1. Anatomy Of Axilla And Shoulder
Dr. Fadel Naim
Orthopedic Surgeon
Faculty of Medicine
IUG

2. SURFACE ANATOMY ACROMION CLAVICLE DELTOID ( IM INJECTIONS) HUMERUS
BICEPS MUSCLE
BICIPTAL GROOVE
BRACHILA PULSE( BLOOD PRESSURE)
TRICEPS
OLECRNON PROCESS( PT OF THE ELBOW)
MEDIAL /LATERAL EPICONDYLES
TRIANGLE
CUBITAL FOSSA
MEDIAN CUBITAL VEIN- IV
CEPHALIC VEIN
ULNA
RADIUS
STYLOID PROCESS
RADIAL ARTERY( PULSE)
ULNAR ARTERY
ANATOMICAL SNUFF BOX
THENAR EMINENC
HYPOTHENAR EMINENCE
CARPAL TUNNEL

6. CUBITAL FOSSA

7. STYLOID PROCESS

8. Axilla(Arm pit)

9. AXILLA
A pyramid-shaped space between the upper part of the arm and the side of the chest through which major neurovascular structures pass between neck & thorax and upper limbs.
Axilla has an apex, a base and four walls.

10. Axillary Walls Bones Anterior Posterior Medial Lateral Clavicle
Scapula
Ribs
Humerus

11. Muscles Anterior Posterior Medial Lateral Pectoralis major
pectoralis minor
subclavius
Subscapularis teres minor teres major latissimus dorsi
Serratus anterior
Tendon of long head of biceps

13. Contents Of The Axilla Axillary artery Axillary vein
Cords of brachial plexus
Axillary lymph nodes
Fat
Axillary sheath

14. Pectoralis Major Origin INSERTION Action Nerve Clavicular head:
Medial half clavicle.
Sternocostal head:
Lateral manubrium
Sternum
Six upper costal cartilages
External oblique aponeurosis
INSERTION
Lateral lip of bicipital groove of humerus
Action
Flexes and adducts arm.
Sternal head:
Adducts and medially rotates arm .
Accessory for inspiration
Nerve
Medial pectoral nerve (from medial cord)
Lateral pectoral nerve (from lateral cord)

15. Subclavius Origin INSERTION Action Nerve
Costochondral junction of 1st rib
INSERTION
Subclavian groove on inferior surface of middle third of clavicle
Action
Depresses clavicle and steadies it during shoulder movements
Nerve
Nerve to subclavius (upper trunk of brachial plexus)

16. Pectoralis Minor Origin 3, 4, 5 ribs INSERTION Action Nerve
Medial and upper surface of coracoid process of scapula
Action
Elevates ribs if scapula fixed
Pulls shoulder downward and forward
Nerve
Medial pectoral nerve (from medial cord of brachial plexus)

17. Subscapularis Origin INSERTION Action Nerve
Medial two thirds of subscapular fossa
INSERTION
Lesser tuberosity of humerus
Upper medial lip of bicipital groove
Capsule of shoulder joint
Action
Medially rotates arm
Stabilizes shoulder joint
Nerve
Upper and lower subscapular nerves (from posterior cord of brachial plexus)

18. Teres Major ORIGIN INSERTION ACTION NERVE
Lower third of lateral side of inferior angle of scapula below teres minor
INSERTION
Medial lip of bicipital groove of humerus
ACTION
Medially rotates and adducts arm.
Stabilizes shoulder joint
NERVE
Lower subscapular nerve (from posterior cord of brachial plexus)

19. Latissimus Dorsi ORIGIN INSERTION ACTION NERVE Spine T7 lumbar fascia
spinous processes and supraspinous ligaments
of all lower thoracic, lumbar and sacral vertebrae
lumbar fascia
posterior third iliac crest
last four ribs (interdigitating with external oblique abdominis)
inferior angle of scapula
INSERTION
Floor of bicipital groove of humerus after spiraling around teres major
ACTION
Extends, adducts and medially rotates arm.
Costal attachment helps with deep inspiration and forced expiration
NERVE
Thoracodorsal nerve (from posterior cord of brachial plexus)

20. Serratus Anterior ORIGIN INSERTION
Upper 8 ribs and anterior intercostal membranes from midclavicular line.
INSERTION
Inner medial border scapula
1 and 2: upper angle
3 and 4: length of costal surface
5-8: inferior angle

21. Serratus Anterior Action Nerve
A strong protractor of the scapula that is used when punching or reaching anteriorly ("boxer's muscle")
Inferior part rotates the scapula, elevating its glenoid cavity so the arm can be raised above the shoulder
Holds the scapula against the thoracic wall when doing push ups or when pushing against resistance
Nerve
Long thoracic nerve

22. Trapezius Origin INSERTION Action Nerve
Medial third superior nuchal line on the occipital bone
External occipital protuberance
Ligament nuchae
Spine of 7th cervical vertebra
Spinous processes and supraspinous ligaments to T12
INSERTION
Upper fibers to lateral third of posterior border of clavicle
Middle fibers to medial acromion and superior lip of spine of scapula
Lower fibers to medial end of spine of scapula
Action
Laterally rotates, elevates and retracts scapula.
If scapula is fixed, extends and laterally flexes neck
Nerve
Motor fibers form spinal accessory nerve (Cranial nerve XI)
Sensory fibers spinal nerves C3 and C4

23. Levator Scapulae Origin INSERTION Action Nerve
Posterior tubercles of transverse processes of C1-4
INSERTION
Upper part of medial border of scapula opposite the supraspinous fossa
Action
Raises medial border of scapula
In conjunction with middle fibers of trapezius and rhomboids, pulls the scapula medially and upward
Nerve
Anterior primary rami of C3 and C4 and dorsal scapular nerve (C5)

24. Rhomboid Minor Origin INSERTION Action Nerve Lower ligamentum nuchea
Spines of C7 and T1
INSERTION
Small area of posteromedial border of scapula at level of spine, below levator scapulae
Action
Elevates the medial border of the scapula and pulls it medially
Nerve
Dorsal scapular nerve (C5)

25. Rhomboid Major Origin INSERTION Action Nerve
Spines of T2-T5 and supraspinous ligaments
INSERTION
Lower half of posteromedial border of scapula, opposite the infraspinous fossa
Action
Elevates the medial border of the scapula and pulls it medially
Nerve
Dorsal scapular nerve (C5) (from root )

28. Deltoid ORIGIN INSERTION ACTION NERVE
Anterior fibers: Lateral third of clavicle
Middle fibers: Acromion
Posterior fibers: spine of scapula to deltoid tubercle
INSERTION
Deltoid tuberosity
Middle of lateral surface of humerus
ACTION
Abducts arm
anterior fibers flex and medial rotate
posterior fibers extend and lateral rotate
NERVE
Axillary nerve (C5, 6) (from posterior cord)
Forms the rounded contour of the shoulder

29. Supraspinatus Origin INSERTION Action Nerve
Medial three quarters of supraspinous fossa of scapula
Upper surface of spine
INSERTION
Superior facet on greater tuberosity of humerus
Capsule of shoulder joint
Action
Abducts arm
Stabilizes shoulder joint
Nerve
Suprascapular nerve

30. Infraspinatus Origin INSERTION Action Nerve
Medial three quarters of infraspinous fossa of scapula
INSERTION
Middle facet of greater tuberosity of humerus
Capsule of shoulder joint
Action
Laterally rotates arm
Stabilizes shoulder joint
Nerve
Suprascapular nerve

31. Teres Minor Origin INSERTION Action Nerve
Middle third lateral border of scapula above teres major
INSERTION
Inferior facet of greater tuberosity of humerus (below infraspinatus)
Capsule of shoulder joint
Action
Laterally rotates arm
Stabilizes shoulder joint
Nerve
Axillary nerve

32. Rotator Cuff Muscles Four of the scapulohumeral muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Referred to as SITS muscles
Called rotator cuff muscles because they form a musculotendinous cuff around the glenohumeral joint {Dynamic stabilizers (“cuff”)}
All except the supraspinatus are rotators of the humerus

33. The tendons of the muscle blend with the fibrous capsule of the glenohumeral joint to form a musculotendinous rotator cuff, which reinforces the capsule on three sides:
Anteriorly
Superiorly
Posteriorly
The cuff is weakest antero-inferiorly, making shoulder dislocation most common in this direction.

34. The pectoral girdle involves the:
SC joint
AC joint
Glenohumeral joint
Generally, these joints move at the same time
Functional defects in any of the joints impair movements of the pectoral girdle.

36. Sternoclavicular Joint
The only articulation between the upper limb and the axial skeleton
A saddle type of synovial joint functions as a ball and socket joint
The sternal end of the clavicle articulates with the manubrium of the sternum and the 1st costal cartilage
Can be palpated because the sternal end of the clavicle lies superior to the manubrium of the sternum

37. Ligaments of the SC Joint
Anterior and posterior SC ligaments:
The interclavicular ligament
The costoclavicular ligament

38. Articular Disc Divides the SC joint into two compartments
The articular disc serves as a shock absorber of forces transmitted along the clavicle from the upper limb

39. Movements of the SC Joint
Although the SC joint is extremely strong, it is significantly mobile to allow movements of the pectoral girdle and upper limb
Mobility of the clavicle at the sternoclavicular joint is essential for the freedom of movement of the upper limb.
During full elevation of the limb, the clavicle is raised to approximately a 60 ° angle.
The SC joint moves up to 25 to 30 ° along its long axis in several direction:
anteriorly
Posteriorly
Inferiorly

41. Acromioclavicular Joint
The AC joint is a plane type of synovial joint
It is located 2 to 3 cm from the point of the shoulder formed by the lateral part of the acromion
The acromial end of the clavicle articulates with the acromion
The articular surfaces, are separated by an incomplete wedge-shaped articular disc.

42. Ligaments of the AC Joint
The integrity of the joint is maintained by extrinsic ligaments, distant from the joint itself.
The superior and inferior AC ligament:

43. The coracoclavicular ligament
The conoid ligament
Its wide attachment is to the conoid tubercle on the inferior surface of the clavicle
Trapezoid ligament
extends laterally to the trapezoid line on the inferior surface of the clavicle.
provides the means by which the scapula and free limb are (passively) suspended from the clavicular strut
The rotatory movements of the scapula occur at this important ligament

45. Glenohumeral (Shoulder) Joint
A ball-and-socket type of synovial joint
Relatively unstable
The large, round humeral head articulates with the relatively shallow glenoid cavity of the scapula
The glenoid is deepened slightly but effectively by the ringlike glenoid labrum
The glenoid cavity accepts little more than a third of the humeral head, which is held in the cavity by the tonus of the rotator cuff muscles
Both articular surfaces are covered with hyaline cartilage.

47. It becomes taut when the arm is abducted.
The inferior part of the articular capsule is the only part not reinforced by the rotator cuff muscles
Its weakest area.
Here the capsule is particularly lax and lies in folds when the arm is adducted
It becomes taut when the arm is abducted.

48. Ligaments of the Glenohumeral Joint
The glenohumeral ligaments:
Superior , middle and inferior
The coracohumeral ligament
The transverse humeral ligament

50. The Coracoacromial Arch
An extrinsic, protective osseoligamentous structure formed by:
The smooth inferior aspect of the acromion
The coracoid process of the scapula
The coracoacromial ligament
Overlies the head of the humerus, preventing its superior displacement
The supraspinatus muscle passes under this arch

51. Movements of the Glenohumeral Joint
The glenohumeral joint has more freedom of movement than any other joint in the body.
This freedom results from:
the laxity of its articular capsule
the large size of the humeral head compared with the small size of the glenoid cavity.
The glenohumeral joint allows movements around three axes and permits:
Flexion-extension
Abduction-adduction
Rotation (medial and lateral) of the humerus
Circumduction.
Circumduction is an orderly sequence of flexion, abduction, extension, and adduction or the reverse.

52. Glenohumeral motions

53. Glenohumeral motions

54. Glenohumeral motions

55. Scapular motions

56. Scapular motions Protraction – Retraction

57. Scapular Motions Rotational Elevation Of Glenoid Cavity
Rotational Depression Of Glenoid Cavity

58. Shoulder Girdle Movements
Elevation
Shoulder Girdle Movements
Abduction
Adduction
Upward
Rotation
Downward
Rotation
Depression

59. The supraspinatus initiates abduction and the deltoid takes over once the humerus is abducted past 15 degrees
During full abduction of the arm we have to laterally rotate our humerus to move the greater tuberosity out of the way.
Even with this maneuver, space is too limited to allow for the range of motion that is seen in a normal individual.
The remainder of the range of motion is made possible by scapular rotation.
Once we have abducted the arm past 20 degrees or 30 degrees, for every 3 degrees of abduction at the glenohumeral joint, 1 degree occurs at the scapulothoracic surface and only 2 degrees occurs at the glenohumeral joint.

61. Bursae Around the Glenohumeral Joint
Several bursae containing synovial fluid
Bursae are located where
Tendons rub against bone, ligaments, or other tendons
Where skin moves over a bony prominence.
Some of them communicate with the joint cavity (the subscapular bursa)
opening a bursa may mean entering the cavity of the shoulder joint.

62. Subacromlal Bursa
Large bursa lies between the deltoid, the supraspinatus tendon, and the fibrous capsule of the glenohumeral joint.
The subacromial bursa is located inferior to the acromion and coracoacromial ligament, between them and the supraspinatus.

63. Subdeltoid Bursa
This bursa lies between the deltoid muscle and the fibrous joint capsule over the head of the humerus.

64. Subscapular Bursa
Located between the neck of the scapula and the subscapularis muscle
Often communicates with the glenohumeral joint cavity through an opening in the fibrous joint capsule