Flexor Tendon Anatomy

• Flexor Tendon System

• The flexor tendon system of the hand consists of the flexor muscles of
the forearm, their tendinous extensions, and the specialized digital
flexor sheaths.
• These components work in concert to produce smooth and efficient
flexion of the individual digits of the hand.
• Injury to the flexor tendon system can lead to significant morbidity for
patients.
• In addition to having technical expertise, experienced hand surgeons
must have precise knowledge of flexor tendon anatomy to guide
appropriate treatment of injuries to the flexor tendon system.
Flexor tendons with attached vincula.
• Flexor Muscles of the Digits
• The forearm can be divided anatomically into anterior and posterior
compartments.
• The anterior compartment contains the flexor-pronator group of muscles, most of
which arise from a common flexor attachment on the medial epicondyle of the
humerus.
• The 8 muscles of the anterior compartment may be divided further into 3 distinct
functional groups, as follows:
• (1) muscles that rotate the radius on the ulna,
• (2) muscles that flex the wrist, and
• (3) muscles that flex the digits.
• The muscles that flex the digits include the
• flexor digitorum profundus (FDP),
• flexor digitorum superficialis (FDS), and
• the flexor pollicis longus (FPL).
• Flexor digitorum profundus
• The FDP muscle is a long, thick muscle that originates from the proximal
three fourths of the medial and anterior surfaces of the ulna and interosseous
membrane.
• According to Moore, the FDP clothes the anterior surface of the ulna.
• Occasionally, a proximal attachment to the radius is present just distal to the
radial tuberosity.
• As the single muscle belly of the FDP travels distally in the forearm, it
separates into a radial bundle and an ulnar bundle.
• At the musculotendinous junction, the radial bundle forms the profundus
tendon of the index finger.
• The ulnar bundle forms interdigitating slips that are covered by a single
paratenon, ultimately forming the individual profundus tendons of the middle,
ring, and small fingers.
• Motor branches from the C8 and T1 distribution of the ulnar
nerve provide innervation for the ring and small finger muscle
bellies. The anterior interosseous branch of the median nerve
(C8 and T1) innervates the index and middle finger muscle
bellies.
• The blood supply of the FDP muscle is made up of muscular
branches from the ulnar artery, anterior interosseous artery, and
common interosseous artery. Each tendon arising from the FDP
muscle flexes the proximal interphalangeal (PIP) joint and the
distal interphalangeal (DIP) joint.
• Flexor digitorum superficialis
• The FDS, as its name suggests, lies superficial to the FDP in the
anterior compartment of the forearm. This muscle has 2 heads of
origin in the proximal forearm. The ulnar head of the FDS arises from
the medial epicondyle of the humerus and the medial collateral
ligament of the elbow joint; a contribution from the coronoid process
may also be present. The radial head arises from an area distal to
the radial tuberosity.
• The FDS muscle forms 4 distinct bundles in the middle aspect of the
forearm, each of which, in turn, forms 4 distinct tendons in the distal
forearm. The tendons to the middle and ring fingers lie superficial to
the tendons of the index and little fingers, a relationship that aids in
their identification during surgery. Innervation to the FDS muscle is
provided by the C7, C8, and T1 distribution of the median nerve.
• The arterial blood supply of this muscle is provided by branches
of the artery of the median nerve, muscular branches of the
ulnar artery, and, occasionally, branches of the radial artery. The
FDS tendons to the index, long, ring, and small fingers insert
into the respective middle phalanx of the digit. The primary
function of the FDS is to flex the PIP joint.
• Flexor pollicis longus
• The FPL muscle lies lateral to the FDP muscle and originates
from the midanterior aspect of the radius and adjacent
interosseous membrane. The single muscle belly gives rise to 1
tendon, and it is innervated by the anterior interosseous branch
of the median nerve (C8 and T1). The FPL inserts into the distal
phalanx of the thumb, and its action is to flex the
interphalangeal and the metacarpophalangeal (MCP) joints of
the thumb.
• Flexor Tendons of the Digits

• The anatomic relationships of the flexor tendons are usually

discussed in terms of zones, shown in the image below. The 5 flexor
tendon zones are modifications of Verdan's original work, which
based zone boundaries from distal to proximal on anatomic factors
that influenced prognosis following flexor tendon repair.[22] The 5
zones discussed below apply only to the index through small
fingers—separate zone boundaries exist for the thumb flexor tendon.
• Zones of the hand. Note the relationships to the u Zones of the hand.
Note the relationships to the underlying structures.
• Zone I consists of the profundus tendon only and is bounded
proximally by the insertion of the superficialis tendons and distally by
the insertion of the flexor digitorum profundus (FDP) tendon into the
distal phalanx.

• Zone II is often referred to as "Bunnell's no man's land," indicating

the frequent occurrence of restrictive adhesion bands around
lacerations in this area. Proximal to zone II, the flexor digitorum
superficialis (FDS) tendons lie superficial to the FDP tendons. Within
zone II and at the level of the proximal third of the proximal phalanx,
the FDS tendons split into 2 slips, collectively known as Camper
chiasma. These slips then divide around the FDP tendon and reunite
on the dorsal aspect of the FDP, inserting into the distal end of the
middle phalanx.
• Zone III extends from the distal edge of the carpal ligament to
the proximal edge of the A1 pulley, which is the entrance of the
tendon sheath (see the A1 pulley in the image above). Within
zone III, the lumbrical muscles originate from the FDP tendons.
The distal palmar crease superficially marks the termination of
zone III and the beginning of zone II.

• Zone IV includes the carpal tunnel and its contents (ie, the 9
digital flexors and the median nerve). Zone V extends from the
origin of the flexor tendons at their respective muscle bellies to
the proximal edge of the carpal tunnel.
• Digital Flexor Sheath

• The digital flexor sheath is a closed synovial system consisting of

membranous and retinacular portions. The membranous portion is made
up of visceral and parietal layers that invest the flexor digitorum profundus
(FDP) and flexor digitorum superficialis (FDS) tendons in the distal aspect
of the hand. The retinacular component consists of tissue condensations
arranged in cruciform, annular, and transverse patterns that overlie the
membranous, or synovial, lining.

• Ultrastructural analysis by Cohen and Kaplan confirmed that the flexor

tendon sheath is a continuous, uninterrupted membrane.[23] The parietal
and visceral layers are qualitatively similar, and synoviocytes are
morphologically identical throughout the length of the flexor sheath
Membranous portion of the flexor tendon sheath
• The digital flexor sheath has been proposed to have a 3-fold function, as
follows: (1) it facilitates smooth gliding of the tendons; (2) the retinacular
component acts as a fulcrum, adding a mechanical advantage to flexion;
(3) it is a contained system, or bursa, with synovial fluid bathing the
tendons and aiding in their nutrition.

• The membranous portion of the sheath appears macroscopically as a

number of cul-de-sacs, or plicae, that interdigitate between the tendons
and the retinacular tissue condensations. The first cul-de-sac is located
approximately 10-14 mm proximal to the distal metacarpal head and
represents the point of transition between the parietal and visceral layers
of synovium. This outpouching occurs for each separate tendon, in effect
forming 2 separate plicae. (Note that this is true only for the middle 3 rays
of the hand. In most instances, the first- and fifth-digit synovial layers begin
much more proximally at the level of the wrist, and are referred to as the
radial and ulnar bursa, respectively.)
• Distally, the parietal layer of synovium forms plicae between
each of the retinacular elements of the pulley system. The
synovium ends distally, forming a final, single cul-de-sac prior to
the insertion of the FDP tendon on the distal phalanx. According
to Doyle, in a study of 61 cadaver fingers, the distal synovial
layer did not extend past the distal interphalangeal (DIP)
joint.[24]
• The retinacular portion, or pulley system, of the flexor tendon
sheath has been described extensively. Doyle described this
pulley system as fibrous tissue bands of various width,
thickness, and configuration that overlie the synovial sheath.[25]
The pulley system is thought to consist of the palmar
aponeurosis (PA) pulley, 5 annular pulleys, and 3 cruciform
pulleys. (See the image below.) The system supplies
mechanical advantage by maintaining the flexor tendons close
to the joint's axis of motion. In doing so, the pulleys prevent
bowstringing, which makes up interphalangeal and
metacarpophalangeal (MCP) joint motion.
Retinacular portion of the flexor tendon sheath (pulley system)
• The PA pulley consists of transverse fascicular bands arising from the PA.[26] The bands are approximately 1 cm in width, and the proximal edge of the pulley is 1-3 mm proximal to the origin of the membranous tendon sheath. The distal edge lies
approximately 8-10 mm from the proximal edge of the first annular pulley. The PA pulley is anchored by vertical septa that attach to the deep transverse metacarpal ligament beneath the tendons. This pulley is not as closely applied to the surface of the
flexor tendons as the annular and cruciate pulleys. However, during the act of grasping, increased tension on the palmar fascia by the flexor carpi ulnaris and palmaris longus muscles moves the pulley closer to the tendon surface.

• Annular pulleys

• The 5 annular pulleys are as follows:

• A1 pulley - The first annular pulley arises from the palmar plate and proximal portion of the proximal phalanx, overlies the membranous sheath at the level of the MCP joint, and is approximately 8 mm in width; this pulley is released during surgical
treatment of trigger finger (stenosing tenosynovitis)

• A2 pulley - The second annular pulley consists of oblique fibers that overlie annular fibers, originates from the proximal and lateral areas of the proximal phalanx, and is approximately 17 mm in width; this pulley should always be preserved when dealing
with injuries to the retinacular system

• A3 pulley - The third annular pulley is located at the level of the PIP joint; it attaches to the palmar plate and is approximately 3 mm in width

• A4 pulley - Like the A2 pulley, the fourth annular pulley, located in the middle phalanx, also consists of oblique fibers overlying annular fibers and is always preserved during surgery of the retinacular system; the A4 pulley is approximately 6.7 mm in width
and has been shown to be the most important biomechanical pulley for maintaining independent interphalangeal joint function

• A5 pulley - The fifth annular pulley is located proximal to the DIP joint, just proximal to the termination of the membranous sheath; the A5 pulley is the thinnest of the 5 annular pulleys and has a width of 4 mm

• Cruciform pulleys

• The 3 cruciform pulleys are as follows:

• C1 pulley - The first cruciform pulley lies just distal to the A2 pulley

• C2 pulley - The second cruciform pulley is located in the space between the A3 and A4 pulleys

• C3 pulley - The third cruciform pulley is located distal to the A4 pulley; a number of anatomic variations have been described for the retinacular system
• Thumb flexor tendon sheath

• A separate flexor tendon sheath has been described for the

thumb.[27] The membranous portion of the sheath originates
proximal to the radial styloid in the wrist and invests the single
FPL tendon. The retinacular system consists of 3 separate
pulleys overlying the membranous sheath, as follows:
• A1 pulley - The first annular pulley is located at the level of the
MCP joint; it is approximately 9 mm wide and originates from
the volar plate and base of the proximal phalanx
• Oblique pulley - This pulley overlies the sheath at the
midportion of the proximal phalanx; the fibers of the pulley are
angled obliquely in a proximal ulnar–to–distal radial direction,
the pulley is 11 mm wide, and fibers from the adductor pollicis
insertion make up the proximal portion (the oblique pulley is
always preserved during surgery of the retinacular system)
• A2 pulley - The second annular pulley is 10 mm in width and
attaches to the volar plate of the interphalangeal joint
• Additional details

• The function of the flexor tendon sheath becomes apparent with

an understanding of its anatomy. Bunnell described the
membranous portion of the tendon sheath as an adaptation that
allows tendons to turn corners when he stated, "It glides around
a curve on a thin film of synovial fluid between two smooth
synovial lined surfaces, just as metal surfaces in machinery
glide on a thin film of oil."[28]
• Strauch and de Moura described the membranous synovial lining as
a closed mesenteric system that resembles those of the abdominal
and thoracic cavities more than those of a joint space.[29]
Furthermore, the cul-de-sacs between the retinacular pulleys allow
for contraction and expansion of the entire system as the digits
respectively flex and extend.

• With respect to the function of the retinacular system, Doyle

described 3 key anatomic adaptations that prevent buckling of the
entire system during flexion: (1) the broad A2 and A4 pulleys are
located between joints, whereas the narrow A1 and A3 pulleys are
positioned over joints; (2) an anatomic accommodation always exists
between the A1 and A2 pulleys; (3) the thin and narrow cruciform
pulleys are located near joints where they are able to accommodate
flexion more readily than the larger annular pulleys can.
• Manske and Lesker described the functional anatomy of the
proximal pulley system in terms of total range of motion of
digital flexion.[30] The PA, A1, and A2 pulleys of each individual
digit in 12 cadaver hands were cut sequentially. The total loss in
range of motion was then calculated for the various
permutations of remaining pulleys.
• In terms of functional significance, Manske and Lesker found
that the A2 pulley was the most important, followed by the A1
and PA pulleys, respectively. However, loss of flexion with a
missing A1 or A2 pulley was proven to be insignificant in the
presence of an intact PA pulley. With the absence of an A1 or
A2 pulley, loss of flexion was significantly greater when
combined with loss of the PA pulley, leading the authors to
conclude that the PA pulley should be spared at all costs when
repairing hand injuries.
• Beneath the annular pulleys and on tendon surfaces that are
distant from the vincula (from the French, vincio, meaning "to
bind"; see the image below) and cul-de-sacs, the synovial layer
is attenuated. In these areas, the synovial cells are sparse and
widely spaced, and the supporting collagen is thin and laminar.
Furthermore, capillaries are rarely seen. However, the cul-de-
sacs and areas of vincular origin demonstrate a synovial layer
that is several cells thick, replete with capillaries and loosely
organized collagen bundles
Flexor tendons with attached vincula.
• Flexor Tendon Blood Supply

• From their musculotendinous origin to the level of the A1 pulley, the flexor tendons receive their blood supply from the
surrounding paratenon—a filmy layer of connective tissue that invests the tendon. The vascular supply is positioned
primarily within the dorsal surface of the tendon; segmental blood vessels arise within the connective tissue, enter the
tendon, and run longitudinally between tendon fascicles to supply nutrients.

• The flexor digitorum superficialis (FDS) muscles and the FDS tendons are known to have an overlying avascular
segment at the level of the proximal phalanx. The flexor digitorum profundus (FDP) has an additional avascular zone at
the level of the middle phalanx. However, when the tendons enter the flexor sheath, they are no longer surrounded by
paratenon but are incorporated within the visceral lining of synovium instead.

• Blood vessels are rarely, if ever, seen surrounding the tendons within the sheath. Within the sheath, the only connection
between the tendons and the periphery is at the level of the vincula, which are folds of mesotenon that carry a blood
supply to the tendons within the sheath. A number of variations exist, but most commonly, each tendon within the
sheath is supplied by 2 vincula, 1 long (vinculum longum) and 1 short (vinculum breve).
• The FDS receives a short and long vinculum at the level of the
proximal interphalangeal (PIP) joint. The FDS receives a long
vinculum at the level of the PIP joint, and the FDP receives a short
vinculum at the level of the distal interphalangeal (DIP) joint. In
addition, each vinculum is supplied by a transverse communicating
branch of the digital arteries.

• In the thumb, the flexor pollicis longus (FPL) tendon also is supplied
by 2 vincula within the sheath. The first vinculum receives vessels
either from both digital arteries or from the princeps pollicis artery
alone, whereas the second and more distal vinculum receives
vessels from only the digital arteries. All vincula enter on the dorsal
aspect of the flexor sheath, and in fact, most intratendinous blood
vessels are seen dorsally.[32]
• Within the flexor sheath, the tendons are also known to receive a
significant amount of nutrition by diffusion from the surrounding
synovial fluid. Since the turn of the 21st century, controversy has
existed as to which method, diffusion or perfusion, is more important
for tendon nutrition and healing. Currently, diffusion is thought to be
a more important pathway than perfusion.

• Researchers have used many methods—including vascular injection

studies, isotope and nonisotope tracer studies, and tendon healing
studies—in attempting to determine the relative contribution of each
type of nutrition. A detailed explanation of these studies is beyond
the scope of this article, but the interested reader is referred to the
excellent work by Manske and Lesker