The anatomy and function of Cleland's ligaments

The cutaneous ligaments of the digits have been recognized by anatomists for several centuries, but the best known description is that of John Cleland. Subsequent varying descriptions of their morphology have resulted in the surgical community having an imprecise view of their structure and dynamic function. We micro-dissected 24 fresh frozen fingers to analyze the individual components of Cleland's ligamentous system. Arising from the proximal interphalangeal (PIP) joint, proximal, and sometimes middle phalanx, we found strong ligaments that ran proximally (PIP-P) and distally (PIP-D). On each side of each finger there was a PIP-P ligament present, which passed obliquely from the lateral side of the proximal and sometimes middle phalanx towards its insertion into the skin at the level of the proximal phalanx. The distal (PIP-D) ligaments were found to pass obliquely distally on the radial and ulnar aspects of the digit towards cutaneous insertions around the middle phalanx. A similar arrangement exists more distally with fibres originating from the DIP joint and middle phalanx (the DIP-P pass obliquely proximally, and the DIP-D, distally). Each individual PIP ligament consisted of three different layers originating from fibres overlying the flexor tendon sheath, periosteum or joint capsule, and extensor expansion. Ligaments arising at the DIP joint had two layers equivalent to the anterior two layers of the proximal ligaments. Cleland's ligaments act as skin anchors maintaining the skin in a fixed relationship to the underlying skeleton during motion and functional tasks. They also prevent the skin from 'bagging', protect the neurovascular bundle, and create a gliding path for the lateral slips of the extensor tendon.