SHOULDER

Bones :
Clavicle :
-“Strut bone” or “Collar Bone”
-The only bone that connects upper trunk to axial skeleton
-Most commonly fractured bone
Orientation :

Middle 2/3 Lateral 1/3

Anterior Convex Concave
Posterior Concave Convex

Cleidoranial dysostosis : Absence of Clavice

Middle 1/3 : Most common clavicular fracture
Step deformity : High clavicle; Problem with conoid and AC ligaments

Types of Clavicular Fx:

Middle 1/3 – most common
Distal 1/3
a. Interligament with minimal d/p
b. Medial 2 coracoclavicular space
c. Intra-articular fracture
Proximal 1/3

Scapula :
- Shape: flat, triangular
Scapula Resting Position:
• Superior tilted: 5 degrees
• Retroversion: 7 degrees
- “the summit of shoulder”
- (+) AC problem = 170-180 degrees

Types of Acromion :
I. Flat – MC in dislocation
II. Round/Curve – MC in population
III. Hook – MC for impingement
IV. Upturned/Convex

Humerus :
- Long bone
- Surgical neck fracture = (+) axillary nn. is affected
- Spiral Groove Fracture (above & at level)
Fracture could cause :
A. Radial nerve injury
B.(-) Triceps weakness

ORIENTATIONS
• Acromion – P, L, S
• Glenoid fossa – S, A, L
• Humerus – M, P, S
• Transverse Humeral ligament – roof of bicipital groove of humerus

JOINTS
Structural:
1. GH
2. SC
3. AC
Functional:
1. ST
2. Bicipital Groove
3. Subacromial bursa

Sternocalivular joint/Manubriocostal joint

- Sellar/saddle joint
- 3 degrees of freedom:
Elev/dep – Z axis – convex moves
Protract retract – Y axis – concave moves
Rotation – X axis

Ligaments:
1. Interclavicular
- limits depression of distal clavicle
- protects subclavian artery

2. Costoclavicular – limits elevation of distal clavicle

3. Sternoclavicular
- Ant: limits retraction; post translation of clavicle
- Post: limits protraction; ant translation of clavicle

SC Interarticular Disc
- Shock absorption
- During elevation & depression = AD moves towards sternum
- During protract & retract = AD moves towards clavicle

Kinematics :

SC Elevation of clavicle <90 degrees GH jt. motion

SC Posterior rotation of clavicle >90 degrees GH jt. Motion
SC Anterior rotation of clavicle >90 degrees GH jt. exit

Summary of arthrokinematics of the SC joint :

Roll Slide
Protraction Anterior Anterior
Retraction Posterior Posterior
Elevation Superior Inferior
Depression Inferior Superior

Sternoclavicular Joint Sprain :

- MC direction: Anterior – 1 degrees
Superior – 2 degrees

Types:

I. (+) tenderness; without joint laxity

II. (+) tenderness; with joint laxity but good end-point
III. (+) tenderness; with joint laxity but no good end-point
Acromioclavicular joint :

- Plane joint
- 3 degrees of freedom: affected by scapular motion

Ligaments:
1. Coracoclavicular ligament:
Conoid :
- limit superior translation of distal clavicle
Trapezoid :
- Limit medial translation of scapula

2. AC ligament
Superior :
- Limit inferior translation of distal clavicle
Inferior :
- Limit superior translation of distal clavicle

Fountain sign : Swelling of AC joint

Kinematics:
1. ER & IR (Horizontal curvature)
2. Upward & Downward rotation
3. Ant & Post tilting (Vertical curvature)

Rockwood’s Classification (Types of AC joint Sprain)

I. - AC sprain + coracoclavicular intact
II. - AC torn + CC sprain
III. - AC, CC torn + CC space widened (25-100%)
IV. - III + clavicle displaced posteriorly
V. - III + CC space widened >100% + deltoid, trapezius detached
VI. - III + clavicle displaced inferiorly

Glenohumeral joint :
- Ball and socket joint; universal joint
- Articulation: Humerus & scapula
- Normal shaft angle: 130-150 degrees
- Angle of torsion: 30 degrees
- Stability: Muscles, no pressure, ligaments, labrum

Ligaments:
1. Superior GH lig. (limits 0-45o) = inf & ant translation
2. Middle GH lig. (limits 45o-90o) = ant translation
3. Inferior GH lig/Hammock ligament (limits >90o) = ant & inf translation

Foramen of Weitbrecht – common area for ant. dislocation

4. Coracoacromial ligament – prevents superior translation of humeral head
5. Coracohumeral ligament
- limits ant & inf translation
- (+) Adhesive capsulitis = this ligament thickens
6. Transverse ligament

Glenoid labrum enhances the depth of G.fossa by 50%

Glenohumeral Joint :

Resting position : 40 to 55 degrees abduction, 30 degrees horizontal adduction

Closed packed position : Full abduction, lateral rotation
Capsular pattern : Lateral rotation, abduction, and medial rotation

Acromioclavicular joint :

Resting position : Arm resting by side in normal physiological position

Close packed position : 90 degrees abduction
Capsular pattern : Pain at extremes of ROM, especially horizontal adduction and full elevation

Sternoclavicular joint :

Resting position : Arm resting by side in normal physiological position

Close packed position : Full elevation and protraction
Capsular pattern : Pain at extremes of ROM, especially horizontal adduction and full elevation

Summary of arthrokinematics of the Glenohumeral joint :

Roll Slide
Flexion Spin Spin
Horizontal adduction Anterior Posterior
Internal rotation at 0 degrees Anterior Posterior
abduction
Extension Spin Spin
Horizontal abduction Posterior Anterior
External rotation at 0 degrees Posterior Anterior
abduction
Abduction Superior Inferior

Stability of GH joint :
1. Static
- (-) pressure (glenoid labrum)
- Passive tension ligament
2. Dynamic – muscles
a. Deltoid & supraspinatus – (Deltoid: vertical et. lat pull)
b. Rotator cuff (I,T,S)
c. Supraspinatus

False joints : Scapulothoracic joint

Scapulohumeral Rhythm
- Happens after 30o shoulder elevation
- 2:1 = GH-ST movement
PHASE 1 = 30 degrees PHASE 2 = 60 degrees PHASE 3 90-180
degrees
Humerus Abd 30 degrees Abd 40 degrees Abd 60 degrees, ER 90
degrees
Scapula Setting phase Upward rotation of 20 Upward rotation of 30
degrees degrees
Clavicle Elevation of 5 degrees Elevation of 15 degrees Posterior rotation of 30-
50 degrees and
elevation of 15 degrees
Types of Scapular Winging
Primary – muscle pathology
Secondary – GH pathology
Dynamic – nerve pathology
Static – standard deformity

Subacromial bursa :
- Aka Suprahumeral joint
- Subacromial space
A. Arms at side = 10mm
B. Arms elevate = 5mm; provokes impingement

Bicipital groove :
-Content : long head of biceps
Lat lip: Pects major
Floor: Lats dorsi
Medial lip: Teres major
Roof: Transverse humeral

Muscles :

Supraspinatus
- MC rotator cuff impingement
- Prevents humeral heard to displace inferiorly
- Work horse of rotator cuff muscle
- Primary initiator of abduction (0-30o)

Infraspinatus
- More active: ER with no shoulder abd

Teres Minor
- More active: ER + shoulder 90o abd

Subscapularis
- Chief IR
- Prevents anterior dislocation of humerus

Deltoid
- Affected in inferior displacement of humerus

Serratus Anterior & Upper 8 ribs

- Boxer’s muscle
- Landmark of medial border of axillary

Latissimus Dorsi
- Action in CKC: elevates pelvic posteriorly

Biceps
- Substitutes for absence of supraspinatus and middle deltoids for shoulder abduction

SLAP (Superior Labrum Anterior Posterior) Types

I. Superior labrum affected; (+) biceps intact

II. Biceps detachment at origin – MC
III. Bucket handle tear
IV. Superior labrum → biceps complex
V. Bankart lesion – Anterior inferior labrum
VI. Unstable flap tear
VII. Tension reaches middle GH jt.

Shoulder painful arc :

45-60 degrees = painless

60-120 degrees = GH painful arc
120-170 degrees = painless
170-180 degrees = AC painful arc