The term 'black holes' has been applied to anatomical areas needing further study. The historical account On Growth and Form (D’AW Thompson, Cambridge University Press, 1917) applies mathematical principles to explain how physical forces influence the morphology of bone, tendon, ligament and fascia. The trabecular structure of bone is maintained by force loading, providing a map of strain concentrations to better understand fracture fixation and bone healing. The flexor tendon is classified in zones of sheath pathology, but the site of tendon injury depends on the posture at the moment of injury. Ligaments are multistranded structures and in maintaining joint stability throughout motion different fibrous strands must share load by ligament buckling. The fascial description of Guimberteau visualizes the human body as consisting of microvacuoles, quantifiable from the physical Laws of Plateau. Human morphology can be understood through mathematics. These ‘black holes’ offer possible research avenues to manage some of the unsolved problems in hand surgery or to optimize outcomes.
AllisonD M.Anatomy of the collateral ligaments of the proximal interphalangeal joint. J Hand Surg Am. 2005,
30: 1026–31.
2.
BainGIMacLeanSBMMcNaughtonT, Williams.
Microstructure of the distal radius and its relevance to distal radius fractures. J Wrist Surg. 2017,
6: 307–15.
3.
BallP.Nature’s Patterns; Shapes.
Oxford University Press2011.
4.
BBC. The Pentadactyl limb-Evolution-edexcel-GCSE Biology. 2024 https:www.bbc.co.uk.
5.
BellC.The Hand, its Mechanism and Vital Endowments as Evincing Design.
London:
William Pickering, 1833
6.
ChenSLinYYangHLiZLiS, et al.
A CD26+tendon stem progenitor cell population contributes to tendon repair and heterotopic ossification. Nat Commun. 2025,
16(1): 749.
7.
CohenMJKaplanL.Histology and ultrastructure of the human flexor tendon sheath. J Hand Surg Am. 1987,
12: 25–9.
8.
ChuangXLOoiCCChinST, et al.
What triggers in trigger finger? The flexor tendons at the flexor digitorum superficialis bifurcation. J Plast Reconstr Aesthet Surg. 2017,
70: 1411–19.
9.
Da VinciL. Royal Collection Trust. Folio 919020v and 919040r.
10.
DoyleJRBlytheW.The finger flexor tendon sheath and pulleys: anatomy and reconstruction. In: HunterJMSchneiderLH, eds. American Academy of Orthopaedic Surgeons Symposium on Tendon Surgery of the Hand.
St Louis, MO:
CV Mosby; 1975: 81–7.
GuimberteauJC.How is the anatomy adapted for tendon sliding? In: GuimberteauJC, ed. New Ideas in Hand Flexor Tendon Surgery.
Aquitaine Domaine Forestier; 2001: 47–90.
13.
GuimberteauJCDelageJPMcGroutherDAWongJKF.The microvacuolar system: how connective tissue sliding works. J Hand Surg Eur. 2010,
35: 614–22.
14.
HuiskesRRuimermanRvan LentheGHJanssenJD.Effects of mechanical forces on maintenance and adaptation of form in trabecular bone. Nature. 2000,
405: 704–6.
15.
KakarSKhanUMcGroutherDA.Differential cellular response within the rabbit tendon unit following tendon injury. J Hand Surg Br. 1998,
23: 627–32.
16.
KanavelAB.Infections of the Hand. 5th ed.
London:
Bailliere, Tindall & Cox; 1922.
17.
KembleSCroftAP.Critical role of synovial tissue: resident macrophage and fibroblast subsets in the persistence of joint inflammation. Front Immunol. 2021;
12: 1–17.
18.
KolovichGPHeifnerJJ.Proximal interphalangeal joint dislocations and fracture-dislocations. J Hand Surg Eur. 2023,
48(2_suppl):27S–34S.
19.
MayerL.The evolution of modern tendon surgery. Ann R Coll Surg Engl. 1952,
11: 69–86.
20.
McGroutherDA, Anatomy and Biomechanics of the Flexor System. Tendon Disorders of the Hand and Wrist. New York: Thieme 2022. IFSSH/FESSH Instructional Course Book 2022. Boyce DE, Giddins G, Shewring DS (Eds.).
21.
McGroutherD AO’HigginsP.The Interactive Hand.
London Primal Pictures1997.
22.
MerrileesMJFlintMH.Ultrastructural study of tension and pressure zones in a rabbit flexor tendon. Am J Anat. 1980;
157: 87–106.
23.
SaersJPPGordonADRyanTMStockJT.Trabecular bone ontogeny tracks neural development and life history among humans and non-human primates. Proc Natl Acad Sci USA2022,
119(49).
24.
SampsonSPBadalamenteMAHurstLCSeidmanJ.Pathobiology of the human A1 pulley in trigger finger. J Hand Surg Am. 1991,
16: 714–21.
25.
SchousboeJTDeBoldCRBowlesCGlicksteinSRubinoRK.Prevalence of vertebral compression fracture deformity by X-ray absorptiometry of lateral thoracic and lumbar spines in a population referred for bone densitometry. J Clin Densitom. 2002,
5: 239–46.
26.
SchmidtH-MZhangS-XZiesenissK.Clinical anatomy of the chiasma tendinum (Camper) in the fingers. Clin Anat. 1994,
7: 65–7.
27.
SimonDTascilarKUnbehendS, et al.
Bone mass, bone microstructure and biomechanics in patients with hand osteoarthritis. J Bone Miner Res. 2020,
33: 1695–1702.
28.
TaguchiMSunY-LZhaoC, et al.
Lubricin surface modification improves tendon gliding after tendon repair in a canine model in vitro. J Orthop Res. 2009,
27: 257–26.
29.
ThompsonD’A W.On Growth and Form.
Cambridge University Press, 1917.
30.
WalbeehmETMcGroutherDA.An anatomical study of the mechanical interactions of flexor digitorum superficialis and profundus and the flexor tendon sheath in zone 2. J Hand Surg Br. 1995,
20: 269–80.
31.
WolffJ.The Law of Bone Remodeling.
Berlink:
Springer, 1986 (translation of the German 1892 edition).
32.
WongJKFAlyouhaSKadlerKEFergusonMWJMcGroutherDA.The cell biology of suturing tendons. Matrix Biol2010,
6: 525–36.
