Synopsis of Shoulder Surgery

1 Shoulder Anatomy

Nickolas G. Garbis

Summary

The chapter is intended to be a high-level overview of shoulder anatomy and a quick reference for trainees and surgeons.

Keywords: Shoulder, anatomy, muscles, nerves, tendons

I. General introduction

A. Complex joint

B. Helps position the arm in space

C. Essential in allowing us to interact with the environment

D. Connects the axial skeleton to the upper extremity.

II. Bones and joints

A. Shoulder girdle is composed of four bones:

1. Sternum

2. Clavicle

3. Scapula

4. Humerus.

B. Three major articulations:

1. Sternoclavicular (SC) joint

2. Acromioclavicular (AC) joint

3. Glenohumeral (GH) joint.

C. Other articulations and spaces:

1. Subacromial space

2. Scapulothoracic bursa.

III. Sternum

A. Connection point of the appendicular skeleton to the axial skeleton

B. Bone is composed of three parts:

1. Manubrium

2. Body

3. Xiphoid process.

C. Sternal notch is a depression between the two SC joints

D. SC joints are shallow notches at the superolateral corners of the manubrium (?Fig. 1.1)

Fig. 1.1 Diagram of the sternoclavicular (SC) joint. 1CC, first costal cartilage (ossified); 2CC, second costal cartilage; M, manubrium; 1, interclavicular ligament; 2, articular disc; 3, costoclavicular ligament (posterior lamina); 4, sternocostal joint; 5, manubriosternal joint; 6, anterior sternoclavicular ligament; 7, costoclavicular ligament (anterior lamina).

E. The body and manubrium serve as insertion points for the costal cartilages of ribs 1-7

F. Important to understand role of SC articulation in shoulder biomechanics.

IV. Clavicle

A. Bone that spans from the sternum to the acromion

B. Flat near the lateral third but becomes more convex medially

C. Begins ossifying at 5 weeks in utero

D. The medial epiphysis of the clavicle is the last to fuse at approximately 23-25 years of life

E. The size of the bone changes in cross section at different points:

1. 23 mm × 22 mm at the sternal end

2. 12 mm × 12 mm at the diaphysis

3. 21 mm × 11 mm at the lateral end.

F. The coracoclavicular and AC ligaments stabilize the clavicle (?Fig. 1.2):

1. The conoid and trapezoid ligaments provide the primary restraint in the craniocaudal direction

2. The AC ligaments provide restraint in the anteroposterior direction.

G. Biomechanically, the clavicle acts as a strut to support the arm for activities performed away from the body

H. Serves as protection for the underlying neurovascular structures:

1. Can provide mechanical advantage for the myofascial sleeve around it.

V. Scapula

A. Triangular flat bone

B. Multiple prominences

C. Point of fixation for several upper extremity muscles

D. Has a curved contour to articulate with the rib cage

E. The spine of the scapula divides the supraspinatus and infraspinatus fossae (?Fig. 1.3)

F. The coracoid process is an anterior projection and an important surgical landmark:

1. Sometimes called "the lighthouse" of the shoulder

2. The coracobrachialis and short head of the biceps conjoined tendon have their origin in the coracoid

3. The pectoralis minor inserts on the medial aspect of the coracoid (?Fig. 1.4)

4. The coracoacromial and coracoclavicular ligaments also attach to the coracoid.

G. The acromion process is usually easily palpable in the subcutaneous tissue at the lateral aspect of the scapula:

1. Connects the clavicle to the scapula at the AC joint

2. Serves as the origin of the deltoid muscle.

Fig. 1.2 Gross anatomy of the coracoclavicular ligaments. (a) Anterior view. (b) Anterior medial view. CP, coracoid process; TL, transverse ligament; SSN, suprascapular nerve; CAL, coracoacromial ligament.

Fig. 1.3 Posterior view of a left scapula.

H. The scapula widens laterally into the glenoid neck and glenoid fossa:

1. Glenoid anatomy is variable but usually version will range from 9.5 degrees of anteversion to 10.5 degrees of retroversion

2. The mean inclination of the glenoid is usually 4 degrees of superior tilt

3. Size usually 27.8 mm by 37.5 mm in men and 23.6 mm by 32.6 mm in women.

VI. Humerus

A. Extension of the shoulder joint that allows positioning of the arm in space

B. The humeral head articulates with the glenoid:

1. The average radius of curvature is 24 mm in the coronal plane

2. The average thickness has been reported to be 19 mm

3. The average articular surface diameter is 43 mm.

Fig. 1.4 Anterior view of a left scapula.

C. The greater and lesser tuberosities are the attachment points of the rotator cuff (?Fig. 1.5):

1. Subscapularis attaches to the lesser tuberosity

2. Supraspinatus, infraspinatus, and teres minor attach to the greater tuberosity

3. The biceps groove is between the tuberosities, and can be a useful landmark during surgery.

D. Retroversion of the proximal humerus is variable and can be anywhere from 10 to 5 degrees. It averages approximately 30 degrees of retroversion.

VII. Sternoclavicular joint

A. Joint between medial end of the clavicle and the superolateral aspect of the sternum

B. Has been described as both a ball and socket and a saddle joint

C. The first costal cartilage is at the inferior aspect of the SC joint

D. Only bony connection of the upper extremity to the axial skeleton

E. Thickenings of the capsule serve to provide ligamentous restraint

1. The posterior SC ligament serves as primary restraint for the SC joint

2. The medial end of the clavicle is attached to the first rib with the costoclavicular ligament which helps restrict superior migration

3. There is an articular disc in the SC joint that attaches superiorly and inferiorly.

F. The SC joint moves approximately 30-35 degrees in elevation and 35 degrees in flexion/extension

G. Most of the motion in the SC joint occurs in the first 90 degrees of elevation.

VIII. Acromioclavicular (AC) joint

A. The AC joint is the articulation between the medial end of the acromion and the lateral end of the clavicle

B. The ends of the clavicle and the acromion at the AC joint are both covered in fibrocartilage (?Fig. 1.6):

1. There is also a meniscoid articular disc that covers mostly the superior portion of the joint.

C. The angle of the AC joint can be variable and should be considered during surgical planning

Fig. 1.5 Posterior and anterior views of the proximal humerus demonstrating the tuberosities and the bicipital groove.

Fig. 1.6 Left shoulder: acromial side of the AC joint. The entire capsule, detached from the clavicular side, is still attached at the acromial side, making the acromioclavicular ligaments visible. ACR, acromion, articular side; AL A/C, anterior acromioclavicular ligament; IL A/C, inferior acromioclavicular ligament; PL A/C, posterior acromioclavicular ligament; SL A/C, superior acromioclavicular ligament.

D. The AC ligament provides most of the anterior and posterior stability

E. The coracoclavicular ligaments provide most of the vertical stability and help maintain the relationship between the clavicle and the coracoid:

1. Composed of the trapezoid (anterolateral) and conoid (posteromedial) ligaments.

IX. Glenohumeral joint

A. Ball and socket or "ball on golf tee" joint that serves as the articulation between the humerus and the scapula (?Fig. 1.7)

B. Allows a significant amount of mobility to help position the arm in space:

1. Several dynamic and static restraints to...