1. WINDSOR UNIVERSITY SCHOOL OF MEDICINE St.Kitts
DEPARTMENT OF ANATOMY
UPPER LIMB
SHOULDER

2. SHOULDER
The shoulder is the region of upper limb attachment to the trunk and neck.

3. 1
A large muscle that arises from two heads flexes and medially rotates the arm. It is innervated by nerves arising from different cords of the brachial plexus. This is the:
A.Latissimus dorsi
B.Trapezius
C.Deltoid
D.Subscapularis
E.Pectoralis major

4. Bones of the Shoulder Girdle
Clavicle and scapula, which form the pectoral girdle (shoulder girdle)
The proximal end of the humerus.

5. Muscles
Shoulder Region

6. Anterior Axioappendicular Muscles of the Upper Limb
PECTORALIS MAJOR
PECOTORALIS MINOR
SUBCLAVIUS
SERRATUS ANTERIOR

7. PECTORALIS MAJOR N. supply: Medial and lateral pectoral nerves
Origin: Clavicle, sternum, and upper six costal cartilages
Insertion : Lateral lip of bicipital groove of humerus
N. supply: Medial and lateral pectoral nerves
Action : Adducts arm and rotates it medially; clavicular fibers also flex arm

8. PECTORALIS MAJOR

9. PECOTORALIS MINOR N. supply: Medial pectoral nerve
Origin: Third, fourth, and fifth ribs
Insertion : Coracoid process of scapula
N. supply: Medial pectoral nerve
Action: Stabilizes scapula by drawing it inferiorly

10. SUBCLAVIUS N. supply: Nerve to subclavius
Origin: First costal cartilage
Insertion : Clavicle
N. supply: Nerve to subclavius
Action: Depresses the clavicle

11. SERRATUS ANTERIOR N. supply: Long thoracic nerve
Origin: Upper eight ribs
Insertion :Anterior surface of medial border of scapula
N. supply: Long thoracic nerve
Action: Protracts scapula and rotates scapula

12. Paralysis of the Serratus Anterior(winged scapula )
Due to loss of Innervation-long thoracic nerve
When the serratus anterior is paralyzed owing to injury to the long thoracic nerve, the medial border of the scapula moves laterally and posteriorly away from the thoracic wall, giving the scapula the appearance of a wing.

13. 2
All the following muscles have a relationship to the scapula. If paralyzed, which muscle results in winging of the scapula with inability to elevate the arm above the horizontal? A .Serratus anterior B. Latissimus dorsi C .Levator scapulae D. Rhomboid major E .Deltoid

14. Posterior Axioappendicular Muscles
The posterior axioappendicular muscles attach the superior appendicular skeleton (of the upper limb) to the axial skeleton (in the trunk).
1.Trapezius
2.Latissimus dorsi
3. Rhomboid major and minor
4. Levator scapulae

15. Trapezius N. supply: Spinal part of accessory nerve (motor)
Origin: Occipital bone, ligamentum nuchae, spine of seventh cervical vertebra, spines of all thoracic vertebrae
Insertion : Upper fibers into lateral third of clavicle; middle and lower fibers into acromion and spine of scapula
N. supply: Spinal part of accessory nerve (motor)
Action: Upper fibers elevate the scapula; middle fibers pull scapula medially; lower fibers pull medial border of scapula downward

17. Injury of the Accessory Nerve (CN XI)
The primary clinical manifestation of accessory nerve palsy is a marked ipsilateral weakness when the shoulders are elevated (shrugged) against resistance.

18. Latissimus dorsi N. supply:Thoracodorsal nerve
Origin: Iliac crest, lumbar fascia, spines of lower six thoracic vertebrae, lower three or four ribs, and inferior angle of scapula
Insertion: Floor of bicipital groove of humerus
N. supply:Thoracodorsal nerve

19. Latissimus dorsi Action:
Extends, adducts, and medially rotates the arm

20. Injury of the Thoracodorsal Nerve
Surgery in the inferior part of the axilla puts the thoracodorsal nerve supplying the latissimus dorsi at risk of injury.
With paralysis of the latissimus dorsi, the person is unable to raise the trunk with the upper limbs, as occurs during climbing.

21. Levator Scapulae N. supply:dorsal scapular nerve
Origin: Transverse processes of first four cervical vertebrae
Insertion: Medial border of scapula
N. supply:dorsal scapular nerve
Action:Elevates scapula

22. Rhomboids minor and major
N. supply: Dorsal scapular nerve
Action: Retracts scapula

23. 1.
An 34 year old man, bleeding from a stab wound in the neck, is brought to the emergency department. After the bleeding has been controlled, further examination indicates that her left shoulder is lower than the right shoulder. Which of the following nerve is most likely injured?
A Long thoracic
B  Dorsal scapular
C Axillary
D Suprascapular
E Spinal accessory

24. 2.
A 22 year old woman sustains a traumatic injury to the axilla that severely damages the thoracodorsal nerve. Which of the following movements is most likely affected in this patient?
 a Adduction
B. Flexion
C Lateral rotation
D  Protraction
E Supination

25. Scapulohumeral Muscles
The six scapulohumeral muscles are relatively short muscles that pass from the scapula to the humerus and act on the glenohumeral joint.
1.Deltoid
2.Teres major
3.Teres minor
4.Supraspinatus
5.Infraspinatus
6.Subscapularis

26. Deltoid N. supply: Axillary nerve
Origin: Lateral third of clavicle, acromion, spine of scapula
Insertion: Middle of lateral surface of shaft of humerus
N. supply: Axillary nerve

27. Deltoid
Action:
Anterior part: flexes and medially rotates arm Middle part: abducts arm Posterior part: extends and laterally rotates arm

28. Testing deltoid muscle
The examiner resists the patient's abduction of the limb by the deltoid.
If the deltoid is acting normally, contraction of the middle part of the muscle can be palpated.

29. Injury to the Axillary Nerve
The deltoid is a common site for the intramuscular injection of drugs.
The axillary nerve runs transversely under cover of the deltoid at the level of the surgical neck of the humerus.
The deltoid atrophies when the axillary nerve (C5 and C6) is severely damaged.

30. Deltoid atrophy

31. Teres Major N. supply:Lower subscapular nerve
Origin: Lower third of lateral border of scapula
Insertion:Medial lip of bicipital groove of humerus
N. supply:Lower subscapular nerve
Action:Adducts and medially rotates arm

33. Rotator Cuff Muscles
Four of the scapulohumeral muscles supraspinatus, infraspinatus, teres minor, and subscapularis (referred to as the SITS muscles) are called rotator cuff muscles because they form a musculotendinous rotator cuff around the glenohumeral joint.

34. Supraspinatus N. supply: Suprascapular nerve
Origin: Supraspinous fossa of scapula
Insertion: Superior facet of greater tubercle of humerus
N. supply: Suprascapular nerve
Action: Initiates and assists deltoid in abduction of arm and acts with rotator cuff muscles.

35. Infraspinatus N. supply: Suprascapular nerve
Origin: Infraspinous fossa of scapula
Insertion: Middle facet of greater tubercle of humerus
N. supply: Suprascapular nerve
Action: Laterally rotates arm and stabilizes shoulder joint

36. Teres minor N. supply:Axillary nerve
Origin: Middle part of lateral border of scapula
Insertion: Inferior facet of greater tubercle of humerus
N. supply:Axillary nerve
Action:Laterally rotates arm and stabilizes shoulder joint

37. Subscapularis N. supply: Upper and lower subscapular nerves
Origin: Subscapular fossa (most of anterior surface of scapula)
Insertion: Lesser tubercle of humerus
N. supply: Upper and lower subscapular nerves
Action: Medially rotates and adduct arm

38. Rotator Cuff Injuries and the Supraspinatus
Trauma may tear or rupture one or more of the tendons of the SITS muscles; that of the supraspinatus is most commonly involved.

39. 1.
Which of the following muscles listed below is the rotator cuff muscle involved in medial rotation of the humerus?
A Supraspinatus
B Subscapularis
C Infraspinatus
D Teres minor
E Teres major

40. 2.
A 31 year old man is unable to raise his right arm above his head 3 weeks after dislocating his shoulder in a foot ball game. Examination shows absence of rounded contour of the shoulder. Which of the following nerves was most likely injured?
A. Musculocutaneous
B. Median
C. Axillary
D. Ulnar
E.Radial

41. Gateways to the posterior scapular region

42. Arteries and nerves associated with gateways in the posterior scapular region

43. QUADRANGULAR SPACE: Superior border: Teres Minor Inferior border:
Teres Major
Lateral border:
Surgical neck of the humerus
Medial border:
Long Head of Triceps

44. CONTENTS
1- Axillary Nerve
2- Posterir Circumflex Humeral Artery

45. Quadrilateral Space Syndrome
Quadrilateral space syndrome usually happens from overuse, especially with overhead sports like throwing and swimming. The syndrome can also be caused by an injury, like a shoulder dislocation.

46. TRIANGULAR [upper] space
LATERAL BORDER:
Long Head of the Triceps
Upper border:
Teres Minor and subscapularis
Lower border:
Teres Major
CONTENTS
Circumflex Scapular Branch
of the Subscapular artery

47. Lower Triangular Space
Medially
long head of the triceps brachii
Latterly
shaft of the humerus
Superiorly
teres major

48. Contents
1-Radial nerve
2-Profunda brachii artery