5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?

mode=print

Chapter 5 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Normal Version
Kinesiology and Functional Characteristics of the Upper
Limb

Shahan K. Sarrafian, M.D.

The functional capacity of the upper limb is determined by the shoulder complex, elbow, wrist, and hand developing
multiple integrated spheres of action. Given the normal proportion of limb segments, this capacity is limited in relation to
the surrounding space. In the standing position the upper-limb field of motion reaches the midthigh region. Any more
distal point on the lower extremity or on the ground is reached through mobility provided by the hip, knee, ankle, and trunk
(Fig 5-1). Furthermore, a distant point in space comes within the reach of the upper-limb action through a functional
integration with gait.

FIG. 5-1 The field of motion of the upper limb is a circle, and
the length of the extremity is the radius. Any further point in
space or distal to the midthigh is reached through associated
hip, knee, ankle, and trunk motion.

A maximum arcuate field or envelope of action termed "Ex" (Fig 5-2) is traced by the most distal point of the upper
extremity through the motion of the shoulder complex, all other joints being held in extension. Within this envelope, the
elbow, wrist, and hand develop their own fields of motion, E2, E3, and E4. These contained capabilities enrich the
functional performances of the upper extremity.

1 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-2 Elevation of an externally rotated upper limb in the

frontal plane. Complete exploration of the outer half of a circle
is possible through the envelope of action E1. The elbow
allows sweeping of space E2. The wrist develops motion field
E3. The spiral envelope of motion E4 is determined by finger
motion.

SHOULDER COMPLEX

Motion in the Frontal or Coronal Plane

When the arm and forearm are held in the anatomic position, the antecubital surface facing anteriorly, the upper limb
sweeps a circular surface in the frontal plane. The very distal point of the extremity traces an envelope of action E1 (Fig
5-3).

2 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-3 Motion in the frontal plane, starting with the neutral
position of the upper limb, position 1. It is possible to explore
space from positions 7 to 2 without associated external
rotation. No elbow action is possible then. The limb is further
elevated from positions 3 to 4 through association of external
rotation. Descent from positions 4 to 5 involves internal
rotation. From positions 5 to 6 and 1, the extremity derotates to
reach a neutral position.

In position 1 the shoulder is in neutral rotation, and the extremity can be elevated in the outer half of the circle to positions
2 and 3. The elbow does not contribute to functional exploration in this segment of the arc of motion. If the wrist is initially
held in neutral rotation, the hand sweeps the space E3, and the digits explore the interior of this space through E4. Beyond
position 3 the shoulder externally rotates, and complete elevation is achieved at position 4. In this second arc of motion
the elbow explores the segment of the space through its action envelope E2. The sweeping of the inner half of the
coronal circle is now possible from position 4 to 5 through internal rotation of the shoulder. The elbow action dissipates.
From position 5 to 6 the shoulder externally rotates, and elbow functional capability in this plane reappears, whereas with
further external rotation from position 6 to 1, the elbow action dissipates again.

When the upper limb is maintained in neutral rotation at the shoulder, the motion is quite restricted (Fig 5-4), and no elbow
action is possible in this plane. Maintaining the extremity in complete external rotation permits exploration of the outer half
of the frontal circle with ease, whereas any functional development in the inner half is very restricted. The elbow envelope
of action is clearly visible now in all positions (Fig 5-2).

3 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-4 Motion in the frontal plane with the upper limb in neutral
rotation. No elbow action is present in this plane.

Placement of the limb in complete internal rotation significantly restricts the field of motion (Fig 5-5). Elbow action is
possible from position 1 to 2. The coronal plane is also explored posteriorly in the inner half space (Fig 5-6). With a
position of internal rotation at the shoulder, the limb traces a small arc of displacement just enough for the elbow, wrist,
and hand to sweep the surface corresponding to the gluteal area and up to the opposite scapular region. From position 3
the elbow envelope of action scans the posterior aspect of the head, neck, and shoulder.

4 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-5 Motion in the frontal plane with the upper limb in
complete internal rotation. The field of motion E1, is limited,
but elbow motion is possible by exploring space E2. The wrist
and digits are continuously functional.

5 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-6 Motion in the frontal plane posterior to the body. The gluteal
area and mid and lower portions of the back are within reach of the
internally rotated upper limb, position 1, combined with the elbow field
of motion, position 2. The posterior aspect of the neck and shoulders is
reached by external rotation, position 3, combined with the elbow field
of motion E2.

During elevation of the upper extremity in the frontal plane, motion is determined by the scapulohumeral joint and
scapulothoracic upward rotation. The acromioclavicular and sternoclavicular joints also participate in a synchronized
manner (Fig 5-7). External rotation accompanies the elevation for the performance of a smooth motion. Beyond 90
degrees of elevation this external rotation is necessary to free the greater tuberosity from the acromial process, and more
humeral articular surface is offered to the opposing glenoid (Fig 5-8).

FIG. 5-7 Elevation of the upper limb from 0 to 180 degrees. From 0 to 30 degrees, motion is mostly
scapulohumeral (SH). Scapulotho-racic (ST) motion is variable. From 30 to 180 degrees, there is a
relationship between scapulohumeral and scapulothoracic motion with the ratio SH/ST = 2/1 = 100

6 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

degrees/50 degrees. Sternoclavicular (SC) motion in the form of clavicular elevation of 40 degrees
occurs during the initial 90 degrees. From there on clavicular rotation of 40 to 50 degrees on the long
axis occurs. Acromioclavicular (AC) motion occurs from 0 to 30 degrees and then from 135 to 180
degrees with a range of motion of 20 degrees.

FIG. 5-8 Natural elevation of the upper limb in the frontal plane
involves 90 degrees of external rotation. Elevation in the lower
and inner segment of a circle involves internal rotation.

From 0 to 30 degrees of elevation (Fig 5-7) the motion occurs at the scapulohumeral joint, and the scapular motion is
variable. This is the "setting phase" of the scapular motion. In the remaining arc of motion of 150 degrees, the
scapulohumeral (SH) joint motion and the scapulothoracic (ST) motion of upward rotation participate at a ratio of
SH/ST=2/1 as measured in the frontal plane. The total contribution of the scapulohumeral joint is 130 degrees. The
clavicle does not remain still. In the initial 90 degrees of motion the clavicle is elevated at the sternoclavicular joint for
about 40 degrees, and in the second half of the arc of motion the clavicle rotates on its long axis for another 40 to 50
degrees.8 A combined acromioclavicular motion of 20 degrees occurs during the initial and terminal phases of elevation.

The motor units responsible for scapulohumeral elevation are the middle segment of the deltoid muscle and the
components of the rotator cuff: the supraspina-tus, infraspinatus, teres minor, and subscapularis muscles (Fig 5-9).

FIG. 5-9 Elevators at the scapulohumeral joint in the frontal

plane: 1, middle deltoid; 2, supraspinatus; 3, infraspinatus; 4,
teres minor; and subscapularis (not shown), anteriorly.

7 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

The deltoid acts as the upper vector component of a force couple, whereas the rotator cuff stabilizes the humeral head
and acts as the lower vector force of the couple. Electromyographic study of these muscles (Fig 5-10)8 indicates that the
deltoid action potential increases steadily with elevation, reaches a maximum at 110 degrees, and maintains a plateau
level of activity with a final peak at full elevation. The supraspinatus also reaches a peak at 110 degrees, and beyond this
point its activity diminishes and traces a sine wave. The subscapularis reaches peak activity at 100 degrees, maintains a
plateau level up to 130 degrees, and diminishes rapidly in action. The teres minor reaches the maximum at 120 degrees
and from there maintains the high level of activity, whereas the infraspinatus increases steadily in activity from the initial
position to that of full elevation. The action of these two last muscles is necessary to continue the external rotation of the
humerus during the last stage of the elevation. The posterior segment of the deltoid also participates as an external
rotator (Fig 5-11).

FIG. 5-10 Electromyographic activity of elevators at the

scapulohumeral joint in the frontal plane. All five muscles are
active from 0 to 90 degrees. Beyond 110 degrees the deltoid
holds a maximum level of activity. The supraspinatus
decreases in activity after 100 degrees. The infraspinatus and
teres minor maintain high levels of activity during the second
half of elevation to ensure necessary external rotation of the
shoulder. (From Inman VT, Saunders M, Abbott LC: J Bone
Joint Surg 1944; 26:1-30. Used by permission.)

FIG. 5-11 Rotators at the scapulohumeral joint. Internal rotators: 1, subscapularis; 2, latissimus
dorsi and teres major; 3, pecto-ralis major; 4, anterior deltoid. External rotators: 5,
infraspinatus and teres minor; 6, posterior deltoid.

8 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

The motor units acting during upward rotation of the scapula are the upper and lower segments of the trapezius and the
lower digitations of the serratus anterior. They act on the scapula as a force couple (Fig 5-12).

FIG. 5-12 Upward rotation of the scapula: 1, upper trapezius; 2,

lower trapezius; 3, serratus anterior.

When the upper limb moves in the lower and inner quadrant of the envelope of action E1, it is adducted and internally
rotated. The internal rotation is brought about by the subscapularis, pectoralis major, and anterior segments of the deltoid
(Fig 5-11). Adduction is determined by the latter two muscles, supplemented by the action of the coracobrachialis (Fig
5-13). During the anterior adduction-internal rotation, the scapula is abducted. This motion is controlled by the serratus
anterior and the pectoralis minor (Fig 5-14). When the upper limb moves in a similar lower and inner quadrant but
posterior to the body, the limb is once more adducted and internally rotated. The posterior adduction is brought about by
the latissimus dorsi, teres major, long head of the triceps, and posterior segment of the deltoid (Fig 5-13). The latissimus
dorsi and teres major also determine the associated internal rotation (Fig 5-11). During this same motion, the scapula is
adducted by the middle segment of the trapezius and the combined action of the rhomboidei and latissimus dorsi(Fig
5-15). When the upper limb is in a maximum position of elevation and is brought down in the frontal plane in the outer half
circle, the scapula makes a downward rotation. This is determined by the combined action of the latissimus dorsi, lower
segment of the pectoralis major (the pectoralis minor acting as the lower component for a force couple), and the levator
scapulae, with the rhomboidei acting as the upper component of the rotational couple (Fig 5-16). Downward stabilization
of the limb in the frontal plane is also of important functional significance, such as in crutch walking or parallel bar
exercising. This function is determined by the depressors of the shoulder complex: la-tissimus dorsi, lower segment of
the trapezius, lower segment of the pectoralis major, pectoralis minor, and subclavius (Fig 5-17).

FIG. 5-13 Adductors at the scapulohumeral joint. A, anterior

adductors: 1, pectoralis major; 2, anterior deltoid; 3,

9 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

coracobrachial. B, posterior adductors: 1, latissimus dorsi; 2,

teres major; 3, posterior deltoid; 4, long head of the triceps.

FIG. 5-14 Abductors or protractors of the scapula: 1, serratus

anterior; 2, pectoralis minor.

FIG. 5-15 Adductors or retractors of the scapula: 1, middle

trapezius; 2 and 3, rhomboldei minor and major; 4, latlssimus
dorsi.

10 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-16 Downward rotation of the scapula. A, anterior: 1,

lower segment of the pectoralis major; 2, pectoralis minor. B,
posterior: 1, levator scapulae; 2 and 3, rhomboidei minor and
major; 4, latissimus dorsi.

FIG. 5-17 Depressors of the scapula. A, anterior: 1, lower

segment of the pectoralis major; 2, pectoralis minor; 3,
subclavius. B, posterior: 1, latissimus dorsi; 2, lower segment
of the trapezius.

The upward stabilization in the frontal plane is also necessary for functional purposes, as in carrying heavy loads on the
shoulders. This is controlled by the elevators of the scapula: levator scapulae, upper segment of the trapezius, and
rhomboidei (Fig 5-18).

11 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-18 Elevators of the scapula: 7, levator scapulae; 2,

upper segment of the trapezius; 3 and 4, rhomboidei minor
and major.

Motion in the Sagittal Plane

From a neutral rotational position the upper limb moves in the sagittal plane and sweeps the surface from position 1 to 3
(Fig 5-19). The elbow, wrist, and hand are capable of functioning in this plane through their envelopes of action E2, E3,
and E4.

FIG. 5-19 Elevation in the sagittal plane. Exploration of space

from positions 1 to 3 is possible in the neutral rotational
position of the shoulder. Elbow action E2 is present in the
plane. In position 3 the posterior segment of space is reached
through elbow action.

12 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

In position 3 the elbow action extends farther posteriorly, the hand reaching the posterior aspect of the shoulder. Further
movement in the posterior half of the field is possible through the internal rotation of the shoulder followed by gradual
external rotation to bring the limb to its neutral initial position (Fig 5-20). Elevation of the upper limb, or flexion from
position 1 to 3, is determined by the anterior segment of the deltoid, biceps, coracobrachialis and clavicular head of the
pecto-ralis major (Fig 5-21). The rotator cuff is also active in stabilizing the humeral head. The scapulothoracic
mechanism participates in the motion through upward scapular rotation at a ratio of SH/ST=2/1.8 From the elevated
position 3 the upper limb is brought down by the posterior segment of the deltoid, long head of the triceps, latissimus
dorsi, and pectoralis major (Fig 5-22). Beyond neutral the motion continues as extension, and all motors continue their
action except the pectoralis major. The range of extension is 60 degrees (Fig 5-23).1 Contributors to this motion are
gravity and downward rotators of the scapula.

FIG. 5-20 Motion in the sagittal plane. A posterior arc of

motion from positions 3 to 4 is possible through internal
rotation. From positions 4 to 1 the extremity derotates to
reach the neutral position.

13 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-21 Flexors at the scapulohumeral joint: 1, anterior

segment of the deltoid; 2, clavicular segment of the pectoralis
major; 3, coracobrachialis; 4, biceps. The arrow indicates
flexion.

FIG. 5-22 Extensors at the scapulohumeral joint: 7, posterior

deltoid; 2, latissimus dorsi; 3, pectoralis major; 4, teres major;
5, long head of the triceps.

FIG. 5-23 Flexion at the scapulohumeral joint is 180 degrees,

and no combined rotation is necessary. Extension is 60
degrees.

Motion in the Horizontal Plane

When the upper extremity is elevated to 90 degrees in the frontal plane, the distal point of the limb scans the horizontal
plane and traces an arc of 165 degrees (Fig 5-24).1 The flexors and extensors of the scapulo-humeral joint control the
motion.

14 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-24 Motion in the horizontal plane: flexion of 135 degrees and extension of 30
degrees.

Rotary Capability of the Shoulder Complex

When the upper extremity is held in the neutral rotational position at the shoulder and the elbow is flexed at 90 degrees,
the distal point traces an arc of internal rotation of 80 degrees and an arc of external rotation of 60 degrees. With the
shoulder elevated 90 degrees in the frontal plane, this rotary capability changes to 90 degrees of external rotation and 70
degrees of internal rotation (Fig 5-25).1

FIG. 5-25 Rotation at the scapulohumeral of joint. A, rotation

with the arm in neutral elevation: external rotation of 60
degrees and internal rotation of 80 degrees. B, rotation with
the arm elevated 90 degrees: external rotation of 90 degrees
and internal rotation of 70 degrees.

ELBOW

15 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

The elbow joint determines an arc of motion, E2, of 150 degrees. The orientation of the plane of action is closely
influenced by the rotational position of the shoulder joint. When the arm is elevated in the frontal plane, for example, the
envelope of action E2 of the elbow is located in this plane if the shoulder is in external or internal rotation.

The main flexors of the elbow are the brachialis and the biceps. The brachioradialis and pronator teres are the accessory
flexors (Fig 5-26). There is an intricate interplay and a wide range of participation in the elbow flexors.13 The brachialis is
the baseline flexor and is active at any rotational position of the forearm and any speed, with or without load applied to the
flexing forearm (Fig 5-27). It is also active in flexed elbow posture or during extension of the forearm; it then acts as an
an-tigravity muscle, The biceps is a flexor of the supine forearm, and its activity is evident as soon as slight resistance is
applied. Deactivation occurs when the forearm is pronated unless significant resistance is applied to the pronated flexing
forearm.

FIG. 5-26 Elbow flexors: 1, biceps, reserve flexor; 2, brachialis,

main flexor; 3, brachioradialis, accessory flexor; 4, pronator
teres, accessory flexor.

FIG. 5-27 Elbow flexion: 1, flexion in supination without resistance; 2, flexion in neutral without
resistance; 3, flexion in pronation without resistance; 4, flexion in supination with resistance.
The brachialis is the baseline flexor. The biceps is the reserve flexor. It is the flexor of the
supine forearm, especially when resistance is encountered. Its action is minimum in pronation.

16 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

The brachioradialis is more active in neutral and against resistance. The pronator teres is
active only against resistance. + + + , Maximum activity; + + , mild activity; + , minimal activity;
-, no activity.

The biceps is minimally active as an antigravity muscle or in maintaining a static flexed position. The brachioradialis is
active when the forearm is flexing rapidly at any rotational position. It is also a reserve flexor during flexion against
resistance, especially in neutral rotation of the forearm. The pronator teres does not participate as a flexor unless
resistance is encountered during flexion.

The extensor of the elbow is the triceps assisted by the anconeus (Fig 5-28). The baseline worker during extension is the
medial head of the triceps. Without load being applied, the long head is not active, whereas the lateral head is minimally
active. These last two reserve extensors come into play when resistance is applied to the motion of extension (Fig
5-29).19

FIG. 5-28 Elbow extensors: 1, triceps; 2, anconeus.

FIG. 5-29 Elbow extension: 1, without resistance, the medial head

of the triceps is the main extensor assisted by the lateral head; 2
against resistance, all three heads of the triceps are active. + + + ,
Maximum activity; + + , mild activity; +, minimal activity; -no activity.

FOREARM ROTATION
The average range of pronation-supination of the forearm with the elbow flexed at 90 degrees is 173 degrees measured
at the level of the hand. The corresponding rotation measured at the wrist is 156 degrees.4 The difference of 17 degrees
indicates participation of the radiocarpal and midcarpal joints. When the distal end of the radius and the head of the ulna
are aligned in the vertical plane delineating the neutral position at the level of the wrist, the hand is in a position of minimal
supination of 11 degrees. The average range of pronation is 62 degrees and ranges from 49 degrees to 84 degrees.
The average range of supination is 104 degrees and ranges from 86 degrees to 122 degrees.4

The axis of pronation-supination is variable in location. It extends from the center of the radial head to the distal end of the
radius and ulna and passes "anywhere between the radial and ulnar styloid processes."2 In the average habitual motion,

17 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

the axis passes through the distal end of the radius in line with the third metacarpal or the long finger. During this rotary
motion the distal third of the radius and the head of the ulna trace arcs of motion quite comparable in size (Fig 5-30).
Starting from the position of supination, the head of the ulna is extended and laterally displaced in the neutral position. In
pronation the ulnar head is flexed and further displaced laterally. When the hand rests on its ulnar border on a surface and
rotation is initiated, the motion occurs around the axis passing through the head of the ulna and the little finger. The head
of the ulna remains still. The hand then makes a circumferential transposition. The styloid process of the radius traces a
large arc of motion (Fig 5-30). When rotational motion occurs along an axis passing through the middle finger and near
the radial styloid process, the head of the ulna traces a much larger arc of motion than the radius. One can easily
appreciate the shift of the rotational axis by supinating and pronating the forearm, the elbow being held at 90 degrees
flexion, with the tip of an extended finger applied against the wall or the border of a table. In other words, the peripheral
point of fixation through the finger or through a tool held in the hand determines the location of the axis of pronation-
supination. When the rotation occurs along the oblique axis passing through the head of the ulna, the radial styloid traces
an arc corresponding to the base of a cone. In full pronation the styloid process then appears to be less distal relative to
the head of the ulna.6

FIG. 5-30 Rotation at the distal radioulnar end of the joint. In

habitual rotation the axis passes through the middle of the
distal end of the radius (+). From supination to pronation the
radial styloid traces curve 1, and the head of the ulna traces
curve 2. From supination, S, to neutral, N, the head of the ulna
is extended and laterally displaced. From neutral, N, to
pronation, P, it is flexed and further laterally displaced. When
the axis of motion passes through the center of the ulnar
head, the latter stays still during rotation, whereas the radial
styloid traces a very large curve 3. The location of the axis of
rotation is determined by a peripheral point of fixation.2

The interosseous membrane uniting the radius and ulna relaxes or tenses during pronation-supination. The interosseous
distance measured in the distal, middle, and proximal thirds of the forearm is the largest in neutral position and the
smallest in full pronation (Fig 5-31). The tension in the membrane is thus minimal in full pronation. During a fall on the
outstretched pronated hand, the interosseous membrane is not the main element of pressure transmission to the elbow
through the ulna. When load is applied to the forearm from a distoproximal direction, the radius transmits 57% of the load
directly to the humerus and 43% to the ulna7.

18 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-31 Interosseous distance in pronation, neutral, and supination.

Distance is maximal in neutral and minimal in pronation. (Adapted from
Christensen JB, Adams JP, Cho KO, et al: Anat Rec 1968; 160:261-271.)

The forearm is pronated by the pronator quadratus and pronator teres (Fig 5-32). The main pronator is the pronator
quadratus, the action of the muscle being independent of the position of the elbow. The pronator teres is a reserve
pronator reinforcing the power when speed is required or resistance is applied to the motion (Fig 5-33).14 The
participation of the accessory pronators, flex or carpi radialis and palmaris longus, is controversial. The forearm is
supinated by the supinator (Fig 5-34). The biceps is the reserve supinator and reinforces the action when fast supination
is required or resistance is encountered (Fig 5-35). The extensor carpi radialis longus and brevis are accessory
supinators.

FIG. 5-32 Pronators of the forearm: 1, pronator quadratus,

main pronator; 2, pronator teres, reserve pronator; 3, flexor
carpi radialis, accessory pronator; 4, palmaris longus,
accessory pronator.

19 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-33 Pronation of the forearm: 1, The elbow flexed without resistance; 2, elbow
extended without resistance; 3, against resistance. The pronator quadratus is the main
pronator active at any position of the elbow. The pronator teres increases in activity only
against resistance or when speed is required. + + + , Maximum activity; + + , mild activity; +,
minimal activity.

FIG. 5-34 Supinators of the forearm: 1, supinator, main

supinator; 2, biceps, reserve supinator; 3, extensor carpi
radialis longus and brevis, questionable accessory supinators.
The arrow indicates supination.

20 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-35 Supination of the forearm: 7, elbow flexed without

resistance; 2, elbow extended without resistance; 3, against
resistance. + + + , Maximum activity; + + , mild activity; +,
minimal activity; -, no activity. The supinator is the main
supinator. The biceps is the reserve supinator functioning
best with the elbow flexed at 90 degrees or when speed and/or
power is required.

WRIST
The wrist acts as a universal joint. It develops a spheroid type of motion envelope E3 (Fig 5-36) that permits the hand to
move without digital motion. The wrist flexes, extends, deviates laterally, and participates minimally in pronation-supination.
The wrist traces an arc of 121 degrees of flexion-extension with a minimum of 84 degrees and a maximum of 169
degrees. The average arc of extension is 55 degrees and ranges from 31 degrees to 79 degrees; the average arc of
flexion is 66 degrees and ranges from 38 degrees to 102 degrees, as measured on 55 normal adult wrists.17 The
radiocarpal and midcarpal joints participate in this motion, and both flexion and extension are initiated in the midcarpal joint
(Fig 5-37). Starting from the neutral position, when the wrist flexes, the average range of flexion is 40 degrees at the
midcarpal joint and 26 degrees at the radiocarpal joint. The midcarpal joint contributes 60% of the arc of flexion, and the
radiocarpal joint contributes 40%. During extension the average range of extension is 19 degrees at the midcarpal joint
and 37 degrees at the radiocarpal joint. The midcarpal joint contributes 33.5% of the arc of extension, and the radiocarpal
joint contributes 66.5% (Fig 5-38).18 The scaphoid belongs anatomically to both rows, and yet functionally it is part of the
distal row in extension and part of the proximal row in flexion.18 This behavior of the scaphoid correlates well with the
concept of the carpus becoming a rigid "close-pack" mass in extension and "loose-pack" mass in flexion.14 The rigidity of
the carpal mass in extension favors fracture of the scaphoid or the distal end of the radius on impact. The combination of
wrist extension and pronation-supination permits the hand to explore the outer half of a circle (Fig 5-39). The flexed wrist,
when rotated, permits the hand to explore the inner half of a circle (Fig 5-40). This latter motion is concerned more with
functional activities related to the body. Functionally the hand is used more frequently with the wrist extended and radially
deviated or with flexion combined with ulnar deviation.

21 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-36 Field of motion of the wrist and hand: E3, action envelope of the wrist; E4, action
envelope of the finger tracing an equiangular spiral.12 The field of motion of the finger is
within E3 when the wrist is extended or projects proximally when the wrist is flexed.

FIG. 5-37 Radiocapitate motion in extension and flexion of wrist. (From Sarrafian
SK, Melamed JL: Unpublished data, 1975.)

22 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-38 Contribution of the radiocarpal and midcarpal joints

to flexion-extension. A, flexion: 60% is midcarpal, and 40% is
radiocarpal. B, extension: 33.5% is midcarpal, and 66.4% is
radiocarpal. (From Sarrafian SK , Melamed JL, and Goshgarian
GM: Clin Orthop 1977; 126:153-159. Used by permission.)

FIG. 5-39 The extended wrist, when rotated, explores the outer half of a circle, which is a base of
spheroid E3.

23 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-40 The flexed wrist, when rotated, explores the inner
half of a circle, which is a base of spheroid E3.

The wrist is flexed by the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus. The long digital flexors are the
accessory flexors of the wrist. The wrist extenders are the extensor carpi radialis longus and brevis and the extensor carpi
ulnaris. The digital extensors are the accessory extensors of the wrist. The motion of lateral deviation of the wrist
averages 40 degrees, with 30 degrees in the ulnar direction and 15 degrees on the radial side. The proximal and distal
rows of the carpus participate and move in the opposite direction. During ulnar deviation the distal row rotates with the
metacarpals ulnaward, and the proximal row, including the scaphoid, turns radialward. The reverse motion occurs during
radial deviation. The range of ulnar deviation is greater when the hand is supinated. During radial deviation the scaphoid
rotates posteroanteriorly, the proximal pole turning dorsally and the distal pole with its tuberosity anteriorly. The lunate
follows the scaphoid and flexes. In ulnar deviation, the scaphoid derotates and exposes its full profile (Fig 5-41).

FIG. 5-41 Position of the scaphoid: 1, in radial deviation, the

tuberosity points anteriorly; 2, in neutral; 3, in ulnar deviation,
derotation occurs, and the scaphoid exposes its full profile.

Pronation occurs when the hand extends in a radial direction starting from a neutral rotation position. Supination
accompanies the motion of flexion with ulnar deviation. This combination of motion becomes quite evident during
manipulative functions of the hand and wrist when involved in power-type performance (hammering, casting a fishing line,
swinging a club, etc.).

The center of rotation during radioulnar deviation is located in the head of the capitate. The radial deviators of the wrist are

24 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

the abductor pollicis, extensor pollicis brevis, extensor carpi radialis longus and brevis, long extensors of the index, and
the flexor carpi radialis. The ulnar de viators are the extensor carpi ulnaris, flexor carpi ulnaris, and long extensors of the
middle, ring, and little fingers.

The wrist is a key joint with regard to the functional activities of the hand. Grip power is maximal when the wrist is extended
to 35 degrees and minimal with the wrist maximally flexed. The degree of participation of the digital motors determines,
on the other hand, recruitment of the wrist motors. When the wrist is in extension and the fingers make a soft fist, the
following wrist motors are active in a descending order: extensor carpi radialis brevis, extensor carpi ulnaris, and extensor
carpi radialis longus. With a tight fist, all three extensors are maximally active (Fig 5-42).16

FIG. 5-42 Wrist extension: 1, with a soft fist; 2, with a tight fist. + + + ,
Maximum activity; + + , mild activity; +, minimal activity.

When the fingers are gently extended and the wrist is held in extension, the extensor carpi ulnaris and flexor carpi ulnaris
are active. The forceful opening of the fingers brings into action, in a descending order, the following additional wrist
motors: extensor carpi radialis brevis, palmaris longus, extensor carpi radialis longus, and flexor carpi radialis (Fig
5-43).16

FIG. 5-43 Wrist extension: 1 , with gentle opening of the fingers; 2, with
forceful opening of the fingers. + + + , Maximum activity; + + , mild activity; +,
minimal activity.

HAND

Fingers
Located at the end of a multisegmented system, the hand functions within the action envelope E3 of the wrist. The flexing
finger traces an action envelope, E4, that is an equiangular spiral (Fig 5-36).12

When the wrist is extended, the field of motion of the fingers is within the wrist envelope E3. With wrist flexion the action

25 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

envelope E4 of the fingers extends beyond the field of motion of the wrist (Fig 5-36).

If the fingers are to be used for the purpose of prehension, the interphalangeal and metacarpophalangeal joints must flex
in a coordinated fashion to permit wrapping of the digital palmar surface over the surface of the object. Separately the
distal joint is flexed by the flexor profundus, the middle joint by the flexor superficialis and the metacarpophalangeal joint
by the intrinsic muscles. The coordination of flexion at the interphalangeal joints and the metacarpophalangeal joint is
brought about by the instantaneous participation of the extrinsic-intrinsic motors commanded by the motor cortex.

Furthermore, a fine mechanism of coordination is present locally in the fingers at the level of the interphalangeal joints as
presented by Landsmeer.10 As soon as flexion is initiated at the level of the distal joint (Fig 5-44) by the flexor profundus,
the terminal extensor tendon is displaced distally, and the extensor trifurca-tion is carried distally through the lateral
tendons, thus relaxing the middle slip. Simultaneously, the oblique retinacular ligament attached to the terminal tendon
also increases in tension and, passing volar to the axis of motion at the proximal interphalangeal joint, automatically flexes
the middle phalanx. This is a passive mechanism of interphalangeal joint coordination. When the finger reaches a position
of flexion close to 70 degrees at the proximal interphalangeal joint, the previously relaxed middle slip goes under tension,
and the extensor trifurcation is displaced further distally. This displacement relaxes the lateral slips, lateral tendons, and
terminal tendon. This unloading of the extensor tendon at the distal joint allows completion of the flexion at this joint
without encountering undue resistance. Any break in this system of activation and coordination interferes immediately with
the function of prehension.

FIG. 5-44 Landsmeer's10 concept of coordination of

interphalangeal joint flexion. A, finger in extension. B, active
flexion at the distal interphalangeal joint increases tension in
the terminal extensor tendon and oblique retinacular ligament.
Extensor trifurcation advances distally, extensor middle slip
relaxes, and the middle joint flexes automatically to the same
degree. C and D, as flexion continues the middle slip increases
in tension. Trifurcation advances further distally, thus relaxing
the lateral tendons and terminal tendon, including the oblique
retinacular ligament. The distal joint then flexes without
encountering extensor resistance.

The absence of intrinsic muscle action not only breaks the contour of the longitudinal arch of the finger but also creates
an abnormal pattern of function. The three joints flex successively from a distoproximal direction rather than
simultaneously, and this pattern of flexion prevents the palmar skin from making the necessary surface contact with the

26 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

object.

The opening of the fingers is an essential prerequisite for the act of prehension. Extension of the metacarpophalangeal
joint is controlled by the long extensor. The mechanism is dual. An indirect action of extension is exerted by the long
extensor on the proximal phalanx through the volar attachment of the transverse or quadrilateral lamina. A direct action is
present through a tendinous attachment of the long extensor to the dorsum of the proximal phalanx. This band is present
in only 38.5% of dissected hands.9

The proximal interphalangeal joint is extended by the long extensor middle slip and spiral fibers arising from the intrinsic
tendons. The distal joint is extended by the terminal tendon, which is essentially formed by the long extensor lateral slip
but also receives a contribution from the corresponding intrinsic tendons. The oblique retinacular ligaments participate in
the constitution of this tendon (Fig 5-45).

FIG. 5-45 Extensor system: 1, terminal tendon; 2, middle slip;

3, lateral slip; 4, intrinsic tendon; 5, quadrilateral lamina.

When the middle joint extends actively, the oblique retinacular goes under tension and automatically extends the distal
joint.10 This is another mechanism of coordination on the extensor side of the finger. The flexing finger increases
gradually in skeletal length due to the noncircular contour of the metacarpal head. This creates undue tension in the
extensor system, but immediate adjustment occurs by the distal shift of the entire extensor mechanism and the volar
displacement of the lateral slips at the level of the middle joint. In maximum flexion, the lateral slips are at the level of the
axis of motion of the joint. The side motion and rotation of the fingers are determined by the intrinsic muscles. The dorsal
interossei abduct or spread the fingers, whereas the volar interossei adduct the fingers relative to a functional axis
passing through the third metacarpal. There is more abduction to the finger in extension and less in flexion.

A final passive mechanism of flexion-extension of the finger is present through a tenodesis effect: wrist extension flexes
the fingers, and wrist flexion extends them.

Thumb

The thumb sweeps a conoid surface11 through circumduction. This curved surface is flattened on the palmar aspect (Fig
5-46). All functional activities of the thumb occur within this envelope. Through flexion-adduction the thumb traces the
segment of the base of the cone along the palmar surface. The curve traced during this motion is an equiangular spiral11
(Fig 5-47). Through extension-abduction the ray returns to its initial position.

27 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-46 Conoid field of motion of the thumb. All functional

activities occur within this field of motion. Basic motions are
as follows: 1 to 2, extension and abduction in the palmar
plane; 2 to 3, abduction in the plane perpendicular to the palm
with pronation; 3 to 4, flexion, adduction, and further
pronation; 4 to 1, extension and palmar abduction with
supination; 1 to 4, flexion, adduction, and pronation.

FIG. 5-47 The thumb traces an equiangular spiral11 when

sweeping the palmar surface from A to B.

A fundamental function of the thumb is opposition with the fingers. This occurs as the pad of the thumb is set against the
pulp of a corresponding finger. To bring about this opposition, the thumb is abducted in a plane perpendicular to the palm
and flexed and rotated pronated) on its long axis (Fig 5-48). The thumb and the pulp of the finger make contact along the
equiangular spiral curve of the finger.

28 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-48 Opposition of the thumb. A, stage I is positioning of the thumb against the corresponding
finger. This motion involves curve 1, abduction in a plane perpendicular to the palm; curve 2, flexion;
curve 3, pronation. B, stage II involves clamping of opposed digits. This provides power to opposition.

There are two phases to the opposition. In stage I the thumb is positioned against the pulp of a corresponding finger.
This is determined by the abductor pollicis bre-vis, opponens, and superficial head of the short flexor. Stage I is a
function of the median nerve. Stage II of the opposition is the clamping of the thumb pad against the opposed finger. This
phase provides the power for the opposition. It is controlled by the adductor and deep head of the short flexor and is a
function of the ulnar nerve (Fig 5-48).

Functional Activities
The functional activities of the hand are extensive but can be grouped into nonprehensile and prehensile activities. The
former includes touching, feeling, pressing down with the fingers, tapping, vibrating the cord of a musical instrument,
lifting or pushing with the hand, stirring, etc. Prehensile activities are grouped into precision and power grips.15 Precision
grip involves participation of the radial side of the hand with the thumb, index, and middle finger to form a three-jaw chuck.
When the pulp of these digits comes into contact, the grip is of the palmar type, whereas for very precise work contact
with the tip of the same digits, creates a tip type of grip. A lateral, or key, grip involves contact of the pulp of the thumb with
the lateral aspect of the corresponding finger in its distal segment.

Power grip predominantly involves the ulnar aspect of the hand with involvement of the little and ring fingers. The radial
three digits also participate actively either in a pure power pattern form or by adding an element of precision to the power
grip. A typical power grip is the cylindrical grip. All fingers are flexed maximally, for example, around the handle of a tool,
and the counterpressure to the flexing fingers is provided by the thenar eminence. More power is provided to this grip
when the thumb wraps around the flexed fingers. If an element of precision is necessary, the thumb will adopt a
longitudinal position of adduction that allows for small adjustments of posture. In general, the pattern of the grip during
prehension is determined by the intention and not necessarily by the shape of the object.15 A scalpel is held in a precision
grip for exact work or in a power grip for bold cuts.

The hook power grip involves flexion of both inter-phalangeal joints and minimal participation of the metacarpophalangeal
joint. This pattern is used in carrying a suitcase.

The spherical grip is an interesting grip. If the object held by the digits is large, the grip is of the power type with minimal
flexion of the fingers, which are abducted and rotated, and the thumb participates at the opposite pole by stabilizing the
object and providing the necessary counterpressure. With a smaller spherical object the fingers are adducted, and the
thumb is in opposition; this pattern of prehension is of the precision type.

Despite the multitude of functional activities of the hand, any prehensile act when arrested instantaneously might fit in one
of these patterns in a pure or combined form. In the cylindrical grip the motors responsible are the flexor profundi and the
intrinsic muscles except for the second dorsal interosseous and the three radial lumbricales. The flexor superficialis is a
reserve flexor and participates when more power is necessary. The index finger is an exception; here the flexor
superficialis pattern predominates.13 The thumb brings its contribution with the thenar muscles and the long motors,
except for the abductor pollicis longus.

In the hook type of prehension, the radial intrinsics are silent. The long flexors, fourth dorsal interosseous, lumbricales,
and the abductor digiti quinti, are active.13

During soft opposition of the thumb with the index finger-palmar prehension-the opponens, abductor pollicis brevis, and
short flexor are active in a decreasing order (Fig 5-49).5 When pressure is exerted, the short flexor becomes the more
active, followed by the opponens and abductor pollicis brevis. In the lateral grip the flexor pollicis brevis and the
opponens are very active. The activity of the abductor pollicis brevis is negligible.5

29 de 30 22/07/2011 01:58 a.m.

5: Kinesiology and Functional Characteristics of the Upper Limb | O&P ... http://www.oandplibrary.org/alp/chap05-01.asp?mode=print

FIG. 5-49 Electromyographic activity during opposition. A, soft opposition. B,

hard opposition. O = opponens; APB = abductor pollicis brevis; FB = flexor
pollicis brevis. + + + , Maximum activity; + + , mild activity; +, minimum activity.

References:

1. American Academy of Orthopaedic Surgeons: Joint Motion- Method of Measuring and Recording. Chicago,
1969.
2. Capener N: The hand in surgery. J Bone Joint Surg [Br] 1956;38:128-151.
3. Christensen JB, Adams JP, Cho KO, et al: A study of the interosseous distance between the radius and ulna
during rotation of the forearm. Anat Rec 1968; 160:261-271.
4. Darcus HD, Salter N: The amplitude of pronation and supination with the elbow flexed to a right angle. J Anat
1953;87:169-184.
5. Forrest WJ, Basmajian JV: Functions of human thenar and hypothenar muscles: An electromyographic study of 25
hands. J Bone Joint Surg [Am] 1965; 47:1585-1594.
6. Gemmill JF: On the movement of the lower end of the radius in pronation and supination and on the interosseous
membrane. J Anat Physiol 1901; 35:101-109.
7. Halls AA, Travill A: Transmission of pressures across the elbow joint. Anat Rec 1964; 150:243-247.
8. Inman VT, Saunders M, Abbott LC: Observations on the function of the shoulder joint. J Bone Joint Surg 1944;
26:1-30.
9. Kaplan EB: Functional and Surgical Anatomy of the Hand, ed 2. Philadelphia, JB Lippincott, 1965.
10. Landsmeer JMF: The anatomy of the dorsal aponeurosis of the human finger and its functional significance, Anat
Rec 1949; 104:31-44.
11. Littler JW: Hand structure and function. Symp Reconstr Hand Surg 1974; 9:3-12.
12. Littler JW: On the adaptability of man's hand. Hand 1973;9:187-191.
13. Long C, Conrad PW, Hall EA, et al: Intrinsic-extrinsic muscle control of the hand in power grip and precision
handling: An electromyographic study. J Bone Joint Surg [Am] 1970; 52:852-867.
14. MacConaill MA, Basmajian JV: Muscles and Movements- a Basis for Human Kinesiology. Baltimore, Williams &
Wilkins, 1969.
15. Napier JR: The prehensile movements of the human hand. J Bone Joint Surg [Br] 1956; 38:902-913.
16. Radonjic D., Long C: Kinesiology of the wrist. Am J Phys Med 1971; 50:57-71.
17. Sarrafian SK, Melamed JL: Unpublished data, 1975.
18. Sarrafian SK, Melamed JL, Goshgarian GM: Study of wrist motion in flexion and extension. Clin Orthop 1977;
126:153-159.
19. Travill AA: Electromyographic study of the extensor apparatus of the forearm. Anat Rec 1962; 144:373-376.

Chapter 5 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Normal Version

30 de 30 22/07/2011 01:58 a.m.