Download Joints of the Upper Extremity

Arthrology of the Upper Limb
Presented by
David Rosenthal, DC, CSCS, BA, AS
Click here for professional CV
Resources:
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Main message: 1)
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Anatomy of Movement. (AM) Blandine Calais-Germaine
(PT/dancer)
Anatomy of Movement, The Exercises. BCG
Atlas of Human Anatomy. Frank H. Netter.
Clincally Oriented Anatomy, 3rd. ed. Keith L. Moore
Color Atlas of Anatomy, 3rd ed. Rohen and Yokochi
Upper extremity model from skeleton.
Diagnoses and treatment always come back to the basic sciences:
anatomy, physiology, neurology, biology, histology, microbiology,
etc.
If you know the normal structure and function, you will
immediately know what abnormal is.
If you know the anatomy, you can make up the technique that is
appropriate for the dysfunctional tissue (Tufts University
neurologist perspective).
Lecture notes http:www.DavidRosenthalDC.com/chiropractic.html
Encourage
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2)
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Purchase models of tissue (like a full skeleton w/mm. attachments).
To know what normal is. Use them every day in the office to
express concepts and encourage follow through for care.
Anatomy lab is an unbelievable opportunity to discover a world
that few have the opportunity to. These people have donated
themselves to give you an education. Find a part that interests you
and fully dissect it in your free time in lab – i.e. superior sagittal
sinus, sphenoid, AC jt., axilla, etc.
VIII.
Joints of the Upper Limb
Introduction, General Movements:
6 types of Synovial joints (Please Put Sally Behind Her Cat):
Plane – Glidying or sliding, i.e. acromion of scapulae and clavicle.
Pivot – Rotation, i.e. atlanto-axial joint.
Saddle – Concave and convex, i.e. carpo-metacarpal joint of the thumb.
Ball and Socket – Spheroidal within a socket, i.e. shoulder and hip.
Hinge(Ginglymus) – Flexion and extension only, i.e. elbow.
Condyloid – Bi axial joints allow movement in 2 directions, i.e. knuckles.
3 Features of a Synovial Joint:
Joint cavity
Articular cartilage
Articular capsule
1.
Sternoclavicular Joint [G626;M784-fig. 6.59, N401-402(AM
106)]
a.
Articulation: “modified” saddle type, diarthrotic
synovial jt. Fibrocartilage on ends of bones. Synovial
joints are the most common and important type functionally)
B.
Articular Capsule Ligaments:thick capsule ant./post.
with a interclavicular ligament and a costoclavicular
lig. Has a fibrocartilaginous disc
(NETTER 395/398, MOORE 3RD 609).
c.
Movements: of clavicle at this point(AM106)
Anterior/posterior as scapula is protracted/retracted
Superior/inferior as scapula is elevated/depressed
Rotation
d.
Neurovascular Bundle:Internal thoracic artery(54
MOORE, 3RD ED)[comes directly off the subclavian artery] and
medial supraclavicular nerve (790 Moore, 3rd
ed.)[posterior to the SCM and anterior to the middle scalene](and
n to subclavius) subclavius (AM116)is often a neglected mm –
necessary in clinical evaluation. Has origin and insertion points –
will affect blood supply to UE. Helpful in treating any disorder
affecting he UE)[Hilton’s law-nerves supplying a joint also
supply the muscles moving the joint and the skin covering the
attachments of these mms.])
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e.
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Clinicals: will fracture before it will dislocate on most
occasions. As you will find with many of the ligamentous
attachments – the density makes it often times stronger than bone.
(Functional changes of this joint will affect the apices of the lungs
and vascular affects to the UE)
(SC is supported A&P by SCM)
2.
Acromioclavicular Joint [G627;M784-787; N406]
a.
Articulation: plane, diarthrotic synovial jt.
Fibrocartilage on surfaces and angle of plane varies
(S-C and AC BOTH fibrocartilagenous) (Moore 3rd Ed 609)
b.
Articular capsule / Ligaments: integrity of joint
enhanced by the 2 part extrinsic coracoclavicular
ligament(trapezoid lateral & conoid medial. Has
incomplete fibrocartilagenous disc (NETTER 400)
(Q: Which joint has an incomplete f-c disc?)
c.
Movements: sliding and gliding to slightly help ROM
of shoulder complex
d.
Neurovascular bundle: suprascapular a with help from
TA trunk branches(between SCM and anterior scalenes,
posterior to the internal jugular vein (Moore 795 3rd ed.), nmostly lateral supraclavicular (Moore 790 3rd ed.)but
some lateral pectoral and axillary (Netter 404).
e.
Clinicals: very common dislocation with clavicle
passing superior to the acromial process of the
scapula-referred to as “shoulder separation” (Effective
treatment s/p injury is adjusting and KT (Kinesiotaping
http://www.kinesiotaping.com). Will provide similar support as
the integumentary system).
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3.
Glenohumeral (shoulder) Joint [G628-630;M789-791; N406;
AM 112-113]
a.
Articulation:ball & socket, diarthrotic synovial jt.
Hyaline cartilage on shallow glenoid fossa & covering
head of humerus. Glenoid fossa extended with
figrocartilaginous labrum(like a toilet plunger seal). Joint
sacrifices stability to gain ROM (stabilization exercises for
teres minor/infraspinatus, teres major/subscapularis include lateral
recumbents internal and external rotations with low weight and
low reps).
b.
Articular Capsule / Ligaments/: capsule thickened in 3
places(which are all anterior). Coracohumeral lig.
(Netter 398) aids joint capsule. Transverse humeral
lig. (Netter 398) helps hold tendon of long head of
biceps in place
c.
Bursae: Subacromial(subdeltoid) bursa (N 398) which
is anterior to the subscapularis mm. Subscapular bursa
(Moore’s 3rd 610) which blends in with synovial
membrane of articular capsule and is posterior inferior to
the coracoid and subscapularis mm .
d.
Movements / Scapulothoracic articulation:flex/ext,
ab/adduction, int/ext rotation(med/lat) and
circumduction. With abduction the scapula must begin
moving as you exceed 90°(scapulothoracic artic.)
(AM 119 scapular movement)
f.
Neurovascular Bundle: Suprascapular a (Netter 404)
& ant/post humeral circumflex aa(Netter 404),
Hilton’s Law: Suprascapular(trunk C5-6),
Axillary(terminal branch C5-6)
(Ne.405)
Lat. Pectoral(cord C5-7) are main
nerves.
(Brachial plexus memorize for boards)
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g.
Clinical: Calcium deposits(hydroxyapatite), rotator cuff
tears, dislocation(usually anterior & inferior), labrum
damage. (labral tears can be difficult to diagnose, need MRI –
best to refer earlier than later). Women who are smaller framed,
peri-menopausal and elderly have greater chance of frank
dislocation).
(Clinical evaluation important to look at support system of the
supraspinatus, infraspinatus, teres minor, teres major, subscapularis,
sublclavius and the most neglected mm in UE management – the
pectoralis minor,with it’s 3 insertion points on ribs 3,4 and 5).
(Make sure you learn how to re-set a dislocated shoulder – it’s an
easy procedure and done most effectively as soon as the injury occurs
[ligament creep doesn’t set in]. There is less likelihood of vascular
damage – always determine radial and ulnar pulses along with
capillary bed re-vascularization at the nail beds).
Ligament of Struthers is often neglected in management of CTS
Ligament of Struthers
4.
Elbow Joint [G681-682;M795-802; N419, 421]
a.
Articulation: hinge, diarthrotic synovial jt. Hyaline
cart.(not a great deal of weight bearing on that joint surface).
b.
Articular Capsule / Ligaments: capsule strengthened
by medial/lateral(radial/ulnar) collateral ligs (Netter
412). Medial hd. of triceps and brachialis blend into
capsule to “lift” it out of harms way
c.
Movements:flexion/extension(multiple small bursa)
(although pronation and supination is provided by muscles with
origins of the medial and lateral condyle Netter 414-5.)
d.
Neurovascular Bundle: from brachial, radial and ulnar
aa(collaterals and recurrents), Hilton’s Law: radial,
ulnar and musculocutaneous(and even some median)
(Netter 408, 409, 412).
e.
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Clinicals: Carrying angle (women make better receivers in
volleyball because of an increased CA), bursitis, valgus/varus
(AM 137) Females: 5 degrees, Male: 10-15 degrees.
5.
Proximal/distal radioulnar joint(N 421-422) pivot type
synovial jt. Annular ligament(like a sling – AM 135) holds head
of radius in place. Oblique cord limits supination.
Interosseous membrane (Netter 413) makes the intact unit
a syndesmosis type joint. United by fibrous tissue. Interosseous
membrane mobilization makes a significant impact in carpal tunnel
syndrome)
6.
Wrist Joint[ N437-438]
a.
Articulation:condyloid type, diarthrotic synovial jt.
(Netter 426-427).
b.
Articular Capsules / Ligaments: thickened on all four
sides. Has a fibrocartilagenous disc (Netter 427) from
radius to ulna separating head of ulna from lunate and
triquetral bone
c.
Movements:flexion/extension, ab/aduction (radial and
ulnar deviation), & circumduction.
d.
Neurovascular Bundle: radial/ulnar aa, median, radial
and ulnar nn(Hilton’s Law)
e.
Clinicals: effect of anteriorly displaced lunate on
median nerve. CTS with a multitude of causes from
restrictions
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7.
Intercarpal Joints[N 441]-plane gliding , synovial jts. Many
ligaments (I encourage you to try and dissect one of the carpals out of the
ligamentous mass). AM 150 gliding joints.
8.
Carpometacarpal / Intermetacarpal Joints: Netter 430 with
the exception of thumb these are all plane, synovial joints.
The trapezium to 1st metacarpal is a saddle
joint(ext/flex,ab/ad,opp,circum)
(AM150).
9.
Metacarpophalangeal / Interphalangeal Joints
(Netter 431) Metacarpophalangeal-condyloidext/flex,ab/ad,circumduction
Interphalangeal-hinge type-ext/flex
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