brous tunnel at the wrist

• Many variations (absent, one,

TWO, up to 4 bands)

• May arise from the ECU

• Is responsible for the Wartenberg’s

sign in ulnar nerve palsy

• Beware to use it for tendon

transfer (≈ 20% absent)

Yammine K. The prevalence of the extensor digiti minimi tendon of the hand and its variants in humans: a systematic review and meta-analysis.
Anat Sci Int (2015) 90:40–46
Zilber S, Oberlin C. Anatomical Variations of the Extensor Tendons to the Fingers over the Dorsum of the Hand: A Study of 50 Hands and a
Review of the Literature. Plast. Reconstr. Surg. 2014;113: 214-221
Gonzalez MH et al. The Extensor Tendons to the Little Finger: An Anatomic Study.J Hand Surg 1995;20A:844-847.
Wartenberg R. A sign of ulnar palsy. JAMA 1939;112: 1688.
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 EXTENSOR INDICES PROPRIUS

• Most often one tendon

• Ulnar to EDC 2 at the MP

level (81%) or deeper

• Up to 19% variations
including radial insertion
3-10% of cases

Gonzalez MH. Anatomy of the Extensor Tendons to the Index Finger. J Hand Surg 1996;21A:988-991
Zilber S, Oberlin C. Anatomical Variations of the Extensor Tendons to the Fingers over the Dorsum of the Hand: A Study of 50 Hands and a
Review of the Literature. Plast. Reconstr. Surg. 2014;113: 214-221
Cauldwell EW., Anson, B.J, Wright R.W. The extensor indicies propriius muscle. A study of 263 consecutive specimens. Q Bull Northwest Univ
Med Sch. 1943 Winter; 17(4): 267–279.
Mestdagh H, Bailleul J-P, Vilette B, Bocquet F, Depreux R. Organization of the extensor complex of the digits. Anat Clin. 1985;7(1):49-53.
 EIP

• Its muscular body is more

distal than the EDC (10 mm vs
50 mm from the radial styloid)

• It is always ulnar to the EDC 2

at the wrist

• It has no junctura
 WHEN THE EIP IS
A. 10-25% USED FOR TENDON
B. 30-45%
TRANSFER, WHICH
THE PERCENTAGE
C. 50-65% OF EXTENSION
D. 70-85 %
STRENGTH LOSS
(COMPARED TO
E. 90-100% CONTRALATERAL
SIDE) ?
 35-50 %

Noorda RJP et al. Index Finger Extension and Strength After Extensor Indicis Proprius Transfer. JHS 1984;19A:844-849.
Kerr CD, Gittins ME. Analysis of donor de cit after extensor indicis proprius tendon transfer. J Am Osteopath Assoc
1991;91:245-6,249.
De Smet L, Van Loon J, Fabry G. Extensor indices proprium to extensor pollicis longus transfer. Results and complications. Acta
Orthopedica Belgica 1997;63(3):178-181.
Lemmen MHM, Schreuders TAR, Stam HJ, Hovius SER. Evaluation of restauration of extensor policies longs by transfer of the
extensor indices proprius. J Hand Sur Eur 1999;24(1):46-49
Moore JR, Weiland AJ, Valdata L. Independent index extension after extensor indicis proprius transfer. J Hand Surg
1987;12A:232-6.
Magnussen PA, Harvey FJ, Tonkin MA. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon. J
Bone Joint Surg 1990;72B: 881-3.
Kitano K, Tada K, Shibata T, Yoshida T. Independant index extension after indices proprios transfer.Excision of the juncturae
tending. J Hand Sur Am 1996;21(6):992-996
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 AT THE MP LEVEL
• The extensor tendons
insert on the proximal
phalanx (75% of cases)

• They are joined by the

sagittal bands

• Then they will participate

to the extensor system
(with intrinsics and reticular
system)

Van Sint Jan S, Rooze M, Van Audekerke J, et al. The insertion of the extensor digitorum tendon on the proximal phalanx. J Hand
Surg Am 1996;21:69–76.
 SAGITTAL BANDS
• Free proximal edge

• distal edge merges with

interosseous hood

• Stabilise the tendon over the

MCP during mouvement

• Limit the course of the

extensor

• Avoid extensor bowstringing

in MP extension
Zancolli EA. Structural and dynamic bases of hand surgery. 2nd Ed. Philadelphia: JB Lippincott, 1979:3–36.
Young CM, Rayan GM. The Sagittal Band: Anatomic and Biomechanical Study. J Hand Surg 2000;25A:1107–1113.
Rayan GM, Murray D. Classi cation and treatment of closed sagittal band injuries. J Hand Surg 1994;19A:590–594.
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THE EXTENSOR SYSTEM AT THE FINGERS

• The extrinsics end with a

central band (P2) and two
lateral bands (P3)

• The intrinsics merge on the

central and lateral bands
(Interosseous both sides,
lumbricales radial side)
THE EXTENSOR SYSTEM AT THE FINGERS

• All are linked together by

the retinacular system
 INTEROSSEI
• Vesale: 4 dorsal = Finger
abduction; 3 palmar = nger
adduction

• Distal insertions

• Super cial: nger extension

• Deep: nger abduction and

MP exion
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 LUMBRICALS
• Origin: FDP (1-3,5 cm long)
• Variations:
• Proximal 22%
• Distal 40% (more frequent on the
ulnar side)
• Innervation: 1-2 ☞ Median ; 3-4 ☞
ulnaire 60% of cases 1 ☞ Median ;
2-3-4 ☞ ulnaire 20%; 1-2-3 ☞
Median ; 4 ☞ ulnaire 20%
Fahrer M. Observations on the origin of the lumbrical muscles in the human hand. J. Anat. (Lond.), 1971, 110, 505
Kaplan E.B. Anatomy injuries and treatment of the extensor apparatus of the hand and the digits. Clin. Orthop., 1959, 13, 24-40.
Mehta HJ, Gardner WU. A study of lumbrical muscles in the human hand. Am J Anat. 1961;109:227–238.
Palti R, Vigler M. Anatomy and Function of Lumbrical Muscles.Hand Clin 28 (2012) 13–17
Wang K et al. A Biomechanical and Evolutionary Perspective on the Function of the Lumbrical Muscle. J Hand Surg 2014;39(1):149-155
 LUMBRICALS

• Volar to the intermetacarpal

ligament

• End on the extensor system

(radial side): 25% only on
lateral bands, 58% oblique or
traverse bers, 48% on the
phalanx or palmar plate

Wang K et al. A Biomechanical and Evolutionary Perspective on the Function of the Lumbrical Muscle. J Hand Surg
2014;39(1):149-155
Eladoumikdachi F et al. Anatomy of the intrinsic hand muscles revisited: Part II: Lumbricals. Plast. Reconstr. Surg
2002;110:1225-1231
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 FUNCTION OF THE LUMBRICALS
• Almost null for nger exion (2% vs 22 IO); 12% for index
and middle in ulnar nerve palsy

• Extension of PIP/DIP: limited (90% from the IO). Useful for

knuckle walking

• Radial deviation: NO

• Proprioception +++: insertion on antagonists; bers can

extend up to 85-90% of muscle length; the richest in neuro-
muscular fascicles (136-139)
Buford WL Jr, Koh S, Andersen CR, et al. Analysis of intrinsic-extrinsic muscle function through interactive 3-dimensional kinematic
simulation and cadaver studies. J Hand Surg Am 2005;30(6):1267–75.
Schreuders TA, Stam HJ. Strength measurements of the lumbrical muscles. J Hand Ther. 1996;9(4):303–305.
Tuttle RH. Knuckle-walking and the evolution of hominoid hands. Am J Phys Anthropol. 1967;26(2):171–206.
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 RETINACULAR SYSTEM
• Transverse bers

• Sagittal bands

• Transverse retinacular ligament

• Triangular ligament

• Arciform bers

• Longitudinal bers

• Oblique retinacular ligament

Ueba H et al. An Anatomic and Biomechanical Study of the Oblique Retinacular Ligament and Its Role in Finger Extension. J
Hand Surg 2011;36A:1959–1964.
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 ROLE OF THE RETICULAR SYSTEM
• Stabilise the lateral bands in exion (arciform) and
extension (transverse ligament)

• Coordination between DIP and PIP movements

(cannot extend DIP with the PIP in exion; DIP
exion ==> PIP exion) - contribution of ORL is
25%

Harris, C., and Rutledge, G. L., Jr. The functional anatomy of the extensor mechanism of the nger. J. Bone Joint Surg. (Am.) 1972;54:
713-726.
Adkinson JM et al. The Clinical Implications of the Oblique Retinacular Ligament. J Hand Surg 2014;39(3)535-541.
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 BIOMECHANICS OF FINGER
EXTENSION

• Not so simple

• MP extension ☞ Extrinsics

• PIP/DIP ☞ Extrinsics,
intrinsics and retinacular

Zancolli EA. Structural and dynamic bases of hand surgery. 2nd Ed. Philadelphia: JB Lippincott, 1979:3–36.
Marshall TG et al. Mechanics of Metacarpophalangeal Joint Extension. J Hand Surg 2018; 43(7):681.e1-e5
 FINGER FLEXION
• Interossei then the exors

• Tension of the junctura and

sagittal bands stabilises the
extensor tendon over the
MP joint

• Interossei hood slides

distally ≈ 20 mm which
increases strength of exion
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 EXTENSOR SYSTEM DURING FINGER
FLEXION

• Length increases from 120

to 144 mm

• MP exion = 14 mm

• PIP exion = 6 mm

• DIP exion = 4 mm is
made possible by lateral
sliding of the lateral bands
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 FINGER EXTENSION

• Starts at the ngers

(intrinsics mostly)

• PIP > DIP

• Extrinsics pre-tension of the

sagittal bands (8% of MP
extension)
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 FINGER (MP) EXTENSION

• Extrinsics extend the MP joint

• And secondarily the PIP/DIP IF

the interosseous are functional
(Cruveilhier’s experiment - claw
hand)

Von Schroeder HP, Botte MJ. The functional signi cance of the long extensors and juncturae tendinum in nger extension. J Hand
Surg 1993;18A:641-7.)
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