anatomy of shoulder joint - vamshi kiran
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ANATOMY OF SHOULDER JOINT
PRESENTOR :DR.B.VAMSHIKIRAN
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INTRODUCTION• Shoulder girdle is formed by scapula and clavicle
and humerus upper end.• The only skeletal connection of upper limb to trunk
is clavicle[scapula is connected only through muscular attachments].
• Shoulder area include- -gleno humeral -acromio clavicular -scapulo thoracic -sterno clavicular
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• Surface anatomy land marks• Joint structures.• Ligaments and tendons.• Relations ,muscles and nerves.• Blood supply.• Bursae around shoulder joint• Range of movements.• Applied anatomy.
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SURFACE ANATOMY• Anteriorly -Clavicle -Tip of coracoid process of scapula -Greater tubercle of humerus. -Deltoid contour -axilla and its folds -medial epicondyle shows head of humerus direction -lateral epicondyle show greater tuberosity direction• Posteriorly –Scapula-acromian,crest of spine[T3] medial and lateral borders,inferior angle
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Surface anatomyAnterior aspect Posterior aspect
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BONES• Clavicle-Lateral end• Scapula• Upper end of humerus• Superior shoulder suspensory complex-it is a group of bony and ligamentous attachments
includes coracoid,acromian,glenoid,distal clavicle,coracoclavicular ligament[main bond
b/w scapula and clavicle].• Superior strut by middle 1/3rd clavicle a• Inferior strut by lateral scapular body and spine
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OSSIFICATION CENTRES• PROXIMAL HUMERUS-3 ossification centre.• Humeral head-ossifies at 6mths• Greater tuberosity-ossifies at 1 to 3yrs• Lesser tuberosity-ossifies at 4 to 5yrs.• Tuberosities coalesce at 6to 7yrs and then fuses to humeral head 7 to13yrs.• Physis close at 14-17yrs girls and 16-18yrs boys.• Proximal physis is extra-articular except at medial
aspect
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OSSIFICATION CENTRES• CLAVICLE-It’s the 1st bone to ossify .• It has no medullary cavity.• It occurs by intramembranous ossification.• Secondary ossification centres via endochondral.• Medial epiphysis ossifies at 12-19yrs and fuses at 22
to 25yrs.• Lateral epiphysis ossifies and fuses at 19yrs.• It is most commonly #long bone in body.
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SCAPULA OSSIFICATION CENTRES
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OSSIFICATION CENTRES• SCAPULA-body,spine,coracoid,acromian,glenoid -Body and spine[posterior] ossify at birth -Coracoid process[anterior]-atavastic epiphysis. - centre at1yr,base at 10yrs,tip at variable - all 3 fuse by 15-16yrs. -Acromian[lateral projection]-fuses by 22yrs via 2- 5centres form at puberty -Glenoid-upper1/4th ossify at 10yrs -lower3/4th appear at puberty ,fuse by22
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ACROMIOCLAVICULAR JOINT• Its a plane synovial joint formed by articular facets
of lateral end of clavicle and medial acromial margin
• Cavity of joint is subdivided ay ARTICULAR DISC which may be perforated• Blood supply- suprascapular thoracoacromial [br. of axillary artery]
• Nerve supply-lateral supraclavicular nerve
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SHOULDER JOINT• It’s multiaxial synovial ball and socket[dish]joint.• In anatomical position -
-Glenoid articular surface has 7*posterior version -Proximal end of humerus is 45*tilted upwards
vertical angle with long axis of humerus and 20* RETROVERTED with reference to transverse distal intercondylar line. -Scapula is 30*anterior to body’s transverse plane• The humeral retroversion is 27* right and 21*left• Anatomical neck and surgical neck
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• Glenoid cavity diameters- -transversely-24+/-3mm -superioinferiorly-35+/-4mm -radius curvature 36+/-7mm
-articular surface is PEAR shaped due to anterior incisura acetabuli and relatively small and flat.
-only 1/4th of humeral head is in contact with glenoid cavity hence greater mobility is seen.
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JOINT STABILITYPassive mechanisms like• Joint confirmity• Vacum effect of limited
joint volume• glenoid labrum [static stabiliser]• joint capsule• glenohumeral ligaments• coracoacromial
arch[osseo-ligamentous arch]
• Scapular inclination
Active mechanisms like• Musculo-tendinious
rotator cuff[dynamic stabiliser]
• Muscles attaching limb to thorax like pectoralis major
• Long head of BICEPS and TRICEPS
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LIGAMENTS AROUND SHOULDER JOINT
• GLENOID LABRUM• CAPSULAR LIGAMENT• GLENOHUMERAL LIGAMENT• CORACOHUMERAL LIGAMENT• TRANSVERSE HUMERAL LIGAMENT• CORACOACROMIAL LIGAMENT• CORACOCLAVICULAR LIGAMENT
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GLENOID LABRUM• It’s a fibrocartilagenous rim attached to margin of
glenoid cavity and inc concavity by 50% and suface area of humeral attachment by 75%.
• It further strengthens by long head of biceps origin and sup glenohumeral ligament
• It is a STATIC stabiliser of joint and prevents excessive rollback of humerus
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JOINT CAPSULE• It is lax and attaches along epiphyseal lines of
glenoid and humeral head and extends onto surgical neck medially.
• Capsule is surrounded by synovial membrane which prolongs along tendon of biceps as tubular sheath• Inf part weakest-resulting in dislocations• APPLIED ANATOMY-OSTEOMYELITIS of humerus
upper end spreads directly to joint due to capsule extension to medial side of neck
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RELATIONS OF ARTICULAR CAPSULE• MEDIALLY-beyond supraglenoid tubercle
andlabrum• LATERALLY-attaches to anatomical neck of humerus• INFERIORLY-attachment extends to surgical neck• SUPERIORLY-deficient for biceps long head passage • ANTERIORLY-reinforced by GLENOHUMERAL LIGAMENTS[sup,middle,inf]
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GLENOHUMERAL LIGAMENTS• SUPERIOR-It is the most superior capsular
thickening from labrum anterior to long head of biceps at level of coracoid base
• It passes under supraspinatus and inserts on ANATOMICAL NECK medial to anterosuperior base of lesser tuberosity.
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• MIDDLE GLENOHUMERAL-most variable in size• Arises just inferior to superior GHL and inserts along
middle area of ANATOMICAL NECK opposite to lesser tuberosity
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• INFERIOR GLENOHUMERAL-It’s the THICKEST part• It is very broad arising from lower half of
labrum[anterior,inferior,posterior]• Thick superior margin is called SUPERIOR BAND, rest of it is called AXILLARY POUCH.• Superior band and anterior pouch insert on
ANATOMICAL NECK while the posterior pouch on SURGICAL NECK
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APPLIED ASPECTS OF GLENOHUMERAL LIGAMENTS
• They restrain the selective arcs of abduction and external rotation.
• In arm dependent position all are slack.• The SUPERIOR GHL is primary resistrant to
inferior translation of adducted shoulder• The MIDDLE GHL limits external rotation at 45*
of abduction• The INFERIOR GHL limits external rotation at 45
to 90* of abduction[mainly superior band of it].
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• CORACOHUMERAL LIGAMENT-arises from lateral base of coracoid process and extends onto both tuberosities.
• It forms roof of bicipitaltendon sheath and strengtens capsule anteriorlyImportance-resists inferior and posterior translation.• TRANSVERSE HUMERAL LIGAMENT-bridges upper
part of bicipital groove through which long head of biceps passes down.
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CORACOACROMIAL LIGAMENT• It’s a trapezoidal ligament from base of acromian to
apophysis of coracoid• It along with coracoid and acromian forms CORACOACROMIAL ARCH which is a SECONDARY SOCKET to humerus head.• It plays role in resisting upward displacement of
humerus
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CORACOCLAVICULAR LIGAMENT• Very strong ligament from outer and inferior
clavicular surface to coracoid base• 2components-CONOID and TRAPEZOID• IMP FUNCTION-It is prime suspensory ligament of
upper extremity that couples”glenohumeral abduction and flexion”to”scapular rotation on thorax”.
• Conoid portion is primary restraint to anterior and superior rotation and anterior and superior displacement of clavicle
• Trapezoid has relatively less role than conoid part
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BURSAE RELATED TO SHOULDER JOINT• SUBACROMIAL BURSA-protect suprspinatus• SUBSCAPULARIS BURSA• INFRASPINATUS BURSA
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RELATIONS OF SHOULDER JOINT• SUPERIORLY- coracoacromial arch, subacromial bursa, supraspinatus,deltoid• INFERIORLY- long head of triceps• ANTERIORLY-subscapularis,coracobrachialis biceps short head,deltoid[ant fibres]• POSTERIORLY-infraspinatus,teres minor,deltoid• WITHIN JOINT-Long head of biceps
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BLOOD SUPPLY• Anterior circumflex humeral
artery[axillaryartery]• Posterior circumflex humeral artry[axillaryartery]• Suprascapular[thyrocervical br.] and subscapular
artery[largest br. of axillary artery]
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NERVE SUPPLY
• Axillary nerve-passes close to surgical neck of humerus abt 5cm below acromian
• Musculocutaneous nerve• Suprascapular nerve-Just passes over clavicle
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PRINCIPAL MUSCLES AROUND SHOULDER• Primary role -a.movements of arm b.dynamic stabilisation of glenohumeral joint.• There are 14 muscles which are divided into 4
functional groups.they are1.Three heads DELTOID[anterior,middle,posterior]2.Four rotator cuff muscles and BICEPS muscle3.Two axiohumeral muscles[PECTORALIS MAJOR and
LATTISMUS DORSI] and TERES MAJOR.4.Scapular muscle group –SERRATUS
ANTERIOR,TRAPEZIUS,RHOMBOID MAJOR and MINOR and LEVATOR SCAPULAE
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Pectoralis majorDeltoid-
Long head of triceps
Coracobrachialis ,short head of biceps
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subscapularissupraspinatus
infraspinatus
Teres minor
• SCAPULA POSTERIOR ANTERIOR
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MUSCLE ORIGIN INSERTION NERVE SUPPL ACTION
DELTOID-4septa originAnt border lat 1/3rd clavicleAcromian lateral borderLower lip crest of spine of scapula
Deltoid tuberosity on humerus
Axillary nerve[c5,6]
Acromial fibres-abductors From90*Anterior fibres-flexors and medial rotatorsPosterior fibres-extensors and lateral rotators
SUPRASPINATUS-medial2/3Of supraspinatus fossa
Greater tubercle upperimpresi
Suprascapular nerve[c5,6]
Initiator of abduction0*15* steadies humeralhead
INFRASPINATUS-medial2/3 of infraspinatus fossa
Greater tubercle
Suprascapular nerve[c5,6]
Lateral rotator of arm
TERES MINOR-Upper2/3 of dorsal surface of scapula
Greater tubercle
Axillary nerve[c5,6]
Lateral rotator of arm
SUBSCAPULARIS-medial 2/3 of subscapular fossa
Lesser tubercle
Upper ,lower subscapular N
Medial rotator and adductor of arm
BICEPS-Short head-tip of coracoidLong head-supraglenoid
Radial tuberosity of posteriorly
Musculocutaneous nerve[c5,6]
Strong supinator when forearm flexedFlexor of elbowShort head-arm flexorLong head-prevents upward displacement
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• Table of page 143 chaurasia
MUSCLE ORIGIN INSERTION NERVE SUPPLY ACTION
PECTORALIS MAJORAnt surface of claviclAnt manubrium[ant lamina]2nd-6th coastal cartilageExternal oblique abdominus aponeurosis[post lamin]
Bilaminar tendon on lateral lip.two lamina are continous Fibres from sternum and aponeurosis are twisted and inserted
Medial and lateral pectoral nerve
Adduction and medial rotation of shoulderClavicular-arm flexorSternoclavicular part-extension of flexed arm against resistance
LATTISMUS DORSI-Outer lip of iliac crest post 1/3rd
Posterior layer of lumbar fasciaT7-12 spinous processLower 4ribsInf angle scapula
Winds round lower border of teres major and forms posterior axillary foldTendon is twisted upside down insert into intertubercular sulcus of humerus
Thoracodorsal nerve[c6,7,8]
Adduction,extension,medial rotation of shoulderHelps in voilent expiratory effortClimbing muscleHolds inferior angle of scapula in place
TERES MAJOR-Lower 1/3rd of dorsal surface of lateral and inferior angle scapula
Medial lip of bicipital groove
Lower subscapular nerve[c5,6]
Medial rotator and adductor arm
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MUSCLE INSERTIONS ON HUMERUS
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scapula
Serratus anterior insertion
Dorsal aspect of scapula
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MUSCLE ORIGIN INSERTION NERVE SUPPLY ACTION
SERRATUS ANTERIOR-8digitations of upper 8ribs
Coastal surface of scapula medial border1st digitation sup angle to root of spineNext two-medial borderLower 5-inferior angle
Nerve to serratus anterior c5,6,7
Pulls scapula forward around chest wall to protract limbInf fibres-pull it forward and rotate Steadies scapulaForced inspiration
TRAPEZIUS-Medial 1/3 of superior nuchal lineExternal occipital protuberanceLigamentum nuchaeC7 spineT1-12 spines
Upper fibres-posterior border of clavicle lat 1/3Middle fibres-medial margin acromian and upper lip crest of spine of scapula
Spinal part of accesory nerve-motorC3,4-proprioceptive
Upper fibres[+LS]-elevate scapulaMiddle fibres[+R]-retract scapulaLower fibres[+SA]-rotate scapula forwards ;arm abductio beyond 90*Steadies scapula
RHOMBOIDES MINOR-Ligamentum nuchaeSpines c7-T1
Base of triangular area at root of spine of scapul
Dorsal scapular nerve[c5]
Retraction of scapula
RHOMBOIDES MAJOR Medial border of scapula below of root of spine
Dorsal scapular nerve[c5]
Retraction of scapula
LEVATOR SCAPULA
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MUSCLE ORIGIN INSERTION NERVE ACTION
LEVATOR SCAPULA-Transverse process of c1,2Posterior tubercles of transverse process of c3,4
Superior angle and upper part of medial border of scapula
Branch of dorsal scapular nerve[c5]
Elevation of scapulaSteadies scapula during arm movements
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MOVEMENTS AROUND SHOULDER• Shoulder movements occur by coordinated
motions of –1. Clavicular and sternoclavicular2. Acromioclavicular motion3. Scapulothoracic motion4. Glenohumeral motion
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CLAVICULAR AND STERNOCLAVICULAR MOTION• At sternoclavicular joint,clavicle rises slow and
steadiely 30* with 90* of arm elevation• Clavicular protraction ,retraction also occurs• the clavicle rotates 45* on its long axis during
elevation of arm to full overhaed position180*. ACROMIOCLAVICULAR MOTION• It provides only two small arcs of motion about
15* during first and last 40* of arm elevation.• Clavicular rotation is essential for terminal arc
mobility of acromioclavicular joint
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SCAPULOTHORACIC MOTION• Its not a true joint but scapula glides freely on the
loose aereolar tissue between two surfaces• Direction of movement described by acromian
motion and sternoclavicular joint integrity
• Rotation of scapula is facilitated by sternoclavicular and acromioclavicular joints
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SCAPULA MOVEMENTS• Elevation - moving the superior border of the scapula and the
acromion in an upward direction.• Depression - moving the superior border of the scapula and
the acromion in an downward direction.• Upward Rotation - Moving the scapula so that the glenoid
cavity faces upward.• Increases the ranges of motion during abduction and/or
flexion of the shoulder.• Downward Rotation - moving the scapula so that the glenoid
cavity faces inferiorly.• Increases range of motion during extension and / or
adduction of the shoulder.• Protraction ( Abduction)- moving the scapula away from
midline• Retraction (Adduction) - moving the scapula toward midline
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SCAPULOTHORACIC MOTIONMOVEMENT MUSCLE
VERTICAL PLANEELEVATION
Upper fibres of trapeziusLevator scapulae
Infero lateral compartment
DEPRESSION Lower fibres of serratus anterior and p.minor
Infero lateral compartment
HORIZONTAL PLANEPROTRACTION-moving away from vertical spine
Serratus anterior and pectoralis minor
Superomedial compart.Seen in pushing or punching actions
RETRACTION-moving towards vertical spine
Rhomboides and middle trapezoid fibres
Superomedial compart.seen in squarring of shoulders
FORWARD ROTATION-occurs in arm over head abduction
Trapezius upper fibresSerratus ant lower fibres
Inferolateral compartment
BACKWARD ROTATION Rhomboides and levator scapula
Inferolateral compartment
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GLENOHUMERAL MOTION• Arm elevation is classified by its plane of action• Flexion ,extension in SAGITTAL PLANE• Abduction adduction in CORONAL/FRONTAL PLANE• Medial and lateral rotations with a midflexed elbow• CIRCUMDUCTION-combination of different
movements by which arm moves in circle
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MOVEMENTS OF THE GLENOHUMERAL JOINT – Movements of the shoulder joint (glenohumeral
joint) usually involve moving the humerus on the scapula.
– All movements are to be studied starting from the ANATOMICAL POSITION
– Axis of motion• Flexion - Extension
– Coronal axis through head of humerus
• Abduction /Adduction– Sagittal axis through humeral head
• Rotation– Longitudinal axis through shaft of humerus
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SHOULDER MOVEMENTS
FLEXION
FLEXIONEXTENSION
ADDUCTIONABDUCTION
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• MEDIAL ROTATION LATERAL ROTATION
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• Flexion moving the humerus forward and upward in the sagittal plane.• Extension - bringing the arm down to the side in the sagittal plane.• Abduction - moving the arm in the coronal plane away from the midline
– Stage-initiate -supraspinatus 15*-90*- deltoid 90*-180* - deltoid with upward rotation of scapula
• Adduction - moving the arm in the coronal plane towards the midline.• Inward Rotation - rotating the arm in a transverse plane so that the
anterior surface of the bone turns inward.• Outward Rotation - rotating the arm in a transverse plane so that the
anterior surface of the bone turns outward.
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MOVEMENTS MAIN MUSCLE ACCESSORY MUSCLE
FLEXION0-135*
PECTORALISMAJOR(clavicular part)DELTOID ant fibres
CoracobrachialisBiceps short head
EXTENSION45-60*
DELTOID post fibresLATISSMUS DORSI
Teres majorTriceps long headP major[sternocoastal head]
ADDUCTION PECTORALIS MAJORLATISSMUS DORSIBICEPS long headTRICEPS short head
Teres majorcoracobrachialis
ABDUCTION SUPRASPINATUS[0-15*]DELTOID[15*-90*]SERRATUS ANTERIOR[90*-180*]TRAPEZOIDupper,lower fibres[90-180]
MEDIAL ROTATION[INTERNAL]90*
PECTORALIS MAJORDELTOID ant fibresLATISSMUS DORSITERES MAJOR
subscapularis
LATERAL ROTATION[EXTERNAL]70*-90*
DELTOID posterior fibresINFRASPINATUSTERES MINOR
PRINCIPLE MUSCLES ACTING ON SHOULDER
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• Scapulohumeral Rhythm-Coordinated movements of the scapula and the humerus increasing the range of motion at the glenohumeral joint– Most noticeable during complete flexion and
abduction of the shoulder– 2 * of humeral abduction is associated with 1* of
scapula rotation
• Humerus and scapula move in 2:1 ratio during abduction
• For every 15* of elevation 10* occur at shoulder joint and 5* by scapular movements
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• ABDUCTION-• Humeral head permits only upto 90*• By scapula rotaion making glenoid cavity facing
ouwards the abduction range increased to 180• This is brought about serratus anterior and trapezius
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REFERENCES• Text book of upperlimb-chaurasia• Operative orthopaedics-campbell• Hand book of fractures-zuckerman• Manual of clinical surgery-Das