Shoulder Glenohumeral, Elbow and wrist

Glenohumeral joint 7

40 to 60 degrees of extension 90 to 100 degrees of flexion

Glenohumeral joint 9

45 degrees of horizontal abduction 135 degrees of horizontal adduction

Glenohumeral joint 8

70 to 90 degrees of internal and external rotation

Glenohumeral joint 6

90 to 100 degrees of abduction 0 degrees adduction or 75 degrees anterior to the trunk

abductor pollicis longus muscle

Abduction of thumb at carpometacarpal joint Abduction of wrist Extension of thumb at carpometacarpal joint Weak supination of forearm from a pronated position Weak extension of wrist

Glenohumeral external rotation

Agonists Infraspinatus Teres minor

Glenohumeral diagonal adduction

Agonists Anterior deltoid Coracobrachialis Biceps brachii, short head Pectoralis major, upper and lower fibers

Glenohumeral flexion

Agonists Anterior deltoid Upper pectoralis major

Glenohumeral abduction

Agonists Deltoid Supraspinatus Upper pectoralis major

Glenohumeral internal rotation

Agonists Latissimus dorsi Teres major Subscapularis Pectoralis major

Glenohumeral adduction

Agonists Latissimus dorsi Teres major Lower pectoralis major

Glenohumeral diagonal abduction

Agonists Posterior deltoid Infraspinatus Teres minor Triceps brachii, long head

glenohumeral horizontal abduction

Agonists Posterior deltoid Middle deltoid Infraspinatus Teres mino

radioulnar pronation

Agonists Pronator teres Pronator quadratus Brachioradialis

Glenohumeral extension

Agonists Teres major Latissimus dorsi Lower pectoralis major

Muscles

All wrist flexors generally have their origins on the anteromedial aspect of the proximal forearm and the medial epicondyle of the humerus, with insertions on the anterior aspect of the wrist and the hand Median nerve and all flexor tendons, except the flexor carpi ulnaris and the palmaris longus, pass through the carpal tunnel

Muscles

Anterior Pectoralis major Coracobrachialis Subscapularis Superior Deltoid Supraspinatus

The Shoulder joint

Attached to the axial skeleton Scapula movement usually occurs with movement of humerus Humeral flexion and abduction require scapula elevation, upward rotation, and abduction Humeral adduction and extension result in depression, downward rotation, and scapula adduction Scapula abduction occurs with humeral internal rotation and horizontal adduction Scapula adduction occurs with humeral external rotation and horizontal abduction

Injury of the wrist and hand

Bennett fracture -Longitudinal fracture of the base of first metacarpal Mallet finger -Avulsion of finger extensor tendons at the distal phalanx Result of forced flexion Boutonniere deformity -Stiff proximal interphalangeal articulation -Caused by injury to the finger extensor mechanism

radiounlnar joint

Called syndesmosis because the joint between shafts of the radius and ulna are held tightly together between the proximal and distal articulations by an interosseus membrane Substantial rotary motion between the bones

Bones

Carpal bones form a three-sided arch Concave on the palmar side Bony arch is spanned by the transverse carpal and volar carpal ligaments Creates the carpal tunnel Frequently a source of problems known as carpal tunnel syndrome

Joints of the wrist 2

Carpometacarpal -Articulations between carpals and metacarpals Metacarpophalangeal -Articulations between metacarpals and phalanges Interphalangeal -Articulations between phalanges

Wrist joint

Condyloid-type joint Allows flexion, extension, abduction, and adduction Motion occurs primarily between the distal radius and the proximal carpal row, which consists of scaphoid, lunate, and triquetrum Known as the radiocarpal joint

Wrist adductors

Cross the wrist joint anteromedially and posteromedially to insert on ulnar side of the hand Flexor carpi ulnaris Extensor carpi ulnaris

Glenohumeral joint 5

Determining exact range of each movement is difficult because of accompanying shoulder girdle movement

Diagonal

Diagonal abduction Movement of humerus in a diagonal plane away from the midline of the body Diagonal adduction Movement of humerus in a diagonal plane toward the midline of the body

Adduction

Downward movement of humerus medially toward body from abduction

muscles

Elbow flexors Biceps brachii Brachialis Brachioradialis Pronator teres Elbow extensors Triceps brachii Anconeus

ROM

Elbow moves from 0 degrees of extension to 145 to 150 degrees of flexion Flexion: zero to 150 degrees Extension: 150 degrees to zero Hyperextension: measured in degrees beyond the zero starting point This motion is not present in all persons When it is present, it may vary from 5 to 15 degrees

Joints

Elbow: Ginglymus or hinge-type joint Allows only flexion and extension Interrelated joints Humeroulnar joint Radiohumeral joint

elbow flexion

Example: Bicepscurl Agonists Biceps brachii Brachialis Brachioradialis

elbow extension

Example: Push-downs Agonists Triceps brachii Anconeus

radioulnar supination

Example: Tightening ascrew Agonists Biceps brachii Supinator muscle Brachioradialis

extensor digiti minimi muscle

Extension of little finger at the metacarpophalangeal joint Weak wrist extension Weak elbow extension

extensor digitorum muscle

Extension of second, third, fourth, and fifth phalanges at metacarpophalangeal joints Extension of wrist Weak extension of elbow

extensor indicis muscle

Extension of the index finger at the metacarpophalangeal joint Weak wrist extension Weak supination of forearm from a pronated position

extensor pollicis brevis muscle

Extension of thumb at carpometacarpal and metacarpophalangeal joints Weak wrist extension Wrist abduction

extensor pollicis longus muscle

Extension of thumb at carpometacarpal, metacarpophalangeal, and interphalangeal joints Extension of wrist Abduction of wrist Weak supination of the forearm from a pronated position

extensor carpi radialis longus muscle

Extension of wrist Abduction of wrist Weak flexion of elbow Weak pronation to neutral from a fully supinated position

Extensor carpi ulnaris muscle

Extension of wrist Adduction of wrist together with the flexor carpi ulnaris muscle Weak extension of elbow

extensor carpi radialis brevis muscle

Extension of wrist Abduction of wrist Weak flexion of elbow

Theres major muscle

Extension, particularly from the flexed position to the posteriorly extended position Internal rotation adduction particularly fro the abducted position from the abducted position down to the side and toward the midline of the body

extensor muscles

Extensor digitorum Extensor indicis Extensor digiti minimi Extensor pollicis longus, thumb extensor Extensor pollicis brevis, thumb extensor Abductor of thumb and wrist Abductor pollicis longus

supination

External rotary movement of the radius on the ulna that results in the hand moving from a palm-down to a palm-up position

Muscles

Extrinsic muscles of the wrist and hand are grouped according to function and location Six muscles move the wrist but not the fingers and the thumb Three wrist flexors •Flexor carpi radialis •Flexor carpi ulnaris •Palmaris longus Nine muscles are the primary movers of the phalanges Also involved in wrist joint actions Generally weaker in their wrist actions Three wrist extensors •Extensor carpi radialis longus •Extensor carpi radialis brevis •Extensor carpi ulnaris

Flexor digitorum profundus muscle

Flexion of 4 fingers at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints Flexion of wrist

Flexor digitorum superficiali muscle

Flexion of fingers at the metacarpophalangeal and proximal interphalangeal joints Flexion of wrist Weak flexion of elbow

Flexor pollicis longus muscle

Flexion of the thumb carpometacarpal, metacarpophalangeal, and interphalangeal joints Flexion of wrist Abduction of wrist

Flexor carpi radialis muscle

Flexion of wrist Abduction of wrist Weak flexion of elbow Weak pronation of forearm

Palmaris longus muscle

Flexion of wrist Weak flexion of elbow

the wrist and hand

Flexion, extension, abduction, and adduction of the wrist and the hand 29 bones More than 25 joints More than 30 muscles, of which 18 are intrinsic

Eight carpal bones

Flexion, extension, abduction, and adduction of the wrist and the hand 29 bones More than 25 joints More than 30 muscles, of which 18 are intrinsic Distal row, from the radial to ulnar side Trapezium, greater multangular Trapezoid, lesser multangular Capitate, head-shaped Hamate, hooked

Glenohumeral joint injuries

Frequently injured due to its anatomical design Shallowness of glenoid fossa Laxity of ligamentous structures Lack of strength and endurance in muscles Injury results in: Anterior or anteroinferior glenohumeral subluxations and dislocations, which are common Posterior dislocations, which are rare Posterior instability problems, which are common

Wrist abductors

Generally cross the wrist joint anterolaterally and posterolaterally to insert on the radial side of hand •Flexor carpi radialis •Extensor carpi radialis longus •Extensor carpi radialis brevis •Abductor pollicis longus •Extensor pollicis longus •Extensor pollicis brevis

GIRD

Glenohumeral internal rotation deficit or G I R D Difference in internal rotation range of motion between an individual's throwing and nonthrowing shoulders Overhead athletes with a G I R D of greater than 20 percent have a potentially higher risk of injury Stretching exercises are recommended to regain amount of internal rotation necessary to: Improve performance Reduce likelihood of injury

Pairing of shoulder girdle and shoulder joint movements

Glenohumeral joint is paired with the shoulder girdle to accomplish the total shoulder ROM For example, 170 to 180 degrees of total abduction includes: ~ 60 degrees of scapula upward rotation ~25 degrees of scapula elevation ~95 degrees of glenohumeral abduction Scapulohumeral rhythm Synergistic relationship between the glenohumeral joint and the shoulder girdle Generally accepted ratio is two to one, or for every two degrees of glenohumeral motion, there is one degree of scapula motion May vary within and between individuals

Glenohumeral joint 3

Glenohumeral ligaments provide stability especially anteriorly and inferiorly Multiaxial ball-and-socket joint Classified as enarthrodial

Glenohumeral joint 2

Glenoid labrum Slightly enhances stability by deepening the concavity of the fossa Serves as buttress to excessive humeral head translation May be injured with sudden overhead movements and with trauma

carrying angle

In the anatomical position, it is common for the forearm to deviate laterally from the arm between 5 to 15 degrees Slightly greater in a dominant limb than in a nondominant limb Females commonly have a slightly greater carrying angle than men

Joints stability

Increased joint stability when fully extended As the elbow flexes 20 degrees or more, its bony stability is unlocked, allowing for more side-to-side laxity

Glenohumeral joint 4

Inferior glenohumeral ligament Ligaments are quite lax until extreme ranges of motion are reached because of wide range of motion involved Stability is sacrificed to gain mobility

pronation

Internal rotary movement of the radius on the ulna that results in the hand moving from a palm-up to a palm-down position

Internal rotation

Internal rotation Movement of humerus medially around its long axis toward the midline

Muscles of GH joint

Intrinsic glenohumeral muscles Originate on the scapula and clavicle Deltoid, coracobrachialis, the teres major, and the rotator cuff group Rotator cuff group is composed of subscapularis, infraspinatus, supraspinatus, and the teres minor (SITS) Extrinsic glenohumeral muscles Latissimus dorsi and the pectoralis major

Injury of the wrist and hand

Jersey finger -Avulsion of finger flexor -Result of forced hyperextension Trigger finger -Snapping during flexion and extension of fingers ---Created by nodules on tendons

UCL Injury

Many contact sports and throwing activities place stress on medial aspects of the joint, resulting in injury Ulnar collateral ligament or U C L Particularly crucial to high-velocity sporting activities, such as baseball pitching, that require optimal medial elbow stability Compromise of this structure often requires surgery

golfers elbow

Medial epicondylitis Somewhat less common and is known as golfer's elbow Associated with the medial wrist flexor and the pronator group near their origin on the medial epicondyle Both conditions involve muscles that cross the elbow but act primarily on the wrist and hand

Muscular actions

Most originate outside the hand region Thenar eminence: Mound on radial side of the palm formed by intrinsic muscles acting on the thumb -Hypothenar eminence: Mound on ulnar side of the palm created by intrinsic muscles acting on the little finger

The elbow and radioulnar joint

Most upper extremity movements involve the elbow and radioulnar joints Usually grouped together owing to their close anatomical relationship Elbow joint movements may be clearly distinguished from those of the radioulnar joints Radioulnar joint movements may be distinguished from those of the wrist

Movements: horizontal abduction

Movement of humerus in a horizontal or transverse plane away from the chest

Horizontal adduction

Movement of humerus in a horizontal or transverse plane toward and across the chest Pect Major Corachobrachialis Deltoid (anterior)

extension rotation

Movement of humerus laterally around its long axis away from the midline

Flexion

Movement of humerus straight anteriorly

Extensi0n

Movement of humerus straight posteriorly

Wrist Extension

Movement of the back of the hand and slash or the phalanges toward the posterior or the dorsal aspect of the forearm

Extension

Movement of the forearm away from the shoulder by straightening the elbow to increase its angle

Flexion

Movement of the forearm to the shoulder by bending the elbow todecrease its angle

Adduction, ulnar deviation

Movement of the little finger side of the hand toward the medial aspect or ulnar side of the forearm

Wrist Flexion

Movement of the palm of the hand and or the phalanges toward the anterior or volar aspect of the forearm

Abduction, radial deviation

Movement of the thumb side of the hand toward the lateral aspect or radial side of the forearm

Glenohumeral Joint 1

Multiaxial ball-and-socket joint Classified as enarthrodial

Muscular actions

Muscular actions Hand flexion/extension Hand radial/ulnar flexion Finger flexion/extension Finger abduction/adduction Thumb flexion/extension Thumb abduction/adduction Thumb opposition

Posterior

Posterior Latissimus dorsi Teres major Infraspinatus Teres minor

contributions of the wrist and hand

Power grip Powerful hand position Maximally flexing fingers around an object Precision grip Fine-movement hand position Minimally flexing fingers around an object Examples Eating with fork, Throwing softball, Spiking volleyball, Dribbling basketball, Changing channel with remote control

posterior muscles

Primarily extension and supination Triceps brachii Anconeus Supinator

anterior muscles

Primarily flexion and pronation Biceps brachii Brachialis Brachioradialis Pronator teres Pronator quadratus

Joints of the wrist

Radiocarpal -Wrist -Ellipsoid joint (2 axes of motions) ------Flexion/extension, radial/ulnar flexion Distal radioulnar -Ulna makes NO contact with carpals -Does NOT participate in wrist movements Midcarpal -Articulation between two rows of carpals Intercarpal -Articulation between a pair of carpals

sup, pro

Radioulnar pronators Pronator teres Pronator quadratus Brachioradialis Radioulnar supinators Biceps brachii Supinator muscle Brachioradialis

Rotator cuff injury

Rotator cuff is frequently injured Made up of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles Attaches to the front, top, and rear of humeral head Point of insertion enables humeral rotation Vital in maintaining the humeral head in correct approximation within the glenoid fossa while the more powerful muscles move the humerus through its wide range of motion

Bones 2

Scapula, clavicle, and humerus serve as attachments for shoulder joint muscles Humeral landmarks Head Greater tubercle Lesser tubercle Intertubercular groove Deltoid tuberosity

Bones 1

Scapula, clavicle, and humerus serve as attachments for shoulder joint muscles Scapular landmarks Supraspinous fossa Infraspinous fossa Subscapular fossa Spine of the scapula Glenoid cavity Coracoid process and acromion process Inferior angle

Joint ligaments

Stability in flexion is more dependent on the lateral or radial collateral ligament and the medial or ulnar collateral ligament Ulnar collateral ligament is critical in providing medial support to prevent the elbow from abducting when stressed during physical activity

supraspinatus muscle

Stabilization of the humeral head in the glenoid fossa abduction

radioulnar joint

Supinates 80 to 90 degrees from the neutral position Pronates 70 to 90 degrees from the neutral position Pronation: zero to 80 or 90 degrees Supination: zero to 80 or 90 degrees Total forearm motion: 160 to 180 degrees Persons may vary in the range of supination and pronation Some may reach the 90-degree arc, and others may have only 70 degrees plus

rotator cuff muscles

Supraspinatus Attach to greater tubercle from above or abduct Infraspinatus Attach to greater tubercle posteriorly or external rotation

tennis elbow

Tennis elbow: Common problem usually involving the extensor digitorum muscle near its origin on the lateral epicondyle Known as the lateral epicondylitis or depending upon specific pathology may be termed lateral epicondylagia or lateral epicondylosis Associated with gripping and lifting activities

Injury of the wrist and hand 2

Tenosynovitis -Inflammation of sheath surrounding the tendon Carpal tunnel syndrome -Pressure and constriction of the median nerve ------Caused by repetitive actions at the wrist

Rotator cuff muscles 2

Teres minor Attach to greater tubercle posteriorly or external rotation Subscapularis Attach to lesser tubercle anterior or internal rotation

Tommy johns

Tommy John procedure UCL surgical reconstruction using a tendon graft such as the palmaris longus tendon Radial collateral ligament provides lateral stability and is rarely injured Annular ligament provides a sling effect around the radial head for stability

radioulnar joint

Trochoid or pivot-type joint Radial head rotates around at the proximal ulna Distal radius rotates around the distal ulna Annular ligament maintains the radial head in its joint

brachialis muscle

True flexion of elbow

.

Ulna is much larger proximally than in radius Radius is much larger distally than the ulna Scapula and humerus serve as proximal attachments for muscles that flex and extend the elbow

Pectoralis major muscle

Upper fibers : Internal rotation, horizontal adduction, flexion, abduction or once the arm is abducted 90 degrees, the upper fibers assist in further abduction, and adduction or with the arm below 90 degrees of abduction Lower fibers : Internal rotation, horizontal adduction, extension from flexed position, and adduction

Movement- abduction

Upward lateral movement of humerus out to the side, away from the body

Conditioning

Why condition hand region? Improve grip strength Enhance wrist action for throwing, striking Prevent injury Exercises: Wrist curls Gripping exercises Stretching

Muscles

Wrist extensors generally have their origins on the posterolateral aspect of the proximal forearm and lateral humeral epicondyle, with insertions located on the posterior aspect of the wrist and hand Important in stabilizing the wrist in extension while the finger flexors contract in gripping

ROM

Wrist joint 70 to 90 degrees of flexion 65 to 85 degrees of extension 15 to 25 degrees of abduction 25 to 40 degrees of adduction

Pairing of shoulder girdle and shoulder joint movements

abduction = upward rotation adduction= downward rotation flexion = elevation or upward rotation extension = depression or downward rotation internal rotation = abduction or protraction external rotation = adduction or retraction horizontal abduction = adduction or retraction horizontal adduction = abduction or protraction

triceps brachii muscle

all heads extension of elbow long head extension of shoulder joint adduction of shoulder joint horizontal abduction

deltoid muscle

anterior fibers: abduction, flexion, horizontal adduction, internal rotation middle fibers- abduction posterior fibers- abduction, extension, hormonal abduction and external rotation

Latissimus Doris muscle

extension adduction horizontal abduction internal rotation

anconeus muscle

extension of the elbow

brachioradialis muscle

flexion of elbow pronation from supinated position to neutral

biceps brachii muscle

flexion of elbow supination of forearm weak flexion of shoulder joint weak abduction of shoulder joint when externally rotated

Coracobrachialis muscle

horizontal adduction adduction flexion

pronator quadratura muscle

pronation of forearm

pronator teres muscle

pronation of forearm weak flexion of elbow

Subscapularis muscle

stabilization of the humeral head in the glenoid foes extension adduction internal rotation

Infraspinatus Muscle

stabilization of the humeral head in the glenoid foosa extension horizontal abduction external rotation

supinator muscle

supination of forearm