Professional Documents
Culture Documents
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Bones
Osseous structures of interest are the scapula, humerus and
clavicle. Neither the vertebral column nor the thoracic cage is
discussed here (see chapters on the anatomy of the cervical
and thoracic spine).
Scapula 3
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Subacromial space thicker on its superior, anterior and posterior surfaces than
on the inferior surface. The anteroposterior stability of the
The suprahumeral gliding mechanism consists of the coracoac- acromioclavicular joint is controlled by the acromioclavicular
romial arch (see below) on one side and the proximal part of ligaments and the vertical stability is controlled by coracocla-
the humerus, covered by the rotator cuff and the biceps tendon vicular ligaments (conoid and trapezoid).
on the other. Both parts are separated by the subacromial bursa
that acts as a joint space (Fig. 7). Investigators point to the
importance of contact and load transfer between the rotator
Sternoclavicular joint
cuff and the coracoacromial arch in the function of the normal
The only osseous connection between the skeleton of the trunk
shoulder. Normally there is no communication between the
and the upper limb is formed by the clavicle. Its medial end
bursa and the glenohumeral joint space but it may be estab-
lies in contact with the superolateral angle of the sternal manu-
lished by rupture of the rotator cuff.
brium and with the medial part of the cartilage of the first rib
to form the sternoclavicular joint (Fig. 9, see Putz, Fig. 285).
Acromioclavicular joint In both the vertical and anteroposterior dimensions, the cla-
vicular portion is larger than the opposing manubrium and
The acromioclavicular joint (Fig. 8) is the only articulation extends superiorly and posteriorly relative to the sternum. The
between the clavicle and the scapula. It contains a disc which prominence of the clavicle enables its palpation. The sterno-
usually has a large perforation in its centre. The capsule is clavicular joint is mobile along all axes and almost every
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Fig 6 • The glenohumeral joint capsule and ligaments: superior (1), Fig 7 • The subacromial space and subdeltoid bursa: 1, acromion;
medial (2) and inferior (3) glenohumeral ligaments. 2, supraspinatus muscle; 3, deltoid muscle; 4, subdeltoid bursa; 5,
clavicle; 6, humerus; 7, scapula.
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Costocoracoid fascia
Coracoacromial ligament
Deep to the pectoralis major muscle lies a group of associated
The coracoacromial ligament originates from the lateral aspect muscles and fascia: the clavipectoral fascia, the subclavius and
of the coracoid process and runs laterally and upwards to the pectoralis minor muscles (Fig. 11).
tip of the acromion. It forms, together with the acromion and The costocoracoid fascia is that part of the clavipectoral
outer end of the clavicle, the coracoacromial roof. fascia which is situated superomedial to the pectoralis minor
The coracoacromial arch provides a strong ceiling for the muscle. A spontaneous loss of its normal elasticity may end in
shoulder joint, along which the cuff tendons must glide during a contracture of this structure, causing limitation of elevation
all shoulder movements. Passage of the proximal humerus and of the arm.
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e43
The Shoulder
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The bursae are shown in Figures 12–13, see Putz, Fig. 295. Another clinically important bursa is the subscapularis bursa,
which develops between the upper portion of the subscapularis
tendon, the neck of the scapula and the base of the coracoid
Subacromial–subdeltoid bursa process (see Standring, Fig. 46.14A). The bursa is covered by
the pectoralis major muscle. Bursitis here can give rise to an
It is important to realize that there is only one bursa here. isolated limitation of passive lateral rotation. Since this move-
However, for clinical reasons two portions may be distin- ment stretches the muscle, it will painfully pinch the inflamed
guished: a deep, subacromial part and a more superficial one. subcoracoid bursa, provoking a spasm of the pectoralis major.
The former cannot be palpated, the latter is within a finger’s
reach.
A good idea of the anatomical localization of this bursa is Shoulder movements
obtained if the palm of the contralateral hand is put on top of
the shoulder. The metacarpophalangeal joints must lie contigu- The glenohumeral joint is the most mobile joint of the human
ous with the lateral acromial rim. The area covered by the palm body. It can move around three different axes, all transversing
overlies the deep subacromial portion of the bursa, the area the head of the humerus (Fig. 14):
© Copyright 2013 Elsevier, Ltd. All rights reserved.
e44
Applied anatomy of the shoulder
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Fig 14 • The axes of the shoulder. Fig 15 • Muscle functions: 1, adductors; 2, abductors; 3, medial
rotators; 4, lateral rotators.
• a–a′ – Transverse axis: this is a horizontal axis coursing
from the left to the right shoulder. Anterior and posterior The most important function of the shoulder – arm
directed movements around it are flexion and extension. elevation – has been extensively studied, in particular the
• b–b′ – Sagittal axis: this horizontal axis lies in antero- relationship and contribution of the glenohumeral and scapulo
posterior sense through the head of the humerus. thoracic joints and the ‘scapulothoracic’ rhythm has been
Movement of the arm around this axis is named adduction determined. During full elevation of 180° only 90° takes place
(the arm moves towards the body) and abduction (away at the glenohumeral joint. The remaining half is the conse-
from the body). quence of scapular rotation, clavicular movement and, finally,
• c–c′ – Vertical axis: with the right arm hanging in neutral adduction of the humerus which is only possible when the
position (radial side pointing anteriorly and elbow bent to scapula has been fully rotated.
90°), outward movement of the arm around a vertical
axis, bringing the palm of the hand anteriorly, is lateral
rotation. The movement in the opposite direction is
Muscles and tendons
medial rotation. If the arm is first abducted to 90°,
movement around the vertical axis, which brings the arm The clinically important contractile structures of the shoulder
anteriorly and posteriorly, is named horizontal adduction joint are those whose tendons form the rotator cuff: the
and horizontal extension. supraspinatus, infraspinatus, subscapularis and, of less impor-
tance, the teres minor.
When the patient actively elevates the arm, the initial move-
The adductors are those muscles which act below the sagit-
ment takes place at the glenohumeral joint. Later the scapula
tal axis, and the abductors are those acting above (Fig. 15).
rotates synchronously. Clinically this is easily checked by pal-
Medial rotators act in front of the vertical axis, lateral ones
pating the inferior scapular angle during elevation. Wallace2
behind it.
states that both movements take place in a ratio of about 2 : 1;
The origins and insertions of the muscles are shown in
that means for every 2° of movement at the glenohumeral joint
Figure 16.
there exists 1° of scapular rotation. These simultaneous move-
ments are known as the scapulothoracic or scapulohumeral
rhythm. Adduction
Mobility of the glenohumeral joint is usually tested in three
directions: abduction, medial rotation and lateral rotation. Adduction of the arm is performed by four different muscles:
Abduction is movement in a frontal plane between a mobile teres minor and major, the pectoralis major and latissimus dorsi
humerus and a stabilized scapula. Medial and lateral rotation (see Fig. 18). The first is also a lateral rotator, while the latter
is assessed with the arm hanging in the neutral position. The three are medial rotators.
term elevation indicates the movement of the shoulder complex The teres minor arises at the lower outer rim of the scapula,
(glenohumeral joints and shoulder girdle) in a frontal plane. just above the origin of the teres major muscles and inserts
Normally the arm can move through an angle of approximately on the major tubercle, just distal to the insertion of the infra-
0° to 180° in elevation; the normal range for the glenohumeral spinatus muscle.
joint is about 90° of abduction and the same for medial and The teres major runs from the lower scapular angle towards
lateral rotation. the anterior aspect of the humerus, where it inserts on the
© Copyright 2013 Elsevier, Ltd. All rights reserved.
e45
The Shoulder
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Fig 16 • Muscle origins and insertions: 1, supraspinatus; 2, deltoid; 3, infraspinatus; 4, teres minor; 5, teres major; 6, pectoralis major;
7, latissimus dorsi; 8, subscapularis; 9, pectoralis minor; 10, coracobrachialis; 11, short head of biceps; 12, trapezius; 13, triceps brachii;
14, brachialis; 15, serratus anterior; 16, levator scapulae; 17, rhomboid.
Long head
Humerus
Biceps brachii
Short head Intertubercular tendon sheath
Coracobrachialis *
*
Clavicle Coraco-acromial ligament
*
Coracoid process Acromion
Infraspinatus
Acromioclavicular joint
Suprascapular nerve
Supraspinatus
Spine of scapula
Fig 17 • Supraspinatus muscle from above and anterior. *Capsule of the joint. From Putz, Sobotta – Atlas of Human Anatomy, 14th edn. Urban &
Fischer/Elsevier, Munich, 2008 with permission.
Muscle Nerve Spinal nerve root Muscle Nerve Spinal nerve root
Subscapularis Subscapular C5–C8 Infraspinatus Suprascapular C5 (C6)
Pectoralis major Pectoral C5–C8 Teres minor Axillary C5 (C6)
Latissimus dorsi Thoracodorsal C7 (C6, C8)
Teres major Subscapular C5–C8
Table 5 The flexors of the elbow
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Fig 23 • The posterior scapulohumeral region: 1, suprascapular Fig 24 • The anterior scapulohumeral region; 1, subclavian artery;
nerve; 2, axillary nerve; 3, supraspinatus muscle; 4, infraspinatus 2, suprascapular artery and nerve; 3, axillary nerve; 4, radial nerve;
muscle; 5, deltoid muscle; 6, teres minor muscle. 5, subscapularis nerve; 6, pectoralis minor muscle; 7, subscapularis
muscle; 8, teres major muscle; 9, latissimus dorsi muscle.
It gives a branch to the teres minor muscle and ends in the Subclavian artery and vein
deltoid muscle. The terminal branch is the lateral superior
brachial cutaneous nerve, which innervates the upper and outer The subclavian blood vessels are of particular importance since
aspect of the skin over the deltoid. their compression can give rise to the subclavian steal syn-
drome or may play a role in the thoracic outlet syndrome. The
vessels lie between the first rib and the clavicle, medially to
the brachial plexus, and are separated by the scalenus anterior
muscle.
References
1. Kapandji I. Bewegingsleer, vol I, De Bovenste 2. Wallace W. The dynamic study of shoulder
Extremiteit. Utrecht/Antwerp: Bohn, movement. In: Bayley I, Kessel L, editors.
Scheltema & Holkema; 1986. Shoulder Surgery. Berlin: Springer; 1982.
p. 139–43.
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