Tuesday 28 June 2016

Shoulder Joint-Movements-Stability of the Shoulder Joint-Dislocations of the Shoulder Joint-Anterior Inferior Dislocation--Posterior Dislocations-Shoulder Pain

Shoulder Joint
■■ Articulation: This occurs between the rounded head of the humerus and the shallow, pear-shaped glenoid cavity of the scapula. The articular surfaces are covered by hyaline articular cartilage, and the glenoid cavity is deepened by the presence of a fibrocartilaginous rim called the glenoid labrum.
■■ Type: Synovial ball-and-socket joint
■■ Capsule: This surrounds the joint and is attached medially to the margin of the glenoid cavity outside the labrum; laterally, it is attached to the anatomic neck of the humerus. The capsule is thin and lax, allowing a wide range of movement. It is strengthened by fibrous slips from the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles (the rotator cuff muscles).
■■ Ligaments: The glenohumeral ligaments are three weak bands of fibrous tissue that strengthen the front of the capsule. The transverse humeral ligament strengthens the capsule and bridges the gap between the two tuberosities . The coracohumeral ligament strengthens the capsule above and stretches from the root of the coracoid process to the greater tuberosity of the humerus.
■■ Accessory ligaments: The coracoacromial ligament extends between the coracoid process and the acromion. Its function is to protect the superior aspect of the joint
■■ Synovial membrane: This lines the capsule and is attached to the margins of the cartilage covering the articular surfaces. It forms a tubular sheath around the tendon of the long head of the biceps brachii. It extends through the anterior wall of the capsule to form the subscapularis bursa beneath the subscapularis muscle .
■■ Nerve supply: The axillary and suprascapular nerves

Movements
The shoulder joint has a wide range of movement, and the stability of the joint has been sacrificed to permit this.
(Compare with the hip joint, which is stable but limited in its movements.) The strength of the joint depends on the tone of the short rotator cuff muscles that cross in front, above, and behind the joint—namely, the subscapularis, supraspinatus, infraspinatus, and teres minor. When the joint is abducted, the lower surface of the head of the humerus is supported by the long head of the triceps, which bows downward because of its length and gives little actual support to the humerus. In addition, the inferior part of the capsule is the weakest area.

Stability of the Shoulder Joint
The shallowness of the glenoid fossa of the scapula and the lack of support provided by weak ligaments make this joint an unstable structure. Its strength almost entirely depends on the tone of the short muscles that bind the upper end of the humerus to the scapula—namely, the subscapularis in front, the supraspinatus above, and the infraspinatus and teres minor behind. The tendons of these muscles are fused to the underlying capsule of the shoulder joint. Together, these tendons form the rotator cuff.
The least supported part of the joint lies in the inferior location, where it is unprotected by muscles.

Dislocations of the Shoulder Joint
The shoulder joint is the most commonly dislocated large joint.

Anterior Inferior Dislocation
Sudden violence applied to the humerus with the joint fully abducted tilts the humeral head downward onto the inferior weak part of the capsule, which tears, and the humeral head comes to lie inferior to the glenoid fossa. During this movement, the acromion has acted as a fulcrum. The strong flexors and adductors of the shoulder joint now usually pull the humeral head forward and upward into the subcoracoid position.

Posterior Dislocations
Posterior dislocations are rare and are usually caused by direct violence to the front of the joint. On inspection of the patient with shoulder dislocation, the rounded appearance of the shoulder is seen to be lost because the greater tuberosity of the humerus is no longer bulging laterally beneath the deltoid muscle. A subglenoid displacement of the head of the humerus into the quadrangular space can cause damage to the axillary nerve, as indicated by paralysis of the deltoid muscle and loss of skin sensation over the lower half of the deltoid. Downward displacement of the humerus can also stretch and damage the radial nerve.



 
Shoulder Pain

The synovial membrane, capsule, and ligaments of the shoulder joint are innervated by the axillary nerve and the suprascapular nerve. The joint is sensitive to pain, pressure, excessive traction, and distention. The muscles surrounding the joint undergo reflex spasm in response to pain originating in the joint, which in turn serves to immobilize the joint and thus reduce the pain.
Injury to the shoulder joint is followed by pain, limitation of movement, and muscle atrophy owing to disuse. It is important to appreciate that pain in the shoulder region can be caused by disease elsewhere and that the shoulder joint may be normal; for example, diseases of the spinal cord and vertebral column and the pressure of a cervical rib (see page XXX) can cause shoulder pain. Irritation of the diaphragmatic pleura or peritoneum can produce referred pain via the phrenic and supraclavicular nerves.



















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