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Dr. SREEKANTH THOTA. DEPARTMENT OF ANATOMY. UPPER LIMB. WINDSOR UNIVERSITY SCHOOL OF MEDICINE St.Kitts. SHOULDER . SHOULDER . The shoulder is the region of upper limb attachment to the trunk and neck. . Bones of the Shoulder Girdle .

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Dr sreekanth thota







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

Bones of the shoulder girdle
Bones of the Shoulder Girdle

  • Clavicle and scapula, which form the pectoral girdle (shoulder girdle)

  • The proximal end of the humerus.



Shoulder Region

Anterior axioappendicular muscles of the upper limb
Anterior Axioappendicular Muscles of the Upper Limb





Pectoralis major

  • 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

Pecotoralis minor

  • Origin: Third, fourth, and fifth ribs

  • Insertion : Coracoid process of scapula

  • N. supply: Medial pectoral nerve

  • Action: Stabilizes scapula by drawing it inferiorly


  • Origin: First costal cartilage

  • Insertion : Clavicle

  • N. supply: Nerve to subclavius

  • Action: Depresses the clavicle

Serratus anterior

  • Origin: Upper eight ribs

  • Insertion :Anterior surface of medial border of scapula

  • N. supply: Long thoracic nerve

  • Action: Protracts scapula and rotates scapula

Paralysis of the serratus anterior winged scapula
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.

Windsor university school of medicine st kitts

  • 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.Latissimusdorsi

  • B.Trapezius

  • C.Deltoid

  • D.Subscapularis

  • E.Pectoralis major

Windsor university school of medicine st kitts

  • 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 anteriorB. LatissimusdorsiC .Levator scapulaeD. Rhomboid majorE .Deltoid

Posterior axioappendicular muscles
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


  • Origin: Occipital bone, ligamentumnuchae, 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

Injury of the accessory nerve cn xi
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.

Latissimus dorsi

  • 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

Latissimus dorsi1


Extends, adducts, and medially rotates the arm

Injury of the thoracodorsal nerve
Injury of the Thoracodorsal Nerve

  • Surgery in the inferior part of the axilla puts the thoracodorsal nerve supplying the latissimusdorsi at risk of injury.

  • With paralysis of the latissimusdorsi, the person is unable to raise the trunk with the upper limbs, as occurs during climbing.

Levator scapulae
Levator Scapulae

  • Origin: Transverse processes of first four cervical vertebrae

  • Insertion: Medial border of scapula

  • N. supply:dorsal scapular nerve

  • Action:Elevates scapula

Rhomboids minor and major
Rhomboids minor and major

  • N. supply: Dorsal scapular nerve

  • Action: Retracts scapula

Windsor university school of medicine st kitts

  • 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

Windsor university school of medicine st kitts

  • 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

Scapulohumeral muscles
Scapulohumeral Muscles

  • 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


  • Origin: Lateral third of clavicle, acromion, spine of scapula

  • Insertion: Middle of lateral surface of shaft of humerus

  • N. supply: Axillary nerve



Anterior part: flexes and medially rotates armMiddle part: abducts armPosterior part: extends and laterally rotates arm

Testing deltoid muscle
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.

Injury to the axillary nerve
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.

Teres major
Teres Major

  • Origin: Lower third of lateral border of scapula

  • Insertion:Medial lip of bicipital groove of humerus

  • N. supply:Lowersubscapular nerve

  • Action:Adducts and medially rotates arm

Rotator cuff muscles
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.


  • Origin:Supraspinousfossa 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.


  • Origin:Infraspinousfossa of scapula

  • Insertion: Middle facet of greater tubercle of humerus

  • N. supply: Suprascapular nerve

  • Action: Laterally rotates arm and stabilizes shoulder joint

Teres minor
Teres minor

  • 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


  • Origin:Subscapularfossa (most of anterior surface of scapula)

  • Insertion: Lesser tubercle of humerus

  • N. supply: Upper and lower subscapular nerves

  • Action: Medially rotates and adduct arm

Rotator cuff injuries and the supraspinatus
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.

Windsor university school of medicine st kitts

  • 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

Windsor university school of medicine st kitts

  • 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

Quadrangular space
QUADRANGULAR SPACE: posterior scapular region

  • Superior border:

  • Teres Minor

  • Inferior border:

  • Teres Major

  • Lateral border:

  • Surgical neck of the humerus

  • Medial border:

  • Long Head of Triceps

CONTENTS posterior scapular region

  • 1- Axillary Nerve

  • 2- Posterir Circumflex Humeral Artery

Quadrilateral space syndrome
Quadrilateral Space Syndrome posterior scapular region

  • 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.

Triangular upper space
TRIANGULAR [upper] space posterior scapular region


  • Long Head of the Triceps

  • Upper border:

  • Teres Minor and subscapularis

  • Lower border:

  • Teres Major


  • Circumflex Scapular Branch

  • of the Subscapular artery

Lower triangular space
Lower Triangular Space posterior scapular region

  • Medially

  • long head of the triceps brachii

  • Latterly

  • shaft of the humerus

  • Superiorly

  • teres major

Contents posterior scapular region

  • 1-Radial nerve

  • 2-Profunda brachii artery