Upper Limb

The superior appendicular skeleton articulates with the axial skeleton only at the sternoclavicular joint, allowing great mobility. The
clavicles and scapulae of the pectoral girdle are supported, stabilized, and moved by axio-appendicular muscles that attach to the
relatively fixed ribs, sternum, and vertebrae of the axial skeleton. The medial two thirds of the shaft of the clavicle are convex
anteriorly, whereas the lateral third is flattened and concave anteriorly. These curvatures increase the resilience of the clavicle, and
give it the appearance of an elongated capital S.
The clavicle: Serves as a moveable, crane-like strut (rigid support) from which the scapula and free limb are suspended, keeping them
away from the trunk so that the limb has maximum freedom of motion. The strut is movable and allows the scapula to move on the
thoracic wall at the “scapulothoracicjoint,” increasing the range of motion of the limb. Although designated as a long bone, the clavicle
has no medullary (marrow) cavity. It consists of spongy (trabecular) bone with a shell of compact bone.
The scapula (shoulder blade) is a triangular flat bone that lies on the posterolateral aspect of the thorax, overlying
the 2nd–7th ribs. concave costal surface/convex posterior surface. The glenohumeral (shoulder) joint on which
these muscles operate is almost directly inferior to the AC joint; thus the scapular mass is balanced with that of the
free limb, and the suspending structure (coracoclavicular ligament) lies between the two masses.

Coracoclavicular ligament (Conoid lig. + Trapezoid lig). By which

upper limb is passively suspended from clavicle

Costal surface Posterior surface

Four anterior axio-appendicular muscles (thoraco-appendicular or
pectoral muscles) move the pectoral girdle: pectoralis major, pectoralis
minor, subclavius, and serratus anterior.
Producing powerful adduction and medial rotation of the arm when acting
together, the two parts of the pectoralis major can also act
independently: the clavicular head flexing the humerus, and the
sternocostal head extending it back from the flexed position.
The pectoralis minor stabilizes the scapula and is used when stretching
the upper limb forward to touch an object that is just out of reach. With
the coracoid process, the pectoralis minor forms a “bridge” under which
vessels and nerves must pass to the arm.

Serratus (saw) anterior is a strong protractor of the scapula and is used when punching or reaching anteriorly (sometimes called the
“boxer’s muscle”). The strong inferior part of the serratus anterior rotates the scapula, elevating its glenoid cavity so the arm can be
raised above the shoulder.
The posterior axio-appendicular muscles (superficial
and intermediate groups of extrinsic back muscles) attach the
superior appendicular skeleton (of the upper limb) to the
axial skeleton (in the trunk). The posterior shoulder muscles
are divided into three groups: • Superficial posterior axio-
appendicular (extrinsic shoulder) muscles: 2 trapezius and
latissimus dorsi. • Deep posterior axio-appendicular (extrinsic
shoulder) muscles: 3 levator scapulae and rhomboids major
and minor. • Scapulohumeral (intrinsic shoulder) muscles: 6
deltoid, teres major, and the four rotator cuff muscles
(supraspinatus, infraspinatus, teres minor, and subscapularis).
The latissimus dorsi extends, retracts, and rotates the humerus medially (e.g., when folding your arms behind your back, or scratching
the skin over the opposite scapula). In combination with the pectoralis major, the latissimus dorsi is a powerful adductor of the
humerus, and plays a major role in downward rotation of the scapula in association with this movement. It is also useful in restoring
the upper limb from abduction superior to the shoulder; hence the latissimus dorsi is important in climbing.
levator scapulae acts with the descending part of the trapezius to elevate the scapula, or fix it (resists forces that would depress it, as
when carrying a load). With the rhomboids and pectoralis minor, the levator scapulae rotates the scapula, depressing the glenoid
cavity (tilting it inferiorly by rotating the scapula). The rhomboids retract and rotate the scapula, depressing its glenoid cavity. They
also assist the serratus anterior in holding the scapula against the thoracic wall, and fixing the scapula during movements of the upper
limb.
To initiate movement during the first 15° of abduction, deltoid is assisted by supraspinatus

Six scapulohumeral muscles

The anterior deltoid part assists the pectoralis major in flexing the arm, and the posterior part assists the latissimus dorsi in
extending the arm. The deltoid also helps stabilize the glenohumeral joint and hold the head of the humerus in the glenoid cavity
during movements of the upper limb also resisting inferior displacement of the head of the humerus from the glenoid cavity, as
when lifting and carrying suitcases. Teres Major also extend humerus from the flexed position, and is an important stabilizer of the
humeral head in the glenoid cavity— that is, it steadies the head in its socket.
ROTATOR CUFF MUSCLES; Four of the scapulohumeral muscles (intrinsic shoulder muscles) called rotator cuff muscles because they
form a musculotendinous rotator cuff around the glenohumeral joint. All except the supraspinatus are rotators of the humerus; the
supraspinatus, besides being part of the rotator cuff, initiates and assists the deltoid in the first 15° of abduction of the arm.
The tendons of the SITS muscles blend with and reinforce the fibrous layer of the joint capsule of the glenohumeral joint, thus
forming the rotator cuff that protects the joint and gives it stability. The tonic contraction of the contributing muscles holds the
relatively large head of the humerus in the small, shallow glenoid cavity of the scapula during arm movements.
The teres minor works with the infraspinatus to rotate the arm laterally and assist in its adduction. The subscapularis is the primary
medial rotator of the arm and also adducts it.
 Although the initial 30° of abduction may occur without scapular motion, in the overall movement of fully elevating the arm,
the movement occurs in a 2:1 ratio: For every 3° of elevation, approximately 2° occurs at the glenohumeral joint and 1° at the
physiological scapulothoracic joint. Hence, when the upper limb has been elevated so that the arm is vertical at the side of the
head (180° of arm abduction or flexion), 120° occurred at the glenohumeral joint and 60° occurred at the scapulothoracic
joint.
 The sternoclavicular (SC) joint is a saddle type of synovial joint but functions as a ball-and-socket joint. The sternal end of the
clavicle articulates with the manubrium and the 1st costal cartilage. The articular surfaces are covered with fibrocartilage. it
can be readily palpated because the sternal end of the clavicle lies superior to the manubrium of the sternum.
The glenohumeral (shoulder) joint is a ball-and-socket type of synovial joint that permits a wide range of movement; however, its
mobility makes the joint relatively unstable. The glenoid cavity which is deepened slightly but effectively by the ring-like,
fibrocartilaginous glenoid labrum accepts little more than a third of the humeral head, which is held in the cavity by the tonus of the
musculotendinous rotator cuff.
The loose fibrous layer of the joint capsule surrounds
the glenohumeral joint and is attached medially to the
margin of the glenoid cavity and laterally to the
anatomical neck of the humerus. The capsule of
the joint is attached to the scapula beyond the
supraglenoid tubercle and the margins of the
labrum. It is attached to the humerus around the
articular margins of the head (i.e. the anatomical
neck) except inferiorly, where its attachment is to the
surgical neck of the humerus a finger’s breadth
below the articular margin. The joint capsule has
two apertures: (1) an opening between the tubercles
of the humerus for passage of the tendon of the long
head of the biceps brachii. (2) an opening situated
anteriorly, inferior to the coracoid process that allows
communication between the subtendinous bursa of
subscapularis and the synovial cavity of the joint.
The long tendon of biceps is intracapsular and blends with the glenoid labrum at its attachment to the supraglenoid tubercle of the
scapula.
The subacromial (subdeltoid) bursa is a large bursa which lies under the coracoacromial ligament, to which its upper layer is
attached. Its lower layer is attached to the tendon of supraspinatus
The synovial membrane lines the internal surface of the fibrous layer of the capsule and reflects from it onto the glenoid labrum and the
humerus, as far as the articular margin of the head. The synovial membrane also forms a tubular sheath for the tendon of the long head of
the biceps brachii, where it lies in the intertubercular sulcus of the humerus and passes into the joint cavity. The glenohumeral ligaments
are three fibrous bands, evident only on the internal aspect of the capsule, that reinforce the anterior part of the joint capsule.
(Coracohumeral ligament=coracoid to greater tuberosity)( transverse humeral ligament and coraco-acromial arch (extrinsic,
protective structure= Coracoid process + coraco-acromial ligament+ acromion)
The tendons of subscapularis, supraspinatus, infraspinatus and teres minor fuse with the lateral part of the capsule and are
attached to the humerus very near the joint. They are known as the rotator cuff, although the supraspinatus is not a rotator of
the humerus.
The supraspinatus tendon is particularly prone to such conditions as it passes over the top of the head of the humerus to its
insertion on the greater tubercle. Impingement of the tendon under the coracoacromial arch and a critical area of diminished
vascularity about 1 cm proximal to its humeral insertion are believed to contribute to the occurrence of supraspinatus
tendinitis. The inflammatory swelling of the tendon aggravates the impingement. Pain is felt during abduction of the shoulder
as the arm traverses an arc between 60 and 120 (the ‘painful arc’) when impingement is maximal.
 Bursae: subacromial-subdeltoid and subcoracoid bursae.
 Lateral rotation of the humerus is required to bring additional articular surface into play and allow abduction
to continue. Not more than 120” of abduction is possible at the glenohumeral articulation. Further abduction,
as in bringing the arm vertical beside the head, requires scapular rotation that makes the glenoid fossa face
upwards, brought about by trapezius and serratus anterior
The deltoid atrophies when the axillary nerve (C5and C6) is severely damaged. Because it passes inferior to the
humeral head and winds around the surgical neck of the humerus, the axillary nerve is usually injured during fracture
of this part of the humerus. It may also be damaged during dislocation of the glenohumeral joint, and by compression
from the incorrect use of crutches. As the deltoid atrophies, the rounded contour of the shoulder is flattened
compared to the uninjured side. This gives the shoulder a flattened appearance and produces a slight hollow inferior
to the acromion. In addition to atrophy of the deltoid, a loss of sensation may occur over the lateral side of the
proximal part of the arm, the area supplied by the superiorlateral cutaneous nerve of the arm, the cutaneous branch
of the axillary nerve
The musculotendinous rotator cuff is commonly injured during repetitive use of the upper limb above the horizontal
(e.g., during throwing and racquet sports, swimming, and weightlifting). Recurrent inflammation of the rotator cuff,
especially the relatively avascular area of the supraspinatus tendon, is a common cause of shoulder pain and results in
tears of the musculotendinous rotator cuff. Repetitive use of the rotator cuff muscles (e.g., by baseball pitchers) may
allow the humeral head and rotator cuff to impinge on the coraco-acromial arch (Fig. 6.95B), producing irritation of
the arch and inflammation of the rotator cuff. As a result, degenerative tendonitis of the rotator cuff develops.
Attrition of the supraspinatus tendon also occurs.
Rotator cuff injuries may also occur during a sudden strain of the muscles, for example, when an older person strains
to lift something, such as a window that is stuck. This strain may rupture a previously degenerated musculotendinous
rotator cuff. A fall on the shoulder may also tear a previously degenerated rotator cuff. Often the intracapsular part of
the tendon of the long head of the biceps brachii becomes frayed (even worn away), leaving it adherent to the
intertubercular sulcus. As a result, shoulder stiffness occurs. Because they fuse, the integrity of the fi brous layer of
the joint capsule of the glenohumeral joint is usually compromised when the rotator cuff is injured. As a result, the
articular cavity communicates with the subacromial bursa. Because the supraspinatus muscle is no longer functional
with a complete tear of the rotator cuff, the person cannot initiate abduction of the upper limb.
Shoulder impingement describes a group of conditions characterised by the entrapment of musculoskeletal soft
tissue within the shoulder, which primarily results in pain. Types of shoulder impingement include;

 Subacromial impingement: most common occurs secondary to attrition (deterioration) between

the coracoacromial arch and the underlying supraspinatus tendon or subacromial bursa,
 Subcoracoid impingement: affects subscapularis
 Posterosuperior impingement: involves infraspinatus
 Anterosuperior inner impingement
Internal impingement is a common cause of shoulder pain in overhead athletes. It is commonly described as a
condition characterized by excessive or repetitive contact between the posterior aspect of the greater tuberosity of the
humeral head and the posterior-superior aspect of the glenoid border when the arm is placed in extreme ranges of
abduction and external rotation. This ultimately leads to impingement of the rotator cuff tendons
(supraspinatus/infraspinatus) and the glenoid labrum.
Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. They involve the superior glenoid
labrum, where the long head of biceps tendon inserts. They may extend into the tendon, involve the glenohumeral
ligaments or extend into other quadrants of the labrum.
Flexion The clavicular head of pectoralis major and the anterior fibres of deltoid are assisted in this movement by
coracobrachialis and the short head of biceps.

Extension Effected by latissimus dorsi, teres major and the posterior fibres of deltoid.

The sternocostal part of pectoralis major is able to extend the fully flexed arm and flex the fully extended
arm.

Adduction Gravity aids adduction of the abducted arm; pectoralis major, latissimus dorsi and teres major are powerful
adductors.

Abduction Initial 15” Supraspinatus initiates abduction, The multipennate acromial fibres of deltoid are the
principal abductors

Internal Medial subscapularis and teres major assisted by latissimus dorsi and pectoralis major
rotation
External Lateral infraspinatus and teres minor
rotation
The roots of the plexus (the anterior rami of C5–T1 nerves) are between the scalene muscles, the trunks
in the posterior triangle, the divisions behind the clavicle, and the cords arranged round the second part
of the axillary artery.
Branches of the roots;= C5 Dorsal scapular(levator scapulae and rhomboids,);
C5, 6 Nerve to subclavius; C5–7 Long thoracic. Branch of the upper truk;
Suprascapular nerve (C5, 6) for supraspinatus, infraspinatus