Anatomy Unit 5: Scapula/Shoulder

Lippert: Ch 9-10
Moore: Ch 3 pg 140-146, 151-188, 201-214, 263-270
Clarkson: Ch 3 pf 64-93, 99-139
Chapter 9: Shoulder Girdle
 Shoulder complex-
o scapula,
o clavicle,
o sternum,
o humerus, and
o rib cage.
o Sternoclavicular joint,
o acromioclavicular joint,
o glenohumeral joint,
o scapulothoracic articulation (
 provides increased motion to the shoulder complex).
It is basically the Shoulder girdle (scapula and clavicle) and Shoulder joint (scapula and
humerus)

 Shoulder girdle-
o activities of the scapula and clavicle and to a lesser degree, the sternum and ribs.
Sternoclavicular and acromioclavicular joints allow shoulder girdle motions of
elevation & depression, protraction & retraction, upward & downward rotation.
 Shoulder joints or glenohumeral joint
o is the scapula and humerus.
o Motions of the shoulder joint are
 flexion,
 extension,
 hyperextension,
 abduction & adduction,
 medial & lateral rotation,
 horizontal abduction & adduction. (CH 10, not this chapter)
 Shoulder pic anterior side Fig 9-1 pg 127:
o acromioclavicular joint (AC joint; where clavicle meets up with scapula),
sternoclavicular joint (where clavicle meets sternum),
o glenohumeral joint,
o scapulothoracic articulation (anterior side of scapula with thoracic cage)
 Shoulder pic posterior side Fig 9-2 pg 128: shows how the scapula sits on the thoracic
cage. 2nd rib to 7th rib is the vertebral or medial border of the scapula.
 Scapula-
 o attaches to the trunk indirectly through its ligamentous attachment to the clavicle.
Slightly concave anteriorly and glides over the convex posterior rib cage.
 Plane of the scapula-
o the scapula rests about 30 degrees anterior to the frontal plane in its resting
position, against the posterior thorax.
 Scapula has:
o superior angle,
o inferior angle,
o vertebral border,
o axillary border,
o spine,
o corocoid process,
o acromion process, and
o glenoid fossa
 Superior view of scapula pg 128:
o scapula sits in a plane that is in between the frontal and sagittal plane. It sits about
30 degrees infront of the frontal plane.
 Bony landmarks of the scapula pg 129:
- Anterior view sits on the thoracic cage
- Vertebral border: close to the spine. Attachment of rhomboid and serratus anterior
muscles
- Axillary border: closest to axilla or arm pit
- Inferior angle: determines scapular rotation
- Superior angle: attachment for levator scapula
- Coracoid process, can see more anteriorly: muscular attachments into arm like
pectoralis muscle
- Acromion process, can see better posteriorly:
o provides attachment for upper trapezius.
o Has a lot of tendons and ligaments.
o Can be a point of impingement in the shoulder
- Spine: can only see from posterior view. Attachment for middle and lower trapezius
muscle
- Fossa:
o inferior and superior fossa.
o In areas where muscles (like supra and infra spinatis) sit on the posterior
scapula.
- Glenoid fossa on lateral view: where humerus articulates with scapula
 Clavicle-
o has sternal end (where it attaches to sternum),
o acromial end (where it attaches to acromion on scapula;
 provides attachment for upper trapezius),
o and the body
 Figure 9-5 pg 129: if clavicle damaged it is not easily fixed. Fractures are left untreated
and heal on their own. Tilts and glides, does not rotate
 Sternum-
o has manubrium (attachment for clavicle and first rib),
o body (attachment for remaining ribs), and
o xiphoid process (inferior).
Stable, not a lot of movement
Attachment for clavicle and costal cartilages of the ribs
 Fig 9-6 pg 129: notches are where we have rib articulations. Xiphoid process is delicate
 Sternoclavicular joint-
o articulation between manubrium of sternum and medial sternal end of the clavicle.
o Provides the shoulder girdle with its only direct attachment to the trunk.
o Triaxial joint (allowing movement in three planes of motion).
Double-hinge: During elevation & depression motion occurs between the clavicle and
disk. During protraction & retraction motion occurs between the disk and the sternum.
 Sternoclavicular joint has:
o anterior and posterior sternoclavicular ligaments (clavicle to sternum),
o costoclavicular ligament (clavicle to costal cartilage of first rib), and
o interclavicular ligament (clavicle to clavicle; on top of manubrium)
Anterior sternoclavicular ligament limits posterior motion, Posterior sternoclavicular
ligament limits anterior motion.
Costoclavicular ligament purpose is to limit clavicular elevation
 Anterior view of sternoclavicular joint Fig 9-7 pg 130:
- Costoclavicular ligament is attaching between rib and clavicle
- Interclavicular ligament attaches between the two clavicles, left and right
- Sternoclavicular ligament where clavicle articulates with sternum
- Articular disk that is cushion and allows tilts and glides of the clavicle
 Acromioclavicular joint-
o connect acromion of scapula and clavicle.
 Acromioclavicular joint has:
o superior and inferior acromioclavicular ligaments (acromion to clavicle),
o coracoclavicular ligamets (medial and lateral portions; scapula to clavicle) and
o coracoacromial ligament (coracoid to acromion).
This joint is less stable and a fall on the shoulder may damage this AC joint
 Anterior view of Acromioclavicular joint Fig 9-8 pg 131:
- Acromioclavicular ligament:
o between clavicle and acromion of scapula.
o Joint capsule here is not very stable.
o May get damaged more easily.
- Coracoclavicular ligament:
o has medial (conoid portion) and
o lateral (trapezoid portion).
o Between clavicle and coracoid process of anterior scapula.
o Prevent backward motion of the scapula and limit rotation of the scapula.
 - Coracoacromial ligament:
o Attaches two points of the scapula;
o between acromion of scapula and coracoid process (anterior).
o Allows for more stability of the shoulder.
o Forms a roof over the humerus.
 Lateral view of the acromioclavicular joint Fig 9-9 pg 131:
o Labrum around glenoid fossa is the suction cup for head of humerus to sit in.
o Coracoacromial ligament pans over top of the humerus.
o Coracoacromial and coracoclavicular ligaments form a roof over the shoulder.
o The space below the coracoacromial ligament is where a lot of paint comes from
when we get dysfunction of the shoulder because that is where a lot of tendons run
through and can lead to shoulder tendonitis
 Joint motions of the scapula: Fig 9-10.
o Elevation & depression,
o protraction & retraction,
o upward & downward rotation,
o scapular tilt,
o companion motions of the shoulder joint &
o shoulder girdle (scapula and humerus work together to have similar movements at
similar times),
o scapulohumeral rhythm.
 Scapulohumeral rhythm-
o describes the movement relationship between the shoulder girdle and shoulder
joint.
o Between scapula and humerus.
o First 30 degrees of shoulder joint motion is pure shoulder joint (glenohumeral)
motion, the scapula remains stable.
 After that, for every 2 degrees of shoulder flexion or abduction, the scapula
must upwardly rotate 1 degree. 2:1 ratio. Aka first part of shoulder joint
motion occurs at the shoulder joint but further motion must be accompanied
by shoulder girdle motion
 Elevation & depression-
o space between the scapula and the vertebral spine remains the same.
o Pure up and down movement of the scapula
 Protraction & retraction or abduction & adduction-
o medial/vertebral border of scapula is moving toward (retraction) vertebral spine, or
away from the vertebral spine (protraction)
 Upward & downward rotation-
o inferior angle is moving up and away from vertebral spine (upward rotation) or
moving down and closer to vertebral spine (downward rotation)
 Scapular tilt-
o inferior angle is coming up and away from thoracic cage, tilting posteriorly.
o Shoulder goes into hyperextension
 Muscles of the shoulder girdle & their origin, insertion, action, and innervation:
o trapezius (upper, middle lower),
o levator scapula,
o rhomboids,
o serratus anterior,
o pectoralis minor
 Upper, middle and lower trapezius have different lines of pull but all have an association
with vertebral column and scapula. Innervation is spinal accessory (cranial nerve XI) and
C3 and C4 sensory component
 Upper and Lower trapezius both do upward rotation
 Pg 139- anatomical relationships between the muscles
 Force coupling- muscles pulling in different directions to accomplish the same motion.
- Ex: Fig 9-25 pg 140. Upward rotation of the scapula- upper trapezius are pulling up,
lower trapezius pulling down, serratus anterior are pulling up and more horizontally
- Ex: Fig 9-26 pg 140. Downward rotation of the scapula- levator scapula pulls up,
pectoralis minor pulls down, rhomboids pull in
 Reverse muscle action-
o If the insertion is stabilized the origin will move. Allows some of the shoulder
girdle muscles to have assistive roles in other joints, primarily the head and neck.
 Acromioclavicular separation-
o ligament injury at the AC joint. First-degree sprain: ac ligament is stretched,
second-degree sprain: ac ligament is ruptured & coracoclavicular ligament is
stretched, third-degree sprain: both ligaments are ruptured.
 Clavicular fracture-
o most frequently broken bone in children.
Shoulder Complex Gross Lecture
 Brachial Plexus-
o C4 to T1.
o Trunks then chords then peripheral nerves that innervate the upper extremities.
 Major arteries feed off of the brachial artery.
o Brachiocephalic artery Subclavian artery Brachial artery ulnar and radial
arteriesanterior interosseous artery
 Arteries have a muscular wall that does the pumping action
 Arteries are running under the clavicle and between the scalene and this is where you can
have vascular issues
 3 branches come off the aortic arch, 2 of them are the subclavian arteries. They travel
deep to the anterior scalenes but superficial to the middle scalenes. Common carotid,
Vertebral artery, and Thyrocervical trunk are medial to the anterior scalene. Off of the
thyrocervical trunk is the transverse cervical artery.
 Once the subclavian artery passes the first rib it is known as the axillary artery which is
divided into superior thoracic artery, thoracoacromial artery & lateral thoracic (both
under pectoralis), and anterior & posterior humeral circumflex artery & subscapular
artery
 Once the axillary artery passes the armpit it is called the brachial artery which eventually
splits into radial artery and ulnar artery
 Anterior view of the major arteries of the upper extremities:
 The veins also go under the clavicle
 Median cubital or basilic vein is used to remove blood from the body and it is the vein
that is used to add blood to the body. It comes off of the brachiocephalic vein.
 Subclavian veins travel between anterior and middle scalene. It then turns into the
axillary vein at the arm pit
 Axillary vein has a branch called cephalic vein (runs along bicep)
 Axillary then turns into the brachial vein (deep) which branches into basilic vein (along
tricep)
 Median cubital vein connects the cephalic and basilic veins.
 Brachial also branches into radial and ulnar veins
 Anterior view of the major veins of the upper extremities:

 Arteries are generally deeper and thicker than veins.

o Veins you can see the blood, they are thin and flimsy.
 Nerve supply to upper limb:
o brachial plexus.
o Begins off the lower cervical and upper thoracic vertebrae then travels between
anterior and middle scalenes and extends into upper limb.
 Divided into 4 sections:
o roots,
o trunks,
o divisions,
o cords
 Roots come from anterior rami of C5, C6, C7, C8, and T1.
o Merge to form superior, middle, and inferior trunks.
o Each trunk splits into anterior and posterior divisions.
o All three of the posterior divisions merge together and only two of the anterior
divisions merge together.
o Then you get lateral (come from anterior divisions of superior and middle trunks),
medial (comes from anterior division of inferior trunk), and posterior cords (come
from the posterior divisions).
 Long thoracic nerve-
o only branch that originates from the roots
 Lateral cord branches:
o suprascapular nerve,
o lateral pectoral nerve,
o musculocutaneous nerve,
o median nerve
 Medial cord branches:
o median nerve,
o ulnar nerve (funny bone),
o medial antebrachial cutaneous nerve,
o medial brachial cutaneous nerve,
o medial pectoral nerve.
 Posterior cord branches:
o radial nerve,
o axillary nerve,
o lower and upper subsacuplar nerve on either side of the thoracodorsal nerve.
Chapter 10: Shoulder Joint
 Shoulder joint aka glenohumeral-
o ball-and-socket joint with movement in all three plane and around all three axes.
o Humeral head articulating with the glenoid fossa of the scapula.
o One of the most movable joints and least stable;
o it is a shallow joint
 Joint motions Fig 10-2 pg 146:
o flexion,
o extension, and
o hyperextension,
o abduction/adduction,
o medial (internal) & lateral (external) rotation,
o horizontal abduction & adduction,
o circumduction,
o scaption (combo of flexion and abduction; forward elevation)
 Fig 10-3 pg 147- lateral view of arthrokinematic motions. Convex on Concave; the
arthrokinematics or the joint movements are opposite from the osteokinematics or the
bone itself movements. Convex head of humerus moving on a concave glenoid fossa.
Arthrokinematics and osteokinematics are opposite.
Ex: During shoulder joint extension, when your arm goes more posteriorly, the humeral
head glides anteriorly. During shoulder joint flexion, the arm goes more anteriorly, the
humeral head glides posteriorly.
 Scapula fossas and other landmarks:
o glenoid fossa,
o glenoid labrum,
o subscapular fossa,
o infraspinous fossa,
o supraspinous fossa,
o axillary border,
o acromion process
 Fig 10-4 pg 147. Labrum is a fibrous cartilaginous cup around the glenoid fossa that
increases the depth of the fossa and leads to more stability of the glenohumeral joint. Still
no bony stability but this helps with stability by keeping the humeral head within the
glenoid fossa.
 Humerus has:
o head,
o surgical neck,
o anatomical neck,
o shaft,
o greater tubercle,
o lesser tubercle,
o deltoid tuberosity,
o bicipital groove,
o bicipital ridges
 Fig 10-5 pg 148. Most proximal side has the humeral head and that’s where we get
gliding.
- Anatomical neck: between the head and the greater tubercle (where we have muscular
attachment)
- Surgical neck: below the greater and lesser tubercle. Where a cut is made when there
is a joint replacement. Where we repair when there is a bad fracture
 Ligaments and other structures:
o joint capsule,
o coracohumeral ligament,
o glenoid labrum,
o rotator cuff,
o thoracolumbar fascia
 Fig 10-6, 10-7, 10-8 pg 149.
- Joint capsule has inferior and superior divisions. Thick in posterior view. Dislocation
of the shoulder occurs more anterior because of the thick posterior joint capsule
- Coracohumeral ligament comes over top of the humerus; it attaches to the scapula
then to the superior portion of humeral head. Keeps the humeral head set up into the
glenoid fossa. Damage to it can lead to dislocation of the humerus
- Glenoid labrum in lateral view: cup of glenoid fossa that adds depth to the shallow
joint. Biceps tendon and triceps tendon are around that area. Labrum tears can happen
 Rotator cuff: Fig 10-9 pg 149.
o Allows good function of the arm when doing overhead and overshoulder work.
Tendinous band formed by blending of multiple muscle insertions; Made up of 4
different muscles: supraspinatus (commonly damaged; suraspinatus tendon gets
damaged), infraspinatus, teres minor, and subscapularis. Work together to make
sure there is good muscular control in overhead activities. SITS muscles.
 Thoracolumbar fascia-
o thoracic to sacral tendinous area. Common insertion point for latissimus dorsi
(which attaches to humerus) and adds stability to this muscle. Important for
stability in glutes and abdomen muscles.
 Deltoid:
 o anterior, middle, and posterior. Diff orgin, Same insertion: deltoid tuberosity. All
do shoulder abduction. All innervation is axillary nerves (C5, C6)

 Pectoralis major:
o clavicular portion and sternal portion. All innervation is lateral and medial pectoral
nerves (C5, C6, C7, C8, T1)
 Muscles of the shoulder joint:
o latissimus dorsi,
o teres major (lats little helper),
o supraspinatus,
o infraspinatus,
o teres minor,
o subscapularis,
o coracobrachialis
 Triceps run between the teres minor and teres major. Fig 10-16 pg 155
 Fig 10-20 pg 156 and Fig 10-21 pg 157: anatomical relationships between the muscles
 Fig 10-22 pg 157. Supraspinatus tendon runs underneath the acromion process.
Subacromial bursa is a pillow that protects the bone from friction. The bursa can become
inflamed and painful
 Fig 10-23 pg 157. Force coupling of the deltoid and rotator cuff muscles. Deltoid is
pulling up, rotator cuff muscles are pulling the head of the humerus down into the glenoid
fossa. If the rotator cuff muscles are weak or injured the deltoid could overrule them and
pull the humerus up and inhindge on the acromion process
 Common Shoulder Pathologies:
- Acromioclavicular separation:
o clavicle where it attaches on acromion process on the scapula the ligaments
tend to tear
- Clavicular fracture:
o cant cast the area, so heal on its own or a plate is involved
- Shoulder dislocation:
o humeral head slides anteriorly out of the glenoid fossa, arm will hang
- Impingement syndrome:
o overuse condition that involves compression between the acromial arch,
humeral head, and soft tissue structures. Space under acromion process hook.
Bursitis, tendonitis, etc.
- Adhesive capsulitis:
o inflammation of fibrosis of the shoulder joint capsule which leads to tightness
and strict movement. Frozen shoulder.
- Rotator cuff tear:
o one of the 4 muscles is torn. Distal tendinous insertion of the muscles on the
greater/lesser tubercle area of humerus