Anatomy: Upper Extremity

Application of Health Science Principles 1 2011

Sternoclavicular Joint
Identify the shape of the S/C joint Identify the ligaments around the S/C joint and the movements they restrict.
Consequently, list the movements available to the S/C joint. Are there any other features of the joint which affect function/movement?

Sternoclavicular Joint
Only point of articulation between pectoral girdle, upper limb and trunk.
Medial end of clavicle-convex Manubrium end of sternum is concave

Actions:
Elevation 45, Depression 5 Protraction & retraction 35 Axial Rotation 20-40

Features of Joint:
Saddle or gliding joint Articular disc within the joint Anterior, posterior and interclavicular ligaments Costoclavicular ligs

Sternoclavicular Joint

Acromioclavicular Joint
Identify the shape of the A/C joint Identify the ligaments around the A/C joint and the movements they restrict.
Consequently, list the movements available to the A/C joint. Are there any other features of the joint which affect function/movement?

Acromioclavicular Joint
Lateral end of clavicle articiulates with the acromion process of the scapula The lateral clavicle slightly overlies the flattened acromion. Lateral clavicle - convex Acromion - concave Allows for 20-30 of gliding and rotational movement with other shoulder girdle & joint movements

Acromioclavicular Joint
Features:
Wedge shaped articular disc Superior and inferior A/C ligs Coracoclavicular ligament (Trapezoid/Conoid) Coracoacromial ligament Bursae also found around this joint

Group Work
Consider each of the ligaments of the S/C and A/C joints.

What direction of force or typical impacts would be needed to rupture or avulse each ligament. And what direction would the resultant joint dislocation be in?

Glenohumeral Joint Capsule

Sleavelike fibrous capsule Attaches around the glenoid fossa and around the anatomical neck of the humerus Potential volume of space x 2 size of humeral head & loose fitting and expandable capsule

Extra folds inferiorly when the arm is in the anatomical positionwhy??

but which become increasingly taut in abduction.

Glenohumeral Joint Capsule

The rotator cuff and the capsular ligaments blend into the fibrous capsule, providing extra stability Concept! The anterior capsule is thicker and strengthened due to the presence of the glenohumeral ligaments.
They provide some reinforcement to the capsule anteriorly and help check external rotation.

The coracohumeral ligament strengthens the superior capsule

Important in maintaining glenohumeral relationship Root of the coracoid process to the greater & lesser tubercules, beneath the supraspinatus tendon, and betw the supraspinatus and sunscapularis tendons.

Coracoacromial Arch & Subacromial Space

The subacromial space or subdeltoid space is located betw the top of the humeral head and the coracoacromial ligament and underside of the acromion.

Can anyone list its contents?

1. 2. 3. 4. Supraspinatus muscle & tendon Long Head of the bicipital tendon Part of the superior capsule Subacromial bursa
1. Role of a bursa sac? 2. Supraspinatus & acromion

5. Subdeltoid bursa
Often noted as an extension of the subacromial Its more lateral ; deltoid and the supraspinatus tendon & humeral head

Scapulohumeral Rhythm

Scapulohumeral Rhythm
First 15 of abduction Most of the movement occurs at the glenohumeral joint supraspinatus important at start of movement The shoulder girdle muscles contract to stabilise the scapula. Which ones? Trapezius, levator scapula, rhomboids, serratus anterior, and pectoralis minor Glenohumeral capsule begins to twist medially

Scapulohumeral Rhythm
From 15 30 The deltoid takes over from the supraspinatus to become the prime mover. As it is abducting the arm the humerus is pulled upwards and outwards. Elevation of the clavicle takes place at the SC joint and a gliding movement occurs at the AC joint to accommodate the rotating scapula, thus allowing a greater range of movement to occur in the GH joint. Scapula starts to move around chest wall, it moves forward, elevates and rotates upwards this is due to movement taking place at the SC and AC joints. Which muscles are associated with this scapular movement? Mainly: Serratus anterior and middle fibres of traps. Infraspinatus, teres major and subscapularis create a downward pull to prevent any impingement of soft tissue structures against the acromion. The joint capsule is unfolding, fibres facing anterio-medially tension builds as a result of the twist

Role of the Rotator Cuff in G/H stability

Scapulohumeral Rhythm
At 90
Clavicle reaches a maximum elevation of 30 As the humerus elevates the greater tuberosity begins to approximate the acromial arch and the capsular fibres begin to twist. Tension builds up so much in the capsule that there is a recoil, which takes the humerus from medial rotation into external rotation. This displaces the humeral head posteriorly to prevent the humeral head impinging on the acromial arch As this occurs the subdeltoid bursa pushes in under the arch to avoid impingement. When clavicle reaches full elevation it rotates posteriorly 40 to further facilitate movement of scapula around the chest wall.

Scapulohumeral Rhythm
The combined glenohumeral and scapulothoracic movement contributes to about 160 to the full range of abduction, the remaining movement occurs as a result of the lower cervicals and upper thoracics. From 160
Vertebrae become involved Unilateral abduction cervicals bend to opposite side and upper thoracics extend slightly Bilateral abduction lower cervicals and upper thoracics extend.

So what about flexion?

Flexion
Stage 1: 0 50 Anterior deltoid, coraco-brachialis, clavicular fibres of pec major Movement of flexion at the shoulder opposed by: (keep head in socket) (i) Tension of the coraco-humeral ligament (ii) Resistance of teres minor and infraspinatus Stage 2: 60 120 60 scapula rotation, axial rotation at SC and AC joints. Muscles involved in this are Traps and serratus anterior Stage 3: 120 180 Spinal column movement becomes necessary. Both arms flexed exaggeration of lumbar lordosis by lumbar muscles.

Problem !
What is the likely effect on the glenohumeral joint with paralysis or severe atrophy of the serratus anterior muscle?

Weakness in Middle Traps & Serratus Anterior

Weak middle traps Prolonged low level stretch bad desk posture Reduces scapula adduction strength Problems with providing stability for scapular muscles external rotators Can result in scapular movement instead of humeral. Weakness in serratus anterior Weakness in serratus, traps or both has large affect on total shoulder movement. Impaired function in both flexion and abduction by up to a third May contribute to impingement of sub-acromial space. Client reports pain and weakness with overhead activities.