shoulder, elbow, and wrist for the lecture final exam

Shoulder, Elbow, and Wrist

For the Lecture Final Exam

The Pectoral Girdle

• Provides attachment for many muscles that move the upper limb

• Girdle is very light and upper limbs are mobile– Only clavicle articulates with the axial skeleton– Socket of the shoulder joint (glenoid cavity) is

shallow• Good for flexibility, bad for stability

ClavicleAcromio-clavicularjoint

Scapula

(a) Articulated pectoral girdle

Articulated Pectoral Girdle

Figure 8.1a

PLAYPLAY Shoulder

PLAYPLAY Shoulder

Clavicles• Extend horizontally across the superior thorax• Sternal end articulates with the manubrium• Acromial end articulates with scapula• Provide attachment for muscles • Hold the scapulae and arms laterally• Transmit compression forces from the upper limbs to the

axial skeleton• SCAPULA

– Lies on the dorsal surface of the rib cage– Located between ribs 2–7

Arm• Region of the upper limb between the shoulder and

elbow• Humerus

– The only bone of the arm– Longest and strongest bone of the upper limb– Articulates with the scapula at the shoulder– Articulates with the radius and ulna at the elbow– Many structures of the humerus provide sites for muscle

attachment– Other structures of the humerus provide articulation sites for

other bones

Forearm• Formed from the radius and ulna• Proximal ends articulate with the humerus• Distal ends articulate with carpals• Radius and ulna articulate with each other

– At the proximal and distal radioulnar joints

• The interosseous membrane– Interconnects radius and ulna

• In anatomical position; the radius is lateral and the ulna is medial

PLAYPLAY Elbow

Proximal Part of the Ulna

Figure 8.4a, b

Radial notch of the ulna

Olecranon process

Trochlear notch

Coronoid process

Proximal radioulnarjoint

Distal radioulnar joint

Ulnar notch of the radiusHead of ulna

Styloid process of ulna

Interosseousmembrane

Ulna

HeadNeckRadialtuberosity

Radius

Styloid processof radius

(a) Anterior view

Olecranonprocess

Styloid processof radius

Radius

Neck of radius

Head of radius

Ulnar notchof the radius

Head of ulna

Styloid processof ulna

Interosseousmembrane

Ulna

(b) Posterior view

• RADIUS• Contributes heavily to the wrist joint

– Distal radius articulates with carpal bones – When radius moves, the hand moves with it

• ULNA• Main bone responsible for forming the elbow joint with

the humerus• Hinge joint allows forearm to bend on arm• Distal end is separated from carpals by fibrocartilage• Plays little to no role in hand movement

Proximal Ends of the Radius and Ulna

Figure 8.3c, d

Coronoid fossa

Radius

Radialtuberosity

Head ofradius

Capitulum

Trochlea

(c) Anterior view at the elbow region

Humerus

Medialepicondyle

Coronoidprocess ofulna

Ulna

Radial notch

Olecranonfossa

Ulna

Olecranonprocess

Medialepicondyle

(d) Posterior view of extended elbow

Humerus

Lateralepicondyle

Head

Radius

Neck

Copyright © 2011 Pearson Education, Inc., publishing as Pearson Benjamin Cummings.

Location of styloid processes of radius and ulna. Styloid process

of radius

Head ofulna

Styloid processof ulna(a) Normal position

• Carpal bones– Forms the true wrist—the proximal region of the

hand– Gliding movements occur between carpals– Are arranged in two irregular rows– Proximal row from lateral to medial

• Scaphoid, lunate, triquetrium, and pisiform

– Distal row from lateral to medial• Trapezium, trapezoid, capitate, and hamate

– A mnemonic to help remember carpals:• Sally left the party to take Carmen home

Bones of the Hand

Figure 8.6a, b

TrapezoidTrapezium

ScaphoidTriquetrumLunate

CapitateHamate

5 4 3 2 1 54321

Phalanges

Metacarpals

CarpalsCarpals

(a) Anterior view of right hand (b) Posterior view of right hand

Radius Ulna

Sesamoidbones Base

Shaft

ProximalMiddleDistal

Head

Ulna

TriquetrumLunate

CapitateHamate

Pisiform

Carpals

Metacarpals

• Metacarpals form the palm• Numbered 1–5, beginning with the pollex (thumb)

• Phalanges form the digits– Numbered 1–5, beginning with the pollex (thumb)– Named also by whether it is proximal,

intermediate (or middle), or distal.– The pollex does not have a middle phalanx.– The second middle phalanx refers to the second

DIGIT.

Plane Joints

Movement in the transverse or frontal plane only. These are not axial since the movement does not occur around an axis.

Examples are the carpal and tarsal bones, between the articular processes of the vertebrae


Medial/lateralaxis

Flexion and extension

Uniaxial movement

Hinge Joints

Movement around an axis in the sagittal plane only (uniaxial).

Examples are the elbow, knee, and IPJ = interphalangeal (finger and toe) joints.There are two types of IPJ’s: Distal (DIPJ) and Proximal (PIPJ).


Pivot Joints

Ulna

Radius

Verticalaxis

Rotation

Rotation movement around a vertical axis (uniaxial).

Examples are between the first two vertebrae and proximal radioulnar joint, where the annular ligament on the ulna encircles the head of the radius

Condyloid Joints

Allows for movement in two planes (biaxial) because the bones are shaped like a condyle in a cup.

Examples are the Metacarpal-phalangeal joints (MPJ’s).

These are calledbiaxial condyloid joints

Saddle Joints

Both bones are concave on one side and convex on the other.

Allows for movement in two planes (biaxial).

Example is at the base of the thumb (between the trapezium and metacarpal I)

Saddle joints are biaxial joints; in primate anatomy, allows for the opposable thumb

Ball and Socket Joints

Allows for movement in three planes (multiaxial).

Examples are the shoulder and hip joints.

Bursae and Tendon Sheaths

Figure 9.4a, b

The knee joint has at least 13 bursae

The Shoulder Joint

Diarthrotic (freely moveable) ball and socket joint:

Humeral head in glenoid cavity

Acromioclavicular ligament

Acromion

Tendon of supraspinatus muscle

Coracoacromial ligament

Trapezoid ligament (part of coracoclavicular ligament)

Clavicle

Conoid ligament (part of coracoclavicular ligament)

Superior transverse scapular ligament

Tendon of long head of biceps brachii muscle

Humerus Tendon of subscapularis muscle

Coracoid process

Articular capsule

Scapula (in part)

Shoulder Joint (Glenohumeral Joint)

Ligaments:Glenohumeral ligaments : 3 fibrous bands• From the anterior glenoid labrum to the anatomical neck of humerus• Reinforce the anterior part of the articular capsule (and are inside the capsule, not

visible from outside.)Coracohumeral ligament• From base of coracoid process to anterior aspect of greater tubercle of humerusTransverse humeral ligament• Runs from greater to lesser tubercle of humerus• Creates a channel , bridging over the intertubercular groove• Site for tendon of long head of biceps brachiiCoracoacromial ligament• From inferior aspect of acromion to coracoid process• Forms a protective “arch” preventing superior displacement of the head• Supraspinatus muscle passes under this arch.

Shoulder Ligaments

Shoulder:Glenohumeral Joint

Shoulder Ligaments

• 10 points on lecture final exam:• Label the following drawing with the names of

the ligaments that attach the clavicle to the scapula and to the head of the humerus.

10 pt Essay Question: Label this (½ pt each)

Essay Answer: ½ pt each


The sternoclavicular joint.

Anteriorsternoclavicularligament andjoint capsule

Interclavicularligament

Articulardisc

Manubriumof sternum

Costal cartilageof 1st rib

Costoclavicularligament

Clavicle

(a) Sternoclavicular joint, anterior view

Depression

Protraction

Elevation RetractionPosteriorrotation

(b) Sternoclavicular movements


Fibrous capsule

Hyalinecartilage

Synovial cavityof the glenoidcavity containingsynovial fluid

Glenoid labrum

Humerus

(b) Cadaver photo corresponding to (a)


Elbow joint

Articularcapsule

Synovialmembrane

Synovial cavity

Articular cartilage

Coronoid process

Tendon ofbrachialis muscle

Ulna

Humerus

Fat pad

Tendon oftricepsmuscle

Bursa

Trochlea

Articular cartilageof the trochlearnotch

(a) Mid-sagittal section through right elbow (lateral view)


Humerus

Lateralepicondyle

ArticularcapsuleRadialcollateralligament

Olecranonprocess

(b) Lateral view of right elbow joint

Anularligament

Radius

Ulna

Elbow joint


Anularligament

Humerus

Medialepicondyle

Ulnarcollateralligament

Ulna

Articularcapsule

Radius

Coronoidprocess ofulna

(c) Cadaver photo of medial view of right elbow

Elbow joint


Articularcapsule

Anularligament

Coronoidprocess

(d) Medial view of right elbow

Radius

Humerus

Medialepicondyle


Ulna

Elbow joint


Radius Ulna

Lunate

Triquetrum

Pisiform

HamateCapitate

Scaphoid

Trapezoid

Trapezium

Thumb

Radiocarpaljoint

(a) Right wrist, anterior (palmar) view


Distalradioulnarjoint


ArticulardiscRadial

collateralligament

Radiocarpaljoint

Intercarpaljoint

(b) Wrist joints, coronal section


Hamate

Carpo-metacarpalligaments

Pisiform

Lunate

Radius Ulna


Radialcollateralligament

Palmarradiocarpalligament

Intercarpalligaments

Trapezium

Capitate

Scaphoid

(c) Ligaments of the wrist, anterior (palmar) view


Rheumatoid arthritis


Notice that these are all synovial joints.

Abductor pollicis brevis

Flexor pollicis brevis

Extensor pollicis longus

Flexor pollicis longus Adductor pollicis

Lumbricals

Flexor digitorum profundus

Flexor digitorum superficialis

Opponens digiti minimi

Flexor digiti minimi brevis Abductor digiti minimi

Dorsal interosseus Abductor digiti minimi

Brachial Plexus

ROOTS

TRUNKS

DIVISIONS

CORDS NERVES

Brachial Plexus

Brachial Plexus

• Damage to Brachial Plexus– Congenital (brachial plexus damaged during birth)

• Klumpke’s paralysis– Acquired Brachial Plexus injuries

• Crutch paralysis (total upper extremity paralysis)• Claw Hand • Carpal Tunnel Syndrome, Ape hand, Hand of

benediction • Wrist Drop (Waiter’s Hand)

Major Nerves of the Upper

Extremity

Axillary

Musculocutaneus

Axillary Nerve

• Deltoid• Teres minor

Musculocutaneus Nerve

Supplies anterior muscles of the arm

Axillary

Musculocutaneus

Median Nerve

• Supplies no muscles of the arm• Supplies anterior forearm (except flexor carpi

ulnaris)• Damage can cause

– Carpal Tunnel Syndrome– Hand of benediction– Ape Hand

Patient trying to make a fist

Carpel Tunnel Syndrome


• The median nerve travels under the transverse carpal ligament.

• The nerve is pinched in carpal tunnel syndrome.

MEDIAN NERVE• This is the nerve that gets cut when people try to slit

their wrists. • The arteries are so small in the wrist; people rarely

die from this type of suicide attempt. However, they live with a lot of tissue damage. They are not able to move the thumb towards the little finger, so it is hard to pick up small objects. This is called “ape hand”.

Ulnar Nerve

• Supplies flexor carpi ulnaris• “Funny Bone”• Damage can cause claw hand; cannot adduct

or abduct fingers

Radial Nerve

• Supplies muscles on the posterior arm and forearm– Triceps brachii– Extensor carpi radialis– Extensor digitorum communis

• Damage can cause wrist drop


Ape Hand

Axillary nerve

Ulnar nerve Axillary nerve

Median nerve

Musculocutaneous nerve

Radial nerve Brachial plexus

Ulnar nerve

Radial nerve

Median nerve

Arteries of the Upper Extremity

Radial artery Superficial palmar arch

Ulnar artery Anterior interosseous artery Brachial artery

Arteries of the Upper Extremity

• Subclavian (becomes axillary artery in armpit)• Axillary (becomes brachial artery in arm)

– Supplies triceps brachii

• Brachial (divides into radial and ulnar arteries when it reaches the elbow)– Supplies arm muscles except triceps brachii

• Radial• Ulnar

Axillary

Brachial

Radial

Ulnar

Cephalic

Median cubital

Brachial

Radial

Ulnar

Patient Case

• Susan reports shoulder pain located at the proximal lateral humerus. The pain is worse when sleeping on the right shoulder, and also when she elevates her arm.

• This location is consistent with pain originating from the shoulder cuff tendons, the long head of biceps brachii, or subacromial bursa.

• Her pain may be from the rotator cuff, bursitis, or biceps tendonitis.

• Pain from laying on the shoulder is consistent with pain originating from the subacromial space. The humerus compresses the bursa there when laying on the affected side.

Patient Case

• When the arm is elevated and especially when carrying a load in that position, the subacromial bursa is compressed.

• As the supraspinatus muscle contracts in this position, the blood supply to its tendon is impinged. Repeating these motions during the day may cause a supraspinatus tendon tear, since its nutrient vessels are pinched.

Supraspinatus• The supraspinatus muscle participates in humeral elevation

throughout its range of motion, especially the first 5-10 degrees, so it is under tension most of a person’s waking hours and is vulnerable to tensile overload. The trapezius then takes over most of the rest of the range of motion.

• Supraspinatus is the most vulnerable of the cuff muscles.• Rotator cuff tendinitis produces pain between 60-120

degrees of humeral elevation in relation to the trunk. This range is called the painful arc. Beyond 120 degrees, the tendons have cleared the coracoacromial arch.

• If the pain occurs beyond 120 degrees, it is more likely to be from degeneration of the acromial-clavicular joint.

Rotator Cuff Injury Symptoms

• Pain and tenderness in the shoulder, especially when reaching overhead, reaching behind the back, lifting, pulling or sleeping on the affected side.

• Diagnosis– X-rays– MRI– Ultrasound

Causes of Rotator Cuff Injuries • Normal wear and tear. • Poor posture. When you slouch your neck and shoulders forward, the

space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones (including your collarbone), especially during overhead activities, such as throwing.

• Falling. Using your arm to break a fall or falling on your arm• Lifting or pulling. Lifting an object overhead Likewise, pulling something,

such as a high-poundage archery bow, may cause an injury.• Repetitive overhead movement. This occurs often in athletes, especially

baseball pitchers, swimmers and tennis players. It's also common among people in the building trades, such as painters and carpenters.

Trapezius

• Serratus anterior and trapezius both abduct the arm. Trapezius can abduct the arm through its full range of motion, although it is weaker without serratus anterior.

• Overuse and damage to trapezius can result in a shoulder shrug motion when trying to elevate the arm, and fatigue and pain in that muscle.

• This also might be a cause of Susan’s pain.

Upper Trapezius Strain

• An upper-trapezius strain can be triggered quite easily by consistently overusing the muscle group, even at a low intensity. Because repetitive motions do not allow the affected tissue to rest between movements, they can cause stress and irritation.

• The members of today’s work force don’t often get up to sharpen a pencil, fax documents or walk to the post office to deliver a package. The easy and convenient access of working tools promotes inactivity and therefore a rise in repetitive stress injuries associated with desk and computer work. Simple, everyday movements—like habitually holding a telephone between the ear and shoulder—can trigger upper trapezius pain.

Upper Trapezius Strain• It is easy to understand how the upper trapezius could be in a state

of active insufficiency in certain situations; for example, when the shoulder is elevated and the neck is extended, side-bent and rotated, as when you are cradling a phone between your ear and shoulder.

• Shrugging the shoulders and overhead movements also fatigue trapezius.

• Throughout the day, the upper trapezius might be actively insufficient, while, alternatively, the rhomboids might be passively insufficient (when the shoulders are rounded).

• Developing better posture and moving out of these positions intermittently throughout the workday will place the muscles back at their optimal length.

Trapezius Exercises at the OfficeSitting with upright posture, perform 15–20 reps an hour of the following upper trapezius exercises.1. Scapular Pinches. Roll the shoulders back, and pinch the shoulder blades together.2. Shoulder Shrugs. Raise the shoulders up toward the ears, then lower them back down.3. Neck Side-Bending. Tilt one ear toward the shoulder, and hold briefly. 4. Neck Rotation. Look over one shoulder, and pause briefly. 5. Neck Stretch.•In a standing or seated position, place the right hand on top of the head and let the left arm rest at the side.•Gently pull the head toward the right shoulder with the right hand.•Rotate the head down and look at the right hip. (The stretch should be felt on the left side of the neck/shoulder area.)•Repeat on the opposite side.

Elbow Pain• When the elbow joint capsule is inflamed, the

patient holds the elbow flexed at about 80 degrees.

That is the position at which the least amount of tension is present in the joint capsule and surrounding structures.

Elbow Pain

• Most elbow pain results from overuse injuries; many sports, hobbies and jobs require repetitive hand, wrist or arm movements.

• Elbow pain may occasionally be due to arthritis, but in general, your elbow joint is much less prone to wear-and-tear damage than are many other joints.

Common Causes of Elbow Pain• Fractures, ligament sprains and muscle and tendon tears• Dislocation; usually caused by a fall. Children may dislocate the head of the radius from

being pulled by the arm (nursemaid’s elbow).• Tennis elbow (lateral epicondylitis) from forceful extension of wrist; wrist extension is

painful. Diagnose by resisting extension of third finger, creating pain in lateral epicondyle.• Golfer's elbow (medial epicondylitis) from repeatedly flexing wrists or clenching fingers• Cubital tunnel syndrome, ulnar nerve on the inside of the elbow is irritated or injured• Little league elbow syndrome (pitcher's elbow) — an injury mainly affecting children and

rapidly growing adolescents involved in throwing sports such as baseball• Olecranon bursitis — inflammation of a small sac of fluid (olecranon bursa) on the tip of your

elbow• Osteochondritis dissecans - Caused by reduced blood

flow to the end of a bone, occurs most often in young men, particularly after an injury to a joint.

• Radial tunnel syndrome, which occurs when the radial nerve becomes compressed just beyond the elbow (sometimes called resistant tennis elbow)

Nursemaid’s Elbow

Treatment of Elbow and Wrist Pain

• Splinting• Forearm support bands• Taping• Ultrasound• Manipulation• Exercise• Oral anti-inflammatory medicines• Cortisone injections

Extensor Retinaculum

Patient Case

• George has been a computer programmer for 20 years. He has numbness in his right hand on the thumb, index finger, and middle finger.

• Tapping on the carpal tunnel causes parathesias (tingling) in the median nerve distribution (positive Tinel’s sign).

• Placing his wrist in sustained flexion for one minute also causes the parathesias (positive Phalen’s test).

Patient Case• Treatment began with splinting the wrist in

neutral position and patient education for proper ergonomics (use a wrist pad while typing).

Anti-Deformity Positioning• After trauma to the hand, a custom-fabricated splint is

provided for support and protection during healing.• Because the collateral ligaments of the MP joints are slack

with extension, immobilization in MP extension would place the collateral ligaments at risk for adaptive shortening, limiting joint flexion, which impairs grasp.

• A splint should place the MP joints in flexion. The IP joints should be held in extension to reduce the risk of flexion contractures. The thumb should be placed in slight abduction to prevent contracture.

Ulnar Nerve Damage:Cubital Tunnel Syndrome

When the medial epicondyle is struck while the elbow is flexed, the ulnar nerve can be damaged.The extensor digitorum muscle alone can extend the IP joints of the two small fingers if full MPJ extension is prevented. The splint is shaped so the flexor digitorum longus can still flex.

Wartenberg’s Sign

• Ulnar nerve damage can cause claw hand because the flexors become weak, giving the extensors a mechanical advantage, pulling the two little fingers into a claw.

• The little finger may also assume an MPJ abduction position, called Wartenberg’s sign.

Trigger Finger

• Trigger finger is one example of the disability that can be created when repetitive trauma to a flexor tendon results in the formation of nodules on the tendon. Finger flexion may be prevented completely, or the finger may be unable to re-extend.

Pistol Grip

Power Grip

Precision Handling

Cylindrical Grip

Spherical Grip Hook Grip

Lateral prehension

Tapered shape

Carpal Fractures

• Upper extremity fractures are among the most common of the extremity injuries with carpal fractures accounting for 18% of hand fractures and 6 percent of all fractures.

• Of these, fractures to bones of the proximal row are most frequent.

• Fractures of the pisiform bone occur less often than fractures of the scaphoid, lunate, or triquetrum (triangular).

• Pisiform fractures account for 1-3% of all carpal bone osseous injuries

Pisiform Fracture• Most commonly the pisiform is injured in a fall on the outstretched hand with the

wrist in extension or if the heel of the hand is used like a hammer. • When the wrist is in this position, the flexor carpi ulnaris tendon compresses the

pisiform to the triquetrum. • These mechanisms can create an avulsion fracture of the distal aspect of the

pisiform, a linear fracture, or a chondral injury to its dorsal surface. The bone may need to be removed surgically.

Being an anchor for several ligamentous attachments, and the origin of the abductor digiti minimi, there is a 50% chance of an associated injury to the distal radius or to another carpal bone when a fracture of the pisiform is identified.

Scaphoid Fracture• Scaphoid fractures are among the most common injuries. • They frequently occur following a fall onto an outstretched

hand. • X-rays taken soon after the injury may not reveal a fracture,

but the clinician should assume one is present until definitive proof otherwise is obtained.

Of all carpal fractures, scaphoid fractures are by far the most common, accounting for 10% of all hand fractures and 60-70% of all carpal fractures.

Anatomical Snuffbox• The anatomical snuffbox is a triangular

deepening on the radial, dorsal aspect of the hand—at the level of the carpal bones, specifically, the scaphoid and trapezium bones forming the floor.

The name originates from the use of this surface for placing and then sniffing powdered tobacco, or “snuff.”

Anatomical Snuffbox• The radius and scaphoid articulate deep to the snuffbox to form the basis

of the wrist joint. In the event of a fall onto an outstretched hand, this is the area through which the brunt of the force will focus.

• This results in these two bones being the most often fractured of the wrist. In a case where there is localized tenderness within the snuffbox, the fracture is likely to be of the scaphoid.

• The scaphoid is a small, oddly shaped bone whose purpose is to facilitate mobility rather than confer stability to the wrist joint.

• In the event of inordinate application of force over the wrist, this small scaphoid is clearly likely to be the weak link.

• Interestingly, scaphoid fracture is one of the most frequent causes of medico-legal issues.

Anatomical Snuffbox

• An interesting anatomical anomaly in the vascular supply to the scaphoid is the area to which the blood supply is first delivered.

• Blood enters the scaphoid distally. Consequently, in the event of a fracture the proximal segment of the scaphoid will be devoid of a vascular supply, and will—if action is not taken—avascularly necrose within a sufferer's snuffbox.

• Due to the small size of the scaphoid and its shape, it is difficult to determine, early on, whether or not the scaphoid is indeed fractured with an x-ray.

shoulder, elbow, and wrist for the lecture final exam

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