anatomy of shoulder joint - vamshi kiran

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ANATOMY OF SHOULDER JOINT PRESENTOR :DR.B.VAMSHIKI RAN

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Page 1: Anatomy of shoulder joint - vamshi kiran

ANATOMY OF SHOULDER JOINT

PRESENTOR :DR.B.VAMSHIKIRAN

Page 2: Anatomy of shoulder joint - vamshi kiran

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

Page 5: Anatomy of shoulder joint - vamshi kiran

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

Page 7: Anatomy of shoulder joint - vamshi kiran

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

Page 8: Anatomy of shoulder joint - vamshi kiran

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.

Page 9: Anatomy of shoulder joint - vamshi kiran

SCAPULA OSSIFICATION CENTRES

Page 10: Anatomy of shoulder joint - vamshi kiran

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

Page 11: Anatomy of shoulder joint - vamshi kiran

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

Page 12: Anatomy of shoulder joint - vamshi kiran

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

Page 13: Anatomy of shoulder joint - vamshi kiran

• 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.

Page 14: Anatomy of shoulder joint - vamshi kiran

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

Page 15: Anatomy of shoulder joint - vamshi kiran

LIGAMENTS AROUND SHOULDER JOINT

• GLENOID LABRUM• CAPSULAR LIGAMENT• GLENOHUMERAL LIGAMENT• CORACOHUMERAL LIGAMENT• TRANSVERSE HUMERAL LIGAMENT• CORACOACROMIAL LIGAMENT• CORACOCLAVICULAR LIGAMENT

Page 16: Anatomy of shoulder joint - vamshi kiran

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

Page 17: Anatomy of shoulder joint - vamshi kiran

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

Page 18: Anatomy of shoulder joint - vamshi kiran

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]

Page 19: Anatomy of shoulder joint - vamshi kiran

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].

Page 23: Anatomy of shoulder joint - vamshi kiran

• 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.

Page 24: Anatomy of shoulder joint - vamshi kiran

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

Page 25: Anatomy of shoulder joint - vamshi kiran

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

Page 26: Anatomy of shoulder joint - vamshi kiran

BURSAE RELATED TO SHOULDER JOINT• SUBACROMIAL BURSA-protect suprspinatus• SUBSCAPULARIS BURSA• INFRASPINATUS BURSA

Page 27: Anatomy of shoulder joint - vamshi kiran

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

Page 28: Anatomy of shoulder joint - vamshi kiran

BLOOD SUPPLY• Anterior circumflex humeral

artery[axillaryartery]• Posterior circumflex humeral artry[axillaryartery]• Suprascapular[thyrocervical br.] and subscapular

artery[largest br. of axillary artery]

Page 29: Anatomy of shoulder joint - vamshi kiran

NERVE SUPPLY

• Axillary nerve-passes close to surgical neck of humerus abt 5cm below acromian

• Musculocutaneous nerve• Suprascapular nerve-Just passes over clavicle

Page 30: Anatomy of shoulder joint - vamshi kiran

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

Page 31: Anatomy of shoulder joint - vamshi kiran

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

Page 34: Anatomy of shoulder joint - vamshi kiran

• 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

Page 35: Anatomy of shoulder joint - vamshi kiran

MUSCLE INSERTIONS ON HUMERUS

Page 36: Anatomy of shoulder joint - vamshi kiran

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

Page 38: Anatomy of shoulder joint - vamshi kiran

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

Page 39: Anatomy of shoulder joint - vamshi kiran

MOVEMENTS AROUND SHOULDER• Shoulder movements occur by coordinated

motions of –1. Clavicular and sternoclavicular2. Acromioclavicular motion3. Scapulothoracic motion4. Glenohumeral motion

Page 40: Anatomy of shoulder joint - vamshi kiran

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

Page 41: Anatomy of shoulder joint - vamshi kiran

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

Page 42: Anatomy of shoulder joint - vamshi kiran

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

Page 43: Anatomy of shoulder joint - vamshi kiran

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

Page 44: Anatomy of shoulder joint - vamshi kiran

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

Page 45: Anatomy of shoulder joint - vamshi kiran

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

Page 46: Anatomy of shoulder joint - vamshi kiran

SHOULDER MOVEMENTS

FLEXION

FLEXIONEXTENSION

ADDUCTIONABDUCTION

Page 47: Anatomy of shoulder joint - vamshi kiran

• 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.

Page 49: Anatomy of shoulder joint - vamshi kiran

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

Page 50: Anatomy of shoulder joint - vamshi kiran

• 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

Page 52: Anatomy of shoulder joint - vamshi kiran

REFERENCES• Text book of upperlimb-chaurasia• Operative orthopaedics-campbell• Hand book of fractures-zuckerman• Manual of clinical surgery-Das