Shoulder Joint

Shoulder Joint
Articulation: humerus
glenoid
glenoid labrum
Capsule: attached outside
the labrum + the anatomic
neck (thin and lax)
Ligaments:
glenohumeral ligaments =
#3
transverse humeral
coracohumeral ligament
Articulation: This occurs between the rounded head of the humerus and the shallow, pear-
shaped glenoid
cavity of the scapula.
The articular surfaces are covered by hyaline articular cartilage, and the glenoid cavity is
deepened by the presence of a fibrocartilaginous rim called the glenoid labrum

Type: Synovial ball-and-socket joint
Capsule: This surrounds the joint and is attached medially to the margin of the glenoid cavity
outside the
labrum; laterally, it is attached to the anatomic neck of the humerus

The capsule is thin and lax, allowing a wide range of movement.
It is strengthened by fibrous slips from the tendons of the subscapularis, supraspinatus,
infraspinatus, and teres minor muscles (the rotator cuff muscles).

Ligaments: The glenohumeral ligaments are three weak bands of fibrous tissue that strengthen
the front of
the capsule.

The transverse humeral ligament strengthens the capsule and bridges the gap between the two
tuberosities (Fig. 9.34).

The coracohumeral ligament strengthens the capsule above and stretches from the
root of the coracoid process to the greater tuberosity of the humerus (Fig. 9.34).

Accessory ligaments
coracoacromial
ligament
between the coracoid
process and the
acromion
Relationship
Above- deltoid/clavicle
Below supraspinatous
Between
coracoacromial lig is a
bursa
Accessory ligaments: The coracoacromial ligament extends between
the coracoid process and the acromion.
Its function is to protect the superior aspect of the joint
-----------------
It is in relation, above, with the clavicle and under surface of
the Deltoideus; below, with the tendon of the Supraspinatus,
a bursa being interposed.

Synovial membrane: This lines the capsule and is attached to the
margins of the cartilage covering the
articular surfaces (Figs. 9.34 and 9.35).

It forms a tubular sheath around the tendon of the long head of the
biceps brachii. It extends through the anterior wall of the capsule to
form the subscapularis bursa beneath thesubscapularis muscle (Fig.
9.34).

Nerve supply: The axillary and suprascapular nerves

Synovial membrane

lines the capsule
attached to the margins
of the cartilage covering
the articular surfaces
tubular sheath = long
head of the biceps
brachii
subscapularis bursa
Synovial membrane: This lines the capsule
and is attached to the margins of the cartilage
covering the
articular surfaces (Figs. 9.34 and 9.35).

It forms a tubular sheath around the tendon of
the long head of the biceps brachii. It extends
through the anterior wall of the capsule to form
the subscapularis bursa beneath
thesubscapularis muscle (Fig. 9.34).


Nerve supply
The axillary and suprascapular nerves

Movements
wide range of movement
Lax capsule
Shallow glenoid
* Low stability
Movements
The shoulder joint has a wide range of movement, and the
stability of the joint has been sacrificed to permit this.
(Compare with the hip joint, which is stable but limited in its
movements.)

Strength= Rotator Cuff SItS
Abducted= supported by the long head of the triceps
Inferior part of the capsule = weakest area

The strength of the joint depends on the tone of the short rotator
cuff muscles that cross in front, above, and behind the joint
namely, the subscapularis,supraspinatus, infraspinatus, and teres
minor.

When the joint is abducted, the lower surface of the head of the
humerus is supported by the long head of the triceps, which bows
downward because of its length and gives little actual support to
the humerus.

In addition, the inferior part of the capsule is the weakest area.

Movements

Flexion:
Deltoid,pectoralis major, Biceps,
coracobrachialis muscles

Flexion: Normal flexion is about 90 and is performed
by the anterior fibers of the deltoid, pectoralis major,
biceps, and coracobrachialis muscles.
Extension: Normal extension is about 45 and is
performed by the posterior fibers of the deltoid, latissimus
dorsi, and teres major muscles.
Extension:
Deltoid, latissimus dorsi, Teres major
Abduction
Deltoid (middle fibers )
supraspinatus - holds the
head of the humerus against the glenoid fossa of
thescapula

*****shoulder joint and between the scapula

Abduction: Abduction of the upper limb occurs
both at the shoulder joint and between the scapula
and the thoracic wall (see scapularhumeral
mechanism, page 367). The middle fibers of the
deltoid, assisted by the supraspinatus, are involved.
The supraspinatus muscle
initiates the movement of abduction and holds the
head of the humerus against the glenoid fossa of
thescapula; this latter function allows the deltoid
muscle to contract and abduct the humerus at the
shoulder
joint.
Adduction
pectoralis major, latissimus dorsi, teres major,
and teres minor

Adduction: Normally, the upper limb can be swung 45 across the front of the
chest. This is performed by the pectoralis major, latissimus dorsi, teres major, and
teres minor muscles.

Lateral rotation: infraspinatus, teres minor,
deltoid
Lateral rotation: Normal lateral rotation is 40 to
45. This is performed by the infraspinatus, the teres
minor, and the posterior fibers of the deltoid muscle.



Medial rotation:
subscapularis, latissimus dorsi, teres major
deltoid muscle.

Medial rotation: Normal medial rotation is about
55. This is performed by the subscapularis, the latissimus dorsi, the
teres major, and the anterior fibers of the deltoid muscle.
Circumduction: This is a combination of the above
movements.

Anteriorly: subscapularis, axillary vessels, brachial plexus
Posteriorly:infraspinatus, minor muscles
Superiorly: supraspinatus, subacromial bursa,
coracoacromial ligament, deltoid
Inferiorly: long head of the triceps, axillary nerve,
posterior circumflex humeral vessels
Important Relations
Anteriorly: The subscapularis muscle and the axillary
vessels and brachial plexus
Posteriorly: The infraspinatus and teres minor muscles
Superiorly: The supraspinatus muscle, subacromial
bursa, coracoacromial ligament, and deltoid muscle
Inferiorly: The long head of the triceps muscle, the axillary
nerve, and the posterior circumflex humeral vessels
Stability of the Shoulder Joint
shallow glenoid +weak ligaments = unstable
Strength SItS
Inferior = unprotected
The shallowness of the glenoid fossa of the scapula and the lack of
support provided by weak ligaments make this joint an unstable
structure. Its strength almost entirely depends on the tone of the
short muscles that bind the upper end of the humerus to the
scapulanamely, the subscapularis in front, the supraspinatus
above, and the infraspinatus and teres minor behind. The tendons
of these muscles are fused to the underlying capsule of the
shoulder joint. Together, these tendons form the rotator cuff. The
least supported part of the joint lies in the inferior location, where
it is unprotected by muscles.
Anterior Inferior Dislocation

Dislocates in abduction= weak inferiorly
acromion has acted as a fulcrum
humeral head = inferior to the glenoid fossa
Anterior Inferior Dislocation
Sudden violence applied to the humerus with the
joint fully abducted tilts the humeral head downward
onto the inferior weak part of the capsule, which
tears, and the humeral head comes to lie inferior to
the glenoid fossa. During this movement, the
acromion has acted as a fulcrum. The strong flexors
and adductors of the shoulder joint now usually pull
the humeral head forward and upward into the
subcoracoid position.
Posterior dislocations
Rare
Direct violence to the front of the joint
quadrangular space -damage to the axillary
nerve
Radial nerve- downward displacement of
humerus
Posterior dislocations are rare and are usually caused by
direct violence to the front of the joint. On inspection of the
patient with shoulder dislocation, the rounded appearance of
the shoulder is seen to be lost because the greater tuberosity
of the humerus is no longer bulging laterally beneath the
deltoid muscle. A subglenoid displacement of the head of the
humerus into the quadrangular space can cause damage to
the axillary nerve, as indicated by paralysis of the deltoid
muscle and loss of skin sensation over the lower half of the
deltoid. Downward displacement of the humerus can also
stretch and damage the radial nerve.

Testing axillary nerve function
Motor- deltoid
Sensory- sensation to the lateral aspect of the
upper arm (posterior terminal branch)

Technique for testing axillary nerve function. With the
arm adducted and stabilized by the examiner, the
patient is asked to actively abduct the arm. The motor
component (A) of the axillary nerve is documented by
observing or palpating deltoid muscle contraction.
The sensory component (B) of the axillary nerve is
documented by testing the sensation to the lateral
aspect of the upper arm.
Shoulder Pain
synovial membrane, capsule, ligaments
= axillary nerve and the suprascapular
pain, pressure, excessive traction, and
distention.
Muscle = reflex spasm = immobilize the
joint = reduce pain.
diaphragmatic pleura or peritoneum:
referred pain via the phrenic and
supraclavicular nerves.



Shoulder Pain
The synovial membrane, capsule, and ligaments of the shoulderjoint are
innervated by the axillary nerve and the suprascapular nerve.
The joint is sensitive to pain, pressure, excessive traction, and distention.

The muscles surrounding the joint undergo reflex spasm in response to pain
originating in the joint, which in turn
serves to immobilize the joint and thus reduce the pain.

Injury to the shoulder joint is followed by pain, limitation of movement, and
muscle atrophy owing to disuse.

It is important to appreciate that pain in the shoulder region can be caused by
disease elsewhere and that the shoulder joint may be normal; for example,
diseases of the spinal cord and vertebral column and
the pressure of a cervical rib can cause shoulder pain.

Irritation of the diaphragmatic pleura or peritoneum can produce referred pain
via the phrenic and supraclavicular
nerves.
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scapula and upper limb are suspended from the
clavicle by the strong coracoclavicular ligament
Axis of rotation = coracoclavicular ligament.
Abduction (3) = scapula (1) + shoulder joint (2)
120 = greater tuberosity hits acromion
Further elevation = rotation of scapula
The scapula and upper limb are suspended from the clavicle by the
strong coracoclavicular ligament assisted by the
tone of muscles.

When the scapula rotates on the chest wall so that the position of the
glenoid fossa is altered, the axis
of rotation may be considered to pass through the coracoclavicular
ligament.

Abduction of the arm involves rotation of the scapula as well as
movement at the shoulder joint.
For every 3 ofabduction of the arm, a 2 abduction occurs in the
shoulderjoint and a 1 abduction occurs by rotation of the scapula.

At about 120 of abduction of the arm, the greater tuberosity of the
humerus comes into contact with the lateral edge
of the acromion.
Further elevation of the arm above the head is accomplished by rotating
the scapula

Superficial Sensory Nerves
supraclavicular nerves - halfway down the deltoid muscle (3
4 cervical nerve)
upper lateral cutaneous nerve of the arm- Axillary nerve
lower lateral cutaneous nerve of the arm- radial nerve
Armpit and medial side- medial cut N (medial cord) ,
intercostobrachial N
Back of the arm- posterior cutaneous nerve of the arm (radial
nerve)

Skin
Fascial Compartments
The Upper Arm
The sensory nerve supply (Fig. 9.38) to the skin over the point of the
shoulder to halfway down the deltoid muscle
is from the supraclavicular nerves (C3 and 4). --arise from the third and
fourth cervical nerves

The skin over the lower half of the deltoid is supplied by the upper
lateral cutaneous nerve of the arm, a branch of the axillarynerve (C5
and 6).
The skin over the lateral surface of the arm below the deltoid is supplied
by the lower lateral cutaneous nerve of the arm, a branch of the radial
nerve (C5 and 6).

The skin of the armpit and the medial side of the arm is supplied by the
medial cutaneous nerve of
the arm (T1) and the intercostobrachial nerves (T2).

The skin of the back of the arm (Fig. 9.38) is supplied by the posterior
cutaneous nerve of the arm, a branch of
the radial nerve (C8).
Superficial Veins
Superficial (superficial fascia)
cephalic vein - lateral side of the
biceps
axillary vein.
basilic - medial side of the biceps
venae comitantes of the brachial artery
the axillary vein
Deep
Venae comitantes
axillary vein
Superficial Veins
The veins of the upper limb can be divided into two groups: superficial and
deep.

The deep veins comprise the venae comitantes, which accompany all the large
arteries, usually
in pairs, and the axillary vein.

The superficial veins of the arm (Fig. 9.39) lie in the superficial fascia.

The cephalic vein ascends in the superficial fascia on the lateral side of the
biceps and, on reaching the infraclavicular
fossa, drains into the axillary vein.

The basilic vein ascends in the superficial fascia on the medial side of the
biceps (Fig. 9.39).

Halfway up the arm, it pierces the deep fascia and at the lower border of the
teres major joins the venae comitantes of the brachial artery to form the
axillary vein.
Venipuncture and Blood
Transfusion
cephalic vein- posterior to the
styloid process of the radius
median cubital vein = cubital fossa
separated from the underlying brachial
artery by the bicipital aponeurosis
cephalic vein = frequently
communicates with the external
jugular vein (hematoma in
clavicular fx)
The superficial veins are clinically important and are used for venipuncture,
transfusion, and cardiac catheterization. Every clinical professional, in an
emergency, should know where to obtain blood from the arm.
When a patient is in a state of shock,the superficial veins are not always visible.

The cephalic vein lies fairly constantly in the superficial fascia, immediately
posterior to the styloid process of the radius.

In the cubital fossa, the median cubital vein is separated from the underlying
brachial artery by the bicipital aponeurosis. This is important because it
protects the artery from the mistaken introduction into its lumen
of irritating drugs that should have been injected into the vein.

The cephalic vein, in the deltopectoral triangle, frequently communicates with
the external jugular vein by a small vein that crosses in front of the clavicle.
Fracture of the clavicle can result in rupture of this communicating vein, with
the formation of a large hematoma.
Anatomy of Basilic and Cephalic Vein
Catheterization
median basilic or basilic veins
= veins of choice for central
venous catheterization
increases in diameter
direct line with the axillary vein
cephalic vein
does not increase in size
divides into small branches
joins the axillary vein at a right
angle
Anatomy of Basilic and Cephalic Vein Catheterization
The median basilic or basilic veins are the veins of choice for central
venous catheterization, because from the cubital fossa until the basilic
vein reaches the axillary vein, the basilic vein increases in diameter and
is in direct line with the axillary vein (Fig. 9.39).
The valves in the axillary vein may be troublesome, but abduction of the
shoulder joint may permit the catheter to move past the obstruction.

The cephalic vein does not increase in size as it ascends the arm, and it
frequently divides into small branches as it lies within the deltopectoral
triangle.

One or more of these branches may ascend over the clavicle and join
the external jugular vein.

In its usual method of termination, the cephalic vein joins the axillary
vein at a right angle.
It may be difficult to maneuver the catheter around this angle.

Nerve Supply of the Veins
sympathetic postganglionic nerve
Like the arteries, the smooth muscle in the wall of the veins
is innervated by sympathetic postganglionic nerve fibers
that provide vasomotor tone.
Lymph Vessels
Superficial
lateral side = follow the cephalic vein to the
infraclavicular group of nodes
medial side = follow the basilic vein to the lateral
group of axillary nodes.
The deep lymph
lateral group of
axillary nodes.
Superficial Lymph Vessels
The superficial lymph vessels draining the superficial tissues
of the upper arm pass upward to the axilla (Fig. 9.40).

Those from the lateral side of the arm follow the cephalic vein
to the infraclavicular group of nodes; those from the medial
side follow the basilic vein to the lateral group of axillary
nodes.

The deep lymphatic vessels draining the muscles and deep
structures of the arm drain into the lateral group of axillary
nodes.
thumb and index finger and the lateral part of
the hand cephalic-infraclavicular group of
axillary nodes

3-4-5 fingers- basilic vien supratrochlear
node lateral group of axillary nodes
The lymph vessels from the thumb and index finger
and the lateral part of the hand follow the cephalic
vein to the infraclavicular group of axillary nodes;

those from the middle, ring, and little fingers and
from the medial part of the hand follow the basilic
vein to the
supratrochlear node, which lies in the superficial
fascia just above the medial epicondyle of the
humerus, and thence to
the lateral group of axillary nodes.

Lymphangitis- Infection of the lymph
vessels
Red streaks along the course of the
lymph vessels
Lymphadenitis- Once the infection
reaches the lymph nodes

Lymphangitis
Infection of the lymph vessels
(lymphangitis) of the arm is common.

Red streaks along the course of the lymph
vessels are characteristic of the condition.

Lymphadenitis
Once the infection reaches the lymph
nodes, they become enlarged and tender, a
condition known as lymphadenitis.

lymph vessels from the fingers and palm pass
to the dorsum of the hand edema/abscess
@ dorsum of hand
Most of the lymph vessels from the fingers and palm pass to
the dorsum of the hand before passing up into the forearm.
This explains the frequency of inflammatory edema, or even
abscess formation, which may occur on the dorsum of the
hand after infection of the fingers or palm.

Fascial Compartments of the Upper
Arm

Anterior Fascial
Compartment

Muscles: Biceps, coracobrachialis, and brachialis
Blood supply: Brachial artery
Nerve supply : Musculocutaneous nerve
Structures passing through the compartment:
Musculocutaneous, median, and ulnar nerves;
brachial artery and basilic vein.
radial nerve is present in the lower part of the
compartment

Note that the biceps brachii is a powerful supinator, and this
action is made use of in twisting the corkscrew into the cork
or driving the screw into wood with a screwdriver.
The biceps also is a powerful flexor of the elbow joint and a
weak flexor of the shoulder joint.

Brachial Artery
begins at the lower border of the teres major
terminates opposite the neck of the radius by
dividing into the radial and ulnar arteries
The brachial artery begins at the lower border of the teres
major muscle as a continuation of the axillary artery.
It provides the main arterial supply to the arm (Fig. 9.42).
It terminates opposite the neck of the radius by dividing into
the radial and ulnar arteries.


Brachial Artery
Anteriorly: overlapped
coracobrachialis and biceps
Posteriorly: triceps,
coracobrachialis insertion
,brachialis
Medially:
Upper: ulnar nerve, basilic
vein
lower part :the median
nerve
Laterally:
Above: median nerve and
the coracobrachialis and
biceps muscles
lower part :tendon of the
biceps
Anteriorly: The vessel is superficial and is overlapped from the lateral
side by the coracobrachialis and biceps.
The medial cutaneous nerve of the forearm lies in front of the upper
part; the median nerve crosses its middle
part; and the bicipital aponeurosis crosses its lower part

Posteriorly: The artery lies on the triceps, the coracobrachialis
insertion, and the brachialis

Medially: The ulnar nerve and the basilic vein in the upper part of the
arm; in the lower part of the arm, the
median nerve lies on its medial side (Fig. 9.43).

Laterally: The median nerve and the coracobrachialis and biceps
muscles above; the tendon of the biceps
lies lateral to the artery in the lower part of its course

Branches: Brachial
Artery
Muscular branches
The nutrient artery
profunda - follows the radial
nerve into the spiral groove
superior ulnar collateral
artery - follows the ulnar
nerve
inferior ulnar collateral
artery anastomosis around
the elbow joint
Branches
Muscular branches to the anterior compartment of the
upper arm
The nutrient artery to the humerus
The profunda artery arises near the beginning of the
brachial artery and follows the radial nerve into the spiral
groove of the humerus (Fig. 9.45).
The superior ulnar collateral artery arises near the
middle of the upper arm and follows the ulnar nerve
(Fig. 9.45).
The inferior ulnar collateral artery arises near the
termination
of the artery and takes part in the anastomosis
around the elbow joint (Fig. 9.45).
Musculocutaneous Nerve
lateral cord of the
brachial plexus
pierces the
coracobrachialis
muscle
between the
biceps and brachialis
muscles
The origin of the
musculocutaneousnerve from
the lateral cord of the brachial
plexus (C5, 6, and 7) in the
axilla.

It runs downward and
laterally, pierces the
coracobrachialis muscle (Fig.
9.15), and then passes
downward between the
biceps and brachialis muscles
(Fig. 9.43).
Musculocutaneous Nerve
Elbow- lateral margin of the biceps tendon
lateral aspect of the forearm as the lateral
cutaneous nerve of the forearm
It appears at the lateral margin of the biceps tendon and
pierces the deep
fascia just above the elbow. It runs down the lateral aspect of
the forearm as the lateral cutaneous nerve of the forearm
(Fig. 9.38).

Branches
lateral cutaneous nerve of the
forearm = front and lateral aspects
of the forearm down as far as the
root of the thumb
Articular branches to the elbow
joint
Branches
Muscular branches to the biceps,
coracobrachialis, and brachialis (Fig. 9.22)
Cutaneous branches; the lateral
cutaneous nerve of the forearm supplies
the skin of the front and lateral aspects
of the forearm down as far as the root of
the thumb.
Articular branches to the elbow joint
Median Nerve
Lat side of brachial art
medial side
Elbow- crossed by the
bicipital aponeurosis
no branches in the upper
arm (small vasomotor nerve
to the brachial Artery)
It runs downward on the lateral
side of the brachial artery (Fig.
9.43).
Halfway down the upper arm, it
crosses the brachial artery and
continues downward on its
medial side.

The nerve, like the artery, is
therefore superficial, but at the
elbow, it is crossed by the
bicipital aponeurosis

The median nerve has no
branches in the upper arm (Fig.
9.22), except for a small
vasomotor nerve to the brachial
artery.
Median nerve from the
medial and lateral cords
of the brachial plexus
Ulnar Nerve
origin of the ulnar nerve = medial cord of the
brachial plexus

Ulnar Nerve
Medial side of the art
@ coracobrachialis
insertion pierce medial
fascial septum (with
superior ulnar collateral
artery) post
compartment post to
medial epicondyle
ULNAR NERVE
It runs downward on the medial side of the brachial artery as
far as the middle of the arm (Fig. 9.43).

Here, at the insertion of the coracobrachialis, the nerve
pierces the medial fascial septum, accompanied by the
superior ulnar collateral artery, and enters the posterior
compartment of the arm; the nerve passes behind the
medial epicondyle of the humerus.

The ulnar nerve has no branches in the anterior compartment
of the upper arm (Fig. 9.23).

Radial Nerve
On leaving the axilla, the radial nerve
immediately enters the posterior
compartment of the arm and enters the
anterior compartment just above the lateral
epicondyle
Contents of the Posterior Fascial
Compartment of the Upper Arm
Muscle: The three heads of the triceps muscle
Nerve supply to the muscle: Radial nerve
Blood supply: Profunda brachii and ulnar
collateral arteries
Structures passing through the compartment:
Radial nerve and ulnar nerve

Structures Passing through the
Posterior Fascial
Compartment
Radial Nerve
Ulnar Nerve
Profunda Brachii Artery
Superior and Inferior Ulnar Collateral Arteries
Radial Nerve
From posterior cord
Branches of Radial Nerve
Axilla
long and medial
heads of the triceps
the posterior
cutaneous nerve of
the arm
Branches of Radial Nerve
spiral groove
lateral and medial
heads of the triceps
Anconeus
lower lateral
cutaneous nerve
posterior cutaneous
nerve nerve of the
forearm
In the spiral groove (Fig. 9.46),
branches are given to the lateral and
medial heads of the triceps and to the
anconeus.

lower lateral cutaneous nerve of the
arm supplies the skin over the lateral
and anterior aspects of the lower part
of the arm.

The posterior cutaneous nerve of the
forearm runs down the middle of the
back of the forearm as far as the
wrist.
Branches of Radial Nerve: anterior
compartment of the arm
Brachialis
Brachioradialis
extensor carpi radialis
longus muscles
Articular branches to the
elbow joint
In the anterior compartment
of the arm, after the nerve
has pierced the lateral fascial
septum, it gives branches to
the brachialis, the
brachioradialis, and the
extensor carpi radialis longus
muscles (Fig. 9.47).
It also gives articular
branches to the elbow joint.


Ulnar Nerve
pierced the medial fascial
septum halfway down the
upper arm, the ulnar nerve
descends behind the
septum
covered posteriorly by the
medial head of the triceps
accompanied by the
superior ulnar collateral
vessels
Elbow = lies behind the
medial epicondyle

Ulnar Nerve Having pierced the medial fascial septum
halfway down the upper arm, the ulnar nerve descends
behind the septum, covered posteriorly by the medial head of
the triceps.

The nerve is accompanied by the superior ulnar collateral
vessels.
At the elbow, it lies behind themedial epicondyle of the
humerus (Fig. 9.46) on the medial ligament
of the elbow joint.
It continues downward to enter the forearm between the two
heads of origin of the flexor
carpi ulnaris (see page 390).