SHOULDER

Dr. Paolo M. Ramirez

Introduction
• Diarthrodial
• Multiaxial
• Freedom of motion is at expense of
stability
• Static and Dynamic stabilizers
Anatomy
Bones
• Scapula
• Clavicle
• Proximal Humerus
Scapula
• 2nd to 7th ribs
• Attachement for 17 muscles
• Anteverted 30˚ relative to body
• Glenoid is retroverted 5˚ relative
to scapular body
• Scapular spine
• Acromion
• Coracoid
• Suprascapular notch
Clavicle
• Strut for lateral movement of the
arm
• Double curvature – Sternal-
ventral & Acromial-dorsal
• Attachment for muscles:
Deltoids, SCM, Pectoralis Major,
Trapezius, Subclavius
Humerus
• Humeral head: retroverted 30˚
relative to transepicondylar axis
of the humerus
• Head height is 5.6cm above
superior border of the pectoralis
major tendon
• Greater and Lesser Tuberosity
• Bicipital Groove
Surgical And Anatomical Neck
• Surgical Neck - constriction
below the tubercles of the
greater tubercle and lesser
tubercle
• Anatomic Neck – Blood
supply to main head
fragment is usually disrupted
after anatomical neck
fracture (AO foundation)
Humeral Head Blood Supply
Landmarks
Shoulder AP
Joints
• Glenohumeral Joint
• Acromioclavicular Joint
• Sternoclavicular Joint
• Scapulothoracic Joint
Glenohumeral Joint
• Ball and Socket Joint
• Greatest range of motion in the body
• Static Restraints: Articular anatomy,
glenoid labrum, ligaments, capsule,
negative intraarticular pressure
• Dynamic Restraints: Rotator Cuff and
biceps tendon
Sternoclavicular Joint
• Double gliding with an articular
disc
• Only true joint connecting upper
extremity with axial skeleton
• Posterior sternoclavicular
ligament
• Rotates 30˚ with shoulder motion
 Acromioclavicular Joint
• Plane/gliding joint
• Acromioclavicular ligament –
Horizontal stability
• Coracoclavicular ligament – Vertical
stability (Trapezoid & Conoid)
• Majority of motion is from the
bones, not through the joint
clavicle rotates 40-50° posteriorly
with shoulder elevation
8° of rotation through AC joint
Scapulothoracic Joint
• Not a true joint
• Scapular movement against posterior rib cage
• Positions the glenoid for glenohumeral motion
Muscles*
• Extrinsic – control movement of the scapula
Rhomboids, levator scapulae, trapezius, and serratus
anterior
• Intrinsic – control the glenohumeral joint
Rotator cuff muscles (SITS), deltoids, pectoralis major,
teres major, latissimus dorsi, biceps brachii
Trapezius
• O: Medial third of superior nuchal line;
occipital protruberance, C7 - T12
vertebrae
• I: Lateral third of clavicle, acromion,
and spine of scapula
• A: Elevates, retracts and rotates
scapula;
• N: Spinal Root of Accessory nerve (CN
XI)
• BS: Transverse Cervical Artery
Serratus Anterior
• O: Superolateral surfaces of upper 8th or
9th ribs
• I: Vertebral border of scapula
• A: Draws scapula forward and upward;
protracts scapula and rotates it; stabilizes
vertebral border of scapula
• N: Long thoracic nerve (C5, C6, C7)
• BS: Circumflex scapular artery
Scapular Winging
• Medial Scapular Winging • Lateral Scapular Winging
Levator Scapulae
• O: Posterior tubercles of transverse
processes of C1 - C4 vertebrae
• I: Superior part of medial border of
scapula
• A: Elevates scapula and tilts its
glenoid cavity inferiorly by rotating
scapula
• I: Dorsal scapula (C5) and cervical
(C3 and C4) nerves (C3, C4, C5)
• BS: Dorsal scapular artery
Rhomboid Major and Minor
• O: m: nuchal ligament and spinous
processes of C7 and T1 vertebrae; M:
spinous processes of T2 - T5 vertebrae
• I: Medial border of scapula from level
of spine to inferior angle
• A: Retract scapula and rotate it to
depress glenoid cavity; fix scapula to
thoracic wall
• N: Dorsal scapular nerve
• BS: Dorsal scapular artery
Rotator Cuff Muscles
• Supraspinatus
• Infraspinatus
• Subscaluparis
• Teres Minor
Supraspinatus
O: Supraspinous fossa of scapula
I: Superior facet on greater tuberosity
of humerus
A: Abducts and externally rotates,
shoulder stabilizer
N: Suprascapular nerve
BS: Suprascapular artery
Infraspinatus
• O: Infraspinous fossa of scapula
• I: Middle facet on greater
tuberosity
• A: Externally Rotates, shoulder
stabilizer
• N: Suprascapular nerve
• BS: Suprascapular and circumflex
scapular arteries
Teres minor
• O: Superior part of lateral border
of scapula
• I: Inferior facet on greater
tuberosity of humerus
• A: Externally Rotates, stability
• N: Axillary nerve
• BS: Subscapular and circumflex
scapular arteries
Subscapularis
• O: Subscapular fossa of scapula
• I: Lesser tuberosity of humerus
• A: Internally Rotates
• N: Upper and lower subscapular
nerves
• BS: Subscapular artery
 MUSCLE ORIGIN INSERTION ACTION NERVE
Supraspinatus Scapula Greater Suprascapular N.
(Supraspinous fossa) Tuberosity
ER

Infraspinatus Scapula Greater Suprascapular N.

(Infraspinous fossa) Tuberosity
ER

Teres Minor Scapula Greater Axillary N.

(Lateral border) Tuberosity
ER

Subscapularis Scapula LESSER Tuberosity Subscapular N.

(Subscapular fossa) IR
Teres Major
• O: Dorsal surface of inferior angle
of scapula
• I: Medial lip of intertubercular
groove of humerus
• A: Adducts and medially rotates
arm
• N: Lower subscapular nerve
• BS: Subscapular and circumflex
scapular arteries
 Deltoid
• O: Lateral third of clavicle,
acromion, and spine of scapula
• I: Deltoid tuberosity of humerus
• A: Anterior part: flexes and
medially rotates arm; Middle part:
abducts arm; Posterior part:
extends and laterally rotates arm
• N: Axillary nerve
• BS: Deltoid branch of
thoracoacromial artery
 Pectoralis Major
• O: Clavicular head: anterior surface of
medial half of clavicle; Sternocostal
head: anterior surface of sternum,
superior six costal cartilages, and
aponeurosis of external oblique
muscle
• I: Lateral lip of intertubercular groove
of humerus
• A: Adducts and medially rotates
humerus; protracts scapula
• N: Lateral and medial pectoral nerves
• BS: pectoral branch of the
thoracoacromial trunk
 Pectoralis minor
• O: 3rd to 5th ribs near their costal
cartilages
• I: Medial border and superior
surface of coracoid process of
scapula
• A: Stabilizes scapula by drawing it
inferiorly and protracts
• N: Medial pectoral nerves
• BS: Pectoral branch of the
thoracoacromial trunk
Spaces
• Quadrangular Space
• Triangular Space
• Triangular Interval
Physical Examination
Inspection
• Symmetry of shoulders
• Atrophy
• Rhythm of shoulder movement
• Discolorations
• Scars
• Clavicular contour
• Shoulder contour
• Scapula
Range of Motion
• Flexion: 0-180˚
• Extension: 0-45˚
• Abduction: 0-180˚
• Adduction: 0-45˚
• External Rotation: 0-45˚
• Internal Rotation: 0-55˚
Palpation
Special Tests
References
• Hettrich CM1, Boraiah S, et al. (2010). Quantitative assessment of the
vascularity of the proximal part of the humerus.
https://www.ncbi.nlm.nih.gov/pubmed/20360519
• https://www2.aofoundation.org/wps/portal/surgerypopup?contentU
rl=/srg/popup/further_reading/PFxM2/11/621_2_surg_anat.jsp