CHAPTER CONTENTS

Development of the upper limb 193

Development of the use of the upper limb 194 Function of the upper
Function 194
Structurespermittingfunction 195 limb
Hand function 195
Sensoryfunctions 197 A. Hinde
Foreann/armfiinction 198

OBJECTIVES
At the end of this chapter you should be able to:
1. Outline the development of the upper limb
2. Explaln the classification of functional
activities of the upper limb
3. Describe the structure of the upper limb
4. Discuss how this structure and the function
of the upper limb are interrelated
5. Discuss the functional aspects of the
individual segments of the upper limb.

DEVELOPMENT OF THE UPPER LIMB

The upper limb is usually considered to be the
bones distal to the glenohumeral joint, the clavi-
cle and the scapula with the muscle groups con-
trolling those bones, and the periarticular
structures. The only joint between the limb and
the axial skeleton, as Moffat (1994) points out, is
the sternoclavicular joint, the scapula being
sandwiched between layers of muscle against
the upper part of the posterior surface of the
thorax.
At approximately 4 weeks, limb buds appear
on the fetus and growth occurs untii the eighth
week when the limb shape is fully formed
(Williams et al 1989). From then until birth the
tissues differentiate to form the bone, the peri-
articular and the musculotendinous strucfures of
the limb. There is some migration of the muscu-
lotendinous structures of the axial skeleton to
193
 194 HUMAN MOVEMENT
become attached to the limb, e.g. latissimus
dorsi.
Radiographs of the upper iimb at birth show
ossification in the long bones but not in the
short bones, these still being cartilaginous.
Comparison of the proportions of the segments,
either from radiographs or photographs at birth,
shows the hands to be much larger in compari-
son with other segments (upper arm, forearm)
than during childhood, adolescence or adult-
hood.
Look at a series of 'family' photographs of a
developing child (yo'rrself or a relailve) and by
estimation plot a histogram ol the propo.rtions of
ihe upper limb segments over time. Thdn i'
compare the result with the results of colleagues.
DEVELOPMENT OF THE USE OF THE
UPPER LIMB
The work done by Illingworth (1987) to identifu
the sequences of behaviour and the change in
ability over time has produced the concept of
'milestones of development' as a method of iden-
tifying progress in an individual's development
by comparing actual with expected performance.
From this work it is clear that there
avenues of development to be followed:
o the development of activities of the upper
limb as a discrete unit
e the development of the whole individual as a
result of the use of the upper limb.
To illustrate the first point: the grasp reflex is
present until approximately the eighth week and
it is only r.r'hen the reflex is disappearing that
intentional activih' can start including explo-
- cubes, paper)
ration of 'things' (teething rings, or
environment (splashing water in the bath). These
unrefined activities lead onto play and the grad-
ual refining of movement. To illustrate the sec-
ond: once the upper limb is useful, the rest of the
body benefits, e.g. bv supporting the body on the
forearms rt'hen placed prone (at approximately
12 n'eeks) or by taking weight on the hands
when crawling or pulling the body into standing
(at approximately 40 weeks). During this period
and succeeding weeks the upper limb is also
used in play and to communicate needs by ges-
ture and begins to develop self-help abilities dur-
ing dressing.
Try to identify, then list, the uses to which you
put your upper limb. This might seem initiallylo
be infinite but if you look for'common
denominators'you should be able to produce a
smaller list of 'generalities'.
' An interesting point about the developmental
sequence and the upper limb is that it often con-
tributes heavily to the acquisition of abilities by
other body segments and then reduces its contri-
bution to ihose segments, i.e. it has an enabling
function. The limb then moves on to another
task. Its contribution is not only in these concrete
actions but also in its contribution to the cogni-
tive ability, socialisation and habituation of the
individual. The importance of these contribu-
tions is highlighted when a specific upper limb
function does not itself develop leaving either a
void to be filled by compensatory techniques
(equipment or trick movements) or halting
are two
progress i;r some specific aspect of the individ-
ual's development. McClenaghan (1989) describes
a situation where poor development of sitting
ability has been compensated for by the use of
the upper limb as a support (i.e. as a direct
replacement for an undeveloped postural ability)
and the consequences of that adaptive behaviour
for the accurate perforrr'ance of tasks later in life.
FUNCTION
... function
Is smother'd in surmise, and nothing is
But what is not.
William Shakespeare, Macbeth I. iii. 141
Structure and function are inextricably linked,
each determining the other: although the struc-
 FUNCTION OF THE UPPER LIMB 195

bure allows the functiory the function in its own You should by now be more aware that upper
right demands the structure. I{owever, this limb function goes beyond being the support and
chapter will work fron structure to function. mover of the hand in the rn'ay that the springs,
In order for accurate movements to take place joints and arms of an 'Anglepoise' desk lamp
there must normally be a stable base about which serve only to position the light.
the limb segments (or links in a mecl-ranical
sense) may move. At the other end of the chain of
links will be the 'active' segment, i.e. that which Structures permitting function
is'doing something'. While undertaking Task 2 There are three types of structure in the upper
r-ou should have become aware that some of the
limb which permit function to occur:
uses involved the hand being moved freely in
space and that others involved the hand becom- . levers, i.e. bones
ing the fixed point for the movement of the rest o joints about which levers move (including
of the body. If you did not appreciate this point ligaments which restrict range or direction)
look back through the list again. r muscles causing or controlling movements of
The appropriate way to describe these move- the levers.
ments is to use the term 'open chain' for free
Each type of structure has its own specific
movements of the hand and 'closed chain' for
properties and limitations and the student is
those movements where the hand is the fixed
directed to the References for more detail of
base. The open chain movements enable some
these. It is the combination of these structures
manipulative activity: the hand is the focus of the
that permits the whole limb to be more than the
movement being positioned by the other seg-
sum of the parts, i.e. that gives the limb its ability
ments of the upper limb, for example when using
to undertake functional use.
tools, cutlery or washing hands. The closed chain
movements enable the body to be moved by
ailowing the segments of the upper limb to act to Hand function
compensate for underactivity of some other body
segment.
Examples of closed chain activity include
pushing on chair armrests to assist rising from a
chair and holding stair handrails to help main-
tain balance. Crutch walking and wheelchair-
toilet/bed transfers are examples of closed chain
compensatory use in dysfunction.

.:..:;t:.:
.:.:::,it .: . :..:, .: _::, r::..:. .;L':r:'::.,trl.:l The carpals are short irregular bones which
Box 12.3 Task3
:
''.;i:tta::'.:..:.' lrr.': : .,,..,,,' ,, ':. i:r -ii....i:r-.:,.:i:ill lock together to form a stable block. During most
Repeat Task 2 but this time note the type of actions involving the hand and needing long
activity (open or closed chain) and the base of flexor and long extensor muscle activity, the
support and moving segments. Divide the upper carpals are in compression proximal to distal.
limb into three components: hand, forearm/arm
and pectoral girdle. Tabulate the results, e.g. Transverse section through the carpals shows the
arching form of the group of bones which pro-
Activity Type Hand Forearm/ Pectoral
tects structures anteriorly from damage by items
arm girdle pressed into the palm and helps to maintain arter-
ial supply and nerve conduction when gripping
to Open Grip on Freely Fixed
Biscuit
strongly. During movement the carpals work as
mouth chain biscuit moving base
a disc so that movements at the wrist joint have
their axes through the carpals, with the scaphoid
 196 HUMAN MOVEMENT
and lunate sliding lateraily during ulnar
deviation and medially during radial deviation.
During flexion the articular surface of the
scaphoid and lunate glide posteriorly and during
extensiory anteriorly. Cailliet (!984) explains how
the many facets on the distal surfaces of the
trapezoid and capitate lock the second and third
metacarpals into a fixed unit, with the first
metacarpal, and the fourth and fifth mobile to
either side.
A transverse section through the metacarpals
also shows an arched formatiory concave anteri-
orly. This arch is more mobile than the carpal
arches and will allow flattening or cupping of the
hand with the outer units moving about the sec-
ond and third rnetacarpals as stated above. The
metacarpal heads have condylar shapes with an
articular area on ihe distal and anterior aspects
giving a sweep area or surface arc for the proxi-
mal phalanx of approximately 180". The surface
arc of the base of the proximal phalanx is
approximately 20' and this bone glides across
the surface of the metacarpal head to give a
range of movement between 90" of flexion and
20" hyperextension. The joint is very stable at
90' of flexion because the tension in the collater-
al ligaments is at its maximum (i.e. in the close
pack position). When in extension the collateral
ligament laxity allows abduction and adduction
to occur.
Each of the phalanges is similarly structured
with proximal bases and small surface arcs artic-
ulating with condylar heads and large surface
arcs. In these joints, however, the collateral liga-
ments are in tension in extension at the joint
making this the close pack position. Salter (1987)
emphasises the importance of these details when
splinting the hands and fingers. Flexion and
extension are the only movements produced by
direct muscle action tut rotation dbes occur as
an accessory movement when the metacarpo-
phalangeal (MCP) and interphalangeal (IP) joints
are not in their close pack position.
The static function of the hand is usually called
'grip' and the grips are classified by different
authors in different ways, for examples see
Backhouse & Hutchings (1939) and Salter (7987).
All irave three features:
o a stabie foundation to locate the levers
o the ability to arrange the levers appropriately
o the abiiig to apply forces through the levers.
The stable foundation will normally be provid-
ed by the carpals providing a closelv packed
foundation upon which the metacarpal bases
will be anchored. When arranging the levers, the
arch of the metacarpals is actively or passively
adjusted. Intrinsic muscles of the hand actively
pull the bones into a transverse arch. This posi-
tions the phalanges so that their tips converge
towards a central point for gripping between
thumb and finger pads, or gripping larger,
roughly spherical objects beiween the palm and
phalanges. The arch is passively flattened during
gripping so that the phalanges can move along
parallel pathways to grip cylindrical or cuboidal
shapes. Bray et al (1989) and Wirhed (1988) indi-
cate that the force of contraction of a muscle
depends direcily on its physioiogical cross-
sectional area. The forces that can be generated
during gripping can be very high but there is no
space in the palm of the hand to hold an object
and have large muscle bellies. The upper limb
reconciles these requirements by placing the
source of the forces (long flexor muscles) outside
the hand and using tendons (with verl' much
smaller volumes) and pulley-like arrangements
to transmit the forces to the levers (phalanges).
Cailliet (1984) has some very clear illustrations
of normal and dysfunctional arrangements.
Backhouse & Hutchings (1989) illustrate and
describe the actions.
The long (extrinsic) muscles controlling the
movements of the fingers are each described
anatomicaliy by their actions. The intrinsic mus-
cles are named by their location (interossei),
action (opponens pollicis) or appearance (lum-
bricals). Each group has its own function: to pro-
vide force, or to position the bones for the
efficient application of that force. Hort'ever, the
true functions of the muscles of the hand do not
become apparent until the combinations of
actions are studied, i.e. it is the interplay of
intrinsic and extrinsic actions that give functional
ability to the hand rather than merely anatomical
movement. The work of Cailliet (1984) and Salter

(1987) provides details of these interplays and
their results.
It is worth examining the combination of the
concepts of types of grip and the arches of the
hand. The power grip, for example, places the tool
handle across the supports of the index-little
finger arch and then clamps betn'een these
points with the third support (from the thumb).
The lateral pinch grip and the tip grip use onll' the
index-thumb arch supports, while the spatr grip
uses all three arch supports in a centripetal
motion. The dynamic tripod grip uses the index-
thumb arch to hold the tool (pen); Salter (1987)
emphasises the role of the little finger as a sup-
port for the'working' arch (Fig. 12.1).
il{. W# }f":':ti:'1rl:. ]il+j, ltr*.11i*tt:ii,:.:};:e,ari:r :i:.a.if,;,'117,
Box 12-5 Task
:--"r.,.:--.- 5 .*..: '.'"
."i-;i-.:r '!
Place a ruler on apiece of paper and draw a
line; look at the arches formed by the
' having the opposite effect.
'supporting'hand and compare them'with the
arches formed bythe'drawing' hand.
An understanding ol these arches and the
bones and muscle actions which cause and
maintain them is essential when splinting or
, otherwjse treating;a dysfunctional hand,
whatever the cause of the dysfunction.
As a means of communication the hand and
fingers may parody the spoken word, replace the
Figure 12.1 lllustrations of grips: a) power grip; b) dynamic
tripod grip; c) pinch grip.
FUNCTION OF THE UPPER LIMB 197
spoken word or express (as body language) other-
wise concealed communication. These communi-
cation gestures may take the form of pointing out
features, e.g. on a poster, chalkboard or in a land-
scape. They might involve the hands being used
to indicate the shape of, or relationship between,
objects. A formalised sign language has been
developed and is in use io compensaie for dys-
function of speech or hearing by the Association
of Sign Language Interpreters.
Activities which are intentional movernents
take their origins in the cerebral cortex. There are
many unconscious movement patterns which
express an individual's values and subconscious
judgement. Moods may be indicated by hand
activity, but mood may also modify hand activify
by the influences on the anterior horn cells
,' . j.",. through the meciial pathways and limbic system.
Pain and anger may inhibit movement by
increasing muscle tone, lassitude or relaxation
Sensory functions
Review of the sensory homunculus will show the
relatively large area of sensory cortex 'allocated'
to the hand. This offers a clue about the impor-
tance of the hand as a source of exteroception
and proprioception.
The types and function of sensory end organs
are described more formally elsewhere (Williams
et al (1989) for example), but their functional uses
are worth consideration in more detail. Whether
surfaces are hotter or colder than skin tempera-
ture can be identified by exteroceptors, surface
texture can similarly be identified. The proprio-
ceptive function of the lumbrical muscles is
 198 HUMAN MOVEMENT
essential for accurate functional acdvity from the
hand and fingers. Beyond this, the sensory data
is generated by the combinatiorr of extero- and
proprioception; shape, dimensions and weighi
all require information from proprioceptive
nerve endings in joint capsule, muscle and ten-
don as well as receptors in the skin. Most impor-
tantly, experience and practice are necessary for
the data to be correctly interpreted this differ-
-
entiates the skilled craftsmin or Braille reader
from the beginner, for example. It is worth
reflecting at this point about Illingworth's
(1.987) indication of the importance of maximal
sensory experience during development and
the consequences for chtldren with congenital
dysfunctions compared to those n'ith acquired
dysfunctions.
Combinations of motor and sensory activity
applied within specific contexts carr then be seen
within a wider definition of function. Maslow
(7954) classified the needs of indivtduals into a
hierarchy of five levels:
r The elbow joint is a compiex of three artis.rla-
physiological (to satisfii the needs of
homeostasis)
o safety or security (shelter, protection)
o belongrng (social grouping or position)
o self-esteem (having a sense of 'value')
o self-actualisation (achieving fuIl potential).
Ep.ti.1&
Using each subgroup of Maslovd's (1954)
hierarchy of needs, identify tlvo hand functions
which may be undertaken to satisfy that need.
Forearm/arm function
This segment of the upper limb is made up from
the three long bones and their intermediate
joints; further to this there is a svnovial joint
with the adjacent segment at each extremity, the
wrist joint distalll' and the glenohumeral joint
proximally. The segment has two main func-
tions:
I lever systems for movement or positioning
o the location of muscle attachments.
The wrist joint connects the trand to the fore-
arm and, because only two degrees of freedom
are available at the joint, the extensors and
flexors carpi assist in the alignment of the hand
in readiness for use, or stabilise the carpals for
activities of the fingers. Where the problems of
muscle insufficiency (active or passive) occur, the
mobility of the wrist increases the range of the
movements possible at the firrgers. The third
degree of freedom, sacrificed by the wrist joint, is
transferred to the radioulnar joints. This arrange-
ment increases the stability of the carpal/fore-
arm joint without the loss of potential positions
for the hand. The major tension forces applied to
outside loads at the hand are applied through the
long flexor or extensor muscles and the phal-
anges. The loads on the carpals and metacarpals
are relatively low and are close to the joint axis.
The mechanical arrangement is further assisted
by the pisiform bone acting as a sesamoid bone
to alter the alignment of the flexor carpi ulnaris
tendon.
tions where two have given up freedom of move-
ment for stability and the third is a compromise
between movement and stability. The humerus/
ulna articulation has a single degree of freedom
(flexion and extension) as does the superior
radioulnar joint (rotation). These are both very
stable joints. The humerus/radius articulation
offers both rotatiory and flexion and extension.
The complex serves to assist the wrist and
inferior radioulnar joints to position the hand in
a required position and to move the hand and
any load to a new position.
The muscles acting on the elbo'"v joint have an
attachment close to the axis, cross the joint and
attach the length of the forearm or arm away.
This makes the lever system very disadvanta-
geous in terms of effort applied, but this is com-
pensated for by the advantageous velocity ratio
giving large distance and rapid movement for
the extremities of the segments in return for
small length changes in the muscle during con-
traction. The need to produce high forces in con-
traction is satisfied by having the muscles work
in two groups; those in the arm attached close to
the elbow on the radius and ulna, and those in

'tire forearm attached close to the elbow on the
humerus. Each group will cross the joint and
attach to the further extremity of the opposite
long bone. The combined action can be repre-
sented by drawing triangles of force to estimate
their cumulative effect.
When the hand is used in open chain function-
al moveme'rts, elbow extension will usually be
caused by gravity under the control of the flexor
muscles in eccentric contraction. For closed chain
actions, elbow extension is usually produced
against resistance and so the elbow extensor
comes into action. The effect of the division of the
triceps muscle into three heads can be estimated
by drawing polygrams of force, but more impor-
tantly the division allows an increase in the phys-
iological cross-sectional area and therefore the
capacity to generate high forces increases. !/hen
the hand is fixed and the triceps muscle is mov-
ing the body (as when pushing on chair arms to
assist rising to standing), the lever system is of
the second order and triceps has a slight mechan-
ical advantage. From a practical point of view,
the distance betu'een the olecranon process and
the trochlear notch is small when expressed as a
proportion of the length of the forearm, so
mechanical advantage is minimal. The velocify
ratio still maintains its advantage and for a phys-
ically small range of contraction of triceps the
body is raised considerably.
The glenohumeral joint has three degrees of
freedom permitting the lLand to describe almost
the whole surface of a sphere (the axial skeleton
occupying the missing part). In order to achieve
this range of movement the joint sacrifices some
stability and relies on muscle action to maintain
congruity of the surfaces when under load.
Return once again to your notes for Task 2 (or
carry it out again). This time identify the axis and
plane of the movements of the upper limb.
For many of the activities invoiving the upper
limb the actiorrs have two components at
glenohumeral joint:
FUNCTION OF THE UPPER LIMB 199
o the primary purpose of the movement, e.g.
writing, stirring a cup of coffee
o a symergistic positioning of the segments to
allow more efficient performance of the
primary purpose.
The muscles acting for the synergistic purpose
are tl-re deltoid and the rotator cuff musiles,
which typically need only to work against gravi-
ty's action on the mass of the upper limb.
Primary activity is usually generated by the large
muscles attached to humerus and thorax or
humerus and scapula. This arrangement allor,t s
large forces to be generated in either flexion/
adduction or extension/adduction at this joint.
The importance of these relationships is v.'ell
illustrated in the case histoiies chosen for publi-
cation by Bullock (i990).
For many activities of the upper limb, the axis
arrd plane of movement between the glenoid fossa
and humeral head remains the same even rvhen
the direction moved by the limb changes. This
apparent contradiction is explained by the adjust-
ment in the plane of the glenoid fossa when the
scapula is moved in relation to the thorax.
Although the limb may be swinging in flexion/
extension movements at the glenohumeral joint,
the movement seen in reiation to the axial skeleton
may be across the front, parallel to the sagittal
plane, or forwards and outwards depending on
the degree of protraction / retraction of the pectoral
girdle.
The pectoral girdle is the remaining structure
permitting function in the upper limb. It has
only one synovial joint r.vith the thorax, at the
sternoclavicular joint, and the scapula lies sand-
wiched between layers of muscle. The girdle
acts like the jib of a crane (especially rvhen
viewed from above) to position the gleno-
humeral joint in preparation for activity in the
arm, forearm and hand. The glenohumeral joint
cannot slide around the thorax in a horizontai
plane because the clavicle acts like the spoke of
a wheel (unless fractured) and props the
acromion outwards. When the scapula does
slide forward the glenoid is moved forrt'ards in
the the movement called protraction, retraction
p',rils the scapula towards the vertebral column
 2OO HUMAN MOVEMENT

and ihe glenoid mo\res backwards still a cla-
vicie-length from the sternum.
The muscles joining the scapula to the thorax
may act together to produce rotation of the
scapula about a sagittal axis, raising or lowering
the glenoid in elevation or depressiorL respec-
tivelv. These four mor.ements have the advan-
tage of increasing the volume of space falling
within the reach of the hand in the way a tele-
scopic arrangement rvould in a machine. The
number, size and aiignment of these muscle
groups would seem at first to be excessive for
open chain movements of the upper limb. It is in
closed chain movements when the axial skeleton
is being moved in relation to the upper limb that
their purpose becomes apparent.
Anthropologically, a major function
upper lirnb was to transport the body, as it still is
in primates. When hanging from an overhead
support the animal needs to move 93.5% of its
body mass (Wirhed (1988) suggests the upper
limb is 6.5% of body mass) and therefore needs
muscles of large physiological cross-sectional
area and mechanically advantageous arrange-
ments in terms of force diagrams and lever sys-
tems. Although man no longer relies on this form
of transport, the potential remains useful when
compensation for dysfunction is required, for
example when using walking aids to relieve
lower limb weight bearing for people with spinal
cord lesions when the axial skeleton becomes
slung between the bilateral props of the upper
limbs and crutches or parallel bars.
of the

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