Upper Extremity

Week 9
Presented by Navine Haworth

Shoulder

Glenohumeral Joint
Humeral head: Faces medially, slightly posterior and
superiorly. (approx 45 deg to the shaft). It forms
about half a sphere, although the surface is slightly
oval.
Glenoid Fossa: faces laterally, slightly anterior and
superior. Pear shaped, with superior aspect more
narrow. Deepened by fibrocartilaginous glenoid
labrum.
Capsule: Thin, lax & folded anterolaterally at rest.
Allows distraction of the humeral head. Fibres of the
rotator cuff blend with the capsule.
Ligaments:
Gleno-humeral, strengthens capsule anteriorly,
limits external rotation and extension.
Coraco-humeral, strengthens capsule superiorly,
blends with supra-spinatus tendon at attachment
with greater tuberosity.

Glenohumeral joint

Acromioclavicular Joint (ACJ)

Acromial and clavicular facets are flat and oval.
Clavicle facet faces lateral, posterior and inferior.
Acromial facet is opposite.
Ligaments
Acromioclavicular: strengthens superiorly
Coracoclavicular: 2 parts; trapezoid prevents
lateral displacement of clavicle and conoid
prevents superior displacement
Damage to acromicoclavicular joints are hard to
treat as ligaments are hard to manipulate

Acromioclavicular joint
From: http://ajs.sagepub.com/content/35/5/811/F1.large.jpg
Sourced 27/09/13

Sternoclavicular Joint (SCJ)

Saddle shaped with an intra-articular
disc. Capsule is lax.
Ligaments
Anterior & Posterior Sternoclavicular
and Interclavicular Ligts.
Costclavicular ligt provides further
strength.

Scapulo-thoracic
Scapula is held in close approximation with
the thoracic rib cage by several muscles.
Serratus anterior, rhomboids and trapezius.
(these muscle are responsible for tholding up the scapula)

Loose connective tissue lies between

serratus anterior and subscapularis and
facilitates the slide of the scapula over the
thoracic cage.
Musculofascial joint

Young person with a potential disslocated shoulder, you

can see and indentation in the soft tissue that should be
nice and rounded.

Shoulder Range of Motion

The shoulder is the most mobile joint in the body.
It encompasses movement at the glenohumeral, AC, SC and
scapulothoracic articulations.
Flexion- Up to 180 degrees
Extension approx. 50o
Adduction- 0o neutral, 45o with flexion
Abduction 180o (roughly) comprised of:
0-60 Glenohumeral
60-120 GH, AC, SC, ST
120-180 Lateral flexion of cervicothoracic spine
Rotation- (Measured with elbow flexed to 90o)
Internal rotation 95o
External 80o
Circumduction- Combination of flex/ext & Ab/Ad

Abduction
Stage 1: 0-30o
Initial stage of abduction requires the supraspinatus to depress the
humeral head relative to glenoid fossa. This allows deltoid to contract
without displacing humeral head superiorly.
Stage 2: 30-160o
After 30o the scapula begins to rotate superiorly, abduct and elevate.
Clavicle elevates, pushes forward and rotates posteriorly.
Arm approaches 90o and the greater tubercle begins to approximate
acromion process. Capsule and ligamentous tightening induce
posterior rotation so the tubercle passes behind the acromion.
Stage 3: 160-180o
Final stage requires Cx and Tx spine to laterally flex.
Try this link - http://vimeo.com/67981034

Abduction- Painful Arc

Abduction serves as a useful
diagnostic procedure as the onset
of pain during abduction can help
identify the cause.
Difficulty initiating abduction
Total rupture of the
supraspinatus tendon.
Severe inflammation of the
tendon also.

Abduction- Painful Arc

Pain at 60-120o
Rotator cuff tears and tendinitis:
supraspinatus and deltoid are at
maximum contraction at 90o, so pain
should worsen approaching this point.
Resisted abduction increases pain.
Passive abduction should be painless
unless impingement occurs.
Subdeltoid bursitis: bursa impinges as
the shoulder approaches 90o. Passive
abduction should be less painful.
Capsular involvement, if inflamed, pain
will develop as tension increases. Painful
begins at 70-110deg and continues
throughout abduction. Passive raising

Abduction- Painful Arc

Pain beginning at 90o
Very likely to involve AC pathology. Patient
likely to point to AC as site of pain. Most
painful in the last phase (140o to 180o).
Pain toward the end of abduction
Pain at the final phase also suggests spinal
involvement. Unilateral suggests
costovertebral while bilateral suggests
cervicothoracic.
Try this link - http://vimeo.com/69216535

Anterior Shoulder Dislocation

Onset
Young adult, often athletic and male. Associated with violent
episode.
95% Anterior dislocation to occur
Predisposition
Congenital anomaly e.g. Long narrow glenoid or large humeral
head.
Damaged or anomalous ligaments
Tendency to seizure, fits or fainting.
Strenuous violent sport.
Action
Abduction, external rotation and extension force the humeral head
forward and inferiorly.
Subsequent Damage
Humeral head notching, repeated collision/compression with
glenoid. Hill-Sachs lesion.
Labrum detachment, fraying or tearing from glenoid.
Glenoid notching and deformation.
Capsule ballooning or tearing, avulsion/detached from glenoid
(Bankart lesion)

Shoulder lesions

Hill sachs defect humeral head

http://www.orthop.washington.edu/?
q=patientcare/articles/shoulder/bankart-repairfor-unstable-dislocatingshoulders.html

Anterior Shoulder Dislocation (Cont)

Prognosis
<age 20yrs= 90% chance of
recurrence
>age 40yrs= 10% chance of
recurrence

Dislocated shoulder

Dislocated shoulder and potential humerus fracture

Dislocations
Bilateral
dislocations are
uncommon. They
may result from
waterskiing type
injuries or are
sometimes seen
with seizures or
electrocutions

Adhesive Capsulitis
Also known as Frozen Shoulder. This is a disorder
characterised by progressive pain and gradually
increasing stiffness of the shoulder.
Females more than males
Usually middle to older age group affected.
Cause:
Generally follows soft tissue injury of the shoulder
(often minor): muscle, tendon, capsule, bursa.
Post surgery if patient has not complied with rehab.
Inflammatory changes involve the entire rotator cuff
and capsule. In time adhesions form within the
capsule and glues the anterior capsule to itself, the
humeral head or surrounding tissues.
Results in dramatic, global loss of ROM both active

Review
What are the 3 ligaments of the GH joint of the
shoulder?
What are the ligaments of the AC and SC joint?
What is responsible for scaplua stabilization
against the thoracic region?
What joints encompass shoulder range of motion?
The shoulder is themobile joint in the
body?
What is adhesive capsulitis? Its causes?
What is the prognosis for anterior shoulder
dislocation?

Review
With shoulder abduction, what
joints/regions are responsible during
the following phases
0-60
60-120
120-180