Cont…

The lateral third of the clavicle has 2 surfaces

and 2 borders – upper surface with
attachments of deltoid anteriorly and trapezius
posteriorly.
The under surface has 2 ridges named after the
attachments of conoid and trapezoid ligaments;
anterior border (deltoid attachment) and
posterior border (trapezius attachment).
The medial two-thirds of the clavicle has 3
surfaces and 3 borders – anterior surface is
continuous with the superior surface of the
flattened portion.
It is smooth, convex, and nearly subcutaneous, being
covered only by the platysma.
 Pectoralis major and sternocleidomastoid is
attached medially.
 The posterior or cervical surface is smooth,
and looks backward toward the root of the neck.
It gives attachment near the sternal extremity, to
part of the sternohyoid.
Nutrient artery foramen is present on this surface.
 The inferior or subclavian surface is narrowed
medially, but gradually increases in width laterally,
and is continuous with the under surface of the flat
portion
On its medial part is the attachment of the costoclavicular
ligament.
The rest of this surface is occupied by a groove, which
gives attachment to the subclavius;
 The anterior border provides attachments of the
pectoralis major.
The superior border provides attachment to
sternocleidomastoid.
 The posterior or subclavian border gives
attachment to a layer of cervical fascia which envelops
the omohyoid.
The Acromial End is small, flattened, oval
surface directed obliquely downward, for articulation
with the acromion of the scapula.
• The circumference of the articular facet is rough for
the attachment of the acromioclavicular ligaments.
The scapula and clavicle are bound securely by both
the acromioclavicular and coracoclavicular (conoid &
trapezoid) ligaments
 Clavicle

Clavicle has a double curve, the convexity being

directed forward at the sternal end and the concavity
at the scapular end.
It articulates medially with the manubrium sterni,
and laterally with the acromion of the scapula.
 Its lateral third is flattened from above downward,
while its medial two-thirds is rounded to prismatic
form.
The clavicle provides skeletal protection for adjacent
neurovascular structures and the superior aspect of
the lung.
The subclavian artery and vein and the brachial
plexus pass from a posterosuperior to anteroinferior
direction, between the first rib and the clavicle at the
junction of its medial and middle thirds and are thus
vulnerable during surgery and instrumentation
Fracture of clavicle
 The weakest part is at thejunction of its middle
and lateral thirds
 After fracture
􀀹 Sternocleidomastoid muscle elevates the
medial fragment of bone
􀀹 trapezius muscle is unable to hold up the
lateral fragment owing to the weight of the
upper limb
􀀹 results the shoulder drops
Function
The clavicle provides attachment to various muscles
of the shoulder girdle.
It connects the axial skeleton (thorax) to the
appendicular skeleton (shoulder girdle and arm)
thus provides a stable linkage of the arm–trunk
mechanism and contributes significantly to the
power and stability of the arm and shoulder girdle,
especially in movement above shoulder level.
 Scapula

is a flat, triangular bone bounded by the superior,

medial and lateral borders including three angles.
Two of them, the lateral angle is a three-dimensional
structure formed by the scapular neck and the
glenoid fossa.
On the posterior surface of the scapula, the
scapular body and neck are separated by the
spinoglenoid notch.
The coracoid process curves forward from the
anterosuperior surface of the scapular neck, with its
base separated from the glenoid fossa by a variably
defined coracoglenoidal notch.
The pear-shaped glenoid surface is augmented by a
robust fibrous ring, the glenoid labrum.
The posterior surface is divided by a prominent
triangular plate of bone, the scapular spine, into the
smaller supraspinous fossa and the greater
infraspinous fossa.
Gradually the scapular spine becomes more elevated
lateralward and ends in a flattened bony process
curving forward, the acromion.
The border between the scapular spine
acromial angle.
circle can be drawn in the inferior two
thirds of the articular surface, which defines the
circular area, the part of the glenoid exposed to
the highest load.
The anterior, concave surface of the scapula forms
the subscapular fossa.
Internal Architecture Distribution of bony
mass of the scapula is highly uneven (Fig. 4.1).
When held up to the light, the scapula shows its
highest concentration in the glenoid, the scapular
neck, including the base of the coracoid process, and
the lateral border of the scapular spine
Extending from the glenoid are two bony pillars that
transmit compression forces from the glenoid fossa
to the scapular body.
 The lateral pillar is identical with the lateral border
of the scapular body, which connects the inferior
border of the glenoid with the inferior angle.
From the posterior view it is evident that the two
pillars connected by a markedly thinner
medial border of the scapular body are its basic
load-bearing structure.
This triangle constitutes the biomechanical body of the
scapula, as the superior angle and the superior border
of the scapular body form merely an appendage, which
serves as a surface of insertion or origin of muscles,
but is not involved in transmission of compression
forces from the glenoid.
Therefore, it is necessary to distinguish between the
anatomical and biomechanical bodies of the scapula
The weakened area can be found primarily in the
central parts of the supra- and infraspinous fossae,
with the bone only several millimetres thick.
The weakest area of the circumference of the
biomechanical body of the scapula is the spinomedial
angle, which is confirmed by the fact that in the
majority of scapular body fractures one of the main
fracture lines passes through this region
Another area of weak bone is in the central part of the
scapular spine and is bound by its medial and lateral
columns
Muscles In total, 18 muscles are attached to the
scapula.
Only three of them, namely the subscapularis,
the supraspinatus and the infraspinatus,
that are part of the rotator cuff, originate from the
broad surface of the scapula in their respective
fossae..
Other muscles reinforce with their attachments
individual borders and angles of the scapula or its
processes.
 The muscles of the scapula may be divided into two
systems
The muscles of the scapula may be divided into two
systems.
The first, the scapuloaxial system connects the
scapula with the axial skeleton, particularly the
vertebral column and the chest wall.
 This system stabilizes the position of the scapula
relative to the spine and controls movement of the
scapula over the chest wall
The second, the scapulobrachial system is formed
by the muscles originating from the scapula and
attaching to the bones of arm, i.e. the humerus,
proximal radius and proximal ulna.
 Its task is to control movements between the
scapula
and the humeral head, i.e. to control the glenohumeral
joint.
Nerves and Blood Vessels
The most significant
of all the nerves and blood vessels in the region of
the scapula are two structures. The suprascapular
nerve passing under, but often also above the
superior
transverse scapular ligament continues across
the supraspinous fossa together with the artery and
vein of the same name.
This neurovascular bundle travels below the inferior
transverse scapular ligament (spinoglenoid
ligament) to enter the spinoglenoid notch on the
posterior surface of the scapular neck.
The suprascapular nerve gradually sends
motor branches to the supraspinatus, and to the
infraspinatus. The terminal part of the
suprascapular
artery anastomoses in the spinoglenoid notch
with one of the branches of the circumflex scapular
artery.
This branch, occasionally double, curves around the
lateral border of the scapula, leaving an impression
here, the sulcus circumflexus, when passing through
the teres minor mostly 3 cm distal to the inferior
pole of the glenoid fossa.
Anterior Axioappendicular Muscles
Four anterior axioappendicular
(thoracoappendicular or pectoral) muscles move the
pectoral girdle: pectoralis major, pectoralis minor,
subclavius, and serratus anterior (Fig. 6.10).
 The attachments, nerve supply, and main actions of
these muscles are summarized in Table 6.1.
 FASCIA…

Cont…
􀂾 Beneath the skin various structures are held
together by a
connective tissue called Fascia.
􀂾 Fascia consists of a dense collagenous CT
sheath covering
􀀹 a single muscle ,
􀀹 group of muscles ,
􀀹 an organ ,
􀀹 a body part , or the body as a whole.
The posterior axioappendicular muscles (superficial
and intermediate groups of extrinsic back muscles)
attach the superior P.419
appendicular skeleton (of the upper limb) to the
axial skeleton (in the trunk)
. The intrinsic back muscles, which maintain posture
and control movements of the vertebral column, are
described in Chapter 4.
The posterior shoulder muscles are divided into
three groups
Superficial posterior axioappendicular (extrinsic
shoulder) muscles: trapezius and latissimus dorsi.
Deep posterior axioappendicular (extrinsic shoulder)
muscles: levator scapulae and rhomboids.
Scapulohumeral (intrinsic shoulder) muscles:
deltoid, teres major, and the four rotator cuff
muscles (supraspinatus, infraspinatus, teres minor,
and subscapularis).
The pectoral fascia leaves the lateral border
of the pectoralis major and becomes the axillary
fascia,
which forms the fl oor of the axilla (compartment deep
to armpit).
Deep to the pectoral fascia and pectoralis major, another
fascial layer, the clavipectoral fascia, descends from
the clavicle, enclosing the subclavius and then pectoralis
minor, becoming continuous inferiorly with the axillary
fascia.
The part of the clavipectoral fascia between the
pectoralis
minor and subclavius, the costocoracoid
membrane, is pierced by the lateral pectoral nerve,
which primarily supplies the pectoralis major.
 The part of the clavipectoral fascia inferior to the
pectoralis minor, the suspensory ligament of the
axilla, supports the axillary fascia, and pulls
it and the overlying skin upward during abduction
of the arm, forming the axillary fossa (armpit).
scapulohumeral muscles that cover the scapula, and
form the bulk of the shoulder, are also ensheathed by deep
fascia.
The deltoid fascia descends over the superfi cial
surface of the deltoid from the clavicle, acromion, and
scapular spine.
From the deep surface of the deltoid fascia, numerous septa
penetrate between the fascicles (bundles) of the muscle.
 Inferiorly, the deltoid fascia is continuous with the
pectoral fascia anteriorly, and the dense infraspinous fascia
posteriorly.
The muscles that cover the anterior and posterior
surfaces of the scapula are covered superfi cially with
deep fascia, which is attached to the margins of the
scapula and posteriorly to the spine of the scapula.
This arrangement creates osseofi brous subscapular,
supra spinous, and infraspinous compartments; the
muscles
The supraspinous and infraspinous fascia
overlying the supraspinatus and infraspinatus
muscles, respectively, on the posterior aspect of the
scapula are so dense and opaque that they must be
removed during dissection to view the muscles.
The brachial fascia, a sheath of deep fascia,
encloses the arm like a snug sleeve deep to the skin
and subcutaneous tissue
 It is continuous superiorly with the deltoid, pectoral,
axillary, and infraspinous fascias.
Pectoralis major
• is a large and fan-shaped
• Covers superior part of thorax
• has clavicular and sternal
attachments
• Origin
􀀹 C.H: medial half of clavicle
􀀹 SC.H: sternum, superior six
costal cartilages
• Insertion
􀀹 lateral lip of Intertubercular
groove of humerus
• Innervation
􀀹 Lateral and medial pectoral
nerves
􀂃 Action
􀀹Adducts and medially rotates
humerus;
Superficial Muscles
1) Trapezius
• Attach pectoral girdle to
cranium and vertebral column
• Covers posterior part of neck
and superior half of trunk
• Fibers are divided into 3 parts
􀀹 Superior (descending) part
􀀹 Middle part
􀀹 Inferior ( ascending) part
􀂙Innervation: Accessory
nerve (CN XI) (motor fibers)
and C3, C4 spinal nerves (pain
and proprioceptive fibers)
Deep Muscles
1. Levator scapulae
• Lies deep to(sternocleidomastoid) and trapezius muscles
• Innervation: Dorsal scapular (C5) and cervical (C3, C4)
nerves
2. Rhomboids (major and minor)
• Are rhomboid appearance that form parallel bands that
pass inferolaterally from vertebrae to medial border of
the scapula
• Innervation: Dorsal scapular nerve (C5)
 Scapulohumeral Muscles (Intrinsic Shoulder)

Are short muscles that pass from scapula to

humerus and
they act on glenohumeral joint
FIGURE 6.33. Disposition of rotator cuff muscles.
A. Coming from
opposite sides and three separate fossae on the scapulae, the four
rotator
cuff (SITS) muscles pass laterally to engulf the head of the humerus.
 B. The primary combined function of the four SITS muscles is to
“grasp” and pull the relatively large head of the humerus medially,
holding it against the smaller, shallow glenoid cavity of the scapula.
The tendons of the muscles (represented by three fi ngers and the
thumb) blend with the fi brous layer of
the capsule of the shoulder joint to form a musculotendinous rotator
cuff, which reinforces the capsule on three sides (anteriorly,
superiorly, and posteriorly) as it provides active support for the joint.
 artery

Cont…
1.Superior thoracic artery
􀀹 it supplies upper part of the pectoral region.
􀀹 It forms anastomosis with the intercostal and the internal
thoracic arteries.
2. Thoracoacromial artery gives rise -4-branches.
􀀹 Clavicular branch,
􀀹 Acromial branch
􀀹 Deltoid branch
􀀹 Pectoral branch
3. Lateral thoracic artery
􀀹 descends to the lateral thoracic wall along the lateral
border of the pectoralis minor muscle.
Movement of the pectoral girdle involves the
sternoclavicular, acromioclavicular, and
glenohumeral joints, usually all moving
simultaneously (Fig. 6.29). Functional defects in any
of these joints impair movements of the pectoral
girdle. Mobility of the scapula is essential for the
freedom of movement of the upper limb. When
testing the range of motion of the pectoral girdle,
both scapulothoracic (movement of the scapula on
the thoracic wall) and glenohumeral movements
must be considered.
 Sternoclavicular Joint

This sternoclavicular (SC) joint is a synovial articulation

between the sternal end of the clavicle and the
manubrium of the sternum and the 1st costal cartilage.
The SC joint is a saddle type of joint but functions as a
ball and socket joint (Fig. 6.29).
 The SC joint is divided into two compartments by an
articular disc.
The disc is firmly attached to the anterior and posterior
SC ligaments, thickenings of the fibrous layer of the joint
capsule, as well as to the interclavicular ligament
Although the initial 30° 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 scapulothoracic joint.
This is known as scapulohumeral rhythm.
The important movements of the pectoral girdle are
scapular movements: elevation and depression,
protraction (lateral or forward movement of the
scapula), and retraction (medial or backward
movement of the scapula) and rotation of the scapula.
The SC joint is supplied by internal thoracic and
suprascapular arteries (Table 6.4).
 Branches of the medial supraclavicular nerve and
the nerve to the subclavius supply the SC joint
Acromioclavicular Joint
The acromioclavicular (AC) joint is a plane synovial
articulation (Fig. 6.30).
It is located 2–3 cm from the “point” of the
shoulder formed by the lateral part of the acromion
of the scapula.
The acromial end of the clavicle articulates with the
acromion
The AC ligament, a fibrous band extending from the
acromion to the clavicle, strengthens the AC joint
superiorly (Fig. 6.32C & D).
Most of its strength comes from coracoclavicular
ligament.
 It maintains its integrity and prevents the acromion
from being driven under the clavicle even when the
AC joint is separated.
The strong, extra-articular coracoclavicular ligament
(subdivided into conoid and trapezoid ligaments) is
located several centimeters from the AC joint, which
anchors the clavicle to the coracoid process of the
scapula
The apex of the vertical conoid ligament is attached
to the root of the coracoid process.
Its wide attachment (base) is to the conoid tubercle
on the inferior surface of the clavicle.
The nearly horizontal trapezoid ligament is attached
to the superior surface of the coracoid process and
extends laterally and posteriorly to the trapezoid line
on the inferior surface of the clavicle
The AC joint is supplied by the suprascapular and
thoracoacromial arteries (Table 6.4).
Supraclavicular, lateral pectoral, and axillary nerves
supply the joint

Glenohumeral Joint
The glenohumeral (shoulder) joint is a ball and
socket, synovial joint that permits a wide range of
movement; however, its mobility makes the joint
relatively unstable
Articulation and Joint Capsule of the Glenohumeral Joint
The large humeral head articulates with the relatively
shallow glenoid cavity of the scapula, which is deepened
slightly by the ring-like, fibrocartilaginous glenoid
labrum (L. lip).
Both articular surfaces are covered with hyaline cartilage.
The glenoid cavity accepts little more than a third of the
humeral head, which is held in the cavity by the tonus of
the musculotendinous rotator cuff (supraspinatus,
infraspinatus, teres minor, and subscapularis).
Ligaments of Glenohumeral Joint
The glenohumeral ligaments, evident only on the
internal aspect of the capsule, strengthen the
anterior aspect of the capsule.
The coracohumeral ligament, a strong band that
passes from the base of the coracoid process to the
anterior aspect of the greater tubercle, strengthens
the capsule superiorly (Fig. 6.32C & D).
The glenohumeral ligaments are intrinsic ligaments
that are part of the fibrous layer of the capsule
The transverse humeral ligament is a broad fibrous
band that runs from the greater to the lesser
tubercle, bridging over the intertubercular groove
and converting the groove into a canal for the tendon
of the long head of biceps brachii and its synovial
sheath
The coracoacromial arch is an extrinsic, protective
structure formed by the smooth inferior aspect of the
acromion and coracoid process of the scapula, with
the coracoacromial ligament spanning between them
The coracoacromial arch overlies the head of the
humerus, preventing its superior displacement from
the glenoid cavity.
Movements of the Glenohumeral Joint
The glenohumeral joint has more freedom of
movement than any other joint in the body. This
freedom results from the laxity of its joint capsule and
the large size of the humeral head compared with the
small size of the glenoid cavity. The glenohumeral joint
allows movements around the three axes and permits
flexion–extension, abduction– adduction, rotation
(medial and lateral) of the humerus, and
circumduction. Table 6.13 lists structures that limit
movements of the glenohumeral joint.
Lateral rotation of the humerus increases the range
of abduction. When the arm is abducted without
rotation, the greater tubercle contacts the
coracoacromial arch, preventing further abduction.
If the arm is then laterally rotated 180°, the
tubercles are rotated posteriorly and more articular
surface becomes available to continue elevation.
Stiffening or fixation of the joints of the pectoral girdle
(ankylosis) results in a much more restricted range of
movement, even if the glenohumeral joint is normal.
The muscles moving the joint are the axioappendicular
muscles, which may act indirectly on the joint (i.e., act
on the pectoral girdle), and the scapulohumeral
muscles, which act directly on the joint (Tables 6.1,6.2
and 6.3). Other muscles serve the glenohumeral joint
as shunt muscles, acting to resist dislocation without
producing movement at the joint, or maintain the head
of the humerus in the glenoid cavity.
Blood Supply and Innervation of the Glenohumeral
Joint
The glenohumeral joint is supplied by the anterior
and posterior circumflex humeral arteries and
branches of the suprascapular artery (Table 6.4).
The suprascapular, axillary, and lateral pectoral
nerves supply the glenohumeral joint.
Bursae around the Glenohumeral Joint
Several bursae containing capillary films of synovial
fluid are located near the joint where tendons rub
against bone, ligaments, or other tendons and where
skin moves over a bony prominence. Some bursae
communicate with the joint cavity; hence, opening a
bursa may mean entering the cavity of the joint.
The subacromial bursa, sometimes referred to as the
subdeltoid bursa (Fig. 6.32C), is located between the
acromion, coracoacromial ligament and deltoid
superiorly and the supraspinatus tendon and joint
capsule of the glenohumeral joint inferiorly.
Thus it facilitates movement of the supraspinatus
tendon under the coracoacromial arch and of the
deltoid over the joint capsule and the greater
tubercle of the humerus.
The subscapular bursa is located between the tendon
of the subscapularis and the neck of the scapula.
This bursa protects the tendon where it passes
inferior to the root of the coracoid process and over
the neck of the scapula
. It usually communicates with the cavity of the
glenohumeral joint through an opening in the
fibrous layer of the joint capsule.
Physical Examination of the Shoulder

INSPECTION ;
undress so that both shoulders can be examined and
compared
The patient should be examined from the front and
the back
muscle bulk and scapular positioning can be easily
observed.
Posture should be observed in both the seated and
standing positions and from different angles.
Scars,
Shoulder heights, and scapular positioning should
be evaluated.
 Posture in the standing and seated positions should
be observed for a forward set, protracted head, and
rounded shoulders (humeral internal rotation and
scapular protraction), which will cause functional
narrowing of the subacromial space.
Scapular winging may be seen and can be
accentuated by muscle activation
Look…
Deltoid.infraspin,supra,ACJ …..best seen from
behind
 do not forget the axilla
swelling of the acromioclavicular or sternoclavicular
joint or wasting of the pectoral muscles is more
obvious from the front.
A joint effusion causes swelling anteriorly and
occasionally ‘points’ in the axilla.
 Wasting of the deltoid suggests a nerve lesion
whereas wasting of the supraspinatus may be due to
either a full-thickness tear or a suprascapular nerve
lesion.
 feel

With the shoulder held in extension, the

supraspinatus tendon can be pinpointed just under
the anterior edge of the acromion
Crepitus over the supraspinatus tendon during
movement suggests tendinitis or a tear.
 Feel

Bony points and soft tissues

Start with the sternoclavicular joint, then follow the
clavicle laterally to the acromioclavicular joint, and
so onto the anterior edge of the acromion and
around the acromion.
The AC joint is superficial and is identified with
palpation of the clavicle and spine of the scapula
until they meet laterally.
By externally rotating the arm and flexing and
extending the elbow, the examiner may be able to
feel long head of biceps tendon moving in the
anterior shoulder.
RANGE OF MOTION TESTING
Active range of motion testing is usually performed
first to allow the patient to feel comfortable and
avoid painful positions.
 Passive motion testing can then be performed to
isolate motions for accurate evaluation.
 The active and passive range of motion of both sides
should be compared