Anatomy Unit 5: Objectives

Scapula/Shoulder
1. Identify key bones and bony landmarks of the shoulder girdle and shoulder joint.

Bony Landmarks of Scapula

▪ Scapula: ​a triangular-shaped bone located superficially on the posterior side of the thorax; it and
the clavicle make up the shoulder girdle
▪ Superior angle: ​Superior medial aspect, providing attachment for the levator scapula muscle
▪ Inferior angle: ​Most inferior point and where the vertebral and axillary borders meet. This point
determines scapular rotation.
▪ Vertebral border: ​Between superior and inferior angles medially, and attachment of the
rhomboid and serratus anterior muscles.
▪ Axillary border: ​The lateral side between glenoid fossa and inferior angle
▪ Spine: ​Projection on posterior surface, running from medial border laterally to the acromion
process. It providse attachment for the middle and lower trapezius muscles.
▪ Coracoid process: ​Projection on anterior surface, providing attachment for the pectoralis minor
muscle
▪ Acromion process:​ Broad, flat area in superior lateral aspect, providing attachment for the upper
trapezius muscles.
▪ Glenoid fossa:​ Slightly concave surface that articulates with humerus on superior lateral side
above the axillary border and below the acromion process. The fossa is positioned in an anterior,
lateral, and upward direction.

Bony Landmarks of the Clavicle

▪ Clavicle:​ an “S” shaped bone that connects the upper extremity to the axial skeleton at the
sternoclavicular joint.
- Sternal end:​ Attaches medially to sternum
- Acromial end:​ Attaches laterally to scapula and provides attachment for the upper
trapezius muscle
- Body:​ Area between the two ends

Bony Landmarks of Sternum

▪ Sternum:​ a flat bone located in the midline of the anterior thorax.
- Manubrium:​ The superior end, providing attachment for the clavicle and the first rib.
- Body:​ The middle two-thirds of the sternum, providing attachment for the remaining
ribs.
- Xiphoid process:​ Meaning “sword shaped”, the inferior tip

Bony Landmarks of Scapula When Talking about the Shoulder Joint

▪ Glenoid Fossa​: Shallow somewhat egg-shaped socket on the superior end, lateral side; articulates
with the humerus
▪ Glenoid Labum:​ Fibrocartilaginous ring attached to the rim of the glenoid fossa, deepens the
articular cavity
▪ Subscapular Fossa:​ Most of the area on the anterior surface; provides attachment for
subscapularis muscle
 ▪ Infraspinous Process:​ Below the spine; attachment for the infraspinatus muscle
▪ Supraspinous Process:​ Above the spine; attachment for the supraspinatus muscle
▪ Axillary Border:​ ​Attachment for the teres minor and major muscles
▪ Acromion Process:​ ​ Broad, flat area on the superior lateral aspect; attachment for the middle
deltoid muscle

Humerus
▪ Head:​ Semi-rounded proximal end; articulates with scapula
▪ Surgical Neck:​ Slightly constricted area just below the tubercles where the head meets the body
▪ Anatomical Neck:​ Circumferential groove separating the head from the tubercle
▪ Shaft:​ Body; area between the surgical neck proximally and wider distal end
▪ Greater Tubercle​: Large projection lateral to head and lesser tubercle; provides attachment for
the supraspinatus, infraspinatus, and teres minor muscles
▪ Lesser Tubercle:​ Smaller projection on the anterior surface, medial to the greater tubercle;
attachment for subscapularis muscle
▪ Deltoid Tuberosity:​ Lateral side near the midpoint of the shaft
▪ Bicipital Groove:​ Intertubercular groove; groove between the tubercles, containing the tendon of
the long head of the biceps
▪ Bicipital Ridges:​ Lateral and medial lips of the bicipital groove; lateral lip provides attachment for
the pectoralis major; medial lip provides attachment for latissimus dorsi and teres major

2. Recognize the joints and primary ligaments that comprise the shoulder girdle and shoulder joint.

Shoulder Girdle
▪ Sternoclavicular Joint:​ formed by the articulation between the manubrium of the sternum. It is a
synovial joint that provides the shoulder girdle with its only direct attachment to the trunk.
Debate over whether a modified ball and socket joint, an incongruent saddle joint, or a
plane-shaped double gliding joint. However, consensus on it being a triaxial joint with three
degrees of freedom, allowing movement in three planes of motion. The three major ligaments
supporting this joint are below:
▪ Sternoclavicular ligament:​ connects the clavicle to the sternum on both the anterior and
posterior surfaces and is therefore divided into the anterior and posterior sternoclavicular
ligaments. These ligaments limit anterior-posterior motion, and the anterior sternoclavicular
ligament limit posterior motion. They both reinforce the joint capsule.
▪ Costoclavicular ligament:​ is a short, flat, rhomboid-shaped ligament that connects the clavicle’s
inferior surface to the superior surface of the costal cartilage of the first rib. The primary purpose
of this ligament is to limit the amount of clavicular elevation.
▪ Interclavicular ligament:​ is located on top of the manubrium, connecting the superior sternal
ends of the clavicles. Its purpose is to limit the amount of clavicular depression.
▪ Acromioclavicular joint (AC):​ connects the acromion process of the scapula and the lateral
(acromial) end of the clavicle. It is a plane-shaped synovial joint that allows a gliding motion to
occur, contributing toward movement in three planes of motion. Unlike the sternoclavicular joint,
which allows much clavicular motion, the AC joint allows subtle movements of the scapula. These
motions are minimal but allow continuity between the scapula and thorax during scapular
motions.
- Acromioclavicular ligaments:​ support the joint by holding the acromion process to the
clavicle, thus helping to prevent dislocation of the clavicle. Despite this reinforcement,
 the AC joint is very susceptible to injury, especially with a fall on the outstretched hand
or a blow to the outside of the shoulder.
- Coracoclavicular ligament: ​accessory ligament of the AC joint. It is not directed located
at the joint, but it does provide stability and it allows the scapula to be suspended from
the clavicle. It connects the scapula to the clavicle by attaching to the inferior surface of
the clavicle’s lateral end and to the superior surface of the scapula’s coracoid process. It
is divided into a lateral trapezoid portion and the deeper medial conoid portion.
Together they prevent backward motion of the scapula and individually the limit the
rotation of the scapula.
- Coracoacromial ligament: ​does not cross the AC joint, but rather forms a roof over the
head of the humerus and serves as a protective arch, providing support to the head
when an upward force is transmitted along the humerus and serves as a protective arch,
providing support to the head when an upward force is transmitted along the humerus.
It attaches laterally on the superior surface of the coracoid process and runs up and out
to the inferior surface of the acromion process.
▪ Scapulothoracic articulation:​ is not a joint in the pure sense of the word as there is no direct union
between the bones and there is no joint capsule. It consists of the slightly concave anterior surface
of the scapula resting on the convex posterior aspect of the rib cage. With the lack of a true joint
structure to support the scapula in its normal resting position, stability comes from an indirect link
to the trunk through the clavicle and several surrounding muscles. It provides motion necessary for
normal function of the scapula.

Shoulder Joint
▪ Joint Capsule​: Thin-walled, spacious container that attaches around the rim of the glenoid fossa
and anatomical neck; Formed by outer fibrous membrane and inner synovial membrane ;
Completely surrounds joint; creating partial vacuum
▪ Superior, middle, and inferior ​Glenohumeral Ligaments​ ​reinforce the anterior portion of the
capsule
▪ Coracohumeral Ligament:​ ​attaches from the lateral side of the coracoid process and spans the
joint anteriorly to medial side of greater tubercle. It strengthens the upper part of the joint
capsule
▪ Glenoid labrum:​ ​is a fibrous ring the surrounds the rim of the glenoid fossa. Its function is to
deepen the articular cavity
▪ Bursae: ​There are several bursae in the shoulder joint area.
- Subdeltoid bursa:​ large and located between the deltoid and joint capsule
- Subacromial bursa:​ below the acromion and coracoacromial ligament; continuous with
subdeltoid bursa
▪ Rotator Cuff:​ is the tendinous band formed by the blending together of tendinous insertions of
the subscapularis, supraspinatus, infraspinatus, and teres minor muscles. These muscles help to
keep the head of the humerus against the glenoid fossa during joint motion
▪ Thoracolumbar fascia​: ​is a superficial​ fibrous sheet that attaches to the spinous process of the
lower thoracic and lumbar vertebrae, supraspinal ligament, and posterior part of the iliac crest. It
provides a very broad attachment for latissimus dorsi muscle

3. Describe joint motions that occur at the shoulder girdle and shoulder joint. Describe the
appropriate
plane and axis of motion, as well as the normal ROM for each movement.

Scapular Motions
 ▪ Scapular elevation:​ occurs when the scapula moves superiorly
▪ Scapular depression:​ occurs when the scapula moves inferiorly
▪ Scapular protraction (scapular abduction):​ occurs when the scapula moves away from the
posterior midline
▪ Scapular retraction (scapular adduction):​ ​occurs when the scapula moves back toward the
posterior midline.
▪ Scapular upward rotation:​ ​the inferior angle of the scapula rotates up and away from the vertebral
column
▪ Scapular downward rotation: ​the return from the scapular upward rotation

Joint Motion
▪ Abduction/Adduction: ​Frontal plane, Sagittal axis; ROM: 180 degrees of motion
▪ Flexion, extension, and hyperextension: ​Sagittal plane, Frontal axis; Flexion: ROM: 0-180 degrees;
Extension: ROM: return to anatomical position; Hyperextension : ROM: about 45 degrees is
possible from anatomical position
▪ Medial and lateral rotation
Transverse plane, Vertical axis; ROM: 90 degrees in each direction
▪ Horizontal abduction and adduction:​Transverse plane, Vertical axis; 90 degrees of shoulder
abduction and 30 degrees of horizontal abduction and 120 degrees of horizontal adduction
▪ Circumduction:​ ​Term used to describe the arc or circle of motion possible at the shoulder
▪ Scaption​: Occurs in the scapular plane (approx 30 degrees forward of frontal plane); normal end
feel: firm
▪ Arthrokinematic Motion​: Convex humeral head moves within the concave glenoid fossa; convex
joint surface glides in the direction opposite to the movement of the distal end of moving bone

3. Recognize the companion motions of the shoulder girdle that must occur with shoulder joint
motion.

Shoulder Joint Shoulder Girdle

Flexion Upward rotation; protraction
Extension Downward rotation; retraction
Hyperextension Scapular tilt
Abduction Upward rotation
Adduction Downward rotation
Medial rotation Protraction
Lateral rotation Retraction
Horizontal abduction Retraction
Horizontal adduction Protraction

4. Explain the anatomical relationship between the shoulder girdle and shoulder joint.

▪ The relationship between them is logical. The shoulder girdle muscles originate on the trunk and
inset on the scapula causing either movement or stabilization of the scapula. Shoulder joing
muscles tend to originate on the scapula or trunk and insert on the humerus (or forearm in the
case of the biceps and triceps), causing movement of the shoulder joint.

5. Define scapulohumeral rhythm and the clinical significance of this concept.

 ▪ Scapulohumeral rhythm:​ a concept that further describes the movement relationship between the
shoulder girdle and the shoulder joint. The first 30 degrees of shoulder joint motion is pure
shoulder joint motion. However, after that, for every 2 degrees of shoulder flexion or abduction
that occurs, the scapula must upwardly rotate 1 degree. This 2:1 ratio is known as scapulohumeral
rhythm. It is possible to demonstrate that the first part of the shoulder joint motion occurs only at
the shoulder joint, but further motion must be accompanied by shoulder girdle motion.

7. Describe the muscle origin, insertion, action, and nerve innervation of selected muscles of the
shoulder girdle and shoulder joint.

Shoulder girdle
▪ Trapezius
Upper
O: Occipital bone, nuchal ligament on the upper cervical spinous processes
I: Outer third of clavicle, acromion process
A: Scapular elevation and upward rotation
N: Spinal accessory, C3 and C4 sensory component
Middle
O: Spinous processes of C7 through T3
I: Scapular spine
A: Scapular retraction
N: Spinal accessory, C3 and C4 sensory component
Lower
O: Spinous processes of middle and lower thoracic vertebrae
I: Base of the scapular spine
A: Scapular depression and upward rotation
N: Spinal accessory, C3 and C4 sensory component

▪ Levator scapula muscle

O: Transverse process of first 4 cervical vertebrae
I:​ ​Vertebral border of scapula between the superior angle and spine
A: Scapular elevation and downward rotation
N:​ ​Third and fourth cervical nerves and dorsal scapular nerve (C5)

▪ Rhomboid muscles
O: Spinous process of C7 through T5​
I:​ ​Vertebral border of scapula between the spine and inferior border
A: Scapular retraction, elevation, and downward rotation
N: Dorsal scapular nerve (C5)

▪ Serratus anterior muscle

O: Lateral surface of the upper 8 ribs
I: Vertebral border of the scapula, anterior surface
A: Scapular protraction and upward rotation
N: Long thoracic nerve (C5, C6, C7)

▪ Pectoralis minor muscle

O: Anterior surface, 3rd-5th ribs
 I: Coracoid process of the scapula
A: Scapular depression, protraction, downward rotation, and tilt
N: Medial pectoral nerve (C8, T1)

Shoulder Joint
▪ Anterior Deltoid Muscle
O: Lateral third of the clavicle
I: Deltoid tuberosity
A: Shoulder abduction, flexion, medial rotation, and horizontal adduction
N: Axillary Nerve (C5, C6)

▪ Middle Deltoid Muscle

O: Acromion Process
I: Deltoid tuberosity
A: Shoulder Abduction
N: Axillary Nerve (C5, C6)

▪ Posterior Deltoid Muscle

O: Spine of scapula
I: Deltoid tuberosity
A: Shoulder abduction, extension, hyperextension, lateral rotation, horizontal abduction
N: Axillary Nerve (C5, C6)

▪ Pectoralis Major Muscle, clavicular portion

O: Medial third of clavicle
I: Lateral lip of bicipital groove of humerus
A: Shoulder flexion – first 60 degrees
N: none

▪ Pectoralis Major Muscle, Sternal Portion

O: Sternum, costal cartilage of first 6 ribs
I: Lateral lip of bicipital groove of humerus
A: Shoulder extension – first 60 degrees
N: none

▪ Pectoralis Major Muscle, Clavicular and Sternal Portions

O: Medial third of clavicle, sternum, and costal cartilage of ribs 1-6
I: Lateral lip of the bicipital groove of humerus
A: Shoulder adduction, medial rotation, and horizontal adduction
N: Lateral and medial pectoral nerves (C5, C6, C7, C8, and T1)

▪ Latissimus Dorsi Muscle

O: Spinous process of T7-L5, posterior surface of sacrum, iliac crest, and lower 3 ribs
I: Medial floor of bicipital groove of humerus
A: Shoulder extension, adduction, medial rotation, hyperextension
N: Throacodorsal Nerve (C6, C7, C8)

▪ Teres Major Muscle

O: Inferior axillary border of scapula near the inferior angle
 I: Medial lip of bicipital groove on the anterior surface of the humerus
A: Shoulder extension, adduction, and medial rotation
N: Lower subscapular nerve (C5, C6, C7)

▪ Supraspinatus Muscle
O: Supraspinous fossa of scapula
I: Greater tubercle of humerus
A: Shoulder abduction
N: Subscapular Nerve (C5, C6)

▪ Infraspinatus Muscle
O: Infraspinous process of scapula
I: Greater tubercle of humerus
A: Shoulder lateral rotation, horizontal abduction
N: Suprascapular Nerve (C5, C6)

▪ Teres Minor Muscle

O: Axillary border of scapula
I: Greater tubercle of humerus
A: Shoulder lateral rotation, horizontal abduction
N: Axillary Nerve (C5, C6)

▪ Subscapularis Muscle
O: Subscapular fossa of scapula
I: Lesser tubercle of humerus
A: Shoulder medial rotation
N: Upper and Lower subscapular nerves (C5, C6)

▪ Coracobrachialis Muscle
O: Coracoid process of scapula
I: Medial surface of the humerus near the midpoint
A: Stabilizes the shoulder joint
N: Musculocutaneous Nerve (C5, C6, C7)

8. Identify the muscles that form the force couples responsible for upward and downward rotation of
the scapula of the shoulder girdle.

▪ A force couple is defined as muscles pulling in different directions to accomplish the same motion.
In the case of the shoulder girdle, the upper trapezius muscles pulls up, the lower trapezius muscle
pulls down, and the lower fibers of the serratus anterior muscle pull outward in a horizontal
direction. The net effect is that the scapula rotates upward.

9. Recognize reversal of muscle action of select shoulder girdle muscles and the clinical significance of
such action.

▪ Usually muscles move the insertion near the origin. However, if the insertion is stabilized, the origin
will move.
 10. Define common pathologies of structures around the shoulder joint. Explain the potential
occupational impact of these conditions.

Common Shoulder Girdle Pathologies

▪ Scapular tilt: ​occurs when the shoulder joint goes into hyperextension. The superior end of the
scapula tilts anteriorly and the inferior end tilts posteriorly.
▪ Scapular winging: ​the posterior lateral movement of the vertebral border of the scapula moves
away from the rib cage. This motion occurs primarily at the AC joint, but is observed most often at
the scapulothoracic articulation. This can be demonstrated by asking a person to place his or her
hand on the small of the back. The vertebral border of the scapula lifts away
▪ Acromioclavicular separation:​ Ligament injury at the AC joint. In a
- First-degree sprain​: acromioclavicular ligament is stretched.
- Second-degree sprain:​ acromioclavicular ligament is ruptured and the coracoclavicular
ligament is stretched.
- Third-degree sprain​: both the acromioclavicular and coracoclavicular ligaments are ruptured.
▪ Clavicular fractures: ​most frequently broken bone in children, usually result from a fall on the lateral
aspect of the shoulder or on the outstretched hand. It usually breaks in its midportion.

Common Shoulder Joint Pathologies

▪ Humeral neck fracture: ​injury caused by a fall on the outstretched hand, common in the
elderly and usually results in an impacted fracture.
▪ Midhumeral fracture: ​often caused by direct blow or a twisting force, spiral fractures in this
region increase risk of radial nerve injury as the nerve passes next to the bone in the spiral groove.
▪ Pathological fractures: ​of the humerus may be caused by benign tumors or metastic
carcinoma from primary sites such as the lung, breast, kidney, and prostate.
▪ Anterior shoulder dislocations: ​common joint dislocation, a forced shoulder abduction and
lateral rotation tends to be the dislocating motion to cause the humeral head to slide anteriorly out
of the glenoid fossa.
▪ Glenohumeral subluxation: ​common in people with hemiplegia, paralysis of the shoulder
leaved them no longer able to hold the head of the humerus in the glenoid fossa.
▪ Impingement syndrome:​ overuse condition that involves compression between the acromial
arch, the humeral head, and soft tissue structures (coracoacromial ligament, RTC muscles, long head
of the biceps, and subacromial bursa).
▪ Adhesive capsulitis: ​inflammation and fibrosis of the shoulder joint capsule, which leads to
pain and loss of shoulder ROM, also known as frozen shoulder.
▪ Torn RTC: ​involves the distal tendinous insertion of the supraspinatus, infraspinatus, teres
minor, and subscapularis on the greater/lesser tubercle area of the humerus, caused by acute trauma
or gradual wear
▪ Labral tear: ​damage to the glenoid labrum, caused by trauma or degenerative wear, results in
pain and limited motion in the shoulder joint
▪ Calcific tendonitis: ​chronic inflammation of the supraspinatus tendon can lead to an
accumulation of mineral deposits which results in calcific tendonitis, asymptomatic or quite painful
▪ Bicipital tendonitis: ​usually involves the long head of the biceps proximally as it crosses the
humeral head, changes direction, and descends into the bicipital groove. A rupture of the biceps long
head tendon commonly occurs during repetitive or forceful overhead positions. Irritation as it slides
in the groove can lead to ​subluxing of the biceps tendon.

11. Be able to accurately and safely perform MMT for specified muscles in this unit.
See applied charts
 12.Be able to accurately perform goniometry for specified joint motions in this unit.
See applied charts

Anatomy Unit 6: Objectives

Brachial Plexus
1. Identify nervous system anatomy and function of the various structures within the nervous system.

2. Locate and discuss major components of the central nervous system.

The main components of the CNS are the brain and the spinal cord.
Brain: Cerebrum
▪ Cerebrum​: ​Largest and main portion of the brain and it is responsible for the highest mental functions. It
is made up of ​right and left cerebral hemispheres​ joined across the midline by the corpus callosum.
Each cerebral hemisphere has a ​cortex​, or outer coating, that is many cell layers deep, and each
hemisphere is divided into ​four lobes​.
▪ Frontal lobe:​ Occupies the anterior portion of the skull. This is the area of the brain that controls
personality, motor movement, and expressive speech.
▪ Occipital lobe:​ ​Occupies the posterior portion of the skull. It is responsible for vision and recognition of
size, shape, and color.
▪ Parietal lobe:​ ​lies between the frontal and occipital lobes. These nerve cells control gross sensation such
as touch and pressure along with fine sensation such as the determination of texture, weight, size and
shape. Reading skill brain activity is also located here.
▪ Temporal lobe:​ ​Lies under the frontal and parietal lobes, just above the ear. It is the center for behavior,
hearing, language reception, and understanding.
▪ Thalamus:​ ​Lies deep within the cerebral hemisphere beneath the cortex. It is a mass of nerve cells that
severs as a relay station for body sensations, it is here where pain is perceived.
▪ Hypothalamus:​ ​Deep within the brain that is important for hormone function and behavior. Also, in this
area is the ​basal ganglia​ which is important for motor movement.
Brain: Brainstem
▪ Brainstem:​ ​Lies below the cerebrum and is divided into three parts
▪ Midbrain:​ The upper portion of the brainstem, the center for visual reflexes
▪ Pons:​ The bridge between the midbrain and the medulla
 ▪ Medulla Oblongata: ​The most caudal, or inferior, portion of the brain stem, it is the center for automatic
control or respiration and heartrate. It is continuous with the spinal cord. The transition between the
spinal cord and medulla is the foramen magnum.
Brain: Cerebellum
▪ Cerebellum:​ ​It is located in the posterior portion of the cranium behind the pons and medulla; control of
muscle coordination, tone, and posture; “little brain”

Brain Protection
▪ Brain has three basic levels of protection: bony, membranous, and fluid.
▪ Meninges:​ within the skull are three layers of membrane called meninges; they cover the brain and
provide support and protection. The thickest, most fibrous, tough outer layer is called the ​dura mater​.
The middle, thinner later is the ​arachnoid.​ The inner, delicate layer is called ​pia matter​ which carries
blood vessels to the brain.
▪ Cerebrospinal fluid​: surrounds the brain and fills the four ventricles within the brain, provides shock
absorption. The ventricles are four small cavities containing a capillary network that produces CSF. There
are two lateral ventricles, a third ventricle, and a fourth ventricle.
Spinal Cord
▪ Spinal cord:​ a continuation of the medulla, it runs within the vertebral canal from the foramen magnum
to the cone-shaped ​conus medullaris​.
▪ Gray matter:​ in the middle of the cord in an H or “butterfly” shape. It contains neuronal cell bodies and
synapses. The top portion of the H is the ​posterior horn​, which receives and transmits sensory impulses.
The lower portion, the ​anterior horn​, transmits motor impulses.
▪ White matter​: contains ascending (sensory) and descending (motor) fiber pathways. Each pathway
carries a particular type of impulse. These pathways cross over from one side of the body to the other at
different levels. This crossover phenomenon is what results in a stroke on the left side of the brain to
effect the right side of the body.
▪ Posterior columns:​ are located in the posterior medial portions of the spinal cord and are white matter.
They transmit the sensations of proprioception, pressure, and vibration.
▪ Lateral corticospinal tract​: the pathway of particular significance to muscle control
▪ Upper motor neurons​: located in the cerebral cortex, brainstem, and cerebellum
▪ Lower motor neurons​:​ ​located in the anterior horn
- If a lesion occurs proximal to the anterior horn, it is considered an upper motor neuron lesion.
Examples of diagnoses involving these include spinal cord injuries, multiple sclerosis, parkinsonism,
cerebrovascular accident, and various types of head injuries.
- If a lesion occurs to the cell bodies of the lower motor neurons, it is considered a lower motor
neuron lesion. Examples of diagnoses involving these include muscular dystrophy, poliomyelitis,
myasthenia gravis, and peripheral nerve injuries.

3. Locate and discuss major components of the peripheral nervous system.

▪ Made up of all the nervous tissue outside of the vertebral canal and brainstem, begins are the anterior
horn of the spinal cord, sending motor impulses out to the muscles and receiving sensory impulses from
the skin.
 ▪ Cranial nerves:​ 12 pairs; trigeminal, facial, and spinal accessory are most significant in terms of their
control over certain muscles
▪ Spinal nerves:​ 31 pairs of spinal nerves – includes 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1
coccygeal. Nerves are above matching vertebrae until after T1 where it enter under.
4. Describe the functional significance of spinal cord level in terms of rehabilitative potential of specific
muscle groups.
▪ The lower the level of injury, the more muscles remain intact
▪ Most muscles take innervations from more than one spinal level. Therefore, injury at one spinal level
may weaken a muscle, but some function will remain.
▪ A person with a spinal cord injury at C3 or above would not have the function of the diaphragm and
would be unable to breathe without assistance. Sensation only from top of head to the neck.
▪ With C5, some function of the upper extremities left
▪ At T3, both entire upper extremeties and the chest, level with the axilla, are innervated.
▪ L3 would show loss of senstation in an irregular pattern to approx.. the midthight level.

5. Identify the three major plexuses (cervical, brachial, and lumbosacral), the major nerves
arising from each, and the clinical motor features of paralysis of specific nerves.

Cervical Plexus
▪ The anterior rami of the first four cervical nerves (C1-C4) split and join together in a specific pattern to
form the cervical plexus.
▪ Most significant nerve is the phrenic nerve which is formed by branches of C3 through C5 and
innervates the diaphragm.

Brachial Plexus
▪ Brachial plexus:​ Is formed by the anterior rami of C5 through T1 spinal nerves

Terminal Nerves of the Brachial Plexus

Spina Muscle Innervation Sensory Clinical Motor Features of
l Cord Distribution Paralysis
Axillary C5 -Deltoid -Lateral arm -Loss of shoulder abduction
C6 -Teres minor over lower -Weakened shoulder lateral
portion of rotation
deltoid
Median C6 -Pronators -Palmer aspect -Loss of forearm pronation
C7 -Wrist and finger flexors on of thumb,
C8 radial side second, third,
st​ nd
T1 -Most thumb muscles, 1​ and 2​ fourth (radial
lumbricals half) fingers
Musculocutaneou C5 -Coracobrachialis -Anterior -Loss of elbow flexion
s C6 -Biceps lateral surface -Weakened supination
C7 -Brachialis of forearm
Radial C5 -Triceps -Posterior arm -Loss of elbow, wrist,
C6 -Anconeus -Posterior finger, and thumb
C7 -Brachioradialis forearm extension “wrist drop”
C8 -Supinator
 T1 -Wrist -Radial side of
-Finger posterior hand
-Thumb extensors and
abductors
Ulnar C8 -Flexor carpi ulnaris -Fourth finger -Loss of wrist ulnar
T1 -Flexor digitorum profundus (medial deviation
(medial half) portion), 5​th -Weakened wrist, finger
-Interossei finger flexion
-3​rd​ and 4​th​ lumbricals, muscles -Loss of thumb adduction
of 5​th​ finger -Loss of most intrinsics
“claw hand”

6. Define some common central nervous system pathologies.

Congenital Defects
▪ Spina bifida: ​a congenital defect in which the posterior segments of some of the vertabrae fail to close
during embryo development.
- Spina bifida occulta: ​a small bony defect is present, but the spinal cord and nerves are usually
normal
- Meningocele: ​a bony defect though which the meninges protrude. There is usually little or no nerve
damage
- Myelomeningocele: ​the most severe spina bifida, the meninges and spinal nerves come through the
bony defect. This causes nerve damage and severe disability.
▪ Hydrocephalus: ​"water on the brain" a congenital or acquired defect involving cerebrospinal fluid (CSF)
production, absorption, and flow through the ventricles and subarachnoid space. An excessive
accumulation of CSF results in an abnormal widening of the ventricles, which creates potentially harmful
pressure on the brain tissues.
▪ Cerebral palsy: ​a term used to describe a group of nonprogressive disorders of the brain that result from
damage in utero, at birth, or soon after birth. It is not always congenital. Signs and symptoms vary.
Spinal Cord Trauma
▪ Spinal cord injury (SCI): ​Result in loss sensation and muscle function. Can be split into two categories:
Quadriplegia and Paraplegia
▪ Central cord syndrome: ​greater loss of upper limb function compared with lower limb
▪ Brown-Sequard syndrome: ​weakness and loss of proprioception on the side of the injury and loss of pain
and thermal sensation on the opposite side. Caused by injury to one side of the spinal cord.
▪ Anterior cord syndrome:
loss of muscle function, pain sensation, and thermal sensation
▪ Autonomic dysreflexia (hyperflexia)​: ​"hyperreflexia" a serious potentially life-threatening complication
associated with spinal cord injuries at or above T10. Symptoms include severe headache, sudden
hypertensions, facial flush, sweating and gooseflesh. Blood pressure may rise to dangerous levels-if left
untreated, can lead to stroke or death.

Disorders of the Muscle and the Neuromuscular Junction

▪ Myastenia gravis:​ ​a disease that involves a defect at the neuromuscular junction, where the terminal
axon synapses with the receptor site of muscles. This results in weakness and fatigue of skeletal muscles.
 ▪ Muscular dystrophy: ​a hereditary and progressive disease of the muscle tissue. Weakness of proximal
muscles, followed by progressive involvement of distal muscles.

Degenerative Diseases
▪ Amyotrophic lateral sclerosis (ALS)​: ​a degenerative motor disease involving both upper and lower motor
neurons. Also known as Lou Gehrig's disease
▪ Alzheimer’s disease: ​an irreversible, progressive brain disorder causing dementia and loss of cognitive
functioning. It eventually destroys a person's ability to function.

Demyelinating Diseases
▪ Multiple sclerosis: ​characterized by breaking down of the myelin sheath around axons. This will
interfere with normal nerve transmission. Sclerosis refers to scars or lesions in the white matter of the
brain and spinal cord.

7. Discuss some common peripheral nerve pathologies that may be seen in clinical practice.
▪ Neuropathy: ​neurological deficits along the nerve pathway. They are usually classified according to
cause or anatomical location.
▪ Bell’s palsy: ​involves the facial nerve which controls movement of facial muscles. The condition is usually
temporary and typically affects only one side of the face
▪ Scapular winging: ​occurs when the long thoracic nerve weakens or paralyzes the serratus anterior
muscle, causing the medial border of the scapula to rise away from the rib cage.
▪ Thoracic outlet syndrome: ​a group of disorders that occur when the nerves of the brachial plexus and/or
the subclavian artery and vein become compressed in the thoracic outlet-the space between the clavicle
and first rib and possible the scalene muscles.
▪ Burner, or stinger, syndrome: ​ ​R​elatively common in football players and is also seen in wrestlers and
gymnasts. Symptoms include immediate burning pain, prickly paresthesia radiating from the neck,
numbness, and even brief paralysis of the arm. Results from a stretch or compression injury to the
brachial plexus from a blow to the head or shoulder
▪ Erb’s palsy: ​"tip position" a traction injury to a baby's upper brachial plexus and occurs must commonly
during difficult childbirth. The affected arm hangs in shoulder extension and medial rotation, elbow
extended, forearm pronated, and wrist flexed.
▪ Saturday night palsy: ​Occurs when the radial nerve becomes compressed as it spirals around the
mid-humerus. Gets its name from an intoxicated person falling asleep with their arm over the back of a
chair. Results in wrist drop.
▪ Wrist drop: ​a weakened ability to release objects (finger extension) will result from a high radial nerve
injury, which is often a complication of a mid-humeral fracture.
▪ Carpal tunnel syndrome: ​result of compression of the median nerve as it passes within the carpal tunnel.
The tunnel is formed by the transverse carpal ligament superficially and the bony floor of carpal bones
deeply.
▪ Cubital tunnel syndrome: ​occurs when the ulnar nerve crosses the medial border of the elbow as the
nerve runs through passageway. Hitting your funny bone or sustained pressure on the hypothenar
eminence such as leaning on handle bars during long bicycle rides.
▪ Ape hand: ​loss of thumb opposition (median nerve injury)
 ▪ Pope’s blessing, or hand of benediction: ​"hand of benediction" Inability to flex the thumb, index and
middle fingers (also median nerve injury)
▪ Claw hand: ​loss of the intrinsic muscles due to ulnar nerve damage. The proximal phalanges are
hyperextended, and the middle and distal phalanges are in extreme flexion.

Anatomy Unit 7: Objectives

Elbow/Forearm

1. Identify key bones and bony landmarks of the elbow joint.

Important Bony Landmarks of the Scapula

▪ Infraglenoid Tubercle:​ ​Raised portion on the inferior lip of the glenoid fossa that provides attachment of
the long head of the triceps muscle.
▪ Supraglenoid Tubercle:​ ​Raised portion on the superior lip of the glenoid fossa that provides attachment
for the long head of the biceps muscle.
▪ Coracoid Process: ​Projection on the anterior surface that provides attachment for the short head of the
biceps muscle

Important Bony Landmarks of the Humerus

▪ Spiral Groove: ​The groove that the radial nerve runs though as it spirals around the midhumerus.
▪ Trochlea:​ Located on the medial side of the distal end; articulates with the ulna
▪ Capitulum: ​On the lateral side, next to the trochlea; articulates with head of radius
▪ Medial Epicondyle: ​Located on the medial side of the distal end, above the trochlea; larger and more
prominent than the lateral epicondyle. It provides attachment for the pronator teres muscle.
▪ Lateral Epicondyle:​ Located on the lateral side of the distal end, above the capitulum; provides
attachment for the anconeus and supinator muscles.
▪ Lateral Supracondylar Ridge:​ Located above the lateral epicondyle; provides attachment for the
brachioradialis muscle.
▪ Olecranon Fossa:​ Located on the posterior surface between the medial and lateral epicondyles;
articulates with the olecranon process of the ulna

Important Bony Landmarks of the Ulna

▪ Olecranon Process:​ Located at the proximal end of the ulna, on the posterior surface; forms the
prominent point of the elbow and provides attachment for the triceps muscle
▪ Trochlear Notch:​ Also called the semilunar notch, articulates with the trochlea of the humerus; makes up
the anterior surface at the proximal end
▪ Coronoid Process:​ Located just below the trochlear notch; with the ulnar tuberosity, provides
attachment for the brachialis muscle
▪ Radial Notch: ​Located at the proximal end on the lateral side, just distal to the trochlear notch;
articulation point for the head of the radius
 ▪ Ulnar Tuberosity:​ Located below the coronoid process; provides attachment for the brachialis muscle
▪ Styloid Process:​ ​At the distal end, on the posterior medial surface
▪ Head:​ At the distal end, on the lateral surface; the ulnar notch of the radius pivots around it during
pronation and supination

Important Bony Landmarks of the Radius

▪ Head:​ Proximal end; has a cylinder shape with a depression in the superior surface where it articulates
with the capitulum of the humerus
▪ Radial Tuberosity:​ Located on the medial side, near the proximal end; provides attachment for the
biceps muscle
▪ Styloid Process:​ Located on the posterior lateral side of the radius, at the distal end; provides
attachment for the brachioradialis muscle

2. Recognize the joints and primary ligaments that comprise the elbow joint.

▪ Medial collateral ligament:​ Triangular and spans the medial side of the elbow. Attaches on the medial
epicondyle of the humerus and runs obliquely to the medial sides of the coronoid process and olecranon
process of the ulna.
▪ Lateral collateral ligament:​ Triangular, attaches proximally on the lateral epicondyle of the humerus and
distally on the annular ligament and the lateral side of the ulna.
▪ Annular ligament:​ Attaches anteriorly and posteriorly to the radial notch of the ulna, encompassing the
head of the radius and holding it against the ulna.
▪ Joint capsule: ​Attaches everywhere at the elbow (pg 168), it becomes taut over the posterior aspect of
the joint while it is slack over the anterior aspect of the elbow during flexion; opposite for extension.
▪ Interosseous membrane:​ ​helps the annular ligament with holding together the radioulnar articulations.
It is a broad, flat membrane between the radius and the ulna for most of their length. It helps keep the
two bones from separations and provides more surface area for attachment of the forearm and wrist
muscles.
3. Describe joint motions that occur at the elbow joint and at the proximal and distal radioulnar joints in
terms of appropriate plane and axis. Describe the normal range of motion at those joints.

Elbow Joint: ​Uniaxial hinge joint, only extension and flexion occurring in the sagittal plane around frontal
axis, no hyperextension
▪ Extension:​ return to anatomical position
▪ Flexion:​ ​145 degrees of flexion

Radioulnar Joint​:​ A ​uniaxial pivot joint​, ​only allowing pronation and supination​; second joint of the elbow
complex involving articulations between the radius and ulna and involves each bone articulating with the
other ​at both ends of the forearm​.
Proximal radioulnar joint: ​the head of the radius pivots within the radial notch of the ulna, forming the
proximal radioulnar joint
Distal radioulnar joint: ​Due to the shape of the radius, the distal end of the radius rotates around the
distal end of the ulna.
▪ Pronation:​ transverse plane, vertical axis; 80 degrees of pronation
▪ Supination:​ transverse plane, vertical axis; 90 degrees of supination
▪ When pronation/supination occur, the radius moves around the ulna, the ulna does not rotate, as it
is locked in place by its bony shape at the proximal end.
4. Define the carrying angle at the elbow, and how it differs in males and females.

▪ Carrying angle is the longitudinal axes of the humerus and forearm in the anatomical position.
▪ The angle tends to be greater in women. Normal angle measures about 5 degrees in males, and b/w
10-15 degrees in females.
▪ This angle occurs because the distal end of the humerus is not level. The medial side (trochlea) is lower
than the lateral side (capitulum) , AS the ulna and radius move around the trochlea and capitulum of the
humerus, they do not move in a straight line like a typical hinge joint.

5. Describe the muscle origin, insertion, action, and nerve innervations of selected muscles of the elbow
joint and radioulnar joints.

▪ Brachialis M.
O: ​Distal half of humerus, anterior surface
I:​ Coronoid process and ulnar tuberosity of the ulna
A: ​Elbow flexion
N: ​Musculocutaneous nerve (C5, C6)

▪ Biceps M.
O: ​Long head: supraglenoid tubercle of scapula; short head: coracoid process of scapula
I: ​Radial tuberosity of radius
A: ​Elbow flexion, forearm supination
N: ​Musculocutaneous nerve (C5, C6)

▪ Brachioradialis M.
O: ​ Lateral supracondylar ridge on the humerus
I: ​Styloid process of the radius
A: ​Elbow flexion
N: ​Radial nerve (C5, C6)

▪ Triceps M.
O: ​Long head: infraglenoid tubercle of scapula; Lateral head: inferior to greater tubercle on posterior
humerus; Medial head: posterior surface of humerus
I: ​Olecranon process of ulna
A: ​Elbow extension
N: ​Radial nerve (C6, C7, C8)

▪ Anconeus M.
O: ​Lateral epicondyle of humerus
I: ​Lateral and inferior to olecranon process of ulna
A: ​Not a prime mover in any joint action, assists in elbow extension
N: ​Radial nerve (C6, C7, C8)

▪ Pronator Teres M.
O: ​Medial epicondyle of humerus and coronoid process of ulna
I: ​Lateral aspect of radius at it’s midpoint
A: ​Forearm pronation, assistive in elbow flexion
 N: ​Median nerve (C6, C7)

▪ Pronator Quadratus M.
O: ​Dista, one-fourth of ulna
I: ​Distal one-fourth of radius
A: ​Forearm pronation
N: ​Median nerve (C8, T1)

▪ Supinator M.
O: ​Lateral epicondyle of humerus and adjacent ulna
I: ​Anterior surface of the proximal radius
A: ​Forearm supination
N: ​Radial nerve (C6)

6. Define common pathologies of structures around the elbow joint. Discuss potential effects on
occupational performance.

▪ Lateral epicondylitis (tennis elbow):​ overuse condition that affects the common extensor tendon where
it inserts into the lateral epicondyle of the humerus. The extensor carpi radialis brevis is particularly
affected. Common in ​repetitive wrist extension activities.
▪ Medial epicondylitis (golfer’s elbow):​ an inflammation of the common flexor tendon that inserts into
the medial epicondyle. An overuse condition that results in tenderness over the medial epicondyle and
pain on ​resisted wrist flexion.
▪ Little league elbow: ​overuse injury to the medial epicondyle, usually from a repetitive throwing motion.
Seen in young baseball players who have not reached skeletal maturity. The throwing motion places a
valgus stress on the elbow, causing lateral compression and medial distraction to the joint.
▪ Pulled elbow (nursemaid’s elbow): ​seen in young children under the age of 5 who have experienced a
sudden strong traction force on the arm., often occurs when an adult suddenly pulls on the child’s arm
or the child falls away from an adult while being held by the arm. This forces the radial head to sublux
out from under the annular ligament.
▪ Elbow dislocation: ​Caused when a great deal of force is applied to an elbow that is in a slightly flexed
position. This causes the ula to slide posterior to the distal end of the humerus.
▪ Supracondylar fractures: ​one of the most common fracture in children and are caused by falling on the
outstretched hand. The distal end of the humerus fractures just above the condyles.
▪ Volkmann’s ischemic contracture: ​The elbow dislocation and supracondylar fracture are very dangerous
because of their proximity to the brachial artery. If affected, it can lead to Volkmann’s ischemic
contracture, a rare but potentially devastating ischemic necrosis of the forearm muscles.
▪ Ulnar nerve compression:​ Pain from hitting the funny bone comes from this

7. Be able to accurately and safely perform MMT for specified muscles in this unit.
See attached charts

8. Be able to accurately perform goniometry for specified joint motions in this unit.
See attached charts

9. Be able to palpate identified structures for this unit.

See attached charts
 Anatomy Unit 8: Objectives
Wrist
Joint Structure
▪ Wrist joint​ is made of two joints: radiocarpal and midcarpal
▪ Radiocarpal joint:​ consists of the distal end of the radius and the radioulnar disk proximally and the scaphoid,
lunate, and triquetrum distally. It is a synovial joint classified as a ​biaxial condyloid joint​. This allows radial
deviation, ulnar deviation, flexion, and extension. The combination of these movements is called ​cicumduction​.
*There is no rotation at the wrist.*
▪ Midcarpal joint: ​is located between the two rows of carpal bones, whereas
▪ Intercarpal joints​ :are located between the carpal bones in each individual row. They are irregular and are
classified as nonaxial plane joints. – Gliding motions.
▪ Carpometacarpal joints (CMC):​ appear between the distal row of carpal bones and the proximal end of the
metacarpal bones. They have a direct function in the hand.

Joint motions
Osterkinematic Motion
▪ Flexion=palmar flexon, hyperextension=dorsiflexion
▪ Neutral postion: the term for extended or the anatomical position of the wrist
▪ Flexion and extension: sagittal plan around frontal axis; aprox 90 degrees flexion and 70 degrees extension
▪ Radial and ulnar deviation occur in the frontal plane, about 25 degrees of radial deviation, 35 degrees ulnar
deviation
▪ End feel for all wrist motions = firm except radial deviation (hard)
Artrokinematic Motion
▪ Radiocarpal joint: most joint plat in neutral, convex-on-cancave
▪ During wrist flexion, carpals glide posteriorly on the radius and articular disk
▪ During wrist extension, carpals glide anteriorly
▪ During radial deviation, carpals glide medially
▪ During ulnar deviation, carpals glide laterally

Bones and Landmarks

▪ Carpal bones consist of two rows of four bones each, short bones, concave anteriorly, convex proximally – allows
for the thumbs ability to oppose

▪ Styloid processes: attachment for collateral ligaments

▪ Hook of the hamate: attachment for the transverse carpal ligament
▪ Medical epicondyle: attachment for common flexor tendon
▪ Lateral epicondyle: attachment for common extensor tendon
▪ Lateral supracondylar ridge: attachment for the extensor carpi radialis longus muscle
Ligaments and other structures
▪ Four ligaments of the radiocarpal joint that provide major support of the wrist
▪ Small ligaments then support the intercarpal joints
 ▪ The following provide lateral and medial support:
▪ Radial collateral ligament:​ attaches to the styloid process of the radius and the scaphoid and trapezium
bones
▪ Ulnar collateral ligament:​ attaches to the styloid process of the ulna and pisiform and triquetrum
▪

1. Be able to accurately and safely perform MMT for specified muscles in this unit.
See attached charts

2. Be able to perform goniometry for specified joint motions in this unit.

See attached charts

3. Be able to accurately palpate identified structures for this unit.

See attached charts