Joints of Pectoral Girdle

The pectoral girdle is a partial bony ring

(incomplete posteriorly) formed by the
manubrium of the sternum, the clavicle, and the
scapulae. Joints associated with these bones are
the :
• Sternoclavicular joint
• Acromioclavicular joint
• Glenohumeral joint
 Sternoclavicular Joint
• The sternoclavicular (SC) joint is a saddle type
of synovial joint but functions as a ball-and-
socket joint.
• The SC joint is divided into two compartments
by an articular disc. The disc is firmly attached
to the anterior and posterior sternoclavicular
ligaments, thickenings of the fibrous layer of
the joint capsule, as well as the interclavicular
ligament. It acts as SHOCK ABSORBER.
 ARTICULATION OF
STERNOCLAVICULAR JOINT

The sternal end of the clavicle articulates with

the manubrium and the 1st costal cartilage. The
articular surfaces are covered with
fibrocartilage.
 JOINT CAPSULE OF
STERNOCLAVICULAR JOINT
• The joint capsule surrounds the SC joint,
including the epiphysis at the sternal end of
the clavicle. It is attached to the margins of
the articular surfaces, including the periphery
of the articular disc. A synovial membrane
lines the internal surface of the fibrous layer
of the joint capsule, extending to the edges of
the articular surfaces.
 LIGAMENTS OF STERNOCLAVICULAR
JOINT
• The strength of the SC joint depends on its ligaments and
articular disc.
• Anterior and posterior sternoclavicular ligaments reinforce
the joint capsule anteriorly and posteriorly.
• The interclavicular ligament strengthens the capsule
superiorly. It extends from the sternal end of one clavicle to
the sternal end of the other clavicle. In between, it is also
attached to the superior border of the manubrium.
• The costoclavicular ligament anchors the inferior surface of
the sternal end of the clavicle to the 1st rib and its costal
cartilage, limiting elevation of the pectoral girdle.
MOVEMENTS OF STERNOCLAVICULAR JOINT
Circumduction of the upper limb requires coordinated movements of
the pectoral girdle and glenohumeral joint. Beginning with extended
limb, retracted girdle (B); neutral position (A); flexed limb, protracted
girdle (D); and, finally, elevated limb and girdle (E).
• BLOOD SUPPLY OF STERNOCLAVICULAR
JOINT
The SC joint is supplied by the internal
thoracic and suprascapular arteries
• NERVE SUPPLY OF STERNOCLAVICULAR
JOINT
Branches of the medial supraclavicular
nerve and the nerve to the subclavius
supply the SC joint
 Acromioclavicular Joint
The acromioclavicular joint (AC joint) is a plane
type of synovial joint, which is located 2–3 cm
from the “point” of the shoulder formed by the
lateral part of the acromion.
 ARTICULATION OF
ACROMIOCLAVICULAR JOINT
• The acromial end of the clavicle articulates
with the acromion of the scapula.
• The articular surfaces, covered with
fibrocartilage, are separated by an incomplete
wedge-shaped articular disc.
 JOINT CAPSULE OF
ACROMIOCLAVICULAR JOINT
The sleeve-like, relatively loose fibrous layer of
the joint capsule is attached to the margins of
the articular surfaces. A synovial membrane
lines the fibrous layer.
The joint capsule is strengthened superiorly by
fibers of the trapezius.
LIGAMENTS OF ACROMIOCLAVICULAR
JOINT
• The acromioclavicular ligament is a fibrous
band extending from the acromion to the
clavicle that strengthens the AC joint
superiorly.
• The coracoclavicular ligament consists of two
ligaments:
– Conoid ligament
– Trapezoid ligament
 MOVEMENTS OF
ACROMIOCLAVICULAR JOINT
• The acromion of the scapula rotates on the
acromial end of the clavicle.
• The axio-appendicular muscles that attach to
and move the scapula cause the acromion to
move on the clavicle.
BLOOD SUPPLY OF ACROMIOCLAVICULAR JOINT
The AC joint is supplied by the suprascapular
and thoraco-acromial arteries
NERVE SUPPLY OF ACROMIOCLAVICULAR JOINT
lateral supraclavicular nerve
 Glenohumeral Joint
• The glenohumeral (shoulder) joint is a ball-
and-socket type of synovial joint that permits
a wide range of movement.
• The large, round humeral head articulates
with the relatively shallow glenoid cavity of
the scapula which is deepened slightly but
effectively by the ring-like, fibrocartilaginous
glenoid labrum. Both articular surfaces are
covered with hyaline cartilage.
 JOINT CAPSULE OF GLENOHUMERAL
JOINT
The loose fibrous layer of the joint capsule
surrounds the glenohumeral joint and is
attached medially to the margin of the glenoid
cavity and laterally to the anatomical neck of the
humerus.
Fibrous layer of the capsule encloses the
proximal attachment of the long head of the
biceps brachii to the supraglenoid tubercle of
scapula within the joint.
• The joint capsule has two apertures:
(1) an opening between the tubercles of the
humerus for passage of the tendon of the long head
of the biceps brachii
(2) an opening situated anteriorly, inferior to the
coracoid process that allows communication
between the subtendinous bursa of subscapularis
and the synovial cavity of the joint
• The inferior part of the joint capsule, is its
weakest area.
• The synovial membrane lines the internal surface
of the fibrous layer of the capsule and reflects
from it onto the glenoid labrum and the
humerus, as far as the articular margin of the
head.
• The synovial membrane also forms a tubular
sheath for the tendon of the long head of the
biceps brachii, where it lies in the intertubercular
sulcus of the humerus and passes into the joint
cavity.
 LIGAMENTS OF GLENOHUMERAL
JOINT
The glenohumeral ligaments are three fibrous bands. These
ligaments radiate laterally and inferiorly from the glenoid
labrum at the supraglenoid tubercle of the scapula and blend
distally with the fibrous layer of the capsule as it attaches to
the anatomical neck of the humerus.
The coracohumeral ligament is a strong broad band that
passes from the base of the coracoid process to the anterior
aspect of the greater tubercle of the humerus.
The transverse humeral ligament is a broad fibrous band that
runs more or less obliquely from the greater to the lesser
tubercle of the humerus, bridging over the intertubercular
sulcus
The coraco-acromial arch is an extrinsic, protective
structure formed by the smooth inferior aspect of the
acromion and the coracoid process of the scapula, with
the coraco-acromial ligament spanning between them.
This osseo-ligamentous structure forms a protective arch
that overlies the humeral head, preventing its superior
displacement from the glenoid cavity.
Movement of the supraspinatus tendon, passing to the
greater tubercle of the humerus, is facilitated as it passes
under the arch by the subacromial bursa which lies
between the arch superiorly and the tendon and tubercle
inferiorly.
 MOVEMENTS OF GLENOHUMERAL
JOINT
• The glenohumeral joint allows movements
around three axes and permits flexion–extension,
abduction–adduction, rotation (medial and
lateral) of the humerus, and circumduction.
• Circumduction at the glenohumeral joint is an
orderly sequence of flexion, abduction,
extension, and adduction—or the reverse.
• Stiffening or fixation of the joints of the pectoral
girdle (ankylosis) results in a much more
restricted range of movement, even if the
glenohumeral joint is normal.
BLOOD SUPPLY OF GLENOHUMERAL JOINT
The glenohumeral joint is supplied by the
anterior and posterior circumflex humeral
arteries and branches of the suprascapular
artery.
NERVE SUPPLY OF GLENOHUMERAL JOINT
The suprascapular, axillary, and lateral pectoral
nerves supply the glenohumeral joint
 BURSAE AROUND GLENOHUMERAL
JOINT
• Bursae are located where tendons rub against
bone, ligaments, or other tendons and where
skin moves over a bony prominence.
• The subtendinous bursa of subscapularis
 BLOOD SUPPLY OF GLENOHUMERAL JOINT

• Arterial supply: anterior and posterior

circumflex humeral arteries and branches of
the suprascapular arteries
• Venous drainages: veins corresponding to the
branches of arteries
 INNERVATION OF GLENOHUMERAL JOINT

• suprascapular nerves
• Axillary nerve
• lateral pectoral nerve
 BURSAE AROUND GLENOHUMERAL JOINT

• Several bursae (sac-like cavities), containing synovial

fluid secreted by the synovial membrane, are situated
near the glenohumeral joint.
• Bursae are located where tendons rub against bone,
ligaments, or other tendons, and where skin moves
over a bony prominence.
• The bursae around the glenohumeral joint are of
special clinical importance because some of them
communicate with the joint cavity (e.g., the
subscapular bursa).
• Consequently, opening a bursa may mean entering the
cavity of the glenohumeral joint.
 Subtendinous Bursa of Subscapularis
• located between the tendon of the subscapularis
and the neck of the scapula
• The bursa protects the tendon where it passes
inferior to the root of the coracoid process and
over the neck of the scapula.
• It usually communicates with the cavity of the
glenohumeral joint through an opening in the
fibrous layer of the joint capsule
• it is really an extension of the glenohumeral joint
cavity.
 Subacromial Bursa
• Sometimes referred to as the subdeltoid bursa, the
subacromial bursa is located between the acromion,
coraco-acromial ligament, and deltoid superiorly and
the supraspinatus tendon and joint capsule of the
glenohumeral joint inferiorly
• it facilitates movement of the supraspinatus tendon
under the coracoacromial arch and of the deltoid over
the joint capsule of the glenohumeral joint and the
greater tubercle of the humerus.
• Its size varies, but it does not normally communicate
with the cavity of the glenohumeral joint.
 Calcific Supraspinatus Tendinitis
• Inflammation and calcification of the subacromial
bursa result in pain, tenderness, and limitation of
movement of the glenohumeral joint.
• This conditionn is also known as calcific
scapulohumeral bursitis.
• Deposition of calcium in the supraspinatus tendon is
common, causing increased local pressure that often
causes excruciating pain during abduction of the arm;
the pain may radiate as far as the hand.
• The calcium deposit may irritate the overlying
subacromial bursa, producing an inflammatory
reaction known as subacromial bursitis
• As long as the glenohumeral joint is adducted, no pain
usually results because in this position the painful
lesion is away from the inferior surface of the
acromion.
• In most people, the pain occurs during 50–130° of
abduction (painful arc syndrome) because during this
arc the supraspinatus tendon is in intimate contact
with the inferior surface of the acromion.
• The pain usually develops in males 50 years of age and
older after unusual or excessive use of the
glenohumeral joint.
 Rotator Cuff Injuries
• The musculotendinous rotator cuff is commonly injured during
repetitive use of the upper limb above the horizontal (e.g., during
throwing and racquet sports, swimming, and weightlifting).
• Recurrent inflammation of the rotator cuff, especially the relatively
avascular area of the supraspinatus tendon, is a common cause of
shoulder pain and results in tears of the musculotendinous rotator
cuff.
• Repetitive use of the rotator cuff muscles (e.g., by baseball pitchers)
may allow the humeral head and rotator cuff to impinge on the
coraco-acromial arch, producing irritation of the arch and
inflammation of the rotator cuff.
• As a result, degenerative tendonitis of the rotator cuff develops.
Attrition of the supraspinatus tendon also occurs
test for degenerative tendonitis of the
rotator cuff
• the person is asked to lower the fully
abducted limb slowly and smoothly.
• From approximately 90° abduction, the limb
will suddenly drop to the side in an
uncontrolled manner if the rotator cuff
(especially its supraspinatus part) is diseased
and/or torn.
 …
• Rotator cuff injuries may also occur during a sudden strain of the muscles, for
example, when an older person strains to lift something, such as a window that is
stuck.
• This strain may rupture a previously degenerated musculotendinous rotator cuff.
• A fall on the shoulder may also tear a previously degenerated rotator cuff.
• Often the intracapsular part of the tendon of the long head of the biceps brachii
becomes frayed (even worn away), leaving it adherent to the intertubercular
sulcus. As a result, shoulder stiffness occurs.
• Because they fuse, the integrity of the fi brous layer of the joint capsule of the
glenohumeral joint is usually compromised when the rotator cuff is injured.
• As a result, the articular cavity communicates with the subacromial bursa. Because
the supraspinatus muscle is no longer functional with a complete tear of the
rotator cuff, the person cannot initiate abduction of the upper limb.
• If the arm is passively abducted 15° or more, the person can usually maintain or
continue the abduction using the deltoid.
Dislocation of Glenohumeral Joint
• Because of its freedom of movement and instability, the
glenohumeral joint is commonly dislocated by direct or
indirect injury.
• Because the presence of the coraco-acromial arch and
support of the rotator cuff are effective in preventing
upward dislocation, most dislocations of the humeral head
occur in the downward (inferior) direction.
• However, they are described clinically as anterior or (more
rarely) posterior dislocations, indicating whether the
humeral head has descended anterior or posterior to the
infraglenoid tubercle and long head of the triceps.
• The head ends up lying anterior or posterior to the glenoid
cavity.
 Anterior dislocation of the glenohumeral joint

• occurs most often in young adults, particularly athletes. It is usually

caused by excessive extension and lateral rotation of the humerus .
• The head of the humerus is driven infero-anteriorly, and the fibrous layer
of the joint capsule and glenoid labrum may be stripped from the anterior
aspect of the glenoid cavity in the process.
• A hard blow to the humerus when the glenohumeral joint is fully abducted
tilts the head of the humerus inferiorly onto the inferior weak part of the
joint capsule.
• This may tear the capsule and dislocate the shoulder so that the humeral
head comes to lie inferior to the glenoid cavity and anterior to the
infraglenoid tubercle.
• The strong flexor and adductor muscles of the glenohumeral joint usually
subsequently pull the humeral head anterosuperiorly into a subcoracoid
position.
• Unable to use the arm, the person commonly supports it with the other
hand.
 Inferior dislocation of the glenohumeral joint

• Occurs after an avulsion fracture of the

greater tubercle of the humerus, owing to the
absence of the upward and medial pull
produced by muscles attaching to the tubercle
 Axillary Nerve Injury
• The axillary nerve may be injured when the glenohumeral
joint dislocates because of its close relation to the inferior
part of the joint capsule (Fig. B6.34).
• The subglenoid displacement of the head of the humerus
• into the quadrangular space damages the axillary nerve.
• Axillary nerve injury is indicated by paralysis of the deltoid
• (manifest as an inability to abduct the arm to or above the
• horizontal level) and loss of sensation in a small area of skin
• covering the central part of the deltoid (see the blue box
• “Injury to Axillary Nerve” on p. 710 and Fig. B6.8).
 Glenoid Labrum Tears
• Tearing of the fibrocartilaginous glenoid labrum commonly occurs
in athletes who throw a baseball or football and in those who have
shoulder instability and subluxation (partial dislocation) of the
glenohumeral joint.
• The tear often results from sudden contraction of the biceps or
forceful subluxation of the humeral head over the glenoid labrum.
• Usually a tear occurs in the anterosuperior part of the labrum.
• The typical symptom is pain while throwing, especially during the
acceleration phase.
• A sense of popping or snapping may be felt in the glenohumeral
joint during abduction and lateral rotation of the arm.
 Adhesive Capsulitis ofGlenohumeral Joint

• Adhesive fibrosis and scarring between the inflamed joint

capsule of the glenohumeral joint, rotator cuff, subacromial
bursa, and deltoid usually cause adhesive capsulitis (“frozen
shoulder”), a condition seen in individuals 40–60 years of
age.
• A person with this condition has difficulty abducting the
arm and can obtain an apparent abduction of up to 45° by
elevating and rotating the scapula.
• Because of the lack of movement of the glenohumeral
joint, strain is placed on the AC joint, which may be painful
during other movements (e.g., elevation, or shrugging, of
the shoulder). Injuries that may initiate acute capsulitis are
glenohumeral dislocations, calcific supraspinatus tendinitis,
partial tearing of the rotator cuff, and bicipital tendinitis.