SHOULDER JOINT COMPLEX AND

ARM REGION

OJORA K. A
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 Outline
Clavicle
Scapula
Humerus
Humerus glenohumeral joint
Axilla
Glenohumeral muscles
Rotator cuff muscles
The arm region.

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  The only bony attachment between
Clavicle
the trunk and the upper limb.
 palpable gentle S-shaped contour
 The acromial end of the clavicle is
flat, whereas the sternal end is more
robust and somewhat quadrangular in
shape
 The sternal end has a much larger
facet for articulation mainly with the
manubrium of the sternum, and to a
lesser extent, with the first costal
cartilage.
 The inferior surface of the lateral third
of the clavicle possesses a distinct
tuberosity consisting of a tubercle (the
conoid tubercle) and lateral
roughening (the trapezoid line), for
3 attachment of the important
coracoclavicular ligament.
 Scapular
 The scapula is a large,
flat triangular bone
with:
1. three angles (lateral,
superior, and inferior);
2. three borders  glenoid cavity
(superior, lateral, and  infraglenoid tubercle
medial);  supraglenoid tubercle
3. two surfaces (costal  Spine
and posterior); and  greater scapular notch
4. three processes (spinoglenoid notch).
(acromion, spine, and  coracoid process
coracoid process)  suprascapular notch
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 scapulothoracic joint
Humerus
Proximal humerus consists of the
head, the anatomical neck, the
greater and lesser tubercles,
intertubercular sulcus (bicipital
groove) the surgical neck, and the
superior half of the shaft of humerus.
Roughenings on the lateral and medial
lips and on the floor of the
intertubercular sulcus.
V-shaped deltoid tuberosity(lat)
surgical neck -The axillary nerve and
the posterior circumflex humeral
artery(post.)
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Humerus

distal humerus- medial and lateral supraepicondylar

(supracondylar) ridges,medial epicondyle and the lateral
epicondyle, the trochlea; the capitulum; and the olecranon,
coronoid, and radial fossae, makes up the condyle of the
6 humerus
 Humeral fractions
The following parts of the humerus are in direct
contact with the indicated nerves:
Surgical neck: axillary nerve/ anterior circumflex
humoral vein.
Radial groove: radial nerve/deep artery of the arm-
profunda brachii artery.
Distal end of humerus: median nerve.
Medial epicondyle: ulnar nerve.

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 Glenohumeral joint

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Glenohumeral Joint (introduction)
This is a ball-and-socket type of synovial joint that permits a wide
range of movement.

Articulation of the Glenohumeral Joint

The large, round humeral head
The glenoid cavity of the scapula, which is deepened slightly
but effectively by the ring-like, fibrocartilaginous glenoid
labrum (L. lip).
Both articular surfaces are covered with hyaline cartilage.
The glenoid cavity accepts little more than a third of the
humeral head, which is held in the cavity by the tonus of the
musculotendinous rotator cuff, or SITS,supraspinatus,
infraspinatus,teras minor, subcapsularis muscles
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Joint Capsule of the Glenohumeral Joint
The loose fibrous layer surrounds the glenohumeral joint and
is attached medially to the margin of the glenoid cavity and
laterally to the anatomical neck of the humerus.
Superiorly, the fibrous layer of the joint capsule encloses the
proximal attachment of the long head of the biceps brachii to
the supraglenoid tubercle of scapula within the joint.
The joint capsule has two apertures:
1. An opening between the tubercles of the humerus for
passage of the tendon of the long head of the biceps brachii.
2. An opening situated anteriorly, inferior to the coracoid
process that allows communication between the subscapular
bursa and the synovial cavity of the joint.
The inferior part of the joint capsule, the only part not
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reinforced by the rotator cuff muscles, is its weakest area.
Joint Capsule of the Glenohumeral Joint
The synovial membrane lines the internal surface of the
fibrous layer of the joint capsule.
The synovial membrane also forms a tubular sheath for the
tendon of the long head of the biceps brachii, where it lies in
the intertubercular groove of the humerus and passes into the
joint cavity, extending as far as the surgical neck of the
humerus.

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Ligaments of the Glenohumeral Joint I
 The glenohumeral ligaments(ant), are three fibrous bands, evident only on
the internal aspect of the capsule, that reinforce the anterior part of the joint
capsule.
 These ligaments radiate laterally and inferiorly from the glenoid labrum at
the supraglenoid tubercle of the scapula and blend distally with the fibrous
layer of the capsule as it attaches to the anatomical neck of the humerus
 The coracohumeral ligament(sup), The coracohumeral ligament is a
strong broad band that passes from the base of the coracoid process to the
anterior aspect of the greater tubercle of the humerus.
 Both are intrinsic ligaments, i.e. part of the fibrous layer of the joint capsule
 The transverse humeral ligament is a broad fibrous band that runs more
or less obliquely from the greater to the lesser tubercle of the humerus,
bridging over the intertubercular groove.
 Its converts the groove into a canal(content ?)-tendon of long head biceps
brachii
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 Ligaments of the Glenohumeral Joint II
The coracoacromial arch
This is an extrinsic, protective structure formed by the
smooth inferior aspect of the acromion and the coracoid
process of the scapula, with the coracoacromial ligament
spanning between them.
This osseo-ligamentous structure forms a protective arch that
overlies the humeral head, preventing its superior
displacement from the glenoid cavity.
The coracoacromial arch is so strong that a forceful superior
thrust of the humerus will not fracture it; the humeral shaft or
clavicle fractures first.

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Movements of the Glenohumeral Joint
The glenohumeral joint has more freedom of movement than
any other joint in the body.
This freedom results from the laxity of its joint capsule and
the large size of the humeral head compared with the small
size of the glenoid cavity.
The glenohumeral joint allows movements around three axes
and permits
1. Flexion-extension,
2. Abduction-adduction,
3. Rotation (medial and lateral) of the humerus, and
circumduction.

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 Muscles Moving the Glenohumeral Joint
Flexion- Pectoralis major -clavicular head; deltoid -anterior part)
Extension- Deltoid (posterior part)
Abduction-Deltoid (as a whole, but especially central
part),supraspinatus-initiates abduction
Adduction Pectoralis major; latissimus dorsi
Medial rotation -Subscapularis
Lateral rotation –Infraspinatus SITS
Blood Supply of the Glenohumeral Joint
the anterior and posterior circumflex humeral arteries and
branches of the suprascapular artery.
Innervation of the Glenohumeral Joint
The suprascapular , axillary, and lateral pectoral nerves supply
the glenohumeral joint.
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 Bursae around the Glenohumeral Joint.
 Subacromial – located deep to the deltoid and acromion, and
superficial to the supraspinatus tendon and joint capsule. The
subacromial bursa reduces friction beneath the deltoid,
promoting free motion of the rotator cuff tendons.
Subacromial bursitis (i.e. inflammation of the bursa) can be a
cause of shoulder pain.
Subscapular – located between the subscapularis tendon and
the scapula. It reduces wear and tear on the tendon during
movement at the shoulder joint.

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Dislocation of the Glenohumeral Joint
 most dislocations of the humeral head occur in the downward (inferior)
direction– the inferior part is not reinforced by the tendons of rotator cuff
 they are described clinically as anterior or (more rarely) posterior
dislocations,
 Anterior dislocation of the GHJ occurs most often in young adults,
particularly athletes.
 usually caused by excessive extension and lateral rotation of the humerus.
 A hard blow to the humerus when the glenohumeral joint is fully abducted
tilts the head of the humerus inferiorly onto the inferior weak part of the
joint capsule.
 The head of the humerus is driven inferoanteriorly, and the fibrous layer
of the joint capsule and glenoid labrum may be stripped from the anterior
aspect of the glenoid cavity in the process (avulsion fructure).
 Inferior dislocation of the glenohumeral joint often occurs after an
avulsion fracture of the greater tubercle, owing to the absence of the
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upward and medial pull produced by the muscles attaching to the tubercle.
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 Axillary Nerve Injury
The axillary nerve may be injured when the glenohumeral
joint dislocates because of its close relation to the inferior
part of the joint capsule of this joint.
The subglenoid displacement of the head of the humerus
into the quadrangular space damages the axillary nerve.-
which innervates the deltoid-(abductor)
Axillary nerve injury is indicated by paralysis of the deltoid
(manifest as an inability to abduct the arm to or above the
horizontal level) and loss of sensation in a small area of skin
covering the central part of the deltoid.

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Glenoid Labrum Tears
Tearing of the fibrocartilaginous glenoid labrum commonly
occurs in athletes who throw a baseball or football and in
those who have shoulder instability and subluxation (partial
dislocation) of the glenohumeral joint .
The tear often results from sudden contraction of the biceps
or forceful subluxation of the humeral head over the glenoid
labrum.
Usually a tear occurs in the anterosuperior part of the
labrum.
The typical symptom is pain while throwing, especially
during the acceleration phase, but a sense of popping or
snapping may be felt in the glenohumeral joint during
abduction and lateral rotation of the arm.
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AXILLA I
 The axilla is the pyramidal space inferior to the glenohumeral joint and
superior to the axillary fascia at the junction of the arm and thorax.
 It provides a passageway or distribution center, for the neurovascular
structures that serve the upper limb.
 The axilla has an apex, a base, and four walls, three of which are
muscular
 The apex is the cervicoaxillary canal, the passageway between the
neck and the axilla, bounded by the 1st rib, clavicle, and superior edge
of the scapula.
 The base is formed by the concave skin, subcutaneous tissue, and
axillary (deep) fascia extending from the arm to the thoracic wall
(approximately the 4th rib level), forming the axillary fossa (armpit).
 The anterior wall has two layers, formed by the pectoralis major and
pectoralis minor and the pectoral and clavicopectoral fascia associated
with them.
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AXILLA II
The posterior wall is formed chiefly by the scapula and
subscapularis on its anterior surface and inferiorly by the teres
major,latissimus dorsi and overlying integument.
The medial wall is formed by the thoracic wall (1st-4th ribs
and intercostal muscles) and the overlying serratus anterior.
The lateral wall is a narrow bony wall formed by the
intertubercular groove in the humerus

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Boundaries of the axilla
 Contents of the Axilla
Axillary blood vessels (axillary artery and its branches,
axillary vein and its tributaries),
lymphatic vessels, and several groups of axillary lymph
nodes, all embedded in a matrix of axillary fat.
The axilla also contains large nerves that make up the cords
and branches of the brachial plexus.
Proximally, these neurovascular structures are ensheathed
in a sleeve-like extension of the cervical fascia, the axillary
sheath.

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Axillary Artery
 Origin -lateral border of the 1st rib as the continuation of the
subclavian artery
 Termination-ends at the inferior border of the teres major.
 It passes posterior to the pectoralis minor into the arm and becomes
the brachial artery when it passes the inferior border of the teres major,
at which point it usually has reached the humerus.
3 parts by the pectoralis minor
 1st part located between the lateral border of the 1st rib and the medial
border of the pectoralis has one branch the superior thoracic artery
 2nd part lies posterior to pectoralis minor and has two branches the
thoracoacromial and lateral thoracic arteries
 3rd part extends from the lateral border of pectoralis minor to the
inferior border of teres major and has three branches. The subscapular
artery(largest branch), the anterior circumflex humeral and posterior
27 circumflex humeral arteries.
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 Axillary Vein
formed by the union of the brachial vein and the basilic vein
at the inferior border of the teres major.
The axillary vein is described as having three parts that
correspond to the three parts of the axillary artery.
The axillary vein (first part) ends at the lateral border of the
1st rib, where it becomes the subclavian vein.
The veins of the axilla are more abundant than the arteries,
are highly variable, and frequently anastomose.
The axillary vein receives tributaries that generally
correspond to branches of the axillary artery with a few major
exceptions:

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 Axillary Lymph Nodes
The axillary lymph nodes are arranged in five principal
groups: pectoral, subscapular, humeral, central, and apical.
The groups are arranged in a manner that reflects the
pyramidal shape of the axilla.
Three groups of axillary nodes are related to the triangular
base, one group at each corner of the pyramid.
The pectoral (anterior) nodes,3-5 nodes that lie along the
medial wall of the axilla.
Receive lymph mainly from the anterior thoracic wall,
including most of the breast.
The subscapular (posterior) nodes,6-7 nodes that lie along
the posterior axillary fold and subscapular blood vessels.
Receive lymph from the posterior aspect of the thoracic wall
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and scapular region.
 Axillary Lymph Nodes II
The humeral (lateral) nodes,4-6 nodes that lie along the lateral
wall of the axilla, medial.
These nodes receive nearly all the lymph from the upper limb.
The central nodes are 3-4 large nodes situated deep to the
pectoralis minor near the base of the axilla.
Efferent lymphatic vessels from these three groups pass to the
central nodes
Efferent vessels from the central nodes pass to the apical nodes.
The apical nodes are located at the apex of the axilla along the
medial side of the axillary vein and the first part of the axillary
artery.
The apical nodes receive lymph from all other groups of axillary
lymph nodes as well as from lymphatics accompanying the
31 proximal cephalic vein.
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Anterior Axioappendicular Muscles of the Upper Limb
Four anterior axioappendicular (thoracoappendicular or pectoral)
muscles move the pectoral girdle: pectoralis major, pectoralis
minor, subclavius, and serratus anterior. 1. PECTORALIS
MAJOR PA- Sternal – anterior surface of sternum,
cartilages of ribs 1-6 or7
Clavicular – anterior surface of sternal ½
clavicle
DA- crest of humerus’s greater tuberosity
INNERVATION
 Sternal – medial pectoral nerve (C5-
C6)
 Clavicular – lateral pectoral nerve
(C7-T1)
FUNCTIONS
• Adducts and medially rotates the
humerus
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• Clavicle Head- flexing the humerus
Pectoralis Minor  PA/origin
 Superior margins and outer
surface ribs 3-5 near cartilages
 Fascia overlying corresponding
intercostal muscles
 DA/insertion
 Medial border, superior surface
of coracoid process
 INNERVATION
 Medial Pectoral nerve C8 –T1
 FUNCTION
 Scapular depression, downward
rotation, protraction
 Subclavius
PA-Junction of 1st rib
and its costal cartilage
DA-Inferior surface of
middle third of clavicle
INNERVATION-Nerve
to subclavius (C5, C6)
FUCTION-Anchors and
depresses clavicle

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Serratus Anterior
 PA-Outer surfaces and
superior border of ribs 1-8
 DA- Ventral/Anterior
scapular surface on medial
border from superior angle
to inferior angle
 INNERVATION- Long
Thoracic (C5-C7)
 F UNCTIONS
Scapular protraction,
upward rotation
Scapular depression
(lower fibers)
Scapular elevation (upper
fibers
Posterior Axioappendicular and
Scapulohumeral Muscles
The posterior axioappendicular muscles attach the superior
appendicular skeleton (of the upper limb) to the axial
skeleton (in the trunk).
The posterior shoulder muscles are divided into three groups.
1. Superficial posterior axioappendicular (extrinsic
shoulder) muscles: trapezius and latissimus dorsi.
2. Deep posterior axioappendicular (extrinsic shoulder)
muscles: levator scapulae and rhomboids.
3. Scapulohumeral (intrinsic shoulder) muscles: deltoid, teres
major, and the four rotator cuff muscles (supraspinatus,
infraspinatus, teres minor, and subscapularis).SITS

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Superficial Posterior Axioappendicular
(Extrinsic Shoulder) Muscles - Trapezius
PA- Medial third of superior nuchal
line; external occipital protuberance;
nuchal ligament; spinous processes of
C7-T12 vertebrae
DA- Lateral third of clavicle;
acromion and spine of scapula
INNERVATION- Accessory nerve
(CN XI) (motor fibers) and C3, C4
spinal nerves (pain and proprioceptive
fibers)
FUNTIONS-Descending part elevates;
ascending part depresses; and middle
part (or all parts together) retracts
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scapula.
Latissimus Dorsi
 PA- Spinous processes of
inferior 6 thoracic vertebrae,
thoracolumbar fascia, iliac
crest, and inferior 3 or 4 ribs
 DA- Floor of intertubercular
groove of humerus
 INNERVATION-
Thoracodorsal nerve (C6, C7,
C8)
 FUCTIONS- Extends, adducts,
and medially rotates humerus;
raises body toward arms during
climbing
Deep posterior axioappendicular (extrinsic
shoulder) muscles: Levator scapulae
PA- Posterior tubercles of
transverse processes of C1
&C4 vertebrae
DA- Medial border of scapula
superior to root of spine
INNERVATION- Dorsal
scapular (C5) and cervical (C3,
C4) nerves
FUNCTIONS- Elevates scapula
and tilts its glenoid cavity
inferiorly by rotating scapula
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Rhomboid minor and major
 PA-Minor: nuchal ligament; spinous
processes of C7 and T1 vertebrae
Major: spinous processes of T2-
T5 vertebrae
 DA-Minor: smooth triangular area at
medial end of scapular spine
Major: medial border of scapula
from level of spine to inferior angle
INNERVATION-Dorsal scapular nerve
(C4, C5)
FUNCTION-Retract scapula and rotate
it to depress glenoid cavity; fix
scapula to thoracic wall
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Scapulohumeral (intrinsic shoulder) muscles:
Deltoid.
PA-Deltoid Lateral third of
clavicle; acromion and spine of
scapula
DA-Deltoid tuberosity of
humerus
INNERVATION-Axillary nerve
(C5, C6)
FUNCTIONS
 Anterior part: flexes and
medially rotates arm
 Middle part: abducts arm
 Posterior part: extends and
laterally rotates arm
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Teres major
PA-Posterior surface of inferior
angle of scapula
DA-Medial lip of
intertubercular groove of
humerus
INNERVATION-Lower
subscapular nerve (C5, C6)
FUNCTION-Adducts and
medially rotates arm

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Rotator Cuff Muscles
supraspinatus, infraspinatus,
teres minor, and subscapularis
(referred to as the SITS
muscles)are called rotator cuff
muscles because they form a
musculotendinous rotator cuff
around the glenohumeral joint .
All except the supraspinatus are
rotators of the humerus; the
supraspinatus, besides being part
of the rotator cuff, initiates and
assists the deltoid in the first
15° of abduction of the arm.
Suprspinatus
PA-Supraspinous fossa of
scapula
DA-Superior facet of greater
tubercle of humerus
INNERVATION-Suprascapular
nerve (C4, C5, C6)
FUCTIONS-Initiates and assists
deltoid in abduction of arm and
acts with rotator cuff muscles
Infraspinatus
PA-Infraspinous fossa of
scapula
DA-Middle facet of greater
tubercle of humerus
INNERVATION-Suprascapular
nerve (C5, C6)
FUNCTIONS-Laterally rotate
arm; help hold humeral head
in glenoid cavity of scapula
Teres Minor
PA-Middle part of lateral
border of scapula
DA-Inferior facet of greater
tubercle of humerus
INNERVATION-Axillary
nerve (C5, C6)
FUNCTION-Laterally rotate
arm; help hold humeral head
in glenoid cavity of scapula
Subscapularis
PA-Subscapular fossa
(most of anterior surface
of scapula)
DA-Lesser tubercle of
humerus
INNERVATION-Upper
and lower subscapular
nerves (C5, C6, C7)
FUCTIONS-Medially
rotates and adduct arm;
helps hold humeral head
in glenoid cavity
THE ARM REGION
The arm extends from the shoulder to the elbow.
Two types of movement occur between the arm and the
forearm at the elbow joint: flexion-extension and pronation-
supination.
Muscles of the Arm
Of the four major arm muscles, three flexors (biceps brachii,
brachialis, and coracobrachialis) are in the anterior (flexor)
compartment, supplied by the musculocutaneous nerve, and
one extensor (triceps brachii) is in the posterior
compartment, supplied by the radial nerve.
A distally placed assistant to the triceps, the anconeus, also
lies within the posterior compartment.

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 Biceps brachii
PA-Short head: tip of
coracoid process of
scapula Long head:
supraglenoid tubercle of
scapula
DA-Tuberosity of radius
and fascia of forearm via
bicipital aponeurosis
FUCTIONS-Supinates
forearm and, when it is
supine, flexes forearm;
short head resists
50 dislocation of shoulder
 Brachialis
PA-Distal half of
anterior surface of
humerus
DA-Coronoid process
and tuberosity of ulna
Flexes forearm in all
positions

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 Coraco-brachialis
PA-Tip of coracoid
process of scapula
DA-Middle third of
medial surface of
humerus
FUNCTION-Helps flex
and adduct arm; resists
dislocation of shoulder

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 Triceps brachii
 PA-Long head: infra-glenoid
tubercle of scapula
Lateral head: posterior surface
of humerus, superior to radial
groove
Medial head: posterior surface
of humerus, inferior to radial
groove
 DA- Proximal end of olecranon
of ulna and fascia of forearm
 FUNCTIONS- Chief extensor
of forearm; long head resists
dislocation of humerus;
especially important during
abduction
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 Anconeus
PA-Lateral epicondyle of
humerus
DA-Lateral surface of
olecranon and superior
part of posterior surface
of ulna
FUNCTIONS-Assists
triceps in extending
forearm; stabilizes
elbow joint; may abduct
ulna during pronation
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Bicipital Myotatic Reflex
 The biceps reflex is one of several deep-tendon reflexes that are
routinely tested during physical examination.
 The relaxed limb is passively pronated and partially extended at the
elbow.
 The examiner 's thumb is firmly placed on the biceps tendon, and
the reflex hammer is briskly tapped at the base of the nail bed of
the examiner 's thumb.
 A normal (positive) response is an involuntary contraction of the
biceps, felt as a momentarily tensed tendon, usually with a brief
jerk-like flexion of the elbow.
 A positive response confirms the integrity of the musculocutaneous
nerve and the C5 and C6 spinal cord segments.
 Excessive, diminished, or prolonged (hung) responses may indicate
central or peripheral nervous system disease or metabolic
55 disorders(e.g., thyroid disease).
Rupture of the Tendon of the Long Head of
the Biceps
Rupture of the tendon usually results from wear and tear of an
inflamed tendon as it moves back and forth in the
intertubercular groove of the humerus.
This injury usually occurs in individuals > 35 years of age.
Typically, the tendon is torn from its attachment to the
supraglenoid tubercle of the scapula.
The rupture is commonly dramatic and is associated with a
snap or pop.
The detached muscle belly forms a ball near the center of the
distal part of the anterior aspect of the arm (Popeye deformity).
Rupture of the biceps tendon may result from forceful flexion
of the arm against excessive resistance, as occurs in weight
56 lifters (Anderson et al., 2000).
Brachial Artery
the main arterial supply to the arm
the continuation of the axillary artery.
begins at the inferior border of the teres major and ends in
the cubital fossa opposite the neck of the radius where, it
divides into the radial and ulnar arteries.
relatively superficial and palpable throughout its course
BRANCHES
many unnamed muscular branches
deep artery of the arm
the humeral nutrient artery
the superior and inferior ulnar collateral arteries.

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 Veins of the Arm
 Two sets of veins of the arm, superficial and deep.
 Both sets of veins have valves, but they are more numerous in the deep
veins than in the superficial veins.
Superficial Veins
 The two main superficial veins of the arm, the cephalic and basilic
veins.
Deep Veins
 Paired deep veins, collectively constituting the brachial vein,
accompany the brachial artery
 The pulsations of the brachial artery help move the blood through this
venous network.
 The brachial vein begins at the elbow by union of the accompanying
veins of the ulnar and radial arteries and end by merging with the basilic
vein to form the axillary vein. At the inferior border of teres major

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 THE END

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