The Back and Scapular region
By Prof.M.H.Al-Muhtaseb
Muscles Connecting the Upper Limb to the Vertebral Column
Trapezius
Origin Occipital bone(external occiptal protuberunce), superior nuchal line, ligamentum nuchae, spine of seventh cervical vertebra, spines of all thoracic vertebrae and their supraspinous ligament Insertion Upper fibers into lateral third of clavicle; middle and lower fibers into acromion and spine of scapula Nerve Supply Spinal part of accessory nerve (motor) and C3 and 4 (sensory) XI cranial nerve (spinal part)
Action Upper fibers elevate the scapula; middle fibers pull scapula medially (retracts); lower fibers pull medial border of scapula downward , anterior fibers rotates the scapula
Latissimus dorsi
Origin Iliac crest, lumbar fascia, spines of lower six thoracic vertebrae(T7-T12), lower three or four ribs, and inferior angle of scapula (5) Insertion Floor of bicipital groove of humerus (1) Nerve Supply Thoracodorsal nerve C6, 7, 8,
Action Extends, adducts, and medially rotates the arm (3) Its called the climbing muscle Raising of the trunk above the arm
Levator scapulae
Origin Transverse processes of first fourth cervical vertebrae (1) Insertion Medial border of scapula (1) Nerve supply C3 and 4 and dorsal scapular nerve C3, 4, 5 Action Raises medial border of scapula
Rhomboid minor
Origin Ligamentum nuchae and spines of seventh cervical and first thoracic vertebrae (3) Insertion Medial border of scapula (1) Nerve supply Dorsal scapular nerve C4, 5 Action Raises medial border of scapula upward and medially
Rhomboid major
Origin Second to fifth thoracic spines (1) Insertion Medial border of scapula (1) Nerve supply Dorsal scapular nerve C4, 5
Action Raises medial border of scapula upward and medially
Muscles Connecting the Scapula to the Humerus
Deltoid
Origin Lateral third of clavicle, acromion, spine of scapula Insertion Middle of lateral surface of shaft of humerus Nerve supply Axillary nerve C5, 6 Action Middle fibers Abducts arm; anterior fibers flex and medially rotate arm; posterior fibers extend and laterally rotate arm Abduction from 15-90 degrees
Supraspinatus
Origin Supraspinous fossa of scapula Insertion Greater tuberosity of humerus; capsule of shoulder joint Nerve supply Suprascapular nerve C4, 5, 6 Action Abducts arm and stabilizes shoulder joint Initiation of abduction 0-15 degrees
Infraspinatus
Origin Infraspinous fossa of scapula Insertion Greater tuberosity of humerus; capsule of shoulder joint Nerve supply Suprascapular nerve C4, 5, 6 Action Laterally rotates arm and stabilizes shoulder joint
Teres major
Origin Lower third of lateral border of scapula Insertion Medial lip of bicipital groove of humerus Nerve supply Lower subscapular nerve C6, 7 Action Medially rotates and adducts arm and stabilizes shoulder joint
Teres minor
Origin Upper two thirds of lateral border of scapula Insertion Greater tuberosity of humerus; capsule of shoulder joint Nerve supply Axillary nerve (C4), C5, 6 Action Laterally rotates arm and stabilizes shoulder joint
Subscapularis
Origin Subscapular fossa Insertion Lesser tuberosity of humerus Nerve supply Upper and lower subscapular nerves C5, 6, 7
Action Medially rotates arm and stabilizes shoulder joint
Rotator Cuff
The rotator cuff is the name given to the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles are fused to the underlying capsule of the shoulder joint The cuff plays a very important role in stabilizing the shoulder joint The tone of these muscles assists in holding the head of the humerus in the glenoid cavity of the scapula during movements at the shoulder joint
The cuff lies on the anterior, superior, and posterior aspects of the joint
The cuff is deficient inferiorly, and this is a site of potential weakness.
Quadrangular Space
The quadrangular space is an intermuscular space, located immediately below the shoulder joint It is bounded above by the subscapularis and capsule of the shoulder joint
below by the teres major muscle
It is bounded medially by the long head of the triceps and laterally by the surgical neck of the humerus. The axillary nerve and the posterior circumflex humeral vessels pass backward through this space
Triangular space
The triangular space is an area of communication between the axilla and the posterior scapular region Posteriorly, when viewed from the posterior scapular region, the triangular space is formed by: the medial margin of the long head of triceps brachii; the superior margin of teres major; the inferior margin of teres minor. The circumflex scapular artery and vein pass through this gap to the infraspinous fossa Radial nerve and the profunda brachi artery also passes
Axillary Nerve
The axillary nerve arises from the posterior cord of the brachial plexus (C5 and 6) in the axilla It passes backward and enters the quadrangular space with the posterior circumflex humeral artery As the nerve passes through the space, it comes into close relationship with the inferior aspect of the capsule of the shoulder joint and with the medial side of the surgical neck of the humerus It terminates by dividing into anterior and posterior branches
The axillary nerve has the following branches: An articular branch to the shoulder joint An anterior terminal branch, which winds around the surgical neck of the humerus beneath the deltoid muscle; it supplies the deltoid and the skin that covers its lower part. A posterior terminal branch, which gives off a branch to the teres minor muscle and a few branches to the deltoid, then emerges from the posterior border of the deltoid as the upper lateral cutaneous nerve of the arm It is thus seen that the axillary nerve supplies the shoulder joint, two muscles, and the skin covering the lower half of the deltoid muscle The axillary nerve can be injured in dislocations of the shoulder joint
Suprascapular nerve
The suprascapular nerve originates in the base of the neck from the superior trunk of the brachial plexus It passes posterolaterally from its origin, through the suprascapular foramen to reach the posterior scapular region innervates the supraspinatus muscle, then passes through the greater scapular (spinoglenoid) notch, between the root of the spine of the scapula and the glenoid cavity, terminate in and innervate the infraspinatus muscle. the suprascapular nerve has no cutaneous branches
Arterial Anastomosis Around the Shoulder Joint
The extreme mobility of the shoulder joint may result in kinking of the axillary artery and a temporary occlusion of its lumen To compensate for this, an important arterial anastomosis exists between the branches of the subclavian artery and the axillary artery
ensuring that an adequate blood flow takes place into the upper limb irrespective of the position of the arm
Branches from the Subclavian Artery The suprascapular artery, which is distributed to the supraspinous and infraspinous fossae of the scapula The superficial cervical artery, which gives off a deep branch that runs down the medial border of the scapula
Branches from the Axillary Artery The subscapular artery and its circumflex scapular branch supply the subscapular and infraspinous fossae of the scapula, respectively. The anterior circumflex humeral artery The posterior circumflex humeral artery
Both the circumflex arteries form an anastomosing circle around the surgical neck of the humerus
