JOINTS OF UPPER LIMB

Suprascapular
Suprascapular nerve artery and vein A vertical incision is given in the posterior part of the
Suprascapular ligament
capsule of the shoulder joint. The arm is rotated medially
and notch and laterally. This helps in head of humerus getting
separated from the shallow glenoid cavity.
lnside the capsule the shining tendon of long head of
biceps brachii is visible as it traverses the intertubercular
sulcus to reach the supraglenoid tubercle of scapula.
This tendon also gets continuous with the labrum
glenoidale attached to the rim of glenoid cavity.

Spinoglenoid
ligament Type
The shoulder joint is a synovial joint of ball and socket
variety.
Spine (cut)
The articular surface, ligaments, bursae related to this
important joint are explained below.
Fig- 10.3: The suprascapular and spinoglenoid ligaments
Arliculor Sut'oce
The suprascapular lignment: It converts the scapular The joint is formed by articulation of the glenoid cavity
notch into a foramen. The suprascapular nerve passes of scapula and the head of the humerus. Therefore, it is
below the ligament, and the suprascapular artery and also known as the glenohumeral articulation.
vein above the ligament (Fig. 10.3). Structurally, it is a weak joint because the glenoid
The spinoglenoid ligamenf; It is a weak band which cavity is too small and shallow to hold the head of the
bridges the spinoglenoid notch. The suprascapular humerus in place (the head is four times the size of the
nerve and vessels pass beneath the arch to enter the glenoid cavity). However, this arrangement permits
infraspinous fossa. great mobility. Stability of the joint is maintained by
the following factors.
1 The coracoacromial arch or secondary socket for
the head of the humerus (see Fig. 6.8).
DISSECTION 2 The musculotendinous cuff of the shoulder
Having studied all the muscles at the upper end of the (see Fig.6.7).
scapula, it is wise to open and peep into the most mobile 3 The glenoidal labrum (Latin lip) helps in
shoulder joint. deepening the glenoid fossa. Stability is also
ldentify the muscles attached to the greater and provided by the muscles attaching the humerus
lesser tubercles of humerus. Deep to the acromion look to the pectoral girdle, the long head of the biceps
for the subacromial bursa. brachii, the long head of the triceps brachii.
ldentify coracoid process, acromion process and Atmospheric pressure also stabilises the joint.
triangular coracoacromial arch binding these two bones
together. Ligomenls
Trace the supraspinatus muscle from supraspinous I The capsular ligament: It is very loose and permits free
fossa of scapula to the greater tubercle of humerus. On movements. It is least supported inferiorly where
its way it is intimately fused to the capsule of the shoulder dislocations are common. Such a dislocation may
joint. ln the same way, tendons of infraspinatus and teres
damage the closely related axillary nerve (seeFig. 6.72).
minor also fuse with the posterior part of the capsule. . Medially, the capsule is attached to the scapula
lnferiorly trace the tendon of long head of triceps beyond the supraglenoid tubercle and the margins t!
brachii from the infraglenoid tubercle of scapula. E
of the labrum.
Cut through the subscapularis muscle at the neck of . Laterally, it is attached to the anatomical neck of =
.o
scapula. lt also gets fused with the anterior part of CL
the humerus with the following exceptions: IL
capsule of the shoulder joint as it passes to the lesser f
tubercle of humerus.
Inferiorly, the attachment extends down to the
surgical neck. 'o
Having studied the structures related to shoulder
joint, the capsule of the joint is to be opened. Superiorly, it is deficient for passage of the tendon ()
o
of the long head of the biceps brachii. @
 UPPER LIMB

• Anteriorly, the capsule is reinforced by supple­ coracoacromial ligaments from the supraspinatus
mental bands called the superior, middle and tendon and permits smooth motion. Any failure of this
inferior glenohumeral ligaments. mechanism can lead to inflammatory conditions of the
The area between the superior and middle supraspinatus tendon.
glenohumeral ligament is a point of weakness in
the capsule (Foramen of Weitbrecht) which is a Relations
common site of anterior dislocation of humeral • Superiorly: Coracoacromial arch, subacromial bursa,
head. supraspinatus and deltoid (Fig. 10.4).
The capsule is lined with synovial membrane. An • Inferiorly: Long head of the triceps brachii, axillary
extension of this membrane forms a tubular sheath nerves and posterior circumflex humeral artery.
for the tendon of the long head of the biceps • Anteriorly: Subscapularis, coracobrachialis, short
brachii. head of biceps brachii and deltoid.
2 The coracohumeral ligament: It extends from the root • Posteriorly: Infraspinatus, teres minor and deltoid.
of the coracoid process to the neck of the humerus
• Within the joint: Tendon of the long head of the biceps
opposite the greater tubercle. It gives strength to the
brachii.
capsule.
3 Transverse humeral ligament: It bridges the upper part
Blood Supply
of the bicipital groove of the humerus (between the
greater and lesser tubercles). The tendon of the long 1 Anterior circumflex humeral vessels.
head of the biceps brachii passes deep to the 2 Posterior circumflex humeral vessels.
ligament. 3 Suprascapular vessels.
4 The glenoidal labrum: It is a fibrocartilaginous rim 4 Subscapular vessels.
which covers the margins of the glenoid cavity, thus
increasing the depth of the cavity. Nerve Supply
1 Axillary nerve.
Bursae Related to the Joint 2 Musculocutaneous nerve.
1 The subacromial (subdeltoid) bursa (see Figs 6.7 3 Suprascapular nerve.
and 6.8).
2 The subscapularis bursa, communicates with the Movements of Shoulder Joint
joint cavity. The shoulder joint enjoys great freedom of mobility
3 The infraspinatus bursa, may communicate with the at the cost of stability. There is no other joint in the
joint cavity. body which is more mobile than the shoulder joint. This
The subacromial bursa and the subdeltoid bursae are wide range of mobility is due to laxity of its fibrous
commonly continuous with each other but may be capsule, and the four times large size of the head of the
separate. Collectively they are called the subacromial humerus as compared with the shallow glenoid cavity.
bursa, which separates the acromion process and the The range of movements is further increased by

------ Subacromial bursa

Acromion -------::,,o ----- Coracoacromial ligament

Supraspinatus ---� &---- Anterior fibres of deltoid

lnfraspinatus ----llil .,____ Tendon of long head of biceps brachii

Posterior fibres of deltoid ----1

Coracoid process
Teres minor ----Ii Capsule of shoulder joint

Glenoidal labrum ----I

Coracobrachialis
Long head of triceps brachii -----=---lllill
L--- Short head of biceps brachii
Axillary nerve and posterior ------;:;;a.
circumflex humeral vessels P"-- -- Pectoralis major

Teres major ________, ,....._______ Subscapularis

c::
0 �� ------- Brachia! vessels

Fig. 10.4: Schematic sagittal section showing relations of the shoulder joint
 JOINTS OF UPPER LIMB

concurrent movements of the shoulder girdle Flexion

(Figs 10.5a and b and 10.6a to f).
However, this large range of motion makes
glenohumeral joint more susceptible to dislocations,
instability, degenerative changes and other painful
conditions specially in individuals who perform
repetitive overhead motions (cricketers).
Movements of the shoulder joint are considered in
relation to the scapula rather than in relation to the
sagittal and coronal planes. When the arm is by the side Extension
(in the resting position) the glenoid cavity faces almost
equally forwards and laterally; and the head of the
humerus faces medially and backwards. Keeping these
directions in mind, the movements are analysed as
follows. \*
Latera
Flexion and extension: During flexion the arm moves
forwards and medially, and during extension the
arm moves backwards and laterally. Thus flexion
and extension take place in a plane parallel to the
surface of the glenoid cavity (Figs 10.6a and b). (b)
Abduction and adduction take place at right angles Figs 10.5a and b: Planes of movements of the shoulder joint:
to the plane of flexion and extension, i.e. (a) Flexion, extension, abduction, adduction, and (b) medial and
approximately midway between the sagittal and lateral rotations

tt
F

=
.0,
CL
o-
f
C
o
Figs10.6atof: Movementsoftheshoulderjoint:(a)Flexion,(b)extension,(c)abduction,(d)adduction,(e)medialrotation,(f)lateral o
(I)
rotation a
 UPPER LIMB

coronal planes. In abduction, the arm moves glenohumeral joint contributes 100-120 degrees of
anterolaterally away from the trunk. This flexion and 90-120 degrees of abduction to the total 170-
movement is in the same plane as that of the body 180 degrees of overhead movements. This makes the
of the scapula (Figs 10.6c and d). overall ratio of 2 degree of motion of shoulder to 1
3 Medial and lateral rotations are best demonstrated degree of scapulothoracic motion and is often referred
with a midflexed elbow. In this position, the hand to as "scapulo-humeral Rhythm". This for every 15
is moved medially across the chest in medial degrees of elevation, 10 degrees occur at shoulder joint
rotation, and laterally in lateral rotation of the and 5 degrees are due to movement of the scapula.
shoulder joint (Figs 10.6e and f). The humeral head undergoes lateral rotation at
4 Circumduction is a combination of different move- around 90 degrees of abduction to help clear the greater
ments as a result of which the hand moves along tubercle under the acromion. Although deltoid is the
a circle. The range of any movement depends on main abductor of the shoulder, the rotator muscles,
the availability of an area of free articular surface namely the supraspinatus, infraspinatus, teres minor
on the head of thehumerus. and the subscapularis play a very important role in
Muscles bringing about movements at shoulder providing static and dy:ramic stability to the head of
joint are shown in Table 10.1. Abduction has been the humerus. Thus the deltoid and these four muscles
analysed. constitute a "couple" which permits true abduction in
the plane of the body of the scapula.
Anolysis of the ovelheod movement of the shoulder In addition, the scapular muscles such as trapezits,
The overhead movements of flexion and abduction of serratus anterior, levator scapulae and rhomboids
the shoulder are brought about by smooth and provide stability and mobility to the scapula in the
coordinate motion at all joints of the shoulder complex: coordinated overhead motion.
glenohumeral, sternoclavicular, acromioclavicular, and Serratus anterior is chiefly inserted into the inferior
scapulothoracic. Only glenohumeral joint motion angle of scapula. It rotates this angle laterally. At the
cannot bring about the 180 degrees of movement that same time trapezius rotates the medial border at root
takes place in overhead shoulder movements. The of spine of scapula downwards. The slmergic action of
scapula contributes to overhead flexion and abduction these two muscles turns the glenoid cavity upwards
by rotating upwardly by 50-60 degrees. The increasing the range of abduction at the shoulder joint.

Table10.1: Muscles bringing about mwements at the shoulder ioint

Movements Main muscles Accessory muscles
1. Flexion . Clavicular head of the pectoralis major . Coracobrachialis
. Anterior fibres of deltoid . Short head of biceps brachii
2. Extension . Posterior fibres of deltoid . Teres major
. Latissimus dorsi . Long head of triceps brachii
. Sternocostal head of the pectoralis major
3. Adduction . Pectoralis major . Teres major
. Latissimus dorsi . Coracobrachialis
. Short head of biceps brachii
. Long head of triceps brachii
4. Abduction . Both initiate abduction and are involved
throughout the range of abduction from 0'-90'.
. Serratus anterior 90'-1 80'
a Upper and lower fibres of trapezius 90"-180'
ll 5. Medial rotation . Pectoralis major . Subscapularis
E
a Anterior fibres of deltoid
=o a Latissimus dorsi
Et
CL a Teres major
= 6. Lateral rotation . Posterior fibres of deltoid
E
.9 . lnfraspinatus
o
o . Teres minor
a
 JOINTS OF UPPER LIMB

membrane become adherent to each other.

The clavicle may be dislocated at either of its ends. Clinically, the patient (usually 40-60 years of age)
At the medial end, it is usually dislocated complains of progressively increasing pain in the
forwards. Backward dislocation is rare as it is shoulder, stiffness in the joint and restriction of
prevented by the costoclavicular ligament. all movements particularly external rotation,
The main bond of union between the clavicle and abduction and medial rotation. As the contri-
the manubrium is the articular disc. Apart from bution of the glenohumeral joint is reduced, the
its attachment to the joint capsule the disc is also patient shows altered scapulo-humeral rhythm
attached above to the medial end of the clavicle, due to excessive use of scapular motion while
and below to the manubrium. This prevents the performing overhead flexion and abduction.
sternal end of the clavicle from tilting upwards The surrounding muscles show disuse atrophy.
when the weight of the arm depresses the acromial The disease is self-limiting and the patient may
end (Fig. 10.1). recover spontaneously in about two years and
The clavicle dislocates upwards at the acromio- much earlier by physiotherapy.
clavicular joint, because the clavicle overrides the . Shoulder joint disease can be excluded if the
acromion. patient can raise both his arms above the head and
The weight of the limb is transmitted from the bring the two palms together (Fig, 10.9). Deltoid
scapula to the clavicle through the coraco- muscle and axillary nerve are likely to be intact.
clavicular ligament, and from the clavicle to the
sternum through the sternoclavicular joint. Some DANCING SHOUTDER
of the weight also passes to the first rib by the When one flexes the arm at shoulder joint.
costoclavicular ligament. The clavicle usually there is one smallpoint
fractures between these two ligaments (Fig. 10.1).
which you must remember;
Dislocation: The shoulder joint is more prone to
whether it is July or November
dislocation than any other joint. This is due to there is a gamble of two muscles
laxity of the capsule and the disproportionate area
Pectoralis major and Anterior deltoid in the tussles.
of the articular surfaces. Dislocation usually occurs
when the arm is abducted. In this position, the To Teres major, Latissimus dorsi was happily married
head of the humerus presses against the lower but while extending, these got joined with Posterior deltoid.
unsupported part of the capsular ligament. Thus
almost always the dislocation is primarily ln adduction of course,
subglenoid. Dislocation endangers the axillary the joint decided a better course.
nerve which is closely related to the lower part of It went off with two majors (Pectoralis major and Teres
the joint capsule (seeFig.6.12), majo),
Optimum attitude: In order to avoid ankylosis, On the way they stopped for some gazers,
many diseases of the shoulder joint are treated in The two majors danced with Subscapularis
an optimum position of the joint. In this position, during medial rotation,
the arm is abducted by 45-90 degrees. Even Anterior deltoid and Latissimus dorsi,
Shoulder tip pain: Irritation of the peritoneum soon joined the happy flirtation
underlying d'iaphragm from any surrounding
pathology causes referred pain in the shoulder. lf one wants the joint to laterally rotate,
This is so because the phrenic nerve carrying then there is difference in the mate.
impulses from peritoneum and the supraclavicular Posterior deltoid dances with lnfraspinatus,
nerves (supplying the skin over the shoulder) both Even Teres minor comes and triangulates.
arise from spinal segments C3, C4 (Figs 10.7a When just abduction is desired,
and b).
Supraspinatus and Mid-deltoid are required. ll
The shoulder joint is most commonly approached tr
But if Kapil Dev has to do the bowling
(surgically) from the front. However, for come Trapezius and Serratus anterior following.
aspiration the needle may be introduced either =o
anteriorly through the deltopectoral triangle Small muscles provide stability
CL
CL
(closer to the deltoid), or laterally just below the . Large ones give it mobility f
acromion (Fig. 10.8). And shoulder joint dances,
Frozen shoulder: This is a common occurrence. o
dances and dances. o
Pathologically, the two layers of the synovial ao