Anatomy Physiology Pulp

Anatomy and Physiology
of the (fingertip) pulp
Pulp Facts
Christian Dumontier, MD, PhD
Centre de la Main, Guadeloupe
Thanks to Francesco
Brunelli, MD
Pulp Anatomy: ten fingers, should we

be afraid of it ?
1st message: All the fingertip pulps

are identical
A dorsal basement
A dorsal basement
Nail plate and nail structures
Nails are both a help or a problem to fingertip physiology
A dorsal basement
Bone
Bony anatomy
The distal phalanx

is divided in three
parts: base, shaft
and tuft
Li
Ann
Mi
Ind
The distal phalanx
Is surrounded by multiples fibrous structures that hold

the nail apparatus dorsally, the pulp septa volarly
The distal phalanx has evolved to allow

prehension
Monkey
Somewhere between 3 and 2

million years ago, the robust
parts of the bony distal
phalanx that evolved
characterized the early
hominids.
Hadar,
3,5 M BC
Gorilla
Olduvai
1,8 M BC
Man
Neanderthal
Early man must have

exploited this feature as he
became a tool user.
Shrewsbury MM, Johnson RK. Form, function, and evolution of the distal phalanx. J Hand Surg 1983; 8: 475-479.
Distal phalanx
Distal phalanx length is 11 mm and its width is 7mm at the tuft,

and around 3.0 mm at the shaft on a PA or a lateral view, similar on
radiographs and CT (2, 3)
Length of the medullary canal is, on average, two fifths of the external
length (1)
Most headless screws are too large to fit into the diaphysis (2)
1- Schulter-Ellis F, Lazar GT. Internal morphology of human phalanges. J Hand Surg 1984; 9A: 490-495.
2- Mintalucci D, Lutsky KF, Matzon JL, Rivlin M, Niver G, Beredjiklian PK. Distal Interphalangeal Joint Bony
Dimensions Related to Headless Compression Screw Sizes. J Hand Surg Am. 2014;39(6):1068-1074
3- Wang WL, Darke M, Goitz RJ, Andrews CL, Fowler JR. A Comparison of Plain Radiographs and Computed
Tomography for Determining Canal Diameter of the Distal Phalanx. J Hand Surg Am. 2015;40(7):1404-1409
A dorsal basement
Bone
Flexor tendon
FDP insertion
Insertion is widest proximally and

tapered distally
Length and width were 6.2 mm

(5.1-7. mm) and 7.9 mm (6.9-8.4
mm), w/o difference regarding
finger or sex
Insertion distance from the

proximal joint surface is 1.2 mm
(range, 0.4-2.1 mm) due to the
insertion of the volar plate
Chepla KJ, Goitz RJ, Fowler JR. Anatomy of the Flexor Digitorum Profundus Insertion.
J Hand Surg Am. 2015;40(2):240-244.
FDP insertion
Average surface area is

20% of the distal phalanx
(15-27%)
Calculated centroid is 3.6

mm (2.5-5.1 mm), 20% of
phalanx length (where to
place anchors !)
20%
Chepla KJ, Goitz RJ, Fowler JR. Anatomy of the Flexor Digitorum Profundus Insertion.
J Hand Surg Am. 2015;40(2):240-244.
FDP insertion at the distal phalanx (magnification x 6.3)
FDP bony insertion is partially

responsible for vascularization of
the tendon through two types of
vascular inflow
Plus the vinculum brevis proximally
Leversedge FJ, Ditsios K, Goldfarb CA, Silva MJ, Gelberen RH, Boyer MI. Vascular Anatomy of the Human
Flexor Digitorum Profundus Tendon Insertion. J Hand Surg 2002;27A:806812
The pulp itself is not homogenous
It is not filled
with fat (would
be unstable),
nor divided by
waterproof
septa
The pulp as a closed space (Kanavel 1912)
According to Kanavel the pulp is a

closed sac with multiples septa
This is partially true
Infection (or hematoma) stays in

the pulp which is closed
proximally
But during surgery there is no

need to break all the septa to
drain the infection
The pulp is separated by

multiples prominent rigid
collagen fibers that hold the
pulp in place, much as a
parachutist is attached to a
parachute
Uniformity of the fat distribution

(in columns) within the fingertip.
Pulp Nonfiction: Microscopic Anatomy of the Digital Pulp Space. Hauck RM, Camp L, Ehrlich HP, Saggers GC,
Banducci DR, Graham WP. Plast. Reconstr. Surg. 2004; 113: 536-539.
Shrewsbury MM, Johnson RK. Form, function, and evolution of the distal phalanx. J Hand Surg 1983; 8: 475-479.
Nerves and vessels
The collagen fibers allow for penetration

of vessels and nerves through the pulp
Whose anatomical distribution

sometimes allows for distal replantation
Arteries
Usually the collateral artery

divides into three branches at the
level of the DIP joint
One from the dorsal nail wall, one

for the nail bed and one for the
pulp
Arteries of the pulp
A palmar arch is present in

95,5% of 67 digits
Average diameter is 0.8 mm
Smith DO, Oura C, Kimura C, Toshimori K. Artery anatomy and tortuosity in the distal finger. J Hand Surg 1991;
16A: 297-302
Arteries
Palmar arch average distance is

of 13 mm from the most distal
skin
Located at the level of the

germinal matrix in 73,4% of
cases and distal to it in 26,6%
The arch is protected by the bony

prominence which serve as a bumper and
is located at the distal base of the slope
16A: 297-302
Arteries
A single dominant artery is

present in 98,5% of cases
and is usually tortuous
(protective anatomy and
allow for local flaps
advancement)
16A: 297-302
Distal arterial distribution
Non systematic
Through a very rich

anastomotic subcutaneous
patchwork
That allows the design of

numerous flaps
Elliot D, Moiemen NS, Jigjinni VS
(1995). The neurovascular
Tranquilli-Leali flap. Journal of
Hand Surgery, 20B: 815823.
Veins
Numerous, non systematic
Larger vessels are palmar

distal to the DIP
A single vein is found in 68%

at the joint line and in 96% of
time is > 0.5 mm.
Smith DO, Oura C, Kimura C, Toshimori K. The distal venous anatomy of the finger.
J Hand Surg 1991; 16A: 303-307
Nerves
5% branch off proximal to the DIP

crease, while 78% are branching
distally whatever the long finger
61% had a terminal trifurcation,

19% four to five terminal branches
and 20% a bifurcation.
Average thickness at the level of

the DIP joint is 0.85 mm (index),
0.84 mm (long), 0.72 mm (ring) and
0.49 mm (little).
Zenn MR, Hoffman L, Latrenta G, Hotchkiss R. Variations in digital nerve anatomy. J Hand Surg 1992; 17A:
1033-1036.
Kim J, Lee YH, Kim MB, Rhee SH, Baek GH. Anatomy of the direct small branches of the proper digital nerve of the
fingers: A cadaveric study. JPRAS 2014; 67, 1129-1135
The epidermis
0.7-0.9 mm thick
Covered with fingerprints

which are unique to an
individual
Gorillas, chimpanzees and

koalas all also have
fingerprints
Fingerprints appear at 10
weeks in the foetus as the
basal layer is crunched
between the dermis and
epidermis and, unlike special
diseases, are permanent
Formula to calculate the

formation of fingerprints
Kcken M, Newell AC . Fingerprint formation. Journal of Theoretical Biology 235 (2005) 7183
Pulp mensurations
Pulp length is 27 mm (index and

middle), 26 mm (annular) and 22
mm (little)
Pulp width is 15 mm
Pulp volume is 2000 mm3, 55%

of total fingertip volume
Pulp circonference is :
( x 15)/2 = 23,5 mm
Murai M, Lau H-K, Pereira BP, Pho RWH. A cadaver study on volume and surface area of the fingertip. J
Hand Surg 1997; 22A: 935-941)
Physiology of the pulp
Multiple and complex
Prehension which implies
Sensation which implies
Sensibility
Sensory receptors
Stability
Nerve fibers
Strength
Two dierent functional parts of the pulp
Distal: From the tuft to the

hyponychium
Proximal: from the DIP crease

to the proximal part of the tuft
Limited laterally by Flints

interphalangeal ligament
Thicker, More mobile for

prehension
Shrewsbury MM, Johnson RK: The fascia of the distal phalanx. J Bone Joint Surg (Am) 1975; 57:784-88
Prehension includes pushing and pulling forces
Pulling forces
One finger tip: 59,5 N (+/- 25)
One knuckle: 94,5 N (+/- 28),

an increase of 58%
Pushing forces
Force transmission is
modulated by the nonlinear
stiffening of the pulp.
The pulp is compliant at forces

less than 1 N (82% of the
displacement) and stiffens
rapidly at higher forces.
Cort JA, Potvin JR. Maximum isometric finger pull forces. Int J Industr. Ergonomics 2011; 41: 91-95
Serina ER, Mockensturm E, Rempel D. A structural model of the forced compression of the fingertip.
Journal of Biomechanics 31 (1998) 639646
Role of the proximal pulp in

prehension
Thickness and mobility of the

proximal pulp allows the soft
tissue to firmly mold about an
object and to hold the object
against the buttress of the
distal pull
All structures are useful for prehension
Fingerprints are useful to improve grasping, and make our ability

to regulate pressure and movement more precise.
Koala
Sweat glands are numerous (500 / cm ) and exit onto the

epidermal ridges. There are no pores between the ridges, though
sweat tends to spill into them.
The collagen fibers stabilize the skin to the underlying phalanx
Uniform repartition of the fat
The shape of the phalanx is also adapted to prehension with its

large tuft
Pan
Homo
Pulp of a double bassist

Randall WC. Quantification and regional distribution of sweat glands in man. J Clin Invest. 1946 Sep; 25(5): 761767.
Distal pulp is mostly made for sensation
2/3 of nerve fibers are sensory fibers: the pulp

is the eye of the hand
A Weber two-point discrimination test over 8 mm

at the pulp is equivalent to a non-functional pulp
Over 2500 receptors / cm at the

pulp: Merkels cells
Merkels cells are oval receptor cells

associated with the sense of light touch
discrimination of shapes and textures.
They are found in the stratum basale (at

the bottom of sweat duct ridges).
They are associated with slowly adapting

(SA1) somatosensory nerve fibers.
They are stimulated by low pressure and

their answer is maintained during the
stimulus that allow to differentiate
between two points (Reading Braille for
example)
Over 2500 receptors / cm at the pulp:

Meissners receptors
Meissners corpuscles are rapidly

adaptative receptors with highest
sensitivity when sensing vibrations
between 10 and 50 Hz.
They are located under the epidermis

and are stimulated by friction,
especially the speed of friction (after a
few minutes we do not feel that we are
wearing gloves, for example).
Their number on the fingertips drops

fourfold between the ages of 12 and
50 and this correlates well with the
age-related loss in touch sensitivity for
small probes (Semmes-Wenstein).
Thornbury JM, Mistretta CM. Tactile Sensitivity as a Function of Age J Gerontol (1981) 36 (1): 34-39
Over 2500 receptors / cm at the pulp:

Pacinian corpuscles
Pacinians corpuscles are located

into the dermis and hypodermic
and are mechanoreceptors only
responding to vibration (optimal
sensitivity is 250 Hz) and
variation of pression
The vibrational role may be used

to detect surface texture, e.g.,
rough vs. smooth.
Lamellar corpuscles are rapidly

adapting (phasic) receptors that
detect gross pressure changes
and vibrations in the skin
Distal pulp is also made for precise prehension
The papillary skin ridges are

transverse to assist in
resistance of dorsal-palmar
loads during precise grip
Shrewsbury MM, Johnson RK. Form, function, and evolution of the distal phalanx. J Hand Surg 1983; 8:
475-479.
Not to forget its social role
The skin is a sensory organ

for Touch, Vibration, Heat,
Cold, pain,.
It also carries socio-sexual,

and emotional sensations
Nor its artistic role
The ideal pulp should be
Thick
Stable
Sensible
Painless
but not
too
much !
How does a pulp regenerate ?
Cells that re- populate a regenerated

mammalian fingertip are tissue resident
There is limited dedifferentiation.
Circulating blood cells do not appear to

contribute.
Roshan A. Grant I. Lessons for Adult Fingertip Regeneration: Glimpses From Basic Research. J Hand Surg
2012;37A:12871290.
To be wiser: Why pulp fiction ?
It refers to books (pulps

magazines) in the first half of the
XXth century that were made
with cheap paper (woodpulp) and
sold at low prices - most of them
were fiction
It has been said that it brought

lectures and modernism in the
population
Famous pulps include: Tarzan,

Conan, Zorro,

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Anatomy and Physiology

of the (fingertip) pulp

Pulp Anatomy: ten fingers, should we

1st message: All the fingertip pulps

Nails are both a help or a problem to fingertip physiology

The distal phalanx

The distal phalanx

Is surrounded by multiples fibrous structures that hold

The distal phalanx has evolved to allow

Somewhere between 3 and 2

Early man must have

Distal phalanx length is 11 mm and its width is 7mm at the tuft,

Insertion is widest proximally and

Length and width were 6.2 mm

Insertion distance from the

Average surface area is

Calculated centroid is 3.6

FDP insertion at the distal phalanx (magnification x 6.3)

FDP bony insertion is partially

Plus the vinculum brevis proximally

The pulp itself is not homogenous

The pulp as a closed space (Kanavel 1912)

According to Kanavel the pulp is a

This is partially true

Infection (or hematoma) stays in

But during surgery there is no

The pulp is separated by

Uniformity of the fat distribution

Nerves and vessels

The collagen fibers allow for penetration

Whose anatomical distribution

Usually the collateral artery

One from the dorsal nail wall, one

Arteries of the pulp

A palmar arch is present in

Average diameter is 0.8 mm

Palmar arch average distance is

Located at the level of the

The arch is protected by the bony

A single dominant artery is

Distal arterial distribution

Through a very rich

That allows the design of

Numerous, non systematic

Larger vessels are palmar

A single vein is found in 68%

5% branch off proximal to the DIP

61% had a terminal trifurcation,

Average thickness at the level of

Covered with fingerprints

Gorillas, chimpanzees and

Formula to calculate the

Pulp length is 27 mm (index and

Pulp volume is 2000 mm3, 55%

Physiology of the pulp

Multiple and complex

Prehension which implies

Sensation which implies

Two dierent functional parts of the pulp

Distal: From the tuft to the

Proximal: from the DIP crease

Limited laterally by Flints

Thicker, More mobile for