Functional Anatomy of the Upper Limb

Bill Sellers

Email: wis@mac.com

This lecture can be found at:

http://mac-huwis.lut.ac.uk/~wis/lectures/

In previous lectures you have learnt about the general principles of musculoskeletal function.
This lecture will cover specific details of the functional anatomy of the upper limb to
illustrate the points made previously and as useful information in its own right. In the course
of the lecture I will move distally down the limb from the pectoral girdle to the phalanges.
This is not an exhaustive coverage but will cover the main functional anatomical features of
the joints and musculature including ranges of movement and the major actions of the
muscles.

Figure 1. The sternoclavicular joint

The only joint in the upper limb between the axial skeleton and the pectoral girdle is the
sternoclavicular joint between the sternum and the clavicle. This is a ball and socket
synovial joint with an articular disk. Its range of movement is shown in figure 1. It is an
extremely strong joint supported by tough ligaments and the subclavius muscle which acts as
a dynamic ligament. This means that the joint almost never dislocates – when the forces
acting on the joint get too great the clavicle tends to break.
 Figure 2. The acromioclavicular joint

Moving distally the next joint is the acromioclavicular joint: a sliding synovial joint
between the acromion process on the scapular and the clavicle. Once again there are strong
ligaments binding the two bones together especially the coracoclavicular ligament whose
two parts have perpendicular fibres to prevent excessive movement both medially and
anteriorly.

Figure 3. Movements of the scapular

Between the two of them the sternoclavicular and acromioclavicular joints allow a large
range of movements of the scapular as shown in figure 3. There is no specific joint between
the scapular and the thoracic cage although the movements all consist of the blade of the
scapular sliding around the various curves of the thoracic cage. There is no bone to bone
contact though since the deep surface of the scapular is covered by both the subscapularis
and serratus anterior muscles. It is important to remember that a great deal of the overall
mobility of the shoulder is actually due to the mobility of the scapular. The limb girdle for the
lower limb (the pelvis) is firmly fixed to the axial skeleton and so sacrifices mobility to gain
increased stability and better load bearing capacity.
 Figure 4. Muscles acting on the scapular

With such a complex array of possible movements it should come as no surprise that there
are quite a large number of muscles that act on the scapular. The main ones are shown in
figure 4. These muscles do not tend to act in isolation and because they tend to be muscular
sheets rather than fusiform or strap muscles the precise action depends on which fibres within
the muscle are activated (this is because the fibres in sheet muscles rarely run in parallel
throughout the whole of the muscle).

Figure 5. Dorsal aspect of the arm

The next joint is the glenohumeral joint between the head of the humerus and the glenoid
fossa of the scapula. This is a highly mobile ball and socket joint and to cope with this
mobility a large number of muscles. Figure 5 shows the main extensors of the shoulder but
note that triceps is also an elbow extensor and only the long head acts as a shoulder extensor.

Figure 6. Ventral aspect of the arm

The flexors of the shoulder are on the ventral aspect (figure 6). Note that the very important
arm flexor, pectoralis major, has additional actions (adduction and medial rotation) so that if
a pure flexion is required then other muscles need to act antagonistically for adduction (e.g.
deltoid, supraspinatus) and medial rotation (e.g. teres minor, infraspinatus) to prevent the
unwanted actions. Similarly latissimus dorsi is a major extensor which again produces
adduction and medial rotation and would require antagonistic action in other muscles for pure
extension. Latissimus dorsi and pectoralis major often act together to produce very powerful
adduction since their extension and flexion components cancel each other although this
would still leave the medial rotation component.

Figure 7. Superior view of the shoulder

If we look down on the shoulder from above (figure 7) we can see the medial and lateral
rotators, and the abductors. Deltoid is a triangular (delta) shaped muscle which has all three
actions depending on which fibres you look at. Its main action is as an abductor though.
Rotation is performed by the small rotator cuff muscles and as a side effect of the big
abductors.

Figure 8. Shoulder abduction

Shoulder abduction (figure 8) is a more complex activity than might originally be thought. If
you start from the anatomical position and begin to abduct the arm the initial 10° is
performed entirely by supraspinatus because initially the fibres of deltoid are in the wrong
direction to help. After that the much larger deltoid takes over the work. Abduction continues
for about 110° at the glenohumeral joint but subsequent abduction takes place by upward
rotation of the scapular. The full range of abduction (180°) can also only take place if the arm
is medially rotated.
 Figure 9. The glenohumeral joint

The extreme mobility of the glenohumeral joint means that it cannot be stabilised by the
normal, passive elastic mechanisms of ligaments. Instead it has active stabilisation from the
short muscles that surround the joint – the so called rotator cuff muscles (figure 9). You can
see from the joint shape and locations of the muscles that there is little to support the joint
inferiorly and indeed dislocations of the shoulder are almost always in this direction.

Figure 10. The elbow joint

The elbow joint is a complex of three joints that share the same synovial sheath (figure 10).
These are the humeroradial, humeroulnar, and superior radioulnar joints. The
humeroradial and humeroulnar joints allow flexion and extension at the elbow whilst the
superior radioulnar, humeroradial, and the more distal inferior radioulnar joints allow the
specialised actions of supination and pronation. This action is a rolling of the radius around
the ulna that produces an apparent rotation of the wrist around a longitudinal axis. The elbow
flexors and extensors can be seen in figures 5 and 6. Triceps is the main extensor and
brachialis and biceps brachii the main flexors. Biceps brachii is also a major supinator and
this action stops it being an effective flexor of the pronated forearm.
 Figure 11. Pronation and supination

The muscles pronator teres and pronator quadratus act to pronate the forearm (see figure
11). When they contract they role the radius anteriorly across the ulna. The converse action,
supination, is mainly produced by biceps brachii with some help from supinator. Biceps
brachii is a much larger muscle than the other three and this means that the action of
supination tends to be much stronger than pronation. Supination of the right arm is the action
used to drive screws into a substrate and produces more torque than unscrewing which uses
pronantion.

Figure 12 Superficial extensors in the forearm

The forearm contains a large number of muscles. Dorsally these are primarily extensors of
the wrist and fingers as shown in figure 12. They do attach to the common extensor origin on
the lateral epicondyle of the humerus so you might expect them to have an action at the
elbow but because this attachment point is so close to the centre of rotation of the elbow their
effect is minimal except for brachioradialis which is actually a strong elbow flexor.

Similarly there are superficial flexors in the ventral compartment (see figure 5) which
originate on the common flexor origin on the medial epicondyle of the humerus whose effect
at the elbow is minimal and whose primary actions are more distally at the wrist and hand.
Palmaris longus is actually missing in 13% of individuals – it is a weak wrist flexor and acts
to tense the palmar aponeurosis. It is therefore a prime candidate (in those of us who have
one) for surgical removal for use as a tendon repair material elsewhere in the body.
 Figure 13 Middle and deep flexors in the forearm

The deeper muscles in the flexor compartment are extrinsic hand muscles – they are powerful
flexors of the fingers. Their force is transmitted to the hand through long tendons. Somewhat
oddly the deeper flexor digitorum profundus attaches more distally on the fingers than the
more superficial flexor digitorum superficialis which means that the FDS tendon has to split
to let the FDP tendon pass through it.

Figure 14. Middle and deep extensors in the forearm

The arrangement in the extensor compartment is somewhat similar although the extensor
muscles are smaller than the flexors (figure 14). Flexors are used to produce the clenched-fist
power grips whereas there is not much need for forced extension.
 Figure 15. Joints of the hand

Moving to the hand there are a large number of complex joints at the wrist and between the
fingers. These are illustrated in figure 15. The wrist consists of 10 small carpal bones but
fortunately it can be functionally divided into two components: the radiocarpal and
midcarpal joints. The wrist complex is usually described as a condyloid synovial joint
allowing adduction, abduction (also known as ulnar and radial deviation), flexion and
extension. The exact ways that the wrist bones move to produce these composite movements
is complex but flexion occurs mostly at the midcarpal joint and extension is mostly at the
radiocarpal joint. The radiocarpal joint also provides most of the adduction and abduction.

Other joints that you can see are the carpometacarpal joints that are numbered from 1 to 5
between the distal row of carpal bones and the five metacarpals. The first CMC joint is the
best example of a sellar (saddle-shaped) joint which allows flexion, extension, adduction and
abduction of the first ray. The other four are under tight ligamentous control and only allow a
small amount of sliding. Distally are the five metacarpophalangeal joints. This time the
first MCP joint has little mobility but the other four allow flexion, extension, adduction and
abduction.

Figure 16. The bones of the hand [Netter 1997]

More distally still are the simple hinge joints of the phalanges (see figure 16): the five
proximal and distal interphalageal joints and the four middle interphalangeal joints since the
first ray only has two phalanges.

Figure 17. Wrist cross-section [Snell 1986]

When we look at the muscles that act over the wrist joint (figure 17) we get a complex
picture because as well as the specific wrist muscles (FCR, FCU, ECR, ECU and PL) all the
tendons from the extrinsic hand muscles also pass this joint and so have an effect depending
on the relative position of their tendon to the joint centre. The primary movers of the wrist
(FCR, FCU, ECR, ECU) also act the 4 corners of the joint so all produce a dual action. Thus
FCR produces wrist flexion and radial deviation, FCU flexion and ulnar deviation, ECR
extension and radial deviation, and ECU extension and ulnar deviation. Thus to produce pure
flexion, extension, abduction or adduction requires the activation of the correct two muscles:
the two flexors produce flexion together because the adduction and abduction actions cancel
out etc. If finger movements are required without corresponding wrist movements then the
wrist only muscles need to act antagonistically to avoid the unwanted wrist movement.

You can also see from figure 17 that the median nerve shares a rather small and inextensible
space with the extrinsic finger flexors. This is the carpal tunnel where tendonitis can cause
swelling which presses on the median nerve producing pain and in severe cases paralysis of
some of the intrinsic hand muscles: carpal tunnel syndrome.
 Figure 18. Various types of grip [Aiello & Dean 1990]

The primary role of the hand itself is grasping and manipulation. Figure 18 shows the variety
of grips that have been classified. A and B are simple grips, C, D and E are precision grips
and F, G and H are power grips. It is suggested that the precision grips are unique to humans
among the primates.

Figure 19. The superficial intrinsic hand muscles [Jacob 1996]

These fine movements are controlled by the intrinsic hand muscles in conjunction with the
more powerful extrinsic hand muscles of the forearm. Figure 19 shows the superficial palmar
(ventral) group. These are the muscles of the thenar and hypothenar eminences which
move the first and fifth digits respectively. As you might imagine movements of the fifth
digit are not terribly important but the relatively large thenar eminence muscles are very
important for the various movements of the thumb. The first ray is rotated 90° to the other
rays so that flexion of the thumb moves it medially across the palm of the hand, abduction
moves it anteriorly, perpendicular to the palm, extension moves it laterally in the plane of the
palm and adduction moves it posteriorly perpendicular to the palm. The special movement,
opposition, is the combined flexion and adduction that brings the palmar surface of the tip of
the first digit towards the palmar surfaces of the tips of any of the other four digits.
The lumbricals are muscles that attach to the tendons of the flexor digirorum profundus
muscles and the extensor digitorum comunalis tendons. They allow a controlled transfer of
power from the FDP to the EDC when flexing and extending the fingers and also allow
flexing of the MCP joint whilst keeping the IP joints extended.

Figure 20. Palmar and dorsal interossei [Jacobs 1996]

The other intrinsic muscles are the palmar and dorsal interossei. These act to abduct
(palmar) and adduct (dorsal) the MCP joints of the fingers. The first dorsal interosseous
muscle is very important fin pincer or pinch grips. These are shown in figure 20.

Figure 21. The extensor mechanism of the hand [Snell 1986]

The tendon arrangement around the fingers is complex as illustrated in figure 21. As
previously mentioned the FDP tendon pierces the FDS tendon to attach to the base of the
distal phalanx and the lumbricals attach the FDP tendon to the EDC. The EDC tendon
connects to the lumbricals, the dorsal interossei and to all three phalanges and is known as the
extensor expansion. This arrangement allows complex movements such as the unscrewing
of a pen top whilst holding the pen in one hand, but none of the movements are entirely
independent because single muscles act over several joints at once.

Bibliography

Jacobs S. Anatomy: a dissection manual and atlas. 1996 New York: Churchill Livingston.

Netter FH. Atlas of human anatomy. 1997 East Hanover, New Jersey: Novartis.
Snell RS. Clinical anatomy for medical students. 1986 Boston: Little, Brown.