SHOULDER OSTEOLOGY & ARTHROLOGY

1. Full elevation of the upper limb in the scapular plane requires the coordinated
movement of the clavicle, scapula, and the humerus. List the normal movements of
the clavicle and scapular during scapular plane aBduction.

Scapular = upward rotation, posterior tilt, external rotation

Clavicle =posterior/upward rotation, retraction, little elevation
Tightens conoid ligament
Pulls coronoid process further away

2. Name the three anatomical joints, in order from most to least, that contribute to full
range of upper limb aBduction.

Glenohumeral joint -> sternoclavicular joint -> acromioclavicular joint

- Sternoclavicular joint, acromioclavicular joint (together – conjunct rotation -> SCJ

- ACL)

3. Explain what is meant by “conjunct rotation of the clavicle” during upper limb
elevation in the scapular plane. What is the benefit of this?

- Isolated movement - done by itself - rotating arm in GHJ

- Conjunct rotation - cannot done by itself - scapula upward rotation causes the
coracoclavicular ligament (conoid ligament) to tighten, pulling the posterior
aspect of the clavicle and posteriorly rotating the clavicle. Posterior rotation of
the clavicle cannot be performed by itself
- Clavicular retraction then occurs to make space for the proximal end to depress
more, to enable more elevation of the upper limb.
- Increases range of motion

4. a. What is the most common mechanism of fracture of the clavicle and the most
common location of the fracture?

- Middle 1/3 of the clavicle

- Direct impact to a point on the shoulder which a common fracture point
- Caused by fall on outstretched hand or direct fall on shoulder.

b. Describe and explain the resulting deformity.

The deformity of this will cause

- Drop in the shoulder as nothing is keeping and sustaining the lateral hold of the
shoulders, contributing to a person’s posture.
- The clavicle also moves forward due to no lateral protrusion
- Causes the clavicle to move forward and protrude anteriorly.

5. a. What is the most common mechanism of acromioclavicular joint (ACJ) dislocation?

Direct - fall onto point of shoulder with adducted arm -> inferior force onto acromion
(clavicular movement restricted at SCJ -> acromion forced inferior and medial)

Indirect - fall onto outstretched hand or elbow -> humerus into acromion - AC ligaments
tear but not coracoclavicular ligaments

b. Describe and explain the resulting deformity.

As the dislocation releases the acromion, the conoid ligament is not taut meaning it is not
stabilizing and keeping the acromion with the acromion process, clavicle sticks up and out of
the shoulder compartment of the arm.

6. a. Which structures are the primary stabilisers of the glenohumeral joint (GHJ) in
anatomical position?

1. Coracohumeral ligament
2. Superior glenohumeral ligament

b. Which structures are the primary stabilisers of the GHJ through range of
movement?

Rotator cuff muscles (SITS) + ligaments

- Anterior band is taut in ER, posterior band is taut in IR

c. Which structures stabilise the GHJ in a position of aBduction & external

rotation?
External rotation: Anterior band of IGHLC
Abduction: anterior, posterior, transverse band

7. What is the most common mechanism and most common direction of glenohumeral
joint (GHJ) dislocation?

Hyperabduction, external rotation in an anterior-inferior direction and forced

hyperadduction across the body in a posterior direction
SHOULDER MUSCLE & NEUROVASCULATURE

1. Full elevation of the upper limb in the scapular plane requires the coordinated
movement of the clavicle, scapula, and the humerus. List the normal movements of
the clavicle and the scapular during scapular plane aBduction. For each movement,
indicate the main structures that produce the movement.

1. Upwards rotation - serratus anterior, all trapezius

2. Posterior tilt - serratus anterior and lower trapezius
3. External rotation - serratus anterior and middle trapezius

2. What evidence exists that supports the argument that the middle deltoid and the
muscles of the rotator cuff work together throughout the range of full upper limb
aBduction?

e.g. EMG evidence that all the muscles are active throughout all ranges of
movement. If you multiply their PCSA x moment arm they are able to produce
torque. If you use middle deltoid alone, it has significant anterior/superior shear
force and compressive force. Require the additional compression of rotator cuff to
offset the superior shear to limit the translation of the head of humerus on the
glenoid due to the confined subacromial space -> would result in impingement +
pain -> subacromial bursa would become irritated and inflammation, therefore
minimises its function of protecting the underlying supraspinatus.

- GHJ F, Abd, IR & ER cannot result from a pure rolling of joint surfaces
- There also must be a glide (translation) to offset the directional role
During UL elevation:
- GHJ compression by rotator cuff increases stability
- Inferior line of action of rotator cuff muscles opposes the superior shear of
middle deltoid

3. a. What is the normal acromiohumeral distance on an anterior-posterior x-ray in

standing? 7-11mm
b. Name two (2) structures located in the subacromial space.
1. tendon of long head of biceps brachii
2. supraspinatus tendon (rotator cuff)
3. Subacromial bursa

c. How is the reduction in this space minimised during upper limb aBduction?
Minimised by moving the coracoacromial arch upward and posteriorly to maintain
the space and avoid impingement.

4. Why is it important for the rotator cuff to work with middle deltoid during upper
limb aBduction from anatomical position?
- The glenohumeral compression by rotator cuff increases stability
- Because the middle deltoid does not have enough torque to produce arm
abduction from anatomical position and continue due to its moment arm
 whereas rotator cuff muscle can compress other muscles and apply shear
which increases their activity
- Stops the humerus from interfering in the glenohumeral space

5. a. What is a dermatome? Provide details of one dermatome test in the upper limb.
A dermatome is an area of skin innervated by sensory neurons from a single spinal
segment/nerve.

e.g. numbness and tingling down the right arm to the thumb and middle finger may
involve C6-C8 dermatomes and indicate abnormalities in the spinal nerves of the C6-
8 nerve roots. T2 which is at the apex of the axilla, testing sensory innervation of the
armput which connects to the spinal level of T2

b. What is a myotome? Provide details of one myotome test in the upper limb.
A myotome is a collection of muscle fibres innervated by the motor neurons from a
single spinal segment/ nerve.
e.g. C6 innervates elbow flexion (biceps brachii and brachialis flexes the elbow). Ask
the patient to perform this movement which is associated with the C6 spinal nerve.
c. **Why are skeletal muscles usually innervated by several spinal levels? Give an
example.
- Because several spinal nerves innervate different parts of muscle bellies or fibres
of the same muscle, so therefore, a skeletal muscle needs to be innervated by
more than one spinal segment
e.g. Adductor longus is innervated by the obturator nerve which arises from L2, L3,
L4 spinal nerves.

6. **The brachial plexus innervates muscles of the pectoral girdle and upper limb.
Describe the location of the specific parts of the brachial plexus relative to other
anatomical structures.

- The brachial plexus is made up of spinal segments C5-T1 that arise from the
ventral rami
- They arise from rootlets, which from roots, forming trunks, divisions, cords then
finally branches that give innervation to certain muscles
- Root come out of intervertebral foramen, come through interscalene triangle
- Roots and trunks are supra clavicular

7. The brachial plexus innervates muscles of the pectoral girdle and upper limb.
a. Which spinal levels contribute to the brachial plexus? C5, 6, 7, 8, T1
b. ***Describe the general pattern of spinal level innervation to the muscles of the
pectoral girdle and upper limb. Provide four (4) specific examples (muscle name and
spinal level innervation) in your answer.

- Upper levels innervate more proximal structures, lower levels innervate more
distal structures.
- Deltoid – axillary C5,6
- Supraspinatus – suprascapular nerve C5,6
 - Subscapularis – Upper and lower subscapular nerve C5,6,7
- Latissimus dorsi – Thoracodorsal C6-C8

ARM, ELBOW & FOREARM REGION

1. a. **What are the normal ranges of movements for elbow flexion and extension and
forearm pronation and supination?

Elbow flexion: 0-150*

Elbow extension: -6-11*
Forearm pronation: 70-75*
Forearm supination: 85*

b. What ranges of flexion – extension and pronation – supination are required to

accomplish most activities of daily living?

Range of flexion: 130*

Range of extension: 30-130*
Range of supination: 50*
Range of pronation: 50*

2. Describe the passive stability of the elbow hinge joint (humeroulnar and
humeroradial joints).

Passive stability in the elbow joint are the capsular ligaments such as
- annular ligament which wraps around the head of the radius
- lateral collateral ligament from the humerus to the radius
- medial collateral ligament which has an anterior and posterior fibre bundle from
the humerus to the ulna
- lateral ulna collateral ligament which goes from the ulna anteriorly to the
posterior aspect
3. a. Regarding joint stability, what is a primary constraint?
- A stabliser, without this constraint causes laxity in the joint

b. Regarding joint stability, what is a secondary constraint?

- Insufficient to form laxity, without the primary constraint, it increases laxity
c. The elbow joint complex is exposed to high valgus forces during activities of daily
living. What is a valgus force?
- Is the lateral deviation of the distal segment in relations to the proximal
segment of a bone.
- 10-15*
- Predisposes to elbow valgus injuries
d. Name the two (2) PRIMARY PASSIVE constraints against elbow valgus.
1. medial collateral ligament
2. humeroulnar articulation
e. Name one (1) SECONDARY PASSIVE constraint and one (1) SECONDARY ACTIVE
constraint against elbow valgus.
 Passive: humeroradial articulation
Active: common flexor-pronator tendon
4. a. Which three (3) muscles are the main flexors of the elbow?
1. brachioradialis
2. brachialis
3. biceps
b. What makes them the main elbow flexors?
They cross the elbow joint on the anterior side
Main as: they have the largest moment arm +PCSA = greatest torque production
c. What is the optimal position for elbow flexor strength? Explain why.
70-90* flexion
Greater flexor torque in supinated or neutral forearm rotation
5. Describe the structure and stability of the distal radioulnar joint (DRUJ).
- Is a synovial plane joint which has a primary stabiliser called the triangular
fibrocartilage complex and dorsal and palmar radioulnar ligaments as
secondary constraints
- Helps prevent medial and lateral glide of the joint from the proximal
segment but also from the wrist joint
- Keeps the joint locked into its capsule and keep ulna as the stable portion
for the movement of radius
- Annular ligament -> posterolateral stability
6. a. Describe the relative distribution of force transmission from the hand to the two
bones of the forearm.
- during supination, the largest force transmission occurs from the wrist to
the radius
- when the IOL is relaxed in supination of 60*, that is where the most force
transmission happens between the radius through to the ulna via the IOL
as the pressure has decreased.

b. Describe how the position of the elbow and forearm affects load transmission
from the forearm to the humerus.
- During neutral to 60* supination is when most of the force transmission
happens between the two joints of the forearm including the PRUJ and
DRUJ
- Occurs through the interosseous membrane allowing the force to be
transmitted through to the humerus through the articulating surfaces of
the humerus, radius and ulna
- In pronation, no force loading is happening so the radius is weighted
down
- Valgus increases contact between radial head and capitulum
If you fall on a pronated arm with a flexed or outstretched hand this is where
most of distal radius fractures occur as there is no force transformation
between the radius and ulna causing the radius to take all of the force
weakening its stability as it articulates with the wrist joint directly

7. a. What are the margins of the cubital fossa?

Base = imaginary line between medial and lateral epicondyles
 Lateral = pronator teres
Medial = brachioradialis
b. What are the palpable structures in the cubital fossa from lateral to medial?
Biceps Brachii, brachial artery, medial nerve
8. **Describe the course of the median nerve through the forearm. Indicate its main
branches and their sensory and/or motor innervation.
- Arises from the lateral and medial cords of the brachial plexus (C5-T1)
enters the arm at the axilla
- Travels with the brachial artery down the shaft of the humerus bone and
into the cubital fossa -> innervates anterior forearm muscles (flexor
digitorum superficialis and pronator quadratus solely innervated by this)
- Branches into the “recurrent branch of the median nerve” -> innervates
the muscles of the thenar eminence of hand
9. Cubital tunnel syndrome is the second most common chronic compression
neuropathy in the upper limb.
a. Which anatomical structures form the floor, ceiling, and walls of the cubital
tunnel?
Roof = cubital retinaculum joining the medial epicondyle to olecranon
Floor = UCL
Walls = medial epicondyle and olecranon
b. What travels through the cubital tunnel and what sensory and motor deficits
would you expect to see resulting from compression of this structure?
- Contains the ulnar nerve
- Motor deficits from compression of the ulnar nerve would cease all motor
innervation to muscles of the anteromedial forearm and sensory loss to the
medial 1/3 of palm and both palmar and dorsal side of fingers
Sensory: is an upper extremity neuropathy involving the compression of the
median nerve at the area of the wrist – leads to tingling, numbness, pain, and
weakness
Motor: results in muscle weakness in hand but a slight sensory innervation would
be present
10. **Describe the pathway of the radial nerve and its main branches through the arm
and forearm. Indicate the structures innervated by each branch.
- Stems from the ventral roots of the spinal nerves C5-T1 of brachial plexus
which eventually forms the posterior cord.
- Posterior compartment of the arm -> anterior compartment of arm ->
posterior compartment of forearm
Arm:
- Crosses the lateral epicondyle of the humerus where the nerve branches into
superficial and deep branch
- Muscular branches to supply long head, medial head, and lateral head of
triceps brachii muscles before and during its course in the radial sulcus
- After emerging from the radial sulcus, it supplies the brachialis,
brachioradialis, and extensor carpi radialis longus
- Above the radial sulcus, the radial nerve gives off posterior cutaneous nerve
of the arm which supplies the skin at the back of the arm.
 - In the radial sulcus, it gives off lower lateral cutaneous nerve of the arm and
posterior cutaneous nerve of the forearm
- Also gives articular branches to supply the elbow joint
Forearm:
- Divides into superficial branch (primarily sensory) and a deep branch
(primarily motor)
- Superficial branch: crosses the brachioradialis to enter posterior forearm ->
sensory supply to hand
- Deep branch: pierces supinator and then becomes the posterior interosseous
nerve and lies between the superficial and deep muscles of the back of the
forearm.

WRIST & HAND

1. Describe the stability of the radiocarpal joint (RCJ).

RCJ = a synovial ellipsoid joint, biaxial diarthrosis

2. Describe the typical carpal bone deformity and alteration in loading that occurs
secondary to wrist ligament instability.

- Rheumatoid arthritis is a wrist deformity causing the carpel translocation in a

volar, ulnar, proximal direction
- When the radius does not align correctly with the carpel bones which affects
the articulation with them
- Causes load transfer to more on scaphoid and put the force slanted rather
than directly on the radius which protrudes the hands out (valgus)
3. What is scapholunate dissociation and what are the consequences for wrist
function?
- When the scaphoid and lunate bones in the wrist move apart by falls on an
outstretched (flexed) hand
- Because they keep the two bones together, Lunate is important for stability
in the proximal row and since no muscles attach to it, it relies on shape of
articular surfaces and ligaments so when the two bones move apart it has no
stability to keep it interlocked
- The two primary complications due to scapholunate dissociation are
Scapholunate Advanced Collapse (SLAC) and general arthritis of the wrist.
4. a. Describe the structure of the first carpometacarpal (1st CMC) joint.
- a biconcave-convex saddle joint
- consists of the articulation between the first metacarpal of the thumb and the
trapezium carpal bone

b. Explain how the first carpometacarpal (1st CMC) joint is stabilised during pinch
grip.
- Enables you to pierce your two fingers together with force without
protruding the thumb out of its joint socket
 - The 1st MCP joint is stabilised during a pinch grasp as the volar beak ligament
is compressed which tightens the dorsal ligament complex creating a screw-
home mechanism which allows you to pinch the index and thumb together.
5. Compare the mobility of the carpometacarpal (CMC) joints with the
metacarpophalangeal (MCP) joints.
- The CMC joints is a saddle joint and is the second most mobile joint in the
human body
- MCP: ellipsoid
- CMC mobile, 2nd least, 3-4 more as you increase
- The MCP joints mobility increases 2nd – 5th MCP
- Circumduction
- Little bondy stability of trapezium – stabilised to 2nd and 3rd MCP by ligaments
- Dorsal ligament
- Beak ligament
6. a. What are the boundaries of the carpal tunnel?

- Carpal bones
- Flexor retinaculum
b. What are the contents of the carpal tunnel?
- Median nerve
- Flexor tendons
c. Describe and explain the likely sensory changes resulting from sustained increased
pressure within the carpal tunnel (as in carpal tunnel syndrome).
- Increased pressure = compression on median nerve
- Sensory innervation of median nerve = dorsal aspect of distal 2 digits
of the hand is supplied by median nerve
- Tingling, numbness, pain, weakness

d. **Describe and explain the likely muscle weakness resulting from sustained
increased pressure within the carpal tunnel (as in carpal tunnel syndrome).
- muscle weakness - lose grip
- half of FDP, FDS, pollicis, FPL??
- intrinsics (lumbricals)
7. Many muscles cross the wrist however there are five dedicated wrist muscles which
act to move and/or stabilise the wrist.
Name these five muscles, state their distal attachments.
a. Flexor carpi radialis – bases of 2nd + 3rd mc
b. Flexor carpi ulnaris – pisiform and hook of hamate + base of 5th mc
c. Extensor carpi radialis longus – dorsal surface of base 2nd mc
d. Extensor carpi radialis brevis – dorsal surface of base of 3rd mc
e. Extensor carpi ulnaris – dorsal surface of base of 5th mc

b. Describe how we use the combined actions of these muscles to perform wrist
movements.
As they all cross the carpals they all work together to flex the wrist as they are bipennate
muscles so produce more force when contracted together due to their high contraction
force so have a more effective moment arm

8. a. **Describe the proximal attachments, location of muscle bellies, tendon pathway

and insertion of flexor digitorum superficialis and flexor digitorum profundus.
b. Explain the difference in their action at the elbow joint.
- Below/above elbow
- Contribute to elbow flexion – minimal
c. Explain the difference in their action on the digits.
- profundus inserts more distally -> Distal
9. **Describe and explain the action of the lumbrical muscles.

flex the fingers at the metacarpophalangeal (MCP) joints, and extend them at the
interphalangeal (IP) joints. These actions are important for many functions of the hand, such
as grip

10. **Describe the differences in the patterns of spinal nerve versus peripheral nerve
sensory innervation of the palmar and dorsal aspect of the hand.
Spinal nerves -> dermatomes
Peripheral nerves -> medial, radial, ulnar nerves.