HUMAN ANATOMY

LECTURE SERIES
EKWERE OKON EKWERE, PhD
DEPARTMENT OF HUMAN ANATOMY
UNIVERSITY OF JOS, NIGERIA.
UPPER LIMB
SHOULDER REGION
 Introduction
• the region of upper limb attachment to the
trunk and neck.
• bony framework consists of:
üthe clavicle and scapula, which form the
pectoral girdle (shoulder girdle)
üthe proximal end of the humerus.
 …..Introduction
• superficial muscles of the shoulder:
Øthe trapezius
Ødeltoid muscles
• together they form the smooth muscular
contour over the lateral part of the
shoulder.
• These muscles connect the scapula and
clavicle to the trunk and to the arm,
respectively.
 Joints of the shoulder region
• The 3 joints in the shoulder complex are:
Ø sternoclavicular
Ø acromioclavicular
Ø glenohumeral
• The sternoclavicular and acromioclavicular joints link
the two bones of the pectoral girdle to each other
and to the trunk. The combined movements at these
two joints enable the scapula to be positioned over a
wide range on the thoracic wall, substantially
increasing 'reach' by the upper limb.
• The glenohumeral joint is the articulation between
the proximal end of the humerus and the scapula
…..Joints of the shoulder region
The sternoclavicular joint
•occurs between the proximal end of the clavicle and
the clavicular notch of the manubrium of sternum
together with a small part of the first costal cartilage.
Type & Shape:
•It is synovial and saddle-shaped. The articular cavity
is completely separated into two compartments by an
articular disc.
•The sternoclavicular joint allows movement of the
clavicle, mainly in the anteroposterior and vertical
planes, with some levels of rotation.
….. Joints of the shoulder region
….. Joints of the shoulder region
Stability
• The sternoclavicular joint is surrounded by a joint
capsule and is reinforced by four ligaments:
• the anterior and posterior sternoclavicular ligaments
are anterior and posterior, respectively, to the joint
• an interclavicular ligament links the ends of the two
clavicles to each other and to the superior surface of the
manubrium of sternum
• the costoclavicular ligament is positioned laterally to
the joint and links the proximal end of the clavicle to the
first rib and related costal cartilage.
…..Joints of the shoulder region
Acromioclavicular joint
Type:
•a small synovial joint between a small 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.
…..Joints of the shoulder region
…..Joints of the shoulder region
…..Joints of the shoulder region
…..Joints of the shoulder region
Stability:
• The acromioclavicular joint is surrounded by a joint
capsule and reinforced by:
ü a small acromioclavicular ligament superior to the
joint and passing between adjacent regions of the
clavicle and acromion.
ü a much larger coracoclavicular ligament, which is
not directly related to the joint, but is an important
strong accessory ligament, providing much of the
weightbearing support for the upper limb on the
clavicle and maintaining the position of the clavicle
on the acromion.
…..Joints of the shoulder region
• coracoclavicular ligament spans the
distance between the coracoid process of
the scapula and the inferior surface of the
acromial end of the clavicle
• comprises an anterior trapezoid ligament
(which attaches to the trapezoid line on
the clavicle) and a posterior conoid
ligament (which attaches to the related
conoid tubercle).
…..Joints of the shoulder region
Glenohumeral joint
Type:
•is a synovial ball and socket articulation between
the head of the humerus and the glenoid cavity of
the scapula.
•is multiaxial with a wide range of movements
provided at the cost of skeletal stability.
Joint stability is provided by
üthe rotator cuff muscles, the long head of the
biceps brachii muscle, related bony processes,
and extracapsular ligaments.
…..Joints of the shoulder region
Disposition of rotator cuff (SITS)
muscles. Main function:
üto grasp and pull the large head of
the humerus medially, holding it
against the smaller, shallow glenoid
cavity of the scapula.
ütendons of the muscles
(represented by three fingers and the
thumb) blend with the fibrous layer of
the capsule of the glenohumeral 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 glenohumeral joint.
…..Joints of the shoulder region
• articular surfaces of the glenohumeral joint are the
large spherical head of the humerus and the small
glenoid cavity of the scapula. Each of the surfaces is
covered by hyaline cartilage.
• glenoid cavity is deepened and expanded
peripherally by a fibrocartilaginous collar (the
glenoid labrum), which attaches to the margin of
the fossa.
• Superiorly, the labrum is continuous with tendon of
the long head of the biceps brachii muscle, which
attaches to the supraglenoid tubercle and passes
through the articular cavity superior to the head of
…..Joints of the shoulder region
…..Joints of the shoulder region
…..Joints of the shoulder region
…..Joints of the shoulder region
• synovial membrane attaches to the
margins of the articular surfaces and lines
the fibrous membrane of the joint capsule.
The synovial membrane is loose inferiorly.
This redundant region of synovial
membrane and related fibrous membrane
accommodates abduction of the arm.
…..Joints of the shoulder region
• synovial membrane protrudes through apertures in
the fibrous membrane to form bursae, which lie
between the tendons of surrounding muscles and
the fibrous membrane. The most consistent of these
is the subtendinous bursa of subscapularis,
which lies between the subscapularis muscle and
the fibrous membrane. The synovial membrane also
folds around the tendon of the long head of the
biceps brachii muscle in the joint and extends along
the tendon as it passes into the intertubercular
sulcus. All these synovial structures reduce friction
between the tendons and adjacent joint capsule and
bone.
…..Joints of the shoulder region
• addition to bursae that communicate with the
articular cavity through apertures in the fibrous
membrane, other bursae are associated with the
joint but are not connected to it. These occur:
• between the deltoid and supraspinatus muscle and
the joint capsule - the subacromial bursa
Ø between the acromion and skin
Ø between the coracoid process and the joint capsule
• in relationship to tendons of muscles around the joint
(coracobrachialis, teres major, long head of triceps
brachii, and latissimus dorsi muscles).
…..Joints of the shoulder region
…..Joints of the shoulder region
…..Joints of the shoulder region
• The fibrous membrane of the joint capsule
attaches to the margin of the glenoid
cavity, outside the attachment of the
glenoid labrum and the long head of the
biceps brachii muscle, and to the
anatomical neck of the humerus
…..Joints of the shoulder region
• On the humerus, the medial attachment
occurs more inferiorly than the neck and
extends onto the shaft. In this region, the
fibrous membrane is also loose or folded
in the anatomical position.
• This redundant area of the fibrous
membrane accommodates abduction of
the arm.
…..Joints of the shoulder region
• Openings in the fibrous membrane provide
continuity of the articular cavity with
bursae that occur between the joint
capsule and surrounding muscles and
around the tendon of the long head of the
biceps brachii muscle in the intertubercular
sulcus.
…..Joints of the shoulder region
• The fibrous membrane of the joint capsule is thickened:
• anterosuperiorly in three locations to form superior,
middle, and inferior glenohumeral ligaments, which
pass between the superomedial margin of the glenoid
cavity to the lesser tubercle and inferiorly related
anatomical neck of the humerus
• superiorly between the base of the coracoid process and
the greater tubercle of the humerus (the coracohumeral
ligament)
• between the greater and lesser tubercles of the humerus
(transverse humeral ligament)-this holds the tendon of
the long head of the biceps brachii muscle in the
intertubercular sulcus
…..Joints of the shoulder region
…..Joints of the shoulder region
 …..Joints of the shoulder region
Joint stability is provided by:
• surrounding muscle tendons and a skeletal arch formed
superiorly by the coracoid process and acromion and the
coraco-acromial ligament.
• Tendons of the rotator cuff muscles (the supraspinatus,
infraspinatus, teres minor, and subscapularis muscles) blend
with the joint capsule and form a musculotendinous collar that
surrounds the posterior, superior, and anterior aspects of the
glenohumeral joint.
• This cuff of muscles stabilizes and holds the head of the
humerus in the glenoid cavity of the scapula without
compromising the arm's flexibility and range of motion. The
tendon of the long head of the biceps brachii muscle passes
superiorly through the joint and restricts upward movement of
the humeral head on the glenoid cavity.
…..Joints of the shoulder region
• Movements at the joint include flexion,
extension, abduction, adduction, medial
rotation, lateral rotation, and
circumduction.
…..Joints of the shoulder region
…..Joints of the shoulder region
…..Joints of the shoulder region
• Vascular supply to the glenohumeral joint:
Ø branches of anterior and posterior circumflex
humeral arteries.
Ø suprascapular arteries.
• Nerve supply:
Ø branches from the posterior cord of the brachial
plexus
Ø the suprascapular
Ø axillary
Ø lateral pectoral nerves.
 Applied Anatomy
Fractures of the clavicle and dislocations of the
acromioclavicular and sternoclavicular joints.
• The clavicle provides osseous continuity
between the upper limb and thorax. Given its
relative size and the potential forces that it
transmits from the upper limb to the trunk, it is
not surprising that it is often fractured. The
typical site of fracture is the middle third. The
medial and lateral thirds are rarely fractured.
 …..Applied Anatomy
• The acromial end of the clavicle tends to dislocate at
the acromioclavicular joint with trauma. The outer
third of the clavicle is joined to the scapula by the
conoid and trapezoid ligaments of the
coracoclavicular ligament.
• A minor injury tends to tear the fibrous joint capsule
and ligaments of the acromioclavicular joint,
resulting in acromioclavicular separation on a plain
radiograph. More severe trauma will disrupt the
conoid and trapezoid ligaments of the
coracoclavicular ligament, which results in elevation
and upward subluxation of the clavicle.
 …..Applied Anatomy
• The typical injury at the medial end of the
clavicle is an anterior or posterior
dislocation of the sternoclavicular joint.
Importantly, a posterior dislocation the
clavicle may impinge on the great vessels
of the superior mediastinum and compress
or disrupt them.
 …..Applied Anatomy
Dislocations of the glenohumeral joint.
• The glenohumeral joint is extremely
mobile, providing a wide range of
movement at the expense of stability. The
relatively small bony glenoid cavity,
supplemented by the less robust
fibrocartilaginous glenoid labrum and the
ligamentous support, make it susceptible
to dislocation.
 …..Applied Anatomy
• Anterior dislocation occurs most frequently and is usually
associated with an isolated traumatic incident (clinically,
all anterior dislocations are anteroinferior). In some
cases, the anterior inferior glenoid labrum is torn with or
without a small bony fragment. Once the joint capsule
and cartilage are disrupted, the joint is susceptible to
further (recurrent) dislocations.
• When an anteroinferior dislocation occurs, the axillary
nerve may be injured by direct compression of the
humeral head on the nerve inferiorly as it passes through
the quadrangular space.
 …..Applied Anatomy
• The 'lengthening' effect of the humerus may
stretch the radial nerve, which is tightly bound
within the radial groove, and produce a radial
nerve paralysis. Occasionally, an anteroinferior
dislocation is associated with a fracture, which
may require surgical reduction.
• Posterior dislocation is extremely rare; when
seen, the clinician should focus on its cause, the
most common being extremely vigorous muscle
contractions, which may be associated with an
epileptic seizure caused by electrocution.
 …..Applied Anatomy
Fracture of the proximal humerus
• It is extremely rare for fractures to occur across the
anatomical neck of the humerus because the obliquity of
such a fracture would have to traverse the thickest
region of bone. Typically fractures occur around the
surgical neck of the humerus. Although the axillary nerve
and posterior circumflex humeral artery may be
damaged with this type of fracture, this rarely happens. It
is important that the axillary nerve is tested before
relocation to be sure that the injury has not damaged the
nerve and that the treatment itself does not cause a
neurologic deficit.
 …..Applied Anatomy
Rotator cuff disorders
• The two main disorders of the rotator cuff are
impingement and tendinopathy (disease of tendon).
The muscle most commonly involved is
supraspinatus as it passes beneath the acromion
and the acromioclavicular ligament. This space,
beneath which the supraspinatus tendon passes, is
of fixed dimensions.
• Swelling of the supraspinatus muscle, excessive
fluid within the subacromial/subdeltoid bursa, or
subacromial bony spurs may produce significant
impingement when the arm is abducted.
 …..Applied Anatomy
• The blood supply to the supraspinatus tendon is
relatively poor. Repeated trauma, in certain
circumstances, makes the tendon susceptible to
degenerative change, which may result in calcium
deposition, producing extreme pain.
• When the supraspinatus tendon has undergone
significant degenerative change, it is further
susceptible to trauma and partial or full thickness
tears may develop. These tears are most common in
older patients and may result in considerable
difficulty in carrying out normal activities of daily
living such as combing hair. However, complete
tears may be entirely unsymptomatic.
 …..Applied Anatomy
• Between the supraspinatus and deltoid
muscles laterally and the acromion medially,
there is a bursa referred to clinically as the
subacromial subdeltoid bursa. In patients
who have injured their shoulder or who have
supraspinatus tendinopathy, this bursa may
become inflamed, making movements of the
glenohumeral joint painful. These
inflammatory changes may be treated by
injection of a corticosteroid and local
anesthetic agent.
 References
• Anatomy at a glance- Faiz and Moffatt
• Clinical Anatomy by regions – Richard
Snell
• Gray’s Anatomy for students
• Clinically oriented Anatomy-Moore and
Dalley
• Clinical Anatomy-Harrold Ellis
• Gross Anatomy-Chung and Chung