A&P: Upper Extremity

College of Rehabilitation Sciences

Del La Salle Medical & Health Sciences Institute

De La Salle Medical & Health Sciences Institute

College Of Rehabilitation Sciences
Department Of Physical Therapy

 The upper extremity (UE) is associated with the lateral aspect of the lower portion of the neck and with the thoracic wall.
 It is suspended from the trunk by muscles and a small skeletal articulation between the clavicle and the sternum (sternoclvicular
joint).
 It is divided into regions: (1) the shoulder girdle and arm, (2) elbow and forearm, and (3) wrist and hand regions.
 The upper extremity is highly mobile for positioning the hand in space.

PART I: ANATOMY OF THE SHOULDER COMPLEX

 The shoulder complex, is a set of four articulations involving the sternum, clavicle, ribs, scapula and humerus.
 The joints of the shoulder complex provides extensive range of motion to the upper extremity. This increases the ability to reach
and manipulate objects.

Bones of the Shoulder Complex

 The clavicle or collarbone is the only bony attachment between the trunk and the upper limb.
 These are slender, S-shaped bones that lie horizontally across the anterior part of the thorax superior to the first rib.
 The bone is S-shaped because the medial half is convex anteriorly, and the lateral half is concave anteriorly. The junction between
the two curves is considered as the weakest part of the clavicle and the most commonly fractured site.
 The medial or sternal end of the clavicle is rounded and articulates with the manubrium of the sternum to form the sternoclavicular
joint. On the other hand, the lateral or acromial end is broad and flat. This articulates with the scapula to form the acromioclavicular
joint.
 The inferior surface of the clavicle is rougher compared to its superior surface because of the attachments of muscles and ligaments
that connect the clavicle to the thorax and neck. For example, the conoid tubercle on the inferior surface of the lateral end is a point
of attachment for the conoid ligament.

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

 The scapula, or shoulder blade, is a large, triangular, flat bone in the superior part of the posterior thorax between the levels of the
second and seventh ribs.
 The scapula has these distinct features:
o Two angles (superior angle and inferior angle)
o Three borders (superior border, lateral or axillary border, and medial or vertebral border)
o Two surfaces (costal and posterior surfaces)
 A prominent ridge called the spine of scapula runs diagonally across the posterior surface. The lateral end of the spine of scapula
projects as a flattened, expanded process called the acromion process. This is considered as the highest point of the shoulder.
 On the lateral side, there is a cavity called the glenoid fossa which accepts the head of the humerus to form the glenohumeral
(shoulder) joint.
 The suprascapular notch is a prominent indentation along the superior border of the scapula through which the suprascapular nerve
passes.
 On the posterior surface, there are two fossae: the supraspinous fossa and the infraspinous fossa, which serves as attachment sites
for the supraspinatus and infraspinatus muscles, respectively.
 On the costal surface, is a slightly hollowed-out area called the subscapular fossa which serves as attachment site for the
subscapularis muscle.

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

 The proximal end of the humerus consists of the head, the anatomical neck, the greater and lesser tubercles, the surgical neck, and
the superior half of the shaft of the humerus.
 The head of humerus is a half-spherical in shape and project medially and somewhat superiorly to articulate with the glenoid fossa
of the scapula.
 The anatomical neck is very short and is formed by a narrow constriction immediately distal to the head.
 The greater and lesser tubercles are prominent landmarks on the proximal end of the humerus. They serve as attachment sites for
the rotator cuff muscles. The greater tubercle is found on the lateral side while the lesser tubercle is on the medial. In between the
two tubercles is a sulcus or groove called intertubercular groove/sulcus or bicipital groove. The tendon of the long head of the biceps
brachii passes through this sulcus. The walls (or lips) of the sulcus also provides attachments for muscles that acts on the shoulder
joint.
 An important feature of the proximal humerus is the surgical neck. This is weaker and is a common site for humeral fractures.
 On the posterior aspect of the proximal shaft of the humerus, the spiral groove is located. This is the site where the radial nerve
spirals around the humerus. This also separates the origin of the lateral head of the triceps brachii above and the origin of the medial
head of the triceps brachii below.

 Clavicle. The long axis of the clavicle is slightly above the horizontal plane, resting 20 degrees posterior to the frontal plane.
 Scapula. Since the scapula lies on the posterior ribs and conforms to the upper thorax, therefore it does not lie purely in the frontal
plane. The scapula is rotated on its transverse axis approximately 35 degrees so the glenoid fossa is tilted anterior to the frontal
plane.
 Proximal Humerus. In the frontal plane, the humeral head is angled at 135 degrees to the long axis of the humeral shaft (angle of
inclination). Moreover, the head of the humerus is rotated posteriorly at approximately 30 degrees. This allows the humeral head to
align with the glenoid fossa.

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

Angle of
Inclination

Joints of the Shoulder Complex

 The shoulder complex is composed of six joints. Three of those are considered as true joints, while the other three are considered
as false joints.
 These joints function as a series of links, all cooperating to maximize the range of motion available to the upper limb.

Joints of the Shoulder Complex

True Joints False Joints
1. Sternoclavicular joint 1. Suprahumeral Joint
2. Acromioclavicular joint 2. Bicipital Groove
3. Glenohumeral joint 3. Scapulothoracic Joint

 The sternoclavicular joint (SC) joint is a complex articulation, involving the medial end of the clavicle, the clavicular facet of the
sternum, and the superior border of the cartilage of the first rib.
 This joint serves as a basilar joint of the entire upper extremity, linking the appendicular skeleton with the axial skeleton.

Sternoclavicular Joint
Articulation Sternal end of the clavicle, the manubrium sterni, and the first costal cartilage
Type of Joint Synovial, diarthrodial, saddle
Degrees of freedom 2 degrees of freedom / biaxial
Movements Protraction-Retraction, Elevation-Depression
Ligaments 1. Sternoclavicular ligaments - Divided into anterior and posterior SC ligaments. Limits protraction and
retraction of the clavicle.
2. Interclavicular ligament – connects the medial ends of the right and left claviclesl.
3. Costoclavicular ligament – from the 1st rib to the costal tuberosity; stabilizes the joint through all
motions except for depression.

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

 The acromioclavicular (AC) joint is the articulation between the lateral end of the clavicle and the acromion of the scapula.

Acromioclavicular Joint
Articulation Acromion process of the scapula and the acromial end of the sternum
Type of Joint Synovial, diarthrodial, plane/gliding
Movements Gliding movements during scapular motions
Ligaments 1. Acromioclavicular ligament – reinforces the joint capsule.
2. Coracoclavicular ligaments – provides an important extrinsic source of stability to the AC joint; helps
in suspending the scapula (and the UE) from the clavicle. Two parts of the coracoclavicular ligaments:
a. Trapezoid ligament : extends in superolateral direction from the superior surface of the coracoid
process to the trapezoid line on the clavicle.
b. Conoid ligament : extends almost vertically from the proximal base of the coracoid process to
the conoid tubercle on the clavicle.

 The glenohumeral joint (GH) joint is the articulation formed between the large convex head of the humerus and the shallow cavity
of the glenoid fossa.
 The GH joint operates in conjunction with the moving scapula to produce an extensive ROM of the shoulder.

Glenohumeral Joint
Articulation Head of the humerus and the glenoid cavity/fossa of the scapula
Type of Joint Synovial, diarthrodial, ball and socket
Degrees of freedom 3 degrees of freedom / triaxial
Movements Shoulder flexion-extension, abduction-adduction, and internal-external rotations
Ligaments 1. Glenohumeral ligaments: thickening of the external layers of the anterior and inferior walls of the joint
capsule.
2. Coracohumeral ligament: attaches from the coracoid process to the greater tubercle; it is taut in
adduction and restrains the inferior translation of the humeral head.
3. Transverse humeral ligament: extends between the greater and lesser tubercles and holds the tendon
of the long head of the biceps brachii in the intertubercular groove.

Glenohumeral Ligaments/ Capsular Ligaments

 The glenohumeral ligaments, which serves as one of the static stabilizers of the shoulder joint, is composed of three ligaments:

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

 There is a weakness in the capsule of the GH joint between the superior and middle glenohumeral ligaments. This weak capsular
region is called the foramen of Weitbrecht. This is a frequent site for anterior dislocation of the joint.

Other Structures of the Glenohumeral Joint

Glenoid Labrum Deepens the glenoid fossa. This is continuous with the tendon of the long head of the biceps brachii.
Subacromial Bursa Form a lubricating mechanism between the rotator cuff and the coracoacromial arch during movement of the
shoulder.
Subdeltoid Bursa Lies between the deltoid muscle and the shoulder joint capsule. This facilitates the movement of the deltoid
muscle over the capsule and the supraspinatus tendon.

Foramen of Weitbrecht

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

 The scapulothoracic joint is not a true joint but rather a point of contact between the anterior surface of the scapula and the posterior-
lateral wall of the thorax.
 The tow surfaces do not make contact and are separated by muscles.
 The wide range of motion available in the shoulder joint is due, in part, to the large movement available to the scapulothoracic joint.

Scapulothoracic Joint
Movements Scapular elevation-depression, protraction-retraction, and upward-downward rotation

 Located between the head of the humerus and the arch formed by the acromion process, the rigid, coracoacromial ligament, and
the coracoid process.
 This provides an area for the movements of the glenohumeral joint.

 Formed by the coracohumeral and the transverse humeral ligaments.

 It houses the tendon of the long head of the biceps brachii.

Muscles of the Shoulder Complex

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

© Ram Janzen C. Fauni, PTRP

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

© Ram Janzen C. Fauni, PTRP

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

 Four deep muscles of the shoulder – subscapularis, supraspinatus, infraspinatus, and the teres minor – strengthen and stabilize the
shoulder joint.
 The flat tendons of these muscles fuse to form a nearly complete circle of tendons around the shoulder joint, like a cuff of sleeve.

© Ram Janzen C. Fauni, PTRP

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

The Axilla

 This is the gateway to the upper limb, providing an area of transition between the neck and the arm. This is formed by the clavicle,
the scapula, the upper thoracic wall, the humerus, and related muscles.
 It forms an important passage for nerves, blood and lymph vessels as they travel from the root of the neck to the upper limb.
 This is an irregularly shaped pyramid space with four sides, an inlet, and an outlet.

 Anterior wall: pectoralis major, subclavius, and pectoralis minor muscles

 Posterior wall: subscapularis, latissimus dorsi, and teres major muscles
 Medial wall: upper four or five ribs and the intercostal spaces covered by the serratus anterior
 Lateral wall: coracobrachialis and bicep brachii in the bicipital groove of the humerus
 Base or floor: formed by the skin stretching between the anterior and posterior walls
 Apex: it is bounded anteriorly by the clavicle, posteriorly by the upper border of the scapula, and medially by the outer border of the
1st rib.

 The axilla contains the axillary artery and its branches, the axillary vein, lymphatic vessels of the upper limb, and the nerves of the
brachial plexus.

Radiographic Anatomy of the Shoulder

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

© Ram Janzen C. Fauni, PTRP

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 A&P: Upper Extremity
College of Rehabilitation Sciences
Del La Salle Medical & Health Sciences Institute

Surface Anatomy of the Shoulder Complex

© Ram Janzen C. Fauni, PTRP

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