Session 3

Question 0

How does the trapezius rotate the scapula?

Answer 0

Superior and inferior parts of trapezius act together to rotate scapula upwards and outwards on chest wall (elevating Glenoid cavity)

Serratus anterior muscle also assists in upward rotation of the scapula.

Scapular rotation is responsible for abduction of arm above horizontal (90 degrees)

Question 1

Describe the Trapezius

Answer 1

• Direct attachment of pectoral girdle to trunk
• Act on scapulothoracic joint
• Innervation: spinal accessory nerve (CNXI) and C3, C4 spinal nerves (pain and proprioceptive fibres)
• Divided into 3 parts: superior part elevates scapula (shrugging), middle part retracts scapula (squaring shoulder), inferior part depresses scapula
• Test trapezius by asking patient to shrug shoulder against resistance

Question 2

Describe the Latissimus Dorsi

Answer 2

Wide origin, narrow insertion, fan-shaped

Powerful adductor of arm (climber’s muscle) and extends arm at shoulder joint, medial rotator innervation:

Thoracodorsal nerve (C7, C6, C8 from posterior cord of the brachial plexus)

Question 3

Describe the Levator Scapulae

Answer 3

Elevates Scapula

Rotates scapula depressing Glenoid cavity

Question 4

Describe Rhomboids Major and Minor

Answer 4

2 flat muscles with parallel fibres

Retracts scapula, rotates scapula, depresses Glenoid cavity, fixes scapula to thoracic wall

Innervation: dorsal scapular nerve (C4, C5)

Question 5

Deltoid Muscle

Answer 5

Anterior fibres (Clavicular) - flexion of arm at shoulder joint

Middle fibres (Acromial) - abducts arm from 15-90

Posterior fibres (Spine of Scapula) - extends arm at shoulder joint, lateral rotation

Nerve supply: axillary nerve C5, C6

Question 6

Describe the Teres Major

Answer 6

Adducts arm and medial rotation

Helps extend the arm from the flexed position

Lower subscapular nerve (C5, C6)

Question 7

Describe the Shoulder Joint

Answer 7

Synovial joint of ball and socket

AKA gleno-humeral joint

Movement occurs at both glenohumeral and in abduction movement in scapulothoracic joints as well

Greatest range of movement of all joints but it is the most commonly disclosed joint.

Mobility is achieved at the cost of stability.

Question 8

Why is the Shoulder Joint unstable?

Answer 8

Glenoid cavity is shallow

Disproportion of articular surfaces - the Glenoid cavity accepts little more than a third of the large, round humeral head

Multi planar movements

Lax capsule: loose fibrous layer of the joint capsule surrounding the joint

Question 9

How is stability of the shoulder joint achieved?

Answer 9

Rotator cuff muscles (most important)

Other muscles

Ligaments

Capsule

• Glenoid labrum deepens the Glenoid cavity

Question 10

Describe the synovial membrane around the shoulder joint

Answer 10

Lines the capsule and bone up to the edge of the articulating surfaces,

A tubular sleeve of synovium reflected back around the biceps long head tendon (which lies within the joint) like a tube

The synovium and joint capsule is continuous with subscapular bursa through a gap in the capsule.

Question 11

What are the intracapsular ligaments of the shoulder joint?

Answer 11

3 glenohumeral ligaments (superior, middle, inferior)

Coracohumeral ligament

Question 12

Describe the glenohumeral ligaments

Answer 12

3 fibrous bands that reinforce the anterior part of the joint capsule

Radiate from the Glenoid labrum at the supraglenoid fossa and blend display with the fibrous layer of the capsule as it is attached to the anatomical neck of the humerus.

Question 13

Describe the coracohumeral ligament

Answer 13

Strong broad band that passes from the base of the CORACOID process to the anterior aspect of the greater tubercle of the humerus

Strengthens joint capsule superiorly

Question 14

What are the extracapsular ligaments of the shoulder joint?

Answer 14

Transverse humeral

Coraco-Acromial ligament

Question 15

Describe the Transverse Humeral Ligament

Answer 15

Broad fibrous band that runs obliquely from greater to lesser tubercle, bridging over the intertubulcular groove.

It holds the synovial sheath and long biceps head tendon in place during movement - maintains stability.

Question 16

Describe the Coracoacrmial Arch

Answer 16

Strong osseoligamentous structure formed by the acromion, CORACOID process and the coraco-Acromial ligament spanning between them.

Structure overlies humeral head

Prevents upper/superior displacement of humerus from Glenoid cavity

Supports joint superiorly

It is so strong that a forceful superior thrust of the humerus will not fracture it; the humeral shaft or clavicle fractures first.

Question 17

How the Rotator Cuff Muscles stabilize the shoulder joint?

Answer 17

Hold the head of the humerus in the Glenoid cavity

Tendons blend with each other as they approach the humeral head to form a cuff which also fuses with capsule and strengthens it

Supraspinatus tendon is separated from the coracoacromial arch by subacromial bursa

Support joint anteriorly, posteriorly and superiorly.

Question 18

What is the space between the acromion and head of humerus?

Answer 18

About 1-1.5 cm

Interposed in this space are: subacromial bursa, rotator cuff tendons, capsule, tendon of long head of biceps

Question 19

What are the other muscles stabilising the shoulder joint?

Answer 19

Deltoid

Long head of biceps

Long head of triceps

Question 20

Describe the subtendinous bursa of subscapularis

Answer 20

Facilitates movement of tendon of subscapularis muscle over scapula - protects tendon where it passes inferior to the root of the CORACOID process and over the neck of the scapula

Communicates with the joint cavity

Question 21

Describe the subacromial bursa

Answer 21

Facilitates movement of supraspinatus tendon under the coracoacromial arch and deltoid muscle over the shoulder joint capsule and the greater tubercle of humerus.

Inflammation of bursa - subacromial bursitis - causes pain on abduction of the arm between 50 and 130 degrees (‘painful arc syndrome’

Question 22

What are the movements of the shoulder joint and muscles that produce them?

Answer 22

Flexion: Pec Major (Clavicular head), anterior fibres of deltoid, coracobrachialis and biceps brachii

Extension: posterior fibres of deltoid, Latissimus dorsi and Teres Major Abduction: Supraspinatus, Deltoid, Trapezius and Serratus Anterior (above 90 by rotating scapula)

Adduction: pec major, latissimus dorsi, teres major, long head of triceps brachii (+gravity in upright position)

Medial rotation: subscapularis, teres major, pec major, lat dorsi

Lateral rotation: infraspinatus and teres minor

Resisting downward dislocation (shunt muscles): deltoid, long head of triceps brachii, coracobrachialis, short head of biceps brachii

Question 23

Describe the neurovascular supply to shoulder joint

Answer 23

Anterior and posterior circumflex humeral arteries and suprascapular artery

Suprascapular, axillary and lateral pectoral nerves from the brachial plexus

Question 24

Which part of the shoulder joint is least supported?

Answer 24

Inferior

Question 25

Describe a dislocation of Glenohumeral joint

Answer 25

Dislocation in inferior direction

Usually caused by trauma on a fully abducted arm

Clinically defined as anterior due to pull of powerful adductors - humeral head comes to lie below the CORACOID process

Capsule and rotator cuff may tear and poor healing may occur leading to recurrent dislocation

Axillary nerve is most likely to be damaged –> paralysis of deltoid muscle loss of sensation (regimental badge area)

Shoulder drops

Posterior dislocations are rare.

Question 26

What are the rotator cuff problems?

Answer 26

Tendons rubbing under coracoacromial arch cause irritation and inflammation of the rotator cuff tendons/subacromial bursa.

Leads to subacromial bursitis (+/- calcification), supraspinatus tendinitis (+/- calcification), rotator cuff injury and degeneration and rupture of tendons.

Question 27

What are the predisposing factors (a combination of factors may be present)?

Answer 27

Repetitive overuse sporting activites (racquet sports, swimming) and work involving overhead use of arms e.g. painting a ceiling

In older people, degenerative changes in tendons

Avascularity of supraspinatus tendon

Slight differences in anatomy may may impingement more likely

Question 28

What is Painful Arc Syndrome?

Answer 28

On abduction of the arm, pain experienced during 50-130 degrees of abduction.

Due to impingement of inflamed rotator cuff tendons or inflamed subacromial bursa between acromion and head of humerus.

Question 29

What can repetitive use of the rotator cuff muscles lead to?

Answer 29

Allows the humeral head and rotator cuff to impinge on the coraco-Acromial arch, producing irritation of the arch and inflammation of the rotator cuff.

As a result degenerative tendinitis of the rotator cuff develops.

Attrition of the supraspinatus tendon may occur.

Question 30

A fall on the shoulder may also tear a previously degenerated musculotendinous rotator cuff. What might have happened?

Answer 30

The intracapsular part of the tendon of the long head of the biceps brachii becomes frayed (even worn away) leaving it adherent to the intertubulcular space.

As a result shoulder stiffness occurs.

Question 31

What happens when the Axillary nerve is damaged e.g. In a surgical neck of humerus fracture?

Answer 31

Deltoid atrophies.

The rounded contour of the shoulder is flattened compared to the undamaged side.

This gives the shoulder a flattened appearance.

Loss of sensation may occur over the lateral side of the proximal part of the arm, the area supplied by the superior lateral cutaneous nerve of the arm (cutaneous branch of the axillary nerve)

Inability to abduct the arm to or above the horizontal level.

Question 32

Describe a normal dislocation of the glenohumeral joint

Answer 32

Presence of the coraco-Acromial arch and support of the rotator cuff are effective in preventing upward dislocation so most dislocations occur in the inferior direction. However they are described clinically as anterior (or more rarely posterior) dislocations, indicating whether the humeral head has descended anterior or posterior to the infraglenoid tubercle and long head of the triceps. The head ends up lying anterior or posterior to the Glenoid cavity.

Question 33

Describe an anterior dislocation of the glenohumeral joint in young adults, particularly athlete

Answer 33

Usually caused by excessive extension and lateral rotation of the humerus.

The head of the humerus is driven infero-anteriorly and the fibrous layer of the joint capsule and glenoid labrum may be stripped from the anterior aspect of the Glenoid cavity in the process.