Upper limb

S H O U L D E R A N AT O M Y
Upper limb
 Objectives

 At the end students should know:

o Bones forming shoulder region.
o Joints of shoulder region.
o Ligaments of shoulder region
o Muscles moving shoulder region
o Vasculature around shoulder Region(Task).
o Nerves of shoulder
 The shoulder

Is the region attaches to the trunk and neck.

Bony frame work:
o Clavicle and Scapula(pectoral girdle).
o Proximal part of humerus.
Superficial muscles of the shoulder consist of
Trapezius and deltoid, they connect the
clavicle and scapula to the trunk and arm.
Bones forming shoulder
Region
 Bones of shoulder

Clavicle
Bony attachment b/w trunk and upper limp.
palpable along the entire length with S-shape
contour.
Has forward facing convex medial part and
concave lateral part.
It has acromial end which is flat and sternal
end which is quadrangular
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Acromial end has small facet for articulation

with acromion process of scapula.
Sternal end has a much larger facet for
articulation with manubrium of sternum.
Inferior surface of lateral third of clavicle has
a distinct tuberosity(Conoid tubercle) and
lateral roughening(Trapezoid line) for
attachment of coracoclavicular ligament
Clavicle
Clavicle
 Clinical Correlates

The clavicle is the most commonly fractured bone in the

body.
 may result from a fall on the shoulder or outstretched
hand.
 It may also occur in a baby in breech presentation
during delivery through the birth canal.
Fractures occur most commonly at the junction of its
middle and lateral thirds, resulting in upward
displacement of the proximal fragment and downward
displacement of the distal fragment It may cause injury
to the brachial plexus (lower trunk), fatal hemorrhage
from the subclavian artery, or thrombosis of the
subclavian vein, leading to pulmonary embolism.
 Scapula

The scapula is a large, flat triangular bone

with:
three angles (lateral, superior, and inferior).
three borders (superior, lateral, and medial).
two surfaces (costal and posterior)
three processes (acromion, spine, and
coracoid process).
Comma shaped glenoid cavity in the lateral
edge which articulates with humerus head
(Glenohumeral joint).
A large triangular-shaped roughening (the
infraglenoid tubercle) inferior to the glenoid
cavity is the site of attachment for the long
head of the triceps brachii muscle.
Supraglenoid cavity is important for the
attachment for long head of biceps brachii.
Spine of the scapula divides the posterior
surface of the scapula into supraspinous fossa
much larger and small infraspinous fossa.
 Acromion

The acromion, which is an anterolateral

projection of the spine, arches over the
glenohumeral joint and articulates, via a
small oval facet on its distal end, with the
clavicle.
The superior border is marked on its lateral
end by:
 the coracoid process.
 Suprascapular notch.
 Coracoid Process

Is a hook-like anterior projection located on

the superolateral border of the scapula.
Provides the origin of the coracobrachialls
and short head of biceps brachii, and the
insertion of the pectoralis minor.
Is the attachment site for the
coracoclavlcular, coracohumeral, and
coracoacromial ligaments and the
costocoracoid membrane.
The Scapula
 Scapular Notch

Is a notch in the superior border, just medial

to the coracoid process.
 It is bridged by the superior transverse
scapular ligament and converted into a
foramen that transmits the suprascapular
nerve.
Suprascapular Notch
Suprascapular Foramen
 Clinical Correlates

Calcification of the superior transverse

scapular ligament is a common cause of
suprascapular nerve entrapment syndrome,
and familial cases have bean described
recently.
It may trap or compress the suprascapular
nerve as it passes through the scapular notch
under the superior transverse scapular
ligament,. affecting functions of the
supraspinatus and infraspinatus muscles.
 Proximal Humerus

The proximal end of the humerus consists of

the head, the anatomical neck, the greater
and lesser tubercles, the surgical neck, and
the superior half of the shaft of humerus.
The Humerus
 Humerus Head and Neck

The head:
 half-spherical in shape and projects medially
and somewhat superiorly to articulate with the
much smaller glenoid cavity of the scapula.
The anatomical neck:
 Is very short and is formed by a narrow
constriction immediately distal to the head.
 It lies between the head and the greater and
lesser tubercles laterally, and between the
head and the shaft more medially.
 Clinical importance of surgical neck

surgical neck is weaker than more proximal

regions of the bone, it is one of the sites
where the humerus commonly fractures.
Axillary nerve and posterior circumflex
humeral artery pass posterior to surgical
neck, and can be damaged by surgical neck
fractures.
 Greater and lesser tubercles

The greater and lesser tubercles are

prominent landmarks on the proximal end of
the humerus and serve as attachment sites
for the four rotator cuff muscles of the
glenohumeral joint.
 Bicipital groove

The lesser tubercle is marked by a large

smooth impression for attachment of the
subscapularis muscle.
A deep intertubercular sulcus(bicipital
groove) separates the lesser and greater
tubercles.
 The tendon of the long head of the biceps
brachii passes through this sulcus.
 Continue,,,,,,,,,

Roughening of the lateral and medial lips of

intertuburcular sulcus mark for the
attachment of the pectoralis major, teres
major, and latissimus dorsi muscles.
The lateral lip of the intertubercular sulcus is
continuous inferiorly with a large V-shaped
deltoid tuberosity which is where the deltoid
muscle inserts onto the humerus.
 Bicepital tendinitis

Biceps tendinitis is inflammation of the

tendon around the long head of the biceps
muscle.
Biceps tendinosis is caused by degeneration
of the tendon from athletics requiring
overhead motion or from the normal aging
process
Bicepital tendenitis
Calcific tendenitis
Joints Of shoulder Region
 Shoulder joints

Three joints: Sternoclavicluar,

acromioclavicular and glenohumeral joints.
The sternoclavicular joint and the
acromioclavicular joint link the two bones of
the pectoral girdle to each other and to the
trunk.
 Glenohumeral joint articulates with humerus
of the arm and the scapula.
 Sternoclavicular Joint

b/w the proximal end of clavicle and clavicular

notch of the manubrium of sternum, together with
small part of first costal cartilage.
Synovial and saddle shaped.
 united by the fibros capsule.
Articular surface separated in to two
compartments by intra-articular disc.
Permits anteroposterior movement of the clavicle.
Allows elevation and depression, protraction and
retraction, and circumduction of the shoulder.
Ligaments of Sternoclvicular joint

Surrounded by capsule.
Re-inforced by four ligaments:
 Anterior sternoclavicular ligament.
 Posterior sternoclavicular ligament.
 Interclavicular ligament.
 Costoclavicular ligament.
Sternoclavicular joint
 Acromioclavicular Joint

Small synovial joint.

b/w small oval facet of medial surface of
acromion and similar small facet of acromial end
of clavicle.
Surrounded by joint capsule.
Re-inforced by:
 Small acromioclavicular ligament.
 Larger coracoclavicular ligament(Strong
accessory ligaments,provides support for the
upper limb on the clavicle and the clavicle on
the acromion.
Acromioclavicular joint
 Clinical Correlates

Dislocation of the acromioclavicular joint can

result from a fall on the shoulder with the
impact taken by the acromion or from a fall
on an outstretched arm. The shoulder is
separated from the clavicle when the joint is
dislocated with rupture of the
coracoclavicular ligament.
 Glenohumeral Joint

Ball and socket joint.

Articulation b/w humeral head and glenoid
cavity of scapula.
Provides multiaxial range of movement(Flexion,
extension,abduction,adduction and
circumduction).
Joint stability provided by rotator cuff
muscles,long head of biceps brachii,bony
processes and extracapsular ligaments.
 Glenoid labrum

Synovial joint covered by hyaline cartilage.

Glenoid cavity deepened by
fibrocartilagenous (Glenoid labrum)which
attaches to the margin of the fossa.
The labrum is continuous with the long head
of biceps brachii which attach to the
supraglenoid tubercle.
Glenoid labrum
Glenoid Cavity
 Dislocation of glenohumeral joint

The glenohumeral joint is extremely mobile,

providing a wide range of movement.
Small glenoid cavity and less
fibrocartilagenous glenoid labrum make
suceptibility for dislocation.
Anterior shoulder dislocation is most
frequent.
If joint capsule disrupted reccurent
dislocations result.
Posterior dislocation is rare
 Synovial Membrane

The synovial membrane attaches to the

margins of the articular surfaces and lines
the fibrous membrane of the joint capsule .
The synovial membrane is loose inferiorly.
The synovial membrane protrudes through
apertures in the fibrous membrane to form
bursae, which lie between the tendons of
surrounding muscles and the fibrous
membrane, the most common is
Subtendenous bursa of subscapularis.
 Bursa

 SUBSCAPULAR BURSA.
 INFRASPINATUS BURSA.
SUBACROMIAL BURSA (SUBDELTOID).
 SUBCORACOID BURSA
 Other bursae

between the deltoid and supraspinatus

muscle and the joint capsule (the subacromial
bursa).
between the acromion and skin.
between the coracoid process and the joint
capsule.
Synovial membrane and joint capsule
 Bursitis

Inflammation of shoulder Bursa.

Commonly Subacromion Bursa.
 Usually related to shoulder impingement of
Subacromion Bursa between rotator cuff
tendon and acromion.
 Subdeltoid bursa less commonly inflamed.
 Commonly co-exists with rotator cuff tears or
tendonitis
 Capsule of glenohumeral joint

attaches to the margin of the glenoid cavity.

In outside the attachment of the glenoid
labrum and the long head of the biceps
brachii muscle, and to the anatomical neck of
the humerus.
On the humerus, the medial attachment
occurs more inferiorly than the neck and
extends onto the shaft.
The rerudant area accommodates abduction
of the arm.
Capsule of glenohumeral joint.
 Joint capsule

Fibrous membrane is thickened in:

 Anterosuperiorly to form: superior,middle and
inferior glenohumeral ligament.
 superiorly between the base of the coracoid
process and the greater tubercle of the
humerus (the coracohumeral ligament).
 between the greater and lesser tubercles of
the humerus (transverse humeral ligament)this
holds the tendon of the long head of the biceps
brachii muscle in the intertubercular sulcus.
 Adhesive capsulitis

Frozen Shoulder
Pain and Stiffness in the Shoulder.
 Shoulder capsule thickens and becomes
tight.
Stiff bands of tissue called adhesions develop.
In many cases, there is less synovial fluid in
the joint.
Unable to move your shoulder - either on
your own or with the help of someone else
Ligaments of Glenohumeral
Joint
Superior, Middle and Inferior Glenohumeral
Ligaments
Coracohumeral Ligament
Transverse Humeral Ligament
Glenohumeral Ligaments
Muscles of shoulder
 Shoulder flexors

Normal flexion is about (0-90) degree.

Its performed by:
 Anterior fibers of deltoid.
 Pectoralis major.
 Biceps brachii.
 Coracobrachialis.
Muscles flexing shoulder joint
 Shoulder Extensors

 Extension (0–45◦):
teres major.
latissimus dorsi.
deltoid (posterior fibres).
 Shoulder Internal Rotators

 Internal (medial) rotators (0–40◦):

o pectoralis major.
o Latissimus dorsi.
o Teres major.
o deltoid (anterior fibres).
o subscapularis.
 Shoulder External Rotators

 External (lateral) rotators (0–55◦):

o Infraspinatus.
o Teres minor.
o deltoid (posterior fibres).
Shoulder Adductors and Abductors

 Adductors (0–45◦):
o pectoralis major.
o latissimus dorsi.
 Abductors (0–180◦):
o Supraspinatus.
o Deltoid.
o trapezius.
o Serratus anterior.
 Rotator cuff muscles

Tendons of the rotator cuff muscles (the

supraspinatus, infraspinatus, teres minor, and
subscapularis muscles) blind with joint
capsule to form musculotenous collar.
Surrounds the posterior, superior and
anterior of Glenohumeral joint.
Stabilizes and holds the head of humerus in
the glenoid cavity of scapula.
 Facets for rotator cuff muscle tendons

The greater tubercle is lateral in position.

Its superior surface and posterior surface are
marked by three large smooth facets for
muscle tendon attachment:
the superior facet is for attachment of the
supraspinatus muscle.
the middle facet is for attachment of
infraspinatus.
the inferior facet is for attachment of teres
minor.
Teres Major
Supraspinatus
Infraspinitus
Teres Minor
Subscapularis
Teres Major and latissimus dorsi
 Muscles of Shoulder

Two most superficial are trapezius and

deltoid.
trapezius attaches the scapula and clavicle to
the trunk.
deltoid attaches the scapula and clavicle to
the humerus.
Deep to trapezius the scapula is attached to
the vertebral column by three muscles:
 levator scapulae.
 rhomboid minor and rhomboid major
Trapezius and deltoid
 Trapezius

The trapezius muscle has an extensive origin

from the axial skeleton, from CI to TXII, and
inserts to the clavicle,acromion and scapular
spine
The trapezius muscle is a powerful elevator
of the shoulder and also rotates the scapula.
Innervation of the trapezius muscle is by the
accessory nerve [XI] and the anterior rami of
cervical nerves C3 and C4 .
 Deltoid

The deltoid muscle is large and triangular in

shape, with its base attached to the scapula and
clavicle and its apex attached to the humerus.
 originates along a continuous U-shaped line of
attachment to the clavicle and the scapula.
It inserts into the deltoid tuberosity on the
lateral surface of the shaft of the humerus.
The major function of the deltoid muscle is
abduction of the arm.
 The deltoid muscle is innervated by the axillary
nerve.
 Levator scapulae

The levator scapulae originates from the

transverse processes of CI to CIV vertebrae
to the posterior surface of the medial border
of the scapula.
The levator scapulae muscle is innervated by
the dorsal scapular nerve and directly from
C3 and C4 spinal nerve.
Levator scapulae elevates the scapula
 Rhomboid minor and major

The rhomboid minor and major muscles

attach medially to the vertebral column and
descend laterally to attach to the medial
border of the scapula inferior to the levator
scapulae muscle.
Rhomboid minor originates from the lower
end of the ligamentum nuchae and the spines
of CVII and TI vertebrae to the spine of
scapula.
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The rhomboid muscles are innervated by the

dorsal scapular nerve, which is a branch of
the brachial plexus, and by branches direct
from the anterior rami of C3 and C4 spinal
nerves.
Rhomboid minor and major retract and
elevate the scapula.
Shoulder muscles
 Muscles Connecting the Upper Limb to the
Thoracic Wall

Pectoralis major.
Pectoralis minor.
Subclavius.
Serratus Anterior.
 Muscles Connecting the Upper Limb to the
Vertebral Column

Trapezius.
Latissimus Dorsi.
Levator Scapula.
Rhomboid major.
Rhomboid Minor.
 Muscles Connecting the Scapula to the
Humerus

Deltoid.
Supraspinatus.
Infraspinatus.
Teres Major.
Teres Minor.
Subscapulris.
 Task

Vasculature around Shoulder

Region
Blood supply of shoulder
 Nerves of shoulder

Axillary nerve
Suprascapular nerve
Musculocutaneous nerve
Nerves of shoulder