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Shoulder to Shoulder
A Partial Survey of the Bones, Muscles, Ligaments, Nerves, and Blood Vessels of the Pectoral Girdle and Adjacent Areas
Today we leave the axial skeleton and begin the appendicular skeleton. The appendicular skeleton includes the bones of the limbs and their supporting girdles. We will concentrate on the pectoral girdle, the supporting bones of the upper limb. The pectoral girdle consists of two bones, the oddly shaped scapula and the S shaped clavicle. We will also examine the superior region of the upper arm bone, the humerus. There are a number of muscles that are directly related to the pectoral girdle as well. Today we will discuss those mainly involved with the movement of the scapula. Many others will be covered in the arm exercise. We will also examine the brachial plexus, a nerve network located near the axillary region of the body and we will discuss a few blood vessels that are associated along with this area.

Part I: Bones of the Pectoral Girdle

A. Scapula (Martini page 184, figure 7.5; Calais-Germain, p. 107)
The scapula is the shoulder blade. This irregularly shaped bone rests superiorly, posteriorly, and somewhat laterally in the body on the rib cage. It is the point of origin and insertion for a number of muscles and also holds the humerus in place. Lets first examine the scapula as a bone. The broad, flat blade of the scapula is simply called the body of the scapula. Essentially the scapula is a flat, triangular bone with three borders. The longest border is located medially on the skeleton facing the vertebral column, and so it is called the medial or vertebral border. The superior border is at the superior margin of the scapula. The superior region of the scapula is easy to find because it has a long narrow bony processes jutting out below it. This bony process is called the spine of the scapula. If we follow the spine latertally, we see that it forms a flat process called the acromion process, which is the shoulder point. You will also see a dishlike fossa, the glenoid cavity that rests on the lateral region of the scapula anterior to the acromion process. Glenoid means like a socket of a joint. Hey, IT IS A SOCKET OF A JOINT; the simile is not necessary, but its the name we need to live with. By contrast, acromion means tip of the shoulder, and indeed it is. At least this one translates well. Two tubercles can be found on the glenoid cavity. The supraglenoid tubercle is found at the superior most point on the border of the cavity; the infraglenoid tubercle is found on the lateral border of the scapula just below the inferior part of the glenoid cavity. Fibrocartilage is found along the edge of the glenoid cavity forming a feature

called the glenoid labrum (labrum means lips) see Calais-Germain, page 112). The glenoid labrum makes the socket deeper without sacrificing flexibility. Now follow the glenoid cavity downward until you reach the edge of the body of the scapula. This is the lateral border. Note that the lateral border is shorter compared to the medial border. Because it is found in the area of the armpit, the lateral border is also called the axillary border. Perhaps now its time to review or take a breather, but remember, were not finished yet! Because the scapula is a triangular shaped bone, it possesses three angles. The superior angle is the point where the superior and medial borders meet; the inferior angle is where the medial and lateral borders meet. The third angle is obstructed by the glenoid cavity and the acromion process. The coracoid process is also found in this complex. The term coracoid means crow-like. Indeed this process resembles the head and beak of a crow or raven while the body of the scapula makes its open wing. Lets return to the spine of the scapula. There are two depressions where the spine fuses with the body, one on the superior edge of the spine and one of its inferior edge. The superior depression is called the supraspinous fossa; the inferior depression is called the infraspinous fossa. I should also note here as well that the scapula has a smooth interior surface (facing anteriorly toward the ribs) which contains a broad shallow depression called the

subscapular fossa. The two surfaces are easy to distinguish. The anterior surface of the scapula is devoid of processes while the exterior surface sports the spine. This information will help with muscle placement later. So why are there so many points of interest on the scapula? Many muscles are associated with the scapula. Heres a short summary of scapula landmarks and the muscles that are associated with them. The medial border is the point of insertion for the levator scapulae, the serratus anterior and the rhomboids. The coracoid process is the point of insertion for the pectoralis minor and the point of origin for the coracobrachialis. The acromion process is the point of insertion for the trapezius along with the scapular spine, while the acromion process also serves as an origin for the deltoid muscle. The supraspinatus originates in the supraspinous fossa, and the infraspinatus originates in the infraspinous fossa. The teres major originates at the inferior angle, while the teres minor originates at the lateral border. Even the heads of the large muscles of the humerus have an association here. The short head of the biceps brachii originates at the coracoid process while the long head originates in the supraglenoid tubercle. By contrast, the long head of the triceps brachii originates in the infraglenoid tubercle. Finally, the subscapularis muscle rests in the subscapular fossa, making it the deepest muscle on the scapula. We will study some these muscles and their actions later in this exercise, but I want you to understand that we study the bony landmarks for a reason.

B. Clavicle (Martini, figure 7.4, p. 183; Calais-Germain p. 106)

The clavicle, or collarbone, is a less demanding bone than the scapula. For one thing, its short. Its also very simple. This bone resembles a lazy S and should never be confused with a rib, which resembles a C. It has two ends. The box-like end is the sternal end and it articulates with the sternum at the clavicular notches of the manubrium. The acromial end is flat. It resembles the acromion process to some degree. It also articulates with the acromion process, hence the name. By contrast, the clavicle passes over the top of the coracoid process and is held there via ligaments (well examine these later).

The clavicle is an interesting bone because it is the only appendicular bone of dermal origin. The cat, for instance, has a clavicle embedded directly in its dermis. The trapezius muscle inserts in the clavicle and the deltoid has a point of origin here. There is also a small subclaviculus muscle that inserts on the clavicles inferior border that depresses and protracts the shoulder. Although I have to saw through this muscle when I dissect a brachial plexus, it is too small to be of concern in our class. You lucked out.

C. Humerus (Martini, figure 7.6, pages 186-7; Calais-Germain p. 111).

I still dont see whats so funny about this bone. Actually, humerus is Latin for shoulder and has nothing to do with comedy, but sometimes when languages merge, as they do in English, words that sound the same take on a double meaning Humorous, as in being funny, comes from the an old French word that means to moisten. I dont quite get the connection between water and laughter. Maybe they laughed so hard they peed. Once again, I digress. We will not study the full humerus today, only the superior region. We do so because the humerus is the point of insertion for a number of the shoulder muscles. Before we proceed with the humerus, Id like to comment about long bones in general. The humerus is really the first long bone that we will study, so this is as good a time as any for digression. Long bones are always found in the appendicular skeleton. The shaft (long middle part) of a long bone is called a diaphysis. Recall that the ends of such bones are called epiphyses. Find the diaphysis and two epiphyses on the humerus. The diaphysis is devoid of red bone marrow, containing yellow bone marrow made of adipose tissue at its core instead. The core of a long bone is the hollow medullary cavity. Recall that this cavity is made via action of osteoclasts during endochondral bone formation. Long bones are distinct from all other bones because they have a medullary cavity internal to their shaft. Henceforth, we will call the shaft of all long bones, the diaphysis. Now go forth and study the humerus, by order of the king (or someone like him). Now back to the humerus. Lets begin with the head of the humerus because it is easy to find. Look for the smooth, convex surface that resembles a ball. The head articulates with the glenoid cavity described above; the ligaments that permit this arrangement will be discussed below. Below the head is a place where the smooth and rough

surfaces meet. This is the anatomical neck of the humerus. The surgical neck, located just below the anatomical neck, is a region where the bone narrows. It is so named because it is a point that is frequently broken. Now lets travel back to the head. Lateral to the head are two bumps with a groove running down the middle of them. These bumps are the greater and lesser tubercles; the groove is the intertubercular groove. Traveling midway down the diaphysis of the humerus, we find a rough edge called the deltoid tuberosity. The intertubercular groove runs on the anterior side of the deltoid tuberosity; a smaller radial groove runs posterior to this tuberosity but it is of little interest to us because it is often difficult to find.

Lets get back to the muscles. Muscles that insert onto the upper diaphysis of the humerus include the coracobrachialis and the deltoid. The supraspinatus, pectoralis major and teres minor insert into the greater tubercle, while the infraspinatus and subscapularis insert into the lesser tubercle. The teres major muscle and latissimus dorsi muscle insert into the intertubercular groove. The muscles we associate with the upper arm, the long head of the biceps brachii inserts at the head of the humerus, its tendon traveling through the intertubercular groove. More muscles associated with the humerus will be discussed later, but the ones listed above are directly related to the movement of the shoulder.

Part II: Ligaments of the Shoulder (Martini, page 226, Figure 8.11; Calais-Germain page 112)

The glenohumeral (shoulder) joint is our first diarthrosis, or freely movable joint. A diarthrosis is a joint that consists of two bones held together by a joint capsule that is filled with an oily synovial fluid. The fluid is a product of areolar tissues housed within the joint cavities that form an unusual gland (most glands are made of epithelial tissue). The gland, simply called a synovial gland, produces synovial fluid that is partly absorbed by the hyaline cartilages that cover the smooth epipyseal ends of the bones. Movement milks the synovial fluid out of the cartilage, literally lubricating the joint. This is why your joints may creak and ache when you wake in the morning, but feel better once youre on the move. Diarthrosis are often named for their actions. In the case of the shoulder joint, a number of actions can take place including the complex actions of circumduction and rotation. The name also may reflect the anatomy of the joint itself. In this case, the head the humerus fits into the socket of the scapula making this diarthrosis, a ball and socket joint. We will examine other types of diarthroses as we progress through the skeleton. Now lets examine the ligaments of the shoulder joint. Before we begin our work on ligaments, be aware that many ligaments are named for the bones or joint that they support. For example, the name, acromioclavicular, tells me that its a ligament that can be found between the acromion process and the clavicle. You see, it is not difficult, even though the names sound a bit obtuse. Typically, the larger bone comes first in the name as in acromionclavicular. Recall that the

scapula is larger than the clavicle. If size is a not a issue, the medial most point of attachment comes first in the name, such as in coracoacromial. We will not discuss all of the ligaments of the shoulder, but we will examine a few which are associated with the articulation of the humerus. Examine the shoulder ligament model. The ligaments on the model have been labeled as follows: (A) acromioclavicular ligament, (B) the paired coracoclavicular ligaments, (C) coracoacromial ligament, (D) glenohumeral ligaments, and (E) coracohumeral ligament. Another feature of this model is (F) the tendon of the long head of the biceps brachii muscle. Now lets discuss their functions individually. The acromioclavicular ligament (A) is found between the acromion and the clavicle (no surprise here). Its job is to restrict the movement of the clavicle. If you separate your shoulder, you dislocate this joint. Do not do this at home. The Coracoclaviular ligaments (B) are paired ligaments that once again help limit movement of the clavicle. Theres nothing worse than a frisky clavicle. The coracoacromial ligaments (C) helps support the joint capsule around the articulation of the head of the humerus and the glenoid cavity. This cavity is supported in earnest by the thick glenohumeral ligaments (D) that surround the entire joint capsule. These ligaments also articulate with the glenoid labrum discussed earlier. Our final ligaments, the coracohumeral ligaments, (E) course between the inferior regions of the clavicle to the head of the humerus,

providing support for weight bearing for the superior region of the shoulder joint. Of course, all of the ligaments work together to ensure the freest movement without dislocation or tearing, but no movement is without restriction, unless your parents are away and youre still in your teens.

The tendon of the long head of the biceps (F) will be discussed here because it can be easily seen on the model. Examine this tendon and note, for now, that it travels through the intertubercular groove on its way to its point of origin, the supraglenoid tubercle. Well get back to this one when we study the arm.

Part III: Muscles of the Shoulder

The shoulder muscles are designed to move the shoulder blades and assist the upper limb. As we have seen, most have a direct association with the scapula. The

following is a summary of the major muscles of the shoulder. 1. Serratus anterior (Martini, figure 11.3,page 293; Calais-Germain, page 114-115) The serratus anterior muscles are often mistaken for the external abdominal obliques. Their origin is the anterior and superior margins of ribs 1-8 and sometimes rib 9. The Insertion of the serratus anterior muscle is the entire medial border of the scapula. This means that the serratus anterior travels under the scapula before it inserts into it. Part of the job of the serratus anterior muscles is to fix the scapula in position, as when you are pushing against a wall. It does so along with the trapezius muscle. The serratus anterior also helps rotate the scapula upward. It also assists in depressing the scapula and at protracting the shoulder which happens when you throw a punch, an action also called abduction (See Calais-Germain p. 119). This muscle is usually well developed on boxers. 2. Pectoralis minor (Martini, figure 11.3, page 293; Calais-Germain, page 116) The pectoralis minor is a muscle that insists in deep breathing. It helps to elevate the ribs on which it originates (ribs 3-5). Because then pectoralis minor inserts on the coracoid process of the scapula, contraction also helps pull the scapula downward and forward. It is located below the largest chest muscle, the pectoralis major which will be discussed when we study the arm. 3. Sternocleidomastoid (Martini, figure 10.4, page 270; Calais-Germain, page 116)

Weve seen this muscle before when we studied the neck, but it is worth visiting again because of the relationship of the strenocleidomastoid and the clavicle. As its name clearly states, the sternocleidomastoid muscle has its origin where the sternum and clavicle meet (if you think this region is called the sternoclavicular joint youre well on your way to winning the Buick. See Calais-Germain, page 106 for details). Its insertion, obviously enough, is the mastoid process. The sternocleidomastoid is used when we bow our heads from the neck, or when we bend our neck from side to side. When the head is in a fixed position, the sternocleido-mastoid also helps to raise the clavicle and sternum, expanding the rib cage. This muscle is therefore also used during deep inspiration. Just remember that any muscle that expands the rib cage is used for inspiration. (Im inspired by that fact. I hope you are too). 4. Levator scapulae (Martini, figure 11.2, page 292; Calais-Germain, page 117 As we know from the facial muscles, the term levator means to raise (something you would do with a lever). Its no surprise to find that the levator scapulae raises the scapula. Its origin is the transverse processes of the first four cervical vertebrae; it inserts on the medial (vertebral) border of the scapula near the superior angle. Because the insertion is on the superior angle of the scapula, and because this angle is medial to the scapular body, strong contractions of the levator scapulae also rotate the scapula downward. When the scapula is in a fixed position, the levator scapulae also provide additional support for the neck.

5. Rhomboids (Martini, figure 11.2, page 292; Calais-Germain, page 117) The term rhomboid means rhombus-like, and if you remember your geometry from high school, you recall that a rhombus is similar to a square or rectangle, that has of angles that deviate from ninety-degrees. It other words, a rhombus looks like a square at ease. There are two rhomboids, a small superior rhomboid minor and a large inferior rhomboid major. Both originate on the spinous processes (minor: C7T1; major: T2-T 5) and insert on the medial border of the scapula. They adduct the scapula, therefore aiding in retraction of the shoulders, but also help support the thoracic spine by pulling the vertebrae laterally. 6.Trapezius (Martini, figure 11.2 , page 292; Calais-Germain, page 118) The trapezius is back (no pun intended). Recall that the trapezius has its origin in association with the occipital bone, the ligamentum nuchae, and C7 and T1-T12, but it inserts on the lateral 1/3 of the clavicle, the acromion process and the scapular spine. Because it has fibers running in opposite directions, the trapezius can be used to depress as well as elevate the scapula. It can also be used to adduct the scapula, assisting the rhomboids, and it can perform an upward rotation of the scapula, acting as an antagonist to the rhomboids. Before we go on, permit me to explain that last statement. A muscle that contracts is called an agonist. The term agony comes from the same Greek root,

which originally meant to wrestle. Wrestling was part of the original Olympic Games and its a spectator sport to this day. Theres nothing like watching a couple of guys trying to pull each others limbs off to make your weekend. By contrast, the muscle that is relaxing during a particular action is called the antagonist. We can see this demonstrated in the relationship between the trapezius and the rhomboids. When we rotate our scapula upward, the trapezius contracts. The rhomboids must relax to permit this action to happen. In this case, the trapezius is the agonist; the rhomboids are the antagonists. When the scapula is rotated downward the opposite occurs. Now the rhomboids are agonists and the trapezius is the antagonist. There is yet another relationship between the trapezius and rhomboids. The trapezius and rhomboids can work together to adduct the scapula. Muscles that act work together to perform the same task are called synergistic muscles. If a large muscle is being assisted by a small muscle, the little muscle is called a synergist. The rhomboid minor could be considered a synergist to the rhomboid major. In the case of the trapezius and rhomboid muscles working together to adduct the scapula, both rhomboids, which are smaller, would be the synergists. There are several muscles associated with the scapula that I have yet to cover. We will discuss these muscles our next exercise. For now, lets move on the nervous system

Part IV: The Brachial Plexus (Martini, figures 14.11, 14.12, & 14.13, pages 367, 368 & 369).
Arguably the most complex nerve plexus of the body is brachial plexus. In this plexus, dorsal and ventral roots merge to form three short nerves called trunks. These trunks split to form divisions, which in turn merge to form cords. The cords divide once again to form branches which we typically refer to as nerves. To recall the order of progression from roots to branches, remember this phrase: Randy Travis Drinks Cold Beer. The brachial plexus is located in the internal region of the body traveling to the arm. We find parts of it in the neck, the region below the clavicle, in the axillary region (armpit) and its branches travel the length of the arm. To do a proper dissection of this plexus, the clavicle must be removed. Now lets begin with its origin. Its best to look at the schematic diagram Ive provided along with the illustration. The roots of the brachial plexus begin at C-4 and end at T1. The roots merge into three trunks. The superior trunk, the middle trunk, and the inferior trunk. We find the trunks below the clavicle and their positions match their names. The trunks split into six divisions. The superior division of the superior trunk continues to form the lateral cord with the superior division of the middle trunk. The inferior division of the superior trunk joins with the inferior division of the middle trunk and the superior division of the inferior trunk to form the posterior cord. The posterior cord and its branches will run deep to the other cords and branches of this plexus. The inferior division of the inferior trunk becomes the medial cord. Now for the branches (nerves). The lateral cord divides to form the lateral-most nerve called the musculocutaenous nerve. The musculocutaneous nerve innervates the flexor muscles of the arm as well as the skin of the forearm, hence the name. The medial branch of the lateral cord merges with the lateral branch of the medial cord to from the most obvious nerve in this plexus, the median nerve. The median nerve innervates the flexor muscles of the forearm as well as the anterior lateral skin of the hand (see illustration in handout). The median nerve initially courses along with the brachial artery and vein, forming a neurovascular bundle. Coming directly below the median nerve is the radial nerve. The radial nerve emerges from the posterior cord and innervates the extensor muscles of the arm and forearm and the skin of the posterior lateral surface of the hand (see illustration in handout). The radial nerve also has a little offshoot that can often easily be found. This is the axillary nerve. The axillary nerve branches laterally to innervate the deltoid and teres major muscles. The most medial branch of the brachial plexus is the ulnar nerve. The ulnar nerve arises from the medial cord and innervates thumb and finger muscles. It also innervates the skin over the medial surface of the hand (see illustration in handout). There are a few other small branches that we will not deal with here. We will study the nerves of the brachial

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plexus again when we study the nerves of the arm and forearm.

Summary of Muscular Innervation

1. C-5: levator scapulae and rhomboids 2. C-5 to C-7: serratus anterior

Part V: Blood Vessels

A few major blood vessels are worth mentioning associated with the shoulder area. We will cover them again at a later date, but I will briefly introduce them to you now. A. Arteries (Martini, figures 22.12 & 22.13, pages 584 & 585) If you look in the general region of the clavicle, you will see two arched arteries rising form the heart. These are the right and left subclavian arteries. The left and right subclavian arteries have different origins. The left subclavian comes directly off the aortic arch and is the lateral most of the arch arteries to do so on the side. The right subclavian artery branches from a short brachiocephalic trunk then rises from the aorta laterally on the right. The brachiocephalic trunk splits into the right common carotid artery which rises medially through the cervical region while the right subclavian artery arches laterally and passes under the clavicle, a fate shared by its left counterpart. Indeed, the name subclavian means, below the clavicle. The subclavians are the major arteries that will supply blood to the upper limbs. The vertebral arteries we studied earlier are branches of the subclavians. They arch into the cervical region forming their apex around C7, and then descend first between the anterior and middle scalene muscles then between the clavicle and first rib toward the armpit (axillary region). At the armpits the subclavian arteries become the left and right axillary arteries. The axillary arteries are superficial to the serratus anterior and intercostal muscles, but lie to deep to the pectoralis minor, pectoralis major and the deltoids. The subclavian arteries become axillary arteries just before crossing under the pectoralis minor, so this muscle is a good landmark to remember. Beyond the armpit, the axillary arteries branch into the left and right brachial arteries. The division is marked by three small arteries, the anterior and posterior circumflex arteries that make their way around the head of the humerus, and the subscapular artery which will branch into two arteries traveling toward the scapula and the thorax. The brachial artery will course down a neurovascular bundle which includes the brachial veins and the median nerve, as well as the ulnar nerve. Recall the radial nerve is deep to all of this, but can often be found under the bundle. Cool enough. The entire bundle courses over the surface of the slender coracobrachialis muscle and, as such, blocks the muscle from view. While the brachial arteries run anteriorly, at approximately the region of the deltoid tuberosity, a small artery branches off and runs down the arm posteriorly. This artery is happily named the deep

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brachial artery. It branches into several smaller arteries that supply blood to the posterior arm. We will visit the brachial artery again when we study the forearm. C. Veins (Martini, figure 22.23, page 597). Before we tackle the veins, its important to recall something about what they do. Veins carry blood to the heart, and arteries carry blood away from the heart. So, if I were to discuss veins in terms of there blood flow, I should do everything backwards. I should start with the smaller veins, say the digital veins of the fingers and work my way to the large superior vena cava that enters the heart. Perhaps we can explore the veins in that manner later, once we are more familiar with the blood vessels. For now, Id rather like to forget about blood flow here and compare the veins with the arteries they follow in the same order. I think it will less confusing, Just keep in mind the blood form the arteries and veins are traveling in opposite directions, and well all be fine. Its time now to consider the veins that match the arteries covered above. The right and left subclavian, axillary, and two brachial veins course along with the arteries of the same name, and are therefore, easy to find and easy to remember. There are some differences between the arteries and veins that I should discuss now. Unlike the subclavian artery, the subclavian veins arise from two short brachiocephalic veins that in turn rise form the superior vena cava. The superior vena cava drains deoxygenated blood form the arms, head and neck into the heart for recycling. Unlike the single brachiocephalic trunk,

which is only found on the right side of the heart, the brachiocephalic veins are paired. Each gives rise to a subclavian vein and to an internal jugular vein. Another difference between the subclavian arteries and veins is that the veins course superficially over the anterior scalene muscle, not below it. As with the subclavian artery, the subclavian veins become the axillary veins at the armpit. Just before crossing under the pectoralis minor muscle, a vein branches from the subclavian vein. This is the cephalic vein, which will be discussed shortly. It is also marks the transition between the axillary and subclavian veins. Time for the brachial veins. Recall that the brachial veins join the neurovascular bundle with the brachial artery and median nerve. Heres a surprise. There are two of them, and they course together, right below the brachial artery. In addition to the veins that course with arteries, there are two superficial veins worth mentioning. These are the cephalic vein, which I have already introduced to you and the basilic vein. Recall that the cephalic vein branches at the junction between the axillary and subclavian veins and runs superficially along the anterior surface of the shoulder between the deltoid muscle and pectoralis major. This area is called the deltopectoral triangle. To do this, the cephalic vein pieces the fascia around rib number one and crosses over the pectoralis minor muscle near the coracoid process. The cephalic vein follows the lateral region of the arm (thumb side) just below the skin, draining the hand and superficial forearm . I will discuss this in more detail in subsequent chapters.

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By contrast basilic vein merges with a deep vein, the brachial vein to form the axillary vein. In other words, three veins, two brachial and one basilica come together to form the axillary vein. Again, he neurovascular bundle is the easiest place to detect the upper region of the basilic vein. The basilic vein becomes more superficial are it runs medially up the arm just below the skin (little finger side). To contrast then, the cephalic vein runs laterally; the basilic vein runs medially. If youre an arm, its good to drain both sides. I should probably tell you the derivation of these terms. Cephalic means head. No, it doesnt travel to the skull, but recall that this vein is visible when traveling over the head of the humerus. Basilic means basilica, which is a large church or tomb of a royal or important person. It probably meant something to the guy who named it, but is does us little good. Oh well. Perhaps he wanted to emphasize the veins importance. If so, his point is well taken. We will visit the basilic vein again in the arm and forearm exercises. I hope you find it a meaningful experience.

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