I.

Introduction to the upper extremity

1. Primitive position- abduction of arm until horizontal, palm facing forward (approximates
pectoral fin of fish)

a. Primitive surfaces. Primitively ventral surface ( anterior-flexor side); primitively dorsal

(posterior or extensor side)

b. Axial borders. Imaginary plane drawn side to side- Preaxial border (cephalad); Postaxial
border (caudad)

2. Early terrestrial adaptation. Brachium rotated 90 deg, extending wrist 90 degrees (

amphibian/ reptilian upper extremity)

3. Late terrestrial adaptation. Humans rotated brachium 90 degrees caudally, flexor surface
facing anteriorly. Anatomic position.

a. Manipulation. From support & propulsion to high intrinsic mobility. Function of upper
extremity is to place hand able to manipulate the environment

b. Grasp. 2-point grasp between thumb & index (only humans).

c. Sensation. Hand is a sophisticated sensory organ

B. Basic organization. The arm, forearm and hand are supported by

the pectoral girdle.
1. Bony support.

a. The only bony articulation between the pectoral girdle and the axial skeleton is through
the clavicle at the sternoclavicular joint.

2. Muscular support.

a. Dynamic stability. Muscles of the pectoral girdle support (stability) and produce
movement. Extensors on the dorsal side, flexors on the ventral side

b. Mobility at the expense of stability. Extreme lateral rotations may result to dislocations
at the genohumeral joint.

C. Regions of the upper extremity

1. Pectoral girdle. Clavicle and scapula.

2. Arm or brachium. Humerus

3. Forearm or antebrachium. Radius and ulna

4. Wrist or carpus. 7 carpal bones in 2 rows and a sesamoid bone

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5. Hand. 5 metacarpals, 14 phalanges

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II. Bones of the pectoral girdle
A. Clavicle.
S-shaped. Between scapula & sternum

1. Location.

a. Articulate with sternum at

sternoclavicular joint, with scapula
at the acromioclavicular joint

2. Ossification.

a. First bone to ossify (5th week fetal

development), last to complete
ossification (21 y.o.). Only bone
formed by intramembranous
ossification

3. Fracture.

a. Common in young to middle age

A. MOI. Fall onto an outstretched arm. Shear forces transmitted from arm to sternum
though clavicle near middle of the S-shaped bone.

B. Bone displacement. Middle 1/3rd upward displacement of proxl fragment

(sternomastoid mm pull), downward displaced distal fragment ( pull of deltoid mm and
gravity)

b. Complications. Nerve damage or internal bleeding (clavicle and first rib)

B. Scapula.
Identify the spine, acromion process,
coracoid process, vertebral border, apex
(inferior border)

Characteristics. Lies against post

border of rib cage. Flat. Inverted
triangle.

a. Spine (subcutaneous,
horizontal). Divides dorsal
surface into supraspinous and
infraspinous fossa

b. Acromion process. Lateral

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expansion of spine. Articulates

 with clavicle. Attachments for trapezius, deltoid mm, end of coracoacromial
ligament
c. Coracoid process. Projects anteriorly. Palpable medial to head of humerus.

Attachments for: pectoralis minor, short head biceps brachii, coracobrachialis muscle.
Coracoacromial ligament transmit tensile forces from coracoid to spine

d.Glenoid fossa. Articulate with head of humerus. Faces laterally, anteriorly and
superiorly, deepened by glenoid labrum

Supraglenoid tubercle- attachment for long head of biceps m.

Infraglenoid tubercle- attachment for triceps m.

C. Humerus.
Identify head, intertubercular groove, greater and lesser tuberosity

1. Head. Covered with hyaline cartilage.

Articulate with glenoid (GH joint)

2. Anatomic neck. Separate head from

metaphysis. Location of epiphyseal
plate which fuses between 19 to 21
y.o.

3. Lesser tuberosity. Anterior, just distal to

anatomic neck, attachment for
subscapularis m.
4. Greater tuberosity. Lateral to anatomic
neck. Attachments for supraspinatus,
infraspinatus, and teres minor mm.
5. Intertubercular or bicipital groove.
Between greater and lesser
tuberosities, contain tendon of long
head of biceps. Bridged by transverse
humeral ligament. Lateral- pectoralis
major, floor- lat dorsi, medial lip- teres
major 3
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III. Articulations of the shoulder joint
A. Sternoclavicular joint
1. Structure.

a. Clavicle with manubrium. Fibrocartilaginous

discs. 2 synovial capsules

2. Movement.

a. 2 deg of freedom

Elevation/depression. AP axis

Protraction/retraction. Vertical axis

Circumduction. Combination of a and b

3. Support.

a. Fibrous capsule supported by strong ligaments, so dislocation is uncommon

Anterior and posterior sterocalvicular joint (between clavicle & manubrium)

Costoclavicular ligament (between clavicle and first rib

B. Acromioclavicular joint.
1. Structure. Clavicle articulate with
acromion

2. Movement. Sliding. Rotation of the

scapula.

3. Support

a. Coracoclavicular lig.
from coracoid process to clavicle,
subdivided into conoid and trapezoid
ligament for superior & inferior
stability
b. Acromioclavicular lig.
Provide AP stability
c. AC subluxation (shoulder
separation)-
result from trauma, downward scapular displacement
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 C. Scapulothoracic joint
1. No bony articulation.
Pseudojoint.
Between subscapularis and serratus
anterior. Movement occurs at the SC
and AC joints
2. Movement.
3 degrees of freedom
a. Protration/retraction. Vertical
axis at SC joint. Scapula slides
anterolaterally and posteromedially
on post thoracic wall
b. Elevation/depression. AP axis of SC joint. Scaula slides cranially/caudally
c. Rotation. AP axis of AC joint. Scapula rotates on post thoracic wall
3. Support.
Clavicle and muscles: Rhomboids, serratus anterior, trapezius, levator scapulae

D. Glenohumeral (scapulohumeral) joint

1. Structure. Glenoid fossa with humeral head. Shallow but deepened by glenoid labrum

2. Movement. Ball & socket joint

a. Flexion/extension

b. Abduction/adduction

c. Internal & external rotation

d. Circumduction

3. Ligamentous support. Lax capsule reinforced

by tough articular ligaments

a. Superior, middle & inferior

glenohumeral ligaments from the glenoid
lip to neck of humerus

b. Coracohumeral ligament.
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Between coracoid & humerus.

 Supports dead weight of the arm

cCoracoacromial ligament.

Between coracoid process and acromion

1) With acromion form the Coracoacromial arch

2) Buttress superior portion of GH joint to prevent superior displacement of humerus

3) Transmit tensile forces from muscles that originate on the coracoid to acromion

4. Dynamic stability.
Shallow, unstable. Reinforced by muscles

a. Rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis. Rotator tear limit
shoulder mobility

b. Tendon of long head of biceps brachii muscle. Forces humeral head medially in the joint

5. Bursae.

a. Subacromial bursa. Between acromion and

supraspinatus m.

1) Subacromial bursitis or calcific deposits of

supraspinatus tendon/ calcific tendinitis

2) Pain associated with subacromial bursitis, felt

during initial stages of abduction of shoulder,
limit shoulder mobility

b. Subdeltoid bursa, Between head of humerus & rotator

cuff muscle

c. Communications. May occasionally communicate but

never with capsule. Communication with capsule indicate
rotator cuff tear

6. Shoulder dislocation.

Due to extreme mobility and shallowness of GH joint

a. Anterior dislocation. Humeral head sits inferior to coracoid process. Axillary nerve injury is
sometimes seen. May also avulse the glenoid rim or labrum which contribute to recurrence

b. Posterior dislocations (uncommon). Humeral head displaced posteriorly, axillary nerve injury
is low.
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IV. Muscle function at the shoulder joint
A. Movement of the pectoral girdle.

1. Organization of Muscles on the pectoral girdle.

Shoulder movement occurs at the SC, AC and scapulothoracic joints

a. Major posterior muscles. 2 layers

1) Superficial: Trapezius muscle

2) Deep: levator scapulae, major rhomboids, minor rhomboids

b. Major anterior muscles.

1) Superficial: pectoralis minor& subclavius

2. Group actions
a. Elevation/depression. AP axis thru SC joint

1) Elevators: cervical portion of trapezius, levator scapulae, rhomboid major, rhomboid minor

2) Depressor: PECTORALIS MINOR, SUBCLAVIUS, thoracic portion of trapezius

1) Protraction/retraction (abduction): pectoralis minor (acting on coracoid process) & serratus anterior (acting on
the vertebral border)

2) Retraction (adduction): rhomboids and trapezius

3) Upward rotation: cervical head of trapezius, serratus anterior, thoracic head of the trapezius

4) Downward rotation. Pectoralis minor and rhomboids

3. Group innervation.
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Muscles acting on the scapula are innervated by spinal accessory nerve (trapezius and sternomastoid muscle),
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thee dorsal scapular nerve (rhomboids), long thoracic nerve (serratus anterior) and twigs from brachial plexus
 Posterior muscles acting of the pectoral girdle

Muscle Origin Insertion Primary action Innervation

Trapezius: Upper Superior nuchal line, Lateral 3rd of clavicle Elevate, rotate Spinal accessory (CN
portion lig nuchae and C7 and acromion scapula upward in XI) and C3-C4
spine process elevation of arm

Trapezius: Lower Spines of T1-T12 Spine of scapula Elevates scapula CN XI and lower
portion cervical nn

Levator scapulae Transverse Superior portion of Elevates scapula Nn to levator

processes C2-C4 the vertebral border scapulae (C3-C4)
of the scapula

Rhomboids minor Lower part of PROXIMAL PORTION Retracts and Dorsal scapular n.
ligamentum nuchae OF spine of scapula elevates scapula (C5, posterior)
and spines of C7-T1

Rhomboids major Spine of T2-T5 Vertebral border of Retracts and Dorsal scapular n.
scapula inferior to elevates scapular
the spine

Trapezius: Upper Superior nuchal line, Lateral 3rd of Elevate, rotate Spinal accessory (CN
portion lig nuchae and C7 clavicle and scapula upward in XI) and C3-C4
spine acromion process elevation of arm

Trapezius: Lower Spines of T1-T12 Spine of scapula Elevates scapula CN XI and lower
portion cervical nn

Levator scapulae Transverse Superior portion of Elevates scapula Nn to levator

processes C2-C4 the vertebral border scapulae (C3-C4)
of the scapula

Rhomboids minor Lower part of PROXIMAL PORTION Retracts and Dorsal scapular n.
ligamentum nuchae OF spine of scapula elevates scapula (C5, posterior)
and spines of C7-T1

Rhomboids major Spine of T2-T5 Vertebral border of Retracts and Dorsal scapular n.
scapula inferior to elevates scapular
the spine
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 Anterior muscles acting on the pectoral girdle
Muscles Origin Insertion Primary Innervation

Sternomastoid Mastoid process of Manubrium and Elevates sternum and Spinal accessory n (CN
cranium proximal 3rd of clavicle, rotates the XI)
clavicle head

Subclavius Costochondral junction Middle 3rd of clavicle Depresses and Nn. to subclavius
of the first rib protracts scapula

Pectoralis minor Outer surface of ribs 3- Coracoid process Depression, protraction Medial pectoral nerve
5 of scapula (elevates
ribs if shoulder is fixed

Serratus anterior Outer surface of ribs 1- Vertebral border of Protracts (abducts) LONG THORACIC n.
9 scapula and rotates scapula
upward

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B. Movement of the arm
1. Muscles acting on the arm
a. Major posterior muscles

1) Superficial layer: Deltoid, latissimus dorsi, triceps

2) Deep layer: SITS muscles (rotator cuff)

b. Major anterior muscles

1) Superficial: deltoid and pectoralis major

2) Deep: coracobrachialis and biceps brachii

2. Group actions
a. Abduction: supraspinatus (initial 15 degrees) and the lateral part of the deltoid
(10-100 degrees)

b. Adduction: pectoralis major, latissimus dorsi, coracobrachialis, teres major, ant and posterior
portion of the deltoid

c. Flexion: deltoid, coracobrachialis, long head of the biceps brachii

d. Extension: posterior part deltoid, latissimus dorsi, teres major, long head of the triceps

e. Rotation

3. Dynamic stability:
rotator cuff muscles

4. Displaced fractures
a. Fracture of the humeral neck: abduction of
proximal fragment (supraspinatus action) and medial
displacement of the distal fragment (traction from
pectoralis major and latissimus dorsi)

b. Fracture in the proximal 1/3rd of the humerus

can lead to lateral and upward displacement of the distal
fragment (traction from deltoid muscles), medial
displacement of proximal fragment (traction from
pectoralis and lattimus dorsi.
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