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Flashcards in Ioints Of The Upper Limb Deck (63):
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Movement of pectoral girdle

Sternoclavicular, acromioclavicular and glenohumeral joints

1

Elevation

Initial 30 degrees may occur without scapular motion
2:1 ratio
Every 3 degrees of movement, 2 degrees at glenohumeral joint and 1 degree at scapulothoracic joint
Scapulohumeral rhythm

2

Sternoclavicular joint general

Synovial articulation between Sternal end of the clavicle and the manubrium of the sternum and the first costal cartilage
Saddle type of joint but functions as a ball and socket joint

3

Sternoclavicular joint divisions

Divided into two compartments by an articular disc
Disc attached to anterior and posterior SC ligaments and the inter clavicular ligament
Serves as a shock absorber of forces transmitted along clavicle from upper limb
Fracture of clavicle more common than dislocation

4

Joint capsule of SC joint

Surrounds joint, including epiphysis at Sternal end of clavicle
Fibrous layer of capsule attached to margins of articular surfaces
Synovial membrane lines internal surfaces of fibrous layer

5

Ligaments of SC joint

Anterior and posterior SC ligaments reinforce capsule anteriorly and posteriorly
Inter clavicular ligament strengthens capsule superiorly. From Sternal end of one clavicle to Sternal end of the other, also attached to superior border of manubrium
Costoclavicular ligament anchors inferior surface of Sternal end of clavicle to the 1st rib and it's costal cartilage,limiting elevation of the pectoral girdle

6

Movement of SC joint

Very strong but significantly mobile
During full elevation if limb, clavicle is raised to approximately 60 degree angle
Can also be moved anteriorly or posteriorly over a range up to 25 to 30 degrees

7

Blood and nervous supply to SC joint

Internal thoracic and suprascapular arteries
Branches of medial supra clavicular nerve and subclavian nerve supply SC joint

8

Acromioclavicular joint general

Plane synovial articulation
2 to 3 cm from the point of the shoulder, formed by the lateral part of the acromion of the scapula
The acromial end of the clavicle articulates with the acromion
The articular surfaces, covered with fibrocartilage are separated by an incomplete wedge shaped articular disc

9

Joint capsule of AC joint

Sleeve like, relatively loose fibrous layer is attached to margins of articular surfaces
Synovial membrane lines internal surface of fibrous layer of the capsule
Relatively weak but strengthened superiorly by fibers of the trapezius

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Ligaments of AC joint

AC ligament
Coracoclavicular ligament: conoid and trapezoid

11

AC ligament

AC ligament: fibrous band from acromion to clavicle: strengthens AC joint superiorly

12

Coracoclavicular ligament

Coracoclavicular ligament: gives most of strength: prevent acromion from being driven under clavicle even when joint is separated: extra articular, strong, subdivided into conoid and trapezoid ligaments, located several centimeters from joint, clavicle to coracoacromial process of scapula. Provides means by which scapula and free limb are suspended from clavicle
Conoid: vertical: apex attached to root of coracoid process, base is to conoid tubercle on inferior surface of clavicle
Trapezoid: nearly horizontal: attached to superior surface of coracoid process and extends laterally to trapezoid line on the inferior surface of the clavicle

13

AC joint blood and nervous supply

Suprascapular and thoraco-acromial arteries
Supra clavicular lateral pectoral and axillary nerves

14

Glenohumeral joint general

Ball and socket synovial joint
High mobility, low stability
Large spherical humeral head articulates with relatively small and shallow glenoid cavity which is deepened slightly by ring like, fibrocartiliginous glenoid labrum
Both articular surfaces: hyaline cartilage
Glenoid cavity accepts about 1/3 of humeral head, which is held in cavity by Rotator cuff

15

Glenohumeral joint joint capsule

Loose fibrous layer surrounds glenohumeral joint and is attached medially to margin of glenoid cavity and laterally to anatomical neck of the humerus. Superiorly encloses proximal attachment of long head of biceps to supra glenoid tubercle
Inferior part of capsule not reinforced by rotator cuff: weakest: lies in folds when arm adducted: becomes taut when abducted
Synovial membrane lines internal surface and reflects onto humerus as far as articular margin of head. Also forms tubular sheath for tendon of long head of biceps brachii
Anteriorly, Communication between subscapular bursa and synovial cavity of joint

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Ligaments of glenohumeral joint

Glenohumeral, coracohumeral, transverse humeral ligaments, coraco-acromial arch, coraco-acromial ligament

17

Glenohumeral ligaments

Evident only on internal aspect of glenohumeral joint capsule
Strengthen anterior aspect of capusle

18

Coracohumeral ligament

Strong band that passes from base of coracoid process to anterior aspect of greater tubercle, strengthens glenohumeral capsule superiorly

19

Transverse humeral ligament

Broad fibrous band that runs from greater to lesser tubercle, bridging over the intertubercular sulcus and converting the sulcus into a canal for the tendon of the long head of biceps brachii and it's synovial sheath

20

Coraco-acromial arch

Extrinsic, protective structure formed by smooth inferior aspect of acromion and coracoid process of the scapula, with coraco- acromial ligament spanning between them
Overlies head of humerus, preventing its superior displacement from glenoid cavity
So strong that forceful superior thrust of humerus will fracture shaft of humerus or clavicle first

21

Blood supply and innervation of glenohumeral joint

Anterior and posterior circumflex humeral arteries and branches of suprascapular artery
Suprascapular, axillary and lateral pectoral nerves supply joint

22

Bursae around glenohumeral joint

Subacromial or sub deltoid bursa and subscapular bursa

23

Subacromial or sub deltoid bursa

between acromion, coracoacromial ligament, and deltoid superiorly, and supraspinatus tendon and joint capsule of glenohumeral joint inferiorly. Facilitates movement of supraspinatus tendon under coracoacromial arch and of deltoid over joint capsule and greater tubercle of humerus

24

Subscapular bursa

Between tendon of subscapularis and neck of scapula
Protects tendon where it passes inferior to root of coracoid process and over neck of scapula
Usually communicates with cavity of glenohumeral joint through an opening in the fibrous layer of joint capsule

25

Rotator cuff injuries

Usually repetitive use of upper limb above the horizontal
Tendinitis of rotator cuff, usually supraspinatus tendon
Cannot initiate abduction if upper limb
If passively abducted 15 degrees or more, deltoid takes over

26

Dislocation of acromioclavicular joint

Easily injured by direct blow, fall on shoulder or outstretched limb
Shoulder separation
Severe when both AC and coraco clavicular ligaments are torn
When coraco clavicular ligament tears, shoulder separates from clavicle and falls because of weight of limb
Makes acromion more prominent and clavicle may move superior to acromion

27

Dislocation of glenohumeral joint

Most in inferior direction but described as anterior or (more rare) posterior
Anterior: more often in young adults: excessive extension and lateral rotation, head of humerus driven infero anteriorly
Axillary nerve may be injured
Capsule torn
Strong adductors and flexors may pull into sub coracoid position

28

Calcific supraspinatus tendinitis

Males 50 and up after unusual or excessive use of glenohumeral joint
Calcific scapulohumeral bursitis
Calcium deposits in supraspinatus tendon irritate subacromial bursa
No pain in adduction
Pain in 50-130 degrees of abduction

29

Adhesive capsulits of glenohumeral joint

Frozen shoulder
Caused by adhesive fibrosis and scarring between inflamed capsule of glenohumeral joint, rotator cuff, subacromial bursa and deltoid
Difficulty abducting arm but can obtain apparent abduction of 45 degrees by elevating and rotating scapula
Initiated by glenohumeral dislocations, Calcific supraspinatus tendinitis, partial tearing of rotator cuff, bicipital tendinitis

30

Movements of glenohumeral joint

Flexion extension
Abduction, adduction
Rotation
Circumduction

31

Things affecting movement at glenohumeral

Lateral rotation increases range of abduction
When arm is abducted without rotation, greater tubercle contacts coracoacromial arch preventing further abduction
If Arm is then laterally rotated 180 degrees, tubercles are rotated posteriorly and more articular surface becomes available to continue elevation
Stiffening or fixation of joints of pectoral girdle (ankylosis) results in a much more restricted range of movement

32

elbow joint general

hinge type of synovial joint
located 2 to 3 cm inferior to the humeral epicondyles
spool shaped trochlea and spheroidal capitulum of the humerus articulate with the trochlear notch of the ulna and the slightly concave superior aspect of head of radius, respectively

33

articulation and joint capsule of elbow joint

fibrous layer of joint capsule surrounding joint is attached to humerus at margins of lateral and medial ends of articular surfaces of capitulum and trochlea
anteriorly and posteriorly, it is carried superiorly, proximal to the coronoid and olecranon fossae
synovial membrane lines internal surface of fibrous layer of joint capsule and intracapsular nonarticular parts of humerus. continuous inferiorly with synovial membrane of proximal radio ulnar joint

34

ligaments of elbow joint

collateral ligaments of elbow joint: strong triangular bands that are medial and lateral thickenings of fibrous layer of the joint capsule
radial collateral ligament, anular ligament of radius, ulnar collateral ligament

35

radial collateral ligament

: lateral, fan like, extends from the lateral epicondyle of humerus and blends distally with anular ligament of radius:

36

anular ligament of radius

encircles and hold head of radius in radial notch of the ulna, forming proximal radio-ulnar joint and permitting pronation and supination of forearm

37

ulnar collateral ligament

medial, triangular, extends from medial epicondyle of humerus to coronoid process and olecranon of ulna
three bands:
1. anterior cord like band: strongest
2. posterior fan like band: weakest
3. slender oblique band: deepens socket for trochlea of humerus

38

movements of elbow joint

flexion and extension
long axis of fully extended ulna makes 170 degree angle with long axis of humerus: carrying angle
obliquity of angle is more pronounced in women than in men

39

blood supply and innervation of elbow joint

arteries derived from anastomosis of arteries around elbow joint
supplied by musculocutaneous, radial and ulnar nerves

40

bursae around elbow joint

intratendinous olecranon bursa: sometimes present in tendon of triceps brachii
subtendinous olecranon bursa: located between olecranon and triceps tendon, just proximal to its attachment to the olecranon
subcutaneous olecranon bursa: located in subcutaneous connective tissue over olecrana

41

bicipitoradial bursa

or biceps bursa
separates biceps tendon from anterior part of radial tuberosity

42

proximal radio-ulnar joint general

pivot type of synovial joint that allows movement of the head of the radius on the ulna

43

articulation and joint capsule of proximal radio-ulnar joint

head of radius articulates with radial notch of ulna
fibrous layer of joint capsule encloses joint and is continous with that of elbow joint
synovial membrane lines internal surface of fibrous layer and nonarticulating aspects of bones
synovial membrane is inferior prolongation of synovial membrane of elbow joint

44

ligaments of proximal radio ulnar joint

anular ligament: attaches to ulna, anterior and posterior to radial notch, which forms a collar that, with the radial notch, forms a ring that completely encircles the head of the radius. deep surface lined with synovial membrane which continues distally as a sacciform recess of the proximal radio-ulnar joint on the neck of the radius
arrangement allows radius to rotate within anular ligament without binding, stretching or tearing synovial membrane

45

elbow extension joints

humero-ulnar
humeroradial

46

elbow extension limiting structures

musces: flexor muscles of elbow
joint capsule: anteriorly
bony apposition: between olecranon of ulna and olecranon fossa of humerus

47

elbow flexion joints

humero-ulnar
humeroradial

48

elbow flexion limiting structures

muscle: triceps brachii
joint capsule: posteriorly
soft tissue:apposition between anterior forearm and arm
bony apposition: between head of radius and radial fossa of humerus

49

elbow pronation joints

humeroradial, proximal radio-ulnar, distalradio-ulnar, interosseus membrane

50

elbow pronation limiting structures

muscles:supinator, biceps brachii
ligaments: dorsal inferior radio-ulnar, interosseus membrane
bony apposition of radius on ulna

51

elbow supination joints

humeroradial
proximal radio ulnar
distal radio ulnar

52

elbow supination limiting structures

muscles: pronator teres, pronator quadratus
ligaments: anterior inferior radio ulnar, interosseus membrane

53

distal radio ulnar joint general

pivot type of synovial joint
radius moves around the relatively flexed distal end of the ulna

54

articulation and joint capsule of distal radio-ulnar joint

fibrocartiliginous articular disc of the distal radio-ulnar joint binds theend of the ulna and radius together. base of disc attaches the medial edge of ulnar notch of radius, and apex is attached to the lateral side of the base of styloid process of ulna
proximal surface of this triangular disc articulates with the distal aspect of the head of the ulna.
sacciform recess of distal radioulnar joint is extension of synovial membrane

55

ligaments of distal radio-ulnar joint

anterior and posterior ligaments strengthen the fibrous layer of joint capsule. relatively weak

56

movements of proximal and distal radio-ulnar joints

pronation and supination: head of radius rotates within the cup shaped anular ligament and the distal end of the radius rotates around the head of the ulna

57

arteries and nerves of proximal and distal radio-ulnar joints

proximal: supplied by radial portion of peri-articular arterial anastomosis of elbow joint. innervated by musculocutaneous, median and radial nerves
distal: anterior and posterior interosseous arteries and nerves
pronation: median nerve
supination: musculocutaneous and radial

58

bursitis of elbow

subcutaneous olecranon bursitis: students elbow
excessive friction between triceps tendon and olecranon
pain severe during flexion of forearm because of pressure exerted on inflamed subtendinous olecranon bursa by triceps tendon

59

avulsion of medial epicondyle

in children, can result from a fall that causes severe abduction of external elbow
traction on ulnar collateral ligament pulls medial epicondyle distally
traction injury of the ulnar nerve is a complication of the abduction type of avulsion of the medial epicondyle

60

ulnar collateral ligament reconstruction

rupture, tearing and stretching more common because of throwing
reconstruction: "Tommy John procedure" : transplant of a long tendon from contralateral forearm or leg

61

dislocation of elbow joint

posterior dislocaion may occur when children fall on their hands with their elbow flexed

62

subluxation and dislocation of radial head

nurse maids elbow
dislocation of head of radius, tear of anular ligament