SCAPULA

Introduction
The scapula, also known as the shoulder blade, is a flat triangular bone located at the back of
the trunk and resides over the posterior surface of ribs two to seven. The scapula, along with
the clavicle and the manubrium of the sternum, make up the pectoral (shoulder) girdle
which connects the upper limb of the appendicular skeleton to the axial skeleton. The scapula
is an important bone as each scapula provides a point of attachment for a number of muscles
that make up the arm and shoulder. It also articulates with the humerus and clavicle, forming
the glenohumeral (shoulder) joint and acromioclavicular joint respectively.
However, because the medial aspect of the scapula is not attached to the axial skeleton but
are rather held in place to the thorax and vertebral column by muscles, the scapula can move
freely across the posterior thoracic wall (scapulothoracic joint). This allows the arm to move
with the scapula, providing a wide range of movement and mobility for the upper limb
compared to the lower limb.
Recommended video: Humerus and Scapula
Overview of the humerus and scapula.
Bony Landmarks
Borders and Angles
Like any triangle, the scapula consists of three borders: superior, lateral and medial. The
superior border is the shortest and thinnest border of the three. The medial border is a
thin border and runs parallel to the vertebral column and is therefore often called the
vertebral border. The lateral border is often called the axillary border as it runs
superolaterally towards the apex of the axilla and it is the thickest and strongest of the three
borders for muscle attachment. It also has the glenoid cavity or socket along this border, a
shallow fossa which articulates with the head of the humerus, forming the glenohumeral
joint. There are also three angles to the scapula. The superior border meets the lateral
border at the lateral angle and with the medial border at the superior angle. The third
angle is the inferior angle where the medial and lateral borders meet.
Surfaces
The scapula has two surfaces; on the anterior aspect is the smooth costal surface which is
concave in shape and is majorly taken up by the subscapular fossa. At the back of the
scapula is the convex and uneven posterior surface which has a protruding ridge of bone
(spine of the scapula) that unevenly separates it into two divisions: the superior
supraspinous fossa and the much bigger, inferior infraspinous fossa.
Processes
Along with the spine, there are two more processes: the coracoid and acromion process.
The coracoid process is a beak-like bent anterolateral projection from the superior border.
Inferior to the coracoid process is the glenoid cavity, superiorly lies the lateral part of the
clavicle and medial to the coracoid process is the suprascapular notch (for nerve passage)
which connects the base of the coracoid process to the superior border. The coracoid process
allows the attachment of various muscles and ligaments. Ligaments of the coracoid process
are:
Coracohumeral ligament - to the greater tubercle of the humerus

Coracoclavicular ligament - to the clavicle

Coracoacromial ligament - to the acromion process

The acromion process is a palpable lateral and enlarged extension of the posterior spine of
the scapula which projects anterolaterally to the spine. It arches over the glenohumeral joint
and articulates with the lateral acromial end of the clavicle to make up the synovial
acromioclavicular joint. This joint is supported by the acromioclavicular ligament which
attaches to the acromion process at one end and the clavicle at the other.
Blood supply to the posterior scapular region
Several arteries form an anastomosis to supply blood to this area:
Suprascapular artery: a branch of the thyrocervical trunk, which in turn arises from
the subclavian artery. It runs along the suprascapular nerve and mostly supplies the
supraspinatus and infraspinatus muscles
Posterior circumflex humeral artery: a branch of the axillary artery supplying the
glenohumeral joint
Circumflex scapular artery: originating from the subscapular artery, which in turn is
a branch of the axillary artery
Transverse cervical artery: a branch of the thyrocervical trunk running along the
medial border of the scapula
Muscle Attachments
Due to the large surface area of the scapula there are a large number of muscles attached (17
in total) which fix the scapula to the thoracic wall and allow it to move. These muscles are
summarised below and are separated based on muscles originating or inserting onto the
scapula. Four of these muscles form the rotator cuf, which covers the shoulder capsule
(subscapularis, infraspinatus, teres minor and supraspinatus).
Muscles originating from the scapula, where they originate on the scapula, their action and
innervation:
Deltoid muscle inferiorly along the scapula spine to the acromion (and lateral third of the
clavicle). Flexion and medial rotation (anterior fibres), abduction (middle fibres), extension
and lateral rotation (posterior fibres) at the shoulder joint. Axillary nerve.
Supraspinatus muscle supraspinous fossa. Abduction at the shoulder joint. Suprascapular
nerve.
Infraspinatus muscle infraspinous fossa. Lateral rotation at the shoulder joint. Suprascapular
nerve.
Triceps brachii muscle (long head) infraglenoid tubercle found on the lateral border
inferior to the glenoid cavity. Elbow extension. Radial nerve.
Teres minor muscle lateral border of the posterior surface. Lateral rotation at the shoulder
joint. Axillary nerve.
Teres major muscle posterior surface of the inferior angle and the lower part of the medial
border. Adduction and medial rotation at the shoulder joint. Subscapular nerve.
Latissimus dorsi muscle inferior angle (inconstant). Adduction, extension and medial
rotation at the shoulder joint. Thoracodorsal nerve.
Coracobrachialis muscle coracoid process. Adduction and flexion at the shoulder
joint. Musculocutaneous nerve.
Biceps brachii muscle (long and short head) long head: supraglenoid tubercle; short
head: coracoid process. Elbow flexion. Musculocutaneous nerve.
Subscapularis muscle subscapular fossa. Adduction and medial rotation at the shoulder
joint. Subscapular nerve.
Omohyoid muscle superior border (adjacent to the suprascapular notch). Depression of
hyoid bone. Ansa cervicalis (from cervical plexus).
Muscles inserting on the scapula, their insertion sites on the scapula, their action and
innervation:
Trapezius muscle superiorly along the spine, acromion process (and clavicle). Elevation of
the scapula, rotation of scapula during abduction of humerus beyond 90 degrees. Accessory
nerve.
Levator scapulae muscle superior angle and medial border (superior to the
spine). Elevation of scapula. Innervation by branches of C3-C5.
Rhomboid major muscle medial border (inferior to the spine). Elevation and retraction of
scapula. Dorsal scapular nerve.
Rhomboid minor muscle above the scapular spine. Elevation and retraction of
scapula. Dorsal scapular nerve.
Serratus anterior muscle along the medial border from the superior angle to inferior
angle. Protraction and rotation of the scapula. Long thoracic nerve.
Pectoralis minor muscle coracoid process. Protraction and depression of the
scapula. Medial pectoral nerve.
Clinical Notes
Scapulothoracic dysfunction
The most common form is winging of the scapula. Surgery to the axilla, e.g. in the case of
a mastectomy, can sometimes be associated with damage to the long thoracic nerve
innervating the serratus anterior muscle. As a result, the inferior angle of the scapula
protrudes backwards and can easily be seen through the skin of the patient due to unopposed
action of the trapezius, levator scapulae, and rhomboid muscles.
Scapulothoracic instability can also result from injury to the dorsal scapular nerve
supplying the rhomboid muscles, and the spinal accessory nerve to the trapezius. Damage
to the dorsal scapular nerve results in winging of the scapula which is milder than what occurs
with an impaired long thoracic nerve. Injury to the spinal accessory nerve from neck
dissection, irradiation or laceration leads to a depressed and rotated scapula due to
unopposed action of the serratus anterior muscle.
Another cause of winging of the scapula is fascioscapulohumeral dystrophy, an autosomal
dominant condition affecting several muscles related to the scapula: serratus anterior,
rhomboids, trapezius, teres major and minor, pectoralis minor and major, biceps, and triceps
muscle. As a result, only the deltoid can move the shoulder and winging of the scapula occurs.
Scapular dysplasia
Scapular dysplasia describes an abnormal morphology of the scapula which can either be
primary or acquired, secondary to obstetric brachial plexus palsy. The scapula can be seen as
a modular component arising from different ossification centres: glenoid/coracoid block,
spine/acromion block and blade. Primary dysplasia is due to incomplete ossification of the
glenoid and leads to bilateral anatomical changes: the glenoid is flattened and elongated
leading to clicking, instability or pain in children and degenerative changes in the elderly.
Morphological changes of the scapula can also be seen in infants featuring a brachial plexus
injury at the time of delivery due to an abnormal development of the cartilage of the posterior
glenoid. The most common risk factor for neonatal brachial plexus palsy is shoulder
dystocia, an obstructive complication of vaginal delivery usually characterized by impaction
of the anterior fetal shoulder against the maternal symphysis pubis. Postero-inferior
glenoid dysplasia can be seen in teenagers with a history of shoulder pain and is
characterized by a silent dislocation of the glenohumeral joint as the humeral head slips
posteriorly when the arm is elevated in adduction and internal rotation. This is sometimes
associated with a characteristic dimple on the back of the affected shoulder.
Snapping Scapula Syndrome
For the scapula to smoothly glide over the chest wall (termed the scapulothoracic joint) there
are a number a muscles that lie between the ribs and scapular to facilitate this. Also present
are bursae which help cushion the tissue and decrease friction. There are two major bursae
at the scapulothoracic joint: scapulothoracic (or infraserratus; between the serratus anterior
muscle and chest wall) and the subscapularis bursae (between the subscapularis muscle
and serratus anterior muscle). Snapping scapula syndrome is when there is abnormality at the
scapulothoracic joint which leads to non-smooth articulation. The two most common causes
are either lesions or when the bursae become inflamed termed scapulothoracic bursitis.
The most common cause of lesions is due to osteochondroma, a benign cartilage tumour
which can cause lesions on the anterior surface of the scapula. Scapulothoracic bursitis is
often due to repeated movements of the joint usually due to an over-the-head arm motion.
Fractures
Like any bone, the scapula is subjective to fractures. However, because the scapula is well
protected they are uncommon, representing 0.5 to 1% of all fractures; anteriorly, the scapula
is protected by the rib cage and thoracic cavity and posteriorly, it is covered with a lot of soft
tissue (i.e. muscle). Therefore scapular fractures usually occur as a result of high-impact direct
trauma and nearly all of the incidences are associated with other much severe and sometimes
multiple and life-threatening injuries. Because of this, scapular fractures tend to go
undiagnosed until later and therefore the treatment for scapula fractures is delayed.

HUMERUS
Introduction
The arm is the region between the shoulder and the elbow and consists of one bone, the
humerus. The humerus, the longest and largest bone of the upper limb, articulates with the
scapula proximally at the glenohumeral joint and has distal articulations with the radius and
ulna at the elbow joint. The distal end of the humerus consists of two rounded prominences
referred to as the medial and lateral epicondyles. The medial epicondyle lies on a more
posterior plane than the lateral epicondyle resulting in the humerus appearing medially
rotated when the arm is by the side of the trunk. This is important when considering
movements of the arm and forearm. The humerus consists of a proximal end, a shaft and a
distal end, all which contain important anatomical landmarks. This article will talk about these
aspects in detail including muscular attachments and anatomical landmarks followed by an
overview of clinical pathology related to the humerus.
Recommended video: Humerus
Anatomy, definition and function of the humerus.
Proximal End
The proximal end of the humerus consists of a head, an anatomical neck and the greater and
lesser tubercles. Between the tubercles, an intertubercular sulcus is located. There is also a
narrowing below the tubercles referred to as the surgical neck, which is a common fracture
site and is in close proximity to the axillary nerve and the posterior circumflex humeral artery.
This is where the proximal end of the humerus joins with the long shaft.
The head is a hemispheroidal shape and hyaline cartilage covers its smooth articular surface.
In the anatomical position, the head faces in a medial, superior and posterior direction where
it articulates with the glenoid fossa of the scapula.
The anatomical neck is a slight narrowing below the articular surface of the head. Here, the
joint capsule of the shoulder joint is attached.
The greater tubercle is the most lateral portion of the proximal end of the humerus. It
consists of three smooth flat impressions at the posterosuperior aspect for the attachment of
muscles. From superior to inferior, the muscles that attach at these impressions are: the
supraspinatus, the infraspinatus and the teres minor. The deltoid muscle covers the lateral
aspect of the greater tubercle resulting in the normal rounded shape of the shoulder. The
lateral aspect also contains multiple vascular foramina.
The lesser tubercle is located anterior to the anatomical neck and has a smooth palpable
muscular impression. The lateral part forms the medial margin of the intertubercular sulcus.
The subscapularis muscle attaches at this tubercle and the transverse ligament of the
shoulder also attaches on its lateral part.
The intertubercular sulcus is an indentation located between the two tubercles and is also
sometimes referred to as the bicipital groove. The long tendon of the biceps brachii and a
branch of the ascending circumflex humeral artery are located within the sulcus. The sulcus
consists of a lateral lip and a medial lip. The tendon of the pectoralis major muscle attaches
on to the lateral lip and the teres major tendon attaches on to the medial lip. In addition, the
tendon of lattisimus dorsi attaches to the posterior aspect.

Shaft
The proximal half of the shaft is of a cylindrical shape whereas the distal half is triangular. It
consists of three borders known as the anterior, lateral and medial borders. The shaft also
contains three surfaces referred to as the anterolateral, anteromedial and posterior surfaces.
The anterior border begins at the greater tubercle and runs downward almost to the end of
the bone. The proximal third of the border forms the lateral lip of the intertubercular sulcus.
The lateral border thickens distally to form the lateral supracondylar ridge. The middle part
of the border has a rough V shaped area referred to as the deltoid tubercle.
The medial border is similar to the lateral border in that it forms the medial supracondylar
ridge distally. The radial groove is a shallow groove that interrupts the medial border in its
medial third. The radial nerve and profunda brachii artery are located in this groove.
The anterolateral surface has a smooth upper surface and is covered by the deltoid
muscle. The deltoid inserts into the deltoid tubercle around the middle of the surface. The
distal fibres of the brachialis muscle originate from the distal part of this surface. The lateral
supracondylar ridge is a site for two muscular attachments: the brachioradialis on the
proximal two thirds and the extensor carpi radialis longus on the distal third.
The upper third of the anteromedial surface forms the floor of the intertubercular sulcus
and there is a small area distal to this sulcus where there is an absence of muscular
attachment. However, the lower half of the surface is covered by the medial portion of the
brachialis muscle. Coracobrachialis is also attached to this surface in the middle part as well
as pronator teres, which is attached distally to the medial supracondylar ridge.
The posterior surface is bounded by the medial and lateral borders and is covered mostly
by the medial head of the triceps brachii muscle. A ridge on the proximal third also gives
attachment to the lateral head of the triceps brachii.
Distal End
The distal end consists of both articular and non-articular parts. This part of the humerus is a
modified condyle and is wider transversely. This end articulates with both the ulna and radius
and consists of a medial trochlea and a lateral capitulum, which are separated by a faint
groove. The non-articular part consists of the medial and lateral epicondyles as well as the
olecranon process, coronoid fossa and radial fossae.
The trochlea has a surface shaped like a pulley and covers the anterior, posterior and inferior
surfaces of the medial condyle of the humerus. It articulates with the ulna at the trochlear
notch. When the elbow is in the extended position, the posterior and inferior aspects of the
trochlea are in contact with the ulna. However, when the elbow is flexed the posterior part is
no longer in contact as the trochlear notch slides towards the anterior aspect of the humerus.
The capitulum is a projection that is convex and rounded and covers the anterior and inferior
surfaces of the lateral condyle of the humerus. Unlike the trochlea, it doesnt cover the
posterior surface. It articulates with the head of the radius. In extension, the inferior surface is
in contact with the ulna but in the flexed position the radial head slides towards the anterior
aspect of the humerus.
The medial epicondyle is a blunt projection superomedial to the medial condyle, which
forms at the end of the medial border of the humerus. The ulnar nerve crosses its smooth
posterior surface and is palpable in this location. The superficial muscles of the anterior
compartment of the forearm originate from the anterior surface of the medial epicondyle.
These muscles are the flexor carpi ulnaris, palmaris longus, flexor carpi radialis and the
pronator teres.
The lateral border of the humerus ends at the lateral epicondyle. There is an impression on
the lateral and anterior surfaces where the seven muscles of the superficial group of the
posterior compartment of the forearm originate. These include the brachioradialis, extensor
carpi radialis longus, extensor carpi radialis brevis, extensor digitorium, extensor digiti minimi,
extensor carpi ulnaris and the anconeus.
The olecranon fossa is a deep hollowed area on the posterior surface superior to the
trochlea. In elbow extension, the tip of the ulnar olecranon process lodges into this fossa.
The coronoid fossa is a smaller hollow that is also located superior to the trochlea but on the
anterior surface. During flexion of the elbow, the coronoid process of the ulna lodges into the
coronoid fossa. Lateral to the coronoid fossa and superior to the capitulum is another
depression referred to as the radial fossa. It is so named as the margin of the head of the
radius lodges there in full flexion.
Clinical Notes
Fractures of the humerus are relatively common and can occur at any location on the
humerus. At the proximal end, most fractures are located at the surgical neck and are most
common in the elderly, especially those with osteoporosis.
An impact fracture, often the result of a humeral fracture, is where one bone fragment is
driven into the spongy bone of another bone fragment. This is usually due to the force of a fall
on the hand.
When the greater tubercle is pulled away from the head of the humerus this results in an
avulsion fracture. It is most commonly seen in the middle-aged and in the elderly. A fall
onto the acromion of the shoulder usually causes this fracture in these age groups. In young
adults, it can result from falling on the hand when the arm is in abduction.
A direct blow to the arm can result in a transverse fracture of the humeral shaft. The pull of
the deltoid muscle causes the proximal fragment to displace laterally.
A fall onto the outstretched hand can also cause a spiral fracture of the shaft of the
humerus. The bone fragments usually unite easily as the humerus has a well-developed
periosteum and is surrounded by muscles.
An intercondylar fracture can occur due to a fall on the elbow whilst it is in flexion. This
results in separation of one or both of the condyles from the shaft of the humerus.
The following nerves are located on the following aspects of the humerus:
The axillary nerve: surgical neck
 The radial nerve: radial groove

The median nerve: distal humerus

The ulnar nerve: medial epicondyle

If any of these aspects of the humerus are fractured, there may be damage to these nerves.