RESEARCH ARTICLE
Probability of Spacesuit-Induced Fingernail Trauma
Is Associated with Hand Circumference
Roedolph A. Opperman, James M. A. Waldie,
Alan Natapoff, Dava J. Newman, and Jeffrey A. Jones
OPPERMAN RA, WALDIE JMA, NATAPOFF A, NEWMAN DJ, JONES JA.
The primary NASA EVA training facility, the Neutral
Probability of spacesuit-induced fingernail trauma is associated with
Buoyancy Laboratory (NBL) at the Johnson Space
hand circumference. Aviat Space Environ Med 2010; 81:907–13.
Center, Houston, TX, simulates the weightless condiIntroduction: A significant number of astronauts sustain hand injuries
tions of orbital operations. The NBL is a 23.5 million L
during extravehicular activity training and operations. These hand injuries have been known to cause fingernail delamination (onycholysis)
water tank that contains full-sized mock-ups of the
that requires medical intervention. This study investigated correlations
Space Shuttle cargo bay, flight payloads, and Internabetween the anthropometrics of the hand and susceptibility to injury.
tional Space Station (ISS) elements. The spacesuit asMethods: The analysis explored the hypothesis that crewmembers with
semblies used in the NBL are certified for training only
a high finger-to-hand size ratio are more likely to experience injuries.
A database of 232 crewmembers’ injury records and anthropometrics
Delivered by Ingenta
to: ? the custom training gloves. Initial crewmemand accept
was sourced from NASA Johnson Space Center.
Results: No signifi
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EVA
qualifi
cation, evaluation, and skills training
effect of finger-to-hand size was found on the probability of injury, but
requires
;
65
h,
as
compared with specific mission traincircumference and width of the metacarpophalangeal (MCP) joint were
ing which consists, on average, of 11.6 h per hour of
found to be significantly associated with injuries by the Kruskal-Wallis
test. A multivariate logistic regression showed that hand circumference is
flight EVA and begins approximately a year before the
the dominant effect on the likelihood of onycholysis. Discussion: Male
scheduled spaceflight (23).
crewmembers with a hand circumference . 22.86 cm (9”) have a 19.6%
Despite the advances in spacesuit glove technology
probability of finger injury, but those with hand circumferences ⱕ 22.86
and fabrication, astronauts still claim that the hardest
cm (9”) only have a 5.6% chance of injury. Findings were similar for female crewmembers. This increased probability may be due to constricpart of any EVA is working with the hands (2). Hand
tion at large MCP joints by the current NASA Phase VI glove. Constriction
dexterity, tactility, strength, and endurance are reduced
may lead to occlusion of vascular flow to the fingers that may increase
because of the large force required to bend the rigid, gasthe chances of onycholysis. Injury rates are lower on gloves such as the
pressurized materials from the neutral position (17,3,21).
superseded series 4000 and the Russian Orlan that provide more volume
for the MCP joint. This suggests that we can reduce onycholysis by modiIn addition, the gloves are often uncomfortable to the
fying the design of the current gloves at the MCP joint.
point of pain and/or minor physical injury to the hand:
Keywords: fingernail delamination, onycholysis, extravehicular activity,
they cause calluses, abrasions, contusions, fingernail
anthropometric data, EMU glove, hand injury, space suit, astronaut.
trauma, wrist and forearm muscle stress, and nerve imCopyright: Aerospace Medical
Association
pingements
between the thumb and forefinger (20,21,18).
E
XTRAVEHICULAR activity (EVA) spacesuits are a
key enabling technology for space operations, particularly during construction, maintenance, and exploration missions (10). The NASA EVA suit, called the
Extravehicular Mobility Unit (EMU), is a 14-layer bodyshaped enclosure pressurized with 100% oxygen at 29.6
kPa (4.3 psi) (22,11). The current Phase VI EMU glove
was first flown in December 1998. The design of the
gloves is regarded as the greatest engineering challenge
to suit design. Developing a small tactile joint for the
fingers has been extremely challenging (10,6,16). The
Phase VI is custom-made for each crewmember using
hand casting, laser scanning, 3D computer modeling,
stereo-lithography, laser cutting, and CNC machining.
This yields better fit and improved comfort and mobility
as compared to the superseded Series 4000 gloves. At
the same time, they can be produced more quickly and
at lower cost (5). When a crewmember is selected for an
EVA mission, a pair of gloves is fabricated and delivered
for fit-check. This pair will be used for training, while
other pairs are crafted for flight use.
In a study of in-flight EVA injuries to U.S. astronauts, 20
instances of hand injury were reported, followed by 12
to the foot (14). Strauss (19) found that in 770 EVA training sessions conducted from 2002 to 2004, 352 injury
symptoms were reported. Of those, the largest number
related to the hand (47.2%) and the shoulders (20.7%).
More than half of the hand symptoms were due to fingertip and nail contact with the glove. During the study
period 18 astronauts required continued medical care
From the Department of Aeronautics and Astronautics, Massachusetts Institute of Technology, Cambridge, MA, and Space Medicine &
Healthcare Systems, NASA Johnson Space Center, Houston, TX.
This manuscript was received for review in April 2010. It was
accepted for publication in July 2010.
Address correspondence and reprint requests to: Prof. Dava J.
Newman, Department of Aeronautics and Astronautics, Massachusetts
Institute of Technology, 77 Massachusetts Ave., Rm. 33-307, Cambridge,
MA 02139; [email protected].
Reprint & Copyright © by Aerospace Medical Association,
Alexandria, VA.
DOI: 10.3357/ASEM.2810.2010
Aviation, Space, and Environmental Medicine x Vol. 81, No. 10 x October 2010
907
EMU ONYCHOLYSIS ANTHROPOMETRICS—OPPERMAN ET AL.
Grasping power is, therefore, shared better between the
for hand complaints, 13 of which were for fingernail debase of the fingers and the palm (almost like a mitt), which
lamination from the nail bed (19).
effectively reduces the finger-to-hand length ratio (4). The
Fingernail delamination or onycholysis is probably
aim of this study was to determine if any hand or finger
caused by axial loading of the fingernails during hard
dimension predicts a greater likelihood of fingernail decontact with the protective ‘thimbles’ inside the glove
lamination injury when using the EMU glove. In particuwhen reaching or forcefully grasping an object (18). Axial
lar, the finger-to-hand ratio was analyzed to explore the
loading is also increased during training, as the common
hypothesis that astronauts with proportionally longer
pose of pitching forward (and even lying supine) forces
fingers are more prone to onycholysis.
the fingers to support part of the bodyweight when
stretching the arms out to work below the body’s center
of mass. The presence of moisture (9) and abnormal perMETHODS
fusion of blood to the fingernail bed as a result of contact
Injury data was collected from the Injury Tracking
pressure inside the glove (12) may also contribute. This is
System (ITS) at NASA Johnson Space Center (JSC).
analogous to reperfusion injury commonly observed folThis database, recently compiled by Wyle Laboratories
lowing organs that have been made transiently ischemic.
(Houston, TX) from several existing medical logs, is the
Following post-ischemia reperfusion, there is capillary
most comprehensive injury archive for U.S. astronauts
fluid and cellular leak, which could result in increased
(7). ITS data sources include JSC EVA logs, NBL training
interstitial fluid pressure or swelling. In a fingertip with
reports, flight surgeon records in the Electronic Medical
an intact nail, the increased tissue pressure against the
Records during ISS and Space Shuttle missions, and
rigid nail could be sensed by the pain fibers in the nail
from other NASA or NASA-sponsored physiologic rebed, thus causing crewmember discomfort. This reperfusearch projects. Anthropometric data was obtained
sion-induced pressure increase in the nail matrix is
Delivered
to: sizing
?
from JSC
measurements taken during the custom
hypothesized to cause the nail to detach from
the nailby Ingenta
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glove-fitting process for each hand. A NASA flight surbed, resulting in the onset of fingernail delamination.
geon reviewed the ITS for completeness and accuracy,
Hyperperfusion, the term used for the fierce return of
recorded the anthropometric data to each subject, and
once constricted blood to a blood-deprived in vivo tissue
anonymized the archive before release. Fig. 1 shows the
region, is hypothesized to intensify these effects. The
22 hand parameters recorded for each hand of each asmost effective countermeasure for onycholysis as retronaut in that process, which were combined with subported by Strauss (18) is optimal glove sizing and fitting.
ject height and weight to form the complete individual
Other countermeasures include cutting the fingernails
anthropometric variables included in this study. The
as short as possible, applying dressings that will protect
the fingertips, and keeping the fingers free of moisture.
Dressings commonly used for this purpose include:
Dermabond™ topical skin adhesive (New Brunswick,
NJ); Tegaderm™ (St. Paul, MN); Band-Aidw; and Medfix
Moleskin adhesive bandage (Indianapolis, IN) (18). The
continuing high prevalence of onycholysis shows that
these countermeasures have been largely
ineffective:
at
Copyright:
Aerospace
Medical Association
least one astronaut had his/her fingernails removed for
EVA operations to prevent pain, obstruction of the fingertip by the loose/protruding nail inside the glove, and the
risk of secondary bacterial or yeast infection of the exposed bed in the moist confines of the glove (4).
The complexity of joints and dimensions inherent in
the hand pose a fundamental challenge to glove performance beyond the glove design itself: if fingers are short,
for example, the hand has no significant fulcrums about
which to bend the pressurized joints (17). Crewmembers
with longer fingers need apply only small fingertip pressure to create the necessary torques. We hypothesized,
however, that to hold a given item, EVA crewmembers
with longer fingers (or large finger-to-hand ratios) must
grasp with proportionately more finger articulation, causing greater movement, contact force, and consequent
trauma inside the glove. Crewmembers have also noted
that finger injury is subjectively lower in the Russian
Orlan glove, which despite being pressurized at a higher
and inherently more rigid level of 38.6 kPa (5.6 psi), has a
larger palm and shorter, stubbier finger lengths than the
EMU. It is also not so closely fitted into the finger crotches.
Fig. 1. Measured hand parameters for EMU glove sizing.
908
Aviation, Space, and Environmental Medicine x Vol. 81, No. 10 x October 2010
EMU ONYCHOLYSIS ANTHROPOMETRICS—OPPERMAN ET AL.
TABLE I. NUMBERS OF INJURED AND UNINJURED CREWMEMBERS
WHO HAVE COMPLETE ANTHROPOMETRIC DATA.
We found no difference between the results for righthanded male crewmembers and for the average of all
male crewmembers. Our analysis focused on the rightInjured Uninjured
Gender Handedness Crew
Crew % Injured
handed male crewmembers, as this constitutes the largest group of subjects.
Male right hand M
Right
16
141
10.19
Before the experiment we expected that hand length,
Male left hand
M
Left
3
16
15.79
hand circumference, and finger-to-hand ratio would be
Male unknown
M
Unknown
1
15
6.25
hand
most closely related to delamination. Therefore, to inMale fingernail
M
20
172
10.42
sure a family significance level of 0.05, we applied a
delamination
Bonferroni correction that requires P , 0.05/3 5 0.0167
Female right hand F
Right
1
27
3.57
Female left hand F
Left
0
6
0.00
separately for each measure. If the distributions of a
Female unknown F
Unknown
1
5
16.67
measure, injured and uninjured, were consistent with a
hand
normal distribution [one-sample Kolmogorov-Smirnov
Female fingernail F
2
38
5.00
(KS) test] we applied a two-sample t-test. Otherwise, we
delamination
Total
M&F
22
210
9.48
applied a Kruskal-Wallis (KW, i.e., the Mann-Whitney
test in this special case of one degree of freedom) test. It
is also possible to have significant differences between
finger-to-hand ratio is the length of the lateral side of
(e.g., variances of) the injured and control subgroups
the middle finger (metric 12) divided by the total hand
even if their means are identical. The two-sample KS
length (metric 22). The hand width and hand circumfernonparametric test was applied to rule out anomalies
ence measurements were taken at the metacarpophalanarising from differences in the distributions of the ingeal (MCP) joint, across all the knuckles on the dorsum
jured and control groups.
Delivered
to: ?
of the hand. Each crewmember would, while
keepingby Ingenta
A multivariate
logistic regression analysis and receiver
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the fingers together, flex at the MCP joint to form a
operating characteristic (ROC) analysis was performed
slightly closed hand. Two creases are observed to apto assess the contributions of these independent varipear on either side of the palm which extend inward,
ables as predictors of a “not/injured” (0/1) outcome. A
forming a line that runs parallel to the knuckles. The
standard significance level of P , 0.05 was used for the
measurement was taken by following this line as best as
regression analysis. A cumulative fraction plot was genpossible. A total of 192 male and 40 female crewmemerated to identify possible cut-off values of relevant anbers have complete injury and anthropometric records.
thropometric parameters that relate to higher probability
Among them, 20 men (10.42%) and 2 women (5.0%)
of finger injury. The cut-off point may be used during
showed at least one instance of fingernail delamination.
glove fitting for new crewmembers to identify individTable I shows the composition of the two cohorts.
uals with a high probability of injury.
Several statistical tests were performed using SYSTAT
12 software (Systat Software Inc., San Jose, CA). DataRESULTS
sets were formed for the left and right hands from all
subjects for each anthropometric metric and the fingerSingle results were considered significant if P ,
to-hand ratio, and further divided into
injured Aerospace
and un- Medical
0.0167, Association
with results shown in parentheses as P 5 left
Copyright:
injured (or control) subgroups. As the number of female
hand, right hand. Two measurements (denoted by numcrewmembers and injuries was too small to support reliber as shown in Fig. 1) were not rejected by the KS test
able analysis, only the male population was considered.
of normality: distance between proximal interphalanTABLE II. SIGNIFICANT (P 5 0.0167) PARAMETRIC AND NONPARAMETRIC STATISTICAL RESULTS FOR FINGERNAIL
INJURY IN MALE CREWMEMBERS.
Two-Sample t-Test
Hand Parameter
A Priori
Hand circumference
Hand width
Total hand length
Finger-to-hand ratio
Accidentals
Right Middle Finger Circ (DIP)
Left Middle Finger Circ (PIP)
Ring Finger Circ (DIP)
Ring Finger Circ (PIP)
Right Little Finger Circ (DIP)
Two-Sample
Kolmogorov-Smirnov
Kruskal-Wallis
#
Left
Right
Left
Right
Left
Right
21
20
22
12/22
0.341
0.801
0.993
0.111
0.103
0.721
0.338
0.054
0.106
0.061
0.402
0.009*
0.021
0.293
0.480
0.007*
0.010*
0.061
0.513
-
-
0.154
0.037
0.208
-
0.243
0.031
0.170
0.225
0.030
0.002*
0.052
-
0.046
0.042
0.037
0.025
R10
L11
14
15
R18
DIP 5 distal interphalangeal joint; PIP 5 proximal interphalangeal joint.
* P , 0.05 (family significance).
Aviation, Space, and Environmental Medicine x Vol. 81, No. 10 x October 2010
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EMU ONYCHOLYSIS ANTHROPOMETRICS—OPPERMAN ET AL.
Fig. 2. Injury distribution vs. finger-to-hand ratio.
mass index (BMI) to the model increases the area under
geal thumb joint and MCP joint (4) and finger-to-hand
the ROC curve slightly. The result of the cumulative
ratio (12/22). No measurements were found to have sigfraction analysis is presented in Fig. 6. The graph shows
nificantly different means under the two-sample t-test
Delivered by Ingenta to: ?
more
than
50% of all delamination cases are reas between the injured and control subgroups.
The
fi
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ported for hand circumferences ⱖ 22.86 cm (9”) and an
to-hand ratio showed no significant difference (P 5 0.80,
increasing fraction of the crewmembers with hand cir0.99).
cumferences larger than 20.32 cm (8”) are injured.
After Bonferroni correction there were no significant
control/delaminated differences in distribution on the
two-sample KS test for the remaining metrics. The KW
DISCUSSION
test (which does not presume normal distributions) inEffective gloves are critical to successful EVA perfordicated a significant effect of hand circumference (21)
mance (1,5). Improvements in glove flexibility, dexterity,
(P 5 0.009, 0.007) and hand width (20) (P 5 0.02, 0.01)
tactility, and comfort, with a reduction in muscle fatigue
for both hands and left ring finger circumference (14) at
and injury, will therefore have great impact on astronaut
the distal interphalangeal (DIP) joint (P 5 0.002, 0.04) on
productivity (13,8,15). With the expected dramatic inthe Bonferroni-corrected P , 0.0167 criterion. Table II
crease in EVAs required for imminent planetary explosummarizes the significant results. Figs. 2–4 show the
ration missions, the demands on safe and effective hand
injury distributions for finger-to-hand ratio, hand cirfunction will also increase (20). Nevertheless, EVA injucumference, and hand width, respectively.
ries have
actually become more prominent since 2002,
Table III contains the results of theCopyright:
logistic regression
Aerospace Medical
Association
probably due to the unprecedented increase in training
analysis and Fig. 5 shows the ROC density curve with
to support construction and maintenance of the ISS
a maximum area under the curve of 0.73. While hand
(23,19). It is, therefore, essential that new studies and
circumference is the dominant variable, adding body
Fig. 3. Injury distribution vs. hand circumference.
910
Aviation, Space, and Environmental Medicine x Vol. 81, No. 10 x October 2010
EMU ONYCHOLYSIS ANTHROPOMETRICS—OPPERMAN ET AL.
Fig. 4. Injury distribution vs. hand width.
pressure on the MCP area may reduce (or even occlude)
protocols be applied to address the high incidence of
blood flow from the fingers (12). This, combined with
onycholysis injuries among astronauts.
agitation of the fingertips due to axial loading inside the
We found no significant difference in the number of
Delivered by Ingenta
to: ?the presence of moisture, ultimately irritates
glove and
cases of onycholysis between short- and long-handed
IP: 5.10.31.211 On: Wed, 12 Jul 2017 22:05:20
the nail bed (9). Removing the constriction after claspastronauts in our sample. Our original hypothesis based
ing may result in hyperperfusion of the fingers, causing
on finger length was not sustained by the data, but sevfurther injury. Thumbnail delamination is extremely
eral hand anthropometrics based on width and circumrare and is documented in only a single case. As the
ference have been found to be significantly different
thumb is proximal to the MCP joint, the lack of injury
between injured and uninjured groups in our sample.
compared to the main digits supports the suggestion that
The most significant anthropometric factor in injury
the glove’s MCP joint plays a significant role in blood
prevalence is hand circumference. The KW test found
occlusion and injury. Hand width was found to have a
the magnitude of (right, left) hand circumference was
significant effect (P 5 0.02, 0.01) on injury (Table II and
significantly greater (P 5 0.009, 0.007) for the injured
Fig. 4), but width and circumference measured at the
astronauts in our sample than for the uninjured. The
knuckles are in the same family of anthropometric meatwo-sample KS test found (marginally) no significant
surements and not considered to be independent.
difference between injured and uninjured distributions.
Viegas (20) believes that onycholysis has only ocTable II shows the KW and KS results and Fig. 3 clearly
curred in Phase VI spacesuit gloves (gradually introshows that the injured sample had larger hand circumduced from
1998) and not in the preceding Series 4000
ferences. It is reassuring that both hands
give the
same Medical
Copyright:
Aerospace
Association
gloves. Moreover, since the incidence of delamination is
significant result.
very low in older astronauts, it is possible that the deThe cumulative fraction analysis shows that crewsign of the older gloves also inhibits injury. This contrast
members with a hand circumference of 22.86 cm (9”) or
between gloves suggests that the Phase VI custom glove
above are almost four times more likely to be injured as
sizing protocols do not sufficiently accommodate larger
those below 22.86 cm (9”), with injury rates of 19.6% (11
MCP joints. Current sizing protocols increase glove
out of 56) and 5.7% (9 out of 157), respectively. The inwidth as hand width increases, but hand thickness is not
jury rate for female crewmembers in the ITS is low
addressed (Hodgson E; written communication; 16 De(5.0%), which is consistent with the low rate for male
cember 2009). The new glove may also impose increased
crewmembers with comparable hand circumference.
contact force on larger knuckles due to different bendOur logistic regression suggests that large hand circuming characteristics of the bladder or restraint structure
ference is the dominant effect on the likelihood of ony(such as the palm bar). The increase in EVA injuries since
cholysis and that crewmembers who have a lower BMI
(taller, lighter crewmembers) are marginally more susceptible to injury. Hand width was found to have a sigTABLE III. LOGISTIC REGRESSION RESULTS FOR HAND
CIRCUMFERENCE AND BODY MASS INDEX (BMI).
nificant effect (P = 0.02, 0.01) on injury (Table II and Fig. 4),
but width and circumference measured at the knuckles
Parameter
Estimate Standard Error
Z
P-Value
are in the same family of anthropometric measurements
Constant
5.339
213.637
20.554 0.011
and not considered to be independent.
Hand Circumference (R21)
1.890
0.645
2.928 0.003*
These findings suggest that onycholysis may be
0.135
20.206
21.523 0.128
BMI 5 weight (lb) x 703 /
caused in part by the impact that the glove’s constricting
height2 (in2)
of the hand around the MCP joint has on finger perfusion—perhaps when clasping. Increasing the contact
* P , 0.05 (family significance).
Aviation, Space, and Environmental Medicine x Vol. 81, No. 10 x October 2010
911
EMU ONYCHOLYSIS ANTHROPOMETRICS—OPPERMAN ET AL.
ence have a significant effect on the onset of onycholysis.
It is likely that the current EMU Phase VI gloves constrict large MCP joints and impede perfusion to the fingers. Crewmembers with a MCP joint circumference of
more than 22.86 cm (9”) are approximately four times
more likely to suffer onycholysis than those of 22.86 cm
(9”) or less. The increase in onycholysis injuries coincides with the replacement of the Series 4000 with the
Phase VI glove and the associated closer-fitting custom
sizing protocols. Injury rates are also subjectively lower
with the Russian Orlan glove, which provides generous
accommodation around the MCP joint. This finding suggests that the Phase VI sizing protocol should allow for
increased accommodation around the MCP joint to reduce constriction. Crewmembers with MCP joints
greater than 22.86 cm (9”) should also be especially diligent in using current fingernail injury countermeasures.
Fig. 5. ROC curve from logistic regression analysis (area under ROC
The results of this study may assist in the selection of
curve 5 0.73).
EVA crewmembers, decrease the incidence of medical
interventions (by suggesting early use of onycholysis
countermeasures for those at higher risk), and highlight
2002, noted above, may therefore also be due in part to
specific glove sizing configurations in which design imthe dominance of the Phase VI glove since that date,
Delivered
to: ? could significantly improve performance
provements
rather than solely due to increased training. The
reducedby Ingenta
IP: 5.10.31.211 On: Wed, 12 Jul 2017 22:05:20
and decrease injury.
rates of finger injury in the Russian Orlan gloves also
suggests MCP constriction may be a contributory factor,
ACKNOWLEDGMENTS
as that design provides greater accommodation around
The authors would like to thank ILC Dover as primary sponsor
the MCP joint.
of this project, particularly Phil Spampinato and Keith Splawn. We
Of the remaining metrics, only the ring finger circumwould also like to thank Dr. Robert Ploutz-Snyder from NASA-JSC
for his input and feedback and Dr. Samuel Strauss and Dr. Richard
ference (at the distal interphalangeal joint) (14) showed
Scheuring for contributing findings to the EVA injury database. Lastly
a significant difference between the injured and the conwe would like to thank the NASA-JSC engineers and scientists who
trol group (P 5 0.04, 0.03) by two-sample KS test. The
supported this effort.
KW test also indicates a significant difference for the left
Authors and affiliations: Roedolph A. Opperman, B.Eng., James M.
A. Waldie, Ph.D., B.Bus.(Admin.), Alan Natapoff, Ph.D., and Dava
ring finger circumference at the DIP joint (P 5 0.002,
J. Newman, Ph.D., S.M., Man-Vehicle Laboratory, Department of
0.04). The ITS reports unfortunately rarely specify which
Aeronautics and Astronautics, Massachusetts Institute of Technology,
finger(s) were injured. NASA flight surgeons and crewCambridge, MA; and Jeffrey A. Jones, M.D., S.M., Space Medicine &
Healthcare Systems, NASA Johnson Space Center, Houston, TX.
members indicate that multiple fingers on each hand are
usually affected.
In summary, our results show that Copyright:
finger length
is not
Aerospace
Medical Association
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