Anatomy- Ue1

Front 1

Shoulder (Pectoral) Girdle Region

Back 1

a. Bony ring…scapula and clavicle
b. Posterior …attaches to axial skeleton via ”scapthoracic joint” …not a “true” joint
c. Anterior…attaches to axial skeleton via SC joint (true synovial joint)

Front 2

Arm Region

Back 2

a. Region between shoulder and elbow
b. Humerous

Front 3

Forearm Region

Back 3

a. Region between elbow and wrist
b. Radius and ulna bones

Front 4

Hand REgion

Back 4

a. Contains carpals, metacarpals and phalanges

Front 5

Clavicle

Back 5

1. “S” shaped bone, shape allows optimal shoulder elevation
2. Only “connection” of axial skeleton to UE

Articulations
a. Medial: articulates with manubrium, forms SC (sternoclavicular) joint
b. Lateral: articulates with the scapula…forms AC (acromioclavicular) joint

Clinical
a. Fractures – MC at junction between middle and lateral third
b. Severe OA of SC or AC joints – limit functional movement of shoulder

Front 6

Back 6

Acromial end= lateral, acromial facet at end

(also note that inferior surface is rough for articulations/attachments)

Front 7

Back 7

Sternal end- medial, sternal facet at end

Front 8

Back 8

Impression for costoclavicular ligament (inferior surface)- attachment for costoclavicular ligament

Front 9

Back 9

Subclavian Groove (inf surface)

attachment for subclavius muscle

Front 10

Back 10

Trapezoid line (inf surface)

attachment for trapezoid ligament

Front 11

Back 11

Conoid tubercle (inf surface)

Attachment for coronoid ligament

Front 12

Back 12

Deltoid tubercle (superior)

attachment of deltoid muscle

Front 13

Scapula

Back 13

1. triangular flat bone commonly referred to as the “shoulder blade”
2. function; plays critical role in shoulder function

Articulations
a. Scapulothoracic “articulation”
b. Glenohumeral (GH) joint - glenoid fossa of scapula articulates with head of the humerus)
c. AC joint – acromion process of scapula articulates with lateral end of clavicle

Front 14

Back 14

b. Blue- Glenohumeral (GH) joint - glenoid fossa of scapula articulates with head of the humerus)
c. Red- AC joint – acromion process of scapula articulates with lateral end of clavicle

Front 15

Back 15

Acromion- AC jt, deltoid and trap attachment

Front 16

Back 16

coracoid process- short head biceps brachii, coracobrachialis and pec minor attachments

Front 17

Back 17

Spine of scapula- deltoid and trap attachments

Front 18

Back 18

supraspinous fossa- posterior surface, supraspiantous attachment

Front 19

Back 19

infraspinous fossa- posterior surface, infraspinatus attachment

Front 20

Back 20

Subscapular fossa- anterior surface, subscapularis attachment (articulate with ribcage)

Front 21

Back 21

Suprascapular notch

Front 22

Back 22

Supraglenoid tubercle- attachment sites for long head of biceps brachii

Glenoid cavity/fossa

Infraglenoid tubercle- attachement sites for long head of triceps

Front 23

Back 23

Neck

Front 24

Back 24

Superior, Medial and Inferior Borders

Front 25

Back 25

• superior angle – junction of medial and superior borders
• inferior angle – junction of medial and lateral borders
• lateral angle – junction of lateral and superior borders not as “distinct” as the other two angles

Front 26

Humerus

Back 26

aka “arm bone”

Articulations

Glenohumeral joint (GH) - head of humerus articulates with glenoid fossa of scapula

Elbow
• Humeroradial jt – articulation between capitulum of the humerus and radial head
• Humeroulnar joint – articulation between trochlea of the humerus and trochlear notch of ulna

Front 27

Back 27

Head of Humerus

Front 28

Back 28

Anatomical neck
• medial to tubercles, indentation distal to head of humerus provides attachment for articular capsule

Surgical neck
• distal to tubercles, very common site for fracture

Front 29

Back 29

Greater tubercle
• Attachment site for external rotators of rotator cuff muscles
• Supraspinatus, infraspinatus, teres minor muscles

Lesser tubercle
• Attachment site for internal rotator of rotator cuff muscles
• Subscapularis muscle

Front 30

Back 30

Bicipital groove
• Located between lesser and greater tubercles
• Groove for tendon of long head of biceps brachii
• Also attachments for pec major (lateral lip), latissimus dorsi (floor) and teres major (medial lip)

Front 31

Back 31

Deltoid tuberosity
• lateral aspect of humerus near mid-shaft, attachment for deltoid

Front 32

Back 32

Radial (spiral) groove
• “groove” for radial nerve as it travels posterior to humerus

Front 33

Back 33

Lateral and Medial epicondyles= attachement site for extensor muscles of the foramen

Front 34

Back 34

Lateral and medial epicondyles from the other side

Front 35

Back 35

Coronoid fossa and radial fossa- of three distal humerus fossa, anterior surface

capitulum- articulation for radius (round=rotation)

Trochlea- ulna node for flexion

Front 36

Back 36

3rd fossa of distal humerus- Olecranon fossa= posterior surface

Front 37

Back 37

Just some plain film

Front 38

Muscle Hierarchy

Back 38

Muscles of Anterior Thoracoappendicular Region- pc major and minor, subclavius, serratus anterior

Muscles of Posterior Thoracoappendicular Region-

Superficial- Traps, Lats,

Deep- Levator scapulae, Rhomboids

Scapulohumeral Muscles- deltoids, teres major and rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis- all stabilize GH joint)

Front 39

Back 39

Pectoralis major (Lateral and medial pectoral nerves)
• Two heads…clavicular head and sternocostal head
• Inferior border of deltopectorial triangle
• Lateral border forms anterior wall of axilla
• Major function…adduction and medial rotation of the humerus, also assists in flex/extension of the humerus

Front 40

Back 40

Pectoralis minor (medial pectoral nerve)
• Deep to pec major, also part of anterior wall of axilla
• Function…stabilizes the scapula, protraction and depression of the scapula

Front 41

Back 41

Another view of pec minor

Front 42

Back 42

Subclavius (nerve to subclavius)
• Located inferior to clavicle (attachment - subclavian groove of clavicle)
• Function: stabilize clavicle and SC joint…role not completely understood, possible role in protecting subclavian artery

Front 43

Back 43

Serratus anterior (Long thoracic nerve)
• Forms medial wall of axilla
Major functions
(i) protraction and stabilization of the scapula..
(ii) synergistically assists in external rotation of the scapula

Clinical…
(i) Damage to long thoracic nerve results in paralysis/weakness of serratus anterior
(ii) “Winging of the scapula”
(iii) Dysfunction of shoulder abduction

Front 44

Back 44

Serratus Anterior and the long thoracic nerve

Front 45

Back 45

Deltopectoral Triangle (p 685)
a. Deltoid, pec major and clavicle form triangle
b. Significance: cephalic vein passes superficial to deep to join with axillary vein

Front 46

Back 46

Trapezius (CN 11 – Accessory nerve and C2,C3 C4)
(i) Attaches shoulder girdle to axial skeleton
(ii) Three divisions of trapezius
1. all three acting synergistically will retract the scapula
2. upper…elevate, upward rotation, retraction of scapula
3. middle…retraction of scapula
4. lower… depression, upward rotation, retraction of scapula

Front 47

Back 47

Latissimus dorsi (“widest back” – Latin) (Thoracodorsal nerve)
(i) Acts directly on GH joint…indirectly on scapulothoracic jt of the shoulder girdle
(ii) Major function…extends, adducts and medially rotates humerus
(iii) Distal attachment part of “PLT of the biciptal groove”
1. pec major – lateral lip of bicipital groove
2. lats – floor
3. teres major – medial lip of bicipital groove
4. NOTE: all three medially rotate humerus

Front 48

Back 48

PLT

Front 49

Back 49

Levator scapulae (C3, 4 and Dorsal scapular nerve)
(i) Elevates and downward rotation of scapula (with proximal attachment fixed)
(ii) Lateral flex and ipsilateral rotation of the neck (with distal attachment fixed)

Front 50

Back 50

Rhomboid major and minor (Dorsal Scapular nerve)
(i) Deep to the trapezius
(ii) Retract and downward rotation of the scapula, stabilize scapula
(iii) Clinical…damage to dorsal scapular nerve…will see scapula deviate laterally from midline (spine)

Front 51

Back 51

a. Deltoid (Axillary nerve)
• Anterior, middle and posterior head
• Functions
(i) All three synergistically contract to abduct the arm…posterior and anterior heads “stabilize” the humerus during abduction
(ii) With arm in adducted position – deltoid assists in resisting distraction of GH joint
(iii) Individual function
1. Anterior head – flex and IR humerus
2. Middle head – abduct humerus
3. Posterior head – ext and ER humerus

Front 52

Back 52

Teres major (Lower subscapular nerve)
• Forms inferior portion of the posterior wall of the axilla

Function – adduct and IR the humerus
(i) Similar to latissimus dorsi
• Distal attachment part of “PLT of the biciptal groove”
(i) pec major – lateral lip of bicipital groove
(ii) lats – floor
(iii) teres major – medial lip of bicipital groove
(iv) NOTE: all three medially rotate humerus

Front 53

Back 53

Supraspinatus (Suprascapular nerve)
(i) P: Supraspinous fossa
(ii) D: superior facet of greater tuberosity
(iii) N: suprascapular nerve
(iv) A: “isolated” action – abduct humerus

Front 54

Back 54

Infraspinatus (Suprascapular nerve)
(i) P: Infraspinous fossa
(ii) D: inferior to the supraspinatus attachment, middle facet of GT
(iii) N: suprascapular nerve
(iv) A: works synergistically with teres minor to ER (external rotation) humerus

Teres minor (Axillary nerve)
(i) P: superior portion of lateral boredr of scapula
(ii) D: inferior to infraspinatus attachment, inferior facet of GT
(iii) N: axillary nerve
(iv) A: works synergistically with infraspinatus to ER (external rotation) humerus

Front 55

Back 55

Subscapularis (Upper and lower subscapular nerve)
(i) P: subscapular fossa
(ii) D: LESSER tuberosity of humerus
(iii) N: upper and lower subscapularis nerve
(iv) A: IR (internal rotation) of humerus

Front 56

Back 56

Upper Triangle
(i) Superior - teres minor; inferior - teres major; lateral – long head of triceps
(ii) Contents – circumflex scapular artery

Front 57

Back 57

Lower Triangle
(i) Superior – teres major; medial – long head of the triceps; lateral – lateral head of triceps
(ii) Contents – radial nerve and deep artery of the arm (profunda brachii artery)

Front 58

Back 58

Quadranglular Space
• Superior – teres minor and subscapularis
• Inferior - teres major
• Medial – long head of the triceps
• Lateral – surgical neck of the humerus
• Contents – axillary nerve and posterior humeral circumflex artery

Front 59

Back 59

Triangle of Auscultation
• Bordered by trapezius, latissimus dorsi and medial border of scapula
• Breath sounds heard most clearly

Front 60

Division of Blood Supply to Shoulder Girdle and Arm

Back 60

Overview of pathway

Aorta

Subclavian artery…..R/L Difference
• Right: brachiocephalic trunk and then becomes subclavian artery
• Left: subclavian artery

Axillary artery
• Arises from subclavian artery
• Begins: outer border of first rib
• Ends: inferior border of teres major
• Three portions of axillary artery

Brachial artery
• Arises from axillary artery
• Begins: inferior border of teres major
• End: divides into radial and ulna arteries at elbow

Divides into ulna and radial arteries
f. Supplies hand by forming two loops
• Superficial and deep palmer arches

Front 61

Scapular Blood Supply

Back 61

• Major blood vessels that supply the scapula region
(i) Suprascapular a. + Subscapular a. + Transverse Cervical a. (deep branch)

Front 62

Shoulder Blood Supply

Back 62

• Anterior and posterior circumflex humeral arteries branch off the 3rd portion of the axillary artery

Front 63

Elbow & distal humerus blood supply

Back 63

• Deep artery of the arm branches off the brachial artery and wraps posteriorly around the humerus
• Eventually supplies radial collaterals that supply the elbow
• Brachial artery supplies ulnar collaterals to supply the elbow
• Recurrent arteries of radial and ulna arteries form anatomoses with above collaterals

Front 64

Back 64

Front 65

Back 65

Front 66

Back 66

Front 67

Back 67

Front 68

Back 68

Front 69

Axilla

Back 69

Description
1. a pyramidal shaped region at junction of arm and upper thorax

clinical correlation
a. palpation to identify enlarged lymph nodes…lymph drainage of breast drain into nodes located in axilla

Boundaries of axilla
Medial Wall
a. Thoracic wall (1-4 ribs + intercostals); serratus anterior
Lateral Wall
a. Narrow wall formed by the humerus
Anterior Wall
a. Pec major & minor
Posterior Wall
a. Subscaplaris, teres major, latissimus dorsi
Base
a. Axillary fascia and concave skin
Apex
a. Connection between neck and axilla
b. Space between clavicle, 1st rib and scapula

Contents
1. Neurovascular bundle enclosed in axillary sheath
a. Axillary artery and it’s branches
b. Axillary vein
c. Brachial plexus
2. Axillary lymph nodes

Front 70

Brachial Plexus

Back 70

Nerve Supply..overview
1. The nerves that supply the Thoracoappendicular region and UE originate primarily from C3 -T1
2. The network of the ventral rami of the spinal nerves of C5 -T1 form the brachial plexus
a. The ventral rami “merge & divide” to form peripheral nerves
b. The “major” peripheral nerves of the upper limb are…
• Axillary n.
• Musculocutaneous n.
• Radial n.
• Median n.
• Ulnar n.

Brachial plexus is divided into regions
1. Roots
2. Trunks
3. Divisions
4. Cords
5. Branches

Front 71

Back 71

C. Roots
1. formed by ventral rami of spinal nerves C5-T1
2. pass through anterior and posterior scalene muscles
3. roots merge to form the three trunks
4. 2 peripheral nerves emerge from roots
a. dorsal scapular n
b. long thoracic n

Front 72

Back 72

Trunks
1. superior trunk = C5 – C6
2. middle trunk = C7
3. inferior trunk = C8-T1
4. each trunk divides into anterior and posterior to form divisions
5. one peripheral nerve emerges from trunks
a. nerve to subclavius

Front 73

Back 73

Divisions- Anterior Red, Posterior Blue

Divisions
1. Anterior and posterior divisions merge to form cords
2. one peripheral nerve emerges from divisions
a. suprascapular n

Front 74

Back 74

Cords
1. Lateral cord formed from anterior divisions of superior and middle trunk
2. Medial cord formed from anterior division of inferior trunk
3. Posterior cord formed from posterior divisions of all three trunks
4. cords are named according to their relationship with the axillary artery
5. cords divide and merge to form branches (peripheral nerve)

Front 75

Back 75

Branches- medial cord divides into
a. lateral cord and medial cord merge to form median n
b. medial pectoral n
c. medial brachial cutaneous n
d. medial antebrachial cutaneous n
e. ulnar n

Front 76

Back 76

Branches- posterior cord
a. axillary n
b. radial n
c. thoracodorsal n
d. upper subscapular n
e. lower subscapular n

Front 77

Back 77

Branches- lateral cord divides into
a. musculocutaneous n
b. lateral pectoral n
c. lateral cord and medial cord merge to form median n

Front 78

Back 78

Front 79

Roots

Back 79

• dorsal scapular n
(i) pierces through medial scalene
(ii) rhomboids and occasionally levator scapulae
• long thoracic n
(i) serratus anterior

Front 80

Trunks

Back 80

• nerve to subclavius
(i) supplies subclavius

Front 81

Divisions

Back 81

• Suprascapular n
(i) Passes through scapular notch
(ii) Supplies supraspinatus and infraspinatus

Front 82

Lateral Cord Divisions

Back 82

• musculocutaneous n (will discuss in future lecture)
(i) pierces coracobrachialis
(ii) supplies coracobrachialis, brachialis, biceps brachii
(iii) continues on as lateral cutaneous n of the forearm (aka lateral antebrachial cutaneous nerve)
• lateral pectoral n
(i) supplies pectoralis major
• median n…lateral cord and medial cord merge to form median n (will discuss in future lecture)
(i) median nerve supplies wrist/hand flexor muscles of forearm and muscles in thenar region of hand

Front 83

Medial Cord Divisions

Back 83

• median n…lateral cord and medial cord merge to form median n (will discuss in future lecture)
(i) see above
• medial pectoral n
(i) supplies pec minor and major
• medial brachial cutaneous n
(i) supplies skin of medial arm
(ii) DOES NOT supply any muscles
• medial antebrachial cutaneous n
(i) supplies skin of medial forearm
(ii) DOES NOT supply any muscles
• ulnar n (will discuss in future lecture)
(i) supplies muscles of hand and 1½ flexor muscles of forearm

Front 84

Posterior Cord Divisions

Back 84

f. posterior cord divides into
• axillary n
(i) exits through quadrangular space
(ii) supplies deltoid and teres minor
(iii) continues on as superior lateral brachial cutaneous nerve (supplies skin over deltoid region)
• radial n (will discuss in future lecture)
(i) travels posteriorly around humerus in radial (spiral) groove
(ii) supplies triceps brachii, anconeus, brachioradialis and wrist/hand extensor muscles of forearm
• thoracodorsal n
(i) supplies latissimus dorsi
• upper subscapular n
(i) supplies superior portion of subscapularis
• lower subscapular n
(i) supplies superior portion of inferior portion of subscapularis and teres major

Front 85

Arm Divisions

Back 85

A. Anterior and posterior compartments
1. divided by medial and lateral intermuscular septum
2. anterior muscles supplied by musculocutaneous nerve
3. posterior muscles supplied by radial nerve

Front 86

Back 86

1. Coracobrachialis
a. Proximal attachments
• Coracoid process of scapula
b. Distal attachments
• Middle third of medial humerus
c. Musculocutaneous nerve
d. Flex and adduct arm
e. Misc.
• Musculocutaneus nerve pierces through coracobrachialis

Front 87

Back 87

2. Biceps brachii
a. Proximal attachments
• Long head – supraglenoid tubercle of scapula
• Short head – coracoid process of scapula
b. Distal attachments
• Radial tuberosity of radius
• Bicipital aponeurosis – fascia the extends from distal biceps tendon and blends with fascia of the flexor muscles of the forearm; provides protection for structures in cubital fossa
c. Musculocutaneous nerve
d. Flexes arm and forearm, supinates forearm
e. Clinical correlations of biceps brachii:
• transverse humeral ligament “contains” tendon of the long head in bicipital groove…potential for dislocation of tendon
• “biceps tendonitis” – irritation of long head tendon as it passes through bicipital groove
• rupture of long head tendon
• rehab strengthening…optimal in supinated position

Front 88

Back 88

3. Brachialis
a. Proximal attachments
• Distal half of anterior surface of humerus
b. Distal attachments
• Coronoid tuberosity of ulna
c. Musculocutaneous nerve
d. Primary flexor of forearm, flexes forearm in all positions (supinated, neutral or pronated)
e. Clinical
• Rehab strengthening – active in all positions

Front 89

Back 89

4. Triceps brachii
a. Proximal attachments
• Long head – infraglenoid tubercle
• Lateral head – posterior humerus superior to radial groove
• Medial head – posterior humerus inferior to radial groove
b. Distal attachments
• Olecranon process of ulna
c. Radial nerve
d. Primary extensor of forearm
e. Clinical
• Lower cervical SCI – important for therapist to identify if triceps functional…makes significant difference in ADL’s (note: triceps supplied by C7 and C8)

Front 90

Back 90

5. Anconeus
a. Proximal attachments
• Lateral epicondyle of humerus
b. Distal attachments
• Olecranon process of ulna
c. Radial nerve
d. Assists in forearm extension, stabilizes elbow joint

Front 91

Back 91

1. Axillary nerve
a. Branches off posterior cord travels posteriorly
b. Exits through quadrangular space and supplies teres minor and deltoid

Front 92

Back 92

2. Musculocutaneous nerve
a. Begins inferior border of pec minor
b. Pierces coracobrachialis
c. Travels between biceps brachii and brachialis
d. After innervation of biceps and brachialis the nerve becomes lateral cutaneous nerve of the forearm

Front 93

Back 93

Front 94

Back 94

3. Radial nerve
a. Travels posterior to brachial artery and medial to humerus
b. Descends with deep artery of arm (deep brachial artery)
c. Travels posterior to humerus in radial groove
d. Wraps anterior and pierces lateral intermuscular septum
e. Travels between brachialis and brachioradialis to elbow

Front 95

Back 95

Another view of radial nerve

Front 96

Back 96

4. Median Nerve
a. In arm the median nerve follows brachial artery
• Runs lateral to brachial artery and then crosses to run medial to brachial artery
b. The median nerve does not have any branches in axilla or arm

Front 97

Back 97

5. Ulnar nerve
a. Travels medial to brachial artery and anterior to triceps
b. Mid point of humerus it pierces medial intermuscular septum and descends posteriorly
c. Passes posterior to medial epicondyle
d. And enters the forearm
e. The ulnar nerve does not have any branches in axilla or arm

Front 98

Back 98

1. Acromioclavicular joint (AC)
a. Ligaments of AC joint
• AC Ligament – superior and inferior portion
• Coracoclavicular ligament
(i) 2 ligaments that connect coracoid process of scapula and inferior surface of clavicle
1. trapezoid ligament (coracoid process to trapezoid line of clavicle)
2. conoid ligament (coracoid process to conoid tubercle of clavicle)
b. Clinical correlations
• AC joint separation…five grades of AC jt sprain
(i) Type1 = partial injury to AC ligaments, Corcoclavicular is intact
(ii) Type 2 = disruption of AC ligaments, coracoclavicular ligament still intact
(iii) Type 3 = disruption of AC and coracoclavicular ligaments, clavicle displaced superiorly

Front 99

Back 99

AC Joint

Front 100

Back 100

GH Joint

2. Glenohumeral Joint (GH) (pages 788-795)
a. humeral head articulates with glenoid cavity of humerus
b. glenoid labrum increases congruency of the joint
c. ligaments of the GH joint
• glenohumeral ligaments (strengthen anterior aspect of joint)
(i) superior glenohumeral ligament
(ii) middle glenohumeral ligament
(iii) inferior glenohumeral ligament
• coracohumeral ligament
(i) coracoid process to greater tuberosity of humerus
• Coracoacromial ligament
(i) forms part of the coracoacromial arch
1. this arch consists of coracoacromial ligament and acromion process (fig 6.63 in book)
2. “subacromial space”…supraspinatus tendon passes through this space
3. the supraspinatus tendon is protected by subacromial bursa (lies between arch and tendon)
• transverse humeral ligament
(i) acts as a “bridge” over the bicipital groove
(ii) contains long head of biceps tendon

e. Clinical correlations
• Supraspinatus tendonitis
• Impingement syndrome
• Rotator cuff tears
• Dislocation of GH joint

Front 101

Back 101

Glenohumeral Joint (GH) (pages 788-795)
a. humeral head articulates with glenoid cavity of humerus
b. glenoid labrum increases congruency of the joint
c. ligaments of the GH joint
• glenohumeral ligaments (strengthen anterior aspect of joint)
(i) superior glenohumeral ligament
(ii) middle glenohumeral ligament
(iii) inferior glenohumeral ligament
• coracohumeral ligament
(i) coracoid process to greater tuberosity of humerus
• Coracoacromial ligament
(i) forms part of the coracoacromial arch
1. this arch consists of coracoacromial ligament and acromion process (fig 6.63 in book)
2. “subacromial space”…supraspinatus tendon passes through this space
3. the supraspinatus tendon is protected by subacromial bursa (lies between arch and tendon)
• transverse humeral ligament
(i) acts as a “bridge” over the bicipital groove
(ii) contains long head of biceps tendon

e. Clinical correlations
• Supraspinatus tendonitis
• Impingement syndrome
• Rotator cuff tears
• Dislocation of GH joint

Front 102

Back 102

d. bursa of GH joint
• subacromial bursa – see above
• subscapularis bursa
(i) lies between subscapularis tendon and the neck of the scapula
(ii) communicates with GH joint capsule…really extension of GH joint capsule