Research Article| Volume 13, ISSUE 4, P473-484, July 1988

Anatomy of the finger flexor tendon sheath and pulley system

  • James R. Doyle
    Reprint requests: James R. Doyle, MD, 1380 Lusitana, Suite 608, Honolulu, HI 96813.
    From the Division of Orthopedics, John A. Bums School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
    Search for articles by this author
      This paper is only available as a PDF. To read, Please Download here.
      Additions and changes in the description of the anatomy of the finger flexor sheath and pulleys that I published in 1974 and 1975 have prompted me to restudy this system. Sixty-one fresh human cadaver fingers were dissected using the operating room microscope. This study demonstrated a flexor synovial sheath composed of visceral and parietal elements from the neck of the metacarpal to the distal interphalangeal joint, which was overlaid with a series of retinacular structures (pulleys). The pulleys identified were the palmar aponeurosis pulley, five annular pulleys, and three cruciform pulleys. Although significant variations were noted in the morphology of the first annular and the cruciform pulleys sufficient similarity exists between my first description and the present study to support the use of the original descriptive terminology. A significant addition to the pulley system is the palmar aponeurosis pulley described by Manske and Lesker.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hunter JM
        • Cook JF
        • Ochiai N
        • Konikoff J
        • Merklin RJ
        • Mackin EA
        The pulley system. Proceedings of the American Society for Surgery of the Hand.
        Orthop Trans. 1980; 4: 4
        • Idler RS
        Anatomy and biomechanics of the digital flexor tendons.
        Hand Clinics. 1985; 1: 3-12
        • Kleinert HE
        • Broudy AS
        Direct repair and dynamic splinting of flexor tendon lacerations.
        in: Clinical biomechanics. Churchill-Livingstone, New York1981: 1-23
        • Kleinert HE
        • Lubahn JD
        Current state of flexor tendon surgery.
        Ann Chir Main. 1984; 3: 7-17
        • Manske PR
        • Lesker PA
        Palmar aponeurosis pulley.
        J Hand Surg. 1983; 8: 259-263
        • Strauch B
        • de Moura W
        Digital flexor tendon sheath: an anatomic study.
        J Hand Surg. 1985; 10A: 785-789
        • Strickland JW
        Flexor tendon repair.
        Hand Clinics. 1985; 1: 55-67
        • Strickland JW
        Flexor tendon injuries.
        Orthop Rev. 1986; 15: 21-34
        • Takahashi M
        Micro-constructive studies of human digital flexor tendon and tendon sheath—observation by scanning electron microscope and light microsurgery.
        Nippon Seikeigeka Gakkai Zasshi. 1982; 56: 133-147
        • Doyle JR
        • Blythe W
        Macroscopic and functional anatomy of the flexor tendon sheath.
        J Bone Joint Surg. 1974; 56A: 1094
        • Doyle JR
        • Blythe W
        The flexor tendon sheath and pulleys: anatomy and reconstruction.
        in: AAOS Symposium on tendon surgery in the hand. The CV Mosby Co, St. Louis1975: 81-87
        • Sakovich L
        • Burn HF
        Vacuum embedding of tissues in nitrocellulose.
        Am J Clin Pathol. 1965; 43: 396-398
        • Sheldrup EW
        Tendon sheath patterns in the hand an anatomical study based on 367 hand dissections.
        Surg Gynecol Obstet. 1951; 93: 16-22
        • Resnick D
        Roentgenographic anatomy of the tendon sheaths of the hand and wrist: tenography.
        Am J Roentgenol. 1975; 124: 44-51
        • Cohen MJ
        • Kaplan L
        Histology and ultrastructure of the human flexor tendon sheath.
        J Hand Surg. 1987; 12A: 25-29
        • Whittaker CR
        The arrangement of the synovial membrane in the palmar digital sheaths.
        J Anat. 1907; 41: 155-157
        • Bunnell SB
        Surgery of the hand.
        Philadelphia: JB Lippincott. 1944; : 277-278
        • Bojsen-Moller F
        • Schmidt L
        The palmar aponeurosis and the central spaces of the hand.
        J Anat. 1974; 117: 55-68
        • Fahrer M
        The proximal end of the palmar aponeurosis.
        Hand. 1980; 12: 33-38
        • Verdan CE
        Half a century of flexor-tendon surgery current status and changing philosophies.
        J Bone Joint Surg. 1972; 54A: 472-491
        • Barton NJ
        Experimental study of optimal location of flexor tendon pulleys.
        Plast Reconstr Surg. 1969; 43: 125-129
        • de la Caffiniere JY
        Anatomie fonctionnelle de la poulie proximal des doigts.
        Arch Anat Pathol. 1971; 19: 357-366
        • Knott C
        Schmidt HM.
        The fibrous reinforcing arrangements of the digital peritenons in the human hand Gegenbaurs morph Jahrb. 1986; 132: 1-28
        • Lister GD
        The hand, diagnosis and indications.
        2nd ed. Churchill Livingstone, Edinburgh1984
        • Lister GD
        Indications and techniques for repair of the flexor tendon sheath.
        Hand Clinics. 1985; 1: 85-95
        • Lundborg G
        • Myrhage R
        The vascularization and structure of the human digital tendon sheath as related to flexor tendon function.
        Scand J Plast Reconstr Surg. 1977; 11: 195-203
        • Schneider LH
        • Hunter JM
        Flexor tendons—late reconstruction.
        in: Green DP Operative hand surgery. Churchill Livingstone, New York1982: 1423
        • Shrewsbury M
        • Johnson RK
        The fascia of the distal phalanx.
        J Bone Joint Surg. 1975; 57A: 784-788
        • Azar C
        • Fleegler EJ
        • Culver JE
        Dynamic anatomy of the flexor pulley system of the fingers and thumb.
        in: Presented at 39th annual meeting. American Society for Surgery of the Hand, Atlanta1984
        • Yahia SR
        • Duncan H
        Synovial fluid analysis.
        Clin Orthop. 1975; 107: 11-24