Surgical Anatomy & Physical

examination of shoulder & arm

Dr. Sharew (Orthopedics & trauma surgery resident)
Adama hospital medical college
April 2023
Outline of presentation
Introduction
Anatomy of shoulder & arm
 Bone
 Joint
 Ligament & tendon
 Muscle
 Blood supply
 Innervation
Physical examination & some clinical correlation

11/28/2023 2
Introduction
The shoulder is the region of upper limb attachment to the trunk.
The bone framework of the shoulder consists of:
 The clavicle and scapula, which form the pectoral girdle
(shoulder girdle), and
 The proximal end of the humerus.

11/28/2023 3
 Clavicle
 Long bone placed horizontally.
 First bone to ossify.
 Two primary centers appear in 5th to
6 th weeks of intra uterine life & fuse
to form a single center on 45th day.
 Only long bone ossifying in
membrane.
 It has no medullary cavity.
 Connects appendicular with axial
skeleton & involved in weight
transmission.

11/28/2023 4
Scapula
The scapula is a large, flat
triangular bone with:
Three angles (lateral,
superior, and inferior),
Three borders (superior,
lateral, and medial),
 Two surfaces (costal and
posterior), and
Three processes (acromion,
spine, and coracoid process)

11/28/2023 5
Humerus
The proximal end of the
humerus consists of the
head, the anatomical neck,
the greater and lesser
tubercles, the surgical neck,
and the superior half of the
shaft of the humerus

11/28/2023 6
11/28/2023 7
Joint
The three joints in the shoulder complex are the sternoclavicular,
acromioclavicular, and glenohumeral joints.
The sternoclavicular joint and the acromioclavicular joint link the two
bones of the pectoral girdle to each other and to the trunk.
The glenohumeral joint (shoulder joint) is the articulation between
the humerus of the arm & scapula.

11/28/2023 8
 Sternoclavicular joint
Between the proximal end of
the clavicle and the clavicular
notch of the manubrium of the
sternum.
Only true attachment of upper
extremity to axial skeleton.
It is synovial and saddle
shaped.
Allows movement of the
clavicle, in the AP and vertical
planes, although some
rotation
11/28/2023 also occurs. 9
Acromioclavicular joint
A small synovial joint between
an oval facet on the medial
surface of the acromion and a
similar facet on the acromial
end of the clavicle.
It allows movement in the
anteroposterior and vertical
planes together with some
axial rotation.

11/28/2023 10
Glenohumeral joint
Is a synovial ball and socket
articulation between the head of
the humerus and the glenoid
cavity of the scapula.
Provide wide range of
movements at the cost of skeletal
stability

11/28/2023 11
Ligament
Several ligaments limit the
movement of the GH joint
and resist humeral
dislocation. These include
Glenohumeral
Transverse humeral
ligaments and
Coraco-humeral,

11/28/2023 12
Muscle of the shoulder

11/28/2023 13
Muscle of the shoulder

Trapezius
11/28/2023 Levator Scapulae Rhomboid minor & Deltoid 14
major
Muscle of the posterior scapular region

11/28/2023 15
Muscle of the posterior scapular region

Supraspinatus Infraspinatus Teres Minor Teres major

11/28/2023 16
Muscle of the anterior wall of the axilla

11/28/2023 17
 Pectoralis Major Pectoralis Minor
11/28/2023 18
11/28/2023 19
Muscle of the lateral & posterior wall of the axilla

11/28/2023 20
11/28/2023 Subscapularis 21
Latissimus dorsi
Muscle of anterior compartment of arm

11/28/2023 22
 Bicep Brachiali Coracobrachialis
s s
11/28/2023 23
Muscle of the posterior compartment of arm

Triceps

11/28/2023 24
 Blood supply of shoulder and arm
The subclavian artery and its branches supply structures in the neck,
part of the thoracic wall, and the entire upper limb

11/28/2023 25
Cont…

11/28/2023 26
11/28/2023 27
 Scapular arcade
Main blood supply to scapular
region with
Suprascapular artery
Dorsal scapular artery
Circumflex scapular artery
Thoracodorsal artery

11/28/2023 28
 Cont…
Blood supply to Glenohemural joint
and Humeral head
 suprascapular,
 anterior and posterior humeral
circumflex,
 scapular circumflex arteries

11/28/2023 29
Veins
The limbs have both deep and
superficial veins
Deep veins accompany the
major arteries and their
branches and have similar
names
The superficial veins are found
in the subcutaneous tissue and
drain into the deep venous
system via
perforating(connecting) veins

11/28/2023 30
 Nerves
The upper limb is innervated almost
entirely by the nerves of the brachial
plexus
Anterior rami of spinal nerves C5–T1
Roots C5 to T1 combine to form three
trunks , divisions, three cords, five
terminal nerves

11/28/2023 31
Physical examination of shoulder & arm
Look
Feel
Move (Range of Motion)
Strength
Special Tests
Neurovascular

11/28/2023 32
Look for any visible pathology

11/28/2023 33
Feel

11/28/2023 34
Cont.

11/28/2023 35
Assess for Range of motion examination

11/28/2023 36
Cont.

11/28/2023 37
Cont.

11/28/2023 38
Cont.

11/28/2023 39
Cont.

11/28/2023 40
Cont.

11/28/2023 41
Cont.

11/28/2023 42
Cont.

11/28/2023 43
Strength test
• Assess strength of specific muscle or group of muscle
• Compare your finding on both side
• Grade strength on 0 → 5 scale
0: no contraction
1: muscle flicker; no movement
2: motion, but not against gravity
3: motion against gravity, but not resistance
4: motion against resistance
5: normal strength

11/28/2023 44
External rotation
 Arms at the sides
 Elbows flexed to 90 degrees
 Externally rotates arms against resistance
 Tests strength of muscles that externally
rotate the shoulder.

11/28/2023 45
Internal rotation
 Arms at the sides
 Elbows flexed to 90 degrees
 Internally rotates arms
against resistance
 Other techniques(lift off test)
 Tests strength of muscle that
IR the shoulder
 Subscapularis

11/28/2023 46
 Subscapularis Lift-Off Test

11/28/2023 47
Belly press test

11/28/2023 48
Empty can test/Jobe test
 30o angle
 Steady downward
pressure
 Tests supraspinatus
strength and pain

11/28/2023 49
Jobe test

11/28/2023 50
Special provocative test
Impingement Signs
Drop-Arm Test
Speed’s Test
Yergason Test
Cross-Arm Adduction
Sulcus Sign
Apprehension test
Relocation test
O’Brien’s Test
Crank test
11/28/2023 51
Subacromial Impingement Syndrome
Impingement of:
 Subacromial bursa
 Rotator cuff muscles and tendons
 Biceps tendon
• Between
 Acromion
 Coraco-acromial ligament
 AC joint
 Coracoid process
 Humeral head

11/28/2023 52
Neer’s sign
 Arm fully pronated
and placed in forced
flexion
 Trying to impinge
sub-acromial
structures with
humeral head
 Pain is positive test

11/28/2023 53
 Hawkins' sign
 Arm is forward elevated
to 90 degrees, then
forcibly internally
rotated
 Trying to impinge
subacromial structures
with humeral head
 Pain is positive test

11/28/2023 54
Rotator cuff tear
Rotator tear are among the most common problems afflicting the
shoulder.
They may vary from reversible bursitis and overuse tendinitis to frank
massive rupture of the tendinous cuff.
May be due to Impingement,Degeneration,Overuse

11/28/2023 55
Drop arm test

11/28/2023 56
Biceps tendinosis
Injury to long head of biceps tendon
Typically an overuse injury
 Repetitive (overhead) lifting Young Adult
 Impingement/rotator cuff disease Elderly population

11/28/2023 57
Speed’s test
Purpose
 To identify biceps tendon pathology, and
unstable superior labral anterior posterior
(SLAP) lesions.
Technique
 Sitting or standing position
 Forward flex shoulder to about 90°
 Abduct shoulder to about 10°
 The elbow is fully extended and forearm
supinated.
 Apply downward force to lower forearm &
ask the patient to resist the force.
Positive test
 Pain at bicipital groove-Bicep tendinopathy
 Deep seated pain-Biceps/labral complex
lesion
 Weakness without pain: muscle weakness or
11/28/2023 58
rupture
Yergason test
Purpose
 To identify biceps tendon pathology, and
unstable superior labral anterior posterior (SLAP)
lesions.
Technique
 Sitting or standing position
 Elbow flexed to 90° with fore arm pronated
 Heel of the hand placed over dorsum surface
of lower radius & fingers wrapped around
 Ask the patient to supinate forearm against
resistance.
Positive test
 Pain -Bicep pathology/SLAP lesion
 Clicking or snapping sensation at the bicipital
groove-Laxity or tear of transverse humeral
ligament.

11/28/2023 59
Assessment Shoulder instability
Failure to keep humeral head
centered in glenoid
It can be
dislocation,subluxation,laxity

11/28/2023 60
Apprehension test
 Shoulder abducted to
90°
 Slight stress to humeral
head directed in anterior
direction
 While externally rotating
shoulder
 Positive test is
apprehension due to
feeling of instability or
impending dislocation.
 Helps to assess Anterior
instability
11/28/2023 61
Relocation test
 After a positive
apprehension
 Apply posteriorly directed
force over externally
rotated humeral head
 Positive test is relief of
apprehension
 Anterior release test
 Helps to assess Anterior
instability

11/28/2023 62
Glenoid labral tear
Tear in glenoid labrum
Usually due to instability

11/28/2023 63
O’Brien’s Active Compression Test
 Used to assess Labral, AC, or
biceps pathology
 Arm flexed to 90°
 Arm cross-arm adducted 10-
15°
 Elbow extended
 Max pronation
 Resist downward force
 Positive test if painful
 Beware location of pain

11/28/2023 64
Assessment of axillary nerve

11/28/2023 65
Reference
• Gray’s Anatomy for student 4th edition
• The orthopedic physical examination 2nd edition
• Clinical orthopedic examination 6th edition
• Orthopedic examination and assessment 2nd edition
• Stanford medicine25.Stanford.edu
• Special test in musculoskeletal examination evidence based guide line
for clinician 2010
• Internet

11/28/2023 66
 Thank you!

11/28/2023 67